American College of Physicians: Internal Medicine — Doctors for Adults ®

Thursday, December 26, 2013

Health at an impasse: the case for getting past collusion

Collusion might reasonably be defined as meeting the enemy and discovering it is both them and us. In the case of health, personal well-being and public health alike, exactly this sort of thing is going on. It is way past time to take the way past these toxic impasses.

Let’s start with public health, and then get more personal. The leading public health problems of our time are obesity and related chronic diseases. This is well studied and thoroughly established. As bad as the current situation is, with chronic diseases imposing an enormous burden in both human and economic terms, things are projected to get far worse. Chronic diseases are proliferating around the globe, affecting ever more people here in the U.S. and taking hold at ever younger ages. We are losing an enormous number of years from our lives and an all but incalculable amount of life from our years.

What makes this truly tragic is that it is almost entirely preventable. We have known exactly what it takes to reduce the aggregate burden of chronic disease by fully 80% for literal decades. The relevant research is noteworthy for its power, clarity, consistency, and lack of controversy. Instead of staring down the barrel of a figurative gun at a future in which one in three of us is diabetic, we could readily be looking at a future in which 90% of all diabetes is eliminated outright. There are few forks in the road of life as flagrant as that.

But since we have known for decades that better use of our feet (physical activity), forks (dietary pattern), and fingers (not holding cigarettes) could transform public health, and have done relatively little with the information, at least with regard to diet and physical activity, we are squandering an incredible opportunity. We squander it by eating a diet in which nearly 50% of calories come from certifiable “junk,” and in which we talk about the benefits of exercise and then go on displacing every former use of our muscles with schedules that preclude them, and new technologies that do them for us.

We could blame it all on the food companies that make the junk food, and the technology companies that keep inventing more ways for us to be sedentary. But as noted, the enemy is both them and us.

What’s the collusion? We let their inventions become the mothers of our previously-unrecognized necessities. Nobody needed soft drinks before they were invented; thirsty people did just fine with water. But we sure seem to need them now, downing sugar measured in tonnage, an astronomical number of calories, and spending fortunes for the privilege of propagating our collective risk for obesity and diabetes. Rakes once seemed to suffice, but now a wayward leaf clearly demands the revving engine of a power blower. To say nothing of the need to play soccer on a screen using only our thumbs, while an actual soccer ball sits unused in the yard. You get the idea.

Nobody is making us stay on the couch or eat junk food, they are just selling stuff we keep buying.

Yes, it is true that junk food is willfully engineered to be addictive, but so are illicit drugs, and most of us choose not to use them in the first place. We have no fundamental obligation to call toaster pastries “breakfast,” French fries a snack, or to keep runnin’ on Dunkin. We do have choices.

When we complain that food companies should make better food, and they should, they counter that they make and sell what we buy and eat. It’s a bit of judo and a bit of theater on their part, but it is also one part true. If we only bought better food, they would stop making junk pretty quick. If we want to transform our food supply into one that makes loving food that loves us back the norm, we can’t just keep wagging a finger at Big, bad Food even as we stock up on their concoctions. We need to share a taste for change, by showing we actually prefer to buy products that are good for us. A process of taste bud “rehab” is readily available to us all to set just a cascade in motion.

As for personal health, the story is much the same. An 80% reduction in the collective burden of chronic disease means that you, and I, have the means available to slash our personal risk of all major chronic disease, heart disease, cancer, stroke, diabetes, dementia, by that same 80%. It means that if knowledge were power, if we used what we have long known, there are fully eight chances in 10 that our loved ones who have been diagnosed with any of the above, would not be. This is not about some remote, anonymous public. This is up close and very personal. It’s all about us and the people we love.

But here, too, we tend to squander the opportunity. While knowing just what it takes to lose weight and find health, to add years to life and life to years, we turn again and again to lose-weight-fast diets and variations on the theme of false promises and magical thinking.

Here, we could blame the fad diet authors, hucksters, and other malefactors of the military-industrial establishment. But again, the enemy is both them and us.

