Calling a spade a spade

Countless numbers of fat people have been denied treatment by their doctors until they lose weight. Some of the cruelest cases I’ve seen have been in patients suffering excruciating pain and disability from genetic crippling arthritis that’s destroyed their hips or knees. These patients were left to suffer because their doctors said they didn’t want to “waste” a hip or knee replacement on them. They were denied the pain relief and return to functional living simply because they were fat.

Unlike here in America, when this happens in Britain, it makes the news. A controversy that’s been raging there since 2005 — when the East Suffolk primary care trusts stopped funding joint replacements for patients unless the patient has a body mass index (BMI) below 30 — has again reared its ugly head. The Daily Mail reports:

Millions in danger of being deemed too fat for NHS surgery

Millions of patients could be denied some NHS treatments because they are overweight or smoke. The controversial policy has already been adopted by around one in ten hospitals - many of them battling to claw back huge cash deficits.

Health Secretary Patricia Hewitt has stirred the row further, saying a ban on surgery to replace problem joints is "perfectly legitimate". Doctors say the risks of operating on obese patients are higher and the treatment may be less effective, with new hips and knees wearing out sooner....

But the spread of the policy has brought angry protests from obesity experts, Opposition MPs and patient groups. They say patients are being denied treatment to save money, rather than on clinical grounds, and point out that problems with joints can often be a reason for obesity, as sufferers cannot exercise....

A survey of 116 primary care trusts found that nine are refusing joint replacements to obese patients and four have blocked orthopaedic surgery for smokers. The trusts, which cover six million patients between them, are almost all heavily in debt....Health trusts in Suffolk were among the first to say that obese people would be denied hip and knee replacements as part of an attempt to save money.

In the most bizarre argument, one doctor said BMI shouldn’t be used to rule out surgery, but waist circumference should, as if there is any evidence that hour-glass figures have less joint impact. The article concludes with cautionary notes about other discriminations such initiatives could lead to:

Joyce Robins, co- director of Patient Concern, said: “A national health service should not be deciding on who is worthy of treatment. This is a slippery slope. Do we next decide that those with criminal records should be denied healthcare? “These people have paid into the system all their lives. They will find it hard to understand why they must pay for someone to have their fourth child or for those who injure themselves in dangerous sports while they are excluded from the service.

“It may help trusts balance their budgets but could cost society far more. Deny a much needed new hip and the patient will become crippled and the cost of caring for them will soar. It makes no sense."

As the Telegraph reported today, nine NHS primary care trusts, which provide care to 6 million people, are refusing to give joint replacements to patients who are obese:

"That is a perfectly legitimate clinical decision. I support doctors making clinical decisions in the interests of their patients." Miss Hewitt's comments come amid growing calls for the NHS to take a tougher line on heavy smokers and the seriously overweight. Last summer, a survey found that two in five hospital doctors believed that smokers should pay for bypass operations.

But Andrew Lansley, the Tory health spokesman, said: "Trusts shouldn't have a policy which excludes people from treatment because they either smoke or are overweight, because treatments should be based on clinical needs."

It appears that the opposition over the 2005 Trust’s decision has gone unnoticed. A Cambridge doctor had written in the December 17th issue of the British Medical Journal:

The decision of the East Suffolk primary care trusts... breaches basic principles of health care that do not seek to judge patients for their illness....No evidence supports withholding joint replacement from obese people, even on utilitarian grounds.

A UK health technology assessment of hip replacement concluded that obese patients ... did not noticeably increase the operative risk. Chan et al found no significant difference in the improvement in scores (of quality of life) between the non-obese and obese groups, concluding that relative body weight alone does not influence the benefit derived from primary total hip arthroplasty.

Since obesity does not increase the risks or diminish the benefits of joint replacement, the trust's decision to deny such treatment seems to be based on prejudice or attribution of fault, or both. Logically extended, such a policy would deny treatment to, among others, smokers, most patients with HIV infection, and those who sustain sports injury.

And a Gloucesterhire doctor wrote:

Delaying operations on “punitive" grounds may increase long term costs. Personal experience shows that delaying joint replacement surgery causes deterioration of functional capacity, which is difficult or impossible to reverse after later operation. What is the evidence that these strict conditions are not in the longer term damaging?

This is rationing by any other name.

Joint replacement surgeries are soaring worldwide and it’s become popular to blame obesity. The American Academy of Orthopedic Surgeons reported last month that total knee replacements among ages 38 to 56 has doubled here in the past ten years, according to a Los Angeles Downtown News story. But, in contrast to beliefs that they’re mostly due to fat people, the AAOS said: “Many of these younger patients are athletic types who sustained injuries in their 20s, or are people who continue to indulge in high impact sports.” Otherwise, these surgeries will likely become more common as the prevalence of arthritis increases as the general population ages. An Australian surgeon at Brisbane Orthopaedic Specialist Services, estimated that 90 per cent of the 30,000 joint replacement operations in Australia are because of osteoarthritis. “There is an increase of people under 50 having the operations,” he said. But it isn’t because of obesity. It is “because of an increase in competitive and contact sports and also high- impact activity,” he said.

But misconceptions go far beyond pointing fingers, it affects the treatment people receive. Don't people rightly deserve medical care that’s based on credible science and quality medical research, not colored by bias?

The belief that fat people don’t deserve joint replacements because these surgeries are less successful and a “waste” on them is widespread, but is not well-founded. The fact such a belief perpetuates despite the enormous amount of evidence against it calls for health care professionals and public health officials to do some very deep soul-searching.

The evidence isn’t just found in a few outlier studies, but in the bulk of them. While this review is by no means all-encompassing, it will hopefully help open eyes as to how much preconceived prejudices can blind us to contrary evidence we don’t want to see. And when instances of unnecessarily poor outcomes are found at certain centers, hopefully the first response will be to examine the quality of care and not just blame the patients. I also hope that this information will benefit fat people when they encounter such discrimination to realize equitable care includes them.

How do the “obese” fare after joint replacement surgeries as compared to “nonobese?”

A 2002 study of 180 total knee replacement (TKA) procedures in the Journal of Arthroplasty looked at how body weight affected one-year outcomes and reported that “body weight did not influence adversely the outcome of TKA.”

A longer-term study following patients for an average of seven years was conducted by researchers at the Department of Orthopaedics, Johns Hopkins University School of Medicine in Baltimore, Maryland, reported: “There were no significant differences in the combined percentage of good and excellent results between the two groups. On the basis of the results of this study, it is believed that weight as a factor by itself should not compromise the ... results of total knee arthroplasty.”

