The Health Costs of Hunger

I hope someday we will be able to proclaim that we have banished hunger in the United States, and that we’ve been able to bring nutrition and health to the whole world. –Senator George McGovern

Food. Nothing is more basic to our existence than eating. However, in our modern era of plenty, we often take the presence of food for granted. That is, we take it for granted until we no longer have access to it or it makes us sick.

Food insecurity, when individuals lack access to adequate and safe food due to limited resources, is pervasive in the United States. In 2018, 37.2 million Americans were food insecure and of that, 6 million were children. A recent analysis found that 20-50% of college students were food insecure and hunger affects their ability to learn, be economically stable, and navigate social situations. While food insecurity tends to be higher in rural areas, it affects people of every gender, age, race and ethnicity throughout the United States.

The health consequences of food insecurity are well-described and have a disproportionate impact on cardiovascular health. In children, food insecurity is associated with birth defects, cognitive and behavioral problems, increased rates of asthma, depression, suicide ideation, and an increased risk of hospitalization.  In adults, food insecurity is linked to mental health problems, diabetes, high blood pressure, and high cholesterol. Food insecurity affects health in multiple ways (Figure 1). Conceived of as a cyclical process (in which people have periods fluctuating between food adequacy and inadequacy), fewer dietary options lead to increased consumption of cheap, energy dense, but nutritionally poor foods. Over-consumption of these foods during periods of food adequacy can lead to weight gain and high blood sugar, and reduced consumption of food during food shortages can lead to weight loss and low blood sugar. These cycles are exacerbated by stress and result in obesity, high blood pressure, and ultimately diabetes and coronary artery disease. The cycle continues until access to adequate, safe, high-nutrition foods stabilizes.

As a driver of poor nutritional intake, food insecurity is among the leading causes of chronic disease-related morbidity. As such, there is increasing recognition that for many food insecurity is not behavioral challenge but a structural one. Indeed this is the reason for the creation and continued re-authorization of the supplemental nutritional assistance program (or SNAP) that in 2018 provided $60.8 billion to more than 40 million Americans. SNAP was initially conceived during the Great Depression as a strategy to stave off mass starvation while providing American farmers with a fair price for their surplus agricultural products. It has gone through many legislative and administrative updates since the 1930’s (for a full history, please see Dr. Marion Nestle’s recent review in the American Journal of Public Health) and today remains the 3rd largest, and one of the most effective anti-hunger programs in the United States. Yet, despite its success at reducing food insecurity, today, proposals to reduce the monthly benefit levels and impose restrictions to limit access to SNAP are gaining political traction.  If the proposed SNAP reforms were enacted, 2.2 million American households would no longer be eligible for SNAP and an additional 3.1 million households would receive reduced benefits–many of those affected would be elderly and disabled. Thus, the cycle of food insecurity and chronic disease would worsen.

Food nourishes us and provides the sustenance we need to get through each day with our health, livelihood, and dignity intact.  While I have outlined the public health case for mitigating food insecurity; it is clear that food insecurity is not just a health issue, or even just a political issue. Above all else, it is a moral issue and one that we that we cannot be on the fence on. We must decide if today, in the richest country on the planet, at its most prosperous time in history, our friends, patients, and neighbors – men, women, and children who are just like us – should be hungry.

If your answer is no, then thankfully there is much that we can do about it. Check back for next month’s blog on strategies that health care providers, neighbors, citizens, and professional associations can do to help address food insecurity in America. In the meantime, please share your experiences addressing food insecurity in your own practice or community with me at @AllisonWebelPhD.

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”



How to Celebrate the Year of the Nurse

Full disclosure. I am nurse. A proud nurse. I am a nurse because the strongest, kindest, and most adventurous women I knew when I was growing up were nurses. And throughout the course of my nursing career, I have been repeatedly reminded that nurses are privileged to experience some of the most distressing times in a person’s life alongside them – and to expertly help them through it.

My love for my chosen profession is one of the reasons I celebrate the World Health Organization declaring 2020 The Year of the Nurse and Midwife. This official recognition of the pivotal role that nurses, around the globe, have in creating healthier lives for all people regardless of their age, sex, or social status. As countries and health care rapidly evolved during the 20th-21st centuries, fewer people died from maternal and child illness and infectious diseases and today cardiovascular disease is one of the biggest killers of adults around the globe. The type of cardiovascular disease varies in different global settings- we see more ischemic heart disease in more developed countries and more hypertensive heart disease and cardiomyopathies in low income countries. Yet, despite the differing types of cardiovascular disease, in every corner of the globe nurses are helping people prevent, manage, and recover from cardiovascular disease.

