June Newsletter
In This Issue
Death By Fast Food
Best Time To Exercise
Sports Can Heal
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. Summer in Milwaukee is awesome! There is so much to do, the hardest thing is choosing. Of course we have Summerfest, the largest music festival in the United States going on right now. If you haven't been to the Tour of America's Dairyland (TOAD) bike races, you are missing out. TOAD is the largest competitive road cycling series in the nation. Each year nearly 1,100 male and female pro and amateur athletes from more than 40 U.S. states and 15 countries descend on SE Wisconsin to compete. You can see some of the top cyclists from the US and around the world racing in our front yard. These races are a great time (imagine huge block party) and my favorite race, Downer Avenue is tomorrow. Check out the schedule for this weekend and support the riders!
We know that processed and fast food is bad for us. For many Americans, processed food provides the majority of their calories. But how bad is it? What if I told you it could kill you. This goes beyond causing diseases. I'm talking about death by food. The first article explores how much is too much and why it is so bad for us. 

Some people like to exercise in the morning. Others are in the afternoon or evening. Is one time better than the other? I usually tell people the best time to exercise is the time that you will do it. But if you are prone to high blood pressure, there may be a time of day that is better for you to exercise. The second article has the answer. 

The incidence of anxiety and depression is increasing in our young people. A possible trigger for these conditions are adverse childhood experiences ( physical and sexual abuse, emotional neglect, parental alcohol or substance abuse, parental incarceration, and divorce or living with a single parent) which are associated with long-term poor mental health. As a sports medicine doctor, I certainly believe in the positive power of sports. The last study looks at the effect that team sports can have on long-term mental health for kids with these adverse experiences.  

Click on the links the the left to check out our  web site .
Death By Fast Food
High intake of ultra-processed foods increases mortality
Processed foods are manufactured to be convenient, ready to eat, extremely tasty, and have attractive packaging. They have become the most common source of calories for many Americans and are responsible for up to 90% of all the added sugar we consume. 

This Spanish study followed almost 20,000 people over 15 years. The group consuming the most processed food had a 62% higher risk of death than those consuming the lowest amount. Each additional serving of processed foods increased mortality by 18%. 
  • Objective: To evaluate the association between consumption of ultra-processed foods and all cause mortality.
  • Design: Prospective cohort study.
  • Setting: Seguimiento Universidad de Navarra (SUN) cohort of university graduates, Spain 1999-2018.
  • Participants: 19,899 participants (12,113 women and 7,786 men) aged 20-91 years followed-up every two years between December 1999 and February 2014 for food and drink consumption, classified according to the degree of processing by the NOVA classification, and evaluated through a validated 136 item food frequency questionnaire.
  • Main outcome measure: Association between consumption of energy adjusted ultra-processed foods categorised into quarters (low, low-medium, medium-high, and high consumption) and all cause mortality, using multivariable Cox proportional hazard models.
  • Results: 335 deaths occurred during 200,432 persons years of follow-up. Participants in the highest quarter (high consumption) of ultra-processed foods consumption had a higher hazard for all cause mortality compared with those in the lowest quarter (multivariable adjusted hazard ratio 1.62, 95% confidence interval 1.13 to 2.33) with a significant dose-response relation (P for linear trend=0.005). For each additional serving of ultra-processed foods, all cause mortality relatively increased by 18% (adjusted hazard ratio 1.18, 95% confidence interval 1.05 to 1.33).
  • Conclusions: A higher consumption of ultra-processed foods (>4 servings daily) was independently associated with a 62% relatively increased hazard for all cause mortality. For each additional serving of ultra-processed food, all cause mortality increased by 18%.

It is well known that dietary habits influence many risk factors for chronic diseases including heart disease, diabetes, cancer, and dementia. But what are the effects on our lifespan? This study shows us that eating several servings of processed foods can lead to not just disease, but death. This is a dose-responsive finding so the more processed or fast food one eats, the higher the risk of death. Another study in the same issue of the BMJ followed over 105,000 people in France and found a definite relationship between ultraprocessed foods and higher rates of heart disease and strokes.  

