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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.”

 

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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.

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Keep Out The Rain

cvd umbrella

It has been well established that cardiovascular disease (CVD) is a condition that leads to chronic symptoms that are generally thought of as a primary disease. However, vascular injury leads to subsequent disease such as metabolic disease, obesity, high blood pressure and kidney disease. There are several contributing factors starting a person on the path of having cardiovascular disease. Some of these include:

  1. Oxidative (ox)stress—potentially results in DNA damage
  2. Increased low density lipid (LDL) that can become oxidized into oxLDLs
  3. Overeating/over-nutrition leads to hormonal imbalances and subsequently obesity and/or metabolic disease
  4. Distress/Eustress is controversial, but the body does not know the difference and they can both lead to shear stress due to increased blood flow through laminar areas of the vascular system.
  5. Toxins that come produced within the body (endobiotics) or enter the body from outside source (xenobiotics). Environmental effects have strong impacts on how the body responds. It is important to manage the things that are within one’s control such as smoking, exercise, and consuming a well-balanced diet.

With people livings becoming busier, it is easy to miss the warning signs. A slight weight gain here or a headache there. What then can be done about the progression of CVD and other disease states such as hypertension? I am glad you asked. Controlling hypertension for example can be maintained by making lifestyle changes consisting of exercising at least 150 minutes per week, modifying one’s diet to potentially include the dash diet, and reducing stress levels. This sounds like a lot but planning ahead is key. Often times I find myself going to a fast food restaurant because I have gotten too hungry to cook, or because I have not had time to go shopping. When I plan ahead and purchase my food for a week and pack healthy snacks, I evade the urge to go for those french fries (my go-to weapon against hunger). Additionally, I find I am less stressed if I spend some time performing rigorous exercises or get moving throughout the day. I attempt at least 250 steps every hour and 10,000 steps over the course of the day.

However, the symptoms are not the same for everyone, thus one should know what to look for to identify vascular disease early as well as forming a trusting relationship with a primary care provider because, “You’re the Cure”!! Let’s keep this conversation going. Follow me on Twitter (@AnberithaT) or on my site. I will take a deeper look at each of these topics and discuss what, if anything, can be done to combat or control these symptoms.

 

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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.

 

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Getting To The Heart of Long-Term Space Travel

During my last years in graduate school, I learned that the coolest experiment to ever be conduct was about to take flight – literally. In the genetics world, twin studies have been a classical tool used to study the nature vs. nurture effect of any given trait or disorder in humans. With the ever-increasing interest in understanding how long-term space travel affects humans, exploring this idea would obviously benefit from controlled twin studies, but what are the chances that NASA could actually find identical twins that are both qualified enough to be astronauts?

Turns out not as low as you would think!

Mark and Scott Kelly are twin brothers who joined NASA in 1996 and already had many spaceflights under their belts before the idea of a twin study even popped in to anyone’s head. However, in 2015, NASA jumped at their opportunity to perform what I think, is the coolest science experiment to have ever been executed. To get a better understanding of how being in space for an extended period of time, the NASA Twin Study would monitor an outstanding number of biological variables in both brothers before, during and after Scott’s 1-year long stay at the International Space Station, while Mark stayed on Earth.

While that alone makes for a pretty outstanding story, the best part of this experiment was truly how collaborative and integrative the studies were. The study was coordinated by NASA’s Human Research program, and over 84 researchers across 12 different universities performed the insane amount of work to analyze 10 different biological areas, including:

  • Biochemistry
  • Cognition
  • Epigenomics
  • Gene Expression
  • Immune
  • Metabolomics
  • Microbiome
  • Proteomics
  • Physiology
  • Telomeres
NASA Twin Study experimental design via Garrett-Bakelman et al., Science 364, 144 (2019)

NASA Twin Study experimental design via Garrett-Bakelman et al., Science 364, 144 (2019)

