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Month: August 2017

Heart Disease: Linked to Dementia

A recent NIH-funded study suggests that middle-aged people with risk factors for cardiovascular disease, including heart attacks and stroke, are more likely to develop dementia in old age than people without vascular risk factors.

The study, published in JAMA Neurology, included factors like diabetes, high blood pressure and smoking. “With an aging population, dementia is becoming a greater health concern. This study supports the importance of controlling vascular risk factors like high blood pressure early in life in an effort to prevent dementia as we age,” said Walter J. Koroshetz, MD, director of NIH’s National Institute of Neurological Disorders and Stroke.

The NIH has funded a public health campaign titled “Mind Your Risks,” with the goal of raising awareness of the strong correlation between cardiovascular and brain health. “What’s good for the heart is good for the brain,” says Koroshetz. Among the study’s participants, smoking in middle age was associated with 41% higher odds of dementia; diabetes was linked to a 77% greater risk.

The study’s results contribute to a growing body of evidence and scientific literature that links midlife vascular health to dementia, including the potential of modifying the vascular risk factors to lessen the possibility of dementia. Factors like obesity, diabetes, high blood pressure, and smoking can all be controlled–over time, reducing the risk of dementia.

By focusing on risk factors before middle age, patients have an opportunity to treat and reverse these factors, with the ultimate goal of reducing dementia risk before it is too late.

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Reducing Inflammation Lowers Risk of Heart Attack

It turns out that cholesterol isn’t the only thing you have to worry about to keep your heart healthy. In recent years, doctors have started to focus on inflammation — the same process that makes cuts red and painful — as an important contributor to a heart attack. It’s the reason doctors recommend low-dose aspirin to prevent recurrent heart attacks in people who have already had them, why they also prescribe statins, which lower both cholesterol and inflammation, and why they have started to measure inflammation levels in the blood.

But it’s never been clear exactly how much inflammation adds to heart disease risk. Since statins lower both, it’s hard to tell whether inflammation or cholesterol has the bigger impact on heart problems.

But in a new paper published in the New England Journal of Medicine and presented at the European Society of Cardiology meeting, scientists say they now have proof that lowering inflammation alone, without affecting cholesterol, also reduces the risk of a heart attack.

In the study, 10,000 people who have already had a heart attack were randomly assigned to get injected with a placebo or different doses of a drug called canakinumab. Canakinumab, made by Novartis, is currently approved to treat rare immune-related conditions and works to reduce inflammation but does not affect cholesterol levels. After four years, the people who received the drug had a 15% lower chance of having a heart attack or stroke compared to people who didn’t get the drug. The medication also reduced the need for angioplasty or bypass surgery by 30%.

“Even I am pinching myself,” says Dr. Paul Ridker, who led the study and is director of the center for cardiovascular disease prevention at Brigham and Women’s Hospital and is a pioneer in exposing the role inflammation plays in heart disease. “This outcome is more than we hoped for. The bottom line is we now have clear evidence that lowering inflammation through this pathway lowers rates of heart attack and stroke with no change at all in cholesterol.”

About a quarter of people who have heart attacks will have another heart event even if they keep their cholesterol at recommended levels. For them, it may not be cholesterol so much as inflammation that is driving their heart disease. So the study further solidifies the fact that heart doctors should be measure inflammation as well as cholesterol in their heart patients. An inexpensive blood test that looks for a protein that rises in the blood with inflammation, called C-reactive protein (CRP), can tell doctors how much inflammation their patients have. Beginning in 2003, the American Heart Association started to provide guidelines on how doctors should use CRP testing; for patients like those in the current trial, the group did not see any additional benefit to CRP testing since those patients should already be treated with statins, which can lower both cholesterol and inflammation.

But with the new results, those guidelines may change. Ridker says the findings should clarify how doctors can optimize the way they treat their heart patients — about half of people who have had a heart attack tend to have high levels of inflammatory factors, while half have high cholesterol levels. The inexpensive CRP test could identify those with higher inflammation, who might be candidates for taking a drug like canakinumab.

