Every few months I receive a computerized invitation from my doctor asking me to have a colonoscopy to screen for polyps in my bowel. I always tell myself that I am too busy just now, I will have it another time. But really I don’t want to have it at all, and I know that when the next invitation comes I will be too busy then as well.
I am also eager to find a rational reason, or at least a rationalization, for my refusal. I thought I found it in a paper from Norway in a recent edition of the New England Journal of Medicine.
The authors examined the death rate from colorectal cancer in Norway among the 40,826 patients between 1993 and 2007 who had had polyps removed at colonoscopy in that country (the records are more or less complete). They compared the number of deaths in that population with the expected death rate from the disease in the population the same age as a whole. 398 deaths were expected and 383 deaths were observed.
This small difference does not mean that colonoscopy does not work in preventing death from colorectal cancer, of course. This is because the relevant comparison is with people who had polyps not removed by colonoscopy rather than with the population as a whole.
The 40,826 patients who had polyps removed at colonoscopy, however, were not a random sample of the adult population because Norway does not have a screening program for colonic polyps. The patients had colonoscopy in the first place because they were symptomatic, for example bleeding per rectum. They were therefore much more likely to suffer from polyps or cancer in the first place than the rest of the population.
Many people have been misinformed regarding human-to-human transmission of Ebola. The Canadian Health Dept. States that airborne transmission of Ebola is strongly suspected and the CDC admits that Ebola can be transmitted in situations where there is no physical contact between people, i.e.: via airborne inhalation into the lungs or into the eyes where individuals are separated by 3 feet. That helps explain why 81 doctors, nurses and other healthcare workers have died in West Africa to date. These courageous health care providers use careful CDC level barrier precautions such as gowns, gloves and head cover, but it appears they have inadequate respiratory and eye protection. Dr. Michael V. Callahan, an infectious disease specialist at Massachusetts General Hospital who has worked in Africa during Ebola outbreaks said that minimum CDC level precautions “led to the infection of my nurses and physician co-workers who came in contact with body fluids.”
Currently the CDC advises health care workers to use goggles and simple face masks for respiratory and eye protection, and a fitted N-95 mask during aerosol-generating medical procedures. Since so many doctors and nurses are dying in West Africa, it is clear that this level of protection is inadequate. Full face respirators with P-100 replacement filters would provide greater airway and eye protection, and I believe this would save the lives of many doctors, nurses and others who come into close contact with, or in proximity to, Ebola victims.
It is apparent that the primary mode of person-to-person Ebola transmission is through direct contact with the body or bodily fluids of Ebola victims, but it is unwise to ignore the airborne mode. I believe the current evidence supports healthcare workers using a higher level of airway and eye protection than is currently recommended. Since CDC level respiratory/eye precautions for Ebola are inadequate for healthcare workers in West Africa, I assume they will also be inadequate in the United States.
What stands to reason is not always borne out by facts, for reality is often refractory to human wishes. There was a good illustration of this unfortunate principle in a recent edition of the New England Journal of Medicine.
It has long been known that low concentrations of high-density lipoproteins (HDL) and high concentrations of low-density lipoproteins (LDL) are associated, in a more or less linear fashion, with cardiovascular disease such as strokes and heart attacks. It would seem to stand to reason, therefore, that raising the HDL and lowering the LDL would lead to fewer cardiovascular “events,” as strokes and heart attacks are called.
One way to achieve this wished-for biochemical change is to treat patients at risk of such events with niacin, a B vitamin, in addition to the statins that they are already taking. The largest placebo-controlled trial of niacin ever undertaken, with 25,673 patients who had already had a stroke or heart attack, has shown that the addition of niacin, though it does indeed increase HDL and decrease LDL, has no effect on the rate of heart attack or stroke. Worse still, it gave rise to serious side effects, such as worsening of diabetes and unpleasant gastrointestinal, musculoskeletal and dermatological effects. One of the most unexpected findings of the trial was the excess of infections in people treated by niacin. If anything, the overall death rate in the niacin-treated group was higher than that in the placebo control group, though the difference was not statistically significant (which is not quite the same thing as saying that it was not real). The patients were followed up, on average, for nearly four years and at no time was treatment with niacin superior to that with placebo.
All medical journals these days feel the compulsion to be high-minded, but none is as high-minded as the Lancet. It is as if the editors had taken lessons both in moral philosophy and rhetoric from Mr. Pecksniff himself.