They knew they probably wouldn’t have a shot like this again and took advantage it. I was ecstatic in April when I saw the published results of the study since I’ve been following this experiment for years. Obviously, I was most interested in how cardiovascular function was impacted by long-term space travel. It’s been well known that the gravity-free environment of space takes some pressure of the heart from working so hard, but since the heart is a muscle, this lack of use causes a decrease in muscle mass. To combat this loss of muscle mass, astronauts typically spend ~ 2.5 hours exercising on the International Space Station! The heart also changes shape in space becoming more circular rather than elongated. Luckily, these changes return to normal once the astronaut returns to space, but what does spending a year in space do to your heart and vasculature? Here are the main cardiovascular changes from this study:

  • Cardiac output increased by of 10% while moderate decreases in systolic and mean arterial pressure were observed (these findings are consistent with previous studies)
  • The carotid intima-media thickness increased while Scott was in space and remained thicker 4 days after landing.
  • Inflammatory cytokines and chemokines were increased during all spaceflight timepoints and returned to normal after landing.
  • Urine levels of Collagen alpha-1(III) chain (COL3A1) and collagen alpha-1(I) chain (COL1A1) proteins were increased compared with preflight values, and these returned to baseline levels postflight.
  • An increase in the ratio of plasma levels of apoliprotein B (APOB; a major constituent of LDL particles) to apolipoprotein A1 [APOA1; a major constituent of high-density lipoprotein (HDL) particles] during the last 6 months of the mission in space. This ratio came back to baseline once Scott returned to Earth.

One of the most important take-home messages is that many of the variables analyzed either stayed the same or returned back to baseline once Scott came back to Earth, suggesting the effects of being in space for a year, on the heart in particular, is temporary and reversible. Obviously, the results of this study are limited because only one set of twins was analyzed so it’s hard to definitively say that these results represent how a year in space affects all of us – but it gives great insight into the biological effects of long-term space travel.

While I only focused on the cardiovascular results here, this study has an insane amount of information that is definitely worth reading, particularly since there were some variables, such as telomere length and DNA damage that changed during Scott’s time in space, but never returned back to his normal levels. That SpaceX flight might not be the best idea *just* yet.

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The Key Messages from 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease

The newest ACC/AHA guidelines were just published and is exclusively discusses the primary prevention of CVDs and excludes the care of patients with known atherosclerotic cardiovascular diseases as they are classified as “secondary prevention.”1

Here are the most important messages from the 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease.1

 

Promotion of healthy lifestyle.

nutrition

physical fitness to promote healthy lifestyle

 

Prevention in patients with known cardiovascular risk factors.

 

high blood pressure in prevention

high blood cholesterol in prevention

overweight and obesity

prevention in type 2 diabetes

prevention with smoking

 

Aspirin Use

Aspirin is well established for secondary prevention of ASCVD and is widely recommended for those with existing heart disease2. As per the new guideline, most adults without a history of heart disease should not take low-dose daily aspirin to prevent a first heart attack or stroke. Alow dose daily aspirin is recommended in the following instances.

aspirin use

 

References

  1. Arnett Donna K, Blumenthal Roger S, Albert Michelle A, Buroker Andrew B, Goldberger Zachary D, Hahn Ellen J, Himmelfarb Cheryl D, Khera A, Lloyd-Jones D, McEvoy JW, Michos Erin D, Miedema Michael D, Muñoz D, Smith Sidney C, Virani Salim S, Williams Kim A, Yeboah J and Ziaeian B. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease. Circulation. 2019;0:CIR.0000000000000678.
  1. Piepoli MF, Hoes AW, Agewall S, Albus C, Brotons C, Catapano AL, Cooney MT, Corra U, Cosyns B, Deaton C, Graham I, Hall MS, Hobbs FDR, Lochen ML, Lollgen H, Marques-Vidal P, Perk J, Prescott E, Redon J, Richter DJ, Sattar N, Smulders Y, Tiberi M, van der Worp HB, van Dis I, Verschuren WMM and Binno S. 2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts)Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J. 2016;37:2315-2381.
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Five Lessons From My Heart Attack Patients

