May Newsletter
In This Issue
Fat Chance
Lower Risk Quick!
Save Your Knees
A Better Model of Medical Care
Old-fashioned medicine with 21st Century convenience and technology
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Welcome to the May 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.   
As we continue to progress from "sheltering in home" and begin to venture out, more information is necessary to determine who is actually at increased risk of a COVID-19 infection turning into a severe problem. We all know by now that age seems to be a risk factor, living in a nursing home is a huge risk factor, and "preexisting conditions" are risk factors. The first article outlines what I have not seen mentioned in many reports and may be the largest risk factor for the general population.    
While we have all been focusing on COVID-19 disease and deaths, we need to remember that the number one cause of death in the United States by far is cardiovascular disease. The second study focuses on changes we can make in our nutrition to quickly lower markers used to detect cardiac damage and strain. 
The knee is the joint most affected by arthritis with up to 45% of us developing symptoms during our lifetimes. Are there things we should do or avoid to "protect our knees"? The third study looked at the effects of strenuous exercise and prolonged sitting on our knee cartilage. If you are concerned about your knees, check out this article. 
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 now have saliva based PCR tests readily available in my office with 24 hour turnaround. Serum antibody tests can be performed as well with 24 hour turnaround. Please continue to wash your hands frequently, avoid touching your face, and avoid going out if you are sick.   
Fat Chance
Obesity associated with increased severity of COVID-19
fat belly
As the coronavirus pandemic has progressed, we have been presented information regarding risk. We know there is increased risk from older age and chronic medical conditions. However, many other demographic and clinical characteristics of this novel coronavirus and how these factors might affect disease progression remain unclear. 

Previous studies suggest that obesity is associated with poorer immune response and outcomes in patients with respiratory disease. This study explored the hypothesis that higher BMI is a risk factor for progression to severe COVID-19 infection, independent of common risk factors. 

The researchers studied 383 consecutive patients hospitalized during the outbreak in China. They found that obesity significantly increased the risk of developing severe COVID-19 infection symptoms, especially in men (women not clear due to smaller numbers). Patients who were obese were at increased odds of progressing to severe disease, and the association remained significant after adjusting for comorbidities and other risk factors.
  • OBJECTIVE: Patients with obesity are at increased risk of exacerbations from viral respiratory infections. However, the association of obesity with the severity of coronavirus disease 2019 (COVID-19) is unclear. We examined this association using data from the only referral hospital in Shenzhen, China.
  • RESEARCH DESIGN AND METHODS: A total of 383 consecutively hospitalized patients with COVID-19 admitted from 11 January 2020 to 16 February 2020 and followed until 26 March 2020 at the Third People's Hospital of Shenzhen were included. Underweight was defined as a BMI <18.5 kg/m2, normal weight as 18.5-23.9 kg/m2, overweight as 24.0-27.9 kg/m2, and obesity as ≥28 kg/m2.
  • RESULTS: Of the 383 patients, 53.1% were normal weight, 4.2% were underweight, 32.0% were overweight, and 10.7% were obese at admission. Obese patients tended to have symptoms of cough (P = 0.03) and fever (P = 0.06) compared with patients who were not obese. Compared with normal weight patients, those who were overweight had 1.84-fold odds of developing severe COVID-19 (odds ratio [OR] 1.84, 95% CI 0.99-3.43, P = 0.05), while those who were obese were at 3.40-fold odds of developing severe disease (OR 3.40, 95% CI 1.40-2.86, P = 0.007), after adjusting for age, sex, epidemiological characteristics, days from disease onset to hospitalization, presence of hypertension, diabetes, cardiovascular disease, chronic obstructive pulmonary disease, liver disease and cancer, and drug used for treatment. Additionally, after similar adjustment, men who were obese versus those who were normal weight were at increased odds of developing severe COVID-19 (OR 5.66, 95% CI 1.80-17.75, P = 0.003).
  • CONCLUSIONS: In this study, obese patients had increased odds of progressing to severe COVID-19. As the severe acute respiratory syndrome coronavirus 2 may continue to spread worldwide, clinicians should pay close attention to obese patients, who should be carefully managed with prompt and aggressive treatment.

