Mediterranean diet without breakfast the best choice for diabetics, new study says

For patients with diabetes, it is better to eat a single large meal than several smaller meals throughout the day. This is the result of a current dietary study at Linköping University in Sweden.

30 nov 2013--In the study the effect on blood glucose, blood lipids and different hormones after meals were compared using three different macronutrient compositions in patients with type 2 diabetes. The three diets were a low-fat diet, a low-carbohydratediet and a Mediterranean diet. The scientists included 21 patients that tested all three diets in a randomized order. During each test day blood samples were collected at six time points.

The low-fat diet had a nutrient composition that has traditionally been recommended in the Nordic countries, with about 55% of the total energy from carbohydrates. The low-carbohydrate diet had a relatively low content of carbohydrate; approximately 20% of the energy was from carbohydrates and about 50% of the total energy came from fat. The Mediterranean diet was composed of only a cup of black coffee for breakfast, and with all the caloric content corresponding to breakfast and lunch during the other two test days accumulated to one large lunch.

Furthermore, the total caloric content included energy from 150 ml (women) to 200 ml (men) of French red wine to ingest with the lunch. The food in the Mediterranean diet had an energy content from carbohydrates that was intermediate between the low-fat and the low-carbohydrate meals, and sources of fat were mainly olives and fatty fish.

"We found that the low-carbohydrate diet increased blood glucose levels much less than the low-fat diet but that levels of triglycerides tended to be high compared to the low-fat diet," says Doctor Hans Guldbrand, who together with Professor Fredrik Nystrom was the principal investigator of the study.

"It is very interesting that the Mediterranean diet, without breakfast and with a massive lunch with wine, did not induce higher blood glucose levels than the low-fat diet lunch, despite such a large single meal," says Professor Nyström.

"This suggests that it is favorable to have a large meal instead of several smaller meals when you have diabetes, and it is surprising how often one today refers to the usefulness of the so-called Mediterranean diet but forgets that it also traditionally meant the absence of a breakfast. Our results give reason to reconsider both nutritional composition and meal arrangements for patients with diabetes," says Professor Nystrom.

More information: A randomized cross-over trial of the postprandial effects of three different diets in patients with type 2 diabetes by Hanna Fernemark, Christine Jaredsson, Bekim Bunjaku, Ulf Rosenqvist, Fredrik H Nyström and Hans Guldbrand. PLOS ONE Nov 27 2013. DOI: 10.1371/journal.pone.0079324

Provided by Linköping University

Vitamins can damage the body's own defences

Each year, we spend billion of dollars on dietary supplements. New research indicates that vitamin pills may upset the fragile balance in our cells and thus cause more harm than good.

29 nov 2013--Vitamin supplements are a billion-dollar industry. We want to stay healthy and fit and help our bodies with this. But perhaps we are achieving precisely the opposite?

"We believe that antioxidants are good for us, since they protect the cells from oxidative stress that may harm our genes. However, our bodies have an enormous inherent ability to handle stress. Recent research results show that the body's responses to stress in fact are important in preventing our DNA from eroding. I fear that the fragile balance in our cells can be upset when we supplement our diet with vitamin pills," says Hilde Nilsen to the research magazine Apollon. Nilsen is heading a research group at the Biotechnology Centre, University of Oslo.

Maintenance of genes

Our DNA – the genetic code that makes us who we are – is constantly exposed to damage.

In each of the hundred trillion cells in our body, up to two hundred thousand instances of damage to the DNA take place every day. These may stem from environmental causes such as smoking, stress, environmental pathogens or UV radiation, but the natural and life-sustaining processes in the organism are the primary sources of damage to our DNA.

How can the repair of damage to our DNA help us stay healthy and live long lives?

A small worm provides the answer

To answer this question, Hilde Nilsen and her group of researchers have allied themselves with a small organism – a one millimetre-long nematode called Caenorhabditis elegans (C. elegans). This roundworm, which lives for only 25 days, is surprisingly sophisticated with its 20 000 genes; we humans only have a couple of thousand more.

"C. elegans is a fantastically powerful tool, because we can change its hereditary properties. We can increase its ability to repair DNA damage, or we can remove it altogether. We can also monitor what happens when damage to DNA is not repaired – in several hundred specimens and through their entire lifespan."

Different "repair proteins" take care of various types of damage to the DNA. The most common ones are repaired by "cutting out" and replacing a single damaged base – by itself or as part of a larger fragment.

Affecting lifespan with the aid of genes

In some specimens that do not have the ability to repair the damage, the researchers observe that the ageing process proceeds far faster than normal. Is it because the damage accumulates in the DNA and prevents the cells from producing the proteins they need for their normal operation? Most researchers have thought so, but Hilde Nilsen doubts it.

One of the genes studied by the researchers has a somewhat shortened lifespan: on average, this mutant lives three days less than normal. Translated into human terms, this means dying at the age of 60 rather than at 70.
– We were surprised when we saw that these mutants do not in fact accumulate the DNA damage that would cause ageing. On the contrary: they have less DNA damage. This happens because the little nematode changes its metabolism into low gear and releases its own antioxidant defences. Nature uses this strategy to minimize the negative consequences of its inability to repair the DNA. So why is this not the normal state? Most likely because it comes at a cost: these organisms have less ability to respond to further stress ‒ they are quite fragile.

Hilde Nilsen and her colleagues have now –for the very first time – shown that this response is under active genetic control and is not caused by passive accumulation of damage to the DNA, as has been widely believed.

This provides an opportunity to manipulate these processes. And that's exactly what we have done: we have re-established the normal lifespan of a short-lived mutant by removing other proteins that repair damage. Hence, the cause could not be accumulation of damage, since there is no reason to assume that a mutant with no other alternative ways to repair its DNA will be less exposed to damage. There must be something else.

The researchers have gone on to discover that this "something else" in fact is the other repair proteins. They believe that the proteins inhibit damage that they fail to repair completely.

"The consequence is that they establish a barrier – a road block. This triggers a cascade of signals that reprogram the cell.

"Wouldn't this imply that the repair proteins defy their own purpose – after all, the result is a shorter lifespan?

"We need to remember that most likely, the purpose of the DNA repairs is to ensure that we produce healthy offspring – not necessarily that we live as long as possible after our reproductive age interval. Initiating a survival response that reinforces the antioxidant defences means that a lack of ability to repair the DNA has less impact than it would otherwise have on our reproduction. To the species as a whole, it's a small cost that some individuals will be less good at handling stress and have a shorter life."

Because this is an active process within the cells, the researchers refer to it as reprogramming.

"We have found several proteins that trigger this reprogramming. The process has the same effect as a reduction in caloric intake, which we know helps increase the lifespan in many species. In other words, there are two routes to a long life. When we stimulate both of these two routes in our nematode at the same time, we can quadruple its normal lifespan," Nilsen says.

