July Newsletter
In This Issue
Two Day a Week Diet
Is Less Aspirin More, or Less?
iPhone ADHD
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. I can't believe we are at the end of July. It has been great to have such nice weather and I hope you all have been able to get out and enjoy all that our state has to offer. 

Weight control and weight loss are things we all think about. What is the best type of diet? When should I eat? What should I eat? There is really no one size fits all answer. Intermittent fasting is a concept that I have gotten interested in and discuss with my patients. The first study compares full time calorie restriction to twice a week calorie restriction. I think the answers are quite interesting. Check out the first article for more information. 

Many people take aspirin for prevention of heart attacks, strokes, and colon cancer. Is this effective? Could it be harmful? The answers may surprise you. 

Consumption of digital media is at an all-time high. We all consume tremendous amounts. What are the effects on our kids and teens? The third article looks at symptoms of attention deficit hyperactivity disorder (ADHD) in relation to amount of digital media consumed. While this study looked at teens, there may be a lesson for all of us. 

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Two Day a Week Diet
Intermittent fasting similar to calorie restriction
Can you restrict calories just two days a week and have the same results as daily calorie restriction? This study, from J AMA Network says yes, at least when it comes to hemoglobin A1c levels. Hemoglobin A1c is what we measure in diabetics and others to get an idea of average blood glucose levels (and insulin resistance) over the past three months. This study of diabetics found that restricting calories to 20-25% of usual levels (500-600 calories/day) on two non-consecutive days of the week and eating usual diet the other 5 days/week was equivalent to cutting caloric intake by 30-45% (taking in 1200-1600 calories/day) every day of the week. The authors found that the reduction in hemoglobin A1c was equivalent between the daily calorie reduction group and the intermittent fasting group. However, the intermittent fasting group lost more weight  and had over twice as much fat loss. 
  • Objective:  To compare the effects of intermittent energy restriction (2 days per week) with those of continuous energy restriction on glycemic control and weight loss in patients with type 2 diabetes during a 12-month period.
  • Design, Setting, and Participants:  Adult participants (N + 137) with type 2 diabetes were randomized 1:1 to parallel diet groups (intermittent energy restriction [n = 70] or continuous energy restriction [n + 67] between April 7, 2015, and September 7, 2017, at the University of South Australia. Medications likely to cause hypoglycemia were reduced at baseline according to the medication management protocol.
  • Interventions:  An intermittent energy restriction diet (500-600 kcal/d) followed for 2 nonconsecutive days per week (participants followed their usual diet for the other 5 days) or a continuous energy restriction diet (1200-1500 kcal/d) followed for 7 days per week for 12 months.
  • Main Outcomes and Measures:  The primary outcome was change in hemoglobin A1c (HbA1c) level, with equivalence prespecified by a 90% CI margin of ±0.5%. The secondary outcome was weight loss with equivalence set at ±2.5 kg (±1.75 kg for fat mass loss and ±0.75 kg for fat-free mass loss). All other outcomes were tested for superiority.
  • Results:  Of the 137 randomized participants (77 women and 60 men; mean [SD] age, 61.0 [9.1] years; mean [SD] body mass index, 36.0 [5.8] [calculated as weight in kilograms divided by height in meters squared]; and mean [SD] HbA1c level, 7.3% [1.3%]), 97 completed the trial. Intention-to-treat analysis showed similar reductions in mean (SEM) HbA1c level between the continuous and intermittent energy restriction groups (-0.5% [0.2%] vs -0.3% [0.1%]; P = .65), with a between-group difference of 0.2% (90% CI, -0.2% to 0.5%) meeting the criteria for equivalence. Mean (SEM) weight change was similar between the continuous and intermittent energy restriction groups (-5.0 [0.8] kg vs -6.8 [0.8] kg; P = .25), but the between-group difference did not meet the criteria for equivalence (-1.8 kg; 90% CI, -3.7 to 0.07 kg), nor did the between-group difference in fat mass (-1.3 kg; 90% CI, -2.8 to 0.2 kg) or fat-free mass (-0.5 kg; 90% CI, -1.4 to 0.4 kg). There were no significant differences between groups in final step count, fasting glucose levels, lipid levels, or total medication effect score at 12 months. Effects did not differ using completers analysis. Hypoglycemic or hyperglycemic events in the first 2 weeks of treatment were similar between the continuous and intermittent energy restriction groups (mean number [SEM] of events, 3.2 [0.7] vs 4.9 [1.4]; P = .28), affecting 35% of participants (16 of 46) using sulfonylureas and/or insulin.
  • Conclusions and Relevance: Intermittent energy restriction is an effective alternative diet strategy for the reduction of HbA1c and is comparable with continuous energy restriction in patients with type 2 diabetes.    
Intermittent fasting (IF) is a concept that is prominent in the news over the past few years. Different forms of IF have been expounded including the 16:8 ratio (no food for 16 hours, regular diet for 8 hours), 12:12 ratio which is no food for 12 hours daily, twice a week IF as described in this study is 500-600 calorie/day intake two non-consecutive days weekly with consumption of normal diet the other days. Some people will completely fast 1-2 days weekly as well. Does this work? The thought is that during IF the body depletes liver glycogen stores resulting in the breakdown of fats for energy. Additionally, neurotrophic factors which support the growth, survival, and differentiation of both developing and mature neurons are increased during this state. Fasting likely improves metabolic function, reduces fatty liver, and provides neuro-protection. This study shows that IF can produce similar results from twice weekly calorie restriction as cutting calories every day. While this study only looked at very low intake twice a week, other types of IF may be beneficial as well.  Intermittent fasting in some form may be something to consider incorporating in your regimen to lower your insulin resistance and control weight.

