Obesity: A Stubbornly Obvious Target for Stroke Prevention

Association of obesity with recurrent stroke and cardiovascular events

BACKGROUND AND PURPOSE

The relation between obesity and stroke recurrence is still under debate. In this study, we investigated whether initial obesity was associated with recurrent stroke and major cardiovascular events over a long period of time.

MATERIALS AND METHODS

Five-years follow-up data of the Ege Stroke Registry for stroke recurrence and cardiovascular events related to obesity were analyzed. Data include age, gender, stroke severity, neuroimaging studies, cardiovascular risk factors. Within the inclusion period, all of the included patients were followed until censoring (10th of December 2011) or readmission because of recurrent stroke, cardiovascular event or death, whichever came first. The Kaplan-Meier method was used for survival analysis. Cox proportional hazard model was applied to identify predictors of stroke and all major vascular events.

RESULTS

Of 9285 eligible patients for evaluation, 5158 (56%) were male and 3068 (33%) with a prior stroke were obese at baseline. Among 2198 patients with recurrent stroke, 843 (38%) had obesity while 2229 (62%) had no obesity (HR, 1.36; 95% CI, 1.23-1.50; P<0.001). Overall major vascular events (recurrent stroke, cardiovascular events, and death) occurred in 1464 obese patients (48%) and in 2182 non-obese patients (35%) (HR, 1.69; 95%CI, 1.55-1.84). Cox hazard model showed that being obese was associated with increased recurrent stroke risk compared with those without obesity (HR, 0.85; 95%CI, 0.76-0.94; P<0.001), being obese was not associated with cardiovascular events (HR, 1.09; 95%CI, 0.95-1.26; P=0.22).

CONCLUSIONS

Our results showed that obesity is a significant risk factor for recurrent stroke, although obesity was not associated significantly with myocardial infarction and death after 5-years of first stroke. Further clinical goal-directed weight reduction outcome trials in this area will be critical to validate the most effective approaches and, ultimately, to guide policy is certainly needed.

Association between dynamic obesity and mortality in patients with first-ever ischemic stroke: A hospital-based prospective study

Although obesity is an established risk factor of primary stroke, the association between obesity and post-stroke mortality remains unclear. The aim of this study was to investigate the association between dynamic obesity status and mortality in survivors of their first stroke in China.Of 775 patients with first-ever ischemic stroke included in a longitudinal study, 754 patients were included in this study and categorized into 4 categories of body mass index (BMI) (underweight, normal weight, overweight, and obese) and 2 categories of waist circumference (WC) (normal WC and abdominal obesity) according to standard Chinese criteria. The mortality information and obesity status were obtained via telephone follow-up every 3 months, beginning in 2010 through 2016. Time-dependent Cox proportional hazards models were used to estimate the unadjusted and adjusted hazard ratios (HRs) for the relationship between all-cause mortality and dynamic obesity status.Of 754 patients, 60.87% were male, and the overall mean age was 61.45 years. After adjusting for possible confounders, significant inverse associations were identified between BMI and WC and all-cause mortality. Compared with those with normal BMI or WC, those with abdominal obesity or overweight had a significantly lower risk of all-cause mortality (HR and 95% confidence intervals [CIs]: .521 [.303-.897] and 0.545 [.352-.845], respectively), whereas patients with underweight had the highest risk and those with obesity had lower risk of mortality, though it was not statistically significant (1.241 [.691-2.226] and .486 [.192-1.231], respectively).Overweight and abdominal obesity were paradoxically associated with reduced risk of mortality in patients who survived their first-ever ischemic stroke in China. Future prospective studies must look at evaluating the role of obesity in different stroke subtypes and devise appropriate weight-management strategies for optimal prognoses in secondary prevention in these survivors.

Predictors of Recurrent Ischemic Stroke in Obese Patients With Type 2 Diabetes Mellitus: A Population-based Study

BACKGROUND

Diabetes and obesity are established risk factors for stroke. The current study aimed to assess risk factors of ischemic stroke recurrence in diabetic patients based on their body mass index (BMI).

METHODS

A total of 4005 diabetic patients who had a history of ischemic stroke were identified in a retrospective cross-sectional dataset from the Malaysian National Neurology Registry. Patients were classified based on BMI, and multivariable regression analysis was used to evaluate the association between risk factors and recurrent ischemic stroke.

RESULTS

Among obese patients, those with ischemic heart disease (aOR, 1.873; 95% CI, 1.131-3.103), received formal education (aOR, 2.236; 95% CI, 1.306-3.830), and received anti-diabetic medication (aOR, 1.788; 95% CI, 1.180-2.708) had a higher stroke recurrence risk, while receiving angiotensin receptors blockers (aOR, 0.261; 95% CI, 0.126-0.543) lowered the odds of recurrence. Overweight patients with hypertension (aOR, 1.011; 95% CI, 1.002-1.019) for over 10 years (aOR, 3.385; 95% CI, 1.088-10.532) and diabetes prior to the first stroke (aOR, 1.823; 95% CI, 1.020-3.259) as well as those received formal education (aOR, 2.403; 95% CI, 1.126-5.129) had higher odds of stroke recurrence, while receiving angiotensin-converting enzyme inhibitors (aOR, 0.244; 95% CI, 0.111-0.538) lowered the recurrence risk. Normal weight East Malaysians (aOR, 0.351; 95% CI, 0.164-0.750) receiving beta-blockers (aOR, 0.410; 95% CI, 0.174-0.966) had lower odds of stroke recurrence.

CONCLUSIONS

Ischemic heart disease, hypertension, receiving anti-hypertensive agents, and educational level were independent predictors of recurrent stroke in obese patients. Managing the modifiable risk factors can decrease the odds of stroke recurrence.

Recommendations of the Spanish Society of Neurology for the prevention of stroke. Interventions on lifestyle and air pollution

OBJECTIVE

To update the recommendations of the Spanish Society of Neurology regarding lifestyle interventions for stroke prevention.

DEVELOPMENT

We reviewed the most recent studies related to lifestyle and stroke risk, including randomised clinical trials, population studies, and meta-analyses. The risk of stroke associated with such lifestyle habits as smoking, alcohol consumption, stress, diet, obesity, and sedentary lifestyles was analysed, and the potential benefits for stroke prevention of modifying these habits were reviewed. We also reviewed stroke risk associated with exposure to air pollution. Based on the results obtained, we drafted recommendations addressing each of the lifestyle habits analysed.

CONCLUSIONS

Lifestyle modification constitutes a cornerstone in the primary and secondary prevention of stroke. Abstinence or cessation of smoking, cessation of excessive alcohol consumption, avoidance of exposure to chronic stress, avoidance of overweight or obesity, a Mediterranean diet supplemented with olive oil and nuts, and regular exercise are essential measures in reducing the risk of stroke. We also recommend implementing policies to reduce air pollution.

