Changes in breakfast and dinner timings can reduce body fat

Modest changes to breakfast and dinner times can reduce body fat, a new pilot study in the Journal of Nutritional Sciences reports.

During a 10-week study on 'time-restricted feeding' (a form of intermittent fasting), researchers led by Dr Jonathan Johnston from the University of Surrey investigated the impact changing meal times has on dietary intake, body composition and blood risk markers for diabetes and heart disease.

Participants were split into two groups - those who were required to delay their breakfast by 90 minutes and have their dinner 90 minutes earlier, and those who ate meals as they would normally (the controls). Participants were required to provide blood samples and complete diet diaries before and during the 10-week intervention and complete a feedback questionnaire immediately after the study.

Unlike previous studies in this area, participants were not asked to stick to a strict diet and could eat freely, provided it was within a certain eating window. This helped researchers assess whether this type of diet was easy to follow in everyday life.

Researchers found that those who changed their mealtimes lost on average more than twice as much body fat as those in the control group, who ate their meals as normal. If these pilot data can be repeated in larger studies, there is potential for time-restricted feeding to have broad health benefits.
Although there were no restrictions on what participants could eat, researchers found that those who changed their mealtimes ate less food overall than the control group. This result was supported by questionnaire responses which found that 57 percent of participants noted a reduction in food intake either due to reduced appetite, decreased eating opportunities or a cutback in snacking (particularly in the evenings). It is currently uncertain whether the longer fasting period undertaken by this group was also a contributing factor to this reduction in body fat.
As part of the study, researchers also examined if fasting diets are compatible with everyday life and long term commitment. When questioned, 57 percent of participants felt they could not have maintained the new meal times beyond the prescribed 10 weeks because of their incompatibility with family and social life. However, 43 per cent of participants would consider continuing if eating times were more flexible.
Dr Jonathan Johnston, Reader in Chronobiology and Integrative Physiology at the University of Surrey, said:
"Although this study is small, it has provided us with invaluable insight into how slight alterations to our meal times can have benefits to our bodies. Reduction in body fat lessens our chances of developing obesity and related diseases, so is vital in improving our overall health.
"However, as we have seen with these participants, fasting diets are difficult to follow and may not always be compatible with family and social life. We therefore need to make sure they are flexible and conducive to real life, as the potential benefits of such diets are clear to see.

"We are now going to use these preliminary findings to design larger, more comprehensive studies of time-restricted feeding".

Components of heart healthy diet may differ from what was previously thought

The foods that make up a heart healthy diet for people worldwide may differ from what was previously thought, according to late breaking results from the observational Prospective Urban Rural Epidemiological (PURE) study presented today in a Hot Line Session at ESC Congress 2018¹ and simultaneously published in the Lancet.

Professor Salim Yusuf, senior author and director of the Population Health Research Institute (PHRI) at McMaster University in Hamilton, Canada, said: "Thinking on what constitutes a high quality diet for a global population needs to be reconsidered. For example, our results show that dairy products and meat are beneficial for heart health and longevity. This differs from current dietary advice."
Recommendations for a high quality diet to avoid cardiovascular disease are largely based on studies conducted decades ago in high income countries. There is little information on what people eat today across the world.

This study aimed to clarify the constituents of a modern and international diet that promotes heart health and longevity. A dietary quality score was developed based on foods associated with a lower risk of death in previous studies (fruit, vegetables, nuts, legumes, fish, dairy products, and meat).
Participants of five studies including more than 218,000 people from over 50 countries in five continents2 were divided into five groups according to the quality of their diet. The risks of cardiovascular disease and death in those with the highest quality diet (18 points or more) were compared to those with the poorest quality diet (11 points or less).
"People who consumed a diet emphasising fruit, vegetables, nuts, legumes, fish, dairy products, and meat had the lowest risks of cardiovascular disease and early death," said co-principal investigator Dr Andrew Mente, of the PHRI. "Regarding meat, we found that unprocessed meat is associated with benefit."
The results suggest that we should limit the amount of refined carbohydrates we eat and that dairy foods and unprocessed meat can be included as part of a healthy diet.
Co-principal investigator Dr Mahshid Dehghan, also a PHRI investigator, added: "Our results appeared to apply to people from different parts of the world and so the findings are globally applicable."
To conduct the study, the association between diet quality, cardiovascular disease and death was first examined in 138,527 people aged 35 to 70 years without cardiovascular disease from the PURE study. It was then validated in 31,546 patients with vascular disease from the ONTARGET and TRANSCEND studies, 27,098 patients with a first heart attack from the INTERHEART study, and 20,834 patients with a first stroke from the INTERSTROKE study.
During a median follow-up of 9.1 years in PURE, there were 6,821 deaths and 5,466 major cardiovascular events (death from cardiovascular causes, nonfatal myocardial infarction, stroke, heart failure). After adjusting for factors that could influence the relationship, compared with the poorest quality diet, the highest quality diet was associated with significantly lower risks of major cardiovascular events (hazard ratio [HR] 0.89, 95% confidence interval [CI] 0.80-1.00, p=0.0193), stroke (HR 0.83, 95% CI 0.71-0.97, p=0.0402), cardiovascular death (HR 0.71, 95% CI 0.59-0.85, p<0 .0001="" 0.66-0.84="" 0.68-0.83="" 0.74="" 0.75="" 95="" and="" ci="" death="" deaths="" non-cardiovascular="" p="" total=""> Similar results were found in patients with vascular diseases in ONTARGET and TRANSCEND. The highest quality diet was associated with significantly lower risks of major cardiovascular events (HR 0.86, 95% CI 0.78-0.94), cardiovascular death (HR 0.79, 95% CI 0.69-0.91), non-cardiovascular death (HR 0.89, 95% CI 0.75-1.05), and total deaths (HR 0.75, 95% CI 0.67-0.83).
In the INTERHEART and INTERSTROKE studies, the highest quality diet was associated with a lower risk of myocardial infarction (odds ratio [OR] 0.77, 95% CI 0.70-0.84) and stroke (OR 0.78, 95% CI 0.70-0.86), respectively.

Low carbohydrate diets are unsafe and should be avoided

Low carbohydrate diets are unsafe and should be avoided, according to a large study presented today at ESC Congress 2018.¹
 
Study author Professor Maciej Banach, of the Medical University of Lodz, Poland, said: "We found that people who consumed a low carbohydrate diet were at greater risk of premature death. Risks were also increased for individual causes of death including coronary heart disease, stroke, and cancer. These diets should be avoided."

Obesity is a major health issue worldwide and raises the risk of several chronic conditions, including cardiovascular disease, hypertension, type 2 diabetes, and cancer. Different diets have been suggested for weight loss, such as diets low in carbohydrates and high in protein and fat. The long-term safety of these diets is controversial, with previous studies reporting conflicting results of their influence on the risk of cardiovascular disease, cancer, and death.

This study prospectively examined the relationship between low carbohydrate diets, all-cause death, and deaths from coronary heart disease, cerebrovascular disease (including stroke), and cancer in a nationally representative sample of 24,825 participants of the US National Health and Nutrition Examination Survey (NHANES) during 1999 to 2010. Compared to participants with the highest carbohydrate consumption, those with the lowest intake had a 32% higher risk of all-cause death over an average 6.4-year follow-up. In addition, risks of death from coronary heart disease, cerebrovascular disease, and cancer were increased by 51%, 50%, and 35%, respectively.
The results were confirmed in a meta-analysis of seven prospective cohort studies with 447,506 participants and an average follow-up 15.6 years, which found 15%, 13%, and 8% increased risks in total, cardiovascular, and cancer mortality with low (compared to high) carbohydrate diets (see figure for total mortality).
Professor Banach said: "Low carbohydrate diets might be useful in the short term to lose weight, lower blood pressure, and improve blood glucose control, but our study suggests that in the long-term they are linked with an increased risk of death from any cause, and deaths due to cardiovascular disease, cerebrovascular disease, and cancer."
Participants in the NHANES study had an average age of 47.6 years, and 51% were women. They were divided into quartiles based on the usual percentage of carbohydrates in their diet. The risks of all-cause and cause-specific death over an average 6.4-year follow-up rose with each fall in carbohydrate intake (see table), and remained significant after adjusting for all available factors that might have influenced the association (model 2 in the table).
The researchers also examined the link between all-cause death and low carbohydrate diets for obese (body mass index [BMI] 30 kg/m2 or greater) and non-obese (BMI under 30 kg/m2) participants in two age groups (55 years and older versus under 55) and found that the link was strongest in the non-obese older participants.
Regarding the mechanisms underlying the correlation between low carbohydrate diets and death, Professor Banach noted that animal protein, and specifically red and processed meat, has already been linked with an increased risk of cancer. He said: "The reduced intake of fibre and fruits and increased intake of animal protein, cholesterol, and saturated fat with these diets may play a role. Differences in minerals, vitamins and phytochemicals might also be involved."
He concluded: "Our study highlights an unfavourable association between low carbohydrate diets and total and cause-specific death, based on individual data and pooled results of previous studies. The findings suggest that low carbohydrate diets are unsafe and should not be recommended."

Anxiety, depression, other mental distress may increase heart attack, stroke risk in adults over 45

Adults ages 45 or older who experience psychological distress such as depression and anxiety may have an increased risk of developing cardiovascular disease, according to new research in Circulation: Cardiovascular Quality and Outcomes, an American Heart Association journal.
In a study of 221,677 participants from Australia, researchers found that:

• among women, high/very high psychological distress was associated with a 44 percent increased risk of stroke; and
• in men ages 45 to 79, high/very high versus low psychological distress was associated with a 30 percent increased risk of heart attack, with weaker estimates in those 80 years old or older.

