How to Use the NHS

Some now expect miracles – there is no benefit and therefore no point in going to your GP if you have a cold. Nor do you need to go to A&E with a broken fingernail or a year old rash (these are real examples).

It may be a bit of an understatement to mention that a lot has changed recently. No more so than for those working in the health service and, while many are unwell with Covid-19 and while those that need it most struggle to get the PPE they need, the everyday aspects of their jobs have somewhat fallen by the wayside. Figures for February and March show a 22% fall in A&E attendances. General practice and outpatient secondary care have also seen a drop in demand for routine enquiries.

While this has freed up resources for the issue at hand, some may notice that many of the issues for which they might normally have sought help and advice have gone away on their own. Others have been able to find the answer to their questions online. The sore throat that you had might have cleared up on its own without antibiotics. That painful ankle might have cleared up with measures you followed from the NHS website.

This unusual set of circumstances has highlighted an area that perhaps we can all learn from as we emerge from this crisis (though there is a long way to go yet). As a nation, we have become somewhat spoilt by the free healthcare we can expect; our perspectives have shifted over time as more becomes possible. Some now expect miracles – there is no benefit and therefore no point in going to your GP if you have a cold. Nor do you need to go to A&E with a broken fingernail or a year old rash (these are real examples).

In 1948, at the inception of the NHS, paracetamol was yet to become readily available, open heart surgery was 4 years old, statins had not yet been invented and antibiotics were in their infancy. Fast forward to the present day and we are seeing around 200 heart transplants a year in the UK, an entire pharmacy of medications available to us at our beck and call, lifesaving emergency services 24/7 and access to state of the art intensive monitoring equipment. Around half of the UK population takes at least one regular prescription medication. If your hips or knees go, you are entitled to have metal replacements inserted for no extra charge. If you have a rash, you can have it seen to or if you want your ingrowing toenail sorted, you can have it clipped or lopped off. If your ears are blocked, someone will clear that for you too.

With our population increasing and growing older, it is little wonder that the whole thing is beginning to creak. The outcome…? You have to wait a long time for your hip replacement, you might be denied the chance to have your bunions sorted out because it is a low funding priority. Your GP is running late by 20 minutes or even a bit longer. That may seem a bit insensitive or flippant (or both) but, believe me, I’m not happy about it, certainly not if it means people are waiting in agony for treatments. While most people have a rational grip on such situations, a few do not. Those are the ones that sometimes abuse staff who are only trying their best in impossible circumstances.

This current situation may therefore serve as a not so gentle reminder of what are reasonable expectations in terms of our healthcare. That said, between early and late March, there has been a fall of 150 patients per day presenting with symptoms of heart attack. Now, it is unlikely that the Covid-19 pandemic has somehow cured heart disease altogether and, though many people with chest pain turn out to be fine, there will be some within that cohort of 150 who have had real heart attacks; heart attacks that are currently going untreated.

Lack of presentation for this sort of thing, or indeed other worrying symptoms of things like cancer (loss of weight and appetite or a change in bowel habit to name just three), means the health impact of this pandemic will not be just related to Covid-19. For anyone with worrying symptoms like this, you absolutely must not ignore them just because of the outbreak.

There have been some cases of people cancelling urgent cancer referrals due to concerns over the virus. While one can understand the anxiety surrounding this, these referrals are there for a reason. Do not delay them.

We need to use the NHS sensibly. Not too much, but not too little. We have swung from one extreme to the other in the last few weeks. Once we emerge from this, we must all consider how best to use it going forwards, and focus on the bigger issues at hand, no doubt at a time of great change. Self-care is an enormous part of that, not just in how we deal with an acute medical situation but also in how we look after ourselves in general. Smoking, alcohol, diet and exercise are the key areas that cost nothing to improve.

As doctors we want to ensure that everyone who needs to be seen, and whom we can help, presents to us appropriately. At the same time, we would request that others, who might reasonably be able to manage their own minor issues, do so. It is a fine balance and even writing this makes me uneasy that some may stay away for fear of overusing the service. The level of disparity in people’s views of how best to use the NHS is, in my experience, remarkable.

In summary then, urgent care must remain a priority for the service as a whole, but how we look after an ageing population effectively is also vital. Prevention of health problems is key. We should look after ourselves properly as far as is practicable but also seek help when appropriate in order to avert bigger health issues down the line. Staying away isn’t always the answer (particularly at the moment) but there is a balance to be achieved. Now might be a good time to redress that balance.

Dieting: The right way

“The heaviest man ever recorded weighed in at around 635kg (99 stone) – about the weight of an American Bison.”

As January draws to a close, so too will many new year’s resolutions be wavering. In fact, around 80% of peoples’ resolutions will have failed by the second week of February. One of the most common ones will be to go on a diet and to join the gym. January accounts for around 12% of gym applications but most will have completely stopped after about 24 weeks. Even worse, around 87% of diets will have already failed by the 12th.

While I think the use of new year’s resolutions to kick start such health drives is a positive thing, there is so much information around, particularly online and largely unregulated, that may render those well intentioned efforts fruitless, quite literally.

Dieting is nothing new. At the beginning of the 20th Century, people turned to eating tapeworms to help them with weight loss – that is until they started getting intestinal cysts, meningitis and seizures. For some reason, during the 1930s and again in the 1970s, it became popular to eat half a grapefruit with every meal in the hope that the scales would become more complimentary. In the 1800s, apple-cider vinegar was added to water (apparently popularized by Lord Byron) and in the 1960s, a ‘drinking man’s diet’ emerged which consisted of eating lots of meat and washing it all down with alcohol, even at breakfast. 

The purpose of all of these, you will notice, will have been to lose weight. I suspect now, if you asked most people why they go on a diet or go to the gym, it will be ‘to lose weight’ or ‘to look better’. We have an ideal body shape these days which is endlessly highlighted through online and social media. There is a huge pressure for us to look right.

Arguably, this has been with us for a long time. One only has to look at the statues from ancient Greece and Michelangelo’s famous statue of David in Florence to see the template for the ideal build and shape of a human that has persevered ever since.

