hidden

A New Year, A New Story: Tips for a Healthy Lifestyle in 2019

A new year presents a new opportunity for improvement. Each year, thousands of advertisements beckon us to join or buy the most recent fitness and wellness craze – wearable technologies, personal coaching, pea protein and oat milk. However, if trends are not your thing, you may find it reassuring that “traditional” fitness and wellness strategies (e.g., training for a 5K walk/run, taking the stairs instead of the elevator, and reducing your sugar intake) can also be re-imagined and integrated into your daily routine leading to a healthier, and likely happier you.

Perhaps contrary to the many images trying to sell wellness products, adopting fitness and wellness strategies are equally if not more important for those who are living with a chronic disease. In November 2018 at the American Heart Association Scientific Sessions, the Physical Activity Guidelines were updated and, for the first time, specified that physical activity can help to manage chronic conditions including decreasing pain, reducing the rate of progression for high blood pressure and diabetes, reducing anxiety and depression, and improving cognition in those with chronic comorbidities. These critical health outcomes symptoms are particularly important for adults living with HIV, who tend to experience worse symptoms than many living with other chronic illnesses – and consequently, they may stand to benefit the most from increased and improved physical activity.

Figure 1 Photo by Christine Schmitt via flickr (http://bit.ly/2LZufoz)

However, in addition to physical activity, nutritional intake is a critical part of improving health and wellness among adults living with HIV. A recent practice paper of the Academy of Nutrition and Dietetics found that nutritional status affects the overall health and longevity of this population. They suggest that improved diet can lead to reduced blood pressure, obesity, and diabetes, which will result in improved cardiovascular health. Lead author of the report, Amanda Willig, RD, PhD, from the University of Alabama at Birmingham, suggests that when anyone (especially someone with a chronic disease such as HIV) is starting to adopt a new diet to “Remember, the enemy of good is perfect. A perfect diet is not needed to see big changes in your health.”

So what are the good diet changes needed to improve health? Regardless of one’s HIV status, Dr. Willig’s recommendations on healthier eating are the same: “Watch your portion sizes, try to eat vegetables every day / fill ½ of your plate with vegetables at meals, limit the amount of sugar in your diet, and choose water over sugar sweetened beverages like soda, sports drinks or sweet tea.”

However, for those with HIV, there are some special considerations. While the evidence is still emerging, Dr. Willig indicated that those with HIV may need more Vitamin D than they did prior to their HIV infection for their overall health.  And if one’s CD4+ T-cell count is less than 250, they may want to avoid eating raw or undercooked meat and seafood, as they be at higher risk for food poisoning. Additionally, for the growing number of people living with HIV who are over 50, they may need to increase their protein intake from 0.8 grams per kg per day to 1.2 grams per kg per day. This will help with maintaining muscle mass and preventing bone loss.

Yet whether you are decreasing your portion size or increasing your daily protein intake, changing behavior can be hard and as we age, it can seem complicated and sometimes discouraging. In addition to seeking help from registered dietitian or a Physician Nutrition Specialist who can help you decide which lifestyle nutrition plan is best suited to you, Dr. Willig also suggested several tips for adopting a healthy diet in 2019 (see insert).

 

Dr. Willig’s Tips for Adopting a Healthy Diet in 2019

  • Keep a food diary for 3-4 days to learn not just what you are eating but why.
  • Start with the small steps that can produce big changes, such as cutting out sugary drinks or not eating during the night.
  • Regardless of the nutrition plan, portion sizes still matter. One can eat too many of the “right” foods, so learn what a portion of the foods you eat actually looks like.
  • Make sure your nutrition plan fits your lifestyle. If you want to cook, you can to experiment with baking and sautéing instead of frying foods. If you travel often, learn to read nutrition labels and restaurant nutrition information to avoid eating too many calories.

 

Additional strategies can be found on the American Heart Association’s Healthy Living Website.

As you start to navigate how to start the year committed to becoming healthier you, there will undoubtedly be challenges – busy schedules, competing demands, mood, weather and so on. But you can overcome them and take small steps to become a healthier you in 2019. As you start this journey, consider the words of writer Alex Morritt, “New year — a new chapter, new verse, or just the same old story? Ultimately we write it. The choice is ours.” The new year has just begun, and regardless of your age, sex, health status, or neighborhood in 2019 you get to write your own story – one in which you relentlessly pursue a healthier you.

