August Newsletter
In This Issue
Can Diet Help Our Knees?
Sunshine Thinking
We "Heart" Chocolate
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'm not sure where the summer went and it's hard to believe it's Labor Day Weekend already. As I sit in my office I can hear the Harleys rumbling past as they roll into town. It should be a great weekend in Milwaukee! Hopefully the weather cooperates for all the festivities. If you are driving, keep your eyes open and if you are riding, keep the rubber on the road! I hope everyone has a great weekend!

Osteoarthritis is a major problem worldwide. As the population ages, more of us will have issues with arthritis, especially of the knees. Is there a way that we can improve or protect our knees from arthritis? The authors of the first study think that there is. The best part is that it doesn't involve drugs or even supplements. 

We all worry about cognitive decline as we age. Unfortunately, we currently don't have any medications that make meaningful changes in this problem. Can we prevent it from happening? Are there ways to treat it besides medications? There may be a couple of simple things we can incorporate into our lives to help improve our chances of preventing or slowing the onset of cognitive decline. 

Chocolate. Most of us like it. Some of us love it. The third article explores the health benefits of chocolate and specifically how much we can eat to achieve these health benefits. Enjoy!

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Can Diet Help Our Knees? 
Mediterranean diet improved knee cartilage
knee arthritis
Can you prevent or even improve the thickness of your knee cartilage through diet? That is the question investigators set out to answer in this study from Clinical Rheumatology. The followed 783 patients and evaluated their adherence to the Mediterranean diet and used MRI scan to evaluate knee cartilage thickness and quality. They found that those people who adhered most closely to the Mediterranean diet had improvement in knee cartilage volume and thickness on MRI. This diet may have a protective effect on knee osteoarthritis. 
  • The Mediterranean diet appears to be beneficial for osteoarthritis (OA), but the few data available regarding the association between the diet and the condition are limited to X-ray and clinical findings. The current study aimed to investigate the association between adherence to the Mediterranean diet and knee cartilage morphology, assessed using magnetic resonance (MRI) in a cohort of North American participants. Seven hundred eighty-three participants in the Osteoarthritis Initiative (59.8% females; mean age 62.3 years) in possession of a MRI assessment (a coronal 3D FLASH with Water Excitation MR sequence of the right knee) were enrolled in our cross-sectional study. Adherence to the Mediterranean diet was evaluated using a validated Mediterranean diet score (aMED). The strength of the association between aMED and knee MRI parameters was gauged using an adjusted linear regression analysis, expressed as standardized betas with 95% confidence intervals (CIs). Using an adjusted linear regression analysis, each increase of one standard deviation (SD) in the aMED corresponded to a significant increase in the central medial femoral cartilage volume (beta = 0.12; 95%CI 0.09 to 0.15), in the mean central medial femoral cartilage thickness (beta = 0.13; 95%CI 0.01 to 0.17), in the cartilage thickness of the mean central medial tibiofemoral compartment (beta = 0.12; 95% CI 0.09 to 0.15, and in the cartilage volume of the medial tibiofemoral compartment (beta = 0.09; 95% CI 0.06 to 0.12). Higher adherence to a Mediterranean diet was found to be associated with a significant improvement in knee cartilage as assessed by MRI, even after adjusting for potential confounding factors.
Osteoarthritis (OA) is found in worldwide in 10% of men and 20% of women over age 60 and OA is the most common cause of musculoskeletal disability in the elderly. As our population ages, the prevalence of OA is continuing to increase. MRI can improve early detection of changes in the knee articular cartilage, but due to cost isn't used routinely to evaluate the articular cartilage of the knee. This study sought to look at diet as a possible factor in the quality of knee cartilage and used MRI scans for assessment. Findings included increased cartilage volume and thickness in people who most closely adhered to the Mediterranean diet. People who most closely followed the diet also had lower body mass index (BMI) values, higher education levels, higher income, and fewer medical problems. After accounting for these factors, the authors still found signficant association between Mediterranean diet and knee joint cartilage thickness and volume, which suggests a protective effect on knee OA since loss of cartilage volume and thickness are signs of early OA. 

I'm not sure that we can account for all of this based only on diet. However, the Mediterranean diet has been shown to lower weight and BMI, which we know is helpful for people with OA. Additionally, this diet may lower inflammatory markers and oxidative stress markers while also  improving remodeling, all of which could be beneficial. While I don't think this study definitively proves improvement and didn't address function which is more important than imaging in how OA is treated, it certainly gives us yet another reason, along with potential reduction in heart disease, cancer and Alzheimer's to consider incorporating a Mediterranean style diet into our lifestyle. 

Sunshine Thinking
People with low vitamin D levels more likely to have lower cognitive function scores

This study, from the Cooper Clinic in Dallas evaluated 4,358 relatively healthy people and found that low vitamin D levels (< 30 ng/mL) was associated with lower scores on cognitive testing. The also assessed cardiorespiratory fitness with stress testing. They found risk factors for lower cognitive testing were age and low vitamin D level. Protective factors were female sex, higher education and physical fitness. Having a low vitamin D level increased risk of lower cognitive scores by 26%.  

