November Newsletter
In This Issue
Not All Fat Is Created Equal
Eat Your Veggies
A Way To Slow Knee Arthritis
A New 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. I hope everyone had a wonderful Thanksgiving. It's nice to start the hectic holiday season with a reflection of what is really important, our families. My daughter is home from college 1000 miles away and although this weekend is a whirlwind, I am thankful we are all able to be together. I am also thankful to work in a situation where I get to take time with my patients. I couldn't do it any other way. 


The first article this month looks at the dangers of belly fat. Even people who are 'normal' weight may be at increased risk of premature death if they carry increased belly fat. To see if you are at risk check out this section. 


Last month I discussed how certain fruits and vegetables were beneficial in losing weight. This month I focus on yet another reason eating more fruits and vegetables is beneficial, prevention of heart disease. 


Knee arthritis affects a majority of people during their lives. We are always looking for ways to prevent or treat arthritis. While maintaining a normal weight will always be at the top of the list, there is a supplement that could be beneficial. Check out the third section to see which one it is. 


Click on the links the the left to check out our web site...

Not All Fat Is Created Equal
Belly fat is bad, even if your weight is normal
Can belly fat be a problem even for people who are not overweight? We have all heard about BMI (body mass index) and may even know what ours is. But is BMI the best way to determine risk? This study, published in the Annals of Internal Medicine, shows that measuring your waist may be a better indicator of your risk of premature mortality. The authors studied over 15,000 adults over a mean of 14 years and found that normal weight adults with extra belly fat had the worst long-term survival, regardless of BMI. This was especially true of men with larger bellies. 
Summary of findings:
  • Background: The relationship between central obesity and survival in community-dwelling adults with normal body mass index (BMI) is not well-known. 
  • Objective: To examine total and cardiovascular mortality risks associated with central obesity and normal BMI.
  • Design: Stratified multistage probability design. 
  • Setting: NHANES III (Third National Health and Nutrition Examination Survey). 
  • Participants: 15,184 adults (52.3% women) aged 18 to 90 years.
  • Measurements: Multivariable Cox proportional hazards models were used to evaluate the relationship of obesity patterns defined by BMI and waist-to-hip ratio (WHR) and total and cardiovascular mortality risk after adjustment for confounding factors.
  • Results: Persons with normal-weight central obesity had the worst long-term survival. For example, a man with a normal BMI (22 kg/m2) and central obesity had greater total mortality risk than one with similar BMI but no central obesity (hazard ratio [HR], 1.87 [95% CI, 1.53 to 2.29]), and this man had twice the mortality risk of participants who were overweight or obese according to BMI only (HR, 2.24 [CI, 1.52 to 3.32] and 2.42 [CI, 1.30 to 4.53], respectively). Women with normal-weight central obesity also had a higher mortality risk than those with similar BMI but no central obesity (HR, 1.48 [CI, 1.35 to 1.62]) and those who were obese according to BMI only (HR, 1.32 [CI, 1.15 to 1.51]). Expected survival estimates were consistently lower for those with central obesity when age and BMI were controlled for.
  • Limitations: Body fat distribution was assessed based on anthropometric indicators alone. Information on comorbidities was collected by self-report.
  • Conclusion: Normal-weight central obesity defined by WHR is associated with higher mortality than BMI-defined obesity, particularly in the absence of central fat distribution.

Yes, it appears that belly fat is likely a problem for people who are not even overweight. Having excess fat around your middle boosts your risk of premature death, even if your BMI is in the 'normal' range. This belly fat has been linked to high cholesterol, inflammation, heart disease, stroke and diabetes. More fat around the belly is worse than more fat around the hips. This study found an 87% increased risk of death in a normal weight man with more belly fat compared to a man with normal weight without belly fat. The risk of death was twice as high compared to even overweight or obese men (as measured by BMI). Normal weight women with extra belly fat had almost 50% increased risk of death versus a normal weight woman with lower waist measurement. The risk of death was 32% higher than the higher BMI women. The reason for this is likely related to deposition of fat around the abdominal organs. This type of fat is actually metabolically active, as compared to subcutaneous fat (found in other areas of the body) likely causing the increased inflammation and insulin resistance. This study adds to the evidence that weight alone is not enough to look at risk of chronic disease and death. 

Here are directions on how to measure your waist.   If you waist measurement is over 40 inches for men and 35 inches for women, you are likely at higher risk of chronic disease and premature death.  

Eat Your Veggies, It's Good For Your Heart!
Eating fruits and vegetables when younger may prevent coronary disease in later life
fruits and vegetables

Last month in this section I highlighted a study that showed some types of fruits and vegetables help with weight loss. This month, I am highlighting a study that shows (again) that they can help prevent a chronic disease, the most common killer in our country, heart disease. This study, from the journal Circulation, followed people for over 20 years and found lower incidence of coronary artery calcification in people who had a larger intake of fruits and vegetables when younger. 

