It’s a big fat lie.

It’s a big fat lie.

I read today [OECD] that Britain has the highest rates of obesity, and fatness, in Europe and is the 6th most obese country in the world. There is also  the terrifying statistic that the rate of obesity has doubled since the 1990’s and we face the serious prospect of this bankrupting the NHS. Obesity is a major risk factor, as we all know, for diabetes, cancer, hypertension, heart disease, stroke and dementia – this rate of change should alarm us – but it won’t.

For many years, most of my working life, I ignored a growing problem. This problem was the growing size of my belly and my increasing size. By the time I changed my lifestyle 6 years ago I had managed to create quite a respectable problem for myself. My waist was 35 inches, my weight was 14 stones and unfortunately not being a tall man my BMI was 31.6. I was quite clearly obese. This had crept up on me, I knew as I aged I was becoming less fit but I didn’t look that different to many other middle-aged men and nobody passed any adverse comments. As a doctor, I knew I was building up risks for myself but I was able to  minimise these in my head. Nothing bad had happened, I don’t look that unusual, my blood pressure is OK, I still stay active – it really was easy to convince myself that this was no great deal.

Then came the rude awakening. Five years ago I was diagnosed with Type II diabetes mellitus with blood sugars so high I had the full range of symptoms and was started on metformin instantly, at a pretty high dose. I then went through the NHS’s education package. This told me to take my medicines, eat regularly and sensibly, and take a bit of exercise. With this, I was assured, the thing was manageable and I’d be fine. No-one took a blind bit of notice of the large, and obvious, wobbly bundle of fat I had around my middle even though this was the most conspicuous thing of my appearance. (If you want to imagine me then – not recommended – then imagine a potato with four cocktail sticks as limbs, that was me to a “T”). I sat on classes with other similarly shaped people and we all pretended that there was nothing amiss, nothing that eating a stick of celery couldn’t sort out. I went to the gym, where the rhythmical bouncing of my and my new friends’ bellies, while we tried to jog on the treadmills, was almost hypnotic to watch. Through it all no doctor, no nurse, no dietician, no-one said – for goodness sake get rid of that belly ! They were all too polite to mention it.

When I received the diagnosis a cold shiver went down my spine. I’d worked in an area where I’d seen the consequences of diabetes. I’d spoken to men about to have their feet amputated, I’d given rehab advise to folk after their stroke, I’d completed forms confirming that a diabetic man was now blind, and I’d consoled widows after their spouse’s fatal heart attack. I knew my mortality risk was now considerably increased and I knew some of the problems I might face. I also knew, from very cursory information gathering, that my poor diet and obesity were the main factor in this.

I decided to change, I was so scared and shocked, I knew I had to change. I went on a low carb diet and lost 3 stones, I kept on the diet and took regular exercise. I saw my waistline shrink, my belly disappear and my blood return to near normal. After a few months I came off medication and have remained medication free, and with relatively normal bloods, for the past years. A couple of my diabetic pals, who were equally shocked, did the same thing with similarly good results.  But I meet my other pals, who were never troubled by the thought of their weight; still obese, still taking medication and now starting to experience the adverse consequences of this illness.

So I have a personal interest in this report of growing obesity in the UK even though I am a relative neophyte to the world of diets and healthy eating. What are we to do to try and stop this growing trend. It is clear that there are some things we can’t do.

We can’t reduce the availability of food. This is a non-starter, there is no way we can limit what people eat – they must do this themselves. If you don’t sell the double pack of Mars bars I’m smart enough to get around this by buying two packs as is everybody else. Attempt to limit things by smaller packaging could only work if we were happy to accept central rationing of our food, otherwise we just buy more of the smaller packets.

I don’t think that we will get around this by education. I don’t think that there is anyone left that thinks a Big Mac and fries becomes a healthy option because it has a gherkin in it. We all know that a salad is healthier than a bar of chocolate – education is the answer when ignorance is the problem. That is not the issue here.

I doubt we will have much success tackling our increasingly sedentary lifestyles. Anyone suggesting we get rid of the automobile, or suggesting we dig roads by hand or get rid of any other  labour saving machinery, is unlikely to have a successful career in politics. We can suggest that people exercise and find ways to make it easier but, unless we are going to have forced marches then we need to find ways to make people want to do this.

