{18645} muscle definition

The most sensible measure of body fat would seem to be the thickness of the triceps skin fold, and that is how it is generally measured (the cited upper limit of good ranges from 1 cm to 1 inch).

Rather than define "obesity" or "excess body fat", let's just review the problems that fat causes:

Many cultures consider body fat to be un-aesthetic on one or both sexes. Other (less well-fed?) cultures think it's gorgeous on one or both sexes.

Musculoskeletal problems (bad back, hips, knees) result from the sheer weight of fat. According to some studies, this is the most troublesome aspect of being fat (Br. Med. J. 301: 835, 1990).

For some reason, obesity seems to contribute to high blood pressure, and losing weight makes high blood pressure easier to control. Nobody knows why (the explanations I've read seem pretty far-fetched.)

Fat is an endocrine organ, and when abundant produces a welter of hormones that are only now being sorted out. Lots of fat contributes to insulin resistance, and can unmask type II (insulin resistance) diabetes. This remains poorly-understood though there are many ideas.

Obesity somehow contributes to the development of gallstones.

"Fat is the surgeon's enemy", making surgery more of a physical problem, and perhaps delaying healing (J. Am. Coll. Surg. 185: 593, 1997; idea dismissed Lancet 361: 2032, 2003).

Very obese people have trouble keeping their airways open, especially during sleep ("Pickwickian syndrome" / "bad sleep apnea", not the whole story).

Obesity contributes to uterine cancer by enhancing activation of estrogens. (Supposedly. For the same reason, women with very little body fat do not menstruate and are at extra risk for osteoporosis.) By contrast, however, obese older women often have scanty or absent menstrual periods "because the fat binds all the estrogens". (* Sound dubious to you, too?)

Somehow obesity supposedly raises serum uric acid levels and increases the risk for gout.

It is harder for a fat person to keep the intertriginous regions of the skin dry and clean, and skin breakdown and superficial fungus infections are common here.

The physics of being fat may contribute to varicose veins.

Obesity supposedly also lowers HDL cholesterol as part of syndrome X. Wait until this is sorted out, and remember that exercise does help these folks.

Obesity supposedly causes left ventricular hypertrophy (JAMA 266: 231, 1991, maybe from extra work carrying all that bulk; I'm not aware that this is necessarily bad). In an autopsy series of 76 fat Texans, every one of them had a big heart using the unscientific criteria of "maximum 280 gm for women, 360 gm for men" (Arch. Path. Lab. Med. 132: 1397, 2008) -- the authors attributed this to "the high metabolic activity of excessive fat" and "cardiomyopathy of obesity"; your lecturer think both the cardiac changes and the also-described changes in the pulmonary vasculature (mostly veins) result from years of lugging around all that extra poundage. Being fat also correlates with lack of exercise and perhaps smoking and/or "stress"; all these (plus hypertension and diabetes) are "bad for the coronaries", and losing weight reverses some of this effect. Obesity pretty much disappears as a coronary risk factor when you control for high cholesterol, high blood pressure, smoking, diabetes, and lack of exercise. Ask your internist. (The claim that "fat makes the heart work harder because of the extra blood vessels" is basically a myth, since the heart is pumping the same amount of blood. You are lugging around more physical weight. The epicardial fat pads are NOT atherosclerosis.)

There's a popular claim that adiposity, apart from hypertension, diabetes, tobacco, and so forth is an independent risk factor. It usually doesn't hold up to scrutiny (Am. J. Pub. Health 84: 14, 1994), or if it does, it's the abdominal adiposity (i.e., forget "Quetelet's index" and "the triceps skin fold" and just tell us you waist size.) It's true that really fat people seldom live to be very old. But even the latest "big study" (Ann. Int. Med. 138: 24, 2003) controlled for smoking but DID NOT control for high blood pressure, diabetes, or failure to exercise. And it's hard to control for the fact that somebody who's overweight may otherwise not be so health-conscious.

Given all the above, I have seen no clear evidence that being moderately fatter than the next person is, by itself, anything more than a cosmetic problem.

* In fact, I have taught the politically incorrect idea that non-extreme obesity, by itself and not as an indicator of otherwise-poor self-care, is not a health risk ever since I started in the late 1970's. But it's common sense. This now has strong empirical support despite all the government and pop-culture hoopla. Americans are fatter than we were even in the 1950's. But where is the excess mortality? Live expectancy rises, and incidence and deaths from stroke and heart attack drop steadily even as we get fatter and fatter. Finally, full-time scientists are saying the same thing. See especially Sci. Am. 252(6): 70, June 2005, "Obesity: An Overblown Epidemic", which reviews what I've always believed and give you the facts so that you can begin thinking about how this particular crock was perpetrated on the American public. (Uh, you decide. The business people couldn't be trying to sell us anything, could they? The entertainment industry, showing us skinny "beautiful people", couldn't be trying to get business for sponsors, could it? The government couldn't be trying to take our minds off something else, could they?)

