Fasting: A physical challenge you can do while sitting on the sofa

Since reading a bit about diet and nutrition and fasting, I thought it would be fun to try a proper fast myself. Firstly I think it’s probably a pretty useful treatment for type II diabetes and I wanted to see what it was like to see if it’s something I could recommend. Then, Tim Ferris’s podcast was quoting Seneca (I think), saying the way to not fear being poor, was to live as a poor person for a week, eating simple food and wearing plain clothes, so (summarising) that makes fasting a philosophical exercise. And Herman Hesse’s Siddhartha also described the importance of being able to fast so that, not needing to be busy chasing after food, you can sit back and let opportunities come to you. I haven’t read the novel, but I came across that passage somewhere.

So I wanted to try fasting too.

I started small. I did a few one day fasts on Sundays in the first half of 2017. I was thinking about it quite a bit but I got started almost accidentally, I decided to not eat till 12, I ended up going for a walk in the park at that time so I missed out on eating lunch, and while walking I felt so well and energetic, that I just carried on for the rest of the day.

As background, I should point out that I don’t have any health issues myself, I’m not diabetic and I’d been eating low-carb high-fat for four years at that point. I.e. replacing bread, potatoes, rice and pasta with vegetables, eating the full fat version of food, but then sticking to this only around 85% of the time. So I’m probably more adjusted to burning fat than the average person.

After that start I carried on with one day fasts on Sundays and these were reasonably easy, though I did have a tendency in the evenings to remember that the local shop which is open till late and I had to remind myself that I wasn’t not eating because I forgot to buy food, I was not eating deliberately.

Then in August 2017 I tried a five day fast. I didn’t know what the effect would be and I was afraid I might faint at work, so I waited till I had time off. I initially intended to do three days, but the book on fasting I bought said the first three days were the hardest and there was no point stopping there and in their clinic they only recommended 7 or 14 day fasts, so I carried on! My stop time was defined as the day before work as I had no clue how my body would respond to eating again. The book was Jason Fung and Jimmy Moore’s The Complete Guide to Fasting.

So I ate nothing whatsoever for three days, but drank plenty of  water and had my normal amount of black coffee, i.e. one or two cups a day. On the fourth and fifth days I also included bone broth. I boiled up two or three bones for hours on end and added veg to the mix. However, I was very careful to filter out any solid food, more for the principle of the thing, as there is plenty of fat in bone marrow, so I was getting some calories there, as well as, I assume, plenty of minerals. These weren’t marrow bones though (i.e. the bones were narrower) so there was less fat.

I can’t work out if my five day fast was easy or hard. In some ways it was easy, I wasn’t too hungry, I could happily watch other people eat (I only tried it twice), I wasn’t cold, I didn’t feel the slightest bit faint, I felt pretty well. In some ways it was hard, I felt slightly under the weather, if you imagine a mild cold I’d say I felt half as bad as that. Without feeling hungry as such, I spent the evening of the fourth and fifth days imagining how much I would eat on the sixth day, though in the morning of the sixth day I felt fine and didn’t eat till an hour after waking up. Of course I saved a bit of time and money on eating.

I actually found the first thee days easier than the second two days though. By the fourth day I was getting pretty peckish and as my fasting book recommended bone broth I did make and eat that. I did eat the broth with quite an intense concentration, which was funny to ‘watch’.

When I started eating again I didn’t do anything complicated. I started with a small version of my normal breakfast. Normally I have two eggs fried in a lot of butter and this time I had one egg fried with very little butter (I have a vague impression fat is bad for delicate stomachs). I felt really fine and normal and two hours later I had a normal breakfast, i.e. two more eggs fried in butter. Later in the morning when I was out and I promised myself that if I wanted a croissant I could have one, then I totally forgot to buy one! After that I ate normal meals in what felt like a normal quantity, but again, I did have that strong concentration while I was eating on the first day and felt totally uninterested in the salad. I think my body thought salad leaves were a pointless waste of time with too few calories to be worth eating. After that I carried on as normal. No problems.

Having done something as huge as a five day fast I didn’t feel that I needed to do any one day fasts anymore and I stopped doing those. However, if there is any health/medical benefit to fasts, and I do assume there may be, I wouldn’t assume that one five day fast a year is better than weekly one day fasts. We probably need more research and it would also depend on what you want to achieve. However, in terms of a personal challenge, I definitely feel that an annual five day fast gets me off the hook for a weekly one day fast.

So annual… ? Yes in 2018 it was time for next fast. This time I made it a seven day fast in July. As I had been so well in 2017 and didn’t faint at all, I fasted while working as normal (I only have an office job). In fact I highly recommend being in work as it filled up my day, kept me distracted and busy and this seemed to made things much easier. I started on a Sunday and though I did feel a bit tearful in the evening about my laptop, I really think it was nothing to do with food and was just about how annoying my laptop is.

Again I had as much water as liked (mostly fizzy water) and the normal amount of black coffee (two americanos a day). This time I didn’t have any bone broth.  I do think fasting was easier this time and that my body is getting into practice.

I also thought of it as a physical challenge, like running a marathon. Every time I felt a bit miserable, or fed up (especially on the Wednesday afternoon, day four, while working from home), I thought: ‘would I rather do a two mile run?’ No I would not. Obviously I appreciate that training for a marathon takes more than two mile runs, but even a two mile run seems harder and more unpleasant than fasting. That means this is a physical challenge I can do while sitting on the sofa! Best challenge ever.

I preferred to spend the fast quietly at home in the evenings, as it seemed like a good combination with a bit of a retreat from the world. Plus I didn’t want to join friends in restaurants, though I was happy with the idea of soda water in the pub. However, on the Tuesday (day three) I did join a friend for a three hour walking tour of central London, so I don’t think I was low on energy. Again I felt well, and normal, no faintness, no coldness (it was the middle of a heatwave), no problems with concentration at work or at home. I felt a bit ‘faint hearted’ like faint headed, but around my heart, for a short time in the shower one morning, but that was pretty much it for physical symptoms.

My weight over a seven day fast
My weight over a seven day fast

I kept a careful eye on my weight. If I had dropped below 60kg, I would have considered stopping the fast. As it is I didn’t even get to the bottom half of the healthy weight range for my height. Though I lost quite a bit of weight, it was evidently mostly water, as it snapped back on again once I started eating again (though I kept hydrated and drank plenty). It’s quite interesting to see my weight return right back to the original amount (or a hair lower) without me paying any attention to the amount I was eating.

