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 #23

Welcome to episode 23 of the weekly wellbeing round-up!  Some of you may have noticed an item or two in the news this week about the publication of the NHS’s vision for prevention, publicised by Matt Hancock the health secretary.  Plenty to chew over there and for this reason I will be devoting this week’s post to the subject, looking at the positives, the negatives and the unanswered questions – for patients and for doctors – from a pragmatic perspective.  Let’s jump straight into it!

Prevention is better than cure

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OK, so it’s a pretty obvious title for a government paper on the subject, but one that is clearly appropriate and hard to argue with.  The paper was published this week and you can read the full forty-one page document here, as well as Matt Hancock’s blog post on its publication here.  Just in case you don’t have the time or inclination to read all of that, I have summarised some of the key points and some of the issues that arise as a result.

The importance of prevention

Whilst it’s not necessary to spend a lot of time agreeing with motherhood and apple pie, there are a few points made that are worth reflecting on.  Firstly, how might we define prevention?  Here it is described as “about staying people stay healthy, happy and independent for as long as possible”.  Not a bad definition.  It is worth remembering that we can’t prevent everything (ageing and death being two obvious examples) and sometimes it might be more accurate to use the term “delayative” rather than “preventative” medicine.  However, it’s still very important as one key area is the number of years of life that we enjoy in good health… something we will touch on later.   It is pointed out in the document that we spend over ten times more money on treating disease rather than preventing it (£97 billion vs £8 billion).  This demonstrates that, whatever the rhetoric may have been, we clearly aren’t getting the balance right and it still needs to shift significantly.  If we do what we’ve always done, we should be entirely unsurprised when we get what we have always got.

Funding for prevention

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Much play is made of the increased funding for the NHS, an apparently rising amount up to £20.5 billion a year in five years’ time.  Clearly this is welcome.  The welcome should be a cautious one, however.  First of all we need to be sure that none of this is simply rebadged money.  Secondly, money absorbed into existing NHS deficits (e.g.  overspent clinical commissioning groups and hospital trusts) is not available to be spent and therefore not a real terms increase,  so we need to be clear about where it’s going.   Thirdly,  the big issue of funding for public health was not addressed by the health secretary when he was asked this question repeatedly on the Today program this week.  Public health funding provides services such as smoking cessation, weight management and sexual health clinics.  The budget has been slashed in the last few years.  There has not been an announcement yet about the budget for next year.  If this is further reduced (or in my view, not increased) then a lot of the rhetoric about funding will ring hollow.

Who is responsible for practising prevention?

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There are a lot of references to personal responsibility in the vision document.   Generally speaking, I’m a big fan of personal responsibility.  Ultimately we all make our own decisions about what we put in our mouths, how much we drink and whether we are physically active.  I really struggle when I talk to people about the risks they face to their long-term health and wellbeing and their response is either to shrug or to suggest that it’s up to the medical profession to sort it out for them.   That said, life is not a level playing field.  There is evidence of inequalities in society increasing rather than decreasing in some areas.   Many factors influence a person’s wellbeing and the majority of them are not directly related to physical health e.g. housing, employment, education and social networks.

One area that is highlighted is the aim to halve reduce childhood obesity by 2030.  In the UK we have one of the highest childhood obesity rates in Western Europe. Serious public policy is required here, not just telling kids and their parents to eat more fruit.  People worry about the nanny state and curbs on freedom, but the biggest advances to health have often been the result of large-scale public health interventions such as safe drinking water, vaccination and smoking bans.  I’m a massive fan of the nanny state.  We need cities safe for cycling, better public transport,  advertising bans and more tax on unhealthy foods and sugary drinks, mandatory calorie counts on menus, regulation of fast food shops on the high street and near schools, and increased input into the school curriculum.  We need the government to take responsibility for this as well as expecting local authorities to do their bit.  If this does not happen, then very little else will.

Social prescribing for prevention

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Social prescribing involves helping patients to improve their health, wellbeing and social welfare by connecting them to community and other third-party services – for example those run by a council, local charity or lifestyle and wellbeing service provider.  The vision document highlights the  important part that social prescribing has to play in prevention.  It is important to “change the mindset from condition management to health creation”.

