Nearly 2 million American adults each year are diagnosed with cancer. If you receive a diagnosis, your schedule can quickly start to fill up with doctor's appointments, medical procedures and pharmacy visits. Creating a checklist of things to do can help keep you busy and feeling more in control. But acknowledging the effects a cancer diagnosis can have on your emotions — and healthily managing those emotions — is almost as important.
Doctors and psychologists now recognize that healing improves after a diagnosis when both our physical and emotional needs are met, says Niki Barr, Ph.D., a psychotherapist at the Center for Cancer and Blood Disorders in Texas, who consults with medical doctors, extended families and caregivers about emotionally coping with a cancer diagnosis.
Learning you have cancer is a stressful experience, and it's important to acknowledge and cope with that stress. Fully understanding how your emotional needs can change after you receive a cancer diagnosis can go a long way in helping you and your family heal. The tips here can help you support your mental health as you navigate your diagnosis and treatment.
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Upon hearing your diagnosis, you might experience grief, fear or even a feeling of denial until some time has passed. "These are all normal and emotionally healthy responses, but it's all too easy to spiral out of control with fear in the beginning," says Barr. Fortunately, these tips can help you manage the anxiety and fear that come along with learning about a cancer diagnosis.
Lessen the Impact of Anxious Thoughts
Start by writing your thoughts down on note cards or in a journal. Identify the first one that's leading you to feel uneasy. For example, you might write down something like "I'm afraid of my hair falling out." Then, move onto the subsequent fear and write it down. That might be something like "People will treat me differently if they see I have cancer."
When you've identified most of your anxious thoughts, go back to the first one and write something new on the card that can help ease your stress. It should be a thought that's confident and empowering. For example, suppose you're worried about your hair falling out. In that case, a positive view could be: "I've been looking forward to getting a new hairstyle anyway." When you're feeling nervous, read the more positive strategies, says Barr.
Work On Your Internal Dialogue
It can also help to defuse all those "What if?" questions you might ask yourself, such as "What if my cancer has spread?" or "What if the treatment doesn't work?" One scary question tends to lead to another and often turns into full-fledged anxiety. Try to focus on those things you have the power to improve on your own. The next time you start asking yourself the what-ifs, substitute the upsetting ideas with this one: "Is this thought helping me or hurting me?" You can also ask, "Is this thought moving me forward or backward?" Your answers might surprise you, and they can help you move away from the thoughts that are holding you back.
Get Grounded
Interrupting periods of anxiety by focusing on small details around you can help you shift your perspective away from negativity and towards the present moment. "Look at the beautiful color of the walls in the room you're in; look at the person you're talking to, the clothes [they're] wearing," Barr suggests. Becoming very present and focused on physical details nearby helps soothe sudden anxious thoughts. Turn your focus towards absorbing the colors, smells, people and each new sound around you. Build those sensations up very clearly in your mind. You can use this technique as a distraction tool the next time you're waiting for a medical procedure or want a diversion from your thoughts.
Meditate to Music
Research shows that 15 to 30 minutes of both guided imagery and soothing tunes can alleviate deep feelings of stress about a cancer diagnosis. The Cancer Treatment Centers of America (CTCA) reviewed 30 clinical cancer trials that analyzed more than 1,890 cancer patients. They found that music therapy can have a beneficial effect on anxiety, pain, mood, quality of life, heart rate, respiratory rate and blood pressure.
The CTCA also offers many classes and therapies to help people relax, reduce stress and improve their quality of life as part of an extensive mind-body medicine program. Many centers provide calming background music during healing therapies.
What Are Your Next Steps?
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You have a cancer diagnosis: Now what? Learning how to clear your mind and focus on positive thoughts is a helpful step in the right direction. Here are other soul-soothing strategies you can try.
Start Journaling and Reflecting
Research published in the Journal of Clinical Oncology has shown that expressing your innermost feelings can reduce stress and have a range of other emotional and social benefits. Researchers aren't sure why putting thoughts down on paper is effective. Still, it allows you to process complex emotions and help you chart a way forward, whether you've been diagnosed with cancer or are taking care of someone who has.
Exercise When Possible
Exercising for 2.5 hours per week can help you beat symptoms of depression and fatigue. Among the nation's millions of cancer survivors, there are hints — but not proof yet — that active exercisers may lower their risk of their cancer coming back.
The American College of Sports Medicine hosted a medical panel of cancer specialists to evaluate this exercise evidence. It issued guidelines suggesting that cancer patients and survivors should exercise for about 30 minutes most days of the week. This exercise should be enjoyable to you but also build up a sweat. When patients and their family caregivers exercised together, research found, everyone was more likely to stick with the fitness regimen, boost their physical stamina and experience less emotional strain.
Strengthen Your Social Support System
Connecting with others who've been through this kind of emotional diagnosis already can be a source of comfort and support. Learn more about online communities and your local chapters and support groups that meet up. The American Cancer Society also suggests attending one-on-one professional therapy or its "I Can Cope" online support groups to learn more.
Resource Links:
Find Local Cancer Support Programs | Cancer Support Groups
Strategies Used in Coping With a Cancer Diagnosis Predict Meaning in Life for Survivors
Coping Well with Advanced Cancer: A Serial Qualitative Interview Study with Patients and Family Carers
Coping with cancer
Coping Attitudes of Cancer Patients and Their Caregivers and Quality of Life of Caregivers
Korean skincare is known for its innovation and forward-thinking products, leading to it becoming a growing beauty trend around the world. Now, a new hair tonic from Korean brand Vitabrid C¹², claims to be able to treathair losswith a vitamin C solution.
But can vitamin C really help to regrow hair? And, if so, is applying it directly to the scalp better than ingesting it? We asked Belgravia superintendent pharmacist,Christina Chikaher, for her thoughts on this new product as well as how vitamin C can affect hair growth.
