Do you like goldfish? The Chinese kept and studied carp and goldfish more than one thousand years ago. Here are some beautiful goldfish images. Let’s enjoy it. Here is a video for top 10 Goldfish Breeds!
Top 10 Chinese beautiful Goldfish
Best Tips for Gmail Webiste
Many people like using gmail. But you might also have some basic questions about gmail website. So I decide to write this post. Let’s begin. What is gmail website? Gmail is a free, advertising-supported email service provided by Google. Gmail website link: http://www.gmail.com http://gmail.google.com Gmail Website Video Tutorial If you have any problem, you can search by […]
How to make money online as a teen
There are many ways to make money online. Online Earning is easy. Even a child can do it. Most adults who are making money online would disagreen this statement. For them, making money online is not a easy thing. They need hundreds of hours of study and write, and even this will no guarantee success […]
Google blogger help
To use Blogger, make sure you have a compatible browser and operating system: Browsers: Google Chrome Safari version 4 and up Firefox version 3.6 and up Microsoft Edge Internet Explorer version 10 or 11. If you experience issues, try another browser or turn off Compatibility View. Operating systems Windows Linux (Ubuntu) Mac OSX For Blogger […]
Ebook Torrent Sites
Are you looking for free ebooks? You want to download free ebooks. If the answer is ‘yes’, you come to the right place. In this post, I will share some Ebook Torrent Sites. Every thing is free. 1.Project Gutenberg offers over 39,000 free eBooks compatible with several devices. Download them or read them online. 2.Goodreads the […]
Top 10 Best Blogger widgets and Plugins 2016
At Google, blogger gadgets are simple HTML and JavaScript applications that can be embedded in web pages and other apps, including Blogger. When you build a gadget for Blogger, it becomes available to millions of active bloggers. Just submit your gadget to us, and it will surface in Blogger.com where users can easily browse, configure, […]
Top 10 Chinese Kung Fu movies
Do you like Chinese Kung Fu? Here is a list of top 10 Chinese Kung Fu movies. No.1 The Way of the Dragon 《猛龙过江》 No. 2 Fist of Legend《精武英雄》 No. 3 Iron Monkey《铁马骝》 No. 4 Shaolin Temple《少林寺》 No. 5 Jet Li’s Fearless《霍元甲》 No. 6 S.P.L.《杀破狼》 No. 7 Martial Arts of Shaolin《南北少林》 No. 8 Tiger Cage […]
Useful Blogger API Directory
Do you know about blogger api? In this post, I will share some useful blogger api on the web. You can use it. Here is a list. Blogger API The Blogger Data API allows client applications to view and update Blogger content in the form of Google Data API feeds. Your client application can use the […]
How to choose a best domain name
A good domain name is crucial to the survival of your blog no matter what type of site you want to build. So how to choose a best domain name? In this post, we will talk about it. Five Tips for Choosing a Domain Name 1.unique name If you are marketing your blog or website, ideally […]
Top 15 best Torrent Sites 2016
Are you looking for a torrent site? If the answer is ‘yes’, you come to the right place. Here are the top 15 Most Popular Torrent Sites 2016. 1 | ThePirateBay 2 | KickAssTorrents 3 | Torrentz 4 | ExtraTorrent 5 | YifyTorrents 6 | BitSnoop 7 | IsoHunt 8 | SumoTorrent 9 | TorrentDownloads […]
Top 10 Universities in China 2016
Which University is best in China? Do you know? Today, I will tell you top 10 Universities in China 2016. Tsinghua University Peking University Fudan University Shanghai Jiao Tong University University of Science and Technology of China Nanjing University Beijing Normal University Zhejiang University Wuhan University,We have packages of insurance live leads to fit any budget. Read more. page contents TestimonialsB2C Insurance Leads has automated my lead streams to my agents.I have had a 50% increase in the number of applications my agents have written due to these live leads. We owe that to B2C Insurance Leads.
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Obamacare Fines: How to Escape a Hefty Penalty If You Really Can’t Buy Insurance
Already, the fear-mongers are sounding the alarm: If you don't purchase exactly the type of health insurance that the Affordable Care Act (ACA) requires, come tax-time the IRS will slap you with a stiff penalty.
As I explain in the post below, the ACA mandates that if you're not already covered, you must buy insurance that includes "essential benefits" such as hospitalization, maternity and newborn care, and mental health services. Ignore the mandate this year, and you will be fined when you file your taxes next year.
How Much Would You Owe?
If you opt out of purchasing insurance that covers you and your family in 2015, the penalty will equal Either:
1 percent of your income over your “filing threshold” (about $10,000 for an individual $20,000 for a couple) OR
a flat dollar amount, of $95 per uncovered adult and $47.50 per child, up to a maximum of $285, whichever Is greater.
“Whichever is greater” means that wealthier taxpayers will be required to pay 1% of their income, and as a result can easily wind up owing significantly more than $285. This doesn’t mean that millionaires would be fined tens of thousands of dollars. An affluent family’s penalty also is capped, at the average cost of bronze plans sold in state Exchanges nationwide.
In 2014, nationwide, the average bronze plan premium was $2,448 per individual and $12,240 for a family with five or more. This year, across the nation, average premiums were slightly higher, so a family of five earning more than roughly $145,000 would have to fork over a little more than $12,240.
If This Sounds Complicated, Turbo-Tax Makes it Simple
If, at this point, your eyes are glazing over, the good news is that you can calculate your penalty, quickly and easily, on Turbotax’s online calculator. Just type in your income, zip code, and the size of your household, and in about three minutes, TurboTax will tell you the size of your fine—and, most importantly, whether you might qualify for an exemption to the penalty.
How You Might Escape the Fine
The chances that the IRS will fine you are slim. What the fear-mongers rarely mention is that, thanks to the many exemptions built into the law, only about 10 percent of the uninsured will owe a penalty. The Congressional Budget Office (CBO) estimates that in 2016, just 4 million uninsured Americans will face fines, while 26 million will qualify for waivers.
Recently, I wrote a piece for Consumer Reports listing some of the most common exemptions:
if the lowest-priced coverage available to you, even after applying a government subsidy, would cost more than 8 percent of your household's income, the fine is waived;
–if you earn less than $10,150 (or $20,300 for a married couple) and so are not required to file income taxes you owe no fine and don’t even have to apply for a wavier;
if you were uninsured for less than 3 consecutive months, you will not be fined.
(As I explain in the post below, this means that if you sign up for 2015 coverage by February 15 you will be insured as of March 1, and will not owe a penalty for 2015.)
Little Known “Hardship Exemptions”
On the Consumer Reports website, I also point out that late in 2013, the government added 14 new waivers
for people who have experienced personal hardships such as domestic violence, substantial property damage from a fire or flood, from a fire or flood, the death of a close relative, a utility cut-off, or bankruptcy.
Perhaps most importantly, the government is offering a one-year waiver to people who don't qualify for Medicaid because they live in a state that has refused to expand the program under ACA rules.
To learn more about the hardship exemptions, how to apply for any exemption, and information on how you might escape the penalty, but still buy catastrophic insurance, read the rest of the post on Consumer Reports.org.
As I explain in the post below, the ACA mandates that if you're not already covered, you must buy insurance that includes "essential benefits" such as hospitalization, maternity and newborn care, and mental health services. Ignore the mandate this year, and you will be fined when you file your taxes next year.
How Much Would You Owe?
If you opt out of purchasing insurance that covers you and your family in 2015, the penalty will equal Either:
1 percent of your income over your “filing threshold” (about $10,000 for an individual $20,000 for a couple) OR
a flat dollar amount, of $95 per uncovered adult and $47.50 per child, up to a maximum of $285, whichever Is greater.
“Whichever is greater” means that wealthier taxpayers will be required to pay 1% of their income, and as a result can easily wind up owing significantly more than $285. This doesn’t mean that millionaires would be fined tens of thousands of dollars. An affluent family’s penalty also is capped, at the average cost of bronze plans sold in state Exchanges nationwide.
In 2014, nationwide, the average bronze plan premium was $2,448 per individual and $12,240 for a family with five or more. This year, across the nation, average premiums were slightly higher, so a family of five earning more than roughly $145,000 would have to fork over a little more than $12,240.
If This Sounds Complicated, Turbo-Tax Makes it Simple
If, at this point, your eyes are glazing over, the good news is that you can calculate your penalty, quickly and easily, on Turbotax’s online calculator. Just type in your income, zip code, and the size of your household, and in about three minutes, TurboTax will tell you the size of your fine—and, most importantly, whether you might qualify for an exemption to the penalty.
How You Might Escape the Fine
The chances that the IRS will fine you are slim. What the fear-mongers rarely mention is that, thanks to the many exemptions built into the law, only about 10 percent of the uninsured will owe a penalty. The Congressional Budget Office (CBO) estimates that in 2016, just 4 million uninsured Americans will face fines, while 26 million will qualify for waivers.
Recently, I wrote a piece for Consumer Reports listing some of the most common exemptions:
if the lowest-priced coverage available to you, even after applying a government subsidy, would cost more than 8 percent of your household's income, the fine is waived;
–if you earn less than $10,150 (or $20,300 for a married couple) and so are not required to file income taxes you owe no fine and don’t even have to apply for a wavier;
if you were uninsured for less than 3 consecutive months, you will not be fined.
(As I explain in the post below, this means that if you sign up for 2015 coverage by February 15 you will be insured as of March 1, and will not owe a penalty for 2015.)
Little Known “Hardship Exemptions”
On the Consumer Reports website, I also point out that late in 2013, the government added 14 new waivers
for people who have experienced personal hardships such as domestic violence, substantial property damage from a fire or flood, from a fire or flood, the death of a close relative, a utility cut-off, or bankruptcy.
Perhaps most importantly, the government is offering a one-year waiver to people who don't qualify for Medicaid because they live in a state that has refused to expand the program under ACA rules.
To learn more about the hardship exemptions, how to apply for any exemption, and information on how you might escape the penalty, but still buy catastrophic insurance, read the rest of the post on Consumer Reports.org.
Look Into This Surgeon’s Face . . .
Below, a photo from:
Faith in Humanity @TheWorldStories · Feb 16
A Heart surgeon resting after a long 23-hour (successful) heart transplant. His assistant is sleeping in the corner
Clearly, he has given his all. (MM)
Faith in Humanity @TheWorldStories · Feb 16
A Heart surgeon resting after a long 23-hour (successful) heart transplant. His assistant is sleeping in the corner
Clearly, he has given his all. (MM)
Losing Weight—What the Experts Are Reluctant to Tell You – Part 1
Have you ever shed 15 or 25 pounds and, then, over the next year or so, put it all back on? Usually, we blame ourselves.
But, as I reported on HealthBeat in 2008, physicians who treat obese and overweight patients know that only about 5% of us are able to lose weight and keep it off—even in highly controlled experimental settings where patients diet and exercise under a doctors' supervision. Over two years, 95% of us will put the pounds back on, and in some cases, add more.
A National Institutes of Health (NIH), working group study published in the January 2015 issue of the journal Obesity, confirms that: "Despite advancements in our understanding of obesity, weight regain after weight loss remains the most substantial problem in obesity treatment – with both the body and the mind conspiring against individual efforts to maintain weight loss."
What Randomized Controlled Trials Reveal
University of Minnesota Psychologist Traci Mann has spent 20 years running an eating lab and, based on her experience, she reports: "Long-term weight loss happens only to the smallest minority of people."
Indeed, when she and five other researchers analyzed outcomes for patients in randomized trails where one group dieted, and the other group did not, the studies showed that, after two years, the average patient on a calorie restricted regimen had lost only one kilogram, or about two pounds, while one third to two thirds of dieters had actually regained more weight than they lost. (In many of these trials, the patients not only cut calories, but also exercised.)
What about folks who combine intensive lifestyle changes with drugs designed to help us lose weight? "Studies show that patients on drug therapy lose around 10 percent of their excess weight," but "the weight loss plateaus after six to eight months," UCSF's Medical Center reports. "As patients stop taking the medication, weight gain usually occurs."
Low-Carb vs. Low-Fat Diets
Does it matter which diets you try?
At one time, most physicians were convinced that fatty foods led to obesity, and a low-fat diet offered the best route to becoming svelte. But in recent years, a growing number of doctors and health advocates have begun to argue that increased consumption of sugar and refined carbohydrates is the most likely explanation for our obesity epidemic.
Last summer WIRED published an impressive in-depth review of what we do and do not know about whether certain foods will make us fat.
The story notes that that in 2009, "Robert Lustig, a pediatric endocrinologist, rose to national fame after a 2009 lecture in which he called sugar 'poison' went viral on YouTube.
Meanwhile, newer science has undermined the consensus that fat is all that bad for you. A recent meta-analysis published in the Annals of Internal Medicine found no clear evidence that eating saturated fat contributes to cardiovascular disease."
What about carbs? "In trials, carbohydrate restricted diets almost invariably show significantly better short term weight loss," WIRED reported, but "over time, the differences converge towards non-significance." In other words, the available evidence suggests that over the long term, both low-fat and low-carb diets fail.
Why Is Losing Weight, and Keeping it Off, So Difficult?
We don't know.
The cruel truth is that obesity is an incredibly complicated disease. Physicians and scientists who specialize in studying it acknowledge that medical science still has not yet sliced through the tangle of genetic, metabolic, social, psychological and environmental factors that cause most of us to regain whatever weight we lose.
The conventional wisdom tells us that shedding fat is simple: just eat fewer calories than you burn. In other words, put less food in your mouth, and exercise more. As the post above reveals (URL) many family doctors and GP's still believe this. After all it was only two years ago that the American Medical Association acknowledged that obesity is a "disease."
(If they didn’t think obesity was a disease, what did they think it was? I’m afraid that, like many in our culture, deep down, they viewed obesity as a sign of sin. Actually, two sins: “gluttony” and “sloth.” My guess it that this is true of doctors who were, themselves, overweight– and felt guilty about it.)
2008—What We Knew Then
Seven years ago, when I first wrote about a PBS documentary titled "Fat: What the Experts Don't Tell You" I learned that, for most people, the received wisdom doesn't work. Eating less and moving more does not lead to long-term weight loss. (Let me add: I highly recommend this film. It is by turns, moving, entertaining, and eye-opening. It will tell you what most of the mainstream media may never reveal about losing weight.)
