Geographic variation and trends in prevalence of obesity among US adolescents, 2016-2021.

OBJECTIVE: Recent updates of geographic variations, trends, and sociodemographic disparities in obesity prevalence among US adolescents are limited. The study aimed to fill those research gaps. STUDY DESIGN: Serial cross-sectional analysis of the US nationally representative study. METHODS: Data from six cycles of the National Survey of Children's Health (2016, 2017, 2018, 2019, 2020, and 2021) with information on physical health at the national and state level were used. A total of 107,274 adolescents aged 10-17 years old were included with sociodemographic data (age, sex, race/ethnicity, parental education level, and family income) and state of residence. Logistic regression models were used to estimate the odds ratios (ORs) associated with obesity across sociodemographic groups. In addition, ORs were calculated to compare obesity rates between the pandemic period (2020-2021) and the pre-pandemic period (2018-2019) overall and by sociodemographic subgroups. Survey analysis procedures were used to account for complex survey designs to derive representative estimates. RESULTS: From 2016 to 2021, obesity prevalence increased from 16.1% (95% confidence interval [CI], 14.9%-17.4%) to 17.6% (95% CI, 16.4%-18.9%) (P-trend = 0.04). The combined prevalence of obesity varies substantially by state, from 9.34% (95% CI, 6.96%-12.4%; Colorado) to 27.1% (95% CI, 23.1%-31.5%; Mississippi) for adolescents aged 10-13 years and ranged from 9.86% (95% CI, 7.63%-12.7%; Utah) to 22.4% (95% CI, 19.0%-26.1%; West Virginia) for adolescents aged 14-17 years. Except for subgroups male gender and parents with college degrees or above, the prevalence of obesity showed stable trends across sociodemographic subgroups. Compared to the pre-pandemic period, the multivariable-adjusted ORs of obesity were 1.18 (95% CI, 1.06-1.32) for male adolescents, 1.16 (95% CI, 1.04-1.28) for non-Hispanic White adolescents, 1.81 (95% CI, 1.15-2.84) for non-Hispanic Asian adolescents, 1.26 (95% CI, 1.05-1.52) for adolescents whose parents had a high school education, and 1.15 (95% CI, 1.0-1.33) for adolescents whose parents had a college degree or higher. CONCLUSIONS: The prevalence of obesity among US adolescents increased significantly between 2016 and 2021. The prevalence of obesity was relatively high in southern states. Those with low household income, low parental education, or being non-Hispanic Black or Hispanic were also more likely to be obese. Compared to the pre-pandemic period, several groups of adolescents increased their likelihood of obesity during the pandemic period.

Clinical failure of natalizumab in multiple sclerosis: Specific causes and strategy.

BACKGROUND: Natalizumab is a very effective treatment of multiple sclerosis (MS). Failure is rare and should lead to consider some specific etiologies. The purpose of our study was to describe causes of subacute neurological events under natalizumab. METHODS: Observational single-center retrospective study in the MS expert center of Lyon, France. INCLUSION CRITERIA: any patient with definite MS who received at least three infusions of natalizumab between April 2007 and February 2017. Clinical data were extracted from the Lyon EDMUS/OFSEP database. Events of interest: occurrence of a subacute neurological deficit, characterized by new clinical symptoms. We excluded pseudo-relapses and progression. FINDINGS: A subacute neurological deficit occurred in 35 cases, for 607 patients treated with natalizumab. Ten patients presented natalizumab antibodies, nine had progressive multifocal leukoencephalopathy (PML), five presented an isolated subacute neurological deficit and two had AQP4 antibodies. No myelin oligodendrocyte glycoprotein (MOG) antibodies were found. INTERPRETATION: The occurrence of an acute or subacute neurological deficit with natalizumab is rarely a MS relapse and should lead systematically to explore some important alternate etiologies, eliminating PML first.

How physical activity behavior affected well-being, anxiety and sleep quality during COVID-19 restrictions in Iran.

