Sex matters

An article on sex with a slant towards diabetes....

Impotence.  It’s a somewhat old fashioned word, but it appears in our computer template at work when I carry out a diabetic check.  It’s something we should ask men AND women about during the diabetic check, but I must admit, it’s usually only the men who get asked routinely.

The one good thing about mentioning this is that for some people, not motivated by the threat of stroke and heart disease often find their ears pricking up at the thought of something going wrong down below.  In fact I’ve just finished mopping up the last bits of filming for a programme for channel FIVE on celebrities stopping smoking and I found the same phenomenon there.  The men were shocked when I told them that smoking can affect their erections but seemed relatively unbothered by the threats of lung cancer and heart disease.

In the healthy body, sex is the culmination of a number of physiological responses.  Arousal occurs through physical and mental stimulation, and all sorts of mechanisms come into play.  Senses like touch are important, as is blood pressure and circulation (you cannot have a good erection without good blood flow for example), and mood is also important.

In diabetes, poor control affects various systems which can all affect sexual health.  Problems affecting sex are collectively known as ‘sexual dysfunction’ in medical jargon. 

Here’s what happens in diabetes.  Poor diabetic control means an increased likelihood of thrush infections which is itchy and sore.  It also means decreased energy levels, can lead to low mood, poor circulation, high blood pressure.  In men, all of these things can present as erectile dysfunction – difficulty in achieving or maintaining erections.  I’ll come back to this and it’s causes and treatments but most of us will at least have heard of Viagra.

In women, sexual dysfunction can be more subtle.  Problems include decreased desire or arousal, poor libido, sometimes pain on intercourse.  Sadly female sexual dysfunction has not had the same revolutionary treatments that male sexual dysfunction has enjoyed (Viagra etc).  There is a medical treatment which works by increasing testosterone levels in women (mainly post-menopausal) but it is not prescribed commonly and needs careful medical supervision.  The main aim is to find out the underlying cause and treat appropriately.  Simple measures like lubricants or clitoral stimulation may be of help.  But if vaginal thrush is the problem, for instance, then it’s worth checking diabetic control and making sure that the last spores of the thrush infection are eradicated by aggressive treatment.  I often recommend women use a tampon soaked in tea tree oil (it is anti-fungal so work against thrush) as well as clotrimazole (Canesten) creams and pessaries.

Age

The ageing process naturally affects sex.  But sex life can continue quite enjoyably into the 90’s.  Sexual desire lessens with old age and bodily changes can cause trouble - vaginal dryness for instance is common after the menopause in women.

Men often find that their erections are more difficult to sustain as they get older and their ejaculations are not as powerful.  Add to all this problems like high blood pressure and the side effects of medication and you have several factors against you.

Main causes of sexual dysfunction in women –

Poor circulation causing poor arousal

Nerve damage (neuropathy) causing reduced sensation

Endocrine hormone disturbance – diabetes or problems with the thyroid or pituitary glands

Low oestrogen levels – can affect lubrication

Drugs and alcohol.

Main causes of sexual dysfunction in men -

High blood pressure

Poor circulation causing poor arousal

Nerve damage (neuropathy) causing reduced sensation

Endocrine hormone disturbance – diabetes or problems with the thyroid or pituitary glands

And smoking, drugs and alcohol.

Could it be something else apart from diabetes?

Well… yes.  Psychological causes for sexual dysfunction are very common.   There’s also the causes which are not because of diabetes directly, but related to its treatment.   One of the problems is that most diabetics (both Type 1 and 2) are on a number of essential tablets and occasionally many of these can affect sexual performance.  Statins, thiazide diuretics (ending in –zide) and beta blockers (ending in –lol) for blood pressure (not commonly used first line) are all guilty of causing erectile problems in men.  It’s best to discuss these with your doctor.  Beta blockers can also have an effect on mood in both men and women.  The bottom line is that if sex is not what it used to be, mention it to your doctor.  As part of your review, medication must be looked at.

What the doctor wants to know…

It can be hard to mention sexual problems but be prepared for the doctor to fire some questions at you if he/she is going to be able to help.  The problem is sexual dysfunction can have so many underlying causes.  Here’s a possible hit list of questions:

Do you have problems achieving or maintaining erection?

Do you have problems with arousal?

Do have vaginal dryness?

Do you feel tired / depressed?

Do you suffer with recurrent infections?  (Urine or thrush?)

Do you have any pain during sex?

Do you enjoy sex or does it make you feel bad/ sad/ embarrassed?

Have you ever suffered any sexual abuse?

Is there a problem with your partner or relationship?

How often do you have sex?

The good news

The good news is that most of the causes of sexual dysfunction are treatable.  Phosphodiesterase inhibitors (such as Viagra and Cialis) have revolutionised the physical erectile problems men suffer with.  It is not a cure all however, and treatment very much depends on the cause.  I regularly see men who have erectile problems as a side effect to medicine or because they are depressed. 

If there appears to be something complex underlying the problem, such as relationship difficulties then psychosexual counselling can help.  Occasionally the problem may be not perceptible at a conscious level and skilled counselling is the only way to uncover the issue.

Complex physical problems may need the expertise of a hospital specialist such as a gynaecologist, urologist or sexual health physician who may prescribe medication or specialist devices such as vacuum pumps.

For diabetics, to bullet proof yourself against problems arising from the condition, pay attention to good control, ask your doctor or specialist nurse about your medication and its possible side effects at your annual review. 

The main thing is, if you think you are suffering with any kind of sexual dysfunction, please mention it to your doctor as most cases 


Adapated from an article in SWEET magazine - www.sweetmagazine.org

Cold and flu - again!

It’s that time of the year again. Cold and flu season is upon us, but with the threat of swine flu should we be more worried than usual? And what really works and what should we do to combat symptoms?

28 days later, I am Legend, Outbreak are just a few films from the last decade or so which focus on the possibility of the world ending due to a viral pandemic. I remember watching these films and enjoying that mix of excitement and anxiety that these thrillers are designed to elicit, thinking that despite their realism they are ultimately the stuff of fantasy. It’s that protective kind of thought that allows us to sleep at night, a bit like Nick Ross’s reassurance about crime being rare at the end of Crimewatch. It’s almost as though a small part of our brains know that these films are from books – exciting fictional stories which are never actually going to happen – or are they?

We live in a world in which the events depicted in these movies are possible, even probable. Ebola, SARS, avian flu, swine flu are just a few viruses which have dominated headlines over the last few years. More and more I get asked by patients about flu, colds, swine flu and whether they should take a vaccine of sorts or how they can protect themselves from such viruses.

No prizes for guessing what I’m going to say next, but I’m going to say it. In fact sometimes it’s worth just stating the facts to avoid confusion.

1. There’s no cure for the common cold.

2. Taking a flu jab does not stop you catching colds and coughs, it stops you catching influenza (which can kill).

3. If you have a long term condition like diabetes, heart or lung disease the you must take both the flu vaccine and the swine flu vaccine. No question.

Let’s look at what happens to the body when it encounters a cold or flu virus. The virus forces the host (i.e. our cells) to make virus DNA. The host cells eventually burst and the virus easily spreads to healthy cells. Once a certain amount of cells have been affected, the body will experience symptoms, which are mainly a reflection of your body’s response to the virus rather than the virus itself. This includes excess mucus production and muscle ache. The mucus traps the virus and the muscle.


So what about ways to prevent colds and flu?

Well, there are so many remedies offered up around these ailments it can be confusing to know what to do.

In basic terms if you stay healthy you are less likely to catch viruses as your immune system will be harder to penetrate. So to prevent catching winter bugs, you should think about the following:

Choose the right food and drink
A balanced diet is the best way to ensure an adequate intake of nutrients. Certain foods boost your immune system, which is responsible for combating infection from viruses. Oily fish like tuna, mackerel, salmon and sardines contain Omega-3 Essential Fatty Acids are some of them. In fact as I’ve written previously, many choose to take an omega-3 supplement. Fruits and fruit juices (although a bit sugary) are a great source of Vitamin C, which finds it’s way into your immune system’s "white" blood cells responsible for fighting infection. Green vegetables like peppers, cauliflower and cabbage also provide plenty of Vitamin C.
Certain herbs and spices used in cooking such as cinnamon, cloves, cardamoms, turmeric, ginger and garlic are also of benefit. Turmeric and ginger are used in Ayurvedic cold remedies, and garlic has anti-bacterial properties so add loads of these to winter stews, curries or hotpots. Vitamin D also has an important role in boosting your immune system and staving off infection.

Exercise
Getting yourself out of breath for 30 minutes four to five times a week, is considered moderate exercise. This can be almost anything – from jogging to pilates. Within limits, regular exercise can make you less prone to infection. Other beneficial effects include improved fitness and a positive effect on mood.

Supplements and herbs
Echinacea is the gold standard herb for boosting your immune system. It is available from health shops and chemists, and is usually taken for no longer than two weeks at a time. The evidence on echinacea is patchy but one study at least found that it reduced the symptoms of a cold.



Keep warm and get some sun
Humidity protects your mucous membranes, (the body’s moist linings), against attack from viruses. Sunlight, or just being out in natural daylight, can improve your mood at wintertime, (possibly in part because we absorb vitamin D better which can benefit mood).
Beyond this, basic hygiene like handwashing with normal soap and cleaning surfaces is key in avoiding the spread of cold and flu germs.

Finally, avoid stress and sugar – this may be easier said than done but both affect the function of your immune system

In fact the best time to work on a cold is when you haven’t got one!

But what should we take if we’ve already got cold and flu? Well, no medicine cures colds or flu but for symptoms like fever, stuffy nose and muscle pain paracetamol and ibuprofen can help. There are also various drinks, syrups and sprays which can also help with symptoms. For instance many of my patients find sinus pain relief from pseudoephedrine. It’s really about what makes you fell better. One study from years ago compared a popular codeine based cough syrup to chicken soup and they were equally effective, so each to their own. There’s really no proven remedy. In addition to this there are certain drinks which make matters worse when you are congested. Stick to clear fluids as much as possible and avoid alcohol altogether.

Diabetes

If you are diabetic, remember that any illness can make your blood sugar levels rise. Cold and flu themselves can affect appetite which can make blood glucose control tricky. Nausea and vomiting in diabetics can be serious symptoms reflecting poor glucose control. If in doubt, seek medical advice especially with persistent vomiting, diarrhoea or a steady fever of over 38 degrees. Try to drink plenty of water. Also, do check the label to see whether any over the counter flu medicine contains sugar. For instance some decongestants can raise blood sugar, whereas paracetamol will not. If in doubt, ask your pharmacist.

Finally, make sure you are realistic about what you can do if you are struck down with cold or flu. A survey last year of British businesses showed that most bosses and colleagues would prefer that anyone who was ill stayed home and recovered rather than came back early or put others at risk. For swine flu for instance, people ought to stay indoors for a week.

Whatever you do, remember if you do get sniffles to catch it, bin it, kill it – that is the best way to prevent spread of cold and flu germs.


Some common winter viruses:

Croup – can affect any age but mainly children. Characteristic ‘barking’ cough and breathing difficulty often with wheeze.

Rotavirus – affects children and adults. Runny nose, vomiting then severe diarrhoea.

Flu (influenza) – sudden onset of runny nose, fever, muscle ache and cough.

