Wellbeing for Real Life: what is resilience and how do we build it?

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I was recently asked to write a module on resilience for clients of a healthy lifestyle service provider. We had previously put together modules on anxiety, depression and stress management. The feedback that we were getting from some team members delivering the modules was that they found the subjects rather complex and difficult to discuss and there was a risk of ending up focussing on the negative. We therefore decided to simplify the modules, fuse them together where appropriate, and to take a more positive tone discussing fitness rather than illness. As I put the module together I was reminded that teaching something is a great way of learning something , and so thought I would share what I have learnt in the hope that it is useful to you.

Let’s start with some questions people commonly ask. What is resilience? Do I have it? How do I know? Can I measure it? If I don’t have it, can I get it, or improve it? How can I help my kids to have it?

Defining resilience

A very basic definition of resilience is the ability of a substance or object to spring back into shape after trauma. To make it more human, we could describe it as the ability to cope with setbacks, or the ability to overcome difficult experiences and to be shaped positively by them. It might be described very simplistically as physical or mental strength or fitness.

Resilient people are not just born, they can be made

As my wife pointed out to me during the writing of this post, anyone who has had a few children can tell you that we are all in different places on the scale of natural resilience. It’s undeniable. However, where we end up is not inevitable. Nurture has at least as important a role as nature. I used to be a bit daunted by the people in the weights section at the gym, heavily muscled and confident specimens stalking around the equipment as if they owned the place, occasionally grabbing hold of some colossal bits of metal and wrestling them into submission before grunting and moving on to the next unsuspecting piece of apparatus. This was until I realised that they hadn’t become like this spontaneously but had developed themselves over time, with regular practice and commitment and maybe some pain. I’ve heard physios encouraging people to keep doing their exercises, advising them that they should be aiming to stretch their muscles and cause them to ache because that’s the only way they will ever strengthen them. When you exercise, you need to get your heart rate up for it to do you some good, which isn’t always comfortable.

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So it’s good news for all of us, particularly if we are feeling life’s challenges. The route to resilience is adversity – getting through it, and learning from it. Machine parts are tested before they leave the factory, to ensure they are strong enough. In the same way that a person who never makes a mistake never learns anything, you can’t be resilient if you have never suffered any setbacks. I’m not suggesting you go seeking adversity, or deliberately make decisions that are likely to have a bad outcome, but its ok and indeed necessary to endure traumas to build resilience. In the same way however that an athlete would prepare to compete, there are of course things that we can do to prepare ourselves for life’s challenges.

My top tips for developing resilience, based on my own life and what I have learnt from others, include:

  1. Self nurture. Sleeping well, being physically active and eating a healthy varied diet will mean that we are physically and mentally in as good a place as possible to take on whatever comes our way each day. Relaxation is an important part of this too, setting aside some regular time that is just for you. That could include reading, listening to music or meditating.
  2. Good connections. With friends, family and other people that you have a shared interest with. Prioritise the positive relationships with people that encourage and support you, and who you can do the same for. Put dates in the diary to make sure it happens, or it won’t. If you have kids, make sure that they have positive, nurturing relationships in their life. These could be with friends, teachers, relatives, health care practitioners and of course…parents! It can be vital to be able to ask others for help when we feel we don’t have the strength for ourselves.
  3. Positive action. Take a positive attitude towards your abilities and encourage yourself, especially in difficult situations. Be assertive and open in your relationships, whether personal or professional. Set goals in the short, medium and long term and make a plan for how you are going to achieve them, breaking it down day by day and moment by moment if need be.
  4. Develop new skills and hobbies. You could learn a new language or take up an instrument. This is good for your brain, encourages further social networking and helps with practising delayed gratification. This is particularly important for children who have been born into this era of instant gratification and rarely having to wait for anything for any significant length of time.
  5. Learn from challenges. Whether it’s a mistake that you made, or something beyond your control that happened, take time to reflect on how it made you feel and what you can learn from it or do differently next time. If you have kids, it’s important to let them make decisions and live with the consequences. Obviously you have to pick and choose depending on the stakes for their immediate health and wellbeing. Resist being a helicopter parent. It’s understandable but rubbish preparation for life and not in your child’s long term interests. If you wrap them up in cotton wool, they will just break later in life when you may not be around to support and encourage them. Better to let them make mistakes at a younger age and be stronger and wiser for it.
  6. Practice gratitude. This is such a simple and yet profound thing to do. I would be willing to bet that if you are reading this blog you have at least one thing in your life to feel grateful for, no matter how bad today or this week or month has been. You can start with the very basic stuff (like being born!), narrow it down a bit (like living in a democratic society in here in the UK where you are allowed to express and practice your beliefs) and then focus on the more personal and specific things you are thankful for like the place where you live, your friends and family…maybe even your job!

