Association of 100% fruit juice consumption and 3-year weight change among postmenopausal women in the in the Women's Health Initiative

Consumption of 100% Fruit Juice and Body Weight in Children and Adults: A Systematic Review and Meta-Analysis

Importance

Concerns have been raised that frequent consumption of 100% fruit juice may promote weight gain. Current evidence on fruit juice and weight gain has yielded mixed findings from both observational studies and clinical trials.

Objective

To synthesize the available evidence on 100% fruit juice consumption and body weight in children and adults.

Data Sources

MEDLINE, Embase, and Cochrane databases were searched through May 18, 2023.

Study Selection

Prospective cohort studies of at least 6 months and randomized clinical trials (RCTs) of at least 2 weeks assessing the association of 100% fruit juice with body weight change in children and adults were included. In the trials, fruit juices were compared with noncaloric controls.

Data Extraction and Synthesis

Data were pooled using random-effects models and presented as β coefficients with 95% CIs for cohort studies and mean differences (MDs) with 95% CIs for RCTs.

Main Outcomes and Measures

Change in body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) was assessed in children and change in body weight in adults.

Results

A total of 42 eligible studies were included in this analysis, including 17 among children (17 cohorts; 0 RCTs; 45 851 children; median [IQR] age, 8 [1-15] years) and 25 among adults (6 cohorts; 19 RCTs; 268 095 adults; median [IQR] age among cohort studies, 48 [41-61] years; median [IQR] age among RCTs, 42 [25-59]). Among cohort studies in children, each additional serving per day of 100% fruit juice was associated with a 0.03 (95% CI, 0.01-0.05) higher BMI change. Among cohort studies in adults, studies that did not adjust for energy showed greater body weight gain (0.21 kg; 95% CI, 0.15-0.27 kg) than studies that did adjust for energy intake (-0.08 kg; 95% CI, -0.11 to -0.05 kg; P for meta-regression <.001). RCTs in adults found no significant association of assignment to 100% fruit juice with body weight but the CI was wide (MD, -0.53 kg; 95% CI, -1.55 to 0.48 kg).

Conclusion and Relevance

Based on the available evidence from prospective cohort studies, in this systematic review and meta-analysis, 1 serving per day of 100% fruit juice was associated with BMI gain among children. Findings in adults found a significant association among studies unadjusted for total energy, suggesting potential mediation by calories. Further trials of 100% fruit juice and body weight are desirable. Our findings support guidance to limit consumption of fruit juice to prevent intake of excess calories and weight gain.

Change analysis for intermediate disease markers in nutritional epidemiology: a causal inference perspective

BACKGROUND

Several approaches are commonly used to estimate the effect of diet on changes of various intermediate disease markers in prospective studies, including "change-score analysis", "concurrent change-change analysis" and "lagged change-change analysis". Although empirical evidence suggests that concurrent change-change analysis is most robust, consistent, and biologically plausible, in-depth dissection and comparison of these approaches from a causal inference perspective is lacking. We intend to explicitly elucidate and compare the underlying causal model, causal estimand and interpretation of these approaches, intuitively illustrate it with directed acyclic graph (DAG), and further clarify strengths and limitations of the recommended concurrent change-change analysis through simulations.

METHODS

Causal model and DAG are deployed to clarify the causal estimand and interpretation of each approach theoretically. Monte Carlo simulation is used to explore the performance of distinct approaches under different extents of time-invariant heterogeneity and the performance of concurrent change-change analysis when its causal identification assumptions are violated.

RESULTS

Concurrent change-change analysis targets the contemporaneous effect of exposure on outcome (measured at the same survey wave), which is more relevant and plausible in studying the associations of diet and intermediate biomarkers in prospective studies, while change-score analysis and lagged change-change analysis target the effect of exposure on outcome after one-period timespan (typically several years). Concurrent change-change analysis always yields unbiased estimates even with severe unobserved time-invariant confounding, while the other two approaches are always biased even without time-invariant heterogeneity. However, concurrent change-change analysis produces almost linearly increasing estimation bias with violation of its causal identification assumptions becoming more serious.

CONCLUSIONS

Concurrent change-change analysis might be the most superior method in studying the diet and intermediate biomarkers in prospective studies, which targets the most plausible estimand and circumvents the bias from unobserved individual heterogeneity. Importantly, careful examination of the vital identification assumptions behind it should be underscored before applying this promising method.