Mr. Pecksniff, you may remember, was the preposterous hypocrite in Dickens’ Martin Chuzzlewit, who introduces his daughters, Charity and Mercy, by adding “Not unholy names, I hope?” As Know thyself was inscribed over the entrance to the temple to Apollo at Delphi, and Abandon hope, all ye who enter here over the entrance to Dante’s hell, so Mr Pecksniff’s words, Let us be moral, must be inscribed over the entrance to the offices of the Lancet, figuratively if not literally
In the week before a Malaysian Airlines plane, taking many AIDS doctors and activists from Amsterdam to Melbourne for an international conference on AIDS, was shot down over eastern Ukraine, the Lancet published a statement called the Declaration of Melbourne, a typically sickly and nauseatingly unctuous statement of ethical principles. It began by saying something that, if not a lie exactly, was certainly not a truth:
We gather in Melbourne, the traditional meeting place of the Wurundjeri, Boonerwrung, Taungurong, Djajawurrung and the Wathaurung people, the original and enduring custodians of the lands that make up the Kulin Nation, to assess progress on the global HIV response and its future direction, at the 20th International AIDS Conference, AIDS 2014.
This, of course, is the purest 21st century Pecksniffery; and unless the signers of the declaration (who look extremely self-congratulatory in photos accompanying the article) can each and severally explain in what sense the Djajawarrung are the custodians of the lands on which the city of Melbourne is built, I suggest that they be banished to the outback for five years to live as pre-contact Australian Aborigines lived.
One of my first medical publications was on the nocebo effect, the unpleasant symptoms patients may suffer as a result of being made aware of potential side effects of a treatment they are about to receive or a procedure they are to undergo. Thus patients who were having a lumbar puncture were either told or not told they might suffer a headache afterwards; and lo and behold, those who were told that they might get headaches duly got headaches while those who were not told didn’t.
On the whole, as an article in a recent edition of the Journal of the American Medical Association points out, doctors are well aware of the placebo effect, that is to say the good that their treatment may do patients by means of mere suggestion, but have little awareness of the opposite nocebo effect, the harm that their treatment may do their patients by mere suggestion.
The nocebo effect poses an ethical dilemma for doctors, say authors of the article. On the one hand, doctors are supposed to do their patients no harm; on the other, they are supposed to be open and honest with their patients about the potential harms of drugs and other treatments. The dilemma is this: foreknowledge of those harms can harm some patients. Should the need for honesty trump the ethical injunction to do no harm?
When my PJ Media editor suggested that I write about having lupus, I almost said no.
I was diagnosed with SLE in 1991 and have been in remission since around 1995. My book about living with this chronic illness came out two years later. Like most writers, by the time a book comes out, I’m so sick – pun intended – of its topic that I dread having to revisit it.
Having been in remission for almost 20 years, I can honestly make the rather unusual claim that not even the perspective of hindsight has changed my ideas or feelings about what being a pain-wracked invalid was like. Not even a little bit.
I feel like I’m supposed to say the opposite: that looking back, I could have “handled” my disease differently, or learned other, “better” lessons from it, and so forth.
But then, from the very beginning, I didn’t fit the mold of the “disease of the week” TV movie heroine, or some “poster child” for lupus.
Here are some things I learned (or, perhaps more accurately, some pre-conceived ideas I had reinforced) when I was at my very sickest.
Warning: What follows is NOT inspirational. At all.
Is there ever any good news without bad? Good and bad seem to be inextricably locked in a Hegelian dialectic, or perhaps Manichaean struggle would be a more accurate way of putting it. For example, tuberculosis became the captain of the men of death, the white plague, between the seventeenth and the nineteenth centuries. Then it began its long decline, accelerated by the discovery of the first effective anti-tuberculous drugs. Then, just as large numbers of people became more susceptible to tuberculosis because of the spread of the human immunodeficiency virus, the germ of tuberculosis developed resistance to the most effective drugs against it. It seemed that the disease might once more become what it had been not so very long before. But then, for the first time in 40 years, a new anti-tuberculous drug, bedaquiline, was developed by the pharmaceutical company Janssen. Good news has not retained the upper hand for very long, however. An article in a recent edition of the Lancet suggests that bedaquiline is not the answer to Mankind’s prayers, at least where tuberculosis is concerned.
The distinction between what the law permits and what the law enjoins is often blurred. An absence of proscription is sometimes mistaken for prescription. The more the law interferes in our lives, the more it becomes the arbiter of our morality. When someone behaves badly, therefore, he is nowadays likely to defend himself by saying that there is no law against what he has done, as if that were a sufficient justification.
The recent Supreme Court decision in the cases of Burwell v. Hobby Lobby Stores and Conestoga Wood Specialties Corp. v. Burwell illustrates the difficulties when two or more rights clash irreconcilably. The complex issues involved were the subject of an article in a recent edition of the New England Journal of Medicine. The matter is still far from settled. It seems to me likely that the Supreme Court will one day reverse itself when its philosophical (or ideological) composition has changed.
