"Death Book" claims vs what really happens

Teach us to number our days, that we may apply our hearts unto wisdom. Psalm 90.12

These days wisdom seems in short supply in the health-care debate: to wit the August 18 Wall Street Journal article by Jim Towey where he criticizes the VA booklet, "Your Life, Your Choices," which he dubbed "The Death Book for Veterans." Towey's allegations are amply refuted in the Huffington Post's response, "How Conservatives Got the Facts Wrong on Their Latest Obsession," so I won't go into the details here. I would just like to make a personal observation about the VA.

A close family member has been a VA patient off and on for over a decade. He will be 74 next month and has been in very poor health for years. Thanks to the VA, he has had open-heart surgery, countless tests, and repeated hospitalizations for syncope, ischemia, esophageal disorders, psychiatric episodes ... I don't know the half of it. He also has dementia. His monthly expense on medications is astronomical. If it weren't for the VA, he would have died years ago.

Now I'm going to be painfully honest here: I have sometimes wondered if the VA is spending too much on him. He often refuses to follow his doctor's orders. He is unhappy because he can no longer drive, operate machinery, or work on the many projects he began before his medical problems began. He does not seem to want to live. But live he does, and at enormous public expense.

I am not an ethicist, and I find end-of-life issues confusing. I do not believe that assisted suicide is ever justified (though in some cases, one can sympathize), but face it: we are all going to die. To what lengths should we go to preserve life? When is it appropriate to withhold further intervention and make the patient comfortable? When, on the other hand, should all available medical tools be employed?

I don't know what the VA should be doing for my relative, but I do know what they are doing. They are doing everything in their power to keep him alive, and never once have they suggested letting him die. If they are erring, it is on the side of life.

Review: The Healing of America

For an informative and interesting explanation of health care around the world, read the transcript or listen to the recorded interview of T.R. Reid by Terry Gross in Monday's "Fresh Air."

Reid, formerly a reporter for the Washington Post, is the author of The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care, published just last week. After describing health care models in various developed countries, he says that in the United States we have four models operating simultaneously: Britain, Germany, Canada, and Malawi.

The Neffs are currently enrolled in the German model, will be in the Canadian model in about four years, and hope the publishing industry remains strong enough to allow them to avoid the Malawian model in the meantime.

Reid also had an excellent article in Sunday's Washington Post: "Five Myths About Health Care Around the World." It should be required reading for every American who thinks our system is better than all the others.

P.S. (September 8): I've now read the whole book. Click here to read more about it.

Review: Half the Sky

If you liked Greg Mortenson’s Three Cups of Tea or Tracy Kidder’s Mountains Beyond Mountains, here’s another great book for you: Half the Sky by Nicholas Kristof and Sheryl WuDunn. I haven’t read it yet; it won’t be published until September 8. But I just read a lengthy essay adapted from the book in the New York Times Sunday Magazine, and it was stunning.

The authors explain their title:

“Women hold up half the sky,” in the words of a Chinese saying, yet that’s mostly an aspiration: in a large slice of the world, girls are uneducated and women marginalized, and it’s not an accident that those same countries are disproportionately mired in poverty and riven by fundamentalism and chaos.

Kristoff is an op-ed columnist for the New York Times; WuDunn, his wife, “is a former Times correspondent who works in finance and philanthropy.” Together they won a Pulitzer prize for their reporting on the Tiananmen Square massacre.

Their article, “The Women’s Crusade,” is full of information that I—a well fed, well educated, adequately doctored late-middle-aged female—find shocking. The article’s fascination, though, comes not so much from the data as from the stories of women who changed their lives and brought hope to their families, their villages, and beyond. There’s no way to summarize these moving stories: you’ll want to read the article and, soon, the book. But here are some of the facts and figures that fuel Kristof and WuDunn’s pursuit of a better life for millions of women.

In many countries of the world, it is dangerous to be female.

• In 1989, “as many infant girls died unnecessarily every week in China as protesters died at Tiananmen Square.” This was because they did not receive the same medical care as their more valued brothers.
• “In India, a ‘bride burning’ takes place approximately once every two hours, to punish a woman for an inadequate dowry or to eliminate her so a man can remarry.”
• “More girls and women are now missing from the planet, precisely because they are female, than men were killed on the battlefield in all the wars of the 20th century.”

When women are powerless, suffering increases: for their families, their countries, the whole world.

