Smoking Cessation and Cardiac Rehabilitation: A Priority!

Cardiac rehabilitation programmes afford the opportunity to enhance cardiovascular health and reduce the risk of subsequent cardiac events. They permit the management of cardiac risk factors while addressing significant psychosocial and vocational issues. Tobacco addiction is the most important of the modifiable cardiac risk factors, and smoking cessation is the most important secondary prevention strategy. Cessation is more likely when cessation pharmacotherapy is accompanied by supportive advice and strategic assistance. A systematic approach to the delivery of cessation services, such as the Ottawa Model of Smoking Cessation, greatly enhances the likelihood of success. Cardiac rehabilitation programmes are ideal venues for the delivery of such programmes.

Hypertension Canada's 2017 Guidelines for Diagnosis, Risk Assessment, Prevention, and Treatment of Hypertension in Adults.

Hypertension Canada provides annually updated, evidence-based guidelines for the diagnosis, assessment, prevention, and treatment of hypertension. This year, we introduce 10 new guidelines. Three previous guidelines have been revised and 5 have been removed. Previous age and frailty distinctions have been removed as considerations for when to initiate antihypertensive therapy. In the presence of macrovascular target organ damage, or in those with independent cardiovascular risk factors, antihypertensive therapy should be considered for all individuals with elevated average systolic nonautomated office blood pressure (non-AOBP) readings ≥ 140 mm Hg. For individuals with diastolic hypertension (with or without systolic hypertension), fixed-dose single-pill combinations are now recommended as an initial treatment option. Preference is given to pills containing an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in combination with either a calcium channel blocker or diuretic. Whenever a diuretic is selected as monotherapy, longer-acting agents are preferred. In patients with established ischemic heart disease, caution should be exercised in lowering diastolic non-AOBP to ≤ 60 mm Hg, especially in the presence of left ventricular hypertrophy. After a hemorrhagic stroke, in the first 24 hours, systolic non-AOBP lowering to < 140 mm Hg is not recommended. Finally, guidance is now provided for screening, initial diagnosis, assessment, and treatment of renovascular hypertension arising from fibromuscular dysplasia. The specific evidence and rationale underlying each of these guidelines are discussed.

Ecologically optimizing exercise maintenance in men and women post-cardiac rehabilitation: Protocol for a randomized controlled trial of efficacy with economics (ECO-PCR).

BACKGROUND: Exercise-based cardiac rehabilitation (CR) participation results in increased cardio-metabolic fitness, which is associated with reduced mortality. However, many graduates fail to maintain exercise post-program. ECO-PCR investigates the efficacy and cost-effectiveness of a social ecologically-based intervention to increase long-term exercise maintenance following the completion of CR. METHODS/DESIGN: A three-site, 2-group, parallel randomized controlled trial is underway. 412 male and 192 female (N=604) supervised CR participants are being recruited just before CR graduation. Participants are randomized (1:1 concealed allocation) to intervention or usual care. A 50-week exercise facilitator intervention has been designed to assist CR graduates in the transition from structured, supervised exercise to self-managed home- or community-based (e.g., Heart Wise Exercise programs) exercise. The intervention consists of 8 telephone contacts over the 50week period: 3 individual and 5 group. Assessments occur at CR graduation, and 26, 52 and 78weeks post-randomization. The primary outcome is change in minutes of accelerometer-measured moderate to vigorous-intensity physical activity (MVPA) from CR graduation to 52weeks post-randomization. Secondary measures include exercise capacity, quality of life, and cardiovascular risk factors. Analyses will be undertaken based on intention-to-treat. For the primary outcome, an analysis of variance will be computed to test the change in minutes of MVPA in each group between CR graduation and 52week follow-up (2 [arm]×2 [time]). Secondary objectives will be assessed using mixed-model repeated measures analyses to compare differences between groups over time. Mean costs and quality-adjusted life years for each arm will be estimated.

Hypertension Canada's 2016 Canadian Hypertension Education Program Guidelines for Blood Pressure Measurement, Diagnosis, Assessment of Risk, Prevention, and Treatment of Hypertension.