The drug is not currently approved for any heart conditions, but Novartis will likely look at doing more studies to confirm its effectiveness in treating heart disease.

Perhaps more intriguing are additional results that Ridker reported, related to cancer. In a separate study published in the Lancet using data from the same study, he found that people taking canakinumab lowered their risk of dying from any cancer over four years by 50%, and their risk of fatal lung cancer by 75%.

While the connection between heart disease and cancer may not seem obvious, Ridker says that many people who have had heart problems, like those in the study, are former or current smokers, since smoking is a risk factor for heart attacks. And smoking increases inflammation. “People who smoke a pack of cigarettes a day are chronically inflaming their lungs,” he says. That’s why he decided to look at cancer deaths as well as heart events in his study population.

The cancer data is still preliminary, and needs to be confirmed with additional studies, but it’s encouraging, says Dr. Otis Bradley, chief medical officer for the American Cancer Society, who was not involved in the study. “We know that free oxygen radicals and inflammation can damage DNA and can cause cancer,” he says. “This all makes sense to me.” Studies have already shown, for example, that inflammation may be a factor in prostate cancer and colon cancer.

But whether anti-inflammatory agents, like canakinumab, or even over-the-counter drugs like aspirin, should be part of standard cancer treatment isn’t clear yet. There are a number of different inflammatory pathways, and canakinumab targets just one. Other pathways, along with new anti-inflammatory drugs, may emerge with more research.

When it comes to heart disease, however, it’s clear that inflammation-fighting medications like canakinumb may represent the next generation of treatment. “Ten years from now we will be doing more personalized medicine,” says Ridker. “Some people will get more cholesterol lowering. Some will get more inflammation-lowering drugs. Some will get other agents that we haven’t considered yet. It’s a wonderful new era in heart disease treatment.”

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Increases in Pediatric Hypertension

More children and teens are likely to be categorized as having abnormal blood pressure during their annual wellness visits, based on new recommendations released this week by the American Academy of Pediatrics.

High blood pressure is mostly a “silent” condition, with no visible symptoms. Yet it can have long-term health consequences, including cardiovascular disease. The new guidelines, aimed at prevention, were published Monday in the journal Pediatrics. They include new diagnosis tables based on normal-weight children.

The academy convened a 20-person committee to update the previous guidelines, issued in 2004, and develop new evidence-based recommendations. As part of its work, the committee reviewed nearly 15,000 articles focused on diagnosis, evaluation and early management of abnormally high blood pressure in children and teens.

An estimated 3.5% of all children and teens in the United States have hypertension, according to the guidelines. “The prevalence of 3.5% is based on fairly recent large-scale screening studies,” said Dr. Joseph T. Flynn, lead author of the guidelines and a professor of pediatrics at University of Washington. In the past, the percentage of children diagnosed with high blood pressure was lower, he said: “based on previous studies, maybe 1% to 2%.”

The cause of hypertension depends on the age group. “In infants and very young children, we worry about an underlying cause like kidney disease,” Flynn said. With older school-age children and teenagers, the cause is more likely to be primary hypertension, sometimes called essential hypertension, “where there’s no specific problem,” he said. “This is like adults.”

Obesity does contribute to higher blood pressure, yet the physiological mechanisms causing high blood pressure are very complicated, and not all kids who are overweight or obese are hypertensive, while some normal-weight kids may be.

“If, for example, a child is known to have kidney disease or heart disease, then they would be at higher risk for hypertension. Another group would be kids whose parents have hypertension,” Flynn said. The guidelines include updated blood pressure tables based on normal-weight children for more precise classifications of hypertension. As a result, more children will be categorized as needing treatment.

“Untreated, we believe that high blood pressure in a child will lead to high blood pressure when that child becomes an adult, so that would potentially lead to an increased risk of cardiovascular disease later in life,” Flynn said, adding that untreated hypertension can also cause heart and kidney damage. The new guidelines are aligned with those for adults, according to Flynn. “The blood pressure levels that are concerning in adults would also be concerning in an older teenager,” meaning those age 13 and older. “It simplifies things for doctors,” he said.

