The Obesity Paradox

Fat's bad and thinner is better, right? Maybe not. For instance, overweight men with certain diseases of the heart live longer than men of normal weight with the same diseases. For many of us, the idea that fat can be good and thin may be bad is counter-intuitive. Hence the term: obesity paradox.

I have never looked terribly overweight. I'm six feet and at my heaviest I weighed about 215 pounds straight from the shower. These numbers gave me a BMI of 29.2. A BMI from 25 to 30 is said to be overweight, while anything above 30 is, let's be blunt, fat. A BMI greater than 35 is obese. Hit 40 or more and one is morbidly obese. Link: Calculate Your Body Mass Index (BMI)

Recently, at the urging of my doctors, I've been trying to lose weight. I had my weight down to about 185 pounds before a bowel obstruction forced me to undergo emergency surgery. After being discharged from the hospital, I discovered I had lost ten full pounds. Luckily, I didn't lose any bowel, the surgeon simply removed a tight band of connective tissue. Today, I'm in amazingly good heath. My BMI is 23.7.

I feel good. I'm happy with my new weight and my tummy is almost flat. My friends are not so keen on my new look. "You're too thin," they tell me. "You've got to put some fat on those bones. It's important to have some fat in reserve if and when another health issue surfaces," they say. I used to shake my head "no" when I heard this advice. I have since discovered there is some support for their ideas. In certain cases being somewhat overweight decreases mortality.

In my personal experience, the strongest advocates for keeping some fat on the bones are themselves high on the BMI scale. No paradox here. These people like their weight and want to keep their rotund figures.

But fat people are not the promoters of the obesity paradox. Medical researchers, some of whom were truly puzzled by their findings, are behind this story. T. Jared Bunch, MD, wrote:

I observed the obesity paradox in a published study I conducted while studying at the Mayo Clinic. We looked at 226 people who experienced a heart arrest in the community and were resuscitated. What we found was that people that were slightly overweight (BMI from 25-30) had the highest 5-year survival at 78 percent. People who were underweight had a significantly lower survival at 67 percent, similar to people considered morbidly obese.

In other words, extremes are not good. Being too thin may be bad for you and being way too fat is definitely bad. According to this theory, at six feet I don't want my weight to drop below 140 pounds or climb above 257 pounds. Calculate your BMI and if your number is 40 or more, the obesity paradox is of no concern to you. You are morbidly obese. Lose some weight.

If you are curious as to what weight puts a man of six feet in the BMI sweet-spot, the answer is a weight in pounds from 184 to 221. So, should I put some of the fat back on my bones as recommended by my friends? I think not.

I believe what we are seeing is a failure of the BMI numbers to accurately define healthy weights. Some experts go so far as to claim that the obesity paradox doesn't exist. It is an illusion, a misunderstanding resulting from an overly simplistic way of calculating healthy body weight.

Doctors Vojtech Hainer and Irena Aldhoon-Hainerov wrote in their essay Obesity Paradox Does Exist:

The obesity paradox may be partly explained by the lack of the discriminatory power of BMI to differentiate between lean body mass and fat mass. Higher mortality in the low BMI categories may be due to . . . low muscle mass . . . Many obese patients demonstrate not only increased fat mass but also increased muscle mass. Elderly patients with heart failure who exhibited high BMIs and had improved survival rates also had a better nutrition than many of those patients with lower BMIs.

BMI and triceps skinfold thickness did not predict mortality, while a larger mid-arm muscle area, as a protective factor, did. A composite measure of mid-arm muscle mass and waist circumference was proposed as the most effective predictor of mortality in older men. Men aged 60 to 79 years with low waist circumference and above-median muscle mass demonstrated the lowest mortality rate.

Google "obesity paradox" and you'll find yourself in the middle of controversy. Here's a link to get you started: There's No 'Obesity Paradox' for Stroke, Study Finds. 

If you are still into books. I still am. Visit your local library and borrow The Obesity Paradox by Dr. Carl Lavie. Lavie writes that fat is like real estate: it's location, location, location. Not all fat cells are the same. Abdominal fat is bad, while bottom, hips, upper arms, and thighs is not so bad. For really bad fat, think visceral fat -- the fat surrounding abdominal organs. That stuff can increase fatty acids, the production of inflammatory compounds and create hormones resulting in higher rates of bad cholesterol, blood fat (triglyerides), blood sugar (glucose) and higher blood pressure.