Not reaching that ideal puts huge pressure on our mental health. The trouble is, achieving it is getting harder and harder with the choices and options available to us, both in the modern diet and our increasingly sedentary lifestyles.

In the UK, 29% of adults are classed as obese, as are 20% of year 6 children.  It is thought that around 10,660 admissions to hospital each year are directly attributable to obesity. Thus the importance of controlling weight and fitness is not just about looking right.

All too often, people choose to make their lifestyle changes after something has happened – if they are lucky enough to do so – at which point the aims change from honing their body image to things like reducing blood pressure, preventing or controlling diabetes, treating depression, and lowering the risk of heart attacks and strokes. Ultimately, all of this is achievable, but not through the short term fad diets that are so popular in the consumer market of today.

Let’s look for a moment at the physiology of our body and its energy supply. We need energy to live, that much is obvious. That means every cell of the body, in order to function, needs a supply of energy. This comes from our diets which can broadly be split into three categories: fats, carbohydrates and proteins.  The majority of our energy comes from fat and carbohydrates. Fat is too large to be absorbed into the blood stream on its own, so when we eat it, it is broken down in the gut to form fatty acids and glycerol so it can be absorbed.

Fat is mainly stored in the liver and in the subcutaneous (skin) tissue. It can also accumulate around internal organs (visceral fat). When we are not eating and need energy, we draw on these stores to power our bodies, a process kick started by a drop in insulin levels. This will also bring into play the sugars stored around our body, again largely in the liver, in the form of glycogen. A drop in insulin will convert this glycogen into glucose and the fat into fatty acids and glycerol once more, which can then race around the body to power things.

As we eat, insulin levels rise. This encourages cells to take up glucose as a source of energy in the short term, but also promotes a reversal of the process above and stimulates the storage of all of the new energy we are ingesting so we can use it later.

Put simply, our weight is governed by the rate at which we store the energy from the foods we eat against the rate at which we use that energy.

Energy is measured in calories and one calorie is the amount of energy required to raise the temperature of water by 1 degree Celsius or 4.184 joules. 1,000 calories is equivalent to 1 kilocalorie and it is kilocalories that we see on the sides of our food packaging.

Hopefully therefore it should be fairly clear that, in order to maximise our health, there is a need for both healthy intake of food and an active, energy burning lifestyle. If not, then our weight will suffer along with a lot of other things. The heaviest man ever recorded weighed in at around 635kg (99 stone) – about the weight of an American Bison. In the UK, the record stands at 444kg (70 stone) – the weight of the average Moose.

Our intake of fats should be around 30% of what we eat. Any more and it can build up in our bodies and cause problems, for example high cholesterol, heart disease and obesity.

In the same way, getting all of our energy from carbohydrates (sugars) is not the answer either, as this can reduce our body’s sensitivity to insulin and cause diabetes. In a cruel twist, excess sugar can also be converted to fat anyway.

We all lament the fact that, in general, the foods that are bad for us are the ones that taste nice. The key, as I suspect you have heard many times over, is balance. This is not repeated for the sake of it but because it is truly important. Many modern diets will hinge on cutting out whole areas of energy – for example the Atkins diet and its dislike for carbohydrates. While this can result in fast initial loss in weight, it falls down in many other areas. If one cuts out an entire food group, one loses the benefits of the foods within that group. If you cut out carbohydrates, you’re cutting out a tremendous source of fibre, vital for gut health and a healthy microbiome. It is also likely you are depriving yourself of the many vitamins and minerals contained within those foods that your body needs. Longer term it falls short and, perhaps most important of all, it is not sustainable.

This brings me to my most important point. If you want to be healthier, reduce your risk of heart disease and diabetes, look better, feel better, lose weight, or whatever your goal, you need to make a permanent and sustainable change to your diet and lifestyle and avoid something that is unrealistic. If you say that you are going to the gym every day but one having not been for the past 5 years, it won’t work. Likewise, if you say you will cut out fat completely from your diet forever, it won’t work.

That’s not to say that making a change won’t be difficult but crucially, if you do it in the right way, it is something your body will eventually assimilate as the norm.

So…

  • Prepare your food for the week ahead and don’t shop while you’re hungry. If that chocolate bar is in the cupboard, you’ll eat it!
  • Join a gym, club or class but make your activity levels fun and sustainable so you aren’t put off it.
  • Watch out for portion size.
  • Use brown rice, brown bread and brown pasta
  • Avoid saturated fats and eat more polyunsaturated fats and cooking oils.
  • Plenty of fruit and vegetables
  • Set goals and guidelines to stay within
  • Eat 3 main meals a day and snack only on nuts and seeds (a tricky one but very important)
  • Drink 6-8 glasses of water a day
  • Reduce your alcohol intake
  • Stop smoking!

Good luck!

Summertime!

 

With all the hot weather recently, I have decided to focus a little on the impacts that a warm summer might have on our health. (Cue thunderstorms and rain). Many associate summer with some of the finer things in life – trips to the coast, beautiful clear skies, Pimms and a high concentration of bank holidays. For others, it means unbearable heat, vicious sunburn, stifling sleepless nights, sun cream all over your clothes and the long agonising wait for the start of the domestic football season to begin again.

In order to enjoy the positive aspects, I have put together some tips on staying healthy through the change in environment during these warmer months.

Let us start first with how our bodies regulate heat. The word homeostasis is used to describe the way the body maintains balance in various processes, including electrolytes in the blood and blood pressure. Part of this homeostatic balance however is related to thermoregulation. In other words, the body’s constant battle to keep its core temperature stable within quite fine margins – around 37.0 degrees on average. Any higher or lower than ideal and this begins to affect many of the normal processes going on in the body at any one time. For example, diabetics tend to absorb more insulin in warmer weather and so a closer eye on insulin doses is required.

Our main tactic in controlling temperature, at least in losing heat, is through the process of sweating. As we sweat, the water from our tissues takes heat from beneath the skin, and the heat energy is lost as the sweat then evaporates. It stands to reason therefore that, in warmer weather we sweat more and so our requirements for fluid go up. Normally we should be drinking 6 to 8 glasses of water each day (about 1.2 litres) but in warmer weather, we should increase this to allow for the extra fluid loss. It is no surprise that summer is kidney stone season, with twice as many presentations when compared to the winter months. This is in part due to greater rates of dehydration but also, as your skin gets more sun exposure, you produce more vitamin D which in turn increases calcium absorption and promotes the build-up of these stones in the kidneys.

