October Newsletter
In This Issue
Don't Worry, Be Happy
Nut Intake and Weight
Sleep Position and Birth Weight
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 noticed some "frost on the pumpkin" the other night so it definitely appears colder weather is around the corner. I'm hoping for a bit more time to really get outside and enjoy our fall colors before the leaves come down. 
Do happy people live longer? Is an optimistic mind set beneficial to our health? The first study looks at the relationship between measures of optimism, cardiovascular deaths, and all-cause mortality. You may be "happy" to see the results. Be sure to check out how to measure your personal level of optimism and what you can do if you are a "half empty" person.  

Weight gain and avoiding weight gain are probably two of the topics I spend the most time discussing with people. How can we lose that excess weight we are carrying, and if we are not carrying extra weight, how can we avoid gaining weight? The second article looks at some substitutions we can make in our nutrition to avoid weight gain and also be beneficial in weight loss. 

Getting a decent night sleep can be tough when pregnant. But can the position a soon to be mother sleeps in have an effect on her baby's birth weight? It appears this is the case. A simple change in sleep position may be beneficial. If you or someone you know is pregnant, you will want to check out the third article. 

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Don't Worry, Be Happy
Optimism is good for you health
Is a mindset of optimism associated with a lower risk of cardiovascular events and all-cause mortality? Do happy people really live longer? In this meta-analysis of 15 studies, over 229,000 participants were followed for a mean of 13.8 years to examine the relationship between measures of optimism, cardiovascular deaths and all-cause mortality. They found that measures of optimism were associated with a 35% lower risk of cardiovascular events as well as a 14% lower risk of all-cause mortality. An optimistic mindset is associated with a lower cardiovascular risk.  

  • Importance: Optimism and pessimism can be easily measured and are potentially modifiable mindsets that may be associated with cardiovascular risk and all-cause mortality.
  • Objective: To conduct a meta-analysis and systematic review of the association between optimism and risk for future cardiovascular events and all-cause mortality.
  • Data Sources and Study Selection: PubMed, Scopus, and PsycINFO electronic databases were systematically searched from inception through July 2, 2019, to identify all cohort studies investigating the association between optimism and pessimism and cardiovascular events and/or all-cause mortality by using the following Medical Subject Heading terms: optimism, optimistic explanatory style, pessimism, outcomes, endpoint, mortality, death, cardiovascular events, stroke, coronary artery disease, coronary heart disease, ischemic heart disease, and cardiovascular disease.
  • Data Extraction and Synthesis: Data were screened and extracted independently by 2 investigators (A.R. and C.B.). Adjusted effect estimates were used, and pooled analysis was performed using the Hartung-Knapp-Sidik-Jonkman random-effects model. Sensitivity and subgroup analyses were performed to assess the robustness of the findings. The Meta-analysis of Observational Studies in Epidemiology (MOOSE) reporting guideline was followed.
  • Main Outcomes and Measures: Cardiovascular events included a composite of fatal cardiovascular mortality, nonfatal myocardial infarction, stroke, and/or new-onset angina. All-cause mortality was assessed as a separate outcome.
  • Results: The search yielded 15 studies comprising 229,391 participants of which 10 studies reported data on cardiovascular events and 9 studies reported data on all-cause mortality. The mean follow-up period was 13.8 years (range, 2-40 years). On pooled analysis, optimism was significantly associated with a decreased risk of cardiovascular events (relative risk, 0.65; 95% CI, 0.51-0.78; P < .001), with high heterogeneity in the analysis (I2 = 87.4%). Similarly, optimism was significantly associated with a lower risk of all-cause mortality (relative risk, 0.86; 95% CI, 0.80-0.92; P < .001), with moderate heterogeneity (I2 = 73.2%). Subgroup analyses by methods for assessment, follow-up duration, sex, and adjustment for depression and other potential confounders yielded similar results.
  • Conclusions and Relevance: The findings suggest that optimism is associated with a lower risk of cardiovascular events and all-cause mortality. Future studies should seek to better define the biobehavioral mechanisms underlying this association and evaluate the potential benefit of interventions designed to promote optimism or reduce pessimism. 

Does our outlook on life affect our health? Can perceptions develop into physical disease? We know that negative emotions such as stress and depression directly correlate with increased risk of cardiovascular disease. This study shows us that a positive emotion, optimism, can be protective for cardiovascular disease as well as mortality. So how does this work? Optimism creates a neuropeptide which triggers our immune system to promote health and resiliency. Optimism has been shown to improve multiple measures including inflammation, metabolic function, telomere length (associated with chronic diseases and death), blood pressure, endothelial function, hypothalamic-pituitary function, and healthy behaviors. 

