Category Archives: Technology

Can a Fitness Tracker Help You Lose Weight?

Sure, but a fitness tracker can’t tell what behavioral changes will result in a change in your body fat percentage or a smaller waist.*

Last week, a Washington Post writer reported “Apple told me it does not track research about weight loss because that is not the focus of the Apple Watch.” So far, good. Then he added, “(That’s disappointing.)” I applaud Apple for declining to make weight claims, because a watch simply cannot “make” that happen. Changing your daily habits consistently enough to change your body in a sustainable way requires a lot of moving parts, and a fitness tracker isn’t a mind reader—it just collects and displays the information that the maker has set as defaults or that you ask it to display. Fitbit, in contrast to Apple, makes weight claims because it has gone in heavy with providing devices to wellness programs and other contexts that have (of course) additional information available for users.

A fitness tracker can nudge you in a particular direction, but you have to have at least the direction (if not a destination) in mind. Is it more steps? Is it more sleep? Is it a particular mix of high- vs moderate-intensity exercise? (To which I would guess most new users of fitness trackers would say, “a what?”) Is it number of minutes of exercise per week? Is it spending less time sitting? It doesn’t know what’s important to you. And I don’t think any of them have integrated food records—food recording is a whole thing with enough twists and turns to earn a master’s degree, and the most a fitness tracker will do is import a calorie total from a dedicated food tracker. And that’s the other common theme, also hit in the article linked above—the writer even passes along the opinion of the WeightWatchers Chief Scientific Officer to present the typical, binary-opposition response to any discussion of exercise and weight, “But a fitness gadget still can’t automate what Foster considers most important data in weight loss: what you eat.” Of course, says the CSO at the company dedicated to helping people adjust how and what they eat.

What you eat and what your activity pattern is, along with how much and how restfully you sleep, contribute to the condition of your body—from your health to your performance to your body fat percentage to your waist size to your alertness during the day, and on and on. Your fitness tracker can assess your sleep, too—sort of**—but again, just observing it (or including some nudges to remind you that it’s important) isn’t enough to make change happen. People rarely end up with unhelpful eating, activity, and sleep patterns because they want that; they have made a variety of choices against the backdrop of many external factors that are not always easy to change—or, in some cases, identify.

Fitness trackers are undermined by two main issues: People buying one for the first time don’t necessarily know what they want, and once they have one, they almost never know how to configure it to be most helpful. In the early years of Fitbit availability, they were often called “glorified pedometers,” and even the first release of Apple Watch was essentially in that category. There is nothing wrong with a glorified pedometer—for people who just want to nudge more activity into their day (lots of people!), tracking and gradually increasing daily steps is a great approach (and Apple kind of lives this strategy in its track record of offering simple initial versions of hardware and then building on them). But pedometers are simple enough that very little explanation is needed, and as these devices have become more and more glorified, one wonders if people are expecting more simplicity rather than less, as if every new capability is as easy to understand and act on as a steps goal.

Modern fitness trackers are not that simple, and people aren’t prepared to do homework when they get a fun new device (or have it given to them by a workplace wellness program). Someone on Quora recently asked whether it was OK that his watch showed well over 200 “heart points” for the week after he completed a 10k running event, because the “recommended” number of weekly “heart points” is 150. Which brings up another risk: that using a cutesy name to differentiate your exact same base fitness recommendations as every other device—based on CDC, WHO, and AHA† recommendations for the minimum recommended activity level—may increase the probability of that default being misinterpreted.

