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Senin, 31 Juli 2017

Higher Sugar Intake Linked to Depression in Men

Men who have more than 67g of sugar per day – about the amount found in two cans of cola – could be increasing their risk of common mood disorders by 23% after 5 years, compared to those with consume less sugar, researchers say.

A study also says having a mood disorder does not make people more likely to eat foods high in sugar.

High Sugar Intake

Adults in Britain consume roughly twice the recommended level of added sugar in their diets, and previous studies have linked higher sugar consumption with an increased risk of depression.

The study, published in the journal Scientific Reports, examines the association between sugar intake and common mood disorders.

The researchers, led by Dr Anika Knüppel from the Department of Epidemiology and Public Health at University College London, analysed people’s sugar intake from sweet food and drinks and the occurrence of common mental disorders.

They explain that few studies have investigated ‘reverse causation’, referring to the possibility that a mood disorder could lead to higher sugar intake, which they wanted to explore.

For their study, they examined repeat measures of sweet food and drink consumption and mental health to look at the association between the two.

They used data from the Whitehall II cohort, a long-term study on health (and nowageing), using participants working at different levels in the UK’s civil service.

Of the 10,308 participants recruited in 1985, about two-thirds are men and one-third are women.

After the first wave of data collection, self-completed questionnaires and clinical data continued to be collected every 2 to 5 years.

Fizzy Drinks, Cakes and Biscuits

For their analysis, the researchers used data collected up to 2013 and included participants who reported their consumption of at least 8 of a list of 15 items of sweet foods and drinks such as cakes, biscuits, fizzy soft drinks and added sugar in coffee or tea.

Participants were divided into groups based on their daily sugar intake from sweet food and drinks.

For men, these were:

More than 67g
Between 67g and 39.5g
Less than 39.5g

For women, these were:

More than 51g
Between 30g and 51g
Less than 30g

Their analysis found that men in the top third group, who consumed the most sugar at more than 67g per day, were 23% more likely to have common mental health disorders after five years when compared to those in the bottom third group, who consumed less than 39.5g of sugar per day.

This finding was independent of other diet-related factors, health behaviours and socio-demographic characteristics such as marital status and pay grade.

The researchers say they could not find a similar observation among women, but this may be due to the lower number of female participants.

The researchers also conclude that from the results of their study, they “were able to exclude potential ‘reverse causation’ as the reason for the observed link between high sugar intake and low mood”. They explain that the associations observed in their analysis were not the result of changes in consuming sugary foods and drinks.

Limitations of the Study

The study has limitations, noted by the researchers themselves.

Among them, for example, is that processed foods – which can be a hidden source of added sugar – were not included in the study; and self-reporting on questionnaires is often not reliable, with participants liable to underreport or otherwise misreport data.

In addition, nutrient content was based on food composition tables from 1991, and it is likely that food compositions have changed since then.

Reaction

Catherine Collins, a registered dietitian and spokesperson for the British Dietetic Association, agrees that “food portion sizes would have distorted the calculated sugar intake significantly”.

She explains that, for example, “a muffin or doughnut has almost doubled in size over the last 10 years” and that a can of cola soda is normally 330ml but it could also be a downsized 250ml.

Ms Collins also has other concerns about the study. She notes that only one-third of the participants in the original group were female, which is not typical of the UK population. However, she says, “Women have a far greater emotional engagement with food, yet this study failed to find any correlation between sugar intake and depression short term or longer term in women.”

She adds: “Whilst the food frequency questionnaire used to determine sugar intake was an appropriate tool, ‘translating’ this into daily sugar intake was deeply flawed…”

As an example, Ms Collins refers to the participants reporting their alcohol intake, but its contribution to sugar intake wasn’t taken into account. She says, “for heavy drinkers this could have been a significant oversight, especially if the favourite tipple was beer, lager or cider”.

She also mentions that there appears to be confusion on sugar intake “from both naturally occurring (e.g. milk) and added (‘free’ sugars, such as sugar added to hot drinks, in sweets and chocolates etc.)”.

