Health for life

While the population health management service industry has a successful track record when it comes to chronic heart failure, diabetes and asthma, the Disease Management Care Blog thinks, after a quick scan of the literature, that there are fewer studies of its impact on hypertension.

 A recent Morbidity and Mortality Weekly Report (MMWR) reminds us that thats a problem.

The National Health and Nutrition Examination Survey(NHANES) performs interviews and physical examinations of a representative sample of U.S. households.  This particular report on the prevalence and treatment of high blood pressure was based on a sample of 20,811 individuals from four 2-year survey cycles that were performed from 2003 to 2010.

Extrapolating from the sample, 66.9 million persons or 30.4% of the U.S. populationn have high blood pressure. Of this population, just over half (54% or 35.8 million) have uncontrolled hypertension.  Of these persons, 31 million (or 88%) had been seen by a health care provider in the preceding year. The prevalence of uncontrolled hypertension among those hypertensives with Medicare was 52%. Not having health insurance or having seen a health care provider in the past year increased the risk of untreated and uncontrolled high blood pressure.

Whats more, the DMCB discovered control of hypertension doesnt appear to be getting better over time.

The good news is that the treatment of high blood pressure is not all that complicated and that team-based non-physicians can play an important role.  Patients should be engaged on weight control, a DASH diet, restricting salt, exercise and moderating alcohol intake. Medication therapy can be individualized and tailored to meet mutually agreed-upon goals and to minimize any barriers.  Check out this MMWR table and youll see erences to "lifestyle counseling," "self monitoring," "self-management education."

Given the looming shortage of primary care care settings and the coming influx of newly insured persons, the DMCB believes population health management will need to be part of the solution.  In addition to the established science, the industry 1) understands the importance of risk stratification, 2) can be bolted onto accountable care arrangements and 3) understands that optimal outcomes are somewhere between 46% and 100% control.

Hopefully, given the relative dearth of high quality studies, this opportunity will be accompanied by ongoing studies of outcomes.

Whether you hope to lose weight or just stay healthy, what you eat is a crucial factor. The right nutrients can not only trim your waistline, but also provide energy, improve your mood, and stave off disease. Now a Tel Aviv University researcher has found that its not just what you eat — but when.

Metabolism is impacted by the bodys circadian rhythm — the biological process that the body follows over a 24 hour cycle. So the time of day we eat can have a big impact on the way our bodies process food, says Prof. Daniela Jakubowicz of TAUs Sackler Faculty of Medicine and the Diabetes Unit at Wolfson Medical Center. In a recent study, she discovered that those who eat their largest daily meal at breakfast are far more likely to lose weight and waist line circumference than those who eat a large dinner.

And the benefits went far beyond pounds and inches. Participants who ate a larger breakfast — which included a dessert item such as a piece of chocolate cake or a cookie — also had significantly lower levels of insulin, glucose, and triglycerides throughout the day, translating into a lower risk of cardiovascular disease, diabetes, hypertension, and high cholesterol. These results, published recently in the journal Obesity, indicate that proper meal timing can make an important contribution towards managing obesity and promoting an overall healthy lifestyle.

The study was done in collaboration with Dr. Julio Wainstein of TAU and the Wolfson Medical Center and Dr. Maayan Barnea and Prof. Oren Froy at the Hebrew University of Jerusalem.

A dramatic difference

To determine the impact of meal timing on weight loss and health, Prof. Jakubowicz and her fellow researchers conducted a study in which 93 obese women were randomly assigned to one of two isocaloric groups. Each consumed a moderate-carbohydrate, moderate-fat diet totalling 1,400 calories daily for a period of 12 weeks. The first group consumed 700 calories at breakfast, 500 at lunch, and 200 at dinner. The second group ate a 200 calorie breakfast, 500 calorie lunch, and 700 calorie dinner. The 700 calorie breakfast and dinner included the same foods.

By the end of the study, participants in the "big breakfast" group had lost an average of 17.8 pounds each and three inches off their waist line, compared to a 7.3 pound and 1.4 inch loss for participants in the "big dinner" group. According to Prof. Jakubowicz, those in the big breakfast group were found to have significantly lower levels of the hunger-regulating hormone ghrelin, an indication that they were more satiated and had less desire for snacking later in the day than their counterparts in the big dinner group.