Vitamin C and hair growth
Christina explains, "Vitamin C is a water soluble vitamin. The human body cannot manufacture or store it, therefore it must be consumed on a daily basis. In addition to being taken orally via food sources such as oranges, strawberries, kale and bell peppers, or through nutritional support supplements, vitamin C is essential for collagen biosynthesis and is available in a variety of topical creams, lotions and transdermal patches."
The anti-oxidant is also used in topical cosmetic skincare products for its 'anti-ageing' properties and alleged skin brightening effects.
"Vitamin C is needed for a wide range of bodily functions, including wound healing, tissue support, bone health and collagen production. It also offers protection from free radical damage, also known asoxidative stress, which is important where hair loss is concerned," advises Christina.
Oxidative stress is described by the Department of Medicine at the Sir Jules Thorn Institute in London's The Middlesex Hospital, as 'a disturbance in the balance between the production of reactive oxygen species (free radicals) and antioxidant defenses'. Essentially, it is a damaging form of internal stress caused by an excess of free radicals. These free radicals can be formed as a reaction to various lifestyle issues, including physical and emotionalstress, excessive alcohol intake, smoking and/or an unbalanceddiet, as well as environmental issues such as air pollution.
The reason this is important is because oxidative stress has been linked to premature hair lossin two recent clinical studies.
"Additionally, vitamin C is vital for the absorption of iron. An iron deficiency can cause chronic hair loss from anaemia-relatedDiffuse Thinning, though an excess of iron can also lead to this same hair loss condition," notes Christina. "How effective Vitamin C would be in aiding iron absorption as a topical preparation is unclear."
Topical vitamin C as a hair loss treatment
Having looked into the new Korean hair tonic, we asked Christina, pictured, for her opinion on whether this vitamin C 'hair loss treatment' could work.
"In principle the theory behind this preparation seems very logical. However, I am always of the belief that if it seems too good to be true then it's likely to be just that," she tells us. "Perhaps I would have had more confidence if it was an oral and not a topical preparation as topical vitamin C is usually quite unstable. Because it is unstable and difficult to deliver into the dermis in the optimum dosage, research is constantly being done to find stable compounds of Vitamin C and newer methods of delivery of Vitamin C into the dermis."
The hair tonic is the brand's latest beauty product to use the Vitabrid C12 ingredient which was developed by Dr. Jinho Choy, a chemist working at Seoul's Ewha Womans University. It is also used in skin brightening products and acne treatments. The tonic comprises a powder element which the user mixes in to a liquid spray bottle containing another solution, is sold by high-end department store Barney's New York in the US, which states on its product information: "Through proprietary biotechnology, vitamin C is mixed with stabilizing zinc, a combination designed to capture the nutrient's potency and allow it to penetrate the skin and scalp over the course of 12 hours."
Despite zinc and vitamin C both having beneficial properties for hair health – hence their inclusion in Belgravia's exclusive range of hair supplements for men and women, Hair Vitalics – Christina is still sceptical as to their topical benefits in relation to treating hair loss.
Cosmetic hair boosters
"This tonic claims stability and increased scalp penetration over 12 hours. It also claims – or rather hopes – that 'because hair growth is a function of epidermal stem cells, the use of vitamin C may be able to trick the cells into behaving like they did when they were younger', in order to generate hair from the follicles. However, I cannot find any published scientific research to reliably substantiate these claims."
"Also, there is the question as to which hairloss conditions it is meant to benefit as, for example, vitamins cannot treatandrogenetic alopecia as they do not address the DHT issue. This is why we included saw palmetto in Belgravia'sHair Vitalics for Men supplements and the soy isoflavones genistein and daidzen in the Hair Vitalics for Women–because research has shown that these can lower the levels of DHT in the bloodstream."
In fact, it may be media coverage that is misconstruing the product's actual purpose – which, thanks to cleverly worded marketing material, is easy to do. Though the brand's website is still under construction, the available marketing information from vendors clearly states that the hair tonic is a 'beauty treatment' – meaning a product designed to cosmetically enhance the look of the hair, not ahair loss treatment, meaning a medical regime used to stabilise hair fall, promote hair growth and prevent baldness.
This sentiment is backed by various claims stating that the product is, in fact, "specifically formulated for intensive care of hair and scalp to promote the look and feel of thicker, fuller hair" and to "diminish the appearance of hair loss". 'Promoting the look and feel' of thicker hair and 'diminishing the appearance of hair loss' infers a beauty product that works on a cosmetic level. For instance, a wig or microscopic hair fibres can make the same claims as they can temporarily make the hair appear thicker and reduce the appearance of hair loss. What these types of products do not do – unlike clinically-proven medications – is actually treat hair loss. With this in mind, whilst we do not doubt that this product may be useful to some, we believe it should be considered as a cosmetic concealant, or may possibly fall into the category ofhair growth supporting products, rather than be classed – as media reports have done – as any kind of hair loss treatment.
The Belgravia Centre
The Belgravia Centre is an organisation specialising in hair growth and hair loss prevention with two clinics and in-house pharmacies in Central London, UK. If you are worried about hair loss you canarrange a free consultation with a hair loss expert or complete ourOnline Consultation Form from anywhere in the world. View ourHair Loss Success Stories, which includes the world's largest gallery of hair growth comparison photos and demonstrates the levels of success that so many of Belgravia's patients achieve. You can also phone020 7730 6666 any time to arrange a free consultation.
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Hepatitis is a condition that causes inflammation of your liver. Currently, there are an estimated 6 million people living with hepatitis in the United States, and more than 50,000 people are diagnosed with this disease every year. There are three primary types of hepatitis, and while their symptoms can be similar, they vary largely in the ways they're transmitted. Learning more about each type of hepatitis can help you better understand the condition as a whole.
Hepatitis A is the most easily transmitted of the three viruses. It affects approximately 2,500 people every year in the United States. It typically spreads through feces-contaminated food or water and is found in the feces of people who have the virus. Hepatitis A causes a short-term, acute sickness that most people heal from without treatment. However, it can cause serious illness in some people. This virus is more common in places with underdeveloped sanitation systems.
