No Shit Sherlock!

The Royal College of Surgeon's (RCS) recent report on the appalling death toll of patients admitted for out of hours and emergency surgery is to be commended. It has been a long time in coming and highlights the dangers associated with being admitted to Accident and Emergency in the evening, or worse, at the weekend. It sheds light on the dangerous and often fatal, lack of care imposed upon patients who present with, often simply diagnosed conditions, who then become even sicker than on admission due to lack of manpower, facilities and very basic care that all of us hope to avail ourselves of, should we be unfortunate enough to have an accident or become ill outwith the Primary Care pathway.

The NHS is quite good at the provision of elective surgery, especially cardiac surgery. It is however significantly lacking in safety when it comes to major general and emergency surgery, with both higher mortality and complication rates than are acceptable in the setting of modern hospital care. Of 170,000 patients treated for non-cardiac surgery we manage complication rates of more than half at 100,000! And of those, we actually manage to kill 25,000! Mortality rates for emergency surgery in England and Wales is over 25%, with early discharge and subsequent re-admission being a significant factor in these statistics. The other horrifying figure is that our chances of dying is 10% greater if it's a weekend!

Well I'm no stranger to this situation, when she, with whom I have have decided to end my days, became part of these same statistics. Delays, both in pain management, diagnosis and treatment at a very basic level were missing, possibly because it was early on a Friday evening. No Consultant on duty, just a few nurses or rather 'healthcare assistants'. Of Doctors, well none until some five hours into admission. Tests, well there were plenty of those, in fact it seemed to be a goal rather than any sort of pathway to treatment, as hindsight indicated that none of the results were followed up! An X-ray was eventually carried out, but nonetheless a a treatment protocol was then pursued that was contraindicated and injurious and resulted in an outcome she still lives with to this day and which will blight her life until it's end.

Weekend surgery did take place, 'squeezed' into the list between the 'elective' private patients who had the surgical suite given over to them for some Saturday 'bunce' for the Consultants. Postoperative care was poor to non-existent with severe hypotension ignored, as was the diabetic keto-acidosis, and very low oxygen saturation that kept triggering alarms ( to my alarm).

So, this report does not surprise me in the least. The apathy and stupidity demonstrated to me by my personal involvement in this event did at the time. Up to then (2008) I had not had any chance to witness first hand the terrible position in our hospitals especially in emergency care. Any contact I did have had faded, like most bad memories do; part of that 'defence' mechanism our minds have to retain sanity. Despite my many ailments, and a minor wound in my early history with firearms, none was dependant on a hospital stay and I hope that it remains so. So dear reader, I would suggest that you plan for any emergency you may have in health care for you and yours, on a weekday between 0900 and 1700hrs. Or of course join with me and others to press for a whole new paradigm in health care and medicine, that is patient centred and based on scientific treatments. I want to tear it all down, rip it to shreds, along with many of those that perpetuate it by virtue of vested interest or hubris or worst, apathy.

The Road to Perdition.

So as the Greek storm threatens the destruction of what is left of it's fragile democracy, and the two Ed's join together in a trip to Knotty Ash, in an attempt to rival Ken Dodd's stage presence, I look to our leaders for guidance and comfort. Cameron's not for turning; I vaguely remember that from my past. No, it's gone. Ball's will not promise any change. And Angus is pissed off with Tesco.

So, as the sun slowly sinks over the UK economy I am left to my own devices to ponder the solution for our ills, and I am reminded of something that one of my few hero's said. "The world cannot get out of the current crisis with the same thinking, that got it there in the first place." Yes it's from the wondrous Albert (Einstein that is). As is usual, that which he said about the crisis of capitalism applies equally now, as it did way back in 1949.

The British political classes, irrespective of whichever party to whom they belong, have one priority; the repayment of the 'deficit' by those who can ill afford it, and didn't cause it, rather than those that did and can. The Financial sector, basking in the sunlight of handouts and bonuses, is completely unperturbed, safe in the knowledge that Governments all, are held in thrall by their pronouncements about whole economies, and remain hostage to the fortune of diktats honed by wankers bankers in boardrooms throughout the Western World, despite their implication in the very crisis to which they profess to have the solution. All whilst we continue to wage wars in lands afar, support the 'Arab Spring' with strong (ish) words to the dictatorships to which we still peddle arms, and rain down Brimstone missiles on the opposing side, and the innocents, in a Libyan 'proxy' war, fueled more by the prospect of oil, than any righteous hope of the rise of Democracy. I have no time for Gadaffi, but frankly none for the self styled rebel leader Mustafa Abdel Jalil either, who is staging little more than 'coup' than any revolution, and has slaughtered thousands both in the past, and now in his pursuit of power. Not of course forgetting the Napoleonic ambitions of one Nicolas Sarkozy.