The two corporations were owned by strongly religious people. Corporations of their size were enjoined by the government to provide their staff with health insurance which would cover contraceptive services. However, some contraceptive methods violated the religious beliefs of the owners of the companies. Did the companies have the right to except these methods from the policies that they offered to their staff (who, incidentally, numbered thousands, many of whom would not be of the same religious belief)?
In principle medical research is supposed to result in unequivocal guidance to doctors as to how to treat their patients. As often as not, however, the waters are muddied as much as cleared. Two papers in a recent edition of the New England Journal of Medicine about atrial fibrillation and the cause of stroke illustrate this. It has long been known that people with a clinically-detected chaotic heart rhythm called atrial fibrillation (AF) have an increased incidence of stroke by embolism; and likewise that no cause of such stroke can be found in up to 40 percent of patients who suffer from one. Their strokes are called cryptogenic. The two papers addressed the question whether, if you monitor patients with cryptogenic stroke for long enough, some or many of them will turn out to suffer from AF. This is important, because it is generally agreed that, in patients with clinically detected and symptomatic AF, anti-coagulation reduces the subsequent risk of stroke. AF, however, is not an all or none phenomenon. Some people suffer it continuously, but others only occasionally and for only a few seconds at a time. The additional risk of stroke in the latter is unknown, but is an important question because the anticoagulation designed to reduce the risk of stroke is not itself without risk, including that of another kind of stroke, the haemorrhagic kind. In other words, the risk caused by treatment could outweigh its benefits.
If the future were knowable, would we want to know it? When I was young, a fortune teller who predicted several things in my life that subsequently came true predicted my age at death. At the time it seemed an eternity away, so I thought no more of it, but now it is not so very long away at all. If I were more disposed to believe the fortune teller’s prediction than I am, would I use my remaining years more productively or would I be paralyzed with fear?
In a recent edition of the New England Journal of Medicine a question was posed about a 45-year-old man in perfect health (insofar as health can ever be described as perfect) who asked for genetic testing about his susceptibility to cancer, given a fairly strong family history of it. Should he have his genome sequenced?
A geneticist answered that he should not: to have his entire genome sequenced would lead to a great deal of irrelevant and possibly misleading information. But if the family history were of cancers that themselves were of the partially inherited type – more factors than genetics are involved in the development of most cancers – then the man might well consider having the relevant part of his genome, namely that part with a known predisposing connection to the cancers from which his family had suffered, sequenced.
This is not a complete answer, however. Two obvious questions arise: is additional risk clinically as well as statistically significant, and if the risk is known can anything practicable and tolerable be done to reduce it? There is no point in avoiding a risk if to do so makes your life a misery in other respects. You can avoid the risk altogether of a road traffic accident or being mugged on the street by never leaving your house, but few people would recommend such drastic avoidance.
There are few phrases more dangerous in medicine than “it stands to reason,” because what stands to reason may in fact not be a good idea, however brilliant it may once have seemed. This is because reality is always more complex than our theories about it; grey is theory, said Goethe, but green in the tree of life.
Perhaps the greatest single intellectual advance in the medicine of the last century was the realization that “it stands to reason” is no reason at all; everything must be studied in the light of experience. There was a good example of this necessity in a recent edition of the New England Journal of Medicine, which studied the effect of giving patients doses of aspirin or clonidine before and after undergoing non-cardiac surgery.
One of the most serious and feared complications of such surgery is heart attack, especially as the age at which people are operated on has increased. There are good theoretical reasons for believing that either aspirin or clonidine, or both, given peri-operatively might reduce the rate of heart attack in the first month after operation. Aspirin prevents the blood platelets from sticking to one another and the lining of the blood vessels, agglomeration of platelets being one of the mechanisms of heart attack; clonidine blocks the activity of the sympathetic nervous system whose overactivity is thought to be another such mechanism. Therefore it stands to reason, if anything does, that making the platelets less “sticky,” or the sympathetic nervous system less active, before, during and after operation might reduce the rate of post-operative heart attack. But does it?
A large trial was conducted in 135 hospitals in 23 countries, comparing the rates of heart attacks of people given aspirin, clonidine or placebo before and after operation. 10,010 patients were recruited in all, and the rate of follow-up was so high (99.9 percent) that it resembled the results of a Soviet-era election. Surprisingly, more than 40 percent of the patients were already taking low-dose aspirin prophylaxis when they entered the trial; but they were treated in exactly the same fashion as their peers who were not on aspirin.
One of the few laws of political science is that when governments make mistakes, they tend to be whoppers. Luckily for them, the public’s memory is short, and the outrage of today soon declines into the apathy of tomorrow.
