Tuesday, February 25, 2014

Stop calling me Skinny!

You’ll often hear it said that approximately 50% of the western world are either overweight or obese and that this can lead to serious health issues. And I agree with that. But I’m in the other 50% and am starting to get a bit fed up with being told that I’m getting skinny, or that I need a good feed to fatten me up.
Now, although I frequently write about the huge health threat that comes with obesity, what I do not do is go round telling people to their faces that they are fat and, why don’t they cut down on their eating.
The reasons behind this reversal of fortunes is that with so many people now being overweight or obese, half the population now think that their body image is normal and that the skinny ones are the abnormal ones.
As you all know, this year it’s 100 years since the start of that terrible first world war, and there have been lots of film footage of troops signing up and going to the front. So far I haven’t seen one fat person signing up in all that archival footage. Fair enough, smoking was more prevalent and cigarettes part of a soldiers rations, AND they did a great deal of marching up and down. But if they introduced conscription these days ( and heaven help they never do again) then there are going to need an awful lot of XXX large uniforms for over half of the troops.
Being overweight or obese is not the norm, but the pattern for it can so often be laid down in the first five years of life and that’s where we need to focus part of our efforts to fight the trends toward obesity related Diabetes, heart disease and cancers.

I was reminded of this after reading an article in the past on “Risk factors” for heart disease and in particular a study in the US which has been going on since 1972, and which has followed a community of people to study the incidence and causes of heart and blood vessel disease. This study, which is called the Bogalusa Heart Study and which has been an ongoing study for over 40 years now, has not provided any revolutionary results but some of the conclusions need to enter the mainstream thinking of every family, every school and every community.

But first a look at what we know, and you’ve heard it all a thousand times, but Smoking remains the No 1 bad guy when it comes to vascular disease - the type of disease that leads to heart attacks and strokes. Second comes Hypertension, or high blood pressure, which needs to be measured if you want to find out whether you have it or not. Then comes Diabetes, which if poorly controlled often leads not only to heart attacks and strokes, but also to disease of blood vessels supplying the legs, and when they get blocked gangrene and amputation may follow! And finally comes raised Cholesterol, obesity, age and being white - the Bogalusa study being run in a mixed biracial American community.

In this particular study the finding that neither obesity nor raised cholesterol rank highly as a risk will be of interest to the experts in those fields and will be the subject of intense, ongoing debate. But what we do know is that:

Since the introduction of ‘Statins there has been a 30% reduction in developing the risk for atherosclerosis - the plaque that leads to heart attacks and strokes. And that people with a Cholesterol level lower than 160mg/dL do not get heart disease irrespective of what their HDL, LDL cholesterol are or their Triglycerides are.
Obesity is linked with diabetes and diabetes is a significant risk for developing blood vessel disease. It is also linked to cancers and other medical problems and remains a real focus of necessary life style changes.

In fact one of the glaring outcomes of this 40 year old trial is that childhood nutrition and obesity should be the main focus of all preventative programs. If it’s left uncorrected then it’s linked to life long health problems that are not only physical but mental, educational and social too. So that’s why the childhood nutrition story needs to be told loud and clear and repeated in new ways year in and year out. If we give our children a healthy start in life then not only are they going to be able to make the most of their opportunities, but they are going to be healthier and get less disease. And what this means is that they are not going to need the services of our fantastic, but very expensive hospital services, which are paid for out of our taxes and our insurances. So the “price” of investing in getting our kids to eat healthy nutritious food is going to be a wonderful investment in their future and in our Nations too.

So where do we begin? Well in most places the machinery is already in place and beginning to work really well.