While doctors can't treat hepatitis A with medication, people who get this virus can manage its symptoms with fluids, rest and good nutrition. There's also a safe and effective vaccine available to protect you against hepatitis A.
What Is Hepatitis B?
Hepatitis B can occur both acutely (meaning it develops quickly and lasts a short time) and chronically (meaning it develops slowly over time and worsens over months or years). According to the Centers for Disease Control and Prevention, up to 2 million people in the United States are chronically affected with hepatitis B. Hepatitis B can be transmitted through sexual activity and exposure to infected blood. It can also be passed from a parent to their newborn child during birth.
Hepatitis B usually causes short-term discomfort that many people recover from completely after about four to eight weeks. However, it can turn into a chronic condition that lasts for years; this is more likely in older adults. Doctors can treat severe chronic hepatitis B with antiviral medications. However, in most cases, treatments focus on proper hydration and nutrition. There's a safe vaccine available to protect you against hepatitis B, too.
What Is Hepatitis C?
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Approximately 4 million people in the United States are affected with hepatitis C. This form of hepatitis causes a chronic illness in over 50% of people who get this type of the virus. It's the least transmissible of the three viruses and can spread through contact with infected blood.
Hepatitis C occurs more commonly in people who engage in intravenous drug use. If you received a blood transfusion before 1992, you should also get tested for hepatitis C if you haven't previously. Hepatitis C can spread through unprotected sexual intercourse, but this is a less common way to transmit it. While there's no vaccine for chronic hepatitis C, treatments that are available today offer a 95% cure rate.
Chronic hepatitis C can significantly affect how your liver works. It can cause cirrhosis, which means that your normal liver tissue is replaced with scar tissue. It can also cause liver cancer. However, there are medications that can help keep this disease in check. Making lifestyle changes, such as reducing or eliminating alcohol from your diet, can also decrease your chances of experiencing complications. In severe cases, hepatitis C may require a liver transplant.
The varying forms of viral hepatitis affect millions of people in the United States. Chronic hepatitis often has few symptoms in its early stages, so recognizing the associated dangers and getting tested if you've been exposed may save your life. Although there are five types of viral hepatitis, only A, B and C are the forms commonly found in the United States.
Resource Links:
"Hepatitis A, B, and C: Learn the Differences," Immunization Action Coalition
"What's the Difference Between Hepatitis A, B and C?," UNC Health Talk
"The ABCs of Hepatitis," Centers for Disease Control and Prevention
"What's the Difference: Hepatitis B vs Hepatitis C?," Hepatitis B Foundation
Vitamin E is a compound that plays many important roles in your body and provides multiple health benefits. In order to maintain healthy levels of vitamin E, you need to ingest it through food or consume it as an oral supplement. Read on to find out which foods are recommended sources of this essential nutrient, along with other basics to know about vitamin E.
Vitamin E is classified as an antioxidant. This means that vitamin E helps to destroy harmful compounds called free radicals that can build up in your body. Free radicals cause damage to cells through oxidative stress, and they've been linked to aging and health problems such as cancer and heart disease. Getting enough vitamin E on a daily basis may help to combat these conditions by protecting the outer membranes of your cells from free radical damage.
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Vitamin E also plays an important role in your immune system and your body's ability to fight infection. At certain doses, vitamin E has been shown to stimulate the function of T cells — a type of cell that responds to pathogens that cause disease. Recent studies have shown that increasing your vitamin E intake may correlate with a stronger immune response and greater resistance to infection.
Vitamin E is present in the following whole foods:
As people age, their daily dosage recommendation for vitamin E increases. For these standard recommended daily doses, a healthy balanced diet is usually sufficient for getting the required amount of vitamin E:
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Birth to 6 months: 4 milligrams (mg)/day
1 to 12 months: 5 mg/day
1 to 3 years: 6mg/day
4 to 8 years: 7mg/day
9 to 13 years: 11mg/day
14+ years, including adults and seniors: 15mg/day
A person's age, gender and health conditions can help determine their recommended daily dose of vitamin E. Always consult a healthcare professional before altering your intake of vitamin E from the recommended daily dosage.
Taking Vitamin E Supplements
If it becomes necessary, such as if you become deficient in vitamin E, your doctor may advise you to start taking vitamin E supplements. Vitamin E supplements may come with some minor side effects if you take more than the recommended daily amount or if you combine these supplements with certain medications.
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For example, vitamin E may increase the risk of bleeding if you take it with anticoagulants (also called blood thinners) like warfarin. Other medications, like chemotherapy drugs and cholesterol-lowering drugs, have potential harmful interactions when combined with vitamin E supplements. Talk to a healthcare professional before introducing daily vitamin E supplements, and be sure to discuss current medications you're taking.
Signs of a Vitamin E Deficiency
Because most people are able to get a sufficient amount of vitamin E through their normal daily diet, vitamin E deficiency is rare and typically related to an underlying health issue. For example, because vitamin E is a fat-soluble nutrient, there's a risk for vitamin E deficiency in people whose bodies are unable to absorb fat properly. Premature infants may also become deficient in vitamin E.
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When vitamin E deficiency does occur, these are some of its common symptoms:
Muscle weakness
Unsteady gait
Nerve pain or numbness
Impaired vision
Vitamin E deficiency can be detected with a blood test. It typically resolves with minor changes in your diet or the addition of vitamin E supplements. It's important to address any out-of-range vitamin E levels with your doctor. Chronic deficiencies may prevent your immune system from functioning normally.
Dragon fruit—also called pitaya,pitahaya, or strawberry pear—is a member of the Cactaceae family (cactus species). The bright pink, bulb-shaped fruit is known for its sweet, fresh taste and unique, ornamental appearance (its spiky scales give it its name). The meat of the dragon fruit may be either pink or white.
