Try to Have Yours Elsewhere
It turns out that one of the worst places to suffer an unexpected heart attack is while in a hospital. Based on recent studies covering over 60,000 patients and 300 hospitals, persons who’ve been hospitalized for medical problems or surgeries unrelated to heart disease who have heart attacks while there are from three to ten times more likely to die than persons who arrive at the hospital ER after having heart attacks somewhere else. Overall, some five percent of all major heart attacks in the U.S., or roughly 10,000 per year, occur to people in hospitals for unrelated reasons ranging from cancer and pneumonia to hip or knee replacement. Among the reasons: those patients are often already weakened, and their medical issues or medications may mask telltale heart attack symptoms.
See Your Doctor ASAP
Signs of cardiac arrest - chest pain, shortness of breath, palpitations, dizziness - present themselves up to a month before the event in more than half of middle age men who experience it, finds research presented at the American Heart Association’s Scientific Sessions, Dallas, TX. Cardiac arrest is when the heart stops due to a failure in its electrical system and is not to be confused with heart attack which is caused by a blockage that stops blood flow to the heart. “You'll die within 10 minutes of a cardiac arrest unless you are lucky enough to get emergency assistance quickly,” says senior author Sumeet Chugh, cardiologist, Cedars-Sinai, LA. If you have symptoms, see your doctor asap, warns Chugh who adds that researchers are also studying cardiac arrest in women.
Protects Against, Uh, Flu, Too
Getting a flu shot may lower the risk of heart attack and other cardiovascular events for a year, finds research from the University of Toronto that looked at studies on the heart health of 6,735 men and women with the average age of 67. Half got a flu shot; half got a placebo or standard care. One-third of patients had heart disease while the rest had risk factors including high blood pressure or high cholesterol. Patients who had suffered recent heart attacks and who got flu shots had a 55% lower risk of having another major heart event. “This could be a vaccine against cardiovascular events,” said cardiologist Dr. Jacob Udell. He said it was his hope that the flu vaccine would prevent heart issues for “potentially everyone,” including those who had not had a recent heart event.
Regular consumption of gazpacho, a popular cold Mediterranean soup, may help to reduce hypertension (high blood pressure). Researcher Alexander Medina-Remon of the University of Barcelona says that nutrients within the main ingredients of gazpacho – tomato, cucumber, garlic, and olive oil) are associated with reduced arterial pressure, despite the fact that the soup also usually contains salt. He suggests that the bioactive elements in the vegetables, particularly carotenes and vitamin C, may counteract the effect of sodium ingestion. High blood pressure is a major public health problem affecting about 25 percent of the adult population. It is a primary risk factor for heart attack and stroke, both leading causes of death in the US.
Early menopause exposes women to a greater risk of heart attack and stroke, says researcher Dr. Melissa Wellons who looked at 2,509 women enrolled in the Multi-Ethnic Study of Atherosclerosis with 693 reporting menopause before age 46. Wellons found that early menopause in European, African-American, Hispanic and Asian women doubled the risk for CV disease. She cautions that her study is observational and definitive conclusions can’t be drawn, “but our findings do support the use of age at menopause as a marker of future heart and vascular disease risk” and says clinicians should ask about menopause when collecting a female patient's medical history." Cardiovascular disease is the leading cause of death among US women. Lifestyle and medical strategies are known to reduce that risk.
Limit High-Mercury Fish
Fish is a healthful food, with several studies showing that people who eat seafood have a lower risk of cardiovascular diseases than those who eat little or none at all. A key heart-healthy nutrient in fish is omega-3 fatty acid, which may help reduce inflammation leading to heart disease as well as other chronic conditions such as cancer and arthritis. However, some fish contain a significant amount of environmental pollutants which can be harmful to human health, such as mercury, which has been linked to an increased risk of heart attack. To balance out the risks and benefits, the Swedish National Food Agency recommends that people eat fish 2 to 3 times per week, but limit intake those that tend to be high in mercury such as marlin, tilefish, swordfish, mackerel, and tuna.
