Demonizing Fat in the War on Weight

But a growing group of historians and cultural critics who study fat say this obsession is based less on science than on morality. Insidious attitudes about politics, sex, race or class are at the heart of the frenzy over obesity, these scholars say, a frenzy they see as comparable to the Salem witch trials, McCarthyism and even the eugenics movement.

"We are in a moral panic about obesity," said Sander L. Gilman, distinguished professor of liberal arts, sciences and medicine at the University of Illinois in Chicago and the author of "Fat Boys: A Slim Book," published last month by the University of Nebraska Press. "People are saying, `Fat is the doom of Western civilization.' "

Now, says Peter Stearns, a leading historian in the field, the rising concern with obesity "is triggering a new burst of scholarship." These researchers don't condone morbid obesity, but they do focus on the ways the definition of obesity and its meaning have shifted, often arbitrarily, throughout history.

Mr. Stearns, provost and professor of history at George Mason University, has written that plumpness was once associated with "good health in a time when many of the most troubling diseases were wasting diseases like tuberculosis." He traces the equation of obesity and moral deficiency to the late-19th and early-20th centuries. In 1914, an article in the magazine Living Age, for example, stated, "Fat is now regarded as an indiscretion and almost a crime." Mr. Stearns cites it in an essay he wrote for the aptly named "Cultures of the Abdomen," a collection to be published by Palgrave Macmillan next November, edited by Christopher E. Forth, a senior lecturer at Australian National University, and Ana Carden-Coyne, a lecturer at the University of Manchester, in England. During World War I, Mr. Stearns writes, some popular magazines actually said that eating too much and gaining weight were unpatriotic, presumably because of concerns about food shortages.

A great example of this "movement" - The big fat con story

Size really doesn't matter. You can be just as healthy if you're fat as you can if you're slender. And don't let the obesity 'experts' persuade you otherwise, argues Paul Campos

His book - The Obesity Myth - represents his treatise on this issue. The article summarizes his argument.

Several important points need addressing. We can ignore the argument about BMI. Yes, many healthy athletes have elevated BMI. We should focus our definition more on fat percentage or waist circumference. Second, when we do that, we find that as fat increases, so does the risk of type II diabetes mellitus (and therefore atherosclerotic complications) and obstructive sleep apnea. Anyone you makes rounds with me for a month would see the devastation that those disease cause.

Physicians are not making a moral argument, rather we are focusing on prevention. When we have patients exercise and lose fat, their outcomes improve. Admittedly, we need a new method to achieve that goal.

Health Care Blog comments favorably on a critique of the malpractice system - QUALITY/MALPRACTICE: Change malpractice system to patient safety system, say Pfizer doc. He references an article from Health Politics - The Road from Medical Malpractice to Safety: You Can't Get There from Here. Quoting from the original article:

A head-to-head comparison tells the story. The tort system uses litigation as its lever for change. The safety movement uses quality improvement analysis. Tort law focuses on the individual. Safety focuses on the process. The tort system's punitive and adversarial style drives information down, encouraging secrecy. The safety movement uses a non-punitive and collaborative approach, which encourages openness, transparency, and continuous improvement. With tort law, exposing oneself can end one's career and harm one's mental health. In the safety movement, contributing is career-enhancing and therapeutic.

It may seem counterintuitive, but for medical malpractice to achieve its stated social purpose it must abandon the emphasis on a tort-based approach and embrace safety. Alternate dispute resolution, no-fault systems, raising fault to the institutional level, and exploring the use of medical courts all merit consideration and could begin to break the cycle of blame and provide a level of security necessary to ensure openness and transparency.

I do believe that most physicians would endorse a true safety process. The Health Care Blog finishes their rant

The AMA and the rest of organized medicine need to take the lead here, get off their high horse about the malpractice issue, and while they have a very sympathetic (i.e. Republican) Congress, develop some real bipartisan consensus on replacing the current tort system with a legally mandated patient safety system. That system will need real teeth to assure the public that it's not biased in favor of physicians and providers. And of course we need a neutral public education campaign about why such a system is required; reason number one being that most malpractice currently goes on unimpeded, and this system will stop that.

Physicians support malpractice reform - including a safety system. Do not attack physicians and Republicans here. Rather attack the Democrats and the trial lawyers who apparently have no interest in safety, rather an interest in the tort process.

Recently, a reader wrote to ask if I allowed "guest rants". The reader wanted to rant against vaccinations.

I do not allow guest rants, this page is my ranting place. You can comment, but I chose the rants.

I had not thought much about the request until I came across this article - Anti-Vaccination Fever. The author relates the story of pertussis (whooping cough) and how the anti-vaccination lobby has allowed this disease to make a comeback.

Distorted numbers, confusion of correlation with causation, and statistical innumeracy certainly played roles in this sad story. Sensationalist media campaigns fanned the glowing embers. But in each of the countries that experienced the raging fires of epidemics there were other forces at work. Most prominent in passive anti-vaccination movements were religious groups whose opposition was based on religious or moral grounds. Prominent in both passive and active anti-vaccination movements are followers and practitioners of homeopathy, chiropractic, and natural and alternative medicine (Gangarosa et al. 1998).

