tag:theconversation.com,2011:/africa/topics/health-risk-factors-32738/articlesHealth risk factors – The Conversation2023-05-15T15:01:07Ztag:theconversation.com,2011:article/2051842023-05-15T15:01:07Z2023-05-15T15:01:07ZThriving in the face of adversity: Resilient gorillas reveal clues about overcoming childhood misfortune<figure><img src="https://images.theconversation.com/files/525949/original/file-20230512-23918-udbd4r.jpeg?ixlib=rb-1.1.0&rect=837%2C1234%2C5222%2C3305&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A lot of bad things can happen to young mountain gorillas in the wild.</span> <span class="attribution"><span class="source">Dian Fossey Gorilla Fund</span></span></figcaption></figure><p>In 1974, an infant mountain gorilla was born in Volcanoes National Park in Rwanda. Researchers named him Titus. As is typical for young gorillas in the wild, Titus spent the first years of his life surrounded by his mother, father and siblings, as well as more distant relatives and unrelated gorillas that made up his social group.</p>
<p>In 1978, however, tragedy struck. Poachers killed Titus’ father and brother. In the chaos that followed, his younger sister was killed by another gorilla, and his mother and older sister fled the group. Juvenile Titus, who was at a developmental stage similar to that of an 8- or 9-year-old human, <a href="https://www.imdb.com/title/tt1922764/">experienced more tragedy</a> in his first four years of life than many animals do in a lifetime.</p>
<p>In people, <a href="https://doi.org/10.1016/j.neuron.2017.09.027">a rough start in life</a> is often associated with significant problems later on. <a href="https://www.npr.org/sections/health-shots/2015/03/02/387007941/take-the-ace-quiz-and-learn-what-it-does-and-doesnt-mean">Early life adversity</a> can take a wide variety of forms, including malnutrition, war and abuse. People who experience these kinds of traumas, assuming they survive the initial event, are <a href="https://doi.org/10.1542/peds.2011-2663">more likely to suffer health problems</a> and social dysfunction in adulthood and to have shorter life spans. Often, <a href="https://doi.org/10.1111/nyas.13928">these outcomes trace back at least in part</a> to what public health researchers call health risk behaviors – things like smoking, poor eating habits and a sedentary lifestyle.</p>
<p>But researchers have documented the same kinds of <a href="https://doi.org/10.1073/pnas.1205340109">problems in adulthood in nonhuman animals</a> <a href="https://doi.org/10.1016/j.cobeha.2020.06.006">that experienced early life adversity</a>. For example, female baboons who have the hardest childhoods have <a href="https://doi.org/10.1038/ncomms11181">life spans that are on average only half as long</a> as their peers that have the easiest. Activities like smoking and unhealthy food choices can’t be the whole story, then, since animals don’t engage in typical human health risk behaviors.</p>
<p>Given the connection between adverse events while young and poor health later in life, one might expect that Titus’ unlucky early years would predict a short, unhealthy adulthood for him. However, there are interesting hints that things <a href="https://doi.org/10.1016/j.cub.2023.04.051">might work differently in mountain gorillas</a>, which are one of humans’ closest living relatives.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/525945/original/file-20230512-23-8omdyq.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="juvenile gorilla seated" src="https://images.theconversation.com/files/525945/original/file-20230512-23-8omdyq.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/525945/original/file-20230512-23-8omdyq.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/525945/original/file-20230512-23-8omdyq.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/525945/original/file-20230512-23-8omdyq.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/525945/original/file-20230512-23-8omdyq.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=499&fit=crop&dpr=1 754w, https://images.theconversation.com/files/525945/original/file-20230512-23-8omdyq.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=499&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/525945/original/file-20230512-23-8omdyq.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=499&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Researchers analyzed decades of observational data to determine how life turned out for young gorillas that had faced adversity.</span>
<span class="attribution"><span class="source">Dian Fossey Gorilla Fund</span></span>
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</figure>
<h2>Decades of gorilla observations</h2>
<p><a href="https://scholar.google.com/citations?user=GxpHf-AAAAAJ&hl=en&oi=ao">As scientists who have spent</a> <a href="https://scholar.google.com/citations?user=1I9_QM0AAAAJ&hl=en&oi=ao">many years studying wild gorillas</a>, we have observed a wide variety of early life experiences and an equally wide variety of adult health outcomes in these great apes. Unlike other primates, mountain gorillas don’t appear to suffer any long-term negative effects of <a href="https://doi.org/10.7554/eLife.62939">losing their mothers at an early age</a>, provided that they reach the age at which they are old enough to have finished nursing.</p>
<p>Losing your mother is only one of many bad things that can happen to a young gorilla, though. We wanted to investigate whether a pattern of resilience was more generalized. If so, could we gather any insight into the fundamental question of how early life experiences can have long-lasting effects?</p>
<p>To do this, we needed exceptionally detailed long-term data on wild gorillas across their lifetimes. This is no mean feat, given <a href="https://doi.org/10.1038/sdata.2016.6">gorillas’ long life spans</a>. Primatologists know that males can survive into their late 30s and females into their mid-40s.</p>
<p>The best data in the world to conduct such a study comes from the <a href="https://gorillafund.org/">Dian Fossey Gorilla Fund</a>, which has been following individual mountain gorillas in Rwanda almost daily for 55 years. We conducted doctoral and postdoctoral research with the Fossey Fund and have collaborated with other scientists there for more than 20 years.</p>
<p>From their database, which stretches back to 1967, we extracted information on more than 250 gorillas tracked from the day they were born to the day they died or left the study area.</p>
<p>We used this data to identify six adverse events that gorillas younger than age 6 can endure: maternal loss, paternal loss, extreme violence, social isolation, social instability and sibling competition. These experiences are the gorilla equivalent of some kinds of adversity that are linked with long-term negative effects in humans and other animals.</p>
<p>Many young gorillas didn’t survive these challenges. This is a strong indication that these experiences were indeed adverse from the perspective of a gorilla.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/525946/original/file-20230512-15-ldzmn2.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Adult female gorilla seated tightly together with two young gorillas" src="https://images.theconversation.com/files/525946/original/file-20230512-15-ldzmn2.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/525946/original/file-20230512-15-ldzmn2.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/525946/original/file-20230512-15-ldzmn2.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/525946/original/file-20230512-15-ldzmn2.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/525946/original/file-20230512-15-ldzmn2.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/525946/original/file-20230512-15-ldzmn2.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/525946/original/file-20230512-15-ldzmn2.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Ubufatanye experienced the loss of her mother and father and the disintegration of her family group before the age of 5. Now 20, she has become a successful mother, raising three offspring.</span>
<span class="attribution"><span class="source">Dian Fossey Gorilla Fund</span></span>
</figcaption>
</figure>
<p><a href="https://doi.org/10.1016/j.cub.2023.04.051">We were surprised to discover</a>, however, that most of the repercussions of these hardships were confined to early life: animals that survived past the age of 6 did not have the shorter life spans commonly associated with early life adversity in other species.</p>
<p>In fact, gorillas that experienced three or more forms of adversity actually had better survival outcomes, with a 70% reduction in the risk of death across their adult years. Part of this hardiness, especially for males, may be due to a phenomenon called <a href="https://www.biologyonline.com/dictionary/viability#:%7E:text=Viability%20selection%20can%20be%20defined,on%20the%20road%20for%20it.">viability selection</a>: Only the strongest animals survive early adversity, and thus they are also the animals with the longest life spans.</p>
<p>While viability selection may be part of the story, the patterns in our data strongly suggest that as a species, mountain gorillas are also remarkably resilient to early adversity.</p>
<h2>Where do gorillas get their resilience?</h2>
<p>Although our findings corroborate previous research on maternal loss in gorillas, they contrast with other studies on <a href="https://doi.org/10.1037/pag0000394">early adversity in humans</a> and <a href="https://doi.org/10.1111/1365-2656.13785">other long-lived mammals</a>. Our study indicates that the negative later-life consequences of early adversity are not universal.</p>
<p>The absence of this connection in one of our closest relatives suggests there might be protective mechanisms that help build resiliency to early-life knocks. Gorillas may provide valuable clues to understand how early life experiences have such far-reaching effects and how people can potentially overcome them.</p>
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<a href="https://images.theconversation.com/files/525944/original/file-20230512-20526-7wom64.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="two adult and one young gorilla seated together" src="https://images.theconversation.com/files/525944/original/file-20230512-20526-7wom64.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/525944/original/file-20230512-20526-7wom64.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/525944/original/file-20230512-20526-7wom64.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/525944/original/file-20230512-20526-7wom64.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/525944/original/file-20230512-20526-7wom64.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/525944/original/file-20230512-20526-7wom64.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/525944/original/file-20230512-20526-7wom64.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Young gorillas live with their parents as part of larger social groups.</span>
<span class="attribution"><span class="source">Dian Fossey Gorilla Fund</span></span>