Can do great harm

The balance between oxidants and antioxidants is crucial to our physiology, but exactly where this equilibrium is situated varies from one person to the next.

"This is where I start worrying about the synthetic antioxidants. The cells in our body use this fragile balance to establish the best possible conditions for themselves, and it is specially adapted for each of us. When we take supplements of antioxidants, such as C and E vitamins, we may upset this balance," the researcher warns.

"It sounds intuitively correct that intake of a substance that may prevent accumulation of damage would benefit us, and that's why so many of us supplement our diet with vitamins. Our research results indicate that at the same time, we may also cause a lot of harm. The health authorities recommend that instead, we should seek to have an appropriate diet. I'm all in favour of that. It's far safer for us to take our vitamins through the food that we eat, rather than through pills," Hilde Nilsen states emphatically.

Huge consumption of dietary supplements

The National Research Centre in Complementary and Alternative Medicine (NAFKAM) has investigated the volume of dietary supplements consumed in Norway in 2012:

• Last year, 70 per cent of the population purchased dietary supplements.
• In total, Norwegians spent nearly NOK 3 billion on pills or beverages intended to supplement our diet.
• Many of us use dietary supplements as elements of an alternative diet or in dosages that exceed the recommendations given in the instruction leaflet.

Provided by University of Oslo

The good news about the global epidemic of dementia

It's rare to hear good news about dementia. But that's what a New England Journal of Medicine Perspective article reports. The article discusses several recent studies that show how age-adjusted rates in aging populations have declined for people born later in the last century, particularly in those older people most likely to develop dementia and Alzheimer's disease. The Perspective also describes what researchers have reported to be associated with this encouraging trend.

28 nov 2013--The authors are Eric B. Larson, MD, MPH, executive director of Group Health Research Institute and Group Health's vice president for research; Kristine Yaffe, MD, a professor of psychiatry, neurology, and epidemiology and biostatistics, the Roy and Marie Scola endowed chair in psychiatry, and vice chair for clinical and translational research in psychiatry at the University of California, San Francisco and the San Francisco Veterans Affairs (VA) Medical Center; and Kenneth M. Langa, MD, PhD, a professor of medicine at the University of Michigan and VA Healthcare System. Dr. Larson is also an adjunct professor at the University of Washington Schools of Medicine and Public Health.

"Of course, people are tending to live longer, with worldwide populations aging, so there are many new cases of dementia," Dr. Larson said. "But some seem to be developing it at later ages—and we're optimistic about this lengthening of the time that people can live without dementia." Dementia in those affected may be starting later in the course of life, closer to the time of death.

In 2008, Drs. Langa and Larson reported one of the first studies suggesting a decline in U.S. dementia rates, using information from the U.S. Health and Retirement Study. They found that the decline tracked with education, income, and improvements in health care and lifestyle. Since then, several studies in Europe have confirmed this trend—and the reasons behind it.

"We're very encouraged to see a growing number of studies from around the world that suggest that the risk of dementia may be falling due to rising levels of education and better prevention and treatment of key cardiovascular risk factors such as high blood pressure and cholesterol," Dr. Langa said. He added that it will be very important to continue to follow these trends in the population given the wide-ranging impact of dementia on patients, families, and the health care system.

"This is a fascinating example of personal health changes earlier in life having an impact on personal and public health in late life," Dr. Yaffe said. She and Dr. Larson have reported that regular exercise may help delay dementia. In an earlier publication this year in the New England Journal, Dr. Larson's team reported that people with lower blood sugar levels tend to have less risk of dementia. And Dr. Yaffe and her team have focused on a host of other lifestyle factors that have the potential to reduce risk.

"Still, we need to be aware that recent increases in obesity and diabetes threaten to reverse these gains, because of the impact these conditions can have on the aging brain," Dr. Yaffe said. "The obesity and diabetes epidemics are not affecting age groups most at risk for dementia—yet." But it's just a matter of time.

"To help more people avoid dementia, we'll need to find better ways of preventing obesity—and avoiding obesity-linked health risks, including diabetes and dementia," Dr. Larson said. Narrowing health disparities will also be crucial, because obesity and diabetes are more common among certain racial and ethnic minorities and others who lack access to education and health care.

"As luck would have it, preventing obesity and diabetes jibes with preventing dementia," Dr. Larson said. "In other words, we must focus on exercise, diet, education, treating hypertension, and quitting smoking."

On December 11, the New England Journal of Medicine will post a podcast of Dr. Larson discussing this perspective piece, and that day he and Dr. Yaffe will also address the U.K. Department of Health's G8 Dementia Summit in London. The Summit aims to develop coordinated global action on dementia.

Provided by Group Health Research Institute

A gene mutation for excessive alcohol drinking found

UK researchers have discovered a gene that regulates alcohol consumption and when faulty can cause excessive drinking. They have also identified the mechanism underlying this phenomenon.

27 nov 2013--The study showed that normal mice show no interest in alcohol and drink little or no alcohol when offered a free choice between a bottle of water and a bottle of diluted alcohol.

However, mice with a genetic mutation to the gene Gabrb1 overwhelmingly preferred drinking alcohol over water, choosing to consume almost 85% of their daily fluid as drinks containing alcohol.

The consortium of researchers from five UK universities – Imperial College London, Newcastle University, Sussex University, University College London and University of Dundee – and the MRC Mammalian Genetics Unit (MGU) at Harwell, funded by the Medical Research Council (MRC), Wellcome Trust and ERAB, publish their findings today in Nature Communications.

Dr Quentin Anstee, Consultant Hepatologist at Newcastle University, joint lead author said: "It's amazing to think that a small change in the code for just one gene can have such profound effects on complex behaviours like alcohol consumption.

"We are continuing our work to establish whether the gene has a similar influence in humans, though we know that in people alcoholism is much more complicated as environmental factors come into play. But there is the real potential for this to guide development of better treatments for alcoholism in the future."

Working at the MRC Mammalian Genetics Unit, a team led by Professor Howard Thomas from Imperial College London introduced subtle mutations into the genetic code at random throughout the genome and tested mice for alcohol preference. This led the researchers to identify the gene Gabrb1 which changes alcohol preference so strongly that mice carrying either of two single base-pair point mutations in this gene preferred drinking alcohol (10% ethanol v/v - about the strength of wine), over water.

The group showed that mice carrying this mutation were willing to work to obtain the alcohol-containing drink by pushing a lever and, unlike normal mice, continued to do so even over long periods. They would voluntarily consume sufficient alcohol in an hour to become intoxicated and even have difficulty in coordinating their movements.

The cause of the excessive drinking was tracked down to single base-pair point mutations in the gene Gabrb1, which codes for the beta 1 subunit, an important component of the GABAA receptor in the brain. This receptor responds to the brain's most important inhibitory chemical messenger (GABA) to regulate brain activity.

