Past News Stories on Heart Health
Could gut bugs be the global obesity epidemic culprit?
By Dr. Michael Sarin, Toronto Rehab’s Cardiac Rehabilitation & Secondary Prevention Program
A global pandemic of diabetes is on the horizon. According to International Diabetes Federation, diabetes is expected to affect nearly 400 million people; about seven per cent of the adult population by 2025. Diabetes kills 3.8 million people every year; the same number of people as HIV/AIDS . India and China have the highest number of people with diabetes; about 40 million each. Diabetes is spreading fastest in Eastern Mediterranean and Middle Eastern countries. More children and teens are being affected by diabetes. Without a doubt, these occurrences are linked to an epidemic of obesity and overweight which has a strong link with the onset of Type 2 Diabetes.
Is this all due to a lifestyle of poor eating habits and inactivity occurring simultaneously worldwide? This is a crucial question which is receiving urgent attention by global public health agencies and obesity researchers alike.
A startling alternative explanation has been proposed:
A new type of research called pyrosequencing, previously used to assess the richness of bacterial ecosystems in marine environments and soil, is being used to look at the ecosystem within our bodies.
Living in each of us - on our skin, in our mucous membranes, and in our gut - are microorganisms whose numbers dwarf the number of our own cells and genes. Although some of these microbes are pathogens, most are harmless and even beneficial. The body's assortment of microorganisms, collectively called the microbiota, is similar to an organ in that it performs functions essential for our survival. Some microbes produce vitamins and other essential nutrients. Many metabolize food that we cannot digest on our own. They also break down drugs and toxins and regulate many aspects of innate and acquired immunity; protecting the host from infections and chronic inflammation as well as possibly many immune-based disorders. When an environmental agent alters the function of the microbiota, the result can be disease. This reaction may also be what happens in the beginning stages of the development of heart and lung disease.
Most environment-microbiota research has focused on the gut; home to about 100 trillion microorganisms—the vast majority of our complement of microbes. Shifts in the microbial species that reside in our intestines have been associated with a range of health issues including autoimmune disorders, obesity and even different types of cancer.
Each of us carries thousands of bacterial species in our gut along with a few species of other types of organisms. Although all humans have grossly similar microbiota, no two people have exactly the same composition of bacterial species in their guts. In fact, each individual's microbial consortium may turn out to be as unique as a fingerprint. Yet a study published in Nature(January 22, 2009) reported that, “although individual bacterial species can differ widely between people, the species tend to encode the same metabolic pathways”.
Outside influences such as antibiotic use, diet and psychological stress have shown strong correlations with what lives inside our bodies. Researchers are just beginning to understand how these environmental factors may affect our health. Recent advances in genomic sequencing technologies have pushed the field forward. In the past, scientists could only study microorganisms. Now they can sequence the entire collection of DNA in a microbial sample and identify the component species. This approach is known as pyrosequencing and has been key to many recent advances in understanding the relationship between our microbiota and health.
Jeffrey I. Gordon of Washington University School of Medicine, recently reported findings of his research studies in Nature. Using genetically obese and lean mice, the study aimed to discover the differences that occurred when the mice were given identical feeds. The gut microorganisms were found to be different in these two breeds. Obese mice were found to have guts teeming with bacteria which were efficient at super-digesting food and were able to harvest more calories from the food they ate leading to obesity. Lean mice had gut bacteria which were not as efficient in extracting calories from the food they ate. The issue then was to determine which came first: the fat or the bacteria. To find out, the lab took mice that had never been exposed to any bacteria, whose guts were totally germ-free. Half of them received bacteria taken from skinny mice and the other half received bacteria from obese mice. Overall, the mice that received bacteria from obese donors gained more fat over the course of the experiment.
More recently, this research was applied to humans. His team of researchers compared the gut flora of 12 obese volunteers with that of lean subjects. Similar findings confirmed the hypothesis. Furthermore, as the 12 people lost weight over the year, their gut population of bacteria changed to resemble that of the skinny mice. The study did not attempt to transfer the bacteria from obese human volunteers to the gut of lean subjects for ethical reasons.
Many questions remain. It is unclear what determines the make-up of a person's gut flora. It might be the microbes they pick up from their mothers; it might be their exposure to antibiotics. It is also unclear how fat tissue and gut flora might affect one another and whether the change in gut bacteria causes or is a result of the weight loss.
Other promising aspects of microbiota research include advances in sequencing technologies that allow huge numbers of humans and their microbes to be studied. Global surveys of human microbiota, for example, may start to address issues of how geography, history, diet, and culture all feed into determining bacterial structure and function. Genome wide association studies are also coming down the pipeline to examine how genetic variation in the human genome predicts bacterial composition.
