Spectator Health February 2015

21 FEBRUARY 2015

THE CASE FOR E-CIGARETTES Vaping saves lives, says Derek Yach

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PRE PRESS

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elcome to this, the fourth edition of Spectator Health. In this issue our cover piece is by Derek Yach, defending e-cigarettes. Dr Yach has been a Professor of Global Health at Yale University, and executive director at the World Health Organisation. E-cigarettes have caused considerable debate within the medical community and have very much polarised opinion. Dr Yach provides a solid, reasoned case for why — despite all the scare stories you might read about them in the press — they should be welcomed as a healthier alternative to smoking cigarettes.

Also in this issue we have a world authority on eating disorders, Dr Eric Johnson-Sabine, giving his expert view on this group of conditions. With the help of the charity Prostate UK, Victoria Lambert has written an in-depth guide to prostate screening. We also have Dr Carol Cooper writing about pulmonary circulation and Dr Laura Corr, a consultant cardiologist, has a guide to how to eat your way to low cholesterol. We’ve also got Lord Coe writing about the legacy of the Olympic Games, while geriatrician Dr Trisha Macnair gives her advice on choosing a nursing home for yourself or loved ones.

And of course we have all our usual columnists, including Tom Chivers, Theodore Dalrymple, Christine Webber and David Delvin, Ian Marber and Maureen Lipman.

Remember that as well as the supplement that comes free with the Spectator magazine, Spectator Health is also online at spectator.co.uk/health. Do continue to email, write and tweet with your thoughts and views about the magazine.

Max Pemberton Editor Max Pemberton Design and art direction Sasha Bunch Cover illustration David Humphries Advertising Jemma Rossiter Tel: 020 7961 0217 Email: jrossiter@pressholdings.com Supplied free with the 21 February 2015 e ­ dition of The Spectator www.spectator.co.uk The Spectator (1828) Ltd, 22 Old Queen Street, London SW1H 9HP, Tel: 020 7961 0200, Fax: 020 7961 0250

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No.04 2015

Contents

Regulars

Features 8-10

12-13

The case for e-cigarettes What’s so bad about vaping?

Derek Yach

Focus on backs

14-16 Life after high cholesterol You don’t have to become a monk Dr Laura Corr 18-19

6-7

22-24 Prostate of the nation Should all men over 50 be tested?

Victoria Lambert

Check up Health in the headlines

12-13 Personal view Lord Coe on exercise and the Olympic legacy 40

26-28 From bingeing to bulimia An expert guide to eating disorders Dr Eric Johnson-Sabine

Spa review Vidago Palace, Portugal

29 Cold comforts Keep sniffles at bay Dr Roger Henderson

Opinion 17

Second opinion Theodore Dalrymple on hypochondria

21

Bad Medicine Tom Chivers on reading books under the blankets

32

What to eat Ian Marber on the right amount of protein

41

Sex and relationships Christine Webber and Dr David Delvin on what women want in bed

42

Well worried Maureen Lipman on the cure for migraines

Nursing home truths How to choose the right place Dr Trisha Macnair 33

Spines explained Dr Rob Hicks

36

Treatments for pain Sophia Martelli

38

Q&A Mr Damian Fahy IN ASSOCIATION WITH VITALITYHEALTH

30-31 An overlooked ailment Dangerous PH is hard to diagnose Dr Carol Cooper

30 - 31

14 - 16

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Check up We take the pulse of the health stories hitting the headlines The new flu picks on senior citizens ● Cases of flu in the UK

are on the up, according to the latest official figures.

Statistics from Public Health England show that doctors and hospitals have reported significant weekly increases in the number of patients they are treating for flu. This winter, the age of eligibility for a free preventative NHS flu jab was extended: it’s now offered to children aged four, as well as pregnant women, young babies and the elderly.

Doctors have identified the main virus circulating this winter as influenza A type H3N2, which tends to affect elderly people more than others. This could explain why hospitalisations have risen, because flu can trigger respiratory and other health problems in older individuals.

For more information on colds and flu, read Dr Roger Henderson’s no-nonsense guide on page 29.

according to a recent study, contracting the disease is often down to pure bad luck. Researchers at Johns Hopkins University School of Medicine and the Bloomberg School of Public Health analysed different tissues and discovered that some cells mutate just by chance.

They found that a significant two thirds of all cases of cancer are due to bad luck because of the way an individual’s tissues mutate.

… to improve your chances, try this ● The turnover of cells takes

place at various paces in different parts of the body, meaning some organs and tissues may be more likely to be affected by cancer than others. However, it is important to remember that certain lifestyle factors can still contribute to the onset of cancer. Smoking accounts for approximately one fifth of all cases of the disease worldwide.

Additionally, excessive consumption of alcohol, being overweight and spending long periods of time in the sun can all increase a person’s risk of developing the life-threatening condition. Read Dr Derek Yach’s article in this issue (page 8) on why he thinks e-cigarettes might help bring down lung cancer rates.

Contracting cancer really is bad luck… ● It’s well known that people

can make certain lifestyle changes, such as stopping smoking, that will potentially reduce their risk of developing certain types of cancer, but

But is she using it right?

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Asthmatics never inhale —honestly

Migraines are worse than you thought

● A significant number

● People could be at a greater

of people who have been diagnosed with asthma do not receive adequate training on how best to use an inhaler, according to a new report.

Asthma still kills three people a day, so this finding matters.

The charities Asthma UK and Allergy UK are calling for improved training to be given to those diagnosed with asthma or serious allergies to ensure they are adequately equipped should they experience an attack. The study found that only 16 per cent of people knew how to use an epipen while just 7 per cent could use an asthma inhaler properly. For more information on asthma, including videos of how to use inhalers properly, look at Asthma UK’s website www.asthma.org.uk

risk of developing Bell’s palsy if they regularly experience migraines, according to a new study. Bell’s palsy is a condition that results in temporary weakness or paralysis of the facial muscles, often affecting just one side, creating a drooping effect. The onset of the illness has been attributed to facial nerves becoming compressed or inflamed in the past, while diabetes, high blood pressure and gender can all influence its development too.

However, new research suggests migraines could be to blame. It is thought that viral infections may lead to inflammation of the cranial nerves, triggering migraines, as well as Bell’s palsy.

