November Newsletter
In This Issue
It's the Inflammation!
Work Out for Mental Health
Gamechanger Vaccine
A Better Model of Medical Care
Old-fashioned medicine with 21st Century convenience and technology
Quick Links
Join Our List
View my profile on LinkedIn 
Follow me on Twitter
Welcome to the November 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.   
We have been discussing healthy nutrition over the past couple of months. We have reviewed what appears to be the optimum diet to reduce our risk of chronic disease and mortality, improve our insulin sensitivity, and gets us the nutrients we need without weight gain. This month we take it further to look at directly at inflammatory foods in our diets. This study looks at the link between the inflammatory potential of our diet and risk of three of the major causes of death in our society; cardiovascular disease, coronary heart disease, and stroke. How much can we reduce our risk through nutrition? Which foods increase or decrease your risk? Read on for answers. 

We are in the middle of a viral pandemic, but we are also in the middle of a mental health pandemic. The coronavirus pandemic has been associated with mental health challenges related to the morbidity and mortality caused by the disease, mitigation activities including the impact of physical distancing and stay-at-home orders, as well as losses of employment and income. In July, a majority of U.S. adults 18 and older (53%) said that worry and stress related to coronavirus has had a negative impact on their mental health, and close to half (46%) of older adults (ages 65 and older) said that worry and stress related to coronavirus has had a negative impact on their mental health. Finding ways to alleviate the symptoms of anxiety and depression are especially important right now which makes the second study especially relevant. An activity you can do at home could reduce your anxiety and depression by 60-98%! I hope you are interested in learning more. 

The potential of a near-term COVID-19 vaccine is the biggest news around. There now seems to be potential for several options being ready for use soon which wasn't known even a few weeks ago. But many people are expressing concerns about getting the vaccine and there is plenty of "antivax" sentiment around. How much of a difference can vaccines make? Our third article looks at the effectiveness of one of our more recent vaccines, which carried quite a bit of controversy when it was introduced but has proven to be quite effective. It addressed a disease that most of us will get, is asymptomatic or relatively mild for the majority, but can be very severe for a few. Sound familiar?  
Information regarding COVID-19 is constantly changing. Wisconsin continues to be 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. Please continue to wash your hands frequently, avoid touching your face, and avoid going out if you are sick.   
It's the Inflammation!
Proinflammatory dietary patterns increase cardiovascular disease
This study prospectively followed over 210,000 subjects from the Nurses' Health Study I, Nurses' Health Study II, and Health Professionals Follow-Up Study to examine the relationship between proinflammatory diets and cardiovascular disease (CVD) risk in participants with no evidence of cancer or CVD at baseline. Participants completed food frequency questionnaires every 4 years, and this information was used to evaluate the inflammatory potential of their diet using a food-based empirical dietary inflammatory pattern (EDIP score). There were 15,837 incident CVD cases and 6174 strokes during 5,291,518 person-years of follow-up. Analysis of pooled data from all three databases comparing highest and lowest quintiles of EDIP score found increased risks of CVD (38%), coronary heart disease (46%), and stroke (28%) in participants with a higher dietary inflammatory potential (based on EDIP scores). There was also an association between a higher EDIP and multiple measures of risk and inflammation. 

