The Weekly Wellbeing Round-Up #25 – Mental Health

Welcome back to my Weekly Wellbeing Round-Up.  This week I will be focussing on mental health, partly because items about this have been hitting me between the eyes all week and partly because of an amazing experience that I was privileged to be part of this week…but more of that later.  Let’s get into it!

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This week saw the publication by NHS Digital of its report into the Mental Health of Children and Young People in England, 2017.

On the positive side, in the opinion of the Children’s Commissioner, mental health services are showing some slight, slow signs of improvement.  Also , despite the daily reporting by all and sundry that we are in fact Going To Hell In A Handcart, there was only a very slight worsening in the prevalence of significant mental illness amongst children and young people, most of it due to emotional disorders and anxiety.  I’m not sure this could strictly be reported as a positive but a lot of expert commentators have been surprised that it wasn’t significantly more.

On the negative side, it is concerning that more than one in ten young people (12.8%) suffer from a formally diagnosed psychiatric disorder and one in four young women will  be struggling with  a mental disorder of some kind. Children with mental health disorders are also more likely to be heavy users of social media.  In addition, the burden of mental health problems is carried by those who are disadvantaged and vulnerable, particularly in northern England.

Specialist services for children and young people are known as CAMHS (Child and Adolescent Mental Health Services).  These services are seeing a continuing rise in demand.  The children’s commissioner found that one third of referrals into CAMHS were not accepted. Those of us who have tried to access these services either as a health professional or a parent or young person will be entirely unsurprised to hear this.  The average wait nationally is currently two months.  For many people it is a lot longer than that.   There is some good news.  There is to be a new target of 28 days for CAMHS access, which is being piloted at present.

Austerity and Mental Health in the UK

 

This week also saw a damning report by Professor Philip Alston, the United Nations Special Rapporteur on extreme poverty and human rights.  The twelve page document makes uncomfortable reading.  Professor Aston, in commenting on 20% of the country living in poverty, says “in the fifth richest country in the world, this is not just a disgrace, but a social calamity and an economic disaster, all rolled into one”.  He goes on to highlight the potential further risks of Brexit.  The government response has been to take issue with the definition of poverty, which is defined by a new measure in this report.   Speaking of Brexit, the Journal of Epidemiology & Community Health reports an association between the Brexit vote and rising prescriptions of antidepressants.  Whilst interesting, we should remember that association is not causation and whilst this is topical, it’s also probably both simplistic and even a little opportunistic.

Positive steps to improve mental health

You might be forgiven for feeling a little on the gloomy side after reading this post so far. You might be asking yourself what you can do either for yourself, your friends or (if you are a medical professional), your patients?  

Here are some of my suggestions:

Don’t be afraid to ask the question

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A lot of people who are struggling with mental health issues feel ashamed and unworthy.  They need help but find it difficult to ask for it.  Most of us can sense when someone we know is struggling.  Don’t be afraid to ask them how they are.  You might get an initial, superficial response but it’s worth taking a little bit of extra time to dig a little deeper.  Ask yourself what you would like others to do for you, and what a meaningful relationship really looks like.

We might also worry about asking someone whether they have had thoughts of suicide, in the belief that it might encourage suicidal thoughts that weren’t already there.  There is absolutely no evidence for this.  I have been asking patients this question for almost twenty years.  No one has ever been offended or upset by my asking it and many have been relieved to be able to answer it honestly and open up about how they are really feeling.

Don’t give negative messages about medication

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I spend a lot of time writing and talking about things that are at least as good if not better than drugs for mental health such as physical activity, a good diet, practising mindfulness and having good real life social connections.  However, that doesn’t mean that drugs are unhelpful.  Some people really benefit from them, particularly those who are more severely affected by serious mental health problems.  I know friends and colleagues who have found them very beneficial.  It’s important that we avoid “pill shaming”, as highlighted in this short vlog for BBC news.

Consider social prescribing

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We hear the term “social prescribing” bandied about a lot these days.  The government certainly seems very keen on it, as described in this article in the BMJ (subscription required for full article).  According to NHS England, social prescribing (also known as community referral) “involves helping patients to improve their health, wellbeing and social welfare by connecting them to community services which might be run by the council or a local charity.”   The determinants of health and wellbeing include socioeconomic status,  education, physical environment and social environment – so it’s really important that GP’s and other health professionals have as wide a range of tools available to them to help patients to help themselves.   In Hertfordshire, we have an organisation called Herts Help which contains within a network of locality-based Community Navigators.   Patients can self refer or be referred.  In some of our practices now, we also now have social prescribing groups set up by patient participation groups.  Examples of social prescribing activities include volunteering, arts activities, group learning, gardening, befriending, cookery, healthy eating advice, debt advice and a range of sports.

