by Michael Applebaum, MD, JD, FCLM
This rant is not as light as some others. It is a bit more serious.
Godwin's Law states, "As an online discussion grows longer, the probability of a comparison involving Nazis or Hitler approaches one." (For a more complete discussion, go to http://en.wikipedia.org/wiki/Godwin's_law )
The longer the discussion, the older it is.
The NEJM did not take long to compare the sick care workers at Abu Ghraib to the Nazis.
Perhaps this is NEJM's nod to anti-aging medicine.
NEJM has had to admit to publishing some bad information. For examples, see:
NEJM, perhaps a bit self-righteously, was quick to condemn the sick care workers as Nazis. Whether their behavior is worthy of that comparison is debatable.
But when NEJM had a chance to really "expose" sick care at its World War II best, it lost courage.
It is apparently tougher for NEJM to do something to help people (i.e., patients) than it is to engage in name-calling.
Then again, who really suffers when bad medical treatment is administered? Why the patients, of course.
And who benefits? Why the medical profession, of course. It gets paid to create the problem and then administer the new therapy in an attempt to fix the problem it caused in the first place.
Perhaps NEJM is just being a good servant of the profession.
The following text was submitted to the NEJM for publication. They chose not to publish it. Another bad decision, in my humble opinion.
In the July 29, 2004 issue of
The New England Journal of Medicine, [i] psychiatrist Robert Lifton,
suggestively placed the behavior of physicians at Abu Ghraib on a continuum in
direct line with the Nazis who, “In addition to cruel medical experiments,
many Nazi doctors, as part of military units, were directly involved in
This is a decidedly weak
When all is said and done,
the number of sick care workers implicated at Abu Ghraib is likely to be small.
In contrast, the Nazi killing machine was of substantial size, since, according
to Dr. Lifton and NEJM, “many Nazi doctors…were directly involved in
killing.” Also the quantity of those affected at Abu Ghraib was relatively
small compared to the victims of the Nazi physicians. [iii]
Such an anemic comparison
does not begin to approximate the true magnitude of harm that can be caused when
a systemic policy emulates Nazi conduct. [iv]
If Dr. Lifton and NEJM
feel a need to draw comparisons between the behavior of “many” involved in
sick care and the Nazis, a much better place to look may be the weight loss
advice the sick care industry provides to the public. [v]
“Killing” is defined as:
To deprive of life
or apt to kill; fatal. [vi]
Thus, it can be reasonably
inferred that shortening life or placing one in a position where life can be
shortened is a form of “killing.”
If we believe what the sick
care industry says, the answer has to be a definite “yes.”
These conditions [vii]
which can result in morbidity, mortality and diminished quality of life are
associated with overweight/obesity:
Coronary heart disease
The sick care industry
recommends weight loss for the overweight or obese.
Illustrative of what the sick
care industry prescribes to the public, i.e., patients, de jure or de facto, as
to the proper dietary intake for successful weight loss are the following:
is from the Mayo Clinic: [ix]
To lose weight, talk
to your doctor about setting these daily calorie (sic) goals:
Your weight in pounds
Daily calorie (sic) goal
250 or less
251 to 300
301 or more
is from David L. Katz, MD [x]
and Jorge Cruise: [xi]
Weight in Pounds [xii]
Daily Caloric Goal - Men and Women
200 to 249
250 to 299
300 or more
This is from Harvard and
Calories: Doing the Math
say you’re a woman who is 5 feet, 2 inches tall and weighs 150 pounds, and you
need to lose about 15 pounds to put you in a healthy weight range. If you
multiply 150 by 15, you will get 2,250, which is the number of calories (sic)
per day that you need in order to maintain your current weight
(weight-maintenance calories (sic)). To lose weight, you will need to get
below that total. For example, to lose one to two pounds a week—a rate that
experts consider safe—your food consumption should provide 500–1,000
calories (sic) less than your total weight-maintenance calories (sic).
If you need 2,250 calories (sic) a day to maintain your current weight,
reduce your daily calories (sic) to 1,250–1,750. If you are sedentary,
you will also need to build more activity into your day. In order to lose at
least a pound a week, try to do at least 30 minutes of physical activity on most
days, and reduce your daily calorie (sic) intake by at least 500 calories
If we assume that recommended
activity burns 300 Calories/day, we end up with the following daily Calorie
intakes to sustain the body:
Your weight in pounds
Daily calorie (sic) goal
250 or less
251 to 300
301 or more
Katz and Cruise:
Weight in Pounds
Daily Caloric Goal - Men and Women
200 to 249
250 to 299
300 or more
Harvard and eDiets (150 pound woman example): 950–1,450 Calories.
How do these numbers compare
to Dr. Lifton’s and NEJM’s Nazis?