There are several things we have seen as possibilities for increased risk for poor COVID-19 outcomes. One is the higher rate of severe outcomes and deaths in people who have preexisting conditions like diabetes, hypertension, and heart disease. Additionally, there seem to be more severe infections in minority populations (African-American and Hispanic). One issue that has not been addressed in the media reports is what this paper addresses, the effects of obesity on outcomes. This study factored out other preexisting disease processes (hypertension, diabetes, lung disease, and heart disease) and looked at obesity as an independent risk factor. What they found was very significant. People who were even in the overweight category showed an 84% increased chance of severe illness and those in the obese category (BMI >28) had a whopping 340% increase in severe illness. Another study found that people with fatty liver disease, found in overweight and obese people, had a 6-fold increased risk of severe disease. When we look at the other disease processes generally mentioned as an increased risk, they are all associated with obesity. But how much increased risk is the medical condition and how much is obesity? Obesity is not mentioned in the reports of people who have died as a preexisting condition, but it definitely should be as it appears from this study and others that it may be THE major risk factor for severe disease. I suspect obesity may play a role in the worse outcomes from COVID-19 infections we are seeing in our minority populations. According to CDC data, the prevalence of obesity in non-Hispanic blacks was 49.6% and 44.8% in the Hispanic population (vs 42% in white and 17% in Asian) with non-Hispanic black women were 56.9%. What this means is that our health care system should keep very close tabs on any COVID-19 positive individuals who are overweight or obese as there are greatly increased potential risk of severe disease outcome. 
Lower Risk Quick!
Eating more vegetables and fruits quickly lowers cardiac risk markers
fruits and vegetables

Cardiovascular disease is the number one cause of death in the United States with almost 650,000 deaths annually. We all know that a healthy lifestyle including a healthy diet is the best way to maintain our cardiovascular health and a poor diet is one of the biggest risks. This study reviewed data from the original DASH study pulling out data on 3 biomarkers corresponding to cardiac damage, strain, and inflammation. These are "subclinical" markers of cardiac damage. The subjects were fed 1 of 3 diets, a control diet that was low in fruits, vegetables, and dairy but high in fat; a "fruit and vegetable" diet that was also high in fat; or the DASH diet, which was high in fruits, vegetables, and dairy but low in fat. The groups were then followed for 8 weeks. Both the fruit and vegetable diet and the DASH diet reduced troponin I concentrations (cardiac damage) and NT-proBNP levels (cardiac strain), compared to the control diet. But levels of hs-CRP (inflammation) did not differ among diets.

  • Background: The DASH diet has been found to lower blood pressure (BP) and low-density lipoprotein cholesterol levels.
  • Objective: To compare diets rich in fruits and vegetables with a typical American diet in their effects on cardiovascular injury in middle-aged adults without known preexisting cardiovascular disease (CVD).
  • Design: Observational study based on a 3-group, parallel-design, randomized trial conducted in the United States from 1994 to 1996. ( NCT00000544)
  • Setting: 3 of the 4 original clinical trial centers.
  • Participants: 326 of the original 459 trial participants with available stored specimens.
  • Intervention: Participants were randomly assigned to 8 weeks of monitored feeding with a control diet typical of what many Americans eat; a diet rich in fruits and vegetables but otherwise similar to the control diet; or the DASH diet, which is rich in fruits, vegetables, low-fat dairy, and fiber and has low levels of saturated fat and cholesterol. Weight was kept constant throughout feeding.
  • Measurements: Biomarkers collected at baseline and 8 weeks: high-sensitivity cardiac troponin I (hs-cTnI), N-terminal pro-B-type natriuretic peptide (NT-proBNP), and high-sensitivity C-reactive protein (hs-CRP).
  • Results: The mean age of participants was 45.2 years, 48% were women, 49% were black, and mean baseline BP was 131/85 mm Hg. Compared with the control diet, the fruit-and-vegetable diet reduced hs-cTnI levels by 0.5 ng/L (95% CI, −0.9 to −0.2 ng/L) and NT-proBNP levels by 0.3 pg/mL (CI, −0.5 to −0.1 pg/mL). Compared with the control diet, the DASH diet reduced hs-cTnI levels by 0.5 ng/L (CI, −0.9 to −0.1 ng/L) and NT-proBNP levels by 0.3 pg/mL (CI, −0.5 to −0.04 pg/mL). Levels of hs-CRP did not differ among diets. None of the markers differed between the fruit-and-vegetable and DASH diets.
  • Limitation: Short duration, missing specimens, and an inability to isolate the effects of specific foods or micronutrients.
  • Conclusion: Diets rich in fruits and vegetables given over 8 weeks were associated with lower levels of markers for subclinical cardiac damage and strain in adults without preexisting CVD.

