If Treatment Is Expensive, Is It Therefore Effective?

           Our hospital CEO mentioned at an administrative meeting the other day that an anesthesiologist who owns a pain clinic on the mainland is aggressively pursuing an appointment with her.  He wants to talk, she thinks, about providing some service on our island.  She says that he has an impressive website and 20 employees.  We Googled the website at the meeting.  It is impressive.

            She’s been resisting the meeting on the grounds that he wouldn’t find enough work here, but he’s insistent.  She’ll meet with him soon, I imagine.

            What can he offer?  Treatment for pain, certainly.  How?  Simple things are already available here, so he will probably want to offer complex and expensive options – injections (the website lists more than 15 general types), implanted drug delivery systems, and implanted spinal cord stimulators.

            Though he’ll probably want to do procedures, he will probably not propose a complete coordinated multidisciplinary service.  Still, wouldn’t that be great?  Somebody could come help us stamp out pain through technology and drugs.

            But there’s a question.  Do interventional pain procedures really stamp out pain? I had dinner last week with an old friend from the University of Washington, an anesthesiologist who has been involved in chronic pain work for more than 40 years.  In his view, there’s very little objective evidence that any of the expensive, high-tech new therapies work well in treating or eliminating chronic pain.  In particular, few double-blind studies justify the procedural approach to pain relief, despite its popularity and despite the fact that pain docs bill bushels of money for performing these procedures.

            Our CEO is one of the smartest and most dedicated administrative people I’ve ever known.  But she’s in no position to say, “Yeah, well prove that all this expensive stuff works, Bub.”  Instead, she may feel obliged to make space for a doc who wants to do procedures that produce substantial revenue for the hospital.  She’s obliged to serve the hospital’s financial viability, not make judgments about the efficacy of expensive treatments.

            So she may need to support procedure-based medicine that sounds good and is reimbursed without question by all insurance companies, whether or not it’s really of lasting value to patients.  She can’t question the value of pain procedures, any more than she can question the value of invasive cardiac procedures or cancer therapies.

            But there’s certainly room to question.  Who should be doing that?

            Jeffrey Parks questions.  Dr. Parks is a general surgeon who blogs courageously as Buckeyesurgeon.  His most recent entry refers to a review of Broken Hearts: The Tangled History of Cardiac Care, a new book by Harvard medical historian David S. Jones.  Jones’ book, he observes, “explores the rise of interventional cardiology and cardiac surgery since the 60's and how much of the rationale for such a procedure-dominated treatment strategy is undergirded by some surprisingly shoddy data.”

            Parks says that Jones’ book cites the troubling lack of evidence from controlled trials that either coronary artery bypass grafting or less-invasive coronary stenting has any demonstrable effect on survival when compared to medical management of coronary artery disease.  Parks recalls no time during his surgical training when he heard cardiac surgeons question whether CABG procedures were effective, though they lamented the decline in such procedures, as it restricted new jobs available for fellows.  Cardiologists, too, he says, have persisted in inserting coronary stents in spite of lack of evidence clearly showing improved long-term survival.

“We may be too far gone to change anything,” Parks says.  “The coronary intervention/surgery sector is a $100 billion industrial complex.” The idea that the medical/pharmaceutical/industrial complex might be as troubling as the military/industrial complex against which Dwight Eisenhower warned us is increasingly part of conversation now.  See Steven Brill’s lengthy Time Magazine piece entitled “Bitter Pill: Why Medical Bills are Killing Us” . Brill covers a lot of ground, but he’s pretty clear that medical billing is out of control.  Hospitals charge whatever they want, according to seldom shared price lists that he calls “chargemasters.” People pay whatever their insurance companies have negotiated – except for the uninsured, who are expected to pay the hugely inflated prices of the chargemaster.  It’s been that way all the time I’ve been in medicine, but the gap between what’s charged and what’s paid is much greater now.

When I was diagnosed with prostate cancer in 2000, I didn’t care how much it cost to cure it, if somebody else was paying.  And I definitely didn’t want to wait for double-blind studies to validate the treatments that sounded best to me. I found it difficult at that time to compare one treatment with another, and very difficult to get an idea of the side effect and survival profile of any particular treatment.  At some point I realized that it was virtually impossible to get any information on the difference between being treated and not being treated.  I had some idea what might happen with different treatments, but almost no information on what would happen if I took no treatment at all.  I could clearly see that some people were dying of prostate cancer, but I couldn’t see clearly that any of the treatments I was looking at would have “saved” those people.  Controlled trials were completely unknown.

