News and analysis · Nouvelles et analyses

CMAJ 1999;160:1689-91

• Nova Scotia MDs to earn more for treating elderly
• BC exercise program studies cardiac kids
• Have North Americans taken "fat phobia" too far?
• Pickets descend on CMA during May protest
• Pulse: Cancer numbers rise but risk remains stable
• DNA testing via the Internet

A recent fee settlement gives Nova Scotia physicians 30% more for treating the elderly under a new geriatric patient office visit fee. The agreement also features fee increases for family physicians who visit patients in hospital, reimbursement for some medical supplies, and more. The Department of Health and the Medical Society of Nova Scotia finally agreed to the revised fee schedule during arbitration early this spring.

Dr. Robert Mullan, the society president, says the schedule is a fair compromise. He is particularly pleased with the development of the special fee for geriatric patients. "The number of patients in this province 65 years of age and older is continuing to increase, and the creation of the geriatric office fee code will help address the needs of both patients and physicians," he says.

Statistics Canada reports that 500 Nova Scotians turn 65 years old every month — a trend that is expected to continue for the next 6 to 7 years. The percentage of Nova Scotians older than 65 now stands at 13.4%, which is slightly higher than the national average.

Under the new deal, the office fee a physician will receive for seeing patients aged 65 and older will be set at 15 medical service units worth $1.84 each, for a total of $27.60. The regular office visit fee for younger patients also increased slightly, from $19.32 to $20.24. And general practitioners visiting hospital patients will receive $24.84, up from $13.43.

The medical society had hoped the province would implement a special fee for patients with multiple problems who require additional time and expertise, but this didn't happen. However, the settlement, which will cost the province about $13 million a year, does include other fee schedule improvements and covers the cost of many of the supplies doctors use in their offices. The latter concession means Nova Scotian physicians will no longer be required to pay the supply costs associated with Papanicolaou smears, vaccinations and the provincial childhood immunization program.

Mullan is optimistic about the positive effects the settlement will have on medical practice. "You never get everything you want," he says. "However, this does bring us into the middle of the pack of general practitioners' fees across the country. It will also put us in a more competitive position in terms of recruiting doctors for Nova Scotia and convincing them to stay."— © Dorothy Grant, Halifax

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In a noisy gymnasium, a group of children are jogging, shooting hoops and hitting hockey pucks. It could be any after-school program, but it isn't — each of the children has undergone heart surgery and is wearing a cardiac monitor while trying to get fit.

The program is part of a unique study at British Columbia's Children's Hospital, which is taking the exercise tolerance of children with heart abnormalities to a new level. "We have extended the exercise period beyond what other people have done, and in addition to measuring maximum oxygen uptake we are also assessing them with stress echocardiography," explains Dr. George Sandor, the cardiologist leading the study. "The other unique thing is that we are involving physiotherapists and occupational therapists in an attempt to gauge exercise capacity on a number of different levels. If they can't do the activity, it may not be the heart that is so much of the problem — the problem may lie with coordination or other skills."

The children are aged between 7 and 15, and some are functioning with only 1 ventricle. Twenty children have been divided equally into experimental and control groups. The experimental group comes into the hospital twice weekly for the 16-week exercise program, followed by 6 months of exercising at home. Both groups are tested for motor skills and respiratory and cardiac function 3 times during the study. Stress echocardiography allows researchers to see children's cardiac output and myocardial function as they semi-recline on an exercise bicycle. Over a 12-minute period, they progress from 25% to 90% of their exercise capacity. Dr. Jim Potts, an exercise physiologist and project coinvestigator, says that an interesting preliminary finding is that the children's total heart output is dependent on increasing their heart rate rather than on stroke volume, which falls off as they increase the intensity of exercise.

Recently, the researchers added children with cancer — primarily leukemia — to the study, and they will soon be joined by children with solid tumours. These children start the exercise program from 3 to 12 months after finishing their chemotherapy. The activities are slightly modified to accommodate the compromised cardiac function resulting from treatment.

The project has been funded by the Heart and Stroke Foundation of BC and the Children's Hospital Foundation until the end of 1999, but the researchers hope to find funding to extend the program for a further year. — © Heather Kent, Vancouver

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The Metropolitan Life Insurance Company played an important role in the 1950s when it convinced many health professionals that obesity causes heart disease and that overweight people could be cured, US historian Roberta Seid said during a recent Toronto conference on obesity.

The company is probably best known for its table of ideal weights. By 1959, the "desirable" weights for women were considerably lower than the comparable figures for 1942 — 53 to 59 kg (116 to 130 lb) for a 165-cm (5 ft 5 in) woman, compared with 58 to 61 kg (127 to 135 lb) 17 years earlier.

