Not All Obese People Die From Fatness. Well, Duh

Aside

Most of us know how inaccurate the BMI is as a measure of fat & health. A 16-year prospective study just released shows that obesity alone does not determine mortality down the road.The study followed 29,533 volunteers from the Cooper Clinic in Dallas over an average of 16.2 years; 6,224 were considered obese; the obese folks were categorized into a 4 point classification system based on fatness-related illnesses – Edmonton Obesity Staging System (EOSS) levels 0-3.

One of the things I did in my former life was to critique scientific articles. I won’t do that in detail here but will point out a few limitations and summarize. Plus, I encourage you to read the results in the abstract plus look at Table 1 to see the EOSS classification system of health that they used rather than BMI and Table 2 to see the characteristics of the participants.

Bottom line: the more obesity-related diseases at the start (for example, diabetes, heart disease, hypertension, sleep apnea, limitations in daily activities, even mental health issues), the higher risk of mortality over follow-up in  EOSS groups 2 & 3. Those in the EOSS classes 0 or 1 actually had lower risk for heart deaths. All EOSS categories had higher risk of cancer. (See Figure 1 from the article below for a picture of risk of death at the end of the study.)

The participants were highly educated, White men (sigh), which means this is not representative of most of us. Not all participants were available for follow-up over the entire study, and the length of time the participants were followed varied by group. (For example the normal weight people were followed for an average of 17.6 years, EOSS 0 and 1 for 18.4, EOSS 2 10.2, and EOSS 3 11.9) I don’t see that the authors attempted to account for this statistically. (But I didn’t read it that closely in my attempt to get this on the blog quickly.) Weight or fat measure was not analyzed over time, so fluctuations could have occurred differentially among the groups.

This doesn’t mean stay fat. This lends credence to the saying, “fat and fit” (If you are a wealthy, educated White male living in Texas…) But the cancer risk is hard to ignore. More importantly it provides a measure for other studies to use rather than BMI for measuring risk in fat folks. Also, if I were a practicing doc, I would start incorporating this scale to assess risk and advise patients. (Because BMI sucks so badly.)

A final caveat. Although this study shows increased risk of death among those with more fat-related (my words) conditions, it does not prove that treatment of fatness or the related conditions will decrease the risk of dying or dying from cancer or heart disease. This study does not address that question. But it is always tempting to extrapolate…

HR=hazard ratio. How much more at risk than the normal weight group. NW=normal weight. CVD=cardiovascular disease

I Scream

This is unofficial rant day for da blog. So I’ll make these kinda brief and to the point:

Another plateau. After 565 days, one would think I would be used to these. My devout adherence to <1200 calories/day plus no sugar/starch/grains is my own body’s proof that calories in/calories out math does not apply to weight as measured on a scale.

My in-laws continue to bring ice cream into the house. Finally told clinically crazy mother-in-law (MIL) that putting ice cream in our freezer is like giving whiskey to an alcoholic. Blank stare.

They removed “my” chair from the living area to put a chair MIL bought for herself. Now I’m beginning to feel more than a little displaced but have found a source of firewood for our cool desert evenings…invasive inlawsIt’s too darn hot! I either have to walk at 6 am or at dusk now, which is when rattlesnakes are most active on the trails. Lovely. Maybe spring will return for a few more days before I have to walk elsewhere.

Why can’t all clothes be sized the same? I leapt for joy when apparently dropping 2 sizes only to find that in another store I was a size larger. So, add sizing to the scale as a bad measure of fat loss. The tape measure is best if you can’t measure your actual fat stores.

A grocery store clerk turned down my ID when paying with a credit card because I looked nothing like the picture. Oh wait, that’s maybe a good thing, except now I probably need to go get a new driver’s license.

