Monday, January 09, 2012

Welcome to Britain's Nagging Health Service

Some health fanatics want everyone from GPs to hospital porters to lecture to us about our lifestyles.

‘Make every contact count’ is the big idea. Whenever a health worker - any health worker - meets a patient, they should be ready with advice on how to change that patient’s lifestyle. This notion is crystallised in a new proposal to discuss patients’ habits every time they see their doctor. In other words, it’s ‘make every contact a nag’.

The proposal, put forward by the National Health Service’s Future Forum, would see patients asked about their eating, smoking and drinking habits whenever they see a health professional - even when the patient is suffering from an unrelated illness. Dr Steve Field, the Lib-Con coalition’s so-called NHS troubleshooter and chair of the NHS Future Forum, told the Guardian: ‘In future if you come for your flu vaccine at a GP’s surgery or pharmacy, the health professional should give you your injection but also use the opportunity to talk to you about your diet, smoking, alcohol intake and how much exercise you’re taking, discuss any anxieties you may have about these, and offer advice and support. Similarly, a podiatrist who’s looking after the feet of a diabetic patient has an absolute responsibility to talk to the patient about their smoking, because smoking makes diabetes worse and means the patient is more likely to have a foot amputated.’

Now, it is obviously entirely sensible to talk to someone about their personal habits when those habits have a direct connection to a health problem and during a consultation with the person in charge of dealing with that problem. So, if I have breathing problems, it would seem sensible for my doctor or hospital consultant to find out if I smoke. If I have a gastric ulcer, then my eating or drinking habits might be making that worse.

However, there is nothing worse than going to the doctor only to be lectured about something irrelevant to your condition. There is every chance that this policy will simply put people off visiting their doctors. The chair of the Royal College of General Practitioners, Dr Clare Gerada, made exactly this point to the Guardian: ‘Young men pluck up the courage to go and see their GP, maybe about a sexually transmitted infection, and would not want to be lectured by a middle-aged woman like me. So we have to be careful that we don’t impose our agenda on to the patients and don’t inadvertently frighten patients who are coming in to see the doctor and who fear that they might be preached at.’

Turning the NHS into the Nagging Health Service will only compound problems. It’s bad enough when your doctor bends your ear about your smoking or drinking. But some would like to take the nagging culture much further. Writing for the Guardian’s Public Leaders Network last year, Dr Wendy Richardson - director of public health for Hull - discussed how the NHS in Yorkshire and Humberside is getting everyone involved: ‘Instead of relying solely on medically trained staff or public-health professionals to promote healthier lifestyles, we need to recognise the huge potential of the wider NHS workforce. From hospital porter to GP receptionist, every day frontline staff have millions of interactions with people that could make a positive difference to their health. Yet all too often, through lack of awareness or confidence in addressing what are often sensitive issues, they miss these opportunities.’

Who would find this process more cringe-inducing? The patient, for whom every contact with the NHS is now an opportunity to be lectured about his or her personal pleasures, or the porter or receptionist given a script to lecture every patient with? If any idea could be more exquisitely designed to poison the relationship between NHS staff and its users/customers/clients, it is this ubiquitous evangelising about ‘lifestyle behaviour change’.

But while the criticisms of the new policy made by Gerada and others are correct, there is another more fundamental point: what I choose to drink, smoke, eat and so on is no business of health workers. In fact, it reverses the proper relationship between doctor and patient.

When people with power over us - like the gatekeepers of healthcare: family doctors - start quizzing us or lecturing us, it has an entirely different character to a friend or workmate gently suggesting we should ease off on the booze or fags. When a doctor starts dishing out stern advice, there is the implication of a refusal to help if we don’t play along. That inference is not an unreasonable one to make; in recent years, treatment has been refused more and more to those who do not live in the prescribed manner.

Yet as the microbiologist Rene Dubos noted in the 1960s: ‘In the words of a wise physician, it is part of the doctor’s function to make it possible for his patients to go on doing the pleasant things that are bad for them – smoking too much, eating and drinking too much – without killing themselves any sooner than is necessary.’ Doctors should apply medical knowledge so that I can be free to live as I see fit, not use medical authority - at the bidding of their political masters - to browbeat me into adopting a lifestyle that receives the official seal of approval.


Chew over a few diet truths

Consider these two related facts.

Fact one: Australians spend a staggering $745 million on weight-loss products every year. This includes low-calorie pre-prepared meals, meal-replacement shakes, supplements and diet books (but not gym memberships and other exercise-related expenses).

