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Afraid of What’s in Vaccines? Here Are 5 Things You Ingest or are Exposed to Everyday Without Thinking Twice About Their Effects on Your Body and Heart Health

The American divide regarding the COVID-19 vaccine is a passionate topic for everyone. This article is not intended to prove to readers why getting vaccinated for COVID-19 is safe but to provide some insight on the daily decisions we don’t think twice about that have both theoretical and established health consequences.

  1. The beef you eat and the milk you drink: Many farm-raised cattle are injected with artificial growth-promoting hormones such as oestradiol, progesterone, testosterone, zeranol, trenbolone and melengestrol to promote rapid meat production. Recombinant bovine growth hormone (rBGH) is a genetically-engineered synthetic hormone used to increase milk production in cattle, which then communicates to your liver to increase the production of Insulin-Like Growth Factor-1 (IGF-1). Although no systemic studies have directly researched the health effects of these hormones in the body, associations with DNA damage, infertility, premature puberty and risk for breast, prostate, colon, and lung cancer have been found retrospectively1,2.
  2. Ultra-processed foods: How often are you eating chips, bagels, pizza, soda, and other highly-processed food items without thinking twice about how they are manufactured? Based on the NOVA system classification, ultra-processed foods go beyond the addition of salt, sweeteners, or fat and include artificial flavors and preservatives that increase the shelf-life in your kitchen cupboards, preserve the texture of foods and increase their palatability to leave you craving for more. More and more studies are being published linking these foods to heart disease, heart attacks, and death from cardiac causes3.
  3. Aspirin, Tylenol, and Ibuprofen: You likely reach for these common analgesics in your cabinet when you have pain, inflammation, or fever to alleviate the symptoms you are suffering from. However, there are risks and rare side effects associated with taking these drugs that include serious allergic reactions, kidney damage, bleeding, heart attacks, and stroke4. This is not meant to scare you into never taking these medications but to bring to light the many decisions we make that are more likely to benefit us rather than harm us.
  4. Air pollution: How often do you grab your smartphone to check the air quality for the day? If the quality is less than ideal, how often does that impact whether you go outside? Poor air quality has been associated with heart disease, long-term respiratory problems, stroke, and low life-expectancy5,6. However, the benefits of staying physically active outside, experiencing life events, socializing to improve mental health, and anything else that provides meaning in our lives by being outside likely outweight many of these risks.
  5. The sun: Everyday, UV radiation from the sun and our atmosphere produce reactive oxygen species that cause direct DNA damage. This can lead to skin aging, skin cancer, and eye damage. Despite these risks, the benefits the sun provides to our planet and existence outweigh the risk and allow us to appreciate the positives7.

Every decision we make involves a conscious or subconscious risk assessment rooted in our values. As physicians, we are committed to providing medical advice based on whether the benefits outweigh the risks for our patients. While I can and will validate your concerns and fears, I hope that in the future you might consider seeing the forest for the trees.

References:

  1. https://www.jswconline.org/content/68/4/325
  2. http://ifrj.upm.edu.my/25%20(01)%202018/(1).pdf
  3. https://www.jacc.org/doi/10.1016/j.jacc.2021.01.047
  4. https://link.springer.com/article/10.1007/s12325-019-01144-9
  5. https://link.springer.com/content/pdf/10.5487/TR.2014.30.2.071.pdf
  6. https://www.sciencedirect.com/science/article/pii/S1875213617301304
  7. https://link.springer.com/article/10.1007/s13273-017-0002-0

“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 health matters. If you think you are having a heart attack, stroke, or another emergency, please call 911 immediately.”