Here in the U.S., the Agency for Healthcare Research and Quality (AHRQ) under its Evidence-based Practice Program recently examined the evidence on TKA procedures, the most common orthopaedic procedure performed. They noted that it had previously been established that the evidence supports these surgeries because they improve functional status, relieve pain and result in relatively low perioperative morbidity. For this NIH report, the AHRQ was especially interested in determining who is most likely to benefit and in what patients the procedure may be contraindicated. Their conclusion: “Age, obesity, or gender do not seem to be significantly correlated with TKA outcomes.”

Do things other than clinical data influence who gets these surgeries or in treatment delays? The AHRQ report found “lower rates of TKAs among blacks despite a higher prevalence of osteoarthritis in this group.” They found “the evidence regarding non-white groups is quite consistent. Non-whites receive TKAs about half as often as whites.” And a Canadian study looking at the equitable nature of waiting lists reported that while there were no biases in waiting times for joint replacement surgeries with respect to age, gender, education or work status; there were in other respects. Waiting time was determined by the patient’s body mass index and the primary language they spoke, as well as marital status.

While it is believed that the surgeries won’t last as long and need more revisions in the obese, this isn’t necessarily the case. Researchers at the University of Utah, Salt Lake City, published their study of 840 hip and 911 knee joint replacement surgery patients, aged 55 to 74 years, in a recent issue of the American Journal of Preventive Medicine. They also found “no statistically significant association was found between obesity and the risk for hip or knee revision procedures.”

And a ten-year follow-up study of TKAs performed on 22 obese patients and 34 nonobese patients at the Complete Knee Center of Arkansas, Van Buren, found that while stair climbing was more difficult among obese post-op patients, overall, “10-year Hospital for Special Surgery scores and Knee Society scores for patients who were obese were comparable with scores for patients who were nonobese and given lower preoperative Hospital for Special Surgery scores, improvement in knee score was greater. Revision rates in patients who were obese were not higher than in patients who were nonobese at 10 years follow-up.”

Addressing the specific question as to if obesity is contraindicated because of surgical complications, researchers at the University of Arizona, College of Medicine in Tucson examined 405 primary bilateral TKAs done under one anesthetic for incidences of wound infections and systemic complications. They found: “Preoperative and postoperative knee scores were not significantly different for any patient group. Local wound complication rates did not differ between any of the study groups.... there was no significant difference in complication rates between patients with obesity who underwent unilateral or simultaneous bilateral total knee arthroplasties. Based on these findings, obesity does not seem to be a contraindication to bilateral total knee arthroplasties under one anesthetic.”

A retrospective examination of complications for the two years following joint replacements in 130 obese and 51 nonobese patients at Lutheran General Hospital in Park Ridge, Illinois, concluded: “The hospitalization time, number of days with a fever, number of transfusions, preoperative and postoperative hemoglobin levels, and days requiring intramuscular narcotics were very similar between the two groups. There were 0.29 minor complications per nonobese patient, but only 0.22 per obese patient. Major complications were encountered 0.22 times per nonobese patient and 0.10 times per obese patient. The patient is not necessarily at a higher risk for perioperative complications in total joint arthroplasty.”

As the AHRQ noted, function and quality of life can greatly improve after a joint is replaced. This benefit is shared equally among fat and thin. A study of TKAs performed from 1989 and 1994 by University Orthopedic Specialists in Tucson, Arizona, reported: “Knee prosthesis and functional scores improved statistically after TKA.” Among the patients who had limited functional capacity, the most common cause was “progression of their arthritis at other sites, especially lumbar spine and hips, and cardiopulmonary problems....[but] Patient weight, body mass index (BMI), and age at surgery showed no correlation with postoperative functional scores.”

A study published in Obesity Research examined one-year outcomes among 592 primary total hip arthroplasty patients and 1011 primary TKA patients. It concluded: “Obese patients enjoy as much improvement and satisfaction as other patients from total joint arthroplasty.”

If our goals as healthcare professionals are to help improve the lives of patients, don’t all patients deserve that — not just the ones whose bodies it's popular to think are more fitting?

© 2007 Sandy Szwarc

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The tragedy of overwhelming fear

As if there weren’t already enough scary things in the news, today’s London-based paper, The Independent, heightened concerns over another invisible danger that is tasteless, odorless and supposedly putting children at risk: electronic smog.

Earlier this week, a tragically sad article appeared in another London paper, the Daily Mail, that illustrated the consequences of such scares.

The woman who needs a veil of protection from modern life

Sarah, 51, is one of a growing band of people who claim to be experiencing extreme - and incapacitating - sensitivity to electrical appliances, as well as to certain frequencies of electromagnetic waves. “Wi-Fi, or wireless broadband networks, seem to be the worst thing," she says. “I have to restrict the amount of time I spend on the computer or watching television, and make sure I don't have too many household appliances on at once, because that sets me off as well."

This may sound bizarre, but there is no doubt that Sarah's symptoms are real. To date, they include hair loss, sickness, high blood-pressure, digestive and memory problems, severe headaches and dizziness....She can't work. When she wants to phone friends, she has to use a land-line - a significant advancement, it turns out, because she was so ill at one stage, she says, that she couldn't even touch an ordinary receiver without feeling a violent shock pass up her arm....And she can venture into built-up areas only if she is swathed in a net-and-hat ensemble made from a special “shielding fabric" that makes her look like a bee-keeper....

The first symptoms started about five years ago....A stream of doctors, complementary practitioners and Chinese herbalists all failed to alleviate any of her symptoms or come up with a diagnosis. Instead, she found an answer on Google - through websites ...All her symptoms seemed to match those of people who believe they are allergic to modern life....Convinced that she had almost certainly found the cause of her illness, she ordered, from the internet, some special rolls of foil wallpaper and a fabric called Swiss bobbinet - a netting made from polyester filaments dipped in silver. Both promised to “shield" her from any emissions from phone masts or wireless broadband systems. Within a few weeks of the wallpaper going up and the windows being hung with netting, she began to feel better....

While her bee-hive get-up was the brunt of endless cruel jokes around the world, these sufferers sincerely believe in their illnesses. And clinical ecologist practitioners and lay support groups are quick to reinforce their anxieties. It doesn’t matter how comprehensive the medical evidence or how many careful studies have been conducted or how many scientific and medical experts have investigated concerns, and found no support for environmental illnesses, such as multiple chemical or electrical sensitivity. Victoria Moore, the Daily Mail reporter, reiterated the lack of scientific support for these sensitivities to modern life:

The World Health Organisation's position is that “there is no scientific basis to link ES symptoms to EMR exposure. “Further, ES is not a medical diagnosis, nor is it clear that it represents a single medical problem."... In one “provocation" study, a number of people who claimed to have electrical sensitivity were placed in a room with a mobile phone and not told whether or not it was switched on. Asked by a researcher how they felt, they failed to establish any link between physical symptoms and the alleged trigger.

What is Electrical sensitivity (ES)?