There are more than 12 million cardiovascular nurses around the globe making them the largest discipline promoting cardiovascular health. Decades of evidence demonstrate that nurses have a critical role in promoting high-quality, cost effective care to improve cardiovascular health. As Leonie Rose Bovino, PhD, APRN, FAHA – Nurse Practitioner at Yale New Haven Hospital Outpatient Cardiology – states “Much of the premature cardiovascular morality is due to modifiable factors and nurses excel at building a rapport and establishing shared decision-making with patients about their health. This allows them to have an integral, immense and important role in decreasing CVD mortality.”

Francis Njoroge and his team at the Cardiac Care Unit at Moi Teaching & Referral Hospital in Eldoret, Kenya.

Francis Njoroge and his team at the Cardiac Care Unit at Moi Teaching & Referral Hospital in Eldoret, Kenya.

Nurses and nurse practitioners use this rapport to manage hypertension and high cholesterol; provide smoking cessation, diabetes and nutrition counselling; facilitate patients completing cardiac rehabilitation; and help manage the distressing symptoms of heart failure. And when nothing more can be done, nurses are there to help patients die with the comfort and dignity they deserve—holding hands, crying with family, and comforting those who don’t know what tomorrow will bring.

Francis Njoroge (pictured left) is the Nursing Officer-in-Charge at the Cardiac Care Unit at the Moi Teaching & Referral Hospital in Eldoret, Kenya. He provides care to patients with rheumatic heart disease, infective endocarditis, and heart failure. He helps them understand how to prevent complications from these conditions, conducts home visits after their discharge, and counsels both patients and their family members about their “ongoing disease process, adherence to medication, dietary habits and lifestyle modification”.  Like Dr. Rose Bovino, Francis’ role as a nurse and a leader is big and diverse, and sometimes complicated by familiar challenges – patients being unable to buy necessary medicines, high acuity patients, not enough time with patients, and too few hospital beds.  But despite these challenges, Francis and Dr. Rose Bovino chose their profession because they wanted a challenging career – one that would allow them to make a difference in people’s daily lives and, themselves, to be changed by the patients and their own stories. Asked what he wants young people to know about nursing, Francis states, “Nursing is a career that helps a person save lives, brings happiness to individuals and their families, and comfort to those in need. Despite being a challenging job, it’s very interesting and makes a difference in people’s lives. I would encourage young people to join us, and join nurses everywhere, in making a difference in their own communities”.

Many of the readers of this blog will be nurses, and many will not. But no matter what your profession is, chances are you know a nurse. So this year, ask the nurses you know about their stories. Why did they choose nursing? Why do they continue to be a nurse? What would make it easier for them to provide the best quality nursing care possible? Listen to them. Let their stories change how you think about your own health, or your work, or your relationships. Let them inspire you to be stronger, kinder, bolder, and seek out adventure in your right. Because when we recognize the pivotal role that nurses have in our community, we recognize the best of all of us. And I hope that recognition lasts long after the Year of Nurse and Midwife concludes.


The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.


It’s a small, small world…

It is probably fair to say that most of the #AHA19 attendees know that cardiovascular disease is the leading cause of death in their respective country. We’ve heard this fact repeatedly throughout our entire careers and its hard (but not impossible) to imagine this not being the case.

But we also know how much progress we have made in preventing and treating cardiovascular disease. Medications to reduce hypertension and hyperlipidemia are relatively inexpensive and available; there is widespread recognition of, and repeated UN commitments, to enhancing access to primary prevention strategies such as physical activity, better diet quality, and smoking cessation; and new evidence suggests that we can prevent heart attacks by medication alone in patients with some at-risk patients.

cvd realityYet, we may not always recognize that those at risk for cardiovascular disease in other parts of the world have challenges that don’t allow for equitable access to the benefits of this knowledge. Which is why I was delighted to see so many sessions on global cardiovascular disease at #AHA19. To kick off this programming, the World Heart Federation and the American Heart Association hosted a panel of Dr. Thomas Gaziano of Brigham and Women’s Hospital, Dr. Rita Kalyani of Johns Hopkins University School of Medicine, and Dr. Dorairaj Prabhakaran of the World Heart Federation. Together, they described the rapidly growing burden of cardiovascular disease; potential technological innovations for controlling cardiovascular risk factors in low and middle income countries; the increasing prevalence of shared risk factors with, and consequences of diabetes and cardiovascular diseases; and health system interventions to reduce cardiovascular morbidity. While this session highlighted challenges many low- and middle-income countries face in improving cardiovascular health including shortages of a trained healthcare workforce, inconsistent access to safe essential medicines, and more. It also provoked optimism because solutions are within our reach. Dr. Gaziano said that these strategies are “More about changing the mindset [of healthcare systems] to embrace chronic disease management rather than acute care or emergency needs only”.

