Issue: 48

January, the Beginning of a Beautiful Friendship!
Remember the classic line of Humphrey Bogart (Rick) at the end of the classic film Casablanca? "Louie, I think this is the beginning of a beautiful friendship!" He said this as beautiful Ingrid Bergman flew off the tarmac and out of his life forever! I love this scene (as do millions of movie fans!). Why?  Because it shows how a patriot and decent person is willing to make a fresh start on life! January gives you the opportunity to make a fresh start!
Here are some fresh medical highlights/insights to help you build a new and better life in 2016!

John A. Schmidt, MD 
U.S. Dietary Guidelines: "An Evidence-Free Zone"
As reported in the Annals of Internal Medicine on January 19, the U.S. Department of Health and Human Services and Department of Agriculture have released the Dietary Guidelines for Americans for the next five years. The preliminary report released a year ago had generated considerable media attention by reversing decades of dogma with the statement, "Cholesterol is not a nutrient of concern for over-consumption." Incredibly, in the final report issued on January 19, this controversial statement has been removed, instead suggesting that, "Individuals should eat as little dietary cholesterol as possible." Which version should we believe?
In the accompanying editorial, Dr. Steven Nissen, one of the world's leading experts on cholesterol, points out that there is a shortage of high quality data to guide the selection of the foods we eat. He concludes by citing PREDIMED, a high quality study recently conducted in Spain. As previously discussed in this newsletter, PREDIMED showed that a Mediterranean style diet supplemented with extra virgin olive oil or mixed unsalted nuts led to superior cardiovascular outcomes. A follow-up analysis suggested that the principle value of this diet was reduction in the incidence of type II diabetes, the often self-inflicted scourge ruining many Americans.
My recommendation? While considerable doubt remains regarding the composition of the ideal diet, invest your 2016 shares in a Mediterranean style diet rich in low starch vegetables supplemented with vegetable oils and unsalted nuts. While definitive data are still lacking, it makes sense to reduce the intake of cholesterol rich foods, salt, and concentrated carbohydrates. "Lean and mean in 2016" means emphasis on low sodium/low calorie/low cholesterol/low carbohydrate foods rich in protein and fiber to build muscle mass and avoid truncal obesity! Match feeding to exercise to maximize your benefit!
(A one-day dispensation for Super Bowl Sunday is hereby granted--but just one day!)
When Diet and Exercise Are Not Enough to Treat Obesity in Adolescents
Food has the potential to addict. In normal amounts, food is life sustaining. In excessive amounts, food can be life destroying. While difficult to prove, it is reasonable to conjecture that more damage is done by excessive food intake than heroin. While exercise and diet are held up as the cure, careful studies show that this approach is futile once Body Mass Index exceeds 40. The pharmaceutical industry has spent billions to arrive at a medical solution and has largely failed. Bariatric surgery, on the other hand, continues to show real promise.
Obesity often begins in adolescence so it makes sense to address the problem early. As reported in the January 14 issue of the New England Journal of Medicine, most obese adolescents undergoing bariatric surgery were cured of type 2 diabetes, hypertension, and hyperlipidemia, the risk factors that are known to lead to heart attack and stroke later in life. Adolescents undergoing bariatric surgery continued to grow. Some required follow-up abdominal surgery, less so for the sleeve procedure. The follow-up period was only three years but results thus far are very promising and suggest, as Rick would say, the "beginning of a beautiful friendship!"
Updated Guidelines for Breast Cancer Screening.
Amid much recent concern regarding the effectiveness of breast cancer screening, the United States Preventive Services Task Force (USPTF) has issued timely guidance for asymptomatic women 40 and older of average risk, that is, the vast majority of women who do not have (a) breast cancer already, (b) a previously diagnosed high-risk lesion (such as DCIS), (c) a positive family history of breast or ovarian cancer, a genetic mutation (such as BRCA1 or BRCA2), or history of chest radiation at a young age. Calculators to assess risk are available on my web site.
As summarized in the Annals of Internal Medicine on January 12, the USPSTF recommends:
  1. Screening mammography between 50 and 74 every other year (biennial).
  2. Women who place a higher value on the potential benefit rather than the potential harms (for example, false positive test requiring biopsy) may choose to begin biennial screening at age 40.
  3. Current evidence is insufficient to assess the benefits and harms of digital breast tomosynthesis (DBT) as a primary screening method for breast cancer. (DBT, as currently practiced, usually results in greater radiation exposure and radiation exposure increases the risk of breast cancer, albeit slightly.)
