February Newsletter
In This Issue
Gout Treatment Lowers Risk of Heart Attack and Stroke
Less Heartburn, More Dementia?
Exercise Adds Years to Your Brain
A New 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 know February is a short month, but wow did this one fly! I just got back from Spring Training. It was great to get into some warm weather and enjoy the start of the baseball season. Nothing like the crack of bats on balls to remind you that summer and warm weather is just around the corner!



Heart disease is the #1 cause of death in the US and about 735,000 people have heart attacks each year. Someone in the US has a stroke every 40 seconds and strokes cause 1 in 20 deaths in the United States. It is the leading preventable cause of disability. Hypertension is one of the major risk factors of both of these diseases. An inexpensive medication ($3-10/month) may be able to cut the risk of heart attack and stroke by almost 50% for people who have high blood pressure. Check out the first article for the details and be sure to read my analysis at the end for natural ways to lower your risk. 


My readers know that studies showing ways to potentially prevent dementia are common in my newsletter. This month I am looking at a couple of studies in this realm. The first study explores the link between a common class of medication (sold over the counter) and the risk of dementia. 


The second study looking at brain health this month compared fitness levels over time and the the level of brain atrophy. Your muscles are not the only thing that you may lose if you don't exercise!


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

Gout Treatment Lowers Risk of Heart Attack and Stroke
Allopurinol decreases risk in people with high blood pressure. 
Allopurinol is the most common medication used for gout. A new study published in the journal Hypertension suggests that this old medication may possibly significantly reduce the risk of heart attacks and strokes in people with high blood pressure.  
Summary of findings:
  • Allopurinol lowers blood pressure in adolescents and has other vasoprotective effects. Whether similar benefits occur in older individuals remains unclear. We hypothesized that allopurinol is associated with improved cardiovascular outcomes in older adults with hypertension. Data from the United Kingdom Clinical Research Practice Datalink were used. Multivariate Cox-proportional hazard models were applied to estimate hazard ratios for stroke and cardiac events (defined as myocardial infarction or acute coronary syndrome) associated with allopurinol use over a 10-year period in adults aged >65 years with hypertension. A propensity-matched design was used to reduce potential for confounding. Allopurinol exposure was a time-dependent variable and was defined as any exposure and then as high (≥300 mg daily) or low-dose exposure. A total of 2032 allopurinol-exposed patients and 2032 matched nonexposed patients were studied. Allopurinol use was associated with a significantly lower risk of both stroke (hazard ratio, 0.50; 95% confidence interval, 0.32-0.80) and cardiac events (hazard ratio, 0.61; 95% confidence interval, 0.43-0.87) than nonexposed control patients. In exposed patients, high-dose treatment with allopurinol (n=1052) was associated with a significantly lower risk of both stroke (hazard ratio, 0.58; 95% confidence interval, 0.36-0.94) and cardiac events (hazard ratio, 0.65; 95% confidence interval, 0.46-0.93) than low-dose treatment (n=980). Allopurinol use is associated with lower rates of stroke and cardiac events in older adults with hypertension, particularly at higher doses. Prospective clinical trials are needed to evaluate whether allopurinol improves cardiovascular outcomes in adults with hypertension.

Over 85 million Americans are living with cardiovascular disease or the after-effects of stroke. Obviously, this is a huge issue for our population and health care system. It is estimated that these diseases cost more the $320 billion in direct and indirect costs to our country. Anything that could lower our risk for these diseases could be a huge breakthrough. This study compared the 10-year risk of heart attack and stroke in over 2000 allopurinol treated and 2000 non treated hypertensive adults over the age of 65. Allopurinol was associated with over 50% reduction in the relative risk of both cardiac events and stroke. Based on this, it appears uric acid (which allopurinol lowers and the main cause of gout) is a risk factor for heart disease and stroke. In a separate study, lowering uric acid independently lowered blood pressure. It seems that lowering uric acid is a good thing for people with hypertension to lower their risk of further problems and could possibly be helpful in even lowering their blood pressure! All this from a medication that costs between $3-10/month. 

Now, I'm not saying that we should all be on allopurinol. There is not enough data for this yet. However, it certainly appears that lowering uric acid is a good thing. This is the reason I chose to review this article. We can lower our uric acid naturally through our diet and lifestyle. 

Some simple ways to lower uric acid: 
  • weight loss: losing weight lowers uric acid levels
  • drink more water (8-16 glasses), remember from a previous newsletter that 16 oz of water prior to a meal help with weight loss too!
  • add lemon juice to your water
  • more vegetables and fruits, especially apples, pears, oranges, blueberries, strawberries, tomatoes, and bell peppers. High fiber foods such as help to lower the uric acid levels
  • eat cherries
  • dairy products may be beneficial
  • lower red meat and avoid organ meats
  • avoid sweets, white bread, processed foods, sugar sweetened beverages and high-fructose corn syrup
  • avoid beer (sorry). The metabolism of alcohol is thought to increase uric acid production. Wine may be ok. 
  • consider 500 mg of vitamin C daily
After reading these tips, you can see that this is very close to a Mediterranean type of diet. 