Bottle of Red
Alcohol-free red wine lowered blood pressure in a study of 67 older men who were at risk for heart disease. The men were asked to drink 1 of 3 beverages consistently every day for a month: 2 glasses of red wine, non-alcoholic red wine, or 2 shots of gin. Researchers found that neither the red wine nor gin had an effect on blood pressure yet after a month of consuming the non-alcoholic wine, the men’s systolic blood pressure dropped by an average of 6 points while their diastolic pressure fell by 2 points. The drops were small but are enough to reduce the risk of heart disease and stroke by up to 20%. Researchers think polyphenols are responsible for lowering blood pressure but that alcohol counteracts the effects. More research is needed to confirm results on healthy men and women.
America's Oldest Teenager
Dick Clark, eternally youthful television personality, producer and entertainment mogul has died. He was 82. Often called America’s Oldest Teenager because of his preternaturally youthful appearance, Clark is perhaps best known for his 30-year stint as host of American Bandstand, a dance show that introduced some of the world’s most famous rock and roll bands and performers to generations of American teens. Each December 31st, millions of people rang in the New Year with Dick Clark’s New Year’s Rockin’ Eve. Clark is also remembered as the host of popular television shows including Pyramid and TV’s Bloopers and Practical Jokes. Clark, whose health was compromised when he had a stroke in 2004, died after suffering a heart attack. He is survived by his wife, Kari, and three children.
A Sleepy Medium for Heart Health
Preliminary results from a study looking at over 3,000 patients over 45 years old in the U.S. National Health and Nutrition Examination Survey showed that getting less than six hours or more than eight hours of sleep can increase the risk of cardiovascular problems. Sleep deprivation raises the odds of suffering a stroke, heart attack and congestive failure while those who oversleep risk angina and coronary artery disease in which the vessels that bring blood and oxygen to the heart muscles get narrow. Factors such as sleeping difficulties, age, cholesterol, smoking and obesity were accounted for but the strong association remained. Prior research has shown that lack of sleep leads to a wide range of problems such as diabetes, inflammation and increases stress hormones and blood pressure.
Unique Risk Factors
Pregnant women and are at and triple to quadruple increased risk of having a heart attack than their non-pregnant counterparts, they are more severe and they are a 2 to 3 time more likely to die. in physiology, hormone levels and greater blood volume due to pregnancy are three of the factors that increase their risk and they can last up to three months postpartum. Another reason which is quite common in pregnant women is coronary dissection which results when the layers of the arterial wall separate and occlude blood flow. Because the reasons for a pregnant woman having a heart attack differ from factors for other demographics, researchers conclude that the standard treatment for heart attacks many not be the best approach.
Higher Dose Poses Higher Risk
A worldwide study involving over 11,000 people who had a heart attack found no difference in protection from subsequent cardiac events in those who taking a low dose aspirin (150 milligrams or less) and those who took a high dose aspirin (150 milligrams or greater). While studies show that a daily aspirin reduces the risk of having another heart attack or a stroke, there is a risk of bleeding, particularly with a higher dose. The study found that in North America, 67 percent of patients are prescribed a high dose aspirin, a number that flips for the rest of the world. Patients with risk factors for cardiac problems and high cholesterol were more likely to be prescribed high dose aspirin, but based on these results researchers do not think high dose aspirin is necessary for this reason.
It Was Only a Matter of Time
In a dramatic case of either irony or inevitability, a man in his 40's suffered a heart attack Saturday night while eating a 6,000-calorie Triple Bypass Burger at the Heart Attack Grill in Las Vegas. Although there have been "incidents" at the Grill, the owner noted, this was the controversial restaurant chain's first actual instance of cardiac failure, despite the signs at the entrances warning of possible health hazards, the offer that those weighing over 350 pounds eat for free, and the restaurant's promise of "Taste Worth Dying For!" As the man was sweating and shaking with chest pain, the other diners reportedly continued eating their Bypass Burgers and Flatliner Fries, or paused to take photos of the victim, who is said to be recuperating.
Unbreak My Heart
Broken heart syndrome, or stress cardiomyopathy, is real with symptoms that mimic heart attack, including chest pain and difficulty breathing, but that leave no lasting damage to the heart, says Loyola U. Health System cardiologist, Dr. Binh An P. Phan. It may be brought on by the death of a loved one, a breakup or the loss of a job. In broken heart syndrome, a surge of adrenalin and other stress hormones can cause the arteries that supply blood to the heart to narrow. Similarly, during a heart attack, a blood clot in a coronary artery restricts blood supply to heart muscle. Phan says it’s difficult to distinguish between heart attack and broken heart syndrome and for that reason people who experience chest pains or difficulty breathing should seek medical help immediately.