This moral bankruptcy is redolent of the paradigm in politics of the past thirty years, the Neoliberal agenda. That which espouses the 'market' as the most efficient tool of Administration and accepts, on behalf of those who vote for them, that a large proportion of the people will be condemned to both poverty and/or inequalities that spring from it's policies. It's democracy usurped by the rich for the impoverishment of the remainder. Forged by the 'Iron Lady' in concert with an aging film star who ruled the USA in the early eighty's, it has predominated Western politics ever since. This is why politics is bankrupt of any new ideas that can extricate us from the hole in which we now reside, but which nonetheless pursues the same one's anyway, as it has for the past thirty years. The word 'Socialist' has been eliminated from all the parties of power in the Western World just like 'nuclear' was expunged from the names of the power generators, and who now hold out their hands for subsidy from the people, to build a new generation of reactors, so they can charge even more for the product we can none of us live without.

Neoliberalism is the reason why the NHS is what it is now and more, what it is to become. The Paymaster once more becomes the supplicant, hoping for some crumbs that may be scattered from the 'top table' of Serco, Carillon, Crapita, and all the myriad facilities managers, management accountants, hedge funds, merchants bankers who 'leech' off the funder of their profligacy, the people. This agenda is not openly touted, so the 'paranoid indifference' of the masses is largely a myth, invented at the dinner parties of the chattering classes, and the pages of the 'Indy' or the 'New Statesman'. It is in fact a hidden agenda, an open secret that is almost the 'elephant in the room'.

It's the movers and shakers, who 'flit' through the revolving door of public service, and back again with the ease of those who know power and relish in it who have shaped this model. Heavily subsidised from the taxpayer, they feign resolute independence and ardent if not passionate belief in the 'market' to sort out all of economy's ills whilst enjoying the hypocrisy of their six figure comfort of taxpayer gold. The rest of us look on in startled incredulity that such a belief system can be sustained, but that is the supreme tenet of politicians; perverse and single minded confidence in their own stupidity, as being wisdom. It is the MP's who have never known what it is to work for a living in a 'real' job, who came straight from University, to research assistant, to PPS, or the 'Parliamentary Silk' from a lowly place in 'chambers'; all of these are responsible for the paucity of 'real people' in the corridors of power, and for the rise and rise of the Neoliberal agenda.

So then Ed and err...Ed. Try to remember you are in the Labour Party, an organisation formed from the blood, sweat and tears, all spilt on its foundations, in a world that was different from today's. We can return there if you continue with the cowardice and hypocrisy of Blair and Brown. But I cannot forget the men of my youth who recounted tales of fighting in the Spanish Civil War, of battles with mine owners, and of blood spilt to provide the children with enough food to sustain life. If you want us to return to those days then just go as before. You and your ilk will not feel the sting of poverty, wrought in the name of the 'deficit', your deficit will be in the integrity that you fail to display. Less 'bollocks' and more balls is what we need!

Lying Bastards!

Writing this post on my shiny new computer, after the old one gave up the ghost and left me bereft of data, that I still have to retrieve, and of course the means to post anything. Should have gone to 'laptop savers' ie; Angus Dei's Kitchen but took it to my local poxy computer shop, where it still resides.

Andrew Lansley has been bemoaning the dreadful position  of NHS Trusts who have been burdened by huge debt born of the Private Finance Initiative 'foisted' upon them by the 'previous lot' ( Blair and Brown). In the process conveniently forgetting that, for all their faults, which were legion, it was an inheritance of Conservatism of the Neo-Thatcher era, who actually 'spawned' the beast. Politics has a dreadfully short memory.

PFI was the invention of a certain Norman Lamont (with others) upon the relaxation of the Ryrie Rules in 1992. In fact a number of major projects were well under way or had even been completed prior to the victory of the Blair Administration in 1997.

The M6 Toll Road (1992)
The Second Severn Crossing (1990)
Croyden Tram link (1996)
Northern Line Trains (1995)
And many others, including the Channel Tunnel.

