medifast - sexercise

As a red blooded male, this is just plain awesome of medifast.  I'd like to meet the individual who decided to include this in their Exercise Log.  They allow you to record all manner of exercises, intensity and duration which then calculates your caloric burn based on your body weight.  To what am I referring specifically, though?  A picture is worth a thousand words....(warning to my parents, this will probably make you uncomfortable...)

It includes not only sex but how involved it was and how long it lasted.  Let's look at the caloric expediture of a 'quickie' from the female perspective, shall we?  It involves minimal effort and only lasts 5 minutes.  Your reward (other than happy husband)???  A whopping 7 calories.  But what if you're involved, too?

Sorry ladies.  It only bumps up to 11 calories.  But what if it's a night, er, nearly an hour of passion?

For 48 minutes of vigorous sexual activity (and I'd love to know how they defined and calculated that), you burn 101 calories.  That doesn't sound like a lot but when you're only eating 800-900 calories daily, that's just north of 10% of your total caloric intake.  That's not trivial which is why they probably decided to include it as an exercise activity.  (Plus, it keeps one's mind off of being hungry.)  Couple that with walking with dog for half an hour and you're up to 20% thereby inducing some serious weight loss.  On their website, they say that over 15,000 physicians recommend their plan.  If they keep promoting activities like this, they may have to make it 15,001.

review - the good earth

In keeping with reading good literature, my wife and I joined a book club and first on the list was The Good Earth by Pearl S. Buck.  It tells the story of a rural farmer in 19th century China as he struggles with bounty and famine, floods and droughts, marriage and parenting.  Life, basically.  It was an interesting book as the characters were all very human complete with their shortcomings and flaws.  But perhaps most interesting to me was the take from the book club.  Most of the members are women and nearly 80% of them completely and utterly bashed the male protagnonist while defending the female protagonist despite them both having flaws and insecurities.  I, on the other hand, saw them both as being unique individuals with neither being the better person.  It made me wonder what being an OB would be like being around that much estrogen.

review - the picture of dorian gray

Synopsis - a young Victorian playboy - handsome, rich, young, and all the embodiement of the excitement of youth - is captured in a portrait by a painter who becomes a close friend.  Adonis-like in form, the Dorian is memorized by his own beauty and one day while looking at the painting realizes that the form in the portrait is the one aging, not him.  It continues to age accumulating all the hideous stains of sin and a misspent, hedonistic life while he remains emaculate in life.  He eventually loses it, murders his painter friend and destroys the painting thereby ending his own life.

Medical relation - this book should be read by cosmetic surgeons.  Way too much of a hang up on beauty as an end in itself and justification for all things.  Half the time I can't tell if the author (Oscar Wilde) is condoning the "beauty as an end" or criticizing it.  In trying to be coy about it, the beauty thing comes across as cheap and tawdry, much like some aging actress who has had wwaaayyyy too much bad cosmetic surgery.

Conclusion - this is the first classic that I haven't liked.  In my estimation, there are three major components to literature - Plot, Character(s), and Writing Style.  The last one is a bit tricky.  For instance, I've read books where the plot was so-so, the characters were decent, but the writing style was phenomenal (Salman Rushdie comes to mind).  I'll read over a sentence or paragraph and based on the word choice and flow it's a sensual experience in and of itself much like eating a deeply satisfying meal.  It's great if the meal is accompanied by good friends and family or if it makes sense (hamburgers and french fries go along, not hamburgers and stir fry which would be analogous to the plot).  But if the food is spectacular, that's enough to justify a meal even if you're surrounded by jerks.  Well, Oscar Wilde's writing style is just not for me.  Way too many homoerotic overtones for me.  And it's not just that, they were way too ridiculous and over the top.  At times, it seemed cheesier than those horrible books where Fabio graces the cover artwork or some teeny bopper Hannah Montana song.  I wouldn't want to read those absurd, completely unrealistic and untrue to life lines in any relationship - homo or hetero.  It had a very interesting concept and just took it nowhere.  To have that in what is supposedly literature just seems infantile to me, and incidently the mark of intellectualism.  I wish I could have read this book in a college or high school class so I could have ripped it apart in a paper.  I disliked it that much.

