The Elephant in the Flood

Posted on February 13, 2014 by Elen Samuel

As we all look at our TV screens at the devastation caused by the recent flooding of the Somerset levels, the Thames and the Severn, our thoughts turn to climate change. Storms, unstable weather, floods were all predicted years ago by scientists noting the increased levels of carbon dioxide in the atmosphere, and most people can see the connection. Global climate change is also influenced by other factors such as sunspots1 and normal cyclical changes in weather systems, but few can now deny the contribution that our species makes.  So, looking for answers to the floods, we turn first to spending money for relief, making sure insurance systems pay up, then to better management of our rivers, more planting of trees at the river sources, possibly dredging (though this is disputed2), managed retreat of our coastal regions, and even looking at whether we really should continue building on flood plains.

But I see no mention at all of the basic problem. England, taken on its own, is already the most over-crowded country in Europe; the UK is 73% ecologically overshot (data from the Blue Planet Award-winning Global Footprint Network), and it is England that is suffering from the floods. Yes, Wales and Scotland have been affected, but not nearly to the same extent. (Anyway, they are used to rain aren’t they?) England, and especially the South of England, is suffering from severe problems of sustainability. The pressure on housing, especially in the Thames valley, is immense and flood plains are easy targets. In dry summers, people love to be by the river, and the risk of floods is forgotten.

It is hard-wired into our brains to want children. They bring meaning to our lives, joy, and even now, prestige. Some of my friends, now grandparents, take great pride in their tribe of offspring – some have ten, fourteen grandchildren. They are wealthy people, why shouldn’t they? But there has been an 18% increase in the birth rate in the UK in a decade, according to figures from the national census3. This is partly due to the higher birth rate of recent immigrants, but the indigenous population is having most of the babies. Britain’s population rose by more than 400,000 in 2012- the largest increase of any European Union member state – putting the present total at 63.7 million.

Project these figures forward, and we find that each additional person requires us to spend £165k on housing, infrastructure, equipment and training, to extend to them the services and living standard of current UK residents4. This cost is borne by existing residents, through a higher cost of living. At the current population growth rate, this corresponds to over £1k per person each year. We will need to spend vast amounts on new power stations as well as building many more wind turbines, and it is likely that we will miss the green and renewable targets, weak as they are, in the pressure to just stay still.

How will we feed ourselves? We can’t at the moment, of course. It seems we couldn’t even during the First World War! At current consumption levels, the maximum sustainable UK population would be 15million.4 The extra food we have to buy from abroad. If the population rises to 75 million we have to import much more, and on a global scale it is far from clear that the food will be there to import. Certainly our present high standard of living, eating so much meat, is not sustainable and we are likely to see world food shortage by 2040.5

Economists always tell us that we need more and more growth – that is the only way to pay our debts, and to have prosperity in the future. So how many new jobs would the UK have to create to keep unemployment at mid-2000 rates under different population projections to 2050? If there are 88 million of us, there would have to be an annual job creation rate of 0.60%; in a lower projection, 79 million, of 0.45%; and the lowest projection, 68 million, of 0.25%. A stable population is the best economically sustainable strategy to achieve long-term economic prosperity (real income per person). 
Conversely we are also told that we need more young people to care for the increasing elderly population – we need enough tax-paying young adults to pay their pensions!  This is certainly true, as at population sizes below 50 million we would struggle with rising pension and health-care costs. Inevitably the older generation will have to keep economically active for much longer, and more women will have to work. So a stable population would bring great advantages.

In the final analysis, we may never achieve a steady state of economic activity. It seems that as the world burns fossil fuels, we get economic growth, and if we try to limit it we will get a downturn in which everyone will suffer. And if we continue to grow our economies so that people in the developing world can increase their standards of living, we will, unless we are very careful, use up the earth’s resources and destroy it. The only way out would be to continue to innovate (nuclear fusion for energy? better food production?) to prevent this catastrophe.

In the meantime, I don’t think there is any doubt that the UK needs to limit its growth. 80% of people want a smaller UK population. Immigration is becoming a huge issue, and has been too unbalanced in the past, with very young, uneducated people coming to the UK, and some may have many more children than they can support on their own. Educated and hard-working people are very welcome and contribute a lot to our society.  But family planning issues are paramount, so that each family, whether rich or poor, should have a maximum of two children.

As a doctor, I think family planning and health education need to be improved, particularly to lower the teenage pregnancy rate. Teenage pregnancy in Britain has declined substantially over the past decade, as a direct result of the work of the teenage pregnancy unit, (now closed down), and this was a great success story. However it remains the highest in Western Europe. Personally I think this may reflect several things, such as poor quality sex education in schools7 , and a youth culture where alcohol is cheap and drugs are readily available.  There is very little evidence that teenagers get pregnant in order to get benefits such as housing benefit; the usual reasons in my experience is lack of clear aims and of control over their lives.  The present changes to withdraw housing benefit to the under 25’s is unlikely to reduce the teenage pregnancy rate much, but as many of the younger generation already find it tough to get jobs and housing, it will certainly concentrate people’s minds on the affordability of more children. Another thing that should really should be prioritised is adoption – only 60 babies were adopted in 2010/118 , a record low.

Quite apart from any efforts to stop global population increase and to try to reduce the effects of global warming and climate change, we ought to look to our own interests.

A recent report from Population Matters, a charity which aims to raise awareness of the cost to humanity of population growth, concludes that the Government should:

  1. Create a national consensus that a stable or smaller population is an urgent national interest;
  2. Add Population to the duties of an inter-departmental Minister, with a small coordinating staff;
  3. Review tax and benefit policies, removing perverse incentives for large (>two children) families;
  4. Set a long-term UK policy aim of balanced migration;
  5. Promote population stabilisation policies, by voluntary means, internationally.

What do you think?

