Perceived Stress May Predict Future Risk of Coronary Heart Disease

27% increased risk for newly diagnosed heart disease or death among those with high perceived stress

Are you stressed? Results of a new meta-analysis of six studies involving nearly 120,000 people indicate that the answer to that question may help predict one’s risk of incident coronary heart disease (CHD) or death from CHD. The study, led by Columbia University Medical Center researchers, was published in a recent issue of the American Journal of Cardiology.

The six studies included in the analysis were large prospective observational cohort studies in which participants were asked about their perceived stress (e.g., “How stressed do you feel?” or “How often are you stressed?”). Respondents scored either high or low; researchers then followed them for an average of 14 years to compare the number of heart attacks and CHD deaths between the two groups. Results demonstrate that high perceived stress is associated with a 27% increased risk for incident CHD (defined as a new diagnosis or hospitalization) or CHD mortality.

“While it is generally accepted that stress is related to heart disease, this is the first meta-analytic review of the association of perceived stress and incident CHD,” said senior author Donald Edmondson, PhD, assistant professor of behavioral medicine at CUMC. “This is the most precise estimate of that relationship, and it gives credence to the widely held belief that general stress is related to heart health. In comparison with traditional cardiovascular risk factors, high stress provides a moderate increase in the risk of CHD – e.g., the equivalent of a 50 mg/dL increase in LDL cholesterol, a 2.7/1.4 mmHg increase in blood pressure or smoking five more cigarettes per day.”

“These findings are significant because they are applicable to nearly everyone,” said first author Safiya Richardson, MD, who collaborated with Dr. Edmondson on the paper while attending the Columbia University College of Physicians and Surgeons (she graduated in 2012 and is currently a resident at North Shore Long Island Jewish Health System in Manhasset, New York). “The key takeaway is that how people feel is important for their heart health, so anything they can do to reduce stress may improve their heart health in the future.”

Coronary heart disease (CHD), also called coronary artery disease, is a narrowing of the small blood vessels that supply blood and oxygen to the heart. It is caused by a buildup of plaque in the arteries, which can lead to hardening of the arteries, or atherosclerosis. CHD is the leading cause of death in the United States for men and women; more than 385,000 people die each year from CHD.

The researchers did further analysis to try to learn what might underlie the association between stress and CHD. They found that while gender was not a significant factor, age was. The people in the studies were between the ages of 43–74; among older people, the relationship between stress and CHD was stronger.

“While we do not know for certain why there appears to be an association between age and the effect of perceived stress on CHD, we think that stress may be compounding over time. For example, someone who reports high perceived stress at age 60 may also have felt high stress at ages 40 and 50, as well.” Dr. Edmondson also noted that older individuals tend to have worse CHD risk factors such as hypertension to begin with, and that stress may interact with those risk factors to produce CHD events.

“The next step is to conduct randomized trials to assess whether broad population-based measures to decrease stress are cost-effective. Further research should look at whether the stress that people report is about actual life circumstances (e.g., moving or caregiving), or about stable personality characteristics (e.g., type A vs. B), said Dr. Edmondson.

“We also need to ask why we found this association between stress and CHD, e.g., what biological components or mechanisms are involved, and what is the role of environment or lifestyle (e.g., diet, alcohol and drug use, exercise), and how best to moderate these factors to lower the risk of CHD,” said Dr. Richardson.

Sunlight may help ward off rheumatoid arthritis in women

Use of sunblock could lessen protective effects, suggest authors

[Exposure to ultraviolet-B and risk of developing rheumatoid arthritis among women in the Nurses Health Study Online First doi 10.1136/annrheumdis-2012-202302]

Regular exposure to sunlight—specifically ultraviolet B (UVB)—may reduce the risk of developing rheumatoid arthritis, indicates a large long term study published online in the Annals of the Rheumatic Diseases.

But the effect of UVB exposure was only evident among older women, possibly because younger women are more aware of the hazards of sunlight and so cover up with sun block, suggest the authors.

They base their findings on participants in two phases of the US Nurses Health Study (NHS), the first of which has tracked the health of more than 120,000 nurses since 1976, when they were aged between 30 and 55, until 2008.