Read Maureen Lipman on migraines on page 42.

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The new risks of reading in bed ● Did you get

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Our website can work wonders ● Have you had a look at the

Spectator Health website yet?

Well, it might just be good for your health. According to research published last month, older people who regularly use the internet are more likely to be able to manage their health by themselves as they age.

Using data relating to almost 4,500 participants of the English Longitudinal Study of Ageing from 2004 to 2011, doctors looked at the health literacy levels of over-50s living in England as they got older.

When the study began, 73 per cent of participants had adequate health literacy, with the score for this falling by one or more points for 19 per cent of people after six years.

It was noted that there was a gradual decline in health literacy as people aged,

meaning they were less able to make choices about their health at precisely the time in their life when they were most likely to need it.

Although factors such as low wealth, few educational qualifications and poor cognitive function all contributed towards declines in health literacy, rarely using the internet or enjoying a cultural activity also contributed to this fall. To keep abreast of the latest news and views on health, look at www.spectator. co.uk/health.

Health check

night, while also having potential long-term adverse effects on their health.

Backlit e-readers often contain ‘blue light’, which has been found to prevent the body from producing its usual levels of the sleep hormone melatonin. This type of light is also present in smartphones, tablets and LED bulbs. Blue light

Even more reasons to eat up your greens ● Nitrate, a chemical naturally

present in green vegetables such as spinach, celery and lettuce, has been discovered to have significant benefits for cardiovascular health in a series of studies. Doctors from the University of Cambridge and the University of Southampton have been exploring exactly how eating greens can be good for people, finding that not only can they aid with heart health, but they can also reduce a person’s risk of becoming obese and lower their blood pressure.

They found that this is because of the presence of nitrate in certain green foods, which can help to reduce the body’s production of the hormone erythropoietin.

This chemical is made in the kidneys and liver and regulates red blood cell levels.

In situations where the body is short of oxygen — such as at high altitudes or when a person

can disrupt a person’s body clock, particularly if it is shining directly into their eyes. The study found that those who read from a backlit screen took longer to fall asleep, did not sleep as deeply and were more likely to feel tired the next morning in comparison to when they read from a paperback. We’ll be covering sleep in the next issue.

has a cardiovascular condition — the organs increase their production of erythropoietin.

However, this can adversely affect the health, due to high numbers of red blood cells making the blood thicker, therefore potentially starving organs and tissues of oxygen, as blood can no longer flow through smaller vessels.

The investigation also revealed that greens can assist in turning ‘bad’ fat cells into ‘good’ fat cells. By converting potentially harmful fats, nitrate can help to prevent the onset of obesity, as well as type 2 diabetes. For more on nutrition and what to eat, read Ian Marber’s column on page 32.

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an e-reader for Christmas? They have become some of the most popular gifts as more and more people find them easy and convenient to use.

But according to a new study from a research team at Harvard Medical School, regularly reading from such a device can seriously impact an individual’s ability to sleep at

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E-cigarettes save lives I understand why health activists are so reluctant to trust them, says Derek Yach.

But the verdict is in — and it’s time to act

I

n the 1970s, a group of students in South Africa were planning a campaign against tobacco. I was one of them. We paid a visit to Rembrandt, the country’s leading cigarette manufacturer, to hear their side of the story.

They showed us shiny floors, introduced us to wellpaid employees of all races — a rarity in apartheid South Africa — and proudly described their extensive support for the arts, culture and the environment. We replied that this was great, but it failed to address the core issue: their products killed half their regular users and harmed many more.

So the campaign went ahead. For me, it was the start of decades of battles with tobacco companies that led to strong regulations in South Africa — and culminated in the World Health Organisation (WHO) Framework Convention on Tobacco Control, now in effect in almost 180 countries.

Along the way, I learnt to distrust every move by tobacco companies and felt fully justified when an inquiry, supported by WHO and the World Bank, declared: ‘Evidence… reveals that tobacco companies have operated for many years with the deliberate purpose of subverting the efforts of WHO to control tobacco use. The attempted subversion has been elaborate, well financed, and usually invisible.’

It’s not surprising that most people in public health strongly endorse the view of Dr Neil Schluger, a lung specialist and professor of medicine at Columbia University, that ‘If there ever was an industry that does not deserve the benefit of the doubt when it comes to protecting or promoting the public’s health, it is the tobacco industry.’ The industry’s deceptions have included the development of low-tar products and a crafty message suggesting that they did less harm. Years after their launch, however, research showed that low-tar cigarettes had exactly the opposite effect.

Now we have electronic cigarettes. Is this the latest ruse, or is it really an innovation we should welcome?

Let’s review the appalling statistics. There are about 1.3 billion smokers in the world and roughly

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It’s about as common for someone who’s never smoked to start vaping as it is for them to start using nicotine patches or gum

Our blanket approach to tobacco control is all wrong

six million smoking-related deaths every year. In the United Kingdom alone, smoking causes 80,000 deaths. That’s 18 per cent of all deaths. What’s more, for every death there are 20 smokers suffering from tobacco-related diseases, resulting in 450,000 hospital admissions each year. No other single cause of death and disease can so easily be prevented.

The WHO framework convention stresses the value of government-led measures: increasing excise taxes, banning all marketing and advertising, and promoting smoke-free workplaces. Early in its development, we invited tobacco company scientists to provide evidence that their harm-reduction measures were real and not merely marketing ploys.

Their responses were unconvincing.

At the same time, the first public evidence 21 FEBRUARY 2015 | SPECTATOR HEALTH

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A toxic legacy

emerged that, for decades, tobacco companies had a sophisticated understanding of the role of nicotine (see box). But they had failed to act on this knowledge and separate the harm caused by combusted tobacco from the ‘pleasure’ some people obtain from nicotine.

Let’s take a quick look at another tobacco product — one that’s never caught on in the UK. Snus is smokeless tobacco in a little packet that Swedes tuck against their gum in order to get a nicotine buzz. For many years, the increased use of snus versus regular tobacco has been a major factor in Swedish men having the lowest death rate in the European Union.