The key in the affluent west is that we need people to want to be normal sized, to fear being obese. This is what we have lost. As I walked around I saw other people the same shape as me, it normalised my obesity. Chairs, cars, everything has been slightly adapted to suit the larger body, each step making it easier to be obese and, more importantly, making it easier to ignore your own obesity. I needed somebody to tell me – “Whoa ! You’ve got far too big there. That doesn’t look right” but even when I had fallen ill people were too afraid to mention it. They were happier to let me die earlier or loose my sight, or foot,  than to be accused of “fat shaming”

We would prefer people to be comfortable in their obesity, than in any way upset – but this is precisely what we do not need.  Discomfort might prompt thought and redirection and improvement to their health and life. I wish someone had spoken honestly to me, when I asked “How do I look ?” I wish they had said “you are getting fat” rather than lied with “Fine”. There is no need to be unpleasant about this we just need to be honest. We also need to be careful about attempts to actively normalise obesity. I noted, when in the supermarket today, this is not as strange and impossible idea as I had thought –  three of the covers of magazines (directed to young women) were using obese models. It may be dangerous to promote anorexic stick insect ideals of beauty but it is equally dangerous to promote obesity as a good choice.

The problem of obesity  has unfortunately got bound up in the gender issues of objectification of womenWe  but obesity doesn’t affect only one gender. All of us are at risk when we treat our health and future in a cavalier way like this. There are many vested interests who would prefer us not to think about it; the food and pharmaceutical industries would be much happier we consumed more of their products and dealt with the consequences. The media and beauty industry can sell us their products either way, fat or thin models, it is of no concern to them simply which model sells more copy.

People are free to live as they wish, they are free to be fat or thin as they choose, but they must choose with adequate knowledge. We should not influence these decisions because of our political biases and we should net let people die early because we were too afraid to tell the truth.

 

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Cosmopolitan – This photo series shows that “fat” can be as beautiful as any other body type

 

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In Loco Parentis – the terrifying tale of Charlie Gard

In Loco Parentis – the terrifying tale of Charlie Gard

As a doctor I have found the unfolding tragedy befalling Charlie Gard and his family extremely upsetting to follow.  This poor boy and his family are butterflies being crushed on a wheel to press home a legal point, they are unfortunates being punished having committed no crime.

Let us firstly be clear what this case is not about. Despite protestations to the contrary this case is not about the best interests of Charlie Gard. The best interests of the child (1)  are clearly important and made paramount both in the UN Convention of the Rights of the Child (2) and in British Law with the Children Act of 1989 (3) . It is clear that all the parties involved in this debate are acting because they have the best interests of Charlie at heart. The doctors and hospital feel that they, by virtue of their knowledge, know what is best to do. His parents, through love and affection, also believe that they can see the best plan and hope for their son. Both are acting in the best interests of Charlie, this is not the problem. The problem is who decides what exactly are Charlie’s  best interests.

It has always been the case that the parents of the child decide what is in the best interest of the child. This is as it should be as it reflects the natural law and ensures that the people most attached to the child’s interest are those who act as the child’s guardian. There are very few circumstances when this can be changed and they depend upon proving that the parent is being either negligent or malevolent. Neither of these factors are in play here and, if anything, the parents have taken extraordinary steps to secure chances for their child, well over and above what many parents would have been able to do.

It is interesting that, at the 24th hour, Great Ormond Street Hospital has made an application to court to revise its plans (4) possibly starting to realise that the parents’ opinion may have been closer to Charlie’s best interests, than had their own opinion been. So in this difficult calculus of what is the best plan of action it appears that Charlie’s parents may have been the better judge all along.

While these arguments over the ‘best interests’ may mean that the parent disagrees with the medical team it does not mean that the parent can compel a doctor to do something they feel is inappropriate or wrong. But again this is not the case in this situation. Charlie’s parents have never asked GOSH or the NHS to undertake treatments they do no agree with. They have gathered together sufficient resources to enable Charlie to receive this treatment by doctors who believe it is, worth a trial, in the child’s interests. This should have been the end of the dispute. Charlie and his parents should have used their money to go and try this last ditch attempt, to catch this glimmer of hope.

GOSH and its staff, however, stopped this. Their court battle stopped the treatment and refused the parents the ability to move their child. In their paternalism they not only refused to help but also stopped anyone else helping. The thousands of people who collected money to help Charlie were thwarted by this as well as Charlie’s parents and the other hospitals and doctors who wanted to help.