ES is an environmental illness that clinical ecologists claim is triggered by common levels of electromagnetic fields (EMF) from power lines, motors, computers, cell phones, televisions, etc. It’s also been called radiowave illness and microwave sickness. According to Linda Grant, a support group advocate and author of The Electrical Sensitivity Handbook, those who fall prey to ES are usually also patients with multiple chemical sensitivity, where they develop symptoms with any level of exposure to modern chemicals. “Other at-risk groups for developing ES seem to be chronic fatigue syndrome patients and those experiencing mercury toxicity from dental amalgams,” she says.

For many, it includes a belief in chi — the energy force that they believe influences moods, emotions, physical energy and health; and which feng shui followers believe needs to move freely throughout a home and can be affected by colors, shapes and materials. Artificial light is believed to be unhealthy. Plants, especially peace lilies, are said to help minimize the effects of electrical radiation.

Overall, electrical sensitivity is more publicized in Europe than the United States, partly because of the Swedish Association for the ElectroSensitive which began in 1987 as a support group to disseminate information on the “problem.” Its members report a lot of computer-related symptoms, which just so happen to match the “warning signs” of ES in their literature — dry eyes and irritations, blurred vision, problems concentrating, headache, jaw pain and muscular aches, cold-like symptoms. If those sound a lot like common symptoms everyone spending too many hours in front of the computer experiences, you’re right; but when members are told it’s low-level electricity harming them, the nocebo effect kicks in and not surprisingly, they find their symptoms “gradually worsen.”

A related story in the news this past week illustrated just how devastating these environmental illnesses can be. A couple from Allentown, Pennsylvania, is hundreds of thousands of dollars in debt from bills for the wife suffering from multiple chemical sensitivity. Her husband recently purchased a modular housing unit with filtered air and water to put in the backyard for his wife when they could no longer afford for her to stay in a specially designed chemical-free house in Texas. The structure has resulted in conflicts with neighbors and community officials, however. According to The Morning Call, her self-reported symptoms include headaches, vertigo, stomach pain, tight throat and irritable bowel syndrome.

Which brings us to this morning’s scary news. The first uncritically-researched article targeted parents and reported that wireless computer networks in schools could be damaging children’s health. It said some feared hazards of Wi-Fi gadgets, such as mobile phones, as possibly causing cancer and premature senility and are calling for an inquiry and more research. Among those quoted was the chairman of the Electromagnetic Radiation Research Trust, an independent lobbying organization, creating news about electro-magnetic radiation and its effect on health, and seeking funding for research on the health problems of mast emissions and cancer clusters.

A second article reported “Scientists demand inquiry over Wi-Fis,” inaccurately claiming “the research hasn’t been done” on the safety of things like lap top computers and cell phones and that “no one is really aware of what we are dealing with.” This article quoted Dr. George L. Carlo, the chairman of the Science and Public Policy Institute, an impressive sounding organization but is simply the Safe Wireless Initiative, run by the author of the book Cell Phones: Invisible Hazards in the Wireless Age. He is organizing “a global registry of people suffering from symptoms relating to the technology,” the paper said.

Unlike scientists supporting investigations into the health risks, he doesn’t, saying:

Most of the public has been tricked by the industry and government agencies into believing that the answers to all of the question lie in more research on cause and effect. That is perhaps the biggest ruse of all. Cause/effect research done today, helps no one today, and it may not even help anyone tomorrow. In my view, what we need to help people exposed today is surveillance related research aimed at identifying high risk groups for intervention.

An epidemiologist’s lack of support for research to identify cause and effect might not surprise some. The notion that electric power lines can cause cancer originated with a single, flawed epidemiological study in 1979, according to John W. Farley, Ph.D., physics professor at the University of Nevada, Las Vegas.

In fact, the root of virtually every modern health scare is brought to us by epidemiology which dredges through factors — environmental, dietary or physical — looking for correlations to some disease or affliction. Of course, researchers can pull out thousands of meaningless associations and scare people endlessly. And they have. No matter that the correlations often contradict each other and are nonsensical, they slowly erode through our consciousness and leave increasingly more of us believing that our everyday life is dangerous and virtually everything can hurt us.

Most consumers have been led to believe that these studies can help them in some way and that the associations are actually things that lead to a disease, but that’s the farthest thing from the truth. These correlations are not the same thing as a cause or contributing risk factor to a disease. Yet this is one of the most promoted myths of our time.

An early epidemiologist, Austin Bradford Hill, proposed criteria that epidemiologists could use to help them judge if their correlations could even point to a possible cause — but practically none of today’s health scares could even meet those criteria and don’t even try! Among his standards were:

· a powerfully strong association (associated with many times the risk, not minor percentages) that is graded (the greater the exposure, the greater the risk);

· the correlation stands despite all confounding factors (not just select ones convenient for the researcher);

· the association is consistent and can be replicated by different researchers and among different populations;

· the association is specific (an exposure is associated with a very specific disease, not broad symptoms or illnesses);

· the exposure precedes the onset of the disease and is consistent with how the disease naturally progresses;

· the association is reversible (remove the exposure and risk drops);

· that experimental evidence is consistent with the association;

· and that the correlation has a biological plausible explanation.

Even with these rigid criteria, however, epidemiology can never establish causality. Epidemiological research only finds correlations. (Correlations are not causations.) Its greatest value for us today, and its greatest strength, may most lie in its ability to disprove a possible causation — thereby debunking a fear — by failing to even show a correlation. Those negative studies are our friends.

The most feared diseases are those that kill most of us — cancer and heart disease — and literally thousands of things have been reported to be associated with them. But the fact always ignored is that old age is the most significant association, with about 1,000 times risk associated with cancer, for example, and dominates and outweighs any other associations reported by epidemiologists, according to Dr. John Brignell, Ph.D., a British scientist and engineer, publisher of Number Watch, and author of The Epidemiologists — Have they got scares for you!

Epidemiological research is endlessly easy to manipulate to conclude pretty much whatever a researcher wants to find, and it’s a favorite and fertile technique for just about any entity with an agenda. [Look at the nonstop fears associated with obesity!] “‘Health’ is a surrogate for their real interests,” said Dr. James LeFanu, M.D. in “Body Politics” published in a 1994 issue of GQ Magazine:

The first are the environmentalists who have found the best way of gaining support for their campaigns is to exaggerate the threats to health from industrial progress. So comprehensive is their doom-mongering, it is surprising there is a healthy person left on the planet — nuclear plants, nitrate fertilisers, lead in petrol, vehicle exhaust emissions, chemicals in the water supply, synthetic pesticides and suchlike are all allegedly responsible for a bewildering variety of cancers, heart disease, bronchitis and asthma as well as adversely affecting children’s intelligence.

