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Aug 9

A Harvard nutritionist shares the No. 1 vitamin that keeps her brain ‘young and healthy’and foods she eats ‘every day’ – CNBC

As a nutritional psychiatrist, I always make it a point to maintain a well-balanced diet. Much of that has to do with making sure I get all the right vitamins, especially because it's essential to preventing cognitive decline.

And given that the risk of neurological diseases increases as we get older, one question I often get from my patients is: "What is the best vitamin for protecting our aging brains?"

Each of our microbiomes is like a thumbprint, so a truly effective eating plan is personalized to the unique needs of an individual. But the vitamin group I prioritize the most to keep my brain young and healthy are B vitamins.

Depression, dementia and mental impairment are often associated with a deficiency of B vitamins, a study from the Wayne State University School of Medicine found.

"A B12 vitamin deficiency as a cause of cognitive issues is more common than we think, especially among the elderly who live alone and don't eat properly," says Rajaprabhakaran Rajarethinam, a psychiatrist and the lead author of the study.

There are eight different B vitamins, each with its own primary health benefits:

Vitamin B1, or thiamin, is crucial for the basic function of our cells and the metabolism of nutrients for energy.

The brain is one of the most metabolically active organs in your body, which means it needs the support of thiamin to prevent the deficiencies that can lead to neurological problems down the line.

Vitamin B2, or riboflavin, acts as an assistant to enzymes in our cells that carry out important reactions, such as in the body and brain.

It also helps to grow cells, produce energy and break down fats and external materials like medications.

Vitamin B3, or niacin, works with more than 400 enzymes to produce materials like cholesterol and fat needed within the body, and to convert energy for all our organ systems. Niacin is also an antioxidant, which helps reduce excess inflammation.

Vitamin B5, or pantothenic acid, is essential for making a molecular compound called coenzyme A, which helps our body's enzymes build and break down fatty acids for energy.

It also helps our cells generate acyl carrier proteins, helping to produce necessary fats. The brain is primarily fat, so pantothenic acid is among the most important vitamins in supporting brain health.

Vitamin B6, or pyridoxine, is notable for its role in disease prevention because proper levels of this vitamin is associated with lower risk of a number of cancers.

Additionally, pyridoxine helps many chemical reactions in the body that support immune function and brain health.

Vitamin B7, most commonly known as biotin, regulates cell signals for quick and efficient communication throughout the body. In the brain, it's crucial for cellular signaling via neurotransmitters.

Vitamin B9, or folate, is a popular supplement and a key vitamin for supporting brain and neurological health, optimal neurotransmitter function, and balanced psychological health.

Another benefit is that it helps encourage cellular detoxification.

Vitamin B12, or cobalamin, is an essential vitamin for forming red blood cells and DNA, and supporting the development and function of the nervous system.

B12 also supports the breakdown of homocysteine, a protein that can negatively impact cardiovascular health and lead to dementia when in excess.

I'm a "food-first" person, so I always encourage people to incorporate foods containing these vitamins into their meals. However, our diets are not perfect, so there may be instances where supplements may help. If that's the, case my simple advice is to "test, not guess" and consult with your doctor first.

The goods news is that B vitamins are among the easiest to work into your diet because foods that are rich in one B vitamin often contain many, if not all, of the B vitamins when consumed as whole foods.

Here are six vitamin B-rich foods I eat every day:

1. One egg contains a third of the recommended daily value of vitamin B7, while also containing small amounts of many of the other B vitamins.

2. Yogurt is high in both vitamin B2 and vitamin B12, as well as in natural probiotics, which support both gut health and mental health.I like plain Greek yogurt for the added protein.

3. Legumes such as black beans, chickpeas, edamame and lentils all help to boost your mood and brain health. They are an excellent source of vitamin B9, and include small amounts of vitamin B1, vitamin B2, vitamin B3, vitamin B5 and vitamin B6.

4. Salmon is naturally rich in all of the B vitamins, especially vitamin B2, vitamin B3, vitamin B6 and vitamin B12. Be mindful of the source of your seafood, and remember that frozen or canned salmon is a budget-friendly option, too.

5. Sunflower seeds are one of the best plant sources of vitamin B5. You can get 20% of the recommended daily value of this vitamin from just one ounce of seeds!

6. Leafy greens such as spinach, Swiss chard and cabbage are a great source of vitamin B9. This is the first food I suggest to patients who want to boost low mood.

Dr. Uma Naidoois a nutritional psychiatrist, brain expert, and faculty member atHarvard Medical School. She is also the Director of Nutritional & Lifestyle Psychiatry at Massachusetts General Hospital and author of the best-selling book"This Is Your Brain on Food: An Indispensable Guide to the Surprising Foods that Fight Depression, Anxiety, PTSD, OCD, ADHD, and More."Follow her onTwitterandInstagram.

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A Harvard nutritionist shares the No. 1 vitamin that keeps her brain 'young and healthy'and foods she eats 'every day' - CNBC


Aug 9

The Lunch Box: A New Option for People on Special Diets Detroit Jewish News – The Jewish News

Inside her neat Oak Park home, Shirah Fish is layering lettuce, sliced avocado, broiled chicken and quinoa in the 20+ plastic containers spread along the kitchen counter. Soon customers will be picking up their lunches, and shell deliver the rest in the Oak Park/Southfield/Huntington Woods area.

People forget to take care of themselves. Moms are busy with their kids all day and lunch is the first thing they forget, Shirah said. Then there are people who work through lunch, especially if theyre working remotely.

Shes pleased to help with that. I prepare a healthy lunch for them. A healthy meal can keep them going, can prevent that sluggish feeling and gives them a good boost of energy.

Shirah keeps strictly kosher, although her enterprise is not under rabbinical supervision. She has always loved cooking, but the busy mom of six with a degree in behavioral psychology never thought it would be something she would do professionally. This job started by accident. In February, her friend Aliza Ancier shared her struggles finding drop-in childcare.

You probably wont find it, Shirah told her. I never found any either. What worked for me was to figure out the things I wanted to get done while my babies were in daycare and then pay someone to do those things.

Aliza shared she was too swamped to cook and wasnt eating healthy lunches.

You could totally pay someone to make you lunch, Shirah told her. Anyone would do that. I would.

Really? Aliza asked eagerly. Can you start Monday?

Shirah was taken aback. She hadnt meant it like that But after thinking about it, she figured she might as well try. It would probably be good for her, too!

Thats when Aliza mentioned she was gluten-free. Intimidated, Shirah reached out to her friend Samm Wunderlich for recipe ideas.

After offering some suggestions, Samm said, If youre already making lunches for Aliza, can you make some for me, too? Im gluten-free and vegan.

As Shirah prepared lunches for Aliza and Samm, she took pictures of the food and shared with her friends. Soon she was getting more requests. Things quickly snowballed and the week before Pesach, Shirahs newly named The Lunch Box was preparing almost 10 lunches every day.

As word spread, her happy customer branch grew and now Shirah is preparing about 100 lunches every week.

She also began preparing a Shabbat menu, which includes different kugels, gefilte fish, baba ghanoush and other dips, chicken soup and desserts. She recently even catered a bridal shower and has prepared platters for office lunches.

I tell my customers, whatever theyre interested in, just ask. If I can do it, Im happy to help, Shirah said. She began selling customized protein shakes after a customer requested it and has recently begun providing breakfast power bowls, which include steamed spinach and scrambled eggs on a base of rice and beans, with pico de gallo and guasacaca sauce.

Most of her clientele are people with some kind of special diet dairy free, allergies, gluten-free, vegan and there arent many kosher choices for them in Metro Detroit.

Out of all the kosher local restaurants, there are maybe two things I can order off the menu, Samm said, who is on a vegan, whole foods, plant-based diet. Shirah is filling a huge need. Its so convenient and shes been wonderful at accommodating my requests for modifications and has been very receptive of my feedback.

Samms favorites are Shirahs ethnic dishes. The lunches are great, but the best is when she makes an elaborate curry or urban tofu, something I wouldnt usually bother making myself.

Shirah creates a menu early in the week, with at least one type of Mexican bowl. So far, Ive never made the same thing twice, Shirah said. Shes always skimming magazines and cookbooks for new ideas and is discovering and using ingredients she never before knew existed.

Her daughter Lea, 15, works as her sous chef, but Shirah does the artistic presentation herself.

The best part is seeing people enjoying my food, said Shirah, who has received tremendously positive feedback. But the hardest part is that I dont actually taste my food. Its hard for me to gauge what will be popular because Im actually a really picky eater!