Association of health behaviors, dietary habits, and oral health with weight gain after 20 years of age in community-dwelling Japanese individuals aged 40 years and older: a cross-sectional study

OBJECTIVES

This cross-sectional study investigated the factors associated with weight gain ≥ 10 kg after 20 years of age in the general Japanese population, with a focus on the number of teeth.

MATERIALS AND METHODS

We included individuals aged ≥ 40 years from Yamagata prefecture, Japan from 2017-2021. A postal survey was conducted using a self-administered questionnaire; 5,940 participants were included in the final analysis. The questionnaire included items on lifestyle factors, medical history, physical and mental conditions, oral health, and dietary intake. A multivariate logistic regression analysis was used to identify independent associations between weight gain ≥ 10 kg after 20 years of age and various parameters; adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were estimated.

RESULTS

Less than 20 teeth, male sex, drinking habit frequency, eating very fast or fast, and a higher frequency of eating-away-from-home were significant factors associated with weight gain ≥ 10 kg after 20 years of age; individuals with < 20 versus > 20 teeth exhibited a 1.35-fold higher OR (95% CI 1.15-1.59; p < 0.01).

CONCLUSIONS

Our results suggest that having < 20 teeth may affect weight gain ≥ 10 kg after 20 years of age. However, owing to the cross-sectional study design, causality could not be determined. Therefore, maintaining healthy lifestyle behaviors to avoid tooth loss may also affect weight gain ≥ 10 kg after 20 years of age.

CLINICAL RELEVANCE

Having < 20 teeth has the potential to affect long-term weight gain after 20 years of age.

Sugar-sweetened beverage consumption and weight gain in children and adults: a systematic review and meta-analysis of prospective cohort studies and randomized controlled trials

BACKGROUND

Sugar-sweetened beverages (SSBs) have been implicated in fueling the obesity epidemic.

OBJECTIVES

This study aimed to update a synthesis of the evidence on SSBs and weight gain in children and adults.

METHODS

MEDLINE, Embase, and Cochrane databases were searched through September 8, 2022, for prospective cohort studies and randomized controlled trials (RCTs) that evaluated intake of SSBs in relation to BMI and body weight in children and adults, respectively. Eligible interventions were compared against a noncaloric control. Study-level estimates were pooled using random-effects meta-analysis and presented as β-coefficients with 95% CIs for cohorts and weighted mean differences (MDs) with 95% CIs for RCTs.

RESULTS

We identified 85 articles including 48 in children (40 cohorts, n = 91,713; 8 RCTs, n = 2783) and 37 in adults (21 cohorts, n = 448,661; 16 RCTs, n = 1343). Among cohort studies, each serving/day increase in SSB intake was associated with a 0.07-kg/m² (95% CI: 0.04 kg/m², 0.10 kg/m²) higher BMI in children and a 0.42-kg (95% CI: 0.26 kg, 0.58 kg) higher body weight in adults. RCTs in children indicated less BMI gain with SSB reduction interventions compared with control (MD: -0.21 kg/m²; 95% CI: -0.40 kg/m², -0.01 kg/m²). In adults, randomization to addition of SSBs to the diet led to greater body weight gain (MD: 0.83 kg; 95% CI: 0.47 kg, 1.19 kg), and subtraction of SSBs led to weight loss (MD: -0.49 kg; 95% CI: -0.66 kg, -0.32 kg) compared with the control groups. A positive linear dose-response association between SSB consumption and weight gain was found in all outcomes assessed.

CONCLUSIONS

Our updated systematic review and meta-analysis expands on prior evidence to confirm that SSB consumption promotes higher BMI and body weight in both children and adults, underscoring the importance of dietary guidance and public policy strategies to limit intake. This meta-analysis was registered at the International Prospective Register of Systematic Reviews as CRD42020209915.