On the other hand, no reasonable person questions that morbid obesity (i.e., the sort of obesity that will get you a gastric bypass) is a health problem. It's now clear that the surgery greatly reduces one's chance of dying young (NEJM 357: 741 & 753, 2007).

The "being fat is bad for you" business continues. JAMA 298: 2028, 2007 looks at body mass index and actual cause of death, as somebody should have decades ago.

"Underweight was associated with significantly increased mortality from noncancer, non-CVD causes, but not associated with cancer of CVD mortality." (I trust no one was surprised that the cirrhotics, AIDS patients, heroin addicts, pink puffers, Alzheimer's patients, and frail elderly died skinny.)

"Overweight was associated with significantly DECREASED [emphasis added] mortality from noncancer, non-CVD causes, but not associated with cancer or CVD mortality." (So I've been right all along in telling folks that "being a little bit overweight isn't bad for you.")

We've been right about cancers that are considered obesity-related (postmenopausal breast, endometrium colon, kidney, esophagus), but it only matters in the really obese.

Obesity is less associated with CVD mortality now than in the past. (This tells me folks are watching their diets and taking their medication.)

You can read up yourself on "obesity as the cause of systemic inflammation"; the hormonal milieu is different, and we already know this contributes to diabetes and perhaps to hypertension, Alzheimer's, and goodness-knows what else. Obviously we did not evolve in conditions on unlimited food supply like we have now, and obesity being new can't be entirely beneficial. There's an easy introduction in Nature 447: 525, 2007 ("The Two Faces of Fat") -- a stuffed adipocyte is hormonally unlike a lean adipocyte.

When someone asks me, "Doctor, what is my ideal weight?", my "unscientific" answer is, "Whatever looks and feels right to you".

HUNGER IN THE U.S.

Malnutrition is a common finding in the chronically sick (who may have malabsorption, may not feel like eating, may not be able to afford good food, or may need help that is not available)

In alcoholism, look first for folate and thiamine deficiency and protein-calorie malnutrition. Vitamin A and vitamin B₆, listed in "Big Robbins", are less obvious. The two cases of scurvy that I have seen were both in chronic alcoholics.

Poverty, ignorance, stupidity, faddism, indifference and child abuse are the causes of malnutrition of healthy children. Simply putting single moms on the dole does not help if they are physically or mentally sick or substance-abusing (Am. J. Pub. Health 94: 109, 2004 -- documents what has long been common knowledge.) Prosecuting Texas parents who starve their children on a goofy fad diet: Pediatrics 116: 1309, 2005.

WORLD HUNGER (See CMAJ 173: 279, 2005): Still our world's most serious problem.

As used by social scientists, POVERTY means a total income less than three times the cost of a healthy, varied diet. ABSOLUTE POVERTY means a total income less than the cost of a diet sufficient to allow the person to work at his or her maximum capacity. Presently, one human being in seven lives in absolute poverty. The DEMOGRAPHIC TRANSITION is the transformation of a society from high-birth-rate, high-mortality to low-birth-rate, low morality, along with all the changes that happen as a result (adequate nutrition, peace, safety, more opportunities to lead satisfying lives, public health, a cleaner environment, the rule of decent law).

KCUMB students: The rest of this handout is "for your information" rather than tomorrow's exam. Don't be surprised if it impacts not only your discussions with friends, or even your own future.

It is very difficult to 'love thy neighbor' when basic resources such as clean water, energy, land, work, health care, and food are severely limited. These resources become daily more scarce because of the policies of the leaders of [---] and [---]. A huge "underclass" exists on a global scale and is evolving even within the richest nations. To organize an equitable distribution of basics worldwide seems impossible; and we face a future of even more nationalism, racism, ethnic and religious fanaticism, and ecological disaster. How to solve these problems nobody knows, but one thing is clear -- that the larger the world population, the more difficult it will be to achieve peace and justice on earth.

-- Lancet 342: 473, 1993 (read it all)

Neglect of an effective birth control policy is a never-failing source of poverty which in turn is the parent of instability and crime.

-- Aristotle, "The Politics", c. 334 B.C.

All wars arise from population pressures.

