Tag Archives: public health

Why our jobs are making us fat

We spend most of our time at work.

  • Expressed as terms of a percentage of your life, this 39.2 hours a week spent working is equivalent to:
  • 14% of your total times over the course of a 76 year period (based on the average projected life expectancy of 76 for people born in the year 2000 according to the ONS’s National Life Tables for the United Kingdom.)
  • 23.3% of your total time during the course of a 50 year working-life period
  • 21% of your total waking hours over a 76 year lifespan, assuming 8 hours of sleep a night.
  • 35% of your total waking hours over a 50 year working-life period assuming 8 hours of sleep a night
  • 50% of your total waking hours during any given working day. ReviseSociology

This is a significant chunk of our lives. Yet we note that many people are disengaged at work.

Gallup

This is a problem because being disengaged at work is also associated with other behaviours that are problematic. Faragher and colleagues reported in the BMJ:

A systematic review and meta-analysis of 485 studies with a combined sample size of 267 995 individuals was conducted, evaluating the research evidence linking self-report measures of job satisfaction to measures of physical and mental wellbeing. The overall correlation combined across all health measures was r = 0.312 (0.370 after Schmidt-Hunter adjustment). Job satisfaction was most strongly associated with mental/psychological problems; strongest relationships were found for burnout (corrected r = 0.478), self-esteem(r = 0.429), depression (r = 0.428), and anxiety(r = 0.420). The correlation with subjective physical illness was more modest (r = 0.287).

There is increasing evidence for an association between job dissatisfaction and the most significant health challenge we face in the next decade- namely obesity. A survey of nurses in Ohio concluded that:

..disordered eating differed significantly based on perceived job stress and perceived body satisfaction. Nurses with high levels of perceived job stress and low levels of body satisfaction had higher disordered eating involvement. King et al

A more recent paper in BMC obesity reported that obesity rates varied across industries and between races employed in different industries:

Obesity trends varied substantially overall as well as within and between race-gender groups across employment industries. These findings demonstrate the need for further investigation of racial and sociocultural disparities in the work-obesity relationship to employ strategies designed to address these disparities while improving health among all US workers. Jackson et al

Lui and colleagues suggest a possible explanation:

Study 1 sampled 125 participants from 5 Chinese information technology companies and showed that when participants experienced higher levels of job demands in the morning, they consumed more types of unhealthy food and fewer types of healthy food in the evening. In addition, sleep quality from the previous night buffered the effect of morning job demands on evening unhealthy food consumption. Study 2 used data from 110 customer service employees from a Chinese telecommunications company and further demonstrated a positive association between morning customer mistreatment and evening overeating behaviors, as well as the buffering effect of sleep quality. J Appl Psychol

Possibly a very useful question we can ask people seeking medical advice with weight management: ‘ What do you do for a living and how do you feel about it?’. It may be that they are eating their feelings. Review what people are eating at their desk or during breaks. Snacks have become the fourth meal of the day — accounting for 580 extra calories per day, most of which come from beverages — and may be a primary contributor to our expanding waistlines. Here’s why employees become disengaged at work. A summary:

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What’s the shortest route to where you want to go?

As the conference season begins we note that response rates in the order of 10-20% are not unusual in primary care research. Hardly generalisable. And yet we need sustainable and workable solutions that will promote health and well being in an ageing demography with increasing multimorbidity. Researchers take note the traditional gatekeeper in primary care, the general practitioner is occupied just keeping up with demand. There is no time to recruit, to seek informed consent or to deliver interventions that are being tested in a traditional randomised trial. At one time membership of networks with ‘committed’, well meaning practitioners were considered essential to successful research. In 2017 relying on anyone or any organisation that purports to guarantee recruitment rates or ‘collaboration’ seems at best naive and at worst risky.

Health requires people to make different choices. Eat better, drink less, take more exercise, jettison bad habits, consider when and where to seek medical advice. The traditional model of healthcare is evolving. The evolution is driven by technology that has fundamentally changed our experience of many if not all things. People consider themselves more time poor than they ever were.

