Cereal fibre reduces risks after MI
A LARGE prospective study of dietary intake after myocardial infarction (MI) has found dietary fibre, especially cereal fibre, was significantly inversely associated with all cause and cardiovascular (CV) mortality. The research, published in the BMJ, included 2258 women, from the US Nurses’ Health Study, and 1840 men, from the US Health Professionals Follow-up Study, who were free of CV disease, stroke and cancer at enrolment, had survived a first MI during the 32-year follow-up, were free of stroke at the time of initial onset of MI, and completed food frequency questionnaires pre- and post-MI. The researchers found participants increased their average dietary fibre intake after MI, and the greater the increase, the lower the risk of subsequent all cause and CV mortality. They examined cereal, fruit and vegetable fibre, finding only cereal fibre had a strong association — pooled hazard ratio 0.73 (95% CI, 0.58–0.91) for all cause mortality, 0.72 (95% CI, 0.52–0.99) for cardiovascular mortality. The researchers speculated that the possible mechanisms for the beneficial effects of the high fibre diet included reductions in systemic inflammation, lower serum low-density lipoprotein cholesterol level, reduced lipid peroxidation, improved insulin sensitivity, overall better glycaemic control, and a beneficial gut microbiota environment. “In the general population, a 20-40% risk reduction in coronary heart disease has consistently been observed among those who consume fiber-rich whole grains regularly, yet less than 5% of Americans consume the minimum recommended fiber intake of 25 g/day for women and 38 g/day for men”, they wrote.
Global targets could save 37 million lives
ACHIEVING globally agreed targets to reduce modifiable risk factors for the four main non-communicable diseases (NCDs) — cardiovascular diseases, chronic respiratory disease, cancers and diabetes — could prevent more than 37 million premature deaths over 15 years, according to new research published in The Lancet. A modelling study found that if the six risk factors — tobacco use, harmful alcohol use, salt intake, high blood pressure and blood sugar, and obesity — were reduced, it would almost meet the United Nation’s global target to reduce premature deaths from NCDs by 25% relative to 2010 levels by 2025 (25×25). Using country-level data on deaths and risk factors, and epidemiological models, the researchers estimated the number of deaths that could be prevented between 2010 and 2025 by reducing the burden of each of the six risk factors to globally agreed target levels for tobacco use (30% reduction and a more ambitious 50% reduction), alcohol use (10%), salt intake (30%), high blood pressure (25%), and halting the rise in the prevalence of obesity and diabetes. The findings suggested that meeting the targets for all six risk factors would reduce the risk of dying prematurely from the four main NCDs by 22% in men and 19% for women in 2025 compared to what they were in 2010. Worldwide over 15 years, this improvement would be equivalent to delaying or preventing at least 16 million deaths in people aged 30–70 years and 21 million in those aged 70 years or older. An accompanying commentary said the targets were well within reach with political will. “But despite robust evidence, well proven cost-effective interventions, and a compelling case for action … to address risk factors for NCDs to save millions of lives, political apathy prevails”, the commentary author said.
Success with older liver donors
GOOD results for donation after circulatory death (DCD) liver transplantation, even with grafts from older donors and when donor risk factors such as warm and cold ischaemia time are minimised, have been reported from a retrospective study published in the British Journal of Surgery. The researchers found that short duration of ischaemia could limit graft loss and donor advanced age did not appear to compromise results, as no difference was demonstrated between DCD liver grafts from young donors and those from septuagenarians. The researchers retrospectively evaluated the outcomes of 70 consecutive DCD liver transplantations between 2003 to 2012, comparing three age groups in terms of donor and recipient demographics, procurement and transplantation conditions, peak laboratory values during the 72 hours post-transplant and results at 1 and 3 years. The transplants included 32 liver grafts from donors aged 55 years or less, 20 aged 56–69 years, and 18 aged 70 years or more. Overall graft survival was 99% at 1 month, 91% at 1 year and at 72% at 3 years. “The age of deceased liver graft donors has increased over the past 20 years”, the researchers wrote. “It has already been shown that older [donation after brain death] liver grafts can provide excellent post-transplant results if there are no other risk factors and if they are not used in [hepatitis C virus-positive] recipients.” They wrote that in the future donors aged above 50 years could provide “a large proportion of potential DCD donations enabling the procurement of liver grafts”.
