The Arrow #178

Hello friends.

Greetings from Montecito.

If you haven’t read my kid’s comment on last week’s Arrow on the part he played in the Ricki Lake fiasco, you should. Gives his side of the story. He was miffed that I implied he somehow knew the schedule of the RL show by heart.

No real aggravations or personal angst to rant about this week, so let’s get to it.

I Just Can’t Lose Weight No Matter What I Do

Over the past few weeks, I’ve received a handful of emails and a poll response or two along the lines of the above headline. What I’m about to say will doubtless piss a bunch of people off, but I have to say it.

All you have to do to lose weight is not eat.

I’m not being facetious here. At least not entirely. Not eating is a drastic solution, but it will work. Without a doubt. And it even works without exercise. If you don’t eat, you will lose weight. I’ll bet the farm on that one.

So, people who can’t lose weight are eating something. If these same people go on a total fast, they’ll lose weight. Guaranteed.

The strategy then becomes figuring out where between what I’m eating now that is preventing my losing weight and a total fast will get me to lose.

I’m always a bit skeptical when people tell me they can’t lose weight no matter what. I’ve had too many experiences with way too many patients to fall for that.

Let me give you an example.

I had one late-middle-aged lady who came to see me about losing weight. She was maybe 40 pounds overweight and had no medical issues. I went over the diet I thought she should try, which was a low-carb diet. She came back for a recheck in a week or two and had lost a bit of weight. Then her weight loss stalled. It fluctuated up and down a bit at each visit. She was annoyed at me and at the staff, but primarily at me.

I discussed with her going on a protein-sparing modified fast. She agreed to it. She told me she was desperate and would do anything.

She came back for a recheck and had lost a little weight, but not a lot. She then fell into the same pattern as before. Each visit a little up or a little down, but not much change overall.

I sat down with her to go over her program in an effort to see what kind of other changes we might make. When I went into the room, she unloaded on me. She told me the program I had put her on was for crap. It hadn’t helped at all. She had followed it to the letter. And had spent a lot of money for nothing. And she was pissed to the max.

It was kind of a classic case of psychologist Stephen Karpman’s drama triangle, and I was caught up in it. Karpman wrote that there were three personas people could take, usually unconsciously, in any relationship to meet their own psychological needs. The three personas were persecutor, victim, or savior.

The persecutor is someone (or could be a group, or even society as whole) who criticizes, blames, and/or attacks.

The victim is the one who feels helpless and powerless. And obviously a victim.

The savior or rescuer is the person or group who steps in and rescues the victim from the persecutor.

This entire drama triangle can rotate, and with this lady, it rotated against me.

At the start, this lady was the victim. I don’t know who her persecutor was. Her husband? Society demanding thinness? I don’t know. But she was the victim, and I became her savior.

But then as she failed to lose weight, the drama triangle rolled around. She became the persecutor and I became the victim. Problem was, I didn’t have a savior. Or at least I didn’t think so. But as it turned out, fate was my savior.

I spent a lot of time with her during this office visit going over every aspect of her diet. Every question I asked her was answered with “I did everything just as you told me to.” She didn’t cheat; there was no carb creep; she ate all her protein. She did everything I told her. To. The. Letter.

I told her, Okay, let’s make this program a bit more Spartan. I asked her to ditch the one meal she was eating along with her four protein shakes. I told her to use another protein shake in place of the evening meal to see if that would help stimulate a bit of weight loss.

She assured me she would follow my instructions precisely just as she had been doing all along.

As you might imagine, I was dreading her next visit.

But here is where fate intervened.

A few days after this encounter, MD and I went to a late afternoon movie. Somehow, we got the time screwed up and arrived about 30 minutes early. There was a McDonald’s right next to the movie theater, so we went in for a coffee. (Before we started drinking Americanos, we loved McDonald’s coffee. We thought it was the only thing there worth consuming.)

So, we get our coffee and are sitting there in the booth drinking it when who should walk in but my angry patient, who didn’t see me because my back was to her. But MD recognized her. The lady walks up to the counter and orders two ice cream cones.

She then turns and walks out taking a big bite out of one of them. Just as she has it in her mouth, she sees me. She doesn’t say a word, but walks on out. I turn around and watch her give one of the ice cream cones to a man about her age (her husband?), and they both walked away eating their ice cream.

She never came back to see me.

I’ve had versions of this experience a number of times, but never this dramatic. And I’ve had patients who have later apologized for giving me a rough time over the same issues.