Our foods today are more processed than ever, which generally means more sugar. These processed foods supply around 90% of the added sugar in our diets. We also know that eating higher levels of processed foods lead to weight gain. People eating high levels of processed foods usually consume more calories as these foods are manufactured to taste good and cause hormonal changes leading to more consumption. Studies have even shown that these foods are consumed faster. This is a visual menu from a study showing the difference between a processed and unprocessed menu. Some of the foods deemed "processed foods" on the menu surprised me. It's not just Big Macs, fries and chips. 

To be truly healthy and reduce our risk of both chronic disease and death, we need to limit our intake of processed foods. When choosing foods for yourself and your family, stick to the packaging mother nature supplied. 

Best Time To Exercise
More benefits to evening exercise in people with hypertension

Exercise is recommended for everyone, but is especially important for people with high blood pressure. Exercise has been shown to lower blood pressure but is there more benefit to a specific time of day for exercise? This study looked at 50 hypertensive men and divided them into three groups. The first exercised in the morning (7-9 AM), the second exercised in the evening (6-8 PM) and the third group did no aerobic exercise and just stretched. Results showed more blood pressure reduction in the evening exercising group which was equivalent to an 8% reduction in risk for stroke and 5% reduction in risk for coronary artery disease. 



  • Introduction The acute blood pressure (BP) decrease is greater after evening than morning exercise, suggesting that evening training (ET) may have a greater hypotensive effect.
  • Objective This study aimed to compare the hypotensive effect of aerobic training performed in the morning versus evening in treated hypertensives.
  • Methods Fifty treated hypertensive men were randomly allocated to three groups: morning training (MT), ET, and control (C). Training groups cycled for 45 min at moderate intensity (progressing from the heart rate of the anaerobic threshold to 10% below the heart rate of the respiratory compensation point), while C stretched for 30 min. Interventions were conducted 3 times per week for 10 wk. Clinic and ambulatory BP and hemodynamic and autonomic mechanisms were evaluated before and after the interventions. Clinic assessments were performed in the morning (7:00-9:00 AM) and evening (6:00-8:00 PM). Between-within ANOVA was used (P ≤ 0.05).
  • Results Only ET decreased clinic systolic BP differently from C and MT (morning assessment −5 ± 6 mm Hg and evening assessment −8 ± 7 mm Hg, P < 0.05). Only ET reduced 24 h and asleep diastolic BP differently from C and MT (−3 ± 5 and −3 ± 4 mm Hg, respectively, P < 0.05). Systemic vascular resistance decreased from C only in ET (P = 0.03). Vasomotor sympathetic modulation decreased (P = 0.001) and baroreflex sensitivity (P < 0.02) increased from C in both training groups with greater changes in ET than MT.
  • Conclusions In treated hypertensive men, aerobic training performed in the evening decreased clinic and ambulatory BP due to reductions in systemic vascular resistance and vasomotor sympathetic modulation. Aerobic training conducted at both times of day increases baroreflex sensitivity, but with greater after ET.


I found this to be an interesting study. I wouldn't expect a significant difference in results between evening and morning exercise. The authors didn't present any specific physiological reasons for this. Perhaps it could be related to timing of taking blood pressure medications. If people take their medications in the morning perhaps a difference is seen in their readings after morning exercise vs evening. Most cardiovascular events occur in the early morning hours so the lowered blood pressure in the evening may provide some overnight protection from these events.  

Exercise in general will help with blood pressure, but based on this study it may make sense to target exercise for the evening if you have high blood pressure. I definitely wouldn't recommend stopping morning exercise if that is when you can get it in. That being said, the most important thing is to exercise regularly, regardless of time of day the exercise occurs. Maybe a nice brisk walk after dinner would be a good thing to add. 
Sports Can Heal
Teens exposed to adverse childhood experiences who play team sports have better adult mental health
Adverse childhood experiences (ACE) include physical and sexual abuse, emotional neglect, parental alcohol or substance abuse, parental incarceration, and divorce or living with a single parent and are associated with long-term poor mental health. Not much is known about which factors improve long-term outcomes for children exposed to ACE. 

