August Newsletter
In This Issue
Prevention of Alzheimer's Disease
Diet Coke Dangerous?
Eat Better. Don't Die.
A Better Model of Medical Care
Dr. Niedfeldt
Old-fashioned medicine with 21st Century convenience and technology
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I hope this newsletter finds you and your family well. I can't believe it's late August already. I still have more summer in me! Since we can't turn back time, we can enjoy what we have. Let's hope the Brewers continue to play well so we can have some fall baseball to go along with our football...

The first article this month looks at prevention of Alzheimer's Disease. This devastating disease affects over 5 million Americans and their families. I doubt there is a single one of us who hasn't been affected by this affliction. So far, medications haven't been the answer. The first article takes a different approach. What we can do to prevent it. Check out the article to see how much risk you have and what to do about it. 

Some of us can't live without our Diet Coke (or Diet Pepsi). We drink it because it's supposed to be healthier than the regular stuff. But is it healthy at all? The second article outlines the risk of consuming our favorite drinks. 

Does our diet affect our risk of death? According the the third article, absolutely! Can we change? Read on for the answer. 

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Prevention of Alzheimer's Disease
Medications have minimal effects, risk factor reduction is needed        
Dementia is a major problem in our society and incidence increases with age. The effects are not limited to the individual but affect the family and society as well. The medications available for treatment of dementia have not been shown to be preventive and have underwhelming effectiveness once dementia has set in. Unfortunately, medications for prevention have not panned out yet although there are ongoing trials. This review, from the Journal of the American Geriatrics Society, concludes that prevention may be the most important 'treatment' for dementia and focuses on modifiable risk factors, lifestyle factors, medications, and protective factors. 
  • Alzheimer's disease (AD) affects more than 5 million Americans, with substantial consequences for individuals with AD, families, and society in terms of morbidity, mortality, and healthcare costs. With disease-modifying treatment trials unsuccessful at the present time and only medications to treat symptoms available, an emerging approach is prevention. Advances in diagnostic criteria, biomarker development, and greater understanding of the biophysiological basis of AD make these initiatives feasible. Ongoing pharmacological trials using anti-amyloid therapies are underway in sporadic and genetic forms of AD, although a large number of modifiable risk factors for AD have been identified in observational studies, many of which do not appear to exert effects through amyloid or tau. This suggests that prevention studies focusing on risk reduction and lifestyle modification may offer additional benefits. Rather than relying solely on large-sample, long-duration, randomized clinical trial designs, a precision medicine approach using N-of-1 trials may provide more-rapid information on whether personalized prevention plans can improve person-centered outcomes. Because there appear to be multiple pathways to developing AD, there may also be multiple ways to prevent or delay the onset of AD. Even if these precision approaches alone are not successful in preventing AD, they may greatly improve the likelihood of amyloid- or tau-specific therapies to reach their endpoints by reducing comorbidities. Keeping this in mind, dementia may be a disorder that develops over a lifetime, with individualized ways to build a better brain as we age.

Modifiable risk factors for Alzheimer's disease include insulin resistance levels, inflammation, dyslipidemia, high blood pressure and sleep apnea. As I look at these, I think that the insulin level is the key. Lowering our insulin resistance will lower our insulin level. We know that this results in weight loss, improvements in inflammation, lipid profiles, and blood pressure. Weight loss also is generally beneficial in sleep apnea. Last month we discussed watching TV as something that increased our insulin resistance. We also know that a diet higher in sugar and starch (processed foods) has an adverse effect on our insulin levels. As we move to lifestyle factors which includes obesity we see the affects of insulin resistance. Additionally, it is important to not smoke as this increases risk of dementia. Alcohol abuse is also associated with more dementia. Other factors include traumatic brain injury as we are seeing in some former athletes along with psychological and social stressors. On the other hand, protective factors include cognitive and physical activity, social engagement, mindfulness and stress reduction exercises, education, a diet rich in omega-3 fatty acids (Mediterranean style diet), modified fasting (at least 12 hours) which helps lower insulin resistance, and finally optimism and purpose in life. Working with people on an individual basis to maximize these factors may be the key to stemming the tide on this terrible affliction. 

Diet Coke Dangerous?
Artificial sweeteners may increase BMI and cardiometabolic risk

Artificial sweeteners have been touted as a weight loss tool. But do they really help people lose weight? This meta-analysis looked at the association between non-nutritive sweeteners and adverse cardiometabolic outcomes and found an association between increased intake of them and increased obesity, hypertension, metabolic syndrome, type 2 diabetes and cardiovascular events. 