Thin folk with belly fat are often at a higher risk of cardiovascular disease that those considered fat based on their BMI number alone. The truth is, that unlike abdominal fat, saddlebags and thunder thighs may actually be good for you. If you are thinking of liposuction to shrink those difficult to lighten body areas, don't!

Dr. Lavie would like to move the focus from fat to health -- to fitness. As he reports, and I think we all can agree, a person can be exceedingly healthy at many different BMI values. Before putting too much emphasis on a little fat by the BMI standard, improving fitness may deliver far more health benefits for the effort.

Clearly, it's not just total weight that matters; it's where one carries that weight. It's better to be a pear than an apple. Carrying excess weight around the abdomen is bad. Carrying the excess around the hips while keeping the waist narrow is far better. And always try to be fit with good muscle mass. An extremely thin person, with poor muscle mass and no reason to claim they are fit, has more health issues than a mildly overweight person whose fat hides a fit, muscular body.

It may be that as long as you are a small, fit pear, you may well call out triumphantly, "BMI be damned."

Vinyl: The record of who we were (or weren't)

Larry Cornies is a former editor with The London Free Press who now writes a weekly opinion piece for the paper. The weekend column, it runs every Saturday, is a window into media groupthink. A column that ran a few weeks ago, Vinyl the record of who we were, ties a number of common media myths into one tidy package.

Cornies tells us "The children of the ’60s are easing their way toward retirement now, like an old hippie easing himself into a warm bath. . . . for many of us, the dusty, slightly warped and invariably scratched LPs and 45s, still wrapped in their fading and musty jackets . . . are the most revealing parts of the archives of our early lives."

Larry's core premise in this piece is dead on: The record collections of those of us who grew up in the '60s do contain clues as to who we once were. In reading Larry's piece one thing is clear: I don't remember the world like Larry Cornies does. My world is not and never has been the world of Larry Cornies.

My friends and I never had a "stack of vinyl" as Cornies apparently did. Records were kept in their jackets and stored on their edges. They stood upright on a shelf in an area of the room that did not get direct sunlight and was removed from hot air vents. Heat could warp vinyl LPs.

We played our records on either a Dual or Garrard turntable. No one used a record player as most were too wearing on the record's grooves. Record player tone arms were heavy and the automatic ones, which dropped 45s and LPs into the play position, were not trusted. I recall having an Empire cartridge on a low mass tonearm with the pressure set to less than two grams. Minimal wear was the goal.

It's funny but I am not surprised that Larry Cornies found the presets on the AM car radio so important. Most teens I knew found a way to upgrade their car radio, even if it was in the family car, to an AM/FM model. Not that AM wasn't important. It was but it was under attack from FM stations like WABX out of Detroit. AM DJs in the style of Juicy Brucey Bradley and Dick Summers of Boston's WBZ were going out of favour. (The skip enjoyed at night by powerful AM band stations gave DJs like Bradley and Summers tens of thousands of fans over an immense listening area.)

As for Cornies claim that the Beatles’ Sgt. Pepper’s Lonely Hearts Club Band broke the mould when it came to cover art -- maybe. I'd argue the Velvet Undergound album cover designed by Andy Warhol and featuring a peel-able banana deserves the mould breaker honours. Peel the banana and discover a flesh-coloured fruit. Shocking! The difficult to produce album cover was a big reason for the album's late release.

Cornies may have dumped his record collection but I haven't. My albums are not warped and scratched. I still like to listen occasionally to Cat Mother and the All Night News Boys, Savoy Brown, Spirit, Kennsington Market . . . When Don Van Vliet died in 2010, I played my old Safe As Milk album by Captain Beefheart and his Magic Band. Ah, the memories.

