Wahida Karmally

Upright Posture and Postprandial Hypotension in Elderly Persons

Syncope and falls are common in elderly persons, resulting in significant morbidity and mortality. Aging is associated with changes in cardiovascular structure and function that predispose elderly persons to orthostatic and postprandial hypotension (1). Although postprandial hypotension is cited as a potential cause of falls and syncope, previous investigators have measured postprandial declines in blood pressure in the supine or sitting position. These studies did not demonstrate that postprandial hypotension by itself is an important risk factor for falls or syncope (2). Because falls in elderly persons are often due to the interaction of multiple coexistent clinical abnormalities (3), we hypothesized that postprandial and orthostatic hypotension would be synergistic, resulting in symptomatic hypotension in a subset of elderly persons. We therefore sought to evaluate in a controlled manner whether meal ingestion enhances orthostatic hypotension in a cohort of elderly persons. Methods Participants were recruited from local senior centers in the community surrounding the Columbia Presbyterian Medical Center (n =47) and from patients hospitalized with an unexplained fall or syncope (n =3). Persons who agreed to participate underwent history taking, physical examination, and resting 12-lead electrocardiography. Exclusion criteria were age younger than 60 years, presence of clinical coronary artery disease or congestive heart failure, systemic hypotension (systolic blood pressure<85 mm Hg in the sitting position), diabetes mellitus, Parkinson disease, atrial fibrillation or atrial tachyrhythmia, more than one premature ventricular or atrial beat on a standard electrocardiogram, second-degree heart block, or a pacemaker. Currently prescribed medications were not withheld, and each participants medical regimen had been stable for at least 2 weeks. All participants took their medications at 8:00 a.m. and reported to the Autonomic Function Laboratory in the fasting state at 9:00 a.m. After an intravenous line was inserted in the left antecubital vein and leads for electrocardiographic monitoring were attached, the participant rested in a supine position for 15 minutes. Heart rate and blood pressure were recorded and stored on a computer, the latter by using a noninvasive beat-to-beat monitor (Finapres, Ohmeda, Madison, Wisconsin). The study was a controlled paired comparison of the hemodynamic response to upright tilt-table testing before and after meal ingestion. Participants underwent two sequential head-up tilt-table tests at 60 degrees for 30 minutes before and 30 minutes after ingestion of a standardized meal. A tilt-table test was considered positive if it was terminated prematurely because of symptomatic hypotension with a systolic blood pressure less than 80 mm Hg. In the sitting position, participants ingested a standardized liquid meal over 5 minutes, as recommended by Jansen and Lipsitz (4); however, we modified the meal so that caloric content was normalized for body surface area and the meal was warmed to 55 C. Beat-to-beat hemodynamic measurements were averaged for each 5-minute interval of tilt-table testing. KaplanMeier estimates of time to a positive result on preprandial and postprandial tilt-table testing were computed. Two-way repeated-measures analysis of variance with interaction terms was used to test for differences in systolic blood pressure over time and between preprandial and postprandial testing. We used a multivariate approach to repeated-measures analysis in participants for whom data were complete (n =39). Both independent variablestime after tilt-table testing and meal ingestion (preprandial vs. postprandial)were considered as within-subject factors. We also analyzed all available data by using a univariate approach with the GeiserGreenhouse correction (5). To evaluate whether symptomatic hypotension occurred earlier after meal ingestion (compared with before meal ingestion), we tested whether the median of the paired differences in time to syncope was zero by using the sign test and calculated an exact P value based on the binomial distribution (5). All analyses were performed by using SPSS/PC+ software, version 6.1 (SPSS, Inc., Chicago, Illinois). Results The mean age of the participants was 78 years (range, 61 to 96 years), and 68% were female. Sixty percent had had a self-reported fall in the previous year (all 3 participants who were hospitalized with an unexplained fall or syncope and 27 [57%] of the participants recruited from local senior centers). Forty-four percent of participants had hypertension. Twenty-five participants were receiving antihypertensive therapy, of whom 10 were taking more than one antihypertensive agent. Changes in average systolic blood pressure with head-up tilt during preprandial and postprandial tilt-table testing are shown in Figure 1. Average systolic blood pressure decreased progressively by 16 mm Hg (95% CI, 8 to 23 mm Hg) after 30 minutes of head-up tilt-table testing before meal ingestion and by 16 mm Hg (CI, 9 to 23 mm Hg) after 30 minutes of testing after meal ingestion. The difference between the postprandial and preprandial average decrease in systolic blood pressure was 0.2 mm Hg (CI, 7 to 7 mm Hg). Average diastolic blood pressure did not change significantly. The average heart rate increased 10 beats/min (CI, 7 to 14 beats/min) preprandially and 12 beats/min (CI, 8 to 16 beats/min) postprandially. Figure 1. Average change in systolic blood pressure during preprandial ( circles ) and postprandial ( squares ) tilt-table testing in 50 study participants. P P P Both meal ingestion (P <0.01) and time spent upright (0 to 30 minutes) (P <0.001) were significantly associated with systolic blood pressure, but no significant interaction between meal ingestion and time spent upright was found (P >0.2). The latter absence of interaction indicates that the rate of decrease in blood pressure with head-up tilt was similar before and after meal ingestion and suggests that the effects of meal ingestion and head-up tilt were additive and not synergistic. Meal ingestion was associated with an 8mm Hg (CI, 3 to 14 mm Hg) decline in systolic blood pressure that was additive to the orthostatic response. The number of elderly persons with symptomatic hypotension increased from 6 (12%) during preprandial head-up tilt-table testing to 11 (22%) during postprandial testing. Figure 2 shows a KaplanMeier plot comparing time to symptomatic hypotension during preprandial and postprandial head-up tilt-table testing in all participants. Symptomatic hypotension tended to occur more often and sooner after meal ingestion than before meal ingestion (P =0.03, sign test). Figure 2. Association between meal ingestion and time to symptomatic hypotension. P Discussion Postprandial hypotension was first described in a cohort of institutionalized elderly persons (2). Numerous investigations have confirmed postprandial reduction in blood pressure in elderly persons (6, 7), but its clinical significance is unknown. In a casecontrol study, Lipsitz and colleagues (2) found no statistically significant difference in the degree of postprandial hypotension in supine elderly persons with syncope and those without syncope (15 2 mm Hg vs. 11 4 mm Hg, respectively). A subsequent study found no postprandial decline in blood pressure in healthy elderly persons in the supine position (8). Vaitkevicius and associates (9) found that sitting during the postprandial period was associated with a more severe decline in postprandial blood pressure among nursing home residents. These findings are consistent with the hypothesis that falls and syncope in the elderly have a multifactorial cause and often result from the interaction of multiple coexistent clinical abnormalities. In this study, we show that among elderly persons, meal ingestion does not alter the magnitude of orthostatic hypotension and the effects of postprandial hypotension and orthostatic hypotension are additive but not synergistic. Our results contrast with those of other investigators who sought to determine whether postural changes enhance postprandial hypotension. In a controlled trial of 20 participants who stood up 90 minutes after eating (when the hemodynamic effect of meal ingestion is waning), Imai and coworkers (10) found no augmentation of postprandial changes. Ooi and colleagues (11) found that orthostatic hypotension during standing was ameliorated postprandially in a large cohort of nursing home residents. That study used only a single cuff measurement of changes in orthostatic blood pressure. By using continuous beat-to-beat monitoring, we may have identified hemodynamic alterations that previous studies missed. In addition, our participants underwent head-up tilt-table testing 30 minutes after meal ingestion, during which time the greatest postprandial reductions in blood pressure occur. This represented a clinically relevant interval because meal ingestion typically lasts 30 minutes in many elderly persons. We carefully controlled the caloric composition and quantity of the meal. Meal composition and temperature have been shown to affect the degree of postprandial hypotension; a high carbohydrate content and warmer temperature are known to cause substantially more hypotension than protein or fats and colder foods (12). We used a higher percentage of carbohydrates than did other studies and warmed the liquid meal to 55 C to amplify the postprandial hemodynamic response. The meal that we used is comparable to the ingestion of a turkey sandwich and a cola beverage. Our study has limitations. We used head-up tilt-table testing as the hemodynamic stress. Compared with active standing, tilt-table testing causes more venous pooling and greater hypotension. Thus, our results may overestimate the association of eating and active standing with blood pressure in functionally independent elderly persons. However, the results may be