 

hidden

Improving Vascular Health: Nutritional Coaching

There has been an ongoing misconception of weight being a consequence of over-nutrition. The relationship between calorie intake versus calories spent continues to overshadow the biological forces that resist the maintenance of weight. Although scientists started to recognize obesity as a chronic disease in 1985, it was about 28 years later before the American Medical Association made the acknowledgement. The recognition of obesity being classified in the cluster of metabolic syndrome (MS) was a significant milestone in weight loss and primary health care.

Metabolic syndrome (MS) is defined as a homeostatic disturbance in the metabolic system characterized by visceral obesity, atherogenic dyslipidemia, hypertension, insulin resistance, and more recently, adipose tissue dysfunction. Increasing studies are exploring adipose tissue (AT) as an endocrine organ system encompassing physiological functions that assist in the regulation of weight, insulin sensitivity, inflammation, and vascular function. Matthews et al (opens in a new window) described the role of macrophages in the inflammatory response. Additionally, Dias et al (opens in a new window) expounded on the various inflammatory cytokines in AT that can potentially be modulated suggesting an anti-inflammatory role for statins. These reports have demonstrated a reduction in stress-induced inflammatory cytokines such as IL-6 and C-reactive protein as well as the upregulation of PPARγ, inhibition in ER stress, PA1 promoter activity through MAPKKK1 and to a lesser extent NFκB with the therapeutic use of statin drugs. There are conflicting data on the utilization of statins; however, their potential to induce the expression of PPAR and SRB1 in adipocytes can directly and inadvertently lower cholesterol and SRB1 stimulation. Generally, obesity has been controlled using pharmaceutical supplements; some examples include: Topiramate, Diethylpropion, Phentermine, and Lorcaserin. Among the medicinal weight therapies, Orlistat plays a direct role in digestion by inhibiting the absorption of dietary fat and subsequently body weight reduction. Orlistat inhibits diacylglycerol lipase (DAGL), the enzyme that catalyzes the hydrolysis of diacylglycerol leading to the liberation of free fatty acids and monoacylglycerol. This information is noteworthy due to the mechanistic pathways delineated in an article by Matthews and Lee (opens in a new window) (Figure) suggesting an important connection between the endocannabinoid ligand 2-arachidonylglycerol (2-AG) and oxidized low density lipoproteins (oxLDLs). This group and others have demonstrated DAGL and PLC-β are Ca2+ dependent enzymes that are important in the biosynthesis of 2-AG. However, during my time in Dr. Matthew Ross’s lab we found oxyradical fluxes and 2-AG generation had a positive correlation that lead to an antioxidant and anti-inflammatory effect associated with the 2-AG ligand. Thus, Orlistat combined with a low-calorie diet can have a synergetic effect of inhibiting fat absorption, reducing leptin concentration in plasma, CRP, IL-6 TNFα and inducing vascular protection.

In relation to food and nutrition, there are several articles that are related to the mechanistic action of the gut in relation to blood pressure including the role of gut microflora, oxidative stress, and lipid pathways that lead to metabolic changes. Being that my knowledge of nutrition is limited. I interviewed Tina Brown, FNP (opens in a new window) from Elite Health for expert advice.

Improving Vascular Health: Nutritional Coaching

 

I met Tina one morning on my way to campus. As I started my long walk down the sidewalk, I saw a sign across from a restaurant saying, “Weight Loss”. I thought to myself, “There is always a weight program somewhere. I’m in Memphis after all.” Memphis is known for their food, such as the Green Beetle that became popular back in 1939, the flavorful Curry-N-Jerk Caribbean cuisine, BB King BBQ Joint, the Redbird Field food court, and anything down Beale Street. Memphians are foodies and have the whole month of May dedicated to Blues and Barbeque! So, it comes as no surprise to see a “Weight Loss” facility in Memphis. Shelley White-Means, PhD (opens in a new window), University of Tennessee Health Science Center presented on, “Disparities in Breast Cancer Mortality: A Perfect Storm in Memphis.” I would like to modify that to say, “Disparities in CVD mortality: A Perfect Storm in Memphis” due to the culture and prevalence of food, as well as the activities surrounded by an abundance of great barbeque.

I spoke with Tina via phone in addition to a face-to-face interview. To give some background as to why nutrition is an important second step in one’s health journey, it is important to understand that one in three Americans are diagnosed with a metabolic dysfunction consistent with cardiovascular disease, such as hypertension, diabetes, renal dysfunction, or obesity.

