The New York Times - USA (2020-12-01)

D6 N THE NEW YORK TIMES, TUESDAY, DECEMBER 1, 2020

A combination of
healthy sleep habits
may help reduce the
risk for heart failure,
new research suggests.
Scientists studied 408,802

generally healthy people aged 27
to 73 between 2006 and 2010,
collecting information on their
sleep habits. Each person got a
zero-to-five “healthy sleep score,”
based on five healthy sleep prac-
tices: being a “morning person,”
sleeping seven to eight hours a
night, rarely or never snoring,
rarely having insomnia and rarely

being excessively sleepy during
the day.
Over an average follow-up of 10
years, there were 5,221 cases of

heart failure. Compared with

people who scored zero or one,

those who scored two had a 15

percent reduced risk for heart

failure; those who scored three

had a 28 percent reduced risk;

and those who scored four a 38

percent risk reduction. Those who

scored a perfect five had a 42

percent lower risk of heart failure

compared with those who scored

zero or one.

The study, in the journal Circu-

lation, controlled for smoking,

alcohol intake, physical activity,

diabetes, hypertension and other

variables. It is an observational

study, however, so it does not

prove causality.

SLEEP

Better Rest for Better Hearts

Girls born extremely
prematurely may have
an increased risk of
depression from child-
hood through young adulthood.
Using Finnish birth and health
registries, researchers studied
37,682 people diagnosed with
mild, moderate or severe depres-
sion, comparing them with
148,795 healthy controls. The

children were born between 1987
and 2007, and their average age at
diagnosis was 16.
After adjusting for parents’ age,
depression, substance abuse,
smoking, socioeconomic status
and other factors, they found that
in girls, but not boys, younger
gestational age was strongly

associated with a diagnosis of

depression in childhood, adoles-

cence or young adulthood. Girls

born before 28 weeks’ gestation

were at roughly three times the

risk for depression as those born

at full term. After 28 weeks gesta-

tion, the association was no long-

er significant. The study is in The

Journal of the American Academy

of Child & Adolescent Psychiatry.

The authors suggest that the

limited age range in the study of 5

to 25 years means that it was

primarily early onset depression

that was detected, and this may

underestimate the effect in boys,

whose diagnoses of depression

typically occur at older ages.

PREGNANCY

Premature Birth and Depression

Vegetarian diets are
generally considered
healthy, but new re-
search suggests they
may have a significant risk: an
increased chance of bone frac-
tures.
Between 1993 and 2001, British

researchers collected diet, health
and behavioral data on 54,858
people, average age 50. They
categorized them by diet: 29,380
meat eaters, 8,037 who ate fish
but no meat, 15,499 vegetarians,

and 1,982 vegans, who ate no
meat, fish, dairy products or eggs.
They followed them for an aver-
age of 18 years, tracking the
number and location of fractures.
The study, in BMC Medicine,

controlled for sex, physical activi-

ty, smoking, alcohol intake, di-

etary supplement use and other

factors, and found that compared

with meat eaters, vegetarians had

a 9 percent increased risk for any

fracture, and vegans a 43 percent

increased risk.

Vegetarians and fish eaters had

a roughly 25 percent increased

risk for hip fracture, and the risk

for hip fracture in vegans was

more than twice that of meat

eaters. The risk for leg fracture

was 81 percent higher in vegans

than in meat eaters.

The associations were weaker,

but still significant, after addi-

tional adjustments for protein and

calcium intake.

EAT

Bone Woes With Meat-Free Diet

In Brief NICHOLAS BAKALAR

I have an

autoimmune

condition, a

variant of rheumatoid

arthritis, and recently

started medications to

suppress my immune

response. Am I at

increased risk of getting

sick and dying from

Covid-19?

Autoimmune conditions such as
rheumatoid arthritis or lupus
occur when the immune system

mistakenly attacks normal body
tissues. Treatments that suppress
the immune system in an effort to

thwart the damage to normal
tissues may leave patients more
susceptible to infections.

It stands to reason that a per-
son with an immune system
disorder thus might be more

likely to get infected with Covid-19
and die from the virus. But that
may not be the case.