In the documentary, Harvard's Dr. Lee Kaplan, head of the Weight Reduction Program at Mass General Hospital, acknowledges that: "Obesity doesn't seem like a subtle disease. But it is. If something is off kilter by just 1 percent in your system that can lead to a 100- pound weight gain. More than 400 genes are involved in weight regulation. And that doesn't include the environmental factors."
In that 2008 post, I also quoted Arthur Frank, medical director of the George Washington University Weight Management Program: "People think that dieting is 'a matter of choice.'" In other words, with a little will power, you can simply choose to eat less. But in fact, losing weight requires overcoming powerful brain signals that are working against you.
Dr. Michael Rosenblaum, a Columbia University researcher who, at the time was working on an NIH-funded study on weight control, explains: "Obesity is the one disease where your body fights the cure. By and large, the body is programmed to help you heal." But not in this case.
If you ever have dieted you already know that, once you lose some weight, your metabolism seems to slow down, and stops burning as many calories. For all your body knows, you are stranded on a desert island, starving to death. So it tries to "save you." Some argue that this is how the human species has survived.
"We are very efficient biological machines," says University of Alberta health professor Tim Caulfield, who writes about health misconceptions. "We evolved not to lose weight. We evolved to keep on as much weight as we possibly can.”
But saying that your body fights weight loss does not shed light on the more fundamental question of how and why your metabolism slows—or why you hit a plateau—and ultimately re-gain the weight you lost.
Not everyone believes that this is all about evolution. Some argue that the obesity epidemic has more to do with what we eat today— and how compulsively we diet–See part 2 of this post, below
But, as I reported on HealthBeat in 2008, physicians who treat obese and overweight patients know that only about 5% of us are able to lose weight and keep it off—even in highly controlled experimental settings where patients diet and exercise under a doctors' supervision. Over two years, 95% of us will put the pounds back on, and in some cases, add more.
A National Institutes of Health (NIH), working group study published in the January 2015 issue of the journal Obesity, confirms that: "Despite advancements in our understanding of obesity, weight regain after weight loss remains the most substantial problem in obesity treatment – with both the body and the mind conspiring against individual efforts to maintain weight loss."
What Randomized Controlled Trials Reveal
University of Minnesota Psychologist Traci Mann has spent 20 years running an eating lab and, based on her experience, she reports: "Long-term weight loss happens only to the smallest minority of people."
Indeed, when she and five other researchers analyzed outcomes for patients in randomized trails where one group dieted, and the other group did not, the studies showed that, after two years, the average patient on a calorie restricted regimen had lost only one kilogram, or about two pounds, while one third to two thirds of dieters had actually regained more weight than they lost. (In many of these trials, the patients not only cut calories, but also exercised.)
What about folks who combine intensive lifestyle changes with drugs designed to help us lose weight? "Studies show that patients on drug therapy lose around 10 percent of their excess weight," but "the weight loss plateaus after six to eight months," UCSF's Medical Center reports. "As patients stop taking the medication, weight gain usually occurs."
Low-Carb vs. Low-Fat Diets
Does it matter which diets you try?
At one time, most physicians were convinced that fatty foods led to obesity, and a low-fat diet offered the best route to becoming svelte. But in recent years, a growing number of doctors and health advocates have begun to argue that increased consumption of sugar and refined carbohydrates is the most likely explanation for our obesity epidemic.
Last summer WIRED published an impressive in-depth review of what we do and do not know about whether certain foods will make us fat.
The story notes that that in 2009, "Robert Lustig, a pediatric endocrinologist, rose to national fame after a 2009 lecture in which he called sugar 'poison' went viral on YouTube.
Meanwhile, newer science has undermined the consensus that fat is all that bad for you. A recent meta-analysis published in the Annals of Internal Medicine found no clear evidence that eating saturated fat contributes to cardiovascular disease."
What about carbs? "In trials, carbohydrate restricted diets almost invariably show significantly better short term weight loss," WIRED reported, but "over time, the differences converge towards non-significance." In other words, the available evidence suggests that over the long term, both low-fat and low-carb diets fail.
Why Is Losing Weight, and Keeping it Off, So Difficult?
We don't know.
The cruel truth is that obesity is an incredibly complicated disease. Physicians and scientists who specialize in studying it acknowledge that medical science still has not yet sliced through the tangle of genetic, metabolic, social, psychological and environmental factors that cause most of us to regain whatever weight we lose.
The conventional wisdom tells us that shedding fat is simple: just eat fewer calories than you burn. In other words, put less food in your mouth, and exercise more. As the post above reveals (URL) many family doctors and GP's still believe this. After all it was only two years ago that the American Medical Association acknowledged that obesity is a "disease."
(If they didn’t think obesity was a disease, what did they think it was? I’m afraid that, like many in our culture, deep down, they viewed obesity as a sign of sin. Actually, two sins: “gluttony” and “sloth.” My guess it that this is true of doctors who were, themselves, overweight– and felt guilty about it.)
2008—What We Knew Then
Seven years ago, when I first wrote about a PBS documentary titled "Fat: What the Experts Don't Tell You" I learned that, for most people, the received wisdom doesn't work. Eating less and moving more does not lead to long-term weight loss. (Let me add: I highly recommend this film. It is by turns, moving, entertaining, and eye-opening. It will tell you what most of the mainstream media may never reveal about losing weight.)
In the documentary, Harvard's Dr. Lee Kaplan, head of the Weight Reduction Program at Mass General Hospital, acknowledges that: "Obesity doesn't seem like a subtle disease. But it is. If something is off kilter by just 1 percent in your system that can lead to a 100- pound weight gain. More than 400 genes are involved in weight regulation. And that doesn't include the environmental factors."
In that 2008 post, I also quoted Arthur Frank, medical director of the George Washington University Weight Management Program: "People think that dieting is 'a matter of choice.'" In other words, with a little will power, you can simply choose to eat less. But in fact, losing weight requires overcoming powerful brain signals that are working against you.
Dr. Michael Rosenblaum, a Columbia University researcher who, at the time was working on an NIH-funded study on weight control, explains: "Obesity is the one disease where your body fights the cure. By and large, the body is programmed to help you heal." But not in this case.
If you ever have dieted you already know that, once you lose some weight, your metabolism seems to slow down, and stops burning as many calories. For all your body knows, you are stranded on a desert island, starving to death. So it tries to "save you." Some argue that this is how the human species has survived.
"We are very efficient biological machines," says University of Alberta health professor Tim Caulfield, who writes about health misconceptions. "We evolved not to lose weight. We evolved to keep on as much weight as we possibly can.”
But saying that your body fights weight loss does not shed light on the more fundamental question of how and why your metabolism slows—or why you hit a plateau—and ultimately re-gain the weight you lost.
Not everyone believes that this is all about evolution. Some argue that the obesity epidemic has more to do with what we eat today— and how compulsively we diet–See part 2 of this post, below
Does Over-Eating Make You Fat, Or Do You Eat More Because You Are Fat? (PART 2 of “Obesity—What the Experts are Reluctant to Tell You”)
Today, researchers are digging into what drives weight gain, and some are beginning to suggest that we have been confusing cause and effect.
What if it's not overeating that causes us to get fat, but the process of getting fatter that causes us to overeat?"
Recently The Journal of the American Medical Association (JAMA) published a provocative piece that asked precisely that question. Shortly before publishing in JAMA, the authors, summed up their argument in a New York Times Op-Ed: "Always Hungry? Here's Why."
There, David Ludwig, a professor of pediatrics at Harvard Medical School and director the New Balance Foundation Obesity Prevention Center at Boston Children's Hospital, and Mark Friedman, vice president of research at the Nutrition Science Initiative did a superb job of distilling their argument into terms a layman can understand.
They suggest that chronic overeating represents a symptom rather than the primary cause of piling on the pounds. Indeed, Ludwig and Friedman argue, dieting itself may induce changes in our metabolism that leads us to regain weight when we begin to lose it.
They explain their theory: When we eat hearty meals, "we lock . . . more calories away in fat tissue." As a result, "fewer are circulating in the bloodstream to satisfy the body's requirements." In other words, there are not enough calories in our bloodstream to give us the energy to do what we want to do.
"If we look at it this way," they continue, "it's a distribution problem: We have an abundance of calories, but they're in the wrong place. As a result, the body needs to increase its intake. We get hungrier because we're getting fatter."
Ludwig and Friedman compare the process to what happens when patients suffer from "edema, a common medical condition in which fluid leaks from blood vessels into surrounding tissues. No matter how much water they drink, people with edema may experience unquenchable thirst because the fluid doesn't stay in the blood, where it's needed.
"Similarly," they suggest, "when fat cells suck up too much fuel, calories from food promote the growth of fat tissue instead of serving the energy needs of the body, provoking overeating in all but the most disciplined individuals."
Ludwig and Friedman acknowledge that: "many biological factors affect the storage of calories in fat cells, including genetics, levels of physical activity, sleep and stress."
But, they argue, "one has an indisputably dominant role: the hormone insulin. We know that excess insulin treatment for diabetes causes weight gain, and insulin deficiency causes weight loss. And of everything we eat, highly refined and rapidly digestible carbohydrates [like white bread, that dissolves on your tongue and tastes like sugar] produce the most insulin."
Maybe Carbs Are the Culprit After All?
Ludwig and Friedman believe that the increasing amount and processing of carbohydrates in the American diet [as food manufacturers replace fats with carbs] has "increased insulin levels, put fat cells into storage overdrive and elicited obesity-promoting biological responses in a large number of people." In other words, the problem may not be how much we eat (as measured by calories) but what we eat.
"If this hypothesis turns out to be correct, it will have immediate implications for public health," they write. "It would mean that the decades-long focus on cutting calories", a strategy that was "destined to fail for most people. . . . would fade" and "obesity treatment would more appropriately focus on diet quality rather than calorie quantity."
Gary Taubes, author of Good Calories, Bad Calories shares their suspicion about carbs driving fat cells to load up. In an article that drew widespread attention when it was published in BMJ (formerly the British Medical Journal) in 2013, Taubes argues that we gain weight, not because we are gluttons, but because what we are eating is "promoting fat accumulation" and thus "driving an increase in appetite.”
Like Ludwig and Friedman, he is suggesting that we have confused cause and effect. His theory is that dieting encourages our bodies to store fat—and storing fat makes us hungry. One would think that a well-fed, well-padded woman would be less hungry than her skinny sister. But Taubes is saying "No": if the 170-pound sister is dieting, she may well be hungrier.
Needed: New, More Objective Research
Ludwig, Nieman, and Taubes all agree that they cannot prove their theories.
“Unfortunately, existing research cannot provide a definitive test of our hypothesis" Ludwig and Nieman acknowledge. Indeed, they admit, "Several prominent clinical trials report no difference in weight loss when comparing" high protein, low carbohydrate and low fat diets.
But Ludwig and Nieman are not convinced by these trials. They "had major limitations," they explain. "At the end, subjects reported that they had not met the targets for complying with the prescribed diets." Clearly if patients are less than compliant (i.e. they cheat), the results cannot be trusted.
As WIRED reports, Taubes is even more critical of past studies:"Most of the existing knowledge gathered in the past five decades of research comes from studies marred by inadequate controls, faulty cause-and-effect reasoning, and animal studies that are not applicable to humans, WIRED notes.
Taubes' critique is scathing: "The whole body of literature," says Taubes "is based on science that was simply not adequate to the task of establishing reliable knowledge."
In BMJ Taubes suggests that entrenched beliefs have hampered research: "Substandard science is not sufficient to establish reliable knowledge, let alone public health guidelines. When the results of studies are published, the authors must be brutally honest about the possible shortcomings and all reasonable alternative explanations for what they observed."
He goes on to quote Nobel-prize winning physicist Richard Feynman "If science is to progress, what we need is the ability to experiment, honesty in reporting results—the results must be reported without somebody saying what they would like the results to have been—and finally—an important thing—the intelligence to interpret the results. An important point about this intelligence is that it should not be sure ahead of time what must be."
Taubes is now setting out to do the research that he believes we need. Last year, he co-founded a not-for-profit organization called the Nutrition Science Initiative (NuSI.) "Our strategy is to fund and facilitate rigorously well controlled experimental trials, carried out by independent, skeptical researchers," Taubes declared. The Arnold Foundation (a philanthropy founded by former natural gas trader John Arnold), has now committed $40 million over the next three years to this research program."
Some of the top scientists in nutrition research have signed on. Many of them are opposed to Taubes' alternative theory about why we gain weight. But they have been guaranteed the freedom to design and conduct their trials– and oversee reporting–without interference.
To say that the NuSI’s trials are controlled would be an understatement. Patients enrolled in a NuSI study at the National Institute of Health in Bethesda Maryland must stay at the Institute for eight weeks. During that time, they are forbidden to leave. Over the eight weeks, they spend two days of each week insider tiny airtight rooms where scientist can measure exactly how many calories they are burning by measuring changes in oxygen and carbon dioxide in the air. Food is delivered to them through vacuum-sealed portholes. The food itself has been chemically analyzed to ensure an exact number of carbohydrate, protein and fat calories.
If Doctors Know that Cutting Calories Is Not A Solution, Why Don't They Tell Us?
In two years, when the NuSI study ends, we may well know much more about carbs vs. protein and fat.
But even in 2008, when I first wrote about obesity, it was becoming clear that curtailing calories and hitting the treadmill would not lead to long-term weight loss. Conbtrolled trails supervised by physicians revealed that up to 95% of patients would put the pounds back on.
Why didn't someone tell us?
First, keep in mind that the weight loss industry—which sells diets, pills ,and other products—spends billions o advertising..This could be one reason why the mainstream media has been slow to tell us that losing weight the conventional way is all but impossible for most of us.
Moreover, newspaper editors and television producers know that the American public doesn't like to hear discouraging news about what modern medicine can and can't do. We prefer to believe that there is a "cure" for everything—including "curves."
Secondly—and this is terribly important—our doctors live in the same culture that the rest of us do. As the first post in this series illustrates (URL) ) family doctors who don't specialize in obesity tend to share the popular belief that weight loss is all about "calories in and calories out’—how much you stuff into your mouth, and how much energy you expend. As I explain in that post, this is understandable. In our med schools, few students study obesity.