Finally – In an attempt to cut spending, Congress wants to repeal Medicare (for those currently born after 1955) and replace it with private health insurance. Yes, those of you who have paid in will lose out. The most efficient health insurance program for our nation’s elderly will be handed over to the most inefficient industry on earth. How about going after some revenue from the big corporations that pay ZERO taxes? (Apologies, this comes from my concern over health care for seniors and the poor. I don’t give a rip which political party is proposing such idiocy.)

Now off for a brisk walk along a local park route.

Have a great weekend! (I wish cause they will be gone after next weekend.)

Lady Killer

February is always “Heart Month” as designated by the American Heart Association. This year there is a special emphasis on women and heart disease. None too soon as heart disease is the number 1 killer of adult women, symptoms of heart attacks in women are different from men and are often misdiagnosed, and for years women were intentionally left out of medical research investigating heart disease – yes, the very same #1 killer of women.

Today bloggers are sharing their sites with heart-health information and links to help fight this killer of women because many risk factors are preventable. The strongest, preventable risk factor for heart attacks in women in smoking. You might not smoke, but over 20% of American women (highly dependent on ethnicity) still smoke. Between 10-15% of pregnant women smoke.

Quitting is hard, very hard. Everyone knows smoking is bad – so why does anyone continue to smoke? I am not an apologist for smokers. I don’t smoke, but I worked with smokers in practice and in public health & medical research (non-pharmaceutical) to develop methods to help those who wanted to quit. Nicotine is highly addictive. Women who smoke often are surrounded by others who smoke, and the pressure to continue smoking can be tremendous. Women especially are concerned about weight gain if they quit. Many girls and young women start smoking in attempts to help control their weight. Smoking is used as a stress reducer. (Did you know that nicotine has anti-depressant properties?) Although smoking is being seen at higher levels on college campuses, women who smoke tend to have lower educational levels (they are NOT less smart) and probably are less likely to read blogs or even be on the Internet.

So, why am I blathering on about smoking to those of you who are probably among the most health conscious? Tobacco is a killer of women. You probably know women who smoke or use tobacco products. You also have faced your own battles with food or struggled to exercise and thus have a good understanding of how hard it is to change behaviors. If you have a chance to reach out to a smoker, do so in productive ways. Sure the best method to quit  is medication combined with brief counseling (by a doc, pharmacist, nurse, or phone advice). BUT, many people are not ready to quit. Telling them to go buy some Nicorette just turns them off. They know they shouldn’t smoke – just like we know that we should eat better and keep our weight in a healthy range. They need motivation and confidence. How can you help? Here is a list of excellent tips to help you help your friends and family members stop smoking.  These are very familiar to us who are trying to change our relationship with food: respect the smoker/quitter while letting her know you are there to help, don’t nag, help them reduce stress, celebrate small steps, don’t offer advice but ask how you can help with whatever plan they are using, keep you own home smoke free, don’t nag (did I mention that?), understand that most quitters take 6-10 serious attempts before becoming successful. You can suggest this site specifically geared toward women, even those not yet ready to quit. This motivational approach is evidence-based and works.

For those of you who have quit, I applaud you for stopping a substance that is as addicting as heroin and causes more damage to pregnancies than cocaine.

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Statins and Me

What can I say. Statins are bad drugs for my body. They do have a role in people at risk for cardiovascular disease. HOWEVER, these drugs are not without side effects (beside monetary), and I have been subjected to the very common but almost disabling muscle pain that can occur with any statin medication.

First let me say that my cholesterol and LDL have climbed as my weight has dropped (more in a few sentences). About 8 years ago after a cardiac cath for chest pain and an abnormal ECG, I was diagnosed with diastolic dysfunction (left-sided heart failure probably from being too fat), but my coronary arteries were perfectly clean. My cholesterol at the time was 200 with low HDL (the good kind), borderline high LDL, and the only risk factor for heart disease was my father’s history of MI at a young age (56). I was put on a medication that rhymes with lipitor, and about 2 weeks later experienced extreme muscle weakness in my legs. That was stopped and another statin was started. I tolerated that med well but stopped it after I started losing weight.

