Stress may damage your immune response long term

Adapted from: Stress related disorders and physical health.  Song H. et al. BMJ 26 Oct 19.

This Swedish study of almost 145,000 brothers and sisters showed that any sort of anxiety or stress disorder was associated with an increased risk of life threatening infections, even when familial background, physical and psychiatric problems were adjusted for.

The study went on between 1987 and 2013. The stresses included post traumatic stress disorder, acute stress reaction, adjustment disorder and others. The patients were matched with healthy siblings when possible or matched comparative children from the general population.  They then looked for diagnosis of severe infection in the coming years such as sepsis, endocarditis, meningitis and other infections.

Severe infection rates per 1,000 person years were 2.9 for the stressed person, 1.7 for the healthy sibling, and 1.3 for the matched person in the general population.

They found that the effects were worse the earlier the age the diagnosis of the stress occurred.

Treatment with serotonin re-uptake inhibitors for PTSD seemed to reduce the negative effects on the immune system when given within a year of the stress diagnosis.

This research builds on information that PTSD produces more gastrointestinal, skin, musculoskeletal, neurological, heart and lung disorders.  Cardiac mortality has been found to be raised 27% and autoimmune disorder by 46%.

Why this happens could be due to the interplay between biological, psychological and social factors. Increased inflammatory response is considered by Song and colleagues to be a likely mechanism. Increased levels of interleukin 6, interleukin 1 beta, tumour necrosis factor alpha and interferon gamma have been found in those with PTSD.

PTSD has a heritability factor of 5-20% which is similar to what is found in families with depression.  It is likely to be polygenic.

Talking based therapies are generally even better for PTSD than drugs, so earlier intervention may have long term benefits not just on mental health, but physical health as well.

BMJ 2019;367:16036

Fitter, better, sooner

From BJGP May 2020 by Hilary Swales et al.

Having an operation is a major event in anyone’s life. There is a lot a patient can do to improve their physical and mental health before surgery that will improve their recovery and long term health.

Fitter, better, sooner is a toolkit was produced by the Royal College of Anaesthetists with input from GPs, surgeons and patients.

The toolkit has, an electronic leaflet, an explanatory animation and six operation specific leaflet for cataract surgery, hysteroscopy, cystoscopy, hernia, knee arthroscopy and total knee joint replacement.

These can be seen at: https://www.rcoa.ac.uk/patient-information/preparing-surgery-fitter-better-sooner

The colleges want more active participation with patients in planning for their care.

The most common complications after surgery include wound infection and chest infection. Poor cardiorespiratory fitness worsens post op complications. Even modest improvement in activity can improve chest and heart function to some extent.  Keeping alcohol intake low can improve wound healing. Stopping smoking is also important for almost all complications. Measures to reduce anaemia also reduce immediate and long term problems from surgery and also reduce the need for blood transfusion. Blood transfusion is associated with poorer outcomes particularly with cancer surgery. HbA1Cs over 8.5% or 65 mmol/mol causes more wound complications and infections.  Blood pressure needs to be controlled to reduce cardiovascular instability during the operation and cardiovascular and neurological events afterwards.

This toolkit is already being used in surgical pre-assessment clinics but access to the materials in GP practices will also help. After all, the GPs are the ones who are initially referring the patients for surgery, and improving participation early can only be helpful.

It is hoped that this initiative will result in patients having fewer complications, better outcomes from surgery but also from their improved lifestyle.

 

Bariatic surgery doubles congenital abnormalities in babies

From BMJ 30 Nov 19

A retrospective analysis from Quebec of 2 million pregnant women who had delivered between 1989 and 2016 showed that offspring of women who had become pregnant after bariatric surgery had roughly twice the risk of birth defects compared to women who were not obese or who were obese but had not had surgery.

The defects were mainly heart and musculoskeletal defects.