-- Robert Heinlein

Beyond a critical point within a finite space, freedom diminishes as numbers increase. This is as true of humans in the finite space of a planetary ecosystem as it is of gas molecules in a sealed flask. The human question is not how many can possibly survive within the system but what kind of existence is possible for those who do survive.

-- Frank Herbert, "Dune"

"Big Robbins" eloquently describes the problem of people simply not having enough to eat. There is a great deal of bad information about the causes and possible remedies for world hunger, and there are many opportunities for people with agendas to lie with statistics.

Goya, "Famine"

The most important event of the twentieth century was the DEMOGRAPHIC TRANSITION, the change throughout much of the world from high-fertility and high-mortality to low-fertility and low-mortality. In a majority of today's nations, people now have a reasonable expectation of living, and having their children live, through healthy middle age. And there is far greater personal security and many more opportunities for a person to choose his or her path through life. Antibiotics, safe surgery, sanitation, immunization, and reliable birth control have made this possible. And of course real democracy is at the heart of the change. As a result, fertility drops to zero-total-growth. Today, the populations of the US, Northern Europe, and Australia-New Zealand grow only by immigration. And as less-developed countries such as Mexico, Brazil, India, and Indonesia urbanize, the fertility rate has been dropping dramatically.

In 2008, the highest fertility rates were in the poorest nations of sub-Saharan Africa, with 48 births / 1000 population each year. Even with enormous childhood mortality, populations will double every 25 years or so. Palestine, Afghanistan, and Yemen also have very high birth rates. In the Western Hemisphere, Haiti, Guatemala and Bolivia have the highest rates. Each of these nations has special problems that have prevented the demographic transition. The lowest birth rates (around 8 per 1000) are in the emerging Soviet-block nations, with older populations and transitionining to a first-world economy.

In 1950, half the people in the world went to bed hungry. Today, only about 1 person in 7 goes to bed hungry. In 1960, the average person got 1900 calories per day; in 2000, it was up to 2700. In the developing world, grain production per capita has grown from 155 kg/person in 1960 to 225 kg/person today; the rise has been basically steady. Much of this is the result of the "green revolution" of the 1970's that developed and introduced strains of staple plants that grow more food when subjected to intensive irrigation and fertilization.

* Average grain production per person worldwide peaked in 1984 at 344 kg/person and has been declining slightly ever since. The real reason is that people in the developed nations simply cannot eat any more of the locally-grown stuff, or even feed any more to the animals we eat. And there are many more people in the developing world. This statistic is often cited by "environmentalists" as a sign of impending disaster. Do you see the fallacy?

* We are often told that the prosperity of the developed nations (including the health and opportunities that we enjoy) is built upon, and depends upon, the poverty of the rest of the world. This is dogma in many "progressive" circles. (It's a favorite claim of many of my fellow-Anglicans.) And it is noxious falsehood. It's true that many countries use natural resources to produce luxury goods for export while they still have hungry citizens. But this contributes very little to the prosperity of the developed world, which is based on the rule of law and government policies that promote a strong economy and opportunity for anyone willing to work hard. No one has been able to explain to me how I am enriched by the hunger of a child in a kleptocracy where being honest, smart and hard-working gets you nothing (or gets you in trouble or dead) -- a fact that the Left simply ignores. More on this below.

Only a fool or an ideologue could believe that we could feed our 6 billion people without chemicals and other technology. And the Green Revolution has not been without its problems. Radical irrigation programs have contributed to the expansion of the world's deserts. So has the kind of overcultivation that leads to the washing away of soils. And even fertilizers, of course, damage soil over the long run. You'll hear many different claims about just how serious this is; I have noticed that very little is being written in refereed scientific journals about soil depletion as a long-term threat. I do expect that there will be some new conflicts over water availability in the next decade, especially in India, Pakistan, North China, and the Middle East. When (not "if") we run out of petroleum, we will need an alternative source of cheap energy to continue producing fertilizer. (I'm hoping for controllable nuclear fusion, but this may never be possible. Perhaps I'll live long enough to see construction begin on the huge solar panel in the Sahara...)

Somalia, early 1990's

The bottom line is that in today's world, all hunger is political. Until 2007, there was a global food surplus, i.e., plenty of food to feed everyone, including the children. The problem was in the distribution -- and herein lies the ongoing problem. Today's world food shortage should be remediable in the short-run, but the problems remain the same, and will only get worse as long as it is in the interest of people in the poor nations to have large families. Yes, it's baffling (J. Am. Diet. Assoc. 103: 1046, 2003) -- especially if you don't think the near-unthinkable. Right or wrong (or neither), hunger remains the major means of keeping people under control throughout the poor nations. Wherever there is widespread hunger, it is because people with guns are preventing good people from the rest of the world from bringing in food.

