Obesity patients are not victims

by David Gratzer, MD

Call it the McVictim syndrome. Too many pundits, public health experts and politicians are working overtime to find scapegoats for America’s obesity epidemic.

In his latest book, former FDA Commissioner David A. Kessler argues that modern food is addictive. In it, he recounts how he was once helpless to stop himself from eating a cookie. In a paper in this month’s Journal of Health Economics, University of Illinois researchers join a long list of analysts who blame urban sprawl for obesity. In November, former Carter administration advisor Amitai Etzioni argued that it’s so hard for Americans to keep weight off that adults should simply give up and focus attention on the young instead.

The peak of the trend: A recently released Ohio study, using mice, suggests “fine-particulate air pollution” could be causing a rise in obesity rates.

How long before we’re told that the devil made us eat it?

The McVictim syndrome spins a convenient — and unhealthy — narrative on America’s emerging preventable disease crisis. McVictimization teaches Americans to think that obesity is someone else’s fault — and therefore, someone else’s problem to solve.

The truth: In the vast majority of cases, obesity is a preventable condition. So those of us in the medical community must be candid with overweight patients about the risks they face and the rewards of better health choices. But it’s also time for American policymakers to show the same level of candor.

All things being equal, the simplest explanation is often the right one. And the simplest explanation for the dramatic rise in obesity rates — roughly doubling as a percentage of the total population in just a quarter-century — is the surge in our daily caloric intake. Excess food now, excess weight later. And Americans won’t make better choices if the McVictim syndrome provides a convenient excuse to carry on as before.

Obesity is preventable, but its consequences seem difficult to avoid. Consider that the cost of treating resulting conditions such as diabetes is about 7% of all U.S. healthcare spending — and a significant drain on federal and state budgets. Obesity is a national security threat because it severely limits the pool of military recruits; in 2009, the Pentagon indicated that since 2005, 48,000 potential troops had flunked their basic physical exams because they weighed too much. Most important, obesity is a human threat, destroying otherwise healthy lives and increasing personal health costs, all for the sake of a few daily moments of instant gratification.

For these reasons, there is a role for government to play in attacking obesity. Public policy can help. School lunch programs shouldn’t push our children toward obesity at taxpayers’ expense. We should stop subsidizing agribusinesses; many are using taxpayer dollars to produce and market unhealthful foods. We should promote insurance reforms that support preventive medicine.

But we must also launch a direct attack on the philosophy behind the McVictim syndrome. Policymakers must accept the fact that a poor diet is almost always a poor personal choice.

Yes, it’s fair to say that many Americans try to choose better — and fail because they’ve chosen quack drugs or crash diets as the solution. Yes, it’s fair to say that losing weight solely for appearance’s sake isn’t a healthful choice. Yes, it’s fair to say we shouldn’t crush the self-esteem of those who’ve tried, and failed, to keep off excess weight. In other words, our society makes healthful choices tougher.

But even so, encouraging Americans to cut their dietary health risks is a responsible act of citizenship. And it’s absurd to pretend that Americans are helpless to make that choice — or that it’s too late for them to reap the benefits. Contrary to claims like Etzioni’s, even a modest, voluntary improvement in the average American diet could pay huge dividends.

Just as a little more weight causes more damage over time (to joints, to cardiovascular systems, to organs), a little less weight can produce dramatic health benefits. To take one example, a study cited in the Journal of the American College of Cardiology found that obese patients on a program of mild weight loss and modest exercise cut their odds of getting diabetes by as much as 60%. Imagine the benefits that would flow from keeping millions of future Medicare recipients from ever needing an insulin prescription.

The McVictim syndrome is far too prevalent, which promotes the notion that regulations and laws are the primary solution to the problem. But governments can’t micromanage your waistline for you. Even if governments could magically walk you to work, ban food advertising, regulate sugar out of food and suck those fat particles out of the air, in a free society you would still have the power to drive to the nearest restaurant, shake your salt shaker and order a second piece of pie.