  • BACKGROUND:  Nonnutritive sweeteners, such as aspartame, sucralose and stevioside, are widely consumed, yet their long-term health impact is uncertain. We synthesized evidence from prospective studies to determine whether routine consumption of non-nutritive sweeteners was associated with long-term adverse cardiometabolic effects.   
  • METHODS: We searched MEDLINE, Embase and Cochrane Library (inception to January 2016) for randomized controlled trials (RCTs) that evaluated interventions for nonnutritive sweeteners and prospective cohort studies that reported on consumption of non-nutritive sweeteners among adults and adolescents. The primary outcome was body mass index (BMI). Secondary outcomes included weight, obesity and other cardiometabolic end points. 
  • RESULTS: From 11 774 citations, we included 7 trials (1003 participants; median follow-up 6 mo) and 30 cohort studies (405 907 participants; median follow-up 10 yr). In the included RCTs, nonnutritive sweeteners had no significant effect on BMI (mean difference -0.37 kg/m(2); 95% confidence interval [CI] -1.10 to 0.36; I(2) 9%; 242 participants). In the included cohort studies, consumption of nonnutritive sweeteners was associated with a modest increase in BMI (mean correlation 0.05, 95% CI 0.03 to 0.06; I(2) 0%; 21 256 participants). Data from RCTs showed no consistent effects of nonnutritive sweeteners on other measures of body composition and reported no further secondary outcomes. In the cohort studies, consumption of nonnutritive sweeteners was associated with increases in weight and waist circumference, and higher incidence of obesity, hypertension, metabolic syndrome, type 2 diabetes and cardiovascular events. Publication bias was indicated for studies with diabetes as an outcome.
  • INTERPRETATION: Evidence from RCTs does not clearly support the intended benefits of nonnutritive sweeteners for weight management, and observational data suggest that routine intake of nonnutritive sweeteners may be associated with increased BMI and cardiometabolic risk. Further research is needed to fully characterize the long-term risks and benefits of nonnutritive sweeteners.
Wow, this one changes things. For years, many people have recommended diet drinks as a weight control tool. You know, the old calories in calories out thing. Turns out, maybe that isn't the case. This study reviewed 37 studies and found no weight loss in 7, but increase in weight in the other 30 studies! Additionally, further review of the studies showed increased risk of just about everything diet soda was supposed to prevent; obesity, hypertension, metabolic syndrome, diabetes and cardiovascular events. What is the mechanism of this? It's hard to say for sure but I suspect it has to do with insulin (yes, I detect an obsession coming on). The body releases insulin in anticipation of food and especially sweet foods. Therefore, it seems likely that there is increased insulin release for artificial sweeteners. This likely causes increased hunger shortly afterwards (for something sweet or starchy) which then could spur more insulin release with a net result of increased insulin resistance. It seems best to skip the diet drinks and instead stick with water. If you want some flavor add lemon, lime, or cucumber. If you like fizz, try some club soda. Remember, diet drinks aren't doing your body any favors. 
Eat Better. Don't Die.
Improved diet quality associated with less mortalitiy
This study, from the New England Journal of Medicine, examined the diet in women enrolled in the Nurses' Health Study and men in the Health Professionals Follow-up Study from 1998-2010. They examined diet quality over a 12 year period as well as changes in diet over this time. Few studies are this large or have this long a follow-up time period to look at end points of heart attacks, strokes, and death. Diet was evaluated through multiple tools. Improved diet quality (20% improvement) over the 12 year period was consistently associated with decreased risk of death. Maintenance of good quality diet was also associated with lower risk of mortality. 
  • BACKGROUND:  Few studies have evaluated the relationship between changes in diet quality over time and the risk of death.
  • METHODS: We used Cox proportional-hazards models to calculate adjusted hazard ratios for total and cause-specific mortality among 47,994 women in the Nurses' Health Study and 25,745 men in the Health Professionals Follow-up Study from 1998 through 2010. Changes in diet quality over the preceding 12 years (1986-1998) were assessed with the use of the Alternate Healthy Eating Index-2010 score, the Alternate Mediterranean Diet score, and the Dietary Approaches to Stop Hypertension (DASH) diet score. 
  • RESULTS: The pooled hazard ratios for all-cause mortality among participants who had the greatest improvement in diet quality (13 to 33% improvement), as compared with those who had a relatively stable diet quality (0 to 3% improvement), in the 12-year period were the following: 0.91 (95% confidence interval [CI], 0.85 to 0.97) according to changes in the Alternate Healthy Eating Index score, 0.84 (95 CI%, 0.78 to 0.91) according to changes in the Alternate Mediterranean Diet score, and 0.89 (95% CI, 0.84 to 0.95) according to changes in the DASH score. A 20-percentile increase in diet scores (indicating an improved quality of diet) was significantly associated with a reduction in total mortality of 8 to 17% with the use of the three diet indexes and a 7 to 15% reduction in the risk of death from cardiovascular disease with the use of the Alternate Healthy Eating Index and Alternate Mediterranean Diet. Among participants who maintained a high-quality diet over a 12-year period, the risk of death from any cause was significantly lower - by 14% (95% CI, 8 to 19) when assessed with the Alternate Healthy Eating Index score, 11% (95% CI, 5 to 18) when assessed with the Alternate Mediterranean Diet score, and 9% (95% CI, 2 to 15) when assessed with the DASH score - than the risk among participants with consistently low diet scores over time.
  • CONCLUSIONS: Improved diet quality over 12 years was consistently associated with a decreased risk of death.

This large study found that people who ate better had less heart disease and lowered risk of death. While other studies have shown trends, usually through decreased blood pressure, lipids, or weight, this one is especially strong becaues it looks at what we care about, risk of death. It shows that even if our diet wasn't good previously, making changes (20% improvement) can have a significant affect on our mortality. The dietary tools used tend to stress low sugar, low processed food diets. Again with the insulin! Remember, it's never too late to improve what we are eating. Eat for life!

Thank you for taking the time to read through this newsletter. I hope you have found this information useful as we work together to optimize your health. 


As always, if you have questions about anything in this newsletter or have topics you would like me to address, please feel free to contact me by email , phone, or just stop by! 

To Your Good Health,
Mark Niedfeldt, M.D.