March Newsletter
In This Issue
Reverse Diabetes!
Fitness Beats Dementia!
Music Gives You a Boost
A Better Model of Medical Care
Old-fashioned medicine with 21st Century convenience and technology
Quick Links
Join Our List
View my profile on LinkedIn 
Follow me on Twitter
I hope this newsletter finds you and your family well. I know it's technically spring, but it sure doesn't feel like it. Hoping for some improved weather to get outside soon! Good thing Miller Park has a roof, looking forward to the team getting home and getting the baseball season under way! 

Over the past three months we have examined the relationship between dietary patterns and long-term survival, the timing and even the speed of of our meals. This month we are looking another reason to do all these things. Putting diabetes into remission. Even if you don't have diabetes, many of us are prediabetic or insulin resistant. Continue reading the article below for details. 

The second study adds more to the growing literature that middle age fitness has long-term effects. This study, from Sweden shows that fitness may reduce the incidence, onset and timing of dementia, even 40 years later!

The final study may not be a surprise. Many people exercise with music (probably most). While it may make the exercise time go faster, does it make us faster (or work harder)? This abstract, from the American College of Cardiology 2018 Scientific Session show us that music can likely help us to objectively perform better. 

Click on the links the the left to check out our  web site ...
Reverse Diabetes!
Weight loss causes remission of diabetes
Over 29 million people in the US have diabetes and another 8.1 million additional people have it and are not aware of their condition. Over one in four people over age 65 have diabetes. Almost 95% of cases of diabetes are Type 2, or adult onset. Risk factors include older age, excess weight, family history, certain ethnicities, physical inactivity and poor diet. Diabetes is a chronic disease requiring lifetime treatment. Bariatric surgery (stomach stapling) has been shown to put diabetes into remission in about 75% of cases, but this is a fairly dramatic approach. This study, published in the journal Lancet, looked to see if intensive weight management within primary care could put diabetes into remission. The researchers found that to intervention (12 weeks of low calorie diet, 2-8 weeks of meal re-introduction, maintenance program) helped the group lose an average of 22 lbs and 45% of the subjects had their diabetes go into remission. The group that lost over 33 lbs had an 86% remission of their diabetes! 
  • BACKGROUND: Type 2 diabetes is a chronic disorder that requires lifelong treatment. We aimed to assess whether intensive weight management within routine primary care would achieve remission of type 2 diabetes.
  • METHODS: We did this open-label, cluster-randomised trial (DiRECT) at 49 primary care practices in Scotland and the Tyneside region of England. Practices were randomly assigned (1:1), via a computer-generated list, to provide either a weight management programme (intervention) or best-practice care by guidelines (control), with stratification for study site (Tyneside or Scotland) and practice list size (>5700 or ≤5700). Participants, carers, and research assistants who collected outcome data were aware of group allocation; however, allocation was concealed from the study statistician. We recruited individuals aged 20-65 years who had been diagnosed with type 2 diabetes within the past 6 years, had a body-mass index of 27-45 kg/m2, and were not receiving insulin. The intervention comprised withdrawal of antidiabetic and antihypertensive drugs, total diet replacement (825-853 kcal/day formula diet for 3-5 months), stepped food reintroduction (2-8 weeks), and structured support for long-term weight loss maintenance. Co-primary outcomes were weight loss of 15 kg or more, and remission of diabetes, defined as glycated haemoglobin (HbA1c) of less than 6·5% (<48 mmol/mol) after at least 2 months off all antidiabetic medications, from baseline to 12 months. These outcomes were analysed hierarchically.
  • FINDINGS: Between July 25, 2014, and Aug 5, 2017, we recruited 306 individuals from 49 intervention (n=23) and control (n=26) general practices; 149 participants per group comprised the intention-to-treat population. At 12 months, we recorded weight loss of 15 kg or more in 36 (24%) participants in the intervention group and no participants in the control group (p<0·0001). Diabetes remission was achieved in 68 (46%) participants in the intervention group and six (4%) participants in the control group (odds ratio 19·7, 95% CI 7·8-49·8; p<0·0001). Remission varied with weight loss in the whole study population, with achievement in none of 76 participants who gained weight, six (7%) of 89 participants who maintained 0-5 kg weight loss, 19 (34%) of 56 participants with 5-10 kg loss, 16 (57%) of 28 participants with 10-15 kg loss, and 31 (86%) of 36 participants who lost 15 kg or more. Mean bodyweight fell by 10·0 kg (SD 8·0) in the intervention group and 1·0 kg (3·7) in the control group (adjusted difference -8·8 kg, 95% CI -10·3 to -7·3; p<0·0001). Quality of life, as measured by the EuroQol 5 Dimensions visual analogue scale, improved by 7·2 points (SD 21·3) in the intervention group, and decreased by 2·9 points (15·5) in the control group (adjusted difference 6·4 points, 95% CI 2·5-10·3; p=0·0012). Nine serious adverse events were reported by seven (4%) of 157 participants in the intervention group and two were reported by two (1%) participants in the control group. Two serious adverse events (biliary colic and abdominal pain), occurring in the same participant, were deemed potentially related to the intervention. No serious adverse events led to withdrawal from the study.
  • INTERPRETATION: Our findings show that, at 12 months, almost half of participants achieved remission to a non-diabetic state and off antidiabetic drugs. Remission of type 2 diabetes is a practical target for primary care.