No More Strenuous Than Golf
Sex is safe for most heart and stroke patients says Loyola University cardiologist John Moran who explains, "For a patient who has sex with a familiar partner in a familiar setting, sexual activity generally is safe and no more strenuous than golf.” Dr. Moran echoes a new scientific statement released by the American Heart Association which says that people with stable heart disease and no or minimal symptoms during routine activities can safely engage in sexual activity. Medical experts recognize that resuming sexual activity and intimacy is important to heart patients and their partners. "Enhanced communication and post-stroke sexual education are paramount to a healthy, ongoing relationship," says Loyola stroke specialist Dr. Jose Biller.
Deficiency Ups Risk and Death
Researchers studied 16 years worth of data and found that vitamin D deficiency was linked to having more risk factors and dying from cardiovascular disease. Over 2000 women had their vitamin D levels measured and 788 were found to be deficient. Being deficient also increased the likelihood of having elevated triglyceride levels, higher faster blood sugar levels, greater body mass index and decreased HDL (“good” cholesterol). Smoking was linked to being deficient. Another study showed that inflammation was reduced in those who took 4000 units for five days after a cardiac event. Another study shows that low vitamin D with chest pains were linked to an increased chance of dying within two years and higher levels of the vitamin reduced mortality rates due to cardiovascular disease.
Bedtime Is for Heart Health
Nighttime is the right time to take your blood pressure medications, according to a study conducted in Spain involving 661 individuals with high blood pressure and chronic renal disease. Previous research has found that taking drugs at certain times of the day affect the pattern of a person’s blood pressure but this study looked at the health benefits by using chronotherapy, coordinating a patient’s biorhythms to the time a drug is taken. One half took their medications before bed while the other took them in the morning. Follow-up found that taking them at night reduces the risk of going into heart failure or having a heart attack or stroke by two-thirds. They also found that blood pressure values obtained while asleep was more reflective of heart health.
Controlling Disease Lowers Risk
Having diabetes is a risk factor for cardiovascular disease, and a new study has confirmed this link. Researchers from Duke University Medical Center have found that diabetics who suffer a first stroke or transient ischemic attack (TIA) - sometimes called a mini-stroke - are at a greater risk of having another cardiovascular event. The findings come from data on over 4,700 stroke patients enrolled in the SPARCL Trial. Compared with non-diabetics, stroke patients with the disease were more likely to have another stroke, TIA or heart attack and were more likely to need an angioplasty to open blocked arteries. Lowering cholesterol using statin drugs and properly controlling blood sugar and blood pressure reduced the risk of a second stroke.
Measuring Tape Trumps BMI
BMI (body mass index) is a poor measure of heart risk, but measuring waist size is an accurate way to predict the risk of dying early from heart attack or other causes. Study findings were reported in Journal of the American College of Cardiology. According to CNN, the study reveals that measuring BMI, but not body shape, is a flawed method of predicting heart risk since it doesn't take into account fat distribution. Previous studies have shown that a large waist size (greater than 35 for women or 40 for men) increases death risk. The new study findings help reinforce the need for doctors to consider waist size, perhaps even telling normal weight patients to lose belly fat.
Disrupts Inflammatory Pathway
Research at the University of Leicester shows an injection of an antibody disrupts the inflammatory tissue response that occurs after an ischemic event such as a heart attack or stroke. In animal studies, one injection of an antibody against the enzyme Mannan Binding Lectin-Associated Serine Protease-2 (MASP-2) reduce the damage caused by disruptions in blood flow the prevent oxygen from getting to tissues and yielded better outcomes. MASP-2 is involved in the lectin pathway which plays a role in innate immunity and is activated during an ischemic event such as a heart attack or stroke. Patients who have surgeries where blood flow had to be interrupted such as transplants may also benefit from this injection. Researchers are currently preparing to conduct human clinical trials.
Mortality Rate Increased
Data from 16 previous studies suggests the Avandia increases the risk of heart attack and congestive heart failure by 16 and 23 percent, respectively, compared to another drug. The mortality rate was increased by 14 percent. The drug controls blood sugar levels in type 2 diabetics and previous studies linking it to cardiovascular problems did not yield consistent results but in September health officials were worried enough that they decided people who could control their blood sugar only with Avandia could use it. The other drug, Actos, was shown to double the risk of fractures in women and slightly increase the risk of bladder cancer. A similar study by an insurance company conducted last year of their younger and healthier group found no difference in heart health risks.
