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Resident: This is an 85 year old woman who presented in sepsis from a multilobar pneumonia. Her temperature was 103.2 and she had a blood pressure of 100/60. Her chest x-ray showed pneumonia. Two hours after the antibiotics, she is up and around and wants to go home.

Me: Wow

Resident: I know, based on the CURB-65 criteria her predicted mortality is about 50%

I give away a lot of advice, that people may or may not want.  People come to me not for information regarding their disease but for a cure. They want to feel better. This is in part an residual of the miracles of the antibiotic age that I was a part of this weekend. Pneumonia, the “old man’s friend” is now, if treated efficiently and effectively, almost always curable as attested to by my patient form this weekend. The proliferation of “urgent care”s and “immediate care”s is partly because people want to feel better immediately (it isn’t Dr. Perkins I need, it is a prescription and a steroid shot) and partly they don’t want to miss a pneumonia and die (it isn’t pneumonia, is it?).

The antibiotic model is that it works great for pneumonia in old people in part because the outcome is so dramatic. The older person is still old but the pneumonia is now gone. It is a lousy model for chronic illness. Take insulin for 4 days for your diabetes and you still have to take it the 5th day. And the 365th day for that matter. Unlike the pneumonia, which if untreated will kill you quickly, the high blood sugar of diabetes rarely kills. It is the aftereffects, the sequelae, of diabetes that kills with heart disease, stroke, infection, and blindness.

The New York Times covered a science story regarding the differences in premature mortality between the rich and the poor (found here). In it they point out that the differences can be explained by smoking (the poor are much more likely to smoke, now) and prescription narcotic abuse (just because it came with a prescription doesn’t mean it is safe). The third contributor is obesity. The rich are less likely to be obese than the poor, but not that much less (31% vs 37%), so why is obesity more of a problem for them? The investigators didn’t know why, exactly.

We had another patient this weekend who was admitted for her diabetes that explains why obesity isn’t so bad for the poor but the sequelae of obesity is. Her diabetes is well controlled when she has her insulin. Her job provides her insurance. Unfortunately her job doesn’t pay enough to cover the copay for the insulin, her grocery bill, and her housing expenses. So often, she has to make a choice between food and insulin, especially if her job doesn’t give her enough hours. So it isn’t the obesity per se. It really isn’t the diabetes, per se. It is the need to choose between a warm place to stay, food for her family, or her insulin that forces her to neglect herself. The sequelae of being poor in America.



gca0111lThere is a great need to address the social factors that contribute to obesity and to initiate efforts on a broad scale to modify these factors. Much skepticism exists regarding the possibility of achieving success in the treatment of obesity. It is important to note that many of the cardiovascular complications of obesity arise as a result of mild to moderate degrees of overweight. The availability of ancillary personnel, eg, dietitians and exercise therapists, will be required to assist physicians in the treatment of obesity in the clinical setting. Finally, management of associated risk factors (atherogenic dyslipidemia, hypertension, prothrombic state, and insulin resistance) will help prevent the cardiovascular complications of obesity.

Krauss et al, Obesity, impact on cardiovascular disease, American Journal of Cardiology 1998

According to Moss, the first response came from the CEO of General Mills.

“[He] got up and made some very forceful points from his perspective,” Moss tells Fresh Air’sDave Davies, “and his points included this: We at General Mills have been responsible not only to consumers but to shareholders. We offer products that are low-fat, low-sugar, have whole grains in them, to people who are concerned about eating those products. “Bottom line being, though, that we need to ensure that our products taste good, because our accountability is also to our shareholders. And there’s no way we could start down-formulating the usage of salt, sugar, fat if the end result is going to be something that people do not want to eat.”

Report of a meeting about childhood obesity attended by processed food manufacturers in 1999

NPR “How the Food Industry Manipulates Taste Buds with ‘Salt Sugar Fat'”

Americans spent $676 trillion on food in 2012. Of that, 22% was spent on processed food, up from 11% in the 1980s. The percent of the population that is obese was 13% in 1987 and 28% in 2007. The health care expenditure per non-obese person in 1987 (constant dollars) was $2400 in 1987 and $4033 in 2007. The expenditure per OBESE person was $2630 and $5560 in 2007. A cardiologist (the specialty most likely to benefit from the obesity epidemic) makes about $400,000 today. That cardiologist in 1989 made about $200,000 (constant dollars). 