I have to say I really enjoyed my first meal. I had a whole avocado mixed up with a tin of sardines on a bed of rocket with olive oil, salt and pepper and a few walnuts (I’d say that was about double or 1.5x a normal quantity). When I sat back with my full tummy I felt so happy. Like imagine if you’d given up coffee and chocolate and TV as a challenge, and then after you were done, you sat in front of your favourite programme with a coffee in one hand and chocolate in the other… that’s how happy I was. I think this is literally due to serotinin production by my gut, if this is the case, that’s pretty fast work.

The thing is though that neither coffee, nor chocolate nor TV are essential. I actually took this to mean that as much as I enjoyed eating again, I had a lot more than seven days worth of food stored on me. We’ll see what a fast is like in 2019! I also need to make more of an effort to do exercise on the first day, like a two hour walk, to get me into ketosis quicker. And in the past, on two occasions, it really is the combination of not eating and exercise that has made me feel really well, even euphoric.

So in summary, I’d definitely recommend fasting as an exercise in philosophy or as a physical challenge to see what your body is capable of. If anyone is interested in fasting, but worried it might be unsafe, I’d say, start small. Start with just fasting till noon, then go up to one day at a time and learn about it as you go. Remember, when you feel hungry, it’s not a straight line up. You won’t feel more and more hungry. Its more like a curve that goes back down again. So if you can wait that out, you will feel comfortable again. But if not, just eat, and learn more and try again later. After all we were born in the crucible of evolution, our bodies can do a lot more than we think.

The old story of continuing snobbery.

I recently read The New Book of Snobs, A definitive Guide to Modern Snobbery by DJ Taylor and I was quite disappointed that it was the actual thing it said on the cover, and not the book idea I had in my head.

My take on snobbery is that it’s about pre-judging people on something other than merit, or their value as a human being. We have, perhaps a fairly natural, tendency to like things that are more familiar, so we can get locked into only hanging out with other similar people and as that is how people find and get jobs and careers, it tends to define what jobs and lives are available to people. (I’m not saying people are only getting jobs because of who they know, I’m saying the jobs you think to apply to comes from your social background). So assuming all the above, I think snobbery stunts lives. Also are different classes really different ethnic groups? according to a non-English anthropology friend: definitely not, I still think there could some useful ideas there.

So the book I’d like to read is: how can I recognise and work on my own snobbery and how can I become more inclusive and how can we change our institutions and society to be more inclusive, with particular reference to class?

This is not that book.

This book does discuss class a bit, but then gives up the discussion with the line, that because all our literature talks about snobbery , if we didn’t have snobbery we wouldn’t have literature. (I’m sure other less snobby countries manage somehow!). This argument essentially boils down to: its ok to make our lives miserable, as long we can write serious literature about it, it’s a good trade-off. When I was growing up and reading comics about poor exploited orphans most of the stories where set in Victorian times. So it’s totally possible to have good stories without human misery in our own society.

After that the book just slips into comfortable groove of vignettes which seem like they were already written and published before and just stuck on to make up the number of pages (I could look it up, but I haven’t). The problem with these vignettes is that they really buy into the superior attitude of the narrator. The high class mum with the lower class daughter, the couple invited to the literati dinner party, they don’t learn anything, they just get an extra appreciation of how dreadful it is to not be them and go back to their own lives. And I don’t think it’s an unreliable narrator thing, we the reader, don’t learn anything either. So rather than learning more about other people and broadening our horizons we just reinforce our own stereotypes.

I‘d recommend Kate Fox’s Watching the English over this, while it equally isn’t aimed at ending all the pernicious effects of snobbery at least it describes class differences in a far less judgmental way. Or the book I read after writing this: Darren McGarvey’s, Poverty Safari, is a much more interesting and useful book about class.

Getting a linux laptop as a non-computer expert. What if you’re really sick of Apple and Microsoft?

So after my laptop was stolen, I was in the market for a new laptop. Should I get a second hand one? (painful as I had just lost one! Probably someone else is buying my second hand laptop as we speak).

Should I even get a desktop? But I do like reading webcomics working on the sofa, or on the train, or anywhere, so a laptop it was.

Should I get a Mac or a PC? Unfortunately, I have completely bought in to all that stupid advertising that makes Apples seem cool and better, and they are pretty glossy. Plus, I always wanted a Macbook Air and that is now the basic version.

But I don’t feel Apple has any good options. I paid £1000 for a PowerBook four years ago, but now they cost £1200 because they are the better version while the Macbook air is the basic version, but because that’s solid state memory, I have to pay extra just to have the same amount of memory (which to be fair is plenty, and nobody even quotes the memory anymore, but I grew up in an era when more memory was cool. When my first laptop had 40GB storage, that was a big deal and my friends were impressed [one friend]. It’s quite funny to root around in my brain and see where this idea, that more memory is cool, comes from).

At least the Mac book Air has a few ports, but the Powerbook only has the new USB3 ports. I’d say power, headphones, two USB-normal ports and one thingy to plug in a screen or projector (HDMI or VGA) is the minimum a laptop should have. Apple computers do not provide this, so I’d have to spend money on adaptor cables (And then I’d have to store, them! It’s just more stuff to keep track of, they wouldn’t bring me any joy. Marie Kondo should give Apple a good talking to). Meantime my basic work PC laptop has got millions of ports. And no laptop has a DVD player anymore, which is quite annoying. I really had thought laptops were supposed to be getting better and cheaper, but I don’t get to even pick one. They are just getting more expensive and have less stuff. When are the economies of a mature technology going to kick in?

So having had PC’s at work all my (working) life and as I prefer Microsoft excel on a PC I did look into buying a PC, but I already had the Mac version of Microsoft Office software paid for (the thieves didn’t take the piece of paper the the licence was printed on so that was still mine). Meantime it currently costs £120 for a PC, so as the nicer laptops were not that far below the MacBook Air, I thought I could stretch to an Airbook (anybody who thinks I am wasting my money on a pointless glossy status symbol is right. Macs are so nice and glossy).

So, standing in the shop, just before I bought my nice shiny MacBook Air that I always wanted, I had one last question. Of course, the most widespread software in the world, Microsoft Office, that I only bought four years ago, is still supported isn’t it?

No. No it is not. New Microsoft Office software is £240. More than double what I paid in 2014, when it was £108. Apple is dead to me. I mean maybe this is not all Apple’s fault and it’s equally Microsoft’s fault. They’re dead to me too. Damn their rent seeking monopoly based business models.

