Chocolate, CV Disease and Stroke

Heartwire from Medscape
Higher Chocolate Intake May Lower Risk for CV Disease, Stroke in Healthy Adults

Deborah Brauser June 16, 2015


NEW YORK, NY — Rejoice, chocolate lovers: more findings suggest that regular consumption of the sweet stuff may decrease the risk of CV events and stroke in otherwise-healthy individuals[1].

Analysis of almost 21,000 adults from the UK's EPIC-Norfolk study showed that those who ate the most chocolate had an 11% lower risk of developing coronary heart disease (CHD) and a 25% lower risk of CV-related death over 12 years of follow-up when compared with those who ate no chocolate. In addition, the highest-consumption group had a 23% lower risk of stroke.

A separate meta-analysis of more than 155,000 participants in studies examining possible links between chocolate and CV outcomes showed similar findings.

The authors, led by Dr Chun Shing Kwok (University of Aberdeen, Scotland), note that although cause and effect could not be shown in these observational studies, cumulative evidence suggests that there is an association at play.

Interestingly, the participants in the cohort study ate more milk chocolate than dark chocolate, which may indicate that "not only flavonoids, but also other compounds, possibly related to milk constituents such as calcium and fatty acids, may provide an explanation for the observed association," write the investigators.

The findings were published online June 15, 2015 in Heart.

More Chocolate, Less Risk

For the current analysis, the researchers examined records from 20,951 EPIC-Norfolk participants who filled out the food frequency questionnaire at baseline, which included questions about chocolate consumption. The participants were then divided into five "quintiles" based on their chocolate habits, with the highest group consuming 16 to 99 g/day of chocolate.

After a median of 11.9 years of follow-up, there were 2434 CHD events. Of these events, 13.8% occurred among those who ate the least amount of chocolate and 9.7% occurred among those in the highest quintile of chocolate consumption. There were also 848 strokes overall, including 5.4% and 3.1% of the lowest and highest quintiles, respectively.

Compared with those who didn't eat any chocolate, the adjusted hazard ratio (HR) for the highest-consumption group was 0.89 (95% CI 0.79–1.00, P=0.02) for total CVD and 0.75 for CVD mortality (95% CI 0.62–0.92, P=0.01). This group also had significantly lower risk of CHD-related hospitalization or mortality in minimally adjusted models, but not in the fully adjusted models.

However, the highest-consumption group did have a significantly lower risk of stroke in both types of models (both HR 0.77, P<0.05).

In the systematic review of nine studies and 157,809 participants, the highest quintile of chocolate eaters vs the lowest quintile had significantly lower risk of CHD, stroke, composite CV adverse outcomes, and CV mortality—with pooled risk ratios (RRs) of 0.71, 0.79, 0.75, and 0.55, respectively.

Interestingly, the non–chocolate-eating group had the highest mean body-mass index, the highest percentage of participants with diabetes, and the highest levels of inactivity. On the other hand, "higher chocolate intake was associated with a higher energy intake, with lower contributions from protein and alcohol sources and higher contributions from fat and carbohydrates," write the investigators.

Overall, they reiterate that their analyses do not show causation. However, "within the general context of existing recommendations for behaviors conductive to cardiovascular health, there does not appear to be evidence that chocolate should be avoided."

EPIC-Norfolk was funded by grants from the Medical Research Council and Cancer Research UK. Kwok and the coauthors report they have no relevant financial relationships.

Doctors' Relationship With Second Opinions

Medscape Business of Medicine
Doctors' Love/Hate Relationship With Second Opinions

Neil Chesanow Disclosures June 18, 2015

Opinions on Second Opinions Vary

Many if not most doctors would probably agree with Melissa Walton-Shirley, MD, a clinical cardiologist at Cardiology Associates in Glasgow, Kentucky, when she insists that "patients absolutely have a right to a second opinion." Dr Shirley did not qualify when a second opinion might or might not be justified.

But while many physicians say they agree with Dr Shirley, not all of them do.

"If a doctor is upset that a patient got a second opinion, I would consider that a knock," says John Mandrola, MD, a cardiac electrophysiologist at the Louisville Cardiology Group in Louisville, Kentucky. Dr Mandrola specializes in treating patients with atrial fibrillation, a condition for which patients commonly seek a second opinion regarding treatment. "I think it's a mark of a good physician that they don't get upset if a patient wants a second or third or even a fourth opinion."

But some physicians do get upset. Even Dr Mandrola sometimes does.

"It would be a little overconfident to say that I don't ever get emotionally attached to my recommendations," he admits. "But I am actively mindful of not being attached to what the patient chooses to do."

Not every doctor is always so mindful, however.

"I've seen situations where doctors who are threatened by second opinions might sometimes be the high-ticket guys," says Charles Davant, III, MD, a family physician in Rolling Rock, North Carolina. "The more money the doctor has at stake, the more likely they might be to lean toward doing something that would not be my first choice."

"I have rarely seen doctors get genuinely upset about patients who go for second opinions, says Ira H. Kirschenbaum, MD, chairman of the Department of Orthopaedics at Bronx-Lebanon Hospital Center in the Bronx, New York. In the rare event that a doctor does get upset, "I am sure there's ego involved: 'I spent time with this person. I thought we had a good rapport. Are they going to the other doctor because he marketed better?' People don't like to lose business."

