The Medicine Page 7
During a medical-school lecture on the layout of the human gut, our professor of anatomy told us that the lumens of the oesophagus, stomach, intestines and rectum are not – technically – inside our bodies. “The alimentary canal,” he said, “is outside of you.” We were all, like, “Woah.” It was our first year and I was in a constant state of “woah”. I put his proposition into my sack of facts and eventually forgot it was there. It wasn’t until I found myself splayed on the floor of a Boeing 747 toilet, arms and chin pressed into the plastic seat like it was my mother, my head in the bowl for nine hours straight, that I remembered his claim. Who the hell cares? I thought. What’s your point? I thought. At that moment my alimentary canal did not feel as if it was outside of my body. My protesting, secreting, in-reverse-gear gut had become my entire being.
Turns out that almost every textbook of anatomy or physiology mentions (sometimes with an exclamation mark!) that the gut lumen is outside of the body. Not many go on to explain why this fact is not just a piece of nerd trivia. But consider this: chew something – say, a piece of steak – then swallow. Somehow in that outside-inside tunnel the meat will be churned, broken down and eventually absorbed. That is, there’s stuff in the lumen of our guts that can dissolve a cow. And that stuff, those enzymes and acids, have to be kept “outside” our insides or – given we’re basically hunks of walking Wagyu – we’d dissolve.
The borders of our gut are under heavy patrol. Tiny armies cling there and defend us, but if there’s war, there’ll be collateral damage. (And allergies are when our immune system attacks something it need not.) We do our best to avoid battle: pasteurisation, boiling, baking, hand hygiene, the five-second rule. The hospital kitchen’s main concern (apart from how to adequately feed a human on a few bucks a day) is how to keep food bacteria-free. We have an inside and an outside, but we are permeable. Our bodies are under constant assault: pathogens, malodours, sharp objects, bright light, thunderous noise. This permeability exposes us to risk but also allows us to procreate, to grow, to feel.
Food is a source of sustenance, pleasure and comfort. National identities rest upon it. Preparing it or sharing it can be an act of love, and the time we devote to it is commensurate with the rewards we receive. Food can cause harm if we’re allergic, if it’s full of pathogens or if we eat far too much. Soylent, a brand of home-delivered “complete nutrition” liquid championed by young male tech-types, is efficient, safe and very clean. You don’t have to prepare, taste or chew. Petrol for the engine, and you can fill ’er up in one minute flat. Low risk. Low pleasure.
The plane touched down and we were asked to stay seated. A quarantine officer – part of our country’s immune system – boarded to interview me before anyone could leave. I opened one eye and explained that, given my symptoms, I had most likely ingested staphylococcal toxin a few hours before take-off. Some chef had a festering finger-wound; the bugs jumped into the food and gleefully excreted their toxins (which are impervious to heat, though it kills the actual bugs). I swallowed, the toxin wreaked havoc in my lumen, and my lumen responded with forceful expulsion per mouth. The quarantine officer listened to the neat summary of my travel history, symptomatology, physical findings and diagnosis, and allowed us to disembark (me in a wheelchair). I thought I’d never eat again. I’d be an all-food intolerant. They’d have to feed me Soylent through a nasogastric tube. Twenty-four hours later I was thinking, Turkish or Vietnamese?
The Next Big Thin
I once read a book called Eat!, which I vaguely recall claimed you could eat as much as you wanted as long as the food had zero fat. I wasn’t overweight, but I was twenty-one and thought extreme skinniness would solve all my world’s problems. I gave it a go. Fat-free yoghurt and milk, fat-free stir-fry and pasta and soup, fat-free crackers. Even if it were true that you could consume tonnes and never gain a kilo, who’d want to overeat those terrible industrial concoctions? Who’d want to give up butter and cream and olive oil? Diet trends appear, capture the popular imagination, fill plates and online forums, and then fade away: cabbage soup, Russian gymnast, low-carb, no-carb, fruit, juice, Paleo. The most popular ones have in common the claim that you can still eat lots and lots but only of a certain thing. But right now it’s all about intermittent fasting.
