The People Awakening Project (1RO1 AA 11446-03) had two purposes, completed in Phase I and Phase II of the project. The purpose of Phase I was to complete a qualitative study; the research objective was discovery oriented with the specific aim of identification of protective and recovery factors in Alaska Native sobriety. Results were used to develop a heuristic model of protective and recovery factors, and measures based on these factors. The research objective of Phase II was to pilot these measures and provide initial validity data.Phase I utilized a life history methodology. People Awakening interviewed a convenience sample of 101 Alaska Natives who had either recovered from alcoholism (n = 58) or never had a drinking problem (n = 43). This later group included both lifetime abstainers (LAs) and non-problem drinkers (NPs). Life histories were transcribed and analyzed using grounded theory and consensual data analytic procedures within a participatory action research framework. Analyses were utilized to generate heuristic models of protection and recovery from alcohol abuse among Alaska Natives.Analyses generated a heuristic model of protective factors from alcohol abuse. The resulting multilevel and multi-factorial model describes interactive and reciprocal influences of (a) individual, family, and community characteristics; (b) trauma and the individual and contextual response to trauma, (c) experimental substance use and the person's social environment; and (d) reflective processes associated with a turning point, or a life decision regarding sobriety. The importance of cultural factors mediating all these protective processes is emphasized. For NPs, the resilience process drew from personal stores of self-confidence, self-efficacy, and self-mastery that derived from ability to successfully maneuver within stressful or potentially traumatizing environments. In contrast, for many LAs, efficacy was instead described in more socially embedded terms better understood as communal mastery. One style of mastery is more associated with individualistic orientations, the other with more collectivistic. Future research is needed regarding the generalizeability of this group difference.Results suggest that preventative interventions should focus on intervening simultaneously at the community, family, and individual levels to build resilience and protective factors at each level. Of particular importance is the building of reflexivity along with other cognitive processes that allow the individual to think through problems and to reach a life decision to not abuse alcohol. Many American Indian and Alaska Native people experience problems with alcohol abuse that lead to social, psychological, and physical problems -3. UnforRecent research on resilience identifies and describes protective factors that moderate risk and adverse environmental circumstances; this work has relevance to understanding the sobriety process -10. ResiBecause protective factors include personality traits and family, community, and environmental characteristics, it is difficult to compile a universal list of factors appropriate to all groups of people in very diverse contexts, especially when the nature or the composition of those categories includes diverse cultural dimensions . For exaTriadic Influence theory (TI)  providesInstead of attempting to study cultural factors through measurement of identification with Alaska Native culture, the narrative form of the qualitative study reported in this paper allows for an alternative approach involving the generation of hypotheses on ways in which specific culturally mediated processes are conceptualized as protective by the members of the culture themselves.In summary, there is a need for research that examines the resilience experience of Alaska Natives who lead sober lives, and in particular, for research that includes an examination of the role of cultural factors in the protective process. In order to provide the rich description necessary to understand the range of experience and cultural processes of Alaska Natives who never drank abusively or who have recovered, qualitative methodologies are used. The goal of this study is to generate a theoretical model  of proteA purposive sampling procedure was used. Selection criteria were established by the PA Coordinating Council, a statewide group consisting of Alaska Native community leaders, individuals involved with grassroots Alaska Native sobriety movement efforts, and Alaska Native substance abuse services providers, who functioned as co-researchers in the participatory methodology. The Council distinguished three groups of interest: (1) lifetime abstainers (LAs) defined as individuals who have never drank more than two drinks per year, (2) non-problem drinkers (NPs) who report drinking alcohol with no problem and score less than 12 on the lifetime total consequences score of the Drinkers Inventory of Consequences for Alaska Natives (DrInC-AN)-a culturally adapted version of the Drinkers Inventory of Consequences (30), and (3) five years or greater of sobriety (5+) who identified themselves as recovered after a serious problem with alcohol, scored greater than 12 on the DrInC-AN lifetime total consequences score, and reported abstinence for at least five years. The project goal for Phase I was to select 36 participants with equal representation from the five Alaska Native tribal groups-Aleut/Alutiq, Athabascan, Inupiaq, Tlingit/Haida/Tsimshian, and Yup'ik/Cup'ik,-balanced by gender, age, and sobriety group status, and to oversample 12 additional interviews from the Yup'ik because Phase II measurement development would focus on this group. PA utilized nomination and snowball procedures to identify potential participants. Age representation was categorized into three age groups: 21 to 30, 30 to 55, and 56 and over. These age ranges were selected by the Council as indicative of culturally significant age ranges, marking indigenous age transitions from young adulthood to middle adulthood to elder. The Council selected these three sobriety categories to maximize our ability to discover potential protective factors as well as recovery factors, together which would define broadly resilience factors used by Alaska Natives in dealing with alcohol. Consultants from the respective tribal communities, the regional non-profit corporations, area health service providers, and other Native political organizations nominated individuals for participation, who then nominated others. Additionally, radio shows, advertisements, and newspaper articles solicited volunteers. This yielded 152 volunteers. Because our Council indicated it would be culturally inappropriate to not interview people following their offer to tell their life story to the project, PA offered interviews to all volunteers, and 101 completed the entire interview process. The results presented here analyze 37 long life history interviews and 14 briefer interviews on sobriety experiences. These participants were distributed across tribal group affiliation (Aleut/Alutiq-6, Athabascan-7, Inupiaq-6, Tlingit/Haida/Tsimshian-6, Yup'ik/Cup'ik-26), and the three sobriety types: LA - 10, NP - 19, and 5+ - 22, with proportional representation of the long life histories by gender and age in each sobriety category. In addition to over-sampling from the Yup'ik cultural group for life history interviews, 14 Yup'ik briefer interviews are included in this analysis in order to maximize the generalizeability of the findings to this cultural group, as the next phases of PA involve the development of measurement instruments and preventative interventions in regions of Alaska that include a Yup'ik majority.Sixty-two percent of participants spoke English as a first language and 48% their indigenous language. Eighty-two percent had been married at one time, with the average length of marriage being 10 years. At the time of the interviews 57% remained married. Participants' immediate families averaged 3 children. Participant incomes ranged from below $10,000 to over $100,000 per annum with the mean at $46,800. Most participants had graduated from high school (84%) and education ranged from no school to doctoral degrees. Of those who had recovered from alcohol abuse/dependence, mean years of sobriety was 17.5 years.PA was approved by the Institutional Review Board at the University of Alaska Fairbanks prior to participant enrollment. Nominees were contacted initially by phone, the purpose and structure of the interviews was described, and participation invited. Preference for location of interview, gender of interviewer, indigenous language or English interviewer, and interviewer that they knew or did not know was established. Interviewers were trained in the interview protocol, including protection of human participant procedures, prior to this contact.Life history interviews followed an open-ended for long life histories (LLH) or semi-structured format for brief life stories (BLS). The mean for LLH was 173.5 minutes (SD = 87.5), median was 159.5, and mode was 141.9. For BLS the mean was 119.5 minutes (SD = 49.5), median was 110, and mode was 106.5. Range for LLH were 20 to 452 minutes and for BLS were 45 to 272 minutes. The interview protocol elicited lifespan information with a focus on what the person considered most important in their process of sobriety. The intent was to garner rich detail about each person's life story. Briefer interviews were semi-structured. Questions addressed specific issues including the role of culture, spirituality, role models, parenting, and the methods of coping that individuals utilized to either not abuse alcohol or to recover. However, it is important to note that Alaska Native narrative patterns  at timesOur analytic approach combined elements of grounded theory analysis  with recEach analysis team member memoed the recordings of assigned interviews while also making additions and corrections to the transcripts for fidelity to the recorded interview. Memoing entailed three steps: (1) open coding identify possible codes, (2) connecting codes through overarching themes, and (3) documenting how codes and themes fit possible theories of protection. Team members then read all memos. Additionally, some of the team members shared their memos with the participant to gather feedback on the accuracy of their perceptions. Changes to the coding and analysis were made to reflect the perceptions of the participant. Most participants made no changes to the transcripts or small changes to the transcripts. A small number made changes by adding material or deciding to delete material, e.g. a number of individuals dropped names of people that were in the interview. A few added material that they had remembered. We gave the participants their verbatim transcripts  and discovered participants were often embarrassed by their unedited nature. We learned immediately we needed to explain the nature of the transcription process and its intent, and that their interviews would not be published in such a form . An initial set of codes and overarching themes or domains under which the codes clustered was identified and then systematized in an initial draft coding manual.Two research team members continued to read and open-code interviews. The team met periodically with Gerald V. Mohatt, Principal Investigator, who also coded a number of transcripts, to discuss coding discrepancies and refine coding rules. The goal at this stage was inclusive not exclusive, and to add as many codes as possible; therefore, we did not limit ideas. We spent much time operationalizing definitions in order to ensure that each code was clearly distinguished from others and could be reliably scored using the codebook criteria. This was done through hours of discussion, with final agreement regarding the definition of each code arrived at between the PI, the research Project Director, and at least one of the Co-Investigators or research assistants. This process resulted in 220 separate codes organized under 25 hierarchical domains. Coding reliability was enhanced in the revised coding manual through development of definitions for each code, along with examples of the code in use and decision rules where appropriate.kappa statistic [kappa less than .90 indicated a problem with agreement in the way a code was being used in qualitative research. However, insistence upon very high levels of reliability can also