I expected to get a number of questions commonly this year; “So why did you do a PhD?”, “What’s it like being a trophy husband?”, “Missing clinical work much?” What I didn’t expect was for by far the most common to be “So how’s PhD life (treating you)?” Well, let me tell you a story. Thick fog hangs low over the water, filtering even the midday sunlight to a dim glow. From the wheel one can barely see the front of the bowsprit, piercing the hazy curtain like a lance in outstretched arm, much less the top of the mainmast, extending up into the heavens beyond the enclosed crow’s nest. Though it feels like a distant memory it’s been barely six weeks since leaving Glasgow in a flurry of shouted well-wishes and drifting chaff from the flourmills, flung up by young and old alike. They had come from miles around to see the beginning of what would be a history-defining or rapidly-forgotten event. The fledgling University, flush with Government support and donations from those who would style themselves as patrons of science, had sponsored yet another young and energetic man with an idea to further the collective understanding of the world. If the expedition failed the University would lose funds it would replace easily enough, the sailors on the ship however, had far more at stake. All that was far from the sailors’ minds, at least the ones whose turn it was to brave the elements on deck, entrusted to prevent disaster while their colleagues slept below decks. These waters are perilous; icebergs as big as ships drift south from the northern waters, pirates lie in wait behind islands to surprise unsuspecting captains, and the ever-present fog obscures all, threatening to throw even the most careful navigators off course. Deckhands and able seamen alike dread the sudden command “Hard to starboard!” signifying the sudden appearance of a threat requiring evasive action. The demand of maintaining constant alertness for this takes a toll, a minute’s delay in responding can be the difference between the end of one’s journey and living to sail another day. Ships in the north Atlantic have but one defence against chaos. Sitting high above them in the crow’s nest is their greatest weapon, the lookout. High above the fog this lookout, always an experienced surveyor sent by the University, has a literal bird’s eye view of the sea ahead. It is a foolish captain indeed who doesn’t listen to the instructions periodically called out from above and redirect course. Lookouts have been known to fall asleep, leaving their ship with no warning of impending threats. But as long as they remain alert and the captain listening, there are far fewer perils that can surprise a ship. The captain gazes dead ahead, cursing the fog below their breath for an uncountable time. The University expects the ship’s arrival in New York before the year is out but at this rate they could be heading for the Spanish colonies or the French territories and be none the wiser. Even making port in Baltimore or Martha’s Vineyard would be considered acceptable, though not ideal. “5 degrees to port cap’n!” the disembodied voice calls down from above, breaking the reverie. “Thank goodness for the lookout,” the young captain mumbles for an uncountable time, turning the wheel as he does.
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Most everyone accepts that overweight and obesity are problems, understands that they are only becoming more common, and realises they are more difficult to address than a passing understanding would seem to suggest. Overweight and obesity (obesity hereafter for ease of reference) cause a raft of health problems from arthritis and sleep apnoea through diabetes and many types of cancer. Even obesity without these complications, so-termed ‘metabolically healthy’ obesity seems to shorten one’s lifespan. Treatment in Australia is usually a stepwise progression through what are largely seen as three tiers with later tiers being added to earlier ones when a patient ‘fails’ (medical professionals have a hard time divesting the cold language of certainty) an earlier tier:
Each tier is progressively more intense, that is the options within them tend to have a greater impact upon weight but also more effects on the patient’s life. Due to funding and the way the Australian system has evolved we are in a peculiar situation where lifestyle therapy is seen as the default first-line option for all-comers. For those in whom this is ineffective and can afford the non-PBS medications these are trialled, and those who can’t afford the medications (or if these are ineffective) and meet the criteria for publically-funded weight-loss surgery are put on the waitlist for this. The problem lies in the execution. Most publicly-funded bariatric clinics don’t have access to the full spectrum of lifestyle therapy options. Certainly there will be doctors and dieticians present but exercise physiologists / physiotherapists and psychologists usually don’t feature amongst the clinic staff. Thus it is arguable whether these clinics, hamstrung by insufficient funding, are able to provide comprehensive lifestyle therapy, thus reducing its potential benefit for patients. What is clear is that funding needs to increase and this should be directed towards greater access to all tiers of obesity therapy, especially to medications, which are at present completely unfunded in this country. However, a conversation with a colleague recently raised an interesting point for me. It is increasingly clear that obesity is not purely a ‘lifestyle disease’ but a complex gene-environment interaction. Genes affecting everything from appetite to fat cell metabolism have been linked to obesity and the interplay of one’s genetic predisposition to obesity and exposure to the modern calorie-rich obesity-causing environment cause obesity rather than a moral failure on the part of the struggling patient. Medications target various aspects of these disease mechanisms. Yet it is clear that lifestyle measures targeting behaviour, when administered in an appropriately supported environment, work. The DiRECT trial in the UK recently proved this. Recent medication trials of liraglutide and lorcaserin also showed this; while the medications caused impressive weight loss, they were compared to placebo groups that were given intensive lifestyle therapy, groups that also lost significant amounts of weight. The key seems to be in providing sufficient support. When someone in the community is trying to lose weight but they’re fighting against the easy availability of calorie-dense food, the eating habits of their family and work colleagues, and a modern environment that actively discourages physical activity, it’s a wonder anyone is successful. But when part of a program where everyone else is trying to lose weight or trying to help you do so it becomes a whole lot easier. Thus when my colleague said they felt we would be doing a disservice to our obese patients by asking them to see exercise physiologists, much less psychologists, I was initially taken aback. They clarified that by doing so, the message we send obese patients and the general public is that obesity is a ‘lifestyle disease’ caused by ‘moral failure’ and if you can just get your head right you won’t be obese any more. Nothing could be further from the truth but I see their point. This is especially true when we have to tell patients that they can access clinical psychology through various government-subsidised pathways (though not in the clinic itself) but the PBS won’t fund the medication we would like to prescribe them. Considering all these elements together it is clear my colleague has identified a symptom of the deeper problem. When a complex disease such as obesity is lazily ascribed to nothing but poor self-control at a policy level we get the current situation. But if appropriate recognition of the wider causes were achieved with government and other authorities then it would be only natural for medications to become a subsidised part of therapy. In this situation both intensive lifestyle and medical therapy could be given concurrently, long been shown to be the most effective treatment paradigm for obesity. As Daniel Drucker, a renowned researcher in the field has said, the key will be to show an improvement in mortality with obesity treatment. When we show this, no one will be able to argue that obesity is not a disease worthy of treatment. Thus it is clear clinicians, scientists, and the informed public need to redouble our efforts to reframe the general understanding of obesity, that it is a complex disease and not a lifestyle ‘choice’. Only then can we expect to be able to give our obese patients the comprehensive care they deserve. |
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