Health-care reform should give incentives for prevention

In the debate over health-care reform, one elephant in the waiting room isn't being discussed. We have been told repeatedly that our health-care system is not only the most expensive in the world but one of the least efficient in meeting the health-care needs of the nation. So how do we solve these two problems? From my perspective as a physician, I would say we need to start by taking a hard look at the diseases we are doing such a bad job of controlling and at the individuals who suffer from them.

Those of us providing front-line care for Americans — nurses, physicians' assistants, pharmacists — have a perspective that differs from the bureaucratic physicians in the American Medical Association and other specialist organizations, because we literally have our fingers on the pulse of Americans. And a lot of us have come to realize that most medical problems are brought on by the failures of humans.

Human metabolism is not that far evolved from the Stone Age and is better geared toward surviving famine than it is to the current abundance of high-calorie food and the pervasiveness of passive activity.

Obesity and lack of exercise are behind many common diseases. Type 2 diabetes, which leads to heart disease, vascular problems, hypertension, kidney failure and erectile dysfunction, is at epidemic proportions and is primarily a disease of the obese. And we're seeing the problem in younger and younger people.

An article in the Journal of the American Medical Association this spring delineated how excessive weight gain in the first three months of life is associated with cardiovascular disease and Type 2 diabetes in early adulthood. Yet for many reasons, exclusive breast-feeding, which often prevents early and dangerous weight gain, just doesn't happen much in our country. Another article this summer concluded that a diet high in fruits, vegetables and nuts and relatively low in meat (a "Mediterranean" diet), coupled with physical activity, was associated with a reduced risk of Alzheimer's dementia. Many common types of cancer also strike the inactive and the obese at a higher rate.

Among the patients I treat are some who work in the fields of California's San Joaquin Valley, and I am intrigued by them. Although their genetic inheritance makes them a target for high cholesterol and joint pain, and of course diabetes, they don't tend to get those conditions often — at least not until they stop working in the fields.