OBJECTIVE: The Islamic Republic of Iran has displayed one of the highest rates of COVID-19 infection in the world and the highest rate of mortality in the Middle East. Iran has used a stringent package of preventive health measures to mitigate the spread of infection, which however has negatively affected individuals' physical and psychological health. This study aimed at examining whether physical-activity (PA) behavior, anxiety, well-being, and sleep-quality changed in response to the COVID-19-related public health restrictions enforced in Iran. PATIENTS AND METHODS: An online questionnaire was disseminated to adults residing in Iran from November 17, 2020, to February 13, 2021 (~88 days), during Iran's strictest public health restrictions. Main outcome measures included Godin-Shephard Leisure-Time Exercise Questionnaire, General Anxiety Disorder-7, Mental Health Continuum-Short Form, and Pittsburgh Sleep Quality Index. RESULTS: A total of 3,323 adults (mean age 30±11 years, 54.3% female) participated in the survey. Firstly, the restrictions generally reduced PA behavior: (a) among inactive participants (IPs), 60.6% became less active vs. 5.1% who became more active; and (b) among active participants (APs), 49.9% became less active vs. 22.8% who became more active. Secondly, PA behavior was associated with higher well-being and sleep quality during the restrictions: (a) APs reported higher (or lower) levels of well-being and sleep quality (or anxiety) than did IPs; and (b) among IPs as well as among APs, the more active the participants, the greater (or lower) the levels of well-being and sleep quality (or anxiety). CONCLUSIONS: This study showed the beneficial role of PA behavior for well-being, anxiety, and sleep quality during the COVID-19 restrictions, whereas such restrictions appeared to decrease PA participation. Active lifestyle should be then encouraged during the COVID-19 outbreak while taking precautions.

The impact of inflammation on the obesity paradox in coronary heart disease.

BACKGROUND: Despite the well-known adverse effects of obesity on almost all aspects of coronary heart disease, many studies of coronary heart disease cohorts have demonstrated an inverse relationship between obesity, as defined by body mass index (BMI), and subsequent prognosis: the 'obesity paradox'. The etiology of this and the potential role of inflammation in this process remain unknown. PATIENTS AND METHODS: We studied 519 patients with coronary heart disease before and after cardiac rehabilitation, dividing them into groups based on C-reactive protein ((CRP)⩾3 mg l-1 and CRP<3 mg l-1 after cardiac rehabilitation). BMI was calculated and body fat was measured using the skin-fold method. Lean mass index (LMI) was calculated as (1-%body fat) × BMI. The population was divided according to age- and gender-adjusted categories based on LMI and body fat and analyzed by total mortality over >3-year follow-up by National Death Index in both CRP groups. RESULTS: During >3-year follow-up, all-cause mortality was higher in the high inflammation and in the low BMI group. In proportional hazard analysis, even after adjusting for ejection fraction and peak O2 consumption, higher BMI was associated with lower mortality in the entire population (hazard ratio (HR) 0.38; confidence interval 0.15-0.97) and a trend to lower mortality in both subgroups (HR 0.45 in low CRP, P=0.24 vs HR 0.32, P=0.06 in high CRP). High body fat, however, was associated with significantly lower mortality in the high CRP group (HR 0.22; P=0.03) but not in the low CRP group (HR 0.73; P=0.64). Conversely, high LMI was associated with markedly lower mortality in the low CRP group (HR 0.04; P=0.04). CONCLUSIONS: The obesity paradox has multiple underlying etiologies. Body composition has a different role in different populations with an obesity paradox by BMI. Especially in the subpopulation with persistently high CRP levels, body fat seems protective.

Trimetazidine does not alter metabolic substrate oxidation in cardiac mitochondria of target patient population.