That’s why understanding — and rejecting — the McVictim culture is crucial to obesity reduction policy. And the first step in that process is to reject the temptation to find an easy scapegoat.

David Gratzer is a physician and senior fellow at the Manhattan Institute. He is author of The Cure: How Capitalism Can Save American Health Care.

Cholera in Haiti Outbreak

Cholera in Haiti
Cholera in Haiti - news.nationalpost image

An epidemic cholera strain has been confirmed in Haiti, causing the first cholera outbreak in Haiti in many years. Cholera is a potentially fatal bacterial infection that causes severe diarrhea and dehydration.

The disease is most often spread through the ingestion of contaminated food or drinking water. Water may be contaminated by the feces of an infected person or by untreated sewage. Food is often contaminated by water containing cholera bacteria or because it was handled by a person ill with cholera.

The majority of cases have been reported in the Artibonite Departmente, approximately 50 miles north of Port-au-Prince. Affected hospitals are being strained by the large number of people who are ill.

This outbreak is of particular concern given the current conditions in Haiti, including poor water and sanitation, a strained public health infrastructure, and large numbers of people displaced by the January earthquake and more recent flooding.

The World Health Organization, along with a number of international agencies, is mobilizing to assist local and national response efforts.

Advice for Travelers

At this time, CDC and the U.S. Department of State maintain travel warnings for Haiti. These warnings recommend that U.S. citizens avoid all nonessential travel to Haiti. For more information, see Travel Health Warning: Major Earthquake in Port-au-Prince, Haiti on the CDC website.

Most travelers are not at high risk for getting cholera, but people who are traveling to Haiti should still take their own supplies to help prevent the disease and to treat it. Items to pack include

  • A prescription antibiotic to take in case of travelers’ diarrhea
  • Water purification tablets*
  • Oral rehydration salts*

*In the United States, these products can be purchased at stores that sell equipment for camping or other outdoor activities.

Although no cholera vaccine is available in the United States, travelers can prevent cholera by following these 5 basic steps:

1) Drink and use safe water*

  • Bottled water with unbroken seals and canned/bottled carbonated beverages are safe to drink and use.
  • Use safe water to brush your teeth, wash and prepare food, and make ice.
  • Clean food preparation areas and kitchenware with soap and safe water and let dry completely before reuse.

*Piped water sources, drinks sold in cups or bags, or ice may not be safe. All drinking water and water used to make ice should be boiled or treated with chlorine.

To be sure water is safe to drink and use:

  • Boil it or treat it with water purification tablets, a chlorine product or household bleach.
  • Bring your water to a complete boil for at least 1 minute.
  • To treat your water, use water purification tablets, if you brought some with you from the United States, or one of the locally available treatment products, and follow the instructions.
  • If a chlorine treatment product is not available, you can treat your water with household bleach. Add 8 drops of household bleach for every 1 gallon of water (or 2 drops of household bleach for every 1 liter of water) and wait 30 minutes before drinking
  • Always store your treated water in a clean, covered container.

2) Wash your hands often with soap and safe water*

  • Before you eat or prepare food
  • Before feeding your children
  • After using the latrine or toilet
  • After cleaning your child’s bottom
  • After taking care of someone ill with diarrhea

* If no soap is available, scrub hands often with ash or sand and rinse with safe water.

3) Use latrines or bury your feces (poop); do not defecate in any body of water

  • Use latrines or other sanitation systems, like chemical toilets, to dispose of feces.
  • Wash hands with soap and safe water after using toilets or latrines.
  • Clean latrines and surfaces contaminated with feces using a solution of 1 part household bleach to 9 parts water.

What if I don’t have a latrine or chemical toilet?

  • Defecate at least 30 meters away from any body of water and then bury your feces.
  • Dispose of plastic bags containing feces in latrines, at collection points if available, or bury it in the ground. Do not put plastic bags in chemical toilets.
  • Dig new latrines or temporary pit toilets at least a half-meter deep and at least 30 meters away from any body of water.

