September Newsletter
In This Issue
Eating for Life
BPA, Is It a Big Deal?
Oh, Honey!
A Better Model of Medical Care
Old-fashioned medicine with 21st Century convenience and technology
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Welcome to the September newsletter. The goal of this newsletter is to provide information and analysis of timely topics from recent articles published in the medical literature. I hope you find this information useful and helpful in your health journey.   
Fall is my favorite time of year. I think we appreciate the warmth of the sun more and the changing of the leaves reminds us that we only have a little time left before the shorts and t-shirts go into the back of the closet. It a great time to get outside and enjoy these last few warm days!

Last month we discussed being an athlete for life. We reviewed exercise techniques that will help us to age well and maintain our function. This month I would like to turn our attention to nutrition. I came across a review in The Journal of the American College of Cardiology which I thought was excellent. While it doesn't answer every question, it provides a nice blueprint for us as we design our individual Eating for Life plans. We need a plan that reduces risk of chronic disease and mortality, improves our insulin sensitivity, and allows us to get the nutrients we need without weight gain. There is a bonus strategy included in the article that you may want to try as well. 

We have all heard of Bisphenol A, more commonly known as BPA, at least peripherally. We see "BPA free" labels and many of us may seek these out. Over 90% of us have significant amounts of this chemical in our bodies. How important is avoiding BPA? Where is it found and what are the long-term effects of high exposure to BPA? 

With the change of seasons comes the cold and flu season. Upper respiratory infections are common, but the symptoms can make us miserable. Most of these infections are viral and antibiotics are not helpful (and may be harmful). Many of the over the counter remedies have side effects and can be problematic for children. What if there is a completely natural remedy with no side effects that we could use to help us feel better? And it tastes great!
Information regarding COVID-19 is constantly changing. Wisconsin is currently a "hot spot" for the virus. If you are feeling sick or concerned about symptoms, please call me first. We can discuss your symptoms and decide the best course of action for you, including testing. I have saliva based COVID-19 PCR tests available in my office with 24+ hour turnaround. Serum antibody tests can be performed as well with 24-hour turnaround. Point of care testing is moving forward and will hopefully be more available soon. Please continue to wash your hands frequently, avoid touching your face, and avoid going out if you are sick.   
Eating for Life 
Pesco-Mediterranean diet with intermittent fasting looks like a winner
Humans are adapted to obtain nutrition form both plant and animal foods. However, many of us overconsume animal products and processed foods. This review looked at the evidence regarding diet and health and made the following conclusions. A Pesco-Mediterranean diet of plants, nuts, extra virgin olive oil and seafood has strong cardioprotective evidence and a daily time-restricted eating window of 8-12 hours is a central component of this diet. 
  • As opportunistic omnivores, humans are evolutionarily adapted to obtain calories and nutrients from both plant and animal food sources. Today, many people overconsume animal products, often-processed meats high in saturated fats and chemical additives. Alternatively, strict veganism can cause nutritional deficiencies and predispose to osteopenia, sarcopenia, and anemia. A logical compromise is a plant-rich diet with fish/seafood as principal sources of animal food. This paper reviews cumulative evidence regarding diet and health, incorporating data from landmark clinical trials of the Mediterranean diet and recommendations from recent authoritative guidelines, to support the hypothesis that a Pesco-Mediterranean diet is ideal for optimizing cardiovascular health. The foundation of this diet is vegetables, fruits, nuts, seeds, legumes, whole grains, and extra-virgin olive oil with fish/seafood and fermented dairy products. Beverages of choice are water, coffee, and tea. Time-restricted eating is recommended, whereby intermittent fasting is done for 12 to 16 h each day.
Humans are adapted to be opportunistic omnivores. We have the enzymes and anatomic adaptations to consume calories from both plant and animal sources. Our ancestors likely consumed between 14-50% of their calories from animal-based foods. However, these were typically low in saturated fats and high in omega 3 fatty acids. Our modern diet overconsumes processed meat and grain products and under consumes high omega 3 foods, whole vegetables, and fermented foods. 

