Lifestyle Matters

On MedHeads

I chat with DR Andrew Rees about a particularly challenging case of a military veteran in his fifties who ahs been a victim of both a traumatic abusive childhood and combat trauma.

He suffers from chronic pain secondary to degenerative disease of both knees and spine (rather than combat trauma) and is dependent on high dose opioids (oxycontin 40 mg bd) and various benzodiazepines. He also suffers form PTS. In terms of his lifestyle, he is obese, he smokes twenty to thirty cigarettes per day. He lives with a partner and has a child from a previous relationship.

We discussed firstly what his needs might be according to the “SPEW CRAFT” mnemonic.
Sustenance – there do not seem to be any unmet needs in this domain
Protection.
His PTSD may indicate an unmet psychological need for protection.
Engagement with meaningful activities.
He does not engage in any meaningful activities; he has no hobbies or interests and self isolates for most of the time.
Wisdom – He may not know how to seek help, or for that matter that help is available
Creativity – there do not seem to be any unmet needs in this domain
Rest – He does not work, and as mentioned above he does not engage in any meaningful activities, but this does not mean he has rest. He does not have rest from psychological restlessness, and his diurnal rhythms are disturbed.
Freedom – He feels trapped and isolated and is not sure who his tribe is. There is a reluctance to engage with the local RSL for fear of exacerbating his PTSD.
Transcendence or Legacy.
He has no idea of his identity or his personal worth.

Starting from this apparently hopeless situation Dr Rees has been able to engage with this patient and help this patient grow by simply asking the right questions.

What does he hope for in life?
This man’s quest for his purpose in life led him to realize that he wanted to re-establish his relationship with his daughter.
What is he good at, what would his spouse think he is good at, what would his daughter think he is good at?
He identified that his strengths included reliability, conscientiousness, and a sense of duty.

After understanding the answers to these questions then comes the miracle question.
“If all your problems magically disappeared overnight, what would it look like for you, what would it feel like for you and what would be the first sign that someone else would notice?”
In this case the answer was that he would smoke less, take less medication, and do more exercise.

The miracle question has unlocked in this patient the potential for deprescribing and a healthier lifestyle. Finding his purpose in life has shifted his focus from being dependent on medication and has unlocked his desire to be medication free, to enjoy mental clarity and to engage with his family.

Archimedes once said that with a big enough lever he could move the earth. Dr Rees has shown us a similarly profound effect: that with the right question we can unlock a willingness for change and a desire for a drug-free life.

Maree Eisma is a mental health social worker who has an expertise in dealing with children who are experiencing school refusal.

School refusal usually presents with an escalating school reluctance before frank refusal occurs. Behaviours can include repeated sick bay attendances or multiple but intermittent absences due to various illness presentations.

I like to classify the presentation of school refusal according to primary, secondary or tertiary gain.

Primary gain refers to the intrinsic benefit of the sick role. In the context of school refusal, it suggests that the child who presents with an illness benefits from being sick in terms of care giver attention. This may be an issue of care givers are very busy or otherwise emotionally distant.

Secondary gain refers to a secondary benefit that the sick child enjoys, which in the context of school refusal may indicate a desire to escape from bullying, a test or other academic pressure or sometimes merely the overstimulation that may occur in a busy school yard.

Tertiary gain refers to the benefit that the care giver may derive from a child’s illness behaviour triggering school refusal. Divorce, separation, or other sources of parental disharmony can perpetuate this.

Underlying the phenomenon of primary gain is the concept of somatisation, i.e. the manifestation of medically unexplained symptoms that are not consciously feigned.

It can be challenging from a. medical perspective to distinguish organic pathology from somatisation, but the distinction needs to be made to prevent harm to the patient in terms of unnecessary tests and treatments.

Further to the diagnostic dilemma it is also important to approach the management of the problem from a socio-psycho-biomedical model of care. it is not sufficient simply to advise parents to “Just make their child attend school”.

In a similar vein I remember telling the parents of a young child who was refusing to swallow antibiotics to “just make the child take the medicine”.

Graded exposure can be used to help children re-integrate back into school. This process relies on a patient and gradual exploration of a child’s situational anxiety and providing coping mechanisms to deal with situations as they arise. It is important that both parents and the school be closely consulted and involved in this treatment.

Watch this discussion on MedHeads

Exercise is for all

‘Exercise not only improves our well-being as we get older, but it can also potentially reduce our biological age by 8.8 years!’

In this episode of Lifestyle Matters, we review the importance of exercise as we get older and briefly touch on the significance of exercise in people with disabilities.

