ajva | (no subject)

I love how they admit it's financial. Instead of trying to get their funding altered so these operations were breaking even instead of losses, they're just trying to do less of them.

I'm increasingly coming to the conclusion that a lot of doctors (and vets) aren't really scientifically trained. They may have a hell of a lot of knowledge about human biology, but many of them don't seem to understand how that knowledge was acquired, nor how trustworthy it is.

This is obviously being done in a mad way - but how would we react if it was being done in a sane way ie more accurate measures of obesity and a higher threshold?

A good question, of course, which leads into a more general debate about how much responsibility it is reasonable to expect people to take for their own health, particularly with respect to limited NHS funding. Indeed, what justification can we ever give for not treating individuals, even though the financial reality of the situation might necessitate rationing of treatments? This was always going to be an issue in any publicly-funded health service as soon as we got to the point as a society that the availability of medical solutions for the ill among the population outgrew the funding available. I don't think there is an easy answer.

However, for me this story is more about unthinking prejudice; the fact that a health board can come up with this "mad way" of doing things, knowing that it will be largely accepted, reflects what I think this afternoon I shall call our culture's "anti-bigness" bigotry.

The BMI thing is a particular bugbear of mine, you see. I see it quoted all over the place, not only by health or fitness professionals, but also by friends on livejournals. I seem to remember you have even quoted it yourself in the past. What irritates me is that everyone's attitude to it seems to be "well, we know it's not perfect, but it's a *reasonably* good proxy for what it is we're getting at". But the fact is, it *isn't*. It is fundamentally flawed and its universal acceptance not only throws up shocking examples of medical prejudice such as the above, but also lures the unhealthy slender into a false sense of security...

>rant mode off/<

Phew. feel better now. :o)

The trouble is that height and weight are the only things you can expect people to be able to measure by themselves at home. Given that there's a correlation between weight and adiposity for a given height, you need some way of estimating the latter given only the former two. If there's a better way of doing that than BMI I'd like to know about it.

Actually, I think that the measurement of girth can also be useful, I should probably be figuring that in too.

Better than BMI might be to get a proper medical measure of adiposity, then use changes in weight to make guesses about changes in adiposity...

Given that there's a correlation between weight and adiposity for a given height...

I'm afraid I must take issue with your postulate. Since muscle mass is heavier than fat, then no such useful correlation exists. BMI is meaningless without information about bodyfat composition.

There's seriously no correlation between weight and adiposity for a given height? That is astonishing and shocking. I'd like to read more about that if you can point me in the right direction - thanks!

If you want me to dig up some links then I'll get onto it, but surely it's well known that muscle is more dense than fat, that it's heavier per unit volume?

So surely from there just a moment's reflection will tell you that two similarly-boned large people who look exactly the same size, but have different body composition, will be different weights, the more muscular one being heavier, but the more "adipose" one being unhealthier, though lighter? Would you not accept that this would screw up the correlation you're suggesting?

The word "unhealthier" in the above, of course, makes the assumption that more muscle and less fat is a healthier state to be in, which may well itself not have been proven - but either way I think it does away with the weight/fat correlation theory.

I'll concede right away what you seem to be arguing for, which is that the correlation won't be 100% because there are other factors that affect weight than adiposity. But I can't believe the correlation is statistically insignificant either, because adiposity does affect weight, and I can't see why the other factors would exactly compensate. I've known people whose weight and adiposity visibly changed in tandem, in both directions. It would take some really amazing evidence to convince me that the correlation is zero.

I find it really difficult to know how to respond to this. It seems as if there is no possible way to proceed to try to win you over on this issue. :o)

Body composition is not routinely measured, so it is difficult to get hard statistics that I could use to further my argument. You say this:

But I can't believe the correlation is statistically insignificant either, because adiposity does affect weight, and I can't see why the other factors would exactly compensate.

But where is your evidence for other factors not "compensating", as you put it? It is based on your own anecdotal judgement:

I've known people whose weight and adiposity visibly changed in tandem, in both directions.

If there be, as you instinctively believe, some sort of positive correlation between adiposity and weight, then surely it is a correlation relating somehow to the absolute levels of fat tissue, rather than the proportional. This is all you could realistically deduce by sight, surely? Do you have X-ray Fat Vision? But the health aspect depends on the proportionality, which is in no way measured by weight, and therefore is in no way measured by BMI.

