The internet provides a wonderful opportunity for doctors to rack up CME (continuing medical education) credits in the comfort of their own homes. Last night, I sat in a cozy chair while listening to a high level lecture on HDL cholesterol. The presenters were two of the biggest names in the lipid research world. After reviewing the lecture and answering a couple of computer-generated questions, I was able to add an hour of educational time to my yearly requirement. That was good. Not so good, however, was the feeling I had after hearing the presentation. I've grown used to this feeling of discomfort because it happens frequently. It's actually more of a nagging question. Might we docs and researchers be barking up the wrong tree?
This particular CME was centered around efforts to raise levels of good cholesterol in patients with diabetes. A number of case studies were presented. In each one, the patient had metabolic syndrome, the combination of deadly fellow travelers that accompany visceral fat: high blood pressure, high lipids and high blood sugar. This profile often includes a particular type of dyslipidemia: high triglycerides and low good cholesterol (HDL). Current thinking says that raising HDL cholesterol confers protection against cardiovascular risk. But how to accomplish this?
Here's what set off my discomfort: each case discussion started with the idea that the best treatment for the patient was weight reduction and lifestyle change. But the experts quickly passed over these options and moved to drugs. The rest of the discussion was devoted to the problems with available drugs, their limitations and the various side effects of drug treatment. Finally, the experts discussed a class of new drugs that are in development which specifically target HDL. Unfortunately, the first of these drugs was quickly pulled out of trials when it turned out to raise, rather than lower, cardiovascular death. (To read more on this drug, Torcetrapib, click here).
This morning, I read about some research on mice which has suggested that white fat (the kind that stores calories), might be transformed into brown fat (a type that actually burns calories) by blocking a certain protein. Of course, blocking this protein has problems and may cause an issue with the immune system, therefore practical application of such research is very far away indeed. Each day brings another new potential drug, another research approach, another chance to stem obesity.
I'm not anti-research, but here is my problem. As I see it, obesity is a societally created problem. Let's examine another societal problem with addictive elements: tobacco. Our approach toward tobacco has vastly changed in recent years and as a result, so have our smoking rates. But our way of dealing with smoking never included trying to find research solutions that would allow us to continue to smoke...but without medical consequence.
Another analogy. Suppose I told you that I had a procedure that could cure you of your desire to smoke? Then I explained the procedure. We would cut your nose in half and reroute your tongue so that smoking would become completely unpleasurable and the smoke would never reach your lungs. Undoubtedly you'd be horrified. But now let's suppose I told you that I had a procedure that could cure you of your desire to eat? Then I explained the procedure. We would cut your stomach in half, staple it, take hold of your intestines and reroute them, make a new hole in your intestines and connect them back to your stomach in a new place. There are thousands of people who have lined up for this operation. The only difference between these two surgeries is that one alters your outer physiology and the other, your internal workings. Both are intense, surgical alterations performed on a person who is struggling with a problem created by our society: not by a cancer, bodily deformity or medically resistant illness.
The problem that I have with our interventions for obesity and the direction of our research is that they have the strong potential to hurt the very people they intend to benefit. This is because (medically) we are toying with systems which are highly interrelated. Move one pick-up-stick and others tend to shift and fall. Surgically, we are operating on people who already have risk and are using techniques that can cause problems later (malabsorption, ulcers at the site of anastamosis, etc...). We need to take risks when there are no other solutions. But in the case of obesity, there is a very definite solution: lose weight and permanently change eating habits. Rather than think of stronger ways to promote this solution, rather than give more support to these efforts, rather than making healthy eating "sexy", we throw up our hands and pass right by. "Well, that's not possible", we say. And on we go to the surgery, the pills, the research.
A few thoughts:
Sugar substitutes have been a successful product, have had a good safety profile and have allowed millions to cut calories. Why don’t we spend more of our research dollar on looking for ways to make foods less obesogenic? If we insist on eating day and night and if we must each factory foods, perhaps we can find better fat and carbohydrate substitutes for processed food. This would not be ideal for me or for those I counsel, but I would still prefer to alter food rather than to alter people.
Why are we still allowing food ads on TV? Banning the advertising of cigarettes and alcohol was a major step in decreasing their cultural profile. Do we really need to know when McDonald’s restocks the McRib? Are the pictures of sizzling shrimp and forkfuls of desserts a good idea in a country that is nearly 70% overweight? And if we don't have the cojones to stand up to the food industry on adult ads, why in earth are we still allowing them to market to children?
Why aren't we developing a strong, easy, consistent curriculum for educating kids about food? They need guidelines for eating that will allow them to maneuver through our world of instantly accessible food. These basic rules should be a part of the ABC's, because without them we are liable to have a generation of children who won't live long enough to use the things they learn in school. For me, the optimal education would be teaching kids about ancestral diet. It's easy to understand, lends itself to kid-friendly presentation, and leads to the simplest conculsion: we need to eat real food and food that is mostly proteins, vegetables and fruits. Everything else is window dressing and should be minimized.
In a country that is falling under the heavy foot of diabetes, why aren't we also spending more time educating our kids about bodily structure and function? I've written about this before, but I often use a slide show where I display a car and ask the location of certain parts. The next slide shows a body and I ask about the location of certain parts. Most people score inifinitely better on the car.
On the medical end, why do we give up so easily on dietary intervention? Those of you who write to me through this blog are proof that increasingly there are people out there who get it. And most of you are willing to share! Doctors, medical schools, hospitals and clinics need to recruit your expertise and listen to your stories. Life change can be done. Personal change leads to lifesaving bodily rescue with nothing but positive benefit: no significant side effects or risk.
Our country is full of creative minds. Might I suggest that we rely less on trying to find "cures" that will enable us to eat badly? Let's start a new era: one in which we rely on inspiration, innovation and education to create a cultural shift toward health. Let's ignite people and get them fascinated with the process of self-rescue. As all of you in the maintenance community know, far beyond the bagel and the brioche, enacting true life change is the most powerful magic.