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<p>While there is still much left to explore, we suspect that gorillas’ food-rich habitat and cohesive social groups could underpin their resiliency. When young gorillas lose their mothers, <a href="https://doi.org/10.7554/eLife.62939">other social group members fill in</a> the companionship hole she leaves behind. Something similar may happen for other types of early adversity as well. A supportive social network combined with plentiful food may help a young gorilla push through challenges.</p>
<p>This possibility underscores the importance of ensuring that human children who experience early adversity are <a href="https://doi.org/10.1001/jamapediatrics.2016.1559">supported in multiple ways</a>: socially, but also economically, especially since early adversity is particularly prevalent among children living in poverty – itself a form of adversity.</p>
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<a href="https://images.theconversation.com/files/525223/original/file-20230509-25-vqm6q4.JPG?ixlib=rb-1.1.0&rect=436%2C0%2C3845%2C2702&q=45&auto=format&w=1000&fit=clip"><img alt="large adult male gorilla against leafy background" src="https://images.theconversation.com/files/525223/original/file-20230509-25-vqm6q4.JPG?ixlib=rb-1.1.0&rect=436%2C0%2C3845%2C2702&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/525223/original/file-20230509-25-vqm6q4.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/525223/original/file-20230509-25-vqm6q4.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/525223/original/file-20230509-25-vqm6q4.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/525223/original/file-20230509-25-vqm6q4.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/525223/original/file-20230509-25-vqm6q4.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/525223/original/file-20230509-25-vqm6q4.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Titus, pictured here as an adult, survived more adversity before age 4 than many animals confront in a lifetime.</span>
<span class="attribution"><span class="source">Dian Fossey Gorilla Fund</span></span>
</figcaption>
</figure>
<p><a href="https://www.imdb.com/title/tt1922764/">And what became of Titus</a>? Despite his difficult start in life, Titus went on to lead his group for two decades, siring at least 13 offspring and surviving to his 35th birthday, making him one of the most successful gorillas the Dian Fossey Gorilla Fund has ever studied.</p>
<p>Though Titus’ story is only a single anecdote, it turns out that his resilience is not so unusual for a member of his species.</p><img src="https://counter.theconversation.com/content/205184/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stacy Rosenbaum receives funding from the National Institutes of Health (NIH) and the University of Michigan. </span></em></p><p class="fine-print"><em><span>Robin Morrison receives funding from the Dian Fossey Gorilla Fund and the Swiss National Science Foundation. </span></em></p>In many animals, including humans, adverse events in youth have lasting negative health effects over the life span. But new research suggests something different is going on in mountain gorillas.Stacy Rosenbaum, Assistant Professor of Anthropology, University of MichiganRobin Morrison, Postdoctoral Fellow in Animal Behavior, University of ExeterLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2001532023-02-20T20:11:51Z2023-02-20T20:11:51ZEpigenetic and social factors both predict aging and health – but new research suggests one might be stronger<figure><img src="https://images.theconversation.com/files/510905/original/file-20230217-22-uooeg7.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C3295%2C2549&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Epigenetics is but one of many factors that influence aging, health and disease.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/clock-and-dna-royalty-free-image/1094434840">bestdesigns/iStock via Getty Images</a></span></figcaption></figure><p>Can we objectively tell how fast we are aging? With a good measure, scientists might be able to change our rate of aging to live longer and healthier lives. Researchers know that some people age faster than others and have been trying to concisely measure the internal physiological changes that lead to deteriorating health with age.</p>
<p>For years, researchers have been using <a href="https://doi.org/10.1093/gerona/gls233">clinical factors</a> normally collected at physicals, like hypertension, cholesterol and weight, as indicators to predict aging. The idea was that these measures could determine whether someone is a fast or slow ager at any point in their life cycle. But more recently, researchers have theorized that there are other biological markers that reflect aging at the <a href="https://doi.org/10.1016%2Fj.cell.2013.05.039">molecular and cellular level</a>. This includes modifications to a person’s genetic material itself, or epigenetics.</p>
<p>While each person has a genetic makeup that largely does not change over their lifetime, chemical changes to their genetic material that occur throughout life can change which genes are turned on or off and lead to more rapid aging. These changes typically involve the addition of methyl groups to DNA and are <a href="https://doi.org/10.1016/j.ssmph.2022.101071">influenced by social</a> and <a href="https://doi.org/10.1186/s13148-022-01286-8">environmental exposures</a>, such as adverse childhood experiences, smoking, pollution and depression.</p>
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<iframe width="440" height="260" src="https://www.youtube.com/embed/GASaqPv0t0g?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">The body undergoes many changes as it ages.</span></figcaption>
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<p>But how well do epigenetic markers predict the important health changes that happen with aging? We are <a href="https://scholar.google.com/citations?hl=en&user=xcXH8QcAAAAJ">social</a> <a href="https://scholar.google.com/citations?user=0aj9ZoEAAAAJ&hl=en">scientists</a> who study how social factors predict aging. Our <a href="https://doi.org/10.1016/j.arr.2020.101136">previous research</a> has shown that factors like education, poverty, race, access to medical care and certain health behaviors can influence aging rates. We are incorporating biological measures like epigenetic age in large population studies to understand how social factors get “under the skin” and affect aging. In our <a href="https://www.pnas.org/cgi/doi/10.1073/pnas.2215840120">recently published study</a>, we found that while epigenetic age does predict certain health outcomes later in life, it does little to explain important differences related to social factors.</p>
<h2>What is epigenetic aging?</h2>
<p>In 2013, geneticist and biostatistician <a href="https://scholar.google.com/citations?user=mEM8q5cAAAAJ&hl=en">Steve Horvath</a> introduced the idea that a person’s rate of aging would be captured by the <a href="https://doi.org/10.1186/gb-2013-14-10-r115">level of methylation</a> in their genome. He also developed ways to measure epigenetic age in terms of years and compare this age to one’s chronological age.</p>
<p>Researchers have since developed <a href="https://doi.org/10.18632/aging.101684">several measures</a> that can more reliably predict health outcomes based on epigenetics. Some have suggested that DNA methylation could potentially be used to summarize the amount and rate of aging with a <a href="https://doi.org/10.7554/eLife.54870">few drops of blood</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/510924/original/file-20230217-18-vamim0.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Diagram of DNA methylation" src="https://images.theconversation.com/files/510924/original/file-20230217-18-vamim0.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/510924/original/file-20230217-18-vamim0.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=408&fit=crop&dpr=1 600w, https://images.theconversation.com/files/510924/original/file-20230217-18-vamim0.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=408&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/510924/original/file-20230217-18-vamim0.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=408&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/510924/original/file-20230217-18-vamim0.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=513&fit=crop&dpr=1 754w, https://images.theconversation.com/files/510924/original/file-20230217-18-vamim0.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=513&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/510924/original/file-20230217-18-vamim0.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=513&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Epigenetics can influence health in a number of ways.</span>
<span class="attribution"><a class="source" href="http://commonfund.nih.gov/epigenomics/figure">National Institutes of Health</a></span>
</figcaption>
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<h2>Comparing epigenetic and social factors</h2>
<p>It has been unclear how well epigenetic age predicts health outcomes compared to other nongenetic factors like demographics and socioeconomic status. We wanted to see whether epigenetic age, measured by DNA methylation levels in the blood, predicted four aging-related health outcomes: death, chronic disease, physical disability and cognitive dysfunction.</p>
<p>Using data from the <a href="https://hrs.isr.umich.edu/about">Health and Retirement Study</a>, a large, nationally representative sample of Americans over the age of 56, we found that epigenetic age <a href="https://www.pnas.org/cgi/doi/10.1073/pnas.2215840120">predicted all of the health outcomes we examined</a>. Epigentic age most strongly predicted death and morbidity later in life. So overall, people with a higher epigenetic age experienced poorer health.</p>
<p>On the other hand, epigenetic age did not explain why people with certain demographics – such as having less education, smoking, being Black or Hispanic, being obese or having a more difficult childhood – experienced worse health outcomes earlier or more frequently. These social factors were able to predict mortality and morbidity just as well as epigenetics and substantially predicted physical and cognitive functioning better than epigentic age.</p>
<p>Our findings suggest that while DNA methylation is a useful addition to the toolbox to predict health outcomes later in life, other factors such as demographics, socioeconomic status, mental health and health behaviors remain equally, if not more robust, predictors of health.</p>
<h2>Better predicting aging and health</h2>
<p>Epigenetic aging processes like DNA methylation show promise in explaining aging. But there is still a long way to go before researchers fully understand the molecular and cellular mechanisms underlying aging.</p>
<p>Improving our ability to measure both the lifetime social experiences that affect biology and the biological mechanisms that underlie aging could lead not only to better measurements of aging, but to better treatments and disease prevention for those who need it the most.</p><img src="https://counter.theconversation.com/content/200153/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Eileen Crimmins receives funding from the National Institute on Aging .