Blair of course embraced PFI with almost evangelistic zeal and built further upon it, to the extent that almost every public project on his 'watch' was financed in this way. Graham Allen's paper from 2003 details the position taken by 'NuLabour' in its flawed construct to sell off our childrens' futures, to finance grandiose plans, that would make them look good, but conceal the real cost. Even to the extent of selling the Army's estate along with that of HMRC, then leasing it back at guaranteed rates. The company involved was of course based off-shore so we don't even get any tax back for that which we pay. Which is that which all parties involved in PFI actually factored into the cost, so as to represent the deals as 'better', than less complex vehicles for funding that were cheaper, and at least left the taxpayer with an asset at the end.

What has happened, is that the Governments Advisers, both now and then, (KPMG) factored in the taxation element into the cost analysis for public consumption, then were retained by the PFI outfits to advise on how then, to avoid the tax. Some might call them treacherous bastards, but I could not possibly comment. What is sure is that Government, both central and local were queueing up to get deals brokered and operated by the 'usual suspects' ( Carrilion, Serco, Interserve, Capita et al) which were then often sold to offshore equity' finance outfits and they then 'pocketed' the difference, or simply refinanced once the rates got lower. After all, the new owners were looking at profit stream of the order of 15% to 17% per annum and the operators were able to charge £200 to change a light bulb, or £500 to hang a picture, (I've just hung 12 in 1.5 hours for £6 in hooks) as well as exorbitant service charges.

As all these participants were and are contributors to the Tory party 'coffers' and a number of the cabinet have either worked for them directly or indirectly, and they objected little about the use of PFI during Nu-Labours years, it seems a little hypocritical to 'cry wolf' about at this stage. And of course Gove has just sold the Governments share of the 'Building Schools for the Future'  LLP, (as reported in Private Eye) which owns the 700 schools already built under the PFI scheme, he recently closed on the grounds of "massive overspends". And to whom were they sold? Yet another 'offshore' investment outfit called International Public Partnerships, based in Guernsey. So no tax there then!

This Government, despite all the rhetoric they spout about about PFI, seem to be just as hell bent on utilising this highly flawed model of financing, as the 'last lot', and they did after all both invent it and facilitated the legislation needed to allow its rise. So I would posit that Lansley's complaints are really for 'public consumption' only, with  a whole different agenda, being planned behind the scenes. So is anything safe in the ConDems hands? Well probably not; they are politicians after all. A treacherous breed at best!

The Point of Departure.

As the Leviathan that is the Health and Social Care Bill, lumbers inexorably to a vote, shrugging off the attacks on its content, like a Tank does small arms fire, I have pondered as to what I would like to see the NHS become. Certainly not that which it is now, so I do not want to 'save it'. And 'curing it' does not appear in any agenda for Health that I can conceive of, because the cancer within has all but consumed the host. Spectacles of a rosy hue, seem to have been donned by the 'liberals', now that their precious NHS is under threat. All the transgressions of the past seem to have been forgotten and it is now to seen  as a beneficent, almost angelic body that we should strive to save from the evil machinations of the Tory's. In reality, nothing could be further from the truth.

At it's inception, the NHS was a construct based upon universal health care for all. Sadly that did not compute with Doctors of the day, so it was 'hijacked' by the Consultants and whilst the 'proles' got their boils lanced and their teeth pulled for free (well almost), there still existed a 'cabal', a 'mafia' of senior Doctors and Surgeons who dispensed their largess very much on a part-time basis, but nonetheless held sway at the BMA and called most of the shots. Several incarnations later (there were many), once a few of the miners son's had made it to Medical School and infiltrated into Hospitals it became it little less elitist, but the 'firms' still held sway, with the 'rugger playing' registrar being more the norm than a lad from the terraces of an Allan Sillitoe novel, even more unlikely a girl! So we move forward through time and seventeen major reports and reorganisations later we arrive to today, or rather the white paper of the Coalition of July 2010 Liberating the NHS (didn't realise it had been imprisoned) from which sprang the Health and Social Care Bill. But, long before then the NHS had lost it's way.

