ADA: Statins for Young T1D Patients, Too?

Heart risk in 30s might warrant statin use, observational data suggest

BOSTON -- Type 1 diabetes patients younger than 40 may be candidates for statin use, as guidelines recommend after age 40, researchers suggested.

Under the American Heart Association/American College of Cardiology definition, the 10-year cardiovascular risk was about 5% for type 1 diabetes patients ages 30 to 39 and about 13% in those ages 40 to 44, Rachel G. Miller, MD, of the University of Pittsburgh, and colleagues found.

Adding coronary revascularization to that definition -- which also included cardiovascular death or nonfatal stroke or myocardial infarction -- brought the 10-year risk to nearly 7% for type 1 diabetes patients in their 30s, the group reported here at the American Diabetes Association meeting.

Although still a little shy of the 7.5% 10-year risk threshold recommended for statin treatment in the guidelines, the 20% of the cohort already on a statin before age 40 was excluded along with a number of events that happened before the start of follow-up.

"We conclude that young adults aged 30 to 39 years with 20 or less years' type 1 diabetes duration are at sufficiently high atherosclerotic cardiovascular disease risk to merit statin therapy," the group concluded in their poster presentation.

Both the AHA/ACC and the American Diabetes Association guidelines recommend statins after 40 for essentially all diabetes patients and support possible use for younger people with cardiovascular disease risk factors.

"We've been comfortable with the concept that anybody over the age of 40 with type 2 should be on a statin and by extrapolation anybody who has type 1 over the age of 40 should be recommended for statins," commented Naveed Sattar, MD, a metabolic medicine specialist at the University of Glasgow, Scotland.

"What we now need is good guidance: Who are these people under 40 with type 1 who should get a statin, and how do we recognize them?"

There isn't enough data to develop a risk score for type 1 diabetes yet, he noted. Lifetime risk might be a better criterion in that population than the 10-year risks, which are heavily predicated upon age and which underpin current guidelines, Sattar noted.

"I think in the next 2 or 3 years either from national databases within Scandinavia or Scotland we're going to have a type 1 diabetes risk score that might allow us to look at this question," he suggested.

Comparisons with the general population in the surrounding county showed huge elevations in risk with type 1 diabetes even at these early ages, but absolute event numbers were small in Miller's study.

Among the 517 people under age 45 without pre-existing atherosclerotic cardiovascular disease followed from 1996 to 2011 in the Pittsburgh Epidemiology of Diabetes Complications study (a prospective group of childhood-onset cases seen at a single center soon after diagnosis):

• One event occurred in 20- to 29-year-olds
• 18 accrued in those in their 30s
• 22 occurred in participants in their early 40s

The fatal coronary artery event and nonfatal stroke or MI rates were 134 per 100,000 in the cohort ages 20 to 29, 502 per 100,000 people in their 30s, and 1,336 per 100,000 in the 40 to 44 age range.

Sattar cautioned against overinterpreting the "very crude analysis."

Miller disclosed no relevant relationships with industry. A co-author disclosed relationships with Eli Lilly and Company and Profil Institute for Clinical Research.

Sattar disclosed relationships with Amgen, AstraZeneca, and Sanofi.

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Chocolate: is it really good for our health?

With the average American consuming around 4.5 kg of chocolate each year, it is safe to say it is one of the nation's most loved treats. It is not hard to fathom why; it tastes delicious and stimulates the release of endorphins - the "feel-good" hormones. And according to numerous studies in recent years, chocolate is amazingly good for our health... or is it?

The average American eats around 4.5 kg of chocolate annually.

In this Spotlight, we ask, can chocolate really be good for our health? Or are the potential health benefits of this much-loved treat overstated?

The 'food of the gods'

When we think of chocolate, many of us visualize a big, chunky bar of sweet deliciousness. But originally, chocolate was only consumed as a bitter beverage.

Chocolate - which is made using beans from the cacao tree, native to Central and South America - is estimated to date back as far as 1900 BC, when it was created by pre-Olmec cultures residing in present-day Mexico. The ancient Mesoamericans roasted the cacao beans, or cocoa beans, before grinding them into a paste that was mixed with hot water, vanilla, chili and other spices to make a frothy drink.

The Olmec, Aztec and Mayan civilizations found chocolate to be a mood-lifting drink and an aphrodisiac, so much so that they believed the beverage had spiritual qualities. The Mayans even worshipped a cacao God, and the beverage was used for religious and sacred ceremonies, hence why chocolate is often referred to as the "food of the gods."