The WeightWatchers expert said their users don’t use trackers consistently. This makes perfect sense. WeightWatchers members don’t need to rely on a fitness tracker; WeightWatchers is a supportive system that offers them an accounting method for food and basic activity tracking. Indeed, the WeightWatchers points system is a pretty good (and accessible) framework for approaching these things. The recent UCLA assessment of use of the Oura ring‡ (a very simple, screen-free device) found that personalized feedback based on fitness tracker results helps people improve their behaviors and get better results, a classic for the annals of “well, yeah,” but it’s important to have the data. And it’s not like this is easy; having live humans provide that feedback is labor-intensive and costly, and fitness trackers can’t offer that automatically. My own fitness tracker has an “insights” feature that is supposed to do something like this but has literally never, not one single time, told me anything other than the absolutely simplest thing to guess at and thus nothing insightful at all. I have configured that thing to kingdom come and look at it at least 25 times a day, and it still can’t figure out what I care about on its own.

Is it possible to build something inexpensive and easily accessed that can help a person get the most out of a fitness tracker from day 1? I think it could be done to some extent in a booklet or website—and working on a project like that sounds like a dream job to me—but it would go far beyond the user manual (“this option is on that screen”) and deep into helping people identify and prioritize different kinds of goals at a much more granular level than “fit into the clothes I used to wear.” Indeed, it would probably end up being a kind of choose-your-own-adventure curriculum of quizzes and knowledge base that would require a multidisciplinary team and regular updates to do well. Because at the end of the day, a fitness tracker is not a trainer or a coach (or a doctor or a dietician). It’s a compass. It can help you stay on your route, but it can’t plan the route for you.

*Weight loss as a goal is a blunt instrument – for example, weight loss is a common feature of serious illnesses such as cancer and dementia. People almost always mean fat loss or an aesthetic goal. Unfortunately, there are no good, cheap, easy options for measuring body fat percentage accurately, and what people really want is probably localized fat loss, anyway, which isn’t really how fat loss works. For most people, the easiest way to track whether a “weight loss” plan is working is monitoring changes in waist measurement.

**Sleep tracking in a fitness tracker is generally a mix of accelerometer and heart rate data, trying to estimate a rest state from a lack of motion and using heart rate patterns that have been observed in sleep studies to be correlated with one sleep stage or another. Any avid “quantified self” enthusiast can tell tales of a watch that said they were in deep sleep while they were reading in bed or perhaps in REM sleep while playing a video game.

†CDC, https://www.cdc.gov/physicalactivity/basics/adults/index.htm ; WHO, https://www.who.int/news-room/fact-sheets/detail/physical-activity ; AHA, https://www.heart.org/en/news/2018/08/21/google-just-launched-heart-points-here-are-5-things-you-need-to-know .

‡”Lifestyle Modification Using a Wearable Biometric Ring and Guided Feedback Improve Sleep and Exercise Behaviors: A 12-Month Randomized, Placebo-Controlled Study.” The study compared simply using the ring with some generic information provided with using the ring while also receiving personalized, reinforcing messages. You’ll never guess which group showed the most improvements. https://pubmed.ncbi.nlm.nih.gov/34899398/

Is Fitbit the best?

My guilty pleasure is Quora, which I dip into if a question intrigues me. Sometimes I “archive” the more interesting topics here.

Is Fitbit the best fitness tracker, or is it just the best known brand?

Fitbit was early to market with wearable trackers. Wearable pedometers had been around for a while but were mostly a niche product (even after the release of Manpo-Kei, a Japanese product with a punning name that is the origin of the “10,000 steps a day” recommendation). There was also a chest-strap-based Polar product, paired with a watch-style display, that was released in the 1980s – Polar is still a top heart-rate monitor brand. The availability of small accelerometers helped launch the wearable fitness tracker market in earnest, and Fitbit was the first to market a small wearable (a clip-on, if I recall correctly), dedicated to fitness tracking, using this technology (a couple of years after Nokia incorporated it into a phone and around the same time Apple incorporated it into a miniature iPod – also a clip-on device).

The combination of being so early to market, launching the product at a tech conference attended by an extremely interested demographic, and a savvy marketing approach, which included actively reaching out to corporate wellness programs, gave its devices both a ready group of enthusiasts and wide distribution. Add to that some notable PR nightmares – like users’ sexual activity being exposed in people’s online public profiles in 2011 and a US Senator, a few years later, calling Fitbit out by name for its casual approach to user privacy – and Fitbit definitely acquired a brand awareness that would be hard for any other tracker to match.

