Wednesday, May 16, 2012

The Skinny on the Fat Lie - Part 2

Understanding the Problem and Medical Magical Thinking

While I was working on the first blog post (See: The Skinny on the Fat Lie) my 11 year old, Nate, seemed incredulous that I had something I wanted to write about - "Mom - you want to blog?" I was about two sentences into my explanation when he said "Oh! I get it - it's like that guy you told me about - the one who figured out ulcers were caused by bacteria - but other doctors didn't believe him. So, he swallowed some of the bacteria, gave himself ulcers and then cured it with antibiotics and even then not all the doctors believed him! Right?" Stunned (he actually listens to some of my rants - inner smile) I couldn't say anything for a moment. "Mom?" he said " are you ready for the hate mail? Cause you know there will be haters."  Ah, yes, that...

Me, ranting and questioning conventional wisdom - these things go together. We all know what causes obesity - right? It's easy - we eat too much and move too little. A calorie in, a calorie out. We live in a "toxic" food environment with food deserts and too many fatty, crappy school lunches. When I hear these things trotted out, without question, my inner wonk starts to simmer. If you look at these assumptions and your own life, your own experiences,  you know they cannot all be true and yet every day we are bombarded with these "truths" and we make our family dinner with them ringing in our ears.  Every magazine cover admonishes us - low-fat this, exercise that - whether it's Oprah, or Martha or Newsweek. During every daily newscast you will be urged to move more, eat less, and cook differently. We as a society are completely vested in these "truths" and it's getting us worse than nowhere - we just keep getting fatter.

When I read, in Gary Taubes book, Why We're Fat, that if it's really true that a calorie in must be burned by a calorie out - if it always, in all circumstances and for all people, takes 3,500 calories to burn one pound of fat - then any miscalculation on your part -- even as small as an extra 20 calories a day -- will land you in obesity territory within 25 years, my inner wonk swooned (I love a man who does the math!) Then I got a little jealous (why didn't I think to do the math!) and then my inner wonk got mad. Hadn't anybody done the math?!! If all it takes is 20 calories a day for things to go wrong, how come we aren't all morbidly obese?!

And, I must admit, I also felt a little vindicated because I've been sure for a while that we've had the obesity thing wrong - I just didn't understand the magnitude of our misplaced assumptions. One of the first lessons my grad school mentor, Dr. Clint Oster taught us about public policy: you can't find a solution to a problem you don't really understand. And one of the things that makes me crazy is that clearly we don't understand the obesity 'epidemic' since almost all studies show, that as a nation, we're doing what the experts are telling us to do. 

Since the 1960's fat consumption has dropped from 45% of our average daily diet to 35% of our diet today. Gyms and gym membership revenues have risen 17 fold (adjusted for inflation!) from 1972 to 2005 and recreational equipment sales increased almost $30 billion dollars from 1987 to 2004. So if we've made these changes, how come we're still getting fatter? And why are we still being bombarded with the message that we just need to do even more of what hasn't worked so far? Why are we being told to count more, move more, go lower fat...... I keep asking: is this really what we did back when we were a 'thinner' nation???

So this has been my obesity rant over the past few years: This whole paradigm for the fight on obesity has been wrong! We have made the wrong assumptions and thus been asking all the wrong questions and consequently chasing the wrong answers. Just think about it - think about the assumptions which underpin the advice thrown at us every day and you'll see how these things can't be true.

If you're around my age - 50 - you grew up in that 'thinner' era. That era when we supposedly moved more. Name the grown-ups you knew back then who were runners. I can't come up with one. Grown-ups who were 'gym-rats'? Tri-athletes? Yoga classes? Zumba? Well, then certainly then they must have walked a lot? Had a job that required a lot of activity? No, no, no, no. (Well, my parents did play doubles tennis once or twice a week - but mixed doubles also included cocktails and fatty snacks.)  Hmmm.

Well, what about the kids back then - we were more active?  We didn't have cable - heck - we only had 6 TV stations! I have vague memories of some gymnastic classes here and there. Short stint on the summer swim team. Occasional games of kick-the-can. I don't recall any 4 and 5 year olds in soccer leagues or T-ball or doing a "Family Fun Run" at school. Only the hardcore 'jock' kids started serious sports before High School. On the other hand, I do remember a lot of Brady Bunch and Gilligan's Island re-runs. And a lot of reading - the physical equivalent of video-game playing. Hmm. So, who were those mythical Americans of the last century who moved so much more than we do now? Certainly when we were more agrarian, but that transition happened long before the obesity problem began. Hmmm.