Both MD and I had our patients keep diet diaries, so when they came in to see us, we could pinpoint any issues they might be having. (Keeping an honest food diary is a real benefit when you’re trying to make a nutritional change, especially weight loss.) For instance, a common issue was to find patients eating a lot of bananas and/or orange juice. (From which they’d get more than their day’s worth of carbohydrate in a single banana.) When asked, they always responded with, I thought you told me to take plenty of potassium.

Which we did, but we also gave them potassium supplements.

We would sometimes see patients who had perfect diet diaries, yet they weren’t losing weight. I knew that if these particular patients were eating nothing but what they put down in their diet diaries, they would have to lose weight. So I would challenge them. I would say, Okay, here’s the deal. You stay here in the clinic under lock and key for a week, and we’ll feed you only what you’ve put down in your diary. If you don’t lose weight, I’ll give you $5,000. No one took me up on it.

My point in all this is that it is not impossible to lose weight. It can be done. It sometimes just takes a bit of fiddling to figure out what exactly to do to bring it about.

Some people have a much tougher time of it than do others, but it can be done. All those people on the Ricky Lake show I wrote about last week could have lost their excess weight using the proper diet, though it would have taken a lot of effort, a lot of hand-holding, and a lot of time.

Which brings to mind, how do people end up weighing 500+ pounds? The average overweight person gains 30-40-50-60 extra pounds, but they stop well before they hit the 500 pound mark. Yet some people are 500 pounds and gaining. What’s the difference?

In my view, it’s a difference in insulin resistance.

Different tissues become insulin resistant at different rates. This is pretty well established in the scientific literature.

If you develop insulin resistance in muscle—a major consumer of blood sugar—you’ll gain weight at a faster rate than if you develop insulin resistance in your fat cells. Once your fat cells become resistant to insulin (the signal for them to take in fat) you won’t gain additional fat. That’s why some people gain to a point then stop gaining. But if the fat cells remain relatively insulin sensitive and the muscle is resistant which makes the blood sugar go up and with it insulin levels, then you’ll continue to gain weight (500+ and gaining).

If your insulin levels are high because you’ve developed insulin resistance in muscle, then this elevated insulin will shovel fat into your less insulin resistant fat cells right and left. Evidence seems to indicate that as the fat cells expand, the expansion itself begins to create insulin resistance. In other words, larger, expanded fat cells are more insulin resistant than smaller fat cells.

So, ultimately, when insulin resistance of the fat cells sets in for one reason or another, weight stabilizes.

I’m not sure this is an inviolable law, but typically people who become overweight or obese as children do so by increasing their number of fat cells. They are overweight because they have a lot of normal sized fat cells.

People who become obese as adults do so by increasing the size of their fat cells, not simply by increasing their number, although there is probably some increase in number.

It is much more difficult to make normal sized fat cells abnormally small than it is to make abnormally enlarged fat cells return to normal size. Which is why it is more difficult for people who have been overweight from childhood to lose weight than it is for adults who have only gained weight in adulthood to lose it.

I always think about something I read in one of Peter Dobromylskyj’s blog posts last year. He discussed some studies in rodents showing that the GLP-1 agonists people are lining up to take will increase the number of fat cells. Smaller, baby fat cells, but they will ultimately grow. Here is his caution after saying he is sure these drugs will eventually be withdrawn from the market (an assumption with which I agree), but only after millions of people have been on them.

So what will happen to folks with years of adipocyte hyperplasia [growth in number of fat cells], where individual cell hypertrophy has been suppressed? Their very numerous small adipocytes will, without their uncoupling drug, become enormous. People will become hungry as they develop hypertophy of all of those lovely tiny insulin sensitive adipocytes. Oops. It's gonnabe bad, but that's years down the road.

I’m getting a little far afield here from what I began talking about, so let’s get back to fasting and weight loss.

The more fatty tissue one carries around, the greater the response is to fasting. Body fat is the body’s energy storehouse. Glycogen, aka stored carbohydrate, doesn’t amount to much in the great caloric scheme of things. The total stored glycogen amounts to about 500-600 grams in adult males, somewhat less in females. Since 550 grams of carbohydrate provide about 2,200 kcal, stored glycogen represents about a day’s worth of energy.

