better health by designLearn More

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

4795444359_03021bc8b1_z

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

17871051465_e18b52224e_z

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

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

Picture by Indiamos

First we have to agree that there is a problem

5352592011_fff4a2dce4_z

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.

Picture by Will Temple

Twenty minutes every three months

5002318500_e8a4a2919c_z

I recently said goodbye to my patients when I moved to another job. One of my general practitioner friends also said goodbye to his patients, albeit it temporarily. He has been visiting Australia this week. I am pleased to recount his story.  For him the light bulb moment came when he noticed that people were concerned that he ‘might never return’. He wondered if he could deploy this connection to encourage his patients to be more active and or stop smoking.

Two months before Dr Klein left ( for one year), he wrote to his patients, challenging them to set 1 health-related goal to work on while he was away. He suggested they consider a lifestyle change, such as losing weight or quitting smoking.

Two of his colleagues offered to support the patients in their efforts to achieve any goals they set in Dr. Klein’s absence.

About 1 in 8 adult patients (48 out of 350) set goals, including losing weight, exercising so many times per week, and quitting smoking; some set more than 1 goal.

The ‘intervention’ took only a few minutes to initiate and 20 minutes of staff time every 3 months. This was essentially a reminder letter every 3 months. The results were impressive.

Among the participants, 18 (38%) did not achieve their goals; another 15 (31%) could not be reached, so their results were unknown. The remaining 15 patients (31%) succeeded, 8 completely and 7 partially reaching their goals, and some meeting more than 1 goal. The successes included 3 patients who quit smoking, 7 who increased physical activity levels, 7 who lost weight, 1 who reported decreased shoulder pain after exercising more often, and 1 who made an overall lifestyle change.

It sounds as if the reminder letters were triggers to keep working towards the goal. This ‘lean innovation’ did not require a research grant or a large team to complete. No drugs were prescribed, no tests were required. It was rewarding and demonstrated the value of the social capital in the doctor patient relationship. A relationship that defines the role of the medical practitioner even in 2015. The same relationship that creates tangible results. Medicine is a people business. We do well to remember that at a time when there is an obsession with quantified self.  You can read more about Doug Klein’s experience here.

Picture by Kellan.

Removing the triggers to unhealthy choices

Much of the work in medicine is persuading people to give things up; tobacco, fizzy drinks, junk food, alcohol. Health professional also need people to do things- take medication, have surgery, keep appointments, exercise and so on. An entire industry profits on persuading people to make such choices and on helping doctors to sell more effectively. BJ Fogg has distilled such business into a simple equation.

My Behavior Model shows that three elements must converge at the same moment for a behavior to occur: Motivation, Ability, and Trigger. When a behavior does not occur, at least one of those three elements is missing. (Behaviour= Trigger+ ( Motivation+ Ability)

Our health and well being depends on how effectively doctors can do this. Notwithstanding that medicine hasn’t always got it right. Not that long ago doctors were trying to persuade people to take up smoking. Perhaps something like this could happen again, but I digress. The point is that health professionals are in the business of selling health messages, services and treatment. Last week I raised concerns about how some elements of this industry has taken to offering data as the key cue to action. Data elicitation and display has become a very profitable business. This week I explore this issue with reference to obesity.

It is often assumed that people make decisions about food and eating in rational conscious ways. However, if this were so, the obesity epidemic would not be happening. People overconsume in response to environmental cues and they lack insight into the extent to which their food choices and eating behaviors are being manipulated by sophisticated advertising and marketing techniques. They also have a limited capacity to sort through the increasingly overwhelming mountains of information and claims about food choices and, as a result, too often choose default option foods high in fat and sugar that, when consumed routinely, lead to chronic diseases. Deborah A. Cohen

So the challenge is trying to persuade people to eat less or at least less often. I offer four pieces of empirical advice to any of my patients who wants to lose weight some of which has come from the extensive review by Cutler, Glaeser and Shapiro:

1. Don’t put anything in your mouth while standing up other than a tooth brush-based on the observation that people consume a lot of calories while preparing food or snacking on the move.

2. Don’t eat other than at a dinning table- people often eat at their desks or worse, in front of the TV.

3. Don’t go shopping when you are hungry- it tempts you to bring things home that will sabotage your efforts to reduce consumption.

4. Don’t eat between meals…Duhhh!

Foggs Behavior Wizard suggests that to persuade people to decrease a behaviour:

  1. Remove the trigger that leads to the undesirable behaviour
  2. Reduce ability to perform the behaviour (make it harder to do)
  3. Replace motivation for doing the behaviour with de-motivators:  pain, fear, or social rejection

So the trigger that leads to the undesirable behaviour is the feeling that you are ‘hungry’. What Fogg recommends is:

When you design for persuasion, you don’t start by manipulation for motivation. That’s what you do last.