In one study out of Italy, 1
percent of almost 2,300 patients
hospitalized with Covid-19 had

autoimmune rheumatologic con-
ditions such as rheumatoid arthri-
tis or lupus. Most of these pa-

tients had been treated with
corticosteroids or other drugs
that can suppress the immune

system before that admission.
When compared with other pa-
tients without autoimmune condi-

tions who were admitted to the
same hospital, there did not ap-
pear to be any difference over all

in Covid-19 symptom duration, the
length of the hospital stay or the
likelihood of dying.

A small study out of New York,
also conducted in patients with

autoimmune rheumatologic con-

ditions who had Covid-19, found a

hospitalization rate similar to that

of the city’s general population.

Another study examining elec-

tronic health records in the

United States compared Covid-19

patients who had a different

immune-mediated condition,

inflammatory bowel disease, with

Covid-19 patients without I.B.D.

The investigators found no differ-

ence in Covid-19 severity or death

between the two groups, though

in this study patients previously

treated with corticosteroids may

have had a higher risk of severe

Covid-19 infections.

In all three of these studies,

older patients were more likely to

have severe Covid-19 or die,

which is true of the population as

a whole. In two of the studies,

those with accompanying medical

conditions such as hypertension

and obesity were also at higher

risk of dying, which is also true of

the general population.

It is possible that patients with

autoimmune conditions, and

particularly those receiving im-

munosuppressive therapy, are

particularly rigorous with infec-

tion prevention practices such as

social distancing, wearing masks

and hand washing. Such meas-

ures may have contributed to

improved outcomes from Covid-19

infection in this group compared

with what might have been ex-

pected in an immunosuppressed

population, therefore affecting the

overall results of these studies.

But in general, doctors have not

observed a greatly increased risk

of severe Covid-19 infections or

death in those with autoimmune

disorders.

MIKKAEL A. SEKERES, M.D.

Ask Well

We l l

WHILE WE EXERCISE,we raise and lower the

levels of hundreds of molecules in our

bloodstreams that are related to our meta-

bolic health, even if we work out for only a

few minutes, according to a complex and

encouraging new study of the molecular ef-

fects of being active. The study, which in-

volved more than 1,000 men and women,

adds to growing evidence that exercise im-

proves our health in large part by trans-

forming the numbers and types of cells in-

side of us.

There is at this point, of course, no rea-

sonable debate about whether exercise is

good for us. It is. Countless studies show

that people who are active are less likely

than more-sedentary people to develop or

die from a host of health problems, includ-

ing heart disease, diabetes, dementia, can-

cer, obesity and many others. Active people

also tend to live longer and feel happier.

But we still know surprisingly little about

just how exercise changes us for the better.

What are the many, interconnected biologi-

cal steps and transmutations that allow a

walk today to add to our life span decades

from now?

That question has been driving consider-

able interest recently in research looking at

exercise “omics” — the study of all of the

molecules in our blood or other tissues that

are part of a particular biological process.

Genomics, for instance, quantifies the

many, many molecules involved in genetic

activities. Proteomics does the same for

proteins, microbiomics for the multiple con-

tents of our microbiomes and metabolomics

for molecules related to metabolic pro-

cesses. (There can be overlap between vari-

ous ’omics, obviously.)

Understanding how exercise affects the

levels of the various molecules within us is

important, because these changes are likely

to be the preliminary step in a complex cas-

cade of further biological actions that con-

tribute to better health. Increase some mol-

ecules, decrease others, and you jump-start

inter-organ messaging, gene expression

and other processes that subsequently alter

how we make and use insulin, burn or store

fat, respond to cholesterol and so on.

A number of important recent studies

have delved into the ’omics of exercise, in-

cluding a fascinating experiment showing

that a short workout rapidly changes the

levels of 9,815 molecules in people’s blood-

streams. But that study, like most other ex-

aminations of exercise and ’omics, involved

relatively few volunteers — 36, in that case

— and did not link molecular changes with

subsequent health outcomes.

So, for the new study, which was pub-

lished in September in Circulation, re-

searchers at Massachusetts General Hospi-

tal in Boston and other institutions decided

to increase the number of exercisers whose

’omics would be parsed and also try to find

connections between the ’omics data and

later health.

Conveniently, they had access to a large

group of potential volunteers among men

and women already enrolled in the long-

term Framingham Heart Study, which is

overseen primarily by researchers at Bos-

ton University. The scientists now asked 411

middle-aged volunteers enrolled in the

study to visit the lab and exercise, by ped-

aling to exhaustion on a stationary bicycle.