She says: “The researchers concluded boldly that ‘their research confirms an adverse effect of sugar intake on long-term psychological health’ and make an unproven recommendation that a lower sugar intake would improve psychological health. Neither of these statements can be justified based on major issues with the diet survey which limits their findings.”

Ms Collins notes that reducing your consumption of free sugars may be good for your weight and teeth, but says “as protection against depression? It’s not proven.”

Tom Sanders, professor emeritus of nutrition and dietetics at King’s College London, also has reservations about the results. In his response to the report, he says: “From a scientific standpoint it is difficult to see how sugar in food would differ from other sources of carbohydrate on mental health as both are broken down to simple sugars in the gut before absorption and the glycaemic index of sugar is less than refined starchy foods such as white bread and rice.”

He also notes that, “When individuals reduced their sugar intake in the later follow up phases there was no change in risk of poorer mental health.” He explained that he would expect “to see the association with high sugar intake to persist with long-term follow-up which was not the case”.

SOURCES:

Scientific Reports: “Sugar intake from sweet foods and beverages, common mental disorder and depression: prospective findings from the Whitehall II study”

Science Media Centre

UCL Department of Epidemiology and Public Health

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Look Again at Look AHEAD: Weight-Loss Benefit Only in T2D Subgroups

There may be subgroups of patients with type 2 diabetes who experience marked health improvements in response to intensive weight-loss interventions, while others may experience substantially worse outcomes, the results of a reanalysis of data from a randomized controlled trial indicate.

The original Action for Health in Diabetes (Look AHEAD) trial of a weight-loss intervention in individuals with type 2 diabetes was stopped early in 2012 by the National Institutes of Health after finding no difference in a composite of cardiovascular events between the groups. Results were first fully reported and published in 2013.

However, the current researchers used machine learning to conduct an analysis of data on almost 5000 participants from the trial, finding that approximately 85% of patients with a particular combination of baseline plasma glucose levels and self-reported general health had a clinically meaningful response to weight loss.

In contrast, the remaining 15% of patients with well-controlled or mild diabetes at baseline but a negative perception of their health status experienced a significant increase in cardiovascular events during follow-up.

Study author Ronald Tamler, MD, medical director at the Mount Sinai Clinical Diabetes Institute, New York, commented in a press release: “This analysis restores my faith in basic common sense.

“For the vast majority of people with diabetes, a healthy lifestyle with weight loss carries significant benefits; however, it’s not for everyone. Thanks to this work, clinicians can infer which patients will benefit the most from such a lifestyle intervention.”

Study coauthor Aaron Baum, PhD, from Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, added: “As researchers and data scientists, we are always concerned that an overall study result could mask important disparities in benefit or harm among different types of patients, which is exactly what this study revealed.

“Being able to identify individuals who could benefit from an intervention is fundamental to patient care.”

However, the clinical meaning of the findings, which were published online in the Lancet Diabetes & Endocrinology on July 12, has been questioned by some experts, who describe the results as “puzzling” in an accompanying comment.

Digging Deeper: Reanalyzing the Analysis

Look AHEAD was a randomized, controlled, open-label trial that involved 5145 patients at 16 sites in the United States aged 45 to 75 years with a history of type 2 diabetes and overweight and obesity, who were enrolled between 2001 and 2004.

Of those, 2570 were assigned to an intensive weight-loss intervention involving healthy eating and increased physical activity, and 2575 were assigned to a diabetes support and education control group.

Hypothesizing that the overall neutral treatment outcome masked heterogeneous treatment effects from the intensive weight-loss intervention, the researchers decided to dig deeper and conduct a post hoc analysis on 4901 trial participants included in the National Institute of Diabetes and Digestive and Kidney Diseases Repository.

They performed causal forest modeling on a randomly selected training set of 2450 participants, constructing causal decision trees using 84 baseline predictors. These were then tested in the remaining 2451 participants.

Over a mean follow-up of 8.5 years, 199 (16.2%) of 1231 patients in the training set from the intervention group experienced the primary outcome, defined as a composite of death from cardiovascular causes, nonfatal myocardial infarction, nonfatal stroke, or hospitalization for angina. The primary outcome also occurred in 186 (15.2%) of 1219 control patients in the training set.