Next are the food activists, whose animus is directed at a wicked food industry adversely affecting our health with hidden fats and sugars, or concealing their harmful products with irradiation, colourings and additives.

The net effect of this scaremongering is to create a public neurosis. People quake at the sight of a hamburger for fear of what harm it might do to their arteries, feel guilty about having bacon and eggs for breakfast, worry about...

Scares about health risks associated with exposures to electricity have a lot in common with other health scares, said Dr. Farley:

Magnetic fields are not understood by the public. Nor can they be felt, tasted, seen, or touched. This makes them mysterious, easily portrayable as threatening, and profitable to their advocates.

“Public distrust of utilities, big business, and established scientists also plays a role” in their perpetuation, he says. And once a health scare has been raised, the concerns persist for decades, despite evidence to the contrary. According to Dr. Farley, since that first flawed study, “subsequent epidemiologic and animal studies have failed to find a consistent and significant effect [and] no plausible mechanism linking power lines and cancer has ever been found.” He adds:

In recent years, the verdict from large-scale scientific studies has been conclusively negative, and scientific and medical societies have issued official statements that power lines are not a significant health risk. In short, there is nothing to worry about.

Even though science can’t prove a universal negative, there have been so many studies over two decades that it’s virtually certain that if there was any real hazard, it would have been discovered by now, said physicist Dr. Farley. He explained the science and agendas behind these fears in an article, “Power Lines and Cancer: Nothing to Fear,” in which he began by saying:

The fields produced by power lines are very small. Power lines produce both electric and magnetic fields. The electric field is greatly reduced in magnitude within the human body, because the body is an electrical conductor. In fact, power lines produce electric fields inside the human body that are much smaller than the electric fields that normally exist in the body.

Dr. LeFanu also urged reliance on reasoned risk assessments using credible science, over groundless speculations, saying:

Mobile phones transmit radio frequencies of such low intensity that their biological effects can scarcely be detected; even the most high-powered devices...The question as to whether they may have any long-term adverse effects has been examined in over 15 years in nearly 200,000 employees of Motorola. The conclusion?

You could buy a mobile [phone] tomorrow and use it continuously for 2.7 million years without fear that it might be doing you any harm.

Today’s fostering of epidemiology-driven scares, said Dr. LeFanu, “deprives the few valid official health warnings of any force or meaning.”

That doesn’t help anyone.

Dr. LeFanu, who also authored the book, The Rise and Fall of Modern Medicine, wrote of the madness of epidemiology and government officials who simply relent to “anxiety-mongering by consumer health watchdogs,” falling back on the fact it’s impossible to prove a negative and guarantee absolute safety. It’s regrettable, he said, because “it suggests, falsely, that scientific investigation cannot distinguish truth from falsehood.”

In fact, good science can go a long way towards alleviating needless worry and enrich our sense of well-being and help us to get a little more pleasure from life.

© 2007 Sandy Szwarc

Click here for complete article (and single page version).

Your ketchup is safe, but what about your privacy?

Two stories have been circulating the internet concerning HIV databases. One turned out to be a hoax, the more disturbing one didn’t.

As the Arkansas News Bureau reported yesterday, an email warning of possible HIV-infected blood in the ketchup of a fast food restaurant is a hoax. According to the circulating email, which appears to come from a state Department of Health and Human Services employee, an HIV-positive man was caught putting his blood in a ketchup dispenser. But Department officials explain this is an urban legend that’s been around since 2004 and isn’t true. In addition, the employee listed on the email has no access to the closely guarded medical records of the department’s HIV program, said DHHS spokesperson, Julie Munsell. Barbara and David P. Mikkelson explain the history and medical fallacies behind this internet hoax at their popular Urban Legends Reference Pages.

The second story circulating the internet is true.

Health departments in all 50 states will soon be tracking everyone with positive HIV tests individually, using their full names. Anonymous patient code identifiers will no longer be accepted. To force compliance, any agency not using name-based surveillance records will have their federal funds for HIV/AIDS care cut off, according to new provisions in the Ryan White CARE Act. As a Kaiser Family Foundation HIV/AIDS Policy Fact Sheet explains, $13.2 billion in the 2007 federal budget will go towards health care for those with HIV/AIDS alone, mostly provided through Medicare and Medicaid. This is significant money and has proven to be effective pressure with state and metropolitan agencies that the government needed.

As part of our continuing coverage of medical electronic databases and privacy issues, this is worthy of note because it affects all of us. According to news reports:

HIV patient names to be tracked

The names of people infected with HIV will be tracked in all 50 states by the end of 2007....The states are bowing to federal pressure so they won't lose money for medications and health services for patients. This is the first year federal funding has been tied to names-based surveillance of HIV. More than $1.4 billion in federal money will be distributed this fiscal year based on new formulas that include numbers of people with HIV counted by states using names. In some states, including Illinois, millions of dollars are at stake.

[Advocates] still worry that collecting names will deter some people from getting tested and seeking treatment, and about the possibility of names being released due to security breaches. “I have patients who are very high-profile individuals - physicians in practice, people who are politicians" who don't want their real names reported, said Dr. Dan Berger, medical director of NorthStar Healthcare in Chicago's Lincoln Park.

In a 2005 security breach in Palm Beach County, Fla., the names of 6,500 HIV and AIDS patients were mistakenly e-mailed to 800 county health workers. Other security breaches have occurred in California and Kentucky. Some worry that names-based reporting could have the greatest effect on whether minorities and the poor get tested and treated because they may be less likely to trust the government to keep their names secret....

Some states, including Illinois, and the city of Philadelphia previously tracked HIV with identifying codes that preserved anonymity and were unique to each patient. Illinois' code-based system was "instituted to protect people's confidentiality because of fears of stigmatization and potential disclosure to insurance companies and family members," said Dr. William Wong, medical director of the AIDS division of the Chicago Department of Public Health.

Illinois started names-based HIV surveillance Jan. 1, 2006, because of federal pressure....For now, public health officials are trying to reassure people who test positive for HIV that stiff security measures protect state databases of names.

A similar story made the news last year when Massachusetts, facing cuts in federal funding of $15 million, adopted its HIV reporting system using people’s names:

State may track names in HIV registry

...After years of using a confidential code-based reporting system to track HIV-positive patients, the state plans to implement the new name-based system by fall of this year. The federal government has put pressure on states that use code-based reporting... to implement a single, uniform system for tracking HIV cases that uses names instead of codes...

"The name-based system makes it easier to make sure that everyone gets counted individually," said Brigida Guyot, HIV counselor and tester at La Clinica del Pueblo, a Washington, D.C.-based clinic....However, Guyot said that the major drawback for a name-based system would be guaranteeing patient confidentiality, which could potentially be a deterrent for people who may want to get tested, especially when many of those at risk are illegal immigrants. “People are deeply concerned about their confidentiality with HIV," said Denise McWilliams, director of Public Policy and Legal Affairs for the AIDS Action Committee in Massachusetts. “The switch to reporting by name is going to discourage some people from coming in to get tested."

