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March Newsletter
In This Issue
Another Reason to Avoid Unecessary Antibiotics
Losing Sleep Increases Risk of Diabetes
What Type of Exercise Loses Belly Fat
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. Spring is here (theoretically) and I am sure hoping we can get a few more nice days soon. It will be good to get back outside on the bike and my patients will be more likely to get out and exercise.  


This month I am focusing the newsletter on diabetes. This disease affects more than 29 million Americans and 1 in 4 doesn't know that they have it. Another 86 million adults (1 in 3) have prediabetes. Many of these people will go on to develop diabetes in the future. People with diabetes are at increased risk of serious health complications including vision loss, heart disease, stroke, kidney failure, amputation of toes, feet or legs, and premature death. In 2012, diabetes and its related complications accounted for $245 billion in total medical costs and lost work and wages. This figure is up from $174 billion in 2007. The good thing is that most cases of type 2 (adult-onset) diabetes can be prevented through lifestyle. Previous newsletters have discussed dietary changes that can be beneficial. The articles this month will focus on other lifestyle ways to prevent this disease. 

The first article is good to keep in mind this time of year. May people have colds, plugged ears, coughs, laryngitis, bronchitis, and sinusitis. Many people feel like antibiotics are the answer to these problems. But research is showing that the vast majority of these infections are viral. Drug resistant bacteria are a concern, but now we find that multiple courses of antibiotics seems to increase your risk of developing diabetes. Might be best to think twice...


Almost everyone will have trouble sleeping at times. But are there long-term effects to sleep deprivation? The second article shows that even losing 30 minutes of sleep per night during the week can increase your risk of developing diabetes.  


Finally, we have belly fat. No one wants it. Those who have it are at higher risk of diabetes (as well as heart disease, liver disease and hypertension). What type of exercise helps us to lose belly fat. The answer may surprise you.   


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

Another Reason to Avoid Unnecessary Antibiotics 

Antibiotics increase risk of diabetes 

Over the past several years, physicians have been trying to get people to take fewer unnecessary antibiotics. Research has shown that most bronchitis, sinusitis and sore throats are due to viruses and that giving antibiotics for these conditions doesn't help. This article, from the University of Pennsylvania and published in the European Journal of Endocrinology, show the results of giving antibiotics for these conditions is not only higher risk of drug resistance bacteria such as MRSA, but may be putting people at a higher risk of diabetes in the future.    


Summary of findings:

  • Objective:

    • Gut microbiota influence metabolic pathways relevant to the pathogenesis of obesity, insulin-resistance and diabetes. 

    • Antibiotic therapy can alter the microbiota and is commonly used in western countries. 

    • We sought to evaluate whether past antibiotic exposure increases diabetes risk.

  • Research design and methods:
    • We conducted a nested case-control study using a large population-based database from the United Kingdom (UK). 
    • Cases were defined as those with incident diagnosis of diabetes. 
    • For every case, 4 eligible controls matched on age, sex, practice-site, and duration of follow-up before index-date were selected using incidence-density sampling.
    • Exposure of interest was antibiotic therapy >1 year before index-date. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using conditional logistic regression. 
    • The risk was adjusted for body mass index (BMI), smoking, last glucose level and number of infections before index-date, as well as past medical history of coronary artery disease and hyperlipidemia.
  • Results: 
    • The study included 208,002 diabetic cases and 815,576 matched controls. 
    • Exposure to a single antibiotic prescription was not associated with higher adjusted diabetes risk. 
    • Treatment with 2-5 antibiotic courses was associated with increase in diabetic risk for penicillin, cephalosporins, macrolides and quinolones with adjusted OR ranging from 1.08 (95%CI 1.05-1.11) for penicillin to 1.15 (95%CI 1.08-1.23) for quinolones. 
    • The risk increased with the number of antibiotic courses and reached 1.37 (95%CI 1.19-1.58) for >5 courses of quinolones. 
    • There was no association between exposure to anti-virals and anti-fungals and diabetes risk.

    Conclusions: Exposure to certain antibiotic groups increases diabetes risk.            

