Keeping weight in check - does the weight of the adviser matter?

A wide range of advisers - from family doctors to pharmacists - can be effective in providing lifestyle advice aimed at reducing risk of serious diseases of the heart, brain and circulation - including advice on diet and exercise aiming to help with weight loss.
However a new study, organised by the Royal Society for Public Health, suggests that people seeking advice on weight loss are less likely to take it seriously from someone who is overweight, whether from a health professional or another source, including hairdressers and celebrities.
In response to this report, the Royal Society for Public Health is recommending that NHS staff not only advise 'do what I say'  but also 'do what I do' when it comes to advise on weight loss – ie NHS staff and others involved in advice on reversing overweight should be aware of the importance of acting as role models to help the public at risk to engage in losing weight.
A major challenge for the NHS as "more than half its 1.3 million-strong workforce, are estimated to be overweight or obese".

See more on the study

Diet, Lifestyle and Cardiovascular Risk: from Evidence to Policy

Three weeks to go to this Evidence and Policy Symposium organised by the healthy heart charity the Cardiovascular Research Trust in partnership with the Fellowship of Postgraduate Medicine, publisher of the Postgraduate Medical Journal and Health Policy and Technology.

Authoritative, evidence-based information on how to protect cardiovascular health is vitally important for researchers, clinicians, policy makers and the public.

Symposium Sessions include Mediterranean diet and cardiovascular health; the impact of voluntary and mandatory policy; cardiovascular risk in childhood;  cardiovascular effects of dietary bioactives; evidence on risks and benefits of new dietary approaches.

Attendance is limited to 90 delegates.
See the online registration link and the full programme below. 

Friday 5 December 2014 at the Medical Society of London – Map of venue
11 Chandos St, Cavendish Square, London W1G 9DRT
5 minutes walk from Oxford Circus

Register for the Symposium

9.00 – 9.30  Registration and coffee

9.30 – 10.10 am
Impact on cardiovascular disease of voluntary and mandatory policy on diet and lifestyle. See abstract
Dr Martin O’Flaherty, University of Liverpool

10.10 – 10.50 
Emerging ethnic differences in cardiovascular risk in childhood
Professor Peter Whincup, St George’s University of London

10.50 – 11.25 Coffee

11.25 – 11.40
Alcohol consumed ‘with a meal’ or ‘without a meal’ is differently associated with risk of coronary heart disease in a UK prospective population study. See abstract
Lentjes MAH, Khawaja AP, Mulligan AA, Luben RN, Bhaniani A, Wareham NJ and Khaw KT.
Department of Public Health & Primary Care, University of Cambridge.

11.40 – 12.20
Impact of dietary nitrates on blood pressure
Professor Amrita Ahluwalia,
William Harvey Research Institute, Queen Mary’s University of London

12.20 – 13.00
Diet, lifestyle and cardiovascular risk
Professor KT Khaw, University of Cambridge

13.00 – 14.00 Lunch

14.00 – 14.40
Is chocolate good for you? Health claims versus evidence-based nutrition
Professor Roger Corder, William Harvey Institute

14.40 – 15.30
Effects of Mediterranean diet on cardiovascular outcomes in high risk people
Professor Ramon Estruch, University of Barcelona

15.30 – 16.00
Policy implications of current evidence on diet, lifestyle and cardiovascular risk
Speakers’ Round Table

16.00 Close

Healthy heart charity CVRT and Hippocrates Initiative jointly launch Healthy Heart Poetry project by and for school children and young people

On behalf of the healthy heart charity the Cardiovascular Research Trust (CVRT), London-based poets Wendy French and Rebecca Goss will be editing a book of poems on the heart written by children for children of all ages. 

Entries are welcome from anywhere in the world from schools or individually from children and young people. 

Wendy said: “The aim is to bring to children, from an early age, awareness of the importance of keeping the heart healthy through diet and exercise. The idea for this came from a pilot poetry project in schools in and around London. Please do get your pupils writing! Our experience of this type of project in schools has shown that it can be very exciting both for pupils and teachers."

She added: "We would like as many children and older school students to enter as possible so we have a wide selection of poems to choose from. The book will be published in print and online by the Hippocrates Press for Poetry and Medicine. The book will be launched at a celebration in London on December 4th 2014, which children and older school students and their teachers will be invited to attend.”

