The Arrow #118

Hello everyone.

Greetings from Montecito.

As the say at the start of just about every medical conference I’ve ever attended: First, a little housekeeping.

Last week I wrote that I was going to remove the paywall from The Arrow #116. As a consequence of my incompetence and Substack’s opacity, it didn’t get done. I thought I had taken down the paywall, but there was one more little button I missed. It’s all fixed now, so you can find it here in its full unpaywalled glory.

Also, I heard from a number of readers that they were unable to take the quiz. Some were paid subscriber, but most who reached out were free subscribers. I checked and can’t find any reason why the poll shouldn’t work for everyone. I didn’t do anything I know of to put it behind a paywall. In fact, I didn’t even see that option.

Finally, every week I hear from a handful of readers who didn’t get their newsletter by email. When I look at my subscriber list on Substack, it tells me I have X subscribers. Then, when the newsletter is sent out, Substack tells me X minus about 100 were sent. Why Substack doesn’t send to the entire list of subscribers is a mystery to me. I, myself, was victimized by it three weeks ago. I am a subscriber, so I can see what it looks like when it comes via email. And I didn’t get my own newsletter three weeks ago, so it can happen to anyone.

If you don’t get your copy of the latest newsletter by late Thursday, just go to michaeleades.substack.com and read it there. You may have been in the lucky (or unlucky) 100 that week.

The poll from last week indicated that a majority of readers wanted to read the personal drivel. Which was also reflected in the comments. A good chunk were willing to put up with a bit of it, and a minority (<8 percent) wanted me to stick purely to writing about medicine and nutrition.

Since 90+ percentage of people want to read about some drivel, I will accommodate them now.

MD’s Concert and other Drivel

First, MD’s concert was absolutely phenomenal. Voctave is fantastic. Much better in person than in the YouTube I put up last week. The venue was great, the acoustics terrific, and my seat was perfect.

Here is a photo of one of the numbers.

MD is right behind the left arm of the guy on the left with the grey shirt, tie, vest, and the purple sleeves. As per usual, she has her mouth open. [The bride defends this posture as she was singing at the time and an open mouth is a pre-requisite.]

The place was filled. The vacant seats in front were where the singers on stage sat before they went onstage to perform backup. This was the first time ever Voctave sang with another live choir, and they seemed to enjoy doing it themselves.

That was the good drivel. All the rest are disasters of one form or another.

Our son and fam took off for Colorado to go skiing/snow boarding with some friends over Spring Break. MD and I moved into their house to keep an eye on things and wrangle their two dogs and two cats.

Early last Monday, the power went out. Which was strange, since they have a monster Tesla roof and a couple of big power walls of batteries. I called Tesla and finally got through to a service person. He put me through all kinds of troubleshooting exercises to get things going. All to no avail. He ended up telling me that we may have had an outage on the grid, which tripped something on the Tesla system. He told me to call the power company to find out, then get back to Tesla.

As anyone knows who has tried to call a public utility, it’s a fool’s errand and takes forever to get to a human. In the case of the local power company here, you can’t even get to a human no matter how long you wait. I had to leave a call back number. MD got online to check if an outage had been posted, but none had.

A very nice lady called me back a couple of hours later and told me there hadn’t been an outage to the house and that she could see power going to the meter. She told me I needed to get back with Tesla.

So I did. Got another tech who put me through all my paces again, doing all the stuff the last one told me to do. Finally, she says, We just need to get a tech out there. Let me see what I can do.

I wait until 3:30 or so, and no tech and no call. So, I call back only to be told that tech service was available only from 8am to 2pm California time.

While I’m grousing around trying to figure out what to do, I get a text from my kid, who tells me Tesla is going to be calling you. Take the call.

Which I did about five minutes later. The guy asks me what the problem is, and I tell him. He sends me out to the Tesla panels and puts me through all the same tests and procedures the other two did. But before I go out there, he asks if I am physically able to run through the check list. I said, Of course, why wouldn’t I be. He said, Your son said you were old, so I just wanted to make sure I didn’t over tax you. During this time I was also dealing with the dogs who every time you stand up think you’re going to the kitchen to feed them. And I mentioned to him that the dogs were in the way, or whatever. He asks what kind of dogs, and we have a brief conversation about them.