have the effect of diminishing validity [kappa .90 or greater, and coding of the 220 lower level categories of no less than .60. Kappas ranged from .60 to .81 for all lower level categories, and all hierarchical categories were at .90 or above. The team continued to reconcile divergences in coding, refine coding categories, open code, and revise the codebook. Previously coded transcripts were recoded, using the revised codebook.The research team trained coders to code using AnSWR software  and conttatistic . Carey, tatistic  judged tvalidity , and thiThe team submitted a sample of transcripts to the PA Coordinating Council as part of a cultural auditing procedure. The co-researcher role of this Council, which included members of all five Alaska Native tribal groups interviewed by the project is described elsewhere . The CouFor example, Council members understood "being a role model" within the context of the cultural value of contributing to the good of the family or community, and not merely in terms of individual achievement. The Council also indicated that we should add codes such as shame, praise, and pride to our coding system, and elaborated on their definitions. An overall comparison of the coding and domains generated by the Council with those of the research team displayed high levels of consistency, along with selected important divergences which were discussed to mutual understanding, then adopted by the research coding team.Team members next identified how coded segments clustered and interacted, generating potential theories on protective factors through comparison of the life histories of LAs and NPs to 5+ individuals. The team discussed multiple theories, and reconciled potential theories to case histories of non-agreement through revision or abandonment of the theory.Team discussions were summarized and synthesized by the principal investigator into competing models. The team reread transcripts, discussed and refined models, converging on one model that best fit the majority of transcripts, which was then presented to the PA Coordinating Council. The Council added refinements and culturally grounded elaborations to this model.The team re-read transcripts and reassessed the model, refining and elaborating elements until consensus that the full set of transcripts supported the model. As part of this process the team enlisted the Cuiliat Group of Yup'ik speakers, who were our cultural consultants, and would also assist us in the Phase II measurement development. Translating each of the protective factors into Yup'ik forced us to clarify definitions and ensured that they differentiated culturally specific dimensions of each protective factor. For example, from this process the importance of collective group factors became clearer.credibility, which can be defined through (1) the confidence that can be placed in the data and analysis [In qualitative research, the analogue for validity in quantitative research is often termed analysis ,43, (2) analysis , and (3)analysis . In thisanalysis  were useThe research aim of the PA study was discovery-based, and not proof through hypothesis testing and falsification. Our objective was to characterize the types of protective factors utilized within this purposive sample, and not to generalize to all Alaska Natives or American Indians. Our goal was to generate a heuristic theory that would suggest testable hypotheses that could later be investigated in a larger, population based study, using measures developed in Phase II. We also hoped to offer ideas to services programs regarding variables that they could test for effectiveness in prevention or treatment.Using the above process we first identified a set of factors protective from alcohol abuse. We use the direct words of participants to illustrate each to allow the reader to move through the process in a manner similar to the research team. Each protective factor in the model is translated into Yup'ik, the indigenous language of the group we plan to collaborate with on an intervention program. The complete Heuristic Model of Alaska Native Protective Pathways can be found in Figure Yuut cayarait. Participants described the context of the community that protected them during childhood and provided a sense of security. As one participant indicated, "I guess, my life as a child was pretty much sheltered...so, as the expression goes, the village was my oyster then." Protective communities possessed role models for the proactive caring of others that exemplified a sense of a collective responsibility for the care of children, or, as another participant described this, "That's also what I remember is people taking care of us even if we're not their children, they looked after us, and they corrected us." Participants described how protective communities provided both opportunities to learn and alternatives to drinking. One young man described how the community school gave opportunities to travel, engage in sports, debate, and engage in student leadership that gave him ideas about college and careers. Opportunities were also often contextualized in ways the community helped children through important culturally defined transitional rites in the development of adult roles: "They still do this community sponsored moose hunt. They go out and they go hunting for the moose and for a lot of young men that is the time that they have the rite of passage. This is their first moose. And in the beginning when it started out it was just the men, just boys were allowed to go. And it evolved into a community wide project and it does include girls. And the whole community is involved because they'll go and they'll come back in and they'll have a big potluck and it's the rite of passage for he who caught his first moose. Everybody gets to participate. He gets to provide for his community, you know for the first time and that is something that he can do."One of the most important community protective factors related to how the community established limits. While some individuals discussed the local option laws that allow some communities to vote to regulate or ban alcohol, a larger number discussed how significant individuals in the community took a personal stand to protect children from alcohol-related harm. What was fascinating was in which community characteristics were frequently embedded within the context of the family, and occurred within the interface between the family and the community. A vivid instance of this is described by a middle-aged woman recalling her childhood: "When I first was aware of somebody drinking, I was already nine years old. And I never saw anybody drunk before. ...And my father stood up, and he said no; he just let him turn around and he walked out with him. And then I heard him out there, 'Don't you ever come in my house like that.' We asked my mom, what is wrong with that man? And she would never tell us; she would say in due time you will know. In your own time, you will know." Here we see the individual actions within a family as an important component within a community-wide expectation regarding the setting of limits upon alcoholic behavior, reciprocally mirroring and contributing to a community standard.safe places children could go to that prevented them from becoming victims of alcohol-related violence. Most often the safe place was with a close relative, but it could include a friend, teacher, or member of the clergy. As one participant described: "I like the way my grandma took care of me when I was small. Her house was always clean, everything smelled good. It was always a safe place to go to. And I have realized after I got my own place and became an adult, that my home, to other people, was always a safe place to go to."Participants reported how they were exposed in childhood to adults that abused alcohol. Protective communities had Family Characteristics (FC), Ilakelriit Cayarat. In the words of one participant: "In the Native community families are tied together in a certain way that they're close. And it doesn't matter who you are, we're tied together like a woven hat." This interdependence of family and community highlights both the kinship and collectivist [affection and praise that included important culture specific elements providing children a sense of being valued appears in the following narrative: "And I remember my grandparents bringing us to other elders' homes, just to introduce us to them, because our grandparents were proud of us, and they wanted to share us with the elders in the community. So they brought us to the elders and let us visit with them. I remember when we started hunting and fishing, we got a lot of praise, and even more praise than today, from our relatives and elders. You know, if an elder found out that you caught your first rabbit or your first moose, everybody praised you for that. And it helped to build up the esteem."ectivist  nature ospecial, as very important to the family. One participant noted: "So I grew up to be pretty special, only because I was the only girl of my family. My older brothers took very good care of me. They treated me well." Others who avoided alcohol problems in their lives recalled being told they were to become healers or shamans, or would have similar important roles in the community, and were encouraged to live in a way that prepared them for this role.Another quality of the caregiver relationship was a sense of being treated as safety/protection from harm. In addition to simply providing a place of safety, caregivers also established limits and enforced them for the good of children. One narrative related the importance of modeling values through the power of both words and action: "I would put the kids to bed and make, you know, put them to bed and make sure those people that were there, some of them I would kick them out and other ones, a lot of times I would let them go, say 'Go drink somewhere else. This is not the place to drink."'Families also provided models of sobriety in the family who taught them explicitly about how to deal with alcohol: "So my Dad was a non-drinker. And he said when I was eight year old he say, he sat me down, and he told me he said, my son being the oldest in the family, he said, there is something that I want you to do for me. And he said, I want you to carry a torch for me, a torch that you would say that all of my life I wouldn't drink and I wouldn't smoke. He say I took his word for it and he say, I want you to do the same for me. Carry that torch for me. And I guess that's the biggest thing you know that right there and then I thought okay."Participants who never developed a drinking problem also described transmission of the expectations they had for their children: "We were a poor family as any village people. But things were happy when we were growing up, and our Mom very seldom went out to work so she was home with us a lot. And my dad would talk to the boys about what's expected of them when they grew up, and how to take their place in the community or in their tribal relatives, how everything worked together. So that's how we all grew up." Many of these protective factors mirror each as interdependent community/family systems that protected children from exposure to alcohol abuse and alcohol related violence.Protective families also actively engaged in Yuum Ayuqucia. Protected individuals displayed a set of characteristics that included a preference towards a cognitive style of thinking through reflectively about what one will or will not do. This reflective style allowed self-control around alcohol use and decisions to immerse oneself in activities that avoid or are incompatible with alcohol use: "But, like I said, it hasn't bothered me – drinking hasn't bothered me. I don't know if it will. In my head – in my mind, it never will. I'm – I'm a positive person and that's the way I like to live my life, is live positively and things go smoother that way. But, living a Yup'ik life, just in general, doing all the traditional activities that we do on a daily – day-to-day basis here in the village, this keeps me away, makes me not think about it."wanting to be a role model: "And I had made a choice when I was ten or eleven to not drink alcohol, to remain sober and to show my brother, my sister that there is something different to do besides drinking and alcohol." The sense of responsibility within a kinship network led to a desire to give to others – contribute: "I think he [father] meant that I was going to help people sort out their lives, help them to understand, that you know, be a good listener for them, and counsel them when they need it, or at least let them know they have tools to help themselves.Participants describe this reflective process as part of a collectivist, other-centered orientation specific to Alaska Native cultures. One participant talked about belief in self, as a competent individual. One participant describes: "Like I mentioned, my parents, from as far back as even both of us can remember, I have always been an adult to them. I have always talked to them. Even like when I was ten years old, I talked to them like I was an adult, meaning I listened to them, I didn't talk about silly things. But we were able to converse, and so they treated me like an adult...that gave me the choice to do what I wanted and also to make the decision not to drink."In order to give and contribute one must have a fundamental sense of one's own capacity, a Some participants described a sense of mastery as knowing and caring for oneself and one's capacity to endure. In the words of one Alaska Native person: "My mother taught me too much to love myself. I've always felt I was a very strong person. I have been able to put up with a lot of shit." However, important differences in mastery emerged between NPs and LAs. NPs often described a sense of efficacy and self-actualization focused more on self-confidence and independence than responsibility to the family and community. One traditional Yup'ik elder NP described how he took the initiative in his socio-cultural education. "Yes I learned on my own. Whenever I am going to construct something I would look at it from all sides and memorize it. When I was about to construct a large boat fashioned after one that is manufactured, I looked at a finished one from all sides and then I constructed it without anyone guiding me. I was not given a lot of advice by anyone." In contrast, for LAs, efficacy was described in more socially embedded terms better labeled as communal mastery ,47, or aawareness of consequences: ellangneq. Ellangneq is a Yup'ik concept, but similar elements appeared throughout many of the narratives across all the Alaska Native cultural groups. The child learns that reciprocity exists between individual actions, and the good of the community and family: control over one's own actions can affect others positively. Ellangneq is this culturally valued awareness of the consequences of one's individual actions upon the whole. This special type of awareness is incompatible with intoxication; intoxication only reduces awareness and the ability to control oneself and one's own life, thereby engendering potentially negative reciprocal effects on family, community, and others. In the words of a Yup'ik LA, "But at that time I had already decided for myself that I wasn't going to drink. Part of that had to do with getting out into the woods. And that was part of my reason for refusal. Why would you want to go out and drink and kind of get out of your mind, loose mental control? You know I had so much fun doing the things I wanted to so I wanted to be aware of what I was doing."In this way, several of the life stories describe a socialization process within interconnected collectivist community and family structures that foster becoming aware of how one's actions affect others, described as an Ellangneq), and a sense of responsibility to family and community.Community and family protective characteristics lowered exposure to alcohol and alcohol-related trauma, or moderated the negative impact of traumatic experiences. They also fostered individual protective characteristics such as sense of mastery, awareness (Trauma and/or trauma exposure (TR), Akngirenq, included the death of loved ones or other unexpected and intense loss, witnessing domestic violence, or the experience of child abuse including sexual abuse. The pathway of participants who did not use alcohol as a coping response to trauma was facilitated by the protective community, family, and individual characteristics identified in the model, along with the youth's social environment, (SE) Yuuyaraq, including the presence of healthy, non-alcohol abusing role models and social support for lifestyles free of alcohol abuse from extended family, peers, and other adults outside of the immediate, nuclear family. Social environment is a subset of community characteristics specific to the time in youth when experimental substance use (ESU), Meqerraaryaurtellemni, begins, that functions as a support during periods of ESU or in times of crisis such as the experience of trauma. A male who had experienced significant family trauma described this:Nearly half who never drank abusively describe directly experiencing or frequently observing significant trauma during childhood. "I have a Russian Orthodox priest who's going to wed us in a civil ceremony. And I asked him when I was 15, 'If I ever get married, will you marry me?' He is also somebody who was a mentor for me as a kid.... I think that he was there for me at the right time. Especially, I think, and I probably don't remember a lot of things that happened at that age, but I knew that there was somebody who I could look to."Ellangneq, NPs and in particular many LAs who tried alcohol decided in youth after ESU, or after the experience of significant alcohol-related trauma, that the consequences of alcohol did not fit with how they wanted to affect others. Though even in the presence of multiple family, community, and individual protective factors, children would often still engage in a period of ESU, the outcome among NPs and LAs who experienced these protective factors was a conscious decision, a turning point (TP) Ayuqucinellemn, that virtually all identified as a pivotal event in their narratives, to either not continue to use alcohol or not use it in a manner that led to abuse. This turning point typically occurred as part of a reflective process of thinking over (TO), Umyuangcallemni, one's personal experience with alcohol. As one NP described:A period of ESU was quite common in the narratives; a majority of NPs and several LAs engaged in ESU. This typically occurred in early or mid-adolescence, after which the decision to drink responsibly or not drink was made. Consistent with a worldview imbued with concepts allied with that of "Later on after I graduated from high school I still knew I didn't want to be a drunk or you know, get drunk or look all ugly and do stupid stuff. (...) I didn't want to not know what I was going through. I wanted to be totally aware of my every live moment and I wanted to be in control of everything that I was doing. And so I think that's when my responsible drinking started." Through this process of thinking over and turning point, LAs and NPs composed a personal life narrative in which they were in charge of their lives.Figure We present here a multifactorial and multilevel model for the understanding of the sobriety process of Alaska Natives that lead a life free of alcohol abuse. The model was generated through a participatory action research process, elements of which can be adapted for work with American Indian and other ethnic minority communities. Cultural factors emerged central to an understanding of the sobriety process of Alaska Natives demonstrating the importance of culture as proximal variable  in reseaEllangneq, a sense of awareness, mindfulness, and the reciprocity of action developed through the teaching of parents, extended family, and community. Ellangneq can be understood as a manifestation of an interdependent [The resulting heuristic model for Alaska Native protective pathways is an indigenous explanatory model  describiependent , constitependent , or expaependent  found amependent . Individependent , with a Ellangneq becomes operative through the actions of family and community. Many researchers have found that a significant relationship with at least one parent is a critical variable in protective outcomes [outcomes , though outcomes ,11,54. TOne important difference distinguished the NP and LA sobriety groups in this sample. For NPs, the resilience process drew from personal stores of self-confidence, self-efficacy, and self-mastery that derived from ability to successfully maneuver within stressful or potentially traumatizing environments . In contIndeed, cultural factors surfaced repeatedly as important components in an understanding of how social influences within a community and family context functioned as salient protective factors in sobriety for Alaska Natives. As Triandis  remarkedThis study presents a heuristic model of Alaska Native pathways to sobriety. What is significant about the model is that it emerged from in-depth study of the experience of Alaska Natives, rather than that of other groups. The model moves current research in the direction of developing a culturally and contextually based explanatory model  or emic This initial analysis of the PA data set provides as many questions as answers for our understanding of the sobriety process of Alaska Natives. We hope that as the answers become more clearly defined, those pathways to recovery and resilience walked by the research participants become more known to those in need. The seeds of resilience form a sense of the family and community, a desire to make a difference as one Alutiq elder acknowledges:"We're not here tomorrow. Got to leave a few tracks around, right? I want to. So my grandkids could say, well, I remember when grandma used to – you know. You know you feel like, hey, you want to be able to leave some kind of memory."The author(s) declare that they have no competing interests.GVM is PI for the research. He led the analysis and interpretation, and completed many of the interviews. SMR completed much of the text analysis, wrote the first draft, and edited many drafts. LT interviewed most of the Tlingit participants, participated in all analysis and interpretation, and edited the paper. JA was a collaborating investigator involved in all aspects of data gathering, analysis, and interpretation. He edited each draft and significantly contributed to the final draft. KH was also a collaborating investigator and edited a number of the drafts. The People Awakening Team completed many of the interviews and assisted with the analysis and interpretation of the data. CH was research coordinator for PA and assisted in model development, analysis, interpretation of data, and editing.


Low back pain is a common disorder in western industrialised countries and the type of treatments for low back pain vary considerably.In a randomised controlled trial the cost-effectiveness and cost-utility of an intensive group training protocol versus physiotherapy guideline care for sub-acute and chronic low back pain patients is evaluated. Patients with back pain for longer than 6 weeks who are referred to physiotherapy care by their general practitioner or medical specialist are included in the study. The intensive group training protocol combines exercise therapy with principles of behavioural therapy ("graded activity") and back school. This training protocol is compared to physiotherapy care according to the recently published Low Back Pain Guidelines of the Royal Dutch College for Physiotherapy. Primary outcome measures are general improvement, pain intensity, functional status, work absenteeism and quality of life. The direct and indirect costs will be assessed using cost diaries. Patients will complete questionnaires at baseline and 6, 13, 26 and 52 weeks after randomisation.No trials are yet available that have evaluated the effect of an intensive group training protocol including behavioural principles and back school in a primary physiotherapy care setting and no data on cost-effectiveness and cost-utility are available. Low back pain is a very common complaint with major social and economical consequences. In a recent cross-sectional study the annual prevalence of low back pain in the general Dutch population was estimated at 44% . The couEvidence-based physiotherapy for sub-acute and chronic low back pain patients consists of adequate information and an active approach, including behavioural principles. As physiotherapists have not yet put these principles into practice -7 two imThe study is a randomised controlled trial (RCT). Alongside the trial a full