Postmenopausal health interventions: Time to move on from the Women's Health Initiative?

Menopause is a critical period during which, without timely interventions, increased risks of cardiovascular and metabolic diseases, osteoporosis, sexual dysfunction and premature cognitive decline will contribute to diminished quality-of-life in women. Hormone therapy (HT) used to be the standard of care for managing vasomotor symptoms and prevention of chronic diseases until publication of the Women's Health Initiative (WHI) in 2002. Concerned about risks highlighted in WHI publications, many symptomatic women promptly ceased HT which resulted in increased vasomotor symptoms, osteoporosis-related-fractures and insomnia. Data from post-hoc WHI analyses and newer clinical trials consistently show reductions in coronary heart disease and mortality when estrogen therapy is initiated soon after menopause, whereas administration in later years and/or in combination with progesterone carries increased risks. However, no validated primary preventive strategies are available for younger postmenopausal women (<60 years), highlighting the need to re-evaluate the use of estrogen alone for which the risk-benefit balance appears positive. In contrast, in older women (>60 years), risks associated with oral HT exceed benefits; however transdermal estrogen may offer a safer alternative and should be further evaluated. Alternative therapies such as phytoestrogens and non-hormonal prescriptions may be beneficial for older women or those who are unsuitable for HT. Long-term head-to-head comparisons of HT with alternative interventions are warranted to confirm their efficacy for chronic disease prevention.

Comparison of two low-fat diets, differing in protein and carbohydrate, on psychological wellbeing in adults with obesity and type 2 diabetes: a randomised clinical trial

Background

Although higher-protein diets (HP) can assist with weight loss and glycemic control, their effect on psychological wellbeing has not been established. The objective of this study was to compare the effects of a HP and a higher-carbohydrate diet (HC), combined with regular exercise, on psychological wellbeing both during weight loss (WL) and weight maintenance phases (WM).

Methods

In a parallel RCT, 61 adults with T2D (mean ± SD: BMI 34.3 ± 5.1 kg/m², aged 55 ± 8 years) consumed a HP diet (29% protein, 34% carbohydrate, 31% fat) or an isocaloric HC diet (21%:48%:24%), with moderate intensity exercise, for 12 weeks of WL and 12 weeks of WM. Secondary data evaluating psychological wellbeing was assessed using: Problems Areas in Diabetes (PAID); Diabetes-39 Quality of Life (D-39); Short Form Health Survey (SF-36); Perceived Stress Scale-10 (PSS-10) and the Leeds Sleep Evaluation Questionnaire (LSEQ) at Weeks 0, 12 and 24 and evaluated with mixed models analysis.

Results

Independent of diet, improvements for PAID; D-39 diabetes control; D-39 severity of diabetes; SF-36 physical functioning and SF-36 general health were found following WL (d = 0.30 to 0.69, P ≤ 0.04 for all) which remained after 12 weeks of WM. SF-36 vitality improved more in the HP group (group x time interaction P = 0.03). Associations were seen between HbA1c and D-39 severity of diabetes rating (r = 0.30, P = 0.01) and SF-36 mental health (r = − 0.32, P = 0.003) and between weight loss and PAID (r = 0.30, P = 0.01).

Conclusion

Several improvements in diabetes-related and general psychological wellbeing were seen similarly for both diets following weight loss and a reduction in HbA1c with most of these improvements remaining when weight loss was sustained for 12 weeks. A HP diet may provide additional increases in vitality.

Trial registration

The trial was prospectively registered with the Australian New Zealand Clinical Trials Registry (ACTRN 12613000008729) on 4 January 2013.

Can Curcumin Counteract Cognitive Decline? Clinical Trial Evidence and Rationale for Combining ω-3 Fatty Acids with Curcumin

The rate of cognitive decline in the elderly is highly variable. One potential factor contributing to accelerated cognitive decline is chronic systemic inflammation, because it has been linked to cognitive impairment and increased dementia risk. Certain lifestyle factors, such as excess body weight and sedentary behavior, can exacerbate a proinflammatory state in older adults, resulting in chronic low-grade inflammation. Supplementing the diet with curcumin, an anti-inflammatory polyphenolic compound from the curry spice turmeric, is a potential approach to prevent accelerated cognitive decline by counteracting chronic inflammatory processes. Although the anti-inflammatory effects of curcumin are well established, the potential cognitive benefits of curcumin were discovered more recently. Several animal and epidemiologic studies on the effect of curcumin supplementation on cognition showed promising results; however, randomized controlled trials in humans are limited. In this review, we identified 5 randomized controlled trials, of which only 2 observed a beneficial effect of curcumin supplementation on cognition by improving working memory. By critically examining the methodologies of those studies, we identified some limitations, one of which is that none of the studies explored the possibility that anti-inflammatory mechanisms were mediating cognitive benefits (i.e., no study tested participants with low-grade inflammation or measured inflammatory biomarkers). Other factors influencing the likelihood of conclusive outcomes include choice of study population (cognitively unimpaired compared with impaired), study duration, curcumin dose and its bioavailability, and neurocognitive test battery. On the basis of these findings, we offer recommendations for future studies to examine the potential cognitive benefits of curcumin in humans, which include evaluating its effects on cerebral endothelial vasodilator function and boosting its cognitive effects by combining it with long-chain omega-3 (n-3) fatty acids.