It is grown primarily in tropical and subtropical areas of the world. While the fruit is popular throughout Asia and Central America, it is less commonly consumed in the United States. But dragon fruit can be a healthy and delicious addition to your diet, as it contains vitamins, fiber, and even iron and healthy fats (unusual for a fruit).
Dragon Fruit Nutrition Facts
The following nutrition information is provided by the USDA for one 6-ounce (170g) serving of cubed dragon fruit.
Calories:102
Fat:0g
Sodium:0mg
Carbohydrates:22g
Fiber:5g
Sugars:13g
Protein:2g
Carbs
Dragon fruit is a naturally low-calorie food, with most of the calories coming from carbohydrate. There are two types of carbohydrate in dragon fruit: naturally occurring sugars (13g per 6-ounce serving) and fiber. You'll get 5 grams of fiber—or about 18% of your recommended daily intake—in a 6-ounce serving.
The exact glycemic index (GI) of dragon fruit has not been recorded, although one study estimates the glycemic index to be similar to that of a banana—or about 48 to 52. As a reference, foods with a GI of 55 or more are considered high glycemic foods.
Fat
There is a very small amount of fat in dragon fruit. The edible seeds contain omega-3 fatty acids, omega 6-fatty acids, and polyunsaturated fat which are all healthy fatty acids.
Protein
Dragon fruit provides a small amount of protein, about 2 grams per serving.
Vitamins and Minerals
Dragon fruit provides vitamin C and riboflavin, along with about 17% of your daily recommended intake of magnesium—a mineral that is responsible for aiding in hundreds of biochemical reactions in the body. Dragon fruit also contains iron, niacin, and calcium.
Health Benefits
Like many fruits and vegetables, dragon fruit contains fiber, vitamins, minerals, and antioxidants that have beneficial qualities.
Helps Build and Heal Cells
Vitamin C (L-ascorbic acid) is essential for good bone structure, cartilage, muscle, and blood vessels. It promotes wound healing, and it may also help to prevent disease.
Vitamin C must be consumed in the diet because our bodies are unable to make it naturally. Vitamin C also aids in the absorption of iron, and dragon fruit is one of the rare fruits that contains some iron (about 1mg per 6-ounce serving, or 7% of the daily value).
Reduces Inflammation
Dragon fruit is rich in flavonoids, one of the many types of antioxidants that can help repair cell damage caused by oxidative stress and reduce inflammation. In turn, this can help the body ward off some chronic diseases.
Improves Digestive Health
Fiber helps to boost satiety, improves digestion and regularity, and may help to lower blood cholesterol. Current FDA guidelines recommend 28 grams of fiber per day. Fiber also provides many other health benefits, including decreased risk of some types of cancer, obesity, cardiovascular disease, and diabetes.
Helps Manage Blood Sugar
In a collection of four studies, dragon fruit appears to improve blood sugar in people with pre-diabetes. In type 2 diabetes, dragon fruit didn't appear to provide significant outcomes, but there was a trend in improving blood glucose with higher doses of dragon fruit. More studies are warranted to conclude dragon fruits effect on blood glucose.
Allergies
There have been limited reports of allergic reactions to dragon fruit or to fruit juice containing dragon fruit. Reported symptoms included itchy, swollen red skin, swelling around the mouth, and severe itching.
If you suspect an allergy to dragon fruit, speak to your health care provider to get a proper diagnosis. If you or someone near you experiences a severe reaction after consuming the fruit, experts recommend that you call 911. Anaphylaxis (a severe allergic reaction) can be life-threatening, so it is important to seek immediate medical attention.
Adverse Effects
There has been only been limited research into whether or not dragon fruit interacts with medications. Study authors recommend that patients speak with their healthcare provider to get the most personalized information regarding their medications and possible interactions.
Varieties
There are three main types of dragon fruit: white flesh with pink skin, red flesh with pink skin, and white flesh with yellow skin. The taste and nutritional benefits of the fruit are the same, regardless of color.
Many people describe the flesh as having a pear-like taste with hints of berry and watermelon. The flesh has a texture that is often compared to kiwi, and the small black seeds are edible, just as in kiwi.
Dragon eye fruit is not the same as dragon fruit. Dragon eye fruit is another name for the longan, which is related to the lychee.
When It's Best
Peak season for dragon fruit is summer to early fall. The hardest part about buying dragon fruit may be finding it in your local market. Typically, American grocery stores do not carry the fruit but many Asian markets sell the fruit and some farmers markets may have them as well, depending on the part of the country where you live.
Look for fresh fruit with a bright pink color. Avoid any dragon fruit with wilted stems or brown markings. The flesh should yield slightly when pressed. But if there are none available that are ripe, you can buy a firm fruit and let it ripen for a day or two.
Sometimes dragon fruit juice is more readily available than whole fruits. The juice contains important vitamins and minerals, but it doesn't have the fiber that the fruit provides. Also, some dragon fruit drinks are actually mixes of several different types of juice and can provide a substantial amount of sugar. Or they are marketed as "dragon fruit flavor," but don't actually contain dragon fruit.
If you can't find whole dragon fruit in your local market, you can also buy frozen cubed dragon fruit, which is just as healthy. But be sure to check the ingredients list to make sure that you are buying just the fruit (with no added syrups or sugars).
Storage and Food Safety
Ripe dragon fruit will keep at room temperature for a few days. Or, store in the refrigerator in a plastic bag. Avoid cutting the fruit until you are ready to eat it; once cut, it should be refrigerated in an airtight container. If your dragon fruit starts to turn brown or mushy, discard.
How to Prepare
You should only eat the flesh (inside) of the dragon fruit, not the skin. To peel, simply cut it into quarters and peel the skin back. You can also remove the skin from a whole fruit with a paring knife or cut the fruit in half and scoop out the flesh with a spoon.