The Thatcher years saw the invention of 'fundholding' and of course the bureaucracy attached to that hugely expensive and pointless accounting system that it was, causing mountains of paper invoices to be generated and mailed to each component of the system. The invention too of the Hospital Trusts, and of course the 'internal market', providing an entry for Private Health care to the NHS, and a proliferation of 'for profit' organisations and Hospitals. Tony Blair, not wishing to be seen in any way as 'socialist' perpetuated and embellished many of these policies including privatising the 'out of hours' provision of Primary Care, Foundation Trusts, incentivisation of GP's and of course the spectacularly useless and costly IT projects, together with the expansion of the Private Finance Initiative. In fact the only good thing he did was to eliminate the internal market, only sadly to decide to reinvent it just before he left office.

In all of this we have seen the 'legacy' of the Thatcher years become the Neo-Thatcherite agenda of today which sprang from the Neo-Liberals of yesterday, all completely oblivious to the vast sums of money they were spending, to achieve little other than the enrichment of an 'elite' cartel of Accountants, Facilities Management Companies, and Consultants, not forgetting 'Big Pharma' of course and to the detriment of the 'end user', the patient, who had no input to all of this, except of course to become a 'victim'. I say victim without any hesitation, because the joint efforts of the politicians, GP's, Consultants, and all the retinue of Nurses, Bureaucrats and hangers on have done virtually nothing to improve the lot of the patient but simply improved their own. I have no desire to save anything for any of them, they are completely undeserving even of the the little patience that I have left.  The GP's are more concerned about their pensions than patients, the Hospitals more interested in the preservation of their empires, even if it's at the expense of patient safety, than adopting better and less invasive protocols, or the concentration of specialist services in regional centres and thus improving mortality (childrens heart surgery?). The health care charities have been 'hi-jacked' by Pharma as patient advocates, to peddle drugs like Avastin which may prolong very slightly, the lives of terminal cancer patients, at enormous expense (and their profit) and with a whole host of side effects that can be terminal in their own right. All in the NHS and those outside it who will be 'willing providers', have an agenda that has nothing to do with patient care and everything to do with profit, with preserving power, extending control and personal gain.

Why for instance do we continue with Angeograms when we can utilise Electron Beam Computerised Tomography which is non-invasive, less dangerous and considerably less unpleasant. Because it's cheap and a lot of people will lose their jobs, power and influence if we 'can' it. Why do we continue with the 'sham' treatment of healthy people for heart disease they haven't actually got, because they have fulfilled some test criteria for a 'surrogate marker' evidenced by one of (several) computer 'risk scores' that are frankly useless and have been proven so. We also 'treat' perfectly healthy pregnant women, simply because 'we can', to ultra-sound scans, hospital births, inductions and other invasive procedures that for most are not needed, when we should be saving them for those that are 'at risk'. Why do we allow 'Pharma' to 'bribe' physicians and Surgeons with nice little 'jamborees' in exotic locations, 'free lunches', financial support for 'pet' projects and studies, all in the interest of promoting their dubious and often dangerous drugs and devices. Of course no Doctor would be influenced by such largess (and Genghis Khan was a really nice guy).

That is where I depart from the 'curers' and the 'savers'. I have seen my best friend die from stupidity and misdiagnosis. My father from neglect of his chronic illness. Almost lost my sight in one eye and watched the woman I love treated with appalling callousness, have her life endangered and her future blighted forever, for the want of diligence in simple protocols that are the foundation of medicine. Many of my friends have lost everything in their lives at the hands of those who swear to 'do no harm' and I have seen them rage at the impotence they have felt in their pursuit of justice and candour.

Denial of their incompetence seems to be the only thing at which Doctors are actually any good. So I want not to save the NHS, I wish it to be demolished like a fire gutted, dangerous building. Let the ConDems do their worst and destroy what is left whilst the Labour dissemblers snipe at the minutiae of the Bill, sure in the knowledge that they would have done little differently. Perhaps then, when we see yet again the differences and inequalities that will have been forged in England's NHS and we look North to Salmond's fiefdom where a new social democratic model is being invented, we can rebuild it as it should have been. I truly hope so, before I'm saddled with the DNAR.

Screening for Cancer Fails to Prove its Worth.

I have talked at some length about Breast Cancer Screening  before, and accused those involved to be more interested in perpetuating the myth that 'screening saves lives' than in providing facts for women to make an informed decision. Well, the clamour is getting louder for 'real information' to be available for this and other screening protocols and what are the advocates doing to quell the disquiet? Closing their eyes, ears and more importantly their mouths.

