Good morning and welcome to the latest edition of my weekly wellbeing round up. Plenty to cover today, so let’s get started…
This BBC news article reminds us that passive smoking has effects way beyond childhood, including a significantly increased risk ischaemic heart disease and chronic lung disease in adulthood. Participants were questioned about their exposure to smoking throughout their lives, and then their health was tracked over the next 22 years. As I reported last week, children were also more likely to end up with respiratory illnesses and spending time in urgent care or the local emergency department. Now when I talk to people about quitting smoking, if they are parents I explore this as well. We might feel comfortable making a decision that affects only our own health…hopefully most of us would feel less comfortable if we were reminded it affects others too and there is no safe level of smoking.
If people are thinking about quitting smoking, they might well consider using increasing popular e-cigarettes. Whilst there has been some debate about potential safety issues (as reported in this article about changes to immune cells exposed to vaping chemicals in a laboratory setting), the House of Commons Science and Technology committee has published its report on vaping, and strongly recommends that more be done to encourage it. The report states:
“These recommendations are based on a fair and accurate assessment of existing evidence from the UK that suggests vaping is significantly less harmful than smoking, few young people who have never smoked regularly vape, smoking in young people continues to decline, and e-cigarettes are helping smokers to quit.”
In one line? E-cigarettes are much less bad for you than real ones. Duh.
More good news for ex-smokers and those trying to quit came in this article in the New England Journal of Medicine. The headline is that smokers are better off (in terms of health gains) after they quit, even if they gain weight. To quote the Journal Watch commentary, “even quitters who gained over 10 kg had a 67% reduction in cardiovascular mortality and a 50% reduction in overall mortality, relative to current smokers”. The next time I am talking to someone about quitting smoking and they say that weight gain is one of their reasons not to, I will explore this a little bit more with them to check whether it’s just gaining a few pounds they are worried about, or the consequence of weight gain on their health…in which case I will encourage them to quit first and work on the weight later.
A few weeks ago I posted about the revised american guidance on hypertension and the explosion in the numbers of people labelled with the disease that would occur should this frankly bonkers approach be adopted around the world. One thing to consider is how much more time and capacity will be needed by the NHS to help all these people control their blood pressure, should such an approach be taken. This study published in the Journal of the American Medical Association reports on the effectiveness of a low dose 3-drug pill in controlling hypertension. We already know that multiple drugs at a low dose are more likely to achieve blood pressure control than slowly titrating up one drug at a time to a higher dose. This result is not surprising. It is worth noting that adverse events were reported to be no higher taking this approach.
Take home message for me? Whilst I will always try to encourage lifestyle measures where relevant to lower or control BP, when considering starting therapy it may be worth adopting a different mindset, considering multiple drugs not to necessarily be a bad thing. Particularly if GP’s have patients with hypertension coming out of their ears, so to speak.
On the back of this report on the worrying rise of children with Type 2 Diabetes in the UK, there was some encouraging news for people with diabetes who are trying to control their risks factors in this study published in the New England Journal of Medicine. Patients with type 2 diabetes who had five risk-factor variables within the target ranges appeared to have little or no excess risk of death, myocardial infarction, or stroke, as compared with the general population. So whilst I would much rather focus my efforts on helping people not to become diabetic to start with, we can encourage our patients who have diabetes that with good control of their blood pressure, blood sugar, cholesterol etc, their risk of developing these complications is not significantly different from those without diabetes.
Carb Wars…the saga continues.
You may well be aware of this prospective cohort study and meta analysis published recently in the Lancet Public Health. The headline is “Moderate Carb Intake Seems Best for Longevity”. As you can imagine, the publication of such an article made Twitter explode as troops on either side of the Low Fat vs Low Carb war lined up to either crow jubilantly or defend their positions respectively. I will summarise in a moment but if you would like to do some further reading around the responses to and limitations of the study, here are some links:
Consultant Cardiologist Dr Aseem Malhotra’s response on the BBC news (YouTube clip, pro-low carb)
Science Media Centre briefing (anti-low carb)
As most readers of my blog will know, I am broadly in favour of a lower carb approach. I no longer eat cereal, have cut back on bread, love my eggs for breakfast, enjoy some nuts each day and tend to have salads for lunch with either chicken or oily fish. However, I still have the odd sandwich for lunch and am known to enjoy a bag of pork scratchings and a pint with my work colleagues during our friday evening debrief in our local. It is rumoured that fish and chips made an appearance last week when neither my wife nor I could be bothered to cook after a long day. The study cannot fully bear the weight of the headlines because it is observational and there are some concerns about the statistics and claims arising as a result (check out Dr Zoe Harcombe’s comments here and Luis Correia’s comments here ).
So what will I tell my friends, colleagues and patients when we end up talking about this over the next few days? I will say that moderation is the key. All extreme diets pose health risk. The one thing that we do NOT consume “in moderation” at present in most western diets is carbohydrates. In fact, you could argue that the western world is in the grip of an extreme high carb diet experiment. We consume far too much, driven by decades of messages about low fat and the evil genius of the food companies who produce cheap, highly processed foods (with “low fat” labels on them) which are almost impossible to avoid. So don’t worry about no or very low carb diets, just think a bit lower than most of us are eating now. Less in the way of beige carbohydrates (most of which have zero nutritional value), lots of vegetables, more protein (fish, meat, eggs). Eating a lower carb diet does not mean eating bacon every day and dying early of bowel cancer or heart disease. Polarising the debate is unhelpful and will leave most people bewildered. Let’s be pragmatic – eating a lower carb diet will result in weight loss partly because of it being lower carb and partly because it will inevitably result in reduced calorie intake for most people. Having debated evidence based medicine, I will give you a bit of anecdote based medicine: I have lost over half a stone on a lower carb diet and no longer need to use medication for my inflammatory bowel disease.
Finally, we will finish on a more positive and entirely uncontroversial note.
Over the years I have had the privilege of working with our local cardiac rehabilitation team. They are a great team of people, providing an important service to all of our patients with heart disease. They work with patients with angina, heart attacks, stents, coronary artery bypass grafts, valve replacements and heart failure. I have taken part in some of their sessions. Many patients speak very highly of the service. One of the trickier aspects of the job is proving what a difference the service makes. This can be either because it is hard to prove that something was prevented from happening or sometimes because the service hasn’t been set up to properly collect the necessary outcome data. So this systematic review and meta analysis published in Heart is most welcome. It concludes that there is evidence of physical activity in patients who have had cardiac rehab, whilst also recommending that further high quality studies need to be conducted to give us more detail and measure other outcomes. Shockingly, only about 50% of patients who have been offered cardiac rehab actually take it up. Take home message? All health professionals should strongly encourage patients to take up this offer, and encourage them to stick with the programme.
In Herts Valleys Clinical Commissioning group we have taken the principles of cardiac rehab and commissioned a cardiac prehab service for our patients at high risk of cardiovascular disease. Working with my colleagues in cardiac rehab, public health and the CCG I designed the specification for this service. For the first time this year, practices will be identifying such patients and offering education and support in the hope of improving outcomes and preventing disease occurring. I will report back at a later date.
That’s it for this week’s wellbeing round up. Stay tuned for next week’s edition and in the meantime, take care of yourself!
Dr Richard Pile.