Although not particularly hairy when compared to most mammals, the small hairs that cover our skin also help in the process. If our body decides it needs to lose heat, signals from the hypothalamus in the brain prompt the hairs to flatten across our skin. Conversely, if we need to warm up, the hairs stand on end (hence goosebumps) thus creating a tiny layer of air trapped in amongst them to warm us up a bit.

If we are getting too hot, our heart rate tends to speed up in order to speed the circulation from the core out to the peripheries where the heat can be transferred from the body through our skin.

As you can see, we have some inbuilt mechanisms to prevent ourselves from becoming overheated, but sometimes that is not enough. Heat stroke can be nasty and causes headaches, dizziness, confusion, cramps, and pale clammy skin. If this happens on a warm day, lie down in a cool shaded place, try to cool the skin with water and a fan, and drink lots of water or rehydration solutions (you can get these over the counter at any pharmacy or supermarket and are good to have handy, particularly on holidays in the sun). If this is not improving things within half an hour, or if you are concerned, you must seek urgent medical attention.

To keep cool in general, avoid prolonged exposure in the sun (fairly obvious), wear a hat to provide some shade, make sure you are well hydrated and avoid drinking too much alcohol which can dehydrate you.

At night, warm temperatures can really disrupt sleep, leaving you tired and unrested the next day. If flipping the pillow to the cool side isn’t quite cutting it, you could try the following measures.

  • Start when you get up… close the blinds and keep windows closed during the day if it is hot outside to prevent heat building up inside.
  • Avoid a heavy meal, especially with spicy food before bedtime.
  • Drink cold water, but not ice cold as sometimes this can confuse the body’s normal heat losing measures.
  • Take a tepid shower before bed.
  • Use light, cotton bedding
  • Encourage air flow with a fan
  • You can even put your bedding in a bag and then in the freezer for a bit so it is extra cool at bedtime.

Summer’s drawbacks are not always directly related to heat though. The other big drawback is hay fever. This is a real menace for many people and ranges from the very mild to the debilitating. The most severe cases require specialist input with immunotherapy. It is not a new problem and even as far back as the 9th Century, numerous remedies were put forward, some more successful than others. Inhaling tobacco, chloride of ammonia, chlorophorm or using cocaine spray never really caught on.

Classically, hay fever causes sneezing, coughing, runny nose and itchy eyes but it can manifest itself in other ways too. Loss of smell, headaches around the temples and forehead and tiredness can also be signs.

Over the counter remedies are often your best option to treat these, such as anti-histamines and eye drops but you can alleviate some of the symptoms even more by following these steps:

  • Use vaseline under the nose
  • Don’t dry your clothes outside (so they don’t pick up all the pollen)
  • Keep the windows shut and stay indoors when you can on days with a high pollen count
  • Use wrap around sunglasses
  • Vacuum and dust regularly
  • You can even get fit pollen filters for your car air conditioning

Hopefully for the most part, all of the negatives of summer are outweighed by the positives but if you follow the above steps, it will make things even easier on your body. And in some cases, the sun can even improve things. Those with skin conditions like eczema and psoriasis will see an improvement in their symptoms due to the increase UV exposure (UV phototherapy is a recognised treatment for psoriasis). Having said that, for most cases you should protect your skin from the sun as much as possible. Sun cream is essential and, if you neglect it, in later life you will be far more prone to damaged and unhealthy skin, not to mention a far greater risk of skin cancer. You have been warned.   

Heart and Soul

“Normally about the size of your fist (unless you’re Donald Trump)”

To say our bodies are complicated is somewhat of an understatement. The number of processes each one carries out every second is staggering. From managing all the thoughts racing through your brain, digesting last night’s dinner, pumping oxygen into the blood from the outside world and contracting a select group of muscles just to stop you from falling over, it is in perpetual activity even if it doesn’t always seem like it. The organs of the body take on all these different roles, each one vital to the workings of all the others.

For now, however, I will focus on one of the most vital of all our organs – the heart. For obvious reasons, it is pretty useful. With every beat, it pumps blood into the arteries taking with it all the vital components of the blood into your tissues and all the other organs of the body as well. Indeed so vital is its role that it is little wonder it has adopted an almost spiritual role. We’re often told to follow our hearts – though this makes little sense in literal terms – and apparently that’s where home is as well. Part of the reason the Aztecs most commonly extracted people’s hearts as a form of sacrifice was their belief that it was the seat of the individual, more so than the brain, a belief shared by classical philosophers such as Aristotle.

In reality, the only bearing it has on our thinking and individuality is in its relationship with the brain – without the heart, the brain would be nothing. Normally about the size of your fist (unless you’re Donald Trump), it is made up mostly of muscle and comprises four chambers. Two of these called the atria and these sit atop the two larger ventricles, which do most of the pumping. The right atrium and ventricle take returning blood from the veins of the body and send it straight out to the lungs to be resupplied with oxygen. From there, the blood returns to the left atrium and then left ventricle, where it is given a final push into the body to do all of its good work. Generally it takes around 20 seconds for blood to circulate round the body before it gets back to the right atrium again.   

To prevent back flow, there are several valves and, as these close, they cause the characteristic sound of your heart beating that we can listen to more closely using a stethoscope. Often we can pick up whether there is a bit of turbulence in the system if the valves are not functioning properly – ie a heart murmur.

If all is well, your heart will beat regularly and the signal for this comes from within the heart itself, from a collection of cells in the atria (called the sino-atrial node). Electrical impulses originate from here and spread like a circuit through the heart tissue, making the muscles contract in time with each other. In a lifetime, you can expect your heart to beat around 3 billion times, or 115,000 times a day. When the tissue that conducts these electrical impulses throughout the heart muscle is damaged, this can sometimes result in funny rhythms, or arrhythmias, of which there is a spectrum varying from serious to not so serious. Ultimately, the beating of the heart is governed ‘in house’ and though signals from the brain can stimulate it to speed up and slow down, the rhythm originates from the heart itself which is why, if a heart is removed from the body, it will continue to beat on its own for a little while.

