Panaceia or Hygeia

immunize yourself against the pandemic of lifestyle diseases

Archive for March, 2007

ILLUSTRATE illustrates the futility of measuring and treating blood “cholesterol”

Posted by Colin Rose on March 31, 2007

Intravascular ultrasound is a sensitive method for measuring the size of atherosclerotic plaques in the arterial wall. When testing a drug to see if it will have an effect on plaque volume, this technique is the gold standard.

ILLUSTRATE set out to show that adding torcetrapib, a drug that increases HDL, the “good” cholesterol, to Lipitor, that decreases, LDL, “bad” cholesterol would reverse plaque or at least stop its progression.

Here are the baseline characteristics of the subjects. Note that the average BMI was 30. Overweight is defined as a BMI over 25 and obesity over 30. So, all of them were overweight or obese. 20% were diabetic, most likely Type 2, related to obesity, and 75% were hypertensive. 18% smoked. All of those factors are risk factors for atherosclerosis related to lifestyle. Therefore, unless one intends to first completely eliminate these lifestyle risk factors, it was unethical to even conceive such a trial particularly since it is proven that atherosclerosis can be reversed by lifestyle change alone. The trialists probably rationalized that atherosclerosis, like pneumonia, must be treatable by drugs and Pfizer, who funded the trial, has a slogan, “Working for a Healthier World” it is ethical to do such a trial. Besides the money helps to keep one’s IVUS lab going and one is promoting the notion that the technique will some day lead to the cure for atherosclerosis.

 

Legal Addictions

The typical ILLUSTRATE patient

Here are the reported results. What was not mentioned in the abstract above is that plaque actually INCREASED in both the the Lipitor only group and the Lipitor plus torcetrapib group. Now, before actually starting the trial, the subjects were given enough Lipitor to adhere to the guidelines written by doctors paid by Pfizer and other statin dealers. So, following the guidelines for blood cholesterol lowering with Lipitor does not slow progression of plaque. The obsession with blood cholesterol is completely futile.

nejm-illustrate-result.jpg

The conclusions of the authors shows their blinkered view of atherosclerosis. While Dr. Nissen donates his personal drug money to charity (how much is paid to run his IVUS lab, if any, is not stated), all the other authors have major financial connections to drug dealers. Revkin, Shear and Duggan are employees of Pfizer and own stock. Naturally this group would ignore non-drug methods for reversing atherosclerosis

We have known how to reverse the atherosclerotic process very easily since the revolutionary work of Dean Ornish the final report of which was published in 1998. No drugs are necessary, only a change in lifestyle which was not seriously attempted in this study. There is even no reference to Ornish’s work in the paper, a major oversight of the reviewers. So, why don’t the IVUS groups do a study of plaque volume after significant lifestyle change? Who would fund it? If Pfizer is really “Working for a Healthier World” and not just making a profit, Pfizer should be funding an IVUS lifestyle trial.

Posted in atherosclerosis, cholesterol, coronary artery disease, professionalism, statins | Tagged: , , , , , , , , , , , , , , , , , , , , , | Leave a Comment »

Child obesity and trans fat, a politically correct scapegoat

Posted by Colin Rose on March 28, 2007

Here is a classic example of politicians trying to deflect responsibility for a problem away from the average voter, whom they are loath to antagonize, to a politically powerless scapegoat. You will never hear a politician say that eating TOO MANY CALORIES because of food addiction is the cause of pandemic obesity. That would upset the whole food supply industry and rural voters whose votes are worth twice a much as city dwellers. So, politicians blame trans fat and recommend building more gyms, changes that will make ABSOLUTELY NO difference but will not injure an delicate voter sensibilities.

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Child obesity an epidemic, Ottawa told

25% OVERWEIGHT: COMMONS COMMITTEE For first time, Canada’s younger generations are expected to live shorter lives than parents

OTTAWA – More Canadian children are overweight and for the first time the country’s younger generations are expected to live shorter lives than their parents because of obesity, says a new Commons committee report made public yesterday.

Committee MPs said they were “shocked” to learn about the increase in overweight children, from 12 per cent to 18 per cent, and obese children, from three per cent to eight per cent, between 1978 and 2004.

That makes about one in four Canadian children overweight or obese.

