Wellbeing for Real Life

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 #22: What do we mean by Lifestyle Medicine?

At the end of last week’s wellbeing round-up I touched upon the growing interest in lifestyle medicine within my profession and the opportunities that exist to develop knowledge, experience and qualifications in this area. I described the impact it had upon my professional and personal life and promised to return to this topic in more detail. Since I am a man of my word, I thought I would devote this week’s post to it. This is driven partly out of my own passion for the subject, and partly because of some interesting debates on the subject via social media in the last week or so.

Is Lifestyle Medicine a thing…and if so, how should we be doing it?

Wikipedia defines lifestyle medicine as “a branch of medicine dealing with research, prevention and treatment of disorders caused by lifestyle factors such as nutrition, physical inactivity, and chronic stress”. It’s a reasonable enough definition. I would add that, if done properly, it is also an evidence based speciality. No one is disputing that prevention is better than cure and that reducing risk factors for wellbeing such as weight, blood pressure, smoking, excess alcohol, sleep deprivation, anxiety and social isolation will result in better wellbeing for individuals and the population as a whole. If the term “lifestyle medicine” can be used to cover interventions which address this, then clearly it is not just a thing but a really good thing. The question is more over what it means to practise it, particularly who should be doing it and how.

What is a Lifestyle Medicine specialist?

There has been much debate in the internet shouting factory of late (particularly the Twitter part of it) about whether there is or should be such a thing as a lifestyle medicine specialist. Doctors can do courses (such as the Prescribing Lifestyle Medicine offered by Lobe Medical ) and even obtain a diploma in it from the British Society of Lifestyle Medicine. It certainly seems to be gaining traction as an idea. General practice is the most obvious setting to practise it in, as we know our patients, have plenty of information about many different aspects of their lives and aspire to practise in a holistic way. It could be any member of the primary care team, most obviously a doctor or a nurse. GP’s often sub-specialise within practices (for example in dermatology, women’s health or cardiovascular medicine) – so why not in this area?

There are of course different views on this. The concerns I have heard raised can be philosophical (i.e. we should all be doing this all the time, let’s not call it a speciality), pragmatic (i.e. we don’t have doctor time to spare on this, you don’t need a medical qualification so let’s give it to someone else to do) or around the issues of equity (i.e. for all the patients who aren’t acutely unwell that you spend time with, others end up seeing people who are sicker and pose a greater clinical risk). The last one was summed up by my colleague who said over a pint in the pub the other day “No one’s going to sue you for telling them to lose weight and exercise more”.

My responses to these issues are as follows:

Yes, we should all be doing this but for whatever reason, we clearly aren’t. Not consistently. The fact that discussing lifestyle medicine seems to be a novel if not entirely alien concept to some clinicians shows how far we have to go.
The relationship between a patient and their doctor/nurse/pharmacist/physio etc can be very helpful and powerful in at least starting these conversations. Priests are not just allowed to talk about God at funerals but are actually expected to. If they don’t, they are doing those they have a duty of care towards a disservice. In primary and care we are perfectly placed to start these conversations with a patient who trusts us and needs help. The term “doctor as drug” is often used to describe the reason that patients keep attending their GP surgery even though we can actually do very little for them. Why wouldn’t we value this when we can actually help them to make a big difference to their lives?
I agree that appropriate use of resources, including doctor time, is key. Not all lifestyle medicine-based conversations need to take place with a doctor. The follow up conversations could be with a nurse, health care assistant, dietician or social prescriber. After all, we don’t want patients to become dependent on us for this too…it’s all about encouraging them to take ownership of this for themselves.
I believe that practices or practice networks will benefit from having clinical practitioners for whom this is a special interest. We cannot expect every doctor or nurse to have all the facts and expertise at their fingertips, or to be up to date with behavioural psychology and the latest research. Of course such specialists can cascade their expertise down to their colleagues, offering themselves as available for referral up occasionally if required. And before anyone gets too snooty about how important such a special interest is and whether those who are doing it are pulling their weight or have a diploma in it, we could consider the fact that sub-specialisation has been going on ever since the inception of general practice and particularly over the last 20 years or so. GP’s are used to referring to each other internally if required. This need be no exception. With regard to workload and equity, GP’s also vary widely in how closely they follow up patients in terms of how often they are seen and for how long. There is generally an environment of high trust and a degree of individual autonomy and freedom within GP partnerships, as long as it isn’t being taken to extremes.

Does Lifestyle Medicine mean “victim” blaming?