Is Less Aspirin More, or Less? 
Low dose aspirin ineffective for people over 154 lbs

Low dose or baby aspirin has been recommended for prevention of cardiovascular disease (heart attacks and strokes) for many years. Current guidelines recommend the low-dose form (81 mg) if people have a 10-year cardiovascular risk of over 10% and are between the ages of 50-59 and for may between the ages of 60-69. Aspirin has also been recommended for reduction in colon cancer risk. It is recommended that a full aspirin (325 mg) be avoided due to risk of bleeding. The thought is that the low-dose is the smallest effective dose with least side-effects. This meta-analysis of 10 trials investigating aspirin in the primary prevention of cardiovascular events, compared the effect of low- vs high-dose aspirin therapy. The authors also evaluated the role of height or weight in aspirin dosing on 20-year cancer risk. They found that low-dose aspirin had benefits for people under 70 kg (154 lbs), but had no effect on the rate of cardiovascular disease in people over 70 kg. Higher dose aspirin (325 mg) was only of benefit in people over 70 kg in weight and caused more bleeding in lower weight individuals. People who weighed less than 50 kg (110 lbs) had an increased all-cause death even with low-dose aspirin. People over age 70 had a 3-year risk of cancer that was increased by aspirin, especially if they weighed less than 70 kg.   