Effectiveness and safety of rivaroxaban versus warfarin in obese nonvalvular atrial fibrillation patients: analysis of electronic health record data

Background: Although rivaroxaban has demonstrated consistent drug levels in normal weight and obese patients, sufficient confirmation of equal clinical effectiveness and safety is currently lacking.Purpose: To evaluate the effectiveness and safety of rivaroxaban versus warfarin for prevention of stroke and systemic embolism (SSE) in obese nonvalvular atrial fibrillation (NVAF) patients.Methods: Using Optum de-identified Electronic Health Record (EHR) data from November 2011 to September 2018,we evaluated NVAF patients with a body mass index (BMI)≥30 kg/m² newly initiated on rivaroxaban or warfarin (index date), with ≥12-months of EHR activity and ≥1 encounter before the index date. We excluded patients with valvular disease or evidence of oral anticoagulant (OAC) use at baseline. Patients who were prescribed rivaroxaban were 1:1 propensity-score matched to patients who were prescribed warfarin (standard differences <0.10 achieved for all covariates). Outcomes included SSE and major bleeding using an intent-to-treat approach. Subanalyses stratified by BMI (30.0-34.9, 35.0-39.9 and ≥40 kg/m²) were performed. Cox regression was performed and reported as hazard ratios (HRs) and 95% confidence intervals (CIs).Results: We included 35,613 rivaroxaban and 35,613 warfarin users with NVAF. Patients were followed for a median of 2.6 years (25%-75% range = 1.2-4.1). Rivaroxaban was associated with a reduced risk of SSE (HR = 0.83, 95%CI = 0.73-0.94) and major bleeding (HR = 0.82, 95%CI = 0.75-0.89) compared to warfarin. Subanalysis did not show a statistically significant interaction across BMI categories for SSE (p-interaction = .58) or major bleeding (p-interaction = .44) outcomes.Conclusions: Among obese NVAF patients, prescription of rivaroxaban was associated with a reduced risk of SSE and major bleeding compared to warfarin, which remained consistent across BMI classes.

Sex influence in ischemic stroke severity and outcome among metabolically unhealthy overweight patients

INTRODUCTION

The role of metabolically unhealthy (MU) overweight in influencing stroke prognosis has not been fully assessed and conclusive data about the impact of sex are lacking. Aim of this study was to evaluate the possible correlations among MU overweight, sex and ischemic stroke severity and outcome.

METHODS

All consecutive patients with acute non-lacunar ischemic stroke observed over a one-year period were considered. MU subjects were selected and classified according to the body mass index (BMI) values. The relationships among sex, BMI and National Institutes of Health Stroke Scale (NIHSS) score at admission and modified Rankin scale (mRS) score at discharge were analysed with multivariate models.

RESULTS

180 patients were included. A significantly increasing trend in the NIHSS (p = .030) and in the mRS (p = .001) scores along with the increase of the BMI category was detected in women. Men showed a significantly decreasing trend in the NIHSS (p = .040) and a non-significant decreasing trend in the mRS (p = .290) scores with increasing BMI category.

CONCLUSIONS

Our findings show that sex can influence stroke severity and outcome among MU patients. The worse outcome observed in women suggest the need of considering differential sex-based clinical approaches in stroke overweight patients.

Reversal of prolonged obesity-associated cerebrovascular dysfunction by inhibiting microglial Tak1

Prolonged obesity is associated with cerebrovascular dysfunction; however, the underlying mechanisms remain largely unclear. In the present study, using a prolonged obesity mouse model that suffers from basilar artery (BA) abnormalities, we find that microglial transforming growth factor β-activated kinase 1 (Tak1) is over-activated in the brainstem. Both pharmacological inhibition primarily in the brainstem and genetic microglia-selective deletion of Tak1 ameliorated BA vascular dysfunction. Conversely, microglia-specific activation of Tak1 in the brainstem was sufficient to cause an impairment in BA function in chow-fed mice. Mechanistically, Tak1 activation leads to increased interleukin-18 (IL-18) production, whereas blockade of IL-18 receptor in the brain helped protect against cerebrovascular dysfunction despite prolonged obesity. Microglia-selective deletion of Tak1 also protects against ischemic stroke in prolonged obesity. Taken together, these findings provide evidence that microglial Tak1 in the brain, and particularly the brainstem, contributes to the pathogenesis of obesity-associated cerebrovascular dysfunction.

Intracranial Atherosclerotic Stenoses: Pathophysiology, Epidemiology, Risk Factors and Current Therapy Options

Intracranial atherosclerotic stenoses (ICAS) are one of the most common causes of first and recurrent cerebrovascular ischaemic events worldwide, with highest prevalence in Asian, Hispanic and African populations. Clinical trials have improved the understanding of epidemiology, risk factors and imaging characteristics of patients with ICAS. Current therapeutic approaches concerning these patients include management of risk factors, best medical therapy, potentially endovascular and rarely surgical therapy. In our review, we elucidate the current epidemiology and evidence in evaluation of risk factors and therapeutic options for providing favourable outcome for patients with ICAS.

Obesity and diabetes are jointly associated with functional disability in stroke survivors

BACKGROUND

Stroke is the most common cause of complex disability. Obesity and diabetes increase risk for functional disability in the general population, but their contribution to functional disability in stroke survivors is unknown.

OBJECTIVE

To investigate the joint association of obesity and diabetes with functional disability in stroke survivors.

METHODS

Cross-sectional data from 34,376 stroke survivors from the 2015 and 2017 Behavioral Risk Factor Surveillance System (BRFSS) surveys were examined. Weighted and age-adjusted prevalence estimates and adjusted odds ratios (AOR, adjusted for sociodemographic characteristics) with 95% confidence intervals (CIs) were calculated to compare prevalence and odds for self-reported functional disability, stratified by obesity-diabetes status (i.e., neither condition, obesity only, diabetes only, both conditions).

RESULTS

Prevalence of functional disability increased across obesity-diabetes categories in the total sample: neither condition (45.4%, 95% CI: 43.4%-47.4%), obesity only (55.3%, 95% CI: 52.7%-58.0%), diabetes only (60.8%, 95% CI: 57.5%-64.1%), and both conditions (70.3%, 95% CI: 67.7%-72.9%). Compared to respondents with neither condition, those with both obesity and diabetes had 2.62 (95% CI: 2.23-3.08) higher odds for functional disability; odds were also increased for respondents with obesity only (1.52, 95% CI: 1.32-1.76) and diabetes only (1.71, CI: 1.45-2.01).

CONCLUSIONS

Our findings indicated a joint effect of obesity and diabetes on functional disability that exceeded either condition alone, placing stroke survivors with both health conditions at greatest risk for diminished functional capacity. Recognizing obesity and diabetes as modifiable risk factors may be useful for identifying stroke sub-populations that could benefit from lifestyle intervention.

