Thursday, February 27, 2014
Obesity and oblivion, or what I've learned under general anesthesia
I am going to tell you what I’ve learned under general anesthesia, but I ask you to bear with me kindly and wait a few paragraphs for that revelation.
I am a rambunctious guy, pretty much always have been. I have always loved active recreation and was one of those kids who had to be reeled in for dinner from outside play with a winch and a cable. As an adult, I placate the restlessness of my native animal vitality with about 90 minutes of exercise every day. In addition, I hike whenever I can, and pretty much share my dogs’ attitude about it: the more miles, the better. I studied the martial arts for years. I am a lifelong, avid alpine skier, and an ardent equestrian, privileged to share that latter brand of rambunctiousness with my beautiful horse, Troubadour, who seems to enjoy running and jumping as much as I do, and is far better at it.
This is all part of family tradition. Women in the family are generally quite active, and some have their share of perennial restlessness. But the guys are a case apart. My son’s rambunctiousness is, quite literally, famous of song, story, and program. The ABC for Fitness™ program Gabriel directly inspired is now reaching hundreds of thousands of kids around the country and world, and paying forward the benefits of daily exercise in schools. Gabe helped me appreciate the importance of asserting that the proper remedy for rambunctiousness in our kids is recess, not Ritalin.
And then there’s my father, whose restlessness is the granddaddy of all, and the stuff of legend, or at least family lore. We celebrated his 74th birthday last summer with a hilly, 56-mile bike ride.
By and large, the effects of this rambunctiousness are extremely positive. My animal vitality is spared the constraints of leash or cage, and rewards me reciprocally with energy, stamina, and vitality. But everything has a price. My particular brand of rambunctiousness has involved pushing limits, and limits have a tendency of pushing back. The result is several concussions (I am now a consistent helmet wearer), too many stitches to count, roughly 20 broken bones, and general anesthesia to restore the mangled anatomy of some joint or other not fewer than a half dozen times.
Which leads, at last, to what I’ve learned under general anesthesia: Nothing. Nada. Zip.
Nobody learns anything under general anesthesia. General anesthesia involves unconsciousness, oblivion.
And on that basis, I consider it a societal travesty that hyperendemic obesity and the metabolic mayhem that often follows in its wake are treated ever more frequently, in ever younger people, under general anesthesia. Our answer to obesity is, it seems, oblivion.
True, bariatric surgery is effective. But it is also expensive, and subject to all of the potential complications of surgery. We don’t really know how long the benefits last, particularly for the children and adolescents who are candidates in growing multitudes. We do know that lasting benefit requires ancillary lifestyle change, and that there is often some, and sometimes a lot, of weight regain despite the rewiring of the gastrointestinal tract.
And we know as well that we are relying on scalpels in the hands of others to do what forks in our own hands (and feet in our own shoes) could do better, at dramatically lower cost and risk, if our society committed to empowering their more salutary use. We have evidence to suggest that schools and aptitudes acquired there could do for weight what scalpels applied under anesthesia do. But in my experience, they could do so much more. As a medical advisor at Mindstream Academy, a boarding school producing weight loss to rival bariatric surgery, I have been far more impressed with what the kids find than what they lose, impressive though the latter may be. They find pride and proficiency; confidence and competence; skillpower and self-esteem. They learn, in other words -- as nobody ever does under general anesthesia.
Our society’s tendency to “over-medicalize“ has been chronicled by others. The consequences extend to expecting from our clinics what only our culture can deliver. Among the most vivid illustrations of this is the lifelong work of my friend, Dean Ornish. Dr. Ornish was involved in groundbreaking work that showed the capacity for a lifestyle overhaul to rival the effects of coronary bypass surgery. With evidence in hand that feet and forks (and a short list of other priorities attended to) could do for coronaries what scalpels could do, Dr. Ornish set out to make his lifestyle program a reimbursable alternative to surgery. He succeeded, earning Medicare reimbursement after—wait for it—17 years! I don’t know that Dean has the patience of a saint, but he apparently does have the patience of a cicada.
It took 17 years to gain reimbursement for lifestyle as a cost-effective treatment of coronary artery disease, whereas surgery was reimbursed from the get-go. That’s how we roll, and then wring our hands about the high costs of health care.
With that in mind, I ask my fellow parents reading this column. I ask the grandparents, godparents, aunts and uncles to contemplate this: How many of our sons and daughters, nieces, nephews, and grandchildren will have passed through the O.R. doors if it takes us two decades to establish lifestyle intervention as a culturally sanctioned alternative to bariatric surgery? However many that is, I can tell you exactly what they will all learn while under general anesthesia: Nothing. Nada. Zip.
Knowledge and experience are the foundational elements of culture itself. Culture derives from the capacity of our species to learn, and pay forward our learnings to our contemporaries and our children. Among the impressive manifestations of effective school-based approaches to adolescent obesity is the capacity, and proclivity of the kids to pay their newly acquired skillpower forward. When last I visited Mindstream Academy, one of the young girls there, who had lost some 80 pounds, was most proud to tell me about her father back at home who, courtesy of her long-distance coaching, had lost about 40. There is nothing to pay forward following the oblivion of general anesthesia.
Bariatric surgery is effective and should be available to those who need it. I have referred patients for such surgery over the years. But our culture will be defined by what we learn and share. We could learn and share the skill set for losing weight and finding health, and make that our cultural norm. That remains unlikely so long as we put our money preferentially where our medicalizations are. The AMA has proclaimed obesity a disease, but that’s just symptomatic of our culture tendencies. It is more a disease of the body politic than of the often healthy bodies that succumb to it in a culture that propagates its causes.
The healthiest, happiest, leanest, longest-lived populations on the planet do not attribute such blessings to the proficiency of their surgeons or the frequency of their clinical encounters. They attribute them to the priorities and prevailing norms of their culture.
Nobody learns anything under general anesthesia. General anesthesia is oblivion. If we keep prioritizing the medical over the cultural, oblivion over enlightenment, my friend Dean Ornish will remain a lonely pioneer. And the cicadas, when next they emerge, will see nothing new. They will have cause to roll their protuberant eyes at us and trill out: same as it ever was.
It doesn’t have to be that way. We could choose oblivion a bit less often, and stay conscious instead. Conscious, we would have a chance to think outside the box of surgical gloves, and perhaps thereby perceive a new world of opportunity.
David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.
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