The closing date for entries is 12 midnight GMT July 16^th 2014.

Poems may be entered on-line (see the Hippocrates website link) or sent to
Wendy French at 4 Myton Road, West Dulwich, London, SE21 8EB. 

Wendy has a quiz devised by the CVRT on the heart and can email this with lesson plan suggestions to teachers who are interested.

Kidshealth also has very helpful facts to help get started on the project.

The book will be divided into four sections, selected poems by primary children, selected poems by secondary school students, and a section devoted to heart healthy recipes supplied by anyone of school age. 

Medical professor Donald Singer said: “This looks a very interesting way to engage children and young people actively in understanding ways to prevent heart disease. I will be adding a section in the book on how to keep the heart healthy so that book could be used in schools for teaching about health as well as just for pure enjoyment of the poems."

See YouTube videos of examples of Healthy Heart Poetry by schools from the 2013 CVRT Healthy Heart Awards:

Little Red Balloon: from Chevening C.E. Primary School - read by Raphael Shirley

Heart or Else: heart poem from Chevening C.E. Primary School read by Raphael Shirley

Healthy Heart Poem during Assembly - performed by Year 6Ws at Dulwich Hamlet Junior School

You can read more about the Healthy Heart Poetry initiative on the Hippocrates website.

If you wish any further information or would like to help by involving your local school in the project, or in other ways, you can contact Wendy French on wendy.french6@btinternet.com 

Sharpening memory and cocoa - how interested should you be?

Farzaneh Sorond and colleagues from Harvard and the Mass. General Hospital have attracted worldwide interest in their study published in the US journal Neurology "Neurovascular coupling, cerebral white matter integrity, and response to cocoa in older people". 

Listen to interview on the story on BBC local radio
 
The theme of the interest - from the LA Times to the Belfast Telegraph - is that cocoa "not only soothes the soul, but might also sharpen the mind'.

Fruit of the theobroma cocoa tree: Corti et al. Circulation 2009 

Why even think that it might? The authors drew on two background concepts:
- Earlier research using sophisticated brain imaging had reported that cocoa intake is associated with an increase in blood flow to the brain; and brain blood flow is linked to intellectual capacity.
- And cocoa contains flavonols, bioactive chemicals present in many foods associated with measures of healthy cardiovascular health, including increasing blood flow to the gray matter of the brain.
The question asked by the researchers was whether previous interest in chocolate containing products and better brain function might be explained by flavonol effects. 
To address this they carried out a study in which the design was high quality with regard to a possible effect of flavonols on 2 measures - brain blood flow and a test they used to assess memory.
What did they find? No difference in the effects of flavonol-rich vs low in flavonol cocoas as 2 cups per night for 30 days.
However, they reported a significant improvement in blood flow and in the intellectual function test by 30 days.
Should we all now start drinking large amounts of cocoa? Not yet based in this interesting but small study. To consider my question in a different way, key points arising from this work are:
- does cocoa sharpen the mind?
- does it protect from dementia?
- does it help people with dementia?
With these points in mind:
- the study was small - only 60 participants included and only 18 of these were noted to have improvements with regular cocoa
- the study was only for 30 days - more work would be needed to show whether these apparent benefits would be sustained
- the study was performed in older people - average age 73, who already had risk factors for cardiovascular disease - not safe to generalise study findings to other age groups and to people without cardiovascular risk factors.
- the 70% of volunteers who had normal blood flow and managed the test well at baseline should no improvement with cocoa
- the study was designed to test an effect of flavonols. However there was no time control for the effect of cocoa - e.g. vs other hot drinks. The authors cannot therefore rule out a time effect on their results e.g. people not managing the test well at the start doing better simply through  the initial practice
- the tests of brain function were 'Trailing Making Tests' ie involved a timed 'joining the dots' test. It would be important to confirm that more real world aspects of brain function were also improved
- no patients with dementia were included - further studies would be needed to show whether patients with dementia would also benefit and that any benefits were helpful for activities of daily living 
Thus results of the study could be explained as an artefact of the study design - ie not be due to the cocoa. At best they only applied to people with identified cardiovascular factors who also already had impaired brain blood flow and difficulty in performing the type of mental activity tests used by the researchers. 
And the concern about large amounts of cocoa is the associated increase in dietary sugar and fat intake of typical Western milky cocoa drinks. Neither are good for cardiovascular health, as they increase risk of overweight, high cholesterol, diabetes and high blood pressure. To compensate for those risks, the researchers under the strict conditions of the study made sure their volunteers made appropriate adjustments in other parts of the diet to balance sugar and fat intake over the month. In real world use, even if cocoa were confirmed to be helpful for the brain, it would be very important that people increasing their cocoa intake were very careful to avoid these unintended consequences of increased cocoa intake. Of note the researchers were not studying cocoa with added cream and marshmallows - not good for the circulation.
What about different sources of chocolate in cocoa? Not addressed by the researchers - except that they appeared to show at least that any benefits were not related to the types of flavonol they studied.
And how about eating chocolate instead? Again - not studied by the researchers. And in previous observational research on chocolate, there was an apparent benefit on heart disease protection from very small amounts (chocolate 1-3 times per month) with larger amounts reported to be harmful for the heart.
As a final thought, one of the reported uses by ancient Aztecs and Incas of chocolate drinks was as sedatives in religious rituals. Another explanation for the study findings is that calming effects of cocoa ('soothing the soul') reduced anxiety during the tests as a contribution to the observed improvements in brain blood flow and test performance with the drinks.