Hypertension Canada's Canadian Hypertension Education Program Guidelines Task Force provides annually updated, evidence-based recommendations to guide the diagnosis, assessment, prevention, and treatment of hypertension. This year, we present 4 new recommendations, as well as revisions to 2 previous recommendations. In the diagnosis and assessment of hypertension, automated office blood pressure, taken without patient-health provider interaction, is now recommended as the preferred method of measuring in-office blood pressure. Also, although a serum lipid panel remains part of the routine laboratory testing for patients with hypertension, fasting and nonfasting collections are now considered acceptable. For individuals with secondary hypertension arising from primary hyperaldosteronism, adrenal vein sampling is recommended for those who are candidates for potential adrenalectomy. With respect to the treatment of hypertension, a new recommendation that has been added is for increasing dietary potassium to reduce blood pressure in those who are not at high risk for hyperkalemia. Furthermore, in selected high-risk patients, intensive blood pressure reduction to a target systolic blood pressure ≤ 120 mm Hg should be considered to decrease the risk of cardiovascular events. Finally, in hypertensive individuals with uncomplicated, stable angina pectoris, either a ß-blocker or calcium channel blocker may be considered for initial therapy. The specific evidence and rationale underlying each of these recommendations are discussed. Hypertension Canada's Canadian Hypertension Education Program Guidelines Task Force will continue to provide annual updates.

Effectiveness of performance coaching for enhancing rates of smoking cessation treatment delivery by primary care providers: Study protocol for a cluster randomized controlled trial.

UNLABELLED: Smoking cessation is one of the most powerful preventive interventions available to primary care providers. Rates of tobacco treatment delivery in primary care settings, however, remain sub-optimal. This paper reports on rationale, design, and protocol for a matched-paired, cluster-randomized controlled trial to compare the incremental effectiveness of performance coaching on physician delivery of smoking cessation assistance when delivered as part of a practice-level intervention for smoking cessation (the Ottawa Model for Smoking Cessation; OMSC). Outcome measures included frequency of provider smoking cessation treatment delivery, patient quit attempts, and 7-day point prevalence abstinence measured at 6 months, and changes in provider attitudes and beliefs related to smoking cessation treatment delivery. Primary care clinics were randomly assigned, using a matched paired design, to one of two treatment conditions: OMSC Group or OMSC+Performance Coaching Group. All practices were supported with implementing the OMSC. Half of the practices also received a 1.5 hour, skills-based, coaching session to address barriers encountered in the delivery of smoking cessation treatments and individualized performance feedback reports. All providers, and a cross sectional sample of patients from their practices, were surveyed before and after the implementation of the intervention. Multi-level modeling was used to compare intervention groups. If shown to be effective, the study will lead to an improved understanding of how to best assist clinicians to enhance the delivery of smoking cessation practice and will provide evidence to guide the design of smoking cessation interventions in primary care. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01603524.

The 2015 Canadian Hypertension Education Program recommendations for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension.

The Canadian Hypertension Education Program reviews the hypertension literature annually and provides detailed recommendations regarding hypertension diagnosis, assessment, prevention, and treatment. This report provides the updated evidence-based recommendations for 2015. This year, 4 new recommendations were added and 2 existing recommendations were modified. A revised algorithm for the diagnosis of hypertension is presented. Two major changes are proposed: (1) measurement using validated electronic (oscillometric) upper arm devices is preferred over auscultation for accurate office blood pressure measurement; (2) if the visit 1 mean blood pressure is increased but < 180/110 mm Hg, out-of-office blood pressure measurements using ambulatory blood pressure monitoring (preferably) or home blood pressure monitoring should be performed before visit 2 to rule out white coat hypertension, for which pharmacologic treatment is not recommended. A standardized ambulatory blood pressure monitoring protocol and an update on automated office blood pressure are also presented. Several other recommendations on accurate measurement of blood pressure and criteria for diagnosis of hypertension have been reorganized. Two other new recommendations refer to smoking cessation: (1) tobacco use status should be updated regularly and advice to quit smoking should be provided; and (2) advice in combination with pharmacotherapy for smoking cessation should be offered to all smokers. The following recommendations were modified: (1) renal artery stenosis should be primarily managed medically; and (2) renal artery angioplasty and stenting could be considered for patients with renal artery stenosis and complicated, uncontrolled hypertension. The rationale for these recommendation changes is discussed.

E-health physical activity interventions and moderate-to-vigorous intensity physical activity levels among working-age women: a systematic review protocol.

