Visual of Sensory Brain Function....

Tips to keep your Brain Fit....

 Exercise—Physically active people can reduce their risk of dementia by 30 to 40 percent. Weight Training—Studies have shown that resistance training can increase brain growth factors, which protect nerve cells.

 Learn Something New—Challenging your brain does in fact increase the number of brain cells and the connections between them. 

Relax—Regular, chronic stress can lead to impaired memory because it floods your brain with cortisol.

 Go Greek—Eating a diet rich in fish, vegetables, fruits, nuts and beans (otherwise known as a Mediterranean diet) has been shown to reduce Alzheimer’s risk by 34 to 48 percent in Columbia University studies. 

Spice It Up— Many herbs and spices are high in antioxidants, which may help build brainpower. Set a Goal—Having a clear path or mission in life can reduce your chances of developing Alzheimer's disease. 

Socialize—People who need people, well, they may be protected against dementia because social interaction provides emotional and mental stimulation. 

Reduce Other Risk Factors—Many chronic health conditions, such as diabetes, obesity and hypertension, have been linked with an increased risk of dementia. 

Take a Vitamin—Declines in digestive acids or as a result of medication interference can inhibit your absorption of some of the nutrients you need from foods, particularly B12, which can affect your brain’s vitality. Incorporate some or all of these tips into your daily life and you will be doing your part to keep your mind sharp and your brain active long into your golden years.....

Stroke Risk Associated With Diet Quality, Energy Intake Overall.....

 

Clinical Context...

Undernutrition before birth, as well as in infancy, childhood, and adulthood, is associated with an increased risk for stroke in later life. However, the mechanism of increased stroke risk is poorly understood.

In addition, overnutrition also increases stroke risk. The likely mechanism is by hastening the onset of obesity, hypertension, hyperlipidemia, and diabetes. The objective of this review by Hankey was to describe recent evidence regarding the effects of nutrition on stroke risk.

Study Synoposis and Perspective

The overall quality of a person’s diet and the balance between caloric intake and caloric expenditure appear to be more important determinants of stroke risk than the actual foods and nutrients consumed, according to a new review published in the January 2012 special issue of the Lancet Neurology.

In general, the 2 biggest threats to health and risk of stroke are overeating and excess salt, author Graeme J. Hankey, from Royal Perth Hospital, Perth, Western Australia, writes.

"These behaviors are a normal response by people to an abnormal environment," Dr. Hankey notes. "Our living environments have become more conducive to consumption of energy and less conducive to expenditure of energy in developed and increasingly in developing regions."

He writes that between 1970 and 2008, the incidence of stroke in high-income countries fell by 42%, probably as a result of increased public awareness about the dangers of high blood pressure, high cholesterol, and cigarette smoking.

But in poorer countries, the incidence of stroke increased by more than 100% during this period. This rise coincided with food and lifestyle changes associated with industrialization and urbanization.

Small Number of Trials

In his review, Dr. Hankey examines the evidence linking nutrition and diet to the risk of stroke. He searched PubMed articles published in English from 1970 to October 2011, using a variety of search terms.

The review included a small number of randomized trials and large observational and epidemiological studies.

He found that the findings from these studies were diverse, owing to the fact that most were epidemiological and therefore "prone to substantial methodological challenges of bias, confounding, and measurement error."

For example, one observational study found that a high intake of a healthy diet was associated with an increased risk of stroke, whereas another observational study found just the opposite.

Dr. Hankey's review also revealed the following effects of individual foods and beverages on the risk of stroke:

• Fish: 3 servings a day associated with a 6% lower risk of stroke
• Fruits and vegetables: >5 servings a day associated with a 26% lower risk of stroke
• Meat: Each daily serving associated with a 24% increased risk of stroke
• Reduced-fat milk: associated with a lower risk of stroke vs full-fat milk
• Chocolate: High consumption associated with a 29% lower risk of stroke
• Coffee: 3 to 4 cups per day associated with a 17% lower risk of stroke
• Tea: ≥3 cups per day associated with a 21% lower risk of stroke
• Sugar-sweetened beverages: high intake associated with increased obesity, diabetes, metabolic syndrome, and coronary heart disease
• Whole grains: high intake associated with a 21% lower incidence of cardiovascular events
• Rice: intake not associated with risk of stroke
•  

"Further research is needed to improve the quality of evidence relating to the association of many nutrients, foods, and dietary patterns with stroke risk," Dr. Hankey suggests.

This requires adequately powered, large randomized trials with carefully described patient populations and interventions. The outcomes of such trials should also distinguish first-ever and recurrent stroke, as well as ischemic and hemorrhagic stroke, and their different etiologies.

Dr. Hankey also suggests that population-wide salt reduction programs led by governments and with industry cooperation could be highly cost effective.

"In the USA, modest, population-wide reductions in dietary salt of up to 3 g per day…are projected to reduce the annual number of new cases of stroke by 32,000 to 66,000, similar to the benefits of population-wide reductions in tobacco use, obesity, and cholesterol levels," he writes.

Dr. Hankey told Medscape Medical News that he hopes his study will stimulate conclusive studies "by means of large, randomized controlled trials of the effect of dietary nutrients, foods, and patterns on stroke and its pathological and etiological subtypes."

The current evidence associating dietary nutrients, foods, and patterns with stroke is generally suboptimal for providing reliable conclusions about causality, he reiterated.

"The effect of only a few supplements on stroke risk have been studied by means of large, randomized controlled trials, and all of those have shown no benefit of antioxidant vitamins, B-vitamins, and calcium supplements in preventing stroke, despite large, more suboptimal, epidemiological studies claiming they should be beneficial," he said.

