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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The Weekly Wellbeing Round-Up #3: My Weekend Wellbeing Clinic

How was your weekend?  Maybe like me on sunday afternoon you found yourself in a glorious alternative reality, as the match commentator stated that it was 5-0 to England.  At half time.   It doesn’t get much better than that!  My weekend had started less positively, as I found myself getting up (a little resentfully, if I’m honest) earlier than desired to go into work and do a three hour surgery.   I decided that for both my patients and I to get the most out of the surgery,  I would make a note of how many of the consultations were rooted in wellbeing and lifestyle issues, and to dig a little deeper with those patients to help them get the most out of the consultation.  After all, if I’m going to blog about wellbeing I need to make sure I’m practising what I preach, not just summarising the theory.  The results genuinely blew me away…so today’s blog contains the summarised highlights and learning points of my experience.  In case you’re worried about GDPR (that’s General Data Protection Regulations to those of you fortunate enough not to have to know this), there is no patient identifiable data contained in this blog. For those of you desperately disappointed that this isn’t the Weekly Wellbeing Round #3, I promise that it will be back next week!

So what did I learn?

  1. There’s a lot of it about.  Two third of the consultations were primarily about an underlying wellbeing or lifestyle issue.  I was expecting it to be high, but not that high!   Of those two thirds it was about a fifty fifty split between those that openly acknowledged this was the problem and those that either weren’t aware of it, or chose not to acknowledge it.
  2. It’s easy to take the path of least resistance with a prescription and do your patient a disservice.  At least two of the patients that I saw presented with one simple symptom, for which they were asking for a quick fix, usually a prescription.  One patient had a rash.  They just wanted some cream for it, having tried nothing at all so far.  I could have just prescribed steroids.  I’ll be honest – depending on how late I’m running and what sort of day I’m having, I have historically taken the easy way out, gained myself five minutes of catch up time and breathed a sigh of relief. However, the reason they had this rash was because of chronically swollen and inflamed legs, which in turn was due to their weight.   I did give them some cream, but only after we had spoken about their weight, what they felt about it, what they had previously tried in terms of weight loss etc.  They left not just with their prescription but with a weight management referral.  I could have spent time talking to them about a low carb diet but they gave me the very clear steer that they really wanted to be told what to eat and to be held accountable and would prefer a weight management programme.
  3. Social history is important, particularly occupation.  Doctors are taught to take a social history.  This is particularly pertinent in primary care.  However, as the years have gone by and the time pressures have increased, I find myself sometimes taking shortcuts.  That may well be okay in the case of minor illness and discussing blood results, but it’s an important part of the picture as a determinant of wellbeing.  Of the cases that I identified as related to wellbeing and lifestyle, half were at least partly occupation related.  They were either the primary cause of stress and multiple symptoms, or contributing significantly to the problems.   I may not be a career advisor, but what’s the point of repeatedly consulting for mental health issues, signing prescriptions and sick notes to address the symptoms, without challenging a person to consider addressing the cause?
  4. Ideas, concerns and expectations.  Oh how we love them.  Anyone who is a GP reading this will be familiar with these terms.  They are all about the importance of establishing a patient’s understanding, their fears and what they want to get out of the consultation.  Having been a GP for almost eighteen years now,  I sometimes end up feeling that all a lot of patients want is a referral for a fancy test or to see a specialist who will fix the problem that I can’t (or that they don’t believe I can).  What was really interesting about my wellbeing surgery experience was that my assumptions were often incorrrect.  When we began to explore the issues and the options for dealing with them, a significant number of the patients did not want a blood test, or a drug, or a referral.  They were actually very happy with advice about lifestyle medicine and even expressed relief that it was something they could be in control of.
  5. It’s okay to be honest and you don’t have to “fix it”.  The consultation that I found the most challenging was with a patient who was actually very up front about the reasons for their wellbeing concerns and clearly identified work and relationship issues that were causing them a lot of stress.  They had adopted some unhealthy coping mechanisms as a result and , in my opinion, their situation was clearly unsustainable in the long term without serious consequences for their health.  The problem for me was that they made it very clear they weren’t immediately planning on taking personal responsibility for the situation and making any of the vital changes that they needed to improve things.  They also made it very clear that that felt it was up to me to sort them out, and requested various medications to this end.  When I was younger and less experienced, I would have felt pressured into prescribing because it was the only thing that I could do.  It would have also made the consultation much shorter.  Now that I recognise this is actually not serving the patient well at all, I pushed back and (having checked they were safe from a mental health perspective) challenged them about expecting medical solutions to a problem that they should be dealing with themselves.   We agreed to a further consultation to discuss this some more and I also gave them our wellbeing team phone number so they have someone else to talk things through with.
  6. Wellbeing and lifestyle medicine is increasingly on the patient agenda.   A lot of patients are very well informed, even if they don’t have my obsessional podcast/blog reading habit.  Wellbeing is increasingly on the political agenda and in the media.   Some of the patients who identified lifestyle issues were already well on the way and we talked about a number of concepts and resources such as Public Health England’s Active Ten campaign and app, Dr Rangan Chatterjee’s excellent 4 Pillar plan,  the concepts of a low (or low-ish!) carb diet, time restricted eating and weight management programs.   It’s very rewarding to see people making changes and just to touch base with them occasionally or give them a gentle nudge here and there as they work their way through managing their own wellbeing.
  7. It does take a bit longer.  Case selection is key!   My clinic did finish on time, thanks to the one third of people who came with minor and easily addressible problems.  I’m not going to lie to you…to do this properly does take a little longer.  My belief is that if health professionals invest just a little extra time with the right people, the benefits in the long term will be significant.  A very small proportion of people genuinely have no insight and are not willing to take any responsibility for their own wellbeing and may not respond to this approach.   However, if a doctor would offer a double appointment to a patient with serious mental illness, a complex long term condition or a newly diagnosed cancer, why would we not do the same for someone who could make huge, lifelong gains in wellbeing as a result of a little extra time?  A GP can sometimes feel a bit of a lightweight if they book too many extra long appointments.  Patients may feel they are taking up too much of the doctor’s time with “minor” issues.  I would argue that of all the things we spend more time on, this is one of the most potentially beneficial areas for patients and health professionals alike.

