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Dr Ross Walker
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Prolonging life or extending suffering and death?

Monday, January 21, 2019

With the recent political rumblings about the aged care sector, along with the Royal Commission into this sector about to commence, I thought I’d repeat my comments around this entire issue. Firstly, without a radical rethink of the entire aged care subject, nothing will change, regardless of a Royal Commission or grand standing by any political party on this issue.

It is my opinion that the current function of aged care is to make huge amounts of money for the people running aged care institutions and not specifically for the recipients of this care, which it definitely should be. This is precisely the reason the Federal government is starting the Royal Commission. For too long, companies and financial consultants involved in the aged care sector have been making enormous amounts of money by draining the limited coffers of vulnerable people, who need some form of supervised care once they age.

Even more independent people living in retirement villages are often charged exorbitant amounts of money for the privilege, gradually draining their children’s inheritance. We have seen the horrendous behaviour of the banks affecting many unsuspecting people living in this country, even charging people who are no longer alive. Suffice to say, it’s my view that the aged care sector is no better.

This brings us to the rather thorny topic of end-of-life care. The aged care sector is, of course, divided into many areas with one of the most contentious issues being high dependency nursing homes for people who are, typically, towards the end of their life.

For anyone who has visited or been involved in this level of care for very dependent and often very ill people, these institutions leave a lot to be desired. I am not criticising the hard-working staff, who in the vast majority of cases are very dedicated, caring people, who do offer comfort to people in this miserable situation. What I am criticising is the entire philosophy behind this aspect of aged care. As a doctor with 40 years’ experience, I think it’s important that we prolong everyone’s life but no one’s death. Any sensible doctor knows when a person has entered the death phase. This is where someone has end-stage Alzheimer’s disease, where they cannot recognise their loved ones; a person with terminal cancer; a severe disabling stroke; a chronic end-stage neurologic condition, such as motor neuron disease, where a person is wheelchair bound finding it difficult to breathe or swallow or some other severe disabling chronic condition from which there is no recovery but certainly ongoing misery.

With any of these above conditions, a common practice these days is that when someone gets sick with an acute infection, they’re filled to the eyeballs with antibiotics rather than allowing the person to pass on naturally without any intervention, thus ending their misery. The other day I was driving past one of these facilities and saw an emergency ambulance in the driveway. In my view, there is no such thing as a medical emergency in a high dependency nursing home!

I saw a patient the other day in my practice whose husband (who is not my patient) fits this criteria but is still being administered cholesterol lowering pills, blood pressure treatment and blood thinning agents. It is time that the medical profession and relatives of people in these situations worked together to make the decision to end the person’s suffering as quickly as possible. I am not suggesting these people should be euthanised but am suggesting that chronic therapy for conditions such as high cholesterol, hypertension or blood thinning be stopped and the only therapy the person be administered is pain relief and sedation.

Regular morphine for these “death phase” cases takes away the terror of death and hastens the inevitable. It is my opinion that the average stay in one of these high dependency nursing homes should be, at most, less than a month, rather than the months to years that some people endure until their inevitable death. Surely the job of any good doctor is to relieve suffering. In my view, the obvious suffering of languishing in a nursing home for months to years is unacceptable and society as a whole needs a complete rethink on this issue.

 

The 5 keys to good health

Thursday, January 17, 2019

Now that our New Year’s resolutions have been firmly forgotten, only to be dusted off and brought out in another 12 months, we are now either back at work or gearing up for the start of the working year.

Just as we’re not particularly good with following New Year’s resolutions, human beings aren’t particularly good with all forms of compliance. To give you an example, if I start therapy in a group of patients, such as a particular medication, around 50% have stopped that therapy after 12 months. When I see these people in follow-up and ask them why, I received various answers, such as: “I ran out and didn’t get round to obtaining another script”; “I didn’t feel any different, so I stopped; I thought they were giving me side-effects so I thought it better that I didn’t take them anymore”; “I thought I was only on one course of pills and didn’t realise I had to take them indefinitely” etc. etc.

What most of us fail to realise, as far as our health goes, is that most forms of medications prescribed by doctors on a chronic basis typically reduce your risk for the disease by somewhere between 20% to 30%. It may come as some surprise for you to realise that following healthy lifestyle principles reduces your risks for all modern diseases, somewhere between 70% to 80%. I’ve included below a schematic that summarises these healthy lifestyle principles.

Two recently released studies have reinforced the importance of lifestyle. The first, published in the Journal of the American College of Cardiology followed just under 4,000 individuals living in Spain, as part of the Progression of early subclinical Atherosclerosis Study (PESA). Atherosclerosis is the progressive build up of fats, calcium and inflammatory tissue in the walls of arteries, which is the precursor to a heart attack and a stroke. 