</span></em></p><p class="fine-print"><em><span>Jessica Faul receives funding from the National Institute on Aging.</span></em></p>People don’t all age at the same rate. Untangling the factors that influence health and disease – such as epigenetics, demographics and behavior – could lead to better care for those who need it most.Eileen Crimmins, Professor of Gerontology, University of Southern CaliforniaJessica Faul, Research Associate Professor of Epidemiology, University of MichiganLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1791692022-04-13T12:13:53Z2022-04-13T12:13:53ZALS is only 50% genetic – identifying DNA regions affected by lifestyle and environmental risk factors could help pinpoint avenues for treatment<figure><img src="https://images.theconversation.com/files/456422/original/file-20220405-14-ks7fbg.png?ixlib=rb-1.1.0&rect=0%2C0%2C2309%2C1299&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Epigenetics is how behavior and environment affect gene expression.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/the-dna-spiral-royalty-free-image/1293534045">Iryna Dobytchina/iStock via Getty Images Plus</a></span></figcaption></figure><p><a href="https://medlineplus.gov/amyotrophiclateralsclerosis.html">Amyotrophic lateral sclerosis</a> is a devastating neurodegenerative disease that affects about <a href="https://dx.doi.org/10.1038%2Fncomms12408">1 in 50,000 people</a>. Well-known people who suffered from ALS include baseball player <a href="https://www.als.org/understanding-als/lou-gehrig">Lou Gehrig</a>, who lived two years after he was diagnosed, and scientist <a href="https://www.nbcnews.com/health/health-care/stephen-hawking-had-als-55-years-how-did-he-do-n857006">Stephen Hawking</a>, who lived for an extraordinary 55 years after his diagnosis. While the severity and speed of disease progression <a href="https://www.als.org/understanding-als">vary from person to person</a>, most people with ALS die within two to five years after diagnosis. <a href="https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Amyotrophic-Lateral-Sclerosis-ALS-Fact-Sheet">No effective therapy</a> currently exists.</p>
<p>Little is known about what causes or increases someone’s risk of developing ALS. Researchers think it’s only <a href="https://doi.org/10.1001/jamaneurol.2019.2044">around 50% genetic</a>, indicating that there are strong environmental and lifestyle risk factors affecting disease development. But very few of these risk factors have been identified.</p>
<p><a href="https://www.researchgate.net/profile/Ramona-Zwamborn-2">We</a> <a href="https://www.researchgate.net/profile/Paul-Hop-2">are</a> <a href="https://www.researchgate.net/scientific-contributions/Jan-H-Veldink-39091027">a</a> team of <a href="https://www.projectmine.com/country/the-nederlands/">neuroscientists</a> with a special interest in <a href="https://medlineplus.gov/genetics/understanding/howgeneswork/epigenome/">epigenetics</a>, the study of how the environment influences DNA. By examining the epigenetics of ALS, we found that differences in metabolism, cholesterol and immunity may play a role in disease progression.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/xrIjFVMliOQ?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">ALS involves the progressive degeneration of the neurons involved in muscle movement.</span></figcaption>
</figure>
<h2>Nongenetic risk factors</h2>
<p>Epigenetics opens a window into the role environmental factors play in genetic diseases like ALS. One common type of epigenetic mechanism is <a href="https://doi.org/10.1007/978-1-61779-612-8_23">DNA methylation</a>, an on-off switch for certain regions of DNA that shift throughout a person’s lifetime. The ways these on-off patterns change are known to be shaped by environmental and lifestyle factors.</p>
<p>To unravel how DNA methylation affects ALS, we analyzed DNA samples and lifestyle questionnaire responses from almost 10,000 patients with and without ALS. This data was collected by <a href="https://www.projectmine.com/">Project MinE</a>, an international initiative creating a database of the genetic profiles of ALS patients. </p>
<p>We discovered <a href="http://dx.doi.org/10.1126/scitranslmed.abj0264">differences in methylation</a> patterns between people with ALS and people without ALS in 45 DNA regions. When we examined the specific genes located in these areas, we found that people with ALS mainly showed differences in methylation on genes that play a role in metabolism, cholesterol production and immunity. These findings support a recent <a href="https://doi.org/10.1038/s41588-021-00973-1">Project MinE study</a> that showed a causal link between high cholesterol levels and ALS.</p>
<p>Our team also examined DNA methylation patterns that reflect exposure to certain environmental or lifestyle factors (such as smoking or high body mass index), or biological processes (such as aging). Even after controlling for the effects of these other common risk factors, we found that metabolism, cholesterol and immunity were still associated with ALS.</p>
<p>Changes in methylation patterns for multiple DNA regions, and especially those related to immune processes, were also associated with survival rates for people living with ALS.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/456406/original/file-20220405-14-p1qj70.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Diagram of DNA methylation and histone modification" src="https://images.theconversation.com/files/456406/original/file-20220405-14-p1qj70.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/456406/original/file-20220405-14-p1qj70.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=408&fit=crop&dpr=1 600w, https://images.theconversation.com/files/456406/original/file-20220405-14-p1qj70.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=408&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/456406/original/file-20220405-14-p1qj70.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=408&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/456406/original/file-20220405-14-p1qj70.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=513&fit=crop&dpr=1 754w, https://images.theconversation.com/files/456406/original/file-20220405-14-p1qj70.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=513&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/456406/original/file-20220405-14-p1qj70.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=513&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Environmental factors can affect genetic material through an epigenetic mechanism that involves methyl groups tagging DNA to turn it on or off.</span>
<span class="attribution"><a class="source" href="http://commonfund.nih.gov/epigenomics/figure">National Institutes of Health</a></span>
</figcaption>
</figure>
<h2>Next steps</h2>
<p>Currently, no cure exists for this devastating and deadly disease. Our study helps clarify the biological processes that underlie ALS risk factors and disease progression, and could potentially be used to develop new treatments or preventive interventions.</p>
<p>It is important to emphasize, however, that the epigenetic differences between people with and without ALS that we found were small. Our study also doesn’t prove that changes in genes involved in metabolism, cholesterol production or immunity cause or are influenced by ALS. More research is needed before physicians can confidently recommend lifestyle changes to help cut the risk of ALS.</p>
<p>[<em>Get fascinating science, health and technology news.</em> <a href="https://memberservices.theconversation.com/newsletters/?nl=science&source=inline-science-fascinating">Sign up for The Conversation’s weekly science newsletter</a>.]</p><img src="https://counter.theconversation.com/content/179169/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jan Veldink receives funding from the European Research Council (ERC) and Biogen (sponsored research agreements).</span></em></p><p class="fine-print"><em><span>Paul J. Hop and Ramona Zwamborn do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Genetic modifications to DNA regions involved in metabolism, cholesterol and immunity may play a role in ALS disease progression.Ramona Zwamborn, PhD candidate in Neurogenetics, Utrecht UniversityJan Veldink, Professor of Neurology and Neurogenetics, Utrecht UniversityPaul J. Hop, PhD candidate in Neurogenetics, Utrecht UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1623112021-07-06T15:54:12Z2021-07-06T15:54:12ZGood storytellers get better health care — but childhood trauma confuses the narrative<figure><img src="https://images.theconversation.com/files/409669/original/file-20210705-26172-1opejpp.png?ixlib=rb-1.1.0&rect=802%2C0%2C1173%2C755&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Survivors of childhood trauma often struggle to clearly describe current health issues to health-care providers, and may not get the help they need. </span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>When describing their symptoms, medical history and health changes at a clinic or hospital, every patient is the storyteller of their own health. Good storytellers tend to get better health care, but a history of childhood trauma plays havoc with telling your own story. </p>
<p>Consider Florence, as a (fictional) example:</p>
<p>It is a hot July night and Florence is having dizzy spells again. She feels dreadful and is worried. What if it happens when she is driving? What if it doesn’t get better? How can she work like this? What if it is a stroke or a tumour? She goes to the emergency department in spite of her past experience that it isn’t very helpful. </p>
<p>The triage nurse asks what she is there for. “Well, I had this bad thing… they did tests and it was almost normal…” </p>
<p>The nurse looks puzzled. “When was that?” </p>
<p>“October. I was…” The triage nurse doesn’t need to hear what happened nine months ago. She cuts Florence off and points her toward the waiting area. </p>
<p>A while later Florence meets with a doctor. She has been practising what to say while she waits. He interrupts after a few seconds to ask what Florence means by “dizzy.” </p>
<p>Florence replies, “You know, it’s like that dizzy feeling, oh I hate that, you know …”</p>
<p>Although it doesn’t occur to either Florence or the doctor, a lifetime of difficulty — starting with violence that she witnessed and experienced as a child — is compromising Florence’s health.</p>
<h2>ACEs and health</h2>
<p>Research on the links between <a href="https://www.cdc.gov/violenceprevention/aces/index.html">adverse childhood experiences</a> (ACEs) and poor mental and physical health has made this formerly hidden risk factor for many of our most common and burdensome chronic diseases a topic of public discussion. </p>
<p>The numbers are mind-boggling. <a href="https://www.cdc.gov/violenceprevention/aces/fastfact.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fviolenceprevention%2Facestudy%2Ffastfact.html">About 60 per cent of adults experienced at least one type of ACE</a> as they are usually defined. <a href="https://dx.doi.org/10.1503%2Fcmaj.131792">About one in three children experience serious physical or sexual abuse or are exposed to interpersonal violence</a>. It is a major public health problem.</p>
<figure class="align-center ">