Arguably, the best fitness trackers are in the Garmin product line – the first Forerunner model was released some 4 years before the Fitbit was just a model circuit board in a wooden box. However, Garmin’s early focus was on portable GPS devices, and Garmins were long of interest only to niche groups like competitive athletes and other people interested in navigation support (sailors, pilots, multisport and remote outdoor athletes). Also, their devices were fairly large and expensive in the era when Fitbit was gaining traction. They were simply not aimed at the same groups of people. Now, of course, both companies have much larger product lines, with overlapping devices.

My answer at Quora

Setting goals on a fitness tracker

My guilty pleasure is Quora, which I dip into if a question intrigues me. Sometimes I “archive” the more interesting topics here.

How should I set my Apple fitness move goal?

By the “should” I am going to assume this means “what is a good goal” rather than the mechanics of setting goals.

Apple Watch offers a bunch of different dimensions for goal setting – including active calories and time standing – so the first thing to do is explore what goals can be set and decide which are meaningful to you.

Then it’s time to decide what level of goal to set. There are two main philosophies here: set a goal that stretches you a little, and set a goal you know you can hit. Your approach depends on your personality and how you expect the watch to help you. Another dimension is whether you are using the watch as a tool to help increase your overall activity or more as a way to manage it.

Identifying a move goal requires a combination of practicality and unflinching honesty. If I need goals that make me stretch – ie, that in the grand scheme can be easy to miss (say, because I came down with a cold, I had to tend to an urgent problem, or major weather made it unsafe to get to a facility with specific equipment) – but I also need to see that closed circle/green check mark, then I need to find a satisfying way to account for those stretch goals while not frustrating myself regularly with missed “gold stars”. If I am starting from low activity and wanting to work up, then the level of these goals – or maybe even which goals I set – will change, and I also need a plan for that.

Apple Watch has defaults based on demographics, so one way would be to accept those defaults and then see how you feel when you meet/miss them. (I believe these goals will nudge up if you meet them consistently – a way to account for increasing your activity level over time, although you and the algorithm might have different ideas about the velocity of those changes!) You should also explore the other metrics that are not goal based and see if there’s something highly reinforcing for you; this could be something trend-oriented (ie, not right for a daily goal) and meaningful enough to you that you will check it regularly and act on it.

TL;DR – factors in choosing and setting goals

There are a lot of questions that go into the goals an individual should set. Do you expect those goals to change over time? How responsive are you to nudges in general, and to indicators of success or failure in particular? Do you need reinforcement for a lot of different behaviors, or do you have one “lynchpin” behavior that causes other desired behaviors to fall into line? If you are looking to make changes in several behaviors, what is the priority? Or do you need to try prioritizing different behaviors to see if one of them can help guide the others? What is your daily schedule like? Are you looking to move more on a daily basis, or are you more interested in weekly trends? What are the features on your device, and which of those interest you enough to pay attention to them?

The number one thing to keep in mind with a new fitness tracker is that it will take time to understand how it will best help you. Give yourself that time, and permission to change course while you figure out the right direction.

My answer on Quora

“Is a fitness tracker right for you?” A repeatedly missed opportunity in mainstream media

The Washington Post recently dropped a link to this article from December in one of its newsletters, and I finally realized I’ve seen a lot of these takes over the last few years as wearables have become ubiquitous: maybe you should stop using a fitness tracker, if you’re letting it tell you what to do and it’s making you anxious. These articles feature lots of precious quotes about losing the ability to simply enjoy taking a walk and so on. Not infrequently, the tracker that ends up getting junked is one that was provided gratis by an employer or an insurance company. It’s a basically good idea for an article that is routinely undermined by superficial and extremely incomplete treatment.

