Catherina Chang Martinez, PhD – The Early Career Voice

American Heart Association and California Walnut Commission Joint Initiative to Support Walnut Research

August 20, 2021August 17, 2021 Catherina Chang Martinez, PhD

Picture from https://www.heart.org/en/healthy-living/healthy-eating/eat-smart/fats/go-nuts-but-just-a-little

Earlier this year, The American Heart Association and the California Walnut Commission (CWC), a non-profit organization funded by mandatory assessments of the growers, announced a special award to support early career scientists pursuing human clinical or epidemiological research on walnut consumption.¹ This presents an exciting opportunity to engage early scientists interested in improving public health outcomes through walnut research. This initiative with the American Heart Association opens new opportunities to increase our scientific knowledge of the benefits of walnut consumption in heart and brain health. With the ongoing efforts to pursuit a healthy lifestyles through a healthy diet, we find ourselves with nuts being inclusive in the many diet options we see these days.^2-3

Walnuts provide 190 calories per one-ounce serving, which is equivalent to 1/4 cup, which is equivalent to approximately 12-14 walnut halves or a handful. They are also a good-fat food with 13 grams of polyunsaturated and 2.5 grams of monounsaturated fat of the 18 grams of total fat in one ounce of walnuts. Other benefits include its 2 grams of fiber per one ounce serving, important for heart health, gut health, and weight management. Walnuts are a rich source of Vitamin B6, Magnesium, Melatonin, Copper, and Manganese.⁴ The Dietary Guidelines for Americans recommends the consumption of unsaturated fats over saturated fats, thus supporting the consumption of nuts, and walnuts.⁵ These further present a healthy option as a non-animal source of proteins. The 2013 American College of Cardiology/American Heart Association document on lifestyle management to reduce cardiovascular disease risk supported its inclusion due to cardiovascular benefits associated with walnut consumption in the studies.⁶ Given the ongoing burden from heart attacks and strokes, we will continue to see a shift towards optimization of dietary patterns as modifiable risk factors in the prevention of cardiovascular disease.

There are many benefits from the consumption of walnuts. There is an increasing body of knowledge as a result of the studies targeting health outcomes. Study findings suggest benefits in diastolic function in young to middle-aged adults. ⁷ Based on results from prospective cohort studies, the consumption of peanuts and tree nuts (2 or more times/week) and walnuts (1 or more times/week) has been associated with a 13% to 19% lower risk of total cardiovascular disease and 15% to 23% lower risk of coronary heart disease.⁸ Most recent studies suggest that walnut consumption may benefit cognitive performance and lead to improvement in memory in adults.⁹Other studies report maintenance of weight loss and self-reported satiety.¹⁰

Despite these research findings, additional studies are needed to further advance our understanding of the complexity of plant protein vs. animal protein comparisons.¹¹ While many epidemiologic and intervention studies have evaluated their respective health benefits, it has been difficult to isolate the role of plant or animal protein on cardiovascular disease risk. The potential mechanisms responsible for specific plant and animal protein effects are multifaceted.¹¹ Further investigations should test the effects of long-term consumption of nuts on cardiometabolic events.

A better understanding of its benefits may also contribute to higher consumption of walnuts. Especially when Americans do not meet the recommendations in the consumption of seafood, nuts, seeds, and soy products.⁵ Nuts have been shunned away for many years due to the perception as high-fat foods and promoters of weight gain. Work remains to be done to change this perception of weight gain associated with nuts, and walnuts.

The initiative as a result of joint efforts between the American Heart Association and the California Walnut Commission will provide the booster needed to support research and science on walnuts. A better understanding of its mechanism of action, benefits, and people’s perceptions of nuts, and walnuts perhaps may contribute to their increased consumption for heart and brain health, among other outcomes.

Applications open in October, for more information visit: https://professional.heart.org/en/research-programs/application-information/career-development-award

References:

1.American Association for the Advancement of Science (AAAS). California Walnuts and American Heart Association announce first joint funding award. EurekAlert! https://www.eurekalert.org/news-releases/589498. Jan 5, 2021. Accessed August 9, 2021.

Uusitupa M, Khan TA, Viguiliouk E, et al. Prevention of Type 2 Diabetes by Lifestyle Changes: A Systematic Review and Meta-Analysis. Nutrients. 2019;11(11):2611. Published 2019 Nov 1. doi:10.3390/nu11112611
Chiavaroli L, Viguiliouk E, Nishi SK, et al. DASH Dietary Pattern and Cardiometabolic Outcomes: An Umbrella Review of Systematic Reviews and Meta-Analyses. Nutrients. 2019;11(2):338. Published 2019 Feb 5. doi:10.3390/nu11020338
California Walnut Commission. Walnuts Support Overall Wellness. https://walnuts.org/wp-content /uploads/2021/07/P0274-NutritionFactsHandout_8.5×11-1.pdf. 2021. Accessed August 15, 2021
U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2020-2025. 9th Edition. December 2020. Available at DietaryGuidelines.gov.
Ros E. Eat Nuts, Live Longer. J Am Coll Cardiol. 2017;70(20):2533-2535. doi:10.1016/ j.jacc. 2017. 09.1082
Steffen LM, Yi SY, Duprez D, Zhou X, Shikany JM, Jacobs DR Jr. Walnut consumption and cardiac phenotypes: The Coronary Artery Risk Development in Young Adults (CARDIA) study. Nutr Metab Cardiovasc Dis. 2021;31(1):95-101. doi:10.1016/j.numecd.2020.09.001
Guasch-Ferré M, Liu X, Malik VS, et al. Nut Consumption and Risk of Cardiovascular Disease. J Am Coll Cardiol. 2017;70(20):2519-2532. doi:10.1016/j.jacc.2017.09.035
Chauhan A, Chauhan V. Beneficial Effects of Walnuts on Cognition and Brain Health. Nutrients. 2020;12(2):550. Published 2020 Feb 20. doi:10.3390/nu12020550
Rock CL, Flatt SW, Barkai HS, Pakiz B, Heath DD. Walnut consumption in a weight reduction intervention: effects on body weight, biological measures, blood pressure and satiety. Nutr J. 2017;16(1):76. Published 2017 Dec 4. doi:10.1186/s12937-017-0304-z
Richter CK, Skulas-Ray AC, Champagne CM, Kris-Etherton PM. Plant protein and animal proteins: do they differentially affect cardiovascular disease risk?. Adv Nutr. 2015;6(6):712-728. Published 2015 Nov 13. doi:10.3945/an.115.009654

“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.”

Bridging the Disparity Gap in Cardiovascular Health in Transgender and Gender Diverse Population: Insight into the Scientific Statement from the American Heart Association

July 26, 2021July 22, 2021 Catherina Chang Martinez, PhD

In recent years, there has been increased attention to health-related disparities experienced by the transgender and gender diverse population (TGD). In fact, it has become a public health priority to improve the health, safety, and well-being of lesbian, gay, bisexual, and transgender people in the U.S. Therefore, one of the Healthy People 2030 goals is to target the collection of data on LGBT health issues to help inform effective health promotion strategies for LGBT people.¹The topics of adolescents, drugs and alcohol use, mental health issues, sexually transmitted infections, and our public health infrastructure are highlighted as key objectives for the Healthy People 2030 Goals.¹

Nearly a decade ago, the 2011 report from The Institutes of Medicine (IOM) highlighted the need to look at the distinct health concerns and needs of the TGD community and its subgroups. It also reported on the importance of understanding differences based on race, ethnicity, socioeconomic status, geographic location, age, and other factors among lesbians, gay men, bisexual men and women, and transgender people.² Based on the 2011 IOM report, lesbians and bisexual women encounter higher rates of breast cancer than heterosexual women. The data on whether lesbians had a higher risk for cardiovascular disease was conflicting at the time. Limited research suggested that transgender groups may experience negative health outcomes, because of long-term hormone use.²

Recent studies suggest that trans people appear to have an increased risk for myocardial infarction and death due to cardiovascular disease when compared to cisgender people. In studies that followed trans people on hormone therapy, the rates of myocardial infarction and stroke were consistently higher in trans women than trans men. Estrogen therapy for trans women has been reported to increase their risk for venous thromboembolism.³ This presents opportunities for screening TGD groups for cardiometabolic risk factors in much the same way as their cisgender counterparts.⁴ A recent scientific statement from the American Heart Association emphasizes on the importance of screening and risk reduction for cardiovascular disease in TGD people.