Enter a new doc in a new town and another cholesterol check. I was now post-menopausal, adding to increased risk of coronary artery disease, my cholesterol had climbed above 200, but my HDL was surprisingly higher, and my LDL was much higher. My weight at this time was 305 – YIKES. I was started on a medicine that rhymes with crestor – a very low dose 3 times a week. As my weight plummeted, I saw a new cardiologist who declared me free of my former diastolic dysfunction and didn’t seem too upset about my cholesterol.

Next visit to my primary care doc, she suggested increasing the dose of the statin to every day. Enter the debilitating hip pain in late October, so bad that I couldn’t sleep some nights. Figuring this was a side effect of the medication, I quit the drug but continued to walk around like a little old lady, even unable to walk around the block, barely able to grocery shop. Repeating my cholesterol showed that the LDL continued to climb (despite my excellent diet!) as did the total cholesterol. Off to a rheumatologist – a wonderful woman who took time to listen to my sob story, praise my weight loss, and do extensive history taking (family history full of autoimmune disease), physical exam, and lab work-up. Thankfully everything was normal. So, statin side-effect this is. She suggested Coenzyme Q10, which is not cheap if you buy the good stuff. One week later I am feeling better! Yay, tolerating a one-mile now.

What I have learned: Statins should be reserved for those at high risk of heart disease with cholesterol problems. Not all LDL is created equal. Regular lipid profiles only calculate LDL, they do not differentiate between dangerous (small) LDL particles and the not dangerous (“fluffy”) particles. Good LDL can increase as one’s diet improves. There is much to read on this. I suggest the Heart Scan Blog linked on my page for more info and references. I’m still learning myself. I have changed to a low carb, no wheat, no grain, no sugar diet. And, I high recommend Gary Taubes, Why We Get Fat: And What to Do About It to debunk many nutritional myths about calories in/calories out paradigm.

More in later posts. This is already too long.

cholesterol cartoon

Heck Of A Week

Staying “on plan” while having my father visit, well, I knew that would be difficult. He enjoys eating, but as with many seniors, will taste a few bites of anything then quit. The saga of his mal-treated back fractures, surgery, and recent death of my mother have left him 50 pounds lighter and holding. We planned for his love of snacking and food by having a special place in the pantry his treats, cereal, etc. But then this week hit… (If you don’t want to read the fine print skip to the bottom for summary.)

It’s downright scary when your father knocks on your bedroom door at 2 a.m. and says, “Honey, something’s not right.” That was an understatement. He was bleeding rapidly from a stomach ulcer and barely able to remain conscious. Let me say now that having 2 doctors in the house and going to one of those physician’s hospital for emergency treatment doesn’t guarantee great medical care. I won’t rag on about the 12-hour wait in the ER for a hospital bed; the admitting doctor whose physical consisted of listening to Dad’s chest; the nurses who were eager to ignore him once he was “admitted” but still in the ER for hours; the lack of attention to his obvious hemodynamic instability (blood loss); waiting for almost 24 hours for a GI doc to see him; the admitting doctor for some fucking reason not ordering his routine medications correctly even though they were written correctly by the ER doc; waiting too long to transfuse him.

Side rant note: Think we don’t need an overhaul of our medical care system? This is a man with insurance, a devastating acute illness, and 2 physicians hovering at his bedside and HE STILL COULD NOT GET EFFICIENT, QUALITY CARE AT A PRIVATE HOSPITAL.