BACKGROUND AND PURPOSE: Trimetazidine, known as a metabolic modulator, is an anti-anginal drug used for treatment of stable coronary artery disease (CAD). It is proposed to act via modulation of cardiac metabolism, shifting the mitochondrial substrate utilization towards carbohydrates, thus increasing the efficiency of ATP production. This mechanism was recently challenged; however, these studies used indirect approaches and animal models, which made their conclusions questionable. The goal of the current study was to assess the effect of trimetazidine on mitochondrial substrate oxidation directly in left ventricular myocardium from CAD patients. EXPERIMENTAL APPROACH: Mitochondrial fatty acid (palmitoylcarnitine) and carbohydrate (pyruvate) oxidation were measured in permeabilized left ventricular fibres obtained during coronary artery bypass grafting surgery from CAD patients, which either had trimetazidine included in their therapy (TMZ group) or not (Control). KEY RESULTS: There was no difference between the two groups in the oxidation of either palmitoylcarnitine or pyruvate, and in the ratio of carbohydrate to fatty acid oxidation. Activity and expression of pyruvate dehydrogenase, the key regulator of carbohydrate metabolism, were also not different. Lastly, acute in vitro exposure of myocardial tissue to different concentrations of trimetazidine did not affect myocardial oxidation of fatty acid. CONCLUSION AND IMPLICATIONS: Using myocardial tissue from CAD patients, we found that trimetazidine (applied chronically in vivo or acutely in vitro) had no effect on cardiac fatty acid and carbohydrate oxidation, suggesting that the clinical effects of trimetazidine are unlikely to be due to its metabolic effects, but rather to an as yet unidentified intracardiac mechanism.

Obesity and the "obesity paradox" in cardiovascular diseases.

Obesity adversely affects most cardiovascular (CV) risk factors and is strongly associated, probably as an independent risk factor, with most CV diseases. However, substantial evidence points to the existence of an "obesity paradox," in that overweight and obese patients with established CV diseases typically have a better prognosis than leaner patients with the same CV disease. Despite this paradox, we believe that the "weight" of evidence still supports efforts at purposeful weight loss in both primary and secondary CV prevention.

Dyslipidemia in the metabolic syndrome: clinical implications and management.

Dyslipidemia is an important component of the metabolic syndrome. Dyslipidemia in the metabolic syndrome is characterized by hypertriglyceridemia, low serum levels of high density lipoprotein cholesterol (HDL-C) and an increase in the serum fraction of small dense low density lipoprotein cholesterol (LDL-C) particles. Serum LDL-C elevation is frequently present, but is not a criterion of the metabolic syndrome. A Medline search was conducted using the terms metabolic syndrome, dyslipidemia, hypertriglyceridemia and HDL cholesterol. The metabolic syndrome is a common and important risk factor for cardiovascular disease and progression to type 2 diabetes mellitus. Dyslipidemia is present in most patients with the metabolic syndrome and is treatable with therapeutic lifestyle changes and pharmacotherapy. Aggressive management of atherogenic dyslipidemia is justified by the very high cardiovascular risk associated with this disorder. Atherogenic dyslipidemia is frequently present in patients with the metabolic syndrome and requires aggressive treatment due to the very high risk for cardiovascular disease and progression to type 2 diabetes mellitus.

Ventricular-vascular uncoupling increases expression of B-type natriuretic peptide in heart transplantation.

BACKGROUND: Allograft adaptation to a foreign circulation is imperfect as noted from persistent limitations to stress. Effective arterial elastance (Ea), a measure of afterload, provides an estimate of aortic impedance. End systolic elastance (Ees) is a load-independent measure of ventricular performance as well as its interaction in the periphery. The ratio (Ea to Ees) characterizes ventricular-vascular coupling; a value close to unity signifies poor mechanical efficiency. The purpose of this investigation was to correlate mechanical efficiency of work with expression of B-type natriuretic peptide BNP, a specific marker of ventricular stress and strain. METHODS: We measured BNP levels in 40 consecutive stable heart transplant recipients free from rejection. In addition, echocardiography was performed to obtain Ea, Ees, and their ratio (Ea to Ees) by the single-beat method. We examined correlates of BNP expression by assessing Ea to Ees, while correcting for mean arterial pressure, body mass index, left ventricular mass index, ejection fraction, and serum creatinine. RESULTS: BNP levels were significantly and positively correlated (r=0.38, P=.05) with an increased Ea to Ees ratio. By multivariable analysis, this relationship persisted independently (t=2.1, P=.04), while the five other measures were insignificant predictors. CONCLUSION: This investigation indicated that the transplanted heart demonstrates poor contractile efficiency and operates at maximal left ventricular work. This is paralleled by a tandem increase in BNP, suggesting that elevation in this stress peptide is at least partly explained by ventriculo-vascular uncoupling in heart transplantation, independent of alterations in blood pressure.

Comparison of the efficacy and safety of pravastatin and simvastatin in heart transplantation.

