Watchful waiting reasonable for patients with diabetic macular edema and good vision


During the 2-year study, the detection of 2 lines of visual acuity loss at one visit or 1 line of visual acuity loss at two consecutive visits prompted aflibercept injections to be given to the people in the laser or observation groups.Brooksie Beard
People with good vision despite having center-involved diabetic macular edema can safely forego immediate treatment of their eye condition as long as they are closely monitored, and treatment begins promptly if vision worsens, according to clinical trial results. The findings are published online today in the Journal of the American Medical Association.
The study was conducted by the DRCR Retina Network (link is external) a multicenter clinical research network funded by the National Eye Institute, part of the National Institutes of Health (NIH).
Diabetic macular edema is the most common cause of vision loss among people with diabetic eye disease in the United States. Diabetes can result in the development of leaky blood vessels in the retina — the light-sensing tissue at the back of eye. Diabetic macular edema is the result of fluid build-up in the central area of the retina, called the macula, which is important for sharp vision. Swelling of the macula can distort vision required for reading and driving.
The evidence from this study should help physicians and patients navigate a common conundrum in ophthalmology: Treating diabetic macular edema in people who still have good vision too soon may subject them to unnecessary costs and risks associated with treatment. Other patients who get treatment too late might risk losing vision permanently.
“We now know that in patients with good vision and diabetic macular edema, similar to those enrolled in this trial, it’s an acceptable strategy to closely monitor patients, and initiate treatment only if their vision starts to show signs of decline,” said the study’s lead investigator Carl W. Baker, M.D., an ophthalmologist at Paducah (Kentucky) Retinal Center.
Controlling blood sugar in diabetic patients helps prevent diabetic eye disease. In addition, therapies that directly target diabetic macular edema — laser photocoagulation and injections of anti-vascular endothelial growth factor (anti-VEGF) agents — reduce or eliminate abnormal leakage from blood vessels.
The trial included 702 participants with diabetic macular edema and 20/25 vision or better, which is considered normal or near normal vision. At the start of the study, participants were randomly assigned to one of the following three management strategies for one of their eyes: 1) inject into the eye the anti-VEGF agent aflibercept (EYLEA®) as frequently as every four weeks, 2) perform laser photocoagulation, or 3) conduct observation of the participants.
During the two-year study, the detection of visual acuity loss prompted aflibercept injections to be given to the people in the laser or observation groups.  Aflibercept injections were thus required among 25% of the laser group and 34% of the observation group. Eyes that started aflibercept injections in the laser and observation groups required a similar number of injections overall compared to the group initially assigned to aflibercept.
The researchers checked participants’ visual acuity throughout the study at regular follow-up visits in retina specialty clinics. Researchers measured visual acuity in the laser and observation groups at eight and 16 weeks after study entry, and then every 16 weeks unless their visual acuity worsened.
After two years, the percentage of participants whose study eye met a prespecified threshold for visual acuity loss — one or more lines on an eye chart — did not differ among the groups: 16% of the aflibercept group, 17% of the laser group, and 19% in the observation group.  The average visual acuity, which was 20/20 at baseline, remained 20/20 in all three groups at two years.
“Based on what we’ve seen in previous, longer-term studies of people with diabetic macular edema, the visual acuity outcomes observed at the end of this two-year study are likely to be maintained if patients continue regular follow-up and treatment as needed over subsequent years,” said DRCR Retina Network Co-Chair, Jennifer K. Sun, M.D., M.P.H., Associate Professor of Ophthalmology, Joslin Diabetes Center, Harvard Medical School.
“Future technology may do a better job of identifying who might benefit from early treatment, before diabetic macular edema affects vision,” said the director of the study’s coordinating center, Adam R. Glassman, MS, Jaeb Center for Health Research in Tampa. “But for now, close monitoring of diabetic macular edema in patients with good vision is an appropriate initial strategy as long as they are closely followed and subsequently treated if vision worsens.”
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Daily folic acid supplement may reduce risk of gestational diabetes N



Taking a folic acid supplement daily before pregnancy may reduce the risk of gestational, or pregnancy-related, diabetes, according to a study by researchers at the National Institutes of Health and other institutions. The findings appear in Diabetes Care.
Folic acid is the synthetic form of folate, or vitamin B9, which is found in leafy green vegetables, nuts, peas, beans and other foods. The U.S. Preventive Services Task Force recommends (link is external) that all women of reproductive age take a daily supplement containing 400 to 800 micrograms of folic acid to reduce the risk of conceiving a child with a neural tube defect, a class of birth defects affecting the brain and spinal cord.
Gestational diabetes results when the level of blood sugar, or glucose, rises too high. It increases a woman’s chances for cesarean delivery and for blood pressure disorders during pregnancy. It also raises the risk of cardiovascular disease and type 2 diabetes later in life. For infants, gestational diabetes increases the risk of large birth size and of obesity during childhood and adulthood.
In the current study, researchers analyzed data from nearly 15,000 women enrolled in the Nurses’ Health Study II (link is external), a long-term study of diet, lifestyle factors and disease outcomes among female nurses. Among more than 20,000 pregnancies, there were 824 cases of gestational diabetes. Compared to women who did not take a folic acid supplement, those who took less than 400 micrograms were 22% less likely to develop gestational diabetes. Those who took 600 micrograms were 30% less likely to develop the condition.
“In addition to reducing the risk for neural tube defects, our findings suggest that taking folic acid supplements before pregnancy might provide a low-cost way to reduce the risk of gestational diabetes,” said the study’s senior author, Cuilin Zhang, M.D., Ph.D., of the Division of Intramural Population Health Research at NIH’s Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD).
The researchers did not find a lower risk of gestational diabetes associated with consumption of foods that contain high amounts of folate. They cited earlier studies showing that folic acid is absorbed more easily into the body, compared to the naturally occurring form of the vitamin. Researchers also noted that previous studies have found that insufficient folate is associated with insulin resistance (difficulty using insulin to lower blood glucose), which may precede the development of type 2 diabetes in non-pregnant people.
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Education may be key to a healthier, wealthier US


According to the United States Department of Education, the U.S. high school graduation rate will reach an all-time high this year, which is good news for both our economy and health. Policy makers often use education policy to strengthen the workforce and boost earnings, productivity and employment. But earning a diploma may also lead to a longer, healthier life.
A new study from the University of Colorado Denver is the first to estimate the economic value of education for better health and longevity.
The study finds that the reduced disability and longer lives among the more educated are worth up to twice as much as the value of education for lifetime earnings.
The study, "The Economic Value of Education for Longer Lives and Reduced Disability," was published in The Milbank Quarterly.
"We often think about health insurance access or medical procedures, like mammography or colonoscopy, as the most important drivers of health," said study co-author Patrick Krueger, PhD, associate professor in the Department of Health and Behavioral Sciences at CU Denver.
"But education could be a more substantial contributor to longevity than medical care. Policy makers seldom act on that evidence, though, because researchers haven't demonstrated the value of education for longer, healthier lives in terms of dollars and cents."
Compared to adults who never finished high school, adults with a high school degree live longer and with less disability. Those longer, healthier lives are worth an additional $693,000 among men and $757,000 among women. The incremental earnings associated with a high school degree are much smaller - amounting to an additional $213,000 among men and $194,000 among women.
To estimate the economic value of education for longevity, the authors used data from the National Health Interview Survey-Linked Mortality Files, Current Population Survey-Annual Social and Economic supplement, and published estimates of the economic value of a statistical life.
"We weren't surprised that the economic value of longer lives would top lifetime earnings, but we couldn't have guessed the magnitude," said Virginia Chang, MD, PhD, associate professor of social and behavioral sciences at NYU College of Global Public Health. "One additional year of life is a significant change in life expectancy and has a lot of economic value. When you consider the cost of completing high school or college is significantly less than what we spend on health care, it's clear that spending on education is going to have a much greater return."
In fact, researchers found that education has a bigger impact on health and longevity than targeted behavioral or medical interventions in adulthood. That's because the benefits of new drugs, medical treatments and behavioral interventions largely go to the most educated, who are already among the most healthy. Pulling together the big picture was important to Krueger and Chang.
"It's easy to assume that if we improved life expectancy, it would lead to increased health care costs," says Krueger. "But our inability to control medical costs is what drives our excess health care spending, not living to older ages. Other high income countries have longer life expectancies and lower health care expenditures than the U.S., suggesting that we can and should improve both."
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Being a car commuter with obesity linked to a 32% increased death risk