But the company's assertions about the link between weight and health were not backed up by evidence, she said. "I was astonished at how the Metropolitan Life Insurance Company had fabricated data. . . . [The majority of] studies since the 1950s have shown that weight is relevant to health only at the extreme ends," Seid said at the conference, whose sponsors included the University of Toronto Department of Psychiatry and the National Eating Disorder Information Centre.

In 1983 the company revised its "desirable" weight upward by 11 lb from the 1959 standard, but Seid said "fat phobia" had become so engrained in American society by then that the changes were dismissed.

Slimness came into fashion around 1900, but the "religion" that built up around thinness really took hold in the 1950s as the "ideal" female form became slimmer and slimmer. For example, while the winner of the 1922 Miss America Pageant weighed 64 kg (140 lb) and was 170 cm (5 ft 7 in) tall, the average weight of pageant winners during the 1980s was only 53 kg (117 lb), even though the average height was now 173 cm (5 ft 8 in).

Seid attributed the new fat-is-bad fervour to both the fashion industry, which idealized a slender body just as postwar affluence allowed more women to follow fashion, and to the health professions, which accepted the idea that obesity is the most important health problem. "There seemed to be a fear that America was getting soft both physically and morally," she said.

Today, warned Seid, the underlying principles of fat phobia have caused many people to become obsessed by weight loss. Seid said incorrect assumptions surrounding people's weight include a belief that there is an ideal weight for every height, that body weight and fat distribution is absolutely controllable, and that people can function well on minimal calories. In our weight-conscious society, many have concluded that if people eat "with an unbridled appetite there is something wrong with them or with food, that food itself is addictive."

Seid noted that the obsession may be at its worst in the US, with its unique strain of perfectionism and self-improvement. In France, by comparison, appetite is not suspect and weight is not associated with "character, dignity or one's psychic state." — © Ann Silversides, Toronto

Approximately 200 pro-life protesters marched on CMA House in Ottawa May 13 as part of a day of protest against abortion laws the organizers consider too liberal. The pickets called on the CMA to "Put the Hippocratic ethic back in medicine." Police maintained a visible presence during the demonstration, but there was no violence. The protesters also lobbied members of Parliament during the day of protest. (Steven Wharry photo)

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Although changes in age and population growth have caused a steady increase in the number of deaths caused by cancer, figures from the National Cancer Institute of Canada indicate that the individual risk has remained stable since 1971. About 80% of cancer deaths involve people who are at least 60 years old.

The average annual percent change in age-standardized mortality rates from 1987 to 1994 shows decreases for many types of the disease, including cancer of the stomach, bladder, breast and prostate, as well as leukemia. Average annual increases occurred for skin and thyroid cancer. The institute notes that if lung cancer was removed from the equation, the death rate for women would have decreased by 15% since 1971.

The number of new breast cancer cases continues to rise, but earlier detection has led to an almost 10% drop in the death rate since 1986. It is estimated that 15 Canadian women will die of breast cancer every day this year.

The data in Canadian Cancer Statistics 1999 also point to a sharp increase in the incidence of prostate cancer in the 1990s, primarily due to earlier detection. The age-standardized incidence rate increased from 100 cases per 100 000 males in 1990 to 127 per 100 000 males in 1994. Rates are now starting to show a decline; it is estimated that this year's rate will be 114 cases per 100 000 males.

Lung cancer rates continue to rise among women, and at 45 cases per 100 000 women the rate is now 5 times higher than in 1969. This is still far less than the rate for males, estimated at 81 cases per 100 000 for 1999. Lung cancer mortality rates for males are highest in Atlantic Canada and Quebec, and lowest in BC (Fig. 1). This year, 48 Canadians will die from lung cancer every day.

This column was written by Lynda Buske, Chief, Physician Resources Information Planning, CMA. Readers may send potential research topics to Patrick Sullivan (sullip@cma.ca; 613 731-8610 or 800 663-7336, x2126; fax 613 565-2382).

You've heard of home-pregnancy tests and home blood-glucose monitoring? Now there's home-based DNA testing, thanks to a new kit available via the Internet. The manufacturer says the Easy Answers DNA-Testing Kit, which went on sale in late March, provides a simple way to resolve identity issues in the privacy of your own home — all for US$280, plus shipping and handling.

The kit contains cotton swabs for collecting buccal cells from the inner lining of the cheek. The swabs are then placed in a storage tube and returned to the North Texas company for testing. Company spokesman Steven Calvert says the kits are primarily designed to establish paternity in divorce cases. They are also used to determine whether twins are identical or fraternal, and to provide a source of conclusive identification if it is ever required. The company expects to be selling 100 kits a week by the end of this month.

The kit is available through a shopping mall Internet site. For information, visit www.d-fwmall.com/DNA/dna_testing_home.htm.

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© 1999 Canadian Medical Association (unless otherwise indicated)