Lipid Profiles: Fasting Not Necessary, Concludes Large Study

Medscape Medical News

Joanna Broder

November 12, 2012

Requiring a patient to fast for many hours before a lipid test may soon be a thing of the past.

Although present guidelines encourage doctors to test for total lipids and lipid subclass levels only when a patient has fasted for more than 8 hours, a report published online November 12 in Archives of Internal Medicine found that there may no longer be a need for a patient to fast. There is very little difference in lipid levels when measured in a fasting or nonfasting state, according to the research.

"The incremental gain in information of a fasting profile is exceedingly small for total and HDL [high-density lipoprotein] cholesterol values and likely does not offset the logistic impositions placed on our patients, the laboratories, and our ability to provide timely counseling to our patients," J. Michael Gaziano, MD, writes in an accompanying editorial. "This, in my opinion, tips the balance toward relying on nonfasting lipid profiles as the preferred practices," writes Dr. Gaziano, who is with the Department of Medicine at Veterans Affairs Boston Healthcare System, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts.

Two other doctors agree. "Given the current lack of evidence for the superiority of fasting lipid testing, it is reasonable to consider nonfasting lipid testing in most individuals who present for a routine clinic visit," Amit Khera, MD, and Samina Mora, MD, write in asecond editorial. Dr. Khera is with the Division of Internal Medicine and Dr. Mora is with the Department of Preventive Medicine and Cardiovascular Disease at Brigham and Women's Hospital and Harvard Medical School.

A few prior studies have also suggested that measuring all lipid subclasses when the patient has not fasted will produce acceptable results — even beneficial results in some cases because some nonfasting markers are better predictors of future cardiac events, study authors note. Most of those studies, however, had the limitation of pertaining only to certain groups of patients.

"Therefore, there was a need for a large-scale study of the association of fasting time with lipid levels in an unselected population," study authors Davinder Sidhu, MD, LLB, and Christopher Naugler, MSc, MD, Department of Pathology and Laboratory Medicine, University of Calgary, Alberta, Canada, write.

To investigate the relationship between fasting duration and lipid levels in a large community-based population, the authors designed the study as a cross-sectional analysis of laboratory data.

They used secondary data from Calgary Laboratory Services and examined the test results of every individual with lipid test panels between April 1, 2011, and September 30, 2011.

A policy change in 2011 allowed the laboratory to process samples for fasting lipid levels regardless of the duration of fasting time.

Fasting times ranged from 1 hour to more than 16 hours. Lipid results included the mean levels of HDL cholesterol, low-density lipoprotein (LDL) cholesterol, total cholesterol, and triglycerides. A total of 209,180 participants were included in the analysis. Authors used linear regression models to project average cholesterol levels at various fasting times.

The study found that variation among mean cholesterol subclass levels was less than 2% for total cholesterol and HDL cholesterol, less than 10% for calculated LDL cholesterol, and less than 20% for triglycerides among individuals with various fasting times. Only a minority of fasting intervals had statistically significant differences among cholesterol subclasss levels.

"While there are some circumstances in which a fasting level may be useful, most of the time it is probably not necessary," Dr. Gaziano stresses in his editorial.

But the study is not without limitations, he writes.

"The analyses assume that there is no systematic bias introduced by the timing of the blood draw, " Dr. Gaziano notes in his editorial. "No information was available on medications or repeated measures. More data by age would have been helpful," he says.

Other limitations, according to the authors, are that the study did not examine individual meal choices before testing or control for recall errors of self-reported fasting time.

Future research, the authors suggest, should involve "examining repeated measurements with differing fasting times in the same individuals."

Arch Intern Med. Published online November 12, 2012. Full text Gaziano commentary Khera and Mora commentary

Low Back Pain Tied to Flat Feet: Study

Reuters Health Information  October 17, 2013 

By Kathleen Raven

Women who walk with flat feet are 50% more likely than those with normal or high arches to have low back pain, a new study suggests.

"The key takeaway from the study is that if women have low back pain, it may not be just the back," said senior author Marian Hannan of the Institute for Aging Research at Hebrew SeniorLife in Boston. "It turns out that feet are important for the back."

