Archive for May, 2009

Low levels of brain chemical may lead to obesity, NIH study of rare disorder shows

May 15th, 2009 BMI

A brain chemical that plays a role in long term memory also appears to be involved in regulating how much people eat and their likelihood of becoming obese, according to a National Institutes of Health study of a rare genetic condition.

Brain derived neurotrophic factor (BDNF) is, as its name implies, produced in the brain. Studies of laboratory animals have suggested it also helps control appetite and weight. The NIH study, appearing in the August 28 New England Journal of Medicine, provides the first strong evidence that BDNF is important for body weight in human beings as well.

The NIH researchers studied children and adults with WAGR syndrome, a rare genetic condition. The researchers found that some of the people with this syndrome lack a gene for BDNF and have correspondingly low blood levels of the substance. The people in this subgroup also have unusually large appetites and a strong tendency towards obesity.

“This is a promising new lead in the search for biological pathways that contribute to obesity,” said Duane Alexander, M.D., director of the NIH’s Eunice Kennedy Shriver National Institute of Child Health and Human Development. “This finding may eventually lead to the development of new drugs to regulate appetite in people who have not had success with other treatments.”

The study’s first author was Joan C. Han, M.D. and the senior author was Jack A. Yanovski, M.D., Ph.D., both of NICHD’s Unit on Growth and Obesity. Other authors of the study were from the National Human Genome Research Institute and the National Institute on Drug Abuse, also part of the NIH. Funding for the study was provided by the NICHD and the NIH Office of Rare Diseases.

WAGR syndrome is an acronym for the complex of symptoms seen in people who have the condition. These include Wilms tumor, a tumor of the kidneys; aniridia, absence of the iris, in the eye; genital and urinary tract abnormalities; and mental retardation. WAGR syndrome occurs in one out of every 500,000 to 1 million persons.

People with WAGR syndrome lack genes that are grouped on chromosome 11. All people with WAGR syndrome lack two specific genes, called WT1 and PAX6, but each person can also be missing other nearby genes. For the most part, human chromosomes are arranged in pairs, and the genetic deletions found in WAGR syndrome occur on only one of the two copies of chromosome 11.

WT1 and PAX6 are located in the region of the chromosome that’s near the gene for BDNF. For this reason, the NIH researchers examined chromosome 11 from WAGR syndrome patients to learn if the gene for BDNF was affected, explained Dr. Yanovski.

Studies of mice had determined that animals missing a working copy of the BDNF gene were prone to excessive eating and obesity. Studies in human beings, however, hadn’t proved that BDNF was important in people.

In the current study, the NIH researchers conducted analyses of chromosome 11 in 33 patients with WAGR syndrome. A total of 19 patients (58 percent) had deletions of all or a major proportion of one copy of the gene for BDNF. By age 10, all of the 19 were obese and were reported to have a strong tendency to overeat. Moreover, all of the 19 had blood levels of BDNF that were roughly 50 percent lower than those of patients who had two working copies of the BDNF gene. The patients who had two working copies of the BDNF gene were no more likely to develop childhood onset obesity than the general population, and did not report unusually high levels of overeating.

Dr. Yanovski explained that BDNF is believed to work in combination with a variety of other substances that regulate appetite and body weight. Chief among these is leptin, a hormone found to be involved in signaling hunger. Dr. Yanovski added that release of BDNF in the hypothalamus, a part of the brain involved in controlling eating, is believed to be indirectly triggered by leptin. Studies of the relationship between the two, and of BDNF’s action on tissues, may lead to the development of new drugs to treat obesity in some individuals.

Source: NIH/National Institute of Child Health and Human Development

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Not all fat is created equal

May 15th, 2009 BMI

A Temple University study finds fat in obese patients is “sick” when compared to fat in lean patients.

When our bodies don’t work properly, we say we’re sick. A study published in the September issue of Diabetes finds that the same could be said for fat tissue found in obese patients. The cells in their fat tissue aren’t working properly and as a result, are sicker than cells found in lean patients’ fat tissue.

Lead author Guenther Boden, M.D. theorizes that “sick fat” could more fully explain the link between obesity and higher risk of diabetes, heart disease and stroke.

Researchers from the departments of endocrinology, biochemistry and surgery at the Temple University School of Medicine took fat biopsies from the upper thighs of six lean and six obese patients and found significant differences at the cellular level.