BACKGROUND: The rapid pace of modern life requires working-age women to juggle occupational, family, and social demands. Despite the large numbers of working-age women in developed countries and the proven benefits of regular moderate-to-vigorous intensity aerobic physical activity (MVPA) in chronic disease prevention, few women meet current physical activity (PA) recommendations of 150 min of MVPA per week. It is important that appropriate and effective behavioral interventions targeting PA are identified and developed to improve the MVPA levels of working-age women. As women worldwide embrace modern technologies, e-health innovations may provide opportune and convenient methods of implementing programs and strategies to target PA in an effort to improve MVPA levels and cardiometabolic health. Previous reviews on this topic have been limited; none have focused on working-age women from developed countries who exhibit inappropriately low PA levels. It remains unknown as to which e-health interventions are most effective at increasing MVPA levels in this population. The purpose of this systematic review is to examine the effectiveness of e-health interventions in raising MVPA levels among working-age women in developed countries and to examine the effectiveness of these interventions in improving the health of women. METHODS: Eight electronic databases will be searched to identify all prospective cohort and experimental studies examining the impact of e-health interventions for increasing MVPA levels among working-age women (mean age 18-65 years) in developed countries. Gray literature including theses, dissertations, and government reports will also be examined. Study quality will be assessed using a modified Downs and Black checklist, and risk of bias will be assessed within and across all included studies using the Cochrane's risk of bias tool and Grades of Recommendation, Assessment, Development and Evaluation approach. A quantitative synthesis in the form of meta-analyses for measures of MVPA and health outcomes will be conducted where possible. DISCUSSION: This review will determine the effectiveness of e-health interventions in raising MVPA levels in working-age women in developed countries. It will form a contemporary, rigorously developed, and reliable research base for policy makers and stakeholders; and inform and influence the development and implementation of effective e-health interventions designed to increase MVPA levels and improve health outcomes in this population. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42014009534.

Economic evaluation of a hospital-initiated intervention for smokers with chronic disease, in Ontario, Canada.

INTRODUCTION: Cigarette smoking causes many chronic diseases that are costly and result in frequent hospitalisation. Hospital-initiated smoking cessation interventions increase the likelihood that patients will become smoke-free. We modelled the cost-effectiveness of the Ottawa Model for Smoking Cessation (OMSC), an intervention that includes in-hospital counselling, pharmacotherapy and posthospital follow-up, compared to usual care among smokers hospitalised with acute myocardial infarction (AMI), unstable angina (UA), heart failure (HF), and chronic obstructive pulmonary disease (COPD). METHODS: We completed a cost-effectiveness analysis based on a decision-analytic model to assess smokers hospitalised in Ontario, Canada for AMI, UA, HF, and COPD, their risk of continuing to smoke and the effects of quitting on re-hospitalisation and mortality over a 1-year period. We calculated short-term and long-term cost-effectiveness ratios. Our primary outcome was 1-year cost per quality-adjusted life year (QALY) gained. RESULTS: From the hospital payer's perspective, delivery of the OMSC can be considered cost effective with 1-year cost per QALY gained of $C1386, and lifetime cost per QALY gained of $C68. In the first year, we calculated that provision of the OMSC to 15 326 smokers would generate 4689 quitters, and would prevent 116 rehospitalisations, 923 hospital days, and 119 deaths. Results were robust within numerous sensitivity analyses. DISCUSSION: The OMSC appears to be cost-effective from the hospital payer perspective. Important consideration is the relatively low intervention cost compared to the reduction in costs related to readmissions for illnesses associated with continued smoking.

Delivering evidence-based smoking cessation treatment in primary care practice: experience of Ontario family health teams.

