Category Archives: obesity


Over at his blog, the Six Pack Doc talks about balancing caloric intake after you have had a bad nutritional day, pigging out on food and causing nutritional havoc.
If you want to share the gory details of his nutritional excesses, please go there, and spare me!


According to a Japanese study published in the British Medical Journal, if you eat fast, and you eat till you are full, you are likely to be fatter: by three times! What you eat makes you fat, how much you eat also does so, but how you eat is also important. Weight gain from eating fast or till fullness is independent of total energy intake.
It makes sense for weight-watchers to eat slowly. The more you chew your food, the faster the satiety. If you are prone to gulp down your food, you tend to eat more. This is why television dinners are such an important factor in weight gain, especially in children. Among the interventions recommended to reduce the obesity epidemic in school children, reducing the time television is watched has been considered one of the most important.
In the Japanese study, eating fast till fullness is associated with insulin resistance, a condition that accounts for that pot belly that is so troublesome to get rid of.
Moral of the story: eat slowly, like the Italians, and eat smaller, more frequent meals.


The recent controversy about the ENHANCE study is an important illustration of a serious and long-standing problem with the medical profession, and its allied siblings.

What is the ENHANCE study all about? Surely not a penis-enlargement issue, my readers may be forgiven for wondering even fleetingly. Well, it is a study on two treatment modalities for patients with high lipid (cholesterol, for example) levels. But, first, the basics.

You may have high lipid levels because of genetic reasons, or because you eat, drink, or smoke too much. Many of us are obese, too. Traditionally, if you have high cholesterol, apart from the usually discarded ‘lose weight-do exercise’ kind of advice to the patient, your doctor would give you drugs. These lipid-lowering drugs are called, broadly, statins. One of the most common ones today is Lipitor (atorvastatin).

Why is it important to lower cholesterol? Because high cholesterol can lead to fatty plaques being deposited in the coronary arteries (atherosclerosis), leading to a heart attack.

Statins are prescribed to millions of patients around the world, including those with heart disease, hypertension and diabetes (conditions commonly associated with high lipid levels). All statins act by blocking a liver enzyme that normally results in the formation of cholesterol.

The problems with statins are mostly with their cost and side effects. In addition, in a number of patients, they don’t work well enough. Increasing the dose may increase the side effects. So, what can your doctor do in this kind of scenario?

Enter Ezetimibe. This drug reduces the absorption of cholesterol from the intestines, which bear the brunt of all the cholesterol-rich good things in life that the mouth (along with the mind it carries) chases relentlessly.

With me so far?

So, you have statins that reduce cholesterol, and you have ezetimibe, that also does the same in a different way. Why not combine the two? Will surely work better, and reduce the fatty deposits in your coronary arteries, logically. Merck did that in collaboration with Schering-Plough, with Zetia (ezemitibe) and Vytorin (a $5 billion product).
A 30-day course of Vytorin costs around $100, while Zetia costs $93, compared to $32 for a course of generic simvastatin.

That is what the ENHANCE trial was supposed to prove. Unfortunately, it did not show any such benefit.

However, some experts are discounting the trial, saying it is not a fair representation of the truth, that it is botched, and that they would wait for further trials before changing their prescriptions away from Zetia. Around 60% of doctors, however, are likely to stop prescribing the drug. Obviously, it would be a catastrophe for the company, reeling as it still is from the Vioxx losses. Merck stocks have slid down after this trial has come to light.

The important issue that has come up again in this debate is captured in two quotes:

The main problem is that after six years on the market, there are no data for ezetimibe demonstrating any health outcome benefit. In the absence of any demonstrable effect beyond LDL lowering, nearly one million prescriptions per week are written for ezetimibe. Is this rational?

If the ENHANCE trial had shown regression of atherosclerosis or slowed progression, both the company and advocates of ezetimibe would be trumpeting the results as a landmark study. Now that the trial has failed, they describe ENHANCE as a small and unimportant imaging study. You can’t have it both ways!

THAT, ladies and gentlemen, captures a huge truth. Much of what we do as doctors stems from trials that prove one or the other. Products become available commercially, too, and we are tempted or habituated to use them, especially if treated well at cruises and exotic junkets. However, as clinicians, we would still want to do better for the patient, and refine our treatment methods as evidence improves. Therefore, it is vital that we know which data is proven, and which is putative, suggestive or alleged.

That, however, is a tall order!