But what about the experts who know the research. Why haven't they warned us that yo-yo dieting won't get us anywhere?
In fact, some have tried. But as University of Alberta professor Tim Caulfield, who researches and writes about health misconceptions confides, his fellow obesity academics "tend to tiptoe around the truth."
Last year, he told CBS News: "You go to these meetings and you talk to researchers, you get a sense there is almost a political correctness around it, that we don’t want this message to get out there. You’ll be in a room with very knowledgeable individuals, and everyone in the room will know what the data says and still the message doesn’t seem to get out.”
In part, that is because it’s such a harsh message. “That’s one of the reasons why this myth of weight loss lives on," says Caulfield.
"Health experts also are afraid people will abandon all efforts to exercise and eat a nutritious diet — behavior that is important for health and longevity," explains CBS medical correspondent Kelly Crowe "even if it doesn’t result in much weight loss."
Nevertheless, Traci Mann, the psychologist who has spent 20 years running an eating lab at the University of Minnesota, declares that, at this point in time, "the emphasis should be on measuring health, not weight.
“You should still eat right, you should still exercise, doing healthy stuff is still healthy,” she declares. “It just doesn’t make you thin."
But you will live longer—and, most importantly, enjoy life more.
What if it's not overeating that causes us to get fat, but the process of getting fatter that causes us to overeat?"
Recently The Journal of the American Medical Association (JAMA) published a provocative piece that asked precisely that question. Shortly before publishing in JAMA, the authors, summed up their argument in a New York Times Op-Ed: "Always Hungry? Here's Why."
There, David Ludwig, a professor of pediatrics at Harvard Medical School and director the New Balance Foundation Obesity Prevention Center at Boston Children's Hospital, and Mark Friedman, vice president of research at the Nutrition Science Initiative did a superb job of distilling their argument into terms a layman can understand.
They suggest that chronic overeating represents a symptom rather than the primary cause of piling on the pounds. Indeed, Ludwig and Friedman argue, dieting itself may induce changes in our metabolism that leads us to regain weight when we begin to lose it.
They explain their theory: When we eat hearty meals, "we lock . . . more calories away in fat tissue." As a result, "fewer are circulating in the bloodstream to satisfy the body's requirements." In other words, there are not enough calories in our bloodstream to give us the energy to do what we want to do.
"If we look at it this way," they continue, "it's a distribution problem: We have an abundance of calories, but they're in the wrong place. As a result, the body needs to increase its intake. We get hungrier because we're getting fatter."
Ludwig and Friedman compare the process to what happens when patients suffer from "edema, a common medical condition in which fluid leaks from blood vessels into surrounding tissues. No matter how much water they drink, people with edema may experience unquenchable thirst because the fluid doesn't stay in the blood, where it's needed.
"Similarly," they suggest, "when fat cells suck up too much fuel, calories from food promote the growth of fat tissue instead of serving the energy needs of the body, provoking overeating in all but the most disciplined individuals."
Ludwig and Friedman acknowledge that: "many biological factors affect the storage of calories in fat cells, including genetics, levels of physical activity, sleep and stress."
But, they argue, "one has an indisputably dominant role: the hormone insulin. We know that excess insulin treatment for diabetes causes weight gain, and insulin deficiency causes weight loss. And of everything we eat, highly refined and rapidly digestible carbohydrates [like white bread, that dissolves on your tongue and tastes like sugar] produce the most insulin."
Maybe Carbs Are the Culprit After All?
Ludwig and Friedman believe that the increasing amount and processing of carbohydrates in the American diet [as food manufacturers replace fats with carbs] has "increased insulin levels, put fat cells into storage overdrive and elicited obesity-promoting biological responses in a large number of people." In other words, the problem may not be how much we eat (as measured by calories) but what we eat.
"If this hypothesis turns out to be correct, it will have immediate implications for public health," they write. "It would mean that the decades-long focus on cutting calories", a strategy that was "destined to fail for most people. . . . would fade" and "obesity treatment would more appropriately focus on diet quality rather than calorie quantity."
Gary Taubes, author of Good Calories, Bad Calories shares their suspicion about carbs driving fat cells to load up. In an article that drew widespread attention when it was published in BMJ (formerly the British Medical Journal) in 2013, Taubes argues that we gain weight, not because we are gluttons, but because what we are eating is "promoting fat accumulation" and thus "driving an increase in appetite.”
Like Ludwig and Friedman, he is suggesting that we have confused cause and effect. His theory is that dieting encourages our bodies to store fat—and storing fat makes us hungry. One would think that a well-fed, well-padded woman would be less hungry than her skinny sister. But Taubes is saying "No": if the 170-pound sister is dieting, she may well be hungrier.
Needed: New, More Objective Research
Ludwig, Nieman, and Taubes all agree that they cannot prove their theories.
“Unfortunately, existing research cannot provide a definitive test of our hypothesis" Ludwig and Nieman acknowledge. Indeed, they admit, "Several prominent clinical trials report no difference in weight loss when comparing" high protein, low carbohydrate and low fat diets.
But Ludwig and Nieman are not convinced by these trials. They "had major limitations," they explain. "At the end, subjects reported that they had not met the targets for complying with the prescribed diets." Clearly if patients are less than compliant (i.e. they cheat), the results cannot be trusted.
As WIRED reports, Taubes is even more critical of past studies:"Most of the existing knowledge gathered in the past five decades of research comes from studies marred by inadequate controls, faulty cause-and-effect reasoning, and animal studies that are not applicable to humans, WIRED notes.
Taubes' critique is scathing: "The whole body of literature," says Taubes "is based on science that was simply not adequate to the task of establishing reliable knowledge."
In BMJ Taubes suggests that entrenched beliefs have hampered research: "Substandard science is not sufficient to establish reliable knowledge, let alone public health guidelines. When the results of studies are published, the authors must be brutally honest about the possible shortcomings and all reasonable alternative explanations for what they observed."
He goes on to quote Nobel-prize winning physicist Richard Feynman "If science is to progress, what we need is the ability to experiment, honesty in reporting results—the results must be reported without somebody saying what they would like the results to have been—and finally—an important thing—the intelligence to interpret the results. An important point about this intelligence is that it should not be sure ahead of time what must be."
Taubes is now setting out to do the research that he believes we need. Last year, he co-founded a not-for-profit organization called the Nutrition Science Initiative (NuSI.) "Our strategy is to fund and facilitate rigorously well controlled experimental trials, carried out by independent, skeptical researchers," Taubes declared. The Arnold Foundation (a philanthropy founded by former natural gas trader John Arnold), has now committed $40 million over the next three years to this research program."
Some of the top scientists in nutrition research have signed on. Many of them are opposed to Taubes' alternative theory about why we gain weight. But they have been guaranteed the freedom to design and conduct their trials– and oversee reporting–without interference.
To say that the NuSI’s trials are controlled would be an understatement. Patients enrolled in a NuSI study at the National Institute of Health in Bethesda Maryland must stay at the Institute for eight weeks. During that time, they are forbidden to leave. Over the eight weeks, they spend two days of each week insider tiny airtight rooms where scientist can measure exactly how many calories they are burning by measuring changes in oxygen and carbon dioxide in the air. Food is delivered to them through vacuum-sealed portholes. The food itself has been chemically analyzed to ensure an exact number of carbohydrate, protein and fat calories.
If Doctors Know that Cutting Calories Is Not A Solution, Why Don't They Tell Us?
In two years, when the NuSI study ends, we may well know much more about carbs vs. protein and fat.
But even in 2008, when I first wrote about obesity, it was becoming clear that curtailing calories and hitting the treadmill would not lead to long-term weight loss. Conbtrolled trails supervised by physicians revealed that up to 95% of patients would put the pounds back on.
Why didn't someone tell us?
First, keep in mind that the weight loss industry—which sells diets, pills ,and other products—spends billions o advertising..This could be one reason why the mainstream media has been slow to tell us that losing weight the conventional way is all but impossible for most of us.
Moreover, newspaper editors and television producers know that the American public doesn't like to hear discouraging news about what modern medicine can and can't do. We prefer to believe that there is a "cure" for everything—including "curves."
Secondly—and this is terribly important—our doctors live in the same culture that the rest of us do. As the first post in this series illustrates (URL) ) family doctors who don't specialize in obesity tend to share the popular belief that weight loss is all about "calories in and calories out’—how much you stuff into your mouth, and how much energy you expend. As I explain in that post, this is understandable. In our med schools, few students study obesity.
But what about the experts who know the research. Why haven't they warned us that yo-yo dieting won't get us anywhere?
In fact, some have tried. But as University of Alberta professor Tim Caulfield, who researches and writes about health misconceptions confides, his fellow obesity academics "tend to tiptoe around the truth."
Last year, he told CBS News: "You go to these meetings and you talk to researchers, you get a sense there is almost a political correctness around it, that we don’t want this message to get out there. You’ll be in a room with very knowledgeable individuals, and everyone in the room will know what the data says and still the message doesn’t seem to get out.”
In part, that is because it’s such a harsh message. “That’s one of the reasons why this myth of weight loss lives on," says Caulfield.
"Health experts also are afraid people will abandon all efforts to exercise and eat a nutritious diet — behavior that is important for health and longevity," explains CBS medical correspondent Kelly Crowe "even if it doesn’t result in much weight loss."
Nevertheless, Traci Mann, the psychologist who has spent 20 years running an eating lab at the University of Minnesota, declares that, at this point in time, "the emphasis should be on measuring health, not weight.
“You should still eat right, you should still exercise, doing healthy stuff is still healthy,” she declares. “It just doesn’t make you thin."
But you will live longer—and, most importantly, enjoy life more.
What Doctors Should– and Should Not– Say to Obese Patients
Below a remarkably candid and compelling essay by Emma Lewis titled "Why there's no point in telling me to lose weight. " It originally appeared in the January 2015 issue of BMJ (formerly the British Medical Journal). Hat-tip to Helen Haskell, president and founder of Mothers Against Medical Error, who sent me Lewis' piece.
In her editorial (cross-posted below), Lewis explains why she has "opted out" of the "weight-loss game." She confides that she has been "fat" since she was a child. She still remembers the humiliations, which continue to this day– especially when she visits a primary care doctor.
It doesn't matter whether she is seeing the physician because she has broken an ankle or needs contraception. Inevitably, he or she brings up her Body Mass Index (BMI.) And when a GP admonishes her that she should diet and work out, he rarely asks what she eats now, or how much she exercises. He doesn't listen; he lectures.
In fact, Lewis does care about her health: she exercises regularly and has switched to a whole meal vegetarian diet. For years, she has been in good health. But her BMI remains above 30.
What Many Doctors Don’t Know—And What Even the Experts Don’t Understand
What these general practitioners don't know is what doctors and scientists who specialize in obesity have discovered: the vast majority of overweight patients cannot shed pounds—and keep them off—even in highly controlled experimental settings where patients diet and exercise under a doctor's supervision. As I explain in the post below two years after starting a diet, roughly 95% will have put all of the weight back on.
And even the experts who study the obesity epidemicdon't understand why.
When I first wrote about obesity back in 2008, I had just seen an eye-opening NPR documentary titled "Fat: What No One is Telling You"
As the film opens we see a fetching red head, puffing away on a treadmill. She's perspiring, but she's smiling gamely into the camera. "It's not an average work-out, but I wasn't an average weight," she explains. "I have to do above and beyond what any of you guys would have to do. I have to try twice as hard, sometimes three times as hard—just to maintain this level of . . . chubbiness."
And she is right. She is chubby. By 21st century mainstream (and magazine) standards of beauty this young woman is probably 20 or 30 pounds overweight. Charismatic and dimpled, she also is very appealing. But there is no doubt that most physicians would urge her to slim down.
Later in the film, we learn that she exercises three hours a day. Dedicated and determined, she eats healthy meals and sticks to a strict exercise regime. Why, then, is she "chubby?"
The questions are endless, a narrator tells the audience. "Is it her genes, her childhood, a flaw in her character, stress, sadness, a lost love, processed food, television, seductive advertising, lack of sleep, a government that subsidizes corn, sugar and beef?"
All of the above may well contribute. But taken together, they still don't constitute an answer: we don't know what causes obesity.
The strictly controlled long-term randomized, controlled trials that might tell us have not yet been done. As you might imagine, it is not easy to corral human beings into such trials, make sure that they do not cheat, and persuade a control group of obese patients to stop trying to lose weight for a period of one or two years.
At this point, all we know with certainty is that obesity is an extremely complicated disease driven by genetic, metabolic, social, psychological and environmental factors.
But while we still haven't cracked the mysteries of "Fat," the evidence is mounting: counting calories and eating less does not seem to be the answer.
Indeed, as I explain in the post below, some of the newest research suggests that dieting is counter-productive because reducing the amount of food we eat sends a signal to our bodies to store even more calories as fat, and, as a result, we feel even hungrier. Thus, over time, we regain whatever weight we shed—and many people gain more than they originally lost. This is a cruel disease.
Why there's no point telling me to lose weight (BMJ 2015)
By Emma Lewis
I am one of over 97% of people for whom dieting does not lead to sustained weight loss.
I've experienced health benefits from increased exercise, and from switching to a wholemeal vegetarian diet. My blood pressure's normal, as are my fasting glucose and my lung function—as far as I can tell, my health is great. But my body mass index (BMI) has been above 30 my entire adult life.
When I worry that I might be unwell, I often try to avoid visiting a general practitioner. Almost every consultation I've ever had—about glandular fever, contraception, a sprained ankle—has included a conversation about my weight; and that's inevitably the conversation that destroys any rapport or trust that might have existed between me and my doctor.
Fighting "the obesity epidemic" is supposed to be about making me—as a "severely obese" person—more healthy; but the impact of obesity rhetoric on my life has been quite the opposite.
I've been out dancing in some slightly inadvisable shoes. On the walk home, I step awkwardly in a gutter and hurt my ankle. The next morning, the swelling is pretty severe, so I decide I ought to get it checked out.
The doctor tells me that I should be exercising more. I say: I know that increased circulation boosts healing, but as it currently hurts to stand I'm not sure what it's best to do for exercise. He says: he's not talking about healing up the ankle, he means, in general.
He hasn't asked me how much exercise I already do. He doesn't know that just last night I danced energetically for four hours then walked several miles home.