The second (NHSII) has tracked the health of a further 115,500 nurses since 1989, when they were aged between 25 and 42, until 2009.

Rather than simply relying on geography to quantify likely levels of UVB exposure, the researchers used a more sensitive assessment, known as UV-B flux, which is a composite measure of UVB radiation, based on latitude, altitude, and cloud cover.

It is measured in R-B units: a count of 440 R-B units over 30 minutes, for example, is sufficient to produce slight redness in untanned white skin.

Exposure was then estimated according to the US state of residence, and ranged from an annual average of 93 in Alaska and Oregon to 196 in Hawaii and Arizona. Likely estimates of UV exposure at birth and by the age of 15 were also included.

Over the study period, 1314 women developed rheumatoid arthritis. Among nurses in the first NHS cohort, higher cumulative exposure to UVB was associated with a reduced risk of developing the disease.

Those with the highest levels of exposure were 21% less likely to develop rheumatoid arthritis than those with the least, the analysis showed.

This backs up the findings of other studies, showing a link between geography and the risk of rheumatoid arthritis as well as other autoimmune conditions, including type 1 diabetes, inflammatory bowel disease, and multiple sclerosis, say the authors.

But no such association for UV-B exposure was found among women in NHSII. These women were younger than those in the first NHS, and so might have been more savvy about the potential hazards of acquiring a tan, suggest the authors.

"Differences in sun protective behaviours (eg greater use of sun block in younger generations) may explain the disparate results," they explain.

They add that it is unclear at what stage of life the protective effect of UV-B occurs. Many of the study participants didnt move house between birth and their teens, and there was no difference in the results for these time points.

But they conclude: "Our study adds to the growing evidence that exposure to UV-B light is associated with decreased risk of rheumatoid arthritis. The mechanisms are not yet understood, but could be mediated by the cutaneous production of vitamin D and attenuated by use of sunscreen or sun avoidant behaviour."

Diet may not impact certain health outcomes in older persons

Eating diets high in sugar and fat may not affect the health outcomes of older adults ages 75 and up, suggesting that placing people of such advanced age on overly restrictive diets to treat their excess weight or other conditions may have little benefit, according to researchers at Penn State and Geisinger Healthcare System.

"Historically people thought of older persons as tiny and frail," said Gordon Jensen, head of the Department of Nutritional Sciences at Penn State, "but that paradigm has changed for many older persons. Currently, 30 percent or more may be overweight, and by 2030, almost 30 percent are projected to be obese, not just overweight. Recent reports even suggest that there may be survival benefits associated with overweight and mild obesity status among the elderly."

"We all know that adverse dietary patterns, such as a Western diet containing high amounts of fat or a diet containing high amounts of ined sugar, both of which may contribute to obesity, are associated with adverse medical conditions and health outcomes for many people, but until now, the health effects of these types of poor diets have not been characterized for people who live to 75 years of age and older," said Pao Ying Hsao, postdoctoral fellow at Penn State.

The teams research is part of a decades-long collaborative study between Penn State and the Geisinger Healthcare System on the effects of nutritional status and diet on the health of more than 20,000 older people living in Pennsylvania. In the current study, the team followed 449 individuals for five years who were on average 76.5 years old at the beginning of the study.

"This is one of the first studies to examine obesity-related health outcomes and dietary patterns in such aged persons," Jensen said.

At study baseline, the team assessed the participants dietary patterns by calling each of them by telephone four or five times during a 10-month period and asking them about their diets over the previous 24 hours. The participants were categorized as adhering to one of three different dietary patterns. The "sweets and dairy" pattern was characterized by the largest proportions of energy from baked goods, milk, sweetened coffee and tea and dairy-based desserts, and the lowest intakes of poultry. The "health-conscious" pattern was characterized by relatively higher intakes of pasta, noodles, rice, whole fruit, poultry, nuts, fish and vegetables, and lower intakes of fried vegetables, processed meats and soft drinks. The "Western" pattern was characterized by higher intakes of bread, eggs, fats, fried vegetables, alcohol and soft drinks, and the lowest intakes of milk and whole fruit.

