January Newsletter
In This Issue
When to Eat
But It's Only One!
A "New" Treatment for PTSD
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. We are in the middle of winter but it is sure an exciting time. The Brewers are making great moves which have excited the team and fan base with good reason. The Cubs are officially on notice and spring training can't come soon enough! The Bucks are on a roll as well with Giannis playing like the league MVP and Jabari Parker returning to action later this week. I just got back from the final Olympic Qualifier for the Freeski and Snowboard teams in Mammoth, California. What a great competition and I am excited to catch the action from PyeongChang. Watch for Kelly Clark in her 5th Olympics for snowboard halfpipe and Shaun White in his 4th. Seventeen year-old Chloe Kim is the favorite for the women and watch out for the Japanese men. David Wise and Maddie Bowman will try to repeat as Gold Medalists in Freeski halfpipe but will be chased by their teammates.   

The first article this month continues our exploration of best practices for eating. Last month we looked at the relationship between dietary patterns and long-term survival. This month we look at timing of our meals. When should we eat? Is it better to eat early or later? Continue reading for the answers. 

The number of people smoking one pack of cigarettes daily or more has thankfully decreased greatly over the past several years. This is great news. However, there are still a significant number of "social smokers", people who only smoke a few, often less than 5 cigarettes daily. This isn't a bid deal, right? Well, actually it is. The second article, from the journal BMJ, shows us that even a single cigarette daily can have major health implications. This also raises major concerns about potential risks of second hand smoke exposure. 

I watched the recent news coming out of Michigan with horror and outrage. To see complete breakdown of our system of protection for our girls and athletes was appalling. To have a doctor molesting children for years while teachers, coaches and administrators turned a blind eye can never happen again. Thinking about the trail of physical and emotional destruction he created made me think of the third article, which addresses post-traumatic stress disorder. Watching the strength of the girls who testified and spoke out against him was sad and inspiring at the same time. However, there are hundreds of other victims suffering in silence. Some have committed suicide. Any treatment that can benefit their recovery is welcomed and this article shows an old medication being used as a "new" treatment. . 

Click on the links the the left to check out our  web site ...
When to Eat
Eat earlier to lose weight
Our bodies have a natural rhythm to their functions. This naturally makes us more insulin sensitive earlier in the day and less insulin sensitive later in the day. This study proves this relationship. When subjects were given a glucose load at 8 AM and then compared findings when given the same load at 8 PM, they found that blood glucose readings were significantly higher at 8 PM than in the morning. This finding was also found even when eating a diet that shouldn't trigger large changes in blood glucose levels if the food was consumed at 8 PM or midnight as compared to first thing in the morning. 
  • BACKGROUND & AIMS:  Glucose metabolism is, in part, regulated by the circadian rhythm. Postprandial glucose response is exaggerated and insulin sensitivity is reduced at night compared with the morning. Sustained poor glucose tolerance may be related to the increased risk of type-2 diabetes mellitus and cardiovascular disease experienced by shift workers. Manipulation of meal type may be able to dampen such postprandial excursions. Therefore, the study's aim was to investigate postprandial glucose and insulin responses to a low glycemic index (GI) meal in the morning compared to night in healthy volunteers.
  • METHODS: An oral glucose tolerance test (OGTT), was undertaken to confirm diurnal glucose response. Participants consumed a glucose solution at 0800h (morning) and 2000h (evening). In a separate trial, participants consumed a low GI meal (3.3 MJ, 48% energy (E) from carbohydrate, 40%E from fat and 11%E from protein, 22 g fiber) at 0800h, 2000h and 0000h (midnight). Postprandial glucose and insulin were collected over 3 h. Incremental area under the curve (iAUC) was calculated and significance tested using Wilcoxon-signed rank. A p-value <0.05 was taken as significant.
  • RESULTS: In the OGTT (n = 10), postprandial glucose iAUC was higher in the evening compared to morning (p = 0.007). In the low GI meal trial (n = 9), postprandial glucose iAUC at evening and midnight were higher than the morning (p = 0.008, p = 0.021) but not significantly different between evening and midnight (p = 0.594). Postprandial insulin iAUC was also higher in the evening and at midnight compared to the morning (p = 0.008 for both).
  • CONCLUSIONS: The current study confirms that meal intake at night, even when comprised of low glycemic ingredients, contributes to higher glucose excursions and concomitantly greater insulin levels, compared with an equivalent meal in the morning. This demonstrates that meal timing has an effect on glucose metabolism, which can be observed from as early as 8pm and persists throughout the night. This identifies meal timing as an important modifiable risk factor for metabolic-related disease, which may have implications for high risk populations such as shift workers but also the general population.