He then asks me if my wife might have dropped a hair dryer in the bathtub and shorted everything out. I said no. He said, Well, you know how old people are. Which I thought exceedingly strange.

Then he says, We need to get a tech out there. I can get one in 15 minutes or so, will you still be there. I tell him yes. He’s says, I’ll send him and we hang up.

About ten minutes he calls back and tells me the tech guy was outside the house, but no one was there. I tell him I’m right there and ask where the tech guy is. It’s a big property. He tells me he says he’s right there at the address I had given him. I ask, Is he down by the gate?

He’s says, I don’t know. Let me patch through to him. Next thing I know, he’s talking to this guy. He says, Where are you Scoby. Scoby says I’m right at the address. Meanwhile I’m walking down to the gate—which is open—to see if I can find Scoby. He’s nowhere to be found, and I can see up and down the street.

I tell him to head back to the main street, and he’ll drive right by me.

Then, I hear a bunch of dogs barking in the background and Scoby screaming. He’s being attacked. The guy on the phone tells me to call my dogs off. I tell him that whatever dogs they are, they aren’t ours. By this time I’ve gone back up to the house, and I can see our dogs. They are inside watching me out the window.

Meanwhile Scoby is screaming, and the dogs sound like they’re tearing him to pieces. The tech guy says, Sir, sir, you’ve got to get your dogs off Scoby. I’m telling him my dogs are in the house and I can see them.

In the midst of this drama, I get a call from my kid. I try to put the tech guy on hold to see what my kid wants or if he has new info and accidentally hang up on the tech guy with Scoby screaming and the dogs snarling in the background. When I answer my kid, he tells me the whole thing is some sort of scam.

Apparently this guy got hold of a bunch of Eades cellphone numbers. He called my youngest son first and asked for the middle son. The youngest said, He’s not here now. Could I take a message. The guy says, Eff off and hangs up on him. Then he calls the middle kid, tells him he’s from Tesla and he’s here to help. So the middle kid, thinking it’s all legit, gives him my number. He then calls me and the whole thing starts.

Then the youngest finally gets a chance to call the middle son and tells him about what happened. The middle son then calls me. I never hear from the guy again.

By this time, it’s too late to do anything more to get help from Tesla.

The next morning, I call them at 8 on the dot. Get a terrific tech customer service lady who again puts me through the troubleshooting process with one additional step that solves the problem. Bam. All the power is back.

The bizarre thing about the scammy guy was that he knew the whole troubleshooting process to try to get the system booted back up. He put me through all the same exercises the others did, so he was obviously familiar with a Tesla roof and power system. The whole thing was weird.

The other strange thing was that when the middle kid told the scam guy to call me, he asks my kid if his dad is old. The kid says, Yes, he’s old. The guy asks if I’ll be able to go out and check the system. The kid says, He’s old, but not old like that. He can walk 36 holes and carry a golf bag. He works out. He lifts weights.

I don’t know what the guy’s deal was, but I never heard from him again. It was a strange experience. And it seemed more like a practical joke than a scam. I would think it was one of my friends pulling my leg if the guy hadn’t called all the kids first.

One last bit of personal drivel. This one will affect you, the reader. I had another calamity this past week. When I’m working on projects using my laptop, I always have a ton of tabs open. Maybe four or five browser windows with 50-80 tabs open on each one. When I’m writing, it takes me forever to hunt down the particular tab I’m looking for. And since I’m usually under the gun time-wise to get something out, it makes for major frustration.

I’ve tried several solutions, none of which worked with my particular writing process. I used Pin Tab for awhile until it lost about 2,000 saved tabs (no exaggeration), so I haven’t trusted it since. And there have been a handful of others over the years.

A PhD friend of mine who does a lot of research suggested an app called Workona. I downloaded it several months ago when he told me about it. I even went with the paid version. Then when I tried to use it, I realized it was more complex than I thought, so I back burnered it.

