text:
Wherein a surgeon tells some stories, shares some thoughts, and occasionally shoots off his mouth. Like a surgeon.
Thursday, February 08, 2007
No Frickin' Way, Doc!
Among many, many who've needed it and accepted it, I've had two patients who refused colostomy. One is dead, the other alive and well. More than that: both eventually had colostomies, and each said, nearly identically, "If I'd known how easy it is, I'd never have refused."
No one likes the idea of a colostomy. When talking to a patient who needs one, I try to point out that there's nothing -- NOTHING -- a person who has one can't do. I list a few famous people who've had them, talk about the various ways to handle it. With enough education -- which, unless there's no time, always includes a visit ahead of time with an ostomy nurse -- people generally accept the idea and we move ahead. Not these guys, no frickin' way. I tried. I really did.
Step one in curing colon cancer is removing the portion of bowel that contains it, with some room on either side to be sure you're not leaving any tumor behind. Fairly early in my surgical life, it was learned that for rectal cancer, it's not necessary to give as wide a berth on the south side as had been believed: lymphatics and blood from the low rectum tend to flow upward, so if cancer cells were to spread locally beyond the obvious tumor, they'd be heading north. Less than an inch beyond a tumor in the deep pelvic part of the colon is considered safe as a point of division. If that leaves enough ano-rectum to sew to (staple to), you can re-attach the ends after removal, avoiding colostomy. People with tumors located pretty far into the pelvic confines have been able to have curative operations with re-attachment -- but it's not always possible to be sure ahead of time whether things will work out. You have to leave open the possibility that, in the name of safety -- in the name of choosing cure -- you might not be able to hook the ends together, and the patient will end up with a colostomy. No frickin' way, doc, these guys said. I'd rather die than have one. Period. Non-negotiable. Try as I might, educate till my brain was empty, there was no budging. So I operated anyway.
My rule of thumb (rule of finger) is that when the tumor is high enough that I can't feel it with my finger on rectal exam, I'll have enough room to get it out and hook the free ends up. In each of these men, it was barely beyond.
Patient A was in his forties, and his tumor was a big one. There's no question that, had he not refused, I'd have given him a colostomy: I could work my way past it, but not far enough within the safe-connect zone. I wanted to go further, but he'd given me no choice: I got a little bit beyond, removed that part of the rectum, and stapled it all back together. Patient B was late sixties, with a smaller tumor. In his case, we elected (I with some reluctance) to remove the tumor simply, transanally. Both men got local radiation: A got it pre-op, B post-op.
I followed Patient B very closely; Mr A came in for a while, and then disappeared. When B's tumor recurred a year or two later, I told him he was out of options: the remaining chance of cure was ano-rectal resection and permanent colostomy. Unhesitatingly, he agreed. Despite the prior radiation, he healed fine and never looked back (as it were.)
Patient A wasn't as lucky. When he re-appeared, he was in big trouble: the colostomy was because of impending obstruction. Not long after, his kidneys were obstructed, too. But before he died, he'd noted that the colostomy was nowhere near as bad as he'd thought it would be.
It may be apocryphal (if you're reading this, medblog-addict, maybe you could de-lurk and let us know): I've heard of doctors being sued for failing to talk someone into an operation. More properly, it was (so the story goes) for enumerating possible complications to the extent that the patient freaked out and refused, later to suffer the consequences of not having had the surgery. Short of tying him down and dragging him into the OR, I don't think there's anything more I could have done for Patient A. But it still bothers me. Mr B was glad to have had a couple of extra years without a stoma, and is cooking along just fine. I wish I knew the lesson.
Looking at comments on my previous post, and knowing from my own experiences, it's apparent that consent is a much cloudier issue than those who urge those forms upon us would have us think. Both for doctors, and patients. What we say, what they think we say; what they heard, what we think they heard -- it's as flimsy as a curtain of fog. When you're sick as hell, any consent you give is subject to the effects of the illness, maybe the drugs you're getting. Even when it's an operation planned well in advance, it still is questionable what "consent" really means. I've seen the fear-glazed eyes, whose opacity blocks words. Consent is just a concept, a hall of mirrors. It's vapor.
In that impossible best of all worlds, where people eat well and wars don't happen, where lawyers spend their time painting and planting flowers, all doctors are worthy of trust, and all patients trust them. Doctors, in other words, are like me. Patients are like you.
46 comments:
Cancer is a situation where it might be easier to consent to surgery. I mean, it's THE most classic and understood treatment for tumors. It gets really tricky for patients with other problems, like chronic pain. Sometimes there really is a feeling that the doctor is looking to make a sale. I feel like this is really common in gynecology, particularly with hysterectomy. Worst case scenario, you think your doctor thinks your body is an ATM on payday. I've been reading about gynos being VERY upset by interventional radiologists stealing hysterectomy business from them by using uterine embolization therapy to shrink or remove fibroids at a fraction of the cost or recovery time.
I hope there is still a good doctor left out there if I ever get cancer. - 2/08/2007 9:45 AM
celeste, as a mostly cheerful but still occasionally grumpy survivor of surgery for cancer, let me point out that it all depends on the kind of prognosis anyone can try to offer you before the surgery. There's a big difference between surgery intending to cure you, if possible, and surgery that can only palliate symptoms. There's also a difference, at least in my head, between the kind of decisions a surgeon might make intra-operatively for someone who has a very good chance of healing afterwards and living with it for long healthy years, versus what you might subject a patient to whose years are probably more numbered, whose ability to heal will be compromised by adjuvant chemo, etc. I guess I'm saying that not even "life or death" surgery is always "life or death." In my view, the best surgeon is the one who, if things go well and I do live through it, will help me celebrate my having survived and having a much better prognosis, post-surgically speaking, by now treating me like a living person, not someone on still on death's door and therefore without much in the way of meaningful choices or preferences besides "risk all and trust me." It's a fine line, I guess, but I am willing to believe that it makes a giant difference to outcomes, and that onc-surgeons who learn this have better outcomes.
My onc's NP told me, long after my surgery, just how worried she had been about me in the days afterwards, because I lay there so passively and uncomplainingly, and how she didn't really become optimistic (whatever she allowed to show in my presence) until about day four, when I finally just demanded that they remove the damned Foley this minute, for christ's sake, and get a commode in here. It's the only time in my life I've ever been told that a person actually found herself a little weepy--tears of joy--when I complained about a "minor inconvenience." - 2/08/2007 10:17 AM
- Sid Schwab said...
I posted on the fine-line aspect of it a while back, and I've got a couple of posts coming up (I write ahead sometimes) about "attitude." I think this is a very important aspect of the surgical "experience," for lack of a better word, and I'm glad to see these comments.
Anonymous, I think I was probably referring to more simple kinds of tumors. Most patients' gut reaction is to get it out. Of course, so much depends on the cancer in question.
I'm also familiar with the more complex cascade of problems. We recently dealt with a relative who spent a 10 MONTHS SOLID in the hospital. A colonoscopy punctured the colon, several surgeries were done to clean out peritonitis and repair the bowel, MRSA set in, and several surgeries were done to clean out infected areas and to replace spinal bones that were eaten. Then there were the surgeries to try to repair the damaged vocal cords from the respiratory interventions (leading to a permanent trach and general medical fragility). I totally GET that you have to ask what benefit is expected for the risk. We didn't end up going to a funeral, but now we deal with somebody who can't muster enough voice to talk on the telephone or do much activity past walking from one room to another on the main floor of the house. Trade-offs ensue. - 2/08/2007 10:55 AM
- Cathy said...
Attitude is alot of it post op. On the day after my cancer surgery. The surgeon and his team came in. He sat down and began to discuss certain aspects of my surgery.
He was concerned, because at that time, this infomation really didn't mean much to me. He said, "Why are you not responding to any of this I am telling you?" "You look depressed" is what he told me. He planted an HRT patch on me thinking my reaction was caused from the instant menopause. It may have been. I also remember in those early days, not asking for anything to be done. I know I didn't communicate with the nurses when they came in . I couldn't have cared less about anything. I didn't even get worked up over going for 8 days with no food or water.
But, I think it might have been the fact I was on a morphine pump, I was in alot of pain, I was zoned and really his words were not sinking in. I guess it was also about day 3 or 4 when I started to complain a bit (I wanted my damn hair washed and combed) that he was happy.
Only in the hospital can you get to the point of complaining and it makes a man smile. - 2/08/2007 11:47 AM
If in your special world all patients are like me, then there's a tour guide named Virgil showing some other guy around arriving any minute now...
- ERnursey said...
I remember one of my very first patients, seventeen years ago. The patient had refused a colostomy or treatment for the cancer and when I became acquainted with them the tumor had eaten through the pelvis and become an open, necrotic, constantly draining ulcerative mass. The poor patients pain must have been incredible. Their doctor prescribed morphine tablets in huge quantities, providing the means if the patient had decided they couldn't go on. But they never did and ended up dying a slow, horrible death.
ANON #2 - I'm one of those patients who thought a colostomy would be the worst possible outcome in a 42 year old woman without cancer. But I had been reassured that I only had a 5% chance of waking up in the recovery room with a permanent stoma so I signed the consent form. Well, I fell in that 5% and after a few bumpy weeks I made the adjustment. Now I can't imagine my life any other way and wonder what all of the fuss was about. Thank God for surgeons who do their very best for the best possible outcome.
Dr. Schwab, may I suggest something? Of course all patients are different, as are their circumstances, but as a survivor of an unplanned colostomy--a situation complicated by the fact that I wasn't suffering from any bowel disease or symptoms, so I didn't even get to feel relieved that that was over--I'll tell you what worked best for me. A lot of people kept saying to me, "Everyone freaks out about this, and everyone learns to deal with it." That went more or less in one of my ears and out the other. Then I got The World's Best WOC Nurse, who talked to me for a while, got a sense of who I am, and then looked me in the eye and said, "Of course it's bullshit. A lot of people would rather die than have a colostomy and they do. A lot of people never learn to deal with it, never learn to care for it properly. However, you will." It was something like 50% expression of confidence in me, and 50% commitment to getting me there on her part. It did what it was intended to do.