Employers and insurance companies often provide simple trackers such as devices from Fitbit, who aggressively courts this business. Based on wristwatches, these devices are easy to use and interact with, and they promise to provide a wealth of data (particularly around notoriously hard-to-measure activities such as sleep). It is common to fall down a whole series of rabbit holes, seeing what it tracks, seeing how you can influence that, and fretting about numbers that don’t seem “good enough.” If you learn more about the technology or just observe very closely, you soon see the weaknesses in the measurements themselves or in the conclusions drawn from them – from simple miscounts of steps to poor extrapolations of mileage to some truly laughable “sleep detection” failures. And once the trust is gone, the brain goes all kinds of bad places.

One problem with mainstream media articles on issues around fitness trackers is that they almost always assume a Fitbit-like wrist device and flatten the discussion to the category of “trackers” as if that is the only form factor. Although some “rah rah fitness tracker!” product pieces discuss the wide variety of options, I don’t think I have ever seen an article about user ambivalence go on to discuss the different types of trackers available. Some people will prefer a simpler device that gives them gentle nudges to move about more during the day, or something that tracks without constant readouts a glance away. Bellabeat makes jewelry-style trackers that can be worn as clips, pendants, or bracelets and that have no screen. There are several simple – and inexpensive – pedometers that can be clipped on or hung from a loop for people who just want to track a step goal, which can also, for that matter, be done with free apps on a smartphone. I understand a bit about how an article is planned in these environments, but this is a great example of how a specific focus robs the piece of value for the reader. In this case the reader is invited to relate to the person who is stressed by the tracker (or to judge that person as weak or not “getting it”), nothing is learned, and the comments section fills up with predictable trash.

Another problem with these articles is the narrative around the value – or risks – of the fitness tracker. Like a lot of issues involving productivity, health, and happiness, the dysfunctional-fitness-tracker story is typically framed around the individual who either can’t seem to get the process right or who is, perhaps rightfully, frustrated by being told what to do by a little piece of metal and plastic. Very few issues involving productivity, health, and happiness are fully in the individual’s control. Between schedules, commutes (or home environments that making working there a challenge), family commitments, and everything else, any change a person wishes to make almost always touches multiple moving parts, many of which touch other people who might push back in ways that are impossible (or inappropriate) to reject.

This willingness to, in essence, blame the individual is particularly annoying to me when a very reasonable quote about the challenges of developing a good food pattern comes from someone who sells coaching or instruction in “intuitive eating.” If it’s intuitive, you don’t need a coach for it. But it’s not even intuitive – the term is used for a variety of practices that involve deliberate food choices, changing your emotional relationship with food, and otherwise being more present and mindful and positive about eating (as opposed to using a reward/punishment frame). I love all those things, and I definitely love an anti-dieting frame for talking about eating, but calling any of that “intuitive” just seems like an extra twist of the knife in the back of everyone who finds it nothing of the kind, ie, almost everyone.

Most surprisingly, I can’t remember seeing a mainstream media article address both user ambivalence AND the source of the tracker. There is a separate genre of article – the discussion of privacy issues around insurance- or employer-provided devices (example linked above) – that clearly details the contextual issues that probably should make an individual reluctant to use a device from those sources. But even mentioning those issues is rare in the “is your fitness tracker making you obsessed” articles, even when quoting people who received the tracker from an employer or insurance company. It beggars belief that these articles have no room for a single quote along the lines of “Yeah, maybe the company-provided device or wellness program isn’t the right path. Some people just need [a different form factor | a free phone app | something that lets them control their data in a particular way].”

The end result is the same careful instruction in learned helplessness that characterizes the fitness / health / wellness industry as a whole: A small insight into a problem. A narrow, narrow discussion of one way of resolving it. An overall emphasis on the individual, with near-zero acknowledgement of the family, work, and social contexts that individuals spend their whole lives in. And no meaningful information about the kinds of questions a person should ask about what they want from a fitness tracker (or other form of accounting – could be a paper calendar with stickers!) that will help them get what they need when embarking on a deliberate change or management of a behavior – or even a hint that such self-understanding is a possibility.

