August Newsletter
In This Issue
It's Worse Than We Thought
Pump Some Iron Grandma!
Give Your Baby Skills
A Better Model of Medical Care
Old-fashioned medicine with 21st Century convenience and technology
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I hope this newsletter finds you and your family well. I don't know about you but I've been trying to cram in a whole lot of summer over the past couple of weeks. Can't believe Labor Day is just around the corner. 
Cigarette smoking is bad for you. Not exactly a news flash. But how bad is it and how long do the effects of smoking last after someone quits? Health measures start to improve within 20 minutes but the lingering effects can last for a decade or more. The first article shows us that the cardiovascular effects of smoking actually persist even longer than previously calculated. 

I often have patients tell me aging isn't for wimps. The second study shows us that not being a "wimp" may actually be important for healthy aging and lowering your risk of mortality. Find out what measures increase your risk and how you can lower your risk.    

Every parent is trying to give their kids a boost. We try to get them into good schools, find enriching activities for them, and provide a safe and nourishing environment for them. What if there is something we can do BEFORE they are born that could give baby a boost? Check out the third article for more information.  

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It's Worse Than We Thought
Increased cardiovascular risk persists for years after quitting smoking
The fact that cigarette smoking is bad for us is not new news. The good news is that many health parameters start to improve as soon as a smoker quits and after a long enough time the risk tends to regress close to the levels of non-smokers. However, this study, from JAMA, shows us that people who accumulate 20 pack/years of smoking (the equivalent of 1 pack daily for 20 years) have a higher risk of cardiovascular disease for 10-15 years after quitting. The risk does start to decline after 5 years, but is still elevated for a much longer period. 
  • Importance: The time course of cardiovascular disease (CVD) risk after smoking cessation is unclear. Risk calculators consider former smokers to be at risk for only 5 years.
  • Objective: To evaluate the association between years since quitting smoking and incident CVD.
  • Design, Setting, and Participants: Retrospective analysis of prospectively collected data from Framingham Heart Study participants without baseline CVD (original cohort: attending their fourth examination in 1954-1958; offspring cohort: attending their first examination in 1971-1975) who were followed up through December 2015.
  • Exposures: Time-updated self-reported smoking status, years since quitting, and cumulative pack-years.
  • Main Outcomes and Measures: Incident CVD (myocardial infarction, stroke, heart failure, or cardiovascular death). Primary analyses included both cohorts (pooled) and were restricted to heavy ever smokers (≥20 pack-years).
  • Results: The study population included 8770 individuals (original cohort: n = 3805; offspring cohort: n = 4965) with a mean age of 42.2 (SD, 11.8) years and 45% male. There were 5308 ever smokers with a median 17.2 (interquartile range, 7-30) baseline pack-years, including 2371 heavy ever smokers (406 [17%] former and 1965 [83%] current). Over 26.4 median follow-up years, 2435 first CVD events occurred (original cohort: n = 1612 [n = 665 among heavy smokers]; offspring cohort: n = 823 [n = 430 among heavy smokers]). In the pooled cohort, compared with current smoking, quitting within 5 years was associated with significantly lower rates of incident CVD (incidence rates per 1000 person-years: current smoking, 11.56 [95% CI, 10.30-12.98]; quitting within 5 years, 6.94 [95% CI, 5.61-8.59]; difference, −4.51 [95% CI, −5.90 to −2.77]) and lower risk of incident CVD (hazard ratio, 0.61; 95% CI, 0.49-0.76). Compared with never smoking, quitting smoking ceased to be significantly associated with greater CVD risk between 10 and 15 years after cessation in the pooled cohort (incidence rates per 1000 person-years: never smoking, 5.09 [95% CI, 4.52-5.74]; quitting within 10 to <15 years, 6.31 [95% CI, 4.93-8.09]; difference, 1.27 [95% CI, −0.10 to 3.05]; hazard ratio, 1.25 [95% CI, 0.98-1.60]).
  • Conclusions and Relevance: Among heavy smokers, smoking cessation was associated with significantly lower risk of CVD within 5 years relative to current smokers. However, relative to never smokers, former smokers' CVD risk remained significantly elevated beyond 5 years after smoking cessation.


Thankfully, only 14% of people in the US now smoke (down from 42% in 1965), but it still leaves over 30 million people who still smoke. This study helps to show us the long term risks of prolonged smoking and that many of the risks may not be seen until years later. Many of the risk calculators used by physicians to calculate a person's risk of heart disease have generally assumed that the risk would be down in 5 years. However, this study suggests that the negative effects of smoking on the cardiovascular system actually persist much longer, even decades after quitting. This really brings home the idea of quitting ASAP if you smoke and strongly encouraging anyone who does smoke to stop. You can't start lowering risk until you are no longer exposed. Of course the best advice is to never start!

Pump Some Iron Grandma!
Low muscle mass tied to increased mortality in the elderly
older woman with weights

Bette Davis said, "Old age ain't no place for sissies!". This study suggests that she was definitely correct. Researchers enrolled 839 community dwelling people over 65 years old and measured their body composition using DEXA scanners (the most accurate way of determining body composition). Over the 4+ year follow up over 15% of the subjects died. They found two factors associated with higher risk of overall mortality and cardiovascular mortality, lower muscle mass and higher visceral fat. 