Our clinical commissioning group has a strong social prescribing model which has received national recognition .  We have a team of  community navigators serving each of our local areas.   My practice patient participation group has just launched a social prescribing group that dovetails in with this service, offering weekly clinics for primary care team members to refer into where we feel that a person’s needs might be better met by this than by a medical practitioner (e.g.  to address loneliness and debt).   However, we need to ensure that we don’t see social prescribing as an option to compensate for lack of funding and support from central government and local authorities, relying on the good will and free time of individuals and charities.  If it works as a concept and in reality, it must be properly commissioned.

I was rather tickled to read this BBC news article which reports the health secretary advocating GP’s prescribing song playlists as well as medication.  I like the idea although I’m not sure that this is necessarily something that will ever make it into the core general medical services contract.  I’m also not sure that my sharing any of my playlists with my patients would be a kindness, but just in case you are interested, here are my apple music playlists for ambient music, jazz , electronic dance music and rock.  A little something for whatever suits your mood, I hope.

 

Technology for prevention

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Our secretary of state for health is very keen on his technology.  I was rather suspicious at the beginning of his tenure that a lot of statements were made about using apps to transform the NHS.  Don’t get me wrong – I’m proud to consider myself a bit of a geek and have always looked to use technology to help me work smarter and more efficiently – but it did raise the suspicion that this might be a message that all we need to do to save the NHS is to use our smartphones more.  Maybe this isn’t entirely fair as there is going to be an increase in funding, which I have already covered. Two particular aspects of using technology caught my eye in this document.

Predictive technology

The first aspect is use of a predictive technology to assess risk which is not just limited to a body system or a disease.  Bearing in mind my earlier comments about the determinants of wellbeing outside of health,  I think this is a really interesting idea and would be a considerable extension above and beyond current risk tools such as Qrisk2, which allow you to put in a postcode as part of calculating a person’s risk but nothing more than that.   How such a tool would be developed and demonstrated to be valid is another issue altogether but one that I look forward to learning more about.

Telehealth

Oh how we love our telehealth in the NHS.  The great solution to everything.  The thing that everyone of every age demands and desires.  The thing that will radically change the NHS.  The thing that has lots of evidence behind it…oh, wait.  No, it doesn’t.  As someone who used to be responsible for telehealth developments in our clinical commissioning group, may I take this opportunity to say just how weary and cynical I am about the whole thing?  It may augment NHS services if used in just the right group of people with just the right level of engagement.  It will be convenient for some patients.  However, an appointment with a doctor remains an appointment with a doctor and takes up the same amount of time as any other kind of appointment.  Next time you are at your doctor’s surgery,  try asking about the level of excitement they feel about now having to consider telehealth as well.  See?  Told you.

Prevention…what’s the point?

This is what it all comes down to.  We need to be clear about this.  We can’t stop people ageing or dying (despite NICE’s best efforts when it approves yet another drug with marginal gains for £20,000 per quality adjusted life year).  So what is it all about?  I was pleased to see that Matt Hancock states that the aim is for an extra five years of healthy independent life.   Assuming I have understood this correctly, this is a welcome emphasis on quality rather than quantity of life – something that we can all get behind.

That’s all from me for this week.  The weekly wellbeing round up will return.  Until next week, take care of yourself!

Dr Richard Pile

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

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

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

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

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Why do we need a plan?

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

Do wellbeing plans work?

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

Accepting the need to make changes

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

Being specific about the changes

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

A plan makes us accountable for the changes

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

A plan helps us to measure success as well as failure

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

My top tips for making your wellbeing plan

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

Wellbeing planning in the real world.

I thought I would finished with some real life examples.

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

And finally, my own personal wellbeing plan

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

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

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

Until next week, take care of yourself!

Dr Richard Pile

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The Weekly Wellbeing Round-Up #14

Welcome back to the Weekly Wellbeing Round Up.  We’ve taken a couple of weeks off to focus on the low down on low carb diets, and digital wellbeing.  I’m pleased to say that this week normal service is resumed.   Topics for today include calorie counts in menus,veganism, probiotics, the cost of eating health food, heart age and heart disease.  Let’s tuck in….

