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 #20: a miracle cure!

Good morning and welcome to another edition of the Weekly Wellbeing Round-Up.  This week I thought I would get your monday morning off to a great start by offering you…a miracle cure.  The ultimate tonic with guaranteed improvement to your health and wellbeing.  It has  been shown to improve physical and mental health and cognition as well as reducing the risk of cancer, heart disease, diabetes and other long-term conditions.  It works as well as if not better than many drugs and unlike drugs there are no side effects as long as it is taken in the appropriate dose.  Best of all, it’s free and available to every person on the planet.  You don’t need a prescription from a doctor, and you don’t need any special training or expensive kit.  You can start treating yourself with this wonder drug whenever and wherever you like.   I am, of course, referring to the medicine of movement: physical activity.  People are, I hope, used to health professionals banging on endlessly about this.  I thought it was worth reminding ourselves why  this is such an important issue, before we explore the benefits of it and then take a pragmatic approach to moving more.

The bad news about physical activity

Let’s start with looking at the scale of the challenge that we face in terms of physical activity being a part of our daily lives.   Once upon a time, it was.  We were hunter-gatherers, often chasing our prey over long distances.  If we sat still, we perished.   Nowadays, our day-to-day existence is much more sedentary.   We have enjoyed the benefits of tremendous technological advances and the associated convenience, but there are also tremendous downsides that are gradually becoming more and more apparent. The nearest we get to hunting our food may be tapping our password into our device when doing our online food shop from the couch.   Being inactive has roughly the same health risks as smoking 15 cigarettes a day and the overall risk of mortality due to inactivity may be double that of obesity. .  This is worth thinking about for a minute:  most people would clearly not choose to take up smoking, but by default we risk choosing inactivity.  The irony of all of this is that by sitting still we still perish (sooner) but for now for entirely different reasons.

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I used to think, a long time ago, that by default we were probably active enough and that to stay healthy all people needed to do was to avoid eating too much unhealthy food.   I have come to the realisation that this is nowhere near enough.  The default, the baseline that we operate from in today’s world, is not just inadequate but actually toxic.   In 1949, 34% of all journeys travelled by a mechanical mode were by bicycle.  Nowadays it’s less than 2%.  The design of our homes and our cities, our patterns of working, our use of technology and all the associated infrastructure have all contributed unwittingly to the making us less physically active. The consequence of all of this is that almost half of adults over 65 years of age are inactive, and most working adults spend at least 5 hours of their day entirely sedentary.   To overcome this requires thought, planning and effort.

The good news about physical activity

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Before you sink into despondency,  there is good news.  These problems did not appear overnight with a bang.  A lot of it has been incremental.   The good news is therefore that we can take the same approach to addressing the balance.  Let’s leave aside the need to lobby government about how we build communities and transport links in future, how we make cities safe for cycling and encourage working lives that are more physically active.  These things are important but you and I can’t do anything about them right now, whereas there are other changes that you can start with today to help you and, if you are a medical professional, your patients.