Indeed, death rates from all causes among European men are about 2.5 times higher than among Swedish men — thanks, in part, to snus. Also,

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Evidence that the tobacco companies knew of the importance of nicotine to smokers 50 years ago: — ‘Nicotine is addictive. We are, then, in the business of selling nicotine, an addictive drug effective in the release of stress mechanisms.’

17 July 1963, Brown & Williamson general counsel/vice president Addison Yeaman.

— ‘It is my conviction that nicotine … both helps the body to resist external stress and also can as a result show a pronounced tranquillising effect. … under modern conditions of life people find that they cannot depend just on their subconscious reactions to meet the various environmental strains with which they are confronted. … smoking has considerable psychological advantages and a built-in control against excessive absorption.

It is almost impossible to take an overdose of nicotine in the way it is only too easy to do with sleeping pills.’

29 May 1962, BAT memo ‘The Smoking and Health Problem’

as snus use has increased, smoking has decreased.

Snus was banned in all EU countries except Sweden (and Norway, which isn’t in the EU). In Finland, the ban slowed down the drop in smoking. In Norway, by contrast, snus consumption by adults rose from 4 per cent in 1985 to 28 per cent in 2012 — and overall tobacco use fell by 20 per cent.

What drove these changes? Tobacco advertising (including for snus) has long been banned in all three countries. Public health authorities speak out against all forms of tobacco, including snus. Nonetheless, consumers, influenced by price and information from social networks, have increased their use of snus.

So what has this to do with the emerging e-cigarette debate?

We’ve seen that snus is banned in most of Europe despite overwhelming evidence that it is harmreducing. And now e-cigs and other innovative ways of delivering nicotine without the dangers created by burning tobacco face the same challenge.

Traditionalists demand more of the same policies that have significantly reduced tobacco use: excise taxes, full implementation of smoke-free workplaces and more effective anti-smoking advertising. Longterm projections say this would reduce smoking in the United States from the current 20 per cent to 10 per cent by 2030. That’s welcome — but it still leaves millions of smokers at risk.

The call for higher excise taxes ignores rising concerns about their regressive impact on poorer and more-addicted smokers. It also ignores advances in the genetics of nicotine use, suggesting that half of all smokers may not respond to tax increases because of their need for nicotine. In other words, our one-sizefits-all approach to tobacco control is doomed to fail.

Action on Smoking and Health estimates that 2.1 million British adults currently use e-cigs. About one third are former smokers, and two thirds are still smokers. Meanwhile, regular use of e-cigarettes by children and adolescents is confined almost entirely to current and former smokers. Users claim that e-cigs help them stop smoking entirely (38 per cent) or reduce the amount they smoke (25 per cent). Robert West, professor of health psychology at University College London, reports that e-cig use by neversmokers is negligible and similar to that of nicotinereplacement therapy (NRT).

In recent years, the increase in the popularity of e-cigs has more than offset a decrease in NRT use. Successful attempts to quit smoking, although escalating, are still low, at between 5 and 7 per cent.

E-cigs could play a major role in helping those smokers most addicted to nicotine, who are shifting in increasing numbers from NRT products to ‘vaping’ as their means of quitting the tobacco habit.

Safety concerns were addressed recently. Two analyses reviewed toxicological, laboratory and clinical research on the potential risks. They concluded that e-cigs are by far less harmful than smoking, and that ‘significant health benefits are expected in smokers who switch from tobacco to e-cigs’. Yet

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ucontinued from page 9

governments and the WHO remain unconvinced about the benefits of e-cigs. There is deep distrust of tobacco companies. This is borne out by article 5.3 of the framework convention, which requires that ‘in setting and implementing their public health policies with respect to tobacco control, parties shall act to protect these policies from commercial and other vested interests of the tobacco industry in accordance with national law’ — i.e., avoid any interaction with tobacco companies. But this policy is impossible to implement in countries where democratic law-making processes require interaction with all stakeholders, or where the government owns a tobacco company.

Moreover, it limits the potential to make use of scientific discoveries by tobacco companies. At a WHO tobacco control conference last October, governments stressed the need to protect tobaccocontrol activities from all commercial and other interests. That effectively means not talking to researchers developing new and safer products. They also wanted governments to consider prohibiting or regulating e-cigs as tobacco products — which would be a huge boost to the deadly status quo.

The US Food and Drug Administration (FDA) has already announced its intention to regulate e-cigs as tobacco products. About $2.2 billion was spent on e-cigs in America last year, exceeding the amount spent on NRT but still representing a small part of the $85 billion cigarette market.

At the same time, however, the FDA seems to favour a transition away from lethal combustible products. Mitch Zeller, director of its Centre for Tobacco Products, wants us to look at nicotine differently. People ‘smoke for nicotine but die from tar’, he says, and new products represent a public health opportunity.

The FDA’s measured approach is in contrast to the continued unscientific approach of the US Centres for Disease Control and Prevention, whose director Dr Tom Frieden stated last year that ‘many kids are starting out with e-cigarettes and then going on to smoke conventional cigarettes’. They have yet to produce evidence that this is the case. In November, Penny Woods from the British Lung Foundation said ‘[new] data should again alleviate the fears expressed by some over an e-cig gateway effect’. Let’s spell this out. Unsupported statements are accepted as truth by policymakers and are used as the basis for stringent regulation of e-cigs in many jurisdictions.

This may well end up causing more public health harm than good. The benefits of e-cigs in helping smokers quit or cut down should be weighed against the danger of either recruiting new smokers or creating e-cig addicts. So far, there is no evidence that either of these things is happening. Studies in both Britain and America suggest that, as e-cig use increases, youth cigarette consumption declines.

Why are we in this position? One reason is that governments have become addicted to tobacco excise 10

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People smoke for nicotine but die from tar

tax and may fear that, as e-cigs take off, they will lose a valuable source of revenue. Many leading NGOs and academics exert strong influence at WHO, within governments, in the media and among the general public. In the past, they helped bring tobacco control out of the shadows and into the mainstream of health policy. Now, alas, their intransigence threatens more profound progress.

We need clear, unambiguous messages to smokers about the safety and benefits of e-cigs.

