Valentine’s Day is a celebration of love and affection. If you want to feel better and be here longer for all the ones you love, remember that your heart needs tender loving care, too. Cleveland Clinic cardiologist Curtis Rimmerman, MD, says, “Even if you have the perfect genetic history, with no heart disease, it is still very important to live a heart-healthy lifestyle.”

So, how can you love thee? (Your heart, that is!)  Let us count the ways…

Eat HealthyTip #1. Eat a diet that is low in saturated fats, cholesterol and sodium.

Taking the time to read food labels will help you understand what foods you should avoid or eat in small quantities. Saturated fats are found in prepared foods and animal products including meats, milk, butter and eggs. Limit your red meat intake, choose lean cuts of chicken and turkey, and eat more soy protein and fish, including salmon, tuna and sardines (high in cholesterol lowering omega-3 fatty acids). In prepared foods, avoid products made with transfats and hydrogenated vegetable oils. One great way to reduce your cholesterol is to increase your fiber intake with more fruits, vegetables, beans and whole-grain foods. Try to consume 25 to 35 grams of fiber each day. Keep an eye on sodium too. Sodium is found in many foods like processed meats, eggs and bread. Make a conscious effort to consume only 2 grams or less of sodium per day (1/3 of a teaspoon).

Exercise DailyTip #2. Do 30 minutes of daily exercise that gets your heart rate up.

Simply make exercise a part of your daily routine. Find an activity that fits your lifestyle and take the time to do it. If you are busy, the good news is that the 30 minutes does not have to be consecutive. You can do three 10 minute spurts (or two 15 minute spurts) of activity that get your heart rate up. You might do short and brisk walks two to three times a day.

Quit SmokingTip #3. If you smoke: STOP.

Smoking is a major risk factor for heart disease. Smokers have about a 70 percent higher death rate from coronary artery disease than do nonsmokers. When you want to quit smoking, help is available. When you quit, your heart will begin to rejuvenate. Think about it. It will make you and your loved ones healthier and happier at the same time. Also, do your best to avoid secondhand smoke.

Blood Pressure CheckTip #4. Keep your blood pressure and cholesterol at normal levels.

If you do all three of the above, your blood pressure and cholesterol levels will probably be in a healthy range. A good blood pressure is around 120/80 mm Hg and a good total cholesterol level should be 200 mg/DL or lower. To keep them in check, be sure to have these levels measured regularly, and take medications from your doctor when necessary.

Couple LaughingTip #5. Keep stress levels in check.

Don’t ignore it when you’re feeling stressed for more than a day. To keep your ticker healthy, it’s important to assess your stress level every so often. Ideas for stress reduction include everything from listening to music to having a regular exercise routine to taking the time to meditate. Whatever you do, find what works for you. Doctors are even finding that laughter eases blood flow and reduces our stress, so try bringing some levity into your daily life. Another way to keep stress in check for the long term is to have a good network of friends with whom you can talk. Finally, be sure to separate your family time from work time. This can do wonders.

We all want to be heart-healthy, and ensuring healthy levels of cholesterol — a fat, or lipid, carried through the bloodstream — is the first step.

Low-density lipoprotein or LDL (bad) cholesterol contributes to plaque buildup along with triglycerides, another lipid. High-density lipoprotein or HDL (good) cholesterol discourages plaque buildup. Plaque can threaten the blood supply to the heart, brain, legs or kidneys, leading to heart attack, stroke or even death.

To reduce your risk for heart-related emergencies, registered dietitian Kate Patton, MEd, RD, CCSD, LD, and exercise physiologist Michael Crawford, MS, share 10 tips — five for lowering cholesterol through diet and five for making the most of exercise:

  • Chicken in fryer

    1. Cut back on animal fats

    Forgo fatty meats, like processed meats such as bologna, salami, pepperoni and hot dogs; and fatty red meats, such as ribs and prime cuts of beef, pork, veal or lamb. Also, skip skin on chicken or turkey. Avoid full-fat dairy products such as whole milk, cheese, cream, sour cream, cream cheese and butter. These foods contain saturated fat as well as cholesterol — both associated with higher blood cholesterol and plaque buildup.

  • Oats

    2. Make friends with fiber

    Specifically, get friendly with foods high in soluble fiber. In the gut, soluble fiber can bind to bile (which is made up of cholesterol) and remove it. Look for soluble fiber in oats, oat bran, ground flaxseed, psyllium,  barley, dried beans and legumes, fruits and root vegetables, as well as some whole-grain cereals.