economic evaluation will be conducted. The Medical Ethics Committee of VU University Medical Centre has approved the study design, protocols and informed consent procedures.The trial will be conducted in a primary physiotherapy care setting in Amsterdam and its surroundings. Eighty-five physiotherapists will participate in the trial; 40 physiotherapists are trained to provide the intensive group training protocol and 45 physiotherapist are instructed to provide usual physiotherapy care according to the Low Back Pain Guidelines of the Royal Dutch College for Physiotherapy (KNGF).Patients with non-specific low back pain referred to one of the participating physiotherapists by their general practitioner are eligible for participation in the trial. Patients are included if the current episode of low back pain lasts more than 6 weeks and if the complaints show no tendency to decrease, meaning that the patient has not increased his activities in the last three weeks. Furthermore, patients have to be between the age of 18 and 65 years old, live or work in Amsterdam and have a health insurance with one insurance company (Agis). This health insurance company covers about 80 to 90 percent of the Amsterdam population and is the only company that reimburses the intensive group training protocol. Patients are excluded from the study if 1) they have specific low back pain, attributable to e.g. infection, tumour, osteoporosis, rheumatoid arthritis, fracture, inflammatory process, radicular syndrome or cauda equina syndrome; 2) their general practitioner or medical specialist advised them not to perform physically straining activities; 3) they are pregnant; 4) they have pelvic pain/instability; 5) they are dealing with a lawsuit related to either their low back pain or related to their disability for work. Patients are recruited by participating physiotherapists. If patients are interested in participating in the trial, they receive written information about the trial and their name and phone number is given to a research assistant. The research assistant calls the patient two days later and explains the aim and implications of the study. If the patient agrees to participate, an appointment is made at a local research centre. At the local research centre a research physiotherapist checks again if the patients meets the eligibility criteria. Patients who meet the criteria and agree to participate in the trial must sign an informed consent form. Patients are asked to complete baseline questionnaires and the research physiotherapist will conduct baseline assessment of physiologic outcome measures.In accordance with the CONSORT statement, information on number of recruited and eligible patients and reasons for exclusions or refusal to participate will be registered for all recruited patients by the participating physiotherapists and the research physiotherapist.Patients are randomly assigned to either the intensive group training protocol or physiotherapy guideline care. Randomisation is stratified for duration of complaints to ensure a sufficient number of sub-acute and chronic patients in each treatment group. To avoid inconvenience for the patients, seven local research centres are set up in different parts of the city. For each research centre two randomisation lists are prepared and permuted blocks of 4 patients are made to ensure equal distribution of patients for each research centre. An independent statistician generated the randomisation lists, using series of random numbers. The principle investigator (NvdR), who is not involved in the selection of patients, prepared the opaque, sealed envelopes, guaranteeing concealed randomisation. At the local research centre the administrative assistant hands the next envelope to the patient who then opens the envelope. The administrative assistant then checks the envelope and informs the participating physiotherapist about the treatment allocation.Both the research physiotherapists and the principle investigator remain blinded for the allocation of treatment. Patients cannot be blinded for the interventions. As a consequence most outcome measures, consisting of self-report questionnaires are not blinded either. All physical outcome measures are blindly assessed by the research physiotherapist as we ask the patients not to reveal information about their treatment to the research physiotherapists. Participating physiotherapists can not be blinded for treatment allocation, but they are not involved in the assessment of outcome measurements.Patients who are assigned to physiotherapy guideline care are treated according to the recently published Low Back Pain Guidelines of the Royal Dutch College for Physiotherapy (KNGF) . The guiThe intensive group training protocol combines exercise therapy with principles of back school and behavioural therapy. Back school principles include group lessons with adequate information on causes of low back pain, factors influencing low back pain, advice on physical activity and dealing with a relapse. Operant conditioning and graded activity as components of behavioural therapy are included in the protocol. Baseline measurements, goal setting and time-contingency are the main elements of the intervention. The purpose of the protocol is to improve activities and participation in work or other social activities, instead of focussing on pain or anatomical impairments. The patient has an active role and is responsible for the results of the therapy. The physiotherapist has the role of coach and focuses on the achieved improvement instead of the remaining complaints . Active The protocol has a total duration of 30 weeks and consists of three phases: the starting phase, the treatment phase and the generalisation phase. It concerns 10 individual sessions of 30 minutes per session and 20 group sessions of 1,5 hours per session. During the first phase of three weeks, six individual sessions are planned for patient history and physical examination, providing information on the treatment, determining baseline level of functional capacity and signing a treatment contract. During the treatment phase the group sessions have a frequency of twice a week for eight weeks. Every patient has his own gradually increasing exercise program, with an operant-conditioning behavioural approach based on the baseline level of functional capacity. The treatment phase gradually changes into the generalisation phase in which patients learn to apply everything they have learned in the treatment phase to their own daily situation. Therefore the frequency of the sessions decrease in the last four weeks; patients are encouraged to exercise more at home and to choose a physical activity they will continue after treatment has finished. Two individual sessions are planned for evaluation during the twelve week training period and two additional individual sessions are planned three weeks and three months after the group sessions have finished.The exercise program consists of:1. warming-up and cooling down2. aerobic exercises on a rowing machine, stationary bike or treadmill3. muscle strengthening exercises of the lower back, abdomen and buttocks4. exercises that specifically apply to the patient's situation5. home exercisesThe exercises mentioned at point 4. are determined by a Patient Main Complaint Form . During For training, the physiotherapists will receive instruction on the background and content of the protocol, and will be trained to include behavioural principles in the physiotherapeutic management of low back pain at two meetings of six hours each. In groups of 7–8 physiotherapists discussions and role playing are supervised by one expert trainer with extensive experience in behavioural principles. Four months after the last meeting 2 follow up sessions of 4 hours are organised to discuss practical problems and practice difficult situations with the trainers. The principal investigator (NvdR) will regularly visit the group sessions at the physical therapy practices to monitor the conduct of the intensive group training protocol. For each participating patient the physiotherapist is asked to complete a registration form containing the treatment goals, content of the different sessions and evaluation of the protocol.The intensive group training protocol is a standardised approach consisting of 30 treatment sessions. As the physiotherapy guideline care is not a protocol, the number of sessions will vary per patient. In daily practice the average number of treatment sessions is 9 and the average duration of treatment is 6 weeks [During the intervention period, co-interventions are discouraged. However, co-interventions will be reported and evaluated. Compliance to the intensive group training protocol is assessed by registering the number of treatment sessions that patients attend. The content of treatment and number of treatment sessions received by the physiotherapy guideline care group will be registered.In 1998 a proposal for standardised use of outcome measurement in low back pain studies was published . An inte1. The functional status is assessed with the Roland Morris Disability Questionnaire . The que2. General improvement is measured on a 6 point scale ranging from "much worse" to "completely recovered".3. An 11-point numerical rating scale is used for determining pain intensity, ranging from 0 "no pain" to 10 "very severe pain" .4. Work absenteeism is measured with the Short Form Health and Labour Questionnaire ,16. This5. The EuroQol instrument is administered to assess the patient's general health status. The questionnaire describes the general health status in 5 dimensions: mobility, self-care, usual activities, pain/discomfort and anxiety/depression . Because6. The Tampa scale for kinesiophobia is developed as a measure of fear of movement/(re)injury by Miller et al. . The que7. Cognitive and behavioural pain coping strategies are assessed using the Pain Coping Inventory . This qu8. Self-efficacy beliefs are measured using the Pain Self-Efficacy Questionnaire . With th9. For measuring patient satisfaction four items (out of 17 items) of the Patient Satisfaction Scale of Cherkin et al.  are combThe physical measurements will be performed at several local research centres. Therefore all physical tests must be easy to administer en practical. To minimize patient burden the tests should take as little time as possible en should not be too strenuous for the patient.10. Anthropometric measurements will be done for interpretation of the physical outcome measures. Body weight, body height and skin fold measures are assessed. Skin fold thickness of biceps, triceps, subscapular and suprailiac will be assessed with a Harpenden skin fold calliper. The skin fold-thickness equation developed by Durnin and Womersley will be used to determine body fat mass .11. Aerobic capacity will be assessed with the Chester Step Test ,29. This12. The isometric endurance of the back muscles is evaluated with the test according to Ito . The pat13. The fingertop-to-floor distance is measured to determine the flexibility of the spine . StandinAt baseline, data of various prognostic measures will be collected to evaluate if randomisation successfully resulted in two prognostically comparable groups and to be able to adjust for baseline differences in the analysis, if necessary.1. Data on individual factors such as age, gender, level of daily activity and preference for one of the treatment groups will be gathered by the administrative assistant.2. Characteristics of low back pain: duration and severity of the current episode and number of previous episodes will be assessed by the research physiotherapists.The aim of the economic evaluation will be to determine and compare all back pain related costs of patients receiving the intensive group training protocol or physiotherapy guideline care. The costs will be related to the effects of the interventions. Cost effectiveness will be conducted from a societal perspective. Direct health care costs, including the costs for physiotherapy, additional visits to other health care providers, prescription medication, professional home-care and hospitalisation and direct non-healthcare costs such as out-of-pocket expenses, costs for paid and unpaid help and travel expenses will be included. Also data on indirect costs of loss of production due to back pain will be estimated for both paid and unpaid labour. Direct and indirect costs will be evaluated with cost diaries that patients keep during the whole time they participate in the trial . The genPatients will be asked to complete questionnaires at baseline and 6, 13, 26 and 52 weeks after randomisation. Physical measurements will be performed at baseline, 13 and 52 weeks after randomisation. Table To be able to detect a clinically relevant difference in pain intensity  with a We expect a drop-out rate of 10% at most. Drop-out rates of similar RCT's on neck pain and tennis elbow conducted at our institute were less than 3%. Therefore, to get complete data sets of 120 patients with sub-acute and 120 patients with chronic low back pain, 280 patients will be recruited, 140 sub-acute and 140 chronic low back pain patients. 