Inevitably with such an important role, when things go wrong, we tend to know about it. In the past, infectious disease tended to be the leading cause of death but, since the middle of the last century, heart disease rose considerably, overtaking infectious disease (certainly in the developed world) as the biggest killer. However, due to plenty of research and advances in healthcare, in the last 15 years death rates from heart disease and stroke have reduced by about 50%. It is still the leading cause of death in males between the ages of 50 -79 years old and, though more common in men, heart disease is something we should all, including women, be thinking about.

Heart disease is a term thrown around a lot but what is it exactly? It falls into a broader category of cardiovascular disease which encompasses things like stroke as well. Essentially the main issue for any cardiovascular disease is the process in which arteries become blocked resulting in loss of blood flow to the areas these arteries supply. When the area that blocked arteries supply is heart muscle, we call this ischaemic heart disease. (Most strokes occur when blood supply is blocked to a part of the brain).

When an artery supplying heart muscle (coronary artery) is partially blocked, the heart needs to work harder as one exerts oneself. If the supply cannot meet the demand, this gives rise to chest pain which resolves when rested. This is angina.

When a coronary artery becomes blocked and blood supply is cut off completely, this results in chest pain not relieved by rest (often accompanied by nausea, shortness of breath, sweating and a feeling of impending doom), and areas of heart muscle can die. This is a heart attack, also known as a myocardial infarction. (myo = muscle, cardia = heart)

Following damage or weakening of the heart muscle (sometimes due to valve problems), the heart sometimes beats less powerfully than before and can result in reduced cardiac output that doesn’t meet the normal demands of the body. This can result in fluid build-up in the legs and reduced exercise tolerance and is known as heart failure.

The process that blocks the arteries is known as atherosclerosis which is essentially a build-up of fatty material that circulates inside your blood vessels. Over time, this atheroma gradually accumulates, like a natural dam in a stream, and restricts the blood flow, often without any symptoms until the last minute. Like many things there is no one cause for this but rather a group of risk factors that are commonly preached about by healthcare professionals but that are worth repeating here.

Smoking (stop it!)

Inadequate physical activity

Poor diet

Obesity

High blood pressure (the higher the blood pressure in the blood vessels, the harder the heart has to pump to push the blood around, inducing extra strain that can damage heart muscle over a period of time, not to mention increasing the chance of blood vessels blocking)

High cholesterol

All of these are things that can be managed and optimised and are extremely important to consider, particularly if you have a family history of heart disease. If you are concerned about any of the above, it is always best to come and have a chat with your GP to talk about the best ways to reduce your risk of heart disease. Having a healthy heart doesn’t need to be more complicated than addressing the above factors and prevention is always better than the cure.

Dry January: Probably a good idea

‘Billionaire Vodka’ is filtered through ice and then some Nordic birch charcoal before being passed through sand made from crushed diamonds and gems.

I saw a programme on television a while back (I think Chris Packham was involved) in which there was a gentleman who, seemingly unprovoked, would quite regularly lose co-ordination, become disorientated and somewhat ‘lary’. Despite his protestations, his wife began to suspect that he was sneaking off to the pub at every available opportunity without telling her. Understandably this placed rather a strain on their relationship until finally it transpired that he was innocent after all. It turns out he was suffering from something called Auto-brewery Syndrome.

This thankfully rare condition is thought to occur when there is an overgrowth of yeasts in the intestines that produce a natural fermenting process in the gut, resulting in high alcohol levels that make the sufferer quite literally drunk without having consumed any alcohol.

Fermentation (the science of which is known as zymology for the purposes of pub quiz trivia) is key to producing alcohol and there is evidence to show that we, as a species, have been using it to make alcoholic drinks for thousands of years, as far back as 7000 BC. In the middle ages we were brewing beer as an everyday drink, often protecting against various water-borne diseases. It was also quite handy for sailors to take along with them on long voyages. Essentially, alcohol – specifically in alcoholic drinks ethyl alcohol or ethanol – is produced when yeasts and bacteria break down natural sugars found in fruits and grains in the absence of oxygen. Lactic acid that causes cramp in muscles during exercise is formed through a similar process.

Of course, as much as we like it, drinking the stuff does not always result in the best of outcomes. Some research has estimated that, at any one time, up to 0.7% of the world’s population (equivalent to around 50 million people) are drunk. Unfortunately in the UK in 2016 7,327 people died from alcohol specific causes and around 40% of all violent crime involves alcohol in some way. It accounts for more than a million hospital admissions each year.

As you can imagine, this creates rather a strain on the health service as well as on a person’s general health. When we drink alcohol, it creates a numbing effect on the brain, resulting from inhibition of certain neurotransmitters. Most likely it is this sensation that has us coming back for more each time. While in the moment it could be described as pleasant, it has some far more negative effects.

Your body reacts to ethanol as a toxin and this causes a reduction in insulin effectiveness in the long term if we drink a lot. Conversely, in the hours after drinking lots of ethanol, there will be an upturn in insulin production, lowering our blood sugar and causing tiredness and fatigue. As it is broken down, it produces acetaldehyde, which is heavily implicated in hangovers. It is also something which has been implicated in ethanol’s role in causing cancer, in this case by damaging DNA.

There are seven proven types of cancer (probably more yet to be proved) in which alcohol has a causative role: bowel, breast (possibly due to increased oestrogen levels), laryngeal, pharyngeal, mouth, oesophageal and liver. The liver becomes more and more damaged with persistent alcohol use and the scarring produced from this (cirrhosis) can cause irreparable and unpleasant consequences which may ultimately be fatal.

If that is not enough, excessive alcohol will drive up blood pressure and predispose a drinker to diabetes, all of which increase the risks of heart attacks and strokes. Alcoholic drinks account for around 11% of the UK population’s sugar intake further compounding this risk. It will inevitably cause weight gain and likely some tooth decay along the way.

Sleep can be greatly affected by alcohol. While many people drink as an aid to sleep, although that initial numbing effect may help them drift off, the sleep achieved will be restless and inefficient. Time spent in REM (rapid eye movement) sleep will be increased, resulting in less time spent in deep and restful slumber. This only causes fatigue and makes things worse rather than better. 

