Your recent commentary on weight-loss surgery is a bit off-base. Bariatric surgery is a well-established treatment for morbid obesity (those people who are about 100 pounds overweight). In fact, weight-loss surgery is the only intervention that has been demonstrated to maintain long-term weight loss. When performed in expert comprehensive centers that are interested in long-term follow-up, the benefits far exceed the risks of surgery. Marketing for weight-loss surgery has become an unfortunate part of business. As the media and uninformed medical professionals continue to have significantly biased views against the obese individual and medically necessary procedures, surgeons have adopted other means to educate, most commonly the Internet.

Bariatric surgery is not a marginal solution. Telling a person who is 100 pounds overweight to diet and exercise is a marginal solution. Giving that patient more antidiabetic medications is a marginal solution. Ignoring the health of the obese individual because of deep-rooted societal biases against the obese is against medical ethics. The nutriceutical business is a $300 billion industry that profits without an effective product–and there are no cries of outrage.

RAMSEY DALLAL
Cleveland, OH

Dear Ramsey,

I stand by my earlier comments. Even for patients who are 100 pounds overweight, in addition to a careful medical evaluation, I believe that diet and exercise should be tried before surgical options are considered. And by diet, I am not talking about hyped or fad diets. By exercise, I do not automatically mean to refer to expensive health clubs and high-priced trainers. As I said before, surgery has a use for extreme cases. You are right, the nutriceutical business is a “$300 billion industry that profits without an effective product.” But that statement alone is surely not a justification for jumping unthinkingly into surgery.

I very much enjoy some meatless treats like soy burgers topped with soy cheese. My physician suggests that since soy products are sometimes recommended as a supplement to or substitute for female hormones that there might be some issues with the unrestricted use of soy products by men. Are you aware of any such issues?

DWIGHT MENARD
Shoreham, VT

Dear Dwight,

I know of no such issues, though soy, like most things, should be used in moderation. You’re probably much better off with the soy rather than the fattening hormones and steroids that they inject into the meat that we eat!

I’m 68 and have rheumatoid arthritis (in remission), osteoarthritis, osteoporosis and Graves’ disease. I have good insurance right now, but every year the cost increases, and I won’t be able to afford it much longer. I use several medications and some expensive over-the-counter remedies.

My question: I have been taking prednisone for at least twelve years to keep the rheumatoid arthritis from flaring up. I take only 5 mg. and a few times have had to increase it temporarily. My new doctor tells me to try to get off prednisone but only suggests methotrexate, which I understand is a drug used for chemotherapy. I think that since I am in remission and that the drug does nothing for osteoarthritis it is much too hard on the body to justify continuing with. What do you suggest I do about this, and is there a medication that can help you with getting off prednisone?

JOYCE KREBNER
Baltimore, MD

Dear Joyce,

There are new medicines to be considered, like tumor-necrosis-factor (embrul), but low-dose methotrexate is often used for rheumatoid arthritis. I’m not sure if you need it or not, if you are asymptomatic, but the long-term side effects of even low-dose steroids are not insignificant. There are other, more benign drugs, like plaquinil, that might be considered. The main thing is for you to open a dialogue with your physician and work out a joint (pun intended) solution.

In the past several years I have become much more politically aware. Of late I have committed myself to educating the “next generation” of physicians. May God help them with their chosen profession!! I hope they are wise enough to ask. I have never considered myself a liberal, nor a conservative, just a free-thinking American.

Truly we are a nation divided. All the polls show this clearly. Perhaps this is the price of freedom: constant debate, turmoil and uncertainty. However, when one compares the United States overall, our quality of life would seem on the average to be better than most, or at least some.

Our healthcare system is pluralistic–approaching anarchy if one is not a card carrying HMOist or PPOist or whatever red, blue and white stripe is printed on your insurance credential.

When I am called in to see a patient as the attending surgeon by my first-, second- or third-year resident in ophthalmology, I usually punctuate the consultation with some words about politics and the outside world. The residents seem to barely know what is going on in the world. At the annual graduation dinner for residents the senior residents did their annual skit focusing on the vagaries and eccentricities of their professors. When it came to me, they thanked me for my “outside interests” and political commentary.

How would you like a ghost writer or another pundit to assist you in your columns??

GARY M. LEVIN, M.D.
Palm Desert, CA

Dear Gary,

I appreciate the offer, but I already have the able-bodied assistance of a wonderful editor who adds his insights to mine and corrects me when I am wrong. And though doctors do have a unique perspective on the political aspects of healthcare and health policy, I don’t automatically assume we are more qualified to spout truths then our patients are. In fact, I believe just the opposite.