New research presented at this year's European Congress on Obesity in Glasgow, Scotland (28 April - 1 May) shows that individuals with obesity who commute by car have a 32% higher risk of death, from any cause, compared with those individuals with a normal weight and commute via cycling and walking. The study is by Edward Toke-Bjolgerud, University of Glasgow, UK, and colleagues.
Previous work, using UK Biobank data, has shown that active commuting, mainly cycling, was associated with a 50% lower risk of death, from any cause, and heart disease compared to car commuting. Since 57% of men and 66% of women in the UK are overweight or obese -- a condition linked with a range of poor health outcomes -- the authors of this new research aimed to investigate how different modes of active commuting (car, cycling, walking, mixed-mode) might alter the association between obesity and adverse health outcomes.
Their analysis includes 163,149 UK Biobank participants who have been followed up for a mean of 5 years. The age range was 37 to 73 years and 50.8% were women. Obesity was defined as a body mass index (BMI) (kg/m2) of greater than 30. Active commuting to and from work was self-reported and people classified in one of the following groups: car commuters, walking and cycling (active-mixed), cycling-only and walking-only. The health outcomes of interest were death from any cause, death due to heart disease and hospital admission due to non-fatal heart disease.
Dr Carlos Celis, from the British Heart Foundation Glasgow Cardiovascular Research Centre at the University of Glasgow and lead investigator of this work, reported that during the follow-up a total of 2,425 participants died and 7,973 developed heart disease. Compared with having a healthy body weight and reported mixed active commuting (walking and cycling to and from work; reference group), being obese combined with car commuting was associated with a 32% higher risk for premature death, a doubling of risk of heart disease mortality and a 59% increase in risk non-fatal heart diseases.
In contrast, those people with obesity who reported being active commuters had a risk of death from any cause that was similar to normal weight active commuters, suggesting that cycling or walking to and from work could reduce the detrimental effect of obesity. However, the risk of heart disease was still increased by 82% in active commuters with obesity compared with normal weight active commuters.
The authors conclude: "Our findings, if causal, suggest that people with overweight or obesity could potentially decrease the risk of premature mortality if they engage in active commuting."
They add: "Regardless of your body weight, being physically active could partly reduce the excess risk associated with obesity. However, compared to other forms of physical activity -- such as gyms and exercises classes -- active commuting can be implemented and fitted within our daily routines, often with no additional cost, but at the same time could increase our overall physical activity levels and therefore help to meet the current physical activity recommendations for health."
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Stressed at work and trouble sleeping? It's more serious than you think E



Work stress and impaired sleep are linked to a threefold higher risk of cardiovascular death in employees with hypertension. That's the finding of research published today in the European Journal of Preventive Cardiology, a journal of the European Society of Cardiology (ESC).1
Study author Professor Karl-Heinz Ladwig, of the German Research Centre for Environmental Health and the Medical Faculty, Technical University of Munich, said: "Sleep should be a time for recreation, unwinding, and restoring energy levels. If you have stress at work, sleep helps you recover. Unfortunately poor sleep and job stress often go hand in hand, and when combined with hypertension the effect is even more toxic."
One-third of the working population has hypertension (high blood pressure). Previous research has shown that psychosocial factors have a stronger detrimental effect on individuals with pre-existing cardiovascular risks than on healthy people. This was the first study to examine the combined effects of work stress and impaired sleep on death from cardiovascular disease in hypertensive workers.
The study included 1,959 hypertensive workers aged 25-65, without cardiovascular disease or diabetes. Compared to those with no work stress and good sleep, people with both risk factors had a three times greater likelihood of death from cardiovascular disease. People with work stress alone had a 1.6-fold higher risk while those with only poor sleep had a 1.8-times higher risk.
During an average follow-up of nearly 18 years, the absolute risk of cardiovascular death in hypertensive staff increased in a stepwise fashion with each additional condition. Employees with both work stress and impaired sleep had an absolute risk of 7.13 per 1,000 person-years compared to 3.05 per 1,000-person years in those with no stress and healthy sleep. Absolute risks for only work stress or only poor sleep were 4.99 and 5.95 per 1,000 person-years, respectively.
In the study, work stress was defined as jobs with high demand and low control - for example when an employer wants results but denies authority to make decisions. "If you have high demands but also high control, in other words you can make decisions, this may even be positive for health," said Professor Ladwig. "But being entrapped in a pressured situation that you have no power to change is harmful."
Impaired sleep was defined as difficulties falling asleep and/or maintaining sleep. "Maintaining sleep is the most common problem in people with stressful jobs," said Professor Ladwig. "They wake up at 4 o'clock in the morning to go to the toilet and come back to bed ruminating about how to deal with work issues."
"These are insidious problems," noted Professor Ladwig. "The risk is not having one tough day and no sleep. It is suffering from a stressful job and poor sleep over many years, which fade energy resources and may lead to an early grave."
The findings are a red flag for doctors to ask patients with high blood pressure about sleep and job strain, said Professor Ladwig. "Each condition is a risk factor on its own and there is cross-talk among them, meaning each one increases risk of the other. Physical activity, eating healthily and relaxation strategies are important, as well as blood pressure lowering medication if appropriate."
Employers should provide stress management and sleep treatment in the workplace, he added, especially for staff with chronic conditions like hypertension.
Components of group stress management sessions:2
  • Start with 5 to 10 minutes of relaxation.
  • Education about healthy lifestyle.
  • Help with smoking cessation, physical exercise, weight loss.
  • Techniques to cope with stress and anxiety at home and work.
  • How to monitor progress with stress management.
  • Improving social relationships and social support.
Sleep treatment can include:3
  • Stimulus control therapy: training to associate the bed/bedroom with sleep and set a consistent sleep-wake schedule.
  • Relaxation training: progressive muscle relaxation, and reducing intrusive thoughts at bedtime that interfere with sleep.
  • Sleep restriction therapy: curtailing the period in bed to the time spent asleep, thereby inducing mild sleep deprivation, then lengthening sleep time.
  • Paradoxical intention therapy: remaining passively awake and avoiding any effort (i.e. intention) to fall asleep, thereby eliminating anxiety.
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Morning exercise can improve decision-making across the day in older adults S



A study of older Australians has found a morning bout of moderate-intensity exercise improves cognitive performance like decision-making across the day compared to prolonged sitting without exercise.
Furthermore, the study showed that a morning bout of exercise combined with brief light-intensity walking breaks to frequently disrupt sitting throughout an 8-hour day can boost your short-term memory compared to uninterrupted sitting, according to the study published in the British Journal of Sports Medicine.
The 'Brain Breaks' study, led by the Baker Heart and Diabetes Institute and The University of Western Australia, also shows that the distinct responses in cognitive performance to exercise versus exercise and sitting breaks point to different patterns of physical activity being able to enhance distinct aspects of cognition.
The study of more than 65 males and females aged 55 - 80 years examined the effects of acute morning exercise on a treadmill with and without brief 3 minute walking breaks during an 8-hour day of prolonged sitting, and assessed aspects of cognition and concentration including psychomotor function; attention; executive function such as decision-making; visual learning and working memory.
Central to mediating the benefits of exercise on learning and memory is brain-derived neurotropic growth factor, a protein which plays an important role in the survival and growth of information-transmitting neurons in the brain. The results demonstrated that this protein was elevated for 8 hours during both exercise conditions, relative to prolonged sitting.
Physical activity researcher, Michael Wheeler says the study highlights that uninterrupted sitting should be avoided to maintain optimal cognition across the day, and that moderate-intensity exercise such as a brisk walk should be encouraged for the daily maintenance of brain health.
He says the study also reveals that not all aspects of cognition respond in the same way to a given dose of exercise and that it may be possible to manipulate the pattern of activity across the day to optimise specific cognitive outcomes.
"With an ageing population which is looking to live healthier for longer, these studies are critical to people enjoying a productive and satisfying quality of life," Michael says.
"This study highlights how relatively simple changes to your daily routine could have a significant benefit to your cognitive health. It also reveals that one day we may be able to do specific types of exercise to enhance specific cognitive skills such as memory or learning."
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Despite health risks, energy drink consumption in the United States has increased substantially over the past decade among adolescents, young adults, and middle-aged adults


