The Weekly Wellbeing Round-Up #8: my week of sleep for wellbeing

I have previously confessed on the pages of this blog that of the four pillars of health and wellbeing, sleep is the one that I need to work on the most.   I have suffered from Sleep-Is-For-Wimps machismo and been convinced that I could get much more done in life and generally enjoy myself more if I can just sleep less.  I have always proudly considered myself an owl rather than a lark, or even both an owl and a lark at times.  I have (sort of) gotten away with it because I probably do need a little less sleep than the average person and so have pushed it and given myself even less.  I often get sleepy during day, particularly in CCG board meetings and church sermons!

As I have developed my knowledge and understanding of wellbeing, however, I have really felt challenged in this area.  Reading the excellent Four Pillar Plan, the fascinating Why We Sleep and listening to podcasts on the topic has made me realise I needed to address this area for personal and professional reasons.   What put the tin lid on it, however, was the results of analysing my personal health data and looking at the effects of sleep (or lack thereof) on my recovery.  My friend and colleague Simon Shepard is the chief executive of a company called Optima-Life.  He offered to fit me with a device that measures something called R-R interval variation.  I won’t go into all the science for the purpose of this blog post today but essentially wearing this device for three days resulted in a lot of data being generated which could then be meaningfully interpreted to look at the implications for my health and performance, and where the areas for improvement are.  I decided to use myself as a guinea pig for the three days and nights I wore it.   For the first night I did not drink alcohol and went to bed at a sensible time.  For the next night, I had some alcohol, went to bed later and spent some time on my phone before going to sleep.  For the final night, I was away on a weekend with friends and stayed up late and drank more alcohol (all in the interests of science, you understand!)…followed the next day by reasonably intense physical activity which included mountain biking and a water park.  After the data had been analysed, we sat down together and Simon went through it with me very carefully (and non-judgementally!) explaining the results, which were really eye opening.  My body’s “recovery” over the first night was good with excellent quality sleep. Without boring you with the details, it all went downhill from there.  Nice big green bars of sleep and recovery became little angry red ones and frankly I’m amazed I made it back home from the weekend alive!  It left me asking some big questions about what I wanted for myself from both a personal and professional perspective.

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Why should we be bothered about sleep?

Sleep is freely available to all of us regardless of our means and circumstances.  It may turn out to be the bedrock of our health.  There is increasingly compelling evidence both of the benefits of good sleep, and the links between sleep deprivation and health conditions including heart disease, cancer and dementia.   There must be a pretty good evolutionary reason that we spend about a third of our lives in an apparently comatose, vulnerable state.  The evidence is not clear why the amounts and type of sleep varies between organisms but there is speculation that neurological complexity could be part of the picture, along with many other factors that we are only just beginning to learn about. Going to work sleep-deprived has similar effects cognitively and physically to being hung over or even drunk.  The general medical council would clearly have something to say about my doing the latter…so why shouldn’t I take sleep as seriously?  If you really want to learn more, I recommend reading Why We Sleep by Professor Matthew Walker.

So, feeling inspired by all this evidence based medicine, I thought I would apply these principles to myself and report back with my personal, anecdote based medicine outcomes.

