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Many Doctors Dont See Past the Fat


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2016 Sep 26, 11:21am   14,588 views  52 comments

by zzyzzx   ➕follow (7)   💰tip   ignore  

http://www.nytimes.com/2016/09/26/health/obese-patients-health-care.html

Why Do Obese Patients Get Worse Care? Many Doctors Don’t See Past the Fat

You must lose weight, a doctor told Sarah Bramblette, advising a 1,200-calorie-a-day diet. But Ms. Bramblette had a basic question: How much do I weigh?

The doctor’s scale went up to 350 pounds, and she was heavier than that. If she did not know the number, how would she know if the diet was working?

The doctor had no answer. So Ms. Bramblette, 39, who lived in Ohio at the time, resorted to a solution that made her burn with shame. She drove to a nearby junkyard that had a scale that could weigh her. She was 502 pounds.

One in three Americans is obese, a rate that has been steadily growing for more than two decades, but the health care system — in its attitudes, equipment and common practices — is ill prepared, and its practitioners are often unwilling, to treat the rising population of fat patients.

The difficulties range from scales and scanners, like M.R.I. machines that are not built big enough for very heavy people, to surgeons who categorically refuse to give knee or hip replacements to the obese, to drug doses that have not been calibrated for obese patients. The situation is particularly thorny for the more than 15 million Americans who have extreme obesity — a body mass index of 40 or higher — and face a wide range of health concerns.

Part of the problem, both patients and doctors say, is a reluctance to look beyond a fat person’s weight. Patty Nece, 58, of Alexandria, Va., went to an orthopedist because her hip was aching. She had lost nearly 70 pounds and, although she still had a way to go, was feeling good about herself. Until she saw the doctor.

“He came to the door of the exam room, and I started to tell him my symptoms,” Ms. Nece said. “He said: ‘Let me cut to the chase. You need to lose weight.’”

The doctor, she said, never examined her. But he made a diagnosis, “obesity pain,” and relayed it to her internist. In fact, she later learned, she had progressive scoliosis, a condition not caused by obesity.

Dr. Louis J. Aronne, an obesity specialist at Weill Cornell Medicine, helped found the American Board of Obesity Medicine to address this sort of issue. The goal is to help doctors learn how to treat obesity and serve as a resource for patients seeking doctors who can look past their weight when they have a medical problem.

Dr. Aronne says patients recount stories like Ms. Nece’s to him all the time.

“Our patients say: ‘Nobody has ever treated me like I have a serious problem. They blow it off and tell me to go to Weight Watchers,’” Dr. Aronne said.

“Physicians need better education, and they need a different attitude toward people who have obesity,” he said. “They need to recognize that this is a disease like diabetes or any other disease they are treating people for.”

The issues facing obese people follow them through the medical system, starting with the physical exam.

Research has shown that doctors may spend less time with obese patients and fail to refer them for diagnostic tests. One study asked 122 primary care doctors affiliated with one of three hospitals within the Texas Medical Center in Houston about their attitudes toward obese patients. The doctors “reported that seeing patients was a greater waste of their time the heavier that they were, that physicians would like their jobs less as their patients increased in size, that heavier patients were viewed to be more annoying, and that physicians felt less patience the heavier the patient was,” the researchers wrote.

Other times, doctors may be unwittingly influenced by unfounded assumptions, attributing symptoms like shortness of breath to the person’s weight without investigating other likely causes.

That happened to a patient who eventually went to see Dr. Scott Kahan, an obesity specialist at Georgetown University. The patient, a 46-year-old woman, suddenly found it almost impossible to walk from her bedroom to her kitchen. Those few steps left her gasping for breath. Frightened, she went to a local urgent care center, where the doctor said she had a lot of weight pressing on her lungs. The only thing wrong with her, the doctor said, was that she was fat.

“I started to cry,” said the woman, who asked not to be named to protect her privacy. “I said: ‘I don’t have a sudden weight pressing on my lungs. I’m really scared. I’m not able to breathe.’”

“That’s the problem with obesity,” she said the doctor told her. “Have you ever considered going on a diet?”

