Category: health

Musculoskeletal problems and arthritis have large effects on UK health

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Adapted from The State of Musculoskeletal Health Report 2023 by Versus Arthritis

Over ten million people in the UK have arthritis.

Health inequalities are defined as “unfair and avoidable differences in health across the population, and between different groups in society”.

One health inequality is deprivation. For example hip and knee osteoarthritis is commoner in the most deprived compared to the least deprived. Some ethnic groups are also affected considerably more than others. As a reference point, White British people have a 16.8% prevalence of a long term musculoskeletal problem (MSK). UK Chinese people have a 7.4% prevalence and UK Pakistani people have a 20.8% prevalence.

People with a MSK problem are 20% less likely to be in work compared with those who don’t have such a condition. In 2021 23.3 million working days were lost due to these conditions making it the third most common reason for working days lost.

I in 3 current UK employees have a long term health condition. 1 in 10 have a MSK condition. I in 3 of these employees with a long term MSK condition have not discussed it with their employer.

Of people who have no long term health condition 82.1% are in employment but this drops to 62.4% of those with a MSK condition. Of those with no long term health condition 15.2% are economically inactive. This rises to 34.9% of those with MSK conditions.

MSK conditions account for the third largest area of NHS spending at £4.7 billion in 2013-14 and are estimated to have cost £6.3 billion in 2022-23. The cost due to just Osteoarthritis and Rheumatoid arthritis will be £3.43 billion by 2030.

For many people, joint replacement surgery is the most effective treatment for their MSK condition. But many operations were not carried out over the Covid period. The conditions have not got better, the waiting lists have just got a lot longer. Approximately half of the operations done in 2019 were carried out in 2020 and the figures were still lagging in 2021.

Rheumatoid Arthritis affects 27,000 new patients each year. 30% of those with the Rh A develop osteoporosis. One in ten will develop interstitial lung disease over their lifetime. 60% of people with Rh A are physically inactive. One third of them have a mental health problem such as anxiety or depression. About a third of diagnosed people will stop work within five years of diagnosis.

Risk factors for getting the condition include age. It comes on most commonly between the ages of 40 and 70. It is 2 to 3 times more common in women compared to men. Being overweight increases the risk. There are hereditary factors involved. The gut microbiome is thought to play a part. Smoking increases the risk, worsens the disease and weakens treatment response.

My comment: As a GP I had hoped that new therapies and operations would revolutionise the outlook for musculoskeletal conditions and indeed there has been a lot of positive change. There is still some way to go. There isn’t much you can do about your heredity or gut microbiome but you can be a non smoker, keep slim and keep active. Meanwhile I wonder if anyone is researching how people of Chinese extraction have much fewer MSK conditions than any other group.

These are the factors that are important for metabolic health

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I was asked recently what I thought the definitions of good metabolic health and bad metabolic health should be. These were my criteria.

Metabolic health consists of two groups of factors: what you have and what you don’t have.

Metabolic health exists on a spectrum and your place on this spectrum may change over time. Perfection in anything is rarely obtainable and if obtained may not be sustainable. In general as we age we lose metabolic health for instance. Conversely exercise improves metabolic health at almost any age.

If you have good metabolic health you have:

Adequate or good muscle mass.

Normal to low fat mass for your life stage and gender.

A blood pressure of less than 140/90 and ideally lower than 130/80.

Fasting blood sugar less than 6.0 mmol/l.

HbA1c of 5.6 or lower.

Normal kidney function, liver function, haematology, low inflammation markers,  and low insulin.

Low triglycerides and high /normal HDL.

Be able to move quickly and without undue effort while walking and running appropriate to your life stage.

Be able to get up from a chair or the ground without using your arms depending on your life stage.

Have good grip strength.

Have good coordination, balance, memory, problem solving abilities, and sensory function.

You sleep well.

You are in a good mood most of the time.

If you don’t have metabolic health, remember the spectrum issue. You can always aim to improve some of these parameters.

Signs that your metabolic health needs some work are:

You have low muscle mass.

You have excess fat mass.

Your blood pressure is consistently over 140/90.

You require medication for blood pressure.

Fasting blood sugar over 6.1 mmol/l

HbA1c over 5.6.

Less than normal kidney function, liver function, haematology, raised inflammation markers other than transiently due to acute illness, and raised insulin.

High triglycerides. Low HDL.

Can’t move at a reasonable pace for the circumstances eg you can’t keep up with your classmates or friends during walks, dancing,  games or exercise classes.

You can’t get up from the floor without using your arms if you are under the age of 40 (and have no disabilities) or from seated in a chair otherwise.

Your grip strength is poor.

You have poor coordination, balance, memory, problem solving abilities, and sensory function that is not correctable with aids.

