Wednesday, 30 December 2015
We are all getting older, and as we do so we hope that the NHS will be there to put us right if we get ill. But increasingly it is starting to look as if perhaps they will not, or at least they may no longer be able to afford to put us right for long. New drug treatments often cost many thousands of pounds a year and the expectations of improved life are often marginal.
The National institute for Care and Health Excellence (NICE) have a formula for determining if a particular intervention should be recommended. If it will cost less than £20-£30K per year to add one full year of life then the treatment can be recommended. This cost level is known as a QALY (Quality Adjusted Life Year).
This is all very good in theory (in practice it’s actually a right mess!) but it leaves me wondering why other non-drug interventions are prescribed so very infrequently. For example, the cost of enrolling with an expert Personal Trainer, having two hour-long sessions a week and receiving expert advice on diet and health is somewhere between £5K and £10K per year, depending on the experience of the trainer. If the treatment worked then the ongoing costs per year of maintaining the results is likely to be less as time goes by. Not many people would doubt the effectiveness of this intervention. So long as the patient were to commit to the programme of treatment I don’t think anyone would doubt that doing so would increase the chance of them living a longer and happier life.
Using the guidelines from NICE you might expect that this intervention would cost significantly less per QALY then many common drug interventions. So why are we not using health and fitness programmes as a medical intervention in order to increase lifespans, improve patient well-being and save the NHS a huge amount of money?
Yes, in some cases doctors are referring patients to weight management programmes like Slimming World or Weight Watchers, but the attrition rate for these programmes is high and the benefits if they happen at all are often short-lived. According to Slimming World the average weight loss from their 5 million clients has been 12 pounds, and yet on their sign-up page they estimate you will lose 10 pounds in your first 8 weeks; so it must all go a bit pear-shaped after that! The reason for this is often that they are only addressing one side of a multi-sided problem. They do not address personal fitness, and many nutritionists might argue that they barely address the problem of diet as they simply provide a regime for eating less, using the out-dated formula “calories in=calories out”. These programmes are cheap, but the cost per QALY is is still high as they are not effective in the long term and so life expectancy is not improved by very much.
And so I have tried to estimate the cost of a Personal Training QALY, using my wife’s fitness business as an example.
Of 20 PT clients training for the past year, all have lost over 10% of their body weight, some have lost lots more. All have lost several inches from their waistlines (a key marker for improved health and life expectancy), all report feeling more energised, happier and healthier. My problem lies in estimating what this has done to their longevity; but I suspect that none of them would argue if I suggested that the intervention of personal training had improved their chances of living least 3 or 4 years longer. In fact, given the choice of training or not training and the state of their health a year ago I would estimate that most of them are likely to live on average at least 5 years longer than they would have done without the intervention. As with drugs there is an ongoing cost in order to maintain the benefit but it reduces over time as healthy living becomes a way of life, with drugs the cost remains, forever.
So, the cost of a Personal Training QALY would appear to be somewhere between £1,000 and £2,000 and reducing year by year. According to NICE that’s quite cheap actually, and very much cheaper than the cost of the conventional treatment of type 2 diabetes, the effects of which (including dependency on drugs) can be seen to be reversed by targeted programmes of diet and exercise.
Does anyone have a better solution for saving the NHS a large pile of money?
Saturday, 24 October 2015
Nearly two years ago I made a big change to my life. I adopted a diet that had me fuelling my life and my running with fat, not carbohydrates. The low carb high fat diet is hugely beneficial for treating type 2 diabetes but it also has benefits for the distance runner.
There have been positives and negatives along the way but the positives, particularly with regard to my health have now made the diet a permanent change.
There was a big challenge too. Could I prove that it is possible to run just as fast fuelled by fat as I could when fuelled by carbs?
I thought I had reached a peak in performance a few years back. I ran a 3:06 flat marathon, I ran a sub 4-hour 3 Peaks and I ran the Beachy Head Marathon in 3:36:30 5 years ago. That last race was amazing, I was on top form and I came 24th. I was very proud of that achievement and I thought at the time that I would never better it.
But I’d heard a lot about how the low-carb high-fat diet can enable you to perform better and better the longer you stick with it. The science here is simple enough, we adapt to oxidize fat as a fuel source more efficiently over time, to the point where we can perform at perhaps 80% of our VO2 Max burning mostly fat. I knew that If I could do that then perhaps I could still get close to that Beachy Head time.
