Villenweg 21

Germany

Villenweg 21

Germany
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This paper deals with the sociomedical expertising of the professional efficiency in cases of disability pensions from the perspective of an internist who has had experience in this field for over 40 years. First of all, the new legal regulations, which have been in force since 1.1.2001, are described. In accordance with these regulations there are pensions of partial and of complete disability. A partial disability exists if working time is possible only for 3 to less than 6 hours per day. A complete disability exists if possible working time has dropped to below 3 hours a day. According to a ruling of the Social Federal Court the part time labour market is at present closed, so any applicant who has a partial disability receives a full disability pension. A special case is the pension of partial disability in occupational disability which applies only to insured persons which were born before 2.1.1961 and who have an occupation requiring a vocational qualification. The amount of the pension is only half of the full pension. The assessment of the professional capacity depends on the occupational burden and the medical findings in order to assess the physical and psychological resilience. The most important methods of examination, which can be used for the assessment of the quantitative capacity, are discussed from the perspective of internal medicine. In case of a cardiovascular disease, especially coronary heart disease (CHD), this includes besides anamnesis, physical examination and previous results from available case records ergometry, echocardiography and 24-hours-holter monitoring. In case of chronic pulmonary disease, especially chronic obstructive pulmonary disease (COPD), this also includes besides ray thorax investigation the result of pulmonary function testing. On the basis of three assessments which are intended to serve as representative examples, practical experience, difficulties and results of the sociomedical expertising in accordance with the currently valid legal requirements are described. In conclusion there follows a critical evaluation of the new legal regulations which have been in force since 2001, and proposals are made for a legal amendment to the act on disability pensions as they have been brought into discussion by the social association Sozialverband VdK Deutschland and the trade unions.


In the introduction it is explained that health care in Germany is in realty a «disease care». In spite of different statements, the prevention of lifestyle caused chronic diseases does not play any important role. The first part deals with the topic «Social inequality and diseases». The main focus of the investigations of the British epidemiologists WILKINSON and PICKETT are described in their book «The spirit level». The authors have explored the statistics of the rich industrial societies and have searched for correlations between social inequality expressed in income distribution patterns and the amount of health and social problems. The book shows that most of the problems are not correlated to the average income level but to the grade of social inequality in the countries which are compared. That is also valid for obesity which is, besides smoking, the most important factor for lifestyle caused chronic diseases. Many peoples in the lower but also in the middle and upper classes are affected by this. It is probably a causal relationship form which is well founded by the actual scientific literature in the field of sociology. The conclusion is: that all measures to lower social inequality work as well for health and social prevention. In the middle of part two, the prevention of lifestyle caused chronic diseases is described. In the rich countries the far greatest part of annual cases of deaths is caused by lifestyle-caused chronic diseases. That includes e.g. coronary heart disease and myocardial infarction, cerebral ischemia and infarction, essential hypertension, obesity and adult-onset diabetes, chronic obstructive lung disease and most frequent cancer diseases. According to the WHO priority should be given to the prevention of the deadly quartet. It consists of the risk factors smoking, obesity in combination with lack of exercises and alcohol abuse. About 40 percent of all cases of death are linked to it and about 70 percent are closely connected with it. The prevention of lifestyle caused chronic diseases is a duty of the whole society. It only functions as a unity of behavioural prevention in the form of primary prevention, e. g. in kindergartens, schools and companies, and secondary prevention, e.g. in doctor's offices, in combination with social prevention. In part three, the national health insurance (GKV) is confronted with the private health insurance (PKV). The main problem of the GKV is that its income is dropping because the income of the employees during the last decades is stagnating or falling and the payments of the employers are frozen (abolition of equal financing of health insurance between employees and employers). As a result, the amount the employees pay is increasing, the national health insurance must get higher grants from taxes, the catalogue of services is reduced or questioned, and the extra charges have increased. In addition, there is a growing tendency towards a two-class-medical system. Therefore, I am pleading for strengthening the principles of solidarity by creating a united form of health insurance for all citizens, the re-establishment of equal financing of health care, a creation of fair fees based on income and a step by step increase of the income threshold. It is the further development of a health insurance system based on solidarity for all citizens in which there is still much support in the German population today.