  • Body composition changes as a result of ageing may impact the survival of older adults. However, its influence on mortality risk is uncertain. Currently, the best method for body composition analysis in clinical practice is DXA. Nonetheless, the few studies on body composition by DXA and mortality risk in the elderly have some limitations. We investigated the association between body composition by DXA and mortality in a cohort of elderly subjects. Eight hundred thirty-nine community-dwelling subjects (516 women, 323 men) >/= 65 years of age were assessed by a questionnaire, clinical data, laboratory exams, and body composition by DXA at baseline. Total fat and its components (eg, visceral adipose tissue [VAT]) were estimated. Appendicular lean mass (ALM) adjusted for fat and ALM divided by height² was used to ascertain the presence of low muscle mass (LMM). Mortality was recorded during follow-up. Multivariate logistic regression was used to compute ORs for all-cause and cardiovascular mortality. Over a mean follow-up of 4.06 ± 1.07 years, there were 132 (15.7%) deaths. In men, after adjustment for relevant variables, the presence of LMM (OR, 11.36, 95% CI, 2.21 to 58.37, P = 0.004) and VAT (OR, 1.99, 95% CI, 1.38 to 2.87, P < 0.001, for each 100-g increase) significantly increased all-cause mortality risk, whereas total fat, measured by the fat mass index, was associated with decreased mortality risk (OR, 0.48, 95% CI, 0.33 to 0.71, P < 0.001).  Similar results were observed for cardiovascular mortality. In women, only LMM was a predictor of all-cause (OR, 62.88, 95% CI, 22.59 to 175.0, P < 0.001) and cardiovascular death (OR, 74.54, 95% CI, 9.72 to 571.46, P < 0.001). LMM ascertained by ALM adjusted for fat and fat mass by itself are associated with all-cause and cardiovascular mortality risk in the elderly. Visceral and subcutaneous fat have opposite roles on mortality risk in elderly men. Thus, DXA is a promising tool to estimate risk of mortality in the elderly.
This study found a relationship between muscle mass, visceral fat and mortality. Visceral fat is the fat found inside our abdominal region surrounding our organs. Typically, visceral fat makes up around 10% of our overall fat. People with larger waist sizes (apple shape) tend to have more visceral fat. This type of fat causes increased insulin resistance and is linked to multiple health problems including heart attacks, strokes, diabetes, cancers and dementia.So it does make sense that those subjects with higher visceral fat levels had more mortality. Lower overall muscle mass was also linked. There could be a number of reasons for this including less activity. So as we age it is very important to maintain our muscle mass. Resistance training is the best way to maintain and improve our muscle mass. The great news is that exercise (aerobic and resistance) also has the effect of lowering our visceral fat levels and thus decreasing our risk of mortality. So it looks like Bette Davis had it right, you can't be a sissy, you have to work to age well. Make sure some of that work involves resistance training!

If you are interested in evaluating your true body composition, DEXA scans look to be a good way to go about this. DEXA scanners use beams of very low-energy radiation to evaluate our body composition and are commonly used to look at bone density in women. This typical hospital scan won't give us our fat percentages and muscle mass, just bone density. Here in our community we can have relatively inexpensive scans available at UWM or Marquette to get this information. 
Give Your Baby Skills
Exercise during pregnancy improves babies neuromotor development
Research shows us that exercise during pregnancy is good for both mother and baby. Babies born to exercising mothers may achieve earlier developmental milestones and have lowered body fat at age 3. In this study researchers divided pregnant women into two groups. One group exercised three times a week and the other did their usual activity only. After birth they measured the neuromotor skills of the babies at 1 month of age and found that babies born to the exercising group scored higher on tests measuring interrelated motor abilities. 

  • Purpose To determine the effects of exercise during pregnancy on the neuromotor development of 1-month-old offspring. We hypothesized that aerobic exercise during pregnancy would be associated with higher neuromotor scores in infants at 1 month of age, based on standard pediatric assessment of neuromotor skills.
  • Methods Seventy-one healthy, pregnant women between 18 and 35 yr were randomly assigned to either aerobic exercise intervention or no exercise (control) group. Women in the exercise group performed 50 min of moderate-intensity, supervised aerobic exercise, three times per week; those in control group maintained usual activity. Neuromotor skills were measured at 1 month of age using the Peabody Developmental Motor Scales, 2nd Edition (PDMS-2). Unpaired t-tests were used to compare infants' PDMS-2 subtest percentiles, Gross Motor Quotients, and Gross Motor Quotient percentile between groups.
  • Results Infants of women in the exercise group had higher PDMS-2 scores on four of the five variables analyzed relative to infants of nonexercisers. Female infants tended to have improved scores relative to male infants of controls; this difference was attenuated in infants of exercisers.
  • Conclusions Exercise during pregnancy can positively influence developing systems allowing for improved neuromotor development, thus leading to infants who are more adept at movement, and presumably more likely to be active. Because physical activity is a modifiable risk factor of childhood obesity, these findings suggest that exercise during pregnancy may potentially reduce childhood risk of obesity.
This study looked at early neuromotor development in infants of women who did aerobic exercise during pregnancy and compared it to infants born to women who didn't exercise. The testing involved six developmental measures ( Reflexes, Stationary, Locomotion, Object Manipulation, Grasping, Visual-Motor Integration) that measure interrelated motor abilities. Their findings suggest that e xercise during pregnancy can positively influence babies developing systems resulting in improved neuromotor development. So what does this mean? This was a short-term study but the findings suggest that exercise during pregnancy could lead to infants who are more adept at movement. This could account for other studies showing improved milestones in the offspring of exercising mothers and could also make the babies more likely to be active. A nice way to give your children a leg up!

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. Feel free to pass this on to anyone you think would benefit from this information. 

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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.