Meaningful Medicine In Your Medical Home

February/2015

Issue: 37

Thank Goodness February is SHORT!

Whoever decided to keep February to no more than 29 days must have had this one in mind. Cold, snow, ice, ugh...can't wait for pitchers and catchers to arrive in Clearwater!!

John A. Schmidt, MD

Internist

Advisory Board Deemphasizes Dietary Cholesterol

As reported by the New York Times on February 19, The Dietary Guidelines Advisory Committee, which convenes every five years, has promoted sugar, not cholesterol, to the status of Public Enemy Number One. The committee's recommendations reflect the growing body of data that high calorie diets, especially those rich in digestible sugars (white bread, fruit juices, etc.) are primarily responsible for the obesity epidemic sweeping developed and developing nations. Cholesterol is not a fuel so it adds no calories. Also, most of the cholesterol in our body is made in the liver by an enzymatic pathway that begins with HMG CoA reductase, the enzyme blocked by the statins (atorvastatin (Lipitor�), rosuvastatin (Crestor�), simvastatin (Zocor�). This explains why most patients see a far greater drop in blood cholesterol levels, a known risk factor for heart attack and stroke, with medication than with diet alone.

Has the Committee Gone Off the Deep End?

The committee is right to target excessive caloric intake in the form of simple sugars because we know that these foods lead to obesity and obesity leads to ___________ (Ans: Diabetes!). Diabetes is a major risk factor for cardiovascular disease not to mention blindness and kidney failure.

One way to reduce sugary foods is to look at glycemic index (GI), a measure of how much and how fast a food raises blood glucose/sugar. The University of Sydney has a searchable website where you can input a given food and learn its GI. The Harvard School of Public Health has a GI data base that also includes Glycemic Load (GL) per serving. The table published on February 3 shows some interesting surprises. For example, tomato juice has a much lower GI and GL than every other juice (and is available as a low sodium product!). Peas and carrots have much lower GI than potatoes and yams. Pears, apples, and peaches have lower GI and GL than bananas, grapes, and raisins. Beans and nuts have low GI and GL in general. As you can see, foods low in GI and GL are among those included in the Mediterranean Diet, which has been found to ward off diabetes, heart attack, and stroke.

In 2011, the U.S. Department of Agriculture replaced its Food Pyramid with MyPlate, a conceptual advance because it replaced the pyramid with a far more intuitive dinner plate divided into quadrants. Simply put, if your or your child's dinner plate is covered with pizza, you need to visit the MyPlate website. An even better rendition is the Healthy Eating Plate from the Harvard School of Public Health. The Healthy Eating Plate emphasizes whole grains such as whole wheat products over refined grain products such as white bread and white rice; removes potatoes from the "vegetables and fruits" category; emphasizes fish, chicken, beans, and nuts as versatile protein sources; recommends the use of healthy plant oils such as olive, canola, soy, corn, sunflower, and peanut oil over butter; advises water and black coffee over sugary drinks and no more than a small glass of juice per day.

Coming back to the topic of cholesterol, I believe the Committee has gone off the deep end. I have many patients who have been able to reduce their blood cholesterol levels following the Healthy Eating Plate guidelines. Why the committee would encourage patients to eat egg yolks is beyond me!!

To Immunize or Not to Immunize? That is the Question!

Now that there has been an outbreak of measles in the United States among children whose parents refused vaccination, it is time to explore the reasons behind their reluctance. The book,On Immunity, by Eula Biss and published in 2014, does just that. Biss attributes parents' reluctance in part to their strong desire to return to nature. In other words, infection is natural, vaccination is not. Vaccines contain preservatives, it is true. But as Parul Sehgal accurately wrote in the New York Times Sunday Book Review on Oct 3, 2014, breast milk may contain traces of paint thinners, flame-retardants, and even rocket fuel! As reported by the Centers for Disease Control and Prevention, the widely held belief that autism spectrum disorders are attributable to vaccines has been studied intensively and disproven.

Biss, a non-physician who has refused speaking engagements from pharma companies, wrote her book while expecting her first child. As she discussed on WNYC on February 20, she was struck that her child's pediatrician insisted on starting hepatitis B vaccination before leaving the hospital. She was all the more skeptical after she was told that the major risk factors for hepatitis B were sex and IV drug abuse. "What does this have to do with my baby," she said. But it turns out that hepatitis B infection only began to decline when newborns were vaccinated. "There is much we don't understand about the transmission of hepatitis B in youngsters," she concluded. Paraphrasing her radio commentary, "Babies are exposed to lots of things in nurseries and day care centers that come out of other people's bodies and it's good to protect them early."