Lunches are a flat rate of $15 per day. Follow The Lunch Box on Instagram @thekosherlunchbox or on Facebook. For the weekly menu or more information, call, text or WhatsApp Shirah at (248) 607-4549.

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The Lunch Box: A New Option for People on Special Diets Detroit Jewish News - The Jewish News


Aug 9

HALL THINGS CONSIDERED: Why lifestyle changes are better than diets – Times Tribune of Corbin

Since my weight is the heaviest its ever been, and since that number just continues to grow, I want to start the month of August by trying to at least watch what I eat.

I hope to squeeze in some exercise as well in order to help my weight loss and help me get in better shape, but I feel like my food intake is certainly something I can control better than I have been doing.

Right off the bat, some changes I can make include cutting out soda pop, limiting how much kiddie cereal I eat for breakfast (and sometimes as a late-night snack), and packing healthy food to work that I can eat instead of relying on our vending machines or local fast food restaurants.

Those all sound simple enough but I love having something flavored to drink with dinner, Im addicted to sugary cereal, and I cant help but to snack all night long when Im here at the office.

But I think if I can find some substitutions or at least cut back a little, that will certainly help a lot.

Of course they say that diets dont really work and instead you need to make a lifestyle change.

This means that you cant just say for a few months youre going to watch what you eat, and then afterwards fall back to your old routines.

You have to find what works best for you and then make permanent changes for the better.

Trying out a fad diet or making crazy sacrifices for 30 days will ultimately just burn you out and put you right back where you started.

I certainly agree with that way of thinking and hopefully I can make some permanent changes over the next few weeks and months.

When we are backslidden in our relationship with God, or if we dont have a relationship at all, we also need to make changes that are permanent.

Too often we just find ourselves attending church for special occasions, but sleep in the rest of the year. Or we force ourselves to get through a weeklong Bible study only to never look at the Bible ever again.

We also have to choose to be all in with all aspects of our lives as well.

Devoting an hour a week to God while spending the rest of the week living a life of sin is certainly not enough.

Its great if youre involved in church but you need to live according to Gods will the rest of the time also.

Otherwise, youre simply using church as a country club or as a way to put on a phony face for your peers.

Romans 12:1 says, I beseech you therefore, brethren, by the mercies of God, that ye present your bodies a living sacrifice, holy, acceptable unto God, which is your reasonable service.

Just like with our eating habits, we have to make complete lifestyle changes for God that are permanent.

If we only make little changes here and there, or if we just do a nice activity here and there, well ultimately end up right back where we started.

We have to think about how God wants us to live all of the time and not just some of the time.

Only then will we be truly sold out to the Lord and ready to take on the world.

Brad Hall is the nighttime editor at the Times-Tribune. He can be contacted at bhall@thetimestribune.com.

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HALL THINGS CONSIDERED: Why lifestyle changes are better than diets - Times Tribune of Corbin


Aug 9

Is Carb Withdrawal A Real Thing? – Health Digest

Taking control over your eating habits is a noble cause, but like most good things, it does require some perseverance. Verywell Fit explains that after the first few days of a low-carb diet, some people encounter a set of symptoms often referred to as "low-carb crash" or "keto flu". Harvard Health Publishing asserts that the condition has neither been recognized by the medical community nor substantiated by scientific research, but the phenomenon is widely discussed on the internet in articles, blogs, and online forums.

So while we can't say for certain why keto flu happens, Verywell Fit offers up the theory that it occurs when the body has used up the last of its glucose reserves, which are stored in the liver as glycogen, but has not yet adapted to getting energy from fat and protein.

Healthline explains that while some people kick carbs without any side effects, others have reported symptoms including nausea, headache, diarrhea, dizziness, weakness, muscle cramps or soreness, difficulty sleeping, poor concentration and irritability, and sugar cravings.

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Is Carb Withdrawal A Real Thing? - Health Digest


Aug 9

Gay nutritionist shares tips on how to bottom without douching – PinkNews

Daniel O'Shaughnessy says douching isn't always necessary. (PinkNews)

Daniel OShaughnessy had worked as a nutritionist for years before he thought of writing a book specifically about queer peoples nutritional needs.

The idea first came to him when he was dragged onto a gay cruise ship.Throughout his career, Daniel had worked extensively with LGBTQ+ clients people had come to him because he, as a gay man, seemed like a safe space, like somebody who understood their needs better than a straight nutritionist could.

On that cruise ship, people kept asking Daniel for tips on what foods would help them bounce back from a wild weekend.

I thought, Why is there no resource anywhere for the LGBTQ+ community?' Daniel says. Not everyone can afford a nutritionist what if the information was just in a book?

The result isNaked Nutrition: An LGBTQ+ Guide to Diet and Lifestyle. It caters to people all across the LGBTQ+ spectrum, with chapters on nutrition for people with HIV to the specific dietary requirements a trans person undergoing medical transition might need to be aware of.

There are other topics too theres a section that deals with nutrition for bottoms (spoiler alert: you really dont need to be douching very often, if at all), while the book also offers some tips for a fast recovery if you like going clubbing at the weekends.

At the core of the book is the idea that nutrition is so much more than the simplistic (and somewhat harmful) model of calories in, calories out that so many people cling to. Daniel is careful to note thatNaked Nutritionis not a diet book.

Thats the big difference between dieting and nutrition, Daniel explains. Nutrition is fuelling the body, giving your body what it needs to thrive. I practice something called functional medicine it looks at the body as a whole. For example, if you have a digestive issue, youre looking to find the root cause of it.

He says calories can be important for some people, but theyre not everything.

Particularly with weight loss for example, or even muscle gain, yes, they play a role, but they dont take into account the person and the trauma the person has.

You need to have a very 360 view of your health and when you just look at calories, its a very, very tiny bit of someones health. You can drink 2,000 cans of Diet Coke a day and be within your calorie allowance is that healthy?

He warns people away from fad diets, which are usually sold as a quick fix or as a way of controlling something else, Daniel says.

I would say one issue is, why do you need to control something? Unpick control maybe you cant control something else in your life, he says. Fad diets are a plaster on the main issue. Essentially what Im aiming to do is to give someone a whole health approach and say, You cant do a fad diet forever. Its pretty impossible. Yes, they work most diets work if you stick to them but the sticking to them is the problem.

He urges LGBTQ+ people who are in a cycle of fad diets, or who are thinking of going on one, to look inward and to reflect before they try to make drastic changes to their lifestyle.

It ties in to the self-love thing. Many LGBTQ+ people have self-love issues because weve always been told were not good enough. We have a lot of rejection trauma. So thats quite important for me to just unpick why you want to diet.

Naked Nutritionisnt all about calories and nutrition either the book also touches on muscle gain and fitness. If youve spent any time in gay spaces, youll know how much emphasis is placed on a muscled physique. Daniel says people who want to bulk up should first of all question why they want to do so in the first place.

Is it for yourself or is it about looking for external validation? Daniel asks.

If your motivations are coming from a good place, fitness and muscle-gain can be a healthy and rewarding journey to embark on. Still, Daniel knows that many LGBTQ+ people will have had negative experiences in the past that might make them nervous about the idea of going to a gym.

You dont need to go to these fancy gyms, you can do lots of workouts at home and there are plenty of free workouts online, he says. Pick and choose what you want to do.

He takes a non-judgemental approach to anabolic steroids in his book he instead provides readers with the information they need on side-effects.

I always say, heres the information Im not going to tell you what to do. Theres a lot of side-effects to taking anabolic steroids, theyre not a quick fix, and the minute you take them you have side-effects you probably wish you didnt have. Ive had personal experience of taking anabolic steroids and I could not sleep. I was so anxious. Was that worth it for me? No, so I dont see the point in taking them, and they can become very addictive in themselves.

Naked Nutritionalso touches on some of the more practical, day-to-day issues queer people might want tips on. One of those is bottoming.

If youre a regular bottom, the chances are that you put a lot of work into it. Douching is one of the most common ways to ensure the passageway is clear and clean before sex but Daniel is firmly of the belief that the right diet could eliminate the need for douching entirely.

Chances are, we shouldnt really need to lets put it that way but there are times we might have to, Daniel says. Every gay man has had an accident somewhere along the line, and you just have to realise that we are having sex somewhere where pieces come out of us, so accidents do happen.

However, the biological reality is that we should be ready for sex at most times because of the way the colon is constructed, Daniel explains.

Thats because we should be able to have complete and healthy bowel movements in the time we have them. But there are things that get in the way of that, whether its digestive concerns, stress, what we eat, what we drink all of these may impact the structure of our faeces, so that may then change our bowel habits and whether we feel completely clean.

