Health risks of overweight St. Nick are over the rooftops

Call it a yuletide dream sparked, perhaps, by a bit of bad eggnog or the crushing realization that Christmas is now just 13 days away. Or, call it a holiday-themed thought exercise -- a sort of medical fable, as it were.

Whatever it was, it began with Dr. Mitchell Forman walking into an examining room to meet a new patient: a big, roundish guy who for some reason seemed to be much older than he appeared, with billowing white whiskers, rosy cheeks and an infectiously jolly manner.

Most striking, though, was the way the man was dressed, in "all red, and wearing a strange hat," Forman recalled. "I put that in my short-term memory bank, because he was a little more unusually dressed than my typical patient."

But a patient he was, so Forman, dean of Touro University Nevada College of Osteopathic Medicine, began the exam, as he does every exam with a new patient, with a medical history.

Age? "He told me, 'Timeless,' " Forman said. "I thought that was kind of funny, and that told me he has a sense of humor."

Occupation? "He told me he was self-employed and a distributor."

Tobacco use? "He told me he used to smoke a pipe, but no longer smokes."

Alcohol use? The man said he works mostly outdoors, Forman said, and occasionally indulges in a nip to "help him warm up a bit."

"He said he hasn't seen a physician in quite some time," the doctor continued. "He's been extraordinarily busy and has a very hectic job, and his job entails a fair amount of physical activity and a great deal of traveling."

Forman noticed first that his new patient was very obese -- he admitted that he didn't always eat healthfully and never passed up a plate of cookies and a glass of milk offered by his customers -- which led him to consider the possibility that the man might be at risk from a few medical conditions.

For example, the patient said he has had high blood pressure and that a previous doctor had prescribed a diuretic to treat it. But with all of the traveling the patient had to do for his work, "it became so inconvenient for him to take it because it made him go to the bathroom frequently," Forman said.

The patient's blood glucose level also "had been elevated," Forman added, which puts him at risk from diabetes. Previous doctors "had told him he needed to go on a diet and that would likely take care of the problem," Forman said, but the doctor made a note to order a blood glucose test.

The patient said his job involves a good deal of physical activity, which puts him at risk from strains, sprains and other aches and pains.

"He generally carries a sack that can weigh from 50 to 80 pounds," Forman noted, "and he periodically has problems with his lower back and knees from carrying such a heavy load. I mentioned to him that his weight certainly didn't help that very much and that if he lost a significant amount of weight and got down to his ideal body weight, at the very least it would help his knees and his back."

The man admitted to sleeping "very poorly," Forman said, and that he sometimes falls asleep at "inopportune times" and "snores excessively at night. He'll wake up very suddenly and doesn't feel he slept well and feels tired all the time, and I explained this can be related to his excess weight and what we call obstructive sleep apnea."

Obstructive sleep apnea -- in which a sleeper's air flow is reduced or actually stops during sleep -- is "certainly related to obesity, and could be a very serious matter because it's associated with heart disease, stroke and even with sudden death," Forman said.

During the examination, Forman found that the front part of the patient's neck "was a little bit full."

"I asked him whether anyone had talked to him about hypothyroidism, or underactive thyroid. That can be associated with weight gain, fatigue and some other symptoms, so I plan to do a few simple blood tests as well."

Because the patient has several risk factors for heart disease, Forman ordered a lipid panel -- a blood test that determines levels of total cholesterol, as well as HDL, or good cholesterol, LDL, or bad cholesterol, and triglycerides, a type of blood fat.

Then, because of the patient's obesity and risk factors for diabetes, "I also would want to do a blood sugar -- blood glucose -- test, and a test called hemoglobin A1c, which will tell me what his blood sugar has been like over a longer period of time," Forman said.

He also ordered a comprehensive metabolic panel, a blood test that "gives me a very broad look at what's going on in his body, as well as a complete blood count, which tells me if he's anemic or not."

Dr. Arezo Fathie, a Las Vegas internal medicine physician, said that if the jolly ol' guy happened to be her patient, she'd recommend a "stress test of his heart to screen for any abnormalities, and probably an echocardogram."

Because the patient is older -- presumably much older -- than 50, Fathie also would order a colonoscopy. According to the National Cancer Institute, most people who develop colorectal cancer are older than 50. But, Fathie noted, "if it's caught early, it can be curable."

Fathie also would recommend the patient undergo regular screenings for prostate cancer. For most men, screening begins between ages 40 and 50, "and definitely, after 50, once a year you need to get a digital rectal exam," Fathie said, and possibly a PSA (prostate-specific antigen) blood test as well.

Fathie would want to make sure the patient has had all of his vaccinations, including an annual flu shot and vaccinations for pneumococcal disease, shingles (herpes zoster) and -- given that his work requires climbing around in dirty chimneys -- tetanus.

Speaking of which: Fathie noted that the patient may be at risk for all sorts of cancers -- including lung and bladder cancer -- because his job requires climbing up and down chimneys. So a doctor may suggest that the patient take precautions -- a respirator and protective clothing and gloves to prevent soot-to-skin contact -- to reduce his exposure.

Dr. Diane Chau, program director and chief of the division of geriatric medicine at the University of Nevada School of Medicine, said the effects of aging can include a diminishing of reflexes that can make recovering from a stumble more difficult. Because Forman's patient's job requires navigating icy, slanted roofs, this could be something he would need to be made aware of.

Some older people fall into depression, but Chau noted that having a solid social support network can help. Here, she said, "the social structure he's built over the years can help him, because a lot of older adults may not have that social structure."

Forman noticed that his patient had a ruddy complexion and a red nose, which the patient attributed to frequent spells out in the cold. But both also can be caused by a skin condition called rosacea.

Although it's benign, "it could be disfiguring," he said. "It could be, cosmetically, a problem, particularly when women get it."

The patient also mentioned that he sometimes feels acute pain and experiences swelling on his big toe.

"I mentioned the possibility of gout," Forman said. "I asked if they ever told him he has a high uric acid level. He said: 'You know, they did. They gave me some medicine for a while and I took it; then I stopped taking it.' "

People with high blood pressure have a higher incidence of gout, Forman noted, which is "associated with deposits of uric acid crystals in certain joints, and the first toe is the most common place for that to occur."

"The patient mentioned that he sometimes forgets to wear gloves when he travels to cold climates, and notices his hands feeling as if they're going to sleep," Forman said. "I told him he has to be careful about frostbite, since he's traveling mostly at night when the sun is down.

"I also explained to him that drinking alcohol while he is exposed to the cold is not a healthy thing to do, and cautioned him about drinking alcohol and driving what he called his 'sleigh.' "

Forman noted during the exam that his new patient was a "very funny guy" with a positive, even jolly, outlook and a great sense of humor, despite the job stress he apparently faces this time of year.

That's good. "Humor is very important for our health and helps us deal with stress," Forman said.

Fathie noted, also, that "people who have a sense of purpose and positive goals and a mission in their lives tend to be healthier, and their stress does not seem to be as harmful to them."

Forman suggested that the patient remain active even after his holiday rush is over.

"He travels so much during the year, and particularly at this time of the year, that all he thinks about when he doesn't is just kind of coming home and being a couch potato," Forman said. "I told him that wasn't a good thing for him to do.

"But I think the one thing I needed to state to him is that he needed to take more control of his own personal health. He can't just think about other people, but has to start thinking about himself."

The bottom line: If the patient resolves to make a few lifestyle changes and take better care of himself, Forman said, "I think he could live longer than a lifetime so far ... or, 'forever,' as he said."

Contact reporter John Przybys at
jprzybys@reviewjournal.com or 702-383-0280.