So is there any way to opt out? Obviously, I’ve heard of linux, but I’m not an expert, I don’t want to spend time and effort and make my laptop my hobby, I just want a box, small enough to travel, with a big enough screen to work on, with a browser, and email and file storage (so I can scan all my papers and chuck them as they don’t bring any joy). Also some degree of a glossy status symbol! (It’s ridiculous, but there it is).

So I googled linux laptops (there are only a few out there). I.e. a laptop that works out of the box, no more different from an Apple/PC than they are from each other, and landed on Purism. The 13″ one is the same price as a PowerBook, or a MacBookAir plus Microsoft Office. The big, big, BIG selling point is that they will not spy on you and all their software is open source and verifiable by third parties. I remember how betrayed I felt when I realised that the Mac address book tool, that I’ve been filling in with data on my friends since I bought my very first laptop, is now imported onto your phone and freely available for any app to help themselves to. And you can’t export it to an excel spreadsheet (I did export some sort of wall of text version) and you can’t even delete people on your phone wholesale, you have to delete each person one by one! It was exhaustingly tedious.

Purism talk about how they are making their computers as secure as humanly possible and they won’t spy on you ever. And they can’t sell your data as they don’t collect it in the first place. Not having all my data sold to companies who want to use it to exploit me, is quite a nice feature in a laptop. As a tiny company producing laptops for the same price as Apple one of the biggest manufacturers in the world, that really seems like they might break open Apple’s stupid monopoly (which this blog should show: that monopoly is partly powered by my own brain).

Purism looks pretty good, I haven’t researched their claims properly, just the bits where they say it’s a laptop that works, and it isn’t a Mac or a PC, and it has a free version of Office. I never wanted to learn to use the apple equivalents, but I’m willing to put the effort in for a good cause this time.

So speaking of status symbols, that whole ‘being part of a movement’ idea is good enough for me. I’m assuming the actual laptop won’t be quite as smoothly glossy as a Mac, it does look fairly glossy, and I’m pretty sure the power cable will be hideous, but I’m part of a movement, and the computer won’t spy on me. And it won’t default to google which definitely does spy on me. Plus all the free software sounds good, there seems to be a free version of photoshop which is certainly better than the nothing I have now, (I used to have photoshop at work so I did miss not having any useful image manipulating tools).

I have to say, this is a bit of a leap of faith. I don’t think their online order form really speaks to the non-expert buyer (me) who has no clue which sort of memory to buy: M.2 SSD vs 2.5” SATA 3SSD (I looked it up, but I’ve forgotten. If you don’t know the difference, it means you’ll be fine with the default one, but they should still define their acronyms).

It’s not heavy-handed symbolism. It’s Art.
Harold E. Edgerton, 1964, Smithsonian American Art Museum

So see my next post on how to order from the US to the UK, what fees and charges you need to pay, how do you pay VAT at customs, after I’ve gone through it and figured it out. Then we’ll find out if the normal, non-expert computer user (me) can use a Linux laptop.

How to navigate police bureaucracy; Or, I’ve been burgled, what should I do?

Unfortunately, I got home on Thursday to find the back door open and my flat burgled. People and cats were unharmed and safe but I can’t say the same for my laptop (at least it was backed up).

It turns out if you are burgled you need to navigate police systems in the right way if you want to get the forensics team to visit the next day. Their current systems have some pretty big cracks for people to fall through. (I’m speaking about the metropolitan police in London).

This blog post is written with David Greaber’s book, The Utopia of Rules in mind. The book is about how we are so mired in bureaucracy we don’t even notice it anymore, and here I am, writing a whole blog post to help other people navigate yet more bureaucracy.

So I called 999 when I came home to find the back door open and my stuff rummaged through (I suppose 101 would also work, but they often have long queues and it really felt immediate and scary).

So I’m quite annoyed that after calling 999 at quarter to 10 in the evening, I didn’t get onto the forensic teams list till 2pm the next day, and then only because I chased the case.

It turns out 999 does not log the call in any meaningful sense. Instead the call gets put on a list and sent to the telephone team. These guys write it up and assign a crime number. It doesn’t land on the forensic team’s list or get sent to the local police until this happens.

The telephone team work from  7am to 11pm, albeit with reduced numbers of staff at the earlier and later ends. 999 cannot put you through, but 101 can.

So after you register your crime at 999 and get your call number, you need to go straight to 101, wait in the queue, then ask to be put through to the telephone team, so your crime can be registered with immediate effect and land on the forensic teams desk immediately. (However, if you don’t expect any action, like time my car back window was smashed in and my friend’s rucksack stolen out of the boot, and you just want to register it as a good citizen and/or to claim insurance, then don’t worry, that will eventually work out).

I called 999 at 9:44pm. They gave me a call reference, told me forensics would be out the next day and I’d get a call from someone in a day or two with the crime number. That was it, no further info. The next morning I called 101 at 8:24 am (no queue!) and they told me that I could send my laptop info to cms@met.police.uk (or phone on 020 7230 3400, 9-5), which I did. CMS e-mailed me back at 9:07am to say I needed a crime-ref number, but no info on how to get one, I replied saying the call number reference was in the subject line and that I didn’t have a crime number yet. At 1:40pm I called 101 again to chase forensics (it’s horrible being at home but not being able to tidy up or touch the things that might have fingerprints) and to register my laptop serial number. Now 101 finally put me through to the telephone team who told me that they get 400 phone calls a day from 999 to register and my one was in the pile and they were working their way down. By phoning up I got my crime registered, got a crime number and the request was finally, at around 2pm, sent through to forensics (and the local police). One more call to 101 to chase that and they were, to be fair, there quite soon after (a bit before 4pm). A team of two people covers two London boroughs with about 10-15 cases per day. Which I think is actually quite a reasonably low number of burglaries for the population. So the annoying thing is that I called 999 well before 11pm and if I’d known I could have gone through to the telephone team via 101 immediately. Or better yet: why didn’t 999 just put me straight through! Apparently, they can’t, but why not? Or why not tell me to call 101 to be put through?

So if you have a crime that you don’t expect any help with and are only reporting so the police have good statistics, you’re fine. If your case is time sensitive, if you need forensics to do fingerprints, chase it via 101 . No crime number means it’s not in any systems yet.

24 hours after I got the crime registered and my laptop serial number put on the relevant databases, CMS e-mailed me back to say they had looked up my call reference from 999 everywhere and couldn’t find it at all. I’m a bit confused if CMS is the same or different from the telephone team.

Confused.com says if the perpetrator is found and convicted, the court can order them to pay you compensation to cover loss and damage. But, for some reason, you need to tell the police in advance. So do put your claim in when the police take a statement (and then keep receipts).