I hate to burst Cornies' balloon but I doubt the oh-so-conservative, oh-so-religious journalist knows anything about hippies. True hippies, not the hangers-on so loved by the media, were dedicated. Some of the hippie types I knew are still fighting for the big issues. Maude, of Harold and Maude fame, would understand.
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Two of my music heroes from my youth have died since I started this blog. One, Jack Bruce, the bassist-composer-singer of Cream died at 71 in his home in Sussex. Read about Bruce here.

Bruce was, for me, a cross-over artist. Cream was a top-40 hit-maker as well as a popular underground band. Badge may have been 60 notches down from number one on the AM station charts, but Badge was a monster hit on the alternative FM network.

Steve Miller was another great cross-over artist. Think Song of Our Ancestors. AM radio often chopped off the foghorn beginning, if they played it at all. The whole piece, taken as a whole, is a great entry point to the psychedelic music of the time. I have been told dropping acid to Song of Our Ancestors makes for a very good trip.

The other artist from my youth that I have blogged about is Don Van Vliet, known to many as Captain Beefheart. He died at 69, succumbing to complications from multiple sclerosis.

16 hours in the ER; 16 hours well spent

Long wait times in hospital emergency departments are a persistent problem around the world. The American College of Emergency Physicians in a paper on ER overcrowding reported:

"The news media have given great attention to the crowding “crisis” in emergency departments as if this were a recent development. However, as far back as 1987, after sustained and unsolvable problems with crowding, the first statewide conference on crowding was held in New York City. . ."

Recently, The London Free Press ran a story reporting that ER wait times at London Health Sciences Centre (LHSC) University Hospital (UH) have been as long as 19 hours. The newspaper went on to bemoan the fact that patients with serious conditions were "spending hours in the ER." Although this is all true, this is not the whole story.

Less than two weeks ago I spent 16 hours in emergency at UH. Those 16 hours may well have been the most import block of time in my entire life. Those 16 hours led directly to my undergoing emergency surgery for a life-threatening bowel obstruction.

Two mornings earlier I had awakened with a severe pain in my gut. By mid-afternoon I was at the St. Joseph Urgent Care Centre. The service was fast but that is all I can say for it. When nothing concrete could be found to explain my pain before the centre closed at six p.m., I was told an unnamed virus was the probable cause, given a shot of morphine for pain and sent home. I asked to stay overnight for observation but was told that St. Joe's does not have any rooms for that purpose.

An interesting aside: This lack of rooms is a main reason St. Joe's fared so well in the CBC Rate Your Hospital report. Patients appearing on St. Joe's doorstep who are exceedingly ill, possibly dying, are  shipped off to University Hospital. UH takes the patients, the responsibility and the risks. Meanwhile, St. Joe's accepts the accolades for its lower than usual mortality rates.

Now, back to my story. As soon as the morphine wore off, the pain returned. I suffered all night. My difficulty with keeping stuff down, a problem dismissed by the doctor at St. Joe's, was now a constant. As I take meds for my heart and other meds to prevent stroke, I feared I was losing these all-important pills when I got violently ill. By late afternoon I called the doctor at UH who monitors my meds. I was instructed to get to the UH emergency department immediately. This was serious.

I arrived by ambulance at the ER shortly before five in the afternoon. I was parked in a hallway but I was not parked and forgotten. An EKG was done and I believe blood was taken for testing. I'm not sure how long I was in the hallway. I really didn't care. The pain had been so severe that I was just grateful to be in the hospital where I was receiving something for the pain.

At some point in the early evening an ER cubicle became free and I was moved to a small bed in the ER. I met with an ER doctor who immediately ordered x-rays. He was concerned I might have a bowel obstruction. I did.

It seems a tight band had formed around part of my small intestine. Why it formed was not clear but what was clear was that it had to be removed and soon. The tight band was shutting off blood flow to a section of my intestine and if not removed soon would irreparably damage the constricted intestine. If the band was not removed soon, surgical removal of the damaged section of intestine would be necessary.

But the doctors in ER faced another complication. I take Pradaxa. This is an anti-coagulant or a blood-thinner in common parlance. Unlike coumadin, there is no easy way to reverse the effect Pradaxa has on blood's ability to clot. Major surgery can result in life-threatening bleeding in patients taking Pradaxa. Discontinuing Pradaxa a day or two before surgery is the usual answer but my doctors did not have that luxury.