I assume that he tells all his fat patients the same thing, without bothering to find out about their individual situations. This doesn't exactly fill me with trust that I'm receiving responsible medical advice. I don't visit this practice again.
I have been fat my whole life. So when healthcare professionals ask me—in the middle of a consultation about something completely unrelated—whether I know that my BMI is too high and whether I'm engaged in any weight management, I'm always a little surprised when they act like they might be the first to have ever brought it up. As if I might have made it through my 30 years without ever once noticing that I was fat and that some people think that fat is bad.
It's just a little reminder that my GP—like many other people in the world—sees me as a fat person first, and an individual second. It makes me feel like a problem to be solved—something unpleasant that needs to be eliminated.
I recently took up weightlifting. I'm happier in myself now—my stamina has increased, as has my strength; I can cycle up hills that used to defeat me.
Unfortunately, building up enough muscle mass to squat a 100 kg barbell has tipped my BMI over from "obese" to "severely obese." I haven't been back to a GP since, but I'm dreading it more than ever.
When health professionals bring up my weight in a consultation, I don't feel like they're looking out for my health. All my health markers are fine, I'm active and happy, and I've spent years fighting against the low self esteem that came from an adolescence spent believing that I'd never be attractive to anyone, yet they still think that it's important to tell me to do something that I know to be impossible.
They give me the impression that my weight is the most important thing about me—more important than, say, my penchant for body piercing and platform shoes, both of which have caused me more infection and injury than my adipose tissue has. They put me right back to where I was when I was a binging-fasting teenager: full of shame.
They tell me that my body type is a "risk factor" for all kinds of diseases, and that statistically I'm more likely to be healthy if I lose weight. I might query the science behind that supposition—citing the "obesity paradox," which indicates that fat people have better survival rates than thin people for all sorts of diseases, but I do accept that it's orthodox medical opinion.
Even if I did want to change my body type to be less of a "risk factor"—it's not that easy. I'm already physically active well beyond the recommendations of the chief medical officer, and I don't rate my chances of being one of those seemingly mythical people who manage to maintain weight loss through dietary intervention.
My childhood contained so many diets, so many humiliations in school PE (physical education). No attempts to make me lose weight have ever had any long-term effects. All they did was give me a constant sense of shame and of not being good enough. This led to unhealthy eating habits that would have been labelled "disordered" in someone with a lower BMI.
It has taken me years to unlearn those habits. And it's only recently that I've really discovered the joys of physical exertion, having spent most of my life thinking of exercise as "that punishment I get given for being fat"—impact based activities like running are physically painful for someone with my body type.
I've opted out of the weight loss game. If that makes me a non-compliant patient, then so be it. I'm healthier and happier than I was when I hated myself. I just wish that my healthcare providers would work with me on that.
Key messages:
1. Focus on what the patient has come to see you about today. If you only do that, you've done a good job. Think twice before offering unsolicited advice in the guise of "education," particularly when your patient is consulting you about something unrelated. If your patients hear the same potted advice during every appointment, it'll soon lose its impact; and if you insist on bringing up a subject that they find traumatic you could put them off seeking your advice in future.
2. It is appropriate to give diet or exercise advice when somebody asks you directly, but try to focus on the other benefits of eating well and getting regular exercise, rather than treating weight loss as an end in itself.8 That way your patients won't get discouraged from healthy behaviours even when they do not result in permanent weight loss.
3. Fat people know that they are fat. You don't need to tell us; society's been doing that our whole lives. Many of us have been traumatized by constant reminders about weight loss culture—about how shameful you seem to find our bodies.
Note from MM: As Emma Lewis has learned, exercise, combined with a healthy diet, is the key to giving her the energy she needs to take great pleasure in life. And, very likely, she will enjoy a long life. (A recent 12-year-study reveals that a lack of physical activity claims twice as many lives as obesity does. While obesity carries a social stigma, being inactive is more likely to shorten your life.)
Nevertheless many well-meaning GP's are still lecturing, and in some cases, blaming and shaming, overweight patients. This is understandable. They truly believe that if their patient just consumed less, and moved more, the pounds would melt away.
After all, our doctors also live in a culture where the notion that obesity is caused by some combination of gluttony and sloth is deeply entrenched. And in medical school, the mysteries of how and why we gain weight is rarely explored.
Why is the topic neglected? Medical education (like the media) focuses on what doctors can do—the miracles and successes of medicine.
Perhaps a course that explains "the limits of medicine" should be required in our medical schools. It might zero in on diseases that we cannot "cure" (like obesity and Alzheimer's), and discuss taboo topics (like death).
Until that happens, caring doctors can support patients by explaining that whether or not they conform to our culture's current norms for what counts as attractive, how they feel is far more important than how they look.
If they eat healthy foods, avoid junk, and are active, they can be "fit" even if others perceive them as "fat."
In the posts below (here and here ) I explain what medical science now knows—and still does not know—about obesity.
In her editorial (cross-posted below), Lewis explains why she has "opted out" of the "weight-loss game." She confides that she has been "fat" since she was a child. She still remembers the humiliations, which continue to this day– especially when she visits a primary care doctor.
It doesn't matter whether she is seeing the physician because she has broken an ankle or needs contraception. Inevitably, he or she brings up her Body Mass Index (BMI.) And when a GP admonishes her that she should diet and work out, he rarely asks what she eats now, or how much she exercises. He doesn't listen; he lectures.
In fact, Lewis does care about her health: she exercises regularly and has switched to a whole meal vegetarian diet. For years, she has been in good health. But her BMI remains above 30.
What Many Doctors Don’t Know—And What Even the Experts Don’t Understand
What these general practitioners don't know is what doctors and scientists who specialize in obesity have discovered: the vast majority of overweight patients cannot shed pounds—and keep them off—even in highly controlled experimental settings where patients diet and exercise under a doctor's supervision. As I explain in the post below two years after starting a diet, roughly 95% will have put all of the weight back on.
And even the experts who study the obesity epidemicdon't understand why.
When I first wrote about obesity back in 2008, I had just seen an eye-opening NPR documentary titled "Fat: What No One is Telling You"
As the film opens we see a fetching red head, puffing away on a treadmill. She's perspiring, but she's smiling gamely into the camera. "It's not an average work-out, but I wasn't an average weight," she explains. "I have to do above and beyond what any of you guys would have to do. I have to try twice as hard, sometimes three times as hard—just to maintain this level of . . . chubbiness."
And she is right. She is chubby. By 21st century mainstream (and magazine) standards of beauty this young woman is probably 20 or 30 pounds overweight. Charismatic and dimpled, she also is very appealing. But there is no doubt that most physicians would urge her to slim down.
Later in the film, we learn that she exercises three hours a day. Dedicated and determined, she eats healthy meals and sticks to a strict exercise regime. Why, then, is she "chubby?"
The questions are endless, a narrator tells the audience. "Is it her genes, her childhood, a flaw in her character, stress, sadness, a lost love, processed food, television, seductive advertising, lack of sleep, a government that subsidizes corn, sugar and beef?"
All of the above may well contribute. But taken together, they still don't constitute an answer: we don't know what causes obesity.
The strictly controlled long-term randomized, controlled trials that might tell us have not yet been done. As you might imagine, it is not easy to corral human beings into such trials, make sure that they do not cheat, and persuade a control group of obese patients to stop trying to lose weight for a period of one or two years.
At this point, all we know with certainty is that obesity is an extremely complicated disease driven by genetic, metabolic, social, psychological and environmental factors.
But while we still haven't cracked the mysteries of "Fat," the evidence is mounting: counting calories and eating less does not seem to be the answer.
Indeed, as I explain in the post below, some of the newest research suggests that dieting is counter-productive because reducing the amount of food we eat sends a signal to our bodies to store even more calories as fat, and, as a result, we feel even hungrier. Thus, over time, we regain whatever weight we shed—and many people gain more than they originally lost. This is a cruel disease.
Why there's no point telling me to lose weight (BMJ 2015)
By Emma Lewis
I am one of over 97% of people for whom dieting does not lead to sustained weight loss.
I've experienced health benefits from increased exercise, and from switching to a wholemeal vegetarian diet. My blood pressure's normal, as are my fasting glucose and my lung function—as far as I can tell, my health is great. But my body mass index (BMI) has been above 30 my entire adult life.
When I worry that I might be unwell, I often try to avoid visiting a general practitioner. Almost every consultation I've ever had—about glandular fever, contraception, a sprained ankle—has included a conversation about my weight; and that's inevitably the conversation that destroys any rapport or trust that might have existed between me and my doctor.
Fighting "the obesity epidemic" is supposed to be about making me—as a "severely obese" person—more healthy; but the impact of obesity rhetoric on my life has been quite the opposite.
I've been out dancing in some slightly inadvisable shoes. On the walk home, I step awkwardly in a gutter and hurt my ankle. The next morning, the swelling is pretty severe, so I decide I ought to get it checked out.
The doctor tells me that I should be exercising more. I say: I know that increased circulation boosts healing, but as it currently hurts to stand I'm not sure what it's best to do for exercise. He says: he's not talking about healing up the ankle, he means, in general.
He hasn't asked me how much exercise I already do. He doesn't know that just last night I danced energetically for four hours then walked several miles home.
I assume that he tells all his fat patients the same thing, without bothering to find out about their individual situations. This doesn't exactly fill me with trust that I'm receiving responsible medical advice. I don't visit this practice again.
I have been fat my whole life. So when healthcare professionals ask me—in the middle of a consultation about something completely unrelated—whether I know that my BMI is too high and whether I'm engaged in any weight management, I'm always a little surprised when they act like they might be the first to have ever brought it up. As if I might have made it through my 30 years without ever once noticing that I was fat and that some people think that fat is bad.
It's just a little reminder that my GP—like many other people in the world—sees me as a fat person first, and an individual second. It makes me feel like a problem to be solved—something unpleasant that needs to be eliminated.
I recently took up weightlifting. I'm happier in myself now—my stamina has increased, as has my strength; I can cycle up hills that used to defeat me.
Unfortunately, building up enough muscle mass to squat a 100 kg barbell has tipped my BMI over from "obese" to "severely obese." I haven't been back to a GP since, but I'm dreading it more than ever.
When health professionals bring up my weight in a consultation, I don't feel like they're looking out for my health. All my health markers are fine, I'm active and happy, and I've spent years fighting against the low self esteem that came from an adolescence spent believing that I'd never be attractive to anyone, yet they still think that it's important to tell me to do something that I know to be impossible.
They give me the impression that my weight is the most important thing about me—more important than, say, my penchant for body piercing and platform shoes, both of which have caused me more infection and injury than my adipose tissue has. They put me right back to where I was when I was a binging-fasting teenager: full of shame.
They tell me that my body type is a "risk factor" for all kinds of diseases, and that statistically I'm more likely to be healthy if I lose weight. I might query the science behind that supposition—citing the "obesity paradox," which indicates that fat people have better survival rates than thin people for all sorts of diseases, but I do accept that it's orthodox medical opinion.
Even if I did want to change my body type to be less of a "risk factor"—it's not that easy. I'm already physically active well beyond the recommendations of the chief medical officer, and I don't rate my chances of being one of those seemingly mythical people who manage to maintain weight loss through dietary intervention.
My childhood contained so many diets, so many humiliations in school PE (physical education). No attempts to make me lose weight have ever had any long-term effects. All they did was give me a constant sense of shame and of not being good enough. This led to unhealthy eating habits that would have been labelled "disordered" in someone with a lower BMI.
It has taken me years to unlearn those habits. And it's only recently that I've really discovered the joys of physical exertion, having spent most of my life thinking of exercise as "that punishment I get given for being fat"—impact based activities like running are physically painful for someone with my body type.
I've opted out of the weight loss game. If that makes me a non-compliant patient, then so be it. I'm healthier and happier than I was when I hated myself. I just wish that my healthcare providers would work with me on that.
Key messages:
1. Focus on what the patient has come to see you about today. If you only do that, you've done a good job. Think twice before offering unsolicited advice in the guise of "education," particularly when your patient is consulting you about something unrelated. If your patients hear the same potted advice during every appointment, it'll soon lose its impact; and if you insist on bringing up a subject that they find traumatic you could put them off seeking your advice in future.
2. It is appropriate to give diet or exercise advice when somebody asks you directly, but try to focus on the other benefits of eating well and getting regular exercise, rather than treating weight loss as an end in itself.8 That way your patients won't get discouraged from healthy behaviours even when they do not result in permanent weight loss.
3. Fat people know that they are fat. You don't need to tell us; society's been doing that our whole lives. Many of us have been traumatized by constant reminders about weight loss culture—about how shameful you seem to find our bodies.
Note from MM: As Emma Lewis has learned, exercise, combined with a healthy diet, is the key to giving her the energy she needs to take great pleasure in life. And, very likely, she will enjoy a long life. (A recent 12-year-study reveals that a lack of physical activity claims twice as many lives as obesity does. While obesity carries a social stigma, being inactive is more likely to shorten your life.)
Nevertheless many well-meaning GP's are still lecturing, and in some cases, blaming and shaming, overweight patients. This is understandable. They truly believe that if their patient just consumed less, and moved more, the pounds would melt away.
After all, our doctors also live in a culture where the notion that obesity is caused by some combination of gluttony and sloth is deeply entrenched. And in medical school, the mysteries of how and why we gain weight is rarely explored.
Why is the topic neglected? Medical education (like the media) focuses on what doctors can do—the miracles and successes of medicine.
Perhaps a course that explains "the limits of medicine" should be required in our medical schools. It might zero in on diseases that we cannot "cure" (like obesity and Alzheimer's), and discuss taboo topics (like death).
Until that happens, caring doctors can support patients by explaining that whether or not they conform to our culture's current norms for what counts as attractive, how they feel is far more important than how they look.
If they eat healthy foods, avoid junk, and are active, they can be "fit" even if others perceive them as "fat."
In the posts below (here and here ) I explain what medical science now knows—and still does not know—about obesity.
Over-Eating: Confusing Cause and Effect–Does Overeating CAUSE You to Re-Gain Weight, Or Do You Eat More BECAUSE You Are Overweight?
Today, researchers are digging into what drives weight gain, and some are beginning to suggest that we have been confusing cause and effect.
What if it's not overeating that causes us to get fat, but the process of getting fatter that causes us to overeat?"
