September Newsletter
In This Issue
The Pendulum Has Swung!
Sugar and Your Brain
Better Food, Better Fertility
A Better 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. It's officially fall. My favorite time of year. A great time to get outside and enjoy our changing colors and the great temperatures (while they last). I'm thrilled our Brewers are taking it down to the wire and let's hope we can get into the playoffs. For a team no expert expected to do anything, It's great to see our team believe in itself, overcome injuries and continue to play well right to the end. 

The first article is really exciting to me. For the past few years I have been talking to my patients about the dangers of processed carbohydrates and that fats are not necessarily bad. Well, it looks like a large study proves this correct! This is a major paradigm shift and it's great to see more proof of this concept. 

I reviewed an article looking at modifiable risk factors of Alzheimer's disease last month. This month we have an article looking at the effects of sugar on your brain and the link to cognitive impairment. 

Up to 25% of couples have difficulty getting pregnant. This often leads to stress between the couple and expensive medical procedures and medications. The third article looks at a way to improve chances of pregnancy and improve your overall health as well. 

Click on the links the the left to check out our web site ...
The Pendulum Has Swung!
High carbs=higher mortality;  High fat=lower mortality    
The dietary intake of 135,335 people in 18 countries was evaluated over a median follow up of 7.4 years to determine if there was an association between macro nutrient intake, mortality risk, and cardiovascular disease. High carbohydrate intake was associated with increased risk of mortality. Total fat intake was associate with lowered total mortality risk and no increased risk of cardiovascular disease. Higher intake of saturated fat was actually inversely related to stroke risk. 
  • BACKGROUND:  The relationship between macronutrients and cardiovascular disease and mortality is controversial. Most available data are from European and North American populations where nutrition excess is more likely, so their applicability to other populations is unclear.
  • METHODS: The Prospective Urban Rural Epidemiology (PURE) study is a large, epidemiological cohort study of individuals aged 35-70 years (enrolled between Jan 1, 2003, and March 31, 2013) in 18 countries with a median follow-up of 7·4 years (IQR 5·3-9·3). Dietary intake of 135,335 individuals was recorded using validated food frequency questionnaires. The primary outcomes were total mortality and major cardiovascular events (fatal cardiovascular disease, non-fatal myocardial infarction, stroke, and heart failure). Secondary outcomes were all myocardial infarctions, stroke, cardiovascular disease mortality, and non-cardiovascular disease mortality. Participants were categorised into quintiles of nutrient intake (carbohydrate, fats, and protein) based on percentage of energy provided by nutrients. We assessed the associations between consumption of carbohydrate, total fat, and each type of fat with cardiovascular disease and total mortality. We calculated hazard ratios (HRs) using a multivariable Cox frailty model with random intercepts to account for centre clustering. 
  • FINDINGS: During follow-up, we documented 5796 deaths and 4784 major cardiovascular disease events. Higher carbohydrate intake was associated with an increased risk of total mortality (highest [quintile 5] vs lowest quintile [quintile 1] category, HR 1·28 [95% CI 1·12-1·46], ptrend=0·0001) but not with the risk of cardiovascular disease or cardiovascular disease mortality. Intake of total fat and each type of fat was associated with lower risk of total mortality (quintile 5 vs quintile 1, total fat: HR 0·77 [95% CI 0·67-0·87], ptrend<0·0001; saturated fat, HR 0·86 [0·76-0·99], ptrend=0·0088; monounsaturated fat: HR 0·81 [0·71-0·92], ptrend<0·0001; and polyunsaturated fat: HR 0·80 [0·71-0·89], ptrend<0·0001). Higher saturated fat intake was associated with lower risk of stroke (quintile 5 vs quintile 1, HR 0·79 [95% CI 0·64-0·98], ptrend=0·0498). Total fat and saturated and unsaturated fats were not significantly associated with risk of myocardial infarction or cardiovascular disease mortality.
  • INTERPRETATION: High carbohydrate intake was associated with higher risk of total mortality, whereas total fat and individual types of fat were related to lower total mortality. Total fat and types of fat were not associated with cardiovascular disease, myocardial infarction, or cardiovascular disease mortality, whereas saturated fat had an inverse association with stroke. Global dietary guidelines should be reconsidered in light of these findings.