Using outpatient electronic medical records, the researchers identified whether the participants developed cardiovascular disease, diabetes mellitus, hypertension (high blood pressure) and metabolic syndrome during the five-year period. They found no relationship between dietary pattern and prevalence of cardiovascular disease, diabetes, metabolic syndrome or mortality in the participants; however, they did find an increased risk of hypertension in people who followed the "sweets and dairy" pattern.

The results appeared in this months issue of the Journal of Nutrition Health and Aging.

"We dont know if the participants had been following these dietary patterns their entire adult lives, but we suspect they had been because people dont usually change dietary practices all that much," Jensen said. "The results suggest that if you live to be this old, then there may be little to support the use of overly restrictive dietary prescriptions, especially where food intake may already be inadequate. However, people who live on prudent diets all their lives are likely to have better health outcomes."

Metabolic factors may increase mens risk of dying from prostate cancer

High blood pressure, blood sugar, blood lipids, and body mass index—characteristics that are often lumped together as the metabolic syndrome—are jointly linked with an increased risk of dying from prostate cancer. That is the conclusion of a new study published early online in CANCER, a peer-reviewed journal of the American Cancer Society. The studys results suggest that public health recommendations regarding diet and lifestyle to prevent heart disease and diabetes may also decrease a mans likelihood of dying from prostate cancer.

Researchers have little knowledge about possible links between metabolic factors, separately and combined, and mens risk of being diagnosed with or dying from prostate cancer. To investigate, Christel Häggström, MSc, Tanja Stocks, PhD, both of the Umeå University in Sweden, and their colleagues analyzed information from 289,866 men enrolled in a study called the Metabolic syndrome and Cancer project. The analysis was completed under the leadership of Pär Stattin, MD, PhD, a visiting scientist at Memorial Sloan-Kettering Cancer Center in New York City.

During an average follow-up time of 12 years, 6,673 men were diagnosed with prostate cancer and 961 died from the disease. Men in the highest categories of body mass index and blood pressure had a 36 percent and 62 percent increased risk of dying from prostate cancer, respectively. Also, when comparing a composite score of all metabolic factors, men with a high score were more likely to die from prostate cancer.

The study found no evidence for a link between high levels of metabolic factors and a mans risk of developing prostate cancer but revealed a link between these factors and his risk of dying from the disease. This suggests that while men with the metabolic syndrome are not more likely than others to develop prostate cancer, if they do develop it, they are more likely than other men to die from the malignancy. "These observations suggest that cardiovascular risk factors such as overweight and hypertension are involved in stimulating the progression of prostate cancer," said Dr. Stattin.

Seafood Rich Diet Of Alaska Natives May Reduce Risk Of Diabetes

A new study of Yup’ik Eskimos in Alaska suggests that high intake of omega-3 fats, the type found abundantly in seafood, may protect against obesity-related diseases such as diabetes:

Associations of obesity with triglycerides and C-reactive protein are attenuated in adults with high red blood cell eicosapentaenoic and docosahexaenoic acids, European Journal of Clinical Nutrition, March 2011

Of the 330 people living in the Yukon Delta region of Alaska who took part in the study, 70% were either overweight of obese, yet only about 3.3% had type 2 diabetes, compared to 7.7% for the total US population.

Senior author Alan Kristal, Dr. PH:

"The new finding was that obesity did not increase [risk factors for heart disease and diabetes] among study participants with high blood levels of omega-3 fats.”

Lead author Zeina Makhoul, Ph.D:

“Interestingly, we found that obese persons with high blood levels of omega-3 fats had triglyceride and CRP concentrations that did not differ from those of normal-weight persons.” ... “It appeared that high intakes of omega-3-rich seafood protected Yup’ik Eskimos from some of the harmful effects of obesity.”

This was an epidemiological study. To determine whether it was indeed the omega-3 fatty acids in seafood that protected the Yupik people, or some other genetic or lifestyle factor, a clinical trial is needed. Lead author Makhoul cautioned against taking high doses of supplements based on this research.
________
Results of poll: How often do you eat seafood?


________The study was led by researchers at the Fred Hutchinson Cancer Research Center. Their press release:
Study of Yupik Eskimos suggests high consumption of Omega-3 fats reduces risk of obesity-related disease
Photo of salmon drying outside an Alaskan home by Camille Lieske from The Center for Alaska Native Health Research.