You can eat dragon fruit just like you'd eat many other sweet fruits. Throw slices or cubes into a green or fruit salad, or toss in the blender when you're making a fruit smoothie. Some people also use dragon fruit as a garnish for cocktails or other fresh summer drinks.
Dragon fruit pairs well with other tropical fruits like banana and pineapple. If you're looking for new and interesting breakfast ideas, toss dragon fruit on top of Greek yogurt and sprinkle a tablespoon of granola on top. Or make a batch of whole wheat pancakes and enjoy them with cubed mango and dragon fruit instead of syrup.
Background. Hypertension is regarded as a major and independent risk factor of cardiovascular diseases, and numerous studies observed an inverse correlation between vitamin C intake and blood pressure. Aim. Our aim is to investigate the relationship between serum vitamin C and blood pressure, including the concentration differences and the correlation strength. Method. Two independent researchers searched and screened articles from the National Library of Medicine, Cochrane Library, Web of Science, China National Knowledge Infrastructure, VIP databases, and WANFANG databases. A total of 18 eligible studies were analyzed in the Reviewer Manager 5.3 software, including 14 English articles and 4 Chinese articles. Results. In the evaluation of serum vitamin C levels, the concentration in hypertensive subjects is 15.13μmol/L lower than the normotensive ones ( , 95% CI [-24.19, -6.06], and ). Serum vitamin C has a significant inverse relation with both systolic blood pressure ( , 95% CI [-0.20, -0.15], ) and diastolic blood pressure ( , 95% CI [-0.20, -0.10], ).Conclusions. People with hypertension have a relatively low serum vitamin C, and vitamin C is inversely associated with both systolic blood pressure and diastolic blood pressure.
1. Introduction
Cardiovascular diseases (CVDs) are a series of disorders of blood vessels and the heart, primarily including coronary heart disease, cerebrovascular disease, and rheumatic heart disease [1]. Owing to its increasingly high worldwide morbidity and gradual tendency in younger people, CVD is considered to be one of the most serious diseases that damaged public health in the 21st century [2]. The number of deaths due to CVD is increasing year by year. For example, a total of 17.9 million individuals died from cardiovascular events in 2015, which is much higher than that in 1990 [3]. In developing countries, it is reported that more than 75% of CVD deaths occur; approximately 41% of total deaths in China are related to CVD with an annual death toll reaching 3.5 million [4–6].
Individuals with a risk of CVD might manifest with a raised blood pressure (BP) [7]. As researches continuing, numerous epidemiological studies have repeatedly recognized that hypertension is a major and independent risk factor of CVD [1, 8, 9]. As the most common chronic noninfectious disease, hypertension is closely related to several risk factors, including genetics [10, 11], family history [12–14], overweight and obesity [15], tobacco smoking [15–18], physical inactivity [19, 20], and unhealthy dietary intake [17, 20]. Nutrient intake and electrolyte level are complex and varied, but population-based evidence has shown that the consumption of magnesium, sodium, potassium, and calcium is inversely associated with BP [21, 22]. Other studies also revealed the relationship between vitamin C and BP, one of which was that hypertensive patients present a lower intake and serum vitamin C [23]. A variety of observational and interventional studies has additionally reported that vitamin C intake and its concentration status were significantly related to a reduction of resting BP [24]. For example, Kamran et al. [25] found that the correlation between vitamin C intake and systolic BP was -0.02 in uncontrolled hypertensive patients. Yet another study by Yoshioka et al. [26] discovered that serum vitamin C had an inverse and the strongest association with systolic BP. Given the potential oxidation resistance of vitamin C, researchers attributed this association to that vitamin C could prevent the formation of free radicals, thereby reducing the vascular oxidative in the progress of hypertension [27]. However, these preliminary findings have not been confirmed, since some researchers drew an opposite conclusion, like the study conducted by Duthie et al. [28]. Even relevant systematical review and meta-analysis articles have not been found regarding the relationship between them.
To consider the controversial role of vitamin C in the prevention and management of hypertension, we are inspired to conduct this meta-analysis, with a purpose to compare serum vitamin C levels between hypertensive and normotensive individuals. Furthermore, we aim to confirm whether there was a correlation between serum vitamin C and BP and calculate the strength of the relationship.
2. Methods
2.1. Search Strategy
Two independent reviewers comprehensively searched the National Library of Medicine (PubMed), Cochrane Library, Web of Science (WOS), China National Knowledge Infrastructure (CNKI), VIP databases, and WANFANG databases to obtain relevant studies from their earliest publication up to January 2019. We used the following searching strategy: (Vitamin C OR ascorbic acid OR risk factor) AND (hypertension OR high blood pressure OR blood pressure). There was no limitation to language. All the records were screened and scrutinized independently by two partners. All the studies were screened and selected according to the guidelines for Systematic Reviews of Observational Studies (MOOSE) [29].
2.2. Inclusion and Exclusion Criteria
The eligible studies should fulfill the inclusion criteria as follows: (1) investigated the relation between serum vitamin C and blood pressure among hypertensive subjects or normotensives; (2) participants were males or females over 18 years old; (3) observational articles including cross-sectional studies, case-control studies, and cohort studies; (4) provided with Pearson's correlation coefficient ( ), Spearman's correlation coefficient ( ), or regression coefficient ( ); (5) the means and standard deviations (SD) of serum vitamin C were available in case-control studies; and (6) if there were over two similar articles published based on the same sample, the one with higher quality would be included.
Studies were excluded with the following criteria: (1) duplicated or similar articles; (2) nonobservational studies, such as animal testing and intervention experiment; (3) correlation coefficient, means, or SD could not be acquired to calculate the pooled effect size; (4) the level of vitamin C was measured from urine; and (5) participants used supplements with vitamin C beyond the recommended dietary allowances.