I asked the physician who ultimately became my treating physician in Georgia why it was so hard to get good comparative data, and why people seemed so reluctant to be objective about the treatment they offered.  “It’s big money,” he said.  Each of the docs offered only a single treatment modality – external beam radiation, seeds, prostatectomy, cryotherapy, and so on. And everybody was so desperate to hang onto the big money in cancer treatment that docs simply could not afford to have their business fall off substantially if patients moved to a more appealing treatment, one which would be provided by somebody else.  Objectivity was an expensive luxury for docs maintaining a state-of-the-art treatment center.

Treatment was expensive even then, thirteen years ago -- $25,000 to $50,000 – and it was paid for because the treating docs believed in it and convinced insurers of their beliefs, not because they’d clearly shown effectiveness.  They knew that they could make prostates disappear, but they didn’t know whether that would make a long-term difference in who survived the disease.  And not one of us wanted to wait ten or fifteen years for results, imagining all the time that the disease was crawling through our innards and destroying our precious generative organs.  We patients were never, ever, going to argue for restraint in medical spending, especially if somebody else was going to pony up the money for us.

On another note, I’ve been interested in end-of-life care for a number of years.  I’ll practice palliative medicine when I leave the OR, and I’m training in the meantime to be a hospice volunteer.  In addition, Jan and I have just been through the process of filling out extensive end-of-life directives with each other.

I’m reminded especially, now, that medicine at the end of life is more of the same.  We fear death, and we do whatever we can to avoid it – we commit ourselves to operations, to chemotherapy, to intensive care, to CPR, to intubation and artificial ventilation, to tube-feeding. When we lose the ability to choose, those who love us may commit us to these same options.

As a society, we support that. Medicare will pay for any care a doctor orders, including all futile efforts at preserving fleeting life at the end. On the other hand, Medicare pays a severely limited amount of money for six months for a patient who elects hospice care.  How much of this limited care do people on Kauai actually use?  We learned that on Kauai people who come to hospice get an average of three weeks of care.  We’re that afraid of giving up.

Here’s where palliative care has a role, the search for what Ira Byock calls “the best care possible,” not simply the most interventions.  Right now if we simply insist on the next possible treatment, Medicare will pay for it all, no matter how futile.  On the other hand, if we actively make a selection in favor of pain relief, comfort, support, and gentle death we swim against the tide of technology, and we find that money available for our care is limited and carefully doled out.

            We have plenty of money to provide good medical care. Powerful forces distort the distribution of this money.  Our medical/industrial/pharmaceutical complex has effective ways of attracting money preferentially to the new and glamorous – not necessarily the effective.  Not all that money improves patient health.

            On a final note, a group of Canadian docs who were teaching in the Difficult Airway Course pointed out an interesting difference between their practice and mine.  In Canada, they said, the money is all on the table at the start of the game.  Surgeons and proceduralists do procedures that use up the money, and are regarded as cost centers.  In the US, on the other hand, hospital income comes from reimbursement for medical procedures.  Surgeons and proceduralists do procedures that generate revenue for themselves and for hospitals.  They’re revenue generators.  Cost center versus revenue center.  Which has the most power?  How can we expect hospital systems to resist the temptation to support procedures that increase revenue, no matter how poorly-studied they may be?  Whose job is it to put a flag on the play when a medical procedure is unstudied?  Or worse, studied and shown of little value?  If we stop paying for unproven procedures, will we have anything left we can offer?

OH SAY, CAN YOU SEE...?

        Today was the day for my cataract removal – technically, a phacoemulsification and insertion of intraocular lens in my left eye.  That’s my only working eye, about which more later.  If you haven’t thought about how that’s done, here’s a nice short video: http://www.youtube.com/watch?v=UIApXNXOnHs

         Basically, the surgeon puts the eye to sleep, exposes the lens, inserts a device that emulsifies the lens (sort of like putting a portable blender into a pot of boiled potatoes and moving it around until you have a pot of mashed potatoes), then sucking it out.  The intraocular lens is a piece of optical plastic slipped into the cavity created by the absent natural lens, held in place by springy arms that extend out to the sides.

         It’s highly skilled bit of surgery that has become very common.  I’ve watched more than a hundred, and thought it looked as though patients had a pretty easy time.  However, I now know that their experience is more complicated than I thought. 