It turned out that the woman had several small blood clots in her lungs, a life-threatening condition, Dr. Kahan said.

For many, the next step in a diagnosis involves a scan, like a CT or M.R.I. But many extremely heavy people cannot fit in the scanners, which, depending on the model, typically have weight limits of 350 to 450 pounds.

Scanners that can handle very heavy people are manufactured, but one national survey found that at least 90 percent of emergency rooms did not have them. Even four in five community hospitals that were deemed bariatric surgery centers of excellence lacked scanners that could handle very heavy people. Yet CT or M.R.I. imaging is needed to evaluate patients with a variety of ailments, including trauma, acute abdominal pain, lung blood clots and strokes.

When an obese patient cannot fit in a scanner, doctors may just give up. Some use X-rays to scan, hoping for the best. Others resort to more extreme measures. Dr. Kahan said another doctor had sent one of his patients to a zoo for a scan. She was so humiliated that she declined requests for an interview.

Problems do not end with a diagnosis. With treatments, uncertainties continue to abound.

In cancer, for example, obese patients tend to have worse outcomes and a higher risk of death — a difference that holds for every type of cancer.

The disease of obesity might exacerbate cancer, said Dr. Clifford Hudis, the chief executive officer of the American Society of Clinical Oncology.

But, he added, another reason for poor outcomes in obese cancer patients is almost certainly that medical care is compromised. Drug doses are usually based on standard body sizes or surface areas. The definition of a standard size, Dr. Hudis said, is often based on data involving people from decades ago, when the average person was thinner.

For fat people, that might lead to underdosing for some drugs, but it is hard to know without studying specific drug effects in heavier people, and such studies are generally not done. Without that data, if someone does not respond to a cancer drug, it is impossible to know whether the dose was wrong or the patient’s tumor was just resisting the drug.

One of the most frequent medical problems in obese patients is arthritis of the hip or knee. It is so common, in fact, that most patients arriving at orthopedists’ offices in agonizing pain from hip or knee arthritis are obese. But many orthopedists will not offer surgery unless the patients first lose weight, said Dr. Adolph J. Yates Jr., an orthopedics professor at the University of Pittsburgh School of Medicine.

“There are offices that will screen by phone,” Dr. Yates said. “They will ask for weight and height and tell patients before they see them that they can’t help them.”

But how well grounded are those weight limits?

“There is a perception among some surgeons that it is more difficult, and certainly some felt it was an added risk,” to operate on very obese people, Dr. Yates said. He was a member of a committee that reviewed the risks and benefits of joint replacement in obese patients for the American Association of Hip and Knee Surgeons. The group concluded that heavy patients should first be counseled to lose weight because a lower weight reduces stress on the joints and can alleviate pain without surgery.

But there should not be blanket refusals to operate on fat people, the committee wrote. Those with a body mass index over 40 — like a 5-foot-5-inch woman weighing 250 pounds or a 6-foot man weighing 300 — and who cannot lose weight should be informed that their risks are greater, but they should not be categorically dismissed, the group concluded.

Dr. Yates said he had successfully operated on people with body mass indexes as high as 45. What is behind the refusals to operate, he said, is that doctors and hospitals have become risk-averse because they fear their ratings will fall if too many patients have complications.

A lower score can mean reductions in reimbursements by Medicare. Poor results can also lead to penalties for hospitals and, eventually, doctors.

A recent survey of more than 700 hip and knee surgeons confirmed Dr. Yates’s impressions. Sixty-two percent said they used body mass index scores as cutoffs for requiring weight loss before offering surgery. But there was no consistency in the figures they picked.

“The numbers were all over the map,” Dr. Yates said. And 42 percent who picked a body mass index cutoff said they had done so because they were worried about their performance score or that of their hospital.

“It’s very common to pick an arbitrary B.M.I. number and say, ‘That is the number we won’t go above,’” Dr. Yates said. Yet a person with an index of, say, 41 might be healthy and active, he said, but in terrible pain from arthritis. A knee replacement could be life transforming.

“It’s a zero-sum game, with everyone trying to have the lowest-risk patient,” Dr. Yates said. “Patients who may be at a marginally higher risk may be treated as a class instead of individuals. That is the definition of discrimination.”