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Fruits, Vegetables, Wholegrains, Plant proteins, and your Heart

Cardiovascular diseases (CVD) are the leading cause of death in Western countries and accounts for 17.3 million deaths/year globally1. In the United States, one in every three deaths are caused by CVD, and more than 130 million adults are projected to express CVD by 2035 clinically1. The unhealthy diet and physical inactivity, obesity, stress, smoking, and alcohol consumption are major risk factors for CVD development1. Nutrition has been reported to be the most preventable risk factor of CVD death1,2. Further, a healthy diet is crucial for managing body weight, diabetes, and hypertension1,3. Therefore, it is essential to identify foods and dietary patterns beneficial for cardiovascular health.

AHA 2021 Dietary Guidance to Improve Cardiovascular Health was presented for the first time by Dr. Alice Lichtenstein, a lead scientist at Tufts University, at #AHA21 scientific sessions and was recently published in Circulation4. AHA suggests that instead of emphasizing one food/nutrient, one should focus on dietary patterns that are the sum of all foods and beverages consumed4. The dietary habits can be adapted to personal preferences, ethical/religious practices, and life stages so that healthy patterns can be followed in the long run4. A heart-healthy diet promotes a healthy planet, meets essential nutrients and fiber requirements, and benefits stroke, type 2 diabetes, kidney disease, and cognitive function4. AHA 2021 Dietary Guidance is organized in following ten features:

 

  1. Adjust energy balance to achieve and maintain healthy body weight.
  2. Include plenty and a variety of fruits and vegetables.
  3. Pick food made with whole grains rather than refined grains.
  4. Choose healthy protein sources, mostly plants, fish, and seafood, and low-fat/fat-free dairy products. If meat or poultry is desired, replace red and processed meat with lean cuts and unprocessed form.
  5. Use liquid plant oils rather than tropical oils and trans-fat.
  6. Choose minimally processed foods.
  7. Minimize consumption of beverages and foods with added sugars.
  8. Consume food prepared with no or little salt.
  9. Limit intake of alcohol. If you do not drink alcohol, do not start.
  10. Adhere to this guidance regardless of where food is prepared or consumed,

 

However, is it easy for everyone to follow a heart-healthy diet? Our food environment is an essential element when we talk about diet quality and can make it difficult for people to adhere to heart health guidelines. Although diet quality improved from 1999 to 2012, disparities are evident based on race/ ethnicity, education, and income5. Dr. Maya Vadiveloo, assistant professor at the University of Rhode Island, explained that the food environment mainly consists of:

  1. Regulatory environment (federal, state, and local practices, and food marketing).
  2. Physical environment (places we eat, live, and acquire food).
  3. Social environment (family and peers).
  4. Individual choices.

She further explained that several state and federal policies, structural racism, neighborhood segregation, unhealthy built environments impede the adaption to a healthy diet. Furthermore, availability, price, and varied access make choosing unhealthy and processed food easier4. Federal food assistance programs, including Supplemental Nutrition Assistance Program (SNAP) and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), are not universally effective and only cover a fraction of the monthly household supply4. Food companies tend to target low-income and racial minorities households. High processed food and beverages are telecasted more on TV, digital media, and print advertisements4. Dr. Vadiveloo concluded her talk by discussing the concept of precision nutrition which includes the evaluation of genetics, microbiome, dietary intake, and socioeconomic and physical environment to determine the most fruitful dietary plan to prevent and treat disease.  Increased access to affordable housing, enhancing access to supermarkets and green space, and increased access to online food delivery can help achieve dietary goals. She emphasized the power of artificial intelligence, which is unfortunately used for promoting unhealthy food. Still, it can help design personalized dietary interventions, population-level diet quality, and help people choose healthier and medical tailored diets when they buy groceries.