To provide a foundation to answer some of these questions, the National Institutes of Health launched the Human Microbiome Project at the end of 2007. The project has targeted an estimated $115 million over five years to determine what parts of the microbiota are similar in all humans and what parts differ—and how those differences may relate to disease. The European Commission is funding a related effort, called Metagenomics of the Human Intestinal Tract, and in October 2008 scientists from around the globe formed the International Human Microbiome Consortium to share data on the human metagenome—comprising the genomes of all our microorganisms—among researchers around the world.
Being able to sequence thousands of microbes quickly and easily will likely lead to another field - the consideration of the individual's microbiota in the development of personalized medicine. The differences between each person's microbiota will influence not only their health risks but also how they respond to interventions including probiotic treatment and dietary changes. One should think about differences in microbiota being analogous to genetic differences that make our responses distinct.
According to Nita Salzman, assistant professor of Pediatrics at the Medical College of Wisconsin, simply knowing the constituents of our microbiota will not be enough to reach this goal. Even when we can determine the entire microbiota of a species and every gene of the metagenome, it's still hard to say which of those things is actually important in driving health or disease. Efforts to provide such an understanding are now focusing not on the genome sequences of resident bacteria but on the proteins they produce.
In The International Society of Medical Ecology Journal (Feb. 2009), Jansson's group released an analysis of the human bacterial proteome—the thousands of bacterial proteins that are expressed in our bodies. "The proteome [tells] you what's actually going on in the gut," she says. She and her colleagues found that proteins involved in carbohydrate metabolism and food utilization were very highly expressed, whereas other proteins, such as those involved in motility, were nearly absent. They are now working on analyzing the microbial proteomes in people with Crohn’s disease.
Another way of analyzing relevant microbial function is to examine the metabolites produced by the microbes, which reveals not just what the bacteria are expressing but what the body is actually absorbing. A study by William R. Wikoff et al., published in March 10th, 2009 Proceedings of the National Academy of Science, shows that many aspects of mammalian metabolism rely on the microbiota. In the absence of microbiota, the metabolites found in the blood of mice were significantly changed, suggesting that an animal's ability to metabolize drugs—and by extension, many other chemicals—likely relies in part on its community of microbes.
Combining genomic inventories of the microbial species that live inside us with functional analyses of the proteins they express and the metabolites we absorb will advance this field significantly in terms of understanding what's going on and how it relates to obesity and disease. Technological advances have profoundly pushed the field.
Consuming excess calories usually spurs what is called insulin resistance - when cells in the body that normally respond to the action of the hormone insulin fail to be stimulated by it. This greatly increases the risk of diabetes.
Now scientists at the Nestlé Research Centre, Lausanne, Switzerland, report in the FASEB Journal (Journal of the Federation of American Societies for Experimental Biology) that changing the make-up of gut microbiota reverses the insulin resistance that occurs progressively with obesity.
Obese, diabetic animals were given antibiotics to change the make up of microbes in the gut - their microbiota- in turn altering the way the body uses glucose, which is controlled by insulin. This lab experiment strongly supported the hypothesis that altering gut mirobiota could be beneficial in reducing insulin resistance.
Although there are many yoghurt and probiotic drinks on the market, more work would have to be done to determine which strains of probiotics would be most helpful for diabetes.
Prof Jeremy Nicholson of Imperial College London recently commented that this work adds to evidence that microbiota influence energy and fat use in the body "but we don't really know how much percentage wise it contributes to the obesity epidemic and how the bug influences varies between each person - that means for certain people- perhaps not all - that gut microbial engineering of some sort could be used as a future therapeutic route."
As for the hope of treating obesity this way, he stresses that "nothing will stop you getting fat if you overeat and exercise too little - that surpasses any host genetic or microbial variation”.
"But bugs do also respond to diet- if you get a high fat/calorie diet- you get a set of bugs that are better at making those calories available, a vicious circle."
Stay tuned for further news on the relationship of bugs in the gut to obesity and perhaps diabetes.
References:
1. Gordon.J and associates.Nature 2006;Volume 444:1022-1023
2. Ronaghi M and associates . Genome Research,2001;Volume ; 3–11
3. http://nihroadmap.nih.govt.hmp/
4. Salzman,N and associates, Proceedings National Academy Sciences. 2005;Volume 103:18129-181234
5. Verberkmoes N and associates. Shotgun Metaproteomics of the Human Gut Bacteria..ISMEJ;Vol 3:179-1896.
6. Wikoff W and associates.Metabolomics analysis reveals large effects of gut microflora on mammalian blood metabolites.Proceedings of National Academy of Sciences, 2009.Vol 106:3698-36703-36703
Women with Heart
When you think of "Women", what images come to mind? Do you think of the women you work with, the women in your family, the women you meet in all areas of your community? Women touch our lives in more ways than you may first think. Women are entrepreneurs, executives, decision makers, and also retired. Women are single, married, and widowed. Women are managers and care givers. Women may have flexibility with their time or their time may be very structured due to the demands of their careers or families such as caring for children, teenagers, or aging parents. With so many different roles in a woman's life, how can they keep active in order to maintain their health?