An example is the March 2014 statement on the Royal College of Physicians website that ‘the main benefit of e-cigarettes is that they provide inhalable nicotine in a formulation that mimics the behavioural components of smoking but has relatively little risk…

Switching completely from tobacco to e-cigarettes achieves much the same in health terms as does quitting smoking and all nicotine use completely.

Furthermore… risks associated with passive exposure to e-cigarette vapour are far less than those associated with passive exposure to tobacco smoke.’

If influential health officials were to make these points repeatedly, public sentiment towards e-cigs would shift quickly. And this could be done at the same time as strengthening anti-smoking measures.

We should praise ‘good’ e-cig companies who commit to safety, to avoiding youth marketing, and to making smoking obsolete. They need to be explicit about their long-term plans. Are they seriously committed to harm reduction, or introducing new products simply to delay progress and confuse policymakers, as many in public health believe?

From my meetings with major tobacco companies, it’s clear that they are hedging their bets. Some of them have indicated, in private, a long-term goal of moving out of manufacturing harmful tobacco products — but these statements are not enough to inspire trust. Tobacco companies’ intention to change must be stated publicly and backed by action.

Other market sectors need to adapt to the reality of e-cigs as a force for good. Retailers should voluntarily withdraw cigarettes from stores, or at least reduce their prominence, in favour of e-cigs and NRTs. CVS Health has yet to offer e-cigs, despite the fact that they work better than pharmaceutical products. Life insurers still treat e-cig users as regular smokers when they calculate premiums. This is shortsighted and misses a golden opportunity to spell out the benefits of quitting smoking and the positive impact of switching to e-cigs on people’s longevity.

At the moment, it’s estimated that there will be a billion tobacco-related deaths before 2100. That is a dreadful prospect. E-cigs and other nicotine-delivery devices such as vaping pipes offer us the chance to reduce that total. All of us involved in tobacco control need to keep that prize in mind as we redouble efforts to make up for 50 years of ignoring the simple reality that smoking kills and nicotine does not.

Derek Yach is executive director of the Vitality Institute and previously headed tobacco control at the WHO. 21 FEBRUARY 2015 | SPECTATOR HEALTH

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12/02/2015 14:39

Exercise is for everyone Personal view We must cherish the legacy of London 2012, says Lord Coe

T

he benefits of exercise are well documented. Whatever your age, there’s strong scientific evidence that being physically active can help you lead a healthier and happier life.

It can help you lose weight, reduces your risk of major illnesses such as heart disease, stroke, diabetes and cancer by up to 50 per cent, and lowers your risk of early death by up to 30 per cent. Research shows that physical activity can also boost self-esteem, mood, sleep quality and energy, as well as reducing your risk of stress, depression and Alzheimer’s disease.

From the very start, a core rationale of London 2012 was to ensure it provided opportunities for people across the UK long after the games finished and leave a tangible legacy reaching across the community, business, tourism and regeneration. A key part is to make sport and exercise accessible for all, from the enthusiast through to elite athletes.

Companies which backed the games have continued to support sport, particularly at grass roots level. Elite sport is also benefiting

from an increase in lottery and Exchequer funding from UK Sport. Funding for elite sport has increased by 13 per cent for the four years leading to Rio 2016, a 7 per cent increase for Olympians and a 45 per cent increase for Paralympians. The Prime Minister announced that government funding for Britain’s Olympic sports will be extended until the Rio Olympics in 2016. UK Sport will also receive £125 million per year. It had previously been announced that the estimated £40 million from the Exchequer for that funding would only be guaranteed until the end of 2014. UK Sport has set the very challenging target of winning more Olympic and Paralympic medals than the fantastic numbers achieved in 2012.

We also need to use this momentum and get the public on board by promoting the benefits of exercise and healthy lifestyles to those who were inspired by what they saw in 2012. Inactivity is the biggest threat to our wellbeing as a nation. We need to start at the very beginning and set lifelong good habits. The cornerstone of London’s bid was to inspire children globally to take up sport.

However, inspiring youngsters today is a tall order. A lot of young people live in a world of reality television and instant fame, which is the opposite of an athlete’s journey. Our challenge is to engage with young people in something that does not happen overnight. When a coach sees a talent in the swimming pool or on the running track he might explain to them, ‘You may not see much

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The benefits of exercise Energy

Selfesteem

Mood

Sleep quality

Boost

Reduce

Dementia

Stress

Depression

Running for life: Sebastian Coe in record-breaking form in 1979 and, below right, as he is now

development over the first five years, but I think you have talent, and if you apply yourself, you could be really good.’

But there is so much progress being made. I am lucky as I spend a lot of time seeing it first-hand and I know there is massive excitement and creativity. There are many organisations with a thirst for achievement. When I went to Stoke recently I saw people rowing and canoeing on Trentham Lake who wouldn’t 21 FEBRUARY 2015 | SPECTATOR HEALTH

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even have known that the lake existed two years ago.

The whole nation has to support this mission because it is a once-in-a-lifetime opportunity.

Marginal changes can make a difference and everyone needs to play their part. That’s the health lesson we need to learn, for ourselves and Britain as a whole.

The National Health Service obviously has an important role, but it is being weighed down by the cost of treating avoidable

Inactivity is the biggest threat to our wellbeing as a nation

high blood pressure, so there is work to be done.

Sometimes it is about one change you could make. These days I don’t train like I did when I was a professional athlete, but I keep my exercise up — running every other day, on a treadmill or around the countryside with my dog. I’ll try to build activity into my working day, too: walking between meetings rather than taking the bus. Not everyone can be an Olympic athlete. Indeed not everyone will take up a sport. But I believe everyone can find a form of physical activity they enjoy. You have to make adjustments but the changes don’t have to be dramatic.

So I was delighted to see the companies and employees who took part in Britain’s Healthiest Company playing their part, making changes to their lifestyles or encouraging good practice in the company as a whole.

I know from those hectic years vying for the right to hold the London 2012 Olympic Games, the preparations, the staging and lastly managing the legacy, that if you want to have a happy, healthy workforce, then you need to encourage everyone to do the best they can, and support them too, to achieve a healthy work-life balance.

My main hope for the Olympics is that people will challenge themselves to do things they might never have done before. We can all help encourage this by reaching people in every area of their lives, starting when they are at school, through to the workplace and making facilities available for all in their local communities.