The diet business is booming because we're fatter than ever and plenty of us are desperate to get thin.
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Fact two: Almost without exception, anyone who tries to lose weight rapidly with a diet fails. They might shed kilos in the short term but will ultimately put it all back on - and then some. In fact, one of the authors of a study published in the American Psychologist journal in 2007 went so far as to call dieting "a consistent predictor of future weight gain".

Perversely, it seems, if you want to get fatter, just go on a diet and wait for a bit.


Dr Leah Brennan, a clinical psychologist and senior research fellow at Monash University's centre for obesity research and education, says research that tracks dieters for one to two years is unequivocal.

"Usually, people are very close to their starting weight at two years, if not already there at 12 months," she says. "Generally, the research shows that six months is the maximum people can sustain the behaviour changes that lead to weight loss. Beyond that, people particularly have problems with weight maintenance."

There are many well-established reasons why diets don't work, both physiological and psychological. One of the many psychological stumbling blocks revolves around so-called "primary goals". These are what people hope to achieve by losing weight. In other words, most people don't go on a diet just to see decreasing numbers on the scales; they want to find a partner, wear nicer clothes, be more popular or get a better job.

Even if they manage to get the weight off rapidly, disillusion sets in because those goals aren't realised. This is despite the fact they were never weight-dependent in the first place.


As well as expecting unrealistic benefits, dieters often try to lose far more weight than is reasonable. You could call it the Biggest Loser effect.

"Realistically, if you can lose 5 to 10 per cent and keep it off, you are doing very well," Brennan says. "That's enough to see improvements in health indicators. But most people go in trying to lose 20 to 30 per cent of their body weight. So one of the reasons people don't continue to put in the effort to maintain their achieved weight loss is because they never got to the point they hoped they would."

The compliments also start drying up as friends and family become used to your new look, further removing the incentive to maintain the weight loss.

And, if the psychological factors aren't enough, physiological changes conspire to make losing weight and keeping it off desperately difficult.


One recent Australian study, published in The New England Journal of Medicine, looked at 50 overweight or obese adults who managed to lose about 13 kilograms using a low-calorie diet. Researchers found that the levels of many of the hormones that regulate appetite changed markedly, leaving the dieters feeling more hungry than ever. By the end of the study, most participants were well on the way to regaining the weight they had lost.

Another group of researchers, from the Albert Einstein College of Medicine in New York, found that when we starve ourselves, some of the neurons in the brain that stimulate hunger start to cannibalise each other, which, in turn, sends out more "hunger" signals.

There is also evidence to show your body reacts to sudden weight loss by slowing your metabolic rate by an even greater proportion.


So if diets don't work, why are we seduced time and again by the quick fix, confident that "this time, it will be different"?

Janette Gale is a health psychologist and founder of a company that trains doctors and others to better help people lose weight. She says that when dieters inevitably regain their lost weight, they rarely focus on the futility of quick-fix dieting.

"They will either blame themselves for not trying hard enough or they will say the diet is just not for them," she says. "But they will try the next one because it worked for so-and-so."

Superficially, each diet is different but health experts agree there are many more similarities than differences between them. While each diet might seem like a new strategy, in reality, it is the same old routine that is doomed to fail.

Each failure makes the next attempt even harder and less likely to succeed. All of which, of course, suits a diet industry that's constructed on failure and keeps the customers coming back.

The truth about real weight loss

At the heart of it, shedding kilograms is a simple, mathematical proposition: kilojoules in versus kilojoules out - create a deficit between these two and you will lose weight. But, of course, making it work is one of the hardest things you'll ever do.

That's what keeps the weight-loss scams in the business, promising the world but in the end only making your wallet thinner.

But it's not hard to find credible advice, such as this from a fact sheet from the reputable Mayo Clinic: "The foundation of every successful weight-loss program remains a healthy, calorie-controlled diet combined with exercise. For successful, long-term weight loss, you must make permanent changes in your lifestyle and health habits."

No miracle cures, no wacky diets just sensible food and exercise. Boring but true.

The Mayo Clinic offers six strategies for successful, sustainable weight loss. Alongside making a commitment to yourself and being clear about your motivation, it recommends setting realistic goals. Losing between 500 grams and one kilogram a week over time is a sensible target.

Healthy eating is another key strategy but, as the fact sheet explains, "decreasing calories need not mean giving up taste, satisfaction or ease of meal preparation".

Finally, there is exercise and a "change in perspective".

"It's not enough to eat healthy foods and exercise for only a few weeks or even months if you want long-term, successful weight loss," the clinic says. "These habits must become a way of life."


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