The ability to satisfy desires instantly also breeds impatience, fuelled by a nagging sense that one could be doing so much else. People visit websites less often if they are more than 250 milliseconds slower than a close competitor, according to research from Google. More than a fifth of internet users will abandon an online video if it takes longer than five seconds to load. When experiences can be calculated according to the utility of a millisecond, all seconds are more anxiously judged for their utility. The Economist

The lesson for those hunting for better ways to reach people is to consider the least that can be done to get there. The answer may be waiting in all of our pockets.

Picture by Toshihiro Gamo

Junk used to wallpaper doctors’ offices

Of all the things doctors can do in their practice they can certainly choose what to display on their walls. In 1994 a group of researchers reported:

To determine whether patients read and remembered health promotion messages displayed in waiting rooms, 600 patients in a UK general practice were given a self-complete questionnaire. Two notice-boards carried between 1 to 4 topics over four study periods. Three-hundred and twenty-seven (55%) of subjects responded. Twenty-two per cent recalled at least one topic. Increasing the number of topics did not in crease the overall impact of the notice-boards. The numbers of patients recalling a topic remained constant, but increasing the number of topics reduced the number remembering each individual topic. Patients aged over 60 years were less likely to recall topics, but waiting time, gender and health professional seen had no effect on results. Very few patients (<10%) read or took health promotion leaflets. Wicke et al

It would appear that the notices are basically used as wallpaper. They do not seem to serve any other useful purpose. Researchers suggest that the design of such ‘community communication channels’ requires further thought:

Our results highlight how they are used for content of local and contextual relevance, and how cultures of participation, personalization, location, the tangible character of architecture, access, control and flexibility might affect community members’ level of engagement with them. Fortin et al

Essentially the role of the notice board with its myriad of posters and leaflets is to ‘sell and inform’ not to decorate and distract. They sell ‘health’ or services related to health. Vaccinations, antenatal care, weight loss, smoking cessation, early diagnosis, screening, the list is endless. They might also inform about practice policy. The notice board, or as it often seems almost every available space on the walls is used in a vain attempt to ‘communicate’ with people. But this sort of communication is carefully choreographed in the retail and service industry:

Businesses like gas stations and banks regularly provide information about the availability and price of particular items, such as gas, convenience items, loans, and savings certificates. The display of this information plays a central role in these companies’ business strategies for increasing traffic and sales. Indeed, the value of a corner or other highly-visible location rests largely on the ability to use signs to inform passers-by about the availability of a business’ goods and services. University of Cincinnati Economics Center

The way these notices are displayed can have an impact on the bottom line of the business:

In conclusion, exterior electronic message boards offer business a lift in store sales performance and generate a relatively quick return on investment. While the overall 2.12 percent lift in sales is modest, in a high-volume store with low installation costs, the investment returns to using this technology can be significant. University of Cincinnati Economics Center

Your bank, department store, hairdresser does not stick everything they have on their walls and hope for the best. The walls in a doctors’ premises are high-value real estate, not a back street that can be pasted with whatever junk is sent by whoever wants to get attention until the material becomes dog-eared or torn. The key is to focus on ‘content of local and contextual relevance’. However, in the end, the wall space should prepare the patient for the consultation. It is in the consultation that the advice can be tailored to the patient and as Wicke and colleagues concluded in 1994:

More modern methods of communication such as electronic notice-boards or videos could be used. However, the waiting room might best function not as an area where a captive audience can be bombarded with health promotion messages, but rather as a place for relaxation before consulting a health professional, making patients more receptive to health advice in the consultation. Wicke at al.

Would it really do any harm to jettison this confetti altogether?

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The first thing people see is an ugly great barrier

For effective engagement with their quarry, the service provider has to be open. When the first point of contact with that person is a tall desk it sends the wrong message. The reception counter says:

  • You are on that side, we are on this side.
  • We are hiding things from you back here.
  • You are here to ‘get something’ from us, we’re not sure we want you here just now.
  • We are very busy and your needs are one of many things we have to cope with today.