There are women who manage to build physical activity into their days. Despite competing priorities or varying stages of life, these women have found solutions to barriers and have made being active a priority.
But for those women who struggle with barriers to physical activity, encouragement to overcome the restrictions that life presents is necessary.
Women need to know how important being physically active is to staying healthy longer. Being physically active can help control blood pressure, blood cholesterol levels, and blood glucose measures. Being active burns calories and assists with weight management. By controlling weight, women can relieve stress on joints that may be inflamed with arthritis. Being active also reduces your risk of developing coronary artery disease (1,2). Physical activity is the solution to many health conditions women may experience.
So what is holding women back? Women face many barriers to being physically active. Some of these barriers are external such as the cold, icy Canadian winters or heavy rain and humidity of the summer. Transportation to an appropriate facility can be a barrier for some women who rely on public transportation or others to drive them (3) . The design of our communities which may lack sidewalks or create great distances to fitness centres also can be an obstacle. The cost of joining a fitness facility may be a burden to many women.
Others barriers may include internal feelings such as poor body image, lack of confidence, lack of skill or knowledge. Some women have feelings of guilt when they exercise because they are taking time for themselves and not caring for their loved ones. This can be a limiting factor for women to become involved in activities. Women often put other's needs ahead of their own. As life marches along, women's roles and responsibilities are for ever changing so that consistency with physical activity is interrupted by demands of aging parents, ailing partners, or children (young and old). Sometimes women feel isolated as they retire, move, or lose a spouse or partner, which makes it difficult to find new friends who enjoy being active. (4)
How can women become more physically active?
Moore et al (5) looked at women enrolled in a cardiac rehabilitation program for over 3 months. She found that social support was directly related to a woman continuing with her fitness program. Management of co morbid conditions such as muscle and joint pain or depression may be useful to influence the frequency and intensity of exercise. And most importantly, she reports that interventions to improve behaviour performance and to build self confidence should be addressed in all cardiac rehabilitation programs. Moore also found that younger women (<55 years of age) described more competing work and family obligations interfered with exercise than it did for older women.
These findings are consistent with research by Marzolini et al (3) who found younger women were at a higher risk of non-completion of a cardiac rehabilitation program. As well, a greater number of women than men did not complete cardiac rehabilitation due to transportation difficulties and family obligations. This study did find that women had a desire to complete a fitness program but may need encouragement.
We need to help women to initiate and maintain an active lifestyle. Here are a few suggestions:
- Encourage women to focus on their successes with all physical activities
- Facilitate self-directed goals to allow women to set meaningful physical activity goals
- Identify potential barriers that might prevent women from remaining active (eg. Family obligations, transportation, or co morbid conditions)
- Develop strategies for overcoming barriers (6) (eg. Plan an active get-together with friends and family, take a walk while waiting at child's lesson or practice, ask family to help with a household task in order to allow time for you to exercise)
- Arrange for a follow-up assessment after you have been exercising (7)
- Increase your knowledge of the benefits of being active by reading books, magazines, or information on the internet.
- Have FUN! If you are enjoying the activity, there is a much greater chance you with continue doing it.
Resources
1. CDC Collaborative Centre on Physical Activity and Health Promotion, 2005
2. Corrao,J.M. et al. Coronary heart disease risk factors in women. Cardiology 1990;77:8-12
3. Marzolini,S et al. Sex differences in completion of a 12-month cardiac rehabilitation programme:an analysis of 5922 women and men, European Journal of Cardiovascular Prevention and Rehabilitation 2008;
4. Canadian Association for the Advancement of Women and Sport and Physical Activity: The Voices of Women 55 - 70: Examining Physical Activity 2008
5. Moore, S. et al. Predictors of women's exercise maintenance after cardiac rehabilitation, Journal of Cardiopulmonary Rehabilitation 2003; 23 : 40 -49
6. Wolansky, T. et al. Strategies to keep people exercising after they finish a chronic condition exercise program, Alberta Centre for Active Living, 2009; 20: vol 2
7. Hughes, AR. Et al. Effect of an exercise consultation on maintenance of physical activity after completion of phase III exercise-based cardiac rehabilitation. European Journal of Cardiovascular Prevention and Rehabilitation 2007; 14(1),114-121
Late Breaking News in Heart Health June 2009:
What’s New in Nutrition? [PDF]
By: Katie Chapman BHSc.
Project Leader of the Heart Health for Life program, presented by Scotiabank
Toronto Rehab’s Cardiac Rehabilitation & Secondary Prevention program
Do you ever wonder why some people can eat whatever they want and still keep their weight, blood sugar and cholesterol within the normal range while others must try so hard, dieting, exercising and making all the right choices to attain these same results?
Are you confused by the overwhelming amount of diet plans, pills and miracle cures out there that offer hard-to-believe results?
Do you ever wonder if one day you may be able to find a unique and individualized diet and lifestyle plan that optimizes your health and well-being and protects you and your loved ones from disease?