Recently The Journal of the American Medical Association (JAMA) published a provocative piece that asked precisely that question. Shortly before publishing in JAMA, the authors, summed up their argument in a New York Times Op-Ed: "Always Hungry? Here's Why."
There, David Ludwig, a professor of pediatrics at Harvard Medical School and director the New Balance Foundation Obesity Prevention Center at Boston Children's Hospital, and Mark Friedman, vice president of research at the Nutrition Science Initiative did a superb job of distilling their argument into terms a layman can understand.
They suggest that chronic overeating represents a symptom rather than the primary cause of piling on the pounds. Indeed, Ludwig and Friedman argue, dieting itself may induce changes in our metabolism that leads us to regain weight when we begin to lose it.
They explain their theory: When we eat hearty meals, "we lock . . . more calories away in fat tissue." As a result, "fewer are circulating in the bloodstream to satisfy the body's requirements." In other words, there are not enough calories in our bloodstream to give us the energy to do what we want to do.
"If we look at it this way," they continue, "it's a distribution problem: We have an abundance of calories, but they're in the wrong place. As a result, the body needs to increase its intake. We get hungrier because we're getting fatter."
Ludwig and Friedman compare the process to what happens when patients suffer from "edema, a common medical condition in which fluid leaks from blood vessels into surrounding tissues. No matter how much water they drink, people with edema may experience unquenchable thirst because the fluid doesn't stay in the blood, where it's needed.
"Similarly," they suggest, "when fat cells suck up too much fuel, calories from food promote the growth of fat tissue instead of serving the energy needs of the body, provoking overeating in all but the most disciplined individuals."
Ludwig and Friedman acknowledge that: "many biological factors affect the storage of calories in fat cells, including genetics, levels of physical activity, sleep and stress."
But, they argue, "one has an indisputably dominant role: the hormone insulin. We know that excess insulin treatment for diabetes causes weight gain, and insulin deficiency causes weight loss. And of everything we eat, highly refined and rapidly digestible carbohydrates [like white bread, that dissolves on your tongue and tastes like sugar] produce the most insulin."
Maybe Carbs Are the Culprit After All?
Ludwig and Friedman believe that the increasing amount and processing of carbohydrates in the American diet [as food manufacturers replace fats with carbs] has "increased insulin levels, put fat cells into storage overdrive and elicited obesity-promoting biological responses in a large number of people." In other words, the problem may not be how much we eat (as measured by calories) but what we eat.
"If this hypothesis turns out to be correct, it will have immediate implications for public health," they write. "It would mean that the decades-long focus on cutting calories", a strategy that was "destined to fail for most people. . . . would fade" and "obesity treatment would more appropriately focus on diet quality rather than calorie quantity."
Gary Taubes, author of Good Calories, Bad Calories shares their suspicion about carbs driving fat cells to load up. In an article that drew widespread attention when it was published in BMJ (formerly the British Medical Journal) in 2013, Taubes argues that we gain weight, not because we are gluttons, but because what we are eating is "promoting fat accumulation" and thus "driving an increase in appetite.”
Like Ludwig and Friedman, he is suggesting that we have confused cause and effect. His theory is that dieting encourages our bodies to store fat—and storing fat makes us hungry. One would think that a well-fed, well-padded woman would be less hungry than her skinny sister. But Taubes is saying "No": if the 170-pound sister is dieting, she may well be hungrier.
Needed: New, More Objective Research
Ludwig, Nieman, and Taubes all agree that they cannot prove their theories.
“Unfortunately, existing research cannot provide a definitive test of our hypothesis" Ludwig and Nieman acknowledge. Indeed, they admit, "Several prominent clinical trials report no difference in weight loss when comparing" high protein, low carbohydrate and low fat diets.
But Ludwig and Nieman are not convinced by these trials. They "had major limitations," they explain. "At the end, subjects reported that they had not met the targets for complying with the prescribed diets." Clearly if patients are less than compliant (i.e. they cheat), the results cannot be trusted.
As WIRED reports, Taubes is even more critical of past studies:"Most of the existing knowledge gathered in the past five decades of research comes from studies marred by inadequate controls, faulty cause-and-effect reasoning, and animal studies that are not applicable to humans, WIRED notes.
Taubes' critique is scathing: "The whole body of literature," says Taubes "is based on science that was simply not adequate to the task of establishing reliable knowledge."
In BMJ Taubes suggests that entrenched beliefs have hampered research: "Substandard science is not sufficient to establish reliable knowledge, let alone public health guidelines. When the results of studies are published, the authors must be brutally honest about the possible shortcomings and all reasonable alternative explanations for what they observed."
He goes on to quote Nobel-prize winning physicist Richard Feynman "If science is to progress, what we need is the ability to experiment, honesty in reporting results—the results must be reported without somebody saying what they would like the results to have been—and finally—an important thing—the intelligence to interpret the results. An important point about this intelligence is that it should not be sure ahead of time what must be."
Taubes is now setting out to do the research that he believes we need. Last year, he co-founded a not-for-profit organization called the Nutrition Science Initiative (NuSI.) "Our strategy is to fund and facilitate rigorously well controlled experimental trials, carried out by independent, skeptical researchers," Taubes declared. The Arnold Foundation (a philanthropy founded by former natural gas trader John Arnold), has now committed $40 million over the next three years to this research program."
Some of the top scientists in nutrition research have signed on. Many of them are opposed to Taubes' alternative theory about why we gain weight. But they have been guaranteed the freedom to design and conduct their trials– and oversee reporting–without interference.
To say that the NuSI’s trials are controlled would be an understatement. Patients enrolled in a NuSI study at the National Institute of Health in Bethesda Maryland must stay at the Institute for eight weeks. During that time, they are forbidden to leave. Over the eight weeks, they spend two days of each week insider tiny airtight rooms where scientist can measure exactly how many calories they are burning by measuring changes in oxygen and carbon dioxide in the air. Food is delivered to them through vacuum-sealed portholes. The food itself has been chemically analyzed to ensure an exact number of carbohydrate, protein and fat calories.
If Doctors Know that Cutting Calories Is Not A Solution, Why Don't They Tell Us?
In two years, when the NuSI study ends, we may well know much more about carbs vs. protein and fat.
But even in 2008, when I first wrote about obesity, it was becoming clear that curtailing calories and hitting the treadmill would not lead to long-term weight loss. Conbtrolled trails supervised by physicians revealed that up to 95% of patients would put the pounds back on.
Why didn't someone tell us?
First, keep in mind that the weight loss industry—which sells diets, pills ,and other products—spends billions o advertising..This could be one reason why the mainstream media has been slow to tell us that losing weight the conventional way is all but impossible for most of us.
Moreover, newspaper editors and television producers know that the American public doesn't like to hear discouraging news about what modern medicine can and can't do. We prefer to believe that there is a "cure" for everything—including "curves."
Secondly—and this is terribly important—our doctors live in the same culture that we all live in. As the first post in this series illustrates family doctors who don't specialize in obesity tend to share the popular belief that weight loss is all about "calories in and calories out’-–how much you stuff into your mouth, and how much energy you expend. As I explain in that post, this is understandable. In our med schools, few students study obesity.
But what about the experts who know the research. Why haven't they warned us that yo-yo dieting won't get us anywhere?
In fact, some have tried. But as University of Alberta professor Tim Caulfield, who researches and writes about health misconceptions confides, his fellow obesity academics "tend to tiptoe around the truth."
Last year, he told CBS News: "You go to these meetings and you talk to researchers, you get a sense there is almost a political correctness around it, that we don’t want this message to get out there. You’ll be in a room with very knowledgeable individuals, and everyone in the room will know what the data says and still the message doesn’t seem to get out.”
In part, that is because it’s such a harsh message. “That’s one of the reasons why this myth of weight loss lives on," says Caulfield.
"Health experts also are afraid people will abandon all efforts to exercise and eat a nutritious diet — behavior that is important for health and longevity," explains CBS medical correspondent Kelly Crowe "even if it doesn’t result in much weight loss."
Nevertheless, Traci Mann, the psychologist who has spent 20 years running an eating lab at the University of Minnesota, declares that, at this point in time, "the emphasis should be on measuring health, not weight.
“You should still eat right, you should still exercise, doing healthy stuff is still healthy,” she declares. “It just doesn’t make you thin."
But you will live longer—and, most importantly, enjoy life more.
What if it's not overeating that causes us to get fat, but the process of getting fatter that causes us to overeat?"
Recently The Journal of the American Medical Association (JAMA) published a provocative piece that asked precisely that question. Shortly before publishing in JAMA, the authors, summed up their argument in a New York Times Op-Ed: "Always Hungry? Here's Why."
There, David Ludwig, a professor of pediatrics at Harvard Medical School and director the New Balance Foundation Obesity Prevention Center at Boston Children's Hospital, and Mark Friedman, vice president of research at the Nutrition Science Initiative did a superb job of distilling their argument into terms a layman can understand.
They suggest that chronic overeating represents a symptom rather than the primary cause of piling on the pounds. Indeed, Ludwig and Friedman argue, dieting itself may induce changes in our metabolism that leads us to regain weight when we begin to lose it.
They explain their theory: When we eat hearty meals, "we lock . . . more calories away in fat tissue." As a result, "fewer are circulating in the bloodstream to satisfy the body's requirements." In other words, there are not enough calories in our bloodstream to give us the energy to do what we want to do.
"If we look at it this way," they continue, "it's a distribution problem: We have an abundance of calories, but they're in the wrong place. As a result, the body needs to increase its intake. We get hungrier because we're getting fatter."
Ludwig and Friedman compare the process to what happens when patients suffer from "edema, a common medical condition in which fluid leaks from blood vessels into surrounding tissues. No matter how much water they drink, people with edema may experience unquenchable thirst because the fluid doesn't stay in the blood, where it's needed.
"Similarly," they suggest, "when fat cells suck up too much fuel, calories from food promote the growth of fat tissue instead of serving the energy needs of the body, provoking overeating in all but the most disciplined individuals."
Ludwig and Friedman acknowledge that: "many biological factors affect the storage of calories in fat cells, including genetics, levels of physical activity, sleep and stress."
But, they argue, "one has an indisputably dominant role: the hormone insulin. We know that excess insulin treatment for diabetes causes weight gain, and insulin deficiency causes weight loss. And of everything we eat, highly refined and rapidly digestible carbohydrates [like white bread, that dissolves on your tongue and tastes like sugar] produce the most insulin."
Maybe Carbs Are the Culprit After All?
Ludwig and Friedman believe that the increasing amount and processing of carbohydrates in the American diet [as food manufacturers replace fats with carbs] has "increased insulin levels, put fat cells into storage overdrive and elicited obesity-promoting biological responses in a large number of people." In other words, the problem may not be how much we eat (as measured by calories) but what we eat.
"If this hypothesis turns out to be correct, it will have immediate implications for public health," they write. "It would mean that the decades-long focus on cutting calories", a strategy that was "destined to fail for most people. . . . would fade" and "obesity treatment would more appropriately focus on diet quality rather than calorie quantity."
Gary Taubes, author of Good Calories, Bad Calories shares their suspicion about carbs driving fat cells to load up. In an article that drew widespread attention when it was published in BMJ (formerly the British Medical Journal) in 2013, Taubes argues that we gain weight, not because we are gluttons, but because what we are eating is "promoting fat accumulation" and thus "driving an increase in appetite.”
Like Ludwig and Friedman, he is suggesting that we have confused cause and effect. His theory is that dieting encourages our bodies to store fat—and storing fat makes us hungry. One would think that a well-fed, well-padded woman would be less hungry than her skinny sister. But Taubes is saying "No": if the 170-pound sister is dieting, she may well be hungrier.
Needed: New, More Objective Research
Ludwig, Nieman, and Taubes all agree that they cannot prove their theories.
“Unfortunately, existing research cannot provide a definitive test of our hypothesis" Ludwig and Nieman acknowledge. Indeed, they admit, "Several prominent clinical trials report no difference in weight loss when comparing" high protein, low carbohydrate and low fat diets.
But Ludwig and Nieman are not convinced by these trials. They "had major limitations," they explain. "At the end, subjects reported that they had not met the targets for complying with the prescribed diets." Clearly if patients are less than compliant (i.e. they cheat), the results cannot be trusted.
As WIRED reports, Taubes is even more critical of past studies:"Most of the existing knowledge gathered in the past five decades of research comes from studies marred by inadequate controls, faulty cause-and-effect reasoning, and animal studies that are not applicable to humans, WIRED notes.
Taubes' critique is scathing: "The whole body of literature," says Taubes "is based on science that was simply not adequate to the task of establishing reliable knowledge."
In BMJ Taubes suggests that entrenched beliefs have hampered research: "Substandard science is not sufficient to establish reliable knowledge, let alone public health guidelines. When the results of studies are published, the authors must be brutally honest about the possible shortcomings and all reasonable alternative explanations for what they observed."
He goes on to quote Nobel-prize winning physicist Richard Feynman "If science is to progress, what we need is the ability to experiment, honesty in reporting results—the results must be reported without somebody saying what they would like the results to have been—and finally—an important thing—the intelligence to interpret the results. An important point about this intelligence is that it should not be sure ahead of time what must be."
Taubes is now setting out to do the research that he believes we need. Last year, he co-founded a not-for-profit organization called the Nutrition Science Initiative (NuSI.) "Our strategy is to fund and facilitate rigorously well controlled experimental trials, carried out by independent, skeptical researchers," Taubes declared. The Arnold Foundation (a philanthropy founded by former natural gas trader John Arnold), has now committed $40 million over the next three years to this research program."
Some of the top scientists in nutrition research have signed on. Many of them are opposed to Taubes' alternative theory about why we gain weight. But they have been guaranteed the freedom to design and conduct their trials– and oversee reporting–without interference.
To say that the NuSI’s trials are controlled would be an understatement. Patients enrolled in a NuSI study at the National Institute of Health in Bethesda Maryland must stay at the Institute for eight weeks. During that time, they are forbidden to leave. Over the eight weeks, they spend two days of each week insider tiny airtight rooms where scientist can measure exactly how many calories they are burning by measuring changes in oxygen and carbon dioxide in the air. Food is delivered to them through vacuum-sealed portholes. The food itself has been chemically analyzed to ensure an exact number of carbohydrate, protein and fat calories.