This study used a device that monitors sleep for a period of seven days and found that those people who slept less than six hours every night had a 27% increased risk for atherosclerosis, when compared with those people who had the recommended seven to eight hours of sleep per night. Also, individuals who have poor quality sleep (for example, waking often during the night) had an increased risk of Atherosclerosis by 34%. Interestingly, the study also showed that people who slept for more than eight hours per night, especially women, had a high risk of atherosclerosis as well.

The second study appearing in The European Heart Journal looked at the vital importance of physical activity. This study looked at the cardio respiratory fitness of just over 4,500 people as part of a health survey known as HUNT3. All these participants were healthy with no history of pre-existing disease. Around 50% were women and 80% were deemed to be at low risk for developing cardiovascular disease over a 10-year period. At the end of the study period, 147 people suffered heart attacks or some form of coronary artery disease and the study clearly showed that those in the top 25% of fitness compared with those in the lowest 25% had half the number of cardiovascular events.

It is a great pity that only 50% of the Australian population performs any exercise and only 25% of the population performs the recommended amount of exercise, which is somewhere between three to five hours of moderate exercise every week. A study performed a few years ago known as the MORGEN trial demonstrated an 83% reduction in cardiovascular disease in those people who were the best compliers to healthy lifestyle principles.

How many times do health professionals have to stress the importance of lifestyle as opposed to much less effective medical therapy before human beings start to take on this advice? I have been practising medicine for over 40 years and the patients in my practice who do the best, despite whether I identify them at high risk or low risk for cardiovascular disease are those who firstly pick the right relatives i.e. have good genes but also follow these healthy lifestyle principles.

If I have deemed it necessary that they also take medications, whether they be orthodox pills or complementary therapies, being compliant with these treatments offers an added bonus to lifestyle. But what I’m asking you to do is to take the message into the New Year that “Lifestyle is king and always will be”.

 

Tests for cocaine, crystal meth, heroin

Thursday, January 10, 2019

Over the festive season, there is usually a lull in medical news and information. Because of yet another death at a music festival recently, the discussion has reemerged about pill testing at these venues.

Firstly, let me make the point that it is my opinion that any intervention that saves lives is important and should be considered. Secondly, let me make the even more important point that 80% of drug-related deaths in our society are due to cigarette smoke and 17% to alcohol because both are legal and freely available. It is only 3% of drug-related deaths that are due to illegal drugs because they are harder to get and, the clue is in the title, it is against the law to use them.

Thirdly, society is becoming increasingly regulated in all regards and I am certainly not suggesting we should have an nanny state but human beings have shown clearly that they cannot regulate their own behaviour, thus the importance of all forms of law.

Fourthly, many people use so-called recreational drugs on a regular basis and avoid any significant medical issues as a consequence. But I see this in the same way as using seatbelts. Most of us could probably drive without a seatbelt and come to no harm but if we are in an accident then the seatbelt may save our life or prevent a serious injury. Thus, we all strap on our seatbelts, firstly because it is law and secondly as a strong preventative measure to minimise harm. I believe we should all avoid illegal drugs for exactly the same reasons.

Now to the issue of pill testing.

There many people who believe this is an important intervention that should be freely available at dance festivals. There is, in fact, no clear evidence that this does minimise death risk but certainly may alert some people that the pills they have purchased from illegal vendors may have other substances contained in the pill which they were not expecting. What a shock that you cannot trust drug dealers!

Although I am not convinced that pill testing will minimise harm, if it does save one life, it is probably worth the effort. But I believe we need to look at the much bigger issue here which is the clear concern that these (typically) young people need to use mind altering substances to enjoy a dance festival. Let us not just blame dance festivals. Many young people now are using substances such as cocaine, ecstasy and the even more concerning heroin and crystal meth. Equally, people continue to smoke cigarettes and to use excessive amounts of alcohol.

As a species, we are a very disappointing lot where we cannot enjoy the more natural ways of living without introducing mind altering substances into our body purely to have a good time. It is also a bizarre notion to think that it is necessary to have a mobile intensive care unit at a dance festival with the knowledge that a number of the attendees will have issues with the taking of illegal substances. Unfortunately, I suspect that pill testing will lull many individuals into a false sense of security and a false belief that taking tested illegal substances will not cause any harm. Unfortunately, there are a number of individuals who do not know they have an underlying cardiac condition or some other serious medical disorder and when exposed to a severe stress such as standard cocaine or ecstasy or any other illegal substance may have a serious medical consequence.