According to a new study appearing in the American Journal of Preventive Medicine, published by Elsevier, energy drink consumption in the United States has increased substantially over the past decade among adolescents, young adults, and middle-aged adults. Energy drink consumers had significantly higher total caffeine intake compared with non-consumers and the beverages represented a majority of their total daily caffeine. While the findings indicate that daily intake among adolescents and middle-aged adults may be leveling off and overall use across all groups is relatively limited, use by young adults continues to steadily rise.
"The increasing use of energy drinks, especially among young adults, is cause for concern and warrants continued study and surveillance," explained senior author Sara N. Bleich, PhD, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA. "Although the beverages are marketed to reduce fatigue and improve physical and mental performance, frequent consumption of these highly caffeinated and sugary beverages has been linked to negative health consequences."
Energy drinks are non-alcoholic beverages that contain caffeine, other plant-based stimulants (e.g., guarana), amino acids (e.g., taurine), herbs (e.g., ginkgo biloba), and vitamins. Introduced to US markets in 1997, their caffeine content ranges from 50 mg to 500 mg per serving, compared to 95 mg for an eight-ounce cup of coffee. Although moderate caffeine intake (up to 400 mg/day for adults and 100 mg/day for teens) is considered safe, higher volumes may increase the possibility that individuals will engage in risk-seeking behaviors, experience mental health strains like increased depression, and/or adverse cardiovascular effects like increased blood pressure. Added sugar in many of the energy drinks may also increase risk for obesity, type 2 diabetes, and dental caries. Mixing energy drinks with alcohol, which is growing in popularity among young adults, can lead to overconsumption of alcohol and incidence of alcohol-related events (e.g., car accidents).
Although US Food and Drug Administration (FDA) regulations require that energy drink labels indicate if the product contains caffeine, the FDA does not impose a caffeine limit or require reporting of the actual level of caffeine. While some energy drink companies are taking part in voluntary labeling initiatives, Dr. Bleich noted, "Our findings point to the need for an evidence-based upper caffeine limit and consistent labeling on these beverages to reduce the potential negative health impact on consumers."
The study's objective was to provide national estimates of the percentage of energy drink consumers in the US by age group (adolescents, young adults, and middle-aged adults), as well as analyze trends in energy drink consumption between 2003 and 2016. The investigators also examined the differences in the prevalence of energy drink consumption by demographic characteristics (age category, sex, race/ethnicity, and educational attainment), and compared total caffeine intake between energy drink consumers and non-consumers.
The analysis used data from the National Health and Nutrition Examination Survey (NHANES), a repeated cross-sectional study that is representative of the American non-institutionalized population. The study sample included data for 2003-2016 from 9,911 adolescents, 12,103 young adults, and 11,245 middle-aged adults. Because it was necessary to pool data across the seven survey cycles to ensure a sufficient analytic sample, it was only possible to examine differences in the prevalence of energy drink consumption by sex, race/ethnicity, and educational attainment category for all years combined.
From 2003 to 2016, the prevalence of energy drink consumption on a typical day increased significantly for adolescents (0.2 percent to 1.4 percent); young adults (0.5 percent to 5.5 percent); and middle-aged adults (0.0 percent to 1.2 percent). Per capita consumption of energy drinks increased significantly from 2003 to 2016 only for young adults (1.1 to 9.7 calories). Pooled across years, energy drink consumers had significantly higher total caffeine intake compared with non-consumers for adolescents (227.0 mg vs 52.1 mg); young adults (278.7 mg vs 135.3 mg); and middle-aged adults (348.8 mg vs 219.0 mg).
Notably, middle-aged Mexican Americans and young adults with low educational attainment were found to have the highest prevalence of energy drink consumption. "This important finding signals the need for targeted policy and programmatic efforts among these groups," added Dr. Bleich.
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More intensive blood pressure therapy helps patients with type 2 diabetes regardless of cardiovascular risk



People with type 2 diabetes who received intensive treatment to keep their blood pressure levels at 130/80 mm/Hg or below had fewer heart attacks, strokes and other diabetes complications, according to a study published in the American Heart Association's journal Hypertension. These patients also had lower overall risk of dying from any cause--a benefit that was observed regardless of a person's preexisting cardiovascular risk and baseline blood pressure, the research shows.
The findings shed new light on optimal blood-pressure targets and could help reconcile conflicting guidelines for the treatment for hypertension in people with type 2 diabetes--the more common form of the disease affecting more than 420 million people worldwide.
"Our findings demonstrate a benefit of more intensive therapy aiming for blood pressure thresholds at 130/80 or below and should help resolve some ongoing confusion over optimal blood pressure targets for people with diabetes," said study senior investigator J. Bill McEvoy, M.B., B.C.H., M.H.S., professor of preventive cardiology at the National University of Ireland, Galway Campus, and the Irish National Institute for Preventive Cardiology.
The study results suggest that aiming for blood pressure levels of 130/80 mm/Hg or lower can benefit patients at various degrees of baseline blood pressure elevation and with different cardiovascular risk -- a composite score that estimates a person's likelihood of having a heart attack or stroke within 10 years.
"Patients, including those with diabetes, with blood pressure levels above 130/80 on two consecutive checks should discuss with their physicians whether they need change in treatment to get to a lower number," McEvoy added.
The 2017 American College of Cardiology/American Heart Association blood pressure guidelines call for beginning anti-hypertensive treatment at a blood pressure of 130/80 mmHg or higher for adults with diabetes and hypertension, with a goal to reduce blood pressure to below 130/80 mmHg.
The new Hypertension study findings are based on analysis of outcomes among nearly 11,000 patients with type 2 diabetes followed over 4 years across 215 clinical centers in 20 countries as part of the international study ADVANCE.
The researchers compared outcomes between moderate to high cardiovascular risk people with type 2 diabetes and hypertension--a condition defined as persistently elevated blood pressure--receiving anti-hypertension combination treatment (perindopril and indapamide) and people with diabetes and hypertension receiving placebo. This trial had already reported benefit overall for the additional hypertension treatment, however, it was not known whether this benefit also applied to people with diabetes who started off with a blood pressure below 140/90 mmHg, To determine treatment benefit, the analysis compared rates of overall death from any cause as well as the rate of major vascular events, including heart attacks, strokes, diabetes-related kidney disease and diabetes-related eye damage.
Both patients at higher baseline risk for cardiovascular disease and those with lower cardiovascular risk benefitted from the more intensive treatment. In addition, those with diabetes and with blood pressures in the 130/80 mmHg to 140/90 mmHg range before starting the trial benefited from more intensive therapy, achieving lower blood pressures during the trial.
During the study, there were 837 deaths and 966 major vascular events, a category that includes heart attacks, strokes, diabetic kidney disease and diabetic eye disease. The group receiving intensive blood pressure therapy experienced 9 % fewer events and 14 % fewer deaths than the group taking placebo.
Untreated hypertension fuels the risk for cardiovascular issues, including heart attacks and strokes, while diabetes drives cardiovascular risk independently of high blood pressure. The simultaneous occurrence of hypertension and diabetes dramatically magnifies a person's risk for cardiovascular disease.
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Following a healthy plant-based diet may lower kidney disease risk A



A new study has uncovered a link between plant-based diets and kidney health. The finding, which appears in an upcoming issue of CJASN, indicates that consuming a diet based on nutrient-rich plants may help protect against the development of chronic kidney disease (CKD).

The consumption of plant-based diets is becoming more common for ethical, environmental, and health reasons. The quality of plant sources of food can differ, however, with nutrient-rich plants being more healthful and plants that are high in refined carbohydrates being less healthful.

Emerging evidence suggests that the risk of chronic conditions varies by types of plant-based diets. To evaluate the associations between plant-based diets and the development of CKD in a general population, a team led by Hyunju Kim and Casey M. Rebholz, PhD (Johns Hopkins Bloomberg School of Public Health) analyzed information on 14,686 middle-aged adults enrolled in the Atherosclerosis Risk in Communities study.

Among the major findings:
  • During a median follow-up of 24 years, 4,343 new cases of CKD occurred.
  • Participants with the highest adherence to a healthy plant-based diet had a 14% lower risk of developing CKD than participants with the lowest adherence to a healthy plant-based diet.
  • Participants with the highest adherence to a less healthy plant-based diet had an 11% higher risk of developing CKD than participants with the lowest adherence to a less healthy plant-based diet.
  • The association between plant-based diets and CKD risk was especially pronounced for participants who had a normal weight at the start of the study.
  • Higher adherence to an overall plant-based diet and a healthy plant-based diet was associated with slower kidney function decline.
"For kidney disease risk, it appears to be important to choose healthy options for plant sources of food, including fruits, vegetables, whole grains, nuts, and legumes," said Dr. Rebholz. "Also, our finding of a significant interaction by weight status at baseline suggests that following a healthy eating pattern may be particularly beneficial before becoming overweight or obese."

In an accompanying Patient Voice editorial, Patrick Gee describes his dietary experiences as a person who spent 4.5 years on peritoneal dialysis and is now approximately 2 years into a kidney transplant. He found plant-based diets to be lacking in several areas and has settled on the ketogenic diet, which is very low in carbohydrates, high in fat, and moderate in protein.