The new analysis revealed that baseline HbA_1c levels and self-reported general health on the Short Form Health Survey (SF-36) general health score were able to distinguish participants with a high vs low benefit from the weight-loss intervention.

Specifically, Cox models revealed that, among 2015 (83.7%) participants in the training set and 2101 (85.7%) in the testing set with an HbA_1c ≥6.8% or HbA_1c <6.8% and an SF-36 general health score of ≥48, there was an absolute risk reduction of the primary outcome of 3.46% (P = .038), at a number needed to treat of 28.9 to prevent one event over 9.6 years.

In contrast, among 400 (16.3%) of 2450 participants in the training set and 350 (14.3%) participants in the testing set with an HbA_1c <6.8% and an SF-36 general health score <48, there was an absolute risk increase in the primary outcome of 7.41% (P = .033).

These latter subgroups reported significantly fewer minutes of exercise during both the first 6 months and last 6 months of the intervention than those in the first subgroup, at -495 minutes and -924 minutes, respectively (P < .0009 for both).

Among participants with an HbA_1c ≥6.8% or HbA_1c <6.8% and an SF-36 general health score of ≥48, there was also evidence of greater improvements in HbA_1c, self-reported mental health, and blood pressure related to the intervention compared with other patients.

Data-Driven Methodology Can Reveal Hidden Benefits, or Can it?

Discussing the study, the authors write that their data-driven methodology “can reveal otherwise-undiscovered and clinically meaningful relationships between interventions, outcomes, and subgroups and can complement expert-based preregistered subgroup hypotheses.”

While noting that there is a need for further, prospective examination of their findings, they add: “Identifying robust subgroup treatment effects can increase the quantity of clinically relevant findings generated by clinical trials and enable clinicians to better individualize patient care.”

But in an accompanying comment, Edward W Gregg, PhD, from the Centers for Disease Control and Prevention, Atlanta, Georgia, and Rena R Wing, PhD, from the Alpert Medical School of Brown University, Providence, Rhode Island, say the findings are “difficult to interpret.”

While they acknowledge that “speculatively, good baseline health status might prime participants for better adherence to the lifestyle intervention, and a more favorable improvement in health and lower baseline HbA_1c might be a marker of less severe diabetes or better adherence to treatment regimens — the combination might therefore potentiate a better health outcome.”

They write, however, that this explanation is “unsatisfying” due to the lack of significant difference in compliance or metabolic risk factors between the subgroups.

They continue: “The finding of increased relative risk of the primary outcome among participants with low HbA_1c and poor health status is intuitively puzzling, and the very low absolute hazard ratio in the trial control group in this ostensibly unhealthy subgroup raises the question of whether this observation is simply a chance finding.”

Nevertheless, Drs Gregg and Dr Wing note, “Despite the questions left unanswered by this analysis, novel and rigorous study of the heterogeneity in intervention response is important to guide personalized care, risk stratification, and translation of prevention studies to clinical and community settings” and will becoming increasingly relevant as lifespans increase.

The authors and editorialists report no relevant financial relationships.

Lancet Diabetes Endocrinol. Published online July 12. Abstract, Editorial

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FDA Approves Long-acting Injectable for Bipolar Disorder

Trump Threatens to End Insurance Payments If No Healthcare Bill

WASHINGTON (Reuters) – U.S. President Donald Trump threatened on Saturday to end government payments to health insurers if Congress does not pass a new healthcare bill and goaded them to not abandon their seven-year quest to replace the Obamacare law.

In a Twitter message on Saturday, Trump said “if a new HealthCare Bill is not approved quickly, BAILOUTS for Insurance Companies and BAILOUTS for Members of Congress will end very soon!”

The tweet came a day after Senate Republicans failed to muster enough votes to repeal parts of the Affordable Care Act, President Barack Obama’s signature healthcare bill commonly known as Obamacare.

The first part of Trump’s tweet appeared to be referring to the approximately $8 billion in cost-sharing reduction subsidies the federal government pays to insurers to lower the price of health coverage for low-income Americans.

