US Pharm. 2022;47(9):27-31.
New Guidelines Aim to Prevent Obesity in Midlife Women
Women between the ages of 40 and 60 years are the focus of new national guidelines aimed at preventing unhealthy weight gain that can lead to serious illness. The study review paper and clinical guidelines were published in Annals of Internal Medicine.
“More than two-thirds of middle-aged women are overweight or obese. Given women’s increased risk for weight gain in midlife, there is a critical need for intervention aimed at preventing obesity and the host of serious health outcomes associated with it,” said Kimberly D. Gregory, MD, MPH, corresponding author of the clinical guidelines and vice chair, women’s healthcare quality and performance improvement in the Department of Obstetrics and Gynecology at Cedars-Sinai.
Dr. Gregory is part of the Women’s Preventive Services Initiative (WPSI), which developed the recommendations based on the review of clinical trials involving nearly 52,000 middle-aged women. The initiative was launched in 2016 by the American College of Obstetricians and Gynecologists and operates in collaboration with the U.S. Department of Health and Human Services’ Health Resources & Services Administration.
“In the past, most studies and recommendations have focused on investigating the benefits and harms of weight-loss tools used by women who were already overweight. But as a prevention strategy, these new guidelines strongly encourage healthcare providers to begin addressing the issue of weight gain and obesity risk with patients who are at normal weight,” said Dr. Gregory.
Obesity has been declared an epidemic in the U.S., with 42% of adults having a BMI of over 30, according to the CDC. A BMI of 18.5 to 25 is regarded as healthy, and one between 25 and 30 qualifies as overweight.
According to the study, women gain weight at an average of 1.5 pounds per year during midlife, which increases their risk for transitioning to an overweight or obese BMI. The new guidelines emphasize the need to help with weight management by counseling women while they are at a healthy weight and not waiting until they are overweight or have developed obesity.
“Women are at higher risk for severe obesity due to menopause and age-related physiological changes,” said Amanda Velazquez, MD, director of obesity medicine in the Department of Surgery at Cedars-Sinai. “Significant weight gain is associated with a serious risk of developing cardiovascular disease, hypertension, type 2 diabetes, fatty liver disease, and numerous cancers. That is why advising middle-aged women with normal to overweight BMI on the need to limit weight gain is critical,” said Dr. Velazquez, who did not participate in the study.
The WPSI review suggests that some behavioral counseling approaches to preventing future weight gain in midlife women could result in modest weight loss. Dr. Velazquez, an obesity and weight-loss expert, says it is important to remember that weight management is a lifelong journey and investment in good health, and that there is plenty of help available.
“Do not give up. It is never too late to start making changes. There are quite a few weight-management tools available, including individualized lifestyle plans, support groups that provide accountability and community, nutritional counseling, and new weight-loss medications. For people with severe obesity, a BMI over 40, bariatric surgery may be an option to consider,” said Dr. Velazquez.
Vegetarian Women Face Higher Hip Fracture Risk
A study of more than 26,000 middle-aged UK women reveals that those with a vegetarian diet had a 33% higher risk of hip fracture compared with regular meat eaters.
University of Leeds researchers investigated the risk of hip fracture in occasional meat eaters; pescatarians, people who eat fish but not meat; and vegetarians compared with regular meat eaters. Their findings appeared in the journal BMC Medicine.
Among 26,318 women, 822 hip fracture cases were observed over roughly 20 years—that represented just over 3% of the sample population. After adjustment for factors such as smoking and age, vegetarians were the only diet group with an elevated risk of hip fracture.
This study is one of very few to compare risk of hip fracture in vegetarians and meat eaters where the occurrence of hip fracture was confirmed from hospital records.
The scientists stress the need for more research into the exact causes of the greater risk of hip fracture in vegetarians.
Study lead author James Webster, a doctoral researcher from the School of Food Science and Nutrition at Leeds, said: “Our study highlights potential concerns regarding risk of hip fracture in women who have a vegetarian diet. However, it is not warning people to abandon vegetarian diets. As with any diet, it is important to understand personal circumstances and what nutrients are needed for a balanced healthy lifestyle.