Following this, Dr. Lawrence J Appel, professor at John Hopkins University, explained how a multisector approach including government (regulatory and agriculture policy), health care sector, private sector, and health advocacy organizations is needed to change the default of food sector/eating. Dr. Appel focused on how policy changes can help individuals to eat healthily. In the US, processed and restaurant foods are significant sources (>70%) of sodium6FDA generated guidance for food manufacturers and restaurants to reduce salt in their processed, packaged, and prepared foods to achieve a 12% reduction in sodium and slash rates of heart diseases7WHO has generated public food procurement policies that require food and beverages served/sold in a public setting to promote a healthy diet8indirectly influencing manufacturers to reformulate their products. Although not common in the US, several other countries have front-of-pack warning labels (nutrient specific labels, nurtiscore and guideline daily amount) and health taxes on sugary drinks and salty food. Currently, only New York City requires restaurants to post a warning label next to the menu that contains more than 2300 mg of sodium and applies to restaurants with more than 15 locations nationwide. He concluded his talk by the importance of advocating and supporting policies that improve the health of patients and the broader community.

The last talk of the session was by Dr. Anne N. Thorndike from Massachusetts General Hospital and Harvard Medical school. Dr. Thorndile explained how clinicians and the healthcare sector could help implement 2021 dietary guidelines. She suggested that clinicians emphasize overall nutritional patterns and ask patients about barriers to access and consuming a healthy diet. Further, a clinician can deliver simple patient-centered guidance consistently over time by encouraging fruits/vegetables, plant proteins and oils, whole grains and discouraging the use of added sugars, processed meat, and excess alcohol. Further, hospitals employ approximately 6 million people and treat 750 million people annually. Therefore, many patients are exposed to cafeteria food. Hospitals can opt for traffic-light labels to promote healthy eating where green light suggests choosing often, yellow light means choosing less often, and a red light indicates a better choice available.

There is plethora of scientific evidence present that have helped in building 2021 AHA dietary guidelines. However, we need a multisector approach which will help imply the dietary goals to a larger population.

Reference

  1. Casas R, Castro-Barquero S, Estruch R, Sacanella E. Nutrition and Cardiovascular Health. Int J Mol Sci. Dec 11 2018;19(12)doi:10.3390/ijms19123988
  2. Mozaffarian D, Ludwig DS. Dietary guidelines in the 21st century–a time for food. JAMA. Aug 11 2010;304(6):681-2. doi:10.1001/jama.2010.1116
  3. Lacroix S, Cantin J, Nigam A. Contemporary issues regarding nutrition in cardiovascular rehabilitation. Ann Phys Rehabil Med. Jan 2017;60(1):36-42. doi:10.1016/j.rehab.2016.07.262
  4. Lichtenstein AH, Appel LJ, Vadiveloo M, et al. 2021 Dietary Guidance to Improve Cardiovascular Health: A Scientific Statement From the American Heart Association. Circulation. Dec 07 2021;144(23):e472-e487. doi:10.1161/CIR.0000000000001031
  5. Rehm CD, Peñalvo JL, Afshin A, Mozaffarian D. Dietary Intake Among US Adults, 1999-2012. JAMA. Jun 21 2016;315(23):2542-53. doi:10.1001/jama.2016.7491
  6. Harnack LJ, Cogswell ME, Shikany JM, et al. Sources of Sodium in US Adults From 3 Geographic Regions. Circulation. May 09 2017;135(19):1775-1783. doi:10.1161/CIRCULATIONAHA.116.024446
  7. Edward E. New FDA guidance aims to drastically cut salt in food supply. NBC News. Accessed December 15, 2021. https://www.cnbc.com/2021/10/13/new-fda-guidance-aims-to-drastically-cut-salt-in-food-supply.html
  8. Public Food Procurement and Service Policies for Healthy Diet. WHO. Accessed December 15, 2021. https://apps.who.int/iris/bitstream/handle/10665/338525/9789240018341-eng.pdf

“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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The New Phase of the Prevention Pyramid–the Primordial Prevention

You are what your mother eats: launch a new generation into a lifetime of ideal cardiovascular health

––#AHA21 Recap from presidential lecture by Dr. Don Lloyd-Jones, AHA President

My PhD research was focused on maternal nutrition and epigenetics. When I started graduate school, the field of epigenetics just started to make some splash in the scientific community. As a new graduate student, I have a plethora of questions. What is epigenetics? Why should I care to study it? How does that have anything to do with nutrition? You are what your mother ate. The food your mother had during pregnancy and lactation can forever change your health through epigenetic regulation (without changes in your genetic makeup). This became my passion, to understand how maternal nutrition affects offspring and how to promote healthy life from the beginning of everything.

