July Newsletter
In This Issue
Kill Your TV
Are Long Work Hours Bad For Your Heart?
Shingles and Strokes
A Better 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. It seems like summer continues to pick up speed the further we get along. For me, July 4th starts the acceleration and the next thing I know it's sweater weather!  My daughter has done her first ride on her new 21 speed bike so I think some longer family bike rides are in store (maybe even some trails?).  I'm going to try to get outside and enjoy as many warm days and evenings as I can. Hopefully, you can do the same. 

The first article this month looks at something we all have in our homes that is a major risk factor for the development of intra-abdominal or visceral fat. This is the fat around our internal organs and it is a major risk factor for chronic disease. Check out the article to see how much risk you have. 

Atrial fibrillation is the most common heart arrhythmia and will affect 25% of us over our lifetimes. Last month we examined a delicious preventive strategy. This month we are looking at a significant risk factor and some ways to avoid that risk. 

Shingles, or herpes zoster is generally considered an annoying condition. But could it be a major risk factor for a stroke?

Click on the links the the left to check out our web site ...
Kill Your TV
Watching television is independent risk factor for visceral fat             
Intra-abdominal fat, also called visceral fat, is located within the abdominal cavity and surrounds the organs. This type of fat differs from subcutaneous fat, which is located directly below the skin as is easily visible. A growing body of evidence suggests that visceral fat is metabolically active and thus a central driver of the health risks associated with obesity. Researchers have found that excess visceral fat is a stronger predictor of cardiovascular and metabolic disease risk than overall body fat. Visceral fat can be lowered by exercise and is likely increased by sedentary behaviors. This study, from Medicine & Science in Sports & Exercise, found that sedentary behaviors, especially watching television were linked to increased levels of dangerous visceral fat. 
  • Purpose: We examined whether sedentary lifestyle habits and physical activity level are associated with abdominal visceral adipose tissue (VAT), subcutaneous adipose tissue (SAT), intermuscular adipose tissue (IMAT), and liver attenuation, independently of one another and potential confounders.
  • Methods: This study analyzed 3010 African American and Caucasian men and women, 42-59 yr old, from the Coronary Artery Risk Development in Young Adults (CARDIA) study, who completed multiple-slice abdominal computed tomography in 2010-2011. Participants reported average hours per day sitting (television, computing, paperwork, music, telephone, and car). Physical activity was assessed with the CARDIA physical activity history. VAT, SAT, IMAT, and liver attenuation were estimated from computed tomography. Multivariable general linear regression models regressed means of fat depots on total sedentary time, task-specific sedentary time, and total physical activity.
  • Results: Television viewing was positively, and physical activity inversely, associated with fat depots. For each 1 SD increment in television viewing (1.5 h·d−1), VAT, SAT, and IMAT were greater by 3.5, 3.4, and 3.9 cm3, respectively (P < 0.03 for all). For each 1 SD increment in physical activity (275 exercise units), VAT, SAT, and IMAT were lower by 7.6, 6.7, and 8.1 cm3, respectively, and liver attenuation was greater (indicating more liver fat) by 0.5 Hounsfield units (P < 0.01 for all). Total sedentary time was associated with VAT, IMAT, and liver attenuation in White men only after controlling for physical activity, SAT, and other potential confounders (P ≤ 0.01 for all). No other task-specific sedentary behaviors were associated with fat depots.
  • Conclusions: Sedentary behaviors, particularly television viewing, and physical activity levels have distinct, independent associations with fat deposition.  

More and more research is showing that fat is not just fat. It isn't inert, sitting on our bellies and doing nothing. It is a metabolically active tissue. It is responsible for changes in some of our hormone levels and adversely affects our insulin sensitivity. It can also be quite aggressive in maintaining its level in our bodies (as we all know when trying to lose body fat). There are different types of fat. Most of us focus on our subcutaneous fat. This is what we can see and easily pinch.  People who have larger waists tend to also have more intra-abdominal fat. This  intra-abdominal fat (visceral fat) is deep fat, stored around our organs and is much more dangerous. It is capable of provoking inflammatory pathways in the body and affecting hormonal signals which makes losing weight even more difficult. It can act independently so it is often considered to be an separate organ by many researchers. People with high levels of intra-abdominal fat have much higher risks of diabetes, heart disease, strokes, and dementia, likely due to this fat causing more insulin resistance. Obviously, we want to minimize our intra-abdominal fat. We know that sedentary behaviors such as sitting and lying down increase or risk of poor health. This study found that watching television may be especially bad for our health. For each additional 1.5 hours of television watched, visceral fat was greater by 3.5 cubic centimeters, even among those who were physically active and had a normal body weight. No other sedentary behaviors were associated with visceral fat. These findings suggest that television viewing may have a unique and independent influence on visceral fat. People may 'fidget' and change posture less often and many people tend to snack while watching television (especially with junk food, soda and beer commercials constantly being shown). It appears watching the Kardashians won't only make you stupid, it will likely make you fatter as well!