Well, then it's those darn school lunches! Right? They're really bad in this day and age - or else Jamie Oliver wouldn't be over here making a TV show about it - right? I don't know about you, but my school lunch 40 years ago included sloppy-joes on white bread, canned veggies and usually dessert. Other than maybe the occasional red delicious apple, a fresh fruit or vegetable never made the scene in our cafeterias. My husband Stuart fondly remembers the one day a week when his mom would allow them to buy the hot school lunch. He loved the days when they served chili with cinnamon buns (true!), and his second favorite was "meat blanquette" (thick hamburger gravy over mashed potatoes). No one talked about low-fat or low-sodium and everyone drank whole milk. By the time my oldest, Jake, started daycare 22 years ago school lunches had already started their transformation to "healthier!" He had whole wheat pizza, low sodium cheese, fresh veggies. Nate's school lunches are even "healthier" still  - whole grain, low-fat and locally sourced to boot - in the DC public school system. Hmmm.

Then we just need to focus more intensely on that a calorie-is-a-calorie thing. Right? You know - like in those articles - 10 things to change in 10 days to lose 10 pounds? I hate those things! Switch from waffles to oatmeal and skim milk - drop 300 calories right there! (But what if I never let myself eat waffles to begin with?) Leave the mayo off the burger at lunch, score another 100 calories a day! (When have I ever been able to eat a burger every day for lunch? To maintain my then-skinny self in graduate school I had a small bag of plain popcorn and a Tab diet soda for lunch every day).  Hmmm.

All I have to do is have lunch with my friend to know this whole line of thinking, this whole obesity paradigm is. not. true. Cannot be true. My itty-bitty friend (and I mean this in the most loving and envious way) can eat like a lumber jack and stay a size 1, while I eat my 6 inch low-fat Subway sandwich and half a bag of baked Lays, struggling to maintain the weight loss I achieved 8 years ago on Atkins (and a dress size I'd rather not divulge). But, you say, she must exercise more? No, that's not her thing. Me, yoga at least 3 times a week. OK then, she's more active in general? She lives WAY out in the 'burbs - almost nothing walkable in sight. Me - extremely pedestrian neighborhood that I love to take advantage of.

In fact, according to Taubes, researchers have seen in study after study, time after time, that the obese eat the same or even fewer calories than the lean. Researchers and doctors never report it, because they just  assumed, in study after study, that the obese and overweight participants were cheating! (Another important lesson from my Professor Oster: don't allow the assumption that someone is stupid or lying to drive your data - it will always get you in trouble). There has only been ONE study - only one truly scientific, controlled study that shows that exercise helps with weight loss and even that was utterly underwhelming. In 1989, Danish researchers decided to train 18 overweight men and 9 overweight women to run a marathon in the hopes of having them lose weight. All participants did run a marathon at the end of 18 months. However, only the men lost weight - and then only 5 pounds on average - and they gained it back after the study. The women lost no weight at all. Really, I'm not making this up!!

Then why are we so sure that exercising works for weight loss. That a calorie in is a calorie out? Why do we think these things are true? Because we've been told over and over that it's true! Doctors, researchers, nutritionists seem to believe that to tell us otherwise would be a "bad" message (granted, there are other benefits to being fit) so they just cling to that one study and urge us all to exercise despite the academic evidence that it will most likely just make us hungrier! Call it Medical Magical Thinking. 
But the truth sometimes seems more outrageous than the Medical Magical Thinking when we've been bombarded by the latter day after day, year after year. Research has repeatedly shown that even rats on exercise regimes eat more. Attempts to get them to eat less by filling them with water or adding fiber to their diet all fail. Take a moment to think about how many articles you've read giving you that same advice - drink water - add fiber - to help you lose weight. If it doesn't  work on rats in a controlled environment, why  in the world would it work for us?? As crazy as it sounds, other research has shown that little ground squirrels who put on fat every September in preparation for hibernation will do so even on a calorie-restricted, enforced  exercising regime. Their little bodies pull the fat from their internal organs and they die of malnutrition - still fat, but dead from starvation.

Every study undertaken to prove the Atkins diet is not only ineffective, but also bad for you, has found the complete opposite. In every published study, people on Atkins lose more weight than those on the low-fat Ornish diet, the Zone diet and a traditional low calorie diet. And more people stayed on the Atkins diet throughout the studies than the other 3 diets. Their blood pressure went down, their "good" cholesterol  went up, their "bad" down, the ratio improved, triglycerides went WAY down and their risk of heart attack decreased significantly. I think of the little ground squirrels and worry about our internal organs - especially our brains, which are roughly 70% fat (makes me wonder about the rapidly increasing rates of autism and dementia that have coincided with the push towards lower and lower fat consumption).

