Acquired immunodeficiency syndrome (UPDATE 2000)
The Canadian Medical Association has developed the following general principles to serve as guidelines for various bodies, health care professionals and the general public. Specific aspects of infection with human immunodeficiency virus (HIV) and acquired immunodeficency syndrome (AIDS) that relate to physicians' ethical responsibilities as well as society's moral obligations are discussed. Such matters include: the need for education, research and treatment resources; the patient's right to investigation and treatment and to refuse either; the need to obtain the patient's informed consent; the right to privacy and confidentiality; the importance of infection control; and the right to financial compensation in the case of occupational exposure to HIV.
Physicians should keep their knowledge of AIDS and HIV infection up to date.
Physicians should educate patients and the general public in the prevention of AIDS by informing them of means available to protect against the risk of HIV infection and to avoid further transmission of the virus.
Health authorities should maintain an active public education program on AIDS that includes the school population and such initiatives as public service announcements by the media.
All levels of government should provide resources for adequate information and education of health care professionals and the public on HIV-related diseases; research into the prevention and treatment of HIV infection and AIDS; and the availability and accessibility of proper diagnosis and care for all patients with HIV infection.
HIV antibody testing
Physicians have an ethical responsibility to recommend appropriate testing for HIV antibody and to care for their patients with AIDS or refer them to where treatment is available.
Physicians should provide counselling to patients before and after HIV antibody testing.
Because of the potential psychologic, social and economic consequences attached to a positive HIV test result, informed consent must, with rare exceptions, be obtained from a patient before testing. However, the CMA endorses informed mandatory testing for HIV infection in cases involving the donation of blood, body fluids or organs.
The CMA recognizes that people who have doubts about their serologic status may avoid being tested for fear of indiscretion and therefore supports voluntary non-nominal testing of potential HIV carriers on request.
The CMA supports the Canadian Blood Service and Hema-Québec in their programs of testing and screening blood donations and blood products.
Confidentiality in reporting and contact tracing
The CMA supports the position that cases of HIV infection should be reported non-nominally with enough information to be epidemiologically useful. In addition, each confirmed case of AIDS should be reported non-nominally to a designated authority for epidemiologic purposes.
The CMA encourages attending physicians to assist public health authorities to trace and counsel confidentially all contacts of patients with HIV infection. Contact tracing should be carried out with the cooperation and participation of the patient to provide maximum flexibility and effectiveness in alerting and counselling as many potentially infected people as possible.
In some jurisdictions physicians may be compelled to provide detailed information to public health authorities. In such circumstances, the CMA urges those involved to maintain confidentiality to the greatest extent possible and to take all reasonable steps to inform the patient that their information is being disclosed.
The CMA Code of Ethics (article 22) advises physicians that disclosure of a patient’s HIV status to a spouse or current sexual partner may not be unethical and, indeed, may be indicated when physicians are confronted with an HIV-infected patient who is unwilling to inform the person at risk. Such disclosure may be justified when all of the following conditions are met: the partner is at risk of infection with HIV and has no other reasonable means of knowing of the risk; the patient has refused to inform his or her sexual partner; the patient has refused an offer of assistance by the physician to do so on the patient's behalf; and the physician has informed the patient of his or her intention to disclose the information to the partner.
The CMA stresses the need to respect the confidentiality of patients with HIV infection and consequently recommends that legal and regulatory safeguards to protect such confidentiality be established and maintained.
Health care institutions and professionals should ensure that adequate infection-control measures in the handling of blood and body fluids are in place and that the rights of professionals directly involved in patient care to be informed of and protected from the risks of HIV infection are safeguarded.
The CMA does not recommend routine testing of hospitalized patients.
The CMA urges appropriate funding agencies to assess the explicit and implicit costs of infection control measures and to ensure that additional funds are provided to cover these extraordinary costs.
Occupational exposure and the health care professional
Health care workers should receive adequate financial compensation in the case of HIV infection acquired as a result of accidental occupational exposure.
Physicians and other health care providers with HIV infection have the same rights as others to be protected from wrongful discrimination in the workplace and to be eligible for financial compensation for work-related infection.
Physicians with HIV infection should consult appropriate colleagues to determine the nature and extent of the risk related to their continued involvement in the care of patients.