“Vegetarian diets can vary widely from person to person and can be healthy or unhealthy, just like diets that include animal products,” he said.
“However, it is concerning that vegetarian diets often have lower intakes of nutrients that are linked with bone and muscle health. These types of nutrients generally are more abundant in meat and other animal products than in plants, such as protein, calcium, and other micronutrients.
“Low intake of these nutrients can lead to lower bone mineral density and muscle mass, which can make you more susceptible to hip fracture risk. This makes it especially important for further research to better understand factors driving the increased risk in vegetarians, whether it be particular nutrient deficiencies or weight management, so that we can help people to make healthy choices,” Dr. Webster added.
Vegetarian diets have gained popularity in recent years, with a 2021 YouGov survey putting the size of the UK vegetarian population at roughly 5% to 7%. It is often perceived as a healthier dietary option, with previous evidence showing that a vegetarian diet can reduce the risks of several chronic diseases, including diabetes, heart disease, and cancer, compared with omnivorous diets. There is also a worldwide call for reducing the consumption of animal products in an effort to tackle climate change. Understanding hip fracture risk in vegetarians is therefore becoming increasingly important to public health.
The research team found that the average BMI among vegetarians was slightly lower than the average among the regular meat eaters. Previous research has shown a link between low BMI and a high risk of hip fracture.
Lower BMI can indicate a state of underweight, which can mean poorer bone and muscle health and higher risk of hip fracture. Further investigation is needed, however, to determine if low BMI is the reason for the observed higher risk in vegetarians.
Study co-author Darren Greenwood, a biostatistician in the School of Medicine at Leeds, said: “This study is just part of the wider picture of diet and healthy bones and muscles in older age.
“Further research is needed to confirm whether there could be similar results in men, to explore the role of body weight, and to identify the reasons for different outcomes in vegetarians and meat-eaters.”
Annual Screening Before Age 50 Years Lowers Proportions of Advanced Breast Cancer
A new study led by University of Ottawa (uOttawa) professors has found that Canadian provinces that annually screen women aged 40 to 49 years had lower proportions of advanced breast cancer compared with women aged 50 to 59 years from provinces that did not hold annual mammograms.
The study, published in Current Oncology, found lower proportions of stage 2, 3, and 4 breast cancer in women aged 40 to 49 years and lower proportions of stage 2 and 3 breast cancer in women aged 50 to 59 years from provinces that annually screened the subset aged 40 to 49 years.
“This is the first Canadian study to show that screening policies for women 40-49 impact women 50-59,” said co-lead author Anna Wilkinson, an associate professor in the Faculty of Medicine at uOttawa. “Women who are not screened in their forties are presenting with later stage breast cancer in their fifties. This means more intensive treatment and a worse prognosis for these women than if their cancers were diagnosed at an earlier stage.”
Dr. Wilkinson and fellow lead author Jean Seely reviewed the data of 55,490 women aged 40 to 49 years and aged 50 to 59 years from the Canadian Cancer Registry who were diagnosed with breast cancer between 2010 and 2017. They evaluated the impact of the 2011 Canadian breast cancer screening guidelines by looking at changes in the incidence of breast cancer by stage from 2011 to 2017.
The authors found that since Canadian guidelines changed in 2011 to recommend against screening women aged 40 to 49 years, there has been a 13.6% decrease in incidence of stage 1 breast cancer and a 12.6% increase in stage 2 breast cancer for women in their forties. For women in their fifties, the incidence of stage 2 increased by 3.1% over the same period. In provinces that did not continue to have organized screening programs for women aged 40 to 49 years, there was a 10.3% increase in stage 4 breast cancer in women aged 50 to 59 years over the 6 years.
Survival rates decrease in relation to the more advanced stage of breast cancer at diagnosis. The 5-year survival rate for stage 1 breast cancer is 99.8% compared with 23.2% for cancers diagnosed by stage 4. Such outcomes potentially lead to more advanced cancer and intensive treatments and surgeries as well as increased mortality.
