Lifestyle management : preventing Type 2 diabetes and cardiovascular complications

For individuals with Type 2 diabetes, cardiovascular disease is the principle cause of morbidity and mortality. Lifestyle management is recognized as being an essential part of diabetes and cardiovascular disease prevention. Meta-analyses demonstrate that lifestyle interventions, including diet and physical activity, led to a 63% reduction in diabetes incidence in those at high risk. ‘Real-world’ lifestyle modification programs have demonstrated encouraging improvement in risk factors for diabetes; however, the effect on diabetes incidence has not been reported. It has been demonstrated that lifestyle interventions reduce cardiovascular risk factors; however, data on long-term cardiovascular outcomes is lacking. The aim of this review is to discuss the current evidence of lifestyle interventions in the prevention of diabetes and cardiovascular disease.

Addressing evidence treatment gaps for cardiovascular disease through primary care collaboration

Aims & Rationale/Objectives
The aim is to establish the frequency of counselling by general practitioners (GPs) and community pharmacists (CPs) for patients with uncontrolled CVD risk factors. This will identify conditions for which CPs might collaborate with GPs in addressing evidence-treatment gaps.

Methods
A population survey undertaken in the Wimmera region of Victoria in 2006. 1425 adults aged 25-84 yrs were randomly selected using age/sex stratified electoral role samples. A representative 723 participants were recruited.

Principal Findings
Data on GP and CP visits were available for 694 participants. Overall, participants visited GPs 4.6 times and CPs 6.0 times/annum. However, one third of participants never consulted a pharmacist in 12 months compared to just 11.5% for GPs. Among obese patients (BMI ?? 30), the average number of visits/annum was 4.5 to GPs and 6.8 to CPs. The equivalent numbers were 5.6 and 8.6 respectively for those with systolic BP ?? 140 mmHg; 3.7 and 5.5 for total cholesterol > 5.0 mmol/L; and, 6.7 and 14.6 for patients with random blood glucose concentrations ?? 7.0 mmol/L.

Implications
People with suboptimal status for most common CVD risk factor are counselled frequently by CPs. A coordinated approach with GPs to the delivery of cardiovascular health promotion could provide valuable reinforcement of key messages and offers greater opportunity to identify at-risk individuals. Acknowledgements: KM is a pharmacist-academic at Greater Green Triangle UDRH, a position funded by the Department of Health and Ageing through the Rural and Remote Pharmacy Workforce Development Program

Frequency of migraine and the risk of cardiovascular disease for women : limited evidence of an association

Evaluation of: Kurth T, Schurks M, Logroscino G et al. Migraine frequency and risk of cardiovascular disease in women. Neurology 73, 581–588 (2009). There is substantial evidence that migraine with aura (MA) is associated with ischemic stroke and myocardial infarction in women. The mechanisms of this association are poorly understood. Analysis of data from the Women’s Health Study, from 27,798 women over 45 years of age who were initially free of cardiovascular disease, found that women with baseline MA at a frequency of less than monthly had increased risk of major cardiovascular disease (HR: 2.28; 95% CI: 1.70–3.07) relative to women without migraine, and those who reported MA with a frequency of more than weekly had more than four-times the risk of ischemic stroke (HR: 4.25; 95% CI: 1.36–13.29) compared with those without migraine. Low numbers of outcome events in each of the frequency categories and lack of information on migraine frequency during follow-up limit the interpretation of these findings, but they suggest that frequency of migraine may be a moderating factor in the link between MA and cardiovascular disease.

Overview of risk prediction models in cardiovascular disease research

Many risk prediction models have been developed for cardiovascular diseases in different countries during the past three decades. However, there has not been consistent agreement regarding how to appropriately assess a risk prediction model, especially when new markers are added to an established risk prediction model. Researchers often use the area under the receiver operating characteristic curve (ROC) to assess the discriminatory ability of a risk prediction model. However, recent studies suggest that this method has serious limitations and cannot be the sole approach to evaluate the usefulness of a new marker in clinical and epidemiological studies. To overcome the shortcomings of this traditional method, new assessment methods have been proposed. The aim of this article is to overview various risk prediction models for cardiovascular diseases, to describe the receiver operating characteristic curve method and discuss some new assessment methods proposed recently. Some of the methods were illustrated with figures from a cardiovascular disease study in Australia.

Laboratory and non-laboratory-based risk prevention models for secondary prevention of cardiovascular disease : the LIPID study

Aims : The aims of this study were to examine whether risk prediction models for recurrent cardiovascular disease (CVD) events have prognostic value, and to particularly examine the performance of those models based on non-laboratory data. We also aimed to construct a risk chart based on the risk factors that showed the strongest relationship with CVD.

