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Month: November 2017

The Co-Occurrence of Diabetes & Heart Disease

The number of people living with diabetes has tripled since 2000, leading to enormous financial ramifications: the global cost of the disease is $850 billion each year. The latest estimates from the International Diabetes Federation indicate that one in 11 adults worldwide have diabetes; most have type 2 diabetes, which is strongly linked to obesity and lack of exercise. There is a strong link between type 2 diabetes and cardiovascular disease, as people with diabetes are more than twice as likely to develop cardiovascular disease and lower life expectancy.

According to a study presented at the American Heart Association’s Scientific Sessions last week, data indicates that children and young adults with diabetes mellitus have a fivefold increased risk of all-cause mortality, and a sevenfold increased risk of sudden cardiac death, compared with age-matched individuals without diabetes. The findings highlight the critical need for continuous cardiovascular risk monitoring and management in young people with DM.

Less than half of those diagnosed with diabetes are aware that the diseases places them at a much higher risk for cardiovascular disease complications; the lack of awareness prevents addressing risks and improving health–often leading to preventable deaths. Ken Thorpe, Chairman of the Partnership to Fight Chronic Disease, urges education and the power of prevention. “We must do better to diagnose, treat, and prevent chronic conditions like diabetes and cardiovascular diseases, and one of the first and most important actions we can take is to raise awareness among patients, providers, and policymakers of the alarming co-existence of these two debilitating conditions, and what can be done to avoid them in the first place.”

The total number of diabetes worldwide is now 451 million, and is expected to reach 693 million by 2045 if current trends continue.

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New Guidelines for High Blood Pressure

According to a joint statement issued Monday by the American Heart Association and the American College of Cardiology, nearly half of all adult Americans will be considered to have high blood pressure under new guidelines. “The numbers are scary,” said Dr. Robert M. Carey, professor of medicine at the University of Virginia and co-chair of the committee that formulated the new guidelines.

The nation’s leading heart experts state that tens of millions more Americans will now meet criteria for the condition of high blood pressure, as the redefinition is now a reading of 130 over 80, down from 140 over 90. The number of adults with high blood pressure, or hypertension, will rise to 103 million from 72 million under the previous standards—meaning that 46% of U.S. adults will be considered hypertensive.

Carey states that the reformulation stems from the recognition that blood pressure considered ‘normal’ in the past—or ‘pre-hypertensive’—actually placed patients at significant risk for heart disease and death and disability, as medical evidence confirms that people with high blood pressure in the 130-139 range carry a doubled risk of heart attack, stroke, and heart and kidney failure. “The risk hasn’t changed. What’s changed is our recognition of the risk.”

Nevertheless, the report’s authors predict that few of those who fall into the new hypertensive category will require medication. Rather, the hope is that many with early stages of the condition will address it through lifestyle changes, including weight loss, diet improvements, increased physical activity, less alcohol and sodium consumption, and lowered stress. “An important cornerstone of these new guidelines is a strong emphasis on lifestyle changes as the first line of therapy. There is an opportunity to reduce risk without necessarily imposing medications,” said Richard Chazal, the immediate past president of the American College of Cardiology.

High blood pressure is the leading cause of death worldwide, and the second-leading cause of preventable death in the United States, after cigarette smoking. Hypertension is often a precursor for cardiovascular disease, strokes, severe kidney disease, and other disorders that kill millions annually. Thomas R. Frieden, the former director of the U.S. Centers for Disease Control and Prevention who now runs a global health initiative that focuses on heart disease and stroke, has called hypertension “the world’s most under-addressed preventable health problem.”

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Big Data for Better Hearts

The genomics revolution has brought personalized medicine to cancer and rare diseases; an EU-funded initiative aims to bring cardiovascular care into the genomics era. The €19 million project, funded by the EU’s Innovative Medicines Initiative, was launched in order to apply the power of genomics and big data to cardiovascular health.

The project is a recognition that in the face of the enormous burden of heart failure, atrial fibrillation and acute coronary syndrome, the field lags behind other major disease areas in using genomic and big data to improve patient outcomes.

It is hoped that the outputs will lead to a major revamp of clinical guidelines in cardiology. The researchers involved in BigData@Heart have been instrumental in shaping current treatment and management of heart conditions and there is an emerging consensus that these should be updated to reflect advances in big data.

“Today’s treatment guidelines reflect the scientific constraints of an earlier era where clinical markers to guide therapy were limited to conventional risk factors and end-organ damage, and where the main endpoint in clinical trials is patient death and hospitalization,” said project member Stefan Anker of Charité University Medicine, Berlin. “Our goal is to build a much more personalized, data-driven system that brings cardiology into the ‘omics era.”