The Association Between Consumption of 100% Fruit Juice and Risk of Age-Related Macular Degeneration: Data From the National Health and Nutrition Examination Survey Database

Age-related macular degeneration (AMD) is the main irreversible blindness disease worldwide. The current study aimed to investigate whether the consumption of 100% fruit juice increases the risk of age-related macular degeneration and find approaches to prevent and reduce the development of age-related macular degeneration from the aspect of dietary habits. A cross-sectional clinical study design was adopted. We screened participants from the 2005 to 2006 NHANES database. The logistic regression model was used to evaluate the relationship between 100% fruit juice consumption and advanced AMD and to adjust variables such as demographics, general health status, body mass index (BMI), health-related behaviors, systemic complications, and ophthalmic complications. The results show that 100% fruit juice consumption did not affect early AMD and any AMD. High consumers of 100% fruit juice are more likely to develop advanced age-related macular degeneration than those who never drink 100% fruit juice.

Tolerable upper intake level for dietary sugars

Following a request from five European Nordic countries, the EFSA Panel on Nutrition, Novel Foods and Food Allergens (NDA) was tasked to provide scientific advice on a tolerable upper intake level (UL) or a safe level of intake for dietary (total/added/free) sugars based on available data on chronic metabolic diseases, pregnancy-related endpoints and dental caries. Specific sugar types (fructose) and sources of sugars were also addressed. The intake of dietary sugars is a well-established hazard in relation to dental caries in humans. Based on a systematic review of the literature, prospective cohort studies do not support a positive relationship between the intake of dietary sugars, in isocaloric exchange with other macronutrients, and any of the chronic metabolic diseases or pregnancy-related endpoints assessed. Based on randomised control trials on surrogate disease endpoints, there is evidence for a positive and causal relationship between the intake of added/free sugars and risk of some chronic metabolic diseases: The level of certainty is moderate for obesity and dyslipidaemia (> 50-75% probability), low for non-alcoholic fatty liver disease and type 2 diabetes (> 15-50% probability) and very low for hypertension (0-15% probability). Health effects of added vs. free sugars could not be compared. A level of sugars intake at which the risk of dental caries/chronic metabolic diseases is not increased could not be identified over the range of observed intakes, and thus, a UL or a safe level of intake could not be set. Based on available data and related uncertainties, the intake of added and free sugars should be as low as possible in the context of a nutritionally adequate diet. Decreasing the intake of added and free sugars would decrease the intake of total sugars to a similar extent. This opinion can assist EU Member States in setting national goals/recommendations.

100% Fruit juice intake and cardiovascular risk: a systematic review and meta-analysis of prospective and randomised controlled studies

PURPOSE

The relationship between 100% fruit juice (100%FJ) consumption and cardiovascular risk is object of debate: indeed, recently published investigations provided new but discrepant evidence on this important question and International dietary guidelines are not in agreement on recommendations about fruit juice consumption. Therefore, we performed a meta-analysis of the prospective studies and the randomised controlled trials (RCTs) that explored the relationship between 100%FJ intake, cardiovascular risk profile and risk of cardiovascular events.

METHODS

We performed a systematic search of publications up to August 2019. Summary relative risks and exploration of linearity of the association were estimated for prospective studies and summary mean differences (MDs) calculated for RCTs.

RESULTS

A total of 21 prospective studies and 35 RCTs met the inclusion criteria. Dose-response analysis detected a significant inverse association between low-moderate 100%FJ consumption and risk of stroke (up to 200 ml/day) or total CV events (up to 170 ml/day) compared with no consumption, with a non-linear relationship (p for non-linearity < 0.05). No significant association was found for coronary heart disease and diabetes risk. In RCTs, a favorable and significant effect of 100%FJ intake was detected on blood pressure (systolic, MD: - 3.14 mmHg; diastolic, MD: - 1.68 mmHg), arterial compliance (carotid-femoral pulse wave velocity, - 0.38 m/s) and endothelial function (flow-mediated dilation, 2.10%). Neutral effects were found on body weight, blood lipids and glucose metabolism.

CONCLUSIONS

The results of these analyses indicate that 100%FJ consumption is not associated with higher CV risk. A non-linear inverse dose-response relationship occurs between 100%FJ consumption and CV disease, in particular for risk of stroke, probably mediated by the decrease in blood pressure.

TRIAL REGISTRATION

PROSPERO registration number (CRD42019135577).