The report said parents must be in denial, as a Canadian Medical Association survey found only nine per cent report they have a child who is at least somewhat overweight.

The health committee called yesterday for aggressive measures to halt child obesity, and said they share fears of experts that “today’s children will be the first generation for some time to have poorer health outcomes and a shorter life expectancy than their parents.”

Highlights of recommendations are a ban on trans fats as advised by a federal task force; use of a mandatory, simplified, standardized food labelling system; and designation of federal funds to build or replace aging playgrounds, sidewalks, rinks, pools and other community exercise spots across the country.

The report said most Canadian children spend too much time in front of TV and computer screens; don’t get the expert-recommended 90 minutes a day of exercise; eat too much fat and junk food; consume too many sugary drinks and don’t eat the recommended five daily servings of fruit and vegetables.

The committee also reported the “distressing” and “most alarming” number of 55 per cent of First Nations children living on reserves, and 41 per cent off reserves, are overweight or obese.

There is so much poverty among First Nation and Inuit people that many people cannot afford nutritious food, especially in remote northern communities, the report said.

And of more than 500 First Nations schools, only half have a gym.

The health committee proposed Canadians take up a national challenge to halt a 30-year rise in overweight children in just three years – by the 2010 Olympic games in Vancouver. Then targets to reverse the trend could kick in.

“It is ambitious but it is doable,” committee chairperson Rob Merrifield, an Alberta Conservative MP, told a news conference.

“For the first time in recorded history, our younger generations are expected to live shorter lives than their parents due to obesity,” he said in a prepared statement.

“New and aggressive action is required to address this complex and, ultimately, very costly problem.”

The report was welcomed by the Heart and Stroke Foundation, which has long warned “fat is the new tobacco,” and by the Canadian Medical Association.

Foundation chief Sally Brown said overweight children are on “a fast track” to developing hypertension, heart disease and stroke.

New Democratic Party MP Penny Priddy said by chronicling links between poverty, poor diet and lack of exercise, the report busts a myth that overweight children all sit around playing on computers and watching TV. She cited the example of children in poor families being fed Kraft Dinner instead of going to bed hungry.

Kraft Dinner is a brand of macaroni and cheese, an inexpensive food.

Expressing concern that the committee would get into trouble with the Kraft corporation, Merrifield said “I love Kraft Dinner.”

The report said on average, adolescents in Canada spend almost 35 hours a week in front of a TV or computer screen – more time than in the classroom over the course of a year. Studies had shown the less time in front of a screen and the more activity, the less weight.

The committee also postponed a decision on a possible ban on food advertising to children, saying it would assess the impact of self-regulation in Quebec, Sweden and other jurisdictions in a year before deciding on the issue.

Bloc Québécois MPs issued a dissenting report, saying the Quebec government already has a well-defined strategy to deal with juvenile obesity and that the federal government should stick to its own jurisdiction in health, which is confined to First Nations and Inuit people.

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According to studies conducted at the University of Guelph, Canadians consume an average of eight to 10 grams of trans fats per day. At 9 kcal/gm for fat, trans fat account for at most 90 kcal/day. This is the cause of the obestiy pandemic? One pound of fat is about 3500 kcal, so it would take about 40 days to gain or lose one pound of fat if one adds the trans fat or eliminates it respectively. But that trans fat is always REPLACED with another form of fat with the same calories. A gram of trans fat has the same caloric value as a gram of oil or other fat. So one has to reduce the TOTAL FAT and TOTAL CALORIE intake to make any difference.

Here is what is often used to replace trans fat. No cholesterol, no trans fat, omega-3. These slogans are now used by food manufacturers to market even more junk calories. I predict the pandemic will only worsen. Nobody wants to deal with the fundamental problem, food addiction. See my photo essay on food addiction.