Well today I did just that. I’ve had an almost injury-free year that has enabled me to prepare perfectly for today. I ran a PB in a tough 20 miler a fortnight ago. I had a scare a week ago when I couldn’t run at all because of an odd knee problem but I rested up and this morning I felt great. The weather was perfect and so were the conditions.
I won’t bore you with a big description of the race, I wrote a long post about it last year. But for the record, today I knocked 6 minutes off my unbeatable PB! I came 21st in 3:30:39.
Tomorrow I will be 50 years old and I am entering my fifties knowing that I am fitter and faster than ever before.
Tomorrow I will be 50 years old and I am entering my fifties knowing that I am fitter and faster than ever before.
Wednesday, 14 October 2015
Taking a Statin might change what it says on your death certificate - but it will not change the date.
Seven Mind-Numbing Facts about Statins
1) The NHS spends about £500 million each year on Statins. Enough to build a large hospital each year or pay 16,000 nurses. Most of this money ends up as income for drugs companies, who in turn pass a lot of it on to clinical research units who produce papers that say how great statins are.
2) Statins work by lowering the ‘bad’ cholesterol in our blood. This in turn is expected to lower our risk of Coronary Heart Disease (CHD) and prevent us from dying of a heart attack or stroke. They may have other effects but we do not know for sure. The fact that they reduce cholesterol has elevated statins to be a "wonder-drug". Experts have told us we should all take them every day. And many of these experts are now rather rich.
3) There is not a strong correlation between people experiencing a heart attack and having high cholesterol. In fact many studies show that low cholesterol may be just as dangerous. Cholesterol is carried by Lipoproteins that can be ‘bad’ (Low Density Lipoproteins) or ‘good’ (High Density Lipoproteins). Recent research has shown that the key attribute of LDL Cholesterol which may be associated with CHD is it’s particle size or density; small-dense is bad, larger less-dense is good. We do not measure this attribute in UK blood tests but we know that it is NOT affected by statins – note that it IS affected by diet. We also know that many populations with the highest cholesterol often have the lowest rates of heart disease.
4) We all need cholesterol. Every cell in our body depends on it in order to grow. Our brains in particular need cholesterol; indeed 25% of the cholesterol in our bodies lives in the brain. Studies have shown that higher cholesterol is associated with better memory function. It would not be surprising if a lowering of cholesterol had a negative effect on brain function.
5) There is a startling lack of research that proves that taking statins will reduce CHD. One of the most widely respected studies (The Heart Protection Study, 2001) made its authors famous and led in part to the recent boom in statin use. The study's authors claimed that statins would save thousands of lives and should be prescribed to anyone with even a modest risk of CHD. What the study actually proved was that about 0.5% of men who already have CHD will live a few months longer if they take a statin. The other 99.5% will not. Men who do not already have CHD cannot expect that taking a statin will prevent them getting it. The all-cause mortality figures show that there is negligible improvement in life expectancy gained by taking a statin, despite the much lauded claims that they will save your life! You are just as likely to die, but you might die of something else. By contrast the positive effect of taking Aspirin has been shown to be much higher.
6) The likelihood of experiencing side-effects from taking statins is estimated at less than 1% by the drug manufacturers and somewhere between 5% and 20% by most GPs. Who would you trust here? The list of possible side-effects on a packet of statins is long and scary. Amazingly it includes Type 2 Diabetes, which in turn increases the risk of CHD as well as being a particularly nasty condition to grow old with. Also, recent research is suggesting a possible link between statins and Parkinson’s disease; remember how the brain needs cholesterol? The risk of taking a statin might be literally mind-numbing.
7) If someone says that your mother may die if she stops taking her statin then you should reply by asking: “So what are the chances of that happening?”. A recent article in the British medical Journal explained how on average the best outcome we can hope for from taking statins is to extend life by a few days. This is really not very impressive, is it?
My thanks to the brilliant Dr Malcolm Kendrick (author of The Great Cholesterol Con and Doctoring Data) for the title of this post and for exposing the scale of the miss-use of statistical data in clinical trial reporting.
Friday, 2 October 2015
In the last 10 minutes a hundred runners have passed me by as I've hobbled along the ridge and stood stretching my calves against this dry-stone wall pleading with them to start functioning again. They have good reason to complain after 450 meters of near vertical climbing 2 hours into the 3 Peaks Fell Race. I have to confess that as a southerner without the ability to train on hills like these the east face of Whernside appears like a dark shadow in my dreams; and so despite the pain, with that shadow behind me now I am actually feeling a bit chuffed.