“The fat cells we found in our obese patients were deficient in several areas,” said Boden, Laura H. Carnell Professor of Medicine and chief of endocrinology. “They showed significant stress on the endoplasmic reticulum, and the tissue itself was more inflamed than in our lean patients.”

Endoplasmic reticulum (ER) is found in every cell and helps synthesize proteins and monitor how they’re folded. The stress that Boden describes causes the ER in fat cells to produce several proteins that ultimately lead to insulin resistance, which has been found to play a major role in the development and progression of obesity-related conditions.

The National Institutes of Health recently reported that each time a body mass index (BMI) over 25 is raised by one point, the risk for diabetes increases 25 percent and the risk for heart disease increases 10 percent.

Reducing weight can help reduce stress on the ER, which can lower the risk of insulin resistance and the resulting conditions. Currently Boden and his team are looking at whether free fatty acids are a potential cause for this ER stress.

Source: Temple University

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Early trigger for type 1 diabetes found in mice, Stanford scientists report

May 15th, 2009 BMI

STANFORD, Calif. – Scientists at the Stanford University School of Medicine are shedding light on how type-1 diabetes begins.

Doctors have known the disease is caused by an autoimmune attack on the pancreas, but the exact trigger of the attack has been unclear. Now, a new study in mice implicates the immune signal interferon-alpha as an early culprit in a chain of events that upend sugar metabolism and make patients dependent on lifelong insulin injections.

“We never considered that interferon-alpha could be a major player in early type-1 diabetes,” said Qing Li, MD, PhD, a postdoctoral scholar in microbiology and immunology who was the primary author of a paper describing the new result. The study is published in today’s issue of Proceedings of the National Academy of Sciences. “This was a pretty surprising finding.”

Interferon-alpha normally helps the body fight viruses. Synthetic interferon-alpha is injected as a drug for treating hepatitis C and some forms of cancer, Li noted.

“Everybody’s been wondering what process initiates type-1 diabetes,” said Hugh McDevitt, MD, professor of microbiology and immunology and the study’s senior author.

Type-1 diabetes is caused by complete deficiency of insulin, a hormone that helps the body store and burn sugar. About 1 million Americans have the disease, also known as juvenile diabetes because it tends to be diagnosed in children and young adults, for which there is no effective prevention or cure. Diabetes is a leading cause of heart disease, blindness, limb amputations and kidney failure.

The early pathology of type-1 diabetes is hard to study in humans, McDevitt said, because it’s almost impossible to predict who will get the disease and when it will develop. Scientists have relied on animal models, such as diabetic mice, because they predictably develop high blood sugar and other features of the human disease.

To pinpoint interferon-alpha, Li and McDevitt worked backwards from what they knew about how type-1 diabetes starts. Prior studies in diabetic mice showed a pathogenic role for immune cells called CD4+ T cells. These cells are an early player in the immune attack on the body’s insulin factories, pancreatic beta cells. The scientists used silicon gene-chip technology to measure which genes are revved up in the CD4+ T cells just before they assault the pancreas. The measurements fell into a pattern: many of the upregulated genes were known to be controlled by interferon-alpha.

To confirm the signal’s nefarious role, the researchers gave mice an antibody that blocks interferon-alpha activity several weeks before the animals were expected to develop diabetes. Thwarting interferon-alpha delayed the start of the disease by an average of four weeks, and, in 60 percent of treated mice, it prevented diabetes entirely.

The finding confirmed the importance of interferon-alpha and helped the scientists connect the dots between normal mouse physiology and early diabetes. Mice are born with more pancreatic beta cells than they need, Li noted. The extras soon undergo programmed cell death, leaving plenty of working beta cells to pump out insulin. However, in mice that develop diabetes, debris left behind by the dying cells triggers an inappropriate immune response, with lots of interferon-alpha. The interferon-alpha cues immune destruction of more and more beta cells, causing insulin deficiency and diabetes.

The mechanism may be more complex in humans, the scientists cautioned, explaining that while their new finding goes a long way toward explaining the beginnings of diabetes in the mice, additional genetic and environmental factors influence the human disease. But the basic principle of disease is likely the same in diabetic mice and humans, they said.

“A normal process – programmed cell death – causes a normal response,” McDevitt said. “But it does this in such a way that, in a small subset of the population, it starts them on the road to type-1 diabetes.”

