May Newsletter
In This Issue
Good For the Joints, Good For the Heart
Can Screen Time Cause ADHD?
Food and Disability
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. The observance of Memorial Day is the unofficial start of the summer season (although I don't think Mother Nature got the memo) but more importantly a solemn reminder of the blood shed for the freedom we enjoy in this country. I came across pictures taken by Milwaukee Journal-Sentinel photographer Mike De Sisti of Wisconsin Army National Guard soldiers reuniting with their families. Seeing pictures of kids in their father's arms really reminds one of the sacrifices made by our soldiers but also by their families. On Tuesday the front page of the Wall Street Journal showed a girl who is growing up without her father who gave his life for our country. I would like to take this opportunity to thank all who have served and the families who support them. 

Can a supplement used to relieve arthritic joint pain actually help protect you from cardiovascular disease? The first article this month explores the relationship between this musculoskeletal supplement and cardiovascular disease. The results may surprise you. This is of special interest if you are a smoker or previously smoked. 

We all spend a ton of time looking at screens. Many of us are looking at screens all day for work or school. When we aren't looking at large screens, we are probably staring at our phone screens. Many of us feel like we are getting more ADD because of this. But what about our kids? What are the effects of screens on their development? The second study looks at the relationship between the quantity of screen time in preschoolers and the incidence of inattentive behavior and diagnosis of ADD. It may make you want to put your phone away.  

One of the major concerns many of us have as we age is disability, the inability to care for ourselves. This problem leads to more hospitalizations, nursing home admissions, and mortality. But what if there is a way to significantly decrease the risk of developing disability and maintaining our independence as we age? Interested? Check out the third article for more information. 

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Good For the Joints, Good For the Heart
Glucosamine use associated with decreased cardiovascular disease
Can a supplement taken for joint pain and arthritis actually help prevent heart disease? The answer appears to be yes. This prospective study looked at data over a 7-year period from 466,039 people to see if there was a link between long-term use of glucosamine and risk of cardiovascular disease and strokes. They found that regular use of glucosamine resulted in a lower risk of cardiovascular events independent of  traditional risk factors, including sex, age, income, body mass index, physical activity, healthy diet, alcohol intake, smoking status, diabetes, hypertension, high cholesterol, arthritis, drug use, and other supplement use.
  • Objective: To prospectively assess the association of habitual glucosamine use with risk of cardiovascular disease (CVD) events.
  • Design: Prospective cohort study.
  • Setting: UK Biobank.
  • Participants: 466,039 participants without CVD at baseline who completed a questionnaire on supplement use, which included glucosamine. These participants were enrolled from 2006 to 2010 and were followed up to 2016.
  • Main outcome measures: Incident CVD events, including CVD death, coronary heart disease, and stroke.
  • Results: During a median follow-up of seven years, there were 10,204 incident CVD events, 3060 CVD deaths, 5,745 coronary heart disease events, and 3,263 stroke events. After adjustment for age, sex, body mass index, race, lifestyle factors, dietary intakes, drug use, and other supplement use, glucosamine use was associated with a significantly lower risk of total CVD events (hazard ratio 0.85, 95% confidence interval 0.80 to 0.90), CVD death (0.78, 0.70 to 0.87), coronary heart disease (0.82, 0.76 to 0.88), and stroke (0.91, 0.83 to 1.00).
  • Conclusion: Habitual use of glucosamine supplement to relieve osteoarthritis pain might also be related to lower risks of CVD events.

Glucosamine is a supplement commonly taken by many people to help with joint pain and arthritis symptoms. It is thought to be a disease-modifying agent for osteoarthritis by retaining fluid in the joint cartilage and has been shown in a study to be as effective and Celebrex (a prescription anti-inflammatory medication).

In this study, regular users of glucosamine had an overall 15% decrease in cardiovascular events and a 22% decrease in death due to cardiac disease. Smokers benefited the most and had a huge 37% decrease in cardiovascular events. These are pretty impressive numbers. 

