Menopausal transition period is a "critical window" for cardiovascular prevention in women

A healthy lifestyle during the perimenopausal and menopausal years reduces the risk of cardiovascular events in later life report the result of a prospective, cohort study published in in the December 4 issue the Journal of the American Heart Association.

The study is a secondary analysis of data from the ongoing, multicentric, multiethnic, prospective Study of Women's Health Across the Nation (SWAN) initiated in 1996 to know more about transition across menopause.  The researchers looked at data from 1143 women to create a composite 10-year average Healthy Lifestyle Score (HLS) involving smoking, diet quality, and physical activity. All three are modifiable behavioral risk factors for CVD and earlier studies have shown an inverse association between healthy lifestyle and various CV outcomes.

The study participants were followed for an average of 15 years with the last follow-up in the year 2015-2016. Carotid ultrasound scans were performed after 14 years to measure the markers of subclinical atherosclerosis which include common carotid artery intima‐media thickness (CCA‐IMT), adventitial diameter (CCA‐AD), and carotid plaque.

Information about the diet was collected at baseline, visit 5, and visit 9 using a modified version of the Block Food Frequency Questionnaire (FFQ) and the amount was quantified using the Alternate Healthy Eating Index (AHEI).

To assess whether the recommended physical activity (≥150 minutes/week of moderate-intensity physical activity) is met or not, the participants were asked to fill the sports and exercise questions on the Kaiser Physical Activity Survey.

Data on smoking were collected using the standardized questions from the American Thoracic Association.

The HLS was calculated based on the sum of individual scores on all the three parameters at baseline, visit 5 and visit 9 and averaged to get the final score. Other covariates included in the study at baseline were age, race/ethnicity, education, financial status, marital status, depression, self-reported health status, and menopausal status.

Physiological risk factors, including BMI, high blood pressure, impaired fasting glucose, serum triglycerides, total cholesterol, HDL cholesterol, LDL cholesterol, use of antilipidemic medications, and use of antihypertensive medications were adjusted in a separate model.

The association between the individual component of HLS and the three markers of subclinical atherosclerosis were also looked at.

At 10 years follow-up, average HLS was found to be inversely and statistically significantly associated with CCA-IMT and CCA-AD — an association that persisted, even after "extensive" adjustment for confounders (P = .0031) and physiological risk factors (P < .001 for both CCA-IMT and CCA-AD).

Compared with participants with the lowest range of HLS, those with highest HLS had a 0.024 mm smaller CCA-IMT and a 0.16 mm smaller CCA-AD.

After adjusting for various physiological risk factors, the researchers did not find a statistically significant association between carotid plaque and average HLS.

Analyzing individual component of HLS, smoking conferred the highest risk for a CV event and those who never smoked had a 0.047 mm smaller CCA-IMT, a 0.24 mm smaller CCA-AD, and 49% lower odds of having a higher carotid plaque index.

The investigators message for the physicians “the menopausal transition represents a crucial, yet understudied, window of increased cardiovascular risk in women. For the prevention of future cardiovascular disease among women undergoing the menopausal transition, the physician should focus on modifiable health behaviors including smoking, diet, and physical activity."

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Landmark cancer prevention report puts forth a blueprint to reduce the risk of cancers

The American Institute for Cancer Research (AICR) and the World Cancer Research Fund (WCRF) recently issued an evidence-based blueprint for healthy living that could prevent nearly half of all cancer cases.

This is the 3^rd report in the series of expert reports Diet, Nutrition, Physical Activity, and Cancer: A Global Perspective, and updates the two previous comprehensive reports, which were published in 1997 and 2007.

The report has distilled evidence of 30 years of research into 10 recommendations that could help prevent cancer by lifestyle modification. The report is based on a review of data from 51 million people, including 3.5 million cancer cases in 17 cancers.

The evidence shows that a modification in your diet, staying physically active, having a healthy body weight and other health-related choices can prevent 12 cancer diagnoses. These include breast, colorectal, pancreatic, endometrial, ovarian, prostate, liver, gallbladder, kidney, bladder, stomach and esophageal cancers.