Until right after last week’s Arrow, which caused major time frustration due to tab searching. I decided early this week to fire up Workona and figure out how to use it. I watched a video that was a little over a minute long, said, I’ve got this, and proceeded to lose all my tabs. I ultimately figured out where they were, but not before spending a ton of time screwing with it.

Along with the lost tabs, which were duplicated and even triplicated in some cases, I found hundreds of other tabs the app had saved. Many of these I thought had been lost as I couldn’t find them weeks ago when looking for them. I figured I had inadvertently closed them. But, no, Workona, after a certain time, sucks them down and stores them. So mixed in with the tabs I thought I lost when I tried to use the app, there were hundreds of others.

I did what I should have done right at the get go and watched about an hour’s worth of videos and learned how to use the app. Now I know how to use it, and it really is useful. And I think will solve my tab issues. Problem is, I still have to go through all these tabs and put them in the right places. And all my tabs on the ketogenic diet and cancer are still buried away in there. Here is all I could screenshot at one go, so you can see what I mean.

If I click on any one of these, the current browser window closes down, and a new browser window pops up with all the tabs listed. The name you see above is the first tab in the window. The +number is the number of tabs in that browser window. And what you see is about a third of what I’ve got to deal with.

My plan is to have this finished over the next few days, and have all these tabs sorted in a way I can find and use them.

Okay, on to one more personal issue.

I’ve had emails from a few readers asking if my family in Little Rock is okay. Last Friday a devastating tornado ripped through the very area in which we lived and worked for many years in Little Rock. Everyone is fine. No injuries or property damage involving any of my immediate family members. Our main clinic—the one both MD and I had our offices in—took a pretty bad hit. The restaurant right across the street—owned and operated by good friends of ours—sustained a lot of damage. The tornado tore hell out of an area where one of our youngest son’s best friend lives. His car’s totaled, but he’s okay.

I asked my kid to go take a photo of our clinic, but he said the National Guard was patrolling the area and wouldn’t let people in who didn’t have business there.

I’ve had countless videos sent to me from friends there, but I can’t embed them in Substack. Here is one from Twitter that shows the tornado pretty well. It was fearsome.

The beat goes on. When I tried to put up the Twitter post, I got this pop up.

I checked on YouTube and there are a ton of them on there if you would like to see it. Just put in “Little Rock tornado 2023.”

Who Will Win the Presidency in 2024?

I have no idea. But I did see the first prediction on this event from our old friend pony-tail guy. Here’s what he had to say (assuming I can embed a YouTube):

I disagree with him about his characterization of the breakdown of voters. He says there are about 25 percent on each side of the political spectrum who would vote for their party’s candidate even if he/she were a child rapist (my characterization; not his). And there are about 20 percent who lean one way or the other. Which leaves 10 percent, who are true independents. He includes himself in this group, which I think is bullshit. But, it’s his video.

The independents, according to PTG, are the real thinkers. They decide based on merit or what they truly think is best for the country irrespective of the candidate’s party affiliation.

Here’s my take on it. I agree that there are maybe 25 percent who are political junkies and party ideologues who will vote the straight party line. Years ago in the South there were many yellow-dog Democrats. So called because they would vote for a yellow dog if it ran as a Democrat over anyone on the GOP ticket. This 25 percent are yellow-doggers, but for both parties.

I would guess there are maybe 15-20 percent of people who have strong leanings one way or another.

And probably 10-20 percent who are independent. But not independent like PTG believes. My opinion is that much of this 10-20 percent are, for the most part, totally uninformed and don’t really give a flip. It’s all just the next big entertainment in their lives. They watch the Olympics, then they watch the World Series, and then, the next big drama: The presidential election. They haven’t really followed the primary campaigns, because, basically, they don’t care.