Exercise and individuals above the age of 65:

It is common knowledge that exercise is important for our well-being, but many retirees wonder why they need to exercise after slogging it out for years. I frequently hear retirees ask rhetorically, ” Is this not the leisurely part of life?”.

Indeed, it is true that life in retirement is meant to be leisurely but to reap the benefits of those years and truly enjoy ourselves, the body needs to be physically fit. Exercise has been shown to increase life expectancy. Our DNA strands are protected by telomeres. Telomeres shorten as we get older due to fraying. However, it appears that exercise can in fact lengthen these telomeres which translates to a biological age of up to 8.8 years younger.

First, let us understand the effects of ageing. Some of these effects or changes are inevitable due to the physiological changes that happen in our bodies as we age.

Some of the changes include:

• Sarcopenia i.e. progressive loss of muscle bulk

• Osteopenia i.e. progressive loss of bone density

• Reduced joint flexibility & mobility

• Reduced cardiorespiratory reserve

• Reduced balance and coordination

• Increased susceptibility to mood disorders – multifactorial

However, these can be slowed down with exercise!

“The recommended guideline for individuals above the age of 65 years is 30 minutes of moderate intensity exercise per day on most days or, if feasible, all days. Include the different types of exercises as listed below if possible”

Each exercise category listed below has its own benefit for example, resistance training helps improve bone density and muscle mass whereas aerobic training increases our cardiorespiratory fitness.

Hence try incorporate 1 from each group:

• •Aerobic Training: walking, jogging, swimming, golfing (without the use of a golf cart, of course)

• Resistance Exercise: push-ups on the wall, climbing stairs, lifting groceries / grandkids, ½ squats holding the back of a chair, wall-sits etc

• Stretch / flexibility: Tai Chi ( my favourite as it also improves balance, coordination and cognition), heel raises, hamstring stretches

• Balance: One legged stand- start off with holding on a chair / table, step ups

Consulting an Exercise Physiologist is especially important if one has any physical or medical limitations. Safety is paramount hence I would recommend the use any hearing / visual aids if needed. You must also ensure adequate lighting is available and always use comfortable clothes and supportive shoes to make the exercise more enjoyable and effective.

Exercise and disability

¾ of people with a disability do not meet current guidelines. These guidelines are the same as the age-matched guidelines and should be modified based on a person’s disability. It is extremely important for this to occur as disabilities can come with their own set of cardiorespiratory/metabolic/bone/muscular/joint complications and to decelerate these, exercise can be a huge value added.

Once again, an Exercise Physiologist can be accessed through a variety of systems and one of the easiest ways to do so in Australia is through the National Disability Support Scheme (NDIS)

Apart from all the above benefits, exercise not only increases the likelihood of us getting some sunshine and fresh air, but it also provides us opportunities to increase our social network.

In this episode of Lifestyle Matters, we discuss tools to use when choosing a diet and what a weight loss plateau is.

Over the upcoming weeks, we will be reviewing the various diets that are out there from a medical perspective.

 The purpose of today’s blog is to introduce how beneficial diets can be to our lives when chosen correctly. However, the first dilemma most face is: “How do I choose the right diet?!!” We hear you; it really is quite overwhelming to find that there are over 100 diets out there! So many of these diets are ‘in trend’ and promoted all over social media. For example, just because the Ornish diet worked well for Bill Clinton, it does not necessarily mean it will work for all.

 So, how do we choose a diet? The most important factor is sustainability. Some can follow a rigorous calorie restricted diet to lose weight, but this is rarely sustainable.

Other factors that we should look at when choosing a diet so that it is sustainable includes:

• Cultural factors – it can be hard to make a change if rice / pasta is a staple in our diet

• Social and family support – it is always easier when our social circle is supportive of our choices

• Lifestyle – e.g. work type / hours which can impact our ability to meal prep thus requiring us to become more creative

• Budget – making smart choices when buying fresh foods as some can be more expensive

• Underlying medical conditions – may restrict or advocate certain foods Nutrigenomics

When we follow a diet, calorie restriction is only inevitable which then results in weight loss. However, a weight loss plateau can occur over 6-12 months. One of the potential causes for this is the reduction of our basal metabolic rate when we reduce our calorie consumption. A 10% reduction in calorie intake can result in up to a reduction of about 12 % in basal metabolic rate! This happens as our bodies adapt to the reduced calorie intake.

 So, if we continue to consume the same number of calories with a reduced basal metabolic rate, our weight will naturally remain static or increase. Many people tend to perceive this stagnation or increase in weight as a failure on their part which is incorrect. This phase can be overcome with some simple changes and a positive mindset which include:

• Increase or change exercise intensity / style

• Increase Non-Exercise Activity Thermogenesis e.g. park the car further from the shops, take the stairs instead of the lift etc.)

