Issue: 70

November: The United States of Cognitive Dissonance
We Americans are good at Cognitive Dissonance and its getting us into deep trouble!  I offer two examples from recent interviews broadcast on National Public Radio (NPR).

The first was a rebroadcast of an interview by Terry Gross (WHYY, Philadelphia) of Professor Ewe Reinhardt, a Princeton economist, who was a youngster in Germany during World War II and advocated for the Personal Mandate that became law with the enactment of the Affordable Care Act (aka, Obamacare).  Reinhardt: "Cognitive Dissonance means that you hold two different theories that are in conflict with one another. For example, many Americans say the government doesn't have the right to require them to buy health insurance.  But the same Americans will say if they get hit by a truck and lie bleeding in the street, society is obliged to send an ambulance and emergency room doctors are obliged to save their lives.  How could both be true?  If you believe society has a duty to save your life when you get hurt, you have a duty to chip into a fund that pays for that." The interview was particularly timely now that the US Senate is weighing repeal of the Personal Mandate as part of their tax overhaul proposal.

When asked if citizens in other countries suffer from the same cognitive dissonance, Reinhardt said flatly, "No.  Canadian, German and English citizens understand that they have to pay taxes or premiums to be insured.  They understand 'tit for tat'.  I grew up in a tool shed and remember how good it was to have health insurance like everyone else in Germany....No Canadians or Germans ever go bankrupt over medical bills.  Why should we in America do that?", he asked.

The second radio interview was by NPR Morning Edition's Steve Inskeep of evangelical leader, Ed Stetzer.  Stetzer holds the Billy Graham Distinguished Chair at Wheaton College in Illinois and is the author of "This Is What IT Means to Sell Your Soul for a Bowl of Trump", published in Christianity Today.  Inskeep: "Why would so many evangelicals change their views for apparent partisan political gain?"  Stetzer: "The ultimate intervening variable was President Trump.  When 81 percent of white evangelicals supported President Trump, they recalibrated their ethical standards to do so.  This was unhelpful, even sinful recalibration.  I'm not saying that every person who voted for President Trump is sinful, but I am saying that to change your views on morality in order to support a candidate is deeply troubling.  We need to disciple people better so that they actually think biblically, not politically, about every issue."  

Professor Stetzer nailed it.  When self-righteous evangelicals stand up for President Trump and Nobel Peace Prize Laureate, Aung San Suu Kyi, does an about-face and presides over murderous ethnic cleansing of Rohinga Muslims, one suddenly realizes how cognitive dissonance can poison the minds and souls of even the most well-intentioned persons. Take heed and maintain your moral compass! 
John A. Schmidt, MD 
New Guidelines for Blood Pressure, At Last!
It's about time! As reported on November 13 , essentially every professional medical organization, including the American Heart Association, is now finally recommending lowering of blood pressure to an average daily value of 130/80.  Shockingly, it has taken these erudite societies more than two years to acknowledge the earth shattering results of the now-famous, NIH-sponsored Sprint (Systolic Pressure Intervention) trial published in the New England Journal of Medicine in 2015.  Sprint showed that adults of all ages who were treated to a systolic blood pressure (top number) of 120 or less did much better, so much so that the trial was stopped in its fourth year because it was no longer ethical to settle for the former standard of 140/90.  This means that many patients who thought their blood pressure was OK now suddenly find out that they are at increased risk of serious life-threatening complications of hypertension such as heart attack and stroke , the number one and number two killers of Americans.  

But here's the good news.  Controlling blood pressure is easy.  Simply curb sodium intake to 1500-2000 mg daily, exercise, lose weight and/or take medicines that, for the overwhelming majority, have no side effects whatsoever.  In Sprint, patients were treated with a generic ARB (e.g., losartan ), a weak diuretic (e.g., hydrocholorothiazide or chlorthalidone ), and/or a calcium channel blocker (e.g., amlodipine ), all of which work well when taken once daily.  Small price to pay to avoid a life devastating heart attack or stroke!  

Please buy a battery-operated blood pressure cuff (e.g., Omron® available at Amazon ), measure your morning blood pressure, and bring the results and your medication bottles to your next appointment!  More than 65% of Americans over the age of 65 have high blood pressure according to the new criteria.  Chances are you are one of them!!

Personal Testimonial: When Sprint published two years ago, I measured my blood pressure and, holy smokes, it was too high!  I abstain from added salt, exercise, control my weight as best I can, and take losartan and triamterene-hydrochlorothiazide every day with excellent results!  I love my four beautiful grandchildren and there is no way I am allowing hypertension to take them away from me!
Management of Chronic Kidney Disease (CKD)
I measure my patients' serum creatinine annually to estimate their glomerular filtration rate  (GFR) and kidney function .  You can find these results in your Follow My Health Patient Portal   account or by requesting a copy of your lab results. Creatinine is inversely proportional to GFR and kidney function. Translation: the higher your creatinine, the lower your GFR and kidney function.  The report will tell you if you have normal kidney function or mild, moderate, or severe kidney disease ( CKD III, IV, or V , respectively). 