I will only add that I learned to be amazed at how many nurses don't know how to deal with the practical matters of ostomy appliances, especially with those of us who are not elderly and are perfectly ambulatory. I spent 5 days on a med-surg floor several months after my colostomy, and my nurses kept 1) insisting on assisting me with draining the thing and 2) not doing it right. The WOC nurse told me that she thought it was because most nurses don't deal with ambulatory ostomy patients who have, ahem, higher standards of personal hygiene than are considered acceptable in your average nursing home. Lord, does my heart break for those nursing home patients. - 2/09/2007 6:27 AM
- Sid Schwab said...
anonymous: good points, all. I told my patients that on one will be as good at managing it -- not me, not any nurse -- as you will become. People figure out what works best for them. In my community, for a long time we were lucky enough to have an ostomy nurse who was an ostomate herself. That was great. Even still, it wouldn't be long before a patient was telling HER how they preferred to do things.
- Medblog Addict said...
I'll look into it. But first I have to look up "apocryphal".
- Bo... said...
I frequently teach new colostomy patients (and their spouses) how to manage their colostomies, and it's a pretty rewarding experience for me. I remember in nursing school where we students each identified one thing that we thought we just couldn't live with. My buddy stated adamantly that if she "ever had to get a colostomy" she would shoot herself. For me it was Meniere's Disease. I ended up getting Meniere's, dang it. (And so I hope she doesn't have a colostomy...)
Hi! I've been reading your blog from the beginning..Thank you for your wonderful work! Keep up the good work.
Accounts of such litigation are not apochryphal. Some years ago, I defended a family practitioner who was sued, along with a GI consultant and others, for failing to recommend/talk the patient into a colectomy & ileostomy. Medical management quickly relieved acute manifestations of her ulcerative colitis and kept her symptom-free for long periods (3 brief flare-ups in 4 yrs), but she maintained they should have pushed definitive surgical intervention at the time of her 2nd flare-up, thereby averting a 3rd episode a year later.
Dr Sid, can you provide a list of famous people who have have colostomies? It might be more helpful than telling patients that people who say that they would rather die than getting on, do.
- Sid Schwab said...
jb: I'm not sure I get the final phrase of your question. If you have inferred that I tell potential ostomy patients about those who refuse and die, I never did or would. Likewise, the subject of my post was an aspect of informed consent, as opposed to what you seem to have derived. Nevertheless, here's a list I got from a recent ostomy site. In my practice, I usually mentioned Fred Astaire, the Queen Mum, and Rolf Benirshke.
Annie(UK) - senior solicitor (employment law)
· Paul Ashley - management consultant
· Fred Astaire - actor/dancer
· Barbara Barrie - actress
· Allan Bawell - drywall hanger
· Rolf Benirschke - professional US football player/game show host/ConvaTec spokesperson
· Napoleon Bonaparte - world leader and military conqueror
· Carol Browning - executive assistant
· Marvin Bush - financial advisor and son of former US president
· Crusher218 - fire engineer and member of the San Diego Urban Search and Rescue Team
(heavy rescue team)
· Earl/ Dutch retired Air Force officer with 30 years of service in WW II, Korea and
· Gerry Duquette - retired, former director of environmental services at long term health care facilities
· Bill Foy - retired air traffic controller
· Gary in Maine - ship captain
· Al Geiberger - professional golfer
· Serv Gonsalves - Director, Computer Operations & Networks
· Steve Haith - analyst/programmer
· Bob Hope - entertainer/comedian/actor
· Irene - university resource center director
· Yale Jacobson - district manager
· Robert James - I.T. Consultant
· Renay Jarrell - self employed Auto Cad designer
· Bob Lee - police sergeant
· Tip O'Neil - US Speaker of the House and Ambassador to Ireland
· Rene Marinelli - customer service manager for a large medical billing firm
· Kevin McHugh - owner of research consulting company-McQ Research Services, coordinator of the CCFC IBD Research Network, educational/inspirational speaker, etc.
· William Powell - actor
· Queen Mum (colostomy since 1966)- British royal
· Jim Rice - computer systems analyst
· Lori Robb - volunteer with disabled people
· Suzanne Rosenthal - CCFA founder
· Sam (former ileostomate) - marketing management and public guitar player with an ostomy
· Crystal Scotti - legal transcriber and proofreader
· Shaz - government worker, State Housing Dept in Western Australia
· Reilly Sheffield - kindergartner
· Red Skelton - comedian
· Barbara Skoglund - government communicator
· Ed Sullivan - TV host
· Walt - dispatcher for a rural electric co-op
· Carl White - lawyer-in-house counsel for a real estate title insurance company
· Loretta Young - actress
· YTS - retired meteorologist
I was diagnosed with ulcerative colitis back in 1985. My disease was successfully managed with azulfidine for almost 20 years. It got to be a routine: Coloscopy each September/October so the pathology report would be back in time to decide on how much $$$ to put in my health care spending account for the coming year.
That all ended three years ago. The initial pathology came back "normal": Low grade dysplasia, no need for surgery. What I didn't know is that the sample were also sent to the UCLA pathology team for a second opinion. So I was surprised with a second result came back in January saying "high grade dysplasia found, total colectomy needed". So much for being able to plan this financially!
Given the conflicting results I wanted a second opinion, so I went in to see Dr. Tarjan at Cedars-Sinai, who it seems is The Man when it comes to this stuff.
After looking at the pathology and hearing my family history (father had colon cancer, mother two different types of breast cancer then lung cancer much later), he sided emphatically with the UCLA report. (I got the impression he was wondering what the first bunch of pathologists had been smoking.)
So the time had come for surgery. I asked if this could wait until summer and I was told it could, but no longer. I used the time I had to lose weight because I figured less belly fat would make life easier for my surgeon and then for me. Five months and 45 pounds later (down to 210), I had a total colectomy with ileoanal anastomosis.
I nearly ended up in 2-3% that cannot be reattached because I'm apparently built "long" inside. (My kidneys being twice normal size due to PKD probably doesn't help.) As it was the procedure was difficult and took well over six hours for a surgeon that usually does it in four. I'm also glad I didn't opt for the laparoscopic version because I'm sure they would have had to convert to an open procedure.
Past cholecystectomy experience taught me the virtue of getting and staying ambulatory. I quickly settled in to a routine of walking the entire floor of Cedars once every four hours, then twice, then three times. The only really rough time was getting my gut restarted - two days of ileus made me absolutely miserable and was without doubt the worst part of the whole thing.
I was doing so well that I ended up leaving the hospital too soon. On the second day at home I started losing fluid rapidly through every available orifice. This led to an emergency readmit for IV fluids. The only place they could find a vein was in the side of my index finger. I'm sure getting the needle in hurt like a son of a bitch, but by then I was so euphoric from fluid loss (over 15 lbs in four hours) I didn't even notice it. It also scared my wife more than anything that had happened up to that point.
Of course I had a temporary ileostomy at this point. Aside from some worry about how full it could get without coming loose (answer: very full indeed) I had little trouble adjusting to it and I can easily see how people could tolerate this indefinitely. My take on this is that everyone needs to figure out the routine that works for them. For me changing the thing in the shower worked best, and as I recall the suggestion to do that first came from one of the residents, not a nurse.
In any case, a couple of months later I had an uneventful takedown procedure and at this point I'm basically back to where I was before the surgery.
So: Attitude is important, but active participation in your own care was the key for me at least. My surgeon told me that had I not lost the weight I'd be wearing a bag today. I don't really know how vital dragging myself out of that bed was, but I think it helped. And having someone (my wife) help me through it at all was invaluable. I honestly don't know how people who are alone in life get through this. - 2/11/2007 9:55 AM
Dr Sid, thanks for the list.
I never meant to imply that you (or I) would ever snark at our patients like that. I was referring to the Anon 2/9 6:27 a.m. comment, who quoted "The World's Best WOC Nurse" as saying, "A lot of people would rather die than have a colostomy and they do."
Sorry for any misunderstanding. - 2/11/2007 2:36 PM
- Sid Schwab said...
jb: thanks for the clarification. pas de problemmo.
jb, I am anonymous with TWBWOCN.
If I understand you correctly, you seem to think that people who face having a colostomy--or those of us who just wake up with them, not having already faced it before hand--have no sources of information or thoughts about the subject other than what the doctor says in the consent conversation. You think we come to this as mental virgins? That we know, or think we know, nothing except what you tell us? C'mon.
In my case--which I do not assume is "typical," I don't know what "typical" is--I put forth the opinion that "everybody learns to deal with it" sounds like bullshit. Hell, I know people who can't deal with getting wrinkles and go off the deep end. So, instead of telling me that that's incorrect, and that in reality every ostomate is a sane, resilient, practical person and I'm just misinformed, my WOC nurse conceded the point while reminding me that I don't have to be in that group. I thought it was a nice piece of patient "manipulation," and still do. Hell, I'd learn to be a nice functional little ostomate just to make my bitchin' nurse happy. At least she took me seriously and didn't try to sugarcoat everything.
What would you have done? Given me a list of celebs? You want to know how much I care about the Queen Mum's colostomy? It would involve references to shit not given, but if you aren't an ostomate you might not understand "giving a shit" jokes the way I do. - 2/12/2007 9:26 AM
Dr. S. -- Just stumbled onto this site. I had APR surgery for cancer 5 years ago (yes, I've reached the holy grail of 5 years!) I've always yearned to know what it's like on the OTHER side of the knife, to do such a surgery.
Question: what is your opinion/position on irrigation for sigmoid/descending colostomies?