At 2021 scientific sessions of American Heart Association (AHA), Dr. Don Lloyd-Jones gave an inspirational speech about the next phase of the Prevention Pyramid–the Primordial Prevention (Fig.1). The previous Prevention Pyramid contains three segments which were chronically progressed: Tertiary Prevention,

Secondary Prevention, and Primary Prevention. With the development of medical devices and acute therapy, the Tertiary Prevention helped in-hospital mortality rate drop from more than 30% to less than 5%. The Secondary Prevention applies discharge therapies and significantly reduces the recurrent incidences of cardiovascular diseases (CVD) events. The current strategy to fight CVD is through reducing incidences via targeting risk factors, called the Primary Prevention. Starting from the Framingham Heart Study, many important risk factors of CVD such as age, blood cholesterol level, blood pressure, smoking status have been identified. The previous Prevention pyramid made a big success in terms of CVD prevention until 2011. Then the progress curve starts to show stagnation, partly because of obesity epidemics sequelae and widening social-economics disparities.

With the help of pioneer research from Dr. Jeremiah Stamler from Northwestern University, modern CVD studies start to shift focus to study healthy people for low risk factor identification. AHA developed criteria, “Life’s simple 7TM” , defining ideal cardiovascular health (CVH): stop smoking, eat better, get active, lose weight, manage blood pressure, control cholesterol, and reduce blood sugar1. High CVH is associate with better CVD events prevention, the CVH trajectories from childhood are set as early as the 3rd grade2. Current research showed that women with ideal maternal gestational CVH is 8+ times more likely to have offspring with ideal CVH 10 years later3. The importance of Primordial Prevention is unignorable. From the latest discoveries of epigenetics studies, results suggest that not only mother’s CVH can affect babies’ CVH, father’s CVH could potentially possess certain influences as well4.

“No man is an island”, as John Donne wrote. Social determinants of health can affect 80% to 90% of a person’s risk factors (Fig. 2). To promote a better CVH for the whole community, AHA relentlessly aims to drive a more equitable health impact to the society. “Let’s do this for all the children in our life”, as Dr. Lloyd-Jones concluded, AHA is dedicating funding for more research studies to guide us towards an exciting phase of CVD prevention, the Primordial Prevention in the foreseeable future.

REFERENCES

  1. Lloyd-Jones DM, Hong Y, Labarthe D, Mozaffarian D, Appel LJ, Van Horn L, Greenlund K, Daniels S, Nichol G, Tomaselli GF, Arnett DK, Fonarow GC, Ho PM, Lauer MS, Masoudi FA, et al. Defining and Setting National Goals for Cardiovascular Health Promotion and Disease Reduction. Circulation. 2010;121(4):586–613.
  2. Allen NB, Krefman AE, Labarthe D, Greenland P, Juonala M, Kähönen M, Lehtimäki T, Day RS, Bazzano LA, Van Horn L V, Liu L, Alonso CF, Webber LS, Pahkala K, Laitinen TT, et al. Cardiovascular Health Trajectories From Childhood Through Middle Age and Their Association With Subclinical Atherosclerosis. JAMA Cardiology. 2020;5(5):557–566.
  3. Perak AM, Lancki N, Kuang A, Labarthe DR, Allen NB, Shah SH, Lowe LP, Grobman WA, Lawrence JM, Lloyd-Jones DM, Lowe Jr WL, Scholtens DM, Group HF-USCR. Associations of Maternal Cardiovascular Health in Pregnancy With Offspring Cardiovascular Health in Early Adolescence. JAMA. 2021;325(7):658–668.
  4. Hughes V. Epigenetics: The sins of the father. Nature. 2014;507(7490):22–24.

