Angels for Obesity

"There's more to it of course, but I wanted to give the flavor of the choices you can be faced with way before you think you'll need to."

That, my friends, is a message from Curt.  Read it carefully, because it is a message from a young man who is facing a circumstance that none of us ever want to contemplate.  His need to make decisions about his life and death came upon him without warning at a time when no one would have ever expected this to happen.

I don't know Curt personally.  I have "met" him through a good friend and colleague, who in turn was concerned about his good friend who suddenly found himself facing his mortality.  Otis Brawley-who is the American Cancer Society's chief medical officer-and I were consulted several times to provide advice to Curt and his wife during his time of need.

Curt is a young man with a loving, concerned wife and family who had just started a new job which I suspect he was looking forward to with enthusiasm.  He had been engaged in this new position for about a month when suddenly one day he had a seizure and was taken to the emergency room.

The doctors treated the immediate medical problem, but then did their initial evaluation and delivered terrible news: it looked like cancer had spread throughout Curt's body, with hundreds of tumors in his brain, his lungs, his liver and probably elsewhere.

The seizures were stabilized, treatment was started.  More complications came quickly thereafter, and then Curt-in a time of lucidity-had to make the ultimate decision:  whether or not to continue his treatment, or pursue care with comfort.

Curt wrote a blog, and this was his entry (reprinted with permission):

"Real Life (and Death) Choices

Posted by Curt Ewald on August 26, 2010 at 12:38pm

"Sudden New Situation: Aggressive blood-clots in both legs and both lungs that will eventually cause breathing to get worse and worse. The lung clots will kill me in days or weeks.

"Choice A: Start blood thinners to help the lung clots dissolve, but will surely cause bleeding of my brain mets and a seizure-filled, painful death experience for the kids/family. Oncologist says he has never seen so many brain mets in a single patient (100's)

"Choice B: Switch to a "comfort & care" approach in a professional home hospice environment that is already proven and I like & trust. Choose DNR status and make it clear we're not going back to the hospital. Install a little cage (already done) in my blood vessel to catch any more clots rising from the leg. This is not giving up, it's managing the death process.

"BTW - Pain relief is very well covered. I get to play with morphine, marijuana and anything else that helps!

"There's more to it of course, but I wanted to give the flavor of the choices you can be faced with way before you think you'll need to."

When I read this blog, I stopped for several minutes and just stared, contemplating its power and its guidance, coming from someone whose life had so shortly before been so promising, and was now so mortal.

Perhaps you will be as impacted by Curt's words as I have been.  But if I had my wish, I would want everyone to contemplate Curt's message, especially that last sentence.  It's worth reading again:

"I wanted to give the flavor of the choices you can be faced with way before you think you'll need to."

Curt is now sedated, and probably unable to say much.  But his words are profound, his message from the heart, and in this moment of sorrow for Curt and his family, perhaps there is solace in his words for others who have-and who will-face their own mortality at a moment when it is least expected.

Thank you, Curt.  You are in our thoughts and prayers.

If a study in the current issue of the New England Journal of Medicine was a report about a new treatment that extended the lives of patients with advanced lung cancer by almost 3 months, the crowds would be cheering.  But it isn't a study of a new chemotherapy drug, targeted therapy or vaccine.  And I doubt there are lots of cheers in the audience.

It's much simpler than an expensive, complicated new treatment for a devastating disease.  It's about starting palliative care to help patients deal with the symptoms from their disease and its treatment early in the course of that disease leading to a dramatic improvement in survival in a cancer that is almost always fatal.

Non-small cell lung cancer is a killer for many people.  Lung cancer is the leading cause of cancer death in this country, although the numbers are declining with the decrease in smoking, especially among men.  But once diagnosed as having spread outside the primary area of the cancer, the outlook is grim and for most folks is less than one year.

That one year is difficult enough knowing that you have a fatal illness.  But the treatments for the disease-and the disease itself-can be devastating.  Those treatments may buy a couple of months, but there is no dramatic impact for most people and the inevitable outcome can't be avoided.

Couple that very sad fact with the other reality that we don't do much in this country to help people through the process.  Dealing with pain, treatments, nausea, vomiting, weight loss-the common effects of cancer treatment and the illness-is very difficult under the best of circumstances.  And these folks-since they have usually (but not always) been smokers for much of their lives-have other serious medical problems with their hearts and lungs which complicates the situation further.