If youre eating a healthy diet with plenty of fibre, the likelihood is that youll be clean and ready to rumble, Daniel says the problem is the psychological element. People get anxious about the possibility of having an accident, so they douche as a preventative measure.

If youre a person that douches, youll probably want to douche, so its about douching well.

It ruins sex it gets in the way of sex, you panic, you dont relax, so in those moments you might think, Im going to douche. There are people who think douching is very unhealthy for us, but if youre having prolonged sex, or you just want to make sure youre clean, then it might be better to do that than to not do that.

However, Daniel does make the point that there is such a thing as too much douching. Going overboard can wipe out beneficial bacterias in your gut.

That can impact risk of STIs and is bad for our health as well, Daniel says. Its about weighing it up ultimately if youre a person that douches, youll probably want to douche, so its about douching well.

If you do want to move away from douching, Daniel recommends people take a look into the loo to get an idea of where the problem might lie.

Look at your food triggers, he says. Theres something called the Bristol Stool Chart and your stool should look like the healthy stool on that. If it doesnt then you have to look into why and figure out how to get a healthy stool.

There are, of course, some quick hits for bottoms if they dont want to deprive themselves of their favourite foods. The market is flooded with supplements for queer men Daniel recommends Psyllium Husk, which is a plant-derived source of fibre.

Just be mindful not to take that with any medication because it might pull that with it because its actually a soluble fibre, he says. People can also try eating fermented foods like yoghurt, kefir, kimchi and sauerkraut to help with their beneficial bacteria.

The book is a first step to taking responsibility for self-love.

Theres a lot inNaked Nutrition, but at the end of the day, Daniels most important piece of advice is that people dont overload themselves while trying to make changes.He wants people to know its possible to do a couple of small things differently if they want to improve their health and wellbeing they dont need to radically transform how they eat.

The book is a first step to taking responsibility for self-love. I want to encourage you to step up, read the book, take what you want from it. It doesnt have to be such a hard life.

Naked Nutrition: An LGBTQ+ Guide to Diet and Lifestyle is out now.Daniel OShaughnessys Instagram is here.

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Gay nutritionist shares tips on how to bottom without douching - PinkNews


Aug 9

Mindy Kaling in Bathing Suit is "Excited to Model" Celebwell – Celebwell

Mindy Kaling is showcasing her incredible weight loss journey in a gorgeous blue swimsuit, saying she is excited to show off her new look. "The lowkey romantic gift my friends @traceywigfield and @loulielang gave me was this sexy blue one piece bathing suit which I was so excited to model. You know you have good friends when they're excited to buy you intimate apparel!," she captioned an Instagram post. How does she stay so fit? Read on to see 7 ways Kaling stays in shape and the photos that prove they workand to get beach-ready yourself, don't miss these essential 30 Best-Ever Celebrity Bathing Suit Photos!

Kaling is passionate about not being too restrictive with diet, as it usually backfires. "I eat what I like to eat," the actress told ET. "If I do any kind of restrictive diet, it never really works for me. I just eat less of it." Experts agree that severely restrictive diets rarely work over the long term. "At any given time, more than a third of Americans are on a specific diet, with weight loss as a leading reason," says Robert H. Shmerling, MD. "Most are going to be disappointed, because even when successful, lost weight is frequently regained within a few months."

While Kaling refuses to diet, she understands moderation is crucial for health. "I'm never going stop being a foodie. I'm never going be someone who can just have spinach and salmon every day," Kaling says. "I just am really for the first time in my life, trying moderation, and I love it."

Kaling makes a point to keep moving throughout the day. "Sometimes I'll be like, 'Well, I have four different times today where I have 10 minutes so let's just walk instead of sitting down and checking Instagram,'" she says. "So instead of it being like one chunk of exercise in the beginning of the day or none at all, I'm now just deciding that I'm going to be a more active person all the time."

Kaling understands that when it comes to exercise, it's important to find something you enjoy."In my 20s, I thought a workout had to be something that was punishing, like 45 minutes of running and you had to hate it the whole time," she says. "I don't have that relationship with exercise anymore."

Like most people who instinctively understand what works for their body, Kaling doesn't overthink her diet and fitness regimen. "Honestly, I didn't really do anything differently. I eat what I like to eat. If I do any kind of restrictive diet, it never really works for me. I just eat less of it I wish there was something more juicy or dynamic about the way that I've lost a little bit of weight, but that's the way I've done it," she explains.

Kaling appreciates the mental health benefits of exercise. "I love working out," she says. "I don't go to therapy, and I think that's because I get endorphins from exercise. It's such a powerful tool for me mentally. I know that working out is not the path for me to be skinny. For my body type, that entails eating well and making healthy choices. Working out is a way for me to have mental strength, and now, with a kid, it's also time that I have just for myself and to focus on my body."

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Kaling continued working out throughout her pregnancy to make post-baby weight loss easier. "I did a lot of yoga and a lot of walking, and I jogged until I couldn't jog anymore," Kaling says. "I exercised until the morning I gave birth. Also, about a week after I had the baby, I started walking a couple of miles a day. I don't recommend that for everyone, obviously, but I didn't have that difficult of a delivery. All those things were really helpful when it came to losing the weight."

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Mindy Kaling in Bathing Suit is "Excited to Model" Celebwell - Celebwell


Aug 9

As Health Disparities Weave Their Way Through Hypertension, New Agents Are on the Way – AJMC.com Managed Markets Network

Shifting guidelines, lack of access to insurance, and a failure to focus on lifestyle as the primary tool to manage hypertension have allowed the United States to lose ground in the battle for blood pressure control, according to 3 of the countrys leading experts on cardiovascular and kidney disease who spoke during the recent 2022 Congress of the American Society for Preventive Cardiology (ASPC), held July 29-31 in Louisville, Kentucky.

Keith C. Ferdinand, MD, professor of medicine at Tulane University School of Medicine; Kim Allan Williams, MD, who last month became the chair of the Department of Medicine at the University of Louisville; and George C. Bakris, MD, professor of Medicine and director, Comprehensive Hypertension Center, University of Chicago Medicine, spoke about different aspects of hypertension treatment and access to careand how management of hypertension is essential to avoid chronic kidney disease (CKD).

Bakris said that in 2014, improvements in treatment had allowed blood pressure (BP) control rates among US adults to reach 53.8%, up from 31.8% in the early 2000s. Williams explained how the Joint National Committee 8 guidelines (JNC 8) in 2014 included a hotly debated recommendation to not initiate treatment for hypertension for patients over age 60 until BP reached 150/90; this contributed to a nosedive in control rates, until they hit 43.7% in 2018.

Then in 2015, the SPRINT trial, funded by the National Institutes of Health, showed beyond a doubt that controlling BP to below 140/90, even down to 121/80 dramatically reduced heart attacks, strokes, and cardiac deaths with limited effect on acute kidney injury, from which patients recovered. Williams retraced how the findings propelled the American College of Cardiology (ACC) and the American Heart Association (AHA) to execute new BP guidelines in 2017 that list BP just above that level as elevated and BP that reaches 130/90 as Stage 1 hypertension.

Confusion over guidelines played a role in the United States regression in BP control, but Bakris said that doesnt tell the whole story. He noted in sharing a global report card on hypertension that the countries with the best rankingsCanada, Costa Rica, South Korea, and Taiwanall had universal health coverage. Thats not a political statement. Thats just a fact, he said.

Ferdinand, who spoke a day prior to Williams and Bakris during a symposium on womens heart health, also raised the issue of access to insurance coverage for at-home BP monitors. Williams and Ferdinand agreed that hypertension cannot be properly diagnosed and managed without out-of-office BP readings. Besides the well-known white coat effect, which can lead to higher-than-normal readings in the physicians office, the phenomenon of masked hypertension can cause some patients to have lower readings when away from stressful home environment.

Ferdinand discussed findings from a small, unpublished sample that showed when patients had access to a BP device and at-home results were transmitted to the clinic via Bluetooth technology, Were able to show increased adherence and improvement in blood pressure.

Hypertension and Disparities

Ferdinand reviewed why hypertension is so important in addressing health disparities: although longevity has increased overall prior to the pandemic, the shortest life expectancy among the major racial/ethnic groups are the non-Hispanic Black populations.

The White-Black gap has been present for decades, he continued, and COVID-19 has only made the gap worse. And the protective effect of being Latino has been lost.

Meanwhile, Hypertension in the Black population is perhaps the most powerful risk factor, he said, tracing data that show how it appears first among males but then rises over time among females, until the disease burden is significantly higher among women as they get past age 60. Loss of estrogen between age 50 and 60 is a factor for increased hypertension in older women, Ferdinand said.