What’s the collusion? We could, any time we like, concede that quick fix diets cannot be a solution to the lifelong challenge of weight control. We could acknowledge that going on diets that leave our children behind in an age of epidemic childhood obesity is not only fraught with the likelihood of failure but is fundamentally irresponsible. Apparently, we are saying to our children: Grow up and get fat, then you, too, can try to sort it out for yourselves. As long as we keep buying lotions, potions, and fad diets, the individuals and industries involved will all too happily keep selling them.

What, then, is the way past the impasse? Pretty straightforward, actually:

1) Apply common sense more commonly
Reasonable, responsible people apply common sense to everything that matters, money and mortgages; education and careers; pet care and vacation planning. And yet, we turn it off and go into some kind of “trance of gullibility” when promises about weight loss and health promotion come along. We could stop, and apply common sense more commonly to health, which certainly belongs on the short list of priorities we all respect and take seriously.

2) Get real
We know that get-rich-quick schemes tend to be the stuff of sit-coms, not serious people. Serious people know that worthwhile things generally take time and some actual effort. We need to approach losing weight and finding health in the real world, not fantasyland.

3) Get empowered to be responsible
The Spiderman movies famously served up the adage, “With great power comes great responsibility.” That implies a corollary we all too often ignore: Before we can take responsibility, we must be empowered. There is an empowering set of skills for getting to health in spite of it all that successful experts apply to themselves. Such skills can be acquired, and applied, by anyone willing to make the effort. Only those who were empowered with the skill of literacy can take responsibility for all the reading and writing we need to do throughout our lives; there can be no such responsibility in the absence of ability. There is health literacy, too. There is a skill set for getting to health. We can go and get it.

4) See the forest through the trees
We do not have epidemic obesity and chronic disease because of any one food, nutrient, ingredient, chemical, or device. We live in a perfect storm of obesigenic factors. Similarly, no active ingredient or silver bullet will fix everything. We are unlikely to get out of the woods until we see the relevant forest through the trees.

5) Take one step
The journey of a thousand miles famously begins with one step. The journey to health in most cases is substantially shorter than that but also begins with one step. Learn and apply a skill to sleep better, or manage stress, and you may find you have the energy to be more active. Be more active by applying skills to fit fitness in, and you may find you sleep better, or feel less stressed. Improve your stress, sleep, and activity level, and you may suddenly find yourself prepared to start improving your diet. Do that, and you may find you feel better and want to get a bit more exercise. Rather than giving up foods you love, you could learn how to trade up foods you love to better choices in the same category, better chips, for instance, so that you keep loving the food, but the food starts loving you back. In the process, you could rehabilitate your taste buds so one choice at a time, you actually come to prefer foods that are better for you. We readily get caught up in a pattern where each thing that conspires against our health, lack of sleep, excess stress, weight gain, poor eating, lack of exercise, compounds the next, until the degenerating spiral takes our quality of life right down the drain. This process can be reverse engineered one step a time, so we are climbing a spiral staircase up to the health and vitality we want, and deserve.

That’s it.

We could, I suppose, just go with the status quo. We could all undergo more operations and take more drugs, like the statins we heard this week millions more of us need. We could let our kids get fatter and sicker at younger ages than we, and let them undergo ever more surgery and take more drugs, too. We could do that, at huge cost in both dollar and human terms.

But why would we? Lifestyle is more powerful medicine than anything ever developed by a pharmaceutical company, accessible to us all, stunningly free of side effects, safe enough for children and octogenarians alike, under our control, suitable for everyone every day, and requires no prescription. It is also the means to a truly luminous prize: a better life. That’s what health is for, it makes living better. We could add years to life, and life to years, not only for ourselves, but for those we love as well. We could give this gift to our children and grandchildren.

It may seem as if what stops our progress to health is unfixable. Just the opposite is true. If we initiate the right process, take one step on the way past the impasses, then what would fix health could very well be unstoppable.

Shall we get started?

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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