Maggie's Farm

Historically, it was the medical staff that ran the place.  In this new era, businessmen run the hospitals and the docs have become employees: Lawsuit fights “existential threat” to medical staff independence

Last week, I posted on one reason for the paradox of why overweight people tend to feel more hunger, and to eat more avidly, than others even though they have no nutritional needs.

How can that be adaptive? Not all of physiology is adaptive to everything.

Today, we'll look at why cardio workouts suppress appetite and subjective hunger. Weight-lifting sessions, not so much.  High-intensity exercise suppresses Appetite By Affecting Appetite Hormones

It's an interesting effect which may have some adaptive value, or maybe not. It does explain why many normal-weight fitness-seekers need to force themselves to eat some protein when they have no appetite and no interest in food. It could be part of why hard cardio exercisers lose weight. Exercise doesn't provide fat loss, but the cardio reduces appetite. I am not talking about anorectics, just regular people who want to be in fighting shape and kind to their joints.

Weight Gain and Aging: An explanation and solution

Good info on this depressing topic.

Aging is characterized by changes in body composition. CT studies demonstrate that as we age, subcutaneous fat (below the skin, SF) decreases and visceral fat (in abdominal cavity, VF) increases. VF is the enemy. Because it causes systemic inflammation, it is an independent risk factor for coronary artery disease, stroke and death. If that’s not enough, VF also provides the Buddha-belly mid-life midriff.

The other most common age-related change in body composition is muscle loss. Because muscle has a high metabolic rate, its loss is associated with a reduction in energy expenditure. This decrease in caloric burn lends itself to weight (fat) gain.

We term this phenomenon "False Hunger" because overweight people have no need for outside energy sources.  In fact, though, overweight people tend to experience more subjective hunger than normal-weight or ectomorphic people. Is that cause, or effect?

A bit of both but mostly effect, as it turns out. It mostly has to do with how pudgy people ramp up their insulin response and the resulting, or related, insulin insensitivity. Illogical as it seems, having extra body fat makes people feel hungrier. Feed me, Seymour. It's a vicious cycle: Always Hungry? Here’s Why.

Overweight people can survive weeks or months without carbohydrates/sugars using their body fat as an energy source as long as they consume protein, fats, and oils to prevent muscle deterioration.

Can you lose weight via exercise? No, not practically

Does high-intensity exercise reduce appetite? Yes, usually. Dedicated fitness people force-feed themselves to keep their strength and endurance improving.

Stomach-stretching? People who eat bulky meals on any regular basis do stretch their stomachs, which can result in increased subjective appetite and hunger. We recommend small meals for everybody, regardless of weight. Except on feast days or special occasions.  People feel less tired, more energetic, and more productive with small meals. 

Fast eaters, voracious eaters?  Fast eaters trick their satiety signals by overeating (ie, greater volume of nutrients than needed to thrive) before satiety can kick in. Very few fast eaters are in good shape. A bad habit, and bad manners too.

General anesthesia has risks which are well-known and calculable. Sadly, Anesthesia may have lingering side effects on the brain, even years after an operation.

It is not just the compensation that discourages physicians, especially internists and pediatricians, from working for the government (eg Medicare, Medicaid).  A major issue is the paperwork burden. The government paperwork requires a specialized back office staff which only large practices can afford. 

A recent sample of the bureaucratic mess doctors are supposed to figure out.  A Medicare billing error is a potential felony, even if inadvertent.  

There are plenty of fad but fake diseases out there. Peak US public health body warns of risk from treatments for disease that doesn’t exist.

From knee and hip replacements to coronary bypass, there is considerable evidence for permanent brain damage in some individuals.

This phenomenon seems to be not unusual in patients over age 55. It seems to be an unmentioned risk of surgery. I have seen several cases of long-lasting (? permanent) cognitive setbacks after surgeries, so I am glad that people are exploring the topic.

Much or most of what you know about health, nutrition, and medical practice is already obsolete, but it can take years for new information to be accepted by doctors, hospitals and, God knows, the government.

It's a truism that all knowledge is transient. I sometimes catch myself thinking "I can't believe they used to believe...." before I call myself on it and realize that in fifty years people will be saying that about us.

Dr. Semmelweiss possibly did more for women than any other person in history, or at least in medical history. He is a stand-out in the medical pantheon, but acceptance of his ideas was extremely slow and he was thought a nut and a crank by the medical establishment.

His life was a sad one, and short. I suspect he died of neurosyphilis, known then as General Paresis of the Insane. He might have gotten syphilis from the many prostitutes he tended to, or from prostitutes who tended to him.

Out of consideration for the delicate sensibilities of Maggie's readers, I have refrained from including a photo of advanced Toenail Fungus

These unpleasant, common, but generally not-dangerous fungal infections (except, for example, in diabetics or the immunosuppressed) are caused by several species of fungi which thrive in the moist, confined area of shoes. Those fungi are basically everywhere. You do not need to be a barefoot gym rat to pick them up, but most people probably pick them up around pools, gyms, locker rooms, and the like. If you never go anywhere, you probably won't pick these things up.