Counting the cost of counting calories

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The department of health and social care is to launch a consultation on its plans to require calorie counts on menus as part of its childhood obesity strategy.  The BBC reported this week that concerns had been raised by the treasury about the cost to small businesses, and the risk of distressing people with eating disorders. recommended this week that.   Whilst I have sympathy for both potentially affected groups, I think we should ask ourselves what our priorities should be for the health of our nation and particularly our nation’s children.  I seriously doubt that my local greasy spoon cafe will go out of business because they have to work out the calories in their full english breakfast.

Is being vegan good for your health?

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The BBC reported this week on the experience of Dr Giles Yeo going vegan for a month, in an episode of Trust Me I’m A Doctor.  During his trial, Giles lost weight, reduced his body fat and his cholesterol.  He required dietary advice to avoid becoming deficient in certain nutrients such as iron, vitamins B &D, omega 3 fatty acids, calcium, iodine and protein.  Some of this can be sourced from plants, but some probably requires supplementation.

This meta-analysis found that people on a vegetarian (including vegan) diet had an overall descreased risk of dying from heart disease and cancer but that there was no overall decrease in cardiovascular deaths or all cause mortality compared to non-vegetarians.

Take home message?  You might be slightly less likely to die of heart disease and cancer but overall vegetarians don’t live longer.  It is sensible to consider going meat free for some of your meals each week…maybe replacing them with oily fish.  Whilst my quality of life might be improved in some respects, I could no longer have a sausage, egg & bacon bap with my buddy Al on a sunday morning after our bike ride.  That would be a No then.

Children in food poverty

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On a more serious note, the Food Foundation issued a report stating that “a healthy diet is beyond the reach of 3.7 million children in the UK“.  It’s a shocking statistic.  There isn’t an easy answer to this one.  It’s easy to glibly state that an apple costs less than a mars bar (which is generally true, in fairness), but it is a fact that crap food is cheap, and good food either costs more or (and I think this is part of the problem) takes more time and knowledge to prepare.

The answer for me has to be pragmatic.  Whilst influencing national policy and financial instruments is beyond the ability of most of us, we can take simple steps to improve the situation even if we can’t achieve perfection.  There are plenty of books and websites out there about cooking on a budget.  Some examples include:

BBC Good Food Seven Days of Cheap Healthy Meals

Jamie Oliver’s cheap and cheerful recipes

Jack Monroe’s Cooking On A Bootstrap

Some providers of lifestyle services including cooking lessons, not just lectures about healthy eating.   If you really want to be challenged and inspired in this area, I heartily recommend Dr Rangan Chatterjee’s interview with Jamie Oliver in Episode 16  of his Feel Better Live More podcast.   Jamie’s passion for this subject shines through.  I particularly like his ideas about using his recipes like a jukebox for types of meal and associated costs, to come out with some realistic options for families struggling in this area.   If you are a health professional talking to a family about this, just remember that even if they eat one or two healthier family meals per week, and their kids have maybe one or two healthier lunches at school, that is making a difference and it’s a start.

Probiotics…the sage continues.

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Finally  for our food section this week, the BBC reported on this study in the journal Cell which reported on the use of probiotics and whether they have a meaningful impact on our gut flora.  It’s a very long paper and to summarise very simply…they don’t have much effect if taken in a one-size fits all approach.  If you think about it logically, introducing a tiny amount of unsuspecting friendly bacteria into a person’s entire gut flora or “microbiome” is going to have very little impact in terms of relative numbers.

Take home message?  Our understanding of the gut microbiome is still at a very basic stage and there is very little available to us so far in terms of evidence that has immediate practical applications.  In the future we will look back and realise how little we knew.  Probiotics might work better if it is possible to take a personalised, individual approach to treatment.  For now, if a patient asks me whether they should take some “friendly bacteria”, I advise them that they won’t do any harm but in the average person they won’t do much good either.

