Super-sticky 'ultra-bad' cholesterol revealed in people at high risk of heart disease

Scientists from the University of Warwick have discovered why a newly found form of cholesterol seems to be 'ultra-bad', leading to increased risk of heart disease. The discovery could lead to new treatments to prevent heart disease particularly in people with type 2 diabetes and the elderly.

31 may 2011--The research, funded by the British Heart Foundation (BHF), found that 'ultrabad' cholesterol, called MGmin-low-density lipoprotein (LDL), which is more common in people with type 2 diabetes and the elderly, appears to be 'stickier' than normal LDL. This makes it more likely to attach to the walls of arteries. When LDL attaches to artery walls it helps form the dangerous 'fatty' plaques' that cause coronary heart disease (CHD).

CHD is the condition behind heart attacks, claiming 88,000 lives in the UK every year (1).

The researchers made the discovery by creating human MGmin-LDL in the laboratory, then studying its characteristics and interactions with other important molecules in the body.

They found that MGmin-LDL is created by the addition of sugar groups to 'normal' LDL – a process called glycation – making LDL smaller and denser. By changing its shape, the sugar groups expose new regions on the surface of the LDL. These exposed regions are more likely to stick to artery walls, helping to build fatty plaques. As fatty plaques grow they narrow arteries - reducing blood flow - and they can eventually rupture, triggering a blood clot that causes a heart attack or stroke.

The discovery might also explain why metformin, a widely prescribed type 2 diabetes drug, seems to lead to reduced heart disease risk. Metformin is known to lower blood sugar levels, and this new research shows it may reduce the risk of CHD by blocking the transformation of normal LDL to the more 'sticky' MGmin-LDL.

Dr Naila Rabbani, Associate Professor of Experimental Systems Biology at Warwick Medical School, who led the study, said:

"We're excited to see our research leading to a greater understanding of this type of cholesterol, which seems to contribute to heart disease in diabetics and elderly people. Type 2 diabetes is a big issue – of the 2.6 million diabetics in the UK, around 90 per cent have type 2. It's also particularly common in lower income groups and South Asian communities. (2, 3)

"The next challenge is to tackle this more dangerous type of cholesterol with treatments that could help neutralise its harmful effects on patients' arteries."

Dr Shannon Amoils, Research Advisor at the BHF, which funded the study, said:

"We've known for a long time that people with diabetes are at greater risk of heart attack and stroke. There is still more work to be done to untangle why this is the case, but this study is an important step in the right direction.

"This study shows how the make-up and the shape of a type of LDL cholesterol found in diabetics could make it more harmful than other types of LDL. The findings provide one possible explanation for the increased risk of coronary heart disease in people with diabetes.

"Understanding exactly how 'ultrabad' LDL damages arteries is crucial, as this knowledge could help develop new anti-cholesterol treatments for patients."

The research was published in the journal Diabetes.

Age, gender and social advantage affect success in quitting smoking

The study, commissioned by the National Institute for Health and Clinical Excellence (NICE) and undertaken by the UK Centre for Tobacco Control Studies (UKCTCS), reviewed published studies from between 1990 and 2007 to establish success rates for the NHS smoking cessation services. It found that older smokers are more likely than young smokers to successfully quit, some men appear to be more successful at quitting than women despite the fact that more women attend the smoking cessation services, and more disadvantaged groups face greater challenges when giving up smoking.

30 may 2011--The findings support other international research that also suggests that while women are highly motivated to quit smoking, men may be more likely to succeed when they access services to help them stop. Several factors seem to explain the lower success rates of women, such as less confidence in quitting, the inter-relationship between gender and deprivation and differences in the meaning and role of tobacco in men and women's lives.

Pregnant women and more disadvantaged groups face particular challenges in quitting. Pregnant smokers who enrol in smoking cessation programmes may just suspend their smoking for the duration of their pregnancy as opposed to quitting altogether. These smokers are more likely to be shift and manual workers and may experience multiple barriers that make it harder to stop smoking in the long-term.

There are similar difficulties for smokers from more deprived areas where smoking is more prevalent. In such areas, smoking is often perceived as the norm which makes quitting harder.

While cessation rates for smokers accessing NHS stop smoking services were lower in disadvantaged areas (52.6 per cent) than elsewhere (57.9 per cent) the proportion of smokers being treated by the services was higher (16.7 per cent compared with 13.4 per cent). The net effect with the additional treatment meant that a higher proportion of smokers in the most disadvantaged areas reported success (8.8 per cent) than in more advantaged areas (7.8 per cent).

The UK remains the only country in the world to have a comprehensive, free-at-the-point-of-use cessation services and the study suggests that these services do provide effective support for smokers who want to quit. However, a number of important research questions remain regarding the effectiveness of different forms of intervention offered by the services.

For example, because gender, ethnicity, class, age and level of dependency affect success in giving up smoking, tailored interventions may help to improve cessation rates. In the case of pregnant women, two reviews of NHS smoking cessation services provide evidence that the most effective treatment for pregnant smokers includes elements such as systematic training of midwives in how to refer pregnant smokers, flexible home visits, and providing intensive multi-session treatments delivered by a small number of dedicated staff.

The research team concluded that NHS stop smoking services have made a contribution to reducing inequalities in smoking prevalence. To achieve government targets will require both the development of more innovative cessation interventions for some specific groups of smokers and recognition that tobacco control policy will need to take account of the unique challenges these groups face when trying to quit smoking.

Provided by Economic & Social Research Council

Large rehabilitation study looks at getting stroke patients back on their feet

In the largest stroke rehabilitation study ever conducted in the United States, stroke patients who had physical therapy at home improved their ability to walk just as well as those who were treated in a training program that requires the use of a body-weight supported treadmill device followed by walking practice.

29 may 2011--The study, funded by the National Institutes of Health, also found that patients continued to improve up to one year after stroke, defying conventional wisdom that recovery occurs early and tops out at six months. In fact, even patients who started rehabilitation as late as six months after stroke were able to improve their walking.

The results of the study will be published in the May 26, 2011 edition of the New England Journal of Medicine. NIH's National Institute of Neurological Disorders and Stroke (NINDS) provided primary funding for the study.

"More than 4 million stroke survivors experience difficulty walking. Rigorously comparing available physical therapy treatments is essential to determine which is best,'' said Walter Koroshetz, M.D., NINDS deputy director. "The results of this study show that the more expensive, high tech therapy was not superior to intensive home strength and balance training, but both were better than lower intensity physical therapy."

The walking program involves having a patient walk on a treadmill in a harness that provides partial body weight support. This form of rehabilitation, which is known as locomotor training, has become increasingly popular. After the patients complete their training on the treadmill, they practice walking.

Previous studies suggested that these devices, also called commercial lifts or robot-assisted treadmill steppers, are an effective intervention in helping stroke patients walk. But this walking program had not been tested on a large scale or examined in terms of the most appropriate timing for therapy.

The investigators of the Locomotor Experience Applied Post-Stroke (LEAPS) trial set out to compare the effectiveness of the body-weight supported treadmill training with walking practice started at two different stages--two months post-stroke (early locomotor training) and six months post-stroke (late locomotor training). The locomotor training was also compared against an equivalent schedule of home exercise managed by a physical therapist, aimed at enhancing patients' flexibility, range of motion, strength and balance as a way to improve their walking. The primary measure was each group's improvement in walking at one year after the stroke.

The investigators had hypothesized that the body-weight supported treadmill and walking program, especially early locomotor training, would be superior to a home exercise program. However, they found that all groups did equally well, achieving similar gains in walking speed, motor recovery, balance, social participation and quality of life.

At the end of one year, 52 percent of all the study participants had made significant improvements in their ability to walk. The timing of the locomotor training program did not seem to matter. At one year, no differences were found in the proportion of patients who improved walking with the early or late treadmill training program, nor did the severity of their stroke affect their ability to make progress by the end of the year.

The patients' measure of improvement was based on how well they were able to walk independently by the end of the study period. For example, severely impaired stroke patients were considered improved when they were able to walk around inside the house, whereas the patients who were already mobile at home were considered improved when they could progress to walking independently in the community.

All groups achieved similar gains in the speed and distance of their walking, their physical mobility, motor recovery and social participation, resulting in an improved quality of life.

Simultaneous with intensive therapies, all study participants received usual care, physical therapy consistent with current practice standards, which involved a variable number of sessions of about an hour each. The study found that both the locomotor training and the home physical therapy were superior to usual care. After six months, the patients who were assigned to usual therapy recovered only about half as much as the participants who received one of the two study therapy programs for three months. This finding suggests that either the treadmill training program or the at-home balance and strength training sessions are effective forms of physical therapy, and both are superior to usual care.