It wasn't until 1847 that chocolate became the solid edible bar we know and love today. A British chocolate company called J.S Fry & Sons created it using cocoa butter - vegetable fat extracted from the cocoa bean - cocoa powder and sugar.

In the late 1800s and early 1900s, well-known chocolate manufacturers such as Hershey, Cadbury and Mars were formed, and they have been bringing us an array of heavenly sweet treats ever since.

But while we are thankful to these companies for catering to our chocolate needs, they are also responsible for adding potentially unhealthy ingredients to what could be an otherwise healthy - albeit less tasty - food, giving chocolate its reputation as a diet demon.

What is in our chocolate?

Cocoa beans - from which chocolate is made - are believed to contain more than 300 compounds that are beneficial to health.

They are packed full of flavanoids and flavanols, such as anthocyanidin and epicatechins. These are antioxidants, which are known to destroy free radicals in the body - chemicals that can cause damage to DNA and other cell components, accelerating aging and contributing to heart disease, cancer and other diseases.

The main ingredient in chocolate - cocoa beans - contains more than 300 compounds that are beneficial to health.

The darker the chocolate, the more flavanoids and flavanols it contains, which explains why the majority of chocolate studies have hailed dark chocolate - rather than milk or white - for its health benefits.

Cocoa beans also contain dopamine, phenylethylamine and serotonin, all of which are compounds that are known to enhance mood and promote feelings of well-being.

So if the main ingredient in chocolate is full of healthy compounds, why shouldn't we eat it by the bucketload?

Put simply, the negative health effects of chocolate primarily come from the additional ingredients that are added to it during the commercial manufacturing process. Sugar, full-fat cream and milk are just some of these ingredients, and the quantities in which they are added are not slight.

A standard 43 g bar of Hershey's milk chocolate contains 13 g of fat, 24 g of sugar and 210 calories. Eating this product in high quantities could lead to weight gain, and being overweight can increase the risk of numerous health problems, including hypertension, diabetes and heart disease.

Because of its high sugar content, chocolate may also raise the risk of dental problems - including gum disease and cavities - if consumed in high amounts.

Referring back to the Heart study, however, researchers claim that participants who consumed up to 100 g of chocolate a day were at lower risk of stroke and heart disease. This is an amount the equivalent to more than two Hershey's milk chocolate bars each day, which would take a person well above the recommended daily sugar intake of 25 g for woman and 37.5 g for men.

Can eating this amount of chocolate daily really be good for our health? Or has this study and many like it been overstated?

Are we succumbing to the media's hype?

Looking at the results of the Heart study more closely, the average daily chocolate consumption of the almost 158,000 participants studied was 7 g, while only some of the participants consumed 100 g of chocolate each day.

However, the researchers claim that higher chocolate consumption - up to 100 g daily - was associated with a greater reduction in heart disease and stroke risk. But it should be noted that most of these participants were younger with a lower body mass index (BMI) and blood pressure, and they were less likely to have diabetes.

Many studies associating chocolate with health benefits are badly conducted, but many news outlets continue to report their findings.

"It is hard to know if the lower risk comes from chocolate or those other factors," says Science Media Centre - a media watchdog based in the UK. "The authors have tried to account for these as far as possible, but the nature of the study means that it is not possible to do that perfectly. Therefore, it is possible that the protective effect might be because of something else - not chocolate."

Despite this, the Internet was engulfed with media outlets claiming, "Two bars of chocolate a day 'lowers risk of stroke and heart disease'" and "Two chocolate bars a day can SLASH the risk of heart attack and stroke."

Could such media coverage be luring the general public into potentially false beliefs that chocolate consumption can have major health benefits?

Earlier this month, news outlets around the globe reported on a study conducted by Johannes Bohannon, PhD, research director of the Institute of Diet and Health, which claimed people who ate one chocolate bar a day alongside a low-carbohydrate diet lost weight 10% faster than controls.

As MNT revealed, however, the purpose of this study was to see how easy it would be to get badly conducted research into the news. Though the study was real, it was actually conducted by a journalist called John Bohannon, and the Institute of Diet and Health does not exist.

The study, which was published in the International Archives of Medicine and covered by news outlets including the Huffington Post and The Daily Mail, was hugely flawed. It contained only 16 participants who were only assessed for a 3-week period, meaning the findings were insignificant - factors that many news reporters failed to acknowledge.