A CT scan was ordered. A couple of hours before the procedure I was given a litre of a contrast-enhancing fluid to drink. The surgeons needed to know exactly what it was that they were up against. A CT scan was the answer. An MRI might have been another option but not in my case. I have an ICD/pacemaker in my chest. For me, MRIs are not an option.

Served cold the contrast liquid was not all that difficult to drink. The nurse divided my dose into two 500ml portions. I slowly consumed the first 500ml during the first hour. The nurse thoughtfully put my second dose on ice.

Normally, I was told, I would have been given close to two litres of the contrast-enhancing fluid but as I was slated for surgery first thing in the morning the volume of the dose was kept to a minimum. One never has anything by mouth before surgery and here I was drinking a full litre of liquid. As soon as the CT scan was complete, a young doctor threaded a tube through my nose and down my throat into my stomach. He pumped what he could of the contrast-enhancing fluid out of my stomach.

At 9 a.m. I was in the operating room. Thanks to the CT scan the surgical team had determined the exact location of the offending intestinal band. The lead surgeon, an expert in laparoscopic surgery, a minimally invasive surgical approach that does not require splitting the abdomen open, led the team down a surgical path that would skirt the Pradaxa bleeding risk. Brilliant.

After about three and a half hours I was wheeled into the recovery room. When I was asked if I needed another shot of painkiller, I said, "No. The pain is gone."

I had spent 16 hours in emergency. A reporter searching ER records would learn a patient at LHSC University Hospital spent 16 hours in the ER but would not learn that those 16 hours saved the patient's life.

I send my heartfelt thanks to the young doctors, the team-leading surgeon and to the nurses in the ER, the nurses in the recovery room and the nurses on the eighth floor where I eventually found a room. What a fine team! They saved my life.

Thank you!

Understanding ER Wait Times Information

What does “ER Wait Times” mean?

An ER Wait Time is the total time that someone who visits an ER looking for immediate, unscheduled care spends in the ER. The measurement of wait time :

• Starts when a patient registers or is triaged (“triage” is the process for deciding which ER patients need, or are likely to benefit from, immediate treatment).
• Ends when the patient is discharged from the ER or is admitted to a hospital bed.

During the time that a patient is in the ER, doctors and nurses may be treating the patient's condition or ordering tests and waiting for test results so they can decide on  the best course of treatment/

Some months after I wrote the above post, I had another event. This time I had a severe chest pain that left me doubled up. The pain then moved from my chest to my back and eventually settled in my chest. I spend all day in emergency. I was given another CAT scan and when nothing was found I was pushed to the side but not forgotten. It took a full day but before I was released I was given a three page document detailing the findings of the CAT scan.

Again, the wait times information looks bad. Eight or more hours in emergency seems unbelievable on the surface. A reporter might roast the hospital for this. Me? As the patient who has spent these on-the-surface unreasonable times in the ER, I'd still give the ER staff a big thumbs up. I feel my time spent in ER was time well spent. In fact, I'm alive on account of it.

Lathenia: inspired by good blog on Greek cuisine

My quick version of lathenia: A pizza like Greek dish.

As many of you already know, the heart and stroke specialists in London, Ontario, have put me on a cholesterol reduced diet. If it has a face, I can have it only every other day. And if it is red meat, once a month is often enough. Ice cream? I can have it on my birthday.

This diet may sound restrictive, and it is, but it doesn't feel that way. My wife, Judy, is going to Weight Watchers and she is bringing home oodles of good, low fat, vegetable-centric recipes. We have both lost a lot of weight. I am about to drop below 180 pounds and my doctors are very happy with the weight loss. If my heart could smile, it would be sporting a grin.

In searching the Internet for recipes and just inspiration, I have found a good blog on Greek cuisine: OliveTomato posted by Greek-American Nutritionist and writer Elena Paravantes. She discusses the Greek-Mediterranean diet, Greek food, and supplies a constant flow of recipes while touching on the latest research on one of the healthiest "diets" on the globe. I believe my doctors would approve.