Smoking. Nearly every child I meet hates the smell of smoke, but sadly there are a great number of teenagers to take up the awful habit and unbelievably, cigarettes are still sold as Duty Free items in airports around the world. But in most developed countires, the good guys are wining and the percentage of smokers continues to fall, but we must never relent!
Childhood obesity requires serious, sensitive handling. Childhood obesity leads to a plethora of life long health problems. The key factors of teaching, showing, sharing better ways to eat need to be tailored to the individual and to be creative. The involvement of Chefs in school programs that allow children to try foods - and these are foods that they would normally “hate” -  prepared and presented in different ways so that the kids actually enjoy eating them, does have a huge impact. The widespread appearance of school vegetable gardens is another creative way of involving kids in making nutritious food choices and understanding how a healthy food chain operates..
Physical activity. Whilst not really impacting on weight itself, the direct benefits of physical activity in so many areas of life - heart disease, cancers, mood disorders and so on - mean that being active must always be an integral part of our education system.

Reducing risk is a lifelong health education challenge. We should not wait until mid-life to try and correct things that need not have occurred in the first place. So lets give our children the best tools available to build healthy lives, so that when their turn comes, then they will know how to build a great world for their children too.

Ampersands & angle brackets need to be encoded.

Wednesday, February 19, 2014

To Sleep or not to sleep?

We all try and do it each and every night. Babies will do it for 20 to 22 hours each day and Teenagers seem to take to it like a duck to water. But for many people, trying to get a good nights sleep can be a challenge. Each year more than 5 million prescriptions are written in Australia, a rise of almost 9% since 2001. And a study released in 2011 found 95 per cent of patients who went to the GP to report an issue with sleep were given sleeping pills. These are very worrying trends and ones that we need to reverse as soon as possible. 

Recently, our nocturnal sleeping habits have been in the news because of the concern about the negative impact that these Sleeping Pills can have on our health. It’s been known within the medical community for many decades that giving sleeping pills to older people increases the risk of falls, confusion and the very real potential for serious interactions with other powerful medications that they take. But a report, released last year has now highlighted a possible link between taking these medications and premature death.
According to Daniel F. Kripke, MD, of the Viterbi Family Sleep Center at Scripps Health in San Diego, his study shows that (quote) “sleeping pills are hazardous to your health and might cause death by contributing to the occurrence of cancer, heart disease and other ailments." (unquote) In fact even those who reported taking between 1 and 18 sleeping pills in one year increased their risk of premature death by a factor of 3.6.

Their study is not only an interesting read, but it should sound alarm bells ringing within the wider community about the safety of sleeping tablets and why people need to take them. Despite the 2011 study findings about the ease with which sleeping pills appear to be prescribed, in my experience, most people within the medical profession treat sleeping tablets with the
respect and will generally only prescribe them when the benefits of using them outweigh the potential harm that they may cause - and then only for a very short course too. But for many with sleep disturbance there are usually some other underlying issues that need to be looked at such as:
Stress and anxiety 

All of which need to be attended to before one reaches for the sleeping pill bottle. The challenge here is that if you’ve missed several nights sleep, the benefits of a long term sleep hygiene program seem less attractive than popping a pill to get you to sleep that night - hence the emotional pressure on the treating doctor to use short term hypnotics as an aid to achieving a longer term, non sleeping pill associated goal. 

But another article which intrigued me from the New York Times, was on the subject of what is “Normal Sleep”? Because if we can’t define normal sleep and pass that onto our patients, then many people may ask for help when, in fact, they are having a “normal” nights sleep.

The article was based on the work of the historians Ekirch (2005) and Koslofsky (2011) who propose the theory that before the Industrial Revolution, segmented sleep was the normal pattern. In these pre- industrialized times there were two distinct sleep phases that were bridged by a period of wakefulness. In fact, during this wakeful period people used the time to reflect and pray: for the tired labourer who went to bed “dog tired”, this was the time that they usually had sex: and for the poet and writer these early hours were often the most fruitful as they were able to write uninterruptedly.
Some people used to get up and visit the neighbours and of course, it was also the time when the “bad guys” went and did their evil deeds!

Today, there is sound scientific evidence that a midday nap associated with nighttime wakefulness is associated with greater alertness than with the “mono-phasic” sleep-wake cycle - or a straight eight hours.