The traditional Mediterranean diet is associated with lower risks for all-cause and CVD mortality, coronary heart disease, metabolic syndrome, diabetes, cognitive decline, neurodegenerative diseases (including Alzheimer's disease), depression, overall cancer mortality, and breast and colorectal cancers. Fish and seafood are important components of the Mediterranean diet due to the cardioprotective properties of the omega 3 fatty acids and provide an array of vitamins, minerals, and other nutrients, some of which are not readily accessible in vegetarian or vegan diets. Dr. David Rakel, Chairman of Family Medicine at the University of New Mexico uses this illustration to rank protein choices.  

Our ancestors did not have access to unlimited food supplies throughout the year and likely adapted to periods of stress and less food supply. Time-restricted eating (a type of intermittent fasting) is the practice of limiting the daily intake of food to a specific window of time, usually between 6-12 hours daily. When done on a regular basis, this practice has been shown to decrease intra-abdominal fat tissue and reduce free-radical production. It elicits powerful cellular responses that improve glucose metabolism and reduce systemic inflammation which may reduce the risk of diabetes, cardiovascular disease, cancer, and neurodegenerative disease (dementia). In the fasted state (12 hours) our insulin levels are low, glycogen stores are depleted and our bodies are mobilizing fatty acids for fuel. Our receptors have a chance to reset and insulin sensitivity improves. Some studies suggest blood pressure is lower as well. When our insulin levels are low, we can burn adipose tissue (fat) and the level of inflammation in our bodies tends to go down. I suggest stopping food intake at a specific time in the evening (perhaps 7 PM) and no food until at least 7 AM the following morning. This is a good opportunity to get some exercise in the morning in a fasted state. With practice, you will be able to extend the fasting period a few more hours. If you would like to try this, start with a couple times a week extended fasting times and work from there. 

Based on this review, our diets should be based on fresh whole foods including vegetables, fruits, nuts, and olive oil with fish from the sea. This pesco-Mediterranean diet with the addition of time restricted eating (8-12 hour eating window) may be the idea cardioprotective diet. 
BPA, Is It a Big Deal? 
Bisphenol A (BPA) associated with increased death

I think we have all heard about Bisphenol A (BPA) and have certainly seen the BPA free labels on water bottles and other containers. But is this a big deal? This study followed 3,883 subjects over an average of 9.6 years and looked at rates of death. At the onset of the study all subjects had their urine tested for BPA levels. Subjects with the highest levels of BPA in their urine were found to have a 49% increased all-cause mortality and 46% increased cardiovascular mortality as compared to those with the lowest levels. 

  • Importance:  Bisphenol A (BPA) is a major public health concern because of its high-volume industrial production, ubiquitous exposure to humans, and potential toxic effects on multiple organs and systems in humans. However, prospective studies regarding the association of BPA exposure with long-term health outcomes are sparse.
  • Objective:  To examine the association of BPA exposure with all-cause mortality and cause-specific mortality among adults in the United States.
  • Design, Setting, and Participants:  This nationally representative cohort study included 3883 adults aged 20 years or older who participated in the US National Health and Nutrition Examination Survey 2003-2008 and provided urine samples for BPA level measurements. Participants were linked to mortality data from survey date through December 31, 2015. Data analyses were conducted in July 2019.
  • Exposures:  Urinary BPA levels were quantified using online solid-phase extraction coupled to high-performance liquid chromatography-isotope dilution tandem mass spectrometry.
  • Main Outcomes and Measures:  Mortality from all causes, cardiovascular disease, and cancer.
  • Results:  This cohort study included 3,883 adults aged 20 years or older (weighted mean [SE] age, 43.6 [0.3] years; 2032 women [weighted, 51.4%]). During 36,514 person-years of follow-up (median, 9.6 years; maximum, 13.1 years), 344 deaths occurred, including 71 deaths from cardiovascular disease and 75 deaths from cancer. Participants with higher urinary BPA levels were at higher risk for death. After adjustment for age, sex, race/ethnicity, socioeconomic status, dietary and lifestyle factors, body mass index, and urinary creatinine levels, the hazard ratio comparing the highest vs lowest tertile of urinary BPA levels was 1.49 (95% CI, 1.01-2.19) for all-cause mortality, 1.46 (95% CI, 0.67-3.15) for cardiovascular disease mortality, and 0.98 (95% CI, 0.40-2.39) for cancer mortality.
  • Conclusions and Relevance:  In this nationally representative cohort of US adults, higher BPA exposure was significantly associated with an increased risk of all-cause mortality. Further studies are needed to replicate these findings in other populations and determine the underlying mechanisms.