  • BACKGROUND: Inflammation plays an important role in cardiovascular disease (CVD) development. Diet modulates inflammation; however, it remains unknown whether dietary patterns with higher inflammatory potential are associated with long-term CVD risk.
  • OBJECTIVES: This study sought to examine whether proinflammatory diets are associated with increased CVD risk.
  • METHODS: We prospectively followed 74,578 women from the Nurses' Health Study (NHS) (1984-2016), 91,656 women from the NHSII (1991-2015), and 43,911 men from the Health Professionals Follow-up Study (1986-2016) who were free of CVD and cancer at baseline. Diet was assessed by food frequency questionnaires every 4 years. The inflammatory potential of diet was evaluated using a food-based empirical dietary inflammatory pattern (EDIP) score that was pre-defined based on levels of 3 systemic inflammatory biomarkers.
  • RESULTS: During 5,291,518 person-years of follow-up, we documented 15,837 incident CVD cases, including 9,794 coronary heart disease (CHD) cases and 6,174 strokes. In pooled analyses of the 3 cohorts, after adjustment for use of anti-inflammatory medications and CVD risk factors including body mass index, a higher dietary inflammatory potential, as indicated by higher EDIP scores, was associated with an increased risk of CVD (hazard ratio [HR] comparing the highest to lowest quintiles: 1.38; 95% confidence interval [CI]: 1.31 to 1.46; p for trend <0.001), CHD (HR: 1.46; 95% CI: 1.36 to 1.56; p for trend <0.001), and stroke (HR: 1.28; 95% CI: 1.17- to 1.39; p for trend <0.001). These associations were consistent across cohorts and between sexes, and they remained significant after further adjustment for other dietary quality indices. In a subset of study participants (n = 33,719), a higher EDIP was associated with a higher circulating profile of proinflammatory biomarkers, lower levels of adiponectin, and an unfavorable blood lipid profile (p < 0.001).
  • CONCLUSIONS: Dietary patterns with a higher proinflammatory potential were associated with higher CVD risk. Reducing the inflammatory potential of the diet may potentially provide an effective strategy for CVD prevention.

This study examined prospective data from three of the most studies groups in regard to nutrition and health, the Nurse's Health Study I and II and the Health Professionals Follow-Up Study. It is a huge study with over 5 million person-years of follow up. Dietary food surveys were done along with serum inflammatory markers every 4 years for 24-32 years. The empirical dietary inflammatory pattern (EDIP) was used to score the balance between inflammatory foods and anti-inflammatory foods. These EDIP scores were divided into five groups ranging from the least inflammatory to the most inflammatory. When the least inflammatory group was compared to the most inflammatory group, they found a 38% increased incidence of cardiovascular disease, 46% increase in coronary heart disease, and a 28% risk in stroke. 

The illustration below demonstrates that sugar, refined carbohydrates, red and processed meats were the most inflammatory foods, correlated with increased risk of disease as well as increased levels of systemic, vascular, and metabolic inflammation. Inflammation plays a key role in atherosclerosis and thrombosis, the two main causes of heart disease and strokes. This study provides more evidence that lifestyle, specifically quality of nutrition is a powerful intervention to reduce the largest causes of mortality we face today. 

Work Out for Mental Health
A clear link between low physical fitness and the risk of experiencing symptoms of depression, anxiety, or both 
Cancer survivor exercising

It is estimated that over 18% or 40 million Americans will be affected by anxiety disorder each year and 17 million adults (7.1%) will suffer a major depressive episode at some point. These statistics are for an average year, and as we all know this is no average year. The study, which included more than 150,000 participants, found that lower cardiorespiratory fitness and muscle strength independently contribute to a greater risk of worse mental health. The participants completed two standard clinical questionnaires relating to anxiety and depression to give the researchers an overview of their mental health over a 7-year period. Participants who were classified as having low combined cardiorespiratory fitness and muscle strength had 98% higher odds of experiencing depression and 60% higher odds of experiencing anxiety.


  • Background: Depression and anxiety are common mental disorders that increase physical health risks and are leading causes of global disability. Several forms of physical fitness could be modifiable risk factors for common mental disorders in the population. We examined associations between individual and combined markers of cardiorespiratory fitness and grip strength with the incidence of common mental disorders.
  • Methods: A 7-year prospective cohort study in 152,978 UK Biobank participants. An exercise test and dynamometer were used to measure cardiorespiratory and grip strength, respectively. We used Patient Health Questionnaire-9 and Generalised Anxiety Disorder-7 scales to estimate the incidence of common mental disorders at follow-up.
  • Results: Fully adjusted, longitudinal models indicated a dose-response relationship. Low and medium cardiorespiratory fitness was associated with 1.485 (95% CIs, 1.301 to 1.694, p < 0.001) and 1.141 (95% CIs, 1.005 to 1.297, p = 0.041) higher odds of depression or anxiety, compared to high cardiorespiratory fitness. Low and medium grip strength was associated with 1.381 (95% CIs, 1.315 to 1.452, p < 0.001) and 1.116 (95% CIs, 1.063 to 1.172, p < 0.001) higher odds of common mental disorder compared to high grip strength. Individuals in the lowest group for both cardiorespiratory fitness and grip strength had 1.981 (95% CIs, 1.553 to 2.527, p < 0.001) higher odds of depression, 1.599 (95% CIs, 1.148 to 2.118, p = 0.004) higher odds of anxiety, and 1.814 (95% CIs, 1.461 to 2.252, p < 0.001) higher odds of either common mental disorder, compared to high for both types of fitness.
  • Conclusions: Objective cardiorespiratory and muscular fitness markers represent modifiable risk factors for common mental disorders. Public health strategies to reduce common mental disorders could include combinations of aerobic and resistance activities.

