A patient with recurrent colon cancer in the abdomen came in to see you urgently one day. She had been vomiting for 2 days and unable to tolerate anything orally. Plain x-ray of the abdomen showed intestinal obstruction and the CT scan also showed extensive peritoneal deposits of the recurrent colon cancer. The most likely diagnosis was intestinal obstruction secondary to the peritoneal cancer.

After rehydrating her with intravenous fluid infusion overnight, she felt better and you discussed the best treatment option with her. She was told that the best option was an operation to bypass the blockage. Alternatively, she could try to treat this conservatively with intestinal decompression with a tube placed into the stomach via the nose (called a naso-gastric tube) and taking nothing orally. The former would have a high chance of resolving the blockage and would allow her home in about 7 - 10 days. The latter, after several days of resting the intestine, may result in the intestine working sub-optimally and the patient may get discharged. However, she is very likely to be readmitted soon with a recurrence of the blockage. This would mean repeated hospital admissions.

Which action would you take? Most patients would most likely choose surgery. However, this lady refused surgery. Why? It is because her previous surgeon had told her she should not or could not have anymore surgery for her recurrent colon cancer. She was also very keen to spend the least amount of time in hospital since she does not have much time left. Despite repeated explanation that the suggested surgery was to bypass the blockage and not to remove her inoperable cancer in the abdomen, and also the operation was to allow her to be discharged sooner and allow her to resume normal feeding at home, she was not prepared to have surgery. Over the next few days she was made more comfortable by decompressing her intestine via the naso-gastric tube. Subsequently she agreed to have a special X-ray study of the intestine to delineate the site of the obstruction. After showing the patient that the intestine was almost completely blocked, she relented and underwent the bypass operation.

The patient was perfectly right in her mind to refuse surgery because she was told further surgery was impossible. Would she have agreed to the bypass surgery sooner if her previous surgeon had warned her she might need future surgery for intestinal obstruction? Maybe, maybe not. Although surgery would shorten her overall hospital, she is unlikely to appreciate that fact in her state of mind then. In addition, for some, it may be the underlying fear that one might die after surgery that prevent one from considering the operation. In such cases, the patient has to be given time. The doctor can only support the patient until he / she is ready to reconsider. Eventually he / she will most likely come round to the idea of surgical intervention.

There has been a steady increase in overweight and obese people worldwide. In 1976, 14.5% of American adults were overweight and obese. By 2003 – 2004, the percentage had increased by almost 5 times to 66.3%! Does weight gain during early adulthood and mid-life adversely impact upon one’s healthy survival beyond 70 years of age?

Researchers from the Harvard School of Public Health and University of Warwick tested their hypothesis that mid-life adiposity is associated with a reduced probability of maintaining an optimal health status among those who survive to 70 or older by using the data in the Nurses’ Health Study (BMJ 2009; 339: b3796). This study involved 121,700 female registered nurses aged 30 – 55 living in one of 11 US states who responded to a questionnaire about history of disease and demographic and lifestyle characteristics every 2 years from 1976 to 2000. Those nurses who survived to age 70 or older and as of age 70 were free from 11 major chronic diseases (cancer, diabetes, myocardial infarction (MI), congestive heart failure, coronary artery bypass surgery (CABG), stroke, kidney failure, chronic pulmonary disease, Parkinson’s disease, multiple sclerosis and amyotrophic lateral sclerosis), had no major cognitive function impairment, had no major physical functions limitation and had good mental health were termed “healthy survivors”. Nurses who survived to 70 but did not meet these 4 criteria are termed “usual survivors”. There were only 1686 (9.9%) “healthy survivors”.

At baseline, the healthy survivors were healthier, had received more education, a lower prevalence of cigarette smoking and somewhat better diet. In addition, when compared to usual survivors, they were less likely, at baseline, to have overall or central obesity and tended to gain less weight since age 18. The most common chronic diseases were cancer, coronary heart disease (MI and CABG) and diabetes. Increasing BMI at baseline was associated with reduced odds of healthy survival. Every one unit increase of BMI was associated with a 12% reduction of the odds of healthy survival. Compared to stable weight, weight gain since age 18 was significantly associated with reduced odds of healthy survival. For every 1 kg increase of weight since age 18, the odds of healthy survival were decreased by 4 – 6%. Even among non-smokers, compared to lean women (BMI 18.5 – 22.9), women with a BMI of 30 at baseline had 73% lower odds of healthy survival. Compared to women who maintained a stable weight, women who gained 20 kg had 84% lower odds of healthy survival. A higher BMI at 18 also adversely affected the chances of healthy survival. Relative to women with a BMI of 18.5 – 22.9 at age 18, those with a BMI of 23.0 – 24.9 had 15% lower odds of healthy survival and for those with a BMI ≥ 25, it was 33% lower.

The above study would imply that there is no safe period for becoming overweight in our lifetime. It behoves every one of us to stay vigilant about our weight and try to stay lean if we want to enjoy healthy survival at 70 and beyond.