December Newsletter
In This Issue
Is My Cough Bacterial?
Sit, Stand, Pace, Repeat
Artificial Sweetener and Obesity
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. The end of a year is always a time of reflection on the past and looking forward to the future. At this busy time, take a few minutes to give thanks for the past and plan for the future. I wish you and your families all the best in 2017!


It often seems that everyone is coughing this time of year. The combination of weather, being indoors, holiday visits and celebrations puts us all in the petri dish of germs. So when is that respiratory infection bacterial? This is a decision I make almost daily. The first article is interesting as it looks at the percentage of these coughs/respiratory infections that are bacterial and their outcomes over the short and long-term.  

Many of us sit for most of the day. We are tied to our desks, computer monitors or television sets. Previous studies have shown that this is unhealthy. The second study looks at a possible reason for the unhealthy findings and I will give you some strategies to decrease your risk. 

Splenda (sucralose) is the most common artificial sweetener used today. It is supposed to be metabolically inactive, but is it? 

Click on the links the the left to check out our web site...

Is My Cough Bacterial? 
Antibiotics usually not needed         
This time of year it probably seems like everyone is coughing. The combination of cold weather and holiday gatherings lead to more exposure to illness. This article from the Annals of Family Medicine examined the disease course of people with lower respiratory infections (coughing). We usually assume that infections caused by bacteria are different than viral infections. However, this study showed that most infections, either viral or bacterial, are generally mild, self-limited (will improve without antibiotics), and uncomplicated. Keeping this in mind can help to reduce unnecessary antibiotic use and lower the risk of bacterial resistance.  

  • PURPOSE:  Bacterial pathogens are assumed to cause an illness course different from that of nonbacterial causes of acute cough, but evidence is lacking. We evaluated the disease course of lower respiratory tract infection (LRTI) with a bacterial cause in adults with acute cough.  
  • METHODS: We conducted a secondary analysis of a multicenter European trial in which 2,061 adults with acute cough (28 days' duration or less) were recruited from primary care and randomized to amoxicillin or placebo. For this analysis only patients in the placebo group (n = 1,021) were included, reflecting the natural course of disease. Standardized microbiological and serological analyses were performed at baseline to define a bacterial cause. All patients recorded symptoms in a diary for 4 weeks. The disease course between those with and without a bacterial cause was compared by symptom severity in days 2 to 4, duration of symptoms rated moderately bad or worse, and a return consultation. 
  • RESULTS: Of 1,021 eligible patients, 187 were excluded for missing diary records, leaving 834 patients, of whom 162 had bacterial LRTI. Patients with bacterial LRTI had worse symptoms at day 2 to 4 after the first office visit (P = .014) and returned more often for a second consultation, 27% vs 17%, than those without bacterial LRTI (P = .004). Resolution of symptoms rated moderately bad or worse did not differ (P = .375).
  • CONCLUSIONS: Patients with acute bacterial LRTI have a slightly worse course of disease when compared with those without an identified bacterial cause, but the relevance of this difference is not meaningful.
This study actually tested everyone who came in with a cough for bacterial infection and found the incidence of bacterial infection was just under 20%. The researchers found that those who had a bacterial infection had worse symptoms days 2-4 of illness after physician visit. People who had bacterial infections returned for a second visit more often (27% vs 17%). By day 7 after the visit, 50% of both groups no longer had significant symptoms and by day 26, 90% of people in both groups no longer had symptoms. So the bottom line is that the vast majority of coughs don't need antibiotics and antibiotics may not make any difference in outcomes. 
Sit, Stand, Pace, Repeat
Light activities improve insulin sensitivity and glucose control

