Category Archives: weight loss

THE MAY CHALLENGE!

My brudder, the Six Pack Doc, has issued a May Challenge that calls for a 10 lb fat loss in one month while getting stronger.
Is that even possible? I think you can either lose fat or gain muscle, but not do both at the same time.
Check it out yourself then!

THE 7-DAY CHALLENGE

Over at the other blog, the Sixpackdoc throws the 7-Day Challenge at you:
“A lot of people need a kick on a part of the body occupied by the gluteus maximus muscle in order for them to do something good.
People like these (and include me in this august majority) can’t change anything in life, including the way they feel and look. Unless severely provoked. In such circumstances, ordinary people do extraordinary things.

f20042challenge-runner-posters
(pic: http://1stepcloser2im.blogspot.com/2008/05/cda-bike-course-computrainer.html)

This post is for those of you who need to shed fat. I am throwing this challenge to all of you:
Starting this Monday (or any day of the week), can you go for one week (seven days, or one hundred and sixty-eight hours) without eating one milligram of bad food?
Specifically, do you have it in you to do ALL of the following, for one full week, no excuses?

If you want to know if you have it in you to take up the challenge, read on and do it!

EFFING!

My long-suffering readers know that I am not famous for using intemperate language in this and other blogs.
The taken-aback, perineally loyal Rambophile may wonder, “Pagla gaya kya?”, which is a Hebrew expression meaning, “I love him, V Day to D Day!”. Speaking of which, incidentally, I posted on Facebook that I was wondering if, at my tender age, I should be celebrating this:
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Tender, incidentally, is not a politically correct word, in this age and context.

Do check out my short piece called ‘Microvalentine’s Day’ (old post).

Before I wade into another mile of this nonsensical ramble, I should set the record straight:
I don’t mean Effing in your kind of effing sense.
This is a radical, new verb. My invention. It intends to describe an activity that “uses E-sources for Food and Fitness.”
Brilliant, wouldn’t you say?
So, let us carry on about Effing.
This post, following on from the earth-shaking previous one titled ‘The Fat Loss Plateau and Beyond’, is focused more on the same, by popular demand.
I promise you I will talk sense, and will not bore you with statistics and evidence. I will, instead, use my anecdotal example.
I started working out in the gym an year ago. I found I was getting stronger, but I knew I had a long way to go before I could be considered fit. I also found that I had lost only so much fat in spite of a lot of effort. This is the very common conundrum that is called the fat loss plateau.
I used certain tricks that are threatening to make me the next Adonis with a six-pack neck (anywhere else, it is all so passé, so upwardly upper class!).
I got a free account in FitDay. This made me focus on exactly what I was eating on a daily basis. The results astounded me. Take a look.
This is a typical day’s intake when I was working hard and yet seeing no fat loss worth the name:

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You can see that a huge truck-load of calories was coming from carbohydrates in the flour and other grain sources, apart from sugars. Luchis are fried breads, aloo dum is fried potatoes in gravy, and samosa is a savory- fried flour pastry stuffed with spicy potatoes and a few minor vegetables.
I decided to cut that out. On the day when I fast and then break it, eating gustily in the four-hour window (read previous post on the subject linked to above), see what happens:
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I still ate rice and pancakes (the Indian equivalent) but I logged less than a hundred grams of carbs (and far too low of the proteins I need), and only half the calories I could have eaten. But that was because my mother cooked for a family get together, and who can miss out on mothers’ cooking, right? Incidentally, you can see how badly balanced a South Indian vegetarian diet is (the last four items were ‘aloo curry’, ‘sevai’, ‘kirai’ and ‘appam‘) from the chart. The names ‘ON’, and ‘ON’ powder refer to the whey protein supplement made by Optimum Nutrition. Casein is ‘channa‘- milk protein.

So, I cut out grains from my diet. I checked again, another day:
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I was still eating some rice, and worse, I was getting a lot of calories from the occasional ‘treat yourself’ sweets and the modest alcohol I drank on a given day (a get-together of family or friends). This was revealing: in spite of a conscious effort, I was still letting things slip, thereby blunting the results. I became more vigilant. Look at the typical IF day chart now:

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Violá! I was hitting the sweet spot: I was actually consuming more proteins and fats, and getting closer to the 50 grams daily dose of carbs I was looking for. I think a carb intake of up to 100 grams daily should be good enough for fat loss, especially if you eat clean and keep within your total caloric requirements. Think Primal Living.

