TIME Heart Disease

Why Your Heart Disease Risk Might Be Lower Than You Think

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Of the five popular tools that doctors rely on to predict whether you’re headed for heart trouble, four of them have a pretty major flaw

For decades, doctors have relied on the undisputed champion of heart disease risk assessment: the Framingham Risk Score. It emerged from a massive study of heart disease risk factors in more than 5,000 men and women and pointed out advanced age, being male, smoking, having diabetes, high total cholesterol, low levels of good cholesterol and high blood pressure. Scoring higher on these factors meant you had a greater chance of developing heart problems in the next 10 years, and most successive models included some version of these core culprits.

Now, scientists led by Dr. Michael Blaha, director of clinical research at the Ciccarone Center for Prevention of Heart Disease at Johns Hopkins Medicine, have published a new study in the Annals of Internal Medicine that finds that those risk calculators—four of which doctors use regularly—tend to overestimate the risk of heart attack in patients.

MORE: New Guidelines for Cholesterol Treatments Represent “Huge Change”

“It’s not that scientists made mistakes when coming up with the [calculators],” says Blaha, “They did the best job they could with the data they had. But there may be inherent problems in using historical data to predict things now.”

The diet and lifestyle of Americans have changed considerably since the Framingham days, when heart attacks occurred more frequently in younger people and more often in men than women. Americans on average now eat more trans fat and salt and have lower exposure to secondhand smoke, which can all affect heart disease rates.

MORE: Cholesterol Whiplash: What to Make of the New Heart-Risk Calculator

But even the most recent guidelines for predicting heart disease risk, released in 2013 by the American Heart Association and the American College of Cardiology, relied on the Framingham Risk factors. In the current analysis, these guidelines overestimated heart attack risk by 86% in men and 67% in women when Blaha and his team compared the predicted risk to actual rates of heart events in a group of more than 4,000 people aged 50 to 74 years, who were followed up for an average of 10 years. The other models overshot the risk by anywhere from 37% to 154% for men, and from 8% to 67% for women.

That’s a lot of extra heart disease that, under current guidelines, doctors may start treating with blood pressure medications, insulin and cholesterol-lowering drugs. All of those come with potential side effects and complications. In fact, the study found that statins to keep cholesterol in check were least effective among those with the lowest risk of having future heart events, meaning the benefits may not outweigh the risks for many.

MORE: Single Gene Responsible for Group of Heart Disease Risk Factors

“We’re getting close to the idea of re-thinking risk,” says Blaha. Instead of relying on decades-old data that draws conclusions and recommendations on a population level, ideally everyone’s risk should be more individualized and based on his own particular history. The Framingham model, for example, includes data collected from a single measurement of blood pressure and cholesterol, and a yes-or-no answer on whether the patient smokes. But someone who has smoked for years and just quit is physiologically different from someone who never lit up at all, just as having blood pressure that’s under control thanks to medication is not the same as never having hypertension to begin with. The most accurate way to predict someone’s risk of having a heart attack is to survey his blood pressure and cholesterol readings over his lifetime, or at least for many years. That may soon be possible with electronic health records and the popularity of medical monitoring bracelets. But until then, any model that relies on population-based data like Framingham may suffer from overestimating someone’s heart danger, Blaha says.

MORE: Eating Fruit Cuts Heart Disease Risk by 40%

“These data point squarely to the idea that we need to be rethinking risk prediction,” he says. That may require not just combing through more data per patient, but also folding in other factors that may be more sensitive to the health of a person’s heart. Imaging techniques, including coronary calcium scores that measure the amount of calcium—a foundation for the plaques that eventually rupture to cause heart attacks—may provide more valuable and accurate information on a person’s risk, for example.

