Wellbeing for Real Life: what is resilience and how do we build it?

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I was recently asked to write a module on resilience for clients of a healthy lifestyle service provider. We had previously put together modules on anxiety, depression and stress management. The feedback that we were getting from some team members delivering the modules was that they found the subjects rather complex and difficult to discuss and there was a risk of ending up focussing on the negative. We therefore decided to simplify the modules, fuse them together where appropriate, and to take a more positive tone discussing fitness rather than illness. As I put the module together I was reminded that teaching something is a great way of learning something , and so thought I would share what I have learnt in the hope that it is useful to you.

Let’s start with some questions people commonly ask. What is resilience? Do I have it? How do I know? Can I measure it? If I don’t have it, can I get it, or improve it? How can I help my kids to have it?

Defining resilience

A very basic definition of resilience is the ability of a substance or object to spring back into shape after trauma. To make it more human, we could describe it as the ability to cope with setbacks, or the ability to overcome difficult experiences and to be shaped positively by them. It might be described very simplistically as physical or mental strength or fitness.

Resilient people are not just born, they can be made

As my wife pointed out to me during the writing of this post, anyone who has had a few children can tell you that we are all in different places on the scale of natural resilience. It’s undeniable. However, where we end up is not inevitable. Nurture has at least as important a role as nature. I used to be a bit daunted by the people in the weights section at the gym, heavily muscled and confident specimens stalking around the equipment as if they owned the place, occasionally grabbing hold of some colossal bits of metal and wrestling them into submission before grunting and moving on to the next unsuspecting piece of apparatus. This was until I realised that they hadn’t become like this spontaneously but had developed themselves over time, with regular practice and commitment and maybe some pain. I’ve heard physios encouraging people to keep doing their exercises, advising them that they should be aiming to stretch their muscles and cause them to ache because that’s the only way they will ever strengthen them. When you exercise, you need to get your heart rate up for it to do you some good, which isn’t always comfortable.

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So it’s good news for all of us, particularly if we are feeling life’s challenges. The route to resilience is adversity – getting through it, and learning from it. Machine parts are tested before they leave the factory, to ensure they are strong enough. In the same way that a person who never makes a mistake never learns anything, you can’t be resilient if you have never suffered any setbacks. I’m not suggesting you go seeking adversity, or deliberately make decisions that are likely to have a bad outcome, but its ok and indeed necessary to endure traumas to build resilience. In the same way however that an athlete would prepare to compete, there are of course things that we can do to prepare ourselves for life’s challenges.

My top tips for developing resilience, based on my own life and what I have learnt from others, include:

  1. Self nurture. Sleeping well, being physically active and eating a healthy varied diet will mean that we are physically and mentally in as good a place as possible to take on whatever comes our way each day. Relaxation is an important part of this too, setting aside some regular time that is just for you. That could include reading, listening to music or meditating.
  2. Good connections. With friends, family and other people that you have a shared interest with. Prioritise the positive relationships with people that encourage and support you, and who you can do the same for. Put dates in the diary to make sure it happens, or it won’t. If you have kids, make sure that they have positive, nurturing relationships in their life. These could be with friends, teachers, relatives, health care practitioners and of course…parents! It can be vital to be able to ask others for help when we feel we don’t have the strength for ourselves.
  3. Positive action. Take a positive attitude towards your abilities and encourage yourself, especially in difficult situations. Be assertive and open in your relationships, whether personal or professional. Set goals in the short, medium and long term and make a plan for how you are going to achieve them, breaking it down day by day and moment by moment if need be.
  4. Develop new skills and hobbies. You could learn a new language or take up an instrument. This is good for your brain, encourages further social networking and helps with practising delayed gratification. This is particularly important for children who have been born into this era of instant gratification and rarely having to wait for anything for any significant length of time.
  5. Learn from challenges. Whether it’s a mistake that you made, or something beyond your control that happened, take time to reflect on how it made you feel and what you can learn from it or do differently next time. If you have kids, it’s important to let them make decisions and live with the consequences. Obviously you have to pick and choose depending on the stakes for their immediate health and wellbeing. Resist being a helicopter parent. It’s understandable but rubbish preparation for life and not in your child’s long term interests. If you wrap them up in cotton wool, they will just break later in life when you may not be around to support and encourage them. Better to let them make mistakes at a younger age and be stronger and wiser for it.
  6. Practice gratitude. This is such a simple and yet profound thing to do. I would be willing to bet that if you are reading this blog you have at least one thing in your life to feel grateful for, no matter how bad today or this week or month has been. You can start with the very basic stuff (like being born!), narrow it down a bit (like living in a democratic society in here in the UK where you are allowed to express and practice your beliefs) and then focus on the more personal and specific things you are thankful for like the place where you live, your friends and family…maybe even your job!

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I hope you have found some of these tips helpful. Remember – we should not and cannot avoid adversity in life. It’s the route to resilience and can make us stronger.

The Weekly Wellbeing Round-Up #18: a weekend of wellbeing in Valencia.

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

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

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

Eat

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

Connect

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

Sleep

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

Move

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

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

Relax

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

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

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

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

Dr Richard Pile

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

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

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

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

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Why do we need a plan?

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

Do wellbeing plans work?

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

Accepting the need to make changes

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

Being specific about the changes

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

A plan makes us accountable for the changes

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

A plan helps us to measure success as well as failure

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

My top tips for making your wellbeing plan

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

Wellbeing planning in the real world.

I thought I would finished with some real life examples.

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

And finally, my own personal wellbeing plan

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

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

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

Until next week, take care of yourself!

Dr Richard Pile

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The Weekly Wellbeing Round-Up #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 # 7

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

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The Health Supplements Don’t Work

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

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

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

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

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

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Social Prescribing

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

 

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Public Health and Prevention

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

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

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

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

Dr Richard Pile

 

 

 

 

The Weekly Wellbeing Round-Up #6

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

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Cardiovascular disease 

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

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

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

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Hypertension

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

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Food 

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

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

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

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

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Sleep

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

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

Dr Richard Pile

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