My top tips for physical activity

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  1. Make the first few steps.  The really good news about becoming more physically active is that the greatest reduction in risk of cardiovascular disease (heart attacks, stroke and diabetes) occurs in those who go from being completely inactive to mildly active.   If you break into a sweat at the thought of breaking into a sweat and are put off by images in your head of lycra-clad latte-sipping gym bunnies in a spinning class or ex-military personnel with personality disorders barking instructions to groups of miserable looking people dragging mud-covered tractor tires across the park in the rain – never fear.  The journey of a thousand miles literally begins with a single step.  If you don’t do anything that gets your heart rate up at present, try starting with just 5 minutes a day of brisk walking round your garden or down the street and back.  All you need are shoes on your feet.   Public Health England have a nice app which you can download onto your smartphone called Active 10.   You can get it for iOS devices from the app store, or for android devices from Google Play.
  2. Make it rational, routine and relevant.  For us to face the challenges of inactivity individually and collectively, it’s only going to work if physical activity becomes a simple, meaningful and sustainable part of our lives.   If a gym subscription works for you because you will feel motivated by parting with your hard-earned cash, you like the idea of being able to work out in all weathers and at any time of day, or you just like sitting in the cafe and chatting afterwards, then great.   If you have a dog, make the walks a bit longer and for part of each walk push yourself a bit harder to get your heart rate up.   If you don’t have a dog, think about getting one.  They provide people with company, keep their owners fitter than non-dog walkers, and encourage socialisation.  I love chatting with other dog walkers when I’m out and about.   If your job involves walking, whether it be commuting or delivering the post, use the opportunity to do likewise.  Try getting off the bus, tube or train a stop or two earlier.   Use the stairs at work rather than the lift.  Consider getting a standing desk.  You could suggest standing or walking meetings when appropriate – just think how much quicker they would go without people distracted by their laptops and phones!  T4YactPmS1KcJ4xRvSwLCA
  3. Make a plan.  I posted about this a few weeks ago.  Whatever you do, plan how it’s going to happen.  In my personal experience, if I don’t make a plan then nothing changes.  Once you have a regular slot and you’ve done it often enough then it becomes a habit and so more likely to stick. mdHKUVBWR9yqCTjy2IjpKQ
  4. Make it social.  Behaviour change is more likely to occur if it is socialised.  Taking part in physical activity with others is beneficial for a number of reasons.  Firstly most of us are social animals to one degree or another, so it’s a good way of connecting for our mental wellbeing.  Secondly, we are in effect making ourselves accountable to others or even allowing them to be our “referee”.  Your friend/spouse/cycling club/fellow dog walkers will encourage and check up on you.   If you aren’t sure what you would like to do, check out what information is available from your local council, community centre, library or GP surgery.  QMt5W8BPQq2F68v5UBFttg5. Make it pleasurable.  Pick something that you enjoy.  Don’t think of it as “exercise”, which sounds like something you have been told to do and probably won’t enjoy.  Instead think of it as something that gives you pleasure, makes you feel good and helps you connect with others.  Just getting out of the house and enjoying some fresh air and daylight is good for your wellbeing.  Two of my most favourite things are going for a bike ride on a sunday morning with my friend Al and taking my dog Prince for walk in the afternoon.The fact that the my sunday morning bike ride includes breakfast and a cuppa and that my afternoon walk involves a pint in my local is not a coincidence and a great example of “temptation bundling” – having a reward which is associated with a specific activity.

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Real life examples of the benefits of physical activity

I thought I would finish with two stories from this week.  The first was from a patient that I reviewed as part of teaching our medical students about mental health.  They had seen one of my colleagues previously with a longstanding history of depression.  They were physically inactive and presenting with a lot of physical symptoms which were really manifestations of how they felt in themselves.   They had been consulting about these physical symptoms frequently and eventually were persuaded by my colleague that the root cause of their symptoms was their depression.  They were encouraged to start being more physically active.  When I reviewed them with our medical students, they were transformed.   I asked them what they felt the reason was for the improvement and they told me that they had started to walk every day for half an hour, either in the park or up and down in their garden.  Their mood was better.  They had more energy, were sleeping better and were much less bothered by the occasional aches and pains that previously had preoccupied them.  They also had a much better understanding of how their mood might influence physical symptoms as a result.

The other story I really enjoyed listening to this week was that of Vassos Alexander, sports presenter, formerly of Radio 5 Live and now Virgin radio.   He was interviewed by Dr Rangan Chatterjee in Episode 31 of the Feel Better Live More podcast.  He described himself as being overweight, unfit and a smoker in his early 30’s.  He decided he wanted to make some changes.  He decided to go for a run.  His first run lasted just a few minutes.  He describes being out of breath and having to pretend to some of his neighbours that he had just finished a run, to avoid embarrassment.  Vassos didn’t give up, however.   To cut a long story short,  in 2017 he completed the Spartathlon, an endurance event run over 153 miles.  His enthusiasm for running, it’s benefits and his encouraging other people just to get out there and do something is infectious.  Well worth a listen.

We’re almost done.  I wanted to finish off with something to challenge and encourage you, your family,  friends or patients.  There is a great video available on YouTube called “Twenty three and a half hours“.  It’s got a fantastic punch line at the end and is well worth 5 minutes of your time.

That’s it for this week.  I hope that you have found this week’s wellbeing round-up helpful.  As ever, I would appreciate your feedback and you sharing it with others if you have enjoyed it.  You can subscribe to the blog to automatically receive email updates in future.  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

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 # 7

Good morning and welcome to the latest edition of the Weekly Wellbeing Round Up! Today I thought I would kick things off  with news about things that don’t work.

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The Health Supplements Don’t Work

As you may be aware, it is recommended in the UK that we take a daily over the counter dose of Vitamin D in the winter months.  This is to compensate for our rubbish weather at that time of year with insufficient sunlight.  Whilst it’s all very sensible to top up levels of things we might be deficient in, this does not necessarily mean therefore that more and more of something is better and better.