Best Diet Still Uncertain

Commenting on this study for Medscape Medical News, Eugene Storozynsky, MD, a cardiologist from the University of Rochester Medical Center, Rochester, New York, said that he agrees with Dr. Hankey's conclusions.

"This is a good review of the literature as to what role diets and their components would have on reducing stroke, and what it tells us is that there still is a lot of uncertainty about the best diet. One study suggests benefit of a certain food or strategy, the other may come to the opposite conclusion," Dr. Storozynsky said.

The take-home message here is as Dr. Hankey notes, Dr. Storozynsky continued. "We need rigorously done randomized controlled trials to really monitor the long-term effects of diets and nutrients, rather than observation studies that look at individual factors, to see whether or not there is any benefit to adopting certain strategies."

Dr. Storozynsky also noted what he considers to be an important omission from Dr. Hankey's review.

"This review did not look at the effect of exercise and how it affects nutrition or stroke results. Does routine daily exercise mitigate the effect of intermittent poor eating? Exercise definitely needs to be part of the equation," he said.

Helmi L. Lutsep, MD, from the Oregon Stroke Center at Oregon Health Science University in Portland, added, "My quick read of the article suggests that it is a very nicely written, comprehensive review of our current knowledge regarding nutrition and stroke."

Dr. Lutsep, who is also a spokesperson for the American Academy of Neurology, added, "While I haven't seen all of these pieces summarized in one place before, I don't think that the article provides novel observations."

Dr. Hankey reports that he was the principal investigator of the VITAmins TO Prevent Stroke (VITATOPS) trial and has financial relationships with Sanofi-Aventis, Johnson & Johnson, Bristol-Myers Squibb, Boehringer Ingelheim, Bayer, and Pfizer Australia. Dr. Storozynsky and Dr. Lutsep have disclosed no relevant financial relationships. 

 

Lancet Neurol. 2012;11:66-81. Abstract

The National Stroke Association provides a comprehensive discussion for patients about stroke prevention.

Study Highlights

• On the basis of a literature review, the reviewer noted the following findings:
  • Vitamin A supplementation increases all-cause mortality risk.
  • β-carotene supplementation increases cardiovascular and all-cause mortality risks and does not prevent stroke.
  • Vitamin C supplementation does not prevent stroke.
  • Vitamin E supplementation increases all-cause mortality risk and does not prevent stroke.
  • Although folic acid supplementation does not prevent stroke in populations with high folate intake, deficiency in regions of low folate intake may be a causal and treatable risk factor for stroke.
  • Vitamin D deficiency is associated with hypertension, cardiovascular disease, and stroke, but to date, supplementation has not been shown to prevent cardiovascular events. Randomized trials are underway.
  • Salt supplementation by 5 g per day is linked to a 23% increase in stroke risk (95% confidence interval [CI], 6 - 43).
  • Although decreasing salt intake has not been shown to reduce stroke risk, lowering consumption by 2 g per day is associated with a 20% decrease in cardiovascular events (95% CI, 1 - 36), and lower salt intake is also linked to blood pressure reduction.
  • Potassium supplementation by 1 g per day is associated with an 11% reduction in the risk for stroke (95% CI, 3 - 17), but supplementation is not proven to prevent stroke.
  • Potassium supplementation by 0.8 g per day is associated with a decrease in blood pressure by 5/3 mm Hg.
  • Calcium supplementation exceeding 0.5 g per day is linked to a 31% increase in the risk for myocardial infarction (95% CI, 2 - 67), does not prevent stroke, and may actually increase stroke risk.
  • High intake of total fat, trans fats, and saturated fats is not associated with an increased risk for stroke, and reduced total fat intake does not lower stroke risk.
  • High intake of plant n-3 polyunsaturated fats is associated with a reduced risk for stroke.
  • Marine n-3 polyunsaturated fat supplementation lowers cardiovascular events and death by 8% (95% CI, 1 - 15), but in a randomized trial, it did not reduce stroke risk.
  • High intake of carbohydrates with high glycemic index and glycemic load is associated with increased blood glucose levels, body weight, and stroke mortality.
  • High fiber intake is linked to lower blood pressure, blood glucose levels, and low-density lipoprotein cholesterol levels.
  • High protein intake is not associated with stroke risk.
  • High intake of a healthy diet was linked to an increased risk for stroke in one observational study and a reduced risk for stroke in another observational study.
  • High intake of an unhealthy diet was linked to an increased risk for stroke and a population-attributable risk for stroke of 19% (99% CI, 11 - 30).
  • In women, a prudent diet or Dietary Approaches to Stop Hypertension (DASH)–style diet is associated with a lower risk for stroke, and a Western diet is linked with a higher risk for stroke.
  • In women, the Mediterranean diet is associated with lower risks for stroke, cardiovascular disease, cardiovascular mortality, and all-cause mortality.
  • The effects of a vegetarian diet and a Japanese diet on stroke risk are unknown.
  •  
  •  

Clinical Implications

• Reliable evidence from randomized trials suggests that dietary supplementation with antioxidant vitamins, B vitamins, and calcium does not reduce the risk for stroke. However, methodologic limitations of studies to date preclude firm conclusions regarding the effect of many other nutrients on stroke risk.
• Less reliable evidence suggests that stroke can be prevented by prudent diets; Mediterranean or DASH-type diets; diets that are low in salt and added sugars and high in potassium; and diets that meet, but do not exceed, energy requirements. The overall quality of dietary pattern and the balance between energy intake and expenditure seem to affect stroke risk to a greater extent than individual nutrients and foods.

Borrowed from- Medscape Education Clinical Briefs

Diabetes, Heart Disease, and Stroke....