So there you go, I hope that bureaucracy wrangling is useful for someone.

This is what my keyboard looked like. Let me know if you spot it anywhere.

The calorie theory vs the insulin theory of overweight and why it matters

Our understanding of why we get fat matters because these two different theories result in different actions for us if we want to loose weight.

The calorie theory is that we get fat because we eat more than we exercise.

Obviously this is true. If you gain weight then you have eaten more energy than you used in running your body and brain and in exercising.

The question is: do the excess calories cause the fatness in a meaningful way.

Or to put it another way. When you ate enough calories why didn’t you feel full and stop eating. What made your body store them as fat instead of just running a bit hotter.

So is the amount of calories we eat and the lack of exercise all the explanation we need or is something important happening behind that?

Advice for overweight people based on this theory

  • Cut back on food. Especially cut back on high density food like fat (9kcal per g vs 4 for protein and carbohydrates). If you get hungry, when you eat the recommended food at the recommended amount (like my gestational diabetes friend eating porridge and fruit for breakfast), then that’s odd and weird, just keep going.
  • All calories are equal. It doesn’t matter if you get your target number of calories from fat or protein or carbohydrates. Sugar is no better or worse than any other food, as long as you stick to the right amount of food and get enough vitamins etc in the other food.
  • Exercise more.

The insulin theory of overweight and obesity.

Insulin causes fat cells to lay down fat. It also prevents us from accessing the fat inside our cells. So while insulin is high you have to burn glucose to survive. If insulin is high but you have no glucose, you are in trouble (also you insulin will start to come down now). If you injected insulin you might hypo, as it can’t go away. If your body produced the insulin you might be hungry, hangry or starving till your insulin levels come down (or you eat carbs), but you probably won’t have any more serious effects.

Insulin is raised by eating carbohydrates. Therefore carbohydrates are uniquely fattening compared to protein and fat.

The higher the GI (the glycaemic index) or the more carbohydrates are processed so that they can be very quickly absorbed into the blood, the more they spike up insulin, the more they are fattening.

The more you snack between meals*, the more your insulin levels are permanently high the more you are laying down fat and also unable to access that fat in case you get hungry and run out of blood glucose.

GI alone isn’t a perfect measure, if you eat very high GI food with fat, that makes it low GI, so chocolate, or nutella contains lots of sugar but are still low GI. Sugar itself actually has a GI that’s not too bad because only half of sugar counts to GI**. So while I wouldn’t call nutella healthy, I’d call it better than drinking the same amount of sugar in coke.

So the insulin theory of overweight suggests that you eat a meal and, due to high insulin, immediately lay some of it down as fat even if you would be doing exercise later. At exercise time your breakfast or lunch is already laid down as fat, if you have a little snack (of carbs) or a coke your insulin levels will be too high to allow you to access that fat, and you will need to eat more.

Advice based on this theory:

  • Cut back on carbohydrates with particular reference to what effect they’ll  have on your insulin levels.
    • Avoid starchy foods, i.e. bread, cereal, white rice, potatos. Even if bread is whole grain, the wheat kernel has still been mashed up to flour and it is still very easily digested.
    • Eat as much fat as you like it won’t raise insulin, so it won’t be fattening and your natural appetite mechanisms will soon have you feeling full. Bear in mind that ‘fat’ does not include donuts or pizza, as they both contain far more easily digestible carbohydrate (white flour) than they contain fat. Though the fat from the cheese/frying will slow down the absorption of that carbohydrate compared to if you just ate a spoonful of flour and sugar.
    • At the very least, enjoy the full fat version of your normal food.
    • Eat as much as you want, as long as you stick to the right type of food.
    • Avoid snacking, stick to three meals a day and consider fasting on a regular or occasional basis. This will get your insulin levels down and allow your body to access your fat stores
  • All calories are not at all equal. Carbohydrate, fat and protein are treated completely differently in your body (for example you can only get very limited amount of energy from protein so if your diet cook book says to eat low carb and low fat, they are just wrong. They probably man low ‘white’ carbs and high ‘green’ carbs). Sugar is different again because it is our only source of fructose, which will sleet into the liver and get converted to fats with unknown effects.
  • If you are on a high fat low carb diet you may well get hungry less often as the fat increases satiety and if your insulin levels are generally low, it’s easier for your body to then dip down into using up your fat stores.
  • Exercise is not directly relevant, except that it does use up glucose in your muscles and allows them to then take up more glucose from your blood. That is good, but you can equally just not eat the glucose in the first place. The choice is yours (of course exercise is generally good, but not that relevant for weight loss).
  • Pay attention to how much of your meal is easily digested carbohydrates (bread, rice sugar), more slow release carbohydrate (all veg which is still ~80% carbohydrate), vs fat or protein. If you have a sandwich, some popcorn chips and a banana for lunch, you will have gotten over 60% of your food as carbs. Our current dietary advice is to eat no more than 30% fat are you even getting that much?

Ways in which we know hormones work in other contexts.

When children grow up, they don’t get taller because they eat more than they exercise, they grow because of growth hormone. No growth hormone (or growth hormone receptor) no growth, no matter what you eat. Too much growth hormone leads to being super tall, cutting down on food and exercising more wouldn’t really stop that.

Women have ~21% body fat vs ~14% body fat for men, this is due to hormones, not because all women eat more than they exercise compared to men.

A friend of mine went on thyroid hormones and put weight on, the weight then came off when they came off the hormones.

OK, but what should I do?

So these two theories of why we get fat really determine what changes we try to make to loose weight (eat less and exercise, vs cutting carbs but eating as much as we want). And we can see that while some changes will match up (eating less overall vs eating less carbs specifically, also everyone agrees on cutting out sugar), some are kind of opposite (cut fat vs embrace fat) so if we have the wrong theory, we’ll have the wrong advice. If the wrong advice is just unworkable, and if someone is told to try something and it just doesn’t work, will they fell that it is their own fault they are fat and they just can’t change things?

So if you’re reading this and have tried one set of advice (eat less?) but are not sure if the other set could work (eating more fat instead of bread, rice, potatoes and pasta??) try it for a month? You should see the effects within that time. See if your GP will test your blood before and after that month too. Even if I’m totally wrong, you can’t do that much damage in a month. So have fun experimenting***.

*This could be more complicated, but the point is what is going on with your insulin levels is more important than  the number of calories.

**New blog post coming soon about why sugar has a quite ok GI (unfortunately sugar still needs to stay as an occasional treat).