Back to the week from hell. Three days later, Dad is stabilized, ulcer has stopped bleeding, and we whisk him out the grasp of the hospital. (Meanwhile, Sue has dipped into Dad’s stash of snacks, and I indulge in the M&M spree.) He sees my primary care doc for follow-up and guess what? His Medicare policy will not pay for any out-of-state care unless it is in an ER or hospital – no excuses, no matter how far up the chain I went, that was their answer, “sorry, he needs to come back to Texas to see a doctor.” So, I pay cash, and we still have to see the GI doc in follow-up ’cause he ain’t going home yet. What do people do who don’t have “disposable income” to pay for medical care – that’s right they don’t get care until things get awful or maybe even die. Did you know the highest percentage of inappropriate ER visits are from those who have health insurance? Hmm, wonder why…

Back to the saga. Dad continues to feel better and wants to go shopping for some clothes. We had promised to make a big deal of out his 60th wedding anniversary 10/16 (Mom has been dead for less than 3 months), and he wanted to look cool. I’m yapping away while picking out shirts only to realize he is another aisle over sobbing – huge gulping sobs that he never did during the funeral. With my arms around my thin, stooped Dad who suddenly seems every bit of his 83 years, he whispers that he saw something he and mom had bought together. Funny, my tears about Mom hit most when shopping – that woman loved to buy clothes!

Before dinner, Dad even gives himself a haircut (because I had been ragging him) and with a little touch-up from clippers, damn, he looks like Patrick Stewart or maybe even Bruce Willis. All duded up, we take him out for a 3-hour, 5-course dinner with wine pairings, which was a new experience for him. I had planned for this meal since his arrival and planned to thoroughly enjoy every bite. I passed off the little scoop of ginger-pineapple ice cream topping my dessert because that is the one food I have sworn never to touch. The meal was wonderful. We talked fondly about Mom, and he softly sang their favorite song.

With a song in my heart
I behold your adorable face.
Just a song at the start
but it soon is a hymn to your grace.
When the music swells
I’m touching your hand
It tells me you’re standing near, and ..
At the sound of your voice
heaven opens its portals to me.
Can I help but rejoice
that a song such as ours came to be?
But I always knew
I would live life through
with a song in my heart for you.

Summary for TL;DR (too long; didn’t read):                                                                             Dad visits, I prepare to stay on plan. Dad tries to die from a bleeding ulcer. Hospital care sucks, as usual. Medical insurance sucks, as usual. Jan gobbles M&M’s. Dad and Jan go shopping. Dad breaks down while shopping. Jan holds Dad while he sobs, and she tries to remain strong. Dad, Jan, and Sue do fine dining for Dad’s 60th anniversary, just 3 months after Mom’s death. Jan enjoys the dinner but won’t eat ice cream. Dad serenades them. Jan cries while blogging.

You Gotta Have (a normal) Heart

… to finally stop taking a medication that ruins your stamina, slows your metabolism, makes you prone to depression, and lowers your sex drive. After 7 years of paying outrageous prices for a brand name beta-blocker because the generic was never effective, my heart function has returned to normal but not because of the medication.

Last year when I saw the cardiologist, and weighed 300 pounds, my echocardiogram still showed some abnormalities related to the functioning of my left ventricle. (In 2003, I was diagnosed with diastolic dysfunction that was causing intermittent heart failure.)

This week I visited the cardiologist to discuss getting off of the beta-blocker. She hemmed and hawed (do non-Texans ever write those words?) and agreed that with weight loss I was probably “OK” to try getting off the med. But first, another echocardiogram. The echo itself is just like a pregnancy ultrasound, only on your chest and not nearly as fun or easy to view. My visit with the sonographer was delightful because she, too, takes beta-blockers and hates the side effects, but we really bonded when she shared her boob job story. No, not that kind of boob job. After she lost 50 pounds, her breasts remained huge, hung to her waist, and caused neck pain from trying to keep them cinched up with a bra (sounds painfully familiar). We discussed the breast reduction and tacking procedure, recovery, costs, surgeon; it was a fun time. More fun was her discussing the changes in my echo. Totally normal.  Funner Better yet was the surprise in the cardiologist’s voice when she called to say that my echo was “amazingly normal”.  Funnest Most rewarding was the positive reinforcement for all of the hard work paying off in yet another tangible way. Plus, all the great feedback that I received from the doc and her staff about my weight loss.

