Research presented at the recent International Congress on Obesity showed that childhood obesity has stabilized or decreased in many countries over the last ten years. Rates are up in China, Vietnam and Germany, but have decreased or stabilized in Australia, Denmark, England, France, Greece, Japan, the Netherlands, Norway, Russia, Scotland, Sweden, Switzerland, and the US. In India, rates have stabilized for boys, but are still rising for girls.

When you dig a little deeper into the numbers, however, there’s a difference between the children of the rich and the children of the poor. An English study, for example, found that obesity was decreasing for 5-to-10-year-olds from higher socioeconomic groups, but was still increasing in lower socioeconomic groups. When the two sets of data balance each other out, it creates the appearance of a plateau.

Studies in the US draw similar conclusions: Obesity rates are much higher among those who are economically disadvantaged or belong to certain ethnic groups.

The cost of healthy and junk food

The quality of the food you eat makes a huge difference when it comes to obesity and health. That’s why I was surprised to see Dr. George Lundberg, former editor of Medscape and JAMA, argue recently that gaining weight was simply a matter of failing to exert enough will power. In a video entitled “How to Prevent Obesity — Stop Eating” (transcript available at Medpage Today and KevinMD), he says:

If you are overweight (BMI 25 to 30), consider this a wake-up call and ACT NOW, before you become obese. STOP EATING. … [S]top eating fats and refined carbohydrates when you can eat fresh fruits and vegetables and complex carbohydrates.

Dr. Lundberg’s advice is probably quite appropriate for educated, comfortably middle-class adults who are currently employed. But consider these statistics from The New England Journal of Medicine (emphasis added):

[B]etween 1985 and 2000, the retail price of carbonated soft drinks rose by 20%, the prices of fats and oils by 35%, and those of sugars and sweets by 46%, as compared with a 118% increase in the retail price of fresh fruits and vegetables.

This widening cost differential, in combination with the global economic crisis, has profound implications in terms of increasing socioeconomic disparities in the incidence and management of obesity, hypertension, diabetes, and other diet-sensitive chronic diseases.

The focus of the NEJM article wasn’t even obesity. It was food insecurity in the US – the risk of going hungry due to an inability to afford food. In households with incomes below the federal poverty level, the rate of food insecurity is 42%. For all households, the rate increased 32% in 2008.

The obese don’t shop at Whole Foods

Commenting on a study that compared the obesity rates of shoppers at Whole Foods and low-cost grocery stores such as Albertsons, the study’s author pointed out the obvious. (emphasis added)

It’s not a matter of availability, Drewnowski said. All of the stores in his study stocked a wide range of nutritious food, including plenty of fruits and vegetables.

Instead, he contends it’s because healthy, low-calorie foods cost more money and take more effort to prepare than processed, high-calorie foods. In a separate study two years ago, Drewnowski estimated that a calorie-dense diet cost $3.52 a day compared with $36.32 a day for a low-calorie diet.

“If you have $3 to feed yourself, your choices gravitate toward foods which give you the most calories per dollar.”

Obesity rates are more than a question of will power. They’re an economic — and therefore a political — issue. When the time comes that we can fill up on fruits and vegetables as cheaply as on junk food, maybe the experts will stop telling us the obesity problem is simply a matter of will power.

Dr. George Lundberg: STOP EATING

Here’s Dr. Lundberg’s editorial.

Related posts:
Obesity: Moving beyond willpower vs. the food-industrial complex
The So-Called Obesity “Epidemic”
Sanjay Gupta, George Lundberg, and Obama’s Enneagram type
Sanjay Gupta a victim of obesity myths?
Do children really need chocolate baby formula?
Sin taxes: Financing health care with soda pop

Resources:

Image source: The Insurance Helpline, UK

Andy Coghlan, Rise in childhood obesity is slowing worldwide, New Scientist, August 7, 2010

Experts warn against being happy too early about child obesity stabilization in developed world, Xinhuanet News, July 15, 2010

E Stamatakis et al., Childhood obesity and overweight prevalence trends in England: evidence for growing socioeconomic disparities, International Journal of Obesity, November 3, 2009 (DOI: 10.1038/ijo.2009.217)

Katherine M. Flegal et al., Prevalence and Trends in Obesity Among US Adults, 1999-2008, Journal of the American Medical Association, January 20, 2010, Vol. 303 no. 3 (scroll down for complete article)

Pam Belluck, Obesity Rates Hit Plateau in U.S., Data Suggest, The New York Times, January 13, 2010

Success of Community Interventions for Childhood Obesity Varies Depending on the Target Age Group, Science Daily, July 13, 2010

George Lundberg, MD, Stop eating before you become obese, KevinMD,

George Lundberg, MD, How to Prevent Obesity — Stop Eating, Medscape Today, July 26, 2010

Hilary K. Seligman, M.D., and Dean Schillinger, M.D., Hunger and Socioeconomic Disparities in Chronic Disease, The New England Journal of Medicine, July 1, 2010

JoNel Aleccia, Pricey grocery stores attract skinniest shoppers, MSNBC, May 24, 2010

Adam Drewnowski and Nicole Darmon, The economics of obesity: dietary energy density and energy cost, The American Journal of Clinical Nutrition, July 2005

While browsing the KevinMD site, I came across a post by “A Country Doctor,” Evidence based medicine at the expense of the art of medicine. My post was on the tradition of doctors as” humanists” – educated professionals who contribute to the “fine” arts as writers, visual artists, and musicians. There’s a connection, however, between that tradition and the “art” of medicine.