I made my quick version of lathenia by using a low-fat pizza crust purchased ready-made at the grocery store. I used just a smidgen of tomato sauce as instructed by Paravantes. I covered the crust with tomato and onion slices and brushed the surface with a little good olive oil. I baked this in the oven at 350-degrees until the simple topping began to caramelize. Five minutes before it was done, I sprinkled a very light dusting of grated Parmesan cheese over the top. I returned the lathenia to the oven just long enough to melt the Parmesan.

My wife said this was delicious and it was only about 4-points per quarter. Today my wife was weighed. She was down and this means my version of lathenia gets a thumbs-up.

If you are trying to keep your weight in check, or trying to develop a heart healthy diet, check out Elena Paravantes' site, OliveTomato. She has posted some good, easy and oh-so-healthy recipes with a Mediterranean/Greek cuisine slant.

You will notice that Paravantes was very generous in her use of olive oil when making her version of lathenia. I may try this again and make her flaky crust but I will restrict my use of olive oil in the topping. I cannot bring myself to use a third of a cup of olive oil. I'll simply brush the surface. For me, that will be sufficient.

Subconjunctival hemorrhage: Nasty looking but harmless

My eye was well on its way to be healed when I took this picture.

My granddaughter noticed it first. The white of my right eye appeared to be filling with blood. It looked nasty.

As I take the anticoagulant Pradaxa, bleeding in my eye was concerning. I headed off to the the ER at University Hospital in London, ON.

Moments after entering the ER I was interviewed, my OHIP information was taken and I was asked to sit down and await triage. A few short minutes later I was being interviewed by the triage nurse. She seemed remarkably calm about my bleeding eye. A good sign. She asked me to take a seat in the waiting room.

A notice in the waiting room warned the wait for a doctor was running anywhere from four to six hours. I took a seat, picked up a magazine and scanned it for something to read. Interesting, I thought, my right eye is filling with blood and yet my vision seems unaffected. Another good sign.

I hadn't waited even two hours when I my name was called and I was taken from the waiting room to a small examining room where I noted there was what appeared to be a slit lamp instrument. These have a support for the chin and a brace for the forehead. With the patient's head held steady, an optometrist or doctor can shine a bright light into the eye to conduct a careful examination.

Soon a nurse arrived and had me read an eye chart. This tests visual acuity. I did fairly well. There was certainly no big difference between my two eyes. Whatever was occurring in my right eye was not affecting the vision.

The nurse left and an ER doctor entered. He carefully noted the meds I take and seemed especially interested in the Pradaxa, the anticoagulant I take to lessen my risk of suffering a stroke. He looked at the results of my visual acuity test and then examined my eye using the slit lamp unit. He put drops in my eye and left to help someone else while the freezing took effect.

When he returned, he used a computerized pen-type instrument to gently touch the surface of my eye to get an accurate eye pressure reading. All was normal.

He had a diagnosis: Subconjunctival hemorrhage. According to the Mayo Clinic this is caused by a tiny blood vessel breaking just underneath the clear surface, the conjunctiva, of the eye. There is usually no pain and no visual problems associated with this despite the frightening appearance. The blood trapped below the transparent layer will usually disappear in a week or two. There is no specific treatment.

The ER doctor made it quite clear that if pain should develop or my vision become blurry, I should return to the emerg. I believe the Pradaxa was a bit of question mark hanging over this whole incident. When one is on a powerful anticoagulant, any bleeding is cause for immediate concern. That said, it did not appear my eye was bleeding all that profusely and the Pradaxa did not appear to be the cause of my problem nor did it appear to be making the event worse.

The doctor sent me home. I had been in the ER a total of four hours.

In the last few months, the ER department at our local hospital has come in for criticism in the local paper. With my own personal defibrillator in my chest, an ICD, with a pacemaker in charge of my heart rate about 93 percent of the time, with a rather rare genetic-based heart condition, I have made more than my share of visits to the ER in recent years. I have no complaints.

The medical staff in the ER have tough jobs. In my experience, they are an amazing group doing damn fine work. Part of the reason I am alive today is because of the fine work done by the doctors and nurses in hospital emergency departments.

