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While 6% of children under three years of age suffer from a food allergy, the figure for adults varies between 1.5 and 3%. Leading allergens in foodstuffs are glycoproteins having a molecular weight of between 10,000 and 60,000. The symptoms of an immediate type nutrient allergy mediated by IgE usually manifest within a matter of a few minutes to two hours after ingestion of the offending nutrient and take the form, for example, of tingling and itching, tissue swelling in the mouth, hoarseness, asthma, gastrointestinal complaints or acute urticaria; in severe cases anaphylactic shock may even occur. In contrast, no IgE antibodies are to be found in nutrient-induced enterocolitis, which is associated with diarrhea and vomiting occurring after a delay of one to six hours. Differential diagnostic considerations must include intolerance for certain foodstuffs, such as lactose intolerance, or pseudoallergic reactions.

When LDL cholesterol is elevated, HDL cholesterol is low or triglycerides are raised, dietary changes form the basis of treatment. Such changes are most important in the case of hypertriglyceridemia. Some 3 to 4 hours after a meal, triglycerides increase to an extent determined by the composition of the meal. Hypertriglyceridemia cannot be successfully treated unless alcohol is banished and rapidly assimilatable carbohydrates are restricted. In patients with elevated LDL cholesterol, a change in eating habits can have an appreciable effect (on average 10-15%). Since this measure can save the use or reduce the dose of medications, its value is obvious, and it must not be neglected. The measures aimed at elevating HDL cholesterol have only a moderate effect, so that more importance should be attached to lowering the LDL fraction.

Sibutramine and Orlistat are suitable "supporting drugs" for use in patients trying to lose weight. Orlistat reduces the absorption of fat from the intestine by about one-third. Over the long term too, the weight loss achieved under Orlistat (9%) has been greater than that seen under placebo (6.5%). Increased fat losses via the stools are associated with side effects and abandonment of treatment. Sibutramine inhibits the uptake of serotonin and noradrenaline in the synaptic gap, thus enhancing the CNS effects of these two transmitters, and prolonging the sensation of satiety. The most common side effects of sibutramine are dry mouth, headache and fatigue. The effects of sibutramine on weight reduction are similar to those of orlistat. For both drugs, the indications have been defined, and in the case of sibutramine, interactions with other medications have to be taken into account.

Homocystinuria, a rare inherited disturbance of amino acid metabolism is associated with severe atherosclerosis and thromboembolism already in childhood. The incidence of the homozygous disease of cystathionine beta synthase is estimated to be 1:200,000, that of the heterozygous form 1:300. There are, however, numerous other causes of a mild to moderate homocysteinemia, for example, a deficiency of the cofactors vitamin B6, B12 and folic acid. The question as to whether a mild to moderate elevation of homocysteine in the plasma is also associated with an increased risk of CAD has been investigated in a number of studies in recent years. In summary, however, the presently available data do not provide a basis of proof that a mild to moderate homocysteinemia is an independent risk factor for CAD. Our present knowledge suggests that only when the family history is clearly positive does it appear reasonable to undertake a diagnostic search for possible homocysteinemia.

Hypoglycemia is often associated with typical, but not specific symptoms. A differentiation is made between neuroglucopenic symptoms (e.g., confusion, somnolence) on the one hand, and those that arise as a result of the counterregulatory response of the sympathetic nervous system (e.g., tremor, sweating), on the other. The diagnosis of hypoglycemia can cause considerable problems, in particular when only isolated single symptoms present (e.g., confusion, psychosis, seizures, coma). For the elective clarification of recurrent hypoglycemia, further diagnostic examinations (e.g., fasting with determination of hormones, measurement of insulin) are employed in addition to the patient's history. For differential diagnostic considerations not only organic causes, but also adverse drug reactions and a factitious genesis must be excluded. In the event of an emergency (e.g., hypoglycemic coma) the usual form of treatment is the administration of glucoses or glucagon.

A scientific assessment of dietary risks encounters great difficulties, since reliable prospective studies are hardly possible, and the various forms of retrospective studies are associated with considerable error probabilities. Nevertheless, on the basis of the similar results obtained with numerous investigations, it is possible to make statements about definite or potential risks. Thus, the correlation between high levels of dietary fat and meat and colorectal cancer, and that between high levels of fat and mammary carcinoma, have been adequately demonstrated. Alcohol is a proven risk factor for numerous carcinomas of the gastrointestinal tract, in particular for tumors of the oropharynx and larynx, the esophagus and liver. But it may also be a possible risk factor for breast cancer and other gynecological tumors. Conversely, with respect to protective factors it is accepted that what is generally recognized to be a healthy diet (fruit, vegetables, fiber) can apparently offer a certain degree of protection from malignant disease.

