Anti-inflammatory diet linked to reduced risk of early death

Adhering to an anti-inflammatory diet was associated with lower risks of dying from any cause, dying from cardiovascular causes, and dying from cancer in a recent Journal of Internal Medicine study.
In the study of 68,273 Swedish men and women aged 45 to 83 years who were followed for 16 years, participants who most closely followed an anti-inflammatory diet had an 18% lower risk of all-cause mortality, a 20% lower risk of cardiovascular mortality, and a 13% lower risk of cancer mortality, when compared with those who followed the diet to a lesser degree. Smokers who followed the diet experienced even greater benefits when compared with smokers who did not follow the diet.

Anti-inflammatory foods consist of fruits and vegetables, tea, coffee, whole grain bread, breakfast cereal, low-fat cheese, olive oil and canola oil, nuts, chocolate, and moderate amounts of red wine and beer. Pro-inflammatory foods include unprocessed and processed red meat, organ meats, chips, and soft-drink beverages.

"Our dose-response analysis showed that even partial adherence to the anti-inflammatory diet may provide a health benefit," said lead author Dr. Joanna Kaluza, an associate professor at the Warsaw University of Life Sciences, in Poland.

Annual Cancer Progress Report

The American Association for Cancer Research (AACR) today released its annual Cancer Progress Report highlighting how federally funded research discoveries are fueling the development of new and even more effective ways to prevent, detect, diagnose, and treat cancer.

Key advances outlined in the AACR Cancer Progress Report 2018 include the following:

• Twenty-two treatments for cancer were approved for the first time by the U.S. Food and Drug Administration (FDA) or approved for new types of cancer between Aug. 1, 2017, and July 31, 2018. Among these treatments are revolutionary new immunotherapeutics called CAR T-cell therapies, exciting new targeted radiotherapeutics, and numerous new targeted therapeutics that are expanding the scope of precision medicine.
• The U.S. cancer death rate declined by 26 percent for adults from 1991 to 2015, a reduction that translates into almost 2.4 million lives saved, according to the latest data.
• The cigarette smoking rate among U.S. adults has fallen to 14 percent, down from 42 percent in 1965, thanks to public education and important policy initiatives.

Research supported largely by federal investments in the National Institutes of Health (NIH) and National Cancer Institute (NCI) is altering the trajectory of cancer by driving advances in public health and improvements for patients being treated across the entire cancer care continuum.
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"The unprecedented progress we are making against cancer has been made possible largely through basic research," said Elizabeth M. Jaffee, MD, President of the AACR and deputy director of The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University in Baltimore. "A continued increase in federal funding for both basic, translational, and clinical research will allow us to make major headway moving forward."

Cancer: An Ongoing Challenge and Costly Disease. Research: A Vital Investment

The report emphasizes that despite the significant strides we are making against cancer, the disease continues to pose enormous public health challenges.

According to the report:

• The number of new cancer cases in the United States is predicted to rise from more than 1.7 million in 2018 to almost 2.4 million in 2035, due largely to the increasing number of people age 65 and older.
• More than 609,000 people in the United States are projected to die from cancer in 2018.
• HPV vaccination could prevent nearly all cases of cervical cancer, as well as many cases of oral and anal cancer, but less than 50 percent of U.S. adolescents ages 13 to 17 are up to date with the recommended vaccination series.
• Advances against cancer have not benefited everyone equally. Cancer health disparities are some of the most pressing challenges posed by the disease.

The report explains that the increasing burden of cancer underscores the need for continued transformative cancer research to develop new approaches to prevention and treatment. It also calls for our elected leaders to:

• Continue to support robust, sustained, and predictable growth of the NIH budget by providing an increase of at least $2 billion in fiscal year (FY) 2019, for a total funding level of at least $39.1 billion.
• Ensure that the $711 million in funding designated through the 21st Century Cures Act for targeted initiatives, including the National Cancer Moonshot, is fully appropriated in FY 2019 and is supplemental to the healthy increase for the NIH's base budget.
• Increase the FDA base budget in FY 2019 to $3.1 billion, a $308 million increase above its FY 2018 level, to ensure support for regulatory science and accelerate the pace of development of medical products that are safe and effective. Specifically, the AACR supports a funding level of $20 million for the FDA Oncology Center of Excellence in FY 2019.
• Support the Centers for Disease Control and Prevention (CDC) Cancer Prevention and Control Programs with total funding of at least $517 million. This includes funding for comprehensive cancer control, cancer registries, and screening and awareness programs for specific cancers.