This study, published in Rheumatology, focused on the arch while a person walked.

Among 1,930 men and women recruited from Framingham, Massachusetts, pronated feet - which tend to roll inward as a person walks - were linked to lower back pain in women only.

"There has been only weak correlation between pronated feet and low back pain so I was happy to see some evidence of this in the study," said Dr. Christopher Kevin Wong, an associate professor of rehabilitation and regenerative medicine at Columbia University in New York City. Wong was not involved with the current study.

For their study, Hannan and her colleagues measured each person's arch in the standing position, then had everyone walk across a mat with embedded sensors to measure pressure from the heel to the tip of the foot while walking.

"It's a method that shows promise, and will need to be validated against other measures of motion analysis," Wong told Reuters Health.

Women in the study were in their 60s, on average. About 38% overall reported having low back pain.

Dr. Stephen Pinney, an orthopedic surgeon at St. Mary's Medical Center in San Francisco, called the size of the study "impressive."

He told Reuters Health future studies should follow participants with different arches forward in time to confirm these findings. Research should also determine what effect, if any, interventions such as orthotics might have on who develops back pain.

"We've known that putting a patient in a foot cast after surgery, for example, can lead to lower back pain because this creates asymmetric forces on the back," said Pinney, who didn't participate in the new research.

Hannan said the body may use other muscles to help make up for flat feet when a person walks, which could explain the link to back pain.

Standing and walking use the foot in different ways. Both a flat foot in standing position and a pronated foot walking could be something to consider during a doctor's visit, Hannan said.

She and her team suggested reasons why women could be more affected by flat feet while walking than men.

For example, women's pelvic bones are wider and not as flexible as men's. In general, women rotate their hips more than men while walking. Women also move their upper bodies more than men when they walk.

"Women probably don't know if their foot function contributes to low back pain, but they can find out about it," Hannan told Reuters Health.

One simple trick to strengthen muscles in the feet is to lay a towel on a flat surface and then scrunch the toes together in order to pick up the towel and lower it back down. Foot orthotics are another option.

"Once you have back pain, you'll want to do core muscle exercises and perhaps take anti-inflammatory medication, but anything that is contributing to asymmetry - you will also want to address that," Pinney said.

"There are a bunch of different reasons for getting low back pain, and this adds another category for people to consider," he said.

SOURCE: http://bit.ly/16RGJ8E

Rheumatology 2013

Exercise May Beat Drugs in Lowering Some Disease Death Rates

Medscape Medical News

Tinker Ready

Oct 02, 2013

Exercise may be just as effective as many drugs in lowering risk for death in the secondary prevention of coronary heart disease, rehabilitation after stroke, and prevention of diabetes, according to an analysis of randomized controlled trials published online October 1 in the British Medical Journal.

Although the researchers note that they were able to find a limited number of randomized controlled trials of exercise, their analysis of combined trial data found no detectable differences in death rates between exercise and drug interventions in the secondary prevention in coronary heart disease and in prediabetes. For stroke patients, the findings suggest that physical activity is more effective at preventing death than drug treatments, including anticoagulants and antiplatelets. However, diuretics appear more effective than exercise in preventing death in cases of heart failure.

The research was conducted by Huseyin Naci, MHS, from the London School of Economics and Political Science in the United Kingdom and the Drug Policy Research Group, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, and John P.A. Ioannidis, MD, from the Stanford Prevention Research Center, Stanford University School of Medicine in California.

The researchers looked at 16 meta-analyses including research that combines data from multiple research studies. Four of the studies looked at exercise and 12 measured the effect of drug treatment. The researchers added 3 new exercise trials for a review that included 305 randomized controlled trials with 339,274 participants. For the 4 conditions with evidence on the effectiveness of exercise on mortality, 14,716 participants were included in 57 trials.

The authors note that the lack of exercise trials is a limitation of their study.

"Evidence from randomized controlled trials on the mortality benefits of exercise is scarce," they write. "Even in treatment areas where such evidence exists, exercise trials evaluating mortality outcomes were at a disadvantage in two ways: considerably fewer trials evaluated exercise than drugs...and fewer people participated in exercise trials."