"It was terrible science," said Bohannon in an article he penned for website io9. "The results are meaningless, and the health claims that the media blasted out to millions of people around the world are utterly unfounded."

Bohannon noted, however, that the general public were very critical of the findings, asking questions that should have been addressed by the reporting journalists. This suggests that many of us are not completely taken in by attention-grabbing headlines hailing the health benefits of chocolate.

However, this is not to say chocolate consumption offers no health benefits. Some well-conducted studies have found it could be good for us.

The potential health benefits of chocolate

For years, numerous studies have associated moderate chocolate consumption with better heart health. As well as the most recent example published in Heart, in February 2014, MNT reported on a study linking daily consumption of dark chocolate to reduced risk of atherosclerosis - thickening and hardening of the arteries.

A study published in 2012, conducted by researchers from the University of California-San Diego School of Medicine, found dark chocolate may benefit patients with advanced heart failure and type 2 diabetes by enhancing the structure of mitochondria - the "powerhouses" of cells - while another study found that cocoa products may help to lower blood pressure.

The heart health benefits of chocolate have been put down to the antioxidants it contains, which, as mentioned previously, are found in cocoa beans. High levels of antioxidants can reduce the amount of low-density lipoprotein (LDL), or "bad," cholesterol that build up in artery walls, for example.

More and more studies are emerging in support of the heart health benefits of chocolate, particularly dark chocolate. However, increasingly, studies are suggesting there may be many more health benefits attached to the yummy treat.

In 2013, a study by researchers from Harvard Medical School in Boston, MA, claimed drinking two cups of hot chocolate each day may stave off memory decline in older age by preserving blood flow in working areas of the brain.

And another study, published in the Journal of Agricultural Food and Chemistry in 2014, suggested a flavanol in cocoa - called oligomeric procyandins - may protect against obesity and type 2 diabetes.

Our Knowledge Center article on the health benefits of chocolate looks at some of the other ways in which it could be good for us.

While numerous studies suggest there may be additional perks to indulging in a chocolatey treat, it should be noted that they are not conclusive, and research is ongoing to determine exactly what health benefits chocolate offers.

What is conclusive, however, is that eating excessive amounts of chocolate - as tempting as it might be - can lead to weight gain, increasing our risk of overweight and obesity and associated conditions, such as heart disease and diabetes.

But this doesn't mean we have to miss out. Like most foods high in sugar and fat, they can be consumed in moderation. As dietitian and spokesperson of the British Dietetic Association Alison Hornby says:

"As an occasional treat, chocolate can be part of a healthy diet. Eaten too frequently, it is an unhealthy choice."

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Fasting: what are the health benefits and risks?

Fasting is commonly associated with the month of Ramadan. As you read this, billions of Muslims around the world are engaging in this declaration of faith that involves abstaining from food and drink from dawn until dusk. While fasting for Ramadan is down to spiritual beliefs, many of us choose to fast with the belief that it benefits our health. But does it?

A number of studies have suggested intermittent fasting has numerous health benefits, including weight loss, lower blood pressure and reduced cholesterol.

In recent years, numerous studies have suggested that intermittent fasting - abstaining or reducing food and drink intake periodically - can be good for us, making it one of the most popular diet trends worldwide.

One of the most well-known intermittent fasting diets is the 5:2 Fast Diet - a plan that involves eating the recommended calorie intake for 5 days a week but reducing calorie intake to 25% for the remaining 2 days - to 500 calories a day for women and 600 a day for men.

According to Dr. Michael Mosley - author of The Fast Diet books - this eating plan can not only help people lose weight, but it offers an array of other health benefits.

"Studies of intermittent fasting show that not only do people see improvements in blood pressure and their cholesterol levels, but also in their insulin sensitivity," he adds.

In June 2014, for example, Medical News Today reported on a study suggesting periodic fasting - defined in the study as 1 day of water-only fasting a week - may reduce the risk of diabetes among people at high risk for the condition.

Another study, conducted by Dr. Valter Longo and colleagues from the University of Southern California (USC) in Los Angeles, found longer periods of fasting - 2-4 days - may even "reboot" the immune system, clearing out old immune cells and regenerating new ones - a process they say could protect against cell damage caused by factors such as aging and chemotherapy.

But what are the mechanisms underlying the suggested health benefits of fasting?

The potential benefits of intermittent fasting

Since the body is unable to get its energy from food during fasting, it dips into glucose that is stored in the liver and muscles. This begins around 8 hours after the last meal is consumed.