On a more chronic basis, we need much more information as to the recurrent use of these substances. As we clearly know with long-term use of cigarettes and alcohol abuse, the medical consequences are disastrous and I have no doubt it will be exactly the same for the vast majority, if not all illegal drugs.

 

Is there a cure for Alzheimer’s in sight?

Friday, January 04, 2019

There is an estimated 426,000 people living with some form of dementia in Australia alone. With the rising and ageing population, it’s no surprise that this figure is predicted to rise to astronomical proportions over the next few decades. At present, it is the second leading cause of death in Australia affecting 5.4% of males and 10.6% of females.

It is estimated that three in 10 people over the age of 85 experience some form of dementia, whilst one in 10 over the age of 65. It is said to be the single greatest disability for people over the age of 65. It is also estimated that well over 1 million people in Australia are either directly or indirectly involved in the care of a person with dementia.

The commonest cause of dementia is Alzheimer’s disease but there are other causes such as vascular dementia and less common genetic variants that can also present with similar symptoms.

The cure

So, is there any end in sight for this horrible scourge that affects so many people? The answer is clearly yes! In fact, a few years back a small pilot trial of only 11 patients with varying degrees of Alzheimer’s disease was published titled the MEND trial. This program involves the combination of lifestyle changes, specific vitamin supplementation based on each individual’s assessment, brain training and trans cutaneous cranial stimulation. In 10 out of the 11 patients, the disease was reversed and this did not involve any pharmaceutical therapy.

Recently at a Dementia conference in Chicago, two new experimental therapies were presented showing great promise for the management of Alzheimer’s disease. The first trial involved in a monoclonal antibody, BAN2401. You always know a therapy is not available clinically because it doesn’t even have a proper name. This treatment reduces the amyloid plaques in the brain of people with Alzheimer’s, which are accumulation of junk proteins destroying normal nerve tissue.

Therapy on trial

Eight hundred and fifty six patients with early Alzheimer’s disease were given this therapy in a placebo controlled trial and in varying doses. After 18 months there was a 26% reduction in the clinical decline towards Alzheimer’s disease, compared with placebo, and 50% in those given the high-dose. Previously, the same company had released the results of a small part trial of a similar drug Aducanumab which again showed very similar results.

The second trial, albeit small, was an Australian trial of 32 patients with mild-to-moderate Alzheimer’s disease. This demonstrated that a new experimental treatment, Anavex which is a sigma-1 receptor agonist, appeared to slow, and in some cases, even reverse the disease. The study also looked at a variety of genetic abnormalities and found that 20% of patients had two variants of specific genes that reduced the effect of Anavex. This trial was to continue for just over 12 months.

Vitamin-B the answer?

Interestingly, a few years ago the results of the Optima trial, performed in Oxford University were released. This was a placebo-controlled study of high dose B-group vitamins in 271 people with mild cognitive impairment (a precursor to Alzheimer’s disease). This two-year study, using MRI and neurocognitive testing, demonstrated a 30% reduction in progression to Alzheimer’s disease in the people given the high dose vitamins.

There has also been some promising work using the antidepressant Cipramil and some early data for chronic non-steroidal anti-inflammatory drugs.

It is my opinion that with an integrative approach combining lifestyle modification, brain training and brain stimulation, complementary therapy and evidence based pharmaceutical drugs we are at the cusp of a new era in the management of Alzheimer’s disease. Hopefully, in the very near future, this scourge will become a thing of the past.

 

Are vitamins just expensive pee?

Wednesday, January 02, 2019

Osteoporosis is incredibly common. To quote the osteoporosis Australia website, there is an estimated 1.2 million people living in Australia with the condition and a further 6.3 million people with low bone density. Although postmenopausal women are at the greatest risk for osteoporosis, well over 20% of males over the age of 50 suffer the condition as well. For postmenopausal women, there is around a 2% per year bone loss for several years after the onset of menopause.

The Osteoporosis website also states that low calcium and vitamin D levels are strong risk factors for osteoporosis. The website suggests that adults require around 1,000 mg per day of calcium, which increases to 1,300 mg per day for women over 50 and men over 70. The website also states that low vitamin D levels, due to lack of sun exposure, may imply you are not getting enough vitamin D, which your body needs to absorb calcium. The website doesn’t mention that vitamin D is intricately involved in many aspects of calcium metabolism, not just absorption.

There are other risk factors for osteoporosis, including corticosteroid therapy for many inflammatory conditions, low hormone levels in both men and women, thyroid disease, malabsorption (the most common being coeliac disease) along with the number of chronic inflammatory conditions and medications.