Put plainly, these are examples of your body trying to rot while still alive - but that applies to any bacterial infection too. Both are associated with the same several fungi, often with Athlete's Foot progressing to Toenail Fungus (aka Onchymycosis). 

Athlete's Foot can be just a little itching, but it can get nasty sometimes.  It is manageable or even curable with anti-fungal creams used diligently.

The Toenail Fungus infection is more of a problem, because topical treatments have trouble penetrating the nails to attack the infection in them and beneath them. They are not just cosmetically problematic but can be painful because of the distortion of the nails. Toenail infections are the bread and butter of Podiatric practices, partly because of their chronicity. People sometimes think they just have one or two toenails affected, but usually all of the nails have some of it.

Some people just decide to live with it and let a Podiatrist attack it when wanted, but what you want to do for treatment is to treat any Athlete's Foot and then decide to go for a topical nail treatment (sometimes effective, like Jublia Topical), Toenail removal (ouch but most effective) with oral treatment with Jublia, oral Jublia alone, or Laser treatment (of uncertain effectiveness, unfortunately).  Jublia is very expensive.

'Patient zero': The misunderstood stories of how disease spreads.

I have always been interested in how psychological disorders/aberrations spread, too. Mass hysterias, fad diseases, and the like. In the 1990s it seemed as if half the hysteric women in New England believed they had chronic Lyme disease and there was no way to dissuade them. Before that, it was Chronic Fatigue. Both are now old hat and no longer in vogue.

I have been reading about the sudden upsurge of trans children. What is that about? It seems rather unusual, and disturbing.

There is no settled science on dietary fat and cardiovascular disease except in the case of the familial hyperlipidemias. However, in those cases, the hyperlipidemia is generated by the liver far more than by diet. The liver is the main controller of blood lipids.

A high-fat meal, or any meal, produces a temporary surge of blood lipids just as a high-sugar or high-carb meal produces a surge in blood sugar. That is normal. 

The low saturated fat craze was triggered by a 1950 study by Ancel Keys, a study which is now generally accepted as fraudulent. It spurred many further studies over the years but, as yet, there is no proven causal relationship between dietary fat and cardiovascular disease.  In fact, there are very high saturated fat cultures (Eskimos, Masai) with very low cardiovascular disease rates. 

Does your cholesterol level matter? Other than in familial hypercholesterolemia, probably not. So why check them on your every-3 year physical exams?  Medical advice is conservative, slow to change, and fearful of being wrong so too-often adopts the precautionary principle. Thus when articles like this one comes out: Popular belief that saturated fat clogs up arteries is a myth, experts say, there is always pushback like "Don't tell people that, they'll get confused."

While it is established that arterial disease is related to inflammation in arterial walls, the cause of that is elusive. The known risk factors for arterial disease seem to be smoking, overweight, diabetes, familial hyperlipidemia, and sedentary life style. Almost forgot the biggest one: age. Avoid ageing at all costs because it has a 100% mortality rate.

We are far from settled science with cardiovascular diseases. In recent years, we were advised to eat margarine not butter. Now advised to eat butter and avoid margarine. Now advised to eat olive oil. It's all a shot in the dark and it could be that diet has little or nothing at all do do with it.

If you feel like putting a non-lethal curse on somebody, curse them with a case of Plantar Fasciitis. It's like an epidemic these days.

It's a common affliction of the middle-aged (like Frozen Shoulder), and usually there is never an identifiable cause although weight gain seems to be one. It can be in one foot or both. Sometimes it can be easily fixed with ice and stretching but it can be a chronic problem which eventually will disappear as mysteriously and suddenly as it appeared.

The most common symptom is feeling like somebody put thumbtacks in the heel of your shoe. The problem is not your shoe (although arch supports sometimes help it). The problem is inflamed tendons. 

The differential diagnosis is Achilles Tendonitis.

Besides the pain of simple walking around, Plantar pain can lead to other joint or lower back problems because of altering one's gait to minimize the foot pain. 

Some basics on Plantar Fasciitis 

More info from the Pain Doctor 

Stanford researcher: “Most published research findings are false.”

Always be a skeptic. 

We post here frequently about the components of general fitness and physical training goals: strength, athleticism, power, endurance, etc.  The variety of exercises that we recommend are stressing and training neuro-muscular and cardiac systems.

However, while we are stressing and challenging our bodies in all of the ways needed for balanced fitness, we are also training our metabolic energy systems for higher capactiy and efficiency. There is no need to know anything about it, but it is interesting.

It's basic high school biology. Animals (and plants) use ATP as an energy source for cellular functioning. ATP is generated and regenerated in the mitochondria. 

However, our resting ATP batteries store very little reserve energy so 5- 20 seconds of high intensity, maximum anaerobic effort (eg 20-second sprints and HIIT sprints, or a set of heavy deadlifts) require instant regeneration of ATP. That's our "emergency" Phosphagen System. After depleted, it takes a couple of minutes to restore itself which is why you rest between deadlift sets or walk ("active recovery") between sprints. The Phosphagen system is trained by stressing it, but it has its limits.

