The solutions are neither dark nor mysterious, but like so much else require exertion, and the literature on how to change bad habits is as old and as predictable as the habits themselves.
The good news is that the advice is straightforward, even if “no one is particularly good at it,” according to Dr. David Greenberg, lecturer at the University of Toronto and member of the Department of Family and Community Medicine at St. Joseph’s Health Centre in Toronto. But the advice is readily available.
Greenberg will speak on Oct. 21, the second day of the seventh annual Ministry of Health healthcare conference, subtitled “The Chapters of a Healthy Life.” He will address an audience at The Ritz-Carlton, Grand Cayman from 2-3 p.m.
The formal title of his talk is “Development and Implementation of Men’s Health Guidelines for Family Practice and the Alpha Male – How to Care for the Man Who Doesn’t Think He Needs Your Care.”
Men’s health has gained significant attention in the past decade, but the same issues continue to plague the demographic. Greenberg, director of the Canadian Society for the Study of the Aging Male and director of the Canadian Men’s Health Foundation, which promotes the health of men of all ages, says “there are 56 million people in Canada – and $27 billion is spent for lost time and productivity at work.”
Men at risk for a variety of conditions
He also notes that Canada has 8 million men over age 40 who are “at risk for a variety of conditions” that are either unique to men or who are subject to specific issues requiring management – and “there are loads and loads of issues.”
He lists: Loss of sex drive leads the list, followed by anemia, low energy, depressed moods, high blood pressure and obesity.
Others are: sleep deprivation and sleep apnea, osteoporosis, loss of muscle mass and pre- or full-blown diabetes. All, he said, are associated with the condition generally diagnosed as low testosterone.
Low – and lowering – levels of the hormone begin to affect men as they turn 40 years old. “When you hit that age, two things start to happen,” Greenberg says. “You lose 1 percent of your testosterone every year, and the body uses less.”
He points to the 10-point ADAM [Androgen Deficiency in the Aging Male] questionnaire, developed in September 2000 to assess “low-T.”
“We use it as a screen to figure out if men have an issue,” Greenberg says, as an empirical counter to what he describes as typical male attitudes toward their health.
“Real men don’t go to doctors; real men don’t talk about their problems; real men are invincible and real men cannot NOT go to work because the system cannot function without them.”
The questionnaire is a series of yes-or-no propositions such as “do you fall asleep after dinner,” “are you sad or grumpy,” “do you have a decrease in libido” and “do you have a lack of energy.”
“Yes” to more than three of the queries – or to numbers 1 and 7 in the list – may indicate low-T, and a need to visit the doctor.
“I have a picture of what the post-40 guy looks like,” Greenberg says. “He has trouble concentrating, he falls asleep on the sofa and isn’t interested in having sex with his wife, and this makes him neither a great spouse nor employee.”
The solutions, he says, involve more than just a conversation. Pointing to the diversity of the Cayman Islands, for example, he says the 130 nationalities generally comprise small and wealthy groups of people.
“I have 3,000 patients,” he says, and Canada comprises every economic and social class – talking to them alone is an enormous undertaking. His degree in sociology, he says, means that unlike most physicians, he has thought about social and psychological backgrounds, “cultural perspectives,” and how he can most effectively speak to a patient.
“You learn how to size them up very quickly,” he says, identifying broadly general “archetypes.”
“You need to know how to talk to them and what is the right thing to say.” Sadly, he says, “no one is particularly good at it. There is a Nobel Prize waiting for whoever figures that out.”
Mostly, he says, the conversations regard “basic lifestyle changes: eating properly, for example,” he says, which is not necessarily counting calories as much as embracing guidelines about fiber, fruit, vegetables, avoiding sugar and achieving an overall balance; “quitting smoking,” which most guidelines indicate must embrace total abstinence to be effective; exercising and not drinking too much.
As such, his conversations about male health are “not so much about transferring information, but about changing behaviors.” He points to the “transtheoretical model,” marking stages of change, developed from 1977 by James O. Prochaska, professor of psychology and director of the Cancer Prevention Research Center at the University of Rhode Island.
Prochaska’s model suggests five stages to behavioral change: Precontemplation, meaning the subject is unready to change for any number of reasons; contemplation, meaning the subject intends to change in the next six months; preparation, meaning the subject intends to act, probably in the next 30 days and may have taken steps in the previous year; action, in which people have made specific modifications within the previous six months; and maintenance, in which the subject has made modifications and is trying to prevent a relapse.
“We try to move along one step at a time,” Greenberg says, “and that means, for example, not moving from smoking and drinking straight to Olympic athlete, but taking ‘baby steps.’”
Behavior modification is exactly what Cleveland Clinic’s Dr. Wael Barsoum plans to discuss as the final speaker at the conference.
Titled “The Chapters of a Healthy Life: Change your Chapter by Modifying your Behavior,” Barsoum’s one-hour talk, at 11:30 a.m. on Oct. 22, will confront the origins and treatment of chronic conditions, the factors driving costs in the U.S. healthcare system and preventive measures that can reduce a patient’s costs by reducing exposure to the most expensive care.
Like Greenberg, Barsoum says health management must be the future of medicine, reducing costs and improving the patient experience.