References

  1. http://www.scientificamerican.com/article/sun-spots-and-climate-change/
  2. George Monbiot, The Guardian, Thursday 30 January 2014 14.30 GMT
  3. http://www.populationmatters.org/2014/newswatch/british-birth-rate-leaps-18-decade/
  4. Population Matters O’Sullivan Jane Univ Brisbane, http://www.populationmatters.org
  5. Aiking H Trends in Food Science & Technology xx (2010) 1e9
  6. http://ourfiniteworld.com/2011/02/21/there-is-no-steady-state-economy-except-at-a-very-basic-level/
  7. http://www.ncb.org.uk/media/333301/young_peoples_survey_on_sex___relationships_education.pdf
  8. http://www.theguardian.com/news/datablog/2011/sep/29/adoption-statistics-england
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GP Fat Cats?

Posted on November 28, 2013 by Elen Samuel

I was recently gossiping with an ex-colleague of mine, who works as  a NHS manager. We were talking about colleagues we both knew (in management) who were well known to take their jobs very lightly – they used  to take time off without documenting it, and were often “working from home” and uncontactable during office hours. I asked whether the recent austerity had changed anything, and apparently the answer was “no”. I wasn’t surprised – the NHS locally has never been good at managing its employees, at least the senior ones. There weren’t very many of them doing that, but some seemed to get away with a very easy lifestyle. I compared that to a GP’s lifestyle – the workload GPs have is fixed by demands of the patients and they are effectively self employed, so it is not easy to get away with being unavailable or not pulling you weight. She was less than impressed however.

A little later on we were talking about the recent OECD  report “UK GPs among best paid in developed countries’ and my friend said yes GPs really are overpaid fat cats aren’t they? ” That does seem to be the impression most people and especially managers and hospital staff have of GPs. GPs are supposed to earn more than consultants according to these figures.

But it isn’t quite so simple .

GP pay in this survey includes professional earnings from ALL sources, NHS or private. Consultant earnings are from the NHS ONLY. That is because it is difficult to collect figures from self employed GPs and therefore they take overall earnings rather than from the NHS.

Also the job is very different in different countries. German GPs for example don’t do Gynae, psychiatry or see kids under 4, GPs in the Netherlands don’t deal with depression (they send patients to psychiatrists and psychotherapists). GPs in the UK  do a lot more chronic and acute disease management than GPs in other countries, so the job is broader in its scope and responsibilities. In many of the comparator countries GPs are more of a sorting house where they either send everyone off to a hospital or deal with less severe acute self-limiting illnesses. So it’s a different job.

According to this survey GP partners in the UK earned 3.4 times the average national wage. This compared with those in Ireland, Canada and the Netherlands who earned three times the average.  But UK salaried GPs earned 1.9 times the average wage, the figures showed, and there are getting to be far more salaried doctors under the recent changes to the GP contract.

According to a GP negotiator. GPs hours are much longer, and pay when stripped back to 40 hrs pw, is now an average of  £55K after all expenses of employing staff paying employers’ and employee’s superannaution, and defence costs paid by the doctor, are removed.  Many managers earn far more than this.

Doctors on a chat site were angry that the survey misrepresented them.

One doctor, having worked for many years in Canada said that the pay was over twice as much, the hours the same and the quality of life so much better, both at work and at home. Unfortunately he  had to come back to the UK for family reasons and now hates every second of it!  One doctor quoted from an email from a recruiting company in Australia (said in this survey to pay GPs only 1.7 times the average wage), “The average annual income for GP’s working for this company ranges from $200,000 – $350,000 (£135,000- £236,000) per annum –in a fee for service system”.

Possibly the average wage is much higher in Australia, and we know that the cost of living is higher in many areas of the UK. Another doctor speaking to a GP from Belgium said that his income, before tax, is 14000 euros a month.

This post isn’t going to convince many of the British public who now really do see GPs as fat cats. But the NHS, more than most other countries, has to ensure that GPs do a proper job, that is dealing with the many conditions that can be safely dealt with in primary care, and not sending everyone to hospital where the care may be excellent, but sometimes unnecessary. Our taxes are going to spread to looking after everyone as efficiently as possible. Morale is very low amongst GPs at the moment, and fewer and fewer young doctors are training to be GPs – they are all piling into the hospital system. So we either pay GPs adequately or we really are going to have to add our own money to the cake to pay for all this extra hospital care.  What would that do to the cost of living I wonder?

OECD (2011), Health at a Glance 2011: OECD Indicators, OECD Publishing.
This work is published on the OECD iLibrary,
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Vital stuff not to waste your money on

Posted on November 7, 2013 by Elen Samuel

Vitamin. Its derivation is VITal AMINe or Vital amine – an amine essential to life. An amine is a biochemical substance and not all vitamins are in fact amines. But that doesn’t matter – the dictionary definition is “an organic compound essential to life”. So if something is essential to life we need lots of it, right? It is good for us, therefore it is something a bit magic, and gives us a lift or an edge on those people who don’t have it, who are going to suffer from all sorts of maladies, doesn’t it?
People spend lots of their hard earned cash on buying vitamins. “Which” magazine recently estimated costs1  for some of the common vitamins consumed – £300 per year seemed to be an average cost of a product. Advertising campaigns are everywhere, and there is always a “glow” about them – vitamins, healthy, good, good, good.

There is only a grain of truth in all this hype. Yes, vitamins are essential to life. But only people who are actually sick – enough to see a doctor and get diagnosed properly and then get prescribed them – need to take them, because almost all vitamins are either already present in a normal diet, or can be made by the bacteria that live in our gut (so arguably aren’t really vitamins at all). Vitamin D, which needs sunlight to be synthesised in the skin, is an exception and I cover this later. Other common nutrients – iron, zinc, magnesium and so on, are also present in more than adequate amounts in a good normal diet. There are groups of people who are at risk of vitamin deficiencies – pregnant women and the foetus, children, some old people and those in poor and disadvantaged groups, but surely we shouldn’t be encouraging healthy adults, especially those who are short of money, to buy these expensive artificially produced additives?