Surgery involves anesthesia, of course, giving rise to another issue.

There are no requirements for drug makers to figure out appropriate doses for obese patients. Only a few medical experts, like Dr. Hendrikus Lemmens, a professor of anesthesiology at Stanford University, have tried to provide answers.

His group looked at several drugs: propofol, which puts people to sleep before they get general anesthesia; succinylcholine, used to relax muscles in the windpipe when a breathing tube must be inserted; and anesthetic gases.

Propofol doses, Dr. Lemmens found, should be based on lean body weight — the weight of the body minus its fat. Using total body weight, as is routine for normal-weight people, would result in an overdose for obese patients, he said. But succinylcholine doses should be based on total body weight, he determined, and the dosing of anesthetic gases is not significantly affected by obesity.

As for regional anesthetics, he said, “There are very few data, but they probably should be dosed according to lean body weight.”

“Bad outcomes because of inappropriate dosing do occur,” said Dr. Lemmens, who added that 20 to 30 percent of all obese patients in intensive care after surgery were there because of anesthetic complications. Given the uncertainties about anesthetic doses for the obese, Dr. Lemmens said, he suspects that a significant number of them had inappropriate dosing.

Yet for many fat people, the questions about appropriate medical care are beside the point because they stay away from doctors.

“I have avoided going to a doctor at all,” said Sarai Walker, the author of “Dietland,” a novel. “That is very common with fat people. No matter what the problem is, the doctor will blame it on fat and will tell you to lose weight.”

“Do you think I don’t know I am fat?” she added.

#fat

« First        Comments 13 - 52 of 52        Search these comments

13   turtledove   2016 Sep 26, 6:00pm  

zzyzzx is deplorable says

should be informed that their risks are greater

"We, the jury, find for the plaintiff." Informed consent isn't as bullet proof as one might think.

14   115d   2016 Sep 26, 8:37pm  

Anyone who weighs 500+ lbs has no credibility.

Having said that, Docs should treat every patient with respect...even patients who don't respect themselves.

15   Y   2016 Sep 26, 9:09pm  

If you can't get past the slabs of unharvested bacon to plant the stethoscope, why bother at all???

16   ja   2016 Sep 27, 1:06am  

justme says

. I tried once to explain to a doctor that what constitutes normal blood pressure must necessarily depend on your height, since the vertical distance from the heart to the top of the head directly affects the peak pressure required to perfuse (I think that is the word) the brain. Talk about getting a blank stare in return! Basic physics should be an absolute requirement for medical school.

http://www.scientificamerican.com/article/why-is-normal-blood-press/

17   carrieon   2016 Sep 27, 3:57am  

Obesity is part of the plan. The healthcare system doesn't make money from healthy people.

18   lostand confused   2016 Sep 27, 5:19am  

zzyzzx is deplorable says

When an obese patient cannot fit in a scanner, doctors may just give up. Some use X-rays to scan, hoping for the best. Others resort to more extreme measures. Dr. Kahan said another doctor had sent one of his patients to a zoo for a scan. She was so humiliated that she declined requests for an interview.

Well, when you look like this, the normal MRI will not fit!!

19   carrieon   2016 Sep 27, 5:51am  

lostand confused says

zzyzzx is deplorable says

When an obese patient cannot fit in a scanner, doctors may just give up. Some use X-rays to scan, hoping for the best. Others resort to more extreme measures. Dr. Kahan said another doctor had sent one of his patients to a zoo for a scan. She was so humiliated that she declined requests for an interview.

Well, when you look like this, the normal MRI will not fit!!

Also note, All the garbage and sugary drinks these mammoths consume every day is approved for purchase with the EBT card.

20   Strategist   2016 Sep 27, 6:12am  

carrieon says

Also note, All the garbage and sugary drinks these mammoths consume every day is approved for purchase with the EBT card.

It's just a little snack until dinner time.

21   Y   2016 Sep 27, 6:19am  

Where are the poachers?
Where are the tusks?

carrieon says

Also note, All the garbage and sugary drinks these mammoths consume every day is approved for purchase with the EBT card.

