“I don’t think I can go ahead with this, I’m so sorry, after everything you’ve done for me doctor”
Trisha pulled some tissues out of the box I keep on my desk for soaking up my patients’ tears.
“I feel like I’ve let you down”
For the last few weeks her panic attacks had been disabling. In the middle of the night she would wake up, soaked in sweat, a lump in her throat, barely able to breathe, her heart pounding. The same symptoms overwhelmed her almost every time she went out and so her 12-year-old grand-daughter was having to collect her shopping or escort her to appointments. She sat in the waiting room while I handed tissues to Trisha.
I asked if she had ever felt like this before.
“Oh yes, a few times, the worst was when I had my teeth wired together”
Trisha had only been my patient for a year and there was a lot I had to learn about her. The benefits of a long-term stable relationship with a trusted family doctor are so clear to those patients and doctors who have experienced them and so easily overlooked by people whose experience of illness is by and large limited to episodic or self-limiting conditions. It is one reason why policy-makers and journalists, by and large, relatively young, wealthy and healthy are so blind to the dangers of NHS reform. The benefits of a long-term stable relationship between a doctor and his or her patients cannot be weighed in the economic balance, or by the sliding scales of pharmacologically malleable biological parameters, nor even perhaps on the digital scales of satisfaction. Long partnerships consist of slow-burning battles through adversity rather than the instant gratification and instant online feedback demanded by the Amazonian generation seduced by websites like ‘iwantgreatcare’.
“I remember waking up one night, literally screaming. All I could think of was what happens if I’m sick, you know, like what if I vomit and I can’t open my mouth? I’ll choke to death on my own vomit. And that was like all I could think about all the time and panicking about it made me feel like I really was going to be sick, and so there I am in front of the bathroom mirror with blood all over my face cutting the wires from off my teeth with these dirty old pliers and I’d only lasted a week”
Ask a GP how to lose weight and they will probably say, ‘eat less and exercise more, and before you ask … the pills don’t work, yes I know what they say on TV, but nobody’s fat in chocolate ads either’. Or in other words, ‘it’s simple really, just don’t believe the hype’. Not all are that blunt, but most of us feel pretty helpless, even if we know it really isn’t simple at all. If a new diet pill passes NICE muster we might prescribe it for a few months before realising that like all the others the effects are short-lived and the side effects are messy. What I fear we are missing when our patients ask us how to lose weight, is to recognise that they are very often asking us for a different kind of help, and we need to ask the right questions. These are not questions suited to a ten minute consultation.
“I used to think it was the pills that started off the panic attacks. My mum and me got them from this private clinic up in Tottenham, you know I’m sure they were amphetamines. My mum lost loads of weight and then she had that trouble with her heart and we both knew it must be something to do with the tablets but we didn’t tell the doctors that were treating her heart anything in case we got into trouble, but she made us stop them after that. I remember having panic attacks then, I don’t know if it was the pills or what was going on with my mum, she was going nuts. They didn’t make me lose weight either, I still used to get up in the middle of the night and get the chocolate and cakes I’d hidden downstairs, because my mum used to search my room, anything to make me feel better, to calm me down. I used to keep eating until I stopped crying.”
Obesity is defined as a body mass index (BMI) of more than 30. At my practice of about 11 ooo patients we have weighed and measured 2082 obese patients with a BMI greater than 30. 382 are severely obese with a BMI greater than 40 and 79 patients have a BMI greater than 50. I suspect our practice figures underestimate our true proportion since there are a fair few patients who we have yet to weigh. The prevalence of obesity among adults worldwide has increased sharply in recent years. In the UK the proportion who were categorised as obese increased from 13% of men in 1993 to 22% in 2009 and from 16% of women in 1993 to 24% in 2009 (HSE). By 2050 the prevalence of obesity is predicted to affect 60% of adult men, 50% of adult women and 25% of children (National Obesity Observatory).
The causes and effects are myriad, as this splendidly complex Obesity influence Diagram shows. Obesity is associated with a wide range of medical conditions including vascular disease, diabetes and cancer. It is also a cause and effect of psychological distress including poor self-esteem, depression and even suicide. This is hardly surprising since the overwelming cultural message is that obesity is a punishment for the twin sins of gluttony and sloth.To add insult to injury, most, if not all of the new antipsychotic drugs cause weight gain. Unsurprisingly there is a trend to treat obesity as a disease,
While it might nevertheless be possible to achieve a social consensus that it is a disease despite its failure to fit traditional models of disease, the merits of such a goal are questionable. Int Journal of Obesity 2001
One effect of treating obesity as a disease is to expand the medical ‘treatments’ available for it. Since the tablets have been tried and found by and large to be at best intolerable and ineffective, and at worst fatal, the present trend is for even more intolerable, occasionally fatal, but more dramatically effective gastric surgery. It is a sad fact of NICE guidelines that most doctors skip the complex preamble about the social, psychological and political determinants of disease. It even says in the guidelines that healthcare professionals should support and promote community schemes and behavioural change programmes facilities that improve access to physical activity, such as walking or cycling routes. I doubt many have done this, even if some of us still consider ourselves to be ‘social physicians, in the service of society’. Perhaps this is unsurprising since our familiar tools are a prescription pad and a scalpel rather than a legislative pen. Sadly, I fear we are becoming ‘technical physicians’, allowing politicians and economists to have us judged and paid according to empirical data at the expense of therapeutic relationships.