We need an education campaign to tell people that the best way to get any vitamin is by eating it – in fresh food. So why is all this money wasted on gimmicks? Fresh food can be expensive, but surely not that expensive and is far more enjoyable, and if you eat the right food you can stay healthy and hopefully slim. (There is another argument raging at the moment about fat and sugar; see previous blog). The problem seems to me that people have been brainwashed into thinking that if they are feeling below par or tired and lacking in motivation, then all they need is a vitamin fix. And it will be proved by the placebo response, that well known fact that 30% people will feel better after taking something they believe will help them, even if it is actually proved to be useless – and even in some cases if you know it is a placebo! 2

Instead, we seem to be in the middle of yet another advertising campaign to encourage us to worry about vitamins and nutrients, supported by no less a person than England’s Chief Medical Officer, Dr Sally Davies. She calls for NICE, the Clinical Excellence body, to examine the cost-effectiveness of offering vitamins A, C and D to all children under five. 3 Of course, children are a very important special group; they are growing quickly and so are likely to need a good supply of vitamins. The report highlights that in many families – often those on low incomes – the quality of children’s diets is restricted, and children often spend long periods indoors. Vitamin D deficiency is a big concern because the lack of sunlight in most of the northern hemisphere means it is difficult for the body to make enough vitamin D. Rickets, characterised by soft and deformed bones and general ill health, has now returned in parts of the UK. It is indeed a disgrace for it to be occurring in 21st century UK. But what a cop out! Instead of ensuring that healthy food is cheap enough for families to buy, and that children are encouraged to play outdoors, we are thinking of giving vitamin supplements to everybody, including children who don’t need it, which is most of them. This is in spite of the fact that it is free right now to disadvantaged families, and the children most at risk – those in families which are too disorganized to take daily tablets – are still going to miss out.

A better way, if vitamin D is really needed, might be food supplementation – the vast majority of liquid milk in the United States is fortified with vitamin D at a level of 10 mcg/quart. Surprisingly, there is very little vitamin D naturally occurring in milk, and the US have had a proactive milk fortification policy since the early 1990’s, even though 49 of the US states are south of the UK and have higher year-round UVB levels than we do. At least it would get us away from the idea that we can take pills instead of eating a good diet.

For adults the marketing gimmick is to customize the vitamin packs you should buy –for male or female, or old age. It is easy to do and there is some science behind the campaigns. Women having periods lose a lot of iron; folic acid is essential to prevent neural tube abnormalities, and the package includes 24 vitamins and nutrients altogether. It sounds so plausible, as if the manufacturers really have our interests at heart, but they don’t. They are misleading us into thinking we need something when we don’t.

The recommendation of the government at present is for all pregnant women, and those intending to get pregnant, to take supplements of folic acid and vitamin D, to reflect the great needs of the growing foetus. Without enough folic acid stores in early pregnancy, babies can be born with spina bifida, which was common in the past, so this is absolutely essential. But you don’t have to pay for them – all these vitamins are of course free on the NHS when prescribed to these groups.

For the over 65’s, vitamin D is indeed essential to prevent osteoporosis and muscle wasting, which can result in fractures after only light trauma, and it is recommended that all people over 65 should supplement with vitamin D tablets. (Free on the NHS of course). But a recent article indicated that taking vitamin D supplements to prevent osteoporosis is not justified in healthy adults. The research (a meta-analysis), funded by the Health Research Council of New Zealand, included 23 randomised controlled trials comprising 4000 participants with an average age of 59, found very little evidence of an overall benefit in terms of bone density of vitamin D supplementation 4. Also it appears that bone density measurement – by Dexa scan – does not necessarily correlate well with the risk of fractures. It is another surrogate measure – you would need to measure the fracture rate in these people to be sure the intervention is  effective.5  It is sound advice to take supplementation, which will be prescribed by your doctor (10 micrograms a day), if you are immobile and don’t go out, but for active healthy over 65’s it is probably not necessary.

It is even more true for all the other vitamins, that people are wasting their money. The “Which?” report is clear, and I hope it has at least some effect in counteracting all the hype about the need for extra vitamins. I have written about vitamins in detail in in my book 6, giving some of the science behind them, and the effects of problems with lack of vitamins and nutrients when people are ill.

But for adults on a healthy diet, it is wasting money. I would like to get away from pill popping in any shape or form, unless it is proved by clinical evidence to be necessary in your case. In the case of vitamins, the amount you need is usually tiny, and any more will not do you any good at all. Excess in some cases can definitely harm you. If you are not feeling well, you need a proper diagnosis, and if nothing shows up, you will need to think of lifestyle factors and your diet rather than resorting to pills, which are no more than quack remedies.

1. Which? September 2013 “Pills Popped”
2. Ted J Kaptchuk PLoS ONE, December 22, 2010, online publication
“Placebos without deception: A randomized controlled trial in irritable bowel syndrome”
3. Annual Report of the Chief Medical Officer 2012; Our Children Deserve Better: Prevention Pays

Click to access 33571_2901304_CMO_All.pdf

4. Reid I, Bolland MJ, Grey A. Effects of vitamin D supplements on bone mineral density: a systematic review and meta analysis. Lancet 11 Oct 2013, doi:10.1016/S0140-6736(13) 61647-5.
5. Clifford J Rosen, of the Maine Medical Center Research Institute, Published Online October 11, 2013 http://dx.doi.org/10.1016/ S0140-6736(13)61721-3p
6. A Sceptical GP, Elen Samuel, Rheafield Publishing, May 2013

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Butter is fine (again!)