Physical Activity

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The World Health Organisation has recently produced a report on global levels of activity.  It was a self reported study based in 168 countries with 1.9 million participants from 2001 to 2016.   The BMJ reported on the findings this week.  Sufficient activity was defined as 150 mins of moderate intensity activity per week.  36% of UK adults were insufficiently active, with Kuwait winning the wooden spoon at a whopping 67%.  Women were generally less active than men.   Inactivity was a worse problem in high income activities.  Over the study period, levels of physical activity did not rise.  The solutions are large scale and up to governments when it comes to decisions about transport and infrastructure etc.  Personally, I think 36% of UK adults being insufficiently active is a massive under-estimate and a reflection of a lot of people kidding themselves when they filled int the report.  My take home message is that health professionals should bear this in mind and drill down a bit more into a person’s history when asking about how active they are.  Physical activity is a miracle cure, a wonder drug.   If you haven’t seen it, I recommend you take five minutes to view Twenty Three and a Half Hours on YouTube.  It ends with an excellent challenge that puts all our excuses about physical activity into perspective.

My dog Prince has offered to be share, with anyone who wants to know, how he feels about exercise.  All you need to do is to come round to our house, look him in the eyes and ask him if he would like a walk.   You may wish to consider wearing body armour with an anti-slobber coating for this exercise.  Don’t say I didn’t warn you.  Here is the presentation he has put together.

Heart health and disease

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In a collaboration between Public Health England have released a Heart Age online tool that allows you to calculate what your heart age is compared to your actual age.  When it comes to risk, people often struggle to get their heads around risk scores as percentages over a number of years and scoring tools are increasingly calculating the age of the relevant organs in your body (heart, brain, lungs) as it is felt that this is a more powerful motivator for people to make changes.   You can take the test online.   If your heart appears to be significantly older (according to Public Health England!) then you actually are, it may be worth booking a phone call with your GP to talk things through.  If you haven’t already done so and are between the ages of 40 and 74, I recommend you take up the offer of a free NHS health check.

Lifestyle Medicine

As a new user of EMIS (a GP computer system), I attended the national user group conference in Birmingham this year.   It was a great event and both I and the rest of my surgery team learnt a lot and came away with loads of ideas for how we can provide better and more efficient care for our patients.  One of the highlights of the conference was the Lifestyle Medicine presentation by Dr Rangan Chatterjee and Dr Ayan Panja. Excellent, inspiring stuff.  The real time roleplay between Rangan and Ayan of a GP consulting with a stressed, sleep deprived patient was particularly good and could have taken place in any GP surgery in the land.  I was able to catch up with both of them afterwards and we talked about the difference that this approach can make to our lives as patients and healthcare professionals.  I have already seen a positive impact on the lives of some of my patients.   I am definitely going to sign up for their highly rated, RCGP-approved Prescribing Lifestyle Medicine course in January 2019.  If you can’t wait that long, I recommend you get a copy of Rangan’s Four Pillar Plan in the meantime.  I recommend it to all my patients who need to make changes in their life, as it has helped me to make changes in my mine.

That’s it for this week.  I hope you have enjoyed the blog.  Your comments and feedback would be really helpful.  If there are particular topics you would like me to cover, please let me know and I will do my best to keep it real.    Until next week, take care of yourself!

Dr Richard Pile

The Weekly Wellbeing Round-Up #11

Good morning and welcome to the latest edition of my weekly wellbeing round up.  Plenty to cover today, so let’s get started…

Smoking

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This BBC news article reminds us that passive smoking has effects way beyond childhood, including a significantly increased risk ischaemic heart disease and chronic lung disease in adulthood.  Participants were questioned about their exposure to smoking throughout their lives, and then their health was tracked over the next 22 years. As I reported last week, children were also more likely to end up with respiratory illnesses and spending time in urgent care or the local emergency department.   Now when I talk to people about quitting smoking, if they are parents I explore this as well.  We might feel comfortable making a decision that affects only our own health…hopefully most of us would feel less comfortable if we were reminded it affects others too and there is no safe level of smoking.

If people are thinking about quitting smoking, they might well consider using increasing popular e-cigarettes.  Whilst there has been some debate about potential safety issues (as reported in this article about changes to immune cells exposed to vaping chemicals in a laboratory setting), the House of Commons Science and Technology committee has published its report on vaping, and strongly recommends that more be done to encourage it.   The report states:

“These recommendations are based on a fair and accurate assessment of existing evidence from the UK that suggests vaping is significantly less harmful than smoking, few young people who have never smoked regularly vape, smoking in young people continues to decline, and e-cigarettes are helping smokers to quit.”