The association between psychological distress and increased cardiovascular disease risk was present even after accounting for lifestyle behaviors (smoking, alcohol intake, dietary habits, etc.) and disease history.

"While these factors might explain some of the observed increased risk, they do not appear to account for all of it, indicating that other mechanisms are likely to be important," said Caroline Jackson, Ph.D., the study's senior author and a Chancellor's Fellow at the University of Edinburgh in Edinburgh, Scotland.

The research involved participants who had not experienced a heart attack or stroke at the start of the study and who were part of the New South Wales 45 and Up Study that recruited adults ages 45 or older between 2006 and 2009.
Researchers categorized psychological distress as low, medium and high/very high using a standard psychological distress scale which asks people to self-assess the level.
The 10-question survey asks questions such as: "How often do you feel tired out for no good reason?" How often do you feel so sad that nothing could cheer you up?" How often do you feel restless or fidgety?"
Of the participants - 102,039 men (average age 62) and 119,638 women (average age 60) - 16.2 percent reported having moderate psychological distress and 7.3 percent had high/very high psychological distress.
During follow-up of more than four years, 4,573 heart attacks and 2,421 strokes occurred. The absolute risk - overall risk of developing a disease in a certain time period - of heart attack and stroke rose with each level of psychological distress.
The findings add to the existing evidence that there may be an association between psychological distress and increased risk of heart attack and stroke, she said. But they also support the need for future studies focused on the underlying mechanisms connecting psychological distress and cardiovascular disease and stroke risk and look to replicate the differences between men and women.
Mental disorders and their symptoms are thought to be associated with increased risk of heart disease and stroke, but previous studies have produced inconsistent findings and the interplay between mental and physical health is poorly understood.
People with symptoms of psychological distress should be encouraged to seek medical help because, aside from the impact on their mental health, symptoms of psychological distress appear to also impact physical health, Jackson said. "We encourage more proactive screening for symptoms of psychological distress. Clinicians should actively screen for cardiovascular risk factors in people with these mental health symptoms."
All factors analyzed in this research, apart from the outcomes of heart attack and stroke, were identified at the same point in time, which made it difficult for researchers to understand the relationship between psychological distress and variables such as unhealthy behaviors like smoking and poor diet. With that analysis approach, they may have underestimated the effect psychological distress has on the risk of heart attack and stroke.

Take a vacation -- it could prolong your life

European Society of Cardiology

IMAGE: Figure of the intervention and control groups. view more 

Credit: European Society of Cardiology

Taking vacations could prolong life. That's the finding of a 40-year study presented today at ESC Congress and accepted for publication in The Journal of Nutrition, Health & Aging.^1,2
 
"Don't think having an otherwise healthy lifestyle will compensate for working too hard and not taking holidays," said Professor Timo Strandberg, of the University of Helsinki, Finland. "Vacations can be a good way to relieve stress."

The study included 1,222 middle-aged male executives born in 1919 to 1934 and recruited into the Helsinki Businessmen Study in 1974 and 1975. Participants had at least one risk factor for cardiovascular disease (smoking, high blood pressure, high cholesterol, elevated triglycerides, glucose intolerance, overweight).

Participants were randomised into a control group (610 men) or an intervention group (612 men) for five years. The intervention group received oral and written advice every four months to do aerobic physical activity, eat a healthy diet, achieve a healthy weight, and stop smoking. When health advice alone was not effective, men in the intervention group also received drugs recommended at that time to lower blood pressure (beta-blockers and diuretics) and lipids (clofibrate and probucol). Men in the control group received usual healthcare and were not seen by the investigators.
As previously reported, the risk of cardiovascular disease was reduced by 46% in the intervention group compared to the control group by the end of the trial.³ However, at the 15-year follow-up in 1989 there had been more deaths in the intervention group than in the control group.^4,5
The analysis presented today extended the mortality follow-up to 40 years (2014) using national death registers and examined previously unreported baseline data on amounts of work, sleep, and vacation. The researchers found that the death rate was consistently higher in the intervention group compared to the control group until 2004. Death rates were the same in both groups between 2004 and 2014.
Shorter vacations were associated with excess deaths in the intervention group. In the intervention group, men who took three weeks or less annual vacation had a 37% greater chance of dying in 1974 to 2004 than those who took more than three weeks. Vacation time had no impact on risk of death in the control group. (see figures)
Professor Strandberg said: "The harm caused by the intensive lifestyle regime was concentrated in a subgroup of men with shorter yearly vacation time. In our study, men with shorter vacations worked more and slept less than those who took longer vacations. This stressful lifestyle may have overruled any benefit of the intervention. We think the intervention itself may also have had an adverse psychological effect on these men by adding stress to their lives."
Professor Strandberg noted that stress management was not part of preventive medicine in the 1970s but is now recommended for individuals with, or at risk of, cardiovascular disease.⁶ In addition, more effective drugs are now available to lower lipids (statins) and blood pressure (angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, calcium channel blockers).
He concluded: "Our results do not indicate that health education is harmful. Rather, they suggest that stress reduction is an essential part of programmes aimed at reducing the risk of cardiovascular disease. Lifestyle advice should be wisely combined with modern drug treatment to prevent cardiovascular events in high-risk individuals."

Current advice to limit dairy intake should be reconsidered

The consumption of dairy products has long been thought to increase the risk of death, particularly from coronary heart disease (CHD), cerebrovascular disease, and cancer, because of dairy's relatively high levels of saturated fat. Yet evidence for any such link, especially among US adults, is inconsistent. With the exception of milk, which appears to increase the risk of CHD, dairy products have been found to protect against both total mortality and mortality from cerebrovascular causes, according to research presented today at ESC Congress 2018, the annual congress of the European Society of Cardiology.¹

Therefore, current guidelines to limit consumption of dairy products, especially cheese and yogurt, should be relaxed; at the same time, the drinking of non-fat or low-fat milk should be recommended, especially for those who consume large quantities of milk.

"A meta-analysis of 29 cohort studies² published in 2017 found no association between the consumption of dairy products and either cardiovascular disease (CVD) or all-cause mortality," said Professor Maciej Banach, from the Department of Hypertension at Medical University of Lodz, Poland. "Yet a large 20-year prospective study of Swedish adults3, also published in 2017, found that higher consumption of milk was associated with a doubling of mortality risk, including from CVD, in the cohort of women."

Professor Banach and his co-researchers examined data from a 1999-2010 National Health and Nutrition Examination Surveys (NHANES) study of 24,474 adults with a mean age of 47.6 years, 51.4% of whom were female. (NHANES is conducted by the US's Centers for Disease Control and Prevention.) During the follow-up period of 76.4 months, 3,520 total deaths were recorded, including 827 cancer deaths, 709 cardiac deaths, and 228 cerebrovascular disease deaths. The researchers found consumption of all dairy products to be associated with a 2% lower total mortality risk and consumption of cheese to be associated with an 8% lower total mortality risk (hazard ratio [HR]: 0.98, 95% confidence interval [CI]: 0.95-0.99; HR: 0.92, 95% CI: 0.87-0.97, respectively). For cerebrovascular mortality, they found a 4% lower risk with total dairy consumption and 7% lower risk with milk consumption (HR: 0.96, 95% CI: 0.94-0.98; HR: 0.93, 95% CI: 0.91-0.96, respectively).
A meta-analysis by Professor Banach and his co-researchers of 12 prospective cohort studies with 636,726 participants who were followed for approximately 15 years confirmed these results. But milk consumption was also associated with a 4% higher CHD mortality, while consumption of fermented dairy products such as yogurt was associated with a 3% lower rate of total mortality. The yogurt finding, however, was determined to be not significant after further adjustment (Q4: HR: 0.98, p=0.125).
The researchers concluded that among US adults, higher total dairy consumption protected against both total mortality and mortality from cerebrovascular causes. At the same time, higher milk consumption was associated with an increased risk of CHD, an association that needs further study. Causality, however, could be difficult to determine, as most people who consume milk also consume other dairy products.
"In light of the protective effects of dairy products," said Professor Banach, "public health officials should revise the guidelines on dairy consumption. And given the evidence that milk increases the risk of CHD, it is advisable to drink fat-free or low-fat milk."

Writing a 'thank you' note improves well-being for letter writers and recipients

New research from The University of Texas at Austin proves writing letters of gratitude, like Jimmy Fallon's "Thank You Notes," is a pro-social experience people should commit to more often. The gesture improves well-being for not only letter writers but recipients as well.
Published in Psychological Science, research conducted by assistant professor of marketing in the McCombs School of Business at UT Amit Kumar and Nicholas Epley at The University of Chicago asked participants, in three different experiments, to write a letter of gratitude to someone who's done something nice for them and then anticipate the recipient's reaction. In each experiment, letter writers overestimated how awkward recipients would feel about the gesture and underestimated how surprised and positive recipients would feel.
"We looked at what's correlating with people's likelihood of expressing gratitude -- what drives those choices -- and what we found is that predictions or expectations of that awkwardness, that anticipation of how a recipient would feel -- those are the things that matter when people are deciding whether to express gratitude or not," said Kumar.
Kumar says anxiety about what to say or fear of their gesture being misinterpreted causes many people to shy away from expressing genuine gratitude.
"I don't think it's a societal thing," said Kumar. "It's more fundamental to how the human mind works and a well-established symmetry about how we evaluate ourselves and other people. When we're thinking about ourselves, we tend to think about how competent we are, and whether we are going to be articulate in how we're expressing gratitude."
Kumar says what is significant about the research and its results is that thank-you notes and letters of gratitude should be written and sent more often.
"What we saw is that it only takes a couple of minutes to compose letters like these, thoughtful ones and sincere ones," said Kumar. "It comes at little cost, but the benefits are larger than people expect."