Diabetes and heart health

Diabetes raises the chances of developing heart problems... eating well and getting or staying active. Even if you have had a heart attack already, you can do a lot more than just take medicines your doctor prescribes.

What causes heart disease?

Atherosclerosis is when, over time, fat deposits from cholesterol build up on the walls of your arteries. As the fat builds up, less blood is flows through. If the blood to your heart is blocked enough, you have a heart attack. If these fat deposits break loose, the result is a stroke. This is why doctors focus on reducing cholesterol.
Diabetes is also more likely to cause heart problems due to damage from high glucose levels and high blood pressure.

Managing A1c levels

A1c is a measure of your blood sugar control over a period of time....daily testing for glucose levels will help manage how well you feel. Regular A1c tests help you know what steps you have to take to keep your blood sugar under control to protect your heart.

Managing blood pressure

 High blood pressure can cause heart and kidney disease. Some people can reduce it with changes in diet or physical activity. Others require medicines. Your doctor or doctors will help you make the best decision for your specific situation.

Managing cholesterol

 This chart shows you what most doctors agree are good measures of the scores you get.

Normal	less than 150 mg/dL
Borderline High	150-199 mg/dL
High	200-499 mg/dL
Very High	500 mg/dL

What are the risk factors for heart disease and stroke in people with diabetes?

Diabetes itself is a risk factor for heart disease and stroke. Also, many people with diabetes have other conditions that increase their chance of developing heart disease and stroke. These conditions are called risk factors. One risk factor for heart disease and stroke is having a family history of heart disease. If one or more members of your family had a heart attack at an early age (before age 55 for men or 65 for women), you may be at increased risk.
You can't change whether heart disease runs in your family, but you can take steps to control the other risk factors for heart disease listed here:

• Having central obesity. Central obesity means carrying extra weight around the waist, as opposed to the hips. A waist measurement of more than 40 inches for men and more than 35 inches for women means you have central obesity. Your risk of heart disease is higher because abdominal fat can increase the production of LDL (bad) cholesterol, the type of blood fat that can be deposited on the inside of blood vessel walls.



• Having abnormal blood fat (cholesterol) levels.
  - LDL cholesterol can build up inside your blood vessels, leading to narrowing and hardening of your arteries-the blood vessels that carry blood from the heart to the rest of the body. Arteries can then become blocked. Therefore, high levels of LDL cholesterol raise your risk of getting heart disease.
  
  - Triglycerides are another type of blood fat that can raise your risk of heart disease when the levels are high.
  
  - HDL (good) cholesterol removes deposits from inside your blood vessels and takes them to the liver for removal. Low levels of HDL cholesterol increase your risk for heart disease.



• Having high blood pressure. If you have high blood pressure, also called hypertension, your heart must work harder to pump blood. High blood pressure can strain the heart, damage blood vessels, and increase your risk of heart attack, stroke, eye problems, and kidney problems.



• Smoking. Smoking doubles your risk of getting heart disease. Stopping smoking is especially important for people with diabetes because both smoking and diabetes narrow blood vessels. Smoking also increases the risk of other long-term complications, such as eye problems. In addition, smoking can damage the blood vessels in your legs and increase the risk of amputation.

What is metabolic syndrome and how is it linked to heart disease?

Metabolic syndrome is a grouping of traits and medical conditions that puts people at risk for both heart disease and type 2 diabetes. It is defined by the National Cholesterol Education Program as having any three of the following five traits and medical conditions:

Traits and Medical Conditions	Definition
Elevated waist circumference	Waist measurement of 40 inches or more in men 35 inches or more in women
Elevated levels of triglycerides	150 mg/dL or higher or Taking medication for elevated triglyceride levels
Low levels of HDL (good) cholesterol	Below 40 mg/dL in men Below 50 mg/dL in women or Taking medication for low HDL cholesterol levels
Elevated blood pressure levels	130 mm Hg or higher for systolic blood pressure or 85 mm Hg or higher for diastolic blood pressure or Taking medication for elevated blood pressure levels
Elevated fasting blood glucose levels	100 mg/dL or higher or Taking medication for elevated blood glucose levels

Source: Grundy SM, et al. Diagnosis and Management of the Metabolic Syndrome: An American Heart Association/National Heart, Lung, and Blood Institute Scientific Statement. Circulation. 2005;112:2735-2752.
Note: Other definitions of similar conditions have been developed by the American Association of Clinical Endocrinologists, the International Diabetes Federation, and the World Health Organization.
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What can I do to prevent or delay heart disease and stroke?

Even if you are at high risk for heart disease and stroke, you can help keep your heart and blood vessels healthy. You can do so by taking the following steps:

• Make sure that your diet is "heart-healthy." Meet with a registered dietitian to plan a diet that meets these goals:
  • Include at least 14 grams of fiber daily for every 1,000 calories consumed. Foods high in fiber may help lower blood cholesterol. Oat bran, oatmeal, whole-grain breads and cereals, dried beans and peas (such as kidney beans, pinto beans, and black-eyed peas), fruits, and vegetables are all good sources of fiber. Increase the amount of fiber in your diet gradually to avoid digestive problems.
  • Cut down on saturated fat. It raises your blood cholesterol level. Saturated fat is found in meats, poultry skin, butter, dairy products with fat, shortening, lard, and tropical oils such as palm and coconut oil. Your dietitian can figure out how many grams of saturated fat should be your daily maximum amount.
  • Keep the cholesterol in your diet to less than 300 milligrams a day. Cholesterol is found in meat, dairy products, and eggs.
  • Keep the amount of trans fat in your diet to a minimum. It's a type of fat in foods that raises blood cholesterol. Limit your intake of crackers, cookies, snack foods, commercially prepared baked goods, cake mixes, microwave popcorn, fried foods, salad dressings, and other foods made with partially hydrogenated oil. In addition, some kinds of vegetable shortening and margarines have trans fat. Check for trans fat in the Nutrition Facts section on the food package.
  
