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Why when you are sick don’t you do what you can to help yourself?

At 68 Frank has been prescribed the usual mix of medications: three different drugs for blood pressure, a statin and two different pain killers. His problems, as he lists them are fatigue, snoring and back pain. From his doctor’s perspective, the problems are obesity, a dreadful diet, and sedentary lifestyle.

OK doc, but I think I need a referral for my snoring.

Two weeks ago he wanted a different pain killer and the week before that he wanted to be referred to a physiotherapist. The major challenge in helping people who are struggling with chronic disease is persuading them that they have the wherewithal to slow or possibly cease the march towards disability. It seems incredible that someone who cannot walk to the end of the street without stopping for breath several times cannot see any reason to stop eating junk food and sugary drinks while watching telly from 6 pm until two in the morning. Bad habits will drive choices even when people are aware of their growing disabilities. There may be many reasons for this but one that may be worth considering is boredom.

Our culture’s obsession with external sources of entertainment—TV, movies, the Internet, video games—may also play a role in increasing boredom. “I think there is something about our modern experience of sensory overload where there is not the chance and ability to figure out what your interests, what your passions are,” says John Eastwood, a clinical psychologist at York University in Toronto. Anna Gosline.

What is challenging is that some people who have already developed a life-limiting illness cannot be ‘educated’ to make different choices while they don’t admit even to themselves how and why they are contributing to their own demise. If healthcare is to actively promote well-being we need to find ways to help people identify when they are bored and not just focus on the consequences including atheromatous vascular disease. The role of doctors needs to include tackling harmful habits and not limited to therapeutics.

Picture by Craig Sunter

Does encyclopaedic technical knowledge make a doctor?

Life as a clinician is challenging.  Hours are long and resources limited. People may not be helpful, not even the ones who are supposed to be working with you or even for you. There maybe joy but there will also be sadness and even anger. You can expect to feel tired. You may be concerned and even confused. Occasionally you will be very intuitive but just as often you can expect to be wrong. However, you cannot let any of that have an impact on the care provided to patients. And yet each day clinicians respond as if none of this is ‘fair’ and should not be so.

The practice of medicine is more than a technical science. Medicine requires a great sense of personal mastery. An uncommon mastery in which the doctor is resilient and resourceful. Do we prepare young people for such a life?

This week after 30 years I stepped into one of the rooms now decommissioned but where I once spent my teens learning anatomy. It was a core part of that school’s curriculum, the only subject in clinical medicine that was introduced within the first year of a six-year course. The author of one of the seminal texts taught there. His dissections were legendary and the specimens are still preserved to perfection. I reflected on whether the experience of being taught by his protege prepared me in any way for the subsequent years in practice. Did my encyclopaedic knowledge of how the body is constructed allow me to better handle the following years in clinical practice?  By comparison, we learned relatively little about what drives people to make decisions that make no sense. And yet over the 30 years, I have practised medicine it has been more often problematic knowing how to handle someone whose choices will lead to self-destruction than working out exactly which nerve is responsible for the numbness of a portion of his thigh.

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Healthcare will do better when Joe accepts that he is in trouble

There is nothing especially remarkable about Joe. At 49 he works as an administrator for a company in the city. He walks to work from the station having taken a train from the suburbs. He weighs 78Kgs and is 170cm tall (BMI 27). To stay that way he needs to consume no more than 1900 calories per day. He has a bowl of cereal for breakfast, a  panini sandwich for lunch and a home cooked dinner with a glass of wine. That’s about 1900 calories. Joe isn’t inspired at work but he earns a reasonable living. They bought a new car last year and Joe is tied to a hefty car loan, his wife Bridgette gave up her job as a nurse when they had their children ten years ago. They now have three children under 10. The youngest has asthma but he seems so much better since he was put on a steroid inhaler. Joe and Bridgette have had their ups and downs. They worry about money.  Mostly they work hard and are doing their best to raise their boys. At the weekend Joe goes to a football match but since his mid-twenties doesn’t play any sport. With the kids doing sport and music lessons there isn’t time. Joe has never smoked a cigarette.

During the week Joe goes for coffee with his colleagues at 10.30 every morning. He also enjoys a small muffin. Then he has a banana at 2 pm and a couple of small biscuits while he is watching television in the evening. He doesn’t think too much about it. He is consuming 500 calories more than he needs per day and in 6 months when Joe is 50 his BMI will put him over the line into obesity.