***I have a whole blog post in my head based on John Kay’s book on why the rich countries are rich: disciplined plurality is key. Plurality means trying a different things, disciplined means stopping that thing if it doesn’t work.

 

New year, new energy, Some ideas for resolutions

New Year, new energy, I do like the start of the year (there just might be a link to all the time off I had at Christmas and New years).

I was thinking about some ideas for changes you could make if you were thinking of New Years resolutions. And  if you think the new year is an arbitrary time of year then, good news! you can also read this blog post at any other time.

  • Having decided the ‘rules’ you want to live by: think how mindfully achieving your aims and having a sense of agency is better than, say, the monkey brain enjoyment of a cheap supermarket cake that doesn’t even taste that good.
  • Enjoy mindfully planned exceptions. It’s not about never having treats. Plan your exceptions by imagining you are in the future looking back and decide if you think it would make you more or less happy to indulge. Then later actually look back and decide if you were right or not and what you will choose to do if the same choice comes up in the future.
  • Be fair on yourself. If you skip lunch and get hungry you will crave snacks and chocolate before you become consciously ‘hungry’ (I certainly do, I get a good 30-60 min phase of thinking about chocolate before I ever feel consciously hungry). If you find yourself eating junk food, think whether the junk food is the problem or if the previous meal was the problem. Look out for yourself. If you were looking after a five year old child you wouldn’t be too busy to get them a proper lunch and you’d get them home in time for a proper supper.
  • Swap to full fat milk, yogurt, etc.
    The fat will increase satiety in good proportion to the amount of extra calories, leading to more fullness and less need to snack.
  • Swap starchy foods for half the amount of fat.
    Halve your rice and put a quarter the amount of butter or olive oil on top. The same calories but more delicious and you’ll feel fuller.
    Highly processed starchy foods, like bread and cereals, crisps and popcorn and rice, will spike your blood sugar up and the resulting drop will make you feel hungry. Half the amount of fat will have the same calories, will keep you nice and full and will keep your blood sugar on a comfortable, controlled, even keel.
  • Alternate every glass of wine with water.If you are out a party and if you like drinking all the time, instead of trying to drink less, substitute what you drink. My favourite is apple-shorle. A little apple juice with sparkling water. The nudge unit (in David Halperns book) has advised for ecigs purely on the basis that a substitution is so much easier than quitting (and ecigs really are so much safer than cigarettes, though that is the lowest bar ever).
  • Substitute fizzy drinks with sparkling water with a dash of lemon and/or lime, or even just plain sparkling water. Obviously if I have a choice of sparkling water or coke, my monkey brain will prefer the coke. But you could reframe it as nothing vs a drink. Sparkling water is much more fun than nothing.
  • Consider drinking your coffee black, then it’s zero calories, but apparently it still has soluble fibre. Practically good for you, or actually good for you, who knows. Who cares! Coffee is delicious.
  • Substitute breakfast cereal with fried eggs, or boiled eggs if time is tight.
    Again this gets you away from the highly processed, empty calories in the processed wheat/maize (which is what every single cereal is apart from oats, and swaps in a vitamin rich food with the full range of essential fatty acids and essential amino acids). In case you didn’t get the memo, we’re not worried about dietary cholesterol anymore (I wish there was an actual memo, or people admitting that the old advice was wrong and presenting the reasons for the old advice and the reasons for the new advice. Let me know if you know find that).
  • Only eat cakes/chocolate when out with friends, never snack alone.
  • Quit all snacks. Eat three meals a day and that’s it.
    Saves time and thought. If you can’t go between meals without feeling hungry you are doing your meals wrong.
  • Mindfully discuss a desired habit change with a friend.
    • Figure out the problem (for example: I have lunch at 12, I work till 7, when I get hungry and there is only vending machine food available and I don’t want to spend time and energy on bringing cooked food in, also I only sometimes get hungry so I can’t bring in perishable food, as it would get wasted).
    • Discuss a range of solutions, when the first three ideas aren’t a good fit keep discussing ideas.
    • Answer: Ryvita and babybel.
  • One day go to the supermarket before supper. The next day eat a really good supper then go to the supermarket. Watch yourself glide paste those donuts on sale, with no difficulty. Everyone always said you shouldn’t shop on an empty stomach but when I did this experiment, pretty much by chance, I was really surprised at how strong an effect it was.
  • Only enjoy sweet foods and drinks as a dessert on a full stomach.
    Sugary drinks, including orange juice and fruit smoothies, will give you a massive sugar spike. Avoid the spike by only eating sweets on a full stomach.
  • Swap white for green
    Instead of boiling up pasta, what about boiling some frozen green beans to have with your sauce.
    The Swiss food pyramid caps starchy carbs at 3x 30-50g a day (p19). That’s three small slices of bread or three very small helpings of pasta per day. Replace white, nutritionally empty carbs with green vegetables (still 80% carbs which are slow release with some plant protein (not nutritionally complete without complicated mixing and matching, but still useful) and the water-soluble vitamins).

There we go: a few ideas for changing habits and some ideas for what habits you could change. Hope some of them are useful and spark some further ideas of your own. Have a happy year.

Obesity 50 years ago when the medical advice was to cut the carbs

For Obesity Day I thought I’d quote the advice Gary Taubes describes as treatment for obesity in the 1950s.

So seven prominent British clinicians, led by Raymond Greene, published The Practise of Endocrinology in 1951:

Foods to be avoided

  1. Bread and everything else made with flour
  2. Cereals, including breakfast cereals and milk puddings
  3. Potatoes and all other white root vegetables
  4. Food containing much sugar
  5. All sweets

Foods to be embraced

  1. Meat, fish and birds
  2. All green vegetables
  3. Eggs, dried or fresh (do dried eggs even exist anymore?)
  4. Cheese
  5. Fruit if unsweetened or sweetened with saccharin, except bananas and grapes.

In 1940 a monograph on 50 obese patients found that 41 of them had a “more or less marked preference for starchy and sweet foods; only one patient claimed preference for fatty foods” these patients included “an extremely obese launderers [who had] a craving for laundry starch which she used to eat by the handful, as much as a pound a day…”

When you make the low fat version of food you can do so by adding starch, e.g. Morrison low fat Crème Fraîche has tapioca starch added.

