December Newsletter
In This Issue
Holiday Heart Attack?
More Mediterranean, Less Heart Attacks
Fitness and Vitamin D
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 would like to wish all of you a Happy New Year! Some of us may have had a great 2018 while others may want to forget the year. The nice thing about starting a new year is that we have a clean slate. It's a great time to think about who we are and who we want to be. While most (or all) of our resolutions may fall by the wayside, I hope that we can all work to make 2019 our healthiest year ever. 

A couple notes for my patients. We have been switching to a new electronic health record over the past month. As a result, at some point you may get an invitation to join the new record. I think it will be a much better choice for my office and my patients. Also, please update our email contacts. You can reach the office at (this goes to Colleen). I can be reached directly at and Colleen can be reached at Our phone number and fax are unchanged. Thanks for your patience during this transition. After 10 years it isn't easy. 

The Holidays are stressful for everyone. But are we more likely to actually have a heart attack? Find out if you are at risk and what to look for. 

I have written about the Mediterranean diet before and the health benefits associated with this type of diet. The second article looks at the incidence of heart attacks in relationship to compliance with the major aspects of this diet. 

Can a cheap, legal, easily obtained supplement actually give us better fitness? The answer may surprise you. Check out the third article for more information. 

Click on the links the the left to check out our  web site .
Holiday Heart Attack?
Highest risk is Christmas Eve
We know that external factors can cause myocardial infarctions (heart attacks). Some of these short-term risk factors include emotional stress, heavy physical activity, cold weather exposure and air pollution. Additionally, events such as sports events and stock market volatility have been associated with higher risk of myocardial infarction. Studies have shown peak cardiac mortality between Christmas and New Year's holidays. This study from BMJ looked at medical records over a 16 year period to try to determine the various triggers and timing of heart attacks. They found higher incidence of events at Christmas and the Midsummer holidays. Christmas Eve was associated with a 37% higher risk of myocardial infarction with the peak time of 10 PM. New Year's Day had a 20% increase in risk. 

  • Objectives: To study circadian rhythm aspects, national holidays, and major sports events as triggers of myocardial infarction.
  • Design Retrospective observational study using the nationwide coronary care unit registry, SWEDEHEART.
  • Setting Sweden.
  • Participants 283,014 cases of myocardial infarction reported to SWEDEHEART between 1998 and 2013. Symptom onset date was documented for all cases, and time to the nearest minute for 88%.
  • Interventions Myocardial infarctions with symptom onset on Christmas/New Year, Easter, and Midsummer holiday were identified. Similarly, myocardial infarctions that occurred during a FIFA World Cup, UEFA European Championship, and winter and summer Olympic Games were identified. The two weeks before and after a holiday were set as a control period, and for sports events the control period was set to the same time one year before and after the tournament. Circadian and circaseptan analyses were performed with Sunday and 24:00 as the reference day and hour with which all other days and hours were compared. Incidence rate ratios were calculated using a count regression model.
  • Main outcome measures Daily count of myocardial infarction.
  • Results Christmas and Midsummer holidays were associated with a higher risk of myocardial infarction (incidence rate ratio 1.15, 95% confidence interval 1.12 to 1.19, P<0.001, and 1.12, 1.07 to 1.18, P<0.001, respectively). The highest associated risk was observed for Christmas Eve (1.37, 1.29 to 1.46, P<0.001). No increased risk was observed during Easter holiday or sports events. A circaseptan and circadian variation in the risk of myocardial infarction was observed, with higher risk during early mornings and on Mondays. Results were more pronounced in patients aged over 75 and those with diabetes and a history of coronary artery disease.
  • Conclusions In this nationwide real world study covering 16 years of hospital admissions for myocardial infarction with symptom onset documented to the nearest minute, Christmas, and Midsummer holidays were associated with higher risk of myocardial infarction, particularly in older and sicker patients, suggesting a role of external triggers in vulnerable individuals. 