So Intermittent Fasting works well to reduce total calorie intake, but you have to be very careful and diligent if you want to reduce your carb intake. Too often, even geniuses can eff up with their resolve, allowing the calories to slip in.
If there is one thing for the reader to take home now, it is the fact that so much of your intake is what you would forget when asked: “I don’t eat at all, but I still gain weight!” The blame is shifted to last year’s hysterectomy, gall bladder surgery, thyroid problems, baby, genetics, and even the weather!

Eating clean will bring in results, especially if you are active physically, and not merely doing what my son said (when asked about his exercise of the day), “I worked out my fingers really hard, playing FIFA World Cup on my Playstation!”

Keeping an online journal lets you be objective in analysing your results:
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So, I know how much tighter I should control my food, or when to be a little easier on myself, without losing track of the larger goals.
I also keep a mini-diary in the site, like this:
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So you think you burn a thousand calories in the treadmill, so you can hog that dinner tonight? Look at this:
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I believe I burn more than 3500 calories a day, but that does not make an effing difference to the computer! So, sadly, we have to believe the records. Moral of the story:
Keep your food journal diligently, and learn from your mistakes. It takes 5-10 minutes a day. It gives you more rewards than Twitter/Facebook/blogging, and other things for which we try to carve out some time.
Happy eating, this Valentine’s Day! Incidentally, if you think of gifting me a bottle of Ballantine’s for next year’s V Day, think of a fifty year old single malt instead. It’s twice my age!

THE FAT LOSS PLATEAU AND BEYOND

Long post alert!

Many of you may not have realised (as I have not) that this blog has become one of the most Googled sources of fat loss info in the web.

Oh, sorry! I had initially set for this intro to the post to appear in 2025, so let us not move that far ahead. Restart (not you, moron)!

I am writing on fat loss because of the insistent demands of many of my wild-eyed fans like her. “Rambodoc”, they say in different accents, “When will you shine the light on my fat? When will I lose that handle around my waste waist so that I can start looking as young as you, you delishius hunk of meat, you..” And many, many words to that effect. No, Rads did not say any of this, but we can all expect her, as a mark of her eternal gratitude for this post, to send me one of her used 7-series BMWs or, if she feels cheap, the keys to a property in Manhattan (such low prices these days!) or somewhere. Anywhere, actually.

Okay, let us now get serious here. Restart.

Fat loss stops after the initial effort in a program of diet and/or exercise. This is common knowledge. Let us first see what are the reasons for the fat loss plateau:
1. You are not working out the right way.
2. You are working out the right way (maybe you even have a great coach) but you are not eating right.
3. You are eating less calories, working out long, but your metabolism is too slow, i.e., your body burns calories slowly. A common ‘note to self’ by women, men, older men and women, hypothyroid men and women, post-menopausal women, and some other groups we may have forgotten about.
In the next few thousand words (kidding!) I will give you the juice from the research of around 935 (again!) research articles without boring you to death with the sources.
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(Fat people are easily seen everywhere even in India)

Let us simplify issues: if your body needs 2000 calories as its basic metabolic demand (known as BMR or Basal Metabolic Rate), and if you spend another, say, 400 calories in your activities, then you would need to eat less than 2400 calories a day consistently to run a calorie deficit. Right? Many of us know that you will lose a kilogram of fat if you run up a calorie deficit of around 7000 calories. So, a 500 calorie deficit a day should result in the loss of one kilo of fat in two weeks. A pound a week. Clear?
There are lots of compounding issues to this simple equation, but you still have to keep touching base with this simple reality to achieve fat loss:
Calories burnt must be greater than calories eaten.
The most important way to accelerate fat loss is to eat less calories. Not in working out. Trainers are fond of saying that “you can’t out-train a bad diet”. Very true. Unless you are Michael Phelps who, at last Census, was not known to have met a fat loss plateau.
“Oh, no! He is going to talk of diets? Not again?!” Was that you saying that? Can you see me nodding my head sympathetically, like a politician at election time?
Some more basic truisms:

All diets work. But only for some time.
Diets don’t work by themselves in the long run.