In only few months, I leave my clinic where I have been seeing patients with heart disease for the past three years. It was not until I started discussing with them the transition to a new cardiologist that I appreciated the unique relationship we have built.  It has only been few years since we first met in in the Emergency Department in the middle of the night as they were having a heart attack, but somehow this journey feels longer.  I witnessed their heart attacks change their lives in many different ways, as they learned to cope, recover and carry on in life with a story to tell. Being one of the characters in their stories, I learned five lessons about life that will stay with me.

 

1- You can make any terrible event a wake up call or the beginning of the end.

A big heart attack or sudden cardiac arrest is arguably the most terrible event one could experience. As my patients recovered from such an event and came to see me in clinic, I could tell that the event changed them, either to the better or to the worse. While some lost weight, started training regularly, left their high stress jobs, or decided to travel the world, others became even more sedentary, gained weight, and started lamenting their bad luck and “missed opportunity” for good health.  It was striking to observe those two trajectories of opposite directions. Like my heart attack patients, when you are faced with a terrible event in life, you can either use it as a wake up call to do better afterwards or fall off a ledge and spiral down. You decide your own fate.

 

2- A supporting family is worth all the medicine of the world.

One patient after another, it became clear to me that the presence of a supporting family member that cares for you during difficult times is worth the most state-of-the-art medicine. It is that person that ensures that your food is low in salt and has no butter, that you do your daily exercise and not miss your medication, that you come to your appointments and ask all the right questions, or that simply hold your hand and tell you it’s going to be okay when things turn sour.

 

3- You’re as old as you think you are.

I met a 90 year-old woman who had a big heart attack and went for the most aggressive therapies. A year later she still shows to my clinic fully groomed and cheerful telling me she picked up dancing and life could not be any better.  I also met a 50 year-old man who after a small heart attack gave up on enjoying life or hoping for better future and couldn’t be convinced otherwise.

 

4- Faith, hope, and courage are your best friends when you’re not in control.

When patients are waiting for a high risk surgery or intervention, they simply are not in control of their fate. I found that those that fared well had three unique characteristics. First, they had faith in themselves, their doctors, or God. Second, they always hoped for the best. Third, they had the courage to face a difficult reality when things don’t go as well.  Whenever you’re not in control, let faith, hope, and courage always be your best friends.

 

5- Write your best story today because you never know when it ends.

While I learned so much from the stories of those patients who made it to my clinic, many did not, and their stories ended in the hospital. As you go through life, live every day to the fullest and write your best story page by page, because you really never know when it ends.

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The Social Determinants of Cardiovascular Health

Social epidemiology “proposes to identify societal characteristics that affect the pattern of disease and health distribution in a society and to understand its mechanisms.” [1]

At AHA EPI|Lifestyle Scientific Sessions this year, the conference theme was “Genes,  Behavior, and Environment: Putting the Pieces Together,” as I discussed in my blog post in early March. [Read the post]

Both within and between the ideas of genes, behavior, and environment was the thread of health disparities and social epidemiology. Oral abstract sessions included Epidemiology of Major Cardiovascular Disease, where Dr. Ben King discussed the burden of CVD among homeless persons in Austin, Texas; Dr. Gail Daumit highlighted interventions to reduce CV risk factor burden among those with serious mental illness; and Dr. Catherine Tcheandjieu called for more inclusion of non-European descent populations in polygenic risk studies.

In the Social Determinants of Cardiometabolic Disease, social determinants of health (SDOH) came to the forefront, as would be expected. From Dr. Emily D’Agostino presenting results comparing use of different poverty measures, to Dr Marialaura Bonaccio highlighting the effect of cumulative socioeconomic disadvantage across the lifespan on heart failure hospitalizations, we in the audience learned not only how to measure and evaluate these measures of social determinants of health, but saw how they quantifiably and undeniably affect CV health and outcomes.