What happens to doctors when the latest scientific methods of clinical decision making — as well as a reimbursement system that determines how medicine is practiced — encourage doctors to be little more than scientific technicians? Will their insight into the humanity and individuality of patients suffer? What happens to the physician’s art of addressing the uniqueness of each patient’s illness?

This issue comes up when discussing evidence-based medicine (EBM). Country Doctor points out that EBM emphasizes science to the detriment of art.

The proponents of uniformity … [fail] to understand the art in what we do. Health care is like food, wine or music. The ingredients, even the recipes, may look similar, but the interpretation and delivery makes it what it is. Two different doctors can deliver the same care in theory but get different clinical results and different patient satisfaction. And two patients with the same stage of a disease may respond differently to the same treatment. … Physicians need to take pride in their work and act like doctors, not health care drones, who blindly and mindlessly toil for the big health care machine. …

Even the New England Journal of Medicine recently printed an article that suggested that computers could make unnecessary the “master diagnosticians of past eras.”

Is it any wonder that so many hard-working, decent doctors are dissatisfied with their careers? Is it any wonder that the primary care specialties are having recruitment problems?

In the comments section for this post, a medical student confirms the trend towards an emphasis on the science rather than the art of diagnosis.

I’m a third year medical student, and I can’t tell you how hard they try to push Evidence-Based Medicine at us in school. It is not that I am against medicine practiced based on evidence, but the concept of using data from other patients (that are not our patient, and may not even be similar to our patient) to guide our decisions only brings an inappropriate uniformity and standardization to the practice of medicine.

Ars longa, vita brevis

In 1806, Thomas Jefferson wrote to Edward Jenner, congratulating him on the success of his smallpox vaccine. In his praise, Jefferson compares Jenner’s accomplishment to William Harvey’s discovery of the circulation of the blood (1628):

Harvey’s discovery of the circulation of the blood was a beautiful addition to our knowledge of the animal economy, but on a review of the practice of medicine before and since that epoch, I do not see any great amelioration which has been derived from that discovery.

The science of medicine has indeed come a long way since Jefferson’s time.

The art remains, however. As the father of Western medicine put it in an aphorism addressed to medical doctors: Life is short, the art is long, the occasion fleeting, and judgment difficult. By “art,” Hippocrates was referring to the years of training and patient observation that a physician must invest before acquiring the necessary skills of medicine.

A more nuanced translation of Hippocrates’ original Greek text might read: Life is too short; the task is huge; the right time is like a razor blade; the road to experience is fraught with hazards; to continuously accept reality and critical thought over hope and prejudice is taxing.

2400 years later, it’s an observation that still rings true for the medical profession.

Related posts:
The physician as humanist
Physician as lone practitioner
The doctor/patient relationship: What have we lost?
Universal health care: What would Socrates do?

Resources:

Image source: The Tile Design Company

Roy Porter and W.F. Bynum, The Art and Science of Medicine, Companion Encyclopedia of the History of Medicine, 1993

Ars longa, vita brevis, Wikipedia, last update September 3, 2010

The website offers insights into food, delicious recipes with a detailed cost analysis, and beautiful, step-by-step photographs of the cooking process.

The physiology, evolutionary significance, and pleasure of taste

Back in March and April of 2009 I wrote a long series of posts on taste. I got interested in the subject when I came across the idea of supertasters – individuals who are overly sensitive to bitter tastes and, as a result, have their own peculiar food preferences. The percentage of people who are supertasters varies by nationality and ethnicity, but in the US it’s about 25%.

When More Thyme Than Dough contacted me about quoting one of my posts on taste (see the result at I Am not a Picky Eater!), I decided to resurrect them and present them here as a series.

A matter of taste
Taste happens on the tongue, but flavor is a combination of taste, smell, and touch. Without smell (think: stuffed up nose), food loses flavor. … Taste is the most important factor in choosing food, followed by cost. Whether food is actually nutritious and good for us is much less relevant to the decision process. … There are biological reasons for the five tastes — sweet, sour, salty, bitter, and savory. They promote survival.

How do you taste?
An introduction to taste buds – their anatomy, chemistry, and neurophysiology. “The structures involved in taste aren’t exactly like nested dolls. There’s only one Paul inside of John, but there are many taste buds in a papilla, many taste cells in a taste bud, and many taste receptors in a taste cell. The terms papillae, taste buds, and taste receptors come up in subsequent posts, which is why I explain them here.”