Spatiotemporal dynamic monitoring of fatty acid-receptor interaction on single living cells by multiplexed Raman imaging

Numerous fatty acid receptors have proven to play critical roles in normal physiology. Interactions among these receptor types and their subsequent membrane trafficking has not been fully elucidated, due in part to the lack of efficient tools to track these cellular events. In this study, we fabricated the surface-enhanced Raman scattering (SERS)-based molecular sensors for detection of two putative fatty acid receptors, G protein-coupled receptor 120 (GPR120) and cluster of differentiation 36 (CD36), in a spatiotemporal manner in single cells. These SERS probes allowed multiplex detection of GPR120 and CD36, as well as a peak that represented the cell. This multiplexed sensing system enabled the real-time monitoring of fatty acid-induced receptor activation and dynamic distributions on the cell surface, as well as tracking of the receptors' internalization processes on the addition of fatty acid. Increased SERS signals were seen in engineered HEK293 cells with higher fatty acid concentrations, while decreased responses were found in cell line TBDc1, suggesting that the endocytic process requires innate cellular components. SERS mapping results confirm that GPR120 is the primary receptor and may work synergistically with CD36 in sensing polyunsaturated fatty acids and promoting Ca²⁺ mobilization, further activating the process of fatty acid uptake. The ability to detect receptors' locations and monitor fatty acid-induced receptor redistribution demonstrates the specificity and potential of our multiplexed SERS imaging platform in the study of fatty acid-receptor interactions and might provide functional information for better understanding their roles in fat intake and development of fat-induced obesity.

Adult obesity complications: challenges and clinical impact

The complications associated with adult obesity are overwhelming national healthcare systems. No country has yet implemented a successful population-level strategy to reverse the rising trends of obesity. This article presents epidemiological data on the complications of adult obesity and discusses some of the challenges associated with managing this disease at a population and individual level.

Lifestyle Risk Behaviors Among Stroke Survivors With and Without Diabetes

OBJECTIVE

History of stroke and diabetes increases risk for cardiometabolic disease, which can be mitigated through lifestyle management. To evaluate lifestyle risk behaviors among stroke survivors, we compared the prevalence of three lifestyle risk behaviors-physical inactivity, consuming one or less fruit and one or less vegetable daily, and overweight/obesity-between stroke survivors with and without diabetes.

DESIGN

Data from the 2013 and 2015 Behavioral Risk Factor Surveillance System were examined. Weighted and age-adjusted prevalence estimates as well as crude and adjusted odds ratios (adjusted for sociodemographic characteristics) were calculated to compare lifestyle risk behaviors between US stroke survivors with and without diabetes.

RESULTS

Prevalence and adjusted odds ratios for lifestyle risk behaviors were higher in respondents with diabetes compared with those without diabetes for consuming one or less fruit and one or less vegetable daily (58.8% vs. 53.7%, adjusted odds ratio = 1.14), physical inactivity (65.7% vs. 54.6%, adjusted odds ratio = 1.41), and overweight/obesity (87.2% vs. 63.1%, adjusted odds ratio = 2.42).

CONCLUSIONS

Prevalence of select lifestyle risk behaviors exceeds 50% in adults with stroke but is higher in adults with diabetes compared with adults without diabetes. Effective interventions, community programs, and healthcare policy are needed to promote lifestyle management in adults with stroke, particularly among those with diabetes.

The Factors Associated with the Fatal Outcome of Stroke

The aim of this study is to determine the risk factors associated with the fatal outcome of stroke. The research was designed as observational, non-interventional study, conducted by the type of case series, and it included 290 patients hospitalized with a diagnosis of stroke at Neurology Clinic of the Clinical Center Kragujevac during the observed period from 01/02/2013 to 31/01/2014. The data used for the research were: documentation of Neurology Clinic of the Clinical Center Kragujevac, documentation of the Institute of Public Health Kragujevac and patients’ questionnaires. The results of univariate binary logistic regression pointed out a relevant connection between the fatal outcome of stroke and age (p˂ 0.0001), gender (p˂ 0.0001), the severity of the disease (p = 0.002), smoking (p = 0.021), care for the parents’ health (p = 0.018), the concern about business problems (p = 0.018), while the influence of antidepressants was indicative (p = 0.066), whereas using the multivariate binary logistic regression, it was concluded that age (OR=1.096; 95% CI=1.059-1.134; p<0.001), the severity of the disease (OR=4.324; 95% CI=1.256-14.885; p=0.020) and the use of antidepressants (OR=5.578; 95% CI=1.178-26.423; p=0.030) were factors independently associated with the mortality rate. These findings suggest that it would be useful to carry out additional comprehensive research about all potential risk factors for the occurrence of stroke, and also to establish all the steps that can be taken in order to identify and detect risk factors, their elimination or reduction, and, accordingly, to take aggressive measures of primary and secondary prevention.

Body Mass Index and Clinical Outcomes in Large Vessel Occlusion Acute Ischemic Stroke after Endovascular Therapy

Background and Purpose

Several reports have described lower mortality rates in overweight or obese patients as compared to normal weight ones. In the past decade, several studies have investigated the phenomenon, commonly known as the obesity paradox, with mixed results thus far. We sought to determine whether outcomes differ between patients with large vessel occlusion strokes (LVOS) after endovascular therapy (ET) according to their body mass index (BMI).

Methods

We reviewed our prospectively collected endovascular database at a tertiary care academic institution. All patients that underwent ET for acute LVOS were categorized according to their BMI into 4 groups: (1) underweight (BMI < 18.5), (2) normal weight (BMI = 18.5-25), (3) overweight (BMI = 25-30), and (4) obese (BMI > 30). Baseline characteristics, procedural radiological as well as outcome parameters where compared.

Results

A total of 926 patients qualified for the study, of which 20 (2.2%) were underweight, 253 (27.3%) had a normal weight, 315 (34%) were overweight, and 338 (36.5%) were obese. When compared with normal weight (reference), overweight patients were younger, had higher rates of dyslipidemia and diabetes and higher glucose levels, while obese patients were younger, less often smokers, and had higher rates of hypertension and diabetes and higher glucose levels. Other baseline and procedural characteristics were comparable. The rates of successful reperfusion (modified treatment in cerebral ischemia, 2b-3), parenchymal hematomas, 90-day good clinical outcomes (modified Rankin scale, 0-2), and 90-day mortality were comparable between groups. On multivariate analysis, BMI was not associated with good outcomes nor mortality.

Conclusion

In patients treated with mechanical thrombectomy, BMI is not associated with outcomes. However, patients who are overweight or obese have more comorbidities and a higher stroke risk and, thus, should strive for a normal weight.