According to Eklrcks theory, it was the introduction of street lighting that allowed people to stay up later, and that, coupled with domestic lighting, started the trend to longer social evenings. With longer evenings came the idea that an eight hour sleep should be the “norm”. But according to Erlick there are abundant references throughout literature that refer to “first sleep” or first waking, with examples to be found in Shakespeare, Homers Odyssey as well as many personal records of lay persons who were able to write in centuries past.

If Erlick and Co are correct in their assessment, then I would suspect that millions of people will take a big sigh of relief and realize that their sleep patterns are “normal” after all.

In this 21st century of ours we like to have everything neatly packaged and labelled so that we have a feeling of control - and for many millions of people, this applies to their work/play/sleep cycles too. If there is one thing that sleep and dreams teach us, it’s that in the sleeping state there is no control and that we still have so much to learn about what sleep actually is and what dreams are.
For those who would like to improve the quality of their sleep, then my suggestion is to try to improve your sleep “hygiene”. So here are a few tips taken from the Mayo Clinic that I hope will enhance your quality of sleep over the months ahead.

  • Stick to a sleep schedule in other words. try to go to bed at around the same time each night.
  • And if you're not sleeping Give yourself 20 minutes and Get out of bed. read a book or magazine until you are sleepy and then try again.
  • Avoid the temptation of trying to sleep when you can’t. The frustration this causes will only make you more alert
  • Use your bed and bedroom for just two things: sleeping or sex. PLEASE, no TV or computer screens in the bedroom.
  • Find ways to relax. A warm bath before bedtime can help prepare you for sleep. Having your partner give you a massage also may help relax you. Create a relaxing bedtime ritual, such as reading, soft music, breathing exercises, yoga or prayer.
  • Try and take your Exercise and physical activity. at least five to six hours before bedtime.
  • Avoid or limit caffeine, alcohol and nicotine in the evening. 
  • Avoid large meals and beverages before bed. 
  • Check your medications. Especially anti-cold and flu medications.
  • Don't put up with pain. See your Doc.
  • Hide the bedroom clocks. The less you know what time it is at night,
    the better you'll sleep. 

     Happy dreams
Ampersands & angle brackets need to be encoded.

Wednesday, February 12, 2014

SME's and the future of Health Care in our Communities


It’s been almost imperceptible, and yet it’s been quite dramatic. I’m not talking about the Internet, Facebook or even Twitter, although they have played a significant role in the social changes that we see and read of, each and every day.

I’m talking about Health Care.

Notice, I’m not talking about Sickness, Disease or Accident care, but about Health Care.
Now …
If you were to time travel back to the post war period in any western country, you went to the Doctor because you were sick. The Doctor would invariably know your Mother and your father and may even have brought you into the world you at the local hospital or perhaps at home. And if you were really sick that Doctor would almost certainly have visited you in your own home … and probably stayed on for a cup of tea too. However it wasn’t all Nirvana back then in GP land, because in all likelihood, your Family Doctor would have sat at the side of your bed smoking a pipe - but I digress.

Over the ensuing decades, with the massive increase in technology that was associated with medical diagnostics, plus all the paramedics that are vital to the normal running of our current Health Care systems, the cost of providing health care services has sky rocketed. So the emphasis on so-called Preventative medicine became the norm, with the logical precept that if you reduce risks for certain chronic medical conditions - such as Heart disease, Diabetes, Cancer and many others -  then the savings accrued would reduce the future burden of burgeoning health care costs. And we’re talking of billions of dollars here.

So it became the norm for GP’s to promote Preventative Medicine as the way forward, as they were seen to be in the ideal position with their knowledge of medicine and of their patients. But then two invisible forces began to collide.

The time it takes to action many of these preventative screening programs started to eat into the time that the GPs actually had to see sick patients. Because not only did they have to go through a particular screening process, they then had to document it all. All of which does not fit neatly into a 15 to 20  minute standard consultation.

Secondly, GPs had stopped visiting patients in their homes. And because so many GPs were now part-timers, continuity of care was rapidly disappearing too. That has led to the current situation where many time poor GPs do not know the social or family history of their patients, apart from what the previous treating GP had written in the patients electronic notes.