2.3. Quality Assessments
Considering that different types of observational studies were included in our meta-analysis, we used two methodological quality checklists. The first one was the Newcastle-Ottawa Scale (NOS) [30], assessing case-control and cohort studies. The assessment of NOS was performed on the items of the selection of study population, comparability between cases and noncases, exposure, and the outcome, with a maximum score of 9. We regarded the article awarded a score ≥5 as a high-quality assessment, owing to that the standard validated criteria have not been established [31]. Cross-sectional studies were assessed using 11 items recommended by the Agency for Healthcare Research and Quality (AHRQ) [32]. These items would be answered with "yes," "unclear," and "no," separately scored with 1 and 0.
2.4. Data Extraction
We extracted the following data to describe the main characters of each study, including the first author's name, publication year, country conducted in, the age of subjects, sample size, BP value, study design, outcomes (correlation coefficient or means and standard), and variables adjusted for.
2.5. Data Conversion
If the Pearson correlation coefficient ( ) was not provided, the Spearman coefficient ( ) and regression coefficient ( ) with standard error (SE) could be used to estimate the value [33]. Details are as follows: (1) was calculated if was available:(2) was calculated if was available:
"" is the standard error of , so
We performed Fisher's transformation to convert every correlation coefficient to an approximately normal distribution, and then the pooled effect size was weighted with the inverse variance. Fisher's transformation was according to the following formulates [34]: where stands for the value of summary Fisher's .
2.6. Statistical Analysis
The mean difference (MD) was applied for continuous variables in case-control studies (or cross-sectional studies) while Fisher's value was applied for correlation coefficients to calculate the pooled effect size; for both, the corresponding 95% confidence intervals (CI) were available and the forest plots were used to display the results graphically. Subgroup analyses were performed by sex, with or without hypertension, antihypertensive drugs, level of vitamins A and E, study area, and sample size. All the statistical analysis was conducted with the Reviewer Manager (RevMan) 5.3 software.
Heterogeneity was detected by Q-statistics, derived from the Chi-squared test and I-squared (inconsistency). Notable heterogeneity was indicated when the value was below 0.05 or an value was above 50%, and in this case, a random-effects model was preferred. Then, a sensitivity analysis would be performed to investigate the potential sources of heterogeneity. Publication bias was visually assessed with the funnel plot, and Begg's test and Egger's test could also be applied with the Stata 14.0 software when necessary.
3. Results
3.1. Study Selection
A total of 2757 articles were searched from English and Chinese databases. There were 2104 articles excluded by screening the titles and abstracts, and finally, 18 eligible articles [35–52] were included in our meta-analysis based on full-text review and manual search. The study selection procedure is outlined in Figure 1
3.2. Study Characteristics and Quality
As shown in Table 1, the selected articles included 11 cross-sectional studies and 7 case-control studies. These studies comprised 22200 observational subjects and were conducted from the year 1990 to 2017. Of the 18 articles, 14 were published in the English language, and 4 were in Chinese.
First author
Year
Study area
Sample size
Age
BP value
Study design
Outcome
Adjusted variable
Quality score
Male
Female
Overall
(SBP/DBP)
Zhao
1990
China
NA
NA
416
40-59
NA
Cross-sectional
Correlation coefficient
/
5
Moran
1993
USA
60
108
168
19-70
/
Cross-sectional
Correlation coefficient
/
6
Tse
1994
UK
39
34
73
C: N:
C: / N: /
Case-control
Regression coefficient
Age, sex, smoking
7
Wen
1996
Ireland
32
27
59
C: N:
NA
Case-control
/
7
Toohey
1996
USA
42
126
168
F: M:
F: / M: /
Cross-sectional
Correlation coefficient
/
4
Ness
1996
UK
835
1025
1860
45-75
/
Cross-sectional
Correlation coefficient Regression coefficient
Age, sex and BMI
4
Pierdomenico
1998
Italy
NA
NA
42
C: N:
C: / N: /
Case-control
/
7
Sakai
1998
Japan
919
1266
2185
≥40
F: / M: /
Cross-sectional
Correlation coefficient
Age, sex, BMI, smoking, physical activity
5
Bates
1998
UK
NA
NA
541
≥65
/
Cross-sectional
Regression correlation
/
4
Tang
1998
China
NA
NA
84
30-60
NA
Case-control
Correlation coefficient
/
6
Sherman
2000
USA
31
21
52
C: N:
NA
Case-control
/
8
Langlois
2001
Belgium
96
123
219
C: / N: /
Case-control
/
7
Chen
2002
USA
NA
NA
15317
≥20
C: / N: /
Cross-sectional
OR
Age, sex, race, education, alcohol, BMI
7
Chen
2004
China
28
72
100
19-40
NA
Cross-sectional
Correlation coefficient
/
4
Rodrigo
2007
Chile
66
/
66
35-60
C: / N: /
Cross-sectional
Correlation coefficient
/
5
Kumar
2014
Malaysia
NA
NA
690
56-64
C: / N: /
Case-control
/
8
Zhou
2014
China
28
72
100
19-40
NA
Cross-sectional
Correlation coefficient
/
5
Naregal
2017
India
NA
NA
60
60-80
C: / N: /
Cross-sectional
Correlation coefficient
/
5
C: case, N: non-case, F: female, M: male, M: mean, SD: standard deviation, SE: standard error, OR: odds ratio.
Assessed with NOS, all the case-control studies yield a high quality averaging with 7.143 scores. And the result of AHRQ indicates a moderate quality with all cross-sectional studies scoring between 4 and 7.
3.3. Meta-Analysis of Outcome
3.3.1. Serum Vitamin C Concentration
The level of serum vitamin C between hypertensive subjects and normotensives is described in Figure 2, which involved 10 studies composing of 16914 participants [37, 40, 43–46, 50]. Owing to high heterogeneity ( , , , ), the analysis was conducted on the random-effects model. It was obvious that the serum level of vitamin C of hypertensive subjects was 15.13μmol/L lower than the normotensives ( , 95% CI [-24.19, -6.06], ).