In one line?  E-cigarettes are much less bad for you than real ones.  Duh.

More good news for ex-smokers and those trying to quit came in this article in the New England Journal of Medicine.  The headline is that smokers are better off (in terms of health gains) after they quit, even if they gain weight.  To quote the Journal Watch commentary, “even quitters who gained over 10 kg had a 67% reduction in cardiovascular mortality and a 50% reduction in overall mortality, relative to current smokers”.  The next time I am talking to someone about quitting smoking and they say that weight gain is one of their reasons not to, I will explore this a little bit more with them to check whether it’s just gaining a few pounds they are worried about, or the consequence of weight gain on their health…in which case I will encourage them to quit first and work on the weight later.

Hypertension

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A few weeks ago I posted about the revised american guidance on hypertension and the explosion in the numbers of people labelled with the disease that would occur should this frankly bonkers approach be adopted around the world.   One thing to consider is how much more time and capacity will be needed by the NHS to help all these people control their blood pressure, should such an approach be taken.  This study published in the Journal of the American Medical Association reports on the effectiveness of a low dose 3-drug pill in controlling hypertension.  We already know that multiple drugs at a low dose are more likely to achieve blood pressure control than slowly titrating up one drug at a time to a higher dose. This result is not surprising. It is worth noting that adverse events were reported to be no higher taking this approach.

Take home message for me? Whilst I will always try to encourage lifestyle measures where relevant to lower or control BP, when considering starting therapy it may be worth adopting a different mindset, considering multiple drugs not to necessarily be a bad thing.  Particularly if GP’s have patients with hypertension coming out of their ears, so to speak.

Diabetes

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On the back of this report on the worrying rise of children with Type 2 Diabetes in the UK, there was some encouraging news for people with diabetes who are trying to control their risks factors in this study published in the New England Journal of Medicine.  Patients with type 2 diabetes who had five risk-factor variables within the target ranges appeared to have little or no excess risk of death, myocardial infarction, or stroke, as compared with the general population.   So whilst I would much rather focus my efforts on helping people not to become diabetic to start with, we can encourage our patients who have diabetes that with good control of their blood pressure, blood sugar, cholesterol etc, their risk of developing these complications is not significantly different from those without diabetes.

Carb Wars…the saga continues.

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You may well be aware of this prospective cohort study and meta analysis published recently in the Lancet Public Health.  The headline is “Moderate Carb Intake Seems Best for Longevity”.  As you can imagine, the publication of such an article made Twitter explode as troops on either side of the Low Fat vs Low Carb war lined up to either crow jubilantly or defend their positions respectively.  I will summarise in a moment but if you would like to do some further reading around the responses to and limitations of the study, here are some links:

Consultant Cardiologist Dr Aseem Malhotra’s response on the BBC news (YouTube clip, pro-low carb)

Science Media Centre briefing (anti-low carb)

As most readers of my blog will know, I am broadly in favour of a lower carb approach.  I no longer eat cereal, have cut back on bread, love my eggs for breakfast, enjoy some nuts each day and tend to have salads for lunch with either chicken or oily fish.  However, I still have the odd sandwich for lunch and am known to enjoy a bag of pork scratchings and a pint with my work colleagues during our friday evening debrief in our local.   It is rumoured that fish and chips made an appearance last week when neither my wife nor I could be bothered to cook after a long day.  The study cannot fully bear the weight of the headlines because it is observational and there are some concerns about the statistics and claims arising as a result (check out Dr Zoe Harcombe’s comments here and Luis Correia’s comments here ).