Joe rarely sees his doctor. In winter he occasionally gets a chesty cough and makes an emergency appointment with any doctor who is available because Bridgette says he might need an antibiotic. Once or twice since his thirties, a doctor checked his blood pressure and it is always normal. He had a medical as part of his mortgage application when he was 35 and everything was ‘normal’. Most of Joe’s friends are heavier than Joe and he still thinks of himself as ‘healthy’.  After all, he walks to work, has a healthy banana as a snack in the afternoon and he makes sure his evening meal is a healthy one.

Joe doesn’t see any problem. There is really time to talk to the doctor about why he likes that large cup of coffee and the muffin or to say that he is stuck in a dead-end job with a mortgage to pay and children to raise. Joe doesn’t admit that he is bored. The coffee break is the highlight of an otherwise long day of drudgery.  Joe’s trousers are getting a little bit tighter. Bridgette has noticed but his friends are all so much bigger and Joe doesn’t think she’s worried about it. She herself has gone up three dress sizes since the children were born so she doesn’t tease him too much. Besides, he just got a bigger size recently and he still thinks he looks good.

Joe is at risk of becoming a statistic in the epidemic of Globesity. All that stands in the way is the ingenuity and interest of those who care to find a way to help Joe turn things around.

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The chasm between patient experience and clinical practice

Can you guess what this abstract relates to without clicking on the link:

ABC is advisable if the patient does not show sustained improvement after a year of active treatment by other indicated means. The operation often represents the turning point in effective treatment. After the first year of ineffective treatment valuable time is being lost, with danger of fixation and deterioration. Then it is safer to operate than to wait. Calif Med. 1958 Jun; 88(6): 429–434.

That operation was last carried out in the 1960s. 40-50,000 were performed in the USA alone. This is what was reported about one person post op:

The reason for Dully’s lobotomy? His stepmother, Lou, said Dully was defiant, daydreamed and even objected to going to bed. If this sounds like a typical 12-year-old boy, that’s because he was.

What is being described below in 2011?

Remission of diabetes mellitus occurs in approximately 80 percent of patients after XYZ. Other obesity-related comorbidities are greatly reduced, and health-related quality of life improves. Complications and adverse effects are lowest with laparoscopic surgery, and vary by procedure and presurgical risk. Am Fam Physician. 2011 Oct 1;84(7):805-814.

In the same abstract the authors, Schroeder et al say:

The family physician is well positioned to care for obese patients by discussing surgery as an option for long-term weight loss…. Patient selection, pre surgical risk reduction, and postsurgical medical management, with nutrition and exercise support, are valuable roles for the family physician.

What do we know about this surgery?

According to the Schroeder:

Complications and adverse effects are lowest with laparoscopic surgery, and vary by procedure and presurgical risk…. Overall, these procedures have a mortality risk of less than 0.5 percent.

Here are some videos of what we are talking about. So what’s the patient experience?

Immediately post op:

Days 7-10: Now, at this stage, I shall only eat 4-6 Tablespoons of food each “meal” and I should have 5-6 meals a day. I can add mashed potatoes, custard, and pudding, but I must be VERY careful to keep it really low sugar and really low fat. Otherwise, my tiny pouch will rebel and make me regret it. Big Fat Blog

After a couple of years:

I had a lap-band. Then I had it removed after 2 years. The restrictions on drinking meant that exercise was difficult. And while I’ve felt emotionally broken for years, those two years were the only time I’ve felt physically broken. The experience was miserable. Big Fat Blog

Years later:

….almost 12 years later, there are still foods I have trouble eating. It still takes me 30 to 45 minutes to eat a meal, even if it’s just a sandwich and some chips. I have to stay away from anything that has a lot of sugar or a lot of grease in it (explosive diarrhea is not something you want to deal with in a public space, take it from me, been there done that). Big Fat Blog

Here are reflections from another blogger:

  • A few months after my surgery I started to have significant hair loss.
  •  It is important to take your vitamins.
  • There have been times that I have forgotten and do drink after I have eaten and when I do this I become quite uncomfortable and this is the occasions I may feel the need to vomit.
  • My taste buds have changed.
  • After I eat most of my meals or have a drink I get a little burppy. Not sure if it’s because I have eaten my meal too quickly (which I do), but it’s a side effect that hasn’t gone away.
  • This is really hard, everybody knows I have had the surgery but what they don’t understand is how little I can eat. I have to remember to ask for a small plate of food and I feel awful when I can’t eat all they gave me.
  • I hit a dark place about 2 weeks in, as I could only drink soups, watered down gatorade, sorbet etc. I really struggled with people eating around me being that I couldn’t eat.
  • I have tuckshop arms, which only recently have started to bother me like this morning when I saw them wobbling when I was drying my hair. It also does get me down a little when I lift my arm up and I notice people noticing my arms. I have an apron fold on my stomach from my pregnancy with the twins. When I have lost all my weight I would like to get the excess skin on my stomach removed. I will only do this when I have lost all my weight though. The organised housewife 

Experience of referral:

A few years later I moved and had to find a new primary care physician. She suggested Weight Loss Surgery… I asked her if she was familiar with WLS research regarding success (lack thereof), mortality rate, etc. After she answered, no, I asked her how she could recommend such a surgery when she was ignorant of its effects. She had no answer. Big Fat blog

So back to the literature (note the dates):

Undergoing laparoscopic sleeve gastrectomy induced efficient weight loss and a major improvement in obesity-related comorbidities, with mostly no correlation to percentage of excess weight loss. There was a significant weight regain and a decrease in remission rates of diabetes and, to a lesser extent, other comorbidities over time. JAMA Surg 2015

And

Not all bariatric patients, however, experience mental health gains from weight loss surgery, which is likely attributable to patients’ reactions to common undesired physical outcomes postsurgery: lack of weight loss, weight regain, and undesirable skin changes. Patients’ expectations that bariatric surgery will undoubtedly change their life may also set them up for psychological failure if expectations are not met. Journal of Obesity 2013

Finally we might reflect on the lobotomy as per Gregory Myers:

  1. The surgeon who introduced the world to the lobotomy was awarded the Nobel prize
  2. Some thought it was better than the alternative
  3. There was poor patient follow up
  4. It had significant adverse effects
  5. There was inadequate patient information and consent
  6. It destroyed people’s lives
  7. It was often a rushed procedure
  8. The indications for this invasive surgery were not limited to severe illness
  9. It was replaced by drug treatment

Is history repeating itself? It may by relevant that the global bariatric surgery market size was valued to be over USD 1,300 million in 2014.

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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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Doctor now that my ears are older I can hear you so much better

He was much more willing to listen than the twenty nine year old who was only interested in his sprained ankle. The attitude that millennials consider themselves invincible might explain it. Dave on the other hand wanted a certificate for work. Bit of a headache that morning. Didn’t go to work.

So, we got talking. He coaches a local football team. Now 50 can’t keep up with the young blokes on the field. Can still drink ten pints of beer on Saturday night at the club but most other nights happy to settle for two and some nights doesn’t drink at all. He snores. His trouser size gone up to 36 for the first time ever. Feels too stiff and breathless to do any real exercise. His blood pressure is borderline though be feels well enough.

Just under 1 million Australians were born between 1962 and 1966. Even though birthdays at each decade are usually marked by a special celebration, those for 50 are often unusually large. Being fifty is a bid deal.

It is in their 50’s, for example, that most people first think of their lives in terms of how much time is left rather than how much has passed. This decade more than any other brings a major reappraisal of the direction one’s life has taken, of priorities, and, most particularly, how best to use the years that remain. NY Times

  • 50 year olds are now officially “middle aged” technically ‘Generation X’.
  • Retirement benefits are only going to be available when they reach 67 and the money may have to last another 20-30 years.
  • At 50, many couples still have kids in the nest, with educations to be financed, teaching them to drive with attendant expenses , and, perhaps, weddings and helping with house purchase.
  • They may have parents in their 70s and 80s. They are watching mum and dad and their worries about healthcare and long term care expenses.
  • At 50 the majority of people are over weight or obese, the risk of hypertension begins to rise at this age, some men suffer erection dissatisfaction, many may start to have problems seeing clearly at close distances, especially when reading and working on the computer, the prevalence of hearing loss ranges from 20 to 40 percent. Things just don’t work like they used to!

Gen X has to stay healthy because in this economic climate early retirement is not an option. Within this context Dave and I began the work of focusing on his physical well being. The conversation was much more satisfying. This ‘teachable moment’ allowed us to engage in some simple strategies- reducing portion size, drinking less, taking up gentle exercise and keeping an eye on his blood pressure. Now Dave is earnest in his desire to invest in his health. That’s a good thing because at 50 one in 15 men will have heart disease by the time he is 60 one in four men will have developed that condition. Now is the time to invest. For his sake if not for the economy.