There are many aspects to designing the ‘ideal’ reception counter but first, consider the reason for having one in the first place:

What kind of impression should it make? Should it be warm and inviting, or bold and austere? What kind of reaction do you want to create in the visitor? Is it purely functional or a real ‘statement piece’ aimed at dominating the whole area? Jo Blood

For many practices, it seems that the counter is designed to process a queue much the same as the counter at an airport check-in or a vehicle licensing office. It speaks to what we think of our visitor:

Who will be using it from the visitor side? Will it be treated with respect by all who come into contact with it, or must it be able to withstand some abuse? Maybe a tough, metallic finish plinth would help to prolong the counter’s working life. Jo Blood

When you arrive you must:

  • Check in.
  • Prove that you are entitled to be there ( i.e. you have an appointment)
  • Prove that you can pay or that someone will pay or make a payment.
  • State your business clearly and briefly.

The counter hides PCs, printers, fax machines, security equipment. It’s there to keep people from abusing staff and to keep people out. To complete the ‘look’ the walls may be covered in mismatching posters and the counter stocked with leaflets dispenser full to the brim. Who reads this stuff? There is limited evidence that such communication has any impact. There are suggestions from the retail industry that less is more.

As for the counter, it is generally as tall as it can be.

An able-bodied visitor with a typical minimum height of 1540mm approaching a raised counter tall enough to hide a large monitor on a desktop height of 740mm, would clearly struggle to make eye contact with a seated receptionist. As a rough guide, a counter height of over 1200mm will create a potential ‘blind spot’ resulting in the visitor remaining almost unseen and making the counter simply too high to be practical for signing in.

But what if the reception counter were removed altogether? It’s not unthinkable if hotel chains are beginning to consider it:

Two bloggers walk into a hotel …No, that’s not the opening line to a joke. We’re talking about two travelers who picked the same hotel chain — Andaz, a boutique Hyatt property. One stayed at a Los Angeles Andaz, the other at a New York City Andaz. Neither lobby contained a front desk — a budding hospitality-industry trend that’s equal parts chic and shrewd. Bill Briggs

But of course, doctors clinics are not hotels or airport terminals. But that’s not to say that clinics should not be welcoming, comfortable and inspiring places to be. This issue received some attention in the medical literature last year- with the authors of the paper were cited as concluding:

96 percent of patient complaints are related to customer service, while only 4 percent are about the quality of clinical care or misdiagnoses. Kelly Gooch

There are umpteen ‘reasons’ why it is so. Primarily the process of dealing with payments. However such administrative tasks are also a part of many other industries and they are striving for better solutions rather than risk their customers take their business elsewhere.

The critique of the paper quoted above included an insightful comment from a ‘front of house’ staff member:

Our role has developed from “just scheduling staff” to a more complex, and crucial, role for any healthcare organization. We are the start and end of every patient visit and also the start of the revenue cycle. In order for “customer service” to improve, an organization first recognize the importance of their Patient Access department and understand that their processes are directly related to the culture of the organization. Kelly Gooch

Is it possible that people who perceive that their visits are welcomed are more likely to take the advice on offer? Isn’t that what healthcare is about? We have had evidence for this for decades. This quote from the literature says it all:

…the feeling in the practice when you arrive, busy…exhausted receptionists, people fed up, waiting , a feeling of delapidation and stress…You can hear people being put off on the phone and you can hear ‘no no I can’t put you through to the doctor now’, ‘no no you’ll have to call back’ and that makes you feel worse because you don’t want to call back at an inappropriate time. Gavin  J Andrews

The reception area engenders the circumstances in which the outcomes of care are compromised. There is a better way and at least one Australian practice has redesigned the experience.

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Who are you and what do you do for a living?

It was a dangerous time to be a forklift driver. One day I saw four of them each reported gastroenteritis. Now recovering but not fit to go to work. Or so they said. They were not related in any way, not even working in the same place and each had been poisoned by their spouse with something different: pizza, meat pies or lasagne. So either the partners of forklift drivers were terrible cooks or there was something else going on.

In April Wynne-Jones and Dunn reported data on sickness certification in the UK in the BMJ open. Their conclusion caught my eye:

Rates of sickness certification for back pain demonstrated a downward trend between 2000 and 2010. While the reasons for this are not transparent, it may be related to changing beliefs around working with back pain.