  
  
• Make physical activity part of your routine. Aim for at least 30 minutes of exercise most days of the week. Think of ways to increase physical activity, such as taking the stairs instead of the elevator. If you haven't been physically active recently, see your doctor for a checkup before you start an exercise program.
• Reach and maintain a healthy body weight. If you are overweight, try to be physically active for at least 30 minutes a day, most days of the week. Consult a registered dietitian for help in planning meals and lowering the fat and calorie content of your diet to reach and maintain a healthy weight. Aim for a loss of no more than 1 to 2 pounds a week.
• If you smoke, quit. Your doctor can help you find ways to quit smoking.

•  
• Ask your doctor whether you should take aspirin. Studies have shown that taking a low dose of aspirin every day can help reduce the risk of heart disease and stroke. However, aspirin is not safe for everyone. Your doctor can tell you whether taking aspirin is right for you and exactly how much to take.
• Get prompt treatment for transient ischemic attacks (TIAs). Early treatment for TIAs, sometimes called mini-strokes, may help prevent or delay a future stroke. Signs of a TIA are sudden weakness, loss of balance, numbness, confusion, blindness in one or both eyes, double vision, difficulty speaking, or a severe headache.

How will I know whether my diabetes treatment is working?

You can keep track of the ABCs of diabetes to make sure your treatment is working. Talk with your health care provider about the best targets for you.
A stands for A1C (a test that measures blood glucose control). Have an A1C test at least twice a year. It shows your average blood glucose level over the past 3 months. Talk with your doctor about whether you should check your blood glucose at home and how to do it.

A1C target
Below 7 percent

Blood glucose targets
Before meals	90 to 130 mg/dL
1 to 2 hours after the start of a meal	Less than 180 mg/dL

B is for blood pressure. Have it checked at every office visit.

Blood pressure target
Below 130/80 mm Hg

C is for cholesterol. Have it checked at least once a year.

Blood fat (cholesterol) targets
LDL (bad) cholesterol	Under 100 mg/dL
Triglycerides	Under 150 mg/dL
HDL (good) cholesterol	For men: above 40 mg/dL For women: above 50 mg/dL

Control of the ABCs of diabetes can reduce your risk for heart disease and stroke. changes in diet, activity, and medications can help reach  goals.

What types of heart and blood vessel disease occur in people with diabetes?

Two major types of heart and blood vessel disease, also called cardiovascular disease, are common in people with diabetes: coronary artery disease (CAD) and cerebral vascular disease. People with diabetes are also at risk for heart failure. Narrowing or blockage of the blood vessels in the legs, a condition called peripheral arterial disease, can also occur in people with diabetes.

Coronary Artery Disease

Coronary artery disease, also called ischemic heart disease, is caused by a hardening or thickening of the walls of the blood vessels that go to your heart. Your blood supplies oxygen and other materials your heart needs for normal functioning. If the blood vessels to your heart become narrowed or blocked by fatty deposits, the blood supply is reduced or cut off, resulting in a heart attack.

Cerebral Vascular Disease

Cerebral vascular disease affects blood flow to the brain, leading to strokes and TIAs. It is caused by narrowing, blocking, or hardening of the blood vessels that go to the brain or by high blood pressure.

Stroke

A stroke results when the blood supply to the brain is suddenly cut off, which can occur when a blood vessel in the brain or neck is blocked or bursts. Brain cells are then deprived of oxygen and die. A stroke can result in problems with speech or vision or can cause weakness or paralysis. Most strokes are caused by fatty deposits or blood clots-jelly-like clumps of blood cells-that narrow or block one of the blood vessels in the brain or neck. A blood clot may stay where it formed or can travel within the body. People with diabetes are at increased risk for strokes caused by blood clots.
A stroke may also be caused by a bleeding blood vessel in the brain. Called an aneurysm, a break in a blood vessel can occur as a result of high blood pressure or a weak spot in a blood vessel wall.

TIAs

TIAs are caused by a temporary blockage of a blood vessel to the brain. This blockage leads to a brief, sudden change in brain function, such as temporary numbness or weakness on one side of the body. Sudden changes in brain function also can lead to loss of balance, confusion, blindness in one or both eyes, double vision, difficulty speaking, or a severe headache. However, most symptoms disappear quickly and permanent damage is unlikely. If symptoms do not resolve in a few minutes, rather than a TIA, the event could be a stroke. The occurrence of a TIA means that a person is at risk for a stroke sometime in the future.

Heart Failure

Heart failure is a chronic condition in which the heart cannot pump blood properly-it does not mean that the heart suddenly stops working. Heart failure develops over a period of years, and symptoms can get worse over time. People with diabetes have at least twice the risk of heart failure as other people. One type of heart failure is congestive heart failure, in which fluid builds up inside body tissues. If the buildup is in the lungs, breathing becomes difficult.

Blockage of the blood vessels and high blood glucose levels also can damage heart muscle and cause irregular heart beats. People with damage to heart muscle, a condition called cardiomyopathy, may have no symptoms in the early stages, but later they may experience weakness, shortness of breath, a severe cough, fatigue, and swelling of the legs and feet. Diabetes can also interfere with pain signals normally carried by the nerves, explaining why a person with diabetes may not experience the typical warning signs of a heart attack.