When the stored glucose has been used up, the body then begins to burn fat as a source of energy, which can result in weight loss.

As well as aiding weight loss, Dr. Razeen Mahroof, of the University of Oxford in the UK, explains that the use of fat for energy can help preserve muscle and reduce cholesterol levels.

When the body has used up glucose stores during fasting, it burns fat for energy, resulting in weight loss.

"A detoxification process also occurs, because any toxins stored in the body's fat are dissolved and removed from the body," he adds, noting that after a few days of fasting, higher levels of endorphins - "feel-good" hormones - are produced in the blood, which can have a positive impact on mental well-being.

As mentioned previously, the study by Dr. Longo and colleagues suggests prolonged fasting may also be effective for regenerating immune cells.

"When you starve, the system tries to save energy, and one of the things it can do to save energy is to recycle a lot of the immune cells that are not needed, especially those that may be damaged," Dr. Longo explains.

In their study, published in the journal Cell Stem Cell, the team found that repeated cycles of 2-4 days without food over a 6-month period destroyed the old and damaged immune cells in mice and generated new ones.

What is more, the team found that cancer patients who fasted for 3 days prior to chemotherapy were protected against immune system damage that can be caused by the treatment, which they attribute to immune cell regeneration.

"The good news is that the body got rid of the parts of the system that might be damaged or old, the inefficient parts, during the fasting," says Dr. Longo. "Now, if you start with a system heavily damaged by chemotherapy or aging, fasting cycles can generate, literally, a new immune system."

With the potential health benefits of fasting widely hailed by nutritionists worldwide, it is no wonder many of us are putting our love of food to one side in order to give it a try.

But intermittent fasting isn't all bells and whistles, according to some researchers and health care professionals, and there are some people who should avoid the diet altogether.

The health risks

According to the UK's National Health Service (NHS), there are numerous health risks associated with intermittent fasting.

People who fast commonly experience dehydration, largely because their body is not getting any fluid from food. As such, it is recommended that during Ramadan, Muslims consume plenty of water prior to fasting periods. Other individuals following fasting diets should ensure they are properly hydrated during fasting periods.

If you are used to having breakfast, lunch, dinner and snacks in between, fasting periods can be a major challenge. As such, fasting can increase stress levels and disrupt sleep. Dehydration, hunger or lack of sleep during a fasting period can also lead to headaches.

Fasting can also cause heartburn; lack of food leads to a reduction in stomach acid, which digests food and destroys bacteria. But smelling food or even thinking about it during fasting periods can trigger the brain into telling the stomach to produce more acid, leading to heartburn.

While many nutritionists claim intermittent fasting is a good way to lose weight, some health professionals believe such a diet is ineffective for long-term weight loss.

"The appeal is that [fasting] is quick, but it is quick fluid loss, not substantial weight loss," says Madelyn Fernstrom, PhD, of the University of Pittsburgh Medical Center's Weight Loss Management Center. "If it's easy off, it will come back quickly - as soon as you start eating normally again."

"My experience has been that [this] way of eating does not produce weight loss even in the short term," dietitian and author ofDiet Simple Katherine Tallmadge told ABC News in 2013.

Some health professionals believe intermittent fasting may steer people away from healthy eating recommendations, such as eating five portions of fruits and vegetables a day. Many fear fasting may also trigger eating disorders or binge eating.

In a blog for The Huffington Post last year, fitness and nutrition expert JJ Virgin wrote:

"The 'anything goes' mentality some experts permit during the feeding state could lead someone to overeat, creating guilt, shame, and other problems that only become worse over time. For someone with emotional or psychological eating disorders, intermittent fasting could become a convenient crutch to amplify these issues."

While Dr. Mosely says there is no evidence to suggest the 5:2 Fast Diet is associated with eating disorders, he stresses people who have eating disorders should not engage in intermittent fasting.

Other people who should not follow this diet include people who are underweight, individuals under the age of 18, pregnant women, people with type 1 diabetes and individuals recovering from surgery.

Could we reap the benefits of fasting without fasting?

While intermittent fasting may have health risks, nutritionists claim it can be good for us if individuals consult with their doctors before adopting such a diet and adhere to it correctly.

But could there be a way to reap the potential health benefits of fasting without actually having to fast? Dr. Longo believes so.

Researchers say a fasting-mimicking diet could simulate the effect of fasting without the food deprivation and side effects.