“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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Blood pressure and the consumption of sodium and potassium, which is more important?

Nutrition is one of many lifestyle factors that contribute to cardiovascular disease. Specifically, both sodium and potassium are known to influence the regulation of blood pressure (raising and/or lowering). The dysregulation of blood pressure is related to either too much sodium or little potassium (1-2). Jackson et. al., 2018, surveyed 765 participants to obtain estimates of sodium and potassium intake through 24 hour urine collections. Only about 4.2% dietary sodium intake met the dietary guidelines of less than 2300mg/d, and dietary potassium was reported as 1997 mg/d. The recommended intake for potassium is 4700mg/d. Furthermore, the study highlighted that a 1000-mg-lower level of sodium intake was associated with a –4.4 mmHg level of systolic BP and a 1000-mg higher level of potassium intake a –3.4 mmHg level of systolic BP.

Source: https://ods.od.nih.gov/factsheets/Potassium-HealthProfessional/

Similjanec et al., 2020, showed how dietary potassium could reduce the detrimental effects of sodium on vascular function. The investigators used a 24-hr urine collection and were able to group individuals into a salt-resistant group. Salt resistance was defined as a change of 5 mmHg or less in 24-h mean arterial pressure. In the figure to the left, the authors show how

a potassium-rich diet can mitigate the effects of high dietary sodium on flow-mediated dilation, a technique that shows the strong association of cardiovascular disease risk (3). See figure 3.Thus, adequate consumption of dietary potassium could be protective to many people in the U.S.

Source:  https://pubmed.ncbi.nlm.nih.gov/31562419/

Looking at the nutrients together and the impact on health is vital, especially in the case of blood pressure regulation. Similjanec et. al., 2000, results in highlight the need to consider potassium in future investigations for the management of blood pressure and cardiovascular disease risk.

Kogure et al., 200, used an OMRON Healthcare urinary Na/K ratio monitor to look at the urine ratio of Na/K. This handheld self-monitoring device was supported through multiple measurements of the urinary Na/K ratio which were strongly related to home hypertension regardless of the treatment status for hypertension (4). Figure 4 highlights the prevalence of home hypertension over 10 days.

A solid starting spot for keeping your blood pressure in check is to look for some dietary sources you enjoy. Here are some good dietary sources of potassium to add to the diet from the national institute of health’s webpage.

Apricots for the win!

Source: https://ods.od.nih.gov/factsheets/Potassium-HealthProfessional/

 

References:

1) Jackson, S. L., Cogswell, M. E., Zhao, L., Terry, A. L., Wang, C. Y., Wright, J., Coleman King, S. M., Bowman, B., Chen, T. C., Merritt, R., & Loria, C. M. (2018). Association Between Urinary Sodium and Potassium Excretion and Blood Pressure Among Adults in the United States: National Health and Nutrition Examination Survey, 2014. Circulation137(3), 237–246.

2) Smiljanec K, Mbakwe A, Ramos Gonzalez M, Farquhar WB, Lennon SL. Dietary Potassium Attenuates the Effects of Dietary Sodium on Vascular Function in Salt-Resistant Adults. Nutrients. 2020; 12(5):1206.

3) Ras RT, Streppel MT, Draijer R, Zock PL. Flow-mediated dilation and cardiovascular risk prediction: a systematic review with meta-analysis. Int J Cardiol. 2013 Sep 20;168(1):344-51. doi: 10.1016/j.ijcard.2012.09.047. Epub 2012 Oct 4. PMID: 23041097.