1981 DOLL and PETO have stated in an often cited publication that about 40 per cent of cancer is due to nourishing deficits including alcohol overconsumption, overweight respectively obesity and lack of movement. Today for such estimates it is necessary to evaluate a huge number of epidemiological studies by international scientific specialized panels, which are no longer assessable for an individual. Since in the area of cancer prevention there exist (nearly) no randomized and controlled intervention studies, the evaluation must rely on prospective and retrospective cohort studies and/or case-control studies, so that only statements with either convincing, probable or possible evidence can be made. As well known in the last decades there is a clear increase of overweight respectively obesity. In parallel there is also an increase of obesity conditioned cancer. So can be assumed that obesity meanwhile is responsible for approximately 20 per cent in women and 14 per cent in men of deaths standing in connection with cancer. For many years fruit and vegetables play an outstanding role in the discussion about cancer prevention by food. The analyses of the scientific studies since the beginning of the 90's of the last century give a convincing evidence for the connection between the consumption of fruit and vegetables and the occurrence of cancer. That was the cause for the campaign »5 a day« (at least 5 portions of fruit and vegetables during a day). In the 2007 submitted second WCRF-report (World Cancer Research Found) about nutrition, physical activity and cancer prevention, which was a result on the basis of the evaluation of 7000 epidemiological studies developed, this risk relationship was downgraded on probable evidence. Due to the results of newer studies, especially the particular evaluations of the large European EPIC-study, there must be assumed today that there is only a probable connection between a plentiful consumption of fruit and vegetables and a smaller occurrence of cancer of the upper and lower intestinal tract and the lung. Further it is to be taken from the WCRF-report that (red) meat probably increases the risk for cancer of rectum and colon and a nutrition with high fiber probably decreases this risk, ω-3-fatty-acids and the consumption of fish possibly lower the risk for cancer of colon. Only for excessive consumption of alcohol in the second WCRF-report there is accepted a convincing evidence for cancer in the upper and lower intestinal tract. In addition in the present publication the significance of regular physical activity for primary prevention of cancer is worked out. While regular physical activity possesses a great importance for weight reduction and concomitantly for primary prevention of cancer in people with obesity, there is a number of newer investigations, from which it can be derived that regular physical activity works also directly in cancer prevention. That is valid in particular for cancer of the breast in women and cancer of colon in both sexes. In the concluding result is to say, that today weight reduction, when there is overweight respectively obesity, is of greatest importance in primary prevention of cancer. Beyond that the occurrence of cancer can be reduced by a favourable selection of food and regular physical activity. Possibly the percentage of the cancer reduction, which thereby can be reached, lies furthermore in the order of magnitude in the range of 30 to 40 per cent, as it was estimated at the beginning of the 80's of the last century.


2004 a sensational study in the USA found out that avoidable causes of death are responsible for almost half of the annual cases of death. On the top of the causes of death stand smoking and obesity in combination with lack of exercise. The WHO speaks in this context of the deadly quartet to whom also alcohol abuse belongs. These dramatic results take place, because smoking and obesity in combination with lack of exercise promote the occurrence of many non transferable chronic diseases, e.g. coronary heart disease with myocardial infarction, essential hypertension, cerebral ischemia with cerebral infarction, adult-onset diabetes, chronic obstructive lung disease and the most frequent cancer diseases. In Germany there are 10-20 million people, who suffer from at least one of the announced chronic diseases. tial for diminishing the number of chronic diseases. Convincing examples for this are the adultonset diabetes and the essential hypertension. These diseases are not only improved but often are healed by a long lasting loss of weight in obese people. The research during the last decades has shown that non transferable chronic diseases are found more often in people with lower income than in those of the middle and upper classes. This social difference obviously cannot be reconciled by means of the established ambulatory and stationary medical care, but requires more efforts in the field of prevention and health care. Measures of prevention must promote the selfresponsibility. This means that a single person actively takes care of its health. During the last years this term unfortunately is used as an argument for a stronger orientation of health care on profit interests, because this aim is combined inevitably with a reduction of solitary achievements of our social system. Concerning prevention there is a difference between behavioural and social prevention. Behavioural prevention is a task of the health profession, especially the physicians. In the meantime there exist some effective measures of behavioural prevention which are useful to be carried out in a medical practice, e.g. measures for smoking cessation, obesity therapy and primary prevention of the adult-onset diabetes. Lifestyle changes as cessation of smoking, a healthy nutrition and regular exercise can avoid 80-90% of these chronic diseases or can improve its course. Concerning lifestyle changes you can differentiate between measures of primary prevention with the aim to prevent the occurrence of chronic diseases and measures of secondary prevention with the aim to influence favourably the progression of existing chronic diseases or to stop them. According to the motto to prevent a disease is better than to heal it, the priority belongs to primary prevention of non transferable chronic diseases. Nevertheless, it is important, that to be ill does not mean automatically that you must be ill for your whole life. It must be understood that also secondary prevention bears an enormous poten- If measures of behavioural prevention will be popular, it must be completed with measures of social prevention. The latter are part of the frame conditions of our life and therefore firstly a task for politics. On the field of tobacco control a law for public non smoking without any exception belongs to it and in the field of obesity control the labelling of food according to an ample-system. These and more measures can only be achieved if the public interest of health is attached a greater value than the private interest of profit of particular industries, which live from a disease promoting behaviour of our population.


