CORRESPONDENCE
1 Veronesi U, Maisonneuve P, Sacchini V, that HRT was not a factor for
et al. Tamoxifen for breast cancer among
hysterectomised women. Lancet 2002; 359:
1122–24.
2 Fisher B, Constantino JP, Wickerman DL,
et al. Tamoxifen for prevention of breast
cancer: report of the National Surgical
Adjuvant Breast and Bowel Project P-I
study. J Natl Cancer Inst 1998; 90: 1371–88.
3 Veronesi U, Maisonneuve P, Costa A, et al,
for the Italian Tamoxifen Study Group.
Prevention of breast cancer with tamoxifen:
preliminary findings from the Italian
randomised trial among hysterectomised
women. Lancet 1998; 352: 93–97.
4 Rosen PP, Groshen S, Kinne D, et al.
Factors influencing prognosis in node
negative breast carcinoma: analysis of 767
TINOMO patients with long term follow
up. J Clin Oncol 1993; 11: 2090–100.
5 Fisher B, Dignam J, Wolmark N, et al.
Tamoxifen and chemotherapy for lymph
node negative oestrogen receptor positive
breast cancer. J Natl Cancer Inst 1997; 89:
1673–82.
Authors’ reply
Sir—In our and the NSAB-P1 trial,
there is a reduced risk of breast cancer
in the group receiving tamoxifen,
although the reduction is significant in
the NSAB-P1 trial but not in our trial.
An overview analysis of the available
intervention trials would show that
the outcomes are similar in magnitude
but differ in CI for the effect.
A more important issue surrounds
the comment that some of the
differences between the two studies
could be related to the high rate of
attrition in our study. This issue was
initially raised by Kathleen Pritchard1
who underlined that there were clearly
difficulties with adherence in our
preliminary analysis. Similarly, Fisher
and colleagues, whom Benson cites,
noted that non-adherence rates were
appreciable in the European trials.
We have previously reviewed the
data of the three studies in which the
same criteria were used to define
drop-out: the number of discontin-
uations for reasons other than major
events, including women lost to
follow-up, divided by the total
number of women included in the
analysis.2 With application of these
criteria, 36% of patients stopped
prematurely in Powles and colleagues’
study,3 29% in the NSAB-P1, and
21% in our preliminary analysis.
Differences in drop-out rates are not
the cause of differences in findings
between studies. Additionally,
tamoxifen cannot be considered as a
population-based prevention agent
without taking into account the large
non-adherence rate observed in all
three studies.
As we noted in our report, findings
on HRT must be interpreted with
caution for several reasons, mainly
THE LANCET • Vol 360 • November 30, 2002 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.
workers to encourage patients to
randomisation. Benson seems to have
misread our findings. We stated that
our results suggest that the use of
HRT increases the risk of breast
cancer and that tamoxifen use in
women using HRT seems to reduce
the risk of breast cancer to that of
non-users of HRT.
We are interested in Benson’s
proposal that, in premenopausal
women with oestrogen deprivation
due to chemotherapy, HRT plus
tamoxifen might keep to a minimum
breast-cancer risk and improve
adverse effects of oestrogen
deprivation on the cardiovascular
system and bones. He suggests this
regimen’s use in women with good
prognosis and expected long-term
survival. However, women with good
prognosis do not generally undergo
chemotherapy, and there is not
sufficient evidence that administration
of oestrogens to women treated for a
breast carcinoma does not increase
the risk of metastatic potential at the
disease. Certainly the hypothesis
deserves to be discussed and tested in
a clinical setting.
U Veronesi, P Maisonneuve, N Rotmensz,
*P Boyle
Divisions of Senology, and *Epidemiology and
Biostatistics, European Institute of Oncology,
Via Ripamonti 435, 20141 Milan, Italy
(e-mail: peter.boyle@ieo.it)
1 Pritchard KI. Is tamoxifen effective in
prevention of breast cancer? Lancet 1998;
352: 80–81.
2 Veronesi U, Maisonneuve P, Costa A,
Rotmensz N, Boyle P. Drop-outs in
tamoxifen prevention trials. Lancet 1999;
353: 244.
3 Powles T, Eeles R, Ashley S, et al. Interim
analysis of the incidence of breast cancer in
the Royal Marsden Hospital Tamoxifen
randomised chemoprevention trial. Lancet
1998; 352: 98–101.
Dietary effect on blood
pressure
Sir—Jeyanthi John and co-workers
(June 8, p 1969)1 describe a sustained
improvement in fruit and vegetable
intake with a specific community-
based dietary intervention in a
southern England population.
Biomarkers confirmed the self-
reported increase and showed a
beneficial effect on blood pressure
and plasma antioxidant status.
Clearly an effective strategy for
dietary modification in the general
population would be a major step
towards achieving some of the
Government’s targets in public
health. It is tempting to try the
approach used by John and co-
take the recommended five portions
of fruit and vegetables per day.