Health Food in Costco

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COURAGE demolishes the myth of the “widow maker” and the “time bomb” but does not use optimal medical therapy

Posted by Colin Rose on March 26, 2007

For 30 years since the development of a balloon-tipped catheter to dilate coronary arteries, now known as PCI (percutaneous coronary intervention), it has been revealed truth from “experts”, most of whom paid their mortgages by doing PCI’s, that all significant coronary narrowings should be dilated to prevent a heart attack. In spite of overwhelming evidence that heart attacks are caused by rupture or early, unstable, non-obstructive plaques, most cardiologists still believe that heart attacks (sudden complete blockage of a coronary artery) occur at the site of the largest plaques. Patients are shown angiograms and told they have a “widow maker” or are “sitting on a time bomb”. I refused to do angioplasties until there was some proof for this superficial but very lucrative theory. Again, it turns out I was right. Even in patients with major narrowings and symptoms, PCI does not prolong life or prevent heart attacks. Chronic symptoms were slightly more improved in the PCI group but most medically-treated patients had symptom improvement just with pills.

 

Legal Addictions

The COURAGE type subject

All cardiologists give lip service to the necessity for lifestyle change as the ultimate cure for atherosclerosis, but in this study there was no attempt at lifestyle change. Most patients were overweight or obese, gained weight over the five year study. 20% smoked and did not stop. While the authors claim to using “optimal” medical therapy, they did not even try significantly changing lifestyle, the obvious cause of the patients’ atherosclerosis. No doubt even better results that could have been obtained with just lifestyle change, without pills or PCI, as Dean Ornish showed many years ago.

If you want an explanation for why, except for a feeble attempt to raise HDL by exercise, NO attempt was made to change lifestyle meaningfully before using statins or PCI you need look no further than the source of funding and the disclosure statements of the authors. Those who recieve substantial income from drug dealers are not keen on proving that cost-free lifestyle change alone will do the same or better than expensive drugs.

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Now, why has it taken 30 years to finally prove the futility of PCI in patients with stable or stabilized coronary disease? Unlike new drugs, there are no rules and no government agency mandating that surgical procedures have to undergo clinical trials before being done on the general population. Any surgeon can develop some operation that seems superfically rational and he and his colleagues can do many thousands of those operations, costing millions or billions of dollars and risking many lives until someone gets around to actually testing it to see if the outcome is really as advertised.

Doctors profess to want to practice “evidence-based medicine” but when change negatively affects bank accounts habits change very slowly if at all. Angioplasty in stable CAD can always be rationalized by the classic, “my patient is different than those in the controlled trial”. We can predict that angioplasties in patients with stable CAD will not decline significantly until most of those trained in the procedure have retired. The system could save a lot of money by giving each of them $one million and a house in Mexico to retire to.

Posted in angioplasty, atherosclerosis, coronary artery disease, diet, drugs, professionalism, statins | Tagged: , , , , , , , , , , , , , , , , , , , , , , , , , , , , | 1 Comment »

A TO Z trial. Atkins tops?

Posted by Colin Rose on March 12, 2007

The recent publication of the results of the A TO Z trial of four weight-loss “diets” made headlines around the world: “ATKINS DIET TOPS”. The group on the Atkins diet lost about 10 pounds, a few more pounds than the others, after one year of “dieting”.

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Did anyone, including the paper’s reviewers, actually look at the numbers behind this conclusion? Table 1 shows the baseline parameters.

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Note that the average BMI was about 32. One is considered to be obese above a BMI of 30. So most were obese. Note also the weights. About 85 kg. Now look at the results in Table 2 (below). Remember that these numbers are derived by SELF REPORTING of food consumption and exercise. The subject could tell the investigators anything. There was no check on what they said. They were paid, so the subjects had an incentive to the investigators what the subjects thought the investigators wanted to hear. The subjects claimed to be eating about 1900 kcal/day at the outset of the trial. Any adult who eats only 1900 kcal/day is UNLIKELY TO GET OBESE in the first place. During the trial they claimed to be eating only about 1500 kcal/day. So even if they hadn’t increased exercise they should have had a deficit of 400 kcal/day, 2800 kcal/wk. One pound of fat is about 3500 kcal. So, if we are to believe what they reported, they should have lost at least 3 pounds per month or 36 pounds per year. But even the Atkins group only lost 10 pounds. It gets worse. They reported total energy expenditure of about 35 kcal/kg/day. Multiply by their weight and you get about 3000 kcal/day. But they claimed to be eating only 1500 kcal/day. So they should have lost two to three pounds per week, at least 100 pounds per year. Also note that total calorie intake remained about the same in all groups in spite or a wide range of percentages of protein, fat and carbohydrate and by the end of the trial these percentages tended towards the same fraction in all groups. The First Law of Thermodynamics says energy cannot be created or destroyed. Any study of energy flows that cannot first show that energy is conserved should never be published. The methods employed by the study are fatally flawed. No conclusion can be drawn from this data. Many interpretations are possible. So, if all groups ate the same REPORTED calories on the average and burnt the same REPORTED calories on average, why did the Atkins group lose a little more weight? Maybe the Atkins group did a little more exercise. Who knows? They were lying about everything. Or, maybe, for some reason those presumably following the Atkins diet were slightly less proficient liars as the others.