If you fast, you pretty quickly begin to break down body fat. Some of this fat is burned in the cells and some is converted to ketone bodies, which can replace glucose in many cells. Over time almost all of the energy needed to fuel the body and brain come from fat. A 150 pound person has enough fat to power a walk from St. Louis to New York, so you can imagine how much energy is stored in an overweight person weighing 500 pounds. For example, all those people on the Ricki Lake show I wrote about last week.

But how long would it take to lose weight on a total fast?

A long time. But it has been done.

Here’s the story.

Back in 1965, a guy from Scotland—who weighed 456 pounds—decided he’d had enough, so he committed to a total fast. He checked into a hospital and did so under medical supervision. It took him 382 days to lose 275 pounds. But he did it, and without any real problems. And not only that, he kept it off. Here is his story.

I don’t want to get into all the technical and physiological details of this fast, but if you want to read about it, a study was published a few years later. Here is a copy I stuck in my Dropbox for you.

The point is, if you don’t eat, you lose weight. If you don’t eat for a long time, you lose a lot of weight. So the notion that it is impossible to lose weight is simply incorrect.

Now you may not want to fast for a prolonged period of time, despite the fact that it might be very good for you just like it was for the guy mentioned above. And, believe me, I understand. I wouldn’t want to do it either. I would look for alternative solutions.

A bit over a year ago, I wrote in an earlier Arrow about a study by Klein and Wolfe who fasted young men for three days or gave them IV fat for three days. During both arms of this experiment, good things happened metabolically to the subjects.

The conclusion of the authors after this experiment was that it is the carbohydrate restriction part of the fast that controls the metabolic response to fasting.

In summary, the present study underscores the importance of carbohydrate intake for normal fuel homeostasis. Our results demonstrate that carbohydrate restriction, not the presence of a negative energy balance, is responsible for initiating the metabolic response to fasting. [My bold]

In other words, if you restrict carbohydrates sufficiently, you can achieve the same metabolic response as if you fasted.

If you read the study linked above, you’ll see that the subjects who got the IV fat didn’t lose as much as those who were on the total fast, but they still lost weight. And the subjects getting the full-fat IV got the amount of fat they required to maintain their body mass, yet they lost weight.

Dietary fat is satiating, as is protein. If you follow a diet composed mainly of protein and fat, then you will be satiated quickly. Following such a diet will bring about the same metabolic results as fasting, although the weight won’t come off as quickly.

But long term weight loss should be a marathon, not a sprint.

Now, the one caveat I have about all this is that the 3-day study I linked above was performed on young, normal weight males. The guy who fasted for 382 days was a male and did it under hospital supervision. As far as I know, there are no such studies on overweight menopausal or peri-menopausal women, so I can’t say with certainty that these results would apply to them.

But, based on a lot of years taking care of overweight menopausal and peri-menopausal women, I can tell you that it works for most of them.

And if you fall into this category and a low-carb or keto diet doesn’t work for you, you can try a protein sparing fast, or intermittent fasting. Or if needed, total fasting. I guarantee that will work. It’s extreme, but it will work.

One last caveat: total fasting ought not to be attempted without some knowledge and supervision. If you’re contemplating it, read about it and then find a knowledgeable doctor to supervise your journey. You’ll need to replace fluid (water) and electrolytes (potassium, magnesium, sodium, etc) especially early on. And this caveat goes triple if you currently take any medication for blood pressure or blood sugar.

Whenever I think of a total fast, I always remember a hilarious conversation MD related to me that she overheard in the women’s locker room of a golf club we used to belong to.

First woman: Let’s go out to the bar, meet the boys, and have a glass of wine.

Second woman: I’ve been working on losing weight, and I just cannot lose weight if I drink wine.

First woman: Well, that is just too extreme.

It’s all a matter of degree.

Dermatologists Take the Fun Out of Everything

In my troll through the countless newsletters and news sources I try to read every day, I came across an article on conspiracy theorists. As I was reading along, I came across this paragraph:

These include, but are not limited to, discredited intellectuals who promote race science; butthole sunners who believe that by harnessing the sun’s rays, they live longer; and semen retention enthusiasts, which is a practice that discourages ejaculation as a way to boost testosterone levels. [My bold]

I had heard of semen retention enthusiasts—which I think is way out there—but butthole sunners was a new one for me. So I had to look it up.

Turns out it actually has a formal name, which is perineal sunning. It’s also called anal sunning. In case you’re not up on your anatomy and are wondering, the perineum is the small area between the genitals and the anus.

Don’t feel bad if you didn’t know what this fad is. I didn’t either until I read about it in this article. What’s really strange is when I glanced at the title before reading the article, I didn’t notice butthole sunning was even part of the title.