Very, very intriguing blog, you write well. - 2/28/2007 4:03 PM
- Sid Schwab said...
blogsnooper: thanks for the kind words, and congrats on your success. To irrigate or not is stricly a matter of what works best for the individual. Irrigation is a little too "intimate" for some people, but has the advantage of making it move when you choose rather than when it chooses. People with "well-trained" colostomies who irrigate can often get along without a bag at all, or just a small "security pouch." I think if I had one, I'd irrigate. Many of my patients tried it both ways and ended up not irrigating. So, as I said, it's just about what fits best with individual feelings.
- blogsnooper said...
Dr. S. -- (I'm having all sorts of hell replying to this thread -- forgive me if this is the THIRD time this tiresome post appears) Thank you for your response re irrigation. I've been doing this procedure since I finished treatment (6 fun-filled months! I can now add the ability to wash my hair while wearing a PICC line in one arm to my Life List of Skills.)
Irrigation changed my quality of life dramatically, and literally overnight. I do peer-couselling pre and post-op for colostomates and am always astonished at how few [good candidates, too] want to try it. Bit as yous say, it may be too Intimate' for many. I like the term 'intimate'. Nicer than 'creeped out'.
Another question: in your experience, are there any negative side-effects associated with long-term irrigation? Such as 'bowel stretching', electrolyte imbalance, loss of bowel motility and impairment of the immune system due to unnatural loss of friendly colon bacteria? I've heard all of these theories.
I'm not about to stop irrigation -- to be frank, if it means I don't have to wear bags, I don't care what mayhem I may be causing down there -- but I'm curious to get a surgeon's opinion. - 3/01/2007 9:24 PM
- Sid Schwab said...
I know many people who've irrigated forever. I'm unaware of any deleterious effects (it's possible to get overly agressive and cause damage, just as it would be with a careless enema. As long as you provide enough fiber to create solid stool that moves its way to the south end, I don't know of any problems.
I stumbled on this looking for info on a colostomy takedown. I went in to the ER 8 weeks ago for abdominal pain. They diagnosed ruptured appendix. They went in and found a healthy appendix in a pool of pus. My colon perforated from diverticulitis and they removed 5" on my descending colon. I have it reversed this week. Im trying to understand how the process works. Anyway - interesting article - and if anyone refuses a colostomy they are not thinking it through.
I woke up from appendix surgery with one and was quite shocked. Even when they said it was temporary I was freaked out. But after I got home and figured out how it worked - its not worth dying over I can assure you. Thankfully I am cancer free.
Thanks for your article and if you can explain how the put the colon back together that would be great. Im trying to imagine how the stapler works. - 11/13/2007 1:13 PM
- Sid Schwab said...
there are several stapling techniques using different type staplers. It depends on how far into the pelvis is the distal end. If you look here you'll see why I like hand-sewing when I can. But a hookup deep in the pelvis is ideal for staplers. Here is a diagram that shows one technique. Imagine the left side of the image is the rectum; ie, the stapler inserted through the anus, to bring down and connect to the upper end (the colostomy you currently have.)
- Isabella Zambezi said...
I know you are all serious doctors, but I am the daughter of an ostomy patient. My family does think that this was a mistake for her, but as one of you mentioned, a permanant stoma is just there and there is nothing to do about it!
I am writing a blog about helping my mom. Here it is: http://helpingout.wordpress.com/
Warning, I am trying to see the lighter side of this! - 7/23/2008 8:33 PM
I'm a 30 year survivor of ulcerative colitis....and I'd be one of the people who WOULD say, "No Frickin' Way!" to a colostomy if they said I've have to have one. I've fought like a dog these last 30 years to NOT have go through that. I know people who've had ostomies. They tell me they're just trading in one set of problems for another. I find the idea of wearing an ostomy bag repulsive. I'm not weird or anything, just a normal person who thinks the idea of wearing an ostomy bag is the most horrible thing that could happen to anyone. I'm hoping and praying my UC never gets to that point, because I'd say NO and I wouldn't change my mind.
It isn't bad at all and isn't even all that unattractive. I have one and it is one of those things that one gets used to and you all would be surprised at how accepting the opposite sex is of it.
It can't be helped, I would be dead now from sepsis if I didn't do it. Yes, I cried and was very upset about it at first. Eventually, I came around and never feel I did the wrong thing.
The hardest part is being intimate with someone new. One never knows how they will view such a hack job that a colostomy appears to the unaccustomed. Other than that, no one ever knows. - 12/18/2008 9:09 PM
I agree entirely with the 30yo with ulcerative colitis.
I am in my late 20s, single, into partying and casual relationships and very sporty. I have been told that an upcoming surgery that I will have (to remove cancer) will leave me with a permanent colostomy. As far as I'm concerned, there is no well in hell that I am going to consent. Who at my age wants to end up being a shit bag attached to a body for the rest of your life?
I'm happy with my life so far and I'm not prepared for the drastic reduction in quality of life that having a bag entails. It's funny, everyone I know of or who have interacted with who has a bag says 'it's not that bad' ie what they're not saying is that it's shit (literally and figuratively) but they put up with it. Oh sure you might be able to go hiking, swimming, horse riding, skiing etc. Big deal - how much preparation do you need to do so that you can do all those things? Having to carry spare bags, glue etc. on you all the time - how fun is that!? It's not like you can just think to yourself - I need to go to the bathroom but I'm just going to hold on until I'm busting because I'm busy at the moment. Bags do burst and leak (yeah, go on about the fantastic supplies there are these days as much as you want - the reality is that none of them are foolproof). Mmm, shit dribbling down your front - that's nice for everyone around you, isn't it!
I know that if I met someone I was interested in romatically and found out they had a colostomy, that's it - I wouldn't want to touch them with a barge pole. I'm not saying I wouldn't want to know them - just that I wouldn't want physical contact with them. And I'm not prepared to have to constantly watch what I eat, spend hours in a bathroom emptying the stinky slops or fart at inopportune moments or have to throw out all my skin tight, slinky party clothes, boob tubes and bikinis.
This surgeon's post is representative of the majority of surgeon's opinions - ie no consideration for quality of life issues, especially where younger patients are concerned. All a surgeon sees is a tumour with a body attached - they don't give a shit (excuse the pun) what you have to deal with afterwards as a result of their butchery.
I've made my choice and I'm at peace with it. It's a shame that noone has done enough research to come up with acceptable alternatives. - 1/28/2009 2:28 AM
- Sid Schwab said...
anonymous: thank you for your thoughts on this. It's a difficult decision. It appears, from what you've said, that you are far from fully informed, and that's too bad.
On the other hand, I'm inclined to think this isn't a "real" comment from a "real" person. I was inclined to delete it because I'd guess I'm right. But I'll leave it because it's an example of what actual people might think who have poor knowledge of the options.
It's also the case that my post here was about cancer and not ulcerative colitis, about which there are even more complex issues. Finally, I'd not be inclined to give general credence to one who thinks she knows what "the majority of surgeons" think. But that's just me. - 1/28/2009 8:51 AM
Dr Schwab, thanks for your blog.
Could you please explain why you think the last 'anonymous' is mis-informed? I'm in my mid-20s faced with the prospect of a bag and need those myths properly expelled from my mind. - 4/11/2010 10:48 AM
- Sid Schwab said...
Well, first off the commenter suggests that all surgeons care about is butchery, which is a bit off-putting. And I guess it's how one sees it. No one would choose an ostomy if there were a better option. But when it's done, it's for a reason: in the case of UC, I never had a patient say it wasn't worth it, because they'd been so sick for so long they'd forgotten what well feels like.
The problems the commenter mentions are real, but he/she puts a very negative spin on them all. People get very good at managing their ostomies -- better than their docs, their ostomy nurses. It becomes a part of life; not a pleasant one, but necessary, manageable, and not limiting in any way.
I'd suggest you look at websites for ostomates. Like this or this. - 4/11/2010 11:30 AM
To the person in their 20s - if you're facing a colostomy due to cancer, PLEASE get multiple opinions rather than just going ahead with the APR.
If I had stuck with the original surgeon I saw when I was first diagnosed, I would have ended up with a bag unnecessarily. The surgeon was adamant that I would have to 'get used' to having a bag & that was that. As far as I was concerned, that was not an acceptable prospect for a young woman. As it was, it took me 3 more goes to find the right surgeon for me & I am now both bag-free & cancer free 2 yrs later.
To be honest, avoiding a bag became my primary goal over & above curing the cancer - but I'm lucky & very grateful that everything has worked out (so far - touch wood!). I have both my oncologist & my awesome surgeon to thank for this.
Here are a few things I learnt along the way:
* if you have a low tumour, 6 weeks of neoadjuvant chemoradiation is non-negotiable. I had xeloda, 5 weeks of radiation to the pelvic region then 1 week of radiation targeted to the tumour (that's radiation + chemo Monday-Friday with weekends off). There are studies now showing that the addition of Avastin to chemorad improves response rates even more (in some cases, it up to doubles the chance of a near-complete or complete response). Also, xeloda is slightly more effective than 5FU.
* you MUST find yourself a board certified, specialist colorectal surgeon. Studies show that hospitals where high rates of colorectal cancer are performed have lower rates of permanent colostomies. Interestingly, the first surgeon that I saw who told me I'd HAVE to have a bag was a general surgeon & wasn't board certified.
* you also need to find a progressive oncologist who doesn't simply stick with the 'standard' approach but will go the extra mile if necessary. On top of the neoadjuvant chemorad, I had additional full strength xeloda before surgery.
* studies show that the optimum time between ending chemorad & having surgery is between 8-12 weeks. The chemorad keeps working during this break so if you have surgery sooner, the chemo hasn't had the chance to finish working.
* your response to chemorad is critical. Before any treatment, I was Stage III with one suspicious enlarged node. I had a near complete response to chemorad + chemo & was down staged. When you have such a good response to chemorad, the chance of you still having positive nodes (assuming there were any to begin with - enlarged nodes do not guarantee that they are cancerous, they may just be inflamed) is greatly reduced. From memory, there's only about a 5% chance of positive nodes turning up in final pathology if you have had a complete response to chemorad.