They decide at the last minute based on who gave the best acceptance speech or who got the worst end of a negative campaign, or some real or imaginary October Surprise, or who knows why. I seriously doubt that the majority of them know much about the candidates or the various party platforms. To them, it’s kind of like voting for the Academy Awards. It’s fun and filled with drama, but doesn’t make any difference in their lives. The Academy Awards that is. The political outcome can make a big difference in their lives, but they don’t care enough to study the issues and vote appropriately.

I’m sure there are some true independents who do fall into the category PTG says he falls into. Smart people who put candidate above party and are well informed on all the issues. But I don’t think the percentage of those people is anywhere near 10 percent.

Over the past few decades the presidential elections have been within just a few percentage points. Which means the people who actually pick the president are those who don’t really care and who don’t even start thinking about it till the last couple of weeks before the election. A sad state of affairs.

If you disagree, let me know in the comments.

Speaking of Presidents… As I’m sure everyone knows, the last one just got indicted. Which may keep him out of the Oval Office, or put him in. In all my years of watching politics, I’ve never seen anyone so hated by the elites, uniparty, insiders, neocons, whatever term you want to use.

From what I’ve read, the charges are pretty bogus and may even be kicked out. As someone on CNN said, they were underwhelming.

If you want to read about the charges in detail, Jeff Childers, an attorney, did a pretty thorough job of spelling them out in his column yesterday. Also, Andrew McCarthy, who was a federal prosecutor at the SDNY for many years, says the charges are a sham with no chance of holding up. Granted, both of these are from conservative sources, although McCarthy was on the Fox news show of a real anti-Trumper. But Alan Dershowitz, who is on the left, said the same thing. Because of his stance on this and a couple of other issues involving Trump, he’s been deemed by the wokesters as being a tool of the right. I haven’t heard anyone who is on the far left say anything about them one way or another.

I hate it because it’s going to make politics even more divisive. Believe me, the Republicans are licking their chops with the thoughts of all the Democrats they can indict.

The Democrats apparently haven’t learned the lesson from the Harry Reid fiasco. Remember Harry Reid? He was the Senate Majority Leader during the 2nd Obama administration. He was trying to get a bunch of liberal judges through the federal judicial confirmation process, and Mitch McConnell held them up. At that time, it took a 2/3 vote of the Senate to get someone confirmed. Reid got pissed, and in an effort to get these judges through, he declared the nuclear option. He changed the rules to that he could get these judges through with a simple majority. Which he then did. McConnell told Reid he would be very sorry that he did it, because the Senate wouldn’t always be in the Democrat’s hands.

Sure enough, when Trump got elected, McConnell put one conservative judge after another onto the bench while the Dems fumed because there was no way to stop him. And McConnell got three Supreme Court Judges confirmed the same way.

None of that would have happened had not Harry Reid breached the tradition of the 2/3 requirement. Which I think should be restored. You don’t want far right and far left judges on the bench. You (at least I) would want more middle of the road judges, who would tend to decide cases on their Constitutional merits with no, or at least less partisan bias.

Now that the tradition of leaving former presidents alone has been broken, God only knows what will happen. I fear the worst.

A Medical Crisis Looming

I posted the graphic below a year or so ago in an effort to show why medicine is so expensive in the United States.

It brings to mind the great Thomas Sowell quote:

It is amazing that people who think we cannot afford to pay for doctors, hospitals, and medication, somehow think that we can afford to pay for doctors, hospitals, medication, and a government bureaucracy to administer it.

The growth of bureaucracy in medicine is astonishing, but so is the growth in bureaucracy everywhere. Think colleges and universities. When the feds bumped the student loan amounts to vastly higher than when I got student loans, tuition began increasing and the colleges all added layers of bureaucracy.

But that’s not the crisis I want to talk about today.

When I first posted this chart, I kind of did first order thinking about it. Which told me that the rapid growth of administrators was obscene. Then I saw the same graphic somewhere else recently, and I started looking at it in a little more depth.

First, you can see the slow growth of physicians over the 40 years represented in the chart. The growth of administrators appears to be unrestrained. There is a major impediment to the growth of physicians that is not an impediment to the growth of administrators: medical school and residency.