In 2012, an estimated 14.1 million new cases of cancer occurred worldwide, with nearly 1 in 6 deaths due to cancer.

Biology Computes

“The evidence is clear that making changes to diet and exercise and maintaining a healthy weight cuts cancer risks, regardless of age. The message may not be glamorous, but these changes can save your life,” said Kelly Browning, Chief Executive Officer of AICR.

The ten recommendations are:

1) Maintaining a healthy weight is the most important thing you can do to reduce your risk of cancer. Aim to be in the lower end healthy Body Mass Index (BMI) range.

2) Be physically active-incorporate physical activity as a part of your daily life. Walk more and sit less, for maximum health benefits, aim for 150 minutes of moderate, or 75 minutes of vigorous, physical activity a week.

3) Eat a diet rich in vegetables, fruits, whole grains, and beans. AICR recommends a plant-based diet that forms at least two-thirds of your plate.

4) Limit the intake of fast food. There is strong evidence that consuming "fast-foods" and a "Western-type" diet are causes of weight gain, overweight and obesity, which are linked to 12 cancers. Glycemic load also increases the risk for endometrial cancer.

5) Limit red meat and avoiding processed meat - red meat includes beef, pork and lamb and processed meat includes ham, bacon, salami, hot dogs, sausages.

6) Limit consumption of sugar-sweetened beverages- Whenever you feel thirsty drink water or unsweetened beverages.

7) Limit alcohol consumption- alcohol in any form is a potent carcinogen. It's linked to 6 different cancers. The best advice for those concerned about cancer is not to drink.

8) Do not take the supplement for cancer prevention-Aim to obtain nutrition from diet instead of popping the supplements. The panel doesn’t discourage the use of multivitamins or specific supplements for those sub-sections of the population who stand to benefit from them, such as women of childbearing age and the elderly. But, dietary supplements will not avoid cancer.

9) Mothers, please breastfeed your baby- There is a strong evidence that breastfeeding your baby protects against breast cancer later in life.

10) If you are already diagnosed with cancer, you should follow the nutritional advice from an appropriately trained professional. For breast cancer survivors, there is persuasive evidence that nutritional factors and physical activity reliably predict important outcomes from breast cancer.

The report emphasizes the need for knowledge about the link between lifestyle and cancer. In a 2017 AICR Cancer Risk Awareness Survey more than 50% of the population who responded was not aware of the link between obesity and cancer.

The report provides robust evidence for healthcare professionals and government officials to advise the patients about healthy eating and making policies that make healthy eating more affordable.  

AICR today launched Cancer Health Check – an easy-to-use tool, which shows how your lifestyle stacks up against known cancer risks and outlines the changes you can make to follow AICR’s evidence-based Cancer Prevention Recommendations.

ACIR News Release

Cancer Health Check – an easy-to-use tool

Diet, Nutrition, Physical Activity, and Cancer: A Global Perspective, the Second Expert Report

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Here is a video about AICR 10 recommendations for cancer prevention.

Consuming the right amount of Calcium is key to prevent postmenopausal osteoporosis: EMAS guidelines

Courtesy: Washington post 

Intake of right amount of Calcium, preferably from dietary source is the key to manage bone health in postmenopausal women and anything in excessive may not help, and can be harmful, says the new European Menopause and Andropause Society (EMAS) clinical guidelines published in forthcoming issue of Maturitas.

Postmenopausal osteoporosis is rife throughout the world and despite recommendations about diet and lifestyle changes from societies and governmental bodies, many issues remain unresolved. Calcium is drug which is often consumed as either single supplement or in combination with Vitamin D3 and self-dosing is very common.

Different societies have recommended different doses ranging from 700 and 1200 mg/daily and uncertainties prevail about the most appropriate dose.

Excessive intake of calcium beyond 2000mg/day is linked to increases risk cardiovascular events, dementia, urolithiasis and even fractures, but the issue remains unresolved.

To develop the current EMAS guidelines the authors looked at systematic reviews, meta-analyses, and randomized controlled trials from 2007 till present.

The key recommendations by EMAS are:

The guidelines reiterate the role of adequate intake of calcium in preventing postmenopausal osteoporosis and fracture risk.