The recent study in the BMJ showed clearly that screening (mammography) is not responsible for the reduction in Breast Cancer mortality seen in six Eurpoean populations. In fact, in a few of these countries, mortality was reducing prior to any screening protocols being in place. The response of the screening lobby   ( a powerful vested interest), has been resounding silence, to these obvious negative inputs to the argument. Displaying the trait it seems of the 'three wise monkeys', as Richard Smith  explained on his BMJ blog.

Screening for Bowel Cancer too has been having some bad press as the relative risks are presented as absolute in the leaflet provided to the prospective cohort (including me). In truth the risks are quite small and the relatively 'crude' methods involved in screening lead to many false positives, waits for confirmation, and much unneccessary treatments, investigations and, the attached risks of harm involved in colonoscopy are actually higher than the likelihood of Colerectal Cancer (much higher at 1 in 150) and the risks of  procedure causing perforation and the consequent risk of pertonitis is 1 in 1500. Risk of death is pretty low at 1 in 10,000, but that is close to the absolute risk anyway, which is less than 1 per 1000 in ten years of screening.

Mitzi Blennerhassett, wrote in Macmillan blogs about the dearth of information, and indeed the bias of that available and she is (thus far) a survivor of colerectal and breast cancer, so she talks from the frontline. The replies to the BMJ about the study also make fascinating reading, with much criticism of the lack of evidence and indeed the arrogance portrayed by most in the 'business' (for that is what is) when questioned as to the efficacy of mammography or indeed most forms of cancer screening.

The NHS spends vast amounts on these protocols, allegedly to save us from 'harm' and an untimely end, but fails consumately in simple areas of diagnosis of illness in so many patients, treats the elderly with appalling disdain, even cruelty. Is lacking in 'adequate out of hours' trauma provision. Trains Doctors to be patently less good at the job than in the past, then 'throws' them into the maelstrom of A&E with little or no mentoring or backup. When scientific evidence is presented that indicates that a drug or procedure is harmful, especially Primary interventions for prevention using 'surrogate markers' or end points, rather than a patient actually being ill, they ignore it!

Prof. Michael Baum with others, ( 3 pages of them) wrote to the Sunday Times about this lack of information and the virtual conspiracy of silence that exists around the harms, way back in 2009. He was ignored. He wrote again recently but that's behind a paywall now so I can't post that link. The signatories are seeking  a judicial review of the screening programme because they are so incensed by the lack of information and potential harms it causes. The conspiracy of silence continues with evidence stacking up in the aisles that we do little to end the tyranny of Cancer but much to find it, where it doesn't exist and even more to treat it with questionable drugs and procedures that may in fact add to it's virulence. A scientifically informed choice is what is needed and an NHS dedicated to curing the sick and the lame, and giving comfort to the dying, not that which we have now.

Obesity (Again).

Being overweight remains in the news, with bulk of opinion being slanted toward the view that people who are in this state (obesity and the UK) are largely responsible for their own predicament. I not only find that somewhat cruel, but also founded in poor or even bad science.

I've already said in my previous post that is unlikely to be the fault of the 'fatties' but more of those who are advising them to eat a 'healthy diet' which in the DH 'speak' will largely be carbohydrate based and 'low fat'. In the latter's case that will be monounsaturated fats and polyunsaturated fats instead of saturated fats. Plant based oils (generally) then, in lieu of animal fats. This last bit of advice seems to fly in the face of the fact that homo-sapiens have some problems in metabolising some fats with CIS bonds (and even more problems with fats containing trans bonds). Animal fats such as lard, tallow and dripping, also contain quite large amounts of mono and polyunsaturated fats despite their undeserved reputation for being  entirely 'saturated'. Yet, it is patently obvious that this advice to avoid saturated fats and animal fats in particular, has done nothing to reduce the incidence of obesity and the associated risks of Diabetes, CHD, CVD and Cancer, because it continues to increase.

Looking in more depth at Nutrition and it's relationship with obesity we have to consider the mechanisms involved in becoming overweight. 'Hyperphagia' is synonymous with obesity, that is over-eating in simple terms. It can be a result of some genetic disorders or Diabetes, especially in Type 1's who inject insulin. It also manifests itself in Type 11's who are in advanced stages of the disease. High Carbohydrate diets typically can bring about this problem due to increased gene expression of the neuropeptide Y(NPY) in the hypothalamus, and causing a reduction in the expression of the hormone (CRH). What that means is that the brain is increasing its output of orexigenic (hunger generating) agents and decreasing output of anorectic (hunger suppressing) agents. This is how the brain stimulates our nutritional needs of hunger and satiety. So, it is evident that early stage diabetics (metabolic syndrome), Type 11 diabetics and the obese subjects will be permanently hungry. If, however we feed them a diet of fats and proteins and eliminate most carbohydrates, this phenomena is suppressed in a more 'normal' manner and appetite is curtailed at a much earlier stage in eating.