Registered Dietitian and nutrition expert, Maria Ricupero of Toronto Rehab offered some shocking and very interesting answers to these questions at a recent Take C.H.A.R.G.E. lecture presented at Bloorview Kids Hospital as part of the Heart Health for Life graduate program. Maria shared her knowledge and tips for navigating a ground-breaking development in the world of nutrition called Nutrigenomics with a group of 120 Toronto Rehab graduates, friends, and family on Thursday April 23rd, 2009.
Here’s an update for you to share with your friends, family and community courtesy of Maria Ricupero of Toronto Rehab’s Cardiac Rehabilitation & Secondary Prevention Program.
What is Nutrigenomics?
- A new area of research
- Investigates how the foods we eat interact with our genes to affect our health.
- Explains how individual genetic differences can affect the way we respond to food.
What will it aim to do?
- Prevent and treat conditions including obesity, diabetes and cardiovascular disease
- Tailor and prescribe diets based on “personalized nutrition” that will help individuals stay healthier longer.
How is genetic testing done?
- A sample is collected – e.g. cheek swab.
- Genetic copying occurs.
- DNA strands are separated for analysis.
- Results are then obtained.
How will this affect me?
- At Present …
- Public health recommendations on diet are generally based on what is good for the greatest number of people
- In Future …
- Your response to diet may depend on your genes.
What can Nutrigenomics do for me?
In the future you may receive:
- Diet plans and specific foods tailored to your genetic makeup.
- Increased confidence that a particular food recommendation will actually work.
- Accurate counseling that will modify and reduce your personal risk.
What are the pros?
- People can take charge of their health
- Can provide an early marker for disease
- New products to improve your health may be developed, such as supplements & specialty foods
What are the cons?
- People may not bother to change their ways
- This may create a sense of fatalism that leads to high risk behaviours
- These new products are likely to be very expensive. If only wealthy citizens can afford them, this creates inequalities
- Labeling e.g. people may be viewed as “disease susceptible,” “lazy” and blaming may occur. For example, “It’s your fault you had a heart attack since you should have known better.”
- Marketing scams are likely to surface. More products for you to buy, buy, buy!
What are the Key Points?
- Do not be fooled by products on the market that promise miracles! So far, no concrete conclusions have been drawn about the effectiveness of diets and lifestyle plans based on your genes. There are many books, kits and ads out there that will want to convince you otherwise.
- Nutrigenomics is still a very young science! More studies are needed to determine how, what and where Nutrigenomics may play a role in our health and well-being in the future.
Resources for more information:
Health Canada: Food and Nutrition
The Environmental Working Group
- Not-for-profit organization
- Provide people with information to protect public health and the environment.
- www.ewg.org
Take C.H.A.R.G.E. lectures presented by Toronto Rehab and the Cardiac Rehab Graduates Association (CRGA)
- Monthly seminars based on recent and relevant topics on heart health and well-being
Visit the
Calendar of Events section of the Heart Health for Life website or contact
Rob Bertelink at Toronto Rehab, 416-597-3422 ext. 5250
New Exercise Opportunities for Individuals with Heart Disease and Other Chronic Health Conditions
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Introducing: Heart Wise Exercise
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Beginning April 1st, 2009 the Heart Wise Exercise Network-Toronto was launched. A program that began at the University of Ottawa Heart Institute founded by Physiotherapist Jennifer Harris, Heart Wise is an exciting community-based initiative that increases opportunities for exercise for individuals of all fitness levels and physical conditions. More specifically, Heart Wise is aimed at improving access to exercise in the community for individuals with heart disease and other chronic health conditions.
In Toronto, Heart Wise is a partnership program with Toronto Rehab, Women’s College Hospital, YMCA North York, YMCA Metro Central and YMCA West End. Patients and graduates of cardiac rehab, and individuals in the GTA community looking to begin a safe exercise routine will have many options for group and individual exercise to choose from at these Heart Wise Exercise locations. Heart Wise Exercise classes and individual fitness leaders meet the criteria outlined below.
A Heart Wise Exercise Program:
- Encourages regular, daily aerobic exercise
- Incorporates and encourages warm up, cool down and self-monitoring with all exercise sessions
- Allows participants to exercise at a safe level, and has progressive options to increase intensity if appropriate
- accepts participants with a known history of cardiac disease – provided they have physician approval
- provides health screening for all participants
- has an emergency plan that is documented and known to all exercise leaders, including the requirement of current CPR certification, phone access to EMS and presence of an AED
Contact information for Heart Wise Exercise partners is below. Call today to learn more about Heart Wise programming in your community and to connect with heart friendly fitness leaders who will help you find the right Heart Wise exercise class for you!