Why don’t fitness apps work?

My guilty pleasure is Quora, which I dip into if a question intrigues me. Sometimes I “archive” the more interesting topics here.

Why do you think many fitness and/or nutrition apps are not very effective? I’m writing a paper for my class and I would love to know what you think these apps are missing. What features do you like and dislike? All comments are appreciated.

I think a lot of apps are only as effective as your capabilities allow. If you’re careful about weighing/measuring foods and reading labels, a calorie tracker will work well. If you’re consistent and attentive in your exercise, a fitness tracker will work well. So like a lot of things: they work well for people who “don’t need them” – ie, already have the skills and habits. Designing something that both provides a pleasant and useful experience for the novice and enables configuration to satisfy the expert is a classic challenge, so as a practical matter, the “best” tool might have to be replaced periodically, and unless someone discovers a deep, intrinsic motivation, that sets the stage for them simply abandoning the tool instead.

Some apps are thoughtfully designed to reinforce common psychological responses – by making a note of streaks, personal bests, and trends or by offering indicators that can be collected for activities or patterns that are typically sustained and/or repeated over time (eg, monthly threshold “step count” badges at Garmin). Some apps build in features to support advanced management of patterns outside the ordinary Western diet and mealtimes (MacroFactor app’s support for training- vs nontraining-day calorie/macro settings and for indicating fasting periods). Fitocracy was a fun demonstration of the way that using game-design techniques could encourage someone to develop consistency and also explore new activities, but it quickly ran up against the enormous need for creative design, fantastically broad subject-matter expertise, and constant updates that are probably required to keep that experience engaging.

Part of the challenge for these apps is that eating patterns and exercise patterns are highly variable, so it’s not practical to design a single app or device that will serve all kinds of users well, over and above the novice/expert issue. That means that people might never learn about the niche option that would suit them best. Selecting a product might, in essence, require knowledge a user can’t have, because so many people are seeking a product to tell them something they don’t know yet.

And many people have extremely negative feelings and experiences around food, exercise, and their relationships to social experiences such as rejection or the fear that can come with a diagnosis like heart disease. To the extent that apps (and devices) are marketed as a way to change habits, they only work if someone makes the effort to learn how to fit them into a new pattern, which is a lot of cognitive load for anyone but runs up against additional resistance in the presence of negative feelings.

My answer on Quora

Do fitness trackers actually work?

My guilty pleasure is Quora, which I dip into if a question intrigues me. Sometimes I “archive” the more interesting topics here.

Do Wearable fitness trackers actually work?

Yes and no. Complex fitness trackers, like Garmin watches, are excellent for people who already want to exercise a lot and use metrics to meet performance and recovery goals. For those people, the value of wearables is unquestionable – it’s just a question of which model gives them the right mix of features, and they’ll come to that question with lots of knowledge and specific preferences.

Simple fitness wearables, especially those that are designed to blend in better with non-exercise clothing, work on the principle that if you give people information, they will make better choices. In general, that doesn’t hold across the board for people (look at the range of ideas out there about vaccination, for example), but at least in the case of wearables, you are usually talking about people who are already interested enough to buy one.

When people ask whether fitness wearables work, they usually mean “do people who wear fitness trackers exercise more?” Any stimulus for behavior change has to have 3 elements: the person has to know what to do, it has to be achievable, and the stimulus has to be salient. That’s different from “you have to really want to” – it means you have to notice it and respond to it in a predictable way.

The design of a fitness tracker can make or break the response even of a person who wants to use a fitness tracker. I tested a Nike Fuel Band almost 10 years ago. In many ways it was a nice device, although I wasn’t really the ideal user for it. It had one “feature,” though, that made me hate it. You set an activity goal and throughout the day, as you racked up more activity, a line of colored dots would change from red to green. So far, so good, right? But any changes to the activity goal only took effect the following day. While I was testing it, I had an injury early one day, and then was followed around by this red line all day even though it would have been absurd for me to pursue the goal. I was actually amazed by how angry it made me, and I’m a confident, knowledgeable exerciser who was just testing the thing for a week. (I have a dim memory of really enjoying some of the other ways it presented information, but at this remove, all I can remember clearly is that infuriating red line!)