Despite the compelling case for vaccination that the anti-pertussis vaccination movement has inadvertently made, the Ström, Kuhlenkampff, and Stewart papers are still frequently cited in anti-vaccination literature. Speaking to Science News, Eugene Gangarosa, of Emory University, had this to say of anti-vaccine movements: "There's no question these movements undermine, collectively and individually, the benefits of vaccination" (Christensen 2001).

When anti-vaccination alarm takes hold-characterized by sudden attacks of the media, mistaken researchers, fervent religious groups, and alternative medicine quacks-the infected society begins to make horrid, whoppingly bad decisions. There is, as yet, no Latin name for this peculiar social disease.

Read this fascinating, albeit technical, exposition.

Cheaper drugs or siren songs?

Next week, the Department of Health and Human Services's Medicare drug card discount Web site is going to go "live," giving seniors the first chance to shop for the lowest prices for drugs under the new program — which also includes about $8 billion in cash, about $4 billion in discounts and billions more in direct benefits from biotech and pharmaceutical companies themselves. All told, millions of seniors will wind up paying less for drugs than they pay in Canada, or even next to nothing.

Yet, critics of the card and groups like Families USA are actively telling seniors they won't save any money because any discounts will have been eaten up by huge price increases now and in the future. They — along with the governors of many states — are instead pushing for the importation of medicines at government-controlled prices or for outright federal-price regulations.

Here are the facts about the Medicare drug discount program. All seniors are eligible to sign up for cards providing average discounts of about 20 percent on all drugs. In addition, 10 million seniors making less than $16,000 a year will get $600 to buy drugs and, depending on the card they choose, can be automatically enrolled in drug and biotech company programs that will cover the rest of the cost of medicines for about $25 a month or less.

The Families USA response? A "road show" that includes as its centerpiece a video narrated by Walter Cronkite that tells seniors that drug companies have raised drug prices by 15 percent a year, while drug discounts will only be 10 percent a year. The implicit message to old folks: Why bother signing up? Wait for the price-control revolution and drug imports to see the "true savings."

As usual, politics dominate. I have not researched these drug cards sufficiently to understand the benefits or drawbacks. I suspect that the truth lies somewhere in the middle.

As a physician, my major responsibility remains knowing drug costs and lower cost alternatives. We try to teach our residents about drug costs and how to minimize costs while meeting therapeutic goals.

We should emphasize several principles. New is not necessarily better. The newest PPI (Nexium) should never be a drug of first choice. One should switch to a more expensive drug only when the data clearly show an advantage, and the less expensive drug has failed. Try to minimize the number of prescriptions for each patient.

If we remember those principles we can help patients afford their medications without making them choose between food and medications.

I suspect that the drug cards will help some patients. This strategy seems to have more "staying power" than the drug importation strategy (which will likely fail for economic reasons).

Too often, new surgical techniques do not receive a careful analysis. The VA came through to answer an important question - what is the best approach to hernia repair - Open Mesh Better Than Laparoscopic Mesh Inguinal Herniorrhaphy

Of 2,164 men with inguinal hernias enrolled from one of 14 VA medical centers and randomized to open or laparoscopic repair, 1,983 had surgery, and 1,696 (85.5%) completed two-year follow-up.

There were recurrences in 87 (10.1%) of 862 patients in the laparoscopic repair group and in 41 (4.9%) of 834 patients in the open repair group (odds ratio [OR], 2.2; 95% confidence interval [CI], 1.5 - 3.2). Complications occurred in 39.0% of the laparoscopic repair group and in 33.4% of the open repair group (adjusted OR, 1.3; 95% CI, 1.1 - 1.6).

However, the laparoscopic repair group fared better than the open repair group in terms of pain on a visual analog scale on the day of surgery (difference in mean score, 10.2 mm; 95% CI, 4.8 - 15.6) and at two weeks (6.1 mm; 95% CI, 1.7 - 10.5), and they returned to normal activities one day earlier (adjusted OR, 1.2; 95% CI, 1.1 - 1.3).

Rates of recurrence after repair of recurrent hernias were similar in both groups (10.0% vs. 14.1%). In prespecified analyses, the surgical approach (open or laparoscopic) was associated with the type of hernia (primary or recurrent) (P = .012).

For laparoscopic repair, the recurrence rate was less than 5% for 20 surgeons in the study who reported having done more than 250 of these procedures, but it was consistently above 10% for 58 laparoscopic surgeons who reported less experience with this type of repair. Outcomes of open surgery were far less dependent on the surgeon's experience.

Study limitations include a nonrepresentative sample of high average age and low health-related quality of life; self-reporting of surgeons' experience; and exclusion of patients who had previously undergone a hernia repair using mesh.

Surgical studies are always difficult. This study does remind us that we can not randomize surgical skill. Some surgeons obtain better results than others. The wise generalist figures out which surgeons to whom he/she should refer.

If patients need major surgery, they should try to find outcomes if at all possible. At least use a surgeon with significant experience doing that procedure.