Many of us seem to have a built in mindset for optimism or pessimism. Optimism has several positive attributes such as happiness, motivation, hopefulness, self-esteem, self-confidence, gratitude, sense of achievement, and resilience. How can we find out how optimistic we are? We can find out where we stand by taking a simple test called the Life Orientation Test-Revised. This test includes statements about how we feel about ourselves, others, and life - in general, under stress, and during happy times. If you take the test, it can be interpreted as follows, 0-13 is low optimism/high pessimism, 14-18 moderate optimism, 19-24, high optimism. This article provides more information about this test and interpretation.  

What can we do if we are more pessimistic than optimistic? Can we change? Research suggests that we can "re-wire" our brains, but it does take work. 
  • Make an active effort to "try on" positivity. Look at a situation perceived as negative and find something positive in it. It takes practice!
  • Spend more time with positive people (it's contagious)
  • Turn off the news (maybe take a break from social media)
  • Write in a journal. Gratitude helps foster a positive attitude. At the end of each day write down 1-2 things that happened that day that you are thankful for. Keep it simple! Just 3 days of this activity has been linked to lasting effects on mood. 
  • Acknowledge what you can and cannot control. Focus on the things you can control.
  • Do acknowledge reality (the negative). Work to combine optimism and a realistic outlook.  
When it comes to optimism and health I'm a big fan of William Shatner. His secret to live a good, long life? Don't die. Simply keep living and try not to slow down.

Nut Intake and Weight
Increased nut intake associated with lower weight gain and lowered risk of obesity

This study examined three large groups including 144,885 subjects followed up to 25 years and found a negative correlation between nut intake and weight gain, with walnuts showing the least weight gain. There was a lower risk of obesity with increasing nut intake. 

Substituting specific types of proteins (like nuts) for refined carbohydrates was associated with weight loss. 


  • Background: Dietary guidelines recommend interchanging protein foods (e.g., chicken for red meat), but they may be exchanged for carbohydrate-rich foods varying in quality [glycemic load (GL)]. Whether such exchanges occur and how they influence long-term weight gain are not established.
  • Objective: Our objective was to determine how changes in intake of protein foods, GL, and their interrelationship influence long-term weight gain.
  • Design: We investigated the association between 4-y changes in consumption of protein foods, GL, and their interaction with 4-y weight change over a 16- to 24-y follow-up, adjusted for other lifestyle changes (smoking, physical activity, television watching, sleep duration), body mass index, and all dietary factors simultaneously in 3 prospective US cohorts (Nurses' Health Study, Nurses' Health Study II, and Health Professionals Follow-Up Study) comprising 120,784 men and women free of chronic disease or obesity at baseline.
  • Results: Protein foods were not interchanged with each other (intercorrelations typically <|0.05|) but with carbohydrate (negative correlation as low as −0.39). Protein foods had different relations with long-term weight gain, with positive associations for meats, chicken with skin, and regular cheese (per increased serving/d, 0.13-1.17 kg; P = 0.02 to P < 0.001); no association for milk, legumes, peanuts, or eggs (P > 0.40 for each); and relative weight loss for yogurt, peanut butter, walnuts, other nuts, chicken without skin, low-fat cheese, and seafood (−0.14 to −0.71 kg; P = 0.01 to P < 0.001). Increases in GL were independently associated with a 0.42-kg greater weight gain per 50-unit increase (P < 0.001). Significant interactions (P-interaction < 0.05) between changes in protein foods and GL were identified; for example, increased cheese intake was associated with weight gain when GL increased, with weight stability when GL did not change, and with weight loss when exchanged for GL (i.e., decrease in GL).
  • Conclusion: Protein foods were commonly interchanged with carbohydrate, and changes in protein foods and GL interacted to influence long-term weight gain.

Nuts have been shown to be beneficial in reduction of all-cause mortality for people eating 4 oz daily. This large study found that people who at the most nuts gained less weight and had a lower incidence of obesity that people who ate few or no nuts. Walnuts had a 15% lower risk of obesity. Nuts are higher in fiber, essential fatty acids, and key nutrients. They make you feel full and delay gastric emptying by raising GLP-1 (the "I'm full" hormone). Additionally, people tended to replace foods that lead to obesity with nuts. When nuts replace french fries, chips, desserts, and processed meats, the frequency of obesity decreased. 