Sleeping five hours or less a night associated with doubled risk of cardiovascular disease

Middle-aged men who sleep five hours or less per night have twice the risk of developing a major cardiovascular event during the following two decades than men who sleep seven to eight hours, according to research presented today at ESC Congress 2018.

Study author Ms Moa Bengtsson, of the University of Gothenburg, Sweden, said: "For people with busy lives, sleeping may feel like a waste of time but our study suggests that short sleep could be linked with future cardiovascular disease."
Previous studies have generated conflicting evidence on whether short sleep is associated with a greater chance of having a future cardiovascular event. This study investigated this relationship in 50-year-old men.
In 1993, 50% of all men born in 1943 and living in Gothenburg were randomly selected to participate in the study. Of the 1,463 invited, 798 (55%) men agreed to take part. Participants underwent a physical examination and completed a questionnaire on current health conditions, average sleep duration, physical activity, and smoking. The men were divided into four groups according to their self-estimated average sleep duration at the start of the study: five or less hours, six hours, seven to eight hours (considered normal sleep duration), and more than eight hours.
Participants were followed-up for 21 years for the occurrence of major cardiovascular events, which included heart attack, stroke, hospitalisation due to heart failure, coronary revascularisation, or death from cardiovascular disease. Data on cardiovascular events were collected from medical records, the Swedish Hospital Discharge Registry, and the Swedish Cause of Death Register.
Men with incomplete data on sleep duration, incomplete follow-up information, or who had a major cardiovascular event before the start of the study were excluded, leaving a total of 759 men for the analyses.
High blood pressure, diabetes, obesity, current smoking, low physical activity, and poor sleep quality were more common in men who slept five or fewer hours per night compared to those who got seven to eight hours.
Compared to those with normal sleep duration, men who slept five or fewer hours per night had a two-fold higher risk of having a major cardiovascular event by age 71. The risk remained doubled after adjusting for cardiovascular risk factors at the start of the study including obesity, diabetes, and smoking.
Ms Bengtsson said: "Men with the shortest sleep duration at the age of 50 were twice as likely to have had a cardiovascular event by age 71 than those who slept a normal amount, even when other risk factors were taken into account."
She continued: "In our study, the magnitude of increased cardiovascular risk associated with insufficient sleep is similar to that of smoking or having diabetes at age 50. This was an observational study so based on our findings we cannot conclude that short sleep causes cardiovascular disease, or say definitively that sleeping more will reduce risk. However, the findings do suggest that sleep is important -- and that should be a wake-up call to all of us."

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Short and fragmented sleep linked to hardened arteries

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Sleeping less than six hours or waking up several times in the night is associated with an increased risk of asymptomatic atherosclerosis, which silently hardens and narrows the arteries, according to results of the PESA study presented today at ESC Congress 2018.

Dr Fernando Dominguez, study author, of the Spanish National Centre for Cardiovascular Research (CNIC) in Madrid, said: "Bad sleeping habits are very common in Western societies and previous studies have suggested that both short and long sleep are associated with an increased risk of cardiovascular disease. However, there is a lack of large studies that have objectively measured both sleep and subclinical atherosclerosis."
The PESA study enrolled 3,974 healthy middle-aged adults who wore a waistband activity monitor for seven days to record sleep quality and quantity. They were divided into five groups according to the proportion of fragmented sleep, and four groups designating average hours slept a night: less than six (very short), six to seven (short), seven to eight (the reference), and more than eight (long). Atherosclerosis was assessed in leg and neck arteries using three-dimensional ultrasound.
The average age of participants was 46 years and 63% were men. After adjusting for conventional cardiovascular risk factors and potential confounding factors, including age, gender, moderate to vigorous physical activity, body mass index, smoking status, alcohol consumption, blood pressure, education level, blood glucose levels, total cholesterol, total calorie consumption per day, marital status, stress and depression questionnaire scores and obstructive sleep apnoea risk (STOP-BANG score), very short sleepers had significantly more atherosclerosis than those who got seven to eight hours (odds ratio [OR] 1.27, 95% confidence interval [CI] 1.06-1.52, p=0.008).
Those in the highest quintile of fragmented sleep were more likely to have multiple sections of arteries with atherosclerosis compared to those in the lowest quintile (OR 1.34, 95% CI 1.09-1.64, p=0.006).
Dr Dominguez said: "People who had short or disrupted sleep were also more likely to have metabolic syndrome, which refers to the combination of diabetes, high blood pressure, and obesity, and depicts an unhealthy lifestyle."
He concluded: "Failure to get enough sleep and restlessness during the night should be considered risk factors for blocking or narrowing of the arteries. Studies are needed to find out if sleeping well and long enough can prevent or reverse this effect on the arteries. In the meantime it seems sensible to take steps to get a good night's sleep -- such as having a physically active lifestyle and avoiding coffee and fatty foods before bedtime."

Blood pressure and cholesterol lowering drugs continue to improve survival after a decade

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Blood pressure and cholesterol lowering drugs continue to improve survival in patients with hypertension after more than a decade, according to late breaking results from the ASCOT Legacy study presented today at ESC Congress 2018 and published in The Lancet.

Dr Ajay K. Gupta, of the William Harvey Research Institute, Queen Mary University London, UK, said: "Patients in their mid-60s with high blood pressure were less likely to die from heart disease or stroke by age 75-80 if they had taken both calcium channel blocker-based blood pressure lowering treatment and a statin."

The ASCOT Legacy study is the long-term follow-up of 8,580 patients from the UK who took part in the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT), which between 1998 and 2000 recruited patients with high blood pressure and three or more additional risk factors for cardiovascular disease.
Patients who took a newer blood pressure lowering treatment (based on a calcium channel blocker) for 5.5 years were 29% less likely to have died from a stroke ten years later than those taking an older regimen (based on a beta-blocker). There was a non-significant trend towards 10% fewer cardiovascular deaths with the newer therapy.

Patients with average (6.5 mmol/l) or below average blood cholesterol levels at the start of the trial who took a statin for 3.3-5.5 years were 15% less likely to have died from cardiovascular causes such as heart disease and stroke 16 years later than those randomised to placebo.

A subgroup of patients with above average cholesterol who received standard lipid-lowering therapy for 5.5 years had 21% fewer cardiovascular deaths over ten years of follow-up with the newer blood pressure therapy compared to the older one. There was a non-significant trend towards lower all-cause and stroke deaths with the newer treatment.
"These results are remarkable," said Professor Peter Sever, of the National Heart and Lung Institute at Imperial College London, UK, who jointly led the study with Dr Gupta. "We have previously shown that statins confer long-term survival benefits after trials have stopped, but this is the first time it has been found with a blood pressure treatment."
Dr Gupta said: "The findings provide further support for the use of an effective blood pressure lowering therapy plus a statin in most patients with high blood pressure."
A main objective of the initial ASCOT trial was to find out whether a new treatment strategy for high blood pressure was more effective in preventing heart attacks than an old strategy. Patients with high blood pressure were randomly allocated to the new treatment of amlodipine (a calcium channel blocker) plus perindopril (an angiotensin-converting enzyme inhibitor) if needed to achieve the target blood pressure, or the old therapy of atenolol (a beta-blocker) plus bendroflumethiazide (a diuretic) and potassium if needed. The medicines were taken for a median of 5.5 years, when the trial was stopped because the newer treatment prevented more strokes and deaths. After the trial, patients went on to receive usual (or routine) care.
A second aim of the trial was to discover if a statin would provide added protection against coronary heart disease in patients with high blood pressure and cholesterol levels below 6.5 mmol/L. Patients with a blood cholesterol level of 6.5 mmol/l or less were randomly allocated to atorvastatin or placebo for 3.3 years, when the trial was prematurely stopped because atorvastatin prevented more heart attacks and strokes. Following this, patients were offered atorvastatin for the remainder of the blood pressuring lowering arm of the trial. During this 2.2 year period approximately two-thirds of patients previously assigned to either atorvastatin or placebo took atorvastatin.
A third aim of the trial was to evaluate the effectiveness of the newer versus older blood pressure lowering treatment in patients with high blood pressure and high cholesterol (above 6.5 mmol/l). These patients did not participate in the randomised lipid-lowering arm of the trial and all received standard lipid-lowering therapy for 5.5 years.
Professor Mark Caulfield, Director of the William Harvey Research Institute, said: "This study confirms the importance of lowering blood pressure and cholesterol to prevent disabling and life-shortening cardiovascular disease."

Clock drawing cognitive test should be done routinely in patients with high blood pressure

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A clock drawing test for detecting cognitive dysfunction should be conducted routinely in patients with high blood pressure, according to research presented today at ESC Congress 2018.

Patients with high blood pressure who have impaired cognitive function are at increased risk of developing dementia within five years. Despite this known link, cognitive function is not routinely measured in patients with high blood pressure.

"The ability to draw the numbers of a clock and a particular time is an easy way to find out if a patient with high blood pressure has cognitive impairment," said study author Dr Augusto Vicario of the Heart and Brain Unit, Cardiovascular Institute of Buenos Aires, Argentina. "Identifying these patients provides the opportunity to intervene before dementia develops."