Body mass index and fatal stroke in young adults: A national study

Rates of stroke and obesity have increased in recent years. This study aimed to determine the body mass index (BMI) of fatal stroke cases amongst young adults, their clinical characteristics and the association with BMI with risk factors. All cases aged 15-44 years where death was attributed to stroke for whom BMI was available were retrieved from the National Coronial Information System (1/1/2009-31/12/2016). 179 cases were identified: haemorrhagic (165), ischaemic (5), thrombotic (6), mycotic (3), embolic (0). Proportions in each BMI category were: underweight (5.6%), normal weight (37.4%), overweight (27.4%), obese (29.6%). There was a significant linear trend in the proportion of subarachnoid haemorrhages as BMI increased (p < 0.05), and between higher BMI and hypertension (p < 0.001). There were no group differences in cardiomegaly or left ventricular hypertrophy where known causes were other than hypertension, cardiomyopathy, severe coronary artery atherosclerosis, endocarditis or cerebral arteries atherosclerosis. A history of alcoholism (p < 0.01) was less likely with higher BMI. There was no association between BMI and previous stroke, diabetes, vasculitis, gravid/post-partum, tobacco use, psychostimulant use or injecting drug use. Overweight and obese cases were prominent among young fatalities of stroke. Reducing rates of obesity, and associated hypertension, would be expected to reduce the escalating stoke rates among young adults.

Achievement of Guideline-Recommended Weight Loss Among Patients With Ischemic Stroke and Obesity

Background and Purpose- The proportion of patients with acute ischemic stroke or transient ischemic attack (TIA) and obesity who successfully achieve goals for weight reduction recommended by major professional organizations is unknown. Methods- We examined the experience of participants in the placebo group of the IRIS trial (Insulin Resistance Intervention after Stroke) with a body mass index ≥30 kg/m2 at entry. Patients were of age ≥40 years, with a qualifying stroke or TIA within 180 days of randomization and documented insulin resistance without diabetes mellitus. Weights at baseline and at years 1 and 2 after entry were analyzed to determine the proportion of patients achieving a 5% weight loss and achievement of body mass index <27 kg/m2. Results- Of 1937 subjects assigned to placebo, 855 (44%) had obesity at entry. Median age of these 855 subjects was 60 years (interquartile range, 53-68), 41% were women, and median time from stroke/TIA to trial entry was 79 days. Among 788 subjects in the trial at 1 year, 166 (21%) had lost at least 5% of their starting weight and 12 (2%) had achieved a body mass index <27 kg/m2. One hundred nine (14%) participants gained at least 5% of their baseline weight at 1 year. Among 744 subjects in the trial at 2 years, 185 (25%) had lost at least 5% of their baseline weight and 23 (3%) had achieved a body mass index <27 kg/m2. One hundred forty (19%) participants gained at least 5% of their starting weight at 2 years. Conclusions- Only one quarter of obese patients with a recent ischemic stroke or TIA lost a clinically significant amount of weight after their vascular event. Many patients gained weight. Enhancing weight loss after ischemic stroke or TIA may help improve functional outcome and reduce risk for future vascular events, but clinical trials are needed to test and confirm these potential benefits.

Prevalence of five lifestyle risk factors among U.S. adults with and without stroke

BACKGROUND

History of stroke increases cardiometabolic risk, which can be exacerbated by the presence of unhealthy lifestyle factors. Population-based estimates of lifestyle risk factors in people with stroke are lacking but could be used to inform research, policy, and healthcare practice.

OBJECTIVE

To compare population-based estimates of the prevalence of five lifestyle risk factors-low fruit and vegetable consumption, insufficient physical activity, smoking, heavy alcohol consumption, and overweight/obesity-among U.S. adults with and without stroke.

METHODS

Representative data from noninstitutionalized adults aged ≥18 years (stroke, n = 37,225; no stroke, n = 851,607) from the 2015 and 2017 Behavioral Risk Factor Surveillance System (BRFSS) were used to estimate prevalence of individual and total number of risk factors. Logistic regression models were used to determine the odds of lifestyle risk factors in adults with stroke, adjusting for sex, age, ethnicity, marital status, education, income, and disability.

RESULTS

Prevalence and adjusted odds ratios (AOR) were higher in individuals with stroke compared to those without stroke for insufficient physical activity (56.5% vs. 49.5%, AOR: 1.14) and smoking (30.1% vs. 16.6%, AOR: 1.16), but lower for heavy alcohol consumption (5.4% vs. 6.1%, AOR: 0.76). Prevalence for low fruit and vegetable consumption (51.7% vs. 46.0%) and overweight/obesity (70.2% vs. 64.5%) was higher among adults with stroke, but differences were attenuated by demographic characteristics. Additionally, clustering of 4-5 lifestyle risk factors was higher in adults with stroke (9.0% vs. 5.3%, AOR: 1.12).

CONCLUSION

Additional research and healthcare interventions are needed to improve lifestyle risk factors in adults with stroke.

Prevalence of obesity among stroke patients in five Brazilian cities: a cross-sectional study

ABSTRACT Objective There is gap in knowledge about obesity prevalence in stroke patients from low- and middle-income countries. Therefore, we aimed to measure the prevalence of overweight and obesity status among patients with incident stroke in Brazil. Methods In a cross-sectional study, we measured the body mass index (BMI) of ischemic and hemorrhagic stroke patients. The sample was extracted in 2016, from the cities of Sobral (CE), Sertãozinho (SP), Campo Grande (MS), Joinville (SC) and Canoas (RS). Results In 1,255 patients with first-ever strokes, 64% (95% CI, 62–67) were overweight and 26% (95%CI, 24–29) were obese. The obesity prevalence ranged from 15% (95%CI, 9–23) in Sobral to 31% (95%CI, 18–45) in Sertãozinho. Physical inactivity ranged from 53% (95%CI, 43-63) in Sobral to 80% (95%CI, 73–85) in Canoas. Conclusions The number of overweight patients with incident stroke is higher than the number of patients with stroke and normal BMI. Although similar to other findings in high-income countries, we urgently need better policies for obesity prevention.

The Importance of Assessing Nutritional Status to Ensure Optimal Recovery during the Chronic Phase of Stroke

Background

Despite evidence that many of the consequences of stroke that hinder recovery (i.e., obesity, muscle atrophy, and functional declines) have nutritionally modifiable behavior components, little attention has been focused on the significance of nutrition beyond the acute phase of stroke.

Objective

This literature review summarizes the evidence for and against the influence of nutrition on optimal recovery and rehabilitation in chronic (>6 months) stroke.

Results

The literature, which is mainly limited to cross-sectional studies, suggests that a suboptimal nutritional status, including an excess caloric intake, reduced protein intake, and micronutrient deficiencies, particularly the B-vitamins, vitamin D, and omega 3 fatty acids, may have deleterious effects on metabolic, physical, and psychological functioning in chronic stroke survivors.

Conclusions

Careful evaluation of dietary intake, especially among those with eating disabilities and preexisting malnutrition, may aid in the identification of individuals at increased nutritional risk through which early intervention may benefit recovery and rehabilitation and prevent further complications after stroke.