Impaired cerebrovascular responsiveness and cognitive performance in adults with type 2 diabetes

AIM

Cognitive deficits in type 2 diabetes mellitus (T2DM) may be partly attributable to stiffness in cerebral arteries and impaired vasodilator function, limiting the ability to increase blood flow in brain regions to meet cognitive demands. We undertook a comparison of cerebrovascular responsiveness (CVR) and cognitive performance in adults with and without T2DM.

METHODS

Older adults with (50) and without (Herath, Cherbuin, Eramudugolla, & Anstey, 2016) T2DM underwent transcranial Doppler ultrasound measurements of basal cerebral mean blood flow velocity (MBFV) and pulsatility index (PI), a measure of arterial stiffness, in the middle cerebral arteries (MCA). A battery of tasks assessing domains of working memory, executive function and information processing/motor speed was then administered while MBFV was recorded. CVR to cognitive tasks was calculated as a percentage increase in MBFV from the basal level.

RESULTS

There was no difference in basal MBFV between groups. However, PI was 14% higher in the T2DM group (P<0.05), who performed poorer across all cognitive domains assessed and displayed poorer CVR in three tasks. Cognitive performance was inversely related to the PI/MBFV ratio, an indicator of intracranial stenosis.

DISCUSSION

Impaired cerebral perfusion during mental tasks is accompanied by poor cognitive performance and stiffness in the cerebral vessels.

Low dose resveratrol improves cerebrovascular function in type 2 diabetes mellitus

BACKGROUND AND AIMS

Progressive microvascular dysfunction in type 2 diabetes mellitus (T2DM) may impair the ability of cerebral vessels to supply blood to brain regions during local metabolic demand, thereby increasing risks of dementia. Having previously demonstrated that resveratrol can enhance vasodilator function in the systemic circulation, we hypothesised that resveratrol could similarly benefit the cerebral circulation. We aimed to determine the most efficacious dose of resveratrol to improve cerebral vasodilator responsiveness (CVR) in T2DM.

METHODS AND RESULTS

In a double-blind, placebo-controlled, balanced crossover intervention, 36 dementia-free, non-insulin dependent T2DM older adults (49-78 years old) consumed single doses of synthetic trans-resveratrol (0, 75, 150, and 300 mg) at weekly intervals. Transcranial Doppler ultrasound was used to assess CVR to a hypercapnic stimulus, both before and 45 min after treatment. CVR, measured bilaterally in the middle cerebral arteries (MCA) and posterior cerebral arteries (PCA), was expressed as the percentage change in mean blood flow velocity from baseline to the peak velocity attained during hypercapnia. Resveratrol consumption increased CVR in the MCA; mean within-individual changes for each dose from placebo were 13.8 ± 3.5% for 75 mg (P = 0.001), 8.9 ± 3.5% for 150 mg (P = 0.016), and 13.7 ± 3.3% for 300 mg (P < 0.001); only the 75 mg dose was efficacious in the PCA (13.2 ± 4.5%, P = 0.016).

CONCLUSIONS

Our results provide the first clinical evidence of an acute enhancement of vasodilator responsiveness in cerebral vessels following consumption of resveratrol in this population who are known to have endothelial dysfunction and sub-clinical cognitive impairment. Importantly, maximum improvement was observed with the lowest dose used.

CLINICAL TRIAL REGISTRATION

ACTRN12614000891628 (www.anzctr.org.au).

Adiposity is related to decrements in cardiorespiratory fitness in obese and normal-weight children

BACKGROUND

Obese children are typically less physically active than their normal-weight peers and are often assumed to be 'unfit'.

OBJECTIVE

Investigate the relationships between adiposity, physical activity levels and cardiorespiratory fitness (CRF) in obese and normal-weight children. A secondary aim was to examine obese/normal-weight differences in CRF.