Most riders’ efforts lasted for a little less

than 12 minutes. The researchers drew

blood before the ride and afterward, within

about a minute of when, worn out, the cy-

clists quit.

The scientists then ran the blood samples

through a mass spectrometer, a machine

that counts and quantifies molecules. The

researchers focused on metabolites, which

are molecules related to metabolic pro-

cesses. The label “metabolite” is somewhat

arbitrary, but for this study, the researchers

focused mostly on molecules that could af-

fect people’s insulin, fat burning, choles-

terol, blood sugar and other aspects of cellu-

lar fueling.

They found plenty. Of 588 metabolites

checked, the levels of more than 80 percent

generally grew or dropped during the short

rides. To reinforce those findings, the scien-

tists repeated the experiment with another

783 Framingham volunteers, checking their

blood before and after exercise for changes

in about 200 of the molecules that had been

most altered in the first group. Again, these

metabolites changed in the same ways as

before.

Last and perhaps most intriguing, the re-

searchers created what they called molecu-

lar “signatures” of the levels of a few repre-

sentative metabolites that changed with ex-

ercise. They then looked for these same pat-

terns of metabolites in stored blood samples

gathered decades before from past Fram-

ingham participants, while also checking to

see if and when any of these volunteers had

passed away.

The relevant signatures popped up in

some of the blood samples, the researchers

found, and these samples tended to be from

people who had not died prematurely, sug-

gesting that the kinds of metabolite

changes that occur with exercise might in-

fluence and improve health well into the fu-

ture.

That idea is “speculative,” though, said

Dr. Gregory Lewis, the section head of the

heart failure program and director of the

cardiopulmonary exercise laboratory at

Massachusetts General Hospital, who over-

saw the new study. The decades-old blood

samples were drawn during standard medi-

cal testing, not after exercise, he said, so

some people with desirable metabolite sig-

natures might have been born that way and

not needed workouts to remodel their me-

tabolites.

Even among the current volunteers, he

pointed out, different people’s molecules re-

sponded somewhat differently to their ex-

ercise. Over all, people with obesity devel-

oped fewer changes than leaner riders, sug-

gesting they might somehow resist some of

the benefits of exercise. Men and women, as

groups, also showed slightly discordant mo-

lecular signatures, but age did not influence

people’s molecular responses.

Larger future ’omics studies should help

scientists tease out how and why we each

react as we do to exercise, Dr. Lewis said,

and enable researchers to define more-pre-

cise molecular signatures that might indi-

cate, with a blood test, how fit someone is or

how their bodies might respond to different

types of exercise.

But for now, the current study under-

scores just how pervasive and immediate

the effects of exercise can be. “This was

barely 10 minutes of exercise,” Dr. Lewis

said, “but it shifted so much” inside people.

PHYS ED GRETCHEN REYNOLDS

Detecting the Effects of a Workout

Activity raises and lowers

levels of molecules that

regulate metabolism.

GETTY IMAGES

For the past 20 years, whenever patients

asked me about exercising while recover-

ing from a viral illness like the flu, I gave the

same advice: Listen to your body. If exer-

cise usually makes you feel better, go for it.

Covid-19 has changed my advice.

Early in the pandemic, as the initial wave

of patients with Covid-19 began to recover

and clinically improve, my colleagues and I

noticed that some of our patients were

struggling to return to their previous activi-

ty levels. Some cited extreme fatigue and

breathing difficulties, while others felt as if

they just couldn’t get back to their normal

fitness output. We also began to hear of a

higher than normal incidence of cardiac ar-

rhythmias from myocarditis, inflammation

of the heart muscle that can weaken the

heart and, in rare cases, cause sudden car-

diac arrest. Other complications like blood

clots were also cropping up.

What was surprising is that we saw these

problems in previously healthy and fit pa-

tients who had only mild illness and never

required hospitalization for Covid-19.

In my sports medicine practice, a cyclist

in her 40s with recent Covid-19 symptoms

had leg pain that was abnormal enough to

warrant an ultrasound, which showed near

complete cessation of blood flow because of

arterial and venous blood clots in both legs.

Thankfully, our team caught these early

enough that they didn’t spread to her lungs,

which ultimately could have killed her. Re-

cently, a college student in Indiana with

Covid-19 died from a blood clot that traveled

to her lungs. As the pandemic has evolved,

we’ve learned of a much higher risk of blood

clots from people who contract the virus.

