Statin study shows no memory loss

From BMJ 18 Jan 2020

An Australian study looked at how 1,000 community living Australians aged between 70 and 90 got on with memory and cognition tests over a six year period.

It found no differences between people who took statins and those who had never taken them. If anything, statin use reduced decline in memory especially in those with heart disease or who were carriers of apolipoprotein E4.

Magnetic resonance imaging of some of the group detected no effects of statins on total brain volume or on hippocampal or para-hippocampal volumes.

BMJ 2020; 368:m52

Sheri Colberg: Motivate yourself to exercise

From Diabetes in Control: Getting and Staying Motivated to Be Physically Active
Jan 4, 2020

Author: Sheri R. Colberg, PhD, FACSM

Every New Year all of the fitness clubs and gyms run specials to bring in new members, and they know—and even count on the fact that—most of those people will no longer be regularly attending classes or doing workouts by the time spring hits. How do you avoid becoming one of those exercise dropouts?
Even elite athletes have some days when they are not as motivated to exercise. You know those days—the ones when you have trouble putting on your exercise gear, let alone finishing your planned workout. For the sake of your blood glucose and your health, do not use one or two bad days as an excuse to discontinue an otherwise important and relevant exercise or training routine.
Here is a list of motivating behaviors and ideas for regular exercisers and anyone else who may not always feel motivated to work out:
Identify any barriers or obstacles keeping you from being active, such as the fear of getting low during exercise, and come up with ways to overcome them.
Get yourself an exercise buddy (or a dog that needs to be walked, you can borrow one!).
Use sticker charts or other motivational tools to track your progress.
Schedule structured exercise into your day on your calendar or to-do list.
Break your larger goals into smaller, realistic stepping stones (e.g., daily and weekly physical activity goals).
Reward yourself for meeting your goals with noncaloric treats or outings.
Plan to do physical activities that you enjoy as often as possible.
Wear a pedometer (at least occasionally) as a reminder to take more daily steps.  You can get free pedometer apps that turn your mobile into a pedometer.
Have a backup plan that includes alternative activities in case of inclement weather or other barriers to your planned exercise.
Distract yourself while you exercise by reading a book or magazine, watching TV, listening to music or a book on tape, or talking with a friend.
Simply move more all day long to maximize your unstructured activity time, and break up sitting with frequent activity breaks.
Do not start out exercising too intensely, or you may become discouraged or injured.
If you get out of your normal routine, and are having trouble getting restarted, take small steps in that direction.
As for other tricks that you can use, start with reminding yourself that regular exercise can lessen the potential effect of most of your cardiovascular risk factors, including elevated cholesterol levels, insulin resistance, obesity, and hypertension.

Even just walking regularly can lengthen your life, and if you keep your blood glucose better managed with the help of physical activity, you may be able to prevent or delay almost all the potential long-term health complications associated with diabetes.
From Colberg, Sheri R., Chapter 6, “Thinking and Acting Like an Athlete” in The Athlete’s Guide to Diabetes: Expert Advice for 165 Sports and Activities. Champaign, IL: Human Kinetics, 2019.
Sheri R. Colberg, Ph.D., is the author of The Athlete’s Guide to Diabetes: Expert Advice for 165 Sports and Activities (the newest edition of Diabetic Athlete’s Handbook), available through Human Kinetics (, Amazon (, Barnes & Noble, and elsewhere. She is also the author of Diabetes & Keeping Fit for Dummies. A professor emerita of exercise science from Old Dominion University and an internationally recognized diabetes motion expert, she is the author of 12 books, 28 book chapters, and over 420 articles. She was honored with the 2016 American Diabetes Association Outstanding Educator in Diabetes Award. Contact her via her websites ( and


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

Do you have a chronic disease or a long term condition?

Adapted from BMJ 23rd Nov 19. A chronic problem with language by Dr Helen Salisbury

Helen is a GP in Oxford she writes…..

Some years ago I was told the term “chronic disease” had been replaced by “long term condition”. When I asked my non medical friends about it, they thought that both “chronic” and “acute” both meant “severe”.  My comment: whereas they mean something more like “long lasting” and “short lasting” to a doctor.

So a chronic disease sounds like one likely to harm or kill you, whereas a long term condition sounds like something you live with but not die from. As doctors now copy patients into their letters, then perhaps we need to be more responsive to their beliefs?

Impaired renal function, from natural ageing is one of the problems that has arisen from the misunderstanding of the term “chronic kidney disease”.  It can cause people real worry because they imagine that they are a candidate for dialysis or death, yet they are unlikely to be affected symptomatically, nor is it likely to hasten death. Heart failure is another term that causes a lot of distress.