I hope that you have found my sharing this helpful, whether you are a patient or a health professional.  Weekly Wellbeing Round Up service resumes next week

Until next week, look after yourself!

Dr Richard Pile

 

The Weekly Wellbeing Round-Up #2

Welcome back to the Weekly Round Up.  Have you enjoyed the start of the World Cup?  Or are you already counting the days until it’s over?  In our house, we fall firmly into the former category.  My kids have already chosen world cup fantasy football teams and we are planning our family last sixteen sweepstake and what the prize might be for the lucky winner.  So let’s kick off (bad pun fully intentional) with some…

Physical activity

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Resting heart rate (RHR) has long been considered a proxy measure for physical fitness.  I first encountered this as a junior doctor when I met an olympic rower with a resting heart rate of 35 beats per minute.   Does this mean, therefore, that a higher resting heart rate is a bad thing and a possible predictor of increased risk of death?  The answer may be yes, according to the Melbourne Collaborative Cohort Study which found that a rise in resting heart rate over a decade was associated with increased risk of death from cardiovascular disease, cancer or other causes.   Of course this may be an association rather than a cause.  So what can we take from this practically in primary care?  Consider a RHR of greater than 70 in men and 80 in women to indicate a higher risk of mortality and target those individuals not with drugs to slow their heart rate down, but with more intensive lifestyle counselling.  It could be an added dimension to an NHS health check.

Weight

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It can be a little awkward broaching the subject of wellbeing with an overweight patient…especially if they are a child.  Here is  a useful video on childhood obesity that has been made by Public Health England to inform and support health professionals in this area.   Take home message – we need to start with women who are pregnant or planning to become pregnant to have these conversations.  Additional materials can be found here.

Food 

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Patients and health professionals alike may be aware of the ongoing debate about food related issues such as carbs vs fats and what helps most with weight loss.  In an attempt to provide balance, and to act as an anecdote to the unedifying behaviour sometimes seen on social media in this area, the BMJ will be publishing a series of articles covering this and other contentious areas, looking at both sides of the argument.  This week’s article is on Food based dietary patterns and chronic disease prevention.  You will need to have a BMJ subscription to view the full text.  The key messages are

  • Food based prevention of chronic disease risk should prioritise fruits, vegetables, whole grains and fish and lower consumption of red and processed meats and sugar sweetened drinks

  • Higher consumption of nuts, legumes, vegetable oils, fermented dairy products, and coffee are further likely to confer benefit

Personally I recommend that you use olive oil in salads and dressings, and use other oils such as ghee or coconut oil if you are going to fry food, as they oxidise at higher temperatures than olive oil and other vegetable oils. Make of this what you will, but may I recommend you avoid behaving badly on twitter, wherever you stand?

 

Digital Wellbeing

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The Children’s Commissioner has recommended that social media must be made less addictive for children.  The example of “streaks” in Snapchat has been highlighted.  The protestations of social media companies that their products are not designed to be addictive sound very similar to those of Big Tobacco.  No immediate, tangible results here.  My recommendation to my patients in the meantime is that no child should have a mobile phone before secondary school age or access to social media until they are older e.g. 14+.  Parents who roll their eyes and say that they don’t understand technology and can’t figure out how their home wifi works or how to restrict applications on their kids’ phones should be asked whether they would take as relaxed an approach to allowing their kids to have access to pornography, cigarettes or under age drinking.  I will be dedicating a whole blog topic to this.  I think social media addiction is the new inactivity, which was the new obesity, which was the new smoking etc etc etc.

