The future of healthcareLearn More

What is the role of doctors in health promotion?

Our health is a cause for concern.

  • Over 1 in 5 Australians aged 18+ (22%) reported having Cardiovascular disease in 2011.
  • In 2009, the risk of being diagnosed with cancer before their 85th birthday was 1 in 2 for males and 1 in 3 for females.
  • 1 in 10 Australians aged 18+ (10%) had biomedical signs of chronic kidney disease in 2011–12, with the majority of these showing early signs of the disease.
  • 1 in 19 Australians (5.4%) had diabetes in 2011–12 (self–reported and measured data). This is includes approximately 1% of the population who did not self-report they had diabetes, which may indicate they were unaware they had the condition.
  • In 2007, 1 in 5 Australians aged 16–85 (20%) experienced a mental disorder in the previous 12 months.
    In 2013–14, 1 in 7 children aged 4–17 (14%) were assessed as having mental health disorders in the previous 12 months .
  • Over 1 in 4 Australians (28%) reported having arthritis and other musculoskeletal conditions in 2011–12. The most prevalent conditions were back problems, osteoarthritis, osteoporosis and rheumatoid arthritis.
  • 3 in 10 Australians aged 25–44 had untreated tooth decay in 2004–06.
  • 1 in 10 Australians (10%) reported having asthma in 2011–12. This rate is significantly lower than the rate of 11.6% in 2001.
    1 in 42 Australians (2.4%) reported having COPD in 2011–12. The development of COPD occurs over many years and mainly affects middle aged and older people.

It seems:

  • We eat too much. Almost 2 in 3 Australian adults (63%) are overweight or obese. 1 in 4 Australian children (25%) are overweight or obese.
  • We don’t take enough exercise. Based on estimates that between 60 and 70 per cent of the Australian population is sedentary, or has low levels of physical activity, it has been suggested that increasing participation in physical activity by 10 per cent would lead to opportunity cost savings of $258 million, with 37 per cent of savings arising in the health sector.
  • We drink too much alcohol and have been drinking more every year.
  • We don’t eat enough vegetables. In 2007–08, just over half of all children aged 5–7 years (57%) and a third of children aged 8–11 years (32%) ate the recommended amount of fruit and vegetables but only 5% of people aged 12–18 years and 6% of people 19 years and over did so.
  • Too few of us avail of cancer screening tests.
  • We drive too fast. Speeding is a factor in about one third of road fatalities in Australia. Additionally, more than 4100 people are injured in speed-related incidents each year.

Someone must be to blame for all this- if only they would do their job and tell us to eat and drink less, exercise more and slow down.  But wait there are industries profiting from our bad choices. We are influenced by more than our doctor. We have known this for decades. It is known as the Bronfenbrenner’s Ecological Model:

Hchokr

At the core of Bronfenbrenner’s ecological model is the child’s biological and psychological makeup, based on individual and genetic developmental history. This makeup continues to be affected and modified by the child’s immediate physical and social environment (microsystem) as well as interactions among the systems within the environment (mesosystems). Other broader social, political and economic conditions (exosystem) influence the structure and availability of microsystems and the manner in which they affect the child. Finally, social, political, and economic conditions are themselves influenced by the general beliefs and attitudes (macrosystems) shared by members of the society. Wikipedia

Most Australians (13 Million) spend over 18 hours a day online. One in every five minutes (3.6 hours) a day is spent on social media. On the other hand time spent with general practitioners (GPs) is declining:

The proportion of GPs providing ‘Level C’ consultations (longer than 20 minutes) is substantial (96%) and constant; however, the number of long consultations provided per GP decreased by 21% between 2006 and 2010. The proportion of GPs providing Level D consultations (longer than 40 minutes) decreased from 72% in 2006 to 62% in 2009, while the number of Level D consultations provided per GP decreased by 26%. AHHA

Secondly the number of problems presented to doctors in increasing. In one survey of the 8707 patients sampled from 290 GPs, approximately half (47.4%, 95% CI: 45.2–49.6) had two or more chronic conditions.

Junk food is cheap and readily available. It is advertised to children. Fresh fruit and vegetables are less available, more expensive and of poorer quality in rural and remote Australia. These areas are also among our most economically disadvantaged and residents generally have less disposable income to spend on expensive, healthier food options. According to one report a multinational fast food company paid $500 million in taxes to the Australian government and might be due to pay more.

A 2017 poll  found that most Australians (78 per cent) believe Australia has a drinking problem, 74 per cent believe our drinking habits will worsen over the next five to ten years, and a growing majority (81 per cent) think more should be done to reduce alcohol harm. A price increase of 10%  on alcohol has been shown to reduce consumption by an average of 5%. Similarly for every 10% increase in price, consumption of tobacco reduces by about 4%. Finally a significant proportion of people are unhappy at work and this has been associated with snacking and weight gain.

So it seems that we are choices are triggered by far more than a doctor informing us that we are making bad choices. Doctors can make a huge difference to the individual who seeks advice in a teachable moment and can be triggered to make better choices. This requires more time with the patient and a greater focus on the needs of that individual patient rather than the distraction of a public health agenda.  At a public health level doctors’ impact is miniscule because of the much more powerful and ubiquitous drivers of poor choices that are fueled by those who profit from our dubious behaviour. A summary:

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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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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.

Picture by Rosebud23

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.

Picture by Khuroshvili Ilya

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.

Picture by rossodilbolgheri

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.

Picture by Saxbald