This New Zealand study published in JAMA found that there was no difference in cancer rates between those given vitamin D and those given placebo.  Previous studies have suggested there may be an inverse relationship between Vitamin D dose and incidence of cancers, although the data is inconsistent.   In fairness, this was  a post hoc analysis on a study into cardiovascular health and high monthly doses of Vitamin D were taken.  So you could speculate whether taking the vitamin D in a different way (i.e. lower dose, more regularly) might work differently.   But that would just be speculation.

Speaking of things that don’t appear to work, this article giving commentary on the Cochrane review into Omega 3 supplementation makes interesting reading.  Omega 3 fat acids have been generally considered to be a good thing,  being anti inflammatory with some observational studies suggesting improved outcomes and reduced mortality in cardiovascular disease.  This cochrane review states that for primary and secondary prevention of cardiovascular disease, there is no evidence that supplementation with omega 3 has any effect.  But before you throw your oily fish in the bin, it’s worth considering a few things.  Firstly, it is probably a mistake just to take one specific nutrient and focus on giving people more of it.  The benefits that have been observed historically from eating oily fish may well not just be due to omega 3 in isolation.  So just as I recommend you eat the fruit, not the juice, I also recommend you eat the fish, not the tablets.   Supplements are not a replacement for a health diet. Secondly, there is much more omega 3 in our foods generally now than there was a few years ago, so this may be a confounding factor which potentially disguises any benefits from introducing a supplement in a study population.   Previous studies have demonstrated a threshold for certain levels of fatty acid below which the increase of heart disease increases.  It doesn’t necessarily follow that mega doses of these same fatty acids have any increased benefit once an adequate level in the body is reached.

To summarise…too much of a good thing can be completely ineffectual.  In fact, anything can be toxic in the right dose, including sunshine and water!   There is a large and growing industry out there in nutritional supplementation.  I tell my patients that by and large if they are eating a healthy varied diet and do not suffer from any known malabsorption problems, there is no need solid evidence to support taking nutritional supplements and therefore no need to waste their money on it.  I suspect this makes me a persona non grata in my local health food shop.  Unless I’m buying goji berries and nuts.

Continuing on the theme of things that either don’t work or are potentially bad for you, I found this article in the BMJ on the risks of sulfonylureas (a second line drug for type 2 diabetes) rather concerning.  An increased risk of cardiovascular events and hypoglycaemia (low blood sugar) was noted.  The recommendation was made that metformin (the drug that most people with type 2 diabetes are first started on) be continued along with the sulfonylurea (rather than swapped out).  It is accepted that metformin has cardiovascular benefits, or, to put it in every day language, “gives your heart a hug”.  What really concerns me here is that this recommendation is basically saying we should use one drug to counteract the side effects of another.  In my view is that doctors and patients should be discussing lifestyle medicine as the main first line treatment to control or cure diabetes, way before we end up introducing first/second/third line drugs for this condition, which are not without their risks.

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Social Prescribing

Having spent the first part of this blog bashing drugs and supplements, let’s take a look at  a different kind of prescribing…social prescribing.  This is something that we have been focussing on in Hertfordshire and there is some great work being done in this area.  We have people called Community Navigators who are there to help when the issues are not directly medical but more about the other, possibly more important, determinants of health such as housing, employment and social networks.   This survey discussed in GP Online shows that social prescribing continues to gain traction amongst GP’s with almost one in four GP’s now using it.   The Royal College of GP’s has recommended that there should be a social prescribing service in every GP surgery.  I agree.  For me, the GP practice of the future is not just a surgery but a wellbeing hub with all these services accessible as simply as possible, ideally under one roof.

 

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Public Health and Prevention

Our new secretary of state for health Matt Hancock (yep, I’d never heard of him either until the cabinet reshuffle) has gone on record as saying he would like to see an end to the “over-prescription of unsophisticated drugs”, focusing instead on approaches that address a person’s physical and mental well-being.  This is very welcome.  However, fine words butter no parsnips.  There have been huge cuts to to public health budgets which is going to pose a challenge when it comes to his apparent commitment to spending money on prevention.  It was handed over to local authorities in 2013, which I believe was  a mistake.   The cuts are having a real impact.  Smoking cessation services in some part of the country have already been affected, as detailed in this article in GP online.   CCG’s and Public Health teams are going to have to talk to each other about this as a matter of urgency.  I would go a step further.   For me, Public Health needs to become part of the NHS again with more decision making by front line clinicians.  That’s not to say my colleagues in public health are not doing their level best with what resources they have, but I believe to best serve our patient population we need more clinical leadership.   Dr Michael Dixon offers the same opinion in this other article on GP online about public health.  As before, I believe that this is likely to work better if delivery of these services is more GP practice or wellbeing hub-based, perhaps making better use of volunteers where appropriate.