<img alt="A doctor consulting with a patient." src="https://images.theconversation.com/files/409736/original/file-20210705-126544-jdl040.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/409736/original/file-20210705-126544-jdl040.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/409736/original/file-20210705-126544-jdl040.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/409736/original/file-20210705-126544-jdl040.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/409736/original/file-20210705-126544-jdl040.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/409736/original/file-20210705-126544-jdl040.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/409736/original/file-20210705-126544-jdl040.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">There is a strong relationship between unresolved developmental trauma and impaired storytelling. This ‘narrative incoherence’ makes it more difficult to get good health care.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>ACEs are linked to unhealthy behaviour and experiences later in life. They increase the risk that a child <a href="https://doi.org/10.1016/S2468-2667(17)30118-4">will smoke cigarettes, adopt unhealthy drug and alcohol use, become obese,</a> or <a href="https://doi.org/10.3402/gha.v9.31516">experience further trauma as an adult</a>. Because of this, and because of other effects of stress on health, ACEs <a href="https://www150.statcan.gc.ca/n1/en/pub/82-003-x/2016003/article/14339-eng.pdf?st=BgdCGxS8">increase the risk of diseases of the heart, lungs and liver, pain syndromes, and some cancers</a>. </p>
<p>What Florence is experiencing in the emergency room is a further consequence of childhood adversity — one that makes it much harder to get good health care. There is a strong relationship between unresolved developmental trauma and impaired storytelling. <a href="https://doi.org/10.1521/pdps.2012.40.4.549">This is technically called “narrative incoherence</a>.”</p>
<h2>Storytelling and health</h2>
<p>The qualities of a good narrative were <a href="https://doi.org/10.1163/9789004368811_003">described by the philosopher Paul Grice in four maxims</a>: </p>
<ul>
<li>have evidence for what you say (quality),</li>
<li>be succinct, yet complete (quantity),</li>
<li>be relevant to the topic at hand (relation) and </li>
<li>be clear and orderly (manner).</li>
</ul>
<p>Psychologist Mary Main and her collaborators <a href="https://doi.org/10.1177%2F00030651000480041801">used Grice’s maxims to describe how unresolved childhood trauma and loss can affect a person’s state of mind</a> regarding important relationships in their life. They found people with unresolved trauma could be identified by failures in the quality, quantity, relation and manner of the stories they told during an emotionally taxing interview about those relationships. </p>
<p>It is a short leap from that research to high-stakes conversations in an emergency department or doctor’s office where someone like Florence struggles to make her condition clear and receive the help they need. </p>
<h2>Styles of narrative incoherence</h2>
<p>There are two common <a href="https://dx.doi.org/10.1097%2FPSY.0000000000000107">patterns of incoherence</a> in these interactions. Florence’s pattern is called <em>preoccupied</em>. Her anxiety is obvious. She is too overwhelmed by fear to organize her thoughts. She presents events out of sequence; her thoughts are unfinished; there are too many details; it is hard to tell the signal from the noise. </p>
<p>As a result, it can seem like the story of Florence’s health is a jigsaw puzzle and all the pieces have been dumped on the table at once. A listener feels baffled and frustrated. The doctor may start his note with the comment “poor historian.” </p>
<p>The second pattern of narrative incoherence is quite different from Florence’s preoccupied pattern of providing too much disorganzied information. A person with a <em>dismissing</em> pattern tends to provide conclusions without evidence, and generalizations without examples. </p>
<p>Q: “How does that feel?” A: “Same as always.” </p>
<p>Q: “How long has this been going on?” A: “A while.” </p>
<p>The conversation is short and at its end a health-care provider is unilluminated. While someone like Florence wears her anxiety on her sleeve, a person with the dismissing style keeps their cards close to their chest. A listener feels uninvited to ask more.</p>
<h2>Practical steps</h2>
<p>If Florence and her health-care providers are able to recognize that trouble telling her own story is a clue to what is going on — not just a marker that she is a “poor historian” — they can take steps to meet the challenge. Some steps Florence can take include:</p>
<ul>
<li>Bringing a friend with her who helps her stay calm and organized.</li>
<li>Explaining that she is anxious and needs a little time to describe the trouble.</li>
<li>Making notes in advance about her most important points and questions.</li>
</ul>
<p>Even more importantly, health-care workers need to recognize the face of fear. The doctor can help Florence to organize her thoughts instead of interrupting to interrogate her. They can help each other to find the story that allows her dizziness to be understood.</p>
<p>Every patient is forced to be a storyteller; a health-care professional’s job is to make them an excellent one.</p><img src="https://counter.theconversation.com/content/162311/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Adults who experienced trauma in childhood may get poor medical care because they have trouble telling a clear story about their health.Robert Maunder, Professor of Psychiatry, University of TorontoJon Hunter, Professor of Psychiatry, University of TorontoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1316372020-09-29T21:05:41Z2020-09-29T21:05:41ZThe obesity paradox: Obese patients fare better than others after heart surgery<figure><img src="https://images.theconversation.com/files/358962/original/file-20200921-22-12bewf7.jpg?ixlib=rb-1.1.0&rect=33%2C107%2C4425%2C3853&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Patients who were overweight and obese had lower mortality rates following cardiac surgery than those with BMIs in the normal or underweight range.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>The World Health Organization has <a href="http://www.who.int/nutrition/topics/obesity/en/">declared obesity to be a global epidemic</a> that “threatens to overwhelm both developed and developing countries.” However, is obesity always bad when it comes to health? </p>
<p>Certainly, obesity is a significant risk factor for the development of many chronic conditions, <a href="https://www.heartandstroke.ca/get-healthy/healthy-weight/maintaining-a-healthy-weight">including heart disease</a>. However, research has shown that in a number of situations, being overweight may actually be of benefit. This phenomenon has been called the “<a href="https://doi.org/10.1007/s10198-016-0803-4">obesity paradox</a>.” </p>
<p>Our group from the departments of public health sciences and anesthesiology and perioperative medicine at Queen’s University <a href="https://doi.org/10.1161/JAHA.115.002140">investigated the relationship between body mass index (BMI, a commonly used ratio of weight to height) and outcomes after heart surgery</a>. We analyzed a large database of health records of almost 80,000 patients having open coronary bypass surgery in Ontario over a 13-year period <a href="https://www.ices.on.ca/">using data from ICES</a>, a not-for-profit research institute in Ontario. We tracked five-year survival rates as well as complications occurring during the year after surgery. </p>
<p>We found that patients in the overweight and moderately obese categories made up two-thirds of all cardiac surgery patients. However, these patients actually had lower death rates and complications than patients in the normal weight, underweight and morbidly obese categories. </p>
<p>The highest risk of complications was seen at the extremes of BMI, meaning patients in the underweight and the morbidly obese categories. Such a relationship <a href="https://www.tctmd.com/news/obesity-paradox-alive-and-well-across-racialethnic-spectrum-heart-failure-patients">has also been found in other patient groups</a> with different <a href="https://doi.org/10.1371/journal.pone.0195853">medical conditions or procedures</a>. </p>
<figure class="align-center ">
<img alt="Bar graph showing mortality rates for BMI ranging from underweight through morbidly obese. The underweight category has significantly higher mortality that the others, while the overweight and obese categories have the lowest." src="https://images.theconversation.com/files/316365/original/file-20200220-92541-mx7whv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/316365/original/file-20200220-92541-mx7whv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=635&fit=crop&dpr=1 600w, https://images.theconversation.com/files/316365/original/file-20200220-92541-mx7whv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=635&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/316365/original/file-20200220-92541-mx7whv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=635&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/316365/original/file-20200220-92541-mx7whv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=798&fit=crop&dpr=1 754w, https://images.theconversation.com/files/316365/original/file-20200220-92541-mx7whv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=798&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/316365/original/file-20200220-92541-mx7whv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=798&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Mortality rates following cardiac surgery by BMI.</span>
<span class="attribution"><span class="source">(Ana Johnson)</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<h2>Economies of scale</h2>
<p>In addition to the difference in complication rates, there are <a href="https://doi.org/10.1007/s10198-016-0803-4">economic implications</a> for these findings. We analyzed the financial costs of coronary bypass surgery and the medical care during the year following surgery in a group of over 53,000 patients over a 10-year period. </p>
<p>Not surprisingly, due to the disproportionate number of patients in these categories having heart surgery, overweight and obese patients accounted for the overall majority of health-care costs, a total of $1.4 billion (in 2014 Canadian dollars), compared to $788 million for the other BMI categories combined. However, the average cost of care per patient in the overweight and obese categories was substantially lower than in the normal weight, underweight and morbidly obese categories. </p>
<h2>Weighing in on weight gain</h2>
<p>This does not necessarily mean that weight gain should be recommended to reduce these risks. The scientific literature is consistent that <a href="https://www.heartandstroke.ca/get-healthy">obesity and lack of fitness are associated with cardiovascular disease</a>, as well as many other risk factors for heart disease such as high blood pressure and diabetes. </p>
<p>However, once the need for surgery is determined, having excess body fat may provide increased energy reserves during a period of stress and healing that are not available to lower-weight patients. This advantage is lost in the case of extreme obesity, where the common presence of other related diseases and reduced mobility after surgery likely contribute to the increased complication rate. </p>
<h2>The perils of frailty</h2>
<p>On the other hand, we found that being underweight is associated with increased mortality in hospital patients and increased health costs. In fact, low BMI is more detrimental to the recovery from heart surgery than even extreme obesity. This may reflect the <a href="https://doi.org/10.1161/JAHA.118.009882">negative effects of frailty</a>, which has been shown to adversely affect recovery from surgery. </p>
<figure class="align-right ">