Williams continued this theme. If we can just control hypertension, were going to do so much better, he said. We know what it does, and if we focus on the fact that our ethnic disparities really weave their way through hypertension, starting with renal disease and congestive heart failure, the need to keep BP levels below 140/90 to reduce the risk of cardiovascular mortality makes sense.

Hypertension is the most powerful and potent predictor for morbidity and mortality both in men and women, but even more so in womenespecially in older women, Ferdinand said. Combination drug therapy is now the best practice in order to control blood pressure, and we need more attention to hypertension and appropriate diversity in research.

Starting With Lifestyle

Williams, who has long advocated plant-based diets, addressed criticism that the 2017 ACC/AHA update to the blood pressure guidelines was a way to get patients to take more medication. We werent recommending more drugs for a lot of people, he said. We were talking about lifestyle.

Williams spent most of his talk on the need to give more attention lifestyle change, including weight loss, smoking cessation, and limiting alcohol consumption. But I always like to focus on dietary evidence, he said.

Theres abundant evidence in support of the DASH diet (Dietary Approaches to Stop Hypertension), but not everyone looks at the DASH diet the way I do. he said.

The key takeaways from the many studies are that diets with less fat and less cholesterol, which are more towards a vegetarian, non-exclusive vegetarian dietthat gives you the largest impact on blood pressure.

More studies have accumulated about the mechanisms of why these diets work as an intervention. Some of them are very strong, some of them are less strong, but the data is really bending toward the more intervention you do with plants, the better off you're going to be. And I'm irritated that we've had to say it for quite a while, we just didn't know exactly why.

However, in the last 3 to 5 years, thats changed. Its all about the microbiome, Williams said, offering a primer on microbiologyand how the bacteria, fungi, and viruses, which help digest food and make up a persons immune system, are affected by the environmentin other words, by the people around them. This was seen during COVID-19, he said, as people who ate a lot of red meat got very sick.

When it comes to hypertension, he said, a major factor is, What species do you have in your microbiome?

Bakris, who followed Williams, agreed. One factor that makes kidney disease such a major cardiovascular risk factor, he said, is that when the estimated glomerular filtration rate (eGFR) gets down to the 40s (90 is normal; below 15 is kidney failure), the microbiome totally changes and becomes very cardiotoxic.

Flurry of Activity in Drug Pipeline

Medication adherence is a known problem in managing hypertension, but so is measuring BP correctly, which gets less notice. We are not paying attention to very simple things, Bakris said.

Hypertension has been perceived as dead for the last decade, because nothing really new is happening, he said. But theres a huge flurry of activity coming in the next 5 to 7 years specifically in resistant hypertension.

He highlighted the current recommendation for resistant hypertension, published in 2018 for the AHA, which calls for:

However, he noted that these recommendations were based on a trial where patients had close to normal eGFR; most patients with advanced hypertension also have advanced CKD, with eGFR in the 40s. Its not so easy to go to spironolactone(an MRA) with potassium issues, he said.

Its important to keep in mind what could be coming soon. He discussed:

Nonsteroidal MRAs. Bakris said these agents have a very different chemistry from MRAs with far less adverse effects. He mentioned finerenone, already approved as Kerendia to reduce renal and cardiovascular risks in patients with type 2 diabetes. The gossip is it doesnt lower blood pressure, he said, Well, it actually does, and the papers are in press.

He focused discussed several possible therapies being studied for resistant BP, including ocedurenone, which he said, lowers blood pressure significantly and has a very good pharmacological profile.

Bakris then discussed the BLOCK-CKD trial involving KBP-5074, an investigational agent being developed by KBP Biosciences. Results of the phase 2b study in patients with stage 3b/4 CKD showed a reduction of 10.2 mm Hg compared with placebo of systolic BP at the larger dose (0.5 mg), with some elevation of hyperkalemia.

Like other speakers at ASPC, Bakris warned that albumin, not just eGFR, must be monitored to catch CKD at early stages.

Endothelin receptor agonists. Therapies in this class are already approved to treat pulmonary arterial hypertension (PAH), but Bakris said whats coming is a joint endothelin A/endothelin B receptor agonist. He urged the audience to look forward to results from the PRECISON trial, studying aprocitentan.

Brain aminopeptidase inhibitor. Bakris said the first drug in this class, firibastat, appears to offer more benefit in treating hypertension to Black patients, although the reasons for this are unclear.

Angiotensinogen knockouts.Yet another approach is to target angiotensinogen, which would address hypertension by addressing overactivity at the top of the reninangiotensin-aldosterone system pathway. According to an article in JACC: Basic to Translational Science that Bakris cited, the idea is to go after the RAAS pathway at its source, rather than downstream which is how angiotensin-converting enzyme inhibitors or type I angiotensin receptor blockers work.

So, weve left the kidney; weve left the vessels, and weve moved into the liver, Bikras said.

He cited an article that presented phase 2 results for IONIS-AGT-LRx, which is being developed for hypertension and heart failure indications. Early data for a therapy that would treat BP by injection for up to 6 months are promising very promising, but Bakris noted the need for reversal agent, which he said is being addressed.

In the near term, Bakris expects the FDA to consider renal denervation, a process that removes nerves from the renal artery. This is already approved in some parts of Europe.

With at least 4 different classes of BP lowering agents in the pipeline, he said, I'm confident that over the next 3 to 4 years, there's going to be a lot more in the armamentarium to use, to get the blood pressure lower with fewer side effects than what we have right now.

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As Health Disparities Weave Their Way Through Hypertension, New Agents Are on the Way - AJMC.com Managed Markets Network


Aug 9

Processed Foods (Like Ice Cream) Hurts Brain Function, Study Finds – Being Patient

By Simon Spichak, MSc | August 4th, 2022

As we age, cognitive function declines. In some people, this process happens faster than others. Mounting research points to the idea that highly processed foods with lots of calories, salt, fat and added sugars think: sugary sodas, grocery store birthday cake, fast food burgers and fries may cause older adults cognitive abilities to decline faster.

At the Alzheimers Association International Conference this week, Natalia Gonalves, PhD, from the University of So Paulo Medical School presented research that compared the cognitive health of older adults who frequently partook in foods that contain few to no unprocessed ingredients against the cognitive health of those who ate more than 80 percent healthy foods.

The main takeaway is that diet is a modifiable lifestyle factor, Gonalves told Being Patient. Therefore, we can choose to make better dietary choices in order to protect our brain health long term.

The study tracked 10,775 people with an average age of 50 in Brazil for up to a decade, finding that people who ate lots of ultra-processed food their diets were made up of 20 percent junk food at the start of the study were more likely to experience declining decision making abilities and declining ability to learn, remember and focus on things overall as they aged. The research has now been submitted to scientific journals for peer review.

The findings support past evidence that highly processed junk food i.e. higher cholesterol, more sugars is associated with worse cognitive health. This preliminary work builds on other larger studies that have found older adults who ate more unhealthy foods had a smaller hippocampus, the region of the brain responsible for memory, which may lead to more memory difficulties or other cognitive challenges.

On the flip side, however, mounting evidence supports the idea that health diets like the MIND or Mediterranean-style diet, which are low in processed foods, and high in vegetables, olive oil and omega 3s improve brain health. Studies repeatedly imply that something about these diets helps to protect the brain from cognitive decline and Alzheimers.

In both cases, the science isnt there yet to call these associations proven. Diet studies are often clouded with parallel lifestyle variables that are tough to control for. But Alzheimers Association Senior Director of Scientific Programs and Outreach Claire Sexton said while research continues, people have little to lose in taking up a healthier diet.

There is growing evidence that what we eat can impact our brains as we age, and many studies suggest it is best to eat a heart-healthy diet low in processed foods, and high in whole, nutritional foods like vegetables and fruits, Sexton said in a news release.

Future work is on the way to help clear up the complicated links between food and memory, uncovering why we might really be what we eat.

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Processed Foods (Like Ice Cream) Hurts Brain Function, Study Finds - Being Patient


Aug 9

Im a nutritionist heres what I tell all Premier League footballers about their diet and how you can cop… – The US Sun

ITS come home all thanks to the Lionesses.

And now fans have a new season and the World Cup this winter to look forward to.

6

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Theres no doubt the physical demands of the beautiful game are gruelling for players in the top flight.

But what might surprise you is that you too can follow their lead when it comes to healthy eating.

Performance nutritionist Liam Holmes has worked in elite sport for 12 years, and has helped footballers at Tottenham Hotspur, Fulham and the Republic of Ireland national team.

Liam, who is currently working with Celtic and owns pH Nutrition, tells Sun Health: To achieve the fitness levels and get in the shape that pro footballers are in, it comes down to one thing consistently eating the right things.