What are the potential mechanisms behind this? Other studies have shown a significant reduction in C reactive protein (CRP) concentrations in people taking glucosamine. CRP is a marker of inflammation and thus glucosamine seems to act in the body as an anti-inflammatory. Lowered inflammation results in better outcomes in heart disease. Smokers tend to have higher levels of inflammation so as a result, the anti-inflammatory glucosamine had more effect (37% reduction). Additional studies have shown that it could mimic a low carbohydrate diet by decreasing glycolysis. Low carbohydrate diets have been related to a reduced risk of cardiovascular disease in some studies. As most of my regular readers know, I believe that inflammation in the body is a major culprit in most chronic diseases and that I favor a lower carb nutrition plan. This supplement can potentially aid in both of these areas. A caveat is that people who take glucosamine regularly may have other healthy habits that weren't captured by the data as well, although the researchers did note a large number of factors including sex, age, income, body mass index, physical activity, healthy diet, alcohol intake, smoking status, diabetes, hypertension, high cholesterol, arthritis, drug use, and other supplement use.

This study didn't note the dose or type of glucosamine that people were taking. If you decide to take glucosamine, I usually recommend the sulfate form (glucosamine sulfate). The sulfur may have additional benefits in the body and it has been the most widely studied in arthritis. The usual dose is 1500 mg daily (often taken as 750 mg twice a day). Glucosamine is often combined with chondroitin which may increase the viscosity of joint fluid. There have been studies showing that chondroitin may be beneficial for heart disease as well. If you take these supplements for arthritis, it can take several weeks to months to feel the effects. The overall side-effect profile is quite low and it is usually well-tolerated by most people. So if you have a bit of joint pain or arthritis, glucosamine may be a good option for you with the added benefit of reduced heart disease! 

Can Screen-Time Cause ADHD? 
Screen-time associated with inattention problems in preschoolers

Is letting my child play with the iPad making them more at risk for ADHD?  This study examined the habits of over 2,000 preschool children. The kids in the study averaged 1.4 hours of screen time daily in 3-year-olds and 1.5 hours daily in 5-year-olds. When comparing the lowest group of exposure to screens (<30 minutes) with the highest group (> 2 hours) there was a nearly 6-fold increase in inattention symptoms. Preschoolers in general (outside the study) have been shown to average 2 hours of screen time daily which would seem to put them at higher risk for inattention symptoms and ADHD. 

  • BACKGROUND: Pre-school children spend an average of two-hours daily using screens. We examined associations between screen-time on pre-school behavior using data from the Canadian Healthy Infant Longitudinal Development (CHILD) study.
  • METHODS: CHILD participant parents completed the Child Behavior Checklist (CBCL) at five-years of age. Parents reported their child's total screen-time including gaming and mobile devices. Screen-time was categorized using the recommended threshold of two-hours/day for five-years or one-hour/day for three-years. Multiple linear regression examined associations between screen-time and externalizing behavior (e.g. inattention and aggression). Multiple logistic regression identified characteristics of children at risk for clinically significant externalizing problems (CBCL T-score≥65).
  • RESULTS: Screen-time was available for over 95% of children (2,322/2,427) with CBCL data. Mean screen-time was 1·4 hours/day (95%CI 1·4, 1·5) at five-years and 1·5 hours/day (95%CI: 1·5, 1·6) at three-years. Compared to children with less than 30-minutes/day screen-time, those watching more than two-hours/day (13·7%) had a 2·2-point increase in externalizing T-score (95%CI: 0·9, 3·5, p≤0·001); a five-fold increased odd for reporting clinically significant externalizing problems (95%CI: 1·0, 25·0, p = 0·05); and were 5·9 times more likely to report clinically significant inattention problems (95%CI: 1·6, 21·5, p = 0·01). Children with a DSM-5 ADHD T-score above the 65 clinical cut-off were considered to have significant ADHD type symptoms (n = 24). Children with more than 2-hours of screen-time/day had a 7·7-fold increased risk of meeting criteria for ADHD (95%CI: 1·6, 38·1, p = 0·01). There was no significant association between screen-time and aggressive behaviors (p>0.05).
  • CONCLUSION: Increased screen-time in pre-school is associated with worse inattention problems.


It's so tempting to give our kids a screen (phone or tablet) to entertain them when we are out, at mealtime, or just need to get things done. But is this healthy for our children? Studies have shown that increased screen-time has been associated with unhealthy eating patterns, poor sleep quality, cardiovascular disease, and obesity in kids. Where screen time used to only be television, with our technological advances screens are now constantly available. This Canadian study suggests that giving kids more screen time may be detrimental and there seems to be a dose-response relationship between screen time and behavioral issues. There is a question as to the reason for this relationship. It certainly is possible that kids who are more likely to have behavior issues such as ADHD are more likely to be drawn to screens resulting in more screen time.  