The researchers found that the gene mutation caused the receptor to activate spontaneously even when the usual GABA trigger was not present.

These changes were particularly strong in the region of the brain that controls pleasurable emotions and reward, the nucleus accumbens, as Dr Anstee explains: "The mutation of the beta1 containing receptor is altering its structure and creating spontaneous electrical activity in the brain in this pleasure zone, the nucleus accumbens. As the electrical signal from these receptors increases, so does the desire to drink to such an extent that mice will actually work to get the alcohol, for much longer than we would have expected."

Professor Howard Thomas said: "We know from previous human studies that the GABA system is involved in controlling alcohol intake. Our studies in mice show that a particular subunit of GABAA receptor has a significant effect and most importantly the existence of these mice has allowed our collaborative group to investigate the mechanism involved. This is important when we come to try to modify this process first in mice and then in man."

Initially funded by the MRC, the 10-year project to find genes affecting alcohol consumption was led by Professor Howard Thomas from Imperial College London and initiated at the MRC Mammalian Genetics Unit. The consortium now involves researchers at five UK universities - Imperial College London, Newcastle University, Sussex University, University College London and the University of Dundee. Senior investigators are Dr Quentin Anstee at Newcastle University and Dr Susanne Knapp at Imperial College London (joint lead authors); Professor Dai Stephens at Sussex University; Professor Trevor Smart at University College London; Professor Jeremy Lambert and Dr Delia Belelli at the University of Dundee; and Professor Steve Brown at the MRC Mammalian Genetics Unit.

Professor Hugh Perry, Chair of the MRC's Neurosciences and Mental Health Board, said: "Alcohol addiction places a huge burden on the individual, their family and wider society. There's still a great deal we don't understand about how and why consumption progresses into addiction, but the results of this long-running project suggest that, in some individuals, there may be a genetic component. If further research confirms that a similar mechanism is present in humans, it could help us to identify those most at risk of developing an addiction and ensure they receive the most effective treatment."

More information: Anstee, Q. M. et al. Mutations in the Gabrb1 gene promote alcohol consumption through increased tonic inhibition. Nat. Commun. 4:2816 DOI: 10.1038/ncomms3816 (2013).

Provided by Newcastle University

Regular physical activity in later life boosts likelihood of 'healthy aging' up to sevenfold

It's never too late to get physically active, with even those starting relatively late in life reaping significant health benefits, finds research published online in the British Journal of Sports Medicine.

26nov 2013--Four years of sustained regular physical activity boosted the likelihood of healthy ageing sevenfold compared with consistent inactivity, the findings show.

The researchers tracked the health of almost 3500 people, whose average age was 64, for more than eight years. All were participants in the English Longitudinal Study of Ageing, which involves a nationally representative sample of the household population of England, born on or before 29 February 1952.

The researchers wanted to quantify the impact of physical activity on the risk of developing long term conditions, depression, and dementia, and on the likelihood of "healthy ageing."

This is usually taken to mean not only an absence of major disease and disability, but also good mental health, the preservation of cognitive abilities, and the ability to maintain social connections/activities.

There's a growing body of evidence to suggest that regular physical activity is essential for the maintenance of good health, while across the developed world, inactivity is ranked alongside smoking, excess drinking, and obesity as a leading cause of reduced life expectancy.

Participants described the frequency and intensity of regular physical activity they did in 2002-3, and then every subsequent two years until 2010-11.

Their responses were categorised as: inactive (no moderate or vigorous activity on a weekly basis); moderately active (at least once a week); and vigorously active (at least once a week).

Any changes in frequency and intensity were noted at the two yearly monitoring sessions: always inactive; became inactive; became active; always active.

Serious ill health, such as heart disease/stroke, diabetes, emphysema, or Alzheimer's disease, was confirmed by medical records.

Cognitive abilities and mental health were assessed using a battery of validated tests, while disability was measured according to participants' responses to questions about the ease with which they were able to carry out routine activities of daily living, and an objective test of walking speed.

Nearly one in 10 of the sample became active and 70% remained active. The rest remained inactive or became inactive.

At the end of the monitoring period almost four out of 10 had developed a long term condition; almost one in five was depressed; a third had some level of disability; and one in five was cognitively impaired.

But one in five was defined as a healthy ager. And there was a direct link to the likelihood of healthy ageing and the amount of exercise taken.

Those who had regularly indulged in moderate or vigorous physical activity at least once a week were three to four times more likely to be healthy agers than those who had remained inactive, after taking account of other influential factors.

Those who became physically active also reaped benefits, compared with those who did nothing. They were more than three times as likely to be healthy agers.

And those who sustained regular physical activity over the entire period were seven times as likely to be healthy agers as those who had consistently remained inactive.

"This study supports public health initiatives designed to engage older adults in physical activity, even those who are of advanced age," conclude the authors.

More information: Taking up physical activity in later life and healthy ageing: the English longitudinal study of ageing, Online First, doi 10.1136/bjsports-2013-092993

Provided by British Medical Journal

Prognostic value of lipoprotein (a) with low cholesterol unclear

25 nov 2013—Lipoprotein (a) (Lp[a]) has utility in assessing cardiovascular risk in patients with coronary artery disease (CAD); however, the prognostic value of Lp(a) in patients with low cholesterol levels remains unclear, according to a study published online Oct. 23 in the Journal of the American College of Cardiology.

Michelle O'Donoghue, M.D., from Brigham and Women's Hospital in Boston, and colleagues combined data from three studies of patients with CAD (6,762 participants) and eight previously published studies in which plasma Lp(a) was measured (for a total of 18,979 patients).

The researchers found that increasing levels of Lp(a) were not associated with cardiovascular event risk when modeled as a continuous variable (OR, 1.03) or by quintile (OR Q5:Q1, 1.05), based on data from the three studies. Utilizing the total combined data, subjects with Lp(a) levels in the highest quintile were at increased risk of cardiovascular events (OR, 1.40); however, there was significant between-study heterogeneity (P = 0.001). The association between Lp(a) and cardiovascular events, when stratified on the basis of low-density lipoprotein (LDL) cholesterol, was significant in studies in which average LDL cholesterol was ≥130 mg/dL (OR, 1.46; P < 0.001), whereas this relationship was not significant for studies with an average LDL cholesterol <130 .="" br="">

"Lp(a) is significantly associated with the risk of cardiovascular events in patients with established CAD; however, there exists marked heterogeneity across trials," O'Donoghue and colleagues conclude. "In particular, the prognostic value of Lp(a) in patients with low cholesterol levels remains unclear."

Several authors disclosed financial ties to the pharmaceutical industry, including companies that funded some studies included in the meta-analysis.

