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, Episode #26

Welcome back to my weekly wellbeing round-up.  As usual, I have been scouring the news from the wellbeing world over the last seven days and found the most interesting, relevant and useful stuff to present it on a plate for your delectation.  This week’s topics include food labelling, diets to reverse diabetes, the benefits of eating together, population health and which interventions provide the best return on investment in reducing cardiovascular disease. Let’s dive in!

Prevention at scale

A different vision for population health

This article from the King’s Fund highlights the shift that is taking place in the burden of disease from mortality (death) to morbidity (illness) with people living for many years with chronic conditions, in pain and in poor physical and mental health.  Much of this is preventable.  The challenge for us as users, health professionals and commissioners, is to shift our mindset of viewing the NHS as a treatment service for sickness, to one which offers a more comprehensive approach to keeping us well.  This needs to apply to general practice, with clinicians and patients practising lifestyle medicine together, as well as to our commissioning decisions about what services we are going to spend money on.

So what should we be spending our money on to prevent disease?

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Public Health England have released this  helpful tool to help us understand which health interventions give the best return on investment when it comes to the prevention of cardiovascular disease (heart disease, stroke and diabetes) in larger populations.  Just in case you don’t have time to read the whole thing or spend hours playing with spreadsheets, my summary is as follows:

The best short term outcomes are obtained by detecting and managing people with a QRISK (cardiovascular disease risk) score of > 10% and using statins to lower cholesterol (£216 million saving by year 2).

The best long term outcomes are obtained through each of the following: increasing the detection of people with diabetes, optimising blood pressure control and having an annual review.

Most lifestyle interventions are not cost-saving within the 20 year time horizon of the model…however, this does not rule them out of being cost saving beyond this horizon.  The one exception to this is the excellent National Diabetes Prevention Program, which is shortly to have online versions rolled out for those who find it difficult to attend sessions due to work or family commitments.

My take home messages from this are

  1. We should continue to carry out risk assessments in primary care (and secondary care?).  NHS Health Checks are a great way of doing this and don’t need a doctor to do them.
  2. It’s much better to detect pre-diabetes or early diabetes and intervene as soon as possible with lifestyle changes to avoid a lifetime of complications and increasingly expensive drug treatments.  The National Diabetes Prevention Program is a shining example of how this can really work. 
  3. If people argue against spending money on other lifestyle interventions, they should be asked whether they would also not spend money on medication for diabetes, since the evidence on return on investment over 20 years is no better!

Very low calorie diets to reverse diabetes

As well as enhancing the NDPP offering, Simon Stevens has announced that very low calorie diets will be piloted at scale by the NHS for the first time from next year, after the success of the DiRECT and DROPLET trials in demonstrating weight loss and reversal of type 2 Diabetes.   In my view, whilst this is a potentially useful tool for carefully selected patients, we need to remember that an 800 calorie a day diet is not a long term sustainable option.  Follow up of these patients and assisting them in transitioning back into a healthy, natural diet will be key. 

Food

Food labelling

This week, Kelloggs has agreed to use the traffic light labelling for food introduced by the government’s voluntary scheme in 2013.  This indicates how much salt, sugar and fat foods contain.   This can only be a good thing as hopefully it will increase pressure on other food companies to do the same.  The scheme is already used by most supermarkets and some other companies such as Nestle and Weetabix.  It will begin to come into effect from Jan 2019.  

Whilst this is welcome news, remember that the vast majority of cereals are, to quote Dr Mark Hyman (author of Food: WTF Should I Eat?) “breakfast candy” – highly processed and full of sugar.  As a rule of thumb, any messaging on the packet about how good it is for you and how many of your five a day it contains is at best deceptive and at worst an outright lie.  For breakfast I usually choose from eggs (I eat them most days, usually poached), oily fish, avocado, vegetables (I love mushrooms and peppers)… and bacon if I want to treat myself.

Big Food and its influence over what we eat. 