My comment: This short report does not go into possible causes for this. You would have thought that the risk would have been reduced to the level of the non obese women. I wonder if nutritional issues have a part to play as after bariatric surgery long term vitamin supplements need to be taken. 

Public Health Collaboration conference online a great success

The Public Health collaboration online conference 2020  was very successful.  The videos are available on You Tube for free making the conference even more accessible for everyone who needs advice on what to eat to stay healthy.

If you are able to contribute to the PHC fund to keep up our good work please do so. Sam Feltham has suggested £2.00.  This is via the PHC site.

This year there were contributions from mainly the UK but also the USA.

Visitors to this site will be very pleased to know that keeping your weight in the normal range, keeping your blood sugars tightly controlled, keeping your vitamin D levels up, and keeping fit from activity and exercise, are all important factors in having a good result if you are unfortunate enough to be affected by Covid-19. We have been promoting these factors in our book and website for several years now, mainly with the view to making life more enjoyable, especially for people with diabetes, now and in the future. The reduction in the severity  to the effects of   coronavirus is a side effect of these healthy living practices.

Several talks went into the factors and reasons for this, but in a nutshell, if you are in a pro-inflammatory state already, you will have a much more pronounced cytokine inflammatory response to the virus than is useful for clearing the virus, and you end up with inflammed lung tissue which leaks fluid thereby impairing your blood oxygen levels.

A talk that I found particularly apt was the talk from a GP who had had a heart attack at the age of 44 despite a lack of risk factors except for massive stress. He gives a list of self care practices that helped him. I would also include playing with your animals. Emma and I are cat lovers and can vouch for this!

My talk is about VR Fitness, which was the only talk this year which was specifically exercise related. The Oculus Quest has only been out a year and has been sold out since shortly after New Year. I was fortunate enough to buy one in anticipation of my imminent retirement, and it has been great as an exercise tool over the long, cold, dark winter and more useful than I had ever anticipated over the lockdown as a social tool.

There were several very professional cooking and baking demonstrations on the conference this year, and indeed, this could not have otherwise happened on a traditional stage format.  We had low carb “rice”, bread, pancakes and pizza demonstrations which may well help you if you prefer to see how it is done step by step or if you want to broaden your repertoire.

I was particularly taken with the pizza base idea from Emma Porter and I will follow up with this in a later post.  The whole video is available from the PHC  site which takes you to all the videos on You Tube.

 

 

 

Self caring during illness

Adapted from online presentation by Beverly Bostock ANP 7 May 2020

If you have diabetes you are more at risk of serious complications from Covid-19 and should seek medical advice early in the illness.

Any febrile illness can raise your blood sugars, including the prodromal phase when you don’t otherwise have symptoms. Once you are aware that you are coming down with something there are some useful ways of remembering how to monitor yourself.

Particularly for insulin users:

S – SUGAR – check your blood sugar more frequently than usual. For instance, if you would normally check your blood sugar every 5 hours during the day, double this to every 2.5 hours.

I – INSULIN – Adjust your insulin according to your blood sugars to keep within your target blood sugar level.

C – CARBOHYDRATE – If your blood sugar is low eat or drink more glucose or sugar/starch food items. If your blood sugar is high, drink plain water or more diet drinks.

K – KETONES – Use blood ketone stix or urine ketone stix to monitor your ketones if you are a type one diabetic every 4 hours or so. This is particularly important if you feel very ill, are nauseated, vomiting or have abdominal pain. If your ketones are high consider extra insulin, keep well hydrated and alert medical staff sooner rather than later.

Particularly for type twos:

It is important to keep well hydrated when you experience any illness but particularly an illness where you are febrile, or have  vomiting, limited oral intake, or severe diarrhea.

Some drugs can worsen your response to dehydrating illness and you may need to seek advice from a doctor, nurse or pharmacist about stopping certain drugs and when it is appropriate to restart them.

You can remember what they are with the mnemonic: SADMAN

SGLT2 inhibitors, ACE inhibitors, Diuretics, Metformin, ARBs, and Non- steroidal anti-inflammatory drugs.