  • Peas in pod

    3. Go veggie

    Choose at least one meatless meal per week. Substitute animal protein (meat, poultry, fish, eggs, cheese) for plant based protein such as beans, lentils, tofu or quinoa. Try these plant based proteins in salad, soup, stir fry, or a burrito to decrease your saturated fat intake and increase your fiber intake. If you enjoy meatless meals, try to go meatless for one day per week!

  • Carbs4.Be mindful of carbs

    Research shows that following a low-carb eating plan can help you lose weight and reduce cardiovascular risk factors.  Choose high fiber carbohydrates like oatmeal, whole grain starches, beans, lentils, and fruit which will provide the energy you need, but also keep you feeling full.  The key is to watch your portions, aim for no more than about 1 cup of starch and/or fruit with meals.  Also, fill up on vegetables which are low in calories and high in fiber.

  • Man on scale

    5. Be a loser

    If you’re overweight or obese, shed the extra pounds. Weight loss helps lower bad (LDL) cholesterol. Even a small-to-moderate weight loss — just 10 to 20 pounds — can make an impact.

  • Swimmer

    6. Move more

    Work up to 90 minutes of cardiovascular exercise per day for optimum heart health and weight loss. Cardiovascular exercise means any activity that uses large muscles repetitively and increases the heart rate. Think walking, cycling, rowing, using the elliptical and swimming. If you find 90 minutes daunting, start with 30 minutes and work your way up a little at a time. For some people, 45 to 60 minutes of cardiovascular exercise is enough.

  • Exercise class

    7. Pick the right tempo

    Aim for a moderate level of exercise. You’ll know you’ve reached it when you can carry on a conversation when you exercise but can’t sing. Once you have safely mastered moderate-intensity exercise, consider High Intensity Interval Training (HIIT) one to two times per week. Emerging research suggests this type of training can improve upon moderate-intensity exercise benefits, especially for raising good (HDL) cholesterol.

  • Reminder note

    8. Make a habit of it

    Consistency is the key. Work out regularly and you’ll watch your triglyceride levels drop. Triglycerides are the only lipid in the cholesterol profile used for energy. They decrease an average of 24 percent with regular cardiovascular exercise.

  • Martial artist9. Change it up

    Variety is the spice of life, so try different exercises to stay motivated, to challenge other muscle groups, to reduce the risk of overuse injuries and to enjoy your physical activi

  • Runners sport band

    10. Get technical

    Many great technology tools can give you feedback on your exercise. Smartphone apps often have exercise tracking, motivation techniques, calorie trackers and tips. In addition, biofeedback devices such as heart rate monitors (models with chest straps have better accuracy) and pedometers can help guide your exercise plan or help you with motivation.

Note: If you have heart disease, check with your doctor before beginning an exercise program. A cardiac rehab program is a great way to learn the right exercises for you and jump-start your diet and exercise program. If you experience chest pain, pressure, tightness, excessive shortness of breath, lightheadedness or palpitations, stop exercising and consult a doctor.

The career of a GP can be peppered with tragic events, professional and personal. Perhaps none could be more poignant than the unexpected death of a child. This child was a few days from their 12th birthday and a typical football playing, wise-cracking young man who was unfortunate in having asthma.

He was a good asthmatic – had good inhaler technique, attended for check-ups when asked and readily took on board the advice offered by the asthma nurse. Then one day he had an attack which escalated very rapidly and he died; despite everyone’s attempts to save him. Why it escalated so quickly when he had been well controlled, will never be known.

What makes this story even worse is that it is repeated (with variations) around the UK far too many times a year. According to Asthma UK, every day three families lose a loved one because of a fatal asthma attack. They also estimate that every 10 seconds in the UK, someone is having a potentially life-threatening asthma attack.

However, there are also many individuals who only experience symptoms when otherwise challenged by an infection or allergen. Where you have an illness that has such a wide-ranging spectrum of morbidity, it can be difficult to tailor care that suits all individuals. We need to safeguard those most at risk but should avoid over-medicalising those who can cope. In August 2015 the Royal College of Physicians (RCP) released the National Review of Asthma Deaths (NRAD) report: Why asthma still kills.(1)

This contains 5 recommendations for medical care:

1. All people with asthma should be provided with written guidance in the form of a personal asthma action plan that details their own triggers and current treatment, and specifies how to prevent relapse and when and how to seek help in an emergency. These are available online at the Asthma UK website (see: https://www.asthma.org.uk/globalassets/health-advice/adult-asthma-action-plan.pdf) and are also downloaded onto the EMIS Web system.

