brown stacked logo

February Newsletter
In This Issue
Lower Your Risk of Acute Back Pain
Diet Coke May Be Injuring Your Heart
Exercise: Can There Be Too Much of a Good Thing?
A New Model of Medical Care
Dr. Niedfeldt
Old-fashioned medicine with 21st Century convenience and technology
Quick Links
Join Our List
View my profile on LinkedIn 
Follow me on Twitter



I hope this newsletter finds you and your family well. I am writing this from the Brewers' Spring Training complex in Phoenix. I have to confess, it is REALLY nice to get out of Wisconsin for a few days this time of year. Nothing like the crack of bats in the morning to get you thinking about summertime.   


Photo credit Adam McCalvy (via Twitter) 


I reviewed an article last month which showed healthy lifestyle habits such as not smoking, healthy diet with lots of vegetables and fruit, staying active and low alcohol intake could reduce chronic back pain by 50%. This month, I look at behaviors that increase risk of acute back pain. There is a behavior that will increase your risk 25-fold. You probably want to check out the article.  

Is soda bad for you? Certainly the sugar in regular soda is. This article adds to the idea the even diet soda is not good for your health. This study examined cardiac remodeling, which is an early sign of future heart failure and found that people who drank soda, both diet and regular had increased findings.  


How much should I exercise? This is always a tough question to answer. The third study, part of the Copenhagen Heart Study gives us some recommendations. Be sure to read my commentary for the full picture.  


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

Lower Your Risk of Acute Back Pain 

Modifiable risk factors identified 

Acute back pain is a problem that affects more people worldwide than diseases like diabetes and malaria. Yet up to this point we have not been able to prevent it. This study, from the journal Arthritis Care and Research, identifies several physical and psychosocial triggers which can be modified to prevent acute back pain. This is the first study to look at the relationship of acute episodes of back pain to modifiable behaviors and risk factors.    


Summary of findings:

  • Objective
    • To investigate a range of transient risk factors for an episode of sudden-onset, acute low back pain (LBP).
  • Methods
    • This case-crossover study recruited 999 subjects with a new episode of acute LBP between October 2011 and November 2012 from 300 primary care clinics in Sydney, Australia.
    • Each participant was asked to report exposure to 12 putative triggers over the 96 hours preceding the onset of back pain.
    • Conditional logistic regression was used to estimate odds ratios (ORs) expressing the magnitude of increased risk with exposure to each trigger.
  • Results
    • Exposure to a range of physical and psychosocial triggers significantly increased the risk of a new onset of LBP; ORs ranged from 2.7 (moderate or vigorous physical activity) to 25.0 (distracted during an activity or task).
    • Age moderated the effect of exposure to heavy loads and sexual activity.
    • The ORs for heavy loads for people ages 20, 40, or 60 years were 13.6, 6.0, and 2.7, respectively.
    • The risk of developing back pain was greatest between 7:00 AM and noon.
  • Conclusion
    • Transient exposure to a number of modifiable physical and psychosocial triggers substantially increases risk for a new episode of LBP.
    • Triggers previously evaluated in occupational injury studies, but never in LBP, have been shown to significantly increase risk.
    • These results aid our understanding of the causes of LBP and can inform the development of new prevention approaches.
This study of almost 1000 patients, looked at acute low back pain (pain that comes and goes) as opposed to chronic pain that doesn't go away and is the first to look at how brief exposure to a range of modifiable triggers can lead to low back pain. The survey asked the participants about 12 physical or psychosocial factors they may have experienced in the 4 days before the back pain episode began. The results showed the odds of a new back pain episode was significantly linked to a number of triggers ranging from a nearly 3 times higher chance following moderate to vigorous physical activity, carrying out manual tasks involving awkward postures increases the risk of triggering acute low back pain by eight times, and being distracted during an activity increased risk by 25 times.  Age was also a factor, with younger people more likely to suffer an acute episode of pain after lifting (likely due to older people choosing not to lift as many heavy loads.  The risk of injury was highest in the morning between 7 AM and noon. What can we learn from this? Paying attention to what you are doing is very important when lifting and performing activities using your back. Avoid awkward positions when lifting. Move your furniture in the afternoon. Maybe the best advice is to ask for some help. 
Diet Coke May Be Injuring Your Heart
Soda consumptions associated with cardiac remodeling


The incidence of heart failure is increasing throughout the Western world. Cardiac remodeling is the process of structural and functional changes in the left ventricle in response to internal or external cardiovascular damage or influence by pathogenic risk factors, and is a precursor of clinical heart failure. This study found that consumers of soda and diet soda had higher body weight, left ventricular mass (LVM) and left atrial dimension (LAD) which are signs of cardiac remodeling.    

Summary of findings  

  • Objective
    • Diet soda consumption increases cardiometabolic risk.
    • The aim of this investigation was to assess the relations between self-reported soda consumption and subclinical cardiac remodeling.
  • Methods
    • We assessed the relations between self-reported soda consumption and left ventricular mass (LVM) and left atrial dimension (LAD) (both standardized within sex) in a sample of middle-aged attendees from the Framingham Heart Offspring cohort examination 5 and 6.

  • Results
    • The overall mean age was 55 years and 59% of the participants were women.

    • Compared to non-consumers (n = 1010), soda consumers (n = 3192) had greater body weight (mean 86 vs. 82 kg among men, and 70 vs. 67 kg among women).