Posted on October 30, 2013 by Elen Samuel

For most of the time I was working in general practice, as I was the only female, I saw women with hot flushes and other menopausal symptoms. I advised HRT, which worked fine for the symptoms. Then, as time went on, I was informed by Continuous Professional Development lecturers (to get my “points” for being a good GP) that HRT would prevent heart attacks and strokes in postmenopausal women (over 60) and that I should advise HRT for this group as well. Soon there was an avalanche of stuff from women’s magazines, TV, and newspapers about how good it was, especially at preventing heart problems, and I must have put hundreds of older women on it. Until 2002 that is, when a study1 showed conclusively that women over 60 had a greater risk of heart attacks (and cancer), when they were on HRT than if they weren’t. So we all had to call the women  in and persuade them to come off the tablets. I felt very bad about it, and wondered how I had been taken in.

The reason was obvious when I looked into it – all the worst bits of scientific manipulation were used to persuade me, such as biased trials, exaggerated results, using surrogate outcomes, wrong controls, conflicts of interest, not registering trials, ghost writers and so on.  I put a lot of detail on this in my book2, and of course so did Ben Goldacre in his book Bad Pharma3.

You would think we would learn, or at least science would clean up its act.

But no, it has all started again. Just now we have a very public debate being played out about something very near to our hearts in more ways than one.

Last week we learned that the linchpin of the theory of causation of heart attacks – the cholesterol theory  – is being debunked, by a British cardiologist.4

Now we learn from this article that

1. Saturated fats are not bad for you

2. High cholesterol does not cause heart disease; there is only a correlation,  and in Japan researchers noted a correlation between low cholesterol and mortality from stroke heart disease and cancer.  So there is no evidence that high cholesterol causes heart disease.

3. Not eating saturated fats does not reduce the LDL  (bad cholesterol) that matters – that is a new one on me.

4.  Statins have their effect on lowering risk of recurrence of heart attacks (only in those who have already had a heart attack) because of their anti-inflammatory or coronary plaque stabilising effects, not on lowering cholesterol. No other cholesterol-lowering group lowers the risk. I already knew that statins do as much harm as good for those at low risk.

5. Adopting a particular form of a Mediterranean diet (lots of olive oil, nuts and low sugar) after a heart attack is almost three times as powerful in reducing mortality as taking a statin.

6. Heart disease is associated with metabolic syndrome (i.e. insulin resistance) even in thin individuals). This puts sugar in the frame as the bad guy.

So all those years when I was again being a good GP, putting patients on low cholesterol diets, advising against saturated fats, giving statins even to those who weren’t at high risk, I was wasting my time, and my patients’ time and effort. The comparison is striking – there was evidence that HRT helped women going through the menopause, but the scientific establishment didn’t stop there – all post menopausal women were supposed to need HRT, which would increase profits for the drug companies. The same with statins – we don’t stop at putting patients on statins when they have already had a heart attack or severe angina – we must extend it to everybody even if their risk of heart disease is low, and the harms may outweigh the benefits.

It isn’t as if a lot of this stuff is new –  some of it is, but most isn’t. But it is only now that someone is being brave enough to put their heads above the parapet.

The article was highlighted in the general press, but when I think about it, what are people actually going to make of all this?  I can’t but think that everybody is going to shrug their shoulders and lose faith in anything doctors have to say.

It doesn’t help of course when the news stories don’t actually publish what the researchers had to say. The article on the BBC website5 leaned so far backwards to give an “impartial” view, that it gave more time to the views of an important subscriber to the “cholesterol hypothesis”, this totally confusing the general public and making them think that this wasn’t actually anything new.  This eminent doctor was speaking for the British Heart Foundation, which is funded by Unilever (which makes Flora margarine).

As readers of this blog must now be aware, I am now convinced, along with a bandwagon of other people, that it is sugar that is the problem in causing obesity, diabetes, and also metabolic syndrome, which is a major cause of heart attacks and strokes.  But how can any of us trust any research now, when the flaws are so obvious? Why would anyone believe one theory over another?

Even The Economist, an ardent promoter of “the market” says that science is going wrong, and that competition by researchers for readership and economic advantage is damaging research, (although it doesn’t mention the activities of health business interests).6 The researchers and prominent cardiologists who have promoted the cholesterol theory, who are supported by the food industry (low fat margarines, low fat meals), and the pharmaceutical industry (statins) that have done so well in the last twenty years aren’t going to give up without a struggle. The media are going to help them, and doctors are still going to be advised to stick to the current status quo. Even last week, doctors were being advised by a review in the Cochrane Collaboration, a respected organisation which concentrates on evidence based medicine, that statins were indeed useful in low risk individuals, as a result of a meta-analysis published recently7. For those than can read the BMJ, there is a very good opposing article8 pointing out that all the trials in the meta analysis were conducted by Pharma companies with an interest in cardiovascular drugs, and that side effects are regularly underplayed and under-reported.

But some  doctors will continue to be influenced by the power of the medical establishment and media backed by these companies, and the anti-sugar lobby is going to have to fight its case without the luxury of so much funding. However, a poll of doctors yesterday showed that the same number thought that cholesterol  was most important, as thought that sugar was, but about 30% were undecided, so there is everything to play for.

It will undoubtedly be a hard fight, but unfortunately  science is being more and more discredited, at least in medical and biological fields. Most doctors are going to go on being influenced by the power of the medical establishment and media backed by these companies, and the anti-sugar lobby is going to have to fight its case without the luxury of all this money.

And the public? They are going to shrug their shoulders and say “They all change their minds every few years. I don’t trust the scientists so I will eat what I want.” And rates of obesity and diabetes won’t change any time soon.

  1. Risks and Benefits of Estrogen Plus Progestin in Healthy Postmenopausal Women. JAMA: The Journal of the American Medical Association 2002;288:321–333.
  2. A Sceptical GP. Elen Samuel. Published by Rheafield Publishing 2013 and available through bookstores and the Welsh Book Council
  3. Bad Pharma. Ben Goldacre. Harper Collins, 2013
  4. Saturated fat is not the major issue. Aseem Malhotra, BMJ 2013;347:f6340
  5. Saturated fat heart disease ‘myth’. BBC News Health 23 October 2013
  6. 6. The Economist Oct 19th– 25th How Science Goes Wrong
  7. 7. Statins for the primary prevention of cardiovascular disease. Cochrane Database Syst Rev2013;1:CD004816.
  8. 8. Should people at low risk of cardiovascular disease take a statin? BMJ 2013; 347
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How early would you want to be diagnosed with Alzheimer’s disease?