For several days now I’ve been dousing my eyes with eye drops to kill bacteria and reduce inflammation in preparation, as well as washing with antibacterial soap and scrubbing eyebrows and lashes vigorously to exfoliate bacteria-containing debris.  I now have a really clean eye.

         Though patients usually don’t get more than topical anesthesia and an oral valium pill, they’re treated as though more anesthesia might be necessary.  An anesthesiologist is at hand, an IV is started, and the patient refrains from eating or drinking after midnight to ensure an empty stomach.

         I was to report at 0645 this morning, to be the second case.  I arose at 0430 and made Jan’s breakfast while she cleaned up.  Thinking that I might absent-mindedly take a bite of food or a drink, I plastered a piece of packing tape over my mouth, good for a laugh when I brought Jan her tea.  As it turned out, the tape was a good idea.  I made a mess out of peeling a hard-boiled egg, and only the tape prevented activation of the reflex that causes me to dispose of food mistakes by eating them.  I would have stuffed the whole mess into my mouth to keep Jan from seeing it.

         At the hospital, I thought I knew the drill for the procedure, so I thought I’d be pretty relaxed. Check-in was easy, and soon I was perched on the gurney that I would ride into the eye room.  My anesthesiologist chatted affably as he waited for his first case to be ready, and in short order my nurse began my check-in procedure -- name, birthdate, name of procedure, scan of name tag, scan of all medications, administration of eye drops for numbing and dilation of the pupil. After the eye drops, the nurse placed a tiny sponge in my lower lid and taped the operative eye closed. Finally, it was time for the IV.  My nurse recruited a colleague with a reputation as the best IV starter, and even though she had been up all night she inserted a truly painless IV.

         And then I waited.  Blood pressure had been about 130 over 80, so I knew I was more uptight than I’d admitted.  The valium helped, and simply closing my eyes and relaxing helped.  It was hard to open my eyes without dislodging the tape holding the operative eye closed. Jan held my hand and we talked as we waited.  I thought I was being careful not to start mumbling so Jan would believe she was witnessing my superior self-control, not merely the effect of a potent drug.

         And then it was time.  Down the hall, into the room, monitors on, head down, pillow down to my knees, head wedged into position, oxygen under my nose, Velcro snuggie wrap around my torso, drapes ready to pull up over my face.  Betadine eye scrub, more local anesthetic drops, sticky drapes over the eye after sheets are pulled up over my face.  I had a moment of wondering whether I was going to turn out claustrophobic.  It passed.

         I heard the surgeon’s voice, and in a minute the microscope swung into place over me as he asked the anesthesiologist to lower the bed slightly.  The springy eyelid retainer clicked into place in my eye, and a blinding light gave me an overwhelming urge to close a now wide-open eye.  “Some cool drops…” said the surgeon, an opening line I’ve heard over and over again as he starts a case.

         And he was at work. I could feel pressure and movement, but not at first any discomfort.  As we progressed I realized several times that I was responding to minor discomfort in the same way I do in the dentist’s office – by tensing up in anticipation of the big pain that never comes.  So I relaxed, consciously, several times.  Blood pressure stayed up a bit, and I could hear the occasional skipped heart beat, testimony that the patient hadn’t quite gotten over being a little uptight.

         The surgeon was calm and directive – “look at the black bar between the lights, look down an inch, look down again, thank you, you’re doing very well.” I heard the phacoemulsification process begin, and had an impression of the light image in my eye being fractured into a bunch of sparkly pieces.  Maybe I made that up.  In no time, the old lens was out and the artificial lens had been inserted and I was done, aware of blurry vision in the operated eye as drapes were untaped from my face (really the only uncomfortable part of the procedure).  I sat up, and the gurney was conveyed royally back to my starting point.

         Another vital sign check proved I was still alive, so Jan was invited in and a delicious cup of coffee appeared, along with the ophthalmologist’s special healthy cookie and two kinds of less-healthy hospital crackers.  As soon as the coffee was gone, I was allowed to put on my shirt and retire briskly to the bathroom.  Where does all that water come from when you haven’t had a drink since the night before?