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I hope you have found some of these tips helpful. Remember – we should not and cannot avoid adversity in life. It’s the route to resilience and can make us stronger.

The Weekly Wellbeing Round-Up #19: mental wellbeing.

The more observant of you may have noticed that this week (October 10th) it was World Mental Health day.  In recognition of this, the round-up this week has a mental health focus.  I will be highlighting how this affects people of all ages, the issues raised for the NHS including the mental health of those that work within it, and how we can take simple steps to help ourselves and others.

Global Mental Health Summit.  This was attended by 50 countries on World Mental Health day this week.  The Prime minister announced the appointment of a minister for Suicide Prevention and pledged extra investment in this area including additional funding for the Samaritans.  More details on this in a report from the BBC here.   The article highlighted some contact details for mental health charities which I have listed below:

  • The Samaritans are open 24 hours a day. Call 116 123 or email jo@samaritans.org
  • The Campaign Against Living Miserably (CALM) offers support to men. Call 0800 58 58 58 between 17:00 and 00:00 everyday or visit their web chat page here
  • Papyrus helps people under 35. Call 0800 068 41 41 – Monday to Friday 10am to 10pm, weekends 2pm to 10pm, bank holidays 2pm to 5pm – or text 07786 209697
  • Childline is available for children and young people under 19. Call 0800 1111 – the number will not show up on your bill
  • The Silver Line helps older people. Call 0800 4 70 80 90

Young people’s mental health

Loneliness

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When talking about suicide, this is inevitably and appropriately an area of concern for us.  Social isolation and loneliness shorten our lives, being equated to smoking 10-15 cigarettes a day in terms of the impact on our health.  When we think of the lonely groups in society, we often think of the elderly.  However, children and young people are the group who report being the most affected by loneliness.   Such people might appear to have a wide circle of friends and to be connected by social media but it just demonstrates the truth that you can still feel lonely even if you are not considered alone.

Tracy Crouch is the first minister for loneliness, and gave this interview to the BBC about the need to address this issue.  It’s clearly not an easy one.  The government may not be able to make friends for us, but we do need action at every level ranging from decisions about how we plan and develop our society and infrastructure, right down to individual day-to-day interactions.  When I consult with anyone who is anxious or low in mood, I will always ask about what their connections are with other people and encourage them to seek them out or develop them further.  We are ultimately social animals.  People do better with real life, face to face interactions when they are struggling.

Cannabis use

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Living in an affluent commuter town, you might be forgiven for thinking that there’s no big deal when it comes to casual drug use, particularly amongst the middle classes.  It tends to get lost in the general debate about legalisation but the reality is that there are serious consequences for mental health, particularly that of young people.  This article in the American Journal of Psychiatry highlights the dangers of cannabis use and its impact upon cognitive skills, memory and behaviour.  The effects were greater than those of alcohol, and appeared to be longer term.  Take home message for me?  That we need to be very careful as adults, particularly if we are parents, as to the messages that young people get from us.  Adult brains may not in the same vulnerable state as theirs are.

Child and Adolescent Mental Health Services (CAMHS)

As a GP I know many colleagues who work to provide CAMHS in their localities, and do their best in very difficult circumstances with limited budgets and increasing demands.  This article reports a 26% rise in referrals into such services nationally.   When faced with inadequate resources, services inevitably look at their referral thresholds and it is reported that a similar percentage of referrals are rejected, saying they do not meet the criteria.   This could be because of genuinely increasing rates of mental health problems and also a result of  increasing awareness of the signs of potential mental health problems due to health campaigns in this area.  I don’t have an easy solution for this, but one of the things I recommend is that as parents and professionals we have some knowledge of the options available to us as well as the traditional CAMHS route, which not every young person will need.  These might be third sector or voluntary organisations.  In my locality we recommend Kooth, which offers many different ways for young people to access support.   Suicide awareness and mental health first aid training for young people and adults alike is very important.  In St Albans we have the OLLIE foundation which is a charity doing excellent work in this area.