I am weaning off of the beta-blocker because it is not a med that can be stopped abruptly. After a few days my resting heart rate is out of the 50’s and into the 70’s, but I do have the heebie-jeebies – a sense of heightened body arousal (and not the good kind) as my nerves (literally) readjust to less medication.

Now that this nasty drug is going away, my foot problem has been evaluated by a podiatrist, and I have new work-out shoes, there are no other legitimate reasons to hold back on exercising. Well, my back does ache a little… JUST KIDDING!

My Stamina Sucks & And Other Technical Blatherings

I simply cannot be this unfit (not as in the she is “unfit to be a mother” category). My endurance compared to little, old (emphasis on both) women and men is shameful. 85 pounds lighter should have me breezing through my treadmill/bike routine. Nope. Instead of just breaking the mirrored walls around me, I decided to analyze why the heck I am performing at lower levels than my personal trainer thinks I should be, based on her fitness assessment. Finally, it hit – the damn beta blocker that I have been taking for about 7 years is the most likely culprit.

Back when I was probably weighing more than 300 pounds, I kept having “asthma” attacks, which my primary care doc thought was a strange resurrection of a childhood condition. After a particularly devastating event during a viral infection when my lips turned blue (even my anesthesiologist-sweetie was horrified) followed by a few episodes of chest pain, I referred myself to a cardiologist. I failed an exercise stress test – gasping for air (turns out I had gone in to pulmonary edema and had acute heart failure) my ECG looked as if I had coronary artery disease. Not asthma at all! Given my family history and weight, not a big surprise but scary. (Have I mentioned docs are weenies when it comes to their own health?)

Next up, a cardiac catheterization. I was relieved to find that my coronary arteries were “clean” but was diagnosed with a condition called “diastolic dysfunction” that could cause acute heart failure during heavy exertion or stress, such as with the the viral infection. This type of heart failure is often seen in women of a certain age (cough), and is associated with high blood pressure (not me), diabetes (nope), coronary artery disease (nuh-uh), and diseases of the heart muscle (no). Obesity can certainly be a contributing factor. My inquiring mind and the outstanding cardiologist reviewed all the available research on appropriate treatment. Given that this is primarily a condition of women, not surprisingly there were few quality studies to guide the choice of medications (do not get me started on the bias in medical research against women as participants in studies). We seriously discussed weight loss surgery, which I dismissed after meeting with the head of the WLS program. A beta-blocker was chosen, and my symptoms improved remarkably with about a 30-pound weight loss and the medication. Beta-blockers are also good for my migraines and an anxiety disorder (sigh, starting to reveal more than anticipated), so the drug has been a good one for me.

Fast forward to today. Not only can I not get my heart rate above 80 with vigorous exercise (read that as sweating profusely and a beet-red face), but I poop out waaay too early. The last time I saw a cardiologist was about 1 year ago. My diastolic dysfunction had completely resolved even with minimal weight loss, and she suggested that I could try to slowly wean off the medication, as one cannot stop beta-blockers abruptly. Given that I get other benefits from the drug, I was not keen on this. The obvious solution right now – march myself back to Dr. Bates (who is a fitness fiend), get kudos for my weight loss, and discuss the pros and cons of quitting and continuing my good ol’ beta-blocker. Gah, I hate going to docs, but she is too cool, her office is a fun place to visit, and it’s always fun having people react (positively) to my new body. Appointment made for 9/20. Guess I’ll just have to modify my exercise expectations until then.

cartoon - My doctor tolde me to avoid any unndecessary stress, so I didn't open his bill

Headed Home & Random Updates

Twelve days later, and I am returning home to my “Pack” of critters and my spousal-equivalent (what a romantic term…). In the almost 20 years that we have been together, I had never been away from my family of choice for more than 1 week . Despite all of my concerns over being homesick, leaving the safety of my food controls, and entering into the heart of my past, the time flew by.