Public health researchers warn of dietary supplements containing higenamine

Less than two years after the World Anti-Doping Agency (WADA) added higenamine to its list of substances prohibited in sport, an international team of public health researchers has published a peer-reviewed study documenting inaccurately labeled and potentially harmful levels of the stimulant in weight-loss and sports/energy supplements available in the United States. Based on the findings, the researchers are urging consumers to use caution when consuming supplements labeled as containing higenamine. The research was published in the peer-reviewed journal Clinical Toxicology.

"We're urging competitive and amateur athletes, as well as general consumers, to think twice before consuming a product that contains higenamine," said John Travis, Senior Research Scientist at NSF International and a co-author of the study. "Beyond the doping risk for athletes, some of these products contain extremely high doses of a stimulant with unknown safety and potential cardiovascular risks when consumed. What we've learned from the study is that there is often no way for a consumer to know how much higenamine is actually in the product they are taking."

The independent study was conducted by researchers at global public health organization NSF International, Harvard Medical School and the National Institute for Public Health and the Environment (RIVM) in the Netherlands. The researchers studied 24 products labeled as containing higenamine or the synonyms "norcoclaurine" or "demethylcoclaurine" and found unpredictable and potentially harmful quantities of the stimulant ranging from trace levels to 62 mg per serving. Of the 24 products tested, only five listed a specific quantity of higenamine on the label, and none of those five quantities were accurate. Based on the labeled directions for use, consumers could be exposed to up to 110 mg of higenamine per day. The health risks of higenamine remain poorly understood, but as a beta-2 agonist, it has been prohibited from sport by the WADA, and therefore poses a risk to competitive athletes' careers.

"Some plants, such as ephedra, contain stimulants. If you take too much of the stimulants found in ephedra, it can have life-threatening consequences. Similarly, higenamine is a stimulant found in plants," said Dr. Pieter Cohen, Associate Professor of Medicine at Harvard Medical School, Internist at Cambridge Health Alliance and a co-author of the study. "When it comes to higenamine, we don't yet know for certain what effect high dosages will have in the human body, but a series of preliminary studies suggest that it might have profound effects on the heart and other organs."

Dietary supplements lead to an estimated 23,000 emergency department visits each year in the United States, and weight loss and sports supplements contribute to a large portion of these emergency department visits.

"Higenamine is a natural constituent of several traditional botanical remedies, such as aconite root and Aristolochia brasiliensis," said Travis. "While higenamine is considered a legal dietary ingredient when present as a constituent of botanicals, our research identified concerning levels of the stimulant and wildly inaccurate labeling and dosage information. And, as a WADA-prohibited substance, any amount of higenamine in a dietary supplement should be of concern to the competitive athlete." The research points to the need for independent testing and certification of dietary supplements, a public health service that NSF International provides.

NSF International facilitated the development of the only American National Standard for dietary supplements (NSF/ANSI 173), which became the foundation of NSF's accredited dietary supplement certification program in 2001 (ANSI-Accredited Product Certification Body -- Accreditation #0216). To earn NSF certification, products are tested for product formulation, label claims and harmful levels of specific contaminants and potentially harmful ingredients. Additionally, NSF certified dietary supplements must be produced in a manufacturing facility that is inspected twice a year to comply with the U.S. FDA's Good Manufacturing Practice (GMP) requirements.

Products certified under NSF's Certified for Sport® program must meet additional requirements and are screened for more than 272 athletic banned substances. Many professional and elite sports associations and leagues recommend or require the use of Certified for Sport® products, including MLB, NHL, NFL, PGA, LPGA, CFL and the Canadian Centre for Ethics in Sport.

Fitness, physical activity and low sedentary time: each = lower risk of type 2 diabetes