Peripheral Arterial Disease

Another condition related to heart disease and common in people with diabetes is peripheral arterial disease (PAD). With this condition, the blood vessels in the legs are narrowed or blocked by fatty deposits, decreasing blood flow to the legs and feet. PAD increases the chances of a heart attack or stroke occurring. Poor circulation in the legs and feet also raises the risk of amputation. Sometimes people with PAD develop pain in the calf or other parts of the leg when walking, which is relieved by resting for a few minutes.
 

How will I know whether I have heart disease?

One sign of heart disease is angina, the pain that occurs when a blood vessel to the heart is narrowed and the blood supply is reduced. You may feel pain or discomfort in your chest, shoulders, arms, jaw, or back, especially when you exercise. The pain may go away when you rest or take angina medicine. Angina does not cause permanent damage to the heart muscle, but if you have angina, your chance of having a heart attack increases.
A heart attack occurs when a blood vessel to the heart becomes blocked. With blockage, not enough blood can reach that part of the heart muscle and permanent damage results. During a heart attack, you may have

• chest pain or discomfort
• pain or discomfort in your arms, back, jaw, neck, or stomach
• shortness of breath
• sweating
• nausea
• light-headedness

Symptoms may come and go. However, in some people, particularly those with diabetes, symptoms may be mild or absent due to a condition in which the heart rate stays at the same level during exercise, inactivity, stress, or sleep. Also, nerve damage caused by diabetes may result in lack of pain during a heart attack.
Women may not have chest pain but may be more likely to have shortness of breath, nausea, or back and jaw pain. If you have symptoms of a heart attack, call 911 right away. Treatment is most effective if given within an hour of a heart attack. Early treatment can prevent permanent damage to the heart.
Your doctor should check your risk for heart disease and stroke at least once a year by checking your cholesterol and blood pressure levels and asking whether you smoke or have a family history of premature heart disease. The doctor can also check your urine for protein, another risk factor for heart disease. If you are at high risk or have symptoms of heart disease, you may need to undergo further testing.

What are the treatment options for heart disease?

Treatment for heart disease includes meal planning to ensure a heart-healthy diet and physical activity. In addition, you may need medications to treat heart damage or to lower your blood glucose, blood pressure, and cholesterol. If you are not already taking a low dose of aspirin every day, your doctor may suggest it. You also may need surgery or some other medical procedure.

For additional information about heart and blood vessel disease, high blood pressure, and high cholesterol, call the National Heart, Lung, and Blood Institute Health Information Center at 301-592-8573 or see www.nhlbi.nih.gov on the Internet.

How will I know whether I have had a stroke?

The following signs may mean that you have had a stroke:

• sudden weakness or numbness of your face, arm, or leg on one side of your body
• sudden confusion, trouble talking, or trouble understanding
• sudden dizziness, loss of balance, or trouble walking
• sudden trouble seeing out of one or both eyes or sudden double vision
• sudden severe headache

If you have any of these symptoms, call 911 right away. You can help prevent permanent damage by getting to a hospital within an hour of a stroke. If your doctor thinks you have had a stroke, you may have tests such as a neurological examination to check your nervous system, special scans, blood tests, ultrasound examinations, or x rays. You also may be given medication that dissolves blood clots.

What are the treatment options for stroke?

At the first sign of a stroke, you should get medical care right away. If blood vessels to your brain are blocked by blood clots, the doctor can give you a "clot-busting" drug. The drug must be given soon after a stroke to be effective. Subsequent treatment for stroke includes medications and physical therapy, as well as surgery to repair the damage. Meal planning and physical activity may be part of your ongoing care. In addition, you may need medications to lower your blood glucose, blood pressure, and cholesterol and to prevent blood clots.

For additional information about strokes, call the National Institute of Neurological Disorders and Stroke at 1-800-352-9424 or see www.ninds.nih.gov on the Internet.

• If you have diabetes, you are at least twice as likely as other people to have heart disease or a stroke.
• Controlling the ABCs of diabetes-A1C (blood glucose), blood pressure, and cholesterol-can cut your risk of heart disease and stroke.
• Choosing foods wisely, being physically active, losing weight, quitting smoking, and taking medications (if needed) can all help lower your risk of heart disease and stroke.
• If you have any warning signs of a heart attack or a stroke, get medical care immediately-don't delay. Early treatment of heart attack and stroke in a hospital emergency room can reduce damage to the heart and the brain.

Hope through Research

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) is one of the National Institutes of Health (NIH) under the U.S. Department of Health and Human Services. The NIDDK conducts and supports research in diabetes, glucose metabolism, and related conditions. Several studies related to diabetes, heart disease, and stroke are under way.

• The Look AHEAD (Action for Health in Diabetes) trial is studying whether strategies for weight loss in obese people with type 2 diabetes can improve health. This trial is also sponsored by other NIH Institutes and by the Centers for Disease Control and Prevention. For more information on the Look AHEAD trial, visit the website at www.niddk.nih.gov/patient/SHOW/lookahead.htm.
• The EDIC (Epidemiology of Diabetes Interventions and Complications) study is examining the long-term effects of prior intensive versus conventional blood glucose control. It is a follow-up study of patients who took part more than a decade ago in the Diabetes Control and Complications Trial (DCCT), a major clinical study funded by the National Institutes of Health.
• The BARI 2D (Bypass Angioplasty Revascularization Investigation 2 Diabetes) trial, sponsored by the National Heart, Lung, and Blood Institute, in partnership with NIDDK, is studying approaches to the medical care of people with type 2 diabetes who also have coronary artery disease. For more information on the BARI 2D trial, visit the website at www.bari2d.org or call the nearest research center (listed on the website).
• The ACCORD (Action to Control Cardiovascular Risk in Diabetes) trial is studying three approaches to preventing major cardiovascular events in individuals with type 2 diabetes. For more information on the ACCORD trial, visit the website at www.accordtrial.org or call 1-888-342-2380.
• The NIDDK and other components of the NIH will continue to fund research on the best ways to enhance health promotion, self-management, and risk reduction in people with diabetes.