Pertussis – known as the ‘hundred day cough’


(Adapted from an article for SWEET magazine - www.sweetmagazine .org)   MERRY CHRISTMAS!

Supplements - my verdict

I’m going to start by telling you a story. Almost ten years ago when I was a junior doctor in a busy casualty department I met a chap who had fallen into the local canal and broken his ankle. Whilst robotically asking him his past medical history, (as most tired junior doctors do), he mentioned he had sero-positive arthritis which is usually very painful and debilitating. I asked him what medicines he was taking and to my amazement he said he was on none but had got rid of all his joint pain. It turned out that he did not get on with any of the drugs that his rheumatologist (joint specialist) had prescribed, and had decided to look at alternative treatments. He was, instead, on a special diet including flax oil, something called ‘Alpha Rice’, no red meat at all and various supplements including omega-3, glucosamine, a special cherry derived product and a multivitamin. In addition to this he was on a special exercise programme which had been started by a local osteopath.

I referred him on to orthopaedics for his broken ankle and only thought about him again some weeks later when I noticed an advert in a magazine for a product called Cherry Active. At the time I scoured all our medical resources (Medline, Cochrane, PubMed) which collate all the latest medical studies and I could not find much evidence that sour or tart cherries could aid arthritis. I understood the chemistry as these cherries contain powerful anti-oxidants, which in theory could prevent inflammation in a similar way to anti-inflammatory drugs, but there was hardly any hard ‘evidence’ that it worked. And there began my interest in illness prevention and supplements.

There are so many supplements from vitamins, to fish oils, chromium (mentioned frequently along with diabetes), co-enzyme Q10 to prevent the side effects of statins (I’d recommend these), through to saw palmetto for an enlarged prostate. Let’s start with the basics. Most people who take a basic supplement will take a multivitamin. These seem innocuous enough and I get asked about them all the time. But there have been stories in the news about Vitamin A and E possibly causing harm, and that smokers might be at increased risk of cancer if they take vitamins. It seems confusing. Let’s start by looking at what they actually do. Vitamins are to food what mortar is to bricks. And we all know that you can’t build a house with just bricks and no mortar. They are essential for proper blood, bone and digestive function. Many people think that the RDA (or recommended daily allowance) is sacrosanct. There is much debate about this. Originally described after World War II, RDAs were thought to be the bare minimum level of vitamin intake to stave off disease. For instance, scurvy, a deficiency of vitamin C requires an intake of around 60mg of vitamin C daily. Add in to the fact that we live in a world of hectic living (longer days at work, smoking and alcohol), processed foods and increasing diabetes and it is questionable as to whether 60mg a day would be enough for ‘optimum’ health. But we’ve got to be careful here. There are frequent reports in the press about how some vitamins can be dangerous in excess.

We know that Vitamin A for instance is potentially damaging to the baby if taken excessively in pregnancy. Too much vitamin C can cause diarrhoea and increase the propensity to developing kidney stones. And as for vitamin E, there have been several news stories over the years about it causing an early death if taken in excess, and there are reports of links to increased rates of lung cancer in smokers. This all sounds pretty grim and many of you are probably already thinking that you should dispose of your stash of multivitamins, but just hold your horses.

The Vitamin E story

I want to drill down on the evidence on Vitamin E (a powerful anti-oxidant), because it illustrates beautifully the problem around trying to work out whether supplements are good or bad for you.

One commonly cited study from 1993 (by O’Keefe et al), shows a significant correlation between a high intake of vitamin E and a decreased risk of heart disease, but it was just a correlation and as I have mentioned in a previous article, this sadly proves nothing as far as science is concerned. More studies are needed to prove that vitamin E actually reduces the risk of heart disease. (As a friend said to me once, just because there is more global warming these days but less pirates across the globe, it doesn’t mean that pirates prevent global warming). And that’s the trouble with correlation. A famous large scale study on Vitamin E was a meta-analysis (i.e. the study of studies which looks at all the studies on one topic over many years, in this case from 1966-2004) by Miller et al at Johns Hopkins University, which showed high dose vitamin E actually caused an increase in all-cause death. However, almost all the participants in this study had chronic disease and were over the age of 60. Maybe the vitamin E reacted with certain medications or maybe it was the high dose and type of vitamin E given? The limitation of this study is whether this can be applied to all age groups. The problem is that suddenly it does not seem so clear cut as to whether vitamin E is good or bad for us.

Ask experts and they’ll tell you that there are various forms of vitamin E (tocopherols) which can be synthetic or natural and that natural forms are better for you. My verdict is try to get Vitamin E from food if you can (walnuts, pecan nuts, corn, sesame seeds) and if you do take supplements of it, do not exceed the RDA.

Chromium and trace elements

Okay, so we’ve covered one vitamin in depth but what about the rest? And what about the fashionable supplement for diabetes called chromium?

Chromium is a mineral which is found in apples, bananas and chicken amongst other foods. It is poorly absorbed and highly excreted by the body and is widely used as a supplement by diabetics and dieters to stave off carbohydrate cravings (many swear it does) and possibly improve diabetes control as many diabetics seem to have low levels of chromium. The latest study on this was carried out in 2008. It did not show any statistically significant improvement in weight, cholesterol or glucose metabolism after 16 weeks in a group of 63 diabetics, but it did show an improved acute insulin response to glucose. Other papers have claimed to show some improvements in almost all areas including blood glucose control, weight and cholesterol levels but the papers did not have statistical values or the doses used were higher than recommended in specific populations in Asia. So the chromium argument continues. It’s also important to remember that as it is a nutrient it is found naturally in the food mentioned above as well as broccoli, green beans, nuts and whole grains. It is an important mineral which plays a part in our body processing carbohydrates.

My own view is that we need to tailor supplements as far as possible to the individual (for instance if you drink alcohol on most evenings you will eventually run low on B vitamins). And when looking at the evidence for supplements, if it’s not rock solid, try as best you can to get your nourishment and nutrients from foods. So despite many people claiming that chromium has helped them, I cannot hand on heart recommend chromium supplementation as I am not wholly convinced by the studies thus far. But there’ll be more studies and my opinion may change, and if you find benefit from normal dose chromium supplementation, then that’s just fine. But it is better to eat apples, nuts, beans and broccoli regularly to get your chromium in its most natural form.

That said, a balanced multivitamin supplement with standard RDA’s, (i.e.no more than 100%) is unlikely to do much if any harm and will usually contain all essential vitamins and trace elements and minerals (including chromium in small amounts). You may wonder why trace elements are so important, but magnesium for instance, is essential in helping our bodies absorb calcium, even though Vitamin D usually gets all the credit.

Nutrients from food

Getting adequate nourishment from foods is part of the problem in modern society as processed foods tend to be less nutritious. We all need to be eating more nuts, seeds, lentils and vegetables and less red meat and fried foods - and the more ‘raw’ or al dente vegetables we eat the better. Cooking destroys many of the nutrients in legumes. (In fact while I’m on the subject of cooking and heat damage, for those of you who do take multivitamins, their effects are ruined if you have a hot drink within 30 minutes of taking them, so don’t drink tea or coffee when you take them). As for oils like olive oil, flax oil and omega-3, again, they too are more beneficial to our health if not heated. In our house we force ourselves to eat greens and salads most nights with lots of extra virgin olive oil poured over the salads. We also try to eat a handful of nuts or seeds daily.

The bottom line

Are there any supplements which I feel are really necessary? Well, I have to say that I am a big fan of omega-3 supplements. There is now indisputable, (grade A evidence from a systematic review in the British Medical Journal last year), that those with established heart disease benefit from omega-3 and that their risk of having a heart attack or stroke is lowered by up to 30%. It’s well known that regional diets rich in omega-3 protect their populations from heart disease. Other effects of omega-3 which are widely touted have not been studied with as much rigour (benefits for skin, mood, insulin sensitivity and joints), but it is a good supplement and one which I myself take. Sources from food include oily fish like mackerel.

The verdict or ‘company line’ is that we ought to try as much as possible to get nutrients from our food and that means eating lots of fruits and vegetables, not overcooking them, eating raw olive and flax oils, nuts, seeds, fish and white meat and anti-oxidant teas.

Coming full circle to the chap I saw in casualty all those years ago, he was clearly tailoring his supplements to his own needs which were focused around his joints. It can be hard to do this based on good evidence, as often it is lacking as I have demonstrated above, but it clearly worked well for him.

An easier example might be what someone ought to do to try to minimise his risk of a disease such as prostate cancer, which in my mind is very important. Again, the evidence is not solid (it rarely is with health outcomes and nutrition), but we know that men in the China and Japan have a diet low in fat and dairy products, yet it is high in green tea and fermented soya. They also have had very low rates of prostate cancer (before their diet became more Westernised). There is also some evidence that lycopenes (a natural anti-oxidant found in tomato skins) can help slow down progression in prostate cancer, so it would seem sensible that if prostate cancer runs in the family, it would be worth adapting your diet in these ways, as over the course of twenty or so years it may help delay or even prevent the onset of the disease and that would be pretty amazing.

Adapated from an article in SWEET magazine - www.sweetmagazine.org

Smoking and diabetes

Ok, so you’ve heard it all before but I’m going to say it anyway. Guess what? Smoking’s bad for you. “We know!!! Tell us something new…”, I hear you all shout. So what’s new? Well, for a start smoking is worse for you if you’re diabetic. Also, a recent study released at the National Smoking Cessation Conference earlier this summer shows that people are more likely to spend less on food and clothes before they decide to cut down on their cigarettes. Can you believe that? Those of you who smoke may not be surprised, because however hard times get there’s always money for fags. Talking of money, the government make a huge amount of revenue from smokers, but has decided in some parts of the UK, to even pay smokers to give up their guilty pleasure. It’s a big issue and is a psychologically intricate one too. How can someone know that doing something’s killing them but still carry on doing it? For those of you who smoke, how many of you would want your children to start smoking? How many of you think you’ll stop smoking ‘one day’?

An admission:

Before I incur the wrath of irritated smokers by the questions I’ve just asked, (nothing irritates smokers more than being told to stop), I have something to share with you. I myself am an ex-smoker. I don’t want a medal for my admission and I’m not proud of it, and I am certainly not a smug ex-smoker. I remember just how impossible it seemed to stop which is why I want to challenge smokers with the questions above. Sometimes I thought I’d never do it. In fact, I only stopped because I knew I really had to and I’ll tell you later how I did it and how it changed my health and my life.

The risks of smoking related to diabetes

I want to talk a little about smoking and it’s effect on diabetes in particular because it is so important. The emphasis of smoking on lung disease is very clear in all our minds but not many people know that smoking is now proven to be an independent risk factor for diabetes. Let me just clarify that. That means that smoking on its own can increase your risk of developing diabetes by making your tissues resistant to your body’s insulin. There’s more. If you are diabetic and you smoke then you risk of developing heart disease, kidney disease and stroke (which are increased anyway in diabetes), are all increased even more. For men there’s the added problem of erectile dysfunction.