In this scientific statement, distal and proximal minority stressors are presented, which may contribute to higher overall stress levels that can increase the risk for poor mental and physical health outcomes in TGD individuals. The Gender and Minority Stress Resilience model is presented and highlights these factors, as well as the presence of resilience factors that may counteract the effects of transphobic violence and stigma, and promote TGD health equity.⁵ This Scientific Statement is definitely a step in the right direction to address cardiovascular related health disparities for TGD people. It addresses the value of Life’s Simple 7 (tobacco use, physical activity, diet, weight status, blood pressure, glycemic status, and lipids), targeting key risk factors towards the reduction of cardiovascular disease. Other factors such as HIV infection status, vascular dysfunction, alcohol use, lack of sleep, stigma, discrimination, violence, lack of affordable housing and access to health care are also discussed.⁵

Advancing the cardiovascular health of people who are TGD will require a multifaceted approach that integrates best practices into health promotion, cardiovascular care, and research for this understudied population. This presents opportunities for innovation in areas such as the electronic health record, especially to capture sociocultural factors relevant to heart health among TGD groups. Longitudinal research examining psychosocial, behavioral, and clinical determinants of optimal cardiovascular health in TGD people at the individual, interpersonal, and structural levels is also advocated. Healthcare professionals and clinician training on the proper assessment of sex and gender in healthcare settings, and identification of TGD health disparities will also be necessary to the identification of interventions and the reduction of disparities experience by TGD groups.⁵

In conclusion, the recent Scientific Statement from the American Heart Association on TGD people highlights the unique, health care needs of TGD individuals. It also highlights opportunities to improve their health status though screening and preventive lifestyle practices incorporating Life’s Simple 7. Clinician education and training on the psychosocial, cultural, behavioral, and biological factors in TGD people may help bridge the gaps in cardiovascular care for these groups.

References:

S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion. Healthy People 2030. LGBT: Goal: Improve the health, safety, and well-being of lesbian, gay, bisexual, and transgender people. https://health.gov/healthypeople/objectives-and-data/browse-objectives/lgbt. Published 2020. Accessed July 13, 2021.
Institute of Medicine (US) Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. Washington (DC): National Academies Press (US); 2011. https://www.ncbi.nlm.nih.gov/books/NBK64806/ doi: 10.17226/13128. Accessed July 12, 2021.
Irwig MS. Cardiovascular health in transgender people. Rev Endocr Metab Disord. 2018;19(3):243-251. doi:10.1007/s11154-018-9454-3
Slack DJ, Safer JD. Cardiovascular health maintenance in aging individuals: the implications for transgender men and women and hormone therapy. Endocr Pract. 2021;27(1):63-70. doi:10.1016/j.eprac.2020.11.001
Streed CG Jr, Beach LB, Caceres BA, et al. Assessing and Addressing Cardiovascular Health in People Who Are Transgender and Gender Diverse: A Scientific Statement from the American Heart Association [published online ahead of print, 2021 Jul 8]. Circulation. 2021; CIR0000000000001003. doi:10.1161/CIR.0000000000001003

Fighting for Health Equity and Social Justice during the COVID-19 pandemic: Insights from the 2021 Epi/Lifestyle Scientific Sessions

June 17, 2021June 16, 2021 Catherina Chang Martinez, PhD

This year’s Epi/Lifestyle Scientific Session took place on May 20-21, 2021. Despite the change in venues to virtual mode because of the COVD-19 pandemic, the conference was a success! Many attendees had the opportunity to participate, network, and learn about the latest science on Epidemiology, prevention, lifestyle, and cardiometabolic health. The opening remarks and keynotes centered on two particularly important topics, health equity, and social justice, and the commitment of the American Heart Association to eliminate health disparities in underserved ethnic communities.

Dr. Mitchell S. V. Elkind, MD, MS, FAAN, FAHA, American Heart Association President, opened the conference, highlighting the commitment of the American Heart Association to health equity and structural racism research, driving systemic public health change, while focusing on removing barriers to equitable health for everyone, everywhere. He also provided updates on new scientific research programs to address health inequities and structural racism, and diversity research opportunities for underrepresented racial and ethnic groups.

From a healthcare provider standpoint, many of these programs offer opportunities to bridge the gap in preventive CVD measures in our communities. Other important contributions highlighted at the conference included the COVID-19 Registry, a hospital-based quality improvement program to explore the links between COVID-19, cardiovascular risk factors, and adverse cardiovascular outcomes.

In alignment with the lead topic of the conference, two keynote speakers, Dr. Olajide A Williams and Dr. Laprincess C. Brewer highlighted the effects of structural racism on the social determinants of health, and their relation to health equity and social justice. Dr. Olajide A. Williams presented on the relationship between structural racism and poor health. He highlighted the importance of social determinants of health and primordial prevention from the perspective previously reported by Dr. Camara Jones.¹

Dr. Jones’ “Cliff Analogy” gives a clear picture of the three dimensions of health interventions to help people who are falling off of the cliff of good health: providing health services, addressing the social determinants of health and equity.¹ The deliberate movement of the population away from the edge of the cliff represents our efforts to improve on the social determinants of equity through interventions on the structures, policies, practices, norms, and values that differentially distribute resources and risks along the cliff. By doing so, we can improve health outcomes and eliminate health disparities.¹ His presentation is also a call to continue efforts to overcome the long-term effects of structural racism and eliminate its associated disparities by organizations outside of government.

Another keynote speaker, Dr. Laprincess C. Brewer discussed the importance of community-based participatory research as a strategy to promote cardiovascular health for all. She highlighted the importance of diversity in clinical trials and research studies as well as the need to build and maintain community partnerships to dismantle structural inequities, racism, and consequently lead to cardiovascular health equity in our communities. Innovative approaches through community-based participatory research, involving our communities and key stakeholders have the potential to support lifestyle change for cardiovascular disease (CVD) prevention, especially in ethnic minority groups, such as African Americans, who carry the largest CVD burden.

Dr. Brewer highlighted the ongoing disparities in CDV mortality for African Americans. Despite improvements in mortality rates over the past decades, CVD remains the leading cause of death for African-Americans. She further messaged the American Heart Association’s Life Simple 7 as important factors to address in the fight against cardiovascular disease in ethnic minorities experiencing greater health disparities. Her presentation also highlighted the importance of community stakeholders, including faith-based organizations and community members in the identification of the research problem, development of research questions, as well as interventions that may be relevant to these groups.² The various types of programs she discussed, including Mobile Health, emergency preparedness, and COVID testing, through a partnership with a faith-based organizations, served as examples of trusted social networks and established stakeholders that underserved communities may be more likely to reach out for support during health crises. These may further contribute to the delivery of culturally sensitive resources through community partnerships aimed to achieve health equity among ethnic minorities.

As I reflect on the message from the speakers during the opening session, it reminds me of the opportunities available in my community for engagement in the prevention of CVD, especially in underserved minority groups, and the need to reach out to key stakeholders trusted by these underserved groups. It is also a call to engage with these stakeholders in the delivery of interventions aimed at disease prevention, setting up guardrails to prevent them from falling off the cliff of good health.