The interview went as follows:

Q1. What are your qualifications?

A. I attended Nursing school at University of Memphis (@UofM) as an adult learner receiving a Bachelor of Science in Nursing. After working for several years as a nurse, first doing rotations and finally settling in the medical surgical unit I returned to UofM to specialize.

Q2. Are you aware of any nutritional requirements for a patient that has cardiovascular disease namely, hypertension?

A. I was watching an infomercial about L-Arginine and how it helps with cleaning the vascular system and vasodilation. After watching for several minutes, I realized it was an infomercial, but it was good information and research. I don’t recall the author.

Note: Upon looking for the information, I was not able to find the exact infomercial that Tina was referring; however, I did find information on L-arginine’s effect on the vascular system. Arginine is the precursor for nitric oxide (NO) in endothelial nitric oxide (eNOS), since eNOS is necessary for gas exchange and the regulation of various biological functions it is reasonable that L-arginine can play a role in maintaining vascular homeostasis. Allerton et al (opens in a new window) (Figure) compared in a review the use of L-arginine with citrulline supplementation to determine whether there were any significant changes in cardiometabolic health. Patients with elevated blood pressure has been reported to display labs with reduced NO bioavailability and subsequent vasoconstriction. Incorporating L-arginine (and l-citrulline) into the diet can potentially indirectly or directly increase vasodilation by increasing eNOS expression and NO production thereby its bioavailability leading to reduced blood pressure.

Q3. What advice will you give a patient regarding these diagnoses?

A. Eating a low carbohydrate diet. Choosing the good carbs such as eliminating white bread and sugars.

Note: In a randomized clinical trial, Dr. Christopher Gardner et al (opens in a new window). evaluated the effects of low-fat (HLF) versus low-carbohydrate (HLC) healthy diets to determine whether there were any genotypic alterations in regard to weight loss that were effected by either of the dietary patterns. The HLF or HLC diets had no statistical significant in weight loss by genotype, insulin interactions. These data and others suggest that eating a low carb diet can be beneficial in weight loss, but in addition to other healthy lifestyle changes. Especially in light of statin therapy assist in reduction in fat absorption.

B. Combining the ketogenic diet (high protein, high fat) and paleo (organic) diets together can work as a sustainable diet that will allow one to get all the nutrients the body need to work properly. The keto diet done alone is not as healthy:

  • Ketogenic diet is a plan that consist of minimizing carbohydrate intake while maximizing fats to force the body to use fat as its form of energy for expenditure. Generally, this mechanism translates to calories being consumed from 60-75% fat, 15-30% protein, and 5-10% carbohydrates. On average it takes about 2-7 days for the body to go into ketosis on this meal plan.
  • Paleolithic times was a period when certain food stuffers were not available, thus the paleo diet is a nutritional approach that is focused on eating unprocessed foods based on those guidelines. The primary backbone of it is to only consume food that would have been available before the industrial agriculture, domestication of animals, and modern food processing.

Note: There is a vast amount of research indicating that branched chain amino acids (BCAA) are linked to diabetes, and this is showing an increasing trend over the past decade. In an Editorial in the Journal of Diabetes (opens in a new window), Bloomgarden described a Young Finn’s Study suggesting phenylalanine and tyrosine, aromatic amino acids are linked to insulin resistance in men and obesity my track more strongly in the presence of BCAA. In addition to BCAA leading to increased risk of MS: obesity CVD, dyslipidemia, and hypertension; medium-and long-chain acylcarnitine’s, the metabolic byproducts of mitochondrial catabolism of BCAA, plays a role in insulin resistance.

C. Know that vitamins are being taken and do not just listen to what you are hearing. If you are healthy, you will lose weight as a side effect if weight loss is necessary. Making lifestyle changes that will result in small gains will generate the momentum needed to be successful in moving forward in sustaining the lifestyle. Once a person sees results, compliance becomes easy.

Note: Dalia Gaddis, PhD and Wei Ling Lau, MD also gave some insightful information in their blogs on these topics such as: “Weight Loss and Exercise: A Remedy For A Better Functioning HDL”, “Can Increasing HDL Reduce Heart Disease? An Issue of Constant Debate!”, “Natural Supplements Can Be A Pain in The Kidneys” and “If you give a patient calcium…” respectively.

