February Newsletter
In This Issue
Can Food Cause Pain?
Being Slim Isn't Enough
An Appetizer That Lowers Blood Sugar
A Better 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. This has been a crazy month for me as I racked up some frequent flier miles. First it was off to Mammoth, CA for the USSA Grand Prix. This was an Olympic qualifying event for the US Freeskiing and US Snowboarding athletes as they prepare for next year's Olympic Games in Pyeongchang, South Korea. The weather was challenging but we had a great competition with gold medalists Shaun White and Kelly Clark coming out on top for the snowboarders. Then it was off to Phoenix for the opening of Spring Training, New Orleans for the NBA All-Star game and finally back to Phoenix. It was a lot of fun, but I have to say it's nice to sleep in my own bed again. 

The articles this month have a common theme around inflammation and prediabetes which are closely related. The first article looks at how we can use our diet to reduce our pain through an anti-inflammatory diet. The second shows us how being 'normal' body weight isn't enough to protect us from prediabetes, a condition which puts us at higher risk of not just diabetes, but also heart disease, kidney disease, eye disease and dementia. The third article shows how a low calorie "appetizer" before meals may help to blunt our blood sugar response after eating. Thanks for reading!   

Click on the links the the left to check out our newly redesigned  web site ...
Can Food Cause Pain? 
What you eat influences your pain level          Mediterranean diet
An association between obesity and chronic pain has been noted previously, but does the type of foods we eat influence our level of pain? This study, from the journal Pain, evaluated weight, eating patterns, and pain perception. Participants ranging in age from 20-78 years old were given the Health Eating Index (HEI) which is scored on a 0-100 scale with 100 being the healthiest diet reflecting foods that are considered anti-inflammatory such as fish, nuts, plant proteins, and vegetables. Inflammatory foods can increase arachidonic acid which is part of the inflammatory cascade. Subjects with the highest HEI scores had the lowest pain scores after factoring out other contributing factors. It appears your diet can influence your pain levels. 
  • Prior studies have documented an association of obesity with chronic pain, but the mechanism explaining the association remains unknown. This study evaluated the degree to which dietary intake of foods with anti-inflammatory effects mediates the relationship of body fat to body pain. Ninety-eight community-residing healthy adults (60% women; mean age = 43.2 ± 15.3 years; range: 20-78 years) participated in a home-based study of home environment, food-related behaviors, health, and adiposity. During a 3-hour home visit evaluation, 3 measures of body fat were collected, including height and weight for calculation of body mass index (BMI). Participants also completed a 24-hour food recall interview and self-report measures of bodily pain (BP; BP subscale from the Medical Outcomes Study Short Form-36) and psychological distress (Hospital Anxiety and Depression Scale). Quality of dietary intake was rated using the Healthy Eating Index-2010. Mediation models were conducted with the PROCESS macro in SAS 9.3. Mean BMI was consistent with obesity (30.4 ± 7.8; range: 18.2-53.3), and BP values (73.2 ± 22.1; range: 0-100) and dietary intake quality (59.4 ± 15.5; range: 26.8-88.1) were consistent with population norms. Modeling in PROCESS revealed that Healthy Eating Index-2010 scores mediated the relationship between BMI and BP (bindirect = -0.34, 95% confidence interval = -0.68 to -0.13). The mediation model remained significant when controlling for biomechanical factors (arthritis/joint pain), medication use, psychological distress, age, and education, and models remained significant using the other 2 body fat measures. Thus, the data indicate that dietary intake of foods with anti-inflammatory effects mediates the relationship of body fat to body pain in healthy men and women.

It's all about the inflammation! My patients hear me say this all the time. This study looked at pain levels in the study group as related to diet. After factoring out cofounders a significant relationship was noted between pain levels and levels of inflammatory foods. If you eat more inflammatory foods, you will likely have more pain. If you are having pain, it makes sense to consider significant dietary changes to reduce inflammation. Remember, inflammation does not only cause joint and muscle pain, it is also linked to other chronic diseases including heart disease, cancer, and dementia. Many of the problems our bodies have with inflammation are not visible or even felt. This is why it is important for EVERYONE to consider eating an anti-inflammatory diet. What wasn't mentioned specifically in the abstract are some of the most inflammatory things of all, sugar and processed starches. Here is a chart looking at some of the inflammation ratings of various foods. While this isn't the end-all, it is a nice thing to look at to get an idea what you are eating. What you will notice is that the simple carbohydrates (wheat flour, rice, pasta) are some of the most inflammatory foods while foods high in omega 3 (salmon, tuna), the green leafy vegetables, acerola cherries, and some spices (ginger, turmeric) are the most anti-inflammatory. The simple take home point is to eliminate as much sugar and starch from your diet and substitute vegetables, cold water fish, grass-fed beef, monounsaturated fats (avocado, olive oil), along with berries and cherries. 
Being Slim Isn't Enough
Sedentary lifestyle linked to prediabetes, even in healthy-weight adults
watching TV