In September, 1944, the
internees at Dachau were fed 1,071 Calories daily. [xv] This is almost 20% more
Calories than Mayo, Harvard and eDiets recommend for some women, about the same
as Mayo recommends for some men and merely 7% less than Katz and Cruise
recommend for men and women up to 200 pounds. [xvi]
And these expert diet
representatives of the sick care industry expect people to eat this way
Because the sick care
establishment cannot forcibly ensure compliance with its Draconian,
industry-wide Dachau Diet Plan, people quit.
“[U]nder the conditions
of ruthless control of Nazi occupation” the inhabitants of the Western
Netherlands were brought “to a state of starvation.” [xvii]
The daily caloric intake of these starving, sedentary Hollanders was a
relatively generous 1529 Calories in 1944. [xviii]
When competent researchers
wanted to intentionally starve people, they fed male subjects weighing an
average of 152.6 pounds a “whopping” 1570 calories on average per day. [xix]
Sick care industry experts
blame dieters for the failure, "’Everybody can lose weight,’ said Dr.
George Blackburn, a Harvard Medical School nutrition expert familiar with the
survey who also has consulted for Glaxo. If people failed in the past, ‘they
didn't try long enough and effectively enough,’ he said.” [xx]
This is despite the
observation that “the grumbling and grousing that are inevitably provoked when
the energy intake is deficient to the extent of 15 – 20 per cent, to the
apathy and dissolution of higher human qualities that come with severe
starvation, there is a wide variety of psychological reactions to hunger, many
of which are almost, of themselves, diagnostic of the level of calorie intake”
and the fact that some diets, e.g., the Mayo Clinic, expect dieters to reduce
caloric intake by as much as 52% from the calculated BMR. [xxii]
It should be remembered that BMR does not include energy spent performing
activities of daily living. [xxiii]
Therefore, the reduction from total daily caloric expenditure is greater – up
to approximately 69%. [xxiv]
It may be of interest to note
that even if dieters (understandably, wisely?) fail to engage in 300 Calories
worth of daily activity, the experts’ numbers still represent inanition fare
for many at a level comparable to or less than the starvation cuisine of the
Western Netherlands under Nazi control. [xxv]
Failed dieting is not without
Once freed from the torture
of starvation dieting, dieters tend to overeat. [xxvi]
This makes them even bigger
and fatter than before.
also maintains or increases their risk for developing the deadly conditions
associated with overweight and obesity since increasing BMI is associated with
increasing risk. [xxvii]
it is no stretch to consider expert diet advice as not only the cause of diet
failure, but a vehicle for killing, i.e., shortening life or placing one in a
position where life can be shortened.
other words, given the size of the sick care industry’s diet advice division(s),
arguably “many…doctors are…involved in killing,” as are, arguably, other
there are the concomitant suffering and diminished quality of life experienced
by failed dieters who survive the diet advice of the sick care industry as they
progress towards a possibly hastened death.
Failed dieting is considered
among the indications for bariatric surgical intervention. [xxviii]
In fact, SAGES [xxix] and ASBS [xxx]
consider it a mandatory requirement. [xxxi]
Bariatric surgery itself has long-term consequences, including “lifelong
follow- up with nutritional counseling and biochemical surveillance.” [xxxii]
Although beyond the scope of this article, an investigation into liability for
“needless” surgery when impossible dieting was the treatment precedent,
might be of interest. This exploration would include such discussions as
whether: the prescriber of the impossible/starvation diet regimen is at fault,
the surgeon may be at fault for operating on a patient who had not received
appropriate pre-surgical diet advice, the institution is at fault for permitting
“unnecessary” surgeries as matter of policy, etc. [xxxiii]
Recommending what is
essentially starvation dieting as the proper path to weight loss for the general
public is plausibly a mistake. Such error likely contributes to diet failure and
therefore continuing (and increasing) overweight/obesity and the consequential
severe diet approach currently recommended and described above is but one
problem extant in the system. There are others. These include conflicting
failure to aggressively combat patently erroneous weight loss program claims, [xxxv]
and a continued reliance on the flawed premise underlying the foundation of
virtually all weight loss advice. [xxxvi]
there is a reasonable possibility that the diet advice of the experts from the
sick care industry contributes substantially to the overweight/obesity epidemic,
it is suggested that the industry reconsider its recommendations and the data
Contemplating a moratorium on providing advice while undertaking this re-evaluation may be appropriate (and life-saving). Until such time as the system can be reviewed and corrected, it is possibly better for the sick care and weight loss industries to remain silent than to fulfill the behaviors described by Dr. Lifton and NEJM.
Lifton RJ. Human Rights: Doctors and
Torture. N Engl J Med 2004; 351:415-416, Jul 29, 2004
[ii] Id at 416
[iii] This does not suggest exculpation from proven wrongdoing.