The Rogers Law Firm in Boston recently sent out a client advisory to physicians, informing them:

On November 14, 2006, the Public Health Council of the Massachusetts Department of Public Health voted unanimously to require physicians in Massachusetts to report to DPH the name of any patient who tests positive for HIV. The requirement will go into effect on January 1, 2007. Physicians in Massachusetts are already required to disclose the names of AIDS patients to DPH. However, up until now HIV cases were only reported using a code. DPH has stated that the basis for requiring physicians to disclose the names of HIV patients was in response to threats from the Federal Center for Disease Control to withhold approximately $15 million in funding for the state. The federal government is placing increased pressure on states to adopt uniform HIV reporting standards.

Pursuant to the HIPAA Privacy Rule, a physician is permitted to disclose protected health information to a public health authority without the written authorization of the individual or without providing the individual with an opportunity to agree to object to such disclosure.

And last spring in California, with more than $50 million annually in federal funding for HIV/AIDS care at stake, the Governor signed into law its HIV reporting law. In it, the “California Department of Health advises that health care providers, laboratories, and LHDs report cases of HIV infection by name if an HIV-related laboratory test has been performed on or after April 17, 2006.”

Schwarzenegger Signs Bill to Track HIV Cases by Name

The shift will ensure that California continues to receive more than $50 million annually for HIV/AIDS care from the federal government, which has ruled that code-based reporting is unreliable. With at least 38 states already signed on to use patient names, California is one of a handful of states still using alphanumeric codes to identify HIV cases. The bill, sponsored by Sen. Nell Soto (D-Pomona), unanimously cleared the state Senate and Assembly and was lauded by health officials around the state....

Under the code system, enacted in July 2002, healthcare providers and labs reported HIV infections to local health agencies and the state Department of Health Services using codes created from birth dates, gender and elements of the patient's last name. The practice of using codes was created to ensure patient confidentiality, but proved to be a bureaucratic nightmare for health officials....

According to new provisions in the Ryan White CARE Act, which provides funding to states and metropolitan areas for HIV/AIDS care, states using patient codes will no longer be eligible for funds, which will be allocated later this year....without switching to names-based reporting, California is "likely to lose an enormous amount of funding," Curtis said.

These developments won’t be news to those who’ve followed this issue for many years, but may be to many readers. The debate began when the CDC first issued its Guidelines for Improved Data on U.S. HIV Epidemic to “track the course of the HIV epidemic.” Its 1999 press release stated:

... To address the need for information to ensure effective targeting of prevention services, in September 1997, CDC called for all states and territories to conduct HIV case surveillance as an extension of their AIDS surveillance programs.....

Based on published evaluations to date, CDC has concluded that name-based HIV surveillance systems are currently the most likely system to meet the necessary performance standards and provide the quality data necessary to direct community prevention and treatment programs. CDC therefore advises that state and local surveillance programs use the same name-based approach for HIV surveillance as is currently used for AIDS surveillance nationwide.

The CDC’s recommendations for name-based registries were not without controversy within the medical community, either, and were widely debated in the medical literature from the get go, such as a 1999 issue of the British Medical Journal.

However, government officials, such as Julie Gerberding, director of the CDC, have been telling state agencies that because of the HIV epidemic it was critical to move as quickly as possible to adopt name-based reporting registries. According to the government, name-based tracking systems are more accurate and efficient than alternatives. This point has been criticized by groups such as the American Civil Liberties Union, which reported that non-name-based HIV monitoring programs using random, unique alpha-numeric codes to ensure privacy, have already proven successful.

Christopher Anders, a legislative counsel for the ACLU, lamented: “The clear weight of scientific studies shows that mandatory names reporting discourages people from getting tested for HIV....Why the CDC is proposing guidelines that violate basic privacy rights — and run counter to the weight of public health research — is simply incomprehensible."

Initially, the CDC allowed “for flexibility if states wish to implement alternative systems.” A 1998 CDC study had found that 19% of gay men cited fear of their name being reported as a reason they hadn’t been tested. The CDC recognized the problems with name-based registries in its original guidelines and said the “CDC has and will continue to provide financial and technical assistance to states working to design systems that rely on codes or ‘unique identifiers’ rather than names.” It went on to say:

CDC continues to strongly support anonymous HIV testing and recommends that all states provide anonymous testing options. CDC studies indicate that the lack of anonymous testing serves as a deterrent to testing in some high-risk populations. Unless prohibited by law, CDC requires that states receiving prevention funds make anonymous testing available in order to make testing as accessible as possible. Maintaining anonymous testing sites is important for prevention efforts and will not seriously inhibit our ability to track the epidemic.

Most people are diagnosed with HIV infection in care settings where their identities are known, and CDC recommends that individuals who test positive in anonymous settings be promptly referred to treatment and prevention services. Maintaining an anonymous testing option may help ensure that more individuals learn their status, and if infected, seek early treatment and care.

By the late 1990s, 34 states and the Virgin Islands had already implemented HIV surveillance registries. When the Illinois Department of Health established its statewide registry using the names of everyone testing positive for HIV; similar to registries for syphilis and gonorrhea; its provisions allowed for anonymous testing for those who didn’t want their names reported. Even so, the Chicago Tribune reported concerns very similar to those noted by the CDC:

Plan to Track HIV Raises Questions Loss of Confidentiality May Deter Testing for AIDS

[AIDS activists] raise several ethical issues regarding confidentiality. They contend that instead of helping to stop the spread of the disease, the requirement would actually deter people from getting tested and thus keep them from seeking counseling and medical care.

The issue is muddied by fears that such a registry could someday be accessible to insurers, the courts or employers.

“Once you add this element of name reporting, you introduce an element of fear," said Robert Rybicki, assistant commissioner of HIV/AIDS Public Policy and Programs for the Chicago Department of Public Health. “This disease, unlike any others, has ramifications for people," Rybicki said: “They can lose their job, they can lose their housing and they can lose their health insurance. As a disease, it's in a pretty unique category.”

As it turned out, despite the CDC’s initial allowance for anonymous reporting, it proved a moot point. After starting names reporting, many states had eliminated anonymous testing, according to the ACLU.

Advocates for the decision by the Tacoma-Pierce Country Health Department in Washington to do so said name registries were needed “as part of an aggressive effort to fight the epidemic....with such standard epidemic-fighting tactics as contact tracing, follow-up counseling and long-term case management” by the state. An un-bylined editorial said names would be “carefully guarded from public disclosure under CDC-recommended security guidelines.”