The biggest risk to diabetics is that smoking is bad for the circulation. Here’s what happens (the science bit). The internal lining of our blood vessels are usually silky smooth and ‘non-stick’ making sure that blood flow carried on normally and that our organs receive enough oxygen. Cigarette smoke adds carbon monoxide damages this ‘non-stick’ vessel wall and makes it attract fats and plaques, thus beginning the clogging up process of the blood vessel known as atherosclerosis. This is the beginning of what is known as ‘cardiovascular disease’. When a blood vessel becomes completely clogged up or blocked, it effectively kills off what it supplies – so in the case of a heart blood vessel, blockage would lead to a heart attack and in the brain it would result in a stroke, but it can be a vessel in your leg (known peripheral vascular disease). It’s not just big arteries that become blocked. The vessels in your eyes and kidneys can accelerate the complications of retinopathy and nephropathy. You get the picture. Add to this the fact that diabetics have a propensity to developing earlier cardiovascular disease you have a recipe for disaster. Diabetes + Cigarette smoking = Early death is likely.

The good news:

There’s loads of ways to stop. No-one can force people to stop smoking, but once you’ve made the decision you’ll find that there is lots of help at hand.

The most popular way to stop is nicotine replacement therapy (NRT). This has up to 20% success rate. What’s more it is more effective with one to one counselling. Willpower alone works in around 3% of cases. Most people “try to give up” around 6 times before they succeed.

NRT exists in many forms: Patches, lozenges, tablets, gum, an inhaled method called an ‘inhalator’ (which gives the same hand-to-mouth feeling as a cigarette) and there are other non-NRT tablet based medications too. Your GP or practice nurse can help you find the best method for you or you can contact your local NHS smoking clinic. In terms of cost, NRT will cost around £3.55 a week when prescribed by your GP. To compare this to the cost of cigarettes, if you smoke 10 a day you’re looking at spending just under £20 a week.

Other commercial ways to help you stop smoking include hypnotherapy, drinking syrups which makes cigarettes taste awful, going cold turkey or reading one of several books on the subject. The latter is how I did it, but to be honest, use whatever you think will work for you.

Quick wins:

The quicker you stop, the quicker you stop the damage to your blood vessels. In fact even after 24 hours of stopping smoking, your chances of suffering a heart attack decrease. How amazing is that?

I told you earlier that I would tell you about how stopping smoking changed my life. Well, I quit using a book by the late and great anti-smoking guru Allen Carr. After about six weeks I was jumping out of bed every morning with bags of energy, I could taste food properly for the first time in years, my skin was much clearer and less dry, my fitness improved dramatically and my general feelings of tiredness disappeared. All in all, I felt like kicking myself that I hadn’t stopped before – it was much easier than I thought. Also I realised that my life was not being controlled by cigarettes any more. I was free. The number of times I used to drive out of my way via a petrol station just to buy some cigarettes, go out in storms or the freezing cold to have a drag or two, or have to get change from the bar just for the cigarette machine at the pub. It’s laughable thinking about it now. The most amazing thing was that I wasn’t missing cigarettes at all, and my friends who were still smoking were simply jealous. The craving feeling passed after two or three days. After all, no-one’s ever died of craving a cigarette and smokers can incredibly control it when they are on an aeroplane or in a public building.

Some smoking facts:

Male smokers have lower sperm counts than non-smokers on average and female smokers are more likely to miscarry.

Each cigarette cuts around 8 minutes off your life on average

After three months of stopping smoking your lung function can increase by up to 30%

Top tips and a challenge:

If you’ve been thinking about stopping then you’re almost there. Once you know you want to stop it’s time to action. Can you take the 12 week challenge? Could you be a non-smoker within 12 weeks from now?

1. Seek help now and set a ‘stop’ date - visit your GP surgery, or ring 0800 022 4 332 or visit smokefree.nhs.uk
2. Remember that smoking does not really help you relax and that it is in fact, a source of stress
3. Try to actively visualise yourself as a ‘non-smoker’
4. Hard times and stress befall us all so do not be tempted to reach for cigarettes when this happens as they are significant destroyers of your health and financial status and will only add to your stress.
5. Remember that cravings will pass and you won’t die of that feeling
6. Good luck – you can do it!

Adapted from an article in SWEET magazine - www.sweetmagazine.org

Circumcision - an ethical minefield

If you go to the video bar at the top of this page you'll see that YouTube provide links to video of me on the web. One of these videos is currently of me talking for under a minute on 'circumcision' at the end of an hour long interview about various mens health topics for Bizzibox, a new business communications website.

Now circumcision is a little bit like terminations (abortions) in terms of subject area. It rouses a lot of emotion in people. Some feel it is a religious rite of passage, others think that it is sheer barbaric mutilation of children for cosmesis.

I was surprised at some of the comments left by viewers implying that I was in a far more extreme camp of my own which simply thinks kids (male and female) should all be circumcised without any ethical consideration. Most of the comments were from people clearly vehemently opposed to circumcision (which is fine) aside from the fact that the only doctor they want to hear from is one that shares their view - which I understand to be that circumcision should never be allowed unless medically necessary. Ethically this makes complete sense. If we look at the primary care ethical framework, pretty much none of the criteria are met by religious circumcision of a baby, however 'religious grounds' can and does somehow trump all of these.

Here's the ethical framework I use:

A - Autonomy (of the child)
B - Beneficience (doing good)
C - Consent and Confidentiality (by parents)
D - Do no harm (it's painful)

So where does a GP fit into all this day to day? Firstly, let me say that my job as a doctor is not to judge people. I am here to help people and offer them honest advice. Secondly, medical ethics are present in every consultation, however simple they may seem, not just with trenchant topics like circumcision. If you treat two patients with the same condition, (however minor), in different ways then you need to think ethically about why that's the case.

My experience as a family doctor in urban North London, is that parents who are set on circumcision for their sons for religious reasons are not swayable as they are doing what they believe is culturally appropriate - no matter whatever anyone says, they're going to get it done - right or wrong. It then becomes my job to give them other options (not having the procedure done based on it's risks and the ethics around it) or - (what usually ends up happening) - I direct them to someone who can carry out the procedure properly rather than putting the child at even more risk by having it performed badly by someone who's not done it before. I do actually mention ethics in the video clip but maybe I should have expanded, but the ethical premise here is really around whether the baby has his own rights and whether a parent should have the right to consent for a medically unnecessary procedure based on religious grounds. The thing to remember as well is that parents carry out religious circumcision because of their belief system. Do you honestly think millions of law abiding and loving parents around the world would want to harm their child knowingly? Of course not.

In reality, any doctor who refused to have anything to do with circumcision would easily be circumnavigated, just like women who need abortions - parents would find someone to do it, good or bad, back street or not.

In the context of religious circumcisions alone, my point is that if the parents are sure that they are going to get it done anyway, the earlier the better. I've seen some painful post-operative cases in older children and the older the child or adult, the more severe the physical and sometimes psychological effects.

In terms of circumcision and cancer, I would never recommend circumcision at birth just to prevent penile cancer. The grading of evidence for circumcision and cancer prevention is poor and is mainly by association and there are small studies on this by Dean et al, but it is crucial not just to focus on the developed world. In Africa, circumcisions in trials have reduced rates of HPV, HSV 2 and HIV transmission, so over there it is being considered as a real strategy for penile cancer prevention. It's a huge risk benefit argument and more studies are probably needed. It's certainly not just men over the age of 60 who develop penile cancer over there, so there's potentially a real case for circumcision as a new medical intervention. Medically in the UK, circumcision is used to treat lichen sclerosis in adults (a very tight thickened foreskin) and phimosis in older children (the foreskin is tight and almost closed over and won't open properly).

The circumcision debate will continue forever and I hope I have shed some light on it from my perspective as a family doctor. I don't think any amount of talking or ranting about it will change the fact that there will be people who are indifferent, people who oppose it and people who are proponents of it.

Tests - what not to have...

Doctors usually refer to tests as ‘investigations’ and broadly speaking these include blood tests, x-rays and scans. Investigations are basically one step beyond a consultation and physical examination by the doctor and their role is to shed light on a person’s health status. In fact many patients come to see me purely because they want me to send them for a scan or x-ray!

There are a number of instances when we ought to have tests. Just thinking about blood tests to start with, I tend to order these for a whole host of symptoms that people might come in with – tiredness, abdominal pain, joint pains, itching being just a few. In these cases the blood test is to help me make a diagnosis. Is the itching because of anaemia? Is this person tired because their thyroid is underactive? Are these joint pains because of an autoimmune disease like rheumatoid arthritis or lupus? X-rays and scans can also help to make a diagnosis. If I’m thinking about a long term cough possibly being TB I would ask for a chest x-ray and if a female patient was suffering from very heavy periods I would usually ask for a pelvic ultrasound scan. This is all fairly straightforward.

Blood tests are also essential in keeping track of how certain conditions are being managed. Diabetes is a perfect example here. HbA1c, cholesterol and other lipids and kidney function are all very necessary tests which must be done regularly.

There are a number of important aspects of tests in general which must be borne in mind. Firstly, hardly any test is 100% accurate. People often think that a scan or a blood test is like a magic eye or marker which will give doctors a quick answer, but this is often not the case. For instance, the number of times I have had to recheck a blood test where a potassium level has come back high or not been run because it had ‘haemolysed’ (disintegrated) are too frustrating for both me and the patient to recount! And as for scans and x-rays, they often come back reported normal yet the person still has a symptom. Keeping on the accuracy theme, I have sent several patients to my local hospital outpatients with chest pain over the years which I thought was stable angina (chest pain on exertion arising from the heart). Many were sent back to me with reassurance from the heart specialists that their ‘exercise test’ (a gold standard test which elicits whether the pain is from the heart) was negative – i.e. the test suggested they didn't have heart disease. Some of these patients went on to have a heart attack within the following few weeks. So much for a negative exercise test being reassuring! This particular test will thankfully soon be out-phased by 64 slice CT which shows a graphic picture of any blockages in the heart’s blood vessels.

The reason for this is that often the best test available isn’t good enough. We know that there is a national screening programme for cervical and bowel cancer, but ovarian cancer and prostate cancer are still not screened for. Why? Because the tests for them are simply not accurate enough.

Then there is the rationale of whether to carry out a test at all. Some say that a really good doctor knows when not to order a test and that no test should be seen as ‘routine’. For instance, I would say that most doctors would not perform blood tests or x-rays on children unless really necessary. One of the reasons for this is that no-one wants to put a needle into a child for no reason. In addition to this, x-rays expose us to radiation and it seems unacceptable to do that to a child unless it was absolutely necessary. One study showed that 0.6% of all cancers in the UK are due to having x-rays (and CT scans) taken. A CT scan of the chest or abdomen gives you the equivalent of a few years of ‘background’ radiation which is what you’d normally be exposed to in the environment, whereas a chest x-ray gives you a few days worth. All this is worth thinking about when asking your doctor to send you for that x-ray again. (Nitpickers may like to know that x-rays should actually be called radiographs, but it's such a mouthful)!

I often get asked about health screening and whether it is worth having a whole body MRI or other screening scans or private healthcheck. Most of us have seen advertisements or received mailshots about this type of thing and many of my patients do go and have a watered down version of this. It’s often called a health screen or wellness check. I don’t think that there is anything wrong with having these tests although the number of times some companies will take your money and send you back to your own GP when they pick up an abnormality irritates me. Here’s my advice. If it’s a simple check up where you are being offered a basic cholesterol check, ECG, blood pressure, weight, height, examination then save your money and please ask your GP to do this.