References

Jones CP, Jones CY, Perry GS, Barclay G, Jones CA. Addressing the social determinants of children’s health: a cliff analogy. J Health Care Poor Underserved. 2009;20(4 Suppl):1-12. doi:10.1353/hpu.0.0228
Brewer LC, Hayes SN, Caron AR, et al. Promoting cardiovascular health and wellness among African-Americans: Community participatory approach to design an innovative mobile-health intervention. PLoS One. 2019;14(8):e0218724. Published 2019 Aug 20. doi:10.1371/journal.pone.0218724

Anticoagulation in Subclinical Atrial Fibrillation and the Prevention of Stroke

May 24, 2021May 21, 2021 Catherina Chang Martinez, PhD

May is National Stroke Awareness Month. This initiative began in May 1989 to promote public awareness and reduce the incidence and associated burden of stroke in the United States.¹ Despite ongoing efforts, stroke remains a leading cause of death and long-term disability in the United States.^2-4 Every year about 795,000 people in the United States have a stroke.²

Stroke can be preventable. One of its major risk factors, atrial Fibrillation, affects as many as 2.2 million Americans. In people over 80 years of age, atrial fibrillation remains the direct cause of 1 in 4 strokes.^5-6 There are documented benefits to the administration of direct oral anticoagulants and vitamin K antagonists in new-onset atrial fibrillation (> 24-hour duration). There is controversy on the use of these agents with asymptomatic, subclinical atrial fibrillation (SCAF), or atrial fibrillation (< 24 hour duration).^7-8 Results from a meta-analysis of 50 studies suggested SCAF being commonly detected within in patients after a stroke.⁹ Studies also report shorter episodes of SCAF associated with a higher likelihood of subsequent longer episodes of SCAF and nearly six times higher risk of clinical atrial fibrillation.^10-11

It has been well documented that the use of cardiac implantable electronic devices and wearable monitors leading to increased detection of subclinical atrial fibrillation in patients. It is argued that in efforts to reduce the stroke risk, with the detection of subclinical atrial fibrillation, clinicians may have a window of opportunity in the initiation of anticoagulation. The American Heart Association published a scientific statement on the prevalence, clinical significance, and management of subclinical atrial fibrillation. It also highlighted current gaps in knowledge and areas of controversy around the treatment of subclinical atrial fibrillation.⁸

With the lack of clearly defined thresholds of atrial fibrillation burden to initiate oral anticoagulation, clinicians are faced with having to weight the clinical benefits and contraindications to anticoagulation therapy for patients with SCAF.⁸ A population health approach, leveraging the use of the electronic medical record may present alternatives into risk stratification and therapeutic management of direct oral anticoagulants .⁶ Options such as the use of anticoagulation clinics may need to be explored in the case of oral anticoagulant agents that do not require routine laboratory monitoring.

Findings from two ongoing clinical trials in patients with Cardiac Implanted Electronic Devices-detected SCAF will inform on the management of SCAF in the prevention of strokes: the ARTESiA (Apixaban for the Reduction of Thrombo-Embolism in Patients With Device-Detected Subclinical Atrial Fibrillation; NCT 01938248)41 and NOAH (Non–Vitamin K Antagonist Oral Anticoagulants in Patients With Atrial High Rate Episodes; NCT 02618577).⁸ Until then, it will be important for clinicians to continue working, following a patient centered approach. Factors such as patient goals and preferences, adherence, gaps in knowledge, will need to be addressed in order to support a more personalized, therapeutic approach.⁸

References:

Bush, George. Peters, Gerhard; Woolley, John T. (eds.). “Proclamation 5975—National Stroke Awareness Month, 1989”. The American Presidency Project. University of California at Santa Barbara.
Kochanek KD, Xu JQ, Murphy SL, Arias E. Mortality in the United States, 2013. NCHS Data Brief, No. 178. Hyattsville, MD: National Center for Health Statistics, Centers for Disease Control and Prevention, Department of Health and Human Services; 2014.
Mozzafarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, et al., on behalf of the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2016 update: a report from the American Heart Association. Circulation 2016;133(4):e38–360.
Virani SS, Alonso A, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, et al. Heart disease and stroke statistics—2020 update: a report from the American Heart Associationexternal icon. Circulation. 2020;141(9):e139–e596.
National Institute of Neurological Disorders and Stroke. Atrial fibrillation and stroke information. 2019. https://www.ninds.nih.gov/Disorders/All-Disorders/Atrial-Fibrillation-and-Stroke-Information-Page
Jame S, Barnes G. Stroke and thromboembolism prevention in atrial fibrillation. Heart. 2020;106(1):10-17. doi:10.1136/heartjnl-2019-314898
Healey JS, Amit G, Field TS. Atrial fibrillation and stroke: how much atrial fibrillation is enough to cause a stroke?. Curr Opin Neurol. 2020;33(1):17-23. doi:10.1097/WCO.0000000000000780
Noseworthy PA, Kaufman ES, Chen LY, Chung MK, Elkind MSV, Joglar JA, Leal MA, McCabe PJ, Pokorney SD, Yao X; on behalf of the American Heart Association Council on Clinical Cardiology Electrocardiography and Arrhythmias Committee; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular and Stroke Nursing; and Stroke Council. Subclinical and device-detected atrial fibrillation: pondering the knowledge gap: a scientific statement from the American Heart Association. Circulation. 2019;140:e944–e963. doi: 10.1161/CIR.0000000000000740.
Sposato LA, Cipriano LE, Saposnik G, Ruíz Vargas E, Riccio PM, Hachinski V. Diagnosis of atrial fibrillation after stroke and transient ischaemic attack: a systematic review and meta-analysis. Lancet Neurol. 2015; 14:377–387. doi: 10.1016/S1474-4422(15)70027-X
Mahajan R, Perera T, Elliott AD, Twomey DJ, Kumar S, Munwar DA, Khokhar KB, Thiyagarajah A, Middeldorp ME, Nalliah CJ, et al.. Subclinical device-detected atrial fibrillation and stroke risk: a systematic review and meta-analysis. Eur Heart J. 2018; 39:1407–1415. doi: 10.1093/eurheartj/ehx731
Swiryn S, Orlov MV, Benditt DG, DiMarco JP, Lloyd-Jones DM, Karst E, Qu F, Slawsky MT, Turkel M, Waldo AL; RATE Registry Investigators. Clinical implications of brief device-detected atrial tachyarrhythmias in a cardiac rhythm management device population: results from the Registry of Atrial Tachycardia and Atrial Fibrillation Episodes. Circulation. 2016; 134:1130–1140. doi: 10.1161/CIRCULATIONAHA.115.020252

Get with the Guidelines (GWTG) – Stroke Patient Registry Use in Primary and Comprehensive Designated Stroke Centers during COVID-19 Pandemic

April 20, 2021April 19, 2021 Catherina Chang Martinez, PhD

This year many of the professional conferences that traditionally took place live have had to change to virtual mode due to the global COVID-19 pandemic and its related social distancing rules. The International Stroke Conference and Nursing Symposium was no exception. Yet it presented an excellent opportunity for many to attend, especially those who could not have joined the conference in-person had the opportunity to participate virtually. Healthcare professionals, academicians, researchers, and supporters of stroke prevention were able to join from different places in the world, under different time zones. There were many options for participants to engage and interact in the many discussions and presentations through the online platform.

Earlier I had the opportunity to write about various topics presented during the #ISC21 (you can read them here: “Reducing Disparities through Diversity and Inclusion in Stroke Science, Clinical Trial Enrollment, and Community Engagement”; “Transformation of the GWTG – Stroke Patient Registry to into a National Representative Database of Acute Ischemic Strokes (AIS) in the U.S.”).

Today, I wanted to interview a couple of conference participants who could share with you about their experience attending this virtual conference. I also wanted them to share with you their experience with the GWTG Stroke Registry and the prevention of stroke in the midst of the COVID-19 pandemic. My guests for this post-conference interview are Ms. Jessilyn Pozo, Baptist Health South Florida System-Wide Stroke Program Manager, and Dawntray Radford, Stroke Coordinator for South Miami Hospital (You can follow them for more information here). This transcript is a lightly edited version of the interview we conducted on webcam, shortly after the 2021 International Stroke Conference.

Catherina: How was your experience at the 2021 International Stroke Conference (ISC) delivered in virtual mode?