Another Reason 13 Is Bad Luck
Over 22,000 people with either coronary heart disease or with a history of having a heart attack had their DNA examined and compared to those of 60,000 healthy people. Researchers found 13 variations, also known as mutations in genes that had not been previously discovered that are linked to factors that increase the risk of heart disease such as elevated LDL levels and high hypertension. They also confirmed at least 10 more variants. Researchers hope the results help them gain better insight into the development of heart disease which should lead to better treatments and prevention. It also supports the idea that analyzing an individual’s genetic profile for these variants should become part of the standard of care since heart disease is the world's number one killer.
Women's Heart Health Month
Cardiovascular disease kills nearly twice as many women in the United States than all types of cancer, according to the American Heart Association, but simply being a woman does not increase the risk of dying from a heart attack. A study from the University of Michigan Cardiovascular Center found that although overall women had higher in-hospital heart attack deaths, the difference was related to age and additional health problems, not gender. Women account for about one-third of patients who undergo cardiac procedures such as angioplasty, but they tend to be older and have more co-morbidities in addition to primary disease. Women are also more likely to have vascular complications or a bleeding episode in the hospital that requires a transfusion.
O for Heart Attack Protection
Researchers have discovered the gene that leads to developing type O blood appears to reduce the risk of having a heart attack even in the presence of cardiovascular disease. About 13,000 people with heart disease were compared to 7,400 healthy people. They also looked at 5,800 who had a heart attack and 3,600 with the condition who did not and discovered a gene called ADAMTS7 linked to an increased risk of coronary artery disease and also found that the gene that produces type O blood reduces the risk of a heart attack. This does not mean people with type O should not prevent heart disease, but researchers believe that these results will provide them with a better understanding of heart disease and lead to treatments by altering the function of the gene and blood typing.
Yes, Says a New Study
A Johns Hopkins study finds that statin therapy to ward off cardiovascular disease may not benefit everyone. The six-year study found that nearly 95 percent of all heart attacks and strokes occurred in participants who had a measurable buildup of calcium in their blood vessels, while 47 % of participants had no detectable levels of calcium buildup and experienced about five percent of cardiovascular events during the study period. "Our results tell us that only those with calcium buildup in their arteries have a clear benefit from statin therapy, and those who are otherwise healthy and have no significant calcification should with their physician focus on aggressive lifestyle improvements instead of early initiation of statin medications," says investigator Dr. Michael Blaha.
Danger of Heart Risk Revealed
About eight million people use the weight loss drug, Meridia, but they’re going to have to find something else to use because Abbott Laboratories is taking it off the shelves. It’s being voluntarily recalled because clinical studies have shown that people who use the drug have an increased risk of heart attacks and strokes. The original data for Meridia, which was approved in 1997, showed that people lost at least 5% more of their body weight than those who used a placebo or relied on diet and exercise alone. After reviewing the results of a new study, the Sibutramine Cardiovascular Outcomes Trial, the FDA requested that the drug be withdrawn because it showed a 16% increase in the risk of serious heart events, including non-fatal heart attacks, non-fatal strokes, and death.
No Experience Necessary
New research in Arizona demonstrates that compression-only cardio-pulmonary resuscitation (COCPR) is better than the traditional mouth-to-mouth or CPR for heart attack victims, even when provided by someone who has no medical training. A study involving 4,415 patients over 18 who had heart attacks outside of a hospital from January 2005 to December 2009 was conducted. The survival rate for those who only got compressions was 13.3 percent, while those who had mouth-to-mouth and no CPR had rates of 7.8 and 5.2 percent, respectively. The study was the product of a program Arizona created in 2005 with the goal of increasing survival rates of individual who had heart attacks outside settings such as hospitals that include the equipment and personnel qualified to deal with such situations.