Due to the high heterogeneity, a sensitivity analysis was conducted, in which one single study was omitted at a time while the others were recalculated to estimate if the result could affect markedly. We found that the average level of vitamin C concentration in Kumar's study [50] was several times higher than the others, which might indicate to some mistakes in raw data. It was additionally found that vitamin C intake between the groups was significantly different. The value reduced from 98% to 94% after removing this study, whereas it remained stable after omitting other studies. A subgroup analysis was subsequently performed, revealing that hypertensive subjects who took antihypertensive drugs had a 15.97μmol/L lower serum vitamin C compared with normotensive ones. And no obvious heterogeneity was found.
3.3.2. The Correlation between Vitamin C and Blood Pressure
(1) Systolic Blood Pressure. The correlation between serum vitamin C and the systolic blood pressure (SBP) was described in 12 studies, 1 of which was excluded in our meta-analysis for the missing value of SE [47]. As illustrated in Figure 3 the analysis was conducted with fixed-effects model due to a low heterogeneity ( , , , ). The pooled Fisher's was -0.17 ( , 95% CI [-0.20, -0.15], ), indicating a reverse relation between serum vitamin C concentration and SBP significantly. And the summary value was -0.168 calculated with the formula above.
(2) Diastolic Blood Pressure. By conducting on a random-effects model, serum vitamin C concentration was inversely correlated to diastolic blood pressure (DBP) with Fisher's value of -0.15 ( , 95% CI [-0.20, -0.10], ). The summary was -0.149, and there was a moderate heterogeneity ( , , , ) (Figure 4
(3) Subgroup Analysis. Reflected in Table 2, the subgroup analyses of the association between plasma vitamin C and blood pressure were carried out based on gender, with or without hypertension, antihypertensive drugs, level of vitamins A and E, study areas, and the sample size. Results of all subgroups revealed that serum vitamin C was negatively correlated to SBP and DBP, with significance. In the analysis of SBP, the heterogeneity in each subgroup was not quite high, except for male subjects ( , , , ) and hypertensive subjects ( , , , ). In the analysis of DBP, there was an obvious heterogeneity in male ( , , , ), female ( , , , ), and studies in Asia area ( , , , ).
Subgroups
SBP
DBP
Studies ( )
Fisher's
95% CI
(%)
Studies ( )
Fisher's
95% CI
(%)
All studies
11
-0.17
(-0.20, -0.15)
37
0.10
10
-0.15
(-0.20, -0.10)
51
0.02
Sex
Male
5
-0.20
(-0.28, -0.12)
60
0.03
6
-0.15
(-0.24, -0.06)
65
0.01
Female
2
-0.13
(-0.17, -0.09)
0
0.63
2
-0.12
(-0.20, -0.04)
73
0.05
Hypertension
Yes
2
-0.16
(-0.36,0.03)
86
0.008
2
-0.23
(-0.42, -0.03)
57
0.13
No
6
-0.24
(-0.32, -0.17)
0
0.54
5
-0.20
(-0.28, -0.13)
11
0.34
Antihypertensive drugs
Unclear
4
-0.15
(-0.18, -0.12)
18
0.30
4
-0.10
(-0.14, -0.06)
0
0.69
No
7
-0.22
(-0.27, -0.16)
14
0.32
7
-0.17
(-0.23, -0.12)
35
0.16
Level of vitamin A and vitamin E
Normal
2
-0.53
(-0.79, -0.28)
0
0.69
2
-0.26
(-0.51, -0.00)
59
0.12
Abnormal
3
-0.19
(-0.25, -0.13)
45
0.16
3
-0.18
(-0.24, -0.12)
57
0.10
Area
America
3
-0.31
(-0.42, -0.20)
55
0.08
3
-0.23
(-0.34, -0.11)
0
0.45
Europe
2
-0.17
(-0.21, -0.13)
0
0.67
2
-0.16
(-0.20, -0.12)
0
0.38
Asia
6
-0.17
(-0.20, -0.13)
22
0.26
5
-0.13
(-0.20, -0.05)
61
0.02
Sample size
<100
4
-0.37
(-0.50, -0.25)
32
0.21
3
-0.16
(-0.30, -0.02)
53
0.09
100-500
4
-0.21
(-0.28, -0.14)
0
0.99
4
-0.21
(-0.28, -0.14)
20
0.29
>500
3
-0.16
(-0.19, -0.13)
4
0.37
3
-0.13
(-0.16, -0.10)
54
0.09
Adjusted Confounders
Age
Male
2
-0.12
(-0.17, -0.07)
75
0.04
2
-0.12
(-0.16, -0.07)
51
0.15
Female
2
-0.10
(-0.14, -0.06)
14
0.28
2
-0.09
(-0.14, -0.05)
46
0.17
Age+sex
2
-0.11
(-0.14, -0.08)
0
0.65
2
-0.11
(-0.14, -0.08)
0
0.85
Age+BMI
Male
2
-0.11
(-0.16, -0.07)
78
0.03
2
-0.10
(-0.15, -0.06)
67
0.08
Female
2
-0.09
(-0.13, -0.04)
0
0.52
2
-0.09
(-0.13, -0.05)
6
0.30
Age+sex+BMI
2
-0.09
(-0.12, -0.06)
0
0.50
2
-0.10
(-0.13, -0.07)
0
0.72
:
value of heterogeneity.
(4) Adjustment of Main Confounders. Two studies [38, 41] provided correlation coefficients adjusting for potential factors. After adjustment for the confounders of age, sex, and body mass index (BMI), the association remained the same. As displayed in Table 2, there was a significant negative correlation between serum vitamin C and SBP with low or moderate heterogeneity, except for male adjusted with age or age and BMI. The association between DBP and plasma vitamin C were inverse and stable after adjustment for confounders.
