445 - Melanoma Screening, “Health Food” Imposters, Last-ing Love

From the Literature

1) Melanoma Screening and the Importance of the Right Information

Researchers at the University of Pittsburgh Medical Center have published a retrospective analysis of a large quality improvement project designed to increase primary care screening for melanoma. Primary care physicians in the UPMC system were invited to begin screening all patients over age 35 for melanoma (based on a German screening program model) and were offered optional online training in skin cancer detection.

Out of over ½ million patients seen in the five years of the program, almost 145,000 were screened. As a result of screening, clinicians diagnosed significantly more in situ melanomas (hazard ratio (HR) 2.6, 95% CI 2.1 to 3.1) and melanomas <= 1mm in depth (HR 1.8, 95% CI 1.5 to 2.2), but there was no difference in diagnosis of more advanced melanomas. The increase in early melanoma detection accounted for the increased overall melanoma detection HR of 1.8 (95% CI 1.6 to 2.1). The authors expressed concern that this pattern of early detection could lead to overdiagnosis unless we continue to track these patients for longer-term outcomes.

Two accompanying editorials discussed this finding with opposite perspectives. The first celebrates the increased early detection, reminding us that melanoma is more aggressive at earlier stages than most cancers, that skin biopsies carry relatively low morbidity (limiting harm from overdiagnosis), and warning us of the dangers of “not screening.” They do offer a suggestion to screen only those at highest risk (personal or family history of skin cancer, or advanced age). The other editorial worries about early detection leading to overdiagnosis and reminds us that histological diagnosis of melanoma does not always predict metastatic potential and that research has to date failed to demonstrate a reduction in mortality from skin cancer screening programs.

John’s Comments: 

The US Preventive Services Task Force has not found evidence to justify routine screening for melanoma, though it does recommend counseling to increase sun-avoidance behaviors (including sunscreen use) in patients under age 25 with fair skin types. The solution to the screening question is a large, randomized trial with long-term outcomes to avoid issues of length and lead time bias. It is unclear if this will ever be prioritized. In the meantime, it behooves us to keep in mind that increased detection is not always a good thing.

References:

·         Matsumoto M, Wack S, Weinstock MA, et al. Five-Year Outcomes of a Melanoma Screening Initiative in a Large Health Care System. JAMA Dermatology. Published online April 6, 2022. Link

·         Kulkarni RP, Yu WY, Leachman SA. To Improve Melanoma Outcomes, Focus on Risk Stratification, Not Overdiagnosis. JAMA Dermatology. Published online April 6, 2022. Link

·         Swerlick RA. Melanoma Screening—Intuition and Hope Are Not Enough. JAMA Dermatology. Published online April 6, 2022. Link

From the Lay Press and Backed by Science

2)  “Health Food” Imposters That Fool Many Clinicians

A food myth is a misconception or unfounded idea about a specific food or food in general.  As our culture tends to be “food conscious” but “nutrition naïve,” there are many such myths in circulation, including some that have incredible staying power for the general public and often for healthcare clinicians as well. 

The reality is that many of the “healthy” foods we eat are actually unhealthy, even some of the so-called “superfoods.” These foods gain a foothold because of clever marketing campaigns, but if you look at the ingredients on the label, it’s easy to see they aren’t as healthy as you might imagine. The health benefits of these foods are overstated. Here are some common offenders. 

Energy Bars

Many energy bars are glorified candy bars with extra protein, some nuts and/or grains, and fiber added. They are often made with significant added sugar, saturated fats, and numerous artificial ingredients.   Some of the “healthier” energy bars substitute lower-calorie sugar alcohols, but 3 of the more common ones (sorbitol, maltitol, xylitol) can cause significant GI distress in many people as they are the “P” (polyols) in FODMAPs. 

As with many of the potential health food “imposters,” those who eat energy bars must become discerning consumers if they are truly going to obtain health benefits.  Look for those with a short list of ingredients comprised of real food.  The more additives you see, the less healthy benefits it likely has.  Also pay attention to calories and serving size.  These bars can be quite calorie dense. 

