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July Newsletter
In This Issue
Fatty Liver Could Be Sign of Coming Diabetes
Early CPR Improves Survival
The Facebook Phenomenon...
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 can never believe how fast our summer is going. August always sneaks up on me. Thanks to all of you for the feedback last month. I think we could all identify with the annoying Facebook friend. Additionally, I got nice feedback on the CPR article. It's a skill that is easily learned and could save a life. I was also turned on to a device invented here in Milwaukee to assist with CPR. 


The first article this month looks at a common finding, non-alcoholic fatty liver. When ordering routine lab work, it isn't uncommon for people to have some mild elevations. This study shows that this finding may have significant health consequences in the future. Thankfully, it can also be easily cured.  


Heart failure is becoming more and more common. The second article will give you simple ways to reduce your chance of getting this disease by around 50%. Definitely worth a read. 


Finally, I often advise people with some cardiac risk factors to get a heart scan. When asked what a 0 score meant, I couldn't give a definite answer. The third study answers this question. 


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

Fatty Liver Could Be Sign of Coming Diabetes

Nonalcoholic fatty liver disease improvement is associated with lowered risk of diabetes
Fatty liver is a common finding. It is often manifested by slight increases in liver functions on routine blood work and further imaging (ultrasound or CT scan) will often reveal this finding, which is different than liver function elevations due to infectious hepatitis, medications, or high alcohol intake. This study, from the journal Diabetes Care, demonstrated a positive correlation between the finding of fatty liver and subsequent development of diabetes. When patients lost weight (thus eliminating fatty liver) their risk of diabetes decreased by 64%. 

Summary of findings:

  • OBJECTIVE: Only a few studies have evaluated the long-term effects of nonalcoholic fatty liver disease (NAFLD) on type 2 diabetes mellitus (T2DM), and none have examined whether NAFLD improvement reduces T2DM incidence. We investigated the association between NAFLD improvement and T2DM incidence. 
  • RESEARCH DESIGN AND METHODS: Between 2000 and 2012, 4,604 participants who underwent a health check twice with >10 years between were enrolled. Exclusion criteria were positive hepatitis B surface antigen, positive hepatitis C antibody, ethanol intake >20 g/day, and diabetes. The 3,074 eligible participants were divided into an NAFLD group (n = 728) and a non-NAFLD group (n = 2,346) according to ultrasonography-detected fatty liver. The NAFLD group was categorized into an improved group (n = 110) and a sustained NAFLD group (n = 618) based on fatty liver disappearance at the second visit. Incident T2DM odds ratios (ORs) were estimated by logistic regression models adjusted for age, sex, BMI, impaired fasting glucose, family history of diabetes, dyslipidemia, hypertension, and physical exercise. 
  • RESULTS: T2DM occurred in 117 participants (16.1%) in the NAFLD group and 72 (3.1%) in the non-NAFLD group. NAFLD at baseline was associated with T2DM incidence (multivariate OR 2.37 [95% CI 1.60-3.52]). T2DM occurred in 7 participants (6.4%) in the improved group and in 110 (17.8%) in the sustained NAFLD group. NAFLD improvement was associated with reduced T2DM incidence (multivariate OR 0.27 [95% CI 0.12-0.61]). 
  • CONCLUSIONS: NAFLD improvement is associated with T2DM incidence reduction.
This is a 10 year retrospective study comparing the incidence of type 2 diabetes in people who improved their non-alcoholic liver disease (NAFL) and those who did not. Of those who improved, 6.4% went on to develop diabetes, while 17.8% of those who didn't improve went on to diabetes. The mechanism of development of both fatty liver and diabetes is too much sugar. When we eat too much sugar (or starches converted easily to sugar), our liver makes more triglycerides to store the extra sugar which accumulates in the liver as fatty deposits. This same excessive sugar causes insulin resistance which promotes inflammation in the body and leads to not only to diabetes but other chronic diseases (heart disease, cancer, etc). So we can see that there are two separate mechanisms leading to the same result; diabetes and chronic disease. What is the solution? It's rather simple: consume less sugar (and starch). A 10% loss in body weight has been associated with a 97% resolution of fatty liver. Yes, you read that correctly. An 8 lb weight loss can reduce risk of diabetes by 58% in people with prediabetes. Foods rich in resveratrol (berries, grapes, pistachios, red wine) may be protective for the development of NAFLD. The Mediterranean diet tends to be high in this. Finally, in people who can't lose weight, we could consider a medication. Metformin has been shown to prevent the progression to diabetes in those with prediabetes. Obviously, my preference is to do this through diet and exercise. If you have mildly elevated liver function tests on routine blood work, it may be a call for action. Don't miss it!
How to Cut Your Risk of Heart Failure By Half
Lifestyle factors play key role


Heart failure is a growing problem in our aging population and is a leading cause of hospitalizations in people over age 65. 
Over 5 million people have heart failure and $39.2 billion was spent on heart failure in the US in 2010. 
Long-term prognosis remains poor, despite advances in treatments. Therefore, prevention of the development of heart failure is key. This study, from the Journal of the American College of Cardiology, demonstrates that five factors can reduce risk of developing heart failure by half. 

Summary of findings   

  • Objectives: The goal of this study was to determine the relative contribution of major lifestyle factors on the development of heart failure (HF) in older adults.  

