Last month, a report appeared in the British Journal of
Cancer reporting that nearly half of all cancers in the UK were due to
lifestyle choices, and were therefore preventable. As if in response, the NHS
Future Forum released a report last week recommending that NHS providers talk to their patients about diet, exercise, smoking, and alcohol consumption at all visits, even if the patient was coming in for an ‘unrelated illness’, in an
effort to tackle a dramatic rise in obesity and cancer in the UK. I’d like to
take today’s column to laud this initiative and discuss some of the objections
that have been raised.
First, though, let’s set the stage. For those not familiar
with healthcare in the UK, the UK enjoys a publicly-funded healthcare system,
the National Health Service, which was set up after World War II to create a
coherent, nation-wide healthcare system. Though some private insurances exist
in the UK, the majority of Britons receive their care through the NHS. Because
of the scope and size of the NHS, there is an ability to set a national
healthcare agenda in a way that is more difficult to achieve here in the
States. Our medical system, because it is privately-funded and not fully
integrated, allows for doctors to have much more individual freedom in the way
they practice, for better or for worse. The way the NHS works means that this
recommendation would hold considerable sway in the way docs practice in the UK,
should it become an official policy.
Now on to the part where I sing the praises of these recommendations. I blogged earlier this week about the aforementioned study showing that a significant portion of cancers
are due to preventable lifestyle factors, factors these recommendations are
meant to modify. Additionally, I blogged over the summer about a study which
showed that, in combination with each other, smoking, excessive alcohol, poor
diet and lack of exercise take about a decade off a person’s lifespan. The
imperative of promoting healthy lifestyle to reduce death and disease is clear.
The main objection that has come up against this proposal is
that patients would view these questions as intrusive, and may decline to seek
medical care for fear that they would be badgered about their habits. While I
think there’s a reasonable point to be made here, it’s a poor comment on the
clinical skills of clinicians if they are viewed as ‘lecturing’ their patients
or ‘intruding’ on their lives. I’d like to think that all doctors, no matter
their own personal styles, can learn to communicate in ways that encourage open
conversation and partnership with their patients, rather than the moralizing
and lecturing we might have expected from our Victorian forebears. The NHS
Future Forum’s head, Professor Steve Field, said in an interview to the
Guardian that the policy would not create a ‘nanny state’, and I agree, and
likewise agree that the practice of healthcare workers asking their patients
about health habits need not be overbearing when conducted in a spirit of
cooperative problem solving.
The main issue I would raise with the report is that I
believe it has an unfortunate misconception at its core. I know this is a large
accusation to levy at a report that I’ve just touted very loudly, but I think
it’s a true one. Here’s the misconception: that some diseases are unrelated to
diet, exercise and other health habits. It’s true that some diseases are more
directly caused by environmental and lifestyle factors, but the body’s ability
to combat nearly any given illness is largely determined by its nutritional
status, how efficiently its organ systems operate, it’s overall antioxidant
status and other factors that are strongly influenced by issues such as
smoking, diet, exercise, etc. So really, doctors shouldn’t be checking up on
these topics even if they are unrelated
to the presenting illness, but because they are almost certainly
related to the current illness. Not only
does checking in on the health habits give the provider an opportunity to help
prevent future chronic disease, but it helps the provider deal with the patient’s
current illness, whether it be elevated liver enzymes, chronic back pain or the
common cold.
The interrelatedness of health habits and disease also goes
some of the way to solving the objections raised. Yes, it’s nosy to ask about
topics that are unrelated to the current illness, but when you’re asking about
factors that are related to the current illness, you’re doing your job as a
health care practitioner.
To wrap things up, I think this is great news. By inquiring
about health habits at all patient encounters, the NHS would start to shift
from a disease-management system to a health-promotion system. A reactive
system that deals with problems once they have come up is playing a losing
game, because it’s always chasing what has already happened. A proactive
system, one that looks down the road, predicts potential pitfalls, and takes
action to prevent future problems is positioned to win. As I’ve said, the
current proposal is imperfect, but laudable, and it could mark a significant
step forward in the fight against diseases both acute and chronic.