Despite reports that most improvement after stroke is complete by six months, the patients assigned to usual care for six months made significant improvements in walking speed after they entered the body-weight supported treadmill and walking program. The researchers said this suggests that recovery beyond six months can be enhanced by further therapy.

Individuals in the locomotor training groups were more likely to feel faint and dizzy during the exercise, and those severely affected patients who received early locomotor training experienced more multiple falls. Fifty-seven percent of participants in the study experienced one fall, 34 percent had multiple falls and 6 percent had a fall resulting in injury. Falls are a common problem among stroke survivors, and the investigators say this study builds on evidence that additional research is needed to prevent falls.

The at-home strength and balance therapy group was the most likely to stick with the program; only 3 percent dropped out of this arm of the study, compared to 13 percent of the locomotor training groups. The authors noted that the home training programs were progressive, intensive, and repetitive, and were highly effective in improving functional status and levels of walking ability, and quality of life at one year post-stroke.

"We were pleased to see that stroke patients who had a home physical therapy exercise program improved just as well as those who did the locomotor training," said Pamela W. Duncan, Ph.D., principal investigator of LEAPS, and professor at Duke University School of Medicine in Durham, N.C. "The home physical therapy program is more convenient and pragmatic. Usual care should incorporate more intensive exercise programs that are easily accessible to patients to improve walking, function and quality of life."

The home exercise programs require less expensive equipment, less training for the therapists and fewer clinical staff members. The LEAPS authors suggest that this intervention may help keep stroke survivors active in their own homes and community environments.

More than 400 patients were randomly assigned into the three study groups and participated in 36 90-minute sessions over 12 to 16 weeks. They had either severe or moderate walking impairments. The average age of the patients was 62 years. Fifty-four percent were men and 22 percent were African American. The trial took place at six inpatient rehabilitation centers in Florida and California.

More information: Duncan PW, Sullivan KJ, Behrman AL, Azen SP, Wu, SS, Nadeau SE, Dobkin BH, Rose DK, Tilson, JK, Cen S, Hayden SK "Body-Weight-Supported Treadmill Rehabilitation Program After Stroke." New England Journal of Medicine, May 26, 2011, Vol. 364;21, pp. 32-42.

Provided by National Institutes of Health

Stress may increase risk for Alzheimer's disease

Stress promotes neuropathological changes that are also seen in Alzheimer's disease. Scientists from the Max Planck Institute of Psychiatry in Munich have discovered that the increased release of stress hormones in rats leads to generation of abnormally phosphorylated tau protein in the brain and ultimately, memory loss.

27 may 2011--Protein deposits in nerve cells are a typical feature of Alzheimer's disease: the excessive alteration of the tau protein through the addition of phosphate groups – a process known as hyperphosphorylation – causes the protein in the cells to aggregate into clumps. As a result, nerve cells die, particularly in the hippocampus, a part of the brain that plays an important role in learning and memory, as well as in the prefrontal cortex which regulates higher cognitive functions.

Fewer than ten percent of Alzheimer cases have a genetic basis. The factors that contribute to the rest of the cases are largely unknown. Following up on epidemiological studies, scientists at the Max Planck Institute of Psychiatry hypothesized that adverse life events (stress) may be one trigger of Alzheimer's disease.

In cooperation with colleagues at the University of Minho in Braga, Portugal, the Munich-based researchers have now shown that stress, and the hormones released during stress, can accelerate the development of Alzheimer disease-like biochemical and behavioural pathology. They found increased hyperphosphorylation of tau protein in the hippocampus and prefrontal cortex of rats that has been subjected to stress (e.g. overcrowding, placement on a vibrating platform) for one hour daily over a period of one month. Animals showing these changes in tau also showed deficits in memories that depended on an intact hippocampus; also, animals with abnormally hyperphosphorylated tau were impaired in behavioural flexibility, a function that requires proper functioning of the prefrontal cortex.

These results complement previous demonstrations by the scientists that stress leads to the formation of beta-amyloid, another protein implicated in Alzheimer's disease. "Our findings show that stress hormones and stress can cause changes in the tau protein like those that arise in Alzheimer's disease", explains Osborne Almeida from the Max Planck Institute of Psychiatry.

The next challenge will be to see how applicable the results obtained in animals are to the development of non-familial forms of Alzheimer's disease. "Viewing stress as a trigger of Alzheimer's disease offers exciting new research possibilities aimed at preventing and delaying this severe disease. Moreover, since vulnerability to major depression is known to be increased by stress, it will be interesting to know the role of molecules such as beta-amyloid and tau in the onset and progress of this condition", says Osborne Almeida.

More information: Ioannis Sotiropoulos, Caterina Catania, Lucilia G. Pinto, Rui Silva, G. Elizabeth Pollerberg, Akihiko Takashima, Nuno Sousa, and Osborne F. X. Almeida, Stress Acts Cumulatively to Precipitate Alzheimer's Disease-Like Tau Pathology and Cognitive Deficits, Journal of Neuroscience, May 25, 2011; 31(21):7840-7847

Provided by Max-Planck-Gesellschaft

New protein linked to Alzheimer's disease

After decades of studying the pathological process that wipes out large volumes of memory, scientists at The Feinstein Institute for Medical Research discovered a molecule called c-Abl that has a known role in leukemia also has a hand in Alzheimer's disease. The finding, reported in the June 14th issue of the Journal of Alzheimer's Disease, offers a new target for drug development that could stave off the pathological disease process.

25 may 2011--Peter Davies, PhD, head of the Feinstein Institute's Litwin-Zucker Center for Research in Alzheimer's Disease, became interested in c-Abl when he found that the protein was part of the plaques and tangles that crowd the brains of Alzheimer's patients. The protein c-Abl is a tyrosine kinase involved in cell differentiation, cell division and cell adhesion. In patients with chronic myeloid leukemia (CML), c-Abl is turned up in B cells. Inhibiting c-Abl with the cancer drug Gleevec prevents cell division. There was quite a lot known about c-Abl when Dr. Davies began thinking about its possible role in Alzheimer's. He was looking at kinases that phosphorylate tau, the protein that accumulates inside of the neurons during the disease process.

Dr. Davies questioned whether activated c-Abl turned on the cell cycle and could kill adult cells. He designed the study to test this idea and found that turning on the cell cycle in adult brain damages the cells. In their current study, the investigators devised a clever way to activate c-Abl in neurons of normal adult mice. They turned on human c-Abl genes in two different regions – the hippocampus and the neocortex – in adult mice and discovered abundant cell death, especially in the hippocampus. "You don't even need to count, you can just look and see holes in the cell layers of the hippocampus," said Dr. Davies. "It is stunning. Even before the neurons die, there is florid inflammation."

He said that the animal model is ideal for testing the benefit of drugs that turn off c-Abl. While Gleevec works in CML, it does not cross the blood-brain barrier so it would not be useful. Dr. Davies and his colleagues are looking for other drugs that inhibit c-Abl and can get into the brain. "We have a great model to test compounds for Alzheimer's disease. Will regulating c-Abl make a difference for patients? We won't know unless we try it in double blind clinical trials."

The researchers are now working to understand the mechanism of cell death. They are also investigating why males die considerably sooner than females – 12 to 15 weeks compared to 24 to 26 weeks. "It is an incredibly interesting model," said Dr. Davies. "If c-Abl is important we can learn how it works."

More information: The paper detailing the findings has been published in an early online version. It is scheduled for publication in the June 14th issue of the Journal of Alzheimer's Disease (http://www.j-alz.com).

Provided by North Shore-Long Island Jewish (LIJ) Health System

Tai chi helps prevent falls and improve mental health in the elderly

Tai chi has particular health benefits for older people, including helping to prevent falls and improving mental wellbeing, reveals a review published ahead of print in the British Journal of Sports Medicine.

24 may 2011--But the Chinese martial art widely practised for its health benefits does not help improve the symptoms of cancer or rheumatoid arthritis and the evidence is contradictory for many other health conditions and symptoms.

The effectiveness of t'ai chi for a variety of medical conditions and symptoms has been assessed in several studies and reviews, but their findings have been contradictory, so researchers from Korea Institute of Oriental Medicine in South Korea and the University of Exeter in the UK decided to compare the conclusions of these reviews to gain a better understanding of the benefits of t'ai chi.

Thirty five relevant reviews assessing t'ai chi were identified from English, Chinese and Korean databases. They looked at the effectiveness of the technique in a variety of disease areas, including cancer, Parkinson's disease, musculoskeletal pain, osteoarthritis, rheumatoid arthritis, cardiovascular disease, high blood pressure, osteoporosis and type 2 diabetes. Some reviews also assessed the benefits of t'ai chi for psychological health, balance and fall prevention, muscle strength and flexibility and improving aerobic capacity.