More information: Full Text (subscription or payment may be required)

Large study links nut consumption to reduced death rate

Credit: Lawrencekhoo / Wikipedia.

In the largest study of its kind, people who ate a daily handful of nuts were 20 percent less likely to die from any cause over a 30-year period than were those who didn't consume nuts, say scientists from Dana-Farber Cancer Institute, Brigham and Women's Hospital, and the Harvard School of Public Health.

24 nov 2013--Their report, published in the New England Journal of Medicine, contains further good news. The regular nut-eaters were found to be more slender than those who didn't eat nuts, a finding that should alleviate the widespread worry that eating a lot of nuts will lead to overweight.

The report also looked at the protective effect on specific causes of death.

"The most obvious benefit was a reduction of 29 percent in deaths from heart disease – the major killer of people in America," said Charles S. Fuchs, MD, MPH, director of the Gastrointestinal Cancer Center at Dana-Farber, who is the senior author of the report. "But we also saw a significant reduction – 11 percent – in the risk of dying from cancer," added Fuchs, who is also affiliated with the Channing Division of Network Medicine at Brigham and Women's.

Whether any specific type or types of nuts were crucial to the protective effect couldn't be determined. However, the reduction in mortality was similar both for peanuts and for "tree nuts" – walnuts, hazelnuts, almonds, Brazil nuts, cashews, macadamias, pecans, cashews, pistachios and pine nuts.

Several previous studies have found an association between increasing nut consumption and a lower risk of diseases such as heart disease, type 2 diabetes, colon cancer, gallstones, and diverticulitis. Higher nut consumption also has been linked to reductions in cholesterol levels, oxidative stress, inflammation, adiposity, and insulin resistance. Some small studies have linked increased nuts in the 

diet to lower total mortality in specific populations. But no previous research studies had looked in such detail at various levels of nut consumption and their effects on overall mortality in a large population that was followed for over 30 years.

For the new research, the scientists were able to tap databases from two well-known ongoing observational studies that collect data on diet and other lifestyle factors and various health outcomes. The Nurses' Health Study provided data on 76,464 women between 1980 and 2010, and the Health Professionals' Follow-up Study yielded data on 42,498 men from 1986 to 2010. Participants in the studies filled out detailed food questionnaires every two to four years. With each food questionnaire, participants were asked to estimate how often they consumed nuts in a serving size of one ounce. A typical small packet of peanuts from a vending machine contains one ounce.

Sophisticated data analysis methods were used to rule out other factors that might have accounted for the mortality benefits. For example, the researchers found that individuals who ate more nuts were leaner, less likely to smoke, and more likely to exercise, use multivitamin supplements, consume more fruits and vegetables, and drink more alcohol. However, analysis was able to isolate the association between nuts and mortality independently of these other factors.

"In all these analyses, the more nuts people ate, the less likely they were to die over the 30-year follow-up period," explained Ying Bao, MD, ScD, of Brigham and Women's Hospital, first author of the report. Those who ate nuts less than once a week had a seven percent reduction in mortality; once a week, 11 percent reduction; two to four times per week, 13 percent reduction; five to six times per week, 15 percent reduction, and seven or more times a week, a 20 percent reduction in death rate.

The authors do note that this large study cannot definitively prove cause and effect; nonetheless, the findings are strongly consistent with "a wealth of existing observational and clinical trial data to support health benefits of nut consumption on many chronic diseases." In fact, based on previous studies, the US Food and Drug Administration concluded in 2003 that eating 1.5 ounces per day of most nuts "may reduce the risk of heart disease."

Provided by Dana-Farber Cancer Institute

Current practice may over-diagnose vitamin D deficiency

The current "gold standard" test for measuring vitamin D status may not accurately diagnose vitamin D deficiency in black individuals. In an article in the Nov. 21 New England Journal of Medicine, a team of researchers report finding that genetic differences in a vitamin D carrier protein referred to as D-binding protein may explain the discrepancy between the prevalence of diagnosed vitamin D deficiency in black Americans – based on measuring the molecule 25-hydroxyvitamin D (25OHD) – and a lack of the usual symptoms of vitamin deficiency.

23nov 2013--The essential role of vitamin D in maintaining bone health is well recognized, but while measurement of 25OHD alone consistently classifies from 70 to 90 percent of black Americans as vitamin D deficient, the usual consequences of deficiency – such as low bone density and increased fracture risk – are actually less prevalent among black individuals. That inconsistency led the team led by Ravi Thadhani, MD, MPH, chief of the Division of Nephrology in the Massachusetts General Hospital (MGH) Department of Medicine, to take a closer look at whether current methods accurately determine vitamin D deficiency.

The investigators examined data from more than 2,000 participants in HANDLS (Healthy Aging in Neighborhoods of Diversity Across the Life Span), a larger National Institutes of Health (NIH)-sponsored study, led by Michele K. Evans, MD, co-corresponding author of the current report, and Alan B. Zonderman, PhD, also a co-author. HANDLS is prospective, long-term, epidemiologic study of age–associated health disparities in socioeconomically diverse black and white individuals in the city of Baltimore. Participants – adults ages 30 to 64 – were interviewed and received medical examinations between 2004 and 2009.

For the current study, researchers analyzed levels of 25OHD, levels and genetic variants of D-binding protein, and levels of calcium and parathyroid hormone – another marker of vitamin D deficiency – along with bone density readings in almost 1,200 white and around 900 black participants. The results indicated that black participants had significantly lower levels of both 25OHD and D-binding protein, compared with white participants and also showed that about 80 percent of the difference in D-binding protein levels could be explained by genetic variation. However, bone density and calcium levels were higher in black participants, and while their parathyroid hormone levels also were higher, the difference between black and white participants was slight.

"Black people are frequently treated for vitamin D deficiency, but we may not be measuring the right form of vitamin D to make that diagnosis," says Thadhani, who is senior and co-corresponding author of the NEJM report. "While our finding that 80 percent of black participants in this study met criteria for vitamin D deficiency is consistent with previous studies, we were surprised to find no evidence of problems with bone health. Most vitamin D in the bloodstream is tightly bound to D-binding protein and is not active. When we determined the concentrations of circulating non-bound vitamin D, which would be available to cells, we found that levels of this form were equivalent between black and white participants, which suggested to us that these black individuals may not be truly deficient."

He adds, "Although currently there are no commercially available assays that directly measure bioavailable levels of 25OHD, these results suggest that such assays would more accurately identify those with true vitamin D deficiency, allowing us to direct treatment toward those who really need it. Additional studies need to be conducted to establish optimal levels of bioavailable 25ODH across all racial and ethnic groups." Thadhani is a professor of Medicine at Harvard Medical School.