The Heart-Brain Study in Argentina evaluated the usefulness of the clock drawing test compared to the Mini-Mental State Examination (MMSE) to detect cognitive impairment in 1,414 adults with high blood pressure recruited from 18 cardiology centres in Argentina. The average blood pressure was 144/84 mmHg, average age was 60 years, and 62% were women.

For the clock drawing test, patients were given a piece of paper with a 10 cm diameter circle on it. They were asked to write the numbers of the clock in the correct position inside the circle and then draw hands on the clock indicating the time "twenty to four." Patients were scored as having normal, moderate, or severe cognitive impairment. The MMSE has 11 questions and produces a score out of 30 indicating no (24-30), mild (18-23), or severe (0-17) cognitive impairment.
The researchers found a higher prevalence of cognitive impairment with the clock drawing test (36%) compared to the MMSE (21%). Three out ten patients who had a normal MMSE score had an abnormal clock drawing result. The disparity in results between the two tests was greatest in middle aged patients.
Dr Vicario said: "Untreated high blood pressure silently and progressively damages the arteries in the subcortex of the brain and stops communication between the subcortex and frontal lobe. This disconnect leads to impaired 'executive functions' such as planning, visuospatial abilities, remembering details, and decision-making. The clock drawing test is known to evaluate executive functions. The MMSE evaluates several other cognitive abilities but is weakly correlated with executive functions."
He continued: "Our study suggests that the clock drawing test should be preferred over the MMSE for early detection of executive dysfunction in patients with high blood pressure, particularly in middle age. We think the score on the clock drawing test can be considered a surrogate measure of silent vascular damage in the brain and identifies patients at greater risk of developing dementia. In our study more than one-third of patients were at risk."
Dr Vicario concluded: "The clock drawing test should be adopted as a routine screening tool for cognitive decline in patients with high blood pressure. Further studies are needed to determine whether lowering blood pressure can prevent progression to dementia."

Contrary to previous report, aspirin DID lower 1st heart attack risk

The ARRIVE study assessed the impact of daily aspirin on heart attacks, strokes, and bleeding in a population at moderate risk of a first cardiovascular event. Moderate risk was defined as a 20-30% risk of a cardiovascular event in ten years. The study enrolled individuals with no prior history of a vascular event, such as stroke or heart attack. Men were at least 55 years old and had two to four cardiovascular risk factors, while women were at least 60 years old with three or more risk factors. Risk factors included smoking, elevated lipids, and high blood pressure.

In the per-protocol analysis, aspirin reduced the risk of total and nonfatal myocardial infarction (HR 0.53, 95% CI 0.36-0.79, p=0.0014; HR 0.55, 95% CI 0.36-0.84, p=0.0056, respectively). The relative risk reduction of myocardial infarction in the aspirin group was 82.1%, and 54.3% in the 50-59 and 59-69 age groups, respectively.

All safety analyses were conducted according to intention-to-treat. Gastrointestinal bleedings, which were mostly mild, occurred in 61 (0.97%) individuals in the aspirin group versus 29 (0.46%) in the placebo group (HR 2.11, 95% CI 1.36-3.28, p=0.0007). The overall incidence of adverse events was similar between treatment groups. Drug-related adverse events were more frequent in the aspirin (16.75%) compared to placebo (13.54%) group (p<0 .0001="" abdominal="" and="" being="" common="" disease="" gastro-oesophageal="" indigestion="" most="" nosebleeds="" p="" pain.="" reflux="" the="" upper="">
Professor Gaziano said: "Participants who took aspirin tended to have fewer heart attacks, particularly those aged 50-59 years, but there was no effect on stroke. As expected, rates of gastrointestinal bleeding and some other minor bleedings were higher in the aspirin group, but there was no difference in fatal bleeding events between groups."

Fish oils do not prevent heart attack or strokes in people with diabetes

Fish oil supplements do not prevent heart attacks or strokes in patients with diabetes, according to late breaking results from the ASCEND trial presented today in a Hot Line Session at ESC Congress 20181 and published in the New England Journal of Medicine.
In observational studies, higher consumption of fish is associated with lower risks of coronary artery disease and stroke. However, previous randomised trials have not been able to show that taking fish oil supplements containing omega-3 fatty acids reduce the risk of having cardiovascular events.
The ASCEND trial (A Study of Cardiovascular Events iN Diabetes)2 examined whether fish oil supplements reduce the risk of a cardiovascular event in patients with diabetes. Between 2005 and 2011, 15,480 patients with diabetes but no history of cardiovascular disease were randomly assigned to fish oil supplementation (1 g daily) or matching placebo.
The primary efficacy outcome was first serious vascular event, which included non-fatal heart attacks, non-fatal strokes or transient ischaemic attacks (sometimes called "mini-strokes"), or deaths from a cardiovascular cause (but excluding any intracranial haemorrhage; i.e. bleeding in the head or brain3).
During an average of 7.4 years of follow-up, a first serious vascular event occurred in 689 (8.9%) participants allocated fish oil supplements and 712 (9.2%) participants allocated placebo. There was no significant difference between the two groups: rate ratio of 0.97 (95% confidence interval 0.87-1.08, p=0.55).
Dr Louise Bowman, principal investigator, Nuffield Department of Population Health, University of Oxford, UK, said: "Our large, long-term randomised trial shows that fish oil supplements do not reduce the risk of cardiovascular events in patients with diabetes. This is a disappointing finding, but it is in line with previous randomised trials in other types of patient at increased risk of cardiovascular events which also showed no benefit of fish oil supplements. There is no justification for recommending fish oil supplements to protect against cardiovascular events."

A good night's sleep: Not too long and not too short

Researchers have found a sweet spot of six to eight hours sleep a night is most beneficial for heart health. More or less is detrimental. Their findings are presented today at ESC Congress 2018.1
Study author Dr Epameinondas Fountas, of the Onassis Cardiac Surgery Centre, Athens, Greece, said: "We spend one-third of our lives sleeping yet we know little about the impact of this biological need on the cardiovascular system."

The study investigated the relationship between sleep duration and cardiovascular disease using a meta-analysis, a statistical tool for combining the results of previous studies on the same topic. The meta-analysis included 11 prospective studies of more than one million adults (1,000,541) without cardiovascular disease published within the last five years.

Two groups, one with short (less than six hours) and another with long (more than eight hours) nightly sleep duration, were compared to the reference group (six to eight hours).

The researchers found that both short and long sleepers had a greater risk of developing or dying from coronary artery disease or stroke. Compared to adults who slept six to eight hours a night, short and long sleepers had 11% and 33% greater risks, respectively, of developing or dying from coronary artery disease or stroke during an average follow-up of 9.3 years.

Dr Fountas said: "Our findings suggest that too much or too little sleep may be bad for the heart. More research is needed to clarify exactly why, but we do know that sleep influences biological processes like glucose metabolism, blood pressure, and inflammation - all of which have an impact on cardiovascular disease."
A strength of the current analysis is that only prospective studies were included, noted Dr Fountas. This avoids recall bias, a source of systematic error in statistics arising from the inability of participants to accurately recall information.
Dr Fountas concluded: "Having the odd short night or lie-in is unlikely to be detrimental to health, but evidence is accumulating that prolonged nightly sleep deprivation or excessive sleeping should be avoided. The good news is that there are plenty of ways to get into the habit of getting six to eight hours a night - for example by going to bed and getting up at the same time every day, avoiding alcohol and caffeine before bed, eating healthily, and being physically active. Getting the right amount of sleep is an important part of a healthy lifestyle."

Patients with high blood pressure unlikely to reduce salt

Patients with high blood pressure are relying solely on medication to reduce their risk of heart attack, stroke and heart failure, rather than decreasing salt intake as instructed by their physicians, according to research presented today at ESC Congress 2018, the annual meeting of the European Society of Cardiology¹.

Lack of adherence to recommended lifestyle changes is leading to higher salt intake for hypertensive patients, more medications needed to treat their condition and more side effects from those medications, according to lead author Dr Kazuto Ohno, Enshu Hospital, Hamamatsu, Japan.

"Patients may be able to improve this vicious cycle by restricting salt intake," Dr Ohno said. "In consequence, they may avoid diseases caused by hypertension, such as heart attacks, stroke and heart failure. Moreover, they may be able to avoid side effects from antihypertensive drugs, such as dizziness and fainting."

Excess salt intake is one of the most important causes of hypertension and salt restriction is a key strategy to manage it, but few studies have been done on the relationship between salt intake and blood pressure in hypertensive patients undergoing antihypertensive drug treatment.