Most of the suffering is borne by children (Br. Med. J. 304: 1423, 1992); in fact, as recently as the 1980's, around 40% of the children in the developing world died before reaching age 5 (Med. J. Aust. 154: 227, 1991), and in the large majority of cases, malnutrition is at least a major contributing factor. How the new, more-effective UNICEF does its work today: Lancet 364: 1801, 2004. (New term: a "complex emergency" means a war using hungry civilians as pawns.)

The world population is growing by perhaps 96 million per year, almost entirely in the poor nations. In some poor countries, population has doubled every 17 years (Lancet 33: 1705, 1990), with hunger providing the principal brake on an even more rapid rate of increase. The U.S., Canada, Northern Europe, and Australia have populations that grow only by immigration. We learn with hope of a spectacular drop in fertility during the 1990's throughout the historically poor nations of East Asia and Latin America as young adults see a future of greater economic opportunity and personal freedom in the new democracies. We can hope that someday that this will be true everywhere. In countries in which the average woman has 7 children and there is 40% chld mortality, the population still doubles every 25 years (Science 266: 771, 1994). In Jamaica (in our own back yard), simply alleviating hunger in the classroom makes for vast improvements in learning (Am. J. Clin. Nut. 67: 790-S, 1998).

In the early 1990's, health care and quality-of-life standards plummeted as sub-Saharan Africa went broke (Lancet 345: 182, 1995). There was talk about "the malthusian ceiling" being approached (Lancet 341: 669, 1993). And not surprisingly, famine, epidemic disease, and race wars ("ethnic conflicts") followed. In the early 1990's, the single country with the worst numbers was Rwanda (Br. Med. J. 311: 1651, 1996); we all saw what happened, and more of the same will happen soon in the area. In the 1994 edition of these notes, I predicted the explosion in Sierra Leone, which soon followed and which the world ignored. (The "rebels" in this weird war had a special fetish for performing machete amputations on children. War crimes trial began 2004.) The Taliban kept the ordinary people of Afghanistan under-nourished (JAMA 286: 2723, 2001). In the past few years, several of the sub-Saharan countries have made dramatic turn-arounds. In 2000, crop failures in Ethiopia were massive but there was no famine as the world relief agencies were able to come in unhindered (JAMA 286: 563, 2001; Lancet 358: 498, 2001; Lancet 362: 1808, 2003). Rescuing children from famine in Guinea-Bissau: Am. J. Clin. Nutr. 80: 1036, 2004. At the same time, Kabila's famine claimed the lives of at least 2.5 million people in the Congo alone, where misgovernment, population pressures, famine, economic collapse, and civil war perpetuate one another. Now it's Mugabe's famine in Zimbabwe, Mwanawasa's famine in Zambia, the genocide in Darfur (NEJM 351: 2574, 2004; Br. Med. J. 330: 110, 2005; Lancet 364: 1315, 2004; JAMA 293: 1490 & 2212, 2005), and the Niger famine (the world's poorest country; the aid from 2004 was taken by profiteers and sold to the highest bidder: Lancet 366: 1067, 2005; the ongoing problem Lancet 375: 1151, 2010.) Starvation in "the new South Africa": Lancet 363: 1110, 2004. Eritrea refused to accept food aid in 2009 in the hopes of gettings its excess population to emigrate to Ethiopia and Somalia. The rest of the world does not even seem to be paying attention.

The world has only recently begun talking straight about the problem, especially in sub-Saharan Africa. Even today, there are still outcries from extremists on both Right and Left against condom distribution. (The last bastion of anti-condom activism now resorts to obviously false claims, i.e., that sperms and HIV viruses easily penetrate the membrane: Nat. Genet. 9: 1443, 2003). Events like the 1992 "Earth Summit" produced enormous documents about how to "conserve the environment", "maintain wilderness areas", and "preserve species diversity" while keeping strict politick silence on population growth to please certain powerful politician-ideologues. One spectacular change was the embracing of thoughtful population-control policies by mainstream Islam: Lancet 343: 583, 1994. Today, the Islamic Republic of Iran has an extremely strong and highly successful family-planning program: Stud. Fam. Plan. 31: 19, 2000.) The taboo about talking of population: Br. Med. J. 315: 1441, 1997; even in 2008, a realist points out that you're still not allowed to say, "People shouldn't be having babies they can't feed" (Lancet 372: 206, 2008 -- this even has a name "The Hardinian taboo").