One day each week I see morbidly obese patients who seek to lose weight. I spend about a quarter of each consultation refuting deleterious diet myths they’ve heard, read or watched: eat six times a day, don’t skip meals, brown bread doesn’t count, artificial sweeteners are fattening, a litre of fat-free ice-cream is not. One 200-kilogram woman told me, “My main problem, I know, I know, is that I don’t eat breakfast.” When I told her she didn’t have to eat breakfast her eyes narrowed, as if she were considering reporting me to the medical board. Bloody breakfast and its purportedly miraculous fatmelting, metabolism-boosting, hunger-diminishing qualities. I don’t eat breakfast and never have. I’ve been lectured about the injurious effects of this trivial lifestyle practice innumerable times. So it was with utterly biased glee that I started to read reports of the health benefits of not eating breakfast, of not eating continuously, and of accruing a decent fast to break.
Current research indicates that eating breakfast does not lead you to consume fewer calories overall throughout the day, it doesn’t boost your metabolism in any meaningful way, and for most of human history it didn’t even exist. Historians blame the invention of breakfast on the aristocracy (and the mimicking of them), the industrial revolution, and Mr Kellogg squashing a stale kernel of corn in 1898. Eating three meals a day is a social custom and a habit, not a physiological requirement. Ancient Greeks and Romans ate only one per day, in the mid-afternoon. In England, until the mid-nineteenth century, the custom was two meals per day. The average citizen in a Western country today eats regularly for fifteen hours of each 24-hour period, feasting and snacking and slave-driving our livers as if in preparation for a famine that never comes.
In 2015 the word “hangry” was granted a place in the online Oxford dictionary. Hangry – a hybrid of “hungry” and “angry” – refers to an irritable mood caused by hunger. It’s a funny time in history for the word to appear, a time when hardly anyone in the developed world need truly be hungry. Did our foremothers and fathers get hangry during the Depression? Did entire village populations walk around snapping at each other during times of famine? It seems hunger has become such a noxious sensation to us that it brings with it an emotional disequilibrium worthy of its very own word. What’s so bad about temporary hunger?
For thousands of years people have fasted for health, for weight-loss, for religious reasons, in political protest, or as a symptom of a mental illness (such as anorexia nervosa). There are now hundreds of blogs that solely document a week or two’s water-only fast, with daily updates on how the faster feels, their ketone and blood-sugar levels, their toileting, mood, decreasing weight, increasing energy and lack of hunger, illustrated with stylised pictures of glasses of water spiked with mint. These blogs often have dozens of comments – congratulatory or mocking or warning about the dangers of not eating. But nothing reaches the hysteria triggered in commenters by the fast-to-the-death, pro-anorexia websites and vlogs. The proana sites are full of “thinspirational” pictures of scarily skeletal teenage girls, outrageous starvation tips and a pervasive self-disgust. A few hours of reading this stuff and vegetable broth for dinner starts to look like a binge.
Eugenia Cooney is a popular YouTube vlogger who is scarily underweight. Each of her posts has thousands of comments, most of them critical. There is concern for her wellbeing and that of the people who watch her, but there is also rage, as if her body is attacking those who eat. Yes, she looks heartbreakingly starved, but to seek to have her banned? For most young girls she will function more like the warning pictures on a cigarette packet than a role model. Starve yourself for too long and you will die. It only took Bobby Sands sixty-six days. The more common practice of eating yourself to death takes years.
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br /> A bariatric surgeon said to me the other day, “We live in a toxic food environment. To stay lean you have to employ conscious restraint and say ‘no thank you’, a lot.” If you take a short break from eating, your body gets a chance to metabolise what you’ve consumed so it’s not stored as fat, and perhaps to tap into the fat you already have. Living in a state of constant satiety also dulls the tastebuds, such that the only food able to rouse them is saltier, sweeter, fattier and usually packaged in crackling, brightly coloured wrappers. Eat what you wish, but for fewer hours per day or days per week. The research into the diabetes-reversing, brain-protecting and life-extending benefits of this way of eating is compelling. Perhaps it will turn out to be the real deal. Wait for hunger. Welcome it. And then, as my high-school English teacher once told me: never waste your appetite.