I would guess most administrators have four year college degrees. Some, I’m sure, have master’s degrees, which require a year more. Probably a good number of them have executive MBAs, which take a couple of years, but can be done while holding down a full-time job. A lot of companies even pay for their execs to get executive MBAs. So the barrier to entry for an administrative job is relatively low.

Not so for a physician. It requires medical school and a residency.

Medical schools are incredibly difficult to get into, at least they were years ago when doctors were virtually guaranteed an upper-middle-class income. I don’t know about now. Currently many administrators make more than doctors.

Medical school admission criteria are high and the competition for spots is intense. And there are a finite number of medical school slots available. Not all states have medical schools. Most states have just one. So, the supply of doctors is restricted at the front end. If someone in the government decides we need to have more physicians and expanded the slots available, it would take seven or eight years before these doctors could go into practice.

The pressure in medical school is pretty intense and there is no room for failure. Medical schools take turns hosting students in the summer who have flunked a class and are trying to stay on track. If you flunk more than one class, you’re screwed. You can’t really make it up. Some schools allow students who have a good reason for flunking—a death in the family perhaps causing class absence—to move back a year and have a do over.

Medical school is four years long. The first two are mainly all classroom. The last two are clinical, on the wards learning first hand about disease instead of from textbooks. When you graduate, you know just enough to be dangerous. It requires post graduate training before you really become competent enough to be loosed on the public.

These last two years are the real bottleneck. You could make as many classrooms as you wanted to make for very little money and teach triple or quadruple or even more the first two years of study. But you have to have enough patients and hospital beds to accommodate the last two years. You can’t create patients in the same way you can classrooms, so medical education—if you want to maintain the quality—is limited by the availability of patients.

None of these hindrances are at work with the administrative class. They can be and are being cranked out by the thousands. Unlike with doctors, there is no supply limitation with administrators.

But where I think the major crisis looms is in the admission of women into medical school. And I say this with a wife who is a physician.

I can’t tell you how many females in my medical school class have abandoned being practicing physicians. When I encountered them a few years after I started practicing and asked what they were doing, the vast majority of them said, Oh, I’m being a mom.

I know very few who have stuck with it and kept practicing for an entire career. The bride’s an exception; she practiced for 20 years in the clinic and raised three well-fed, well-adjusted boys.

I googled how many women are still practicing medicine in ten years, and I got this:

It is worse than I thought. Almost 40 percent leave after only six years. And, even worse, the majority of medical students are now women. It was about 10-20 percent when I was in medical school.

If the majority of medical students are now women and the trend is that 40 percent quit after six years, we’re looking at a major physician shortage in the not-too-distant future.

So, we have a situation in which there is a bottleneck in the production of physicians, and, of those produced, many will quit within six years.

Here is the problem.

We can’t refuse qualified women the opportunity to go to medical school. Especially if it is true, and I believe it is, that, in general, women make better doctors than men. They are much more empathetic, for one thing. And they often have better fine muscle control, which can make them better at procedures requiring a lot of finesse. These are, of course, generalities, but they are ones I’ve witnessed over a long time of watching and hiring both women and men in our chain of clinics.

The problem with medicine as a practice is that it isn’t what it appears to be on the doctor shows on TV. There is a great drawing in one of my medical school annuals that truly sums it up. All my annuals (and MD’s) are in storage, or I would reproduce it here for you.

It is two panels. The first says Medical practice as envisioned by the new doctor. It shows a young male listening with his stethoscope to the heart of an attractive busty female. The lady patient has hearts floating up in the air while being examined by the handsome doctor.

The second panel says Medical practice as it really is. It shows a frustrated doctor talking loudly to an elderly patient who is hard of hearing. She is a wizened crone with a hand to her ear. The young doctor is shouting, Is your poo black? No, your poo, is it black?

The latter panel is vastly more realistic than the first. When you think of all the things you have to do regularly and all the orifices you have to probe, it becomes a lot less glamorous. I’ve had very few patients (read: none) swoon over me. MD has had awful experiences with true perverts, who want to see a lady doctor, that I can’t even write about.

