Personal responsibility and societal structure changes that reduce obesity

I visited my parents this past week. The are both in their 80s and in relatively good health although my mother received a diagnosis of diabetes while having a medical exam for an unrelated problem. I spent some time educating her about Type 2 Diabetes, the causes (genetics and weight gain) and the options (medication and/or weight loss and exercise). I stayed with my brother-in-law and sister and the conversation turned to the health care law and the implication of the upcoming election.

My brother-in-law is thoughtful Republican (his description) and while he would like to see everyone have access to some form of healthcare he questioned whether we weren’t already providing it (through EMTALA ) as well as why couldn’t somehow penalize folks with poor health habits. I already had a pretty good answer for the first part of his question but have always been troubled by the second. The nagging feeling that it is somehow wrong was offset by an e-mail I received offering a $25 per month discount to our health insurance if I certify that we (my spouse and I) are non-smokers.

The public debate leading up to the law (and following the passage of the law, the continuing “conversation”) has been unenlightened. The discussion leading up to the Clinton health plan offers a lot more insight into these issues.

Reinhard Priester wrote an article in Health Affairs detailing what our current collective values were and what societal values should be emphasized in an American health care system.  He points out that access, while considered important, is a confusing concept to most Americans. When we discuss who should have access to care, do we mean everyone gets it or do we mean if you get really sick you get everything you need to get better (or until you are too sick to use it)? The writer feels that we as a society should be working to get everyone access because,

access should be the driving value because of health care’s importance in promoting personal well-being, avoiding irreversible harm, and preventing premature death. Everyone should have access to health care to cure or prevent illnesses, mitigate symptoms, and ease pain and suffering.

He identifies a reason we are still having such trouble accepting the concept of unfettered access.

Although the value that care should be provided to poor and disadvantaged people is long-standing, its ethical obligation is limited to providing charity for the so-called worthy poor. Unlike the value of access, the charity ethic complements other values of American medicine. Individual and institutional providers are free to select which of the patients unable to pay are worthy of receiving free care. The concept of the worthy poor derives from the peculiarly American notion that for many poor people, poverty is somehow deserved. From this perspective, access to necessities such as health care, and clearly to all of life’s luxuries, depends on personal effort, achievement, or merit.

The ensuing 20 years has not led to Americans becoming more accepting of universal access. The concept of the deserving poor has morphed into that of the deserving sick person. Our current surgeon general, for example, has been called to task for her “unhealthy” weight. Along these lines West Virginia tried to impose a “personal responsibility” standard onto their Medicaid program in 2006 but was unsuccessful on several levels. The state was unable to get the “responsibility” paperwork signed by the responsible party due to poor planning on the part of the agency and the “experiment” failed. Many expressed concerns that such a program would lead to a worsening of the health of those the program was intended to help:

There are many reasons why patients might not comply with medical recommendations. These include poor physician–patient communication; side effects of medication; advice that is impractical to follow for reasons that include job responsibilities and difficulties with transportation or child care, psychiatric illness, cost, the complexity of the recommendations, or the language in which they are communicated; and cultural barriers. Patients who may benefit from additional services, such as diabetes care, education in nutrition, or chemical-dependency and mental health services, include many who might have difficulty with compliance, thus increasing the likelihood that they will not be eligible for these services under the West Virginia program.

In an accompanying article, the problems with “personal responsibility” are nicely outlined but best illustrated in a case

Mary Jones is your 53-year-old patient with diabetes and obesity. These conditions developed after she began to take an atypical antipsychotic drug for schizophrenia. Jones signed a treatment contract stating that she will keep all her medical appointments, attend diabetes education classes, and lose weight. She attended one class but became paranoid and left halfway through it, and she has gained 5 lb. You gave her educational materials to read, but you have discovered that she doesn’t understand them. She has just missed her second consecutive appointment with you; last time, she didn’t have bus fare. Neither her glycated hemoglobin nor her blood lipids are at target levels. You are now legally obligated to report this information to your state Medicaid agency, and Jones may lose her mental health benefits and some of her prescription coverage as a result.

In short, before shouting about overweight welfare recipients, perhaps physicians should endorse a more nuanced position (such as has been outlined by the ACP). Even better, perhaps we should support changes in the societal structure that will reduce obesity.

When I left, my mother committed to making better meal choices and exercising more (or even at all). For her, to not do so does not mean that she will lose access to health care. I hope that continues to be true for everyone. On the other hand, perhaps adding the cost of an extra 5 packs of cigarettes a month to the insurance might change some behaviors.

