Blood pressure medication can't undo all damage

Treating out-of-control blood pressure with antihypertensive medication can greatly reduce your risk for heart attack, stroke and heart failure, but the current approach to treatment can't undo all of the previous damage or restore cardiovascular disease risk to ideal levels, a new Northwestern Medicine study suggests.

The study, published in the Journal of the American Heart Association, sought to determine whether effective treatment of hypertension could lower the risk of cardiovascular disease to that seen in people who have always had ideal blood pressure levels.

"The best outcomes were seen in those who always had ideal levels of blood pressure and never required medications," said Donald Lloyd-Jones, MD, chair of the Department the Preventive Medicine at Northwestern University Feinberg School of Medicine and senior author of the study. "Those who were treated with medication and achieved ideal levels were still at roughly twice the risk of those with untreated ideal levels. And, of course, people with untreated or uncontrolled high blood pressure were at even greater risk."

He stressed that it remains very important to treat high blood pressure and that lowering blood pressure with antihypertensive medications has been found to lower the risk of cardiovascular disease significantly in middle-aged and older adults.

The new findings strongly suggest that there should be an even greater effort to maintain lower blood pressure levels in younger adults to avoid increases in blood pressure over time that may eventually require medication.

"A greater focus on healthy lifestyles, such as healthier eating patterns, with more fruits and vegetables and lower sodium intake and regular participation in physical activity are the best means for preventing blood pressure levels that might require medication," Dr. Lloyd-Jones said.

Northwestern Medicine scientists analyzed data from nearly nine thousand participants from the Multi-Ethnic Study of Atherosclerosis (MESA) and the Coronary Artery Risk Development in Young Adults (CARDIA) studies.

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Results from the CARDIA participants indicate that middle-aged adults with blood pressure well-controlled by medication had longer exposure to higher blood pressure levels throughout young adulthood than those with ideal blood pressure without medication. As a result, they had significantly higher risk of end-organ damage, as measured by left ventricular mass, kidney function, and the presence of coronary artery calcification.

Health benefits of pear consumption

To explore the potential health benefits associated with pear consumption and related health outcomes, Joanne Slavin, Ph.D., R.D., professor of food science and nutrition at the University of Minnesota, St. Paul, assisted by food science graduate Holly Reiland, conducted a systematic review of studies from PubMed (database of the National Library of Medicine with citations and abstracts of biomedical literature) and Agricola (database of the National Agricultural Library with citations of agricultural literature) from 1970 to present.

Pears are an excellent source of fiber and a good source of vitamin C for only 100 calories per serving. One medium pear provides about 24 percent of daily fiber needs. They are sodium-free, cholesterol-free, fat-free and contain 190 mg of potassium. The USDA Dietary Guidelines for Americans and CNPP MyPlate advise people who eat more fruits as part of an overall healthy diet are likely to reduce their risk of some chronic diseases, although little is published on the health outcomes associated with individual fruits, including pears.

In the review conducted by Dr. Slavin and Reiland, pears were found to be a source of fructose, sorbitol and dietary fiber. "Americans fall short on dietary fiber," said Dr. Slavin. "The high content of dietary fiber in pears and their effects on gut health set pears apart from other fruit and deserves further study." Slavin found the body of evidence for a relationship between pear intake and health outcomes to be sparse and diverse and believes intervention studies with pears that show positive health outcomes, most likely improvements in gut health, are needed.

According to Slavin, an epidemiologic cohort study conducted by Larsson et al.2 found, among individual fruit and vegetable subgroups, inverse associations with total stroke and the consumption of pears, along with apples and leafy green vegetables. In a meta-analysis of twenty prospective cohort studies Hu et al.3 found apples/pears, citrus fruits and leafy vegetables might contribute to stroke protection.

An epidemiologic study conducted by Wedick et al.4 linked the consumption of anthocyanin-rich foods, particularly pears, apples and blueberries, with lower risk of Type 2 diabetes. An additional epidemiologic study via Mink et al.5 indicated flavonoid-rich foods including pears were associated with a significant reduction in mortality from coronary heart disease and cardiovascular disease in postmenopausal women.

Inherent mindfulness linked to lower obesity risk, belly fat

A study of nearly 400 people finds that those who exhibited more 'dispositional mindfulness', or awareness of and attention to their current feelings and thoughts, were less likely to be obese and had less abdominal fat than people who did not exhibit as much of that awareness.

Dispositional mindfulness is not the same as mindfulness meditation, in which people make a conscious, focused practice of attending to their current state and sensations. Instead, it's more of an inherent personality trait, though it can also be taught.

"This is everyday mindfulness," said lead author Eric Loucks, assistant professor of epidemiology in the Brown University School of Public Health. "The vast majority of these people are not meditating."

Loucks' study, published in the International Journal of Behavioral Medicine, looked at how 394 people in the New England Family Study (NEFS) scored on the six-point Mindfulness Attention Awareness Scale (MAAS). Participants rated their agreement with 15 prompts, such as 'I find it difficult to stay focused on what's happening in the present' and 'I could be experiencing some emotion and not be conscious of it until some time later.'