The major thing parents need to know is that their children should have their blood pressure checked when they see a doctor, Flynn said. Also, know that hypertension can be managed with lifestyle change: for example, more exercise or changing the diet. Sometimes, though, the condition requires medication. Another change in the new guidelines is an emphasis on confirmation of the diagnosis.

“Ambulatory blood pressure monitoring is a procedure in which the person wears a blood pressure cuff for 24 hours, and their blood pressure is measured periodically over 24 hours,” Flynn said. “This is very important in children because there’s a very high rate of what’s called white coat hypertension, where blood pressure is high in the office (due to fear of doctors) but not at home.”

The new recommendation is that ambulatory blood pressure should become standard practice in children after any abnormal in office reading, Flynn said. Dr. Sophia Jan, director of general pediatrics at Cohen Children’s Medical Center in New Hyde Park, New York, said the rationale behind the new guidelines makes sense. With evidence that there may be consequences for kids whose high blood pressure is not treated at lower thresholds, it makes sense to treat them earlier than in the past, said Jan, who was not involved in the new recommendations.

What she would tell parents is that “we’re not doing anything majorly different. We’re still going to check your child’s pressure when he or she comes for wellness child visits. That’s what we’ve done always in the past.” What’s new is that “we may be quicker to recommend that you and your family help your child engage in lifestyle changes if your child’s pressure is within a threshold that is lower than in the past. “Everyone’s loath to put kids on medicines if you don’t have to, but we may need to get there a little bit faster than we have traditionally in the past,” Jan said.

“As doctors, we recommend these lifestyle changes, yet in reality, it requires partnership with schools and public health agencies,” she said. “We in the pediatric community did not necessarily appreciate to what degree kids were starting to exhibit what is traditionally thought of as an adult condition. Kids can show early signs of organ damage and increased risk for cardiovascular disease despite the fact that they’re young.”

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Risks of Poor Medication Adherence

A recent study published in the journal Diabetes Care indicates that poor medication adherence in adults diagnosed with type 2 diabetes is strongly associated with increased risks for “cardiovascular disease, all-cause mortality, and hospitalizations.” Conversely, when patients have good medication adherence, these risks are reduced.

The Leicester Diabetes Center at Leicester General Hospital, in conjunction with the Diabetes Research Centre at the University of Leicester in Southmead, United Kingdom, conducted a meta-analysis surrounding eight observational studies in order to determine the correlation between medication adherence and risk for cardiovascular disease (CVD)—in addition to hospitalization and mortality rates—among adults with type 2 diabetes.

The studies’ poor adherence statistics ranged from 25% to 91%, with a mean of 37.8%; one study demonstrated that there was a decrease in CVD with good medication adherence. Other studies reported that good adherence was further associated with benefits in reduced hospitalization rates. The researchers wrote: “In conjunction with previous studies, these data should encourage health care professionals to routinely assess adherence in clinical practice and make efforts to improve it where it falls below 80%…in addition, our findings should serve to reinforce to patients the importance of taking medications as prescribed, in order to avoid premature death and preventable admissions to the hospital.”

Numerous other studies confirm that poor medication adherence is particularly common among patients with cardiovascular disease, and results in serious adverse health consequences. The American Heart Association cites that medication nonadherence results in approximately 125,000 preventable deaths per year, in addition to dramatically increased risks of hospitalization and premature death. Moreover, medication adherence leads to increased health care costs for both individuals and the health care system.

In order to address the variety of potential reasons for poor medication adherence, in addition to an assessment of solutions that could close the adherence gap, the 12th Annual CMHC will host a pre-conference Business of Medicine day on Wednesday, October 4th, featuring an expert discussion hosted by Robert H. Eckel, MD, and William H. Polonsky, PhD, CDE: “The Psychology Behind Patient Adherence.” Register for the upcoming conference in Boston from October 4-7, and learn about the various methods of diagnosis, treatment, and prevention of cardiometabolic disease.