However, participants who agreed to
take part in the study were defined as
being less materially deprived
than non-respondents. Indeed, the
investigators acknowledge that their
study group had a higher
socioeconomic class than the UK
average.
Socioeconomic status and material
deprivation could impact on the study
group’s willingness to alter habitual
dietary intakes. If there was a high
proportion of well-motivated individ-
uals in the study group, the
intervention would have a greater
likelihood of success. Moreover, in
their education materials, John and
co-workers quite rightly address
potential barriers to change in dietary
habit (cost, eating out, and catering
for children). The barriers to change
frequently described by those in lower
socioeconomic groups2 may differ
notably from those addressed in the
study. Thus, whether these results
could be replicated in lower
socioeconomic groups, in which the
rate of cancer, coronary heart disease,
and strokes is highest, remains
unclear.
We are investigating methods for
promoting dietary changes in relation
to the prevention of colorectal cancer.
After detailed interviews, our
preliminary findings show that in a
typical Scottish cohort of 50 people,
48% do not know why fruit
and vegetables are beneficial to
health, 54% are unaware of how
many portions should be eaten
each day, and 62% are unclear as to
what constitutes a portion. In
addition, 70% thought their diet
was already healthy. In John and
co-workers’ study the mean baseline
fruit and vegetable intake was
3·4 portions per day. In Scotland,
48% of the population eat fresh
fruit once a week or less and 41% eat
green vegetables once a week or less.3
This absence of recognition that
dietary improvement is needed, has
been cited by others as a barrier to
change.4
John and co-workers should be
applauded for outlining a strategy that
improves fruit and vegetable intake
and has a beneficial physiological
effect. However, it must be
established whether the intervention
used would be as effective in lower
socioeconomic groups. Moreover, if
the risk of coronary heart disease and
cancers is to be reduced, much more
effort is required to find methods of
making the public aware of their
1785
 CORRESPONDENCE
dietary habits and why dietary change is
imperative.
*K Dyer, R Richardson, K Fearon,
K Buckner
Departments of *Dietetics, Nutrition and
Biological Sciences, and Information
Management, Queen Margaret University
College, Edinburgh EH12 8TS, UK; and
Department of Clinical and Surgical Sciences,
University of Edinburgh
(e-mail: kdyer@qmuc.ac.uk)
1 John JH, Ziebland S, Yudkin P, Roe LS,
Neil HAW. Effects of fruit and vegetable
consumption on plasma antioxidant
concentrations and blood pressure: a
randomised controlled trial. Lancet 2002;
359: 1969–74.
2 Lang T, Caraher M. Access to healthy foods,
part II: food poverty and shopping deserts—
what are the implications for health
promotion policy and practice? Health Educ J
1998; 57: 202–11.
3 The Scottish Health Survey 1998 Vol 1.
London: Joint Health Surveys Unit, National
Centre for Social Research and Department
of Epidemiology and Public Health,
University College London, 2000.
4 Van Wechem SN, Brug J, van Assema P,
Kistemaker C, Riedstra M, Lowik MR. ‘Fat
watch’: a nationwide campaign in the
Netherlands to reduce fat intake-effect
evaluation. Nutr Health 1998; 12: 119–30.
Authors’ reply
Sir—We agree with Karen Dyer and
colleagues that our participants were not
from a materially deprived population
and recognise the importance of their
work among lower socioeconomic
groups. They also rightly point out the
limited applicability of trials that include
only participants who are well motivated
to make changes. Our results are,
however, more generally applicable than
they suggest.
In subgroup analyses, the intervention
had a positive effect among manual and
non-manual social classes, and was
greater in smokers than in non-smokers,
in those with a baseline intake of three
or fewer portions than with a higher
intake, and in men than in women.
Our participants do not seem to have
been unusually motivated to increase
their intake of fruit and vegetables. By
contrast to some other studies, we did
not select participants according to their
expressed willingness to change.1
However, we did collect information
about stage of change2 to test whether
participants who were contemplators
were any more likely to increase their
fruit and vegetable intake.3 In the
intervention group, 113 (38%) were not
considering a change (precontem-
plators), 104 (35%) were considering
a change (contemplators), and
80 (26·9%) had changed their behaviour
in the past 6 months.
We were interested in Dyer and
colleagues’ data on knowledge and
beliefs that suggest some similarity
between the Scottish and English
1786
For personal use. Only reproduce with permission from The Lancet Publishing Group.
samples. In our follow-up questionnaire
we asked “What is the recommended
minimum amount of fruit and vege-
tables to maintain good health?” 91% of
our intervention group selected five per
day, but 54% of our controls said four or
less per day, which is almost identical to
the unaware proportion they cite.
We did not ask our participants what
constitutes a portion but, because we
recognised that this is not well
understood, we provided a pictorial
portion guide as part of the intervention.