• Make a caloric reduction in diet

• Increase water consumption

• Re- look at our stress level

• Ensure we get the recommended 7-9 hours of sleep

There are many studies demonstrating the benefits of a whole foods plant-based diet for our health. Furthermore, processed red meat has also been classified as a Group 1 carcinogen by the World Health Organisation. Red meat is a Group 2a carcinogen which means it probably increases the chances of cancer in general especially bowel cancer.

 As GP Lifestyle Medicine Practitioners, we advocate eating whole foods that are predominantly plant-based, for a variety of health and environmental reasons.

In this episode of Lifestyle Matters.

Can the Mediterranean diet truly help reduce our risk of cardiometabolic, neurodegenerative and cancer related diseases? Does it truly live up to all its glory?’

This week, we focus on what the Mediterranean diet is and the evidence behind some of its benefits.

The ‘true’ form of the Mediterranean diet (MedDiet) is very different from what we know of it today. The classical form of a MedDiet is a whole- foods plant based diet rich in MUFAs and PUFAs, legumes, beans and wholegrains with moderate consumption of red wine with little saturated fat.
(The Australian Guidelines recommend no more than 4 standard drinks / day, capped at 10 standard drinks / week)

The food pyramid below gives us a general overview on the diet:

This diet was popularised in the 60s by Ancel Keys who conducted the Seven Countries Study in which he studied lifestyle factors that affect our risk of developing heart disease.

He demonstrated that hypertension, hypercholesterolemia, and diabetes are undoubtedly risk factors for heart disease. In the same study he also discovered that a diet high in fibre, MUFAs and PUFAs along with low sugar intake i.e < 25gram / day can reduce risk of heart disease and all-cause mortality. This is exactly what the MedDiet is all about.

Other studies, including the Lyons Diet Heart Study, looked at the protective effect of the MedDiet which demonstrated protective heart effects of the diet such as a 73% relative risk reduction for fatal and non-fatal heart attacks , 70% relative risk reduction for overall cause mortality , and significant risk reductions in developing clots in the lungs and legs.

The Predimed Study was another study showing a possible link between high consumption Extra Virgin Olive Oil (EVOO) and risk of breast cancer reduction. Both olive oil polyphenols and Oleuropin have been implicated in this.

Other potential benefits that have been investigated and demonstrated through various studies include:

• A 50% lower risk of all-cause cancer mortality in certain cancers including prostate, colorectal, head and neck cancers, gastric and pancreatic cancer

• Reduction in neurocognitive disorders such as dementia, Alzheimers Disease

• Improve diabetes control – Hba1c reduced from 0.1-0.6% almost comparable to some pharmacological interventions

• Reduction in the risk of progression to Metabolic Syndrome

• Weight loss

Our awareness of the benefits we can gain from the MedDiet are increasing. This coupled with the fact that it is certainly not a difficult diet to follow, makes this diet quite favourable.

In this episode of Lifestyle Matters.

Can the Mediterranean diet truly help reduce our risk of cardiometabolic, neurodegenerative and cancer related diseases? Does it truly live up to all its glory?’

This week, we focus on what the Mediterranean diet is and the evidence behind some of its benefits.

The ‘true’ form of the Mediterranean diet (MedDiet) is very different from what we know of it today. The classical form of a MedDiet is a whole- foods plant based diet rich in MUFAs and PUFAs, legumes, beans and wholegrains with moderate consumption of red wine with little saturated fat.
(The Australian Guidelines recommend no more than 4 standard drinks / day, capped at 10 standard drinks / week)

The food pyramid below gives us a general overview on the diet:

This diet was popularised in the 60s by Ancel Keys who conducted the Seven Countries Study in which he studied lifestyle factors that affect our risk of developing heart disease.

He demonstrated that hypertension, hypercholesterolemia, and diabetes are undoubtedly risk factors for heart disease. In the same study he also discovered that a diet high in fibre, MUFAs and PUFAs along with low sugar intake i.e < 25gram / day can reduce risk of heart disease and all-cause mortality. This is exactly what the MedDiet is all about.

Other studies, including the Lyons Diet Heart Study, looked at the protective effect of the MedDiet which demonstrated protective heart effects of the diet such as a 73% relative risk reduction for fatal and non-fatal heart attacks , 70% relative risk reduction for overall cause mortality , and significant risk reductions in developing clots in the lungs and legs.