Orange juice and toothpaste
Why does orange juice taste awful after brushing your teeth? All about the detergent in your toothpaste and what it does to the phospholipid bilayer on your tongue. “What’s in your toothpaste? Probably more than you think. Toothpaste contains flourides, abrasives, detergents, thickeners, and water softeners. It also has sweeteners to hide the bad taste of all that other stuff. The ingredient that makes orange juice taste bad is a foaming detergent that cleans your teeth.”

What is a supertaster?
Supertasters, medium tasters, and nontasters … Sensitivity to the bitter taste of the chemicals PTC or PROP … The number of taste buds on the tongue of a supertaster. … Supertaster tongues have more papillae, more taste buds, and are more sensitive to physical stimulation. Taste buds not only transmit information about taste, but information about pain, temperature, and touch. Supertasters detect more bitterness, but also more spiciness, heat, cold, and anything painful.

The genetics of supertasting
If the supertaster’s ability to detect bitterness (and thus poisons) is so valuable, why did nontasters survive genetically? The evolution of taste discrimination and its survival value. … “Supertasters learn not to eat bitter, poisonous berries after the first bite, not after they get a fatal stomach ache. The explanation could be that tasters and nontasters are sensitive to different sets of bitter tastes, and this combination of sensitivities gives an advantage to medium tasters.”

Are you a supertaster: Do you really want to know?
A wine connoisseur is better off not being a supertaster. … It’s good to be sensitive to and tolerant of other people – don’t assume the way food tastes to you is universal. … “I would speculate that supertasters probably enjoy wine less than the rest of us. They experience astringency, acidity, bitterness, and heat (from alcohol) more intensely, and this combination may make wine –or some wine styles — relatively unappealing.”

Are you a supertaster: Look at your tongue
How to count the papillae on your tongue, using blue food coloring and a reinforcement sticker. “When you apply blue food coloring to your tongue, what you’re looking for is the areas that do NOT turn blue. The pink, round dots are the papillae. The pink dots on the tongue here are spaced fairly far apart, which makes them easy to count. This could be the tongue of a mildly sensitive taster, but definitely not a supertaster.”

Are you a supertaster: How does PROP taste to you?
You can purchase supertaster test strips to determine your taste status. The strips are impregnated with a bitter chemical. “You can purchase test strips online from the Supertaster Test website. They come in packages of two, cost $4.95, and the shipping and handling was only an extra $2 for California. They ship internationally and come with a money-back guarantee.”

Are you a supertaster: DNA testing
You can also have your DNA tested to see if you have the gene for bitter taste. As explained in the post on The genetics of supertasting, however, this may not be all that accurate. “It’s not clear that do-it-yourself genetic testing is worth the price. If you’re concerned about disease, you’d probably be better off with a healthy diet, not smoking, and moderate exercise.” (Since I wrote this post in April of 2009, the FDA has decided to look into new rules on direct-to-consumer genetic testing.)

Why do we love high-fat foods?
Fats can make any food taste better, and it’s in our interest — genetically — to prefer foods that the body needs. Unfortunately, a typical restaurant meal can have more than eight tablespoons of fat — more than an entire stick of butter. That’s way more than we need in one sitting. (The recommended daily allowance for fat is four and a half tablespoons.)

Do we taste fat?
The flavors that make good food taste delicious are dissolved in fat. Scientists used to think that when we ate fat, we tasted these dissolved flavors and that fat itself was tasteless. We now know that’s not quite true. But the efforts involved in isolating the “taste” of fat are considerable. … “Do we ‘taste’ fat? It’s complicated. Every so often you see headlines like ‘Taste bud for fatty foods found’ or ‘Tongue sensors seem to taste fat.’ I’m not yet convinced we ‘taste’ fat in the same way we experience the taste of sugar, salt, sour, and bitter.”

The taste advantage
Are there health implications to being a supertaster as opposed to a medium or non-taster? The different groups have different preferences for and aversions to fruits, vegetables, sugar, and fats, all of which have implications for the impact of diet on health and weight gain. ”If you go through life as a nontaster, it takes more to get the flavor out of food than it does for a supertaster.” (Since this post was written (April 2009) there is new research that refutes the popular belief that fruits and vegetables protect against cancer. See Study further erodes evidence for eating fruits and vegetables to prevent cancer.)

“Killer” grapefruit?
Grapefruit is a particularly bitter taste – something supertasters are unlikely to indulge in. This post and the next concern the story of a woman who had been on a grapefruit diet – and taken a long car ride – just before experiencing deep vein thrombosis (DVT). … “How did the media handle this story? It was all about the grapefruit, something anyone might innocently eat — and then promptly die. Or at least lose a leg to gangrene. I suppose, to give the media the benefit of the doubt, they probably saw this as a ‘teachable moment.’ Unfortunately, outright fear of ‘killer grapefruit’ was the wrong lesson.”