This is one of the weirder arguments that seem to have arisen out of the subject, certainly on social media. Some people seem to have it in their heads that by raising the issues of lifestyle medicine and personal responsibility, as opposed to patting patients on the head with a prescription for statins, an antihypertensive, an oral hypoglycaemic and a referral for bariatric surgery, we are victim-blaming. I’m genuinely puzzled by this view. I have two issues with accusations of victim-blaming, namely the use of each of those words. It is right that we acknowledge that life is not a level playing field and that some people will face many challenges, and perhaps not have as many opportunities, purely because of where they are born and in what environment they are raised. However, to label a large proportion of the population as “victims” is depressing, patronising and nihilistic. People born into similar environments can make different decisions about their lifestyle and experience different outcomes as results. To label them as victims suggests they are powerless, can’t be helped and face inevitable poor health and wellbeing. With regard to the second word, there is no reason at all that having a careful and sensitive discussion with a person about the positive ways in which they can take control of their lives and transform their future need be viewed as blaming them. It’s about moving people on from where they are at present. I’m not as bothered about producing lycra-clad, fitbit-wearing, dairy-free, goji berry-gobbling triathletes as I am about people getting off the couch, eating a few more vegetables and being able to walk to the end of the street without going a dusky blue colour.

Individual Versus Population lifestyle medicine.

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I read a thought-provoking post from Greg Fell, Director of Public Health for Sheffield, this week. It’s about the challenge of obesity and whether interventions should take place on an individual or population scale. You can read it here. It makes a number of important points including how much money has to be spent on weight management services to help a small part of the population lose weight and keep it off, and that the current obesity epidemic is not driven by greed or laziness but other socio-economic and environmental factors. I agree with Greg about the importance of the bigger picture stuff. We need to think much more carefully about public policy, how we design our cities and housing developments, good transport links, making cities safer for cycling, education in schools, legislating on what food labelling and on the presence of fast food outlets on our high streets and near our schools.

However, taking off my hat that I wear when considering issues of public health and commissioning, and putting back on my hat as a GP who has one to one interactions with patients every day, I do just need to point out a couple of things:

Firstly, all the admirable big picture stuff is just that…admirable. When the government comes up with the money and the local authority budget is no longer being slashed but actually increased, all will, eventually, be well. I’m sure there are examples of these helpful positive changes already existing and producing tangible results, just not anywhere near me.

Secondly, the view from parliament or county hall is somewhat different from the view on the ground from general practice. If I have a patient in front of me who needs to be supported in making some significant lifestyle changes, one of which includes referral to weight management, I would prefer to be able to do this rather only being able to put my arm around them, advise them simply to eat fewer pies and reassuring them that the picture will probably be a bit rosier for their kids. Ok, maybe their grandkids. Definitely their great, great grandkids.

My Lifestyle Medicine utopia

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Allow me if you will to summarise by describing my vision of the sunlit uplands of wellbeing and of practising lifestyle medicine.

To start with, we will all be living in a society that is much more equal in terms of life chances, as politicians of whatever political hue have finally got the importance of the determinants of wellbeing and invested heavily in this. Infrastructure in our society will have been developed to make it easier for people to live connected, meaningful, active lives. Education in schools will have resulted in parents and children alike making as healthy a choice as they can within their means. Wellbeing Centres will be competing on the high street with fast food outlets, demonstrating that understanding and practising lifestyle medicine is not just confined to medical professionals or a privileged few. In primary care, GP’s will be providing a properly funded service as part of their core general medical services contract which identifies people at higher risk of wellbeing issues and gives them the appropriate support and education, signposting them on to lifestyle services to help them make the changes that they need to for themselves. Just as people have asthma plans or birthing plans, it will be considered routine for them to have a wellbeing plan, which a lifestyle medicine practitioner (of whatever variety) has helped them put together. Those same practitioners will be available to support their colleagues to give extra advice and input when required but this won’t needed all that often because the importance of lifestyle medicine has been understood and embraced and become an integral part of the core of primary care. All of this will be properly paid for by the government who have put their money where their mouth is as they too recognise that lifestyle medicine is indeed a thing.

I hope that you have enjoyed this week’s post. Both your feedback and sharing this with others would be much appreciated. The weekly wellbeing round-up will be back next week. Until then, take care of yourselves!

Dr Richard Pile

The Weekly Wellbeing Round-Up #21

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

Food

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Omega 3 and Oily Fish

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

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

Organic Food and Cancer

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

Food supplements

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

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

Wellbeing for Doctors

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

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

Lifestyle Medicine: it’s a thing.

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

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

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

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

Podcast recommendations

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

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

TED Radio Hour: The meaning of work.