• A study of Ivory Coast families showed that when men control household money, they spend more on alcohol and tobacco; when women control the money, they spend more on food.
• “Gender inequality hurts economic growth.”—a Goldman Sachs research report
• “Some scholars ... believe the reason Muslim countries have been disproportionately afflicted by terrorism is not Islamic teachings about infidels or violence but rather the low levels of female education and participation in the labor force.”

Aid that provides education, medical care, and jobs for women is often more effective than any other kind of assistance.

• “Women are the key to ending hunger in Africa.”—the Hunger Project
• “Investment in girls’ education may well be the highest-return investment available in the developing world.”—Larry Summer
• In Kenya, "the approach that raised student test scores the most was to offer girls who had scored in the top 15 percent of their class on sixth-grade tests a $19 scholarship for seventh and eighth grade (and the glory of recognition at an assembly)." Nineteen dollars!
  

I enjoy the relationship-driven fiction that has become so popular with book clubs over the last decade. I appreciate some of the personal spirituality and self-help books that aim to make us whole. But if you or your reading group are looking for a book that will hold your attention, turn your focus away from yourself, and maybe even suggest small things you can do that will make a big difference--read "The Women's Crusade" and see what you think of Half the Sky.

P.S.: Sensible eating

(Click to start with part 1 of this review.)

Last night Mr Neff and I joined friends for a lovely Indian meal followed by peach pie, cherry pie, and vanilla ice cream. Aware that I had just posted an article urging people to refrain from white flour and sugar, I enjoyed every bite. Hypocrisy never tasted so good.


Blanche at 22

I thought again of my mother, whom (in part 2 of this never-ending review) I described as a sensible person who never gave up desserts. She ate modest portions, though, and she rarely ate bread with meals. I went to this website and put in information for my mother as she was when I was 12 years old and beginning to think about body shapes and sizes: 50 years old, 5'8" tall, 150 pounds, 16 hours resting and 8 hours of very light activity a day (Mother was no athlete). The calorie requirement to maintain her weight: 1617.





Blanche at 72

Changing nothing else, I gave her a weight of 130 pounds, the weight she would have preferred (and indeed the weight she easily achieved once her doctor told her to cut out most dietary cholesterol and start walking three miles a day). Calorie requirement: 1517. A reduction of only 100 calories a day lowered her set point by 20 pounds!

I suppose Mother could have given up white flour and sugar--i.e., desserts--when she was younger and dropped a couple of dress sizes. Since it takes about 3500 calories to add or lose a pound, 100 fewer calories a day would have produced a painfully slow weight loss of just under a pound a month. In two years' time, though, she would have reached her new weight of 130. But would that have been a good idea? She enjoyed her food. She was not a hypereater. She was not overweight. She looked nice. She didn't spend a lot of time thinking about weight or calories. She was happy. I stand by my original assertion: for her, sensible eating was second nature.

People who need to give up white flour and sugar are people for whom sensible eating is not second nature--inveterate snackers, people who binge, hypereaters, people who can't stop with small portions--or people who eat sensibly but who really would rather weigh less than eat sweets and snacks.

For these people, I offered my basically Mediterranean approach to eating in part 4 of this review. If you're more carnivorous than I am, I suggest the South Beach diet instead. Forget all the talk about the wonders of protein and the horrors of carbs: by the time South Beach dieters are at phase 3, they are eating plenty of wholesome carbs. The main difference between South Beach and my approach is that South Beach allows unlimited meat but limits fruits and starches, while my list limits meat but allows unlimited fruits and whole grains. Neither approach allows junk food--what Kessler calls hyperpalatable foods--and that is why both approaches work.

Review: The End of Overeating, part 4

Click to start with part 1 of this review.

"New learning can stick only when it generates a feeling of satisfaction. We can't sustain a change in behavior if it leaves us hungry, unhappy, angry, or resentful."

--David A. Kessler, The End of Overeating (206-7)

In part 5, "Food Rehab," Kessler offers ideas for what he calls "just-right eating." Figure out how much food you need to eat in order to stave off hunger pangs for four hours, and learn what kinds of foods satisfy you the longest.