Wow, where to start with this? Ding, dong, the witch is dead? Or rather, the idea that fat is bad is dead. Since the 1950's we have had this idea that saturated fat is clogging our arteries so eating less fat would be beneficial for our hearts and increase our lifespans. We had the "heart benefits" of carbohydrates pressed into our collective psyches. After all, we have the AHA heart logo on our fat-free Cheerios! The Prospective Urban Rural Epidemiology Study (PURE) looked at 135,335 individuals from 18 countries over and average of 7.4 ears and evaluated the percent of energy obtained from different food sources through a food frequency questionnaire. The group that ate the largest amount of processed carbohydrates, mainly white bread and rice had the highest all-cause mortality including heart disease. The study showed a protective effect from all types of fats, even the much demonized saturated fats. There was no association between fat and saturated fat intake and heart attacks or cardiovascular disease mortality

Understand that all carbohydrates are not created equal. The carbs that will lead to MORE heart disease are the processed (or simple) carbs such as rice, corn, white potatoes and things like white bread, pasta, and pastries. The biggest culprit is sugar. These substances cause changes in lipids and lipoproteins leading to heart disease and mortality (and increased insulin resistance). Vegetables are also carbohydrates but are another story. They contain fiber as well as nutrients (phytochemicals) which are very valuable to our bodies. Fruit contains fructose which can cause its own issues, but in moderation are also useful. Another article in the same journal using the same data set found that 3-4 servings a day of vegetables, fruits and legumes lowered total mortality. The problem is that the processed carbs are inexpensive and often used extensively in poor populations. Combining processed carbs and sugar is a killer, literally. Check your labels for hidden sugars such as corn sweetener, corn syrup, dextrose, fructose, fruit juice concentrates, glucose, high-fructose corn syrup, invert sugar, lactose, maltose, malt syrup, raw sugar, sucrose, sugar syrup, cane crystals, cane sugar, crystalline fructose, evaporated cane juice, corn syrup solids, malt syrup (there are over 61 of them). Avoid sugar, reduce intake of processed carbs, and don't be afraid of fat. Do you feel the pendulum swinging? 

Sugar and Your Brain
Controlling blood sugar leads to less cognitive impairment

Dementia is multi factorial with the two main causes being vascular issues and metabolic issues. This study, from Diabetes Care, evaluated the effects of glucose metabolism and blood pressure on long-term cognitive decline in Type 2 diabetics. Poor cognitive performance was most related to high blood glucose levels but blood pressure was also significant. 