Such a mindset was described by Dr. Craig Sable of Children’s National Medical Center during the T. Duckett Jones Memorial Lecture , who described the progress made in prevention, screening, and management of rheumatic heart disease around the globe. He concluded by saying that the end of rheumatic heart disease is within our reach, if we maintain the momentum of our recent gains.

I am impressed by the global cardiovascular programming at 2019 American Heart Association Scientific Sessions. And we still have two more days.

Some highlights include Sunday’s Bongai Mayosi Memorial Lecture on Disparities in Global Cardiovascular Disease, honoring a true legend in the field of global cardiology. Simultaneously, there will be an oral abstracts session on Implementation Science around Globe. The Presidential Keynote Address will be given by Murat Sönmez of the World Economic Forum… and so much more (search “world” in your AHA sessions planner).

Recognition of our shared commitment to be a relentless force for a world full of healthier lives is humbling.  It inspires a shared purpose for countless health care professionals-from community health workers to ministers of health in every nation throughout the globe.

So as you listen to members of the World Economic Forum and engage with scientists about their work on biomass fuel on cardiac function in Nepali women or women living with Rheumatic Heart Disease in Uganda please stop, take a deep breath, and think about how you will be a force for global good.


The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.


What if? Making the most of your 72 hours at #AHA19

The two most powerful words in the English language are “What If.” These words have created new nations, led to the most memorable books, and landed humans on the moon. They have also inspired almost every scientific breakthrough throughout human history. What if we could isolate radio isotypes? What if we could ultrasound the heart? What if we could transplant heart valves? What if we could create a machine to function like a heart while awaiting transplant? Each breakthrough has led to thousands of additional, and unanticipated, “What If” questions that have formed the foundation of modern cardiology and saved millions of lives.

Dreaming up “What If” questions is the first step of innovation and science is the method of rigorously answering these questions in a reproducible way. At AHA Scientific Sessions (#AHA19) this year, scientific innovation will be on display in every corner of the Philadelphia Convention Center.

In many ways, the entire Health Tech and Innovation Summit is the result of “What If” questions. What if we use artificial intelligence to identify those at risk for heart attacks? What if my K award results in a new Blood Pressure device that can be commercialized? What if we can use our smart watches to detect Atrial Fibrillation? And after smart watches, sensors, medical records and artificial intelligence have been harnessed to their full potential, what nascent technology will next revolutionize cardiovascular health? To find the answers to these questions, and three days’ worth of cutting edge discoveries, please join us in the Health Innovation pavilion, Heart Hub, Science and Technology Hall, Level 2.

And to be truly inspired, please add the AHA competition for best artificial intelligence and machine learning to your itinerary. This year three incredible trailblazers, Dr. Suchi Saria from the Johns Hopkins Bloomberg School of Public Health, Dr. Ramaraju Rudraraju from the University of Alabama at Birmingham, and  Dr. Chun Yuan from the University of Washington, will compete for $10,000 prize sponsored to Amazon Web Service and Circulation: Genomic and Precision Medicine.

This year the World Economic Forum Collaborators will present sessions on big data and deep learning, blockchain in health care, and highlight the value in Healthcare Initiative for cardiovascular practice.

But not every innovation is new or digital. One of the most anticipated late-breaking science presentation is the results of the COLCOT study. The COLCOT study evaluated the impact of colchcine, an anti-inflammatory medication used for hundreds of years, on the recurrence of cardiovascular events in those who have recently experienced a heart attack. Results will be released Saturday morning at 10:45am.

What should you take away from Scientific Sessions this year? Yes, you will see, and hopefully experience, lots of cool and potentially life-changing innovations, develop lifelong networks, and walk a lot. And when you leave Philadelphia, you may be able to apply these innovation to your daily work. But, perhaps more importantly, I encourage you to take a step back and think about these innovations in the aggregate. Think about what prompted the “What If” questions that resulted in the presentations. Then think about your own “What if” questions.

As you attend Scientific Sessions this year, I hope you take away more than just (the important) knowledge about these innovations. I hope you take away the inspiration to ask your own “What If” questions. Let those questions change your practice or your daily work and inspire you to be a relentless force. And next year, or maybe in the next 10 years, bring your innovations back to Scientific Sessions and let them inspire others to dream bigger and see further.


The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.