Both the levels of fat and cholesterol in the diet and its fatty acid composition influence the CAD risk. In recent years, it has been recognized, however, that a high percentage of polyunsaturated fatty acids can have a negative effect, for example on the immune system. It is therefore recommended that 7-10% of dietary energy be consumed in the form of polyunsaturated and saturated fatty acids, but 10-15% as mono-unsaturated fatty acids. In view of the associated favorable effect on CAD mortality, an increase in consumption of sea fish can now be recommended, while the benefits of consuming high doses of fish oil has not been proven. The positive effect of a fiber-rich diet is largely due to the associated decrease in consumption of saturated fatty acids. An additional cholesterol-lowering effect has been demonstrated only for particular substances, for example oat bran. Numerous other dietary constituents, such as alcohol, salt or antioxidants, may also have effects on atherogenesis.

A vegetarian diet has a positive effect on various risk factors for coronary artery disease: these include usually lower average body weight, lower total and LDL cholesterol levels, and lower blood pressure. In conjunction with a generally more healthy way of life (more exercise, less alcohol and tobacco use), vegetarians have roughly 30% reduction in overall mortality. The prevalence of bronchial, colon and breast cancer is also lower. In particular in its strict form (total vegetarianism or veganism), a vegetarian regimen may lead to deficiency disorders, in particular vitamin B12 deficiency, which may occur especially in vegetarian children, pregnant or lactating women. Overall, however, a vegetarian regimen has a more beneficial effect on health than the usual Central European diet.

In 5 intervention studies the beneficial effect of lipid lowering by antilipemic drugs on the course of atherosclerotic lesions has been shown by serial coronary angiography in patients with manifest coronary heart disease. The beneficial effect depended on the level of LDL and HDL cholesterol during drug therapy. This could not only be shown by coronary angiography but also by the frequency of clinical cardial events. The results of these studies indicate that the prognosis of patients with coronary heart disease depends on the LDL and HDL cholesterol concentrations during therapy and not on those before initiating antilipemic drug therapy. Therefore a consequent lipid-lowering therapy is necessary. The best prognosis was observed at LDL cholesterol concentrations lower than 100 mg/dl.

The basis of successful treatment of the various forms of hypercholesterolemia is a balanced diet. Initially this includes a general change in lifestyle with a new approach to nutrition, an increase in physical activity and nicotine abstinence. For the individual this implies a diet containing less fat but more unsaturated fatty acids, less salt, less cholesterol, more proteins, more dietary fiber and more complex carbohydrates. Hyperlipidemia triggered by incorrect nutrition or polygenous hypocholesterolemia can usually be successfully treated by means of a fat-modified diet alone. Hypercholesterolemia due to apolipoprotein E polymorphism responds equally well to dietary change. In some cases such dietary modifications can result in a 25% decrease of LDL-cholesterol.

The therapeutic aim in patients with LDL-hypercholesterolemia and coronary heart disease is to reduce LDL-cholesterol levels to around 100 mg/dl. Since such levels are hardly ever reached solely by diet modifications, inevitably the targeted use of cholesterol-lowering drugs is required. Drug therapy of LDL-hypercholesterolemia nowadays includes the following: anion exchange resins, HMG CoA-reductase-inhibitors, fibrates, nicotinic acid and its derivatives, beta-sitosterol and probucol. If cholesterol levels are not sufficiently lowered in response to monotherapy with one of these drugs combined drug therapy should be attempted. Should this likewise prove unsatisfactory then LDL apheresis can be attempted at regular intervals. This regimen usually achieves the desired LDL-cholesterol level even in severe cases.