The effects on health of the dramatic increase of overweight and obesity which occurred in many countries in the last decades were controversial until short time ago. In the present paper therefore the results of the in 2009 published great international metaanalysis of the Prospective Studies Collaboration about the main associations between the body mass index (BMI) and the overall and the cause-specific mortality is presented which brought firm insights on this field. In men the mortality in relation to a specific BMI was found double as high as in women. In both sexes mortality was lowest at a BMI of about 22.5-25 kg/m 2. Each 5 kg/m 2 higher BMI was on average associated with about 30% higher overall mortality, 40% higher for vascular mortality, 60-120% higher for diabetic, renal and hepatic mortality, 10% higher for neoplastic mortality and 20% higher for respiratory and all other mortality. The study shows that BMI in itself is a strong predictor for overall mortality above and below an apparent optimum of about 22.5-25 kg/m 2. The increase of mortality above this range is due mainly to vascular diseases and is probably largely causal. At 30-35 kg/m 2 median survival is reduced to 2-4 years and at 40-45 kg/m 2 to 8-10 years which is comparable with the effect of smoking. In men and women the combined risk of a specific BMI and smoking was almost doubled and caused a loss up to 20 years. In the discussion the authors criticize some views which relativise the unfavourable effects of overweight and obesity on health. In contrary to these positions the results of the metaanalysis of the Prospective Studies Collaboration show that adult obese people pay a high price and would gain much by a weight reduction. At last it is emphasized that a successful therapy of obesity besides a traditional nutrition consultation needs at its best a regular motivation in the medical practise, as is shown in two actual randomized intervention trials a short time ago.


2004 a sensational study in the USA found out that avoidable causes of death are responsible for almost half of the annual cases of death. On the top of the causes of death stand smoking and obesity in combination with lack of exercise. The WHO speaks in this context of the deadly quartet to whom also alcohol abuse belongs. These dramatic results take place, because smoking and obesity in combination with lack of exercise promote the occurrence of many non transferable chronic diseases, e.g. coronary heart disease with myocardial infarction, essential hypertension, cerebral ischemia with cerebral infarction, adult-onset diabetes, chronic obstructive lung disease and the most frequent cancer diseases. In Germany there are 10-20 million people, who suffer from at least one of the announced chronic diseases. Lifestyle changes as cessation of smoking, a healthy nutrition and regular exercise can avoid 80-90% of these chronic diseases or can improve its course. Concerning lifestyle changes you can differentiate between measures of primary prevention with the aim to prevent the occurrence of chronic diseases and measures of secondary prevention with the aim to influence favourably the progression of existing chronic diseases or to stop them. According to the motto to prevent a disease is better than to heal it, the priority belongs to primary prevention of non transferable chronic diseases. Nevertheless, it is important, that to be ill does not mean automatically that you must be ill for your whole life. It must be understood that also secondary prevention bears an enormous potential for diminishing the number of chronic diseases. Convincing examples for this are the adultonset diabetes and the essential hypertension. These diseases are not only improved but often are healed by a long lasting loss of weight in obese people. The research during the last decades has shown that non transferable chronic diseases are found more often in people with lower income than in those of the middle and upper classes. This social difference obviously cannot be reconciled by means of the established ambulatory and stationary medical care, but requires more efforts in the field of prevention and health care. Measures of prevention must promote the selfresponsibility. This means that a single person actively takes care of its health. During the last years this term unfortunately is used as an argument for a stronger orientation of health care on profit interests, because this aim is combined inevitably with a reduction of solitary achievements of our social system. Concerning prevention there is a difference between behavioural and social prevention. Behavioural prevention is a task of the health profession, especially the physicians. In the meantime there exist some effective measures of behavioural prevention which are useful to be carried out in a medical practice, e.g. measures for smoking cessation, obesity therapy and primary prevention of the adult-onset diabetes. If measures of behavioural prevention will be popular, it must be completed with measures of social prevention. The latter are part of the frame conditions of our life and therefore firstly a task for politics. On the field of tobacco control a law for public non smoking without any exception belongs to it and in the field of obesity control the labelling of food according to an ample-system. These and more measures can only be achieved if the public interest of health is attached a greater value than the private interest of profit of particular industries, which live from a disease promoting behaviour of our population.


The effects on health of the dramatic increase of overweight and obesity which occurred in many countries in the last decades were controversial until short time ago. In the present paper therefore the results of the in 2009 published great international metaanalysis of the Prospective Studies Collaboration about the main associations between the body mass index (BMI) and the overall and the cause-specific mortality is presented which brought firm insights on this field. In men the mortality in relation to a specific BMI was found double as high as in women. In both sexes mortality was lowest at a BMI of about 22.5-25 kg/m2. Each 5 kg/m2 higher BMI was on average associated with about 30% higher overall mortality, 40% higher for vascular mortality, 60-120% higher for diabetic, renal and hepatic mortality, 10% higher for neoplastic mortality and 20% higher for respiratory and all other mortality. The study shows that BMI in itself is a strong predictor for overall mortality above and below an apparent optimum of about 22.5-25 kg/m 2. The increase of mortality above this range is due mainly to vascular diseases and is probably largely causal. At 30-35 kg/m2 median survival is reduced to 2-4 years and at 40-45 kg/m2 to 8-10 years which is comparable with the effect of smoking. In men and women the combined risk of a specific BMI and smoking was almost doubled and caused a loss up to 20 years. In the discussion the authors criticize some views which relativise the unfavourable effects of overweight and obesity on health. In contrary to these positions the results of the metaanalysis of the Prospective Studies Collaboration show that adult obese people pay a high price and would gain much by a weight reduction. At last it is emphasized that a successful therapy of obesity besides a traditional nutrition consultation needs at its best a regular motivation in the medical practise, as is shown in two actual randomized intervention trials a short time ago.

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