3.4. Publication Bias
The funnel plot in the comparison of plasma vitamin C and SBP is suggestive of publication bias, and thus, we conducted Begg's test and Egger's test after that. Summarized in Figure 5(a), the results of Begg's test ( ) and Egger's test ( ) showed notable evidence of publication bias. But in the comparison of plasma vitamin C and DBP, the results of Begg's test ( ) and Egger's test ( ), as well as a funnel plot, manifested no distinctive publication bias (Figure 5(b)).
(a)
(b)
4. Discussion
Previous studies have observed an elevation of plasma marker of oxidative stress in the elderly hypertensive subjects, suggesting that oxidative stress may be the mechanism of hypertension. For this reason, antioxidants prevent free radicals from oxidizing or reduce free radical formation, thus, protecting cell membrane pumps from oxidative damage, which might be the reason and evidence for using it in treating hypertension. As a result, vitamin C, the most effective water-soluble antioxidant in human plasma, is regarded to have a protective role against hypertension disease and CVDs [53].
On the bases of free radical theory, researchers demonstrated that ascorbic-free radicals are first formed and then converted to dehydroascorbic acids and semidehydroascorbic acids, scavenging highly reactive free radicals and oxides, including superoxide anions (O2−), hydroxyl radicals (OH·), organic free radicals (R·), and peroxy radical (ROO·). Therefore, vitamin C may bring vascular endothelial cells injured by oxidization into a reduced state to recover their functionality and keep the vessels pliable [54, 55]. Apart from this, the oxidation resistance of vitamin C may also manifest itself in the facilitation of glutathione (GSH) synthesis, while both the reduction of GSH and the decreased activity of glutathione peroxidase (GSH-Px) would probably trigger hypertension [56, 57]. Currently, studies observed a relatively lower concentration in hypertensive subjects, and the results of our meta-analysis confirmed it. Just as our results exhibited, the mean serum vitamin C level of hypertension was 15.13μmol/L lower compared to nonhypertensions. Additionally, both the hypertensive and the normotensive subjects have a significant inverse correlation to SBP and DBP.
Even though vitamin C has an antihypertensive effect by decreasing oxidative stress and improving vascular endothelial function, there is still no validated conclusion from it. Yet, several limitations and weaknesses in our research findings were aroused, which would be a research field or main concerns in the future.
First of all, there is an obvious individual difference. This difference is embodied in two aspects: serum vitamin C concentration and correlation coefficient. To be specific, hypertensives' serum vitamin C ranges from to , while normotensives' ranges from to . Besides, the value of SBP is from -0.53 to -0.016, while DBP's value is between -0.269 and 0.059. We speculated this difference may come from the age or the individual differences in population; therefore, subgroup analysis of age and race should be conducted if provided in original studies.
In the next place, causal associations between plasma vitamin C and BP cannot be inferred, because all the studies included in our meta-analysis are case-control and cross-sectional studies. What is more, the association is not very strong. The summary value between serum vitamin C and DBP was -0.149. In terms of our included literature, serum vitamin C presents a weak correlation to SBP with a comprehensive value of -0.168, whereas DBP showed a correlation of -0.149. And it is notable that the correlation to SBP in hypertensive ones is insignificant ( , 95% CI [-0.36, 0.03], ).
Last, due to the heterogeneity and publication bias existing in our meta-analysis, we should be more cautious before jumping to any conclusion. In the evaluation of serum vitamin C, despite a lower concentration was identified in hypertensive subjects, there is a high heterogeneity. Through the subgroup analysis, all hypertensive subjects sticking with antihypertensive drugs consistently showed much lower serum vitamin C (15.97μmol/L), whereas those who did not take drugs showed high heterogeneity. We speculated that antihypertensive drugs might consume serum vitamin C. It was additionally found that the serum level of vitamins A and E did not cause the heterogeneity mainly, and it was similar in the correlation analysis. Hence, after comprehensively considering the heterogeneity and publication bias, the results are more stable in females, nonhypertensives, or hypertensives taking antihypertensive drugs, but it calls for more original studies to verify.
For all mentioned above, more details should be considered in further studies. On one hand, prospective studies with high qualities are required to link vitamin C deficiency to the risk of HBP; on the other, a meta-analysis should be conducted on the relation between vitamin C intake and hypertension.
5. Conclusion
Hypertensives are exposed in a lower serum vitamin C concentration. Serum vitamin C generally shows a negative relation to SBP and DBP.
Abbreviations
CVDs:
Cardiovascular diseases
BP:
Blood pressure
PubMed:
National Library of Medicine
WOS:
Web of Science
CNKI:
China National Knowledge Infrastructure
MOOSE:
Systematic Reviews of Observational Studies
SD:
Standard deviations
NOS:
Newcastle-Ottawa Scale
AHRQ:
Agency for Healthcare Research and Quality
SE:
Standard error
MD:
Mean difference
CI:
Confidence intervals
RevMan:
Reviewer Manager
SBP:
Systolic blood pressure
DBP:
Diastolic blood pressure
BMI:
Body mass index
AA:
Ascorbic acid
GSH:
Glutathione
GSH-Px:
Glutathione peroxidase.
Data Availability
All data generated or analyzed during this study are included in this article.
Conflicts of Interest
The authors declare that there are no conflicts of interests regarding the publication of this paper.
All authors contributed to the design and concept, performed the literature searches, wrote the manuscript and critiqued the successive versions, and approved the final manuscript. HEB coordinated the effort and integrated the sections and comments. Li Ran and Wenli Zhao contributed equally to this work.
Acknowledgments
This project was supported by the Construction Project of the Cultivate Discipline of Chinese Preventive Medicine of the State Administration of Traditional Chinese Medicine (2012 (170)) and the Key Project of the Comprehensive Investment in Food Hygiene and Nutrition of the Tianjin 13th Five-Year Plan. The authors thank Dr. Bin Wang for assistance with data extraction.
Vitamin C and hair growth
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The Belgravia Centre
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