         I was ready to leave.  I could see tolerably, partly through the perforated aluminum eye patch over the operated eye, and partly through my other “bad” eye.  My right eye is amblyopic, ostensibly because the brain turned it off when I was a kid to resolve double vision.  So forward vision in my right eye is very limited.  It looks like your vision looks when you push your eye for a minute and then let go, sort of all blackish (I was explaining this to a nurse the other day and she gave me an odd look, saying “Who ever pushes in on their eye like that?”). Whatever I look at directly is blacked out, and the blackness spreads the more I stare and try to resolve the picture.  The only solution is to keep moving the eye around, so I look pretty shifty when I’m trying to see with the bad eye.  It’s useless for advanced life tasks – reading, driving, cutting up food, repairing machinery, practicing medicine.  But it works fine for avoiding walls and noticing when somebody else is in the room.

         So right now I’m using the vision through my perforated eye patch as I type this, while my “bad” eye continues to supply the right-side peripheral vision that it’s supplied so dependably all these years. My experience with the eye patch makes it clear why perforated aluminum is so seldom used in the lenses of spectacles, despite its obvious advantages in durability on the playground.

         I see the ophthalmologist tomorrow morning.  I hope he’s right when he says that vision will get better and better.  I’m ready.

         When I was leaving the hospital to walk out to the car, I was laughing very readily, finding humor in nearly everything.  Jan asked if I was always this way at work.  I said I thought so.  I thought I was good-humored and easy to work with.

         Now it’s afternoon, and I have better perspective.  I’m afraid that was the valium talking this morning.  I’m not actually jolly at work, and perhaps often not even pleasant.  I can see that it might be fun to be that way, though…

         Amazingly, my ophthalmologist called me personally this evening to see how I was doing.  I was moved by the gesture, and my already high opinion of my ophthalmologist has moved even higher.

The Eye Man Cometh

“Better than a poke in the eye with a sharp stick…”

         This week I’ll pay a man to stick a sharp knife in my only functional eye.  He’ll destroy the lens through which I’ve watched my life for 68 years and leave an oddly-shaped bit of clear plastic in its place.  He’ll do all this under topical anesthesia while I’m wide awake.  He’ll make only a tiny incision, much smaller than the lens that he’ll insert, which will start out as a tightly-rolled cylinder and unroll once it’s in the eye.

         This lens, I expect, will restore my once-dependable distance vision.  I could once see so farsightedly, even without glasses, that I was the go-to guy for visual ID questions.  When we travelled, I could usually read the road signs before anybody else in the car.          

         Now, especially in the past year, my ability to resolve detail at a distance has deteriorated alarmingly.  I can’t see small boats on the horizon, I can’t see the whale spouts when Jan points them out, and I can’t read many street signs until I’m abreast of them.

         When we visited Sacramento in October, I drove downtown by myself early in the morning to meet with my men’s group.  Looking for “P” street, I found that I suddenly could not read any of the single-letter signs against the sunrise-bright sky.  I groped my way to the meeting, guessing at familiar sights, feeling for the first time in my life visually impaired.

         In Las Vegas in November, I had the same experience of being unable to read freeway signs against a bright sky unless I already knew what they said.  I found I was leaning heavily on Jan as a sign-reader.

         Driving at night has become incrementally more difficult, and I have difficulty seeing the road in the glare of some oncoming headlights.  When we go to dance lessons, even the brilliant green of the multiple traffic lights at our turnoff from Kuhio Highway seems blinding, forcing me to shade my eyes so I can see where to turn.

         Roadside objects emerge surprisingly from the scenery.  Walkers and cyclists appear on bright days where there was only a shady berm seconds before.  Dark cars with their lights off suddenly appear on empty pavement at dusk and dawn.  People who think they can be seen just have no idea how invisible they are to somebody with even a little visual difficulty.

         My appointment with my ophthalmologist in December revealed that things were actually as bad as they seemed.  It was not likely, his optometrist told me, that I’d be able to pass eye exam for a Hawaii Driver’s License now.  Lord, how the mighty have fallen…

         So it’s time to have the cararact extracted.  I’m on the edge of being significantly impaired, of being unable to read well, of being unable to drive, and of being unable to practice medicine. (“I’ll be putting a breathing tube in your windpipe, ma’am.  I can’t actually see it that well any more, but I’ve done it lots of times and could pretty much do it in my sleep.  Pretty much…”)

         I’ve taken care of lots of patients having this operation, and have watched this surgeon do dozens of these without a hitch.  In fact, I’ve admired his technique from the first time I sat in his room, everybody silent, all the details just so…  And now it’ll be my details that will be just so.