They try to explain their findings but then point out the main deficiency of their research:

This data set is based in one area of the UK, North Staffordshire, and it could be argued that it is not generalisable to the rest of the population. Previous work with this data set has demonstrated that crude rates of certification change very little when the data are standardised to the age and gender of the population as a whole, and there is no indication that this should be any different for this study

I scoured the paper for what might explain the findings because I couldn’t accept their thesis. I didn’t find what I was looking for. So I searched the unemployment statistics for the West Midlands in the UK dataset. As it happens the unemployment rate in that part of the UK, which includes Staffordshire varies quite significantly from the rest of the UK. When you plot the unemployment rates versus sick certification for low back pain the picture tells a different story:

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As unemployment rates climb from 2007 and peak during the Global Financial Crisis in 2009 the sickness certification for low back pain drops and plateaus. From the perspective of the General Practitioner patients are less likely to request sick certification when jobs are scarce. I was more inclined to accept the results of research by Michelle Foley and colleagues writing in the European Journal of General Practice in 2012 having interviewed GPs in Ireland:

GPs can find their role as certifier problematic, and a source of conflict during the consultation process with patients. GPs were concerned with breaching patient confidentiality and in particular disclosing illness to employers. They reported feeling inadequate in dealing with some cases requesting sickness leave, including certification for adverse social circumstances. Sickness certification was often given in response to patient demand. GPs felt a need for better communication between themselves, employers and relevant government departments

A few things struck me at the end of these visits to the library:

  1. Often the research that is most likely to impact on general practice is published in  so-called low impact journals. Often these are not randomised control trials or reviews of large databases.
  2. When interpreting ‘data’ we really need those who have regular contact with patients in the field to draw conclusions based on experience.
  3. The first question to ask a patient isn’t ‘tell me about your symptoms?’ but who are you and what do you do for a living?

For some people forklift driving is not a preferred way to earn a living but while there are options for alternative jobs ‘sick days’ may offer some respite.

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Common sense vs. miracle cures

I’ve seen this person, or someone like her many times before. On that occasion it was a demand for phentermine but it could have been antibiotics, ‘blood tests’, a ‘whole body scan’, benzodiazepines or opiates .

My doctor has prescribed it before. I need it again. So I just need a repeat script.

At a guess she had a BMI just shy of 30 and I noted that she had been prescribed this drug intermittently for a couple of years. She made it clear there was no room for discussion or argument. She had taken the day off work and wanted to get her diet underway. She wasn’t really interested in my opinion. If I’d prescribe it she’d leave. I explained politely that I don’t prescribe this drug (even though I could). I don’t believe it works and could actually harm her. But she persisted:

My professor prescribes it for me

In other words

What do you know about it? You’re ‘only’ a doctor.

I could explain lots of reasons why she shouldn’t be taking this drug. Phentermine is an amphetamine derivative that is used as an anti obesity agent it was approved by the US FDA in 1959 for short term treatment of obesity. It is the most commonly used anti-obesity drug on the US market and many US bariatric physicians use phentermine long term, ignoring the FDA guidelines that it be used for three months or less.

In a trial published in the British Medical Journal in 1968 it was concluded that phentermine has an anorectic effect ‘compared to placebo’. However according to a systematic review published in 2014:

No obesity medication has been shown to reduce cardiovascular morbidity or mortality. Additional studies are needed to determine the long-term health effects of obesity medications in large and diverse patient populations. JAMA

Like so many miracle cures discovered or unveiled decades ago we now know a bit more. Phentermine has been associated with psychosis. But there is precious little else to indicate major problems in the literature and the drug is still listed as available to prescribe. However patient experience is another matter:

I lost about 20 kg’s on [Phentermine] over about 6 months. I didn’t have any of the shaky or jittery, but these are common side effects. Even though my appetite was much less then it normally would be, I made a conscious effort to eat three small meals a day and a few snacks. I Used it in conjunction with a calorie tracker plus exercised. It can make the weight drop off quickly but if you don’t make the steps to eat correctly and exercise you can pick it up weight plus some again when you stop taking the tablets. Glowworm80

And another:

However, there are side effects. Lots of people say it makes their heart feel “racy”. This has not happened to me, but I suffered terrible insomnia. I wasn’t able to sleep before 3am in the morning, just lying in bed with thoughts racing around a million miles an hour. But then when you get up and take the next day’s pill, you get energised and you don’t feel like you’ve only had three hours sleep.