Obesity: Risk factors, complications, and strategies for sustainable long-term weight management

Background and Purpose

The aims of this article are to review the effects of obesity on health and well‐being and the evidence indicating they can be ameliorated by weight loss, and consider weight‐management strategies that may help patients achieve and maintain weight loss.

Methods

Narrative review based on literature searches of PubMed up to May 2016 with no date limits imposed. Search included terms such as “obesity,” “overweight,” “weight loss,” “comorbidity,” “diabetes,” cardiovascular,” “cancer,” “depression,” “management,” and “intervention.”

Conclusions

Over one third of U.S. adults have obesity. Obesity is associated with a range of comorbidities, including diabetes, cardiovascular disease, obstructive sleep apnea, and cancer; however, modest weight loss in the 5%–10% range, and above, can significantly improve health‐related outcomes. Many individuals struggle to maintain weight loss, although strategies such as realistic goal‐setting and increased consultation frequency can greatly improve the success of weight‐management programs. Nurse practitioners have key roles in establishing weight‐loss targets, providing motivation and support, and implementing weight‐loss programs.

Implications for Practice

With their in‐depth understanding of the research in the field of obesity and weight management, nurse practitioners are well placed to effect meaningful changes in weight‐management strategies deployed in clinical practice.

A Systematic Review and Meta-Analysis on Self-Management for Improving Risk Factor Control in Stroke Patients

PURPOSE

The aims of this review were to describe the self-management interventions used to improve risk factor control in stroke patients and quantitatively assess their effects on the following: 1) overall risk factor control from lifestyle behaviour (i.e. physical activity, diet and nutrition, stress management, smoking, alcohol, and medication adherence), and medical risk factors (i.e. blood pressure, cholesterol, blood glucose) and (2) individual risk factors.

METHOD

We systematically searched the PubMed, PsycINFO, CINAHL and Cochrane Database of Systematic Reviews databases to September 2015 to identify relevant randomized controlled trials investigating self-management to improve stroke risk factors. The self-management interventions were qualitatively described, and the data included in meta-analyses.

RESULTS

Fourteen studies were included for review. The model estimating an effect averaged across all stroke risk factors was not significant, but became significant when four low-quality studies were removed (SMD = 0.10 [95 % CI = 0.02 to 0.17], I ² = 0 %, p = 0.01). Subgroup analyses revealed a significant effect of self-management interventions on lifestyle behaviour risk factors (SMD = 0.15 [95 % CI = 0.04 to 0.25], I ² = 0 %, p = 0.007) but not medical risk factors. Medication adherence was the only individual risk factor that self-management interventions significantly improved (SMD = 0.31 [95 % CI = 0.07 to 0.56], I ² = 0 %, p = 0.01).

CONCLUSION

Self-management interventions appear to be effective at improving overall risk factor control; however, more high-quality research is needed to corroborate this observation. Self-management has a greater effect on lifestyle behaviour risk factors than medical risk factors, with the largest effect at improving medication adherence.

Prevalence of Cardiovascular Risk Factors and Strokes in Younger Adults

Importance

While stroke mortality rates have decreased substantially in the past 2 decades, this trend has been primarily limited to older adults. Increasing trends in stroke incidence and hospitalizations have been noted among younger adults, but there has been concern that this reflected improved diagnosis through an increased use of imaging rather than representing a real increase.

Objectives

To determine whether stroke hospitalization rates have continued to increase and to identify the prevalence of associated stroke risk factors among younger adults.

Design, Setting, and Participants

Hospitalization data from the National Inpatient Sample from 1995 through 2012 were used to analyze acute stroke hospitalization rates among adults aged 18 to 64 years. Hospitalization data from 2003 to 2012 were used to identify the prevalence of associated risk factors for acute stroke. Acute stroke hospitalizations were identified by the principal International Classification of Diseases, Ninth Revision, Clinical Modification code and associated risk factors were identified by secondary International Classification of Diseases, Ninth Revision, Clinical Modification codes for each hospitalization.

Main Outcomes and Measures

Trends in acute stroke hospitalization rates by stroke type, age, sex, and race/ethnicity, as well as the prevalence of associated risk factors by stroke type, age, and sex.

Results

The 2003-2004 set included 362 339 hospitalizations and the 2011-2012 set included 421 815 hospitalizations. The major findings in this study are as follows: first, acute ischemic stroke hospitalization rates increased significantly for both men and women and for certain race/ethnic groups among younger adults aged 18 to 54 years; they have almost doubled for men aged 18 to 34 and 35 to 44 years since 1995-1996, with a 41.5% increase among men aged 35 to 44 years from 2003-2004 to 2011-2012. Second, the prevalence of stroke risk factors among those hospitalized for acute ischemic stroke continued to increase from 2003-2004 through 2011-2012 for both men and women aged 18 to 64 years (range of absolute increase: hypertension, 4%-11%; lipid disorders, 12%-21%; diabetes, 4%-7%; tobacco use, 5%-16%; and obesity, 4%-9%). Third, the prevalence of having 3 to 5 risk factors increased from 2003-2004 through 2011-2012 (men: from 9% to 16% at 18-34 years, 19% to 35% at 35-44 years, 24% to 44% at 45-54 years, and 26% to 46% at 55-64 years; women: 6% to 13% at 18-34 years, 15% to 32% at 35-44 years, 25% to 44% at 45-54 years, and 27% to 48% at 55-65 years; P for trend < .001). Finally, hospitalization rates for intracerebral hemorrhage and subarachnoid hemorrhage remained stable, with the exception of declines among men and non-Hispanic black patients aged 45 to 54 with subarachnoid hemorrhage (13.2/10 000 to 10.3/10 000 hospitalizations and 15.8/10 000 to 11.5/10 000 hospitalizations, respectively).

Conclusions and Relevance

The identification of increasing hospitalization rates for acute ischemic stroke in young adults coexistent with increasing prevalence of traditional stroke risk factors confirms the importance of focusing on prevention in younger adults.

Cytotoxic lymphocytes and atherosclerosis: significance, mechanisms and therapeutic challenges

Cytotoxic lymphocytes encompass natural killer lymphocytes (cells) and cytotoxic T cells that include CD8+ T cells, natural killer (NK) T cells, γ, δ (γδ)-T cells and human CD4 + CD28- T cells. These cells play critical roles in inflammatory diseases and in controlling cancers and infections. Cytotoxic lymphocytes can be activated via a number of mechanisms that may involve dendritic cells, macrophages, cytokines or surface proteins on stressed cells. Upon activation, they secrete pro-inflammatory cytokines as well as anti-inflammatory cytokines, chemokines and cytotoxins to promote inflammation and the development of atherosclerotic lesions including vulnerable lesions, which are strongly implicated in myocardial infarctions and strokes. Here, we review the mechanisms that activate and regulate cytotoxic lymphocyte activity, including activating and inhibitory receptors, cytokines, chemokine receptors-chemokine systems utilized to home to inflamed lesions and cytotoxins and cytokines through which they affect other cells within lesions. We also examine their roles in human and mouse models of atherosclerosis and the mechanisms by which they exert their pathogenic effects. Finally, we discuss strategies for therapeutically targeting these cells to prevent the development of atherosclerotic lesions and vulnerable plaques and the challenge of developing highly targeted therapies that only minimally affect the body's immune system, avoiding the complications, such as increased susceptibility to infections, which are currently associated with many immunotherapies for autoimmune diseases.