I don’t blame women who get into the profession, get the chance to leave, and take it. And noble as medicine is as a calling, so is motherhood and child rearing.

Medicine progresses so rapidly, that it’s almost impossible to take ten or more years off to raise kids, then go back. It can be done, but it’s difficult. Those skills quickly wane.

Problem is, there would be a huge (and justifiable) outcry if those responsible for admitting people to medical school decided based on the dropout statistics for females that they were limiting admission to a smaller number of them. Yet it would make perfect sense logically to do so in terms of what has happened in the past.

We’re reaching a situation in which the baby boomers are hitting the first stages of old age. As more and more of that huge demographic surge into old age, more, not fewer, docs will be needed to care for them.

So, we really are headed for a crisis, and I don’t see how we can avoid it.

Don’t Believe Everything You See on YouTube

A reader (I think) recommended that I give the video below a look. It’s a little over an hour and a half long, so I decided to increase the speed and power through a bit of it. I had never heard of the guy being interviewed, but he sounded pretty credible. Until I hit about the 1:03:30 mark.

He was talking about how he was approached for health advice by Dana White, who is the president of Ultimate Fighting Championship (UFC). I know who Dana White is, but I didn’t realize he had so many bad health problems, which Gary Brecka, the guy in the video, said he was authorized to reveal. Apparently, healthwise, he was a basket case.

This issue I have is the extreme exaggeration Brecka indulges in during his explanation of what happened with Dana White’s blood test.

I’ve got the video queued to where it starts, so you can watch it for a couple of minutes to get the full effect.

Here’s the story.

Brecka orders his “medical team” to do bloodwork on White. Which they do and send off to Labcorp, one of the major labs in the country. One we’ve used in our own practice. As Brecka tells it, he, Brecka, gets a call in the middle of the night from Labcorp, which has just run White’s lab. They inform him that they’re giving him a “life threatening alert” on something they’ve found in White’s blood.

With great drama, Brecka explains that the lab told him Dana White had a triglyceride level of almost 800 mg/dL. 800 mg/dL!!! It was a life threatening alert. According to Brecka, he immediately booked a plane ticket to get him to wherever Dana White was to break the news to him in person. When he got the full lab, he found that not only were the triglycerides at life-threatening levels, but his cholesterol was high, he had insulin resistance, and elevated blood sugar.

The whole notion that triglycerides of 768 mg/dL (the exact level) is a “life-threatening” event is total and complete horse shit. It is a sign that things need to be improved, but it isn’t immediately life threatening. MD and I have had many, many patients with triglycerides above 2,000, and we never got a call in the middle of the night from a lab. Nor did we hop a plane.

The whole picture he described based on Dana White’s blood work is really pretty common. And it can be easily and quickly and safely treated with a low-carb or ketogenic diet. In carb sensitive people, carbs can drive triglycerides to ungodly levels. But they come right down when you cut the carbs. There are very few absolutes in medicine, but in the case of triglycerides coming down quickly with carb restriction, it’s as close as you can get.

At least Brecka, despite his histrionics about the lab call (which I don’t believe for a second), did the right thing and put White on a ketogenic diet.

I’m bringing this up just so you’ll be wary of what non-medical people (or even doctors who have had no experience) say about medical topics. And to let you know that if your triglycerides are out the yang, they can easily be fixed.

One of the other almost absolutes in medicine is the triglycerides divided by HDL levels give a pretty good indication of cardiovascular health. The lower the ratio, the better. Restricting carbs almost always brings elevated triglycerides down to fairly low levels. Usually around 100 or lower. And consuming saturated fat drives HDL levels up. So, lowered triglycerides divided by higher HDL gives a lower ratio.

Now tell me again why a low-carb diet is bad for health?

Can Obesity Be Healthy?

In my view, in a word, no.

But some obese people are healthier than others.

I just saw a paper discussing how many obese people are healthy and why those with the condition are often treated differently by the medical profession.

As the paper states, the places in which the excess body fat is stored pretty much define the consequent health of the obese person.