2. People with asthma should have a structured review by a healthcare professional with specialist training in asthma, at least annually. People at high risk of severe asthma attacks should be monitored more closely, ensuring that their personal asthma action plans are reviewed and updated at each review.

3. Factors that trigger or exacerbate asthma must be elicited routinely and documented in the medical records and personal asthma action plans of all people with asthma, so that measures can be taken to reduce their impact.

4. An assessment of recent asthma control should be undertaken at every asthma review. Where loss of control is identified, immediate action is required, including escalation of responsibility, treatment change and arrangements for follow-up. Recognition may be from monitoring requests for repeat prescriptions for inhalers. Overuse of salbutamol and underuse of corticosteroid should prompt action, such as calling the patient for a review.

5. Health professionals should also bear in mind the features that increase the risk of asthma attacks and death, including the significance of concurrent psychological and mental health issues.

In addition the RCP suggest that patients:

  • Should be encouraged to reflect their known triggers, eg increasing medication before the start of the hay fever season, avoiding non-steroidal anti-inflammatory drugs or by the early use of oral corticosteroids with viral- or allergic-induced exacerbations
  • Should be made aware that smoking and/or exposure to secondhand smoke can affect their condition and such exposure should be written in the medical records of all people with asthma. Current smokers should be offered referral to a smoking-cessation service.
  • Should be educated about managing asthma. This should include emphasis on ‘how’, ‘why’ and ‘when’ they should use their asthma medications, recognising when asthma is not controlled and knowing when and how to seek emergency advice.
  • Should try to minimise exposure to allergens and secondhand smoke, especially young people with asthma.

Current estimates are that one in 11 people in the UK have asthma. This means an average (7,000 patient) practice will be looking after approximately 640 patients. When did your practice last discuss your care for this group? Perhaps, as hay fever season comes upon us, it’s time to make sure all your staff are asthma aware. Patient has several asthma-related pages to assist you.

NB: Scottish Intercollegiate Guidelines Network is due to release new guidelines on asthma management in summer 2016 and National Institute for Health and Care Excellence has a release date for their guidance, of June 2017. We will update our articles thereafter.

1. Why asthma still kills; Royal College of Physicians, August 2015.

https://www.rcplondon.ac.uk/projects/outputs/why-asthma-still-kills

Just take a moment to think about your teenaged children, particularly girls, should you have them. Do they seem happy?

I’d love my boy to be less anxious, but Asperger’s creates extra issues there, so I am definitely not expecting huge belly laughs on an hourly basis.

A recently published study into the state of mental health in England found quite alarming evidence that more young people are experiencing mental health problems than ever before, and particularly young women aged 16 to 24. This was a screening document and many of the respondents were undiagnosed and untreated. Sexual violence, childhood traumas and pressures from social media are being blamed for dramatic increases in the number of young women self-harming, having post-traumatic stress disorder (PTSD) or a chronic mental illness.

Psychological distress is now so common that one in four in that age group have harmed themselves at some point, according to the government-funded Adult Psychiatric Morbidity survey (1).

The number of women of that age who screened positive for PTSD had risen from 4.2% to 12.6% between 2007 and 2014, although the use of a more accurate screening tool in the new survey may explain some of that rise. When I first read the headline I was hugely sceptical. How can so many young women have PTSD?

I thought about the importance of resilience, how anxiety can make people more prone to see a blip as a disaster and how the authors were defining PTSD – obviously too loosely, open for interpretation. Unfortunately, I was wrong.

Reading through the document itself, they had been very precise in their definition and had stated specifically the criteria. Traumatic events were defined as experiences that either put a person, or someone close to them, at risk of serious harm or death, like a major natural disaster, a serious car accident, being raped, or a loved one dying by murder or suicide. About one in three adults in England report having experienced at least one such traumatic event.

How can so many young people have experienced this type of event? There we have a very unpleasant reflection of the society our children are growing up in; one that our political leaders should be examining closely. The dean of the Royal College of Psychiatrists said more research was needed to fully understand the rise in PTSD, but said rape or other sexual abuse were possible triggers. She said the rise in chronic mental illness among 16- to 24-year-old young women was clearly worrying, with social media a likely key contributor; 26% of women, and 9% of men aged 16 to 24 reported symptoms of common mental disorders in the week prior to the survey.