Posted on September 12, 2013 by Elen Samuel

How early would you want to know you have Alzheimer’s disease?

Say you are in your fifties or sixties, and one or both parents died recently of (or with) a diagnosis of Alzheimer’s disease? Possibly you were the carer and saw the suffering at first hand?

Wouldn’t you be scouring the internet to find if there is likely to be any cure or alleviation for AD in the offing? And would you want to know as early as possible so that you can put your affairs in order and be ready for any cure for early disease as soon as it comes along?

That is obviously what governments think people want.

In the UK GPs are going to be rewarded (to the tune of over £3000 per practice) for assessing patients over 75, and those in at-risk groups such as those having diabetes or vascular disease, for signs of poor memory and dementia. In the USA, Medicare insurance will now pay for annual wellness checks which will include checking on changes in thinking abilities.

Well, isn’t that wonderful? Governments are actually doing something useful, one would think.

However, what is the point of all this?

Firstly, there is no evidence that any treatment at the moment helps those diagnosed with early or pre –AD. The much lauded drugs for dementia, the anticholinesterases, have a slight effect in improving short term thinking abilities in people with established, moderate or severe AD, and do not work, and so are not licensed, for early dementia. Sp picking it up early will not do any good at all. There are no other drugs in the offing either. So you would undergo some pretty invasive tests, including a lumbar puncture, MRI scans and blood tests, for no benefit.

But wouldn’t you want to know to put your affairs in order? Well you might, if you were sure that the diagnosis was correct – in other words that you would definitely develop Alzheimer’s disease.

But the state of the art memory tests at the moment do not do this accurately.  A recent analysis suggested that, “ if a clinician saw 100 consecutive people in an area where we know that 6% have dementia using current criteria he or she would correctly identify four of the six but would incorrectly identify dementia in a further 23 people.41”

So 23 out of a hundred might be told they have AD when they haven’t! Even if they do have signs of dementia many will improve rather than deteriorate.

No thank you.

The beneficiaries of this are the usual suspects – Pharma companies hoping to sell more drugs especially anticholinesterases which are prescribed often for early AD even though it is known they don’t work, because of patient pressure (at a cost of about £1000 per year per patient); companies making the tests, biomarker testing (cerebrospinal fluid measurements of amyloid and tau) and companies making scanning machines and so on.

It is likely that lifestyle changes, (losing weight, not smoking) would prevent more AD than any treatment, so we all ought to make these changes anyway without waiting for wellness checks to tell us to do it. Putting our affairs in order is something we all ought to do.

Then the money spent on these initiatives could be spent on proper research studies especially on the over 80’s who have hardly been studied at all up to now, and on much more care for those who already have AD and their carers.

BMJ 2013;347:f5125

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Where do you get the best healthcare – France America or the UK?

Posted on September 4, 2013 by Elen Samuel

Last week I did a live broadcast for Radio Wales, to publicise my book.  The first question I was asked was – after 65 years, how does the NHS stand up compared to other countries? Is it fit for purpose for the future?

What a question. It would take another book to answer this question fully!

I answered that, yes, the NHS is fit for purpose, up to standard compared to other countries, especially America. It provides healthcare equitably for everyone.

The interviewer was not impressed. What about France? She said. They don’t have to wait for operations or to see specialists there and their care is excellent!

That was a problem to answer. It is easy to compare the NHS positively to America, where people go untreated, go bankrupt getting medical care and where public health and health safety statistics are awful. France is generally considered to provide excellent coverage and their waits for hospital treatment are short, with plenty of choice for patients. They spend much more than we do but seem to get value for money.

But wait. Are we comparing like with like?

Take a visit to a GP. You would pay (after state re-imbursement) £5 every time unless you were very poor or very sick. You would still wait several weeks for routine appointments, or several hours in the surgery if you thought you needed to be seen as an emergency. GP’s are poorly paid and have to see a lot of patients in order to make a living. You will have a choice of very good hospitals, but will have to pay a surcharge, (20% for the first month) and most people have additional insurance to cover these costs. You will also have to pay a proportion of the costs of an ambulance. Emergency waits can be quite long (though actually that is true almost everywhere).

So patients have to cough up money to get the type of service we get in the NHS. Would we in the UK be prepared to pay? Would my interviewer be prepared to pay?

Many people do in fact pay privately in the UK for a better or quicker service. In my area over 25% of referrals in some specialities were to private consultants. The difference between the NHS and all other European countries that I know of is that if you pay privately you will then be outside the NHS for everything, while in other European countries all patients are entitled to, and expected to get, additional coverage on top of what the state provides. The state provision therefore often entails long waits, just as in the NHS, though the quality when you get to hospital should be high.

The other difference is that in the UK only specialists who are already working for the NHS see private patients, unlike in France where any specialist with the relevant training can set up shop. It is virtually unheard of for someone who is not a respected consultant to see private patients in the UK. The main result of this is that therefore there are fewer specialists in the UK overall, although of course they are all of very high calibre. But this introduces shortages, and also perverse incentives for consultants not to worry too much about NHS waiting lists as this will increase their private practice.

So I stand by my view that the NHS stands up well when compared to other European countries. The statistics (OECD) on public health indices (child mortality etc) are excellent and cancer survival though not in the top league, has improved recently because of the recent increase in funding up to 2012, and is now pretty good.

So would people in the UK prefer to add more of their own money, when they see shortfalls in treatment here?

No, they prefer, and the media prefer, to bash the NHS. They can do that, as it is still one system, in Wales, at any rate and in England at the moment, though that may change. On the continent people grumble about their coverage, the charges, the hospital staff, the GP, but not the system, which they know is designed to make sure that every one gets adequate healthcare. And the media doesn’t have anything to bash unless something goes very wrong.