Bisphenol A (BPA) is a chemical that is found in over 90% of Americans. It is found in plastics, but it mainly gets into our bodies as it is used as a slippery coating inside of cans and water pipes. It has previously been shown to increase blood pressure and is associated with obesity, metabolic dysfunction, atherosclerosis, diabetes, and arrhythmias. 

In this study, urine BPA levels were evaluated and the subjects were followed for an average of almost 10 years. While no increased risk of cancer was noted, much higher rates of overall mortality and cardiovascular deaths were noted. 

This study makes it clear that we should seek out "BPA free" products. Other steps we can take to reduce our exposure include avoiding microwaving food in plastic containers, drinking from BPA free bottles instead of cans, and avoid canned foods unless they are in BPA free cans. The good news is that 90% of cans now have BPA free linings.
Oh, Honey!
Honey effective for relief of upper respiratory infection symptoms
An area of emphasis over the past several years has been reduction of antibiotic prescriptions for upper respiratory infections (URI) because the vast majority of these are viral in nature and the overuse of antibiotics leads to antibiotic resistance. However, URI do cause significant symptoms and can make us feel pretty miserable. Honey is inexpensive and safe. If we show evidence of therapeutic effectiveness, then use of honey for symptom relief should be encouraged. This systematic review and meta-analysis was designed to evaluate the effectiveness of honey for upper respiratory tract infection symptoms. The study concludes that the use of honey is superior to usual care for improvement in symptoms of URIs. 
  • Background: Antibiotic over prescription for upper respiratory tract infections (URTIs) in primary care exacerbates antimicrobial resistance. There is a need for effective alternatives to antibiotic prescribing. Honey is a lay remedy for URTIs, and has an emerging evidence base for its use. Honey has antimicrobial properties, and guidelines recommended honey for acute cough in children.
  • Objectives: To evaluate the effectiveness of honey for symptomatic relief in URTIs.
  • Methods: A systematic review and meta-analysis. We searched Pubmed, Embase, Web of Science, AMED, Cab abstracts, Cochrane Library, LILACS, and CINAHL with a combination of keywords and MeSH terms.
  • Results: We identified 1,345 unique records, and 14 studies were included. Overall risk of bias was moderate. Compared with usual care, honey improved combined symptom score (three studies, mean difference -3.96, 95% CI -5.42 to -2.51, I2=0%), cough frequency (eight studies, standardised mean difference (SMD) -0.36, 95% CI -0.050 to -0.21, I2=0%) and cough severity (five studies, SMD -0.44, 95% CI -0.64 to -0.25, I2=20%). We combined two studies comparing honey with placebo for relieving combined symptoms (SMD -0.63, 95% CI -1.44 to 0.18, I2=91%).
  • Conclusions: Honey was superior to usual care for the improvement of symptoms of upper respiratory tract infections. It provides a widely available and cheap alternative to antibiotics. Honey could help efforts to slow the spread of antimicrobial resistance, but further high quality, placebo controlled trials are needed.

Antibiotics don't work for viral infections. Despite this fact, many people will request them for viral infections including upper respiratory infections (URI). What we need to do is to treat symptoms so that we don't feel as miserable. Any trip to a pharmacy shows an entire shelf dedicated to OTC remedies for cold symptoms. But many of these can have side-effects, especially for children. A previous review found that honey was beneficial for cough in children and this study wanted to see if there were benefits for other symptoms in other age groups. They found the greatest effect was on cough, but there were improvements in other symptoms as well. We aren't sure of the exact mechanism for these improvements, but honey has been shown to have antioxidant and anti-infectious properties along with forming a local soothing barrier. It is as effective or more effective than many OTC remedies in the pharmacy aisle.  

How should we use honey for relief of URI symptoms? Add 2 tsp of honey to a cup of tea. Drink 3-5 cups daily. Be sure to use a decaffeinated tea (like chamomile) in the afternoon or evening to avoid caffeine consumption. 

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.