Source: Stanford University Medical Center

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High cholesterol levels drop naturally in children on high-fat anti-seizure diet, Hopkins study show

May 15th, 2009 BMI

Elevated cholesterol levels return to normal or near normal levels over time in four out of 10 children with uncontrollable epilepsy treated with the high-fat ketogenic diet, according to results of a Johns Hopkins Children’s Center study reported in the Journal of Child Neurology. The study appears online ahead of print at http://jcn.sagepub.com/cgi/reprint/23/7/758.

In the four-year study, the Hopkins Children’s team followed 121 epileptic children with intractable seizures on the high-fat, low-carbohydrate ketogenic diet designed to control such seizures. While most children developed high cholesterol after starting the diet, cholesterol gradually improved in nearly half of them, returning to normal or near-normal levels, with or without modifications to their diet to reduce fat intake.

In fact, researchers point out, diet modifications-including reducing total fat content or certain types of fats called saturated fats and adding nutritional supplements-reduced high cholesterol just as much as doing nothing. High cholesterol is defined as total cholesterol greater than 200 mg per deciliter of blood, bad or LDL (low-density lipoprotein) cholesterol greater than 130, triglycerides greater than 130, and good or HDL (high-density lipoprotein) lower than 35.

Researchers prescribed dietary modifications to increase “good,” polyunsaturated fats in the diets of 15 children with elevated cholesterol. Dietary modifications decreased cholesterol by 20 percent in 9 out of the 15 (60 percent) children whose diets were modified. Surprisingly, cholesterol also dropped by at least 20 percent in 41 percent of the 37 children whose diets remained unchanged. The findings, while encouraging overall, also mean that relying on diet changes alone may not do much for those children in whom cholesterol remains persistently elevated, and that new approaches for these patients are needed, researchers say.

The findings should come as comforting news to pediatric neurologists, general pediatricians and parents of children treated with the ketogenic diet, and reassure them that, in most patients, increases in cholesterol may be short-lived, researchers say. Previous long-term studies by the Hopkins group of children who were on the diet between six and 12 years echoed these findings. The ketogenic diet, believed to work by triggering biochemical changes that eliminate seizure-provoking short-circuits in the brain’s signaling system, is used in many children with hard-to-control epilepsy and in those whose seizures do not respond to traditional anticonvulsant medications.

“We are greatly encouraged by our findings because the nearly half of the children on the diet were either able to maintain healthy cholesterol or gradually metabolized the extra fat and returned to somewhat normal cholesterol levels,” says senior investigator Eric Kossoff, M.D., a pediatric neurologist at Hopkins Children’s. “This means the benefits of the diet-a diet that is lifesaving in many children and therapeutic in most of them-continue to outweigh the risks.”

Noting that 40 percent of children maintained normal cholesterol even after starting the diet, researchers found that children fed a formula-based, liquid-only ketogenic diet were nearly three times less likely to develop high cholesterol. Researches attribute this finding to the nearly zero fat content in commonly used ketogenic diet formulas.

In the group with normal cholesterol, 78 percent of children (31 out of 40) were fed formula-based ketogenic diet. This finding, while requiring further study, points to another possible treatment for high cholesterol, Kossoff says, by switching children with persistently elevated cholesterol to formula-based ketogenic diets at least some of the time. The formula-based ketogenic diet contains only one-third the amount of saturated fats-the worst kind in terms of cholesterol-of the solid food version of the ketogenic diet. Because doctors can tweak the ratio of fat vs. carbohydrates depending on each child’s severity of seizures, the investigators examined whether higher-fat versions of the ketogenic diet raised cholesterol additionally, but found that higher-fat ratio did not make cholesterol worse than a lower-fat ratio.

Some of the other findings:

 

  • One-fourth of 121 children had elevated total cholesterol before starting the diet, which increased to 60 percent (59 out of 99 children at follow-up) after the initiation of the diet.
  • 18 percent (22 out of 119) had triglycerides over 130 before the diet, which increased to 51 percent (49 out of 96) after starting the diet.
  • 19 percent (21 out 110) had bad cholesterol over 130 before the diet, which increased to 53 percent (48 out of 93) after starting the diet.