The big breakfast group also showed a more significant decrease in insulin, glucose, and triglyceride levels than those in the big dinner group. More important, they did not experience the high spikes in blood glucose levels that typically occur after a meal. Peaks in blood sugar levels are considered even more harmful than sustained high blood glucose levels, leading to high blood pressure and greater strain on the heart.

Eliminating late night snacking

These findings suggest that people should adopt a well thought-out meal schedule, in addition to proper nutrition and exercise, to optimize weight loss and general health. Eating the right foods at the wrong times can not only slow down weight loss, it can also be harmful. In their study, the researchers found that those in the big dinner group actually increased their levels of triglycerides — a type of fat found in the body — despite their weight loss, reports Prof. Jakubowicz.

Prof. Jakubowicz suggests an end to late night snacking. Mindless eating in front of the computer or television, especially in the late evening hours, is a huge contributor to the obesity epidemic, she believes. It increases not only poundage, but the risk of cardiovascular disease — making that midnight sugar rush more costly than it appears.

A new study has found that drinking-related hypertension has a higher risk in flushers than in non-flushers, and the risk of hypertension was significantly increased when flushers consumed more than four drinks per week.

Excessive drinking is a known risk factor for hypertension. Drinking that results in facial flushing indicates high sensitivity or even intolerance to alcohol. A study of the relationship between drinking and these two conditions has found that drinking-related hypertension has a lower threshold value and higher risk in flushers than in non-flushers.

Results will be published in the April 2014 online-only issue of Alcoholism: Clinical & Experimental Research and are currently available at Early View.

"Facial flushing after drinking is always considered as a symptom of high alcohol sensitivity or even intolerance to alcohol, unless a patient is taking special medicine," said Jong Sung Kim, head of the department of family medicine at Chungnam National University School of Medicine. "The facial flushing response to drinking usually occurs in a person who cannot genetically break down acetaldehyde, the first metabolite of alcohol."

"Facial flushing after alcohol drinking differs across gender, age, and ethnic groups," added Kyung Hwan Cho, president of the Korean Academy of Family Medicine. "In general, it is more common in women, the elderly, and East Asians versus Westerners."

Cho noted that it is well known that excessive alcohol consumption is associated with elevated blood pressure and the likely development of hypertension. "This association persists regardless of beverage type and shows a dose-response relationship, which means excess drinking for weeks or months can increase blood pressure," he said. "However, the relationship may vary by gender, race/ethnicity, or presence of other risk factors for cardiovascular disease. Conversely, many studies have reported that meaningful blood pressure reductions occur after reductions in alcohol drinking."

"To my knowledge," noted Kim, "there has been no detailed research that has analyzed the relationship between drinking and hypertension while considering individual responses to alcohol."

Kim and his colleagues collected data from the medical records of 1,763 men (288 non-drinkers, 527 flushing drinkers, 948 non-flushing drinkers) who had received a health check-up. The risk of hypertension related to the weekly drinking amount by non-flushers and flushers was analyzed and compared with the risk of hypertension among non-drinkers.

"Our results indicate that hypertension associated with drinking has a lower threshold value and higher risk in flushers than in non-flushers," said Kim. "After adjusting for age, body mass index, exercise status, and smoking status, the risk of hypertension was significantly increased when flushers consumed more than four drinks per week. In contrast, in non-flushers, the risk increased with consuming more than eight drinks per week".

Kim added that these results indicate that facial flushing after drinking may potentially serve as a marker of risk for hypertension associated with drinking. "Our research findings suggest that clinicians and researchers should, respectively, consider evaluating their patients flushing response to alcohol as well as drinking amount in a daily routine care, and researching hazard by drinking."

"Thus, if you or your patient have facial flushing, the risk of hypertension can increase even if you drink less than those who do not have facial flushing," said Cho. "[Under these circumstances, I would] recommend limiting your or their drinking amount even more to prevent the development of hypertension."