April’s Graduate of the Month: Bill Wall
It was a good friend of Bill Wall’s, eager to run in the Boston Marathon, who inspired his journey into running and toward Heart Health for Life. Bill’s friend, a healthy man but not an elite runner, would have to achieve an almost impossible qualifying time of approximately 3 hours. Bill, a man who cannot see through his eyes but always sees through his heart; a man who seeks out challenges as opportunities, offered to enter the marathon so that his friend could follow his dream. At age 77, Bill would be eligible to enter the Boston Marathon with a qualifying time of 5 hours, and his friend, would be allowed to enter the race as his guide.
“Start training me!” Bill declared. And he did.
“We started at 5k, then 8k, then 10k. Then I ran the Toronto Waterfront ½ marathon,” describes Bill. He decided that to ensure his body was in prime condition for the marathon, he would go to his doctor for a full physical check-up. The doctor found a curious heart murmur and ordered an Echocardiogram. Bill was then referred to a Cardiologist who told him that he had severe narrowing of his aortic valve. The doctor could not believe that Bill was able to remain so active and feel so well. At 78 years old, Bill was running half marathons and felt very healthy, but his doctors were very concerned about his heart. “Have you ever heard of sudden death?” his doctor asked him. Bill was determined to get healthy as soon as possible so that he could continue running and working towards his marathon goal. “They all asked me, why are you running? Why start at 77? What are you doing this for” He always told them the story of his friend’s dream and that he was determined to continue working towards it.
Bill was offered an aortic valve replacement and triple bypass surgery in March 2007. He declined at first but in October 2007, Bill started experiencing his first sign of heart disease, shortness of breath. He was admitted to Sunnybrook for surgery in February 2008. With a 25% risk of complications , Bill’s surgeon assured him he must go in to surgery optimistic. “You have to go in with a positive attitude. If you think you’re going to die, you will die,” he said.
After full recovery from surgery, Bill was referred to Toronto Rehab’s Cardiac Rehabilitation & Secondary Prevention Program in April 2008 . He was given an exercise prescription of walking 1 mile in 22 minutes. “I did it in 18 minutes,” Bill says, chuckling. Dr Sarin, Toronto Rehab’s Diabetes, Exercise and Healthy Lifestyle specialist, talked to Bill saying “ Be patient, do the program the way it is set out for you to do.” Bill was so eager to go faster, longer, and to be able to run. His goal was to walk 1 mile in 15 minutes. Eventually, with avid training, a determined mind, and the outstanding support of Toronto Rehab staff, Evelyn Rubin, JD Kato and Dr. Sarin, as well as his wife who often walked beside him, Bill succeeded.
“Evelyn looks after us. You can see in the way she talks to people that this is not just a job for her. She genuinely cares about us,” explains Bill. He describes a meeting with Evelyn’s son on the track in the summer, as the young boy was given the task of helping to monitor him during his exercise, “he looked at my prescription and said to me, Mr. Wall, you’re supposed to do the lap in 2 minutes and you’re doing it in 1:45, you have to slow down!”
Always one step ahead, Bill Wall is a vivacious spirit who motivates others,
“It doesn’t matter what your age is, exercise is going to keep you living!”
Today, Bill and his wife walk their two greyhound dogs three times each day together. They also take part in as many walking, running and biking events as possible, raising thousands of dollars, and encouraging thousands of people to take advantage of this second chance at life by lacing up their walking shoes.
The next big event Bill will be conquering is the 200k Ride to Conquer Cancer June 12-14 2009.
Bill and his wife, Barbara Wall, will also be walking in the 60k Weekend to End Breast Cancer in Toronto September 11-13th 2009 for the second time. He participated in the walk last year, just 7 months post surgery.
Thank you for your story Bill and see you on the road!
Toronto Rehab
Reception
416-597-3422 x. 5200
www.torontorehab.com
Women’s College Hospital
Debbie Childerhose
Program Coordinator, Women’s Cardiovascular Health
416-323-6400 x. 4883
debbie.childerhose@wchospital.ca
North York YMCA
Erin Smith
Director, Adult Programs
416-225-7773 x. 491
erin.smith@ymcagta.org
Metro Central YMCA
Stephanie Uren
Director, Adult Programs
416-975-9168 x. 457
stephanie.uren@ymcagta.org
West End YMCA
Maria Cardozo
Supervisor, Individual Conditioning
416-536-1166
maria.cardozo@ymcagta.org
A National Strategy in the Fight Against Cardiovascular Disease in Canada
Until recently, Canada has not had a national strategy to tackle cardiovascular disease: the number one cause of mortality. In 2006, the Federal Government announced funding for the Canadian Heart Health Strategy and Action Plan (CHHS-AP). A 29-member steering committee was formed and with the recommendations from over 1500 stakeholders and experts the CHHS-AP was created. On February 24th of this year, the steering committee released two documents: Building a Heart Healthy Canada and Realizing our Vision, which outline the strategies and objectives of the CHHS-AP for the prevention and care of cardiovascular diseases.
The publications provide a comprehensive list of initiatives, which the CHHS-AP plans to undertake in order to improve the workplace, community, school and health care system’s impact on the cardiovascular health of Canadians.