Grapefruit and the Pill
How the press scared readers with headlines like “Hunt for DVT Cause Reveals Link to Grapefruit.” Wouldn’t you read a story that claims grapefruit causes deadly blood clots? The case was much more complicated than the grapefruit diet. It included birth control pills, a long car trip, and a pre-existing condition. “As several of the better stories pointed out, it’s unwise to do anything in extreme. When part of a balanced diet, grapefruit should not be dangerous. Given increasing evidence of the potency of the grapefruit flavonoid naringin, medical science may want to consider whether women on birth control pills should avoid eating grapefruit every day.”

This is your brain on sugar — and sugar substitutes
There’s no question that artificial sweeteners have fewer calories than sugar, but does using a sugar substitute lower the total number of calories we consume? Research indicates we might actually eat more. “If you eat a pound of chocolate, you’re done with it. At least for most people, your brain says, ‘That’s enough.’ This is hypothetical and needs to be tested, but maybe the sucralose sets the sweet taste response in motion but it might not turn the brain response off.”

The Pepsi challenge: How beliefs affect what you taste
Taste — essential to our survival — is complex. It’s influenced by our past experiences, the associations we make with specific foods, advertising, brand loyalties, cultural and ethnic preferences, and price. If we think of it as totally objective, determined exclusively by our taste buds, we’re underestimating it. This post describes studies that show food preferences are determined more by marketing promotions than by actual taste.

Resources:

Image source: Natural Home
Additional photo credits listed at each post.

Contemplating death

Death is a huge uncertainty in anyone’s life. A friend once told me of a woman with leukemia who said “At least now I know what I’m going to die from.” For some, this knowledge brings relief.

What I find fascinating about the shared experiences of those with a limited time to live is the uniqueness of each response. What I find valuable is the opportunity to contemplate my own life and death.

Here is Judt’s answer to a question on his thoughts on dying and any insights into living.

I’m better on living than I am on dying because, until you die, you know nothing about it, but by then it’s too late. But I can tell you a little bit about the peculiarity of knowing you’re going to die and knowing when – roughly speaking.

Most of us, most of the time, have absolutely no idea where we’ll be in five years – you, me, anyone — anything could happen to a normal person. But we’re pretty clear where we’ll be next month: doing the same thing we’re doing this month.

My situation is exactly the reverse. I have no idea where I’ll be next month. I could be silent. I could be dead. I could be exactly like this. I could be in a variety of stages. But I know, absolutely with certainty – within reason – that I’ll be dead in five years. And that reversal of consciousness means that I am very focused upon life in the next two weeks.

And that, for me, is rather like when you’re in school. There’s an exam coming up, but you don’t want to think about it. You know perfectly well it’s going to happen. There’s nothing you can do to avoid it. Therefore it’s not a very interesting subject. It’s one best left aside.

Life after death

I have thought a lot about life after death. Now, this sounds strange because I’ve never believed in God. I grew up in a sort of world of declining religion. My parents were secular Jews. I went to Anglican schools, but most of the kids never went to church and so on. My sense of God was always very abstract. That hasn’t changed.

I have no idea whether there is a life after death for me, but I am absolutely sure that there is a life after death for the me living in this world. It will continue in the memory of people. The things I did. The things I failed to do and so on. In that sense, I am morally responsible for behaving now in ways that give my life after death some meaning or use value beyond simple memory. …

But as for living, I guess my view on that is that I’m now very clear that living can be reduced to the business of communication. I can’t move. I can’t travel. I can’t act in any autonomous way. But I can communicate with people, and they can communicate with me. As long as that is a possibility, one is alive. One has relationships which define one’s place in the world. And so, when I will be unable to communicate, when I cease to be able to talk, I think that’s when I’ll be ready to die. Because at that point life — in a quite literal sense — will not be worth living.

In the next-to-last essay Judt published in The New York Review – called “Words” – Judt wrote of his declining ability to speak.

In the grip of a neurological disorder, I am fast losing control of words even as my relationship with the world has been reduced to them. They still form with impeccable discipline and unreduced range in the silence of my thoughts—the view from inside is as rich as ever—but I can no longer convey them with ease. Vowel sounds and sibilant consonants slide out of my mouth, shapeless and inchoate even to my close collaborator. The vocal muscle, for sixty years my reliable alter ego, is failing. Communication, performance, assertion: these are now my weakest assets. Translating being into thought, thought into words, and words into communication will soon be beyond me and I shall be confined to the rhetorical landscape of my interior reflections.

Amyotrophic lateral sclerosis (ALS)

Judt describes his experience of the onset on ALS. He was diagnosed in September of 2008, almost two years before his death.