Physical activity has benefits for children and adolescents and is shown to improve depressive symptoms, stress and self-esteem. Team sports are thought to lead to improved mental health because of their social nature and social support. This study looked at almost 10,000 individuals and found that participation in team sports was associated with better adult mental health and  could be a significant part of the healing process for teens. 

  • Importance  Adverse childhood experiences (ACEs) are associated with long-term poor mental health. Less is known about factors that improve long-term mental health among those with ACEs.
  • Objective  To evaluate, among those exposed to ACEs, whether team sports participation during adolescence is associated with better mental health in adulthood and whether the association between team sports participation and mental health varies by sex.
  • Design, Setting, and Participants  This study used data from 9668 individuals who participated in waves 1 (1994-1995) and 4 (2008) of the National Longitudinal Study of Adolescent to Adult Health. Individuals were included if they had complete data on exposure to ACEs (physical and sexual abuse, emotional neglect, parental alcohol misuse, parental incarceration, and living with a single parent) and a valid sample weight. Statistical analysis was performed from November 6, 2017, to January 4, 2019.
  • Main Outcomes and Measures  The association between team sports participation in grades 7 to 12 (wave 1) and diagnosis of depression and/or anxiety and current depressive symptoms (determined by Center for Epidemiologic Studies Depression scale-10 scores) at ages 24 to 32 years (wave 4) among individuals exposed to ACEs. Multivariable logistic regression models were weighted based on propensity scores for factors associated with team sports participation and controlled for individual, family, and school characteristics. Interaction terms tested whether associations between team sports participation and mental health varied by sex.
  • Results  Of 9668 individuals included in the study (4470 male [50.0%]; mean [SD] age, 15.2 [1.75] years), 4888 (49.3%) reported 1 or more ACE and 2084 (21.3%) reported 2 or more ACEs. Among those with ACEs, team sports participation during adolescence was significantly associated with lower odds of receiving a diagnosis of depression (unadjusted rate, 16.8% vs 22.0%; propensity score-weighted [PSW] adjusted odds ratio [aOR], 0.76; 95% CI, 0.59-0.97) or anxiety (11.8% vs 16.8%; PSW aOR, 0.70; 95% CI, 0.56-0.89) and having current depressive symptoms (21.9% vs 27.5%; PSW aOR, 0.85; 95% CI, 0.71-1.01). There were no significant differences in associations between team sports participation and mental health by sex. Stratified analyses showed significant associations for all outcomes among males (depression: PSW aOR, 0.67 [95% CI, 0.46-0.99]; anxiety: PSW aOR, 0.66 [95% CI, 0.45-0.96]; depressive symptoms: PSW aOR, 0.75 [95% CI 0.56-0.99]) but only 1 outcome among females (anxiety: PSW aOR, 0.73; 95% CI, 0.54-0.98).
  • Conclusions and Relevance  Among individuals affected by ACEs, team sports participation in adolescence was associated with better adult mental health. Team sports may be an important and scalable resilience builder.

Exercise has been proven to markedly reduce anxiety levels, raise energy, and improve mood within several hours of participation. It's remarkable that almost half of the people in the study had at least 1 ACE and 21% had 2 or more. This is quite a burden that is being carried by a lot of our children into adulthood. These groups have a statistically higher probability of a diagnosis of depression or anxiety. Currently, up to 40% of young adults report symptoms of depression, anxiety, and high stress. 

It appears from this study that there is a benefit in encouraging participation in activities like team sports.The reason sports are beneficial isn't completely clear. Is it the exercise or the social aspects? Do sports help to develop resiliency? Perhaps it is all of the above. This correlates with another study which found that participants who reported playing high school sports disclosed significantly more positive scores in their mental health assessments as compared to those who did not participate in sports in high school. There was a strong association between playing sports in adolescence and lower rates of depression and stress, along with higher self-reported mental health.

Based on these studies, it seems that when cuts to school funding come down, team sports shouldn't be the first things on the chopping block. We need to encourage participation. Having the availability of JV teams is likely important as well to encourage participation by teens who may not be the most gifted athletes. Much of the benefit may not be seen on the court or the field, it may be later in life. There are a lot of kids who may benefit.  

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. 

You can find previous newsletters archived on my website here


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.