So, what else has changed in the last 30 years, while our fat consumption went down? Our consumption of refined carbohydrates and sugars - especially high fructose corn sugar went up - way up. Despite what you hear nightly on TV commercials: all sugar is not created equal as far as your body is concerned (they're only the same as far as Monsanto and Archer Daniels Midland are concerned!) (watch the links below from 60 Minutes). If you lay the chart of our increase in weight over the last 30 years with a chart of our increase in consumption of high fructose corn syrup they line up. Fat doesn't make you fat - sugar makes you fat. And as we have removed the fats from our diets, we've replaced it with sugars --  not just the sugar we think of in our sugar bowls, but all kinds of "sugars" (i.e. highly refined carbohydrates and high fructose corn syrup) that are the bread and butter - if you will - of the well paid lobbyists representing multi-national agribusiness and processed food  interests - interests, by the way, which we also subsidize through the Department of Agriculture. I'm talking about the highly refined sugars and flours that fill those low-fat 100 calorie packs, Fiber One bars, Vitamin Water, Gatorade, Juice boxes, etc, lining the aisles at Walmart. 

So yeah, there will be haters.....

P.S. Thanks for the many kind words regarding my first post. I apologize for the delay in posting this second one - had a couple of bad migraine weeks. Most of the numbers used in this post are from Gary Taubes two books, Good Calories, Bad Calories and Why We Get Fat and What to Do About It - I highly recommend both - the first if you want the 600 page detailed version, or the second for more of a synopsis.

Any data not found in his work comes from my research over the years into health care issues.

No time for reading even the shorter book? Then make time to watch Gary Taube's presentation at Google Headquarters - it's a really good one hour synopsis of Why We Get Fat.  

For a discussion from a biochemist on why our bodies react differently to high fructose corn syrup and turn it directly into fat watch this 60 Minutes Overtime piece.

For a quick peek into a controlled study showing that high fructose corn syrup makes you gain weight watch this 60 Minutes Overtime piece.

Wednesday, May 2, 2012

Our Scary Time in the PICU

The Need for Electronic Medical Records: Portability and Patient Access

Apologies for those waiting for my next blog on diet - hope to have that soon. Today, I must digress as my friend Regina Holliday posted a link on Facebook about how the American Hospital Association is fighting the requirement in the new health care law that hospitals and doctors shift to electronic records and make them available to the actual patient! (can you imagine!)

Reading their rationale not only made my inner wonk furious - my inner mom began to cry as memories of Jake in the Pediatric Intensive Care Unit (PICU) at Georgetown University hospital came flooding back.

Jake was at the PICU because in June, 1999, he fell from the high dive at the Wilson High School pool onto the concrete deck below -- suffering a severe traumatic brain injury (TBI).  And as soon as the ambulance arrived at the pool in response to the 911 calls, we made sure everyone knew of his allergy.

Jake is allergic to penicillin. When he was 2 years old he had a horrible reaction after getting penicillin for an ear infection. First his ears turned bright red and then welts the size of small fried eggs appeared all over his body - especially his scalp. It took 3 weeks on antihistamines to quell the hives.

His brain injury was severe enough that he couldn't even breath on his own, so after emergency brain surgery that first night, he was put on a ventilator. As is often the case with ventilators, this led to a series of lung infections, each round requiring a powerful antibiotic. Despite our vigilance, and unbeknownst to us, the doctors at Georgetown put him on an antibiotic, Ancef, that is well known to cause severe allergic reaction in  many people who are also allergic to penicillin.

As I sat in the PICU and watched his ears begin to turn that tell-tale color I begged the doctors and nurses to check his chart, to check his medicines - I knew he was having an allergic reaction to something - but they ignored us. We (my husband Stuart, my mom and I) had to sit beside his bed and watch Jake go into anaphylactic shock just days after suffering both a severe TBI and undergoing major brain surgery. Only when the swelling in his throat put enough pressure on the hose for the ventilator making the alarms to go off and his tongue had swollen to the point it was jutting grotesquely out of his mouth, did anyone take action.