Earlier this week, Dr. Longo and colleagues from USC published a study in the journal Cell Metabolism revealing how a fasting-mimicking diet (FMD) triggered immune cell regeneration and extended the lifespan of mice.

What is more, on testing the diet in humans - who adhered to it for only 5 days a month for 3 months - they found it reduced a number of risk factors associated with aging, cardiovascular disease (CVD), diabetes and cancer.

The FMD is low in protein, low in unhealthy fats and high in healthy fats, according to the researchers. It stimulates markers linked to fasting, such as low glucose levels and high levels of ketone bodies, in order to mimic the effects of prolonged fasting.

Dr. Longo and colleagues say their diet could promote immune cell regeneration and longevity associated with fasting without the need for food restriction and the potential adverse effects that come with it.

"Although the clinical results will require confirmation by a larger randomized trial," they add, "the effects of FMD cycles on biomarkers/risk factors for aging, cancer, diabetes, and CVD, coupled with the very high compliance to the diet and its safety, indicate that this periodic dietary strategy has high potential to be effective in promoting human healthspan."

The team hopes that clinicians will one day have the ability to prescribe this diet to patients. "This is arguably the first non-chronic preclinically and clinically tested anti-aging and healthspan-promoting intervention shown to work and to be very feasible as a doctor or dietitian-supervised intervention," says Dr. Longo.

It may be a while before the FMD receives approval from the US Food and Drug Administration (FDA) for clinical use. First, the team needs to put the diet through a rigorous testing process.

Further research is required to gain a better understanding of the exact benefits and risks the FMD poses, and this appears to be the case with existing fasting diets. One thing is clear, however; talk to your doctor before engaging in any form of fasting.

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Chocolate for your heart

Eating up to 100 g of chocolate every day is linked to lowered heart disease and stroke risk. The calculations showed that compared with those who ate no chocolate higher intake was linked to an 11% lower risk of cardiovascular disease and a 25% lower risk of associated death.

Eating chocolate regularly was linked to a 25% lower risk of any episode of cardiovascular disease and a 45% lower risk of associated death.

Credit: © larisabozhikova / Fotolia

Eating up to 100 g of chocolate every day is linked to lowered heart disease and stroke risk, finds research published online in the journal Heart.

There doesn't seem to be any evidence for cutting out chocolate to lower the risk of cardiovascular disease, conclude the researchers.

They base their findings on almost 21,000 adults taking part in the EPIC-Norfolk study, which is tracking the impact of diet on the long term health of 25,000 men and women in Norfolk, England, using food frequency and lifestyle questionnaires.

The researchers also carried out a systematic review of the available international published evidence on the links between chocolate and cardiovascular disease, involving almost 158,000 people--including the EPIC study participants.

The EPIC-Norfolk participants (9214 men and 11 737 women) were monitored for an average of almost 12 years, during which time 3013 (14%) people experienced either an episode of fatal or non-fatal coronary heart disease or stroke.

Around one in five (20%) participants said they did not eat any chocolate, but among the others, daily consumption averaged 7 g, with some eating up to 100 g.

Higher levels of consumption were associated with younger age and lower weight (BMI), waist: hip ratio, systolic blood pressure, inflammatory proteins, diabetes and more regular physical activity --all of which add up to a favourable cardiovascular disease risk profile.

Eating more chocolate was also associated with higher energy intake and a diet containing more fat and carbs and less protein and alcohol.

The calculations showed that compared with those who ate no chocolate higher intake was linked to an 11% lower risk of cardiovascular disease and a 25% lower risk of associated death.

It was also associated with a 9% lower risk of hospital admission or death as a result of coronary heart disease, after taking account of dietary factors.

And among the 16,000 people whose inflammatory protein (CRP) level had been measured, those eating the most chocolate seemed to have an 18% lower risk than those who ate the least.

The highest chocolate intake was similarly associated with a 23% lower risk of stroke, even after taking account of other potential risk factors.

Of nine relevant studies included in the systematic review, five studies each assessed coronary heart disease and stroke outcome, and they found a significantly lower risk of both conditions associated with regular chocolate consumption.

And it was linked to a 25% lower risk of any episode of cardiovascular disease and a 45% lower risk of associated death.

This is an observational study so no definitive conclusions about cause and effect can be drawn. And the researchers point out that food frequency questionnaires do involve a certain amount of recall bias and underestimation of items eaten.

Reverse causation--whereby those with a higher cardiovascular disease risk profile eat less chocolate and foods containing it than those who are healthier--may also help to explain the results, they say.