thoughts from behind the mower

     I'm out in the elements where the heat indices approach 110 degrees working all day.  I've started working out at the gym with my son.  And I actually gained weight.  In my twenties, I never had any trouble with weight.  I subscribed to the simple notion that weight was all about the simple equation:

calories in = calories out

     To lose weight, just eat less and exercise more.  I'm realizing first hand that's a simplistic biological notion.  Your body is not a like your checking account.  It's as if your checking account could grow or shrink irrespective of how much you make or spend.  So I've realized that when I started working out, my appetite increased voraciously to compensate.  And I didn't necessarily eat bad things either.  Likewise, I've read of multiple studies where starving oneself leads to a slowing of metabolism which is why diets are yo-yo in nature.  It's not only the weight loss that's difficult.  It's the maintenance that's equally hard but just as important.  And I'm not sure the medical community has come up with a satisfactory strategy for that yet.

medifast

     My wife is attempting to lose weight and based on my research of the literature, she elected to go with Medifast.  And after a few days of her experience with it, I have to say that from a physician's perspective, I'm impressed this company so far.  First, a bit of background on the approach.  Medifast is not the approach to lose 5 pounds.  As its name implies, it's pretty much a medical fast.  It's severe.  But the approach seems physiologically sound so far.  The premise is to get the individual to eat about 900 calories.  Like I said, it's severe. 

     The method is to eat 5 of their prepackaged, better living through chemistry, instant 'meals' every 2 to 3 hours.  They consist of shakes, oatmeal, pudding, soups, eggs, etc. so there's quite a lot of variety and the one's we've tried so far actually tasted better than I expected.  You're then to eat one real meal that consists of 7 oz of fish like tuna, or 6 oz of meat like skinless chicken breast, or 5 oz of lean cuts of beef.  Somwhere along the line (3 servings at your real meal or spread out throughout the day) you consume 3 servings of low carb veggies like green beans, asparagus, bell pepper, etc.  Add'em up and you get around 800-1,000 calories daily.

     To keep you honest and on track, you can go into one of their centers and get weekly one on one counseling.  The center we visited boasted of a 93% compliance rate.  That was phenomenal to me.  And then the sticker shock hit and I could see why their compliance was so high.  If you're going to dump that kind of money on something, it's going to weed out the nonserious types.  We had to move to plan B which was to simply purchase the meals online.  But along with that you get access to their online program which helps you track your progress.  You first log your weight and measurements.  You then daily log each of your individual meals and exercise.  The great thing about the software is that it automatically calculates the calories for you.  I expected it to do it for their products but it does it for restaurants, too.  My wife was at a workshop and so had Chick-fil-A.  Type in '8 piece nuggets' and bang, it pulls it up for you with all the nutritional information (calories, fat, protein, carbs, sodium, etc) all listed for you.  On the side is a running total for your daily calorie input, your calories burned through exercise, and your deficit.  It's quite reinforcing to see that negative number jump out at you.  It then gives you weekly status reports based on the information you provide to tell you how you're doing with your goal.  If you're not on track, it's easy to track down whether you're eating too many calories or not meeting your exercise goals.  It's impressive.

     Overall, I'm impressed with this program.  I've had to alter slightly the dinners that I make.  I can't slap tuna salad on a pita and melt pepperjack over it and expect that to work for her anymore.  All that we had to buy was a $7 food scale and their meals online which aren't considerably different than a grocery+eating out bill.  It's damned cheap when one considers future doctor's visits, medications, and just overall psychological and physiological health.  As a husband, I'm trying to be very supportive (a definite requirement for the program if you're not getting the counseling at the center) but it's been pretty easy because as a physician and scientist, I'm inherently intrigued by this program's approach so it's become (to me) an interesting real life case study of how weight loss works for one individual.  So I've convinced my wife to let me blog about the pros and cons of it which wasn't easy for her since she's a pretty private person (or should that be a private pretty person?).  It's an opportunity for me to learn and I thank her for that. 