4) Kogure, M., Hirata, T., Nakaya, N. et al. Multiple measurements of the urinary sodium-to-potassium ratio strongly related home hypertension: TMM Cohort Study. Hypertens Res 43, 62–71 (2020). https://doi.org/10.1038/s41440-019-0335-2

“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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Heart-Healthy Diet for Women

March is both Women’s History month and National Nutrition month. It’s a good time of the year to pay attention to women’s health in a more constructive way. Heart disease is the #1 cause of death in women, according to a 2017 CDC report1. One in 4 women in the United States dies of heart disease, while only 1 in 30 dies of breast cancer. Within 6 years of having a heart attack, about 46 percent of women become disabled with heart failure. Astonishingly, two-thirds of women failed to make a full recovery after a heart attack2. The risks of heart disease and heart attack increase dramatically after a woman reaches menopause. One in 8 women between 45-64 years old suffers some form of heart disease and the number jumps to one in 4 for women are over 65 years old. Therefore, it’s pertinent to tackle this long-ignored problem, especially for women.

Good progress has been made and continued to be making. The American Heart Association (AHA) launched a movement in 2004, Go Red for Women®, which has reached great success in increasing awareness for heart health in women. Through their relentless efforts in education, innovation, health equity, research development, women are more engaged in preventing and fighting heart disease in the recent decades. Clinical research on cardiovascular disease starts to identify sex difference effects on drug response to help physicians develop a more targeted treatment for women3,4.

To have a healthy heart, besides avoiding some known risk factors such as smoking, drinking and obesity, dietary intervention is one of the most attenable, yet effective ways to live a healthy life. AHA made several educational infographics to promote healthy eating habits. For instance, the figure on the right gives simple suggestions on how to increase diversity of your food choice. It emphasizes the importance of fruits and vegetable consumptions. There are more infographics in the AHA website, if you are interested in learning more, please check it out. Many healthy eating suggestions are developed to combat cardiometabolic diseases. In general, fruits, vegetables, whole grain products, fish, poultry, beans, seeds, and nuts are good for your health, while too many calories, processed food, too much salt/sodium, added sugar, trans-fat and saturated fat are bad for you.

Research shows that Mediterranean diet can reduce risks of cardiovascular diseases5. Table 1 on the right represents a breakdown of Mediterranean diet5. Most of recommended foods are considered general healthy foods. Another study suggests that Mediterranean diet decreases incidences and mortality from coronary heart diseases and stroke in women6.

How to decide which healthy dietary pattern you want follow? Eating index was developed to help evaluate healthy eating habits. Four major indexes including Healthy Eating Index-2015, Alternate Mediterranean Diet Score (AMED), Healthful Plant-Based Diet Index (HPDI), and Alternate Healthy Eating Index (AHEI) all show reduced incidences of cardiovascular disease with healthy eating patterns7. If you have trouble deciding which eating habit you want to develop, just follow the general recommendation first. After all, a little bit of deviation won’t change the overall benefits. The key is to stick to it and keep consistent.

 

References

  1. Heron M. Deaths: Leading Causes for 2017. National vital statistics reports : from the Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System. 2019.
  2. Sandmaier Marian A4  – National Heart, Lung, and Blood Institute MA-S. The healthy heart handbook for women. 2005:1 online resource (106 pages) : illustrations (some color)-Other US.
  3. Jin X, Chandramouli C, Allocco B, Gong E, Lam CSP, Yan LL. Women’s participation in cardiovascular clinical trials from 2010 to 2017. Circulation. 2020.
  4. Scott PE, Unger EF, Jenkins MR, Southworth MR, McDowell TY, Geller RJ, Elahi M, Temple RJ, Woodcock J. Participation of Women in Clinical Trials Supporting FDA Approval of Cardiovascular Drugs. Journal of the American College of Cardiology. 2018.
  5. Anon. Primary prevention of cardiovascular disease with a mediterranean diet. Zeitschrift fur Gefassmedizin. 2013.
  6. Fung TT, Rexrode KM, Mantzoros CS, Manson JE, Willett WC, Hu FB. Mediterranean diet and incidence of and mortality from coronary heart disease and stroke in women. Circulation. 2009.
  7. Shan Z, Li Y, Baden MY, Bhupathiraju SN, Wang DD, Sun Q, Rexrode KM, Rimm EB, Qi L, Willett WC, Manson JAE, Qi Q, Hu FB. Association between healthy eating patterns and risk of cardiovascular disease. JAMA Internal Medicine. 2020.