For example, although there is much evidence that drugs such as simvastatin lower death rates in the secondary prevention of cardiovascular disease, research on the mortality benefits of exercise is limited, they write. In addition, evidence on how physical activity compares with drug interventions "is lacking."

Their analysis found that in coronary heart disease, the odds of mortality was reduced with use of statins (odds ratio [OR], 0.82; 95% credible interval [Crl], 0.75 - 0.90), β blockers (OR, 0.85; 95% Crl, 0.78 - 0.92), angiotensin-converting enzyme inhibitors (OR, 0.83; 95% Crl, 0.72 - 0.96), and antiplatelets (OR, 0.83; 95% Crl,0.74 - 0.93) compared with controls. Exercise produced similar results, but with wider credible intervals (OR, 0.89, 95% Crl, 0.76 - 1.04).

Exercise was more effective than any drug intervention in reducing the death rate among patients with stroke (OR, 0.09; 95% Crl, 0.01 - 0.72). However, the researchers note "considerable uncertainty" in that finding because of the small number of events in exercise trials.

Neither exercise nor drugs were clearly effective in reducing death rates in prediabetes, the authors found. In heart failure, fewer deaths occurred with diuretics (OR, 0.19; 95% Crl, 0.03 - 0.66) and β blockers (OR, 0.71; 95% Crl, 0.61 - 0.80) compared with controls. Diuretics were more effective than exercise (OR, 0.24; 95% Crl, 0.04 - 0.85), angiotensin-converting enzyme inhibitors (OR, 0.21; 95% Crl, 0.03 - 0.76), β blockers (OR, 0.27; 95% Crl, 0.04 - 0.93), and angiotensin receptor blockers (OR, 0.21; 95% Crl, 0.03 - 0.73).

"Given the scarcity of financial resources to fund future trials of exercise interventions, one option would be to require such evidence from pharmaceutical companies," the authors write. "In cases where drug options provide only modest benefit, patients deserve to understand the relative impact that physical activity might have on their condition."

The authors have disclosed no relevant financial relationships.

BMJ. Published online October 2, 2013. 

Midlife Stress May Trigger Dementia, Alzheimer's in Women

Medscape Medical News > Psychiatry

Deborah Brauser

Oct 02, 2013

Common psychosocial stressors experienced by women during midlife may lead to a higher risk of developing dementia and Alzheimer's disease (AD), new research suggests.

The population study included 800 women from Sweden who were first examined in 1968 and then followed up periodically for 38 years.

Results showed that the number of stressors, such as workplace problems, serious illness, divorce, and widowhood, experienced at baseline was associated with a 21% higher risk of developing AD and a 15% higher risk of developing dementia during the follow-up period. It was also associated with significantly increased later-life distress.

The findings show that accumulated stress from common events "may have severe and long-standing physiological and psychological consequences," write Lena Johansson, PhD, RN, from the Neuropsychiatric Epidemiology Unit at the Institute of Neuroscience and Physiology at Gothenburg University in Mölndal, Sweden, and colleagues.

They add that these physiologic consequences can include adverse reactions in the central nervous, cardiovascular, endocrine, and immune systems.

However, the investigators point out that more studies are now needed for replication and to investigate whether interventions such as stress management and behavioral therapy should be started in patients who are experiencing these stressors.

The study was published online September 30 in BMJ Open.

Impact of Common Stressors

Although previous research has shown that severe stressors such as combat and natural disasters can influence both physical and mental health throughout the life course, the long-term impact of more common stressors is unclear.

In the current analysis, the researchers assessed 800 participants in the larger Prospective Population Study of Women in Gothenburg, Sweden. It began in 1968, when the women were in their late 30s, mid 40s, or 50s.

Follow-up assessments were conducted in 1974, 1980, 1992, 2000, and 2005.

At baseline, the women were asked whether they had experienced any of 18 specific stressors, which included death of a child, unemployment for themselves or a partner, or alcoholism or mental illness in a close family member.