Sometimes doctors need to be precise in their speech and letters to each other so we can’t abandon all technical language.  Copying clinic letters to patients is good practice, even if patients sometimes struggle to understand them completely, because they have a record of the consultation and a chance to clarify the decisions made.

Sometimes we could use more lay terms to reduce confusion. Abandoning “chronic disease” is a good start.



Dr Chris Palmer: Ketogenic diet now being used in mental health

Dr Chris Palmer from Harvard has been using the low-carbohydrate and ketogenic diets in practice for over 15 years now mostly for weight loss. Recently, he has found an anti-psychotic and mood stabilizing effect from specific types of the ketogenic diet. Now he is pursuing clinical research in this area to better understand the topic. As a result, he has also been speaking at national and international conferences.

Here area few of his podcasts/interviews:…/ and keto putting schizophrenia into remission.…/

My comment: It is a very good idea for those people with schizophrenia to be on a low carb diet, mainly due to the side effects of the anti-psychotics which give people metabolic syndrome and diabetes. It is even better to hear that there conditions are improved so they are less reliant on these drugs.

Thinking clearly: What is mindfulness all about?

Do you ever just wish you could get someone who knows virtually everything that’s known about the brain and quiz them about mindfulness? Well, I do – a lot – and I just got my wish!

It is my pleasure to present this interview with John McBurney MD. A practicing physician with of over 35 years’ experience, he is board certified in Neurology, Clinical Neurophysiology and Sleep Medicine. Dr. McBurney maintains a daily mindfulness meditation practice as well as home yoga practice.

Could you describe the neurological response to mindfulness practice?

Mindfulness practice ultimately comes down to the concept of neuroplasticity.

In mindfulness, in cultivating awareness of the breath and voluntary moment by moment awareness of the brain, we are training the brain – just like when you are learning to play the violin or any other complex skill – we are training to break out of those self-referential ruminative recursive mental states and to achieve an orientation toward the outer world and in the present moment rather than anticipating the future or reliving the past.

contemplative neuroscience mechanisms behind mindfulness

 Could we be losing something by focusing more on the external realities rather than the self?

Occasionally, we do hear of adverse experiences arising from mindfulness. With any robust intervention there are always potential risks.

How long does it take for mindfulness to have a noticeable effect?

The results can happen almost immediately, however, they are also cumulative. We are still figuring out what the minimum effective dose is. 

What is the relevance of the changes in functional connectivity in the brain in someone who has devoted  a monumental amount of time to meditation, such as Tibetan monks, who may put in more than 10,000 hours in to their practice, compared to the likes of you and me?

A very neat study was published by David Cresswell in Biological Psychiatry in 2016. They invited individuals with high level of stress, unemployed adults, to a weekend retreat experience. They were randomised to in 2 groups:

  • a 3 day mindfulness retreat (the treatment group) and
  • a 3 day relaxation retreat where they read stories, told jokes and had a good time (the control group).

The study was conducted in one centre over one weekend, so it is well controlled. Initially, both groups rated the interventions as being equally helpful to them, subjectively.

The researchers looked at the functional connectivity between the dorsolateral prefrontal cortex and the cingulate gyrus. They also looked at Interleukin-6, a known marker of inflammation, that has been previously shown to be elevated in stressed out unemployed people.

Even with this brief weekend mindfulness intervention, the treatment group developed increased connectivity between the dorsolateral prefrontal cortex and the cyngulate gyrus. There was a neuroplastic response even after a 3 day mindfulness retreat. This was also associated with a decrease in the marker IL-6. Even after 4 months, IL-6 was decreased in the treatment group, but in the control group, IL-6 levels continued to rise, independent of whether they managed to get a job or not.

This is also relevant to doctors, who are at high risk for burnout. Because of their work commitments, the mindfulness retreat for doctors was condensed from the standard 8 week model developed by John Kabat-Zinn to a weekend intervention. The question was: does the weekend model work? The research at the University of Wisconsin where this was developed was reassuring: the residents are less stressed out, more effective and have a greater level of satisfaction.

We still don’t know the absolute minimum dose, but it seems that a weekend of mindfulness can be life-changing for the brain.

Another paper published in PLOS ONE from the Benson-Henry Institute for Mind Body Medicine in Harvard looked at the practices such as meditation, prayer, mindful yoga, Tai-Chi, Qi Gong, etc, i.e. ones that elicit a relaxation response (as opposed the stress response).