“This is a great example of the benefit of using Canadian Cancer Registry data housed at Statistics Canada to take advantage of studying the effect of different policies regarding ages to start screening. Our findings align with recently updated USA National Comprehensive Cancer Network guidelines that recommend annual screening mammography for average risk women beginning at age 40,” said Jean Seely, head of breast imaging at The Ottawa Hospital and professor at uOttawa’s Faculty of Medicine.
“Further work will be needed to determine whether finding these cancers at an earlier stage translates into fewer fatal breast cancers and improved long-term outcomes.”
Canadian jurisdictions have different policies for screening women starting at age 40 or 50 years despite evidence that early detection of breast cancer leads to improved survival rates. The provinces and territories utilizing annual screening reminders for women in their forties during the study period were British Columbia, Alberta, Northwest Territories, Nova Scotia, and Prince Edward Island. Currently, only Nova Scotia, Prince Edward Island, and Yukon employ annual reminders.
Pregnant Women at Increased Risk of Severe Illness From COVID-19
COVID-19 infection in pregnant women is associated with increased risk of adverse outcomes compared with women who are not pregnant, according to a review published in JACC: Advances from the American College of Cardiology Cardiovascular Disease in Women Committee. Cardiovascular complications include heart attack, arrhythmias, heart failure, and long-haul symptoms that may be difficult to distinguish from other cardiac complications of pregnancy and require the cardiovascular care team to be vigilant when assessing pregnant women with COVID-19.
As COVID-19 cases increased globally, awareness of cardiovascular complications also increased, especially in certain high-risk populations. Heart attack is estimated in up to 12% of patients. The CDC found pregnant women are at increased risk of adverse outcomes with COVID-19, including severe infection (10%), ICU admission (4%), mechanical ventilation (3%), and use of extracorporeal circulation membrane oxygenation hemodynamic support (0.2%), compared with nonpregnant women of reproductive age. Additionally, pregnant patients who were of increased maternal age, had high BMI, or had other preexisting conditions such as chronic hypertension, preeclampsia, and preexisting diabetes, were at even higher risk for severe infection.
When compared with pregnant women without COVID-19, pregnant COVID-19 patients were at higher risk for preterm birth and stillbirth. Overall, 33% of infants born to patients with COVID-19 were admitted to the neonatal ICU. No other differences have been found for perinatal outcomes.
A U.S.-specific study found substantial racial disparities in outcomes for pregnant COVID-19 patients. While non-Hispanic black women accounted for 14.1% of the study cohort, they represented 26.5% of pregnancy-associated deaths. Pregnancy was associated with a 2.4 times risk of death in Hispanic women with COVID-19, and pregnant Asian and Native Hawaiian/Pacific Islanders were among those at highest risk of ICU admission.
According to the study authors, a reason for increased risk of cardiovascular complications is the low vaccination rate in pregnant women compared with other groups. In a recent study of over 130,000 pregnant patients, more than three-quarters of those requiring hospital admission, the vast majority of patients requiring critical care and all fetal deaths occurred in unvaccinated compared with vaccinated women.
“Pregnant people need to know that they are at increased risk of a severe COVID-19 infection, including ICU admissions, cardiac complications, need for critical care and death for the patient or fetus. Unfortunately, pregnant women have lagged behind other groups getting vaccinated,” said Joan Briller, MD, a cardiologist and professor of clinical obstetrics and gynecology at the University of Illinois at Chicago and the study’s lead author. “Available data support vaccination in pregnancy with good safety profile and protective transfer to neonates. The CDC, American College of Obstetrics and Gynecology and Society of Maternal Fetal Medicine among others recommend vaccination in pregnancy. I believe we should support this recommendation with our patients.”
The management of cardiac complications and diagnosis in pregnant COVID-19 patients can be challenging given the overlap of COVID-19 symptoms, cardiovascular disease, and pregnancy. According to the authors, imaging findings and timing of presentation may be helpful in differentiation and determining diagnosis. Clinicians may also need to adjust medical therapy during pregnancy and lactation.