<img alt="A woman's feet standing on a scale that reads about 51 kilograms." src="https://images.theconversation.com/files/358949/original/file-20200921-24-14bprk2.jpg?ixlib=rb-1.1.0&rect=2%2C548%2C1353%2C1370&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/358949/original/file-20200921-24-14bprk2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=842&fit=crop&dpr=1 600w, https://images.theconversation.com/files/358949/original/file-20200921-24-14bprk2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=842&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/358949/original/file-20200921-24-14bprk2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=842&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/358949/original/file-20200921-24-14bprk2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1058&fit=crop&dpr=1 754w, https://images.theconversation.com/files/358949/original/file-20200921-24-14bprk2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1058&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/358949/original/file-20200921-24-14bprk2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1058&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The higher mortality rates of heart surgery patients in the lowest BMI category may reflect the negative effects of frailty, which has been shown to adversely affect recovery from surgery.</span>
<span class="attribution"><span class="source">(Pixabay)</span></span>
</figcaption>
</figure>
<p>In addition to reduced body fat, patients in the underweight category typically have reduced muscle mass, which limits function and mobility even before surgery. That leaves them with little in reserve to resist the stress of major surgery and the prolonged recovery period afterwards. </p>
<p>Even when taking advanced age and other diseases into account, low BMI was independently associated with death and other complications after heart surgery. This suggests that patients who are frail might do better after surgery if — time permitting — they were offered an exercise and nutrition program before surgery.</p>
<h2>What is normal anyway?</h2>
<p>It’s also important to look at the BMI category that was considered to be the standard for comparison: patients in the so-called “normal” weight category. This is generally considered the optimal BMI and the target for most fitness strategies. However, in our study and others, patients in the normal weight category had worse outcomes than patients in the overweight and moderately obese categories. </p>
<p>Importantly, these results do not mean that fattening up the population in the normal weight band should become a public health goal. </p>
<p>First, as mentioned, patients who are overweight have a far higher risk of developing heart disease in the first place, and an ounce (or gram) of prevention is a much more effective health strategy than a pound (or kilogram) of cure. Improving the fitness of the population is one of the most important <a href="https://www.heartandstroke.ca/get-healthy/stay-active">public health strategies for reducing heart disease</a> and the need for heart surgery in the first place. </p>
<p>Second, it may well be that what is an optimal BMI in other situations should not be considered optimal for recovery from surgery, and so it would make sense to define a “normal” BMI according to the specific situation. In this sense, the obesity paradox might not be a paradox at all.</p>
<p><em>This article was also co-authored by Dr. Brian Milne, professor emeritus, anesthesiology and perioperative medicine, Queen’s University.</em></p><img src="https://counter.theconversation.com/content/131637/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>For patients recovering from heart surgery, being overweight or moderately obese appears to be an advantage over being underweight or even having a normal BMI.Ana Johnson, Professor, Department of Public Health Sciences, Queen's University, OntarioJoel Parlow, Professor, Anesthesiology and Perioperative Medicine, Queen's University, OntarioLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1431222020-07-22T13:56:11Z2020-07-22T13:56:11ZThe ten factors linked to increased risk of Alzheimer’s disease<figure><img src="https://images.theconversation.com/files/348918/original/file-20200722-28-1wg1zru.jpg?ixlib=rb-1.1.0&rect=0%2C8%2C5499%2C3655&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Many of these risk factors are preventable.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/son-take-care-his-father-who-732630985">tonkid/ Shutterstock</a></span></figcaption></figure><p>Although there’s still no cure, researchers are continuing to develop a better understanding of what increases a person’s risk of developing Alzheimer’s disease. A <a href="https://jnnp.bmj.com/content/early/2020/06/01/jnnp-2019-321913">recent study</a> that looked at 396 studies has even been able to identify ten risk factors that are shown to increase the likelihood of developing the disease. </p>
<p>Here are the factors researchers identified – and why they’re associated with a higher risk. </p>
<h2>1. Education level</h2>
<p>A lower education level is associated with an increased risk of Alzheimer’s disease. Previous evidence shows the longer you spend in education, the <a href="https://pubmed.ncbi.nlm.nih.gov/8139057/">lower your risk</a> of developing dementia. <a href="https://academic.oup.com/brain/article/133/8/2210/395786">Research</a> looking at the brains of people from different educational backgrounds also showed that people who were more educated had heavier brains. As you lose <a href="https://pubmed.ncbi.nlm.nih.gov/16227537/">one third</a> of your brain weight because of dementia, a heavier brain may make you more resilient.</p>
<h2>2. Cognitive activity</h2>
<p>Evidence shows that <a href="https://pubmed.ncbi.nlm.nih.gov/17596582/">keeping our brains active</a> can also fight against dementia. Activities such as word puzzles stimulate your brain and can strengthen connectivity between brain cells. This <a href="https://science.sciencemag.org/content/298/5594/789">connectivity is broken down</a> in dementia.</p>
<p>This latest study shows that we need to continue keeping our brains active, even in older age. Other studies agree that challenging our brains does indeed <a href="https://pubmed.ncbi.nlm.nih.gov/16207391/">reduce our chances</a> of developing dementia. </p>
<h2>3. Hypertension in mid-life</h2>
<p>Healthy hearts have long been <a href="https://pubmed.ncbi.nlm.nih.gov/22968344/">linked to a healthy brain</a>. Here, the current study indicates that high blood pressure (hypertension) in middle age increases Alzheimer’s risk.</p>
<p>Higher incidence of heart disease in those suffering from <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5398900/">high blood pressure</a> impacts on the blood and nutrient supply to the brain. Interestingly, this association still exists even for those <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6122131/">who have</a> high blood pressure on its own. The bottom line is that <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3481957/">reduced blood supply</a> to the brain is linked with Alzheimer’s.</p>
<h2>4. Orthostatic hypotension</h2>
<p>The study also highlighted orthostatic hypotension as a risk factor. This is when someone experiences low blood pressure when standing after sitting or lying down. </p>
<p>Because the body is unable to maintain sufficient blood supply to the brain during posture changes, this can have a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6683958/">long-term debilitating influence</a> on <a href="https://pubmed.ncbi.nlm.nih.gov/29111025/">brain activity</a>, as a result of lack of oxygen to the brain, which increases risk of dementia.</p>
<h2>5. Diabetes</h2>
<p>The study found diabetes was associated with higher incidence of Alzheimer’s. As diabetes makes our body unable to properly regulate insulin, this changes both the way our brain cells communicate and our memory function – both of which are <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3443484/">disrupted in Alzheimer’s disease</a>. </p>
<p><a href="https://pubchem.ncbi.nlm.nih.gov/compound/Insulin#section=Springer-Nature-References">Insulin is essential</a>, as it regulates the metabolism of carbohydrates, fats and protein by helping blood glucose absorb into the liver, fat and muscles. Alzheimer’s disease appears to disrupts the brain’s ability to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4253975/#R200">react to insulin</a>.</p>
<h2>6. BMI</h2>
<p>A higher body mass index (BMI) in under 65s is linked to increased risk of dementia. The study suggests a body mass index between 18.5 and 24.9 for those under 65 – a healthy weight, in other words – may lower dementia risk. However, <a href="https://www.thelancet.com/journals/landia/article/PIIS2213-8587(15)000339/fulltext#:%7E:text=However%2C%20the%20association%20between%20BMI%20and%20risk%20of,and%20the%20risk%20of%20dementia%20and%20Alzheimer%20disease">being underweight</a> in middle age and later life can increase dementia risk.</p>
<figure class="align-center ">
<img alt="'Person stands on white bathroom scale'" src="https://images.theconversation.com/files/348882/original/file-20200722-38-prp8fc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/348882/original/file-20200722-38-prp8fc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/348882/original/file-20200722-38-prp8fc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/348882/original/file-20200722-38-prp8fc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/348882/original/file-20200722-38-prp8fc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/348882/original/file-20200722-38-prp8fc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/348882/original/file-20200722-38-prp8fc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Being overweight and underweight both carry increased risk.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/close-shot-woman-standing-on-weight-1463581310">Seksan.TH/ Shutterstock</a></span>
</figcaption>
</figure>
<p>It’s thought that a mixture of genetics, cardiovascular diseases and inflammation all contribute to this association between <a href="https://academic.oup.com/ije/article/doi/10.1093/ije/dyaa099/5861491">BMI and dementia</a>.</p>
<h2>7. Head trauma</h2>
<p>Past head trauma is a risk factor – and there is clear evidence that <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa1908483">head trauma</a>, such as a concussion, can contribute to the <a href="https://pubmed.ncbi.nlm.nih.gov/28269777/">development of dementia</a>. This link was <a href="https://academic.oup.com/brain/article/141/1/318/4774567">first observed in 1928</a>.</p>
<p>However, it’s uncertain whether single or repetitive head trauma is the contributing factor. It’s clear that brain damage from head trauma is similar to that of dementia. This makes people more susceptible to <a href="https://pubmed.ncbi.nlm.nih.gov/16227537/">further damage later</a> from dementia.</p>
<h2>8. Hyperhomocysteinaemia</h2>
<p>High levels of the chemical homocysteine are a risk factor. Homocysteine is a naturally occurring amino acid involved in the production of our body’s defence mechanisms, including antioxidants that <a href="https://theconversation.com/what-are-antioxidants-and-are-they-truly-good-for-us-86062">prevent cellular damage</a>.</p>
<p>Elevated blood levels of homocysteine in people with dementia was <a href="https://pubmed.ncbi.nlm.nih.gov/9823829/">first reported</a> in 1998. Studies have since shown that <a href="https://pubmed.ncbi.nlm.nih.gov/20838622/">reducing levels</a> of homocysteine may <a href="https://pubmed.ncbi.nlm.nih.gov/29480200/">protect against dementia</a>.</p>