After 10-20 seconds of high intensity, our cells turn to splitting sugar (mainly derived from carbs unless you have a Coke before exercise) - Glycolysis - to produce more ATP. This energy system, also requiring no oxygen, can keep us going for up to 2 minutes of intense effort. Like the Phosphagen system, Glycolysis is trained by short bursts of high intensity exertions of any sort. 

A body can't live long, though, without oxygen. Both of the above are anaerobic (oxygen-independent) systems and neither can be sustained for very long without rest and oxygen to restore them. Aerobic exertion (using oxygen to burn sugars and fats - the Aerobic System -) can slowly but almost endlessly produce enough energy to maintain us during less intense activity in which we maintain a pretty good oxygen balance (or at rest, for that matter). Aerobic energy systems are trained and stressed by, say, 1-hour endurance exercises which keep the heart rate continuously well-above a walking heart rate, eg continuous calisthenics, and non-sprinting exercises like swimming speedy but not sprinting laps, treadmill intervals but not HIIT intervals, jogging, and similar exercises when you can breathe uncomfortably but effectively-enough to keep going.

Can aerobic exercise count as "cardio" exercise? Sort-of, maybe. It depends on where you keep your heart rate. High-intensity, high heart-rate bursts are the best heart-stressors and if it doesn't kill you it will make it stronger.  Endurance is a different matter. Is normal walking "exercise"? Basically, no. It's just basic functioning unless it's fast and over 5 miles. "Cardio" means heart rate significantly elevated above walking.

Aerobic metabolism is highly efficient, which is why it takes 3 hours on an elliptical to burn the calories (270) in one plain bagel. It is why you can not lose weight by exercising unless you are fast- hiking 8 hrs/day on minimal caloric intake for a week or two.  The average sedentary person (meaning under 5-10,000 "steps" daily with no other stressful exercise) probably needs less than 2000 calories per day to maintain their status quo. Remarkably, in the USA, it is not unusual for one single cheap meal to provide that much energy. In all of human history, remarkable indeed. Caloric abundance has a downside, thus the "overweight crisis" especially among our American poor.

A balanced fitness program (resistance, calisthenics, cardio, and endurance) ends up stressing all 3 energy systems without your having to think about it at all. That is just one of the many reasons why we endorse balanced fitness exercise programs instead of a single path (such as all weights, or all aerobics). 

Good summary of exercise and energy systems here. 

The article in The Atlantic gets it wrong. 

Young doctors are not "exploited". Young doctors do not complain about 80-hour work weeks, because it's a high privilege to work long and hard taking care of people in trouble.

Only the weak would complain. They need the clinical experience as fast as they can get it. Furthermore, they need to learn how to function under stress and without adequate sleep. Physical and mental endurance need to be learned. When a multi-car crash results in 10 victims in your ER at 3 am and you're on duty, there is no choice but to rise to the occasion. That takes practice, and it is why older doctors are wiser. They have put in the hours. They can find their second wind because they have done it many times.

Nobody in America wants a doctor who would say "I've worked my 8 hours" or "I'm too tired."  Maybe they are thinking of socialized medicine or unionized medicine, because those authors seem to feel that working long and hard is something terrible instead of something wonderful.  Some people are not aware than some surgical procedures can take over 10 hours to complete, and, just then, an emergency comes into the OR.

Many medical treatments do not work, or do not provide the benefits desired. This is not because of deliberate quackery. It is more because of convention and the slowness of medical practice to change. Furthermore, marginal study results frequently have validity, but so marginally that there is no important clinical use. Try explaining that in court.

One example might be the treatment of borderline hypertension, which is dubious but in the US if a doc doesn't address it he'd be looked at askance because the current consensus is to treat.  Next year, it might be the opposite. Another example is coronary artery stents. 

The topic discussed here: When Evidence Says No, But Doctors Say Yes - Years after research contradicts common practices, patients continue to demand them and doctors continue to deliver. The result is an epidemic of unnecessary and unhelpful treatment.

For better or worse, this old guy had the genes for it but staying fit kept him out of a nursing home, thus far.

The half-life of medical knowledge is approximated at seven years. That means that half of what you think you know about health, illness, and medical practice today will be obsolete in seven years.

It will be replaced by new better science of which, in turn, half will be obsolete seven years later. That's how it works. Skepticism about current knowledge is always appropriate. The cholesterol panic is just the most recent, dramatic example. Big mistake. Not all docs have got the memo yet. "Never mind." 

Eat those eggs and bacon and sausages like you always wanted to, and skip the darn oatmeal unless it's all you can afford. And imagine that, in seven years, Mr. Science will tell you to eat candy and Dunkin Donuts for breakfast.

Our tummies might be smarter than today's science. Who knows?  I love deep-fat fried donuts (not at Dunkin) and French Toast. Doesn't everybody?