  • Low blood level of vitamin D and low physical activity have been linked to the development of cognitive impairment in older adults. The purpose of the present study was to examine the relationship between serum vitamin D and cognition as measured via the Montreal Cognitive Assessment (MoCA) in a healthy, older population. The study sample consisted of 4358 patients from the Cooper Clinic in Dallas, TX. All participants underwent a maximal graded exercise test to determine cardiorespiratory fitness (CRF). Cognitive impairment was defined as a MoCA score <25. Low vitamin D status was defined as serum 25-hydroxyvitamin D <30 ng/mL. Multivariable logistic regression analysis was employed to evaluate the association between vitamin D blood level and MoCA score. A low MoCA score was directly associated with higher age (OR: 1.75, 95% CI: 1.53, 1.99), and inversely associated with female sex (OR: 0.63, 95% CI: 0.51, 0.77), and years of education (OR: 0.87, 95% CI: 0.84, 0.91). When controlling for significant predictors (age, sex, and education), the low vitamin D group had a significantly greater likelihood of having a low MoCA score (OR: 1.26, 95% CI: 1.04, 1.51). The vitamin D effect remained significant when CRF was added to the model (OR: 1.23, 95% CI: 1.02, 1.48). In conclusion, low vitamin D was shown to be associated with cognitive impairment. Therefore, preventive measures such as vitamin D supplementation may play a protective role in memory loss and/or age-associated cognitive decline.
Dementia and cognitive decline are one of the major concerns as we age and we are all looking for ways to slow or eliminate this decline. This study found a couple of modifiable factors that  can decrease our risk. The first is physical activity. The more active people are, the lower their risk. Each level of increase in activity and fitness decreases our risk by 6% and improves our brain volume. This is definitely an area we should focus on. Additionally, improved fitness will likely improve our metabolic parameters and insulin sensitivity which will benefit us in multiple other ways as well. 

The second modifiable factor the authors found was vitamin D level. Vitamin D has been found to be neuroprotective by regulating calcium hemostasis, reducing amyloid deposits and reversing inflammatory changes in the brain. This study suggests an association, not causation. 
it seems reasonable to supplement vitamin D as there is a very low side-effect profile and it could have benefits for cognition as well as other functions. 

Additionally, it makes sense to avoid other things that can possibly cause increased cognitive decline by removing certain medications (proton pump inhibitors, anticholinergics), treat depression (exercise is great for this), control blood pressure, and lower insulin resistance. Exercising the mind and body, eating a Mediterranean type diet, increased social support and connection and maintaining optimal weight can lower our risk of cognitive decline by 15-20%. 
We "Heart" Chocolate
Chocolate decreases risk of cardiovascular disease (to a point)
This study was a meta-analysis of several studies to try to answer the question of a dose response to healthy effects of chocolate on cardiovascular disease including stroke, heart attacks and heart failure. They analyzed 14 articles with 23 studies and found evidence of a reduction in risk between chocolate intake, heart disease and heart failure. The greatest reduction was between 45-75 g/week (approximately one square daily). The protective effect is lost when intake exceeds 100 g/week where the increased intake could potentially lead to weight gain. 


  • OBJECTIVE:  Studies investigating the impact of chocolate consumption on cardiovascular disease (CVD) have reached inconsistent conclusions. As such, a quantitative assessment of the dose-response association between chocolate consumption and incident CVD has not been reported. We performed a systematic review and meta-analysis of studies assessing the risk of CVD with chocolate consumption.    
  • METHODS: PubMed and EMBASE databases were searched for articles published up to 6 June 2018. Restricted cubic splines were used to model the dose-response association. 
  • RESULTS: Fourteen publications (23 studies including 405,304 participants and 35,093 cases of CVD) were included in the meta-analysis. The summary of relative risk (RR) per 20 g/week increase in chocolate consumption was 0.982 (95% CI 0.972 to 0.992, I2=50.4%, n=18) for CVD (heart failure: 0.995 (0.981 to 1.010, I2=36.3%, n=5); total stroke: 0.956 (0.932 to 0.980, I2=25.5%, n=7); cerebral infarction: 0.952 (0.917 to 0.988, I2=0.0%, n=4); haemorrhagic stroke: 0.931 (0.871 to 0.994, I2=0.0%, n=4); myocardial infarction: 0.981 (0.964 to 0.997, I2=0.0%, n=3); coronary heart disease: 0.986 (0.973 to 0.999, n=1)). A non-linear dose-response (pnon-linearity=0.001) indicated that the most appropriate dose of chocolate consumption for reducing risk of CVD was 45 g/week (RR 0.890;95%CI 0.849 to 0.932).
  • CONCLUSIONS: Chocolate consumption may be associated with reduced risk of CVD at < 100 g/week consumption. Higher levels may negate the health benefits and induce adverse effects associated with high sugar consumption.

There have been some inconsistent studies looking at chocolate and heart disease. The authors of this study hypothesized that there could be a dose response to chocolate. That is, some chocolate is good, too much is bad. That seems to be what they found. A protective effect was noted for around 1 square of chocolate daily (on average) but more than 100 g/week was detrimental. This study had some issue as intake was self reported and didn't specify the type of chocolate. I always recommend the highest percentage of cacao you like (preferably over 70%) as this has been linked to health benefits. For reference 30 g is 1 oz so keeping chocolate intake in the 1.5-2.5 oz/week will put you in the sweet spot for heart protection! 

Chocolate Consumption and Risk of Cardiovascular Diseases: A Meta-Analysis of Prospective Studies Heart 2018 Jul 30.

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. 

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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.