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Insomniacs unable to get emotional distress off their mind

IMAGE
Cringe-worthy mistakes and embarrassing blunders made today won't seem so bad tomorrow. That is, unless you're an insomniac, research at the Netherlands Institute for Neuroscience shows. The scientists asked participants to relive their most shameful experiences of decades ago while making MRI scans of their brain activity. While good sleepers literally settled those experiences in their head as neutralized memories, people with insomnia were not able to do so. This breakthrough finding suggests that insomnia could primarily be caused by a failing neutralization of emotional distress. Which makes it understandable that insomnia is the primary risk factor for the development of disorders of mood, anxiety, and posttraumatic stress. The findings will be published on 25 April in the leading scientific journal Brain.
Maladaptive sleep
It is a well-known fact that sleep helps us to remember important experiences. But sleep is also essential for getting rid of the emotional distress that may have occurred during those experiences. Both these overnight processes involve changes in the connections between brain cells: some become stronger and consolidate memories, whereas others are weakened and get rid of unwanted associations. "Sayings like 'sleeping on it' to 'get things off your mind' reflect our nocturnal digestion of daytime experiences. Brain research now shows that only good sleepers profit from sleep when it comes to shedding emotional tension. The process does not work well in people with insomnia. In fact, their restless nights can even make them feel worse" says first author Rick Wassing.
Karaoke
The new brain imaging findings explain a recent finding that the same research group has just published in the scientific journal Sleep. In this study, they asked participants to sing along karaoke-style. Headphones prevented them from hearing their own voice and finding the correct pitch. Their singing was recorded and played back later. Participants felt intense shame when listening to their own out-of-tune solo singing. But if they listened once more after a good night's sleep, they didn't feel that distressed about it anymore. They had literally got the distress off their minds. At least: good sleepers did. After a restless night, people with insomnia were in fact even more upset about it.
Emotion
Scientists have been searching for causes of insomnia in brain areas that regulate sleep. The new findings show that causes of insomnia are probably rather found in brain circuits that regulate emotions. These circuits contain risk genes for insomnia and may not activate properly, as they normally do, during rapid eye movement sleep. Without the benefits of sound sleep, distressing events of decades ago continue to activate the emotional circuits of the brain as if they are happening right now. Scientists Rick Wassing, Frans Schalkwijk and Eus van Someren thus show that people with insomnia are haunted by memories of past distress.
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Peanut allergy oral immunotherapy increases allergic reactions


  • Despite effectively inducing desensitisation in the clinic, oral immunotherapy for peanut allergies appears to considerably increase allergic and anaphylactic reactions, compared with avoidance or placebo
  • Authors call for safer peanut allergy treatment approaches and rigorous randomised controlled trials, which use more appropriate measures of allergy reduction based on outcomes that patients want
A systematic review including 12 studies with more than 1,000 patients who were followed for a year finds that, compared with allergen avoidance or placebo, current oral immunotherapy treatments result in a large increase in anaphylaxis and other allergic reactions, rather than preventing them as intended.
The findings, published in The Lancet, highlight the gap between outcomes measured in the clinic and the allergy relief outcomes that patients desire after oral immunotherapy for peanut allergy.
Studies of oral immunotherapy currently measure treatment success by whether a treated patient can pass a supervised food challenge, but this cannot predict a patient's future risk and frequency of allergic reactions in the real world. The study authors call for a new approach to food allergy research to focus on real-world outcomes and everyday exposures.
"Numerous studies of varying quality have been published on oral immunotherapy, but its effectiveness and reliability remains unclear. Our study synthesises all randomized clinical trials comparing peanut oral immunotherapy to no immunotherapy in order to generate the highest quality evidence to inform decision making. It shows that current peanut oral immunotherapy regimens can achieve the immunological goal of desensitisation, but that this outcome does not translate into achieving the clinical and patient-desired aim of less allergic reactions and anaphylaxis over time. Instead, the opposite outcome occurs, with more allergic and adverse reactions with oral immunotherapy compared with avoidance or placebo," says lead author Dr Derek Chu, McMaster University, Canada. "Our results do not denounce current research in oral immunotherapy, but the method needs to be more carefully considered, improvements in safety made, and measures of success need to be aligned with patients' wishes." [1]
Food allergy is a growing global problem. In Europe and North America, more than 6 million people are affected, including up to 8% of children and 2-3% of adults. Although allergy to milk and egg are commonly outgrown by the age of 5-10 years, allergies such as to peanut are lifelong in 80-85% of cases and affect 2% of children and 1% of adults in high-income countries.
The unpredictable and potentially life-threatening nature of food allergic reactions is associated with substantial anxiety and impaired quality of life for patients. There is no treatment for allergies, other than avoidance and medication to treat allergic reactions or anaphylaxis.
Immunotherapy is an investigational therapy for allergies that involves repeated exposure over time to gradually increasing doses of the allergen, with the aim of reducing allergic reactions. While other forms of immunotherapy (sublingual or subcutaneous) for other allergies appear safe and effective in randomised controlled trials, the outcomes of oral immunotherapy are debated.
The authors combined results from 12 randomised controlled trials from the USA, UK, Europe and Australia (including three unpublished trials) including 1,041 patients to compare outcomes after oral immunotherapy with those after no oral immunotherapy. The trials compared oral immunotherapy against placebo, avoidance or other types of immunotherapy, and used different peanut products and doses.
The average age of participants in the studies was around 9 years of age (between 5-12 years), and participants were followed for a year on average. The study measured anaphylaxis (data for this was available in nine trials), allergic or adverse reactions (10 trials), epinephrine use (nine trials), and quality of life (three trials).
The results suggest with high and moderate quality evidence that, compared with no oral immunotherapy, peanut oral immunotherapy increases the risk and frequency of anaphylaxis (by around three times, from 7.1% without oral immunotherapy to 22.2% with oral immunotherapy), epinephrine use (by around two times, from 3.7% without to 8.2% with), and serious adverse events (by around two times, from 6.2% without to 11.9% with) to a similar extent during build-up and maintenance. Allergic reactions involving the gastrointestinal tract (vomiting, abdominal pain, mouth itching), skin and mucous membranes (hives or urticaria and swelling or angioedema), nose (congestion or rhinitis), and lungs (wheeze or asthma) also increased.
However, they found that quality of life was no better in people receiving oral immunotherapy compared to those that did not. The authors note that this is in contrast to observational studies, and this may be due to those studies not being controlled for confounding and bias. They note that large, well done randomised controlled trials are required to clarify the effect, if any, of peanut oral immunotherapy on quality of life.
The authors say that their findings favour avoidance over current forms of oral immunotherapy if a patient wishes to avoid peanut-induced anaphylaxis and allergic reactions, and that the increased risk of reactions associated with these regimens might be a substantial barrier to widespread adoption by patients with peanut allergies.
In future research, it will be important to clarify patient values and preferences regarding food allergy therapies in general - understanding what patients expect from treatment, and what outcomes are desirable and undesirable. The measures to estimate health benefits and harms of food allergy interventions should be patient-centred outcomes, such as a risk and rate of allergic and anaphylactic reactions over time, as recommended by GRADE, the US National Institute of Allergy and Infectious Diseases, the FDA, and other organisations.
"Considering the current view of peanut allergy oral immunotherapy as a model for other food allergies, and the increasing global prevalence of food allergies, these findings are significant and important to the ongoing development of food allergy treatments," concludes Dr Chu. [1]
The authors note some limitations, including that although the study included all available evidence in this area, the number of patients is small, and some studies in the analysis did not report all data for all patients despite requests from the authors. Whether longer term oral immunotherapy or treatment in adults has a different efficacy and safety profile than observed in this study requires further investigation.
Writing in a linked Comment, Graham Roberts, University of Southampton, UK, says: "Although oral immunotherapy undoubtedly reduces the likelihood of reacting to peanuts in a controlled clinic setting, its overall side-effect profile means that patients seem to have more allergic reactions while on therapy. Trading treatment-related side-effects at home for allergic reactions to accidental exposures out of the house (ie, in social situations) might be beneficial for some patients. However, it is not clear which patients might benefit most and the relative balance of reactions in and out of patients' homes. It would also be useful to compare oral with epicutaneous immunotherapy. Although epicutaneous immunotherapy is less effective, it has a better safety profile than oral immunotherapy, which some patients might find more acceptable. Finally, we should not forget that we now know that the early introduction of peanut products into the infant diet can prevent most cases of peanut allergy. Moving forward we need to develop implementation strategies to reduce number of patients with peanut allergy."
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Exercise activates memory neural networks in older adults



How quickly do we experience the benefits of exercise? A new University of Maryland study of healthy older adults shows that just one session of exercise increased activation in the brain circuits associated with memory - including the hippocampus - which shrinks with age and is the brain region attacked first in Alzheimer's disease.

"While it has been shown that regular exercise can increase the volume of the hippocampus, our study provides new information that acute exercise has the ability to impact this important brain region," said Dr. J. Carson Smith, an associate professor of kinesiology in the University of Maryland School of Public Health and the study's lead author.

The study is published in the Journal of the International Neuropsychological Society.
Dr. Smith's research team measured the brain activity (using fMRI) of healthy participants ages 55-85 who were asked to perform a memory task that involves identifying famous names and non famous ones. The action of remembering famous names activates a neural network related to semantic memory, which is known to deteriorate over time with memory loss.