Allen Perkins is Professor and Chair, Department of Family Medicine, University of South Alabama.  He blogs at Training Family Doctors.

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  • Finn

    I think this post adequately explains why insurance discounts for not smoking are far more acceptable than punishments for being overweight, nonadherent to treatment plans, or missing appointments: smoking is a voluntary, intentional behavior that people spend considerable money to engage in, while obesity, skipping meds, and missing appointments are often unavoidable consequences of poverty, illness, and debility. In other words, people who are too poor or sick to follow their treatment plans are the deserving sick, while people who blow their money on cigarettes are the unworthy sick who deserve their illnesses–even if their illness has nothing to do with smoking.

  • BK

    No offense, but it is a really sad state of nutritional education in medicine to read a MD say Type 2 Diabetes is “caused by genetics and weight gain”. Most people I know say that their doctors don’t like talking about nutrition. That’s like an accountant that doesn’t like talking about what their client spends money on.

    The majority of western medicine is toxicology. We need to stop with our carb based diets and get back to food we evolved on. Paleolithic nutrition is the solution.

  • pcp

    “Paleolithic nutrition is the solution.”

    In combination with paleolithic medicine.

  • BK

    I certainly appreciate the humor.

    But what isn’t funny to me is the wide-spread nutritional assumption that human beings were created 20,000 years ago and should be perfectly healthy eating grains and such.

    Sorry… I was just surfing the net and went into a mini-fit of keyboard fury when I read “Type 2 Diabetes is caused by genetics and weight gain.”\

    Children with epilepsy have a 97% reduction in seizures when they are on a ketogenic diet. That is just the tip of the iceberg.

    The majority of western medicine is toxicology…

  • Anonymous

    Paleolithic nutrition is the solution.

    Be sure to get Paleolithic exercise to go with it, stalking and chasing your prey animals for miles before catching and killing them with spears, axes, and bows, and then hauling the catch back to camp while others of your group walk miles to gather and carry back to camp the fruits and vegetables to go with the meat you will bring back. Of course, you will have to then do some chopping and carrying of firewood if you want to cook the food.

  • Allen Perkins

    In the case of my mother, fortunately, all it took was giving up deserts. At 82, I doubt she could take a mastodon. In fact, I suspect the number of Paleolithic octogenarians was very small.

  • BK

    What is important is understanding the evolution of metabolism. Farming helped form civilization, but the bulk of human evolution involved eating animals and foraging. All the talk of how hard life was for pre-historic humans is moot. Today we have hospitals, air conditioning, helicopters, emergency medicine, running water, etc.

    “Paleo” is an observation that forms a hypothesis that our bodies thrive on eating healthy animals, vegetables, nuts, seeds, and fruit. So far we’re moping the floor with other “diets”.

  • Anonymous

    All the talk of how hard life was for pre-historic humans is moot.

    “Hard” or otherwise, it is not moot when you consider that the paleolithic humans got more daily exercise than almost all modern humans in rich countries do, other than those few who are either in heavy manual labor jobs or athletes who train and practice most of the time.

    And even their diet is hard to emulate out of a modern grocery store. Meat in the grocery store (other than wild caught fish) is from domesticated animals which produce a much different nutrient profile from their wild cousins. The fruits and vegetables in the grocery store are also mainly selectively bred varieties whose nutrient profile is different from the wild forms that paleolithic humans found.

  • BK

    Absolutely. Grain fed beef for example is deficient in omega-3s which is why fish oil is such a great supplement.

    Exercise “all the time” is overrated. A few times a week helps keep insulin sensitivity high among other great benefits.

    I’ve seen fat people do Iron Man competitions.

    Grass fed beef, free range chicken, fresh organic (when beneficial) veggies and fruit can be bought at the grocery store.

    Olive oil and coconut oil may not be “Paleo” in the observational sense, but certainly line up in terms of nutrients.

  • Anonymous

    Exercise “all the time” is overrated. A few times a week helps keep insulin sensitivity high among other great benefits.

    Many people are unable to avoid metabolic issues (e.g. insulin sensitivity/resistance, high blood pressure, etc.) exercising just “a few times a week”, or at the amount of exercise that the CDC recommends for adults at a minimum. Greater exercise intensity and volume would go further in addressing the metabolic issues caused by inactivity.

    Grass fed beef, free range chicken, fresh organic (when beneficial) veggies and fruit can be bought at the grocery store.