Due to Heart Attack Risk
Avandia, the diabetes drug manufactured by GlaxoSmithKline, has been restricted in the US and completely suspended from being sold in Europe due to the risk of heart attack. According to one study, more than 47,000 people taking Avandia between 1999 and 2009 suffered a heart attack, stroke or died. The FDA’s decision to restrict the drug to patients whose doctors say they’re aware of the risks and have tried all other diabetes drugs unsuccessfully, indicates the Obama administration is taking a harder line on drug safety issues and ushers in a new era of drug testing prior to gaining FDA approval. The restrictions will take months to be enforced and doctors say that patients currently taking Avandia should continue to do so until they speak with their doctors.
From Hair to Eternity
Health experts proclaim the dangers of chronic stress on heart health but, until now, there hadn’t been a biological marker to measure it. Recently researchers at the U of Western Ontario developed a method to measure cortisol levels in hair. The research provides an accurate assessment of stress levels and predicted acute events, including heart attacks, in the months preceding them. The “stress hormone” cortisol has previously been measured in blood and urine but, because it’s secreted at the time of stress, measuring it was not an accurate predictor of acute events to come. However, cortisol is stored in hair. “... if we take a sample six cm long, we can determine stress levels for six months by measuring the cortisol level in the hair,” says researcher Dr. Gideon Koren.
Eating Fish Still Best Bet
A new study published in the New England Journal of Medicine has found that patients with a history of heart attack who eat an omega-3 enriched margarine in addition to their standard prescription drugs have no statistical difference in their chances of having a repeat attack. The study, conducted in the Netherlands, randomly assigned 4,837 heart attack patients to eat one of four kinds of margarine - one regular and three with varying sources of omega 3 fatty acids. There was no difference between the groups of patients, regardless of the type of margarine eaten. Omega 3 fatty acids are thought to reduce the risk of heart attack by preventing abnormal heartbeat, slowing the growth of plaques that clog the arteries, and by lowering triglyceride levels.
Take a Chill Pill
Having a Type A personality or being unable to control anger is linked to heart health and the increased risk for having a stroke, according to a new study published in Hypertension, a journal of the American Heart Association. Researchers from the National Institute on Aging studied over 5,000 residents of Sardinia in Italy who reported behavior via questionnaire. Ultrasound imaging was used to measure carotid artery and arterial wall thickness at five points. The participants were also screened for other major cardiovascular disease risk factors such as smoking, blood pressure, and cholesterol levels. Those who were considered the least agreeable and most antagonistic had a 40 percent increased risk for arterial wall thickening, a key risk factor for heart attack or stroke.
Supersize with Statins
"A cheeseburger, shake and a statin," may not be such a farfetched fast food order suggest researchers who say that statins can offset the heart attack risk associated with eating fast food, according to a study in the American Journal of Cardiology. "It makes sense to make risk-reducing supplements available just as easily as the unhealthy condiments that are provided free of charge. It would cost less than 5p per customer – not much different to a sachet of ketchup,” says lead author Dr. Darrel Francis, Nat’l. Heart and Lung Inst., Imperial College London. Francis’s comparative studies found that most of the risks from eating fast food are offset by statins but caution that further studies should be conducted to assess the risks of taking statins without medical supervision.
Drink Milk Instead
A study published online in the British Medical Journal has found that calcium supplements are associated with an increased risk of heart attack and cardiovascular events in healthy older women. An international team of researchers analyzed the results of 11 randomized controlled trials of calcium supplements involving 12,000 patients. They found that calcium supplements were associated with about a 30 percent increased risk of heart attack, and smaller increases in the risk of stroke and mortality. Previous studies have found no increased cardiovascular risk with increased dietary calcium intake, such as drinking milk, suggesting the risks are restricted to supplements. The authors suggest a reassessment in the role of calcium supplements in osteoporosis management.
Ozone Bad for the Heart
Preliminary tests suggest that rats who are exposed to ozone over several weeks increased the activity of tumor necrosis factor alpha (TNF-A), which is a marker of inflammation. Previous studies have shown the when TNF-A increases, a protein that protects the heart called Caveolin-1 (Cav1) by inhibiting a protein that causes heart cells to die. Levels of Cav1 were lower in rats exposed to ozone compared to the group who were exposed to filtered air. Several studies have linked pollution to ateriosclerosis and heart attack. Dr. Len Horovitz, a pulmonary specialist, says "Now there is evidence (in rats) that ozone...can trigger a direct effect on cardiac tissue through a cascade of inflammatory mediators. The endpoint in this domino effect can result in death of heart cells."