The best health intervention, freely available to all of us.

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Finally, my favourite podcast this week is Episode 27 of Feel Better, Live More.  Dr Rangan Chatterjee interviews Professor Matthew Walker in part 2 of their conversation about sleep.  I cannot recommend this enough.  Having previously disclosed my struggles with giving myself enough of a “sleep opportunity”, since I listened to these two podcasts and reading Matthew Walker’s excellent book “Why We Sleep”, it has really changed my behaviour.  I’m prioritising sleep more and waking up every morning feeling refreshed, before my alarm goes off…which is my body’s way of telling me that I am now getting enough sleep.  It has helped me with weight loss and I feel that I have a lot more energy.  The added bonus of waking up early is that I now have extra time in my day to do things like exercise, meditate, catch up with work…and write this blog!  Episode 27 was the last in this excellent series which has had over a million listens since it went live in January.  No need for those of us who have enjoyed this to worry, however, as a new series will be coming in September.  So if you haven’t listened to any of the episodes so far, you can enjoy bingeing on them over the summer holidays!

That’s it for this week’s Wellbeing Round Up.  It’s going to be a scorcher this week with temperatures hitting thirty degrees most days and a lot of humidity, so keep your fluids up, stay out of the sun between 11 and 3 (particularly if you are very young or very old), wear a hat and use suncream.  Until next week… take care of yourself.

Dr Richard Pile

 

 

 

 

The Weekly Wellbeing Round-Up #6

Welcome back to the Weekly Wellbeing Round Up!   I hope you have had a good weekend, enjoying the weather and the world cup final.  Having overcome the disappointment of England not getting to the final,  I made the decision not to watch the entirely meaningless 3rd/4th place playoff , and so missed watching England lose to Belgium (again)…which was probably much better for my overall wellbeing!  Let’s start off today with…

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Cardiovascular disease 

Today instead of watching the final, I spent the afternoon with my wife.  This is partly because I am a very caring and considerate husband (hopefully she won’t read this or at least will have the good grace not to contradict me in the comments) but also because I am an evidence based husband as well and had read this systematic review and meta-analysis in Heart concerning marital status and the risk of cardiovascular disease (subscription required for full article).  Being married was associated with a decreased rate of death from heart disease and stroke.  Being divorced was associated with increased CHD mortality, being widowed with increased risk of stroke, and never being married with an increase in mortality in the event of a heart attack.  The article points out the obvious that association does not mean causation, but does raise the idea that marital status could be considered as part of CVD risk calculation in future.  I have shared this with my wife.  She says she needs more evidence before she is convinced.

Whilst I would like to spend all my time helping patients not to get premature cardiovascular disease (such as heart attacks and strokes), clearly a part of a GP’s workload is helping people who have developed it look after themselves as well as possible.  Again, I like to focus on lifestyle measures such as food, physical activity and sleep but inevitably most if not all people in this situation will also be taking a number of medications to reduce the risk of their conditions worsening.  The world health organisation stats for adherence or compliance (i.e. people taking their tablets as prescribed) are truly shocking.  Take for example hypertension or raised blood pressure:  it is estimated that only half of people diagnosed with hypertension are taking their meds regularly (80% or more of the time) within a year of being diagnosed.  Clearly I must have the best patients in the world, because they all look me in the eye and reassure me that they take their drugs every day.  But for doctors out there whose patients are not as well behaved, this systematic review, also published in Heart, may make useful reading.  Three interventions were found to improve adherence and clinical outcomes:  SMS (text) reminders to take medication, a fixed dose combination pill (interesting to consider as these drugs may be more expensive and less flexible in dosing but if the outcomes are better maybe doctors should be prescribing more of them) and a community health worker-based intervention.  It is worth noting that these demonstrated relatively short term improvements so we need longer term outcome data to confirm this.