Yours sleep is habitually poor and you are tired most days.

Your mood is low most days.

Dietary melatonin improves cardiovascular outcomes

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Adapted from Minerva BMJ Sept 11 2023

Melatonin is a hormone that is secreted by the pineal gland in the skull. It is also available in many foods that include cherries, olives, walnuts and goji berries.

A Japanese study evaluated the amount of dietary melatonin reports that over a 16 year period, those who had higher dietary melatonin intakes had slightly lower mortality form cardiovascular and non-cardiovascular mortality.

American Journal of Epidemiology

My comment: We already know that cherries are beneficial for gout, that olives contain healthy fats, and that walnuts have useful Vitamin E. Here is another reason to eat them.

Exercise training for resistant hypertension

A small trial from Portugal reports that blood pressure can be reduced by a moderate intensity aerobic programme. The participants were supervised in 40 minute sessions three times a week. The systolic blood pressure dropped by 7 mm Hg and the diastolic by 5 mm Hg.

Journal of the American Association of Cardiology

Blood sugar control affects cardiovascular mortality across the whole spectrum

A follow up of 300,000 people in the UK Biobank Study shows, as we know, type two diabetes substantially increases the risk of atherosclerotic cardiovascular disease, chronic kidney disease and heart failure. The gradient of severity of these conditions exists on a gradient of risk from pre-diabetes to poorly controlled type two diabetes. This indicates that we should strive for normal blood sugars if we reasonably can.

Journal of the American College of Cardiology

A pregnant woman’s blood sugar levels affect the weight of her children in adolescence

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Adapted from BMJ July 9 2023

An Israeli study which looked at 33,000 mother – child pairs found that the higher a woman’s blood sugar in pregnancy the fatter the baby was when they were in late adolescence.

Even after they adjusted for the birth weight of the baby, and sociodemographic factors, the correlation remained.

The very fattest teenagers had the mums with the highest blood sugars.

My comment: This appears to be the result of some sort of programming in the womb. The woman’s blood sugar in her pregnancy is also likely related to the health of her own mother. It is something that is rather difficult to control for.

What symptoms need to be investigated for ovarian cancer?

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Adapted from Top Tips for Primary Care. Dr Victoria Barber scrutinises the role of primary care in the identification of Ovarian Cancer, an often overlooked malignancy. August 21 2023.

Ovarian cancer is often considered difficult to diagnose, particularly in the early stages, so women need to be aware of when they should visit their General Practitioner and what symptoms may occur.

The symptoms of ovarian cancer can occur with many other conditions too, and this can lead them to being overlooked by both patient and doctor. Yet, there are a group of symptoms that need attention. Ovarian cancer occurs more often in women older than the age of 50, but does occur in young women too.

The symptoms to look out for are: pelvic or abdominal pain, persistent abdominal distention also referred to as bloating, feeling full after very small meals or loss of appetite, and urinary urgency or frequency that is unusual for that woman. Frequent is considered to be more than 12 times in a month or 2 to 3 times a week. Persistent means beyond the time that you would expect a simple cause of a symptom to resolve.

Other symptoms of cancer in general are unexplained changes in bowel habit, unexplained weight loss, and unexplained fatigue. Ovarian, other bowel or pancreatic cancers, leukaemia, lung, and urological cancers can cause these. Further history and examination will help clarify the likely source of the problem and useful investigative tests and referrals.

If these symptoms are reported to the GP, the GP is best to examine the patient and also to take a blood test called the CA125. Next steps will depend on that blood level. Levels over 35 will usually indicate referral for an urgent ultra sound scan of the pelvis. If the scan is abnormal, an urgent “cancer suspected” appointment to gynaecology should be obtained. This is usually within two weeks in the NHS.

If the symptoms are not thought to be of a potentially serious nature or if a CA125 is not done, it can be helpful to arrange a review appointment for when the GP would expect resolution of the symptoms experienced. This is so that persistent symptoms are not missed.

Breast and ovarian cancer tend to run in families and genetic testing may be indicated in some patients.

Sometimes the urinary symptoms sound like a urinary infection but the dipstix test or bacteriological test will be negative. This can be a situation that calls for a CA125 tests for clarification.

Irritable bowel syndrome should not be considered as a new diagnosis in people over the age of 50. It is more likely to be something more serious such as bowel cancer, ovarian cancer, coeliac disease or colitis.

In young women, under the age of 50, bloating of the abdomen related to irritable bowel syndrome tends to come and go throughout the day, be related to meals or stress, and usually improves with having a bowel movement. In ovarian cancer, the bloating tends to last all day, can be there on waking, and is usually unaffected by passing a bowel movement.

Don’t fret too much about not losing those Christmas pounds: older adults have a bit more leeway regarding their weight.