The second part appeared to be a threat to end the employer contribution for Congress members and their staffs, who were moved from the normal federal employee healthcare benefits program onto the Obamacare insurance exchanges as part of the 2010 healthcare law.

Trump has previously threatened to suspend the payments to insurers, which are determined by the Department of Health and Human Services. In April, he threatened to end the payments if Democrats refused to negotiate over the healthcare bill.

Responding to Saturday’s tweet, Senate Democratic leader Chuck Schumer said that if the president carried out that threat, “every expert agrees that (insurance) premiums will go up and health care will be more expensive for millions of Americans.”

“The president ought to stop playing politics with people’s lives and health care, start leading and finally begin acting presidential,” Schumer said in a statement.

Trump later urged Senate Republicans to try again on a healthcare vote. The Senate is in session for another week before it is scheduled to begin an August recess.

“Unless the Republican Senators are total quitters, Repeal & Replace is not dead! Demand another vote before voting on any other bill!” Trump said in a subsequent tweet.

Many insurers have been waiting for an answer from Trump or lawmakers on whether they will continue to fund the annual government subsidies. Without assurances, many plan to raise rates an additional 20 percent by an Aug. 16 deadline for premium prices.

With Republican efforts to dismantle Obamacare in disarray, hundreds of U.S. counties are at risk of losing access to private health coverage in 2018 as insurers consider pulling out of those markets.

In response, Trump on Friday again suggested his administration would let the Obamacare program “implode.” He has weakened enforcement of the law’s requirement for individuals to buy insurance, threatened to cut off funding and sought to change plan benefits through regulations.

Meanwhile, some congressional Republicans were still trying to find a way forward on healthcare.

Senator Lindsey Graham said in a statement issued late on Friday that he and two other Republican senators, Dean Heller and Bill Cassidy, had met with Trump after the defeat to discuss Graham’s proposal to take tax money raised by Obamacare and send it back to the states in the form of healthcare block grants.

Graham said the move would end Democrats’ drive for a national single-payer healthcare system by putting states in charge.

“President Trump was optimistic about the Graham-Cassidy-Heller proposal,” Graham added. “I will continue to work with President Trump and his team to move the idea forward.”

However, a majority of Americans are ready to move on from healthcare at this point. According to a Reuters/Ipsos poll released on Saturday, 64 percent of 1,136 people surveyed on Friday and Saturday said they wanted to keep Obamacare, either “entirely as is” or after fixing “problem areas.

When asked what they think Congress should do next, most picked other priorities such as tax reform, foreign relations and infrastructure. Only 29 percent said they wanted Republicans in Congress to “continue working on a new healthcare bill.”

Asked what they think Congress should do next, most respondents picked other priorities such as tax reform, foreign relations and infrastructure. Only 29 percent said they wanted Republicans in Congress to “continue working on a new healthcare bill.”

Additional reporting by David Lawder in Washington; Editing by Jonathan Oatis and James Dalgleish

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Joint Replacement Weight Loss Requirements Challenged

Obese patients with osteoarthritis do not need to lose weight before knee or hip replacement to benefit from the surgery, a large study has found. They can benefit as much or more from the surgery as patients with normal weight, researchers say.

Wenjun Li, PhD, and colleagues from the University of Massachusetts Medical School, Worcester, published their findings in the July 19 issue of the Journal of Bone & Joint Surgery.

“Our data shows it’s not necessary to ask patients to lose weight prior to surgery,” Dr Li said in a news release. “It’s challenging for a patient who is severely overweight and suffering in pain to exercise — often they just can’t do it.”

But the researchers acknowledge complications from joint replacement surgery are more likely in obese patients. Therefore, it is premature to change guidelines such as those of the American Academy of Orthopaedic Surgeons, Robert Quinn, MD, an academy spokesman, told Medscape Medical News. “We should absolutely not be telling people you don’t have to lose weight,” he said.

The researchers analyzed data from the Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement (FORCE-TJR) cohort, which represents a cross-section of US patients who underwent hip and knee replacements.