* you need to be your own advocate. As Dr Schwab points out, some people adapt to having a bag. But if you want to give yourself the best possible chance of avoiding that outcome, then you need to understand beforehand what the alternatives are & decide whether you can accept the possibility of an increased risk of recurrence. An oldie who just wants the safest way may accept radical surgery without question. But I knew I was WAY too young to have to make changes to my life because of a bag that I could have avoided. I took the risk & accepted a slightly greater risk of recurrence. I found an oncologist who was prepared to provide additional treatment to give me the best chance of having the surgery I wanted, then when I had a good response, I found a surgeon who accepted that I'm ultimately the person who decides what is best for me & what I could live with. - 7/26/2010 11:44 PM
cont. from above:
My choice was to do everything possible to avoid the bag, even if it meant taking a risk that the cancer would return. So I had an excision rather than radical surgery. I didn't even have to have a temporary bag (phew!). Yes, I would have had to have a temporary bag if I hadn't had such a good response to chemorad. Yes, the surgeon who I first saw (and the next couple after that) would still have performed an APR, even despite my good response to the chemorad. But I did have a good response & I had a great oncologist & a great surgeon who respected me & my decision.
I did, of course, have to have adjuvant chemo - xeloda with oxaliplatin (the oxy SUCKED the big one but the resultant neuropathy did wear off with time). I also need more regular follow up (scans, blood work etc.) than if I'd just had an APR – small price to pay though!
I'm only mid 30s & I admit I am pretty vain about my appearance so that played its part in my decision. I guess it might have been different if I was a guy or much older & 'over the hill'. But I have never regretted my decision & like I said, I'm 2 years NED. According to my doctors, that is a great sign as most recurrences (over 80%) occur within the first 2 years.
I don't mean to 'bag' having a bag but I want people to understand that when you have a low tumour, you need to make absolutely sure you get the best possible treatment. Don't just accept the first opinion you get! - 7/26/2010 11:45 PM
ps (sorry Dr Schwab, I will shut up after this ;-)
I should note I have also made lifestyle changes since being diagnosed. I now eat a small protion of meat only once a week (it has been recommended that consumption of red meat should be restricted to no more than 500g per week - any more increases the risk of colorectal cancer), fish once a week and all remaining meals are vegetarian. I eat mostly organic, locally produced (and where possible, home grown) produce. I avoid highly processed foods. I don't buy into the 'sugar feeds cancer' myth but I do manage what I eat to avoid fluctuations in blood sugar levels and I cut out simple sugars as much as possible anyway.
I exercise every day, without fail. Regular exercise has been shown to decrease the risk of a recurrence of colon cancer by up to 50%. It hasn't been shown to have the same impact with rectal cancer but it certainly can't do any harm!
I had my vitamin d levels checked (colorectal cancer patients have been shown to have low levels of vit d) and now take regular supplements of vit d + calcium. I am also on mini-aspirin (aspirin has been shown to decrease the risk of colorectal cancer).
I was told to exercise regularly but the other changes, supplements and addition of aspirin are as a result of my own research. I asked for the vitamin d test (it's not usually a standard test but easy enough to add on when you're getting blood sucked out of you regularly anyway) and I asked about the aspirin.
Here's a good website with more info on colorectal cancer: fightcolorectalcancer.org/ - 7/27/2010 12:03 AM
A few interesting alternatives to colostomy:
http://www.bowelcanceruk.org.uk/home/media-centre/latest-news/saving-my-arse - 7/27/2010 12:34 AM
- Sid Schwab said...
anonymous: thanks for your well-considered comments. My intent, in this quite old post, was to reassure those who need ostomies that they may not be as bad as they think. NEED is the operative (as it were) word. When it can be safely avoided, it should be.
I can't believe how uninformed some people are about life with an ostomy. I didn't have a choice, I went from ulcerative colitis to toxic megacolon and emergency surgery in 2 weeks. There are LOTS of people in their 20s (and far younger) who are living life to the fullest with their ostomy and partying, wearing tight clothes etc. I suggest checking out http://www.uncoverostomy.com and http://www.nogutsknowglory.com. The first website is from a 21 year old model, actress and university student with an ostomy and the second is a young man who just finished climbing the 7 highest summits in the world by conquering Mt Everest in May. There are ostomates who are race car drivers, police officers, black belts, compete in body building (yep with the skimpy little briefs and yep, ostomates who regularly wear bikinis. They are living life to the fullest and like me are trying to shatter the stigmas associated with these much misunderstood surgeries.
There are many people on Shaz's board (http://www.ostomates.org) and the UOAA discussion forum (http://www.uoaa.org) who have resisted having an ostomy for MANY years and finally did and they now wonder why they didn't do it a long time ago as they've been able to return to an active life and do things they could never do when they had ulcerative colitis.
Oh yeah, and they get married and have kids. I didn't choose to have an ostomy, but I celebrate each year the anniversary of my ostomy surgery, even though I nearly died of complications afterwards. I'm still here, and I am doing my best to ensure these stigmas are shattered and people see there is life after ostomy surgery.
I even blog about it, and I too use humor. Yes, I have bad moments, but the good times far exceed the bad and I've met many wonderful people in the ostomate community.
http://www.muggins7.wordpress.com - 9/10/2010 10:32 PM
- Sid Schwab said...
Thanks for that excellent comment.
- Vanessa said...
I jusst came across this post and so glad I did. I had a colonoscopy done 2 weeks ago and was told I likely have FAP after 100 polyps were found. My pathology says the large one in my rectum has sever dysplasia (sp) and it all has to come out. Well that doesn't FLY with me. The top of the line surgeon I went to who I booked surgery wtih and now am going to cancel it Monday said I might have a jpouch or a stoma. Well I only was going to sign up for the IRA, not the other 2. I don't want it, I rather risk it and I don't get why I can't have the large polyp removed and see if it comes back as well as burn the smaller ones out.
I am not seeing the genetic doctor until after my surgery and everyone says I am running out of time, I will be dead in 2 years. How can you say it is FAP when nobody else in my family has it and I haven't been tested for the gene. Well I am not ok with the surgery options presented to me. I don't get why chemo can't get some of it under control. If anyone wants to read my blog and get in touch, please do.
http://vanessaic.wordpress.com/ - 10/08/2011 6:59 PM
I guess it beats the alternative (being dead), but honestly, hearing about all these other people doesn't make it any less of a drag. The worst part is the incessant ITCHING under the appliance! "Misery Loves Company" really doesn't apply here...
- Sid Schwab said...
Well said, Mr Befumo.
Sorry doc, but I'm in my 30's and was given an ileostomy during an emergency surgery. It was not expected and when I woke up and saw it, I wished I had died instead. I still do. It negatively impacts my life in ways I never could have imagined, and it has been extremely hard to find a romantic partner who can get over the "gross factor." I have had my ostomy for a year now, and I am no closer to accepting it than I was when I first woke up from surgery with it. Please don't lie to your patients and act as though this were nothing and they should just suck it up and deal. It isn't nothing. If I cannot be reversed soon and have a decent quality of life afterwards then I will take my own life. The ostomate life I have now is nothing short of torture. Please be aware of this when making recommendations to your patients.
- Sid Schwab said...
In life or death situations, no surgeon can be omniscient. I have to assume yours chose to save your life instead of letting you die. I infer you're young. Hard to imagine, unless specifically told not to, that any surgeon would have chosen differently. I also assume you had emergency removal of your entire colon, rectum, and anus, although that's unusual for emergency surgery. If you have a remaining anus, it's not impossible to reestablish continuity.
I don't think there's anything in my post here that's a lie. And I'm well aware that ostomies are life-changing. You have reason to be angry at the hand life dealt you. You have no reason to be angry with me. In any case, I wish you well. - 12/03/2017 3:49 PM
- Luno said...
I was thinking a lot about ileostomy and colostomy for last few days. I believe it's fair to let people have a choice if It comes to something like this. Some people can imagine living like this and some may not. I wouldn't have mentally enought strengh to handle this. I'm dealing alredy with so many mental health problems, visiting psychiatrist regullarly, get my medications, regular psychotherapy and I stuggle with my self-acceptance even without having ileostomy. Thought that people can normally function is not an argument for someone who would mentally not handle it. Life matters but sometimes the quality of the life may become so low to one individual that death seems to be a relief in comparison. I would never recommend refusing this life-saving surgery to anyone, but If someone is certain about the decission he's about to make I would totally respect that.
Moving this post to the head of the list, I present a recently expanded sampling of what this blog has been about. Occasional rant aside, i...
In no way is it false modesty to say that physicians are not healers. At best, what we do is to grease the way, to make conditions as favora...
Finally I'm getting around to writing about the gallbladder. Don't know what took me so long, seeing as how, next to hernias it'...
I finished the previous post with the sad story of my patient, illustrating diagnostic difficulties at the fringes of biliary disease. An...


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Thursday 3 June 2010
BMI in women's running
Ilsa Paulson (above) won the Twin Cities Marathon in 2009, beating Colleen De Reuk, with a time of 2:31. Should women runners strive to be her weight to be fast, or is she unhealthy?
I've been looking forward to writing this for quite a while. It's a topic basically everyone is hesitant to broach because weight, for some reason, is such a sensitive topic. But what if for a moment, we all talked about weight in women's athletics honestly and realistically?
First, on being skinny:
I would have had to be blind to not notice that the top 5 female finishers at Copenhagen Marathon were thinner than me. First the winner, Colleen Van Deuk has a BMI of 17.3 (normal: >18.5) and certainly has a higher BMI than Ilsa (above), who has beaten her. I saw Anne Sofie Pade Hansen, number three at the Copenhagen Marathon, walking around near me after the race and was astounded by how thin she was. Here is an old picture of her where she weighed more than she does now:
My friend Mette, who took 5th has slipped comfortably into the below normal BMI over the last year and I challenge anyone to find an elite female runner of the 5000 meter to marathon distance who is of normal BMI.