    • Compared with non-consumers, age- and height-adjusted LAD was increased (standard deviation units) among soda consumers by 0.15 standard error 0.042, (p < 0.001) for those drinking > 0-7 diet soda (n = 1023), − 0.010 (0.043, p = 0.82) for people drinking > 0-7 regular soda (n = 907), 0.22 (0.057, p < 0.0001) for individuals consuming > 7 diet soda (n = 372), and 0.20 (0.092, p = 0.034) for participants drinking > 7 regular soda (n = 116) per week.

    • LVM was increased among participants consuming diet soda (p < 0.05), but not in regular soda consumers (p > 0.05).

    • Upon adjustment for weight, however, all aforementioned associations were attenuated.

  • Conclusion
    • The observed associations between soda consumption and LAD or LVM were likely related to the greater body weight of soda drinkers relative to non-drinkers.

Current efforts aim to identify heart failure at its earliest and preclinical stages in order to begin treatment and prevent deterioration before the symptoms escalate. Although this study found that increased body weight in the soda drinkers (both regular and diet soda) likely caused the increase in cardiac remodeling, it would make sense to eliminate soda from our diets. At a minimum, soda drinkers have higher body weights. Due to this increased body weight, they have more heart changes that could potentially lead to heart failure in the future. Looks like it is time to put down the Diet Coke.  


Association of Soda Consumption With Subclinical Cardiac Remodeling in the Framingham Heart Study Metab. Clin. Exp. 2015 Feb 01;64(2)208-212, C Andersson, L Sullivan, EJ Benjamin, J Aragam, P Jacques, S Cheng, RS Vasan  

Exercise: Can There Be Too Much of a Good Thing?
Dose of jogging and long-term mortality women jogging


What is the optimum amount of exercise? How hard should I exercise? What's the best type of exercise? These are all questions I field frequently. This study, from the Journal of the American College of Cardiology, is part of the Copenhagen Heart Study may help to answer these questions. This part of the study followed over 1000 healthy joggers for 12 years. Their findings were interesting. They found a decrease in mortality between moderate joggers and sedentary people which we would all expect. However, they also found an increase in mortality for the highest level joggers, which may not have been expected, suggesting that there is possibly a level of "too much" jogging.

Summary of findings:  

  • Background

    • People who are physically active have at least a 30% lower risk of death during follow-up compared with those who are inactive. However, the ideal dose of exercise for improving longevity is uncertain.

  • Objectives
    • The aim of this study was to investigate the association between jogging and long-term, all-cause mortality by focusing specifically on the effects of pace, quantity, and frequency of jogging.

  • Methods
    • As part of the Copenhagen City Heart Study, 1,098 healthy joggers and 3,950 healthy nonjoggers have been prospectively followed up since 2001. Cox proportional hazards regression analysis was performed with age as the underlying time scale and delayed entry.

  • Results
    • Compared with sedentary nonjoggers, 1 to 2.4 h of jogging per week was associated with the lowest mortality (multivariable hazard ratio [HR]: 0.29; 95% confidence interval [CI]: 0.11 to 0.80).

    • The optimal frequency of jogging was 2 to 3 times per week (HR: 0.32; 95% CI: 0.15 to 0.69) or ≤1 time per week (HR: 0.29; 95% CI: 0.12 to 0.72).

    • The optimal pace was slow (HR: 0.51; 95% CI: 0.24 to 1.10) or average (HR: 0.38; 95% CI: 0.22 to 0.66).

    • The joggers were divided into light, moderate, and strenuous joggers. The lowest HR for mortality was found in light joggers (HR: 0.22; 95% CI: 0.10 to 0.47), followed by moderate joggers (HR: 0.66; 95% CI: 0.32 to 1.38) and strenuous joggers (HR: 1.97; 95% CI: 0.48 to 8.14).

  • Conclusions
    • The findings suggest a U-shaped association between all-cause mortality and dose of jogging as calibrated by pace, quantity, and frequency of jogging. Light and moderate joggers have lower mortality than sedentary nonjoggers, whereas strenuous joggers have a mortality rate not statistically different from that of the sedentary group.

Exercise is a key component of optimum health. The question is whether or not you can get too much of this good thing. This study looked at only jogging as an exercise. It excluded people doing other types of exercise. They found that the lowest level of mortality was in the group that jogged between 1-2.5 hours weekly over 2-3 sessions/week at a moderate pace (12 min/mile). A weakness of this study is that there were very small numbers of deaths in the higher level jogging groups (2.5-4 hrs/week and >4 hours/week) which could account for the difference. Given the evidence from other studies showing increased coronary artery calcification in high level marathoners, it seems that there may be an upper end of exercise intensity or duration that is no longer beneficial, but rather harmful. Previous studies have also shown that well-trained athletes don't have negative effects from somewhat more vigorous exercise. So what is the take home lesson? There seems to be a great deal of smoke around the upper ends of exercise. This makes me thing that there likely is a level of exercise that could be detrimental. This study didn't look at other exercises such as biking, swimming or weight training so we don't know how those people fared. The good news is that getting some moderate exercise weekly through jogging is definitely beneficial. I think that shorter, more intense bouts of exercise are likely beneficial as well for more well-trained exercisers.   
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. 


Acute back pain is something we will all likely experience. It's good to keep in mind some of the things that can help us prevent this. Remember to pay attention to what you are doing when lifting and avoid awkward positions.   

There are just more and more reasons to give up soda. This month's article just reinforces this fact. Remember, no one ever died of a Pepsi deficiency...

As an avid exerciser and athlete, it's hard to get out of the "more is better philosophy". It does seem that there is more medical literature supporting the idea that perhaps there is some truth to "all things in moderation".  


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.