New research published in Diabetologia (the journal of the European Association for the Study of Diabetes [EASD]) shows that cardiorespiratory fitness (CRF), high-intensity physical activity (HPA) and low sedentary time (ST) are all associated with a lower risk of type 2 diabetes. The study is by Jeroen van der Velde and Annemarie Koster, Maastricht University, Netherlands, and colleagues.
While previous research has individually connected CRF, HPA and ST with cardiometabolic health, the majority of studies on HPA and ST did not account for CRF, and this study is the first to examine combinations of ST and CRF.
It is known that differences in CRF between individuals are partly explained by differences in frequency and intensity of physical activity. Further, recent studies have shown that high levels of ST were associated with a lower CRF.
Nonetheless, an estimated 10 to 50% of CRF is explained by factors other than physical activity, including genetic differences and behavioural or environmental elements.
This means that someone could engage regularly in HPA and not have high CRF, or have high CRF without frequently engaging in HPA. The authors say: "Thus, although to some extent they are interrelated, HPA, ST and CRF should be considered different traits and may be independently associated with cardiometabolic health."
This study used data from 1993 people aged 40-75 years from the Maastricht Study, all living in the southern part of the Netherlands. ST and HPA were measured using an accelerometer device. CRF was assessed using cycle-ergometer testing, with various calculations used to determine power output and oxygen consumption.
The researchers found that higher ST, lower HPA and lower CRF were independently associated with greater odds for type 2 diabetes and also metabolic syndrome (a cluster of factors indicating poor metabolic health, such as high blood pressure and large waist circumference).
The authors then looked at high, medium and low levels and ST, HPA and CRF in combination with each other. Compared with those who had both high CRF and high HPA, the group with low CRF and low HPA had a 5.7 times higher risk of metabolic syndrome and a 6.4 times higher risk of type 2 diabetes.
Similarly, all subgroups with medium or low CRF had higher odds for the metabolic syndrome, prediabetes and type 2 diabetes, irrespective of ST. Even in those with high CRF, high ST was associated with a trebling of risk of metabolic syndrome and a doubling of risk of type 2 diabetes, suggesting that high CRF may not be enough to 'counteract' the poor health outcomes associated with high ST. This adds to the accumulating evidence that reducing a person's daily amount of ST could be an important part in improving their cardiometabolic health.
The highest risk of metabolic syndrome and type 2 diabetes was observed in the group with low CRF and high ST; this group had a nine-times higher risk of metabolic syndrome, a trebling of risk of prediabetes and an eight times higher risk of type 2 diabetes when compared with the group with high CRF and low ST.
The authors say: "High ST, low HPA, and low CRF were each associated with several markers of cardiometabolic health and higher risk for the metabolic syndrome and type 2 diabetes independent of each other. A combination of low CRF and low HPA, and a combination of low CRF and high ST, were associated with a particularly high risk of having the metabolic syndrome and type 2 diabetes."
Furthermore, they discovered that a change from low to medium CRF appeared to be more beneficial than from medium to high CRF, since the difference in risk of type 2 diabetes and metabolic syndrome was higher between low and medium CRF than between medium and high CRF.
The authors add: "In order to improve cardiovascular risk and to prevent type 2 diabetes these data support the development of new strategies that target all three components: ST, HPA, and CRF. However, at this stage our study is limited by its cross-sectional design, which makes it difficult to determine causality. Future work that incorporates health changes over time is needed to determine if the observed associations hold true."
They conclude: "We also need to find out what amount of ST is associated with a clinically relevant increase in risk and which levels of HPA and CRF are associated with clinically relevant lower risk for the metabolic syndrome and type 2 diabetes."

Psychological well-being can improve overall heart health

Maintaining positive thoughts and feelings through intervention programs can help patients achieve better overall outcomes when it comes to their cardiovascular health, according to a review paper published today in the Journal of the American College of Cardiology. This paper is part of an eight-part health promotion series where each paper will focus on a different risk factor for cardiovascular disease.
"We addressed how social environment, psychological well-being and the effectiveness of intervention strategies can help strengthen a patient's outlook," said Darwin R. Labarthe, MD, MPH, PhD, professor of Preventive Medicine at Northwestern University Feinberg School of Medicine and the review's lead author. "We focused on whether psychological well-being can be consistently related with a reduced risk of heart disease."
The review defines cardiovascular health in two parts: health behaviors (healthy diet, physical activity, smoking status and body mass index) and health factors (favorable blood pressure, total cholesterol and glucose).
In this review, the authors looked at a growing body of research to examine whether psychological well-being might lead to reduced risk of heart disease. Prospective studies have shown a positive relationship between optimism (one facet of psychological well-being) and heart disease, including a 2017 study showing older women in the highest quartile of optimism had a 38 percent reduced risk of heart disease mortality. Additional studies since 2012 have associated a perceived higher purpose in life with lower odds of having a stroke.
In the four health behavior components, the most optimistic patients were less likely to be current smokers 12 months later, and high levels of psychological well-being were associated with regular physical activity. Optimistic patients sustained healthier diets by consuming more fruits and vegetables, and less processed meats and sweets, leading patients to maintain a healthy BMI.
The review authors found that psychological well-being influenced heart health through biological processes, health behaviors and psychosocial resources.
"Optimists persevere by using problem-solving and planning strategies to manage stressors," Labarthe said. "If others are faced with factors out of their control, they begin to shift their goals and use potentially maladaptive coping strategies, which would ultimately result in raising inflammation levels and less favorable overall heart health."
Having a strong network of social support also gives patients confidence about their future health and helps them act readily on medical advice, engage in problem solving and take active preventive measures. A likely link is that favorable social environment, known to influence heart disease risk, has also been shown to predict psychological well-being.
The authors said intervention programs may strengthen psychological well-being. Mindfulness programs have been shown to improve anxiety, quality of life, smoking cessation, healthy eating and more. Yoga and tai chi, often incorporated in mindfulness-based interventions, have improved outcomes in heart failure patients and lowered blood pressure. Life purpose programs for palliative care patients have led to improvements in mental health, distress from physical symptoms and overall well-being.
"It may seem challenging to help patients modify psychological well-being in the face of a new medical diagnosis, but these events can represent a 'teachable moment.'" Labarthe said. "Just having patient-centered discussions surrounding sources of psychological well-being and information about specific activities to promote well-being are a small, but meaningful, part of a patient's care."