Palliative care is designed to help people and their families address these symptoms, along with the other issues that come along with a diagnosis of a fatal cancer.  How to make the right medical decision for the individual is one example.  What about end-of-life care, and whether or not they want to be aggressively treated with chemotherapy and even resuscitated if they should stop breathing or their heart stop functioning?  When is the best time to seek hospice care? What are the advantages and disadvantages of continuing chemotherapy in the face a relentless progression of the cancer?

These are some of the issues that palliative care teams-composed of doctors, nurses, social workers, dietitians and other professionals-can address with patient and families.  In fact, according to the article, over 80% of large (greater than 300 bed) hospitals in this country have such teams.  But unfortunately for the most part these teams don't get called in to help until very late-and maybe too late-in the course of the illness.

The study reported in the New England Journal addressed the question of whether or not calling in the palliative care team to help patients and their families early in the course of treatment made a difference compared to what usually is done, which frequently means a consultation when a patient is in great pain, severely depressed, or near the end of life.

The researchers found that by engaging the palliative care experts early on made a substantial difference in the quality of life of the patients. 

Those patients who received early palliative care had a better quality of life, less depression, and most remarkably lived 2.7 months longer than those who had routine care (it is important to point out that all patients in the study, including those who received early palliative care and those who did not, were treated by the same group of doctors and had the same access to chemotherapy treatments).  The net difference was 11.6 months for the palliative care patients, compared to 8.9 months median survival (that means half lived less and half lived more) for those patients not receiving the early palliative care intervention.  This improvement occurred despite the fact that the palliative care patients had less aggressive care at the end of life.

If that degree of improvement in life expectancy was seen in a clinical trial looking at survival after treatment with a new chemotherapy drug, there would be applause all over the place.  Instead, I fear that many physicians will just yawn and say something to the effect of "Here they go again with that pain stuff."

How did this simple, straightforward approach result in such a remarkable outcome?  The answer is that no one is really certain.

Years ago, there was a genuine question as to whether or not chemotherapy made any benefit in the outlook for patients with non-small cell lung cancer that had spread through the body. 

It took a number of years of research and clinical trials to come to the conclusion that chemotherapy did in fact improve survival for patients with this disease.  It took more years to determine that we didn't have to throw every drug we knew worked in lung cancer at our patients in order to lengthen their days.   Yet even though the treatments have been shown to have genuine value and increase survival, they come with a huge price in side effects and quality of life.  And, we still remain hugely frustrated as patients, families and doctors at the lack of a true breakthrough in the treatment of metastatic lung cancer.

Now, along comes a study that says if we just paid a bit more attention to our patients' symptoms, offered them more support, answered their questions about their treatment options, and helped them plan for their near-term future and outcome by understanding their wishes and respecting their decisions, and give that care in addition to standard chemotherapy, then we could significantly improve and prolong their lives.

This is not an especially expensive approach to medical care, my friends. 

The investment in palliative care certainly pales in comparison to the costs of the drugs we use in treating cancer, and lung cancer in particular.  But the returns on that investment-at least according to this study and a recent exellent article in The New Yorker magazine by Atul Gawande--are obviously immense.

Maybe it's time to realize that with all of our powerful medicines and other treatments we still have one medicine that we don't utilize often enough, and that is genuine caring and support for someone in distress.

As a young physician years ago, I learned to never underestimate the impact of a healing hand, a willingness to listen and an opportunity to provide support and guidance. It can truly make a world of difference. 

This study shows that rediscovering the value of what we used to do before we were able to do what we can do is a lesson well worth relearning. 

There they go again, trying to ruin my day.  The "they" in question are my epidemiology colleagues down the hall at our American Cancer Society offices in Atlanta. 

The topic a couple of weeks ago that got me going was an article they published suggesting that I had a higher chance of premature death because I sit at a desk most of the day.  Today's "offense" was a report published in the Archives of Internal Medicine showing that the larger your waist size-for the most part, with a couple of exceptions-the greater your chance of premature death.  And even if your body mass index (BMI) was normal-which is a measure of your height relative to your weight, and is used to classify people as normal, overweight or obese-you could still have an increased chance of death if your paunch is, uh, oversized.