  • Background: A one-dose-fits-all approach to use of aspirin has yielded only modest benefits in long-term prevention of cardiovascular events, possibly due to underdosing in patients of large body size and excess dosing in patients of small body size, which might also affect other outcomes.
  • Methods: Using individual patient data, we analysed the modifying effects of bodyweight (10 kg bands) and height (10 cm bands) on the effects of low doses (≤100 mg) and higher doses (300-325 mg or ≥500 mg) of aspirin in randomised trials of aspirin in primary prevention of cardiovascular events. We stratified the findings by age, sex, and vascular risk factors, and validated them in trials of aspirin in secondary prevention of stroke. Additionally, we assessed whether any weight or height dependence was evident for the effect of aspirin on 20-year risk of colorectal cancer or any in-trial cancer.
  • Results: Among ten eligible trials of aspirin in primary prevention (including 117,279 participants), bodyweight varied four-fold and trial median weight ranged from 60·0 kg to 81·2 kg (p<0·0001). The ability of 75-100 mg aspirin to reduce cardiovascular events decreased with increasing weight (pinteraction=0·0072), with benefit seen in people weighing 50-69 kg (hazard ratio [HR] 0·75 [95% CI 0·65-0·85]) but not in those weighing 70 kg or more (0·95 [0·86-1·04]; 1·09 [0·93-1·29] for vascular death). Furthermore, the case fatality of a first cardiovascular event was increased by low-dose aspirin in people weighing 70 kg or more (odds ratio 1·33 [95% CI 1·08-1·64], p=0·0082). Higher doses of aspirin (≥325 mg) had the opposite interaction with bodyweight (difference pinteraction=0·0013), reducing cardiovascular events only at higher weight (pinteraction=0·017). Findings were similar in men and women, in people with diabetes, in trials of aspirin in secondary prevention, and in relation to height (pinteraction=0·0025 for cardiovascular events). Aspirin-mediated reductions in long-term risk of colorectal cancer were also weight dependent (pinteraction=0·038). Stratification by body size also revealed harms due to excess dosing: risk of sudden death was increased by aspirin in people at low weight for dose (pinteraction=0·0018) and risk of all-cause death was increased in people weighing less than 50 kg who were receiving 75-100 mg aspirin (HR 1·52 [95% CI 1·04-2·21], p=0·031). In participants aged 70 years or older, the 3-year risk of cancer was also increased by aspirin (1·20 [1·03-1·47], p=0·02), particularly in those weighing less than 70 kg (1·31 [1·07-1·61], p=0·009) and consequently in women (1·44 [1·11-1·87], p=0·0069).
  • Interpretation:  Low doses of aspirin (75-100 mg) were only effective in preventing vascular events in patients weighing less than 70 kg, and had no benefit in the 80% of men and nearly 50% of all women weighing 70 kg or more. By contrast, higher doses of aspirin were only effective in patients weighing 70 kg or more. Given that aspirin's effects on other outcomes, including cancer, also showed interactions with body size, a one-dose-fits-all approach to aspirin is unlikely to be optimal, and a more tailored strategy is required.
Aspirin has been recommended for years as a primary preventive for heart disease and as a preventive measure for colon cancer. Many people figure that since it's only aspirin, it can't hurt so why not take it? This study, which analyzed multiple trials and over 117,000 patients  found that this isn't the case. For people who are at high risk of cardiovascular disease (>10% 10-year risk) and over 154 lbs, the low-dose aspirin was not effective at all. People over 154 lbs need to take the full aspirin (325 mg) to get preventive effects and there doesn't seem to be an increased risk of bleeding for people in this group, which includes 80% of men and 50% of women. People who are less than 110 lbs shouldn't take aspirin as there appears to be only greater risk of all-cause death. 

As far as colon cancer prevention, people over age 70 appear to have a 20% increased risk of cancer when taking aspirin, especially if they weigh less than 154 lbs. 

So what does all this mean? If you have a high risk of cardiovascular disease (>10% over 10 years), are between the ages of 50-69 and weigh between 110-154 lbs, low-dose aspirin may be helpful. If you are over 154 lbs, a full aspirin would be recommended. If you weigh less than 110 lbs, you probably shouldn't take aspirin. If you are over age 70, you likely shouldn't take aspirin for primary prevention. If you decide to stop aspirin, please discuss with me or your physician as sudden cessation of aspirin can temporarily increase risk of ischemic stroke. These recommendations are based on primary prevention, preventing a condition before it occurs. If you have had a stroke or heart attack, the recommendations would be different. 

To analyze your 10-year risk of cardiovascular disease check this calculator from the American College of Cardiology. 
iPhone ADHD
More frequent use of digital media increased ADHD symptoms
This study examined whether increased digital media use in 2500 teens who did not have ADHD symptoms was associated with increased ADHD symptoms two years later. Increased digital media use led to greater symptoms of inattention and hyperactivity. Students with no high-frequency digital media use had less than half the rate of ADHD symptoms at follow up versus the higher users. 