I intentionally took my professional physician-hood with me – both as a self-protection against the illness surrounding me and to deal with my parents’ doctors (something I had never done as I am loath to play family doctor with my relatives). This worked surprisingly well, and I had warned my family ahead of time of my intentions. Using my jovial and best Texas drawl (doesn’t take long to lope back in to it), I would introduce myself, “Hello, I’m Dr. X, please call me Jan.” I met wonderful nurses, food service personnel, respiratory therapists, and hospital aides during my father’s inpatient stay. He loved the neurosurgery or surgery resident who visited with him every morning. The attending neurosurgeon (see post and comments below) only saw him immediately post-op and right before discharge – just as well. There is a reason the medical school involved graduates the second FEWEST number of primary care doctors out of the 141 schools in the USA.

Comments from family and friends who have had quality experiences with surgeons (including me – thank you again, Dr. Katie Artz) have been swirling rapidly across my phone and e-mail since the post about my father’s surgery. Let me reiterate that many surgeons are wonderful physicians – there just aren’t enough of them, and there are not enough excuses for poor bedside manner among physicians of ANY specialty.

My mother’s cardiologist is a good clinician and excellent communicator, though he looks younger than our puppy. Her primary care doc is amazingly aware of her myriad conditions and addresses most, especially when prompted – it’s good for those visits to have another face in the room to slow him down. I’m glad that I no longer practice primary care – the office setting remains overwhelming; patients management is becoming more complex; needless paperwork continues to grow; and insurance companies are more intrusive than ever. (I had another “lovely” encounter with the folks’ Medicare HMO that ended up with much threatening on my part and finally some service on their’s.)

Spending time with my sister who does the primary care-taking of our parents was a joy and a privilege to be able to give her some respite. The few hours that I was able to be with my hard working bro and his wife (my 3rd seester – our family’s spelling) was an absolute delight and far too short. The family has many tough decisions ahead as my father attempts to recover back to baseline, and my mom probably faces her 3rd heart valve surgery for severe congestive heart failure.

Eating was mostly OK. I experimented with sweets and diet drinks – blech. I pined to be able to walk but self-imposed obligations and ungodly heat/humidity kept me from exercising. I cannot wait to get back on track to “clean” eating in a structured format. Oh, I did buy a swimsuit – my sagging skin would put me in a freak show, but HEY! I have curves again!

Update on Miss Mattie: Her ocular tumor was a melanocytoma meaning almost no risk of spread. We are all most grateful, wondering if something less invasive could have been done (radiation?), but she is learning to bump along with one eye and ominous wink.

I will get back to posting more sanely and also honor Karen@Waisting Times‘s blog award when I get off the iPad. Learned much about my history from my dad…

Post-op Day 1

Who could have imagined that my biggest source of frustration so far would emanate from… other physicians. That is, if surgeons are really physicians and not just technicians.

A physician is respectful of her/his patients – does not make jokes about their age, refer to them as ancient, nor sneer when speaking to family members. A physician does not ignore standards of care when managing postoperative pain – the very pain she/he inflicted. In fact a physician cares about the well-being of his patient beyond the organ or disease or injury he is trying to treat; listens to input of others involved in the patient’s care (nurses, therapists, even lowly family members who know the patient’s baseline health care status best); and takes time to conduct more than cursory examination of the wound site (perhaps then he could recognize the signs of significant blood loss).

Yes, it is a rare surgeon who also is a physician. Fortunately for Dad, my not-so-subtle involvement in his care has brought a hospitalist to his bedside so I can sleep tonight without worrying that he is suffering needlessly or at risk of complications because a real physician is not available 24 hours a day during his recovery.

Closing rant summary:

A surgeon at a top ranking medical facility is not necessarily a good physician.
Families must be ever vigilant in their loved ones’ (and their own) medical care.
No amount of health care reform will make a good physician out of someone with a medical degree.