Or in the 1960s textbook on Human Nutrition and Dietetics Sir Stanley Davidson and Reginald Passmore wrote “In great Britain obesity is probably more common among poor women than among the rich [today it definitely is] perhaps because food rich in fat and protein which satisfy appetite more readily than carbohydrate are more expensive than the starchy foods which provide the bulk of cheap meals”. And “All popular ‘slimming regimes’ involve a restriction in dietary carbohydrate”. “The intake of foods rich in carbohydrate should be drastically reduced since overindulgence in such foods is the most common cause of obesity”

50 million copies of Dr Spock’s book said “Rich desserts , the amount of plain, starchy foods (cereals, bread, potatoes) taken is what determines, in the case of most people, how much [weight] they gain or lose”.

And look at Ancel Keys’ observation of the people of Naples eating the Mediterranean diet (though it was the Cretans that were the long lived ones), he describes the small amount of lean meat and the pasta based dishes (a poor region, made even poorer by the war) “The women were fat”. (Ancel Keys was one of the key scientists arguing that saturated fat caused heart disease).

So a low carb high fat (higher fat than we eat now) was fairly standard diet advice in the 1960s. Since then the idea that fat is bad is because saturated fat was bad, and because there was some evidence that diets extremely low in fat  produced really good results in terms of weight loss, for patients coming off junk food  diets (but we’re talking less than 10% fat with no word on whether those are the only good diets). Those diets were studied by Pritikin and they were what inspired George McGovern when he recommended around a 30% fat diet in the Dietary Goals for the United Stats. 30% fat is the current UK recommendation, though the US has now taken the fat limit off.

You can see some of the confusion here by comparing the UK, the Harvard and the Swiss food plates or pyramids.

2016_uk_eatwellguide harvard-pyramid-jan2015-1024x808 harvard-food-pyramid-1024x950swiss-food-pyramid_2011

The UK Eatwell Guide is 1/3 carbs and, whatever they say about wholewheat, the pictures are all of highly refined carbohydrates, while in the Harvard food plate whole grains (no processed refined carbs) are 1/4 of the plate. In the Harvard pyramid cheese is in the second smallest category, but in Switzerland it’s one rank down in the middle of the pyramid (quite amusing). Both Harvard and Switzerland pyramids allow more oil than the UK and they disagree about how much.

The thing that strikes, me looking at my friends lunch, is how many of them consist of even more than 1/3 carbohydrate. A sandwich is probably around 2/3 bread (carbs) vs filling, or call it half. Then add a bag of crisps, 50% of the calories are carbs, (more than 50% of the weight that’s not water). Then throw in a banana, again as a % of calories thats 92% carbohydrate. E voila, you’re eating way more carbs than are recommended by the UK, and even that is probably too much.

The other thing that really struck me was reading Weston Prices’s description of diets around the world.
I want to go into this properly in another post, but briefly, he was a dentist who, in the 1930s, did a tour of the worlds teeth comparing ‘native’ diets of people not in contact with Western civilisation, with the teeth of the same ‘tribe’ of people who were. This includes the Swiss comparing a distant valley, Loetschental, with the lowlands, St Gallen, and the Western Isle in Scotland comparing the side of the island with a port and shop with the other side of the island, as well as the Inuit, Native Americans, Aborigines, etc. etc. etc. In every case the ‘native’ diet produced wonderful straight, healthy teeth while the Western diet didn’t. Indeed we’re talking, all your teeth rotting out of your head by the time you’re 20 (and my Swiss grandmother only had four teeth). In every case the major feature of the Western diet was white flour and sugar. These people were eating an utterly terrible diet by any standard (no wonder TB was so rampant in the olden days). Western Price’s main idea was that these people weren’t getting the fat soluble vitamins, A, D and K2 needed for healthy teeth. Also they weren’t getting any other vitamins either (but when he gave them a small amount of top quality butter their teeth got better so it seems it is the A, D, and K2 for teeth).

So this is a second argument to reduce easily digested white carbohydrates, that used to be known as uniquely fattening. They are entirely empty calories. If we are sedentary and living in heated homes, we don’t need to eat so many calories, which means the food we do eat needs to be better quality to get enough vitamins, minerals, fibre etc.

The final thing, that I’ll try to mention even more briefly before the blog post: What if vitamins A, D and K2 (which need to work together, no point only getting one or two) are so essential for calcium metabolism (as well as teeth) that if we don’t have enough vitamins we have calcium filling up our arteries and becoming atherosclerotic plaques (Atul Gawande described such arteries as being brittle to the touch when he operated on them). What if all of our heart disease is vitamin deficiency? This deserves it’s own blog post. But what if a trivitamin pill could help enormously and saturated fat had nothing to do with it?

So for world obesity day, and to save the NHS, make an effort to swap out your bread, pasta, potatos, polished rice and crisps for vegetables, an egg and a bit of cheese.

 

How to decide a moral dilemma

I was at a Gresham Lecture yesterday, To Die or not to Die (whether ’tis nobler in the mind to suffer the slung arrows of outrageous fortune, or to take arms against a sea of troubles…). The speaker was Sir Allan Ward a judge with a 60 year career behind him who is now retired with time to give interesting talks.

He started by saying how awful the death penalty is and described two of the prisoners he had met in South Africa who had completely crumpled and been destroyed just by the sentence, even before the actual execution. This was moving, but also, in the UK, safely dated, we have gotten rid of the death penalty now because we all agree it’s bad. This was the jumping off point though, he had thought he would never have to deal with life and death issues again, but they do still exist.

The first story was about a 16 year old Jehova’s witness, who, with his parents, didn’t want a life saving blood transfusion as part of his treatment for leukaemia. The doctors did want him to have the life saving blood transfusion so the case came to court. In some ways it seems like a no-brainer to say of course the child should be ‘forced’ to have the blood transfusion, However, Sir Allan went to visit the boy in hospital, made sure the 16 year old understood the risks and issues, and discussed and listened for some hours. He also wanted to make sure that if he judged  that the child should have the treatment, the boy would accept the judgement and not try ripping the tubes out. Indeed he argued that because the decision had come to him, the judge, this was the heavenly equivalent of a sick note that he could hand over to St Peter at the pearly gates to excuse his sin (I’ve deliberately left the quote marks off there). So when he left the hospital and wrote up the brief on Friday night, the appeals court were all ready and set for the appeal. But there wasn’t one. The family’s solicitor, himself a Jehovah’s Witness, said they had planned to appeal because they had thought their opinion would be dismissed, but when their views and values were taken seriously and listened to, even if ultimately the judge didn’t agree, they were satisfied.

However, there was a sober epilogue. The leukaemia returned 10 years later, and as an adult he refused a transfusion and did die. So the judgement gave him a decade, but ultimately didn’t save him. It seems to me that the boy might have felt that an external court could override him as a child, but as an adult man, his path was clearly to stick with the tenets of his religion.