Essentially, that means a diet based largely on lean protein and whole grains or legumes, supplemented with fruits and nonstarchy vegetables. On a typical day meals might include an omelet for breakfast; a grilled chicken sandwich for lunch; two snacks, such as a piece of cheese and a cup of fruit; and fish with leafy greens for dinner.(214)

Your diet must be personalized, Kessler goes on to say. He knows people who are happy with "a few strips of bacon or a small portion of cheese for breakfast, a plain, reasonable-size hamburger for lunch, and a medium serving of pasta and salad for dinner" (214).

Well, God bless 'em every one, but to me those meal plans sound not only awfully stingy but downright unhealthy. The first example includes only one vegetable--and if by leafy greens he means lettuce, that vegetable was mostly water--and one serving of fruit. The second example has one veg--or possibly two, depending on the size and composition of the salad--and no fruit at all.

Besides, the meals are mostly beige. Where are the bright red and yellow tomatoes, the purplish beets, the yellow-orange butternut squash, the deep orange yams, the bright green broccoli, the red-veined chard, the green and red and orange and yellow peppers, the red and purple plums, the bright red strawberries and soft red raspberries? Where is the joy?

For conditioned hypereaters to turn into just-right eaters, rules and structure are necessary--Kessler is right about that. He just needs to pay more attention to what he puts on his plate.

My favorite way of eating is much like his, but with the order reversed, and that makes all the difference in the world. I eat mostly fruits, vegetables, whole grains, and legumes, supplemented with lean protein, a splash of wine, and a dab of olive oil. Yep, it's the famous Mediterranean diet, though since most people think of a diet as a temporary privation of good things, I'd rather call it the Mediterranean way of life. It includes so much more than food. Think fresh ingredients, attentive preparation, relaxation with family and friends, delight in flavor and texture and color.

As Kessler repeatedly says, you'll need to come up with a program that works for you, with your own structure, your own rules. Just don't call it a diet--it's your new and joyful way of life.

Here are my ten commandments for just-right eating:

Dos

• Eat all the vegetables and fruit you want. Get them fresh and eat them with their skins (unless, of course, your personal favorite is bananas). You can cook the veggies and add salt and pepper and a tiny bit of olive oil, if you want to.
• Eat all the bread and pasta and rice you want--as long as it's 100% whole grain. If whole wheat bread is too heavy for your taste, try white whole wheat flour (it's actually light tan).
  
• Get your protein from fish or poultry (skinless), nuts, beans, eggs, and plain yogurt. You can have cheese if you can keep it to an ounce or less. Keep portions of fish and poultry small--3 or 4 ounces, about the size of a deck of cards. Fill the rest of the dinner plate with whole grains and vegetables. Make it as colorful as you can.
• Compensate for quantity with quality. Buy that $10/lb. chicken breast from a hen who spent her short-but-happy life in the open air, or that $15/lb. filet of wild Alaskan salmon. Eat half as much as you used to, and your budget won't be affected. Eat twice as slowly, and you'll double your enjoyment.
• Prepare simple foods from scratch: fresh fruits and vegetables from local growers or your own backyard. Home-baked bread. Extra-virgin olive oil. Once you get the hang of it, you'll find that this is just as quick and easy as buying pre-cooked food under plastic--and it tastes so much better.
  
• Eat fresh fruit for dessert. Top it with a dollop of Greek yogurt, if you like.

Don'ts

• Generally avoid foods that contain white flour, white rice, or sugar. They just make you hungrier. (This is easy to do at home, but it can take determination to bypass the bread basket at a restaurant. Indulge only if you really can quit after just one.)
  
• Don't use artificial sweeteners. They don't have calories, but they keep those brain circuits firing--the ones that say "Eat more! more! more!"
• Don't drink many of your calories. Fruit juices are not as good for you as fruits. A glass of milk or wine with a meal is fine, but don't overdo it.
• Don't eat junk food between meals. If you feel hungry, drink a glass of water. If that doesn't work, make your snack just as healthy as what you eat at mealtimes.

That's my easy and satisfying program. It is never easy to change eating habits, and Kessler offers invaluable advice on how to recondition our brains. He also offers encouragement that it can be done, and that the change can be lifelong.

For further inspiration, read Mireille Guiliano's French Women Don't Get Fat: The Secret of Eating for Pleasure, or Richard A. Watson's The Philosopher's Diet: How to Lose Weight and Change the World, or Michael Pollan's In Defense of Food: An Eater's Manifesto.

Click to go to a P.S. on sensible eating in which I confess my hypocrisy and offer an alternate plan.