Fundamentals: Cardiovascular risk factors depend decisively on living conditions and nutrition. The aim of the present study was to establish whether the different living conditions in the eastern and western parts of Germany were associated with differences in the frequency and severity of these risk factors., Method: In Leipzig, 15,291 people (9,600 women and 5,691 men), in Nuremberg 8,387 (4,559 women and 3,828 men) were examined either after responding to a public appeal, or in the factory, etc., Results: Clearly elevated cholesterol levels (> 250 mg/dl) were found in 33.8% of the men, and 35.9% of the women in Leipzig, and in 39.1% of the men and 50.7% of the women in Nuremberg. This larger incidence of treatment-requiring hypercholesterolemia in Nuremberg was distributed throughout all age groups up to the age of 60. Hypertension was significantly more common among the 30 to 80-year-old women, and the 20 to 40-year-old and 50 to 80-year-old men in Leipzig. the frequency of cigarette smoking, diabetes mellitus and overweight did not differ significantly between the two cities. In cases with known dyslipoproteinemia, drug treatment was rarely applied, and the therapeutic aim of a cholesterol level < 200 mg/dl, was achieved in only 2-6% of those treated. The most significant difference with respect to cardiovascular risk factors was serum cholesterol. It is possible that a higher ingestion of monounsaturated fatty acids and more physical activity may be responsible for the lower cholesterol levels in Leipzig.

Basic remarks and aims: Alpha-receptor blockers, central sympathicolytic agents and vasodilators are all drugs that are often used to treat hypertension. On the basis of a study of the literature, the effects of these groups of substances on lipid metabolism are described. Main points discussed: Although the data available are few, vasodilators, in particular dihydralazine and hydralazine appear to have no unfavorable effect on serum lipids. Nor do the centrally acting alpha-receptor agonists, such as methyldopa and clonidine have any unfavorable effect, with the exception of the decrease in the HDL cholesterol observed under methyldopa. The selective alpha-1-receptor blockers, prazosin, doxazosin and urapidil, even have a positive effect of varying degree on lipid metabolism: increase in HDL cholesterol and decrease in triglycerides. Long-term studies over a number of years are, however, lacking. The effect of labetalol, reserpine and guanethidine on lipid metabolism cannot yet be definitively assessed owing to a lack of data.

Aim: Cardio-active substances and ACE-Inhibitors are often employed in patients with metabolic disturbances. The question as to whether they have any effect on the lipid levels therefore needs to be answered., Major Points Studied: The effects of antiarrhythmics, ACE-inhibitors, positively inotropic substances and antianginal substances on lipid metabolism are discussed on the basis of a search through the literature. The wealth of data permit the conclusion that many of the drugs in these substance groups are neutral in terms of metabolism. There are, however, also individual substances that lead to an elevation of lipid levels. Via an improvement in glucose tolerance, ACE-inhibitors can contribute to a lowering of triglyceride concentrations and an increase in the HDL cholesterol levels. For a number of substance groups, the data available still do not suffice to permit a definitive conclusion to be drawn., Conclusion: In the case of treatment with the above-mentioned substance groups, effects on lipid metabolism should be checked wherever this is in doubt. This applies, of course, in particular to patients already suffering from hyperlipoproteinemia.

Unlabelled: BASICS: Drug treatment of the risk factor hypertension has not led to the expected reduction in morbidity and mortality of coronary arterial disease. A negative effect of antihypertensive drugs on the lipid metabolism is under discussion as a possible cause., Main Topics: Both the commonly employed thiazide diuretics and chlorthalidone and the loop diuretics furosemide, piretanide and xipamide lead, to varying extents, to an increase in total and LDL cholesterol as well as triglycerides in subjects with normal metabolism. In addition, some diuretics lower the levels of protective HDL cholesterol. These side effects can be avoided--at least in part--by a combination with such drugs as prazosin, pindolol or captopril, which have a favorable effect on metabolism., Conclusion: It is recommended to carefully monitor serum Lipoproteins during diuretic treatment so that possible adverse changes may be counteracted by appropriate measures.

Basic Remarks: The frequency of overweight, together with the associated increase in morbidity--in particular coronary heart disease--means that such patients often require intensive care., Main Points Discussed: The particular features of intensive care of obese patients are the increased risk of aspiration pneumonia (in the presence of lowered pH and elevated gastric juice volume), respiratory insufficiency caused by a reduction in expiratory reserve volume, and a greater incidence of thrombosis and embolism. Ventricular hypertrophy and dilatation results in a reduced cardiac reserve. A clinically unrecognized insulin resistance may become manifest during intensive care. Digoxin, theophylline and aminoglycosides, commonly with a low therapeutic spectrum, when administered on the basis of weight, may lead to dangerously high serum concentrations in the overweight., Conclusions: At a weight of more than about 100 kg, it must generally be expected that the compensatory mechanisms of the body are exhausted and that there will be an increased susceptibility to additional disorders of homeostasis.