Summary of findings      
  • Background: The relationship between intake of fruits and vegetables (F/V) during young adulthood and coronary atherosclerosis later in life is unclear.  
  • Methods and Results: We studied participants of the Coronary Artery Risk Development in Young Adults (CARDIA) study, a cohort of young, healthy black and white individuals at baseline (1985-1986). Intake of F/V at baseline was assessed using a semi-quantitative interview administered diet history and CAC was measured at year 20 (2005-2006) using computed tomography. We used logistic regression to adjust for relevant variables and estimate the adjusted odds ratios (OR) and 95% confidence intervals (CI) across energy-adjusted, sex-specific tertiles of total servings of F/V per day. Among our sample (n=2,506), the mean (SD) age at baseline was 25.3 (3.5) years and 62.7% were female. After adjustment for demographics and lifestyle variables, higher intake of F/V was associated with a lower prevalence of CAC: OR (95% CI) =1.00 (reference), 0.78 (0.59-1.02), and 0.74 (0.56-0.99), from the lowest to the highest tertile of F/V, p-value for trend <0.001. There was attenuation of the association between F/V and CAC after adjustment for other dietary variables but the trend remained significant: OR (95% CI): 1.00 (reference), 0.84 (0.63-1.11), and 0.92 (0.67-1.26), p-value for trend <0.002].
  • Conclusions: In this longitudinal cohort study, higher intake of F/V during young adulthood was associated with lower odds of prevalent CAC after 20 years of follow-up. Our results reinforce the importance of establishing a high intake of F/V as part of a healthy dietary pattern early in life.                      

Following a population over 20 years isn't easy, but that is what the authors of this study did. They found that people who ate 7-9 servings of fruits and vegetables had around a 25% decreased risk of coronary  calcifications  as compared to those who ate only 2-4 servings. We already know that people who report eating more fruits and vegetables have lower rates of heart disease, stroke, cancer, diabetes and death and this study adds to that data. This may be because often times we replace refined grains with high-fiber fruits and vegetables. Fruits and vegetables come in lots of colors, shapes, sizes and flavors and can be served in unlimited ways. I'm sure we could all add more of these foods to our diets (just avoid the starchy ones mentioned last month!).  It looks like one of the best things a parent can do is to get their children to eat their fruits and vegetables! 

A Way To Slow Knee Arthritis 
Chondroitin sulfate appears to slow cartilage volume loss knee arthritis
Knee osteoarthritis affects over 50% of people over their lifetimes and 2/3 of people who are obese. The frequency of knee replacements have soared over the past several years. We are all looking at ways to improve or prevent knee arthritis. The best way is to keep your weight down. However, is there a supplement that can help? This study, presented at the American College of Rheumatology meeting, seems to suggest that chondroitin sulfate may be something that can benefit knee arthritis. 

Summary of findings:   
  • Background/Purpose: In osteoarthritis (OA) treatment, although chondroitin sulfate (CS) was found in a number of studies using radiography to have a structure modifying effect, to date the question is still under debate. A clinical study using quantitative magnetic resonance imaging (qMRI) is therefore of the utmost importance.
  • The present study has the objective to explore, as the first aim, in a two-year randomized, controlled double-blind clinical study (RCT) using qMRI, the disease modifying effect of CS treatment versus celecoxib (CE) on cartilage volume loss (CVL) in knee OA. The second aim was to investigate and compare the effect of CS and celecoxib on symptoms.
  • Methods: Symptomatic primary knee OA patients according to ACR criteria with Kellgren-Lawrence grades 2-3 and synovitis were included and treated with CS (1200 mg a day) or CE (200 mg once daily) for 24 months. Patients at high risk for cardiovascular and/or gastrointestinal disease were not included. MRI was performed at baseline, 12 and 24 months. CVL, bone marrow lesion (BML) size, and synovial membrane thickness were evaluated using qMRI, and presence of joint swelling and effusion clinically evaluated. Clinical symptoms were also assessed by validated questionnaires. Statistical analyses were done on the intention-to-treat (ITT) population (n=194 patients), per protocol set (n= 195) and the according-to-protocol completer population (n=120) using Student's t-test, Wilcoxon Mann-Whitney test, and ANCOVA.
  • Results: In the ITT population, OA patients treated with CS (n=97) had a reduction in CVL at 12 months (p=0.017) and 24 months in the medial tibiofemoral compartment (p=0.013) and global knee at 12 (p= 0.034) and 24 months (p=0.054) compared to CE (n=97). No difference in change in synovial thickness or BML size between the two treatment groups was observed over time. A marked reduction in the incidence of patients with joint swelling plus effusion was observed in both the CS (51%, 59 vs 6 patients) and celecoxib (39%, 55 vs 11 patients) groups from baseline to 24 months, without differences between treatments. Both therapeutic groups experienced a reduction in disease symptoms (WOMAC total, pain, and function, and VAS pain) over time: reduction in VAS pain at 24 months for CS and celecoxib was 48% and 55% respectively, and for WOMAC pain 43% and 54%. The overall daily consumption of rescue analgesic (acetaminophen) was not different between CS and celecoxib (584 vs 472 mg/day) groups. The incidence of adverse events was similar in both treatment groups.
  • Conclusion: This trial demonstrated, for the first time, the superiority of CS over CE at reducing the long term progression of knee OA structural changes. Moreover, both drugs were found equally effective at reducing the symptoms of OA. These findings have important implications regarding the usefulness of CS for long term management of knee OA and its impact on disease outcome.  
While I don't believe chondroitin sulfate is a cure all, it looks like it may help. In the study, people had fewer symptoms and there looked to be some improvement in  cartilage thickness. My thinking toward chondroitin has changed over the past couple of years due to this and other studies. I think that it is now a reasonable supplement for people to take. It is likely most effective in earlier cases. 
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. 


All body fat is not created equal. We need to be aware of our belly (visceral) fat. This fat is metabolically active and really wreaks havoc with our metabolism. Measure to see where you are. 


We are always finding more evidence that out mothers were right. We do need to eat our vegetables!


There isn't a cure all for knee arthritis. But anything that can help is a good thing. It may be reasonable to give chondroitin a try (along with glucosamine sulfate). 


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.