Lord Coe is Chairman of CSM Sport and Entertainment and the British Olympic Association, the Prime Minister’s Olympic and Paralympic Legacy Ambassador and a Vitality Ambassador.

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illnesses such as type 2 diabetes and cardiovascular disease.

The answer could be straightforward. According to work carried out by UK Active, just a 1 per cent increase in national activity could save the NHS up to £2 billion a year. And we now have a real opportunity to tackle the issue. Because this isn’t just a problem for government or local authorities — we need a co-ordinated effort across areas from transport to urban planning, as well as looking at nutrition and exercise. That’s why I helped launch the Moving More, Living More initiative to promote physical activity with government, local authorities and others earlier this year.

Companies can make a difference too and be part of this concerted movement towards improved health for all. As well as the vital funding they provide to make sport and physical activity accessible in the local community, they have a captive audience in their own staff. Many will spend most of their waking hours at work, so it’s the ideal setting to help embed healthy lifestyle changes on a very practical level.

Britain’s Healthiest Company, which is run by Vitality Health, highlights those companies that are doing their bit and are examples of best practice.

The project’s research among over 25,000 working people showed that employees tend to be overly optimistic about their current state of health; a third have three or more bad habits or risk factors but of these, 58 per cent believe they are in ‘good’ or ‘very good’ health, meaning they are less likely to have the motivation to change. Left unaddressed, these lifestyle risks ultimately develop into chronic disease, with around one in five employees already suffering from at least one lifestyle-related chronic condition such as heart disease, diabetes or

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Eat to beat

cholesterol Lobster is fine but go slow on the profiteroles, says Dr Laura Corr

H

e sat there, looking woebegone but resigned, and asked the inevitable question. ‘OK, Doc, so tell me — what mustn’t I eat?’ Freshly informed that his cholesterol was high, he awaited the mild note of concerned triumph in his wife’s voice as she pointed out that he really shouldn’t be eating steaks at his club and omelettes with three eggs (although egg-white-only omelettes were, she acknowledged, an Americanism too far).

As a doctor, it always gives me pleasure to be able to reassure someone that life will carry on, perhaps not regardless, but in a recognisably pleasant way after a health warning. Dietary advice about cholesterol is one easy way to achieve this, although in truth, I hide advice about life-enhancing diets under a guise of lowering cholesterol, because lowering cholesterol is not the be all and end all of the matter.

There is a fashion for cherrypicking epidemiological studies that raise questions, rather than provide answers, and then accusing scientific researchers of being

similarly biased, closed-minded and in the pay of shadowy plots by ‘big pharma’.

Controversy about the role of low-fat diets has arisen because cohort and randomised, controlled trials do not show a relationship between low-fat diets and deaths from heart disease. Many of these observational trials measured diets by a questionnaire only once at the beginning of studies that may have then followed subjects for up to 16 or 20 years, and few of the randomised trials studied what the subjects ate instead of the fat.

I do not intend to wade deeply into the fat-versus-sugar debate; both to excess seem bad.

Saturated fat consumption in the western world has been falling and age-specific death rates from cardiovascular disease have more than halved over the past 30 years, while sugar intake is rising and diabetes and obesity are widespread and growing, literally.

No, I want here to reassure readers that there is finally a gathering consensus about the best food patterns to follow for your heart and the good news

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The best food patterns do not ban eggs, meat or game

is that it does not ban eggs, lean red meat or game and positively endorses seafood, which includes lobster, scallops and oysters. It actually promotes fat in the form of extra-virgin cold-pressed olive oil and nuts — walnuts, hazelnuts, Brazil nuts, and even peanuts (which, I know, are not true nuts… please do not write in). It does not even ban cheese, although the acceptable amounts tend to be those served on the cheeseboard of a three-Michelin-starred restaurant rather than a hearty hunk of ploughman’s cheddar.

Add the known encouragement to eat lots of fibre (aim for double your present intake — this will almost certainly involve more hummus and beans) and plenty of fresh fruit and vegetables and that’s pretty much it. Milk, butter, full-fat Greek yoghurt — all are on the ‘OK in moderation’ list.

At this stage, the hapless patient is generally looking happier, although bewildered: he always understood that hearthealthy diets meant low-fat, low-cholesterol foods — how can everything he thought be so 21 FEBRUARY 2015 | SPECTATOR HEALTH

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On the menu

accusing a single food substance in our diet of being the culprit.

Carbohydrates which have been extracted and refined — table sugar, milled flour, even squeezed fruit juice — are rapidly absorbed by the body and produce an intense release of insulin to control the sugar levels in the blood; insulin drives the sugar into our cells and indirectly causes it to be stored as abdominal fat.

Consumption of refined sugars has exploded in the last decade, mostly in fizzy drinks and added to ‘low fat’ modified foods and readymade meals. But whole grains and the fibre in fruit slow down the release of sugar and dampen down the insulin response.

There is remarkably little evidence that a diet including foods containing high levels of cholesterol, such as eggs or prawns, puts up cholesterol levels and there is absolutely no compelling evidence that it is bad for cardiovascular health. This may seem counterintuitive but makes sense, as cholesterol is an essential element in the body.

wrong? Well, not everything: pork pies, sausage rolls, doughnuts, fizzy drinks and crème brûlée — there are still foods that should be eaten rarely if at all.

But I do think the ‘experts’ need to raise their hands here — not because of some sinister plot by the food or pharmacological industry but because, in spite of good intentions, postwar dietary advice went too far in the promotion of the ‘low fat’ diet and did not focus sufficiently on what was eaten instead.

The excitement of the past few years, which has spawned so many books on the errors of the low-fat diet, is principally based on very large epidemiological studies following populations over 20 or more years, which suggest that avoiding fat but substituting refined carbohydrates like pasta, bread and sugar does not lower heart disease rates.

This raises a question — why promote wholegrain bread and fruit that is full of sugar when ‘carbs’ are the new evil? I hope we do not fall into the same trap, as with fat, of

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It is the principal constituent of the bioactive membrane around all 37 trillion cells in the human body as well as the main constituent of the myelin sheaths insulating our nerves (30 per cent of all the cholesterol in the body is contained within the brain).