Answer, but No Cure, for a Social Disorder That Isolates Many

Task Force Redefines the Domain of General Internal Medicine

The Society of General Internal Medicine (SGIM) asked a task force to redefine the domain of general internal medicine. The recommendations of the Task Force on the Domain of General Internal Medicine (DGIM) are published in the April 20 issue of the Annals of Internal Medicine, along with editorials providing additional opinions.

"The [SGIM] believes that the chaos and dysfunction that characterize today's medical care and the challenges facing general internal medicine should spur innovation," write Eric B. Larson, MD, MPH, from the Group Health Cooperative, Center for Health Studies in Seattle, Washington, and colleagues from the SGIM Task Force on the DGIM. "Remaining true to its core values and competencies, general internal medicine should stay both broad and deep, ranging from uncomplicated primary care to continuous care of patients with multiple, complex, chronic diseases."

Specific recommendations are that postgraduate and continuing education should develop mastery, enabling general internists wherever they may practice to lead teams and be responsible for team care, to embrace changes in information systems, and to provide most of the care required by their patients.

Fee-for-service and other physician reimbursements should be changed to recognize the value of services performed outside the traditional face-to-face visit, and to offer incentives to improve quality and efficiency and to provide comprehensive, ongoing care. Options could include giving physicians a patient management fee plus reimbursement for specific services, or a salary with incentives for productivity, quality, and improved outcomes.

Residency training in general internal medicine should provide both broad and deep medical knowledge, including mastery of informatics, management, and team leadership. The final one to two years of residency training should be flexible and based on practice goals, leading to a certificate of added qualification in generalist fields.

Research initiatives should include practice and operations management, focused on more effective shared decision-making, transparent medical records, and closer personal connection between physicians and patients.

"The task force believes that these changes will benefit patients and the public and reenergize general internal medicine," the authors write. "Our field must adapt to a new world of consumerism, rising public expectations, widespread information dissemination, and contradictory pressures to hold down costs at a time when the demand for services is increasing because more people survive to old age with chronic disease."

I had the opportunity to read and comment on this report during its construction. Like any such report I can find areas which I dislike. On balance though, SGIM has taken an important initiative to address the important question of how to reinvigorate general internal medicine.

A careful reading will reveal many issues that we discuss in this blog. I always try to take such reports in context of the old Southern saying: "If it ain't broke, don't fix it!"

Well, generalist care is broken, and thus requires remedies. I certainly hope that this report focuses the debate. We need a healthy discussion to develop more functional solutions to generalism.

Hold That Stretch: Warm-Up Is Challenged

Now a major study is stirring renewed discussion about when stretching is and is not beneficial.

The study, a review of six decades of research by the Centers for Disease Control and Prevention, found that stretching does little to prevent injury during exercise when done outside of a warm-up. In some cases, the increased flexibility that stretching promotes may actually impede performance.

The researchers analyzed 361 scientific articles on stretching published since 1946. The findings, in the March issue of Medicine and Science in Sports and Exercise, suggest that athletes who devote pre-exercise time to stretching may be better served with a warm-up that prepares the body for activity and regular exercises that build strength and balance.

"The idea of loosening your joints up and muscle stretching makes sense, but the problem is that it really hasn't been shown to prevent injury," said Dr. Stephen B. Thacker, director of the epidemiology program office at the C.D.C. and an author of the study. "If you put on your sweats and simply start stretching, your muscles are not necessarily warmed up."

Warming up, which typically means raising the body temperature enough to send the blood flowing through the muscles, requires more intense activity than stretching.

"For your muscles to function at optimal capability, they should not be too loose nor too tight," said Dr. Lisa Bartoli, an attending physician in physical medicine and rehabilitation at the Beth Israel Medical Center in Manhattan. She likened warming up the body for exercise to taking modeling clay from a refrigerator. "You warm it up and work it a little bit," she said. "And then you can stretch it."

Like many sports physicians, Dr. Bartoli tells her patients that rather than stretching before physical activity, they should do the sporting activity at 50 percent of the target intensity.

The argument against stretching does make some sense. You need not take a joint to an angle that you will not be using. Too much laxity may make injury more likely (by preventing resistance to injury).

I like the recommendation of warming up. I notice in golf that a slow warm up leads to better golf swings on the course. I notice that prior to my weight lifting sessions, a moderate aerobic activity of 10-15 minutes helps me get ready for action.

Iowa governor might not sign tort reform bill

Iowa physicians cleared two of the three hurdles needed to enact a $250,000 cap on noneconomic damages awarded in medical malpractice lawsuits. But it looks as if the third obstacle -- the governor's signature -- will be a stumbling block.

After failing to pass tort reform by one vote in early April, the Iowa Senate April 12 voted 27-21 to pass a bill that would cap the amount injured patients could receive for pain and suffering. The House already had passed the measure.

At press time, it was a long shot that Iowa Gov. Tom Vilsack would sign the bill into law.

" The governor is a past president of the trial lawyers association ," said Iowa Medical Society President Tom Evans, MD. "We knew that going in, but we are hopeful it will be signed." Dr. Evans said Iowa doctors need the relief.

Hmmmm

I like this case a great deal. Read it carefully, and see how quickly you can make the diagnosis. Tunnel Vision, Cramped Hands, Nausea