The practical steps that I took to improve my sleep 

  1. Setting a bed time.  By intentionally choosing a specific time that I wanted to be in bed, lights off, head on the pillow, I was setting a goal for myself which others also knew about and so could hold me accountable for.   This was a different approach to my traditional open ended “I’ll go to sleep whenever I feel like it” approach, often extended even further by phone checking etc.  I decided I wanted to be going to sleep around midnight.   For me, this means going up to bed around 1000-1030 to allow for getting ready for bed and winding down.   I didn’t achieve this every day,  but even achieving it most days was a big improvement.
  2. Not using a mobile device (phone, laptop, kindle, iPad etc) for the last hour before bed.  Whilst I feel that I have always got to sleep quickly once my head hits the pillow, I now know from my optima-life data that using a screen before bed reduces the quality if not the quantity of my sleep.   This was one of my biggest struggles as I had a habit of doing it.  So I asked myself what it was that I was using the phone for (checking social media, reading the BBC football pages for Manchester United transfer gossip etc) and whether it really needed doing just before I was going to go to sleep or whether it could wait until tomorrow.   Of course it didn’t need doing.  I was not going to wake up the next day less well informed or happy as a result.  Some people strongly advocate not having phones in the bedroom if it is too big a temptation.  You can always buy yourself a good old fashioned alarm clock.
  3. Reducing blue light.  As the sun sets and it gets darker, our bodies naturally produce melatonin which is the starting point for a good night’s sleep.  The levels continue to rise into the early hours of the morning and then decrease as dawn approaches and it gets lighter.  Exposing ourselves to light, particularly blue light from screens, sends a conflicting message to our brains and interferes with melatonin production. I turned on the nightlight settings on iPhone and MacBook screens, from 9pm to 7am.  I don’t know whether it’s partly psychological, but looking at a screen that is dimmer with a warmer tint and the blue light reduced feels very different to me.   You can download filters for phones from the usual app stores, or even physically apply a screen filter your phone that does the same thing.
  4. Making the bedroom a room for sleeping.  One of the problems with our modern life is that people’s bedrooms can easily also become dining rooms, living rooms and offices.   Disciplining yourself and making your bedroom a place reserved for rest and relaxation sends a message to your brain when you go there that now is the time for sleep.   I try not to use the bedroom during the day if I can avoid it, particularly not for work.  The laptop tray that I bought a while ago so that I could sit up late at night typing away now lies (mostly) unused by the side of the bed.
  5. Reading before bed.  This helps me relax.  I now do it instead of staring at a screen.  As well as sleeping better, it means I am enjoying reading the books I have been meaning to for ages.  Although I have noticed that I can usually manage about five pages or less before my eyes start to nod…a signal that I now listen to instead of trying to ignore!
  6. Using ambient or white noise.  Dropping off to sleep is not a problem for me, generally speaking.  However, I have both friends and patients for whom this is an issue.  One thing that can help is the generation of quiet background noise.  The easiest way to do this is using a phone app.  Whether you like the sounds of the rainforest, falling rain or breaking waves, there is something for everyone out there.   I personally use the Reflection app designed by Brian Eno.   It’s an ambient music generator which means that you never listen to the same soundtrack twice.  Very cool.  Of course, if you have banned phones from the bedroom you can always use a bluetooth or airplay speaker so that your phone doesn’t have to be in the same room.
  7. Avoiding exercise in the evening.  It’s already well established that this is likely to interfere with sleep.   If I’m going to be exercising, I will get it done during the day.
  8. Reducing use of alcohol.  I had already read about the effects of alcohol and listened to parts one and two of the Feel Better Live More podcast conversation between Dr Rangan Chatterjee and Professor Matt Walker but if I needed any convincing then Simon’s visual demonstration of the effects alcohol consumption had on my recovery during sleep (and the next day) did it nicely.  I know that for many of us, enjoying a glass of wine or beer in the evening is part of winding down.  I’m not going to be pious and preach about bad habits or the alcohol consumption of the middle classes.  I just take this into account when planning my evening and socialising.   I might have a drink earlier rather than later, or not at all.  I might have one rather than two.  If I’m planning a night out with friends and enjoying a few beers, I won’t let that stop me.  I just need to acknowledge what the likely effect is to be the next day, and ideally not to combine it with the perfect storm of alcohol consumption and a very late night, or at least bear in mind that if I do, sympathy from my family and colleagues will be in short supply!

Benefits

So what did I achieve as a result of this new approach to my sleep?  Below is a screenshot from my fitbit, which has a sleep monitoring function.   The figures are crude, but it gives you the overall idea.

Fitbit sleep summary

As you can see, my weekly average sleep was consistently poor beforehand, with figures from February closely tallying with figures from the last week before I made the changes.  Last week’s figures are significantly different, with my weekly average going up by almost an hour and a half a night, from 5 hrs 24 mins to 6 hours 47 minutes.