The average age of GPs in Australia is also about 50. We will make the journey together because that’s what general practice is all about. No gadget, gizmo or app was required to forge the connection, no research grant or policy. Just doing what we are trained to do.

Picture by Rene Gademann

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?

Picture by Niccolo Caranti

You can earn a living without making a difference

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I liked him instantly. There was something very refreshing about his willingness to be honest.

I hate my job. I’m 63 and I’m taking orders from men less than half my age. I had hoped that I could retire from my previous job but they privatised the company and a bunch of us were made redundant. So I took what was offered. So now I have to do all this physical work. On my breaks I eat chocolate. It helps me feel better and besides I like chocolate and milkshakes. I say to myself ‘ it has to be good for you its milk right’? Is Pizza OK doctor?

Several different colleagues had seen the patient over the years. He knew perfectly well that chocolate; milkshakes and pizza were a bad idea. A dietician and the practice nurse had seen him. His blood tests exhibited a worrying trend. Nothing that had happened in the intervening couple of years had changed. His job situation was much as it had been when he was first diagnosed with type 2 diabetes. He had been seen at least three times in the previous year and the picture was the same. If he had refused medication that decision was not recorded. I could imagine the conversation, focusing on diet and exercise. He described sleep apnoea and breathlessness on exertion. He struggled to get through each day. His cravings for comfort food and his sugar addiction were showing no signs of abating. For people like him we watch what plays out like a car crash in slow motion. Will he make it much beyond retirement? Will the vascular disease that appears in my crystal ball be averted?

A systematic review on the effectiveness of self-management training in type 2 diabetes concluded that

No studies demonstrated the effectiveness of self-management training on cardiovascular disease–related events or mortality; no economic analyses included indirect costs; few studies examined health-care utilization. Performance, selection, attrition, and detection bias were common in studies reviewed, and external generalizability was often limited. Norris and Narayan.

Our attempts to advise people like this man scarcely take account of their circumstances. Nowhere in his records did it tell me what this man did for a living, his hopes and dreams or his understanding of this unforgiving chronic condition. What was recorded was that he had received advice to lose weight (tick), to increase his exercise frequency (tick). His blood pressure had been measured at least three times in the past year (tick), lipids (tick), HbA1c (tick), renal function(tick), advised to see an optician(tick) and podiatrist (tick). According to our records he was receiving exemplary care. He was cast as ‘patient’ but not as a ‘person’. We knew nothing about where he lived, who lived with him, where he went on holiday, what he did at weekends, what he hoped to do when he retired. Nothing was noted about why he needs to do manual labour or whether he is in debt. In the fifteen minutes available this time we simply accepted that he was not going to change his lifestyle despite what I could tell him of the potential benefits. In return we shared a mutual concern for the risks he was harbouring. He would start medication and ramp up the doses until his risk for cardiovascular disease was reduced. Not a text book solution but then people are not cardboard cutouts. Our experience was supported by the results of research which reported that:

The core process of integrating lifestyle change in type 2 diabetes was multifaceted and complex. Challenges to the process of integrating lifestyle change included reconciling emotions, composing a structure, striving for satisfaction, exploring self and conflicts, discovering balance, and developing a new cadence to life. These challenges required acknowledgment in order for participants to progress toward integration. Whittemore et al.

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Placebos catering to the desperate and now delivered to your door

2294965204_5d6b5ee39c_zShe was delighted with the ‘results’. She showed me that her blouse was loosely fitting. “A couple of weeks ago this was tight” she insisted. I guessed her BMI was still at least 30 but ‘Tiny deal‘ had sent her the answer to her prayers. An appetite suppressant that you wear on your toes!

They hurt your feet. It’s like walking with corns on your toes but you can eat whatever you like. You just don’t feel hungry. It only cost five bucks and that includes postage.

She recounted a life long struggle with her weight.

It started when I was a little girl. My step mother didn’t like me so I was bashed regularly and given lots of ‘bad’ foods to eat. Later I was teased at school because I was plump. People think I’m lazy because I’m fat. I have been tested for sleep apnea, diabetes and high blood pressure. The doctors have given up, they can’t fix it….I didn’t want that for my little boy. We don’t feed him junk and he isn’t overweight.

Now she was also ‘detoxing’ with insoles that turn black overnight. What do they do I asked?