Study authors enrolled 12,422 patients taking medication for hypertension who visited the hospital for a physical checkup from 2010-2016. Individual salt intake was estimated in grams per day using a spot urine calculation formula shown to be effective in previous studies².
Blood pressure levels and patients maintaining the target blood pressure of less than 140/90mmHg improved during the seven-year study among all groups, but individual salt intake increased across all groups as well.
"Although blood pressure values in hypertensive patients had lowered, salt intake was gradually increased," Dr Ohno added. "We think improvement in blood pressure control is not due to salt restriction but due to drug treatment."
Guidelines for the Management of Hypertension 2014³ published by the Japanese society of hypertension, recommend less than six grams of salt intake per day, Dr Ohno said, but less than four percent of study participants were following those recommendations.
Patients in the study were divided into three groups according to whether they were currently prescribed one, two, three or more antihypertensive drugs.
"The observational study in hypertensive patients with antihypertensive drugs found two comparative facts: an improvement of blood pressure levels and an increase in salt intake," Dr Ohno explained. "In particular, in hypertensive patients with multiple antihypertensive drugs, salt intake was higher than those taking only one antihypertensive drug."
Salt intake for healthy people was targeted less than 8 g/day for men and less than 7 g/day for women in Dietary Reference Intakes for Japanese (2015) published by Ministry of Health, Labor and Welfare⁴.
"However, the National Health and Nutrition Examination Survey 2016 5 reported 10.8 g/day in men, 9.2 g/day in women," Dr Ohno said. "More awareness about the harms of higher salt intake is needed in both hypertensive patients and healthy people. We can check the amount of salt in a lot of food and seasoning, such as soy sauce, miso paste, mayonnaise and so on, which are printed on the food labels. It is impossible to measure salt intake in every meal, so all of us should try to take food with reduced salt by referring to food labels."
Dr Ohno said future research should consider whether nutritional guidance can improve the accomplishment rate of the target blood pressure and decrease the number of antihypertensive drug prescriptions.
"As a new attempt, we have explained their estimated salt intake value and gave nutritional guidance including salt, calories and so on to participants since 2017. We think salt restriction is an important modifiable factor of lifestyle to treat and prevent high blood pressure," he concluded.

Deep forehead wrinkles may signal a higher risk for cardiovascular mortality

Are wrinkles just an inevitable consequence of ageing, or could they signal something more sinister? According to research presented in Munich today at the ESC Congress 2018, the annual conference of the European Society of Cardiology (1), people who have lots of deep forehead wrinkles, more than is typical for their age, may have a higher risk of dying of cardiovascular disease (CVD).
Assessing brow wrinkles could be an easy, low-cost way to identify people in a high-risk category for CVD.

"You can't see or feel risk factors like high cholesterol or hypertension," says study author Yolande Esquirol, associate professor of occupational health at the Centre Hospitalier Universitaire de Toulouse in France. "We explored forehead wrinkles as a marker because it's so simple and visual. Just looking at a person's face could sound an alarm, then we could give advice to lower risk."

That advice could include straightforward lifestyle changes like getting more exercise or eating healthier food. "Of course, if you have a person with a potential cardiovascular risk, you have to check classical risk factors like blood pressure as well as lipid and blood glucose levels, but you could already share some recommendations on lifestyle factors," Dr Esquirol points out.

Risk of heart disease increases as people age, but lifestyle and medical interventions can mitigate the danger. The challenge is in identifying high-risk patients early enough to make a difference.
According to the study authors, previous research has analysed different visible signs of ageing to see if they can presage cardiovascular disease. In prior studies, crow's feet showed no relationship with cardiovascular risk but these tiny wrinkles near the eyes are a consequence not just of age but also of facial movement. A link has been detected between male-pattern baldness, earlobe creases, xanthelasma (pockets of cholesterol under the skin) and a higher risk of heart disease, but not with an increased risk of actually dying (2).
The authors of the current prospective study investigated a different visible marker of age - horizontal forehead wrinkles - to see if they had any value in assessing cardiovascular risk in a group of 3,200 working adults. Participants, who were all healthy and were aged 32, 42, 52 and 62 at the beginning of the study, were examined by physicians who assigned scores depending on the number and depth of wrinkles on their foreheads. A score of zero meant no wrinkles while a score of three meant "numerous deep wrinkles."
The study participants were followed for 20 years, during which time 233 died of various causes. Of these, 15.2% had score two and three wrinkles. 6.6% had score one wrinkles and 2.1% had no wrinkles.
The authors found that people with wrinkle score of one had a slightly higher risk of dying of cardiovascular disease than people with no wrinkles. Those who had wrinkle scores of two and three had almost 10 times the risk of dying compared with people who had wrinkle scores of zero, after adjustments for age, gender, education, smoking status, blood pressure, heart rate, diabetes and lipid levels,
"The higher your wrinkle score, the more your cardiovascular mortality risk increases," explains Dr Esquirol.
Furrows in your brow are not a better method of evaluating cardiovascular risk than existing methods, such as blood pressure and lipid profiles, but they could raise a red flag earlier, at a simple glance.
The researchers don't yet know the reason for the relationship, which persisted even when factors like job strain were taken into account, but theorise that it could have to do with atherosclerosis, or hardening of the arteries due to plaque build-up. Atherosclerosis is a major contributor to heart attacks and other cardiovascular events.
Changes in collagen protein and oxidative stress seem to play a part both in atherosclerosis and wrinkles. Also, blood vessels in the forehead are so small they may be more sensitive to plaque build-up meaning wrinkles could one of the early signs of vessel ageing.
"Forehead wrinkles may be a marker of atherosclerosis," says Dr Esquirol.
"This is the first time a link has been established between cardiovascular risk and forehead wrinkles so the findings do need to be confirmed in future studies," cautions Dr Esquirol, "but the practice could be used now in physicians' offices and clinics."
"It doesn't cost anything and there is no risk," concluded Dr Esquirol.

Cooking with coal, wood, or charcoal associated with cardiovascular death

Long-term use of coal, wood, or charcoal for cooking is associated with an increased risk of death from cardiovascular disease, according to a study presented today at ESC Congress 2018.

Dr Derrick Bennett, study author, University of Oxford, UK, said: "Our study suggests that people who use solid fuels for cooking should switch to electricity or gas as soon as possible."

It has been suggested that air pollution from cooking with solid fuels, such as coal, wood, or charcoal, may lead to premature death from cardiovascular disease, but there is limited evidence. This study assessed the association between solid fuel use for cooking and cardiovascular death, as well as the potential impact of switching from solid to clean fuel (electricity or gas).

The study included 341,730 adults aged 30-79 years recruited from ten areas of China in 2004 to 2008. Participants were interviewed about how often they cooked and the main fuel used at their three most recent homes. The researchers then estimated the duration of exposure to solid fuels. The analysis was restricted to those who cooked at least weekly at their three most recent residences and did not have cardiovascular disease. Information on mortality up to 1 January 2017 was collected from death registries and hospital records.

The average age of participants was 51.7 years and three-quarters were female. Nine out of ten had spent at least 20 years in their three most recent residences. Overall, 22.5% of participants had primarily used solid fuels for cooking for 30 years or more, 24.6% for 10-29 years, and 53.0% for less than ten years. Among the latter, 45.9% had never used solid fuels in their most recent three homes and 49.1% had switched from solid to clean fuels during this period.
During 3.4 million person-years of follow-up, 8,304 participants died from cardiovascular disease. After adjusting for education, smoking and other cardiovascular risk factors, each decade of exposure to solid fuel was associated with a 3% higher risk of cardiovascular death (95% confidence interval [CI] 1-4%, p=0.0002). Participants who had used solid fuels for 30 years or longer had a 12% greater risk of cardiovascular death than those who had used them for less than ten years (95% CI 3-21%, p=0.0045) (see figure 1).
Compared to persistent long-term use of solid fuels, adopting clean fuels was associated with a lower risk of death from cardiovascular disease. Each decade earlier switch from solid to clean fuels was associated with a 5% lower risk of cardiovascular death (95% CI 1-8%, p=0.0067). Participants who had changed for ten years or longer had risks comparable to persistent clean fuel users (see figure 2).
Professor Zhengming Chen, principal investigator, University of Oxford, UK, said: "We found that long-term use of solid fuels for cooking was associated with an excess risk of cardiovascular death, after accounting for established risk factors. Switching to electricity or gas weakened the impact of previous solid fuel use, suggesting that the negative association may be reversible."

Daily aspirin does not show lower risk of first cardiovascular event

The role of aspirin in preventing a first heart attack or stroke among people at moderate risk of heart disease remains unclear. At the 2018 European Society of Cardiology meeting, J. Michael Gaziano, MD, a preventive cardiologist at Brigham and Women's Hospital, presented findings from ARRIVE, a randomized, controlled clinical trial of the use of daily aspirin to prevent a first cardiovascular event among more than 12,500 participants considered to be at moderate cardiovascular risk. The team's findings are detailed in a paper published simultaneously in The Lancet.

"Aspirin did not reduce the occurrence of major cardiovascular events in this study," said Gaziano. "However, there were fewer events than expected, suggesting that this was in fact a low-risk population. This may have been because some participants were taking medications to lower blood pressure and lipids, which protected them from disease. The decision on whether to use aspirin for protection against cardiovascular disease should be made in consultation with a doctor, considering all the potential risks and benefits."

The benefits of taking aspirin to prevent a second or subsequent heart attack or stroke have been well established in previous studies but the effectiveness of taking aspirin to prevent a first cardiovascular event has been unclear, despite 30 years of randomized clinical trials. The Aspirin to Reduce Risk of Initial Vascular Events (ARRIVE) study, sponsored by Bayer, sought to assess both the potential benefits as well as the risks to people at moderate risk of cardiovascular disease who may already be receiving some protection from modern preventative and therapeutic strategies.

Participants were randomly assigned to receive either daily aspirin tablets (100 mg) or a placebo. A total of 12,546 participants were enrolled from primary care settings in the UK, Poland, Germany, Italy, Ireland, Spain, and the U.S. The primary endpoint was time to first occurrence of a composite of cardiovascular death, heart attack, unstable angina, stroke, and transient ischemic attack.

The rate of such cardiovascular events did not statistically differ between the aspirin group and the placebo group. During the study, 269 patients (4.29 percent) in the aspirin group and 281 patients (4.48 percent) in the placebo group experienced such cardiovascular events.