Obesity and Cardiovascular Disease (Update 2004) (Applicable to Canadians aged 20-60 years)
Obesity is a chronic condition that is multi-factorial in origin, complex to treat, and is a major contributor to heart disease, type II diabetes, hypertension, stroke and some cancers. Due to the magnitude of the impact that obesity has on heart disease and stroke, and to the clustering of risk factors for cardiovascular disease that are often found in the obese patient, obesity is recognized as a major risk factor for cardiovascular disease.
The impact of obesity points to the importance of prevention through healthy behaviours including increased physical activity and a healthy nutritional diet beginning early in life, and continuing through all stages of life. Solutions require comprehensive approaches that are both education and environment based, and that target and assist individuals, the family, and communities to engage in healthy lifestyle patterns and behaviours. Solutions also require ongoing research to develop and evaluate comprehensive approaches to obesity prevention, management and treatment, and surveillance data that measures and tracks obesity and its impact in Canada.
The World Health Organization defines obesity as a condition of excessive body fat accumulation to an extent that health may be compromised.
Body Mass Index (BMI) is a widely accepted parameter used to distinguish between obese and non-obese adults aged 20 to 60 years and thus provides information about the subsequent risk of cardiovascular disease.
BMI is calculated by dividing the weight (in kilograms) by the square of the height (in metres).
BMI = weight (in kilograms)
height (in metres) * height (in metres)
A BMI equal to or greater than 30 kg/m2 is classified as obese, while a BMI in the range of 25 to 29.9 kg/m2 is classified as overweight.
Waist circumference (WC) provides an independent prediction of health risks over and above BMI. Increased waist (abdominal) circumference is associated with increased risk of cardiovascular disease, dyslipidemia, type II diabetes and hypertension. As waist circumference increases above 102 cm for men and 88 cm for women, the risks of health-related illnesses increase.
Populations at Increased Risk
Obese individuals with diabetes, hypertension, or dyslipidemias or who are physically inactive are at increased risk of cardiovascular disease, compared to individuals without these conditions.
A BMI between 25 and 29.9 kg/m2 (overweight) is associated with elevated risk of cardiovascular disease, type 2 diabetes, hypertension and dyslipidemia.
Weight gain during young adult life may be one of the most important determinants of future development of cardiovascular risk factors and cardiovascular disease. Adults who gain weight have increased risk of coronary heart disease compared to those with stable weight. Weight gain during adult life may contribute to future development of ischemic heart disease regardless of initial body weight (obese or non-obese).
Canadians of Aboriginal, Chinese, and South Asian (from India, Pakistan, Bangladesh, and Sri Lanka) descent have higher rates of obesity-related chronic diseases (for example diabetes, hypertension and cardiovascular disease).
Individuals with lower socio-economic status have higher rates of obesity than those with higher socio-economic status.
Promotion of Healthy Weights
In April 2002, the Public Health Approaches to the Prevention of Obesity (PHAPO) Working Group of the International Obesity Task Force (IOTF) identified that a comprehensive approach to obesity prevention should:
Address both dietary habits and physical activity patterns of the population
Address both societal and individual level factors
Address both immediate and distant causes
Have multiple focal points and levels of intervention (i.e. at national, regional, community and individual levels);
Include both policies and programs; and
Build links between sectors that may otherwise be viewed as independent.
Research is needed to:
Develop a standard definition and a standard measurement technique for determining obesity in children.
Develop obesity measures for older, ethnic and gender specific populations.
Identify and develop effective primary prevention methods for individuals, families and communities to reduce the prevalence of obesity in all stages of life.
Improve awareness and knowledge about the health effects of obesity and healthy living.
Develop effective primary prevention measures and strategies that are therapeutic, secondary and tertiary in nature.
Identify and track rates of obesity and overweight in Canada.
Assess the effectiveness of obesity prevention and treatment initiatives.
Identify and implement the most effective primary prevention strategies for ethnic populations.
Develop and implement effective healthy public policy for the prevention, treatment, and management of obesity.
Further, the surveillance of obese and overweight Canadians is necessary in order to assess the effectiveness of prevention and treatment initiatives. It is only through the combined action and resources of governments, non-governmental organizations, non-profit and private sectors to develop and implement a comprehensive approach to curb the growing trend of obesity in Canada.