I believe the rationale for limitations like that is “accountability” – to reduce the temptation, if a goal is not being met, to simply make the goal easier. OK but we’re talking about a goal that is supposed to serve the individual, not a test that’s being graded by some outside authority figure. Accountability is going to look different for different people, and the concept of a rigid daily goal with a constantly visible indicator is problematic. Among other things, it “punishes” you for having a rest day. You should have goals but you should also have a clear and healthful balance between “getting the check mark” and putting your foot down (or, perhaps, feet up) when you need to.

In principle, pedometer-based trackers are great for people who want to move more because they offer a clear indicator of how much movement is being done. This can be disheartening but the key as a beginner is to choose an attainable initial goal, even if it seems easy right away. I always urge people to think carefully about what they want out of a tracker to be sure they are not going to resent what it tracks or how it presents information. This can be a long conversation that ultimately touches on things that are unknowable or not much fun to talk about, especially for someone who is struggling to be more active and whose strongest associations with exercise are some crappy middle-school gym class experience. Fortunately, there are quite a few inexpensive options out there to let a person dip their toe in while they learn what will end up being most important – and most helpful.

So do fitness wearables work? Yes and no. Can they work? Definitely.

My answer on Quora

Perceived Effort in Rowing vs Running

My guilty pleasure is Quora, which I dip into if a question intrigues me. Sometimes I “archive” the more interesting topics here.

Why don’t I feel as exerted exercising on a rowing machine as I do with jogging, even when the rowing machine is on highest resistance?

I am not much of a runner but I erg a half-million meters or more per year. Running has always struck me as much more difficult just because of the impact factor (and as a consequence, I do it less). Proficiency, familiarity, experience, and some of the variations in people’s bodies can all account for different perceptions of exertion.

My first high-volume exercise experience, in my teens, was lots of cycling, and I also started doing some barbell training before I started using the erg. I think both of those probably helped, to some extent, with the technique and rhythm/control aspects of the erg. I had to work a lot harder to learn, practice, and become proficient in technique for a smoother, more efficient running stride. So I too find rowing “easier” than running, although I can certainly get a good workout with either one. Someone who grew up loving cross-country running and first used an erg much later might have the opposite experience.

As others have said, if the machine you are using is on “the highest resistance,” and assuming it’s a rowing ergometer, you are probably putting unnecessary pressure on your back and breaking form. There are a few technologies out there, though, and I only have experience with how the Concept2 machines work. For those, though, you should adjust according to the drag factor readout on the performance monitor, and choose a drag factor that suits your age class, weight class, and expertise – somewhere in the range of 100 to 135 for most people. The highest drag factors should be reserved for very short tests.

Concept2 ergometers can produce the desired drag factor at very different damper settings depending on how clean the flywheel assembly is, how old the machine is, and on the environmental conditions (pressure, humidity). With an unfamiliar machine, you should always check the drag factor before you settle on a damper setting.

At a hotel, I once used a very sad, lonely Concept2 erg that could only eke out a drag factor of about 100. A new machine (at sea level) ranges from <90 at the lowest damper setting to >200 at the highest. If you can’t get a normal (up to 140) drag factor out of a Concept2 at a gym, you should probably tell the staff to get someone in to give it some care (or consider replacing it).

Is 10,000 steps a day good for you?

My guilty pleasure is Quora, which I dip into if a question intrigues me. Sometimes I “archive” the more interesting topics here.

Is reaching a daily target of 10,000 steps good for you health-wise?