One of the odd characteristics of ALS, Lou Gehrig’s disease, is that it begins so slowly that it’s almost unremarked. Your left finger — your left index finger – presses the wrong keys on the keyboard. Or you find that turning a corkscrew is a litter harder than it used to be. Then progressively you notice that walking uphill is a bit more tiring than you thought. Then you go telling yourself, well, I can’t be 45 forever. I’m 60. These things happen.

But then it gets more and more. You go to your doctor. He looks very worried and says “You’d best see a neurologist.” And you see a neurologist who tells you that the good news is that you don’t have multiple sclerosis or Parkinson’s disease, but that you may have ALS.

You go home, and you look it up. Like most people, I knew about Lou Gehrig, but very little else. It turns out that ALS – Amyotrophic Lateral Sclerosis – is a disease about which almost nothing is known. It was identified by a French neurologist, Charcot, about 135 years ago, and ever since then all we’ve done is learn more about how it works, but very little about what to do about it.

This next comment is something Judt has said repeatedly in interviews and in his writing since being diagnosed.

I think I was very fortunate. If you are someone who works with your hands – a painter, a plumber, a bus driver – there is nothing you can do but to retire, to sit at home – or in a home – and you’d do nothing. Because I’m a writer — and a teacher — I was able to continue for two years after the initial diagnosis. And that, actually, is what kept me going – the fact that I could continue. I could dictate. I could think. I could – so to speak – write. Therefore, I could even teach for a while. That’s what kept me going.

Related posts:
I am saddened by the death of Tony Judt
Tony Judt — continued
A generation obsessed with material wealth
Tony Judt and the Move for ALS bike ride
Tony Judt: On the edge of a terrifying world
This mess we’re in – Part 3

Resources:

Image source: Charlie Rose

Tony Judy, Charlie Rose, August 23, 2010

The medical reasons:

As kids approach puberty, scientists now know, there is a two-hour shift in when their bodies release melatonin, the hormone that causes sleepiness. As a result, teens and preteens find it impossible to fall asleep until about 11 p.m., even if they try to go to bed earlier. Yet teenagers still need an average of 9.25 hours of slumber each night.

On top of the shift in natural sleeping and waking times, … there is also a delay in when a severe dip in alertness occurs during the early morning hours. In adults, this low point hits between 3 a.m. and 5 a.m.; in adolescents, it falls between about 5 a.m. and 7 a.m. That means that, while their alarm clocks are telling teens to get out of bed and demanding that their brains perform, their bodies are screaming at them to keep sleeping.

The melatonin shift may happen as early as age 10 or 11.

Here are the health issues of early start times:

Overtired kids, studies suggest, struggle with depression. … In addition to the mood, behavior and learning issues, scientists are starting to uncover more subtle ways that such chronic sleep loss can hurt kids. Some studies, for example, show that sleep deprivation compromises the immune system. Others suggest that, with too little sleep, the body releases higher levels of hormones that induce hunger, possibly contributing to growing rates of obesity.

Tired teens may also be more vulnerable to falling asleep at the wheel. … To stay awake, young people often turn to coffee, soda, energy drinks and other caffeinated beverages.

One objection to later school start times is that teens will just stay up later. Here’s what one study found:

Sleep seems to beget sleep, the study suggested. Even though the new schedule started just 30 minutes later, students actually went to bed 15 minutes earlier and got 45 more minutes of sleep each day. When interviewed, kids said they felt so much better from even a little bit of extra sleep that they were motivated to go to bed sooner and sleep even more. Owens suspects that the extra sleep also helped them get their homework done more efficiently, affording them extra time in the evening to wind down and get to bed.

This information is not new. Recent studies continue to confirm what has been learned about teens and sleep. The subject was discussed over a year ago the the Journal of the American Medical Association. Pediatricians should be aware of this.

School boards are conservative by nature and reluctant to make changes. If parents educate themselves on the facts, however, they may be able to exert their influence locally and benefit their own children.

One expert on sleep research comments in this article: “The brain is probably going through as rapid development during the adolescent years as it does during the first year of life” and adds “sleep is brain food.” It’s not uncommon for infants to sleep 16 hours day.

Related posts:
High school students should sleep in
The “lie down and die” model of sleep

Resources:

Image source: TIme

Emily Sohn, Later school start times and Zzzs to A’s, The Los Angeles Times, August 23, 2010

Easing the pain of death was a common medical practice in the 19th century. The doctor’s black bag contained laudanum as early as the 1600s. The 19th century added morphine (1806), codeine (1836), and aspirin (1892), along with the anesthetics chloroform and ether. At a time when physicians had very little to offer patients by way of cures – other than the ineffective “heroic” measures of bloodletting and purges — it was palliative care that made physicians welcome at the deathbed.

In those days, easing pain at the time of death was not called palliative care, but euthanasia. The term referred to the outward death of the body, in contrast to the death of the spirit. Euthanasia literally means a good death.