The researchers also measured the amount of belly and hip fat each person had using the dual energy X-ray absorptiometry scanner at Memorial Hospital in Pawtucket. They also gathered measurements of body mass index and other data on each participant's health, lifestyle, and demographics.

The research team's analysis found that even after adjusting for a multitude of possible confounding factors (e.g., age, smoking, socioeconomic status), people with MAAS scores below four were 34 percent more likely to be obese than people with a score of six. Meanwhile, people with the lower MAAS scores had, on average, a bit more than a pound of belly fat (448 grams) than people with the high score. Both of these results were statistically significant.

Because the volunteers have been NEFS participants since childhood, the researchers could track whether they were obese as children. Among the study's findings is that people who were not obese as children but have become so as adults were significantly more likely to be low MAAS scorers.

Is the connection causal?

The study only measures an association, Loucks and his co-authors note. It does not prove that higher mindfulness causes weight loss. But here's what Loucks hypothesizes is going on: Like other animals, people are evolutionarily predisposed to stock up on calories when they are available and to rest when they get the chance. In prehistoric times that was a sensible survival instinct but in a first-world context of fast food and television, it can easily lead to excessive weight gain.

Mindfulness, which other studies have shown can help people overcome cravings and eat a healthier diet, Loucks said, may be the cognitive tool people need to overcome their instincts. Similarly, it may help people override an aversion to initiating exercise (research suggests that people feel great after working out but often feel ambivalent about getting started).

"That's where the mindfulness may come in," Loucks said. "Being aware of each and every moment and how that's related to what we do and how we feel."

Testing interventions

Loucks acknowledged that the differences inherent dispositional mindfulness seems to make, while significant, are not huge.

"Awareness seems to be enough to have a small to medium effect," Loucks said. "Then there is the question of what could we do to increase it."

Clinical trials of whether specific interventions enhance the apparent benefits of mindfulness would help determine whether it indeed has a causal role in lowering obesity risk. Prior studies of mindfulness in weight loss have yielded promising but still inconclusive results, Loucks said.

What you see is what you eat

IMAGE: FOODS KEPT ON THE KITCHEN COUNTER CORRELATE WITH RESIDENTS WEIGHT.
CREDIT: DANIEL MILLER
The food on your counter can predict your weight - especially if it's cereal or soft drinks.

Over 200 American kitchens were photographed to determine if the food sitting out on counters could predict the weight of the woman living in each home. The new Cornell study found that women who had breakfast cereal sitting on their counters weighed 20-lbs more than their neighbors who didn't, and those with soft drinks sitting out weighed 24 to 26-lbs more. The good news? Those who had a fruit bowl weighed about 13-lbs less.

"It's your basic See-Food Diet - you eat what you see," said lead author Brian Wansink, professor and director of the Cornell Food and Brand lab and author of Slim by Design: Mindless Eating Solutions for Everyday Life. "As a cereal lover, that shocked me. Cereal has a health-halo, but if you eat a handful every time you walk by, it's not going to make you skinny."

Although the study cautions that the findings are correlational, Wansink says, "We've got a saying in our Lab, 'If you want to be skinny, do what skinny people do.' If skinny people make their homes 'Slim by Design' by clearing the counters of everything but the fruit bowl, it won't hurt us to do the same."

The forthcoming study -- dubbed "The Syracuse Study" because all of the photographed households were in Syracuse, NY -- is published in the journal Health Education and Behavior. The research was conducted by Brian Wansink, PhD (Cornell University), Drew Hanks, PhD (now at Ohio State University) and Kirsikka Kaipainen, PhD (Headsted, UK).

Older adults do not accurately predict their own life expectancy

Health care providers must have detailed discussions with their older adult patients to better determine their true life expectancy, as older adults do not accurately predict their own prognosis, a key factor in making decisions about future health interventions, according to researchers at UC San Francisco and San Francisco Veterans Affairs Medical Center.

Their research letter appears online Oct. 19, 2015, in JAMA Internal Medicine.
"We thought older people would have a good sense of how long they had to live and have better estimates than a prognostic calculator that is based on things like age, gender and chronic diseases," said lead author Rafael Romo, PhD, RN, doctoral graduate in the UCSF School of Nursing and VA Quality Scholars Nurse Fellow at the San Francisco VA Medical Center, "but we were wrong."

"It turns out that older people are not very good at predicting their prognosis compared to either their actual survival or a calculated estimate. Further, the older you are, the worse you are at predicting."

Many professional guidelines recommend using life expectancy in considering diagnostic or treatment interventions in cases where the time to benefit may exceed patient survival. Otherwise, the patient is at-risk for up-front harms with little chance of benefit.

The patients' perceptions of prognosis also are important. Those who underestimate their survival may choose to forego interventions likely to help them, while those who overestimate may choose interventions more likely to cause harm. However, little is known about how well older adults estimate their survival.