AIMS: Data on the safety and efficacy of HMG CoA reductase inhibitors in managing dyslipidemia in heart transplant recipients is inadequate. We undertook this study to evaluate the comparative safety and efficacy of simvastatin and pravastatin in lowering lipids in heart transplant recipients. METHODOLOGY: Forty eight patients (38 males) who received heart transplantation between 1995 and 1997, and who had no contraindications to statin therapy or history of myopathy were randomized to receive either pravastatin (n=24) or simvastatin (n=24) for six months. Detailed fasting lipid profiles, hepatic function tests, and serum creatinine phosphokinase were obtained regularly. Baseline and six month characteristics were compared using the unpaired student t test for continuous variables and Chi-square analysis or Fisher's exact test, as appropriate. RESULTS: Baseline total cholesterol levels, LDL cholesterol levels, HDL cholesterol levels, and triglyceride levels were similar in the two groups. At six months, the total cholesterol, LDL cholesterol, and triglyceride levels were greatly reduced in both groups, with greater reductions in the simvastatin group than in the pravastatin group. Only modest increases were noted in HDL cholesterol levels in the two groups. No significant adverse effects were noted, and no complications with drug withdrawals occurred. Patient compliance exceeded 97%. CONCLUSION: Simvastatin and pravastatin are safe and very effective in total cholesterol and LDL cholesterol lowering in heart transplant recipients, with simvastatin being more efficacious than pravastatin in lipid lowering in this group of patients.

Benefits of cardiac rehabilitation and exercise training programs in elderly coronary patients.

The authors review several studies from the Ochsner Heart and Vascular Institute showing the benefits of formal phase II cardiac rehabilitation and exercise training programs in elderly patients with coronary artery disease, including benefits on plasma lipids, obesity indices, exercise capacity, peak oxygen consumption, behavioral characteristics (especially depression), and quality of life. Marked benefits were noted in elderly women and all elderly patients over the age of 75 years. The authors conclude that the therapy has proved to be safe and effective for elderly coronary patients, and that these individuals should be routinely referred to, and vigorously encouraged to attend, cardiac rehabilitation programs following major coronary events.

Should an angiotensin-converting enzyme inhibitor be standard therapy for patients with atherosclerotic disease?

Angiotensin-converting enzyme (ACE) inhibitors appear to possess unique cardioprotective benefits, even when used in patients without high blood pressure or left ventricular dysfunction (the traditional indications for ACE inhibitor therapy). The ACE inhibitors improve endothelial function and regress both left ventricular hypertrophy and arterial mass better than other antihypertensive agents that lower blood pressure equally as well. These agents promote collateral vessel development and improve prognosis in patients who have had a coronary revascularization procedure (i.e., percutaneous transluminal coronary angioplasty and coronary artery bypass graft surgery). Insulin resistance, present not only in type 2 diabetes but also commonly in patients with hypertension or coronary artery disease, or both, sensitizes the vasculature to the trophic effects of angiotensin II and aldosterone. This may partly explain the improvement in prognosis noted when patients who have atherosclerosis or diabetes are treated with an ACE inhibitor. Therapy with ACE inhibitors has also been shown, in two large, randomized trials, to reduce the incidence of new-onset type 2 diabetes through largely unknown mechanisms. The ACE inhibitors are safe, well tolerated and affordable medications. The data suggest that most people with atherosclerosis should be considered candidates for ACE inhibitor therapy, unless they are intolerant to the medication, or have systolic blood pressures consistently <100 mm Hg. Patients who show evidence of insulin resistance (with or without overt type 2 diabetes) should also be considered as candidates for prophylactic ACE inhibitor therapy. Although angiotensin receptor blockers should not be considered equivalent to ACE inhibitors for this indication, they may be a reasonable alternative for patients intolerant of ACE inhibitors.

Exercise and the heart: risks, benefits, and recommendations for providing exercise prescriptions.

Considerable research from the Ochsner Heart and Vascular Institute has focused on the effects of exercise training in patients with coronary heart disease. In this review, the authors discuss the risks and benefits of exercise training in general patients, as well as those with known vascular disease, and provide suggestions for exercise prescriptions for these patients, including modes of exercise and intensity, duration, and frequency of exercise sessions.

The incremental prognostic importance of body fat adjusted peak oxygen consumption in chronic heart failure.