Evans, who is deputy scientific director and chief of the Health Disparities Research Section at the National Institute on Aging Intramural Research Program (NIA-IRP), notes, "This study confirms the value of addressing clinical questions from ahealth disparities standpoint that overcomes barriers to inclusion of diverse populations in biomedical research."

Provided by Massachusetts General Hospital

USPSTF identifies high priority evidence gaps for older adults

22 nov 2013—The U.S. Preventive Services Task Force (USPSTF) has produced their third annual report for Congress identifying high-priority evidence gaps specifically relating to the care of older adults.

Noting that, by 2040, one in five Americans will be older than 65 and one in 13 will be older than 85, Virginia Moyer, M.D., M.P.H., and colleagues from the USPSTF reviewed the literature and identified gaps related to the care of older adults.

According to the report, the priorities for improving the health of older people via clinical preventive services include cognitive impairment and dementia screening; physical and mental well-being screening; prevention of falls and fractures; vision and hearing screening; and avoiding unintended harms of medical procedures and testing.

"Prevention serves an especially important role as people age," Task Force co-chair Albert Siu, M.D., M.S.P.H., said in a statement. "We hope that highlighting evidence gaps related to the care of older adults will help public and private researchers and research funders target their efforts so that together we will be able to improve preventive health and health care for all."

More information: More Information

Aging impacts epigenome in human skeletal muscle

Our epigenome is a set of chemical switches that turn parts of our genome off and on at strategic times and locations. These switches help alter the way our cells act and are impacted by environmental factors including diet, exercise and stress. Research at the Buck Institute reveals that aging also effects the epigenome in human skeletal muscle. The study, appearing on line in Aging Cell, provides a method to study sarcopenia, the degenerative loss of muscle mass that begins in middle age.

21 nov 2013--The results came from the first genome-wide DNA methylation study in disease-free individuals. DNA methylation involves the addition of a methyl group to the DNA and is involved in a particular layer of epigenetic regulation and genome maintenance. In this study researchers compared DNA methylation in samples of skeletal muscle taken from healthy young (18 - 27 years of age) and older (68 – 89 years of age) males. Buck faculty and lead scientist Simon Melov, PhD, said researchers looked at more than 480,000 sites throughout the genome. "We identified a suite of epigenetic markers that completely separated the younger from the older individuals – there was a change in the epigenetic fingerprint," said Melov. "Our findings were statistically significant; the chances of that happening are infinitesimal."

Melov said scientists identified about six-thousand sites throughout the genome that were differentially methylated with age and that some of those sites are associated with genes that regulate activity at the neuromuscular junction which connects the nervous system to our muscles. "It's long been suspected that atrophy at this junction is a weak link in sarcopenia, the loss of muscle mass we get with age," said Melov. "Maybe this differential methylation causes it. We don't know."

Studying the root causes and development of sarcopenia in humans is problematic; the research would require repeated muscle biopsies taken over time, something that would be hard to collect. Melov says now that the epigenetic markers have been identified in humans, the goal would be to manipulate those sites in laboratory animals. "We would be able to observe function over time and potentially use drugs to alter the rate of DNA methylation at those sites," he said. Melov says changes in DNA methylation are very common in cancer and that the process is more tightly controlled in younger people.

More information: "Genome-wide DNA methylation changes with age in disease-free human skeletal muscle," Aging Cell, 2013.

Provided by Buck Institute for Age Research

Cholesterol guidelines are based on strong, evidence-based science, AHA says

The American Heart Association and American College of Cardiology vigorously defend the recently published risk assessment and cholesterol guidelines despite recent media reports critical of the risk assessment calculator tool.

20 nov 2013--"We stand behind our guidelines, the process that was used to create them and the degree to which they were rigorously reviewed by experts," said Mariell Jessup, M.D., president of the American Heart Association.

The risk calculator provides an estimate of a patient's ten year risk of having a heart attack or stroke, and is one component that healthcare providers should use as they discuss whether or not a patient would benefit from a statin drug, a type of medication that lowers artery-clogging LDL cholesterol. The guidelines and risk assessment tool are developed from, and based on, the best evidence available as determined by the expert panel. Authors say the risk assessment tool is intended to spark a conversation between patients and their physician to help drive individualized care based on that patient's health profile.

"Clinical practice guidelines such as these should not take the place of sound clinical judgment. These guidelines should enable a discussion between a patient and their healthcare provider about the best way to prevent a heart attack or stroke, based on the patient's personal health profile and their preferences. The risk calculator score is part of that discussion, because it provides specific information to the patient about their personal health. A high score does not automatically mean a patient should be taking a statin drug" said John Gordon Harold, M.D, president of the American College of Cardiology.

Harold adds the risk assessment is a significant improvement over the previous model. For the first time in a major guideline, it focuses on estimating risk for both heart attacks AND strokes, whereas previous guidelines only focused on heart attack risk. The guidelines also provide estimates applicable to African Americans for the first time ever.

One in three Americans die of cardiovascular diseases such as heart attacks, heart failure and stroke. Strong scientific evidence indicates that statins are a reasonable treatment approach for a large majority of patients, and can help people avoid a heart attack or stroke even if their risk is as low as five percent.

At the invitation of the National Heart, Lung, and Blood Institute (NHLBI), The American Heart Association and the American College of Cardiology assumed the joint governance, management and public distribution of four clinical practice guidelines focused on cardiovascular prevention. Other guidelines, published at the same time address obesity, healthy lifestyle and risk assessment.

The groups published the new guidelines November 12th in the American Heart Association's journal Circulation and the Journal of the American College of Cardiology.

Provided by American Heart Association

Heart attack survival similar among those receiving clot-busting drugs, angioplasty

The one-year survival rate after a severe heart attack was similar among people who initially received clot-busting medications and those who immediately underwent angioplasty, according to a late-breaking clinical trial presented at the American Heart Association's Scientific Sessions 2013.

20nov 2013--The Strategic Reperfusion Early After Myocardial Infarction (STREAM) Trial included 1,892 people who suffered an ST-elevation myocardial infarction (STEMI), a heart attack in which a blood vessel is totally blocked, but weren't able to undergoangioplasty with the first hour of arriving at the hospital. Researchers randomly assigned half of these patients to receive three medications, including age-adjusted bolus tenecteplase, clopidogrel and enoxaparin. If their symptoms persisted, they also underwent angioplasty, a procedure that opens blocked blood vessels. The other half received angioplasty, and standard drugs to prevent blood clots.

Both groups were treated within three hours of the onset of heart-attack symptoms.

Among those who first received the combined medications, 2.1 percent died, including from heart disease and stroke, compared to 1.5 percent of those who initially underwent angioplasty. This was not a significant difference.

In an earlier part of the study, patients who received clot-busting medications were slightly more likely to survive without complications 30 days after treatment. These latest findings represent the original study's one-year follow-up.