You can see how ridiculous this all is … eating next to nothing, sleeping only three hours a night but feeling no hunger and having boudless energy. It is not something that your body will thank you for in the long run. peckingbird

And this one:

I am sorry to say but I think any doctor who prescribes [Phentermine] as a first choice treatment for weight issues is being negligent. I really do understand the attraction when weight is needed to be lost quickly BUT..

I know many people who’ve taken it ( it was very readily available back in the 90s ) they have lost varying amounts of weight and have had varying side effects…some really dangerous and not one of them has maintained their weight loss beyond a couple of months after ceasing the drug. Soontobegran

This has also been my experience when I’ve prescribed it for patients in the past so I won’t prescribe it now. We need to exercise our right to refuse to prescribe treatments that promise more than they can deliver because they rarely do. We don’t need to wait for research evidence to catch up with common sense.

With regard to ‘diet pills’ I agree with this:

The allure of a pill – whether pharmaceutical or nutraceutical – that allows one to lose weight without requiring behavioural changes at the dinner table or in the gym is irresistible. a burgeoning market for both prescription and over-the-counter diet pills exists. Unfortunately to date, the dream of a thin-pill has largely failed to materialise due to unrealised efficacy, safety or both. Mark K Huntington & Roger A Shewmake

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Simply correcting myths may be counterproductive- context is everything

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The spritely 80 year old man who sat in my consulting room was adamant.

No thanks doctor every time I get a flu jab I get the flu. So not this year. Thank you.

That was the third time that day that I had heard this argument against the flu vaccine. It troubled me. The individuals most likely to benefit were refusing vaccination and some of them say the same thing every year. And yet authoritative advice is that:

In randomized, blinded studies, where some people get inactivated flu shots and others get salt-water shots, the only differences in symptoms was increased soreness in the arm and redness at the injection site among people who got the flu shot. There were no differences in terms of body aches, fever, cough, runny nose or sore throat. CDC

Nonetheless 43% of the American public believes that flu vaccine can give you the flu. In the same study it was found that:

Corrective information adapted from the Centers for Disease Control and Prevention (CDC) website significantly reduced belief in the myth that the flu vaccine can give you the flu as well as concerns about its safety. However, the correction also significantly reduced intent to vaccinate among respondents with high levels of concern about vaccine side effects–a response that was not observed among those with low levels of concern. This result, which is consistent with previous research on misperceptions about the MMR vaccine, suggests that correcting myths about vaccines may not be an effective approach to promoting immunization. Nyhan and Reifler

So it seems that providing information, no matter how authoritative,  is not enough to get people who are already opposed to being vaccinated to change their minds, in fact it may do the opposite! According to the theory of planned behaviour human actions are guided by three kinds of considerations:

  1. Behavioural beliefs ( beliefs about the likely consequences of their behaviour)
  2. Normative beliefs ( beliefs about the normative expectations of others)
  3. Control beliefs ( beliefs about the presence of factors that may facilitate or impede performance of the behaviour)

Therefore interventions that are aimed at providing information only do not work. We need to address attitudes, perceived norms and control if we are to see increased rates of immunisation. When this theory was applied to understanding how to improve flu vaccination rates it was concluded that:

Future studies could use social cognition models to identify predictors of actual vaccine uptake, and potentially compare these findings to predictors of people’s intentions to be vaccinated. Once identified, these factors could be used to craft targeted interventions aimed at increasing vaccine uptake. Myers and Goodwin

It seems that the intervention needs to be targeted and that there are several factors that identify people who intend to be immunised:

  • The employed,
  • Older people
  • Having a positive attitude to flu vaccination,
  • Scoring high on subjective norm, perceived control, and anticipated regret,
  • Intending to have a seasonal flu vaccination this year,
  • Scoring low on not being bothered to have a vaccination and
  • Believing that flu vaccination decreases the likelihood of getting flu or its complications and would result in a decrease in the frequency of consulting their doctor.