The most important lifestyle risk factor is physical inactivity, closely followed by smoking, excessive alcohol intake and extremes of weight, either too thin or obese.

In a recent edition of Lancet Diabetes and Endocrinology, a large meta-analysis was published of 81 randomised, controlled trials asking the question: does vitamin D prevent bone fractures and improve bone mineral density in adults? The study involved just over 53,500 people and all the studies were for less than five years. The conclusion of the meta-analysis was that vitamin D had no effect on preventing bone fractures or improving bone mineral density in adults.

This study will prompt many people in conservative medicine to suggest that this is more evidence that vitamin supplements are of no value and trot out the age old argument that all supplements do is give you expensive urine.

Interestingly, a few years back, there was a large meta-analysis of calcium supplementation involving 100 studies, asking the same question as the vitamin D meta-analysis. Again, this study showed no benefits for the use of oral calcium supplements for the prevention of bone fracture or the improvement in bone mineral density. But, most endocrinologists and conservative doctors are still recommending calcium supplementation, despite the suggestion in some studies (although I must state this has been refuted in other studies) that oral calcium supplementation increases heart attack rate by around 30%.

So, is this the end of vitamin D supplementation? Should we purely return to 15 minutes of sunlight during the nonburning times on a daily basis?

I would like to make some very important points regarding this well-done meta-analysis.

1. There is no doubt from a significant number of trials that there is a clear link between low vitamin D levels and a number of medical conditions, including osteoporosis, cardiovascular disease, cancer, multiple sclerosis, type II diabetes, depression and asthma.

2. There is also no doubt that around 30% of the Australian population have vitamin D levels below the recommended range. Because Australia is the skin cancer capital of the world, we have embraced the slip slop slap message and therefore a significant minority of the population does not have adequate vitamin D levels

3. Many of the trials, not just in the osteoporosis area but also for the vast majority of common diseases, study people over the age of 50, although in the trial in question, people as young as 18 were included. Regardless, many of the people in these trials already have established disease or are at high risk for the condition once these trials begin.

4. I have stated on numerous occasions previously that vitamin supplementation in any form can not be seen as the same as pharmaceutical therapy. I constantly make the analogy that pharmaceutical therapy is like a high-performance motorcar, taking you from A to B very quickly but with the potential of crashing and killing yourself or possibly sustaining a major injury and thus the vital need for stringent road rules, seat belts and high-tech safety equipment within the car. Vitamin supplementation is more like a bicycle that gets you from A to B much slower but you also get some exercise along the way, the road rules are less rigid and all you really need to do is wear helmets and be careful of drivers. Pharmaceutical therapy has very strong, relatively immediate effects, whereas supplements are purely that, supplements to a healthy lifestyle, taking much longer to be effective, with minimal side effects, in most cases.

Therefore, we can not apply the same rules of randomised controlled trials, which are vital for pharmaceutical drugs, to supplements because, in my view, it takes many years for the supplements to have a benefit. It is my view that if it is demonstrated that supplements do have an effect on the surrogate markers of risk and disease, this is enough justification for their use for all the reasons I have detailed above. 

5. Now, here’s where the problem arises. Homo sapiens are a very disappointing lot, who are not particularly good at compliance. If I prescribe any medication or supplement to a group of people, after 12 months, only 50% are continuing to take the therapy. It is my view that vitamin supplementation does have benefits when you look at the long-term observational trials (because no company can afford to perform randomised controlled trials that go for 10 to 20 years). There is a significant and consistent benefit from the use of certain supplements over this time. This is very true for multivitamins and fish oil, which don’t appear to have any benefits until the trials are performed for 10 years and beyond, as seen from recent randomised controlled trials of short-term supplements, which showed no benefits whatsoever for the treatment or prevention of cardiovascular disease.

I’m not suggesting that there is absolute proof that the long-term ingestion of Vitamin D does have a benefit for osteoporosis but what I am saying is that all the indirect evidence to date points to the fact that being deficient in Vitamin D is associated with a number of diseases, and that well monitored low-dose vitamin D is harmless and, in my view, should be used by a significant proportion of the population.

This large meta-analysis, although well performed with proper statistical analysis, does not answer any questions about whether vitamin D should or should not be used. I for one will continue to take 1,000 I.U. of Vitamin D on a daily basis and will continue to do so, not just for my bones, but for the health of the rest of my body.

 

What's wrong with our modern diet?