The era of cheap food is over. In the past year, the cost of wheat has risen by 130%, rice by 120%, with corn and soya not far behind. As a result, millions of people are starving.... After the collapse of the US housing market, investors are ploughing trillions of dollars into commodities, such as food and raw materials, resulting in a "commodities super-cycle" where commodity price inflation feeds on itself leading to hugely inflated prices.... Biofuels once perceived as the green alternative to fuel have recently been discredited. After the agricultural displacement effects of these fuels are taken into account, emissions from biofuels are many times worse than those from fossil fuels. Yet in the drive to make the USA self-sustaining for fuel production, massive ethanol subsidies and millions of acres of American corn have led to a boom in biofuels. American cars now burn enough corn to cover the import needs of 82 food-deficit countries...

-- Lancet 371: 1389, 2008

Disaster struck in late 2007, with the sudden skyrocketing prices of basic foodstuffs (which had already been rising for a few years as investors saw the coming "opportunity" presented by a hungrier world -- BMJ 336: 1336, 2008.) In early 2008, there were food riots among the poor throughout much of the developing world. Nina Fedoroff, George Bush's administrator for the US Agency for International Development, gave what I thought was a halfway fair account -- a combination of using grain for biofuels (J. Am. Diet. Assoc. 107: 1870, 2007 -- producing 25 gallons of ethanol for fuel consumes 450 lb. of corn, enough to feed a poor man for a year), a lack of fertilizer in the poor nations, and most of the world's misguided rejection of genetically modified crops (Science 320: 425, 2008). Notice that this is a reversal from Bush's call in his 2007 State of the Union address for a fivefold increase in the production of biofuels in the next ten years. Understandably the spokesperson did not point out the rest of the ugly truth. She didn't mention the ongoing population explosion in the hungry nations, or the likely impact of global warming on weather, or the US sub-prime mortgage fiasco of 2007 that drove investors into the commodities market ("the commodities boom"), doubling the prices of food in the poor nations (Lancet 371: 1648, 2008; J. Am. Diet. Assoc. 108: 615, 2008). Things will get worse before they get better -- in the developing world and in the United States. And in the meantime, the high prices of both food and fuel to deliver it have caused a massive drop in the ability or willingness of the rich nations to deliver food aid (BMJ 336: 1397, 2008).

Following Virchow, and most reasonable people nowadays, I still place most of the blame for today's world hunger and overpopulation on misgovernment in the poor nations. Today's medical literature is no longer keeping silent, either: Lancet 359: 2030, 2002. The economic disparities between rich and poor in today's kleptocracies far exceeds those under colonialism. Too many countries are still governed by hoodlums toting cast-off U.S. and Soviet-made machine guns. Governments are indifferent to the well-being of the governed, and "aid for International Development" usually hasn't reached the poor (Br. Med. J. 311: 72, 1995). Our military campaign in Somalia ("Operation Restore Hope") was undertaken to end a famine, and ended with our realizing the horrible truth -- tyrants don't want famine to end. See JAMA 272: 386, 1994, CMAJ 149: 1522, 1993; Lancet 342: 190, 1993. The ongoing famine in southern Sudan, which has been a fact of life since the mid-1980's, has been deliberately orchestrated by its politicians and warlords (Lancet 354: 832, 1999; J. Med. Ethics 28: 49, 2002). In the late 1990's, Zimbabwe's Mugabe collapsed his own country's economy by calling for "justice" and seizing the productive land for his family and friends (CMAJ 163: 1616, 2000; Lancet 359: 455, 2002). And in 2002, during a famine in his country, Zambia's president Levy Mwanawasa simply impounded the maize that the US donated and let it rot. Of course, he claimed to be outraged because the maize had been genetically modified, just the same as people in the United States and Canada eat every day. ("I refuse to allow my people to be used as guinea pigs." "There's no justification for feeding people 'poison'." "We may be poor and experiencing severe food shortages, but we aren't ready to expose our people to ill-defined risks.") See Lancet 360: 1261, 2002, and draw your own conclusions. In 2008, a "complex emergency" caused famine in Ethiopia, and when Unicef called for desperately-needed food aid, the Ethiopian government called them liars (BMJ 336: 1397, 2008).

The US intervention in Somalia was intended to protect food relief workers.

* Even the postmodernists and super-multculturalists wised-up to the abuse of aid during the 1990's. See "The Symphony of the Damned: Racial Discourse, Complex Political Emergencies, and Humanitarian Aid", Disasters 20: 173, 1996, which describes third-world hoodlums demanding "justice" and putting the Free World's disaster relief into their private bank accounts; "This functional ignorance has allowed a widespread incorporation of humanitarian aid into the fabric of political violence. Developmentalism is an essential underpinning for the growing organizational accommodation to ongoing conflict and eroding standards of justice and accountability".