This study of over 208,000 diabetics and over 815,000 controls showed that exposure to a single antibiotic prescription did not increase risk, but that 2-5 
 did significantly increase risk of developing diabetes (up to 37%). The antibiotics included many common antibiotics such as penicillin (amoxicillin), cephalosporins (cephalexin), macrolides (azithromycin) and quinolones (ciprofloxacin). The highest risk antibiotic was the quinolones. Why is this? Likely a change in GI flora, the bacteria in our GI system. So getting that 'Z-Pack' for you sniffles may not be a benign as we once thought. Most of these illnesses are viral and the best  solution
 is often to wait it out. If you do have to take antibiotics, consider a probiotic afterwards for a couple of months to help restore your healthy balance.  
Losing Sleep Increases Risk of Diabetes
Weight gain, higher blood glucose levels noted


Sleep is something we all need for various reasons. We know that there are problems with alertness, but can losing sleep make us fat? Can it increase our risk of diabetes? The answer to both is yes. 

Summary of findings  


    • It remains unclear how many hours of sleep are associated with the lowest risk of type 2 diabetes. This meta-analysis was performed to assess the dose-response relationship between sleep duration and risk of type 2 diabetes.

    • PubMed and Embase were searched up to 20 March 2014 for prospective observational studies that assessed the relationship of sleep duration and risk of type 2 diabetes. Both semiparametric and parametric methods were used.

    • Ten articles with 11 reports were eligible for inclusion in the meta-analysis. 

    • A total of 18,443 incident cases of type 2 diabetes were ascertained among 482,502 participants with follow-up periods ranging from 2.5 to 16 years. 

    • A U-shaped dose-response relationship was observed between sleep duration and risk of type 2 diabetes, with the lowest risk observed at a sleep duration category of 7-8 h per day. 

    • Compared with 7-h sleep duration per day, the pooled relative risks for type 2 diabetes were 1.09 (95% CI 1.04-1.15) for each 1-h shorter sleep duration among individuals who slept <7 h per day and 1.14 (1.03-1.26) for each 1-h increment of sleep duration among individuals with longer sleep duration.

    • Our dose-response meta-analysis of prospective studies shows a U-shaped relationship between sleep duration and risk of type 2 diabetes, with the lowest type 2 diabetes risk at 7-8 h per day of sleep duration. 

    • Both short and long sleep duration are associated with a significantly increased risk of type 2 diabetes, underscoring the importance of appropriate sleep duration in the delay or prevention of type 2 diabetes.                      


Another abstract, presented at ENDO 15, the Endocrine Society's 97th Annual Meeting and Expo, in San Diego, California, from March 5 - 8, 2015 showed that losing as little as 30 minutes of sleep on weekdays can have consequences on body composition and metabolism. 

  • 522 patients with newly diagnosed type 2 diabetes were randomized into three groups: usual care, physical activity intervention, or diet and physical activity intervention.
  • Participants completed 7-day sleep diaries and calculated their weekday sleep debt. 
  • At baseline, the researchers recorded their height and weight to determine obesity status, measured their waist circumference for central adiposity, and analyzed their fasting blood samples for insulin sensitivity. 
  • At baseline, compared with participants who had no weekday sleep debt, those who had weekday sleep debt were 72% more likely to be obese, and by the 6-month mark, weekday sleep debt was significantly associated with obesity and insulin resistance. 
  • At 12 months, for every 30 minutes of weekday sleep debt at baseline, the risk of obesity and insulin resistance was significantly increased by 17% and 39%, respectively.

ENDO 15, the Endocrine Society's 97th Annual Meeting and Expo, in San Diego, California, from March 5 - 8, 2015. 


These two studies show us the importance of sleep in our body's metabolism. Lack of sleep causes changes in metabolism, likely insulin sensitivity which can lead to weight gain, insulin resistance, and subsequent diabetes. Other studies have shown increased appetite with sleep deprivation which likely contributes as well. It appears there is a 'sweet spot' of 7-8 hours is optimum with more or less increasing risk. The more sleep you lose over a longer period of time, the higher your risk. 

What Type of  Exercise Loses Belly Fat? 
Any exercise = belly fat loss


Visceral fat is stored around your internal organs in your abdomen. The problem with visceral fat is that it is metabolically active. It isn't just sitting there doing nothing. Visceral fat can lead to insulin resistance (the beginning of diabetes), high blood pressure, high cholesterol levels and a higher risk for developing heart disease. Having a waistline greater than 40 inches for men and 35 inches for women is a sign of large visceral fat stores. So what type of exercise can prevent or reduce our belly fat? This study, from the Annals of Internal Medicine, compared three types of exercise: low-amount, low-intensity; high-amount, low-intensity; high-amount, high-intensity. 