On a related note, this article in the BMJ about food industry influence is worth a few minutes of your time.  It includes details of paper that will soon be published, examining 4000 peer-reviewed nutrition studies.  Researchers found that only 14% properly disclosed financial ties.  60% reported results favourable to the study sponsor, while only 3% reported unfavourable results.  Take home message?  We should assume that we face at least as big a challenge with industry influence on research, standards and guideline development from Big Food as we do from Big Pharma.  

Some good food news about family dinners

To finish this week on a positive note, I was encouraged after reading this article in the New England Journal of Medicine which suggests that adolescents and young adults who eat dinner with their families more often have healthier diets – regardless of how well their families function in general.  We already know that sharing meals together is good for our overall wellbeing, particularly our mental health.  It helps us be live mindfully, not just viewing food as fuel to be gobbled down as quickly as possible whilst staring at the screen of our mobile phone and thinking about what’s up next.  It now also appears to result in healthier diets, even if there are a few squabbles over the dinner table!  I have a busy weekend ahead with extended hours on Saturday and an out of hours urgent care shift on Sunday,  but as a family we will do our best to at least have some of our meals together.   If you don’t have family around you this weekend, why not invite friends or neighbours to share a meal with you? 

That’s it for this week.  Never fear…the weekly wellbeing round-up will return.  If you have enjoyed reading this blog, please share it with your friends, family and colleagues.  As every , your feedback is very much appreciated.  Last week’s blog focussing on mental health was the most viewed since I started the round-up!  

Until next time, take care of yourself.

Dr Richard Pile

The Weekly Wellbeing Round-Up #21

Welcome back to the weekly wellbeing round-up!  After a few weeks of posts focusing on more specific topics like the miracle cure of physical activity and mental wellbeing, we are back to a good old-fashioned trawl through the week’s wellbeing news, digging out the most interesting, relevant and useful bits.   Let’s get stuck in…

Food

appetizer crab cuisine delicious

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Omega 3 and Oily Fish

A study in the BMJ this week found that there was an association between the intake of omega 3 polyunsaturated fatty acids (n3-PUFA’s)  from sea food and healthier ageing.  Healthier ageing was defined as the absence of disease and physical dysfunction.  Risk was reduced of unhealthy ageing by up to 25%.  Recommendations are made for further research into the possible causal mechanisms.  This reinforces the existing dietary recommendations already made by most doctors which is to eat oily fish at least twice a week.  I suspect that the benefits of n3-PUFA’s will apply to all age groups but it is easiest to demonstrate reduced risk in older patients who are, by definition, a higher risk group.

Oily fish include herring, salmon, sardines, trout, mackerel and pilchards.  Shellfish (mussels, oysters, squid, crab) and white fish (cod, haddock, plaice) are considered healthy but don’t contain the same amount of the n3-PUFA’s as the oily fish.

Organic Food and Cancer

Research published in JAMA Internal Medicine appears to suggest that eating organic food may be associated with a lower risk of lymphoma, a particular type of cancer.  However, there may be confounding factors such as lifestyle differences in people who choose organic food.   So in summary:   whilst it makes sense to try to minimise chemicals used in growing food that may cause inflammatory responses in our bodies, there is not yet a compelling case for switching to organic food on a large scale, at least in terms of reduced risk of cancer anyway.

Food supplements

 

yellow health medicine wellness

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One of the questions my patients commonly ask me is  – should I take food supplements?  This was debated again in the press this week after the case of a man who ended up with liver failure after taking green tea supplements.   Here is a simple, fairly balanced BBC news article on the subject.  My advice on the subject is:

  1. Most people don’t need food supplements if they have a balanced diet (although I am in favour of children under five having safe doses of multivitamins and I recommend all pregnant women take folic acid)
  2. Getting nutrition from eating whole foods is more desirable than taking supplements
  3. Don’t make the mistake of assuming that if a little extra of something is good for you then a lot must be even better.  Check the recommended daily amount.
  4. Buy from reputable manufacturers

Wellbeing for Doctors

first aid case on wall

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There is a good article in the BMJ this week by Greta McLachlan about the importance of doctor’s wellbeing.  You can read it here.   She describes the challenge of burnout (faced by up to 50% of doctors) and the importance of doctors putting themselves first at times. After all, passengers on a plane are given the advice that they should put their own oxygen masks on first before attempting to help others.   The article contains some links for doctors to use if they are either struggling themselves or are aware of a colleague that is.   These are the  Practitioner Help Programme, the Sick Doctors’ Trust and the Doctors’ Support Network.