Effect of Combination Therapy With Fenofibrate and Simvastatin on Postprandial Lipemia in the ACCORD Lipid Trial

OBJECTIVE The Action to Control Cardiovascular Risk in Diabetes lipid study (ACCORD Lipid), which compared the effects of simvastatin plus fenofibrate (FENO-S) versus simvastatin plus placebo (PL-S) on cardiovascular disease outcomes, measured only fasting triglyceride (TG) levels. We examined the effects of FENO-S on postprandial (PP) lipid and lipoprotein levels in a subgroup of ACCORD Lipid subjects. RESEARCH DESIGN AND METHODS We studied 139 subjects (mean age of 61 years, 40% female, and 76% Hispanic or black) in ACCORD Lipid, from a total 529 ACCORD Lipid subjects in the Northeast Clinical Network. PP plasma TG, apolipoprotein (apo)B48, and apoCIII were measured over 10 h after an oral fat load. RESULTS The PP TG incremental area under the curve (IAUC) above fasting (median and interquartile range [mg/dL/h]) was 572 (352–907) in the FENO-S group versus 770 (429–1,420) in the PL-S group (P = 0.008). The PP apoB48 IAUC (mean ± SD [μg/mL/h]) was also reduced in the FENO-S versus the PL-S group (23.2 ± 16.3 vs. 35.2 ± 28.6; P = 0.008). Fasting TG levels on the day of study were correlated with PP TG IAUC (r = 0.73 for FENO-S and r = 0.62 for PL-S; each P < 0.001). However, the fibrate effect on PP TG IAUC was a constant percentage across the entire range of fasting TG levels, whereas PP apoB48 IAUC was only reduced when fasting TG levels were increased. CONCLUSIONS FENO-S lowered PP TG similarly in all participants compared with PL-S. However, levels of atherogenic apoB48 particles were reduced only in individuals with increased fasting levels of TG. These results may have implications for interpretation of the overall ACCORD Lipid trial, which suggested benefit from FENO-S only in dyslipidemic individuals.