         For a long time I feared having this procedure, back in the days when retrobulbar block with a needle behind the eyeball was the standard method of regional anesthesia for the procedure.  I knew the block usually went well, but with only one eye that works, I wasn’t eager to risk any complication at all from such an injection.

         And now, most surgeons do this operation with topical anesthesia.  Even though we still make a big deal out of it, which it is, surgically, the patient’s experience is more pleasant by far than the average visit to the dentist. Jan reminds me that people don’t even know about eye pain unless they’ve had lids and eyebrows tattooed, a procedure that seems increasingly common here.

         So I’m not nervous.  I’m eager.  Tomorrow I’ll undertake my three-day regimen of eyelash cleaning and cleansing eyedrops, and Thursday I’ll have more to tell.

What's So: Thanksgiving 2012

      Creation requires vision, but it also requires an accurate appraisal of what’s so in the present. I’m powerless to create change without accepting the conditions from which creation starts. 

For example, if I want to restore a hurricane-damaged house, it’s important to have a vision of the restored result.  But it’s even more important to understand the house’s condition now – wiring corroded from salt water, drywall and insulation wet two feet up from the floor, patio cover scattered half a mile downwind, and roof shingles missing from the entire windward side. The path to the house I want begins with the house I have.

         So, too, in my life.  I have clear ideas about how I’d like things to be.  Some areas are not like those ideas at all, and “should be” different.  Yet the path to the life I want begins with the life I have.  What do I have?

         I’ve said that I want a life filled with love.  I want a marriage with a woman I love, a woman who accepts my loving her fully and who loves me.  With Jan, I have that.  In that area, my life is working beyond my most inspired dreams.

         I’ve also said that I want close, loving family relationships.  What’s so is that I live in Hawaii while my parents live in California and Oregon.  My sibs live in California, Oregon, and Vermont.  My children and stepchildren live in England, Indonesia, New York, California, and Hawaii.  My new family of in-laws lives primarily here on Kauai (we had 34 people for Thanksgiving), though my new stepson lives in Iowa.  I phone one parent and one sib weekly; the other parent, episodically; the other sibs hardly ever.  I talk to one son when he calls, my stepdaughter when she calls, my daughter when she e-mails with a purpose, and my other son and stepsons episodically, as the opportunity arises.  Relationships with my many new inlaws have just begun to move beyond cordial.

         I’ve said I want a healthy body so that I can participate fully in life as long as I’m here, and I’ve said I want to be here for a long time.  I lost 70 pounds on an enlightened eating program two years ago, and have coached several others to substantial weight loss on that same program.  I’m set to offer the program to employees of my hospital after the new year, as part of creating a pilot program that might encourage an insurer to pay people to stay healthy rather than fix problems after they occur. 

Right at this moment, I’ve regained 25 of those lost pounds.  Left over from the Thanksgiving meal, our house contains two kinds of pie, cupcakes, ice cream desserts, and leftover Halloween candy.  We have Hawaiian sweet potatoes and corn in the refrigerator.  We also have turkey, ham, vegetables of all sorts, and fruit. 

We eat as though we believe it’s more wasteful to throw food out than it is to convert extra food to fat, then break it down and flush it out of our bodies.  We dispose of extra food by eating it, and then we try to lose the fat deposits that result. 

My regular exercise program consists of a walk once a week or so, and I find walking affected by pain in one knee and one hip.

My doctor has left practice, and I haven’t yet made a move to find another.  Twelve years after being diagnosed with prostate cancer, I don’t have a doc and my insurance-approved supply of a valuable medication is running out.

         I have said that I want a financially secure retirement.  I’m still working at age 68, bringing in much more income than I will ever have in retirement.  I will be working less in 2013, but will still be fully engaged in the practice of anesthesia on the rotating schedule we have in our practice.

My retirement funds halved their value in 2000 and again in 2008 while managed by Merrill Lynch, so I created a self-trusteed 401K to avoid the equity market.  Though I have some clear ideas about investment goals and mechanisms, almost all of the money sits in holding accounts, losing its value to inflation, not invested.  Several small details hamper turning intention into action.  I am not significantly in action to create a secure retirement.