This study is quite interesting as it shows that significant positive changes in cardiovascular risk markers can be achieved in a short period of time. It demonstrates the efficacy of a mainly plant-based diet in lowering the cardiac risk markers of cardiac strain and myocardial damage. This isn't an outcome study so this doesn't prove that people who adhere to the diet will actually have lower mortality over time but it is certainly compelling to note that we can make changes in our diets (addition of several servings of vegetables and fruits) and see very quick reductions in markers of cardiac damage and strain. These are the markers we look at when people are having heart attacks or are in heart failure. It is interesting that the inflammatory marker wasn't lowered but I would suspect that over time this would decrease as well as I have seen this clinically in my practice. While COVID-19 may be our major focus at the present time, over the long haul, cardiovascular disease should be our focus to achieve longevity. Here are a few simple ways to add more vegetables to your diet. I personally enjoy #4. Bon appetit!   
Save Your Knees
Long-term physical activity does not increase knee arthritis 
knee arthritis
Many people avoid strenuous exercise to "save their knees". But do we have to do this? Are runners and people who exercise vigorously more likely to develop knee arthritis later in life? This study, out of Northwestern University, followed 1,194 community-dwelling adults at high risk of knee arthritis in four cities over an 8-year period of time to evaluate the relationship between strenuous physical activity participation as well as extensive sitting on joint health. 
  • Importance  Persons with knee symptoms recognize the health benefits of engaging in physical activity, but uncertainty persists about whether regular strenuous physical activity or exercise can accelerate tissue damage. A sedentary lifestyle of inactivity or underloading may also be associated with deleterious joint health.
  • Objective  To establish whether long-term strenuous physical activity participation and extensive sitting behavior are each associated with increased risk of developing radiographic knee osteoarthritis (KOA) in individuals at high risk for the disease.
  • Design, Setting, and Participants  This cohort study analyzed data from the Osteoarthritis Initiative, a prospective longitudinal cohort study of men and women with or at an increased risk of developing symptomatic, radiographic KOA. Community-dwelling adults were recruited from 4 US sites (Baltimore, Maryland; Columbus, Ohio; Pittsburgh, Pennsylvania; and Pawtucket, Rhode Island) and were followed up for up to 10 years. Individuals were included if they had a baseline Kellgren and Lawrence grade of 0 in both knees and completed a PASE (Physical Activity Scale for the Elderly) questionnaire at baseline and at least 2 follow-up visits over an 8-year interval. Data analyses were conducted from May 2018 to November 2018.
  • Exposures  Baseline to 8-year trajectories of strenuous physical activity participation and extensive sitting behavior were identified using group-based trajectory models.
  • Main Outcomes and Measures  Incident radiographic KOA, defined as Kellgren and Lawrence grade 2 or higher in either knee by the 10-year follow-up visit.
  • Results  A total of 1194 participants were included in the sample (697 women [58.4%]), with a baseline mean (SD) age of 58.4 (8.9) years and mean body mass index (BMI) of 26.8 (4.5). Four distinct trajectories of weekly hours spent in strenuous physical activities and 3 distinct trajectories of extensive sitting were identified. Long-term engagement in low-to-moderate physical activities (adjusted odds ratio [OR], 0.69; 95% CI, 0.48-1.01) or any strenuous physical activities (adjusted OR, 0.75; 95% CI, 0.53-1.07) was not associated with 10-year incident radiographic KOA. Persistent extensive sitting was not associated with incident KOA. Despite relatively mild symptoms and high function in this early-stage sample, 594 participants (49.7%) did not engage in any strenuous physical activities (ie, 0 h/wk) across 8 years, and 507 (42.5%) engaged in persistent moderate-to-high frequency of extensive sitting. Older age, higher BMI, more severe knee pain, non-college graduate educational level, weaker quadriceps, and depression were each associated with a persistent lack of engagement in strenuous physical activities.
  • Conclusions and Relevance  Results from this study appeared to show no association between long-term strenuous physical activity participation and incident radiographic KOA. The findings raise the possibility of a protective association between incident KOA and a low-to-moderate level of strenuous physical activities.

Participation in regular exercise, sports, and recreational activities has multiple health benefits, promotes well being, weight management, and preserve function and quality of life while sedentary behaviors tend to be associated with adverse health outcomes. Osteoarthritis is the most common joint disorder in the United States affecting over 32 million adults. The knee is the most commonly affected joint with the lifetime risk of developing symptomatic, radiographic knee arthritis is approximately 38-45% and an estimated median age at diagnosis of 55 years. 

Many people who feel they are at risk of knee arthritis will avoid strenuous activity as they are concerned that it will accelerate the degeneration of the joint. This study divided people into groups based on activity levels and frequency of sitting. They found that individuals who engaged in physical activity had lower levels of radiographic advancement of arthritis. There was also more arthritis advancement seen in the high-frequency sitting group as opposed to the low or moderate sitting groups. 

The good news is that this study found that people who engaged in strenuous exercise, especially low to moderate exercise did not experience an increase in their risk of developing knee arthritis. If fact, the exercise may be protective. Extensive sitting looks to be associated with a more rapid progression of arthritis. The biggest risk for knee arthritis progression is likely weight gain. Additionally, exercise will help strengthen the muscles around the joint, which is protective. Lack of exercise often makes arthritic joints feel worse. I recommend moving your joints through their full range of motion every day. Do deep knee squats, move your hips, ankles, and shoulders through their full range of motion (yoga is great for this). Here is some information from the Mayo Clinic about exercise and arthritis

Bottom line, if you are concerned about knee arthritis, stay active! 

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.