So what will I tell my friends, colleagues and patients when we end up talking about this over the next few days?  I will say that moderation is the key.   All extreme diets pose health risk.  The one thing that we do NOT consume “in moderation” at present in most western diets is carbohydrates.  In fact, you could argue that the western world is in the grip of an extreme high carb diet experiment.  We consume far too much, driven by decades of messages about low fat and the evil genius of the food companies who produce cheap, highly processed foods (with “low fat” labels on them) which are almost impossible to avoid.   So don’t worry about no or very low carb diets, just think a bit lower than most of us are eating now.   Less in the way of beige carbohydrates (most of which have zero nutritional value), lots of vegetables, more protein (fish, meat, eggs).  Eating a lower carb diet does not mean eating bacon every day and dying early of bowel cancer or heart disease.    Polarising the debate is unhelpful and will leave most people bewildered.  Let’s be pragmatic –  eating a lower carb diet will result in weight loss partly because of it being lower carb and partly because it will inevitably result in reduced calorie intake for most people.  Having debated evidence based medicine, I will give you a bit of anecdote based medicine:  I have lost over half a stone on a lower carb diet and no longer need to use medication for my inflammatory bowel disease.

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Cardiac rehabilitation

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Finally, we will finish on a more positive and entirely uncontroversial note.

Over the years I have had the privilege of working with our local cardiac rehabilitation team.  They are a great team of people, providing an important service to all of our patients with heart disease.  They work with patients with angina, heart attacks, stents, coronary artery bypass grafts, valve replacements and heart failure.   I have taken part in some of their sessions.  Many patients speak very highly of the service.  One of the trickier aspects of the job is proving what a difference the service makes.  This can be either because it is hard to prove that something was prevented from happening or sometimes because the service hasn’t been set up to properly collect the necessary outcome data.   So this systematic review and meta analysis published in Heart is most welcome.  It concludes that there is evidence of physical activity in patients who have had cardiac rehab, whilst also recommending that further high quality studies need to be conducted to give us more detail and measure other outcomes.  Shockingly, only about 50% of patients who have been offered cardiac rehab actually take it up.  Take home message?  All health professionals should strongly encourage patients to take up this offer, and encourage them to stick with the programme.

In Herts Valleys Clinical Commissioning group we have taken the principles of cardiac rehab and commissioned a cardiac prehab service for our patients at high risk of cardiovascular disease.  Working with my colleagues in cardiac rehab, public health and the CCG I designed the specification for this service.  For the first time this year, practices will be identifying such patients and offering education and support in the hope of improving outcomes and preventing disease occurring.  I will report back at a later date.

That’s it for this week’s wellbeing round up.  Stay tuned for next week’s edition and in the meantime, take care of yourself!

Dr Richard Pile.

 

The Weekly Wellbeing Round-Up #10

Good morning and welcome back to the weekly wellbeing round up.  I though this week I would start with…

Digital wellbeing

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Last week I posted from our family holiday in Verona.  My three younger boys are a band, Princes to Kings (shameless promotion:  click here for their instagram,  website, facebook page,  and YouTube channel). During my sunday morning run round this beautiful city,  I was also scouting out locations for their latest video.  Yesterday I was updating Facebook with pictures of me and my son’s camping weekend.   We had a lovely break in Verona and were able to share some of the highlights of this special trip with our family and friends.  It was important for the boys to be able to share some bits and pieces with their followers as well, which added extra enjoyment to the weekend.  Zac and I loved our weekend away.  My posting pictures of what we were up to enabled me to reassure my wife that we safe, having a good time, and had survived our 70 kilometre bike ride to London and back.  I don’t feel that doing this detracted from either of our trips.  The internet and social media can enhance our lives and the lives of our friends and colleagues, and enable us to do and share things that were unimaginable even ten years ago.   It’s a tool.  It isn’t intrinsically good or bad, it depends how we use it.  Just like medicine, exercise and even water, it has a correct dose.  Too much is bad for you, physically and mentally.

This article published in WebMd points out one of the pitfalls of too much screen time, namely weight gain.  Teenagers who exceeded two hours of recreational screen time were twice as likely to be overweight or obese. This will not really come as a surprise to anyone reading this, as this risk is posed by any “activity” which is essentially sedentary.  The American Heart Association recommends limiting screen time to two hours a day.  If you are struggling to persuade your children of this, you could  consider encouraging them to play games which involve physical movement as most of the latest generation consoles from microsoft, playstation and nintendo all have hardware that enables these sort of games to be played.  When my kids were younger, we loved playing games with the xbox’s kinect.   I can still remember laughing so hard it reduced me to tears when my then seven year old beat a series of my adult friends senseless in a (virtual) boxing match in an online gaming session.   We would also do a deal with our kids, such as them agreeing that they could have some screen time after walking the dog or playing football outside.  There is of course always the option of the Off Switch.  If negotiations fail, I recommend throwing the kids out of the lounge or playroom, and just remember that when they say “I’m boooooooooorrrrrrred!” you can tell them that boredom is an important part of childhood and good for their developing brains and creativity!  Of course this doesn’t address the issue of mobile devices.  I will dedicate a future blog post to this as it’s a topic worth looking at in more detail.