Role of fruit juice in achieving the 5-a-day recommendation for fruit and vegetable intake

Although there is strong evidence that consumption of fruit and vegetables is associated with a reduced rate of all-cause mortality, only a minority of the population consumes 5 servings a day, and campaigns to increase intake have had limited success. This review examines whether encouraging the consumption of fruit juice might offer a step toward the 5-a-day target. Reasons given for not consuming whole fruit involve practicalities, inconvenience, and the effort required. Psychologically, what is important is not only basic information about health, but how individuals interpret their ability to implement that information. It has been argued that fruit juice avoids the problems that commonly prevent fruit consumption and thus provides a practical means of increasing intake and benefitting health through an approach with which the population can readily engage. Those arguing against consuming fruit juice emphasize that it is a source of sugar lacking fiber, yet juice provides nutrients such as vitamin C, carotenoids, and polyphenols that offer health-related benefits. Actively encouraging the daily consumption of fruit juice in public health policy could help populations achieve the 5-a-day recommendation for fruit and vegetable intake.

State-level income inequality and the odds for meeting fruit and vegetable recommendations among US adults

Background

Previous research indicates that income inequality is associated with risk for mortality, self-rated health status, chronic conditions, and health behavior, such as physical activity. However, little is known about the relationship between income inequality and dietary intake, which is a major risk factor for common chronic diseases including heart disease, stroke, diabetes, and certain types of cancers. The objective of this study is to determine the association between US state income inequality and fruit and vegetable consumption among adults.

Methods

Cross-sectional data on 270,612 U.S. adults from the U.S. 2013 Behavioral Risk Factor Surveillance System was used. Fruit and vegetable consumption was assessed from the six-item fruit and vegetable frequency questionnaire, which is part of the Behavioral Risk Factor Surveillance System. Multilevel modeling was used to determine whether US state-level income inequality (measured by the z-transformation of the Gini coefficient) was associated with fruit and vegetable consumption adjusting for individual-level and state-level covariates.

Results

In comparison to men, women were more likely to consume fruits and vegetables ≥5 times daily, fruits ≥2 times daily, vegetables ≥3 times of daily, and less likely to consume fruit juice daily. Among both men and women, a standard deviation increase in Gini coefficient was associated with an increase in consuming fruit juice daily (OR = 1.07, 95% CI = 1.03, 1.11). However, among women, a standard deviation increase in Gini coefficient was associated with a decreased likelihood in meeting daily recommended levels of both fruits and vegetables (OR = 0.93; 0.87–0.99), fruits only (OR = 0.95; 95% CI, 0.92–0.99) and vegetables only (OR = 0.92; 95% CI, 0.89–0.96).

Conclusions

This study is one of the first to show the relationship between income inequality and fruit and vegetable consumption among U.S. adults empirically. Women’s health is more likely to be detrimentally affected when living in a state with higher income inequality.

Dietary citrus and/or its extracts intake contributed to weight control: Evidence from a systematic review and meta-analysis of 13 randomized clinical trials

Randomized controlled trials, being published in English and investigating the associations of at least 4 weeks intervention of citrus and/or its extracts on weight loss among adults, were searched from PubMed, Web of Science, Scopus, and Cochrane by June 2019 to conduct a meta-analysis. Thirteen articles, including 921 participants, were selected and evaluated by modified Jadad scale. Pooled results by the random-effects model showed that citrus and/or its extracts administration significantly reduced 1.280 kg body weight (95% CI: -1.818 to -0.741, p = 0.000, I2 = 81.4%), 0.322 kg/m2 BMI (95% CI: -0.599 to -0.046, p = 0.022, I2 = 87.0%), 2.185 cm WC (95% CI: -3.804 to -0.566, p = 0.008, I2 = 98.3%), and 2.137 cm HC (95% CI: -3.775 to -0.500, p = 0.011, I2 = 96.2%), respectively, but no significantly decreased effects on WHR and body fat were observed. Subgroup analysis deduced the different effects of study location, intervention duration on body weight associated indices. No publication bias was observed. Our meta-analysis supported the beneficial effects of citrus and/or its extracts supplement on body weight control, and future well-designed studies are required to firmly establish the clinical efficacy of citrus and/or its extracts intervention on body weight.

