Doctorshealthsystems

One of the physician’s tasks in the sleep disorders clinic is to distinguish between patients with potential sleep apnoea and those with other complaints which adversely affect the quality of sleep. Stress related insomnia, for example, has no place in the laboratory dedicated to sleep related breathing disorders. The following case studies are fairly typical of patient histories which warrant complete evaluation of their symptoms. While they do not accurately reflect the incidence of snoring or OSA in any particular age group or sex, they have been included to demonstrate a diversity of presentations.

Case 1

A 38 year old travelling salesman had been a heavy snorer for years, aggravated to some extent by the consequences of a broken nose. He was a restless sleeper and often awoke in the morning with a headache. Daytime drowsiness was beginning to affect his attention span and driving competence which eventually led to his falling asleep while driving the car on a long business trip. He was not seriously hurt but the incident prompted investigation of his daytime sleepiness. Examination by his local doctor found him to be moderately overweight for his height and it was noted that he enjoyed five or six cans of beer at night. The doctor advised that his long working hours and drinking habits could explain the worsening symptoms and suggested he lose some weight and take time off for a holiday. Some weeks later he was involved in another near miss driving incident, prompting him to seek advice from another practitioner who referred him to a sleep disorders clinic. Overnight studies confirmed OSA and he began a trial of nasal CPAP which he tolerated well. His quality of sleep and daytime alertness were improved to the extent that he purchased his own CPAP equipment for use both at home and in motel rooms when required to sleep away from home. Weight loss and reduction of alcohol intake improved his condition slightly but not enough to eliminate his dependence on nightly CPAP, a situation he has come to accept as necessary for his wellbeing in the foreseeable future.

Comment: An example of OSA as it is most commonly seen. The patient is middle aged, male, overweight, drinks alcohol at night and has a predisposing factor to airway obstruction (a broken nose). For those who have suffered the symptoms of OSA for years, CPAP offers remarkable relief, an advantage which clearly outweighs the disadvantages and inconvenience associated with its use.

Case 2

A 32 year old woman enjoyed good health and led a particularly busy life with three young children and a part time job. She and her husband heard a discussion about snoring and OSA on a late night variety show on television which they viewed with mild amusement until some of the more serious aspects of the syndrome were aired. The wife was in fact a snorer but it rarely disturbed her husband as he was a very sound sleeper. Some months later she had reason to see her doctor on an unrelated matter and although rather embarrassed, she brought up the subject of her snoring. On examination she was found to have excessive fleshy tissue associated with the soft palate at the back of her throat, narrowing the entrance to the upper airway. There was no history of daytime breathing difficulty and no evidence of underlying disease. Referral to a sleep disorders unit confirmed her husband’s account of nocturnal snoring but there were no episodes of complete airway obstruction and none of the measurable features of OSA. Surgery to remove tissue from the throat was an option but as neither the patient nor her husband was particularly disturbed by the snoring, they chose not to intervene.

Comment: This woman’s state of health and level of physical activity makes the diagnosis of OSA extremely unlikely. The exclusion of underlying sleep disorders is reassuring for both doctor and patient and should never be considered a waste of time.

*15/51/5*

Preventive medicine is very difficult to define and today it is no longer acceptable to think simply in terms of preventing the occurrence of specific disease processes. With current trends to whole-person health there is a more holistic approach which involves a more positive approach to preventive health care. Most people understand preventive medicine in terms of public health activities such as immunization for children, the control of fresh water supplies, safe sewage disposal, an assurance that foods and drugs are safe and the detection and control of infectious diseases. These activities are routinely and effectively carried out by local health authorities in most western countries, and we tend to take them for granted. Today we face new problems of prevention, with chronic diseases and self-induced environmental hazards causing a substantial proportion of all illnesses and deaths.

Partly because of the way that preventive medicine has grown out of public health and sanitation and partly because of the way that health care is centered on after-the-fact Procedures, preventive medicine is poorly regarded within medical and health circles and most doctors simply pay lip-service to the concept. This statement is borne out by the fact that only 4 per cent of the total US medical expenditure goes on prevention and only 1.5 per cent of all that country’s doctors are involved in full-time preventive medicine! The figures are not much better in other western countries. The influence of preventive medicine is also obstructed by the fact that it needs little that modern technology has to offer and therefore appears to be outdated and simplistic. All of this limits its appeal to those doctors and other health-care professionals who are looking for drama in medicine rather than what is best for society as a whole.