Caption: A key Healthy People 2020 goal is to “create social and physical environments that promote good health for all”. You can learn more [here]. Image Source: https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health

Caption: A key Healthy People 2020 goal is to “create social and physical environments that promote good health for all”. You can learn more [here]. Image Source: https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health

 

In the Lifecourse Epidemiology session, presenters summarized and argued for the importance of diet quality, smoking prevention, access to green spaces, and healthy diet patterns beginning in childhood to attenuate CVD risk in adulthood. Research from the Lifestyle Council naturally focuses on healthy lifestyle behaviors that are typically found in more affluent groups and likely contribute to the widening health disparities in chronic disease we’ve observed over the past decade, at least. [2]

In Dr. Leslie Lytle’s frank discussion of the lack of NIH funding towards intervention studies [3] to address not only these disparities but the lag in CV Health overall, I’m reminded of the session at #AHA17 “Closing the Gap on Disparities: Practical Strategies and Implementation,” when Dr. Michelle Albert called for epidemiologists to move from describing associations to implementing and evaluating interventions. [Read the post]

I encourage you to think of your research in the framework of social determinants of health. You can learn more about SDOHs, access data sources, and learn how to put SDOH research in action at the CDC Social Determinants page.

 

References:

  1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2723602/ Social epidemiology: Definition, history, and research examples. 
  2. https://www.cdc.gov/nchs/data/hus/hus15.pdf Health, United States, 2015, With Special Feature on Racial and Ethnic Health Disparities
  3. https://www.ncbi.nlm.nih.gov/pubmed/30458950 NIH Primary and Secondary Prevention Research in Humans During 2012-2017

 

 

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Putting Together The Pieces of Genes, Behavior, and Environment

The theme of this year’s #EPILifestyle19 conference was “Genes, Behavior, Environment: Putting the Pieces Together.” The three speakers in the first session, Dr Eric Boerwinkle, Dr Leslie Lytle, and Dr Michael Jerrett presented a cohesive program truly reflecting putting the pieces together.

Dr Eric Boerwinkle genetic researcher, dean, and chair of public health at the UTHealth School of Public Health, kicked things off with a hearty welcome to Houston, and applauding the audience for braving the city during the annual Houston Rodeo. Dr. Boerwinkle’s talk was marked by sincerity and focused passion for precision health and precision prevention – terms to replace “precision medicine” – that mirrors the AHA’s focus on cardiovascular health over cardiovascular disease.

https://en.wikipedia.org/wiki/DNA_methylation

He highlighted that genetics, environment, and lifestyle behaviors can be envisioned in several ways, depending on perspective and discipline. A key challenge in producing science focused on fitting these pieces together is measurement. Variables are often measured separately and differently across disciplines, and no matter the metaphor, Boerwinkle encouraged the audience to step out of their silos and begin measuring key variables together. Dr Leslie Lytle of UNC Chapel Hill Gillings School of Public Health provided a concrete example with the ADOPT project for obesity treatment, which identified high-priority measures to measure across biology, behavior, psychosocial, and environmental processes.

Transitioning from genetics to lifestyle behaviors, Boerwinkle highlighted research finding that even in genetically high-risk patients, modifying environmental factors and lifestyle behaviors can lower risk.

Dr. Leslie Lytle, professor in the department of Health Behavior at UNC Chapel Hill, situated her talk in the puzzle piece landscape by contrasting the NIH’s position on the importance of intervention research with the dismal percent of funding dollars that actually go towards intervention research.

unsplash by yusuf evli

After emphasizing the importance of intervention research to address the lifestyle and behavioral challenges of poor cardiovascular health, particularly obesity, Dr. Lytle showed us what intervention research should look like and what it can accomplish. Combining environment-level interventions based on socioecological models with individual level education can effect change, like in in the CATCH intervention, which involved child-level education, positive social modeling, and healthy changes in physical activity and school meals.