(Sources: Heartwire and Medscape)


The New England Journal of Medicine has published, today, a few leading articles on the subject of child obesity, especially its implications for heart disease and the costs thereof to society. For more on childhood obesity, see my previous post.
The Journal pontificates on the subject and calls for action:

Unfortunately, the U.S. government has thus far invested only a fraction of a cent in research for every dollar that obesity costs society. And although broad consensus exists regarding the dietary and lifestyle habits needed to prevent and treat childhood obesity, we lack anything resembling a comprehensive strategy for encouraging children to eat a healthful diet and engage in physical activity. Such a strategy would include legislation that regulates junk-food advertising, provides adequate funding for decent lunches and regular physical activities at school, restructures the farm-subsidies program to favor nutrient-dense rather than calorie-dense produce, and mandates insurance coverage for preventing and treating pediatric obesity.

In other words, what it is saying is that the responsibility for some kids becoming fat should be shared by all of society, and that no kid should be exposed freely to a Macdonald’s burger or French fries. Not even an ad of the same.

It is, therefore, suggesting that tax money be spent on providing nutritious lunches in schools, and providing gyms and playgrounds for the kids. In addition, it is advocating insurance for all kids. The question I have for the learned journal is: Who is going to pay for it? And why?
Can one dare ask the high-and-mighty Journal, “What gives you the right to assume that State-funded care is all that is possible to tackle healthcare issues? As far as the issue of taxing people for these services, may I ask: By what right?”
What gives an obese kid (or anyone else, for that matter) the right to be a recipient of a part of my hard-earned money, unless I choose to do so?

The Journal assumes a Socialist position on healthcare rather casually.

Elsewhere in the same issue, it thunders on the cough preparations for children (that have been scientifically proven to be useless) and calls for banning them or, at the least, banning the ads. In other words, if your child has a persistent cough, and you want him or her to just take a bit of cough syrup and sleep it off, you don’t have the right. They have the right to stop you. You, the user, can do nothing. You see, you don’t have the brains to know which is good for your kid, or which ad to believe and which one to dismiss as crap. The Government will do this thinking for you.

To get back to the issue of child obesity, the most important things are for each of us to choose consciously what we need to do: watch less television, avoid junk food, and play or work out every day, for example. I accept that all this is easily said, but not done. The responsibility and the outcome squarely rests on the individual, his parent and his doctor.

The NEJM would have none of this. It would want everyone to be deprived of their choices (ads and junk food) just so that some of society would benefit. It is a moot point if any of these interventions will ever work on a large scale in society.
It gets shrill as it raises its political voice:

But why should Mr. and Ms. G.’s efforts to protect their children from life-threatening illness be undermined by massive marketing campaigns from the manufacturers of junk food? Why are their children subjected to the temptation of such food in the school cafeteria and vending machines? Why don’t they have the opportunity to exercise their bodies during the school day? And why must Mr. and Ms. G. fight with their insurance company for reimbursement to cover the costs of their children’s care at the OWL clinic?

Hello, did we hear right? We are all subjected to temptation. I want to be subjected to temptation: do I have a right or not? The NEJM says no, because temptation is bad for kids, at least some kids.

Isn’t a defence against rape to the effect that “she tempted me, it wasn’t my fault!”? So where is the concept of free will here? Where is the parental or school responsibility for the health of the children? Who, gentlemen, are going to pay for those ‘opportunities’ that you demand?

Every modern health problem seems to inspire Statist solutions, irrespective of the fact that State control in anything has not worked anywhere as well as capitalist solutions. Unfortunately, people living in First World countries and occupying prestigious chairs in the NEJM have not (possibly) seen the ground reality of Socialism in healthcare. They need look no further than India.

I wish to ask one final question to the Editors of the NEJM: Is the NEJM a leftist journal mag?


Children are getting fatter. Seriously fatter. To the extent that they are getting all sorts of major, adult-type ailments like diabetes, hypertension, heart disease, acid reflux, orthopedic problems, psychiatric problems, sleep apnea, etc. These kids are not a tiny minority. In the West, they are around a third of all kids.

In Indian society, 70% of kids are too thin to be called normal. Amongst Indian children obesity affects, almost exclusively, urban kids. In several studies, the incidence of weight problems (mild to severe) in urban Indian kids has been as high as 30 percent. In the West, a third of the children are already obese, and around 80% of these are likely to grow up into fat adults. The incidence is expected to grow (more in minorities and the poor), and the obesity epidemic has three phases.

Quote from the New England Journal of Medicine:

Phase 1 began in the early 1970s and is ongoing: average weight is progressively increasing among children from all socioeconomic levels, racial and ethnic groups, and regions of the country.
Though it has attracted much attention from the medical profession and the public, childhood obesity during this phase has actually had little effect on public health, because an obese child may remain relatively healthy for years.

Phase 2, which we are now entering, is characterized by the emergence of serious weight-related problems. The diabetes, the bone problems, the psychiatric problems I mentioned initially are all part of this phase.