Going the Distance: Setbacks and a Meaningful Career in Science

On July 4th, me and 60,000 of my closest friends ran in the 50th Peachtree Road Race in Atlanta, Georgia. This was my first 10K run and as a relatively new runner, my inclination for training for this race was to go hard and go fast – a manta not just for running but possibly for my entire generation. But as I would eventually learn, distance running is not about just getting it done. It is about being patient, listening to (and adjusting) my body, and having a long-term mindset focused on the process as much as the goal.

nih rejectionsThroughout my training, I was struck by how similar distance running is to a career in science and to grant writing in particular. When I finished my PhD 10 years ago, I was confident in my ability to write manuscripts and proposals, secure funding, and ultimately do and disseminate the science that would leave a lasting impact on the health of vulnerable populations. This confidence continued even when, during the last few years of my K award, I submitted grant after grant to the NIH only to have them be not discussed repeatedly.  I understood that NIH success rates were low, with institutes reporting a range of success rates from ~10% to 35% in 2018. Mentors reminded me that failure was part of the process and that everyone has a string of not discussed grants in the early phase of their career. I just needed to keep listening to the reviewers, getting more preliminary data, refining my ideas, developing great teams, and above all writing, and eventually my ideas would hit. However, when my string of not discussed/not funded grants grew to 15 (Figure 1), each set of pink sheets more soul crushing than the last, I knew that statistically I was failing more than I should. And I questioned if I should even be in science or if these past few years were just wasted time.

These setbacks can be devastating – causing approximately 10-15% of early career scientists to leave the field. But what about those who stick it out? What happens to them and, more importantly, what is their long-term impact on science? These are the questions explored in a recent article by Yang Wang, Benjamin Joes, and Dashun Wang, “Early-Career Setbacks and Future Career Impact”. Through a series of pretty cool analyses they examined if early success in obtaining an R01 award from the National Institutes of Health led to more success and a higher impact (measured as highly-cited manuscripts) compared to those who almost, but just missed the funding threshold. Essentially, they wanted to figure out among early career health scientists which perspective is true: Do the “the rich get richer” or will “what doesn’t kill you makes you stronger”?

Unsurprisingly, the results were somewhat mixed but encouraging for an early career scientist who has had many misses. While those with near misses had approximately a 10% chance of leaving the NIH funding system entirely over the next 10 years; of the scientists remaining, those who had an early career funding failure wrote higher impact manuscripts, compared to those who had early funding success. This is a striking finding which needs to be carefully considered (specifically that junior scientists do not need additional roadblocks in their path in order to become “stronger scientists”). Yet, the authors do suggest that for those scientists who persevere, “early failure should not be taken as a negative signal” rather viewed as a chance for refining and improving their program of research.

Wang and colleagues start their manuscript with a quote by Robert Lefkowitz, winner of the 2012 Nobel Prize in Chemistry, “Science is 99 percent failure, and that’s an optimist view.”  While he many have been referring to failed experiments, what Wang’s  new analysis reveals is that even the process of obtaining the funding to support research is likely to be fraught with heartbreaking setbacks. But if you’re in science because you believe in its power to answer important questions which will help us to better understand and improve the human condition, perseverance is necessary.

I finished my first 10K in under 60 minutes. Not a medal-winning time but I preserved through the heat, sun, fatigue, and even a bit of pain to cross the finish line. Similarly, late last year I received the Notice of Award for my first R01 from the NIH- leading a research study that I believe in with a team that inspires me every day.  So whether you are submitting your first or 15th research grant, know that setbacks are common and despite the outcome on any one application, with a long-term mindset you can have a lasting impact on science.


How to Get in the Room Where it Happens: A Conversation with Don Lloyd-Jones About Becoming An Influencer

We’ve all had those moments – where someone we work with, someone in a position to make decisions – big decisions, not the marginal ones – makes THE wrong decision. A new department is created with no resources undermining its long-term viability, or an entire program is eliminated for short-term cost savings. No, I’m not talking about corporations or government. I’m talking about hospitals, clinics, and universities – the places early career clinician scientists hope to work after completing what seems like endless training. Poor leadership is endemic and early career scientists are likely to confront the question, “How to I position myself to influence the issues I’m passionate about?”

To understand this issue, I spoke with Don Lloyd-Jones of Northwestern University. For the past 15 years, Dr. Lloyd-Jones has served in leadership positions on numerous American Heart Association committees including the Statistics Committee, Council on Epidemiology and Prevention (EPI), and co-Chaired the Writing Group for 2013 ACC/AHA Guidelines on the Assessment of Cardiovascular Risk. Given his background of service, it was not surprising that he enthusiastically recommended that all early career clinician scientists become involved with a professional association whose mission resonates with them.  However, it’s important to be strategic about developing your leadership experiences and he offered the following tips.

Tip #1: Be Bold, Work Hard, and if Necessary, Open Your Own Doors

Like other leaders, Don Lloyd-Jones’ mentors introduced him to professional organizations. They advocated he work on the Statistics Committee of the EPI Council, where he helped write the annual Heart Disease and Stroke Statistics Update.  This was hard work, often completed during off-hours but in a timely fashion, and through it Lloyd-Jones established a reputation as a dependable team player. In 2008, as he chaired the stats committee, the AHA was thinking about the strategic impact it wanted to have on cardiovascular health over the next several decades. Described as a “moment of serendipity,” Lloyd-Jones was asked to chair what would become The American Heart Association’s Strategic Impact Goal Through 2020 and Beyond. For him, this was a “career-defining experience where we helped to pivot the AHA from preventing death to promoting cardiovascular health.”