Nevertheless, they add: "Cumulative evidence suggests that higher chocolate intake is associated with a lower risk of future cardiovascular events."

And they point out that as milk chocolate, which is considered to be less 'healthy' than dark chocolate, was more frequently eaten by the EPIC-Norfolk participants, the beneficial health effects may extend to this type of chocolate too.

"This may indicate that not only flavonoids, but also other compounds, possibly related to milk constituents, such as calcium and fatty acids, may provide an explanation for the observed association," they suggest.

And they conclude: "There does not appear to be any evidence to say that chocolate should be avoided in those who are concerned about cardiovascular risk."

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Story Source:

The above post is reprinted from materials provided by BMJ. Note: Materials may be edited for content and length.

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Desk-based employees 'should work standing up'

A group xperts have advised that people working in office environments stand for at least 2 hours a day during working hours, as part of a number of recommendations to protect those engaged with typically sedentary forms of work.

Breaking up long periods of sitting with activity is considered by most experts to be advantageous to the health of workers.

Workers whose jobs are predominantly desk-based should eventually progress to a total of 4 hours standing, advises the panel.

The recommendation comes as part of a set of guidelines, published in the British Journal of Sports Medicine, with the aim to provide guidance to employers and office workers to counteract the health risks that come with long periods of seated office work.

"For those working in offices, 65-75% of their working hours are spent sitting, of which more than 50% of this is accumulated in prolonged periods of sustained sitting," write the authors. "The evidence is clearly emerging that a first 'behavioral' step could be simply to get people standing and moving more frequently as part of their working day."

An increasing number of studies associate sedentary living - including time spent at work - with an increased risk of several serious illnesses and causes of death, including cardiovascular disease, diabetes and some forms of cancer.

Although much of the evidence the panel used to inform its recommendations comes from observational and retrospective studies, they state that "the level of consistent evidence accumulated to date, and the public health context of rising chronic diseases, suggest initial guidelines are justified."

The key recommendations of the guidelines for office workers during working hours are:

• Two hours daily, eventually progressing to 4 hours, of standing and light activity (such as light walking)
• Breaking up periods of seated work with standing work using adjustable sit-stand desks and workstations
• Avoiding prolonged static standing, which may also be harmful
• Altering posture and light walking to reduce fatigue and musculoskeletal pain while adapting to new work practices
• Employers should inform staff of the dangers of spending too much time sitting down, both at work and at home
• Employers should also promote the benefits of other healthful behaviors such as eating a balanced diet and not smoking.

Guidelines 'pose no significant physical or cognitive challenges' for workers

There is a growing interest in changing working environments so that they are no longer wholly sedentary. Many companies now provide office furniture with sit-stand attachments for desks or fully adjustable sit-stand desktops, allowing office employees to work without having to be seated.

While a number of companies have already begun investing in changes to enable their employees to work in a more active environment, many have not. The panel state those that have yet to do so should begin to evaluate how best they can implement these recommendations.

Potential measures that can be taken include making provisions for breaks that involve standing and movement and investing in desks and office designs that allow employees to work easily while standing up.

The panel warns, however, that simply changing a working environment may not be enough to alter behaviors in the long term. "Strategies and programs for implementing change will need careful organizational and behavioral support and public education to prevent current interests in active office environments from simply being a passing fad," they write.

"On the basis that there are a large number of occupations which involve people standing and moving for considerably more than 4 [hours a day] (e.g., hospital staff, teachers, factory workers, retail and catering staff), it is expected that for office-based workers, in general, this should not pose too many significant physical or cognitive challenges," the authors conclude.

The panel of international experts was commissioned by Public Health England and a British community interest company, Active Working CIC.

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Stroke: not just an adult's condition

When you hear the word "stroke," the first picture that pops into your mind is likely to be of an elderly individual. It's true that older adults are at greater stroke risk; the chance of having a stroke doubles with each decade of life after the age of 55. But did you know that infants and children can also suffer stroke? It can even occur before birth.

Stroke affects 6 in every 100,000 children in the US and is one of the 10 leading causes of death among children in the country.

According to the National Stroke Association, stroke affects 6 in every 100,000 children in the US. It is also one of the 10 leading causes of death among children in the country.

The rate of stroke is much higher in adults than children. Every year, more than 795,000 men and women suffer a stroke and around 130,000 die from the condition. However, studies have found stroke rates are on the rise in children in the US.