And, correct me if I'm wrong, but most women who enjoy running competitively would also like to be as thin as these women, but it is HARD to stay so thin. But what is even harder, is knowing where to stop with the weight loss before it becomes unhealthy.
On not being too thin:
In college I lost a lot of weight and for a while plateaud at a happy 5'6" 105 lbs (BMI 16.9). Everyone told me I was too thin, but I felt just AWESOME. But my periods stopped and I felt more and more, well, asexual, and by the second year of med school, I fell to 95 lbs, was admitted to the hospital due to almost being killed by a bacterial gastroenteritis which caused me to lose an extreme amount of blood and was discharged to many follow-ups which revealed what I had feared: my estrogen was too low, I had osteoporosis in some spots and osteopenia everywhere and even had multiple painless stress fractures. I embodied the female athlete triad. Partly against my will (anorexics are crazy), I gained weight and then just kept on gaining. My periods didn't come back and I was just depressed.
Anyway, as of this morning, I'm at 115 lbs (BMI 18.6) and would love to lose at least 5 lbs, bringing me back to where I was a year and half ago when we moved to Denmark. I want to be healthy and feel good and be a fast runner. I want it all. But can I? Can we? I just had this discussion while on a run with Helle and the thought of weight loss is exhillarating to us both (and most people would also look at her and not find she had anything to lose). Don't we all want to be that perfect thin weight without having any health problems? Why is it that all non-elite athletes who are thin are attacked for being "too thin", while elite athletes with the same BMI are praised? What IS actually healthy? I KNOW, I'm a doctor, I should know this, but I don't.
I will quickly add that many people say that the best female ultra runners don't need to be thin. And there is some evidence of this. But if you look at the largest ultras (not that there are any nearing the size of a large city marathon), the female winners also tend to be thin, though there are exceptions.
Here was the winner of the 24 hour run world championships in 2010, Anne Celine Fontaine (who ran a sweet 240km) and the winner of the 2008 USATF 50 mile championship, and course record holder, Suzannah Beck.
I hope if I wave a magic wand now, an interesting conversation will develop in the comments section /**** (that was the wand)
Oops. I almost forgot about this freakishly good running song of the day: Farewell to Wendo by Mock & Toof (deserves it's own blog post, which I won't write)
34 comments:
- Ellen said...
- This comment has been removed by the author.
- 3 June 2010 at 15:51
- PiccolaPineCone said...
I would start the discussion by asking, why use BMI as the indepedent variable? It is a blunt tool that ignores factors crucial to athletes, most importantly it treats muscle, bone and fat all the same. Mass is mass. It also ignores gender. My impression was that it was developed to classify the various degrees of obesity as well as the severely underweight but I don't see it as being applicable to athletes. Here is my study of 1: 2006 - 5 km: 17:36. BMI: 19.5. 2010 - 5 km 17:55, BMI: 18.9. The BMI is lower b/c I have unfortunately replaced muscle with fat and this is reflected in the 5 km time. In my mind,body fat is probably the better independent variable to use though admittedly harder to come by.
p.s. cocotte's bmi is 15 but she probably needs to learn to walk before she can take on Ilsa and Colleen. - 3 June 2010 at 15:53
- Danni said...
Hmmmm. A few random thoughts. First, for those of us who are not professional runners, why live life that way? If it's hard to be that skinny, why do it? To me, being that thin isn't even attractive. On me or anyone else. I don't give a crap about elite runners. I am not one nor do I strive to be one. I ran my marathon PR at the weight I am now and could have run faster if I had the experience I have now. . . maybe I could run faster if I lived a life of misery and starvation but that doesn't sound rewarding to me. I've been 15 pounds lighter and wasn't necessarily faster and certainly wasn't happier.
My next thought is that it's really unhealthy, as you know already, to obsess about weight, especially when it has had terrible consequences in the past. It's one thing to not want to be fat, but quite another to really want to be underweight to look like elite runners. And let's face it, not every underweight runner is elite or even fast. My fat ass kicks plenty of skinny ass at races and I'm not even in top shape for "me."
Of course, I do mountain ultras so my idols are the likes of Olga and Nikki Kimball. Both I know struggle(d) with weight issues but both are talented and strong and are better role models for success in my sport. Olga has placed top 10 at Western States, which is a huge achievement. And, she has beat you ;) And, she doesn't strive to be underweight. Again, this is focused on a different sport -- you seem focused on road running. . . but I hope something coherent emerges from this rambling. Maybe it won't. Ultimately, I feel like I have finally gained the wisdom to appreciate that life and running is about so much more than the mental and emotional flogging of scale obsession. - 3 June 2010 at 16:01
- LK said...
I'll just say that in my opinion, BMI is a total crock! I'm 7 pounds from being in the "overweight" category. Everyone in my workplace thinks I'm skinny, but, more likely, I'm average for an athlete, and muscle weighs a heck of a lot more than fat and displaces fat at a 5:1 ratio per pound. I prefer to look in the mirror, as vain as that sounds, to determine what seems healthy. For me to get down to the bottom top 1/3 of the "normal" BMI weight score (14 pound weight loss), my face would look ematiated (I've been there before). There's also a certain amount of satisfaction when I toe the line in a race where I'm trying to place top 3 and beat much lighter, svelte runners. Yes, my body gets beat up more because of my weight (182), but that's something I have to live with.
On a different note, I can assure you that one runner mentioned in these comments is NOT overweight. I get to enjoy watching her walk naked across the bedroom every morning after she wakes up and I NEVER get tired of seeing that piece of beautiful art. Absolutely perfect! It would make a college girl jealous! ;) - 3 June 2010 at 16:31
- Danni said...
Larry, just so we're clear, I never said or would say that she's overweight. She's obviously not. Only that she's *not underweight* and is awesome.
- 3 June 2010 at 16:33
- Mapp said...
Am I happy being slim? Yes, I am. Do I want to be like Isla? Certainly not! I don't find it remotely attractive and think she just looks sick. But more than the aesthetic side of things, I just don't want to know how she will be and feel when she gets older...
A woman in my running club back in London is in her mid 50's. She is a fast runner if you consider her age-group results, and just ran the London marathon in just under 3.20. She is also totally obsessed with her weight (I am not making this up: she weights her SOCKS before chosing her outfit for a race). Sure, she is skinny, and looks pretty decent when fully dressed. When wearing shorts and a crop top... well, I guess it is an acquired taste. And more importantly, she has multiple health problems, and keeps getting injured... and it is anyone's guess how many more years she'll still manage to run... And I am absolutely convinced her health issues are totally related to being too skinny.
So as for me, if I had to chose, I'd rather be healthy and still be running in 20 years time than losing weight and jeopardising the chance of doing sports well past retirement age!
I guess it is all a matter of when does "thin" becomes "too thin"... and that's where the problem is, because once one starts losing weight, it is only too tempting - and exhilarating - to try and lose a bit more. That's especially true, I find, of long distance runners, who tend to be driven and control freaks (well, I am, at least!). You actually find that a lot of them, especially women, started running TO LOSE WEIGHT...
People focusing on trail running for some reason seem to have a more healthy attitude to weight... Karine Herry, Corinne Fabre, Laurence Klein, these women are all top trail runners, and they are not skinny, just slim, lean, and muscular (and in my view far more attractive than Isla!)... And Laurence Klein has a marathon PB of 2.37.. gained last year, at... 40! Now, if I needed a role model, I'd rather chose her!
End of rant! - 3 June 2010 at 16:44
- Diana said...
I have to agree with Piccola Pine Cone that BMI is a horrible method for measuring weight or the overall health of an individual. It was developed in the nineteenth century by a Belgian astronomer interested in studying the averages of the human body within a large population, and its creation is steeped in the cultural concerns of the time. It was never intended to measure the health of an individual the way the medical community has come to use it. I loathe the use of BMI for the reasons PPC stated above in her comment.
Furthermore, I'm a little troubled by one of the sentences in the post: "Don't we all want to be that perfect thin weight without having any health problems?" What's so perfect about a weight that leaves us vulnerable to sickness and injury or even causes health problems? That doesn't seem so perfect to me.
Yes, losing weight can feel good. I also believe it can be difficult to stop, because being lighter can make you feel faster. But does the actual number on the scale really, truly matter, or is it a matter of having something to control? I threw out my scale a few years ago, and I have refused to be weighed at the doctor's office before, simply because knowing my number only makes me want to control it.
I'm not an elite runner, so I am not faced with the stress of winning competitions and meeting professional expectations. As an aside: I don't know if I agree that elite athletes are praised for being so skinny. I can only say that I wish a focus on health and running would shift away from becoming thinner and achieving a desired BMI. Better to eat well, work hard in workouts to get stronger and faster and ultimately to enjoy the running. - 3 June 2010 at 17:20
- SteveQ said...
First, you have to acknowledge the "more babies born during full moons" thing - there's absolutely no evidence, but ob/gyns and nurses will tell you it seems true. That's because they LOOK for it; if they see the two together, they remember it, if they don't, they ignore it.
You see a skinny woman win a race and remember it, because you want that to be reinforced. There are plenty of counterexamples, but you ignore them.
This is coming from a guy who was once 5'11 1/2 and 128 lbs. and running 32 minute 10K's and now 6'0", 155 lbs. and running closer to 38. I could say it's the weight (30 years older is more likely). VO2(max) is directly proportional to mass, so the less one weighs, supposedly the better - and Matt Carpenter's measurement of 90 is due to his being 118 lbs. at 5'6". But he doesn't always win!
There's only so low one can go before one loses strength, so the smaller one's frame, the better, which is why Tegla Laroupe at 74 lbs (4'7") had an advantage and why top male marathoners are all about 5'2"-5'3." You're never going to get to their weight and you shouldn't try!