Link to interview 8.8.13 with Shane O'Connor on BBC local radio

Mediterranean diet and Cardiovascular Health

Ramon Estruch, a Spanish researcher on benefits of the Mediterranean diet, will speak in London at a Symposium on Cardiovascular Health on 5th December 2013.

Registration and abstract submission is now open for the Symposium.

Professor Estruch's theme will be outcomes of his multi-centre study reporting that, for patients who already are at high cardiovascular risk, a Mediterranean diet without calorie restriction is more effective than a low fat diet in reducing the occurrence of serious cardiovascular events.

His findings were published in the New England Journal of Medicine at the end of February 2013.

This event is one of a series of Symposia on Cardiovascular Health being held by the CVRT at the rooms of the Medical Society of London, one of the oldest continuing medical societies in the world.

Weblink for 5th December Symposium on Cardiovascular Research.

More on the research by Professor Estruch.

The symposium is being organised by  the Cardiovascular Research Trust.

Spanish researchers provide evidence for primary prevention of cardiovascular disease by a Mediterranean diet

Professor Ramón Estruch from Barcelona and his colleagues have published in the New England Journal of Medicine results of an important study on the greater value of a Mediterranean diet vs. low fat diet in the prevention of cardiovascular risk.  

In their multi-centre, randomised trial in Spain, 7447 high risk patients with no clinical vascular disease (age range 55-80, 57% women)  were asked to follow one of 3 dietary options:

• a Mediterranean diet with 
• extra-virgin olive oil
• or with  mixed nuts

• or a control diet with advice to reduce dietary fat.

The primary end point was rate of major cardiovascular events (myocardial infarction, stroke, or death from cardiovascular causes). The trial was stopped early after median follow-up 4.8 years.

What did they find? After adjusting for obvious bias, both Mediterranean diet groups had significantly better outcomes: hazard ratios compared to the control group  (109 clinical events)

- added oil: 0.70 (95% confidence interval [CI], 0.54 to 0.92) - 96 clinical events

- with nuts: 72 (95% CI, 0.54 to 0.96) - 83 clinical events

In other words, the relative risk of serious cardiovascular disease was reduced by one third by following a calorie unrestricted Mediterranean diet vs. a low fat diet. The absolute risk reduction was 3 fewer clinical events for every 1000 patient years of treatment ie ~3 fewer clinical events for every 200 patients following the Mediterranean diet option for 5 years. There were 2-3 future strokes per 1000 patient years of treatment.

Considering the impact of these preventable strokes alone, using UK data as an example, that decrease of 2-3 strokes per 1000 patient years of treatment would represent ~300-450 fewer strokes per year at a saving in direct and indirect health costs, and further societal annual costs of ~£16–25m  [€18-28m].

Of note, patients were supported during the study by regular educational prompts, as well as some free food supplements.

These were clearly patients at high risk from cardiovasular disease either from:

• type 2 diabetes mellitus or 
• at least three of 
• smoking
• hypertension
• raised bad (LDL) cholesterol 
• low good (HDL) cholesterol
• overweight or obesity
• family history of premature coronary heart disease

The authors themselves raise the obvious questions whether people not living in a Mediterranean and/or at lower cardiovascular risk would receive similar benefit.