There are plenty of slim people who show up as normal on BMI measures, but have a high proportion of bodyfat; these are truly "fat", in health terms*, even if the dress/trouser size says otherwise.

* warning: Assuming a useful correlation between bodyfat percentage and healthfulness that, as I said above, may not be proven.

It's not routinely measured, but it is sometimes measured. I googled and found this:

http://www.unu.edu/unupress/food2/UID10E/uid10e05.htm

which, interestingly, suggests that the correlation is good enough to be useful for Europeans, but less useful for non-Europeans.

You are wasting your time with P on this one.

But where is your evidence for other factors not "compensating", as you put it? It is based on your own anecdotal judgement:

I can't speak for

ciphergoth, but I can't think of a single other factor that would compensate in the way you'd need it to to make the correlation zero. For that, you'd need a factor that tended to make people with a higher adiposity lighter, and I don't know of one.

Just to be clear here, I'm talking about a correlation between adiposity and weight as the only two measured variables about a person. I'm not suggesting that that correlation is medically useful, nor am I suggesting that it's a 100% correlation. It won't be, because there are many other factors affecting weight. However, none of those other factors (as far as I know) produces a negative correlation between adiposity and weight, so all they do is increase the scatter about the points on the adiposity/weight graph. Which lowers the correlation, certainly, but not to zero.

But the health aspect depends on the proportionality...

Well, yes. That's what I thought you were talking about when you said that the correlation wasn't a useful measure. I agreed with that, but you seem to be saying something different here; you seem to be saying that the correlation isn't statistically significant, which is something that I doubt very much.

Note, though, that 'the correlation between adiposity and weight (or BMI for that matter) is statistically significant' is a purely mathematical judgement as far as I'm concerned. It leaves totally open the question of whether adiposity should be considered for referrals/treatment. It also leaves open the question of - given that we're talking about beople being denied access to medical help - it's justifiable to use a measure that's less than 100% correlated with the thing that we're trying to measure.

There is, I'm pretty sure, a statistically significant correlation between white-skinned people and those entitled the treatment at an NHS hospital (if you take to population of the world as a whole, I'm much less sure about the population of the UK). I would still be horrified if a doctor were to start refusing to refer someone to a hostpital based purely on the colour of their skin.

There is, I'm pretty sure, a statistically significant correlation between white-skinned people and those entitled the treatment at an NHS hospital (if you take to population of the world as a whole, I'm much less sure about the population of the UK). I would still be horrified if a doctor were to start refusing to refer someone to a hostpital based purely on the colour of their skin.

Footnote - that's purely supposed to be an example if where I think it would be wrong to use even a statistically significant correlation. It wasn't meant to suggest - and I wouldn't suggest - that it's in the same league as anything anyone's suggested here.

and it's true, as

ergotia indicates, that she and I have discussed this before without coming to 100% agreement.

I can start you off - The Obesity Myth by Paul Campos. He belabours the point somewhat, but he does quote lots and lots of scientific studies, and cites them at the back of the book so you can go look them up yourself if you don't believe him.

The gist of it:
- There is no correlation between obesity and morbidity, unless you take into consideration other factors such as smoking, diabetes, cancer, etc.
- In fact, a healthy, active person with a BMI over 25 has a lower risk of mortality than an equivalent person whose BMI is under 25.
- Fat people who try to get thin in order to avoid certain health problems (e.g. hypertension, heart problems, diabetes, etc.) are more likely to wind up with exactly these health problems than either a fat person who takes up regular exercise (e.g. 30 minutes walking a few times a week) or even than a fat person who doesn't change their lifestyle.
- Because a lot of people believe that if they're thinner they'll be healthier, they try to be thinner by restricting what they eat. In fact very few people manage to succeed at this, and those who do actually reduce their life expectancy. And those who yo-yo diet make it even worse. In fact, mortality rates were most reduced in subjects who took up regular, moderate exercise - and hardly any of them got any thinner.

And it goes on and on and on.

I really hope these Trusts get their asses sued off. Even if I do realise that the likelihood of that happening is close to nil. Grrr.