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Staying with the social media theme, the term “snapchat dysmorphia” has been coined by plastic surgeons who are seeing increasing numbers of people come to them requesting surgical procedures to make them look more like their snapchat photos.   The issue is described in this report of an article in JAMA.  I personally have not yet had a patient come to see me to discuss this (and they certainly wouldn’t get past our clinical commissioning group’s low priority policy if they did!) but joking aside, the article makes the point that a facial feature such as a nose that looks good in a manipulated selfie taken from a phone held just a short distance away, would look very small and weird in real life …something we can reassure ourselves and each other about!

So what might the antidote be to some of these digitally induced woes and mental health problems?  You will win no prizes at all for guessing that it’s….

Physical Activity for improving mental health

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Physical activity is good for depression, according to this summary in theBMJ.  I think this is a very encouraging study.  There are a few key points worth noting:

Firstly this was an observational study (as opposed to say a a randomised control trial) of 1.2 million adults in the US. So we can say that people who are physically active have fewer days where there mental health is “not good” compared to those who are not active. There is a consistent association but we can’t confidently claim causation in this study.  However, other variables (known as confounding factors) were taken into account in assessing the likely effects of physical activities, which is important.

The effect was noticeably greater in those with a known history of depression.  So those most in need of this intervention are also the most likely to benefit from it, which is great.

In terms of dose, the greatest effects were seen in those who were physically active for roughly about the number of minutes per week that we recommend here in the UK, which is handy as we can just remember our current guidance which is 150 mins of heart raising exercise a week (e.g. 30 mins a day, 5 days a week).  However, more than 3 hours a day was associated with worse mental health.  I wonder whether this is due to risk of injuries and their consequences, or perhaps excessive exercise being a symptom of more serious underlying mental health issues?

All types of activity (including housework, gardening and running around after children) were beneficial to a degree.  Team sports, cycling, and aerobic and gym exercise were the most beneficial.

The benefits of physical activity with regard to mental health were greater than the effect of education level, financial security or  body mass index.

Weight loss and eating breakfast

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Speaking of body mass index, this study done by the University of Alabama showed that people who were overweight were no more likely to lose weight if they skipped breakfast.   I have often been struck by how many of my patients who are overweight (and not losing any weight despite their apparent efforts) tell me in either a proud or slightly mystified way that they don’t eat breakfast.   I believe that breakfast is an important meal as it gives you nutrients and energy for the day.  A high protein lower carb breakfast (such as eggs or porridge, for example) is much healthier than sugary cereal and toast and will keep you feeling full for longer.  Many people who skip breakfast end up snacking on less healthy food during the day due to feeling hungry.  It is well known that when we then try to recall what we have eaten during the day, we are prone to underestimating (or forgetting entirely) the snacks that we may have had in between meals.

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Passive smoking in teenagers

Finally, I found this article in Paediatrics,reported in Journal Watch, quite thought provoking.  Teenagers without asthma living with a smoker were more likely to report respiratory symptoms and, as a consequence, to miss school or attend the emergency department or seek urgent care.  The suggestion is made therefore that such settings are ideal for offering health promotion to the teenagers and their smoking family members.  When I do an out of hours shift and consult with a teenager with a flare of their asthma, I haven’t necessarily thought to ask about their family smoking history or talk to their parents about this at the time, having felt this is up to their usual GP in normal hours.  However, people are more likely to change their behaviour if an intervention is timely…and surely sitting in A&E with a breathless child is the perfect time to raise the subject?  I will try to do this more in future.

That’s it for the wellbeing round up this week.   See you next week and in the meantime, 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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