When it comes to scans of body parts, you can’t simply ask your GP for these without good reason as the NHS is firmly based on need, so if you haven’t got any symptoms or exceptionally strong family history you won’t get a scan from your GP. No way. If you do decide to go privately to get screened via MRI scans, very rarely do they reveal anything sinister in the absence of symptoms. So it comes down to your own level of anxiety at the end of the day. But how often do you go back for another scan? Every month? Every year? That’s the trouble – once you start it’s hard to stop. The other side is that some conditions have no symptoms at all in the very early stages and screening could potentially identify the disease before it’s too advanced.

Comparing our neighbours across the pond in the USA, they run a private health care system, which means they tend to do a lot more tests as the insurance companies pick up the tab, so there is money to be made by doctors and hospitals from “getting a brain scan even though the headache is mild – just to be on the safe side…” (Of course if you have no insurance you get very different care, if any).

Tests in medicine, then, are important but they are almost never 100% accurate. The bottom line is that they need to be done for a good reason and need to be interpreted carefully so please remember that next time you and your doctor discuss whether to perform one.

Article adapted from SWEET magazine - visit www.sweetmagazine.org

Swine flu - what you can do to minimise your risk

There's a lot of discussion about swine flu at the moment. Influenza A/H1N1 is a hybrid virus and I would urge everyone to follow the advice of their local health body or provider.

Simple things you ought to do in addition to the above (unless advised otherwise by your health care provider)

1. Basic hygiene like handwashing with normal soap and cleaning surfaces well to avoid transmission

2. Keep your vitamin D levels up - Vitamin D has important role in boosting your immune system and staving off infection

3. Take an omega 3 supplement (1000mg a day) - supports the immune system and prevents the development of some long term diseases

4. Avoid: stress and sugar - both affect the function of your immune system

5. Eat green vegetables and garlic - both improve the body's acid-base status and garlic is a natural anti-viral/ anti-bacterial agent.

The link above takes you to the lastest information on NHS CHOICES - www.nhs.uk

Sick notes - why it doesn't always pay to get signed off by your doctor

It happens probably about twice a session during my surgeries. Someone comes in and it turns out that they need a sick note. Or do they? Unless you’re up on employment law, knowing your rights and responsibilities can be tricky. There are also some down sides to sick notes which I’ll touch on later.

Currently, the rules in the UK are pretty clear when it comes to statutory sick pay. Your employer is not entitled to ask you for a medical certificate for the first seven days of illness. It’s worth reading that last line again in case the editor does not stick with the bold typeface! It’s very important to remember this when it comes to going to your GP to get a sick note. Essentially, you do not need one for the first week. You can certify yourself or some employers will give you a form called an SC2 to fill in. If you are off sick for longer than seven days, then your employer will usually need a doctor’s note.

NHS sick certificates come under many names, the commonest being a Med 3 (white), Med 4 (green) and a Med 5 (pink). The Med 4 is the rarest of these forms with its bright green colour, and is never for an employer, only relating to state benefits. The Med 3 is issued only if the doctor has seen you face to face within the past 48 hours, and is the commonest of the sick certificates, given to you if you need time off after the first seven days of illness. The pink Med 5 form can be back dated or written based on the report of another doctor. A good example of when a Med 5 might be issued, is if you break your leg whilst climbing in the Peak District and you have inpatient care in a hospital but your family doctor is based in London, she can issue you a note for work based on the fact that she has seen a letter from the hospital where you were treated.

Occasionally I get asked to write a ‘private’ sick note. This is not an NHS certificate and, as such, is an item which will cost you anything from £5-£30 depending on your surgery’s policies. A private note is usually given when the person or their employer insists that a note is needed despite being off work for less than seven days. This has always been a bit of a mystery to me, but now and again certain agencies need proof of sickness. For instance, insurance companies will ask a doctor to fill out a specific form confirming when a person was ill if a claim is to be made for say cancelling a holiday or relating to a particular illness.

Sick leave from work is also absence from work when seen from another angle. Absence from work costs employers around £600 per year per employee. But why do people need to take time off work? What are the causes of absence? Common reasons for high absence levels include poor flexibility around working, poor support and morale, high stress levels and a bad work environment. No surprises there then.

A slightly odd but important point to bear in mind about sick leave is what it may potentially do to your premiums when you decide to get life insurance. As a GP I get several reports a month to prepare for insurance companies. Say for instance you decide to re-mortgage your house, the insurance company issuing the policy which covers your new mortgage will often need a medical report from your doctor in order to work out whether you’re a safe bet for the term of the mortgage. Sick leave is often something they will pick up on in your notes. I get many letters after I have sent off my report asking for more detail around why someone was signed off sick for a week in 2004 and whether it is related to any other conditions. You get the picture. This fact, however, should by no means deter you from taking sick leave if you really need it, but it may make you think twice next time if you have had many sick notes over the years. I guess what I’m saying is only get a sick note if it’s really necessary.

And that brings me on rather nicely to my next point which is how do you know if you should stay off work or not? This is a tricky one. Illness and how we handle it varies so much from person to person. I have known people stay off work for months with depression and others in a similar situation battle on regardless. Much of it is dependent on personality, the culture and size of the organisation in which one works and severity of symptoms.

Many people worry that it would be unfair to their colleagues if they were to take time off, or they are scared about what the boss might think. A recent survey carried out by the British Chamber of Commerce threw up some interesting results. Almost 3 out of 4 bosses would prefer employees to stay at home when sick rather than struggle in, and an even higher thought that people were less productive at work if they came in whilst ill. On the employees side, more than 8 out of 10 people felt guilty about being off sick and felt they were less productive. What’s more 2 out of 3 people admitted to getting annoyed if a colleague came in with a cold or cough. My advice is that if you really feel ill, rest easy. Going in to work feeling ill may be a false economy.

So what about the future of sick notes? The government have outlined plans to bring in ‘well notes’ which will focus on what a person can do while they are off sick. This mainly concerns those who have been signed off with a long term sickness (back pain and mental health problems are two common reasons). Interestingly I think it is an archaic notion that a GP is supposed to decide if someone can work or not, whether in the long term or not. It is, of course, like many other procedures and practices, something which dates back to the very beginning of the NHS. The trouble is, is that people’s jobs are often quite specific. A mild attack of laryngitis causing a hoarse voice and little else would not be an issue for most of us, but if you are an opera singer, telephone operator or voice actor, you’re in big trouble. Of course, on the other hand, a bruised or even broken arm would not affect these good folk too much at work, in my opinion – particularly compared to someone who works in a factory packing boxes who could probably carry on working with the opera singer’s hoarse voice. It can all be a bit nebulous so it’s often best to some to a shared decision with your doctor.

Anyway, that’s plenty about sickness for now. I wish you the best of health as we leave the Winter bugs and blues behind and move into Spring. Keep well.


Useful links:

www.acas.org.uk – useful information around statutory rights around sick pay

www.takeabenylinday.co.uk – full of useful tips around how to call in sick and how to recover.

Adapted from an article in Sweet magazine - www.sweetmagazine.org

Miracle cures and new health threats - the confusing business of interpreting what's in the papers

It’s hard for us doctors too, keeping up with medical headlines, that is. One minute HRT was the be all and end all in terms of menopause, the next it’s not so safe because of links with breast cancer. Statins used to be the wonder drugs which staved off heart attacks and stroke but is it now true that they may be linked to cancer? Is it true that black tea can keep diabetes under control? And what about that recent story about the dementia-preventing supplement gingko biloba which has now been found to be useless in preventing dementia? How can this be? It all seems so confusing. Let me see if I can explain.

Firstly, let me tell you, you’re not alone. Doctors find it just as hard to keep abreast with all these changes. So how is it possible that this is the case? What’s next? Are we to be told that red meat and full fat milk are actually good for us? Well, no… not quite. I’ll do my best to explain why these headlines hit the papers and how they are generated. Every GP in the land knows what it is like to be handed clippings from papers by patients, so it is also in my benefit to share my view on this phenomenon with you all!

Very simply, it’s all about evidence. Evidence is a strong word which conjures up images of court rooms, but well-practised modern medicine is no less rigorous than legal practice. Ideally, doctors are only supposed to prescribe or advise what they know actually works, based on evidence. It’s particularly hard in general practice to do this as many conditions and complaints are simply so nebulous, but nevertheless we must try our best to uphold ‘best practice’ and that means evidence-based practice.

I want to focus for the next few minutes on what evidence actually means and the ‘grading’ of it. The lowest level of evidence is what is known as anecdotal. “My uncle smoked until he was 80 and he was never sick, so smoking’s probably not that bad for you…” or “I think ginger tea is great for sickness. It worked for my sister last week…” This kind of anecdote and the deductions that follow clearly has its flaws and explains why anecdotes on their own are not good evidence. The story of one case is not good enough. An evidence grade above this is what is known as a case series, which looks at groups of patients given similar treatments and outcomes. Not bad as the numbers a re bigger, but this too can be improved on. Better still are case-control studies. They are retrospective (look back) studies correlating possible links between say an illness or treatment and a person. A good example of this was the link between smoking and lung cancer. This was verified further by looking at a ‘cohort’ of people which looked at a large group of smokers. But a link is just a link. But how do you go one step further to prove categorically that smoking actually causes lung cancer? For this we need to look at the gold standard of all trials – the randomized controlled trial (RCT).

In a RCT, patients are literally randomly allocated into a group for a treatment to be applied. In a double-blind RCT neither the patient nor the doctor knows what group a person is in. For instance you can have two sets of patients, one of whom is given a treatment and the other a placebo (or sham treatment) but neither the researchers or the patients know who is being treated with what. The results can then be analyzed accurately by looking at a measurable outcome (e.g. blood pressure, weight, death or diagnosis) to give reliable evidence on the treatment being studied. These studies usually span a long term and are often prospective (as opposed to retrospective).

The king of all evidence, however, is a beast known as a systematic review. This is a study of studies if you like, and is a painstaking analysis of many studies on one theme. It is a comprehensive analysis of every study that counts regarding the area of interest. The Cochrane Collaboration based in Oxford, (the spiritual home of modern evidence-based medicine) is the best place for further reading around this.

All that said, how does this process apply to us as doctors and patients? Well, firstly, studies help doctors make decisions about treatments. We are not ethically allowed to advise rubbing a potato on a verruca unless we have some evidence to back it up.
Secondly, when it comes to these miracle cures and health scares, the discerning doctor, with enough time, ought to be able to sniff out whether the claim being made is true or not, or at least guide patients in the right direction.

Let me illustrate this with some recent examples. The BBC recently published a story on broccoli possibly being able to protect your lungs. Broccoli contains a compound called sulforaphane which, according to scientists, can indirectly help protect lungs from toxin-related damage. This sounds great, but in reality, the study did not actually look at the health effects of eating broccoli on lungs. The problem here is about making the link between knowing the action that broccoli has and saying that there is proof that it protects your lungs. So what’s my verdict on this one? Eat broccoli – yes - as it is an alkaline, green, cruciferous superfood, but do not assume it will protect your lungs just yet. It may do that, but no-one can be absolutely sure.