Soliciting Direct Input from Older Adults

In this JAMA Internal Medicine research letter, Romo and his colleagues drew a sample of 2,018 participants ages 64, 69, 74, 79, 84 and 89 from the 2000 wave of the Health and Retirement Study (HRS), a prospective cohort study of U.S. adults. They were asked the percentage chance they would live another 10 years or more.

The participants' subjective estimates then were compared both to observed survival and the objective estimates determined from a best-fit analysis. Under- or overestimated survival occurred if the estimate was more than 25 percent less or greater than the calculated prediction. The final sample included 1,722 participants, with the 84-year-old and 89-year-old age groups combined due to small response size.

Overall, 54.7 percent of the study participants had similar estimates to the objective calculation, with 32.7 percent underestimating and 11.5 percent overestimating. Underestimation was relatively similar across age groups, but overestimation increased significantly with age.

Further, those participants age 64 and 69 were moderately able to estimate survival, but older participants were no better than chance alone.

"We were surprised to find that people tended to underestimate how long they have to live - not overestimate - compared to the clinical estimates," Romo said. "This goes against common wisdom that says older people are more likely to overestimate."

As a result of these findings, the discrepancy between older people's perceived prognosis and their clinical circumstances may create conflict when clinicians make recommendations based on clinical indicators.

"We need to understand how these differences impact patient-clinician communication and the type of treatments and care they receive," Romo said. "Of particular interest is whether those who underestimate their prognosis forgo procedures and tests that may be beneficial to them. This is just as harmful to patients as receiving treatments that will not have a benefit, so we need to understand what is happening in both groups."

Physical activity has greater impact on body composition in postmenopausal women

Everyone knows that exercise is good for you, regardless of your age. But a new study coming out of the University of Massachusetts Amherst and presented earlier this month at the 2015 annual meeting of The North American Menopause Society (NAMS) shows that some types of physical activity have a greater impact on body composition in postmenopausal compared to premenopausal women.

That's the good news for postmenopausal women. However, the study also found that postmenopausal women, on average, have a significantly higher body mass index (BMI), waist circumference and percentage of body fat. That's not new news since it is a generally accepted fact that women tend to gain weight as they go through menopause. The encouraging part of the study, however, is that postmenopausal women may have more control over their body composition than their premenopausal counterparts since their body composition is more impacted by light physical activity, such as casual walking or yard work, and by sedentary behavior.

A total of 630 premenopausal and 274 postmenopausal women participated in the study. ActiGraph accelerometers were used to estimate the amount of time spent in various forms of physical activity and sedentary periods. Not surprisingly, postmenopausal women, on average, exhibited less total movement and more sedentary time than premenopausal women. Also, as expected, higher total movement and physical activity, along with lower sedentary behavior, were associated with a lower BMI, waist circumference and percentage of body fat--but not to the same extent in both groups.

"Across the board, for each measure of body composition, we found that light physical activity had a greater impact in postmenopausal compared with premenopausal women," says Dr. Lisa Troy, lead author from the University of Massachusetts. "We additionally found that sedentary behavior was more strongly associated with waist circumference in postmenopausal women. This is an important public health message because, as women go through menopause, physiological changes may decrease a woman's motivation to exercise. What we've found in our study suggests that doing even a little bit of exercise may make a big difference in body composition."

Dr. Wulf Utian, executive director of NAMS, points out that this study provides valuable insights for physicians counseling their middle-aged female patients on weight management. "Regular exercise has so many benefits for women of all ages--from providing more energy and greater mobility to helping to build bone density," says Dr. Utian. "This study suggests, though, for postmenopausal women, weight management may be improved with a variety of physical activities."

Calcium supplements may increase the risk of kidney stone recurrence

While eating foods rich in calcium has protective effects against kidney stones, the effect of supplementation with calcium and vitamin D on the risk of kidney stone formation remains unclear. To investigate, Christopher Loftus, MD candidate (Cleveland Clinic Lerner College of Medicine) and his colleagues reviewed the 24-hour urine collections and CT imaging scans from patients at their institution who had a history of kidney stones. They identified 6050 patients with a history of kidney stones by imaging scans, 2061 of whom had 24-hour urine collections before and after starting supplementation. A total of 1486 patients were supplemented with calcium, 417 with vitamin D only, and 158 with no supplementation.

Patients who took calcium supplements had lower total calcium and oxalate (which are components of kidney stones) in their urine while blood levels were unaffected. However, these patients also had a faster rate of kidney stone growth suggesting that the mechanism of calcium supplementation on stone formation may not be straightforward. Vitamin D supplementation also decreased urinary calcium excretion as well as stone growth, suggesting that it may help prevent the risk of stone formation.

"While taking supplemental calcium has associated positive effects, these results suggest that supplemental, as compared with dietary, calcium may worsen stone disease for patients who are known to form kidney stones," said Loftus.