In 2011, a study published in the Annals of Neurologyreported a 51% increase in ischemic stroke incidence among boys aged 5-14 from the period 1995-96 to 2007-08, while girls aged 5-14 saw a 3% rise in ischemic stroke in the same period.

In many ways, stroke in children - commonly referred to as pediatric stroke - can present more challenges than stroke in adults.

The early signs of stroke in children are much more subtle than in adults, meaning they often go unrecognized. According to the International Alliance for Pediatric Stroke (IAPS), newborns who suffer stroke may not even begin to show any symptoms until the age of 4-8 months.

What is more, because parents, caregivers and even health care professionals do not often associate stroke with children, it may be ruled out as a possibility. As a result, many children fail to receive adequate treatment.

A 2014 study conducted by Dr. Mark Mackay, director of the Children's Stroke Program at the Royal Children's Hospital and Murdoch Children's Research Institute in Melbourne, Australia, and colleagues found that only half of interviewed parents whose children suffered stroke thought their child's symptoms were serious enough to call 911, while 21% of parents adopted a "wait-and-see" approach. What is more, only 36% considered stroke as a possible cause of their child's symptoms.

As with most health conditions, early treatment for stroke is key. Unfortunately, around 20-40% of children die after a stroke, and of those who do survive, around 50-80% will have lifelong neurological problems, such a partial or total paralysis.

May is American Stroke Awareness Month. In this Spotlight, we investigate the risk factors for pediatric stroke, the signs and symptoms to look out for, as well as the treatment options for the condition.

Perinatal stroke and childhood stroke

There are two types of pediatric stroke: perinatal stroke and childhood stroke.

Perinatal stroke, also referred to as fetal or prenatal stroke, occurs between the last 18 weeks of pregnancy and the first 30 days of birth. In the US, perinatal stroke occurs in about 1 in every 2,800 live births.

Most cases of perinatal stroke are ischemic, caused by blood clots breaking off from the placenta and becoming lodged in the child's brain.

Childhood stroke occurs between the ages of 1 month and 18 years. Unlike adults, in whom ischemic stroke is most common, children are equally as likely to have ischemic stroke as they are hemorrhagic stroke - caused by a brain bleed from a ruptured blood vessel.

Around 60% of all pediatric strokes occur in boys, and African-American children are at greater stroke risk than Caucasian and Asian children.

The risk factors for pediatric stroke

Among adults, high blood pressure, irregular heartbeat and atherosclerosis - hardening of the arteries - are some of the most common risk factors for stroke. These factors rarely cause stroke in children, however.

According to the American Stroke Association, around half of all pediatric strokes are triggered by an underlying condition, most commonly sickle cell disease - an inherited blood disorder - and congenital heart disease.

Other underlying conditions that may raise a child's stroke risk include head and neck infections, abnormal blood clotting, head trauma and systemic conditions, such as autoimmune disorders.

Maternal history of infertility, premature rupture of membranes during pregnancy, maternal preeclampsia and chorioamnionitis - inflammation of the fetal membranes due to a bacterial infection - may also increase a child's stroke risk.

Though cardiovascular-related risk factors for stroke in adults are rare in children, recent studies have indicated an increase in these risk factors among the younger population. This is down to a rise in high blood pressure, obesity,diabetes, high cholesterol and tobacco and alcohol use among youth.

A 2014 study published in the journal Neurology also suggested colds and other minor infections in childhood may temporarily raise a child's stroke risk.

"We've seen this increase in stroke risk from infection in adults, but until now, an association has not been studied in children," commented study author Dr. Heather Fullerton, director of the University of California-San Francisco Pediatric Stroke and Cerebrovascular Disease Center.

"It is possible that inflammatory conditions contribute more to the stroke risk in children, however, further research is needed to explore this possible association."

It is important to note, however, that in around half of all childhood stroke cases, no previous risk factor can be determined.

What are the signs and symptoms to look out for?

As mentioned previously, it can be very hard to spot stroke symptoms among very young children. Around 40% of infants do not show symptoms of early stroke; a parent may not know their baby has suffered stroke until months later when they show reduced movement or weakness on one side of their face.

As well as weakness or numbness on one side of the body, other signs of stroke in children may include severe headache, dizziness and vomiting.

Repetitive twitching of the face, arm or leg can be an indicator of stroke in newborns, as can a pause in breathing alongside prolonged staring and extreme fatigue.