4) Cook food well (especially seafood), keep it covered, eat it hot, and peel fruits and vegetables*

  • Boil it, cook it, peel it, or leave it
  • Be sure to cook shellfish (like crabs and crayfish) until they are very hot all the way through.
  • Do not bring perishable seafood back to the United States.

* Avoid raw foods other than fruits and vegetables you have peeled yourself.

5) Clean up safely—in the kitchen and in places where the family bathes and washes clothes

  • Wash yourself, your children, diapers, and clothes at least 30 meters away from drinking water sources.

Before departing for Haiti, talk to your doctor about getting a prescription for an antibiotic to treat travelers’ diarrhea. If you are traveling in Haiti and have severe watery diarrhea, seek medical care right away. Remember to drink fluids and use oral rehydration salts (ORS) to prevent dehydration.

Medical care facilities are strained with the high number of people who are ill. If you will be traveling to Haiti, CDC recommends that you purchase medical evacuation insurance in the event that you become ill while in Haiti. (See the U.S. Department of State list of U.S.-Based Air Ambulance or Medical Evacuation Companies.) If you are in Haiti and need medical care and you do not have access to medical evacuation, you can contact the Embassy of the United States in Port-au-Prince, Haiti, (American Citizens Services Unit office hours are 7:00 a.m. to 3:30 p.m., Monday through Friday. The Consular Section is closed on U.S. and local holidays.):

Boulevard du 15 October, Tabarre 41, Tabarre, Haiti
Telephone: (509) (2) 229-8000
Facsimile: (509) (2) 229-8027
Email: [email protected]

Advice about Cholera for Travelers Arriving in the U.S. from Haiti

Five Basic Cholera Prevention Messages

Info for Healthcare Professionals

Acute Watery Diarrhea & Cholera: Pre-decision Brief

Cholera Outbreak in Haiti

General Cholera Info

Haiti Earthquake and Travel

Facial exercises that firm the muscles in your chin and face

I don’t usually write about vanity issues, but I have to make an exception in this case, because it works. I have practiced a similar routine since I first noticed my “Adam’s Apple” starting to disappear when I was in my late thirties.


Tinnitus (ringing in the ears) highlights poor doctor patient communication

by Martin Young, MBChB, FCS(SA)

I’m both interested in and disturbed by what some doctors have said to patients at the first consultation for Tinnitus, an annoying perception of sound that comes from somewhere within their heads.  Not many of these patients are referred to me – most come of their own accord for a second opinion.  What they tell me their doctor said is a lesson in how not to communicate with patients, and I think worth repeating here.

The most common doctor diagnosis, treatment and reassurance is a curt, “You’ve got Tinnitus, and there’s nothing you or we can do.  Learn to live with it.”

Few patients can be more anxious.  For most, Tinnitus is a minor annoyance, no cause for concern, not due to any serious illness, and simple reassurance is all that is needed.  The unfortunate other end of the scale is the Tinnitus sufferer tormented by the incessant buzzing in his or her head, and whose life becomes consumed by efforts to escape the distraction.  Helping these patients is a real challenge, some driven as far as suicide.

At first glance certainly the first and last parts of the doctor’s statement are true. The middle is a common and mistaken assumption by many doctors, perhaps a bit of medical ignorance, but hardly negligent.  Or is it?  Overall, I’m disturbed by the callousness of this dismissal, for the following reasons.

Tinnitus is a symptom, not a disease.  The original statement is analogous to saying “You’ve got a backache.” Putting only a name to a symptom is a start, but not very helpful in the long term.