Dawntray: The International Stroke Conference was definitely different this year. However, I was appreciative that they (AHA) were able to extend the sessions’ timeframe so that we would be able to take a deeper dive, engage in deeper discussions opposed to the 10-15 minute sessions that we normally would have (in a live conference). I think I got a lot more information (from the presentations and discussions), especially within the different scheduled presentations. Therefore, I think there was an added bonus of extending the sessions’ timeframe.

Dawntray Radford, BSN, RN Stroke Coordinator South Miami Hospital

Jessilyn: This is my second time attending ISC. I went last year to Los Angeles for it. Although I do like the live version more, I liked that we were able to see lectures recorded and delivered on-demand. There were a lot of interesting topics this year, specifically hot topics with Tenecteplase¹, which many hospitals are leaning towards converting its use. There were different topics like the nursing care guidelines, and reports from recent studies released. We were able to take many good notes, and we were able to pause and write down things and keep going with the lectures. I really enjoyed attending the conference, but I am excited for it to be live next year.

Jessilyn Pozo, BSN, RN, SCRN BHSF System-Wide Stroke Program Manager Baptist Hospital of Miami

Catherina: How would you describe your role in the stroke program at your organization?

Jessilyn: I oversee the stroke program for the Baptist Health system. Baptist Hospital of Miami is our comprehensive center. Dawntray Redford runs the South Miami Hospital stroke program, which is a primary stroke center, certified by the Joint Commission.² She worked tirelessly to get it certified with no Requests for Improvements (RIFs). So kudos to her! We are working with West Kendall Baptist Hospital to become a primary stroke center. We are working to have a few of our other entities to be acute stroke ready. We have oversight of the stroke program at each individual entity and as a system to provide standardized great stroke care for all patients.

Catherina: Please tell us Ms. Radford about your role in the stroke program at South Miami Hospital.

Dawntray: We went through our first initial certification as a primary stroke center. There are a lot of moving parts in the program that we need to monitor. In addition to providing care, since we are a primary stroke center, there is an urgency of transferring stroke patients to the comprehensive center. This shows to our community and Emergency Medical Services (EMS) that we have the capabilities of readily identifying the acute stroke patients when they arrive and transferring them out at a target time of sixty minutes. Based on the feedback we received from the certification survey by the Joint Commission, it was very impressive! Because of the national times, the average goal is to push for at least 90 minutes. The literature suggests and has proven (benefits) from taking about 2 hours to 3 hours to actually have a patient transferred out to an equipped hospital. Emergency medical services (EMS) had tried to propose to bypass the primary stroke centers and go to the comprehensive one. They did not want these two-to-three-hour delays of the patient transferred because of so many logistics of trying to transfer a patient from one hospital to another system, as we had to go through that transfer process. With the streamlined process at our Institute, the Miami Neuroscience Institute, we have our own streamlined process and our dedicated transfer center. We can actually execute our transfers in sixty minutes. We worked very hard with our internal system of identifying patients before they even arrived to our institution. We are having that proactive approach of readily identifying that patient that has that large vessel occlusion. We already have a transfer center in place before the patient even arrives. This would make our numbers soar to that target timeframe for patients to get excellent stroke care. During our certification survey, we got compliments on our timeframe, less than the 90-minute-to-120-minutes timeframe, as we probably may be set back a new benchmark for the nation.

Catherina: What are the benefits of the GWTG Stroke Registry at your organizations?

Jessilyn: We are very lucky to have a data analyst team that is driven and just solely dedicated to the management of our stroke data. They are the ones who check on our stroke alert times; make these dashboards with turnaround times that they input in Get With The Guidelines. The Get With The Guidelines Stroke Registry helps us to stay on track. It keeps us on our toes, making sure that we meet the (stroke) goals. We aim to provide the care that we need to (deliver to stroke patients) based on the guidelines and the standards. This (registry data) allows for feedback on how our programs are doing.

Dawntray: The use of The Get With The Guidelines at South Miami Hospital is imperative, especially with the fact that we have different stroke units. The staff at the stroke units would like to see how they are doing as an individual unit, so they know where they need to improve individually as opposed to the hospital as a whole. Especially with the Emergency Department, their metrics would be different from the metrics of an inpatient unit. At least with the registry, I could take the different core quality measures and give the appropriate information specific to their unit. I use the registry 100% to monitor our quality measures and performance improvement measures.

Catherina: What has been your experience with stroke patients seeking stroke care in the midst of the COVID-19 pandemic?

Dawntray: We definitely have seen a decrease in the volume of care, especially with EMS and the patients that walk in. Eighty percent of our patients would arrive by their private vehicles. Many patients did not come through EMS during the pandemic. We noticed at least 50% change in our volume for at least the first two months of the COVID pandemic. We have also seen an increase in ischemic strokes with clots, with occlusive strokes in patients that were positive for COVID. They developed COVID first. The developed stroke as a secondary diagnosis.

Jessilyn: From the comprehensive center standpoint, being like the hub of the system, we have seen internal patient transfers from our sister hospitals. These patients were initially admitted for COVID care. They developed an acute ischemic stroke and were transferred over for neuro intervention. Unfortunately, these have been the trickiest patients. They were on the younger side, ended up being hypercoagulable. Our interventionalists are amazing! However, they do say it is more difficult, they find more clots. It is not just one. They seem to find several clots. These patients also tend to reocclude, even though they have had a successful thrombectomy. Therefore, I think COVID has really posed quite a challenge in stroke care for all.

Catherina: What suggestions do you have for healthcare professionals in educating patients about the prevention of stroke, especially during this COVID-19 pandemic?

Jessilyn: I think one of the biggest issues in stroke is that as high as it is, 80% of the strokes are preventable. Stroke should probably be out of the top 10 issues that are the cause of mortality in our nation or in the world. A lot of it has to do with the fact that people do not recognize the symptoms. It also has to do with getting them in here (hospital) for early treatment. We have those 24 hours for them to be a possible candidate for stroke care. A lot of them do not just even recognize the symptoms or the risk factors of stroke. They do not understand things that they just do in their daily life, that if they were to change one of these minute things, it can help them decrease their risk of stroke and relieve them from possible debilitating life symptoms.

Dawntray: (During the pandemic) we reached out to our marketing department. We have a Facebook page where we have a post on Fridays. (We posted) on recognition of the signs of early stroke: FAST: Face, Arm, Speech, Time of recognizing stroke, calling 911. We also had information on what (symptoms) to look for. We had a message built in to the post as well, stating that, “we know that you may be afraid to come in, that you want to stay at home, but you choose to be aware of, of not being afraid to seek services, to come in to the hospital where it is safe.” “We take a lot of preventative measures to protect ourselves and to the community during the pandemic”. We are just letting them know what the signs and symptoms were and not to be afraid to come in and to seek care (at the hospital). We are just giving them that comfort that it is safe to come into the hospital. Because that is what they feel… it was not safe, so they were afraid to come in (during the pandemic).

Catherina: Thank you for the opportunity to interview you and look forward to the next ICS conference. Anything that you would like to share out there with stroke coordinators, any advice or word of guidance?

Jessilyn: Just hang in there.

Dawntray: You have to be inventive. Just know that a pandemic cannot hinder you from providing the care that you provide every day. You just have to be creative, find a better way, a different way of still executing what you do on a daily basis.