  4. Current evidence is insufficient to assess the value of ultrasound, MRI, or DBT in women with dense breasts and an otherwise negative screening mammogram. In other words, while dense breasts are a risk factor for breast cancer, the value of routine additional imaging has yet to be proven.
Bottom Line: Breast cancer screening is important and an individualized approach is warranted. Let me know if you have questions regarding this important topic.
Screening for Bladder Cancer
One of the great paradoxes in medicine is why certain cancers, such as breast and prostate cancer, have appropriately attracted huge focus on screening while other common cancers, especially bladder cancer, have drifted out of the public eye. I have more patients in my practice with bladder cancer than any other cancer. Smoking increases the risk of bladder cancer. All of these patients were initially found to have blood in their urine (hematuria), either grossly or microscopically. So why not screen everyone for hematuria beginning at age 40? As discussed in the January 26 issue of the Annals of Internal Medicine, screening urinalysis using test strips is very sensitive but can lead to false positive results. Positive test strip results require a follow-up microscopic evaluation, the cost of which is about four dollars. If three or more red blood cells are found per high-powered field, additional testing is warranted including CT imaging and referral to an urologist for cystoscopy. I would add a urine culture since urinary tract infections are a common cause of microscopic hematuria. If the culture is negative, it is important to search for another cause. Hematuria requires further evaluation even in patients taking aspirin and blood thinners.
Fecal Immunochemical Testing for Colorectal Cancer
Colonoscopy remains the gold standard for early detection and prevention of colorectal cancer, one of the most common cancers among Americans. Unfortunately, many of my patients are unwilling to have this test usually because someone told them that the bowel prep is unpleasant. While I heartily disagree with this outlook, there are viable alternatives that do not require cathartics. One is the FDA approved test known as Cologuard�. The maximum out of pocket cost for Cologuard is $649, depending on the insurance plan. Another option, as reported in the January 26 issue of the Annals of Internal Medicine, is the much less expensive Fecal Imunochemical Test (FIT). As with Cologard, patients use a simple kit to supply a stool sample to the laboratory. Annual testing over a four year period detected 80 percent of colorectal cancers.  Of course, a positive test requires, you guessed it, a colonoscopy! 
Screening for Depression
And cancer is not the only thing we need to screen for! As reported in the January 26 issue of the Journal of the American Medical Association (JAMA), the United States Preventive Services Task Force recommends screening for depression in the general adult population including pregnant and postpartum women. This updated recommendation focuses on the depression that can occur during and after pregnancy and the devastating toll it can have on the all-important bonding that must occur between mother and child during the earliest stage of life. Treatment is available and effective. Mothers may be embarrassed to admit to depression during what should normally be a joyous time. Thus asking a pregnant mother, "Are you sad?" is a simple and effective way to improve the life of not one, but two, very important people!
Now Hear This!
With the expert help of Valerie and Morgan, I successfully attested to Meaningful Use Stage 2 for 2015 as required by the Centers for Medicare and Medicaid Services! This marks the fourth time that my practice has done so--no mean feat, I assure you!
And if you are looking for a great read as you stare out the window at mountains of snow, I heartily recommend "The Boys in the Boat" by Daniel James Brown. This true and wonderful story about Joe Rantz and his fellow oarsmen at the University of Washington brought tears to my eyes!
Valerie, Morgan, and I wish you many beautiful friendships in 2016!!
In This Issue
The Beginning of a Beautiful Friendship!
U.S. Dietary Guidelines
Obesity in Adolescents
Guidelines forBreast Cancer Screening
Screening for Bladder Cancer
Fecal Immunochemical Testing for Colorectal Cancer
Screening for Depression
Now Hear This
John A. Schmidt Jr., M.D.
Board Certified Internist
Dr. Schmidt is one of the leading internists in Monmouth County offering Medical Home services.  

He is an Associate Attending in the Department of Medicine, Jersey Shore University Medical Center, and  Clinical Assistant Professor in the Department of Medicine, Rutgers Robert Wood Johnson Medical School.

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""Winter, a lingering season, is a time to gather golden moments, embark upon a sentimental journey, and enjoy every idle hour."
John Boswell

John A. Schmidt Jr., MD
Meaningful Medicine in Your Medical Home
709 Seventh Avenue
Belmar, NJ 07719
Phone:  732-282-8166  
Fax:  732-280-0147 
E-Mail:  [email protected] 
Disclaimer: The articles in Healthy Living are for general information only and are not medical advice.
Discuss all medical concerns and treatment options with your physician.