LINKED ARTICLES

This article is part of a themed section on Targeting Inflammation to Reduce Cardiovascular Disease Risk. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v174.22/issuetoc and http://onlinelibrary.wiley.com/doi/10.1111/bcp.v82.4/issuetoc.

Plasminogen activator inhibitor links obesity and thrombotic cerebrovascular diseases: The roles of PAI-1 and obesity on stroke

One of the global socioeconomic phenomena occurred during the last decades is the increased prevalence of obesity, with direct consequence on the risk of developing thrombotic disorders. As the physiological inhibitor of tissue plasminogen activator (tPA) and urokinase plasminogen activator (uPA), plasminogen activator inhibitor-1 (PAI-1) is well known for its role in fibrinolysis. More and more evidences have shown that PAI-1 involves in physiopathologic mechanisms of many diseases and metabolic disorder. Increased serum level of PAI-1 has been observed in obesity and it also contributes to the development of adipose tissue and then has effects on obesity. Meantime, obesity affects also the PAI-1 levels. These evidences indicate the complicated interaction between PAI-1 and obesity. Many clinic studies have confirmed that obesity relates to the stroke outcome although there are many contradictory results. Simultaneously, correlation is found between plasma PAI-1 and thrombotic cerebrovascular diseases. This article reviews contemporary knowledge regarding the complex interplay of obesity, PAI-1 and stroke.

Association of high waist-to-height ratio with functional outcomes in patients with acute ischemic stroke: A report from the ACROSS-China study

The aim of our study was to investigate the relationship between the waist-to-height ratio (WHR) and all-cause mortality and functional outcomes after acute ischemic stroke in a prospective cohort study.A total of 2076 patients (36.66% females) with ischemic stroke were analyzed from ACROSS-China, which is a nationwide, prospective, hospital-based stroke registry aimed to detect the glucose abnormality in China. One-year follow-up evaluation was done by telephone interview. Outcome measures were all-cause mortality and functional outcome defined as modified Rankin score being 6 and from 0 to 6, respectively. We identified predictors for functional outcomes using logistic regression analysis, and mortality outcome using Cox proportional hazards model which incorporated covariates with P value of < 0.2 in the univariate analysis and those of clinical importance.The higher WHR was associated with worse functional outcome, but not predictive of the patients' mortality outcomes. Compared with the first quartile (≤0.48), the fourth quartile of the WHR was more likely to be associated with poor functional recovery (fourth quartile (≥0.56), OR = 1.38, CI: 1.08-1.77, P = 0.01; third quartile OR = 1.10, CI: 0.86-1.40, P = 0.45; second quartile OR = 1.05, CI: 0.83-1.33, P = 0.71).Our findings suggest that abdominal fat accumulation may be associated with functional recovery after stroke, and is not associated with mortality after stroke. Compared with the lowest quartile, the highest quartile of WHR at admission was possibly associated with worse postacute ischemic stroke functional recovery.

Cerebrovascular Disease: Consequences of Obesity-Induced Endothelial Dysfunction

Despite the well-known global impact of overweight and obesity in the incidence of cerebrovascular disease, many aspects of this association are still inconsistently defined. In this chapter we aim to present a critical review on the links between obesity and both ischemic and hemorrhagic stroke and discuss its influence on functional outcomes, survival, and current treatments to acute and chronic stroke. The role of cerebrovascular endothelial function and respective modulation is also described as well as its laboratory and clinical assessment. In this context, the major contributing mechanisms underlying obesity-induced cerebral endothelial function (adipokine secretion, insulin resistance, inflammation, and hypertension) are discussed. A special emphasis is given to the participation of adipokines in the pathophysiology of stroke, namely adiponectin, leptin, resistin, apelin, and visfatin.

Overweight and Obesity in Young Adulthood and the Risk of Stroke: a Meta-analysis

BACKGROUND

A systematic review assessing the association between overweight and obesity in young adulthood and stroke risk is lacking. Therefore, we conducted a meta-analysis to evaluate the association between overweight and obesity in young adulthood and stroke risk.

METHODS

We systematically searched PubMed and Embase databases for related studies of human subjects in the English language. Two investigators independently selected original studies in a 2-step process. Fixed- and random-effects models were used to calculate pooled relative risks (RRs) and 95% confidence intervals (CIs). Subgroup analyses were also performed.

RESULTS

Eight studies met the inclusion criteria. The pooled adjusted RR of stroke was 1.36 (95% CI: 1.28-1.44) for overweight in young adulthood and 1.81 (95% CI: 1.45-2.25) for obesity in young adulthood. In subgroup analyses, overweight and obesity in young adulthood increased the risk of stroke in most groups, except for the group of stroke subtype. For ischemic stroke, the adjusted RR was 1.40 (95% CI: 1.24-1.58) for overweight in young adulthood and 1.78 (95% CI: 1.003-3.16) for obesity in young adulthood, whereas adjusted RR for hemorrhagic stroke was 1.25 (95% CI: .83-1.90) for overweight in young adulthood and 1.80 (95% CI: .97-3.35) for obesity in young adulthood.

CONCLUSIONS

Overweight and obesity in young adulthood are associated with an increased risk of stroke, probably, independent of other cardiovascular risk factors. The risk effect gradually increases with increasing body weight.

High-fat diet feeding differentially affects the development of inflammation in the central nervous system

Background

Obesity and its associated disorders are becoming a major health issue in many countries. The resulting low-grade inflammation not only affects the periphery but also the central nervous system. We set out to study, in a time-dependent manner, the effects of a high-fat diet on different regions of the central nervous system with regard to the inflammatory tone.

Methods

We used a diet-induced obesity model and compared at several time-points (1, 2, 4, 6, 8, and 16 weeks) a group of mice fed a high-fat diet with its respective control group fed a standard diet. We also performed a large-scale analysis of lipids in the central nervous system using HPLC-MS, and we then tested the lipids of interest on a primary co-culture of astrocytes and microglial cells.