I would like to thank Ms. Jessilyn Pozo and Ms. Dawntray Redford for sharing their experiences during this 2021 Virtual International Stroke conference as well as their experiences with the GWTG Stroke Registry, Primary and Comprehensive Stroke Program, and stroke prevention during the COVID-19 pandemic. For more information, you can reach them at [email protected] and [email protected]

References:

Warach SJ, Dula AN, Milling TJ Jr. Tenecteplase Thrombolysis for Acute Ischemic Stroke. Stroke. 2020;51(11):3440-3451. doi:10.1161/STROKEAHA.120.029749
The Joint Commission. Primary Stroke Center Certification. (2021). Retrieved from https://www.jointcommission.org/accreditation-and-certification/certification/certifications-by-setting/hospital-certifications/stroke-certification/advanced-stroke/primary-stroke-center/
American Heart Association. Get with the Guidelines Stroke Registry. (2021). Retrieved from https://www.heart.org/en/professional/quality-improvement/get-with-the-guidelines/get-with-the-guidelines-stroke

Reducing Disparities through Diversity and Inclusion in Stroke Science, Clinical Trial Enrollment, and Community Engagement

April 6, 2021April 5, 2021 Catherina Chang Martinez, PhD

As part of its mission to be a relentless force for a world of longer, healthier lives, the American Heart Association (AHA) has been working diligently to eliminate barriers to health equity in the U.S. diverse population through education and research, raising awareness through their many programs and initiatives. In the stroke arena, we continue to face significant inequities related to stroke incidence, prevalence, care, and outcomes in ethnic minorities.¹ Consequently, there has been a number of initiatives launched to address these disparities. The Health Equity and Actionable Disparities in Stroke Symposium, a collaborative initiative of the American Heart Association and National Institute of Neurological Disorders and Stroke, took place in 2020 with the goals of reducing inequities in stroke care and research. It also aimed to accelerate the translation of research findings to improve outcomes for racial and ethnic minorities.¹

This year the American Heart Association continues the efforts to promote awareness of the importance of diversity and inclusion in stroke science. A roundtable session took place on Friday, March 17, during the last day of the prestigious 2021 International Stroke Conference. A panel of experts shared their views and presented alternatives to improve diversity and Inclusion in the healthcare workforce, clinical trial enrollment, and community engagement. The expert roundtable included experts in the field such as Dr. Emelia Benjamin, MD ScM FAHA, Michele Evans, MD, Michelle Jones-London, Ph.D., Bernadette Boden-Albala, MD MPH, Fern Webb, Ph.D., Candace Whitfield, BS, Trudy Gaillard, RN Ph.D., Mellanie Springer, MD MSc. Mr. Olajide Williams, MS served as the moderator of the roundtable. The panelists presented a fresh and clear view of the diversity and inclusion barriers encountered in the research arena. They also offered alternatives to support inclusion and diversity in the development of research protocols, proposal procedures through institutional review boards, and through community engagement, with the use of community-based participatory research.

The experts highlighted the issue of representativeness in the conduct of research and presented diversity as a solution. Diversity in research means that people of different ages, different racial and ethnic groups and both men and women participate in research studies. The lack of diversity in participants of research impedes the ability to generalize study results and make medical advancements of effective therapies. It may further prevent some populations from experiencing the benefits of research innovations and receipt of high-quality care.²

In the context of clinical trial enrollment, the speakers emphasized the importance of having a diverse sample. They also discussed the need for inclusivity of minority groups during the enrollment period. They also highlighted the importance of informed consent forms available in other languages to facilitate the diversity of the sample during enrollment. They also suggested the approval of translated informed consent forms in an expedited fashion to avoid delays in the consenting process for ethnic minority groups. Another very important factor was the importance of having the infrastructure to support diversity and inclusion in the stroke science workforce. Factors such as the hiring of clinicians and research personnel that may resemble the target population of interest are vital to facilitate the recruitment of ethnic minority groups much needed in these studies.³

As academicians and researchers, we should advocate for diversity as it drives excellence and enhances innovation in the biomedical sciences, leading to novel findings and treatment of diverse populations.³ Diverse and inclusive scientific teams can generate new research questions, develop methodical and analytical approaches to better understand study populations, and offer approaches to problem-solving from multiple and different perspectives. Moreover, the promotion of diverse groups presents opportunities for the inclusion of individuals with different perspectives who can complement each other and inform of new approaches.³ This may further strengthen the approach of the research team through the various phases of the research process, especially when their diversity and inclusion match the racial and ethnic minority group under study.

One of the experts, Dr. Michelle Evans highlighted the importance of community-based participatory engagement in research, especially in ethnic minorities. Another speaker, Dr. Trudy Gaillard discussed the opportunity to engage members in the community, stakeholders, and utilize this as a venue to engage study participants through community-based participatory research (CBPR). Engaging in active reflection and adopting promising partnering practices are important for CBPR partnerships working to improve health equity.⁴

The roundtable presentation aligns with current National Institutes of Health (NIH) strategies to support diversity and inclusion in the science community. A program called UNITE was launched in 2020 to tackle the problem of racism and discrimination in science while developing methods to promote diversity and inclusion across the biomedical enterprise. Some of its functions include understanding stakeholder experiences through listening and learning, pursuing research on health disparities, minority health, and health equity, improving the NIH culture and structure for equity, inclusion and excellence, transparency, communication, and accountability with internal and external stakeholders, changing policy, culture, and structure to promote workforce diversity (NIH, 2021).⁵

In addition to NIH, the National Institute of Neurological Disorders and Stroke (NINDS) (2021) is committing to diversity, equity, and inclusion in the neuroscience community as both an employer and funding agency, addressing the stark differences in neurological health outcomes related to where one lives, has access to care, their race/ethnicity, and socioeconomic status.⁶ In the process of implementation of these initiatives, it will be important to note that implementation science can exacerbate health disparities if its use is biased toward entities that already have the highest capacities for delivering evidence-based interventions.

There is a call for making efficient use of existing data by applying epidemiologic and simulation modeling to understand what drives disparities and how these can be overcome. There is also a need for designing new research studies that include populations experiencing disparities in cardiovascular disease, neurological disease, and stroke.⁷ It will be interesting to observe in the next coming months, the implementation of some of these strategies to promote diversity and inclusion in stroke science. Much remains to be done to bridge the gap and reduce healthcare-related disparities in racial-ethnic minority groups, especially in the context of stroke science. In the meantime, it is up to us to continue the work of raising awareness, promoting diversity and inclusion in our academic circles, in the science field, and in our communities.

For additional information on the efforts American Heart Association to support diversity and inclusion in heart science, please be sure to check out https://www.heart.org/en/about-us/diversity-inclusion.

References:

Towfighi A, Benson RT, Tagge R, Moy CS, Wright CB, Ovbiagele B. Inaugural Health Equity and Actionable Disparities in Stroke: Understanding and Problem-Solving Symposium. Stroke. 2020;51(11):3382-3391. doi:10.1161/STROKEAHA.120.030423
University of Maryland. Health Equity Project. (2021). Top five reasons why diversity is important in research. Retrieved from https://buildingtrustumd.org/unit/importance-of-research/importance-of-diversity#:~:text=Diversity%20in%20research%20means%20that%20people%20of%20different,specific%20reasons%20why%20diversity%20in%20research%20is%20important.
Swartz TH, Palermo AS, Masur SK, Aberg JA. The Science and Value of Diversity: Closing the Gaps in Our Understanding of Inclusion and Diversity. J Infect Dis. 2019;220(220 Suppl 2):S33-S41. doi:10.1093/infdis/jiz174
Dickson E, Magarati M, Boursaw B, et al. Characteristics and Practices Within Research Partnerships for Health and Social Equity. Nurs Res. 2020;69(1):51-61. doi:10.1097/NNR.0000000000000399
National Institutes of Health. (NIH). (2021). Ending Structural Racism. Retrieved from https://www.nih.gov/ending-structural-racism/unite on 4/2/21.
National NINDS (2021). NINDS is committed to ending structural racism. Retrieved from https://www.ninds.nih.gov/News-Events/Directors-Messages/All-Directors-Messages/NINDS-committed-ending-structural-racism
McNulty M, Smith JD, Villamar J, et al. Implementation Research Methodologies for Achieving Scientific Equity and Health Equity. Ethn Dis. 2019;29(Suppl 1):83-92. Published 2019 Feb 21. doi:10.18865/ed.29.S1.83

Transformation of the GWTG – Stroke Patient Registry to into a National Representative Database of Acute Ischemic Strokes (AIS) in the U.S.