The proposed initiatives include changes to regulations and guidelines as well as incentives for industry to improve the quality of foods, reduce trans and saturated fats, sugar and salt in processed foods. There will be improvements in food labeling and marketing to help Canadians be better able to compare food products. These improvements should make the healthier food choice easier to recognize as well as making it the easier choice. Additionally, there are plans to develop guidelines and monitoring of fast food restaurants and food service outlets to report calorie contents.
The committee is compiling a list of innovative and creative ways that schools, workplaces and communities in Canada and internationally have adopted in order to promote physical activity. These best practices will be shared and disseminated across the country to help plan and build communities and infrastructure to promote physical activity.
In health care there are plans to accelerate the development, education and training of inter-professional health care teams as well as improving the health care system to ensure patients are tested and treated in a timely manner. Best practices in the area of self-care and patient-centred care will be documented and disseminated. Additionally, there are plans to continue developing rehabilitation programs in underserved regions and incorporate more cardiac rehabilitation services into prevention and management programs.
The overall focus of the CHHS-AP over the next couple of years will be collecting information, identifying best practices, and beginning to implement these strategies to reduce the impact of cardiovascular disease.
By 2015 the CHHS-AP, in partnerships with other strategies and initiatives, expects to reach benchmarks that include:
- Increasing the number of Canadians who eat at least five servings of vegetables and fruit per day by 20%
- Increasing the number of physically-active Canadians by 20%
- Reducing the number of overweight or obese adults by 20%
- Reducing the number of obese children by 35%
It is estimated that the cost of implementating the plan will be $100 million per year for seven years. However, by 2020 the CHHP-AP forecasts a decrease of $7.6 billion in direct costs for cardiovascular care with an additional $14.6 billion savings in indirect costs. Discussions about potential funding of these initiatives are ongoing.
For further information and a link to Building a Heart Healthy Canada and Realizing our Vision, visit the CHHS-AP website at www.chhs-scsc.ca.
Courtesy of J.D. Kato, DC, MSc, ACSM-RCEP, CSEP-CEP - exercise leader at Toronto Rehab and has a private practice at the Rosedale Natural Health Clinic in Toronto: http://www.doctorkato.com
The Gender Gap and Heart Disease:
Toronto Rehab’s initiative to enhance women’s health in your community and ensure cardiac rehab is the standard of care
By Katie Chapman, Heart Health for Life Project Leader
& Tracey Colella, Advanced Practice Leader (APL)
Toronto Rehab’s Cardiac Rehabilitation & Secondary Prevention Program
A new study of U.S. Hospitals reveals that women hospitalized with heart attacks aren’t getting the treatment they need and are more likely to die of a massive heart attack than men. Additional findings also suggest that women are often prescribed fewer medications and given fewer treatment options than males, suggesting that women’s heart attacks are treated less aggressively in the medical community. Recent findings from the Journal of the American College of Cardiology authored by Sonia S. Anand et al, concluded that women with acute coronary symptoms (ACS) undergo less coronary angiography, angioplasty, and coronary artery by-pass surgery (CABG) surgery than men. Additionally, women appeared to suffer an increased rate of recurring ischemia and re-hospitalization even though their incidence of heart attack and stroke was the same as men. Sonia concluded that all high-risk women and men with acute coronary symptoms (ACS) should receive optimal medical management, and be considered for coronary angiography or revascularization based on medical need, not gender stereotypes.
Often, women present with different symptoms of heart attack than men. For example, a study in the American Journal of Cardiology by Kerry A. Milner et al, found that women were more likely than men to present with mid-back pain, nausea, vomiting, difficulty breathing or painful breathing (dyspnoea), palpitations and indigestion compared to men. The research was funded by the Heart Association and the findings were reported in the medical journal, Circulation. After examining the data from over 78,000 heart attack victims, it was found that about a third of the heart attacks in the study were major ones. Overall, 10% of the women with massive heart attacks died in the hospital, compared to about 6% of the men. Finally, after taking into account the women's older age, and other co-morbidities, the researchers concluded the women in the study were 12% more likely to die of a major heart attack in the hospital than men.
Cardiovascular disease is the leading cause of morbidity and mortality in women in Canada (HSFC, 2001). Secondary prevention strategies such as involvement in a cardiac rehabilitation (CR) program can reduce the risk of morbidity and mortality by 25% within the first three years following a cardiac event (CACR, 2004; Taylor et al., 2004), through strategies such as risk factor modification, improvement in exercise tolerance, quality of life and development of social support networks. Although cardiac rehabilitation should be considered the standard of care for all patients living with cardiac disease (AHA, 2007, CACR, 2004, HSFC, 2001), women are consistently underrepresented in such programs. Lower referral rates, poor compliance, as well as high drop out rates remain key issues in need of further examination and follow up (CACR, 2004; Marzolini et al., 2008).