For several conditions, the findings of the reviews were contradictory. However, there was relatively clear evidence that t'ai chi is effective for fall prevention and improving psychological health and was associated with general health benefits for older people. On the other hand, t'ai chi seemed to be ineffective for the symptomatic treatment of cancer and rheumatoid arthritis.

The authors conclude: "Our overview showed that t'ai chi, which combines deep breathing and relaxation with slow and gentle movements, may exert exercise-based general benefits for fall prevention and improvement of balance in older people as well as some meditative effects for improving psychological health. We recommend t'ai chi for older people for its various physical and psychological benefits. However, t'ai chi may not effectively treat inflammatory diseases. "

Provided by British Medical Journal

Diabetes guidelines linked to severe low blood sugar in frail elderly

When an independent senior health program implemented new recommended diabetes blood sugar guidelines, episodes of severe hypoglycemia (low blood sugar) tripled among frail elderly patients, according to a study led by Sei J. Lee, MD, a geriatrician at the San Francisco VA Medical Center.

23 may 2011--The study, which was published in the April 2011 issue of the Journal of the American Geriatrics Society, was the first to measure what happened when the guidelines, developed in 2003 by the American Geriatrics Society, were implemented among frail elders, said Lee. The study focused on outcomes at On Lok Senior Health, in San Francisco.

The guidelines call for a hemoglobin A1c level of less than 8 percent. The hemoglobin A1c test, which measures average blood sugar over the previous three months before the test, is considered an indicator of long-term blood sugar control for diabetics.

The long-term goal of such guidelines is the avoidance of vascular complications — including heart attack, stroke, and kidney disease — that are brought about by chronically high blood sugar, which damages circulation in small blood vessels. In order to accomplish this goal, blood sugar is monitored frequently during the day, and kept relatively low through diet, medications, and insulin injections — a regimen known as tight control.

When the frail elders were put on tight control, reported Lee, “there was good news and bad news.” The good news, he said, was that the incidence of hyperglycemia — blood sugar higher than 400 — decreased dramatically compared to pre-guideline levels.

At the same time, episodes of severe hypoglycemia — blood sugars of less than 50 that required trips to the emergency room — increased threefold. “These episodes were quite dangerous for these seniors,” said Lee. “When blood sugar gets too low, patients can become confused, they can fall, they can even become comatose. It can become life-threatening very quickly.”

Significantly, the increase in hypoglycemic episodes occurred during the first 18 months of the guidelines’ implementation; for the two years after that, the rate was similar to what it was before the guidelines were introduced. One possible explanation, according to the authors, is that a small number of patients are especially at risk of severe hypoglycemia in response to even a modest tightening of control. Once those patients have a severe hypoglycemic episode and are identified, the rest are treated successfully with the aggressive regimen.

“This says that the period when you are first implementing tighter control is the time of greatest risk,” said Lee. “That is the time to require closer follow-up of patients in order to make sure that these adverse effects are not occurring.”

Lee noted that the study took place under “ideal conditions” for implementing tight control with a minimum of bad outcomes: “This is a program where patients are seen several times a week, and where health care providers know exactly what medications they are taking, what and how much they’re eating, and how much physical activity they’re getting.”

If the occurrence of severe hypoglycemia increased even under these circumstances, said Lee, “then for the general population of the frail elderly, who are not monitored nearly as closely as our study population, the current guideline may be too aggressive.”

More information: http://onlinelibra … 03362.x/full

Provided by University of California, San Francisco

Early-onset Alzheimer's not always associated with memory loss

22 may 2011-- In a recent study published in the journal Neurology, scientists say that individuals who develop early-onset Alzheimer's in middle age are at a high risk of being misdiagnosed because many of their initial symptoms are not memory related.

Scientists, led by Dr. Albert Llado from the Hospital Clinic of Barcelona, examined the brain tissue from 40 patients who had suffered from early-onset Alzheimer’s disease. Of these 40 patients, 15 had not shown any of the typical signs of memory loss. The patients had displayed language disturbances, vision problems and behavioral changes. Out of these 15 patients, 53 percent had been misdiagnosed with neurological disorders and other forms of dementia, with 47 percent still having the incorrect diagnosis at their time of death. Of the patients that did show signs of memory loss, only four percent had been misdiagnosed at the beginning.

Early-onset Alzheimer’s usually hits patients between the ages of 40 and 60, and this study stresses the importance in recognizing that memory loss is not always an initial symptom. While there is currently no cure for Alzheimer’s, there is medication and behavioral treatment designed to delay the progression of the disease. In all 40 patients in the study, there was a delay of almost three years before a diagnosis was given, even in those with memory issues. The scientists believe this is because most physicians do not look for dementia and Alzheimer’s in patients in this age group.

The Alzheimer’s Association reports that 5.4 million Americans currently have Alzheimer’s and of this number 200,000 of them are between the ages of 40 - 65.

More information: Clinical features and APOE genotype of pathologically proven early-onset Alzheimer disease, Neurology May 17, 2011 vol. 76 no. 20 1720-1725. doi:10.1212/WNL.0b013e31821a44dd

Abstract

Objectives: Early-onset Alzheimer disease (EOAD) diagnosis often represents a challenge because of the high frequency of atypical presentations. Our aim was to describe the clinical features, APOE genotype, and its pathologic correlations of neuropathologic confirmed EOAD.

Methods: Retrospective review of clinical data (age at onset, family history, clinical presentation, diagnostic delay, diagnosis) and APOE genotype of patients with neuropathologically confirmed EOAD (<60 years).

Results: Forty cases were selected. Mean age at onset was 54.5 years (range 46–60). The mean disease duration was 11 years with a mean diagnostic delay of 3.1 years. A total of 37.5% had a nonmemory presentation. Behavioral/executive dysfunction was the most prevalent atypical presentation. Incorrect initial clinical diagnoses were common (53%) in patients with atypical presentations, but rare when anterograde amnesia was the presenting symptom (4%). The incorrect initial clinical diagnoses were 2 behavioral variant frontotemporal lobar degeneration, 2 normal pressure hydrocephalus, 1 semantic dementia, 1 primary progressive aphasia, 1 corticobasal degeneration, 1 pseudodementia with depression, and 1 unclassifiable dementia. APOE genotype was ϵ3/ϵ3 in 59%, with no significant differences between typical and atypical presentations. APOE ϵ4 was 3.3 times more frequent in subjects with family history of AD. A total of 97.5% of the cases presented advanced neurofibrillary pathology. A total of 45% of the patients had concomitant Lewy body pathology although localized in most cases and without a significant clinical correlate.

Conclusion: One third of patients with pathologic confirmed EOAD presented with atypical symptoms. Patients with EOAD with nonamnestic presentations often receive incorrect clinical diagnoses.

Raise A1C targets in elderly diabetics: study

NEW YORK 21 may 2011--- In older diabetics, the hemoglobin A1C level should be maintained below 8.0% but generally not below 6.0%, researchers advise.

In an April 19th online paper in Diabetes Care, Dr. Elbert S. Huang of the University of Chicago and colleagues cite evidence for a U-shaped relationship between mortality and A1C levels.

Medical organizations don't agree on suitable targets in the elderly, they say.

"For clinicians and older patients living with diabetes, I believe the study emphasizes the importance of working together to select the optimal glucose control target for the individual patient. We hope that the information contained within the study can serve as a basis for that discussion," Dr. Elbert S. Huang told Reuters Health by email.

Dr. Huang and his group retrospectively studied more than 71,000 patients over 60 years old with type 2 diabetes, using data from Kaiser Permanente Northern California for the years 2004- 2008.

The average age was 71 and the mean A1C level was 7.0%. The risk of non-fatal complications rose when A1C climbed above 6.0%. Adjusted hazard ratios were 1.09 for an A1C of 6.0 to 6.9%, and 1.86 for an A1C of 11.0% or more.

As recognized before, mortality had a U-shaped relationship with A1C. Compared to levels below 6.0%, levels between 5% and 9% were linked with lower rates of death.

After adjustment for other variables, the lower mortality risk with A1C levels between 8.0% and 8.9% was no longer significant. The hazard ratio for levels of 7.0 to 7.9% was 0.83, but 1.31 at levels of 11.0% and beyond.

Risks of complications or death became significantly higher at AICs of 8.0% or more. These patterns were generally similar across age groups ranging from 60 to more than 80 years.

Dr. Huang thinks the results will help to refine suitable targeting. Also, he said, "I think that the study findings on mortality call out for more research to understand why near normal blood sugars have a link to mortality."