March 8, 2021March 8, 2021 Catherina Chang Martinez, PhD

Stroke remains a leading cause of death and disability in the United States.¹ Approximately 800,000 people in the United States have a stroke every year.¹ Eighty percent of all strokes can be prevented by screening for and treating known risk factors (hypertension, tobacco smoking, and atrial fibrillation).² Recurrent strokes can also be prevented with proper management of these risk factors.³ Disease surveillance is crucial to the prevention of stroke, particularly in high-risk groups. Blacks and Hispanics report increasing stroke rates.⁴ Deprived populations within high-income countries are less likely to receive good-quality acute hospital and rehabilitation care than people with higher socioeconomic status.⁵ Findings from robust surveillance systems can be useful as healthcare providers can make informed decisions in the better medical management of strokes. Policymakers can work towards the development of aggressive campaigns to decrease the incidence of strokes in our communities and associated disparities in ethnic minorities and low-income groups.^4,6 We can further estimate progress made towards the reduction and elimination of common risk factors of stroke.

Previously, the Institutes of Medicine recommended the development of surveillance systems in efforts to monitor the incidence and associated disabling burden from cardiovascular disease and strokes.^7-8 The CDC’s Division for Heart Disease and Stroke Prevention (DHDSP) supports state, local, and tribal efforts to prevent, manage, and reduce risk factors related to stroke. The CDC has supported the implementation of stroke programs through cooperative agreements at these levels (CDC, 2020).⁹ However, due to the voluntary nature of these agreements, stroke surveillance data has been limited to only participant states. Therefore, it has been difficult to estimate the burden of a stroke at the national level.

A recent study by Ziaeian and colleagues presented the transformation of The Get With The Guidelines (GWTG) Stroke Patient Registry into a nationally representative database.¹⁰ This is the first study that has transformed a patient registry using post-stratification weights to represent a larger population of interest. The ability to translate observations from large registries to a national scale fills a considerable gap in the surveillance of the clinical characteristics, quality of care, and outcomes for Acute Ischemic Strokes (AIS) hospitalizations nationally.¹⁰ An acute stroke quality registry that is integrated with a guideline-based support tool can be a powerful tool for measuring and improving the quality of stroke care.¹¹Here we provide a summary of this recent study.¹⁰

Study population: The target population for the post-stratification weighting procedure is the total AIS presenting to U.S. hospitals by year. The NIS defines the AIS burden nationally stratified between the years of 2012 and 2014 and the nine U.S. Census regions – preserving the smallest sampling unit recommended by the NIS sponsors. The National Inpatient Sample (NIS) is a weighted structured random sample of U.S. hospitalizations to represent national hospital utilization. However, the database does not include detailed clinical data such as stroke severity, laboratory data, medical treatments received, and patient-reported outcomes. The NIS is sponsored by the Agency for Healthcare Research and Quality’s Healthcare Cost and Utilization Project.

GWTG Stroke Patient Registry History: The GWTG – Stroke Patient Registry is a voluntary registry and continuous quality improvement initiative that collects data on patient characteristics, hospital adherence to guidelines and inpatient outcomes. It was developed as part of a strategic goal of the American Heart Association (AHA) to reduce stroke and its associated risks, and Healthy People 2010 (HP2010) established national goals for stroke prevention and management. The implementation of the GWTG Stroke registry has led to the implementation of evidence-based care and improved patient outcomes in many hospitals, acute care, and long-term care settings.⁶

GWTG hospitals comprise a mix of Joint Commission-certified stroke centers, PCNASR hospitals and small and large hospitals in urban and rural settings across the USA and Puerto Rico. Based on previous studies, the population of patients enrolled in GWTG is similar in age and racial makeup to the US population according to the U.S. census 2000. Medicare beneficiaries linked to the GWTG registry are similar in demographics, comorbidities, and in-hospital outcomes compared with Medicare beneficiaries who are not linked.^6,10

Methods: Ziaeian and colleagues integrated two data sources, The National Inpatient Sample (NIS), a structured random sample of U.S. hospitalizations weighted to represent national hospital utilization.¹⁰ The AHA-sponsored Get With The Guidelines Program (GWTG) program includes rich clinical data for quality improvement and research analyses. They transformed these non-representative databases into a representative one with the use of post-stratification weights to rebalance over and underrepresented segments of the U.S. acute ischemic stroke (AIS) population. The approach described in the present paper is a far more robust estimation of the characteristics of stroke presentation and the quality of hospital care nationally.

The NIS lacks detailed clinical data such as stroke severity, laboratory data, medical treatments received, and patient-reported outcomes. It is not nationally representative and inadequate to measure stroke burden and quality of care nationally. The GWTG-Stroke patient registry captures 58% of all strokes nationally. The GWTG program registries with volunteer hospitals are not proportionally representative of the entire nation.¹⁰ Ziaeian and colleagues used the GWTG-Stroke registry from 2012 to 2014 to evaluate post-stratification weighting procedures to represent the entire US AIS population.¹⁰

To determine the total number of AIS hospitalizations in the U.S. and marginal population characteristics for post-stratification weights, the investigators used target population counts from the NIS database. The NIS sampled 20% of the administrative discharge records from all participating hospitals (approximately 4300 hospitals) covering 95% of the U.S. population and 94% of all community hospital discharges from 2010 to 2014. Raking and Bayesian interpolation, two parallel methods to estimate post-stratification survey weights, were used and their distribution was analyzed with histograms and treemaps to provide a perspective on the skewed representation of the GWTG-Stroke raw sample.

Results: There were an estimated 1,388,296 AIS hospitalizations between 2012 to 2014 in the U.S. For the raking method, anchored characteristics in the weighted GWTG-Stroke sample matched the exact population totals estimated from the NIS. On admission, 49.2% of stroke patients nationally were using antiplatelet medications, 15.5% anticoagulants, 69.1% antihypertensives, 43.6% cholesterol-lowering medications, and 27.4% used diabetic medications. Approximately 48% of patients were discharged home, 40.2% to transitional care facilities, and 4.6% with hospice-related services.

Conclusions and Implications: This research demonstrated the integration of two valuable data systems to make better population wide clinical estimates of acute ischemic stroke in the U.S., the GWTG Stroke Patient Registry and the NIS. Their work demonstrates that methods exist to marry existing databases to make more reliable statistical inferences of population health and health services utilization. Understanding the effectiveness of hospital systems at a national and regional level is critical to insure consistency and timeliness in the receipt of evidence-based care. With the expansion of patient registries, the inclusion of clinical outcomes in these registries, and advanced statistical methods are available to transform non-random samples into representative population estimates.

References:

Centers for Disease Control and Prevention. Underlying Cause of Death, 1999–2018. CDC WONDER Online Database. Atlanta, GA: Centers for Disease Control and Prevention; 2018. Accessed March 5, 2020.
George MG, Fischer L, Koroshetz W, et al. CDC Grand Rounds: Public Health Strategies to Prevent and Treat Strokes. MMWR Morb Mortal Wkly Rep 2017;66:479–481. DOI: http://dx.doi.org/10.15585/mmwr.mm6618a5external icon.
Caprio FZ, Sorond FA. Cerebrovascular Disease: Primary and Secondary Stroke Prevention. Med Clin North Am. 2019;103(2):295-308. doi:10.1016/j.mcna.2018.10.001
Skolarus LE, Sharrief A, Gardener H, Jenkins C, Boden-Albala B. Considerations in Addressing Social Determinants of Health to Reduce Racial/Ethnic Disparities in Stroke Outcomes in the United States. Stroke. 2020;51(11):3433-3439. doi:10.1161/STROKEAHA.120.030426
Marshall IJ, Wang Y, Crichton S, McKevitt C, Rudd AG, Wolfe CD. The effects of socioeconomic status on stroke risk and outcomes. Lancet Neurol. 2015;14(12):1206-1218. doi:10.1016/S1474-4422(15)00200-8.
Ormseth CH, Sheth KN, Saver JL, Fonarow GC, Schwamm LH. The American Heart Association’s Get With the Guidelines (GWTG)-Stroke development and impact on stroke care. Stroke Vasc Neurol. 2017;2(2):94-105. Published 2017 May 29. doi:10.1136/svn-2017-000092
Committee on a National Surveillance System for Cardiovascular and Select Chronic Diseases; Institute of Medicine, IOM (Institute of Medicine). A Nationwide Framework for Surveillance of Cardiovascular and Chronic Lung Diseases. Washington: National Academies Press; 2011. 201 p. Available from: http://www.nap.edu/catalog/13145
Sidney S, Rosamond WD, Howard VJ, Luepker RV. The “Heart Disease and Stroke Statistics–2013 Update” and the Need for a National Cardiovascular Surveillance System. Circulation. 2013;127(1):21–3 Available from: http://www.ncbi.nlm.nih.gov/pubmed/23239838.
Centers for Disease Control and Prevention. Division for Heart Disease and Stroke Prevention. About the State, Local, and Tribal Programs. Atlanta, GA: Centers for Disease Control and Prevention; 2020. Accessed March 5, 2020. Available from: https://www.cdc.gov/dhdsp/programs/spha/overview.htm
Ziaeian B, Xu H, Matsouaka RA, et al. National surveillance of stroke quality of care and outcomes by applying post-stratification survey weights on the Get With The Guidelines-Stroke patient registry. BMC Med Res Methodol. 2021;21(1):23. Published 2021 Feb 4. doi:10.1186/s12874-021-01214-z
Shahraki AD, Ghabaee M, Shahmoradi L, Malak JS, Jazani MR, Safdari R. Smart Acute Stroke Quality Registry Design-Data Elements Identification. J Registry Manag. 2018;45(1):43-47.