OBJECTIVE: To report on the delivery of evidence-based smoking cessation treatments (EBSCTs) within a sample of 40 Ontario family health teams (FHTs). DESIGN: In each FHT, consecutive patients were screened for smoking status and eligible patients completed a questionnaire immediately following their clinic visits (index visits). Multilevel analysis was used to examine FHT-level, provider-level, and patient-level predictors of EBSCT delivery. SETTING: Forty FHTs in Ontario. PARTICIPANTS: Across the 40 participating FHTs, 24,033 patients were screened and 2501 eligible patients contributed data. MAIN OUTCOME MEASURES: Provider performance in the delivery of EBSCTs during the preceding 12 months and during the index visits was assessed. RESULTS: The rate of provider delivery of EBSCT for the previous 12 months was 74.0% for the advise strategy. At the index visit, rates of EBSCT strategy delivery were 56.8% for ask; 46.9% for advise; 38.7% for assist; 11.6% for prescribing pharmacotherapy; and 11.3% for arrange follow-up. Significant intra-FHT and intraprovider variability in the rates of EBSCT delivery was identified. Family health teams with a physician champion (odds ratio [OR] 2.0; 95% CI 1.1 to 3.6; P < .01) and providers who highly ranked the importance of smoking cessation (OR 1.7; 95% CI 1.1 to 2.7; P < .01) were more likely to deliver EBSCTs. Patient readiness to quit (OR 1.6; 95% CI 1.3 to 1.9; P < .001), presence of smoking-related illness (OR 1.6; 95% CI 1.2 to 2.1; P < .01), and presenting for an annual health examination (OR 2.0; 95% CI 1.6 to 2.5; P < .001) were associated with the delivery of EBSCTs. CONCLUSION: Rates of smoking cessation advice were higher than previously reported for Canadian physicians; however, rates of assistance with quitting were lower. Future quality improvement initiatives should specifically target increasing the rates of screening and advising among low-performing FHTs and providers within FHTs, with a particular emphasis on doing so at all clinic appointments; and improving the rate at which assistance with quitting is delivered.

Flexible and extended dosing of nicotine replacement therapy or varenicline in comparison to fixed dose nicotine replacement therapy for smoking cessation: rationale, methods and participant characteristics of the FLEX trial.

Quitting smoking is the single most effective strategy to reduce morbidity and premature mortality in smokers. Research has demonstrated the effectiveness of pharmacotherapy in smoking cessation, but few studies have directly compared varenicline and monotherapy nicotine replacement therapy (NRT) and none have examined varenicline and combinations of NRT products. The majority of smoking cessation trials involve carefully circumscribed populations, making their results less generalizable to those with severe medical conditions or psychiatric comorbidities. This paper reports on the rationale, methodology and participant characteristics of a randomized controlled trial designed to: (1) determine which pharmacotherapy - NRT, long term combinations of NRT, or varenicline - is most effective in achieving abstinence; (2) investigate the incidence of neuropsychiatric symptoms among participants over the course of their quit attempt; and (3) assess whether there is a significant difference in the incidence of neuropsychiatric symptoms in those receiving differing pharmacotherapies, and between those with and without psychiatric illnesses. The primary outcome was carbon monoxide confirmed abstinence from weeks 5-52 following a target quit date. Secondary outcomes included neuropsychiatric (i.e., depression, suicidal ideation, anxiety, anger) and withdrawal symptoms. Smokers (N=737) were randomly assigned to one of three treatment conditions, and were scheduled to attend 8 follow-up appointments over 12 months. All participants received 6-15 minute practical counseling sessions with nurse counselors experienced in treating tobacco dependence. We expect that the results will lead to an enhanced understanding of the efficacy of these pharmacotherapies, including those with a history of psychiatric illness.

A randomised controlled pilot study of standardised counselling and cost-free pharmacotherapy for smoking cessation among stroke and TIA patients.

Background Tobacco use is a major risk factor for recurrent stroke. The provision of cost-free quit smoking medications has been shown to be efficacious in increasing smoking abstinence in the general population. Objective The objective of this pilot study was to assess the feasibility and obtain preliminary data on the effectiveness of providing cost-free quit smoking pharmacotherapy and counselling to smokers identified in a stroke prevention clinic. Trial design Cluster randomised controlled trial. Methods All patients seen at the Ottawa Hospital Stroke Prevention Clinic who smoked more five or more cigarettes per day, were ready to quit smoking in the next 30 days, and were willing to use pharmacotherapy were invited to participate in the study. All participants were advised to quit smoking and treated using a standardised protocol including counselling and pharmacotherapy. Participants were randomly assigned to either a prescription only usual care group or an experimental group who received a 4-week supply of cost-free quit smoking medications and a prescription for medication renewal. All patients received follow-up counselling. The primary outcome was biochemically validated quit rates at 26 weeks. The research coordinator conducting outcome assessment was blind to group allocation. Results Of 219 smokers screened, 73 were eligible, 28 consented and were randomised, and 25 completed the 26-week follow-up assessment. All 28 patients randomised were included in the analysis. The biochemically validated 7-day point prevalence abstinence rate in the experimental group compared to the usual care group was 26.6% vs 15.4% (adjusted OR 2.00, 95% CI 0.33 to 13.26; p=0.20). Conclusions It would be feasible to definitively evaluate this intervention in a large multi-site trial. Trial registration number http://ClinicalTrials.gov # UOHI2010-1.