 

 

 

Over eating and drinking is causing liver damage in one in five young adults

Adapted from Abeysekera KWM et al. Prevalence of steatosis and fibrosis in young adults in the UK: a population based study. Lancet Gastroenterology and Hepatology. 2020 Jan 15.

A new study highlights just how common liver disease is becoming in young adults in the UK. One in five had fatty liver, known as steatosis. One in 40 had fibrosis, also known as cirrhosis. And the average age was only 24.  These results show how harmful unhealthy eating and drinking habits can be.

Subjects for the study were recruited through the Avon Longitudinal Study of Parents and Children. Transient elastography and controlled attenuation parameter scores were used for assessment of steatosis and fibrosis.

Steatosis was found in 20.7% of the participants and this was severe in 10% of those affected. Being overweight or obese was the main factor for causing this after adjusting for alcohol intake, social class and smoking.

Fibrosis was reported in 2.7% of the participants. This risk was significantly higher in those who also had an alcohol problem or addiction and already had steatosis after adjusting for smoking and social class.

The authors conclude that the obesity epidemic is affecting the current and future health of young adults by increasing their risk of non alcoholic steatohepatitis related cirrhosis, hepatocellular carcinoma, and complications of metabolic syndrome.

 

Belinda Fettke: The origins of the food companies behind the grain based diet

This is part one of a three part series on how we have ended up with a cardiovascular disease epidemic, what treatments we are using which don’t work, and what treatments do work.

The in first episode Belinda Fettke discusses the history behind the 7th Day Adventists who genuinely believed that they were bringing health to the USA population by promoting a grain based diet.

This is a long video but entertaining as well as informative.

 

Monthly lifestyle counselling improves heart outcomes

Adapted from Intensive lifestyle counselling and cardiovascular outcomes in patients with diabetes. September 14 2019  Diabetes in Control by Nour Salhab. Pharm. D from Zhang et al Lifestyle counselling and long term clinical outcomes in patients with diabetes. Diabetes Care. Aug. 2019.

Intensive lifestyle counselling has been shown to improve blood sugars in the Look AHEAD study but it was too underpowered to show any significant conclusions regarding cardiac outcomes.

This new study looked at patients with both type one and type two diabetes who had HbAICs over 7% and were over the age of 18. Lifestyle counselling involved diet, exercise and weight loss management. The goal was to get the patient’s HBAICs under 7%.

19,293 patients were involved and the mean HbAIC at the start was 7.8%. My comment: This is a very good average compared to British diabetics! 

The mean counselling sessions were 0.46 a month and the study ran for 5.4 years.

HbAIC reduced by 1.8% for patients who got monthly counselling and 0.7% for those who got less than monthly counselling.

The primary end point was time to the first episode of angina, heart attack or stroke or death from any cause. There was a small but significant decrease in the group who had monthly counselling compared to three monthly counselling.

The counselling occurred in academic centres so may not be applicable to other settings.

My comment: This level of counselling is much more intensive than can probably be delivered in the NHS population. The blood sugar levels in the patients was also much better to start with compared to the UK population. 

A little care goes a long way

Adapted from Annals of Family Medicine 2019 doi:10.1370/afm.2421

People diagnosed by their GP with type two diabetes had a 40-50% lower mortality rate over the next ten years if they experienced their GP and practice nurses as empathetic during the year after diagnosis, compared to those who considered that their primary health carers had low empathy.

This study looked at 879 patients recruited from 49 GP practices in the east of England.

My comment: The first year is when patients get their head round the fact that they have a long term condition that could affect how long they will live and the quality of the life they have left. At diagnosis many are willing to look at lifestyle changes. Encouraging them, helping them, and helping them set appropriate goals makes a good difference to a person’s ability to change their daily routines. If you are newly diagnosed and don’t get on with your health care providers for any reason, then maybe a change of provider makes sense in the light of this research.