Exercise May be the Best Medicine for Alzheimers

New research out of the University of Maryland School of Public Health shows that exercise may improve cognitive function in those at risk for Alzheimer’s by improving the efficiency of brain activity associated with memory. Memory loss leading to Alzheimer’s disease is one of the greatest fears among older Americans. While some memory loss is normal and to be expected as we age, a diagnosis of mild cognitive impairment, or MCI, signals more substantial memory loss and a greater risk for Alzheimer’s, for which there currently is no cure.

The study, led by Dr. J. Carson Smith, assistant professor in the Department of Kinesiology, provides new hope for those diagnosed with MCI. It is the first to show that an exercise intervention with older adults with mild cognitive impairment (average age 78) improved not only memory recall, but also brain function, as measured by functional neuroimaging (via fMRI). The findings are published in the Journal of Alzheimer’s Disease.

“We found that after 12 weeks of being on a moderate exercise program, study participants improved their neural efficiency – basically they were using fewer neural resources to perform the same memory task,” says Dr. Smith. “No study has shown that a drug can do what we showed is possible with exercise.”

Recommended Daily Activity: Good for the Body, Good for the Brain

Two groups of physically inactive older adults (ranging from 60-88 years old) were put on a 12-week exercise program that focused on regular treadmill walking and was guided by a personal trainer. Both groups – one which included adults with MCI and the other with healthy brain function – improved their cardiovascular fitness by about ten percent at the end of the intervention. More notably, both groups also improved their memory performance and showed enhanced neural efficiency while engaged in memory retrieval tasks.

The good news is that these results were achieved with a dose of exercise consistent with the physical activity recommendations for older adults. These guidelines urge moderate intensity exercise (activity that increases your heart rate and makes you sweat, but isn’t so strenuous that you can’t hold a conversation while doing it) on most days for a weekly total of 150 minutes.

Measuring Exercise’s Impact on Brain Health and Memory

One of the first observable symptoms of Alzheimer’s disease is the inability to remember familiar names. Smith and colleagues had study participants identify famous names and measured their brain activation while engaged in correctly recognizing a name – e.g., Frank Sinatra, or other celebrities well known to adults born in the 1930s and 40s. “The task gives us the ability to see what is going on in the brain when there is a correct memory performance,” Smith explains.

Tests and imaging were performed both before and after the 12-week exercise intervention. Brain scans taken after the exercise intervention showed a significant decrease in the intensity of brain activation in eleven brain regions while participants correctly identified famous names. The brain regions with improved efficiency corresponded to those involved in the pathology of Alzheimer’s disease, including the precuneus region, the temporal lobe, and the parahippocampal gyrus.

The exercise intervention was also effective in improving word recall via a “list learning task,” i.e., when people were read a list of 15 words and asked to remember and repeat as many words as possible on five consecutive attempts, and again after a distraction of being given another list of words.

“People with MCI are on a very sharp decline in their memory function, so being able to improve their recall is a very big step in the right direction,” Smith states.

The results of Smith’s study suggest that exercise may reduce the need for over-activation of the brain to correctly remember something. That is encouraging news for those who are looking for something they can do to help preserve brain function.

Dr. Smith has plans for a larger study that would include more participants, including those who are healthy but have a genetic risk for Alzheimer’s, and follow them for a longer time period with exercise in comparison to other types of treatments. He and his team hope to learn more about the impact of exercise on brain function and whether it could delay the onset or progression of Alzheimer’s disease.

6 Things Your Doctor May Have Trouble Telling You

What your doctor may not mention could matter to your health.

Patients often have trouble talking to their doctors. It can be hard to get the words out when the topic is emotionally charged or one you’d never bring up in polite conversation.

And for various reasons, sometimes including their own embarrassment, doctors may find it hard to bring up certain topics -- and that can compromise the care their patients receive.

“Communication is an inexact science,” says Bob Arnold, MD, professor of medicine at the University of Pittsburgh School of Medicine and director of its Institute for Doctor-Patient Communication. “Communication between doctors and patients is especially hard because the stakes are high and there are strong emotions on both sides.”