Assurances over privacy protections made by the CDC in its Guidelines were hardly reassuring to opponents. It stated that the Service Act governs how the government can use or release the data, saying it can only be used for public health purposes. “Most states also have specific statutory protections for public health data related to HIV,” it said. “However, state legal protections vary widely.”

With recent news, discussions are raging at boards of professional and HIV/AIDS patient advocacy groups, with growing concerns that these lists of names could be used by officials in over-reaching ways, such as targeting people for “forced medications.” Concerns are also being voiced about potential breaches of confidentiality and disclosures to insurers, the courts or employers. They also worry, as the CDC found back in 1998, that the inability to maintain anonymity could prove to be “devastatingly effective and a major argument for ‘don’t get tested.’”

You may think HIV issues are of no concern to you, but maybe they should be — whether your concerns are that people get the care and testing to help them, or over the Big Brother and privacy rights aspects. The distinction between public and personal health is becoming increasingly blurred. We might question the need for everyone’s name, address and phone number, and medical information to be on a government database and wonder where it will end. What next will be declared “a public health issue of epidemic proportions” and in need of government monitoring and mandatory interventions?

Already, in response to the “diabetes epidemic,” we’ve seen the creation of statewide diabetes registries. For example, mandatory electronic reporting of glycosylated hemoglobin (A1c) values by laboratories to the state Department of Health and Mental Hygiene was recently enacted in New York City. The mandatory program is without patient’s knowledge or informed consent, nor are people free to opt out, according to World Net Daily. Add to that, we’ve already had glimpses of how this information can and is being used by government officials. Pennsylvania’s new plan to manage “chronic illnesses, as described in a recent post, includes identifying and tracking those with diabetes first and putting them under state disease management. Are those with genetic tendencies towards high blood pressure or high “cholesterol” next? A number of states, including Maine and Colorado, have introduced legislation making all Medicaid and food assistance recipients, and state employees, who are deemed overweight be required to undergo weight loss interventions, including “behavior modification” and prescription drugs.

As Lawrence O. Gostin, director of the Center for Law and the Public's Health at Georgetown and Johns Hopkins universities, was quoted as saying:

Should the government be collecting this kind of information? Should it be intervening like this? You can imagine it getting to the point where you have a public health worker showing up at your door and asking, ‘Did you remember to exercise, eat right and take your medication today?’

© 2007 Sandy Szwarc

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Of concern to parents: what are children really being told in school?

As a parent, you send your child off to school, hoping he/she will be safe. Like most parents, you care that your child is protected from threats, needless scares and things that could endanger his/her health and future. Yet, few parents realize that the things being taught in schools in the name of wellness are doing just that.

How would you feel if a doctor and famous person came to your child’s elementary school and told the students that they were going to die before their parents, get terrible diseases and might even become retarded, all because they were getting fat from eating bad sugar and fatty foods and not exercising? Incredibly, this is the message young pupils at John B. Russwurm Elementary School in Harlem heard from speeches made to them two years ago. Yet, there were no news reports of incensed parents whisking their small children out of the auditorium, calling or writing the school board in protest, or of a single adult or teacher speaking out and putting a stop to the program.

Why?

Perhaps because the hysteria over a “childhood obesity epidemic” has reached the point where even many adults are willing to do anything to advance a political and marketing agenda — even medical and education professionals who have a responsibility to know the fallacies in the science and that children and teens are too young to comprehend and do anything with such frightening information other than react emotionally and often in self-destructive ways.

Yet, the situation is only getting worse. Children cannot escape these over-the-top messages which now confront them in virtually every classroom, on their computers, in the cafeteria, and are now even being pumped into their homeroom on Channel One.

Unbeknownst to many parents, a key source of health and nutrition information in schools is the Alliance for a Healthier Generation, whose “Healthy Schools Program” was funded in part by $8 million from the Robert Wood Johnson Foundation. We’ve looked at some of the issues surrounding this Alliance, a joint project of the William J. Clinton Foundation and American Heart Association, but let’s take a closer look at what they are actually telling our children.

Former President Bill Clinton and the president and CEO of the RWJF, Dr. Risa Lavizzo-Mourey, M.D., M.B.A. set the tone when they spoke to the young Harlam students at the well-publicized launch of the Alliance’s “Healthy Schools Program.” Mr. Clinton told the children they could be the “first generation in American history to live shorter lives than their parents because so many are eating too much of the wrong things and not exercising enough.” [While this has been repeated so often many believe it to be true, there is absolutely no evidence or research to support it. It began two years ago as a speculation opinioned in a journal and even though its author has since retracted its accuracy, it’s become a runaway urban legend.]

“We are all here today to take a stand against childhood obesity and create a healthy new generation of young Americans,” Mr. Clinton told the children.

He went on to tell them they were eating too much sugar and fatty foods (while a popular belief, as we've learned, children are actually eating well within the Dietary Guidelines), vices which caused his own heart attack, and that “children who don’t exercise enough and whose diet lacks proper nutrients can encounter serious problems, including stunted growth, cognitive impairment and as we all know obesity, which creates an obliterated risk of heart disease, diabetes, and a range of other illnesses.”

Dr. Lavizzo-Mourey, then came to the podium and said:

You know, you kids—and the millions of kids like you all across the country—are why we’re all here today. Your health and your future are important to us, to the country and to the world.

Could these kids possibly be the first generation of Americans to live sicker and die younger than the previous one? Or will they be a healthier generation?...“Energy in and energy burned” is the equation that defines the obesity epidemic...

As already noted, the Alliance partnered with Nickelodeon to create a Let’s Just Play Go Healthy Challenge to “combat the spread of childhood obesity” and Nickelodeon has committed $28 million and 10% of its air time to promote the Alliance’s campaign on healthy eating and active lifestyles. It includes “Go Healthy Challenge” television programming for teens and a website for children.

But what many parents may not realize is that the Alliance recently announced a partnership with Channel One, the content provider “reaching more than 7 million students in nearly 11,000 middle schools and high schools across the country.” This new union will create health programming and accompanying material to “drive home the importance of increased physical activity and balanced nutrition in and outside of school.”

For parents who have been trying to help their children and teens develop healthy, balanced relationships with food and normal eating habits, and to help them feel comfortable with their natural, individual bodies; for parents trying to help their children and teen avoid our society’s obsessive focus on weight and fears about bad food; and for parents concerned about the growing prevalence of dysfunctional eating and food fears, they will be dismayed to discover the messages on Channel One and the Alliance websites, being pumped into school classrooms, and distributed in classroom handouts through the Alliance and Channel One.

These materials are rife with misinformation and unsound information about food and health. They exemplify the ill-informed health messages that Dr. Jennifer O’Dea, M.P.H, Ph.D., an international child nutrition and eating expert at the University of Sydney in Australia, has repeatedly warned (discussed here, here and here) are potentially harmful to children.