85 Participating physiotherapists will be asked to recruit 5 patients; the recruitment period will be of 12 months duration.Intention-to-treat analyses will be conducted for all patients participating in both groups. A generalised linear mixed model will be applied to evaluate differences between groups over a period of 52 weeks. Subgroup analyses will be performed for duration of back pain: sub-acute (6–12 weeks) versus chronic (>12 weeks), for severity of complaints at baseline, for age, and for the psychosocial characteristics somatisation, fear avoidance, catastrophising and self efficacy.Bootstrapping will be used for pair-wise comparison of the mean differences in direct health care, direct non-health care, total direct, indirect and total costs between the intervention groups. Confidence intervals will be obtained by bias corrected and accelerated (Bca) bootstrapping using 2000 replications . Cost-efThe intensive group training protocol includes interventions, such as exercise therapy, behavioural treatment and back school, that have recently been proven to be effective in patients with low back pain. The graded activity intervention is considered the be a form of behavioural treatment and earlier studies have proven the effectiveness of this intervention for workers who are sick-listed due to low back pain ,37. The In the Netherlands, the national physiotherapy guidelines for low back pain consist of general recommendations regarding diagnostic and therapeutic management of low back pain while the intensive group training protocol prescribes the frequency, intensity and duration of the exercise therapy, the content of informative group lessons and graded activity in detail. The intensive group training protocol is expected to be more effective, because it is a detailed protocol and because it combines principles of exercise therapy back school and behavioural therapy, which have recently been proven to be effective for this patient population in systematic Cochrane reviews -40.Although the general practitioner, and if applicable the occupational physician, will be informed about the treatment and progress of the patient, the intervention is mono-disciplinary. A multidisciplinary intervention in a primary care setting has major practical implications and would increase the costs of the intervention considerably. The intensive group training protocol itself probably generates higher costs than physiotherapy guideline care but we expect reduction in health care utilization and productivity losses in the long term, compensating for the increase in treatment cost. This trial will provide physiotherapists with more knowledge and experience in behavioural treatment for low back pain patients and may increase the efficiency of physiotherapeutic care for this complex and expensive patient group. If the intensive group training protocol appears to be more cost-effective than physiotherapy guideline care, a future update of the national physiotherapy guideline will include more specific recommendations in line with this protocol. In that case the protocol will be implemented throughout the Netherlands.KNGF = Royal Dutch College for PhysiotherapyBca bootstrapping = bias corrected and accelerated bootstrappingThe author(s) declare that they have no competing interests.NvdR is responsible for the data collection and drafted the manuscript. MWvT, JMB, WvM and HCWdV were involved in developing the original idea for funding and were co-applicants on the successful funding proposal. WKF and ACO both will contribute to data collection and processing. All authors participated in development of research protocols and in the design of the study. All authors read and corrected draft versions of the manuscript.The pre-publication history for this paper can be accessed here:


To plant or not to plant. A discussion of the environmental benefits and risks of genetically modified crops Corn is one of humankind's earliest innovations. It was domesticated 10,000 years ago when humans learned to cross-pollinate plants and slowly turned a scraggly nondescript grass called teosinte into plump, productive modern corn . As needPlant breeding was once restricted to sexually compatible plants, and generations of offspring were selectively bred to create unique varieties. In fact, corn, along with rice and wheat—today's global crop staples—would not exist without such techniques. With the goal of ever-widening the pool of genetic diversity, conventional plant breeding has gotten more technologically savvy in recent years. For example, realizing that natural mutants often introduce valuable traits, scientists turned to chemicals and irradiation to speed the creation of mutants. From test-tube plants derived from sexually incompatible crosses to the use of molecular genetic markers to identify interesting hereditary traits, the divide between engineering and genetics was narrowing long before kingdom boundaries were crossed.Bacillus thuringiensis (Bt) genes that produce a protein lethal to some crop pests—they triggered an uproar over ethical, scientific, and environmental concerns that continues today.  protein toxins that destroy the gut of invading pests, such as larval caterpillars. So far, over 50 cry genes have been identified and found to affect insect orders differently.Considered safe to humans, mammals, and most insects, Bt has been a popular pesticidal spray since the 1960s because it had little chance of unintended effects. Engineering the gene into corn, however, caused an unexpected public backlash. “We thought it was going to be the greatest thing since sliced bread,” says Guy Cardineau, agricultural biotechnologist at Arizona State University. “Here's a way to withstand insect pressure, eliminate the use of pesticides, and Bt spray was widely used in organic agriculture,” he adds. The Bt wrangle illustrates how differently a product and a process can be regarded.After the expensive development process, today's concern is that broad-scale planting of Bt corn will render the toxin ineffective over time. Pests can gradually build resistance to any pesticide, and so the United States Environmental Protection Agency (EPA) requires that 20% of Bt field areas be planted to non-Bt corn to avoid such pressures. But humans have to follow the rules. A recent report from the Center for Science in the Public Interest shows that almost 20% of farmers in the United States Corn Belt are violating EPA standards by overplanting Bt corn, causing some to question the regulations and enforcement that will be necessary for certain GM crops.Despite such discord, genetically modified (GM) crops have the fastest adoption rate of any new technology in global agriculture simply because farmers benefit directly from higher yields and lowered production costs. See . To dateSince 1987, over 9,000 United States Animal and Plant Health Inspection Service (APHIS) permits have been issued to field-test GM crops. According to APHIS, corn is the most tested plant. The International Service for the Acquisition of Agri-Biotech Applications confirms that biotech corn is the second-most common GM crop (after soybean), with 12.4 million hectares planted in 2002. GM corn starch and soybean lecithin are just two of the ingredients already found in 70% of the processed food supply.With future incarnations on the horizon, GM corn remains a lightening rod for debate. Embroiled in numerous controversies, corn has become biotech's boon and bane.As Danforth Center President Roger Beachy, the first to develop a virus-resistant tomato, describes it, the first-generation GM crops were intended to help farmers reduce not only the impact of pests, but also the use of agrochemicals in modern crop production–a legacy of the Green Revolution. After a decade of cultivation, environmental benefits are emerging.Bt corn reduces the need for pesticides, and while the primary benefit comes largely during a heavy corn-borer infestation, an unpredictable event, a secondary effect is that beneficial insects fare much better under these conditions. The numbers are particularly impressive for Bt cotton: the spraying of almost 2 million pounds of pesticides—roughly 50% of previous usage—has been spared since the large-scale adoption of Bt cotton.According to Leonard Gianessi, senior research associate at the National Center for Food and Agricultural Policy, farmers who adopt GM crops make more money in tougher times. Indeed, insect- and virus-resistance traits have already saved several industries. Bt cotton is credited with reviving the Alabama cotton industry, hard hit by uncontrollable bollworm infestations. Likewise, genetically engineered papaya, made resistant to the papaya ringspot virus, salvaged Hawaii's fifth largest crop industry.Herbicide-resistant crops engendered a different reception. While GM critics acknowledge that the use of a more benign herbicide, called by its trade name Roundup, can have environmental benefits, the creation of a market monopoly is a key criticism. However, the increased planting of herbicide-resistant soybeans is an integral, but not sole, factor in the increased adoption of no-till farming— a strategy that reduces soil erosion.Surprise benefits have also occurred. According to the recent International Council for Science (ICSU) review of GM crops, disease-resistant corn crops may have lower levels of mycotoxins, potentially carcinogenic compounds to humans. They result from fungal activity in insect-infested corn crops. With fewer insect holes in plant tissue, associated fungi are not able to invade and produce toxins.While there is a growing amount of data documenting the intended environmental benefits of GM crops, the potential risks are more elusive.After seven years of GM crop production and no apparent health effects, potential environmental risks—particularly gene flow into other species—have eclipsed food safety as a primary concern. As pollen and seeds move in the environment, they can transmit genetic traits to nearby crops or wild relatives. Many self-pollinating crops, such as wheat, barley, and potatoes, have a low frequency of gene flow, but the more promiscuous, such as sugar beets and corn, merit greater concern.Determining where genes flow is a thriving research avenue, but the real question becomes “so what?” The risks associated with gene flow—such as creating weeds from introduced traits, reducing biodiversity, or harming nontarget species—are similar to those from conventionally bred crops. “I wouldn't dismiss the ecological concerns out of hand, but I think they can be exaggerated,” says Gabrielle Persley, the ICSU report author.There are few instances of crop plants becoming weeds. Bred so intensely for hundreds of years, most crops cannot survive without human intervention. Increased weediness could be conveyed, however, if the plants are more fit or able to out-compete other crop species by producing more seed, by dispersing pollen or seed further, or by growing more vigorously in a specific environment. In fact, transgenic sunflowers can produce over 50% more seed than traditional varieties. Additionally, recent work shows that, compared to pollen, seeds are more likely to spread GM sugar beet genes into wild relatives in western Europe. Norman Ellstrand, plant geneticist at the University of California at Riverside, has shown that gene flow from many conventionally bred crops increases the weediness of nearby wild relatives.For many domesticated crops, wild varieties do not exist in current areas of cultivation. Nevertheless, regions where crop species originated are particularly vulnerable to transgenic gene flow into local varieties, or landraces. Some fear that transgenic varieties with a competitive advantage might gradually displace valuable genetic diversity. For these reasons, transgenic corn is prohibited in Mexico, home to over 100 unique varieties.Despite the ban, transgenes have been found in Mexican corn. “We have in several instances confirmed that there are transgenes in landraces of maize in Oaxaca,” says Ariel Alvarez-Morales, plant geneticist at the Mexican Center for Research and Advanced Studies (CINVESTAV) in Irapuato. The ramifications of this will not be known for some time, but Luis Herrera-Estrella, CINVESTAV's Director of Plant Biotechnology, is convinced that these single gene traits will be of little consequence to native Mexican varieties. “If Bt genes give an advantage to the farmer, they will keep growing it. In that case it will not be bad,” he says of dynamically changing landraces. “Gene flow has been occurring for 50 years from commercial lines to landraces.” While admitting this, Ellstrand points out that “if there are genes that you don't want to get into landraces—this shows how easily they can get there.” See .