Five Senses of Medicine

 

Physical activity: Some of the potential benefits

 

BMJ 2019;366:l5230 doi: 10.1136/bmj.l5230 

The miracle cure

Fiona Godlee, The BMJ

As miracle cures are hard to come by, any claims that a treatment is 100% safe and effective must always be viewed with intense scepticism. There is perhaps one exception. Physical activity has been called a miracle cure by no less a body than the Academy of Medical Sciences (http://bit.ly/2lTqDvc); and, like those who avail themselves of it, the supporting science grows stronger by the day. The BMJ recently published a systematic review showing a clear dose-response relation between physical activity and all cause mortality (doi:10.1136/bmj.l4570). The authors concluded that any level of activity is better than none, and more is better still, a message recently encapsulated in the updated guidelines from the UK’s chief medical officers (doi:10.1136/bmj.l5470).

As summarised by Christine Haseler and colleagues this week, the evidence that activity is good for both body and mind is impressive (doi:10.1136/bmj.l5230). People who are more active live longer and have lower rates of cardiovascular disease, cancer, and depression. Physical activity is safe and beneficial for almost everyone, they say. People should “start slow and build up” to avoid injury, and those with chronic illness may benefit from a tailored exercise prescription.

Are there downsides? There seem to be far fewer than for other widely used preventives and cures. Indeed, physical activity is one of the alternatives to antidepressants and painkillers that Ian Hamilton says we need for people struggling with physical or psychological pain (https://blogs.bmj.com/bmj/2019/09/13/ian-hamilton-prescription-drugs-are-no-cure-for-deprivation). It seems to have few if any side effects, and unlike some prescription drugs it is not generally addictive, although exercise addiction does occur. Nor does it drive overdiagnosis, unlike intensive precision screening as described this week by Henrik Vogt and colleagues (doi:10.1136/bmj.l5270).

So how can we encourage patients to be more active? Haseler and colleagues say that any contact with patients is an opportunity to raise the issue and that even a brief discussion can help. You should feel free to print off the figures from their article and hand them to patients or put them up in your waiting room.

As for doctors, we should take the same advice: be more active, for our own health and wellbeing and as role models to patients and colleagues. Whether walking or cycling to work, having stand-up meetings and ward rounds, or just getting up from your desk between consultations, physical activity is the miracle cure.

Second victim

Elsewhere in this week’s journal, Melissa Clarkson and colleagues make a strong case for abandoning the term “second victim” when it refers to doctors involved in medical error (doi:10.1136/bmj.l1233), as they find that it promotes a mindset that is incompatible with patient safety and accountability. They say that many physicians are also uncomfortable with the term.

“There is a seductiveness to labelling yourself as a victim,” argue the authors. “Victims bear no responsibility for causing the injurious event and no accountability for addressing it . . . We know who the actual victims of medical errors are because we arranged their funerals and buried them.”

Follow BMJ Editor Fiona Godlee on Twitter @fgodlee and the BMJ @bmj_latest

Einladung zum 1. Langener Intensivsymposium

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Placebo

The growing problem of diabetes

Fiona Godlee, The BMJ

Type 2 diabetes affects nearly 10% of the world’s adults, and rates are rising rapidly, especially in low and middle income countries.1 In the UK it affects about four million adults (6% of the population), and if nothing changes this will grow to about five million by 2025.2 And new figures released this week by Diabetes UK show that in England and Wales nearly 7000 people under age 25 now have type 2 diabetes (doi:10.1136/bmj.k4929).

With such numbers, diabetes in one form or another now makes up a substantial part of any doctor’s day (doi:10.1136/bmj.k4723). So what can you do for your diabetic patients? Firstly, don’t call them that, says Judith Hendley (doi:10.1136/bmj.k3119). She wants to be identified as a person first and not as a diabetic patient, a label that reduces her “to someone with diabetes and nothing else.”

Secondly, consider your use of language generally. Hendley suggests avoiding questions such as “Are you well controlled?” She says, “This feels like a question about my behaviour and how ‘good’ I have been.” Better to ask open questions that don’t judge or make assumptions, for example: are you having any difficulties with your blood sugar at the moment, and what is most important to you right now? Such reframing may sound trivial, but, says Hendley, it “could make a big difference to how the people in front of you see themselves and their condition—and how they see you.”

As for the factors behind the global diabetes epidemic, there’s always more to learn. Analysis of data from two large cohorts of nurses confirms the key role of unhealthy lifestyles (doi:10.1136/bmj.k4641). A systematic review looks specifically at the effect of fructose on glycaemic control and concludes that this depends on the source of fructose and how much extra energy it provides (doi:10.1136/bmj.k4644). Sweetened drinks and some other foods that add excess “nutrient poor” energy were most likely to adversely affect glycaemic control.

Weight loss is essential for management of diabetes and can lead to remission, but once achieved it can be hard to maintain. In what may be a ground breaking randomised trial, Cara Ebbeling and colleagues found that energy expenditure was higher when people ate a low carbohydrate diet during weight loss maintenance (doi:10.1136/bmj.k4583). People randomised to a high carbohydrate diet had higher concentrations of the hormone ghrelin, which is thought to reduce energy expenditure.

Ultimately the burden of diabetes is unsustainable. While patients and health professionals manage as best they can, the real and urgent solutions rest with our governments.