What then, is a ‘safe’ level of alcohol? The chief medical officer’s official recommendation is that we do not exceed 14 units of alcohol each week (one unit is 10ml of alcohol). This is a reduction from the old recommendations and represents roughly 6 pints of beer, or 6 glasses of average strength wine.
Often people underestimate how many units there are in their drinks – it is more than you might think!

If you do drink 14 units a week, spreading them out is the way to go rather than all at one time. If you are drinking any more than this, you are really not doing your health any favours, not to mention your bank account. Incidentally, the most expensive vodka in the world will set you back a cool 3.7 million dollars. ‘Billionaire Vodka’ is filtered through ice and then some Nordic birch charcoal before being passed through sand made from crushed diamonds and gems. Served in a diamond encrusted crystal bottle, it is some fairly serious stuff. While not all alcohol is priced that high, it does highlight the glamour that often surrounds it. Therein lies much of its danger.

Dependence on alcohol can creep up on you and, if unchecked, can quite literally kill you. It is thought that only 6% of alcohol dependant people will access treatment every year, so if you are unsure it is worth coming to see your GP or accessing any of the online resources listed at the bottom of this article.

You may have heard every now and again about the benefits of alcohol. In the past, before the advent of anaesthesia, surgeons would ply their patients with alcohol before procedures and physicians would recommend a ‘hot toddy’ to stave off a cold. In fact, while giving an initial boost (due to the effects of alcohol on the mind) a dash of whisky in your hot drink probably only serves to slow down the natural process of fighting off the infection.

Certainly there have been studies reported in the papers about regular red wine being good for your heart. The truth is, certainly in my mind, that there is simply not enough evidence to back this up. While some studies have shown benefits, the context in which they have been carried out is far from conclusive. Things like red wine do contain ingredients known as flavonoids, thought to be rich in anti-oxidants which, among other things prevent clotting disorders. However, current evidence only points towards an overall benefit in a very small amount of alcohol (5 units a week) for women over 55 years old. Before you all go rushing down to the pub, remember that is a mere 5 units a week!

So I would recommend that the next time you feel a spot of cenosillicaphobia coming on – a pathological fear of an empty glass – consider filling it with something other than alcohol instead. I’m not saying we should stop drinking altogether but moderation is the overwhelming key. And if there are any generous billionaires out there, I would much prefer a nice house or three rather than a bottle of vodka. Thanks. 

Exercise

“Fit and fat is better than being unfit and thin.”

Forget pills, staying active is the best medication.
After-all, when it comes to being healthy, there is almost nothing else that comes near it in terms of its effectiveness.

There is a quote from a health promotion consultant called Dr Nick Cavill that seems to pop up more and more regularly these days – ‘If exercise were a pill, it would be one of the most cost effective drugs ever invented.’ When you look at the statistics, it is difficult to disagree.

There is strong evidence to suggest that exercise reduces the risk of the following conditions by the following percentages…

Coronary artery disease and stroke – 35%
Type 2 Diabetes – 50%
Colon cancer – 50%
Breast cancer – 20%
Osteoarthritis – 83%
Depression – 30%
Dementia – 30%
Hip fractures – 68%
Falls in older adults – 30%

These are not insignificant numbers as I’m sure you will appreciate. Exercise really is good stuff and also helps with self esteem, sleep quality and energy levels.
The government’s aim is for everyone to be doing around 150 minutes of moderate aerobic exercise each week. Moderate exercise is something that essentially causes you to breath faster, increase your heart rate and feel warmer – a good way to gauge it is if you are breathing too heavily to sing the words to a song. Examples might be going for a brisk walk or hike or playing a game of volley ball. Only half of us in the UK are reaching that target. It doesn’t take too much of an imagination to consider the effect it would have of all of us matching this target on the mortality rates for all of the conditions above.

It goes deeper than this though. We are a species that evolved as hunter gatherers, constantly on the move, but in world with televisions and remote controls, motorised vehicles, and robots that do your hoovering for you, it comes as no surprise that we are suffering from the effects of a sedentary lifestyle. As such, even if we are reaching our exercise targets, if we spend the rest of the time sitting or lying down (and the average person in the UK sits for 7 hours a day, 10 hours if you’re over 65 years old) then those benefits are lost or at least have less impact on the risk of adverse health conditions.

It is therefore key for us to move about every now and again even if we’re not exercising. The recommendation is that every half an hour, we should get up and move about for 2-3 minutes. Practically I know sometimes it may seem difficult but actually when you think about it, is it really? Sometimes only the smallest things need adjusting to achieve this, whether it be an agreement with your boss to get up and walk around the office once in a while or maybe even (as horrifying as this sounds) keeping the remote in the shed at the bottom of the garden. Essentially we’ve all got a bit lazy and our bodies are experiencing the consequences.

For those thinking, ‘well my knee hurts too much for me to do any exercise’, or ‘the local volley ball court is too far away,’ I’m afraid that’s no excuse. Remember, moderate aerobic exercise is anything that gets you breathing and increases your heart rate, so if your knee hurts, do some swimming or even some armchair aerobics, likewise if you can’t get to your local sports centre easily, go for a brisk walk down the road or around the garden for 30 minutes every day. There is a mode of exercise for almost everyone.

Why does exercise and activity help you may ask? Recently, research has revealed quite in depth benefits that we were previously unaware of. Much of this has to do with the anti-inflammatory effects of activity. At the cellular level, our bodies are in constant turnover. Each cell in our body has something called a mitochondria which is essentially a mini power plant. It is here that we produce energy to be used in various processes throughout the body. Each mitochondria will build up a charge and if we are not using energy, they stay charged. The longer they do, bits of charge will gradually escape in the form of ‘free radicals’. These free radicals are bad news and contribute to cell and mitochondrial damage, aiding the ageing process and generally making us less healthy. It is thought that this process causes microscopic inflammation throughout the body.