SOURCE: http://bit.ly/jpDvnR

Diabetes Care 2011.

Driving errors increase with age among older drivers

Even healthy adults with a safe driving record tend to make more driving errors as they age, including potentially dangerous mistakes, such as failing to check blind spots, according to a study published by the American Psychological Association.

20 may 2011--Most studies of older drivers have focused on people with dementia or other conditions that might impair their performance behind the wheel. This study, conducted in Australia, comprised 266 volunteers age 70 to 88 who showed no signs of dementia, lived independently and drove at least once a week. The results could have implications for skill-based driving tests and training for older drivers, along with the design of roads, signs and vehicles, the researchers said. The study was published online in the APA journal Neuropsychology.

"We wanted to develop evidence-based measures for detecting unsafe older drivers and show how specific cognitive abilities relate to different types of driving errors," said lead researcher Kaarin J. Anstey, PhD, a psychologist who directs the Aging Research Unit at Australian National University. "We hope that policy decisions in this field will be informed by the best possible science."

Normal aging causes various declines in brain functioning and those distinct changes could affect driving skills, including the ability to focus despite distractions on the road, make quick decisions and avoid other vehicles or pedestrians, the study found.

Study participants completed a battery of cognitive tests and questionnaires about their driving history before they drove on a 12-mile route through city and suburban streets in Brisbane. A professional driving instructor rode in the car, which was equipped with an extra brake on the front passenger side for safety. An occupational therapist sat in the back seat and scored the drivers on various errors, including failure to check blind spots, speeding, sudden braking without cause, veering and tailgating.

"All types of driving errors increased with age, and the errors weren't restricted to a small group of unsafe drivers or those with a history of crashes," Anstey said. "It is important to note that there is a large variation in cognitive ability, so some people still have a high level of functioning in later life even if they have suffered some cognitive declines related to normal aging."

While men tend to think they are better drivers, they didn't fare any better on the tests than women, Anstey found. Blind spot errors were the most common mistake, followed by veering across lanes and failure to use turn signals. During the tests, 17 percent of the drivers made critical and potentially hazardous mistakes that required the driving instructor to hit the brake or grab the steering wheel.

The rate of critical errors during the driving test quadrupled from the youngest group, age 70 to 74, which had an average of less than one critical error, to the oldest group, age 85 to 89 with an average of almost four critical errors. There were no crashes during the tests, but participants who had reported an accident during the five years before the study also had a higher rate of critical errors.

Older drivers could remain safe on the roads longer with training on checking blind spots and other driving skills that might decline with aging, Anstey said. The participants had their vision checked before the driving test, but Anstey said more research is needed to determine if visual ability contributed to the high rate of blind spot errors. The study was co-authored by Joanne Wood, PhD, a professor of optometry at Queensland University of Technology.

Despite the study results, Anstey doesn't believe that driver's licenses should be restricted based on age. "In other research, we have shown that age-based restrictions reduce overall driving rates among older adults, but they don't reduce the rate of driving by those with cognitive impairments," she says. "We need evidence-based driver screening tests along with training for older drivers and alternative transportation for those who can no longer drive safely."

Provided by American Psychological Association

Migrants part of solution to growing elderly population: experts

LONDON , 19 may 2011- Rich nations need migrant workers to provide and care for their rapidly aging populations, experts said this week, challenging a wave of hostility towards new arrivals driven by the impact of the economic downturn.

Immigration was a recurring theme of a two-day conference at London's Chatham House on managing graying economies, with speakers from the U.S., Europe and Japan all in favor, despite the social tensions it can cause.

In Europe, for one, antipathy towards foreign workers and asylum seekers has grown in the last few years because of their perceived pressure on scarce jobs and public services.

An influx of immigrants from north Africa this year triggered by upheavals in the region has added to the tension and prompted plans to temporarily restore border controls, eliminated between most EU states under the Schengen treaty.

The experts said turning away young migrants would be short-sighted as their taxes support an increasing number of retirees in developed countries who are living longer.

"You take young migrants who were educated abroad and they are generally net contributors to public finances," said Philippe Legrain, a senior policy analyst at the European Union's executive arm.

Fertility rates in the European Union remain too low to secure future pensions for all EU citizens, a European Commission demographics report showed last month.

Such trends, combined with record budget deficits, have already forced governments across Europe to raise retirement ages despite widespread protests, and many countries, including the United States, are eyeing pension reforms.

Without such reforms, by 2060 the number of people in work for every retired person in the EU is expected to drop from the current level of four to just two, a 2010 report by the European Commission found.

"(A) priority is attracting more migrant workers to improve the dependency ratio, help provide social services and boost economic growth," Legrain told the conference, entitled "Transforming Aging Economies".

Other speakers echoed that view, although some observers said impact on economic growth was negligible.

The arrival of migrants from 10 eastern European countries which joined the EU in 2004 and 2007 has boosted Britain's output by only 0.95%, the National Institute of Economic and Social Research, a think-tank, estimated earlier this month.

But Legrain, the author of "Immigrants: Your Country Needs Them", said demand for migrants would grow because many of them work in health and social care.

"The fastest-growing area of job growth in Europe is not in high tech but in care for the elderly," he said.

Laszlo Andor, a member of the European Commission, said migrants from outside the EU accounted for the bulk of population growth in the bloc.

"Migration remains an important source to rejuvenate the age profile of the European work force and can help bridge anticipated overall labor shortages in the long run," he said.

The European Union was expected to lack between 384,000 and 700,000 information technology (IT) workers by 2015 and between 1 million and 2 million health professionals by 2020. "It is highly unlikely that all these resources would be found within the union," Andor said.

Nicholas Eberstadt, a political economy researcher at the American Enterprise Institute, noted immigration brought with it difficulties, such as problems integrating into host societies.

"Immigration can be part of the solution but I think a rather limited part of the solution," he told the conference.

Legrain noted that migrants' contribution might be limited at first but said it grew over time, citing the examples of Google, EBay, Tesco, EasyJet and Marks and Spencer which were all founded by immigrants or their children.

Referring to the co-founder of Google, he asked: "How many Sergey Brins does Europe turn away and at what cost?"

Coffee may reduce risk of lethal prostate cancer in men

Men who regularly drink coffee appear to have a lower risk of developing a lethal form of prostate cancer, according to a new study led by Harvard School of Public Health (HSPH) researchers. What's more, the lower risk was evident among men who drank either regular or decaffeinated coffee.

18 may 2011--The study will be published May 17, 2011, in an online edition of the Journal of the National Cancer Institute.

"Few studies have specifically studied the association of coffee intake and the risk of lethal prostate cancer, the form of the disease that is the most critical to prevent. Our study is the largest to date to examine whether coffee could lower the risk of lethal prostate cancer," said senior author Lorelei Mucci, associate professor of epidemiology at HSPH. Lethal prostate cancer is cancer that causes death or spreads to the bones.

Prostate cancer is the most frequently diagnosed form of cancer and the second leading cause of cancer death among U.S. men, affecting one in six men during their lifetime. More than 2 million men in the U.S. and 16 million men worldwide are prostate cancer survivors.

"At present we lack an understanding of risk factors that can be changed or controlled to lower the risk of lethal prostate cancer. If our findings are validated, coffee could represent one modifiable factor that may lower the risk of developing the most harmful form of prostate cancer," said lead author Kathryn Wilson, a research fellow in epidemiology at HSPH.

The researchers chose to study coffee because it contains many beneficial compounds that act as antioxidants, reduce inflammation, and regulate insulin, all of which may influence prostate cancer. Coffee has been associated in prior studies with a lower risk of Parkinson's disease, type 2 diabetes, gallstone disease, and liver cancer or cirrhosis.

The study examined the association between coffee consumption and the risk of prostate cancer, particularly the risk for aggressive prostate cancer among 47,911 U.S. men in the Health Professionals Follow-Up Study who reported their coffee consumption every four years from 1986 to 2008. During the study period, 5,035 cases of prostate cancer were reported, including 642 fatal or metastatic cases.

Among the findings:

• Men who consumed the most coffee (six or more cups daily) had nearly a 20% lower risk of developing any form of prostate cancer.
  
• The inverse association with coffee was even stronger for aggressive prostate cancer. Men who drank the most coffee had a 60% lower risk of developing lethal prostate cancer.
  
• The reduction in risk was seen whether the men drank decaffeinated or regular coffee, and does not appear to be due to caffeine.
  
• Even drinking one to three cups of coffee per day was associated with a 30% lower risk of lethal prostate cancer.
  
• Coffee drinkers were more likely to smoke and less likely to exercise, behaviors that may increase advanced prostate cancer risk. These and other lifestyle factors were controlled for in the study and coffee still was associated with a lower risk.