While having a mentor connect you to committees and networks is an efficient way to get involved, it is not the only way to get in the room. For AHA and other professional organizations, introducing yourself to the committee’s Chair, Vice-Chair, Past-Chair and the nominating committee can get you on their radar. Then follow up with an email letting them know that you would love to work on their committee, asking how you can get more involved. When a door opens, even if it’s not exactly the one you wanted, “show up, do the work, share what drives you, create a reputation as a contributing team member, and in doing so you will have almost limitless opportunities to meaningfully effect change.”

Tip #2: Find Your Niche First

While every early career professional should plan to become involved with professional organizations, it is important to first establish a clinical niche or stabilize a successful lab before assuming a leadership position. Once that is accomplished, plan to quickly engage with professional societies because at that time, you have developed a substantive understanding of your field and will bring a voice to the table that will be respected, valued, and sought after. This inflection point often occurs mid-way to the end of one’s Career Development Award and should be planned for and strategically pursued.

Tip #3: Know What You Want

Reflecting on yourself – your goals, capabilities, and weaknesses – is a common theme in leadership books. A critical look at what you want from a leadership experience will help you select the right one and maximize its benefits. In the short-term, if you want highly-cited publications, working with the stats committee might be a great fit. Or if you have a long-term vision of assuming national leadership roles, you may want to try out different committees to see which one aligns with your preferred areas of strategic influence. However, all true leadership engagement, whether at a regional or national level, will lead to a meaningful and expanded professional network. As Dr. Lloyd-Jones stated, “Serving allows you to make connections in robust ways. These new connections can be called upon for letters of support for promotions and tenure or for grant applications. And the personal connections developed through engagement will matter far more than the name of the person who is writing because they bring a lot more color to the applicant.” And over time these professional colleagues can become friends. He shared, “The friendships that you make in AHA, perhaps due to its altruistic nature, are quite unique. AHA draws remarkable people who share a vision to promote health and many become lifelong friends. Why wouldn’t you want to be a part of that?”

Tip #4: Be Open to Change

While many people pursue leadership experiences because they want to change the outcome, oftentimes we are changed by the process of leading with others. Yes, we will have bigger networks, busier travel schedules, and fewer free hours but all of this also changes us — our empathy, perspective, time-management skills, and our ability to adapt to new and ever-changing contexts. For Lloyd-Jones, his two years working on the 2020 strategic impact goals, “Substantially changed the focus of my research, what I talk about, what my whole department is focused on, which is increasingly on children and helping them get a healthier start in life. It’s been a wonderful gift.“

In their review article, Warren and Carnell describe the non-technical skills needed for health care leadership including “creating and communicating a vision, setting clear direction, service redesign and healthcare improvement, effective negotiation, awareness of both self and others, working collaboratively and networking.” No one is born knowing how to create and clearly communicate an inspiring long-term vision for change and collaborating to turn that vision into reality. It takes time, practice, failure, courage, and continued investment. Should you choose to pursue your own leadership path, I hope the time, work, and energy you spend developing influence will be among the most fulfilling investments in your career.

Or as Lin-Manuel Miranda wrote:

“….When you got skin in the game, you stay in the game
But you don’t get a win unless you play in the game
Oh, you get love for it, you get hate for it
You get nothing if you
Wait for it.”


Paradigms and Progress in HIV and Cardiovascular Health

 “Led by a new paradigm, scientists adopt new instruments and look in new places” – Thomas S. Kuhn

For a lot of rational (and some irrational) reasons, hearing the word HIV evokes fear, anger, and sadness. When I first heard about HIV, I was an elementary school student in late 1980’s and at that time, HIV was almost always a death sentence.  But today that is not the case.  Today, due to the hard work of scientists, patients, volunteers, advocates, and countless others, HIV is a chronic, manageable disease. An accomplishment epitomized by the oldest known person living with HIV recently turning 100 years old.

living with HIV graph

While this progress and longevity should be celebrated, the flip-side of age is that it is the primary driver of cardiovascular disease (CVD). In fact, this longevity has ushered in a new era where adults living with HIV are at exceptionally high risk of cardiovascular diseases including heart attacks, heart failure, and stroke. A recent meta-analysis by Anoop Shah, MD, from the University of Edinburgh, found that the global burden of HIV-associated cardiovascular disease has tripled in the past 20 years, especially in low and middle-income countries. Now, after more than two decades of accumulating evidence in this field, the American Heart Association released earlier this month a Scientific Statement on the characteristics, prevention and management of cardiovascular disease in people living with HIV.