When weight goes low enough, one obsesses about food. I know from experience. It's not worth it; if I made a living from running, I might consider low weight for a year or two, but what price misery?
Sadly, I think Ilsa's hot. That's my own neurosis - I was engaged to a woman who died from a heart arrhythmia from malnutrition, trying to lose weight when she was already too thin - and I still think Ilsa's attractive. I'd also think she was attractive if she weighed a lot more, thank God.
Okay... getting too long here. - 3 June 2010 at 17:38
- cherelli said...
Hmm, I'm not a fan of BMI at all. Like others have said it fails to account for the differences in body muscle/ fat composition. Perhaps bodyfat AND BMI should be included in this discussion. Whatever, i guess it's a matter of knowing where your line in the sand is. You are either an elite athlete willing to forgo some elements of long term health to gain results in the present time; or you are a successful competitive athlete who needs a little extra energy for the rest of life like a job and children. Also, there is a fine line between wanting to be "a few lbs lighter" and becoming obsessive about weight - which you have admitted to being susceptible to in the past (I delved a little into the same thing in my teens and recall that exhilerating sense of control - but to the exclusion of so much else). Will you know when you have crossed that line? Oh and I am SOOO not a fan of the skin and bones look in the arms or upper legs. A little healthy bodyfat and muscle tone while still being slim is FAR more attractive. I agree with others that any trail runners I see look far healthier than the road runners.
- 3 June 2010 at 17:47
- Olga said...
Yikes, ouch:) OK, first of all, from a medical/athlete stand point I completely on the side of Piccola saying that BMI is an arbitrary number. To be clear, since my name was brought up, my BMI is 22.5. My fat is around 20% by densitometry (which was taken 2 years ago twice at different weight and waist/hips measurements, as well as by calliper test, so I know it by heart and can always tell you where I am). That's just to begin with. Fat vs muscle give numbers that screw BMI. I am 5'5" and stand at 135 lbs (with fluctuations 5 lbs either way, yes, that much, I bet it would drive you nuts, but it is period dependant and post-race influenced, and I stopped fretting about it). I have a huge muscle mass though, noted by massage therapist and doctors (and regular by-standers, too bad I can't find time to become a body builder, I'd be awesome at that!).
Now, to the first picture. That girl looks sick and reminds me of nazi camps, elite athelete or not. This particular one is unhealthy. I'd say same thing for the Paula Radcliff and alike, although she is not as bad. Still - sick. For them - it's a job. They make a choice. As I said in some other comment, neither you, nor I or 100% (yes, all of us here) of readers here are elite athletes. Neither one of us will ever be - sorry, live with it. We'll get better (or so we strive for, and I believe we will as we try hard), but we will never be elite. I'd stop comparing to those just simply on this fact based.
Now, to the possible core question - does shaving a few oz's make you a faster runner? Depends. Likely. Especially at road short races, to a certain point of course (before you get to be emaciated). Has to be proven for each of us though. While yes, majority of ultra-goddesses (since it's the only field I know) are still on a less-fat side for sure, a few are in a healthy "athletic overweight" issue (like ones we discussed, although normal by regular people's standards). But, again, the real scientific experiment would be to have each of them either gain a few pounds or fat (not muscle) or loose it and have them perform under same training and race conditions - and look for TIMES, not placing (I have to agree that those couple we discussed in email, while won, have not run "elite" times).
I am an experiment of one, and have no answers. When I had my best, fastest year, I raced at 145 lbs. I had PR's at trail 50k, 50M, 100k, placed that infamous top 10 at WS and made 4 100M races a year with 22 ultras total. By the time last 100 miler rolled, I got down to 130 though...just for that one, in 6 weeks, I dropped over 10 lbs. I had a good race. I don't know if I had done better, worse or same at 140.
Now, to MY core - and what seems to be Danni's core too:) Why??? I LOVE my life! I was at 117lbs once and kept it for 2 years, I really enjoy looking at those photos. Do I want to go back? I'd like to look like it, yes - I am a normal female. BUT, I don't want it bad enough to make sacrifices for it, it is NOT THAT important to me. I have way too many more responsibilities - and fun - in life than focusing on what to eat by gramm/calorie (while I do eat healthy and watch the general trend), I feel strong, I am able to do my workouts without exhausting myself for the rest of the day, I get looks and compliments, and - I have that dude who keeps watching me with his jaw dropped every morning:) What's more to wish for???
And as he said, and I said numerous time, it's fun to beat skinny asses at the races...JK! - 3 June 2010 at 18:08
- LK said...
Danni: I knew what you meant. No offense taken. :) -Larry
- 3 June 2010 at 18:16
- SteveQ said...
btw, Helen's blog lists data from Feb 2008 when she was 166 cm. and 66.8kg. and 19.4% body fat - beat her in a race and then you can revisit the question!
- 3 June 2010 at 18:27
- SteveQ said...
And Chris Solinsky's making news as the first "fat guy" to break 27 minutes in the 10K @ 73kg. and 185cm. - neglecting to mention he's also the first non-African.
- 3 June 2010 at 18:40
- Fast Bastard - World's Fastest Hematologist said...
Hi all. Great discussion. I think everyone is in 90% agreement. I have a few points.
1. BMI is getting slammed here. It's used a lot in medicine, and while it may not be perfect, it's a rough number that is used to guide dietary decisions. I know of no better alternative. Most healthy athletes are clamped within 1 or 2 BMI points, so in those cases BMI doesn't make sense.
2. I'm glad that Larry has a chance to see Olga walk across their bedroom naked every day.
3. I think there is little doubt that distances from 5000 to marathons tend to get won by people with lighter builds. For these individuals, as Steve Quivck says, there is a perfect weight that's neither too light nor too heavy. It's my guestimate that a lot of women exist on the lower end of that perfect weight, whereas most men, even elites, tend to be a little heavy. How many years has Chris Solinsky been running great, but not world-beating times? He sure got fast after losing those few extra pounds. Men tend to build muscle easily and, like it not, muscle slows us down. Lance Armstrong has commented on how he was always struggling to stay lean and was told never to do any upper body work. Most men gain weight as they age, sometimes solely because of muscle. Even if it's all muscle, it still has to lugged aorund in a race.
4. Her name is Ilsa, not Isla. Isla, by the way, is the daughter of Paula Radcliffe, whose weight is insanely low, too. As an aside, my young niece, who is half Malaysiian, half Danish, is called Ayla, pronounced like Isla.
5. Steve, Ilsa said in an interview with Runnersworld that she often gets handed the children's menu when she goes out to eat with older people. You two would look odd on a date, methinks.
6. On a personal level, my weight is always inversely proportional to my running performance. I'm a moderately heavy runner and within my little window of weight, I tend to be in the heavy range. I set my best PR (1:13 half marathon) a couple of months after getting braces. I agree with everyone above about healthy weight etc. but I also think the honest truth is that light=fast, at least for men. Sealegsgirl, on the other hand, is on the low end of her weight window and has been getting faster along with gaining a few pounds.
7. Western society's perception of perfect weight varies with sex. Few men are tempted to go below BMIs of 20, simply because it brings no status to be that skinny. Quite the opposite for women. Barbie has a BMI of 12, while Ken's is 23 (source: psychiatrist specializing in anorexia; might be inaccurate).
8. In life outside running, it's very controversial which weight is ideal. There are conflicting studies out there, all full of confounders. In my specialty, cancer medicine, it's well-known that being in the low end of anormal BMI is a risk factor and a low BMI is downright dangerous. - 3 June 2010 at 19:00
- SteveQ said...
@Fast Bastard: I'd take that chance with Ilsa. I dated a woman who was 4'1" and 48 lbs. once and could've passed for 9 years old.
Wow, I'm coming off badly here!
A quick Google search finds women finishers at Western States ranged in BMI from 19.4-21.9 and in another study of women 100 milers, the fastest three were 21.5-22.9 - 3 June 2010 at 19:09
- Coach Jen said...
Like others said BMI alone is difficult to use for judging, you could almost make better comparisons with using body fat % and muscle. According to BMI alone, I would have had the same BMI with a weight of 105 (5'6") at two different points of my life; in high school as a dancer while eating minimal food and restricting calories and a few years ago when I ran my half/full marathon PRs but was eating healthy at had much more muscle. At the first time I lacked energy and looked unhealthy, but when running I was eating plenty, but training hard and felt great but wonder if I could have had a little more energy to go even faster had I kept a few more pounds.
On a side note you and I are the same height and weight and I too would love to drop 5 lbs, but have a feeling that my love of ice cream and wine may prevent this :-) - 3 June 2010 at 19:28
- sea legs girl said...
I knew I would get crucified, but I didn't know it would be because of my inordinate love of a Belgian astronomer. I have to wonder what I should have used instead of BMI: average density? nutritional status? Okay, I agree I'd love to have included %fat, but as if I have access to that. I had to use some sort of measurement and it is better than weight alone. But the pictures tell most of the story, so you gripers can all just skip over the BMI part when you read the post and it won't change much.
I am the fastest I've ever been now and at a higher BMI than I had 1-2 years ago. It's because of training. But if I keep training AND lose weight, I'll get faster, to a point. But I'm nowhere near that point of being too light. It is just extremely difficult to realize exactly when one has gone too far.
I agree Steve, I'm more obsessed with food when I weigh less, but I am always so extremely obsessed anyways that no one would notice the difference. Oh, and is Ilsa single? Though for her sake I hope she dates someone who can talk some sense into her.
Larry, thanks for the comment! Feel free to write about Olga walking around naked anytime. That was exceptionally touching.
SR, you on the other hand, are not allowed to write about Olga walking around naked. - 3 June 2010 at 19:48
- sea legs girl said...
Marathon Princess, cool that we share weight and height! I also love red wine, but not ice cream. Lactose intolerance may be what helps me to lose those pounds.