Apparently there exists a horde of people—a cult, some call it— who believe exposing their nether parts to the sun confers all sorts of health benefits. If you google any of the above terms, you’ll see photos of all kinds of people in all kinds of weird positions in an effort to bare their perineal areas to old Sol.

According to the reports I read from practitioners of the art, a few minutes exposure of these parts reaps the same benefits as hours in the sun with the same parts covered with clothes. I can’t imagine that to be true, but what do I know?

But I can say with total authority that, until I see strong evidence otherwise, you won’t find me nude on my back with my legs spread, feet in the air, and my rear end pointed at the sky.

I have no issue with others going all in (or, more appropriately, all out) on it, because I don’t see any harm in it. And it may well give participants a bit of vitamin D they otherwise might not get. If it weren’t for the chance to expose their parts, these people may never get out in the sun. So, overall, it’s probably a good thing.

But that’s not what the dermatologists say.

Like cardiologists blanch at the term saturated fat, dermatologists do likewise at anything having to do with the sun. If it involves the sun, skin cancer is right around the corner.

Most of the articles I read on the practice had warnings from dermatologists who had been interviewed by the author. In all cases, these dermatologists were against the practice of baring the perineum to the sun.

People who regularly sun their perineum say you should only do it for between 30 seconds and 5 minutes.

But experts view the practice as unsafe.

“The skin of the perineum is some of the thinnest, most vulnerable, and sensitive skin in the body,” Bard [a dermatologist] explains.

Therefore, the biggest worry is the potential development of skin cancer.

“Our skin reacts to UV exposure the same way, whether it’s [via the] perineum or face,” Kormeili [another dermatologist] says. “UV exposure can cause DNA damage that causes skin cancer formation.”

In fact, Kormeili notes that she’s treated skin cancers that have affected this part of the body.

Painful sunburn is one concern. But skin cancer is, of course, the biggest risk.

“This practice is especially worrisome,” says dermatologist Angelo Landriscina, MD. “It compounds on the skin cancer risks presented by the human papillomavirus (HPV) infection.”

HPV, he says, is “a major risk factor” for squamous cell carcinoma (SCC) in the anus and genital area.

Combine the presence of HPV with UV exposure to your perineum, and you could “be creating the perfect storm for the development of SCC.”

Landriscina [yet another dermatologist] also points out that “SCCs that arise in the anogenital region tend to be more aggressive.”

Landriscina adds that they also have “a higher rate of metastasis, meaning they can take root in other organs, leading to serious complications and even death.”

C’mon, man. Give a butt sunner a break.

The most common skin cancer one can get from too much sun exposure is basal cell carcinoma. Basal cell cancers don’t metastasize, and they aren’t deadly. I’ve had half a dozen of them removed. And I still have a couple I haven’t bothered to get treated yet because I haven’t had time.

The sun does age the skin, of that there is no doubt. But the sun also confers a lot of benefits as well. One of which is the production of vitamin D. It doesn’t take the sun long to make a lot of vitamin D if the exposure is over a large area, say, for example, your bare back. In fact, you can get your entire day’s dose of vitamin D if just your face, arms, and hands are exposed for 10-15 minutes per day. If you spend 15 minutes in a swim suit at the beach at midday, you will make ~20,000 IU.

Now all the above is dependent upon your skin color and where geographically you are getting the sun. Darker skin requires more sun exposure as does getting the sun in higher latitudes.

The sun confers all kinds of benefits, which is its positive. Its negative is aging of the skin and minor skin cancers. Here is a chart from a paper by a dermatologist on the benefits of sun exposure.

I’ve put a red rectangle around melanoma, which is a deadly, highly-metastatic, skin cancer. No dermatologist will tell you this, but the sun is protective against melanoma. I think it’s even more protective than the above chart shows.

There are numerous studies showing people who work outside most of the time come down with way fewer cases of melanoma than people who work inside most of the time.

There are two types of ultraviolet light, UVB and UVA. I’m going to make this kind of simplistic, but UVB causes sunburn. You can remember it because of the B for burn. UVB also is what brings about tanning. And the premature aging of the skin.

UVA causes melanoma. Not with just one exposure, but over time.

Here is the kicker.

Many sunscreens protect against UVB only. So people slather on the sunscreen and head for the sun. They keep applying it while they lie on the beach, and they get a bit of a tan. But they get a shit load of UVA. Much, much more than they would get if they wore no sunscreen. Because had they worn no sunscreen, they wouldn’t have spent so much time in the sun because they would have been badly sunburned.