Systematic approaches to smoking cessation in the cardiac setting.

PURPOSE OF REVIEW: Constituents of tobacco smoke are prothrombotic and atherogenic and causative factors in the development of coronary heart disease (CHD). Smoking cessation is the single most important intervention to reduce morbidity and mortality in smokers with CHD. This review presents contemporary information regarding treatments for smoking cessation in the setting of CHD. RECENT FINDINGS: The beneficial effects of smoking cessation may be mediated by improvements in endothelial function. Failure to quit smoking in those with CHD is a typical consequence of nicotine addiction. Practical counseling and pharmacotherapy [nicotine replacement therapy (NRT), bupropion, and varenicline] are well tolerated and effective treatments for CHD patients attempting to quit smoking. Treatments initiated in hospital following a CHD-related event or procedure are more effective than those initiated outside the hospital setting. Extending medication use beyond the initial treatment phase is the most promising means of preventing relapse. Financial coverage for smoking cessation pharmacotherapy improves quit rates. The routine provision of pharmacotherapy and practical counseling in the CHD setting can be assured by implementing proven, systematic approaches to smoking cessation treatment. SUMMARY: Smoking cessation is a fundamental priority in smokers with CHD. Systematic approaches to ensure that cessation assistance is provided by clinicians and to improve cessation outcomes for smokers are effective and available.

Development of the Champlain primary care cardiovascular disease prevention and management guideline: tailoring evidence to community practice.

PROBLEM ADDRESSED: A well documented gap remains between evidence and practice for clinical practice guidelines in cardiovascular disease (CVD) care. OBJECTIVE OF PROGRAM: As part of the Champlain CVD Prevention Strategy, practitioners in the Champlain District of Ontario launched a large quality-improvement initiative that focused on increasing the uptake in primary care practice settings of clinical guidelines for heart disease, stroke, diabetes, and CVD risk factors. PROGRAM DESCRIPTION: The Champlain Primary Care CVD Prevention and Management Guideline is a desktop resource for primary care clinicians working in the Champlain District. The guideline was developed by more than 45 local experts to summarize the latest evidence-based strategies for CVD prevention and management, as well as to increase awareness of local community-based programs and services. CONCLUSION: Evidence suggests that tailored strategies are important when implementing specific practice guidelines. This article describes the process of creating an integrated clinical guideline for improvement in the delivery of cardiovascular care.

Strategies to increase the delivery of smoking cessation treatments in primary care settings: a systematic review and meta-analysis.

OBJECTIVES: A systematic review and meta-analysis was conducted to evaluate evidence-based strategies for increasing the delivery of smoking cessation treatments in primary care clinics. METHODS: The review included studies published before January 1, 2009. The pooled odds-ratio (OR) was calculated for intervention group versus control group for practitioner performance for "5As" (Ask, Advise, Assess, Assist and Arrange) delivery and smoking abstinence. Multi-component interventions were defined as interventions which combined two or more intervention strategies. RESULTS: Thirty-seven trials met eligibility criteria. Evidence from multiple large-scale trials was found to support the efficacy of multi-component interventions in increasing "5As" delivery. The pooled OR for multi-component interventions compared to control was 1.79 [95% CI 1.6-2.1] for "ask", 1.6 [95% CI 1.4-1.8] for "advice", 9.3 [95% CI 6.8-12.8] for "assist" (quit date) and 3.5 [95% CI 2.8-4.2] for "assist" (prescribe medications). Evidence was also found to support the value of practice-level interventions in increasing 5As delivery. Adjunct counseling [OR 1.7; 95% CI 1.5-2.0] and multi-component interventions [OR 2.2; 95% CI 1.7-2.8] were found to significantly increase smoking abstinence. CONCLUSION: Multi-component interventions improve smoking outcomes in primary care settings. Future trials should attempt to isolate which components of multi-component interventions are required to optimize cost-effectiveness.