From several articles published in a recent edition of the British Medical Journal, it appears that many governments around the world, including those of Britain and the U.S., may have made such a mistake in stockpiling billions of dollars’ worth of anti-flu medications, bought principally from Roche, the largest pharmaceutical company in the world as measured by capitalization.
First the governments overestimated the virulence of the new flu epidemic the drugs were supposed to counter, no doubt a forgivable mistake in the circumstances; but then it stockpiled the supposedly anti-flu drugs on the basis of inadequate evidence. It took published studies at face value without apparently realizing that the drug companies had withheld a great deal of data – 150,000 pages of it, as it turned out. When, after what seems like a rear-guard action to prevent it, the drug companies released all the data, re-calculation showed that the drugs were not quite useless, but had practically no value from the public health point of view. At best they reduced the duration of symptoms by a few hours and in some cases prevented the development of symptomatic disease. But they also caused serious side effects, and neither prevented deaths nor serious complications nor the rate of hospitalization. They did not prevent the spread of the infection either.
My home state of Colorado is a guinea pig for the pros and cons of marijuana legalization. Other states are observing closely to see if they should move down the path towards legalization.
There’s plenty of bad news to go around. Police in other states are pulling over Colorado drivers with no justification other than the green license plate. (We’re all stoners now, I guess.) A college student named Levy Thamba fell to his death from a high balcony during spring break after eating a marijuana cookie. And last week a Denver man who ate pot-infused candy became incoherent and paranoid and shot his wife to death.
Is there good news? Turns out there is. Colorado Springs is the source of the Charlotte’s Web strain of medical marijuana that has sent parents with gravely ill children flocking to the city for treatment.
The strain was developed by Joel Stanley and his brothers in their Colorado Springs medical marijuana facility. They’d read that marijuana strains that are high in a chemical called CBD can help to shrink tumors and prevent seizures. The chemical in marijuana that gets users high is called THC, and since it has an adverse affect on seizures the Stanley’s bred it out of the plant.
Their first patient, 5 year old Charlotte Figis, was so affected by a genetic seizure condition called Dravet’s Syndrome that she was not expected to live much longer. Today, she’s almost seizure free. The Stanley brothers named the strain after their first little patient, and it’s showing the world what medical uses marijuana can offer.
Today there are nearly a hundred families with gravely ill children who have relocated to Colorado Springs, purchasing a treatment for their children that would have landed them in prison just a few years ago. Medical marijuana is well known to help in the treatment of nausea in cancer and AIDs patients, but the strains now being investigated may uncover new lifesaving medicines such as Charlotte’s Web.
The recreational use of marijuana is proving to be the problem it was predicted to be, but while the stoners fill the headlines the researchers in medical marijuana are quietly making amazing advances in the treatment of illnesses. That’s some very good news indeed.
Image via CNN Health.
Good and bad news often go together, for what is good news for some is bad for others. Shareholders in pharmaceutical companies that produce statins will have been heartened (no pun intended) by a paper in a recent edition of the New England Journal of Medicine in which the authors calculated that, under the new guidelines of the American College of Cardiology and the American Heart Association with regard to lipid levels in the blood, 12.8 million more adults in the United States alone would be “eligible” for (i.e. ought ideally to have) treatment with statins. In fact, very nearly half the population older than 40 ought to take them, and seven eighths of the population over 60. As a man over sixty who never has any blood tests done, my heart sinks (again no pun intended). We are all guilty of illness until proven healthy: not good news.
The authors compared the therapeutic consequences of the old guidelines with the new. In effect the new guidelines lowered the threshold for treatment. According to these guidelines, anyone over 40 with known cardiovascular disease should receive statins, irrespective of their level of Low Density Lipoprotein (LDL); while anyone with a level of 70 milligrams per decilitre or more and who has diabetes or a statistical risk of a heart attack of more than 7.5 percent within the next ten years should also receive them.
Taking a rather small sample of adults over 40 from the National Health and Nutrition Examination Survey whose blood lipids were measured and extrapolating it to the U.S. population as a whole, the authors conclude that, if the new guidelines were put into practice rather than the old, 14.4 million adults in the U.S. who would not have been “eligible” for treatment under the old guidelines would now be “eligible” for it, while 1.6 million who would have been “eligible” under the old guidelines would no longer be “eligible.”
From The Boston Globe:
“They were making the white-knuckled trip from Connecticut because 14-year-old Justina wasn’t eating and was having trouble walking. Just six weeks earlier, the girl had drawn applause at a holiday ice-skating show near her home in West Hartford, performing spins, spirals, and waltz jumps.