What do we do then? Studies show that only 5 percent of people on a supervised diet manage to sustain weight loss. The rest fail. That includes you and me. Let us, therefore, rephrase this:

Diets don’t work; lifestyles do.
If you do lifestyle, you never feel that you are doing something special or stressful. It comes naturally.
What is this stupid, airy, hair-splitting, you ask?
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(a typical dinner of mine, and ALL mine!)

Many people (author included) follow a lifestyle where you mimic the lifestyle of primitive man (an animal who probably did not have obesity). Which means:
* Eat whole foods that are available in nature.
* Don’t eat processed foods (meaning colas, diet colas, bread, cake, pasta, noodles, biscuits, etcetera).
* Avoid grains (rice, wheat, corn, etc.) and artificial sugars.
* Don’t eat meals at a religious rhythm (like 3 meals a day or 6 meals a day).
* Mimic the movements of primitive man (imagine Caveman Rambo with a pointed object hunting a bore boar): sprinting, waiting, sprinting again, crawling, pulling, pushing (imagine wrestling the boar before killing it finally), lifting heavy weights (taking the hunt back to the cave) and then eating it. If he fails to kill it or find some other source, he starves till the next time.
How will you do this in your 9 to 5 life in the US, UK or India?
Easy. Try these:
1. Don’t jog or walk. Sprint (as if chased by a wild dog in heat) for a few short seconds (take 20-30). Rest for a while (as many seconds as you ran or even a minute). Repeat ten times, or six, depending on your ability. That, ladies and gentlemen, is called High Intensity Interval Training (HIIT) or the Tabata workout (Tabata kept a work:rest ratio of 2:1).
In other words, stop wasting time on those cardio machines in your gym or at home. Four to twenty minutes of hard effort (including the rest periods) is enough cardio for you. A month into this, watch yourself improve your stamina and reduce the inches gradually (remember, you have to give your body time- think of one or two years, in many cases).

2. Push or pull your body weight in major, compound exercises like pull-ups (most women I see are unable to do this unless they are well advanced in fitness), push-ups (keep doing ten more than yesterday), squats, and burpees (the best of them all, I think).

3. Stop doing machine-bound training. In other words, don’t waste time in isolation exercises like biceps curls, preacher curls, pectoral decks, ab trainers, etc. You are not going into a bodybuilding competition, are you? If you want maximum bang for your buck, do the bodyweight exercises above, and also do weight training (squats, deadlifts, or anything that involves pulling or pushing a free weight against gravity).

4. Don’t waste time on ab exercises. Do a couple of planks, holding on till you die. You will have done more than enough for your abs and core stability.

5. Didn’t I say ‘crawl‘?! Yes, I did.
You can do mountain climbers, which is not really crawling, or you can actually go on your hands and feet and climb the stairs, first straight up (head first) or reverse (feet first). This would double as a great cardio workout as well.

Anything else about these exercises? Lots, but suffice it to say that you should train harder than you think possible, and not merely go through the motions. Only then can you see results! Each workout should have a decent volume, which means you could do, for instance, three sets of ten reps for each exercise, with 30-60 seconds rest in between sets. Be strict with the rest periods, avoiding chatting and vacantly meditating.

Let us now move on to nutrition, the cornerstone of fat loss management.

Most people are eating way too much to see results. They are also not eating enough proteins, which reduces their muscle building abilities.
One way to address a fat-loss diet is to cut down on carbs (carbohydrates). This is one of the most tried and tested ways of achieving fat loss. Most of the benefits of a low-carb diet accrue from a total caloric deficit. If you are given the liberty of eating loads of fats and proteins (as in the Atkins diet), you won’t be able to eat all that much for too long. Result: lack of variety in foods leading to weight loss. Someone even lost weight on one month’s continual fast food (McDonald’s, etc.) diet!

Low carb diets are often difficult for many people to follow, for cultural and habit reasons. In such a scenario, losing weight is more difficult, but a caloric deficit needs to be created.

Eating six meals a day (a popular advice for most people) is largely impractical in the long term, not least because designing a diet with such low calories is difficult. Imagine a meal with only 300 calories, for example (if you need to eat six meals within a caloric budget of 1800)! In this regard, a more doable lifestyle is IF: Intermittent Fasting.
In IF, you fast through the day, and then eat within a four hour window. You can choose to fast once a week, or every day, for 15 hours, or 24 hours. Your choice. One of the big things going for IF is that celebrities (like myself) endorse it. I fast for 24 hours once a week, and 15 to 18 hours one or two more days in the week. IF is a lot of posts on its own merit, and check my resources at the end of this chapter post, if you want to learn more. Suffice it to say that it reduces blood insulin levels, is a great way to eat ‘normally’ and yet maintain a caloric deficit. I have found that on the days I fast and then eat in the four hour window, I can’t exceed 1400 calories (I don’t pig out with junk food)!