Another headline I mentioned earlier was about black tea and diabetes. The Daily Mirror reported that black tea may help ‘cure diabetes’. This study was performed on rats liver cells and human kidney cells. The results showed that the tea compounds had an insulin like effect, but this does not mean that it applies to living breathing human beings. My verdict here is drink black tea if you enjoy it (full of antioxidants the potency of which diminishes once milk is added) but don’t expect it to necessarily cure your diabetes as there is no clear evidence for this.

On the health scare side, a headline I read recently was about how women should stop using talcum powder to prevent ovarian cancer. The Daily Telegraph reported a study in which women were 41% more likely to develop ovarian cancer if they used talcum powder around the genital area. The study was a case control study – so in our level of evidence it’s around half way up, so it cannot prove that talc causes ovarian cancer in any case. Also, one could not easily prospectively (look-forward) study this as a double blind RCT for obvious ethical reasons. (You could have two groups of women, one using tals, the other using control-talc but most women would not agree to do this now that we know talc may be harmful). My view on these scare stories are if they advise that something may be harmful, then “if in doubt, cut it out”. Women probably ought to stop using talc in the genital area until more studies follow.

So there you have it. My philosophy is if something is reported as possibly being good for you, and you enjoy it and it is harmless, then why not try it? If it is reported as possibly being bad for you, then cut it out and see what happens for a bit.

Ultimately it is the evidence that is key and always remember the doctors golden rule when it comes to (one of the markers of good medical practice) which is – “first, do no harm” – which is exactly what you should be thinking when it comes to yourself.

Useful links:

NHS Choices, behind the headlines: http://www.nhs.uk/news/Pages/NewsIndex.aspx will give you a very balanced view.

www.cochrane.org if you want a deeper look at evidence based medicine.

(Article adapted from SWEET magazine - www.sweetmagazine.org)

Merry Christmas (and an article on chest pain)

Well, another year draws to an end.... I hope you all have a lovely holiday season and decent New Year. Here's an article I wrote for SWEET recently. As you know my interest is in illness prevention and next year I shall be writing more about this and functional medicine. If you are interested in this then click on the bottom three links on the right hand side of my practice homepage - http://www.medicalplanet.co.uk/. Meanwhile, good health to you all in 2009....

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Chest pain – 999 or see the doctor the next day?

Chest pain - it can be a very serious symptom. It’s the hallmark of that horrible thing we call a heart attack, but can also be caused by other conditions. Do you ignore it or call 999? Dr Ayan Panja tells us what to do…

There’s a very interesting concept in medicine called ‘lay referral’. It’s a term often bandied about by medical sociologists, which essentially sums up how a person acts once when they experience a symptom. It specifically refers to what they do in terms of seeking help through their network of friends and family before they seek professional medical advice. Hence you’ll occasionally overhear an elderly lady at the chemist saying that they’ve been stung by a bee for the first time and that their neighbour told them to “put some vinegar on it”, her daughter then phoned and said to try an anti-histamine cream, only for her husband to come home from the shops to say that she’d be best off seeing the local chemist for some professional advice. This is a classic example of lay referral. We all do it to differing degrees, whether it’s for a bee sting or something more complex.

Chest pain is one of the symptoms which interests me the most when it comes to lay referral. Perhaps unsurprisingly, how someone acts once they have suffered a bout of chest pain depends on several factors including their cultural background, gender, race, age, family dynamics, quality of medical care available to them and probably more banal factors such as whether their parents are doctors. Okay, I made the last one up, but it’s almost certainly true.

I never cease to be amazed at the difference in people’s reactions when it comes to an episode of chest pain. One may call 999 immediately, the other might leave it a few months before he mentions it in passing to his doctor, and another may be dragged against his will to casualty by a worried wife. Believe me when I say that I have seen these very examples numerous times. What’s more, all of us fit into one of these categories. How would you react in response to chest pain? Perhaps it’s happened to you before? The cautious reader might think of calling an ambulance every time. There is certainly some logic in that – why take a chance? It could be a heart attack for God’s sake!

It may sound a little trite that I, having never had a heart attack, am attempting to tell you what it feels like, but the character of pain is often quite telling, and doctors go on the patterns of words used by patients to describe their pain – sharp, dull, heavy, worse on breathing in, like a knife, burning, throbbing – the list goes on.

Aside from the fact that a heart attack occasionally occurs without any pain at all (more common in diabetics and over 75s), there are one or two other very serious conditions which can present with chest pain. They include – pulmonary embolism (a clot in the lung), a pneumothorax (a collapsed lung), aortic dissection (a rupture of the main artery in the body) and an arrhythmia (irregular heart beat). There are also numerous less serious causes for chest pain, including indigestion, Tietze’s syndromes (inflammation of the chest wall), panic attacks and anxiety, shingles and a chest infection. Mmm, that doesn’t really help does it? How can you tell the difference between serious and not so serious? Well, in general, the following features make it much less likely that the chest pain is from the heart (although not impossible) –

Sharp stabbing pains

Obvious worsening of pain on pressing the outer chest wall

Pain that changes when you change position

Pain that fleets past in a few seconds


Factors that make it more likely that the pain is from the heart –

A dull central chest pain which aches and feels like it is inside, like someone is sitting on your chest or squeezing you on the inside

Sweating, greyness, nausea or clamminess accompanies the pain described above

Pain that lasts more than a minute and radiates up to the neck or down the left arm

Changing position does not help the pain

The pain comes on with exertion

A sense that you are about to die


We ought to also look at risk factors. Almost all of the serious causes of chest pain above tend to happen to those who are at highest risk of heart disease. These include those over 50, obese, smokers, people with a family or their own history of heart disease, diabetics, and those of South Asian origin. What I’m saying is that it is very unlikely indeed that a fit, non-smoking 19 year old man with chest pain is having a heart attack – unless he takes regular cocaine or has a birth defect of the heart, whereas a 60 year old smoker who has poorly controlled diabetes probably is having a heart attack until proven otherwise.

Another cause of chest pain includes indigestion, but this is usually more obvious – belching, a feeling of not being able to bend or sit leaning forward, an acid taste in the mouth, pain related to certain food and drink would all point to this. Incidentally, long term regular indigestion symptoms are not to be ignored either, as excess acid from the stomach can lead to ulcers and even some forms of cancer.

Those of you reading this who already have heart disease – i.e. you have had a heart attack or you suffer from angina, will know first hand about what chest pain arising from the heart feels like. Angina simply means chest pain arising from a lack of adequate blood supply to the arteries which supply the heart. If you are a sufferer of angina and you start suffering the pain at rest, or the pain is not relieved within 10-20 minutes of taking your GTN (Glyceryl Trinitrate) spray twice, (which dilates the very arteries which supply your heart muscle with blood), then you too should call 999. If you are not allergic to aspirin, you should take a 300mg dose of it.

So what’s my advice about sudden chest pain? Well, if you’re with someone who suddenly complains of chest pain and you suspect that it is a heart attack, call 999 immediately, sit them up, reassure them that help is on the way, and, if you have it hand, give them 300mg of aspirin if they are not allergic to it and wait with them for the ambulance.

Well, the bottom line is that it’s often very difficult to tell if you are having a heart attack. We know that heart disease is still the biggest killer in Britain claiming around 100,000 lives a year in the UK alone. Every six minutes or so another person dies of a heart attack in this country. Work your risk factors down to prevent the chance of this happening. Do all the boring stuff - stop smoking, eat less sugar and fat, exercise more. But if you do get unexplained chest pain, do not take a chance - call 999.

Thinking about your drinking...

(from Officer Life magazine)

I remember going on CADRE camp to Pippingford Park in Kent in 1989. It was a week long training camp for those of us who wanted to stay on in the sixth form and become NCOs in the schools cadet force. Our RSM, a natural leader of men, took off his beret during the first briefing and said, in his Belfast accent: “Any of you who have any cigarettes on you put them in this here beret – I won’t look you in the face…” and with that he walked up and down the neat rows of cadets standing at ease. There was total silence. No-one handed anything in. He then said, “Right, any of you bring any tins of beer with you? Silence again. “What? No-one bought any tins of beer with them?! Well, then you’re all bloody stupid ’cos that’s something you’re all entitled to!” The reason was obvious. Back then, beer still tasted like urine to most of us, even though only the geekiest kids would ever admit it. We’d all gulp it down and pretend to enjoy it. It took a year or two for us to develop a taste for booze, and the rest is history. The reality of course, is that alcohol still tastes awful, but we’ve all just got used to the taste.

It’s not just the NAAFI that sells cheap beer these days. Most supermarkets now sell some brands of beer cheaper than water. No wonder alcohol related deaths in the UK have doubled since 1991. But how do you know if you’re drinking too much and what are the dangers and warning signs?

Doctors often use what’s known as the CAGE questionnaire –

Have you ever felt you should Cut down on your drinking?


Have people Annoyed you by criticizing your drinking?


Have you ever felt bad or Guilty about your drinking?


Have you ever had a drink first thing in the morning (as an “Eye opener”) to steady your nerves or get rid of a hangover?

Two or more definite YES’s and that means you ought to re-evaluate your drinking habits and seek advice.

In terms of units of alcohol and what is safe, there used to be a belief that people lied when they went to their doctor so you could drink more than recommended and get away with it, but this is not true. Men should drink 21 units or less and women 14 or less. Three pints of beer three times a week is around 18 units, (and that’s normal strength beer). A small glass of wine is 1.5 units – (so nine of these a week is a woman’s limit).

In terms of health effects, drinking too much alcohol effectively steals nutrients and vitamins from your body. Alcohol is full of ‘empty’ calories that do nothing but make you put on weight. It damages your liver, can lead to osteoporosis (bone thinning), several cancers, stomach ulcers, diabetes and high blood pressure which can cause heart attacks and strokes.

The trouble is that often there are no warning signs until alcohol related disease has set in, and that’s why you need to be so careful with your alcohol intake. It can be a silent killer. And that’s not all. Alcohol can cause irritability, depression and erectile dysfunction (brewers droop). Not good. And it doesn’t matter what you drink. Some of my patients who drink too much say to me “Yeah, but I only drink beer doc… I never touch spirits…” The truth is that all alcohol in excess, whatever kind, is really bad for you. OK - enough doom and gloom! I think we all know too much of anything is bad. On a slightly brighter note, a small intake of alcohol can be good for your heart.

I often get asked why hangovers get worse with age. This is because the body contains less water as you get older so the toxic effect is more concentrated.

One final tip - if you are a social drinker and you have a glass or so a night, stop alcohol for one week and just notice how much clearer your thinking is, and how much better your mood is. Do it with a friend if you can’t do it alone. You’ll be amazed.

If you are not sure whether you drink too much or you feel you need help use this NHS link to find out more:

http://www.nhs.uk/livewell/alcohol/Pages/Alcoholhome.aspx

How do you get the most out of your GP in just ten minutes?

What can you do in ten minutes? A crossword? Read a newspaper article? Or maybe chat to a friend on the phone? It’s almost unbelievable that this is the amount of time we get in an appointment with a GP and equally astonishing that modern doctors can work effectively in such a system. But amazingly it works, most of the time.

In fact things used to be much worse. Our predecessors had just six minutes per appointment, and only in recent years has the government’s quality framework recommended that ten minutes ought to be the minimum for a routine appointment.