In the meantime, Blaha isn’t advocating for the elimination of current risk predictors or guidelines that help doctors decide when a patient’s risk warrants treatment with a drug. “The guidelines are still useful, but patients and doctors have to understand the caveats and limitations to them,” he says. Whatever score a patient receives from these calculators, that number should be the starting point of a discussion between doctor and patient about that patient’s particular risk factors—including his family history, whether and how much he smoked, and how much exercise he gets on a regular basis. “Patients need to demand, or ask their doctors to go beyond the number and say, ‘Do you really think I need to starting taking medicine?’ or ‘How much risk do I really have of having a heart attack?’” That kind of conversation is far more valuable than a single-risk calculator will ever be.

TIME Innovation

Five Best Ideas of the Day: February 13

The Aspen Institute is an educational and policy studies organization based in Washington, D.C.

1. After the shootings in Chapel Hill, a Muslim-American school teacher asks what they must do to be ‘part and parcel’ of America.

By Deanna Othman in the Chicago Tribune

2. Imagine insulin that can read a diabetic’s blood sugar level from inside the body and start working on-demand.

By Anne Trafton in MIT News

3. City governments are using Yelp to warn the public about restaurant health code violations.

By Michael Luca and Luther Lowe in Harvard Business Review

4. The FDA is cutting the red tape so doctors can get experimental drugs to patients more quickly.

By Peter Lurie in FDA Voice

5. How can we support entrepreneurial inventors in developing countries? Create innovation ecosystems.

By Alexander Pan in the Aspen Journal of Ideas

The Aspen Institute is an educational and policy studies organization based in Washington, D.C.

TIME Ideas hosts the world's leading voices, providing commentary and expertise on the most compelling events in news, society, and culture. We welcome outside contributions. To submit a piece, email ideas@time.com.

TIME Diet/Nutrition

This Is the No. 1 Driver of Diabetes and Obesity

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Larry Washburn—Getty Images

"A sugar calorie is much more harmful," says the lead researcher

A primary driver for type 2 diabetes is sugar, according to a new report.

In the report, published Thursday in the Mayo Clinic Proceedings, a team of researchers performed a literature review to determine whether certain ingredients are much more dangerous than others when it comes to diabetes, and to challenge the idea that all calories are equal. To do so, they looked at the effects of carbohydrates from similar calories. They compared starch, pure glucose and lactose to added sugars like sucrose (table sugar) and fructose, which occurs naturally in fruit but which we mostly consume as a sweetener, such a with high-fructose corn syrup, added to food and drinks).

What they found was that the added sugars were significantly more harmful. Fructose was linked to worsening insulin levels and worsening glucose tolerance, which is a driver for pre-diabetes. It caused harmful fat storage—visceral fat on the abdomen—and promoted several markers for poor health like inflammation and high blood pressure. “We clearly showed that sugar is the principal driver of diabetes,” says lead study author James J. DiNicolantonio, a cardiovascular research scientist at Saint Luke’s Mid America Heart Institute. “A sugar calorie is much more harmful.”

DiNicolantonio and his fellow authors say current dietary guidelines are harmful since they recommend levels of sugar consumption that are unhealthy. For instance, the Institute of Medicine says added sugar can make up 25% of the total calories we consume, and the 2010 Dietary Guidelines for Americans say up to 19% of calories from added sugars is alright. That varies greatly from the American Heart Association, which recommends no more than 6 tsp of sugar a day for women 9 tsp for men. The World Health Organization has proposed that added sugar make up only 5% of a person’s daily calories.

“The studies that we looked at clearly show that once you hit 18 percent compared to just 5 percent of your total calories from sugar, there’s significant metabolic harms promoting prediabetes and diabetes,” says DiNicolantonio. “In fact, there’s a two-fold increase.”

This is not the first time sugar has been fingered as a primary culprit in American’s bad health. Other researchers are pushing the message that it’s refined carbohydrates like added sugars that are the problem.

“We need to understand that it isn’t the overconsuming of calories that leads to obesity and leads to diabetes. We need to totally change that around,” says DiNicolantonio. “It’s refined carbs and added sugars that lead to insulin resistance and diabetes, which leads to high insulin levels, which drives obesity.”