The authors suggest management of cardiac complications in pregnant COVID-19 patients requires the creation of a “Pregnancy Heart Team” to optimize care, which may include providers comfortable with high-risk pregnancy, obstetric anesthesia, cardiology, critical care, and neonatal care, depending on the nature of the complication, stage of pregnancy, and severity of infection.
“Recognition of cardiovascular complication is hampered by failure to include pregnant women in clinical trials despite calls for inclusion of pregnant populations,” Dr. Briller said. “Consequently, women may be undertreated or inadequately treated due to lack studies addressing safety and efficacy of therapies during pregnancy or conversely be exposed to therapies where safety is not known.”
Women Urged to Eat Potassium-Rich Foods to Improve Heart Health
Women who eat bananas, avocados, and salmon could reduce the negative effects of salt in the diet, according to a study published in European Heart Journal. The study found that potassium-rich diets were associated with lower blood pressure, particularly in women with high salt intake.
“It is well known that high salt consumption is associated with elevated blood pressure and a raised risk of heart attacks and strokes,” said study author Liffert Vogt of Amsterdam University Medical Centers, the Netherlands. “Health advice has focused on limiting salt intake, but this is difficult to achieve when our diets include processed foods. Potassium helps the body excrete more sodium in the urine. In our study, dietary potassium was linked with the greatest health gains in women.”
The study included 24,963 participants (11,267 men and 13,696 women) of the EPIC-Norfolk study, which recruited 40- to 79-year-olds from general practices in Norfolk, UK, between 1993 and 1997. The average age was 59 years for men and 58 years for women. Participants completed a questionnaire on lifestyle habits, blood pressure was measured, and a urine sample was collected. Urinary sodium and potassium were used to estimate dietary intake. Participants were divided into tertiles according to sodium intake (low/medium/high) and potassium intake (low/medium/high).
The researchers analyzed the association between potassium intake and blood pressure after adjusting for age, sex, and sodium intake. Potassium consumption (in grams per day) was associated with blood pressure in women: As intake went up, blood pressure went down. When the association was analyzed according to sodium intake (low/medium/high), the relationship between potassium and blood pressure was observed only in women with high sodium intake, where every 1-gram increase in daily potassium was associated with a 2.4-mmHg reduction in systolic blood pressure. In men, there was no association between potassium and blood pressure.
During a median follow-up of 19.5 years, 13,596 (55%) participants were hospitalized or died due to cardiovascular disease. The researchers analyzed the association between potassium intake and cardiovascular events after adjusting for age, sex, BMI, sodium intake, use of lipid-lowering drugs, smoking, alcohol intake, diabetes, and prior heart attack or stroke. In the overall cohort, people in the highest tertile of potassium intake had a 13% lower risk of cardiovascular events compared with those in the lowest tertile. When men and women were analyzed separately, the corresponding risk reductions were 7% and 11%, respectively. The amount of salt in the diet did not influence the relationship between potassium and cardiovascular events in men or women.
Dr. Vogt said: “The results suggest that potassium helps preserve heart health, but that women benefit more than men. The relationship between potassium and cardiovascular events was the same regardless of salt intake, suggesting that potassium has other ways of protecting the heart on top of increasing sodium excretion.”
The World Health Organization recommends that adults consume at least 3.5 grams of potassium and less than 2 grams of sodium (5 grams of salt) per day. High-potassium foods include vegetables, fruits, nuts, beans, dairy products, and fish. For example, a 115-gram banana has 375 mg of potassium, 154 grams of cooked salmon has 780 mg, a 136-gram potato has 500 mg, and 1 cup of milk has 375 mg.
Dr. Vogt concluded: “Our findings indicate that a heart healthy diet goes beyond limiting salt to boosting potassium content. Food companies can help by swapping standard sodium-based salt for a potassium salt alternative in processed foods. On top of that, we should all prioritize fresh, unprocessed foods since they are both rich in potassium and low in salt.”
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