Instead of talking about cardiovascular risk, the focus of this article is about calculating Cardiovascular Health.  CVH is a concept developed by the American Heart Association.  It takes into account 4 ideal health behaviours: non-smoking, body mass index < 25, regular physical activity and adopting a healthy diet.  It also factors in cholesterol, blood pressure and blood sugar level.   It has been suggested that CVH could be a proxy for wellbeing.  Of course that leaves the question as to what comes first..wellbeing or health.?   What are the practical implications of this for me?  The next time that a patient comes into my consulting room and says that they would just like a bit of an MOT, this is perhaps where I could start, rather than asking them a lot of questions about their bodily functions and sending them off for a load of blood tests.

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Hypertension

Speaking rather less positively about the American Heart Association, I was deeply troubled by their suggestions about changing the threshold for diagnosing and treating hypertension.  The guidelines suggest that a blood pressure of greater than 120 (systolic) and/or 80 (diastolic) should be considered “elevated”.   This would result in a huge increase in numbers of patients diagnosed with a disease and then potentially medicalised by offering them drugs…with the associated risks of this.  The author of this article in the BMJ estimates that this would result in half of the adult population over 45 being diagnosed with hypertension.  My view?  Utterly bonkers.  We should be sticking to identifying people who already have undiagnosed hypertension (>140/90, as defined by the European Society of Cardiology), giving appropriate lifestyle advice as first line management where appropriate, and offering a personalised approach to risk reduction based on an individual person’s risk factors.  I would be very interested to learn more about the individuals and organisations who had input into the AHA guidelines, and where they might have potential conflicts of interest…big pharma, anyone?

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Food 

The low carb debate continues and I for one am more than a bit fed up of the unedifying content and behaviours on social media, particularly twitter.  Yes, it may well be that it’s hard to prove that there is something intrinsically good about eating a diet low in carbohydrates because it is almost inevitably associated with also reducing calories, but then again this is a food group that, plant based carbohydrates aside, we have largely manufactured for ourselves (often with a lot of processing involved) has very little if any nutritional value, and the increased consumption of which (particularly in the US) has been associated with sky rocketing obesity levels.   So its nice to see this article in the BMJ on the role of carbohydrates , quality and quantity, in chronic disease.  It takes a  fairly measured approach to the subject.  It’s well worth a read as it’s too detailed to really summarise, but the key messages are:

  • Human populations have thrived on diets with widely varying carbohydrate content
  • Carbohydrate quality has a major influence on risk for numerous chronic diseases
  • Replacing processed carbohydrates with unprocessed carbohydrates or healthy fats would greatly benefit public health
  • The benefit of replacing fructose containing sugars with other processed carbohydrates is unclear
  • People with severe insulin resistance or diabetes may benefit from reduction of total carbohydrate intake

My view on this is that there might be a number of reasons why a lower carbohydrate diet is of potential benefit for some patients, but really…who cares if the end result is better health outcomes and wellbeing?  It’s particularly worth considering in people who are diabetic, pre-diabetic, or need to lose a significant amount of weight…especially if they have struggled with weight loss in the past.

Staying with diabetes and pre-diabetes, this Cochrane review found that  in order to delay or to prevent the onset of Type 2 Diabetes, there wasn’t sufficient evidence in the meta analysis it carried out for diet or physical activity alone…but both combined together produced results.   Patients who have been told by their doctors that they are pre-diabetic should have be advised accordingly.  I used to talk mainly to patients about their diet and weight loss and say that physical activity didn’t contribute particularly to the latter…but we now know that physical activity is protective in itself and has favourable effects on the way that your body deals with both sugar and cholesterol.  The greatest benefits in reducing the risk of disease and death are seen in patients who go from being inactive to moderately active.   It doesn’t require a gym membership, donning lycra, or dragging a tyre round your local park whilst someone in combat fatigues with anger management issues barks instructions at you.   Just ten minutes a day of heart raising exercise, such as brisk walking, is enough to get you going in the right direction.

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Sleep

Last week I confessed that sleep is one of the areas of my life that I have struggled with.  Not because I can’t get to sleep but because I choose not to get what I really need.  I have done better this last week, inspired by having started to read Why We Sleep by Matthew Walker.  My favourite podcast this week has therefore been Episode 26 (Part 1) of Feel Better Live More podcast by Dr Rangan Chatterjee, who interviews Professor Walker, on this subject.     There’s a quote early on in the book which makes the point (and I’m paraphrasing) that if sleep does not serve a purpose and yet almost all animals spend a third of their life in this state, then it’s the biggest mistake that the evolutionary process ever made. Thought provoking stuff.

That’s it from me for this week.  Until next week…look after yourself!

Dr Richard Pile

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