Ask Twice

One of the messages on World Mental Health day was “ask twice”.  People often say that they are fine when asked the first time.  We’ve all done it over our first cup of tea of the day at work.  Sometimes it feels as if you are obliged to say that you’re fine, as it might throw a spanner in the works and feel a bit awkward if you tell people how you are really feeling!  However, my view on this is that anyone who asks “how are you?” should both expect and be prepared to respond to whatever comes back.  If you sense that your friend, family member or colleague may not be feeling fine, ask them again.   The point is well made by this short video.

Mental health support for NHS workers

Staying with work, NHS chief Simon Stevens announced recently that there would be an expansion in the mental health service for doctors.  It already exists for GP’s and extra funding will be put into making it more widely available.  Clearly this is welcome and has been beneficial for the doctors that have used it so far.  However, if we are to practice preventative medicine when it comes to NHS workers’ health in the same way that we would like to with our patients, we must consider the underlying reasons why there is an increasing mental health burden.   I hope that the secretary of state for health and his colleagues will be considering underlying issues like workforce capacity and conditions as well as proper funding for services.  If not, it will simply be a sticking plaster that will fall off sooner or later.

Mediterranean diet…helpful for reducing depression?

person pouring vegetable oil on vegetable salad

 

It was recently reported that there may be an association between the Mediterranean diet and reduced odds of depression.  Now we all know that association is not the same as causation, but I think this is encouraging enough both to look into more deeply in terms of research, and to try for ourselves in the meantime.  After all, it isn’t complicated or necessarily expensive to do and has none of the risks associated with taking antidepressants.  Here is a simple diagram to remind us of the key components of a mediterranean diet:

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That’s it from me this week.  The weekly well being round-up will return.  Probably next week! Until then,  take care of yourself.

Dr Richard Pile

 

 

 

The Weekly Wellbeing Round-Up #14

Welcome back to the Weekly Wellbeing Round Up.  We’ve taken a couple of weeks off to focus on the low down on low carb diets, and digital wellbeing.  I’m pleased to say that this week normal service is resumed.   Topics for today include calorie counts in menus,veganism, probiotics, the cost of eating health food, heart age and heart disease.  Let’s tuck in….

Counting the cost of counting calories

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The department of health and social care is to launch a consultation on its plans to require calorie counts on menus as part of its childhood obesity strategy.  The BBC reported this week that concerns had been raised by the treasury about the cost to small businesses, and the risk of distressing people with eating disorders. recommended this week that.   Whilst I have sympathy for both potentially affected groups, I think we should ask ourselves what our priorities should be for the health of our nation and particularly our nation’s children.  I seriously doubt that my local greasy spoon cafe will go out of business because they have to work out the calories in their full english breakfast.

Is being vegan good for your health?

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The BBC reported this week on the experience of Dr Giles Yeo going vegan for a month, in an episode of Trust Me I’m A Doctor.  During his trial, Giles lost weight, reduced his body fat and his cholesterol.  He required dietary advice to avoid becoming deficient in certain nutrients such as iron, vitamins B &D, omega 3 fatty acids, calcium, iodine and protein.  Some of this can be sourced from plants, but some probably requires supplementation.

This meta-analysis found that people on a vegetarian (including vegan) diet had an overall descreased risk of dying from heart disease and cancer but that there was no overall decrease in cardiovascular deaths or all cause mortality compared to non-vegetarians.

Take home message?  You might be slightly less likely to die of heart disease and cancer but overall vegetarians don’t live longer.  It is sensible to consider going meat free for some of your meals each week…maybe replacing them with oily fish.  Whilst my quality of life might be improved in some respects, I could no longer have a sausage, egg & bacon bap with my buddy Al on a sunday morning after our bike ride.  That would be a No then.