Does when you eat matter in your fat loss plateau?

Is fasted cardio better than cardio in fed state?

Is breakfast the best meal?!

Dinner is the best meal, and you should avoid breakfast like the plague!

Controversies, controversies! Forget all this, and stick to the basics:
eat clean, work out hard, and be happy. Get enough sleep. Drink less. Be active physically. Read fitness articles and blogs. Enough!

So, if we can sum up, how does one overcome the fat loss plateau?
Reassess your diet (definitely keep an online food journal like FitDay), start IF, train harder than you ever have, change the way you are training, avoid long duration aerobic cardio in lieu of High Intensity Interval Training. Take adequate rest and get enough sleep.

Blogs on Fitness/ Primal Living I silently follow (in no particular order at all):
1. Turbulence Training
2. Fitness Black Book
3. Brian Devlin
4. Health Habits
5. Tom Venuto
6. Caleb Lee
7. Straight To The Bar
8. Mark Sisson’s The Daily Apple
9. Muscle Hack
10. Go Healthy Go Fit
11. Alwyn Cosgrove
12. Son Of Grok
13. Robertson Training Systems
14. The Nate Green Experience
15. Gym Junkies

IF Resources:
1. Brad Pilon
2. The IF Life
3. Leangains

Science-based Nutrition/Fitness sites (heavier stuff):
1. Lyle Macdonald’s Bodyrecomposition
2. Alan Aragon
3. Dr. Michael Eades

I heartily recommend any and all of the above, and I think they contribute hugely to the needs of the public seeking help over the internet. I am also very grateful to them for their advice and availability for people like me and you. I am quite sure I am missing out on some of the others I read, but I hope I can include them later.

Disclaimer: I am not a Fitness or Nutrition guru. I use my medical knowledge and apply it to my personal quest for health and fitness. If you feel the need to heed my advice, you are welcome to, at your own discretion and risk. If you suffer from any physical or mental disease or infirmity, please consult your doctor and get properly (mis)guided!

YOU ARE HOW YOU EAT!

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.

A FIRST, UNIQUE, UN-DESCRIBED BENEFIT OF STRETCHING!

You can get several resources in the web that give you sound advice on various aspects of physical fitness, like this one. In addition, you get comprehensive websites like Bodybuilding.com, where you can get videos of individual workouts you want to do perfectly, or get more knowhow. I prefer the blogs, finding them free of commercial disturbances.

In all these sites, you can find how exercise builds up your muscles, controls your blood pressure and your heart rate, bring your blood sugar levels down, and so many other things. The only thing exercise does not seem to do is to give you a hard-on.
Let us not, however, get distracted into that related minefield of calories and pelvic thrusts.

I have had a unique benefit from exercise, specifically stretching. This particular stretch consists of lying down supine, one knee folded on the other, and bringing the other knee to the chest, thereby stretching the folded one. I am sure this description is very clear, similar to the various descriptions of the Hadron Collider experiment and the physics behind it.

Okay, let me give it its proper name: the pyriformis-gluteus stretch.

(pic source: http://spyhunter007.com/Images/piriformis_gluteus_stretch.jpg)

This morning, as I was doing this, I heard an enormous pop from my right knee. If Usain Bolt had farted while running the 200 meter sprint, it must have been recorded in history as a similar sound. I am, rest assured, no Usain Bolt, either in running or in other matters. I checked my knee, and sure enough, it looked to be in one piece.

I had a long history of a cyst in the meniscus of my right knee. This was the result of an injury sustained in my college days, when I used to kick-start my Kawasaki motorbike every day, on the way to escorting pretty women who would hug me from behind. This used to be in the city of Bombay.

This cyst just ruptured today, and I am cured of the disease, thanks to my diligent exercising on my back.

Representative pictures only:

(source: here).
I am saved from one surgery.
I always knew I had it in me to be famous for doing something unique one day. Who would have known it would be for this!?

SWEET DREAMS ARE NOT MADE OF THESE!