- 3 June 2010 at 19:49
- mmmonyka said...
This is a really interested post and discussion. Mostly because I have never really cared about my running weight. I am such a non-scientific approach runner... But it now seems to me that it is a pretty important issue for distance runners and I should be more careful. I am 6' and my weight is somewhere around 140-144 (I think) and it seems that to be a good distance runner, I should lose some of it. Maybe 135? I did run my HS 1500m PR at 144ish weight (4:41) and am not sure whether losing few pounds would have made me faster. I do not think so thought. I used to run with bunch of very fast middle distance runners and a lot of them were not skinny at all. Well honestly, I was one of the skinniest ones.
But I feel that if I lost few pounds now, it would help me to be faster distance runner. I will try and let you know how it goes. - 4 June 2010 at 00:23
- sea legs girl said...
Mmmonyka, it's certainly not my intention to suggest an of my readers should lose weight! And losing weight is no guarantee for getting faster; it has to be accompanied by the same intense training. And no one says anyone needs to feel compelled to get faster. That being said, it is your decision!!!
Re ealier comments:
Steve Q, your logic about Helen Lavin vs. me could be thrown right back at you with Devon Crosby Helms vs. Helen Lavin. Granted I don't know DCH's BMI (I just googled it and was disturbed to get my own blog?!), but I suspect is is quite low. Once HL beats DCH, then we can take up this discussion again. :).
Diana, I never properly thanked you for that interesting tidbit about the BMI astronomer. That's quite a nice factoid.
Confession: When I really think about who's body I would MOST like my body to resemble, it is Kami Semick's. I actually think she has a normal BMI, but very low body fat. So, despite the fact that she could probably get faster at shorter races if she weighed less, I find myself admiring her more the way she is. - 4 June 2010 at 08:03
- Fast Bastard - World's Fastest Hematologist said...
"@Fast Bastard: I'd take that chance with Ilsa. I dated a woman who was 4'1" and 48 lbs. once and could've passed for 9 years old."
There's a story that deserves a blog post all its own. - 4 June 2010 at 17:15
- amazon said...
I don't know that I have much to add here, except that I can't remember ever hearing praise for elite athletes for being as thin as Ilsa is. In my experience, as others have said, people do tend to get faster as they lose weight, but there is always a point where that trend reverses, and I can't think of anyone who has managed to avoid going past that threshold when losing weight.
And about BMI, I do agree that it's somewhat meaningless when it comes to athletes. My husband, who is short(ish) and muscular is borderline obese by the BMI standards, and of course that notion is absurd. - 4 June 2010 at 23:14
- Amber Dawn said...
I certainly don't know the answer, but I know that my usual race weight (Ironman Peak) is 105lbs. I only weigh that for about 2 weeks and it generally takes me an entire summer of high volume to get there (no dieting). Normally I sit comfortable at 110, year round. 2 weeks before my first 50miler (at the end of May) I decided I should be at race weight. For some reason all of the above info didn't occur to me and I just thought I could diet my way down 5 lbs. I ended up catching a horrific chest cold that has now turned into pneumonia. I am pretty sure if I had just kept eating/drinking normally I would have stayed healthy and been able to run the race. This is a lesson learned for me. I think it is different for everyone, and some people are build leaner than others. I know I won't ever make the mistake again of trying to force my body to a particular weight.
- 4 June 2010 at 23:24
- mmmonyka said...
SLG, no worries, it is not your posts that have influenced me.
It is a pure logic thing. If you have to carry extra 5 pounds for 42k, then you will definitely feel it, right? It is like carrying extra weight in you backpack when hiking. You want to make it as light as possible. The same thing goes for running, I don't want to drag extra weight with me:)
But I love food so....I might continue carrying that extra weight:) - 5 June 2010 at 04:21
- Drs. Cynthia and David said...
I am curious what difference nutritional status makes with respect to the weight-health continuum - what would happen if you were also eating a high nutritional density diet (vegies and meats/dairy with lots of fat soluble vitamins like A, D and K2) instead of a lot of empty carbohydrates for fuel? Under these circumstances, it might be harder to do high intensity training (without replacing carbs religiously), but would the low weight actually be unhealthy? Would you still get the same hormonal imbalances and osteoporosis? The crossfit people doing paleo seem to indicate otherwise, and report miraculous good health and resistance to disease, but I don't know how many of them are in the BMI range you're discussing. Paleolithic peoples are certainly on the thin side and they are not unhealthy. Have you ever tried that experiment? I'm only semi-paleo myself (age 53), but I'm rarely sick anymore (I had pneumonia 3 times some years ago and lifelong asthma). I have tons of running injuries, but all soft tissue, and when I fall or take a hard landing, I get a dislocation instead of a break (not necessarily good but an indication of strong bones anyway). Of course, I'd have to get a lot skinnier to test out the theory on myself and that's not happening anytime soon!
Thanks for the discussion.
Cynthia - 6 June 2010 at 02:25
- SteveQ said...
@Drs. C&D: You just never hear the stories of people on Crossfit and paleo who DON'T succeed. They get shouted down like liberals on FOX.
- 6 June 2010 at 19:38
- sea legs girl said...
I just imagine the section of the article written about Ilsa in the Minneapolis Star Tribune was filled with praises for the young athlete and not a moment's mention of her being too thin. I haven't looked it up to verify. But this is always how it is. Don't you think?
Amber Dawn, I essentially agree with you. But interesting that you tried to lose weight for a 50 miler! I think it is important there is some calorie excess (compared to where one has been in the last month's time) before one runs such a long race. It is however extremely difficult to say exactly WHY some young healthy people get pneumonia and I imagine you will never be able to know whether it was the weight loss that triggered it. As a resident and medical student, I was amazed at how many young, healthy, non-smokers seemed to get pneumonia out of nowhere (especially lobar streptococcal pneumonia). I hope you get over it soon!
Well, you finally got me to look up what the Paleo diet actually is. People in Europe seem to not need to call their diets anything, they just "eat healthier" and "eat less". 1. If we really wanted to eat like our hunter gatherer ancestors, we should include bone marrow into our diet up to a couple times a month 2. I think a lot of women's menstrual irregularity does stem from a lack of fat in the diet and that especially fish fats are important, and you can be thinner and have regular menstrual cycles if you get enough fat. 3. If a woman continues to have regular menstrual cycles, the chances of developing osteopenia are extremely low. Normal estrogen levels keep women's bones strong to a large extent. Bones can in turn be made even stronger by weighing more and by engaging in more weight-bearing activities. 4. I am happy to hear you are rarely sick and have to wonder it it's not at least partly because you are at a place in your life where you have the time and ability to take care of yourself. Are you also getting more sleep and more exercise? Both of those are at least equally important in boosting the immune system as a balanced diet is. Really great questions! Thanks for asking my opinion :). - 7 June 2010 at 09:07
- Drs. Cynthia and David said...
Thanks for your comments. Paleo is a moving target and gets interpreted in different ways- some people treat it as a mostly fruit diet, some as mostly low carb, and some as no grains/no dairy. Not very specific! Steve's comment is well taken too- whatever diet people are on, they may be very enthusiastic and vocal at first and then quietly fade away thereafter when it disappoints. Notably though the freetheanimal blog has broached the subject of failures or struggles on paleo, so some people try to keep it honest.
I thought you might be interested in this post I saw today discussing hormones and diet in connection with fertility patients: http://heartscanblog.blogspot.com/2010/06/low-carb-gynecologist.html This Dr was able to get fertility up to 90% (from 40%) without in vitro treatments using a very low carb diet. He said it was useful for treating nausea too. Eric Westman at Duke has also written quite a bit about his dietary treatment of PCOS patients. I'm not sure how relevant this is for runners (presumably having good insulin sensitivity), but I thought it was very interesting.
And I should have mentioned studies such as those discussed in this (and related) posts: http://wholehealthsource.blogspot.com/2009/03/reversing-tooth-decay.html What is good for keeping teeth strong should be good for keeping bones strong too.
I'm sure some of my better health is due to taking better care of myself in my old age. Now if my runs would just get faster!
Thanks again.
Cynthia - 7 June 2010 at 09:53
- sea legs girl said...
Whaaaa??? She's a woman, not a MAN! She has got to be done growing. Okay, not 100% of women are done growing by 20, but at least 99.9% are. The exceptions being at least to a certain degree pathologic.
- 7 June 2010 at 21:17
- SteveQ said...
A lot of people aren't done growing at 20. My friend Chuck is the extreme example, growing a foot taller during college - he was always about 4-5 years behind developmentally. I grew about an inch after 20, but didn't develop muscularly until 30.
Women do develop faster, but heavy training and concomitant low weight often delay growth in women; there's a number of examples among gymnasts. - 8 June 2010 at 18:08
- Helen said...
This is a great discussion topic and I will have to come back again to read all the comments. I will just say that like most other 'regular' non-elite female runners that read your blog I would love to lose a few lbs (okay, maybe 10) but I don't lose much sleep over it and if I want the donut (or 3) I'll have it (them). I know I won't ever run my goal marathon time of 3:10 without being 135lbs or under (I was that when I ran my current PR of 3:17 in 2007) but it's not my priority right now. Ultras are definitely different - especially the tougher technical ones that have so many factors beyond raw speed (which is most definitely helped by lightness). I was 140lbs when I won and set a new CR at Voyaguer 50M last year and probably closer to 145lbs when I won Hellgate 100K (BMI 22.6 and 23.4). I have no doubt the likes of Nikki K, Krissy M and a dozen other ladies could take another 30 minutes+ off my times in those races but I guess I want to make the point that training, mental and physical strength and race prep can make up for a lot! Now, what did I do with that bar of chocolate...
- 9 June 2010 at 02:20
- Katie said...