External factors can increase risk of heart attacks. One of the things that can increase risk is emotional stressors. The authors of this study hypothesize that this could partially explain the increased risk around the holidays. Additionally, excess food and drink (alcohol) may contribute. These external risk factor most likely affect those already at increased risk the most (diabetics, people with known heart disease). Besides the Holiday season (Christmas to New Year's) the other increased risk found was the Midsummer holiday. Midsummer is the second most important holiday in Sweden (after Christmas). On Midsummer Eve, which precedes the summer solstice, Swedes gather to celebrate by dancing around a maypole, singing, eating, and drinking, often to excess. While we don't generally celebrate this holiday here in the US (although it sounds pretty fun), we could probably equate this to Memorial Day and 4th of July holidays. So what can we do to lower risk to ourselves and our loved ones? Be aware when we visit relatives, especially those over age 75 who have chronic diseases. The stress of travel or hosting may be affecting them more than we think. Sleep deprivation and alcohol can also contribute. Luckily, the authors didn't find a relationship with stock market volatility and sporting events, although the Packer's performance yesterday did give me heartburn...

More Mediterranean, Less Heart Attacks
Higher Mediterranean diet compliance reduces risk of heart attacks
Mediterranean diet

This study looked at long-term adherence to the Mediterranean diet. A scoring system to rank compliance with the Mediterranean diet. This included intake of vegetables (not potatoes), fruits, nuts, whole grains, legumes, fish, more monounsaturated fats than saturated fats, little to no red meat, and 5-15 gms of alcohol (14 gms = 12 oz beer or 4 oz wine). The primary end point was a cardiovascular event including heart attack, stroke, coronary artery revascularization and cardiovascular death. They found a 28% reduction in cardiovascular events in those with the highest score (6 or more). They also found inflammation was the greatest predictor of events at 29.2%. Our nutrition may be our best defense. 


  • Importance  Higher Mediterranean diet (MED) intake has been associated with lower risk of cardiovascular disease (CVD), but limited data are available about the underlying molecular mechanisms of this inverse disease association in human populations.
  • Objective  To better characterize the relative contribution of traditional and novel factors to the MED-related risk reduction in CVD events in a US population.
  • Design, Setting, and Participants  Using a prospective cohort design, baseline MED intake was assessed in 25,994 initially healthy US women in the Women's Health Study who were followed up to 12 years. Potential mediating effects of a panel of 40 biomarkers were evaluated, including lipids, lipoproteins, apolipoproteins, inflammation, glucose metabolism and insulin resistance, branched-chain amino acids, small-molecule metabolites, and clinical factors. Baseline study information and samples were collected between April 30, 1993, and January 24, 1996. Analyses were conducted between August 1, 2017, and October 30, 2018.
  • Exposures  Intake of MED is a 9-category measure of adherence to a Mediterranean dietary pattern. Participants were categorized into 3 levels based on their adherence to the MED.
  • Main Outcomes and Measures  Incident CVD confirmed through medical records and the proportion of CVD risk reduction explained by mediators.
  • Results  Among 25,994 women (mean [SD] age, 54.7 [7.1] years), those with low, middle, and upper MED intakes composed 39.0%, 36.2%, and 24.8% of the study population and experienced 428 (4.2%), 356 (3.8%), and 246 (3.8%) incident CVD events, respectively. Compared with the reference group who had low MED intake, CVD risk reductions were observed for the middle and upper groups, with respective HRs of 0.77 (95% CI, 0.67-0.90) and 0.72 (95% CI, 0.61-0.86) (P for trend < .001). The largest mediators of the CVD risk reduction of MED intake were biomarkers of inflammation (accounting for 29.2% of the MED-CVD association), glucose metabolism and insulin resistance (27.9%), and body mass index (27.3%), followed by blood pressure (26.6%), traditional lipids (26.0%), high-density lipoprotein measures (24.0%) or very low-density lipoprotein measures (20.8%), with lesser contributions from low-density lipoproteins (13.0%), branched-chain amino acids (13.6%), apolipoproteins (6.5%), or other small-molecule metabolites (5.8%).
  • Conclusions and Relevance  In this study, higher MED intake was associated with approximately one-fourth relative risk reduction in CVD events, which could be explained in part by known risk factors, both traditional and novel.