This study also found that some protein foods were better than others. Foods that are higher in glycemic index and glycemic load like refined grains were associated with weight gain. In this study, people who gained weight over time tended to have more high GI/GL foods on their plates. When higher protein foods were substituted for higher GI/GL foods, weight loss occurred. Eating high protein foods (like meat) along with high GI/GL foods (white rice, potatoes, bread) made them cause weight gain. However, eating the high protein food in place of the high GI/.GL food resulted in weight loss. Consuming cheese in place of refined grains, starches, or sugars could reduce weight gain, whereas eating cheese together with high-GL foods might promote long-term weight gain. This supports the idea that rather than focusing on calories alone, we should consider the types of protein foods quality of carbohydrate foods we are choosing. Looking at proteins in particular, subtypes of red meat and processed meat had consistent associations with weight gain, whereas subtypes of nuts had consistent associations with relative weight loss. Chicken with skin was associated with long-term weight gain while and chicken without skin was associated with weight loss. The potential mechanisms to explain this difference are unclear.

The recommendation based on this study would be to substitute intake of processed or refined carbohydrates with proteins such as nuts and poultry without skin. For us Wisconsinites, even cheese is a good substitute for refined carbohydrates.
Sleep Position and Birth Weight
Association between supine sleep position in late pregnancy and reduced birth weight
This study examined the relationship between sleeping position in later pregnancy (> 28 weeks) and baby birth weight and found that going to sleep in a supine position in late pregnancy was independently associated with reduced birth weight. This is a modifiable risk factor for low infant birth weight. 

  • Importance  Supine maternal position in the third trimester is associated with reduced uterine blood flow and increased risk of late stillbirth. As reduced uterine blood flow is also associated with fetal growth restriction, this study explored the association between the position in which pregnant women went to sleep and infant birth weight.
  • Objective  To examine the association between supine position when going to sleep in women after 28 weeks of pregnancy and lower birth weight and birth weight centiles.
  • Design, Setting, and Participants  Prespecified subgroup analysis using data from controls in an individual participant data meta-analysis of 4 case-control studies investigating sleep and stillbirth in New Zealand, Australia, and the United Kingdom. Participants were women with ongoing pregnancies at 28 weeks' gestation or more at interview.
  • Main Outcomes and Measures  The primary outcome was adjusted mean difference (aMD) in birth weight. Secondary outcomes were birth weight centiles (INTERGROWTH-21st and customized) and adjusted odds ratios (aORs) for birth weight less than 50th and less than 10th centile (small for gestational age) for supine vs nonsupine going-to-sleep position in the last 1 to 4 weeks, adjusted for variables known to be associated with birth size.
  • Results  Of 1760 women (mean [SD] age, 30.25 [5.46] years), 57 (3.2%) reported they usually went to sleep supine during the previous 1 to 4 weeks. Adjusted mean (SE) birth weight was 3410 (112) g among women who reported supine position and 3554 (98) g among women who reported nonsupine position (aMD, 144 g; 95% CI, -253 to-36 g; P = .009), representing an approximate 10-percentile reduction in adjusted mean INTERGROWTH-21st (48.5 vs 58.6; aMD, −10.1; 95% CI, −17.1 to −3.1) and customized (40.7 vs 49.7; aMD, −9.0; 95% CI, −16.6 to −1.4) centiles. There was a nonsignificant increase in birth weight at less than the 50th INTERGROWTH-21st centile (aOR, 1.90; 95% CI, 0.83-4.34) and a 2-fold increase in birth weight at less than the 50th customized centile (aOR, 2.12; 95% CI, 1.20-3.76). Going to sleep supine was associated with a 3-fold increase in small for gestational age birth weight by INTERGROWTH-21st standards (aOR, 3.23; 95% CI, 1.37-7.59) and a nonsignificant increase in small for gestational age birth weight customized standards (aOR, 1.63; 95% CI, 0.77-3.44).
  • Conclusions and Relevance  This study found that going to sleep in a supine position in late pregnancy was independently associated with reduced birth weight and birth weight centile. This novel association is biologically plausible and likely modifiable. Public health campaigns that encourage women in the third trimester of pregnancy to settle to sleep on their side have potential to optimize birth weight.

Back or supine position in the third trimester is associated with reduced uterine blood flow. This study examined the association between supine sleeping position and birth weight. Women who usually went to sleep in the supine position gave birth to infants with significantly lower birth weights. This is a risk factor for low birth weight that can be modified. 

Sleep is very important in pregnancy as as baby grows often gets more and more difficult. As the body changes and grows it gets more difficult to find comfortable positions.What is the best position for sleep in the later stages of pregnancySleeping on one side with your knees bent is likely to be the most comfortable position. It is often helpful to use pillows under your belly, between your legs, and behind your back. Lying on your back in a half-sitting position, propped up against some pillows, is also fine and can be helpful if you suffer from heartburn at night as this doesn't put the full.the weight of the uterus onto the spine, back muscles, and major blood vessels, which can decrease blood flow around your body and to your baby. There is some suggestion that the left side is the best position for blood flow, however, either side if fine, just try to stay off your back. If you wake up on your back, that is fine, just reposition to your side. 

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.