The coronavirus (COVID-19) pandemic has been associated with mental health challenges related to the morbidity and mortality caused by the disease, mitigation activities including the impact of physical distancing and stay-at-home orders, as well as losses of employment and income. Symptoms of anxiety disorder and depressive disorder have increased considerably in the United States in 2020 when compared with the same period in 2019. The coronavirus pandemic and resulting economic downturn have taken a toll on the mental health of adults of all ages in the U.S. In July, a majority of U.S. adults 18 and older (53%) said that worry and stress related to coronavirus has had a negative impact on their mental health, up from 39% in May, according to a recent KFF analysis. Close to half (46%) of older adults (ages 65 and older) said that worry and stress related to coronavirus has had a negative impact on their mental health. Previous KFF research found the share of adults reporting anxiety or depression has increased since the start of the coronavirus pandemic, with 40% of adults age 18 and older reporting symptoms of anxiety or depression in July. Younger adults were significantly more likely than older adults to report anxiety or depression. 

We are in the middle of a mental health pandemic. Finding ways to alleviate the symptoms of anxiety and depression are especially important right now which makes this study especially relevant. This study followed a group of over 150,000 subjects over a 7-year period. The assessed their cardiorespiratory fitness and muscle strength and completed questionnaires relating to anxiety and depression. The questionnaires were completed again at the conclusion of the study.  Participants who were classified as having low cardiorespiratory fitness were 50% more likely to have anxiety or depression while those with low muscle strength were found to have 40% higher risk. Participants with low combined cardiorespiratory fitness and muscle strength had 98% higher odds of experiencing depression and 60% higher odds of experiencing anxiety. 

This study makes is obvious that exercise and fitness may be more important now than ever. As lockdowns, mitigation strategies, and economic hardships continue, the incidence of mental illnesses will continue to increase. We all need to look at ways to get activity into our lives. With many gyms still limited or understandable hesitancy to go to the gym we need to find other ways to exercise. A method of exercise that has been shown to increase muscle strength and endurance at the same time are HIIT workouts (see August newsletter). These are quick 20-30 minute workouts that can be done with no equipment, just bodyweight. The important thing is to do something to get exercise. Your mental health depends on it! 

I'm reprinting my COVID update exercise resources recommendations from April below. 

  • Moderate exercise naturally lowers cortisol levels and aids immune function.
  • Walk daily (preferably outside) regardless of the time. Shoot for 30 minutes daily
  • Do fun activities with your kids and pets. Play in the yard, walk together, ride bikes.
  • If you can't get to the gym, body weight exercises or using bands is a good alternative.
  • Here are some 20 minute HIIT workouts you can do at home with no equipment.
  • If you have a spin bike or treadmill at home, the Peloton app is free for 30 days (you don't have to buy the expensive bike to use the app).
  • If you enjoy yoga (or would like to start) CorePower Yoga has a free online library of 30-75 minute online yoga classes.
  • Nike Training Club has a free workout app which includes body weight workouts, yoga, HIIT, strength training programs and home workouts (if you have some equipment). Their premium version integrates with your Apple watch.  They also have sections on nutrition, mindfulness and recovery.
  • There is also a Nike training app for runners.
  • If you enjoy Body Pump or workout classes at your gym, Les Mills has a  30-day free trial with over 800 workouts.
  • Pilates instructor Casey Ho has tons of varied workouts on her free YouTube channel.
  • If you have ever tried 21 Day Fix, P90X or Insanity, Beach Body on Demand has 30-Day Money-Back Guarantee ($99/yr) and gets you access to all of their workout programs which include exercise, yoga, nutrition, and meditation programs. 