<p>Animal studies suggest elevated levels of homocysteine <a href="https://pubmed.ncbi.nlm.nih.gov/32024240/">damage brain cells</a> by interfering with their energy production. Consuming more <a href="https://pubmed.ncbi.nlm.nih.gov/18843658/">folate and vitamin B12</a> can lower homocysteine levels – and may <a href="https://pubmed.ncbi.nlm.nih.gov/28759193/">reduce dementia risk</a>.</p>
<h2>9. Depression</h2>
<p>Those living with Alzheimer’s also often <a href="https://www.ncbi.nlm.nih.gov/books/NBK551552/">suffer from depression</a>, though it’s uncertain if depression causes Alzheimer’s or is just a symptom of the disease. However, a wealth of evidence supports that depression is indeed a risk factor, as this latest study has found. Research has even <a href="https://pubmed.ncbi.nlm.nih.gov/20603482/">indicated a link</a> between the <a href="https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2627700">number of</a> depressive episodes – especially ten years prior to dementia onset – and higher risk.</p>
<p>Depression increases levels of harmful chemicals in our brain. An imbalance in these chemicals can lead to <a href="https://www.sciencedirect.com/science/article/abs/pii/S0955067411001104#:%7E:text=%20Cell%20atrophy%20and%20loss%20in%20depression%3A%20reversal,and%20survival.%20Although%20stress%20and%20depression...%20More%20">loss of brain cells</a>. This, coupled with the loss of brain cells in dementia, increases likelihood of Alzheimer’s.</p>
<h2>10. Stress</h2>
<p>Lastly, stress was identified as a risk factor. Long term stress targets our body’s immune cells, which are important in <a href="https://pubmed.ncbi.nlm.nih.gov/28941639/">keeping dementia at bay</a>. In particular, the hormone cortisol is shown to contribute to stress and can <a href="https://pubmed.ncbi.nlm.nih.gov/19376098/">impact on memory</a>. Aiming to reduce stress and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6405479/">cortisol levels</a> can therefore reduce the chances of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5272965/">developing dementia</a>. </p>
<p>This study offers a complex picture of how we can combat the onset of Alzheimer’s – as well as ten areas that scientists need to concentrate on researching in the future. Though the findings may seem bleak, there is some promise in that many of these risk factors can be managed or modified through lifestyle changes, including <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)60461-5/fulltext#articleInformation">diet and exercise</a>.</p><img src="https://counter.theconversation.com/content/143122/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mark Dallas receives funding from Alzheimer's Research UK. </span></em></p>Stress, depression, and high blood pressure were just some of the risk factors the study’s researchers identified.Mark Dallas, Associate Professor in Cellular Neuroscience, University of ReadingLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1389912020-06-28T06:00:21Z2020-06-28T06:00:21Z‘Prehabilitation’: Training your body for surgery may improve recovery, reduce complications<figure><img src="https://images.theconversation.com/files/343309/original/file-20200622-55009-lsyfn1.jpg?ixlib=rb-1.1.0&rect=429%2C33%2C6610%2C4274&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Exercise training can improve your physical fitness incrementally in as little as two weeks, making it a viable option for people about to undergo a surgical procedure.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>If you’ve had a surgery postponed due to the pandemic, or one is on the horizon, there may be some work you can do right now to prepare and to help improve your postoperative outcome.</p>
<p><a href="https://doi.org/10.12968/hmed.2017.78.12.729">Prehabilitation</a>, a strategy that uses exercise to improve patients’ functional capacity before surgery to help improve outcomes, is increasingly recommended for those facing scheduled surgeries, and it’s improving outcomes and experiences for patients across a wide range of situations. </p>
<p>There’s no guarantee, of course, but it gives patients much greater agency over their own health, and it’s never a bad idea to do what you can to lower your risk of complications following surgery.</p>
<h2>Postoperative risks</h2>
<p>Statistically, dying within a month after an operation accounts for <a href="https://doi.org/10.1016/S0140-6736(18)33139-8">7.7 per cent of deaths globally</a>, which makes it one of the top three factors contributing to global fatalities, trailing only heart attack and stroke. </p>
<p>While death is the most severe outcome, <a href="https://dx.doi.org/10.1016%2Fj.jss.2013.01.032">surgery patients are also susceptible to additional post-operative complications</a> such as intense fatigue, longer hospital stays or hospital re-admittance, anemia and anorexia among a host of others. Those most <a href="https://doi.org/10.1186/s12916-017-0986-2">at risk post-operatively</a> are generally older adults that already live with other chronic diseases, take various medications and have a lower fitness level. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/343310/original/file-20200622-55021-1gepvf6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/343310/original/file-20200622-55021-1gepvf6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/343310/original/file-20200622-55021-1gepvf6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=391&fit=crop&dpr=1 600w, https://images.theconversation.com/files/343310/original/file-20200622-55021-1gepvf6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=391&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/343310/original/file-20200622-55021-1gepvf6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=391&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/343310/original/file-20200622-55021-1gepvf6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=491&fit=crop&dpr=1 754w, https://images.theconversation.com/files/343310/original/file-20200622-55021-1gepvf6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=491&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/343310/original/file-20200622-55021-1gepvf6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=491&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The skill of the surgical team is not the only factor that affects the outcome of surgery.</span>
<span class="attribution"><span class="source">(Unsplash/National Cancer Institute)</span></span>
</figcaption>
</figure>
<p>The success of a surgical procedure depends on more than the skill of the medical staff and the complexity of the operation. It is becoming apparent that the likelihood of the patient returning to a physically and psychologically healthy state is also dependent on <a href="https://www.cfn-nce.ca/impact/get-fit-for-surgery/">what they do in the weeks leading up to the surgery</a>.</p>
<p>Scientists have shown that an effective way of increasing chances of success is to physically train in the time leading up to a surgery. In this time of uncertainty, when many <a href="https://globalnews.ca/news/6948692/covid-19-pandemic-elective-surgeries-canada/">surgeries have been delayed</a>, prehabilitation might be an opportunity to help optimize outcomes. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/343758/original/file-20200624-132951-1jvhm6v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/343758/original/file-20200624-132951-1jvhm6v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/343758/original/file-20200624-132951-1jvhm6v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/343758/original/file-20200624-132951-1jvhm6v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/343758/original/file-20200624-132951-1jvhm6v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1131&fit=crop&dpr=1 754w, https://images.theconversation.com/files/343758/original/file-20200624-132951-1jvhm6v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1131&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/343758/original/file-20200624-132951-1jvhm6v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1131&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Exercise can improve fitness incrementally in as little as two weeks.</span>
<span class="attribution"><span class="source">(Pexels)</span></span>
</figcaption>
</figure>
<p>Doctors are often concerned with a patients’ risk factors, like high blood pressure, blood lipid status or obesity, many of which are difficult to control. Perhaps physical fitness, something you can change with exercise training and impacts several risk factors, should be added to this list. Exercise training can improve your physical fitness incrementally in <a href="https://pubmed.ncbi.nlm.nih.gov/31827347/">as little as two weeks</a>, making it a viable option for people about to undergo a surgical procedure. </p>
<h2>Prehabilitation</h2>
<p>The concept of prehabilitation is based on the idea that <a href="http://doi.org/10.1249/JSR.0000000000000274">patients with a higher functional capacity, or fitness level</a>, will better tolerate a surgical procedure, have fewer post-operative complications and demonstrate better functional, psychological, social and surgical outcomes. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/343330/original/file-20200622-55021-1gong9i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/343330/original/file-20200622-55021-1gong9i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/343330/original/file-20200622-55021-1gong9i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/343330/original/file-20200622-55021-1gong9i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/343330/original/file-20200622-55021-1gong9i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1131&fit=crop&dpr=1 754w, https://images.theconversation.com/files/343330/original/file-20200622-55021-1gong9i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1131&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/343330/original/file-20200622-55021-1gong9i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1131&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">People with higher functional capacity before surgery may have better post-operative outcomes.</span>
<span class="attribution"><span class="source">(Unsplash/Yulissa Tagle)</span></span>
</figcaption>
</figure>
<p>Think of your fitness as a pitcher of water, and each outcome after surgery as a plant. The more water you have at the start somewhat predicts how many plants or outcomes you can care for. Critically, scientific evidence suggests that an <a href="https://doi.org/10.1111/anae.14177">individual’s fitness level may be a stronger predictor of post-operative risk than traditional risk factors</a>, as small improvements in fitness have been associated with substantial improvements in survival.</p>
<p>The great news is that we know that many types of <a href="https://www.exerciseismedicine.org/assets/page_documents/EIM_Rx%20for%20Health_%20Staying%20Active%20During%20Coronavirus%20Pandemic.pdf">exercise training are effective</a>, including brisk walking or jogging, <a href="https://www.vox.com/science-and-health/2019/1/10/18148463/high-intensity-interval-training-hiit-orangetheory">high-intensity interval training</a>, weightlifting, breathing exercises and muscle- or joint-specific training. </p>