Weight loss has been shown to be the strongest way to put Type 2 diabetes into remission. We know that surgical intervention through bariatric surgery can work to accomplish this. This trial shows us that simple weight loss is the key to remission. In this study, the subjects ate a 1200 calorie diet for 2 weeks, followed by a 850 calorie diet for an additional 10 weeks along with a fiber supplement. The study used the Cambridge Weight Plan, a commercial diet which is similar to Medifast or Nutrisystem plans. The subjects then added back a 350-400 calorie meal and eventually went back to 3 meals  daily totaling around 1400 calories (50% carb, 35% fat, 15% protein). Additionally, they did cognitive behavioral therapy to sustain their dietary changes. 

I like that this study was performed in the primary care setting and didn't involve any surgery! The diet is pretty dramatic but the results were pretty dramatic as well. For many people, it is important to have a rapid weight loss to sustain enthusiasm for the work that is being done. I have had similar results from people going on a "Wheat Belly" or similar diet and oftentimes after the first few days people don't experience any hunger. I generally see around 20 lbs of weight loss in the first 2 months and this is either continued or sustained, depending on the individual's goal. This is all done eating real food you can get at any grocery store. There are some online resources to duplicate with Medifast diet using real food as well. Bottom line: diabetes is curable, but it takes discipline and weight loss. Any weight loss is helpful, even a 10-20 lb weight loss had 34% remission rate in this study. And don't forget that physical activity can be beneficial as well! Even if you don't have diabetes, most of us have insulin resistance which can lead to future problems. Let's work together to get those extra pounds off!

Fitness Beats Dementia!
High levels of fitness at midlife may ward off dementia
women jogging

This long-term study followed a group of women over 44 years. A fitness test was done in 1968 and dementia evaluations were done in 1974, 1980, 1992, 2000, 2005, and 2009. They found that the risk of dementia in the high fitness group was around 88% lower than the average group (medium fitness). The low fitness group had a 40% higher than average risk. High fitness also delayed by years the onset and time to dementia in the high fitness group members who developed the disease. 


  • Objective:  To investigate whether greater cardiovascular fitness in midlife is associated with decreased dementia risk in women followed up for 44 years.
  • Methods A population-based sample of 1,462 women 38 to 60 years of age was examined in 1968. Of these, a systematic subsample comprising 191 women completed a stepwise-increased maximal ergometer cycling test to evaluate cardiovascular fitness. Subsequent examinations of dementia incidence were done in 1974, 1980, 1992, 2000, 2005, and 2009. Dementia was diagnosed according to DSM-III-R criteria on the basis of information from neuropsychiatric examinations, informant interviews, hospital records, and registry data up to 2012. Cox regressions were performed with adjustment for socioeconomic, lifestyle, and medical confounders.
  • Results Compared with medium fitness, the adjusted hazard ratio for all-cause dementia during the 44-year follow-up was 0.12 (95% confidence interval [CI] 0.03-0.54) among those with high fitness and 1.41 (95% CI 0.72-2.79) among those with low fitness. High fitness delayed age at dementia onset by 9.5 years and time to dementia onset by 5 years compared to medium fitness.
  • Conclusions Among Swedish women, a high cardiovascular fitness in midlife was associated with a decreased risk of subsequent dementia. Promotion of a high cardiovascular fitness may be included in strategies to mitigate or prevent dementia. Findings are not causal, and future research needs to focus on whether improved fitness could have positive effects on dementia risk and when during the life course a high cardiovascular fitness is most important.