Directed at all who support adults living with HIV, this statement is a general roadmap for raising awareness about the increasing burden of CVD in this population. However, it offers few new tools for providers to use, due primarily to the lack of high-quality “clinical trial data on how to prevent and treat cardiovascular diseases in people living [and aging] with HIV investigating cardiovascular endpoints” said Matthew J. Feinstein, M.D., M.Sc., chair of the writing group for the statement and assistant professor of medicine at the Feinberg School of Medicine, Northwestern University.

Still, what the existing (mostly observational) evidence allowed the writing group to do was to develop a pragmatic approach to assessing and preventing cardiovascular disease in treated HIV (Figure above). This approach includes the following:

  • Ensure all patients living with HIV are on effective HIV treatment
  • Determine risk of cardiovascular disease using tools such as ACC/AHA 10-year ASCVD risk estimator and a family history
  • Optimize lifestyle approach to prevention (e.g., smoking cessation, physical activity, healthy diet intake)
  • If at high risk and between the ages of 40-75 years, talk with the patient about the risks and benefits of lipid-lowering therapy while exercising caution for drug-drug interactions

Yet, while the new AHA Scientific Statement will be an important catalyst for the field, in many ways it creates more questions than answers. For example, are we shifting to a new paradigm in HIV care? Do we need new tools to help reduce CVD in this population or are the general recommendations for risk stratification and lifestyle optimization sufficient?  What is the most effective way to get either existing or new clinical tools to the high-risk patients living with HIV?

Fortunately, some of these questions are starting to be answered. The REPRIEVE study is the first large scale (>8,000 people) clinical trial to test if a daily statin reduces cardiovascular disease in adults living with HIV. Results are expected in the next 3-4 years. Additionally, the PRECluDe grants at the National Heart, Lung, and Blood Institute have stimulated new implementation science research focused on understanding how to best adapt effective CVD prevention studies to the real-world settings where people living with HIV receive their health care. These initiatives, coupled with ongoing research on the discovery of mechanisms of CVD and the testing of CVD prevention interventions in people living with HIV, will eventually allow for the development of guidelines on the prevention and management of CVD in HIV—the true instrument needed to help improve cardiovascular health for all adults living with HIV.



Seeing and Serving Invisible Populations

Like many of you, I chose to be a nurse because I wanted to serve people during their most vulnerable times, knowing that this work would make a difference. Working with people at their most vulnerable has taught me a lot, including that my patients can be braver, kinder, more frightened, angrier, disappointed, lovelier, and in general more surprising than I expect when I walk in the door.

A growing and perhaps surprising population at disproportionally high risk for heart attacks are individuals who identify as transgender. Transgender individuals are those whose gender identity is different from the sex they were assigned at birth. People identifying as transgender can be any age or race, from any background, and reside in all 50 states. In 2016 there were approximately 1.4 million people in the United States who identified as transgender.  Given the increase in the transgender population, new initiatives are attempting to understand the unique health needs of this population in order to provide high-quality health care. Little is known about the cardiovascular health of this population, which prompted a recent study by Dr. Alzahrani from George Washington University who found that the transgender population had a higher reported history of heart attacks compared with the cisgender (those whose gender corresponds with their birth sex) population.

This first-of-its-kind study examined approximately 720,000 U.S. adults who completed the telephone-based Behavioral Risk Factor Surveillance System survey, conducted by the Centers for Disease Control and Prevention between the years of 2014-2017. Of these, 3,055 adults identified as transgender. In gender stratified analyses, Dr. Alzahrani and colleagues found that after adjusting for known cardiovascular risk factors transgender men had (i.e. they were told by a doctor, nurse or health care professional that they had a heart attack) compared to cisgender men and women. And transgender women had a 2-fold increase in the rate of heart attacks compared with cisgender women. Importantly, the investigators also found that transgender men and women were more likely to smoke and be sedentary, and that these and other traditional risk factors were associated with increased odds of experiencing a heart attack. This suggests that while there are about the long-term cardiovascular risk of gender affirming-hormones, mitigating these traditional risk factors are important first line targets for this and all populations.

In an accompanying editorial Dr. Paul Chan evoked Ralph Ellison’s Invisible Man, citing the narrator “I am invisible, understand, simply because people refuse to see me.” Dr. Chan states that today transgender individuals are invisible. But they don’t have to be. We have to actively reject any implicit or explicit expectations we have about this population and simply see them and treat them as they present. This sentiment is echoed by Dr. Billy Carceres, Nurse and Post-Doctoral Fellow at Columbia University Program for Study of LGBT health, “There’s this perception that we can spot transgender people; but if we don’t ask the question about gender identity we might be missing out on people who are at risk. Patients want to have conversations with health care providers about things that influence their health.”