This study showed that in both novice and experienced practitioners of relaxation response modalities, there were changes in the epigenetic transcription of the genome. There was upregulation of pathways associated with mitochondrial integrity, downregulation of inflammatory pathways, improved insulin-related metabolism and improved nitric oxide signalling.

Long term potentiation, the standard mechanism for memory formation, strengthens existing neural connections. This happens immediately, as you read this. Over time, long term potentiation leads to formation of new connections,through synaptogenesis, dendritic arborisation and neurogenesis i.e. brain structure changes. In turn, this affects the most neuroplastic neurons located in the hippocampus.

mindfulness minimum effective dose response neurology

In reference to this fascinating recent study of the fight or flight response, it seems plausible that breathing regulates our stress levels much more than conscious thought. Could you explain the significance of this in terms of mindfulness?

The ancients believed that emotions reside in the body. This comes up a lot in serious yoga classes.

This highly innovative study shows that the control of the adrenal medulla – the main effector of the stress response – is not from the conscious ruminating thinking centres, but by the motor and sensory cortex.

This explains why breathing, as well as yoga and Tai-Chi, are an important part of meditative practice. In my experience, these kind of interventions do affect the stress response in a beneficial way.

Mindful exercise exists in many form. For example, weightlifters need to be very mindful to maintain perfect form. Cycling is another example: it is vital to concentrate on every pedal stroke and maintain an even cadence. Once you start to day dream, you notice straight away that your output is way worse. This overlaps with the concept of flow. It is about getting in the zone. There is a very inspiring TED talk by Judson Brewer MD, Ph.D. that explains the physiology behind flow and how it is augmented by mindfulness. Mindfulness is work, and it does require discipline. There is a paradox here of non-striving and non-doing while also being disciplined.

You are a sleep medicine expert. Could you comment on the relationship between mindfulness and sleep?

Insomnia is a complex problem with many causes. However, for most people with idiopathic insomnia, the cause is these self-referential recursive ruminations. They aren’t able to “turn their brain off”. Through mindfulness practice, they are generally able to tame the default mode network that’s responsible for ruminating and daydreaming. A simple strategy would be to lie in bed and concentrate on the breath. This would ease the transition between wakefulness and sleep.

mindfulness default mode network neurological basis for the self

Mindfulness is a mainstay treatment for many mental health disorders. What about use of mindfulness in the treatment for organic pathology of the brain usually treated by neurologists?

There is some preliminary data that mindfulness training has a beneficial effect of seizure frequency in patients with epilepsy. It is a medical condition associated with tremendous anxiety and stress, so mindfulness could have a significant benefit in more than one way. It may even have a benefit it terms of remembering to take medication on time, etc.

Some robust studies show that the frequency of relapse in multiple sclerosis decreases with mindfulness intervention. The effect from mindfulness is similar in magnitude to the effect from beta-interferon. 

John Kabat-Zinn used to take the patients who suffered from chronic pain or had diseases for which we had no answer, and those patients got better. Even beyond neurology, there is some evidence that mindfulness can have benefits in psoriasis. We are probably only at the bottom of this mountain.

Dr McBurney has given me so much to think about. I will follow up with part 2 of our discussion that focuses more on the philosophical and life experience aspects of mindfulness once I wrap my head around it.

neurological path mindfulness default mode network adrenal medulla

Buried Alive!

burried alive

Adapted from : Hysterical Paralysis and premature burial: A medieval Persian case, fear and fascination in the west, and modern practice. 

By Paul S Agutter et al Journal of Forensic and Legal Medicine April 2013

The fear of premature burial is ancient but reached its heights in 18th and 19th century Europe. The fear has a modern equivalent, the fear of organs being harvested from a living patient. The certainty of a diagnosis of death are of medical and public concern. The diagnosis of brain death remains controversial.  Although multimodality evoked potentials are considered the most accurate way of determining irreversible brain death, doubts remain as to whether any test of brain death can be infallible.

Public fascination remains widespread. Past cases occasionally surface, it is a fear that pervades literature and film, and various means of prevention have been mooted. Some cases involve hysterical paralysis and this article discusses a case of this which arose in Qajarid Persia.

A family  of tobacco farmers had a 14 year old girl. The mother went to waken her daughter to get her ready for a day of work on the farm. As she didn’t want to do this the girl refused but her mother forced her out of bed. Immediately, the girl fell back on the bed and remained motionless. Thinking that her daughter had stopped breathing, the mother started to shout and cry. Other household members came into the bedroom and were also convinced that the girl had no breath or pulse. Partly due to poverty and partly due to the difficulty in obtaining a doctor, the family considered the girl to be dead and arranged the burial.

