Metabolic syndrome is a play with a cast of millions. It's full of characters we all see daily. We see them in shopping malls, restaurants, bars, city streets, on the job, and nearly everywhere (in Western society). B.R., one of my recent encounters, so typifies this syndrome I had to present his case en-blog, to show the somewhat typical and blissfully ignorant face of this illness/modern distillation.
B.R. is a 46 year old male (not his initials and not exactly his age, but close) with non-insulin dependent diabetes (a blood sugar today of 176), obesity, hypertension, hyperlipidemia, sleep apnea (untreated), gastric reflux and a heaping of denial and ignorance that might now be considered epidemic. In a human play involving this constellation of signs and symptoms (he also doesn’t sleep well and feels exhausted all the time) the drama from my perspective involves a backdrop which shows a sheer lack of insight and offers a rich look into what appears to be going wrong with a large segment of society. He is retired/disabled due to a back injury. We open with the interview:
I ask B.R. an open ended question, “You have high blood pressure?”
He chuckles and replies, “Yeah, that’s what they tell me.” His wife, who is also obese, chuckles in response to his reply.
I continue, “Your blood pressure is 155/95 today. It’s not well controlled”
“Yep . . . I don’t always take my medication,” he admits.
I move on, “You have diabetes as well?”
He chuckles again, “I control it with diet.”
His wife corrects him, “No doctor X gave you medication, don’t you remember?” She looks at me, “He takes it once in the morning and once at night.”
He turns to her, “Do I?”
“Don’t you remember?”
His weight is 284 lbs and he’s 5’10” tall. (BMI of 40.2)
He has shortness of breath with minimal exercise, has what may be developing angina, all of which leads to a fairly sedentary life.
The frustration is: Where do you start with someone like B.R.? Is he a lost cause and do we move on to the next generation or do we all simply plod along with him and wait for the wake-up call; the heart attack the stroke the severe angina the coronary artery stent, the peripheral neuropathy the diabetic foot ulcers and the amputations? Usually by then it’s too late and the connection between the gallon of ice-cream and the below the knee amputation isn’t ever made. As B.R.’s metabolic syndrome worsens due to his increasing central obesity, insulin resistance, hyperlipidemia, and more, the treatment is simply to eat less and exercise more. The treatment isn't a medication or a high-tech procedure, but a simple dietary and lifestyle change. But in B.R.'s case the disease processes are setting in solidly and the diet and lifestyle changes, while desperately needed, will without question require medications and expensive procedures to maintian his life over the next 10 years. And what about the cost?
B.R. is a 46 year old male (not his initials and not exactly his age, but close) with non-insulin dependent diabetes (a blood sugar today of 176), obesity, hypertension, hyperlipidemia, sleep apnea (untreated), gastric reflux and a heaping of denial and ignorance that might now be considered epidemic. In a human play involving this constellation of signs and symptoms (he also doesn’t sleep well and feels exhausted all the time) the drama from my perspective involves a backdrop which shows a sheer lack of insight and offers a rich look into what appears to be going wrong with a large segment of society. He is retired/disabled due to a back injury. We open with the interview:
I ask B.R. an open ended question, “You have high blood pressure?”
He chuckles and replies, “Yeah, that’s what they tell me.” His wife, who is also obese, chuckles in response to his reply.
I continue, “Your blood pressure is 155/95 today. It’s not well controlled”
“Yep . . . I don’t always take my medication,” he admits.
I move on, “You have diabetes as well?”
He chuckles again, “I control it with diet.”
His wife corrects him, “No doctor X gave you medication, don’t you remember?” She looks at me, “He takes it once in the morning and once at night.”
He turns to her, “Do I?”
“Don’t you remember?”
His weight is 284 lbs and he’s 5’10” tall. (BMI of 40.2)
He has shortness of breath with minimal exercise, has what may be developing angina, all of which leads to a fairly sedentary life.