Forcing people then, to eat a 'healthy diet', two thirds of which is carbohydrate based, if we include the vegetables and fruit, is contributing to the obesity that it is meant to be reducing! Once we become 'insulin resistant' as well, we can arrive at a position where almost all intake is rapidly stored as fat, despite the fact that we are hungry, even starving, and our ability to 'feel full' is almost non-existent. Low carb diets, especially in the context of this section of society, are proven to have a considerable success in enabling obese and diabetics to attain an optimal weight and, more importantly, to maintain it. The mechanism is not fully understood, and there is considerable conjecture amongst biochemists that it may be down to ' metabolic advantage' with fats and proteins, or the satiety afforded by this food group actually reducing the calorie intake, or even the fact that increasing saturated fat intake, replaces vegetable/seed oil intake (generally Omega-6's) and that in itself helps to reduce obesity. Many hypotheses are propounded, reputations impugned, the science examined, re-examined and much that is known is based upon animal studies, not humans, but whatever the mechanism, it is certain that for most, a low or minimal diet of carbohydrates does bring about considerable weight loss and a 'normalisation' of blood sugars in most diabetics (Type 11's). Dogmatic views about diet and nutrition, without examining the science involved and ignoring outcomes, is what has brought about the ever rising tide of obesity and diabetes.

Those of us who are 'insulin resistant' respond to this more readily than any other cohort, and it is not a panacea for all, by any means, because all of us reach a plateau with our bodies, some quicker or slower than others. In fact being slightly over weight has some advantage for humanoids and was likely a defence mechanism against famine or periods when food was not abundant. The body in fact conserves energy in fat reserves and is quite loath to give them up, which is why so many dieters fail in their endeavours to lose weight because basal metabolism 'slows' as we begin to diet, especially with low fat/low calorie diets. Your body is attempting to 'save' you from yourself.

Completely Unnecessary Picture of Low Carber J- Lo

So why does mainstream advice for lowering the risk of obesity and the morbidity's that stem from it, continue to advocate measures, that are most likely to fail either in the short or long term? Well having your beliefs undermined, no matter how much evidence exists to prove you are wrong , is hard to bear, even for Doctors and Scientists.Being told what you want to hear, is comforting and reinforces preconceptions at the expense of the truth. Selection bias is something we are all guilty of at some time and I admit to it myself. We should not defend the indefensible but all too often the truth becomes clouded by hyperbole. Scientists delight in the rigour of 'peer review' often tearing quite good studies to pieces because 'they can' rather than due to any poverty of evidence. Equally as well they often lose the ability to reflect that 'correlation (and observation) does not prove causation' in the data they present. Which is why we get 'scare' stories extrapolated from views and opinions of Scientists, rather than hard evidence of harm.

It should not be countenanced and I have always believed that all of us  need to be as objective as possible in our search for truth, even when that truth challenges our basic and long held belief system. 'On the word of no-one' (Nullias in Verba), only the proof, is what we need.

This post has been devoid of links thus far. I've saved them  to the end. I've used some before, so don't be surprised to see them again. They all possess the 'gold standard' of trials, they are RC T's.