Less Heartburn, More Dementia? 
Heartburn medication may increase risk of dementia

Proton pump inhibitors (PPI), usually taken for heartburn, are the third highest selling drug category in the United States, accounting for over 113 million prescriptions annually and are now sold over-the-counter as well. These medications (including Prilosec, Nexium, Prevacid, Aciphex and Protonix) account for over $14 billion in sales annually. While initially intended for short-term use, many people stay on these medications indefinitely. This study, from JAMA Neurology, showed a significantly increased risk of dementia in people taking these medications.   

Summary of findings      
  • Importance: Medications that influence the risk of dementia in the elderly can be relevant for dementia prevention. Proton pump inhibitors (PPIs) are widely used for the treatment of gastrointestinal diseases but have also been shown to be potentially involved in cognitive decline.  
  • Objective: To examine the association between the use of PPIs and the risk of incident dementia in the elderly.  
  • Design, Setting, and Participants: We conducted a prospective cohort study using observational data from 2004 to 2011, derived from the largest German statutory health insurer, Allgemeine Ortskrankenkassen (AOK). Data on inpatient and outpatient diagnoses (coded by the German modification of the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision) and drug prescriptions (categorized according to the Anatomical Therapeutic Chemical Classification System) were available on a quarterly basis. Data analysis was performed from August to November 2015.
  • Exposures: Prescription of omeprazole, pantoprazole, lansoprazole, esomeprazole, or rabeprazole.
  • Main Outcomes and Measures: The main outcome was a diagnosis of incident dementia coded by the German modification of the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision. The association between PPI use and dementia was analyzed using time-dependent Cox regression. The model was adjusted for potential confounding factors, including age, sex, comorbidities, and polypharmacy.
  • Results: A total of 73,679 participants 75 years of age or older and free of dementia at baseline were analyzed. The patients receiving regular PPI medication (n = 2950; mean [SD] age, 83.8 [5.4] years; 77.9% female) had a significantly increased risk of incident dementia compared with the patients not receiving PPI medication (n = 70,729; mean [SD] age, 83.0 [5.6] years; 73.6% female) (hazard ratio, 1.44 [95% CI, 1.36-1.52]; P < .001).
  • Conclusions and Relevance: The avoidance of PPI medication may prevent the development of dementia. This finding is supported by recent pharmacoepidemiological analyses on primary data and is in line with mouse models in which the use of PPIs increased the levels of β-amyloid in the brains of mice. Randomized, prospective clinical trials are needed to examine this connection in more detail.

This is a database study with 73,000 participants and compared 2950 people taking PPI with people not taking PPI and found a significant (almost 50%) increased risk of dementia in the group taking the medication. The big question is what is the potential mechanism? In mice, PPI increase beta amyloid in the brain which has been linked to Alzheimer's dementia. Additionally, they may interfere with absorption of some vitamins or minerals such as vitamin B12 which could contribute. Overall, this adds to the growing data showing ill effects of this class of medication. We already have seen increased risk of heart attacks and infectious colitis from these medications (see previous newletters). If you are taking one of these medications daily, it may be time to see about possibly getting off of it. If you have occasional heartburn and are looking for something to take beyond TUMS, consider ranitidine (Zantac) or famotidine (Pepcid). 

Exercise Adds Years to Your Brain
Poor fitness leads to less brain volume
We know that lack of exercise can lead to physical problems. But what if it can contribute to dementia? This study, from the journal Neurology, followed patients over almost 20 years. Those who had lower fitness at the onset of the study, showed more loss of brain volume than the more fit subjects.  

Summary of findings:   
  • Objective: To determine whether poor cardiovascular (CV) fitness and exaggerated exercise blood pressure (BP) and heart rate (HR) were associated with worse brain morphology in later life.
  • Methods: Framingham Offspring participants (n = 1,094, 53.9% female) free from dementia and CV disease (CVD) underwent an exercise treadmill test at a mean age of 40 ± 9 years. A second treadmill test and MRI scans of the brain were administered 2 decades later at mean age of 58 ± 8 years
  • Results: Poor CV fitness and greater diastolic BP and HR response to exercise at baseline were associated with a smaller total cerebral brain volume (TCBV) almost 2 decades later (all p < 0.05) in multivariable adjusted models; the effect of 1 SD lower fitness was equivalent to approximately 1 additional year of brain aging in individuals free of CVD. In participants with prehypertension or hypertension at baseline, exercise systolic BP was also associated with smaller TCBV (p < 0.05).
  • Conclusion: Our results suggest that lower CV fitness and exaggerated exercise BP and HR responses in middle-aged adults are associated with smaller brain volume nearly 2 decades later. Promotion of midlife CV fitness may be an important step towards ensuring healthy brain aging.                   


This study of over 1000 subjects demonstrated brain volume loss equivalent to one additional year of aging per standard deviation of exercise. So I guess it's true. Exercise does make you smarter, or at least you have more brain volume!
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. 


Heart attacks and strokes are a major cause of death and disability. We may someday use allopurinol to help reduce this risk but we can all do things through our diet and lifestyle to lower our uric acid levels which will lower our risk for these terrible diseases. 


Dementia is another chronic disease I'm sure we all want to avoid. It appears that proton pump inhibitors may potentially contribute to this. While these are good medications for specific conditions, we should look at ways to decrease our exposure to them whenever possible. 


More data for the benefits of exercise and physical activity. Not only does it keep our bodies healthy, it looks like it will help to keep our brains healthy (or at least help our brain volumes). 


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.