The results from this study need to be validated in additional populations that have a range of coffee exposure and a large number of lethal prostate cancer cases. If confirmed, the data would add to the list of other potential health benefits of coffee. The authors currently are planning additional studies to understand specific mechanisms by which coffee may specifically lower the risk of lethal prostate cancer.

More information: "Coffee Consumption and Prostate Cancer Risk and Progression in the Health Professionals Follow-up Study," Kathryn M. Wilson, Julie L. Kasperzyk, Jennifer R. Stark, Stacey Kenfield, Rob M. van Dam, Meir J. Stampfer, Edward Giovannucci, Lorelei A. Mucci, Journal of the National Cancer Institute, online May 17, 2011.

Provided by Harvard School of Public Health

Getting along with co-workers may prolong life, researchers find

People who have a good peer support system at work may live longer than people who don't have such a support system, according research published by the American Psychological Association.

17 may 2011--This effect of peer social support on the risk of mortality was most pronounced among those between the ages of 38 and 43. Yet similar support from workers' supervisors had no effect on mortality, the researchers found.

In addition, men who felt like they had control and decision authority at work also experienced this "protective effect," according to the study, published in the May issue of the APA journal Health Psychology. However, control and decision authority increased the risk of mortality among women in the sample.

"[P]eer social support, which could represent how well a participant is socially integrated in his or her employment context, is a potent predictor of the risk of all causes of mortality," the researchers wrote. "An additional (unexpected) finding … is that the effect of control on mortality risk was positive for the men but negative for the women."

The researchers rated peer social support as being high if participants reported that their co-workers were helpful in solving problems and that they were friendly. Control and decision authority were rated high if participants said they were able to use their initiative and had opportunities to decide how best to use their skills, and were free to make decisions on how to accomplish the tasks assigned to them and what to do in their jobs.

The researchers, at Tel Aviv University, looked at the medical records of 820 adults who were followed for 20 years, from 1988 to 2008. The workers were drawn from people who had been referred to an HMO's screening center in Israel for routine examinations. (People who were referred because of suspected physical or mental health problems were excluded from the sample). The workers came from some of Israel's largest firms in finance, insurance, public utilities, health care and manufacturing. They reported working on average 8.8 hours a day. One-third of them were women; 80 percent were married with children; and 45 percent had at least 12 years of formal education.

The researchers controlled for the physiological, behavioral and psychological risk factors of total cholesterol, triglycerides, glucose levels, blood pressure, body mass index, alcohol consumption, smoking, depressive symptoms, anxiety and past hospitalizations. They obtained the data on the control variables from each person's periodic health examinations, including tests of physiological risk factors and a questionnaire completed during the examinations by all participants.

In addition, participants were administered another questionnaire that measured job demands, control at work and peer and supervisor support. During the 20-year follow-up period, 53 participants died.

Asked why workplace control was positive for men but not women, the lead researcher, Arie Shirom, PhD, said that for employees in blue-collar type of jobs (and most respondents belonged to this category), high levels of control were found in jobs typically held by men, rather than jobs typically held by women. "Providing partial support to our finding, a past study found that for women in blue-collar jobs, having low levels of control does not increase their risk of becoming ill with stress-related disorders," Shirom said.

One limitation of the study was that the researchers did not have data on changes in workload, control or support during the 20-year period. "Still, we argue that other researchers have consistently found that the job characteristics of workload, control and support tend to be stable across time," Shirom said.

More information: "Work-Based Predictors of Mortality: A 20-Year Follow-Up of Healthy Employees," Arie Shirom, PhD; Sharon Toker, PhD; Yasmin Akkaly, MA; Orit Jacobson, PhD, MA, RN; and Ran Balicer, PhD, MD; Tel Aviv University, Health Psychology, Vol. 30, No. 3. http://www.apa.org … 30-3-268.pdf

Provided by American Psychological Association

Obesity linked to higher risk of prostate cancer progression

Even when treated with hormone therapy to suppress tumor growth, obese men face an elevated risk of their prostate cancer worsening, researchers at Duke University Medical Center have found.

16 may 2011--The research, reported at the American Urological Association annual meeting Sunday (May 15, 2011), advances the link between obesity and prostate cancer, which has generated research interest in recent years as the incidence of both conditions remains high and often overlaps.

"Over the past decades, there has been increasing prevalence of obesity in the U.S. and Europe, and a high rate of prostate cancer that is the second-most lethal cancer for men," said Christopher J. Keto, M.D., a urologic fellow at Duke University Medical Center and lead author of the study.

An estimated one in six U.S. men will be diagnosed with prostate cancer during his lifetime, according to the American Cancer Society; additionally, one in three U.S. men are obese.

To examine the role obesity may play in prostate cancer, Keto and colleagues at Duke identified 287 men whose diseased prostates had been removed at five U.S. Department of Veteran Affairs hospitals from 1988-2009.

Because their cancers had reappeared, the men had also been given androgen deprivation therapy (ADT). The chemical inhibits production of the male hormone testosterone, which fuels prostate tumors.

Men in the study group who were overweight or obese had a three-fold increased risk of cancer progression compared to normal-weight men, despite receiving the same treatment.

Additionally, overweight men had more than a three-fold increased risk of their cancer spreading to the bone compared to normal-weight men, while obese men had a five-fold increase in the risk of metastases.

Keto said additional studies are needed to determine why heavy men fare worse than normal-weight men, even when treated similarly. One area of scrutiny may be the dosage of ADT.

"We think perhaps obese men may require additional ADT," Keto said. "The dose is the same regardless of weight, while most drugs are dosed according to weight."

Stephen J. Freedland, M.D., associate professor of urology in the Duke Prostate Cancer Center and senior author of the study, said the findings build upon the Duke group's broader research efforts into the connection between obesity and prostate cancer.

"By being thematic in our research we can really get to the bottom of something," Freedland said. "The study supports a growing body of literature showing that obese men with prostate cancer do worse. Our next step is to figure out why."

Freedland said knowing that heavy men are at higher risk for bad outcomes could lead to better interventions. He said the Duke group has launched a new trial to test the effects of diet and exercise on overweight and obese men whose prostate cancer treatment includes hormone therapy.

"If obesity is bad for prostate cancer, we may have to be more aggressive in our treatment," he said. "Ultimately, we aim to learn why, which in turn can lead us to better treatments for these men."

Provided by Duke University Medical Center

Restricting calories lowers body temperature, may predict longer lifespan

15 may 2011-- Nutrition and longevity researchers have found more evidence that eating less may help people live longer.

The research team at Washington University School of Medicine in St. Louis reports in the journal Aging that individuals who significantly reduce their calorie intake have lower core body temperatures compared to those who eat more.

The new finding matches research in animals. Mice and rats consuming fewer calories also have lower core body temperatures, and those animals live significantly longer than littermates eating a standard diet.

The investigators compared core body temperatures of 24 people in their mid 50s who had practiced calorie restriction for at least six years to 24 others of the same age who ate a standard Western diet with higher calorie and fat intake. The researchers also measured core body temperatures in 24 endurance runners of the same age to determine if being lean — like both the calorie restriction group and the runners — was linked to lower body temperature or whether calorie restriction itself was necessary.

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“The people doing calorie restriction had a lower average core body temperature by about 0.2 degrees Celsius, which sounds like a modest reduction but is statistically significant and similar to the reduction we have observed in long-lived, calorie-restricted mice,” says principal investigator Luigi Fontana, MD, PhD. “What is interesting about that is endurance athletes, who are the same age and are equally lean, don’t have similar reductions in body temperature.”

Organisms from yeast to rodents to humans all benefit from cutting calories. In simple organisms, restricting calories can double or even triple lifespan. It’s not yet clear just how much longer calorie restriction might help humans live, but those who practice the strict diet hope to survive past 100.

Those on calorie restriction cut their daily caloric intake by 25 percent or more, but they also carefully track vitamins and nutrients in the diet in order to avoid malnutrition. In this study, all of those in the group practicing calorie restriction were members of the CR Society, and they refer to themselves as CRONies (Calorie Restriction with Optimal Nutrition).

A person’s core body temperature is the temperature at which all of the functions in the body can operate with maximum efficiency. The temperature of the human body is not uniform throughout, and internal readings tend to be higher than those taken closer to the skin. Although the ideal core body temperature is considered to be 98.6 degrees Fahrenheit or 37.7 degrees Celsius, body temperatures vary from about 96 degrees to almost 100 degrees.

For this study, investigators measured core body temperature using telemetric capsules that participants swallowed, which then recorded and transmitted internal body temperatures every minute.