Review: The End of Overeating, part 3

(Click to start with part 1 of this review.)

I've learned to recognize overeating in restaurants all over America. It's not hard, because people who have been conditioned to overeat behave distinctively. They attack their food with a special kind of gusto. I've seen them lift their forks, readying the next bite before they've swallowed the previous one, and I've watched as they reach across the table to spear a companion's french fries or the last morsel of someone else's dessert. Certain foods seem to exert a magical pull on them, and they rarely leave any on their plates.

As I watch this kind of impulsive behavior, I suspect a battle may be taking place in their heads, the struggle between "I want" and "I shouldn't," between "I'm in charge" and "I can't control this." In this struggle lies one of the most consequential battles we face to protect our health. (ix)

So begins former FDA commissioner David A. Kessler's The End of Overeating: Taking Control of the Insatiable American Appetite. After describing how our brains rewire themselves in response to tantalizing concoctions of sugar, fat, and salt, he shows how the food industry offers us more and more of the taste combinations we crave, to the point of completely changing our eating habits. "For most of human history," he writes, "we survived on unadorned animal and vegetable products. Now we eat mostly optimized and potent foods that bear little resemblance to what exists in nature" (137).

In part 3, "Conditioned Hypereating Emerges," Kessler shows how certain foods stimulate the brain circuits that are active in addiction, how our eating behavior sets up powerful stimulus-response loops, how "focusing single-mindedly on not eating eventually pushes us to eat more" (156), how conditioned hypereating is dramatically increasing among preschoolers, and how

a breakdown in meal structure, with the distinction between meals and snacks increasingly blurred, ... promotes increased consumption and, ultimately, conditioned hypereating. It becomes a self-perpetuating cycle, with conditioned hypereating spurring a further breakdown in meal structure as out-of-control eaters pursue every opportunity to consume food. (174)

Then what can a conditioned hypereater do (I ask, my mouth full of salted peanuts)? In part 4, "The Theory of Treatment," Kessler offers a behavioral response:

• Be aware of the cues. "Intervention begins with the knowledge that we have a moment of choice--but only a moment--to recognize what is about to happen and do something else instead" (182).
• Substitute competing behaviors for habitual responses. "To compete successfully with old habits, this competing behavior needs to be planned before you encounter a cue. You need to know exactly how to respond when your brain receives an unwanted invitation" (187).
• Change the way you talk to yourself about food. "Instead of 'That pint of chocolate ice cream looks really good to me; I'll have just a few bites,' we can say to ourselves, 'I know that I can't have one bite, because it will lead to twenty'" (187).
• Get yourself a good support system--though "if your support system does not reinforce your goals, you're better off going it alone" (189). (Click here for an interesting article about how friends influence teens' eating.)
  
• Make up rules to guide your behavior. "Setting rules helps us make the steps of habit reversal real. Rules provide structure, preparing us for encounters with tempting stimuli and redirecting our attention elsewhere" (190).
• Change your emotional response to food stimuli. "When you perceive hyperpalatable food as negative--and place that recognition in your working memory so you can access it quickly--you're better equipped to interfere with the automatic response and make healthier food choices" (201).

Kessler warns that, although we can change our behavior, "our vulnerability to the stimuli doesn't simply disappear. We never fully unlearn earlier responses" (182). Still, we can create new habits in place of old, gradually diminishing the old habits' insistence. We can learn to eat in a way that satisfies hunger, makes us feel good, and is thoroughly enjoyable.

In Part 5, "Food Rehab," Kessler makes an important observation: "The only eating plan that will work for you is one built around the personal likes and dislikes you have accumulated over a lifetime" (214). Apparently my lifetime likes and dislikes differ markedly from Kessler's: his sample meals sound like what most people call diets, and he pays insufficient attention to the joy and beauty and delight that really good food evokes.

I like Kessler's analysis of America's overeating problem, and I like his discussions of brain chemistry and behavioral conditioning. I'm finding it very helpful, when nearly seduced by the image of going downstairs and eating coffee ice cream right out of the carton, to say to myself: "Hey, wait. Eating ice cream won't satisfy this craving you're feeling right now. It will just make you want more. And more. So if you start eating it, either you'll stop while you're ahead and feel even more frustrated because you still want more, or you'll keep on eating and eating until it's all gone--and you know how bad you'll feel if you do that. So why not just go across the hall to the bathroom and get a glass of water instead ..."