While the treatment of cardiovascular diseases has improved vastly in recent decades, the human and economic cost of lost productivity, hospitalization and death remains substantial, said Maureen Cronin of the pharmaceutical company Vifor Pharma, a co-lead of the project. “Advances in ‘omics have changed how we think about disease but have not been fully embraced in cardiovascular disease. If you look to oncology and rare diseases, there has been much greater progress.”

A simple blood test can help predict the risk of developing breast cancer, or guide doctors in selecting cancer drugs. This more personalized approach to cancer care is the result of decades of genetics research and advances in diagnostic testing. Similarly, genomics is making a major contribution to the diagnosis and treatment of rare diseases.

So for example, the National Health Service in England now makes DNA sequencing of tumors to identify mutations against which there are targeted drugs, an integrated part of clinical care. In inherited rare diseases, the genomes of patients are being sequenced in order to try and reach a diagnosis and to inform treatment. Cancers and rare diseases are amenable to this approach because in most cases they are driven by mutations. Cardiovascular diseases, in contrast, tend to have more heterogeneous etiologies, and patients often have comorbidities.

“In cardiovascular conditions, there is most likely a genetic component but the relative roles of genetics, comorbidities, such as hypertension, diabetes or kidney disease and risk factors, such as exercise and diet are not yet fully elucidated,” said Folkert Asselbergs of UMC Utrecht and University College London. “This complicates our understanding of a patient’s prognosis.”

However, advances in computing power and the availability of large patient data sets could allow researchers to build algorithms that take account of a patient’s genes, lifestyles and other chronic illnesses. Ultimately, said Asselbergs, this would pave the way for a more individualized and efficient approach to therapy.

BigData@Heart is one of four disease-specific projects exploring how to use patient information to improve outcomes being funded by IMI. The €5.3 billion collaboration between the pharmaceutical industry and the European Commission is designed to speed up drug discovery and development, through investments in research infrastructure, streamlining clinical trials processes and promoting data sharing.

“Thanks to this public-private partnership approach, BigData@Heart has access to most of the relevant large-scale European cardiovascular disease databases, ranging from electronic health records and disease registries to clinical trials and large epidemiological cohorts,” said Rick Grobee, UMC Utrecht and academic leader of the project. “This brings together data from more than five million cases of atrial fibrillation, heart failure and acute coronary syndrome, as well as [that of] over 16 million healthy individuals.”

Building on the experience gained in other IMI projects, the researchers will use machine learning and data mining to design prognosis algorithms that can predict patient outcomes. The system will use an individual’s medical history, along with hospitalization rates and country-specific statistics for similar patients, to advise on the best course of treatment and the likely results.

Along with more tailored use of existing treatments, the consortium hopes to identify new drug targets. The development pipeline for cardiovascular drugs is slow, expensive and high-risk, Cronin noted. “The chance of eventual approval for a cardiovascular disease drug candidate in Phase I trials is 7 per cent, the lowest of any disease category – along with oncology,” she said. “We need better definitions of these diseases, their markers and endpoints, as well as better segmentation of patient populations. In defining disease outcomes, we must listen to patients and take account of what matters to them, including functional capacity and quality of life.”

The project will run to 2022, focusing on six pilot studies and will also address ethical and regulatory issues. Central to this will be finding ways to access patient data while safeguarding personal privacy, and agreeing on the essential elements of electronic patient records. Cronin says getting that right will make or break Europe’s efforts to catch up with the US in the race to unlock the potential of big data in healthcare.

“The US precision medicine initiative is taking these issues seriously,” she says. “In the EU, the complexities of managing data in several countries, each with its own health system, mean there is a lot of catching up to do. We need to be sure that Europe is not left behind.”

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Adolescent & Childhood Obesity Reaches All-Time High

The number of obese children and adolescents rose to 124 million in 2016: more than 10 times higher than the 11 million classified as obese 40 years ago, in 1975. A further 213 million children and adolescents were overweight in 2016, finds a new study published Tuesday in the Lancet.

Looking at the broader picture, this equated to roughly 5.6% of girls and 7.8% of boys being obese last year. Most countries within the Pacific Islands, including the Cook Islands and Nauru, had the highest rates globally, with more than 30% of their youth ages 5 to 19 estimated to be obese.

The United States and some countries in the Caribbean, such as Puerto Rico, as well as the Middle East, including Kuwait and Qatar, came next with levels of obesity above 20% for the same age group, according to the new data, visualized by the NCD Risk Factor Collaboration.