If Doctors Know that Cutting Calories Is Not A Solution, Why Don't They Tell Us?
In two years, when the NuSI study ends, we may well know much more about carbs vs. protein and fat.
But even in 2008, when I first wrote about obesity, it was becoming clear that curtailing calories and hitting the treadmill would not lead to long-term weight loss. Conbtrolled trails supervised by physicians revealed that up to 95% of patients would put the pounds back on.
Why didn't someone tell us?
First, keep in mind that the weight loss industry—which sells diets, pills ,and other products—spends billions o advertising..This could be one reason why the mainstream media has been slow to tell us that losing weight the conventional way is all but impossible for most of us.
Moreover, newspaper editors and television producers know that the American public doesn't like to hear discouraging news about what modern medicine can and can't do. We prefer to believe that there is a "cure" for everything—including "curves."
Secondly—and this is terribly important—our doctors live in the same culture that we all live in. As the first post in this series illustrates family doctors who don't specialize in obesity tend to share the popular belief that weight loss is all about "calories in and calories out’-–how much you stuff into your mouth, and how much energy you expend. As I explain in that post, this is understandable. In our med schools, few students study obesity.
But what about the experts who know the research. Why haven't they warned us that yo-yo dieting won't get us anywhere?
In fact, some have tried. But as University of Alberta professor Tim Caulfield, who researches and writes about health misconceptions confides, his fellow obesity academics "tend to tiptoe around the truth."
Last year, he told CBS News: "You go to these meetings and you talk to researchers, you get a sense there is almost a political correctness around it, that we don’t want this message to get out there. You’ll be in a room with very knowledgeable individuals, and everyone in the room will know what the data says and still the message doesn’t seem to get out.”
In part, that is because it’s such a harsh message. “That’s one of the reasons why this myth of weight loss lives on," says Caulfield.
"Health experts also are afraid people will abandon all efforts to exercise and eat a nutritious diet — behavior that is important for health and longevity," explains CBS medical correspondent Kelly Crowe "even if it doesn’t result in much weight loss."
Nevertheless, Traci Mann, the psychologist who has spent 20 years running an eating lab at the University of Minnesota, declares that, at this point in time, "the emphasis should be on measuring health, not weight.
“You should still eat right, you should still exercise, doing healthy stuff is still healthy,” she declares. “It just doesn’t make you thin."
But you will live longer—and, most importantly, enjoy life more.
Will the Supreme Court Scuttle Obamacare Subsidies? (No. What Can’t Happen, Won’t. )
Not long ago, I ran across a photo of the Supreme Court captioned: "Maybe this will turn out to be . . . Obamacare's death panel?"
The caption refers to the widespread belief that when the Supreme Court rules on the latest challenge to Obamacare ("King vs. Burwell"), it will strike down most of the government subsidies that have made insurance affordable for so many middle-income and low-income families. (This lawsuit has been financed by the "Competitive Enterprise Institute," a libertarian group with long ties to tobacco disinformation campaigns, and more recently, climate change denial. The Koch brothers are among the funders of the institute.)
The Supremes are expected to announce their decision in June. If Obamacare's opponents prevail, the healthcare.gov system will have no choice but to cut off subsidies for as many as 7.5 million Americans in 34 states, including Texas and Florida, probably within a few weeks after the ruling is announced. The Kaiser Family Foundation has put together an eye-opening map revealing where subsidies are safe, and where they are at risk.
The plaintiffs’ argument turns on just five words buried in the 900-page Affordable Care Act (ACA). In a paragraph describing the tax credits that will be available to people buying policies in online marketplaces, known as “exchanges” the law describes them as "exchanges established by the state."
Seizing on that last phrase, the libertarians who masterminded this legal challenge gleefully point out that only 16 states opted to set up their own insurance exchanges. The remainder of the marketplaces were established by the federal government.
Ergo, the plaintiffs’ lawyers conclude, 34 states cannot legally offer subsidies to their citizens!
As a point of fact, if a person reads the entire ACA, he or she will discover that the law also is very clear that, if a state refuses to open an exchange, the federal government will "establish and operate such Exchange within the State."
An Absurd Argument
When the IRS drafted its rules for implementing the ACA it realized that, of course, Congress intended to make subsidies available both in the state and in the federal exchanges.
By fixating on only five words, the plaintiffs' lawyers ask the Court to ignore the broader goal of the "Patient Protection and Affordable Care Act": universal healthcare.
As Jeffrey Toobin put it in the New Yorker earlier this month: "the King case is notable mostly for the cynicism at its heart. Instead of grandeur" –which is more typical of cases brought to the highest court in the land– "there is a smallness about this lawsuit."
I agree. The plaintiffs are concocting an argument based on semantics, not ideas. It is not that the ideologues bringing this case don't understand the core mission of the ACA. They do. They know that the goal is to provide affordable health care to all Americans.
But Obamaca're opponents are quite coolly and cynically ignoring that mission while plucking a phrase out of the legislation, hoping that, if they sharpen it, by repeating it and harping on it, they can use it to carve the heart out of Obamacare.
Think about it: if subsidies disappeared in 34 states, millions would no longer be able to afford their insurance. At that point, young healthy Americans would drop their policies, leaving the insurance pool filled with sicker, older patients who felt they had no choice but to buy coverage–even without the government’s help.
In order to pay for their care, insurers would hike premiums, and as rates levitated, more and more healthy customers would cancel their coverage. This in turn would trigger what experts call a "death spiral" as premiums rose to unaffordable heights, and insurers simply stopped offering coverage in many states.
To believe that legislators meant to offer subsidies only to people who happened to live in states that create their own exchanges is to believe that the law was consciously designed to self-destruct.
Nevertheless this is what the law's challengers are claiming, and on March 4 the Court will begin hearing oral arguments.
The Media Whips Up Suspense
As that date approaches, the folks who create news have been flogging the story with headlines like these:
"Is Washington Ready for the Death of Obamacare?"
"Obamacare Faces The Abyss. Again."
"Premiums Could Increase as Much As 774% if Subsidies Ruled Illegal"
After all, the media know that fear sells. And if they can persuade the public that this case is a cliffhanger, their audience might follow it for weeks.
2012 All Over Again
HealthBeat readers may remember that this is exactly what happened back in 2012 when the Supremes heard a challenge to Obamacare's "individual mandate."
I wrote about that case on March 26, 2012, the day that the Court began to hear oral arguments.
At the time, I observed: "For months, the media has been feasting on the story, calling it 'The Case That Could Change Health Care Forever.’ Yesterday, the Baltimore Sun declared: 'The most important six hours of recent American history will start to unfold on Monday.'
"No question" I admitted, "the story is sizzling. And I hate to be a wet blanket. But let me suggest that the hullaballoo is totally unwarranted
"I cannot believe for a minute that this Court wants to go down in history as the Gang of Nine that quashed the most important piece of legislation that Congress has passed in 47 years. If the Court strikes down the Obama administration's signature legislation . . . it risks undermining its own credibility, shredding what is left of its reputation for political neutrality."
So I was not surprised in June of 2012 when the Court confirmed that Obamcare's individual mandate was constitutional, ruling 5 to 4, with Chief Justice Roberts providing the swing vote.
This time around, I expect that SCOTUS will once again stand by the ACA, for many of the same reasons.
A More Seasoned Perspective
The media's memory is short. Its mandate after all, is to focus on today's news.
By contrast Jim Jaffe is a pragmatic and experienced beltway observer. For 16 years, he worked for House Democrats who served on the Ways and Means Committee, apprenticing with Representatives Green, Gibbons and Gephardt before being hired by Chairman Dan Rostenkowski where he was, as he puts it, "the staff person/henchman (depending on your perspective) assigned to dealing with the media."
Jaffe has seen the same movie more than once, and knows that, no matter how they grandly they posture, both politicians and Supreme Court Justices are constrained by the reality of what has happened in the past. The court calls it “precedent.” They cannot just wipe the slate clean and start over. And this applies to Obamacare’s critics on the left as well as its enemies on the right.
Last week, I received an email from Jaffe, a long-time HealthBeat reader.
“Health reform isn't newsworthy any more," Jim Jaffe wrote, "instead, we call it history." I know Jaffe and I realized that when the said that the Affordable Care Act is "history," he meant that it's a "done deal"–here to stay.
To illustrate his point he also sent me a column that he had just published on the Huffington Post titled "The Health Reform War Has Been Won."
There, he concedes: "There will continue to be attacks from extremists in caves on both sides who refuse to acknowledge that the war is over and continue to lob grenades in an effort to enlarge consumer choice (from the right) or enact a single-payer scheme (from the left), but these are becoming increasingly irrelevant minor distractions.”
It might seem cavalier to call “King vs. Burwell” a minor distraction. After all, if you take the challenge seriously, the stakes are enormous. But as Jeffrey Toobin has pointed out “there is a smallness about this lawsuit.” It is petty, and the legal basis for the challenge is flimsy.
Why the ACA is "History"
The Affordable Care Act passed Congress five years ago.
Since then the Republicans in Congress have tried to repeal or defund the ACA 67 times. Sixty-seven times they have failed.
In 2014 about 8 million people signed up for private insurance coverage.
This year, 11.4 million enrolled.
Approximately 85% of those who purchased insurance in the Exchanges this year received subsidies—and they expect to get them next year
Obamacare is beginning to move toward its ultimate goal: the share of Americans who are uninsured has plummeted from 18% in the 1st quarter of 2013 to 13.4% in the 3rd quarter of 2014.
In other words, the train hasn't just left the station; it has crisscrossed the nation—leaving its track marks all over a health care system that accounts for about one-fifth of GDP. Obamacare has created jobs, and has steered investments to confom with, and take advantage of, the ACA.
But it is not just its effect on the economy that is important: the ACA has transformed cultural expectations in a way that cannot be rolled back.
This challenge came too late. If Obamacare's opponents had managed to bring it to the Court before people began to receive subsidies, it might have had a chance (assuming the majority of the court was willing to vote its politics, and not the law.)
Let me be clear: when I say that the ACA is now part of history, I am not suggesting that it is set in stone. Over time Obamacare will be refined and, no doubt, improved.
Healthcare 2.0 will begin in 2016 when a new Congress and White House begin to refine the legislation. As Sarah Kliff has reported on VOX, experts who helped Democrats craft the original legislation already are discussing changes, with an eye to lowering costs while improving quality. It's possible that these could include lowering deductibles, and letting Medicare negotiate with drug-makers for lower prices.
Some in Washington say that "'the Democrats did health care,’” Zeke Emanuel, senior fellow at the Center for American Progress and a former Obama advisor on health policy told Kliff. But “You don’t ‘do’ health care once. You do health care forever. It’s not a marathon. It’s life.”
Yet even while the law will be refined, the main provisions of Obamacare will survive. Without the individual and employer mandates, the penalties and the subsidies, the overarching goal– universal healthcare– would be impossible.
Yet media pundits once again have persuaded some that President Obama's landmark legislation is about to be "gutted." At the very least, the talking heads seem to be convincing other talking heads. (Like reporters who all hang out at the same bar during a war, pundits tend to listen to and read each other.)
But I am not convinced. Indeed, I will go further: What can't happen won't.
As a practical matter, as I argue in the posts below, if the Court ruled against Obamcare, the fall-out would be too great, undermining our economy, the social contract between government and its citizens, and the integrity of the Supreme Court itself. Finally, in the end the GOP would take the hit, and Chief Justice Roberts knows this.
The caption refers to the widespread belief that when the Supreme Court rules on the latest challenge to Obamacare ("King vs. Burwell"), it will strike down most of the government subsidies that have made insurance affordable for so many middle-income and low-income families. (This lawsuit has been financed by the "Competitive Enterprise Institute," a libertarian group with long ties to tobacco disinformation campaigns, and more recently, climate change denial. The Koch brothers are among the funders of the institute.)
The Supremes are expected to announce their decision in June. If Obamacare's opponents prevail, the healthcare.gov system will have no choice but to cut off subsidies for as many as 7.5 million Americans in 34 states, including Texas and Florida, probably within a few weeks after the ruling is announced. The Kaiser Family Foundation has put together an eye-opening map revealing where subsidies are safe, and where they are at risk.
The plaintiffs’ argument turns on just five words buried in the 900-page Affordable Care Act (ACA). In a paragraph describing the tax credits that will be available to people buying policies in online marketplaces, known as “exchanges” the law describes them as "exchanges established by the state."
Seizing on that last phrase, the libertarians who masterminded this legal challenge gleefully point out that only 16 states opted to set up their own insurance exchanges. The remainder of the marketplaces were established by the federal government.
Ergo, the plaintiffs’ lawyers conclude, 34 states cannot legally offer subsidies to their citizens!
As a point of fact, if a person reads the entire ACA, he or she will discover that the law also is very clear that, if a state refuses to open an exchange, the federal government will "establish and operate such Exchange within the State."
An Absurd Argument
When the IRS drafted its rules for implementing the ACA it realized that, of course, Congress intended to make subsidies available both in the state and in the federal exchanges.
By fixating on only five words, the plaintiffs' lawyers ask the Court to ignore the broader goal of the "Patient Protection and Affordable Care Act": universal healthcare.
As Jeffrey Toobin put it in the New Yorker earlier this month: "the King case is notable mostly for the cynicism at its heart. Instead of grandeur" –which is more typical of cases brought to the highest court in the land– "there is a smallness about this lawsuit."
I agree. The plaintiffs are concocting an argument based on semantics, not ideas. It is not that the ideologues bringing this case don't understand the core mission of the ACA. They do. They know that the goal is to provide affordable health care to all Americans.
But Obamaca're opponents are quite coolly and cynically ignoring that mission while plucking a phrase out of the legislation, hoping that, if they sharpen it, by repeating it and harping on it, they can use it to carve the heart out of Obamacare.
Think about it: if subsidies disappeared in 34 states, millions would no longer be able to afford their insurance. At that point, young healthy Americans would drop their policies, leaving the insurance pool filled with sicker, older patients who felt they had no choice but to buy coverage–even without the government’s help.
In order to pay for their care, insurers would hike premiums, and as rates levitated, more and more healthy customers would cancel their coverage. This in turn would trigger what experts call a "death spiral" as premiums rose to unaffordable heights, and insurers simply stopped offering coverage in many states.