Actually, I've condensed that whole message into "Ice cream, no. Water, yes." It seems to be working.

But I don't much like Kessler's frugal eating plans. Food is more than fuel. So I'm going to add another installment to this review later this week and describe my own easy-to-follow, riotously colorful, abundantly delectable way of eating. Hey, I like it. But if you don't, Dr. Kessler gives you permission to make up your own plan.

Click to go to part 4 of this review.

Review: The End of Overeating, part 2 (a digression)

(Click to start with part 1 of this review.)

The picture on the left shows my maternal grandfather, aunt, and grandmother in the mid 1920s, when my aunt was a young teenager. My daughters dubbed these three "the sturdy ones."

The picture on the right shows my aunt in 1932, the year she turned 20 and got married. Slender, beautiful, and always impeccably dressed, she would never again be an ounce over fashionable.

Yo-yo dieting was not for my aunt. When she lost weight, she lost it for good. But this is not a success story. It is a tragedy.

Tired of being fat, Bessie decided to reinvent herself. As my mother told the story, her sister simply stopped eating. I don't know how long it took or how much weight she lost, but in a fairly short time she plunged from plump to svelte.

She also lost her hair, her eyebrows, her fingernails, and her teeth.

Back in the 1920s people weren't talking about anorexia, and I don't know from my mother's description if Bessie fit the description. To my knowledge, she did not have a distorted self-image, nor did her weight ever go dangerously low. She had a goal and she achieved it, though at the cost of her health. Once she reached her desired size, she started eating again. Her hair and fingernails grew back. She penciled on new eyebrows. She ordered a set of teeth from her dentist.

Unfortunately, her crash diet did not change her eating habits. To use David A. Kessler's term in The End of Overeating, she was still a "conditioned hypereater." Yet she had no intention of ever being fat again. So Bessie, a determined woman, came up with her own weight-maintenance plan. She ate whatever she wanted, and then she excused herself for a few moments in the bathroom. It worked like a charm.

Back in the 1950s when I learned about my aunt's post-prandial pukes, people weren't talking about bulimia. Aunt Bessie seemed normal enough. She was a wonderful cook, she was slender and beautiful, she had a wardrobe to die for.

As it turned out, that's exactly what she did.

The doctors couldn't figure out what was ailing her when she took to her bed in the 1960s. As she grew weaker, her husband flew her hundreds of miles to an excellent teaching hospital for tests. "Failure to thrive" was the best they could do. She didn't eat. She grew thinner and thinner. When she spoke or smiled, her false teeth clattered.

In 1969, at the age of 56, she died, leaving a husband, two children, and approximately 25 linear feet of clothes closets packed with dresses, furs, and shoes.

-------------------------------------------------

I don't believe in diets. Most dieters lose a few pounds, gain them back, gain some more, and then try a different diet. A few dieters like my aunt go off the deep end and never come back.

My mother couldn't help bringing up Aunt Bessie when, at age 16, I went to France for a year and gained 15 pounds from eating 100 grams of chocolate every day. She couldn't help bringing her up again a few years later when I refused desserts, bread, and second helpings and lost three dress sizes in a few months. I don't know what Mother would have said if she'd known that several times in college I literally tossed my cookies (a whole bag of sugar cookies devoured in one sitting can make one want to do that).

She didn't really need to worry that I was going to copy my aunt. Anorexia and bulimia do not appeal to me. I far prefer my mother's philosophy: "I'd rather have a little tummy and eat what I like," she once told me, "than be slim and have nothing but grapefruit and cottage cheese for lunch." Mother sometimes wished she had flatter abs and a smaller dress size, but she was never overweight, she never dieted, and she never gave up desserts. If I fretted about gaining a couple of pounds, she'd say, "Don't eat between meals," or "Remember that the second bite tastes just like the first." For her, sensible eating was second nature.

In parts 3 and 4 of The End of Overeating, Kessler explains how conditioned hypereaters--not necessarily people like my aunt who have eating disorders, but people like me who can't resist chocolate and cashews and ice cream--can break bad habits and become sensible eaters. Superhuman feats of willpower, he says, are not required, nor is giving up everything that tastes good. I'll say more about his approach later this week. Or maybe you should just read his book.

(Click to go to part 3 of this review.)