It may take many years to reach phase 3 of the epidemic, in which the medical complications of obesity lead to life-threatening disease.
By 2035, the prevalence of CHD (Coronary Heart Disease) will have increased by 5 to 16%, with more than 100,000 excess cases attributable to increased obesity among today’s adolescents. Preliminary data from Canada suggest that adolescents with type 2 diabetes will be at high risk for limb amputation, kidney failure requiring dialysis, and premature death.
Shockingly, the risk of dying by middle age is already two to three times as high among obese adolescent girls as it is among those of normal weight.

In Phase 4 permanent, possibly genetic changes in the body will occur and result in a cohort of hungry, fat people of all ages.

The NEJM likens this epidemic to the global warming theory, but with easier solutions.

For more on adolescent and child obesity, click here (old post of mine).


“The incredible shrinking couple”, says CNN, has lost a total of 580 pounds. No, they did not go in for bariatric surgery. They prayed to God. As did many other people. Faith-based weight loss is now a hot topic in obesity, and in the world’s obesity capital, the USA.


In August 2002, the couple was married and they soon made a decision that would forever change their lives.
Before getting married, a friend introduced Maggie to The Weigh Down Workshop, a faith-based weight loss program, which teaches people to conquer their addiction to food, as well as other substances and vices, by turning to God.

Maggie says she was never consistent or committed enough to stick with the program. But shortly after their wedding, the couple started packing on the pounds and while Andy tried another diet, Maggie gave Weigh Down another try.

“At the end of 2002 and the beginning of 2003, I called Weigh Down and started taking the classes,” says Maggie. “My whole life, I had always wanted somebody to [lose weight] with me. But I knew if I wanted it bad enough, I would have to do it alone.”

She began to lose weight.

“I ate whatever I craved, but only when I was truly hungry and then I ate a lot more slowly, so I could tell when to stop,” Maggie says.

In February 2003, after seeing his wife’s results, Andy stopped counting calories, gave up the low-fat foods and reduced his portion sizes. Fifteen months later, he had lost 257 pounds.

“Once I started this program, it changed my outlook on my entire life. I realized that being happy is a choice. I can either be filled with hate and despair or I can be happy,” says Andy, who realized he no longer needed the anti-depressants.

I went into Weigh Down, the website that is selling this program where you eat all you can and still lose weight like the featured couple.
Truly, the success stories are impressive. So, does piousness melt fat in a magical way?
Before I address that, let me underline that obesity is often the result of an eating disorder, where the victim is obsessed with eating even in the absence of hunger. In the absence of a way of addressing this mental disease, nothing will help the obese patient.
Faith-based weight loss works at this level. The participants of this program are trained to focus on God. Classes help them read the Bible, and communicate with God, all ways of taking the mental bandwidth away from food.
Babies are fed on demand. The same feeding model is used by these people: they eat when they are hungry, otherwise not. At mealtime, they eat whatever they want, irrespective of the calories.
While Gwen Shamblin of Weigh Down would have us believe that this is a divine deliverance for which she is a vehicle, the real reason why she is successful is because she has found a way whereby people can shift their attention to something they can relate to (God) and feel good at the same time. This is a form of behavioral therapy.
As a rational and objective human being, my atheism scoffs at the premise of Shamblin. However, if by turning to religion, people can increase their life-spans and stay slim, why should I complain?


I told ya!
In a previous post, in the comments section, I had mentioned the possibility that, like peptic ulcers, obesity would be found to have not merely dietary and genetic roots, but an infectious one.
Well, read this article.
A study has shown that fat people had evidence of greater exposure to an adenovirus.
On top of that, the viruses have been found to convert stem cells to fat-grabbing cells.
So, there is definite reason to think in terms of an infectious cause, but later research will probably discard this and embrace yet another attractive theory that grabs global headlines.
This is the rum thing about medicine and surgery: when you overcome years of learning and mistakes and master something (in this case bariatric surgery: the science of surgical weight reduction), they turn around and say that the surgery is obsolete. So then you start learning the new, the hip, and the latest. Only to have to turn the whole cycle again!
My next prediction: more likely not a vaccine to prevent obesity, but a pill that knocks out the hunger center in the hypothalamus, and causes massive weight loss!

Friends united by fat!

Here is some more weird news about obesity. According to an article published in the New England Journal of Medicine, obesity tends to occur almost in synchrony within the same group of friends, even if they are in another country. Here is a news article on this.

If you are the snooty sort who likes to access the original research paper, here is how the authors say they did the study:
“We graphed the network with the use of the Kamada–Kawai algorithm in Pajek software. We generated videos of the network by means of the Social Network Image Animator (known as SoNIA). We examined whether our data conformed to theoretical network models such as the small-world,10 scale-free, and hierarchical types (see the Supplementary Appendix, available with the full text of this article at”
Understood, na? Easy! SoNIA, and yet, SoFa!