A Comprehensive Critical Assessment of Increased Fruit and Vegetable Intake on Weight Loss in Women

No previous reviews or meta-analyses have specifically assessed the effects of increased fruit and vegetable (FV) intake on weight loss with a primary focus on women. Several studies show differences between men and women in how increased FV intake affects their weight loss and maintenance, risk of becoming overweight or obese, and the influence of eating speed and frequency on weight control. This analysis provides a comprehensive and visual assessment of the effects of increasing FV intake and long-term weight change from observational studies and weight loss from randomized controlled trials (RCTs) in women. Consistent evidence from prospective studies and RCTs shows that increased intake of FV is a chief contributor to weight loss in women. This effect is enhanced with concurrent dietary restriction of high energy density (ED) or high-fat foods. Yet, the type of FV differentially impacts weight loss in women. Whole FV intake may influence weight through a variety of mechanisms including a reduction in eating rate, providing a satisfying, very-low to low energy density, low glycemic load or low-fat content. Also, FV are the primary source of dietary fiber, which can provide additional support for weight loss in women when consumed at adequate levels.

Association between soft drink, fruit juice consumption and obesity in Eastern Europe: cross-sectional and longitudinal analysis of the HAPIEE study

BACKGROUND

Fruit juice and soft drink consumption have been shown to be related to obesity. However, this relationship has not been explored in Eastern Europe. The present study aimed to assess the cross-sectional and longitudinal relationships between fruit juice, soft drink consumption and body mass index (BMI) in Eastern European cohorts.

METHODS

Data from the Health, Alcohol and Psychosocial factors in Eastern Europe population-based prospective cohort study, based in Russia, Poland and the Czech Republic, were used. Intakes of sugar-sweetened beverage (SSB), artificially-sweetened beverage (ASB) and fruit juice were estimated from a food frequency questionnaire. Participant BMI values were assessed at baseline (n = 26 634) and after a 3-year follow-up (data available only for Russia, n = 5205).

RESULTS

Soft drink consumption was generally low, particularly in Russia. Compared to never drinkers of SSB, participants who drank SSB every day had a significantly higher BMI in the Czech [β-coefficient = 0.28; 95% confidence interval (CI) = 0.02-0.54], Russian (β-coefficient = 1.38; 95% CI = 0.62-2.15) and Polish (β-coefficient = 0.83; 95% CI = 0.29-1.37) cohorts. Occasional or daily ASB consumption was also positively associated with BMI in all three cohorts. Results for daily fruit juice intake were inconsistent, with a positive association amongst Russians (β-coefficient = 0.75; 95% CI = 0.28-1.21) but a negative trend in the Czech Republic (β-coefficient = -0.42; 95% CI = -0.86 to 0.02). Russians participants who drank SSB or ASB had an increased BMI after follow-up.

CONCLUSIONS

Our findings support previous studies suggesting that soft drink consumption (including SSBs and ASBs) is positively related to BMI, whereas our results for fruit juice were less consistent. Policies regarding these beverages should be considered in Eastern Europe to lower the risk of obesity.

Intake of 100% Fruit Juice Is Associated with Improved Diet Quality of Adults: NHANES 2013-2016 Analysis

Fruit intake is generally associated with better diet quality and overall health. This report examined the effect of 100% fruit juice (considered a part of total fruit servings) and its replacement with whole fruits equivalents on nutrient intake and diet quality. National Health and Nutrition Examination Survey 2013-2016 data (24-h dietary recall) from adults 19+ years (n = 10,112) were used to assess the diet quality and nutrient intakes and to isocalorically replace with 100% fruit juice intakes whole fruit equivalents in a modeling analysis. About 15.6% adults were 100% fruit juice consumers. Consumers had higher diet quality (10% higher Healthy Eating Index, HEI 2015 score), and higher intakes of energy, calcium, magnesium, potassium, vitamin C and vitamin D than non-consumers. Consumption of 100% fruit juice was also associated with lower risk of being overweight/obese (-22%) and having metabolic syndrome (-27%). Replacing 100% fruit juice with whole fruits equivalents did not affect nutrient intake except for a modest increase (+6.4%) in dietary fiber. Results show that 100% fruit juice intake was associated with better diet quality and higher nutrient intake. Replacement of 100% fruit juice intake with whole fruits equivalents had no significant effect on nutrients except for dietary fiber.

Frequency of Consumption of Whole Fruit, Not Fruit Juice, Is Associated with Reduced Prevalence of Obesity in Korean Adults

BACKGROUND

Fruit consumption is known to be beneficial to health. However, the health benefits of fruit juice are controversial due to its high sugar content.

OBJECTIVES

To examine the associations of frequency of consumption of whole fruit and fruit juice with obesity and metabolic syndrome.