On a related note, Techcrunch reports that Apple has unveiled digital wellness features for children and adults alike.   These include an upgraded version of Do Not Disturb, options to reduce and restrict the intrusiveness of notifications, a regular report of how much time you have spent on your phone and which apps you use the most,  and parental controls to limit screen and game time.  Well worth a read.  Other companies such as Google are making similar moves.  In my opinion, starting with making us aware of just how much time we are spending on our screens is the first step towards us challenging ourselves and managing it better and more mindfully.

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Technology is not all bad, of course.  So to end on a positive note, here are five free apps for mental health and wellbeing.  I particularly recommend Headspace (available on iOS and Android).  I started using it a few years ago when life was quite challenging because of my son’s severe uncontrolled epilepsy and all the knock on effects this had for him and for the rest of us.  It’s designed by a former buddhist monk (although it doesn’t require you to embrace any particular philosophy or belief system) and has different modules for different aspects of your life.  A subscription is roughly the price of a cup of coffee per month.  As a result of getting into the habit of using the principles regularly, I have found it hugely beneficial (disclaimer – I’m not getting paid or given a discounted membership to promote this!).

That’s all for this week.  Thanks for tuning in.  See you next week!

 

The Weekly Wellbeing Round-Up #1

Welome to my first ever round up!  Each week I scour the news, journals and social media for the latest evidence, updates and opinions so you don’t have to (although just in case you do, I have provided links to each topic).  The round up is separated into different areas to make it easier for you to look at the areas you are particularly interested in.  Whenever possible I will make simple and practical recommendations based on this information, for patients and health care professionals alike.  Ready?  Let’s get started!

Physical Activity

  1.  Walk briskly, don’t worry about 10,000 steps.  Public Health England and the Royal College of GPs are encouraging adults to focus on walking briskly rather than just counting steps to improve their health.  10 minutes of brisk walking a day reduces risk of premature death and will get you almost halfway to your recommended 150 mins a week of moderate intensity activity.   Why not join the 600,000 people who have downloaded the ‘Active 10’ app (ios or android) and take the first steps towards better health? active 10
  2. If you are up to more than some brisk walking, you may be interested in the Parkrun to celebrate the NHS’s 70 birthday.  Over 85, 000 people are expected to have taken part in a special park run this saturday, 9th June.  Park run is a fun, safe and inclusive activity.  There are more than 360 across the UK.  You can easily register for a park run or even start your own park run event
  3. For those of us whose muscles may be aching a little after a parkrun, this Cochrane review of the use of antioxidants (by supplement or food) for preventing or reducing muscle soreness after exercise may be of interest (podcast and transcript available).  Of course people in health food shops will be keen to extol the benefits of such measures..  Unfortunately there is no evidence of any benefit from doing this.  It may even be that the processes that cause aches and pains after exercise are important in building up your muscles. So the good news is that you can save your money and get those new running shoes you’ve had your eye on.   Take home message?  Exercise regularly, warm up gently, do it in moderation.

Food

  1. The health select committee has made recommendations to reduce childhood obesity including a ban on the use of characters such as Tony the Tiger to promote unhealthy food.  Other measures include removing unhealthy snacks from supermarket checkouts, local authorities having the power to limit fast food outlets opening in their area, and social media firms reducing children’s exposure to junk food advertising. It’s a Grrrrrrrrreat start!
  2. Smoothies and fruit juices could be banned from schoolcanteens in Scotland.  These are just some of the measures proposed by the government, according to the BBC.  The intention is to halve childhood obesity by 2030.  An admirably ambitious target.  Smoothies and fruit juices are often a massive health con, laden with even more sugar than other “less healthy” soft drinks…and usually made by the same companies.  My advice?  Eat the fruit, not the juice. sugars-in-smoothies-306086tony the tiger
  3. If you would like to know more about how the food industry operates, I can heartily recommend episode one of the Doctor’s Farmacy, an excellent podcast with Dr Mark Hyman (author of Food: WTF Should I Eat?) and the Pulitzer prize winning journalist Michael Moss (author of Salt Sugar Fat: How the Food Giants Hooked Us).  Alarming and fascinating stuff including how food is engineered to be hyper-palatable and create addiction.   The take-home message for me is that Big Food poses a much greater threat to our society’s health than Big Tobacco or Big Pharma and governments are going to have to gear up for this fight.
  4. Finally, it’s not just what you eat but when you eat that matters.  Check out this great podcast of Dr Rangan Chatterjee interviewing Professor Satchin Panda (Part 1 of their conversation) on the subject of “Why When You Eat Matters”.   It’s all about circadian rhythms, the consequences of them being disrupted, and how we can try to restore the natural balance by encouraging patients to eat all of their food for the day within a 10 to 12 hour window.   Trial data suggests it can help you to lose weight and feel better.  If you want, you can join in helping Professor Panda collect evidence of the effect of time restricted eating by downloading his myCircadianClock app.  I am targetting my pre-diabetic and diabetic patients who are not overweight and whose diets are already not too bad.

That’s it for this week from me.  I hope you have enjoyed the first ever weekly round up.  Your feedback is much appreciated.  Tune in next week!

Dr Richard Pile