Here, Liam breaks down what a professional footballer eats and reveals nutrition tips for you to focus on.

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CARB loading isnt a myth its still something players do. Its just a lot more controlled than back in the eat all the pasta possible days, Liam says.

I encourage the players I work with to make this meal fairly similar each time you dont want to be experimenting the night before the match, he adds.

Most players will eat the exact same meal the night before a match every single time.

If you are planning a big workout or have a big football match, I always advise this strategy.

Their meal will consist of a large serving of carbs such as rice, potatoes, grains or breads, accompanied by a portion of lean protein and vegetables.

This balanced meal helps top up energy stores ready for the match whilst providing micronutrients for recovery.

THE main focus for match day is topping up, Liam explains.

Players are advised not to overload their bodies by trying to eat lots of calories ahead of a match, he says. We dont want players to still be digesting their meal in the warm-up.

What players eat will depend on the time of the match, but a typical pre-match meal will tend to consist of a small serving of lean protein, some simple carbs like a handful of brown rice, a few veggies and a small serving of fat, like cheese or avocado.

Players are encouraged to eat low-fibre carbs such as rice, pasta and bread with easily digestible veg like peas, corn and carrots so they feel light and ready to go by the warm-up.

6

THERES a good reason the player of the match doesnt get champagne anymore, Liam explains.

Alcohol is not a good idea immediately after a game, he says.

Its important that players follow the three Rs rehydrate, repair and replenish.

Players will take some form of recovery shake, which includes protein, electrolytes and carbohydrates to kick-start the process.

Lots of protein shakes now include all of these as standard so you can easily have these yourself.

We then advise players to eat a meal 60 to 90 minutes after a match with protein, carbohydrates and vegetables. Usually appetite is suppressed after a game so using finger food-style meals or smaller dishes can help get players to eat.

TO ease muscle pains and boost energy levels, players usually start the day with eggs, Greek yoghurt, nuts, berries, smoothies and beans, Liam reveals.

And after a morning of stretching and massage, lunch continues the recovery theme.

Salmon, beef, chicken thigh, potatoes, grains and lots of fruit and veg are on the menu, he says.

It is key on these days to make sure protein intake is consistent across the day, to aid muscle repair, so players will snack once or twice in the afternoon before dinner and then before bed.

The pre bed snack will usually be Greek yoghurt and fruit or cottage cheese and oat cakes to provide slow releasing protein overnight and aid recovery even further.

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THIS might come as a surprise but nothing is really off-limits for pro footballers.

Liam says: Alcohol is usually removed as much as possible and if the players do have a drink then they usually wait until off season.

Players need variety in their diets to get ultimate nutrition, so away from matches they can add in their favourite foods.

That said, they are advised to avoid and most do deep-fried food, very oily food like chips, sweets and processed foods like biscuits, crisps and cakes.

They avoid these ultra-processed foods because they have little to no nutritional qualities and they can contribute to inflammation something that we actively want to avoid as much as possible for footballers, Liam adds.

TOP players are human, and like the rest of us they need to snack.

Trying to sneak anti-inflammatory foods in is something we try to encourage players to do when they are snacking, says Liam.

Dark-coloured fruits such as berries, green veg, oily fish such as salmon, tomatoes, peppers and spices can all help recovery.

HOLIDAYS are a time to treat yourself even if youre a top-flight player.

These days its true that players are far more conscious of the effects of alcohol and poor-quality food even while on holiday, Liam says.

But in the off season players naturally are more relaxed when it comes to the foods they limit during the season.

They will make sure they eat a balanced diet still, but might sneak in a few biscuits and crisps.

Due to the demands of elite football now there is less time off so the players still need to be eating well to support recovery.

6

GOOD news if you want to emulate the top flight, theres no need to ditch your morning cuppa.

Caffeine is one of the most researched performance-enhancing substances available for players to use, Liam says.

It can help endurance, sprint performance and decision-making so most players drink coffee but time when they drink it specifically around training and matches.

Taking caffeine in a coffee or energy drink 45 to 60 minutes pre-match or pre-training can help performance.

Footballers also really prioritise their sleep so they are wary of drinking coffee past 2pm because it can interrupt your ability to sleep.

YOU might be surprised to hear cake is a very necessary part of a players diet.

Being on the ball with your nutrition seven days a week for an entire season is impossible, even for the best players.

And while chowing down on a few doughnuts just before a match is not advised, Liam explains the high-sugar treats have their place.

He says: Things like cakes and sweets are very energy-dense, so it can actually help when replenishing energy stores during tough periods of matches as they are usually high in carbohydrates.

So it isnt completely unheard of anymore for players to enjoy a cake, biscuit or even cheesecake as it is also high in protein at half time.

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Im a nutritionist heres what I tell all Premier League footballers about their diet and how you can cop... - The US Sun


Aug 9

Statin therapy is not warranted for a person with high… : Current Opinion in Endocrinology, Diabetes and Obesity – LWW Journals

KEY POINTS

.. there are things we know we know. We also know there are known unknowns; that is to say, we know there are some things we do not know.

Donald Rumsfeld

In 1973, Dr Robert Atkins was called to testify before the US Senate Select Committee on Nutrition and Human Needs [1]. The committee was charged with investigating, amongst others, the eponymously named high fat Atkins diet, which was considered nutritionally unsound and potentially dangerous. Nutrition experts called upon were unanimous in their testimony that this diet was potentially harmful. Dr Fred Stare, for example, Chairman of Harvard's Department of Nutrition stated any diet which tends to be high in saturated fat and cholesterol tends to elevate the chance that the individual will get heart disease. (pg 17). This viewpoint on the potential hazards of the Atkins diet was expressed that year in an editorial in JAMA which stated, Perhaps the greatest danger (of the Atkins diet) is related to hyperlipidemia, which may be induced by such a regimen which could be responsible for accelerating atherosclerosis [2]. These concerns with an Atkins, that is, low carbohydrate diet (LCD) expressed 50 years ago have persisted, as evidenced by the recent proclamation by the National Lipid Association Nutrition and Lifestyle Task Force, that long-term consumption of the LCD increases the risk of all-cause and cardiovascular mortality [3].

Concerns with the safety of the LCD are based, in part, on the diet-heart hypothesis, which postulates that unrestricted consumption of saturated fat (from animal fat and tropical oils) on an LCD may raise serum cholesterol levels, thereby increasing one's risk of developing cardiovascular disease (CVD) [46]. This hypothesis, however, has failed to receive empirical support, with decades of scholarly critiques of its flaws [717,18,1921]. We concur with DuBroff and de Lorgeril [7] that the diet-heart hypothesis survives only because its proponents selectively cite evidence that validates their own viewpoint while disregarding evidence to the contrary.

An extension of the diet-heart hypothesis is the view that an elevated level of low-density lipoprotein cholesterol (LDL-C), under any circumstance, is unequivocally recognized as the principal driving force in the development of (atherosclerotic cardiovascular disease) [22] and that the key initiating event in atherogenesis is the retention of low-density lipoprotein (LDL) cholesterol (LDL-C) within the arterial wall [23]. This perspective on LDL-C as inherently atherogenic has been the driving force in recent concerns that an LCD-induced increase in LDL-C increases one's risk for developing CVD [24,2528,29,30].

Regarding an increase in LDL-C on an LCD in relation to the risk of a coronary event, we shall paraphrase the quote from Donald Rumsfeld by stating there are known knowns and known unknowns about LCD, LDL-C, and CVD. It is known that the LCD improves many CVD-relevant biomarkers, but it is not known with certainty if an increase in LDL-C on an LCD is proatherogenic, neutral or beneficial. The basis of our lack of knowledge on this issue is the absence of any published long-term clinical trials which have characterized hard coronary events, for example, myocardial infarction, stroke or coronary death, in people who develop high LDL-C on an LCD. Therefore, despite the concerns expressed repeatedly over the past 5 decades, there is no conclusive research to indicate whether an increase in LDL-C for someone on an LCD has any effect, beneficial or harmful, on CVD outcomes.

We have approached the issue of LDL-C concerns on an LCD with the following strategy. First, we have evaluated the dogmatic view held by various heart disease organizations that high LDL-C is inherently atherogenic [22,23,31]. Second, we have reviewed research on measures which are superior to LDL-C, such as insulin resistance (IR) and LDL particle subtypes, as markers of CVD risk. Third, we have reviewed findings that demonstrate the LCD improves all biomarkers which are strongly associated with CVD. Lastly, while there is active debate about the merits of statin therapy in primary prevention of CVD [3234], statin therapy in secondary prevention trials and in high risk populations, such as those with type 2 diabetes, have reported a small coronary event and mortality absolute risk benefit [3537,38]. We have addressed whether this modest benefit of statin treatment can be attributed to the lowering of LDL-C, per se, or through other mechanisms. More importantly, we have evaluated whether the benefit of statin treatment reported in clinical trials can be extended to people on an LCD with elevated LDL-C.