Fontana, a research associate professor of medicine at Washington University and a senior investigator at the Istituto Superiore di Sanità in Rome, Italy, says he does not know whether severely limiting calories is lowering body temperatures or whether something else is causing core temperature to drop, but he says the reduced temperature is a key to increased longevity in animals.

“What we don’t know is whether there is a cause/effect relationship or whether this is just an association,” he says. “But in animal studies, it’s been consistently true that those with lower core body temperatures live longer.”

The researchers also note that in an unrelated study called the Baltimore Longitudinal Study of Aging, scientists found that men who had lower core body temperatures, probably for genetic reasons, lived significantly longer than men with higher body temperatures. So it appears body temperature may predict longevity in humans, too, Fontana says.

What is not yet understood is how much longer people with lower body temperatures might live. Rodents on a calorie-restricted diet have been known to live up to 50 percent longer, but those increases can be measured in months.

For now, animal models suggest that simply lowering body temperature isn’t enough to increase lifespan. In mice and rats that regularly swam in cold water, core body temperature dropped due to exposure to the cold water. But those animals didn’t live any longer than normal rodents. Fontana says it appears that how lower temperatures are achieved is important.

“I don’t think it ever will be possible to be overweight and smoking and drinking and then take a pill, or several pills, to lower body temperature and lengthen lifespan,” he says. “What may be possible, however, is to do mild calorie restriction, to eat a very good diet, get mild exercise and then take a drug of some kind that could provide benefits similar to those seen in severe calorie restriction.”

More information: Soare A, Cangemi R, Omedei D, Holloszy JO, Fontana L. Long-term calorie restriction, but not endurance exercise, lowers core body temperature in humans. Aging, vol. 3 (3) March 2011. http://www.impactaging.com

Provided by Washington University School of Medicine in St. Louis

Brazil's health care system vastly expands coverage, but universality, equity remain elusive

Two decades after Brazil's constitution recognized health as a citizen's right and a duty of the state, the country has vastly expanded health care coverage, improved the population's health, and reduced many health inequalities, but universal and equitable coverage remains elusive, experts from four major Brazilian universities and New York University have concluded.

13 may 2011--According to their analysis—one of six articles published in the medical journal The Lancet as a special series on health in Brazil—while federal expenditures have nearly quadrupled over the past 10 years, the health sectors' share in the federal budget has not grown, resulting in constraints on health care financing, infrastructure, and human resources.

The paper's co-authors were: Jairnilson Paim of the Federal University of Bahia; Claudia Travassos of Center for Communication, Scientific Information and Technology at the Oswaldo Cuz Foundation; Celia Almeida of the National School of Public Health, Oswaldo Cruz Foundation; Ligia Bahia of the Federal University of Rio de Janeiro; and James Macinko, an associate professor at New York University's Steinhardt School of Culture, Education, and Human Development.

After more than 20 years of a military dictatorship, Brazil created its present constitution in 1988, which included health as a right of citizenship. Health care reform in Brazil, then, occurred under unique circumstances--simultaneously with the process of democratization and spear-headed by health professionals along with civil society movements and organizations.

To meet this constitutional guarantee, the country established the Unified Health System, or Sistema Único de Saúde (SUS), which was based on the principles of universality, equity, integrality, and social participation. The SUS, which serves more than 192 million citizens, is supplemented by private insurers, which cover about 25 percent of Brazilians.

Overall, the Brazilian health system is made up of a complex network of complementary and competitive service providers and purchasers, forming a public–private mix that is financed mainly by private funds.

During the past two decades, the researchers noted, the SUS has undergone significant changes. Among these were granting municipalities greater responsibility for health service management, along with the flexibility and means which to bring about social participation in health policy making and accountability.

In the Lancet study, the researchers found vastly increased access to health care for a substantial proportion of the Brazilian population. In 2009 alone, the SUS financed about 12 million hospitalizations, delivered nearly 100 million ambulatory care procedures per month, and reached universal coverage of vaccination and prenatal care. It also expanded the supply of related human resources and technology, including enhanced production to meet most of the country's pharmaceutical needs.

But the researchers also observed that "the SUS is a health system under continual development that is still struggling to enable universal and equitable coverage."

"As the private sector's market share increases, interaction between the public and private sectors are creating contradictions and unfair competition, leading to conflicting ideologies and goals—notably, universal access vs. market segmentation," they wrote. "All of this has a negative effect on the equity of health-care access and outcomes."

Further complicating the nation's goal of universal coverage are constraints on federal funding. While federal expenditures have increased nearly four times over the past 10 years, they added, the health sectors' share in the federal budget has not grown, producing constraints on financing, infrastructure, and human resources.

"The development of the Brazilian health system reflects the uneven process of social, economic, and political development within the country," the researchers wrote. "Ultimately, to overcome the challenges that Brazil's health system faces, a revised financial structure and a thorough reassessment of public-private relations will be needed. Therefore, the greatest challenge facing the SUS is political. Such issues as financing, composition of the public–private mix, and the persistent inequities cannot be solved in the technical sphere only."

Provided by New York University

Results from study of 8,000 older people in Ireland launched

The first results from The Irish Longitudinal Study on Ageing (TILDA), a national study of 8,000 older people aged 50 and over in Ireland, were launched this week by the Minister for Health and Children, Dr James Reilly.

12 may 2011--TILDA is the most comprehensive study ever conducted on ageing in Ireland. Between 2009- 2011, over 8,000 people aged 50 and over were randomly selected across the country and interviewed about many aspects of their lives including issues such as health, financial circumstances and quality of life. Almost 85 per cent of the participants also underwent a rigorous health assessment. The same group will be interviewed every two years until 2018. Further health assessments will be undertaken on the participants in 2014 and 2018. This report, Fifty Plus in Ireland 2011: First Results from the Irish Longitudinal Study on Ageing, contains initial findings from the study. TILDA is funded by the Department of Health and Children, Irish Life and The Atlantic Philanthropies.

Commenting on the significance of the study, Principal Investigator of TILDA and Professor of Medical Gerontology, Professor Rose Anne Kenny said: "The importance of this study cannot be understated. By collecting and analysing this data, we will be able to develop a much deeper understanding of the lives and circumstances of older people and of the factors which lead to good health and good quality of life in older ages. This will mean that Ireland will be better placed to plan for the ageing of our population and to help policy makers ensure that limited resources are correctly targeted to those in need. TILDA provides exciting opportunities for Research and Development and new models of service delivery to create employment in this rapidly developing demographic. We are deeply grateful to our participants. Because of their generosity in taking the time to provide us with this crucial information, Ireland now and in the future will greatly benefit."

When launching the report, the Minister said that the Study's high quality objective and subjective measurements of health coupled with its longitudinal design "will provide a truly unique knowledge base that will inform policies for older people in the years ahead."

The findings in the report cover many topics and show that there is considerable diversity across older adults in terms of the various dimensions of their lives. A selection of findings is highlighted below.

When the participants were asked about their quality of life, the following emerged.

• The 50+s report that they derive considerable enjoyment from life. Eighty-five per cent report that they often enjoy the things they do, while 81 per cent often look forward to each day. Over 80 per cent feel that life is full of opportunities.

The report also shows how this group contributes significantly to their families and communities, in terms of both money and time. Specific examples of this are as follows:

• Over one third of people aged 50 and over provide practical household help including shopping and household chores to their children who are not living with them and nearly half provide care to grandchildren.
  
• Over one quarter of 50+ households report giving a financial or material gift worth €5,000 or more to their children within the last ten years.
  
• Over a quarter of 50+s do voluntary work at least once or twice a month.

The report shows the extent to which health declines across age groups and two examples of this are as follows:

• Seventy nine per cent of those aged between 50 and 64 say that their health is excellent, very good or good but this falls to 66 per cent for people aged 75 and older.
  
• The proportion of people with high blood pressure increases from 29.7 per cent for those aged 50- 64 years to 53.7 per cent for those aged 75 and over.

A constant finding across the report is that those with higher levels of education and wealth are likely to enjoy better outcomes later in life. Examples include the following:

• For men aged 50-64, 53 per cent with primary education are employed. This rises to 70 per cent for those with third level education. For women aged 50-64, 28 per cent with primary education are employed. Among the third level group, 62 per cent are employed.
  
• We find that individuals with a primary education report substantially higher levels of chronic lung disease (5.5 per cent) compared to individuals with second or third level education (3.6 per cent and 2.7 per cent respectively). Similarly, older adults in the lowest wealth quartile report almost three times the rate of chronic lung disease compared to older adults in the highest wealth quartile (6.5 per cent versus 2.5 per cent).

Among other findings are the following:

• On the issue of mental health, we find that 10 per cent of respondents reported clinically significant depressive symptoms while a further 18 per cent reported 'sub-threshold' depression.
  