 

“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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Nutrition in the New Year: What is Our Role as Cardiologists?

As we embark on this new year, we are bound to field questions from our patients (and likely, family members) centered around the most popular new year’s resolution: Eating healthier. Reflecting upon my own answers to these questions in clinic over the years, I realize they have been some combination of:

“Eat smaller portions.” “Eat less meat.” “Cut out soda or juice.” “Don’t eat for 3 hours before going to bed.” “Have you heard of the Mediterranean diet?”

And the basis for my recommendations? While I’m sure my years of medical training were factored in somewhere, I feel like these suggestions were largely based on a combination of my own experiences with managing my nutrition, anecdotes from colleagues and friends, and quite possibly my favorite podcasts.

Upon further reflection, though, this is not all too surprising. For all the years that we spend in medical school, residency, and fellowship learning about pathophysiology and pharmacology, we receive much less structured education on nutrition.1 In four years of medical school, one study estimates that the average medical student receives approximately only 19 hours of didactic lectures in total on nutrition, with most of this education focusing on the manifestations of nutritional deficiencies (thiamine, vitamin C, etc.).2 If your recollection is like mine though, 19 hours seems like an overestimation, and it only declines in post-graduate medical training. In a recent study published in the American Journal of Medicine, 31% of cardiologists reported receiving no nutrition education in medical school, 59% reported none during residency, and 90% reported receiving no or minimal nutrition education during fellowship.3

Nutrition Education from Medical School to Fellowship. (From Devries et al.3)

Figure 1: Nutrition Education from Medical School to Fellowship. (From Devries et al.3)

“But we are cardiologists, not nutritionists,” one might say. Yet in the same study, 95% of cardiologists believed that their role is to provide their patients at least basic nutrition information (68.6% believed they should personally provide detailed nutrition information to patients).3 While many of our cardiovascular care teams include dieticians specifically trained to counsel our patients on their nutrition habits, we as cardiologists often find ourselves directly answering these questions from our patients.

Indeed, some physicians have made names for themselves by proselytizing specific diets for their patients. Yet what I find a bit unsettling is the variability of the messages we deliver to our patients when it comes to nutrition. While the AHA provides dietary recommendations we can share with our patients, new diets continue to pop up and gain traction in the headlines, inevitably leading to questions from our patients about whether it is safe for them to adhere to these diets. Notably, (1) intermittent fasting, (2) plant-based or vegan, and (3) ketogenic or “keto” appear to be the diets du jour.

While I personally have experimented with intermittent fasting and a plant-based diet, I am a bit uncomfortable fully endorsing one or the other to my patients, each with his or her own metabolic profile and potential list of glucose-lowering medications. When it comes to diet, more than anything, individualization is key. More so than exercise and medications, diet has deeper roots in the cultural, financial and societal environments in which our patients live. Helping them navigate a healthy lifestyle through these obstacles requires not only more time in clinic but also a deeper, more evidence-based foundation in cardiovascular nutrition.

Fortunately, we are entering an era in which we are gathering more evidence in nutrition science. A recent study published earlier this month in Cell Metabolism studied “time-restricted eating” (AKA intermittent fasting with a 10-hour eating window) in patients with metabolic syndrome,4 finding that it had beneficial effects on weight loss and metabolic profile in its albeit small sample size. (Figure 2) Additionally, a New England Journal of Medicine review article published over the holidays highlighted the existing evidence we have, both in animals and in humans, of intermittent fasting on health, longevity, and various disease states (including cardiovascular disease and cancer).5 Importantly, these recent publications and the responses they have elicited in the news and on social media have called attention to the need for more dedicated studies to address the safety and efficacy of specific diets and dietary patterns in our patients with metabolic and/or cardiovascular diseases. Indeed, more clinical trials are underway: a quick search on ClinicalTrials.gov shows that 24 registered clinical trials with an “intermittent fasting” intervention are actively recruiting participants, including the LIFE AS IF trial from the University of Chicago.