1. Brehm BJ, et al. A Randomized Trial Comparing a Very Low Carbohydrate Diet and a Calorie-Restricted Low Fat Diet on Body Weight and Cardiovascular Risk Factors in Healthy Women. J Clin Endocrinol Metab 2003;88:1617–1623.
2. Samaha FF, et al. A Low-Carbohydrate as Compared with a Low-Fat Diet in Severe Obesity. N Engl J Med 2003;348:2074–81.
3. Sondike SB, et al. Effects of a low-carbohydrate diet on weight loss and cardiovascular risk factor in overweight adolescents. J Pediatr. 2003 Mar;142(3):253–8.
4. Aude YW, et al. The National Cholesterol Education Program Diet vs a Diet Lower in Carbohydrates and Higher in Protein and Monounsaturated Fat. A Randomized Trial. Arch Intern Med. 2004;164:2141–2146.
5. Volek JS, et al. Comparison of energy-restricted very low-carbohydrate and low-fat diets on weight loss and body composition in overweight men and women. Nutrition & Metabolism 2004, 1:13.
6. Yancy WS Jr, et al. A Low-Carbohydrate, Ketogenic Diet versus a Low-Fat Diet To Treat Obesity and Hyperlipidemia. A Randomized, Controlled Trial. Ann Intern Med. 2004;140:769–777.
7. Nichols-Richardsson SM, et al. Perceived Hunger Is Lower and Weight Loss Is Greater in Overweight Premenopausal Women Consuming a Low-Carbohydrate/High- Protein vs High-Carbohydrate/Low-Fat Diet. J Am Diet Assoc. 2005;105:1433–1437.
8. Gardner CD, et al. Comparison of the Atkins, Zone, Ornish, and learn Diets for Change in Weight and Related Risk Factors Among Overweight Premenopausal Women. The a to z Weight Loss Study: A Randomized Trial. JAMA. 2007;297:969–977.
9. Dyson PA, et al. A low-carbohydrate diet is more effective in reducing body weight than healthy eating in both diabetic and non-diabetic subjects. Diabet Med. 2007 Dec;24(12):1430-5.
10. Shai I, et al. Weight loss with a low-carbohydrate, mediterranean, or low-fat diet. N Engl J Med 2008;359(3);229–41.
11. Krebs NF, et al. Efficacy and Safety of a High Protein, Low Carbohydrate Diet for Weight Loss in Severely Obese Adolescents. J Pediatr 2010;157:252-8.
12. Summer SS, et al. Adiponectin Changes in Relation to the Macronutrient Composition of a Weight-Loss Diet. Obesity (Silver Spring). 2011 Mar 31. [Epub ahead of print]
13. Daly ME, et al. Short-term effects of severe dietary carbohydrate-restriction advice in Type 2 diabetes–a randomized controlled trial. Diabet Med. 2006 Jan;23(1):15–20.

Obesity - The Bing Crosby Approach.

"Accentuate the positive, eliminate the negative!" That is the 'spin' of politicians and doctors,  who wish those endowed with excessive subcutaneous fat to be nudged into a healthier paradigm for life. Yet most of their 'crooning' is patently wrong. It is said that more and more of us are getting fatter, and as a consequence, putting ourselves at higher risks for heart disease, diabetes, liver and kidney failure, together with a myriad of co-morbidity's associated with the 'obesity explosion'.

Fellow blogger the masked crusader has a rather darkly humorous solution, but his description of the obese as 'pie eating lardbuckets' is somewhat harsh to say the least, because it is the advice that many of his colleagues provide to 'fatties' that is fueling the crisis. It is also obvious that his cunning plan to recycle the result of liposuction is fatally flawed. The energy needs to enable such a 'rendering' would far outstrip that provided by the resultant product. So, put down that pie and pay attention!

Obesity is defined by having a Body Mass Index of 30kg/m2, which can be ascertained by dividing your weight in kilo's by your height squared. For someone 6ft tall (1.8mt) and 11 stone (70 kgs) that would be a BMI of 21.60kg/m2. There are, as one can imagine, quite a few people with lots of muscle who would then be called 'overwieght' (BMI of 25 - 29.90) and even obese, so the formula does not fit all. In fact, whilst subcutaneous fat is an indicator of obesity, it is visceral fat (the fat around internal organs) that is a better predictor of disease.

The recent survey on health and obesity from the NHS shows some quite interesting data, especially on diet (although it will take some time to read all 112 pages), which does show that advice to eat '5-a-day' is working with the 5 to 15 year old's as consumption has doubled. All people are also eating less trans-fats, saturated fats and sugar than 10 years ago, and calorific intake has tended to decrease since 2006. Yet we are still getting fatter, have more diabetes and heart disease (despite the fatalities from it decreasing). We are as a whole also taking more exercise, with a 7% increase (absolute) between 1997 and 2008, with men exercising much more than women. Surely, it is sensible to assume then that this advice, issued to the public and taken up, should have made some inroads into the obesity epidemic, even if only small, but it hasn't, if anything things are getting worse! Could it be that the advice is wrong? Err... well yes!