Preventing cognitive decline for those with memory loss

With nearly twice the rate of dementia as whites, blacks are at a higher risk for developing diseases like Alzheimer's, but there has been little research on how to reduce this racial health disparity. A new study in black participants with mild cognitive impairment - often a precursor to dementia - shows that a behavioral intervention can reduce the risk of future memory loss by increasing social, cognitive, and/or physical activity. The results of this randomized, controlled clinical study were published in JAMA Neurology September 10th 2018.
"We see higher rates of cognitive decline and dementia in black than in white communities. Differences in rates of medical conditions that are associated with cognitive decline, like diabetes and hypertension, as well as differences in health beliefs, health literacy, and access to healthy foods, safe neighborhoods, and medical care account for these disparities, said senior author, Barry Rovner, MD, Professor of Neurology, Psychiatry, and Ophthalmology at Jefferson (Philadelphia University + Thomas Jefferson University). "There is a clear need for research in this area. This study provides the first evidence that we can prevent memory decline in this high-risk population, and help people maintain independence."
Dementia is a condition that is often associated with changes in the brain's structure and function. Some research suggests that people who remain active and engaged in community or stimulating work are resistant to the cognitive decline that otherwise can accompany these neurological changes.
"Stay busy, and use your mind. Physicians often deliver this common sense advice, but advice is often not sufficient to change behavior," said Dr. Rovner.
To test whether it was possible to help people set goals and engage in a more active lifestyle, Dr. Rovner and colleagues used a treatment called Behavioral Activation. Researchers have shown that Behavioral Activation effectively reduces depression. Rovner and colleagues used this approach to prevent memory loss, and thereby potentially delay the onset of dementia.
Behavioral Activation helps participants increase cognitive, physical or social activity by guiding someone through goal setting and action planning. In this study, Race-concordant community health workers helped participants set the action plans. For example, the goal of increasing physical activity might include a breakdown of: 1) calling a friend after lunch, 2) picking a time to meet, 3) recording the date on the calendar, and 4) taking the walk. If participants don't meet the self-defined goals, the community health workers helped participants break down goals to smaller actionable steps. It was also important that participants choose their own goals - ones they had an interest in achieving. One participant chose to relearn chess, another to play guitar, others to re-join a church group.
Over a three-year period (June 2011 - October 2014), the researchers screened 1,390 people from the black community with self-described memory problems. Of the 1,390 screened, 221 men and women were diagnosed with mild cognitive impairment and randomized to either treatment with Behavioral Activation or to the control or comparison group. The control group received Supportive Therapy, which consisted of open-ended conversations with a community health worker, at the same dose of 11-12 one-on-one sessions over a two-year period, as the Behavioral Activation group. "Supportive Therapy controlled for the effects of social interaction and attention, but importantly, involved no goal setting or discussion of the link between activity and memory," said Dr. Rovner.
Behavioral Activation reduced the risk of cognitive decline by 88 percent compared to Supportive Therapy. The control group had a 9.3 percent incidence of memory decline over the two years, whereas participants who received Behavioral Therapy saw only a 1.2 percent occurrence of decline in memory based on a battery of standardized cognitive tests.
The researchers attribute much of the success of the study and the intervention to a sensitivity to the needs of the black community. "It was important to work with community health workers who were black, in order to help overcome the understandable hesitation about engaging in a research study," said co-author and geriatric psychologist Robin Casten, PhD, at Jefferson. "Our colleagues helped participants feel at ease and unjudged. They provided racially sensitive education and had respect for the participant's values and self-selected treatment goals."
"It's unacceptable that African American patients are twice as likely as white patients to develop dementia," said Stephen K. Klasko, President and CEO of Thomas Jefferson University and Jefferson Health. "It's not only important to address bias in care delivery but we also need to research - with dignity and without judgement - the interventions that can start to close this gap. Dr. Rovner's research is a model for a step in the right direction."
"Currently there is no medical treatment to prevent cognitive decline. This study highlights the need for culturally competent treatments to reduce the burden of dementia for all Americans," said Dr. Rovner.

