Public health

The EU Medicines Directive has decided that Orlistat, a weight-loss drug, can go on sale over the counter. You’ll be able to buy it without a prescription from pharmacies, and online. The difference between the over-the-counter version and the prescription variety will be the dose: the usual prescription strength is 120mg three times a day – the OTC product will be 60mg.

Is patient choice and increased availability a good thing? All drugs have side effects, and Orlistat – or Alli as the OTC version is to be called – is no exception. The side effects are mainly to do with bowels and incontinence – I will spare you any more detail. Still, it seems to suit some people, and there is evidence of benefit. How much benefit? The majority of studies on Orlistat have used the 120mg dose. Most trials also involved people being given stringent dietary and exercise advice. In trials, people taking Orlistat – with these provisos in place – have lost about 2kg-5kg more than people taking a placebo.

The problem is that we won’t know if this OTC development will work or not. As far as I can see, no one is looking into whether it will make a measurable and effective difference to people’s weight under these lower-dose and real-world conditions.

The other problem is fragmentation of care. The fact that more people are becoming involved with a patient’s healthcare without shared notes makes me concerned that we are creating problems-in-waiting. Shouldn’t we get this sorted out before even more drugs obtain an OTC licence?

We have come a long way since the humble bowl of Corn Flakes. Kellogg’s signature cereal was famous for being best enjoyed with “ice cold” milk. Its latest cereal product, Optivita, is being sold along far more complicated lines. Current television advertisements for Optivita proudly proclaim that the cereal has been approved by Heart UK, “the cholesterol charity”. The idea is that by choosing Optivita (an amalgamation of “optimal” and “vitality”) you are going to do good things to your cholesterol, so eat on.

Let us remind ourselves what high cholesterol levels mean in practice. High cholesterol is a risk factor for cardiovascular disease, as are smoking, obesity, diabetes, high blood pressure and a sedentary lifestyle. People can also inherit high cholesterol levels – a condition called familial hypercholesterolemia, which usually requires medication.

Cholesterol receives a lot of attention because it is easily measurable and, unlike one’s family medical history or diabetes, modifiable. Statin medication helps, but many people would, very reasonably, prefer to improve their diet than take a pill. This is where breakfast comes in.

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Why do men’s ears get bigger as they age? I don’t know, I told my editor, but I shall try to find out. Medical school teaches you a lot of things but this wasn’t one of them. The resource most likely to help answer such ponderables is PubMed, an online resource that replaced the book-bound Index Medicus, which was enormously large and hideously time-consuming.

PubMed tells us quite a bit about ears and age. In 1995 a general practitioner called James Heathcote wrote an entire paper in the British Medical Journal on this very subject. Four doctors measured the ears of patients aged 30 and over who were attending the surgery on unrelated matters. Among the 206 patients studied, the mean ear length was 67.5mm and, on average, ear size seemed to increase by 0.22mm per year. This proved, said the authors, that older people have bigger ears. Now, a number of criticisms could be made of the study – for example, the selection criteria might not have been random enough to reflect the general population – but the results are still fascinating, and prompted a number of responses.

A professor of clinical gerontology wrote to the journal to say that his Chinese grandmother had told him he should stretch his ears daily in order to ensure a long life. He also cited a paper from the American Journal of Medicine in which 108 patients were studied to see whether having a diagonal crease in the earlobe was a predictor of lifespan. They followed the patients for eight years, and found that those with a diagonal crease did die earlier from all causes. But, worrying though this is for those with creased skinflaps, it still doesn’t explain why ears get longer as we age.

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Getting out of bed on a January morning can be tough. It’s cold outside, it’s warm under the duvet and you’re tired after another late night. The very last thing you feel ready for is work. But we should ignore any negative messages our mind and body mischievously send us about having a lie-in – because work is good for us. Indeed, it matters to us far more than we might think.

I was convinced of this a few years ago by a superb occupational therapist who pointed out that if somebody has precisely nothing to do, day after day, they will not thrive. Work gives us meaning, structure, social inclusion, relationships and, usually, a visible outcome or product we can be proud of. It also gives us the money needed to buy the heat, light and food that we need to live.

Of course, it is entirely possible for a resourceful individual to find purpose in life without ever resorting to gainful employment. But there is no denying that for most people, work is the best way of avoiding a life of thumb-twiddling.