Activity and exercise helps by utilising this energy and preventing release of free radicals but also produces anti-inflammatory substances from muscle that help to mediate the inflammation at a cellular level. That is not to mention its effect in increasing insulin sensitivity of cells, reducing risk of conditions like diabetes, along with strengthening heart muscle to reduce average heart rates and contributing to lower blood pressure and cholesterol.

There is a lot of focus these days on weight loss when it comes to exercise. This is quite a damaging concept and is reinforced by many commercial diet plans and courses. Although it is important to maintain a good weight and avoid obesity, weight loss is not the be all and end all. There are two types of fat. Subcutaneous fat (sub – beneath; cutaneous – skin) is the stuff that pads out our waist lines and is the most visible. However, arguably far more important is the fat that surrounds our organs like the liver and the heart. This is called visceral fat (viscera meant ‘internal’ in latin) and build-up of this visceral fat has significant implications for our general health. Even if our exercise seems to be doing nothing to our subcutaneous fat, it will be having far greater effects on our visceral fat and this is very important. Therefore we mustn’t measure the success of our exercise or indeed any form of activity with weight loss. Fit and fat is better than being unfit and thin.

The Eye

“…fingerprints have approximately 40 individual features but the average iris has 256.”

What do the following celebrities all have in common? Christopher Walken, Dan Akroyd, Simon Pegg and Jane Seymour. It takes only a quick glance at the title of this article to ascertain that it must be something to do with their eyes. Well done though if you said that they all have ‘Heterochromia’, which means that each of their eyes are different colours. Regardless of whether or not one’s eyes have this rather exotic trait, these clever and intricately complex little organs tend to be a focal point and, at an individual level, one of our most vivid and emotive defining features.

They are thought to have evolved initially in single celled organisms that held light sensitive proteins. Over many millions of years, the process of ‘seeing’ became a reality through a mind-boggling transition into the eyes that we see today. Across the animal kingdom, there are many different types of eye and, as is the outcome of all evolution, the creatures they serve benefit in different ways depending on the environments in which they live.

Geckos can see colour 350 times better than us, bees have 5 eyes, most spiders have 8 and worms merely have a collective of light sensitive receptor cells. Not all eyes are structurally the same. For example, some vertebrates, including cats, have an extra layer of tissue behind the retina (the layer of cells that collects and processes light) called the tapetum lucidum. This reflects any light that has got through first time round and reflects it back into the retina again, giving rise to excellent night vision – very handy for catching unsuspecting mice. It also results in the eye-shine we see when some type of mammal is lurking in the bushes and served as inspiration for the ‘cats’eyes’ we see on our roads.

We humans must make do without these handy features and we are limited to just the two eyes. This is better than one though, as it gives us a perception of depth. To enable us to see, we must collect the light from around us and process it. Light bounces off everything (almost) and if we look towards something the light from this will hit our eyes. This light travels first through the cornea and second through the pupils (the holes made by the retractable fibres that make up the iris (the part that gives our eyes their colour). Here it hits the lens, a rounded clear organ that alters in size as we focus differently. This allows it to redirect light from different distances onto the back of the eye where the retina sits, so that it doesn’t produce a blurry picture. At the retina, the light is converted by different types of cells into nerve signals and the information is then taken via the optic nerve to the brain where it is further compiled into what we understand as ‘sight’. Interestingingly, because of the way in which the light is focused on the retina, the unprocessed image is upside down and back to front, so the brain must flip these back the right way round.

As doctors, the eyes are a useful thing to check when examining a patient because they can tell us a lot about a person’s health. Shining lights into the eyes causes the pupils to constrict and faults here can point to certain neurological conditions as can double vision and loss of visual fields. Looking at the back of the eye, we can sometimes tell if there is raised pressure in the fluid surrounding the brain, and at the front, there are characteristic appearances in or around the eyes of people who might have thyroid problems or high cholesterol. In babies, it is important to check for something called the red reflex, the normal red-orange colour of the eye when light is shone. Asymmetry here or a white reflection can sometimes point to something called retinoblastoma which is a type of cancer.

The most common eye examination one might receive is the visual acuity check. Using the Snellen charts, reading the letters on rows of ever decreasing size, we challenge ourselves to get to the very bottom level. The phrase ‘20/20 vision’ is often talked about, which essentially means we can see something at 20 metres that the average person would see at 20 metres. Outside the USA, we use 6 metres as a scale and if you wanted really exceptional vision, you would aim for something more along the lines of 6/7 (in other words you could see something from 7 metres that the average person would only be able to read at 6 metres).

If our vision isn’t quite up to scratch, we might need a correction and this is where glasses and contact lenses come in. Depending on which survey you read, between 69% and 77% of people in the UK wear glasses or contact lenses – so many that it is isn’t surprising that they have become somewhat of a fashion accessory!

More seriously, there are currently approximately 2 million people in the UK living with a level of sight loss that has a significant impact on their daily life. There are around 350,000 people registered as blind or partially sighted alone.

There are a plethora of conditions that can cause such sight loss.

  • In the UK, age-related macular degeneration is a major cause (a deterioration of the macula, a part of the retina, due either to the formation of deposits on the retina or to fluid build-up underneath the macula).
  • Diabetes is a big cause of sight impairment as well – it causes progressive damage to the blood vessels at the back of the eye and is known as diabetic retinopathy.
  • Glaucoma is a build-up of pressure in the fluid within the eye. Your optician will check your pressures by puffing air at the eye using a machine. As long as it is well controlled and monitored it can be treated with certain medicated drops.
  • Cataracts are a gradual clouding of the lens. When vision is too severely affected, surgery is an option to correct this.
  • Retinal detachment is an emergency and characteristically involves a sudden curtain of vision loss falling over one eye. It may be preceded by flashing lights and a sudden increase of floaters and needs an immediate trip to eye casualty.

Incidentally, floaters are small bits of debris that float in the eye and move around with a slight lag as the direction of gaze changes – these are common, and, except as mentioned above, are not normally something to worry about, though they can be very annoying. Unfortunately they are essentially untreatable.

As GPs, we often see a handful of more common and less serious conditions that could have been dealt with first by a pharmacist or managed at home. Red and gunky eyes most often represent conjunctivitis, while red swollen eyelids (blepharitis) or a cyst or stye over the lid can be treated with hot compresses, and a watering eye can be your body compensating for a dry eye, so try some lubricating drops. Most eye conditions do not need antibiotic treatment.