Most of our emphasis in regards to cardiovascular disease is based on giving people medications to lower blood pressure and cholesterol levels. But inflammation is the leading cause of cardiovascular disease. We have no drug for inflammation, but we do have a diet that reduces inflammation. Additionally, this diet will likely have positive effects on many of the other leading risk factors including insulin resistance, body mass index, blood pressure and lipids. Nutrition may be our most effective therapeutic agent against cardiovascular disease. We don't understand all of the mechanisms of this yet, but the results are clear. I have a link below if you would like more information of the Mediterranean diet. Those of you who know me know that I do have people take it easy on the bread, pasta and rice intake, even if it is whole grain. Emphasize vegetable intake, moderate fruits and healthy fats such as olive oil, avocados, nuts and seeds. 

Fitness and Vitamin D
Higher vitamin D levels linked to better cardiorespiratory fitness
vitamin D
Researchers used data from the National Health and Nutrition Examination Survey to asses the association between vitamin D levels and cardiorespiratory fitness. Their analysis included 1,995 participants between the ages of 20 and 49. They found that subjects in the highest quartile of vitamin D levels had significantly higher cardiorespiratory fitness than those in the lowest quartile. An independent and significant association was found between serum vitamin D levels and cardiorespiratory fitness. 

  • Aims: The small number of studies that have investigated the relationship between serum vitamin D levels and cardiorespiratory fitness (CRF) have reported conflicting results. We investigated the association between vitamin D levels and CRF in a representative sample of the US population using data from the National Health and Nutrition Survey (2001-2004).
  • Methods: We included participants between the ages of 20 and 49 years and excluded those with vitamin D levels at the 5% extremes of the distribution. We used survey-weighted linear regression without and with adjustment for age, sex, race, body mass index, hypertension, diabetes, smoking, C-reactive protein, hemoglobin, and glomerular filtration rate to examine the relationship between the maximal oxygen consumption (VO2 max) (as a surrogate for CRF) and vitamin D levels.
  • Results: Of the 1995 participants, 45.2% were women, 49.1% were white, 13% had hypertension, and 4% had diabetes. The mean +/- SD age was 33 +/- 8.6 years, with as mean +/- SD vitamin D level of 58 +/- 5.3 nmol/L and a mean +/- SD VO2 max of 40 +/- 9.7 ml/kg/min. Participants in the highest quartile of vitamin D levels had a significantly higher CRF than participants in the lowest quartile (difference 4.3, 95% confidence interval (CI) 3.0-5.5; P < 0.001). After adjustment for potential confounders, the difference between the highest and lowest vitamin D quartiles remained significant (difference 2.9, 95% CI 1.6-4.1; P < 0.001). In unadjusted and adjusted linear regression, each 10 nmol/L increase in vitamin D level was associated with a significant increase in VO2 max(B=0.78 ml/kg/min, 95% CI 0.55-1.01; P < 0.001; B=0.51 ml/kg/min, 95% CI 0.23-0.79; P = 0.001, respectively).
  • Conclusions: We found an independent and robust association between serum vitamin D levels and CRF, but our results need to be validated with clinical trials examining the effect of vitamin D supplementation on CRF.


Vitamin D receptors are found on at least 30 different types of cells, including muscle cells so vitamin D has effects on multiple systems in the body. Cardiorespiratory fitness is the ability of the circulatory and respiratory systems to supply oxygen to skeletal muscles during sustained physical activity. Higher cardiorespiratory fitness is associated with better outcomes in all-cause and cardiovascular mortality. This study analyzed the relationship between serum vitamin D level and cardiorespiratory fitness and found a significant association between higher vitamin D levels and fitness. I found this study interesting because it looked at a younger population. The relationship was independent of age, sex, race, BMI, smoking and other chronic diseases. The mechanism isn't completely clear at this point but could be related to vitamin D receptors in skeletal muscle, heart muscle, or heart structure. In turn, better fitness leads to lower risk of thrombotic events, better insulin sensitivity, improved lipid and lipoprotein profiles and lower levels of inflammation. At this time of year it is impossible to get vitamin D in our climate. Therefore, a vitamin D supplement is recommended. I generally recommend at least 2000 IU daily and I think most people should take 5000 IU daily. While a vitamin D supplement won't turn you into a world class athlete, it may help you live longer.  

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. 

You can find previous newsletters archived on my website here


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.