To believe that legislators meant to offer subsidies only to people who happened to live in states that create their own exchanges is to believe that the law was consciously designed to self-destruct.
Nevertheless this is what the law's challengers are claiming, and on March 4 the Court will begin hearing oral arguments.
The Media Whips Up Suspense
As that date approaches, the folks who create news have been flogging the story with headlines like these:
"Is Washington Ready for the Death of Obamacare?"
"Obamacare Faces The Abyss. Again."
"Premiums Could Increase as Much As 774% if Subsidies Ruled Illegal"
After all, the media know that fear sells. And if they can persuade the public that this case is a cliffhanger, their audience might follow it for weeks.
2012 All Over Again
HealthBeat readers may remember that this is exactly what happened back in 2012 when the Supremes heard a challenge to Obamacare's "individual mandate."
I wrote about that case on March 26, 2012, the day that the Court began to hear oral arguments.
At the time, I observed: "For months, the media has been feasting on the story, calling it 'The Case That Could Change Health Care Forever.’ Yesterday, the Baltimore Sun declared: 'The most important six hours of recent American history will start to unfold on Monday.'
"No question" I admitted, "the story is sizzling. And I hate to be a wet blanket. But let me suggest that the hullaballoo is totally unwarranted
"I cannot believe for a minute that this Court wants to go down in history as the Gang of Nine that quashed the most important piece of legislation that Congress has passed in 47 years. If the Court strikes down the Obama administration's signature legislation . . . it risks undermining its own credibility, shredding what is left of its reputation for political neutrality."
So I was not surprised in June of 2012 when the Court confirmed that Obamcare's individual mandate was constitutional, ruling 5 to 4, with Chief Justice Roberts providing the swing vote.
This time around, I expect that SCOTUS will once again stand by the ACA, for many of the same reasons.
A More Seasoned Perspective
The media's memory is short. Its mandate after all, is to focus on today's news.
By contrast Jim Jaffe is a pragmatic and experienced beltway observer. For 16 years, he worked for House Democrats who served on the Ways and Means Committee, apprenticing with Representatives Green, Gibbons and Gephardt before being hired by Chairman Dan Rostenkowski where he was, as he puts it, "the staff person/henchman (depending on your perspective) assigned to dealing with the media."
Jaffe has seen the same movie more than once, and knows that, no matter how they grandly they posture, both politicians and Supreme Court Justices are constrained by the reality of what has happened in the past. The court calls it “precedent.” They cannot just wipe the slate clean and start over. And this applies to Obamacare’s critics on the left as well as its enemies on the right.
Last week, I received an email from Jaffe, a long-time HealthBeat reader.
“Health reform isn't newsworthy any more," Jim Jaffe wrote, "instead, we call it history." I know Jaffe and I realized that when the said that the Affordable Care Act is "history," he meant that it's a "done deal"–here to stay.
To illustrate his point he also sent me a column that he had just published on the Huffington Post titled "The Health Reform War Has Been Won."
There, he concedes: "There will continue to be attacks from extremists in caves on both sides who refuse to acknowledge that the war is over and continue to lob grenades in an effort to enlarge consumer choice (from the right) or enact a single-payer scheme (from the left), but these are becoming increasingly irrelevant minor distractions.”
It might seem cavalier to call “King vs. Burwell” a minor distraction. After all, if you take the challenge seriously, the stakes are enormous. But as Jeffrey Toobin has pointed out “there is a smallness about this lawsuit.” It is petty, and the legal basis for the challenge is flimsy.
Why the ACA is "History"
The Affordable Care Act passed Congress five years ago.
Since then the Republicans in Congress have tried to repeal or defund the ACA 67 times. Sixty-seven times they have failed.
In 2014 about 8 million people signed up for private insurance coverage.
This year, 11.4 million enrolled.
Approximately 85% of those who purchased insurance in the Exchanges this year received subsidies—and they expect to get them next year
Obamacare is beginning to move toward its ultimate goal: the share of Americans who are uninsured has plummeted from 18% in the 1st quarter of 2013 to 13.4% in the 3rd quarter of 2014.
In other words, the train hasn't just left the station; it has crisscrossed the nation—leaving its track marks all over a health care system that accounts for about one-fifth of GDP. Obamacare has created jobs, and has steered investments to confom with, and take advantage of, the ACA.
But it is not just its effect on the economy that is important: the ACA has transformed cultural expectations in a way that cannot be rolled back.
This challenge came too late. If Obamacare's opponents had managed to bring it to the Court before people began to receive subsidies, it might have had a chance (assuming the majority of the court was willing to vote its politics, and not the law.)
Let me be clear: when I say that the ACA is now part of history, I am not suggesting that it is set in stone. Over time Obamacare will be refined and, no doubt, improved.
Healthcare 2.0 will begin in 2016 when a new Congress and White House begin to refine the legislation. As Sarah Kliff has reported on VOX, experts who helped Democrats craft the original legislation already are discussing changes, with an eye to lowering costs while improving quality. It's possible that these could include lowering deductibles, and letting Medicare negotiate with drug-makers for lower prices.
Some in Washington say that "'the Democrats did health care,’” Zeke Emanuel, senior fellow at the Center for American Progress and a former Obama advisor on health policy told Kliff. But “You don’t ‘do’ health care once. You do health care forever. It’s not a marathon. It’s life.”
Yet even while the law will be refined, the main provisions of Obamacare will survive. Without the individual and employer mandates, the penalties and the subsidies, the overarching goal– universal healthcare– would be impossible.
Yet media pundits once again have persuaded some that President Obama's landmark legislation is about to be "gutted." At the very least, the talking heads seem to be convincing other talking heads. (Like reporters who all hang out at the same bar during a war, pundits tend to listen to and read each other.)
But I am not convinced. Indeed, I will go further: What can't happen won't.
As a practical matter, as I argue in the posts below, if the Court ruled against Obamcare, the fall-out would be too great, undermining our economy, the social contract between government and its citizens, and the integrity of the Supreme Court itself. Finally, in the end the GOP would take the hit, and Chief Justice Roberts knows this.
Clinical Man–by Clifton Meador
Editor’s Note–
Below, a post by Dr. Clifton Meador, author of more than a dozen insightful, often witty books including Sketches of a Small Town, Circa 1940 and True Medical Detective Stories. (When reviewing Sketches on Amazon, I compared Meador to Mark Twain.)
One of Meador’s best-known pieces is a tale set in the not too distant future titled "The Last Well Person.” The story, which was published as an “Occasional Note” in NEJM in 1994, uses satire to comment on the folly of our obsessive drive to test and screen every well person in America–until we find something wrong with each and every one of them. That “Note” ultimately inspired Dr. Nortin Hadler to write a book that would help many begin to understand what is wrong with American healthcare: The Last Well Person: How to Stay Well Despite the Health Care System. (2007)
This is not the first time that Clifton Meador has published on HealthBeat. Some of his most popular posts include:
–”The Mind-Body Connection: Could Psycho Somatic Conditions Account for 30% of Chronic Conditions?
–”Unheard Hearts–a Metaphor”
– “How Medicine Became a Growth Business;”
Today, Meador is a professor of clinical medicine at Vanderbilt. The essay below originally appeared Oin The Pharos of Alpha Omega Alpha Honor Society, November 2011, and was recently cross-posted on The Health Care Blog (THCB)
A Postscript: When Meador posted “Cllinical Man” on THCB, a reader asked: “What is your purpose tk tk “ She repeated the question more than once. When I asked Meador for permission to cross-post this essay, he suggested that I try to answer her query.
After thinking about the reader’s question, it strikes me that Meador is trying to warn us that in our increasingly paranoid culture, we are unable to simply live, without worrying that death is waiting around the corner. As Meador puts it: “Feeling good is not enough. There must be objective data that nothing is wrong.”
So, we go for another screening, to make absolutely sure that we don’t have cancer.
Why are we so afraid? Why is PSA testing for prostate cancer so much more popular in the US. than in Europe–even though the U.S. Preventive Services Task Force has toold that there is no sold evidence that the benefits outweigh this risks.?
This TK which appeared where suggests that Americans bombarded with advertisements. . . (URL)
I can’t help but think of this hospital ad
M. M
Clinical Man
by Clifton Meador
In 1994, I recorded a fictitious interview with the person whom I imagined to be the last well person on earth. (1) I mistakenly thought well people were disappearing and I wanted to call attention to their disappearance. I missed the big picture and now want to correct my misconceptions. Well people are not disappearing; instead, a new species of man is emerging: homo clinicus.
An evolution of the symbiotic relationship between man and medicine has been going on for some time. Lewis Thomas deserves the credit for an early spotting of the new species, first observed in America. He called our attention to this phenomenon in the 1970s.
Nothing has changed so much in the health-care system over the past 25 years as the public's perception of its own health. The change amounts to a loss of confidence in the human form. The general belief these days seems to be that the body is fundamentally flawed, subject to disintegration at any moment, always on the verge of mortal disease, always in need of continual monitoring and support by health-care professionals. This is a new phenomenon in our society.
There has been a progression of terms for this new species. First, there was the "early sick" then "the worried well." That was followed by "the worried sick." We now have arrived at a definable new species that differs from pre-clinical man.
Pre-clinical man lived largely with medicine out of his consciousness. In fact he lived to avoid medicine. Those of us who are still pre-clinical will recall the earlier saying, "An apple a day keeps the doctor away." That is almost pure pre-clinical thinking. Pre-clinical man only went to the doctor when he was sick or injured. It was up to pre-clinical man to decide if he was sick or well. It did not take a physician to make that decision. If he felt all right he was well; if he felt sick he was sick. Not so with clinical man. Feelings are no longer a reliable guide to health. Feeling good is not enough. There must be objective data that nothing is wrong. That's the problem. Something is always wrong if you look long and hard enough at or inside any human. As a medical resident told a colleague, "A well person is someone who has not been worked up. We can always find something wrong, if we look hard enough."
Clinical man is neither sick nor well. He is simply in clinical limbo. As you will see in the definitions of this new species below, he is always under medical surveillance. Clinical man requires it. More importantly, medicine requires it. Clinical man either has something that is not quite right or something that needs to be rechecked.
Medicine and man have evolved in a symbiotic manner – like the whale with those little fish that swim in and out of the whale's mouth. The fish need the whale for food particles and the whale needs the fish for dental hygiene –something like that. There is nothing strange about this symbiosis of medicine and man. Big medicine needs clinical man and clinical man needs big medicine. That's just the way it is. Where would all the endoscopists be without clinical man? And what about all those proceduralists who do interventions and biopsies? What would we do with all the CAT scans and MRIs and PET scans without clinical man? How would all the surgi-centers and imaging centers and stand-alone diagnostic centers survive without a long line of clinical men? Don't forget the insatiable needs of big pharma and the relentless mongering of created, pseudo diseases on television.
Clinical man goes to the doctor when not sick. That's part of the definition of the new species. No longer able to decide by themselves, they come in increasing numbers to find out if they are sick or well. Some even demand to know what disease might loom in the future for them.
Here are a few of the characteristics of clinical man:
Knows his cholesterol level within 10 milligrams percent.
Has been biopsied in at least one non-palpable organ by age fifty.
Has been biopsied in a palpable organ by age forty.
Has had at least one major orifice endoscoped within the past twelve months.
Is always waiting on a biopsy report or a repeat of a borderline or false positive lab result.
Never goes more than twelve months without medical contact.
How did this evolution from an avoidance of medicine to medicine becoming a necessity occur? It is actually quite simple; medicine has been assigned successes by television and the public that are not attributable to medical care. Nearly all of the increases in health and life expectancy from birth are traceable to public health measures, clean water and milk, vaccinations, and a myriad of positive effects of the age of modernization.
It is a strange irony that at a time of maximum health, more people than ever are coming to see doctors. Preclinical man will soon be extinct.
1. Meador CK. The Last Well Person. New England Journal of Medicine 1994; 330: 440 –41.
2. Thomas L. On the Science and Technology of Medicine. In: Knowles J, editor. Doing Better and Feeling Worse: Health in the United States. New York: W.W. Norton; 1977: 43.
* The term Clinical Man includes both the male and female gender.
Clifton Meador is a professor of clinical medicine at Vanderbilt. Clinical Man originally appeared Oin The Pharos of Alpha Omega Alpha Honor Society, November 2011. Republished with the author's permission.
Below, a post by Dr. Clifton Meador, author of more than a dozen insightful, often witty books including Sketches of a Small Town, Circa 1940 and True Medical Detective Stories. (When reviewing Sketches on Amazon, I compared Meador to Mark Twain.)
One of Meador’s best-known pieces is a tale set in the not too distant future titled "The Last Well Person.” The story, which was published as an “Occasional Note” in NEJM in 1994, uses satire to comment on the folly of our obsessive drive to test and screen every well person in America–until we find something wrong with each and every one of them. That “Note” ultimately inspired Dr. Nortin Hadler to write a book that would help many begin to understand what is wrong with American healthcare: The Last Well Person: How to Stay Well Despite the Health Care System. (2007)
This is not the first time that Clifton Meador has published on HealthBeat. Some of his most popular posts include:
–”The Mind-Body Connection: Could Psycho Somatic Conditions Account for 30% of Chronic Conditions?
–”Unheard Hearts–a Metaphor”
– “How Medicine Became a Growth Business;”
Today, Meador is a professor of clinical medicine at Vanderbilt. The essay below originally appeared Oin The Pharos of Alpha Omega Alpha Honor Society, November 2011, and was recently cross-posted on The Health Care Blog (THCB)
A Postscript: When Meador posted “Cllinical Man” on THCB, a reader asked: “What is your purpose tk tk “ She repeated the question more than once. When I asked Meador for permission to cross-post this essay, he suggested that I try to answer her query.
After thinking about the reader’s question, it strikes me that Meador is trying to warn us that in our increasingly paranoid culture, we are unable to simply live, without worrying that death is waiting around the corner. As Meador puts it: “Feeling good is not enough. There must be objective data that nothing is wrong.”
So, we go for another screening, to make absolutely sure that we don’t have cancer.
Why are we so afraid? Why is PSA testing for prostate cancer so much more popular in the US. than in Europe–even though the U.S. Preventive Services Task Force has toold that there is no sold evidence that the benefits outweigh this risks.?
