On my first day as a medical student, I was told by a very wise and sage-like professor that medicine is not a science but an art—the art of entertaining people while nature cured them. He also said that there were three rules of medicine to learn. First, children suffer lots of self-limiting illnesses, some that are fatal unless spotted early, and some that are incurable. Second, middle-aged people suffer from their own excesses—such as smoking, drinking, and overeating—and the illnesses associated with that behaviour. Third, old people die.
Not much has changed except that people are living longer into old age with the consequences of their behaviours, and that there is now a perception that if you throw enough money at something, death is preventable. If death does occur, then someone is to blame and can be sued. Death is no longer seen as an acceptable outcome, yet it used to be one of the two certainties of life. That and tax. Though now, if you are rich enough, the tax issue can be avoided. Sadly, no matter how rich one is, death is certain.
The public are bombarded on a daily basis with what is good for you, what is bad for you, and endless solutions to all of life’s ailments. These ‘cures’ come at a cost, but if you are willing to pay, then you don’t have to suffer. The medical profession is as much to blame for feeding this promise of eternal health and wellbeing as the media. We are finding solutions to problems we didn’t know we had and medicalising every aspect of normal life.
You are no longer responsible for your eating to obesity, nor do you need worry about the consequences because we can cure you with bariatric surgery. Using extrapolation models, we can prove that the surgery will be cost effective by preventing all the associated diseases, such as diabetes and osteoarthritis. ‘Buy it now, to save in the future’, as approved by the National Institute for Health and Care Excellence. Sadly, the quick fix is easier than tackling the cause. I have had several patients undergo bariatric surgery who are now ruing their decision. One poor lady has become so malnourished that she is now fed by a percutaneous endoscopic gastrostomy tube and liquid feed. I watched another person trying to eat a sandwich; he had to chew each mouthful nearly thirty times so that he didn’t vomit. His diabetes is cured but his life is miserable. We should be putting as much effort into prevention as we are into treatments, by challenging the decisions of councils on their health and wellbeing policies. Who in their right mind allows a fast-food chain to open on the walking route between a deprived estate and a local school, and then sells off the playing fields? Jamie Oliver started to try and change school meals but the squeeze on funding means only cheap food is affordable. Healthy eating is an afterthought, as is encouragement to exercise. Education is the key to prevention and so is early intervention.
The difficulty is that, unlike alcohol or drugs, we cannot survive without food. The causes of obesity are many and varied and, in my experience, usually relate to some psychological distress. There is often unhappiness, poor self‑image, and guilt about loss of control. I did, however, have a patient who came in having gained several stone after I had started him on a statin to reduce his cholesterol. He had misunderstood that the pill was not a ‘get out of jail’ card to allow him to eat what he wanted because it would reduce the fat in his blood!
I see that it’s my job as a cradle-to-grave doctor not to shy away from the difficult conversations about weight. It can be difficult and upsetting but it does work. Last year, I had a man who came to see me, having lost nearly 5 stone. His blood pressure was back to normal, his fasting sugar and lipids were no longer out of range, and I congratulated him on his achievement. He said he was so offended that I had called him a fruit the last time I saw him that he wanted to prove me wrong. I racked my brains to recall the insult, and remembered I had said he had the classic apple shape of central obesity, which was a cardiac risk factor. Perhaps I should patent that cure!