Job loss common after breast cancer diagnosis
THE loss of paid employment after a diagnosis of breast cancer may be common, undesired, not restricted to the treatment period, and potentially related to the type of treatment administered, according to research published in Cancer. The researchers said although many clinicians believed that patients would “bounce back” after missing work during treatment, the results of their study suggested otherwise and highlighted a possible adverse consequence of adjuvant chemotherapy. The research included 1026 patients aged under 65 years at the time of diagnosis whose breast cancer did not recur. They completed a survey soon after diagnosis and again at 4-year follow-up. Of the 746 patients (76%) who reported they were in paid work before diagnosis, 236 patients (30%) were no longer working at follow-up. The researchers said “excess unemployment” for women who received chemotherapy began soon after diagnosis. Compared with women who did not receive chemotherapy, those who did were more likely to report stopping work 2 or more years before the follow-up survey (30% v 14%) and were more likely to have stopped work during the initial course of therapy (56% v 13%). Overall, 26% of patients treated with chemotherapy and 9% of others were not working both after the initial treatment and in the long-term, and 41% of patients treated with chemotherapy and 67% of others continued working both after the initial treatment and in the long-term. The researchers said the findings supported current efforts to reduce the morbidity and burden of treatments for breast cancer. “Indeed, such initiatives are actively being evaluated, including better strategies to identify those patients who might omit adjuvant chemotherapy because the marginal benefit is small. The results of the current study reinforce the need to advance these evaluative strategies to help physicians ‘first, do no harm’.”
Self-harm a risk with high-dose antidepressants
THE rate of deliberate self-harm (DSH) in children and young adults starting high-dose antidepressant therapy was nearly twice the rate for patients on modal-dose therapy, according to research published in JAMA Internal Medicine. The researchers conducted a cohort study using population-based health care utilisation data from 162 625 US residents aged 10–64 years with depression who initiated antidepressant therapy with selective serotonin reuptake inhibitors (SSRI) at modal or higher than modal doses. The researchers found that for the older cohorts, the absolute risk of DSH was far lower than for those aged 10–25 years. Patients were assigned to one of three empirically derived dose categories based on the distribution of doses prescribed among antidepressant initiators. The modal daily dose for citalopram hydrobromide was 20 mg/day, sertraline hydrochloride 50 mg/day, and fluoxetine hydrochloride 20 mg/day. “Our findings offer clinicians an additional incentive to avoid initiating pharmacotherapy at high-therapeutic doses and to monitor all patients starting antidepressants, especially youth, for several months and regardless of history of DSH”, the authors wrote. An accompany commentary said the study showed the rates of suicide attempts in the year before SSRI treatment were 1.31% for those on a modal dose and 1.46% for the higher dose. However, after treatment started, the rates were 1.47% for the modal dose and 3.15% for the high dose — relative risks of 1.12 and 2.16, respectively, for DSH. The commentary commended the researchers on a “thoughtful and careful analysis of the effects of initiating antidepressants at higher than modal dosages”. The findings added support to current clinical recommendations to begin treatment with lower antidepressant doses. “While initiation at higher than modal doses of antidepressants may be deleterious, this study does not address the effect of dose escalation”, the commentary said.
“Unrelenting” abuse for overweight teens
TREATING obesity by just educating and admonishing young people about lifestyles and being overweight is not only insufficient but also potentially counterproductive, according to the authors of a systematic review on the views of obesity among 12–18-year-olds published in BMJ Open. The researchers reviewed 30 studies involving more than 1400 young people in the UK “of all sizes”, finding they placed considerable emphasis on personal responsibility, and on the social rather than health implications of being overweight. However, obese young people described severe, unrelenting, size-related abuse and isolation. “Regardless of their own size, young people were judgemental of individuals who were overweight, but those with experience of obesity described an environment that contained multiple barriers to weight loss”, the authors wrote. “The overweight young people in the current review describe in some detail how weight-related taunting and abuse, and being marked out as unacceptably different, can lead to them feeling ashamed, isolated and fearful.” Some gave accounts of vicious cycles of bullying or isolation leading to comfort eating and lowered mood, weight gain and further bullying or isolation. Weight-based teasing was found to be associated with maladaptive eating and weight control behaviours, such as binge eating. The researchers highlighted the need to advocate for the inclusion of perspectives of people who are very overweight in policy discussions. They wrote that the review supported demands “that larger young people be encouraged, supported and freed from persecution so that they can deal with the complex phenomenon of obesity in ways that are most appropriate for them”.