Summary of findings:  

  • Background: Exercise reduces obesity and related glucose tolerance, but whether increasing exercise intensity offers additional benefit at fixed exercise amounts is unknown.

  • Objective: To determine the separate effects of exercise amount and intensity on abdominal obesity and glucose tolerance.

  • Design: 24-week, single-center, parallel-group trial from 2009 to 2013. ( NCT00955071)

  • Setting: Kingston, Ontario, Canada.

  • Participants: 300 abdominally obese adults.

  • Intervention:

    • Control (no exercise) (n = 75) or 5 weekly sessions of low-amount, low-intensity exercise (LALI) (180 and 300 kcal/session for women and men, respectively, at 50% of maximum oxygen consumption [V̇o2peak]) (n = 73);

    • high-amount, low-intensity exercise (HALI) (360 and 600 kcal/session, respectively, at 50% of V̇o2peak) (n = 76); or

    • high-amount, high-intensity exercise (HAHI) (360 and 600 kcal/session, respectively, at 75% of V̇o2peak) (n = 76).

    • Daily unsupervised physical activity and sedentary time were measured by accelerometer.

  • Measurements: Waist circumference and 2-hour glucose level (primary outcomes) and cardiorespiratory fitness and measures of insulin action (secondary measurements).

  • Results: 217 participants (72.3%) completed the intervention.

  • Mean exercise time in minutes per session was 31 (SD, 4.4) for LALI, 58 (SD, 7.6) for HALI, and 40 (SD, 6.2) for HAHI.

  • Daily unsupervised physical activity and sedentary time did not change in any exercise group versus control (P > 0.33).

  • After adjustment for age and sex in a linear mixed model, reductions in waist circumference were greater in the LALI (−3.9 cm [95% CI, −5.6 to −2.3 cm]; P < 0.001), HALI (−4.6 cm [CI, −6.2 to −3.0 cm]; P < 0.001), and HAHI (−4.6 cm [CI, −6.3 to −2.9 cm]; P < 0.001) groups than the control group but did not differ among the exercise groups (P > 0.43).

  • After adjustment for covariates, reductions in 2-hour glucose level were greater in the HAHI group (−0.7 mmol/L [−12.5 mg/dL] [CI, −1.3 to −0.1 mmol/L {−23.5 to −1.5 mg/dL}]; P = 0.027) than the control group but did not differ for the LALI or HALI group versus the control group (P > 0.159).

  • Weight loss was greater in all exercise groups than the control group (P < 0.001); however, reduction in body weight did not differ among the exercise groups (P > 0.182).

  • Limitation: The clinical importance of reducing 2-hour glucose level in nondiabetic adults remains undetermined.

  • Conclusion: Fixed amounts of exercise independent of exercise intensity resulted in similar reductions in abdominal obesity. Reduction in 2-hour glucose level was restricted to high-intensity exercise. 


This study shows that exercise decreases belly fat, regardless of type. This is good news. Even lower levels of exercise intensity can help you lose some of your belly fat. All three groups in the study did lose belly fat and waist circumference. However, it seems that in order to improve your glucose tolerance, you need more intense exercise sessions.  It is good to see that approx 30 minutes of low-intensity exercise did show improvement in belly fat (although not as much as the other groups it was not statistically significant). For those who want to also improve glucose tolerance, more intense exercise may be needed.  
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. 


Diabetes can be a devastating disease and anything we can do to prevent it is important. This month we have learned that common healthy behaviors are quite beneficial to prevent this disease. Avoid unnecessary antibiotics. My patients won't get them. If you go elsewhere, ask your doctor if you really need that antibiotics. You may be lowering your risk of diabetes.  


Sleep is important. Previous studies have shown we make poor food choices when we are tired. Now we find that it also independently increases our risk of developing diabetes. So try to hit the hay at a reasonable time.  


Banish belly fat: exercise. The type of exercise doesn't matter as much as just doing it. Start today! 

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.