    Selective breeding has resulted in those foods having different nutrient profiles compared to foods from the wild animals and plants that are the cousins of the domestic animals and plants raised (organic, free range, or otherwise) for food.

  • BK

    You are correct about the nutrient profile of today’s animals being different, but that doesn’t mean we all should eat grains.

    Cut grains, dairy, legumes, and sugar out of someone’s diet, see how remarkable healthy they become and then see if they need to be on a treadmill for an hour a day. The “Biggest Loser” concept of high volume exercise to keep weight down is not the only way. A ketogenic diet, or even something close to it, is like a silver bullet. The real question is what small segment of the population does NOT have a gluten intolerance or does NOT see biomarker improvements through the roof with this kind of food intake. It cannot be overstated.

    Nutrition MUST be evaluated from an evolutionary point of view. It’s silly and borderline religious to not do so. I’m talking Jesus riding a dinosaur kooky to think bread is the bee’s knees.

  • BK

    Yes, I think one is the same as a fundamentalist evangelical southern baptist bible thumping Palin voter to think bread is good for you because “that’s what we’ve been doing for 20,000 years.”

    No offense to southern baptists or Palin voters, I know paleo advocated that are both. I just thought it would conjure a good image.

  • Anonymous

    A ketogenic diet, or even something close to it, is like a silver bullet.

    Hunter / gatherer diets were / are not necessarily ketogenic. Indeed, the percentage of calories from carbohydrate, while lower than many modern day diets, is high enough that being in ketosis on a normal basis is unlikely.

  • BK

    And some neanderthals ground random junk up and made makeshift bread. Some modern HG types live off of sweet potatoes. It happens. Of course if you CAN get carbs people are going to eat them.

    Over 2 millions years of optimal foraging strategy there is no way humo sapiens got lots of carbohydrates on a regular basis.

    I’m glad you’re reading articles with the name “cordain” in it though. Though I feel you googled “debunking paleo” or something similar.

  • Dorothy Green

    “We need to stop with our carb based diets and get back to food we evolved on. Paleolithic nutrition is the solution”

    Going the Paleolithic way is really the only way. Of course we can’t go all the way back and maintain our present level of living but enough is known that it is not incompatable to have an almost Paleo diet for most of us in the future. Much has been discovered and continues to be discovered about humans and their diet and is increasing every day and so are farmer’s markets, urban and suburban farming.

    It is well known now that what drives us to overeat is sugar, fat and salt. This has been going on for a long time now. But 1) the consumption was not as pervasive, chemicalized or industrized and 2) people died from overeating or heart disease before there were any cardiologists and the pharmaceuticals to treat them.

    It was not a good thing – I really loved my grandfather – but found him dead at age 60 when I was 10. He was a butcher – a steak and eggs guy and of course died of a heart attack – circa 1950.

    But now, it is not that we just know you can’t eat steak and eggs, sweets, refinded carbs and other stuff exclusive of veges, fruits. We know what we should eat and still the majority don’t because the cheap tasty stuff is all about us and there are cardiologists, the internists, the other specialists along with Big Pharma to make really good bucks, along with Big Food to promote the food. It is everyone’s failure to have a reasonable eating culture. It is out of control and as a reference point of our poor nutrition state, obesity is expected to rise from it’s present 34% to 42% before stablizining. Take that US health care budget!

    Yet no one thinks seriously about the marriage of individual and societal changes. I say – use the tocacco model for sugar, fat and salt as these 3 substances are what drives our brain to overeat.

    I don’t believe anyone out there, except a few pure, have never been tempted to eat something they knowingly wasn’t good for them. I have and still do but not so much because 1) want to stick around to see what happens and 2) I want to avoid having MY income tax increased or benefits reducted because so many people don’t take it seriously that we are all part of the problem.

    It is the only way to kickstart our culture into the reality of how much we are hurting our potential. I have the plan. Just let me know and I will send it to you.

  • BK

    I don’t think it was the steak and eggs that caused the heart attack. There is mounting evidence that “Syndrome X”, inflammation from excess carbs and high insulin levels, is the main culprit for blood cholesterol and other evils. There are plenty of people that eat NO eggs and NO red meat and have terrible cholesterol/heart problems.

    You’re right about economics and health care. Universal mandating care in this country would bankrupt the world with our eating habits. And growing grain to feed it to cow’s is destroying land.

    Yes please send me whatever you’re working on.

    bjkerley at gmail dot com

  • BK

    RIP Jack Lalanne

    he would have lived to 106 if he didn’t eat whole grain.


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