DiNicolantonio recommends major changes to combat the problem. He says the government should stop subsidizing corn which makes high fructose corn syrup so cheap and should instead subsidize healthy foods so that consumers are encouraged to make the switch from processed foods to whole foods, since it’s the processed stuff that’s putting so much sugar in our diets. He adds that in his opinion, sugar-sweetened beverages should not be sold in schools or hospitals, and perhaps the government should put warning labels on them.

Such severe changes are not likely in the immediate future, but if sugar is indeed the number on cause for diabetes among all other foods, then more needs to happen to help Americans cut back. Especially since there is no real need for added sugar in our diets.

TIME Innovation

Five Best Ideas of the Day: January 15

The Aspen Institute is an educational and policy studies organization based in Washington, D.C.

1. India and the U.S. have much to gain from strengthening their “unique but sometimes frustrating partnership.”

By Nicholas Burns in the Boston Globe

2. Big energy is betting on power storage tools that let customers take advantage of variable energy prices and stock up when rates are low.

By Ucilia Wang in Forbes

3. With class replacing race as a dividing line, some find South Africa is a “less equal place” now than under apartheid.

By Jeb Sharp at PRI’s The World

4. Preliminary research with stem cells shows how the versatile therapy could effectively cure type-1 diabetes.

By Haley Bridger in the Harvard Gazette

5. A critical piece of improving American education is improving teacher quality, and that is finally happening.

By Dan Goldhaber and Joe Walch in Education Next

The Aspen Institute is an educational and policy studies organization based in Washington, D.C.

TIME Ideas hosts the world's leading voices, providing commentary and expertise on the most compelling events in news, society, and culture. We welcome outside contributions. To submit a piece, email ideas@time.com.

TIME Environment

Ingested Drugs, Passed Through Sewers, May Threaten Lake Michigan Fish

Study finds exposure to a diabetic drug can throw a minnow's hormones off balance

Researchers warned that a cocktail of ingested medications has slipped past sewage treatment plants and gradually accumulated in Lake Michigan, threatening to alter the hormonal balance of local fish.

Researchers from the University of Wisconsin – Milwaukee’s School of Freshwater Sciences have detected traces of coffee, birth control pills and antibiotics in Lake Michigan’s waters, the Detroit Free-Press reports. The most prevalent drug was Metformin, a medication commonly used to treat Type 2 diabetes.

Fathead minnows exposed to Metformin at the same concentrations found in the lake exhibited unusual hormonal imbalances four weeks later. Male minnows, for instance, began to produce a hormone typically associated with female egg production, though researchers say they have not yet ascertained the long-term effects of the hormonal changes.

“It’s enough to raise an alarm bell that this might be something that causes changes in reproduction of fish,” study author Rebecca Klaper said.

Read more at Detroit Free-Press.

TIME mental health

The Link Between Mental Trauma and Diabetes

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Women with more PTSD symptoms appear to be at a higher risk for Type 2 diabetes, a new study says

Women with symptoms of post-traumatic stress disorder (PTSD) have a two-fold increased risk for type 2 diabetes, according to a new study.

“When we are under stress we are more likely to get sick, but women with PTSD are in this extreme stress response a lot of the time,” says study author Karestan Koenen, an epidemiology professor at Columbia University’s Mailman School of Public Health. The new study, published in the journal JAMA Psychiatry, looked at 49,739 women participating in the Nurses’ Health Study II to assess the link between PTSD symptoms and type 2 diabetes over 22 years. They found that women with the most symptoms had double the risk of developing type 2 diabetes, and that the association increased based on the number of symptoms women experienced.

“It’s so important that people understand PTSD isn’t just in veterans. Most PTSD is just in regular people in the community,” says Koenen. One of the most surprising findings in the study was that using antidepressants and having a higher body mass index (BMI) accounted for about half of the increased risk for type 2 diabetes in women with PTSD. Past research has linked PTSD to having a higher BMI, with some research suggesting that elevated stress response could result in cravings for highly caloric food and lead to weight gain.