My research

In the world of processed foods, if people choose to drink water from the fountain, Coca Cola doesn’t get paid. The decision point at which the  potential customer decides to put his or her money in a machine and select a product has to happen a whole lot to appease the share holders. The average soda found in a machine costs about $2.00 and (if non-diet) 20 ounces has 227 calories. Why do people want to spend that money and waste those calories? Sugar, Salt, Fat – a new book out by Michael Moss – indicates that we do it because the food in engineered to appeal to all of our senses, leading us to off load some of our hard earned and misleading our bodies into not counting those calories as real. When it became apparent in the 1990s that our food science folks were too good at achieving this “Bliss Point” and childhood obesity was becoming epidemic, industry responded by doubling down on their already proven techniques.

In the fee-for-service world of American medicine, doctors don’t get paid unless people get sick. In the same way that a person walking past a soda machine but drinking from the water fountain is a failure for the vendor, the person who doesn’t have a heart attack is not contributing to the “cardiovascular service line” of their local hospital (they do contribute to the insurance bottom line which is a story for another day). The move Escape Fire (airing on CNN on March 10) “calls out” our current, illness based, system. The movie doesn’t pull any punches regarding patient culpability but makes it clear that our illness system is built on a “Bliss Point” that is unsustainable and does not include confronting the root causes of illness. Our job should be, among other things, counter-programming against the entrenched calorie interests, not benefiting mightily while ignoring 30 years of data regarding the causes and impacts of obesity.

This book and movie, the highly critical article in Time Magazine last week,  the call today of the National Commission on Physician Payment Reform to end the fee-for-service system all point to coming change. I only hope we as physicians end up on the side of health and not fall on our swords trying to protect the status quo.

Mardi Gras has once again hit Mobile and I am taking some time to enjoy the festivities although today it is raining more rain than beads. I did spend some time while running today discussing the relative merits of staying fit, staying skinny, and the effect on health (as opposed to the negative effect on the medico-industrial complex’s bottom line). I have a couple of evidence based observations that I would like to share before I go to collect moon-pies for future consumption thrown to me by perfect strangers.

1) If you want to live a longer and healthier life, it is better to be skinny than fat. From the New England Journal of Medicine:

…overweight and obesity (and possibly underweight) are associated with increased all-cause mortality. All-cause mortality is generally lowest with a BMI of 20.0 to 24.9.

2) If you are overweight, it is better to be in shape than not in shape. From the journal Obesity:

Low Cardiorespiratory Fitness (CRF) in women was an important predictor of all-cause mortality. Body Mass Index, as a predictor of all-cause mortality risk in women, may be misleading unless CRF is also considered.

This remains true even if you look within groups. So, fit people who are very overweight outlive those very overweight people who are unfit, and so on.

3) The real problem for America, in addition to folks dying prematurely,  is that those who are not in shape will consume a lot more health care dollars in their old age. Those dollars are all federal tax dollars. From AHRQ:

Currently, almost one-third of total U.S. health care expenditures is for older adults (over age 65). Health care expenditures for people aged 65 years or older are four times that for 40-year-olds. By 2030, health care spending will increase by 25 percent, simply because the population will be older, before inflation or new technologies are taken into account. Estimates from a study by Harvard researchers calculated that the direct medical costs attributable to inactivity and obesity accounted for nearly 10 percent of all health care expenditures in the United States (Colditz, 1999). Being inactive results in loss of muscle strength and balance and increases the risk of falls. Every year, fall-related injuries among older people cost the nation more than $20.2 billion. By 2020, the total annual cost of these injuries is expected to reach $32.4 billion.

So whose problem is it? As many like to point out, folks need to take “individual responsibility.” Here are some things we all should do from the AHRQ website:

  • Make activity a daily part of your life. Find activities that you enjoy that can become a regular part of your routine, and find others to join you. Partners can make it more fun, can provide encouragement, and help overcome problems of transportation or safety.
  • Consult your clinician about what level of activity is safe and appropriate for you. Discuss any medical issues that might be interfering with more regular activity and review any symptoms and problems that might affect what activities are safe for you.
  • Set specific activity goals. Start slowly and build up to increasing levels of activity. Try to be active for 30 minutes a day on a regular basis.