So what should we do as parents and grandparents about kids and screens? First, it makes sense to limit screen time. Two hours daily looks to be a possible threshold so keeping kids well below that and trying to limit closer to 30 minutes or less daily as a goal. There was almost 6 times increase in inattention problems and 7.7 times increase in ADHD diagnosis between 30 minutes or less group and the 2 hour or more group. Second, not all screen content is equal. Educational content may have a different effect than entertainment media. This study didn't break out this factor. Finally, c hildren who participated in more physical activity were less likely to have behavioral issues. Bottom line, keep screen exposure less than 30 minutes daily, make the majority of screen exposure educational content, read books with them, and get the kids outside to play!
Food and Disability
Healthy diet linked to lower odds of physical impairment 
Can a better diet help protect us from disability as we age? This study examined over 12,000 men and found that better diet quality is significantly associated with lower odds of impairment of physical function. The researchers found that each 10-point increase in total Alternative Healthy Eating Index (AHEI) score was associated with 10 percent lower odds of impairment in physical function. Men with AHEI scores in the top quintile had a 26 percent lower odds of impairment versus men in the bottom quintile. Positive associations were seen for higher intake of vegetables, nuts, legumes, and polyunsaturated fatty acids with lower intake of red and processed meats and sugar-sweetened beverages. 

  • Objectives: Physical function is increasingly recognized as integral to healthy aging, in particular as a core component of mobility and independent living in older adults. Thus, it is important to identify strategies for the prevention of physical function decline.
  • Design: Longitudinal cohort study.
  • Setting and Participants: A total of 12,658 men from the Health Professionals Follow-Up Study were followed from 2008-2012.
  • Measurements: We examined the association between the Alternative Healthy Eating Index-2010 (AHEI), a measure of diet quality combining 11 dietary components (vegetables, fruits, nuts and legumes, red and processed meats, sugar-sweetened beverages and fruit juices, alcohol, whole grains, omega-3 fatty acids, polyunsaturated fatty acids, trans fatty acids, sodium), and impairment in physical function, as measured by the SF-36. Multivariable logistic regression models were used to estimate the odds ratios (OR) and 95% confidence intervals (CI) of impairment in physical function.
  • Results: In the multivariable-adjusted model, each 10-point increase in total AHEI score was associated with a 10% lower odds of impairment in physical function (OR=0.90, 95% CI: 0.86,0.95), and in the categorical analysis, men with AHEI scores in the top quintile had a 26% lower odds (OR=0.74, 95% CI:0.63,0.86) compared with men in the bottom quintile. For individual AHEI components, higher intake of vegetables (p-trend=0.01), nuts and legumes (p-trend<0.01), polyunsaturated fatty acids (p-trend<0.01) and lower intake of red and processed meats (p-trend=0.03) and sugar-sweetened beverages (p-trend=0.01) were significantly associated with lower odds of physical impairment. For specific foods, higher consumption of lettuce, broccoli, blueberries, peanuts, walnuts and other nuts were associated with lower odds of impairment.
  • Conclusions: In this large cohort of older men, better overall diet quality was significantly associated with a lower odds of impairment in physical function. Given the value of physical function to healthy aging and quality of life, this may represent a particularly compelling public health rationale for older men to improve their diet.

Physical function is the ability to perform activities of daily living (ADL) and is integral to healthy aging. ADLs include eating, bathing, dressing, being able to get on and off the toilet and perform personal hygiene, getting out of a chair without assistance and controlling bowel and bladder functions. Decreased physical function is related to hospitalizations, long-term nursing home placement and increased mortality. So this study should be of interest to all of us. A healthier diet pattern was associated with over 25% lower likelihood of developing impairment in physical function with aging. This study only looked at men, but I see no reason that women wouldn't experience similar effects. 

So what should we emphasize in our diets to get this benefit? The study found a higher intake of vegetables, nuts and legumes, and polyunsaturated fats was beneficial along with lower intake of red and processed meats and sugar-sweetened beverages. Greater intakes of green leafy vegetables (lettuce), cruciferous vegetables like broccoli, peanuts, walnuts and other nuts all reduced odds of impairment of physical function. 

Previous studies have shown that diets high in vegetables, legumes, fish, poultry, fruit and whole grains are inversely associated with levels of inflammatory markers in blood tests. Vegetables and fruits are also rich in antioxidants which may reduce accumulation of oxidative damage and thus many chronic diseases such as cancer, heart disease and dementia.

This study adds more proof that what we put in our mouths has a profound effect on our health. Choose wisely! 

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.