The possibility that Tinnitus is due to a disease process is ignored.  Tinnitus may be pulsatile or continuous.  If in time with a patient’s heartbeat, (i.e. pulsatile), there is a reasonable possibility of some disturbance in vascular flow in the neck, skull or brain, varying from as minor a problem as a small and insignificant kink in the normal internal carotid artery due to minor arteriosclerosis, to major challenges like vascular tumors filling large areas of the head and brain. Pulsatile Tinnitus should be investigated, by careful clinical examination and usually an MRI angiogram.

Continuous Tinnitus is often described as “buzzing, like the sea, or crickets” may be due to an abnormality anywhere in the hearing system.  It can be something as minor as wax in the ear canal.  Or as major as a tumor of the vestibulocochlear nerve – an acoustic neuroma. The commonest cause is going to be a degree of nerve deafness due to common everyday wear and tear.  But a diagnosis still needs to be made.  The statement closes the door on the possibility of diagnosing and removing the cause, and risks missing serious pathology.

“There’s nothing you or we can do.”  I guess what the doctor means is, “There’s no medication shown to reduce Tinnitus,” which at this point in time is generally true.  Intravenous lidocaine has been shown to be effective in the very short term, but is very toxic and impractical in any form for Tinnitus sufferers. There are other medications thought to have some benefit, but results of studies are variable.  Unfortunately for Tinnitus there is no magic bullet. But “we cannot write a prescription” should be very distinct from “there’s nothing you can do.”

There is a lot a doctor can do for a sufferer, given a basic understanding of Tinnitus, and a diagnosis is a good place to start.

First, for idiopathic or sensorineural hearing loss-related Tinnitus, the exclusion of serious pathology is very helpful for the anxious patient – an MRI scan of the brain has a good therapeutic effect in offering reassurance.  In my opinion, the worst sufferers have little chance of overcoming Tinnitus until an MRI scan convinces them there is no tumor inside their heads.  Second, an explanation as to why Tinnitus is there in the first place is essential, i.e. “sound perception due to nerve activity within the brain, which is usually not heard by the conscious brain, but which becomes heard due to other abnormalities” or, in other words, a “raising of sensitivity to natural brain ‘sound’, which is not usually heard.”

The majority of patients are happy with just an explanation, especially when they realize that if they focus attention on the Tinnitus, it will naturally become louder.  Advice to “learn to ignore Tinnitus” is very different to “learn to live with it.”

The latter advice is impossible to follow without a basic understanding of why the Tinnitus is there, and why distraction techniques are so important in learning to ignore it.  The patients have to be given the tools to “learn to live with it” – on its own that advice is as meaningless as is “learn to read” to someone who is illiterate.

Those seriously affected by Tinnitus may find wearing hearing aids or Tinnitus maskers – hearing-aid like fittings that mask the Tinnitus sound with another – very useful.  Some may need antidepressants to deal with the associated comorbidities.

And there are conditioning and behavior modification therapies specifically designed to treat Tinnitus – Tinnitus can and should be cured by, among others, audiologists and other professionals who are specially trained to deal with difficult cases.

The majority of my patients need little more than a history, quick physical examination, a hearing test, an MRI scan in selected cases, and then twenty minutes of detailed explanation and communication.  But omit the explanation, and all the rest is money and effort wasted, with little chance of cure.

I was taught to make my goal in medicine application of the three important principles – to do no harm, sometimes heal, and comfort always.

Saying, “You’ve got Tinnitus, and there’s nothing you or we can do.  Learn to live with it,” is a poor five-second substitute for a thirty-minute communication.

Martin Young is an otolaryngologist and founder and CEO of ConsentCare.

How pharmacists address the healthcare needs of patients today

by Thomas Sullivan

In addition to outlining patient’s medications, and teaching them what times of day to take the drugs that will help control their specific disease, pharmacists are now taking on a new role to address the growing healthcare needs and demands of Americans, according to a recent article in the New York Times.