This study shows that time of food intake matters. The same meal causes a different blood glucose response at 8 AM as compared to 8 PM or midnight. Our bodies have a circadian rhythm which promotes better insulin sensitivity and thus better glucose metabolism earlier in the day. So what does this mean for us? We are not programmed to eat at night. When we eat late at night, we will have a more sustained rise of our blood glucose, higher insulin levels and more fat storage. If we are trying to lose or maintain our weight, we should avoid eating after 7 PM and at least 2-3 hours prior to our bedtime. Additionally, we can consider longer periods of time between our last meal of the day and our first meal the following day. There is a term intermittent fasting, which refers to this type of eating pattern. A good start to this is having 12 hours between the last meal of the day and the first meal of the next day. For example, last meal completed by 7 PM and first meal the next day at 7 AM. There may be some benefits to longer period of fasting as well. My recommendation is to complete eating by 7 PM in the evening and likely wait until at least 7 AM for breakfast the following day. This is an easy way to help optimize insulin levels and reduce insulin resistance, which leads to a multitude of health problems. This is especially important for diabetics and people with prediabetes, but is useful for all of us trying to avoid the ill effects of insulin resistance. 

But It's Only One!
Even one cigarette a day seriously raises cardiovascular risk

There has been a shift from people smoking 20-25 cigarettes daily to only a few cigarettes daily. The view is that this is probably "good enough". From a cardiovascular perspective nothing is further from the truth. This study was based on 141 prospective cohort studies from 21 countries and regions that followed 5.6 million individuals for coronary heart disease and 7.3 million for stroke. It includes 110,000 new cases of CHD and 135,000 cases of stroke. The researchers found that over half the risk of heart disease and one-third the risk of stroke was observed from 1 cigarette daily. It appears the only way to decrease cardiovascular risk from smoking is to completely quit.  


  • Objective: To use the relation between cigarette consumption and cardiovascular disease to quantify the risk of coronary heart disease and stroke for light smoking (one to five cigarettes/day).
  • Design: Systematic review and meta-analysis.
  • Data sources: Medline 1946 to May 2015, with manual searches of references.
    Eligibility criteria for selecting studies Prospective cohort studies with at least 50 events, reporting hazard ratios or relative risks (both hereafter referred to as relative risk) compared with never smokers or age specific incidence in relation to risk of coronary heart disease or stroke.
  • Data extraction/synthesis: MOOSE guidelines were followed. For each study, the relative risk was estimated for smoking one, five, or 20 cigarettes per day by using regression modelling between risk and cigarette consumption. Relative risks were adjusted for at least age and often additional confounders. The main measure was the excess relative risk for smoking one cigarette per day (RR1_per_day−1) expressed as a proportion of that for smoking 20 cigarettes per day (RR20_per_day−1), expected to be about 5% assuming a linear relation between risk and consumption (as seen with lung cancer). The relative risks for one, five, and 20 cigarettes per day were also pooled across all studies in a random effects meta-analysis. Separate analyses were done for each combination of sex and disorder.
  • Results: The meta-analysis included 55 publications containing 141 cohort studies. Among men, the pooled relative risk for coronary heart disease was 1.48 for smoking one cigarette per day and 2.04 for 20 cigarettes per day, using all studies, but 1.74 and 2.27 among studies in which the relative risk had been adjusted for multiple confounders. Among women, the pooled relative risks were 1.57 and 2.84 for one and 20 cigarettes per day (or 2.19 and 3.95 using relative risks adjusted for multiple factors). Men who smoked one cigarette per day had 46% of the excess relative risk for smoking 20 cigarettes per day (53% using relative risks adjusted for multiple factors), and women had 31% of the excess risk (38% using relative risks adjusted for multiple factors). For stroke, the pooled relative risks for men were 1.25 and 1.64 for smoking one or 20 cigarettes per day (1.30 and 1.56 using relative risks adjusted for multiple factors). In women, the pooled relative risks were 1.31 and 2.16 for smoking one or 20 cigarettes per day (1.46 and 2.42 using relative risks adjusted for multiple factors). The excess risk for stroke associated with one cigarette per day (in relation to 20 cigarettes per day) was 41% for men and 34% for women (or 64% and 36% using relative risks adjusted  for multiple factors). Relative risks were generally higher among women than men.
  • Conclusions: Smoking only about one cigarette per day carries a risk of developing coronary heart disease and stroke much greater than expected: around half that for people who smoke 20 per day. No safe level of smoking exists for cardiovascular disease. Smokers should aim to quit instead of cutting down to significantly reduce their risk of these two common major disorders.    