Can Vitamin C Prevent COVID-19?

February 16, 2021February 15, 2021 Catherina Chang Martinez, PhD

The outbreak of COVID-19 has created a global public health crisis. Our knowledge continues to be limited about the protective factors of this infection. Therefore, preventive health measures that can reduce the risk of infection, and halt the progression and severity of symptoms and complications related to COVID-19 are desperately needed. In the midst of the COVID-19 pandemic, health promotion measures, such as proper nutrition, physical activity, rest, and stress reduction measures have been advocated. More recently, attention has been shifted to vitamin supplementation as a means to keep American’s health and immune system in optimal status.

Source: https://www.heart.org/en/healthy-living/healthy-eating/add-color

Adequate intake of micronutrients is critical for optimal health, growth and development, and healthy aging. However, the Dietary Guidelines for Americans 2015–2020 highlight low-consumption of important nutrients including vitamins A, C, D and E, calcium, magnesium, iron, potassium, choline and fiber, with variations by age groups.¹ Vitamin C has recently gained attention as a potential micronutrient in the prevention of COVID-19. Vitamin C has been known for promoting the oxidant scavenging activity of the skin, potentially protecting against environmental oxidative stress, enhancing chemotaxis, phagocytosis, and microbial killing.²

Based on previous evidence, oral vitamin C (2-8 g/day) may reduce the incidence and duration of respiratory infections and intravenous vitamin C (6-24 g/day) has been shown to reduce mortality, hospital length of stay, and time on mechanical ventilation for severe respiratory infections^3-4

Given the favorable safety profile and low cost of vitamin C, and the frequency of vitamin C deficiency in respiratory infections, trials are currently underway to determine its effect in hospitalized patients with COVID-19.^4-5 Although there are currently no published results of these clinical trials due to the novelty of SARS-CoV-2 infection, there is pathophysiologic rationale for exploring the use of vitamins such as Vitamin C in this global pandemic.⁶

Source: https://www.heart.org/en/news/2019/07/01/low-vitamin-d-in-babies-predicts-blood-pressure-problems-for-older-kids

While we await for results from these trials, we need to continue being vigilant, and adhere to a varied and balanced diet with an abundance of fruits and vegetables and the essential nutrients known to contribute to the normal immune system functioning. Vitamin C supplementation could present a safe and inexpensive approach to prevention of respiratory diseases, and perhaps aid in COVID-19.⁷

Avoidance of deficiencies and identification of suboptimal intakes of these micronutrients in targeted groups of patients and in distinct and highly sensitive populations could help to strengthen the resilience of people to the COVID-19 pandemic. It will be also important to highlight evidence-based public health messages, to prevent false and misleading claims about the benefits of vitamin supplements. It will also be important to communicate the exploratory state of research on micronutrients and COVID-19 infection and that no diet will prevent or cure COVID-19 infection. Frequent handwashing and social distancing will continue to be critical to reduce transmission during this pandemic.⁸

References:

Blumberg JB, Frei B, Fulgoni VL, Weaver CM, Zeisel SH. Contribution of Dietary Supplements to Nutritional Adequacy in Various Adult Age Groups. Nutrients. 2017;9(12):1325. Published 2017 Dec 6. doi:10.3390/nu9121325
U.S. Department of Health and Human Services. U.S. Department of Agriculture [(accessed on 15 March 2017)];2015–2020 Dietary Guidelines for Americans. (8th ed.). 2015 Available online: http://health.gov/dietaryguidelines/2015/guidelines/
Holford P, Carr AC, Jovic TH, et al. Vitamin C-An Adjunctive Therapy for Respiratory Infection, Sepsis and COVID-19. Nutrients. 2020;12(12):3760. Published 2020 Dec 7. doi:10.3390/nu12123760
Carr AC. A new clinical trial to test high-dose vitamin C in patients with COVID-19. Crit Care. 2020;24(1):133. Published 2020 Apr 7. doi:10.1186/s13054-020-02851-4
Zhang J, Rao X, Li Y, et al. Pilot trial of high-dose vitamin C in critically ill COVID-19 patients. Ann Intensive Care. 2021;11(1):5. Published 2021 Jan 9. doi:10.1186/s13613-020-00792-3
Jovic TH, Ali SR, Ibrahim N, et al. Could Vitamins Help in the Fight Against COVID-19?. Nutrients. 2020;12(9):2550. Published 2020 Aug 23. doi:10.3390/nu12092550
Allegra A, Tonacci A, Pioggia G, Musolino C, Gangemi S. Vitamin deficiency as risk factor for SARS-CoV-2 infection: correlation with susceptibility and prognosis. Eur Rev Med Pharmacol Sci. 2020;24(18):9721-9738. doi:10.26355/eurrev_202009_23064
Richardson DP, Lovegrove JA. Nutritional status of micronutrients as a possible and modifiable risk factor for COVID-19: a UK perspective [published online ahead of print, 2020 Aug 20]. Br J Nutr. 2020;1-7. doi:10.1017/S000711452000330X

Exercise: New Year Resolutions in the Midst of the COVID Pandemic

January 19, 2021January 15, 2021 Catherina Chang Martinez, PhD

New Year. New Resolutions. With the start of the New Year, many of us make commitments to improve our health. Some of us take on a new routine or hobby, give up or change old habits. As the holidays go, many of us take on the resolution to engage in more exercise and lose the extra pounds gained through the indulgence during the holidays. As we embark on the new journey to better health at the start of a new year, it is important to know that we are not alone. There are many around us that are also trying to engage in a healthy resolution to be fit. And there are many resources available to increase our physical activity and remain fit throughout the year.

It has been well established that physical activity contributes to many health benefits. Those who engage in regular exercise benefit from better sleep, growth, development, mood, and overall health.¹ On the contrary, the lack of exercise and an increase in sedentary behaviors may contribute to overweight and obesity. Overweight and obesity have deleterious effects in adults, including increased risk of cardiovascular disease, cancer, metabolic syndrome, depression, poor quality of life, and decreased life span.

As the global COVID‐19 pandemic unfolded in year 2020, over 90% of U.S. adult residents found themselves confined to their homes, with restaurants, shops, schools, and workplaces shut down to prevent the disease from spread.² For some, it meant additional changes, including working remotely, homeschooling children, and personal changes in lifestyle behaviors. Some of these, unfortunately, have led to increased sedentary activity and decreased physical activity, known risk factors associated with overweight and obesity.