<p>The current fitness of the patient is an important factor to consider when prescribing a pre-surgical exercise program, as someone with a higher fitness level will most likely be able to complete a more challenging program, such as high intensity interval training combined with strength training, and will require more activity to see physical gains. By contrast, an older, frail patient undergoing chemotherapy in preparation for a surgical procedure will be more limited in their fitness level, and may only be able to complete deep breathing exercises with a focus on strengthening their inspiratory muscles, which are respiratory muscles used when inhaling, such as the diaphragm. </p>
<h2>Preparing for delayed surgeries</h2>
<p>Regardless of the specific exercise program, it seems that these exercise interventions are safe, and <a href="https://www.ctvnews.ca/health/how-prehab-exercise-could-make-surgery-recovery-easier-1.4457405">may be associated with improved post-operative outcomes</a>.</p>
<p>Like training for a race or sporting event, prehabilitation programs are most effective when combined with nutritional and psychological interventions. Surgery induces a stress response causing an increased need for additional energy sources, which can be relieved with nutritional supplementation, <a href="https://doi.org/10.1111/anae.14506">such as eating a diet higher in protein</a>. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/343331/original/file-20200622-55021-1m4baun.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/343331/original/file-20200622-55021-1m4baun.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/343331/original/file-20200622-55021-1m4baun.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/343331/original/file-20200622-55021-1m4baun.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/343331/original/file-20200622-55021-1m4baun.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/343331/original/file-20200622-55021-1m4baun.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/343331/original/file-20200622-55021-1m4baun.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">People whose surgeries have been postponed due to the pandemic have an opportunity to do prehabilitation.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Addressing a patient’s anxiety regarding pain management, and behavioural modifications like quitting smoking and reducing alcohol consumption, have been shown to independently decrease the risk of postoperative complications. The best postoperative results have been observed when a <a href="https://doi.org/10.1111/anae.14505">multi-pronged approach</a>, or a program designed to address all aspects of a patient’s health, has been applied.</p>
<p>In health care, it’s possible to switch gears. If we use prehabilitation and approach surgery like training for a race, we could see better outcomes, fewer deaths and healthier patients. This is even more important now, amid the current pandemic. With so many surgeries delayed, many patients have some extra time for prehabilitation that could improve their outcome.</p><img src="https://counter.theconversation.com/content/138991/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Emily Dunford receives funding from the Canadian Institutes of Health Research (CIHR). </span></em></p>Physical training before surgery — like breathing exercises or running — boosts the odds of a good outcome. Patients with surgeries postponed during COVID-19 can use the delay for ‘prehabilitation.’Emily C. Dunford, Postdoctoral Fellow in Kinesiology, McMaster UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/812242017-07-21T09:17:22Z2017-07-21T09:17:22ZNine things that can affect whether you get dementia – and what you can do about them<figure><img src="https://images.theconversation.com/files/179027/original/file-20170720-23980-rr6uv4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/344282432?src=yLUgqqvb-dPhlXEZYmyw3A-1-15&size=medium_jpg">SpeedKingz/Shutterstock</a></span></figcaption></figure><p>Dementia is by no means an inevitable result of ageing. In fact, one in three dementia cases can be prevented, according to new findings published in <a href="http://www.thelancet.com/commissions/dementia2017">The Lancet</a>.</p>
<p>For the report – the first for The Lancet Commission on Dementia Prevention and Care – my colleagues and I analysed a number of studies and developed a model showing how lifestyle changes, at different ages, can reduce a person’s risk of developing dementia. </p>
<p>We considered potentially reversible risk factors from different life stages – not just old age. Based on this, we propose a new model to demonstrate the possible impact of eliminating these risk factors across the lifespan. </p>
<p>We have detailed the compelling international evidence for nine lifestyle factors that may reduce, or increase, an individual’s risk of developing dementia. These are more childhood education, exercise, being socially active, stopping smoking, managing hearing loss, depression, diabetes, high blood pressure and obesity. Each of these factors could help prevent or delay dementia. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/179025/original/file-20170720-19155-1efad6v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/179025/original/file-20170720-19155-1efad6v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/179025/original/file-20170720-19155-1efad6v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/179025/original/file-20170720-19155-1efad6v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/179025/original/file-20170720-19155-1efad6v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/179025/original/file-20170720-19155-1efad6v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/179025/original/file-20170720-19155-1efad6v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Nine factors that play a role in dementia.</span>
<span class="attribution"><span class="source">Keck Medicine of USC</span></span>
</figcaption>
</figure>
<p>Our message is: be ambitious about prevention; put these into practice. It’s never too early to start education – and never too late to check your blood pressure and stop smoking. Get your blood pressure checked if you are 45 or over and keep it under control. Ask your family if they think your hearing is a problem and, if so, seek medical help. Be physically, mentally and socially active and watch your weight and blood sugar. </p>
<h2>The greatest healthcare challenge</h2>
<p>Dementia is the greatest global challenge for health and social care in the 21st century – and the greatest fear of most people. People are living longer, and dementia is mainly a disease of old age, which means that rates are going up. About 47m people around the world are living with dementia. That figure is expected to rise to 115m by 2050.</p>
<p>In some countries, such as the UK, US, Sweden and the Netherlands, dementia is already being delayed for years in those with more education, so the proportion of older people living with it has decreased, although more people have dementia, simply because there are more old people. In many other countries, the proportion of older people living with dementia has increased. </p>
<p>The 2015 global cost of dementia was estimated to be US$818 billion (£630 billion) and this will continue to increase as the numbers of people with dementia rise. Nearly 85% of costs are related to family and social – rather than medical – care. It may be that future new medical care, including public health measures, may reduce some of this cost. </p>
<h2>It’s about doing something now</h2>
<p>Giving people information about what to do to prevent dementia is an essential first step, but it is not enough. There is a responsibility, not just as professionals but as a society, to implement this evidence into interventions that are widely and effectively used for people with dementia and their families. So our recommendations need public health as well as individual effort. Interventions have to be accessible, sustainable and, if possible, enjoyable or they won’t be used.</p>
<p>Of course, not everyone will be able to make changes, some changes will not make a difference and some dementia risk is genetic (about 7% of cases) and not currently modifiable. Nonetheless these interventions should delay dementia for some years for many people and this would be an enormous achievement and enable many more people to reach the end of their life without developing dementia.</p>
<p>Effective dementia prevention could transform the future for society. Acting now on what we already know can make this difference happen.</p><img src="https://counter.theconversation.com/content/81224/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Gill Livingston receives funding from National Institue of Helath Research (HTA, EME,RfPB) , ESRC, Alzheimer's society </span></em></p>Many case of dementia can be avoided, and it’s never too early to start taking preventative action.Gill Livingston, Professor of Psychiatry of Older People, UCLLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/719522017-02-16T12:32:43Z2017-02-16T12:32:43ZPopulation versus targeted – which approach is best for preventing heart disease?<figure><img src="https://images.theconversation.com/files/156651/original/image-20170213-18078-wcatee.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/280368827?src=6LSkr-wRl-W4BFpiVFP7pw-1-13&size=medium_jpg"> Monkey Business Images/Shutterstock.com</a></span></figcaption></figure><p><a href="http://www.nhs.uk/Conditions/cardiovascular-disease/Pages/Introduction.aspx">Cardiovascular disease</a> is the number one killer <a href="http://www.who.int/mediacentre/factsheets/fs310/en/">worldwide</a> and the second biggest killer in the <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsregisteredinenglandandwalesseriesdr/2015">UK</a>. However, most cases of heart disease can be prevented by managing <a href="https://www.bhf.org.uk/heart-health/risk-factors">risk factors</a>. </p>
<p>The risk of getting heart disease in people who do not already have it is easily assessed using risk scores. These risk scores use information from a combination of risk factors to calculate how likely you are to develop heart disease. If you have a high score (in the UK, a one in ten or greater chance of getting heart disease in the next ten years), your GP may recommend changes to your diet, more exercise, or medicines, such as statins, to reduce your risk. </p>
<p>In most countries, regular assessment of heart disease risk is recommended for all people above a certain age (universal screening). In the UK, the <a href="http://www.nhs.uk/Conditions/nhs-health-check">NHS Health Check</a> is an example of a universal screening programme which is available to all people who are 40 to 74 years old. It assesses a person’s risk of developing heart disease, stroke, diabetes and kidney disease. </p>
<p>Yet there is debate over whether screening for heart disease should be universal or targeted. Targeted screening involves screening specific groups of people who might be considered to be at higher risk. For example, this could include prioritising screening of people with diabetes or hypertension (known medical risk factors) or people with a high risk score based a combination of their known risk factors.</p>
<p>The benefits of using statins in people who already have heart disease is widely accepted. But some <a href="https://www.theguardian.com/society/2014/mar/21/-sp-statins-for-all-do-the-benefits-outweigh-the-risks">healthcare experts</a> feel that giving statins to reduce risk in healthy people could lead to “over-medicalising” the population. How does this stack up against the evidence and what is the impact of screening? </p>