The Women’s Initiative at Toronto Rehab
This exciting new program, led by Toronto Rehab’s Advanced Practice Leader Tracey Colella, will offer programs and services specifically designed to meet the heart health needs of women in the greater Toronto community.
Initiatives of care are grounded in the Principles of Women’s Health:
- Accessibility
- Health Care
- High Quality of Care
- Collaborative Planning
- Innovative and Creative Approaches
- and Empowerment
The 3 Pillars of Care Include:
- Clinical: This piece will offer women-focused exercise classes, alternative exercise options such as yoga, dance and pilates, a peer support program, a support group for women, expansion of the post-surgical program as well as nutrition and smoking cessation counselling
- Education: This pillar will include the quarterly seminar series Living With Living Well with discussion topics on the unique health, exercise and psychosocial needs of women with heart disease and other chronic health conditions
- Research: This initiative strives to enhance the knowledge and understanding of women’s health and disease among health professionals and the community at large through evidence-based research study. Upcoming studies are the Cardiac Rehab For Her (CR4HR) Study, the Peer Support Program Pilot Study, Focus Group Study, and Access/Barriers Study, many of which will include collaborative work with the Women’s College Hospital of Toronto
Overall, Toronto Rehab’s APL-led Women’s Initiative hopes to achieve the following for women:
- Increase referral, access, participation and adherence to Cardiac Rehab
- Improve functional capacity, decrease risk for heart disease, and improve psychosocial, emotional and social support
- Develop new clinical approaches and educational opportunities specific to women’s needs, including engagement of Cardiac Rehab Alumnae and the surrounding community through community outreach events
At Toronto Rehab we are doing everything humanly possible to provide patients, graduates and their families with the programs, services and resources they need to reach their unique goals and maintain heart health for life.
Keeping Physically Fit Keeps Women Sharp
By Katie Chapman, Project Leader Heart Health for Life Program, Toronto Rehab
A new study to be released in the journal Neurobiology of Aging, by Marc Poulin of the Faculties of Medicine and Kinesiology at the University of Calgary finds a strong relationship between physical fitness and cognitive function in 42 healthy women with an average age of 65.
Compared to a group of non-active women, those who participated in regular aerobic activity:
- Had resting blood pressure that was 10% lower
- Showed 5% better blood flow in their brains when exercising
- Scored 10% higher on cognitive skill tests, such as memory, speed of thinking and ability to multi-task
"Being sedentary is now considered a risk factor for stroke and dementia," said principal investigator Marc Poulin, a physiologist at the University of Calgary.
"This study proves for the first time that people who are fit have better blood flow to their brain. Our findings also show that better blood flow translates into improved cognition."
In the winter months, it can be a challenge to stay active. Here are some helpful tips for keeping your muscles strong and your minds in tip top shape all winter long:
- Get warm first. A proper warm-up is critical. Cold temperatures can make your muscles tight and therefore they are more prone to injuries. So, it's important to get them warmed-up prior to engaging in intense physical activity.
- Insulate your body. The best approach to dressing for outdoor exercise is with layers. Layering provides the most effective heating method, plus it allows you to remove the top layer if you get too hot. The layer closest to your skin should allow moisture to be wicked away. The top layer should be both wind and water resistant.
- No sweat. Don't assume that you have to sweat in order to get a good workout. You should avoid sweating that causes the clothing layer closest to your skin to get wet and cause you to be chilled. Instead monitor your intensity through a heart rate monitor or the Rating of Perceived Exertion.
- Don't strip when you get inside. While you may be tempted to immediately remove your layers when returning inside, give your body time to adjust. Post exercise hypothermia is possible. This happens when your body rapidly loses its heating stores.
- Drink up. It's just as important to stay hydrated when exercising in winter as it is in summer, even though you might not feel as thirsty.
- Lighten up. If possible, it's best to exercise outdoors during daylight areas. But, with shorten days that can be difficult to do. If you exercise outdoors when it is dark, wear reflective materials to ensure that you can be seen.
If the thought of getting outside to exercise makes you dive under the covers, instead choose one of the many indoor workout options. Below are just a few of the many choices.
- Walk at an indoor location, like a mall. If you need extra motivation to get yourself to the mall, join a walking group. This will help you stay accountable to someone other than yourself.
- Join a health club. This will allow you a large variety of physical activities to choose from every week.
- Create a home gym. This doesn't have to be expensive. You can easily set-up a great workout routine with just a set of dumbbells, an exercise ball and a jump rope. Get all of this for around $50.
- Take the stairs. If you have stairs where you live or close by, spend as little as 20 minutes at a time climbing up and down the stairs for a very intense and efficient workout. Pay attention to your heart rate and perceived exertion when you are doing this.
- Get wet. Find a local indoor pool you can use. Try swimming, water aerobics, or even just walking or running laps in the water.
- Visit a library. Usually local libraries offer exercise videos you can check-out for free. Pick-up a new one to try out every time you return the previous video.