Under this misgovernment, a large family offers the only economic security or opportunity for personal satisfaction, and a family's survival often depends upon child labor (especially in rural areas, Sci. Am. 272(2): 40, 1995). Here only 1 couple in 3 uses any kind of birth control (reports vary widely, though, from nation to nation; for example, in Nigeria the large majority of teenaged girls are sexually active, only 5% have ever used a modern contraceptive, and 25% have had an elective abortion: Lancet 345: 300, 1995 -- the figures have probably changed little). Especially as we face climate change, physicians have issued strong calls for universal access to family planning (BMJ 337: 247, 2008)

Overpopulation, hunger, and poor health clearly work in the interests of the hoodlum governments. On the flip side, the people now running most of the world (i.e., the capitalists of the global economy) are quite content with widespread poverty and hunger, since it keeps labor costs down in the sweatshops where the poor people make the rich people's luxury goods.

Most rich and most poor people want access to birth control, regardless of their religion (Lancet 342: 447, 1993; article contains blunt talk); yet certain religious denominations use their political clout in the poor nations to make this hard-to-get (Lancet 342: 473, 1993; more blunt talk; this article sparked a fire-storm and was part of the basis for review by the Islamic leaders).

In addition to overt protein-calorie malnutrition, hungry people are more subject to a host of infectious diseases, including measles, malaria (Am. J. Trop. Med. 71(S2): 55, 2004), and the parasitic infestations.

As with all discussions of science and policy, public discussion of world hunger is marred by disinformation campaigns by the "right", the "left" and the "greens". In particular, you will hear the current "green / animal rights / vegetarian" claims that world hunger is caused largely by animal farming. Historically, it was clearly not true (Nature 355: 582, 1992), and the disinformation campaigns transparently false (Sci. Rev. Alt. Med. 1: 36, 1998). One reason among many for rising cereal prices over the past few years has been the increasing taste of the new middle-classes in China and India for meat (BMJ 336: 1336, 2008). However, the effect seems to be minor compared with the biofuels fiasco and overpopulation. It is still dogma in many left-wing circles that cattle ranching in the United States is the basis of both world hunger and global warming. And this is still obvious disinformation. What do you plan to do with semiarid range land if you do not raise grazing animals? Think about the alternatives (i.e., millions of unmanaged herd animals, dying of old age and rotting where they fall -- while hungry children starve in the rest of the world. What's this about "cruelty"?) And even the one scientific publication I could find on the subject of methane in cattle flatus causing the greenhouse effect estimated the contribution at "a little less than 2%" of the total (J. Animal Sci. 73: 2483, 1995). And the much-missed buffalo herds didn't f*rt? And so forth, ad nauseam.

Of course, ideology has had a terrible impact on global hunger. The greatest famines of modern times were brought about by the stupidity of the Communist superstates. Stalin's biology guru was Thaddeus Lysenko, a left-wing kook who was repelled by scientific biology's vision of a competitive world (too much like capitalism). Lysenko (and Stalin) believed that "living things strive for higher perfection" (harmony-in-nature, cabbages want to be good socialists, etc., etc). Stalin killed the bioscientists who dared to disagree. Lysenko's beautiful mysticism led to moronic agricultural policies (much of Russia was planted with crops -- including some weird hybrids -- that could not possibly have grown where they were planted), enormous crop failures, and the deaths of around 10,000,000 Soviets. During Mao Zedong's "Great Leap Forward" in 1959-1961, between 36 and 50 million Chinese died as a result of similar ill-advised land-management policies, frustrating Mao's intention to overpopulate China and use the surplus as cannon-fodder as he had done so successfully in Korea. (The awful population increase came later, with government policies encouraging large families.) Mao sought (as he put it himself) to "conquer nature". Mao actually announced that he was going to exterminate sparrows and field mice. Lysenko sought "harmony with nature". Neither actually UNDERSTOOD nature. I'd welcome a talk in lab (instead of doing a patient case) on this important topic. The North Korean famine of the 1990's was also caused by government policies that seem to be deliberate: Lancet 345: 291, 1999. Less ideological... Saddam Hussein prevented good people from bringing food to Iraqi children in order to mobilize world opposition to sanctions against his regime: Ann. Int. Med. 132: 155, 2000; Lancet 355: 1851, 2000. And malnutrition among Palestinian children in the Gaza strip is far worse than in most other poor nations (Br. Med. J. 325: 1057, 2002). Again, this is orchestrated by politicians for show.