Some doctors are better than others at broaching touchy topics. Here are six things some doctors leave unsaid -- and what to do about it.
1. “You need to do something about that.”

Doctors are often reluctant to bring up a topic that might cause offense, even when there are pressing medical reasons to discuss it. A patient’s weight problem is one topic doctors sometimes shy away from. Others include whether the patient is depressed, smokes, abuses drugs or alcohol, has marital or sexual problems, or is experiencing financial hardship.

What to do: If your doctor fails to broach a topic that might be relevant to your health, bring it up yourself.

“Patients often think, ‘I will tell the doctor about this only if he or she asks me,’” says Richard M. Frankel, PhD, professor of medicine at Indiana University School of Medicine in Indianapolis. “They should be thinking, ‘Am I telling the doctor everything that I ought to be telling him or her?”
2. “You don’t need that drug.”

Direct-to-consumer pharmaceutical ads can be pretty effective at convincing patients that they need a particular medication (drugs to treat depression, diabetes, or erectile dysfunction are among the most heavily advertised) -- and even doctors can be swayed by these ads, notes David H. Newman, MD, director of clinical research in the emergency department at St. Luke’s Roosevelt Hospital Center in New York and the author of Hippocrates’ Shadow. And when asked for a prescription,  some doctors find it hard to say no--even when the patient doesn’t really need that particular drug.

Why is that? Ultimately, medical practices are businesses, and doctors sometimes fear that turning down a request for a drug could leave the “customer” feeling disappointed. “Doctors are terrible at saying ‘no,’” Newman says.

What to do: Newman says there’s nothing wrong with asking the doctor ifmedication might be helpful. But it’s a mistake to push a doctor to write you a prescription. “It can be dangerous to ask for things,” Newman says.
3. “I don’t know what’s going on.”

For all the advances in medical care, many ailments remain hard to diagnose and treat.

 Back pain is one. Doctors are sometimes quick to blame it on a specific anatomical cause -- for instance, muscle strain or a bulging spinal disk -- even though most back pain is of unknown origin.

Doctors are sometimes understandably reluctant to admit uncertainty. Some are so fearful of looking ignorant or incompetent that they act as if they know what’s causing a particular symptom even when they don’t. When this happens, they tend to order tests and treatments that are likely to prove needless.

What to do: How do you avoid the rush to possibly inappropriate care? Anytime a doctor suggests a test or treatment, ask questions. What will happen if you don’t get that test or treatment? How much will you benefit if you do? Don’t consent to the intervention until all your questions are answered. “You have to keep probing to know whether what the doctor is recommending is really supported by science,” Newman says.
4. “I’m not sure you got what I said.”

Doctors sometimes worry that what they tell a patient goes in one ear and out the other. Unfortunately, that’s often the case. On average, studies suggest, patients grasp only about half of what doctors tell them.

Yet the fault sometimes lies not with the patient’s inattention, but the doctor’s poor communication skills.

“Physicians tend to deliver information in long, dense mini-lectures,” says Debra Roter, DrPH, professor of health, behavior, and society at Johns Hopkins Bloomberg School of Public Health in Baltimore and the author of Doctors Talking with Patients/Patients Talking with Doctors: Improving Communication in Medical Visits. “They’ll say things like, “Let me explain to you the function of the pancreas” when what the patient wants to know what a diagnosis of diabetes means in practical terms.

To avoid misunderstanding, doctors could initiate a back-and-forth discussion with their patients. But not all do.

“Doctors are not good about assessing the patient’s understanding of our explanations,” says Dean Schillinger, MD, professor of medicine at the University of California at San Francisco. “We’re infamous for saying, ‘Are you clear about what I’ve told you?’ What we should be doing is asking patients to restate what we’ve told them.”

What to do: At the end of your appointment, if your doctor doesnt ask you to recap what theyve told you, do so anyway, Schillinger suggests. Simply tell the doctor you want to make sure you understand, and then use your own words to relate what you think you were told.

5. “This is risky.”

Just about every drug and surgical procedure poses risks to the patient. Even something as seemingly benign as a course of antibiotics can cause diarrhea, yeast infections, allergic reactions, and other unpleasant and potentially dangerous side effects.