Thursday, December 27, 2018

By Ross Walker

Colorectal cancer is the second most common cancer in men and women in Australia. The risk of diagnosis by age 85 is one in 11 for men and one in 15 for women. There are many factors that contribute to colorectal cancer including genetics, diet, inflammatory bowel disease, inactivity and to a lesser extent, alcohol and cigarette smoking. 

There is increasing evidence that the modern diet commonly consisting of processed, packaged muck masquerading as food may strongly be contributing to this cancer risk. Over the past decade there has been increasing emphasis placed on the importance of the gut microbiome. The mix and diversity of gut microbes are now being strongly linked to a variety of diseases. These diseases not only involve the bowel itself, but disorders of gut microbes are also increasingly being linked to conditions such as obesity, diabetes, cardiovascular disease and a number of common cancers including colon cancer. 

Research in mice, from the US, has demonstrated that even in low concentrations of the commonly used emulsifiers in food there is low grade inflammation in the body, with subsequent, obesity and metabolic syndrome. This has occurred at even a 10th of the dose commonly used in foods. 

When they studied mice and administered emulsifiers at the same concentration given to humans in food, there was a marked increase in pro-inflammatory gene expression and a change in the balance between cell proliferation and cell death, which tips the balance towards tumour development. 

These emulsifiers - carboxymethylcellulose and polysorbate-80 - are commonly used in many processed foods throughout the western world. 

Energy drinks

Equally disturbing is a recent report discussing the potential problems of energy drinks which I have mentioned and wrote about repeatedly. This report from the US suggested that the majority of energy drinks are consumed by young males in the 18 to 34-year-old age group, and also disturbingly, a third of teenagers consume energy drinks regularly between the ages of 12 to 17. Between 2007 to 2011, the number of energy drink related emergency visits doubled. This is especially so when combined with alcohol, which leads to a marked increase in binge drinking. It is felt that the combination of caffeine and sugar imparts the biggest risk and there is no doubt that these are major culprits. 

But, just in the same way as we don't really consider the significant potential health risks of all the additives in processed, package foods that may be contributing to poor health, rather we focus on the fat, sugar or protein content of the food.

It appears the combination of caffeine and sugar imposes the biggest risks here. 

But, an interesting case report has highlighted the potential for more hidden components of energy drinks to cause harm. This report detailed a 50-year-old man who was consuming four to five energy drinks on a daily basis and had done so for three weeks. He had no change in his diet, alcohol consumption, prescription or over-the-counter medications, did not use illegal drugs and he did not have a family history of liver disease. He was admitted with an acute severe hepatitis and what surprised me is the research has suggested it was the excess dose of vitamin B3 in the form of Niacin in the energy drinks that led to the liver damage. When his liver was biopsied there was acute fatty liver and inflammation in the liver. He was also found to have hepatitis C which may have contributed as well. 

Regardless of the nuances of either of these examples, it certainly highlights the facts that there are downsides to our modern “Quick fix” approach. It’s clear to me that if it is in a box or a container it is probably not particularly good for your health, and the information I have included above certainly supports this argument. 

 

Myth - High blood pressure is 100 plus your age

Monday, December 24, 2018

Years ago, this incredibly simplistic dictum was taken as gospel by the medical profession. 

There have been a number of myths over the decades surrounding high blood pressure and I would like to clear up some misconceptions around this very important topic. Blood pressure is simply the pressure within the arteries when the blood moves as it is pumped. 

The typical designation for BP is systolic/diastolic. The systolic pressure is an indirect measure of the force of contraction of the heart whereas the diastolic pressure is the resting pressure between heartbeats.

For many years, hypertension was defined as a BP of 140/90 or higher. Any level above 120/80 up to 140/90 was considered pre-hypertension and those in this category are at a higher risk than those with a completely normal BP.

Recently, a panel of 21 specialists in the field published new guidelines for the American Heart Association and American Academy of Cardiology task force after analysing 900 published studies.

Hypertension is now categorised as a BP of 130/80 or above. In an interesting twist, the task force is designating blood pressures 120-129 systolic as being elevated BP but not designated high. 

Interestingly, the research is suggesting that people with a blood pressure in the 130 to 139 systolic range and the 80 to 89 diastolic range should also have a 10-year risk assessment for heart disease and if this risk exceeds 10%, medications should be considered and the person treated until the BP is normalised. Recent data has suggested we should be aiming for a BP level of 120/80.

These new guidelines are suggesting that 50% of the adult population have hypertension.

Following on from these guidelines is the new study of 412 adults with elevated blood pressure which was published in the November issue of the Journal the American College of Cardiology. This study suggested that following the DASH diet, which is a diet of fruits and vegetables, whole grains along with dairy, fish, poultry, beans, seeds and nuts combined with low salt reduces blood pressure more than pharmaceutical medication.