And to top it all off, sunscreens that block UVB also prevent the formation of vitamin D, which requires UVB. An SPF of only 15 will stop something like 98 percent of the vitamin D from being made. I could be a little off here on the numbers, but not by much.

So, smearing on a typical sunscreen ends up making you more susceptible to melanoma while at the same time preventing the synthesis of vitamin D. A sort of double whammy, and low vitamin D in and of itself is a risk factor for cancer.

But you don’t burn.

I don’t want to get into all this right now, but I’ll write more in depth on it later if folks are interested, but many of the chemicals in sunscreens in the US are prohibited in Europe in the same doses used in the US, because, among other things, they are endocrine disruptors. They end up making the sunscreen absorb better, so it isn’t so greasy. But there is a consequence to the convenience.

You can get sunscreens that block both UVB and UVA, and those are the ones I use when I use sunscreen. I am careful to avoid those that have the bad chemicals in them. About the only thing that blocks UVA is something with zinc or titanium in it. The zinc (or titanium) is in micro particles, so it spreads across the skin and provides a barrier to the UVA rays reaching the skin. It also blocks UVB. A lot of people don’t like it because it is more greasy than the other sunscreens, which have one or more of the bad chemicals blocking UVA. I would urge you, if you’re going to use a sunscreen, to always look for a zinc- or titanium- based product to block both UVA and UVB.

I didn’t mean to make this a treatise on sunscreens. I intended to take the dermatologists to task for being overcautious about the sun.

Getting back to our butthole sunners, the dermatologists are kind of going overkill. If you read about the practice of perineal sunning, everything says to do if for from 30 seconds to five minutes max. No one is going to get skin cancer from those exposures. So, I don’t understand why the dermatologists are getting their collective panties in a wad about it.

I would say the sun exposure from the practice would be vastly more healthful in terms of vitamin D production than it would be worrisome about the development of serious skin cancers.

Based on the photos I saw in all the articles I read about butt sunning, there is a lot more skin exposed than just the perineum. So five minutes of the practice—if that’s your thing—would probably provide a healthy dose of vitamin D.

So, what’s the harm?

If you want to expose your perineum to the sun, have at it. Just don’t expect me to join you. I get plenty of sun on the golf course. MD might be game, though. She spends all her time indoors watching reruns of Outlander and writing on her next Caddo Bend novel and her Outlander MD substack. Invite her along. [The bride wishes to correct the record: she walks the beach, too, but does not subscribe to butt sunning.]

A Headline that’s Hard to Believe…But Not Really

Just came across this one from Medscape.

That didn’t take long. At least everyone now understands that loss of muscle mass is a bad thing and that GLP-1 agonists bring it about. But of course, Big Pharma being Big Pharma, the solution is another pharmaceutical. Not increasing protein intake. Or doing strength training.

Before I get into the article headlined above, I need to tell you about a conversation I had a few days ago.

Probably three months ago now, MD and I had dinner with a member of my golf club and his new lady friend. At the dinner, what MD and I did came up. The lady friend told us that her son was taking the Ozempic jabs and doing well. I told her about the risk of muscle mass loss, and she replied that he had been on a ketogenic diet of mainly meat and was doing regular strength training. I told her he was doing everything he could be doing to maintain his muscle mass.

A few days ago, MD and I were at the club for an event, and this lady came up to me (MD was gone to get food from the buffet). I asked about her son, and she told me he was doing great. And that he had quit the Ozempic and was just doing the keto diet and strength training. I asked her why he had quit the jabs when he had been doing so well.

She told me it was because his face had become haggard, and he didn’t like how he was starting to look. Her tale gave me some info I had been wondering about re Ozempic face.

Despite eating a high-protein diet and doing strength training, he still lost facial muscle mass. I was wondering if that would happen even with plenty of protein and strength training. At least in this n=1 it did.

The body is pretty smart. It will sacrifice something unimportant to preserve something more important. In the grand scheme of things, facial muscles aren’t all that important. So, when people get inadequate protein nutrition, they quickly sacrifice facial muscles to preserve other muscles. But apparently do so even if they are taking in plenty of dietary protein. At least in this case.