Knowledge, attitudes and behaviours related to dietary sodium among 35- to 50-year-old Ontario residents.

BACKGROUND: Excessive consumption of dietary sodium is an important public health issue. Little is known about the knowledge, attitudes and behaviours related to sodium consumption among Canadians. OBJECTIVE: To examine knowledge, attitudes and behaviours related to sodium consumption among a sample of Canadians 35 to 50 years of age. METHODS: A random-digit-dial telephone survey was conducted among adults aged 35 to 50 years of age in two regions in Ontario. Logistic regression was used to examine the likelihood of having taken action in the past 30 days to reduce sodium consumption, and the likelihood that respondents were intending to reduce sodium in the next six months. RESULTS: A total of 3130 interviews were completed. The majority of respondents were aware of excessive sodium consumption as a health issue and reported that they were taking action to reduce their dietary sodium intake. A large proportion of respondents did not correctly identify many foods as being high in sodium and, consequently, may have incorrectly believed they were consuming healthy amounts of sodium. Respondents who believed sodium reduction was important were more likely to have taken action to reduce sodium within the previous 30 days. Respondents who self-identified as consuming too much sodium were less likely to have taken action. CONCLUSIONS: The findings of the present study suggest that in addition to policy changes designed to reduce the sodium content of foods, there is a need to address the low levels of knowledge surrounding sources of excessive sodium in popular Canadian foods, the importance of a reduced intake of sodium and the availability of lower-sodium alternatives.

Predicting short and long-term exercise intentions and behaviour in patients with coronary artery disease: A test of protection motivation theory.

The purpose of this study was to examine the utility of protection motivation theory (PMT) in the prediction of exercise intentions and behaviour in the year following hospitalisation for coronary artery disease (CAD). Patients with documented CAD (n = 787), recruited at hospital discharge, completed questionnaires measuring PMT's threat (i.e. perceived severity and vulnerability) and coping (i.e. self-efficacy, response efficacy) appraisal constructs at baseline, 2 and 6 months, and exercise behaviour at baseline, 6 and 12 months post-hospitalisation. Structural equation modelling showed that the PMT model of exercise at 6 months had a good fit with the empirical data. Self-efficacy, response efficacy, and perceived severity predicted exercise intentions, which, in turn predicted exercise behaviour. Overall, the PMT variables accounted for a moderate amount of variance in exercise intentions (23%) and behaviour (20%). In contrast, the PMT model was not reliable for predicting exercise behaviour at 12 months post-hospitalisation. The data provided support for PMT applied to short-term, but not long-term, exercise behaviour among patients with CAD. Health education should concentrate on providing positive coping messages to enhance patients' confidence regarding exercise and their belief that exercise provides health benefits, as well as realistic information about disease severity.

Nutritional supplements and doping.

CONTEXT: The problems of doping in sport and the increasing use of nutritional supplements by athletes are issues that intersect to the degree that a large number of supplements may contain substances that are banned in sport. Many supplements contain substances that are associated with significant health hazards. Athletes consuming such supplement products may jeopardize their sporting status, and their health. OBJECTIVES: To clarify and summarize the current status of dietary supplements in general, and to describe specific problems that can be associated with supplement use so that sport physicians might be better prepared to address these issues with their athlete-patients. DATA SOURCE: An analysis of recent and relevant literature accessed through MEDLINE, and interactions with clinicians, laboratory scientists, colleagues, and athletes. CONCLUSIONS: The dietary supplement industry is completely unregulated in the United States; as a consequence, an abundance of supplement products of dubious value, content, and quality are now available around the world. It is known that many supplement products contain substances that are prohibited in sport-typically stimulants or anabolic steroid precursors. Many supplements contain substances (e.g., ephedrine) that have been associated with significant morbidity and mortality. Sport practitioners have particular responsibilities in addressing this issue. Athletes need to be aware of the problems that can follow supplement use, and sport authorities need to ensure that nutritional education and guidance for athletes is of the highest standard. The need for the appropriate regulation of dietary supplements is emphasized.