Are obesity and smoking contagious?

The Framingham Heart Study is perhaps the most famous long-term medical study. As every medical student learns, starting in 1948, the lifestyle habits of thousands of residents of Framingham, Masschusetts were followed to determine important risk factors for cardiovascular disease. It is because of this study that your physician can, with a few keystrokes, predict with great accuracy your risk of having a heart attack within the next 10 years and what you can do to reduce that risk. I've found the "Framingham calculator" to be a terrific educational tool in my practice, especially to illustrate the typically underestimated heart benefits of quitting smoking versus taking costly drugs for high cholesterol or high blood pressure.

In recent years, researchers have begun mining data from the Framingham study for other purposes. Last September, a New York Times magazine article described the work of Harvard physician Nicholas Christakis to test the theory that health-related behaviors, such as eating, exercise, and smoking, could be "contagious" - that is, could spread in a fashion similar to the way an infectious disease spreads. In 2007, Christakis and his collaborators published a paper in the New England Journal of Medicine that gave new meaning to the term "obesity epidemic": they found that Framingham Heart Study participants who had siblings, spouses, or friends become obese were at much greater risk of becoming obese themselves, an effect that was independent of geography. A year later, Christakis's team published another paper that showed the same phenomenon in smoking cessation. Your friends quit, your spouse quits, your brother or sister quits, and chances are good that you will follow their lead.

Doubtless most family physicians won't find these conclusions to be earth-shaking; since they care for all members of a family and are often tightly connected to the community in which they practice, FPs may have long suspected that the one of the keys to motivating patients to lose weight and stop smoking is to convince their family and friends to do the same. The same goes for a recent story in USA Today about pediatricians (who are only trained to care for patients age 18 and younger) belatedly recognizing the profound influence that parental health has on the health of infants and children. Reporter Liz Szabo wrote:

A growing number of pediatricians are now calling on their colleagues to address parental medical needs — such as depression, smoking cessation and vaccinations — that directly affect a baby's health.

I'm glad to hear that pediatricians have started to figure this out, but to family physicians, the benefits of treating parents and caregivers should be second nature, rather than front-page news. Unhealthy behaviors may be contagious, but so are healthy ones. Spread the word!

Guest Blog: Reflections From a Senior Citizen

Dorothy Kligerman is ninety-five years old, widowed, with three married children, four grandchildren and two great-grandchildren. Her first published work appeared in February, 1931, in The Record Book of her graduating class at Simon Gratz High School in Philadelphia, PA. The next time her work appeared in print was not until the 1980s, while she was working as a reporter for the Mt. Airy Express. The paper folded at the end of that decade. Again there was a hiatus, until in 2006 she enrolled at TARP (Temple Association for Retired Persons), sponsored by Temple University, which offers many courses for senior citizens. She enrolled in the Poetry Workshop, led by the energetic and inspirational Peggy Walsh McKenna. The following poem first appeared in Pulse Magazine.

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REFLECTIONS OF A SENIOR CITIZEN

I used to talk of fun and games
Now I talk of aches and pains.
I used to paint the town bright red
Now at nine I am in bed.

I used to dream of lovers bold.
Now, if truth be told
The only men who interest me
Are those with a medical degree.

"Why," you ask, "have they such clout?"
Well - we have so much to talk about:
There's my arthritis and stenosis,
Hypertension, scoliosis.

In a cozy room, alone, we chat.
We never have a lover's spat.
So keep your handsome Romeos
I'll always take those medicos!

- Dorothy Kligerman

Getting health reform done: the Taiwanese experience

My parents were both born in Taiwan, and about every four years (most recently, last November), I travel there to visit relatives. Since I was a child, Taiwan always struck me as in the same league as the U.S. with respect to advanced technology - in fact, they had the newest handheld video games (and later, the Nintendo Wii) months before these games arrived in stores in the States. But it wasn't until recently that I learned from a New York Times blog that Taiwan made the transition to unversal health care insurance in 1995, not long after the Clinton health care plan failed in the U.S. In a single year, Taiwan went from insuring only 55% of its population to 95%, and today the figure is close to 99%. (By comparison, U.S. Census data suggest that about 85% of the U.S. population has health insurance at any point in time, a figure that fluctuates as people lose their jobs and become poor enough to become eligible for state Medicaid coverage.)

How did Taiwan arrive at their health reform plan? After appointing several prominent domestic experts to a special task force that went nowhere due to differing views on how the new system should work, the government invited an American economic professor from the Harvard School of Public Health to break the impasse. As Dr. William Hsiao stated in an interview for the Times blog, "It turned out to be a big advantage that I'm not Taiwanese and had no aspirations of getting a job in Taiwan. At the end of the day, our recommendations and findings were perceived as more objective and free of self-interest."

The task force recommended that Taiwan adopt a single-payer model, analogous to the Canadian national health system. Highlights of the plan that was implemented include coverage for traditional Chinese medicine ("We tried to design a benefit package that would give people what they value," explained Hsiao), prevention and primary care, home health care, and a single, uniform electronic medical record system. With low co-payments and low administrative costs, the share of Taiwan's gross domestic product devoted to health care is about 6 percent, compared to 17.3 percent of GDP in the U.S. in 2009.

While it's hard to escape the irony of Taiwan inviting an expert from the U.S. - a country that has, after all, failed several times since the 1930s to enact comprehensive health reforms - to tell them what to do, the Taiwanese example is instructive as President Obama's bipartisan "health care summit" approaches. Perhaps our Congress should invite a foreign health policy expert without a stake in the outcome to make reform recommendations that are "objective and free of self-interest." Preferably from a country with more insurance coverage, better quality of care, lower infant mortality rates, and longer life expectancies than our own ... which, alas, leaves plenty of countries to choose from.