After toiling from mid-morning to mid-afternoon, like an honest politician a few months before the all-important elections, I crash like Windows Vista when the clock strikes nine, carried away in sleep by a Blue Screen of Dreams to that land which is inhabited by Socialists and Spurned Lovers.
Now, not having any good, positive sensory stimuli through the day (one of the drawbacks of surgical practice), one would expect me to have a dream like one or more of the following:
* Giving a slurring stirring speech before the Society of American Gastrointestinal Endoscopic Surgeons in Phoenix, Arizona, after which the entire audience seems transformed into cheerleaders of a different sort.
* Being awarded the Nobel Prize for discovering that a sharp kick in the pants could cause a permanent cure of all groin hernias that largely afflict males.
* Operating on US President O’Bummer for an abdominal tumor, and calmly announcing to the waiting world, “The President had a couple of loose screws from his past operations that had created a mess in the left side of his brain (in the world of border-less clouds you can do things like that: operate on the belly and take things out from the brain). The only change this operation will have on him will be that he will look transparent, like his wife.”

Now, lest you think I am a scheming, dreaming monomaniac with a scalpel, there are other things I could have been dreaming off:
* A feast of chocolate cake. Locally, the one at Costa Coffee has me babbling like a tongue-tied Mamata Banerjee, the spit hitting the fans, so to speak.
* Becoming the Prime Minister of India and declaring war on all controls, making politics unprofitable, and putting all committees and brokers out of business, thereby increasing national unemployment significantly.

Do I not have a romantic bone in my body, you ask? Of course, I do have one! I could dream of:
* A trip to South Africa with the woman of my dreams, enjoying the Indian Ocean over a chocolate truffle cake…. (aargh! there I go again!)
* A hectic session of laugh-making with my women woman, ending in a candle-light dinner that ends with chocolate…

All said, the impatient reader, if not already lost to more serious blogs, would be wondering where I am going with this post.

I am getting old, or I am losing it. I am not dreaming of any of the above. I am not even dreaming of becoming a social worker who distributes his hardly hard-earned money like an Amar Singh. Instead, as I move in my sleep, my hands feel my sore and hard muscles, and I keep imagining me (surrounded by sundry girls lying around me) pumping hard, ‘fast out, slow in’, as I reach a climax of exertion to loud, sweaty moans.
At the gym, another target is reached, another set complete, another muscle tested. “Next set, no more rest, start!”

I think there is something seriously wrong with me. You guys must already know it, perhaps. What is it you dream of, anyways? Or is your sleep a Blue Screen of Death?

THINGS THAT HAVE BEEN BOTHERING ME

There have been a few people, incidents and things that have been occupying my mental disk space.
Here are just three of them:
1. The old man at the gym: he looks like he has swallowed an intact 75 cm Swiss (gym) ball at last night’s dinner party, and comes to the gym every day. To workout, pound the treadmill, jump ropes, and pump steel, right?
Na. He comes in, sits on a stool, and wiggles his belly so, like a fish flutters when taken out of water. He also breathes visibly. Else people would have been calling out for the Coroner. At the peak of his exertions, he is seen stretching his arms, though not his legs (too far away, you see). So, why is this man, who obviously does not need a gym as much as his verandah at home, bothering me, you ask?
Fair enough. In the meanwhile, you will have noticed me close by straining every sinew, red in the face of a Valsalva maneuver, and gasping for breath before I suddenly, you notice, look like I am having a pulmonary embolism. What happened, you think in alarm? Hungry for oxygen in the air-conditioned environs of the gym, I inhale, only to be shocked out of my wits with the most overpowering stench noticed around a human being outside a hospital. Our old man, we finally conclude (based on significantly long trials), comes to the gym not to workout his skeletal muscles, but the smooth muscles of his intestines, passing gas as regularly as he breathes. I am sure his yoga must be encouraging him to do this. What do I do? I can’t tell him to change his diet, can I? And I can’t change my gym.
I am thinking of donning an oxygen mask attached to a cylinder (taken out on loan from my hospital) and working out near him, so he catches the message. A good idea?