The second story was the longest and concerned conjoined twins. The parents came from a small village in Malta which has an agreement with the NHS that their complex cases can come here for treatment. You probably heard about it at the time, the twins were Jodie and Mary (not their real names).

The twins were joined up around their tummies with their legs sort of stuck out at the sides and grown all wrong, it did look quite bad. Indeed, very understandably, it took the mother days to be able to be in the same room with them and  to touch them.

Jodie was well but Mary was brain damaged. Jodie’s heart was beating for Mary which doctors suggested was equivalent to her little baby heart pumping blood round a 10 foot tall person. The doctors thought they could save Jodie and carry out complex surgery to give her a healthy normal body. Mary would have to die. I did think this moral dilemma was somewhat reduced by the possibility that Jodies heart could fail under the double strain and they could both die. It seems then it’s choice of saving one instead of none. However, in this or another case it might be that Jodies heart would  grow strong and they could both live, though with a limited quality of life and being bed bound.

So the parents thought they should wait things out and if the babies died that was God’s will, while the doctors were sure they could save Jodie. A very cynical person might wonder if some parents might prefer a dead child to a severely handicapped child and might wonder if this influenced the parent’s feeling that Mary should not be sacrificed (though the doctors were confident Jodie would be healthy, the parents were not so sure).

So it came to court. Three days in Sir Allan raised a further point: if the doctors take up a scalpel to separate the twins and save Jody, but knowingly kill Mary, is that murder?

This could have been argued very differently a century ago. Murder involves killing a ‘rational human’ i.e. I guess killing animals is ok. So was Mary a rational human? Her brain damage would, a century ago, have disqualified her as a ‘monstrous birth’. Perhaps it might then have been perfectly ok to let her go quietly, and maybe even to help her along. Nowadays it was quickly agreed that Mary’s brain damage didn’t apply and she definitely counted as a rational human.

So having described this much, I’d like to stop discussing the actual case, take a step back, and say, I think it’s quite right for the state, for the taxpayer, indirectly for us, to take this time and effort and money to discuss these cases and go into the issues. For example, far better to get into the issues of whether the operation is murder or not before hand, so you can figure it out without any doctor having to sit in the dock and wonder if he will wind up in prison (in the end they decided that because Mary was such a drain on Jodie, and could kill her, it was ‘self defence’ for Jody to be separated and the doctors were acting as a proxy for Jody’s self defence). And after all, if the taxpayer spends a fortune in wages, you do get 20-40% of that right back.

Michael Sandal argued at the end of one of his books on ethics, that when you have a knotty, thorny ethical dilemma, perhaps the exact decision you reach is not the most important thing. The whole point of a difficult choice is that there are arguments either way and that perhaps the most important thing is to honour the difficulty with thought, attention, time and effort. You must think carefully every which way, but ultimately there might not be a clearly right or wrong answer. He illustrated this with two men who each had  brother who had committed murder and might do so again. Ultimately one man dobbed his brother in, while the other refused to do so. In the end you could agree with both men.

However, Sir Allan argued this was not exactly the case for Jody and Mary. The question was not what was moral, the question was, what was legal. And he raised this again in a question at the end. Currently assisting suicide is illegal so if someone brings their wife to a Dignitas clinic in Switzerland, this is illegal, even if we all agree the law needs to be changed (and clearly we don’t all agree otherwise we would change it).

I did wonder about all the cases we never hear about because the parents and doctors agree. If the doctors had just gone ahead without any court cases, would they maybe have been up for possible murder (even if Mary’s death turned out to be indirect self defence) or would nobody have thought to raise the issue?

The difference between law and morals also comes out very well in this paper: No Child Left Alone, about mothers and father who leave their children alone. Surprisingly, it is actually readable, even though it’s science! But don’t worry, no children where harmed in the making of this science. The children were only left alone in scenarios that were read and graded by amazon Mechanical Turk (what a brilliant way to get research subjects). The authors, Ashley Thomas et al., conclude that in the US today there is a new moral code and it’s totally immoral to take your eyes off your child for even five minutes, even when the risk of kidnapping/murder is around 0.0007% or 1/1.4 million a year (fairly low) and that when police were called out to bring two lone children home, the kids were more at risk being driven in the car than they had been walking home alone (with the permission of their parents). This even comes up in Patrick Ness’s new novel More Than This. Two brothers are left home alone for a short time, in those few minutes an escaped prisoner pops by and something terrible happens to the younger brother. The parents then spend the next 10 years blaming the older brother, who was eight at the time. The older brother discusses it twice, and both friends are assure him he was not at fault (obviously) but they are entirely happy to throw all the blame on the mother while ignoring the actual person who committed the terrible crime. That was a bit annoying.

The last author of no Child Left Alone, Barbara Sarnecka, concluded that their findings “should caution those who make and enforce the law to distinguish evidence-based and rational assessments of risk to children from intuitive moral judgments about parents — and to avoid investing the latter with the force of law.”  So leaving your children alone in sensible circumstances (not neglect) is now immoral, but should not be made illegal.

Phew that was a lot of thought from one lecture. I’m looking forward to more of these.

1 year cancer survival: is your cancer more important than your hospital?

Nowadays quite a few health statistics are published online. Here I’ve got some graphs on some cancer stats published this year. The stats take a while to collect so we are only just onto the 2014 data (in the perfect world hospitals would submit a months stats the next month so the annual data could be published by the end of February. We are not living in that world yet. Also we wouldn’t get sick in the first place in that world, which is why it would be so easy to submit the stats).

This set of stats is pretty detailed, it lists the number of patients with each of the ‘big 13’ cancers, at  stages 1, 2, 3, 4 or unknown for each CGG  (clinical commissioning group) in England. Stage 1 is early and good, stage 4 is late and bad. The 1 year survival for the ‘big three’ (breast, bowel and lung) has also been published for each CCG (the % of patients diagnosed in 2013 who were still alive at the end of 2014). It’s interesting to compare these two dimensions by graphing early stage of diagnosis (by adding up all the patients diagnosed in 2013 and 2014, except three cancers are new with only one year of data) against 1 year survival for each cancer for each CCG.

compare-early-diagnosis-with-1-year-survival

I find it pretty interesting that three such distinct clusters just fall out of the data.

In the bottom left is lung cancer. This unfortunately has very bad early diagnosis with only 14-37% of patients diagnosed with stage 1 or 2 and equally bad 1 year survival. Of all the patients diagnosed in 2013 only 24-47% where alive at the end of 2014, depending on where in England they were.