“This is the first age group that we have had coming of age with social media,” Lovett said. “There are some studies that have found those who spend time on the internet or using social media are more likely to [experience] depression, but correlation doesn’t imply causality.”

The chief executive of the mental health charity Mind said untreated mental illness was still a huge problem. “It’s still clear that nowhere near enough people are getting the support they need – in fact, more people than not are having no treatment at all,” he said. About half of those who screened positive for PTSD were already receiving mental health treatment: 38.9% were taking medication and 24.0% were having psychological therapy. Child and adolescent mental health services (CAMHS) are usually resource poor and hugely over-burdened. A colleague describes a referral to the CAMHS locally as ‘dropping a letter into a black hole.’ There are some great 3rd party organisations who are trying to pick up the slack, but there still seems to be a growing gap.

The RCGP journal this week was devoted to mental health and describes children and young people’s mental health services as the ‘Cinderella of the Cinderella services’, chronically underfunded and undervalued (2). We know that mental health problems in this group can have an effect on physical, social and educational development with effects lasting into adulthood. This group needs access to timely help, or we are truly storing up problems on a massive scale for generations to come.

We also know that young people find accessing healthcare difficult. How many of you have young people in your PPGs, or have practice news and information on social media? Something to consider maybe, and if you’re feeling truly inspired, have a look at this beacon of good practice.

It is time to recognise that the kids are definitely not alright.

1) National Study of Health and Wellbeing: Adult Psychiatric Morbidity Survey (APMS); September 2016. https://www.statisticsauthority.gov.uk/monitoring-and-assessment/assessment/current-assessments/national-study-of-health-and-wellbeing-adult-psychiatric-morbidity-survey-apms/

2) Mughal F, England E. The mental health of young people; British Journal of General Practice. October 2016.

Some of our long-standing site users will be aware of the collaboration between MAGIC and our authoring team, aiming to promote and facilitate good conversations between patients and their clinicians.

There are many decision aids available on this site which provide necessary information to help decide the best course of action for that individual patient; ‘No decision about me, without me.’

Across the UK we are becoming more aware of the overuse of medical intervention. This can vary across the country. For example, the prescribing of antibiotics can vary by as much as two and a half times between one part of the country and another.

Choosing Wisely UK is part of a global initiative aimed at improving conversations between patients and their doctors and nurses. A study last year found that 82% of doctors said they had prescribed or carried out a treatment which they knew to be unnecessary.

The problem for patients is that most interventions have side effects and some may even cause harm. Choosing Wisely was created to challenge the idea that more is better – just because we can, doesn’t always mean we should. The Choosing Wisely principles encourage patients get the best from conversations with their doctors and nurses by asking five questions.

• Do I really need this test, treatment or procedure?

• What are the risks or downsides?

• What are the possible side effects?

• Are there simpler, safer options?

• What will happen if I do nothing?

The Royal Colleges in the UK were asked to identify five treatments or procedures commonly used in their field where the appropriateness of their use should be discussed carefully with patients before being carried out. The following seem particularly relevant to primary care:

1. When patients are particularly frail or in their last year of life, unless the patient has a clear preference, discuss decreasing the number of medicines to only those used for control of symptoms.

2. Consider dementia when individual patients are seen, rather than routinely screening whole groups of patients.

3. If drug treatment is being considered to prevent heart disease, stroke or osteoporosis in previously well people, ensure that this decision is shared with the individual concerned.

4. Only consider blood pressure treatment with medication when the BP is consistently above 140-159/90-99 mmHg in people with additional risk factors.

5. If you suspect that a woman has polycystic ovaries, check free androgen index or LH: FSH ratio before considering further imaging.

6. If an individual takes a statin at the recommended dose, there is no need to routinely check cholesterol levels unless there is evidence of pre-existing problems.

7. If a woman has abnormal vaginal discharge that is likely to be caused by thrush or bacterial vaginosis and she is at low risk of having a sexually transmitted infection, a vaginal swab is not usually necessary.

8. A woman who may have recurrent thrush should have an examination of the perineal skin to exclude other conditions e.g. lack of oestrogen, allergies or other skin conditions rather than routinely giving further anti-fungal treatment.

9. If a woman is over the age of 45 years with typical symptoms of menopause, blood tests to check hormone levels are not usually necessary.

10. A simple ovarian cyst less than 5cm in diameter in a pre-menopausal woman does not need to be followed up; nor is there any need for a blood test to check levels of the protein CA-125.

11. Aspirin, heparin or progesterone should not be used in a bid to maintain a pregnancy in a woman who has had unexplained and/or recurrent miscarriages.