“The gene flow risk that keeps me awake at night is the possibility of hybridization between crops engineered to manufacture poisons and related crops intended for human consumption,” says plant geneticist Norman Ellstrand. Indeed, this application of GM crops seeks to turn corn into cost-effective pharmaceutical factories and may bear the mark of unacceptable risk. It is currently the subject of intense debate. An open-pollinated crop, corn is known for its promiscuity—making it more prone to gene flow risks than other crops. Genetic contamination takes on a whole new meaning when the escapable trait could produce proteins to treat diabetes or a hepatitis B vaccine.Given that pharma corn demands multiple safety measures—including production in remote areas, separate farm equipment, delayed planting to offset pollination—many ask, “Why use corn?” “We know so much about corn genetics,” explains agricultural biotechnologist Guy Cardineau, “and it naturally lends itself to production with kernel packets of protein that can be stored indefinitely.” A number of scientists and United States food makers are not yet convinced that the benefits outweigh the risks and have joined environmental groups in questioning the use of pharma corn.Over 130 acres of pharma crop field-tests were planted in 2002. Several products have moved on to clinical trials. Aware of concerns, the members of the influential Biotechnology Industry Organization decided last December to overturn its initial decision to remove pharma crops from the United States Corn Belt states and voluntarily police their use. A Colorado trial of corn producing a protein to treat cystic fibrosis recently began.Nature suggested monarch butterfly populations might be adversely affected by Bt transgenes. Corrected by subsequent publications, the field experiments did not support original laboratory results. But effects on other nontarget organisms, such as soil microbes, remain a concern. When microbial genetics research uncovered how genes could be transferred between species in ways other than reproduction, so-called horizontal gene transfer, it not only explained why microorganisms were so diverse, but that microbes could potentially be endowed with GM plant DNA found in the soil. “Although a theoretical possibility, there is no evidence that it happens at any degree of frequency to be meaningful,” says Persley.Indeed, unintended impacts are a primary concern. The potential risk to nontarget organisms took center stage when a 1999 paper in Opinions differ on this, however, and seem to follow the United States–European Union divide over the use of GM crops. Kaare Nielsen, microbial geneticist at Norway's University of Tromsø, is one of the few scientists to find examples of horizontal gene transfer. “There are actually very few studies and most of the ones conducted have been on first-generation plants,” Nielsen explains. Given that plant DNA can last in soil for over two years, Nielsen does not believe the possibility can be dismissed and argues that long-term studies are necessary. Work continues in this area in Europe.The lack of baseline ecological data—even agreeing on what an appropriate baseline is—presents a substantial knowledge gap to environmental impact assessments. Scientists, including Nielsen, wonder whether there could be unexpected risk factors. Allison Snow, weed expert at Ohio State University, agrees with what many feel is the most important risk—the inability to anticipate all the effects. “Do we know all of the right questions we should be asking?” she wonders, adding, “Genes are complicated and can interact.” For these reasons, identifying factors that regulate weed and pest populations and determining how microbial community changes affect larger ecosystems are important areas of research.To two academicians that kindled the biotech revolution, the real GM risks lie in how science is misinterpreted and misused. In fact, much of the currently conducted basic research is not likely to be applied in the near future. Public concerns coupled with corporate consolidation created huge roadblocks, especially in getting the technology to developing nations. While Beachy blames the skyrocketing regulatory costs that “are due to regulators who have not put into context this technology and its relative safety,” Richard Jefferson, chairman and chief executive officer of the Center for the Application of Molecular Biology to International Agriculture in Australia, fears that innovation has been stifled by corporate short-sightedness. “The biggest risk is that [biotechnology] maintains itself as a monolithic, expensive industry with untenable entry barriers for smaller enterprises,” he says.Indeed, when does the risk of not using available technology factor into the debate? See . Many scCurrent regulatory constraints have a choke-hold on innovations for genetic modifications that seek to improve subsistence crops, such as rice. Golden rice, yellowed in appearance because it is infused with the vitamin A precursor beta-carotene, could save thousands of malnourished people each year from blindness and the other vitamin A–deficiency diseases prevalent in Southeast Asia.Intellectual property issues and opposition from anti-GM activists have confounded the development for years. Faced with patent issues and regulatory hurdles and costs, developer and academic researcher Ingo Potrykus formed an alliance with Syngenta (then AstraZeneca Corporation) to allow the free licensing of the patents to public research institutions for humanitarian use. In addition, farmers making less than US$10,000 will receive free golden rice seed.After over a decade of work, golden rice is still not on the market. The retired Potrykus is determined to bring this technology to farmers once it passes regulatory field testing—an additional four-year delay that he feels is scientifically unnecessary. “Nobody can construct even a hypothetical risk to the environment from golden rice,” he says, adding that nutritional risks are nonexistent as well. He acknowledges, however, that field tests will be beneficial for acceptance of this and future bio-fortified products. “I have experienced so much support in these countries, I don't think it [the anti-GM lobby] will be able to stop this project once it passes regulation,” he says.“Food security is not going to come from crops being marketed outside Africa, like wheat or rice,” says John Kilama, Uganda native and president of the Global Bioscience Development Institute. He points out that of traditional staple crops such as cow peas and millet, only cassava has merited some publicly-funded research. Beachy estimates that it takes between US$5 million and US$10 million to bring a GM crop to market. Given regulatory costs, neither industry nor universities can afford to develop products that do not have mass appeal. “If the crop is not worth that much to the seed market, it's likely that we'll never see the varieties because of the cost of regulation,” he says.To ensure a return on research investments, with the regulatory costs often the biggest ticket item, developing blockbuster traits is a priority. “Given the diversity of environments and cropping systems, there are not many more blockbusters such as Roundup resistance in the wings,” says Jefferson. The alternative, he adds, is to make it cheaper to innovate local varieties in ways that are likely to gain public acceptance. See .One way to minimize the problems associated with gene flow is to introduce sterility, such that pollen cannot transmit information. Richard Jefferson has high hopes for an accessible, cheap way for farmers to produce genetically superior seeds, called apomixis.But similar concepts have been floated before. The controversial terminator technology prevented gene flow, but it also outraged activists because it kept farmers from reusing seed.Unlike terminator, apomixis is “germinator” technology—avoiding fertilization altogether by producing seeds without pollination. In effect, seeds can be natural clones of the mother, instead of a genetic exchange between mother and father. Therefore, hybrid quality can be maintained as farmers use seed year after year.Although apomixis occurs naturally in about 400 plant species, Jefferson believes that it can be successfully developed as a useful trait in other crop plants. To ensure its widespread availability, Jefferson and collaborators pledged not to create restrictive patent rights that could block the development of apomixis.“The Green Revolution largely bypassed Africa,” says Josette Lewis, biotechnology advisor for the United States Agency for International Development. Given monetary constraints that prevent access to many biotechnologies, many scientists worry that the Gene Revolution might as well. Looming trade issues coupled with food insecurity shape the debate in Africa. Caught between the United States and European Union trade disputes, sub-Saharan countries are eager to use any technology that will enhance production without jeopardizing trade.Increasingly, industry is responding to the developing nations' needs. Both newly formed, the industry-focused African Agricultural Technology Foundation and the Public-Sector Intellectual Property Resource for Agriculture are attempting to ease cost restrictions and encourage access to current and future patents. By entering into such agreements, industries will be able to protect patent rights and commercially important markets. Such partnerships are already working. The Syngenta Foundation for Sustainable Agriculture is working together with the International Maize and Wheat Improvement Center (CIMMYT) and the Kenyan Agricultural Research Institute to overcome corn stemborer infestations in Kenya . “CIMMYT“Agricultural biotechnology is here to stay” read a recent opinion piece by Gianessi. No doubt he is correct. As genetic engineering continues to evolve, transgenic methods will become just one of many tools. In fact, some researchers are currently focusing their work on manipulating an organism's own genetic code to achieve desired traits.Scientific inquiry will continue to weigh the risks and benefits of such technologies, realizing that there may never be enough evidence to ensure zero risk. Only with data will tolerable levels of environmental risks be determined—case by case.Indeed, the level of risks and benefits may differ for developing nations, where decisions must be made in the face of food security concerns. To many scientists, the risks associated with forgoing genetic engineering far surpass any environmental risk associated with its use and further development. However, all stakeholders must have access to the tools in order to realize future benefits.In the quest to feed the world, a few things are clear. Public outcries will continue to vet the need and use of genetic engineering. Private organizations will necessarily focus on research for profit, while exploring collaborative prospects. Public initiatives, however, will provide the critical bridge between science and global food security.Although genetic engineering cannot be summarily accepted or rejected, any lack of scientific risk now doesn't negate future concerns. And, no matter what direction future research takes, corn will continue to be a bellwether crop.