Nutrition in Oral Health

Oral diseases are a global problem for both children and adults and poor oral health is associated with other systemic diseases. The two most common oral diseases are dental caries and periodontal disease. Diet plays an important role in influencing the oral mucosa; cariogenic foods, such as fermentable carbohydrates, contribute to oral bacteria, which demineralize and erode the tooth enamel. Healthy dietary patterns have a protective effect on oral health. Dental caries can develop very early in life, especially in children who sleep with a bottle containing milk or sweetened liquid. The elderly are also vulnerable to oral problems and are at an increased risk for low nutrient intake and absorption. Multiple medication use can further compromise nutrient bioavailability. Lifestyle factors such as smoking and excessive alcohol consumption also increase the risk of oral diseases. This chapter addresses the role of nutrition in the promotion of oral health.

The Role of Preventive Nutrition in Clinical Practice

The function of protecting and developing health must rank even above that of restoring it when it is impaired.

Abstract B02: ¡Cocinar Para Su Salud!: Long-term effects of a short-term culturally based dietary intervention among Hispanic breast cancer survivors

Background: Guidelines for cancer survivors from the American Cancer Society and the American Institute for Cancer Research recommend a diet high in fruits and vegetables and low in energy dense foods, with the goal of improving cancer outcomes. However, few effective and culturally relevant resources exist to assist minority cancer survivors, including Hispanics, in meeting and maintaining these dietary recommendations. We tested the effects of iCocinar Para Su Salud! (Cook For Your Health!), a short-term (9-week) culturally-based dietary intervention, on increasing fruit/vegetable (F/V) intake and decreasing dietary fat intake over 12 months among Hispanic breast cancer survivors. Methods: Eligible women included those with a prior diagnosis of stage 0-III breast cancer, completion of adjuvant treatment (hormonal therapy allowed), Hispanic and able to speak Spanish. At baseline, women completed three 24-hour diet recalls, detailed interviews, provided fasting blood and anthropometric measures. Subjects were randomized to: A) the control arm (dietary recommendation booklet for breast cancer survivors), or B) the iCocinar Para Su Salud! program, a 9-week culturally-based dietary intervention using group nutrition education, cooking classes and food shopping field trips to promote behavior change. The intervention was developed via a collaboration between academic and NYC-based community partners. All study activities were conducted in Spanish. Participants were followed for 12 months via monthly phone interviews and clinic visits (3, 6 and 12 months). The primary outcome was change at 6 months in daily F/V servings and % calories from fat. Month 12 outcomes are reported here. Change in dietary intake was analyzed using 2-sample t-tests. Results: From April 2011 to March 2012, 70 women were randomized (n=36 control, n=34 intervention). Baseline characteristics: mean age 56.6 yrs (SD 9.7), mean time since diagnosis 3.4 yrs (SD 2.7), mean body mass index (BMI) 30.6 kg/m 2 (SD 5.4), and 63% had an annual household income Conclusions: iCocinar Para Su Salud! is an effective program to increase fruit/vegetable intake among a diverse group of urban Hispanic breast cancer survivors. The benefit of the 9-week intervention was sustained at 12 months. Citation Format: Heather Greenlee, Ann Ogden Gaffney, Ana Corina Aycinena, Pam Koch, Isobel Contento, Wahida Karmally, John Richardson, Emerson Lim, Wei Yann Tsai, Katherine Crew, Matthew Maurer, Kevin Kalinsky, Dawn L. Hershman. iCocinar Para Su Salud!: Long-term effects of a short-term culturally based dietary intervention among Hispanic breast cancer survivors. [abstract]. In: Proceedings of the Twelfth Annual AACR International Conference on Frontiers in Cancer Prevention Research; 2013 Oct 27-30; National Harbor, MD. Philadelphia (PA): AACR; Can Prev Res 2013;6(11 Suppl): Abstract nr B02.