The girl’s body was washed and anointed as was the custom. A wise old woman observed that there appeared to be some movement of the girls head and hand and urged the family to wait overnight to see if recovery would occur. She was overruled and the girl was buried.

The old woman did manage to convince the girl’s brother, so shortly after burial, he exhumed the body. He found her motionless and reburied her.

The next morning a neighbour came to the house saying that he had been disturbed by a dream that indicated that the girl was alive. After a lot of dispute, the grave was eventually opened up again in the afternoon.

This time, the girl was indeed dead, but she had changed her position, was now lying curled up on her front,  and had banged her head on the stone covering the grave when she had tried to untie her shoe ties.  A lot of blood had come from the head wound. A tragedy for the entire family.


Muslim burials are usually carried out within 24 hours of death and sometimes very soon after death.  This was no doubt a factor in this case.

Hysterical paralysis is not the only condition that can simulate death. Severe trauma, Guillain-Barre syndrome, acute polyneuropathies and the effects of a cobra bite can mimic death.

Cardiac arrythmias, typhoid fever, brain stem stroke, and infectious disease epidemics have led to premature burials in the past.

Even in the present day, natural disasters, occupational accidents and the effects of war can lead to entrapment.

Hysterical conversion disorders can cause apparent paralysis and somatosensory loss that are difficult to explain medically. Sufferers tend to have psychosocial and emotional difficulties. But genuine disorders such as poliomyelitis, relapsing tetanus, neurological diseases,  spinal injury, acute transverse myelitis and stiff-person syndrome can mimic hysterical conversion disorders.

Fortunately if you test a person who has a conversion disorder with multi-modality evoked potentials, they show up very much alive but with certain areas of the brain working differently from the usual pattern.

Why do some consultations go wrong and what can we do about it?


One in seven consultations are described as difficult by the doctors doing them. Why this happens can be grouped into several categories: patient, doctor, disease and system. More than one factor may contribute in any consultation.

Patients can come across as uncooperative, hostile, demanding, disruptive and unpleasant. Of course the patient may think exactly the same thing about the doctor! Patients may have unrealistic expectations or be unwilling to take responsibility for their health.

Doctors may be in sub-optimal states even before the consultation has started. They can be hungry, angry, late or tired. Their personal lives may be a mess. Their personality may clash with the patients. They may have pre-conceived ideas about the patient which handicaps the consultation before the patient even opens their mouth.

Some conditions are particularly challenging to deal with. These include chronic pain, ill -defined diagnoses and those with little prospect of improvement. Straightforward conditions where there is a recognised pathway of management broadly understood by both doctor and patient are much easier to deal with.

Limited resources, finances, support, interruptions and particularly time pressures all contribute to the difficulties experienced by doctors.

Difficult interactions with patients can take up a disproportionate amount of the doctor’s time, resources and emotional energy. They can cause the doctor to feel stress, anxiety, anger and helplessness and can lead to a dislike of the patient and the use of avoidance strategies. All this compromises the doctor’s ability to provide good care and can lead to increased mistakes which are bad for both doctor and patient alike.

A difficult interaction makes both parties feel frustrated and dissatisfied and may result in a breakdown of trust. The patient is then likely to seek another doctor in the practice or at the hospital and this uses up more precious health care resources.

A doctor who stops listening to patients, argues, talks over them and interrupts them does nothing to get out of the downward spiral that occurs in these consultations. Instead, these other suggestions, which may be made by either doctor or patient can help set things right again.

The first thing to do is to recognise when these difficult consultations arise and instead of getting sucked into the “I’m right and you’re wrong” game, take a step back and try to say what the problem is.

A doctor may say, “ We both have very different view about how your symptoms should be investigated and that is causing some difficulty between us. Do you agree?”  A patient may say, “We both seem to have very different views about the optimal number of blood sugar tests that a diabetic needs to do. Do you agree?”

This approach names the elephant in the room and avoids casting blame, fun though that sometimes is. It externalises the problem from both the patient and the doctor and creates a sense of shared ownership. Verbalising the difficulty is the gateway to working towards a solution.

Sometimes a person who is coming across as angry and abusive may be highly anxious about for example a terminally ill partner.  A doctor can say,  “You seem to me to be very angry about this.  Tell me more about this.”  It is important to listen to what the patient says, because if the patient really feels that they have been heard they are likely to calm down.