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That obese people lie about food intake was proven beyond doubt by a study using doubly-labeled water to measure true energy expenditure. About 65% of these subjects were overweight or obese. They claimed to be eating only about 1500 kcal/day but were burning 2500. So, they should have had a deficit of 1000 kcal/day and be losing weight dramatically but their weights were stable. Ergo they were “misreporting”, a euphemism for lying.

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The real cause of obesity is food addiction. Like alcoholics food addicts will deny they consume too much and/or exercise too little. See my photo essay on the topic. Which diet is this lady on?

Food Addiction

Is she on a low-fat or low-carb diet?

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Cubans do not measure “cholesterol” and live longer than Americans

Posted by Colin Rose on March 10, 2007

Cubans don’t measure their blood cholesterol obsessively as recommended by “guideline” committees in the US, Canada and Britain, on which sit doctors paid in various ways by statin manufacturers. Statins are almost impossible to get in Cuba but Cubans live longer than Americans who spend $US billions on statins like Lipitor. Cubans eat mostly a unrefined plant-based diet, have few cars and have less obesity. And Cuba spends only 4% of what the US does on “health” care per capita. Just think of what we could do with more than a trillion dollars PER YEAR. That would fund a few manned trips to Mars every year not not to mention funding free university education, cleansing the environment, obliteratiing infectious disease and poverty…

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U.S. healthcare costs more than Cuba’s and may not have an edge in helping people live longer, but Cubans often lack prescription drugs and over-the-counter remedies.

BY JOHN DORSCHNER

jdorschner@MiamiHerald.com

The average Cuban lives slightly longer than the average American, but the American’s healthcare costs $5,711 a year while the Cuban’s costs $251.

Those are the figures of the World Health Organization. Some experts question the accuracy of the Cuban numbers, but no one doubts the underlying revelation: There is little relationship between the cost of your healthcare and how long you’ll live.

”Medical care is responsible for only a small portion of the variation in life expectancy,” says Gerard Anderson, a Johns Hopkins professor specializing in health policy. “Behavioral factors such as diet and exercise are much more important. The U.S., which spends much more than any other industrialized country on healthcare, is getting little value for much of the spending.”

These factors have moved to the forefront of the American political discussion as leaders in both major parties work toward solving what almost everyone agrees is a ”healthcare crisis,” with soaring costs threatening to increase the numbers of the uninsured, which already include 46 million Americans.

In such a discussion, Cuba serves as the starkest possible contrast, a completely government-controlled system in which ailing leader Fidel Castro benefits from the best possible care, including consultations with a Madrid surgeon, while many Cubans struggle to get basic treatment.

Here are the numbers: The average American has a life expectancy of 77.8 years, as of 2006. The average Cuban lives 78.3 years. Even if the Cuban figure is inflated, no one disputes the statistics from European countries, where people tend to live a year or two longer than in the United States — at about half the healthcare costs per capita.

At its highest level, most people agree, the United States has top-quality care. The country offers the latest magnetic resonance imaging, robotic-arm surgeries and drugs to deal with cholesterol, acid reflux and arthritis pain.

Americans want the biotech drug to target tumor cells, but many don’t get basic preventive screening tests. That’s particularly true for the uninsured, who often avoid treatment until their condition sends them to the emergency room.

Cuba offers universal healthcare and has twice as many doctors per capita as the United States. The Cuban government did not respond to The Miami Herald’s request for comment via telephone or e-mail, but its publications have boasted that the country is one of the world’s leaders in healthcare. Ann C. Seror, a professor at Laval University in Quebec, Canada, says Cuba has “achieved a remarkable level of healthcare quality of life for its citizenry.”