However, as I like to point out, we need to change how we spend “health care dollars” as well. If, as I pointed out previously, we were to redirect funds into wellness instead of illness, here are some things that have been proven to work that we could do (again from AHRQ):

  • Conduct community-wide campaigns that combine highly visible messages to the public, community events, support groups for active persons, and creation of walking trails.
  • Establish community-based programs, such as those that take place at community centers and senior centers, that can provide individually tailored programs for seniors to become more active. Such groups help members set individual goals; teach participants how to incorporate physical activity into daily routines; provide encouragement, reinforcement, and problem solving; and help sustain progress.
  • Establish community programs that help build social support (at work or in the community) for physical activity.
  • Improve access to places that people can be active, such as walking or bike trails, classes at gyms or senior centers, athletic fields, etc. A review of 12 studies that created or enhanced access to places for physical activity found, on average, a 25 percent increase in the number of persons exercising at least 3 days per week (Kahn, Ramsey, Brownson et al., 2002).

My son is a junior in college and he tells me that his generation is worried. They are well aware that most growth in real income has gone to the folks that already have most of the money. In fact, he has been somewhat insulated from this as the son of a physician.  It seems that the money has been transferred from the average American’s pocket into the pockets of those of us who provide heathcare (as quoted by Kaiser Family Foundation):

Since 1999, the cost of health insurance provided by an employer rose on average by 160%. In roughly the same time frame, the median household income, after adjusting for inflation, fell by 8.9%. Those two figures, both released in the past two weeks, are connected more than people realize.

As I have spent a lot of time and effort describing (here and here, for example), we as a country spend a lot of money on health care and have relatively  poor health to show for it. Now that a possible candidate for the Republican nomination for the presidency has a little weight problem, once again American obesity is being blamed on our health care costs. Although I tire of putting these words to paper (or blogosphere), while obesity is a problem, preventing obese Americans from accessing our health care sustem is not the answer to our health care inflation.

A big part of the problem is that accessing the health care system is not an activity amenable to the insurance model. As posted on PNHP:

Insurance is a great mechanism that people can use to offset their risk of losing some material thing of great value like their house, boat, car or jewelry….

But for something that is predictable, ongoing, needed by everyone, or necessary for the welfare of our community, an insurance model makes absolutely no sense.l…

We know that almost everyone will eventually need some health care and much of it will be ongoing. For a defined population, the health care needs are predictable, and we know that the health of individuals affects the overall welfare of our community. In addition, most believe that people should get treated for illnesses, diseases and injuries that might befall them and expect that everyone should have access to preventive services like prenatal care and immunizations that make our communities a healthier and better place.

A second problem with the blame the victim mentality is that although some costs are predictable (based on certain identifiable risks including weight), most are not (per KFF):

While discussions about the costs of health care often focus on the average amount spent per person, spending on health services is actually quite skewed. About ten percent of people account for 63% of spending on health services; 21% of health spending is for only 1% of the population. At the other end of the spectrum, the one-half of the population with the lowest health spending accounts for just over 3% of spending.

Lastly, it seems that America’s real income has stagnated, her health care costs have skyrocket, and, as Josh Freeman describes, we physicians as a group are guilty of becoming “job creators” by creating demand for unneeded procedures:

A key finding of the study that also supports Goertz’ argument is that [my bold] “Overall, fees paid by Medicare to US physicians for office visits are comparable to those paid by public insurers in several other countries, and fees paid by US private insurers are slightly higher than those paid by private insurers in other countries. In contrast, fees paid by public payers to orthopedic surgeons for hip replacements in the United States are considerably higher than comparable fees for hip replacements in other countries, and fees paid by private insurers in the United States for this service are double the fees paid in the private sector elsewhere .” This is exacerbated by the fact that “In general, Americans are very low users of office visits and relatively high users of hip replacement surgery.”

To my son’s credit, although he is bright enough to get into medical school he would rather work towards a different America. One, I hope, where as health care professionals we give needed care to people suffering from illness, avoid blaming the victim where possible, and all become a little less greedy. Good luck, Henry.