Source: Johns Hopkins Medical Institutions

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Olive leaf extract can help tackle high blood pressure and cholesterol

May 15th, 2009 BMI

Taking 1000mg of a specific olive leaf extract (EFLA®943) can lower cholesterol and lower blood pressure in patients with mild hypertension (high blood pressure). These findings came from a ‘Twins’ trial, in which different treatments were given to identical twins. By doing this, researchers could increase the power of their data by eliminating some of the uncertainties caused by genetic variations between individual people.

The research is published in the latest edition of Phytotherapy Research.

Hypertension is one of the most common and important disease risk factors imposed by the modern lifestyle. Many people would therefore benefit from finding ways of reducing blood pressure. Experiments in rats had previously indicated that olive leaf extract could be one way of achieving this goal.

To test this in humans, researchers from Switzerland and Germany conducted a pilot trial with 20 identical (monozygotic) twin pairs who had an increased blood pressure. Individuals were either given placebo capsules or capsules containing doses of 500mg or 1000mg of olive leaf extract EFLA®943. Pairs of twins were assigned to different treatments. After the subjects had taken the extract for eight weeks researchers measured blood pressures as well as collecting data about aspects of life-style.

“The study confirmed that olive leaf extract EFLA®943 has antihypertensive properties in humans,” says one of the co-authors, Cem Aydogan, General Manager, Frutarom Health.

“This works showed that taking a 1000mg dose has substantial effects in people with borderline hypertension,” says Aydogan.

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New study shows health benefits of probiotic could extend to the entire body

May 15th, 2009 BMI

Cork, Ireland – August 25, 2008 – Data from a recent study demonstrate the anti-inflammatory and pathogen protection benefits of Bifidobacterium infantis 35624 a probiotic bacterial strain of human origin. Gastrointestinal benefits of probiotics have been well-documented, but more and more research is revealing that probiotic benefits extend to the entire body. The report was published in the August issue of the Public Library of Science (PLoS) Pathogens.

The inflammatory response is a key part of the immune system’s battle against invaders. The normal response to infection is rapid and effective, however, the immune response may occasionally cause inflammation and damage to healthy tissue.

“Inflammation is a major factor in a number of chronic diseases affecting millions of people and can cause an unwanted impact on healthy tissue,” said Dr. Liam O’Mahony, lead investigator. “Past research has shown that the probiotic Bifidobacterium infantis 35624 can positively impact the body’s immune defense3, and this most recent data suggests that its benefits are not restricted to the gastrointestinal tract.”

Inflammation is associated with a wide range of conditions, such as inflammatory bowel disease, arthritis, bacterial-induced colitis, type I diabetes and organ transplantation. Bifidobacterium infantis 35624 has previously shown ability to modulate the inflammatory response in a clinical trial of patients with irritable bowel syndrome.2 The new data suggests additional health benefits of this particular probiotic strain.

The published study examined the effect of Bifidobacterium infantis 35624 administration on immunity to Salmonella (Salmonella typhimurium), harmful bacteria that can cause intestinal infections and trigger the body’s inflammatory response. Bifidobacterium infantis 35624, a probiotic strain isolated from healthy human gastrointestinal tissue, was administered to mice in freeze-dried powder at least three weeks prior to salmonella infection. Animals that received Bifidobacterium infantis 35624 showed dramatically increased numbers of certain immune cells that control the immune system response to harmful pathogens, in this case Salmonella.

Additionally, data show increased numbers of T-regulatory (Treg) cells, or cells that suppress inflammatory disease in a wide range of autoimmune diseases. Administration of Bifidobacterium infantis 35624 resulted in the induction of these Treg cells, which protected the host from excessive inflammation during the course of infection. Researchers concluded that the introduction of Bifidobacterium infantis 35624 results in enhanced protection from infection, while limiting pro-inflammatory damage caused by superfluous activation of the innate immune system.

Source: Manning Selvage & Lee

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Low cholesterol associated with cancer in diabetics

May 15th, 2009 BMI

Low levels of LDL cholesterol as well as high levels are associated with cancer in patients with type 2 diabetes, found a prospective cohort study http://www.cmaj.ca/press/pg427.pdf published in CMAJ.

Researchers from the Hong Kong Institute of Diabetes and Obesity, the Li Ka Shing Institute of Health Sciences and The Chinese University of Hong Kong conducted a study of 6107 Chinese patients with type 2 diabetes and found a V-shaped risk relation between LDL cholesterol and cancer in patients not receiving statin therapy.