Overall, these rates were lower than expected. The authors conclude that this may be reflective of contemporary risk-management strategies, such as the use of statins.

Given that aspirin is known to increase patients' risk of gastrointestinal bleeding, ARRIVE excluded patients at high risk of bleeding. It also excluded patients with diabetes. Gastrointestinal bleeding events (mostly mild) occurred in 61 patients in the aspirin group versus 29 in the placebo group. The overall incidence rate of adverse events was similar in both treatment groups.

"The use of aspirin remains a decision that should involve a thoughtful discussion between a clinician and a patient, given the need to weigh cardiovascular and possible cancer prevention benefits against the bleeding risks, patient preferences, cost, and other factors," the authors conclude.

The authors' declaration of interests and the roles of the Executive Committee and of the sponsor can be found in The Lancet. The sponsor was responsible for the conduct of the trial. The independent Executive Committee, of which Gaziano was a member, was responsible for the study protocol, oversight of the study, writing of the report, and the decision to publish the results. All members of the Executive Committee received personal fees from Bayer during the conduct of the study.

Diet has bigger impact on emotional well-being in women

Women may need a more nutrient-rich diet to support a positive emotional well-being, according to new research from Binghamton University, State University at New York.

Mounting evidence suggests that anatomical and functional differences in men's and women's brain dictate susceptibility to mental disease. However, little is known about the role of dietary patterns in gender-specific psychological wellbeing.

A team of researchers led by Lina Begdache, assistant professor of health and wellness studies at Binghamton University, conducted an anonymous survey of 563 participants (48 percent men and 52 percent women) through social media to investigate this issue. Begdache and her team found that men are more likely to experience mental well-being until nutritional deficiencies arise. Women, however, are less likely to experience mental well-being until a balanced diet and a healthy lifestyle are followed.

According to Begdache, these results may explain reports from previous studies that show that women are at a greater risk for mental distress when compared to men, and emphasize the role of a nutrient-dense diet in mental wellbeing.

"The biggest takeaway is that women may need a larger spectrum of nutrients to support mood, compared to men," said Begdache. "These findings may explain the reason why women are twice more likely to be diagnosed with anxiety and depression and suffer from longer episodes, compared to men. Today's diet is high in energy but poor in key nutrients that support brain anatomy and functionality."
Evidence suggests that our ancestors' diet, which was a high-energy-nutrient-dense diet, contributed significantly to brain volumes and cognitive evolution of mankind, said Begdache.
"Males and females had different physical and emotional responsibilities that may have necessitated different energy requirements and food preference," she said. "Thus, gender-based differential food and energy intake may explain the differential brain volumes and connectivity between females and males. Therefore, a potential mismatch is happening between our contemporary diet and the evolved human brain which is disturbing the normal functionality of certain systems in the brain.
The paper, "Principal Component Analysis Identifies Differential Gender-Specific Dietary Patterns that may be Linked to Mental Distress in Human Adults," was published in the journal Nutritional Neuroscience.

Happiness may be key to longevity

Happy older people live longer, according to researchers at Duke-NUS Medical School in Singapore. In a study published today in Age and Ageing, the scientific journal of the British Geriatrics Society, the authors found that an increase in happiness is directly proportional with a reduction in mortality.

The study utilised data for 4,478 participants of a nationally-representative survey to look at the association between happiness, assessed in the year 2009, and subsequent likelihood of dying due to any cause, until 31 December 2015. The survey was focused on individuals' aged 60 years and older living in Singapore.

Happiness was assessed by asking the survey participants how often in the past week they experienced the following: 'I felt happy', 'I enjoyed life' and 'I felt hope about the future'. Their responses were considered in two distinct ways; a 'happiness score', and a 'binary happiness variable - Happy/Unhappy'. A wide range of demographics, lifestyle choices, health and social factors were accounted for in the analysis.

The researchers found that among happy older people, 15% passed away until 31 December 2015. In contrast, the corresponding proportion was higher, at 20%, among unhappy older people. Every increase of one point on the happiness score lowered the chance of dying due to any cause among participants by an additional nine percent. The likelihood of dying due to any cause was 19 percent lower for happy older people. Further, the inverse association of happiness with mortality was consistently present among men and women, and among the young-old (aged 60-79 years) and the old-old (aged 75 years or older).
"The findings indicate that even small increments in happiness may be beneficial to older people's longevity," explained Assistant Professor Rahul Malhotra, Head of Research at Duke-NUS' Centre for Ageing Research and Education and senior author of the paper. "Therefore individual-level activities as well as government policies and programs that maintain or improve happiness or psychological well-being may contribute to a longer life among older people."
June May-Ling Lee, a co-author, added: "The consistency of the inverse association of happiness with mortality across age groups and gender is insightful - men and women, the young-old and the old-old, all are likely to benefit from an increase in happiness."
Interest in the pursuit of happiness to improve the health of older people has been growing. While previous studies have linked happiness or positive emotions with a range of better health outcomes, the evidence on the effect of happiness on living longer has been inconclusive. Many of these studies do initially observe a greater extent of happiness to be associated with a lower likelihood of dying, but this link disappears once differences in demographic, lifestyle and health factors between those less and more happy are accounted for.
This is one of the few Asian studies to have assessed the association between happiness and mortality among older people, while accounting for several social factors, such as loneliness and social network, therefore extending the generalisability of the findings to non-Western populations.

No amount of alcohol consumption safe for overall health - an opposing view (with which I agree)

....Compared to non-drinkers, people who had one alcoholic beverage per day had a 0.5% higher risk of developing one of 23 alcohol-related health problems, including cancer, road injuries and tuberculosis, in a given year, the study says. At that level, the absolute increase is small, equaling only four additional deaths per 100,000 people per year, according to the study.

...Walter Willett, a professor of nutrition and epidemiology at the Harvard T.H. Chan School of Public Health, questions the conclusion that the cons of drinking always outweigh the pros. While there’s “no question” that heavy drinking is harmful, he says that plenty of data supports links between moderate drinking and lower total mortality and a decreased risk of heart disease — which, he says, are far more relevant concerns for most Americans than something like tuberculosis, which the Lancet paper identifies as a leading alcohol-related disease worldwide. Tuberculosis is very rare in the U.S.

(Other risks that may not be relevant: road injuries and self-harm.)

“I think they went too far in this paper,” Willett says...

Complete article


 

Oatmeal is Good For You

Complete article

...Fiber is oatmeal’s main health attribute. “Fiber is good for so many things throughout the digestive tract,” Slavin says. In the stomach and small intestine, for example, fiber helps slow down food processing and absorption in ways that promote fullness and mellow the body’s insulin response. All that could reduce a person’s risks for type 2 diabetes and metabolic disease, she says. Move farther along into the large intestine, and fiber feeds beneficial gut bacteria and promotes healthy stool, she says.

And unlike wheat and most other grains, oats contain large amounts of a specific type of fiber called beta glucan, which studies have consistently linked to healthier cholesterol scores and a reduced risk for diabetes and cardiovascular disease.

But oatmeal’s health attributes extend beyond fiber. “There’s now increasing evidence showing that whole grain oats contain many phytochemicals, meaning plant-made small molecule compounds, that may have antioxidant and anti-inflammatory effects,” Sang says. He points to one particular oat phytochemical—called avenanthramide—as a promising inflammation fighter.

Oats are also an excellent source of B vitamins, vitamin E and minerals such as magnesium, says Edward Giovannucci, a professor of nutrition at Harvard School of Public Health. But he warns that loading oatmeal up with sugar, sodium or other additives can quickly diminish or offset its health benefits—a warning voiced by other experts. “Instant has all the whole grain components, but my concern is the sugar added,” Sang says...

Treatment for severe heartburn prevents cancer of esophagus

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Medical or surgical treatment of severe heartburn prevents cancer of the esophagus, a study from Karolinska Institutet with almost one million Nordic patients reveals. The results are published in the scientific journal JAMA Oncology.

Pathological heartburn and acid reflux affects 10-20 per cent of the adult population. Long and severe reflux is the strongest risk factor for cancer of the esophagus (type adenocarcinoma), an aggressive cancer that is difficult to treat.
Reflux is usually treated with medicine to make the stomach contents less acidic, which usually eliminates or reduces symptoms. One alternative is to have an operation (anti-reflux surgery) which prevents the stomach contents from coming up into the esophagus. Previous studies have not conclusively demonstrated that these treatments prevent esophageal cancer, but the studies have not been sufficiently large or had enough follow-up time to ensure that conclusions can be drawn on any long-term cancer-preventive effects.
In the present study, researchers used health data records from 1964 to 2014 from the five Nordic countries. Of the more than 940,000 patients with reflux in the study, about 895,000 received medical treatment and of those nearly 2,370 patients (0.3 per cent) developed cancer of the esophagus during the follow-up period. The risk of cancer of the esophagus decreased over time following treatment and was similar to that of the corresponding population after 15 years or more in those who received medication.
Of the more than 48,400 patients who had anti-reflux surgery, 177 (0.4 per cent) developed cancer of the esophagus during the follow-up period. The risk of esophageal cancer clearly fell also in this group and was at the same level as in the corresponding population 15 years or more after the operation.
When the patients with reflux who had an operation were compared with those with reflux who received medication, the patients who had been operated on had a slightly higher risk of esophageal cancer during the entire follow-up period, but the risk did not increase over time. This is probably caused by the fact that the operated patients had more serious reflux from the beginning.
"The results show that effective medical or surgical treatment of reflux prevents cancer of the esophagus. But because the individual's risk of developing esophageal cancer is low, even in those with reflux disease, the results do not justify treating reflux solely as a cancer-preventive measure. The symptoms and complications of reflux disease should continue to govern treatment," says John Maret-Ouda, physician and scientist at the Department of Molecular Medicine and Surgery at Karolinska Institutet in Sweden and the first author of the study.
However, he points out that for the small percentage of people with severe reflux in combination with other risk factors for esophageal cancer, such as obesity, male gender and mature age, effective and continuous medical treatment or an operation to treat reflux is recommended.
"Previous research results have shown poor cancer-preventive effects from anti-reflux surgery. The difference now is that for the first time we can show statistically significant results because we have a sufficiently large study with a long follow-up period of over 15 years following the operation," says Jesper Lagergren, consultant surgeon and professor at the Department of Molecular Medicine and Surgery, Karolinska Institutet, who led the study.
The research is funded by the Nordic Cancer Union, the Swedish Research Council and the Swedish Cancer Society.