METHODS

Obese (N = 107) and normal-weight (N = 132) 10-13-year-olds participated. Fat-free mass (FFM), percent fat, physical activity and peak oxygen uptake (VO2peak ) were assessed. Analyses were adjusted for socioeconomic status (SES).

RESULTS

Higher percent fat was inversely associated with VO2peak normalized for mass (r = -0.780, P < 0.001) even after controlling for physical activity (r = -0.673, P < 0.001). While higher percent fat was also inversely associated with VO2peak normalized for FFM, this was only significant in males (r = -0.247, P = 0.004) and did not persist after controlling for physical activity (r = -0.059 P = 0.526). Compared with normal-weight children, obese children had higher absolute VO2peak , lower VO2peak corrected for mass (P ≤ 0.009) and lower VO2peak corrected for FFM (P = 0.041) that did not persist after controlling for SES (P = 0.086).

CONCLUSION

Obesity-related inefficiencies in CRF were evident. Higher adiposity was associated with poorer CRF relative to mass, irrespective of physical activity levels. However, low physical activity levels may be responsible for associations between adiposity and CRF relative to FFM seen in boys, indicating the importance of encouraging physical activity.

Clinical Evaluation of Effects of Chronic Resveratrol Supplementation on Cerebrovascular Function, Cognition, Mood, Physical Function and General Well-Being in Postmenopausal Women-Rationale and Study Design

Background: This methodological paper presents both a scientific rationale and a methodological approach for investigating the effects of resveratrol supplementation on mood and cognitive performance in postmenopausal women. Postmenopausal women have an increased risk of cognitive decline and dementia, which may be at least partly due to loss of beneficial effects of estrogen on the cerebrovasculature. We hypothesise that resveratrol, a phytoestrogen, may counteract this risk by enhancing cerebrovascular function and improving regional blood flow in response to cognitive demands. A clinical trial was designed to test this hypothesis. Method: Healthy postmenopausal women were recruited to participate in a randomised, double-blind, placebo-controlled (parallel comparison) dietary intervention trial to evaluate the effects of resveratrol supplementation (75 mg twice daily) on cognition, cerebrovascular responsiveness to cognitive tasks and overall well-being. They performed the following tests at baseline and after 14 weeks of supplementation: Rey Auditory Verbal Learning Test, Cambridge Semantic Memory Battery, the Double Span and the Trail Making Task. Cerebrovascular function was assessed simultaneously by monitoring blood flow velocity in the middle cerebral arteries using transcranial Doppler ultrasound. Conclusion: This trial provides a model approach to demonstrate that, by optimising circulatory function in the brain, resveratrol and other vasoactive nutrients may enhance mood and cognition and ameliorate the risk of developing dementia in postmenopausal women and other at-risk populations.

A randomised trial comparing low-fat diets differing in carbohydrate and protein ratio, combined with regular moderate intensity exercise, on glycaemic control, cardiometabolic risk factors, food cravings, cognitive function and psychological wellbeing in adults with type 2 diabetes: Study protocol

BACKGROUND

Hypocaloric low-fat diets, high in protein with moderate carbohydrate (HP) can enhance weight loss, improve glycaemic control and improve cardiometabolic health risk factors in type 2 diabetes mellitus (T2DM). However, it is unclear whether the metabolic benefits observed during weight loss are sustained during energy-balance and weight maintenance. Furthermore, there is a lack of evidence regarding the effect of HP diets on food cravings, cognitive function and psychological wellbeing in T2DM, despite carbohydrate food cravings, cognitive impairment and depression being associated with hyperglycaemia.

METHODS/DESIGN

Overweight/obese adults with T2DM were randomised to consume either a HP diet (n=32, ~32% protein, 33% carbohydrate, 30% fat) or a higher-carbohydrate diet (HC, n=29, ~22% protein, 51% carbohydrate, 22% fat) for 24 weeks with 30 min of moderate intensity exercise five days/week for the study duration. There were 2 phases: a 12 week weight loss phase followed by a 12 week weight maintenance phase. Primary outcome was glycaemic control (glycosylated haemoglobin; HbA1c). Secondary outcomes were cardiometabolic risk factors (body composition, fasting blood pressure, blood lipids, glucose, insulin and C-reactive protein), food cravings, cognitive function (memory; psychomotor and executive function and psychological well-being. Outcomes were measured at baseline and the end of each 12-week intervention phase. Data will be analysed as intention-to-treat using linear mixed effects models.