I recently read an article on the same subject, looking at what we can learn from the history of doctors’ working conditions.  I know I often find myself reminiscing with colleagues about the good old days.  On the one hand, there were undesirable aspects of a macho culture and the “it never did me any harm” mindset.  On the other hand, job satisfaction may have been higher because doctors had a sense of belonging as part of their “firm” and continuity of care and patient relationships were better.  We worked an on call rota as a team and were not fragmented by shift work.  To me, this is a reminder of the importance of purpose and meaningful work – not just the pay or the hours associated with it.   In this age of talk about lifestyle medicine and wellbeing, we must avoid putting the responsibility for doctors’ wellbeing entirely on their heads and consider carefully the system that they are being asked to work within.   Practising a bit of yoga and mindfulness at lunchtime may well be helpful but it shouldn’t be used to paint over the cracks of underlying system failure.

Lifestyle Medicine:  it’s a thing.

women performing yoga on green grass near trees

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In fresh and not entirely shocking news, this article in the BMJ reports the findings of a UK biobank cohort study into the risks of stroke and the role of both genetics and a healthy lifestyle.  It comes to the conclusion that just as genetics can significantly affect your risk of having a stroke, so adopting  a healthy lifestyle may significantly reduce it.  A healthy lifestyle was defined for the study as being physically active, not smoking, having a healthy diet and a BMI of < 30.  People are prescribing and taking their own lifestyle medicine and benefitting from it.

When I was training as a doctor, the only kind of medicine that we learnt about was the kind that was prescribed and came in bottles or packets.  Nowadays we hear more and more about lifestyle medicine.  There are two parts to lifestyle medicine of course – the information and advice that’s given to us , and our actual practice of it.   There is debate within the medical profession as to its value and place.  Whether you view lifestyle medicine as a relatively recent and increasingly important speciality,  an integral part of whatever speciality you practice, or just stating the bleedin’ obvious, it seems to be gaining more and more traction.  As a GP I find it bizarre that having been a doctor for over twenty years it is only in the last few years that I have really begun to understand it and do it properly…both for my sake and the sake of my patients.

This article on lifestyle medicine in this week’s BMJ is well worth a few minutes of your time.   It asks the question as to whether lifestyle medicine is a speciality or should be part of all medical practice, whether it is something to be practised by a few or should be done by everyone.  There is further information about the British Society of Lifestyle Medicine and the diploma that they offer.

From my own perspective, what I can say is that both preaching and practising lifestyle medicine (and in my opinion you have to do both to be credible) has improved my life both personally and professionally.  I was in danger of low-grade chronic burnout as I found myself increasingly frustrated and disillusioned by my experience of general practice and the relatively minor difference that I was able to make for most of my patients.  The medicine I was practising was often just a sticking plaster, an exercise in damage limitation and closing the stable door after yet another horse had bolted.  It was based on a pathological model of health.  Please don’t misunderstand:  this still has value.  Our patients with long-term conditions,  cancer and life limiting illnesses still need our compassion and care, technology and drugs.  However, lifestyle medicine is based on a salutogenic (positive and health-based) model.  It is optimistic, energising and life changing.  In this context, the relationship between a patient and their doctor as a powerful catalyst for change.  The challenge that we face in primary care should not be whether we “do” lifestyle medicine (many if not most GP’s already are, to varying degrees), but how we do it within the constraints of our current consultation model and contract framework.   The answer probably lies partially within and partially outside our current ways of working…but that’s a topic for discussion another week.