The answers to world hunger have come from science, reasonable security, and reasonable freedom. Mainland China's introduction of limited free enterprise resulted in greatly increased agricultural output. Food production literally doubled as soon as individual farmers were allowed to manage their own farms and make a small profit; Vietnam had the same thing happen beginning in 1986, when private farming replaced collective farming. China is now self-sufficient, feeding 1/5 of the world's population on 1/15 of the farmland. The result has been substantial growth for its children (NEJM 335: 400, 1996). The left-wing authors of this curious paper do not see this reflecting the awful truth about socialist government, but spend most of their paper complaining the "improvement has not been equitable", i.e., many kids are still growth-stunted in the communist rural zones but few kids are stunted in the capitalist urban zones.)

In Cairo (1994, review Lancet 353: 315, 1999), most of the world (even the kleptocracies) paid lip-service to population control, sought cost-effective forms of birth-control and laughed (publicly) at the anti-contraception religionists. Curiously, delegates didn't complain much (though some did) about "Western cultural imperialism" as the cause of the worldwide "redefining of sexual roles" (i.e., a woman can decide whether or not to have sex before marriage, who and whether she will marry, and about birth control inside or outside of marriage). We'll hear about the "Cairo Mandate" in the future, and it may help.

I would prefer real democracy (i.e., the ability of the world's poor to force their governments to become representative) to any other solution. You will need to decide for yourself about the current left-wing "good cause" of debt-relief without accountability for past or present kleptocracies, in the hopes they will pass the benefits along. The late unlamented Mobutu Sese Seko's $5 billion dollar estate would be enough to pay the current foreign debt of the Congo, the nation that he looted during his decades in power. Even the Africans now say that the past two decades of "neoliberal policy" (i.e., the developed nations providing financial support for the corrupt governments) is a major cause of the declining standards of health and nutrtion, and that the current "debt relief initiative" is just more of the same (Int. J. Health Serv. 33: 607, 2003). By contrast, debt relief for governments that actually give evidence of governing responsibly and caring for their people is an established fact, supported by a major act of Congress and occupying much of the focus of the International Monetary Fund and World Bank (Health Policy & Planning 18: 138, 2003; Bull. WHO 80: 151, 2002).

Sudan, 1994. A vulture waits for a child to die.

The generally-left-wing anti-hunger group Oxfam has taken the position that it's best to have the governments of the poor nations, rather than private donors, provide health care to the needy, i.e., give the governments the money (BMJ 338: b667, 2009). They note that the worse the health care in a poor nation, the greater involvement of private individuals, NGO's and the World Bank. The fallacy is obvious -- the poorer the care provided by governments, the harder good people work to make up the difference. Go figure. On Oxfam, see also BMJ 338: b1202, 2009 and "The Economist" Nov 7, 2006 ("economic illiteracy" behind Oxfam's campaign against Starbuck's). Over the years, Oxfam has taken widely varying positions on biotech crops, to my eye as the political winds shift. All this would be a subject for a good report in lab.

In the next decade, pay special attention to individual nations, and how government policies affect hunger. When individuals are guaranteed the right to their own land and to the profits from farming, the demographic transition will take place, and the world will be astonished. When governments (using whatever excuses) interfere, expect continued famine. I would hope that the world financial institutions do what they can to make governments choose the right path for their people. Ultimately, I would hope for a world in which it is the norm for people to be able to find satisfaction, fulfillment, and security without having babies they can't afford to raise, and enjoy a reasonable chance for a healthy life. Dr. Virchow's prescription of "true and complete democracy" is also my prescription. There has never been a famine in a real democracy, no matter how poor. Democratization requires breaking the cycle of poverty, tyranny, corruption, maladministration, frustration, violence, and stupid right-wing and left-wing ideologies. Can this happen? After 30 years as a physician, I think I'm finally seeing it. And so do others (Am. J. Pub. Health. 90: 1838 & 1841, 2000). But I do know that physicians are the natural leaders in understanding and clarifying the problems that cause world hunger, and in finding solutions.

If, of all words of tongue and pen,
The saddest are, "It might have been,"
More sad are these we daily see:
"It is, but hadn't ought to be."