CONCLUSION

This study will examine the effects of two dietary interventions on health outcomes in T2DM during weight loss and notably following weight maintenance where there is a paucity of evidence.

Assessing premorbid cognitive ability in adults with type 2 diabetes mellitus--a review with implications for future intervention studies

Associations between type 2 diabetes mellitus (T2DM) and accelerated cognitive decline are well established. However, the sensitivity of neuropsychological tests to detect early deficits in cognitively normal adults with T2DM is unknown. This review examined cognitive domains and specific neuropsychological tests that are impaired in T2DM, based on clinically significant differences (effect sizes >0.5) between T2DM and groups without T2DM. Nine cross-sectional studies were identified which reported means and standard deviations for individual tests. Tests of executive function, working memory and psychomotor and attentional functions were found to be impaired in T2DM. Impairments of executive function and choice reaction time may have consequences for everyday functioning, in particular the risk of falls in older adults. More research on cognitive deficits in dual-task situations and how they impact everyday functioning is needed; the Trail Making Task, Symbol Digit Modalities Test, Verbal Fluency Task and tests of reaction time and processing speed could be included as core components of test batteries in future intervention studies. They could also be assessed in newly diagnosed T2DM and used to monitor progressive deterioration of cognitive function and the efficacy of therapeutic interventions on cognitive function.

Day-to-day physical functioning and disability in obese 10- to 13-year-olds

What is already known about this subject? Compared with their healthy-weight peers, children with obesity have; impaired physical health-related quality of life reduced physical activity levels reduced capacity to perform certain weight-bearing tasks in field-based fitness tests What this study adds? First investigation of obesity-related disability in children using the International Classification for Functioning, Disability and Health framework for Children and Youth. Obesity in children appears to be associated with disability impacting basic locomotor skills and physical health-related quality of life. Children's participation in key life areas related to physical functioning appears to be minimally impacted by obesity.

OBJECTIVE

The aim of this study was to investigate whether obesity is related to impaired day-to-day physical functioning and disability in children.

METHODS

An observational case-control study was conducted in three Australian states. Obese (n = 107) and healthy-weight (n = 132) 10- to 13-year-olds (132 male, 107 female) were recruited via media advertisements. Assessment of body composition (dual energy X-ray absorptiometry), locomotor capacity (six-minute walk test [6MWT], timed up and down stairs test [TUDS] and timed up and go [TUG]) and child-reported physical health-related quality of life (HRQoL) were undertaken. Participants wore an accelerometer for 8 days and completed two use-of-time telephone interviews to assess participation in key life areas.

RESULTS

Compared with their healthy-weight counterparts, obese children had lower physical HRQoL scores (P < 0.01) and reduced locomotor capacity (TUDS z-score, TUG and 6MWT; P < 0.01). Higher percent body fat was significantly related to lower physical HRQoL scores (r = -0.48, P < 0.01), slower performance times for the TUDS and TUG (r = 0.59 and 0.26 respectively, P < 0.01), shorter 6MWT distances (r = -0.51, P < 0.01) and reduced time spent in community participation activities (r = -0.23, P < 0.01).

CONCLUSIONS

As anticipated, obesity appears to undermine physical functioning in children, including the capacity to perform basic locomotor skills yet, unexpectedly, participation in key life areas related to physical functioning appeared largely unaffected.

Proximal correlates of metabolic phenotypes during 'at-risk' and 'case' stages of the metabolic disease continuum

OBJECTIVE

To examine the social and behavioural correlates of metabolic phenotypes during 'at-risk' and 'case' stages of the metabolic disease continuum.

DESIGN

Cross-sectional study of a random population sample.

PARTICIPANTS

A total of 718 community-dwelling adults (57% female), aged 18-92 years from a regional South Australian city.

MEASUREMENTS

Total body fat and lean mass and abdominal fat mass were assessed by dual energy x-ray absorptiometry. Fasting venous blood was collected in the morning for assessment of glycated haemoglobin, plasma glucose, serum triglycerides, cholesterol lipoproteins and insulin. Seated blood pressure (BP) was measured. Physical activity and smoking, alcohol and diet (96-item food frequency), sleep duration and frequency of sleep disordered breathing (SDB) symptoms, and family history of cardiometabolic disease, education, lifetime occupation and household income were assessed by questionnaire. Current medications were determined by clinical inventory.