The antidepressant link is the most unexpected. An obvious explanation for the link is that some antidepressants cause weight gain, but the researchers argue weight gain isn’t caused by all antidepressants and therefore cannot account for all of the effect. “It’s probably one of the most interesting findings and I don’t have a good explanation for it,” says Koenen.

The researchers say it’s possible that extreme stress can cause changes in the regulation of the body’s immune system, inflammation markers and hormones, which could contribute to the onset of type 2 diabetes.

Ultimately, Koenen believes the study is important because it provides further evidence that medicine can benefit from a more holistic look at patients that includes not just disease but also mental health and psychology. “Our health care system acts like the brain and the body are two separate things. This is just one of hundreds of studies that have now shown that mental health affects physical health and mental health,” she says. “We need a more integrated medical system where the mind and body are worked on together.”

Koenen, who used to work in veterans affairs, says veterans have been asking for such care for a long time, with studies and surveys showing patients often ask for alternative services like yoga. “Patients understand this but the medical system hasn’t caught up,” she says.

TIME Diet/Nutrition

The Question Your Doctor Should Be Asking You — but Isn’t

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Almost half of adults surveyed drank at least one soda a day

The last time you went to the doctor, were you asked how much soda you drink? Probably not, but at Montefiore Medical Center in the Bronx, it’s now among the standard questions doctors will ask—and then log into the patient’s electronic health record. Those records, analyzed in a new study, reveal some interesting connections between sugar-sweetened beverage consumption and a slew of health problems.

“Information about a patient’s diet and physical activity are vitally important in preventing and managing certain diseases, yet it’s rarely captured in medical records,” says Ross Kristal, first author on the paper and medical student at Albert Einstein College of Medicine. Kristal and his colleagues looked at how much sugar-sweetened soda people drank, how many vegetables and fruits they ate and how active they were, among other things and noticed a correlation between a person’s soda habit and other health factors.

A full 40% of the people in the study drank at least one sugar-sweetened beverage every day. And the researchers noted that those who drank more than one per day were more likely to smoke, were more likely to eat no fruits or vegetables, and were more likely to have gone a month without much walking or biking.

READ MORE Weight Loss Supplements Don’t Work for Most People, Study Finds

On the flip side, people who didn’t drink a daily soda were less likely to have been diagnosed with type-2 diabetes and hypertension. It seems a doctor’s diabetes diagnosis may get people to drink less soda.

Right now, these health behaviors aren’t collected systematically, says senior author of the paper Peter Selwyn, MD, chair of family and social medicine at Albert Einstein College of Medicine and Montefiore Medical Center. But the more doctors know about each of their patients’ health habits, the more they can engage them in an honest—and hopefully effective—conversation about their health.

“These associations can help our providers narrow down on perhaps who would be more at risk for some of these unhealthy behaviors which can lead to these poor health outcomes,” Kristal says.

TIME global health

This Is Now the Average Life Expectancy Worldwide

Southern sub-Saharan Africa was the only region worldwide to have a decline in life expectancy

Life expectancy across the globe has increased by more than six years since 1990 to 71.5 years, according to a new study.

“The progress we are seeing against a variety of illnesses and injuries is good, even remarkable, but we can and must do even better,” said lead study author Christopher Murray, a University of Washington professor, in a press release.

The study, published Wednesday in the Lancet journal, showed declines in the number of deaths from cancer and cardiovascular disease in high-income countries as well as in deaths from diarrhea and neonatal complications elsewhere. Both of these trends contributed to the overall decline. Importantly, medical funding for fighting infectious diseases has grown since 1990 and helped drive the improvement, according to Murray.

Still, despite the improvement, the number of deaths from a number of ailments increased. Perhaps most dramatically, deaths from HIV/AIDS joined the list of the top 10 causes of premature death. The number of annual deaths from the ailment rose from 2.07 million in 1990 to 2.63 million in 2013, the equivalent of a 344% increase in years of lost life. The increase in deaths from HIV/AIDS made southern sub-Saharan Africa the only region worldwide to experience a decline in life expectancy.