The Relationship Between Depression and Anxiety...

A significant overlap exists between the symptoms of major depressive disorder (MDD) and many anxiety disorders. These common features not only lead to substantial comorbidity between these disorders, but also highlight an anxious subtype of MDD that is prone to worse clinical outcomes compared to patients with “pure” MDD. According to some estimates, as many as 50% of patients with MDD experience a significant level of anxiety symptoms. This finding leads some to suggest that MDD and the anxiety disorders may not be distinct syndromes, but rather part of a single, all-encompassing depressive-anxiety disorder that manifests in subtly different ways. As the classification system of psychiatric disorders continues to evolve, more specific diagnostic criteria may become available that address the often nuanced presentation of what today are considered distinct depressive and anxiety disorders. Advances in genotyping and brain imaging will likely provide insight to the underlying physiologic pathologies that are associated with these disorders and could lead to the development of more effective and focused treatments.

  

What percentage of patients with major depressive disorder also experience a clinically significant degree of anxiety symptoms?

Some data in the literature show that up to 50% of patients with major depressive disorder (MDD) also experience significant levels of anxiety.^1-4 However, in actual clinical settings, the prevalence of such disorders generally exceeds those found in epidemiological studies, which is theoretically caused by the overrepresentation of symptomatic, treatment-seeking patients in these settings. Additionally, it has been shown that patients with MDD who receive treatment from primary care physicians are more likely to experience anxiety symptoms as compared with those who receive treatment in psychiatric settings. This finding is possibly due to the common presentation of somatic symptoms found in anxious patients with MDD.³ Overall, anxiety symptoms are a very common feature in patients with MDD.

What are the typical symptoms of anxiety reported by patients with anxious MDD?

Patients with MDD and high levels of anxiety symptoms typically report the full range of anxiety symptomatology. Some are psychological in nature (ie, those symptoms that are experienced cognitively and emotionally) such as fear, worry, dread, and apprehension. Anxious patients with MDD also exhibit the physical symptoms of fear, such as racing heart, dry mouth, irritable bowels, stomach acid, tremors, sweating, shortness of breath, or difficulty sleeping. Research has shown that, more often than nonanxious patients with MDD, anxious depressed patients exhibit particular symptoms, such as difficulty falling asleep, problems with concentration, somatic symptoms, and fatigability.³

What are the clinically relevant differences between patients with anxious depression and those with MDD or an anxiety disorder?

The clinical relevance of deciding whether a patient has a primary diagnosis of MDD with anxiety symptoms or if the primary diagnosis is an anxiety disorder is not clear. Psychiatrists explore the longitudinal course of the presenting symptoms and examine when the depressive symptoms are present and when the anxiety symptoms are present. For example, if a patient only experiences pathological worry during a full-blown episode of MDD, the MDD diagnosis will be primary and the anxiety symptoms will be described as a component of the MDD. Conversely, if a patient is pathologically worried and has other associated symptoms of generalized anxiety disorder (GAD)—but also occasionally experiences major depressive episodes—the patient would be diagnosed with GAD and described as having comorbid MDD. Longitudinal data have demonstrated that MDD is as likely to predate the onset of GAD as it is to postdate GAD.⁵ This finding is interesting because GAD has traditionally been viewed as a potential prodrome for MDD.⁶ Perhaps, however, the temporal relationship between these disorders is bi-directional, with MDD occurring prior to GAD as often as it occurs later in the disease course.

From the standpoint of clinical implications, because the treatments for both disorders are generally so similar, it probably is not too important to distinguish between a primary depression with anxiety symptoms or a primary anxiety disorder with a coincident depression,  especially for a busy family doctor who has other medical conditions to treat and not a lot of time to get involved with matters that may be more relevant in academic than in clinical settings. This does not mean that there are no comorbid diagnoses that should be identified. For example, a clinically key distinction in patients presenting with MDD and anxiety is whether there is a history of hypomania or mania. Treating bipolar disorder with antidepressant pharmacotherapy can lead to mood switching or rapid cycling.⁷ Another important subdiagnosis that a clinician should be aware of is MDD with psychotic features, such as delusions or hallucinations, which would lead to very different treatment modalities that should be provided by a psychiatrist.⁸ Substance abuse, which may sometimes present similarly to anxious MDD, is another comorbid diagnosis that should not be ignored. In addition, a comorbid medical disorder, such as a brain tumor or endocrinopathy, could present with symptoms of anxiety and MDD in some patients. Naturally, good medical care requires a different approach to treating these disorders, so attending to differential diagnoses is important in medical practice and could make a difference in a patient’s safety and treatment outcomes.

What are the overlapping symptoms of MDD and anxiety disorders?

The diagnostic criteria for GAD and MDD as described in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision,⁹ outlines a number of overlapping symptoms. In fact, MDD and the anxiety disorders have more symptoms in common than can be used to differentiate them.¹⁰ A study conducted in Vantaa, Finland suggested that it is rare to have a patient with an MDD diagnosis exclusively.¹¹ Almost all patients had overlapping diagnoses, such as substance abuse, personality disorders, and, in many cases, a comorbid anxiety disorder (Figure).¹¹ Symptoms of anxiety are often present during episodes of MDD, and some of these symptoms are a part of the MDD diagnostic scheme. For example, low energy, sleep disturbance, and somatic symptoms are common to both MDD and anxiety disorders.^9,10 The overlapping diagnostic criteria between anxiety disorders and MDD have led some researchers to speculate that these disorders may be part of a single disorder, as opposed to different spectra of disorders.¹²

Can MDD and anxiety disorders be described as existing on a continuum as opposed to being two distinct disease entities?