RESULTS

36.5% were pharmacologically managed for a metabolic risk factor or had known diabetes ('cases'), otherwise were classified as the 'at-risk' population. In both 'at-risk' and 'cases', four major metabolic phenotypes were identified using principal components analysis that explained over 77% of the metabolic variance between people: fat mass/insulinemia (FMI); BP; lipidaemia/lean mass (LLM) and glycaemia (GLY). The BP phenotype was uncorrelated with other phenotypes in 'cases', whereas all phenotypes were inter-correlated in the 'at-risk'. Over and above other socioeconomic and behavioural factors, medications were the dominant correlates of all phenotypes in 'cases' and SDB symptom frequency was most strongly associated with FMI, LLM and GLY phenotypes in the 'at-risk'.

CONCLUSION

Previous research has shown FMI, LLM and GLY phenotypes to be most strongly predictive of diabetes development. Reducing SDB symptom frequency and optimising the duration of sleep may be important concomitant interventions to standard diabetes risk reduction interventions. Prospective studies are required to examine this hypothesis.

Acute resveratrol supplementation improves flow-mediated dilatation in overweight/obese individuals with mildly elevated blood pressure

BACKGROUND AND AIMS

Flow-mediated dilatation of the brachial artery (FMD) is a biomarker of endothelial function and cardiovascular health. Impaired FMD is associated with several cardiovascular risk factors including hypertension and obesity. Various food ingredients such as polyphenols have been shown to improve FMD. We investigated whether consuming resveratrol, a polyphenol found in red wine, can enhance FMD acutely and whether there is a dose-response relationship for this effect.

METHODS AND RESULTS

19 overweight/obese (BMI 25-35 kg m(-2)) men or post-menopausal women with untreated borderline hypertension (systolic BP: 130-160 mmHg or diastolic BP: 85-100 mmHg) consumed three doses of resveratrol (resVida™ 30, 90 and 270 mg) and a placebo at weekly intervals in a double-blind, randomized crossover comparison. One hour after consumption of the supplement, plasma resveratrol and FMD were measured. Data were analyzed by linear regression versus log(10) dose of resveratrol. 14 men and 5 women (age 55 ± 2 years, BMI 28.7 ± 0.5 kg m(-2), BP 141 ± 2/89 ± 1 mmHg) completed this study. There was a significant dose effect of resveratrol on plasma resveratrol concentration (P < 0.001) and on FMD (P < 0.01), which increased from 4.1 ± 0.8% (placebo) to 7.7 ± 1.5% after 270 mg resveratrol. FMD was also linearly related to log(10) plasma resveratrol concentration (P < 0.01).

CONCLUSION

Acute resveratrol consumption increased plasma resveratrol concentrations and FMD in a dose-related manner. This effect may contribute to the purported cardiovascular health benefits of grapes and red wine.

Obesity: the new childhood disability?

This review addresses the impact of obesity on paediatric physical functioning utilizing the World Health Organization International Classification of Functioning, Disability and Health Framework (ICF). The ICF encompasses functioning (as it relates to all body functions and structures), activities (undertaking a particular task) and participation (in a life situation) with disability referring to impairments in body functions/structures, activity restrictions or participation limitations. Electronic databases were searched for peer-reviewed studies published in English prior to May 2009 that examined aspects of physical functioning in children (≤18 years). Eligible studies (N = 104) were ranked by design and synthesized descriptively. Childhood obesity was found to be associated with deficits in function, including impaired cardiorespiratory fitness and performance of motor tasks; and there was some limited evidence of increased musculoskeletal pain and decrements in muscle strength, gait and balance. Health-related quality of life and the subset of physical functioning was inversely related to weight status. However, studies investigating impacts of obesity on wider activity and participation were lacking. Further research utilizing the ICF is required to identify and better characterize the effects of paediatric obesity on physical function, activity and participation, thereby improving targets for intervention to reduce disability in this population.

Anti-obesity effects of long-chain omega-3 polyunsaturated fatty acids

Animal studies suggest that increased consumption of the long-chain omega-3 polyunsaturated fatty acids, eicosapentaenoic acid and docosahexaenoic acid, can protect against the development of obesity in animals exposed to an obesogenic diet and reduce body fat when already obese. There is also evidence that increased intakes of these fatty acids can reduce body fat in humans, but human studies are relatively few and have generally been conducted over short time periods with small sample sizes, making it difficult to draw definitive conclusions. Reported reductions in body fat may result from appetite-suppressing effects, adipocyte apoptosis and changes of gene expression in skeletal muscle, heart, liver, intestine and adipose tissues that suppress fat deposition and increase fat oxidation and energy expenditure. We conclude that increased intakes of long-chain omega-3 fatty acids may improve body composition, but longer-term human studies are needed to confirm efficacy and determine whether increasing omega-3 intakes might be an effective strategy to combat obesity.