The Predimed Study was another study showing a possible link between high consumption Extra Virgin Olive Oil (EVOO) and risk of breast cancer reduction. Both olive oil polyphenols and Oleuropin have been implicated in this.

Other potential benefits that have been investigated and demonstrated through various studies include:

• A 50% lower risk of all-cause cancer mortality in certain cancers including prostate, colorectal, head and neck cancers, gastric and pancreatic cancer

• Reduction in neurocognitive disorders such as dementia, Alzheimers Disease

• Improve diabetes control – Hba1c reduced from 0.1-0.6% almost comparable to some pharmacological interventions

• Reduction in the risk of progression to Metabolic Syndrome

• Weight loss

Our awareness of the benefits we can gain from the MedDiet are increasing. This coupled with the fact that it is certainly not a difficult diet to follow, makes this diet quite favourable.

In this episode of Lifestyle Matters.

This week, Dr Ferghal and I explore the ‘Portfolio Diet’; known for its effectiveness in lowering LDL i.e. ‘bad cholesterol’. This diet is said to be as effective as Lovastatin, which is a cholesterol lowering medication!

Before exploring this further let us gain a basic understanding of what Cholesterol is. Cholesterol is an essential waxy substance in our body that is needed for a variety of important functions including making hormones, building cells, and protecting our brains.

However, it often gets bad reputation, and this is largely due to the LDL (low density lipoprotein) which is the molecule that sticks to damaged parts of our blood vessels. This causes a variety of other cells to latch on to it which eventually forms plaques which can break off at any point and potentially obstruct blood flow to our heart. This obstruction leads to heart attacks.

HDL (high density lipoprotein) on the other hand is a molecule that scavenges excess cholesterol through our body and shuttles it to the liver to get excreted. Hence it is often referred to as the ‘good cholesterol’.

The Portfolio study demonstrated a 30.9% LDL reduction in the cohort that received Lovastatin compared to 28.6% who were on the Portfolio diet. This difference is not clinically significant.

So what exactly os the Portfolio Diet?

• High plant protein – soy – 50gm/ day

• High nuts & seeds – 50gm/ day

• High viscous fibres 10-25gm/ day

• High plant sterols – 2gm/ day

 It is a diet very rich in fibre and would achieve the current recommendation of 40gm of fibre / day in women and 45gram/day in men which most of us do not usually consume.

How does the Portfolio Diet improve LDL levels?

• High fibre: Especially soluble fibre. e.g. fruits, vegetables and oats do not get absorbed in the intestines. Instead, they bind to cholesterol molecules thus reducing its absorption

• High plant sterols : These compete with cholesterol absorption in the gut thereby cholesterol absorption is reduced

But what are plant sterols?

These are naturally occurring cholesterol substances at low levels in plants and fruits. Unfortunately, it is not easy to get enough through our diet hence margarine spreads that are high in plant sterols are recommended.
There has been little evidence supporting this hence the Heart Foundation Guidelines have also recommended consumption of 2-3gm plant sterol / day.

Other potential benefits of this diet include reducing insulin resistance and blood pressure. A study demonstrated a 2 % reduction in blood pressure at 24 weeks compared to the DASH diet (Dietary Approaches to Stop Hypertension) which is quite astounding since this diet’s primary aim was not to reduce blood pressure.

This is undoubtedly not an easy diet to follow but if one can adhere to it strictly, there are certainly many benefits to gain.

In this episode of Lifestyle Matters.

The highs and the lows of the “Low Carb High Fat” diet.

Many people tend to subscribe to the famous “Low Carb High Fat” diet and others swear by it but a pertinent question to ask is whether these individuals do it well or if they are successful? Can the diet really improve diabetes control?

This week on Lifestyle Matters, Dr Ferghal and I take a deeper dive into the “Low Carb High Fat” diet”.

Before insulin was discovered in the 1920s, a low carbohydrate diet was commonly prescribed to patients with diabetes. The logic was that the lower the carbohydrates consumed, the lower the glucose levels in our bodies. The prescription of this diet for diabetes control persisted despite the discovery of insulin! They were not wrong; there have been many studies demonstrating the efficacy of this diet in weight loss and reduction in insulin resistance. Insulin resistance is one of the underlying factors in the development of diabetes.

When we eat carbohydrates, these get broken down into sugar molecules which then triggers off insulin release for it to be taken up by our cells. If we have diabetes, insulin does not work very effectively, thus our glucose (sugar) levels rise. So, we can see why a low carbohydrate diet was prescribed for diabetes control.

However, long term studies have shown that this diet is not as sustainable as we may think it is. Further, their potential adverse effects from this diet which we will explore below.