Follow BMJ Editor Fiona Godlee on Twitter @fgodlee and the BMJ @bmj_latest

Margaret McCartney: A summary of four and a half years of columns in one column

1. Screening is only for people with no symptoms. If you have symptoms it’s not screening.
2. Screening is often counterintuitive. False positives proportionately rise when prevalence falls.
3. “Case finding” is the recourse of those who do non-evidence based screening but can’t seem to admit it.
4. Inadequately tested tech can do as much harm as inadequately tested medicine.
5. The NHS is a pie. If you ask the NHS to do more without making the pie bigger, something else won’t get done.
6. Apparent problems are fixed more effectively when they’re first understood.
7. A system that uses blame to attempt improvement is likely to make good professionals miserable and leave.
8. Earlier isn’t necessarily better. Lead time bias and overdiagnosis create mirages and do harm.
9. If it’s not evidence based it might as well be homeopathy.
10. Jeremy Hunt was not my favourite health secretary.
11. Poverty kills. Statins do not effectively treat poverty.
12. Cycling is fantastic. Cities that make cycling easy and safer are healthier cities.
13. Food should be pleasurable, and there are various ways to lose weight. Studies of diets are often flawed. Beware of people touting “simple” solutions and diet books.
14. Many people seek to make money from those who don’t understand science. Doctors should call out bollocksology when they see it.
15. Private companies promising fast access to GPs in exchange for discontinuity of care may result in the fulminant collapse of NHS general practice.
16. Humans make mistakes. Honesty breeds forgiveness and better practice.
17. However, repeating policy errors is unforgivable if predictable. Health policy needs an “evidence desk” to critically review and stop avoidable errors. I make an ongoing offer to any government to staff that desk.
18. Keep your “thank you” cards. They will sustain you through your darkest days.
19. We need to know the absolute risk. What’s the all cause mortality? There’s no use not dying from a disease if the treatment kills you.
20. We should aim not to “raise awareness” but to improve knowledge.
21. Everyone in healthcare should make a public declaration of interests. Charities, think tanks, and pressure groups should tell us where they get their money.
22. Political in-fighting over the NHS wastes time, money, and morale. We should seek cross party cooperation, use evidence, and acknowledge uncertainty in decision making.
23. People should be offered interventions and be given help to make decisions. Doctors should be judged on how helpful they are, not the decision made.
24. Financial incentives have caused a needless professional crisis in medicine.
25. Appraisal is bunk.
26. The General Medical Council—a charity—pays for private health insurance and non-evidence based health screening for its staff. We doctors pay for this. It is a disgrace.
27. Systematic reviews usually shed more light than heat.
28. False promise increases with the opportunity for profit.
29. Markets in medicine increase demand and make people into patients needlessly, while those who need to be patients can’t access care: the patient paradox.
30. We’re all going to die: CPR isn’t good treatment for many. Citizens should know that, unless they opt out, they’ve been opted in.
31. Less medicine may be better treatment. It can often feel risky to deprescribe, even though it shouldn’t.
32. We need #alltrials reported.
33. Appalling workloads that are neither appealing or safe will not be cured with more “resilience.”
34. Medicine is a tough, unglamorous, difficult job which, with understaffing and austerity, often feels impossible to do well.
35. Medicine is an absolutely brilliant job, and having long term relationships with patients and families is one of the most joyous and fulfilling aspects of work.
36. Being a columnist has been great fun. The emails have (mostly) been a delight. But here I stop. Thank you to my editors, who are patient, kind, and clever; and thank you for reading.

BMJ 2018;362:k3745 doi: 10.1136/bmj.k3745 (Published 4 September 2018)

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Red meat: another inconvenient truth

Red meat: another inconvenient truth

Fiona Godlee, The BMJ

Evidence continues to emerge linking high meat consumption with increased mortality. This week Arash Etemadi and colleagues provide further support for the association (doi:10.1136/bmj.j1957). Their population based cohort study links high intake of red and processed meat with increased deaths from all causes and from nine specific ones.

Dietary epidemiology studies are of course fraught with pitfalls. At their worst they attract ridicule for supporting every conceivable association, fuelling public confusion and fake news. This week’s study is large, with more than 7.5 million American person years of observation, and it’s well done. Although its main findings are based on a single dietary assessment, a subgroup had two assessments done on separate occasions, and these associations were if anything stronger. Importantly, death rates were lower in groups who ate a higher proportion of fish and poultry than red meat.

In the accompanying commentary John Potter provides no comfort for anyone wanting to deny an inconvenient truth (doi:10.1136/bmj.j2190). “Overconsumption of meat is bad for health and for the health of our planet,” he says. It seems our ancestors ate meat at most once a week, consuming 5-10 kg a year. Modern diets in rich countries deliver more than 10 times this amount, with animal protein now providing up to a fifth of our energy requirements. The study suggests that haem iron in red meat and nitrate/nitrite in processed meat are among the culprits. But Potter says that the ill effects are likely to be caused in many different ways, including carcinogens caused by cooking, contaminants in animal feed, and reduced intake of plant based foods.

Nor is earlier death the only concern for human health, he says. A high meat economy brings with it accelerated sexual development and antibiotic resistance, together with shortages of food, and animal to human disease epidemics thrown in for good measure. As for the effects on the planet, water depletion, methane production, and pollution of air and groundwater are just the beginning. We must of course reduce the use of fossil fuels in transport, but livestock production outstrips this as a cause of climate change.

Potter outlines two possible courses of action. “As with many contemporary problems of resource overuse and maldistribution, we need to decide whether to act now to reduce human meat consumption or wait until the decay of sufficient parts of the global system tip us into much poorer planetary, societal, and human health.”

What can doctors do? We can lobby for more and better research to support clearer evidence based dietary guidelines. And we can lead by example, as our predecessors did with smoking cessation, by reducing our own red meat consumption. Your own suggestions are welcome.
Follow BMJ Editor Fiona Godlee on Twitter @fgodlee and the BMJ @bmj_latest

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