The recommended calcium intake should be between 700 and 1200 mg per day after menopause.

Diet should be the preferred method for sourcing the daily requirements, as the intake is uniformly distributed throughout day and avoids the calcium peaks in blood.

Higher than recommended amount is not useful, on the contrary it may do possible harm.

If women are not able to take supplements and the diet also does not supply the recommended amount of calcium, they should have regular physical exercise and take Vitamin D to maintain healthy bones.

The EMAS recommendation of 700 to 1200 mg per day differ from US guidelines in terms of daily dosage. The National Osteoporosis Foundation (NOF) and the American Society for Preventive Cardiology (ASPC) the US Institute of Medicine (IOM) Food and Nutrition Board, and the North American Menopause Society(NAMS) recommends 1200 mg of elemental calcium per day.

The National Institutes of Health (NIH) recommended 1500 mg of elemental calcium per day.

But, the study authors opined that the 300-mg difference between European and US guidelines does not matter much as the real problem starts if the daily intake exceeds 2000 mg or more.

The EMAS recommendations does not apply to women receiving antiosteoporotic drugs, which require concomitant supplementation with calcium and vitamin D. 

Abstract

Healthy diet could improve semen parameters in male factor infertility: a systematic review of observational studies

Consuming a healthy diet along with nutrients could improve the quality and fecundability reports the results of a systematic review published in March 2017 in Journal of Human Reproduction Update.

Recent available data estimate that around 50 million couple worldwide experience infertility and were unable to conceive after 5 years of marriage. In US, CDC stats that about 11% of U.S. couples have impaired fertility.

Male factor infertility accounts for 25% to 30% of cases and the number is increasing globally because of worldwide decline in semen quality.

Many environmental and lifestyle factors have been blamed for the decline in sperm count. One of the important possible determinant of sperm quality is diet and nutrients with only few small random RCTs available in literature.

The researchers conducted a detailed systematic review of available literature from till November 2016 following the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

All cross sectional, prospective and retrospective case -control studies in which men were responsible for fertility problems with well-defined semen parameters were included in the analysis.

Out of 1944 articles delineated, 35 were selected for quantitative analysis.

It was seen that:

Diets that are high  in saturated and trans-fat and low in omega-3 fatty acids, some antioxidants (vitamin E, vitamin C, β-carotene, selenium, zinc, cryptoxanthin and lycopene), other vitamins (vitamin D and folate) were all associated with several  low semen parameters.

Consumption of seafood, fish, low fat dairy, cereals, vegetables and fruits were positively associated with several sperm quality parameters.

Processed food, potatoes, soy, full fat dairy, coffee, alcohol, sweetened beverages and desserts are all responsible for falling semen parameters.

Men who consumed too much alcohol, caffeine, processed meat and red meat decreased the chances of pregnancy in their partners.

The authors concluded that making healthy diet a part of your lifestyle could improve the couple chances of fertilization by improving the semen parameters. But, observational nature of the study results only prove association and not causation.

Large Randomized Prospective studies in future should be designed to confirm the causation.

Endocrine Society issues guidelines to treat Functional Hypothalamic Amenorrhea (FHA).

Functional Hypothalamic Amenorrhea is a term used to describe amenorrhea that results from stress, imbalance between the energy intake and energy consumed by the body. These commonly occurs in athletes, ballet dancers, figure skaters, runners and women who have eating disorders, who burn more calories than what they eat.

In response, the hypothalamus gradually slows down or shuts off completely leading to decrease in pulsatile GnRH release, absent LH surge, absence of follicular development, low serum estrogen and anovulation.

The guidelines were published online on March 22,2017 in Journal of Clinical Endocrinology & Metabolism. The other societies which supports the guidelines are The American Society for Reproductive Medicine, the European Society of Endocrinology, and the Pediatric Endocrine Society.

The guidelines were developed by a task force of 8 medical experts, a medical writer and a methodologist. They looked at 2 systematic reviews and other evidence based guidelines in literature to formulate the current guidelines.

Untreated FHA of long standing can lead to infertility, delayed puberty, osteoporosis and stress fractures.