Back in 2008 the 3 Peaks hosted the World Mountain Running Championships and this climb took me 42 minutes from the Ribblehead checkpoint, over half of which was sheer hell. This year as planned it took 40. Dad was there after the railway bridge at the bottom of the hill with a warm handshake and a smile as I passed by and after crossing the river the hill was relentless again. Bog turned to bank and the occasionally runnable slope was followed by greater steepness in turn. At first pumping our fists to drive upwards, then hands on hips, then hands on on knees until there we all were on all-fours, scrambling up the last two hundred meters to the flag that blows on the top marking the route up this pathless slope. It’s just 2 steps ahead to the checkpoint on the ridge, where I look up, pop my dibber into the timer, stand up straight and my calves explode with pain.
|The last few meters up Whearnside|
I have tried to train for this moment. But the hills of Sussex have nothing to compare with it. The nearest I could find was a 100 meter 55% scramble to the ridge of the South Downs Way 2 miles from home. Racing up and down this field to the bemusement of sheep and walkers has been my great pleasure on Wednesday lunchtimes this spring. But this is a sad comparison of the training ascents made by the proper fell runners who now stream past me with their polite rather-you-than-me smiles.
Do not give up on me now! I am imploring to my legs. And they do not give up just yet; they simply remind me again that it is not often that they are asked to behave in this way.
But I understand these things, I have been here before; and as I see my mate Dave cruising past me down the ridge in his Bingley Harriers vest I remind myself that this is all part of the plan. This is the point where the plan comes alive. I am on the ridge of Whernside, 14 miles into perhaps the most famous fell race there is, over half-way and just one mountain, Ingleborough, to go.
If you can be here easing the cramps against this dry stone wall at 13:20 on an April afternoon, then you can run the 3 peaks in 4 hours - the target that I set myself after finishing in 4 hours and 12 minutes 3 years ago. The target that has dominated all of my training and racing for the last 12 months.
So I let them run by. I will see most of them again before the end; right now drink, stretch and take in that view.
|Nice view of Ingleborough from the ridge|
I take a moment to wonder on which nearby rock Dave’s mate Mick might have cracked his head open last year before being air-lifted to Manchester Infirmary for a brain scan. I take another moment to judge the wind – it was actually making life easier on that ascent! And as forecast it will be full in my face on the final descent to the finish. So let’s get going. Steady at first, knees high and ride the bumps on the ridge for half a mile before we dive sideways off Whernside and into the breeze.
I am descending now, every step still a half-controlled form of agony; if I were to leap to the wrong stone on the path below I might twist an ankle, but to hold back would unwise, the cramps in my calves are starting to fade but they will be replaced by a slow death to my knees if I tread too carefully. And so with brain-off I am leaping, sliding, at times hopping with mogul ski-turns down the face of the hill and my faith is returning. The calves have remembered their place and I have regained my pace. I’m sweeping down through fields of sheep and spectators towards Chaple-le-Dale and my second drink bottle and I am still on target.
|Passing Dad at the foot of Whearnside in 2008|
It is my clear understanding that I can do this now. I know the course, I know this hill in front of me and I know the ragged decent to the finish – so fast 3 years ago that I overtook 89 runners on the way down - but today there is a strong easterly and it will be hell to keep going. But I know I can do this.
Four hours was the target. Ambitious for a 45-year old southerner with a love of mountains but no great experience of hard running in them; ambitious yes, but achievable. My meticulous training tells me that I am about 15 minutes faster than last time.
So, one mountain; a beauty it looks from here as I take in the lower grassy slopes and limestone paths with a growing sense of relief that the worst is behind me and the knowledge I have 5 minutes in the bag, for cramps or a fall or that wind.
|Heading up Ingleborough with the route down Whearnside in the background.|
The pastures turn into bogs and the path has been upholstered with wooden pathways and granite steps to aid the runner and ease the erosion of this, Yorkshire’s highest Hill. Overtaking is hard on these pathways, a fall could be ugly here; but fell runners are a kindly breed who will step aside and cheer you on if you are going at a good pace. The last of the energy drink goes down my front and I am a sticky pink mess, but no one cares about the state of your shirt now, just the look in your face: do you believe that you are going up that mountain in just 36 minutes?
