Not to be critical, but I often observed taking care of patients, when it comes to the very heavy ones, the diabetics and smokers, those who fail to take care of themselves, even if it isn’t said explicitly, that some health care workers view them with a certain disdain. This is a trend we all try to combat.  But after all, didn’t they bring their problems on themselves, by eating constantly and with their other unhealthful habits?  Statistically people in poor condition tend to be poorer and less educated and may not be as articulate thin educated as healthy cohorts.  I have been guilty about drawing unwarranted conclusions myself some of the time.

Sick people may become that way over the long term by consuming too much of things they like, too many calories first of all, but lots of carbohydrate, heavily fatted and processed meats, way too much salt.  Some of them  practically live on fast foods, that are cheap and available, and they don’t control their consumption of alcohol and often other dangerous substances, prescribed or unprescribed. I have felt frustrated in my short encounters as their medical practitioner, as they tend to return with serious illness. It seemed to me they had never learned to take care of themselves. I searched for a better solution for them.  I spoke with tons of other people about this, about how was I going to convert them and change their unhealthful habits. I had read many articles lambasting doctors for ignoring sick person’s unhealthful habits. All I heard was the doctor doesn’t care enough to even talk to patients.  Well here was one who did care.

I tried taking some patients to task. For some, I called my approach, reading the riot act. I spoke with whole families in some cases as these habits were firmly entrenched in familial habits or so it seemed to me,  as evidenced by whole families sharing the same  physiognomy ( genes play an important role as well.)   Besides, I felt though it might be too late for a particular individual, with his advanced stroke, it was not too late for some of the younger family members, and I was always wanted in on “a save” in any form. I am sure I may have come on too strongly in my presentation so I did try to tone things down. I really doubt that much of this worked. It is hard to know.

I tried proselytizing with the Mediterranean Diet which I believe in (more about this in another post.)  The dietitians were too busy merely calculating weight (BMI)  and calories.  People were simply told they had to lose weight and it is true some of them didn’t know that. (Occasionally you meet 250 pounders who complain that they lost 20,  which is baffling).  I prepared laminated cards for distribution and short handy guides for stroke prevention and that was met with no reception at all. The System had their own handouts.

People with unhealthful habits are actually not worthy of blame at all in the traditional sense, especially poor people. In my daily practice I noted women especially abused by their bosses and significant others, working long hours for little pay, with children at home that they needed to care for. Fast and prepared food was ever present and relatively cheap, whereas healthy foods took a long time to prepare and were expensive. Their lives gave them very little pleasure and partying and substances provided a quasi-pleasurable distraction.

I was fascinated by studies in Britain that connected low paying positions and stress with over secretion of stress hormones (glucocorticoids) inducing a form of Cushing’s syndrome which in turn multiplied health risks and it all seemed to result from stress induced by socio-economic status.

One day it dawned on me to dichotomize between the thin and healthy v the obese and unhealthy person. Maybe with increased understanding we might have a lever to try to prevent the worst. Here are some differences I came up with:

1.  We live in an environment of plenty, but there may be, if anything too much of a good thing, too many available calories and food specifically designed by the makers and purveyors  of such food, to be cheap and delicious, so much so that you almost can’t stop eating it, which means loads of sweetness and salt. Salt always accentuates the wonderful taste of food. Food and drink are reliably plentiful everywhere.   This was not so until recently. In past times, humans had to deal with periods of plenty alternating with scarcity and a lot more scarcity. Nowadays scarcity is scarce. Until maybe one or two hundred years ago, those of us who survived were able to weather periods of starvation. They must have been very proficient in maintaining life through periods of low caloric intake. When our hunter forebears got an animal, they would pig out on their food, wolfing down thousands of calories having had to do without for long stretches.  This point was made abundantly clear in “The Seven Pillars of Wisdom” by TE Lawrence (of Arabia). There were so many instances where his human colleagues and their camels too, went without for long periods but at good times they would eat and eat. I don’t know if some other readers might have gleaned other lessons from his excellent book.

Strikingly,  those who are thin in our environment of plenty are the very ones who would have died in periods of starvation in the old days. Thin fit people may lack the mechanisms of  intense insulin secretion for example, insulin being the main hormone of caloric storage and fat accumulation.  Under circumstances resembling those in which humans evolved, (preagricultural hunter-gatherers) the very obese people, whom we disdain today, are the very ones who were by far the fittest. We ought to show them more respect. By the same token, the nonagenarians whom our media revere, (I am always in favor of giving the elderly our respect) might never have survived into their 20s even fairly recently in human history.

For decades I had been reading about cohorts recently subject to Western diets such as the Pima Indians who have a very high prevalence of diabetes.  I recently read, “The World Until Yesterday” by Jared Diamond who really makes this point very nicely. Those persons with the most health problems in our modern society were up until recently the most biologically fit. Many other groups, he mentions New Zealanders, he has studied extensively, and Nauruan Islanders,  have suffered the same fate. There seems to be some perverse tendency in those groups recently exposed to the cornfed American diet to overweight, diabetes and heart disease. Consequently we are witnessing the beginnings of an epidemic of atherosclerosis among Chinese, Indians, Bangladeshis. Since these latter are very populous countries this will cause the shortening millions of lives and much suffering. If we think healthcare is expensive and wasteful for America with 330 million people, wait until we see these problems emerge in societies of billions.

2. Here is a great irony. In America people are starving but they are not who you think they are. Another group of people is almost always satiated. The starving ones are fat. Fat people are always on a diet and always seem to be thinking about eating, Thin people rarely think about food or at least their lives are not centered on their next meal. Fat people often exercise excessively.  They try to burn calories and are always famished.  When given food, it is all they can do not eat voraciously as if they have been deprived of food, which they have.  Sometimes we treat fat people by sewing closed their stomachs so they can be permanently hungry. How perverse is that?

The sensation of hunger comes from some combination of hormones maybe partly insulin secretion but now known to involve leptins and many other hormonal combinations and of course there are psychological effects. Like pain or any other sensation it is mediated finally in the brain.  Why do some of people need more sex or sleep? It has to do with appetites for things and predispositions.  It seems to me we will only ever be able to treat overweight by converting ravenously hungry people into satisfied ones. Accomplishing just this would alleviate suffering every bit as real as feeding marasmic big-eyed children.  In the final analysis it is all about appetite and hunger.  How to do that is the sixty-four thousand dollar question. I have some ideas.

3  The provision of medical care is not the solution an epidemic threatening to overwhelm us all. Neither will it be more helpful to treat these conditions by providing more drugs and high tech interventions. Studies show that high tech approaches barely, if at all, save lives in large numbers.  High tech does sometimes save individual lives. This includes intra-arterial approaches which are very exciting, here you put a catheter in an artery and either extract a clot or bust open or stent a vessel or even put a stent in a stent. This approach is very inefficient and expensive and you can only deal with one vessel at a time and always affected folks have multiple clogged vessels. Many studies have shown limited minimal effect and even harm in these approaches, and here I can speak especially for the disorder of stroke with which I am personally most familiar. (Since atherosclerosis affects many arteries, I dream of injecting “plaque-men” nanobots that will simply eat through arterial deposits, Some day…)

So my point is this: Who is your “health care provider?” You think when you go into a hospital with all of its high tech offerings it is them, Nurses, Doctors, Hospitals, Health Care Systems possibly may save your life over the short term but over the long term, your Health Care Provider is you. It is you who need to be enabled to make the right choices.