From the article:

As drugs such as semaglutide (Wegovy) and the dual agonist glucose-dependent insulinotropic polypeptide (GIP)/GLP-1 tirzepatide (Zepbound) are producing unprecedented degrees of weight loss in increasing numbers of people, concern has arisen about the proportion of the lost weight, approximately 30%-50%, that is beneficial lean body mass vs fat mass. While some loss of muscle mass is expected with any rapid overall weight loss, it's not clear what long-term effect that may have on physical function, bone density, and longevity, particularly in older adults with sarcopenic obesity who are at risk for muscle atrophy and frailty. [My bold]

The loss of muscle mass mentioned in the bold above is what I’ve previously described as the muscle mass lost simply because you don’t need as much muscle to move around a lesser overall weight. But these GLP-1 agonists bring about a much greater loss than that. And the folks who prescribe them are realizing that fact.


Several drugs in various stages of development are aimed at preserving or building muscle mass and boosting fat loss when used in combination with one of these medications for weight loss. Trials now underway will need to show improved function — not just increased muscle — and also establish safety, experts told Medscape Medical News.

I’m sure the execs at the pharmaceutical companies are chortling with glee. First they sell you an expensive drug that creates a bad side effect. Then they sell you another expensive drug to prevent the side effect. What a lucrative business model! Next they’ll be getting the government to fund it.

Here’s another sub-headline within the body of the article.

Wouldn’t it be nice, indeed. Especially since they’re selling a drug that destroys muscle mass.

Here’s where that quote comes from:

Endocrinologist Adrian Dobs, MD, professor of medicine and oncology at Johns Hopkins University Medical School, Baltimore, an investigator on both of the Veru-sponsored studies, told Medscape Medical News, "The wishful thinking about these drugs has been around for quite a while, particularly in the cancer population or…in a frail population. The hope was, wouldn't it be nice if there was a drug that built up muscle mass? Certainly, we know that going into the gym does that but looking for some medication had been the goal. The thought was this class of medication would have a muscle-building effect, an anabolic effect without an androgenic effect causing masculinization." [My bold]

The second bolded sentence says it all. “…we know that going into the gym does that but looking for some medication had been the goal.”

Everyone wants to take the easy way out. There are all kinds of advantages to strength training besides gaining or maintaining muscle mass. Gaining strength being one of the primary benefits. But there are others such as increased flexibility, increased blood flow to the muscles, increase metabolic efficiency of the muscle (another term for aerobic conditioning), and increased bone strength and density (as a function of the muscle pulling against the bone). Who knows if any of these other important benefits would be included were muscle mass made to simply appear as an effect of some pill. Or shot. Or whatever.

If I seem a bit tetchy on the subject, it may be because I just put in the effort to do my own brutal workout with the Big Boy bands. I hate it in contemplation, but I love it when it’s over. One of the sayings I read or heard somewhere (and I can’t remember where) that always motivates me to get over the hump and workout is this one. “You can only coast when you’re going downhill.”

And do these drugs cause side effects? Apparently so. They’ve been linked to cardiovascular problems and blood clots. Here’s what one of the docs, who is a major promoter of GLP-1 therapy, had to say about it.

"So, we have to also focus on 'first, do no harm'. A lot of these muscle-promoting medications have been associated with increased risk of other things. So, it is going to take a lot of time and testing to be sure they are safe. While I am supportive of research to look into these risks vs benefits, we have to be mindful of the risks and recognize that in most cases of weight loss in people with obesity losing some lean mass is acceptable and the benefits of fat loss outweigh the risks of lean loss, especially if people are doing resistance exercise and maintaining strength." [My bold]

Prior to her mentioning the above, she discusses the health benefits of the loss of fat that occurs with GLP-1 treatment. She basically says, Sure, you’ll lose some muscle mass, but that pales in comparison to the reduction in diabetes, heart disease, and all the rest. But what she fails to mention is that no one knows how long people can stay on these drugs.

And we pretty much know what happens when folks go off of them: They regain their lost weight. As fat.

So both fat and muscle get lost. But the regain is mainly fat, because it is difficult to regain lost muscle mass. And don’t forget Peter’s warning from above. If these GLP-1 agonist drugs truly do cause people who use them to make more fat cells, there will really be a price to pay in terms of weight gain.

You can read through the list of drugs under development to increase muscle mass or prevent its dissolving under the solvent of GLP-1 in the article linked above. But it will be quite a while—if ever—before these drugs get approved. I wouldn’t hold my breath.