Um. I know that if I read the book I'd be frustratingly half-convinced - I know it's not my field, and I'm sure he presents what seems like a very convincing case, but I just bet that if I met someone equally knowledgable and determined to present the opposite case they'd convince me the other way. I really don't know how to go about figuring out the truth on this one.

However, I am pretty convinced that there's a correlation between weight and adiposity, whether or not reducing either is good for you.

That's not what

ajva said. She said no useful correlation existed (my italics). I think, if you're going to dispute this, you should at least have a working definition of what you mean by 'useful'. Your original comment suggests that you think BMI can be used in a useful way (well, OK, you said 'sane', but it seems to be in the same area) to decide whether or not to grant someone treatment on the NHS.

That's what I think

ajva,

asrana (and I, for that matter) take issue with. Not that a correlation between adiposity and weight exists (as you point out, it doesn't have to be 100% for it to be there) but that it's at all useful in deciding who's a priority for treatment.

It's stupid to use it as a gate for treatment because, quite apart from all the other problems with such a gate, they have more accurate measures at their disposal.

I think I'm arguing that BMI is still a useful proxy for adiposity, and the best at our disposal since we don't have the equipment for better measures of adiposity at home. Some references suggest you classify your frame into one of three types, and use that when interpreting BMI; I'd guess that makes it a better proxy. It still has problems, but I'd need some convincing that it's too misleading to be useful.

Of course, that still leaves the question of whether losing weight/fat is good for your health, which is one I don't know the answer to.

It's not being used as a gate for treatment.
It's being used as a gate for referrals.

It's the PCTs (Primary Health Care Trusts, ie local doctors surgeries) saying they won't refer BMI30+ patients to hospital for such treatment, irrespective of the hospitals' referral criteria.

The hospital would judge if the patient was in a physical condition that made an operation too risky, decide where on the list to place them etc based on their own clinical findings.

Of course, that still leaves the question of whether losing weight/fat is good for your health, which is one I don't know the answer to.

I think that's because, as a general question applied to the population at large, it makes about as much sense as asking whether wearing a particular strength of spectacles would improve people's eyesight.

Yeah, obviously losing weight wouldn't be good for my health, for example. I'm just trying to reference in shorthand a whole bunch of questions that are part of the wider debate about what recommendations should be made with regards weight, adiposity, diet and exercise.

In longhand I guess it looks like: is there really a significant subset of the population who would enjoy better health if they reduced their calorie intake, and if so what measure most accurately indicates if you're one of them? Of those who exercise little or not at all, would some benefit from exercise far more than others and if so which ones? And that's still not a totally precise way of putting it.

*cheers*

Well said that woman!

I remember the day the fitness roadshow came to Clays Lane, and I got my BMI calculated. Five foot six, fifteen stone Marcus.
"Ah, well, according to this you're obese so what you need to do is..."
"Sorry, before you go on, what weight would I have to be not to be obese?"
"Uh, oh, er that's not the way it works, these figures are a guide and.."
"No no, but seriously, what weight would I have to be to be the fattest I could and still be healthy according to the BMI calculation?"
"Um, 10 stone."
"So, as I'm 15 stone I'd need to lose a third of my weight, I'm 50% overweight?"
"Uh, yes."
"It's crap isn't it. I'd only be able to lose five stone if I had my legs chopped off?"
"Yes, okay, fine *mutter*"

Even then, it would be the top of a slippery slope which would have as intermediate stations not treating illegal drug users, not treating smokers, not treating people who've had unsafe sex, not treating people who've had sex outside legal marriage, not treating people who climb mountains, not treating people who break limbs/have heart attacks while jogging... and before you know it, we'd only be treating the most smug and boring of paragons of conventional morality.

Besides, I think the real answer should be that we treat people on the NHS not because they deserve it, but because we don't want to be the kind of people who don't treat a fellow human being in distress.

...before you know it, we'd only be treating the most smug and boring of paragons of conventional morality.

A great way of putting it; you brought a smile to my face, thanks. :oD

We've already crossed that line, in that alcoholics won't get replacement livers on the NHS unless they stop drinking.

Or they're George Best...

Well, yes, but it's not a 'letting the genie out of the bottle' situation, is it? We can (and should IMO) cross back over the line again.