In 1985, Brown and Goldstein received the Nobel Prize for their research on LDL-C in people with familial hypercholesterolemia (FH). They discovered that this genetic condition involves impaired binding of LDL to its membrane receptor, which results in dramatically elevated serum levels of LDL-C. Because people with FH exhibited premature CVD, Brown and Goldstein declared there was a causal relation between an elevated level of circulating LDL and atherosclerosis [39], thereby providing support for the lipid hypothesis, in which LDL-C is described as inherently atherogenic. Since then, this pejorative view of LDL-C as the bad cholesterol has been promoted by high profile heart disease organizations, such as the American Heart Association [40], as well as the European Atherosclerosis Society, which states LDL is unequivocally recognized as the principal driving force in the development of ASCVD (atherosclerotic cardiovascular disease) [22].

Studies on the FH population, however, provide an extensive literature highlighting inconsistencies with the lipid hypothesis. For example, if LDL-C is inherently atherogenic, the burden of atherosclerosis should increase with the time of exposure to LDL-C. That is, cardiovascular mortality would be predicted to increase with age as a direct consequence of the time of exposure to LDL-C. To the contrary, CVD mortality in FH individuals declines with age [41]. Elderly individuals with FH exhibit an equivalent risk of CVD mortality to those in the non-FH population, despite a lifetime of exposure to high LDL-C. This finding directly conflicts with the dual component hypothesis that LDL-C is inherently atherogenic, and that CVD risk increases with the duration of LDL-C exposure [42]. That elderly FH individuals exposed to decades of high LDL-C demonstrate no increase in CVD mortality, as well as no increase in morbidity, for example, ischemic stroke [43], compared to the general population, undermines the lipid hypothesis, that is, that high LDL-C is inherently atherogenic.

Further challenging to the lipid hypothesis is that FH individuals have a lifetime all-cause mortality rate which is equivalent to, or even lower, than that of the general population [41,4447]. We submit three explanations for the longevity of people with FH. First, the small subset of individuals with FH that die prematurely of CVD appear to be genetically susceptible to develop coagulopathy, independent of their LDL-C levels [48,4951]. In one example, Jansen et al., [51] reported that whereas LDL-C did not differ between CVD and non-CVD FH patients, those with a polymorphism for the prothrombin (coagulation factor II) gene exhibited over twice the incidence of CVD than those without the polymorphism. Second, LDL-C is an important component of the immune system [5254]. Chronically elevated LDL-C levels may enhance aspects of immune functioning, thereby lowering rates of mortality from cancer and infection [41,46,47]. In related work, elevated LDL-C may protect against bacterial infection, which can promote the development of atherosclerosis [53,5560]. Third, FH individuals, either through lifestyle choices or favorable genetics, have a relatively low rate of type 2 diabetes [6165], which itself is a significant risk factor for CVD. These three observations help to explain why FH individuals do not face an increased risk of CVD mortality with advanced age, as well as the greater longevity of people in the general population with high LDL-C, compared to those with low LDL-C [66].

Despite several influential heart disease organizations holding the position that LDL-C is a cause of CVD, it has long been recognized that LDL-C is a poor marker of risk for CVD [6769,70,71], as well as cardiovascular and all-cause mortality [66]. For example, calcification within the coronary arteries, in contrast to LDL-C, is a reliable measure of CVD risk. Coronary artery calcium (CAC) scoring has proven to be the single best predictor of fatal and nonfatal coronary events [7275], including CVD risk in diabetic and nondiabetic patients [7678], as well as in young, mid-age and elderly patients [79]. CAC scoring also excels at long-term risk prediction over periods of more than a decade [76,78,80]. Moreover, among those with genetically confirmed FH, approximately half showed no detectable CAC and had a favorable prognosis, despite significantly elevated LDL-C levels [81].

The superiority of CAC to LDL-C in relation to plaque development, as well as coronary events, in high-risk patients was demonstrated recently by Mortensen et al.[82]. These investigators identified CAC levels as being superior to, and independent of, LDL-C, as a biomarker of coronary event rate. In related work, Miname et al.[81] reported that coronary events in statin-treated patients were associated with increased CAC scores, and were unrelated to on-treatment LDL-C. Moreover, these investigators found that the ascending gradient of CAC scores was associated with increases in fasting glucose and not in on-treatment LDL-C values.

In one representative example of the value of CAC scoring, Sandesara et al.[83] reported that over one third of individuals with very high LDL-C (>190 mg/dl) had a zero CAC score. Hence, the zero CAC score had more predictive utility than LDL-C because these individuals had a very low risk for future coronary events. These findings, as well as related research, were discussed by Bittencourt et al.[84], who concluded treatment of individuals with very high LDL-C (>190 mg/dl) irrespective of their clinical risk might not be the most prudent approach . These investigators further noted that low CAC scores, and therefore the low CVD risk, in individuals with very high LDL-C should make us question at least part of our understanding of the atherosclerotic process.

In addition to CAC scoring, serological markers have demonstrated clear superiority to LDL-C levels in assessing CVD risk. For example, Yu et al.[85] reported that markers of the insulin-resistant phenotype, specifically elevated fasting plasma glucose, hemoglobin A1c and triglycerides (TG), were all positively correlated with the severity of coronary stenosis; LDL-C levels, in contrast, showed no correlation with coronary stenosis. In another example, FH individuals that carry an A, B or AB blood group (which is associated with increased coagulation [86]), have a twofold increased risk of CVD, compared to those with blood type O [87].

Often overlooked in the discussion about LDL-C as a cardiovascular risk factor is the heterogeneity of different LDL particles. That is, the total LDL-C reported in a conventional lipid panel represents the sum of a heterogeneous population of different low-density lipoprotein particles [71]. One unique population of LDL particles is known as lipoprotein (a) (Lp(a)). Lp(a) is a modified LDL particle in which an apolipoprotein (a) molecule is covalently attached to the ApoB100 moiety of an LDL particle. The link of Lp(a) to CVD may be driven by its pro-inflammatory effects [88]. Lipid peroxidation colocalizes with Lp(a) to contribute to the pathogenesis of CVD by promoting endothelial dysfunction, lipid deposition, inflammation, and arterial calcification [89]. This research has provided strong support for the view that an elevated plasma concentration of Lp(a) is an independent risk factor for the development of CVD in FH and non-FH individuals [9094]. It is notable that Willeit et al.[95] recently reported that correcting for the Lp(a) component in the total LDL-C measure eliminated isolated LDL-C as a CVD risk factor. This refined assessment of LDL-C, which takes into account the Lp(a) subfraction, provides a mechanistic basis for why LDL-C is a poor marker of CVD risk.

In summary, the pejorative view of LDL-C as the bad cholesterol, which is inherently atherogenic, is not supported by a balanced review of the literature. Numerous investigators who have assessed the clinical literature have concluded that the lipid hypothesis persists today only because of the biases of its proponents [49,67,68,96,97]. Characteristic of this sentiment is the opinion that evidence falsifying the hypothesis that LDL drives atherosclerosis has been largely ignored [98], and the perspective of three cardiologists that LDL cholesterol risk has been exaggerated - Decades of emphasis on the primacy of lowering plasma cholesterol, as if this was an end in itself, has been misguided. [21]. Finally, the negative impact of the emphasis on LDL-C reduction in developing therapeutics has also been recognized, leading DuBroff [96] to conclude that the LDL-C-centric approach to cardiovascular disease prevention may have distracted us from investigating other pathophysiologic mechanisms and treatments.

There is an extensive literature demonstrating that biomarkers other than LDL-C provide more reliable assessments of CVD risk. Furthermore, mechanisms have been clearly described for these biomarkers, affording biological plausibility. Of these other risk factors, IR, which is related to hyperinsulinemia and hyperglycemia, is perhaps the most important. Over 3 decades ago, Gerald Reaven summarized the research on IR by stating that the physiological attempt to compensate for IR sets in motion a series of events that play an important role in the development of both hypertension and coronary artery disease, and that variations in insulin-stimulated glucose uptake determine to an enormous degree the likelihood that an individual will develop premature atherosclerotic vascular disease [99]. Kraft's [100], conviction that those with CVD not known to have diabetes were simply undiagnosed revealed his insight into the core mechanisms of CVD. Contemporary research has confirmed that IR is a strong and independent predictor of CVD, with compelling evidence that IR is a major causal influence on the pathophysiology of CVD [101105]. This is driven in no small part by the causal role of IR in the development of type 2 diabetes, itself being the greatest risk for CVD [106].