[iv] There is no suggestion in this article that any of those mentioned, the sick care industry, its participants, diet gurus, or anyone else, or any business entity, either individually or collectively is/are Nazis or is/are attempting to be Nazis.
[v] In this article, sick care industry participants include: physicians and other sick care workers (e.g., nutritionists/dietitians), medical centers and academic institutions, the government and pharmaceutical companies. Others who participate in the weight loss industry, such as diet gurus, trainers, etc. are included as well.
[vi] Killing. Dictionary.com. The American Heritage Dictionary of the English Language, Fourth Edition, Houghton Mifflin Company, 2004 (Accessed: November 17, 2006 at http://dictionary.reference.com/search?q=Killing)
[vii] This list is non-exhaustive.
[viii] There are many articles and texts covering these conditions. For examples, see: Hubert HB, Feinleib M, McNamara PM, Castelli WP. “Obesity as an Independent Risk Factor for Cardiovascular Disease: A 26-Year Follow-up of Participants in the Framingham Heart Study,” Circulation 67 (1983): 968–77; Eckel RH, Krauss RM, “American Heart Association Call to Action: Obesity as a Major Risk Factor for Coronary Heart Disease—AHA Nutrition Committee,” Circulation 97 (1998): 2099–100; Manson JE, Colditz GA, Stampfer MJ, et al, “A Prospective Study of Obesity and Risk of Coronary Heart Disease in Women,” New England Journal of Medicine 322 (1990): 882–89; Berns MA, de Vries JH, Katan MB, “Increase in Body Fatness as a Major Determinant of Changes in Serum Total Cholesterol and High-Density Lipoprotein Cholesterol in Young Men over a 10- Year Period,” American Journal of Epidemiology 130 (1989): 1109–22; Chiang BN, Perlman LV, Epstein FH, “Overweight and Hypertension: A Review,” Circulation 39 (1969): 403–21; Olshansky, SJ., Passaro DJ., Hershow RC., et al, “A Potential Decline in Life Expectancy in the United States in the 21st Century,” New England Journal of Medicine 352 (2005): 1135–37.
[ix] Weight loss: 6 strategies for success. Make your weight-loss goals a reality. These six strategies can help. (Accessed November 17, 2006, at http://www.mayoclinic.com/health/weight-loss/HQ01625)
[x] Associate Professor Adjunct in Public Health Practice, Yale School of Public Health. “Katz has authored nearly 100 scientific papers and chapters and 10 books to date. He is a syndicated health columnist for the New York Times; nutrition columnist to “O”, The Oprah Magazine; and a medical contributor for ABC News.” (Accessed November 19, 2006 at http://publichealth.yale.edu/faculty/katz.html).
[xi] Representative of “diet gurus.”
[xii] Cruise, J. The 3-Hour Diet: How Low-Carb Diets Make You Fat and Timing Makes You Thin. New York, NY: HarperCollins 2005:85. Foreword by David L. Katz, MD.
[xiii] Weigh Less, Live Longer: Strategies for Successful Weight Loss. (Accessed November 17, 2006, at http://www.ediets.com/harvard/weighless/?section=howtolose)
[xiv] The last sentence both contradicts the previous sentences and is mathematically incorrect.
[xv] Keys A, Brozek J, Henschel A, Mickelsen O, Taylor HL. The Biology of Human Starvation. Minneapolis, MN: The University of Minnesota Press 1950:1243
[xvi] Id at 1239 – 1246 for an overview of how “royally” enemies and others are fed compared to current diet recommendations.
[xvii] Malnutrition and Starvation in Western Netherlands—September 1944 to July 1945, Editorial Committee. PEDIATRICS Vol. 6 No. 5 November 1950, pp. 825 (Accessed November 19, 2006 at http://pediatrics.aappublications.org/cgi/content/abstract/6/5/825-a)
[xviii] Keys A, Brozek J, Henschel A, Mickelsen O, Taylor HL. The Biology of Human Starvation. Minneapolis, MN: The University of Minnesota Press 1950:1242. See generally, Burger GCE, Drummond JC, Sandstead HR, eds. Malnutrition and Starvation in Western Netherlands, September 1944 – July 1945. Parts I and II. General State Printing Office. The Hague, Netherlands, 1948.