shiner time

To my brother who has successfully completed all six rounds of chemotherapy, may your tumors suffer the same fate as this beer.  Sláinte mhaith!

off the reservation

     Last round of chemo.  I can only imagine how my brother feels to be finishing with it.  I think it's a mixed bag for him.  On the one hand, the doc stated, "you should be quite pleased, your cancer is responding to the therapy like I haven't seen in a lllooonnggg while."  The bone lesions show evidence of repairing and on the PET image of the primary (and secondary), even I could tell a big difference between the before and after.  But it vexes my brother that no cures are proffered.  And so I've thought a lot about what can come next.  According to current wisdom, conventional therapy offers no cures.  So at what point does one begin to go "off the reservation" with respect to therapy?  Usually that statement is reserved for those going off into the hinterlands of insanity.  But when one knows the limitations and outcomes of the conventional route, to me it's the sane man who ventures off into those hinterlands. 

     Being uncharted territory, it's littered with anectdotal and hyperbolic claims, many of them almost predatory playing on the hopes and fears of patients.  My research background helps me be able to sort through that bs pretty quickly.  But I also keep telling myself to keep an open mind.  Spontaneous remissions do occur.  How or why is open to debate but discoveries, especially the really big ones, are more often than not when a prepared mind happens upon a chance finding.  I watched it happen enough to know when to follow my gut.  But it's hard to wade through it since the research is so personal.

     It's also a function of how much the patient is willing to embrace.  I can't imagine my brother going off and becoming a hardcore vegan (not that I recommend that).  The negative impact on his quality of life would preclude him from following it.  So we start incrementally.  We start with things that A) have a reasonable chance of helping and just as importantly B) do no harm.  His chemotherapy regimen has granted him an enormous gain and that needs to be honored and not undone.  So first the easy and safe things.  Green tea.  Pomegranate. Broccoli.  Fish oil.  (I'm not going to review the literature on each of these here but I'll probably do it later if I get around to it).  Now that the chemo is done, we'll probably now add curcumin and some other things once he's recovered from this last round.

where they make the assholes

Scene 1

My wife and I are walking down a long skywalk bridge which connects two MDACC buildings.  On one side is the pedestrian pathway.  On the other is the path for carts shuttling patients back and forth who have difficulty walking.  The path narrows down and like in traffic, the natural thing to do is to zipper when merging.  A doctor rudely cuts off my wife and runs into her handbag.

Scene 2

My brother, my mom and I are walking down the same skybridge the next day.  Up ahead are two doctors conversing.  They are standing in such a way as to block the entire pedestrian pathway.  I quickly relate the story of my wife's experience and state matter of factly, "watch, they will make us go around them and go into the cart path."  True to form, the god-like beings force us mere mortals to go around them.  Behind us is an elderly and feeble woman in a wheelchair.  My brother states, "if they don't move for the elderly minority woman....that's just sad."  They break up their conversation before the wheelchair bound woman makes it to them but I have little doubt that they would have remained steadfast in the knowledge that their discussion outweighed any inconvenience the elderly woman would have encountered by having to move.

As we're driving home, we pass my school and I point it out to my wife.  Her reply? 

"That's where they make the assholes."

Doctors don't do themselves many favors when it comes to dispelling the accusation of having a god complex.

battle

Battle = Biomarker-integrated Approaches of Targeted Therapy for Lung cancer Elimination.  Approaches like this is one of the major reasons for driving us towards MDACC.  It's a rather innovative way at conducting clinical trials.  The standard way of looking at new therapies is take a thousand patients with lung cancer and say half get treatment A and half get treatment B.  The problem is that not all lung cancer patients are equal and at the end of the trial, the primary endpoint would often be missed (translation - expensive failure) but in further analyses it may be found that one small percentage may have benefited.  Then one would have to conduct another trial and look at those patients and so on.  At the end of the day, it has not lead to much progress in lung cancer.  This approach hopes to change that.