22   BayArea   2016 Sep 27, 9:49am  

Setting glycemic restrictions on foods purchased by food stamps and EBT cards.

I like it!

23   FNWGMOBDVZXDNW   2016 Sep 27, 9:54am  

This doctor shows a complete lack of creativity. If he had a rudimentary understanding of physics, he could use a lever and the current scale to measure the patient's weight. Maybe the fat person has an excuse for being stupid, but a doctor is supposed to be a thinking individual rather than a rote memory bank.

All one would need is a board, a tape measure, a book, and the scale. You could even do without the tape measure with a little creativity.

Lacking those items, the doc might look for a second scale, and have the patient stand with one foot on each scale.

24   anonymous   2016 Sep 27, 10:16am  

thunderlips11 is deplorable says

Okay, a doctor who tells a 350+ pound person they need to go on a 1200 calorie diet ought to have their license suspended.

At that weight, you could eat 2500 calories and drop weight like crazy. That actually might be too low.

Hogwash

Calorie quantity is all but irrelevant, relative to calorie QUALITY.

Here's a simple exercise to help you understand

Drink a 12 pack of cokes a day - 1800 calories

Or

Eat a 16 oz ribeye (1250 calories)
Six eggs (480 calories)
Two yams (230 calories)

The 1800 calories will make you obese
The 1960 calories is a recipe for weight loss via burning body fat and promoting muscle growth

25   FNWGMOBDVZXDNW   2016 Sep 27, 10:33am  

errc says

The 1800 calories will make you obese

No it won't. A ks professor proved this point by losing weight on a Twinkie diet. There are all sorts of problems with an all coke diet, but magical weight gain is not one of them.

26   anonymous   2016 Sep 27, 10:38am  

YesYNot says

errc says

The 1800 calories will make you obese

No it won't. A ks professor proved this point by losing weight on a Twinkie diet. There are all sorts of problems with an all coke diet, but magical weight gain is not one of them.

False

I'm not sure if you're misinformed, or being intentionally dishonest, but either way, you are harmfully and dangerously wrong.

27   Strategist   2016 Sep 27, 10:39am  

YesYNot says

Lacking those items, the doc might look for a second scale, and have the patient stand with one foot on each scale.

That's a great idea.

28   justme   2016 Sep 27, 4:32pm  

ja says

justme says

. I tried once to explain to a doctor that what constitutes normal blood pressure must necessarily depend on your height, since the vertical distance from the heart to the top of the head directly affects the peak pressure required to perfuse (I think that is the word) the brain. Talk about getting a blank stare in return! Basic physics should be an absolute requirement for medical school.

http://www.scientificamerican.com/article/why-is-normal-blood-press/

That very short article in Scientific American is not very good. To give a concrete numerical example, it is logically unassailable that if the vertical distance from my heart to the top of my head happens to be 13cm more than for the average person on which the 120/80 number is based, then I *must have* a 1cmHg = 10mmHg higher blood pressure at the heart in order to stay alive. There just is no other way. And 10mmHg makes a big difference if you read (just an example) 140/80 mmHg, which is considered mild hypertension. The difference between an equivalent 130/80 and measured 140/80, under current US guidelines, is a lifetime of medications that can have nasty side effects.

By the way, I have looked up a study of blood pressure in children based on age and height, and sure enough the BP pretty much increases as one would expect with age and height, until about age 16-18, when adult height has been achieved.

Like I said, it is basic physics.

In case anyone wonders where the number 13 came from, it is the approximate relative density of mercury to water or blood.

29   Strategist   2016 Sep 27, 4:55pm  

justme says

That very short article in Scientific American is not very good. To give a concrete numerical example, it is logically unassailable that if the vertical distance from my heart to the top of my head happens to be 13cm more than for the average person on which the 120/80 number is based, then I *must have* a 1cmHg = 10mmHg higher blood pressure at the heart in order to stay alive. There just is no other way. And 10mmHg makes a big difference if you read (just an example) 140/80 mmHg, which is considered mild hypertension. The difference between an equivalent 130/80 and measured 140/80, under current US guidelines, is a lifetime of medications that can have nasty side effects.