Methods and results : Cox proportional hazards models were used to calculate a risk score for each recurrent event in a CVD patient who was enrolled in a very large randomized controlled clinical trial. Patients were then classified into groups according to quintiles of their risk score. These risk models were validated by calibration and discrimination analyses based on data from patients recruited in New Zealand for the same study. Non-laboratory-based risk factors, such as age, sex, body mass index, smoking status, angina grade, history of myocardial infarction, revascularization, stroke, diabetes or hypertension and treatment with pravastatin, were found to be significantly associated with the risk of developing a recurrent CVD event. Patients who were classified into the medium and high-risk groups had two-fold and four-fold the risk of developing a CVD event compared with those in the low-risk group, respectively. The risk prediction models also fitted New Zealand data well after recalibration.

Conclusion : A simpler non-laboratory-based risk prediction model performed equally as well as the more comprehensive laboratory-based risk prediction models. The risk chart based on the further simplified Score Model may provide a useful tool for clinical cardiologists to assess an individual patient's risk for recurrent CVD events.

Cardiovascular health behaviours and health needs among people with psychiatric disabilities

Recent research in Australia has found that people with a mental illness experience higher mortality rates from preventable illnesses, such as cardiovascular disease, respiratory disease and diabetes compared to the general population. Lifestyle and other behavioural factors contribute significantly to these illnesses. Lifestyle behaviours that affect these illnesses include lack of physical activity, consumption of a poor diet and cigarette smoking. Research on the influence of these factors has been mainly directed towards the mainstream population in Australia. Consequently, there remains limited understanding of health behaviours among individuals with psychiatric disabilities, their health needs, or factors influencing their participation in protective health behaviours. This thesis presents findings from two studies. Study 1 evaluated the utility of the main components of Roger’s (1983) Protection Motivation Theory (PMT) to explain health behaviours among people with a mental illness. A clinical population of individuals with schizophrenia (N=83), Major Depressive Disorder (MDD) (N=70) and individuals without a mental illness (N=147) participated in the study. Respondents provided information on intentions and self-reported behaviour of engaging in physical activity, following a low-fat diet, and stopping smoking. Study 2 investigated the health care service needs of people with psychiatric disabilities (N=20). Results indicated that the prevalence of overweight, cigarette smoking and a sedentary lifestyle were significantly greater among people with a mental illness compared to that reported for individuals without a mental illness. Major predictors of the lack of intentions to adopt health behaviours among individuals with schizophrenia and MDD were high levels of fear of cardiovascular disease, lack of knowledge of correct dietary principles, lower self-efficacy, a limited social support network and a high level of psychiatric symptoms. In addition, findings demonstrated that psychiatric patients are disproportionately higher users of medical services, but they are under-users of preventive medical care services. These differences are primarily due to a lack of focus on preventive health, feelings of disempowerment and lower satisfaction of patient-doctor relationships. Implications of these results are discussed in terms of designing education and preventive programs for individuals with schizophrenia and MDD.

Effects of strength, flexibility and moderate intensity cardiovascular exercise on measures of fitness in sedentary women