As children develop, the signs of symptoms of stroke are very similar to those in adults. Weakness or numbness on one side of the body and problems speaking or understanding language - such as slurred speech or problems understanding simple instructions - may be signs of stroke.

Other signs of stroke among children may include severe headache, vomiting, fatigue, severe dizziness and appearance of seizures.

The American Stroke Association stress that the F.A.S.T. acronym is an easy way to remember the sudden signs of stroke in both children and adults:

• Face drooping. Is one side of the face numb or drooping? Is the individual able to smile?
• Arm weakness. Is one arm numb or weak? Ask the individual to lift both arms. Does one arm drift downward?
• Speech difficulty. Is the individual's speech slurred? Do they find it hard to speak or are they hard to understand? Can they correctly repeat a simple sentence, such as "the sky is blue?"
• Time to call 911. If the individual shows any of these symptoms, call 911 immediately, even if the symptoms disappear. Check the time at which first symptoms appear.

"Think stroke, act fast and call 911. That message applies to adults and children," says Dr. MacKay. "Getting to the hospital quickly is an essential first step to develop strategies to improve access to emergency treatment in children."

Treatment options for pediatric stroke

For adults suffering ischemic stroke, the first port of call in terms of treatment is the medication tissue plasminogen activator (tPA), which works by dissolving any blood clots that are blocking the arteries, restoring blood flow to the brain. Such treatment must be administered within 3 hours of symptom onset - 4.5 hours for some patients.

The use of tPA among young children with ischemic stroke, however, is controversial. Since children and adults have physiological differences, health care professionals are concerned about the drug's safety and efficacy among children - something that is currently being investigated.

As such, stroke treatment for children tends to vary depending on the cause of their stroke and any underlying medical conditions they may have. A child whose stroke was caused by a heart defect, for example, may be treated with blood-thinning medication, such as warfarin or aspirin.

Children who suffer stroke have around a 15-18% chance of suffering another stroke. Therefore, many children may receive treatment to prevent stroke recurrence, such as antithrombotic therapy - medication that stops blood clots from forming or growing.

One crucial treatment for the majority children who suffer stroke is rehabilitation therapy, which can involve physiotherapy, occupational therapy and speech therapy.

Sixty percent of children experience neurological problems, such as hemiplegia or hemiparesis cerebral palsy, following stroke. Rehabilitation therapy can really help reduce the neurological effects of stroke, and the earlier treatment is started, the more likely it is to succeed.

Severe delays in diagnosis of pediatric stroke

But as Dr. MacKay's study showed, many parents either do not consider the possibility that their child is suffering a stroke or are unable to recognize the signs, which can severely delay treatment.

Dr. MacKay's findings revealed that the average time from symptom onset of pediatric stroke to arrival at the emergency room was 1.8 hours, with some arrivals taking up to 4 hours.

And it is not only parents who may overlook the signs and symptoms of pediatric stroke - doctors can too. Studies have found that in the US, it can often take longer than 24 hours to diagnose stroke in children.

A report from ABC News in 2011 provides evidence of this, revealing how it took more than 25 hours for doctors to diagnose a 15-year-old boy from Ohio with stroke.

Because of the delay in diagnosis, the boy had to have a part of his skull removed to ease pressure from the build up of blood in his brain.

In a 2008 interview, Dr. Fullerton said she believes a delay in diagnosis of pediatric stroke has fallen into a gap in clinical care. "It is a rare disorder in general, and so most child neurologists will not be very comfortable in caring for children with stroke," she said, adding:

"Stroke is considered more a disease of adults, but then adult stroke neurologists aren't familiar of the etiologies of stroke in children or how to manage stroke in children, and so they're often uncomfortable with caring for a stroke in a child.

It can be difficult to diagnose the etiology of their strokes. It often takes sophisticated imaging studies and studies that are done by very experienced practitioners. It really often does take a team approach to figure out why a child has had a stroke and figure out what is the best way to prevent more strokes in that child."

While stroke is much rarer in children than adults, it is important that parents, caregivers and health care professionals are aware that children can be affected by the condition and take note of the signs and symptoms that may arise.

Not only is May American Stroke Awareness Month, 2nd-8th May is dedicated to World Pediatric Stroke Awareness Week. Set up by the IAPS and not-for-profit organization Brendon's Smile last year, the campaign aims to raise awareness of pediatric stroke around the globe and educate communities about how the condition can impact children's lives.

Visit the IAPS website to find out more about pediatric stroke and how you can help raise awareness of the condition.

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