  • Background: HF incurs high morbidity, mortality, and health care costs among adults ≥65 years of age, which is the most rapidly growing segment of the U.S. population.  
  • Methods: We prospectively investigated separate and combined associations of lifestyle risk factors with incident HF (1,380 cases) over 21.5 years among 4,490 men and women in the Cardiovascular Health Study, which is a community-based cohort of older adults. Lifestyle factors included 4 dietary patterns (Alternative Healthy Eating Index, Dietary Approaches to Stop Hypertension, an American Heart Association 2020 dietary goals score, and a Biologic pattern, which was constructed using previous knowledge of cardiovascular disease dietary risk factors), 4 physical activity metrics (exercise intensity, walking pace, energy expended in leisure activity, and walking distance), alcohol intake, smoking, and obesity.   
  • Results: No dietary pattern was associated with developing HF (p > 0.05). Walking pace and leisure activity were associated with a 26% and 22% lower risk of HF, respectively (pace >3 mph vs. <2 mph; hazard ratio [HR]: 0.74; 95% confidence interval [CI]: 0.63 to 0.86; leisure activity ≥845 kcal/week vs. <845 kcal/week; HR: 0.78; 95% CI: 0.69 to 0.87). Modest alcohol intake, maintaining a body mass index <30 kg/m2, and not smoking were also independently associated with a lower risk of HF. Participants with ≥4 healthy lifestyle factors had a 45% (HR: 0.55; 95% CI: 0.42 to 0.74) lower risk of HF. Heterogeneity by age, sex, cardiovascular disease, hypertension medication use, and diabetes was not observed.   
  • Conclusions: Among older U.S. adults, physical activity, modest alcohol intake, avoiding obesity, and not smoking, but not dietary patterns, were associated with a lower risk of HF.
This study of 4,490 men and women over age 65 followed for up to 21 years, clearly demonstrates the importance of lifestyle habits in the maintenance of good health. Older people who walked briskly, were moderately active with their free time, drank alcohol moderately, didn't smoke, and avoided obesity were half as likely to develop heart failure as those who had 0-1 of the behaviors. The physical activity didn't need to be strenuous so see the benefits. Certainly, developing these habits earlier in life wouldn't hurt either.    

Del Gobbo LC, Kalantarian S, Imamura F, et al. Contribution of Major Lifestyle Risk Factors for Incident Heart Failure in Older Adults: The Cardiovascular Health Study. JCHF. 2015;3(7):520-528. doi:10.1016/j.jchf.2015.02.009.  

15-year Warranty Heart Scan
People with scores of 0 have 15 year warranty against mortality heart scan


I often recommend heart scans to evaluate risk in people who have risk factors or family history of heart disease. This study demonstrates a time period of the "warranty" as far as mortality for a heart scan of 0; 15 years. 

Summary of findings:  

  • Objectives: The aim of this study was to examine the long-term prognosis in asymptomatic individuals with a coronary artery calcium (CAC) score of 0 and its associated warranty period. 

  • Background:  Emerging evidence supports a CAC score of 0 as a favorable cardiovascular short-to intermediate-term prognostic factor. 

  • Methods: A total of 9,715 individuals undergoing CAC imaging were stratified by age, Framingham risk score (FRS), and National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) categories and followed for a mean of 14.6 years (range 12.9 to 16.8 years). Cox regression, area under the receiver-operating characteristic curve, and net reclassification information were used to assess all-cause mortality, discrimination, and reclassification of a CAC score of 0 compared with the FRS and NCEP ATP III, respectively. A warranty period was pre-defined as <1% annual mortality rate. Vascular age was estimated by linear regression.

  • Results:  In 4,864 individuals with a baseline CAC score of 0 (mean age ± SD, 52.1 ± 10.8 years; 57.9% male), 229 deaths occurred. The warranty period of a CAC score of 0 was almost 15 years for individuals at low and intermediate risk with no significant differences regarding age and sex. A CAC score of 0 was associated with a vascular age of 1, 10, 20, and 30 years less than the chronological age of individuals between 50 and 59, 60 and 69, 70 and 79, and 80 years of age and older, respectively. The CAC score was the strongest predictor of death (hazard ratio: 2.67, 95% confidence interval: 2.29 to 3.11) that enabled discrimination and consistent reclassification beyond the FRS (area under the receiver-operating characteristic curve: 0.71 vs. 0.64, p < 0.001) and NCEP ATP III (area under the receiver-operating characteristic curve: 0.72 vs. 0.64, p < 0.001).   
  • Conclusions: A CAC score of 0 confers a 15-year warranty period against mortality in individuals at low to intermediate risk that is unaffected by age or sex. Furthermore, in individuals considered at high risk by clinical risk scores, a CAC score of 0 confers better survival than in individuals at low to intermediate risk but with any CAC score.
This study, from the Journal of the American College of Cardiology Cardiovascular Imaging shows what a heart scan score of 0 means. The authors followed 9,715 people over a mean of 14.6 years and found the annual mortality rate to be < 1%. This is unaffected by age or sex. If you have had a scan done and your score was 0, great news!
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. 


This months articles again demonstrate the importance of a healthy lifestyle in longevity but also in quality of life. It really is impossible to emphasize enough the importance of regular physical activity and making activity a part of your lifestyle. Additionally, a diet rich in vegetables and fruits, nuts, seeds and non-processed foods is incredibly important. Together, these can prevent or even cure many of the chronic diseases which affect our modern lives. 


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.