In 1870 a school teacher named Samuel Williams published an essay that used the term euthanasia to mean something else: mercy killing. The essay generated considerable interest and discussion. To make a long story short, the original meaning of the term euthanasia was completely lost.

Between those late 19th century discussions of euthanasia as mercy killing and 1975, when Balfour Mount introduced the term palliative care, there was no name for supportive care of the dying. Without a name, there could be no specialists in the subject, no professors to teach it, no training for physicians. There was little discussion of the subject in medical schools. Without a name, the subject could not be indexed and researched in medical literature. There could be no advances in knowledge or improvement in techniques.

The power of language

What we now call palliative care had greatly enhanced the reputation of the medical profession in the late 19th century. How could the original meaning of “euthanasia” be so easily displaced?

In an essay on the subject, Ezekiel Emanuel suggests that it happened at a particular moment in the development of capitalism — a time of economic panics and stock market crashes, raw individualism, economic competition, and appeals to the Darwinian concept of survival of the fittest. Euthanasia of the elderly, who were no longer productive members of society, was simply part of the universal struggle of the strong over the weak.

This incident illustrates the power of language. If you control the vocabulary – so important today in discussions of morally tinged political issues (death panels, right to life) — you can prevail.

Related links:
Atul Gawande: Modern death and dying
Olbermann on the damage done by “death panels”
Daily Dose: Palliative sedation
Were “death panels” a teachable moment for palliative care?
Death be not visible

Resources:

Image source: The Royal Holloway Victorian MA Blog

Robert B. Baker and Laurence B. McCullough, Medical Ethics through the Life Cycle in Europe and the Americas, The Cambridge World History of Medical Ethics, 2008

Ezekiel J. Emanuel, The History of Euthanasia Debates in the United State and Britain, Annals of Internal Medicine, November 15, 1994, Vol. 121 no. 10 pp 793-802.

There are questions on the writings of Atul Gawande, physicians who tell-all about their patients on their blogs, and how the practice of medical care has come to seem more like shift-work than the venerable profession it once was. Here’s an excerpt from that last topic.

In 20th century America, business and industry became bureaucratized and were subjected to outside control. The medical profession held out against this change for a very long time. It argued that the doctor/patient relationship was special and unique among professions and should be under the control of doctors and patients, not outside bureaucracies.

The medical profession may have also been concerned about loss of prestige and income, but the sanctity of the doctor/patient relationship was central to resisting external control. This more or less committed the practice of medicine to the model of the solo practitioner.

That model didn’t survive 20th century advances in medical knowledge and technology. The lone practitioner was overwhelmed with information. I was just reading something from a 1910 JAMA on the plight of the physician: “For the overworked physician to steal an hour for the perusal of Carlyle or Coleridge when he ought to be ‘reading up’ an obscure case seems a sort of professional suicide.” And that was only 1910!

As medicine had increasingly more to offer, the demand for medical care increased. Ultimately the solo practitioner model was unable to meet the health care needs of the nation.

Bureaucratized shift-work is not good for doctors and it’s not good for patients. I don’t know what the solution will be. Primary care doctors are asking to be paid by the hour, not for piece work. That might help. The wealthy can afford concierge doctors. Maybe something will come out of the medical home concept. If doctors and patients get unhappy enough, perhaps a creative solution will evolve.

Related posts:
Blogging: Time to get over it
The doctor/patient relationship: What have we lost?
The physician as humanist
Are some diseases more prestigious than others?
Are women doctors safer?

Resources:

Photo source: The Renaissance Chick

Jan Henderson, PhD – Medical Historian and Blogger (Part 2 of 3), Inside Surgery, August 18, 2010

This was not without consequences.

• Americans became increasingly preoccupied with diet, exercise, and health habits.

• There was a big uptick in the use of alternative “medicine” and stress reduction practices – acupuncture, chiropractic, herbalism, naturopathy, nutritional therapies, yoga, massage, biofeedback.

• The increase in news and advice columns on health and wellness made people more anxious about their health.

• The public sought medical care much more frequently for symptoms that would have been considered insignificant in the past.

Was “healthy lifestyles” a medical idea?

Health awareness and anxiety are nothing new. Throughout history people have been concerned about threats to their health. Bubonic plague killed 200 million people. The death rate for women who gave birth in the 19th century was 400 per 100,000 births, compared to 10 per 100,000 today.

Before the last century, physicians had very little to offer patients that would cure or prevent disease. This left the field wide open for quacks and charlatans, who could prey on health anxieties to sell their wares. By the late 20th century, however, modern medicine had a great deal to offer. Plus, it had won the confidence of the public – something medicine lacked in the days when the only “cure” was bloodletting or purging (the use of ultra-strong laxatives).

It seems reasonable to ask, then, if the emphasis on healthy lifestyles in the 1970s originated with the medical profession. Americans were living longer and suffering from the diseases of old age (cancer, heart disease, arthritis). Epidemiological research – observing the health and habits of citizens in various countries or ethnic groups – identified associations between lifestyles and diseases (eat yogurt and live to be 100, like the citizens of Georgia; eat soy products and avoid breast cancer, like the Japanese). One can easily imagine that the idea of telling people to be responsible for their health habits came from the medical profession.