Those less keen on  vaccination may be from specific ethnic groups. The authors advise that

These racial disparities emphasise the need to involve stakeholders in the community and to reassure the community and address their concerns and resistance attitudes and beliefs.

Also people may also be more influenced by information obtained from peers and news media than information distributed by the government in print. Such “external” influences also need to be addressed in order to facilitate vaccination uptake. And so back to my patient, it seems that information alone would not change his mind- which was indeed my experience. In order change his mind we will need to target him in the context of his community, his family and his concerns. The battle for hearts and minds includes both hearts and minds. As always context is everything.

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Tailoring lifestyle advice as per patient experience design

16821469876_8d062d433d_zLots of people stop smoking every time the tax on cigarettes is raised. It has been said that:

‘A 10% increase in the price of cigarettes in developed countries will result in a 3 to 5% reduction in overall cigarette consumption.’

And in one study only 6% of people were confirmed as non-smokers one year after receiving advice in general practice.

So if we can dissuade enough people from compromising their health with financial disincentives what is the role of the doctor and primary care? What can a health professional do to help when a smoker with a nasty cough seeks advice, and or treatment? It could be argued that the person is aware that their habit has a bearing on the symptoms. Or that by drawing attention to the link with cigarette smoking that the doctor is heightening a sense of shame, self-loathing and guilt.

So what is the role of general practice or primary care in tackling the big issues —smoking, obesity and alcohol abuse? Are brief interventions delivered in this setting more harmful than necessary? What if innovations delivered by practitioners were even more effective than the modest 6% recorded in the past?

An innovation that I was involved in evaluating led to one in seven smokers quitting. An innovation we subsequently developed as an adjunct to the treatment of obesity may well be more effective than diet and exercise regimens used alone. However if these innovations are delivered in a primary care setting then there is a risk that some patients who access them might feel challenged by the having it drawn to their attention that their results are a reflection of their own efforts. Those who fail to achieve the desired results may become disheartened.

It takes an effort to give up a harmful habit and it is now possible to predict and demonstrate the results of our lifestyle choices in ways that appear to matter to us the most. The key for innovators in the’ patient experience design’ space is to ensure that we minimise the harm that could be done by ensuring that such innovations do what they say on the tin and that they are designed with safeguards. What is beyond dispute is that the prevalence of obesity is increasing at an unprecedented rate and every health care professional has a role in combating this issue, not just those with a public health perspective. Some people respond best to health messages that are tailored to their personal circumstances, and as healthcare practitioners, we have a duty to make those options available to them. If you are interested in staying abreast of innovations developed along these lines click here.

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How do we stop the war over antibiotics next winter?

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She was quite insistent and becoming irate:

Look I am a busy woman. Every time I get these symptoms I come in and get antibiotics and it gets better. Whenever I wait it just gets worse. I don’t have time to mess about so can you just look at the previous notes and prescribe what I usually get?

She had an upper respiratory tract infection. Her throat was mildly inflamed and she had a runny nose. No pyrexia. She sat bolt upright and ready for an argument.

It doesn’t happen that way every time. The patient is usually prepared to allow her doctor to make the call but occasionally it’s not that easy. According to the literature, a third of the public still believe that antibiotics work against coughs and colds. We have seen quite clearly that offering a prescription with the advice to take the antibiotics if the symptoms don’t improve rapidly may help reduce the numbers who take antimicrobials unnecessarily. We know that in at least one study 38% of people may be prescribed an antibiotic this year.  More than one in ten will not complete the course.