I am a very old-fashioned doctor and I don’t fear paternalism per se. A desire to act like a father, is a a desire to be benevolent, guiding, helpful and wise. In itself not a bad thing. It becomes bad when it belittles another party and reduces their agency. When doctors worked in a professional relationship with their patients, the doctor’s paternalism would drive them to seek the best for their patient and was usually leavened by respect for the patient’s autonomy. This combination could be valuable when there were difficult scenarios – when the future was unpredictable and  the efficacy of plans of action difficult to assess. Much of the placebo effect of medical intervention depends on this aspect of the relationship and large parts of the benefit of of healthcare comes from this caring, guiding, advisory aspect of medical care.

There was always one very good safeguard against this paternalism becoming intrusive or  belittling, when the relationship was between doctor and patient, the patient could always terminate the relationship. If they felt that the doctor’s approach was wrong they had no need to continue to use them. This was a way to safeguard the patient and also a way in which the doctor would know that they had overstepped the boundaries and they could learn where paternalism started to erode patient autonomy. But in the NHS this is difficult. The patient can’t change their doctor without a great deal of difficulty. If they change they will probably be labelled a “difficult patient” which might mar relations with their next medical practitioner.

In addition, under the NHS the patient is no longer the employer of the doctor in the UK. The most important relationship for the doctor is the one with his employer – the state, the NHS – not the the patient directly. It is the state who pays his wages, sets his targets and assesses his performance and we know “he who pays the piper calls the tune“. In this scenario paternalism is largely unchecked and can be very dangerous. Paternalism, appearing kindly and wise, can mask actions that are not in an individual patient’s best interest. Rationing and refusal of therapy is hidden as medical advice and choices are withdrawn from the patient. Doctors often find, when working in the NHS, that their attempts to maintain professional standards and a focus on their relationship with the patient can cause them difficulties. They are made to feel as if they are being disruptive when they call for what is appropriate for the patient. They can be told they are jeopardising the budgets, failing to be a team player by not following the organisation’s line, and generally made to feel awkward if they behave in a manner that was formed by their vocation and training.

In this case paternalism seems to be being employed to sweeten a bitter pill. The state wants to end Charlie Gard’s life before all options that are available have been tried. Despite having seen parents act heroically and selflessly for their child, without an ounce of malice, they would prefer Charlie died rather than allowing the parents to try all they can do. But rather than admit this we are told that they are the wise and kindly people who know what they are doing, we are awkward and unruly children causing a fuss.

Well thank God for the fuss that Charlie’s parents have made;  it may not save Charlie but they will have opened the eyes of many people and might save future families from the horror that they have had to endure. They truly are a heroic family who deserve our support (5)

 

 

 

 


[1] https://en.wikipedia.org/wiki/Best_interests

[2] https://en.wikipedia.org/wiki/Convention_on_the_Rights_of_the_Child

[3] https://www.publications.parliament.uk/pa/cm201012/cmselect/cmjust/518/51807.htm

[4] http://www.telegraph.co.uk/news/2017/07/07/hope-charlie-gard-great-ormond-street-seeks-explore-new-evidence/

[5] http://www.charliesfight.org/

The NHS Choir Christmas Single

The  NHS Choir Christmas Single

Feeling rather low on Christmas cheer I was glad to come across the blogpost below. In this excellent piece the author managed to express, much better than I would have been able, what is wrong with this Christmas record.

The NHS Choir’s Christmas Single Is Propaganda Worthy Of North Korea

 

I spent most of my working life in the service of the NHS trying to help the elderly and the mentally ill. In the latter half of my time, I realised that the NHS was no longer delivering healthcare well and outcomes were falling below that of of other comparable European countries. In particular it seemed to be failing the elderly and those with chronic conditions.

Unfortunately attempts to look at alternative ways of working and organizing were rarely pursued as any discussion was held to be breaking a taboo – the taboo that the NHS is wonderful, and provides excellent and comprehensive care. When this was questioned, even gently, we were warned that any attempt to change matters would result in patients dying in the gutters destitute after paying for healthcare and the elderly and infirm kicked out of their homes, as we presume happens elsewhere.

As I travelled widely and saw other healthcare systems in Europe I realised that we could learn from our colleagues there. But a closed mind is a barrier to education. We cover our eyes to the failings of the NHS and lay the blame on inadequate funding when alternative systems spend similar amounts and produce better outcomes. Now it seems we can also close our ears to any doubts and sing along to the company tune – The NHS is great, our saviour in times of need, pure in word and deed, only those with black hearts fail to see the Glory.