OBJECTIVES: We sought to assess whether the adjustment of peak oxygen consumption (PkVO2) to lean body mass would yield a more accurate discriminator of outcomes in the chronic heart failure population. BACKGROUND: Peak oxygen consumption is traditionally used to risk stratify patients with congestive heart failure (CHF) and to time cardiac transplantation. There is, however, considerable variability in body fat content, which represents metabolically inactive mass. METHODS: In 225 consecutive patients with CHF, the percentage of body fat was determined by the sum of skinfolds technique. All underwent CPX using a ramping treadmill protocol. Mean follow-up duration was 18.9+/-11.3 months. RESULTS: There were 14 cardiovascular deaths and 15 transplants. Peak oxygen consumption lean, both as a continuous variable and using a cutoff of < or =19 ml/kg/min, was a better predictor of outcome than unadjusted PkVO2 (p = 0.003 vs. 0.027 for the continuous variables and p = 0.0006 vs. 0.055 for < or =19 ml/kg/min and < or =14 ml/kg/min unadjusted body weight, respectively). Using partial correlation index R statistics, the Cox model using PkVO2 lean < or =19 ml/kg/min, in addition to age and etiology of CHF as covariates, yielded the strongest predictive relationship to the combined end point (chi-square value 24.32). Especially in the obese patients and in women, there was considerably better correlation of PkVO2 lean with outcome than the unadjusted PkVO2. CONCLUSIONS: The adjustment of PkVO2 to lean body mass increases the prognostic value of cardiopulmonary stress testing in the evaluation of patients with chronic heart failure. The use of <19 ml O2/kg of lean body mass/min as a cutoff in PkVO2 should be used for timing transplantation, particularly in women and the obese.

Disparate effects of improving aerobic exercise capacity and quality of life after cardiac rehabilitation in young and elderly coronary patients.

PURPOSE: Although cardiopulmonary exercise variables predict prognosis, functional capacity, and quality of life (QoL) in patients with coronary artery disease (CAD), these variables have not been assessed fully before and after exercise training in elderly with CAD. Therefore, the purpose of this study was to determine the impact of formal Phase II cardiac rehabilitation and exercise training programs on cardiopulmonary variables and QoL in elderly and younger CAD patients. METHODS: The authors analyzed consecutive patients before and after Phase II cardiac rehabilitation and exercise training programs, and compared exercise cardiopulmonary data and data from validated questionnaires assessing QoL (MOS SF-36) and function in 125 younger patients (< 55 years; mean 48 +/- 6 years) and 57 elderly (> 70 years; mean 78 +/- 3 years). RESULTS: At baseline, elderly patients had lower estimated aerobic exercise capacity (-27%; P < 0.001), peak oxygen consumption (VO2) (-19%; P < 0.01), and anaerobic threshold (-10%; P < 0.05), as well as total function scores (-11%; P < 0.01) and total QoL scores (-5%; P = 0.06). Commonly used prediction equations greatly overestimated aerobic exercise capacity compared with precise measurements using cardiopulmonary testing both before (+23% and +12% in younger and elderly patients, respectively) and after the exercise training programs (+51% and +31% in younger and elderly patients, respectively), and more so in younger compared with older patients. After rehabilitation, the elderly had significant improvements in estimated aerobic exercise capacity (+32%; P < 0.0001), peak VO2 (+13%; P < 0.0001), anaerobic threshold (+11%; P = 0.03), total function scores (+27%; P < 0.0001), and total QoL scores (+20%; P < 0.0001). Although younger patients had greater improvements in estimated aerobic exercise capacity (+44% versus +32%; P = 0.08), peak VO2 (+18% versus +13%; P < 0.01), and anaerobic threshold (+17% versus +11%; P = 0.07), the elderly had statistically greater improvements in both function scores (+27% versus +20%; P = 0.02), and total QoL scores (+20% versus +14%; P = 0.03). CONCLUSIONS: These data confirm the benefits of precisely determining aerobic exercise capacity by cardiopulmonary function, especially to determine the benefits of an exercise training program. In addition, these data using cardiopulmonary exercise tests and validated assessments of quality of life demonstrate the disparate effects of cardiac rehabilitation programs on improvements in aerobic exercise capacity and QoL in young and elderly with CAD.