"Physicians may interpret a patient's reluctance to follow their recommendations as a challenge to their expertise and authority," concedes internist Matthew H. Mintz, MD, associate professor of medicine at George Washington University Medical Center in Washington, DC. "But," he adds, "an open and honest discussion may lead to other, more likely causes, such as fear and denial on the part of the patient."

"There's certainly an ego component for some physicians," says emergency physician Miles Varn, MD, medical director of PinnacleCare, a health advisory firm in Baltimore, Maryland, "although what I tell the patients is: 'If a physician is really resisting a second opinion, there has be a reason for that,' and it's not necessarily a reason that's in the best interest of the patient. In our experience, we see very little resistance to second opinions."

50-Year Data Link Pesticide to Breast Cancer

Medscape Medical News > Oncology
50-Year Data Link Pesticide to Breast Cancer
First Study to Find Link

Veronica Hackethal, MD June 16, 2015


There is a significant association between in utero exposure to the pesticide DDT, which was widely used in the 1960s in the United States before being banned, and the risk for breast cancer in young women, according to new research from the state of California.

The study investigators also say there is a "possible association" with more aggressive tumors and exposure to DDT, which is a synthetic estrogen and a possible endocrine disruptor.

"Our findings support the idea that the breast may be particularly vulnerable in utero," commented lead author Barbara Cohn, PhD, of the Public Health Institute, in Berkeley, California.

The nested case-control study is, remarkably, the first to directly link in utero exposure to an environmental chemical to breast cancer.

The "unique" study was made possible by 54-year follow-up of the Child Health and Development Studies (CHDS) cohort in California, which enrolled pregnancies from 1959 to 1967, a period that is coincidentally the "years of highest DDT exposure" in the United States.

A total of 9300 female babies were born into the cohort study, which had the goal of examining "prenatal exposures and health and development over the life course for parents and children."

There were 118 breast cancer cases diagnosed by age 52 years, and investigators identified 345 control individuals who were matched by birth year. The cancers were found using state registry records and a self-report survey of CHDS daughters from 2010 to 2013.

The researchers then went back and determined levels of in utero exposure to DDT in the case patients and control participants by analyzing frozen, stored blood samples from their respective mothers given during pregnancy and 1 to 3 days after delivery in the 1960s.

What they found was groundbreaking.

"The size of the DDT association with breast cancer in our study — a fourfold increase in risk for women in the top 25% of DDT exposure compared to the bottom 25% — is larger than for many known behavioral risk factors for breast cancer," said Dr Cohn.

She explained that daughters born to mothers with increased serum levels of o,p'-DDT ― which is a more estrogenic form of DDT found in commercial pesticides ― had a nearly fourfold increased risk for breast cancer (odds ratio [OR] fourth quartile vs first = 3.7; 95% confidence interval [CI], 1.5 - 9.0; P = .004). This was found regardless of the mother's history of breast cancer.

Notably, 83% of the women had estrogen-receptor-positive breast cancer.

Further analyses linked DDT to advanced stage at diagnosis (estimated OR, 2.2; 95% CI, 1.1 - 4.2; P = .2) and to HER2-positive tumors (estimated OR, 2.1; 95 CI, 1.0 - 4.8; P = .05).

Daughters of women with triple the amount of exposure to DDT had four times the risk of developing advanced-stage and HER2-positive breast cancer compared with daughters of women with lower levels of exposure (for late-stage: OR, 4.6; 95% CI, 1.3 - 16.5; for HER2-positive: OR, 4.6; 95% CI, 1.1 - 19.7).

Laboratory studies have provided support for these findings and suggest that DDT activates the HER2 receptor, write the authors in their article, published online June 16 in the Journal of Clinical Endocrinology and Metabolism.

"Although our human study is not proof of causation, it may be prudent to protect women of childbearing age from avoidable DDT exposure in countries where it is still used," advised Dr Cohn.

The United States and Europe banned DDT in the 1970s, but Asia and Africa continue to use it for malaria control.

"Since some environmental chemicals may be stored in the body for long periods, it may also be prudent to protect children from unnecessary chemical exposures," she added. "Avoiding unnecessary additional exposures to other suspect environmental chemicals is a possible step for women already previously exposed to DDT."

Although the increased risk may be concerning for women exposed to DDT in utero, Dr Cohn put it into perspective.

"The baseline risk of breast cancer for a woman at age 50 is still low ― 2.38%. Increasing that risk fourfold is still a low risk," she reassured.

"All women, whether or not they suspect in utero DDT exposure, should discuss an early detection and prevention strategy with their doctor, who will know their personal history and personal risk," she emphasized.

The present study investigates breast cancer diagnosed before age 52 years. Thus, these results do not address DDT associations with breast cancer diagnosed at an older age, write the authors.

However, continuing follow-up in the cohort will determine whether in utero DDT associations with breast cancer are observed for cases diagnosed in the future, in patients of older ages.

The authors have disclosed no relevant financial relationships.

J Clin Endocrinol Metab. Published online June 16, 2015. Abstract