I'm not sure I agree that we should cross back - there are only so many donated livers and would be even if the NHS had the funding it needed - but I certainly don't think having put a toe in the water makes it morally OK to dive in headfirst. Sorry if it sounded like I was saying that - I just meant to raise another example of where treatment is given preferentially based on lifestyle choices.

there are only so many donated livers

When a donated organ becomes available all sorts of systems swing into operation to match it up with someone who needs it, but sometimes there's no-one currently in the UK who is a tissue match.

So having more people on the list would mean that there was actually more chance of each individual organ getting used, potentially increasing the number of lives saved. But a longer list of people waiting would also mean more people dying while on the list, rather than off of it.

OK, but where there's more than one person waiting for a given liver, I think it's OK to prioritise the one who's less likely to immediately start destroying it, all other things being equal.

I can't disagree with you there. Can't, won't, don't!

But I don't think it's right to deny someone with alcoholism a place in the priorites though - last place is still better than no place. Not all alcoholics are incurable.

Exactly. It's one thing to refer someone and then prioritise by clinical need and ability to benefit - especially if they are offered help in improving their ability to benefit - but it's another not to refer someone at all.

I'm not sure I agree that we should cross back

Yes, actually, you have a point there.

Alcoholics don't get *pushed up the list* for available livers unles they can agree with a GP on a strategy to ensure they won't endanger their recovery to a point of uselessness. Until we can manufacture livers I don't see a better way...

That'd be different, but they admit they want to get the list down to cut costs, and so they're doing this in order to shave the queue.

If there were clinical reasons not to put someone forward for an operation based on their size, they wouldn't have been on the list in the first place - these things are hardly first come first served.

This is saying 'let's drop the fatties and save ourselfves some money, it's wasted on them anyway'. As such it's atrocious.

My mother has been told to lose weight because she has liver problems. The doctor does not know the cause of the liver problems. My mother is a size 12-14 and has been for some years by dint of developing a mild obsession with her size; as she's in her mid-50s, I think she's unlikely to get much thinner than that, and 12-14 is a perfectly reasonable size to be. I'm angry with the doctor because she's bolstering my mother's belief that she is overweight (still) and because she's told her to do something I think may not be possible, or only possible if my mother develops an eating disorder.

Fucking hell, that's outrageous. Mysterious aetiology? Tell the patient it's their fault for being fat, even if it bloody isn't. Doctor, don't admit you don't know; no, shift the blame that should lie at the feet of your own ignorance. Sorted.

Wankers. Your poor mum. :o(

Mm. I can't recall the name, but I remember reading a size-acceptance women's magazine about eight years ago. It had a medical checklist of questions to ask if your doctor told you to lose weight: Things like, how will that specifically improve the condition under consideration? And it advised pointing out if you already had the condition before you gained weight.

My appalling GP in Wales, with whom I was only briefly registered, liked to tell people to lose weight. He weighed a mate of mine and said he could stand to lose a stone - it turned out that he had mis-estimated the chap's height, by several inches.

Sorry to hear about your mother.

Yeah. I hover on the edge of the 30 mark (when I can be persuaded to be weighed at all, which is rarely), but my doctor has expressly told me not to attempt to lose weight because of my eating disorder history. I find it difficult to estimate the chance of any NHS system taking account of this situation without using the words "snowball" and "hell".

While I agree that:

a) BMI is, indeed, a poor measure of health; I had thought been abandoned by the GMC (if that's the UK version?) in favour of the ratio of waist measurement to height. Which is also a poor measure, in other ways.

Just a thought: perhaps a person's health (and fitness for operation) is best assessed by a thorough check performed by an appropriately qualified medical professional? Well, duh.

b) Accuracy, or otherwise, is totally beside the point. Such medical services ought to be delivered to those who need them.

...

I can't help finding that my first thought is: 'better get a good job and pay for private medical insurance.'

Does that make me a bastard?

No, it makes you prudent. I have private medical insurance too, because the NHS is already incapable of delivering simple things like grommets for children who can't hear or counselling for people who are suicidal within a timeframe that I'm willing to accept for my family.

Hah! I thought that meant 'component that I don't know what it does that got left over when I "fixed" my washing machine'...

J

Indeed - small flanged bit of rubber with hole in - useful for fixing washing machines after they fall out of your ears. Honest.

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Aside from the 'is BMI a useful proxy' issue:

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This reminds me...

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Grommets

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