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Time for Some Books

I’ve been reading a new book on the difference between Bayesian and frequentists analysis. Titled Everything Is Predictable: How Bayesian Statistics Explain Our World, the book is an excellent primer on basic statistics that delves into the two primary types of analysis used in science today. Neither is perfect for everything. It’s all in the knowing which to use for what. The book is well written and an easy read for those interested in such information. I am the perfect customer and am about halfway through the book. Highly recommended.

While I’m at it with the books, I’ve got to admit that I’ve been remiss. I’ve been touting End Times by Peter Turchin as my favorite book of 2024, so far. And it is a wonderful book; it’s a futuristic look at what could happen with elite overproduction. In my eagerness to get everyone to read this book, I’ve overlooked another tremendous book. I’ve mentioned it, but not as a favorite for this year.

I just picked up Georgia Ede’s book Change Your Diet, Change Your Mind to look something up and noticed all of my underlinings, highlights, and notes. So I started flipping through it. Made me remember all over again what a fabulous book it is. I can’t believe I haven’t already put it on the 2024 books of the year list, but I am now. I need to give it its official picture, too.

Do Tattoos Cause Lymphoma?

Okay, I’ve got to go over one of the stupidest studies I’ve come across that hasn’t come out of China. This one comes from Sweden, of all places.

Before I get into it, I’ve got to disclose that I have no tattoos. Nor do I ever plan on getting one. In fact, I would be vastly more likely to be found sunning my perineum than I would be found with a tattoo. And I don’t plan any perineal sunning anytime soon. So, let’s just say I’m not biased by a positive predisposition on tattoos.

You can tell this study is a loser simply by how it was presented in the press release from Lund University, the Swedish institution where the study was done. “Possible association between tattoos and lymphoma revealed” screamed the headline.

One weasel word in a headline is enough to tell what’s going on. But two weasel words is a dead giveaway. In this case we have both “association,” a major weasel word indicating an observational study, coupled with “possible.” So we have one weasel word modifying another weasel word. Jesus wept.

Now you might assume—I certainly would—that tattoo parlors may not be the most sterile places in the world. And homemade tattoo applications would probably be even less sterile. I don’t even want to contemplate the degree of sterility in which prison tattoos are done.

Given this lack of sterility, one might wonder what in the heck kinds of bugs and other crud would be injected along with the tattoo ink. And anyone with good sense may well assume that injecting all kinds of unknown stuff into your skin and bloodstream could cause various acute and/or chronic insults to the immune system of the tattooee (is that a real word?). And such immune insults could well give rise to other health problems over time. Maybe even cancer.

(Again, I would gladly accept the risks of baring my butt to the sun for five minutes before I would take on the risk of baring any part of me to a tattoo artist.)

So it would be a reasonable thing to study. Do people with tattoos get more cancer?

The only way to really do it accurately would be to find a bunch of people who want to get tattooed and randomize them into two groups comparable in sex and age and disease status. Then pay for the tattoos for one group and pay the other not to get tattooed. Then wait years and see what happens.

But the easier way is to gather a number of people who have been tattooed and compare them with a similar group who have not been tattooed. Then look at the rates of whatever disorder you’re looking for in both these groups. If those with tattoos have whatever it is at greater rates, then you can hypothesize that tattoos may have caused the issue.

Right off the bat you can see the problem here. People who get tattooed are different from people who don’t. Not everyone rushes down to the tattoo parlor and has themselves decorated. People who get tattoos doubtless have a different mindset than those who refuse to.

I don’t know this for a fact, but I would bet people who line up to be tattooed are probably more likely to drink, smoke, do drugs, and be more reckless in general than those who don’t get tattooed. A broad generalization for sure, but if true, that’s a confounding issue. If the people who get tattooed have more disease, is it because they have other issues or habits that might predispose them to disease?

The researchers who did the study at Lund University interviewed 11,905 people. Of this group, 2,938 had been diagnosed with lymphoma at some point between the ages of 20 and 60. Not all the people recruited for the study filled out the questionnaire, but of those who did 1,398 apparently had lymphoma. Of the group who did not have lymphoma, 4,193 answered the questionnaire. As it turned out, 21 percent of those with lymphoma were tattooed, while only 18 percent of those without tattoos had lymphoma.

“After taking into account other relevant factors, such as smoking and age, we found that the risk of developing lymphoma was 21 percent higher among those who were tattooed. It is important to remember that lymphoma is a rare disease and that our results apply at the group level.