“Over the past four decades, obesity rates in children and adolescents have soared globally, and continue to do so in low- and middle-income countries,” said Majid Ezzati, professor of global environmental health at Imperial College London in the UK, who led the research. “More recently, they have plateaued in higher-income countries, although obesity levels remain unacceptably high,” he said.

Over the same time period, the rise in obesity has particularly accelerated in East and South Asia. “We now have children who are gaining weight when they are 5 years old,” unlike children at the same age two generations ago, Ezzati told CNN.

In the largest study of its kind, more than 1,000 researchers collaborated to analyze weight and height data for almost 130 million people, including more than 31 million people 5 to 19 years old, to identify obesity trends from 1975 to 2016.

“Rates of child and adolescent obesity are accelerating in East, South and Southeast Asia, and continue to increase in other low and middle-income regions,” said James Bentham, a statistician at the University of Kent, who co-authored the paper.

Obesity in adults is defined using a person’s body mass index, the ratio between weight and height. A BMI of 18.5 to 24.9 is classified as a healthy weight, 25 to 29.9 considered overweight and 30 and over obese. Cut-offs are lower among children and adolescents and vary based on age.

“While average BMI among children and adolescents has recently plateaued in Europe and North America, this is not an excuse for complacency as more than one in five young people in the U,S. and one in 10 in the UK are obese,” he said.

Being obese as a child comes with a high likelihood of being obese as an adult and the many health consequences that come with it, including the increased risk of diabetes, cardiovascular disease and some cancers. The potential for these chronic conditions into adulthood also puts an increased burden on health systems — and financial constraints on individuals.

“We are seeing very worrying trends with pediatricians who have children come in as young as 7 with type 2 diabetes,” said Temo Waqanivalu, programme officer for population-based prevention of non-communicable diseases at the World Health Organization. WHO co-led the research with Imperial College London.

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African-Americans More Likely to Die from Cardiovascular Disease

According to the American Heart Association, African Americans experience significantly worsened cardiovascular health, and thus face greater mortality rates from heart disease. African Americans die an average of 3.4 years before white Americans, a gap largely attributable to prevalent cardiovascular disease and risk factors. Recent publication of a scientific statement from the organization reads: “The burden of cardiovascular disease in the African American community remains high and is a primary cause of disparities in life expectancy between African Americans and whites.”

Dr. Mercedes R. Carnethon from Northwestern University Preventive Medicine in Chicago states that traditional cardiovascular risk factors—including high blood pressure, diabetes, obesity, and atherosclerosis—are not only more common among African Americans, but also manifest at relatively young ages. Data indicates that high blood pressure is diagnosed in 13.8 percent of black children, compared to 8.5 percent in white children. The risk of persisting hypertension in black adults, throughout adulthood, is 1.5 times higher than in whites. “Interrupting this process by preventing the early onset of cardiovascular diseases is one strategy to reduce disparities in cardiovascular disease mortality,” Dr. Carnethon writes.

The research team at the American Heart Association notes that circumstances have remained fairly stagnant since 2005; relatively little has changed since 2005, when the same journal pointed to disparities in the rates of cardiovascular disease, disease management, and outcomes for African Americans. While genetic differences between African Americans and other groups do not account for the disparities in cardiovascular disease rates and outcomes, many of the variances arise from “unhealthy behaviors, lower implementation of guidelines shown to improve cardiovascular health, ingrained cultural preferences and attitudes, and lack of persistence in following lifestyle changes that need to be lifelong.”

While Dr. Carnethon’s team notes that cardiovascular disease is often preventable through the implementation and continued practice of a healthy, nutritious lifestyle, she discusses the difficulties faced by many African Americans—particularly those in lower income groups—in accessing the necessary resources to lead healthy lifestyles: specifically, access to healthful foods, safe spaces for physical activity and exercise, and homes that allow for restorative sleep. Moreover, she argues that despite the strides our country has made in broadening access to healthcare, many African-Americans are still unable to afford and prioritize preventive care visits.

Dr. LaPrincess Brewer from the Mayo Clinic in Rochester, Minnesota has continuously worked to promote cardiovascular health in African-American communities, promotes “culturally relevant, community-based cardiovascular health interventions that focus more on positive motivation towards promoting cardiovascular health rather than the negative impact of cardiovascular disease.” Through increased awareness, and a collective, collaborative effort on the part of clinicians, public health workers, researchers, social services, and community stakeholders, the high burden of traditional risk factors among African Americans can be addressed—in tandem with the inherent social and environmental contextual barriers faced by this specific population.

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