This study, from the journal Diabetologia, looked at three groups: a sedentary group (Sitting), a group that exercised for about an hour daily but was sedentary the rest of the time (Exercise), and a group that replaced about 1/3 of their sitting time with movement or standing (Sit Less). Both the exercise and sit less groups had improved blood sugars but only the sit less group had improved insulin sensitivity. This shows that while an hour daily of exercise is good, being active (moving around and standing) throughout the day may be even better than structured exercise.   
  • AIMS/HYPOTHESIS:  We aimed to examine the effects of breaking sitting with standing and light-intensity walking vs an energy-matched bout of structured exercise on 24 h glucose levels and insulin resistance in patients with type 2 diabetes.                     
  • METHODS: In a randomised crossover study, 19 patients with type 2 diabetes (13 men/6 women, 63+/-9 years old) who were not using insulin each followed three regimens under free-living conditions, each lasting 4 days: (1) Sitting: 4415 steps/day with 14 h sitting/day; (2) Exercise: 4823 steps/day with 1.1 h/day of sitting replaced by moderate- to vigorous-intensity cycling (at an intensity of 5.9 metabolic equivalents [METs]); and (3) Sit Less: 17,502 steps/day with 4.7 h/day of sitting replaced by standing and light-intensity walking (an additional 2.5 h and 2.2 h, respectively, compared with the hours spent doing these activities in the Sitting regimen). Blocked randomisation was performed using a block size of six regimen orders using sealed, non-translucent envelopes. Individuals who assessed the outcomes were blinded to group assignment. Meals were standardised during each intervention. Physical activity and glucose levels were assessed for 24 h/day by accelerometry (activPAL) and a glucose monitor (iPro2), respectively. The incremental AUC (iAUC) for 24 h glucose (primary outcome) and insulin resistance (HOMA2-IR) were assessed on days 4 and 5, respectively. 
  • RESULTS: The iAUC for 24 h glucose (mean+/-SEM) was significantly lower during the Sit Less intervention than in Sitting (1263 +/- 189 min x mmol/l vs 1974 +/- 324 min x mmol/l; p = 0.002), and was similar between Sit Less and Exercise (Exercise: 1383 +/- 194 min x mmol/l; p=0.499). Exercise failed to improve HOMA2-IR compared with Sitting (2.06 +/- 0.28 vs 2.16 +/- 0.26; p = 0.177). In contrast, Sit Less (1.89 +/- 0.26) significantly reduced HOMA2-IR compared with Exercise as well as Sitting.
  • CONCLUSIONS/INTERPRETATION: Breaking sitting with standing and light-intensity walking effectively improved 24 h glucose levels and improved insulin sensitivity in individuals with type 2 diabetes to a greater extent than structured exercise. Thus, our results suggest that breaking sitting with standing and light-intensity walking may be an alternative to structured exercise to promote glycaemic control in patients type 2 diabetes.
This study back up what several other studies have found. Standing and moving around during the work day is very beneficial for health, exceeding even structured exercise for an hour daily. Other studies have shown benefits in mortality and onset of chronic diseases. This study looked specifically at diabetics but the interesting finding of improved insulin sensitivity is applicable to all of us and is likely the source of most of the problems found in other studies. Insulin resistance is associated with diabetes, heart disease and obesity. It is also associated with inflammation in the body which my readers know is one of the things I believe contributes to many diseases including cancer and heart disease. So what should those of us working at desks do? While working at a desk, be sure to get up for one to three minutes every half-hour of so and move around. You can consider an adjustment that can raise your computer monitor for standing. When talking on the phone, stand up or pace. While watching TV, stand up and move around or exercise during advertisements. Monitor how much you sit during the day and try to reduce it gradually every week. Aim for at least two to three fewer sedentary hours in a 12-hour day. Regular exercise is good for you, but it doesn't mean you get to sit the rest of the day!
Artificial Sweetener and Obesity
Sucralose (Splenda) may cause insulin resistance
Non-nutritive sweeteners (NNS) are often recommended to people who are obese and trying to lose weight. The thought is that lower calories will lead to weight reduction. However, there may be a caveat to that thought. Studies have shown that in obese subjects, sucralose (Splenda), the most frequently used NNT may cause insulin resistance in people who are obese. This hasn't been shown to be the case in lean people. This small study, presented as an abstract at a medical meeting, shows that this does appear to be the case. Obese people were found to have increased insulin resistance after consuming Splenda. 
  • Background: Whether non-nutritive sweeteners (NNS) are metabolically active is unclear and an issue of much public health and scientific debate. We have recently found that sucralose, the most commonly used NNS, enhances insulinemic responses to an oral glucose tolerance test (OGTT) in subjects with obesity who are not regular consumers of NNS. However, studies conducted in lean adults, none of which control for regular use of NNS, round sucralose does not affect glycemic or insulin responses to the ingestion of glucose or other carbohydrates. Therefore the goal of this study is to determine whether the acute sucralose effects we found in people with obesity are generalizable to lean people when controlling for prior history of NNS use. 
  • Methods: Eight normal weight subjects (BMI 22.9 +/- 1.0 kg/M2) who did not regularly use NNS wand were "insulin-sensitive" (based on a Homeostasis Model Assessment of Insulin Resistance score <2.6), completed a 5-hr modifies OGTT on 2 separate occasions, preceded by consuming either sucralose or water 10 minutes before the glucose load in a randomized cross-over design. 
  • Results: Sucralose did not affect glucose area under the curve (AUC) in either group. However, in subjects with obesity, compared with the Control condition, sucralose ingestion causes a greater increase in insulin and c-peptide AUCs which suggests acute sucralose causes insulin resistance. There were no statistically significant differences between conditions in insulin or c-peptide AUC in lean subjects.
  • Conclusions: Sucralose may have adverse effects on glucose metabolism in people with obesity, which is the group that most frequently  consumes and receives the advise to use NNS to facilitate weight management. 
Sucralose is advertised as being more "natural" than other NNS. However, sucralose doesn't come from sugar the way that cheese comes from milk. It is chlorinated sugar. It is unique in that it is stable at heat unlike others so we can cook with it and it is marketed as being great for diabetics. This study shows us that Splenda may not be metabolically inactive as thought. In people who are overweight, it is shown to increase insulin resistance, exactly what we are trying to combat by consuming it! It is interesting that this effect isn't seen in people who are not overweight. This is a very small study and was presented at a meeting, not published in a peer reviewed journal. However, given this finding (along with some other studies suggesting the same thing) it makes sense for all of us to decrease or eliminate our intake of artificial sweeteners. Having a bit of sucralose every once in a while is likely not harmful, but daily heavier use could lead to some problems. If you need some sweetener in your coffee or tea, consider Stevia or perhaps a little raw honey. 
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.