There are myriad mechanisms whereby IR contributes to the pathogenesis of atherosclerosis. IR-related measures that are well established independent risk factors for CVD include hypertension [107], glycocalyx disruption secondary to hyperglycemia [108], prothrombosis [109], advanced glycation end product associated endothelial dysfunction [110] and impaired nitric oxide synthesis [111]. These IR-related mechanisms contribute to adverse effects on blood vessel structure and function [102,103,112].

Through multiple distinct mechanisms, IR is often the primary driver for hypertension [113,114], including stimulation of sodium retaining channels within the nephron [115], as well as activation of the sympathetic nervous system [116118]. The chronic hyperinsulinemia that occurs concurrently in IR promotes chronically elevated epinephrine, which elicits cardiovascular activation, including increased cardiac output and systemic vasoconstriction [119,120], as well as an enhancement of platelet aggregation [121].

IR-associated hyperinsulinemia is also associated with CVD risk through increased macrophage lipid accrual in blood vessels. As macrophages accrue lipids, they become foam cells. Foam cells are a staple feature of atherosclerotic plaques, not only constituting a major portion of the plaque itself, but also contributing to atherosclerosis by aggressively secreting pro-inflammatory cytokines [122]. Park et al.[123] demonstrated that insulin increased macrophage oxidized LDL uptake by more than 80% and produced almost three times greater total lipid uptake into the macrophage in as little as 16 h.

IR, and more specifically, type 2 diabetes and obesity, are associated with serum lipid components which are well established risk factors for CVD. Specifically, LDL-C is contained in heterogeneous particles which range in size and composition from a small dense LDL (sdLDL) to a large buoyant LDL (lbLDL) (which is distinct from the inclusion of Lp(a) in the total LDL-C measure, as discussed previously). Circulating sdLDL, unlike lbLDL, readily undergoes atherogenic modifications in plasma, including glycation, which is associated with heightened inflammation, hyperglycemia, and an increased incidence of CVD in the general population [127130], and in FH individuals [131,132].

The distinction between LDL particle subclasses based on size and density is also important because sdLDL is a component of the atherogenic dyslipidemia risk triad, composed of elevated levels of TGs and sdLDL, in concert with low HDL-C [124126]. High TGs, elevated sdLDL and low HDL-C are each, individually, strong markers of CVD risk [71,89,133142]. Conversely, lbLDL has not been shown to be a CVD risk factor, as demonstrated in the Atherosclerosis Risk in Communities Study [143], the Quebec Cardiovascular Study [144], the Multiethnic Study of Atherosclerosis [145] and the Framingham Offspring Study [146]. Ultimately, the assessment of sdLDL and lbLDL subpopulations provides a greater prediction of CVD risk than does LDL-C [142].

The superiority of the atherogenic dyslipidemia risk triad over total LDL-C as a reliable means of assessing CVD risk has been known for more than 3 decades [147]. In 1988, Austin et al.[148] reported that individuals with the atherogenic dyslipidemia risk triad, referred to as pattern B, exhibited a threefold increased risk of myocardial infarction, independent of age, sex, and relative weight.. Even then, it was understood that total cholesterol and LDL-C were of limited value as markers of CVD risk (Fig. 1). Comparable findings were demonstrated in the Framingham Offspring Study [149], in which low HDL-C levels and elevated TGs were correlated with reduced lbLDL, increased sdLDL, and an increased incidence of coronary artery disease. Similarly, Jeppesen et al.[150] reported a significantly greater incidence of ischemic heart disease in men with the combination of high TGs/low HDL, compared to men with low TGs/high HDL, independent of whether the men had low or high LDL-C. Related work has shown that an elevated TG to HDL-C ratio is predictive of both a pattern B LDL-C profile, dominated by sdLDL, and an overall increase in cardiovascular risk [151]. Similar findings were reported by Caselli et al.[152], who reported that high TG and low HDL-C levels were associated with CVD progression, which was independent of LDL-C levels and lipid lowering treatments. In summary, the atherogenic dyslipidemia risk triad is far superior to total LDL-C as a measure of CVD risk.

In recent years, investigators have focused on LDL particle number (ApoB), rather than LDL-C, as a superior measure of CVD risk [69,153,154]. This measure, however, has significant limitations. First, it is not limited to the LDL population, with LDL particles also found on Lp(a), an independent CVD risk factor, as well as VLDL-C and IDL-C, both of which are associated with TG, another CVD risk factor [142,155]. Second, the preferential use of particle number, rather than LDL-C, does not distinguish between particle types (sdLDL, lbLDL, Lp(a)), which have been shown to be differentially associated with CVD (as described above).

The appearance of a discordance between LDL-C and total particle number, where the particle count is higher than expected, has been suggested to serve as a superior measure of CVD risk than is LDL-C [69,156]. However, the discordance correlates closely with measures of IR, for example, metabolic syndrome and diabetes [156]. In three representative trials, Otvos et al.[157], Pencina et al.[158] and Cromwell et al.[69] reported that the discordance between LDL-C and LDL particle number was superior to LDL-C, alone, as a CVD risk factor. However, patients presenting with the ApoB discordance had higher BMI, fasting glucose, and TGs, an increased incidence of diabetes and hypertension, as well as lower HDL-C, than those that were concordant. Hence, the discordance between particle number and LDL-C is merely a surrogate marker for atherogenic dyslipidemia (dominance of elevated TGs, low HDL, and smaller LDL particles) and IR (see also [159] for related review and discussion).

Atherogenic dyslipidemia is prevalent in individuals with metabolic syndrome, prediabetes, and type 2 diabetes, which is currently afflicting millions of people in the US [160]. Chronic exposure to high levels of glucose and insulin are driving factors in the development of CVD [161,162]. Modest dietary changes can be more effective in the treatment of metabolic syndrome than commonly used antidiabetic drugs in improving CVD risk [163]. Specifically, improvement in the cluster of components of metabolic syndrome is intimately connected with carbohydrate restriction in adults [164167,168,169,170,171,172,173177,178,179180,181] and in adolescents [182]. LCDs have been shown to improve other CVD risk factors, as well, such as visceral fat, blood pressure, Lp(a) and inflammation [183189]. It is therefore highly relevant that LCDs have been studied in numerous RCTs and case reports which show improvement in glucose, lipid and insulin-based CVD risk factors, including an LCD-mediated reduction in the need for hypoglycemic medication [178,190,191,192,193,194,195,196,197,198,199].

LCDs are also effective at attenuating the atherogenic dyslipidemia risk triad (reducing TGs, sdLDL, increasing lbLDL) [159,169,172,200,201]. In a randomized, parallel trial comparing the effects of an LCD to a low-fat diet (LFD) in obese adults, the LCD resulted in greater weight loss, increased HDL-C, decreased TGs and C-reactive protein than the LFD [202]. A meta-analysis concluded that compared to LFDs, LCDs significantly lowered predicted risk of atherosclerotic cardiovascular disease [203], including reductions in plasma TGs and increased HDL-C [204,205], which collectively carry a robust predictive value that dramatically outperforms LDL-C [206].

While many studies of LCDs have been relatively short-term (<6 months), there are longer-term trials and individual case reports that demonstrate the effectiveness, and sustainability of these diets [166,168,169,207209]. For example, after 1 year, a group of participants with type 2 diabetes following a ketogenic diet demonstrated robust improvements in several cardiovascular risk markers, including decreased TGs, sdLDL particles, blood pressure, and antihypertensive medications [210,211]. These findings have been replicated and extended to 23 year-long LCD trials, documenting improvements in numerous CVD risk biomarkers [212214], including a 2 year LCD intervention which demonstrated improvements in LDL particle size and carotid intima media thickness, a commonly used marker of atherosclerosis [200]. The longest assessment of LCD effects on record is by Heussinger et al.[215], who documented the safety and effectiveness of the ketogenic diet over a 10-year period in the treatment of patients with epilepsy, without evidence of an increase in CVD risk biomarkers.

It is notable that Unwin's group has incorporated LCD guidance in their treatment of patients with type 2 diabetes and prediabetes for over 6 years, including the de-prescribing of diabetes-related medications [168,213,216,217]. These clinicians have reported the safety and efficacy of the LCD, with statistically significant improvements in their patients for weight, HbA1c, lipid profiles and blood pressure.