D. Increasing physical activity is important. One must get the heart rate up and maintain the increased heart rate for short intervals (Note: it is recommended to get heart rate up for ~30 minutes 3 days per week). Doing simple things make a big difference such as standing up and moving around. Incorporate things that will make the muscles work rather than just sitting or standing stationary. For example, there are now the balance boards to stand on at the standing desk, or a body ball to sit on at a sitting desk.

Note: “Therapeutic elevation of HDL-Cholesterol to prevent atherosclerosis and coronary heart disease” Pharmacology and Therapeutics 2006 (opens in a new window); 111(3):893-908. The study delineated that HDLs play a role in cholesterol transport. However, Ross et al (opens in a new window) suggested only free cholesterol is effluxed from macrophages via ABCA1 transporters. It has also been reported that macrophage cholesterol exchange can be modulated by toxins in the body by down regulation of CD36 and SR-A protein expression.

Q4. How will you advise a patient suffering with CVD symptoms on improving their vascular health from a nutrition standpoint?

A. Get weight under control. Determine the underlying reason/condition behind the weight gain/vascular injury. Determine whether there is a metabolic disorder, rule out any hormonal deficiencies such as thyroid or testosterone, vitamin levels

B. Reduce any inflammation if necessary by potentially using a low dose pharmaceutical regimen until the patient lose weight or get hypertension under control. Especially if it is acute rather than chronic.

Q5. Any overall/general nutritional guidelines you would suggest for a patient with hypertension to consider modifying?

A. Meal preparation is the best option. By planning meals, one can look ahead at the menu and make good choices about what is being prepared. Even going to the grocery store, shopping the perimeter will generally give the healthier options.

B. Avoid eating out. When meals are prepared at home everything that goes in the meal can be a healthy option without any cheats. When eating out, one never knows whether there are cheats such as saturated fats or salts

C. Limit sodium intake

D. Have healthy snacks readily available. This will help cut cravings and avoid picking up unhealthy sugary snacks due to the feeling of needing to eat quickly. If a person has the personality that they must eat all the time, it will be hard if not impossible to change, having healthy snacks on hand such as fermented snacks (pickles or sauerkraut) or dehydrated fruit and veggies is better than forcing them to change and these snacks assist in weight loss.

Q6. How important is reporting back to the physician/counselor?

A. Very important, accountability helps with compliance. It is also a trust issue; the medical professional wants them to want to come back. The patient needs to be able to ask questions and discuss any changes in treatment. If a patient starts to lose or gain weight their medicine may need to change thus making it necessary to visit the physician/counselor regularly. It is also a good idea to have a fitness buddy to hold each other accountable.

It is important to not only visit the doctor but also to ask questions about your health. Take the challenge to be the best you that you can be.

 

Upcoming posts:
• Fitness coaching
• Mental coaching

Leave a comment or tweet @AnberithaT and @AHAMeetings if you have questions or are interested in something else specifically.

Follow me and @American_Heart for more #HeartSmart information.

Anberitha Matthews, PhD is a Postdoctoral Fellow at the University of Tennessee Health Science Center in Memphis TN. She is living a dream by researching vascular injury as it pertains to oxidative stress, volunteers with the Mississippi State University Alumni Association, serves as Chapter President and does consulting work with regard to scientific editing.

hidden

Nursing And Allied Professional Sessions At The American Heart Association

During the American Heart Association Scientific Sessions, there were great sessions. It was really a struggle to make an overview of all the nurses and allied professional sessions in a short blog; they were just all very interesting and informative. But I summarized the topics that were for me the most interesting during the Sessions.
 
Adherence to medication use
Dr. Todd Ruppar (@ToddRuppar) presented the importance of the use of behavior prompt for cardiac patients to remember medication intake. Dr. Ellis presented one of the new examples of these behavioral prompt: the printable pillboxes with the possibility to connect to a mobile app (InterACT Pillbox).

Slide showing example of printable pill box with app capabilities

Dr. Rhonda Copper-deHoff suggested that pharmacogenetic testing could be a piece of the adherence puzzle in cardiac patients and Dr. Anton Vehovec (@antonvehovec) points out that medication adherence mediate the relationship between memory and emergency room visits and hospitalization. He stated that we should test interventions that aim to improve memory and look at the effect this has on medication adherence.

