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For sustained behaviour change: show don’t tell

BACKGROUND:
This randomised controlled study evaluated a computer-generated future self-image as a personalised, visual motivational tool for weight loss in adults.
METHODS:
One hundred and forty-five people (age 18-79 years) with a Body Mass Index (BMI) of at least 25 kg/m2 were randomised to receive a hard copy future self-image at recruitment (early image) or after 8 weeks (delayed image). Participants received general healthy lifestyle information at recruitment and were weighed at 4-weekly intervals for 24 weeks. The image was created using an iPad app called ‘Future Me’. A second randomisation at 16 weeks allocated either an additional future self-image or no additional image.
RESULTS:
Seventy-four participants were allocated to receive their image at commencement, and 71 to the delayed-image group. Regarding to weight loss, the delayed-image group did consistently better in all analyses. Twenty-four recruits were deemed non-starters, comprising 15 (21%) in the delayed-image group and 9 (12%) in the early-image group (χ2(1) = 2.1, p = 0.15). At 24 weeks there was a significant change in weight overall (p < 0.0001), and a difference in rate of change between groups (delayed-image group: -0.60 kg, early-image group: -0.42 kg, p = 0.01). Men lost weight faster than women. The group into which participants were allocated at week 16 (second image or not) appeared not to influence the outcome (p = 0.31). Analysis of all completers and withdrawals showed a strong trend over time (p < 0.0001), and a difference in rate of change between groups (delayed-image: -0.50 kg, early-image: -0.27 kg, p = 0.0008).
CONCLUSION:
One in five participants in the delayed-image group completing the 24-week intervention achieved a clinically significant weight loss, having received only future self-images and general lifestyle advice. Timing the provision of future self-images appears to be significant, and promising for future research to clarify their efficacy.

Trials. 2017 Apr 18;18(1):180. doi: 10.1186/s13063-017-1907-6.

Picture by Rene Passet

Dog walking may assist weight control

Height and weight were measured for 281 children aged 5–6 years and 864 children aged 10–12 years. One parent reported their own and their partner’s height and weight (n=1,108), dog ownership, usual frequency their child walks a dog, and usual frequency of walking the dog as a family. Logistic regression analyses were adjusted for sex (children only), physical activity, education, neighbourhood SES, parental weight status (children only) and clustering by school.

Dog ownership ranged from 45–57% in the two age groups. Nearly one in four 5–6 year-olds and 37% of 10–12 year-olds walked a dog at least once/week. Weekly dog walking as a family was reported by 24–28% of respondents. The odds of being overweight or obese were lower among younger children who owned a dog (OR=0.5, 95% CI 0.3–0.8) and higher among mothers whose family walked the dog together (OR=1.3, 95% CI 1.0–1.7). Health Promotion Journal of Australia

Picture by astrid westvang

What we eat at work may be very bad news

We spend so much time at work- what we eat there matters. What makes it worse is that we may be triggered to eat things that are very bad news for our waist line.

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

I summarise in the video:

Picture by fredenslund

The long-term impact of overeating during the holiday season

We do not gain weight steadily through the year. In fact, it is primarily from the end of November to mid-January that we find ourselves tempted and triggered to eat more than we need. With a seemingly endless round of invitations to partake in sugary treats most people succumb and add up to one kilo to their already growing girth.

The average BMI of males in their 40s in the West is 25.6 to 28.4. The numbers are similar for women.  In other words, most are overweight. Researchers document that during this holiday season adults consistently gain weight during this period (0.4 to 0.9 kg).

Participants seeking to lose weight appeared to increase weight although this was not consistently significant and motivated self-monitoring people also appeared to increase weight. These results must be considered for registered dietitian nutritionists, other health providers, and policy makers to prevent weight gain in their patients and communities during this critical period.

Obesity is an epidemic with a rising tide of chronic and life-limiting illnesses in its wake. As healthcare professionals,
we need to be confident about raising the issue of overindulgence without putting a damper on the festivities.


Picture by jrchapoy

It is time for primary care to enter the triggering business

It has been suggested, some would say demonstrated that doctors know very little about their patients. If you are a doctor could you identify your patient’s partner from a line-up of strangers (other than people you see as a couple)?  Or could you tell without seeing the name on the document if this bank statement belonged to that patient? Or whether that utility bill was from where that person lives? Is this internet search history theirs? Do you know how much they spend on lottery tickets? Alcohol? Vegetables?