Sometimes what the patient wants really is unreasonable. A doctor may have to be clear about what is and is not acceptable sometimes. It is useful for all members of the practice to have consistent rules regarding such things as prescribing or late appointments. The way to explain this could be, our practice has a policy about this matter and the policy is…..

Doctors and patients will often have different ideas on issues such as diagnosis, investigations, and management options. Sometimes there seems to be no common ground which is often the result of unrealistic expectations.  Dr Google and The Daily Mail may have something to do with this.  If both can strive to achieve some common ground difficulties usually diminish.

A solution focused process helps the patient feel included and that they are not being abandoned. Asking them to come up with different options can take some of the burden off of the doctor.


Adapted from article by Marika Davies, medico legal adviser, Medical Protection Society, London.

Published in BMJ 3 August 2013

Heri’s Health Points: Why a good sleep should be your priority

When improving wellness, better sleep should a priority vs nutrition, fitness programs or prescription


Too often, the focus is on being more active, look into new diets or exotic holidays.

These would bring energy, improve strength or cure depression.

The cornerstone of a sustainable and healthy body is quality sleep.

Many brush off sleep. Society or human groups do not value or celebrate when you take a good night sleep. Nobody gets alarmed when you miss a night sleep. Even, all-nighters marathons are celebrated as a proof of motivation and dedication.

Yet, lack of sleep or sleep deprivation deregulates main body functions : impaired brain activity, cognitive dysfunction, weakened immune response, hormonal system dysfunction, poor muscle repair, risk of Type 2 diabetes, higher blood pressure, weight gain, heart disease and so on.

This means quality sleep must be a priority, above nutrition, leisure, physical activity and even work.

Here’s my sleeping plan, let me know if it is good for you:

  • If I do not feel well, I try to see first if I had quality sleep recently, before thinking of stress, nutrition or anything else.
  • I close negative emotions.
  • If I have not been sleeping well recently, I make sure not to overstrain. That means in order : not taking any caffeine (coffee or tea) 5 hours before sleep, no strenuous exercise, no blue light 3 hours before sleep, lower home temperature 2 hours before sleep, massage 1 hour before sleep, camomille tisane 1 hour before sleep.
  • Moderate exercise such as 30mn walking at a good pace at 5pm can improve sleep.
  • Move or change sleeping conditions if not optimal. That can include moving out or thinking about the sound environment.
  • Activity trackers and sleep apps can help measure good sleep and give insights. However, trackers do not improve sleep quality and impact is limited.


  • D. J. Bartlett, N. S. Marshall, A. Williams, R. R. Grunstein. June 2007. Sleep health New South Wales: chronic sleep restriction and daytime sleepiness. Internal Medecine Journal
  • June J. Pilcher PhD & Elizabeth S. Ott BS. March 2010. Relationships Between Sleep and Measures of Health and Weil-Being in College Students: A Repeated Measures Approach. Journal of Behavioral Medecine.
  • Hideki Tanaka, Shuichiro Shirakawa. May 2004. Sleep health, lifestyle and mental health in the Japanese elderly. Journal of Psychomatic Research
  • Making sleep a priority – Daily Health Points

Want to feel better? Write down your thoughts and then decide what to do with them.


In experiments with students it has been found that writing down your thoughts, in your own handwriting, can help you feel more positive, provided you fling away your negative ruminations and keep your positive ones close.

Professor Richard Petty of Ohio State University Psychology department collaborated with colleagues in Spain and tested 83 high school students.

Spending time looking at your negative thoughts make you feel bad about yourself. Throwing out negative and positive thoughts immediately has little impact on you, but putting your positive thoughts in your pocket or purse and referring to them later, has all round positive effects on your mood and future behaviour.

Computerised lists that were either retained or deleted had some effect too, but simply imagining that you had deleted them didn’t work.

(Reported in Human Givens Volume 1 2013 from Brinol P et al, Treating thoughts as material objects can increase or decrease their impact on evaluation. Psychological Science, 24, 1, 41-7)

My comments: this little tip could be very helpful. I know that people who keep journals tend to be more depressed than average. This could be partly due to the introspective nature of journal writing but also perhaps because negative thoughts or events can be reinforced by referring to them or even just carrying them around! 

For avid diary writers perhaps they should keep two journals,   one only keep the good events thoughts and another much smaller book that can be thrown in the trash every so often, preferably quite frequently.

It could also help when you want to achieve something.  Put all of the pros in one list, all the cons on the other, and simply toss out the cons!