Ultimately we are social animals and real, physical connections are vital to us, particularly at times when we are struggling with our wellbeing for whatever reason.  This is one of the five ways to mental wellbeing:  connect, be active, take notice, keep learning, give. 

A good news story

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I thought I would finish off  this week with a fantastic example of how a local community service helps people with addictions connect, support each other and recover.   The Living Room is a non-residential service that provides therapy to help people to abstain from their addictions, achieve abstinence and secure long-term recovery.   It does tremendous work and is highly respected in our locality.  This week, an event was held in our church called “Stories From The Living Room”.  It was an evening of spoken word performances delivered by the clients, past and present, of the living room as well as the counsellors who provide the service.  Many of these people have never even written a story or a poem, never mind performed them in public.   It was a truly amazing evening:  a massive eye-opener for those of us who have never experienced serious addiction and its consequences.  For the audience it was a particularly humbling and emotional experience.

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Highly relevant to this issue is this week’s episode of Dr Rangan Chatterjee’s Feel Better Live More podcast.  Episode #37 is a conversation between Rangan and Gabor Maté, a world authority on addiction, on how our childhood shapes every aspect of our health.  I heartily recommend this episode to everyone, whether you have issues with addiction, are trying to support someone who does, or would just like to know more about this issue.  It goes deep and I guarantee it will be well worth your time. 

That’s all from me for this week.  I hope you have found this week’s post interesting and helpful.  Your comments and feedback are much appreciated as ever as they help me to make it as useful and relevant as possible for my readers.  The weekly wellbeing round-up will be return.  Until then, take care of yourself!

Dr Richard Pile

The Weekly Wellbeing Round-Up #21

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

Food

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Omega 3 and Oily Fish

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

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

Organic Food and Cancer

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

Food supplements

 

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

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

Wellbeing for Doctors

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

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

Lifestyle Medicine:  it’s a thing.

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

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

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

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

Podcast recommendations

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

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

TED Radio Hour:  The meaning of work.

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

 

Dr Richard Pile

 

 

 

 

 

The Weekly Wellbeing Round-Up #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 #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 #13: digital wellbeing.

Any doctor reading this who had a pound for every patient who has uttered the words “I think I need an MOT, doc” would probably be reading this from the deck of their yacht, floating on the Mediterranean.  Usually when this is said, it’s in the context of a physical and sometimes interrelated mental health concern.   No one, however, has ever come into my consulting room and said they need an MOT for their digital wellbeing.   This doesn’t mean there is not a problem…it just means that they are not aware of it.  When a health professional asks questions about a person’s health, they will usually ask about things like physical and mental symptoms, smoking, alcohol, sleep, diet, work and social issues.  But how often do we think about our digital health?  The topic of my blog this week was prompted by the news that YouTube has created tools to help users manage their digital wellbeing.  Here is the official YouTube blog on this topic.  Users can now monitor how much time they spend watching YouTube, set reminders to take a break, reduce their notifications to once a day and disable notification sounds and vibrations.   So today I will be focussing on digital wellbeing – the scale of the challenge, the signs and symptoms of digital health problems and how to increase your wellbeing so you feel better as a result.

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Is there really a problem?

Don’t get me wrong..digital technology, the internet, smartphones and social media can improve our lives significantly.  However,  when all of this stuff was invented, no one was sitting down thinking “we can do this, but should we?” or  “how should we use it best?”.  The genie is out of the bottle, and the times, they are a changin’.   In 1996, 16% of households owned a mobile phone.  In 2017 it was 95%.  95% of people between 16 and 34 years of age own a mobile phone, 51% up to the age of 64.   I got my first mobile in my twenties.  The average starting age of smartphone ownership is now 10.3 years.  We have other mobile devices now with software that also allows us to always be connected.  My household has five people in it and between us we own 5 mobile phones, two ipads, 5 laptops, a kindle, a desktop computer, two apple TV’s, a games console and various ipods.

“So what?”, I hear you ask.  The way we live is changing.  People have been predicting the end of the world as we know it on a regular basis since time immemorial.  Is this just another example of moral panic?  Sadly, I don’t think so.