Want more? Here, take this:

“The use of a time-lagged dependent variable (lagged to the previous examination) eliminated serial correlation in the errors (evaluated with a Lagrange multiplier test) and also substantially controlled for the ego’s genetic endowment and any intrinsic, stable predisposition to obesity. The use of a lagged independent variable for an alter’s weight status controlled for homophily. The key variable of interest was an alter’s obesity at time t+1. A significant coefficient for this variable would suggest either that an alter’s weight affected an ego’s weight or that an ego and an alter experienced contemporaneous events affecting both their weights. We estimated these models in varied ego–alter pair types.”

Capital, my dear chaps! I couldn’t have put it better, myself! Nothing does the old noodle as much good as a good, invigorating read of the NEJM’s original scientific papers! Of course, for those surgeons who are too lazy to read such articles, there is always this blog, or the wires!

Hullah over Bariatric Surgery Deaths

The Times of India, I was told in hushed whispers, has run a story on some deaths that have occured in Indian patients who had undergone bariatric surgery. As I said in my last post, WTF? I mean “Why The Fuss?”
Bariatric surgery is a science that causes massive weight loss in severely obese patients. There are a few types of these, which work by reducing the amount of food that the person can eat, and by preventing full digestion and absorption of ingested food. The commonest operations are the Gastric Bypass and the Lap Band.
Now, these operations, done by the popular keyhole (laparoscopic) method, are rather painless and allow rapid return to home and the workplace. Plus there IS weight loss: big time (70% of excess body weight)!
Now this boring medical, technical-kinda blogpost takes an interesting twist: bariatric surgery does cause fatality. There is a known complication rate. But why should it hit the papers? I have known of this happening in virtually every city in the world where bariatric surgeries are done, and there is always a big ruckus, and then things go back to normal again. Why?
Bariatric Surgery has been hyped up by the surgical industry. It’s the truth, and there’s no trying to escape that. The media is always fed stories on the positive aspects of the story, but since there is little point in dampening the enthusiasm of prospective patients, the complications are rarely dealt with. And WE, the surgeons, are guilty of this. I, too, have written about this, and not just once.There has been brand-selling in the name of awareness-building. And, of course, the surgical products industry is solidly behind the initiative. These are truths. You may argue over the ethics of it, but good work does get done because of the awareness building, patients do lose weight and get cured of their diabetes and high blood pressure, and surgeons do get their next big car or mistress, and their children do go to elite schools that wipe your bank accounts clean like Coke does to toilets. But, among the positives, there is a stain of the ugly, and the faint stench of death. Surgeons may underplay the issue of complications of bariatric surgery, resulting in a high level of expectations on the side of the patients. So, whenever a death occurs, there is a jolt, a jhatka. The ensuing agitation reaches the media, and there is hullah. After a while, things become normal when the positive spin starts the next cycle. After all, obesity is always a hot topic.
And, you know what, I do bariatric surgery. I make it a point to balance the hype of the positive endpoints (weight loss, improved outlook in life, etc.) with the possible complications and the mortality risks. Because I speak candidly (“Of course, one can die after this surgery, being in a special high risk group”), I don’t get too many of these onto the operating table. But then, my fat is not on the fire, neither! That is, at least, one good thing to say about being a poor surgeon!


The Journal of the American Medical Association (JAMA) has published an article that deals with weight management programmes for obese kids.
I read this article eagerly, hoping for some new wisdom on the vexing issue of childhood and adolescent obesity, about which I am interested. Eleven authors for one study: very impressive, or… a bit suspicious? Too many authors looks like a few are free-tripping on the basis of position or something. You know, a Head of Department is also listed as an author, even though he may have done nothing more than signing his name. Anyways, I digress, as usual.

What does the article say? It says simply that where the weight reduction program was followed intensively, really hands-on, the results were better than the typical programs used before. Now it is a known fact that 95% of diet-and-exercise regimes fail to provide sustained weight loss. So how does the JAMA article make a difference? Look for yourself:
“The success of the Bright Bodies program undoubtedly relates, in part, to the frequent contacts between families and the professional staff.” Which means that the team sat on the heads of the parents and their fat kids. Obviously, they can’t do this forever, so once their attention is withdrawn, things are liable to turn back all over again.
“While the program was very successful in treating overweight children, the expense incurred in operating such a program is substantial.” Meaning to say, in other words:”Don’t even think you can afford this kind of treatment. This is only because we got big funding to enable us to publish this expensive scientific paper”.

“Future work for our group includes cost-benefit analyses, as this would be helpful for pediatric clinicians or health management organizations that are considering offering similar services to overweight children and adolescents.” Meaning “We are going to ask for more funds so that we can then publish another paper in JAMA that what we are doing is too expensive to be practical, and the State (or somebody) should allocate money for this project, which we will be happy to spearhead.”
Another article that proves that the world is round, as are our bellies!