Unbelievably we were lucky on that count. Later, they would turn the alarms off on his heart monitor in an attempt (failed) to get us to quit asking questions about his heart rate and why they were doing nothing about it.  All his brain functions were going haywire during this period - body temperature, blood pressure, the pressure in his brain. His heart was beating wildly and sometimes as often as every few minutes and at least several times an hour, his heart would go into severe tachycardia and all the alarms would go off next to his bed. A light outside his room would flash an alert and the electronic signs hanging above, all over the PICU would announce he was in danger. The doctors and nurses, however, did nothing, each time turning the alarms off and insisting that this was not unusual in a brain injury and that his young heart could "take it."

To help us during this time my cousin Jay and his wife Tina had arrived from Indiana. Tina is a talented, well-educated, think-outside-the-box pharmacist who was horrified they had ever given Jake Ancef in the first place. We demanded she be allowed to go through his chart and make sure there weren't any other pharmaceutical time bombs lurking there. Everyone at Georgetown (we really pushed this) flatly refused to let either she or us to access his charts and records.

Finally, late one night a resident we had become friendly with took pity on us, swore us to secrecy and made the chart available to Tina, after midnight, in a small room near Jake's. We - Stuart and I - had to promise not to look - only Tina. Fortunately, everything else she saw with respect to medication seemed OK, but other things she found in his chart were shocking. Derogatory remarks about various members of our family (especially me). Complaints that we wouldn't leave his bedside. Outrage that we would demand this level of care for our son. And mocking of the expectations we had regarding the quality of the health care he should receive.

It took a days and days to get his allergic reaction under control because it took us days and days to get the doctors in the PICU to bring in someone from the allergy staff. It took even longer for his tongue swelling to subside, leaving his tongue torn and bloody from the pressure of his teeth. Our pleas for help in protecting his tongue were met with dismissal by the doctors - a damaged tongue wasn't on the list of any of the things they did. They were surgeons! neurologists! - and, as one nurse helpfully explained - our expectations were too high and the doctors far too busy and far too important to meet together to try to find a solution (seriously - she used those words!). Finally, with help and supplies from a friendly nurse Stuart fashioned protection for Jake's tongue and as the allergy medicine took effect the swelling slowly subsided.

With the memories of Jake's earlier penicillin reaction on my mind I begged nurses, doctors and residents to be vigilant about continuing his benadryl as it had taken weeks of the medicine to stop his reaction when he was two. Back then, a missed or delayed dose would cause his ears to redden and welts to begin to appear again. Some on his team assured me they would add the order on his chart, others told me rather bluntly that I was wrong - no one ever had that kind of reaction, nor needed medication that long. I had no access to his chart, to his record, so I had no idea what it really said there about his benadryl.

A few nights later, the night before he was to be taken off the ventilator and begin to breath on his own again, his doctors - without telling us - took him off the benadryl. Early in the morning, not long before we were to take him off ventilation, his allergic reaction came roaring back, over-powering the ventilator. He was again rushed to emergency surgery, this time to cut a hole through his throat to place a tube into his trachea so he wouldn't die from anaphylaxis. Allergy medicine was begun again and I was given a lecture by several doctors and a nurse on the powerful, negative effects of over-the-counter benadryl (not kidding) and thus justifying why they had taken him off it in the first place.

Weeks later (after other harrowing experiences) I rode with Jake in an ambulance from Georgetown to Kennedy Krieger Institute in Baltimore for 4 months of intensive rehab. Stuart, my mother and her dear friend (my 'second mom') Kelly followed behind. The ambulance medics were surprised by his tachycardia and alerted the on-call doctor who would be checking us in at KKI. He wanted to see Jake's charts, his records of what Georgetown had done - I had nothing. They were supposed to send a "report" to KKI at some point, but did not intend to send his complete records.

They hooked Jake up to a heart monitor in his new room. Immediately all the alarms went off and the doctor asked me what Georgetown had done to deal with this because it was really, really serious and really, really bad for Jake. He's asking me - the MOM - because that's all he's got. His mouth dropped open when I said "nothing". He called a nurse ordered some medicine. "What", I asked, "are you ordering?" His answer - "huge doses of benadryl"- was kind of a last mommy straw for me. I burst into tears and fell into a chair. I cried so hard and so long I couldn't talk - my mom had to explain to the doctor why I was crying - as well as fill him in on Jake's care at Georgetown (thank goodness we come from a family of note-takers!)

So yeah, you bet we need electronic records - records that are available when a patient is transferred to another facility and available to the patient and their next-of-kin who have the moral (and should have the legal) right to see them. And you gotta wonder why the American Hospital Association is fighting it.