“LDL cholesterol levels below 2.80 mmol/L and levels of at least 3.90 mmol/L were both associated with markedly elevated risk of cancer among patients who did not use statins,” state Dr. Juliana Chan and coauthors.

The study excluded people on statins as statins obscured the association between LDL cholesterol and all-site cancer.

Increasing data suggests an association between type 2 diabetes and an elevated risk of cancer, including breast, colorectal, pancreatic and liver cancers. An elevated risk of cancer in patients with low LDL was linked to cancers of digestive organs and peritoneum, genital and urinary organs, lymphatic and blood tissues as well as other areas. Patients with an LDL cholesterol level above 3.80 mmol/L had heightened risks of oral, digestive, bone, skin, connective tissue, breast and other cancers.

Regarding clinical implications, the authors suggest “the use of these levels as risk markers may help clinicians to assess their patients more fully and thus to prevent premature deaths in patients who have high risk.”

They call for re-analysis of data from clinical trials to confirm or refute these findings.

In a related commentary, Drs. Frank Hu and Eric Ding of Harvard School of Public Health (Todd Datz, Public Relations, Harvard School of Public Health, 617-432-3952 for Dr. Frank Hu) say confounding factors such as indication for the use of statins, lifestyle and socioeconomic status must be considered when looking at the association of high levels of LDL cholesterol and the risk of cancer.

“Low serum cholesterol is commonly observed in individuals with ill health (e.g. cancer patients) and those with unhealthy lifestyle characteristics such as smoking and heavy drinking,” states Hu.

Source: Canadian Medical Association Journal

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M&Ms as diet food? 100-calorie pack misconceptions

May 15th, 2009 BMI

Beware of mini-packs and mini-foods, especially if you’re a dieter.

Chronic dieters tend to consume more calories when foods and packages are smaller, according to a new study in the Journal of Consumer Research. Authors Maura L. Scott, Stephen M. Nowlis, Naomi Mandel, and Andrea C. Morales (all Arizona State University) examined consumer behavior regarding “mini-packs,” 100-calorie food packages that are marketed to help people control calorie intake.

“Interestingly, one group that over-consumes the mini-packs is chronic dieters—individuals constantly trying to manage their weight and food intake,” write the authors.

The researchers believe their research shows that the ubiquitous small packages may actually undermine dieters’ attempts to limit calories. “On the one hand, consumers perceive the mini-packs to be a generous portion of food (numerous small food morsels in each pack and multiple mini-packs in each box); on the other hand, consumers perceive the mini-packs to be diet food. For chronic dieters, this perceptual dilemma causes a tendency to overeat, due to their emotion-laden relationship with food.”

In a series of studies, the researchers assessed peoples’ perceptions of M&Ms in mini-packs versus regular-sized packages. They found that participants tended to have conflicting thoughts about the mini-packs: They thought of them as “diet food,” yet they overestimated how many calories the packages contained. In subsequent studies, the researchers assessed participants’ relationship with food, dividing them into “restrained” and “unrestrained” eaters. The “restrained” eaters tended to consume more calories from mini-packs than “unrestrained” participants.

The authors conclude that dieters should keep an eye on small packages: “While restrained eaters may be attracted to smaller foods in smaller packages initially, presumably because these products are thought to help consumers with their diets, our research shows that restrained eaters actually tend to consume more of these foods than they would of regular foods.”

Source: University of Chicago Press Journals

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The big gulp: consumers avoid extremes in soda sizes

May 15th, 2009 BMI

As portion sizes have increased, Americans’ waistlines have expanded. And as a new study in the Journal of Consumer Research demonstrates, consumers are tricked into drinking more soft drinks when retailers eliminate small drink sizes.

No matter what the volume of the soft drink, customers tend to avoid the largest and smallest options, according to authors Kathryn M. Sharpe, Richard Staelin, and Joel Huber (all Duke University). “Our basic premise is that consumer purchases are altered by the portfolio of drink sizes made available,” the authors explain.