         I wrote a blog piece in April, 2011, celebrating agreement and moving on after a divorce.  As it happens, that hasn’t entirely occurred yet.  My ex filed a suit nearly a year after the divorce asking the judge to set aside our agreement, contending that I had fraudulently misrepresented the assets available for division in a settlement. We’re now passing through a prolonged discovery phase, with a hearing scheduled in January.  Since there is neither fraud nor misrepresentation to discover, I expect that the matter will be resolved early in the new year, but it hangs over me now as a failure to reach closure.

         So I do know what I want to create.  Much of it has been created.  And I see lots of places where I could be in action to create the results I want.  That’s what’s so today.

DIETARY SCIENCE – OR RELIGION?

         I haven’t written a useful word in the past two weeks.

         Why is that significant?  Because I took an entire income-free two-week period to write.  I promised myself that by the end of that period I’d have a basic website in place, with the basics of an eating program that I’d distilled from the writings of others.

         The period ends today. Today there’s no website, and no distillation.

         Among other things I did instead of writing was to be Grandpa Mike for a few days in Sacramento.  I spent three days with my wonderful granddaughter, and with my much-loved son and his amazing wife.  Yes, I’m at the time in my life when it’s clear that at some future moment of reckoning, I’m more likely to wish I’d spent time with my granddaughter than to wish I’d spent time writing down my thoughts about an increasingly complex set of issues that seem to defy solution.

         And I moved.  I moved from my bachelor condominium near the hospital to a house 20 minutes away, in the Wailua Homesteads.  I moved to begin sharing a house and creating a home with the woman I will marry.  I moved with some trepidation to a house that’s been her family home for 38 years, a house she bought and built with her husband, who died in 2007.  I moved despite plenty of advice from relatives and friends warning me that it would be difficult to create “our” home in a house that’s been “her” home or “their” home.  Three weeks into the process of living in the same house, I have a rapidly-deepening appreciation of her strength, her adaptability, her willingness to embrace change, and her love -- and an even-greater ability to listen to well-meaning advice without incorporating it into my life.

         Lest it appear that I frittered away my research time entirely, I hasten to point out that I devoted the entire return flight from Sacramento to Honolulu to reading and taking notes on Gary Taubes’ Good Calories, Bad Calories, a 2007 book from a science journalist who examines the [lack of] science behind the low-fat diet recommendations of the past 30 years, and the [overlooked] science suggesting that “carbohydrate-rich foods are inherently fattening, some more so than others, and that those of us predisposed to put on fat do so because of carbs in the diet.” (Taubes' account of his appearance on Dr. Oz's show in March)  Moreover, he argues in his subsequent book Why We Get Fat, it’s almost certain that the same foods that make us fat are the foods that cause heart disease and diabetes and cancer – the diseases associated with obesity.

         In short, Taubes says that much of what we think we know is wrong, or at least not proven, and the advice that we fatties should eat less and exercise more is at least inadequate and maybe completely misguided.  He charges that organized medicine, the public health establishment, the food industry, and the government have succumbed to the urge to simplify a complex scientific situation so much that it’s no longer possible to meet the scientific obligation of presenting evidence with relentless honesty. We have created, he says, an enormous enterprise dedicated in theory to determining the relationship between obesity, diet, and disease. In practice, however, the enterprise is dedicated to convincing everyone involved, especially the lay public, that the answers are already known and always have been – “an enterprise, in other words, that purports to be a science and yet functions like a religion.”

         Taubes took five years to write this first book.  Perhaps it’s not surprising that in two superficial weeks I wasn’t yet ready to write, especially when I spent most of that two weeks allowing myself to be distracted by other aspects of my life.

I’ve said that I love to take complex ideas, churn up and digest all the underlying information, and make a distillation of my own ideas – that’s why I enjoyed medical teaching so much.  And I’m beginning to see here that I’ve bitten off a much bigger chunk than I imagined. The more I learn, the more I see that I don’t know.

If I’m to make a difference in the food conversation, I’ll have to get busy churning and digesting.  I hadn’t planned to be overtaken by such an irresistible inquiry while still working full time and in the midst of profound life change, and I don’t have in place a structure that accommodates that sort of intense work on top of everything else.  This will be an interesting challenge…

Nutrition Science: An Oxymoron?

         I used to think that only a fool could experience much confusion about food and nutrition.  When I went to medical school, back in the days of leeches and wooden needles, nutrition was briefly covered in the biochemistry course.  Beyond that, it was pretty much, “Mmm, food good.  Eat food.” And, of course, “Fat people have no impulse control.”  This came from my freshman roommate, himself a skinny guy who went on to become a skilled and apparently compassionate bariatric surgeon.