The study looked at 412 adults including 234 women whose ages ranged between 23 to 76 with a systolic blood pressure somewhere between 120-159 mmHg a diastolic pressure between 80 to 95 mmHg. Over half were African-American.

No people were taking BP pills or Diabetic medication, and did not suffer heart disease, kidney disease, cholesterol elevation or diabetes.

The diet was continued for 12 weeks and the groups were also split into low salt, medium salt or high salt. For example, medium salt intake was considered the equivalent of 1 teaspoon of salt on a daily basis, which is much lower than what most people living in our society would be ingesting.

Those individuals consuming the DASH diet alone had an 11mmHg reduction in systolic pressure if their initial systolic was 150 compared with a 4 mmHg reduction if their systolic pressure was less than 130.

But when the researchers reviewed the people with the highest systolic blood pressure of 150mmHg also on the low salt arm, there was an average reduction of 21 mmHg compared to the high salt, control diet. This is actually better than most BP pills alone. Commonly used drugs such as ACE inhibitors, beta-blockers & calcium channel blockers would typically reduce systolic blood pressure by somewhere between 10 to 15 mmHg.

This study reinforces the vital importance of lifestyle modification for the management of hypertension, no doubt, the most important cardiovascular risk factor.

The most powerful lifestyle factors to reduce BP are follows:

1)  Weight loss and in particular loss of abdominal fat

2)  Regular exercise-3 to 5 hours weekly

3)  Markedly reduced the intake of sugar and salt

4)  No more than 1-2 standard alcoholic drinks per day

5)  Stress management techniques such as regular meditation

Kyolic aged garlic extract, two daily has been shown in a randomised controlled clinical trial of 88 patients with mild hypertension to have a significant reduction in BP similar to a standard pharmaceutical drug.

Bergamot polyphenolic fraction-One pill twice daily of the 47% polyphenolic extract has been shown to have an antihypertensive effect.

Two small pieces of dark chocolate, > 70% cocoa has been shown in a Cochrane review to have a reasonable effect on reducing blood pressure and improving blood flow to organs.

Management of sleep apnoea through either mandibular advancement devices or nasal CPAP has been shown to control BP in affected individuals.

Pharmaceutical therapy is also often necessary but unless there is evidence of end organ damage as seen typically in the heart, the kidneys or the blood vessels in the eye (a good marker for what is happening in the blood vessels in the brain), lifelong drug therapy should not be commenced until all of the other avenues have been utilised.

Regardless, hypertension is the most common cause of stroke and over the age of 60, heart attack. As we collectively become more educated about the vital importance of managing hypertension and bringing in measures to do so, we will see the rates of these devastating diseases markedly reduce. Unfortunately, at present, cardiovascular disease is still our biggest killer.

 

Does a drink a day keep the doctor away?

Thursday, December 20, 2018

With Christmas less than a week away, we are all told it is the season to be jolly and it is certainly the time for winding down and enjoying the variety of Christmas festivities that typically includes the consumption of alcohol.

There have been recent reports suggesting consuming any alcohol whatsoever is deleterious to the health. 

To address this issue, a study published in the August edition of Lancet looked at data from 195 countries and 700 sources to determine the effect of alcohol consumption. This study, known as the Systematic analysis of the global burden of diseases, injuries and risk factor study commenced in 1990 and continued up to 2016.

It concluded that alcohol was the seventh leading risk factor for death and disability, accounting for 2.2% of all female deaths and 6.8% of all deaths in males. This is especially so in the 15 to 49 year age group, where alcohol became the leading cause of death and disability affecting 3.8% of females and 12.2% of males.

There did appear to be a weak benefit for the reduction from cardiovascular disease and diabetes but these benefits were outweighed by an increase in the rate of cancer and tuberculosis. It suggested that alcohol excess was related to 23 health related disorders including damage to the brain, liver disease, heart disease, damage to the pancreas, diabetes, obesity and many common cancers, to name a few.

The study concluded that the only safe level of alcohol consumption was none. There was no doubt from the analysis of the 700 different papers that even one drink a day could increase the risk for one of these 23 alcohol related disorders. So, is that the end of the story? Should we all stop alcohol completely and become a world of teetotallers? 

Let’s look at the statistics. The studies showed that if you follow 100,000 people who consume one alcoholic drink per day for 12 months, the risk of at least one out of the 23 alcohol related disorders developing on a yearly basis is 918 per hundred thousand people studied i.e. less than 1%. If you then compare this to 100,000 people, who do not consume alcohol over the same 12-month period, the risk of similar disorders such as cancer, diabetes, brain or heart disease (to name a few) is 914 cases per 100,000 people per year. Hardly earth shattering statistics.