Fast-food restaurants, in an attempt to boost profit margins, have eliminated smaller drink sizes and added even larger sizes. The authors believe these policies have led to a 15 percent increase in the consumption of these high-calorie drinks. “Consumers who purchased a 16-ounce drink when a 12-ounce drink was available later chose a 21-ounce drink when the 12-ounce drink option was removed, since now the 16-ounce soda is the smallest option,” they write. “This effect also occurred at the large end of the spectrum; people who purchased a 21-ounce drink when the 32-ounce drink was the largest size available moved up to the 32-ounce drink when a 44-ounce drink was added to the range of drink sizes available.”

By adding the 44-ounce option, the restaurant is able to shift the demand curve upward, even though the authors believe customers still want 12-ounce drinks.

The researchers go on to simulate policy directions for slimming America’s waistlines. Their models show that for flat taxation of soft drinks to reduce consumption by 10 percent, it would need to be 28 cents per drink and would reduce corporate profits by at least 7 percent.

But by simply reversing the trend they started in the first place, retailers could do their part to improve public health. If they eliminated the largest drink size and brought back the smallest, retailers could help curb soft drink consumption with only a slight reduction in profit (less than 2 percent).

Source: University of Chicago Press Journals

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Stroke incidence declines among Swedish diabetics

May 15th, 2009 BMI

The incidence of strokes among diabetics in Northern Sweden declined between 1985 and 2003, according to a population-based study published in Stroke: Journal of the American Heart Association.

Researchers also found that survival rates improved leading to a rapid decline in the number of fatal events among diabetic people.

“Prior research has suggested that the trend in strokes was increasing, but our study shows declining incidence in stroke for non-diabetic men, both for first and recurrent stroke, and in recurrent strokes in non-diabetic women,” said Mats Eliasson, M.D., Ph.D., co-author of the study and a senior lecturer in the Department of Public Health and Clinical Medicine at Umeå University and the Department of Medicine at Sunderby Hospital in Luleå, Sweden.

The reasons for the overall decline of strokes among diabetics are uncertain. The decline may be the result of more intensive treatment of hypertension in diabetics and smoking cessation and cholesterol-lowering efforts, Eliasson said.

“The impressive decline in smoking and large decreases in cholesterol levels, and to a lesser degree blood pressure levels, in the population of northern Sweden may have contributed to the declining incidence in both diabetic and non-diabetic subjects over the study period,” he said. “On the other hand, we found more recurrent events among diabetic subjects than non-diabetic subjects, indicating a need for even more intensive secondary prevention among diabetic patients.”

Researchers examined data on 15,382 stroke patients, 35- to 74-years-old, who were part of the Northern Sweden MONICA (Multinational Monitoring of Trends and Determinants in Cardiovascular Disease) Project Stroke Registry, an international collaboration sponsored by the World Health Organization.

Over the 19 years, 11,605 subjects suffered a first stroke and 3,777 had a recurrent stroke. Twenty-two percent of the men and women had previously been diagnosed with diabetes. Although the total number of strokes per 100,000 in diabetics was significantly greater than in non-diabetics, researchers found no significant difference in the rate of decline over time and death rates between the two groups.

Among the major findings:

  • Diabetic women had a yearly decrease in incidence of first-ever stroke of 1.5 percent, while incidence remained unchanged over the observation period for non-diabetic women.
  • Non-diabetic men had a significant declining trend in incidence rates of first-ever stroke of .8 percent per year, while there was an insignificant decline in diabetic men.
  • All groups, except diabetic women with first-ever stroke, had a significant decline in deaths over time.
  • Incidence rates per 100,000 of all strokes among male diabetics fell from 1,961 to 1,815.
  • The incidence rates per 100,000 of all stroke in women fell from 1,921 to 1,176.
  • In non-diabetics, the incidence rates per 100,000 fell from 358 for men and 204 for women to 284 and 183, respectively.
  • For recurrent strokes, the decline was significant for all but diabetic men, with the greatest decline (5.4 percent a year) in diabetic women. Non-diabetic women showed a 2.7 percent yearly drop. Researchers found no apparent explanation for the gender differences. An earlier study in the United States didn’t find gender differences in care or treatment adherence between male and female diabetics.

“The fact that patients with diabetes, to a great extent, had favorable time trends similar to those of non-diabetics is particularly interesting considering that diabetic patients with heart attack, from the same population, did not show any positive trends over the 19-year study,” Eliasson said.

Control of hypertension may have a greater impact in stroke than in coronary heart disease, he said.

Source: American Heart Association

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