Dunno, the information leaflets are all in Chinese.

Don’t you worry about any of this I asked? How does it work? What’s it actually doing?

Nope all I know is that I feel really clean in the morning and that’s proof enough for me.

What would you like me to do for you today? I wondered out loud.

Nothing doc…except that I need a certificate for work. The detox requires you to drink lots of lemon juice and it’s giving me diarrhoea so I can’t work.

So here’s some advice from Health Mango on the use of magnets to treat obesity:

Metabolism of the body is directly related to the thyroid glands. If this gland which is located at the base of the throat is stimulated with the North Pole, the basal metabolic rate goes up and the food is burnt in larger quantity and that too faster.For this purpose a fat person should keep the North pole of a medium, powered (1500 to 200 Gauss) magnet at the base of the throat for about 15 minutes. This action should be repeated 2 or 3 times in a day right after meals. Simultaneously one should drink the water treated with the North Pole of the magnet 3 or 4 times a day. Each time the intake of water should be about half a cup. Try this with some doctor’s advice and it will surely be beneficial.

What would ‘some doctor’s advice’ add? The notions described are entirely alien. The doctor’s advice would be….! this is nonsense. To which my patient’s retort might be:

This blouse is definitely looser, it’s only costing me $5 so what harm?

I did a literature search and found a review published in Acupuncture in Medicine a sister to the BMJ. The paper was entitled: Magnets applied to acupuncture points as therapy. The authors concluded:

Based on this literature review we believe further investigation of acu-magnet therapy is warranted particularly for the management of diabetes and insomnia. The overall poor quality of the controlled trials precludes any evidence based treatment recommendations at this time (2008).

None of this had prevented some enterprising person from selling magnets making extraordinary claims directly to the public. But wait, there is science involved. The placebo response in studies with binge eating disorders is estimated to be a whopping 32.6%. Furthermore the literature says:

Short-term intervention with a placebo, however, appears of little value with respect to the long-term management of these binge eating problems. Even among individuals with fewer complications related to obesity and comorbid psychopathology, Binge Eating Disorder may be a refractory condition.

So I guess we might be forgiven for thinking, as she hobbles over to the door clutching her certificate

See you next time

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First we have to agree that there is a problem

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In order to make progress when we are trying to help someone we have to understand their world view. This was wonderfully portrayed in the Dove commercial. To understand a person’s perspective we have to try to see them as they see themselves but also to accept that as health professionals we may have less influence on people’s choices then we like to think.

It was also underlined in a research paper which concluded:

Overweight and obese youth were significantly more likely to misperceive their weight compared with non-overweight youth (P<0.001). Multilevel modeling indicated that greater parent and schoolmate BMI were significantly associated with greater misperception (underestimation) of weight status among children and adolescents. Maximova et al

Large proportions of the population are now overweight or obese. It may be hard to believe this if you live in affluent suburbs where salad bars, gym membership, jogging and cycling are the norm. In other parts of town it might be routine to eat fast food and wear XL or XXL sizes. As health professionals we have to compete with the messages from ‘healthy’ juice bars where sugar is added to sweet fruit and sold to the public as a better choice than a Mcdonald’s smoothie. Supermarkets sell cereal bars as a healthy snack even though most are loaded in sugar and salt. But all of these pales compared to the gluten-free fad. It is reported that 90 million Americans now follow a gluten-free diet because they believe (despite the lack of research evidence) that it is healthier, or as a weight loss strategy or in some cases to treat extra-gastrointestinal symptoms like a ‘foggy mind’.

Unpacking these beliefs in the course of a routine consultation in primary care is challenging. The belief has to be volunteered and the context understood. The associated behaviours have to be outlined and if there are sufficient grounds challenged without engendering the impression that the health professional does not accept the person’s right to make a choice, even when that choice is dubious or could even be harmful. People have the right to follow a gluten free or lactose free diet whatever their reasons. They have a right to drink too much alcohol and or to smoke cigarettes. However for many such people the consequences may include chronic morbidity and a shorter life expectancy. It is therefore incumbent on health professionals to communicate effectively with those who seek help. This may include demonstrating the outcomes in a creative way. The task is to help people to decide what outcomes they would prefer. However in the first instance we have to understand the ‘why’ as well as the ‘what’ of the decisions they make. That means creating the conditions in which people will feel inclined to share. That only happens when they believe that their perspective as well as their right to choose matter to you.

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