Although weight loss typically occurs in response to an LCD, improvements in atherogenic dyslipidemia are primarily a result of carbohydrate restriction, rather than weight or fat loss, per se [172,199,218,219]. The consistent and often dramatic improvement in these biomarkers in response to LCDs is strong support for the view that carbohydrate restriction, independent of weight loss, lowers CVD risk.

The basis of the diet-heart hypothesis is the great concern that consumption of food rich in saturated fat would increase risk for CVD. However, in an RCT by Volek et al.[189], subjects in the LCD group exhibited superior improvements in CVD risk factors than the LFD group, despite the LCD group having consumed more than three times as much saturated fat as the LFD group. Moreover, Volek et al.[204], Dreon et al.[220], Sharman et al.[201], and Hays et al.[221] all demonstrated that an LCD rich in saturated fat increased LDL size, leading to a dominance of lbLDL, thereby lowering CVD risk. Similar findings were reported by Ebbeling et al.[222], who found that a high saturated fat, LCD improved measures of insulin-resistant dyslipidemia, without affecting LDL-C, when compared to lower saturated fat diets.

In related work, Cole et al.[223] studied the effects of a moderately low carbohydrate (30%), high fat (55%) diet, supplemented with up to 1800 mg/day of cholesterol (from eggs), on serum lipids in FH subjects. These investigators reported that consumption of additional fat and cholesterol, in the context of an LCD, lowered TGs, and raised HDL, while not affecting LDL-C levels. Comparable findings were reported in the DIETFITS weight loss RCT [224]. These investigators reported that LDL-C in subjects on an LCD was stable across a broad range in dietary cholesterol changes from baseline (>500 mg/day) that the participants consumed over 12 months.

These studies, as well as those reviewed by Astrup et al.[18], reinforce the perspective of the cardiologist, Bahl [225], that an overreliance in public health on saturated fat as the main dietary villain for cardiovascular disease has distracted from the risks posed by other nutrients, such as carbohydrates.

In summary, the LCD, independent of the amount of saturated fat in the diet and weight loss, leads to significant improvements in the most robust lipid risk markers for CVD, characterized by reductions in TGs and sdLDL, with associated increases in lbLDL and HDL-C. LCDs also reduce body weight, inflammatory markers, blood pressure, and blood glucose, and increase insulin sensitivity. These findings are summarized in Fig. 2 and in our recent reviews [48,226].

Given that elevated LDL-C may occur for individuals on an LCD, concerns have been raised that the diet may therefore increase CVD risk. These concerns have been expressed despite a paucity of evidence that total LDL-C is a reliable CVD risk factor. In contrast, there is extensive evidence regarding the efficacy of carbohydrate reduction to improve the most reliable CVD risk biomarkers, such as hyperglycemia, IR, inflammation, hypertension, body weight, and the atherogenic dyslipidemia risk triad. The LCD is also effective at ameliorating components of metabolic syndrome, itself a significant CVD risk factor. While the improvements in these biomarkers support the argument in favor of the CVD benefit of LCDs, it remains that they are surrogate markers only. That is, as surrogate markers they do not provide conclusive evidence that an LCD, with an associated increase in LDL-C, will result in a beneficial effect on hard coronary events, such myocardial infarction or coronary death.

The relative degree of uncertainty as to the outcomes of an LCD-induced elevation of LDL-C raises the question as to whether HMG CoA reductase inhibitor therapy (statins) is indicated for those on an LCD. This question takes on more significance in the context of increasing popularity of different LCDs, including assisting in the management of obesity and diabetes, both representing significant cardiovascular risk factors themselves. Despite the popularity of LCDs, we are aware of no published clinical trials involving subjects with high LDL-C on an LCD, or of trials on subjects on an LCD with statin treatment, with an assessment of hard coronary outcomes. Therefore, it cannot be stated with certainty whether a patient should be concerned about high LDL-C on an LCD, and whether a patient with high LDL-C on an LCD would benefit from statin treatment.

With the caveat of this uncertainty explicitly stated, findings from two RCTs provide guidance as to whether people with a typical LCD biomarker profile (high HDL/low TGs) with high LDL-C, are at increased risk of experiencing a coronary event, and whether they may benefit from statin therapy.

The first RCT was based on a reanalysis of the 4S trial [35], which was a secondary CVD prevention trial in men and women with a history of angina pectoris or acute myocardial infarction. The reanalysis of the 4S trial assessed hard coronary events in placebo or statin treated subjects, all of whom had elevated LDL-C, with either an atherogenic lipid profile (high TGs/low HDL) or a nonatherogenic lipid profile (low TGs/high HDL) [227]. The first finding of importance is that within the placebo group, individuals with an LCD-like (nonatherogenic) lipid profile had a lower incidence of coronary events than placebo-treated individuals with an atherogenic lipid profile (Fig. 3). This finding indicates that the presence of an atherogenic lipid profile, independent of LDL-C, provided a reliable indication of the risk of coronary events in untreated individuals.

The second finding of the 4S reanalysis was that statin treatment produced a significant reduction of coronary events only in those subjects with the atherogenic lipid profile. By contrast, statin treatment produced no significant benefit in those subjects with an LCD-like (nonatherogenic) lipid profile (Fig. 3). That is, despite statin treatment reducing LDL-C to an equivalent level in those with an atherogenic and nonatherogenic lipid profile, only the group with a baseline atherogenic profile demonstrated a treatment-associated reduction in hard coronary events. This finding supports the view that individuals on an LCD with high LDL-C and a nonatherogenic lipid profile (low TGs/high HDL-C) would not benefit from statin therapy.

A second RCT provides findings complementary to the 4S posthoc analysis. The prospective study of Pravastatin in the elderly at risk (PROSPER) study [228] enrolled elderly men (aged 7082 years) with preexisting vascular disease or who were at increased risk of CVD because they had hypertension, diabetes, and/or were smokers. The men were administered pravastatin or placebo, and then assessed for fatal and nonfatal coronary events over 3 years. What is noteworthy is the apparent influence of HDL-C levels on coronary events in the placebo and statin-treated groups. Subjects on the placebo with low HDL-C (<43 mg/dl), consistent with IR, and an atherogenic lipid profile, developed a significantly greater incidence of coronary events than placebo subjects with high HDL-C (>53 mg/dl), independent of their LDL-C levels. This first observation demonstrates that the HDL-C level is a superior indicator of CVD risk than is LDL-C in untreated individuals.

The second observation from the PROSPER study is that benefits of statin treatment occurred only for those subjects with low HDL, independent of their LDL-C levels (Fig. 4). As the authors noted Variation in baseline LDL concentrations did not relate to risk of a coronary event or treatment efficacy. Benefit was predominantly in the lowest tertile of HDL-cholesterol . With low HDL-C being a feature of atherogenic dyslipidemia, this finding is consistent with the 4S reanalysis, and provides additional support for the notion that those with high LDL-C and a nonatherogenic lipid profile (low TGs/high HDL-C) are unlikely to benefit from statin therapy.

The absence of a relation between LDL-C and coronary event reduction with statin treatment suggests that it is their pleiotropic, for example, anti-inflammatory and anticoagulant, effects [229238], rather than LDL-C reduction, per se, that results in a relatively small reduction in coronary events and mortality. Therefore, a person on an LCD with a nonatherogenic lipid profile (low TGs/high HDL-C) is more likely to experience the adverse effects of statins [239252], including an increased risk of new onset type 2 diabetes [246,253258], an increase in fasting blood glucose in patients with and without diabetes [259], mitochondrial dysfunction [260262], tendinopathy [263], myopathy [264,265], acute kidney injury/renal failure [266268] and cognitive deficits [247,269276], than benefits.

We have addressed concerns regarding high LDL-C in individuals on an LCD, which began 5 decades ago and persist to the present day. Our review has evaluated whether these concerns are justified based on three levels of analysis. First, critics of the LCD have focused on how the diet may increase LDL-C. However, there is a substantial literature demonstrating that LDL-C is of limited utility as a CVD risk factor. Second, we reviewed the literature on LCD improvements in CVD risk factors which are superior to LDL-C, such as IR, hypertension, hyperglycemia, LDL particle subtypes, and metabolic syndrome. Third, we summarized RCTs which demonstrate that individuals with high LDL-C and an LCD-like lipid profile (low TGs and high HDL-C), had a low rate of coronary events under nontreatment conditions and derived no CVD benefit from statin therapy. Therefore, our review of the literature provides support for the conclusion that LDL-C reduction with a statin would not provide any benefit in primary or secondary prevention of CVD for an individual on an LCD.

None.

The open access publication cost was provided by the Duke University Research Fund.

There are no conflicts of interest.

Papers of particular interest, published within the annual period of review, have been highlighted as:

of special interest

of outstanding interest

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