Let’s take a few examples:

Channel One has a health guide website for young teens, called “One Step to a Better Me.” When children log on, the first thing they encounter is “a personalized health evaluation:” a BMI chart and calorie counter! The instant message is that health is all about weight and calories. The accompanying resources include a food and exercise journal where children daily record what they eat and do; dieting advice, and resources that include such topics as the importance of calories, water and reading labels to understand “good” and “bad” food items.

Every lesson plan includes a “Character Counts” section and tells children what to say to someone who is not “drinking not enough, or the wrong, fluids;” or not eating right or exercising; and how to tell someone they need to “take better notice of nutrition.” In other words, a healthy lifestyle is a moral, character issue.

Children are encouraged to sign a healthy family pact with their parents, in which they promise to learn the differences between “healthy and unhealthy foods;” discourage each other from eating foods high in fat, salt and sugar; only make or buy “healthy” lunches; and to drink 8 glasses of water a day. This alone will alert informed parents that their children are being taught little more than popular myths and urban legends. [We’ll look at the water urban legend, for example, in an upcoming post.]

The interactive Healthy Generation website for children tells them to “take responsibility and control” of their body because it’s their future. A “look at the future” page depicts an animated fat child sitting in a lounge chair, surrounded by stereotypical junk food and media with a scrolling educational message telling them how many teen girls are overweight; how many kids aren’t getting enough exercise; and the problems of too little PE, too many computer games, and too many fast food restaurants.

Among the printable posters for children is one entitled “Food Label Illiteracy — It’s just not natural,” which reinforces lesson plans telling them to read labels and that any long word or word they can’t pronounce is an unhealthy ingredient (chemicals like citric acid, glutamate, sodium, pectin, etc. are to be feared). Packaged and processed foods are not real food, they’re told, and are not things they should put into their bodies.

Tips for Go Health Challengers include fact sheets and charts to track their progress. It also includes an activist packet for children with ready petitions they can take to school officials that say it is “their right to have access to healthy food in school [and that] students should have access to foods that are good for their health.” The clear message is that the food offered in the school cafeteria isn't good for them.

The health “news” being broadcast through Channel One is predominated by foreboding fears over obesity. Even its segment on body image begins by telling children that obesity is the country’s biggest health problem and then tells them how to get in shape in order to develop a “healthy body image,” offering diet and exercise resources! [The very last things already self-conscious, and eating disorder-vulnerable young people need to hear.] Only the merest mention is made of eating disorders. The information on health consequences of obesity presented by the Alliance is taken primarily from the Surgeon General’s recent call to action to combat childhood obesity, a political agenda rather than careful evidence-based science. Information from the Alliance embellishes obesity fears with untenable speculative claims about heart disease; that childhood obesity is raising healthcare costs; that childhood obesity leads to drinking problems and disability and makes it harder to bathe and dress; that one-in-four obese children have constipation; and that the average boy drinks more than 24 ounces of soda a day, indicative of fat children’s poor eating habits.

The "essential concepts about nutrition and diet" used in the school lesson plans are described in Benchmarks for Health. They begin by teaching the concept of good and bad food at pre-kindergarten. Grades 3-5 are to be taught “healthy eating practices,” understand the nutritional value of different foods, and know “how food preparation methods and food-handling practices affect the safety and nutrient quality of foods.” By grade 6, they are to understand how eating properly will reduce health risks such as cancer, heart disease and osteoporosis; and know how to manage their weight, including diet. By high school grades, children are taught to fear food additives and are taught media literacy, which tells them about bad food company advertising, but not literacy concerning healthy food messaging. Obviously, few adults comprehend the complex science, chemistry and medical issues and politics surrounding these topics, let alone expect it of children.

For parents wanting to know more specifically what teachers are telling their children, they will be interested in the Alliance’s Healthier Generation Teacher Guides provided through Channel One. Among the Tip Sheets “designed to help [teachers and their] students take action in the battle against obesity” are:

· Tip Sheet 2: Reading Food Labels 101 which tells them to minimize “bad fats that clog arteries,” to keep sugar low because “sugar means more calories,” and that “the less cholesterol and sodium you eat, the better.”

· Tip Sheet 7: Body Mass Index (BMI) equates health with a proper body weight; if children are “overweight” parents should talk to their doctor and help their children improve their health by eating a “calorie-appropriate” diet and be more active; and that overweight children will develop heart disease and other diseases.

· Tip Sheet 8: Proteins, Carbohydrates and Fats tells children that there are good and bad carbs and good and bad fats; that simple sugars are bad because they are high in calories, and that people should eat only “healthy” sugars that are natural.

· Tip Sheet 13: The Skinny on Fats says that the problem is “most kids, teens, and adults eat too much saturated and trans fats instead of heart-healthy unsaturated fats.” It says it’s critical to educate children on the difference between good and fat fats and that the American Heart Association recommends that less than 7% of calories should come from saturated fat and less than 1% calories come from trans fat per day. [This even contrasts with the 2005 Dietary Guidelines, which recommends adults keep saturated fats below 10% of total calorie intakes for selected calorie levels and notes that lower intakes (such as less than 7% saturated fats) are only “recommended as part of a therapeutic diet for adults with elevated LDL blood cholesterol. People with an elevated LDL blood cholesterol level should be under the care of a healthcare provider.”] Among the Tip sheet’s recommendations are that children eat fat-free and low-fat milk and foods, remove the skin from chicken before eating, eat ground beef that’s been rinsed in hot water after cooking to remove the excess fat, avoid butter or margarines, skip the cheese, and be careful about fish because of mercury!

· Tip Sheet 15: Too Much Salt? says salt is a leading cause of high blood pressure, cancer and osteoporosis and advises that children limit their salt intake; younger children most of all should keep sodium under 1500 mg/day. [This contrasts to even the 2005 Dietary Guidelines which makes no mention of restricting sodium for children and recommends only specific population groups, such as older adults with hypertension, consume no more than 1500 mg daily.] But the Alliance tells children to cut down on salt, choose low-salt foods and condiments, and even request restaurants to prepare their food without salt and to request all sauces on the side and then eat in moderation.

You get the idea. Not only are these dietary lessons inappropriate for growing children and more akin to medical prescriptions for adult heart disease patients and the obsessive behaviors found among weight loss dieters, they have nothing to do with childhood obesity, health or sound nutrition. They dichotomize foods into good and bad, and promote ungrounded fears about perfectly safe and wholesome foods, concerns about their body sizes, and worries about diseases and death that should be the last thing children need worry about.