A few years ago our team then based in the UK was evaluating an intervention to increase access to general practitioners. If the intervention worked we would have to demonstrate improvement over the course of a whole year. Here’s the thing, we noted that year after year there was a pattern to the demand for same day (emergency) appointments- with definite peaks and troughs. So if the intervention worked it would have to be sustained during both the peaks and the troughs. It did. The data on out-of-hours services exhibited very similar patterns- with definite peaks and troughs and at unexpected times of the year. We could not explain the patterns but noted that when the meteorological office recorded  22 hours or more of sunshine in the week the demand for appointments dropped. Not the prevalence of viral or other community pathogens but sunshine of all things! Okay may it was some factor that we hadn’t modelled in the analysis but there was a definite pattern that we could not immediately explain on the basis of what seemed plausible at the time. We called it the Spring Cleaning Effect– we hypothesised that people in the UK were less likely to attend doctors in general practice when there was a run of sunny days on which to do outdoorsy things. We didn’t anticipate this- nor did clinic managers because the patterns of demand were not used to inform the scheduling of doctors’ on-call rosters. It was clear that they were blind to a phenomenon nobody understood fully.

More recently I reviewed some data on certification for low back pain and noted the pattern that as unemployment rates in a locality increased the rates of certification dropped and then plateaued.

Our team is now investigating similar data from a large employers’ records. We hypothesise that rates of submission of sickness certification will show a sharp drop when vacancy rates fall and other markers of economic health decline. People may be far less likely to take time off sick if they are fearful of upsetting their supervisor. With respect to primary care, it is unlikely that doctors will know everything that impacts on their patient’s choices. Time spent with the patient in discovering these things is unlikely to increase as it comes at a financial cost. Therefore doctors will never fully anticipate all the drivers to patient behaviour. Why does that obese person fail to take action on weight management? Why does this other person take ‘medication holidays’ when they need to take the treatment consistently to benefit? Why does the next person refuse to have an X-ray? Why is there a rush of people with relatively minor conditions demanding appointments this week and not last?

Some drivers lead people to behave in unexpected ways as I have commented here previously. Not only that but as Mullainathan and Shafir have postulated people are often unable or perhaps unwilling to follow doctor’s advice. In the end, the best we can hope is to trigger the relevant behaviour in people who are already motivated and seek teachable moments to inspire people to act for their benefit. Primary care may be more about recognising or fishing for opportunities and much less ‘educating’ for change. Such triggers need to fit within the final moments of a 15-minute consult. The work to develop and evaluate such triggers is only beginning. Counselling patients to stop smoking will yield 1:20 quits in a year, showing them a trigger (in less than 5 minutes) that appeals to their vanity results in 1:7 quits. A substantial number (1:5) of obese people will lose weight in 6 months if they are shown what difference that would make to their appearance without having to be extensively counselled on diet and exercise.

Picture by Aimee Rivers

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

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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How can medicine compete against the new normal?

Joanna was exactly the person we are being urged to help. In her forties, overweight verging on obese. Hypertensive, asymptomatic but well on her way to chronic diseases. We discussed her diet.

I like salt. So my food tends to be salty. Also most people in my house are my size. I thought about reducing my portions but I like meat, lots of meat. I’m a member of a gym but I rarely go there.

We talked about her risk of heart disease and encouraged her to banish the salt cellar from the table, perhaps think again about reducing the portion size and making time to go to the gym. She looked at me pityingly her eyes said

Well that ain’t gonna happen

This was not a teachable moment. She was not ready to make an investment in changing her habits. She could not see that she was at risk. She was ‘normal’ as far as she could see. So she was not going to change her diet to deal with a problem that she did not perceive as real.

There are many things that are regarded as ‘normal’.

It is now normal:

  1. To have to wear extra large clothes.
  2. To be offered larger portion sizes when we dine out
  3. For more than one in three Australians aged 14 years and over to consume alcohol on a weekly basis
  4. For friends or acquaintances to be the most likely sources of alcohol for 12–17 year olds (45.4%), with parents being the second most likely source (29.3%)
  5. For more than one in three Australians aged 14 years and over to have used cannabis one or more times in their life
  6. For more one in ten people to drink and drive
  7. For one in three people to lose their virginity before the age of 16 ( i.e. before the age of consent) and also to have multiple partners
  8. For 66 percent of all men and 41 percent of women to view pornography at least once a month, and that an estimated 50 percent of internet traffic is sex-related.
  9. For most people who join a gym to never use it

These and many other trends dictate what is ‘normal’ to the average person. It’s OK to eat and drink far too much because everyone else does. It’s OK to be promiscuous, watch pornography and take risks because that’s what people see happening all around them.

Against these trends the challenge is to seek opportunities when ‘normal’ is seen as risky and hopefully before that risk has manifested as pathology.

Picture by Mario Antonio Pean Zapat