What’s more, the body needs cholesterol to manufacture sex and stress hormones — testosterone, oestrogen and cortisol — as well as vitamin D. So life would be a dull, drab affair if we didn’t have it.

It is precisely because cholesterol is so important that we are capable of making it ourselves, mostly in the liver. On a typical diet, we make about 75 per cent of our cholesterol and get the remaining 25 per cent from our food but we can make all of it, if necessary, even on a cholesterol-free diet. The amount is determined to a great extent by genetic predisposition; for the majority of us the more cholesterol we eat, the less our livers produce.

Similarly, if we eat less, we make more. I say the majority of us because our response to

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Off the menu

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cholesterol in food is also largely genetically determined; around 30 per cent of the population, known as ‘hyper-responders’, do not make this adjustment and for them, not eating cholesterol may lower serum cholesterol levels.

But even in them, this is not to say that dietary cholesterol is bad; the story is more complex than a simple number. Cholesterol measured in the blood is reported as ‘total serum cholesterol’, the level carried in all the different forms within the blood. Since cholesterol is a waxy, fatty substance and blood is largely water, the body has to coat cholesterol in proteins to make it miscible with blood (a bit like adding mustard to an oil and vinegar dressing). The resulting ‘lipoprotein’ complexes have different functions in the body: low-density lipoprotein (‘LDL’) carries cholesterol from the liver to cells where it is needed and it is an excess of this level in the blood that is associated with the risk of early heart disease; on the other hand, high-density lipoprotein (‘HDL’) transports unused or excess cholesterol back to the liver where it is broken down or excreted into the gut as bile.

Eat nuts to avoid strokes and heart attacks

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This is the origin for the idea of ‘good’ (HDL) and ‘bad’ (LDL) cholesterol and it is self-evident that a number for ‘total cholesterol’ tells us little about risk. Food that raises total cholesterol levels may raise the HDL at least as much as the LDL and so pose little risk to health.

Even this paradigm is overly simplistic if you look deeper — nut intake seems to make the type of LDL change from small, dense and dangerous LDL to big, fluffy, less dangerous LDL — although all would still be measured as LDL — while a high intake of refined carbohydrates lowers HDL cholesterol and shifts the type of LDL towards the small, dense type, at the same time also raising insulin levels, promoting abdominal fat deposition and increasing body markers of inflammation and thrombosis.

One of the best dietary studies was the Predimed study carried out in Barcelona and published in the New England Journal of Medicine last year. In this study, almost 7,500 people aged 55 to 80 and at risk of heart disease were randomised to take one of three diets: a standard ‘low fat’ control diet; a Mediterranean diet (Med-diet) with added nuts

(30gm per person/day); and a Med-diet with added extra virgin olive oil (one litre per household per week). The study was stopped early, after less than five years, because those taking the Meddiets had 30 per cent fewer strokes, heart attacks and deaths from cardiovascular disease.

Participants in both Meddiet groups had reduced blood pressure, improved the lipid profile and diminished insulin resistance compared with those allocated to a low-fat diet, and the Meddiet had an anti-inflammatory effect, whereas mediators of inflammation increased after the low-fat diet intervention.

Much more work needs to be done to refine dietary advice and it is highly likely that it won’t be ‘one size fits all’. Perhaps we should try to avoid demonising any single food type but concentrate a little more on putting plenty of the good stuff into our supermarket trolley.

Then a steak at the club every week and a soft-boiled egg or two for breakfast is just fine.

Laura Corr is a consultant cardiologist at Guys and St Thomas’s Hospital. She works privately from 88 Harley Street, London W1.

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Second opinion

Curing hypochondria

For perspective on your anxieties, says Theodore Dalrymple, losing yourself matters more than finding yourself

T

hese days it’s difficult not to be ill. In fact, it’s impossible to be well. Few of us do not have, or at least indulge in, risk factors for catastrophic illness. My doctor is constantly badgering me (by computer-generated letter) to be screened for one or all of them, thereby to destroy my peace of mind if not to delay my demise.

For risk-factor medicine, a meal is a medical procedure. Just as John Stuart Mill thought that matter was the permanent possibility of sensation, so doctors are inclined to think of people as the permanent possibility of illness — or accident. In the long run, of course, they are right.

Surely there must be a condition known as health? But the World Health Organisation defines health as not merely the absence of disease, but complete — yes, complete — physical, psychological and social wellbeing. According to the WHO, then, there’s not a healthy man alive and never has been, at any rate not since prelapsarian times.

Between perfectionist notions of health and risk-factor medicine, it is surprising that we are not more hypochondriacal than we are. But even hypochondriacs are ill. They have the condition known to the Diagnostic and Statistical Manual of the American Psychiatric Association (Fifth Edition) as Illness Anxiety Disorder. The World Health Organisation’s International Classification of Diseases (Tenth Edition) describes hypochondriasis as follows: The essential feature is a persistent preoccupation with the possibility of having one or more serious and progressive physical disorders. Patients manifest persistent somatic complaints or a persistent preoccupation with their physical appearance. Normal or commonplace sensations and appearances are often interpreted by patients as abnormal and distressing, and attention is usually focused

upon only one or two organs or systems of the body.

This gives rise to the possibility of metahypochondriasis, for a patient might start to worry whether his worries about his health constituted illness anxiety disorder, thus starting an infinite regress of diagnosis.

Nor need the sufferer from this disorder actually be well, in the sense of having nothing wrong. All that is necessary is that his concerns be deemed excessive or disproportionate by his doctor. But, as the great physician and researcher into high blood pressure Sir George Pickering once said, a minor operation is an operation performed on someone else.

An unreasonable worry, for most of us, is a worry experienced by someone else.

According to the WHO, there’s not a healthy man alive and never has been There is no doubt that hypochondriacs are boring; you fear to ask them how they are in case they should tell you. But one cannot help but suspect that their excessive concern with the state of their health is a defence against something worse, an existential fear that life has no meaning beyond itself, and that therefore the achievement of health, the avoidance of illness, is the highest goal possible.

Certainly, our obsession with health, safety and security (which have replaced faith, hope and charity as virtues) is not proportional, except possibly inversely, to risk or threat. The hypochondriac is not assuaged by statistics that show that his generation is the healthiest that has ever lived, or that death does not lurk in every

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food and every product and every situation.