Many people in the health professions suggest that consuming two standard glasses of alcohol per day (especially red wine) does have a weak health benefit. I certainly am one of these people, but, feel it is irresponsible for any doctor to encourage people to consume alcohol. But equally if someone does enjoy 1-2 drinks per day it is probably a bit harsh to induce guilt by suggesting this may be causing significant bodily harm. So, what does this study say about the consumption of two drinks per day over 12 months? The rate of alcohol-related diseases increases from 918 up to 977 per 100,000 people studied. Still a significant issue when you consider the millions of people around the globe who drink, but again not momentous statistics.

It is my opinion from a broad analysis of the literature that the consumption of alcohol really depends on whom it is hanging around with. What I mean by this is that most of the data suggesting harm from any drinking whatsoever comes from studies mainly preformed in the US, where alcohol is  combined with the (often) very poor diet consumed by Americans. Also, alcohol by itself is empty calories. In fact, 1 g of alcohol is the equivalent of the consumption of 7 cal. Alcohol consumption is often associated with obesity and diabetes, two conditions well known to cause many health-related disorders. Often, but not always, excessive consumers of alcohol tend also to smoke cigarettes and potentially excess alcohol consumption can lead to reduction in willpower and sometimes may lead to the use of illegal drugs, which are also associated with significant health detriments.

We must also look at the reasons why some people drink and often there is underlying mental health disorders, depression, anxiety and loneliness and many people use alcohol as a distorted form of therapy for these conditions.

Often, people who consume alcohol will also pay less attention to other lifestyle factors such as exercise and alcohol will often impair sleep, which can lead to a number of different diseases & often suggested alcohol related disorders.

Finally, human beings are known to underreport bad lifestyle behaviours including alcohol consumption and the person who answers a survey saying they only drink one drink per day, may be having many more.

These types of analyses certainly raise many questions and all responsible people should be consuming minimal alcohol but whether having none whatsoever is the only way to remain healthy is still a questionable message to be giving the public. I always say to my patients that the definition of an alcoholic is someone who drinks more than their doctor, so let’s not be hypocrites.

I believe if you consume on average 1-2 standard glasses of alcohol most days of the week and combine this with an otherwise healthy lifestyle including maintenance of ideal body weight, then you are minimising any potential harm and possibly deriving a weak health benefit. Regardless, the decision is up to you and if you cannot keep your consumption at these levels I would suggest you do have a problem with alcohol and should not consume alcohol at all.

 

Flying cattle class

Wednesday, December 19, 2018

Around a decade ago, there was significant publicity around the Economy syndrome. A handful of people travelling on long haul flights when they arrived at their destination (or soon after) developed painful, swollen legs and were found to have clots related to many hours of sitting cramped in the economy section of the plane.

These people wanted to sue Qantas but, in reality, should be suing their parents for giving them the genes that led to excessive blood thickening. Around 1% of the population carry one of the variety of genes that predispose to clotting, typically during periods of immobilisation. The immobilisation is the precipitant but not the cause.

The same can be said for the occasional young woman who takes the pill and within a month has suffered a stroke. Hormone therapies can increase blood thickness but typically this is only clinically relevant in people with a genetic predisposition to clotting. Therefore, again, instead of suing the pharmaceutical company that makes the contraceptive pill, the affected person should be suing their relatives for exactly the same reason I have given above.

These genetic abnormalities range from the most common Factor V Leiden to the rather uncommon Anti-thrombin 3 deficiency. If you have a strong family history of any form of clotting, such as deep venous thromboses, pulmonary emboli (clots travelling into the lungs) that affect the venous side of the circulation, or even a very strong family history of arterial clotting, such as recurrent heart attacks or stroke, then there could be a familial predisposition to clotting. There are specific blood tests that can be performed to determine these conditions.

Blood thinners have been available for a number of years, mainly in the form of warfarin or the much weaker aspirin. Aspirin is inappropriate for venous clotting or clots in the lower pressure chambers in the heart i.e. the atriae but typically covers most forms of arterial clotting, although over the past 10 years the evidence has grown to support often using two forms of antiplatelet agents that include aspirin.

Over the past decade, new stronger anticoagulant agents have replaced warfarin in many cases, apart from long-term use with mechanical heart valves.