By staying fit during winter you'll be able to avoid gaining weight, have a head start on swimsuit season, and avoid losing strength and stamina caused from inactivity. Just as tulips need winter nourishment from the Earth to strongly bloom in spring, humans need to continue to nourish their bodies during winter so they too can bloom come spring.
Courtesy of Lynn Bode, certified personal trainer and founder of Workouts for You: http://www.workoutsforyou.com
C-Reactive Protein and Cardiovascular Disease
Written by: J.D. Kato, DC, MSc, ACSM-RCEP, CSEP-CEP
Those who have been on our program know the traditional risk factors for cardiovascular disease (CVD). These are factors such as elevated blood pressure, LDL cholesterol, diabetes, etc. However, another emerging risk factor you may not have heard about is C-reactive protein (CRP). Research into CRP has been going on for decades but recently an interesting study, called Jupiter (Justification for the Use of Statins in Prevention: an Intervention Trial Evaluating Rosuvastatin), was published. This study investigated the effects of Crestor®, a statin medication also known as rosuvastatin. Statins are well known for lowering LDL cholesterol, but they are also known to lower CRP. The subjects of this study did not have any history of CVD or high levels of LDL cholesterol, but did have higher levels of CRP. The results of the study showed that those who took rosuvastatin reduced their LDL cholesterol by 50% and CRP levels by 37%. Associated with these changes were reductions in heart attacks by 54%, strokes by 48%, and death by 20%. The authors report that, after an average of about 2 years, the side effects seen with rosuvastatin were the same as with those taking placebo.
So what is CRP you ask? CRP is a protein made by the liver which circulates in the blood. Its function is still not fully known, however CRP can be used as a measurement of inflammation in the body. The test is called ‘high sensitivity CRP’ (hs-CRP) and is a simple blood test just like cholesterol. Levels of CRP usually range from less than 1mg/L to 10mg/L or more. As hs-CRP is a non-specific indicator of inflammation, a high test result can be due to any injury, infection or inflammatory condition (such as arthritis) in the body. Generally speaking though, 3mg/L is considered a high value and although it does not cause any symptoms it may be a marker of risk for CVD. This is because atherosclerosis that causes CVD is an inflammatory process. If there is no reason to attribute the inflammation to another cause then it may be due to low-level inflammation in the walls of the arteries leading to atherosclerosis. In the Jupiter study the investigators focused on reducing inflammation rather than cholesterol.
So, are there other ways to lower CRP? Yes, there are numerous studies that show lifestyle modification can lower elevated CRP. Many studies have found positive results with weight loss, reduction in waist circumference, increased fibre intake and low-fat eating habits. Research also shows that regular aerobic exercise and physical activity can also reduce elevated CRP.
The results of the Jupiter study were impressive because of the dramatic reduction in CVD in adults who would generally be considered healthy. And even though we do not fully understand the nature of CRP in the body and how it works, it may be a helpful tool to improve our prevention and treatment of CVD in certain populations. As we learn more about risk factors and how to affect them we will be able to make healthier lifestyle choices and optimise medical management.
Late Breaking News
Exercise is Safe, Reduces Hospitalizations and Improves Outcomes for Patients with Heart Failure
One of the most exciting clinical trials presented at the recent American Heart Association Annual Scientific Meeting in November 2008 was the HF-ACTION Trial (A Controlled Trial Investigating Outcomes Exercise TraiNing), the most comprehensive study to date examining the effects of exercise upon patients with heart failure. The study was reported at the meeting by Christopher O’Connor M.D., director of the Duke Heart Center and principal investigator of the trial, and David Whellan, M.D., of Thomas Jefferson University, co-principal investigator.
HF-ACTION enrolled 2331 patients at 82 study sites throughout the U.S., Canada and France. Patients were randomized into either a group that received usual care or to a group that received usual care plus an exercise training program (i.e., cardiac rehabilitation) that began under supervision for 12 weeks but then transitioned to home-based, self-monitored workouts over the next 3 years. Researchers hypothesized that participation in an exercise program would significantly lower the incidence of death and hospitalization among patients with heart failure.
Results showed that there was indeed a modest (11%) improvement in these important outcomes of death or hospitalization. A separate analysis also showed that there was better quality-of-life in those who participated in the exercise intervention. There were no adverse consequences associated with exercise training. One of the concerns seen in the study though was there was a tendency for exercise adherence to drop off over the three year time course of the study. This raised some pessimism about the potential value of exercise (e.g., “why bother if you can’t stick with it?”) while others were enthusiastic over the possibility that the benefits seen could have been even greater with only slight improvements in exercise persistence.
Researchers hope the findings will finally put to rest long-held fears that exercise may be
too risky for some patients. “The most important thing we found from this study is that
exercise is safe for patients with heart failure, and when adjustments were made for
specific baseline characteristics, it significantly improved clinical outcomes,” said
O’Connor.
The message for our graduates living with a range of heart conditions, including those with heart failure is that exercise over the long term can keep us healthier and feeling better.