"In this study, the combined drug strategy proved a reasonable approach to take as an initial treatment immediately after severe heart attack when angioplasty is not immediately available," said Peter Sinnaeve, M.D., Ph.D., the study's lead author and assistant professor of cardiology at the University of Leuven in Belgium.

The American Heart Association currently recommends clot-busting medication within the first 30 minutes and angioplasty within the first 90 minutes of hospital arrival and continues to review and adapt guidelines as appropriate. The association has developed the Mission Lifeline® program to help improve timely access to appropriate care.

More information: The Strategic Reperfusion Early After Myocardial Infarction (STREAM) study. Armstrong PW, Gershlick A, Goldstein P, Wilcox R, Danays T, Bluhmki E, Van de Werf F; STREAM Steering Committee. Am Heart J. 2010 Jul;160(1):30-35.e1. DOI: 10.1016/j.ahj.2010.04.007.

Provided by American Heart Association

Rate of aortic valve replacement for elderly patients has increased; outcomes improved

Jose Augusto Barreto-Filho, M.D., Ph.D., of the Federal University of Sergipe and the Clinica e Hospital Sao Lucas, Sergipe, Brazil, and colleagues assessed procedure rates and outcomes of surgical aortic valve replacement (AVR) among 82,755,924 Medicare fee-for-service beneficiaries between 1999 and 2011.

19 nov 2013--"Aortic valve disease in the United States is a major cardiovascular problem that is likely to grow as the population ages. Aortic valve replacement is the standard treatment even for very elderly patients despite its risks in this age group. With transcatheter aortic valve replacement emerging as a less invasive option, contemporary data from real-world practice are needed to provide a perspective on the outcomes that are being achieved with surgery," according to background information in the article.

The primary measured outcomes for the study were procedure rates for surgical AVR alone and with coronary artery bypass graft (CABG) surgery, 30-day and 1-year mortality, and 30-day readmission rates.

The researchers found that rates of AVR increased between 1999 and 2011, including AVR without CABG surgery, while the rate of AVR with CABG surgery decreased during this time period. Procedure rates increased in all age, sex, and race strata, most notably in patients 75 years or older.

Mortality decreased at 30 days (absolute decrease, 3.4 percent; adjusted annual decrease, 4.1 percent) per year and at 1 year (absolute decrease, 2.6 percent; adjusted annual decrease, 2.5 percent). Thirty-day all-cause readmission also decreased by 1.1 percent per year. In addition, AVR with CABG surgery decreased and women and black patients had lower procedure and higher mortality rates.

"These findings may provide a useful benchmark for outcomes of aortic valve replacement surgery for older patients eligible for surgery considering newer transcatheter treatments," the authors write.

Provided by The JAMA Network Journals

JAMA doi:10.l001/jama.2013.282437

Smartphone apps to help smokers quit come up short

Many of the 11 million smokers in the U.S. have downloaded smartphone apps created to help them quit smoking. But since most of these apps don't include practices proven to help smokers quit, they may not be getting the help they need, reports a new study in the American Journal of Preventive Medicine.

18 nov 2013--"Currently available, popular (most downloaded) smoking cessation apps have low levels of adherence to key evidence-based practices and few apps provide counseling on how to quit, recommend approved quit smoking medications or refer a user to a quit line," said the study's lead author Lorien C. Abroms, ScD., assistant professor at the George Washington School of Public Health and Health Services.

"Still, there appears to be a high global demand for smoking cessation apps since over 700,000 apps are downloaded each month for the Android operating system alone," he said.

Abroms and his colleagues analyzed popular smoking cessation apps in February 2012. Researchers studied the most popular apps—47 for the iPhone and 51 for the Android operating system—and found that apps for both systems had a low adherence to the U.S. Public Health Service's Clinical Practice Guidelines for Treating Tobacco Use and Dependence.

Michael C. Fiore, M.D., MPH, professor of medicine and director of the Center for Tobacco Research and Intervention at the University of Wisconsin School of Medicine and Public Health pointed out that "even though the study found that popular smoking cessation apps have a low level of adherence to evidence-based guidelines, it is a hopeful sign that people want to quit and scientists and technicians are coming up with applications to help them. But the bad news is smartphone apps may not give people the guidance they need."

Researchers acknowledge that while they know what helps people quit smoking generally, little is known about what aspects of smoking cessation programs should be included in mobile apps. Still, Abroms noted that "they [smartphone apps] do not promote aspects of treatments that have proven to work in quitting smoking and so we as public health professionals have reason to be concerned."

"What we're missing with smartphone apps is universally recognized, science-based recommendations," said Fiore. "We're obliged to give smokers the best possible, quality help. Science-based help is what smokers get when they call quit lines—there are over 1,000 quit lines available to U.S. smokers and that's where they can get one-stop help."

More information: American Journal of Preventive Medicine, 2011; 40 (3): 279. DOI: 10.1016/j.amepre.2010.10.032

Provided by Health Behavior News Service

Sofrito contains substances that reduce the risk of cardiovascular disease

The researchers have for the first time identified polyphenols and carotenoids in sofrito. Credit: SINC

17 nov 2013--The combination of tomato, olive oil, garlic and onion in a sofrito increases the amount of polyphenols and carotenoids. These bioactive compounds respectively help to prevent cardiovascular diseases and cancer. This is contained in a study carried out by the University of Barcelona and the CIBERobn network, Spain, which confirms sofrito as an essential part of the Mediterranean diet.

The study, PREvention with a MEDiterranean Diet (PREDIMED) has recently shown the link between the Mediterranean diet and low levels of cardiovascular disease. The questionnaire used as a reference asked consumers how often they ate vegetables, pasta, rice and other dishes made with sofrito, but the beneficial compounds of this product had never been analysed.

Now researchers from the University of Barcelona (UB) and the Biomedical Research Centres Network - Physiopathology of Obesity and Nutrition (CIBERobn) of the Carlos III Health Institute, have for the first time identified polyphenols and carotenoids -healthy antioxidant substances- in sofrito, by using a high resolution mass spectrometry technique.

The results have been published in the Food Chemistry magazine and they show the presence of at least 40 types of polyphenols. "These compounds produced by plants and which we eat are related to reduced cardiovascular diseases", Rosa María Lamuela, researcher at the UB and the person responsible for the project, told SINC.

Other bioactive compounds found in the sofrito are carotenoids and vitamin C. Various studies have shown that the intake of carotenoids such as lycopene prevents prostate cancer and the consumption of foods rich in beta-carotene help to reduce the incidence of lung cancer.

"Eating a daily amount of 120 grams of sofrito, added to pasta for example, the total intake of polyphenols is 16 to 24 milligrams per portion and 6 to 10 milligrams in the case of carotenoids", explains Lamuela.