The maintenance of functional physical fitness across the lifespan depends upon the presence or absence of disease, injury, and the level of habitual physical activity. The prevalence of sedentariness rises with increasing age culminating in 31% of elderly women being classified as leading a sedentary lifestyle. Exercise prescription that involves easily accomplished physical activity may result in the maintenance of mobility into old age through a reduction in the risk of premature death and disablement from cardiovascular disease and a reduction in the risk of falls and injuries from falls. It may be that short bouts of physical activity are more appealing to the sedentary and to those in full time employment than longer bouts, and it may be that short bouts of exercise, performed three times per day, can improve physical fitness. The purpose of this study was therefore to examine the problem: Does exercise session duration, initial cardiovascular fitness, and age group effect changes in functional physical fitness in sedentary women training for strength, flexibility and aerobic fitness? Twenty-three, sedentary women aged between 19 and 54 years who were employed at a major metropolitan hospital undertook six weeks of moderate intensity physical activity in one of two training groups. Participants were randomly allocated to either short duration (3 x 10 minute), or long duration (30 minute), exercise groups. The 3 x 10 minute group (n=13), participated in three, 10 minute sessions per day separated by at least 2 hours, 3 days per week. The 30 minute group (n=10), participated in three 30 minute sessions per week. The total amount of work was similar, with an average of 129 and 148 kcal training day for the 3 x 10 minute and 30 minute groups, respectively. The training program incorporated three walking and stair climbing courses for aerobic conditioning, a series of eleven static stretches for joint flexibility, and isotonic and isometric strength exercises for lower and upper body muscular strength. Measures of functional strength, functional flexibility and cardiovascular fitness were assessed prior to training, and immediately following the six week exercise program. A two way analysis of variance (Group x Time) was used to examine the effect of training and group on the dependent variables. The level of significance, 0.05 was adopted for all statistical tests. Mean hand grip strength showed for both groups no significant change over time for the 3 x 10 minute group (30.7kg to 31.7kg) and 30 minute group (30.2kg to 32.4kg). Leg strength showed a trend for improvement (p=0.098) in both the 3 x 10 minute and 30 minute training groups representing a 15% and 18% improvement, respectively. Combined right and left neck rotation significantly improved in the 3 x 10 minute group (82.8° to 92.0°) and 30 minute group (82.5° to 91.5°). Wrist flexion and extension improved significantly in 3 out of the 4 measurements. Left wrist flexion improved significantly by an average of 7.0% for the 3 x 10 minute and 4.9% for the 30 minute group. Right and left wrist extension improved significantly in the 3 x 10 minute and 30 minute training groups (5.9% and 6.8%, respectively). Hip and spine flexibility improved 3.4cm (35.2cm to 38.6cm) in the 3 x 10 minute group, and 6.6cm (37.4cm to 44.0cm) in the 30 minute group. There was a significant improvement in cardiovascular fitness for both groups representing a 22% improvement in the 3 x 10 minute group (27.2 to 33.2 ml kg min), and a 25% improvement in the 30 minute group (27.5 to 34.4 ml -kg min). No significant difference was shown in the degree of improvement in cardiovascular fitness over six weeks of training for subjects of either low or moderate initial aerobic fitness. Grip strength showed no significant changes over time for either the young-aged (19-35 years) or middle-aged (36-54 years) groups. Leg strength showed a trend for improvement (p=0.093) in the young-aged group (63.5kg to 71.9kg) and middle-aged group (69.3kg to 85.8kg). Neck rotation flexibility improved a similar amount in both the young and middle aged groups representing an improvement of 9.9° and 8.0° respectively. There was significant improvement in two of the four measures of wrist flexibility. Hip and spine flexibility was significantly greater in the young-aged group compared to the middle-aged group (38.5cm and 30.7cm, respectively). There was a significant improvement in hip and spine flexibility over the six week training program representing an increase in reach of 6.5cm for the young age group and 4.9cm for the older group. The middle-aged subjects had significantly lower cardiovascular fitness than their younger peers, scoring 22.8 and 30.7 ml -kg min, respectively. Cardiovascular fitness improved a similar amount in both age groups representing a significant improvement of 23.8% and 28.1% for the younger-aged and middle-aged subjects, respectively. The findings of this study suggest that short bouts of exercise may be equally as effective as longer bouts of exercise for improving the flexibility and cardiovascular components of functional physical fitness in sedentary young and middle aged women. Additionally short bouts of exercise may be more attractive than longer bouts of exercise for the beginning exerciser as they may more easily fit into the busy lifestyle encountered by many people in today's society. Sedentary young and middle-aged women should benefit from static flexibility exercises designed to improve and/or maintain functional flexibility and thus maintain mobility and reduce the incidence of muscular injury. Regular, brisk walking, incorporating some stair climbing, is likely to be beneficial in improving cardiovascular health and perhaps also in improving leg strength, thereby helping to improve and maintain functional physical fitness for both young and middle-aged sedentary women.

Pharmacist assessment of adherence, risk and treatment in cardiovascular disease (PAART CVD)

Cardiovascular disease (CVD) accounts for 18% of disease burden in Australia, and 35% of deaths. Evidence- based management of CVD risk requires systematic consideration of individual risk factors and overall CVD risk, and a balanced approach to lifestyle modification, the optimal use of medicines, and medicines adherence.

This project examines a pHot model for primary prevention of CVD in community pharmacy aimed at improving quality of care. Pharmacists from ten pharmacies received training in CVD risk factor management and facilitating patient lifestyle modification.

They recruited 70 participants aged 50-74 years, taking medicines for blood pressure (BP) or cholesterol, and without diabetes or CVD, At baseline, research assistants conducted a clinical assessment of anthropometric and biomedical risk factors, and conducted interviews to examine health behaviours, medicines use and related issues. Data was analysed by a consultant pharmacist and summary reports produced, with recommendations and targets for risk reduction. These were addressed by patients and their community pharmacists over five monthly sessions. At follow up, the relative risk reduction for CVD onset over the next five years was 24%, contributed to by reductions in mean systolic BP (-7mmHg), diastolic PP (-5 mmHg), total:HDL cholesterol ratio (—0.2), waist circumference (—2cm in males, —0.7cm in females) and other risk factors.

Several key health behaviours improved, including diet quality and physical activity levels. Prevalence of non-adherence to cardiovascular medicines dropped by 1 6% to 22%.

The potential health benefits from this intervention need to be confirmed via larger, controlled clinical trials. Overall, this appears to be a feasible and potentially effective public health measure.

Management of cardiovascular diseases with micro systems and nanotechnology

Cardiovascular diseases are the leading cause of death and morbidity in industrialized nations and are becoming an urgent health problem for all nations due to the unstoppable trend of an ageing and obese population. Due to the rapid development of micro total analysis systems (μTAS) and nanotechnology in recent years, they will play an important role in the diagnosis, management, and therapy of cardiovascular diseases. It is envisaged that the micro and nanotechnologies developed for treating other diseases shall be explored for cardiovascular applications to reduce the research effort required for commercializing the devices and drugs to meet the increasing demand of the cardiovascular patients.