By the way, I have looked up a study of blood pressure in children based on age and height, and sure enough the BP pretty much increases as one would expect with age and height, until about age 16-18, when adult height has been achieved.

Like I said, it is basic physics.

In case anyone wonder...

How do giraffes maintain their blood pressure. You might find this interesting.

http://jeb.biologists.org/content/209/13/iii

30   justme   2016 Sep 27, 7:23pm  

Strategist says

How do giraffes maintain their blood pressure. You might find this interesting.

http://jeb.biologists.org/content/209/13/iii

I was thinking about giraffes as an extreme example yesterday, so thanks for the link. I've been digging into a bunch of articles from the references in your link. Pretty interesting stuff. Much more reading is needed, but the following quote stood out.

"We conclude that mean arterial blood pressure in giraffes is a consequence of the hydrostatic pressure generated by the column of blood in the neck, that tissue pressure around the collapsible jugular vein produces the known jugular pressures, and that a siphon does not assist flow through the cranial circulation."

Basically I think that this means that BP in giraffes is dominated by the need to perfuse their brains. It may be more so the case than in humans, but more reading required. Giraffes do have about 200-210 mmHg systolic pressure. Impact of having a combination of a horizontal trunk and a more or less vertical neck may be significant, too. Strange that I previously was not able to find any significant literature about BP=f(height) for humans.

31   FNWGMOBDVZXDNW   2016 Sep 28, 10:31am  

errc says

False

I'm not sure if you're misinformed, or being intentionally dishonest, but either way, you are harmfully and dangerously wrong.

http://www.cnn.com/2010/HEALTH/11/08/twinkie.diet.professor/
Ironically, he actually ate 1800 calories worth of Twinkies each day, and lost 27 lbs in 10 weeks.

32   MisdemeanorRebel   2016 Sep 28, 11:48am  

carrieon says

Also note, All the garbage and sugary drinks these mammoths consume every day is approved for purchase with the EBT card.

Yep. There's a pizza franchise on the West Coast that sells frozen pizza for the purpose of EBT card usage. If it's sold pre-cooked but frozen/cold, it qualifies for EBT.

Meanwhile States and Fed Gov are lobbied heavily not to allow EBTs at Farmer's Markets.

33   MisdemeanorRebel   2016 Sep 28, 11:52am  

errc says

Hogwash

Calorie quantity is all but irrelevant, relative to calorie QUALITY.

Here's a simple exercise to help you understand

Drink a 12 pack of cokes a day - 1800 calories

Or

Eat a 16 oz ribeye (1250 calories)

Six eggs (480 calories)

Two yams (230 calories)

The 1800 calories will make you obese

The 1960 calories is a recipe for weight loss via burning body fat and promoting muscle growth

Errc, I'm a total believer that counting calories and only calories is not the path to weight loss success, it violates the laws of Thermodynamics. I eat only veggies and lean meats, like Jack Lalanne, whom everybody called a crank. "Exercise will make you muscle bound and give you a heart attack! How can you not eat bread, the staff of diabetes life?"

My point was that to maintain 350lb weight, somebody would have to eat well in excess of their BMR. At 1200 calories, they would be dropping weight dangerously fast. Nor would they be likely to succeed going from 3000+ calories a day (minimum) down to a third of that.

34   FNWGMOBDVZXDNW   2016 Sep 28, 12:09pm  

justme says

To give a concrete numerical example, it is logically unassailable that if the vertical distance from my heart to the top of my head happens to be 13cm more than for the average person on which the 120/80 number is based, then I *must have* a 1cmHg = 10mmHg higher blood pressure at the heart in order to stay alive...

Like I said, it is basic physics.

This is a very interesting topic. I disagree that it's logically unassailable, but it may be about right.

From strategist's link..
justme says

"We conclude that mean arterial blood pressure in giraffes is a consequence of the hydrostatic pressure generated by the column of blood in the neck, that tissue pressure around the collapsible jugular vein produces the known jugular pressures, and that a siphon does not assist flow through the cranial circulation."