This test was conducted 30 minutes after a session of moderately intense exercise (70% of max effort) on an exercise bike and on a separate day after a period of rest. Participants' brain activation while correctly remembering names was significantly greater in four brain cortical regions (including the middle frontal gyrus, inferior temporal gryus, middle temporal gyrus, and fusiform gyrus) after exercise compared to after rest. The increased activation of the hippocampus was also seen on both sides of the brain.
"Just like a muscle adapts to repeated use, single sessions of exercise may flex cognitive neural networks in ways that promote adaptations over time and lend to increased network integrity and function and allow more efficient access to memories," Dr. Smith explained.
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Healthy aging entails reorganization of function in prefrontal brain areas


Researchers from HSE University and York University have become the first to analyse the results of 82 functional neuroimaging studies on working memory mechanisms in different adult age groups. The meta-analyses showed that across studies the agreement of various areas of the prefrontal cortex decreases with ageing, suggesting reorganization of brain function during healthy aging. The results have been published in the paper 'Meta-analyses of the n-back working memory task: fMRI evidence of age-related changes in prefrontal cortex involvement across the adult lifespan': https://doi.org/10.1016/j.neuroimage.2019.03.074
Working memory is a system that helps keep information readily available as we use it for performing tasks here and now, including complex intellectual operations such as learning, understanding and reasoning. For example, we use this type of memory to detect and remember the most important things in another person's speech and then give that person a meaningful answer. The resources of working memory are limited, and with age, its size changes.
Marie Arsalidou, Zachary Yaple, and Dale Stevens analysed data on brain activity in 2020 adults, divided into three age groups: young (18-35), middle-aged (35-55), and older adults (55-85). In all the studies, research volunteers played a game called the 'n-back task': they were asked to detect and respond whether they had seen the image demonstrated at the moment, 'n' positions back. The complexity of the task depends on the value of 'n'. During an experiment, each study monitored the brain areas that are activated using functional magnetic resonance imaging (fMRI).
Meta-analysis demonstrated that the involvement of prefrontal cortex areas and their coordination during a task showed increased agreement across studies in young people, lower agreement in middle-aged adults, and no significant agreement in older adults. Lack of agreement in older adults suggests increased variability and individual differences in this group. With older age, parietal regions of the cortex are activated more often, which might be a sign of functional re-organization of working memory mechanisms or of these regions' compensatory function.
The prefrontal cortex plays a key role in complicated intellectual processes, including the coordination of different brain areas that are activated during the use of working memory.
'Brain changes throughout adulthood, and it appears to be more dynamic that we initially thought. Because the original studies did not consistently report performance scores, we analysed brain responses with the assumption that working memory performance was comparable. Therefore, we cannot say from our study that working memory skills decrease with age. What we can say is that variability in prefrontal cortex activity may suggest differences in strategies used to problem solve across adulthood. This gives a good target for future work to decipher direct relations among age, brain function and performance' believes one of the study's authors, Marie Arsalidou, Assistant Professor at the HSE School of Psychology.
The results of this study are comparable with the conclusions of the previous meta-analysis of working memory mechanisms in children, which was carried out by Marie Arsalidou together with HSE researcher Zachary Yaple: during n-back task performance, not only prefrontal and parietal cortex regions are activated in children, but also other brain areas. Further research in this area will help us understand how working memory mechanisms change during development in humans.
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It's OK to indulge once in a while: The body adapts to occasional short-term overeating


Overeating has been found to impair blood sugar (glucose) control and insulin levels. A new study suggests that the duration of a bout of overeating can affect how the body adapts glucose and insulin processing when calorie intake increases. The article is published ahead of print in the American Journal of Physiology--Endocrinology and Metabolism.

Obesity and type 2 diabetes have increased significantly worldwide within the past 30 years. Lifestyle factors such as overindulging in high-calorie foods play a large role in the development of these two serious health conditions. Understanding how overeating causes changes in blood sugar control and insulin processing may help scientists learn more about metabolic disease.

Researchers from Deakin University in Australia studied a small group of healthy, lean men with an average age of 22. Volunteers participated in a short-term trial consisting of five days "indicative of humans overeating during festivals and holidays" and a long-term model of chronic overeating lasting 28 days. The nutritional composition of the volunteers' diet was representative of a typical Australian diet (55 percent carbohydrates, 35 percent fat and 15 percent protein).

The "overfeeding" portion of the diet included high-calorie snacks such as chocolate, meal replacement drinks and potato chips to add approximately 1,000 more calories to the men's normal food consumption each day. The research team measured the volunteers' weight, fat mass, blood sugar and insulin levels before the trial began and again after five and 28 days.

Although the amount of visceral fat that surrounds internal organs increased substantially, short-term overeating did not have a significant effect on the men's weight or fat mass. In addition, fasting levels of blood sugar and C-peptide--an amino acid the body releases in response to increased production of insulin--did not change. This finding was surprising because fasting levels of endogenous glucose--new glucose the body produces in addition to what it has already stored for future use--increased during the short-term trial.
Chronic overeating increased the amount of total body fat and visceral fat as well as post-meal blood sugar and C-peptide levels. However, it did not alter fasting blood sugar levels, endogenous glucose production or the rate of glucose removal from the body (glucose disposal). This may be because the nutrient profile in the long-term trial was consistent with a typical diet and dietary fat percentages did not increase. Long-term overindulgence in fatty foods, instead of more nutritionally balanced foods, may be an important factor that causes rapid changes in blood sugar control.
These findings "suggest that early adaptations in response to carbohydrate overfeeding are directed at increasing glucose disposal in order to maintain whole-body insulin sensitivity," the researchers wrote.
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Read the full article, "Modest changes to glycemic regulation are sufficient to maintain glucose flux in healthy humans following overfeeding with a habitual macronutrient composition," published ahead of print in the American Journal of Physiology--Endocrinology and Metabolism.
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How to combine 'leg day' with running



James Cook University scientists in Australia say they have the solution for a problem gym-goers have when they combine endurance and weight training.
JCU's Dr Kenji Doma led the review paper. He said his own work and those of other scientists had previously discovered that resistance training, such as weight lifting, may harm performance in endurance training, such as running, when the two are combined on the same or separate days.
The practice of combining the two is commonly referred to as 'concurrent training'.
"Based on previous evidence, we suspect that if appropriate recovery is not accounted for between each training mode, it may impair endurance development," he said.
Dr Doma said the physiological stress caused by a typical resistance training bout of 40 to 60 minutes can continue for several days post-exercise, as opposed to a full recovery within 24 hours following a typical endurance training bout.
"We wanted to increase the awareness of resistance training-induced fatigue in the hope of encouraging coaches to think about aspects such as the order of the training, the recovery period, training intensity, etc. With this new work, we think we now have a roadmap for them to follow," said Dr Doma.
He said the team think there are several training variables that may influence the way in which resistance training impacts the quality of endurance training.
They include the intensity of resistance and endurance training sessions, the volume of resistance training, the speed in which resistance training is performed, the recovery period between resistance and endurance training, and the order of resistance and endurance training sessions.
"By understanding the influence these variables have, it means that both resistance and endurance training can be prescribed in such a way that minimises fatigue between modes of training, which could optimise the quality of endurance training sessions," said Dr Doma.
The researchers have produced flowcharts providing practical guides for improving concurrent training and optimising endurance development.
Dr Doma said it was important that fatigue be monitored between the different training types and different periods of rest enforced after different levels of either endurance or resistance training.
"One of the easiest recommendations to follow is that if the performance of resistance and endurance training sessions on the same day is unavoidable, endurance training sessions should be done prior to resistance training irrespective of the intensity of either, with at least half a day of recovery in-between training sessions," he said.
Dr Doma said the findings were made freely available in the published paper with the hope that coaches and both amateur and professional endurance athletes undertaking concurrent training could use them to increase performance.
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Higher weight increases risk of psoriasis


Risk increases by nine per cent for each increase in whole BMI number 



Studies have linked psoriasis and higher weight, but the causal relationship between the two has been unclear. What triggers what?

Or could other underlying reasons explain the connection?

"Higher BMI may contribute to increased inflammation of the skin, which can exacerbate psoriasis, but it could also be that psoriasis leads to a person being less physically active and thus gaining weight," explains Mari Løset.

She is a medical doctor at the Department of Dermatology at St. Olavs Hospital and a postdoctoral fellow at the Norwegian University of Science and Technology's (NTNU) K.G. Jebsen Center for Genetic Epidemiology.

Løset is part of a team that been involved in a study of the causal relationship between BMI and psoriasis.

BMI stands for body mass index and is a measure of body fat content. It is calculated from a person's height and weight.