This TK which appeared where suggests that Americans bombarded with advertisements. . . (URL)
I can’t help but think of this hospital ad
M. M
Clinical Man
by Clifton Meador
In 1994, I recorded a fictitious interview with the person whom I imagined to be the last well person on earth. (1) I mistakenly thought well people were disappearing and I wanted to call attention to their disappearance. I missed the big picture and now want to correct my misconceptions. Well people are not disappearing; instead, a new species of man is emerging: homo clinicus.
An evolution of the symbiotic relationship between man and medicine has been going on for some time. Lewis Thomas deserves the credit for an early spotting of the new species, first observed in America. He called our attention to this phenomenon in the 1970s.
Nothing has changed so much in the health-care system over the past 25 years as the public's perception of its own health. The change amounts to a loss of confidence in the human form. The general belief these days seems to be that the body is fundamentally flawed, subject to disintegration at any moment, always on the verge of mortal disease, always in need of continual monitoring and support by health-care professionals. This is a new phenomenon in our society.
There has been a progression of terms for this new species. First, there was the "early sick" then "the worried well." That was followed by "the worried sick." We now have arrived at a definable new species that differs from pre-clinical man.
Pre-clinical man lived largely with medicine out of his consciousness. In fact he lived to avoid medicine. Those of us who are still pre-clinical will recall the earlier saying, "An apple a day keeps the doctor away." That is almost pure pre-clinical thinking. Pre-clinical man only went to the doctor when he was sick or injured. It was up to pre-clinical man to decide if he was sick or well. It did not take a physician to make that decision. If he felt all right he was well; if he felt sick he was sick. Not so with clinical man. Feelings are no longer a reliable guide to health. Feeling good is not enough. There must be objective data that nothing is wrong. That's the problem. Something is always wrong if you look long and hard enough at or inside any human. As a medical resident told a colleague, "A well person is someone who has not been worked up. We can always find something wrong, if we look hard enough."
Clinical man is neither sick nor well. He is simply in clinical limbo. As you will see in the definitions of this new species below, he is always under medical surveillance. Clinical man requires it. More importantly, medicine requires it. Clinical man either has something that is not quite right or something that needs to be rechecked.
Medicine and man have evolved in a symbiotic manner – like the whale with those little fish that swim in and out of the whale's mouth. The fish need the whale for food particles and the whale needs the fish for dental hygiene –something like that. There is nothing strange about this symbiosis of medicine and man. Big medicine needs clinical man and clinical man needs big medicine. That's just the way it is. Where would all the endoscopists be without clinical man? And what about all those proceduralists who do interventions and biopsies? What would we do with all the CAT scans and MRIs and PET scans without clinical man? How would all the surgi-centers and imaging centers and stand-alone diagnostic centers survive without a long line of clinical men? Don't forget the insatiable needs of big pharma and the relentless mongering of created, pseudo diseases on television.
Clinical man goes to the doctor when not sick. That's part of the definition of the new species. No longer able to decide by themselves, they come in increasing numbers to find out if they are sick or well. Some even demand to know what disease might loom in the future for them.
Here are a few of the characteristics of clinical man:
Knows his cholesterol level within 10 milligrams percent.
Has been biopsied in at least one non-palpable organ by age fifty.
Has been biopsied in a palpable organ by age forty.
Has had at least one major orifice endoscoped within the past twelve months.
Is always waiting on a biopsy report or a repeat of a borderline or false positive lab result.
Never goes more than twelve months without medical contact.
How did this evolution from an avoidance of medicine to medicine becoming a necessity occur? It is actually quite simple; medicine has been assigned successes by television and the public that are not attributable to medical care. Nearly all of the increases in health and life expectancy from birth are traceable to public health measures, clean water and milk, vaccinations, and a myriad of positive effects of the age of modernization.
It is a strange irony that at a time of maximum health, more people than ever are coming to see doctors. Preclinical man will soon be extinct.
1. Meador CK. The Last Well Person. New England Journal of Medicine 1994; 330: 440 –41.
2. Thomas L. On the Science and Technology of Medicine. In: Knowles J, editor. Doing Better and Feeling Worse: Health in the United States. New York: W.W. Norton; 1977: 43.
* The term Clinical Man includes both the male and female gender.
Clifton Meador is a professor of clinical medicine at Vanderbilt. Clinical Man originally appeared Oin The Pharos of Alpha Omega Alpha Honor Society, November 2011. Republished with the author's permission.
“Clinical Man”–by Clifton Meador (Why Do So Many Of Us Need Medical Tests to Tell Us That We Are Well?)
Editor’s Note–
Below, a post by Dr. Clifton Meador, author of more than a dozen insightful, often witty books including Sketches of a Small Town, Circa 1940 and True Medical Detective Stories. (When reviewing Sketches on Amazon, I compared Meador to Mark Twain.)
In the post below, Meador refers to one of his best-known stories, a tale set in the not too distant future titled "The Last Well Person.” The fiction, which was published as an “Occasional Note” in NEJM in 1994, uses satire to comment on the folly of our obsessive drive to test and screen every well person in America–until we find something wrong with each and every one of them. That “Note” ultimately inspired Dr. Nortin Hadler to write a book that would help many begin to understand what is wrong with American healthcare: The Last Well Person: How to Stay Well Despite the Health Care System. (2007)
This is not the first time that Clifton Meador has published on HealthBeat. Some of his most popular posts include:
–”The Mind-Body Connection: Could Psycho Somatic Conditions Account for 30% of Chronic Conditions?
–”Unheard Hearts–a Metaphor”
– “How Medicine Became a Growth Business;”
Today, Meador is a professor of clinical medicine at Vanderbilt. The essay below originally appeared on The Pharos of Alpha Omega Alpha Honor Society, November 2011, and was recently cross-posted on The Health Care Blog (THCB)
M. M
Clinical Man
by Clifton Meador
In 1994, I recorded a fictitious interview with the person whom I imagined to be the last well person on earth. I mistakenly thought well people were disappearing and I wanted to call attention to their disappearance. I missed the big picture and now want to correct my misconceptions. Well people are not disappearing; instead, a new species of man is emerging: homo clinicus.
An evolution of the symbiotic relationship between man and medicine has been going on for some time. Lewis Thomas deserves the credit for an early spotting of the new species, first observed in America. He called our attention to this phenomenon in the 1970s.
Nothing has changed so much in the health-care system over the past 25 years as the public's perception of its own health. The change amounts to a loss of confidence in the human form. The general belief these days seems to be that the body is fundamentally flawed, subject to disintegration at any moment, always on the verge of mortal disease, always in need of continual monitoring and support by health-care professionals. This is a new phenomenon in our society.
There has been a progression of terms for this new species. First, there was the "early sick" then "the worried well." That was followed by "the worried sick." We now have arrived at a definable new species that differs from pre-clinical man.
Pre-clinical man lived largely with medicine out of his consciousness. In fact he lived to avoid medicine. Those of us who are still pre-clinical will recall the earlier saying, "An apple a day keeps the doctor away." That is almost pure pre-clinical thinking. Pre-clinical man only went to the doctor when he was sick or injured. It was up to pre-clinical man to decide if he was sick or well. It did not take a physician to make that decision. If he felt all right he was well; if he felt sick he was sick. Not so with clinical man. Feelings are no longer a reliable guide to health. Feeling good is not enough. There must be objective data that nothing is wrong. That's the problem. Something is always wrong if you look long and hard enough at or inside any human. As a medical resident told a colleague, "A well person is someone who has not been worked up. We can always find something wrong, if we look hard enough."
Clinical man is neither sick nor well. He is simply in clinical limbo. As you will see in the definitions of this new species below, he is always under medical surveillance. Clinical man requires it. More importantly, medicine requires it. Clinical man either has something that is not quite right or something that needs to be rechecked.
Medicine and man have evolved in a symbiotic manner – like the whale with those little fish that swim in and out of the whale's mouth. The fish need the whale for food particles and the whale needs the fish for dental hygiene –something like that. There is nothing strange about this symbiosis of medicine and man. Big medicine needs clinical man and clinical man needs big medicine. That's just the way it is. Where would all the endoscopists be without clinical man? And what about all those proceduralists who do interventions and biopsies? What would we do with all the CAT scans and MRIs and PET scans without clinical man? How would all the surgi-centers and imaging centers and stand-alone diagnostic centers survive without a long line of clinical men? Don't forget the insatiable needs of big pharma and the relentless mongering of created, pseudo diseases on television.
Clinical man goes to the doctor when not sick. That's part of the definition of the new species. No longer able to decide by themselves, they come in increasing numbers to find out if they are sick or well. Some even demand to know what disease might loom in the future for them.
Here are a few of the characteristics of clinical man:
Knows his cholesterol level within 10 milligrams percent.
Has been biopsied in at least one non-palpable organ by age fifty.
Has been biopsied in a palpable organ by age forty.
Has had at least one major orifice endoscoped within the past twelve months.
Is always waiting on a biopsy report or a repeat of a borderline or false positive lab result.
Never goes more than twelve months without medical contact.
How did this evolution from an avoidance of medicine to medicine becoming a necessity occur? It is actually quite simple; medicine has been assigned successes by television and the public that are not attributable to medical care. Nearly all of the increases in health and life expectancy from birth are traceable to public health measures, clean water and milk, vaccinations, and a myriad of positive effects of the age of modernization.
It is a strange irony that at a time of maximum health, more people than ever are coming to see doctors. Preclinical man will soon be extinct
Below, a post by Dr. Clifton Meador, author of more than a dozen insightful, often witty books including Sketches of a Small Town, Circa 1940 and True Medical Detective Stories. (When reviewing Sketches on Amazon, I compared Meador to Mark Twain.)
In the post below, Meador refers to one of his best-known stories, a tale set in the not too distant future titled "The Last Well Person.” The fiction, which was published as an “Occasional Note” in NEJM in 1994, uses satire to comment on the folly of our obsessive drive to test and screen every well person in America–until we find something wrong with each and every one of them. That “Note” ultimately inspired Dr. Nortin Hadler to write a book that would help many begin to understand what is wrong with American healthcare: The Last Well Person: How to Stay Well Despite the Health Care System. (2007)
This is not the first time that Clifton Meador has published on HealthBeat. Some of his most popular posts include:
–”The Mind-Body Connection: Could Psycho Somatic Conditions Account for 30% of Chronic Conditions?
–”Unheard Hearts–a Metaphor”
– “How Medicine Became a Growth Business;”
Today, Meador is a professor of clinical medicine at Vanderbilt. The essay below originally appeared on The Pharos of Alpha Omega Alpha Honor Society, November 2011, and was recently cross-posted on The Health Care Blog (THCB)
M. M
Clinical Man
by Clifton Meador
In 1994, I recorded a fictitious interview with the person whom I imagined to be the last well person on earth. I mistakenly thought well people were disappearing and I wanted to call attention to their disappearance. I missed the big picture and now want to correct my misconceptions. Well people are not disappearing; instead, a new species of man is emerging: homo clinicus.
An evolution of the symbiotic relationship between man and medicine has been going on for some time. Lewis Thomas deserves the credit for an early spotting of the new species, first observed in America. He called our attention to this phenomenon in the 1970s.
Nothing has changed so much in the health-care system over the past 25 years as the public's perception of its own health. The change amounts to a loss of confidence in the human form. The general belief these days seems to be that the body is fundamentally flawed, subject to disintegration at any moment, always on the verge of mortal disease, always in need of continual monitoring and support by health-care professionals. This is a new phenomenon in our society.
There has been a progression of terms for this new species. First, there was the "early sick" then "the worried well." That was followed by "the worried sick." We now have arrived at a definable new species that differs from pre-clinical man.
Pre-clinical man lived largely with medicine out of his consciousness. In fact he lived to avoid medicine. Those of us who are still pre-clinical will recall the earlier saying, "An apple a day keeps the doctor away." That is almost pure pre-clinical thinking. Pre-clinical man only went to the doctor when he was sick or injured. It was up to pre-clinical man to decide if he was sick or well. It did not take a physician to make that decision. If he felt all right he was well; if he felt sick he was sick. Not so with clinical man. Feelings are no longer a reliable guide to health. Feeling good is not enough. There must be objective data that nothing is wrong. That's the problem. Something is always wrong if you look long and hard enough at or inside any human. As a medical resident told a colleague, "A well person is someone who has not been worked up. We can always find something wrong, if we look hard enough."
Clinical man is neither sick nor well. He is simply in clinical limbo. As you will see in the definitions of this new species below, he is always under medical surveillance. Clinical man requires it. More importantly, medicine requires it. Clinical man either has something that is not quite right or something that needs to be rechecked.
Medicine and man have evolved in a symbiotic manner – like the whale with those little fish that swim in and out of the whale's mouth. The fish need the whale for food particles and the whale needs the fish for dental hygiene –something like that. There is nothing strange about this symbiosis of medicine and man. Big medicine needs clinical man and clinical man needs big medicine. That's just the way it is. Where would all the endoscopists be without clinical man? And what about all those proceduralists who do interventions and biopsies? What would we do with all the CAT scans and MRIs and PET scans without clinical man? How would all the surgi-centers and imaging centers and stand-alone diagnostic centers survive without a long line of clinical men? Don't forget the insatiable needs of big pharma and the relentless mongering of created, pseudo diseases on television.
Clinical man goes to the doctor when not sick. That's part of the definition of the new species. No longer able to decide by themselves, they come in increasing numbers to find out if they are sick or well. Some even demand to know what disease might loom in the future for them.
Here are a few of the characteristics of clinical man:
Knows his cholesterol level within 10 milligrams percent.
Has been biopsied in at least one non-palpable organ by age fifty.
Has been biopsied in a palpable organ by age forty.
Has had at least one major orifice endoscoped within the past twelve months.
Is always waiting on a biopsy report or a repeat of a borderline or false positive lab result.
Never goes more than twelve months without medical contact.
How did this evolution from an avoidance of medicine to medicine becoming a necessity occur? It is actually quite simple; medicine has been assigned successes by television and the public that are not attributable to medical care. Nearly all of the increases in health and life expectancy from birth are traceable to public health measures, clean water and milk, vaccinations, and a myriad of positive effects of the age of modernization.
It is a strange irony that at a time of maximum health, more people than ever are coming to see doctors. Preclinical man will soon be extinct
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