Well I couldn’t say all that in a 2-minute slot of course.

I stand by my answer, because I support the NHS and want people to understand the realities of what is good evidence-based healthcare.

I did say, which is the truth, that France now has a huge problem servicing their health care system as they are in austerity just like us. The French population is very dependent on drugs and treatment fixes and every visit to a GP gets a prescription, most of which are not needed. Their system seems to have produced a nation of hypochondriacs even more than ours!

If you want more on this topic there is loads of stuff on this topic in my book

“A sceptical GP” by Elen Samuel, available on Kindle (Amazon USA and Europe) for £2.43

The print edition is available from the publishers – Rheafield Publishing (email  macfieh@mac-rhea.co.uk), or bookshops throughout Wales at £11.99 (469 pages) +p&p.

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Fat Children

Posted on August 28, 2013 by Elen Samuel

The saddest thing about the world’s obesity epidemic is that so many children, some very young, are getting fat, and this is a new development over the last twenty years.

I said in my last blog that we don’t know what causes obesity. Well, some scientists now think they do.

The conventional wisdom is that people eat too much because they want to – they have no “self-control”.  And then they get fat, because if you eat more than you need the energy will have to be stored, and it will be stored as fat. But can that really apply to children? No child wants to be fat – they suffer teasing and get ostracized by their peers and have a lower quality of life than their thin schoolmates.

The alternative idea, that I mentioned in my previous blog, is that people get fat because of their biochemistry and the type of food they eat, and then their bodies tell them to eat more. So eating too much is a result of the obesity, not the cause.

And scientists are finding out why this might be.

Insulin is the problem. It is a very important hormone in the body; it is what we produce when we eat sugar, as insulin is essential to get sugar into the cells where it is used to release energy for use by the body. In most people insulin is well regulated, but in many obese people the fact that they have been eating the wrong diet has caused the system to go awry, and the body makes too much insulin. Insulin is also the fat making hormone – it diverts more of the sugar to be set down as fat.  So even if children eat the same foods as their thin schoolmates they will get fatter.

It gets worse as over time as the body gets used to these high insulin levels and the cells become insulin resistant, setting off a cascade of reactions.

We all have a switch in our brains telling us that our food stores are full and we don’t need to eat; this is activated as a result of biochemical signals (insulin again and another signaling substance, leptin), coming from our food stores. But in these children the excess insulin paradoxically acts against lepton’s signal that the food stores are full and prevents the switch working, resulting in increased food intake and decreased physical activity. In fact the brain is mislead into thinking the body is starving.

So these children have no choice in the matter – they have to eat. Their behaviour isn’t really under their control any more. The excess insulin acting on the brain also increases pleasure derived from food even when their bodies’ store of energy is full.

It gets into a really vicious circle. Eating more carbohydrate and especially sugars increases the supply of insulin (to allow more sugar into the cells). The more insulin there is, the fatter people get, until eventually the supply of insulin dries up and diabetes is the result.

So these children overeat because they have to, not because they are greedy. If they don’t overeat they will feel tired, hungry and have no energy.

We doctors have been telling people that all they have to do is to eat less and exercise more. But it isn’t really their fault that they can’t do it. The over eating is a result of their obesity not its cause.

We know that dieting does not work for most people over the long term. We know that many attempts at dieting reach a plateau after 3 -4 months, and scientists have found that this is because the insulin has caused the body to think it is being starved. The starvation response reduces expenditure of energy and increases the amount of food energy going to fat. This happens in adults as well and even when drugs are used to help lose weight.

So how do some children, and adults of course, get this abnormality?

We know it is partly inherited. Some racial groups have a much higher incidence of obesity than others – African-Americans, some native Americans, some Polynesians and so on. It is related to insulin resistance which is the underlying cause of diabetes. But scientists now think that many of us can develop this condition if we continually eat the wrong foods. Our diets now can make us produce too much insulin, which over the long term in children can cause this syndrome.

So what are these foods?

We all know now that the worst offenders are free sugars or sugar sweetened beverages. Our bodies are not equipped to deal with so much sugar. Sugar was first refined thousands of years ago, and before that we could only eat the sugar we found in fruit and honey. Since that time more and more sugar has been refined and in the developed countries sugar is a huge component of our diets. Modern fruit drinks contain much more sugar than they used to, and this plus the modern tendency to try to eat less fat so that we end up eating more carbohydrate, has resulted in an overload of sugars.

And of course lack of exercise is also a factor, as now children have lots of interesting things to do with their computer games, social networking and texting, that they don’t ever get bored and can stay in their chairs all day.

How have we got into this situation, that we are causing so much ill health to our children? You can’t really blame the food companies. You have to blame our culture and the faulty science that we have been promoting all these years.

No one has had time to individually prepare meals using fresh ingredients. People are busy making ends meet, with both parents working. Food companies therefore produce food which can easily be put on the table or the tray. Scientists told them that they should reduce fat, because lipids and cholesterol are known to cause heart attacks in older people. The fat in food is the tasty bit, so if you take out the fat, it doesn’t taste good, and people won’t buy it. So the food companies put sugar in it instead and this makes it tasty. So any ready meal, any sauce in a bottle will be high in sugar and carbs. Add in the drinks and you have a perfect recipe for obesity.

So what can be done about it?

The easy bit for a parent to do is to get rid of the sweet drinks. They aren’t necessary “for energy” even for sports, as scientists have proved that they don’t improve sports performance.  They just mess up your sugar balance. Perhaps governments could help by putting pressure on the drinks companies, or taxing high sugar content drinks.

It will be more difficult to get people to alter their diet to reduce sugar and other carbs. The injunction “eat real food” is easy to say, but difficult to do. It takes more time and it can be expensive. Protein, as I said in the previous blog, is expensive because meat especially is a very inefficient way of eating calories and very bad for the environment. Poor people have to eat carbohydrates. And as there are more mouths to feed in the world, especially in the developing world that want to eat more meat, richer people in the west will have to eat more carbohydrate as well.