Meanwhile the duty of politicians to ensure health protection is being continually eroded, by for example, the relationship between the government and the food industry which they treat as an economic ally rather than a crucial component of the nation’s health. Medicalising obesity fits conveniently with the present political obsession with devolving responsibility as far away as possible from the ‘upstream political determinants of health‘ such as the availability of unhealthy foods and the cost of healthy alternatives, or the possibility for safe and affordable exercise, or fundamentally, inquality. But while the responsibility for change is being shifted downstream there is no transfer of power. Responsibility without power or resources with which to act compounds the sense of helplessness and despair. Yesterday I received a letter from a kidney specialist to say that he was very worried that one of my patients with bipolar disorder and renal failure had his benefits stopped and was so worried about his finances that he was not taking his medication regularly and his kidneys were failing fast.
For many people, food is comfort when times are hard.This simple obesity locus of control map is my attempt to put the various factors in their place. Biology, for example diabetes, is influenced by both personal behaviour and environmental pressure.
I know now it’s hard to believe, but I really didn’t think about why I was eating like that until I was in my early 30s. By then I must have spent thousands on every diet under the sun and joined literally dozens of gyms and I even bought an exercise bike and everything you can think of, I must have tried it.
The enormously profitable diet industry which has benefited from thousands of pounds of Trisha’s cash, in return for no loss of flesh, doubtless includes rare instances of benign intent, but mostly it is the worst of big pharma and the food industry combined. According to the Economist in the US over the last four years, the price of the healthiest foods has increased at around twice the rate of energy-dense junk food.
Having tried the wire, the diets and the gyms and failed, I asked Trisha why she had changed her mind about the gastric bypass.
I can’t imagine how I’ll cope. What will I do … when I’ve had my bypass and I can’t eat and I can’t cope with how I’m feeling … what will I do? I know it’s wrong, and I know it’s my own fault and only I’m the only one who can do anything about it, but I just don’t think I’ll be able to cope if I go through with it … food is the only way I know of dealing with it when I feel that bad …
A year later, increasingly disabled, she decided to go ahead with the surgery, and I met with her afterwards. I hardly recognised her. She had lost so much weight that her face had completely changed. She was wearing an old track suit because none of her old clothes fitted her, but she was losing weight too fast for it to be worthwhile buying any decent new ones. Her weight had plummeted down from 25 to 17 stone. She was finding it easier to get around, but her knees were still sore and she had frequent, severe stomach aches and nausea. She will have to take vitamin supplements for the rest of her life and have regular blood tests. Because she can only eat very small amounts of food very slowly, she avoided eating in company or going out for meals. But the panic attacks had stopped, her blood sugar levels had normalised and her diabetes was cured. Her breathing was easier, and in spite of the problems, she had no regrets about the surgery.
It seems obvious now, but I was really naive when I was young. I thought that’s what your dad did because he loved you. I thought that’s what all dads did. That’s why it went on for so long. I never told no-one, not ’til I told my sister, and you know what, that’s what really hurts, I thought she would help me, but she didn’t, she hated me for that, and we’ve never spoken since. By the time I told my doctor, it was too late, my dad was dead for years. I’ve had counselling and all that, but by then I was gone too far to lose weight, my knees were knackered, I got out of breath just getting to the front door, I felt … like … shit. I remember seeing this program on TV about this woman who had a gastric bypass and I thought that’s the only chance I’ve got, otherwise I’m going to die.
Leaflet designed by Caroline Kilduff. 1st year medical student.
More on the Joshua children’s Foundation
Fat Politics. Collected Writing by Deborah Lupton Sydney University
In [the] obesity epidemic, poverty is an ignored contagion. NY Times March 2013
Stuffed and Starved video lecture by Raj Patel about the food industry
Why our food is making us fat. BBC documentary. Guardian review.
Precious. Essential film about an obese 16 year old girl and her violent and abusive parents.
Filling the void. Powerful patient story from the Journal of the American Medical Association.
Is obesity a disease? 2 hour audio download. PLOS blogs
Your body is beautiful. Thoughts on society, medicine and culture. Lashings of ginger beer blog.
The readers’ editor on… avoiding stigmatisation in illustrating obesity stories. Guardian April 2013
TODAY A Stark Glimpse of Tomorrow NEJM (medicalisation of obesity and diabetes in adolescents)
The patient described in this post is a composite of several patients I have met over my years working as a GP. It was also inspired by the film Precious.