Most of my patients with CKD have CKD III, that is, mild kidney disease. Patients with CKD should avoid over-the-counter pain killers ( Aleve® , Motrin® , Celebrex® , etc.) because these medicines can make CKD worse if taken on a regular basis.  

CKD is an important risk factor for cardiovascular disease , so blood pressure control, statins , and aspirin are especially important for patients with CKD.

Patients with CKD IV are at risk of needing dialysis in the future but can often avoid or delay dialysis by paying close attention to their diet.  A useful, though somewhat tedious, guide can be found in table 2 of a review published in the November 2 issue of the New England Journal of Medicine .  Here are some tips to make interpretation a little easier:

First, what goes in must come out.  Our kidneys are responsible for removing excess sodium, potassium, water, and nitrogen from our bodies.  Normally they do an amazing job and easily keep up with our dietary indiscretions. However, the kidneys of patients with CKD may become overwhelmed.  

Not to worry.  Excess sodium and water can be removed with loop diuretics (e.g., furosemide , torsemide, bumetanide ) and excess potassium can be avoided by cutting back on potassium rich foods (citrus fruits, potatoes, bananas, etc.)   

Second, dietary protein is the major source of nitrogen and is converted by the liver into urea.  Urea must be excreted by the kidneys and, if not, " uremic poisoning " results.  Thus, consuming the right amount of protein every day is the most important component of nutrition in patients with CKD. As mentioned in the table, the correct amount for patients with CKD is between 0.6 to 0.8 grams of protein per kg of ideal body weight daily. Consulting a skilled nutritionist is very helpful.  Eating too much protein will accelerate the need for dialysis.  Eating too little protein is also bad because the body will generate urea by breaking down muscle. Thus a "not too much, not too little" approach is best when it comes to consuming protein.  

Consuming enough calories in the form of carbohydrate and unsaturated fat serves to prevent breakdown of muscle so don't skip meals and make sure you have enough calories in your diet to prevent muscle breakdown.

Third, CKD takes a toll on bones. Bones are made of calcium and phosphate (and protein) so the serum concentrations of calcium and phosphate are very important.  Normally, the concentration of calcium is higher. However, in CKD, the reverse is true and leads to a condition known as secondary hyperparathyroidism that weakens bones and leads to fractures. The excellent medicines I typically prescribe for osteoporosis have unfortunately not proven useful in patients with CKD.  The strategy in CKD is to reverse the imbalance by giving vitamin D to improve calcium absorption and by giving phosphate binders (e.g., Renvela / Sevelamer® ) to inhibit phosphate absorption .  This strategy is usually successful in boosting serum calcium while keeping serum phosphorus low, squelching hyperparathyroidism, and protecting bones.
Immunotherapy Is Revolutionizing Therapy for Difficult-to-Treat Cancers!!
Let's review!  Your immune system is powerful and routinely protects you against invading bacteria and viruses.  Vaccines boost the ability of your immune system to destroy bacteria and viruses but haven't proven useful in destroying cancers.  Why?  Cancers are smarter than viruses and bacteria. They figured a way to deactivate their would-be killers, cytotoxic T lymphocytes (CTL).  Here's how tumors defeat CTL.  CTL infiltrate a tumor only to be turned off by a molecule expressed by the tumor known as PDL-1 .  PDL-1 engages a molecule on CTL called PD-1 , thereby deactivating the CTLs and rendering them harmless to cancers.

Antibodies that block the interaction between PD-L1 and PD-1 turn the tables on cancer cells as demonstrated in two exciting reports in the  New England Journal of Medicine. In the November 9 issue, an antibody targeting PD-1 ( Nivolumab, Opdivo® ) significantly prolonged progression free survival of patients with metastatic malignant melanoma . In the November 16 issue, an antibody targeting PD-L1 (Durvalumab, Imfinzi®) significantly prolonged progression-free survival in patients with metastatic lung cancer . Harnessing the immune system to destroy cancers continues to show promise! Stay tuned!
Now Hear This!
We now embark upon the most wonderful season of the Year! Ms. Clark, Morgan, Mandy, Valerie, and I wish you Joy! 
In This Issue
November: The United States of Cognitive Dissonance
New Guidelines for Blood Pressure, At Last!
Management of Chronic Kidney Disease (CKD)
Immunotherapy Is Revolutionizing Therapy for Difficult-to-Treat Cancers!!
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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- E.O. Wilson


Dr. Schmidt's New Office in Spring Lake Heights
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.