In those early months of the pandemic,

my colleagues and I learned of a New York

City mental health worker in her early 30s,

a dedicated athlete with no underlying

health problems who developed symptoms

of Covid-19. Her low-grade fever and con-

gestion went away, but she continued to feel

“sluggish.” As she had done many other

times after getting over an illness, she went

for a run to feel better. She died on the run, of

cardiac arrest; it appears she had undiag-

nosed myocarditis caused by Covid-19.

We now know the heart is a particular

cause for concern after coronavirus infec-

tion. A study in JAMA Cardiology looked at

100 men and women in Germany, average

age 49, who had recovered from Covid-19,

and found signs of myocarditis in 78 per-

cent. Most had been healthy, with no pre-ex-

isting medical conditions. A smaller study

of college athletes who had recovered from

Covid-19 found that 15 percent had signs of

heart inflammation.

As the pandemic continues, we’ve heard

countless stories of elite athletes in top

physical condition struggling to regain their

form after Covid-19. More than a dozen

women on the U.S. Olympic rowing team

who contracted the virus in March de-

scribed persistent fatigue for weeks after

the initial illness. Recreational athletes, in-

cluding runners and triathletes, have com-

plained of prolonged respiratory symptoms

during exercise. Pulmonary issues from

Covid-19, including pneumonia, have

caused breathing difficulty during exercise

for weeks or months following infection.

To help patients safely return to activity

after mild to moderate Covid-19 infection,

my colleagues at Hospital for Special

Surgery and I published an evidence-based

set of guidelines based on the existing medi-

cal literature and our evolving understand-

ing of the disease. Our “return to activity”

guidelines urge far more caution than in the

past, based on the unpredictable nature of

how the virus affects each person.

Anyone who had severe illness or was

hospitalized with Covid-19 needs to consult

a physician about whether it’s safe to exer-

cise. But even people who experienced mild

illness or no symptoms need to take precau-

tions before exercising again. Among our

new recommendations:

DON’T EXERCISE IF YOU’RE STILL SICKDo

not exercise if you have active symptoms,

including a fever, cough, chest pain, short-

ness of breath at rest or palpitations.

SLOWLY RETURN TO EXERCISEEven if you

had only mild symptoms, with no chest pain

or shortness of breath, you should still wait

until you have at least seven days with no

symptoms before returning to exercise.

Start at just 50 percent of normal intensity.

A gradual, step-by-step and slow return to

full activity is recommended.

STOP EXERCISE IF SYMPTOMS RETURNIf you

develop symptoms after exercising, includ-

ing chest pain, fever, palpitations or short-

ness of breath, see a doctor.

SEE A CARDIOLOGIST BEFORE EXERCISINGIf

you experienced chest pain, shortness of

breath or fatigue during your illness, you

should see a cardiologist before restarting

sports activity. Depending on how you feel,

your doctor may conduct a test for myocar-

dial inflammation.

GET TESTEDIf you have cold or flu symp-

toms, get tested for Covid-19 before you re-

turn to exercise. If you think you might have

had Covid-19, a test might help you and your

doctor make decisions about safely return-

ing to exercise.

And remember, as doctors we can run

tests, but youknow your own body better

than anyone else. You know how you nor-

mally feel when you walk up the stairs,

when you run, when you bike. If you’ve had

Covid-19, are those things harder for you?

Are you noticing a change in your body? If

the answer is “yes,” it’s important to speak

with your doctor.

Even if you’ve never been diagnosed with

Covid-19, be mindful of how you are feeling.

Many people with Covid-19 don’t know they

have it, or have general symptoms like

gastrointestinal upset, fatigue or muscle

aches. So if you’ve been feeling “off” during

exercise, listen to your body, ease up and

check with your doctor.

Covid-19, an aggressive virus, spreads

easily and carries significant morbidity and

mortality. Cardiac risk in particular is great-

er with Covid-19 than with other viral dis-

eases, so it makes sense to use caution.

Exercise After Covid-19? Go Slow

New guidelines urge far more

caution about resuming

activity, even after a mild case.

By JORDAN D. METZL, M.D.

DR. JORDAN D. METZL(@drjordanmetzl) is a

sports medicine physician at Hospital for

Special Surgery in New York.

KATHRYN GAMBLE FOR THE NEW YORK TIMES

Those who have had mild or even no symptoms should start exercise at 50 percent capacity.