The frustration is: Where do you start with someone like B.R.? Is he a lost cause and do we move on to the next generation or do we all simply plod along with him and wait for the wake-up call; the heart attack the stroke the severe angina the coronary artery stent, the peripheral neuropathy the diabetic foot ulcers and the amputations? Usually by then it’s too late and the connection between the gallon of ice-cream and the below the knee amputation isn’t ever made. As B.R.’s metabolic syndrome worsens due to his increasing central obesity, insulin resistance, hyperlipidemia, and more, the treatment is simply to eat less and exercise more. The treatment isn't a medication or a high-tech procedure, but a simple dietary and lifestyle change. But in B.R.'s case the disease processes are setting in solidly and the diet and lifestyle changes, while desperately needed, will without question require medications and expensive procedures to maintian his life over the next 10 years. And what about the cost?
3 comments:
WG, thanks for sharing this and raising some difficult questions.
I have recently been reviewing some public health guidances (particularly 'prevention' focused) both in the UK and the US and the emphasis on individual responsibility is strikingly similar.
Relatedly: in a discussion last year about the state of public health and the role of individual awareness in it, my sister-in-law, who is a GP in India, said that close to 80% of her time in her clinic was spent educating her patients about the basics of health and hygiene. She has chosen to work in a deprived area as she is from a family with traditionally a great deal of focus and emphasis on 'sewa' (Hindi for 'service' with spiritual, social overtones). She plans to work full-time on a foundation to promote this kind of awareness, when she retires, she jokes.
A story that stuck with me: she said she finds patients who have diarrhoea, usually very often in summers, whose families are not giving them water. The patients are of course dehydrated. The family's logic? "Doctor Saab (a word like Sir/ Madam), whenever he goes, only water comes out. His stomach is full of water. So we stopped giving him any more."
Both WHO and the Indian Govt have spent bundles of money teaching people about ORS for the last 30 years (at least). Clearly it does not work.
How does responsibility survive without awareness? And who is working to plug that gap? If front-line healthcare personnel are supposed to do this, when do they diagnose and treat? Are they incented to teach prevention, or to see patients and get them in and out of the surgery (a British term for a GP's practice)?
Shefaly:
Thanks again for your thoughtful response. The efforts put forth by our public health organizations are dwarfed by the ever-present food marketing machine. Public health guidelines are given minimal play in a society that values individual freedom, including the freedom to eat a box of donuts or a large cheese pizza daily—never mind the calories, it tastes good. In that same spirit, living and eating “responsibly” has never been clearly defined. And what’s the incentive? You mentioned you were examining incentives. What offers B.R. more incentive, the taste experience of an oversized hamburger with cheese and fries or the promise of improved health somewhere down the self-denial road?
Anyway, I probably came off as overly frustrated. The story your sister-in-law relates is obviously derived from this same frustration. Water comes out in diarrhea; therefore possess too much water. And in this case, food goes in that tastes wonderful, so why would I want to stop eating if it makes me feel so good?
It seems to me, public policy or health and diet related messages need to offer more than the usual nebulous “you will improve your health” and offer financial incentive. In a recent MSN article discussing financial incentives to lose weight, they wrote:
“Last year, Michigan auto parts maker Affinia Group began offering an economic payoff to get more of its 4,500 U.S. employees to commit to a healthier lifestyle.
The company offered a $1,000 reduction in health insurance premiums to employees who agreed to participate in its StayWell health-management program, which includes medical screenings, weight management, smoking cessation and physical fitness plans. The tack worked. A whopping 99% of employees and their spouses now participate in the program.”
Maybe we need to pay people to lose weight.
WG
Thanks WG.
The US/ India healthcare system probably can do that better than the UK system can. In the former two, people pay out of their pockets mainly so a financial incentive makes sense.
The insurance industry in the US is already doing so many different things - life long health accounts to discounts based on proof of good lifestyle - and in a way are more pioneering in their thinking than governments have been.
A perverse way is to penalise using financial incentives of course, which does not seem to upset many people who are clearly paying way more than other, healthier people. I cannot recall exactly but one paper (either by NBER or USDA/ ERS) suggests that the higher cost of health premia paid by employers for obese employees are passed on to those employees through lower wages, and the effect is more pronounced in women than in men..
Of course that is too subtle an argument to get through to most people, except those working in this area. But perhaps it is the exact opposite of the example you talk about.
Thanks - this was a great, 'from the doctor's desk' piece.
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