Still harping on about Cholesterol Malcolm?

I think that by now most of my friends have had 'the cholesterol chat' with me; in pubs, over dinner or even sometimes when out running. I am generally careful now to only harp on about this to people I have not met before. This blog is an exception.

I am not a medical person, nor a nutritionist (although I did follow a correspondence course last year), and I hope I know where to draw the line between my knowledge and that of others. I do happen to know a little about statistics, something that helps to understand the relationship between a health claim and the data that apparently supports it.

But cholesterol is one subject that I have taken a close interest in. The reason for this is that it lies at the crux of the health/diet debate; it has had a massive impact on public health and the practices and finance of the NHS.

When I first saw the FSA video that declared that saturated fat clogs up your arteries just like it could clog up a drain pipe, I was scared; clearly that was the intention. And for many years I lived in fear of my higher than normal cholesterol leading to an early peanut butter induced heart attack.

That said, the concept did seem a bit preposterous at the time.  Humans have always eaten saturated fats and as far as historians can say is seems that we have not always dropped dead of Coronary Heart Disease. Also, the fat in the video only clogged up when it got cold, and human arteries are well known to be warm places!

The fear of fat was created in the 1970s and 1980s when firstly US dietary advice and then the advice we received from the NHS was changed. Very few scientists agreed with this change at the time, but Kellogg's were pretty happy about it all. We all switched from eating real natural food to eating cheap cereals instead. And we started adding more and more sugar to everything in order to make it more palatable. And did we get healthier? No, we did not.

Then along came statins (or did they actually arrive earlier looking for something to cure?). A panacea, no longer even requiring full clinical trails as they meet the simple surrogate endpoint of lowering LDL cholesterol. The claims were that thousands of lives would be saved, and yet the data quoted at the time showed that only small numbers of lives (perhaps 1 in 200) of already ill people might be prolonged, for a short while. Lives were not saved. I get incensed by such things as this. Data like this is being used to support the notion that we should nearly all be taking a drug that has several known side-effects and has clearly ruined the lives of many many people.

And the more I've learned about cholesterol, "good or bad", the more I have become convinced that there is nothing in it. For every report that declares that high LDL will lead to high CHD there is another that shows that there is no causation. The most obvious data here describes whole populations with low LDL and high CHD, high LDL and low CHD. How could this be?  Malcolm Kendrick sums it up perfectly (again) in this article where he points out that Russian men are eighteen times more likely to get a heart attack than Japanese men, and yet their average cholesterol levels are the same. This whole series of Malcolm's articles makes very interesting reading if you have an interest in heart disease.

If we can remove statins, cholesterol and hence saturated fats from the whole heart disease debate then we can start looking at the relationship between health and food in a different way. Fats and carbohydrates both provide us with energy, but which are more healthy and which are making us fatter and unwell? And in my opinion a big clue lies in this simple question - which is the only macro-nutrient that in its natural form has no nutritional value?

Eating to Run

Last month the Food Programme on Radio 4 ran a 2-part series entitled Eating to Run. Naturally I was intrigued and listened in. The program covered a wide range of topics with a focus on how the food we eat can impact on our performance. 

• They spoke to expert sports nutritionists at Loughborough University about the right balance of macros and foods for elite British athletes.
• They spoke to Brendan Foster about what he ate when he was breaking world records. Toast and honey.
• They looked at what the world’s best marathon runners form Kenya eat (mostly rice and potatoes), and the diets of the running mad Japanese who eat a lot of fermented foods and run a lot faster than we do.
• They spoke to Scott Durek, perhaps the worlds most gifted ultra-distance runner. He advocates a vegan diet with lots of fermented foods as this improved the efficiency of the gut.
• And they briefly described Tim Noakes and the LCHF diet. Noakes was the great pionner of nutritional research for performance running and he now admits to have got it all wrong.

Lots of people advocating hugely different diets. And loads of contrasts; the scientists from Loughborough insist that you need to burn carbs and you need to recover quickly with a protein and carb drink; and the Kenyans (who happen to be rather better than the British) who eat nothing at all after a long training run. Brendan foster replenished his body with a couple of pints of shandy!

And the conclusions that I come to are these:

Eat whatever works for you and your body, but make sure you are not harming actually yourself.

I believe that a lifetime of high carbohydrate food is likely to contribute to bad health, especially if you are intolerant to carbs as many people undoubtedly are.

I also believe that most of the science described by sport nutritionists and quoted by Lucozade is aimed solely at elite athletes.  And as Charlie Spedding puts it so well in his biography entitled Last to First: "Why is it that most of that fastest British marathon runners in the last 40 years were running over 20 years ago?"  (In 1984, for instance, 2hr 15min was broken 25 times by British athletes. In 2012 it happened on just three occasions).  Something is not right here.

The notion that we must run on carbs in order to be champions relates to a tiny fraction of runners; and except for sprinters the rest of us could certainly run just as well on fat if we chose to and would be best off considering what energy source is more healthy. And the answer to this would appear to be to “Eat Real Food, mostly vegetables and not too much”.

How to live longer and save the NHS a large pile of money

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?

A Big LCHF PB in the Beachy Head Marathon

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 24^th. 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 21^st 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.