Results

We measured an increase in the inflammatory tone in the cerebellum at the different time-points. However, at week 16, we evidenced that the inflammatory tone displayed significant differences in two different regions of the central nervous system, specifically an increase in the cerebellum and no modification in the cortex for high-fat diet mice when compared with chow-fed mice. Our results clearly suggest region-dependent as well as time-dependent adaptations of the central nervous system to the high-fat diet. The differences in inflammatory tone between the two regions considered seem to involve astrocytes but not microglial cells. Furthermore, a large-scale lipid screening coupled to ex vivo testing enabled us to identify three classes of lipids—phosphatidylinositols, phosphatidylethanolamines, and lysophosphatidylcholines—as well as palmitoylethanolamide, as potentially responsible for the difference in inflammatory tone.

Conclusions

This study demonstrates that the inflammatory tone induced by a high-fat diet does not similarly affect distinct regions of the central nervous system. Moreover, the lipids identified and tested ex vivo showed interesting anti-inflammatory properties and could be further studied to better characterize their activity and their role in controlling inflammation in the central nervous system.

Electronic supplementary material

The online version of this article (doi:10.1186/s12974-016-0666-8) contains supplementary material, which is available to authorized users.

Swipe out Stroke: Feasibility and efficacy of using a smart-phone based mobile application to improve compliance with weight loss in obese minority stroke patients and their carers

RATIONALE

Swipe out Stroke (SOS) examines the use of a smartphone-based mobile application to reduce obesity in high-risk minority stroke patients. At record-high levels in the United States, obesity disproportionately affects minorities and is highly correlated with cerebrovascular disease. Unfortunately, structured weight loss programs are expensive, and compliance significantly decreases upon program completion. Mobile health (mHealth) technology is an innovative, cost-effective way to bridge this gap. Minorities spend over 4.5 billion dollars annually on consumer electronics, making studies that utilize mHealth applications ideal for health promotion and disease prevention.

AIMS AND DESIGN

SOS is a prospective, randomized-controlled trial with open blinded endpoint comparing an mHealth based dietary intervention to usual care to facilitate weight reduction. Ischemic and hemorrhagic stroke survivors and their carers are recruited from the acute care service of a Houston-based comprehensive stroke center. A neurorehabilitation physician or vascular neurologist meets with participants during the index hospitalization, a baseline clinic visit, followed by visits at 1, 3, and 6 month intervals. The SOS Team focuses on feasible modifications to the Southern dietary pattern (fried foods, fatty foods, added fats, eggs, processed meats, such as bacon and ham, organ meats (e.g., liver), and sweetened drinks) and caloric restriction to facilitate a 5% reduction in total body weight. Practical barriers to adherence are addressed, such as access to transportation, financial limitations, and depression.

STUDY OUTCOMES

The primary dependent measure is a reduction of total body weight. Secondary outcomes include systolic blood pressure, hemoglobin A1c, low-density lipoprotein, triglycerides, and Factor VIII.

CONCLUSION

SOS will determine whether a Phase III effectiveness trial of a smartphone-based mobile application to address obesity-related health disparities is warranted throughout the Southeastern United States (Stroke Belt).

[Secondary prevention of ischemic non cardioembolic stroke]

Stroke patients are at high risk for recurrence or new occurrence of other cardiovascular events or cardiovascular mortality. It is estimated that a high percentage of non-cardioembolic ischemic stroke can be prevented by a suitable modification of lifestyle (diet and exercise), reducing blood pressure (BP) with antihypertensive medication, platelet aggregation inhibitors, statins and high intake reducing consumption of. Unfortunately the degree of control of the different risk factors in secondary prevention of stroke is low. The clinical practice guidelines show clear recommendations with corresponding levels of evidence, but only if implemented in a general way they will get a better primary and secondary stroke prevention.

Promoting weight loss methods in parenting magazines: Implications for women

Weight gain before and after pregnancy is important for women's health. The purpose of this study was to assess articles and advertisements related to weight loss in three widely read parenting magazines, "Parenting School Years," "Parenting Early Years," and "Parenting," which have an estimated combined readership of approximately 24 million (mainly women readers). Almost a quarter (23.7%, n = 32) of the 135 magazine issues over a four year period included at least one feature article on weight loss. A variety of topics were covered in the featured articles, with the most frequent topics being on losing weight to please yourself (25.2%), healthy ways to lose weight (21.1%), and how to keep the weight off (14.7%). Less than half (45.9%) of the articles displayed author credentials, such as their degree, qualifications, or expertise. A fifth (20.0%, n = 27) of the magazines included at least one prominent advertisement for weight loss products. Almost half (46.9%) of the weight loss advertisements were for weight loss programs followed by weight loss food products (25.0%), weight loss aids (21.9%), and only 6.2% of the advertisements for weight loss were on fitness. Parenting magazines should advocate for healthy weight loss, including lifestyle changes for sustained health.

Obesity: physiologic changes and implications for preoperative management

The proportion of patients defined as obese continues to grow in many westernized nations, particularly the United States (USA). This trend has shifted the perioperative management of obese patients into the realm of routine care. As obese patients present for all types of procedures, it is crucial for anesthesiologists, surgeons, internists, and perioperative health care providers alike to have a firm understanding of their altered multi-organ physiology in order to safely prepare the obese patient for an operation. A careful preoperative evaluation may also serve to identify risk factors for postoperative adverse events. Subsequently, preoperative measures may be implemented to mitigate these complications. In this manuscript we address the major considerations for the preoperative evaluation of the severely obese patient.

Influence of body mass index and age on functional outcomes in patients with subarachnoid hemorrhage

BACKGROUND

Recent studies have highlighted the obesity paradox where patients with obesity have a greater chance of survival than patients with normal weight.

OBJECTIVE

To investigate the association between body mass index (BMI) and age with severity of subarachnoid hemorrhage (SAH) and functional outcome.

METHODS

We retrospectively reviewed the charts of 274 consecutive patients admitted with SAH between June 2008 and June 2012. Data collected included patient demographic features (age, sex, BMI), severity of SAH at admission (Fisher grade, Hunt and Hess grade, Glasgow Coma Scale score, and the World Federation of Neurosurgeons Scale score), as well as functional outcome measured by the modified Rankin Scale (mRS) by death or discharge.

RESULTS

The median age was 57 years (range, 18-99), and 62% were female; the median BMI was 27 (range, 14.3-55.1). On multivariate analysis adjusting for age and sex, there was no evidence of an association between BMI and Hunt and Hess grade, Fisher grade, World Federation of Neurosurgeons Scale score, Glasgow Coma Scale score, or mRS score (all P≥.17). On multivariate analysis adjusting for BMI and sex, there was evidence of a higher mRS score (P<.001) and lower WFNS grade (P=.016) in older patients, with no significant association observed between age and the remaining 3 measures of SAH severity (all P≥.10).

CONCLUSION

The results of our study indicate that BMI is not noticeably associated with severity of bleeding or functional outcome in patients with SAH. This finding was discovered after performing a multivariate analysis adjusting for age where older age was associated with worsened severity and outcome.