The observational study is a large collaboration among researchers from NTNU, England and North America. Some of the data being used is from the Health Survey in Nord-Trøndelag (HUNT) and the UK Biobank. Together, the analyses include data from 750 000 individuals.
Psoriasis is a chronic inflammatory condition of the skin, which causes a red, scaly rash. The cause of the disorder is probably multifactorial, involving both heredity and the environment.
Worldwide, two to four per cent of the population is affected by psoriasis. The incidence is particularly high in Norway.
"Self-reported data from two large population surveys in Norway indicate that six to eleven per cent of the population may be affected in this country," says Løset.
A study in the city of Tromsø has shown that the incidence of psoriasis was 4.8 per cent in 1980, but had increased to 11.4 per cent in 2008.
"Similar studies from other parts of the world substantiate the fact that the condition is increasing," says the postdoctoral fellow.
To investigate the causal relationship between BMI and psoriasis, the researchers used a method called Mendelian randomization. It is named after Gregor Mendel, who is known as the father of genetics.
According to Mendel's principles of inheritance, whether we inherit a certain variant of genes from our mother or our father is random. Genetic variants are randomly distributed, or randomized, between individuals.
"Mendelian randomization means that nature itself distributes individuals randomly into groups based on genes. This way, we can avoid the results being influenced by external factors," says Løset.
"Our understanding of how genes are related to disease is increasing at record speed, and in this study we used known genetic variants as markers for BMI and psoriasis," she adds.
By using Mendelian randomization, the researchers found that higher weight is a contributing factor to psoriasis. They observed that greater BMI increased the chance of getting the disease.
"We calculated that the risk increased by nine per cent for each higher whole number on the BMI scale," Løset says.
But the researchers are still uncertain about just how higher weight can lead to psoriasis.
"We still don't know enough about the mechanisms behind this connection. Fatty tissue is an organ that produces hormones and inflammatory signalling molecules, which could be a contributing factor," says Løset.
So far, not much research has been done on whether weight loss can cause psoriasis to disappear, although a few clinical studies suggest the possibility.
"Psoriasis is a very complex disease and we hope to study subgroups, especially individuals with severe psoriasis. The hypothesis is that we will be able to observe even greater links with higher weight," says Mari Løset.
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A spoonful of peppermint helps the meal go down



IMAGE
IMAGE: Leaves of the peppermint plant, from which peppermint oil is derived. view more 
Credit: Image from dreamstime.com --Creative Commons Zero (CC0) public domain license.
Imagine that while eating a delicious meal at your favorite restaurant, your joy is cut short because of difficulty swallowing your food, followed by chest pain.
If you go see a doctor about these symptoms, and there is no evidence of a cardiac cause of the chest pain, you could be diagnosed as having some sort of disorder of the esophagus.
Peppermint can help with the difficulty swallowing and non-cardiac chest pain experienced by some patients with disorders of the esophagus, report investigators at the Medical University of South Carolina (MUSC) in Digestive Diseases & Sciences. Of the 38 patients enrolled in the MUSC pilot study, 63 percent overall reported improvement of symptoms. Patients were recruited from the Esophageal Disorders Clinic at the MUSC Health Digestive Disease Center.
"Peppermint oil is an established agent in the treatment of irritable bowel syndrome. We tried to examine its effect on patients with swallowing and chest pain issues with no apparent cause," says Mohamed Khalaf, M.D., an esophageal disorders research fellow at the MUSC Health Digestive Disease Center and first author on the article.
"Our findings suggest that peppermint may help prevent these symptoms by relaxing the smooth muscle in the lower esophagus," says Donald O. Castell, M.D., a professor emeritus in the MUSC College of Medicine, a nationally recognized gastroenterologist, and senior author on the article.
Peppermint oil has been known to have therapeutic effects in multiple disorders due to its muscle-relaxing properties. However, only two previous studies have investigated its role in the upper digestive tract.
The MUSC study found that patients who took peppermint oil tablets before eating felt better after meals than those who did not. Those with both non-cardiac chest pain and unobstructed difficulty swallowing saw the most benefits: 73 percent of them reported feeling better. Of patients with just one of the symptoms, those with non-cardiac chest pain had a more positive response from the peppermint oil (63 percent) than those with difficulty swallowing (53 percent).
The results were even better among patients with spastic disorders of the esophagus: 83 percent reported feeling better or slightly better. Although less well-known than esophageal disorders such as acid reflux, spastic disorders of the esophagus can also disrupt a patient's life. In these disorders, the esophagus undergoes painful spasms that can interfere with eating. Because the spasms occur only from time to time, these disorders are difficult to diagnose and treat.
Current standard of care calls for these disorders involves trying multiple drugs, including tricyclic antidepressants and calcium channel blockers, and hoping that one works.
Peppermint offers an attractive first line of defense for these patients, who experience intermittent symptoms, because they can take it freely as symptoms occur.
"In this study, patients who had experienced difficulty swallowing took two pieces of a commercially available peppermint right before meals. Those with chest pain took the peppermint tablets as needed," says Khalaf.
This study highlights the effects of the so-called Charleston Approach, which advocates a "start low and go slow" treatment strategy. The Charleston Approach differs from current standard of care in that it uses peppermint oil as a first attempt to relieve symptoms.
Castell and Khalaf caution that patients must first be examined by a doctor to rule out heart disease and undergo a procedure known as an endoscopy to rule out obstruction before they are offered peppermint as a first-line treatment. Endoscopy involves inserting a flexible tube fitted with a light and camera into the esophagus.
One of the drawbacks of the study was that researchers did not know the precise dosage of peppermint being given since it was a commercial candy (only one type of which was effective) with a proprietary recipe. Another was the study relied on self-reporting by patients to determine whether symptoms improved.
Although the preliminary findings of this study are promising, they need to be confirmed in a trial that compares outcomes in patients who receive a specific dose of peppermint oil and those who receive only a placebo.
In the meantime, however, patients who have been diagnosed as having spastic disorders of the esophagus and who have no heart disease or obstruction can try using peppermint to see if it relieves their symptoms.
"Given the safety profile, low cost, and widespread availability, there are no risks from empirical use of peppermint oil," says Khalaf.
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Antibiotic use linked to greater risk of heart attack and stroke in women



Women who take antibiotics over a long period of time are at increased risk of heart attack or stroke, according to research carried out in nearly 36,500 women.
The study, published in the European Heart Journal [1] today (Thursday), found that women aged 60 or older who took antibiotics for two months or more had the greatest risk of cardiovascular disease, but long duration of antibiotic use was also associated with an increased risk if taken during middle age (aged 40-59). The researchers could find no increased risk from antibiotic use by younger adults aged between 20-39.
Professor Lu Qi, director of the Tulane University Obesity Research Centre, Tulane University, New Orleans, and adjunct professor of nutrition at Harvard T.C. Chan School of Public Health, Boston, USA, who led the research, says that a possible reason why antibiotic use is linked to an increased risk of cardiovascular disease is because antibiotics alter the balance of the micro-environment in the gut, destroying "good" probiotic bacteria and increasing the prevalence of viruses, bacteria or other micro-organisms that can cause disease.
"Antibiotic use is the most critical factor in altering the balance of microorganisms in the gut. Previous studies have shown a link between alterations in the microbiotic environment of the gut and inflammation and narrowing of the blood vessels, stroke and heart disease," he said.
The researchers studied 36,429 women who took part in the Nurses' Health Study, which has been running in the USA since 1976. The current study looked at data from 2004 to June 2012. In 2004 the women were aged 60 or older, and they were asked about their use of antibiotics when they were young (20-39), middle-aged (40-59) or older (60 and older). The researchers categorised them into four groups: those who had never taken antibiotics, those who had taken them for time periods of less than 15 days, 15 days to two months, or for two months or longer.
During an average follow-up period of nearly eight years, during which time the women continued to complete questionnaires every two years, 1056 participants developed cardiovascular disease.
After adjustments to take account of factors that could affect their results, such as age, race, sex, diet and lifestyle, reasons for antibiotic use, overweight or obesity, other diseases and medication use, the researchers found that women who used antibiotics for periods of two months or longer in late adulthood were 32% more likely to develop cardiovascular disease than women who did not use antibiotics. Women who took antibiotics for longer than two months in middle age had a 28% increased risk compared to women who did not.
These findings mean that among women who take antibiotics for two months or more in late adulthood, six women per 1,000 would develop a cardiovascular disease, compared to three per 1,000 among women who had not taken antibiotics.
The first author of the study is Dr Yoriko Heianza. a research fellow at Tulane University. She said: "By investigating the duration of antibiotic use in various stages of adulthood we have found an association between long-term use in middle age and later life and an increased risk of stroke and heart disease during the following eight years. As these women grew older they were more likely to need more antibiotics, and sometimes for longer periods of time, which suggests a cumulative effect may be the reason for the stronger link in older age between antibiotic use and cardiovascular disease."
The most common reasons for antibiotic use were respiratory infections, urinary tract infections and dental problems.
The study is the largest prospective study to investigate the link between antibiotic use and risk of heart disease and stroke, and this is one of the strengths of the study, as well as the long follow-up and comprehensive information on factors that could affect the results such as life style, diet, age, other diseases and medication use.
Limitations include the fact that the participants reported their use of antibiotics and so this could be mis-remembered. However, as they were all health professionals, they were able to provide more accurate information on medication use than the general population. The researchers did not have information on the different classes of antibiotics used, but believe that the most common type of prescription tends to depend on the infections it is treating, and information on these was included in their analysis. As the study only looked at middle-aged and elderly women, the results cannot necessarily be extrapolated to younger ages and to men.
Prof Qi concluded: "This is an observational study and so it cannot show that antibiotics cause heart disease and stroke, only that there is a link between them. It's possible that women who reported more antibiotic use might be sicker in other ways that we were unable to measure, or there may be other factors that could affect the results that we have not been able take account of.
"Our study suggests that antibiotics should be used only when they are absolutely needed. Considering the potentially cumulative adverse effects, the shorter time of antibiotic use the better."
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Despite health warnings, Americans still sit too much