Autobiographical memory tested for early Alzheimer's detection

Date:

August 23, 2018

Source:

University of Arizona

Summary:

A psychologist found that carriers of a gene variant that increases the risk for Alzheimer's disease have greater difficulty describing detailed memories of past events. The goal of his research is to help detect Alzheimer's disease-related brain changes before they begin to have an obvious effect on cognition and memory.

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Testing how well people remember past events in their lives could help medical professionals make early predictions about who is at risk for developing Alzheimer's disease, according to a new study from the University of Arizona.

Researchers administered an "autobiographical memory" test to a group of 35 healthy adults, about half of whom carry the gene variant APOE e4 -- a known genetic risk factor that nearly doubles the chances of developing Alzheimer's disease. As a group, those with the genetic risk described memories with much less detail than those without it.
Sometimes called a disease with a clinically silent beginning, Alzheimer's is difficult to detect early even though changes in the brain related to the disease may begin to happen years or even decades before an individual starts to exhibit memory difficulties, said UA neuropsychologist Matthew Grilli, lead author of the new research, which is published in the Journal of the International Neuropsychological Society.
"This raises a huge challenge for developing effective treatments," said Grilli, an assistant professor and director of the Human Memory Laboratory in the UA Department of Psychology. "The hope is that in the near future we will have drugs and other treatments that could potentially slow down, stop and even reverse some of these brain changes that we think are the hallmarks of Alzheimer's disease. The problem is that if we can't detect who has these hallmarks early enough, these treatments may not be fully effective, if at all."
Grilli's goal is to help pick up on brain changes much earlier, before they begin to have an obvious effect on cognition and memory.
He and his UA colleagues Aubrey Wank, John Bercel and Lee Ryan decided to focus on autobiographical memory, or people's recollection of past events in their lives, because this type of memory depends on areas of the brain that are vulnerable to early changes from Alzheimer's disease.
"When we retrieve these complex types of memories that have multimodal details, they're highly vivid or rich; they come with narratives, context and backstories," Grilli said. "We've learned through cognitive neuroscience that the ability to recreate these memories in your mind's eye depends on a widely distributed network in the brain, and it critically depends on regions of the brain that we know are compromised early on in Alzheimer's disease pathology."
In autobiographical interviews, study participants, who ranged in age from early-50s to 80, were asked to recall recent memories, memories from their childhood and memories from early adulthood with as much detail as possible. The interviewers -- who did not know which participants had a genetic risk factor for Alzheimer's -- recorded and scored participants' responses, evaluating which details added to the richness and vividness of the memories and which did not.
Those with the genetic risk factor for Alzheimer's disease, as a group, described memories with much less vivid detail than those without the risk factor, despite the fact that all study participants performed normally and comparably on a battery of other, standard neuropsychology tests.
"None of these individuals would be diagnosed with dementia or mild cognitive impairment," Grilli said. "They are clinically normal, they are cognitively normal, but there's this subtle difficulty one group has with retrieving real-world memories, which we think is because there are more people in the group who are at a preclinical stage of Alzheimer's disease."
Not everyone with the gene variant APOE e4, which is present in about 25 percent of the population, will develop Alzheimer's disease, and not everyone who develops Alzheimer's has the gene.
"From this study, we can't identify one person and say for sure this person is in the preclinical phase of Alzheimer's disease. That's the next stage of work that we need to do," Grilli said. "But we know that as a group there probably are more people in the e4 carrier group that are in the preclinical phase of Alzheimer's disease, and we think this is why they had a harder time generating these memories."
Grilli said the next step is to study brain activity in the people who struggle to generate vivid autobiographical memories to see if they have observable changes in brain structure or activation of the regions of the brain affected early on by Alzheimer's.
The hope is the work could lead to the development of a clinical test sensitive enough to the preclinical brain changes of Alzheimer's disease that could be used to identify people who should undergo more extensive testing for early Alzheimer's disease pathology.
"The tests for early signs of Alzheimer's disease pathology are invasive and expensive, so this new cognitive test potentially could be used as a screen," Grilli said. "It also could be used to help clinical trials. At the moment, it's very difficult and expensive to conduct clinical trials of new drugs because it takes a very long time to determine whether that drug has had an impact on memory. If we have more sensitive measures, we might get answers sooner, especially if we're trying to administer drugs before obvious signs of memory impairment are detectable."

Antibiotic side effects in kids lead to nearly 70,000 ER visits in the US each year

Fast Facts

• Antibiotics are among the most commonly prescribed medications in children, but they can lead to adverse drug events and should be used only when needed.
• From 2011-2015, antibiotic use in children led to nearly 70,000 estimated emergency room visits each year for allergic reactions and other side effects.
• The risk of a visit varied by child age and type of antibiotic used, but for most antibiotics, children aged 2 or younger had the highest risk of an adverse drug event.

The use of antibiotics drives the development of antibiotic resistance, a major threat to public health worldwide. But these drugs also carry the risk of harm to individual patients, including children. According to a new analysis published in the Journal of the Pediatric Infectious Diseases Society, antibiotics led to nearly 70,000 estimated emergency room visits in the U.S. each year from 2011-2015 for allergic reactions and other side effects in children. The study helps quantify the risk posed by specific antibiotics in children across different age ranges.

"For parents and other caregivers of children, these findings are a reminder that while antibiotics save lives when used appropriately, antibiotics also can harm children and should only be used when needed," said lead author Maribeth C. Lovegrove, MPH, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention. "For health care providers, these findings are a reminder that adverse effects from antibiotics are common and can be clinically significant and consequential for pediatric patients."
For their analysis, researchers used nationwide estimates for outpatient antibiotic prescriptions and data from a nationally representative sample of hospitals for emergency room visits attributed to the use of antibiotics by children aged 19 and younger. Most of the visits (86 percent) were for allergic reactions, such as a rash, pruritus (itching), or angioedema (severe swelling beneath the skin). The risk of a visit varied by child age and type of antibiotic, but for most antibiotics, children aged 2 or younger had the highest risk of an adverse drug event. Forty-one percent of visits involved children in this age group. Amoxicillin was the most commonly implicated antibiotic in adverse drug events among children aged 9 or younger, while sulfamethoxazole/trimethoprim was most commonly implicated among children 10-19 years old.
Antibiotics are among the most commonly prescribed medications for children, but prior research has suggested that nearly a third, if not more, of outpatient pediatric prescriptions for antibiotics are unnecessary. Efforts to reduce antibiotic overprescribing have largely focused on reducing antibiotic resistance. However, studies have shown that these longer-term societal risks are not always prioritized when clinicians are making decisions about treatment.
"By considering available data on the immediate risks to individual patients, clinicians, and parents and caregivers, can better weigh the risks and benefits of antibiotic treatment," Lovegrove said.
The researchers were not able to determine which antibiotic prescriptions were unnecessary or inappropriate in the study, because data for antibiotic indications, doses, and durations of therapy were not available. The study also likely underestimates how often children experience adverse side effects from antibiotics because the analysis includes only adverse drug events that resulted in a visit to an emergency room. Adverse drug events treated in other settings, such as an urgent care facility or a doctor's office, or cases for which no health care was sought, were not included. Also, adverse events that are less likely to be diagnosed in the emergency room setting (e.g., Clostridium difficile infections that can cause severe diarrhea after antibiotic use) were not included.

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More on no safe level of alcohol

A new scientific study concludes there is no safe level of drinking alcohol. 

The study, published  in the international medical journal The Lancet, shows that in 2016, nearly 3 million deaths globally were attributed to alcohol use, including 12 percent of deaths in males between the ages of 15 and 49.

"The health risks associated with alcohol are massive," said Dr. Emmanuela Gakidou of the Institute for Health Metrics and Evaluation at the University of Washington and the senior author of the study. "Our findings are consistent with other recent research, which found clear and convincing correlations between drinking and premature death, cancer, and cardiovascular problems. Zero alcohol consumption minimizes the overall risk of health loss."

The paper and videos of experts commenting on it may be found at http://www.healthdata.org
The study does not distinguish between beer, wine, and liquor due to a lack of evidence when estimating the disease burden, Gakidou said.

However, researchers used data on all alcohol-related deaths generally and related health outcomes to determine their conclusions.

Alcohol use patterns vary widely by country and by sex, the average consumption per drinker, and the attributable disease burden. Globally, more than 2 billion people were current drinkers in 2016; 63% were male.