Parents are getting wise to these harmful curriculums and venting their outrage on countless online forums. Some are taking action to protect their children. One parent recently wrote how she pulled her sixth-grader out of her required “wellness” class, at least for the nutrition and “obesity” parts of the class. Why? She said:

Because isn't it a great idea to take a bunch of impressionable 6th-graders and brainwash them into thinking that the only healthy food out there is a carrot stick or salad (hold the dressing!)? Given the fact that most eating disorders start between 11 and 17, this seems like a bad idea to me, especially the way such things are taught.

As more parents begin to realize how pervasive the harmful messages being given their children in schools, we can expect to see more organized efforts to protect them. An impassioned essay was recently written by one blogger who objected to youngsters being “scared to death” in school. While he was writing on a different issue and the sentiments may seem dramatic at first, the concerns are surprisingly similar and provide us with some soul-searching food for thought. He wrote:

These kids are way too young to be introduced to such complex subjects... Young minds like this cannot cope with the higher level abstractions required to make any kind of rational judgement.... [They] can only respond to such issues emotionally.

What kind of words can I use to describe the evil of scaring kids to death with a virtual non-problem? Unspeakable? Unthinkable? Even if GW were a problem, it would be the responsibility of adults to address it, not kids.

In the Jonestown mass suicide a mother was taped pouring poison down her child's throat. That mother was the naked essence of evil, the desire to destroy life. But destroying the minds of kids to form concepts and integrate them in an hierarchy, to know instead of believe, is to leave the kid's body alive while destroying the body's means of survival.

Yesterday, you no doubt heard that Mr. Clinton’s Alliance has partnered with a cookbook author and daytime television cook show host, Rachael Ray. She has launched her own “Yum-o! Organization,” to “educate and empower families across America to make healthier food choices by providing them with the tools and information they need to transform their eating habits.” On her show yesterday, she lamented that children were eating such “unhealthy” breakfasts as pancakes with syrup or sausage and eggs in a biscuit, and that she is eager to work with the Alliance to teach families to make better food choices. During the show, Mr. Clinton voiced the oft-repeated myths about how this generation will be the first to not outlive their parents, that 13 million children are overweight and one in three will get type 2 diabetes. Ray’s organization also includes television segments, a website and scholarships.

In turn, the Alliance will reward participating schools with Ray’s own branded cookware and personal appearances by the star.

© 2007 Sandy Szwarc

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Food as judge

Wow, just wow. These posts offer some powerful stuff.

How often do we witness people complimenting others on their weight loss and how good or “healthy” they look? How often do we judge and make assumptions about others by what they eat? How often are we afraid of being judged by what we eat and of even simply eating in front of others?

An incredible and very personal commentary on how society judges us by what, where and how we eat was written by a recovering anorectic who says she’s still in the first, shaky, baby steps phase of recovery. Her bones are still protruding, she says, and “my elbows are actually bigger than my upper arms.” She explains the emotions and harm coming from the messages of “much of society [that] sees this as a great accomplishment and a sign of strength, willpower and perseverance.”

There was a recent New York Times article looking at how people are judged in the workplace based on their eating habits and appearance. She found one boss’ comment horrifying and, as I had, the ultimate demonstration of ignorance:

“When I’m interviewing someone [for a job] and I see their bones protruding, I know it’s a good hire. They’re extremely disciplined.”

The Times article reported that this attitude appears all too common in the workplace and influences not just hiring, but career advancement and salaries:

A co-worker noticing your third cheeseburger of the week is annoying. But a boss sizing up unhealthy choices carries far more influence.

“In a workplace context, the effect of such judgment is not just social but also potentially economic,” said Philip N. Cohen, an associate professor of sociology at the University of North Carolina at Chapel Hill who has taught courses on the sociology of food. “Why would a co-worker or manager trust you with responsibility at work if they see you making bad decisions in your self-management enterprise during meals?”

There are so many personal stories out there that make the destructive consequences of today’s obsession with “healthy eating” and weight painfully real. They are valuable for us to read and hear because few healthcare professionals and those advocating for the “need” to “do something” to address obesity ever stop to see or face the harm their “healthy eating and exercise” initiatives have, let alone see that they are not based on credible evidence for need or effectiveness.

One of the most powerful personal stories recently came from a blogger commenting on our culture’s “anti-fat hysteria that is currently manifesting in an all out ‘War on Obesity.’” Her comments warmed my heart and I can’t begin to tell her how much they meant to me, but she is admirable. She demonstrated remarkable bravery and did something that a lot of men and women can’t bring themselves to do. She “came out” as a recovering anorectic and shared her private story of the consequences that the diet and weight loss messages had on her growing up. Even years later, those struggles continue.

When I am at a restaurant, it rears its ugly head sometimes. I don't want people to look at me eating, because that little voice is telling me that other people are judging me. They think I shouldn't be eating, because I am fat. It doesn't matter what the food item is; even eating a tomato would make me feel that way, but if it's something like cheesecake, I feel even more self-conscious. It's almost like the sick part of me is reading the minds of other customers:

"Look at her, what does she think she's doing? She shouldn't eat until she is thinner."

"Look, she's eating a salad. Isn't that cute, sweetie...but it probably won't do you any good. Why are you bothering?"

"Maybe she should pass the plate to the skinny boyfriend, she certainly doesn't need it."

Worst of all:

"What's a guy like that doing with a pig like her?"

It's there, and I push it away, but every so often, I'll somehow feel full after only a few bites. Almost nauseated, even, because I'm self-conscious, disgusted with myself for just eating, and feeling guilty for not having the self control to starve myself. Yes, I KNOW it doesn't make any sense. It's completely irrational.

It's beyond tragic how many young people may never come to know normal eating and what it's like to truly enjoy food and take pleasure in eating and sharing it.

The pervasive praise of being thin and fit and the condemnation of fat that’s being taken to heart by growing numbers of young people most worried her. She also reminds us that, despite stereotypes, we cannot tell who is suffering by what they look like on the outside.

I'm worried, because this is something that is so deeply rooted, so insidious, and it's being programmed into the minds of every child and teenager today. Generating paranoia about fat and eating is a foolish and cruel thing to do, and I am truly sorry for all of the young people that are going to suffer for it. Those who have the nerve to starve themselves are going to do it, and those who don't will hate themselves for it. Utterly abominable.

For the record, I'm fat now. I don't know if it's genetic (I generally look like my father in facial features and body shape), or the result of damage to my metabolism done in those miserable teenage years, but here I am. My doctors have declared me wonderfully healthy, with great cholesterol scores, excellent blood pressure, and all that nonsense. My tall, thin significant other, however, who eats the same stuff I do and in about the same amounts, has tested high for "bad" cholesterol. I used to blame my vegetarianism for my good cholesterol and blood pressure, but I guess it's all genetics, baby.

Thank you both, for sharing your stories. I sincerely hope people will read and hear what you are so courageously saying. I hope your words and insights will help to save countless young people from having to learn the hard way and suffer the years of pain you had to endure.

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