The team analysed ten types of commercial sofritos, "although the results do apply to homemade sofrito, given that they generally include the same ingredients, without taking into account thickeners: tomatoes, onions, garlic and oil". The combination of these foods equals the bio-health compounds of each one separately.

With regard to oil, scientists recommend using virgin olive oil instead of sunflower oil. In fact, they are now looking for the ideal proportion of the four ingredients and it would seem that the inclusion of 10% extra virgin olive oil gives very good results in the sofrito properties.

Researchers have also performed a statistical analysis with the levels of phenolic and carotenoid compounds present in each sofrito, which has enabled them to identify markers that differentiate the components of each brand.

More information: Anna Vallverdú-Queralt, José Fernando Rinaldi de Alvarenga, Ramon Estruch, Rosa María Lamuela-Raventos. "Bioactive compounds present in the Mediterranean sofrito". Food Chemistry 141 (4); 3365-3372, 2013.

Provided by Plataforma SINC

Retirement makes people more active

16 nov 2013—Retirement may make people more active, at least in the short term, suggests new research from ageing experts at Newcastle University.

The study, led by Dr. Alan Godfrey and published in the journal Age and Ageing, looked at the amount and patterns of time older adults, those aged between 48 and 89, spent ambulatory (walking) and sedentary (sitting/lying). The results show that retired people spent more time walking and less time sedentary than those who were employed.

All 98 study participants wore a small accelerometer on their thigh for a week, allowing the team to analyse how active and inactive they were over that period. There was an increase in activity in retirement but in general time spent walking decreased and time spent sedentary increased in older age groups.

Time spent walking was also considered with respect to public health guidelines which recommend walking approximately 150mins per week in time blocks of 10 minutes. Only 21% of all participants reached any of the recommended guidelines and that in general the older age groups were the worst performers.

Before this study little was known about the effects of retirement and age on this form of physical activity as previous methods relied on diaries or estimates of activity (from self-reported time spent inactive) during a person's daily/weekly schedule.

Live Well

The findings for this study identify the need for suitable physical activity interventions targeting those in the over 50 age group. This is a key objective of the LiveWell Programme, run by Newcastle University. The Programme aims to develop interventions to aid healthy ageing for those in the 'retirement window' that are feasible, effective and cost effective that can be incorporated into everyday life.

Dr Godfrey said: "Retirement may present a critical window for encouraging older people to be more physically active. Family members can obviously help with this period of transition by planning for the future and helping the person set to retire in adopting new or altering old (physical activity) strategies.

"Engaging with community or peer led activity groups (walking clubs, outdoor pursuits etc) would be one simple and effective example of adopting and maintaining any desire to become more active."

More information: ageing.oxfordjournals.org/content/early/2013/10/29/ageing.aft168.short

Provided by Newcastle University

Population aging crisis may have been overestimated

15 nov 2013—Use of an alternative measure for assessing the number of dependent older people suggests that the population aging crisis may have been overestimated, according to an analysis published online Nov. 12 in BMJ.

Noting that the standard indicator of population aging is the old age dependency ratio, or the number of people of state pension age, divided by the number of working age adults, Jeroen Spijker and John MacInnes, Ph.D., from the University of Edinburgh in the United Kingdom, first propose an alternative measure to assess the number of dependent older people and then discuss the implications for public health.

The authors suggest that remaining life expectancy is more important than age in terms of health-related attitudes and behaviors. Due to increasing life expectancy, many older people are healthier and fitter than their peers in earlier cohorts. Using a remaining life expectancy of ≤15 years as the threshold for dependency, there has been a decrease in dependency by more than one-third in the past forty years. Furthermore, the real elderly dependency ratio is set to decrease further and then stabilize around the current level.

"Medical staff will need to stay alert to the changing relation between 'old' and 'age' as life expectancy continues to increase and the typical onset of senescence and its associated morbidities is delayed," the authors write.

More information: Full Text

Clinical Practice Guideline offers roadmap to treat adults affected by obesity, overweight

Healthcare providers are on the front line of the obesity epidemic – poised to identify who needs to lose weight for health reasons and in a prime position to direct successful weight loss efforts. The American Heart Association, American College of Cardiology and Obesity Society have developed comprehensive treatment recommendations to help healthcare providers tailor weight loss treatments to adult patients affected by overweight or obesity. The joint guideline is published simultaneously Circulation: a journal of the American Heart Association, Journal of the American College of Cardiology and Obesity: Journal of The Obesity Society.

14 nov 2013--"Weight loss isn't about will power. It's about behaviors around food and physical activity, and getting the help you need to change those behaviors," said Donna Ryan, M.D., co-chair of the writing committee and professor emeritus at Louisiana State University's Pennington Biomedical Research Center in Baton Rouge, La.

The new guideline report is based on a systematic evidence review that summarizes the current literature on the risks of obesity and the benefits of weight loss. It summarizes knowledge on diets for weight loss, the efficacy and effectiveness of comprehensive lifestyle interventions on weight loss and weight loss maintenance and the benefits and risks of bariatric surgery.

In the United States nearly 155 million adults are affected by overweight (defined as a body mass index or BMI of 25 to 29.9) or obesity (BMI of 30 higher). BMI is used to estimate excess body fat and is a measure of body weightrelative to an individual's height.

The report recommends that healthcare providers calculate BMI at annual visits or more frequently, and use the BMI cut points to identify adults who may be at a higher risk of heart disease and stroke because of their weight. The report also presents evidence showing that the greater the BMI, the higher the risk of coronary heart disease, stroke, type 2 diabetes and all-cause mortality (death from any cause).

The new guideline recommends healthcare providers develop individualized weight loss plans that include three key components – a moderately reduced calorie diet, a program of increased physical activity and the use of behavioral strategies to help patients achieve and maintain a healthy body weight.

The best way to achieve these goals is to work with a trained healthcare professional, such as a registered dietitian, behavioral psychologist or other trained weight loss counselor, in a primary care setting, according to the recommendations.

Weight loss counseling should focus on people who need to lose weight because of obesity or overweight with conditions that put them at higher risk for cardiovascular diseases, such as diabetes, high blood pressure, high blood cholesterol, a waist circumference of more than 35 inches for women and more than 40 inches for men.

The most effective behavior change programs include two to three in-person meetings a month for at least six months. Web or phone-based weight loss programs are also an option for the weight loss phase, although research shows they are not as effective as face-to-face programs, according to the statement authors.

Currently, comprehensive lifestyle programs that assist participants in adhering to a lower calorie diet and in increasing physical activity through the use of behavioral strategies are not widely available, Ryan said.

"We hope that by laying out the scientific evidence that medically supervised weight loss works and significantly reduces the risk factors for cardiovascular disease, it will be more fully embraced by patients and doctors and effective programs will eventually be reimbursed by all third-party payers," Ryan said.