Ethnic disparities among food sources of energy and nutrients of public health concern and nutrients to limit in adults in the United States: NHANES 2003-2006

Background

Identification of current food sources of energy and nutrients among US non-Hispanic whites (NHW), non-Hispanic blacks (NHB), and Mexican American (MA) adults is needed to help with public health efforts in implementing culturally sensitive and feasible dietary recommendations.

Objective

The objective of this study was to determine the food sources of energy and nutrients to limit [saturated fatty acids (SFA), added sugars, and sodium] and nutrients of public health concern (dietary fiber, vitamin D, calcium, and potassium) by NHW, NHB, and MA adults.

Design

This was a cross-sectional analysis of a nationally representative sample of NWH (n=4,811), NHB (2,062), and MA (n=1,950) adults 19+ years. The 2003–2006 NHANES 24-h recall (Day 1) dietary intake data were analyzed. An updated USDA Dietary Source Nutrient Database was developed using current food composition databases. Food grouping included ingredients from disaggregated mixtures. Mean energy and nutrient intakes from food sources were sample-weighted. Percentages of total dietary intake contributed from food sources were ranked.

Results

Multiple differences in intake among ethnic groups were seen for energy and all nutrients examined. For example, energy intake was higher in MA as compared to NHB; SFA, added sugars, and sodium intakes were higher in NHW than NHB; dietary fiber was highest in MA and lowest in NHB; vitamin D was highest in NHW; calcium was lowest in NHB; and potassium was higher in NHW as compared to NHB. Food sources of these nutrients also varied.

Conclusion

Identification of intake of nutrients to limit and of public health concern can help health professionals implement appropriate dietary recommendations and plan interventions that are ethnically appropriate.

A positive association between stroke risk and sarcopenia in men aged ≥ 50 years, but not women: results from the Korean National Health and Nutrition Examination Survey 2008-2010

BACKGROUND AND AIMS

Sarcopenia, the loss of skeletal muscle mass and strength, develops with aging and may be a pivotal risk factor in individual cardiovascular diseases (CVDs). We examined whether sarcopenia was positively associated with the prevalence of CVDs, including angina pectoris, myocardial infarction, and stroke, in adults of each gender aged ≥50 years, independent of other covariates and possible confounders.

METHODS AND RESULTS

This cross-sectional study included 3,009 men and 4,199 women aged ≥550 years who participated in the 2008-2010 Korean National Health and Nutrition Examination Survey. Sarcopenia was defined as appendicular skeletal muscle mass/body weight <1 (moderate) or 2 (severe) standard deviations below gender-specific means for young adults. CVD prevalence was positively associated with sarcopenia in men after adjusting for confounders involved in CVD risk factors (Class I, OR=1.847 and Class II, OR=2.347; P<0.05). However, no such association was found in women. Furthermore, for individual CVDs, a strong positive association between stroke and sarcopenia (Class I, OR=1.734 and Class II, OR=3.725; P<0.05) and a moderate association between angina pectoris and sarcopenia (Class I, OR=1.988 and Class II, OR=1.347; P<0.05) were observed in men only. Interestingly, only the estimated homeostasis model assessment of insulin resistance was greater in men with moderate and severe sarcopenia than in those with normal states, whereas only serum total cholesterol levels were significantly higher in women with severe sarcopenia than in those with normal states. In both genders, serum 25-hydroxyvitamin D levels were significantly lower in moderate and severe sarcopenic states.

CONCLUSIONS

men aged ≥50 years with sarcopenia showed elevated prevalence of CVDs, especially stroke, in a representative sample of the general South Korean population.

Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association

The aim of this updated guideline is to provide comprehensive and timely evidence-based recommendations on the prevention of future stroke among survivors of ischemic stroke or transient ischemic attack. The guideline is addressed to all clinicians who manage secondary prevention for these patients. Evidence-based recommendations are provided for control of risk factors, intervention for vascular obstruction, antithrombotic therapy for cardioembolism, and antiplatelet therapy for noncardioembolic stroke. Recommendations are also provided for the prevention of recurrent stroke in a variety of specific circumstances, including aortic arch atherosclerosis, arterial dissection, patent foramen ovale, hyperhomocysteinemia, hypercoagulable states, antiphospholipid antibody syndrome, sickle cell disease, cerebral venous sinus thrombosis, and pregnancy. Special sections address use of antithrombotic and anticoagulation therapy after an intracranial hemorrhage and implementation of guidelines.

Obesity-associated nonalcoholic fatty liver disease

Obesity is strongly associated with the prevalence of nonalcoholic fatty liver disease (NAFLD) in adult and pediatric populations. Nutrition, physical activity, and behavioral modifications are critical components of the treatment regimen for all obese patients with NAFLD. Bariatric surgeries that affect or restrict the flow of food through the gastrointestinal tract may improve liver histology in morbidly obese patients with nonalcoholic steatohepatitis (NASH), although randomized clinical trials and quasi-randomized clinical studies are lacking. Early detection of NASH and hepatic fibrosis using noninvasive biochemical and imaging markers that may replace liver biopsy is the current challenge.

Obesity and the risk of intracerebral hemorrhage: the multicenter study on cerebral hemorrhage in Italy

BACKGROUND AND PURPOSE

The effect of obesity on the risk of intracerebral hemorrhage (ICH) may depend on the pathophysiology of vessel damage. To further address this issue, we investigated and quantified the correlations between obesity and obesity-related conditions in the causal pathways leading to ICH.

METHODS

A total of 777 ICH cases ≥ 55 years of age (287 lobar ICH and 490 deep ICH) were consecutively enrolled as part of the Multicenter Study on Cerebral Hemorrhage in Italy and compared with 2083 control subjects by a multivariate path analysis model. Separate analyses were conducted for deep and lobar ICH.

RESULTS

Obesity was not independently associated with an increased risk of lobar ICH (odds ratio [OR], 0.76; 95% confidence interval [CI], 0.58-1.01) or deep ICH (OR, 1.18; 95% CI, 0.95-1.45) when compared with control subjects. The path analysis confirmed the nonsignificant total effect of obesity on the risk of lobar ICH (OR, 0.77; 95% CI, 0.58-1.02) but demonstrated a significant indirect effect on the risk of deep ICH (OR, 1.28; 95% CI, 1.03-1.57), mostly determined by hypertension (OR, 1.07; 95% CI, 1.04-1.11) and diabetes mellitus (OR, 1.04; 95% CI, 1.01-1.07). Obesity was also associated with an increased risk of deep ICH when compared with lobar ICH (OR, 1.62; 95% CI, 1.14-2.31).

CONCLUSIONS

Obesity increases the risk of deep ICH, mostly through an indirect effect on hypertension and other intermediate obesity-related comorbidities, but has no major influence on the risk of lobar ICH. This supports the hypothesis of different, vessel-specific, biological mechanisms underlying the relationship between obesity and cerebral hemorrhage.