They identified 2964 patients who underwent primary unilateral total knee replacement and 2040 who underwent primary unilateral total hip replacement for osteoarthritis between May 2011 and March 2013.

At baseline, the patients’ scores on the Physical Component Summary, the Hip Disability and Osteoarthritis Outcome Score (HOOS), and the Knee Injury and Osteoarthritis Outcome Score, on average, were lower the more obese they were.

Six months after surgery, the average scores of all the weight groups improved on these scales. The scores of the heaviest patients remained worse than those of the normal and underweight patients, but they improved at least as much relative to baseline.

The change in Physical Component Summary scores did not differ significantly by body mass index (P = 0.37), and the HOOS and Knee Injury and Osteoarthritis Outcome Score scores improved more in some of the higher-weight groups than in the normal or underweight group.

For example, the baseline HOOS score (where 0 is worst and 100 is best) for morbidly obese hip replacement patients was 38.2 compared with 51.0 for the normal to underweight patients. But 6 months after hip surgery, the HOOS score was 88.4 for the morbidly obese patients and 91.8 for the normal to underweight patients.

The relative improvements of these groups remained similar after adjustment for baseline score, sex, age, race, education, household income, living alone, type of insurance, medical comorbidities, low back pain, number of other painful joints, and hospital surgical volume.

The findings generally correspond to those of similar studies in other cohorts, Dr Li and colleagues report.

This study did not include data on complications. The authors acknowledge that they and other researchers have previously found more complications, such as hospital readmission, among morbidly obese patients undergoing joint replacement surgery than among normal weight patients. And they write that they plan to publish a risk–benefit analysis in the future.

The authors also acknowledge the cohort in this study was not ethnically diverse: 92.7% of the knee patients and 94.1% of the hip patients were white.

Those undergoing hip replacement were 65.2 years old on average, and 42.2% had some other medical condition in addition to their osteoarthritis. Twenty-six percent were under or of normal weight (≤24.99 kg/m²), 37% were overweight (25.00 – 29.99 kg/m²), 22% were obese (30.00 – 34.99 kg/m²),10% were severely obese (35.00 – 39.99 kg/m²), and 4% were morbidly obese (≥40.00 kg/m²).

The knee replacement patients were 67 years of age, on average, and 48.7% had some other medical condition. Twenty-nine percent were obese, 15% were severely obese, and 9% were morbidly obese.

The number of total joint replacements and the prevalence of obesity in the United States have both increased during recent years. At the same time, government and private healthcare plans both are beginning to base payments on outcomes such as complications, pain, and function.

Until now, however, all the studies on obesity and hip and knee replacements Dr Li and colleagues could find were performed in other countries with patients who were older and less obese than the average patient undergoing these procedures in the United States, and these studies used data from single institutions.

Obese Patients Should Understand Potential for Complications

Surgeons should discuss the increased risk for complications with their obese patients, Dr Li said in the news release. “Patients who can lose weight should, but we acknowledge many people can’t, or it will take a long time during which their joints will worsen. If they can get the surgery earlier, once function is restored they can better address obesity.”

Dr Quinn said the risk for complications and the difficulty of the surgery should not be underemphasized in discussions with obese patients. “That’s why I would disagree with the press release,” he said. “We don’t want to tell them you no longer have to lose weight. If you can you should.”

However, he agreed that obese patients who cannot lose weight may still benefit from joint replacement, and he said this study adds to that understanding. “We believed until recently that the benefit part of the equation wasn’t there; there is now evidence to say it is,” he said.

The FORCE-TJR cohort was funded by the Agency for Healthcare Research and Quality. Three authors report receiving grant funding from Biomet outside the submitted work. Two authors report receiving grant funding from Zimmer outside the submitted work. The remaining authors and Dr Quinn have disclosed no relevant financial relationships.

J Bone Joint Surg. 2017;99:1183-1189. Abstract

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Pekan Ini, Sean Gelael Tes F1 Lagi Bareng Toro Rosso

Sean Gelael baru saja menjalani pekan yang tak menyenangkan. Tapi ada “kado hiburan” buat Sean ketika dia duduk lagi di balik kemudi F1 pekan ini.

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