Medicare began covering behavioral counseling for patients affected by obesity in 2012, based on available evidence at that time. Under the Affordable Care Act, most private insurance companies are expected to cover behavioral counseling and other treatments for obesity by 2014.

Other key recommendations include:

• Tailoring dietary patterns to a patient's food preferences and health risks. For example, a patient with high blood cholesterol would benefit most from a low-calorie, lower-saturated fat diet including foods that they find appealing.
• Focusing on achieving sustained weight loss of 5 percent to 10 percent within the first six months. This can reduce high blood pressure, improve cholesterol and lessen the need for medications to control blood pressure and diabetes. Even as little as 3 percent sustained weight loss can reduce the risk for the development of type 2 diabetes as well as result in clinically meaningful reductions in triglycerides, blood glucose and other risk factors for cardiovascular disease.
• Advising adults with a BMI of 40 or higher and patients with a BMI of 35 or higher who have two other cardiovascular risk factors such as diabetes or high blood pressure, that bariatric surgery may provide significant health benefits. The guideline does not recommend weight loss surgery for people with a BMI under 35 and does not recommend one surgical procedure over another.

"Healthcare providers should do more than advise patients affected by obesity or overweight to lose weight – they should be actively involved and help their patients reach a health body weight," said Ryan.

The obesity guideline is one of four cardiovascular disease prevention guidelines being released today by the American Heart Association and American College of Cardiology. Other guidelines address lifestyle management, cholesterol and cardiovascular risk assessment.

The obesity treatment recommendations are based on the latest scientific evidence from 133 research studies.

The expert panel that wrote the report was convened by the National Heart, Lung, and Blood Institute of the National Institutes of Health. At the invitation of the NHLBI, the American Heart Association, the American College of Cardiology and The Obesity Society officially assumed the joint governance, management and publication of the obesity guideline in June. Committee members volunteered their time and were required to disclose all healthcare-related relationships, including those existing one year before the initiation of the writing project.

More information: The full report, "2013 ACC/AHA Guideline for the Management of Overweight and Obesity in Adults" will be published online today on the websites of the ACC and the AHA, as well as in future print issues of the Journal of the American College of Cardiology and the American Heart Association journal, Circulation.

Provided by American College of Cardiology

ACC/AHA publish new guideline for management of blood cholesterol

The American College of Cardiology and the American Heart Association today released a new clinical practice guideline for the treatment of blood cholesterol in people at high risk for cardiovascular diseases caused by atherosclerosis, or hardening and narrowing of the arteries, that can lead to heart attack, stroke or death.

13 nov 2013--The guideline identifies four major groups of patients for whom cholesterol-lowering HMG-CoA reductase inhibitors, or statins, have the greatest chance of preventing stroke and heart attacks. The guideline also emphasizes the importance of adopting a heart-healthy lifestyle to prevent and control high blood cholesterol.

"The new guideline uses the highest quality scientific evidence to focus treatment of blood cholesterol on those likely to benefit most," said Neil J. Stone, MD, Bonow professor of medicine at Northwestern University Feinberg School of Medicine and chair of the expert panel that wrote the new guideline. "This guideline represents a departure from previous guidelines because it doesn't focus on specific target levels of low-density lipoprotein cholesterol, commonly known as LDL, or 'bad cholesterol,' although the definition of optimal LDL cholesterol has not changed. Instead, it focuses on defining groups for whom LDL lowering is proven to be most beneficial."

The new guideline recommends moderate- or high-intensity statin therapy for these four groups:

• Patients who have cardiovascular disease;
• Patients with an LDL, or "bad" cholesterol level of 190 mg/dL or higher;
• Patients with Type 2 diabetes who are between 40 and 75 years of age; and
• Patients with an estimated 10-year risk of cardiovascular disease of 7.5 percent or higher who are between 40 and 75 years of age (the report provides formulas for calculating 10-year risk).

In terms of clinical practice, physicians can use risk assessment tools in some cases to determine which patients would most likely benefit from statin therapy, rather than focusing only on blood cholesterol to determine which patients would benefit.

"The likely impact of the recommendations is that more people who would benefit from statins are going to be on them, while fewer people who wouldn't benefit from statins are going to be on them," Dr. Stone said. Doctors may also consider switching some patients to a higher dose of statins to derive greater benefit as a result of the new guidelines.

The guideline was prepared by a panel of experts based on an analysis of the results of randomized controlled trials. The panel was charged with guiding the optimal treatment of blood cholesterol to address the rising rate of cardiovascular disease, currently the leading cause of death and disability in the U.S.

The panel chose to focus on the use of statins after a detailed review of other cholesterol-lowering drugs. "Statins were chosen because their use has resulted in the greatest benefit and the lowest rates of safety issues. No other cholesterol-lowering drug is as effective as statins," said Dr. Stone. He added that there is a role for other cholesterol-lowering drugs, for example, in patients who suffer side effects from statins.

The report also stresses the importance of lifestyle in managing cholesterol and preventing heart disease. "The cornerstone of all guidelines dealing with cholesterol is a healthy lifestyle," said Dr. Stone. "That is particularly important in the young, because preventing high cholesterol later in life is the first and best thing someone can do to remain heart-healthy. On the other hand, if someone already has atherosclerosis, lifestyle changes alone are not likely to be enough to prevent heart attack, stroke, and death, and statin therapy will be necessary."

In addition to identifying patients most likely to benefit from statins, the guideline outlines the recommended intensity of statin therapy for different patient groups. Rather than use a "lowest is best" approach that combines a low dose of a statin drug along with several other cholesterol-lowering drugs, the panel found that it can be preferable to focus instead on a healthy lifestyle along with a higher dose of statins, eliminating the need for additional medications.

"The focus for years has been on getting the LDL low," said Dr. Stone. "Our guidelines are not against that. We're simply saying how you get the LDL low is important. Considering all the possible treatments, we recommend a heart-healthy lifestyle and statin therapy for the best chance of reducing your risk of stroke or heart attack in the next 10 years."

The guidelines are intended to serve as a starting point for clinicians. Some patients who do not fall into the four major categories may also benefit from statin therapy, a decision that will need to be made on a case-by-case basis. The expert panel that wrote the report was convened by the National Heart, Lung, and Blood Institute of the National Institutes of Health. At the invitation of the NHLBI, the American Heart Association and American College of Cardiology assumed the joint governance, management and publication of this guideline, along with four other prevention guidelines, in June. Committee members volunteered their time and were required to disclose all healthcare-related relationships, including those existing one year before the initiation of the writing project.

More information: The full text of the report, "2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults," will be published in future print issues of the of the Journal of the American College of Cardiology and the American Heart Association's journal Circulation. It will also be accessible today on the ACC website and AHA.

Provided by American College of Cardiology