So what’s it like from the doctors point of view? Well, remember that we doctors are patients too, so we are uniquely placed to give you both angles. Firstly, let’s take a typical surgery so that you can see it from both sides. (The cases are not based on real people but accurately reflect typical case mix in any busy practice).

The first appointment is a young man who sits down and says “Right, I’ve got four things….” By this point I’m usually already thinking that he’ll need about six or seven minutes just to tell me about the four problems he’s got, then I’ll need to dig out some more history and examine him, then he’ll probably think of something else, so with a bit of luck I might get it all done in around twenty minutes if I’m lucky. This means I’ll be running late for my next patient. She’s an elderly lady with hip pain, diarrhoea, blurred vision and dizziness on a lot of medication. She’s recently widowed, has no next of kin and is struggling to cope. After a long conversation I realise she’s confused, depressed, not taking her medication as she should which is causing her symptoms and living on toast and tea. I explain the options for managing her depression, jot down the fact that I need to speak to social services and the pharmacist about her later as well as refer her to the dietician. Next up is a middle aged man with a hard lump in his testicle. His wife forced him to see me and I’m almost certain that it’s a cancer. He’s anxious and I do my best to explain what will happen next and make a note to fax his referral urgently at the end of surgery. I get interrupted on the phone at this point by the practice nurse who is not sure how to adjust a gentleman’s blood pressure medication. As soon as I put the phone down, a receptionist rings through an urgent home visit, so I decide to ring the patient at home and tell him I’ll see him after surgery as it is not a 999 job. I’m now running half an hour late for my third patient and I have at least another twelve to go. You get the picture.

You can see from the snapshot above that it’s crucial to communicate effectively with your doctor as there is so much going on. Modern doctors are all supposed to be patient-centred (work in partnership with patients), thorough and holistic. This means that we have finely tuned communication skills and are forever updating our knowledge and clinical skills. No doctor knows everything, so do not be alarmed if your doctor looks things up – this is completely normal and it would be worrying if your doctor never looked anything up!

So what is the best way to get the most out of your ten minutes? Here are my top tips.

Limit it to two complaints on top of any ongoing conditions

For instance you’ve got tummy ache, dry skin and you want to get your blood pressure, migraine medication and asthma checked. This really is a lot to get through in ten minutes, and although we could try to cover more it becomes a false economy as we are likely to miss things or make mistakes.

Give an honest accurate description of the symptom, how and when it started, what eases it and what makes it worse

This really makes your doctor’s job easier. If you drunk half a bottle of vodka, tried your friends Viagra or had vigorous sex just before you felt faint and vomited the other day, then you really must say so or you could get the wrong diagnosis or treatment. There is no room for embarrassment in the consulting room. Two of the duties of a doctor include upholding total confidentiality and never judging anyone, so you’ve nothing to fear.


List everything you have come in for briefly at the start of the consultation so that your doctor can plan the ten minutes

It’s good to avoid saying “And there’s a couple of more things I wanted to talk about…” after the doctor has spent 10 minutes dealing with what he thought was your only symtpom when you sat down.


Tell the doctor what is really worrying you and what you were expecting

e.g. “I have a really bad headache, I think it’s a brain tumour and I think I might need a brain scan…” We’re generally quite good at eliciting this kind of information anyway, but you may as well cut to the chase!


Be on time and let the surgery know if you can’t make the appointment

There are around 10 million missed appointments a year, so please let your surgery know if you can’t make it so that someone else can be seen. I know it’s frustrating when the doctor actually runs late and the truth is that most good GPs hardly ever run exactly to time.

Up to 90% of all illness is managed by the GP. Remember that getting the most from your doctor is a two way process. If you want the most from him, you must be willing to share decision making and take some responsibility for your condition. Always make sure you have a practice leaflet handy, so that you know opening times, services offered and the doctors areas of interest. And every now and again, make sure you ask to get your blood pressure and cholesterol checked with the practice nurse.

So, there you have it. It seems that the ten minute appointment is a bit of an oddment, but in a weird way, it seems to work most of the time. And what’s more, now you know how I play my hand when I go and see my own GP. I hope that helps and I would be interested to hear how you get on next time you book in to see your doctor.

Good health to you!

(Adpated from Dr Panja's article in SWEET magazine, issue 3, out now)http://www.sweetmagazine.org/

The polypill - marvel or menace?

You’ve probably heard the word polypill being bandied around the media over the last five years and how it is a magic pill combining several medications which will save up to 100,000 lives a year. It has recently been given the green flag by the governments heart disease czar, Professor Roger Boyle, to be available on the NHS to all people over the age of 55. That’s right. I did just say ‘to all people’. Can one pill really be suitable for us all and can it be as fantastic as early research indicates?

Well, let’s start rather morbidly by looking at what actually kills most people – and I’m not talking about serial murderers here, rather the main illnesses and conditions which kill us. It’s important to set the scene properly and you’ll see later how this relates to the polypill.

The two most common causes of death throughout the world are coronary heart disease (CHD) and stroke. It’s a fact and it’s totally indisputable, which is rather nice, as all practitioners and experts agree on this. A rarity indeed. Together CHD and stroke make up between 20-30% of all deaths worldwide and the factors which make the two conditions more likely to happen are actually the same. This means if we can prevent one from happening, we are also working to prevent the other. The rest of the list of ‘killers’ after CHD and stroke includes respiratory illness, AIDS, diarrhoea (unbelievable but sadly true), tuberculosis, cancers and malaria.

So there you have it. Stroke and CHD top the list of conditions most likely to cause death. This means that prevention should start early on in life with rigorous attention to diet, exercise and the avoidance of smoking.

In simple terms, there are certain factors that we know which increase our risk of these conditions.

Let’s start with the risk factors that we cannot do anything about -

Ethnicity – being South Asian puts you at around 50% more risk of both CHD and stroke and being African-Caribbean raises your risk of stroke by 50%.

Family history – If your parents had heart disease below 55 for men and 60 for women then you are at higher risk.

Men are at higher risk of both compare to women, and women going through an early menopause are at higher risk compared to women who don’t.


Moving on to factors we can attempt to do something about –

High blood pressure

High cholesterol and/or triglycerides (types of fat in the blood)

Diabetes

Kidney disease

And finally some factors which are in our own control -

Lifestyle – Smoking, lack of exercise, stress increase risk

Diet – Too many refined carbohydrates, too much saturated fat, excess salt and alcohol all increase risk.

So that’s the territory as it were in terms of what the polypill is up against, its purpose being to prevent stroke and heart disease, thereby extending life.

The key point is that everyone is different. I know what you’re thinking. Person A can smoke, eat cream cakes, red meat and lard all their life until they are 85 and never get any problems because they have no family history, whereas person B may eat well, exercise regularly, and never smoke but may find that everyone on both sides of his family has heart attacks at the age of 45. A word of caution: please do not be fooled by person A. She is just very lucky, or blessed or both. Person B, however, has a job on his hands to prevent a heart attack at the age of 45.

These are both extreme examples and most of us lie somewhere in between and I believe that it is in this ‘in between’ group that the polypill may be most effective at saving lives or at least delaying death.

Contents of the polypill

So let’s take a closer look at it. The polypill is going to contain up to six ingredients: three blood pressure lowering medications (a thiazide, a beta blocker and an ACE inhibitor) which all work in different ways, a cholesterol-lowering drug called a statin, and folic acid. Folic acid reduces levels of an amino acid called homocysteine in the blood. Elevated levels of homocysteine may increase the risk of heart disease.

Trials involving the polypill are under way in Spain and the USA at the moment but they contain aspirin, the 6th ingredient, and one that is traditionally given to those who have already had a heart attack or stroke. Aspirin keeps the blood thin by de-clumping platelets, a sticky component of the blood.

We already know that beyond modifying your own risk factors (smoking, diet etc.), that if high cholesterol and high blood pressure can be lowered, then the risk of having a stroke or heart attack falls. There’s no rocket science here. This is based on robust studies looking at thousands of people over many years.



Pros and cons

On the face of it the polypill sounds like good idea. Why check out with a stroke or heart attack at 60 when you could take a little pill and live for ten more years?

But what if you suffer from side effects? Are the doses too small for those with pre-existing heart disease? What if you’re already on blood pressure medication? What if you’re diabetic? These are all things to consider. My own educated guess is that the polypill would be suitable for people not on any medication as a preventative measure.

Conclusion

The polypill may well save thousands of lives a year, and many of my patients –in fact many of you – take the medications contained within it as separate tablets. The advantage of taking separate tablets is that monitoring side effects is much easier, but the polypill is clearly more convenient. Imagine – one pill instead of five or six?

Currently we need more clear trial data about the polypill. There is talk about it being medicine for the masses, so a very careful analysis of this pill is needed. This is essentially how all drugs make it to the market place, through laborious phased clinical trials, but this drug is different from most others. Much like a vaccine, it is aimed at the masses – the idea is that almost everyone will be offered it - so factors such as cost to the NHS and side effects are critically important.

In the mean time, my advice to prevent CHD and stroke would be boringly obvious. Maybe a story will help illustrate it. I saw a pleasant chap in his early twenties a few months ago who was recalled by my practice nurse for having very high blood pressure. A student, he had been living on take-aways, beer and cigarettes. He was so scared by his blood pressure that he cut the booze and fags and started cooking at home that very evening. Three weeks later his blood pressure was completely normal. That says it all in terms of modifying your risk factors really. Job done.

Would I take the polypill myself in my fifties? Yes, if the evidence showed it was safe and saved lives, yes I would. But I’d do everything I could myself through diet, exercise and supplements to avoid having to take it. It’s very much an individual choice. All we can do now is wait for its arrival and see if there is any change in death rates from stroke and CHD. And that whole process will take years, so I may just go to work on some of my risk factors while I wait. Where did I leave my trainers?



The polypill at a glance:

-Could be available in UK on the NHS by 2009

-Set to save 100,000 lives a year (or rather delay deaths from CHD and stroke)

-Contains 3 blood pressure tablets, folic acid and a cholesterol lowering agent

-Some versions contain aspirin as well

-Likely cost will be £1 a day per person to the NHS (up to £6 billion a year)

-Lives saved should save the NHS around £2 billion a year after cost of the polypill

-Aimed at those over 55 years of age

Article adapted from Dr Ayan's original article in SWEET Magazine issue 2 - www.sweetmagazine.org

Beyond a one off case of brewer's droop? Tell your doctor now... it could save your life

I was at a media medics seminar last week on erectile dysfunction (I'm assuming we all know what that means but basically it's when you're finding it difficult to perform, get it up, or stay hard). The shocking thing is that it is treatable in over 90% of cases but men often find it hard to talk about it. Causes include smoking, diabetes, high blood pressure, stress, psychological reasons but most importantly heart disease. A recent study has shown that 3-5 years after men develop erectile dysfunction, particulalry over 40, they are very likely to suffer a heart attack. For this reason alone, please please please make sure you let your doctor know if you're having trouble down below, as it may be an early warning sign for heart disease.

For some free information and a self-test, visit www.40over40.com

Are you what you eat? - Probably... The importance of nutrition

In recent years, doctors have come under fire for being too disease focused and not looking more closely at the factors which actually create good health.