Little information is available on methods of treatment practiced by patients affected by filarial lymphoedema in Sri Lanka. The frequency and duration of acute dematolymphangioadenitis (ADLA) attacks in these patients remain unclear. This study reports the knowledge, practices and perceptions regarding lymphoedema management and the burden of ADLA attacks among patients with lymphoedema.A semi-structured questionnaire was used to assess morbidity alleviation knowledge, practices and perceptions. The burden of ADLA attacks was assessed using one-year recall data.66 patients  with mean age 51.18 years (SD ± 13.9) were studied. Approximately two thirds of the patients were aware of the importance of skin and nail hygiene, limb elevation and use of footwear. Washing was practiced on a daily and twice daily basis by 40.9% and 48.5% respectively. However, limb elevation, exercise and use of footwear were practiced only by 21–42.4% (while seated and lying down), 6% and 34.8% respectively. The majority of patients considered regular intake of diethylcarbamazine citrate (DEC) important. Approximately two thirds (65.2%) had received health education from filariasis clinics. Among patients who sought private care (n = 48) the average cost of treatment for an ADLA attack was Rs. 737.91. Only 18.2% had feelings of isolation and reported community reactions ranging from sympathy to fear and ridicule.Filariasis morbidity control clinics play an essential role in the dissemination of morbidity control knowledge. Referral of lymphoedema patients to morbidity control clinics is recommended. Lymphatic filariasis, identified as one of the leading causes of permanent disability worldwide, has been targeted for global elimination ,2. Inter2 area of the Gampaha district. A structured questionnaire was formulated to gather information on knowledge of lymphoedema management and limb care activities practiced along with frequency, treatment seeking behavior, cost and the degree of disability incurred in relation to ADLA attacks. A medical officer interviewed all patients regarding their disease history, examined and staged the limb affected by lymphoedema using World Health Organization criteria [The study was carried out in the Gampaha district in the Western province of Sri Lanka in November 2003. Ethical clearance for the study was obtained from the Ethics Committee, Faculty of Medicine, University of Kelaniya. Patients with lymphoedema attending morbidity control clinics conducted by the National Antifilariasis Campaign (AFC) were selected as the study population. These clinics are distributed in the operational areas of the AFC (Western, Northwestern and Southern provinces of Sri Lanka) and offer treatment exclusively to microfilaraemics and patients with chronic filariasis. Two weekly filariasis clinics 3.5 km apart) serve a population of 2,066,096 in a 1,387 km km apartPatient perceptions of disease reversibility and community attitudes towards their altered physical appearance were also explored. At the end of the interview all patients were educated on lymphoedema management practices recommended by the World Health Organization .A total of 66 patients [male:female ratio 22 (43.3%): 44 (66.7%)] with a mean age of 51.18 years (SD ± 13.9) were enrolled in the study. A substantial proportion of this study sample (24.3%) had received only primary school level education.Most subjects had lymphoedema of a single lower limb [n = 56, 84.8%]. Both lower limbs were affected in 6 (9%), a single upper limb in 3 (4.4%) and a single upper limb and a breast in one subject. The oedema was completely reversible (stage 1) in 21 (31.8%) subjects; 30 (45.5%) were in stage 2. Subjects with non-reversible lymphoedema had associated shallow skin folds 11 (16.7%) (stage 3), one (1.5%) had skin knobs (stage 4) and three (4.5%) had deep skin folds (stage 5). The common entry lesions were sole fissures (n = 14), minor injuries (n = 5) and eczema (n = 2).Knowledge and attitudes regarding lymphoedema management are summarized in Figure Most of the study subjects washed the affected body part with soap and water either daily (n = 29, 40.9%) or twice daily (n = 32, 48.5%). A significant proportion of the study sample (n = 19, 29%) also used coir (coconut fibre) to rub the skin while washing. Half and one third of the study population practiced limb elevation on a regular basis while lying and sitting down respectively. Exercising the affected limb was practiced on a regular basis only by a minority (n = 4, 6%) of the patients. Footwear was used on a regular basis by 34.8% of the subjects, while 48.5% used them only outdoors. 7.6% of the sample did not use footwear at all.Almost all the subjects took DEC daily (n = 59, 89.4%) or periodically (n = 7, 10.6%). Only 14.3% required assistance to clean the affected body part and it was usually a family member who assisted them. The need for assistance was associated with advanced age and/or stage of lymphoedema and ADLA attacks. Assistance was required not only for cleaning the affected part (fetching water, washing) but also for surveying for entry lesions owing to failing sight in the elderly.Thirty-one (46.97%) subjects had one or more ADLA attacks during the preceding year. Although around 50% of those who reported acute attacks suffered only one, some had experienced as many as 12 attacks during the past year (Table Out patient departments (OPD) of Government hospitals (44.9%), private practitioners (30.6%) and filariasis clinics (14.3%) were the preferred sources of treatment for acute attacks. The treatment cost of an acute attack ranged from Rs.100 to 3500 (1 US$ = 100 SLR) with an average cost of Rs. 737.91 per attack for those who sought private care (n = 48). The average duration of an acute attack was 3.5 days. Fifty two percent of those who had experienced an acute attack in the past (n = 48) were totally incapacitated (unable to attend to any domestic / economic activity) while 31.3% were moderately incapacitated (able to attend to some domestic / economic activity) for the duration of the acute attack.Almost all subjects (n = 60, 92.3%) believed that their lymphoedema was reversible and treatment with antiparasitic drugs was identified as the most important therapeutic option for reversing/ halting the progression of the disease.Only 18.2% of the study sample felt that they were being shunned by the society and that their altered physical appearance elicited various reactions ranging from sympathy to fear and ridicule from the community.During the period of this study an attempt was also made to collect comparable data from non-clinic attendees. However, it was possible to identify only 10 subjects, all seeking treatment in the OPD of the University Teaching Hospital. These 10 patients were in lymphoedema stages I (n = 2), II (n = 2) and III (n = 6) respectively. According to the data elicited by using the same questionnaire, 8 of these 10 non-clinic attendees (80%) were unaware of the currently recommended disability management measures. Further analysis was not carried out since the sample size was not comparable with that of clinic attendees.The results of this survey indicate that the majority of patients attending filariasis clinics are aware of the importance of the currently recommended morbidity control measures. It was also encouraging to note that many practiced at least some of the morbidity control measures that they had learnt, especially washing the affected part with soap and clean water once or twice a day. Although many were aware of the importance of minimizing skin trauma, a sizeable proportion used coir to clean the skin of the affected part during washing. This is a harmful practice which could traumatize the skin and lead to entry lesions; therefore demonstration of suitable alternatives is clearly necessary. A community educational programme may be especially beneficial as it would also involve the family members of the affected population who are often the caregivers of patients affected with severe grades of lymphoedema. Involving the family in the care of the patient will also help to reduce the feelings of stigma, isolation and neglect experienced by some of the patients.Limb elevation was identified as an important measure by most patients but not practiced on a regular basis by many. Poor compliance with limb elevation has also been reported in Southern India . The autMovement and elevation has been shown to play an important role on the lymphatic and venous systems of the body -9. HowevThe practice of prescribing DEC on a regular basis to patients affected with chronic disease needs to be discouraged as there is no conclusive evidence regarding any beneficial effects of long term use of DEC in the management of lymphoedema ,11. MiscAlthough the data regarding acute attacks may not be highly accurate as it was based on one-year recall, there is reason to believe that recall data reliably reflect the burden imposed by ADLA attacks on the affected population ,13.Where patients had sought private care for ADLA attacks, average total expenditure on treatment was about Rs. 737.91 per attack – it is not surprising, therefore, that more than 50% of the population (59.1%) sought treatment from Government health facilities which provide free health care. Income lost by patients during an ADLA attack due to physical incapacitation was not determined in this study.The findings of this study may not be generalized to all patients with lymphoedema in the Gampaha district as the subjects surveyed were patients already enrolled in morbidity control clinics. Limited information gathered from non-clinic attendees indicated that the level of knowledge among clinic attendees might be far superior to that of non-clinic attendees.Lymphatic filariasis continues to be a major public health burden. Globally an estimated 15 million suffer disfiguring symptoms of lymphoedema and elephantiasis . AlthougReferral of lymphoedema patients to morbidity control clinics is recommended as they appear to play an important role in the dissemination of morbidity control knowledge. The services of these clinics needs to be further improved to ensure that all clinic attendees receive proper education on disability management. Training and education of specialists in the management of lymphoedema may be a useful investment for eliminating the handicap caused by chronic lymphatic filariasis.ADLA: Acute dematolymphangioadenitisMDA: Mass drug administration programmeAFC: Anti Filariasis CampaignDEC: Diethylcarbamazine citrateSD: Standard deviationOPD: Out patients DepartmentSLR: Sri Lanka rupeeUS$: U.S. dollarNone declaredTC designed the questionnaire, conducted the survey and drafted the manuscript. RP Participated in data collection and interpretation. NS provided overall supervision of the study and preparation of the manuscript. All authors read and approved the final manuscript.