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1 Expect a long life

“If I had known I was going to live this long I’d have taken better care of myself.” It’s a quip attributed to, among others, Mark Twain, Jimmy Durante and George Burns – and one reason it’s so popular is that there’s truth in it. Burns cracked that joke on his 99th birthday but, for most of us, wondering how long we’ve got to live is no longer the key question, at least not for affluent westerners, whose life expectancy has risen steadily.

What people should be asking themselves instead, says Phil Hanlon, professor of public health at Glasgow university, is how long they will live free from chronic disease or disability, free from morbid obesity or otherwise limited in our mobility. “If we want to live healthy and long lives, then we need to begin from the earliest age to preserve our healthy physiology,” says Hanlon.

His first prescription is brief: live simply. “One of the important things emerging from the new science of wellbeing – see the work of Felicia A. Huppert, for example – is that if you voluntarily decide to live more simply, then you tend to be happier.” We should try to minimise our commutes, maintain a sensible work-life balance and, hardly music to Alistair Darling’s ears, reduce the quantity of things we buy – maintaining what he calls “less stuff in our lives”.

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When I suggested, a while back, that walking was fabulous for health, I thought I was giving readers of this column sound advice.

All the evidence suggests that it’s good for mental, physical and environmental health, as well as being something many people find pleasurable. Who, I thought, could object?

Well, the man who wrote to tell me that he had tripped over his walking stick and fractured his ankle certainly did. (Sorry about that.) As did the lady who became so enthused by the prospect of reaping all those benefits I had mentioned that she decided to walk everywhere, only to have her bunion become infected – requiring antibiotics and surgical drainage. (I do apologise.) So too, the distinguished editor who, I understand, is still requiring treatment for foot pain. (Again, mea culpa.)

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Sometimes, it is easy to recognise a good idea. Oral rehydration solution, a simple sugar and salt formula, costs about 10 cents per packet. Since its development in the 1970s, it has saved millions of people, mainly in the developing world, from dying of diarrhoea. It could well have saved those in Zimbabwe who, in the past few weeks, are reported to have died from dehydration following cholera.

Western healthcare, meanwhile, is expensive, and our contribution to humanitarian aid remains inadequate. When we fret about whether a test for genetic biomarkers will help us to avoid assault by nefarious disease, we seem to be missing the point. We could be concentrating our efforts on saving other people’s lives with simple remedies instead of worrying about how complicated tests could buy us a few more years.

Indeed, the more advanced the medicine, the more equivocal the benefits. A thought provoking piece in the British Medical Journal last year questioned whether the rise in statin prescriptions for elderly people might decrease the number of sudden deaths due to heart disease, only to increase the incidence of cancer.

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When it was announced that both the presidential candidates were allowing sight of medical information about them to be read and reported on by journalists, I was slightly perturbed. Sure, I could see that perhaps the knowledge that one had no outstanding concerns with their health might – might – have some kind of relevance to an election.

But not really. First of all, while we can say that we are fine “at the moment” who knows what may be around the corner? Not everyone has risk factors for the illnesses that they will later die of. Medical “check-ups” are seriously limited in their abilities to offer a prognosis of any value. And in the case of a declaration of illness, disease or even risk factors for disease, how then can an electorate fairly decide if this will affect the ability to hold office? Many illnesses or disabilities need nothing more than the correct type of support or treatment. The real problem with the declaration of some health issues is not so much the disability that this may or may not reveal, but the disability that the public may imagine.

Lord Owen thinks we should be borrowing pages from the US book. He writes in the British Medical Journal this week: “Everyone who wishes to put themselves forward to the electorate as a potential national leader ought to be compelled by party rules to submit to an independent health examination that doesn’t involve their personal doctors and that is assessed by people of proven independence. This would not run into conflict with any existing legislation protecting the rights of the individual. If potential candidates knew they faced independent assessment and that they had a health problem then either they would not stand or they would make it public of their own volition. For example, John Kennedy, in 1960, believed that he would never be elected president if he admitted he had severe Addison’s disease. Yet there is no reason why someone who has Addison’s disease should not be US president if it is well controlled with replacement therapy.”

This is contradictory, unfair, and oppositional to the tenet that doctors should be first an advocate for the patient, and capable of a confidential professional relationship with them. Why on earth should JFK have “admitted” (in itself a pejorative term) to a condition which Owen rightly says need have had no impact on his abilities in office?