The bog abruptly turns to steep grass and rock and we are climbing now, hands steadying as we wobble and race up a stairway that seems to be cut into the rocks. And racing is still the right word for it, even at this shortened pace; every handhold is an advantage that might propel us faster, perhaps fast enough to overtake another runner over that next buttress. It’s not so gut-wrenching as Whernside despite being 3 hours into the race, but Ingleborough has a nasty surprise all of its own as you reach the crest of the main climb and meet the final ridge of boulders. There is no path! No easy way up to and off the top of the hill. We hop and skip our way over a mine-field of limestone rocks to the checkpoint; picking our legs up over the stones to avoid tripping requires new strength and concentration. Finally the summit comes and then it is the turn of our thighs to feel the agony of dancing down the upper slopes, and time to dis-engage the brain one more time for the descent.
Apparently there is a fine view from the top of this hill, I have been here twice and I couldn’t tell you about it. I can tell you about having cramp in possibly every part of both of my legs at the same time as I descend with improvisations over rocks, clints, grikes and some stuff that should only really be attempted with ropes and a belay; and miraculously unscathed I reach the path below and the end is almost in sight.
I check the watch. The path to Horton in-Ribblesdale is over four more miles of rough work and I have 35 minutes and a 25 mile-an-hour head-wind. No one said this was going to be easy!
Now I am sat in the sunshine at the finish having a beer with Dave and some of his Bingley mates. We are joined by Andy Peace the course record holder and they are sharing their memories of the last 25 years of the race. My dad comes by with Anne and shakes my hand once more. He knew what I was trying to achieve but he doesn’t ask if I made it or not. He has spent the last 20 years challenging himself in the mountains and for him it is the beauty and wildness that brings him back, not just a time on a slip of paper. And besides, he can see it in my face.
Tuesday, 8 September 2015
My top news story of the week comes from The Daily Mail:
A quick summary:
- We have a big problem with type 2 diabetes – the drugs (in particular Metformin) don’t work
- NICE are giving the wrong advice
- Diabetes UK (diabetes.org.uk) are giving the wrong advice
- Diabetes.co.uk are giving the right advice
- Many doctors are giving the wrong advice
- But the tide is turning as more and more healthcare professionals learn the truth about how diabetics can manage their blood sugar (and hence their disease) with a LCHF diet.
I have a lot of respect for the daily Mail when they talk about health. Their comments section is frequented by a vitriolic bunch of smug creeps who abhor any notion that the Great British public might want advice about anything and seem to think that the Laissez-faire life that brought some of them riches in the 90’s should be prescribed for healthcare as well. All the more impressive that The Daily Mail perseveres.
In The BMJ this week we have an interesting article from Dr Simon Tobin and Dr David Unwin; you may recall my post last year on Dr Unwin’s successful LCHF intervention trial in which Diabetes patients lost weight and lowered their dependency on drugs by adopting a LCHF diet. This week’s report describes how a question from a patient about how to reduce the growing list of drugs he was taking provided an opportunity to step back and look at the ineffectiveness of the drugs generally being prescribed for the symptoms of metabolic syndrome. The lesson learned appears to be that the drugs being prescribed are not very efficient at dealing with most patient’s problems; mostly because they have been prescribed to combat the assumed general risk of heart disease rather than a specific ailment. The other big lesson is that weight control is the real key to managing all of the symptoms of metabolic syndrome. This seems to be the common message from all health practitioners promoting the LCHF diet; eat real food, remove processed food and particularly refined carbohydrates from your diet and you will lose weight and lose your dependence on drugs
In my own family the question of over-medication is often a heated one. A relative was recently on 7 separate medicines to combat thin blood, raised cholesterol, hypertention, anxiety and other complications; there was no noticeable improvement in any of her ailments but there was a marked increase in her lethargy, loss of mental acuity and physical ability. None of the drugs that she had been prescribed had ever been tested in conjunction with each other. It was my strong conviction that, much like a teenager spaced out on alcohol, nicotine, paracetamol, red-bull, no sleep and perhaps a little cannabis or crystal meth might not be expected to rise at 10 a.m. and complete the Times crossword over breakfast, my relative was unable to function normally for 7 days a week because of the cocktail of drugs that she was taking. And this is not an unusual situation for a woman of 80. This subject came its natural conclusion when we all listened to this.
My own mother on the other hand refuses to take any drug unless it can be proved to be effective; and as she was a statistics lecturer for 30 years and the proof of effectiveness of any drug is at best an elusive thing, this is a very rare event indeed. Long may her drug-free rhapsody continue!