How many take the drug as prescribed, e.g. three times a day? And why is it that younger people are less likely to complete the course all the while acknowledging that they understand the importance of taking the medicine as prescribedThe context in which people seek antibiotics may help to inform how doctors manage the call for antibiotics. The answer to the challenge thus far is to mount a public health campaign:

We could focus a ‘Do not recycle antibiotics’ message towards the higher educated, young women who are more likely to store and take antibiotics without advice. McNulty et al

An upper respiratory tract infection is an unpleasant experience. Having a ‘cold’ that lasts a few days may seem trivial to some healthcare practitioners or policy makers but to the patient, it is very far from trivial. In a brilliant paper describing work with 719 people, Longmier demonstrated that neither doctors nor patients can accurately predict how long an upper respiratory tract infection would last or how severe the symptoms are going to be. In an intriguing conclusion to their study they said:

Clinicians should not use their predictive assessments or their patients’ predictions when advising patients on the expected course of a URI (Upper Respiratory infection).

The average duration of symptoms  for URI is 7–10 days, with a minority of patients experiencing symptoms for more than 3 weeks. Antibiotics will do nothing to improve symptoms. Therefore, the problem can be framed quite differently. How you feel on the day you consult your GP is not a good predictor of how long you are going to be miserable with this ‘virus’. Your GP might tell you it’ll all be better in a week and that might sound okay alternatively she might say this will go on for two weeks or more and that might sound disastrous. In any case, she is not likely to be right.  So we go back to the scientists who suggest:

As we cannot accurately predict when the URI will end or how bad it will be, our best clinical tools for patients with URIs are empathy, reassurance and education on the self-limited, short-duration nature of viral upper respiratory tract infections. Longmier et al

To my patient my sympathetic demeanour and rehearsed speech about viruses was not satisfactory. What this patient wanted more than anything else was to be free from her symptoms. I was curious as to why but she was not in a mood to talk about it.  It seems that regular paracetamol in combination with chlorphenamine and phenylephrine may be helpful as are nasal decongestants.  Over the counter cough medicines are not. No doubt there is more literature on the topic of effective symptom relief however, no papers suggest that any treatment entirely rids the patient of symptoms immediately. The key question still remains- why do people insist on and or stop antibiotics before completing the course? If we could demonstrate that people stop antibiotics because their symptoms improve after regular use of effective symptom relief then such evidence may be helpful in any discussion with patients about antibiotics. We then reframe consultations on URIs to offering advice on symptom relief. We offer a solution more aligned to the context in which the patient is presenting. Let’s acknowledge that a cold is an unpleasant experience and not as seems to be suggested to the public a minor nuisance not worthy of our attention.

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Someone’s son or daughter

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There is increasing evidence that overweight and obesity exists in the context of families. There may be something about family dynamics that engenders or maintains the problem with excess weight gain.

  •  A 2004 study in the Journal of Pediatrics found that the biggest factor that predicted overweight in children was if the parents were also overweight.
  • Two-thirds of parents underestimate the BMIs of their children, especially when their children are overweight or obese.

Some data has even suggests trends according to relationship of the adults in the household:

  • Children raised by two co-habiting biological parents had the highest rates of obesity, at 31 percent.
  • But if those parents were married, the children had one of the lowest obesity risks, at 17 percent.
  • Children residing with an adult relative had a high (29 percent) likelihood of becoming obese.
  • But if that adult was their single father, they had a very low risk—just 15 percent.
  • The children of single mothers and those of co-habiting (not married) step-parents had similarly high rates of obesity, at 23 percent.

Furthermore:

Non-poor children living with married step-parents had a 67 percent higher risk of obesity compared to similar non-poor children raised by married biological parents.

The authors of the study couldn’t explain why children in married parent households had lower probabilities of obesity.

The final word is:

Information on children’s health and nutrition must reach not only mothers, but the other caregivers (relatives, fathers, step-parents) with whom mothers and children regularly interact. It is also important to ensure that caregivers are in agreement about issues of nutrition and physical activity for children. Augustine and Kimbro

Once again stressing that innovations to tackle obesity need to consider the context in which the person with the problem is presenting for help. That person is someone’s son or daughter. What else are they coping with? Could anything you have done reduce their status to someone who fails to appreciate the first law of thermodynamics? If so, are you going to make a bad situation worse?

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