You used hydrostatic pressure. Blood goes up to the head, through capillaries, and back down to the heart. If their is no air gap, I would expect that the blood draining back down would pull (siphon) the blood up. Meanwhile, there is some viscous drag on the blood, especially in the capillaries. The article on giraffes mentions tissue pressure pumping blood. Maybe this is peristaltic? Otherwise, it would have to be timed with the heart. I've heard that our own motion helps pump blood back from the feet to the heart, but I'm not sure to what effect. While the brain's need for blood is obvious, we also need blood to come back from our feet. I always figured that the hydrostatic pressure from heart to feet offset the hydrostatic pressure in reverse, and that viscous drag was the primary need for pressure at the heart.
The reason for increased blood pressure is narrowing and hardening of the arteries. Narrower passageways create more viscous drag. I would expect that there would be some differences between big and small people, because things don't scale linearly with size, but nature has ways of compensating.
The distance from heart to brain is about 15 inches or 29 mm Hg. This distance from feet to heart is about 4.5 feet, leading to 105 mm Hg static pressure, which is a pretty typical BP for a healthy person. I think that this is a coincidence, though.

35   justme   2016 Sep 28, 1:50pm  

Notice the profound logical difference between the statements:

A. presence of narrowing/hardening of the arteries ==> higher blood pressure

B. higher blood pressure ==> presence of narrowing/hardening of the arteries.

I think A is true, but I'm also pretty certain that B is untrue.

36   FNWGMOBDVZXDNW   2016 Sep 28, 3:09pm  

justme says

Notice the profound logical difference between the statements:

Yeah. I understand what you are saying and don't disagree. That's why I didn't say B. In the point at the end, I merely discussed the change in blood pressure, which requires a baseline for an individual.

I was hoping you would respond to the rest of the comment, which addressed the pressure drop of blood on a round trip from heart to extremity and back. Specifically, the point about siphoning seems relevant to me.

I don't know if this is a personal thing for you, but you brought up 130 and 140. As I understand it, US guidelines medicate at >130, but Brittish guidelines medicate at > 140. The Cochrane group advocates that 140 be the guideline, and states that evidence doesn't justify medicating if BP is

37   justme   2016 Sep 28, 3:33pm  

I wanted to respond, but there were enough details that I could not exactly agree with that I can't find the time right now. Maybe later. Just the one example:

>>The reason for increased blood pressure is narrowing and hardening of the arteries.

If you had said, "ONE reason" and not "THE reason", I can agree. But when you say "THE reason", that is logically equivalent to (B), which is false.

Also, the Mitchell [1] giraffe paper says there is NO siphoning effect demonstrated. Start by re-reading that. Let's not get into too much tit-for-tat, though.

[1] Mitchell et al, 2006, http://jeb.biologists.org/content/209/13/2515?iss=13

39   Tenpoundbass   2017 Jan 5, 7:46am  

Karma counting down the days until zzyzzx gets a herniated disk and gets immobile for three months, then his thyroid craps out and he packs on 120 pounds in 24 months.

41   Shaman   2017 Jun 8, 9:00am  

zzyzzx says

extreme measures. Dr. Kahan said another doctor had sent one of his patients to a zoo for a scan.

Wow! Wake up call much?

42   Shaman   2017 Jun 8, 9:26am  

YesYNot says

This doctor shows a complete lack of creativity. If he had a rudimentary understanding of physics, he could use a lever and the current scale to measure the patient's weight. Maybe the fat person has an excuse for being stupid, but a doctor is supposed to be a thinking individual rather than a rote memory bank.

All one would need is a board, a tape measure, a book, and the scale. You could even do without the tape measure with a little creativity.

Lacking those items, the doc might look for a second scale, and have the patient stand with one foot on each scale.

I'm impressed! This is way good info from you!
To illustrate your point:
So if you put a 50lb weight on one side at eight feet from the fulcrum, and the patient balances where their side of the board is 1 foot from the fulcrum, you have an 8:1 ratio, which means their weight is 8x50=400lbs

43   zzyzzx   2017 Jun 8, 9:34am  

Quigley says

To illustrate your point:

So if you put a 50lb weight on one side at eight feet from the fulcrum, and the patient balances where their side of the board is 1 foot from the fulcrum, you have an 8:1 ratio, which means their weight is 8x50=400lbs

Are doctors required to take physics classes?

