Issue: 78

July: Lessons from the World Cup of Soccer!
The US men didn't qualify. The favored Germans were eliminated early. Who won the coveted cup? The French team, with their multinational stars leading the way! The French team exemplified what the United States has been from its humble beginning: a patchwork of national origins blended and banded together to achieve something the pure breeds never could. Take heed, USA! Close your borders and the future is bleak. Open your borders to those who strive to be free and the future is bright. Why is it so hard for us to remember the well spring that made us great?? 

John A. Schmidt, MD 
SALT: Too Much of a Good Thing Can Hurt You!
Salt, sodium chloride strictly speaking, has been enshrined as a positive in our culture. If someone is described as "Salt of the Earth" or "Worth his/her Salt", a compliment has been paid them. The Morton Salt Girl is an American icon that can be found in most of our cupboards (but not mine--see below!) 

Salt is indeed essential to our health. Sodium and chloride are the major elements in our blood. We perspire sodium chloride when we sweat and putting back the salt with sports drinks like Gatorade┬«, Pedialyte┬«, or salt tabs is essential to those who work and sweat outdoors in the summer heat. When a person is "dehydrated", they have lost too much salt from their body. Their skin wilts and blood pressure plummets. Dehydration is treated in the hospital emergency room by infusing "saline". 

Now for the bad news. Salt expands blood volume and thereby increases blood pressure. Higher blood pressure requires the heart to work harder and makes the heart muscle, especially the left ventricle, grow thicker. A left ventricle with thick walls does not fill well. Pressure rises inside the heart leading to a type of heart failure known as "diastolic congestive heart failure", a serious malady that can lead to shortness of breath and edema. I prescribe diuretics to help your kidneys excrete excess sodium chloride into the urine, thereby reducing blood pressure, and alleviating shortness of breath and edema. 

My favorite salt story has to do with my salt-of-the-earth 90 year old mom who has diastolic congestive heart failure. Her leg edema is severe. She called me once and said, "My legs are crying." When I arrived, her socks were soaked and there were three salt shakers on the kitchen table. I said, "Mom, your son is a doctor. You are an embarrassment." She said, "It's Kosher." I said, "It's still salt!!" She replied, "How about Sea Salt? Is that OK?" Grrrrr.... Now she hides the salt shakers whenever I come to visit! 

The food and restaurant industries have long realized that people love salt and will pay for the taste. Every chef "worth his/her salt" uses a "pinch of salt" or two or three. Because my patients often eat out on weekends, we find that office blood pressures are highest on Mondays and decline as the week goes on. Blood pressures on the Monday following the Saint Patrick's Day parade were very high. The Monday after the Super Bowl-forget about it!! 

The recommended daily allowance of sodium is between 1500 and 2000 mgs, which is equivalent to a level teaspoon of salt. The US Department of Agriculture requires food companies to include sodium content on the label. Make sure you know what the serving size is and then do the math. You will be surprised how much salt is in most processed foods! 

Excess salt consumption increases the risk of cardiovascular disease, especially stroke, and we become less tolerant of salt as we grow older, probably because our blood vessels are less distensible. This is why I often prescribe a weak diuretic such as hydrochlorothiazide/HCTZ to treat high blood pressure. It removes the excess salt from your body before it can hurt you and makes your other blood pressure medications work much better. 

Most of my patients who abstain from salt find that they better appreciate the flavor of food simply because it is no longer masked by the overpowering flavor of salt. They learn to bring out the subtle flavors in food by using other spices. Give it a try! You will be pleasantly surprised at the results and healthier by far!!
Valsartan Recall!
Valsartan is a widely prescribed and excellent blood pressure medication. However, as reported by the FDA on July 19, valsartan supplied by certain generic drug manufacturers contains an impurity, N-nitrosodimethylamine (NDMA), a potential carcinogen. The tainted medication was manufactured by Zhejiang Huahai Pharmaceuticals, Linhai, China, and speaks to the high level of surveillance maintained by the FDA over generic medications in general even when sourced abroad. 