But now Justina’s speech was slurred, and she was having so much trouble swallowing that her mother was worried her daughter might choke to death.
Justina had been sick on and off for several years. A team of respected doctors at Tufts Medical Center in Boston had been treating her for mitochondrial disease, a group of rare genetic disorders that affect how cells produce energy, often causing problems with the gut, brain, muscles and heart.”
At the advice of her specialist Dr. Mark Korson, Justina was taken to Children’s Hospital, rather than Tufts Medical Center where she had standing appointments and ongoing care. Korson wanted her seen by the gastroenterologist that had treated Justina for some time, until he left Tufts to practice at Children’s.
Much to her parent’s dismay, Justina was never allowed to see the doctor, in spite of the fact he knew her case well. Instead, she was assigned a new team of doctors.
Within three days her diagnosis was completely disregarded and her parents were informed that the new team was withdrawing their daughter from her medications. In spite of the fact Justina was physically deteriorating, the Children’s Hospital doctors believed Justina’s problems were psychiatric in nature.
When Justina’s parents objected, they were met with a letter demanding acceptance of the new diagnosis and treatment. The letter also forbid the parents any outside consultation, transfer to a different hospital or even a second opinion.
When Justina’s father arrived he was more than a little upset:
“We have standing appointments for her at Tufts,” he said. “Enough is enough. We want her discharged.”
[Justina's father] assumed it was their right as Justina’s parents to remove their daughter and take her to the hospital of their choice. But behind the scenes, Children’s had contacted the state’s child protection agency to discuss filing “medical child abuse” charges, as doctors grew suspicious that the parents were harming Justina by interfering with her medical care and pushing for unnecessary treatments.
When it became obvious that Justina’s parents were not going to comply, but rather looked for ways to transfer her, the hospital placed a “minder” in her room around the clock to monitor the parents.
Filing charges allowed the hospital to get an emergency order to strip away all parental authority and protection. Justina’s parents were then escorted out of the hospital by security.
Justina has spent over a year in the hospital, locked away on a psychiatric ward, beyond the reach of her parents. Once Justina was locked behind the doors of a psychiatric unit, parental visits became more and more restricted.
As a ward of the state, there was basically no supervision of her care– and the hospital bill is allowed to spiral out of control. One can only imagine what it costs to live in a hospital for a year.
As troubling as this family’s plight is, what’s more worrisome is the fact that this is not an anomaly. Within 18 months this hospital was involved with at least five different cases the Globe could find,where a disagreement over a medical diagnosis resulted in parents losing custody of their sick children.
“It happens often enough that the pediatrician who until recently ran the child protection teams at both Children’s and Massachusetts General Hospital said she and others in her field have a name for this aggressive legal-medical maneuver. They call it a ‘parent-ectomy.’”
The Blaze reports that Massachusetts State Reps. Marc Lombard and Jim Lyons have begun circulating a resolution in hopes of persuading the Department of Children and Families to start the process of reuniting Justina with her parents.
“Parent-Ectomy” is a profound abuse of children, parents and moral authority.
Can you think of a more immoral abuse of power than a hospital that will use the legal system as a weapon to capture and steal sick children away from their parents until every last dime is squeezed out?
Photo taken from Justice for Justine
There is no subject that provokes conspiracy theories quite like the immunization of children. That innocent, healthy creatures should have alien substances forcibly introduced into their bodies seems unnatural and almost cruel. As one internet blogger put it:
Don’t take your baby to get a shot, how do you know if they tell the truth when giving the baby the shot, I wouldn’t know because all vaccines are clear and who knows what crap is in that needle.
The most common conspiracy theory at the moment is that children are being poisoned with vaccines to boost the profits of the pharmaceutical companies that make the vaccines. No doubt such companies sometimes get up to no good, as do all organizations staffed by human beings, but that is not also to assert that they never get up to any good.
A relatively new vaccine is that against rotavirus, the virus that is the largest single cause of diarrhea in children. In poor countries this is a cause of death; in richer countries it is a leading cause of visits to the hospital but the cause of relatively few deaths.
Since rotavirus immunization of infants was introduced in the United States, hospital visits and admissions have declined by four fifths among the immunized. However, evidence of benefit is not the same as evidence of harmlessness, and one has the distinct impression that opponents of immunization on general, quasi-philosophical grounds, almost hope that proof of harmfulness will emerge.
A study published in a recent edition of the New England Journal of Medicine examined the question of one possible harmful side-effect of immunization against rotavirus, namely intestinal intussusception, a condition in which a part of the intestine telescopes into an adjacent part, and which can lead to fatal bowel necrosis if untreated.