  • Importance:  Modern digital platforms are easily accessible and intensely stimulating; it is unknown whether frequent use of digital media may be associated with symptoms of attention-deficit/hyperactivity disorder (ADHD).
  • Objective: To determine whether the frequency of using digital media among 15- and 16-year-olds without significant ADHD symptoms is associated with subsequent occurrence of ADHD symptoms during a 24-month follow-up.
  • Design, Setting, and Participants: Longitudinal cohort of students in 10 Los Angeles County, California, high schools recruited through convenience sampling. Baseline and 6-, 12-, 18-, and 24-month follow-up surveys were administered from September 2014 (10th grade) to December 2016 (12th grade). Of 4100 eligible students, 3051 10th-graders (74%) were surveyed at the baseline assessment.
  • Exposures:  Self-reported use of 14 different modern digital media activities at a high-frequency rate over the preceding week was defined as many times a day (yes/no) and was summed in a cumulative index (range, 0-14).
  • Main Outcomes and Measures:  Self-rated frequency of 18 ADHD symptoms (never/rare, sometimes, often, very often) in the 6 months preceding the survey. The total numbers of 9 inattentive symptoms (range, 0-9) and 9 hyperactive-impulsive symptoms (range, 0-9) that students rated as experiencing often or very often were calculated. Students who had reported experiencing often or very often 6 or more symptoms in either category were classified as being ADHD symptom-positive.
  • Results:  Among the 2587 adolescents (63% eligible students; 54.4% girls; mean [SD] age 15.5 years [0.5 years]) who did not have significant symptoms of ADHD at baseline, the median follow-up was 22.6 months (interquartile range [IQR], 21.8-23.0, months). The mean (SD) number of baseline digital media activities used at a high-frequency rate was 3.62 (3.30); 1398 students (54.1%) indicated high frequency of checking social media (95% CI, 52.1%-56.0%), which was the most common media activity. High-frequency engagement in each additional digital media activity at baseline was associated with a significantly higher odds of having symptoms of ADHD across follow-ups (OR, 1.11; 95% CI, 1.06-1.16). This association persisted after covariate adjustment (OR, 1.10; 95% CI, 1.05-1.15). The 495 students who reported no high-frequency media use at baseline had a 4.6% mean rate of having ADHD symptoms across follow-ups vs 9.5% among the 114 who reported 7 high-frequency activities (difference; 4.9%; 95% CI, 2.5%-7.3%) and vs 10.5% among the 51 students who reported 14 high-frequency activities (difference, 5.9%; 95% CI, 2.6%-9.2%).
  • Conclusions and Relevance:  Among adolescents followed up over 2 years, there was a statistically significant but modest association between higher frequency of digital media use and subsequent symptoms of ADHD. Further research is needed to determine whether this association is causal.  

There is more evidence being found that too much screen time is not healthy for kids and teens. We may inherently think that digital media leads to more inattention. Certainly pop up ads and animations constantly being seen are not helpful when trying to concentrate. The biggest question is - are the findings truly ADHD or is it part of our habits to seek constant stimulation. Most children diagnosed with ADHD receive the diagnosis in childhood, so it seems less likely that they would "develop" ADHD over their later teens as proposed in this study. However, the findings are valid for more inattention and hyperactivity developing with increased consumption of digital media. Many of us often feel similar symptoms. We work at our computers with constant emails popping up. We get distracted by ads and our Facebook, Instagram and Twitter feeds (look -squirrel!). We are tied to our phones beeping and buzzing and keep them with us constantly, even at the dinner table. Our first interaction of the day is with our phone, not our kids, spouse or partner. We are checking our phones instead of watching our kids or talking to those around us. We can't walk down the street or stand in a line without pulling out our phone. People can't even put down their phones to drive! Studies show that more frequent phone interruptions make people less attentive and more hyperactive. So while what is seen in this study is not likely true ADHD, it certainly indicates that teens (and us) should cut back on our screen stimulation and spend some quality time with out friends and family, preferably outside. 

Association of Digital Media Use With Subsequent Symptoms of Attention-Deficit/Hyperactivity Disorder Among Adolescents JAMA 2018 Jul 17;320(3)255-263..

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.