Whether MDD and the anxiety disorders are distinct or exist on a continuum is a point of debate and deliberation with sound arguments that have been presented in either direction. These disorders could be considered as being a part of a single continuum and, at different times, one group of symptoms is more pronounced than the other. For example, at one time the depressive symptoms may be more prominent, while at another time, the anxiety symptoms ascend. However, it could also be that they are, in fact, distinct disorders, which have many overlapping symptoms and characteristics. Ultimately, identifying how depression and anxiety relate to each other may come from biological, genomic, and neuroimaging studies. It may be discovered that these disorders either have strong genetically overlapping characteristics or, quite possibly, that they are associated with dysfunction in adjacent areas of the brain. We are fairly certain that dysregulation of the hypothalamic-pituitary-adrenal axis is related to the symptoms of both anxiety and depression, and this dysregulation is modulated by a number of neurotransmitters and other neurochemicals.¹³ The most widely studied neurotransmitters are serotonin and norepinephrine, which may work in tandem to affect symptoms of these disorders.¹⁰

When examining specific patients, a patient who pathologically worries is part of the same spectrum, in terms of personality and biology, as a patient who is likely to have MDD. In addition, data from epidemiologic studies clearly demonstrate significant lifetime comorbidity between anxiety disorders and MDD.^12,14,15 This finding is particularly true for patients with the anxious subtype of MDD who are at a higher risk for experiencing comorbidities across the spectrum of anxiety disorders. In relation to patients who are not experiencing significant anxiety symptoms, patients with anxious MDD have been shown to have a significantly greater likelihood of experiencing comorbid GAD (OR: 1.7; P<.0001), obsessive compulsive disorder (OR: 1.7; P<.0001), social phobia (OR: 1.3; P=.0287), posttraumatic stress disorder (OR: 1.5; P=.0013), and, in particular, agoraphobia (OR: 2.2; P<.0001) and panic disorder (OR: 3.0; P<.0001) [Table].³

Overall, the diagnostic nomenclature of psychiatry continues to evolve, and as researchers make progress toward the next steps in psychiatric nosology, these issues may be addressed. Any significant changes are more likely to come following the publication of the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders, which is currently in development and slated for completion in 2012. The changes referred to previously are more likely to be 10–20 years off, as the science involved in neuroimaging and genetics is still relatively new and will require greater refinement before such distinctions can be made. By that time, researchers may find that there are biologically distinct drivers for these various conditions, which may then help clinicians directly target treatments to those physiologic pathologies. In the case of anxiety and MDD, it is possible that researchers will find overlapping genetic traits that are modified by early and later life experiences.

Are there particular subtypes of patients who are more likely to
experience anxiety symptoms along with MDD?

According to a study by Fava and colleagues,³ as well as in other reports, patients with anxious MDD are more likely to be found in primary care settings than in specialty care settings. The patient with anxious MDD is also more likely to be female than male, more apt to be in a relationship than single, and is more likely to be unemployed, Hispanic, and less educated. Patients with anxious MDD also tend to have a more severe form of MDD and a greater chance of suffering from a melancholic subtype of MDD.^3,16

What are the other clinical implications of high levels of anxiety on the course of illness and response to treatment? Specifically, are these patients more chronically ill than others?

Anxious MDD generally worsens the long-term prognosis of MDD and lowers the likelihood of a positive treatment response.^1,17 MDD patients with significant anxiety symptoms are generally more difficult to treat and bring to a full symptomatic remission. There are also some data suggesting these patients tend to have worse long-term outcomes, meaning that they have a greater likelihood of a chronic disease course as well as being less likely to respond to treatment.¹⁸

Are there any particular recommendations for managing patients with anxious MDD?

As in most psychiatric disorders, the two broad categories of treatment are behavioral and biological. The currently available biological interventions include antidepressants and anxiolytics, such as benzodiazepines. Of course, an increasing number of stimulation treatments (eg, electroconvulsive therapy, vagus nerve stimulation, repetitive transcranial magnetic stimulation, and deep brain stimulation) are being studied and introduced into practice. Cognitive and behavioral psychotherapeutic approaches seek to teach patients different methods of thinking and behaving that may alleviate anxiety symptoms, which generally involve relaxation techniques and ways of helping the patient  sleep.^19,20 However, a combination of behavioral treatments and pharmacotherapy may be the most effective approach.²¹

Antidepressants are the most appropriate mediciations to treat anxious MDD.^2,22-25 As a group, modern antidepressants are effective for both MDD and most anxiety disorders. In addition, adjunctive benzodiazepine use is recommended for patients with severe anxiety symptoms or a comorbid anxiety disorder.⁸ It is important to be mindful of the hazards of using benzodiazepines in the elderly and in patients with a history of drug or alcohol misuse, because of the risk for abuse. For more difficult to treat cases, the concomitant use of antipsychotics and antidepressants may also be considered.²⁶

What are the goals of treatment for patients with anxious MDD?

The goal of treating all cases of MDD is a full remission of symptoms, which can be defined as an almost asymptomatic state that meets specific rating-scale criteria, such as a score of ≤7 on the 17-item Hamilton Rating Scale for Depression (HAM-D)₁₇ or ≤5 on the Quick Inventory of Depressive Symptomatology, Self-Report.^27,28 In practical terms, remission is defined as the patient being virtually well with a return to normal functioning. The goal for treating MDD with anxiety is similar: having the patient return as closely to a normal baseline state as possible. Physicians should seek to alleviate most symptoms and to return the person to a premorbid level of functioning at home and at work.