Sun Media: nattering nabobs of negativism

Jonathan Sher, of The London Free Press, reported on the treatment received by patients suspected of suffering a certain type of heart attack in Ontario. The news report was well written, was medically accurate and I believe, was overly negative in tone.

I believe it was this negative tone that resulted in a great many oh-so-critical online comments attacking the health care system in Ontario. "For 1 in 5, fast care isn't there," read the headline. According to the article, nearly one in five Ontarians with a specific type of heart attack, known as a STEMI,  are not getting the fast access to treatment required. All true. The reader is also told Canadian experts look to American counterparts for benchmarks against which to judge treatment times. In Ontario 18 percent fall short of the American/Canadian benchmark.

An online comment warned, "Be afraid. Be very afraid. Do not get sick or old in Ontario." This comment attracted the most support from the paper's Web-based readers with the warning sitting at the top of the comment heap. Another reader laid the blame on Deb Matthews, a London MPP and former Minister of Health.

Let's take another look at the situation in the States. We find articles where the Yanks are downright proud of the their health care system and the rapid advances being made in this area. A recent American study looked at 96,738 patients in the heart attack group under discussion and found only 17 percent had treatment times that fell short of the benchmark.

In Canada, Sun Media bemoans the fact that our health care system fails 1 out of 5 patients suffering this type of heart attack. In the States, the Yanks are proud to report that 4 out of 5 patient suffering these attacks are treated within the benchmark time. The numbers from the two counties are separated by about one percent.

Two of my uncles died from heart problems. My father died from a heart attack. I take powerful meds while watching my diet to keep atherosclerosis (hardening of the arteries) at bay. For these reasons, I carefully follow the ever improving treatment for heart attack patients. 

I see the Canadian health care glass as half full and continuing to fill as medical breakthroughs are made around the world. A lot of medical research is done in Canada and our medical community is aware of not only what is being done in the States but around the globe. 

Recently, when I had an ablation procedure to cure my heart rhythm problems, one of my heart surgeons was a doctor from the south of France. When I was wheeled into recovery after the procedure was done, I felt very lucky to be living in Canada and especially lucky to be living in London, Ontario. 

My health care has been world class.

Weight Watchers for those seeking heart healthy diet

With a failing heart and arteries showing signs of plugging up, I've been put on a Mediterranean diet. The hope is that a low cholesterol diet will help keep my blood cholesterol in check. But my doctors are not taking any chances; I'm also taking 10 mg of Ezetrol, a cholesterol absorption inhibitor.

I take Ezetrol in addition to 40 mg of Lipitor daily as the Ezetrol takes a different approach to cholesterol lowering than statins, which lower cholesterol by cutting cholesterol production in the liver.

By happy happenstance, my wife decided to start attending Weight Watchers at the very same time I was being placed on a low fat, low meat, diet. My diet and my wife's diet fit together like two pieces of good-health-diet puzzle. My wife has lost more than forty pounds and I have dropped about twenty-five pounds in the last few months. My doctors will be pleased when I next see them for a consultation.

Tonight we had spanakopita for dinner with a cucumber and tomato salad topped with slices of bocconcini cheese. On the side we had some broccoli florets lightly "buttered" with Becal margarine. My wife made a Weight Watchers' version of spanakopita -- a savoury mix of spinach and feta and low-fat ricotta cheeses wrapped with layers of flaky phyllo pastry. Each serving of the spanakopita was just four points. I enjoyed two pieces as I have a daily goal of 37 points.

I'd post the recipe but my wife adhered fairly closely to the Weight Watchers recipe. If you want the recipe, you'll have to join Weight Watchers. She did stray a little, she added a few roasted pine nuts to the spanakopita and a few slices of bocconcini cheese to the salad. I should note that this recipe did not call for eggs, not even yolkless egg substitutes, and parmesan cheese was also missing.

I admit, cheese is a bit of a no-no to those of us on low cholesterol diets. That said, I figure my daily intake of cholesterol today was well under 100 mg -- my personal cholesterol ceiling. My intake of saturated fat and total fat was also held in check. At the same time, I had lots of fibre while keeping my salt intake low.

Now to head out for a gentle walk about the neighbourhood. Light exercise is the final important ingredient in my heart healthy regimen.