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Adapted from BMJ 22 July 2023

Now here is some news to cheer you all up.

Although we are always being told that having a BMI of 22.5 to 25 is optimal for most of a population’s health, this may not be as accurate as it could be.

A retrospective analysis of data from half a million adults in the USA found that those with a BMI of 25 to 30 had a lower all cause mortality.

In older adults there was no excess mortality until the BMI was above 35.

My comment: The BMI reading is designed for population studies and without specifically knowing about an individual, particularly about their bone and muscle mass, simple statements about BMI need thought about what it may mean to you. In general, wasting diseases, dementia, cancers and degenerative diseases tend to cause a steady fall in weight the longer the condition goes on. Thus there could be higher than expected mortality rate in thinner people. Muscle mass is related to greater fitness and longevity and is also correlated to bone mass. These can raise a person’s BMI to the 25+ and 30+ levels and be an indication of an extremely fit, well muscled person. You would expect someone like this to have a lower total mortality rate. Of course these people are rather rarer than the usual tubby individual who has a high individual BMI. Nonetheless this study seems to indicate that carrying a bit more muscle and fat than indicated by a BMI of 25 may not be such a bad thing after all, particularly if you are “older”. They didn’t say exactly what this meant. I would imagine over 55.

High doses of Statins tend to worsen osteoporosis, so more monitoring in susceptible patients will be required.

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Clinical science
Diagnosis of osteoporosis in statin-treated patients
is dose-dependent
Michael Leutner et al. Department of Internal Medicine. University of Vienna.
Ann Rheum Dis 2019;78:1706–1711.



Key messages


What is already known about this subject?
► There is a relationship between statins and
osteoporosis.


What does this study add?
► Osteoporosis is underrepresented in low-dose
statin treatment.
► There is an overrepresentation of osteoporosis
in high-dose statin treatment.


How might this impact on clinical practice or
future developments?
► In clinical practice, high-risk patients for
osteoporosis under high-dose statin treatment
should be monitored more frequently.


Abstract
Objective: Whether HMG-CoA-reductase inhibition,
the main mechanism of statins, plays a role in the
pathogenesis of osteoporosis, is not entirely known so
far. This study was set out to investigate
the relationship of different kinds and dosages of statins
with osteoporosis, hypothesising that the inhibition of
the synthesis of cholesterol could influence sex-hormones
and therefore the diagnosis of osteoporosis.
Methods Medical claims data of all Austrians from
2006 to 2007 was used to identify all patients treated
with statins to compute their daily defined dose averages
of six different types of statins. We applied multiple
logistic regression to analyse the dose-dependent risks
of being diagnosed with osteoporosis for each statin
individually.


Results: In the general study population, statin
treatment was associated with an overrepresentation
of diagnosed osteoporosis compared with controls (OR:
3.62, 95%CI 3.55 to 3.69, p<0.01). There was a highly
non-trivial dependence of statin dosage with the ORs
of osteoporosis. Osteoporosis was underrepresented
in low-dose statin treatment (0–10mg per day),
including lovastatin (OR: 0.39, CI 0.18 to 0.84, p<0.05),
pravastatin (OR: 0.68, 95%CI 0.52 to 0.89, p<0.01),
simvastatin (OR: 0.70, 95%CI 0.56 to 0.86, p<0.01) and
rosuvastatin (OR: 0.69, 95%CI 0.55 to 0.87, p<0.01).


However, the exceeding of the 40mg threshold for
simvastatin (OR: 1.64, 95%CI 1.31 to 2.07, p<0.01),
and the exceeding of a 20mg threshold for atorvastatin
(OR: 1.78, 95%CI 1.41 to 2.23, p<0.01) and for
rosuvastatin (OR: 2.04, 95%CI 1.31 to 3.18, p<0.01)
was related to an overrepresentation of osteoporosis.


Conclusion: Our results show that the diagnosis
of osteoporosis in statin-treated patients is dosedependent.

Thus, osteoporosis is underrepresented
in low-dose and overrepresented in high-dose statin
treatment, demonstrating the importance of future
studies’ taking dose-dependency into account when
investigating the relationship between statins and
osteoporosis.


Book Review: Forever Strong by Dr Gabrielle Lyon

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Forever Strong: A new science based strategy for aging well by Dr Gabrielle Lyon.

I read this book when it came out in October 2023. It costs £16.99 from Amazon in paperback.

Dr Lyon has worked in psychiatry, geriatrics and nutrition. She thinks that over fatness is less of a problem to being under muscled when it comes to general health, ageing and efforts to live longer in better shape.

She advocates a high protein diet of no less than 100g of protein a day for all adults. This can be more depending on a person’s ideal lean body weight. It is also a lot higher for those who aim to build more muscle.