[xix] Keys A, Brozek J, Henschel A, Mickelsen O, Taylor HL. The Biology of Human Starvation. Minneapolis, MN: The University of Minnesota Press 1950:1131
[xx] Dieters Prefer Own Weight Loss Plans Over Doctors' Advice (Accessed November 19, 2006 at http://www.foxnews.com/story/0,2933,227801,00.html?sPage=fnc.health/nutrition)
[xxi] Drummond J. Foreword in Keys A, Brozek J, Henschel A, Mickelsen O, Taylor HL. The Biology of Human Starvation. Minneapolis, MN: The University of Minnesota Press 1950:xiv
[xxii] Applebaum M. Why Diets Fail: The Simple Mistake That Ruins Millions Of Lives. Chicago, IL: FitnessMed, Inc. 2005
[xxiii] BMR is defined as, “The rate at which energy is used by an organism at complete rest, measured in humans by the heat given off per unit time, and expressed as the calories released per kilogram of body weight or per square meter of body surface per hour.” bmr. Dictionary.com. The American Heritage® Dictionary of the English Language, Fourth Edition, Houghton Mifflin Company, 2004. (Accessed: November 19, 2006 at http://dictionary.reference.com/search?q=bmr)
[xxiv] Applebaum M. Why Diets Fail: The Simple Mistake That Ruins Millions Of Lives. Chicago, IL: FitnessMed, Inc. 2005. The figures in this and footnote xxii are without reducing Calories to account for daily physical activity.
[xxv] Or the “sumptuous” fare offered inmates of a Parisian insane asylum by the Vichy government in April, 1941. See Keys A, Brozek J, Henschel A, Mickelsen O, Taylor HL. The Biology of Human Starvation. Minneapolis, MN: The University of Minnesota Press 1950:1241.
[xxvi] Id at 842 – 847 and 1132
[xxvii] See: Executive summary of the clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. Arch Intern Med. 1998, 158:1855
[xxviii] SAGES GUIDELINES FOR LAPAROSCOPIC AND CONVENTIONAL SURGICAL TREATMENT OF MORBID OBESITY: This guideline was prepared jointly by SAGES and the ASBS (Accessed November 19, 2006 at http://www.lapsurgery.com/BARIATRIC%20SURGERY/SAGES.htm)
[xxix] SAGES = Society of American Gastrointestinal Endoscopic Surgeons (Accessed November 19, 2006 at http://www.lapsurgery.com/BARIATRIC%20SURGERY/SAGES.htm)
[xxx] ASBS = American Society of Bariatric Surgeons (Accessed November 19, 2006 at http://www.lapsurgery.com/BARIATRIC%20SURGERY/SAGES.htm)
[xxxi] SAGES GUIDELINES FOR LAPAROSCOPIC AND CONVENTIONAL SURGICAL TREATMENT OF MORBID OBESITY: This guideline was prepared jointly by SAGES and the ASBS (Accessed November 19, 2006 at http://www.lapsurgery.com/BARIATRIC%20SURGERY/SAGES.htm)
[xxxii] PERI-OPERATIVE AND LONG TERM MANAGEMENT CONSIDERATIONS (Accessed November 19, 2006 at http://www.lapsurgery.com/BARIATRIC%20SURGERY/SAGES.htm)
[xxxiii] Discussion of others potentially bearing responsibility is also beyond the scope of this article.
[xxxiv] E.g., the industry clearly states that a weight loss rate of 1-2 pounds per week is considered “safe.” Yet, it fails to come out strongly in opposition to weight loss plans, such as Art Agatston’s South Beach Diet, that proudly proclaims “8 – 13 pounds lost in the first 2 weeks!” and Cruise and Katz’s 3-Hour Diet which promises, “lose up to 10 pounds in the first 2 weeks—guaranteed!” From Agatston A. The South Beach Diet: The Delicious, Doctor-Designed, Foolproof Plan for Fast and Healthy Weight Loss. Arthur Agatston, MD 2003: dust jacket back and p. 3 and How Our Diet Works. (Accessed November 18, 2006, at http://3hourdiet.com/home/index.php?page=HIW3)
Cruise and Katz proclaimed their 3-Hour Diet as
"The Yale University endorsed 3-Hour Diet™..." Eat every
three hours and you will lose weight - starting with belly fat first
(Accessed August 31, 2005 at http://www.jorgecruise.com/home/index.php?page=HIW2)
and AOL Coach on his new book, ‘The 3-Hour Diet.’ (Accessed November 18,
2006 at http://coaches.aol.com/diet/feature/_a/author-qanda-with-jorge-cruise/20060626125609990001).
Although these individuals are associated with the assertion that
their diet scheme was endorsed by Yale University, this does not appear to
be the case. For further information go to: http://www.yale.edu/licensing/other.html
(Accessed November 19, 2006) and
(Accessed November 17, 2006)
[xxxvi] It is a biological, physiological. mathematical and physical impossibility to lose 1 - 2 pounds per week while in a negative caloric balance of 500 – 1000 Calories per day. McArdle WD, Katch FI, Katch VL. Exercise Physiology: Energy, Nutrition, and Human Performance (5th Ed.). Baltimore, MD: Lippincott, Williams & Wilkins 2001:849. As to whether weight loss at this rate is “safe,” see, generally, Keys A, Brozek J, Henschel A, Mickelsen O, Taylor HL. The Biology of Human Starvation. Minneapolis, MN: The University of Minnesota Press 1950.