Fat City
In the late 1980s I spent a year in the US as an exchange student. The exchange organisation allocated me a local support person named Emily. Emily was white and loud and the fattest person I had ever seen outside a caravan park. She looked different from the rare extremely fat people I’d seen in Australia. She smelled good and her climate-controlled house meant she did not sweat. She was very well dressed. Her husband was some kind of professional; I didn’t know they even made suits that big.
Emily’s family ate like the bejesus. I went to her house once a month for pizza: heavy, oily discs of cheese half a metre across. One each. Before pizza one night I watched the daughter eat a huge bowl of guacamole with a dessertspoon. I couldn’t take my eyes off her. I had no concept of calories; I’d simply never seen anyone eat so much avocado in one sitting. I wondered if it would make her vomit. I kept watching as she put down the empty bowl and turned the page of her novel.
I loved Emily. She cared for me the same way she ate: enthusiastically, generously, without restraint. Her bulk did not disgust me. But I never once ate any pizza. The thought of her pizzas made me sick. All those pools of fat. Twenty-five years later, I am a physician and Australia is filling up with Emilys.
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Louise was an educated 35-year-old who had recently lost her high-ranking job and was making ends meet by freelance consulting. Admitted to my ward with pneumonia, she had a high fever and a fast pulse, needed oxygen and was coughing up large amounts of purulent sputum. She was also fat, weighing about 120 kilograms. I knew that – barring underlying lung disease – obesity was one of the greatest risk factors for life-threatening pneumonia in young people. I felt a responsibility to tell her that her excess fat had harmed her in a way she may not have realised. Every day before my ward round I would say to myself that I was going to broach the subject with her. It seemed a good opportunity to intervene. And yet each time I stood by her bed and looked at her bedside table piled high with literary novels, open blocks of chocolate and teddy-bear biscuits, each time I lifted her pyjama top and pushed my stethoscope into her soft white flesh, I couldn’t do it. I was embarrassed to mention her weight; it felt like I was a puritan taking the high moral ground. It felt mean.
As a doctor, I no longer know what to do about the obese. Australians are getting fatter, and our society is geared towards making us that way – consumption doesn’t just drive economic growth. So is fatness a doctor’s problem? Studies show that verbal interventions during an episode of serious acute illness can result in a change in behaviour – people quit smoking, cut down on their drinking and sometimes lose weight. But usually counselling people to lose weight is hopeless. Then there are the questions of morality, personal responsibility, associated diseases, resource allocation, quality of life and aesthetics. I have moments of clarity – I think of the way Emily ate – and obesity seems simple: more in than out. Then I am engulfed once again by the high science of genetics, by the concept that obesity is a disease.
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I love reading articles with titles like “How I Lost 25 Kilos”, even though the answer is always the same: I ate less. Except for the gravely ill and a couple of men, everyone I know wants to lose weight. We live in a society that judges people for being fat, yet has in place every possible means for making them so. Who wants to eat less – of anything – when food is so good and plentiful? It’s hard to say no to something that is right in our faces, promising a bit of easy pleasure. It is especially hard to say no when the consequences of overeating come about in such a distant, gradual and mysterious way. I find it difficult to believe that an extra scoop of ice-cream will end up as fat somewhere on my body, even though I know how it happens at the enteric, metabolic and cellular levels. Perhaps this is what happens when we reach the head of the queue and order too much: a fantasy where eating has no consequence, where that pile of French fries and the burger with extra cheese are not our future bodies.
Battles with our appetites and with our bodies are played out on television, in magazines, in the workplace, in families and in hospitals. Be fat in public and you will be weighed by strangers’ eyes. One of the most radical things on television in recent years was the ordinarily flawed 70-kilo naked body of Lena Dunham in Girls: little girlish tits above big soft lumps and bumps. How shocking: the protagonist has a paunch and eats cupcakes in the bath. She blatantly displayed her body, a lone counterpoint to the usual stick-insect romantic heroines.