The authors compared the rate of intussusception among infants immunized with two types of vaccine between 2008 and 2013 with that among infants from 2001 to 2005, before the vaccine was used. There is always the possibility that rates of intussusception might have changed spontaneously, with or without the vaccine, but the authors think that this is slight: certainly there is no reason to think it.
Week 1 — Something’s Got To Give
As part of my “taking it easier” with my blog, over at According To Hoyt, I’ve been running ‘blasts from the past’ – i.e. posts a year or more old at least a day a week. (For instance on Tuesday I posted Jean Pierre Squirrel, from February 2011.)
The interesting thing going through the blog is seeing how many days I curtailed posting or posted briefer or weirder because I was ill.
Now I was aware of having been in indifferent health for the last ten years or so. It’s nothing really bad or spectacularly interesting, which is part of the issue, because if it were, I could take time off and not feel guilty. I confess I have found myself at various occasions fantasizing about a stay in the hospital. Which is stupid, because no one rests in the hospital. (What I need, of course, is a stay in a remote cottage for a few days. Even if I’m writing.) And I knew that my health got much worse in the last year. 2013 was the pits, at least since August or so. But it is not unusual for me to spend every third week “down.” – Usually with an ear infection or a throat thingy or some kind of stomach bug.
My friends have said for years that this is because I don’t listen to my body’s signals to slow down or stop, so it has to bring me to a complete stop by making me too sick to work.
This is part of the reason Charlie Martin and I (in collaboration) are doing a series on taming the work monster. Part of it is that I have way too much to do, and part of it is that it’s really hard to compartmentalize things when you work from home. Eventually when we sell the house and move, we’d like to get a place where the office is a distinct area. It was pretty much all of the attic in our last house, which meant if I came downstairs for dinner (which I did) I didn’t go up again. But now my office is half of the bedroom (and before someone imagines me cramped in a corner, the bedroom runs the full front of the house. We just couldn’t figure out what to do with a room that size. We don’t sleep that much.) This is convenient in terms of my getting up really early to work, or of my going to bed way after my husband, because I’m right there… It’s also contributing to a 24/7 work schedule, because I can think “Oh, I should write about that” and roll out of bed, and do so. There is no “I have to be dressed, as the sons might be roaming the house” and there isn’t (as in the other house) “the attic will be cold.”
Someone once said that a good epic starts in the middle. (Actually it was Horace, it was in his Ars Poetica around 13BC, and he made the distinction between something that started ab ovo, “from the egg”, or in medias res, “in the middle of things”, but then inserting a lengthy side bar with references to Classical Latin in a diet column might seem erudite but really would be sort of pretentious and silly, don’t you think?)
In any case, we’re starting in the middle of this story. Tomorrow, 5 January 2014, I’m starting the fifth (and sixth, more on this later) of my 13 week experiments in changing and improving my health and my life. The first one started in November 2012, more than a year ago, motivated by the most reasonable of things: I don’t want to die. I most especially don’t want to die young, and I felt like both of my parents had.
I have reasons to be concerned. I’ve had problems with my weight since I was six, and at the time I started this I was around 300 lbs, I was well along into type II diabetes, and I had severe sleep apnea that was manifesting in something close to narcolepsy. I live in a two-story house and I was finding that I was pre-planning trips up and down the stairs because they wore me out.
Now, a year later, I’ve made some significant changes. I’m around 265 lbs, my blood sugar is much improved, and I run up and down the stairs with wild abandon and cups of hot coffee. But I’m not done yet. I want to lose more weight, and I’ve got some new challenges in my life, with a new job and a certain feeling that I have more to do.
Scientists are often portrayed as archetypally rational men, mere calculating machines in human form who propose correct new theories by infallible deduction from what is already known. Science cannot possibly advance in this way, however, and the philosopher Karl Popper pointed out long ago that leaps of the imagination are as necessary to science as they were to art
I have never been able to make such leaps myself, which is why I admire them in others. I remember meeting a researcher into malaria who was trying to produce a vaccine, not against the malarial parasite itself, but against the stomach lining of the mosquitoes that carried the parasite. He hoped that such a vaccine would kill the mosquitoes – causing them to explode in mid-flight, perhaps – and thus prevent the spread of the disease. The idea did not work, but I was impressed by the boldness of the conception.
For the scientist no information is too obscure to be of potential use. And what information could be more obscure than that the desert-dwelling grasshopper mouse that likes eating the bark scorpion, whose sting causes severe pain in all other possible predators and makes them avoid it? Most of us, I think, would say, “All very interesting, professor, but so what?” The scientist, however, asks why the grasshopper mouse is immune to the painful effects of the scorpion venom, and whether, on discovering the reason, it might not help in the development of new analgesics. Mankind has long believed that remedies for its afflictions are to be found in Nature, but only scientists can go about systematically investigating the possibilities. Imagination is a necessary but not sufficient quality for scientific research.