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Sitting at Work? Exercise to Reduce Cardiometabolic Risk

Regular exercise outside of work can reduce the risk of metabolic syndrome in people whose jobs have them sitting most of the time, according to a small study from Brazil.

“If you have a sedentary occupation, especially in a sitting position for hours, you should move yourself out of work at least 150 minutes per week in a moderate intensity to mitigate the detrimental effects of sedentary behavior at work,” Eduardo Caldas Costa from Federal University of Rio Grande do Norte in Natal reported.

Sedentary behavior has been associated with an increased risk for metabolic syndrome – a cluster of unfavorable markers including abdominal obesity, high blood pressure and low HDL “good” cholesterol – which, in turn, is associated with an increased risk of developing heart disease and type 2 diabetes.

The researchers investigated whether Navy workers who spent about eight hours daily seated, mostly in administrative duties, had different risks for metabolic syndrome based on their activity levels outside of work.

All the workers were men, ranging in age from 26 to 42. Out of 502 workers included in the final analysis, 201, or 40 percent, did not achieve at least 150 minutes per week of moderate-vigorous activity. Nearly half, 48 percent, were overweight and almost 19 percent were obese.

After adjusting for age, time in the job, body mass index (BMI) and tobacco use, researchers found the sedentary workers who met the physical activity recommendations were only about half as likely to have metabolic syndrome, compared to those with lower activity levels.

Workers with higher activity levels were also less likely to have abdominal obesity, high blood pressure and low HDL.

Even those who increased their activity slightly (the “insufficiently active” group) had lower blood pressure than workers who remained sedentary off the job, researchers reported in the Journal of Occupational and Environmental Medicine.

“Sedentary occupation workers should break up prolonged sitting time at work as much as they can in order to reduce the risk for cardiovascular and metabolic diseases,” Caldas Costa said by email. “Be involved in regular physical activity out of work, including leisure time, domestic activities, and active transportation (i.e., walking and/or cycling).”

Only the physically active group, he added, and not the insufficiently active group, had a reduced risk for metabolic syndrome compared to the sedentary group. “Therefore,” he said, “it seems that probably there is a minimum quantity of physical activity that can mitigate the detrimental effects of sedentary behavior at work.”

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Salt Consumption: Enough to Damage Heart?

The amount of salt a typical American adult consumes each day may be enough to damage the heart muscle and make it harder to pump blood, a U.S. study suggests.

A high-salt diet has long been linked to higher odds of developing high blood pressure and heart disease as well as an increased risk of heart attack, stroke and heart failure. But determining the ideal amount of dietary salt is controversial because some research has also found an elevated risk of heart disease, high blood pressure and heart attacks in otherwise healthy people who consume too little salt.

In the current study, published in the Journal of the American College of Cardiology, half of the people consumed at least 3.73 grams a day of sodium, the equivalent of about two teaspoons of table salt.

Compared with adults who ate less sodium, people who consumed more than 3.7 grams of sodium a day were more likely to have enlargement in the left chambers of the heart that are responsible for pumping oxygen-rich blood into the body. They were also more likely to have signs of muscle strain in the heart that can precede structural damage.

“This study enhances our understanding of the adverse effects of salt intake on heart function,” said lead study author Dr. Senthil Selvaraj, a researcher at the Hospital of the University of Pennsylvania in Philadelphia.

While the results don’t settle the debate over the optimal amount of salt, the findings should still encourage people who eat a lot of salt to cut back, Selvaraj said by email. That’s because reducing sodium intake can help reverse high blood pressure, a major risk factor for heart failure, stroke and heart attacks.

“There is still a healthy debate ongoing,” Selvaraj added. “It is still worth the effort to reduce your sodium intake.”

Cardiovascular diseases are the leading cause of death worldwide, killing almost one in every three people. Sodium is found not only in table salt, but also in a variety of foods such as bread, milk, eggs, meat, and shellfish as well as processed items like soup, pretzels, popcorn, soy sauce and bouillon or stock cubes.