"Average consumption" refers to a standard drink, defined in the study as 10 grams of pure alcohol, consumed by a person daily, about the equivalent of:

• A small glass of red wine (100 ml or 3.4 fluid ounces) at 13% alcohol by volume;
• A can or bottle of beer (375 ml or 12 fluid ounces) at 3.5% alcohol by volume; or
• A shot of whiskey or other spirits (30 ml or 1.0 fluid ounces) at 40% alcohol by volume.

"Standard drinks" are different by country. For example, in the UK a standard drink is 8 grams of alcohol, whereas in Australia, the US, and Japan, it is 10 grams, 14 grams, and 20 grams, respectively.

The study, part of the annual Global Burden of Disease (GBD), assesses alcohol-related health outcomes and patterns between 1990 and 2016 for 195 countries and territories and by age and sex.
It provides findings on prevalence of current drinking, prevalence of abstention, alcohol consumption among current drinkers, and deaths and overall poor health attributable to alcohol for 23 health outcomes, such as communicable and non-communicable diseases and injuries, including:

• Cardiovascular diseases: atrial fibrillation and flutter, hemorrhagic stroke, ischemic stroke, hypertensive heart disease, ischemic heart disease, and alcoholic cardiomyopathy;
• Cancers: breast, colorectal, liver, esophageal, larynx, lip and oral cavity, and nasal;
• Other non-communicable diseases: cirrhosis of the liver due to alcohol use, diabetes, epilepsy, pancreatitis, and alcohol use disorders;
• Communicable diseases: lower respiratory infections and tuberculosis;
• Intentional injuries: interpersonal violence and self-harm;
• Unintentional injuries: exposure to mechanical forces; poisonings; fire, heat, and hot substances; drowning; and other unintentional injuries; and
• Transportation-related injuries.

"We now understand that alcohol is one of the major causes of death in the world today," said Lancet Editor Richard Horton. "We need to act now. We need to act urgently to prevent these millions of deaths. And we can."
This study used 694 data sources on individual and population-level alcohol consumption, along with 592 prospective and retrospective studies on the risk of alcohol use. More than 500 GBD collaborators, such as researchers, academics, and others from more than 40 nations contributed to the study, according to Max Griswold, senior researcher and lead author.
"With the largest collected evidence base to date, our study makes the relationship between health and alcohol clear - drinking causes substantial health loss, in myriad ways, all over the world," Griswold said.
In 2016, eight of the leading 10 countries with lowest death rates attributable to alcohol use among 15- to 49-year-olds were in the Middle East: Kuwait, Iran, Palestine, Libya, Saudi Arabia, Yemen, Jordan, and Syria. The other two were Maldives and Singapore.
Conversely, seven of the leading 10 countries with highest death rates were in the Baltic, Eastern European, or Central Asian regions, specifically Russia, Ukraine, Lithuania, Belarus, Mongolia, Latvia, and Kazakhstan. The other three were Lesotho, Burundi, and Central African Republic.
Health officials in those nations, Gakidou said, would be well served by examining the study's findings to inform their policies and programs to improve the health and well-being of their constituents.
"There is a compelling and urgent need to overhaul policies to encourage either lowering people's levels of alcohol consumption or abstaining entirely," she said. "The myth that one or two drinks a day are good for you is just that - a myth. This study shatters that myth."

How healthy is the American diet

Dietary risk factors are among the key contributors to mortality and morbidity in the United States and globally, and there is increasing emphasis on understanding the influence of total diet quality and overall dietary patterns rather than single aspects of what we eat and drink. In order to evaluate the quality of what people eat and drink, researchers often rely on recommendations such as the Dietary Guidelines for Americans (DGA). In the latest issue of the Journal of the Academy of Nutrition and Dietetics, leading nutrition experts describe and evaluate the latest version of the Healthy Eating Index (HEI), which has been issued to correspond to the 2015-2020 Dietary Guidelines for Americans.

The DGA are updated every five years, leading to changes in emphasis and quantification, as the evidence on healthy eating evolves over time. Likewise, a new HEI is issued to correspond to each new edition of the DGA and to reflect these changes. The HEI is a measure of diet quality, independent of quantity, that can be used at various levels of the food stream, including the national food supply, the community food environment (e.g., foods available at a school or a fast food menu), and food intakes among the population.

The HEI score can be used to evaluate how healthy the American diet is in relation to federal dietary guidance. It has been applied by researchers to describe diet quality among the US population, as well as population subgroups such as Mexican Americans, children, and cancer survivors. It has also been used to evaluate the quality of food offerings across the food stream, including the US food supply, restaurant menus, grocery store circulars, and Federal food distribution programs.
"Tracking quality at these different levels is critical since we are increasingly recognizing the power of the food environment on eating behavior. That is, individuals cannot be expected to make healthy choices if those options are not readily available in the home, at work, at school, and in the community," comments Jill Reedy, PhD, MPH, RD, Program Director at the Risk Factor Assessment Branch, Epidemiology and Genomics Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA, and co-author of the papers in this issue.
The latest HEI was developed through a collaboration between researchers at the National Cancer Institute (NCI) and the United States Department of Agriculture's (USDA) Center for Nutrition Policy and Promotion (CNPP). A trio of papers in this special issue introduce the new HEI and describe differences compared to the 2010 and 2005 editions, evaluate the properties of the HEI-2015 for assessing dietary quality, and discuss its applications.
Update
The first paper outlines the steps taken to update the most recent version of the HEI and prepare an HEI-2015 scoring system to reflect compliance with the 2015-2020 DGA food and nutrient recommendations. "The Dietary Guidelines for Americans evolve incrementally over time based on scientific evidence, and updates to the HEI are designed to capture that evolution," explains Susan M. Krebs-Smith, PhD, MPH, Risk Factor Assessment Branch, Epidemiology and Genomics Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, National Institutes of Health, Bethesda MD, USA.
The 2015 edition has 13 components, each reflecting an important aspect of diet quality as per the DGA. Dr. Krebs-Smith and colleagues describe each of the HEI-2015's constituent food and nutrient categories, as well as its 100-point scoring system, including referent standards for each component of the total score. Since the 2005 version, the HEI has been based on densities (e.g., amounts per 1000 kcal), rather than absolute amounts, and relies on a common set of standards that are applicable across individuals and settings. Notable differences compared to the previous edition are that saturated fat and added sugars are each separately tracked, and excessive alcohol contribution to energy is not captured separately. This new version also incorporates modifications to the scoring procedures for legumes.
Evaluation
In the second paper, Jill Reedy, PhD, MPH, RD, and colleagues report on testing of the index's validity and reliability. Known high-quality sample menus from a variety of organizations such as the National Heart, Lung, and Blood Institute (Dietary Approaches to Stop Hypertension [DASH] diet), US Department of Agriculture (USDA), Harvard Medical School (Healthy Eating Guide), and the American Heart Association (AHA) (No-Fad Diet) were scored using the HEI standards. These menus all achieved high scores, ranging from 88 to 100 points.
At the next level of testing, data from the Centers for Disease Control and Prevention's National Health and Nutrition Examination Survey (NHANES) were used to compare HEI-2015 scores across population subgroups to examine if meaningful differences could be detected. Average HEI-2015 scores and ranges demonstrated reasonable variation across the subgroups examined, including groups differentiated by age, gender, and smoking status. Results suggested that the index reflects the many dimensions of dietary guidance. As a final assessment, datasets from the NIH-AARP Diet and Health Study were examined and showed that individuals in the highest quintiles of HEI-2015 scores had a 13-23 percent decreased risk of all-cause, cancer, and cardiovascular disease mortality.
"These analyses demonstrated evidence supportive of validity and reliability for the HEI-2015, as has been shown in earlier work with the HEI-2005 and HEI-2010," notes Dr. Reedy. "However, limitations in the HEI as well as those inherent to dietary intake data more broadly should be considered in any application of the index."
Applications
The third paper examines potential applications of the HEI-2015 in surveillance, epidemiology, and community intervention research. Lead investigator Sharon I. Kirkpatrick, PhD, MHSc, RD, Associate Professor, School of Public Health and Health Systems, University of Waterloo, Waterloo, ON, Canada, and colleagues outline approaches to calculating scores and review their suitability for research questions related to monitoring eating patterns, understanding associations between eating patterns and health/disease, and evaluating dietary interventions.
The focus of this paper is on the use of the HEI for cases in which dietary intake data are available for characterizing diet quality for groups of individuals sampled from the population. Further development of methods for calculating the HEI for individuals will help advance our knowledge on diet quality. "The use of the most appropriate approach to calculating HEI scores for a given purpose can help build a stronger literature on the influence of dietary quality on health and disease risk, helping to inform future policies and programs to support health," comments Dr. Kirkpatrick.
In an accompanying editorial, Barbara Millen, DrPH, MPH, RD, FADA, Millennium Prevention, Inc., and Boston Nutrition Foundation, Inc., Westwood, MA, USA, and Chairman of the 2015 Dietary Guidelines Advisory Committee, points out the growing use of web and mobile platforms and apps in clinical and community settings for purposes such as diet and exercise behavior monitoring. She forecasts a bright future for integrating new methods of nutritional risk assessment, such as the HEI-2015, with advanced analytics and innovative web and mobile technologies.
According to Dr. Millen, "The evidence base is stronger than ever before linking the 'total diet' - its dietary patterns, nutrient density, and overall quality - to health promotion and disease prevention across the human life span. The work of these investigators will hopefully inspire other researchers and nutrition professionals to utilize the HEI-2015 broadly and establish other evidence-based innovations that fully embrace the 2015-2020 DGA's five cornerstone guidelines, and advance research and practice in clinical, public health and consumer settings."