Now I know what you’re thinking  – numbers are all well and good, but what did this mean? What was the end result for my wellbeing?  Well, since you asked…

  1. I now wake up before my alarm most mornings.
  2. I now wake up feeling more refreshed and ready to go.
  3. I have created more time in my day to be genuinely productive e.g. getting admin completed before work (rather than falling asleep over it in front of my laptop the night before, having read the same paragraph at least five times), being able to start the day with a short walk or some brief meditation, or just feeling less hurried as I start the day with time to spare.
  4. Less day time sleepiness.  Whilst it is natural for most of us to go through a bit of a dip in the early to mid afternoon,  I struggled with this particularly if I was sitting in a meeting or doing some work in front of the computer.  I have noticed a definite improvement in this area. I would of course like to issue a disclaimer that I still reserve the right to rest my eyelids temporarily if in a particularly dull meeting.
  5. I feel I’m practising what I preach.  This is important to me.  As a doctor I need to be credible.  Discussing lifestyle medicine with a patient when I can barely keep my eyes open is not really any different from sitting there with an enormous beer belly whilst smoking a fag and opening a can of super strength lager…not internally, anyway.

In the interests of full warts-and-all disclosure, I have noticed a downside to getting more sleep.  Now that I am waking up and getting up earlier, if I crash around too much I wake up my wife.  I’m not sure what you call someone who is neither an owl nor a lark and would like 8 hours or more a night.  Grumpy, possibly.

That’s it for this week.  I hope that this has been helpful for you, whether you want to sleep better yourself or want to be able to help others. The weekly wellbeing round up will be back next week.  In the meantime, take care of yourself.

Dr Richard Pile

 

 

 

 

 

The Weekly Wellbeing Round-Up # 7

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

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The Health Supplements Don’t Work

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

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

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

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

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

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Social Prescribing

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

 

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Public Health and Prevention

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

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

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

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

Dr Richard Pile

 

 

 

 

The Weekly Wellbeing Round-Up #6

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

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Cardiovascular disease 

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

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

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

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Hypertension

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

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Food 

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

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

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

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

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Sleep

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

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

Dr Richard Pile

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The Weekly Wellbeing Round-Up #5: My real life wellbeing week

As someone who spends a lot of time talking to people about their own wellbeing, and summarising wellbeing related news for this blog, I thought that this week I would share with you what my week has been like, and how well I’ve been doing when it comes to my own wellbeing.  After all, if I don’t practice what I preach, why on earth would you be interested in anything I have to say?  I have recently finished reading the Four Pillar Plan by Dr Rangan Chatterjee.  It is the best book I have read for some time.  Inspiring, insightful and honest, it has been a pleasure to read and genuinely life changing for me.  One of the many things that I love about it is the honesty with which Rangan approaches this topic, acknowledging life’s (and his own) imperfections and being pragmatic and gently encouraging.  So for my wellbeing confessional, I will break it down into the four pillars:  Eat, Move, Sleep and Relax.  Here goes…

EAT

Breakfast

I try to eat a low carb, high protein breakfast.   I have stopped eating cereal (or “breakfast candy” as Dr Mark Hyman refers to it in his book “Food, WTF Should I eat?“.  This week I have been practicing my poached egg technique.  The best tip I have read for this is to use white wine vinegar in the water, which keeps the egg white together rather than it spreading all over the bottom of the saucepan.  With whatever kind of eggs I eat, I tend to also have mushrooms and/or avacado and sometimes bacon.   You can do both the mushrooms and the bacon in the microwave.  If I want to fry the bacon (because, let’s face it, it’s delicious), then I do it in ghee or coconut oil, which is less likely to burn then vegetable oils.  If I’m not in the mood for eggs (which you can eat every day, btw…the old idea that they are bad for you because they make your cholesterol go up has been thoroughly debunked), then I will have some porridge oats, perhaps with some berries in them to sweeten them.  I know there are people out there who soak the oats overnight.  It sounds very worthy, but I just can’t be bothered.    I have managed this breakfast 5 days out of 7 this week.   This morning I had a bacon egg and sausage bap in a coffee shop with my best friend after we’d been for a bike ride.  Yes, I ate the bap.  Yes, I added some ketchup.  No, I seriously doubt the sausage came from happy free range pigs.  Yes, it tasted pretty damn good and I’m fairly sure I will be able to live with myself and sleep soundly in my bed tonight.