To lower the risk of heart disease, adults should reduce sodium intake to less than 2 grams a day, or the equivalent of about one teaspoon of salt, according to the World Health Organization (WHO).

For the current study, researchers examined data from lab tests of sodium intake, heart structure and heart function for almost 3,000 adults. Participants were 49 years old on average, 54 percent had high blood pressure and half were African-American. They were typically overweight or obese. To assess how sodium intake influenced the heart, researchers accounted for age, sex, smoking status, alcohol use, activity levels, and certain medications.

The study wasn’t a controlled experiment designed to prove how or if salt damages the heart or impairs heart function.
One limitation of the study is that researchers tested sodium intake using overnight urine samples, which may not be as accurate as the gold standard, 24-hour urine collection, the authors note.

Researchers also didn’t have enough data on people who consumed very little sodium to assess how low salt intake influences the heart. “We know less than we should about salt,” said Thomas Marwick, author of an accompanying editorial and director of the Baker Heart and Diabetes Institute in Melbourne, Australia.

“In general, most of the population take far more salt than is good for them and this is a reminder to reduce intake,” Marwick said by email. “It’s ubiquitous and hard to reduce to very low levels,” Marwick added. “While some zealots want to reduce intake to zero, I’m not sure that drastic reduction is necessarily beneficial.”

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New ADA/AADE Standards Combine Diabetes Education & Support

New recommendations from the American Diabetes Association (ADA) and American Association of Diabetes Educators (AADE) combine the concepts of diabetes self-management education and support for the first time.


The document, published in both Diabetes Care and the Diabetes Educator, is an update from 2014, when guidelines for diabetes self-management support and diabetes self-management education had been outlined separately.

Today, the view is that “diabetes self-management education and support (DSMES) is a critical element of care for all people with diabetes and those at risk for developing the condition,” write task force co-chairs and certified diabetes educators Joni Beck, PharmD, and Deborah A Greenwood, PhD, RN, and colleagues.

“DSMES is the ongoing process of facilitating the knowledge, skills, and ability necessary for prediabetes and diabetes self-care, as well as activities that assist a person in implementing and sustaining the behaviors needed to manage his or her condition on an ongoing basis, beyond or outside of formal self-management training,” they explain.

While the standards define evidence-based DSMES services that meet or exceed Medicare’s diabetes self-management training (DSMT) regulations, they don’t actually guarantee reimbursement. “The hope is that payers will view these standards as a tool for reviewing DSMES reimbursement requirements and consider change to align with the way their beneficiaries’ engagement preferences have evolved,” the authors say.

Currently, less than 5% of Medicare beneficiaries use the DSMES benefits that are covered.

The standards apply to diabetes educators in a variety of settings and within new and emerging models of care, such as virtual visits, accountable care organizations, patient-centered medical homes, and value-based payment models.

These same DSMES standards are used both for ADA recognition and AADE accreditation and also can serve as a guide for non-accredited and non-recognized diabetes education providers.

Although there is overlap between DSMES services and those of the National Diabetes Prevention Program (National DPP) lifestyle-change program, the two are tailored to different audiences (diabetes vs prediabetes) and have different goals (diabetes management vs prevention). Recognition of DPP programs is handled by the US Centers for Disease Control and Prevention. Centers providing both types of services have been shown successful, but they need to meet both sets of standards.

The new document details 10 specific standards for DSMES programs: internal structure, stakeholder input, evaluation of population served, quality coordinator overseeing DSMES services, the DSMES team, curriculum, individualization, ongoing support, participant progress, and quality improvement.

While previous standards have used the term “program,” the current terminology is “services,” which “more clearly delineates the need to individualize and identify the elements of DSMES appropriate for an individual. This revision encourages providers of DSMES to embrace a contemporary view of the new complexities of the evolving healthcare landscape,” the authors write.

Expect the next revision sooner than 3 years from now, they say. “Given the rapidly changing healthcare environment and the ever-growing field of technology, the 2017 Standards Revision Task Force recognizes the potential need to review the literature for evidence-driven updates more frequently in the future as advances in healthcare delivery are evolving.”