Other ailments that caused an increased loss of life include liver cancer caused by hepatitis C, which soared 125% since 1990, and deaths from disorders related to drug use, which increased by 63%.

TIME Research

6 Breath Tests That Can Diagnose Disease

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612383—Getty Images

A new study uses breath to diagnoses diabetes, but other diseases like cancer and obesity may be breath-detectable too

A new study shows that it may be possible to diagnose type 1 diabetes in kids even before the onset of severe illness.

Currently, about one in four kids with type 1 diabetes don’t know they have it until they start having life-threatening symptoms. However, a new study published in the Journal of Breath Research shows researchers might be able to diagnose the disease by detecting a chemical marker (acetone) in the breath that makes it smell sweet, but indicates a build-up of chemicals in the blood (ketones) that occurs when a person’s insulin levels are low. High levels of acetone in the breath can indicate high levels of ketones in the blood. The hope is that if proven effective, this breath test will help physicians make a diagnosis earlier.

Growing research suggests breath tests can be used to detect a variety of diseases, from diabetes to various cancers. Research is still early in some areas—and there are other factors beyond disease that can result in chemical markers in the blood and breath—but some medical institutions are already using the tests of a variety of diagnosis.

Type 1 Diabetes
In the new study, researchers collected compounds in the breath from 113 children and adolescents between the ages 7 and 18. They also measured the kids’ blood-sugar and ketone levels. They found a link between higher levels of acetone in the breath and ketones in the blood. “Our results have shown that it is realistically possible to use measurements of breath acetone to estimate blood ketones,” said study author Gus Hancock, a professor at Oxford in a statement. “We are working on the development of a small hand-held device that would … help to identify children with new diabetes.”

Colorectal Cancer
In a small study published in 2012 in the British Journal of Surgery, researchers from the the University Aldo Moro of Bari in Italy collected the breath of 37 patients with colorectal cancer and 41 healthy control participants. The researchers were measuring the amount of volatile organic compounds (VOCs) in the participants’ breath, with the thought being that cancer tissues and cells may release distinct chemicals. The researchers were able to identify 15 of 58 specific compounds that were correlated with colorectal cancer. Based on this, the were also able to distinguish between cancer patients and healthy patients with 75% accuracy.

Lung Cancer
In 2013, researchers from the University of Latvia used an electronic nose-like device to identify a unique chemical signature in lung cancer patients. As TIME has previously reported, there are several groups who think this process can be standardized for cancer with further research. In June, scientists at the American Society of Clinical Oncology meeting in Chicago presented a device they think has real promise.

Obesity
There are obviously a number of ways that obesity can be diagnosed without a breath test, but a 2013 study published in the Journal of Clinical Endocrinology & Metabolism found that obese people had unique markers in their breath, too. Researchers at Cedars-Sinai Medical Center studied the breath of 792 men and women trying to detect methane. Those with higher levels of methane and hydrogen gases in their breath also tended to be heavier with a BMI around 2.4 points greater than those with normal gas levels. The hope, the researchers say, is that a test could be developed that could detect a type of bacteria that may be involved in both weight and levels of gas in the breath. There may be ways to clinically curb that bacteria growth.

Lactose Intolerance
Johns Hopkins Medicine uses breath testing to help diagnose lactose intolerance. Patients drink a lactose-heavy drink and clinicians will analyzed the breath for hydrogen, which is produced when lactose isn’t digested and is fermented by bacteria.

Fructose Intolerance
Johns Hopkins also uses breath tests to assess whether an individual is allergic or intolerant to fructose, a sugar used to sweeten some beverage and found naturally in foods like onions, artichokes, and wheat. The test is similar to a breath test for lactose intolerance. Patients will drink a cup of water with dissolved fructose and over a three hour period, clinicians will test their breath. Once again, a high presence of hydrogen can indicate that the patient is not properly digesting it.

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