Their results at least however 'support the benefits of the Mediterranean diet for the primary prevention of cardiovascular disease' in patients already at high risk: an important message for policy makers, health professionals, and at least those with the above risk factors for serious vascular events.

See the research paper 

Estruch R, Ros E, Salas-Salvadó J et al: the PREDIMED Study Investigators. Primary Prevention of Cardiovascular Disease with a Mediterranean Diet. N Engl J Med. 2013 Feb 25. [Epub ahead of print]

Waistline and increased risk of premature death: what's so new?

@HealthMed The latest European Society of Cardiology Congress in Munich coincided with the last days of a Gallery of the Modern exhibition of caricatures by Munich satirist Karl Arnold:  amongst them a striking 1922 image of a stylish corpulent man said for 20 years not to have been able to see his feet. Then a social observation, it is of course now well recognized that the frankly obese are at high risk of diabetes, heart disease, stroke and other medical conditions.

At first sight surprising, that there should have been major interest from scientists and the press in new US research presented at the 2012 heart Congress linking a larger waistline to premature death; and not just from a beer belly, but for anyone with a body shape with above normal waist to hip circumference.  What’s so unusual? Surely everyone knows that being overweight increases risk of serious medical problems.

What did these American researchers do? They looked at the strength of the link between different measures of obesity and risk of early death. In the research, lead by Professor  Francisco Lopez-Jimenez from the Mayo Clinic, almost 13,000 American men and women were studied for around 14 years, within a cohort study: the Third National Health and Nutrition Examination Survey (NHANESIII). There were around 2500 deaths of which around 1100 were from cardiovascular causes. The researchers measured body-mass index (BMI), a general measure of fatness, and waist-to-hip ratio (WHR), a measure of central obesity. This meant they were able to include people not currently considered obese based on BMI, but who had a relatively large belly, as well as those overweight both based on BMI and abdominal girth. The surprising finding of the study was that, compared to subjects with normal BMI and WHR, the group with normal BMI but relatively high central fat not only had a high death rate (2.8 times for cardiovascular disease and 2.1 times for all causes), but their risk of premature death was much higher than participants who were obese based on BMI (1.4 times normal cardiovascular risk).

It is already well established that abdominal fat is particularly deadly in relation to risk of heart disease. This new NHANESIII research in addition reported that increasing waist-hip ratio is linked to earlier death from all causes, not just for heart disease. It also provided objective data of the graded increase in risk as abdominal fat and waist-hip ratio increases.

What messages to take from this study? Obvious questions include whether it is reliable and if so generalizable from US to European and other international populations. As a prospective observational study, the results are open to bias – i.e. factors co-incidentally present in the larger waisted people may have been responsible e.g. the type of diet causing the central overweight rather than distribution of the fat itself.

However the authors reported that their findings were similar after adjusting for other well-known risk factors for premature heart disease and death, such age, male gender, ethnicity, socio-economic factors, smoking, hypertension, and diabetes.  Furthermore, this new report from Munich supported the previous systematic review by the authors noting similar findings in patients with coronary artery disease: i.e. central obesity a much stronger link  than BMI to premature death.

Reasons for the observed health risks are thought to include major regional differences in types chemicals secreted by fat from different parts of the body. Unlike fat padding in other part of the body, abdominal (or visceral fat) makes chemicals that promote resistance to insulin, increasing risk of diabetes, an important risk factor for heart disease. This fat also makes inflammatory chemicals that can accelerate damage to arteries, leading to atheroma (deposits of fat and abnormal cells – from the Greek for ‘porridge lump’) in the arterial walls. This both reduces blood flow to vital organs, and increases the likelihood of a clot forming to cause critical narrowing or complete blockage of an artery, a major cause of heart attack and stroke. There is also  evidence that in contrast there may also be a protective metabolic profile associated with the presence of lower body fat.

These findings add to increasing concern about health risks from central overweight and stress the importance of preventive measures, even if BMI is within the normal range. Health professionals need to make the public aware of these risks and explain what preventive measures may help. The good news is that losing excess central weight is practical through a healthy, lower calorie diet, combined with regular aerobic exercise, reduces major risk factors for heart disease: reduces cholesterol, decreases blood pressure and reduces risk of diabetes, and lowers risk of heart and other serious diseases. Other reasons for benefits may include better metabolic profile from the increase in muscle mass with exercise, and the improved tissue nutrition resulting from generation of more micro-vessels.