In the absence of a transcendent purpose in life, staving off death becomes allimportant. Hypochondriasis, then, is in part a religious or philosophical problem.

Few people are completely immune from the temptation to hypochondriasis, and a friend of a friend of mine, Mr Mark Wickham, former art master at Marlborough, developed an original and effective technique to combat it. Having reached the age at which minor aches and pains were to be expected, he found himself enumerating them to a friend of his who, having reached the same age, was likewise liable to such aches and pains. They decided that on meeting each of them should have five uninterrupted minutes of ‘organ recital’. Once it was over, the subject was forbidden; and they found to their surprise that their litanies of woe sounded ridiculous even to themselves. They started to laugh at their ailments, and felt much better for it.

This technique confirmed what I had long suspected: that it is far more important for people to be able to lose themselves that to find themselves. The ability to distance themselves from their own twinges and morbid thoughts is precisely what hypochondriacs lack.

To observe, but also to observe yourself observing: that is the trick. Once, when being mildly beaten by a Balkan policeman with a truncheon, I managed to think about how I was going to describe it, and I found thinking about it a considerable relief. There comes a point, of course, when such detachment is impossible: but by definition, almost, hypochondriacs have not yet reached that point. As Lord Bacon said, ‘It is a poor centre of a man’s actions, himself… That which maketh the effect more pernicious is that all proportion is lost.’

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Home shopping Don’t let choosing long-term care turn into a short-term panic, warns Dr Trisha Macnair

S

peed dating on morphine probably isn’t the best way to choose a long-term partner. But it’s a bleak necessity for many people looking for a care home. Incapacitated in a hospital bed by a sudden illness, such as a broken hip, that slams shut the door back to an independent life, they urgently need to find somewhere to support them in their final years. Even if their health has deteriorated more gradually, the problems that have left them in need of care tend to undermine their ability to search for the right home. So the task often falls to family or friends.

This domestic matchmaking involves finding a place where you feel understood, where you can easily relax but where your wounds can safely be exposed. Few people make clear plans for their final days long in advance of physical decline (apart from an occasional desperate cry of ‘whatever happens, don’t ever put me in a home’). So working out what would be the right home for someone else can be a challenge: ‘arranged marriages’ don’t always work.

The first imperative is to get finances clearly outlined. The principal question is whether the person will be paying for their care home themselves (‘selffunding’) or whether it will be funded by the local social services. Even if you’re self-funding, you are entitled to help from a social worker. They can guide you through the finances and advise about possible extra allowances. They are also an important contact if you become worried about the standard of care in the home you choose. AgeUK also has some useful advice, while in some areas care agencies provide a free service to help those seeking care (although they work on commission from the homes).

New funding arrangements coming in over the next couple of years, under the Care Act 2014, should consolidate what has become a confusingly complex system. Economics are increasingly driving the system

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Don’t just say, ‘Whatever happens, don’t put me in a home’

towards supporting people in their own homes for as long as possible. So don’t assume a care home is an inevitability. When it works well, there’s no doubt that care at home is a better option. However, it can take the logistics of a military manoeuvre to make the arrangements run smoothly.

Once a care home becomes necessary, there is the brutal question of how long the person is likely to survive and how much funding will therefore be needed. These are very difficult to predict although the medical team might give you a rough idea by looking at indicators of frailty such as poor mobility, frequent infections and multiple medications. A recent survey of Bupa homes found that the average length of stay was 801 days (although some longstayers skewed this — half of all residents had died by 462 days, but one lived for over 20 years). The median stay in a residential home was nearly 27 months but when nursing care was needed it was only about 12 months (i.e. when there was more serious disability). But patients often surprise — some go downhill quickly in a care home, perhaps losing the will to carry on, while others find a new lease of life in a place where they are supported and happy.

Exactly what to look for in a care home is as idiosyncratic as choosing a partner. The building and decor will matter to some and not a jot to others.

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conversation. Bingo nights may be a source of relish or revulsion. Some families move a parent to be closer to them. It works for a few but many feel isolated in an unfamiliar community. People with dementia do particularly badly when they are uprooted like this.

For those who can afford them, expensive options may be very tempting. Who wouldn’t love to live in a luxury hotel? Actually quite a lot of people, who find it oppressive to be living somewhere where they are scared about every crumb they drop on the floor (a lot of crumbs will fall in those shaky frail months).

Working in affluent Surrey I often see families who, wracked with guilt that they cannot take in a frail parent, look for glossy options. But when you are at your worst, a scruffy yet clean old building staffed by kind people may be far more soothing than wall-towall parquet and Wilton, with nurses who have crisp uniforms and starched attitudes.

And that really is the nub of choosing a care home — finding out what would indeed feel like home to you. You need to step through the door, poke around the facilities, hear the noise, smell the smells and get a feel for the vibe. On a broad scale, there’s a range to choose from — residential, nursing, dementia. The small details can make all the difference. Is there open visiting, do some people’s pets roam around, how are spiritual needs met? More important clues to the running of the home include staff turnover (often a good way to spot an unhappy home) and training,

Dr Patricia Macnair is a geriatrician, author and journalist.

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Communal fun and games: a grandmothers’ outing sets off from the East End, 1933

and the activities of the residents’ committee. AgeUK have some helpful checklists to guide you when looking at a home.

Once a home appears promising, check that it is registered to provide the level of care needed. And keep one eye on the future. If a resident becomes weaker, can they transfer within the same home from a residential to a nursing bed? Read the home’s contract and conditions and look at recent inspection reports by the Care Quality Commission (CQC — the independent body responsible for regulating and maintaining standards in health and adult social care in England). But don’t expect these to be a guarantee that abuse would never happen. The CQC has had a turbulent few years, criticised for failures in a number of cases, including abuse at Winterbourne View private hospital. It is now undergoing a major overhaul of the way it works.

But nothing can change the fact that things can go wrong, no matter how carefully you choose a home.

Sometimes it’s just a clash of personalities, but abuse in a care home is every family’s nightmare. It can take many forms, from physical to emotional or financial.

Be on alert for anything which doesn’t feel right.