Lunch

I work at my surgery three days a week.  Lunch at the surgery is usually bread, rolls, crackers, crisps, various spreads and some veg.  Not great if you are trying to eat fewer carbs.  So I try to make my own salad for lunch three times a week.  This week I have managed it twice.   It is usually chicken with lettuce, peppers, tomatoes and a handful of nuts (which have healthful fats in them.  This week I had remembered to make my own salad dressing (balsamic vinegar, extra virgin olive oil, tahini and whole grain mustard with a little honey) but if I don’t have any of that, I’ll just use a shop-bought salad dressing or mayo.  Yes, they have sugar and artificial chemicals in them but it is still a salad full of protein and colourful veg, better than half a french stick with some paté (although on some days, I do just want the latter!).

Dinner

I get in from work fairly late on surgery days.  Thankfully my wife is also embracing the lower carb diet (quite a lot more strictly than me, in fact!) and this week our evening meals have included steak or burgers with salad,  and fish with roasted vegetables.  I had a boys night in with two of my kids towards the end of the week and we got a chinese takeaway.  I didn’t have any of the rice.   I am grateful to my children for being discreet enough not to mention my eating the prawn crackers and enjoying some pancake rolls with the crispy duck.

A little disclaimer about alcohol

I know, I know….. alcohol should be taken in moderation.  There is ongoing debate about whether a little alcohol is good for us, or whether we would be better off without any of it.  I won’t get into that in detail today.  The perfect storm of both unexpectedly good weather, an even more unexpectedly good world cup performance from the Three Lions and our practice summer party last night means that this week has not been entirely typical, for which my liver is truly grateful.  I do normally try to drink moderately and to have two alcohol free days per week.  If you are going for the low carb approach, it’s probably better to drink wine than beer.  At least my drinking rosé at the practice party was therefore evidence based.  Sort of.

MOVE

I get up 15 to 20 mins earlier than I used to so that I can either ride to work on my bike (if the weather is good) or drive to work but then walk for 20 mins into town and back before starting surgery.  Getting out in the fresh air gets the day off to a good start.  There is evidence that suggests that outdoor exercise is more beneficial than indoor, gym based exercise (for example, one study showed higher levels of serotonin in the outdoor exercisers). I usually walk rapidly to the town centre to get my heart rate up, and then slow down on the way back , practicing walking mindfully (meditation on the go, basically).    I will usually try to get out at 20 mins for a walk at lunchtime too, workload permitting.  I tell my reception staff where I am going so they can contact me if needed.  I figure that if I’m working an 11-12 hour day, 20 mins break in the middle of it isn’t entirely unreasonable!  This week I have managed to do this every day I have been at the surgery.  One of the other key things that I have been focussing on whilst in the building is keeping moving.  It’s often said nowadays that sitting is the new smoking.  Research has been published showing that people working in a sedentary job felt better as a result of just keeping moving in the day, getting up and walking around at regular intervals, rather than being sedentary all day and then doing a higher intensity workout at the end of the day….good news for all of us, particularly those that either hate the very idea of the gym or just can’t face it at the end of the day.   On the days I was not in the surgery this week, I either rode to meetings at the clinical commissioning group or got in shorter bursts of exercise e.g. going for a run.   One of the things I have not been so good at this week is muscle strengthening exercises (which we should ideally do at least a couple of times a week).  Check out Rangan Chatterjee’s Five Minute Kitchen workout , if you think you really don’t have time to be physically active.

RELAX

It can be difficult to relax in this day and age.  Your working day may  long and intense.  Your mobile device will very likely spend the whole day keeping you on your toes with notifications going left right and centre.  When we get home at the end of the day, we still have responsibilities and tasks.  Even when these are over with, we often have trouble switching off and calming down.  We spend most of our days with our sympathetic nervous system in full flight or fight mood.  This can be helpful and appropriate  for short periods of time, but the changes to our lives in terms of workplace and culture means that we risk being permanently in this mode, with all the associated health consequences of this.  Chronic inflammatory responses raise the risk of all kinds of disease including heart disease, autoimmune disease and cancer.