Graphical Abstract from Wilkinson et al study on Time-Restricted Eating in Metabolic Syndrome.4

Figure 2: Graphical Abstract from Wilkinson et al study on Time-Restricted Eating in Metabolic Syndrome.4

In a prior blog post on “Wearables in Medicine,” I recommended that we consider trialing wearable devices ourselves before counseling patients based on data obtained from them. While I do think our own experiences with diets and dietary patterns may be informative, our personal experiences should not be the sole pillar upon which we base our nutritional recommendations to our patients. Again, individualization is key, and a nuanced approach, factoring in living environments, medications, and metabolic profiles, is necessary.

So what should we do as members of cardiovascular care teams? Well, to provide basic nutrition recommendations to our patients, we can use the AHA Diet & Lifestyle Recommendations. However, we must acknowledge our own limitations regarding the lack of formal training on nutrition during our medical education. As such, my resolution this year is to further my education on nutritional science and attempt to understand how these popular diets may fit within modern cardiovascular disease management. To achieve these goals, I will:

  • Read: Some books recommended by my attendings that I plan to read include The Obesity Code by Jason Fung, MD and The Plant Paradox by Steven Gundry, MD. Additionally, for those interested in learning more about the role of a “keto” diet in cardiology, the ACC.org Sports and Exercise Cardiology section recently published a series of high-yield, informative articles (Link 1 and Link 2).
  • Collaborate: We have a dietician in our cardiovascular care team with whom I regrettably had not spoken directly with until recently. I previously had just referred patients to her, but I did not necessarily know exactly what advice she was giving to our shared patients. Opening and maintaining this channel of communication is essential to delivering a consistent message from our team.
  • Ask: I am now making it a habit to include a simple question in my clinic encounters: “How’s your diet?” I have found the open-endedness of the question to be quite enlightening, often helping me to uncover a new aspect of the world my patient lives in and their own perspective on how their nutrition impacts their health.

I would love to hear your input on this topic. What do you feel our roles are in nutrition counseling for our patients? What are reliable resources to learn more about this topic? How can we be better at delivering appropriate nutrition information to our patients? Please reach out to me on Twitter (@JeffHsuMD) with your thoughts and ideas.

References:

  1. Devries S, Willett W, Bonow RO. Nutrition Education in Medical School, Residency Training, and Practice. JAMA. 2019;321:1351–1352.
  2. Adams KM, Butsch WS, Kohlmeier M. The State of Nutrition Education at US Medical Schools. Journal of Biomedical Education. 2015;2015:357627.
  3. Devries S, Agatston A, Aggarwal M, Aspry KE, Esselstyn CB, Kris-Etherton P, Miller M, O’Keefe JH, Ros E, Rzeszut AK, White BA, Williams KA, Freeman AM. A Deficiency of Nutrition Education and Practice in Cardiology. Am J Med. 2017;130:1298–1305.
  4. Wilkinson MJ, Manoogian ENC, Zadourian A, Lo H, Fakhouri S, Shoghi A, Wang X, Fleischer JG, Navlakha S, Panda S, Taub PR. Ten-Hour Time-Restricted Eating Reduces Weight, Blood Pressure, and Atherogenic Lipids in Patients with Metabolic Syndrome. Cell Metab. 2020;31:92-104.e5.
  5. de Cabo R, Mattson MP. Effects of Intermittent Fasting on Health, Aging, and Disease. N Engl J Med. 2019;381:2541–2551.

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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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.

 

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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.

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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.