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

Dr Richard Pile

The Weekly Wellbeing Round-Up #20: a miracle cure!

Good morning and welcome to another edition of the Weekly Wellbeing Round-Up. This week I thought I would get your monday morning off to a great start by offering you…a miracle cure. The ultimate tonic with guaranteed improvement to your health and wellbeing. It has been shown to improve physical and mental health and cognition as well as reducing the risk of cancer, heart disease, diabetes and other long-term conditions. It works as well as if not better than many drugs and unlike drugs there are no side effects as long as it is taken in the appropriate dose. Best of all, it’s free and available to every person on the planet. You don’t need a prescription from a doctor, and you don’t need any special training or expensive kit. You can start treating yourself with this wonder drug whenever and wherever you like. I am, of course, referring to the medicine of movement: physical activity. People are, I hope, used to health professionals banging on endlessly about this. I thought it was worth reminding ourselves why this is such an important issue, before we explore the benefits of it and then take a pragmatic approach to moving more.

The bad news about physical activity

Let’s start with looking at the scale of the challenge that we face in terms of physical activity being a part of our daily lives. Once upon a time, it was. We were hunter-gatherers, often chasing our prey over long distances. If we sat still, we perished. Nowadays, our day-to-day existence is much more sedentary. We have enjoyed the benefits of tremendous technological advances and the associated convenience, but there are also tremendous downsides that are gradually becoming more and more apparent. The nearest we get to hunting our food may be tapping our password into our device when doing our online food shop from the couch. Being inactive has roughly the same health risks as smoking 15 cigarettes a day and the overall risk of mortality due to inactivity may be double that of obesity. . This is worth thinking about for a minute: most people would clearly not choose to take up smoking, but by default we risk choosing inactivity. The irony of all of this is that by sitting still we still perish (sooner) but for now for entirely different reasons.

I used to think, a long time ago, that by default we were probably active enough and that to stay healthy all people needed to do was to avoid eating too much unhealthy food. I have come to the realisation that this is nowhere near enough. The default, the baseline that we operate from in today’s world, is not just inadequate but actually toxic. In 1949, 34% of all journeys travelled by a mechanical mode were by bicycle. Nowadays it’s less than 2%. The design of our homes and our cities, our patterns of working, our use of technology and all the associated infrastructure have all contributed unwittingly to the making us less physically active. The consequence of all of this is that almost half of adults over 65 years of age are inactive, and most working adults spend at least 5 hours of their day entirely sedentary. To overcome this requires thought, planning and effort.

The good news about physical activity

Before you sink into despondency, there is good news. These problems did not appear overnight with a bang. A lot of it has been incremental. The good news is therefore that we can take the same approach to addressing the balance. Let’s leave aside the need to lobby government about how we build communities and transport links in future, how we make cities safe for cycling and encourage working lives that are more physically active. These things are important but you and I can’t do anything about them right now, whereas there are other changes that you can start with today to help you and, if you are a medical professional, your patients.

My top tips for physical activity

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Make the first few steps. The really good news about becoming more physically active is that the greatest reduction in risk of cardiovascular disease (heart attacks, stroke and diabetes) occurs in those who go from being completely inactive to mildly active. If you break into a sweat at the thought of breaking into a sweat and are put off by images in your head of lycra-clad latte-sipping gym bunnies in a spinning class or ex-military personnel with personality disorders barking instructions to groups of miserable looking people dragging mud-covered tractor tires across the park in the rain – never fear. The journey of a thousand miles literally begins with a single step. If you don’t do anything that gets your heart rate up at present, try starting with just 5 minutes a day of brisk walking round your garden or down the street and back. All you need are shoes on your feet. Public Health England have a nice app which you can download onto your smartphone called Active 10. You can get it for iOS devices from the app store, or for android devices from Google Play.
Make it rational, routine and relevant. For us to face the challenges of inactivity individually and collectively, it’s only going to work if physical activity becomes a simple, meaningful and sustainable part of our lives. If a gym subscription works for you because you will feel motivated by parting with your hard-earned cash, you like the idea of being able to work out in all weathers and at any time of day, or you just like sitting in the cafe and chatting afterwards, then great. If you have a dog, make the walks a bit longer and for part of each walk push yourself a bit harder to get your heart rate up. If you don’t have a dog, think about getting one. They provide people with company, keep their owners fitter than non-dog walkers, and encourage socialisation. I love chatting with other dog walkers when I’m out and about. If your job involves walking, whether it be commuting or delivering the post, use the opportunity to do likewise. Try getting off the bus, tube or train a stop or two earlier. Use the stairs at work rather than the lift. Consider getting a standing desk. You could suggest standing or walking meetings when appropriate – just think how much quicker they would go without people distracted by their laptops and phones!
Make a plan. I posted about this a few weeks ago. Whatever you do, plan how it’s going to happen. In my personal experience, if I don’t make a plan then nothing changes. Once you have a regular slot and you’ve done it often enough then it becomes a habit and so more likely to stick.
Make it social. Behaviour change is more likely to occur if it is socialised. Taking part in physical activity with others is beneficial for a number of reasons. Firstly most of us are social animals to one degree or another, so it’s a good way of connecting for our mental wellbeing. Secondly, we are in effect making ourselves accountable to others or even allowing them to be our “referee”. Your friend/spouse/cycling club/fellow dog walkers will encourage and check up on you. If you aren’t sure what you would like to do, check out what information is available from your local council, community centre, library or GP surgery. 5. Make it pleasurable. Pick something that you enjoy. Don’t think of it as “exercise”, which sounds like something you have been told to do and probably won’t enjoy. Instead think of it as something that gives you pleasure, makes you feel good and helps you connect with others. Just getting out of the house and enjoying some fresh air and daylight is good for your wellbeing. Two of my most favourite things are going for a bike ride on a sunday morning with my friend Al and taking my dog Prince for walk in the afternoon.The fact that the my sunday morning bike ride includes breakfast and a cuppa and that my afternoon walk involves a pint in my local is not a coincidence and a great example of “temptation bundling” – having a reward which is associated with a specific activity.