--Bret Harte, parody of Whittier

LAST STUFF

Irradiating food to kill microbes is a well-established technology and is obviously safe. For decades, the anti-nuclear movement, and particularly "Public Citizen", successfully blocked radiation of food, even though it will go a long way to prevent the 2000-odd annual US deaths from salmonellosis and lower the 20% spoilage loss of food in the poor nations. Of course, the problem was ideology (and of course expense), rather than any realistic health dangers of "nuked food". "Environmentalist" broadsides merely cite the possibility of a radiation leak (so should we close down the cesium-137 treatment units in hospitals, Ralph?), and alleged production of trace amounts of a single suspected carcinogen (so are you going to stop eating pepper, Ralph?) Even the folks who have found "scientific evidence" of the health risks of such things as agent orange and electrical power lines never published on this. For reviews, see JADA 96: 59, 1996; Am. Fam. Phys. 47: 1064, 1993. Dairy Queen introduced nuked burgers in the early 2000's, and thankfully this attracted almost no attention from the mainstream. My most recent search (2007) showed no identified real hazards to humans; irradiating ground beef to prevent E. coli outbreaks is widespread and again is receiving almost no attention.

We have already reviewed "Diet and Cancer" under "Neoplasia". The material in "Big Robbins" is highly speculative. The results are so confusing (for example, in 2008 we have beta-carotene INCREASING one's risk for lung cancer) that you're unlikely to be tested on the subject on licensure exams.

The relationship of diet and colon cancer is once again up for serious questions, with the failure of the last several studies to confirm the traditional wisdom that low-roughage, high meat diet is carcinogenic. More about this later.

High animal-fat diet was never plausibly linked to breast cancer, and the idea now seems to be discredited. (More about this later.)

A group in Hawaii looked at lung cancer and found no correlation whatever with anything whatever in the diet (Arch. Env. Health. 48: 69, 1993).

The epidemic Chinese throat cancer has been tentatively linked to ingestion of a fungus-rich, pickled salt-fish ethnic delicacy.

Bad diet (lots of iron, lots of aflatoxin) conspires with hepatitis B infection to produce liver cancer in poorer nations.

Women who have very low levels of vitamin A are supposedly at greater risk for breast cancer, but beyond this, there's no apparent benefit from extra vitamin A in preventing breast cancer. No relationship between vitamin C and breast cancer could be found (NEJM 329: 234, 1993).

* A huge study in a Red Chinese population with a tremendous prevalence of esophageal and stomach cancer found a small reduction of these tumors in patients supplemented with tablets containing vitamin A, vitamin E, and selenium. No effect was demonstrated for retinol plus zinc, riboflavin plus niacin, or vitamin C plus molybdenum. JNCI 85: 1483, 1993.

* Calorie restriction in experimental animals, notably Li-Fraumeni mice, delays the average onset time of their cancers. Nobody has any idea why, unless perhaps epithelial cells turn over less in hungry critters (Proc. Nat. Acad. Sci. 91: 7036, 1994).

NOTE: Do yourselves a favor and read a chapter on nutrition in a good "path" book. I especially recommend the sections in "Big Robbins" on diet and systemic disease, and diet and cancer, for your own interest. Decide for yourself about the questions raised, after reviewing the evidence in the references. If you want nitrites removed from food, please either get hot dogs banned altogether or find another way of preventing botulism. I believe "Big Robbins" is being over-cautious in questioning the usefulness of dietary modification in preventing and reversing atherosclerosis.

NOTE: In recent years, the single clear instance of "a poisonous chemical in our food" was 1,1'-ethylidenebis[tryptophan]. This impurity caused the gruesome eosinophilia-myalgia syndrome in hundreds of health food store patrons (Review: Mayo Clin. Proc. 66: 535, 1991).

BIBLIOGRAPHY / FURTHER READING

I urge anyone interested in learning more about this topic in pathology to consult these standard textbooks.

Robbins and Cotran Pathologic Basis of Disease
Rosai and Ackerman's Surgical Pathology
Rubin's Pathology: Clinicopathologic Foundations of Medicine
Silverberg's Surgical Pathology


In my notes, the most helpful current journal references are embedded in the text. Students using these during lecture strongly prefer this. And because the site is constantly being updated, numbered endnotes would be unmanageable. What's available online, and for whom, is always changing. Most public libraries will be happy to help you get an article that you need. Good luck on your own searches, and again, if there is any way in which I can help you, please contact me at scalpel_blade@yahoo.com. No texting or chat messages, please. Ordinary e-mails are welcome. Health and friendship!

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Teaching Pathology

PathMax -- Shawn E. Cowper MD's pathology education links
Ed's Autopsy Page
Notes for Good Lecturers
Small Group Teaching
Socratic Teaching
Preventing "F"'s
Classroom Control
"I Hate Histology!"
Ed's Physiology Challenge
Pathology Identification Keys ("Kansas City Field Guide to Pathology")
Ed's Basic Science Trivia Quiz -- have a chuckle!
Rudolf Virchow on Pathology Education -- humor
Curriculum Position Paper -- humor
The Pathology Blues
Ed's Pathology Review for USMLE I
Part I
Part II