But no, it did not.

The dark side of medicine

The emphasis on healthy lifestyles, although salutary in many ways, has a very dark side to it and has led to the increasing peril of a tyranny of health in the United States.

The quotation is from Dr. Faith Fitzgerald, writing in The New England Journal of Medicine in 1994. This was followed in 2000 by Dr. Michael Fitzpatrick’s book, The Tyranny of Health: Doctors and the Regulation of Lifestyle. There was also this statement from O. H. Forde of the Institute of Community Medicine in Tromso, Norway:

The moral and coercive crusade for increased risk awareness and purity in life style can too readily take on the form of cultural imperialism towards conformity. Epidemiologists and the health care movement in general have a mandate to fight disease and premature death: they have no explicit mandate to change culture.

Dr. Fitzgerald’s article in the NEJM addressed the down side – or, as she calls it, the “dark side” – of a medical climate that holds individuals responsible for their health. Such a climate assumes that those who are unhealthy have committed a crime against society. After all, society must pay their health care costs, whether it’s through Medicare and Medicaid, lost time from work, or treatment centers for substance abuse.

Society in turn will expect physicians to educate their patients, to eliminate their unhealthy behaviors, and somehow to coerce them into adopting healthy habits. A “tyranny of health” is bad for both patients and physicians.

What penalty should we impose on the irresponsible?

The push for healthy lifestyles came not from the medical profession, but from political, economic, and social forces of the 1970s and 1980s. It was presented to the public as the need to take “personal responsibility” for one’s health.

The shift in health responsibility from the state to the individual – known as “healthism” — was very successful. Medical journals today – as well as health advice columns — write about the importance of the individual’s behavior in preventing disease.

A recent commentary in the Journal of the American Medical Association asks: If individuals don’t use preventive services, “what kind of penalty … would be ethically and morally acceptable?” The question wasn’t “How do we account for unhealthy behavior,” but what punishment would be sufficient either to change that behavior or at least to save money by denying these people health care.

When “personal responsibility” is endorsed by the authority of the medical profession, we no longer see that healthism is a political position, not simply a medical opinion. And because we don’t see this, it doesn’t occur to us that our attitude towards our own health could have taken a different path, and perhaps it still should.

Related links:
Blogging: Time to get over it
Health insurance industry to consumers: You’re financially responsible for your behavior
Sanjay Gupta a victim of obesity myths?
My personal odyssey through the health culture
The Health Culture: Yesterday. Today. Tomorrow.
“I” Is for Innocent: Health obsession in fiction
The last well person

Resources:

Image source: Under the ash tree

Faith T. Fitzgerald, M.D., The Tyranny of Health, The New England Journal of Medicine, July 21 1994, vol 331, pp 1960198 (subscription required)

Michael Fitzpatrick, The Tyranny of Health: Doctors and the Regulation of Lifestyle

O. H. Forde, Is imposing risk awareness cultural imperialism? : The ethics of epidemiology, Social Science & Medicine, 1998, vol 47 no. 9 pp. 1155-1159 (abstract only)

Robert H. Brook, Rights and Responsibilities in Health Care – Striking a Balance, The Journal of the American Medical Society, June 9, 2010, vol 303 no 22 pp 2289-2290 (subscription required)

The interview is quite long and will be posted in three parts. Here’s an excerpt from Part 1, where Dr. Marcucci asks about the mission of my blog.

I started blogging because I wanted to understand something that changed medicine and ideas about health in the 1970s. Prior to that time, the policies of the Kennedy and Johnson administrations had assumed the state should be responsible for the health of its citizens. When political and economic thinking became more conservative in the 1970s and 1980s, governments began to promote the idea that individuals were personally responsible for their health and should practice healthy lifestyles.

A large segment of the population – mainly the educated and economically secure – welcomed these ideas. Feeling personally responsible for one’s health and practicing healthy lifestyles gives one the reassuring illusion of control. In particular, it’s a good distraction from the things that are beyond individual control, like salmonella in our peanut butter and the superbug MRSA at the gym.

I was caught up in the healthy lifestyles attitude myself. When I look back, I could kick myself for not recognizing what was going on. Public opinion could have been rallied to support those health issues that need government backing – workplace safety, a healthy environment, an equitable distribution of access to affordable health care. But politics took a different path and the public went jogging.

I have nothing against healthy behavior and the concept of prevention. What bothers me is misleading the public for political purposes. Aside from smoking, the evidence for changing behavior is slim – either it doesn’t last (obesity) or, in some cases, it turns out to be wrong (all fats are unhealthy, fruits and vegetables prevent cancer, HRT).