Real life examples of the benefits of physical activity

I thought I would finish with two stories from this week. The first was from a patient that I reviewed as part of teaching our medical students about mental health. They had seen one of my colleagues previously with a longstanding history of depression. They were physically inactive and presenting with a lot of physical symptoms which were really manifestations of how they felt in themselves. They had been consulting about these physical symptoms frequently and eventually were persuaded by my colleague that the root cause of their symptoms was their depression. They were encouraged to start being more physically active. When I reviewed them with our medical students, they were transformed. I asked them what they felt the reason was for the improvement and they told me that they had started to walk every day for half an hour, either in the park or up and down in their garden. Their mood was better. They had more energy, were sleeping better and were much less bothered by the occasional aches and pains that previously had preoccupied them. They also had a much better understanding of how their mood might influence physical symptoms as a result.

The other story I really enjoyed listening to this week was that of Vassos Alexander, sports presenter, formerly of Radio 5 Live and now Virgin radio. He was interviewed by Dr Rangan Chatterjee in Episode 31 of the Feel Better Live More podcast. He described himself as being overweight, unfit and a smoker in his early 30’s. He decided he wanted to make some changes. He decided to go for a run. His first run lasted just a few minutes. He describes being out of breath and having to pretend to some of his neighbours that he had just finished a run, to avoid embarrassment. Vassos didn’t give up, however. To cut a long story short, in 2017 he completed the Spartathlon, an endurance event run over 153 miles. His enthusiasm for running, it’s benefits and his encouraging other people just to get out there and do something is infectious. Well worth a listen.

We’re almost done. I wanted to finish off with something to challenge and encourage you, your family, friends or patients. There is a great video available on YouTube called “Twenty three and a half hours“. It’s got a fantastic punch line at the end and is well worth 5 minutes of your time.

That’s it for this week. I hope that you have found this week’s wellbeing round-up helpful. As ever, I would appreciate your feedback and you sharing it with others if you have enjoyed it. You can subscribe to the blog to automatically receive email updates in future. Until next week, take care of yourselves!

Dr Richard Pile.

The Weekly Wellbeing Round-Up #19: mental wellbeing.

The more observant of you may have noticed that this week (October 10th) it was World Mental Health day. In recognition of this, the round-up this week has a mental health focus. I will be highlighting how this affects people of all ages, the issues raised for the NHS including the mental health of those that work within it, and how we can take simple steps to help ourselves and others.