Children in food poverty

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On a more serious note, the Food Foundation issued a report stating that “a healthy diet is beyond the reach of 3.7 million children in the UK“.  It’s a shocking statistic.  There isn’t an easy answer to this one.  It’s easy to glibly state that an apple costs less than a mars bar (which is generally true, in fairness), but it is a fact that crap food is cheap, and good food either costs more or (and I think this is part of the problem) takes more time and knowledge to prepare.

The answer for me has to be pragmatic.  Whilst influencing national policy and financial instruments is beyond the ability of most of us, we can take simple steps to improve the situation even if we can’t achieve perfection.  There are plenty of books and websites out there about cooking on a budget.  Some examples include:

BBC Good Food Seven Days of Cheap Healthy Meals

Jamie Oliver’s cheap and cheerful recipes

Jack Monroe’s Cooking On A Bootstrap

Some providers of lifestyle services including cooking lessons, not just lectures about healthy eating.   If you really want to be challenged and inspired in this area, I heartily recommend Dr Rangan Chatterjee’s interview with Jamie Oliver in Episode 16  of his Feel Better Live More podcast.   Jamie’s passion for this subject shines through.  I particularly like his ideas about using his recipes like a jukebox for types of meal and associated costs, to come out with some realistic options for families struggling in this area.   If you are a health professional talking to a family about this, just remember that even if they eat one or two healthier family meals per week, and their kids have maybe one or two healthier lunches at school, that is making a difference and it’s a start.

Probiotics…the sage continues.

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Finally  for our food section this week, the BBC reported on this study in the journal Cell which reported on the use of probiotics and whether they have a meaningful impact on our gut flora.  It’s a very long paper and to summarise very simply…they don’t have much effect if taken in a one-size fits all approach.  If you think about it logically, introducing a tiny amount of unsuspecting friendly bacteria into a person’s entire gut flora or “microbiome” is going to have very little impact in terms of relative numbers.

Take home message?  Our understanding of the gut microbiome is still at a very basic stage and there is very little available to us so far in terms of evidence that has immediate practical applications.  In the future we will look back and realise how little we knew.  Probiotics might work better if it is possible to take a personalised, individual approach to treatment.  For now, if a patient asks me whether they should take some “friendly bacteria”, I advise them that they won’t do any harm but in the average person they won’t do much good either.

Physical Activity

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The World Health Organisation has recently produced a report on global levels of activity.  It was a self reported study based in 168 countries with 1.9 million participants from 2001 to 2016.   The BMJ reported on the findings this week.  Sufficient activity was defined as 150 mins of moderate intensity activity per week.  36% of UK adults were insufficiently active, with Kuwait winning the wooden spoon at a whopping 67%.  Women were generally less active than men.   Inactivity was a worse problem in high income activities.  Over the study period, levels of physical activity did not rise.  The solutions are large scale and up to governments when it comes to decisions about transport and infrastructure etc.  Personally, I think 36% of UK adults being insufficiently active is a massive under-estimate and a reflection of a lot of people kidding themselves when they filled int the report.  My take home message is that health professionals should bear this in mind and drill down a bit more into a person’s history when asking about how active they are.  Physical activity is a miracle cure, a wonder drug.   If you haven’t seen it, I recommend you take five minutes to view Twenty Three and a Half Hours on YouTube.  It ends with an excellent challenge that puts all our excuses about physical activity into perspective.

My dog Prince has offered to be share, with anyone who wants to know, how he feels about exercise.  All you need to do is to come round to our house, look him in the eyes and ask him if he would like a walk.   You may wish to consider wearing body armour with an anti-slobber coating for this exercise.  Don’t say I didn’t warn you.  Here is the presentation he has put together.

Heart health and disease

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In a collaboration between Public Health England have released a Heart Age online tool that allows you to calculate what your heart age is compared to your actual age.  When it comes to risk, people often struggle to get their heads around risk scores as percentages over a number of years and scoring tools are increasingly calculating the age of the relevant organs in your body (heart, brain, lungs) as it is felt that this is a more powerful motivator for people to make changes.   You can take the test online.   If your heart appears to be significantly older (according to Public Health England!) then you actually are, it may be worth booking a phone call with your GP to talk things through.  If you haven’t already done so and are between the ages of 40 and 74, I recommend you take up the offer of a free NHS health check.