But one thing should change. If you are obese and go to your doctor, she should not blame you. With more understanding, obese adults should be able to get more useful advice than just “eat less and exercise more”. And perhaps a new generation of children can be prevented from getting obese in the first place.

 

 

AUGUST 2006 VOL 2 NO 8 LUSTIG NATURE CLINICAL PRACTICE ENDOCRINOLOGY & METABOLISM 451

 

 

 

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Why are we fat (some of us anyway!)?

Posted on August 19, 2013 by Elen Samuel

Why are we fat?

Recently I read an article about the science of obesity, which I found very interesting 1. The fact is, we don’t know what causes obesity. People get fat because they eat more than they “need” but why do they do that? Because they can’t control their impulses and are greedy? This is the “energy balance” theory. Or because their bodies are too good at storing fat (or more exactly their bodies trigger a hormonal response that renders what they eat into storage as fat) and therefore they eat to compensate? This is the “endocrine hypothesis”)

The second hypothesis was actually conceived before the first, – by German scientists before WW2 and the first by American scientists after it. The German scientists’ work became unpopular and remained unread after the war, as German science lapsed (most good German scientists had either emigrated or were dead).

“Everyone” knew in the 60’s and 70’s that carbohydrate restriction worked, in that people lost more weight quicker. The Atkins diet was formulated in 1972. It was the conventional wisdom when I trained – insulin was the stuff that enabled sugars to enter the cells and also promoted fat storage. Without insulin you got very thin, the body had to use other very inefficient and dangerous biochemical pathways to get energy and eventually you died. So when insulin was in short supply or didn’t work you cut down the sugar in your diet.  We told everybody they had to only eat a certain amount of carbohydrate each day, so no sugar, very little starchy foods, and you could eat a lot of fat. If they stuck to that, some did manage to control their weight and their diabetes was controlled to some extent.

After WW2 American scientists formulated the theory that the basis of obesity was psychological – you ate more because you lacked the ability to control your eating (and therefore got fat). And this theory became popular despite scientists realizing by now that insulin was crucial to fat metabolism as well as sugar, and that if insulin worked extra-specially well or you had a lot of it, you would get fat. This could well have been an adaptive advantage to populations in times of food famine.

There has never been any evidence that the endocrine theory – that insulin works too well in some people  – is untrue, and we know that the overeating theory (too much energy intake makes you fat) is a dead end because people cannot in fact control their weight.  Neither in fact has been conclusively proved but one theory is at least as good as the other. We certainly know that low carb diets are much better at initiating weight loss for type 2 diabetics than the conventional diets (which I never really understood!) but it has always been assumed that this is irrelevant because over the long term most people revert to “over-eating” and regain weight.

So the American hypothesis of energy balance took over completely, and the German theory was forgotten. Experts in the 70’s pointed out that eating all this fat (which you had to do if you were to get enough calories) was very bad for your cholesterol and your heart.  And the rest is history. Sugars were counted as “empty calories” and despite Dr Yudkin’s efforts 2,  (he wrote “Pure White and Deadly” in 1972 and was pilloried for his efforts), sugars were available for food companies to make more and more sweet drinks, and carbohydrates were used as a cheap source of calories for poor people so that food companies were able to make more and more “low fat” but tasty cheap meals, often with extra sugar added. And lo and behold, population body weights have rocketed in America and in the rest of the developed world, and type 2 diabetes, which develops when you overload the body with calories, has become a modern day plague.

The writer of the article, Gary Taubes, went to to say that he is trying to right the wrongs of previous science and has founded the “Nutrition Science Initiative (NuSI.org)” to improve scientific understanding. Let’s hope this organisation succeeds in finding out the cause of the current epidemic of obesity and the best way of combating it.

           Following on from that, I have recently become interested in the “Primal” or “Paleo” diets. (I am not too sure of the difference, so people are welcome to enlighten me). But both seem to come from the hypothesis that Paleolithic people were thin, and they had low carbohydrate intakes because their diet consisted of meat (from hunting) and naturally occurring protein rich foods such as fruits and vegetables.  It must have been a high protein, moderate fat, and relatively low carb diet.  It was only later with the discovery and spread of agriculture that grains were used, bringing rice, bread, and so on, enabling more people to have calorie rich diets, (and live a more sedentary life), so the theory goes.  Our modern diets are high carb; therefore if we could stick to a high protein, high fat but low carb diet, we ought to be thinner, and possibly fitter.

 So there is some justification for this “Paleo” diet in terms of the scientific ideas above, although if you read some of the blogs of people following these diets, a very large number of them seem to supplement their diets with extra vitamins, nutrients, oils and so on, as if by every tree in those far off times there needed to be a vitamin bush with bottles of “extras” hanging from it! If the diet means anything it should mean that the diet is self sufficient without added nutrients, otherwise we couldn’t have survived.

However does it really fit with what we know about hominids from Paleolithic times, that is 2.6 million years ago, to the end of the Pleistocene around 10,000 BP?  We know from large numbers of Paleolithic carvings that obesity was well established, and possibly admired, at that time.  Obesity was certainly not invented with agriculture. It has been around for much, much longer than that, and is likely to be as human a characteristic as is our walking on two legs.

No, I don’t go much on the prehistoric explanation people give for the success of the “Paleo” diets.  Another theory which, like the German theory above, has not taken off despite never having been disproved is the aquatic ape theory,3  and this is the one I find much more attractive in explaining obesity. According to this theory, long before Paleolithic times, about 5 million years ago, at the time of the split between chimps and us, a group of hominids took a trip to the beach. They got good at fishing and diving and adapted to living in water. There they had a plentiful supply of fish, shellfish, small arthropods and other protein rich foods – and very little carbohydrate. There was another big advantage to this diet and this was that such a diet contains just the right balance of omega 3 and omega 6 fatty acids needed for optimum brain development.  Subcutaneous fat developed in these hominids and was useful for temperature control (they also lost their hair because wet hair is a very poor insulator), and buoyancy.  And it is possible that this source of rich protein and fat was the catalyst needed for the brain to grow so much bigger than it did in the apes that stayed in the trees.