Podcast recommendations

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I thought would finish with a mention of some of the podcasts that I have particularly enjoyed and found helpful this week and are related to some of the topics in this week’s post.  For your aural delectation, I heartily recommend:

Feel Better Live More Episode 32:  The science of happiness with Dr Rangan Chatterjee and Meik Wiking

TED Radio Hour:  The meaning of work.

That’s it for this week’s wellbeing round-up.  I hope you have enjoyed it – if so, do share with your friends, colleagues and patients.  Your comments and feedback are really welcome.  They will help me make it as useful as possible in future.  Until next week, take care of yourself!

 

Dr Richard Pile

 

 

 

 

 

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

worse-for-wear-1438209

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

woman smoking cigarette

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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:

md0-pyramid

 

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 #18: a weekend of wellbeing in Valencia.

When I was a medical student our favourite lecturer was Dr Andy Sparrow. Not because of his subject (which was anatomy) but because at random points throughout his slides he would show us pictures of his holidays – a bit of light relief in the midst of gruesome detail.

I am currently at around 30,000 feet as I write this blog post , returning from a weekend in Valencia with my friends. We are all part of a GP learning set and this was the group’s 19th annual trip. It’s been a great weekend in a fantastic city that I will definitely return to.

During our time away we each prepare a topic to discuss. We do these throughout the weekend, combining continuing professional development with eating, moving, (some) sleeping and plenty of relaxing. My topic this year was Lifestyle Medicine and Wellbeing. I shared my journey thus far and how learning about the importance of this has transformed how I feel about my job and purpose. We discussed models of wellbeing including the four pillars that I have already mentioned.  I had recommended to the group that we try to all read Dr Rangan Chatterjee’s Four Pillar Plan before the trip. We also added another pillar: connection. So for this week’s blog I hope you will indulge me as I share some of our experience how it relates to wellbeing for real life. With a few holiday snaps thrown in.

Eat

One of the pleasures of the trip is finding nice places to eat good food. We like to go on local recommendation, backed up by Trip Advisor. The highlight for me this year was a day spent on a farm learning how to make proper valencian paella and sangria. It was of course terribly gruelling but we did end up with a certificate which I will show to my appraiser next year. Learning about the origin of the dish and what the correct ingredients are (apparently if there’s sea food or chorizo in it then it’s not paella, just rice with things in it) was interesting but the best part was how paella is served up and eaten. First of all everyone makes a point of thanking the cook (whether it tastes good or not!) and then everyone sits round the table with a spoon (not a fork) and eats from their segment of the paella dish. If you want a bit in someone else’s segment you negotiate for it. You can put bits you don’t want in the centre for anyone to take. And you never, ever turn the dish round to take something you want, not unless you enjoy getting stabbed in the hand with a fork by one of your neighbours.

Connect

What struck me is how important this is for a key pillar of wellbeing: connection. The food is cooked from local, seasonal ingredients. The meal is communal. Everyone shows their gratitude. Food is shared together over what will doubtless be good conversation, helped perhaps by a little sangria. It was a wonderful experience that our hosts were very happy to share with us, and send us away as paella ambassadors! Interestingly, the valencians consider paella to be a dish that you only eat at lunch, and as it can be quite heavy then they enjoy their siesta afterwards and tend to have a light evening meal around 10pm, often with tapas dishes. In Valencia, anyone eating paella for dinner is definitely a tourist.

Sleep

In the interests of full disclosure, sleep was a bit of a mixed bag. There is time-stamped photographic evidence on our WhatsApp group of some deep and meaningful discussions taking place in a bar in the early hours of friday morning. However, we were quite sensible for the other nights. What is always striking when going to Spain is the siesta. In his book Why We Sleep, Matt Walker explains how we naturally have a biphasic sleep pattern as humans (i.e. we do best if we sleep twice a day) and so to have a siesta is consistent with this. In the UK we have forced a monophasic sleep pattern on ourselves with a masochistic long working day…which results in less productivity, not more. When Greeks stopped their siesta at the height of the financial crisis, cardiovascular deaths increased significantly as a result. We also get a surge in these events when the clocks go forward and we lose an hour’s sleep every year. The EU will stop the twice yearly changing of the clocks in 2019. It will be interesting to see if population health benefits can be demonstrated. After Brexit (the only topic we banned for the whole weekend) the UK could be the control arm of this large-scale population experiment!