She offers three different eating regimes. The first is for longevity. For this she recommends higher protein meals for breakfast and dinner and a lighter protein snack at lunch time. Carbohydrates are generally restricted to the same number of grams as the protein spread over the day. These can be increased for those engaged in more than one hour’s vigorous exercise a day. Fat is eaten according to the remaining calories available to maintain weight.

For those wanting to lose weight, she recommends that protein is spread evenly over three meals a day. Carbohydrate should be no more than 30g per meal. Fat intake should be low as the aim is to cut back by 10-20% of maintenance calories daily. She thinks that it is crucial to prioritise dietary protein as this reduces muscle loss and improves satiety. Carbohydrates should be low sugar fruit and low starch vegetables in order to minimise calories and insulin response.

For those who want to gain weight, protein intake is higher and usually needs to be spread over 4 meals. Carbohydrate and fat can be increased as the aim is to exceed maintenance caloric intake. A well planned exercise regime needs to be undertaken and this will usually require a personal trainer at a gym.

The exercise regime offered is based at the beginner in the book but she offers different programmes from her website. I wasn’t able to find these when I looked but perhaps they are still undergoing development.

The book covers the science behind her nutritional advice, a discussion of the mental roadblocks that stop people taking control of their diet and exercise regimes, baseline measurements that will help you figure out what exactly you should be eating and some recipes.

I exercise daily and have been weight training since the age of 27. I also have been low carbing for 20 years. Did I learn anything? YES.

I’ve been making several big mistakes regarding my diet and exercise regime.

Firstly, although I eat about double the protein that I see my friends eating, this is still not likely to be high enough for optimal muscle gain.

Secondly, I really should be eating a lot more protein first thing in the morning so that dietary leucine levels come up to the threshold that prevents muscle breakdown and ensures the best use of protein in the body and for muscle development.

Thirdly, like a lot of low carbers my fat intake is very high, and I pile it on oblivious of the caloric intake.

Fourthly, I do indulge in the odd sugar /starch item and during weight loss efforts these would be better cut out entirely. Same for alcohol.

Fifthly, my weight training regime needs altered. I used to do alternate days resistance training and something else but various injuries and back pain led me to experiment with more stretching and back exercises and this led to a definite improvement in my chronic back pain. I have altered my regime again to add in more resistance work. Dr Lyon thinks that three times a week is best. I’ll see how this goes but at my age I need to consider the injuries and degenerative problems that accumulate.

Overall this is a very helpful book for those who seek the best of physical health and contains information that I was not previously aware of.

Jovina cooks: Classic Manhattan Clam Chowder (the one with tomatoes)

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Classic Manhattan Clam Chowder

Ingredients

1 tablespoon olive oil
2 carrots, peeled and diced
2 celery stalks, diced
1 onion, diced
1 medium bell pepper, seeded and diced
1 pound Yukon gold potatoes, peeled and diced
1 garlic clove, minced
1 sprig of thyme
1/4 teaspoon celery seed
2 bay leaves
15 oz can chopped tomatoes
2 cups of seafood broth or clam juice
2 10-ounce cans of diced clams, drained with juice reserved
Salt and black pepper to taste
Chopped parsley
Saltine crackers for serving

Directions

Heat the oil in a dutch Oven, Add vegetables and garlic, and cook, stirring frequently, until the vegetables are soft but not brown, approximately 10 to 15 minutes. Add drained clam broth, seafood broth, thyme and celery seed, and bay leaves.

Partly cover the pot, and simmer gently until potatoes are tender approximately 10 minutes.

When potatoes are tender, stir in tomatoes, and heat them through. Add chopped clams, stirring to combine. Add black pepper to taste. Let chowder come to a simmer, and remove from heat. Fish out the thyme and the bay leaf, and discard. Taste and adjust the seasoning.

The chowder should be allowed to sit for a while to develop flavor. Reheat it before serving, then garnish with chopped parsley. Serve with oyster crackers.

Hobbies make you happier

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Adapted from BMJ 7 Oct 2023

Engaging with a hobby is associated with better self reported health, happiness and life satisfaction and fewer depressive symptoms.

The proportion of people who report having hobbies varied considerably between countries.

Almost everyone in Denmark said they had a hobby and half of those in Spain had a hobby.

My comment: Having a hobby is dependent on having the free time to have a hobby. There also may be some expense involved. Often hobbies are a way of engaging with other people and sometimes they are solitary pursuits. They are a way of carving out time for yourself, doing something that you enjoy and can even nourish your body, mind and soul. One of the great joys of retirement that I have found is finally having lots of time to enjoy myself. I hope you are able to fit in a bit of what you enjoy into your weekly or monthly routine too.