We suspect that the combination of the
portion guide, the eating pattern
assessment questionnaire, and use of the
2-week self-monitoring booklet probably
helped participants to recognise any
gaps in their consumption.
Finally, Dyer and colleagues are right
to state that different socioeconomic
groups experience different barriers.
Although we prepared materials to help
address a wide range of barriers,
including cost, storage, and availability,
poverty is an undoubtedly far greater
hindrance to healthy eating than limited
choice in restaurants. The intervention
had an effect in subgroups that
are commonly poorly responsive to
dietary interventions. However, socio-
economically deprived residents in an
Oxfordshire market town are not living
in a multiply disadvantaged community,
in which a combination of approaches
may be needed.
*Sue Ziebland, Pat Yudkin, Jeyanthi John,
Andrew Neil
*Imperial Cancer Research Fund General
Practice Research Group, and Division of Public
Health and Primary Health Care, Department of
Primary Health Care, University of Oxford, Oxford
OX3 7LF, UK
1 Cox DN, Anderson AS, Reynolds J,
McKellar S, Lean M, Mela DJ. Take five,
a nutrition education intervention to increase
fruit and vegetable intakes: impact on
consumer choice and nutrient intakes Br J
Nutr 1998; 80: 123–31.
2 Prochaska JO, DiClemente CC, Norcross JC.
In search of how people change: applications
to addictive behaviours Am Psychol 1992; 47:
1102–14.
3 John JH, Yudkin PL, Neil HAW, Ziebland S.
Does stage of change predict outcome in a
primary care intervention to encourage an
increase in fruit and vegetable consumption?
Health Educ Res (in press).
Sir—Jeyanthi John and co-workers1
show a rise in self-reported fruit and
vegetable intake after a dietary
intervention, leading to a slight rise in
plasma antioxidant concentrations and a
drop in blood pressure large enough to
predict a reduction of cardiovascular
disease.
The eventual relevance of these
findings may be greater than they
modestly claim. Indeed, significant
healthy outcomes for reduction in risk of
all-cause mortality have been recorded
THE LANCET • Vol 360 • November 30, 2002 • www.thelancet.com
after an increase of just one 50 g serving
of fruit and vegetables per day.2 This
amount is less than half
the increase achieved by John and
co-workers.
The only question we have is about
the possible role of the increase of
potassium intake (and perhaps sodium
reduction) in blood-pressure lowering.
Observational studies3 have recorded an
inverse association between blood
pressure and intake of potassium,
magnesium, calcium, fibres, and
proteins. However, such effects were not
obtained when these micronutrients
were given singly.4 This situation recalls
the inability of molecular antioxidant
supplementation strategies5 to
reproduce the cancer chemopreventive
benefits of fruit and vegetables.
*Moreno Paolini, Andrea Sapone, Donatella
Canistro, Pasquale Chieco, Carlo Bauer
*Department of Pharmacology, Alma Mater
Studiorum, University of Bologna, via Irnerio 48,
40126 Bologna, Italy; Institute of Oncology,
Bologna; and Department of Physiology and
Biochemistry, Biochemistry Unit, University of
Pisa, Pisa
(e-mail: paolini@biocfarm.unibo.it)
1 John JH, Ziebland S, Yudkin P, Roe LS,
Neil HAW. Effects of fruit and vegetable
consumption on plasma antioxidant
concentrations and blood pressure: a
randomised controlled trial. Lancet 2002;
359: 1969–74.
2 Khaw KT, Bingham S, Welch A, et al.
Relation between plasma ascorbic acid and
mortality in men and women in EPIC-
Norfolk prospective study: a prospective
population study: European prospective
investigation into cancer and nutrition. Lancet
2001; 357: 657–63.
3 Obarzanek E, Velletri PA, Cutler JA. Dietary
protein and blood pressure. JAMA 1996;
275: 1598–603.
4 Allender PS, Cutler JA, Follmann D, et al.
Dietary calcium and blood pressure:
a meta-analysis of randomized clinical trials.
Ann Intern Med 1996; 124: 825–31.
5 Paolini M, Abdel-Rahman SZ, Cantelli-Forti
G, et al. Chemoprevention or
antichemoprevention? A salutary warning
from the beta-carotene experience.
J Natl Cancer Inst 2001; 93: 1110–11.
HIV/AIDS in Africa
Sir—Kevin De Cock and colleagues
(July 6, p 67)1 have called for a “back to
basics” approach in the international
response to AIDS in Africa. This is not a
new call. It was frequently heard
throughout the 1980s, and only became
muted after the human rights
framework gained prominence. After all,
who wanted to be seen to be against
human rights?
Since the beginning of the
international response to AIDS, the
situation has evolved. In 1986, we had
little to offer to people living with HIV.
There was no benefit in knowing your
HIV status, for the individual nor for