Move

Walking from cafe to bar to restaurant was, as you can imagine, absolutely exhausting. Somehow we managed. We did take in the sights as well, hitting 10,000 steps most days. There are beautiful museums, markets and churches in Valencia

Having to walk up and down four flights of stairs due to a broken lift was very helpful in this respect. We must write a note of thanks to the hotel. On our last morning I went for a run with my friend through the park that runs along a dry river bed in Valencia. It’s a lovely setting and despite being early it was practically rush hour with the locals in running clubs, walking dogs and riding their bikes…Valencia’s equivalent of Park Run. Running with someone who is a better runner than me really helped me go further and faster than I would normally. I made a point of thanking them for this through only slightly gritted teeth. Incidentally, did you know that Park Run is a global thing? Apparently some people do the Park Run Alphabet challenge finding cities all round the world where it takes place. It takes place in both Mile End and Milan. I suspect the starting letter and hosting Park Run are the only thing they have in common. There’s also a UK version.

Relax

We are not usually short on relaxation during one of our trips. The key idea that underpins very trip is the idea of “me time”…that as human beings we all need and deserve some me time. Our group is very fortunate in being able to do this for a whole weekend once a year. What was interesting is that sitting round the dinner table and talking about which pillars we find easier and which we need to work on, the commonest area for improvement was in relaxing. One of our group described their child had complaining to them that they couldn’t sit in their lap if there was a lap top already there.

It’s great to have an opportunity like this once a year, but probably more important, if you had to choose, to have five minutes every day. We talked about what we found relaxing: reading, listening to music, walking the dog, eating a meal as a family or watching our favourite TV show with them. We discussed practising mindfulness, being present and limiting screen time and I showed some of our group how to use Do Not Disturb and night-shift functions on their phones, before we finally turned in for the night.

By the time this post is published I will be at my desk in the surgery on a cold, busy monday morning. I will feel a bit sad that our trip is over for another year. However, I have got more CPD points for my appraisal, a new background photo on my desktop, more fond memories to add to the nineteen year collection, and a date already in the diary for next year.

Thank you for allowing me to share this with you. I hope that making it personal has been useful. Like James Bond, the weekly Wellbeing round-up will return. Until next week, take care of yourselves!

Dr Richard Pile

The Weekly Wellbeing Round-Up #15: making a plan to improve your wellbeing.

When I first became a GP, I decided that many of my patients who needed to make lifestyle changes also had undiagnosed conditions that resulted in problems with their understanding,  memory and planning processes.  There must be something wrong with them, so my reasoning went, because they left my consulting room chastened by me about their lifestyle choices,  concerned about their impending doom, and clearly intent on turning their lives around….but when I saw them again they hadn’t done anything.   In fact, some of them were even more unhealthy than before.   Some cases stood out, like the man who was still popping out for fag breaks in between ward rounds on the coronary care unit after he’d had his heart attack.  Or the elderly lady with furred up arteries in her legs who looked me straight in the eye and told me that she was more scared by the thought of life without cigarettes than she was by the below knee amputation that she was heading relentlessly towards.   Surely the only explanation was stupidity or a death wish?  Or so I thought.

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Years have gone by and I have learnt a lot about people, which is an inevitable and highly desirable side effect of working in primary care.  I have spent time talking these things through with patients.  I have read round the subject of behavioural psychology (I highly recommend Nudge, Inside the Nudge Unit, and Think Small for a good grounding in this area), met with people from the Nudge Unit (or Behavioural Insights team, to give them their proper name)  and spent time discussing these issues with psychologists and other colleagues.   At Thrive Tribe, we are working with the Centre for Behavioural Change to ensure that all our practitioners are appropriately skilled in this area to help their clients, offering a service that is more than just education about giving up smoking or losing weight.