• On incomes, we find that state transfers are the only source of income for a high proportion of less educated older people. For those in the lowest education group, around 40 per cent of people aged 50-64 have no other source of income and this rises to 53 per cent for those aged 75 and over.
  
• With regard to the use of health care services, we find that among older people in poor health, attendance at either GP clinics or emergency rooms is lower for those without medical cards or private cover thereby raising concerns about diagnosis and treatment deficits for this group.
  
• People with disabilities receive an average of 118 hours of help per month. As the most common primary helper for this group is the care recipient's spouse, this translates into extensive inputs by older adults into the care of other older adults.
  
• Amongst women at work, 41 per cent are not covered by an occupational, PRSA or private pension scheme compared to 20 per cent of men. Pension coverage also varies significantly by socioeconomic group.

More information: Executive summary, full report and chapter-by-chapter versions can be found at http://www.tcd.ie/ … ublications/

Provided by Trinity College Dublin

Evidence insufficient on relationship of modifiable factors with risk of Alzheimer's disease

The available evidence is insufficient to draw firm conclusions about the association of modifiable factors and risk of Alzheimer's disease (AD), according to a report posted online today that will appear in the September issue of Archives of Neurology.

11 may 2011--Estimates suggest that up to 5.3 million people in this country may have AD, and this number will likely increase as baby boomers grow older. In fact, "age is currently the strongest known risk factor for AD," write the authors. Variation in the apolipoprotein E (APOE) gene is also associated with the risk of developing AD. However, existing research to ascertain other risk factors for the condition has been less conclusive.

From April 26 to 28, 2010, the National Institutes of Health convened a State-of-the-Science Conference to examine studies of potential AD risk factors and possible preventive measures. The conference evaluated existing English-language research found in MEDLINE and the Cochrane Database of Systematic Reviews from 1984 through October 27, 2009, as well as a formal evidence report. Topics considered were nutritional supplements and dietary factors, physical activity, other chronic conditions (diabetes, high cholesterol, high blood pressure), substance use (cigarettes, alcohol), and cognitive engagement. Panelists weighed the level of evidence for each risk factor (low, moderate or high) and rated studies accordingly (low for observational studies vs. high for randomized controlled trials).

Martha L. Daviglus, M.D., Ph.D., from Northwestern University Feinberg School of Medicine, Chicago, and colleagues summarized the panel's findings. The group determined "that currently there is no evidence of even moderate scientific quality supporting the association of any modifiable factor with reduced risk of cognitive decline or AD." While some studies appeared to show an increase or reduction of AD risk or progression, they were not strong enough to draw firm conclusions. The authors call for large-scale, long-term, population-based studies and clinical trials to answer these questions. "It is hoped that the panel's report will instigate rigorous high-quality research that can provide conclusive evidence on this issue," they write. "Until more conclusive results are available, individuals should continue to aim for a physically and mentally active and healthy lifestyle and prevention of the well-known major risk factors for chronic diseases."

More information: Arch Neurol. 2011;doi:10.1001/archneurol.2011/100

Provided by JAMA and Archives Journals

Study of health in Brazil highlights major progress

Major progress has been made in reducing the burden of infectious diseases in Brazil as part of a "remarkable" success story for health in the South American country, according to researchers on a series of papers published in The Lancet.

10 may 2011--After decades of marked social change, including the introduction of unified healthcare for all, Brazil can also celebrate a reduction in mortality from chronic diseases and huge inroads into improving maternal and child health. But the nation still faces problems – including some infectious diseases such as dengue and leishmaniasis, rising obesity and a high number of murders and road deaths.

The Lancet's Series on Health in Brazil takes a comprehensive look at the consequences of changes in Brazil such as the creation of the Unified Health System (Sistema Unico de Saude/SUS) in 1988 which marked a crucial turning point. Key improvements in infrastructure have also been made over the past few decades – for example, in 1970 only a third of homes had indoor water compared with 93% by 2007. Edited by leading child health epidemiologist Professor Cesar Victora, of the Universidade Federal de Pelotas, Brazil, who is an honorary professor at the London School of Hygiene & Tropical Medicine, the Series issues a call for coordinated action to continue improving and concludes by saying: "The challenge is ultimately political, requiring continuous engagement by Brazilian society as a whole to secure the right to health for all Brazilian people."

Professor Laura Rodrigues, who was born and trained in Brazil but has worked at the London School of Hygiene & Tropical Medicine since 1981, co-authored one of the six papers in the series. The infectious disease epidemiologist and Head of the Faculty of Epidemiology and Population Health said that although deaths by external causes remain too high, the situation in Brazil overall is a "remarkable success".

"Brazil is changing and this Series explores the stories behind the changes," she says. "It looks at the links between political and economic development and healthcare, and shows that changes in those areas have had a clear impact on the health and wellbeing of Brazil's population. The overall picture in Brazil is a remarkable success.

"There is a lot to be learned from this Series - in particular in the context of Brazil's position in the world and attitudes to national healthcare. We are seeing a significant rearrangement of countries' positions in global terms."

In their paper – studying successes and failures in the control of infectious diseases -
Professor Mauricio Barreto, of the Instituto de Saúde Coletiva and Federal University of Bahia, Salvador-Bahia, Brazil (an LSHTM alumnus), and colleagues including Prof Rodrigues examine why some programmes have worked and others have not.

Control of diseases such as cholera, diarrhoea, Chagas disease, and those preventable by vaccination such as tetanus and polio have all been successful, having each provided universal access to preventable measures and to treatment free at the point of use. According to the paper, these policies need to be reinforced due to challenges such as increasing prevalence and transmission of drug resistance.

They describe the HIV/AIDS plan, which is the largest distributor of free antiretrovirals in the world, as a partly successful programme ( although no less successful than in most developed countries) and point out that tuberculosis control has also improved, partly due to increased HIV control and also specific roll out of treatment programmes, especially those offering directly supervised treatment.

But a small number of failures are noted. Dengue fever is a new public health problem, with some 3.5 million cases reported in the past decade, with 12,000 leading to the more serious dengue haemorrhagic fever, and some 900 deaths. Rates of the most serious forms of Dengue are six times what they were in the 1990s with no safe vaccine available.

Visceral leishmaniasis control is also poor, with current efforts focusing on control of the sandfly vectors and removing domestic animals that can act as reservoirs. The only available treatment currently is highly toxic and while accessible and suitable in urban areas with medical support, this toxicity makes treatment in remote rural areas inappropriate.

The authors conclude: "A pressing need exists to develop new treatments and vaccines for those diseases which have proved difficult to control. In Brazil, biomedical and epidemiological research is thriving, as is public health research into infectious diseases, with much collaboration with developing and developed countries...the fast growth in medical research must be sustained—efforts must go towards identification of new treatments (eg, for leishmaniasis) new vaccines (eg, for dengue) and more effective ways to deliver specific care."

In a Comment for the Series, Ricardo Uauy, Professor of Public Health Nutrition at the London School of Hygiene & Tropical Medicine, says Brazil's "sense of national purpose and pride provides the strength with which the country collectively addressed the challenge of better health for all".

Exploring the impact of the Brazil experience in Latin America, he argues that Brazil turned traditional thinking that countries should first achieve economic growth before spending on social programmes on its head. "Brazil showed the opposite – ie, you need to invest in human and social capital to achieve and sustain economic growth," he writes. "In Brazil those who were intolerant to business as usual were responsible for making injustices a thing of the past; and for placing progress towards a better world at the top of the priority list. Brazil has given us a reason to be proud of our profession in this ever-changing environment."

Provided by London School of Hygiene & Tropical Medicine

Severe Vitamin D Deficiency Tied to Mortality in Diabetes

Vitamin D is not associated with microvascular complications in patients with type 1 diabetes

09 may 2011-- Severe vitamin D deficiency may be predictive of increased all-cause mortality in patients with type 1 diabetes, but it is not associated with microvascular complications in the kidney or eye, according to a study published online April 27 in Diabetes Care.

Christel Joergensen, M.D., from the Steno Diabetes Center in Gentofte, Denmark, and colleagues assessed the role of vitamin D as a predictor for all-cause mortality, and the development of microvascular complications in the kidney and eye in 220 patients with newly diagnosed type 1 diabetes. Plasma vitamin D levels were determined using high-performance liquid chromatography/tandem mass spectrometry before patients developed microalbuminuria. Severe vitamin D deficiency was considered equal to or below the 10th percentile (15.5 mmol/L).