So what have I done to relax this week?  Firsty, I have turned notifications off on my phone.  I briefly suffered from FOMO (fear of missing out), before transitioning through to blessed relief.  It’s fascinating what a little tweak like this can do for you.   Secondly, I use music as self medication every day.  This is helpful for so many people.  Personally I prefer listening to ambient, electronic music and jazz to chill out.   I have lots of playlists I have created on Apple Music, and listen to the radio stations that you can set up based on your favourite music.   Frank Lippman recommends Bob Marley in this podcast on How To Be Well with Rangan Chatterjee.  This weekend my entire family have been away and whilst I have missed them all, I have taken the opportunity to be selfish and enjoy a lot of me-time.  I have spent this afternoon sitting in the garden listening to a Jose Gonzalez album (link here for those of you that have apple music) whilst writing this blog, which I find relaxing , believe it or not!  Finally, I need to mention the football.  I have traditionally found following England in any international tournament for the last twenty years or more a frustrating, anxiety inducing and thoroughly miserable experience.  I have been blown away by the team’s performance this world cup and find myself actually enjoying watching them play.  Apparently football may actually be good for dementia and mental health, according to this article in the Independent recently.

white bed linen
Photo by Kristin Vogt on Pexels.com

SLEEP

I’d like to think I’m not bad at 3 of the 4 Pillars, generally speaking.  Sometimes better than others, but better overall than I used to be (and half a stone lighter as a result).  However, just as Rangan Chatterjee is honest about his hardest pillar being Relax, mine is Sleep.  I think this is because I go to sleep within a minute of two of my head hitting the pillow and sleep solidly through the night.  I can also get back to sleep quickly after being woken.  This was vital in the years that we had our oldest son Luke living at home with us.  He has severe complex epilepsy and I was on call for night time seizures from the age of six through to eighteen, until he left home.  His worst ever night was fourteen seizures and the next day spent in resus in A&E.  I also had to coped with being a junior doctor, being on call for the practice and doing night shifts for the out of hours GP service.   We are all different and I probably don’t need as much sleep as some other people…however,  I think this has encouraged an arrogance in me when it comes to sleep, combined with the “sleep is for wimps” culture that many of us find ourselves living in.   Also because I get in later than most people from work, I feel that I deserve to have time to relax and unwind.  Some days this includes enjoying some online gaming with my xbox live buddies when my family have gone to sleep.   Before I know it, it can be the early hours of the morning, with work the next day.   There is strong evidence to suggest that people going to work tired are cognitively impaired in the same way as those who are drunk or hungover.   So sleep is my biggest challenge because I feel that I can function on what I get, but if I’m honest I know I would probably do better if I had a bit more. I’ve had some really good nights this week, and a couple of less good ones.

For those of you that have a sensible bed time but struggle with your sleep quality, there are lots of things you can do to enjoy good quality sleep including turning off screens for 1-2 hours before bedtime (particularly mobile phones),  no caffeine after midday, no exercise within six hours before bed time (but trying to be physically active and getting outside during the day).   For me, it’s more a question of behaviour change.  This includes telling people that I am going to do it (hence this blog post!) , and having a referee to hold me accountable (my wife may well volunteer for this job) and setting alarms to remind me to go to bed.  You can even use an app like IFTT (If This Then That) which will link to a device like a fitbit and give you feedback on how well you slept by messaging or notifications the next day.   Or I could just go to bed on time………

So there you have it… my wellbeing week.  Better than some weeks, not as good as others.  Overall though, I know that I am much more aware of these four pillars and what I can do to achieve them.  Some measures are for me, some not.  I don’t need to hit perfection in every area every day.  I don’t need to beat myself up if this is the case.  It’s a question of trying things out, learning from my mistakes, and doing these things consistently enough for them to become helpful habits. Whatever I am doing now, it’s more than I was doing before I started on this journey.  That can only be a good thing.

For those of you desperately disappointed at this post not being The Weekly Wellbeing Round Up # 4, fear not…it will be back next week!  Until then, look after yourself.

Dr Richard Pile

The Weekly Wellbeing Round-Up #4

Hello and welcome back to the weekly wellbeing round up.  After my report from my “wellbeing clinic” last week, normal service is resumed.  The main focus of the round up this week will be on obesity, as the government published Chapter Two of “Childhood Obesity – a plan for action”.