I can’t figure out, given the data provided, how they came up with a 21 percent higher risk for those with tattoos. I can’t make the numbers work out that way, but I don’t know how they controlled for smoking and age. I’m sure it’s a relative risk, which is meaningless anyway.

One of the things they did discover I found to be interesting.

A hypothesis that [the] research group had before the study was that the size of the tattoo would affect the lymphoma risk. They thought that a full body tattoo might be associated with a greater risk of cancer compared to a small butterfly on the shoulder, for example. Unexpectedly, the area of tattooed body surface turned out not to matter.

To my mind, that would deflate the entire debate. Or maybe not. Maybe those who could afford the full body tattoos were more health conscious in other ways.

The whole study doesn’t amount to a hill of beans, and even the researchers say that. But it gives them info to delve further into the hypothesis that tattoos cause lymphoma and maybe other cancers. They’ll have to do better studies to make any kind of a valid determination.

What amazes me is that this study got the publicity it did. I saw it mentioned in a half dozen different places. The data sucks. The analysis sucks. But I guess the public interest is there since so many people are tattooed nowadays. It’s just another example of the press jumping all over a worthless study to get eyeballs.

Sad, as Trump would say.

Odds and Ends

Newsletter Recommendations

I haven’t had time to browse many newsletters this week, so I don’t have a recommendation other than MD’s OutlanderMD Substack. Any Outlander fans out there should sign up.

I did read something a couple of days ago in The Morning Brew, which is a free newsletter I read almost every day. The folks who publish it always have a contest at the bottom. One of the contests that shows up from time to time is a ‘guess this product from looking at the ingredients’ one. Here are the ingredients; you guess the food. It’s listed after the Video of the Week.

Ingredient list: Enriched Flour (Wheat Flour, Niacin, Ferrous Sulfate, Thiamin Mononitrate, Riboflavin, Folic Acid), Tomato Puree (Water, Tomato Paste), Imitation Mozzarella Cheese (Water, Palm Oil, Modified Corn Starch, Vegetable Oil [Soybean, High Oleic Soybean And/Or Canola Oil], Rennet Casein, Salt, Sodium Aluminum Phosphate, Potassium Chloride, Citric Acid, Guar Gum, Potassium Sorbate [Preservative], Sodium Citrate, Sodium Phosphate, Titanium Dioxide [Artificial Color]), Water, Vegetable Oil (Soybean, High Oleic Soybean And/Or Canola Oil). Contains Less Than 2% of: Rehydrated Fat Free Mozzarella Cheese (Water, Skim Milk, Cheese Cultures, Salt, Enzymes, Citric Acid), Sugar, Modified Corn Starch, Salt, Modified Whey, Defatted Soy Flour, Spice, Methylcellulose, Modified Tapioca Starch, Onion Powder, Dextrose, Rehydrated Enzyme Modified Cheese (Water, Milk, Cheese Cultures, Salt, ·Enzymes), Maltodextrin, TBHQ (Preservative), Natural Flavor

Yum, yum. Sounds delicious, doesn’t it?

Video of the Week

Todays video is a fabulous rendition of our national anthem sung by a beautiful Navajo girl in the equally beautiful Navajo language. Really spectacular.

MD and I have spent a fair amount of time among the Navajo when we lived in Santa Fe. We’ve been to Window Rock, a Navajo community, a number of times. It’s a pretty, little, dusty town in the high desert of New Mexico.

As the videographer scans the audience, you can see there is an obesity problem with the Navajo. I’ve eaten my share of fry bread and mutton stew, which is kind of a staple. It’s not low-carb, but I ate it anyway. When in Rome and all that. The Navajo have been victimized by the Western diet. I have a valuable print of a bunch of Navajo from the 1880s after a kill. Unfortunately, it is packed away with my library. But since it’s a famous photo, I was able to find a copy online.

Big difference between then and now. I suspect that had they all remained on their native diet, all the people in the stands of the gymnasium would look like the folks above. But don’t think about this now, just listen to this girl’s gorgeous voice.

FOOD QUIZ ANSWER: The food made from the ingredients listed above is Totino’s Pizza Rolls (cheese). Something I’ll be avoiding. Which should be easy since I don’t even know what they are.

Time for the poll, so you can grade my performance this week.

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That’s about it for this week. Keep in good cheer, and I’ll be back next Thursday.

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The information provided in this newsletter and on this site is for educational purposes only and does not substitute for professional medical advice. The author is unable to diagnose, advise, or make medical recommendations for individuals via the internet.

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