Firstly, let us study the amount of energy we should obtain from various macronutrients.

As seen in the chart above, 45-65% of energy intake = 225-325gm of carbohydrate / day.

There are a few different types of low carb diets:
• Very low: 20-50gm of carbs/ day (most effective, almost ketogenic)
• Low: < 130gm / day
• Moderate: < 230gm/ day

The reality is this; it is not easy to sustain a very low carbohydrate diet beyond 6-12 months. Many people fall back onto a low and moderate carbohydrate intake which does not produce results as effective as a very low carbohydrate diet. Further, people tend to increase their protein intake while on this diet which commonly is achieved through a higher meat intake i.e. saturated fat.

We know red meat have other detrimental effects to our health as it is classified as a Group 2A Carcinogenic Food by the World Health Organisation.

It is imperative to keep the saturated fat to < 10 % if one were to follow this diet. This is also extremely important for those who suffer with hypertriglyceridemia (where their triglycerides > 500 mg / dL ) as the ability to remove triglyceride enriched lipoproteins are saturated and can lead to pancreatitis. This shows the indirect effects of going on a low-carb diet.

There are other adverse outcomes from consuming a low carbohydrate diet over long term such as:

• Osteoporosis: Various mechanisms have been identified in rat models (watch this space!)
• Deficiency in vitamins and minerals: Dietary fibre, Magnesium, Phytochemicals that are usually found in complex carbohydrates.

In summary, the key message from this is that if a low carbohydrate high fat diet suits one’s lifestyle it is a reasonable choice as it certainly does demonstrate several benefits. However, due to issues with its sustainability and potential negative implications on our health, it may make it less than an ideal diet to stick to beyond a year.

In this episode of Lifestyle Matters.

Can we generate a super fuel in our bodies by eating differently? This week we look at the popular keto diet from a medical perspective.

This diet was originally founded in the 1920s by Russel Wilder to treat epilepsy and it worked! Once anti-epileptic medications were discovered, this diet became less popular until recent times when it became evident that it also helps with weight loss. Truth be told, this diet is still used for some refractory epileptic patients under medical guidance.

A keto diet is essentially a diet we consume to put our body in a state of ketosis. But first, what is ketosis? To understand that we must understand what ketones are.

Ketones are products of fatty acid breakdown e.g., acetoacetate, beta hydroxybutyrate and acetone. These molecules are continuously produced in our bodies in small amounts as part of normal physiological processes.

Ketosis or ketogenesis is a process when our body uses these ketone bodies to provide energy for our cells.

When we eat a well-balanced diet, our body uses carbohydrates as the main source of fuel. So, reducing our consumption of carbohydrates and increasing protein (amino acids) and fat intake allows our body to break down these macronutrients to provide us with energy via processes called gluconeogenesis and ketogenesis respectively.

Ketosis can also happen as part of disease processes e. g . starvation, alcoholism, poorly controlled diabetes and even extreme prolonged exercising. This is obviously dangerous to our health and requires treatment.

Most cells in our body can utilise ketones as a source of energy except our red blood cells and liver. The brain is really good at doing this!

This is how a Keto Diet looks like:

Ketones are called a super fuel because:
100 gm of glucose we can generate 8700 gm ATP
100gm of beta hydroxybutyrate generates 10 500 gm ATP
100gm of acetoacetate generates 9400gm ATP

Apart from being a super fuel, it has various other benefits such as:

• Treating difficult to control epilepsy

• Reduce the risk of neurodegenerative conditions e.g. Alzheimer’s Disease

• Reduces insulin production

• Increases leptin levels (hormone that tells us we are full hence suppressing our appetite) -> weight loss

• Reduces LDL, TGL

• Increases HDL

However, there are some limitations to the Keto diet that suggest that it may not be suitable for everyone.

Those who have certain enzyme deficiencies e. g. pyruvate kinase deficiency, liver failure, and pancreatitis, should not be on this diet due to the high levels of fat and protein intake. There has been also some research to suggest this diet may result in osteoporosis, kidney stones, fatty liver and gout. Further, most studies on the Keto diet have only been conducted over 6 months which means the long-term implications of the diet are still being investigated.

The main point to note is that this is undoubtedly a great diet to follow if it suits one’s lifestyle provided there are no medical contra-indications to it. However, once again it is a diet that we would suggest one to adhere to for a short period (6-12 months) as we have sufficient evidence to support this recommendation, for now at least. Post that period, transitioning to a normal well-balanced diet would be advisable. Ideally, following a whole food predominantly plant-based diet would produce the best outcome.