For some groups, the transition to lockdown and social distancing has resulted in increased physical activity, especially for bodyweight training, and higher adherence to a healthier diet. Some individuals have engaged in higher consumption of farmers’ produce or purchasing of organic fruits and vegetables, resulting in lower body mass index.³ However, this has not been the norm. More studies report adults experiencing five-to-ten pound increases in weight as a result of increased eating in the home environment. The increased levels of stress, combined with the lack of dietary restraint, snacking after meals, reduced physical activity, and inadequate sleep has further aggravated the risk of overweight and obesity in our population.⁴ Some groups report less frequent consumption of vegetables, fruit, and legumes during the quarantine, and higher adherence to meat, dairy, and fast-foods.⁵Anxiety, depression, self-reported boredom, and solitude have worsened the consumption of snacks, unhealthy foods, cereals, and sweets. These have correlated with higher weight gain for many.⁶

Being overweight not only increases the risk of infection and complications for those categorized as obese. Recent studies also suggest that the large prevalence of obese individuals within the population might increase the chance of appearance of the more virulent viral strain, and prolong the virus shedding throughout the total population. This may further increase the overall mortality rate as a result of COVID-19. A study on previous influenza pandemics suggests losing weight with a mild caloric restriction, including AMPK activators and PPAR gamma activators in the drug treatment for obesity-associated diabetes. Practicing mild-to-moderate physical exercise may further improve our immune response. Regular physical exercise enhances levels of cytokine production mediated via TLR (toll-like receptor) signaling pathways during microbial infection, improving host resistance to pathogen invasion.⁷ Regular physical activity may then serve as a cornerstone measure to improve our defenses against influenza viral infection, cardiometabolic diseases, and COVID-19.

Physical activity remains one of the seven modifiable health behaviors and an important metric of The American Heart Association (AHA) Life’s Simple 7 (LS7), associated with improved cardiovascular disease survival and reduced healthcare costs.⁸ As we battle the restrictions imposed by the pandemic, we have to also think that these circumstances present opportunities to engage our communities in healthy lifestyle practices. Practice aimed to increase our physical activity, may contribute to improving overall health status in the midst of the COVID pandemic.

Here are some ideas on how to meet the New Year resolution to exercise and increase our levels of physical activity:

Move More
- Set up a timer or alarm to move at least once every hour.
- A good starting goal is to engage in physical activity at least 150 minutes a week. This represents three 50-minute sessions or five 30-minute sessions a week.
- Start slowly. Gradually build up to at least 30 minutes of activity on most or all days of the week.
- Check with your healthcare provider before beginning a physical activity program and follow their recommendations.

Establish a routine
- Start with small changes.
- Make the time.
- Try to engage in exercising consistently at the same time every day and every week.
- Stick to the new routine for at least a month.
- Find a convenient time and place to do activities.
- Be flexible. If you miss an exercise opportunity, get back on track.
- Work physical activity or exercise session into your day in another way.
- Keep reasonable expectations of yourself and your physical activity or exercise routines.
- Reward or praise yourself for sticking to the changes.
- Use non-food items to reward yourself.

Get support
- Find buddies or friends who are also making the same commitment to be fit and engage in physical activity.
- Invite others to join you on your journey.
- It becomes more fun when you exercise or move in a company.

Learn more about physical activity
- Learn about additional/ alternate ways to engage in physical activity.
- Check out the American Heart Association resources at https://www.heart.org/en/healthy-living/fitness

Start the New Year with a commitment to better health by increasing activity and engaging in regular exercise. Engage others in exercise while keeping social distancing guidelines. Celebrate the small changes. Make a commitment to a Better You!

References:

Centers for Disease Control (CDC). Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion. Physical Activity Basics. Reviewed 2020 Nov 18. Accessed 2021 Jan 13. https://www.cdc.gov/physicalactivity/basics/index.htm
Bhutani S, Cooper JA. COVID-19-Related Home Confinement in Adults: Weight Gain Risks and Opportunities. Obesity (Silver Spring). 2020;28(9):1576-1577. doi:10.1002/oby.22904
Di Renzo L, Gualtieri P, Pivari F, et al. Eating habits and lifestyle changes during COVID-19 lockdown: an Italian survey. J Transl Med. 2020;18(1):229. Published 2020 Jun 8. doi:10.1186/s12967-020-02399-5
Zachary Z, Brianna F, Brianna L, et al. Self-quarantine and weight gain related risk factors during the COVID-19 pandemic. Obes Res Clin Pract. 2020;14(3):210-216. doi:10.1016/j.orcp.2020.05.004
Sidor A, Rzymski P. Dietary Choices and Habits during COVID-19 Lockdown: Experience from Poland. Nutrients. 2020;12(6):1657. Published 2020 Jun 3. doi:10.3390/nu12061657
Pellegrini M, Ponzo V, Rosato R, et al. Changes in Weight and Nutritional Habits in Adults with Obesity during the “Lockdown” Period Caused by the COVID-19 Virus Emergency. Nutrients. 2020;12(7):2016. Published 2020 Jul 7. doi:10.3390/nu12072016
Luzi L, Radaelli MG. Influenza and obesity: its odd relationship and the lessons for COVID-19 pandemic. Acta Diabetol. 2020;57(6):759-764. doi:10.1007/s00592-020-01522-8
Garg PK, O’Neal WT, Mok Y, Heiss G, Coresh J, Matsushita K. Life’s Simple 7 and Peripheral Artery Disease Risk: The Atherosclerosis Risk in Communities Study. Am J Prev Med. 2018;55(5):642-649. doi:10.1016/j.amepre.2018.06.021

#AHA20: Reflections from 2020 AHA Scientific Sessions

December 22, 2020December 17, 2020 Catherina Chang Martinez, PhD

As an American Heart Association Early Career Professional, attending the #2020 AHA Scientific Sessions will be an unforgettable experience. The virtual modality of the conference provided an alternative to the social distancing challenges presented by COVID-19. There was creativity in the programming to allow opportunity to engage through the various forums and live chats for those interested in live participation; and this added to the unique experience of online networking and learning. Participants also had the opportunity to join the on-demand sessions, learning at their own pace, within the comfort of their home or work setting.

From the early morning health and wellness sessions to late-breaking science, technology application to support better patient outcomes in the treatment of cardiovascular disease, and COVID-19 topics, the conference programming was comprehensive, diverse, and appealing to the interest of the participants. It was also in tune with the current state of global health and social issues, addressing ongoing debates in cardiovascular disease management.

The wide range of topics presented at the sessions truly reminds us of the AHA’s mission to be a relentless force for a world of longer, healthier lives.

Highlights of the #AHA 2020 Scientific Sessions included the following:

Focus on Fitness and Health. Participants had the opportunity to join the morning fitness and dance breaks, as well as and on-demand exercise sessions. Attendees who could not join the early scheduled meetings had the opportunity to join the on-demand model.
Discussion on racism in Medicine. The opening session featured a fireside chat with two legends in the education and treatment of cardiovascular disease, Dr. Eugene Braunwald and Dr. Nanette Wenger. This was followed by a robust discussion of racism as a public health crisis at various sessions delivered over the course of the five days. They also presented a call to support and embrace diversity, equity, and inclusion in the delivery of care to our growing racial and ethnically diverse population.
Late-Breaking Science. Recent findings from clinical trials were presented during the sessions on precision or polypill with TIPS and TIPS+ASA, the STRENGTH and OMEMI trials, the GALACTIC-HF and VITAL Rhythm trial.
Women Professional Development. Session topics ranged from discussions on leadership, self-care during COVID-19, and management of cardiovascular disease risk among women across the lifespan.
Latest Insight on COVID-19 and Cardiovascular Disease. The session addressed a wide range of topics from diagnostics and treatment, to the management of complications as a result of COVID-19. Discussion on complications such as thrombosis and myocardial involvement was presented and provided a fresh view of the latest treatment guidelines and the need for monitoring for cardiovascular complications.

These sessions will be available on-demand until January 4^th, 2020, and AHA Partners have FREE access to Scientific Sessions 2020 OnDemand Extended Access through 2021. Please check these out to learn about the latest evidence.