Welcome back to the Weekly Wellbeing Round Up! I hope you have had a good weekend, enjoying the weather and the world cup final. Having overcome the disappointment of England not getting to the final, I made the decision not to watch the entirely meaningless 3rd/4th place playoff , and so missed watching England lose to Belgium (again)…which was probably much better for my overall wellbeing! Let’s start off today with…
Today instead of watching the final, I spent the afternoon with my wife. This is partly because I am a very caring and considerate husband (hopefully she won’t read this or at least will have the good grace not to contradict me in the comments) but also because I am an evidence based husband as well and had read this systematic review and meta-analysis in Heart concerning marital status and the risk of cardiovascular disease (subscription required for full article). Being married was associated with a decreased rate of death from heart disease and stroke. Being divorced was associated with increased CHD mortality, being widowed with increased risk of stroke, and never being married with an increase in mortality in the event of a heart attack. The article points out the obvious that association does not mean causation, but does raise the idea that marital status could be considered as part of CVD risk calculation in future. I have shared this with my wife. She says she needs more evidence before she is convinced.
Whilst I would like to spend all my time helping patients not to get premature cardiovascular disease (such as heart attacks and strokes), clearly a part of a GP’s workload is helping people who have developed it look after themselves as well as possible. Again, I like to focus on lifestyle measures such as food, physical activity and sleep but inevitably most if not all people in this situation will also be taking a number of medications to reduce the risk of their conditions worsening. The world health organisation stats for adherence or compliance (i.e. people taking their tablets as prescribed) are truly shocking. Take for example hypertension or raised blood pressure: it is estimated that only half of people diagnosed with hypertension are taking their meds regularly (80% or more of the time) within a year of being diagnosed. Clearly I must have the best patients in the world, because they all look me in the eye and reassure me that they take their drugs every day. But for doctors out there whose patients are not as well behaved, this systematic review, also published in Heart, may make useful reading. Three interventions were found to improve adherence and clinical outcomes: SMS (text) reminders to take medication, a fixed dose combination pill (interesting to consider as these drugs may be more expensive and less flexible in dosing but if the outcomes are better maybe doctors should be prescribing more of them) and a community health worker-based intervention. It is worth noting that these demonstrated relatively short term improvements so we need longer term outcome data to confirm this.
Instead of talking about cardiovascular risk, the focus of this article is about calculating Cardiovascular Health. CVH is a concept developed by the American Heart Association. It takes into account 4 ideal health behaviours: non-smoking, body mass index < 25, regular physical activity and adopting a healthy diet. It also factors in cholesterol, blood pressure and blood sugar level. It has been suggested that CVH could be a proxy for wellbeing. Of course that leaves the question as to what comes first..wellbeing or health.? What are the practical implications of this for me? The next time that a patient comes into my consulting room and says that they would just like a bit of an MOT, this is perhaps where I could start, rather than asking them a lot of questions about their bodily functions and sending them off for a load of blood tests.
Speaking rather less positively about the American Heart Association, I was deeply troubled by their suggestions about changing the threshold for diagnosing and treating hypertension. The guidelines suggest that a blood pressure of greater than 120 (systolic) and/or 80 (diastolic) should be considered “elevated”. This would result in a huge increase in numbers of patients diagnosed with a disease and then potentially medicalised by offering them drugs…with the associated risks of this. The author of this article in the BMJ estimates that this would result in half of the adult population over 45 being diagnosed with hypertension. My view? Utterly bonkers. We should be sticking to identifying people who already have undiagnosed hypertension (>140/90, as defined by the European Society of Cardiology), giving appropriate lifestyle advice as first line management where appropriate, and offering a personalised approach to risk reduction based on an individual person’s risk factors. I would be very interested to learn more about the individuals and organisations who had input into the AHA guidelines, and where they might have potential conflicts of interest…big pharma, anyone?
The low carb debate continues and I for one am more than a bit fed up of the unedifying content and behaviours on social media, particularly twitter. Yes, it may well be that it’s hard to prove that there is something intrinsically good about eating a diet low in carbohydrates because it is almost inevitably associated with also reducing calories, but then again this is a food group that, plant based carbohydrates aside, we have largely manufactured for ourselves (often with a lot of processing involved) has very little if any nutritional value, and the increased consumption of which (particularly in the US) has been associated with sky rocketing obesity levels. So its nice to see this article in the BMJ on the role of carbohydrates , quality and quantity, in chronic disease. It takes a fairly measured approach to the subject. It’s well worth a read as it’s too detailed to really summarise, but the key messages are:
- Human populations have thrived on diets with widely varying carbohydrate content
- Carbohydrate quality has a major influence on risk for numerous chronic diseases
- Replacing processed carbohydrates with unprocessed carbohydrates or healthy fats would greatly benefit public health
- The benefit of replacing fructose containing sugars with other processed carbohydrates is unclear
- People with severe insulin resistance or diabetes may benefit from reduction of total carbohydrate intake
My view on this is that there might be a number of reasons why a lower carbohydrate diet is of potential benefit for some patients, but really…who cares if the end result is better health outcomes and wellbeing? It’s particularly worth considering in people who are diabetic, pre-diabetic, or need to lose a significant amount of weight…especially if they have struggled with weight loss in the past.
Staying with diabetes and pre-diabetes, this Cochrane review found that in order to delay or to prevent the onset of Type 2 Diabetes, there wasn’t sufficient evidence in the meta analysis it carried out for diet or physical activity alone…but both combined together produced results. Patients who have been told by their doctors that they are pre-diabetic should have be advised accordingly. I used to talk mainly to patients about their diet and weight loss and say that physical activity didn’t contribute particularly to the latter…but we now know that physical activity is protective in itself and has favourable effects on the way that your body deals with both sugar and cholesterol. The greatest benefits in reducing the risk of disease and death are seen in patients who go from being inactive to moderately active. It doesn’t require a gym membership, donning lycra, or dragging a tyre round your local park whilst someone in combat fatigues with anger management issues barks instructions at you. Just ten minutes a day of heart raising exercise, such as brisk walking, is enough to get you going in the right direction.
Last week I confessed that sleep is one of the areas of my life that I have struggled with. Not because I can’t get to sleep but because I choose not to get what I really need. I have done better this last week, inspired by having started to read Why We Sleep by Matthew Walker. My favourite podcast this week has therefore been Episode 26 (Part 1) of Feel Better Live More podcast by Dr Rangan Chatterjee, who interviews Professor Walker, on this subject. There’s a quote early on in the book which makes the point (and I’m paraphrasing) that if sleep does not serve a purpose and yet almost all animals spend a third of their life in this state, then it’s the biggest mistake that the evolutionary process ever made. Thought provoking stuff.
That’s it from me for this week. Until next week…look after yourself!
Dr Richard Pile