For the purpose of today’s blog post, I am going to share with you a small but important part of what I have learnt over the years.  It’s not very clever or surprising.   Neither is it difficult.  Everyone can do it.  It’s about having a plan.

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Why do we need a plan?

Humans are not rational creatures.  We assume that because we have been well in the past we will be so in the future.  We cleverly avoid joining the dots with all that we know about what is likely to happen as we get older.  We know that there are theoretical risks of things happening, like heart attacks and cancer and road accidents, but we assume that somehow we as individuals are exempt from this risk,  unlike everybody else in the world around us.   I’m sure you can see the potential flaws in this reasoning.  When things unravel, they can unravel quickly.  Even when things are not yet seriously unravelling health-wise, people are often still aware of their wellbeing issues.  When people fail to make changes that are needed, it isn’t because they don’t know what to do.  It’s beause they either don’t know how to do it, or they do know how to but have no plan in place to make it happen.   I know that I would like to catch up with my brother for breakfast over the next few weeks.  I also know based on the endless games of message-tag we play that via text, facebook messenger, what’s app and email unless we actually make a plan, it will  never happen.   It’s better to have a plan.  It could be written on paper, or stored electronically – just as long as you can refer to it and review it whenever you need.

Do wellbeing plans work?

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Plans are not foolproof.  Otherwise we wouldn’t refer to the best-laid ones or talk what the road to hell is paved with.  They do, however, increase our chances of making and sustaining the changes that we want to.   There are various reasons for this.

Accepting the need to make changes

Firstly, making a plan to change means that we have generally (perhaps grudgingly!) accepted that there is a change that needs to be made.  Maybe you’ve been along to see your GP, practice nurse or health care assistant and a few issues have been raised that you concede might be worth a look at – that weight you’ve been meaning to lose for years, your need to quit smoking or reduce your drinking because of the effect it’s having on your health,  or perhaps your worries about getting a bit fitter as you move into middle age.

Being specific about the changes

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Vague plans are not much good.  “I will lose weight/eat fewer biscuits/do more exercise” might work for a small minority, but for more people it will never translate into anything.  Why? Because they have leapt straight to the desired outcome and are too vague.  We need to be clear about what we are going differently that will result in those outcomes.   Each step in the process needs to be considered, broken down into even smaller steps if required, to see how realistic it is and what needs to be done in what order.  A plan makes it easier to achieve than a one-off mental note to self or vague intention.

A plan makes us accountable for the changes

If we have a plan, it means that we are accountable.  Not just to ourselves, which helps a bit, but potentially to others, which significantly increases our chances of success. Letting other people know what you are doing and even asking one or more of them to be a referee and hold you accountable means you are more likely to follow through.

A plan helps us to measure success as well as failure

If we have been specific in terms of what we want to achieve, how we will achieve it and how we will measure our success, then this will help us by encouraging us when we achieve what we have planned (which increases the chances of making further changes and sustaining what we have already done) as well as maybe challenging us with the areas where it hasn’t quite worked out yet.   The plan can always be changed when we learn as we go.   Putting rewards into the plan for when we achieve each stage of success can be quite motivating as well.