I have heard people say thinness is beautiful and coveted because it is difficult to achieve and rare now, the way curves apparently appeal in times of famine. There are activists who have set out to challenge the fat-is-ugly paradigm, to curb all this body-hatred. I am sympathetic to many of their aims. However, their attempts to manipulate what we find beautiful have been crashingly unsuccessful. The Adipositivity Project – which uses artful photographs of morbidly obese half-naked models to reframe fatness as a thing of beauty – remains separatist and marginalised. And the occasional cover shot featuring a so-called plus-sized model is hardly cause for jubilation. These models – often thinner than the nation’s average – are freakishly well-proportioned Amazons with flawless faces. The pro-fat bloggers are smart, sassy and pissed off. I’d hang out with them. Yet if they could click their fingers and be thin, would they? Would Lena Dunham? “I don’t want to be skinny like a model,” I’ve had more than one patient tell me, “I’d just like to look like Kate Winslet.”
I don’t know if there is any force that could purposefully change a culture’s definition of beauty. Is fat inherently ugly? Ask Aristotle, Susie Orbach, Naomi Wolf. Their answers are different, their arguments from different places. It is not an empirical question although it reads as one. Today when we look at those who are thin, part of what we see is a triumph of will over gluttony, so the beauty is a moral beauty; it has little to do with health.
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Questions of aesthetics aside, obesity is bad because it causes disease by, for instance, raising blood pressure and cholesterol levels, stuffing your liver full of fat, blocking your throat so you can’t breathe at night, crushing your joints. Fat people are more likely to get blood clots, gallstones, gout and some cancers – as well as type 2 diabetes, which leads to all manner of medical mayhem. Fat men and women make less money, marry less often and are less educated than the lean. They are more often depressed. In the Framingham Heart Study, which has examined the causes of cardiovascular disease across generations, the very fat lived on average six to seven years less than the lean. The moderately fat lived three years less. If you quit smoking and get fat, you may as well have kept on smoking. These dire facts are not my opinion. They are based on empirical data extracted from large international trials and studies. I wish it were not so. I wish you could get really fat and stay healthy. I wish you could get morbidly obese and be considered beautiful. Maybe it will change with time, as we all become enormous, and we’ll look back on the skinny-is-beautiful era with distaste, regarding high cheekbones, defined jaws and long, sculptured thighs as skeletal and ugly. I cannot imagine this, but neither could I have imagined that we’d end up in a world so fat.
I listen
ed recently to a neurosurgical registrar describing the difficulty of finding a spinal fracture under 10 centimetres of adipose (fatty) tissue. Neurosurgeons love precision; one false move on the inside and you won’t remember your mum. The registrar’s voice was filled with a kind of shocked horror. She’d had to send the car-crash victim to the scanner mid-operation, with a metal screw embedded in his neck so the surgeons could find their bearings beneath the mattress of fat. Post-op, none of the neck braces were big enough to fit. To immobilise the man’s spine, the team used sandbags.
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In 2012 I started work as the physician in an obesity clinic with a group of bariatric surgeons. No one else really wanted to do it. The attempt to help people lose weight is generally seen as one of the most futile acts we as doctors of internal medicine can perform: pretty much all we can do is make you feel crappier about yourself than you already do. But the surgeons can do something: they can clamp a band at the top of your stomach, cut half your stomach out or bypass part of your small intestine so food is not absorbed. The waiting list for our clinic is long. One of my patients gained 60 kilos between referral and consultation. Some of our patients have become so fat they can walk only five steps without needing a rest. Many are only in their thirties. My role at the clinic is to tighten up their diabetes control, make sure they don’t have a catastrophic hormonal condition that has made them fat (no one ever does), treat their high blood pressure and discuss eating and exercise habits. To each patient we show a cartoon of a bolus of food travelling down the surprisingly long oesophagus and squeezing through the junction that leads to the stomach. I watch the food moving down slowly, over and over, one viewing per patient. This is how your food goes down, so if the surgeons lock a band here, it will take four times as long. You’ll have to slow right down when you eat or you will vomit it all back out.