 

2. Technology use
Dr. Maria Liljeroos’ (@MartorMaria) research showed that telemonitoring is feasible to implement, but that we have to remember that it is still a challenge to include older cardiac patients.

Dr. Megan Reading gave a talk on technology use in patients with atrial fibrillation. In her research, they found that being asymptomatic was the main reason for not using technology. Also traveling and simply forgetting to use the technology were important reasons for not using it.

Dr. Mary Dolansky found in her research that the current evaluation of technology used to measure self-care behaviors, such as activity monitors, is insufficient. Future research should be focused on evaluating technologies for measuring and use in self-care in cardiac patients.

examples of self care measures slide

3. Palliative care/end of life in cardiac patients
A quote of Isaac Asimov, which Dr. Lisa Kitko used in her presentation, presents the importance of palliative care in cardiac patients:

Life is pleasant death is peaceful it's the transition that troublesome - Isaac Asimov

She further stated that we should remember that 67% of all patients with an LVAD have 5 or more comorbidities.

Dr. Lorraine Evangelista brings up in her presentation the importance of optimal palliative care in the beginning of the heart failure trajectory. She also presented a poster of Lisa Hjelmfors on the importance of communication about the heart failure prognosis in the US and Europe. And although most nurses think they have knowledge on prognosis and the communication with the patients, around 70% would like further education about this topic.

Dr. Dougherty gave a talk about technology advances create complex decision making for patients, family and providers. Health care professionals need to have conversations and discussions about device management at end of life.

Dr. Loreena Hill (@HillLoreena) and Dr. Donna Fitzsimons (@FitzsimonsDonna) stated that there is a paradigm shift regarding when deactivation should be discussed and who is responsible in long overdue if end of life care for patients with an ICD is to improve.

Study Characteristics

4. The importance of involving caregivers
Dr. Anna Strömberg (@Anna_Submitting) talked about the importance of involving caregivers and the support and education these caregivers want. Caregivers would like easy access to health care and support groups with caregivers alone. This could help them to handle their life situation.

J.N. Dionne-Odem (@jn_dionneodom) pointed out that caregivers are vital in care for patients with heart failure, but that we have to realize that only 1 in 3 are comfortable giving heart failure care.

A poster presented by Dr. Hiroko Ishida shows the importance of health literacy in caregivers. They found that health literacy of patients with heart failure and their caregivers was independently associated with caregivers burden.

5. Diet, fluid restriction and appetite
Dr Anna Strömberg (@Anna_Submitting) stated the importance of the need for more research in nutrition and fluid restriction and Dr. Lennie presented that we are all on a diet, but that just finding the best food for you, as a person is a challenge. Dr. Martha Biddle advised that cardiac patient should have a healthy, varied diet. She even presented a recipe for a cardiovascular health:

recipe for cardiovascular health slide

Dr. Lora Burke suggests that mobile apps could be a tool for nutrition research to increase adherence. Mobile apps could give feedback to the patients, which could improve dietary choice/eating behavior by make patients more aware of their choices. Dr. Misook Chung presented a poster concluding that diet quality was similar in patients with heart failure regardless their adherence to sodium restriction diet. Christina Andrea’s (@C_Andreae) poster demonstrated that patients who are more physically active have better appetites compared to those who are less physically active. This research underscore that in future studies, a need is for attention on physical activity and appetite.

physical activity and appetite in patients poster

6. Physical activities
Dr. Tiny Jaarsma (@DrJaarsma) presented a new way for patients in cardiac care to be active at home: Exergaming. Exergaming is being physical active with a gaming computer. In her research, (@HFWii) they found that installing such a computer at home with patients with heart failure increased their exercise capacity.

Another promising and alternative way to exercise in community-dwelling older adults, presented by Dr. Marjorie Funk, was Qigong. Qigong is a form of exercise composed of movements that are repeated a number of times, often stretching the body, increasing fluid movement (blood, synovial, and lymph) and building awareness of how the body moves through space. This research showed that Qigong was feasible for older adults and that they accepted this form of exercise. This research group next step is to test this on cardiac patients.

A intervention presented was the Heart Up!, (a text message intervention) showed promising in improving in physical activity and decreasing hopelessness in patients with ischemic heart disease.

Leonie Klompstra Headshot

Leonie Klompstra is a Nurse Scientist at the Linköping University in Sweden. Her primary focus is on heart failure and rehabilitations.