Therefore targeting motivation through calorie counting or calorie expenditure isn’t going to work. There are too many hours left in the day after you’ve consumed the few calories you need to lose weight and you have to do an unrealistic amount of exercise to be able to consume more. The real  problem is that people misinterpret four emotions associated with the urge to eat:

  1. Hunger
  2. Thirst
  3. Boredom
  4. Unhappiness

Therefore the trigger is often unrelated to the need for food and more to do with something else that hasn’t been acknowledged. To remove the trigger it must first be recognised as false. Therefore you might substitute or associate with another established trigger – namely answering a mobile phone or checking for email or facebook updates. By associating the urge to eat with checking an app on their mobile phone the person can work out if what they really want is food or something else. To reduce the ability to perform the behaviour (eat that popcorn, cake or choclate bar) the person needs to remove themselves from the place (physical or psychological) where the behaviour takes place- in front of the TV, at their desk at work or on the concourse at the station. This means either finding a new hobby, making a habit of only eating at a dinning table or carrying a bottle of water to and from work. Finally replacing the motivation for doing the behaviour with de-motivators could be part of the proposed solution by offering a diary of the poor choices that have tempted the individual between meals. I look forward to sharing a solution soon. Wearable not required.

 

Innovating to save precious time

When I was at medical school Pendleton’s book on the consultation was required reading. Pendleton maintained that one of the tasks in the consultation was to consider ‘at-risk factors’. It’s one item on an otherwise long list of tasks to be completed. Today it is often the case  that a discussion of  those ‘at-risk factors’ take over the focus of the consultation. Doctors are urged, even rewarded for moving the agenda to- diet and exercise, responsible drinking, colorectal, breast and cervical screening, hypertension, safe sex….the list is endless. The impact of having the doctor’s agenda up front and central in the consult is what has been described as

High controlling behaviours.

Ong et al.

The resultant style of consultation is described thus:

It involves… asking many questions and interrupting frequently. This way the doctor keeps tight control over the interaction and does not let the patient speak at any length.

Recently medicolegal defense organisations have taken to issuing advice against this pointing out that when the patient does not feel they have been heard they are more likely to complain. Research has shown that patients don’t ask for much. They won’t take long to spit out the reason for their visit. In one study:

Mean spontaneous talking time was 92 seconds (SD 105 seconds; median 59 seconds;), and 78% (258) of patients had finished their initial statement in two minutes.

Langewitz et al.

Allowing the patient to speak first is a good start. Then how do we support practitioners to earn a living by also attending to those topics for which they must tick a funder’s check box? Tasks introduced by policy makers as if the primary care consultation was replete with redundant time. In some ways it’s like what happens when you buy a new television, it’s not long before the sales assistant wants to sell you insurance and other products- ‘just in case’ but really because their commission depends on it. What we need in medicine is to stop eating into the time it takes to explore a patient’s ideas, concerns and expectations, time needed to examine the patient and express empathy. We need cheap, agile, intuitive and creative solutions that will quickly offer the patient an indication of their risk from whatever the latest public health issue happens to be- smoking, influenza, prostate cancer…but also the benefits and why they might want to consider ‘taking the test’, accepting ‘the jab’, or changing the habit.  My colleague Oksana Burford invested three years testing one such innovation. What Oksana realised is that in the end it’s the patients choice and the key is to introduce the idea of change in a way that speaks to her but only when she is ready to hear the message.

The reasons why primary care is selected to relay public health messages is that people trust their health care provider and are more likely to comply if that practitioner recommends it. However that does not mean that we should assume the patient can only get the necessary information from one source. What the practitioner can do is sign post where that information can be found and effectively convey why the choice being recommended is better than the status quo. I recommend the food swap app– its downloaded free and saves a lot of time which can then be used to deal with the reason the person had come to see me in the first place. There is lots of room for innovation but it should meet the needs of the patient and the practitioner.

Why aren’t healthcare providers doing more to tackle the biggest health problem?

Obesity is the single biggest health problem facing our generation and the generations to come. It’s already killing, disabling, disfiguring and demoralising more than half of the population in most developed countries. By 2025 the majority in the developed world, and a growing proportion in the developing world will be overweight or obese. We have seen it coming, the warnings have been around for decades and yet we have done very little to combat it. Now it’s reported that doctors can’t see what they can do about it.

Until more effective interventions have been developed GPs may remain unconvinced that obesity is a problem requiring their clinical expertise and may continue to resist any government pressure to accept obesity as part of their workload.

—Laura Epstein and Jane Ogden

The reality about the problem of obesity is:

1. We are all aware that being overweight is harmful and yet we are legally bombarded with subliminal messages that promote unhelpful lifestyle choices .

2. It may be counter productive to raise the issue with someone who already feels a sense of shame and guilt.

3. Simply being offered dietary advice by a health practitioner isn’t making a difference to most people. We already know what we shouldn’t put in our mouths, that an apple is better for us than a chocolate bar.

4. People find it hard to do what needs to be done to tackle the issue—eat less and exercise more. It’s hard to sustain the effort over a period of time and to make permanent lifestyle changes.

5. Our current healthcare interventions and innovations with regard to obesity are not working.

6. In Australia the cost of dealing with the effects of obesity has reached $120 billion. We are not doing enough to tackle the root cause.

7. We must find a sustainable solution to this problem. Handing out diet sheets and making referrals to dieticians is not enough.

The challenge, for the practitioner is to present information that’s hard to hear in a way that it is likely to be taken on board and acted on. To appeal to how people feel about making changes, not just what they know. To provide information that is motivating and affirming. To reduce the time burden on health practitioners to deliver that advice efficiently. To put the tools into the hands of the person who may have to change life long habits. We just need the collective will to make it happen.