Gamechanger Vaccine
Effectiveness of HPV vaccine vs. cervical cancer
The biggest news right now is the COVID-19 vaccine. We have several promising candidates at various stages of development and at least one could be available within the next 1-2 months. But we are seeing a lot of hesitancy from people in regards to the vaccine for a number of reasons. Worldwide 71.5% of participants reported that they would be very or somewhat likely to take a COVID-19 vaccine. We don't yet know the efficacy of the vaccines that will be available in the next few months but the early results look much more promising than expected. 

This study looks at the efficacy of a different vaccine, HPV which is one of the newer vaccines which has been widely used in our society. When introduced, there was a lot of hesitancy from people to give the vaccine to their children. But the outcomes are really very remarkable. This study demonstrated that quadrivalent HPV vaccination administered to girls and women prior to age 31 was associated with significantly reduced (50%) incidence ratio of cervical cancer overall and in the younger age groups given the vaccine there was an 88% decrease in cervical cancer. 

  • BACKGROUND: The efficacy and effectiveness of the quadrivalent human papillomavirus (HPV) vaccine in preventing high-grade cervical lesions have been shown. However, data to inform the relationship between quadrivalent HPV vaccination and the subsequent risk of invasive cervical cancer are lacking.
  • METHODS: We used nationwide Swedish demographic and health registers to follow an open population of 1,672,983 girls and women who were 10 to 30 years of age from 2006 through 2017. We assessed the association between HPV vaccination and the risk of invasive cervical cancer, controlling for age at follow-up, calendar year, county of residence, and parental characteristics, including education, household income, mother's country of birth, and maternal disease history.
  • RESULTS: During the study period, we evaluated girls and women for cervical cancer until their 31st birthday. Cervical cancer was diagnosed in 19 women who had received the quadrivalent HPV vaccine and in 538 women who had not received the vaccine. The cumulative incidence of cervical cancer was 47 cases per 100,000 persons among women who had been vaccinated and 94 cases per 100,000 persons among those who had not been vaccinated. After adjustment for age at follow-up, the incidence rate ratio for the comparison of the vaccinated population with the unvaccinated population was 0.51 (95% confidence interval [CI], 0.32 to 0.82). After additional adjustment for other covariates, the incidence rate ratio was 0.37 (95% CI, 0.21 to 0.57). After adjustment for all covariates, the incidence rate ratio was 0.12 (95% CI, 0.00 to 0.34) among women who had been vaccinated before the age of 17 years and 0.47 (95% CI, 0.27 to 0.75) among women who had been vaccinated at the age of 17 to 30 years.
  • CONCLUSIONS: Among Swedish girls and women 10 to 30 years old, quadrivalent HPV vaccination was associated with a substantially reduced risk of invasive cervical cancer at the population level. 
The development of vaccines is one of the greatest achievements in the history of medicine. Starting with a smallpox vaccine developed in 1798 and polio vaccine in 1955 they have saved untold numbers of lives and millions from morbidity from diseases. It's easy to forget the diseases we no longer see like polio. My mother had polio, so I have seen throughout my life the importance of this vaccine. 

I selected this article as it demonstrates one of the more recent additions to our children's vaccine portfolio. HPV is a viral infection that approximately 80% of us will get at some point in our lives. Most of us will clear it but there are certain strains which can become malignant causing cervical cancer, throat cancer, oral cancers, and anal cancers. This study looked at the incidence of cervical cancer in girls and women who received the HPV vaccine. Overall, a 50% decrease in cervical cancer was noted but in the younger age group the drop was 88%. This vaccine is being shown to be highly effective and now that recommendations are to vaccinate both girls and boys, hopefully many of these cancers will in the future become rarities doctors will only read about in textbooks. 

Should I get the COVID vaccine when it is available? That is the questions everyone is asking right now as our pharmaceutical companies race to develop a viable vaccine for COVID. It appears the finish line is near. I look forward to reviewing all of the data when it is published but I have to say that I am much more optimistic now than I was a few weeks ago that we will have a safe, effective vaccine (and likely several). Achieving the "herd immunity" necessary to control this virus without loss of many more lives seems within our reach. Like the HPV vaccine, although most of us will have few if any issues with a COVID infection, there are some among us who will become critically ill. If we develop a vaccine (or vaccines) that will nearly eliminate this possibility, we will be on our way back to normalcy. 

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.