<p>Death rates from heart disease have been <a href="http://circ.ahajournals.org/content/133/1/8">falling</a> in many countries over time which means that without re-calibration heart disease risk scores often start to <a href="http://www.sciencedirect.com/science/article/pii/S0735109709025029">overestimate risk</a>. This means that when they are routinely applied to a population, as happens in universal screening, some people who are assessed as having a high risk will not go on to develop heart disease. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/157137/original/image-20170216-12972-1yigals.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/157137/original/image-20170216-12972-1yigals.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/157137/original/image-20170216-12972-1yigals.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/157137/original/image-20170216-12972-1yigals.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/157137/original/image-20170216-12972-1yigals.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/157137/original/image-20170216-12972-1yigals.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/157137/original/image-20170216-12972-1yigals.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The benefit of statins is widely accepted.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/199388345?src=leFFFiojQjAHlI0cnQslmA-1-19&size=huge_jpg">roger ashford/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>These otherwise healthy people may be prescribed medicines that are not needed, which can lead to higher healthcare costs as well as potential exposure to side effects. On the other hand, universal screening can also help identify people who go on to develop heart disease who may not have been identified through targeted approaches. Starting treatment in these people earlier can help reduce risk and ultimately can save lives or improve quality of life. Although all medicines have the risk of side effects, statins have been found to be <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)31357-5/abstract">safe and effective</a>.</p>
<p>Universal screening may be more difficult to put into practice compared with targeted screening as it requires high levels of support, funding, awareness, uptake and monitoring. It can also be difficult to encourage healthy people to go to their doctor for screening, so universal screening will never reach the whole population. Between 2009 and 2013, just <a href="http://bmjopen.bmj.com/content/6/1/e008840">12.8%</a> of people who were eligible had an NHS health check, lower than the expected coverage of 30%. Targeted screening is also more <a href="http://www.bmj.com/content/310/6987/1109?variant=full">cost-effective</a> for heart disease risk assessment than universal screening.</p>
<h2>A Goldilocks approach</h2>
<p>Is there a happy medium that balances the pros and cons of universal and targeted screening? In addition to regular heart disease checks for all people aged over 40, <a href="https://www.nice.org.uk/guidance/cg181">guidelines</a> issued by the National Institute for Health and Care Excellence (NICE), the main institute that provides guidance on health issues in the UK, also recommend that information on risk factors in electronic health records is used by GPs to prioritise who should be invited for heart disease risk assessment. </p>
<p>Applying this targeted approach in a systematic and routine way is currently limited due to issues with missing information and poor capturing of some risk factors in health records. But improvements in how missing information is dealt with in risk scores and better recording of risk factors will help make this a reality in the near future. </p>
<p>Given the low coverage of the NHS Health Checks, combining this universal approach with targeted screening using information already recorded in electronic health records could provide the best opportunity for preventing heart disease and saving lives.</p><img src="https://counter.theconversation.com/content/71952/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ellie Paige does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Using electronic medical records may be a better way to treat those at risk of heart disease than treating everyone or treating only known ‘at risk’ groups.Ellie Paige, Research Associate in Epidemiology, University of CambridgeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/677722016-10-31T19:03:56Z2016-10-31T19:03:56ZStudy confirms intimate partner violence leading health risk factor for women<figure><img src="https://images.theconversation.com/files/143837/original/image-20161031-15783-1ha4f2m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">For women of reproductive age and Indigenous women, intimate partner violence is the single biggest health risk factor. </span> <span class="attribution"><span class="source">from www.shutterstock.com.au</span></span></figcaption></figure><p>Barely a week passes without a media report of the suffering or tragic death of a woman at the hands of a partner. Typically, these accounts focus on the individuals involved. While important, in isolation, such a focus can belie the fact intimate partner violence is a wider social problem, obscuring both the factors contributing to it and opportunities to prevent it.</p>
<p>A <a href="http://anrows.org.au/publications/compass/preventable-burden-measuring-and-addressing-the-prevalence-and-health-impacts">study being launched today</a> by Australia’s National Research Organisation for Women’s Safety confirms the serious impacts of intimate partner violence. The analysis, undertaken by the Australian Institute of Health and Welfare, provides estimates of the impact of intimate partner violence on women’s health.</p>
<p>Data from the Personal Safety Survey, Australia’s most reliable violence prevalence survey, was used as a key input.</p>
<p>Since the age of 15, one in four women in Australia have experienced <a href="http://anrows.org.au/research-program/research-program-2014-16/PSS">at least one incident of violence by a partner</a>. This includes violence perpetrated by a live-in partner as well as boyfriends, girlfriends or dates. This is based on a definition of violence, used by the Personal Safety Survey, which includes physical and sexual assault, as well as face-to-face threats the victim believed <a href="http://www.abs.gov.au/AUSSTATS/abs@.nsf/Latestproducts/4906.0Glossary12012?opendocument&tabname=Notes&prodno=4906.0&issue=2012&num=&view=">were likely and able to be carried out</a>. </p>
<p>When emotional abuse by a live-in partner is included, (defined as controlling behaviours aimed at causing fear or emotional harm), it is estimated one in three women have experienced <a href="http://anrows.org.au/publications/compass/preventable-burden-measuring-and-addressing-the-prevalence-and-health-impacts">violence or abuse by an intimate partner</a>.</p>
<h2>Serious impacts on women’s health</h2>
<p>Drawing on Australian and international studies, the Australian Institute of Health and Welfare found an association between women <a href="http://anrows.org.au/publications/landscapes/health-outcomes-intimate-partner-violence-against-women">experiencing partner violence and a wide range of health impacts</a>. Particularly compelling evidence was found linking partner violence to:</p>
<ul>
<li><p>anxiety </p></li>
<li><p>depression</p></li>
<li><p>suicide and self-inflicted injuries</p></li>
<li><p>alcohol use disorders</p></li>
<li><p>homicide and violence</p></li>
<li><p>early pregnancy loss.</p></li>
</ul>
<p>These factors were used in calculating the burden of disease of partner violence.</p>
<p>The burden of disease is a calculation of the impact of particular diseases and risk factors on an entire population. It is a measure of both fatal and non-fatal health impacts, which take into account the severity and duration of health conditions.</p>
<p>The study found partner violence was among the top ten risk factors contributing to disease burden among all adult women, regardless of whether partner violence was defined broadly (violence by both live-in and non-live-in partners, and emotional abuse by live-in partners) or narrowly (only physical and sexual violence in live-in relationships).</p>
<p>Among women 18 to 44 years, it was the biggest single risk factor when violence in all intimate relationships was included, bigger than smoking, alcohol use or being overweight or obese. When considering only violence by live-in partners, in this age group, partner violence ranked second only to alcohol use. </p>
<p>The study found there had been no change in the burden since 2003.</p>
<h2>Burden even larger for Indigenous women</h2>
<p>Physical and sexual partner violence is the leading risk factor contributing to disease burden in Indigenous women aged 18 to 44 years. The rates of burden of physical and sexual violence in both cohabiting and non-cohabiting relationships were compared between Indigenous and non-Indigenous women. Rates for Indigenous women were:</p>
<ul>
<li>6.3 times greater among women 18-44 years; and</li>
<li>5.3 times greater among women of all ages. </li>
</ul>
<p>This burden was the leading contributor to the gap in burden between Indigenous and non-Indigenous women aged 18 to 44; and the sixth largest contributor to the gap among women of all ages.</p>
<h2>A preventable burden</h2>
<p>Front-line services, such as the police, women’s refuges and counselling and support services play a vital role, reducing exposure to violence and its health consequences by helping women to secure safety, supporting their recovery, and holding men who use violence accountable. Recent inquiries in <a href="http://www.rcfv.com.au/">Victoria</a> and <a href="https://www.qld.gov.au/community/documents/getting-support-health-social-issue/dfv-report-vol-one.pdf">Queensland</a> show that although such services have improved, much more needs to be done. </p>
<p>Another effective way to reduce the burden is to prevent “new cases” of partner violence, by tackling its underlying causes. These are increasingly well understood, <a href="https://www.ourwatch.org.au/getmedia/d53470da-fe17-4af1-baca-bedfd7f9b235/Change-the-story-framework-foundations-1-updated.pdf.aspx">along with the means to address them</a>.</p>
<p>Among these factors is inequality between men and women, an influence made particularly potent when coupled with poverty, social exclusion and <a href="http://www.ourwatch.org.au/What-We-Do/National-Primary-Prevention-Framework">other forms of discrimination</a>. </p>
<p>A sustained, coordinated approach is needed which extends beyond affected individuals, and engages a wide range of sectors – not just front-line services - to shift social, community and organisational norms, practices and policies known to increase the likelihood of violence. A similar approach, often referred to as a public health approach, has been used very successfully in Australia to tackle other prevalent risk factors such as tobacco use and road safety hazards.</p>
<hr>
<p><em>Dr Peta Cox, Senior Research Officer for ANROWS co-authored this article. Dr Cox will participate on the expert panel at the launch of the study on 1 November 2016.</em></p><img src="https://counter.theconversation.com/content/67772/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kim Webster works for ANROWS, a not-for-profit that receives funding from Commonwealth and state governments.</span></em></p><p class="fine-print"><em><span>Zuleyka Zevallos works for ANROWS, a not-for-profit that receives funding from Commonwealth and state governments. </span></em></p>A study being launched today by Australia’s National Research Organisation for Women’s Safety confirms the serious impacts of intimate partner violence.Kim Webster, PhD candidate, The University of MelbourneZuleyka Zevallos, Adjunct Research Fellow, Sociology, Swinburne University of TechnologyLicensed as Creative Commons – attribution, no derivatives.