Lifestyle Medicine

As a new user of EMIS (a GP computer system), I attended the national user group conference in Birmingham this year.   It was a great event and both I and the rest of my surgery team learnt a lot and came away with loads of ideas for how we can provide better and more efficient care for our patients.  One of the highlights of the conference was the Lifestyle Medicine presentation by Dr Rangan Chatterjee and Dr Ayan Panja. Excellent, inspiring stuff.  The real time roleplay between Rangan and Ayan of a GP consulting with a stressed, sleep deprived patient was particularly good and could have taken place in any GP surgery in the land.  I was able to catch up with both of them afterwards and we talked about the difference that this approach can make to our lives as patients and healthcare professionals.  I have already seen a positive impact on the lives of some of my patients.   I am definitely going to sign up for their highly rated, RCGP-approved Prescribing Lifestyle Medicine course in January 2019.  If you can’t wait that long, I recommend you get a copy of Rangan’s Four Pillar Plan in the meantime.  I recommend it to all my patients who need to make changes in their life, as it has helped me to make changes in my mine.

That’s it for this week.  I hope you have enjoyed the blog.  Your comments and feedback would be really helpful.  If there are particular topics you would like me to cover, please let me know and I will do my best to keep it real.    Until next week, take care of yourself!

Dr Richard Pile

The Weekly Wellbeing Round-Up #11

Good morning and welcome to the latest edition of my weekly wellbeing round up.  Plenty to cover today, so let’s get started…

Smoking

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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.

Hypertension

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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.

Diabetes

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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.

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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.

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Cardiac rehabilitation

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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.

 

The Weekly Wellbeing Round-Up #10

Good morning and welcome back to the weekly wellbeing round up.  I though this week I would start with…

Digital wellbeing

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Last week I posted from our family holiday in Verona.  My three younger boys are a band, Princes to Kings (shameless promotion:  click here for their instagram,  website, facebook page,  and YouTube channel). During my sunday morning run round this beautiful city,  I was also scouting out locations for their latest video.  Yesterday I was updating Facebook with pictures of me and my son’s camping weekend.   We had a lovely break in Verona and were able to share some of the highlights of this special trip with our family and friends.  It was important for the boys to be able to share some bits and pieces with their followers as well, which added extra enjoyment to the weekend.  Zac and I loved our weekend away.  My posting pictures of what we were up to enabled me to reassure my wife that we safe, having a good time, and had survived our 70 kilometre bike ride to London and back.  I don’t feel that doing this detracted from either of our trips.  The internet and social media can enhance our lives and the lives of our friends and colleagues, and enable us to do and share things that were unimaginable even ten years ago.   It’s a tool.  It isn’t intrinsically good or bad, it depends how we use it.  Just like medicine, exercise and even water, it has a correct dose.  Too much is bad for you, physically and mentally.

This article published in WebMd points out one of the pitfalls of too much screen time, namely weight gain.  Teenagers who exceeded two hours of recreational screen time were twice as likely to be overweight or obese. This will not really come as a surprise to anyone reading this, as this risk is posed by any “activity” which is essentially sedentary.  The American Heart Association recommends limiting screen time to two hours a day.  If you are struggling to persuade your children of this, you could  consider encouraging them to play games which involve physical movement as most of the latest generation consoles from microsoft, playstation and nintendo all have hardware that enables these sort of games to be played.  When my kids were younger, we loved playing games with the xbox’s kinect.   I can still remember laughing so hard it reduced me to tears when my then seven year old beat a series of my adult friends senseless in a (virtual) boxing match in an online gaming session.   We would also do a deal with our kids, such as them agreeing that they could have some screen time after walking the dog or playing football outside.  There is of course always the option of the Off Switch.  If negotiations fail, I recommend throwing the kids out of the lounge or playroom, and just remember that when they say “I’m boooooooooorrrrrrred!” you can tell them that boredom is an important part of childhood and good for their developing brains and creativity!  Of course this doesn’t address the issue of mobile devices.  I will dedicate a future blog post to this as it’s a topic worth looking at in more detail.