         I’ve spent my life thinking that the equation was pretty simple.  If the number of calories taken in exceeded the caloric cost of running the body machinery, excess calories were stored as fat.  Weight loss occurred if we expended more calories than we had taken in, and weight gain occurred in the opposite circumstance.  Good nutrition meant taking in the right quantities of available “healthy food.”

         Now I’m beginning to see that food isn’t an easy or straightforward issue at all.  Perhaps all calories are not equal.  Perhaps all food is not equally good for us.  Perhaps even the “healthy food” that’s available isn’t so healthy, at least for the people who eat it.  For the economy? Maybe so.

The movie Food, Inc. seems to say that we’re guided by advertising and availability to eat what we eat because that’s where the money is for food and agriculture interests.  The once-hallowed FDA Food Pyramid of my youth seems to have been the result of a political process involving lots of lobbying by folks who wanted to be sure we continued to eat what they were being paid to produce – thus the heavy focus on grains.  Apparently, neither nutritionists nor health authorities had much to do with its production, though it has a profound effect on health.

         Individual voices stand out, sometimes out of proportion to the actual proven value of their message.  Gary Taubes’ article, “Is Sugar Toxic?” (NY Times, April 13, 2011) reiterates the story of nutritionist Ancel Keys from the University of Minnesota. Keys was such a strong proponent in the 1970s of his idea that dietary fat consumption was the best predictor of heart disease that he was able to discredit the equally-probably ideas of England’s John Yudkin, along with Yudkin himself.  Yudkin had argued that sugar consumption was linked directly to both the triglycerides of heart disease and the insulin levels of type II diabetes.  Keys’ powerful personality led to widespread acceptance of ideas about fat and heart disease that may have led us to adopt even more harmful high-carbohydrate diets to avoid fat.

         I’m reminded of the Gary Larson cartoon in which a shark in the water near a beach cups his fins around his mouth to yell, “Bear, Bear!!” as panicked bathers stampede into the water to escape.

         Casting caution to the winds, I have boldly asserted that I will wade into the morass of dietary information and sort out scientifically proven ideas from those that merely seem sensible.  In the process, I’ll identify those ideas without a shred of supportive evidence, and those that fly in the face of good sense.  When I’m done with that, it’ll be clear how we should all eat, and I’ll just jot it down and then we can get back to worrying about bigger things, like where Obama was born and whether autism causes global warming.

         Or not.

         Chris Mooney’s article on “Made-up Minds,” published originally in Mother Jones and excerpted in “The Week” (May 20, 2011), reminds us that reasoning is inseparable from emotion. We all tend to pull friendly information close and push threatening information away.  The fight-or-flight response, he says, applies not only to predators but also to information itself.

         What’s that mean?  It means that emotion may not have much bearing on scientific conclusions, but it certainly colors those conclusions to which we give credence, and those we’re willing to talk up.  We accept evidence that supports our views, and reject evidence that doesn’t.  In fact, we often reject as experts those whose conclusions, however well researched, don’t fit our pre-existing views.

         That’s a little awkward.  Does that mean that I can’t make an unbiased analysis of popular writing, looking for its scientific backing?  Will I filter out the stuff that doesn’t agree with my biases, even if it’s well-researched, and even if I think I’m being wonderfully even-handed?  Does that mean people shouldn’t trust me, either? Will my recommendations be just another set of biased ideas, based on that fraction of the literature that supports biases that I already have?

         Yeah, maybe. I’ll be authoritative, but not a “final authority.” I’m a seeker, an inquirer, an asker of questions.  When I present an idea as true, I really think it is.  Remember, however, that my pronouncement and $4.00 will get you coffee at Starbucks.  In other words, my idea is just that -- my idea, however well-spoken.  Even my objective judgments are difficult to separate from emotion, from my urge to affirm that the universe really does look the way I think it should look.

         Trust and verify.

Fat is Not a Character Flaw

        My sister and I have spent our adult lives getting fatter.  Neither of us wanted to do that, yet over the years we’ve accumulated enough extra fat between us to build a couple more people. 

Now I’ve lost about 70 pounds on a healthy eating program, and I feel good.  She and her husband have been eating on this same program, and have each lost substantial weight, enough that people are noticing.

         We talked about how easy this program has been, and how completely unaware we were that this is possible.  I once had the desperate feeling that I was doomed to continue inflating, since no matter what I did I continued to gain weight.