Yet some doctors understate the risks posed by the treatments they recommend.

Similarly, when doctors order X-rays, cardiac catheterizations, and other diagnostic tests, they sometimes fail to explain the risks. These include the risk of a false-positive (indicating a medical problem that doesn’t exist), which can lead to needless anxiety and to even more tests.

”Doctors are very good at talking about benefits,” says Newman. “They’re not good at talking about risks.”

What to do: Ask the doctor to explain any risks posed by a recommended test or treatment.
6. "I dont have anything to offer you."

Some doctors may paint an overly optimistic picture when talking about life-threatening ailments, Newman says. Some encourage patients to undergo debilitating treatments when these are almost certain to fail. Even when death is imminent, Newman says, many doctors put off talking about it out of a sense of failure.

“Giving bad news makes us feel bad,” says Arnold. “Sometimes we feel inadequate and worry that our patients will blame us.” If you’d like the doctor not to pull punches when talking about your prognosis, say so, says Frankel.

What to do: Newman recommends talking to your doctor about end-of-life care while you’re still healthy. Do you want doctors to do everything possible to save your life, even if there’s little chance of survival? Or would you prefer to forgo treatment likely to keep you on a ventilator and a feeding tube? Either way, let your doctor know.

In addition to talking with your doctor, it’s prudent to draw up an advance directive that allows you to detail your wishes regarding end-of-life care and designate a health-care proxy (someone to direct your care in the event that you are incapacitated). And of course, communicate your wishes to your loved ones.

Hitting the gym may help men avoid diet induced erectile dysfunction

Obesity continues to plague the U.S. and now extends to much of the rest of the world. One probable reason for this growing health problem is more people worldwide eating the so-called Western diet, which contains high levels of saturated fat, omega-6 polyunsaturated fatty acids (the type of fat found in vegetable oil), and added sugar. Researchers have long known that this pattern of consumption, as well as the weight gain it often causes, contributes to a wide range of other health problems including erectile dysfunction and heart disease. Other than changing eating patterns, researchers havent discovered an effective way to avoid these problems.

Searching for a solution, Christopher Wingard and his colleagues at East Carolina University used rats put on a "junk food" diet to test the effects of aerobic exercise. They found that exercise effectively improved both erectile dysfunction and the function of vessels that supply blood to the heart.

The article is entitled "Exercise Prevents Western-Diet Associated Erectile Dysfunction and Coronary Artery Endothelial Dysfunction: Response to Acute Apocynin and Sepiapterin Treatment." It appears in the online edition of the American Journal of Physiology: Regulatory, Integrative, and Comparative Physiology, published by the American Physiological Society. The article is online at http://bit.ly/13jYpED.

Methodology

For 12 weeks, the researchers fed a group of rats chow that reflected the Western diet, high in sugar and with nearly half its calories from fat. Another group of rats ate a healthy standard rat chow instead. Half of the animals in each group exercised five days a week, running intervals on a treadmill.

At the end of the 12 weeks, anesthetized animals erectile function was assessed by electrically stimulating the cavernosal nerve, which causes an increase in penile blood flow and produces an erection. The researchers also examined the rats coronary arteries to see how they too responded to agents that would relax them and maintain blood flow to the heart, an indicator of heart health.

Results

The findings showed that rats who ate the Western diet but stayed sedentary developed erectile dysfunction and poorly relaxing coronary arteries. However, those who ate the diet but exercised were able to stave off these problems.

Animals who ate the healthy chow were largely able to avoid both erectile dysfunction and coronary artery dysfunction.

Importance of the Findings

These findings may suggest that exercise could be a potent tool for fighting the adverse effects of the Western diet as long as the subjects remained very active over the course of consuming this type of diet, the authors say. Whether exercise would still be effective in reversing any vascular problems after a lifetime of consuming a Western diet is still unknown.

"The finding that exercise prevents Western diet-associated erectile dysfunction and coronary artery disease progression translates to an intensively active lifestyle throughout the duration of the junk food diet," the authors say. "It remains to be seen if a moderately active lifestyle, or an active lifestyle initiated after a prolonged duration of a sedentary lifestyle combined with a junk food diet is effective at reversing functional impairment."