Without doubt nutrition is a key component of keeping ourselves healthy. So what's new? Well, I mean looking more closely at exactly what we eat, rather than simply getting your five portions of fruit and veg a day. For instance, tinned peaches in sugar syrup are not going to be as good for you as fresh peaches, or fruit juice 'from concentrate' may as well read 'from sugar syrup'.


It's all about making discerning choices about food.


Here are some basic rules which I myself try to follow. I understand that we are all human, so it won't happen overnight but give it a go:

• Cut down on animal fats including milk and meat (particlularly red meat), trying to eat a mainly vegetarian diet. (Vegetable fats are much better for your health than animal fats).


• Cut down or eliminate added or refined sugars of any kind. If you must have sugar, take fructose or honey. (Sugar steals nutrients from your body and any excess is converted into fat).


• Eat more fresh fruit (e.g. apples and bananas), leafy green vegetables, seeds, nuts and raisins for snacks. These help fight heart disease.


• Increase your intake of fermented soya products, such as low salt soy sauce or miso soup, as they can lower your chances of breast and prostate cancer. (In Japan, rates of these diseases are very low as the intake of soya is high). Avoid non-fermented soy if possible.


• Drink minimal alcohol.

To go into detailed explanations around all this would take too long, but I hope I have given you some easy pointers. As is my philosophy, I am only telling you to do what I would do because I honestly believe it is best for your health.

For links to books which I recommend on this topic and others, please visit my practice website - http://www.medicalplanet.co.uk/

Happy eating...

Croup

Apologies for the radio silence. Been very busy... but I'm back...

I thought I'd cover a childhood condition today.

Croup (Laryngotracheobronchitis or LTB) is the name given to a viral infection which is most common in children between the ages of 6 weeks and 6 years, but can affect people of any age. It tends to happen most commonly in late winter or early Spring and is often caused by the parainfluenza virus.

Croup often produces fever and affects the back of the throat and lungs, causing increased mucus production and occasionally a cough which can last a couple of weeks. Measures are usually simple -

• calm the child/ person down
• steam inhalation (little evidence for it, but it eases symtpoms)
• anti-fever and anti-inflammatory drugs (paracetamol and ibuprofen) - if safe to take (e.g. you cannot give ibuprofen to asthmatics without very careful consideration).

Most of the time croup is mild and will resolve within a week, but occasionally it can cause 'respiratory distress' which essentially means very noisy, laboured breathing using abdominal and neck muscles. In this situation the concern is about getting enough oxygen into the lungs without becoming exhausted.

Things to look out for which mean that you need to seek medical attention:

• Persistent, rapid, noisy, laboured breathing for more than two hours, not responding to the simple measures above
• Persistent crying and drooling for more than an hour
• Persistent fever
• Blue lips or blue tongue

Rarely, admission to hospital is necessary and a course of steroids and oxygen therapy may be needed to treat the condition.

I never thought I'd become political, but....

This is a short post.

I am generally not the kind who campaigns for the sake of it and dislike the cynical, disparaging and sometimes vulgar blogs out there which moan about everything for the sake of it, but I am going to briefly become political for the first time in ages and have a bit of a whinge....

I am currently in the middle of filming another series of Street Doctor but aside from being busy at the practice and at home, my mind has been on the recent media coverage of the changes which are afoot for general practice. My own view is that you cannot beat seeing your 'own doctor', but there are a number of reasons why this is currently already quite difficult and will become harder and harder as time goes on.

On average, each full time GP has around 2000 patients on his or her books. In general this means that if you want to see any doctor you'll get seen urgently if needed, on the day, or within a day or two. But if you want to see a particular doctor or your regular doctor, you will probably have to wait. That's just the way it is.... put simply there are not enough hours in the day for your regular doctor to see everyone who wants to see him whenever it suits them... Also, when we are on leave or ill, a locum doctor will have to cover us. Anecdotally, I find that younger patients (under 35) with the odd thing wrong with them once in a blue moon, don't mind who they see... they love the one-stop shop idea and want a probelm sorting out quickly. Older patients identify with one doctor moreso.

The proposed changes to general practice will probably mean more private sector involvement, polyclinics with many doctors and possibly a loss of personal care. Sadly GPs have had little if any say in this. We have had no uplift in funding for two years, are expected to give our staff pay rises and still meet ever evolving government 'targets', all of which is difficult. We are trying, honestly...

In my mind, for patients, it comes down to whether you want to see any doctor or your doctor... and I think if it's urgent, you'd be pretty happy to see any doctor... the service is not designed for people to come and see the same doctor again and again week in week out. This would saturate the appointment system.

If you want to read more about the reforms planned for general practice click here and for a balanced article about the state of play from a doctor's point of view, click here

Also, check out this vid - http://youtube.com/watch?v=1jkZ3GwlPMs&feature=related

On being a GP... and some tips on seeing one...

I often get asked why I chose general practice instead of hospital medicine. Variety is the simple answer.... I can't think of any other medical job where you see so many different conditions and enjoy the continuity of caring for a community over several years.

GPs are often the first port of call for people with symptoms (as are casualty doctors in case of emergency).

The clinical part of our consulting (i.e. the medical bit of seeing patients) has two strands to it (so this does not include repeat prescriptions, hospital correspondence, paperwork, clnical and practice management which makes up around 40% of our work) - so anyway, as I was saying, our consulting is largely made up two strands - ACUTE and/or CHRONIC problems...

ACUTE = immediate treatment for unexpected things that happen out of the blue and quickly... back pain, red eye, shortness of breath, unwell children, chest pain, certain rashes, loss of vision, bleeding in pregnancy, severe headache, blood in your urine etc....

CHRONIC = long term conditions which start at some point in time but need careful 'maintenance' by both the patient and the primary care team - so by that I mean monitoring and check-ups etc. These conditions include diabetes, asthma, high blood pressure, hypothyroidism, mental health problems, heart disease, stroke, dementia, kidney disease, osteoporosis etc.

Of course many people have a bit of both... acute and chronic problems... and nowadays people are so well informed that they do not come in for sprains and strains or coughs and colds, and even if they do, they would often see the practice nurse, not one of the doctors....

I guess the third strand is really a support or pastoral function, for instance when people are bereaved or just need a professional ear... 'Caritas' is a very important part of general practice.

No doctor in the world knows everything or is superhuman, and as GPs we are often criticised by other medical colleagues (my own mates and on other blogs) for dumbing things down too much, using the wrong words to explain something so that it loses accuracy of meaning, not knowing enough and not spending enough time on a patient's symptoms.

GPs all practice slightly differently and have differing levels of expertise, skill, the ability to communicate and medical knowledge but we should all be trying (amongst other things):

a) to help you and to do you no harm

b) to practice evidence-based medicine (i.e.advising on what we know works best through studies)

c) to be the your advocate as far as is possible within a medical practitioner's ethical framework

GPs are jacks of all trades in a medical sense, and we have to tailor our consulting to each individual, often thinking on our feet, both taking on board and giving out a huge amount of information and treatment in a very short time on just about anything that presents to us. We also try very hard to make patients understand things without the use of too much medical jargon and this is often seen as 'dumbing down', although I think it is important for people to understand their condition, in whatever terms it is explained.

So how can you be sure your GP is any good if he can't know everything?

Well, it's unlikely, for instance, that a GP is generally going to know as much about earache as an ENT surgeon, but we'll hopefully know enough to treat the underlying cause and work out whether it might be something serious.... and if we are unsure or need help, then we refer to ENT.

It is important to remember that 90% of all illness is treated in the community.

My philosophy is simple - to treat people as I would like any family member of mine to be treated...

Here are my tips on how to get the most out of your GP:

1. Get to the point quickly and tell the story of your symptoms as accurately as you can.

2. Keep it simple - no more than 2 (maybe 3) things per appointment as it is difficult to deal with too many things at once in just ten minutes.

3. If you want further information after your consultation do not be afraid to ask for a leaflet or web reference.

4. Think about getting a pre-payment certificate for prescriptions from your pharmacist if you get more than one prescription a month. The certificate costs £98.70 for one year and covers as many prescriptions as you need annually.

5. Have a practice leaflet to hand at home so you know who to see when at your surgery and how to access their services best (for example travel vaccines adn smears are the remit of the practice nurse).

Hope this helps...

Back pain

Happy New Year to one and all....

I am writing about back pain as I have been suffering with it for the past three days. Everyone reading this will have had back pain at some point in their life, whether it's for a few seconds or it's day after day....

Back pain can be very debilitating and is a common reason for time off work. We all get the odd back strain now and again but if you have an ongoing problem please do not suffer in silence. Go and see your doctor or a physiotherapist for advice on back care if you have had pain for more than a week. The lower back is most commonly affected.

There are many reasons for back pain including pain arising from muscles, nerves, discs and much rarer causes and good quality information can be found here: http://www.backcare.org.uk/

Long term back pain, or back pain that develops in the age group 30-50 tends to take years to develop and is a result of lifestyle factors, poor posture, poor bending/ lifting technique and the fact that life is much more sedentary in the modern world. Sitting is bad for your back, especially if you slouch.

Basic things to do to protect and strengthen your back:

1. Keep your back straight while bending, sitting or lifting - bend your knees and hips and use them to take the load, not your back. If anything, your back should have a very slight backward curve to it (like Donald Duck).

2. Do some regular core stability exercises and stretches (including tensing your abdominal muscles repeatedly, as well as during lifting and sitting). This link is a good start-

http://exercise.about.com/cs/abs/a/coreandposture.htm

3. Stop smoking and cut down on alcohol. This will help the health of your discs and bones.

Whatever you do, please do not take your back for granted, whatever age you are... the spine is a delicate part of the body and is difficult to 'fix', so make sure you do everything to avoid problems as much as possible...

Good luck!

Flu season is upon us... winter health tips and the flu jab.

Flu can kill.

Having not taken a sick day in several years, I myself was wiped out for a week by 'flu in the late summer and had to miss a week off work. Muscle ache, fever, cough and no energy to get out of bed..... Imagine the same illness in someone older, frailer or with a lung or heart condition?

This is one of the reasons why it is important to get the flu jab if you are in a group 'at risk' -

i.e. You are entitled to a flu jab free from your GP surgery if you are:

over 65

OR - have any of the following:

-asthma or other long term lung disease
-heart disease
-diabetes
-stroke
-kidney disease
-if you are a carer

The important thing to remember is that the jab does not protect you from common winter bugs and coughs and colds, but it can save you catching a severe strain of 'flu which can cause severe illness.

Click here to read more on it in the national press, or visit the BBC health website link -

http://www.bbc.co.uk/health/conditions/flu1.shtml

Other winter health tips

Choose the right food and drink

A balanced diet is the best way to ensure an adequate intake of nutrients. Certain foods boost your immune system, which is responsible for combating infection from viruses. Oily fish like tuna, mackerel, salmon and sardines contain Omega-3 Essential Fatty Acids, which fight infection and help keep your heart and joints healthy. Fruits and fruit juices are a great source of Vitamin C, which finds it’s way into your immune system’s "white" blood cells, thereby supporting it. Green vegetables like peppers, cauliflower and cabbage also provide plenty of Vitamin C. Certain ingredients used in cooking such as cinnamon, cloves, cardamoms, turmeric, ginger and garlic are also of benefit. Turmeric and ginger are used in Ayurvedic cold remedies, and garlic has anti-bacterial properties.