The recommendations of the FDA are as follows: first, ask your pharmacist if your valsartan or valsartan/HCTZ medication was supplied by one of the generic companies affected by the recall (Major Pharmaceuticals, Solco Healthcare LLC, Actavis LLC); second, continue taking your current medicine until your health care provider or pharmacist gives you a safe replacement or a different treatment option. Fortunately, there are a number of generic medications in the same class (e.g, losartan, olmesartan, telmisartan, and others) with similar activity that are unaffected by the recall. It is therefore not necessary to insist on branded valsartan ( Diovan┬«), for which most insurance plans will charge you a hefty premium. 

We have already replaced valsartan for many of our patients. Please review your medication list and medication bottles. If you are currently taking valsartan, kindly contact the office (732-282-8166) or send me a patient portal message and I will promptly prescribe a replacement. Our software unfortunately is not able to search our records for valsartan users. It therefore falls to you to kindly notify us. Because I generally prescribe losartan, which I take myself, relatively few of our patients have been affected by the recall. 
Marijuana/Cannabis: Safer than Cigarettes? 
In the United States, the use and possession of cannabis is illegal under federal law for any purpose. However, the medical use of cannabis is legal with a doctor's recommendation in 31 states, including New Jersey, and recreational use is legal in nine states, not including New Jersey. The Rohrabacker-Blumenauer Amendment, which is currently in effect until at least September 30, prevents the Justice Department from spending federal funds to prosecute individuals who are in compliance with state medical marijuana laws. 

As reported in the Annals of Internal Medicine on July 24, approximately 14.6 percent of US adults use marijuana and the rates are rising. An estimated 7000 persons start using marijuana each day. Smoking remains the main method of consumption. 

"Similarities between marijuana and tobacco smoke are concerning from a public health perspective. Marijuana cigarettes are believed to contain particulate matter, toxic gases, reactive oxygen species, and polycyclic aromatic hydrocarbons at a concentration possibly 20 times that of tobacco smoke. Studies have shown that marijuana causes bronchial inflammation similar to that observed in cigarette smokers." 

"Our review suggested that use (more than once per week for at least 1 year) is associated with cough, sputum production, and wheezing. Evidence on the association between daily use and obstuctive lung disease (COPD/emphysema) is insufficient." 

"Studies of long term tobacco use suggest that changes in FEV1 (a measure of lung function) become measurable only after 5-10 pack years of smoking (36,500 to 73,000 cigarettes). One joint a day for twenty years (20 joint-years) only amounts to 7,300 joints. Given the psychoactive effects of tetrahydrocannabinol/THC (the active ingredient in marijuana) and its effect on overall (brain) function, few users may have sufficient exposure to cause significant changes in pulmonary function testing. In other words, marijuana's effects on lung function may not be among its most important health outcomes in the long term." 
EPCS is Here! 
My office has implemented EPCS (electronic prescription of controlled substances) which means that Ms. Clark and I will no longer be writing paper prescriptions for controlled substances such as tramadol, clonazepam, and zolpidem. These prescriptions will be electronically and securely transmitted to your pharmacy over the internet. Individuals who were having to come to the office to pick up bar-coded scripts for controlled substances will no longer need to do so.
Now Hear This!
We are anxiously awaiting the birth of our dear second daughter's second child, our fifth grandchild! Her due date was yesterday! The baby will be born in Pennsylvania Hospital, Philadelphia, the nation's oldest hospital founded by Benjamin Franklin in 1751! Watching her tummy is like watching a tsunami! Our doctor daughter still makes rounds in the Pediatric Intensive Care Unit almost every day. I am in awe!! 

Valerie, Ms. Clark, Ms. Catong, Ms. Sentner, Jenna, Nicole, Amanda and I wish you and yours a very pleasant summer (without the salt!)
In This Issue
July: Lessons from the World Cup of Soccer!
SALT: Too Much of a Good Thing Can Hurt You!
Valsartan Recall!
Marijuana/Cannabis: Safer than Cigarettes?
EPCS is Here!
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 attending physician at Jersey Shore University Medical Center.
Dr. Schmidt is enrolled in the Maintenance of Certification Program of the American Board of Internal Medicine
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"We have a great sense of togetherness. It is our team spirit that has taken us to this World Cup."

- Robie Keane


John A. Schmidt Jr., MD
Meaningful Medicine in Your Medical Home
2006 Highway 71, Ste. 3, Spring Lake Heights, NJ 07762
Phone:  732-282-8166  
Fax:  732-280-0147 
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.