Impaired glucose tolerance is a risk factor for atherosclerosis in hemodialysis patients and renal transplant recipients.To check the relationship of impaired glucose tolerance with the other atherosclerotic risk factors, fasting blood sugar and the standard two hour glucose tolerance test, serum tryglyceride, serum cholesterol, cyclosporine through level  and hemoglobin A1C were measured in 55 stable renal transplant recipients, 55 hemodialysis patients and 55 healthy controls with similar demographic characteristics. Patients with diabetes mellitus and propranolol consumers were excluded. The mean age and female to male ratio were 39 +/- 7 years and 23/22, respectively.Four of the renal transplant recipients and twelve of the hemodialysis patients had impaired glucose tolerance. Significant linear correlation was observed with body mass index and IGT only in hemodialysis patients (r = 0.4, p = 0.05). Glucose tolerance also had a significant correlation with triglyceride levels . The glucose tolerance had significant relationship with higher serum cholesterol levels only in the renal transplant recipients . In the renal transplant recipients, a linear correlation was observed with glucose tolerance and both the serum cyclosporine level (r = 0.9, p = 0.001) and the hemoglobin A1C concentration (6.2 +/- 0.9 g/dl). The later correlation was also observed in the hemodialysis patients .We conclude that although fasting blood sugar is normal in non-diabetic renal transplant and hemodialysis patients, impaired glucose tolerance could be associated with the other atherosclerotic risk factors. Althougorbidity . Althougorbidity  and renaorbidity  with dia2) were similar in the three groups , under conventional triple therapy composed of cyclosporine A (CsA), azathiopurine and prednisolone. Their allograft sources were living donors. Fifty five stable HD patients and another fifty five healthy controls (C), were also enrolled in this study. The mean age (39 ± 7 years), sex (F/M ratio was 33/22), body mass index (BMI) 24.7 ± 1.28 kg/mThe levels of serum triglyceride, cholesterol (measured by enzymatic spectrophotometry), CsA  patients. It is due to multiple factors, which the two most important of them being insulin resistance at target organs and impaired insulin secretion from the pancreas . InsulinHypertriglyceridemia is common complication in dialysis patients. In non-transplant populations it is regarded  as a prominent feature of insulin resistance syndrome, and also is a cardiovascular risk factor in organ transplant recipients . Our stuThere was increased HgA1C and impaired glucose tolerance in HD and RT patients. This was accompanied by hyperlipidemia in HD patients (with hypertriglyceridemia) and RT recipients (with hypercholesterolemia). The impact upon the progression of atherosclerosis needs more study in haemodialysis and renal transplant populations at a long term follow up.None declared.HA reviewed the literatures and wrote the manuscript and also helped to do statistical analysis, AN performed GTT and the other biochemical markers, MN participated as coordinator between laboratory and clinic, HTK selected the patients and collected dataThe pre-publication history for this paper can be accessed here:


Intervention studies have shown that lycopene-containing foods may reduce cholesterol levels and lipid peroxidation, factors implicated in the initiation of cardiovascular disease. The objective of this study was to determine whether consumption of lycopene rich foods conferred cardiovascular protection to middle-aged adults as indicated by plasma lipid concentrations and measures of Ten healthy men and women consumed a low lycopene diet with no added lycopene (control treatment) or supplemented with watermelon or tomato juice each containing 20 mg lycopene. Subjects consumed each treatment for three weeks in a crossover design. Plasma, collected weekly was analyzed for total cholesterol, high density lipoprotein cholesterol (HDL-C) and triglyceride concentrations and for the antioxidant biomarkers of malondialdehyde formation products (MDA), plasma glutathione peroxidase (GPX) and ferric reducing ability of plasma (FRAP). Data were analyzed using Proc Mixed Procedure and associations between antioxidant and lipid measures were identified by Pearson's product moment correlation analysis.Compared to the control diet, the lycopene-containing foods did not affect plasma lipid concentrations or antioxidant biomarkers. Women had higher total cholesterol, HDL-C and triglyceride concentrations than did the men. Total cholesterol was positively correlated to MDA and FRAP while HDL-C was positively correlated to MDA and GPX. GPX was negatively correlated to triglyceride concentration.The inclusion of watermelon or tomato juice containing 20 mg lycopene did not affect plasma lipid concentrations or antioxidant status of healthy subjects. However, plasma cholesterol levels impacted the results of MDA and FRAP antioxidant tests. Howevoperties -10.Recent epidemiological studies have linked reductions in risks of cardiovascular disease with diets rich in lycopene containing foods. These reductions in risk have been primarily attributed to the antioxidant properties of lycopene ,12. Imprvivo as antioxidants or alter cholesterol levels.Other studies have assessed response of plasma lipids to lycopene-rich diets. In one study, six healthy men were supplemented with 60 mg/day for three months with tomato lycopene (LycoRed) with a 14% reduction in LDL-C and no change in HDL-C . Researcvivo biomarkers.The objectives of this study were to compare the ability of two lycopene containing foods, tomato and watermelon to provide cardiovascular protection to middle-aged adults by measuring changes in cholesterol levels and antioxidant ex Samples for this study came from a larger study, which has been reported in detail . This sttrans lycopene and 6% cis isomers, primarily 5-cis and 13-cis with minimal amounts of other cis isomers [trans lycopene and 10.8% cis isomers, primarily identified as 5-cis, 9-cis, 13-cis, and 15-cis, and minimal amounts of other cis isomers [Watermelon juice for the study was prepared at a pilot plant at the USDA Citrus and Subtropical Products Laboratory, Winter Haven, FL without heat treatment as previously described . Canned  isomers . For tom isomers .Plasma samples were thawed on ice for four hours then mixed by vortexing, prior to preparing for assays. Serum total cholesterol and triglyceride concentrations were determined enzymatically using kits from Roche Diagnostics (Sommerville, NJ). Serum HDL-cholesterol was determined by a direct method  that utilizes the combined action of polymers, polyanions, and detergent to solubilize cholesterol from HDL but not from VLDL, LDL, and chylomicrons as previously described . AnalysiPlasma from subjects was analyzed for plasma glutathione peroxidase using an ELISA kit (OXIS Internatl., Portland, OR). Two replicates per sample of 20 μl of plasma were diluted 1:25 with TRIS-HCl buffer then pippetted into pre-coated polyclonal antibodies microplate wells specific for human plasma glutathione peroxidase (GPX). The amount of enzyme present was determined by reaction with para-nitrophenyl-phosphate and was read using a microplate reader at 405 nm (Elx 808 Ultra Microplate Reader, Bio-Tek Instruments Inc., Winooski, VT). The concentration of plasma GPX was determined from a standard curve for each plate using five dilutions of GPX standard.Malondialdehyde compounds were determined colorimetrically using a commercial kit specific for measuring free and total malondialdehyde compounds (OXIS Internatl., Portland, OR). Two replicates per sample of 210 μl of plasma were added to each test tube with 11 μl of 500 mM butylated hydroxytoluene and 5.3 μl of concentrated hydrochloric acid. Tubes were capped, mixed then incubated at 60°C for 80 minutes, cooled to room temperature and 680 μl of N-methyl-2-phenylindole in acetonitrile was added. Then tubes were mixed, and centrifuged at 13,000 g for 5 minutes. New tubes were prepared and 660 μl of clear supernatant was added with 115 μl of concentrated HCl. Tubes were capped, mixed and incubated at 45°C for 60 minutes. Samples were centrifuged at 13,000 g for 5 min and the supernatant was read on a spectrophometer at 575 nm. Concentration of samples was determined using a five point standard curve.This assay was conducted according to previously published methods . In brieExperimental procedures for the clinical trial were approved by the Institutional Review Board at the Johns Hopkins University Bloomberg School of Hygiene and Public Health; subjects gave their written informed consent to participate. The plasma cholesterol and antioxidant studies were approved by the Institutional Review Board at Oklahoma State University, Stillwater, OK. Data were analyzed using Proc Mixed Procedure and mean separation was performed using LSMEANS, correlation analysis was performed using Spearman's Correlation Coefficient Analysis .Because there were significant four way interactions with gender × intervention period × treatment × weeks with MDA, FRAP, GPX and cholesterol analysis, trends by treatment, intervention period or week of treatment were not seen. Supplementing the diet with 20 mg/day of lycopene of either food did not change the plasma antioxidant status of the subjects and values ranged from 0.66–2.20, 540–1094, and 1296–2596 :mol/L for MDA, FRAP and GPX respectively. These levels are similar to levels reported for healthy subjects in other studie ,23.Intervention with 20 mg of lycopene to the diet of subjects did not alter their total cholesterol, HDL-C or triglyceride  status. However, there were gender differences and the women had higher average levels of plasma triglycerides, total cholesterol and HDL-C than men Figure . The higThere was a significant positive correlation between each pair of total cholesterol and MDA and MDA and FRAP and between HDL-C and MDA and HDL-C and GPX. A significant negative correlation was found between triglycerides and GPX Table .Because of the correlation between cholesterol concentrations and antioxidant analysis, a preliminary analysis of data was conducted to determine if cholesterol levels impacted antioxidant results. Subjects were separated into two groups based upon baseline concentrations of plasma triglycerides, total cholesterol and LDL-C above or below 200, 180 and 160, respectively. Five subjects, two men and three women, fit the criteria of moderately hypercholesterolemic Table .Analyses showed an interaction of cholesterol level × treatment period × treatment factor for MDA and FRAP analysis. Higher MDA and FRAP levels were found in the group having higher cholesterol levels compared to the other group Table . No trenWe found no improvement in the antioxidant status of healthy middle-aged adults supplemented with two lycopene-containing foods. In previous antioxidant studies, reduced lipid peroxidation was reported in subjects supplemented from one to four weeks with 5 to 45 mg lycopene containing tomato products ,16,23,26in vitro in the FRAP assay [The reports from lycopene intervention studies that measured FRAP activity are not in agreement. One study reported improvement in FRAP levels of plasma in subjects supplemented with tomato juice and olive oil , while tAP assay ,29. In tUnlike a previous report by Fuhrman et al., neither lycopene intervention with watermelon nor tomato affected cholesterol levels . DiffereFruits and vegetables are excellent sources of antioxidant compounds and the average American consumes only 1.5 and 3.1 servings per day . In manyThe positive correlation between total cholesterol and MDA antioxidant analysis has been reported in studies with hypercholesterolemic subjects compared to normocholesterolemic subjects ,36. The The trend correlating higher FRAP with higher cholesterol levels has not been previously reported. The significance of this trend is speculative, since the FRAP assay measures the oxidation and reduction potential of compounds based on the reduction of the ferric to ferrous iron , lipid pin vitro [Long-term supplementation studies where diet is controlled will probably be necessary to identify the benefits provided by lycopene. There may be real health benefits associated with lycopene especially since it is stored in various tissues and exhibits strong antioxidant activity in vitro ,10,39,40in vitro ,12,41,42in vitro ,44. The ex vivo antioxidant studies may be due to the cholesterol levels of subjects thus warranting further research.The interaction between cholesterol levels and antioxidant values needs more research. Contradictory findings of this study with other None declared.Mention of trade names or commercial products in this article is solely for the purpose of providing specific information and does not imply recommendation or endorsement by the U.S. Department of Agriculture. All programs and services of the U.S. Department of Agriculture are offered on a nondiscriminatory basis without regard to race, color, national origin, religion, sex, age, marital status, or handicap. The article cited was prepared by a USDA employee as part of his/her official duties. Copyright protection under U.S. copyright law is not available for such works. Accordingly, there is no copyright to transfer. The fact that the private publication in which the article appears is itself copyrighted does not affect the material of the U.S. Government, which can be freely reproduced by the public.JKC: conception and design of the study, drafted the manuscript, BHA: design of study, editing, PLC:design of the study, statistical analysis, PPV: conception of study, editing, RAB: editing, technical assistance, BAC:conception of study, editing. All authors read and approved the final manuscript.