But six Cuban doctors The Miami Herald interviewed — two dissidents still on the island, four now in Miami — say many prescription drugs and even over-the-counter remedies are nearly impossible to get, and patients sometimes have long waits in clinics unless they pay bribes.

One irony is that poverty has forced Cubans into a healthier lifestyle. Juan A. Asensio, a University of Miami trauma surgeon and a Cuban American who is certainly no friend of the Castro regime, put it this way: “No McDonald’s, and Cubans walk everywhere or ride bikes because they can’t afford cars.”

About one in 10 Cubans are obese, according to the Pan American Health Organization. In the United States, one in three are obese, ”increasing risks of high blood pressure, type 2 diabetes, stroke, heart disease and osteoarthritis,” according to the Agency for Healthcare Research and Quality.

Still, the aging American, no matter his weight, can lay claim to a more comfortable life, with access to everything from Advil to Pepto-Bismol and Viagra — products virtually nonexistent in Cuba.

As Nestor Viamonte, a physician who left Cuba in 2003, puts it: “There’s a difference between a 75-year-old with quality of life and a 75-year-old without quality of life.”

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Bariatric Surgery – Psychic Surgery?

Posted by Colin Rose on March 9, 2007

 

Except for the anus, the smallest lumen of the entire gastrointestinal system is the esophagus, just after your mouth. No "bariatric" surgical procedure can make the lumen smaller than the esophagus; otherwise you would inhale your food instead of swallowing it.

 

Finally a commentator has had the guts to attack the bariatric surgery myth (see below).

We have been arguing for years that these operations to reduce stomach size in various ways cannot possibly have any physiological effect on caloric intake and that their effect is purely psychological. “I have been anesthetized, I have scars on my stomach and I have been told that I can’t eat as much as before”. Some sort of vague threat is implied. If they eat too much they will get abdominal pain, nausea or vomiting. But patients eventually figure out that they can indeed eat as much as before without pain or nauseas and the weight is regained. The reason is that the esophagus is the smallest part of the GI tract. It is impossible to make any part further along smaller than the esophagus or food will back up in the esophagus and cause aspiration of food into the lungs which can be fatal. So, whatever will go down the esophagus will go through the stomach no matter how small it is made as long as it is bigger than the esophagus and from there right into the small bowel where it is rapidly broken down by the digestive enzymes.

The only type of bariatric surgery that makes physiological sense is bypass of the small intestine to cause malabsorption, a much bigger and more hazardous procedure with many side effects.

The duodenal switch operation in which most of the small intestine is bypassed. This is the only sort of intestinal surgery that can reduce calorie intake by creating malabsorption. If one eats too much one gets massive diarrhea.

Bariatric Surgery. Psychic Surgery?

The lap band device, the latest in the surgical scams for treating obesity. There is no way this device per se will have the slightest effect on calorie intake; it only extends the esophagus by a few centimetres.

Remembering Susan

In the era before antibiotic treatment of ulcers, many gastrectomies were done to reduce stomach acid production and patient did not lose weight dramatically. Why? Because they were not told they had to eat less.

Here is a typical instruction to patients undergoing bariatric surgery (http://www.obesitysurgery.ca/faq.php ). Note that the patient MUST be “committed to your new lifestyle.”
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Q: How much weight will I lose?

A: Studies show that most LAP-BAND patients successfully lose between one-half and two-thirds of their excess weight. Results vary due to numerous factors. You need to be committed to your new lifestyle and eating habits. We expect that your weight loss will be gradual (2 – 3 pounds per week). Twelve to 18 months after the operation, the rate of weight loss usually slows down. Losing weight too fast creates health risks and can lead to a number of problems. The goal is to have a weight loss that prevents, improves, or resolves the health problems connected with severe obesity.
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And another from a review article in the NEJM by Dr Eric DeMaria in reference to his recommendation for bypass surgery in a case presentation.

“She should be required to make a commitment to an appropriate postoperative regimen of diet, exercise, and medical and surgical follow-up care.”

So why can’t obese patients commit to a new lifestyle WITHOUT the surgery? What is really effective, the surgery or the post-op diet and exercise. The only way to tell is to do a SHAM-OPERATED RANDOMIZED CONTROLLED TRIAL. Obese patients wanting surgery are randomly assigned to one group has some form of bariatric surgery or another group that is anesthetized, the same incisions made bowel is manipulated but no bypass or stapling is done. The post-op care team is blinded to the type of surgery and both groups get the same post op attention. Only after such a trial can we know if the effects of surgery are physiological of psychological, if bariatric surgery is just not another form of psychic surgery.