The investigators found that 44 patients died during a 26-year median follow-up period. After adjusting for confounders, the hazard ratio for all-cause mortality in individuals with severe vitamin D deficiency was 2.7. Eighty-one patients (37 percent) developed microalbuminuria, and 27 (12 percent) of these progressed to macroalbuminuria. Background retinopathy developed in 192 patients (87 percent), and progression to proliferative retinopathy was seen in 34 individuals (15 percent). The presence of severe vitamin D deficiency at baseline did not predict the development of retinopathy or the progression from normoalbuminuria to micro- or macroalbuminuria.

"In patients with type 1 diabetes, severe vitamin D deficiency independently predicts all-cause mortality but not the development of microvascular complications in the eye and kidney," the authors write.

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Editorial

Before you start bone-building meds, try dietary calcium and supplements: study

Has a bone density scan placed you at risk for osteoporosis, leading your doctor to prescribe a widely advertised bone-building medication? Not so fast! A University of Illinois study finds that an effective first course of action is increasing dietary calcium and vitamin D or taking calcium and vitamin D supplements.

09 may 2011--"For many people, prescription bone-building medicines should be a last resort," said Karen Chapman-Novakofski, a U of I professor of nutrition and co-author of a literature review published in a recent issue of Nutrients.

The study reported that adults who increase their intake of calcium and vitamin D usually increase bone mineral density and reduce the risk for hip fracture significantly. These results were often accomplished through supplements, but food is also a good source of these nutrients, she said.

"I suspect that many doctors reach for their prescription pads because they believe it's unlikely that people will change their diets," she noted.

The scientist said that prescription bone-building medications are expensive, and many have side effects, including ironically an increase in hip fractures and jaw necrosis. They should be used only if diet and supplements don't do the trick.

"Bisphosphonates, for instance, disrupt normal bone remodeling by shutting down the osteoclasts—the cells that break down old bone to make new bone. When that happens, new bone is built on top of old bone. Yes, your bone density is higher, but the bone's not always structurally sound," she said.

A bone density test measures quantity, not quality, of bone. "Although the test reports that you're fine or doing better, you may still be at risk for a fracture," said Chapman-Novakofski.

A woman in midlife can get enough calcium in her diet without gaining weight, said lead author Karen Plawecki, director of the U of I's dietetics program.

"Menopausal women should consume 1,200 milligrams of calcium a day. Three glasses of 1 percent to skim milk will get you up to 900 milligrams. The rest can easily be obtained through calcium-rich and calcium-fortified foods," Plawecki said.

According to Plawecki, the number of foods fortified with calcium and vitamin D is increasing exponentially. Examples are soy milk, orange juice, yogurt, crackers, cereal, bread, breakfast bars, and even pancakes.

The researchers also looked at the effects of dietary protein, vitamin K, soy, and sodium in their literature review. The new USDA food pyramid guidelines recommend that Americans decrease their sodium intake.

"Following a low-sodium diet does seem to have a positive effect on bone density. Some people have the habit of adding a generous sprinkle of salt to most foods before eating, but there's more involved here than learning not to do that. You have to choose different foods," Plawecki said.

Smoked or processed meats, bacon, lunch meat, and processed foods all contain a lot of sodium and could sabotage bone health. "Cheese is also very high in sodium so try to get your calcium some other way more often," Plawecki said.

She recommends a "portfolio diet" that contains a number of nutrients, not just extra calcium and vitamin D. For bone health, the researchers also encourage consuming adequate protein, less sodium, and more magnesium and potassium.

"That can be done by following a diet that's high in fruits and vegetables, has adequate calcium and protein, and is light on salt," she said.

Chapman-Novakofski noted that the National Osteoporosis Foundation recommends more physical activity. She suggests a combination of aerobic, strength, balance, and flexibility exercises with a focus on improving your core muscles so you can catch yourself if you start to fall.

Whatever sort of exercise you're doing, you have to introduce new forms of activity every so often because your bones will stop responding to the same old routine and rebuilding will slow, she said.

Plawecki and Chapman-Novakofski set out to determine the impact of dietary, supplemental, and educational interventions over the last 10 years and reached their conclusions after reviewing 219 articles in scientific journals.

More information: For more information, visit their website about osteoporosis at http://urbanext.il … steoporosis/

Provided by University of Illinois at Urbana-Champaign

Families need to know more about feeding tubes for elderly dementia patients

Despite evidence that feeding tubes do not improve survival rates or quality of life for elderly patients with advanced dementia, their frequency of use varies widely across the states. A new survey of family members finds that discussions surrounding the decision to place feeding tubes surgically are often inadequate.

06 may 2011--Advanced dementia is a terminal illness that often affects a patient's ability to eat. In prior research, Joan Teno, professor of community health at Brown University, has documented a striking variation in feeding tube insertion rates.

To gain insight into the decision process and how it is informed by doctors, Teno and colleagues led a five-state survey regarding feeding tube insertion with family members of elderly patients who had advanced dementia. The results, published online in advance by the Journal of the American Geriatrics Society, will appear in the May 13 print issue.

"Our results suggest that in these states with a high rate of feeding tube insertion we need to improve decision making so that the decision to insert a feeding tube is based on a process that elicits and respects patient's wishes," said Teno, the paper's lead author.

Among the study's key findings:

• 13.7 percent of family members who said their family member received a feeding tube stated that medical providers inserted the tube without discussing it first;
  
• 11.2 percent said they felt pressured by the physician to put in a feeding tube;
  
• 38.2 percent believed that that physician was strongly in favor of feeding tube insertion;
  
• 41.6 percent of the time the discussion regarding feeding tube insertion lasted less than 15 minutes;
  
• 39.3 percent did not discuss the risks of feeding tubes.

The study sample size was 486 people in five states, mostly sons and daughters who were either the persons named in an advance directive or were the person identified as the surrogate decision maker for a patient with advanced dementia. Teno led a group of researchers from Brown, the Hebrew Senior Life Institute for Aging Research in Massachusetts, and the University of Texas Southwestern Medical Center in asking people to describe the communication they had with physicians surrounding whether to insert a feeding tube for their loved ones.

The five states were selected because they had especially high (Texas, Alabama, and Florida) or very low (Massachusetts and Minnesota) rates of intubation. Extrapolating the survey group to the entire population of the five states, much like public opinion polls do, the figures would represent 9,652 cases of elderly patients with eating problems while dying from advanced dementia.

Some satisfaction

Despite research studies that question the value of feeding tubes, 32.9 percent of people in the survey said the feeding tube did improve quality of life for their loved ones. That was more than the 23.4 percent who said they regretted using a tube.

Teno cautioned against becoming complacent about the level of satisfaction family members recall, especially after dialogues that sometimes lack all elements necessary for fully informed consent.

"I watch people who make decisions that are really difficult," she said. "To continue on they have to make peace with their decisions."

Provided by Brown University

Age alone should be used to screen for heart attacks and strokes, say experts

Using age alone to identify those at risk of heart disease or stroke could replace current screening methods without diminishing effectiveness, according to a groundbreaking study published today in the open access journal PLoS ONE.

05 may 2011--Existing screening methods which include measuring cholesterol and blood pressure are expensive and time consuming. The authors of the new study from Barts and The London Medical School say that this finding could save thousands of lives by making it easier for more people to have access to preventive treatment.

The new study compared screening using age alone with screening using age and multiple risk factors, measured via blood tests and medical examination. The authors used existing data to estimate the effects of the two screening approaches on a modelled population of 500,000 people.

Age screening alone using a cut off of 55 years had an 84 per cent detection rate and a 24 per cent false-positive rate. This is equivalent to correctly identifying 84 per cent of all the people in a population who will have a stroke or heart attack, while incorrectly identifying 24 per cent who will not. Current screening methods can achieve the same 84 per cent detection rate with a false-positive rate that is only slightly less – 21 per cent.

Professor Sir Nicholas Wald is lead author and Director of the Wolfson Institute at Barts and The London School of Medicine and Dentistry, part of Queen Mary, University of London. He said: "This study shows that age screening for future cardiovascular disease is simpler than current assessments, with a similar screening performance and cost effectiveness. It also avoids the need for blood tests and medical examinations.

With age screening all individuals above a specified age would be offered preventive treatment. Everyone would benefit because, for blood pressure and cholesterol, the lower the better. The policy of selecting people above a certain age is, in effect, selecting people at high risk. It recognises that age is by far the most important determinant of that risk with other factors adding little extra prognostic information.

"Prevention is better than measurement," Professor Wald added. "Identifying people at high risk of cardiovascular disease needs to be greatly simplified, enabling people to obtain easy access to preventive treatment from nurses and pharmacists as well as from doctors.

"Offering appropriate preventive treatment to everyone aged 55 and over in England and Wales could prevent over 100,000 heart attacks and strokes every year."

Provided by Queen Mary, University of London