Prediabetes is impaired glucose tolerance without having diabetes. Often times an elevated fasting blood glucose is noted or if a hemoglobin A1c is checked, it will be > 5.7 but less than 6.1. Inactivity is associated with greater risk of prediabetes and diabetes even in people who are deemed to be healthy weight. This study, from the American Journal of Preventive Medicine, looked at people with BMI in the 'healthy' range (18.5-25) and found that those with a sedentary lifestyle were more likely than active people to have a hemoglobin A1c > 5.7. Almost 25% of all inactive people and over 40% of people age 45 and older fit the definition of prediabetes or diabetes which was double the rate of high activity people. 
  • Introduction:  Physical activity has been linked to prevention and treatment of prediabetes and diabetes in overweight and obese adults. This study examines the relationship between low physical activity levels and risk of abnormal blood glucose (prediabetes or undiagnosed diabetes) in healthy weight adults.
  • Methods:  Data from the 2014 Health Survey for England were analyzed in July 2016, focusing on adults with a BMI ≥18.5 and <25 who had never been diagnosed with diabetes (N=1,153). Abnormal blood glucose was defined as hemoglobin A1c ≥5.7. Physical activity was measured through the International Physical Activity Questionnaire. Bivariate analyses and Poisson models were conducted on the effect of physical activity on abnormal blood glucose, controlling for age, sex, waist to hip ratio, sitting time, age X physical activity interaction, sex X physical activity, and race. 
  • Results:  Abnormal blood glucose was detected in 23.7% of individuals with low activity levels, 14.8% of those with medium activity levels, and 12.2% of those with high activity levels (p<0.003). Similarly, 25.4% of inactive individuals (physically active for <30 minutes per week) were more likely to have abnormal blood glucose levels than active individuals (13.4%, p<0.0001). Higher physical activity was associated with a lower likelihood of abnormal blood glucose in an adjusted Poisson regression. 
  • Conclusions:  Among healthy weight adults, low physical activity levels are significantly associated with abnormal blood glucose (prediabetes and undiagnosed diabetes). These findings suggest that healthy weight individuals may benefit from physical exercise.

Prediabetes is associated with the simultaneous presence of insulin resistance and B-cell
dysfunction, abnormalities that start before glucose changes are detectable. According to an American Diabetes Association expert panel, up to 70% of individuals with prediabetes will eventually develop diabetes and between 5-10% of people with prediabetes will progress to diabetes annually. This is a huge problem in the US and around the world with projections of over 470 million people having prediabetes by 2030. 
Prediabetes has been associated with early forms of nephropathy, chronic kidney disease, small fibre neuropathy, diabetic retinopathy, and increased risk of macrovascular disease. For prediabetic individuals, lifestyle modification is the cornerstone of diabetes prevention with evidence of a 40%-70% relative risk reduction. From this study, one cornerstone of prevention AND treatment of this condition is physical activity. Those who were the most active cut their risk of prediabetes in half. In case you needed more motivation, prediabetes, high insulin levels and diabetes are very inflammatory, which explains why diabetics have more pain, more heart disease, and higher rates of dementia. So let's get moving!

An Appetizer That Lowers Blood Sugar
Almond "appetizer" reduces post meal blood sugar
This study, recently published in the Journal of the American Board of Family Medicine,  looked at people who had prediabetes and underwent a glucose tolerance test with and without an almond appetizer (approximately 12 almonds). They found that after the almonds the glucose was almost 20% lower as compared to no almonds. 
  • Background: The extent to which glucose intolerance can be acutely improved with dietary modification is unclear. The purpose of this study was to test the effect of ingesting a low-calorie almond preload ("appetizer") 30 minutes before oral glucose tolerance testing in glucose-intolerant individuals without diabetes. 
  • Methods: Twenty adults with prediabetes or isolated 1-hour glucose ≥160 mg/dL underwent 2 fasting oral glucose tolerance tests (GTTs)-1 standard GTT and 1 GTT 30 minutes after eating a half ounce (12) of dry-roasted almonds. Fourteen participants met 1 or more prediabetes diagnostic criteria; 6 had only elevated 1-hour glucose ≥160 mg/dL. 
  • Results: The mean 1-hour plasma glucose after the almond preload was 37.1 mg/dL (19.4%) lower (154.6 vs 191.7; P < .001) than in the standard GTT. The almond preload reduced the area under the glucose curve by 15.5% (P < .001). Eight individuals had a marked hypoglycemic effect (glucose reduced by 45 to 110 mg/dL); 4 had a moderate hypoglycemic effect (22-32 mg/dL). 
  • Conclusion: A low-calorie almond "appetizer" showed promise as an option for decreasing postprandial hyperglycemia in individuals with prediabetes or isolated 1-hour postprandial hyperglycemia. Further study is needed to confirm and refine the role of such a premeal appetizer in the self-care of prediabetes.                

In this study, a low calorie "appetizer" prior to a glucose load lowered the extend of the blood sugar rise. This may be a helpful adjunct for some people to lower their blood sugars. Keep in mind that in the study they used dry, roasted almonds (I much prefer raw for more health benefits) and that they ate 12 almonds (around 80 calories). A few months ago I outlined the benefits of drinking a glass of water before meals to help with weight loss. Perhaps adding a small "appetizer" of preferably raw almonds and a big glass of water may be of further benefit for those of us trying to control our weight and avoid prediabetes. Adding increased physical activity during the day and an overall anti-inflammatory diet would greatly reduce our risk. 
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.