In 2014, Ofcom reported that britons spend more time on screens than they do asleep.  When it comes to devices, the same report found that 6 year olds had the same level of knowledge about them as 45 year olds.  It’s not that hard to believe.  Over-reliance on devices has significant potential drawbacks including the effects upon our ability to maintain real life relationships, concentration levels, being present and  in touch with real world.  This article in the Independent in 2017 reports on the findings of  a study that the average briton touches their phone 10,000 times a year or 28 times a day.  That number may not seem particularly high but other studies claim that there are some groups of higher uses who touch their phone thousands of times a day.  Just think about the implications of that in terms of the time spent checking the phone for new updates and content, never mind the time spent reading some of them.

There is increasing evidence to suggest that activities done without a screen are generally associated with increased happiness and screen based activities are generally associated with decreased happiness.    More specifically, the case is being built for increased social media use being related to unhappiness, having consequences for us both personally and professionally.  A good friend of mine has worked in recruitment for various large companies over the years and has seen the consequences both in terms of its impact upon productivity and professionalism at work, and people’s inability to communicate properly when applying for jobs, struggling with simple things like eye contact and a handshake.

One of the most significant impacts on our wellbeing is how devices and being always-on, with the blurring of home and work life, affect our sleep.  This is a particular issue because the type of light (blue/white light) emitted by these screens disrupts out sleep by interfering the natural rise in levels of melatonin that normally occur as the day goes on and natural light diminishes.   The blurring of our boundaries between work and home also means that we find it harder to relax, dominated by the sympathetic nervous system (responsible for our fight-or-flight), at a time of day when our parasympathetic nervous system should be taking over and slowing things down.  A great quote from Dr Rangan Chatterjee, whose Feel Better Live More podcasts I heartily recommend, is that a sympathetic nervous system response for a short burst of adrenaline fuelled fight or flight activity was appropriate when a lion was trying to kill us but now “it’s our life that’s trying to kill us”.

Symptoms and signs of the problem

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All identified disease have signs and symptoms.   Digital malaise is no different.   Like other diseases, having one or two of these might not necessarily indicate a person has a significant problem.  However, if they begin to add up, it’s a red flag.  These might include:

  1.  Checking your device last thing at night and as soon as you are awake.
  2. Cutting off a face to face conversation or any other form of social interaction with someone to check or answer your phone.
  3. Repeatedly checking your phone in any gap in the day no matter how small (on the loo, in the advert breaks, when you get into the car, when the traffic lights are red etc, whilst waiting for the kettle to boil, the microwave to ping or the download to finish) and regardless of when you last checked it.
  4. Feeling worried if you are separated from your phone.  You know where it is, but somehow it doesn’t feel right.  You list to one side when you walk because it isn’t in your pocket.  You start to wonder if your twitter following has grown in the five minutes since you last checked it, and are now concerned you cannot find this out instantly.  Note this is not the same as actually losing your phone.  My friend dropped his iphone on our bike ride the other day and we spent 15-20 mins calling it and then getting his family to Find My Iphone to locate it on the maps app and then ping it until we found it…..fair enough!
  5. Falling behind with your work and personal deadlines but being bang up to date with having checked and responded to the lastest social media updates.   No point getting a snapchat streak and getting canned at the same time.
  6. You get phantom vibrations.  We’ve all felt that sensation that makes us think we have a call or notification.  However, people who are addicted to their phones are more likely to feel this and check for it.
  7. Checking and answering work emails at weekends/evenings.  Of course we’ve all done it, from time to time.  But do you do it regularly…and particularly late at night?
  8. Meaning to go to bed/do that piece of work, but just finding yourself scrolling through social media for hours, disappearing down various side tracks and rabbit holes along the way.

Tips for improving your digital wellbeing…and the rest of your wellbeing as a result