Many researchers and doctors—and broader societies—take it as a given that obesity means ill health. In fact, says Ruth Loos, who studies the genetics of obesity at the University of Copenhagen, “We can be obese but remain healthy.” Scherer, Loos, and other researchers worldwide are examining genes, animal models, and humans to understand how factors such as the distribution of fat in the body and the nature of fat itself can blunt or compound any health impacts of extra weight. The researchers are also working to define metabolically healthy obesity (MHO) and examine how common it is and how long it persists.

Beyond the research lies a knotty practical question: what the science means for people with obesity and the doctors they see. Undoubtedly, “There are subtypes of obesity,” with some more harmful than others, says Sadaf Farooqi at the University of Cambridge. “You’ve got this massive variation that must be driven by other underlying factors.” At the same time, Farooqi suggests, people who qualify as overweight or obese should generally try to lose weight. “There is a clear correlation between gaining weight and increased risk of type 2 diabetes,” she says, “even if you don’t get it right now.” Furthermore, she and others say, obesity is associated with health problems well beyond metabolic abnormalities, including various cancers and wear and tear on joints.

In my view, obesity is problematic irrespective of whether one is metabolically healthy or not. Granted, if you’ve got to have obesity, it’s better to have the type that is metabolically healthy than the other. But it’s a lot better to not be obese.

The difference between metabolically healthy obesity and the non-healthy variety is a function of where the excess fat is stored. If it is stored subcutaneously, i.e., beneath the skin, then it usually doesn’t cause metabolic problems. If it’s stored in the viscera—in the abdominal area and in an around the abdominal organs—it is more problematic.

People are doubtlessly endowed genetically with certain places to store fat. Some have much larger subcutaneous fat storage depots than others. When people first begin to pile on excess pounds, it goes into the subcutaneous reservoirs. Which is where nature wants it to go.

But once these storehouses fill up, more excess fat starts getting shunted to the viscera. When that happens, the metabolic trouble begins.

Why?

Because the subcutaneous areas are designed to store excess fat. As I mentioned, some people have much larger reservoirs than others. It’s like two different houses. One has a big attic and many closets, while another has no attic and just a couple of closets. If the owner of one of these houses brings all kinds of junk into the house, he has plenty of places to store it to keep it out of sight. If the owner of the other house brings that much junk in, he has no place to store it, so it sits out in the living room and is an eyesore.

Same with subQ fat. If you’ve got a lot of space and you bring in more than you get rid of, then your subQ fat stores enlarge. If you don’t genetically have that much space, the incoming fat has to go somewhere else, so it goes into the viscera.

Problem with going into the viscera is that it doesn’t belong there. And since it doesn’t belong there—the viscera weren’t designed to be a fat storage depot like the subQ area is—the body treats it as a foreign body. In medical parlance a foreign body is something that shouldn’t be where it is. Could be a splinter. Could be a bullet. Could be a little piece of glass you stepped on.

Foreign bodies stimulate an immune response. First, macrophages rush into the area to try to get rid of the foreign body. They bombard it with all kinds of chemicals to try to kill it. And they send out distress signals to other macrophages to come join the fray. They stimulate the release of all kinds of cytokines, which attack the foreign body in a variety of ways.

If you get a splinter in your finger, that’s what happens. If you can’t pick it out with tweezers, ultimately it will kind of float to the surface and out on a sea of pus, which is composed of dead cells and all kinds of immune cells called to the area.

If fat gets stored in your viscera, the same thing happens. Macrophages attack it just as if it were a splinter.

In fact, about half the volume of visceral fat can be composed of macrophages. Half the volume! Think about that. All those immune cells trying to attack the fat that shouldn’t be there. All calling for help and releasing all kinds of inflammatory cytokines. That doesn’t happen with subQ fat.

I sometimes tell my patients about the macrophages crawling through their visceral fat like a million maggots to help them maintain their motivation to lose. If that doesn’t make you want to do what it takes to get rid of visceral fat, I don’t know what will.