If your eye is painful however or if you are not quite sure, this must be reviewed, especially if it is red as well. There will be a local eye casualty (if you’re in the UK) that patients can call if they are unable to get to their GP. This may be where your GP refers you if they feel it needs more in-depth specialist review.

The following recommendations can help to keep your eyes healthy:

  • Don’t smoke – Unsurprisingly this causes all sorts of problems including macular degeneration and cataracts.
  • Make sure you wear sunglasses – it protects against harmful UV rays and makes you look awesome.
  • Get regular optician checks – apparently around 10% of the adult UK population have never had an eye check. Problems are not always immediately evident and so it’s best to get checked every two years at the very least, more frequently if you’re over 40.
  • Eat the right things – generally anything with lots of omega 3 fatty acids and vitamin A (also known as retinol which helps with night vision!) Examples would be oily fish, kale, spinach, peppers, oranges, broccoli and eggs.

So overall, eyes are pretty marvellous things and, more than that, they are deeply personal. One only has to look at the rising use of retinal scanning to realise just how individual they are -fingerprints have approximately 40 individual features but the average iris has 256. We only have two of them, so we must take the best care of them possible.

The Brain

While we know more than we ever have, there is still a lot to learn meaning that, in an ironic sense, the brain is still something we can’t fully get our head around.

Someone once said that if the human brain were so simple that we could understand it then we would be so simple that we couldn’t. I would have to agree. The brain is our vastly complicated seat of consciousness and individuality, controlling most functions of the body, some of which we are aware of and some of which are on a more subconscious level.

If one were to zoom in to see it under a microscope, one would find literally billions of nerve cells, or neurons, forming a continuous interconnected network signalling to each other using electrical pulses and chemical transfers. There are around 86 billion of these neurons in the adult brain, meaning that if you were to pick an area of the brain the size of a small grain of sand you might find as many as 100,000 neurons in just that one area. What’s more, each one connects to around 1,000 others via connections known as synapses.

As we zoom out again, we see that the brain has a wrinkled surface that, if stretched out flat, would cover the area of four A4 sheets of paper. It is cushioned and bathed by a viscous layer of cerebrospinal fluid that, as the name suggests, runs all the way down around the spine as well.  Weighing in at around 2% of our body weight, our brains manage around 98% of human function, which is a pretty good return. It follows therefore that it needs a fairly good power supply and, indeed, it has an important network of blood vessels that supply it with oxygenated blood and nutrients – it uses around 20% of the body’s energy supplies.

With such a complex make-up and such a plethora of responsibilities, it is no wonder that it is regarded with such intense interest and yet is still relatively poorly understood compared with other organs of the body. As with much scientific endeavour, much progress has been made in its understanding over the last century.

Take the frontal lobe for example. As part of the quest to understand the brain in more detail, scientists identify areas in accordance with their perceived function. The frontal lobe is thought to be involved in executive function such as judgement, decision-making, planning and control of behaviour – functions that became clear following an accident involving a railway worker named Phineas Gage in which, rather unfortunately, he received a metal pole through his forehead. Though he survived this ordeal, the once calm and understated worker famously showed a marked change in personality towards aggression and surliness.

Had the pole gone through his occipital lobe, he might have had trouble with his vision and, if it had pierced the temporal lobe, he would potentially have had trouble processing sound, using his memory and producing speech.

The point is that certain areas of the brain are involved in particular tasks. This can become apparent when someone has a stroke. Most strokes happen when blood supply to an area of brain tissue is interrupted.  The result can be, for example, loss of motor function in one side of the body. If there is a problem in one half of the brain, then the problem (when talking about motor function – i.e. moving an arm) manifests in the other side of the body. This is because nerve fibres from each side of the brain cross over at a certain point before descending the spine to the rest of the body.

We know that the brain performs so many functions. It allows us to move, to smell, to hear and to sense temperature. It also enables us to think. While this complexity is admirable, when it goes wrong the consequences can often be very distressing. Infection, head injury and cardiovascular disease all affect the brain’s health, as well as conditions such as Parkinson’s disease which affects the production of dopamine, (normally used to regulate our movement) and resulting in involuntary shaking, slow movement and stiff muscles.

Most significant of all, as our population grows older, dementia is becoming the largest cause of mortality in the UK and all over the developed world. Research is ongoing and we still have a long way to go both in understanding the processes involved and in treating the effects. It should be mentioned that dementia is not a single disease, rather a term to describe the symptoms that occur when there is a decline in brain function.

Alzheimer’s is the biggest cause of dementia. Though not fully understood, it is believed to be related firstly to the build-up of amyloid plaques and secondly to neurofibrillary tangles made up of proteins called TAU proteins. As more of these build up, the ability of the neurons in the brain to transmit information gradually diminishes. Research is currently focusing on the processes involved in the development of these two features. Just as importantly, the search is on for biomarkers (markers that we can sample in the blood or spinal fluid) that might give us an idea of whether someone might be developing a dementing condition, giving greater opportunity to take early steps to manage the condition and also to research disease progression over longer periods of time. Although it can be difficult to face, and often slow to present, if you have any concerns about memory, it is important to see your GP as there is often support available and it may also be the result of more benign and treatable conditions (for example low vitamin B12 levels or underlying infection).

When concentrating on the more physical effects of the brain, it is sometimes easy to overlook the deeper thought processes that are involved in our mental health. Much of our individuality comes through the environment in which we grow up. In the same way that we form new connections and synapses in our brains through repetition as we learn an instrument or practise our times-tables for example, it is thought that personality traits develop to some extent in the same way. For untold reasons, however, our minds can be fragile and depression and anxiety can be extremely damaging. Often there are so many different factors, both social and physical, that make such emotional issues difficult not only to treat but also to recognise. Chemical imbalance plays its part, for example in relation to levels of serotonin in the brain, and in such cases there can be a role for medication. More recently, there has been a push for increased awareness of mental health conditions in an attempt to remove any stigma attached to something that can cause a lot of problems if left unaddressed.