This is a really great post. And something that I struggle with too. I'm also 5'6". My BMI is usually around 22.5, which makes me 140 pounds (when I'm not pregnant). This makes me sound down right fat in comparison to you, but here's the deal...I was also a 140 pounds when I ran an 18:20 5K. That season I broke 19 minutes every time I ran a 5K. I usually wear a size 6 and often receive compliments on my appearance. Thus, I generally don't feel fat, but I often wonder if I'd be faster if I lost 10 pounds. I do strive to be faster, but I don't think the elite women or men distance runners are attractive at all. In fact, I find them a bit scary looking. Whether they are healthy or not...I just don't know. I've read studies where being underweight seems to correlate to a longer lifespan, so who knows...
- 9 June 2010 at 13:31
- sea legs girl said...
Katie, wow you are one fast babe! Guess it's not surprise you run fast pregnant, too :).
But I need a little explanation here. So I have read studies where rats that are calorie restricted survive longer (though never seen a corresponding study in humans) and I have seen multiple studies in humans that show having a BMI in the middle of the normal range corresponds to living longer. Could you point me to this study/studies that show weighing less correlates with living longer? - 9 June 2010 at 15:19
- Katie said...
Here are two articles I've seen regarding calorie restriction. The first was study done with humans, the second a study done with monkeys. I'm not a huge fan of calorie restriction, which is probably obvious given my 22.5 BMI, but I'm seeing more and more of it lately. I don't think I could ever actually do it. In fact, in the human study they preferred participants to limit exercise to maintain the restriction. That's definitely not something I'd be able to do...
The Calorie-Restriction Experiment
Dieting Monkeys Offer Hope for Living Longer - 9 June 2010 at 16:04


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(1) The median educational debt acquired by law students should not exceed their median starting salaries.
(2) The relationship between advertised tuition and loans taken out is highly predictable.
The median starting salary of graduates in the class of 2011 was, optimistically speaking, around $45,000 (NALP lists a median of $60,000, but this is based on salaries for just 42% of the class, and given that there's a tight correlation between higher salaries and the likelihood they're reported, and that nearly 15% of the class had no salary at all, an estimate of $45,000 is if anything generous).
But let's give law schools every benefit of the doubt and assume it was $50,000. Let's go further, and not take any other educational debt into account when estimating law graduate debt. What would tuition have to be to generate a median law school debt at repayment of $50,000?
Note that every single law school in the country that accurately reported mean amounts borrowed during law school by its class of 2011 reported a higher total than this. (Drexel, Southern, Texas Southern, and Georgia State initially reported lower numbers to the ABA, but their reports are obviously for one year of debt rather than three. I don't know whether they've corrected these figures with the ABA, but they remain uncorrected on USNWR's webpage, which is the only public source for this information).
Note too that borrowing $14,600 per year will, because of accruing interest, result in a debt level of $50,000 in law school debt alone at repayment.
For the mean law school debt -- the median would of course be higher -- of a graduating class to be in the $50,000 range, tuition should be no higher than $10,000 per year. This can be deduced by comparing historical tuition levels to amounts borrowed (This assumption is generous to schools located in expensive cities. In such cities, a student who debt-finances a $10,000 per year tuition bill would have to pay cash for almost all of his or her living expenses during three years of law school to avoid incurring debt at graduation of more than $50,000. Even in areas with a modest cost of living the large majority of a student's living expenses can't be debt financed if the student paying a $10,000 tuition bill is going to graduate with not much more than $50,000 in law school debt).
Now it's a sign of how warped the economics of law school have become that at almost all law schools the idea of charging $10,000 per year in tuition has come to seem almost inconceivable. But in fact there's absolutely no reason why law schools couldn't be operated perfectly well while charging that amount.
Here's CU's annual resident tuition IN 2011 DOLLARS:
1981: $2,700
1991: $6,000
2001: $8,300
Naturally these tuition levels were made possible in part by tax subsidies. But note that even if tuition in 1981 had been 100% tax-subsidized (in fact it was nowhere close to that) the actual cost of educating each graduate was still hardly more than $10,000 per year. By 2001 the law school was getting less than a third of its operating budget from the state, so the actual per-student cost of operation was still not much more than $10,000 (since all non-resident CU students get resident tuition after their first year, out of state tuition has very little effect on this analysis). In fact, Harvard Law School was charging only $15,862 per year in 1981 in 2011 dollars, and even as late as 1985, i.e., several years after the beginning of the big tuition run-up, median tuition at private ABA law schools was still only about $15,000 (resident tuition at public law schools was under $4,000).
And none of this takes into account the many ways in which technology should be reducing the cost of education. Adjusted for inflation, I paid more for a Honda Accord in 1995 than I would pay for the -- much superior -- 2012 version of that car. The computer I'm typing this on couldn't be sold for $100 (it's four years old), but it still has more computing power than machines that cost several million dollars thirty years ago. Why should education be different?
One answer people sometimes trot out is the Baumol effect. But the very example Baumol and Bowen use to illustrate their theory actually illustrates its inadequacies when it's deployed to explain why tuition is so high:
Baumol and Bowen pointed out that the same number of musicians is needed to play a Beethoven string quartet today as was needed in the 19th century; that is, the productivity of classical music performance has not increased.This line of analysis fails to take into account that the cost to consumers of a performance of a Beethoven string quartet has declined by a factor of close to infinity since Beethoven's time. The relevance of that insight to the consumption of higher education, in a world where the cost of transmitting knowledge is hurtling toward zero, should be obvious.
The only reason law schools charge $30,000 and $40,000, and $55,000 per year in tuition is because they can. Those prices bear absolutely no relationship to either what a law degree ought to cost to acquire, or to what it will be worth to those who acquire it.


text:
The Twilight team finally has earned some love — or loathing — from Team Razzies.
The Twilight Saga: Breaking Dawn — Part 2 was picked as last year's worst picture Saturday by the Razzies, an Academy Awards spoof that hands out prizes for Hollywood's lousiest movies on the eve of the Oscars.
The finale to the blockbuster supernatural romance dominated the Razzies with seven awards, including worst actress for Kristen Stewart, supporting actor for Taylor Lautner, director for Bill Condon and worst screen couple for Lautner and child co-star Mackenzie Foy.
Adam Sandler was named worst actor for the raunchy comedy That's My Boy, his second-straight win after 2011's Jack and Jill, which swept all 10 Razzie categories a year ago. Pop singer Rihanna won worst supporting actress for the action dud Battleship.
Twilight movies had been well represented in Razzie nominations over the years but had not won any key awards there. Razzie voters joke that as with The Lord of the Rings finale winning best picture at the Academy Awards, they were waiting for the last Twilight flick on which to heap their scorn.
"I have a pet theory, which is that the box office on Twilight films is very impressive, but my theory is that instead of 40 million individual girls going to see it, it's 8 million girls going to see it five times each. People who love those movies just adore them," said Razzies founder John Wilson.
"I believe the attitude of people who really love Twilight movies toward this subject is very similar to the pomposity with which the Academy Awards addresses the whole rest of the world. Our whole existence is all about making fun of pompous, so Twilight really is right up our alley."
The Twilight finale also won for worst screen ensemble and worst remake, rip-off or sequel. For worst picture, it beat out Battleship, That's My Boy, the family flick The Oogieloves in the Big Balloon Adventure and Eddie Murphy's comedy flop A Thousand Words.
Stewart's worst-actress prize came for both Twilight and her fairy-tale update Snow White and the Huntsman.
In the five Twilight movies, Stewart stars as sullen teen Bella Swan, who falls for ageless vampire hunk Edward Cullen (worst-actor nominee Robert Pattinson) and finds herself at the centre of a love triangle with him and her childhood pal, werewolf stud Jacob Black (Lautner).
Stewart set a consistent standard of emotional stoniness throughout the Twilight movies, Wilson said.
"Acting should involve having an expression on your face, and she is blank, other than the morose kind of half-Goth thing her character does," Wilson said. "I didn't realize Snow White and Bella were soul sisters, because of the very limited range of what she can do. I think it was Dorothy Parker who said about Katharine Hepburn that she runs the 'gamut of emotions from A to B.' Kristen Stewart is so expressionless she might as well be a brick wall."
Sandler's That's My Boy, which also won the worst-screenplay Razzie, flopped at the box office and continues a gradual decline in receipts for the comic actor's movies.
"He's an enormous star who is on what I call the 'down-alator' of his career," Wilson said. "He's about to step off the same cliff Eddie Murphy stepped off about 10 years ago. Eddie Murphy has never come back, and Murphy is more talented."


text:
Project Members
- Tom Güldemann
- Alena Witzlack-Makarevich
- Martina Ernszt
- Sven Siegmund
A text documentation of N|uu
The project documented the last South African San language and the only surviving member of the !Ui branch of the isolate family Tuu (a.k.a. "Southern Khoisan"). The team consisted of three PhD students and the applicant. It was funded by the ELDP and started in October 2007.
The language is highly endangered, because only less than 10 elderly speakers are known at the time of project start. While the language had been subject to linguistic investigation for five years prior to the start of the project by several linguists including the applicant, it was far from being documented in any sufficient way, because the previous research had mostly been dedicated to specialized topics such as to sound system, certain morpho-syntactic structures, and lexicon. A particularly striking gap in our knowledge of N|uu was a discourse-based description and analysis, and this across the whole spectrum of still existing inter-speaker variation. The project was intended to fill this major gap and ultimately lead to a documentation of N|uu to the fullest possible extent. Since the number of speakers was generally limited, we will attempted, when possible, to gather a representative text corpus for every speaker; this allowed us to compare their respective idiolects in terms of linguistic and stylistic variation. These corpora contained both prompted texts of parallel (and thus comparable) structure (e.g. based on the "Pear story film" or on similar stimuli) and spontaneously produced, culture-specific texts. The project closely collaborated with the community, the South African San Institute (the NGO coordinating community work), and the scholars previously engaged in linguistic research on this language and materials that resulted from this project were made available to these parties.