When fat gets into organs, they don’t work as well. If you’ve got a lot of visceral fat, you’ll probably develop insulin resistance and maybe even diabetes. And a host of other conditions as described in the article.

The only nice thing about visceral fat—if there is a nice thing—is that you tend to lose it faster than subQ fat when you go on the right kind of diet. Which kind of makes sense. It’s somewhere not designed for it, so you would think the body would get rid of it faster.

Most people with a lot of subQ obesity will probably ultimately hit their limit of fat storage and begin to store it viscerally, but until that time the fat is less problematic health-wise. The best thing to do is to work to lose the excess fat.

It’s been my experience that a low-carb or ketogenic (ultra-low-carb) diet is the best way to do that in the shortest time.

Then once you lose the weight, you should stay on the same diet pretty much forever. You can veer from it here and there, but you need to get back on the straight and narrow when you start packing on a few pounds.

People tend to think of a diet in terms of a temporary change to provide a certain result. Then when the result is achieved—a new, thinner you—they think, Great, the diet is over. Now let me eat all those things I avoided to lose this weight.

I always ask, If you had high blood pressure, and I put you on a medicine that brought it back to normal, would you be surprised if it went back up if you quit taking the medicine?

Same thing with diet. If a particular diet helps you lose weight, then you abandon it and go back to what you were eating when you were obese, it’s no surprise it will only make you obese again.

You’ve got to change the way you eat. There are a lot of ways you can do it, but if you want to maintain the new slimmer you, you’ve got to do it. That’s another absolute.

Before we leave this section, there is a paragraph in this article that illustrates a point about doctoring that was lost during the entire Covid debacle.

Hammering people with advice to “lose weight!” is misguided. “It’s very clear that there are a lot of people in that category called obese [who] don’t have any signs of disease and live long, healthy lives,” says Lindo Bacon, a physiologist, author, and advocate for body positivity affiliated with the University of California, Davis. Bacon says a relentless focus on weight loss can come at the expense of vital medical care. For example, “My father and I both went to orthopedic surgeons because we were having bad knee pain.” Bacon, whose weight qualified as normal, was offered surgery after physical therapy failed, but Bacon’s father was told only to lose weight. “My father went to his death with knee problems. … He could have benefited from stretching, strengthening, knee surgery,” Bacon asserts with frustration. “He didn’t get that.” [My italics]

In my view, Lindo Bacon is correct here.

Many doctors believe telling people to lose weight is a futile effort, so they don’t bother recommending it. And they often don’t offer their overweight patients the same advise they do normal weight patients.

What they should do is form a team with their patients in a way that both come up with a viable strategy.

The orthopedic surgeon above should have said to Lindo’s father, Here’s the situation. I can send you to physical therapy to try to help your knee pain. And there may be some stretching exercises you can do that might help. And I could even go ahead and operate. But you have the risk of anesthesia (which is not zero), and will end up with a lot of pain and a lot of down time while you’re healing, and some expense. And if you won’t lose weight, you’ll be right back where you are now in a year or so. What do you think? How do you want to move forward from here? I would recommend weight loss first along with the physical therapy. But it’s up to you. It is your knee, after all.

Well, I intended to discuss one more paper, but believe it or not, the power has gone out at our place. And we don’t have a Tesla roof. I don’t know when it will come back, but I want MD to be able to vet this while I still have juice in my laptop battery. If the power stays off, I can send it out using my iPhone as a hotspot.

This is the second time it’s gone off today. They must be working on the damage from all the flooding from a week or so ago. I guess.

Video of the Week

I came across this great video showing one doesn’t have to be slim and trim to be a good athlete. I can only imagine how good this guy might be if he would lose some weight.

One more thing. No paywall this week. I had more people than I anticipated sign up last week after I didn’t put up a paywall. Maybe that’s the secret.

Or maybe it was the realization for some that $1.50 a week isn’t such a steep price to pay for thoughts based on the years of medical education, decades of research reading, hours of finding and dissecting articles, etc that go into bringing The Arrow to press each week.

At any rate, thank you to all of you who have felt it worth your investment.

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