How do we look after our brains? Staying happy is a good start and there is plenty of support available for people for whom this is not the case. Keeping your mind busy helps to maintain your ‘neural plasticity’ – it ensures you are creating new synapses by learning new things. Maintaining healthy social networks is equally as important.

Regular exercise is vital for brain health as it increases the blood supply to the neurons, reduces blood pressure, helps blood sugar balance, improves cholesterol and reduces mental stress.

Getting enough sleep each night is important (8 hours being the aim).

Your diet can also give you benefits. Anything rich in omega 3 such as oily fish is useful and a ‘Mediterranean-style’ diet is a good start. Blueberries are rich in anti-oxidants, thought potentially to reduce inflammation involved in plaque formation in the brain, and dark leafy greens, such as kale and spinach, will give you good sources of vitamins C and E and folates – all thought potentially to reduce the risk of Alzheimer’s.

There is some evidence to suggest that certain people may benefit from medications like statins and aspirin but it’s always a good idea to come in to discuss any medication with your GP or pharmacist. And don’t forget not to smoke or drink too much alcohol.

While we know more than we ever have, there is still a lot to learn meaning that, in an ironic sense, the brain is still something we can’t fully get our head around.

 

The Problem with Antibiotics

Our honeymoon period with antibiotics and their undeniable benefits ended long ago, but since their inception we have created a deep seated culture of dependence.

Many thanks for your responses to my article last time around – keep those suggestions for topics coming. Shortly after I had finished the article about the common cold, I developed a cold of my own, so I have decided to postpone indefinitely my planned article on smallpox.

Our topic this week is antibiotics – a subject which is garnering more and more attention in the media. Since 2015, there has even been an annual ‘world antibiotic awareness week’ which, appropriately, was last week.

Why the fuss? Well I am sure most people by now have heard all sorts of stories in the news about antibiotic resistance and the emergence of ominously entitled ‘superbugs’. This is all for good reason as I will expand upon.

To begin with, let’s focus on antibiotics and what they actually are. Prior to their discovery and development in the early half of the twentieth century, we had no really effective ways of treating bacterial infections. Historically, all manner of approaches were used, from the rather dramatic process of blood-letting (thought to stabilise the balance of the perceived four humours: blood, phlegm, yellow bile and black bile), to the use of things like willow bark by the ancient Greeks for curing fevers and pains. (Willow bark actually contains salicin, which is chemically related to modern day aspirin).

Things all changed when the Scottish botanist Alexander Fleming returned to his laboratory in 1928 after a family holiday and noticed that mould had grown in his petri dishes of staphylococci bacteria. The mould in question (penicillium) had killed off the surrounding areas of the bacteria prompting Fleming’s famous response – ‘That’s funny’.

The rest, as they say, is history and since then many different families of antibiotics have been developed to fight off bacterial infections that had once been, at best, troublesome and, at worst, fatal. As we approach a century of antibiotic use, we can look back upon a vast improvement in our ability to treat infections such as pneumonia, syphilis, tuberculosis, meningitis and many more. This has no doubt had a vast social and economic impact. However, now we come to the problem.

Antibiotic resistance is a process that has been developing from the very beginning. In broad terms, let us consider a group of bacteria exposed to an antibiotic. In any reproducing population, there will always be random mutations that occur in the genes of certain individual bacterial cells. Sometimes these mutations happen to protect the bacteria from the effects of an antibiotic. Bacteria without that protection die, leaving the resistant bacteria free to multiply without competition. Over time, these populations spread from person to person, meaning that, when the same antibiotic is used repeatedly, it becomes less and less effective in controlling these bacteria. That’s it in a nutshell.

We are now at a stage in which no new class of antibiotic has been found since 1987 and there are thought to be around 12,000 deaths each year in the UK as a result of bacteria resistant to antibacterial treatment. If this trend continues without further action, the World Health Organisation (WHO) state that the global mortality from such infections could be as much as 10 million people a year by 2050. Advancements and achievements in modern medicine such as chemotherapy, organ transplants and routine operations like caesarean sections and hip replacements – all of which rely heavily on the availability of effective antibiotics – are now potentially at risk.

Development of resistance is and always was a natural and unavoidable process but our use of them has unequivocally made things worse than they could have been. In 2015, it is thought that around 25% of antibiotics were taken unnecessarily in the UK. When you factor in un-regulated use of antibiotics in farming and the availability of antibiotics over the counter in some countries, one begins to see how much of a global issue this is.

On a personal note, I have certainly seen strikingly inappropriate use of strong antibiotics prescribed in other countries for even the most trivial of ailments. There is most definitely a responsibility amongst us as healthcare professionals to monitor what we are prescribing. Having said that, there have been surveys suggesting that up to 90% of GPs have experienced pressure from patients to prescribe antibiotics even when this was not appropriate and would serve no purpose. While this obviously differs from area to area (and to be fair you’re a pretty good bunch), we all share a certain responsibility in tackling this issue.

I don’t want to sound too gloomy, and thankfully there has been some international recognition of the issue. The WHO endorsed a global action plan in 2015 (though lamentably it will certainly now have to make do without the help of Robert Mugabe) and since then 193 countries have given further political endorsements via the UN to install tighter regulation and encourage further research into new antibiotic classes.

As often is the case with such gradual phenomena, the effects of such crises are not always immediately apparent. However, in this case, the signs have been there for a long time and Fleming himself warned about the potential for resistance. Now those signs are becoming ever more obvious and we must face up to the inconvenient truth. We stand to lose a lot if we refuse to do so.

Hygiene both in the community and in hospitals is vital to prevent the spread of bacteria. Responsible and restrained prescribing from doctors both here and all over the world is also required. Research into new antimicrobial agents is ongoing but slow, and techniques to bolster our existing agents is important for our short term management of the more serious infections. Crucially, educating people as to why it is often inappropriate to prescribe an antibiotic is just as important – after all we’re all in this together.

Our honeymoon period with antibiotics and their undeniable benefits ended long ago, but since their inception we have created a deep seated culture of dependence. This will be difficult to withdraw from, especially considering the advances we have built around it. Over the coming years, we must now consider whether or not an even more dramatic shift in our utilisation of such medicines is required before nature takes the matter out of our hands.