This study, which followed subjects over 44 years, found a greatly decreased risk of development of dementia, delay in the onset of dementia by 9.5 years and time to dementia onset by 5 years in a high fitness group as compared to a medium fitness group. In contrast, the low fitness group had a 40% increased risk of dementia as compared to the medium fitness group. While this study doesn't prove causation, it is interesting that there would be such a stark difference in the groups divided by one fitness test over 40 years prior to the end of the study period. This seems to indicate that the women who were fit in their younger ages tended to stay fit as they aged, thus lowering their risk for chronic disease. While this study only looked at women, there is no reason to think that this couldn't apply to men as well. So if you are younger, your fitness now may be helping you stave off dementia in the future!
Music Gives You a Boost
Listening to music improved exercise stress test results
People who listened to upbeat music during a standard exercise stress test protocol were able to exercise longer compared to no music. This may be better to help people get to required levels in exercise stress tests. It could also prove beneficial in recreational exercise. 

  • Background: It is not uncommon to see individuals listening to music while exercising. Currently, there are few studies that support the benefits of music on exercise tolerance. The purpose of this study was to conduct a randomized controlled trial, as is the standard in evidence based practice of medicine, to compare impact of music on exercise capacity during scheduled exercise stress tests.
  • Methods: One hundred twenty seven patients (n = 127) who were able to walk on a treadmill were randomly assigned to either headphones which contained up-tempo music or no music during their scheduled stress tests. The randomization was single-blinded where staff members consenting the individuals and supervising their stress tests were unaware of which individuals had music playing on patients' headphones. All patients were already scheduled to have an electrocardiogram (ECG) treadmill stress by Bruce protocol regardless of their participation in the study. We collected and analyzed subjects' demographics (e.g. age, gender, medical history, social history etc.), vital signs (e.g. blood pressure, heart rate), and treadmill end points (e.g. exercise time, maximum heart achieved, symptoms etc.). All data collected were no different from what is routinely collected during an exercise ECG treadmill stress test in a stress testing laboratory.
  • Results: The individuals in both groups were similar with regards to medical history, particularly diabetes and hypertension. There were more females than males in both groups (61.2% in music vs 66.7% in control) with an average overall age of 53.0 years. In the randomized music group (n = 67), there was a significantly longer exercise time (ET, 505.8 vs 455.2, p=0.045) and a trend toward longer metabolic equivalent of task (METs, 9.45 vs 8.67, p=0.094) when compared to the non-music group (n = 60).
  • Conclusion: Our findings show that there is a significant increase in exercise time and a trend toward increased METs with music during ECG treadmill stress testing. In the future, a larger study with adequate power may be able to better demonstrate an evidence based recommendation to offering music during stress testing.


I'm sure this study is not surprising to many of us. A lot of people NEED their music to exercise. This study may show that this is not just subjective. Patients undergoing exercise stress tests all wore headphones. Some were silent and others played upbeat music. The staff performing the tests didn't know if the patients had music on or not. While many people may feel they perform better with music, this study shows that their suspicions could be correct. It may also be interesting to see if the patient's perception of the test was better with music. It seems that if you like to listen to music when you exercise, by all means use it. It could be making you work harder! 

Does Music Impact Exercise Capacity During Cardiac Stress Test? A Single Blinded Pilot Randomized Controlled Study ACC18;1182-006;March 11, 2018.
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.