The assumption going into this study was that people who cut their cigarette intake by 95% would decrease their risk of cardiovascular disease by a similar amount. However, men smoking just 1-2 cigarettes daily still had a 48-74% increase in the risk of coronary heart disease and women had a 57-119% increase. There was a 30% increase in risk of stroke in both sexes. A single cigarette daily accounted for over half the risk associated with smoking a pack daily (20 cigarettes) for heart disease and almost a third the risk of stroke! While this is a major concern for smokers, let's consider second hand smoke. Studies have shown that the effects of second hand smoke can be up to 80-90% of active smoking and the cardiovascular system, platelet and endothelial function, arterial stiffness, atherosclerosis, oxidative stress, inflammation, heart rate variability, energy metabolism, and increased infarct size is exquisitely sensitive to the toxins in secondhand smoke. There is no safe level of exposure to cigarette smoke. I hope this is a wake up call to "social smokers". Even small amounts of smoking carry large amounts of risk. 
A "New" Treatment for PTSD
Propranolol, an older medication appears to be helpful in treatment of post-traumatic stress disorder
Post-traumatic stress disorder (PTSD) is a  disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event. It can 
last months or years, with triggers that can bring back memories of the trauma accompanied by intense emotional and physical reactions.
Symptoms may include nightmares or unwanted memories of the trauma, avoidance of situations that bring back memories of the trauma, heightened reactions, anxiety, or depressed mood.

Multiple methods have been used with various levels of effectiveness. Currently, the best available evidence-based treatments, exposure therapy and cognitive processing therapy, produce only limited benefits. Like many problems in psychiatry, a multi-pronged approach is needed which includes psychotherapy and medications. Propranolol is a medication which has been used for cardiac conditions and sometimes used for stage fright. People taking it for anxiety provoking situations such as public speaking find it useful as it tends to blunt some of the symptoms of the situation (racing heart rate, sweaty palms, etc). This study, from the American Journal of Psychiatry, used a combination of propranolol prior to memory activating sessions. The researchers found significant reductions in objective measures of symptoms, greater than when the sessions were performed without the medication. 

  • Objective: The authors assessed the efficacy of trauma memory reactivation performed under the influence of propranolol, a noradrenergic beta-receptor blocker, as a putative reconsolidation blocker, in reducing symptoms of posttraumatic stress disorder (PTSD).
  • Method: This was a 6-week, double-blind, placebo-controlled, randomized clinical trial in 60 adults diagnosed with long-standing PTSD. Propranolol or placebo was administered 90 minutes before a brief memory reactivation session, once a week for 6 consecutive weeks. The hypothesis predicted a significant treatment effect of trauma reactivation with propranolol compared with trauma reactivation with placebo in reducing PTSD symptoms on both the Clinician-Administered PTSD Scale (CAPS) and the patient-rated PTSD Checklist-Specific (PCL-S) in an intention-to-treat analysis.
  • Results: The estimated group difference in posttreatment CAPS score, adjusted for pretreatment values (analysis of covariance), was a statistically significant 11.50. The within-group pre- to posttreatment effect sizes (Cohen's d) were 1.76 for propranolol and 1.25 for placebo. For the PCL-S, the mixed linear model's estimated time-by-group interaction yielded an average decrease of 2.43 points per week, for a total significant difference of 14.58 points above that of placebo. The pre- to posttreatment effect sizes were 2.74 for propranolol and 0.55 for placebo. Per protocol analyses for both outcomes yielded similar significant results.
  • Conclusions: Pre-reactivation propranolol, a treatment protocol suggested by reconsolidation theory, appears to be a novel and efficacious treatment for PTSD. Replication studies using a long-term follow-up in various trauma populations are required.

PTSD is a difficult to treat condition. People suffering from it have often endured severe physical or emotional trauma. This includes victims of abuse and our returning soldiers. Suicide rates are high for these individuals. Different types of psychotherapy and medications have been used but the condition can be quite resistant resulting in limited success. Using an old (an inexpensive) medication commonly used by people for stage fright may help the cognitive processing therapy be even more effective. I am glad to see another tool in the hands of the physicians and therapists treating the individuals suffering from this disorder and hope that it can be used successfully as they progress toward recovery. 

Reduction of PTSD Symptoms With Pre-Reactivation Propranolol Therapy: A Randomized Controlled Trial. American Journal of Psychiatry. Published online: January 12, 2018 .
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. 

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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.