Some data in the literature have suggested that patients with anxious MDD have a greater incidence of side effects and poorer tolerability of treatment. Does this presentation fit with typical clinical experience?

A patient who is anxious and worried tends to have a greater sensitivity to, awareness of, and concern about somatic symptoms in general. This concern is due to the fact that somatic symptoms may trigger symptoms of anxiety caused by fear about what these symptoms may indicate. Similarly, an anxious patient may also be more alert to and concerned about the adverse events related to antidepressant pharmacotherapy. One study has shown that there is a significant association between somatic symptoms, hypochondriasis, and the severity of anxiety symptoms in patients with MDD.²⁹ A secondary analysis from the Sequenced Treatment Alternatives to Relieve Depression study1 found that patients with anxious MDD experienced a significantly higher number of hospitalizations due to general medical conditions as compared with those without significant anxiety symptoms.¹ This may also be true for anxiety disorders overall as they are traditionally associated with an higher level of hypochondriasis and somatic symptoms.

What rating scales are available to PCPs and mental health professionals to monitor symptoms of MDD and anxiety?

There is a combined screening instrument that includes both the 9-item Patient Health Questionnaire³⁰ and the 7-item Generalized Anxiety Disorder Scale,³¹ which is an effective screening tool for anxious MDD. Anxious MDD can also be assessed using the anxiety/somatization symptoms factor of the HAM-D₁₇.³² This subscale is comprised of depression symptoms, such as psychic and somatic anxiety, general somatic symptoms and hypochondriasis, and a score of ≥7 on this subscale has been used to define anxious MDD.¹

Increasingly, treatment guidelines and expert opinions are calling for measurement-based care of psychiatric disorders. Similarly to how physicians regularly measure blood pressure to monitor progress in treating hypertension, rating scales are regularly used to track improvements in depression and anxiety symptoms. Rating scales are more consistently being used to measure symptoms, side effects, and treatment outcomes. Increasingly, clinicians and health systems are turning to electronic means of capturing important clinical information. In the near future, patients may be asked to provide vital information via electronic means before coming to see a PCP or other health care professional. The clinician will then be able to scan crucial data in graphic form to more quickly assess treatment progress and decide, together with patient and patient’s family, on the next step of treatment.

References

www.primarypsychiatry.com

10 Foods to Boost your Brain Food..........

Opt for wholegrain food
Walk into a room and forget why you're there? Forget already what this article's about? Make sure you're eating a diet rich in a mix of wholegrain foods such as cereals, wheatbran, wheatgerm and wholewheat pasta. One study found that women who increased their folic acid, vitamin B12 and vitamin B6 intake showed an improvement in recalling information compared to women who were not taking a supplement.

Eating oily fish helps boost brainpower Enjoy oily fish
The essential omega-3 fatty acids - found in oily fish, as well as fish oil, walnut oil and flaxseeds (linseeds) - are high in DHA, fatty acid crucial to the health of our nervous system. Low DHA levels have been linked to a higher risk of developing Alzheimer's disease and memory loss. Fish also contains iodine, which is known to improve mental clarity.

Binge on blueberries Research from Tufts University in the United States and published in the Journal of Neuroscience suggests that blueberry extract can improve short term memory loss. Widely available, so there's no excuse!
Eat more tomatoes

Tomatoes are high in lycopene - a powerful antioxidant There is good evidence to suggest that lycopene, a powerful antioxidant found in tomatoes, could help protect against the kind of free radical damage to cells which occurs in the development of dementia, particularly Alzheimer's.



Add vitality with vitamins
Folic acid and vitamin B12 help prevent homocysteine from building up in the body - levels of which have been found to be higher in people who have Alzheimer's.
Fortified cereals are a great source of B12 and also contain complex carbohydrates which release energy over a long period and will keep you more mentally alert throughout the day.

Feast on blackberries and boost levels of vitamin C Get a blackcurrant boost
Vitamin C has long been thought to have the power to increase mental agility. One of the best sources of this vital vitamin is blackcurrants.

Pick up pumpkin seeds
Just a handful a day is all you need to get your recommended daily amount of zinc, vital for enhancing memory and thinking skills.



Sub Navigation for wellbeing

Bet on broccoli A great source of vitamin K, which is known to enhance cognitive function and improve brainpower.

Sage helps improve memory Sprinkle on sage
Sage has long had a reputation for improving memory and although most studies focus on sage as an essential oil, it could be worth adding fresh sage to your diet, too.

Go nuts
A study published in the American Journal of Epidemiology suggests that a good intake of vitamin E might help to prevent poor memory. Nuts are a great source of vitamin E along with leafy green vegetables, seeds, eggs, brown rice and wholegrains.

Lean red meat is high in anti-oxidants Brainpower supplements
Two supplements are causing excitement within the medical world. The first Eye Q, a blend of high grade marine fish oil and evening primrose oil, is thought to boost brainpower in children. A study by Durham County Council and Mansfield College, Oxford, concluded that 40 per cent of the children sampled improved both their reading skills and attention spans when taking the supplements.

The second is called Ethos Endymion, which contains L-Carnosine, a strong antioxidant which appears to have dramatic results for a number of conditions: cataracts, improving skin tone, speeding up wound healing, and protecting the brain from plaque formation that may lead to senility and Alzheimer's. L-Carnosine is found in chicken and lean red meat so this powder supplement could be especially useful for veggies.