A recent article in the New England Journal of Medicine, in a long-running series that tries to connect basic scientific research with clinical progress, draws attention to research on the grasshopper mouse. The article is provocatively entitled Darwin 1, Pharma 0, thereby drawing our attention to the fact that millions of years of natural selection have done for the grasshopper mouse what a century of research by pharmaceutical companies has not been able to do for Man. The comparison seems neither apt nor fair, but any stick these days is good enough to beat Big Pharma with.
The grasshopper mouse, it seems, has a mutant gene that prevents a component in the scorpion venom from activating the peripheral nerve cells involved in the transmission of pain. Could human pain be alleviated or even abolished if a compound were found that acts on the mechanism that the normal version of the gene, present in all other mammal genomes, controls?
Okay, look, the first thing is I owe you folks an apology: with the new day job and holidays and a half-dozen other ordinary-life crises, I’ve just not gotten columns done. I’m sorry.
The most important thing I think I’ve learned in the last year has been just how complicated the whole issue of body weight and glucose regulation can be. Here’s just a selection of diets that have had reports of dramatic weight loss and health effects:
- Low Carbohydrate Diets
- High Fat
- South Beach
- Low Fat
- Stillman’s Quick Weight Loss Diet
- High Fat
- Glycemic Index and Glycemic Load diets
- Low Fat, High Carb diets
- Ornish Eat More, Weigh Less
- The Okinawa Diet
- Balanced, Calorie Restricted diets
- Diabetic “Exchange” Diets
- Weight Watchers
- Radical Calorie Restriction
- Scarsdale Diet
- Duke Rice Diet
- Protein-Sparing Fasts
- Intermittent Fasting
- Fasting 2 days a week
- Sixteen hour fasts every day.
- Eating more often
- Body For Life
- Dietary Restrictions
- Eliminating wheat or grain
- “Never Eat Anything With a Face”
Some of the residents of Hyde, the town in Cheshire, England, where the late Dr. Harold Shipman practiced family medicine, used to say, “He’s a good doctor, but you don’t live long.” Indeed not: it is now believed that Dr. Shipman, over a period lasting a quarter of a century, murdered 200 or more of his elderly patients with injections of morphine or heroin.
If the preservation of life be not the definition of a good doctor, what is? Here is the definition published in a recent edition of the New England Journal of Medicine:
The habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and, the community being served.
Whatever one thinks of this definition, it is clear that it would not make the goodness of doctors altogether easy to measure.
It does not follow from the unmeasurability of something, however, that it does not exist or is unimportant: nor, unfortunately, that what is measurable truly exists or is at all important. Nothing is easier to measure in an activity as complex as medical practice as the trivial, and nothing is easier to miss than the important.
The above definition of a good doctor appeared in an article on the need for Obamacare to ensure that doctors provide value for money so that they can be paid by result. This is a potential problem whenever there is a financial intermediary between the doctor and the patient. Thenceforth it is not the patient who decides what he wants from a doctor but an insurance company or, increasingly under Obamacare, the government.
The last two 13 Weeks columns could have been confused with science columns, which is good because I’ve actually missed the science columns, but bad because I haven’t talked about my progress or lack thereof at all. Well, the last couple of weeks have been confusing to me too, if it’s any consolation — I spent a week in San Francisco in an extended interview/audition for a new web startup called Sumazi. I’m now doing consulting for them, but they’re still operating under the radar so I can’t talk a lot about it, except to say they’re doing exciting things with social media data. But the result is that I’ve been busier than a — oh, hell, pick your own cliché. I’ve been really busy.
As a result, the whole diet-and-exercise thing has gotten away from me — hell, I haven’t left the house since last Sunday and last night I resorted to eating frozen burritos I didn’t even know I had because gleanings were getting pretty slim.
Yes, frozen burritos have wheat.
The results are interesting; my weight has crept back up to 269 — that same old stuck point. Glucose is doing fine, and with the exception of the burritos I have been quite good about eating few carbs — what carbs I’m getting are mostly in the yoghurt I’ve continued eating.
Of course we’re heading for the Season of Diet Horror — Thanksgiving, Christmas, and New Year’s Day.
So here’s my plan. I’m declaring this 13 week season a Learning Experience. As my old therapist Joe Talley called it, an AFOG (“Another F-ing Opportunity for Growth.”) This season would be over on 1 December anyway, so I’m gonna roll with it, and just maintain blood sugar and weight until 1 January — or rather until 4 January, which is the convenient Saturday after New Year’s Day. That will give me a chance to consolidate my other life changes.