Enjoy exercise

Getting yourself out of breath for 30 minutes four times a week, is considered moderate exercise. This can be almost anything – from jogging to a pilate. Within limits, regular exercise can make you less prone to infection. Other beneficial effects include improved fitness and a positive effect on mood.

Herbal remedies

Echinacea is the gold standard herb for boosting your immune system. It is available from health shops and chemists, and is usually taken for no longer than two weeks at a time.

And finally...keep warm and get some sun

Humidity protects your mucous membranes, (the body’s moist linings), against attack from viruses. Sunlight, or just being out in natural daylight, is supposed to improve your mood at wintertime. This can prevent seasonal affective disorder, (SAD), which is a condition in which mood fluctuates with varying light levels.

Cholesterol explained

Cholesterol is one of those words you hear and read a lot about.

It is a type of fat essential for bodily function but too much of it can lead to heart disease and stroke.

The other important thing to remember is that your own body produces cholesterol and that there are only a few sources of dietary cholesterol including eggs and shellfish. Regular exercise, inncreasing intake of whole grain food, pulses and green vegetables also help keep cholesterol down.

A good start in the battle against cholesterol is to cut down on 'saturated' fats, often derived from animal sources. It is worth also thinking about the kind of oil you use to cook. Olive oil, sunflower oil and flax oil are all better for you than coconut oil for example. Coconut oil is very high in saturated fat.

Cholesterol testing

It is important to get your cholesterol checked. There are four figures doctors focus on - your 'total' cholesterol, your HDL (high density lipoprotein), your LDL (low density lipoprotein) and your triglycerides. The last two are BAD! LDL and triglycerides are 'bad' fats which harm the body by building up cholesterol deposits. HDL on the other hand is 'good' cholesterol which munches away bad cholesterol and sends it back to the liver for breaking down.


What should my cholesterol be?

Your total cholesterol should be < 5.0 and your LDL < 3.0 unless you are diabetic or are at risk of heart disease, when the total should be < 4.0 and your LDL < 2.0.

If you have a family history of high cholesterol or heart disease you should get your cholesterol checked through your doctor.

Medical NLP - a revolution in the doctor-patient relationship and its effect on healing

It is not the norm for a doctor to write about a topic on a health blog which is possibly more relevant to the doctor than the patient, but medical NLP is one which I must mention. A few years ago I had some money left over from my study budget and I decided to go on a course which sounded a little 'off the wall'.... intriguing - http://www.medicalnlp.com/. It was an epiphany to say the least, and I now think had I not been on that course at that point in time, I may well have left medicine by now and ended up in a gloomy daze. Luckily for me, that did not happen....

So what's it all about?

Please click on the link below to find out more about the important and valuable work of medical NLP master trainer, Garner Thomson. He and leading GP co-author, Dr Khalid Khan, have distilled the powerful yet elegant techniques from their course into a book called Magic In Practice. This link explains it all....

http://www.hammersmithpress.co.uk/magicinpractice.html

House dust mites - could this be why you or your child gets a blocked nose, cough or itching at night?

House dust mites are tiny creatures which feed off dead skin and are more commonly found in homes with lots of soft furnishings.



They (or rather their faecal matter) can be a cause of asthma and night time symptoms such as coughing, sneezing, blocked sinuses, runny eyes and itchy skin or eczema.




If this all sounds familiar to you then you might want to try the following measures to do your best to eliminate them from your home. If you do, your symptoms should improve dramatically.

1.Minimise or best remove soft furnishings like cuddly toys, fur cushions etc. from your bedroom

2.Try regular thorough vacuuming of your mattresses and carpets, preferably with a vacuum cleaner with an allergy filter

3.Reducing the humidity in your home with adequate ventialtion and possibly a de-humidifier

4.Wash your bed clothes at the highest possible temperature (usually 60 degrees C)

5.Buy a micro-porous mattress cover from a shop like Homebase or Woolworths

Fertility and infertility

Fertility, or rather infertility - It's a big issue affecting more people every year. Why?

Well.... life has changed over the last fifty years. Many say that forty is the new thirty, as people are living longer and in general enjoying better health, often deciding to start families later, particulalry in the Western world.

However, one important thing that has not changed is the number of ovulations (or number of times that a woman will produce eggs) in an average lifetime. Of course this is by no means the only factor involved in fertility, but it is clearly of great importance.

It is important to note that there is a steep and steady decline in ovarian function after the age of 35 - i.e the numbers and the quality of eggs diminish. Many people reading this will think that IVF can get around this problem, and it can - sometimes. There are often long waiting lists on the NHS and the process can be both emotionally and financially exhausting.

Having said this, there are many causes of infertility - male and female - including anatomical, hormonal and lifestyle factors. For instance smoking can decrease sperm count.

Sometimes no cause can be found and this is known as medically unexplained infertility.

So when should you worry about fertility?

Firstly make sure you:

-Stop smoking

-Cut down or even better stop drinking alcohol

-Eat healthily and exercise regularly

-Start taking 400 micrograms of folic acid a day (for women)

If you have done these and are not having success after a year of trying please see your doctor. A set of blood tests for her and a semen analysis for him is a usual starting point in terms of investigations.

The big issue - Overweight or obese? Here's what to do....

It's so topical, what with childhood obesity at an all time high in the UK right now, and the rates of adult obesity being double what it was in the 1980s, I just had to cover it.





Why worry about being overweight?


It basically makes for a short cut to an early grave. It's that simple. Most of us know that being overweight or obese increases the risk of almost every disease or condition including high blood pressure, diabetes, stroke, heart disease, kidney disease and even some cancers.




Overweight or obese?


One way of measuring a person's frame is called body mass index (BMI). Occasionally it seems off the mark as many professional athletes seem to have high BMIs, yet are not obviously overweight.


It is calculated by your height in metres squared divided by your weight in kg.


Click here to work out your BMI.


-If your BMI is in the range 19 to 24.9 you have a healthy weight.


-If your BMI is in the range 25 to 29.9 you are considered to be overweight


-If your BMI is 30+ you are considered to be obese.


There are some medical conditions such as an underactive thyroid or pituitary problems which can lead to being overweight. If you think you are doing all the right things already, then ask your doctor to check these out with a blood test.



The secret?

If there is no medical reason for your weight condition, then there really is no secret. The rules are very simple. A good balanced diet and regular aerobic exercise (ie getting yourself out of breath for twenty minutes) at least three times a week are the key.

All of the research that has been done over the years on various systems whether it be the Atkins diet, the GI (glycaemic index) plans, The Cambridge Diet etc etc... (the list goes on....) shows the same thing consistently, and that is that obesity is ultimately related to overall calorie intake. In simple terms it is important to reduce your calorie intake.

For a healthy diet, I recommend cereal for breakfast and then advocate following the Zimbabwean Hand Jive for the rest of your meals. This is a simple way of telling you how much of what kind of food you should eat with each meal to stay healthy.

Your doctor will be able to refer to a dietician if you are struggling with this or if you need a special diet.

How we eat.... can make a difference


Next time you eat a meal, follow these rules to aid digestion and keep the pounds off.


1. Eat when you are hungry


2. Stop when you feel full


3. Chew your mouthfuls several times before swallowing


4. Do not eat after 7pm if possible (assuming you are following a standard 9-5 working day).





Good luck!

How to.... get a good night's sleep

Insomnia or the feeling of not being able to get enough sleep is quite common. It affects up to one of three of us at any time and increases with age. It is possible to survive longer without water than it is without sleep, so sleep is an important function for our health.

There are certain medical conditions which can affect sleep such as thyroid disorders and depression so if the following 'sleep hygiene' rules don't work for you, it would be wise to visit your doctor.

z z z z Z ......

1. Avoid cat-naps in the day

2. Cut down on caffeinated drinks, cigarettes and alcohol

3. Exercise regularly but never immediately before going to bed

4. Clear your mind of stress - write down any worries

5. Make sure your bedroom is dark and quiet

How to.... stop a nosebleed

Nosebleeds are common. Children are most prone to them, especially under the age of ten. The bleeding is often caused by crusting of the mucus membranes (ie the inner lining of the nose) or from infection by a bacterium called staphylococcus. In the latter case, nosebleeds can be recurrent and an antibiotic cream such as neomycin can help clear it up quickly but this should only be taken under the advice of a doctor.

Follow these simple rules to stop the bleeding quickly...

1. Pinch your nose between your thumb and forefinger, and apply moderate pressure by squeezing either side for ten minutes - just below the bridge of your nose over the 'nasal septum'.

2. Lean your head forward.

3. Breathe through your mouth.

4. Apply a cold compress around your nose but keep the pressure on.

5. Pop some petroleum jelly up the nostril once the bleeding has stopped.

6. Avoid blowing your nose for 24 hours.

Five top tips for keeping your heart healthy

The heart...some would argue it's the most important organ in the body.

Here's how to treat it with respect.


1. Exercise for 20-30 minutes five times a week.


2. Cut down on 'saturated' fats (e.g butter, lard, cream, fatty cheese, coconut oil)


3. Eat more fibrous food (e.g whole grain cereals, oats, fruit, beans, cauliflower, lentils)


4. Do not smoke (or if you do, stop smoking now)


5. Get your blood pressure, weight and cholesterol checked regularly and make sure they are optimum

The sun safety code

It's hardly been a summer of sun in the UK. Nevertheless, whilst enjoying the sun if it chooses to grace your environs, it is important to protect yourself from it. This is with regard to burning, heat stroke and most importantly from the risk of skin cancer.

Here's the quick and easy 'sun safety code' which is worth using...

• Seek shade around 11am and 3pm bearing in mind that the sun is at its hottest around midday

• Protect young children and babies
  

• Cover up and protect the skin
  

• Wear a wide-brimmed hat and sunglasses which conform to the new European Standard BSEM1836:1997 and carry the CE mark
  

• Use a high factor sunscreen (SPF15+) on any part of the body not covered up.

Tip of the day.... stop smoking

Stop smoking

OK, so it's an obvious one.... and we know all the stats. Lets see now...each cigarette takes around 11 minutes off your life.... you are up to 6 times more likely to suffer a heart attack... you have around a 1 in 10 chance of developing lung cancer, are more likely to become impotent, are far more likely to develop mouth and bladder cancer etc. etc., blah blah blah... the list goes on...

Just remember that if you are a smoker that there was a time in your life you did not 'need' fags. No rush to the petrol station on the way home even though your tank is full, or a mad dash to get shelter from the rain to get those precious drags in...

Break the cycle and you'll be able to stop. Honestly.

That feeling you get when you crave a cigarette will pass. You won't die of it...

Speak to the practice nurse at your GP surgery about nicotine replacement, try the phenomenal Allen Carr method (www.allencarr.com), or visit www.gosmokefree.co.uk. You can do it.

If you've never been a smoker, then well done - you've had a lucky escape, and if you've managed to stop, then know every day that it's the best thing you could have ever done for your health, so feel really good about it.

Introduction

Hello and welcome to my blog....

It had to happen.... I have a lot to say and this seemed like a good place to say it.

Blimey..... where to start?


Well, I thought rather than talk about how much I love Indo-Jazz, Chablis or biscotti I thought I ought to talk about something that is of use to others.


As my only area of professional expertise is medicine and health care it seems like a good subject area.

The first instalment will follow soon....