Specialists feel all should share in obesity burden

Should society keep on footing the bill for people who fall ill because of their own lifestyle choices? Doctors in the Netherlands say punishing bad behaviour just doesn’t work.

Mrs. Gouw (61) burst into tears. She had tried so hard, she said. She had been eating one sandwich less and taking 45-minutes walks every day. She vacuumed and scrubbed around the house. Still, she had not dropped a gram since last month, and still weighed exactly 89.5 kilo. “This is hard for you, isn’t it,” said Sophie Hickox, a nurse practitioner at the outpatient clinic for vascular medicine in Utrecht’s UMC hospital. Gouw responded with even more tears.

Just before Gouw stepped in, Hickox explained she did not belief in punishment as a means of changing unhealthy behaviour. “Research shows support, rather than punishment, helps. Support and understanding from medical staff, but also from friends and colleagues is paramount. Punishment only affirms our sense of rejection and the idea that we are incurable wrongdoers, which in turn will only entrench our bad habits more deeply.”

Hickox is a member of a team led by Professor Frank Visseren, a physician who teaches vascular medicine. Visseren is at the forefront of a public debate which is by no means unique to the Netherlands. The question: should people who behave in a manner detrimental to their own health be allowed to draw on public medical facilities, sometimes costing society dearly in the process?

Last week, Dik Hermans, chairman of the Dutch association of medical insurers, posed this emotionally charged question in an interview with Dutch newspaper Trouw. Visseren is one of many Dutch physicians who have come out in opposing his suggestion. Doctors have cited numerous arguments against the idea. Keeping tabs on people’s behaviour would be impossible in practice, and what constitutes unhealthy behaviour is hard to define. Should those suffering from heart disease because they work too much also be punished? Research has also shown smokers are not actually a burden on society, as they live shorter and pay excise over their tobacco.

Visseren has another argument against penalising the unhealthy for their behaviour: it doesn’t work. Visseren could be called something of an expert in the field, at his clinic, he is constantly trying to get people to change their unhealthy ways.

Visseren invited his patient Zur Lage (65) in from his waiting room. Lage, a retired entrepreneur suffers from a hereditary thyroid defect. He only became aware of it 15 years ago when he failed a medical exam conducted by his insurer. “To reduce my risk of vascular disease, I became a teetotaller and tried to avoid tasty food whenever possible,” Lage said.

He would seem to be an exemplary patient. Lage says he cycles 4,000 kilometres a year. He plays tennis four times a week and goes swimming regularly. He doesn’t look fat, perhaps a little bit sturdy. Visseren, however, was blunt with his patient: he has been five kilos overweight for three years already. He has to lose the weight. “I’m going to devise a strategy this time,” Lage said.

At Visseren’s clinic, cure and care are handled by different staffs. Visseren is in charge of cure, Hickox of care. In close cooperation with other specialised nurses working at the UMC, Hickox wrote the book on changing unhealthy lifestyles, literally. Her Manual Vascular Risk Management is a bulky booklet full of tables, protocols, parameters and guidelines. “Patients commonly exhibit numerous of traits placing them at elevated risk," Hickox said. "They are too fat, and they smoke, and they have high blood pressure, and their cholesterol is too high. They can only improve on all by improving their lifestyle. That means changing behaviour and that can be tricky stuff. Someone’s identity is at stake. This is why Mrs. Gouw’s tears are good. They signify a break with the past. “

Hickox helps her patients plan their new lifestyles. “But we only help them for a year, tops. A time-limit motivates people, which is important because, in the end, they are on their own. I can only make sure they know what risks they are exposing themselves to, what kind of medical conditions they suffer from and what they should be taking for it. I also try to give them confidence that they are able to change their own behaviour.”

A 56-year old patient with diabetes proves just how hard that can be. A recent diagnosis showed her veins are slowly deteriorating, a troublesome development in her health which had long been predicted by her doctors. In spite of this ominous prospect, she was unable to quit smoking. “She is heavily addicted. She was also laid off due to the recession, which doesn’t help. Should we really punish someone like her by raising her insurance payments? She is obese and diabetic, making here an extremely high-risk patient. And those are the patients who need and deserve the most care,” Visseren said.