“The issues are that we have a healthcare system that is designed to be disease-focused,” says Barsoum, who is president of Cleveland Clinic Florida and vice chairman of the Department of Orthopedic Surgery, where he specializes in reconstructive and minimally invasive surgery of the hip and knee, including arthroscopy, and primary and revision joint replacements.
America’s healthcare system, he says, becomes involved “only when someone is sick, and that is an expensive way to practice healthcare. We are a system that is reactive rather than proactive in treating and managing chronic disease.”
While he indicates solutions are not complicated, they require personal discipline and even political will: “If you drive health management, obesity management [and] reduce visits to emergency rooms, you will reduce healthcare inflation and reduce costs.
“In the United States, the top causes of death are heart disease, cancer and respiratory diseases. In the Cayman Islands, the top causes of death are cancer, cardiovascular disease and diabetes.”
If risk factors can be modified, he says, quality-of-life issues will improve and longevity increased.
“We empower our patients to focus on wellness and healthy living,” Barsoum says, pointing to financial models correlating prevention and reduced costs.
He lists some of the more obvious modifiable factors – obesity, high blood pressure and diabetes – and says they “will play a major role in the life of the individual and the overall cost of healthcare to society. “
To combat this, he says, “We have to start thinking more about proactive healthcare. Patients have to take an active role in managing their health more and more,” echoing longtime Health Services Authority admonitions in Cayman about “personal responsibility.”
“With healthcare providers and patients working hand in hand,” Barsoum says, “and with strong care coordination, we can make a real difference in bringing better value to healthcare.”
He proposes two steps to achieve the outcome: “First, we must continue the shift in our nation’s healthcare system from fee-for-service to pay-for-performance,” linking cures and restored health, rather than simple treatment, to costs.
“We must place value and quality over quantity, moving to value-based care [and] focusing on quality, safety, efficiency and outcomes.”
Second, he says, “empowering patients to practice wellness and healthy living” means fewer demands on doctors, less-expensive medical treatments and better-controlled costs.
Clinic administrators, demonstrating the efficacy of what Cleveland’s doctors preach, have implemented health-management principles in their own employment practices, resulting in the astonishing loss of a collective half-a-million pounds of excess weight, Barsoum says.
“Many years ago, we made the decision to stop hiring smokers, and we offered smoking-cessation programs to help our existing employees stop smoking,” a risk factor for heart and lung disease.
“We provide our caregivers with gym memberships, an on-site fitness center, yoga classes and Weight Watchers – all free. We also offer a weekly farmers market where employees and patients can purchase locally grown fresh fruit and vegetables.
“Since we began our wellness program,” he says, “our caregivers have lost a combined 500,000 pounds and our employee health costs have plateaued.”
Old models disrupted
Contributing to the changes, many traditional healthcare proscriptions have shifted, disrupting old models and forcing re-examination of old assumptions.
“For decades, we have been given the wrong information,” Barsoum says. For example, “We were told that all fat was the culprit. The traditional food pyramid as we know it does not work for most people because there is a direct correlation between simple carbohydrates and obesity and diabetes.”
Placing responsibility on physicians and, more explicitly, their patients, means better prevention, management and control: “The type of diet and exercise habits we have are the drivers that lead to optimum health.
“Carbohydrates are a huge part of the obesity epidemic. We now know that avoiding some carbohydrates and sugar stabilizes insulin levels. Diet and exercise have a direct effect on modifiable risk factors, which are high blood pressure, cholesterol and diabetes. Smoking, which puts people at risk for many types of cancers, heart disease and lung diseases, is a modifiable risk factor that we can control,” he says.
Physicians can inspire their patients, and it is here that Barsoum echoes some of the themes articulated by Greenberg. “Forty percent of the risk factors for premature mortality are behavioral, which means there are specific behaviors a person chooses that directly contribute to chronic disease.”
He names obesity, poor diet, a sedentary lifestyle and smoking as four clear problems, but observes that no single solution addresses all of them. The implication is clear: Changes must be holistic – and that is where physician support is critical.
“You can’t exercise yourself out of a poor diet. Shifting exercise habits from spending one hour on a treadmill to short bursts of high-intensity interval exercise reduces insulin resistance and reduces hunger. Changing your diet to one that is plant-based, includes healthy fats, lean protein and vegetables has been shown to reduce cardiovascular disease, maintain weight control and blood glucose levels.
“By shifting our focus from managing acute episodes to managing patient populations and shifting from sick care to wellness and prevention, we will provide better care while at the same time empower patients to reduce the environmental risk factors that contribute to chronic disease,” he says.
Barsoum says alternative medicines and treatments are not always effective, and that no single entity – such as the processed-food industry – can be blamed for modern health challenges. Acupuncture, moxibustion, ayurvedic medicines, even vegetarian alternatives may have a value.
“There is conflicting data in the medical community about the efficacy of various types of nontraditional medical alternatives,” he says. “I would encourage people to follow the advice of peer-reviewed data that is science- and evidence-based.
“However, if someone wants to try an alternative, even if it provides a placebo effect and does not harm them, I say go ahead.”
The healthcare conference runs Oct. 20-22.