access application black business

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Staying with the social media theme, the term “snapchat dysmorphia” has been coined by plastic surgeons who are seeing increasing numbers of people come to them requesting surgical procedures to make them look more like their snapchat photos.   The issue is described in this report of an article in JAMA.  I personally have not yet had a patient come to see me to discuss this (and they certainly wouldn’t get past our clinical commissioning group’s low priority policy if they did!) but joking aside, the article makes the point that a facial feature such as a nose that looks good in a manipulated selfie taken from a phone held just a short distance away, would look very small and weird in real life …something we can reassure ourselves and each other about!

So what might the antidote be to some of these digitally induced woes and mental health problems?  You will win no prizes at all for guessing that it’s….

Physical Activity for improving mental health

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Physical activity is good for depression, according to this summary in theBMJ.  I think this is a very encouraging study.  There are a few key points worth noting:

Firstly this was an observational study (as opposed to say a a randomised control trial) of 1.2 million adults in the US. So we can say that people who are physically active have fewer days where there mental health is “not good” compared to those who are not active. There is a consistent association but we can’t confidently claim causation in this study.  However, other variables (known as confounding factors) were taken into account in assessing the likely effects of physical activities, which is important.

The effect was noticeably greater in those with a known history of depression.  So those most in need of this intervention are also the most likely to benefit from it, which is great.

In terms of dose, the greatest effects were seen in those who were physically active for roughly about the number of minutes per week that we recommend here in the UK, which is handy as we can just remember our current guidance which is 150 mins of heart raising exercise a week (e.g. 30 mins a day, 5 days a week).  However, more than 3 hours a day was associated with worse mental health.  I wonder whether this is due to risk of injuries and their consequences, or perhaps excessive exercise being a symptom of more serious underlying mental health issues?

All types of activity (including housework, gardening and running around after children) were beneficial to a degree.  Team sports, cycling, and aerobic and gym exercise were the most beneficial.

The benefits of physical activity with regard to mental health were greater than the effect of education level, financial security or  body mass index.

Weight loss and eating breakfast

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Speaking of body mass index, this study done by the University of Alabama showed that people who were overweight were no more likely to lose weight if they skipped breakfast.   I have often been struck by how many of my patients who are overweight (and not losing any weight despite their apparent efforts) tell me in either a proud or slightly mystified way that they don’t eat breakfast.   I believe that breakfast is an important meal as it gives you nutrients and energy for the day.  A high protein lower carb breakfast (such as eggs or porridge, for example) is much healthier than sugary cereal and toast and will keep you feeling full for longer.  Many people who skip breakfast end up snacking on less healthy food during the day due to feeling hungry.  It is well known that when we then try to recall what we have eaten during the day, we are prone to underestimating (or forgetting entirely) the snacks that we may have had in between meals.

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Passive smoking in teenagers

Finally, I found this article in Paediatrics,reported in Journal Watch, quite thought provoking.  Teenagers without asthma living with a smoker were more likely to report respiratory symptoms and, as a consequence, to miss school or attend the emergency department or seek urgent care.  The suggestion is made therefore that such settings are ideal for offering health promotion to the teenagers and their smoking family members.  When I do an out of hours shift and consult with a teenager with a flare of their asthma, I haven’t necessarily thought to ask about their family smoking history or talk to their parents about this at the time, having felt this is up to their usual GP in normal hours.  However, people are more likely to change their behaviour if an intervention is timely…and surely sitting in A&E with a breathless child is the perfect time to raise the subject?  I will try to do this more in future.

That’s it for the wellbeing round up this week.   See you next week and in the meantime, take care of yourself!

Dr Richard Pile

 

The Weekly Wellbeing Round-Up #4

Hello and welcome back to the weekly wellbeing round up.  After my report from my “wellbeing clinic” last week, normal service is resumed.  The main focus of the round up this week will be on obesity, as the government published Chapter Two of “Childhood Obesity – a plan for action”.

The challenge

Nearly a quarter of children in England are obese or overweight by the time they start primary school aged five, and this rises to one third by the time they leave aged eleven.