Unfortunately, prevention also tends to be handicapped in another way. Because of the difficulties already mentioned those who do go into it become so frustrated at the small resources and slow progress that they tend to become somewhat evangelical in their zeal to get things changed, so that they alienate even some potential allies. As one expert put it: ‘If there is one thing more difficult than submitting oneself to a regime, it is refraining from imposing it on other people’

*15/72/5*

If one person on a weight-loss program is good, then one person with a partner must be better, right? In most cases, the answer is yes.

A buddy can be an encourager, a confidante, a co-conspirator, and a calming influence. She can persuade you to put on your walking shoes and go for a stroll when you’d rather be vegging out in front of the TV or pigging out at the mall. She’ll listen attentively when you confess to eating a whole bag of chocolate-chip cookies, then suggest that the two of you play a couple of sets of tennis that afternoon.

So how do you go about recruiting someone for this all-important position? Use some common sense, and trust your instincts. If you run into trouble every morning at the office when the pastry cart comes around, consider asking the person in the next cubicle to be your morale booster. If you need someone to coax you out of bed for your 6:00 A.M. workout, maybe your spouse is the weight-loss partner for you.

Nobody at home with you? Look on the Internet. There are all kinds of weight-loss chat rooms, including those connected with the Web sites of organizations like Weight Watchers and Jenny Craig.

Once you think that you’ve found your weight-loss buddy, tell that person what you expect. Are you looking for moral support? A workout partner? Somebody to talk to when the going gets rough? Make your wants and needs clear. That’s the only way that your buddy can help you.

*7\89\8*

Chickpeas are more floury than other beans, with a less ‘beany’ taste, and fewer unpleasant after-effects. So they make a good filler if you cannot eat wheat or potatoes. Soak them overnight, pick out any discoloured ones, and cook in a pressure cooker at 15 lb pressure for 20-25 minutes, or in the ordinary way for 1-1 1\2 hours. If you do find that they give you wind, try removing the skins – they rub off very easily. Tinned chickpeas are not expensive if you buy supermarket ‘own-brands’ [eg Sainsbury’s). Add to soups and casseroles. You can also mash them to make hoummous. Other beans and lentils are also useful fillers for those who cannot eat wheat or potatoes.

Pearl barley is sold in most large supermarkets, and in healthfood stores. Add it to stews, casseroles and soups to make them more filling. The barley needs about 1 – ? hours cooking time.

Plantains are obtainable from West Indian groceries and look like very large green bananas. They are starchy and less banana-like in flavour than one might expect. Peel them (quite difficult – needs a sharp knife) and then fry in oil, or boil and mash. They can also be baked in their skins.

Gram-flour pappadams are obtainable in some Indian groceries and can be eaten as an accompaniment to a meal. Check that they do not contain wheat flour. This is a traditional Indian recipe for gram-flour bread: mix two cups of gram flour with a small finely chopped onion, ? teaspoon cumin seeds, ? teaspoon salt and a pinch of chilli powder. Rub in 1 tablespoon of clarified butter. Add a little water – enough to make a stiff doughy mixture. Take small balls of this and press down lightly with your hand on a floured surface. Fry on a griddle or hot plate, turning once.

*404\180\8*

If you are sensitive to milk, you may be able to substitute goat or sheep milk for it once you have completed the diet. But at this stage, it is better to avoid these as well, as there can be cross-reactions. Soya milk is not advisable either at this early stage, as soya is found quite widely in processed foods and meat products, and some people are sensitive to it even though they are unaware of eating it.

You should be avoiding packaged and processed foods anyway, but if you do eat any, be aware that milk may be called by various synonyms on the ingredients label – see p292.

Most margarines contain some milk solids, and should be avoided anyway as they are highly processed.

*357\180\8*

Is food intolerance becoming more common? It is impossible to answer this question because there is little agreement on how common food intolerance is today (see p81) and no way of find out how common it was in the past. But the general impression, among doctors who treat food intolerance, is that it has become increasingly widespread. There is little hard evidence to support this, apart from 3 few epidemiological studies. One of these concerns Crohn’s disease in Africa. It shows that Crohn’s disease – which has been linked with food intolerance (see pll3) – is virtually unknown in rural areas, but becomes more common when people move into towns. In Britain, there has been a dramatic rise in the incidence of Crohn’s disease since World War II. Rheumatoid arthritis is also steadily increasing, although this is a rise that began in the early nineteenth century.

Crohn’s disease is a serious and debilitating illness – most of those with food intolerance have much milder symptoms. Indeed, many people in the early stages of food intolerance may scarcely be aware of being ill: headaches, indigestion, persistent tiredness and occasional diarrhoea are all reported as the early, symptoms, by those who later become more seriously ill and then discover they are sensitive to food. Symptoms of this sort are everyday problems that most people tend to accept as part of life.