12. Chemotherapy that is unlikely to be beneficial and may cause harm should have minimal use in advanced cancer.

13. Children with small unilateral wrist fractures do not usually need a plaster cast. They can be treated with a removable splint and written information. They do not need follow up in fracture clinic as they will get better just as quickly without this. Also small fractures of the base of the fifth metatarsal, do not usually need to be put into a plaster cast as they will heal just as quickly in a removable boot.

14. In cases of a minor head injury, imaging is not likely to be useful.

15. Back pain which is uncomplicated and that is not associated with ‘red flags’ or radiculopathy usually does not require imaging.

16. For children with chronic constipation changes to diet and lifestyle should be considered first to relieve the symptoms. If this is ineffective, macrogols should be considered rather than lactulose.

17. Bronchodilators should not be used in the treatment of mild or moderate presentations of acute bronchiolitis in children without any underlying conditions.

For further information see the Choosing Wisely site.

Being overweight and obesity are the fifth leading risk for global deaths. At least 2.8 million adults die each year as a result of being overweight or obese. Forty-four per cent of the diabetes burden, 23% of the ischaemic heart disease burden and between 7% and 41% of certain cancer burdens are attributable to being overweight or obese.

The fundamental cause of obesity is an energy imbalance between calories consumed and calories expended. Globally there has been a significant increase in the proportion of people who can be defined as overweight or obese. Max Galka created the graphs below which illustrate these trends.

This increase is seen both countries like the United States and the UK, where food is cheap and abundant, as well as countries like Somalia and Angola, where malnutrition remains an epidemic.

The greatest increases were seen in the smaller Pacific island countries. Samoa, Tonga, and Tuvalu all saw their obesity rates double from what they were in 1975.

Perhaps the country that stands out most of all is China. In 1975, only 0.5% of Chinese adults were obese. Today, China’s obesity rate is about 8%, a 16-fold increase in the most populous country in the world.

Globally, the average adult today is three times more likely to be obese compared to the average adult in 1975.

The increase is caused by several factors. These include increased intake of energy-dense foods that are also high in fat; this is compounded by an increase in physical inactivity due to the increasingly sedentary nature of life. Other factors are increasing urbanisation and changing modes of transportation.

Changes in dietary and physical activity patterns are often the result of large-scale environmental and societal issues such as a lack of supportive policies in sectors such as health, agriculture, transport, urban planning, environment, food processing, distribution, marketing and education.

So, how can we tackle this problem? We have dietary and exercise guidance but even when individuals are aware of this, they can find it difficult to adhere to. The government needs to support individuals to follow these recommendations through sustained political commitment. In particular they should make regular physical activity and healthier dietary choices available, affordable and easily accessible to all – especially the poorest individuals.

The food industry needs to support this by reducing the fat, sugar and salt content of processed foods, ensuring that healthy and nutritious choices are affordable to all consumers. They should also be responsible when marketing to children and teenagers.

For your average GP, supporting an overweight patient is fraught with potential issues. Apart from the insoluble environmental confounders (our weather does not encourage folk away from their TV sets) and the usual suspects of poor availability of time and resources, obesity does not follow the classic medical/disease model. It is the patient who ultimately exerts the greatest control over the decision to seek help and, eventually, in the success of any intervention.

As a doctor, you really need to start this conversation but many worry about ruining a working relationship by a few ill-chosen words. The RCGP has some suggestions that should not cause offence, including “How do you feel about your weight?”, “We know weight can affect the safety of doing an operation – has anyone talked to you about this?”, “When did you last weigh yourself?”, “Has your weight changed much over the past few years?” or “Do you keep an eye on your weight?”.

You might be surprised that the patient has already been trying to lose some weight, and giving encouragement and following up with “Is it something you would like to discuss further or get some support for?” may be a good way to start. Remember to check that weight management is a priority for the patient right now. For instance, would they be more likely to succeed if any mental health issues were addressed first?

If you feel your skills could do with a little sharpening this year why not check out this RCGP page.

They have an introductory certificate in obesity, malnutrition and health as well as several useful resources for you and your team. If you have motivated staff, you might support them in setting up a ‘Fit club’. We have a group of around 15 patients who come weekly and are weighed and then walk over to our local primary school’s sports hall where they do a Pilates/tai chi class on alternate weeks. They have all lost weight, lowered their blood pressures and HbA1cs.

It’s New Year, a new start. Help people make that commitment to change.