She also pointed out that there is a communal obligation to vaccinate in order to protect the most vulnerable members of our society. For example, adults should receive one dose of Tdap to boost their immunity against not only tetanus and diphtheria, but also pertussis/whooping cough. Why? Because most kids get whooping cough from unboosted adults!

New Guidelines for Adult Immunization

As published in the Annals of Internal Medicine on February 3, all adults 65 years and older and persons under 65 with chronic diseases such as asthma and emphysema, should receive 13-valent pneumococcal conjugate vaccine (Prevnar-13�) and the 23-valent pneumococcal polysaccharide vaccine (Pneumovax�) 6-12 months later to expand their protection against pneumococcal pneumonia, which is still responsible for tens of thousands of deaths in the United States every year.

Irrational Fears
If you could be vaccinated against Ebola today, would you? Many of the same people who say "yes" refuse the flu vaccine even though influenza, not Ebola, is a near and present danger. Why? Psychologists tell us it's fear of the unknown. Because influenza is familiar many have unfortunately become desensitized instead of immunized. Measles anyone?

New 9-Valent Vaccine to prevent against Human Papilloma Virus (HPV) related Diseases

As reported in the February 19 issue of the New England Journal of Medicine, there is a late stage vaccine providing protection against nine types of HPV. The current vaccine (Gardasil�) covers only four. The new vaccine is predicted to prevent 90 percent of new cervical cancers, an improvement of 20 percent over the current vaccine. The HPV vaccine is covered by the Vaccines for Children program and the Affordable Care Act requires private health insurers to cover these immunizations when given by an in-network provider without copays or deductibles up to the age of 18. Unfortunately, as pointed out in the accompanying editorial, protection of at-risk young women with the HPV vaccination has lagged behind other vaccinations by 20-25 percent because of parent's irrational fears and failure of doctors to stress the importance of this three step vaccination. I remind all of my patients with young children, especially young women, to sign up for Gardasil by age 11 to protect them against cervical cancer which still claims tens of thousands of lives in the United States every year.

Perimenopause, the Beginning of the Transition to Menopause

As reviewed in an excellent article in the February 3 issue of the Annals of Internal Medicine, perimenopause is characterized by abnormal uterine bleeding, hot flashes, and night sweats which occur as a result of declining ovarian function. The average age of onset is 47-48 years of age. Abnormal uterine bleeding can be light and infrequent or unpredictable and heavy. The latter group should consult a gynecologist to rule out structural (e.g., fibroids) and non-structural abnormalities (e.g., a clotting disorder). Most of the time, bleeding can be managed with hormonal contraceptives (HC) which also prevent unintended pregnancies. Forty-eight percent of all pregnancies in women in their forties are unintended. The levonorgestrel intrauterine system (IUS) was shown in a famous study (ECLIPSE) to prevent unintended pregnancies and achieve higher quality of life as compared to pills, patches, rings, and thermal ablation with higher hemoglobin levels and fewer hysterectomies. There is also no risk of clots with the IUS.

The major drawback to the IUS is the lack of control of vasomotor complaints such as hot flashes and night sweats. Combined hormonal contraceptives (CHC) are the most effective means of controlling vasomotor complaints. The lowest effective dose for the shortest possible time is the safest approach. For those unwilling to take CHC or those with contraindications (migraine with aura, cigarette smokers, history of clots, uncontrolled hypertension, lupus, history of bariatric surgery, diabetes, current breast cancer, cirrhosis, valvular heart disease, organ recipient), SSRIs (e.g., escitalopram, paroxetine, sertraline, citalopram, and fluoxetine) may control vasomotor complaints and improve sleep quality. Yoga, paced respiration, exercise, cognitive behavioral therapy, ginseng root, dong quai, and phyotestrogens and others have so far proven ineffective. SSRIs, however, can occasionally lead to reduced libido. Vaginal atrophy or inadequate lubrication is best treated with topical lubricants (e.g., Vagisil�). Measurement of FSH, a pituitary hormone that rises in menopause, can be used to determine when CHC is no longer necessary. Women may then choose to stop hormonal therapy or transition to a weaker estrogen (e.g., Premarin�). Visit Womenshealth.gov for more information. I can also send information to your Patient Portal account on request.

Now Hear This!!

Many of you have signed up for Follow My Health patient portal accounts but have yet to send me a message. Please do so today or contact Valerie for help. This is a key Meaningful Use Stage 2 measure for 2015 and I need your help to attain it!! Unlike regular email and text messages, messages sent via Follow My Health are encrypted, HIPA compliant and become a permanent part of your electronic medical record. Please download the free app to your smart phone as well. Thank you!

Valerie, Morgan, and I wish you warmth and Spring Training!