DISEASES WITHOUT CURE

Posted in Rants on June 25th, 2013 by Ed

This is a few months old, but I can't always stay on top of the latest from monthly magazines in Australia. An Aussie doctor and writer offers a frank, sensitive, and comprehensive take on increasing rates of obesity and why we shouldn't expect doctors to fix it. It's long, but please read it before venting. By classifying obesity as a disease that implies that there are things doctors can do to cure or treat it. However, the doctors' tools are quite limited:

A recent New England Journal of Medicine article dealing with the rise of chronic lifestyle-driven diseases calls for a change in the way physicians think about their patients. The author suggests that medical students should be taught to be less reductionist, to learn how psychological, social and economic factors all act as determinants of disease. I do not know what medical school is like in the US, but even our surgeons – the most hard-arsed of doctors – sit reeling before the tragic combinations of circumstance and choice that lead our patients to weigh two or three (or four or five) times what they should. The doctors I work with have an excellent grasp of the bio-psycho-social factors that contribute to our patients' states, but we are only doctors. All we have are the tools of our trade: our ears, our voices, our hands, our pills and our scalpels. The waiting rooms are full, the waiting lists are long, the demand is swelling. Obesity is in many ways the logical endpoint of the way we live. Prevention beats palliation, but we'd need psychologists, motivational speakers, social workers, dieticians and physiotherapists to work with us in order to have any hope of tackling the problem. We’d need policy makers and activists. All we have are doctors like me.

In the absence of a holistic, comprehensive approach, we have doctors telling patients what they already know ("You should lose some weight!") and making them feel shittier than they already do. What we run up against, she suggests, is the reality that food has become a singular source of pleasure for a lot of people.

I ask a young 200-kilo patient what he snacks on. "Nothing," he says. I look him in the eye. Nothing? He nods. I ask him about his chronic skin infections, his diabetes. He tears up: "I eat hot chips and fried dim sims and drink three bottles of Coke every afternoon. The truth is I'm addicted to eating. I'm addicted." He punches his thigh….My patient is not addicted; he's a very lonely, unemployed young man who has gradually become socially isolated to the extent that the only thing available to him for comfort and entertainment is food. He has no friends, no money to buy other consumables, little education, no partner, no job. Some days he doesn't leave his bed. The choice for him is to eat this food or experience no pleasure.

And then, the kicker:

This is where the obesity-as-disease concept leads us – to a situation in which people demand that medicine shoulder the responsibility. What about the responsibility of the individual? And of society? My patient cries because the highlight of his day is returning from the supermarket with a plastic bag full of junk that he will eat and drink in his empty lounge room. What can I do for him? I can threaten him with his early demise, intensify his shame. I can offer him some evidence-based motivational lifestyle interventions – swap Coke for Diet Coke! Prescribe exercise? Walk for an hour at an average pace and you'll only burn off the equivalent of one slice of bread. I could take the old-fashioned approach and wire his jaw shut. I have no hope of resolving his loneliness, his hopelessness, his lack of a job. I could, and do, refer him to a psychologist – if he's lucky he may land one who is talented and sensitive and will try to get to the root of why this young man hates his own guts. More likely he'll be offered a few sessions of behavioural therapy that will make everyone except him feel better.

This hit me. I've been here.

I haven't been 200kg (440 lbs), but I've been through periods of my life in which eating was the sole thing I had to look forward to for days at a time. When you move to a new city, live alone, know no one, don't have many options for entertainment, and have some food/eating issues to begin with, it doesn't take very long at all for the pint of ice cream or the bag of Doritos or the candy bar to become the highlight of your day. It's the only thing that offers any pleasure. There's no one offering you a back rub before bed, no post-work happy hour with friends, no parties on the weekend, no frolicking outside on a sunny beach. There's food. There's work, dreary gray skies, frigid winters, and food. And that food is cheap – especially shitty food. If I want to do something I will get actual pleasure from, I can pay $75 for an hour massage or $2.99 for a bag of chips that will take me 45 minutes to eat. I can spend $400 on plane tickets and travel to visit friends somewhere, or I can spend $15 on pig-out food for Friday through Sunday.

That's the problem. That's why doctors can't help patients beyond giving them advice they've already heard, pills/surgery that won't work unless they change their eating habits. As the writer states, every "diet" that works amounts to the exact same thing: eat less, and stop eating so much garbage. We get it. The problem is actually doing it. We expect the doctors to "treat" the problem within an entire system set up to encourage it – a depressed and depressing economy, a trillion dollar fast food/snack/beverage industry and its refined marketing techniques, an agribusiness lobby that dominates the institutions of government, and a decreasing number of ways to connect meaningfully with the people around us.

Shockingly, doctors have yet to discover a pill that fixes all of that.