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Is normal too thin?

Try this experiment. If you are tending to overweight ( Body Mass Index (BMI) 25 or over) then try to get to BMI 18.5 -24.9.  If you succeed people will decide you have lost ‘too much weight’  even when your BMI is in the middle of the normal range. If normal was defined as ‘what is most common’ then to have a ‘normal’ BMI is unusual and we may have become blind to normal so that what we perceive as ‘normal’ is not ideal. Rates of overweight and obesity are now at 60-70%.

In an Australian study on the public perception of body size the authors report that:

Overweight participants were also most likely to incorrectly identify themselves as a healthy weight (67 per cent, p<0.001), compared to 12 per cent of obese participants . The majority (89 per cent) of normal weight participants accurately identified themselves as being a healthy weight. Flanagan et al

Therefore it is not surprising that when people are challenged about their weight in healthcare they are reluctant to identify the issue as a problem.

Picture by Phil Gradwell

What price do you pay?

Looking back it was the right decision for me. I decided to choose a different career the day I wiped mayonnaise off my tie. I didn’t want to have my meals on the run. The job wasn’t for me if the price was regularly having to eat out of a paper bag rushing around from place to place or sitting at my desk. Others felt differently. I had to make a choice that worked for me.

While 62 percent of doctors who were normal or underweight reported eating a healthy diet rich in fruits and vegetables, the survey revealed that 44 percent of heavier doctors eat a diet high in carbs, meat and fat, or “on the go” meals. Just 16 percent of doctors who were considered overweight or obese were on a diet meant to help them lose weight or restrict calories. Life

Picture by Chris Blakeley.

Not all solutions are linear

We mistakenly believe that the path to solving some of our customer, client or patient’s problems is linear. Want to improve your liver function? Stop drinking alcohol. Want to lose weight? Go on a diet. Want to have more energy? Stop smoking. The ‘solution’ is simple. But it doesn’t usually work that way.

Sophie sat looking glazed as her doctor suggested a strict diet that might help her shed the kilos. It didn’t end well. She never lost any weight and eventually stopped attending that clinic. Her life was complicated. She had always been overweight and after the babies were born she got steadily heavier until she was obese. She lives in a modest two bedroom rented home with three children and partner. He works as a bus driver. Sophie does shifts at a laundry when her friend needs help covering the roster. The family buy their clothes second hand and just about pay their bills. At the weekend they go to the mall and have a takeaway meal from the food court. Sophie enjoys the day at the mall where she meets her friends and spend the afternoon gossiping while the children are in the play area. She didn’t learn to cook and her small kitchen is barely equipped to turn out the simplest meal. She never enjoyed school and can’t read. In quiet moments Sophie admits she doesn’t like the way life turned out but she has dreams that she might win the lottery and then life will be so much better.

With this as her back story the diet and exercise program wasn’t appealing. She may decide she wants to reduce the risk of developing diabetes, a condition that impacted her father. It may be a meandering journey but the best coach will stick with her.

Picture by jurek d.

What is your approach to the biggest health risk of our time?

Sixty to eighty percent of people are now overweight or obese. This is associated with considerable morbidity. Yet it is a very complex issue and the causes of the condition are many and varied.

…..the dramatic rise in the incidence of obesity in many countries appears to be due to the complex interaction of a variety of factors including genetic, physiologic, environmental, psychological, social, economic, and political. Wright and Aronne

The experience of overweight people with healthcare professionals is not universally good.

Seventy‐six individuals (aged 16–72) were interviewed. Most had struggled with their weight for most of their lives (n = 45). Almost all had experienced stigma and discrimination in childhood (n = 36), as adolescents (n = 41) or as adults (n = 72). About half stated that they had been humiliated by health professionals because of their weight. Thomas et al

Over my whole 40 year dieting history I found two doctors who have said ‘well, come back once a week or once a fortnight and I will weigh you’. I found that very helpful and useful, because you feel like somebody is on your side. (65 year old female)

 They have helped because they guided me and pointed things out and they were there for me. If I’ve got questions they are helpful. (28 year old female)

 Oh well, I have spoken to my doctor about it and he just says get more exercise. I did mention it to one other doctor and he said there is only one way to lose weight and that’s meal replacement drinks or tablets. So I never went back to him because I don’t agree with that. (49 year old male)

 My doctor keeps saying, you need to lose weight. And I say, yes, I know that and I want to and I try to watch what I am eating, but it is just getting harder and harder. (59 year old female)

If you are a healthcare professional it is very likely that you will see several people today who are overweight or obese. How will you raise the topic with them? How will you know they want to address the issue? What help will your offer? How do you know you have been helpful to others in these circumstances?

Picture by Paola Kizette Cimenti

Do you mind if I don’t take your advice?

Your customers, clients or patients are free to choose. Despite your most earnest desire to save them from themselves they may choose to pass on your advice today. Is that alright? They may decide never to give up on the donuts, to stop smoking or head to the gym. As a consequence they may continue on the way to chronic illness. Do people have responsibilities from the ethics point of view?

Autonomous patients do have duties most of which are left out of mainstream medical ethics. Some of these duties flow from the obligations all persons have to each other; others are the
responsibilities citizens have in a welfare state. More specifically, patients have duties corresponding to those that render doctors captive helpers. Patients have to- morally have to do their best to ensure that they minimise this captivity and enable doctors to be willing helpers. Although doctors remain captive in the face of acute or life-threatening illness, it is not unethical for doctors to free themselves from this captivity in cases that fall short of life or death. Draper and Sorell

Picture by Viv Lynch

Are you credible as a lifestyle coach?

The commonest conditions doctors encounter are illnesses directly related to poor life style choices. Diseases that arise because we eat too much and don’t take enough exercise.

People who seek healthcare advice will be told more often than not that they must make different choices. How credible is your advice as a doctor? How persuasive are you as the messenger? How could you do this better?

Picture by Cocoabiscuit ,

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

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

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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