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  1.  Do not have your phone by your bedside.  Charge it in another room or at least in the corner.  And before you protest…buy an alarm clock.  With red not blue light in the display.  Or an actual old fashioned clock.  Or get your fitbit/other quantifiable self type gadget to vibrate to wake you up.
  2. If you can’t go cold turkey with your phone out of arms’ reach, then at least use the operating system’s do-not-disturb options to stop notifications after a certain time (e.g. 10pm to 7am) and if your phone has an option to cut out blue light (e.g. Nightmode on iOS) then use that in the evenings.  Ideally get into the habit of not using your phone for 1-2 hours before you want to be asleep.  I should point out that if you are considering option 2 because you couldn’t contemplate option 1, that’s a red flag and the reason why you should choose option 1.
  3. Turn off notifications on your phone.  This means you will at least be making an active choice to check for updates, instead of having your phone ping/vibrate/display new updates constantly.   You can be selective and turn off notifications from certain apps if you wish.  I have done this and found it a huge release.   I know my wife or kids will ring or text me if it’s something really important.   The rest doesn’t matter and can wait until I’ve got some free time.  You will be less distracted and able to focus on other things like hitting that work deadline, or the conversation you are having with the person in front of you.
  4. Speaking of the person in front of you, think very carefully before you ever interrupt a real life conversation to check or respond to something on your phone. Doing that says to that person that they are less important than someone or something virtual .  Would you turn your back on someone mid sentence?  Or break off to walk away and talk to someone else?  And before you protest that sometimes the message/update might be “very important”, let’s just think about that for a second.  Ask yourself the question “Am I a super hero with a secret identity who needs to look for a phone box to change in/a highly trained special forces operative/a member of the emergency services on call?”  If the answer to those questions is no then take a breath and get a grip.  Your family,  friends and work colleagues will appreciate this.   I apply this during most of my consultations, when I don’t answer the phone unless I am the emergency doctor.  It tells the patient that what they are saying to me is more important, and whoever’s ringing can try again later.
  5. Think about whether you need to answer that work email.  There is a mistaken assumption that working long hours and answering emails even when you are on holiday or at home with your family that it makes you more productive and a better worker.  It’s not true.  You could consider turning on inbox rules.  For example, you could autoreply to all emails between 10pm and 7 am that you will deal with them the next working day.  Or more radically, auto delete all emails that arrive whilst you are on annual leave, with a response advising the sender who to contact if it is urgent and needs dealing with before you return.  If you are a boss, lead by example.  Think about the culture that you want to create within your organisation. If you need to, make a deliberate decision to get up early the next day rather than staying up late.  You will be better for a night’s sleep and it’s a conscious choice to do some focussed work, as opposed to just browsing your inbox.
  6. If you really need help with self control, you can configure the wifi network in your house for time restricted access.  This can be device specific, using what’s called the MAC or wifi address for each device in question.  If your laptop or tablet can’t connect to the internet, it seriously limits some of your options.  More details on this in a future post about looking after our children’s digital wellbeing.
  7.  Think about whether using certain social media platforms is to your benefit and makes you happy.  If you find yourself irritated by most of what you read, feel bad because people’s lives on Instagram look a lot better than yours, or end up getting into spats with people on a regular basis on your local Facebook Mum’s group, ask yourself the question whether this is really life enhancing and what purpose it actually serves.  Does it make you a better and happier person?  A better parent? A better employee?
  8. Take a digital sabbatical.  Why not try a few days or a even a week without social media or reading your (non-urgent) emails?  Or 24 hours with your notifications turned off?  If you feel that’s too much, start with a shorter period of time.   You may start with suffering from FOMO (fear of missing out), but after you’ve got over that, it can be liberating.  You may like to consider Scroll Free September , launched by the Royal Society for Public Health.  Fear not, you don’t have to abandon all forms of social media if that’s a bit too drastic.  They have lots of options that you might like to consider.   I am taking up the Sleeping Dog (no social media after 6pm) and Social Butterfly (no use of social media at social events….just enjoy the moment) options.
  9. Find other enjoyable stuff to do.  If you spend hours on a screen, just think about what else you might be able to do with that time.  Go for a walk, spend time with your kids, make that call you’ve been meaning to, read a book, listen to some music, cook a really nice meal, catch up with your friends, take up a new hobby.   I stopped reading the news every day a couple of months ago.  It’s always the same old depressing nonsense anyway and leaves me with a jaundiced view of humanity. Just listening to the today program for 5 mins in the morning  once or twice a week tells me all I need to know.  I have spent the time reading instead.  OK, and writing this blog.

If we all did some of these things we would find ourselves happier and healthier, more focussed and with better relationships.  If you have any tips for improving your digital wellbeing, they would be most welcome.  Please do share them in the comments section. If you would like to do some further thinking and listening, I recommend the TED Radio Hour Screen Time podcasts, part 1 and part 2.  Good, thought provoking stuff.

That’s it for this week.   Your comments on the blog would be really helpful.  If you like it, please share with other people…particularly anyone you know who might benefit from a digital detox!   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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