My top tips for making your wellbeing plan

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  1. Make it for yourself and only if you really mean it.  Not to make your GP happy.  If you’re not ready to make changes, let them down gently as early as possible and perhaps keep an open mind for the next time you have a wellbeing conversation.
  2. Make it simple.  The more complicated it gets, the more likely you are not to achieve bits of it, which can be disheartening.  Better to have simple success and build on it.
  3. Make it specific.  Losing weight might be the overall desired outcome, but break it down into smaller chunks e.g. cycling or walking to work, cutting out snacks, shopping for and preparing more of your own meals, not eating after a certain time of day.
  4. Make it achievable.  If you are inactive at present and break into a sweat at the thought of breaking into a sweat,  don’t aim for 150 mins of exercise a week from the outset.  Start with 5-10 mins a day every other day.  If you want to learn about mindfulness, start with 5 minutes a day on your smartphone app or just spend the time reading a book or listening to music.  I know a lot of people who say “I tried that” by which they mean they gave it a go a couple of times and gave up because it was too difficult or not immediately rewarding.  Changes are more likely to be made if they are easy, accessible, social and timely.
  5. Make it rational.  Think about what changes you can implement that are compatible with every day life and easy to sustain.  It needn’t involve hours of your time every day or expensive kit, diet plans or gym memberships.  It could be walking more briskly to the shops or whilst out with your dog, taking the stairs at work or working in the garden.
  6. Make it measurable.  It might be weight lost, minutes of activity completed, amount of sleep you have obtained or personal goals achieved (e.g. taking part in a social activity with your friends or playing football with your children or grandchildren)
  7. Make yourself accountable.  Tell people what you are doing e.g. work colleagues, friends and family, social media groups.  Consider asking someone to be a referee who will check in with you regularly.  Some people might ask their spouse.  Some might prefer a friend or colleague depending on how much they enjoy being nagged!
  8.  Make it a work in progress.  Your objectives are likely to change over time.  You will succeed in some areas and maybe not others.  That might simply mean not giving up and then trying again, or it might mean learning from what has worked well and not so well, and coming up with a better plan for the future.

Wellbeing planning in the real world.

I thought I would finished with some real life examples.

  1. Last year, all the GP practices in my area took part in a local Cardiac Prehab scheme which I had designed with some of my colleagues for our CCG.  Part of the service included identifying patients at higher risk of having a heart attack, stroke or developing diabetes and inviting them to an educational event at their GP practice.  The evening included a presentation on wellbeing and finished with each patient signing up to their own personal wellbeing plan.   These plans were collected and scanned into each patient’s records.  When they were reviewed a few months later, the doctor or nurse they saw reviewed their plans with them and discussed what had worked well or not so well.  The majority of the patients I reviewed had achieved at least one of their intended outcomes and were really pleased to see how well they had done, which encouraged them further.  This year the scheme has been rolled out across our entire clinical commissioning group, with a patient population of over 600,000 people.
  2. Those of you that are kind/enlightened/fortunate enough (delete as applicable) to read my blog posts regularly will know that I talk a lot about Rangan Chatterjee’s Four Pillar Plan.  Inspired by this, I have started to develop a welbeing plan template for EMIS (our computer system) which is based on this.  I have shared it with my practice colleagues and am now using it to enter data into the patient’s record and give them a printed copy after our consultation, so they have something to remind them of what we have agreed and to document their progress. Rangan Chatterjee and Ayan Panja did an excellent presentation on Prescribing Lifestyle Medicine at last week’s Emis National User Group conference at which they showcased an early version of their own lifestyle medicine template which is currently in development and  which will no doubt be snazzier than mine when it’s finished!

And finally, my own personal wellbeing plan

It is only right, of course, that I practice what I preach.  For years I have meant to lose a bit of weight.  For years I have surveyed my profile in the mirror in the morning, disappointed in myself for not having achieved anything and disappointed in the Six-Pack Fairy for not having visited overnight as I had hoped.  So in the end, I made a plan.  This included eating a lower carb diet (specifically changes to what I make for breakfast, making salads for lunch and cutting back on biscuits), exercising more regularly (getting up early to walk before work, doing HIIT workouts when I didn’t have time to ride or run), and doing press-ups as strengthening exercises each morning).   I am also much better at getting enough sleep, although there is always room for improvement.  I told my wife about this as I knew full well she would remind me if/when I lost track.   The results?  I have lost just over half a stone without feeling that I am depriving myself.   I feel fitter and have more energy.  I still don’t have a six pack and have decided that I was probably born without one, so maybe I will leave that out of the next version of the plan.

That’s all for this week from me.  Weekly Wellbeing Round Up #10 will be out next week.

Please do make a comment on the blog if you have enjoyed it, if you feel it could be improved, or to suggest future topics for me to work on.  I want to make it as useful as possible for all of you.  Please feel free to share the blog with your friends/colleagues/pateints/family members and sign up to it to receive updates automatically if you haven’t already.

Until next week, take care of yourself!

Dr Richard Pile

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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