But there are a number of obesity “experts” who promote bariatric surgery as the ultimate answer to the obesity epidemic. One of these is Arya M. Sharma, MD, FRCPC, Professor of Medicine, Canada Research Chair for Cardiovascular Obesity Research & Management, McMaster University (http://www.cardio.on.ca/obesity) who is paid handsomely from taxpayer dollars and drug companies to promote the myth of bariatric surgery and various drugs for obesity. He refuses to even entertain the thought of doing a randomized, sham-controlled trial of bariatric surgery before spending billions of taxpayer dollars on the procedures with no proven benefit in a controlled trial.

Here is Dr. Sharma. “I think that much can be derived from careful objective observational studies, and indeed the majority of our knowledge in medical practice comes from empirical observation and NOT from controlled trials (the field of cardiology being the exception – this may be largely, because the field of cardiology lends itself best to such studies). These are far more difficult in other areas of medical practice, especially when dealing with long-term outcomes in low-risk populations. While providing the best possible care, we need to ensure that we do not degrade our patients to the level of laboratory animals just to prove a point that is reasonably obvious and biologically plausible based on what we already know. When you have no Class A evidence the right thing to do is to base your decisions on Class B or even Class C evidence, rather than do nothing. I come back to the point about checks and balances that need to be in place, but I also say that the time to act is now – the clock is ticking…..”

The same has been said about every treatment in the history of medicine; unethical not to do it, improved surgical techniques, can’t do a randomized trial, can’t wait for randomized trials, obviously effective, calculated benefit based on case controlled studies, Medicare pays for it, etc. If we continued to subscribe to the intuitive approach we would still be using blood-letting for pneumonia. Any treatment for any disease (other than hormone deficiency) must be subject to rigorous scientific investigation. Patients are NOT treated like “laboratory animals.” There are very detailed ethical guidelines about conducting controlled trials. Many “obvious and biologically plausible” treatments have turned out to be useless or harmful when subjected to controlled trial. Modern medicine like to pride itself on practicing evidence-based medicine. But when it comes to deeply held beliefs in the power of a treatment, particularly when it is good for one’s bank account, the search for evidence becomes less imperative.

The Roux-En-Y operation, a riskier type of "bariatic surgery." No controlled trials.

Dr. David D’Alessio of the University of Cincinnati says, bariatric surgery is “kind of the Wild West…huge demand, no regulation [and] patients are willing to do whatever it takes to get it.”

It is a mystery to me why the populace insists that its government scrutinize new drugs in great detail and insist on years of testing before they are licensed but any surgeon can come up with a superficially attractive operation and he and his colleagues can perform thousands of them at great expense in money and possibly lives before anyone gets around to doing an experiment to prove that the operation’s benefits outweigh its risks or have some benefit over medical treatment. See my blog on angioplasty for a classic example of billions of dollars spent on a procedure with no benefit. The latest surgical scam is the “liberation” treatment for multiple sclerosis upon which billions of dollars will be spent for a totally unproven, scientifically absurd procedure. Perhaps surgeons are the modern high-tech shamans. Surgery still maintains an aura of supernatural healing; evil spirits are being extirpated. To subject surgical procedures to controlled trials disturbs faith in its magical powers.

Will making the stomach smaller cure this women? The chocolate-coated ice cream bar will melt in the esophagus and pass through any orifice larger than a the diameter of a pin and pass rapidly through a gastic pouch no matter how small. The only cure for this women in mastering her food addiction. See my photo essay on food addiction.