Over the past few years, the “exposome” concept has only gained popularity, along with the “-omics” trend. Wrapping up the themed session with environmental factors, Dr Michael Jerrett of UCLA School of Public Health taught us about characterizing the exposome by incorporating hyper-spatiotemporal components into research to assign exposure. What are hyper-spatiotemporal components? These components measure where people go during the day, what the pollution level is there, what they are doing and how it affects their exposure (walking in a park, biking behind a diesel truck, sitting in a car).

unsplash by adrian williams

Jerrett highlighted several studies examining these concepts, comparing the inhaled pollutants when biking, walking, or commuting by car to work in various areas of a city. How can we measure these spatiotemporal components in a “ubicomp” (ubiquitous computing) environment? Jerrett broke down the inside of our smart phones, calling attention to the numerous sensors present in nearly every smart phone and the research possibilities to harness these.

 

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How the Immune System Favors Females in Pulmonary Artery Hypertension? Another Regulatory T Cell Story.

While it is commonly thought that cardiovascular disease is a man’s disease, CVD is the number one killer of women with the same number of deaths per year as cancer, diabetes and respiratory disease combined (according to 2015 statistical data from AHA). In addition, women exhibit different and more silent symptoms of heart attacks. There is a lot of interest in the difference between how males and females respond to CVD. A lot of emphasis is put on hormonal differences, but the immune system also seems to play an important role in this disparity. Females have a more robust immune system and therefore respond faster to infections providing more protection than in males. However, a more responsive immune system also means a more reactive immune system that can result in increased incidence of autoimmune diseases, such as rheumatoid arthritis and lupus.

Part of the difference in the immune system response in females can be attributed to the fact that multiple immune-related genes are expressed on the X chromosome. Since females have two alleles of the X chromosomes and males have only one, it is evident that females express more genes that regulate immune system functions. One of these genes is Foxp3, the key transcription factor for regulatory T cells, an adaptive immune cell which I have discussed before in a previous post. Regulatory T cells play an important protective role in CVD, especially in atherosclerosis and hypertension.

Pulmonary artery hypertension (PAH) is a fatal cardio-pulmonary disorder where the pulmonary arterioles narrow leading to a right ventricular fibrosis, heart failure and death. Regulatory T cells play an important role in this disease as animal models that lack regulatory T cells are more susceptible to PAH. Adding regulatory T cells back prevents the development of PAH showing the protective power of these cells. A recent study published in the journal Circulation Research, shows that in the absence of regulatory T cells, females rats are more prone to PAH than male animals due to a lower levels of PGI2, a pulmonary vasodilator, and the lack of the enzyme COX-2 that regulated PGI2. The researchers conducting the study show that by transferring regulatory T cells into these rats, these immune cells were sufficient to restore the levels of COX-2 and PGI2, as well as other immune inhibitory molecules PDL1 and IL-10. The authors suggest that regulatory T cells have both a direct and indirect effects on the arteries. The direct effects are exerted on the endothelial cells directly via COX-2 and PGI2, and the indirect effect is through the release of inhibitory molecules such as IL-10 and TGF, both of which would result in immune suppression and preventing inflammation. The results from this report suggested that females are more reliant on regulatory T cells for protection against PAH.

These new findings highlight the subtlety of immune regulation between females and males and further proves that in addition to hormonal differences, immune regulation disparities between genders that can alter the outcome of cardiovascular diseases. By understanding more about gender differences in CVD and the immune system, and figuring out ways to manipulate these subtle differences, scientists hope to achieve a more personalized and effective therapies to women versus men to combat CVD.

 

Dalia Gaddis Headshot

Dalia Gaddis is a postdoctoral fellow at the La Jolla Institute for Allergy and Immunology. She has a Ph.D. in microbiology and immunology. She is currently working on understanding the interactions between the immune system and atherosclerosis development