Children growing up in low income households are more than twice as likely to be obese than those in higher income households.

The ambition is to halve childhood obesity, and reduce the gap between richest and poorest, by 2030.

Obesity costs the NHS £6 billion a year, and wider society £27 billion a year

The planned 5% reduction, within this last year,  of sugar in foods commonly eaten by children has not been achieved (the target is 20% by 2020).  The target for calories in foods consumed by children is a 20% reduction by 2024.

energy drinks

Action Plan

Consultations are proposed in 2018 on –

  • banning the sale of energy drinks to children
  • mandatory calorie labelling for all foods in restaurants and cafes
  • 9pm watershed for adverts for foods high in fat, sugar and salt
  • a ban on unhealthy foods being offered on price promotions or at the checkout or entrance to stores

Local authorities will be encouraged to use their powers to promote healthier environments, and to share best practice across the country as part of a trailblazer program.

Schools will be advised and helped to reduce sugar content of food served to children and every school will be encouraged to adopt the Daily Mile, or a similar program.  As prevention lead for our clinical commissioning group,  I have already met with primary school headteachers, who are beginning to embrace the program.

My view? Fine words.  A good start. Hard to object to, like motherhood and apple pie.  The question is whether the government has the will to legislate against Big Food.  We are now facing the same kind of challenges with these companies as we did in the 1950’s and 1960’s with Big Tobacco.  A report by Public Health England highlights the scale of the challenge, pointing out the not entirely surprising news that England’s fastest areas are fast food hotspots.  For me, this is not just a fight about health and wellbeing, it’s about social justice.  Here in Hertfordshire, our CCG and local authority need to be working together to make meaningful changes..something that we aspire to and need to work harder on.

Practical steps you can take today

We can’t afford to wait around forever for government legislation to change, so what can be done about this in our communities by health care professionals and patients?  This week I have been listening to Episode 22 of Feel Better, Live More podcast.  It’s a conversation between Dr Rangan Chatterjee and Professor Satchin Panda entitled “Why when you eat matters”.   It’s all about time restricted feeding, also known as intermittent fasting.   The idea is that if you eat all your food for the day within a specific time period, your body digests your food better and you can enjoy a number of benefits including weight loss.  There has been good animal data about effects on weight loss and reversing diabetes, and there is now some emerging human data to back it up.  Here is one example of some study data supporting this approach.  In an ideal world, people would modify their diets to eat more healthily and this can be done in conjunction with time restricted feeding.  However, if I have a patient consulting with me that I know is going to struggle to change their diet, at least I can recommend they try this approach as a start.  Once they start to feel better as they lose weight and have more energy, they may well then wish to make further, even better changes.  Dr Chatterjee recommends a 12 hour window in his excellent 4 Pillar Plan book, and I think that this is achievable for most of us, at least some of the time.

white and beige medicine

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On the subject of diets, I am often asked by patients whether they might benefit from supplementation and if so, with what sort of things?  I have always been something of a sceptic in this area.  I found this article from Dr Hazel Wallace, the Food Medic, a very helpful summary for me and I will share it with my patients.  In summary – if you are in good health and do not have any nutritional deficiencies and eat a well balanced diet, you do not generally need any supplementation of your diet.  Dr Wallace does recommend, in line with public health england guidance, that you consider vitamin D supplementation in autumn and winter.  She also highlights other groups who may benefit from some supplementation including pregnant women and children under five.

Finally , I thought I would finish with this encouraging study which appears to demonstrate the benefit of weight loss in patients with atrial fibrillation.  Patients who lost 10% or more of their body weight significantly reduced or reversed the progression of AF.  When you consider the disease burden associated with AF including four to five times the risk of stroke (and the strokes themselves being more likely to kill or disable a person), and the difficulties that some people have in tolerating  drugs for rate and rhythm control, and the risks associated with anticoagulation (taking blood thinning agents), this must surely be something that every significantly overweight person with atrial fibrillation should consider seriously.

That’s it for this episode of the weekly wellbeing round up.  Stay tuned for next week’s episode and in the meantime, take care of yourself!

Dr Richard Pile