Sure – one of the largest studies to look at this question (using accelerometry-monitored activity) just added some evidence to this pile. Accelerometer measured physical activity and the incidence of cardiovascular disease: Evidence from the UK Biobank cohort study

The number 10,000, however, is completely artificial, as is the idea that it should be steps. Almost any amount of daily activity improves health outcomes – not just walking, not just over an hour a day. I have read that 10,000 became popular because it was part of the marketing for a pedometer in the Japanese market (where the number 10,000 is sort of a visual pun in that context). What 10,000 Steps Will Really Get You

It is common to see people try to tear down this number, or insist that it is an inadequate guideline because people should also be doing resistance exercise, or claim the “real” number is higher or lower, but it’s important to look at what question they think they’re answering when they say that.

Studies that try to address this have to choose an outcome to test – in the case of the new accelerometer-based study, that outcome was association with heart disease, and others have simply used all-cause mortality. It’s very unlikely that any of these study designs is directly measuring the “causal” element for those outcomes. For example, if runners are more likely to be hit by a car, does that mean running is dangerous? In the PLOS-published study above, did the exercise prevent heart disease, or were people who were less likely to get heart disease also more likely to enjoy exercise?

But the outcomes they test might not be the most relevant for recommending exercise in general, which can help regulate moods and sleep. No matter what you’re going to die of, you might as well be happier and better rested, right? Also, fairly modest amounts of physical ability are associated with living independently (in the sense of not needing direct assistance for activity of daily living) for longer. Prevention in Older Adults – Fundamentals – Merck Manuals Consumer Version Staying active throughout life is the best way to address this, because older adults who have already lost muscle mass have a particularly hard time adding exercise into their lives.

It is possible that there is truly an ideal, optimal exercise plan that would maximize the potential benefit of exercise in every person who followed it, but it’s more likely that individuals can benefit more than enough from any number of activities as long as they are practiced regularly, ideally daily. In meantime, the good news is that even though many studies show “more is better,” benefits are usually visible with modest amounts, too.

My answer at Quora

False Positives and Unintended Consequences

After an appendectomy, the removed appendix is examined to determine whether appendicitis (or some other problem) was present. In a noticeable proportion of people, it is not. This is not a problem, for a good reason: the consequences of untreated appendicitis can be swift and catastrophic. The consequences of appendectomy are, in general, mild by comparison, at least in societies with good sanitation. (There is always risk from surgery.)

This is being revised after trials with intravenous antibiotics have shown very high rates of survival, but appendectomy was introduced before the antibiotic era, many organisms are involved, and we’re losing antibiotic efficacy – plus appendicitis can still progress after IV therapy – so surgery still needs to be in the toolkit. Still, knowing that there are options well worth trying, and with a good track record, is good news for situations where surgery may not be available, practical, or advisable.

[T]ypes of patients in whom appendectomy might be avoided:

  • Patients with an appendiceal abscess, who would be better treated with percutaneous drainage;
  • Patients who have had a recent myocardial infarct;
  • Patients with severe lung disease;
  • Women in the first trimester of pregnancy; and
  • Persons in a remote environment such as Antarctica or on a mission to Mars.

From Evaluating Acute Appendicitis: Does Everyone Need an Operation? (subscription required)

(Mars – or the Antarctic – is hardly the only remote environment of interest; one of the studies was in Navy personnel on a submarine.)

Appendectomy is a classic teaching case on the value of ending up with a few false positives. It’s better to perform a low-complication procedure a few extra times than to have people walking out of the ER and dying when they get home. But as technology changes – in this case, antibiotic treatment options and CT-scan evaluation – it’s always good to re-evaluate even the obvious “tried and true” approaches, partly to see if there’s a better way across the board and also to address the situations where the outcome of surgery was likely to be bad. On the way, we seem to have discovered some properties of the appendix that can help us understand the environment for other GI disease – a new teaching case for this much-maligned “vestigial” organ!

We are probably right to remain suspicious, though. The appendix may well have more tricks tucked into its submucosa.