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 #12: my week of learning more about low carb diets.

As those of you that read the Weekly Wellbeing Round Up will be aware, there was a bit of a scuffle last week in  the media about the low carbohydrate diet.  This all kicked off due to the  publication in the Lancet Public Health of a prospective cohort study and meta-analysis which suggested there might be an association with lower carbohydrate diets and increased mortality.  This gave rise to sensationalist headlines in the press, linking low carb diets to a grim, early death.  The low carb vs low fat battlelines were already drawn up and ready to go of course, so volleys of invective were being fired each way sooner than you could type twitterspat.  It was a particularly unedifying spectacle to outside observers, to whom it may have appeared that the anti-low carb lobby were crowing triumphantlythat this was the nail in the coffin whilst the low-carbers circled the wagons and sat with their fingers in their ears.

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So in this week’s post I am attempting to make sense of the evidence, pointing out a few obvious things and making practical recommendations about the place of low carb diets.

I will start with a disclaimer:  I am currently eating a low-ish carb diet.  I mentioned this in a previous post about my real life wellbeing week.   I have lost about half a stone in weight having never managed to lose any in the past by just cutting back on the calories.  I’m not a fanatic.  I have friends and family who have found this approach similarly helpful.  I haven’t written a book on low carb, I don’t run a expensive private clinic or have any merchandise to sell.  I will occasionally raid the biscuit tin in reception when I am peckish. I still enjoy a beer and some nibbles with my colleagues in the pub on a friday.   It’s one of the best parts of my working week.  If the price I pay for this is indeed a grim and premature death, then I consider that an acceptable trade-off.

The Evidence

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The problem with the evidence is that there’s both a lot of it and not enough of it.  Plenty of cohort studies asking people what they think they ate 25 years ago.  Not so many randomised controlled trials comparing low carb to very low carb to moderate carb to low fat etc, with long term outcomes that affect people’s lives (e.g. heart attack, stroke etc).  In fact for not so many, read none at all.  Plenty of data around effects on blood sugar, cholesterol and blood pressure, but not the really important outcomes.    There are lots of meta-analyses looking at the same subject which have come to quite different conclusions.  This is due either to the variable quality of the studies that were included or how the analysis was done.  The latter in turn may be affected by where the person or persons conducting the meta-analysis stood on the issue.  It is widely agreed that more good quality long term data is needed.

The negative

It’s important that advocates of a low carb diet be honest about the lack of clinically significant long term outcomes from properly conducted studies (i.e.  randomised controlled prospective studies).  Anyone that can tell you their low carb diet plan has been proved to result in fewer heart attacks and strokes is at best wildly optimistic and not understanding of what constitutes proper evidence, confused by the difference between causation and association , or just lying.   Quite a few meta analyses have found that the low carb diet is not superior to the low fat diet.  Fair enough.  Let’s think about that though…”not superior to”.  Which may also mean “just as good as”.  As in these position statements from Diabetes UK and the NHS UK website.  Drug companies make new drugs that are better than placebo and equivalent to many existing products and they get licensed, accepted and used widely..so why do we have to prove the low carb diet is better than anything else to consider using it?

To be clear, there is no credible evidence that low carb diets cause harm.   Anyone intellectually lazy enough to have read the Lancet publication and newspaper headlines and said “well, that’s that then” deserves a intellectual kick up the backside.  The study is worth discussing but it simply cannot hold all the weight that some seem to be requiring of it and it does not prove causation.  A drug would not be licensed if it couldn’t be proved it caused a positive outcome and neither would it be withdrawn unless it could be proved it caused negative outcomes (and sometimes not even then…that’s another topic!).   Here is a link to Dr Zoe Harcombe’s excellent detailed analysis of the study.

The positive

Whilst there are meta-analyses that can be drawn upon by both sides  it seems clear to me that that there is reasonable evidence from both meta-analyses and individual studies that the low carb diet is at least equivalent to the low fat diet in effectiveness and may even be slightly better in specific patient groups.  That’s as strongly as I’m putting it.  Proponents of the low carb diet should not claim it is a magic bullet, and sceptics should not dismiss it purely because it isn’t one.   The areas where there is, in my view, sufficient evidence to consider it as part of the dietary tools available to us are diabetes (including possibly gestational diabetes), pre-diabetes and obesity.  Relevant links below if you would like to do some further reading.

Diabetes

Improved HbA1c, triglycerides and HDL in Type 2 Diabetes

Best dietary approach for reducing HbA1c in Type 2 Diabetics

A low glycaemic index diet improves glycaemic control in women with gestational diabetes, and reduces birth weight of their children

Obesity

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PLOS One meta-analysis of LCD vs LFD in obese or overweight patients

Long term weight maintenance is superior on a higher protein LCD.  A modest persistant effect was shown with less lean muscle mass lost compared to a LFD

LCD’s result in decreased fat mass, if not a greater long term weight loss than LFD’s.

Reflections

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Everyone has either a starting position, personal experience, bias or vested interest in this area.  We should acknowledge this. For most people, a low carb diet inevitably involves calorie restriction, which will clearly contribute to weight loss.   Low carb diet advocates should acknowledge this.  There are a variety of dietary options that are available to us and some will work better than others for each individual…so health professionals and individuals need to explore what is likely to be the best option in each individual and their situation e.g. I would not recommend low carb high fat diet in someone with Familial Hypercholesterolaemia (an inherited condition causing very high cholesterol).  Neither would I recommend a moderate to high carb intake in someone with diabetes.  We need the right tools for each situation.

We are not coming from a healthy, normal baseline in developed western societies such as UK and US…we massively over-do beige carbs and our rising obesity and overweight figures bear witness to this.  It feels intrinsically right to me that we aim to reduce the portion of our diets that has very little if any nutritional value and is clearly contributing significantly to the rise in obesity and related conditions. Evidence changes all the time.   When I was a junior doctor, I would have failed my exams for membership of the Royal College of Physicians for recommending betablockers to patients with heart failure, which was considered dangerous at the time.  Now it is recommended by NICE and GP’s are expected and incentivised to do exactly this.

In reality, very few people are going to follow a very low carb diet for practical and financial reasons.  A very low carb diet (< 50g per day) is unrealistic in the general population.  A low carb diet (<120-130g a day) is more sustainable.

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Extreme views and practices of whatever kind are unlikely to be useful, safe or achievable in real life.  As a GP and commissioner I am interested in getting the greatest amount of bang for my buck.  When it comes to physical activity, the greatest health gains (and risk reduction) comes from people moving from doing nothing to doing something.  When it comes to diet then from a public health perspective the greatest benefit would come from large numbers of people at significant risk of cardiovascular disease adopting a modest, sustainable reduced carbohydrate diet rather than a smaller number of people (many of whom are already highly motivated and “healthy”) adopting a more extreme, harder-to-sustain, very low carbohydrate diet.

The best medicine is the one that a person will take.  The best diet is one that a person can stick to and lose weight.

That’s it for this week. The weekly Wellbeing Round up will be back next week. Until then…take care of yourselves!

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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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