Yes, fat was good then, as it is now. Human babies are much, much fatter than chimp babies, and women are often fatter than men because they have to provide the fat for babies in milk.  There is nothing much wrong with “the right sort of fat”. Excessive obesity is another matter altogether and may well be caused by the excessive carbohydrate intake many people have now with fructose rich drinks and carbohydrate loaded meals.

         Unfortunately there is a catch in all this. In those very far off days, early humans could take what they wanted from the environment. Just imagine all that naturally occurring food all around them – they could just pick it.  But nowadays there are so many more mouths to feed and we have to grow nearly all of it. If low carb is what at least some of us should be eating, how are we going to feed ourselves? Getting protein from livestock or even fish farming is very energy intensive, appropriates over 30% of all ice-free land, uses up vast amounts of freshwater and contributes to climate change, as well as reducing biodiversity. This is reflected in the fact that high protein, low carb diets are very expensive and completely unaffordable for many people, so that they are forced to eat high carb meals.

         We know that not everyone will put on weight even when offered large calorie meals. Some cannot physically take it in, or will vomit, while others will put the extra weight on as muscle rather than fat. People’s metabolism varies tremendously and it depends very much on our genes.  But those who have the “endocrine disorder”, according to the German theory, will need to eat far fewer carbs if they are not to succumb to obesity and diabetes. We don’t know what percentage of people will put on weight when offered unlimited supplies of a high carb diet, but even if it is as low as 50% that still leaves an awful lot of people consuming too much, and many of these will get diabetes. There are 7 billion people in the world today, many of whom are suffering from poor nutrition, and while many scientists say that the world can sustain food supplies for all these people, with the right distribution and economic systems, what if the population rises to 9 billion as many think it will?  Certainly we would have to stop eating so much meat, and fish farming is also non-sustainable in energy terms.4

         People who gladly eat high protein, low carb diets now, will find such foods totally out of their reach financially, as the world population rises, maybe in the next two decades, and they will have to go back to eating carbs, and getting fat again with all the consequences for our health, and costs for our economies in treating the effects.

         Many scientists are feeling as if Malthus is coming back to revisit us. The solution now, as it was in his day, has to be to use our ingenuity, this time to develop novel plant protein products and to innovate to improve food preservation and waste reduction.5 There are some pointers – scientists from the Netherlands have recently produced “meat” by cloning cells in laboratories. But can we really provide enough protein this way in the time scale that would be needed?  It doesn’t seem as if we are trying very hard.

 

References

1The science of obesity: what do we really know about what makes us fat?  Gary Taubes BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f1050 (Published 16 April 2013)

2John Yudkin  Pure, White, and Deadly: 1972, re-issued by Penguin 2012 with an enthusiastic introduction (doi:10.1136/bmj.e8612).

3Aquatic Ape Theory,  Elaine Morgan “The Descent of woman”, “The Aquatic Ape Hypothesis: Most Credible Theory of Human Evolution” (Independent voices) [Kindle Edition]

4Aiking, H., Future Protein Supply, Trends in Food Science & Technology

22 (2011) 112-120 (original manuscript), doi:10.1016/j.tifs.2010.04.005

5Mark Post, Professor of Vascular Physiology and Tissue Engineering at Maastricht

University

 

 

 

 

 

 

 

 

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A Tale of Broken Bones in a pair of Twins

Posted on August 15, 2013 by Elen Samuel

I like writing about healthcare; and the different ways it is provided  and delivered all over the world. So here is a taster.

This is a tale of 68-year-old twins who both suffered fractures in different countries but with very different consequences. Specifically, there were huge differences in postoperative pain management.

Twin one, a female, was cycling in South Germany when she accidently drove her bike into a lake (the path was very narrow and bumpy and probably she should not have been riding on it at all).  She suffered a typical Colles (wrist) fracture, and was taken to the local hospital where it was efficiently plated under regional anaesthesia. Post-operatively she was given IV paracetamol, but only when she asked for it.  It certainly did not get rid of the pain but it was bearable. Apparently the next step up if she had wanted it would have been pethidine. All went well and she was discharged after a few days for follow up later by the NHS.

The second twin had a very different experience. He was not as fit as his sister, being overweight and on tablets for hypertension. He had also fallen and fractured his femur 6 years previously and had a large heavy plate in situ.  This time he fell awkwardly and instead of fracturing his hip, the head of the femur was driven into the socket, fracturing it. He was admitted to hospital in the UK, and put on traction, with regular intravenous morphine.  After 3 days he developed intestinal problems where the gut was paralysed (paralytic ileus) due to the morphine. However transfer was delayed, and the paralytic ileus took over 10 days to settle on drip and suck. During this time he developed early bedsores and was again offered morphine because it was said they did not have IV paracetamol and he was on “nil by mouth”.  By the time he was transferred it was too late to do the operation and his original injury was healing naturally. Altogether he spent 6 weeks in hospital and lost 3 stone in weight.

Morphine is well known for its constipating effect and some people react very badly to it. It is never used on the continent and this was a problem when a locum GP from Germany working in Kent gave the wrong strength to a patient with renal stones resulting in the patient’s death. Academic papers are very keen that adequate pain relief should be given after operations, but paracetamol was the drug of choice in this hospital in Germany, which incidentally is in a skiing area and therefore sees a lot of orthopaedic injuries.

Why do doctors in the UK routinely use so much morphine after accidents and operations? Especially morphine with its rather unpleasant side effect profile? They use pethidine, another narcotic but with different, but definitely fewer, side effects. Should not UK doctors take a leaf out of their German colleagues’ books and only give paracetamol, titrating up if necessary  to pethidine, rather than using morphine as a first line?

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