Veggie Chips

Similar to “energy bars,” not all veggie chips are created equal, and most are much unhealthier than their name suggests.  Remember, potato chips are “veggie chips.” Even those chips made from other vegetables are often prepared in the same way as potato chips, and once processed into chips, lose many of the healthy vitamins and plant chemicals.   This is true as well for “veggie straws,” which are made from powdered vegetables and other additives, making the end product very low in fiber, protein, vitamins, minerals and actual vegetables and often quite high in fat and sodium.  Once again, learning to read and understand the labels becomes essential if one is to derive any potential health benefits.

Vitamin-Fortified Cereals

While the food industry wants us to believe that breakfast cereals are a healthy food option, many fortified cereals are the equivalent of boxed candy.  Those with “added vitamins and minerals” are often artificially adding back synthetic forms of some of the beneficial nutrients that were removed during processing.  Most also lack fiber and have significant amounts of added sugar.  Minimally processed cereals can have some health benefits, but even many “granolas” contain deceptive labeling and loads of added sugar.  

Flavored Yogurt

While plain yogurt has some potential health benefits, including being a good source of protein, B-vitamins, calcium, zinc, potassium, and magnesium, those with added “real fruit” ingredients are often overflowing with sugar.  For those who eat yogurt, consider adding real fruit to the yogurt for added sweetness.

Agave Syrup

While agave has been a very popular “healthy substitute” for sugar and has been brilliantly marketed, it contains as much if not more fructose than high-fructose corn syrup (HFCS), which has been linked to obesity and numerous chronic diseases. 

Fruit Juice

While fruit juice contains a variety of vitamins, minerals, and potentially beneficial plant compounds, it also contains a similar amount of calories to the equivalent volume of soda.  Because it also lacks the fiber contained in the whole fruit, it will cause a blood sugar spike similar to soda as well.  Stick with the fruit itself. 

Mark’s Comments:

It is amazing to me how often I hear clinicians espousing nutritional mythology, and often quite passionately.  I worry some believe more of what they hear at the gym or on social media than what they read in our medical journals.  Sure , there is controversy about many things in the field of nutrition as it is continuing to evolve, but that doesn’t mean we know nothing.  So, when it comes to nutrition, make it a habit to share (and consume) as many “Healthy Facts” as possible.

References:

Modified from “7 Health Food “Imposters” That Aren’t as Healthy as You Think.  SciTechDaily.com.  20 April 2022.  Link

From PeerRxMed ( www.PeerRxMed.org )

3)  The Secret to Last-ing Love

“If I knew this was the last time I’ll see you, I’d tell you I love you, and would not just assume foolishly you know it already.”  Gabriel Garcia Marquez, novelist

What do you remember about the last time you were with those in your life whom you would claim to love dearly?  What did you talk about?  Did you hug them?  Laugh or cry with them?  Tell them how much they mean to you?  What would you regret having said or not said, done or not done, if you were to never see them again?  

A story that has literally changed my life was told at a memorial service for a man who had died tragically in a car accident, leaving behind a wife and 2 young children.   The pastor who was giving the eulogy concluded by saying, “One thing I know for certain were his last words to his dear wife the last time she saw him.  They were ‘I love you.’  I know this because these were the last words he always said to those whom he loved, including me.”  I have tried to make this a habit ever since. 

The fact is that for everything we do and for everyone we love, there will be a “last time.”  This has certainly been one of the many sobering reminders of the COVID pandemic.  Indeed, there are “last times” that will be happening to you this week, even in your day today, many of which you will only know in retrospect.  And while we “know” this cognitively, if we are willing to stop and reflect on our actions, we don’t always live in a way that demonstrates our awareness of the fleeting nature of those precious present moments.  At least that’s the case for me, and I have a sneaking suspicion for you as well. 

In the ancient Greek philosophy of Stoicism, there is a thought exercise they called the “last time meditation.”  The premise is quite simple.  You are asked to consider, “if I knew this were the last time I was ever doing ____, or being with ____, how would I show up differently than I am presently showing up?”  In other words, the Stoics recognized that every moment represents a precious finite opportunity to savor your life.

Take a moment to reflect on your upcoming week.  Who will you be seeing or communicating with who matters dearly to you?  Who’s not on the list who should be?  When you are with them or corresponding with any one of them, consider pausing to perform a brief “last time meditation” and see if that allows for you to “show up” differently.  And be sure to tell them how much you love and appreciate them.  Even if it’s not the “last time,” you’ll be glad you did – and so will they.

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Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org