Table 1 lists several steps that can help us start to have these conversations. Adopting such steps in our clinical practice and research are critical against the backdrop of the increased social stress, poor socioeconomic status, health disparities, violence, and a perpetuating fear of mistreatment by healthcare professionals experienced by transgender populations. These steps will help us to see this invisible population, gain their trust, and ultimately help engage them in activities to improve their cardiovascular health.

Table 1. Steps to Reducing Cardiovascular Risk in Transgender Populations

  1. Assess the gender of all your patients or research participants on multiple levels
  2. Ask which pronouns they would like you to use
  3. Understand the terminology used by the trans community
  4. Recognize that transgender people may avoid seeking out health care because of fear of discrimination and create a safe and welcoming environment
  5. Assess all potential cardiovascular risk factors for transgender patients and work with them to collaboratively develop a plan to reduce their risk factors
  6. Learn more about the unique health care needs of your transgender patients. Your health care institution may have good local resources and the Center of Excellence for Transgender Health at UCSF and the World Professional Association for Transgender Health have up-to-date resources.

While Dr. Alzahrani’s new article highlights a significant disparity in an often overlooked and vulnerable population, ultimately we need a lot more data before we can develop and tailor cardiovascular treatment guidelines for transgender populations. As Dr. Sangyoon Shin, Medical Director of Co-Management Service for Gender Affirmation Surgery of Mount Sinai stated, “Its important to realize that the transgender population has specialized needs because they are more marginalized and face high rates of discrimination; But the health care practices the guidelines geared towards them need to be just as evidence-based as with any other population.“ Anything less would be a disservice.

People who seek out a health care provider – a nurse, physician, physical therapist, or pharmacist – do so because they need our help. Our job is to serve them, all of them, as they are, with high quality evidence-based health care. How we treat invisible populations, no matter how different or perplexing they are to us, is the true mark of our professionalism.



A Tale of Two Heart Attacks

Differentiation between Type 1 and Type 2 heart attack according to the condition of the coronary arteries (Thygesen, et al., 2012, Circulation)

Differentiation between Type 1 and Type 2 heart attack according to the condition of the coronary arteries (Thygesen, et al., 2012, Circulation)

Crushing. Stabbing. Gut-wrenching, knock the wind right out of you sort of pain in your chest, arms, neck, jaw or back.  This is how we commonly think of heart attacks and for patients and their loved ones – it is the worst of times. But just before the pain or discomfort starts, your body is adjusting to the cause of the heart attack and those causes can be classified as either Type 1 or Type 2 heart attacks. There are actually 6 types of heart attacks, but the vast majority of heart attacks, including those experienced by people living with HIV, are either Type 1 or Type 2.

A Type 1 heart attack is when a person has a sudden block in their blood flow, usually related to a blood clot that has broken off from a plaque, resulting in reduced oxygen going to the heart and death of heart muscle cells.  Whereas a Type 2 heart attack is when the heart needs more oxygen than it gets, due a number of potential causes including a spasm of the heart vessels, critical illness (including sepsis, very low blood pressure, and respiratory failure), or those undergoing surgery.

As I’ve previously written, HIV doubles the risk of heart disease and doubles the risk of having a heart attack. But in order to understand how to reduce this risk, we need to better understand what causes heart attacks in people living with HIV.  Building on previous work demonstrating that half of the heart attacks in people living with HIV are Type 2 heart attacks, Crane and colleagues recently presented new research on the differences in types of heart attacks among people aging with HIV. In over 27,000 adults living with HIV, the investigators determined the type of heart attack, probable cause of all Type 2 heart attacks, and looked at the rates of heart attack by age.

causes of type 2 myocardial infarction among people living with HIVThey identified over 1,000 Type 1 and 2 heart attacks and found that age was a primary predictor of the incidence and type of heart attack. Younger people with HIV had 10-fold more Type 2 than Type 1 heart attacks (although rates were low – only 22 heart attacks in this age group).  Starting in their 50’s, people living with HIV experienced significantly more Type 1 heart attacks than Type 2. Most interestingly were the heterogeneous causes of the Type 2 heart attacks including sepsis, respiratory failure, pneumonia, hypertensive emergency, and GI bleeds (Figure 1).

When asked what initially prompted this work, Dr. Heidi Crane from the University of Washington Center for AIDS Research states, “As an awareness of the importance of Type 2 heart attacks has grown in the general population, we were struck that there was so little data in people living with HIV- a population which has twice the rate of heart attacks as the general population.” This new study demonstrates that younger adults living with HIV are more likely to have Type 2 heart attacks from heterogeneous causes, which change the prevention strategies needed for this group.  While prevention strategies for Type 1 and 2 heart attacks require attention to traditional risk factors, we also need to pay attention to other non-traditional causes that may put someone with HIV at risk for heart attack due to supply-demand mismatch. Ultimately, these prevention strategies will need to be as heterogeneous as the causes. Dr. Crane continues, “There’s not going to be an easy fix for Type 2 heart attacks, there’s a lot going on and we will need to dive deeper to understand how to best tailor strategies to the individual patient.”