  • OBJECTIVE:  To study to what extent differences in cognitive performance between individuals with different glucose metabolism status are potentially attributable to hyperglycemia, insulin resistance, and blood pressure-related variables.  
  • RESEARCH DESIGN AND METHODS: We used cross-sectional data from 2,531 participants from The Maastricht Study (mean age ± SD, 60 ± 8 years; 52% men; n = 666 with type 2 diabetes), all of whom completed a neuropsychological test battery. Hyperglycemia was assessed by a composite index of fasting glucose, postload glucose, glycated hemoglobin (HbA1c), and tissue advanced glycation end products; insulin resistance by the HOMA of insulin resistance index; and blood pressure-related variables included 24-h ambulatory pressures, their weighted SDs, and the use of antihypertensive medication. Linear regression analyses were used to estimate mediating effects. 
  • RESULTS: After adjustment for age, sex, and education, individuals with type 2 diabetes, compared with those with normal glucose metabolism, performed worse in all cognitive domains (mean differences in composite z scores for memory -0.087, processing speed -0.196, executive function and attention -0.182; P values <0.032), whereas individuals with prediabetes did not. Diabetes-associated differences in processing speed and executive function and attention were largely explained by hyperglycemia (mediating effect 79.6% [bootstrapped 95% CI 36.6; 123.4%] and 50.3% [0.6; 101.2%], respectively) and, for processing speed, to a lesser extent by blood pressure-related variables (17.7% [5.6; 30.1%]), but not by insulin resistance. None of the factors explained the differences in memory function.
  • CONCLUSIONS: Our cross-sectional data suggest that early glycemic and blood pressure control, perhaps even in the prediabetic stage, may be promising therapeutic targets for the prevention of diabetes-associated decrements in cognitive performance.
Last month we discussed an article that showed the modifiable risk factors for Alzheimer's disease to include insulin resistance levels, inflammation, dyslipidemia, high blood pressure and sleep apnea. This month, we have an article looking at hyperglycemia and blood pressure as contributing factors in cognitive performance. So it seems that the evidence continues to grow. We need to control our blood sugar to protect our brain. This study looked at diabetics and compared them to people with normal glucose response. The progression to diabetes seemed to have a negative effect on higher function as compared to people with prediabetes. However, the vast majority of people with prediabetes will progress to diabetes. In my opinion, it just makes sense to intervene when prediabetes is present. The best intervention is not developing diabetes or even prediabetes. This is achieved by lowering insulin resistance and is best achieved by a diet eliminating sugar and starchy carbohydrates. Control of blood pressure also appears to be vitally important in the prevention of cognitive impairment and dementia and should be a goal of prevention. 
Better Food, Better Fertility
Improved diet associated with improved fertility for men and women
This review looked at the effects of diet on fertility and found that a healthy diet with high amounts of fish, poultry, whole grains, vegetables and fruits was associated with improved female fertility and better semen quality in men. In women, supplemental folic acid and omega-3 fatty acids are also beneficial. For men, antioxidants are helpful. 
  • The literature on the relation between diet and human fertility has greatly expanded over the last decade resulting in the identification of a few clear patterns. Intake of supplemental folic acid, particularly at doses higher than those recommended for the prevention of neural tube defects, has been consistently related to lower frequency of infertility, lower risk of pregnancy loss and greater success in infertility treatment. On the other hand, and despite promising evidence from animal models, vitamin D does not appear to exert an important role in human fertility in the absence of deficiency. Antioxidant supplementation does not appear to offer any benefits to women undergoing infertility treatment, but it appears to be beneficial when it is the male partner who is supplemented. However, the available evidence does not allow discerning which specific antioxidants, nor at which doses, are responsible for this benefit. Long chain omega 3 fatty acids appear to improve female fertility although it remains unclear to what extent contamination of shared food sources, such as fish with high levels of environmental toxicants, can dampen this benefit. Last, adherence to healthy diets favoring seafood, poultry, whole grains, fruits and vegetables, are related to better fertility in women and better semen quality in men. The cumulative evidence has also piled against popular hypotheses. Dairy and soy, once proposed as reproductive toxicants, have not been consistently related to poor fertility. In fact, soy and soy supplements appear to exert a beneficial effect among women undergoing infertility treatment. Similarly, as data from large, high-quality studies continues to accumulate, the evidence of a potentially deleterious effect of moderate alcohol and caffeine intake on the ability to become pregnant seems less solid than it once did. While a complete picture of the role of nutrition on fertility is far from complete, much progress has been made. The most salient gaps in the current evidence include jointly considering female and male diets, and testing the most consistent findings in randomized trials.
Between 15-25% of couples have difficulty conceiving. Anything that can be beneficial is certainly worthwhile. This review looked to determine dietary factors which could be beneficial for couples attempting to conceive and found that a diet rich in vegetables, fruits, fish, poultry and whole grains is beneficial for both men and women. Women also benefit from supplemental folic acid (found in prenatal vitamins) and increased omega-3 intake. Antioxidants were not helpful for women, but were beneficial for men so should be considered. Vitamin D supplementation didn't appear to help if no deficiency was present.  Caffeine did not seem to have any negative effects. For those attempting or thinking of conceiving, it makes sense to improve your diet to improve your chances of success. 

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. 


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.