Are Long Work Hours Bad For Your Heart? 
Increased risk of atrial fibrillation with more than 55 hours/week of work

This study builds the article last month as we continue to look at risk factors for atrial fibrillation. Atrial fibrillation (AF) is the most common arrhythmia, affecting over 33 million patients worldwide, and 25% of adults will develop AF over their lifetime. People with AF have higher rates of heart failure, hospitalization, stroke and cognitive impairment as well as lower quality of life. 
Unfortunately, there are no effective, proven therapies for the primary prevention of AF. Nearly 60% of AF can be attributed to modifiable risk factors such as high blood pressure, smoking, and obesity. This study, from the European Heart Journal, adds another risk factor, long work hours. The researchers found that people who work more than 40 hours weekly and especially those working over 55 hours weekly had significantly higher risk of developing atrial fibrillation. 

  • Aims:  Studies suggest that people who work long hours are at increased risk of stroke, but the association of long working hours with atrial fibrillation, the most common cardiac arrhythmia and a risk factor for stroke, is unknown. We examined the risk of atrial fibrillation in individuals working long hours (≥55 per week) and those working standard 35-40 h/week.
  • Methods and results: In this prospective multi-cohort study from the Individual-Participant-Data Meta-analysis in Working Populations (IPD-Work) Consortium, the study population was 85,494 working men and women (mean age 43.4 years) with no recorded atrial fibrillation. Working hours were assessed at study baseline (1991-2004). Mean follow-up for incident atrial fibrillation was 10 years and cases were defined using data on electrocardiograms, hospital records, drug reimbursement registers, and death certificates. We identified 1061 new cases of atrial fibrillation (10-year cumulative incidence 12.4 per 1000). After adjustment for age, sex and socioeconomic status, individuals working long hours had a 1.4-fold increased risk of atrial fibrillation compared with those working standard hours (hazard ratio = 1.42, 95% CI = 1.13-1.80, P = 0.003). There was no significant heterogeneity between the cohort-specific effect estimates (I2 = 0%, P = 0.66) and the finding remained after excluding participants with coronary heart disease or stroke at baseline or during the follow-up (N = 2006, hazard ratio = 1.36, 95% CI = 1.05-1.76, P = 0.0180). Adjustment for potential confounding factors, such as obesity, risky alcohol use and high blood pressure, had little impact on this association.
  • Conclusion:  Individuals who worked long hours were more likely to develop atrial fibrillation than those working standard hours.
This study isn't perfect, and it's conclusion that working long hours may result in higher rate of atrial fibrillation may have some significant confounding factors. People who work long hours tend to be more sedentary with less activity during the day and are less likely to exercise. Additionally, they are more likely to have less than optimal diets. These two factors could account for the higher risk as weight gain resulting in obesity raises the risk independently. That being said, using techniques of stress relief, getting some physical activity during the day even if working long hours (remember the article on standing during the work day), and improving diet can help to mitigate the risk. Additionally, as the article last month on prevention pointed out, chocolate may be helpful! People who ate one serving of chocolate (1 oz) per week had a 17% lower rate and 2-6 servings/week had a 20% lower risk of atrial fibrillation than those who ate chocolate less than once/month. 
My recommendation is to eat up to 1 oz daily of the darkest chocolate you like. Oh, and get out of work earlier if possible, your heart will thank you...
Shingles and Strokes
Herpes zoster outbreak increased risk of stroke and heart attacks
This study, from the Journal of the American College of Cardiology, examined a large Korean data base and found a 35% increase in strokes and almost 60% increase in heart attacks in the first year after the development of herpes zoster (shingles).  
  • The association between herpes zoster (HZ) and the occurrence of stroke and myocardial infarction (MI) remains uncertain because confounding factors have not been adequately controlled in previous studies. If the association were established, it would have significant implications for public health, because some cases of stroke and MI caused by HZ might be potentially preventable with antiviral agents and vaccination. In the present work, we adjusted comprehensively for confounding factors, and assessed the risk of the composite of cardiovascular events including stroke and MI associated with HZ by propensity score matching. 

This study found a link between onset of herpes zoster (shingles) and heart attacks and strokes. While these two medical problems don't seem to be related it may be because herpes zoster causes either direct or indirect vascular inflammation. This inflammation could cause existing plaque rupture, blood clots, or more direct damage to the vessels. This finding makes this annoying problem more of a serious issue. Perhaps it makes sense to be more aggressive treating outbreaks of herpes zoster with antivirals, anti inflammatory medications and supplements, or maybe even steroids. It also may be more reasonable to make a Zoster vaccine a stronger recommendation. It is routinely recommended for people over age 60, but might not be a bad idea for high risk people to consider it at a younger age as the study showed they were at higher risk. It is also currently approved for ages 50-59. If you have had herpes zoster, then vaccine should likely be a strong consideration, especially if you have any risk factors or family history of heart disease. Additionally, people who develop herpes zoster may want to consider further risk reduction for cardiovascular disease. If you smoke, stop. Get your blood pressure under control. Lower insulin levels through a low sugar and starch diet. 

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.