The challenge

Nearly a quarter of children in England are obese or overweight by the time they start primary school aged five, and this rises to one third by the time they leave aged eleven.

Children growing up in low income households are more than twice as likely to be obese than those in higher income households.

The ambition is to halve childhood obesity, and reduce the gap between richest and poorest, by 2030.

Obesity costs the NHS £6 billion a year, and wider society £27 billion a year

The planned 5% reduction, within this last year,  of sugar in foods commonly eaten by children has not been achieved (the target is 20% by 2020).  The target for calories in foods consumed by children is a 20% reduction by 2024.

energy drinks

Action Plan

Consultations are proposed in 2018 on –

  • banning the sale of energy drinks to children
  • mandatory calorie labelling for all foods in restaurants and cafes
  • 9pm watershed for adverts for foods high in fat, sugar and salt
  • a ban on unhealthy foods being offered on price promotions or at the checkout or entrance to stores

Local authorities will be encouraged to use their powers to promote healthier environments, and to share best practice across the country as part of a trailblazer program.

Schools will be advised and helped to reduce sugar content of food served to children and every school will be encouraged to adopt the Daily Mile, or a similar program.  As prevention lead for our clinical commissioning group,  I have already met with primary school headteachers, who are beginning to embrace the program.

My view? Fine words.  A good start. Hard to object to, like motherhood and apple pie.  The question is whether the government has the will to legislate against Big Food.  We are now facing the same kind of challenges with these companies as we did in the 1950’s and 1960’s with Big Tobacco.  A report by Public Health England highlights the scale of the challenge, pointing out the not entirely surprising news that England’s fastest areas are fast food hotspots.  For me, this is not just a fight about health and wellbeing, it’s about social justice.  Here in Hertfordshire, our CCG and local authority need to be working together to make meaningful changes..something that we aspire to and need to work harder on.

Practical steps you can take today

We can’t afford to wait around forever for government legislation to change, so what can be done about this in our communities by health care professionals and patients?  This week I have been listening to Episode 22 of Feel Better, Live More podcast.  It’s a conversation between Dr Rangan Chatterjee and Professor Satchin Panda entitled “Why when you eat matters”.   It’s all about time restricted feeding, also known as intermittent fasting.   The idea is that if you eat all your food for the day within a specific time period, your body digests your food better and you can enjoy a number of benefits including weight loss.  There has been good animal data about effects on weight loss and reversing diabetes, and there is now some emerging human data to back it up.  Here is one example of some study data supporting this approach.  In an ideal world, people would modify their diets to eat more healthily and this can be done in conjunction with time restricted feeding.  However, if I have a patient consulting with me that I know is going to struggle to change their diet, at least I can recommend they try this approach as a start.  Once they start to feel better as they lose weight and have more energy, they may well then wish to make further, even better changes.  Dr Chatterjee recommends a 12 hour window in his excellent 4 Pillar Plan book, and I think that this is achievable for most of us, at least some of the time.

white and beige medicine
Photo by Pixabay on Pexels.com

On the subject of diets, I am often asked by patients whether they might benefit from supplementation and if so, with what sort of things?  I have always been something of a sceptic in this area.  I found this article from Dr Hazel Wallace, the Food Medic, a very helpful summary for me and I will share it with my patients.  In summary – if you are in good health and do not have any nutritional deficiencies and eat a well balanced diet, you do not generally need any supplementation of your diet.  Dr Wallace does recommend, in line with public health england guidance, that you consider vitamin D supplementation in autumn and winter.  She also highlights other groups who may benefit from some supplementation including pregnant women and children under five.

Finally , I thought I would finish with this encouraging study which appears to demonstrate the benefit of weight loss in patients with atrial fibrillation.  Patients who lost 10% or more of their body weight significantly reduced or reversed the progression of AF.  When you consider the disease burden associated with AF including four to five times the risk of stroke (and the strokes themselves being more likely to kill or disable a person), and the difficulties that some people have in tolerating  drugs for rate and rhythm control, and the risks associated with anticoagulation (taking blood thinning agents), this must surely be something that every significantly overweight person with atrial fibrillation should consider seriously.

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

Dr Richard Pile

 

 

 

 

 

 

 

 

 

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