Owen also brings up the issue of Tony Blair and his heart irregularity which he says was not, as was contemporaneously reported, a new issue, but an old one.  “I do not believe it is in the public interest that this situation be allowed to continue,” Owen writes, wishing all this information to be placed in the public domain. But these type of heart rhythms are common, and readily treatable, and I can think of no reason why this should stop someone from being PM. What is the point of the public knowing about it? None. It is personal information, and even world leaders are entitled to have privacy.

So what kind of health problem should stop people declaring themselves a potential leader? I know people with metastatic cancer who have stable health, and who are also insightful and thoughtful. I know people who have major mental illness who are not only capable but who work in partnership with health professionals such that they can remain insightful and well. I know people with heart disease who have not stopped from being the same impressive businesspeople that they always were. Nor would I wish to restrict the groups of people who would hope to lead the country to those who are happy for their medical records to be laid bare. This introduces a dangerous bias. Egotism, overconfidence and irrationality are the qualities I most fear in politicians, and none of these are medical conditions.

I am taking a break from the blog for a week or two and will catch up then. 

Much ado with a new paper published by the New England Journal of Medicine . This study was placebo controlled and focused on treating people with ”normal” cholesterol but a high “c-reactive protein” (a marker of inflammation) with rosuvastatin (which is not a new statin as some media outlets have reported, but one already in use). Reports have been rather enthusiastic, eg from the Daily Telegraph: ” risk of a heart attack was reduced by 54%”. One doctor is reported as saying it’s “astonishing”. The trial was stopped early due to “remarkable” results.

The problem is that although the “54%” looks marvellous, and is true, this is the relative risk reduction, not the absolute risk reduction. It does not, by itself, give us a true picture of how meaningful this reduction in cardiovascular events is. We have to know what our risk of having such an event was to start with. From “table 3″ in the paper, the number of patients in the rosuvastatin group was 8901. The number of heart attacks in this group was 31. The placebo group was also made up of 8901 people. The number of heart attacks in the placebo group was 68.  The chance of this group of people having a heart attack on placebo treatment was 68/8901, or 0.76%. The chance of the other group of people, those on rosuvastatin, having a heart attack were 31/8901, or 0.35%. Thus, if you have a normal cholesterol but a high CRP, and if you take rosuvastatin, you can have a 0.35% chance of having a heart attack as opposed to a 0.76% chance.

I’m not very impressed. The other problem with this trial is that it was stopped early. Thus we don’t know what the long term benefits or problems of this approach were (article on this here) . And there did seem to be a small increased risk of developing diabetes in the rosuvastatin group.

However, there may be something else going on here. I mentioned the thought-provoking book The Cholesterol Con by Dr Malcolm Kendrick a while ago. He says, effectively, that cholesterol is nothing to do with heart disease. Statins seem to have some effect on outcomes, but probably have another way of working which has nothing to do with cholesterol, but something to do with inflammation.

Help the Aged have released details of a survey today. They conclude that 1.4m older people in the UK feel socially isolated and that 1.25m are often or always lonely.

I am often dubious about the way in which surveys are interpreted. However, the findings of this survey do bear out many of the sadder observations made in general practice. 

I have long thought that social cohesion is one of the best things for both quality and quantity of life. The current approach to improving health in older people seems to be focused on prescribing more drugs to treat blood pressure, cholesterol and depression. I would much rather see one’s cardiovascular risk factors and mood addressed through meaningful activity, pleasurable and varied diet, and companionship.

Here is Sir Michael Marmot (author of The Status Syndrome, among others) on neighbourhood effects on health: “Rates of mortality and illness differ markedly between areas…Cities all over the world have variations in health by area according to socio-economic level to a greater or lesser extent…Evidence suggests that neighbourhood characteristics such as social cohesion are crucial.”

A systematic meta-analysis published earlier this year  exploring how psychosocial factors relate to health found evidence that favorable psychosocial environments “go hand in hand with better health”.

A couple of years ago in Iceland, I was deeply impressed at the convivial atmosphere after work when whole neighbourhoods seemed to gather every evening – regardless of age or sex – in cheap, local hot spas. The conversation and welcome was fabulous, old people and young people all welcome alike. There was not much exercise going on: mainly people just sat around and chatted. Icelanders have a famously long lifespan. I suspect social cohesion has something to do with it.

Margaret McCartney’s Blog

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A forum on healthcare policy and professional issues, by Glasgow-based GP and FT Weekend columnist Margaret McCartney.

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