I guess my mission is to be alert and not get fooled again. By writing about what’s currently happening in health and medicine, I’m collecting pieces of a puzzle. It’s always hard to see the big picture in the moment, but eventually the pieces add up. Also, while history never repeats itself exactly, looking back at the history of medicine provides clues to the present.

The self-conscious blogger: Get over it

Ah, yes. I definitely want to write more about this. The shift from government/state responsibility for health to personal responsibility is called healthism. The social critic Robert Crawford wrote an excellent article on the subject in 1980: “Healthism and the medicalization of everyday life.” He had written about this even earlier (1977) in “You are dangerous to your health: the ideology and politics of victim blaming.”

Truth is, I struggle with blogging, probably due to my academic background. I don’t want to discuss a subject like healthism before I’ve done enough research. And definitive research never seems to end. Blogging is a different animal. After almost two years, you’d think I’d be ready to embrace that. Guess I need to take Justice Antonin Scalia’s advice and “Get over it.”

Related posts:
Health insurance industry to consumers: You’re financially responsible for your behavior
Sanjay Gupta a victim of obesity myths?
My personal odyssey through the health culture
The Health Culture: Yesterday. Today. Tomorrow.

Resources:

Image source: the frugal law student

Jan Henderson, PhD – Medical Historian and Blogger (Part 1 of 3), Inside Surgery, August 16, 2010

Here’s a long article — by a law professor — that discusses the dangers of oversharing and the “behavioral economics of privacy” — the trade-offs we make, consciously or unconsciously, when we decide to reveal or conceal information.

[A] challenge that, in big and small ways, is confronting millions of people around the globe: how best to live our lives in a world where the Internet records everything and forgets nothing — where every online photo, status update, Twitter post and blog entry by and about us can be stored forever. …

[T]here was the 16-year-old British girl who was fired from her office job for complaining on Facebook, “I’m so totally bored!!”; there was the 66-year-old Canadian psychotherapist who tried to enter the United States but was turned away at the border — and barred permanently from visiting the country — after a border guard’s Internet search found that the therapist had written an article in a philosophy journal describing his experiments 30 years ago with L.S.D. …

The fact that the Internet never seems to forget is threatening, at an almost existential level, our ability to control our identities; to preserve the option of reinventing ourselves and starting anew; to overcome our checkered pasts.

A collective identity crisis

People change. Not just from youthful indiscretion to mature adult, but – ideally – people continue to discover and pursue new interests throughout a lifetime.

“[By] erasing external memories [photos, letters], our society accepts that human beings evolve over time, that we have the capacity to learn from past experiences and adjust our behavior.” In traditional societies, where missteps are observed but not necessarily recorded, the limits of human memory ensure that people’s sins are eventually forgotten. By contrast, … a society in which everything is recorded “will forever tether us to all our past actions, making it impossible, in practice, to escape them.” …

It’s often said that we live in a permissive era, one with infinite second chances. But the truth is that for a great many people, the permanent memory bank of the Web increasingly means there are no second chances — no opportunities to escape a scarlet letter in your digital past. Now the worst thing you’ve done is often the first thing everyone knows about you. All this has created something of a collective identity crisis.

A humane society values privacy

The article briefly mentions how identity – our sense of self – has changed over historical time. Identity used to be defined by the social circumstances of our birth – who our parents were, our social class. A sense of individuality developed only in the late Middle Ages and Renaissance. What we now think of as identity became more fluid, and we came to believe it was something we could control. (For an example of identity fluidity, see this article on the influence of Lady Gaga.)

[T]he Web was supposed to be the second flowering of the open frontier, and the ability to segment our identities with an endless supply of pseudonyms, avatars and categories of friendship was supposed to let people present different sides of their personalities in different contexts. What seemed within our grasp was a power that only Proteus possessed: namely, perfect control over our shifting identities.

But the hope that we could carefully control how others view us in different contexts has proved to be another myth. As social-networking sites expanded, it was no longer quite so easy to have segmented identities: now that so many people use a single platform to post constant status updates and photos about their private and public activities, the idea of a home self, a work self, a family self and a high-school-friends self has become increasingly untenable. In fact, the attempt to maintain different selves often arouses suspicion. Moreover, far from giving us a new sense of control over the face we present to the world, the Internet is shackling us to everything that we have ever said, or that anyone has said about us, making the possibility of digital self-reinvention seem like an ideal from a distant era.

Some argue that social networking, and the web in general, encourages us to merge our identities – to no longer have separate selves for home, office, leisure, and friends. As the author points out, however, “a humane society values privacy, because it allows people to cultivate different aspects of their personalities in different contexts.”

We don’t feel and act the same in all situations. Learning to recognize the people and circumstances that make us feel good or bad about who we are is how we create the life we want.

Related posts:
Is the Internet bad for your health?
Is it a stroke? Diagnosing by email

Resources:

Image source: SFGate

Jeffrey Rosen, The Web Means the End of Forgetting, The New York Times, July 21, 2010