A diagnosis of HA is suspected in adolescent and women who have persistently 45 days between periods or who have amenorrhea of more than 3 months.

The summary of recommendations are as follows:

FHA is a diagnosis of exclusion. It should only be diagnosed after all the anatomic, organic or endocrine causes of amenorrhea are ruled out. 

The physician should perform a complete physical examination to rule out pregnancy as a cause of amenorrhea. A complete psychological evaluation including the drive to achieve perfectionism and need for social approval, ambitions and expectations for self is also necessary to address the psychosocial aspect of FHA.

A detailed diet history, exercise patterns and athletic training along with menstrual history should be elicited.

Initial Screening Laboratory tests should include serum beta HCG, CBC, electrolytes, liver function test, renal function tests and ESR.

Once the diagnosis is made the patients should be administered full endocrine evaluation including serum thyroid-stimulating hormone, free thyroxine, prolactin, luteinizing hormone, follicle-stimulating hormone, estradiol, and anti-Mullerian hormone.

A progesterone challenge test should be done to rule out structural abnormalities of genital tract.

A consultation with nutritionist is a very important form of treatment as regular cycles can be restored with more calories and proper diet.

A Brain MRI is often advised if patient complaints of persistent headache and visual problems to rule out pituitary adenoma.

Those adolescents or women with more than 6 months of amenorrhea should be tested for BMD with dual-energy X-ray absorptiometry.

These patients need an inpatient treatment if they have electrolyte imbalance, bradycardia or hypotension.

Patients who have had a fair trial with nutritional guidance, psychological treatment and exercise limitation should receive short-term transdermal E2 therapy with cyclic oral progestin.

Bisphosphonates, denosumab, testosterone, and leptin to improve bone mineral density is not advised in patients with FHA.

FHA patients wishing to conceive should undergo a complete fertility evaluation and treatment based on the results. Often cognitive behavioral therapy is very successful and restores ovulation and fertility without any medication.

Catherine M. Gordon of Cincinnati Children’s Hospital Medical Center in Cincinnati, Ohio, and the chair of the task force that authored the guideline said in a press release “This energy imbalance needs to be addressed to effectively treat hypothalamic amenorrhea and typically requires behavioral modifications. Referring patients to a nutritionist for specialized dietary instructions is an extremely important part of their care. Menstrual cycles can often be restored with increased calorie consumption, improved nutrition or decreased exercise activity.”

Rethink your drink--Coffee with add-ins ups the caloric content considerably.

Extra calories in Coffee and Tea.
Courtesy of Julie McMahon

People drinking coffee and tea with add-ins add 69 and 43 extra calories respectively to their daily intake. These additional calories come from additives (sugar and saturated fats) that have no nutritive values according to a study published in Public Health. [1]

Researchers from University of Illinois at Urbana-Champaign and department of Public Health, UC San Diego analyzed data over 12 years (2001-2012) from National health and Nutritional Examination Survey (NHANES) from 13,185 adults who drank coffee and 6,125 adults who drank tea in 24-hours prior to the survey.

Coffee and tea are the most widely consumed beverages in US. Over 160 million people in US consume coffee or tea. Adults consume them on regular basis and many people like to perk up the flavor by adding cream, flavored syrup, sugar or other calorie dense additives.

About 2/3 of 51% coffee drinkers   and 1/3 of the 26% tea drinkers    put some sort of add-ins to their drink. Milk product add a little Calcium to the drink but it should not be the reason to add milk to the morning joe. (average 22 mg per day of 1,000 to 1,300 mg RDA).

The daily intake of extra calorie seems very small but in long run they pile up and put on extra pounds. Some people drink more than 5 cups of coffee and tea daily, which adds up more calories to the daily diet.

 Ruopeng An,  kinesiology and community health professor who conducted the study said “Our findings indicate that a lot of coffee and tea drinkers regularly use caloric add-ins to improve the flavor of their beverages, but possibly without fully realizing or taking into consideration its caloric and nutritional implications.”

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[1] http://www.publichealthjrnl.com/article/S0033-3506(16)30453-X/abstract