They were also asked at baseline and at each follow-up point about having ever experienced symptoms of distress (such as sleep disturbances, irritability, and fear) lasting for at least 1 month or longer.

A psychiatric examination, including tests and a neuropsychiatric assessment, was also given at all times of measurement, and medical records for all of the women were collected.

Biological Response

Results showed that 25% of the women reported at baseline having experienced at least 1 of the listed stressful events, and 16% reported having experienced 4 or more of the events.

Interestingly, the most commonly reported stressors were mental illness in a sibling (31.9%) and mental illness in a mother (26.5%).

During the follow-up period, 19.1% of all participants developed dementia; the average age at time of diagnosis was 78 years. A total of 68% of the women who developed dementia went on to develop AD.

"The mean time from the baseline examination in 1968 to dementia onset was 29 years," report the investigators.

The number of stressful events reported at baseline was associated with a higher incidence of the development of AD (hazard ratio [HR], 1.21; 95% confidence interval [CI], 1.08 - 1.36) or all- type dementia (HR, 1.15; 95% CI, 1.05 - 1.27) at some point during follow-up, as well as having symptoms of distress at each time of measurement.

"We have previously reported that long-standing distress in midlife increase risk of AD and structural brain changes," write the researchers.

"These findings are now extended by showing that number of psychosocial stressors and report of distress independently predicted AD, that is, increased distress could not completely explain the association between midlife stressors and dementia," they write.

They note that this may be because of the different ways individuals respond to stressors.

"Thus, biological responses may develop as a reaction to psychosocial stressors."

The study was funded by several organization, which are listed in the original article. The study authors have disclosed no relevant financial relationships.

BMJ Open. Published online September 3, 2013. Abstract

Busting Obesity Myths

Medscape Internal Medicine > Medicine Matters

Sandra Adamson Fryhofer, MD

Oct 01, 2013 

 Magazines are filled with fad diets promising quick and easy ways to lose weight. The truth is, when it comes to losing weight ,there is a lot of misinformation. A new study conducted by an international team of doctors, dieticians, and experts, funded by the National Institutes of Health, debunks some of these weight loss myths.

The first myth was picked up by the media big time. The myth? Having sex burns lots of calories. The truth? Sex may be great, but it's not that great for burning calories. This opinion is based on a study done in 1984, which measured calories burned during this activity for 30 men. According to this study, the 300-calories-for-sex rule is a myth. Six minutes of sex -- and that is on average how long it takes -- burns only about 21 calories, which is only 14 more calories than watching TV.

Next myth: Breastfeeding protects your child from obesity later in life. Breastfeeding is best for baby; there is no doubt about that. It creates a special bond between mother and child. Breast milk has all the nutrients baby needs to be healthy. It contains substances that help your baby fight infections, but it won't keep your baby from getting fat, says a 6-year randomized clinical trial that followed more than 13,000 children.This myth was also dispelled by a recent JAMA study of 17,000 mothers and their infants who were breastfed. Follow-up when the kids turned 12 found that breastfeeding did not prevent them from becoming obese or overweight. That is why we moms have to lead by example and encourage exercise activity and healthy eating habits for our children.

Next is one that we have all heard: It is best to set reasonable, sensible, attainable goals. You will be more successful because you won't get frustrated. Sounds reasonable enough, but the expert panel said, "Malarkey." Sometimes bigger goals can mean better results. In fact, people who set more ambitious expectations often lose the most weight even if they don't reach their goal.

This study also undermines presumptions that snacking leads to weight gain and that eating breakfast protects against obesity.

The expert panel did come up with their own list of obesity truths. Genetic factors play a role, but they are not the whole story. Environmental changes can make a difference. Regardless of your weight, exercise is a win-win to help lose weight and gain health. Involving parents and focusing on home settings can help overweight children.

Combatting obesity takes constant attention and it should be treated like it is a chronic condition. Structured meal plans and meal replacements can be helpful. The panel also acknowledged that medications and weight loss surgery are necessary for some. At the end of the day, you are left with an equation: the difference between calories in and calories burned. Losing weight means using more calories than you consume each day, but with many complex variables. And as you lose weight, those variables change. Losing weight isn't easy.