Colorectal is intermediate, 30-57% of patients are diagnosed at stage 1 or 2 and 68-85% were still alive at the end of 2014.

Breast is best with 72-96% of patients are diagnosed at stage 1 or 2 and 93-97% were still alive at the end of 2014.

I think it’s interesting because the variation across the two dimensions for all the CCGs (each dot in each group) is smaller than the variation between the different cancers (the space between the groups). So which cancer you get will affect you more than any variation that exists around the country. Bear in mind that differences between CCGs, might be due to something about diagnosis/treatment OR they might be due something about the population. Deprivation definitely plays a role, for example deprived areas have a much lower screening, which will reduce early diagnosis. So do the graphs show variation in treatment or variation in populations? This isn’t exactly about lifestyle factors. If you smoke a lot, your odds of getting lung cancer are higher, but what determines whether you are diagnosed at stage 1 or 4? What determines how long you have after that diagnosis?

While we can’t do a similar graph for any other cancers, as 1 year survival is only published for ‘all’ and ‘the big three’, we can look at early diagnosis for the next ten most common cancers.

The same data is shown two ways. The first graph on the left shows the early diagnosis for each cancer lined up by CCG. The second shows each cancer lined up by percentage.

early-diagnosis-2013-14

Looking at the first graph you can see that there isn’t much of a pattern, a CCG that has early diagnosis in one cancer has late diagnosis of another. Even if you can’t see that by eye, when you measure the correlations the surprising thing is that virtually nothing correlates with anything else. Of all of the 10 cancers shown, early diagnosis in one cancer in one place doesn’t predict early or late diagnosis in any other cancer (there are a few weak, correlations, but we can round that down to ‘nothing’). The next thing, shown more clearly in the second graph where each cancer is lined up in size order, is that while there is quite a range in the percentage of patients diagnosed early each cancer still has it’s own pattern. Melanoma is best then I’ve listed them in early diagnosis order on the graph.

Lots of things go into early diagnosis. Obviously it’s easier to spot stuff happening to your skin than to an organ buried in a bony cage, which is why melanoma is top of the list for early diagnosis and lung is near the bottom (though not in the same graph). So part of it will be your whether or not you have symptoms, then spotting those symptoms, going in to the GP, or screening to catch things before they start to produce symptoms…

Coming up to the end of the blog post, I’d like to close on the answer to all this variation, ideally with a few simple bullet points that would totally fix the problem. But unfortunately I’m all out of simple answers today (get changes in your body checked out? watch out for random bleeding? spend more money on the NHS?) It’s not that I don’t believe in simple answers, I just don’t have one here. Still if I haven’t got any good answers, hopefully it’s at least a good question.

Fancy meeting you here

It’s quite fun when two completely random books you’re reading happen to match up perfectly.

I’ve slowly been reading Edward Tufts’ Envisioning Information. One of the infographics describes “The slow, costly death of Mrs K”. (I wouldn’t have thought it was an infographic as it is also a wall of text).

The Slow, Costly Death of Mrs K__ ICUpsych

The case is described in Clinical Bioethics,  she lies in intensive care, being poked and prodded, so she can lie in comatose suffering for a month never recovering and so far as I can see, with no hope of recovering. None of those treatments prolonged her life meaningfully, or gave her a better death, however she might have defined that.

And this is half of what Atul Gawande’s book, Being Mortal is all about (because the ‘some doctors questioning the practice’ in 1984 evidently didn’t have much influence. Hopefully writing a best selling book questioning the practice will have more luck).

The first half is elderly care, equally fascinating, and very current for our aging populations. However it was the end of life care that I found most fascinating.

Atul highlights the difference good end of life care can make comparing two cancer patients and also his own Dad who had cancer, and how important it is to ask the patient the difficult questions and make it clear if they are up against a rock and a hard place. Not a rock and a cure.

He compares the two surgeons who advised his Dad on the rare spinal tumour that was squashing his spine and causing pain and paralysis. One surgeon advised instant action because he could be paralysed any minute and the surgery could cure him. The other surgeon pointed out that the surgery could equally maim or kill him and that these cancers usually grow quite slowly so he should hold out until the current pain and paralysis was intolerable enough that the risks of the surgery became more acceptable.  And the tumour was slow growing and Dr Gawande had two or three years of good life and good work (very important to him) before the surgery. In hindsight the operation went well and he had some more years after that, but that could never have been guaranteed.

Atul also told the story of two cancer patients, and how hospice care, provided in addition to normal cancer care, can actually prolong life (shown to be the case in the US). Part of the benefit was that the palliative care team could train the patient and their family in simple medical procedures so when the inevitable next step came along, they were prepared, knew what to do, had the medication to hand, and could cope. When the second patient became very breathless, without the hospice care they didn’t have oxygen at home, or the training in what to do, so they rushed into hospital where she was put her on as many machines as possible, leaving it to the family to decide when it was time to unplug her and denying her the the death at home she had wished for.

Atul also describes two such home deaths, of his father and of a patient, where, by fully understanding her wishes, he had carried out a much smaller scale surgery than he might normally have done so she was well enough to go home.

In order to fully understand the patients wishes you need to ask the right questions and Atul spelled out what he learnt (here it is in checklist form).

When you want to open up the conversation say: “I’m worried”. Then ask at each stage

  • “What is your understanding of the situation and it’s potential outcomes?
  • What are your fears and what are your hopes?
  • What are the trade-offs you are willing to make and not willing to make?
  • And what is the course of action that best serves this understanding?”

Sitting here writing/reading a blog you can see that these are incredibly easy questions to write down/read out. Applying them in real life probably takes a bit more practice. Indeed Atul was inspired to make the effort after remembering some pretty gruesome ‘wrong’ decisions made by patients who might have mistakenly thought the huge surgery would ‘save’ them rather than ‘give them back bladder control for the last few weeks of life’.

In Almodovar’s All about my Mother we see the Spanish doctors go through quite a lot of training on how to ask family to donate the organs of their loved ones. The people playing the family members think up lots of difficult, and racist, questions to train the doctors.

These are also questions any family member can ask. One story concerned someone who, despite working in this field nearly couldn’t have this conversation with her own Dad. On the way home she realised her mistake and went back to ask him, ‘what is the most important thing for you now’. He replied that as long as he could watch sport on telly and eat ice-cream, life still had meaning for him. When he was in the middle of surgery and the doctor asked the daughter what they should do, she know what the criteria were. If it goes wrong will he still be able to watch telly and eat ice-cream … ?