Global Mental Health Summit. This was attended by 50 countries on World Mental Health day this week. The Prime minister announced the appointment of a minister for Suicide Prevention and pledged extra investment in this area including additional funding for the Samaritans. More details on this in a report from the BBC here. The article highlighted some contact details for mental health charities which I have listed below:

The Samaritans are open 24 hours a day. Call 116 123 or email jo@samaritans.org
The Campaign Against Living Miserably (CALM) offers support to men. Call 0800 58 58 58 between 17:00 and 00:00 everyday or visit their web chat page here
Papyrus helps people under 35. Call 0800 068 41 41 – Monday to Friday 10am to 10pm, weekends 2pm to 10pm, bank holidays 2pm to 5pm – or text 07786 209697
Childline is available for children and young people under 19. Call 0800 1111 – the number will not show up on your bill
The Silver Line helps older people. Call 0800 4 70 80 90

Young people’s mental health

Loneliness

When talking about suicide, this is inevitably and appropriately an area of concern for us. Social isolation and loneliness shorten our lives, being equated to smoking 10-15 cigarettes a day in terms of the impact on our health. When we think of the lonely groups in society, we often think of the elderly. However, children and young people are the group who report being the most affected by loneliness. Such people might appear to have a wide circle of friends and to be connected by social media but it just demonstrates the truth that you can still feel lonely even if you are not considered alone.

Tracy Crouch is the first minister for loneliness, and gave this interview to the BBC about the need to address this issue. It’s clearly not an easy one. The government may not be able to make friends for us, but we do need action at every level ranging from decisions about how we plan and develop our society and infrastructure, right down to individual day-to-day interactions. When I consult with anyone who is anxious or low in mood, I will always ask about what their connections are with other people and encourage them to seek them out or develop them further. We are ultimately social animals. People do better with real life, face to face interactions when they are struggling.

Cannabis use

woman smoking cigarette — Photo by Marlene Leppu00e4nen on Pexels.com

Living in an affluent commuter town, you might be forgiven for thinking that there’s no big deal when it comes to casual drug use, particularly amongst the middle classes. It tends to get lost in the general debate about legalisation but the reality is that there are serious consequences for mental health, particularly that of young people. This article in the American Journal of Psychiatry highlights the dangers of cannabis use and its impact upon cognitive skills, memory and behaviour. The effects were greater than those of alcohol, and appeared to be longer term. Take home message for me? That we need to be very careful as adults, particularly if we are parents, as to the messages that young people get from us. Adult brains may not in the same vulnerable state as theirs are.

Child and Adolescent Mental Health Services (CAMHS)

As a GP I know many colleagues who work to provide CAMHS in their localities, and do their best in very difficult circumstances with limited budgets and increasing demands. This article reports a 26% rise in referrals into such services nationally. When faced with inadequate resources, services inevitably look at their referral thresholds and it is reported that a similar percentage of referrals are rejected, saying they do not meet the criteria. This could be because of genuinely increasing rates of mental health problems and also a result of increasing awareness of the signs of potential mental health problems due to health campaigns in this area. I don’t have an easy solution for this, but one of the things I recommend is that as parents and professionals we have some knowledge of the options available to us as well as the traditional CAMHS route, which not every young person will need. These might be third sector or voluntary organisations. In my locality we recommend Kooth, which offers many different ways for young people to access support. Suicide awareness and mental health first aid training for young people and adults alike is very important. In St Albans we have the OLLIE foundation which is a charity doing excellent work in this area.

Ask Twice

One of the messages on World Mental Health day was “ask twice”. People often say that they are fine when asked the first time. We’ve all done it over our first cup of tea of the day at work. Sometimes it feels as if you are obliged to say that you’re fine, as it might throw a spanner in the works and feel a bit awkward if you tell people how you are really feeling! However, my view on this is that anyone who asks “how are you?” should both expect and be prepared to respond to whatever comes back. If you sense that your friend, family member or colleague may not be feeling fine, ask them again. The point is well made by this short video.

Mental health support for NHS workers

Staying with work, NHS chief Simon Stevens announced recently that there would be an expansion in the mental health service for doctors. It already exists for GP’s and extra funding will be put into making it more widely available. Clearly this is welcome and has been beneficial for the doctors that have used it so far. However, if we are to practice preventative medicine when it comes to NHS workers’ health in the same way that we would like to with our patients, we must consider the underlying reasons why there is an increasing mental health burden. I hope that the secretary of state for health and his colleagues will be considering underlying issues like workforce capacity and conditions as well as proper funding for services. If not, it will simply be a sticking plaster that will fall off sooner or later.

Mediterranean diet…helpful for reducing depression?

It was recently reported that there may be an association between the Mediterranean diet and reduced odds of depression. Now we all know that association is not the same as causation, but I think this is encouraging enough both to look into more deeply in terms of research, and to try for ourselves in the meantime. After all, it isn’t complicated or necessarily expensive to do and has none of the risks associated with taking antidepressants. Here is a simple diagram to remind us of the key components of a mediterranean diet:

That’s it from me this week. The weekly well being round-up will return. Probably next week! Until then, take care of yourself.

Dr Richard Pile

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