Most Americans continue to sit for prolonged periods despite public health messages that such inactivity increases the risk of obesity, diabetes, heart disease and certain cancers, according to a major new study led by researchers at Washington University School of Medicine in St. Louis.
The research team analyzed surveys of 51,000 people from 2001 to 2016 to track sitting trends in front of TVs and computers and the total amount of time spent sitting on a daily basis. Unlike other studies that have looked at sedentary behaviors, the research is the first to document sitting in a nationally representative sample of the U.S. population across multiple age groups - from children to the elderly - and different racial and ethnic groups.
The research, led by Yin Cao, ScD, an epidemiologist and assistant professor of surgery in the Division of Public Health Sciences, is published April 23 in the Journal of the American Medical Association.
"In almost none of the groups we analyzed are the numbers going in the right direction," said Cao, the study's senior author. "We want to raise awareness about this issue on multiple levels -- from individuals and families to schools, employers and elected officials."
Epidemiologist and co-senior author Graham A. Colditz, MD, DrPH, the Niess-Gain Professor of Surgery and director of the Division of Public Health Sciences, said: "We think a lot of these sedentary habits are formed early, so if we can make changes that help children be more active, it could pay off in the future, both for children as they grow to adulthood and for future health-care spending. Sedentary behavior is linked to poor health in many areas, and if we can reduce that across the board it could have a big impact."
The new study fills a gap in knowledge on sedentary behavior, according to the researchers, putting specific numbers on the amount of time Americans actually spend sitting. For example, the most recent edition of the Physical Activity Guidelines for Americans, published in 2018 by the Department of Health and Human Services, recommends less sitting time but offers no guidance on how much.
The researchers analyzed data from more than 51,000 people who participated in the National Health and Nutrition Examination Survey between 2001 and 2016, looking at four age groups: children ages 5 to 11 (as reported by a parent or guardian), adolescents ages 12 to 19, adults ages 20 to 64, and adults ages 65 and older. Race and ethnicity were defined as non-Hispanic white, non-Hispanic black, Hispanic and other races, including multiracial.
Total daily sitting time increased among adolescents and adults from 2007 to 2016, from seven hours per day to just over eight for teenagers, and from 5.5 hours per day to almost 6.5 for adults, the researchers found.
"Until now, we haven't had data demonstrating the amount of time most Americans spend sitting watching TV or doing other sedentary activities," Cao said. "Now that we have a baseline -- on population level and for different age groups -- we can look at trends over time and see whether different interventions or public health initiatives are effective in reducing the time spent sitting and nudging people toward more active behaviors."
The researchers found that most Americans spend at least two hours per day sitting and watching television or videos. Among children ages 5-11, 62 percent spent at least that long in front of screens daily. For adolescents ages 12-19, that number was 59 percent. About 65 percent of adults ages 20 to 64 spent at least two hours watching television per day. And most recently, from 2015 to 2016, 84 percent of adults over age 65 spent at least that much time sitting watching television. And this remained steady over the course of the study.
Across all age groups, 28 percent to 38 percent of those surveyed spent at least three hours per day watching television or videos, and 13 percent to 23 percent spent four hours or more engaged in watching television or videos.
Importantly, males of all age groups, non-Hispanic black individuals of all age groups and participants who reported being obese or physically inactive were more likely to spend more time sitting to watch televisions or videos compared to their counterparts.
In addition, computer screen time outside of work and school increased over this period. At least half of individuals across all age groups used a computer during leisure time for more than one hour per day in the two most recent years of the study. And up to a quarter of the U.S. population used computers outside of work and school for three hours or more.
"How we create public policies or promote social change that supports less sitting is unclear and likely to be complicated," Colditz said. "If a neighborhood in a disadvantaged community is unsafe, for example, parents can't just send their kids outside to play. Our environments -- the way our cities, our school days and working days are designed -- play roles in this behavior that are difficult to change. But at least now, we have a baseline from which to measure whether specific changes are having an impact."
Chao Cao, a recent graduate of the Brown School and a data analyst in Yin Cao's lab, co-led the analyses. Washington University also collaborated with researchers at a number of other institutions, including Charles Matthews, PhD, at the National Cancer Institute (NCI); Lin Yang, PhD, at the Alberta Health Services, Calgary, Canada; the Harvard T.H. Chan School of Public Health; Memorial Sloan Kettering Cancer Center; and Massachusetts General Hospital and Harvard Medical School.
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Number of women who aren't physically active enough is high and growing


Using data from a national survey representing more than 19 million U.S. women with established cardiovascular disease, Johns Hopkins Medicine researchers say that more than half of women with the condition do not do enough physical activity and those numbers have grown over the last decade. These results imply that targeted counseling to exercise more could reduce risk of cardiovascular disease as well as associated health care costs over their lifetimes.
The researchers say their results suggest that women diagnosed with such disorders as coronary artery disease, stroke, heart failure, heart rhythm disturbances and peripheral artery disease should talk to their physicians about how to increase their physical activity levels to maintain optimal cardiac health and decrease health care costs associated with cardiac disability.
According to the American Heart Association (AHA), heart disease remains the #1 killer of American women, 43 million of whom are affected by the condition. The study, described in the April 12, 2019, issue of JAMA Network Open, notes that total health care costs among women with cardiovascular disease who met AHA-recommended physical activity guidelines were about 30 percent less than costs among those who did not meet the guidelines.
"Physical activity is a known, cost-effective prevention strategy for women with and without cardiovascular disease, and our study shows worsening health and financial trends over time among women with cardiovascular disease who don't get enough physical activity," says Victor Okunrintemi, M.D., M.P.H., a former Johns Hopkins Medicine research fellow who is now an internal medicine resident at East Carolina University. "We have more reason than ever to encourage women with cardiovascular disease to move more."
The AHA strongly recommends physical activity to reduce a woman's chances of developing cardiovascular disease (so-called primary prevention) and to advance and maintain recovery after heart attack or stroke (so-called secondary prevention). The standard recommendation is 150 minutes of moderate to vigorous physical activity per week, which works out to at least 30 minutes of brisk movement per day, five days a week. Previous studies have shown that over the span of a lifetime, men are on average more physically active than women.
In the current study, researchers used data from the 2006-2015 U.S. Agency for Health care Research and Quality's Medical Expenditure Panel Survey, a self-reported questionnaire of individual households across the nation. The results of this study are based on data from about 18,027 women with cardiovascular disease between the ages of 18 and 75, including non-Hispanic whites (77.5 percent), Asians (2.3 percent), African Americans (12.2 percent) and Hispanics (8 percent), who in sum are nationally representative of all U.S. women with cardiovascular disease. They compared answers collected in 2006-2007 against those collected in 2014-2015 to assess any trends.
In 2006, 58 percent of women with cardiovascular disease said they were not meeting the AHA-recommended physical activity guidelines. By 2015, that number rose to 61 percent.
Researchers also found that women ages 40-64 were the fastest growing age group not getting enough physical activity, with 53 percent reporting in 2006-2007 not getting enough exercise and 60 percent in 2014-2015. They also found that African American and Hispanic women were more likely to not exercise enough, and women from low-income households who were enrolled in public insurance and had less high school education were also more likely to not meet recommended physical activity targets. Health care costs among women with cardiovascular disease who did not exercise enough was reported to be $12,724 in 2006-2007 compared to $14,820 in 2014-2015. Women with cardiovascular disease who did get enough exercise on average spent $8,811 in 2006-2007 compared to $10,504 in 2014-2015.
The researchers caution that the study was not designed to show cause and effect, but to identify 10-year trends in the levels of physical activity among U.S. women across various demographic groups defined by age, race/ethnicity and socio-economic factors, and to describe associations of physical inactivity with health care costs. Lack of regular physical activity has been independently linked in scores of previous studies to a higher risk of cardiovascular disease, obesity and diabetes.
"The expense of poor health is tremendous," says Erin Michos M.D., M.H.S., associate professor of medicine at the Johns Hopkins University School of Medicine. "Many high-risk women need encouragement to get more physically active in hopes of living healthier lives while reducing their health care costs."
Researchers say there is a need to tailor specific interventions to the most-impacted groups, including older women, women of lower socioeconomic status as well as minorities, and to encourage physicians who care for them to more consistently promote cardiac rehabilitation referrals and safe exercise tips.
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Eating elderberries can help minimize influenza symptoms