Calculate your waist-hip ratio.

Calculate your BMI.

Helpful free software to help with exercise, diet and weight loss.

What's in a medicine?

@HealthMed Most of the weight of a tablet or capsule consists of coatings and fillers to make the enclosed active ingredient is big enough to pick up. Some common medicines such as the heart tablet digoxin or thyroid replacement treatment may have an active ingredient weight of as low as one tenth of a gram - ie it might take around 50 doses to fill a level teaspoon.
That raises the obvious question: what other ingredients are present in medicines? The range of fillers includes usually harmless chemicals such as the sugar lactose. That could prove a problem with patients who suffer lactose intolerance - due to immaturity in or loss of the enzyme needed to break down lactose.
And liquids or tablet coatings may include animal extracts, in the form of gelatin. Although this should be clearly labelled on the package insert that should accompany all medicines, a paper in the latest issue of the Postgraduate Medical Journal has reported that many patients on restricted diets are unaware of this.
The study in the Postgraduate Medical Journal reported that a quarter of patients surveyed who were on restricted diets were unaware that they had been prescribed drugs containing gelatin, contrary to their wishes or beliefs as vegetarians, or for other cultural or religious reasons.
If not clear from the packaging, patients should ask their pharmacist for further information on the non-drug contents of medicines prescribed, or bought over the counter without a prescription.

See BBC report on the PMJ article                                                                                                                                                                                                                                            

Romeo's 'Sick health'

@HealthMed One of Romeo's string of oxymorons [Romeo and Juliet Act 1, Scene 1: reflecting on his heart sickness for fair Rosalind], 'sick health' illustrates the challenge of preventing more conventional heart disease - with its long prodrome of apparent health masking the development of sub-clinical disease from unrecognized risk factors, which may however be reversible if identified and addressed.

Why don't more people engage? Many reasons, including fear of finding a problem if tested, difficulty accessing advice/health checks, lack of interest or knowledge of outcomes of 'treatment', lack of confidence in self-efficacy to achieve supporting or first-line life-style changes, in diet, exercise, weight, smoking cessation, alcohol intake ...

To find out more on challenges and solutions for success in behaviour change, look for sources on Theory of Planned Behaviour e.g. this referenced link from the University of Twente.

See my previous blogs on smoking and alcohol.

Stopping smoking: why and how?

Hip fracture risk and smoking

Smoking: literary warnings

Alcohol: literary warnings

Alcohol and the French paradox

Ideas for maintaining variety in providing for multiple special diets

What to do about special diets? It is possible with a little research to prepare an individual meal to cater for a cluster of guests each with different special dietary needs and preferences, for example allergy to gluten, diabetes mellitus and preference for vegetarian food. There are also now many recipe sources for individual special diets, for example in the UK the BBC website (separate listings for gluten-free, nut allergy, egg-free, dairy-free, 'healthy', pregnancy-friendly, shellfish-free, vegan and vegetarian), the Coeliac Society for gluten allergy and Diabetes UK and other international equivalent organisations for diabetic recipes. But when more than one allergy is present in the same family, maintaining daily variety is much more difficult.
Xavier Ternisien in today's Le Monde [Sunday 14th August] has highlighted a blogger for francophones who has risen to this challenge. Bordeaux 'blogueur' Anne Lataillade worked in financial services after graduating from business school. Struggling for inspiration for meals for separate gluten and egg allergy in her 2 children, she has been blogging on practical recipes since 2005. Her aim is to provide simple to make recipes that work, with ideas for savoury foods and desserts compatible with both these allergies. She accompanies her blogged recipes with photographs of the dishes and information on the sources and properties of the suggested ingredients. Her website also provides information on archived recipes and on publications arising.
A further website worth checking is 'Cooking Allergy Free'. This site, after free registration, allows access to a large menu of potential allergies and then to a limited range of suitable recipes compatible with a a very complex range of needs and preferences.
Attractive varied suggestions are a good approach to complement other measures to encourage adherence to special diets for medical allergies.
US actress Zooey Deschanel highlighted the challenges of catering for multiple food intolerances and preferences by appearing on a 2009 US television programme in which chefs were asked to provide food suitable for vegans intolerant to dairy, eggs, soya and gluten.