2. Open and close case: I go with family to the wife’s boss’ house for a formally casual dinner invite. You know, the kind where you have to pretend to be relaxed while sweating in your underpants in discomfort? Effusive praise greets me for my public work (probably blogging more than surgery). As I sit down and the pleasantries start, I realise that, enamored of my trim fit jeans and a shirt that would do a 20 year old kid proud, I had failed to notice my open zip. I surveyed the room like Samajwadi Party’s Amar Singh would have for hidden cameras prior to unrolling the sacks of cash for bribe-worthy MPs. No one was looking. I quickly zipped up. As I looked up, I saw the hostess looking at me with interest. I smiled in supreme cool, as if these things are gifts that I bestow on those I visit.

Rather, I imagine, like a Shah Rukh Khan zipping up for a chewing gum ad (“keeps your mouth zipped, but no more!”)
My wife has not stopped mentioning this incident for some time now, for whatever reasons. I am disdainful: why should an open zip be an embarrassment? Look, analyse it: what is the big deal about it? Why should anyone feel shame, unless caught on national television with visible crotch? Even if that happened, you could just quit private life, and take to politics instead.

3. A plateau in the fat loss program that is the result of one hundred and eighty mangoes. Yes, ma’am, I have been having six a day for at least the last month. At a time when the divine Chausa is reigning at the store shelves, it is heartbreaking to tell oneself that “six mangoes makes for at least a thousand calories a day EXTRA, you moron!” Especially when one has been mournfully looking at the blue Lindor truffles (the rich dark chocolate made by Lindt) without touching them, rather like how one would look at one’s beloved behind prison bars. Look-look, but no touch, wokay?!

Pic source: from here.

THE ABSENTEE BLOGDOC

The title of this post could have been “What I have been up to to have stopped blogging for so long”. Since I wasn’t sure whether, in the title, I could put into two to’s together, I desisted.

Whew. Life has been hectic, lemme tell ya!

I have been operating a lot, including some pretty difficult cases. Some sad, like a thirty year old girl who had advanced rectal cancer. I knocked off her left colon and rectum along with her uterus. She’s not gonna live too long, though chemo would give her some years, hopefully. She glares at me so angrily (she has a temporary colostomy) that I asked her, “Do you hate me, or you just angry with me?” She burst into tears and wailed “I am so scared!” I felt like a narrow-minded rat. Peculiar, that. Rats would have narrow minds and hinds, too, wouldn’t they?

On top of work, I have changed my life quite a bit without any New Year resolutions.

*For one, I have totally quit smoking, like Shane Warne has totally quit cricket and SMS-sex. The girls who have visiting rights to my mouth say they wished they could move in permadently. If you can stomach this gummy and toothfool statement.

*I eat only one sweet a day, rather (inversely) like an IPO attracts one customer a day.

*I eat rakshashoid portions of veggies and fruits daily, rather similar to the reserves of love that one of the Thackerays has for the Biharis, Gujaratis and Madrasis of Mumbai city. See pic of subject’s breakfast, for example, weighing around two pounds.

breakfast1.jpg

*I do an hour-and-a-half solid gym workout six days a week. This is, I notice, the exact time the guys who kill chickens (cullers, not killers) must be spending a day doing their work. No wonder, West Bengal and its contained bloggers are protein-starved and liable to be renamed Beangalis. The punned plant product being the main source of amine nitrogen in our diet in these days of the H5N1 virus.

*I cooked a very elaborate Chinese dinner one evening, but the flavors fell flatter than my puns.

*I research a bit on what is happening to the stock markets, preparatory to investing a bit of money when the market is down. So far, I think I have invested more money than I ever knew I had earned. Which means about as much money as an Ambani’s driver makes in a month.

End of story. All of this would make it next morning already. 7am, and work starts again.

Net net (as the corporate and CNBC-types say so irritatingly): aforementioned blogdoc is lighter by 4 kilograms in two weeks, plenty of muscle fibers showing, belly flattening, preparatory to the development of the imaginary six-packs. Only my shaven head (another new development) prevents the chicks from accidentally falling on me, lips locked to mine.
I am, of course, poorer now, and very blogopenic (Greek penia=lack, poverty).

Do accept my genuine apologies for not blogging, and for not visiting. And for the ladies who are not falling for me now, I have this to say: “The weight will be worth it!” I think the Emaar-MGF (also called the Bimaar MGF) IPO-wallahs will be saying more or less the same thing, as they nurse sore backsides from the kicks of the non-paying public.

(Oh, this post is dedicated to Geetha for being so sweet!)

GETTING TO THE HEART OF ENHANCED CLAIMS

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)