Worrying Harder on Bad Heart
A study involving 1,015 patients with stable heart disease, 106 of them with generalized anxiety disorder found that those with anxiety were at a higher risk for heart attack, stroke or heart failure. After 6 years and 371 cardiovascular events, 10 percent happened among those with generalized anxiety disorder compared to 7 percent in those without the disorder. Factors related to anxiety were looked at, yet it was anxiety alone that raised the risk of an event by 74 percent. Researchers believe that people with anxiety may have increases in “flight-or-fight” hormones or are less likely to get preventative care. Martens, who led the study says, "Evaluation and treatment of anxiety may also be considered as part of the comprehensive management of patients with CHD."
Time to Switch to Fast Food?
"You have to look at the effects of diet on a population, not an individual"
- Steve Parker, M.D. in the comments
K. Dun Gifford, founder of Oldways Preservation Trust, died Sunday at 71 of a heart attack. Gifford espoused the Mediterranean Diet with its emphasis on plant sourced food and olive oil. Today Washington Post columnist Jennifer LaRue Huget wondered if we should jettison the Mediterranean Diet. She concluded that diet is only one factor in preventing heart disease, genetics play a role and and Gifford had a history of blood clots. In addition, according to life expectancy tables based on his birth date, Gifford was only expected to live to age 63. This isn't the first time that a diet promoter's death has raised eyebrows: Dr. Robert Atkins promoted the consumption of saturated fat and protein as a weight loss technique, but reportedly weighed 237 pounds on the autopsy table.
Sex Doesn't Have to Be Casualty
A heart attack shouldn’t kill your sex life, but it sometimes does. A new study suggests that doctors could change that. Many people who have had heart attacks are afraid sex could send them back to the hospital, or worse, but there’s only a small chance of that happening. According to Dr. Stacy Tessler Lindau, a gynecologist and sexuality researcher, “If you can walk up two flights of stairs or do moderate exercise, then it's OK to have sex," but most people aren’t getting this advice. The study consisted of 1,184 male and 576 female heart attack survivors. Results show that less than half the men and about a third of the women were given any advice from the hospital about resuming sex, with a smaller amount of patients discussing the subject with their doctors during the following year.
Get Healthy for Mother's Day
As Mother's Day approaches, the Centers for Disease Control and Prevention (CDC), offer up some tips to keep moms healthy. They suggest that mothers should try getting up 10 to 15 minutes early to take a brisk walk, enjoying the peace of the early morning. That quick walk can count toward the recommended two and a half hours of aerobic activity per week. Another tip from the CDC is to meditate for 15 to 20 minutes each day to increase well-being and promote relaxation. The CDC also encourages moms to snack on fruits and veggies rather than processed foods to reduce sodium intake, which lowers the risk of hypertension, stroke or heart attack. Finally, the CDC reminds moms that May 10 is National Women's Check-up Day, an ideal time make a doctor's appointment.
Low Testosterone to Blame
Men with erectile dysfunction and low testosterone are at risk of succumbing to cardiovascular disease finds Dr. Giovanni Corona, University of Florence. In a study of 1687 ED patients, low testosterone alone was not to blame for a major cardiac event; however, men with low testosterone who have a major cardiac event are more likely to die than those with higher levels. This is the first study of its kind and “indicates that if you have erectile dysfunction, and if you have a very low testosterone level, then you are up to 7 times more likely to die from a major cardiac event than if you have erectile dysfunction and normal testosterone levels,” says Corona who also found that obesity and ED adversely affect cardiac health. He recommends greater screening for ED and testosterone levels.
"The study doesn't say that the fatter you are, the fewer heart attacks, contradicting the headline in the present post. It says, instead, that given that you have a cardiac event, you’re more likely to survive it, the fatter you are. Not the same at all."
- Margaret in the comments
Researchers out to debunk the theory that extra weight protects against heart attacks not only failed, but ended up finding more evidence to support the so-called "obesity paradox." Specifically, non-obese patients who already suffer from the condition called "heart failure," which is a technical term describing a weakening of the heart muscle (the term is used informally in other senses), were found to be 76 percent more likely to die from a sudden cardiac event (such as a heart attack or myocardial infarction) than obese patients with heart failure. And according to the University of Rochester Medical Center researchers, if the underweight/normal group is compared to the obese group, the non-obese patients are almost twice at risk than the obese patients.