     They biopsied non-small cell lung cancer patients (NSCLC which is what my brother has) who had already undergone chemo and assessed the tumor for 11 different mutations or particular markers.  The first round of initial patients were randomized to one of four different experimental therapies that would inhibit molecular pathways thought to be important in cancer biology.  The goal was to find out which therapies worked in which markers, or just as importantly, what therapies would not work in certain patients.  After the first round they would then engage a technique called adaptive randomization.  It's a bit like artificial selection in medicine.  If patient with markers A, B, and C responded to Therapy 1, then the next patient who came along with markers A, B and C would be nudged towards that same therapy.  Likewise, if the same patient responded horribly to Therapy 2, the next patient would be nudged away from Therapy 2.  It's an iterative process that moves away from a shotgun approach and instead allows for a system to adapt and improve through a darwinian process thereby minimizing costs and failures.

     So how did it work?  First, it showed that a targeted trial using adaptive randomization could work (also see I-SPY for breast cancer) which was not a foregone conclusion.  I suspect that this will slowly but surely begin to change the way cancer trials are conducted.  Second, since these were end stage patients who had already undergone the usual therapies, the primary endpoint was 8 week control of the disease (that means that the tumor had maintained size or shrunk after 8 weeks by imaging).  Historically, that would mean about 30% of the patients would meet those criteria after 8 weeks.  With this approach, it reached 46% which is not at all trivial in very sick patients.  And since they collected good biopsies, they and other researchers can go back and further probe the biopsies with new information and newly discovered mutations.  Now the plan is to take the information learned and go into a BATTLE 2 and BATTLE 3.  If you want more nuts and bolts about the mutations and therapies, you can click here (listening to one patient who was 37 and a triathlete was very poignant).  If you want to listen to a podcast with the clinicians and two of the patients enrolled, you can click here or you can find it iTunes here (it should be podcast #17 with BATTLE in the title).

     I walked away with two distinct impressions.  First, when asked about some of the pragmatic results that can be immediately applied to oncologists, the clinicians stressed the importance of high quality biopsies.  As I look back on my brother's experience, I can attest firsthand to the inadequacy of biopsy harvesting at other institutions (they screwed up the first one which still makes me furious to this day).  The second was something I came across on the web.  Since I haven't yet had a chance to discuss the results with the doc, I perused around a lot on the web reading other oncologist's opinions and thoughts about it.  I came across this forum where an oncologist gave this assessment of the trial which I found amusing:

I think they are encouraging and provocative and show the feasibility of a concept for which feasibility was actually an open question....Part of what he's talking about is that MDACC trials often have highly motivated patients so they can produce results that others may not be able to.  The other is that the comprehensive nature of care there is so wide and cutting edge that it dwarfs many other institutions.  And for both of those reasons, it feeds me hope because my brother is a highly motivated patient and the quality of care he has received there has been top notch.

health wednesday

(I'm a day late but oh, well.)  When discussing food around the table, I'm like a parrot.  "The only dietary pattern with good clinical data relating to meaningful endpoints is the Mediterranean diet."  Everything else is just hypothesis generating in my book.  The ADA (American Diabetes Association) is having its big annual meeting right now so lots of interesting stories are coming out about diabetes.  One in particular caught my eye.  The hot topic is to reduce carbs.  The more nuanced scientific question is, replace them with what?  It would seem to suggest that replacing carbohydrates with any old protein source is not the way prevent diabetes. An observational study of roughly 40,000 men found that men with low carb intake and high red and processed meats had a higher rate of progression towards diabetes.  Granted, this is an observational study but it drives home the point that just because something medically makes sense, doesn't mean it'll be true.  Glucose dysregulation causes diabetes.  Eat less glucose, get less diabetes.  It's more complicated than that.  The medical community and society at large went whole hog into the low fat territory and it simply did not reduce disease in any meaningful way.  Before we go off chasing our tail again, we should rely on data from meaningful clinical studies.  And right now, the Mediterranean diet is the best game in town.