Looking at the advice we have; eat less fat, eat '5-a-day', take exercise, don't smoke, drink only a little of alcohol, don't eat sweets or sugary drinks, and of course consume carbohydrates in vast quantities, up to two thirds of your food intake (when you take fruit and vegetables into account). Now that we have been doing that for about thirty years, at ever increasing frequency, we are then told that; we are all lying about what we eat and we are eating far too much, remembering of course that average calorific intake has diminished since 2006, which together with lack of exercise (or not enough of it) is the reason for the spread of obesity and disease. So by 'accentuating the positives' of low fat, exercise, and non-smoking, and 'eliminating the negatives' of saturated fat, meat, alcohol, lack of exercise etc. etc. we have achieved, well nothing!

Now we are told, that if we are above a certain BMI, we smoke, or drink above a certain limit, that we will be proscribed from various treatments on the NHS, because it's all our own fault and we are a bunch of lying, drunken, "pie eating lardbuckets", who do not deserve the largess of the NHS to help us fix the problems that ensue from our aberrant behaviour. What a crock of s**t! What about the other cohorts in society, who run in marathon's or just run in the the vain hope of 'super fitness' and end up in dedicated 'sport injury clinics' in the NHS? Or those who diet to the point of death, because society's model of beauty is a size 6, or indeed children diagnosed with ADHD, because their parents take the advice of the DH and feed them sugar laden grain products for breakfast, because it's 'healthy grains', pasta (wholewheat of course) and bread with almost every meal (brown of course). Surely all of these are equally responsible for their plight as is anyone who is said to be a chronic 'over eater'. This is Eugenics for 'fat people' and in my view is bordering on racism for adiposity.

You get fat not because you eat too much, or don't exercise but because you eat the wrong things, usually based on the advice of the Dept. of Health, or Heart UK, or Diabetes UK or one of the other self serving organisations we allow to govern our lifestyle choices, simply because they are heeded as being 'expert', when in truth they preach misguided and unscientific dogma. Despite the fact that they have been doing so since the late 1970's with no tangible proof of success, or indeed any evidence to support their ludicrous claims that they 'know best'. Often their advice is based upon Food Industry claims completely unsupported by any evidence because they want to sell you something. Or indeed some pseudo science from the USA that has long been disproved as fantasy.

There is no evidence that fat, makes you fat. None at all. Never. There is no evidence that eating saturated fat causes heart disease. In fact there is considerable evidence that the converse is true, with low carbohydrate, high fat and protein diets being the best solution for weight loss and health. There are many proofs of this but the most meaningful is the biochemistry involved in food intake. Carbohydrates are the food group that requires an insulin reaction to enable them to be metabolised, and conversion to glucose, no matter what their glycemic index is, will be extremely rapid, and more importantly virtually completely, to provide energy needs. The problem is that glucose, if not used up immediately is stored as fat and it is very difficult to utilise all of the glucose from a high carbohydrate meal immediately no matter how much exercise is taken. Fats and proteins are somewhat different in that they are not metabolised rapidly but quite slowly and not with the same ruthless efficiency as carbohydrates. Protein intake is needed for cellular generation from the amino-acids formed from their product in the body, so little is stored as fat. Fat is metabolised very slowly and with very low efficiency with nearly half of intake being 'wasted' and passed as ketones in urine. And of course, the 'calories in calories out' paradigm peddled as the 'gold standard' for diet is fatally flawed because of this.

The use of a 'low carb' diet has proved to be the most effective for weight loss for over a hundred years and it's modern equivalent 'The Atkins Diet', the 'Paleo Diet' or indeed any of the more up to date versions of diets reliant on fats and proteins in varying mixes to achieve a reductions in body fat are in the ascendant, yet the DH and Doctors generally seem hell bent on ignoring evidence of its efficacy. I find it difficult to see why.

It seems perverse to refuse treatment to any sector of society however guilty they may be of their predicament at the same time as providing it to others who are intrinsically as guilty, but worse have deliberately pursued a reckless course of exercise, or driven too fast, when drunk, or taken drugs. Fat people have usually tried hard on low calorie diets, or worse taken some of the awful, and generally useless drugs for obesity and consistently failed. If healthcare continues down the road of diets that set up the obese to fail, they are just as complicit as those they refuse to treat, indeed more so. Taken to extreme, why not have an undertaker posted permanently at A&E to wait whilst undeserving patients expire?

I seem to remember that a certain Steve Field, once head 'honcho' at the RGCP (now replaced by the excellent Claire Gerada) was a bit of a 'lard bucket' at the same time as he was selling us the idea of a 'healthy diet', didn't seem to work for him either! (Sorry, couldn't resist).