And yet, we’re often told that we need to treat the patient, not the disease. But in order to treat the patient, we have to know them, listen to them and understand the risk factors that they face as individuals for heart attacks. Whether it is a chronic disease like HIV infection or some other inflammatory condition, we will need to avoid the temptation to apply blunt prevention strategies, and favor the more challenging personalized solutions.

What are your experiences diagnosing and treating Type 2 Heart Attacks? How can we do a better job preventing them in people living with HIV and others at high risk? Tweet at me at @AllisonWebelPhD to follow the conversation.


Thumbnail photo credit: Photo by Kelly Sikkema on Unsplash

Thumbnail photo credit: Photo by Kelly Sikkema on Unsplash






A Profile in Mentorship: Dr. Thomas Pearson

Every scientist, even those who are particularly good at hiding away in their offices, will have an impact on others. Most of the time, this impact is a byproduct of our everyday work. We don’t give it much thought – it just happens. But what if that impact was not accidental, and instead was a deliberate, strategic path of choices that build up those around us – even those who disagree with us, compete with us, and threaten us? That is the path that has been trodden by Dr. Thomas Pearson who was awarded the 2019 AHA Council on Epidemiology and Prevention Mentoring Award.

Dr. Pearson has an impeccable academic pedigree and an enviable career. After an early start at the University of Wisconsin, he earned his Bachelor of Arts, MD, MPH, and PhD all from the Johns Hopkins University. He has achieved the goal of every early career scientist – over 35 years of continuous NIH support and is a Fellow of the American Heart Association, American College of Cardiology, the American College of Preventive Medicine, and the American College of Physicians. But the degrees, grants, and accolades are a byproduct of a man driven to service for the love of science.

Dr. Pearson’s own mentors reflected his insatiable curiosity. As a student, he drew from a broad mentoring team that left lifelong impressions of the qualities of good mentor. While excellent teaching was important, more so was the “utterly frank” assessment and advice they provided him. He states, “from them I learned that the primary role of a mentor is to provide an honest, encouraging perspective on the mentee’s ideas, plans and experiences. While some mentors may be tempted to acquiesce or tell mentees what they want to hear- that is abrogation of their responsibility of a mentor.” Such frankness can be tough in today’s academic environment, so to help cultivate this skill, Dr. Pearson’s University of Florida developed the Mentorship Academy. Equally important to learning how to deliver a frank assessment of the mentee is helping the mentee learn how to receive and act upon such advice without taking umbrage to it.

Additionally, Dr. Pearson offered this advice on how early stage professionals can intentionally become effective mentors, including:

  • Be a good communicator. Communication is the basis of mentoring. Good communication should include developing shared expectations of the goals, responsibilities, and processes of the mentor-mentee relationship. Many of the problems that occur in the mentoring relationship result from a misalignment of expectations and reality. An honest conversation, with both parties being active listeners, about the mentor and mentee’s strengths, weaknesses and goals early on in the relationship can set both parties up for success.
  • Broaden your network. Every day we hear about new grants, interesting conferences, and visiting professors. Yet because they are just starting their career, mentees may not hear about the same opportunities. Part of being a good mentor, Dr. Pearson suggests, “is to continually be looking out for opportunities for your mentee and actively encouraging them to pursue them”. This includes inviting a mentee to a lecture and offering to introduce her to the speaker. Opening this door can help a mentee broaden her professional network and embolden her to pursue new opportunities.
  1. Focus on the mentee. The mentor must recognize the mentee is not “hers.” Rather the mentor should focus on the mentee’s needs and goals and, if she finds another investigator can provide a better opportunity for the mentee, help to arrange it. Dr. Pearson states, “Mentoring and selfishness are like oil and water- they don’t mix.”
  2. Stay curious. In his acceptance speech, Dr. Pearson talked about how much he learned from each of his mentees. They taught and inspired him as much as he did them. But that can only happen by accepting that mentoring is a partnership in which each person has a lot to offer. Good mentors need to be curious about their mentees and excited about learning from them.

Dr. Pearson has mentored over 60 people during his career. Many have gone to have equally enviable careers where their impact reverberates into every corner of our profession. He told me, “You never really stop mentoring a mentee. People I mentored still call me and talk about their career, their family. At some point, they start being friends.”

Mentors – true mentors – view their work not as a requisite service but as a thread that weaves together the knowledge of the current and past generations to the next. Mentors are the foundation upon which scientific progress is made; and their impact is the greatest when their mentoring is done with humility, enthusiasm, compassion, curiosity, and an infallible sense of optimism. These are the traits Dr. Pearson embodies; and are the ones that all who seek to see further should strive to emulate.