One in four older adults prescribed a benzodiazepine goes on to risky long-term use

They may start as well-intentioned efforts to calm anxiety, improve sleep or ease depression. But prescriptions for sedatives known as benzodiazepines may lead to long-term use among one in four older adults who receive them, according to new research.
That's despite warnings against long-term use of these drugs, especially among older people, because they can increase the risk of car crashes, falls and broken hips, as well as causing other side effects.
The new study, published in JAMA Internal Medicine by a team from the University of Michigan, VA and University of Pennsylvania, looked at benzodiazepine use by low-income older adults in a Pennsylvania program that helps with drug costs.
The researchers say their findings point to a strong need for better education of healthcare providers, and the public, about the risks associated with these drugs.
Of the 576 adults who received their first benzodiazepine prescription in 2008 to 2016, 152 still had a current or recent prescription a year later. The study only included people whose benzodiazepines were prescribed by non-psychiatrists, as the majority of older adults who use benzodiazepines have their prescriptions written by primary care physicians or other non-psychiatrists.
White patients were four times more likely to have gone on to long-term use. Those whose initial prescriptions were written for the largest amounts were also more likely to become long-term benzodiazepine users. For just every 10 additional days of medication prescribed, a patient's risk of long-term use nearly doubled over the next year.
That rate of long-term use is concerning enough in itself, says Lauren Gerlach, D.O., M.Sc., the lead author of the study and a geriatric psychiatrist at U-M.
"This shows that we need to help providers start with the end in mind when prescribing a benzodiazepine, by beginning with a short-duration prescription and engage patients in discussions of when to reevaluate their symptoms and begin tapering the patient off," she says. "We also need to educate providers about effective non-pharmaceutical treatment alternatives, such as cognitive behavioral therapy, for these patients."
Gerlach points to two other concerning findings from the review of records and detailed interviews with program participants. Long-term benzodiazepine users were no more likely to have a diagnosis of anxiety, which is sometimes an indication for long-term use.
Also, long-term users were more likely to say they had sleep problems, despite the fact that benzodiazepines are not recommended for long-term use as sleep aids and may even worsen sleep the longer they are used.
More about the study
Gerlach and her colleagues at the U-M Medical School, VA Ann Arbor Healthcare System, Corporal Michael Crescenz VA Medical Center and University of Pennsylvania used data from the Supporting Seniors Receiving Treatment and Intervention, or SUSTAIN, program. The program provides a supplement to a Pennsylvania medication coverage program for low-income older adults. The program provides behavioral health and case management services by telephone across the state. All of the patients in the study live at home or in other community settings, so the study does not include patients in nursing homes and other skilled nursing facilities.
This included detailed interviews to screen for mental health issues including anxiety, depression, sleep issues and pain, as well as analysis of prescription records and other clinical data. The researchers calculated a medication possession ratio, based on how many days' supply of benzodiazepines the person had been prescribed, and how many days remained in the time the prescription was valid. They set a threshold MPR of 30 percent over the course of a year as the definition of long-term use.
On average, the patients were 78 years old when they received their first benzodiazepine prescription - an advanced age for use of the drugs, which national guidelines say should rarely if ever be given to adults over about age 65. Very few had had any sort of psychiatric, psychological or psychosocial care in the past two years.
While treatment guidelines recommend only short-term prescribing, if any, these long-term patients were prescribed nearly 8 months' worth of medication after their initial prescription.
"This study provides strong evidence that the expectations set out by a provider when they first write a new prescription carry forward over time," says David Oslin, M.D., of Penn Medicine and the Philadelphia VA, and senior author of the paper. "When a physician writes for 30 days of a benzodiazepine, the message to the patient is to take the medication daily and for a long time. This expectancy translates into chronic use which in the long run translates into greater risks like falls, cognitive impairment and worse sleep." "Since mental health providers see only a very small minority of older adults who have mental health issues, we need to support primary care providers better as they manage these patients' care," says Gerlach. "We must help them think critically about how certain prescriptions they write could increase the chance of long-term use."