The study has garnered a lot of media attention, probably because of the increasing concern surrounding the impact of obesity in this country. 

As noted by the researchers, this is not a new topic.  We have known for some time that an increased waist size-40 inches for men and 35 for women-is associated with poorer health outcomes.  The reason for this isn't clear, but there is increasing evidence linking a number of chronic illnesses--including cancer, diabetes and heart disease to name a few-with increased abdominal fat. 

There is reason to believe that fat stored in our abdomens has a worse impact on health compared to fat stored elsewhere.  So if you are a man or a woman shaped like an apple-carrying your weight around your middle--you are worse off healthwise compared to a man or a woman shaped like a pear, where you carry your weight mostly around your hips (as you might have observed, men are more likely to be apples, while women are more likely to be pears).

In this report, the researchers examined information that has been collected for many years as part of an American Cancer Society research program called Cancer Prevention Study II Nutrition Cohort.  They were able to examine records from about 105,000 men and women, including about 14,600 people who died from 1997 and 2006.

They found that-after adjusting for body mass index-that the larger your waist the more likely you were to die prematurely.  In fact, the risk of death for people with very large waists was about doubled.  The disturbing finding was that even if you had a normal BMI-which means that you would not be considered overweight or obese-the larger your waist, the greater your chances of early death. Larger waist size was more related to increased deaths from respiratory disease than cardiovascular disease and cancer.

This isn't the first time researchers have looked at this question of waist size in relation to chances of early death.  There have been other studies, but this one looked at people with very large waists unlike some of the previous reports.  This study also appears to be the first one that looked at the impact of waist size within each of three categories of BMI, including normal, overweight and obese.

The reason that is so important is because this study shows that you can have a normal BMI, be told by your doctor that your weight is "fine," but be at increased risk of death since your weight is carried right there around your midsection. 

One other point of note: for men, the impact of waist size on death was greater for men 70 years and older compared to men under the age of 70.  For women, age did not have as much of an impact on the results of the study.

Why am I so concerned about the results of this study?  You may have already guessed: my waist hovers around 40 inches, give a couple of pounds or so.  Eat too much, waist goes up; starve a bit, waist comes down.  The center point is right there around the magical 40 inches.

Now, I would also offer the thought that a waist of 40 inches on a man (I would never, never, never comment about a waist of 40 inches on women) can mean different things in different settings.

Take for example my experience a couple of years ago when I was looking for a pair of blue jeans.  I am one of those tall guys with a 40 inch waist.  I quickly discovered shortly after moving down South that there were plenty of jeans that would fit me with respect to the 40 inch waist, or 42 or 44 for that matter.  It was the length that was a problem.  They were all 30 inches or less in the inseam.

Travelling to the west-I think it was Texas or Arizona-I walked into one of those Western wear stores looking for another pair of blue jeans.  Now I was in luck-lots of long inseams.  But the waist size?  Try 36 and under.

The moral of the story?  I figure that there are a lot of men in my hometown who are a bit on the short size with large waists, while out West they are more likely tall with smaller waists.

Based on today's report, the Western guys are probably better off than the Southern guys-even if their body mass index is normal (which is not likely with a 44 inch waist and a 30 inch inseam).

So ladies and gentleman, you now have something else to worry about when you think about your health.  The size of your waist is likely directly related to the length of your years.  And if you take comfort that your weight in your 70's is the same as it was in college, forget about it.  The chances are your body has simply redistributed itself into the wrong places, and put you at greater risk of death.  No comfort is available anymore to those who looked the other way as their muscles turned into fat while their weight remained steady.

As to my friendly research colleagues here at the American Cancer Society, I can't wait to see what piece of information they are going to analyze next.  I suspect they have plenty of things to study that will not make my day (and maybe yours) any better. So far-in one month alone--they are two for two. 

So, my congratulations to my colleagues on producing some interesting and timely research reports. I may not like what they tell me, but what they tell me is based on high quality evidence and research.  It's up to me (and you) to take the messages and incorporate them into our everyday lives.

In the meantime can we get something positive for a change, like maybe ice cream is good for your health?  Now, that would be something to talk about.