45   Shaman   2017 Jun 8, 1:43pm  

zzyzzx says

Are doctors required to take physics classes?

Physics 1+2 are required undergraduate work for the normal biology or chemistry degree paths. However you could enter medical school with a degree that didn't require that!

46   HEY YOU   2017 Jun 8, 1:54pm  

Patnetters don't have high blood pressure.
These assholes are heartless.

47   bob2356   2017 Jun 8, 8:33pm  

Quigley says

zzyzzx says

Are doctors required to take physics classes?

Physics 1+2 are required undergraduate work for the normal biology or chemistry degree paths. However you could enter medical school with a degree that didn't require that!

You need physics to take the MCAT's to apply to medical school.

48   bob2356   2017 Jun 8, 8:36pm  

Quigley says

zzyzzx says

Are doctors required to take physics classes?

Physics 1+2 are required undergraduate work for the normal biology or chemistry degree paths. However you could enter medical school with a degree that didn't require that!

You need physics to take the MCAT's to apply to medical school. Quigley says

To illustrate your point:

So if you put a 50lb weight on one side at eight feet from the fulcrum, and the patient balances where their side of the board is 1 foot from the fulcrum, you have an 8:1 ratio, which means their weight is 8x50=400lbs

Doctors offices don't equip themselves with fulcrums, 9 ft boards capable of supporting heavy weights, and a large selection of counter weights.

49   curious2   2017 Jun 8, 10:49pm  

YesYNot says

http://www.cnn.com/2010/HEALTH/11/08/twinkie.diet.professor/

Ironically, he actually ate 1800 calories worth of Twinkies each day, and lost 27 lbs in 10 weeks.

From your link:

"For 10 weeks, Mark Haub, a professor of human nutrition at Kansas State University, ate one of these sugary cakelets every three hours, instead of meals. To add variety in his steady stream of Hostess and Little Debbie snacks, Haub munched on Doritos chips, sugary cereals and Oreos, too.
***
For a class project, Haub limited himself to less than 1,800 calories a day.
***
His body mass index went from 28.8, considered overweight, to 24.9, which is normal. He now weighs 174 pounds.
***
Two-thirds of his total intake came from junk food. He also took a multivitamin pill and drank a protein shake daily. And he ate vegetables, typically a can of green beans or three to four celery stalks."

Celery stalks can subtract calories, due to the energy required to digest them. Also, the article does not state how much muscle Haub might have lost during the period: a person can reduce weight and BMI by losing muscle while gaining fat.

bob2356 says

Doctors offices don't equip themselves with fulcrums, 9 ft boards capable of supporting heavy weights, and a large selection of counter weights.

A scale costs $20. A person maintaining a morbidly obese diet can reasonably be expected to buy two scales.

A single office visit costs more than enough to pay for two scales, a bp&pulse meter, and a thermometer. Unfortunately, the current subsidy and tax models distort purchase decisions in terribly inefficient ways. We have subsidies for all the worst "foods," including extra subsidies for corn, and infinite subsidies for drugs and medical visits. We have taxes on devices. What you subsidize, you get more of: drugs, medical visits, dependence. What you tax, you get less of: devices and independence. I saw an interview recently describing the Flynt water situation: a volunteer explained to a patient that a water filter costs only $30, but she said she could not afford that, though she had "access" to infinite drug and hospital funding. It is much more lucrative to keep people dependent.

50   MMR   2017 Jun 9, 5:55am  

zzyzzx says

There is a perception among some surgeons that it is more difficult, and certainly some felt it was an added risk,

Definitely more difficult and probably more risky as a result

51   Y   2017 Jun 9, 5:59am  

@Jazz
Just trying to help...

They suggest that by constricting the jugular at this point, giraffes could maintain sufficient blood pressure, when they raise their heads after drinking, to prevent themselves from passing out.

52   anonymous   2017 Jun 9, 6:15am  

Also, the article does not state how much muscle Haub might have lost during the period: a person can reduce weight and BMI by losing muscle while gaining fat.

-----------

Which is, without a doubt, what happened

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