*309\180\8*

In theory, the way to treat a disturbed gut flora is to repopulate the gut with the ‘good’ bacteria, and so exclude the more damaging bacteria and yeasts. Unfortunately, a reliable treatment of this sort will be impossible to devise until more is known about the gut flora. At present, the best treatment is to eat live yoghurt, which includes one-of the important bacteria in the gut, Lactobacillus. There are also commercial preparations of bacteria which are intended to restore the normal flora of the gut. Some of these have been tested by Dr John Hunter of Addenbrooke’s Hospital, who found very few live bacteria in them, making them less useful than live yoghurt.

To ensure that the brand of yoghurt you are buying really is live, add a spoonful to some warm milk that has been heated to boiling point and then allowed to cool. Keep the mixture in a vacuum flask for 6-8 hours. If it has not turned to yoghurt, then the original yoghurt was not live. The best way of ensuring your yoghurt is live is to make your own – starter cultures are available from some health-food stores, or by post.

If you cannot eat yoghurt, because of a sensitivity to milk, then commercial preparations of bacteria might be worth considering, but ask to see a bacteriological analysis showing how many live bacteria there are per gram (there should be several million) before buying.

*259\180\8*

Food aversion –the only non-controversial term in this list – means dislike and avoidance of a particular food for purely psychological reasons.

These definitions are ones that the majority of mainstream doctors practising in this field would feel reasonably happy with. But bear in mind, if comparing this book with other books or articles, that the same words may be used in an entirely different way. It is also important to remember that they are theoretical definitions, and there is a sizeable gap between theory and practice when it comes to diagnosing individual patients. In practice the designation of an illness as ‘food allergy’ or ‘food intolerance’ would not depend so much on skin-prick tests or other tests as on the type of symptoms that the patient shows. If the symptoms are among those traditionally associated with allergy, such as asthma or urticaria, and if foods are shown to be responsible, then the condition will probably be labelled as food allergy, even if skin-prick tests are negative, as they sometimes are in such cases. If, on the other hand, the symptoms are not of the allergic kind – as in Susan’s case – then the label ‘food intolerance’ will be used. Skin-prick tests will not normally be carried out because they are most unlikely to give a positive result, so they will not contribute much to the diagnosis.

In theory, then, the distinction between allergy and intolerance is based on causes. In the doctor’s surgery, however, the distinction is likely to be based on symptoms, because it is known that asthma or urticaria are probably true allergic reactions, while migraine or depression are not. With a symptom such as diarrhoea, the cause might be an allergic reaction, an intolerant one, or something else entirely. In such cases, special tests would be needed to make a diagnosis of ‘food allergy’.

Where patients show a collection of symptoms that include, say, asthma and migraine, the diagnosis is more difficult. If all these symptoms clear up at once when certain foods are avoided, is it allergy or is it intolerance? This is not a question that can be easily answered at present, and for the purposes of this book we will use the umbrella term ‘food sensitivity’ to cover such situations.

*11\180\8*

Players: Husband and wife.

Activists: Both.

Setting: Home or hotel.

Aim: Use paradoxical approach to get at couple’s inferiority/superiority feelings.

Game Plan: The couple may take turns being master and slave. If they have a twinship transference, either can go first.

If it is an idealizing transference, the idealizing partner should be the slave first, since that order is closest to their present relationship. The taking of turns at being the slave leads to interesting results.

It may begin after a dinner at a fine restaurant, or in the restaurant of the hotel where they are staying. Upon coming back home, the master sits down on an easy chair and looks at the slave sternly. (In this example I will have the man play master.)

“Come over here.”

“Yes, sir!”

“Kneel down before me.” “Yes, sir!”

“Do you realize that you are nothing and I am everything? Do you realize that you are just a slave and I am your master? Do you?”

“Yes, sir!”

“Do you realize that I know everything and you know nothing? Do you?” “Yes, sir!”

“Without me you would be nothing. Nothing! Do you hear?”

“I hear, sir!”

*116/196/1*

For the husband it is a transforming experience, lifting him out of his own defensive posture—which might range from whining about lack of sex, to passive but begrudging resignation to little or unresponsive sex, to seeking extramarital situations and satisfactions. By dropping his defensive posture and allowing his own playful self to come out, he learns a more successful mode of relating.

Nude indoor volleyball can be played for fun and enlightenment by most of the couples described in this book.

On occasion, hysterics marry active spouses, hoping that such men will sweep them off their feet and take them away from it all. But the actives are more than likely to be of the narcissistic variety, interested in satisfying their own needs, not their spouse’s. For this reason, many such relationships swing from fantasy to disillusionment.

The games in this section have been designed as a five-part antidote to hysteria.

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