In the mean time, the plan is to make this first year of 13 Week Experiments into a book, so I want to use the column to consolidate some of my thoughts about this, and to think more about what I can do to help other people start making their own experiments.
So, in no particular order, here are some thoughts about the process and the results.
Not long after I suggested satirically that money might be the cure for the terrible disease of burglary, experiments were performed to bribe drug addicts into remaining abstinent. I had suggested that money was a genuine pharmacological treatment of burglary because there would be a dose-response relationship (the larger the dose of money given to burglars, the greater and longer-lasting their law-abidingness) and that, as with most drugs, there would be treatment failures. Some burglars are more interested in the excitement of burglary than in its material rewards; money would have little or no effect on them.
It turns out that money as a drug is a bit like aspirin: it can be used for many illnesses. The fat have been bribed to lose weight; the drunk to stop drinking; the diabetic to take their pills and stop eating sugar; the smokers to stop smoking; and the indolent to start taking exercise. It’s enough to make you wonder whether there is anything that can’t be cured by money. The latest disease to yield to money’s curative, or at least alleviatory, properties is schizophrenia.
Medication can improve this condition but unfortunately patients often do not take it for long and then relapse. This is partly because they do not accept in the first place that they are ill and partly because the medicine they are supposed to take has many, and sometimes very disagreeable, side effects.
To counter the propensity of schizophrenic patients not to take their medicine, long-acting injectable forms were developed; but it is easy for schizophrenics not to accept them either. Researchers in England and Switzerland wondered whether, if patients were bribed to take the injections, they would do so with greater regularity. Their trial was a small one, involving only 131 patients, divided into those who were offered a bribe (in the paper, published recently in the British Medical Journal, it is more delicately called a financial incentive) and those who were not. The bribe was not large, $22 per monthly injection; but it must be remembered that most of the patients were probably unemployed and living in relative poverty. There are still people in our society to whom $264 a year would be well worth having.
Today is 19 October. Yeah, I know, you can see it at the top of the article, but that’s an important date, because it’s now exactly a year since I determined I had to take some actions about my weight and glucose. (I came out about it in my first 13 Weeks post, “A Fat Nerd Does Diet,” on 28 October last year.)
The results overall have been good. I had several different issues when I started.
- I weighed 301.5 on the 19th.
- My A1c was 7.5. Although I struggled with admitting it, that’s real no-kidding diabetes mellitus. For me it appears to be type 2, (T2DM) characterized by lowered sensitivity to insulin. That was on a pretty much maximum dose of metformin, 2500 mg/day; if I were depending on drug treatment alone, I was heading for insulin.
- I had a long-term problem with gastric reflux (GERD) and irritable bowel syndrome (IBS); I was on omeprazole every day and had been since a severe esophageal spasm and put me into the ER with chest pain two years before.
- My total lipids were reasonable on 20mg/day of simvastatin but my high-density lipoproteins (HDL) were low, and my low-density (LDL) were high.
- I also had a long-term problem with depression, although I hadn’t had a really acute episode in some years.
Now, a year later:
- I’m down nearly 40 pounds; my recent low was 264.
- My A1c is been between 5.9 and 6.4. The T2DM appears to be under control. I’m down to 1000 mg/day of metformin, and did a long stretch at 500 mg/day.
- My lipids are enough better that I’m off statins, at least for this 13 week period.
- The IBS no longer troubles me — I can’t say it’s completely resolved because, frankly, how would I know? But I haven’t had a painful episode in certainly almost a year. The GERD is also considerably better, and I’m slowly weaning myself off the omeprazole.
- I think I can say the depression is significantly better. I haven’t had an acute episode this year, but then I hadn’t had a really acute episode in some years. But I had also been chronically dysthymic, which in combination with acute depression is called “double depression.” I really feel like that’s significantly better. I plan to write more about depression in the coming months; there are interesting suggestions that there may be some physiology that connects depression, obesity, and T2DM.
What did I do?
- I’ve adopted a consistently low-carb, high-fat diet. I’ve played around with variants, and right now I’m around 50g carbs a day, with most of the carbs coming from fruits and yoghurt.
- I’ve nearly completely eliminated wheat. Occasionally eating wheat seems to result in immediate exacerbation of the GERD and possibly of the IBS.
- I’ve experimented with high-intensity interval training and high-intensity strength training, although I’ve had trouble making that a consistent practice.
- I recently tried a broad-spectrum probiotic, which seems to have had very good effects.
- I’ve largely structured these changes into a series of 13 week long experiments, which appears to be a sufficiently powerful model that a number of other people have adopted it for their own changes.
What have I learned in this year? It’s complicated.