Pity the poor patient then who has a high fever and needs to get back to work as fast as possible, but can’t get in to see the Doctor for 3 or 4 days because the Doctor is “Booked out”. And when they do get an appointment, they are often left sitting in a crowded waiting room where cross infection is a real possibility.

The challenge as I see it is to get GPs to see those who need a Doctor - the sick people of our communities: and to create an environment where people can access real Health Care in the places where they spend most of their time - the places where they go to work.

People will visit the Doctor maybe two or three times a year, but they will often see a different Doctor each time. Those same people go to the same workplace up to five days a week for about eight hours each day: in fact they actually live and work in a little community. And its inevitable that after a period of time, each persons family and social history is known to their fellow workmates.

Today most, if not all large corporations will be offering a whole range of healthy living programs to their staff, because they know that it’s an investment in their most vital resource - the people who work for them - and in nearly all those cases this investment in their staff also helps the financial bottom line too.

However, over 90% of the National Workforce work in small to medium sized enterprises - or SMEs - and the vast majority of these do not have the resources or the skills to enact Healthy living programs for their limited staff numbers. There is no doubt that some employers would see such intervention programs as an extra headache, and it may be that some staff would even see it as a threat. But the benefits of creating a healthy work environment and encouraging the employers and employees to live a healthy lifestyle too, are not just limited to the SMEs themselves. International reviews suggest that it could have far reaching economic benefits for the wider community as well. Dame Carol Black, National Director for Health, Work and Wellbeing, in the UK has calculated that improved workplace health could generate cost savings to the British government of over £60 billion – the equivalent to nearly two thirds of the NHS budget for England. And these figures would no doubt be somewhat similar all around the developed world.

Thus it seems logical for people who are sick to be seen by people who are trained to investigate and treat people who are sick. And it would also seem logical that businesses who need healthy workers to operate efficiently, should be committed to promoting healthy lifestyle for those workers.
The spin offs from such initiatives would include

Better health for the national workforce - in other words the vast majority of the population - with reduced risk of chronic health issues.
More time for Doctors to do their “Doctoring”
Massive savings in the future for the Health care industry allowing scarce Health care dollars to be targeted at areas of most need.
Significant savings for businesses who promote healthier workers: and the reputation of being seen as an employer of choice who cares for their employees.

So how does this work?

Firstly each SME needs to identify the needs of their particular business. Hairdressers would have different needs to a plumber and a car mechanic would have different needs to an office worker, so some basic data collection is needed before any thought to a particular program is started.

Once this data has been collected and a health care initiative identified, then a structured program needs to be set up and monitored. There is absolutely no point in starting something new if you don’t monitor it and review your results regularly. Without monitoring and review there is no way of assessing whether the program is effective, and that will inevitably lead to frustration and abandonment of a potentially helpful program. Involve your staff in gathering information and in choosing an appropriate program, then it’s far more likely to succeed.

If you find that your business is “too small” to consider such an idea, then form a cooperative with other small businesses in your area or within your trade, or contact the small business associations in your town or city. The small effort you put in will result in positive outcomes for you and ever bigger rewards for the wider community as time goes on.

Changing peoples patterns of life is a slow business. But if someone had told me of the huge changes that I’ve witnessed during the course of my medical career I probably wouldn’t have believed them. But I do believe that SMEs are the key to how we can change the health of our countries. And it only takes each of us to dare to do our little part, and then the resulting impact will be massive and long lasting.

Ampersands & angle brackets need to be encoded.

Tuesday, January 7, 2014

Away from my desk

But not totally away from all work.

The bride and I are enjoying a little Italian culture, which is why there haven't been any posts or podcasts recently.

But if you want some edifying reading, then click the link to my Blog on the HBF Website and see what I've been writing about over the Christmas/New Year period.

I wish you all a fantastic 2014, and I'll be back in thd saddle soon. Ciao.
Ampersands & angle brackets need to be encoded.