Since starting the program, I’ve thought repeatedly that it’s appalling how easy it has been for me to lose weight, bring down my glucose, and bring down my blood pressure.  Appalling because I didn’t know this was possible, didn’t know how to do it, didn’t know how to get direction from medical people anywhere.  Appalling because in my anesthesia practice every day I see people who are overweight, hypertensive, on oral hypoglycemics for early type II diabetes, and on cholesterol-lowering medications.  Appalling because I think that’s largely  unnecessary.  And appalling because almost nobody seems to know how to make a difference, yet.

         The program that worked for me, lowering blood pressure and blood glucose in the bargain, was the Ultralite program (www.ultralite.us). The Ultralite people at Transformations.com have a program that works, but in my experience it’s marketed so casually that it’s very difficult to hook people up with it.

I’m now certified as a practitioner for that program. The program is certainly effective, and people who are doing it are pleased with the results.  People learn not only how to lose weight, but how to eat for the rest of their lives to keep the weight off. Why haven’t I recruited a gang of clients, if I think this is such a great program? 

 Two reasons. The program is expensive, and it’s hard to get patients started with other practitioners on the mainland. I think it’s too expensive for many of the folks for whom I’d like to make it available here on Kauai.  Why is it expensive? Mostly because it’s practitioner-supervised, and because it uses a proprietary snack between meals in addition to lots of “real” food.

When people who don’t live here ask about the program, I find it’s hard to get people started with practitioners in other locations, even though people on the mainland might be best served by someone in their own area.  Sure, I could be the practitioner for these people.  I can coach on the phone (the life coach training, you know), but there are a limited number of people for whom I can do that. I’m still practicing full time as an anesthesiologist, and I live in a time zone that’s as much as six hours dislocated from parts of the US.

         Are there other approaches?  In truth, none that I’ve tried. But the ideas on which the Ultralite plan is based are not secret and not proprietary.  They are increasingly general knowledge.  Several people seem to be speaking to the same ideas as those used to create the Ultralite plan – people including Dr. Walter Willett from Harvard, Dr. Steven Gundry (www.drgundry.com), Isabel de los Rios (The Diet Solution, available on the internet), Gary Taubes of “Good Calories, Bad Calories,” and an increasing chorus of others.  All these people seem to be saying that the whole “low-fat” conversation has been a journey off the path, and that the biggest issue with our current way of eating is the preponderance of sugar and high-carb, high-glycemic processed food.  This deserves much more discussion in future articles.  For now it’s sufficient to say that many of my prior ideas about food and nutrition seem to have been all wet.

         My sister and I also talked about the differences between the medical model and the coaching model.  In the medical model, something is wrong and we’re here to diagnose it and fix it.  Find a problem, prescribe a solution.  Pills work for high glucose, for high blood pressure, and for high cholesterol.  They don’t do much for excess weight, but there’s always weight loss surgery if you’re heavy enough to qualify.  I believe that weight loss surgery for most people, by the way, is one of the most inadvisable moves anyone ever can make.  It literally consists of making yourself sick for the rest of your life in order to lose fat.  That’s healthy?

         Coaching (as in life coaching) takes a different approach to issues than does medicine. To coaches, people are whole and complete and have within them all the resources to create the lives they want.  People want help in discovering and developing these resources.  Coaches don’t fix, and don’t give advice.  But they do help people tap their own inner wisdom, learn new ways of being and doing, and create different lives.

         So being fat isn’t something to fix, and it’s not a character flaw.  It is, for most of us, the predictable result of the choices we make and the way our bodies work.  Fat is simply the energy store that accumulates in a body skilled at gathering and storing energy in times of plenty in order to survive times of famine. In my own experience, even when I thought I was eating “healthy,” I was still making choices that directed my body to accumulate fat.  Increasingly, there’s information available that allows me (us) to make different choices.

         Each of us has within us the ability to direct our actions, channel our instincts, and create the best lives of which we’re capable.  

         Over the next few months (years?) I’ll be looking at what we know about food, and what we think we know.  More than 30 popular diet books and a couple of internet programs are piled by my chair right now. I’ll look at places where people pretty much agree, and where they don’t.  I’d like to see a website with a simple eating plan to which I can refer people, one geared to empowering people for the rest of their lives instead of harvesting money, one with straightforward discussion of issues. 

We will change the world’s conversation about food, and about fat.