Disney World

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http://www.theglobeandmail.com/servlet/story/LAC.20060726.REYNOLDS26/TPStory/?query=reynolds

July, 26, 2006
Taxpayers the losers in weight-loss surgery funding

NEIL REYNOLDS

OTTAWA — ‘I n one form or another, the corset has swaddled women since Cleopatra laced herself breathless for Caesar. Medieval women used leather and wood plates to flatten bulges. In Shakespearean times, 13 inches — no more, no less — was deemed the proper circumference of a feminine waist. And 18th century ladies cinched themselves to the point of frequent fainting. The 1890s produced the hourglass silhouette made famous by [actress and singer] Lillian Russell. If modern fashion has its way, the stage joke of a husband lacing his wife’s corset will repeat itself endlessly in connubial bedrooms across the country.” – Life magazine 1948.
For centuries, women handled fat the old-fashioned way. They hid it. More precisely, they shaped it to a particular aesthetic form. Corsets served strictly architectural purposes. Throughout the Victorian era, corsets used vertical steel rods to keep the female figure rigidly aligned with the blueprint, though the use of whalebone continued into the 20th century. These rods were appropriately called stays, defined by Oxford as “appliances used to hold up part of a structure.” Corsets worked and they were cheap. Eatons listed an economy corset in its 1901 catalogue at 28 cents.
With lightweight plastic stays, as Life magazine’s postwar essay suggests, corsets became modern appliances. With further refinements, they remained (along with girdles) essential woman’s wear well into the 1960s when they were rendered obsolete, first by fashion and now, finally, by surgeons with vacuum pumps.
Men used corsets, too, both for aesthetic deception and for medical reasons (wounded by gunshot in 1968, Andy Warhol wore a corset every day for the last 20 years of his life). But corsets primarily shaped the lives of women, just as cosmetic surgery now primarily shapes the lives of women. Casual tummy surgery is probably preferable to corsets — people who have experienced neither really can’t say. But the public policy issue here isn’t the change in fashion.
It’s the difficulty in distinguishing cosmetic alteration from medical procedure — and in determining who pays.
Start with the soaring use of weight reduction surgery in the U.S. These operations range from minimalist procedures (say 10 pounds) to heavy-duty surgery (say 50 pounds or more). On the one hand, cosmetic surgeons insist they do shapes, not weights. But who determines real motives — doctor or client? Since it’s now the client who pays for most of these procedures, the distinction is mostly moot. On the other hand, weight-loss operations performed on the “morbidly obese” — any person 100 pounds or more overweight — are deemed medically necessary. Eighty seven per cent of these patients are women.
In the early 1990s, U.S. doctors performed 16,000 of these bariatric (meaning weight) operations a year. In 2004, they performed more than 100,000. This year, they will perform 200,000. Obesity is, after all, ballooning. And doctors now perform these operations on adolescents. The cost averages $30,000 (U.S.) per operation. Perform it 100,000 times and you have an invoice for $3-billion.
This is an interesting calculation because there are more than 100,000 people in Ontario alone who qualify, by medical definition, for this operation — perhaps 150,000. Last year, the Ontario Health Insurance Plan paid $15-million (Canadian) to send a mere 600 of them to the States for this surgery at an average cost of $25,000. In a study released Monday, however, the U.S. government reported that four bariatric operations in 10 result in serious complications within six months — driving the cost in these cases as high as $65,000 (U.S.).
But, ominous as these costs appear, no one should think that the provinces will be able to restrict medicare access to weight-loss surgery for long. Now that governments are paying for the removal of fat from people who are “morbidly obese,” it’s only a matter of time before they extend coverage. People 90 pounds overweight will want coverage, then people 80 pounds overweight.
Restrictions will finally be deemed discriminatory — violations, no doubt, of the Charter of Rights and Freedoms. Self-indulgent people who eat too much and exercise too little will inevitably come to regard shape and weight as entitlements.
Weight-loss surgery is a dubious proposition. In one Canadian study, Dr. Raj S. Padwal at the University of Alberta Hospital in Edmonton found that bariatric patients shed between 35 and 60 per cent of their baseline weight in these operations — and, 10 years later, may maintain a loss of only 16 per cent. This simply means that a 300-pound person will become — in the long run — a 255 pound person, almost as fat as when he or she started. This person could achieve the same result by losing 4.5 pounds a year.
Fifty per cent of Canadians are now deemed overweight. Depending on your perspective, this means either 17 million people or 17 million patients. What to do with them? A few years back, Dr. Kenneth Walker, the Canadian medical columnist, facetiously suggested the use of force — that fat people be locked up in prison camps until they lose weight. In the end, though, there’s only one responsible option. Self-government. And, perhaps, corsets.
nreynolds@xplornet.com

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