Research by the superb Baker Heart and Diabetes Institute in Melbourne, in conjunction with Harvard University recently published in the Journal of Clinical Investigation Insight, has discovered a new antibody that purely targets fresh clots. This only works on activated platelets, which are the sticky cells that form part of a clot along with the protein clotting factors but leaves normal components of clotting alone and thus markedly reduces any risk of bleeding that can occur with all of our existing clotting agents, including aspirin up to the newer stronger oral anticoagulants.

Thus, people with a strong predisposition to clotting or a prior history of thromboses could have an injection of this antibody prior to travel, or an operation as pure prevention. This may also have a place in the management of heart attack and stroke, dissolving fresh clots that occur in this situation.

To date, the antibody has proven enormously successful in laboratory animals and human blood but it needs to be trialled for clinical safety in humans. It will probably not be available for clinical use for at least five to 10 years but, if proven safe in humans, which is highly likely, this will be a major breakthrough in the prevention and treatment of blood clotting.

 

My 5 point plan to keep fit over Christmas.

Thursday, December 13, 2018

Well, it’s that time of the year when the very common burnout sets in and most of our thoughts turn to the Christmas break. Although Christmas should always be a time for rest, reflection and rejuvenation, it often becomes a time for excessive partying, overeating, overindulging in other bad habits, not to mention those interactions with relatives who we hardly see throughout the year. There is now a new term for this overdose of relatives at Christmas. The term is hyper-co-presence. I would prefer to call this an unavoidable overdose!

Rather than heading towards the inevitable Christmas weight gain, the very common New Year’s Day hangover and the perennially failed New Year’s resolutions, why not resolve before the holiday season gets into full swing to really make this Christmas break the chance to make a fresh start by following what I call my 5 Point Power Plan:

1. Decision.

2. Correct your limiting patterns.

3. Create a new pattern.

4. Train the habit.

5. Live the program.

Decide what life habits you want to break and which ones aren’t working for you. A very good start here is to create a journal or a diary where you actually write down (in decreasing order of importance) your life goals for the coming year, including the list of bad habits that aren’t serving you well and you wish to change.

What’s stopping you right now from not making these changes? If, for example, you wish to cease smoking but every Friday night you go down to the hotel with your friends and have a few drinks, this will certainly weaken your resolve and this pattern may need to change. Many people, as another example, are comfort eaters, often sitting in front of the television consuming unnecessary food. Rather than doing so, now that it’s daylight saving, why not go for a walk instead.

Nature abhors a vacuum. When you change a bad habit that has occupied a significant amount of your time, whether it be excessive eating, drinking or smoking, it should be replaced with a better, more, healthier habit. One of the greatest examples I’ve witnessed in my medical practice was a patient of mine who was a serious alcoholic. He consumed around 20 schooners of beer per day leading to a severe dilated cardiomyopathy. This gentleman made the decision to stop alcohol on my very strong advice and replaced this with an interest in Egyptology. All the money he used to spend on alcohol was placed in a bank account. He had eventually saved up enough money to take him and his wife to Egypt where he had the trip of a lifetime. His severe heart disease returned to normal & he is still a regular patient of mine 25 years later.

Any new habit requires discipline. You need to discipline yourself for a full month for this new habit to be trained and to become a normal part of your life. It is very important, also, to associate rewards with this new habit. For example, once I had destroyed my knee through too much sport, I needed to replace my very enjoyable soccer and squash games with a less rigorous form of exercise. I therefore started using an exercise bike 10 years ago but my reward was to watch enjoyable TV series whilst exercising to associate pleasure with the habit rather than the boredom of the exercise bike for 45 minutes staring out the window. I’m delighted to say that I’ve already broken three exercise bikes through excessive use and am now using my fourth bike. My favourite TV series is “The West Wing”. I’ve watched the seven series through for the third time. Jed Bartlet is the President every President should be. What a pity we don’t have world leaders that emulate this character! 

A number of years ago I wrote a book Diets Don’t Work. The reason diets don’t work is that you go on a diet in the same way as you go on a holiday. You always come back from the holiday. 12-week programs also have a finite ending, which see you return to your old habits. When you have created new, good and healthy habits, these need to stay with you for the rest of your life. You need to have a commitment to maintaining these habits as part of your new way of thinking.

Life isn’t about making the big decision to be healthy and happy, it’s about making 30-50 small decisions every day of your life. Decisions like “I want to eat that biscuit”, “I’ll walk up the stairs rather than take the escalator”, “I will not yell at that fool who just cut in front of me in the traffic”. These are split second decisions that can either take you towards good health and happiness or bad health and unhappiness.

Why wait for the new year to make these decisions and resolutions? Why not start right now before the (often bad) habits of the Christmas break take over?

 

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