For example, at Barney’s Pharmacy in Augusta, Ga., the pharmacy offers classes at the store for patients once a month on how to manage diseases with drugs, diet and exercise. This new service, according to the Times, reflects the expanding role of the nation’s pharmacists in ways that may benefit their customers and also represent a new source of revenue for the profession.” In fact, “some health plans are even paying pharmacists to monitor patients taking regular medications for chronic illnesses like diabetes or heart disease.” And these pharmacists don’t just dispense drugs to patients, they also partner with patients to improve their health as well.”

Another role that pharmacists are playing at independent drugstores and some national chains like Walgreens and the Medicine Shoppe and even supermarkets like Kroger, is “by working with doctors and nurses to care for people with long-term illnesses.”

Pharmacists are also “being enlisted by some health insurers and large employers to help address the fact that “as many as half of the nation’s patients do not take their medications as prescribed, which ends up costing nearly $300 billion a year in emergency room visits, hospital stays and other medical expenditures.”

In their unique role, pharmacists also maintain the “front line of detecting prescription overlap or dangerous interaction between drugs and for recommending cheaper options to expensive medicines.

As a result of the numerous responsibilities pharmacists already carry out, pilot programs, such as the one started by Dr. Andrew Halpert, senior medical director for Blue Shield of California, are attempting to show that pharmacists “could do as well and better than a physician” for less money. Specifically, the program seeks to address the shortage of primary care doctors by using the education, expertise, free time and plain-spoken approach pharmacists use to talk to patients at length about what medicines they are taking and to keep close tabs on their well-being as a way.

“Some health insurers and large employers who pay for programs called medication therapy management, which typically involve face-to-face sessions between pharmacists and patients in retail stores or clinics”, have already taken this kind of approach. Programs such as these pay pharmacists to track patients, monitor cholesterol or blood glucose levels, or prod customers to change their diets or exercise.

Since 2006, some “Medicare plans started covering medication therapy management programs, paying $1 to $2 a minute to pharmacists to review patients’ medicines with them, and in 2010, about one in four people covered by Medicare Part D prescription drug plans will be eligible.”

Pharmacists are also advising patients about medication through grants and such as the Wisconsin Pharmacy Quality Collaborative, which standardizes medication therapy management and ensures quality care. Similarly, Humana, which has offered pharmacists medication advising for a few years, is studying a third of 62,000 pharmacies in its network to see “whether a pharmacist seeing a patient in person has more impact than a phone call.”

According to the Times, the result of these new services “has spawned a new industry of medication therapy management companies to run clinical pharmacy programs for health insurers, contracting with pharmacists and tracking the financial and health outcomes of their services.” And results so far have been positive. For example one recent study financed by GlaxoSmithKline, tracked 573 people with diabetes (30 employers in 10 cities) who took part in at least two sessions with pharmacists who helped them track their blood sugar, blood pressure and cholesterol levels and offered diet and exercise advice. The results of the study showed that after a year, blood pressure, blood sugar and cholesterol levels typically improved — and saved an average $593 a person on diabetes drugs and supplies.

While some groups may be concerned about the proper role pharmacists should play, as Michelle A. Chui, an assistant professor at the University of Wisconsin School of Pharmacy pointed out, “pharmacists do not want to compete with doctors, they merely want to provide more information “so the physician has a more in-depth picture.”

Consequently, pharmacists who provide more education and information to share with health care providers and patients should be encouraged because it gives patients a better chance to understand and follow medication directions in a consistent manner. As a result, using education companies, which teaches other pharmacies how to introduce in-store services, should also be encouraged because as the owner of Barney’s Pharmacy noted, when pharmacists “get involved with chronic care patients, their outcomes improve.”

Accordingly, with 31 million more patients entering the health care system through government programs, and with populations getting older and living longer, the number of prescriptions will grow exponentially. Not only will we need companies and funding to create and discover the drugs to provide to this influx of people, we will also need pharmacists to help fill prescriptions.

Allowing our pharmacists to continue their role in educating patients will help ensure that patients follow their medical therapy and management, which will save lives and money