Folk medicines and herbal products have been used for millennia to combat a whole range of ailments, at times to the chagrin of modern scientists who have struggled to explain their medicinal benefits.
However a recent study by researchers at the University of Sydney has determined exactly how a popular ancient remedy, the elderberry fruit, can help the fight against influenza.
Conducted by Professor Fariba Deghani, Dr Golnoosh Torabian and Dr Peter Valtchev as part of the ARC Training Centre for the Australian Food Processing Industry that was established within the university's Faculty of Engineering and IT, the study showed that compounds from elderberries can directly inhibit the virus's entry and replication in human cells, and can help strengthen a person's immune response to the virus.
Although elderberry's flu-fighting properties have long been observed, the group performed a comprehensive examination of the mechanism by which phytochemicals, compounds that positively effect health, from elderberries combat influenza infections.
"What our study has shown is that the common elderberry has a potent direct antiviral effect against the flu virus. It inhibits the early stages of an infection by blocking key viral proteins responsible for both the viral attachment and entry into the host cells," said Dr Golnoosh Torabian.
The researchers used commercially farmed elderberries which were turned into a juice serum and were applied to cells before, during and after they had been infected with the influenza virus.
The phytochemicals from the elderberry juice were shown to be effective at stopping the virus infecting the cells, however to the surprise of the researchers they were even more effective at inhibiting viral propagation at later stages of the influenza cycle when the cells had already been infected with the virus.
"This observation was quite surprising and rather significant because blocking the viral cycle at several stages has a higher chance of inhibiting the viral infection," explained Dr Peter Valtchev.
"In addition to that, we identified that the elderberry solution also stimulated the cells to release certain cytokines, which are chemical messengers that the immune system uses for communication between different cell types to coordinate a more efficient response against the invading pathogen," said Centre Director, Professor Fariba Deghani.
The team also found that the elderberry's antiviral activity can be attributed to its anthocyanidin compounds -- phytonutrients responsible for giving the fruit its vivid purple colouring.
Otherwise known as Sambucus nigra, the elderberry is a small, antioxidant rich fruit common to Europe and North America that is still commonly consumed as a jam or wine.
The influenza virus is one of the leading causes of mortality worldwide, affecting nearly 10 per-cent of the world population and contributing to one million deaths annually.
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Minor sleep loss can put your job at risk



 Losing just 16 minutes of sleep could be the difference between a clear-headed day at the office or one filled with distractions.
A new study published in the Sleep Health (Journal of the National Sleep Foundation) finds shorting your sleep routine during the work-week greatly interferes with job performance. University of South Florida researchers found workers are more likely to have poor judgement and fall off-task the next day.
Lead author Soomi Lee, PhD, assistant professor in the School of Aging Studies, and her colleagues surveyed 130 healthy employees who work in Information Technology and have at least one school-aged child. Participants reported that when they slept 16 minutes less than usual and had worse quality sleep, they experienced more cognitive issues the next day. That raised their stress levels, especially regarding issues related to work-life balance, resulting in them going to bed earlier and waking up earlier due to fatigue.
"These cyclical associations reflect that employees' sleep is vulnerable to daily cognitive stress and also a contributor to cognitively stressful experiences," said Lee. "Findings from this study provide empirical evidence for why workplaces need to make more efforts to promote their employees' sleep. Good sleepers may be better performers at work due to greater ability to stay focused an on-task with fewer errors and interpersonal conflicts."
Researchers also compared work-days to weekends. They conclude the consequences of less sleep is not as apparent when one has the next day off from work.
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Acupuncture equals disease prevention say new studies



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IMAGE: Medical Acupuncture, the Official Journal of the American Academy of Medical Acupuncture, presents evidence-based clinical articles, case reports, and research findings that integrate concepts from traditional and modern forms of... view more 
Credit: Mary Ann Liebert, Inc., publishers
New Rochelle, NY, April 23, 2019--Well-recognized for its therapeutic effects, acupuncture is increasingly being appreciated for its ability to promote wellness and contribute to the prevention of a broad range of conditions. A new study, which demonstrates the promise of acupuncture as a complementary approach in improving psychological and pain symptoms associated with post-traumatic stress disorder (PTSD) following a natural disaster, is published as part of a Special Issue on Acupuncture to Foster Health Promotion and Disease Prevention in Medical Acupuncture, a peer-reviewed journal from by Mary Ann Liebert, Inc., publishers. Click here to read the full-text article free on the Medical Acupuncture website through May 23, 2019.
The article entitled "An Observational Study on Acupuncture for Earthquake-Related Post-Traumatic Stress Disorder: The Experience of the Lombard Association of Medical Acupuncturists/Acupuncture in the World, in Amatrice, Central Italy" was coauthored by Carlo Moiraghi, MD and Paola Poli, MD, Medical Association of Lombard Acupuncture (Milan, Italy), and Antonio Piscitelli, MD, School of Acupuncture and Traditional Chinese Medicine (Milan, Italy).
The researchers studied the effects of acupuncture on the victims of a 6.0 earthquake that caused nearly 300 deaths and left 30,000 people homeless in Amatrice, Central Italy. The acupuncture effort was led by two medical associations: Lombard Association of Medical Acupuncturists (ALMA) and Acupuncture in the World (AGOM).
Treatments were performed by medical doctors who had at least 3 years of clinical experience with acupuncture. Each subject received four 20-minute acupuncture treatments over consecutive days. Before the acupuncture treatment, more than 68% of the study participants reported having both pain and psychological symptoms that could be associated with PTSD. After the third treatment, both the pain and psychological symptom scores had significantly improved, with no serious adverse effects attributed to the treatment.
Co-Guest Editor Songxuan Zhou Niemtzow, MD (China), a Traditional Chinese Medicine physician in Alexandria, VA, states, "If acupuncture had an alternative name, it could be called 'prevention,'" in her editorial entitled "Acupuncture: Prevention Workarounds."
In the editorial "Prevention at the Core of Acupuncture," Co-Guest Editor Nadia Volf, MD, PhD, Paris XI University (Paris, France) writes "although acupuncture can be a wonderful tool for treating a number of diseases, this therapy can be an even more wonderful tool for preventing them."
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Nicotine replacement therapy




New evidence published in the Cochrane Library provides high quality evidence that people who use a combination of nicotine replacement therapies (a patch plus a short acting form, such as gum or lozenge) are more likely to successfully quit smoking than people who use a single form of the medicine.
Nicotine replacement therapy (NRT) is a medicine that is available as skin patches, chewing gum, nasal and oral sprays, inhalers, lozenges and tablets that deliver nicotine through the body to the brain. In many countries, people can get NRT from healthcare professionals as well as over-the-counter, without prescriptions. The aim of NRT is to replace the nicotine that people who smoke usually get from cigarettes, so the urge to smoke is reduced and they can stop smoking altogether. We know that NRT improves a person's chances of stopping smoking and that it's a popular choice for people who want to quit.
There are many different ways to use NRT. This Cochrane Review looks at the different ways to use NRT to quit smoking, and which of these work best to quit smoking for six months or longer. It includes 63 trials including 41,509 participants. All studies were conducted in people who wanted to quit smoking, and most were conducted in adults. People enrolled in the studies typically smoked at least 15 cigarettes a day at the start of the studies.
The Cochrane authors found that using a nicotine patch and another type of NRT (such as gum or a lozenge) at the same time made it more likely that a person would successfully stop smoking than if they used one type of NRT alone. Just over 17% of people who combined a patch with another type of NRT were able to quit compared with about 14% people who used a single type of NRT .
People were also more likely to successfully quit if they used higher dose nicotine gum (containing 4mg of nicotine) in comparison to lower dose nicotine gum (containing 2mg of nicotine). Higher dose nicotine patches (containing 25mg or 21mg of nicotine) probably make it more likely that a person will quit smoking than lower dose nicotine patches (15mg or 14mg of nicotine), however more evidence is needed to strengthen this conclusion.
When people quit smoking, they often set a quit day, which is the day when they plan to stop smoking entirely. There is evidence that starting to use NRT before a quit day may help more people to quit than starting using NRT on the quit day itself, but more evidence is needed to strengthen this conclusion.
Some studies looked at the safety of different types of NRT use and found that very few people experienced negative effects and those that were mentioned were minor, such as skin irritation with patches or mouth ulcers with lozenges. NRT is considered to be a safe medication, however data on the safety of different types of NRT use in comparison to one another is sparse.
Lead author, Dr Nicola Lindson from the Nuffield Department of Primary Care Health Sciences, University of Oxford, UK said: "NRT is easy to access over the counter for people who would like to quit smoking, but many people don't use it to best effect, so their chances of giving up smoking are reduced."
"This high-quality evidence clearly signposts that the most effective way to use NRT is to use a combination of two products at once, a patch and a fast acting form such as gum, nasal spray or lozenge. Quitting this way increases the chances of you stopping smoking altogether. Some people are concerned about using two forms at the same time, but the evidence does not indicate an increased risk of harms." She added: "While this advice is included in the most recent clinical guidelines in the UK and US, incorporating these findings into training and prescribing guidelines for health professionals, and advice for individuals looking to purchase NRT will likely help more people to give up smoking."
"We tried to answer some more questions about NRT use, such as how long NRT should be used for, whether NRT should be used on a set schedule or as wanted, and whether more people stop smoking using NRT when it is provided for free versus if they have to pay for it. However, more research is needed to answer these questions."
This review is published by the Cochrane Tobacco Addiction Group. This Group has also published other evidence for people considering giving up smoking, including systematic reviews on electronic cigarettes, behaviour therapies, and other medications for quitting smoking.
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