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Why Are Different Countries Obese?

Recently published studies dictate different causes and factors behind the public health epidemic of obesity, focusing on several different countries–many of which have varying reasons for their respective obesity epidemics.

The Pacific Islands, Middle East and Americas lead the way in terms of regions with the greatest obesity rates. In 2014, more than 48% of the population of the Cook Islands was classified as obese. Qatar led the way in the Middle East with 34%, followed closely by the United States at 33%, according to the World Health Organization.

Obesity is defined using a person’s body mass index, the ratio between weight and height, with a BMI of 25 to 29.9 considered overweight and over 30 obese. The number of overweight or obese infants and children under the age of 5 increased from 32 million in 1990 to 42 million in 2013, according to the World Health Organization, with numbers increasing from 4 million to 9 million in the African region alone over that period.

While physical inactivity is said to be aiding the growing rate of obesity worldwide, for example as urbanization leads to more sedentary lives, experts point out that in some populations, exercise simply isn’t a priority.

This is evident in the Middle East and China, they say, namely through perceptions of exercise and its place on residents’ list of priorities. In Kuwait, focus groups from the World Health Organization found that locals consider exercise as sport rather than something done with a group of friends or at home, according to Temo Waqanivalu, team leader of population-based prevention of noncommunicable diseases at the WHO. “There’s a whole cultural barrier,” he said.

In addition, in the Middle East overall, it’s not considered the norm for women to take part in outdoor exercise or physical activity for leisure. “Having women exercise openly is a cultural issue,” he said. Across Asia and the Middle East, Hu thinks there is a great deal of misunderstanding. “Most people are not aware of the benefits of being physically active on their health,” he said.

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CHCP Credentials & Continuing Education

The Alliance for Continuing Education in the Health Professions has recently published an interview profiling the General Manager of the Cardiometabolic Health Congress, Amanda Jamrogiewicz, who recently achieved her CHCP—delivering enhanced credibility to CMHC as a provider of continuing medical education.

The CHCP credential is one of the primary ways to enhance professional development: recognition from the industry that one is both knowledgeable and experienced in CME accreditation. Because there is no formal education or degree in terms of CME, the CHCP credential adds significant value to professional and educational development.

Moreover, the CHCP designation provides CMHC with a valuable CME/CE resource, credible not only to internal organizational activities, but also to outside stakeholders. Through the CHCP accreditation, leaders in healthcare education and training develop the necessary information, tools, and skillsets in order to navigate today’s healthcare industry. CHCP programs are dedicated to providing training in the allied healthcare fields, and students become both highly proficient and knowledgeable in the sphere of healthcare.

The CHCP credential furthers CMHC’s commitment to valuable clinical education, rooted in the most recent scientific discoveries, research, and findings.

Visit the CMHC Education Resource Center for further information. 

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Moderate Drinking May Help Prevent Diabetes

A study published in Diabetologia, conducted by researchers from the National Institute of Public Health of the University of Southern Denmark, suggests that people who drink three to four times a week are less likely to develop type 2 diabetes than those who never drink.

The study, which surveyed over 70,000 people on alcohol intake, found that wine was particularly beneficial—as it likely plays a role in helping manage blood sugar. The study does note, however, that drinking frequency has an independent effect from the amount of alcohol taken: the effects are more beneficial when drinking the alcohol in four portions, rather than all at once.

The researchers concluded that moderate drinking three to four times a week reduced a woman’s risk of diabetes by 32%, while it lowered a man’s risk by 27%, compared with people drinking less than one day a week.

The findings further suggest that not all types of alcohol yielded the same effect: while men who drank 1-6 peers per week lowered their diabetes risk by 21%, there was little to no impact on women’s risk. Conversely, a high intake of spirits among women significantly increased their risk of diabetes—yet there was no effect on men.

The team have used a similar survey to research the effect of alcohol on other conditions, finding that drinking moderately a few times a week was linked to a lower risk of cardiovascular disorders including heart attack and stroke.

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