DESIGN

This cross-sectional study used data from the 2012-2015 Korea National Health and Nutrition Examination Survey.

PARTICIPANTS

A total of 10,460 adults (4,082 men and 6,378 women) aged 19 to 64 years were included in the study.

MAIN OUTCOME MEASURES

Frequency of consumption of whole fruit and fruit juice was evaluated using a food frequency questionnaire, and dietary sugar intake was calculated using a 24-hour recall. Obesity and abdominal obesity were determined using body mass index and waist circumference, respectively. Metabolic syndrome was defined on the basis of the National Cholesterol Education Program Adult Treatment Panel III.

STATISTICAL ANALYSES PERFORMED

Multiple logistic regression analysis was performed to examine the associations between frequency of whole fruit or fruit juice consumption and obesity and metabolic syndrome abnormalities.

RESULTS

The percentage of participants who consumed whole fruit daily was 32.6%, whereas 52.3% consumed fruit juice rarely. The average intake of total sugars was 14.9% of total energy, which was within the recommend range (<20% of total energy) for Koreans. Consuming whole fruit ≥1 time/day was associated with reduced prevalence of obesity, abdominal obesity, and elevated blood pressure compared with consuming whole fruit ≤1 time/wk. However, frequency of fruit juice consumption showed no association with obesity, abdominal obesity, and metabolic syndrome.

CONCLUSIONS

Frequency of whole fruit consumption was associated with reduced prevalence of obesity and metabolic syndrome abnormalities among Korean adults with average total sugar intake within the recommended range.

Whole Fruits and Fruit Fiber Emerging Health Effects

Less than 10% of most Western populations consume adequate levels of whole fruits and dietary fiber with typical intake being about half of the recommended levels. Evidence of the beneficial health effects of consuming adequate levels of whole fruits has been steadily growing, especially regarding their bioactive fiber prebiotic effects and role in improved weight control, wellness and healthy aging. The primary aim of this narrative review article is to examine the increasing number of health benefits which are associated with the adequate intake of whole fruits, especially fruit fiber, throughout the human lifecycle. These potential health benefits include: protecting colonic gastrointestinal health (e.g., constipation, irritable bowel syndrome, inflammatory bowel diseases, and diverticular disease); promoting long-term weight management; reducing risk of cardiovascular disease, type 2 diabetes and metabolic syndrome; defending against colorectal and lung cancers; improving odds of successful aging; reducing the severity of asthma and chronic obstructive pulmonary disease; enhancing psychological well-being and lowering the risk of depression; contributing to higher bone mineral density in children and adults; reducing risk of seborrheic dermatitis; and helping to attenuate autism spectrum disorder severity. Low whole fruit intake represents a potentially more serious global population health threat than previously recognized, especially in light of the emerging research on whole fruit and fruit fiber health benefits.

Preventing Lethal Prostate Cancer with Diet, Supplements, and Rx: Heart Healthy Continues to Be Prostate Healthy and "First Do No Harm" Part I

PURPOSE OF REVIEW

To discuss the overall and latest observations of the effect of diet, lifestyle, supplements, and some prescription heart healthy medications for prostate cancer prevention.

RECENT FINDINGS

The concept of maximizing heart health to prevent aggressive prostate cancer continues to be solidified with the addition of more prospective observational and randomized controlled trial data. Heart healthy is prostate healthy, but heart unhealthy is prostate unhealthy. The primary goal of reducing the risk of all-cause and cardiovascular disease (CVD) morbidity and mortality also allows for maximizing prostate cancer prevention. The obesity epidemic in children and adults along with recent diverse research has only strengthened the nexus between heart and prostate health. Greater dietary adherence toward a variety of healthy foods is associated with a graded improved probability of CVD and potentially aggressive cancer risk reduction. Preventing prostate cancer via dietary supplements should encourage a "first do no harm", or less is more approach until future evidence can reverse the concerning trend that more supplementation has resulted in either no impact or an increased risk of prostate cancer. Supplements to reduce side effects of some cancer treatments appear to have more encouraging data. Medications that improve heart health including statins, aspirin, and metformin (S.A.M.), and specific beta-blocker medications are primarily generic or low-cost and should continue to garner research interest. A watershed moment in medical education has arrived where the past perception of a diverse number of trees seemingly separated by vast distances, in reality, now appear to exist within the same forest.