Does your loved one look happy and bright, dressed in clean clothes and well nourished, or are they subdued, grubby or losing weight? Has behaviour changed, are they tearful or depressed? Clues to physical abuse include unexplained cuts, bruising or other symptoms but try not to jump too quickly to conclusions as the cause can be muddied. Very thin elderly skin can tear with the evening breeze, while spontaneous bruising may just be the result of taking anticoagulant drugs.

From the start you need to be clear about the official channels for making a complaint but it’s more important to find someone you can trust, with whom you can discuss worries informally at an early stage. If you dislike a member of staff, ask to speak to the home’s manager. It may simply be a matter of changing who works with each resident — we can’t all get on with everyone else. Other channels for complaints include the social services case manager, the local council or local government ombudsman (if it is a council-funded home) or directly to the CQC. You could also turn to the charity Action on Elderly Abuse, which has a UK-wide helpline.

If your concerns aren’t addressed adequately, starting looking around at alternative homes to help pin down your own feelings about what should be right. But striving to find just the right home can be fruitless. Like all marriages it takes work and ultimately will be a matter of compromise.

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12/02/2015 12:44

Bad medicine

An eye for a book

Does reading in dim light really damage your sight?

It’s frustratingly hard to know, writes Tom Chivers

I

t’s quite hard, growing up as a bookwormy kid. It’s rock and a hard place, Scylla and Charybdis (bookwormy, see?). On the one hand, you get called ‘Data’ by your friends’ older brothers, who go around repeating ‘Need more input... Need more input.’ On the other, you get told by your friends’ parents that if you keep reading your Terry Pratchett books when the light gets bad, it’ll hurt your eyes. I assume this experience is pretty typical.

Eyes, in fact, get top billing in a fair few old wives’ tales; certainly more than do livers or gall bladders. Presumably that’s because while no one can really see how their gall bladder is doing, changes in the function of your eyes are pretty obvious. So if someone notices that, say, a kid who reads after dark a lot later needs glasses — or a kid who sits too close to the telly, or spends too much time locked in the bathroom with a copy of the Littlewoods catalogue — then they assume that thing A caused thing B. A few of the myths we can fairly simply debunk. If masturbation caused blindness, there would be a global pandemic. Since a large percentage of teenage boys make it to adulthood in full possession of their eyesight, we can rule that one out.

Watching telly up too close is also, probably, not a problem. An article in Scientific American suggested that, in fact, the myth might have the causal arrow backwards — children who sat close to the telly did so because they couldn’t see it well when further away. If your child is pressed up against Peppa Pig, then it might be worth getting their eyesight checked, but not, most likely, because the telly is causing it.

The more difficult question arises with the idea that reading in dim light causes blindness. It’s always a complicated problem teasing out these sort of causal

relationships, because — as in so many of these situations — you can’t force a group of children to not read in order to compare them to the ones who do and see who has better eyesight after 15 years. There are natural experiments — compare children who read lots with ones who read less, and then try to work out, with careful analysis.

But there doesn’t seem to have been much research done, at least that I can find.

What there has been, interestingly, is a 2007 study by Rachel Vreeman and Aaron Carroll, published in the BMJ, into what medical myths were most prevalent among medical professionals. Among others — that your fingernails continue to grow after death; that eating turkey makes you drowsy — was the low-light claim.

Scientists can’t force a group of children not to read What the researchers found was that while reading in low light can strain your eyes in the short term, there was little evidence that it caused long-term damage. ‘The majority consensus in ophthalmology…’, it says, ‘is that reading in dim light does not damage your eyes.’

There was one review, by Douglas Fredrick, from 2002 and also in the BMJ, which suggested that the idea that ‘the idea that the way in which we use our eyes early in life can affect ocular growth and refractive error is gaining scientific credence’. He notes that in a study in the 1960s of 1,200 Eskimo people in Alaska, the local level of myopia was strikingly different among those who had grown up with little contact with the western education system, before the second world war, and those who grew up after. None of those 56 or above

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had myopia; 8 per cent of those 30 and up did; and 59 per cent of their children did.

Further, he points out that ‘people whose professions entail much reading… (lawyers, physicians, microscopists, and editors)’ are more likely to have myopia than the rest of the population. The usual claim is that more intelligent people are more likely to have myopia, but Fredrick suggests that link has been confounded by the fact that more intelligent people tend to read more.

Vreeman and Carroll are unswayed by that argument, pointing out, first, that ‘hundreds of online expert opinions conclude that reading in low light does not hurt your eyes’, and second that although myopia has increased over recent centuries, that doesn’t necessarily square with the fact that artificial light has become cheaper and more available, so fewer people have to read in dim light these days. Another group has pointed out that the Inuit myopia claims are somewhat confounded by the fact that the children in the study were those brought to the clinic by parents who were worried about eye problems, and so were not a representative sample.

As always with these complex issues, it’s hard to give a definitive answer. Probably, there’s no causal link between reading under the covers with a dying torch and losing your eyesight, but it would be foolhardy of me to rule it out. But more importantly: these days, does it matter?

Pretty much everyone wears glasses or contact lenses anyway, and they’re affordable and available; the skill of reading is hugely important to life chances; and frankly, glasses look good. Just check out my byline picture. If you’re stopping your child from reading when they’re actively trying to, out of concerns that they might need glasses later, I suggest you have your priorities backward.

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Should you take the prostate test?

Y

ou probably know your blood pressure numbers, have a fair idea of your weight, perhaps even your waistline, but — gentlemen only — hands up if you monitor your prostate specific antigen (PSA) levels? Unless you’ve had prostate cancer, chances are you won’t have a clue how much PSA is swilling around in your blood. Or even if you should know.

Yet PSA testing, which has now been around for nearly 45 years, is still one of the best indicators of prostate cancer currently available.

According to the most recent 13-year follow-up findings from the European Randomised Study of Screening for Prostate Cancer (ERSPC), published in The Lancet last August, screening men aged 55–69 with the PSA test resulted in a 21 per cent reduction in prostate cancer deaths, compared with a control group who did not undergo screening.

And experts have advised men to be more PSA-aware, with one leading urologist, Roger Kirby, who was treated successfully for prostate cancer last year, suggesting that men over 50 should be much more proactive in asking for a test at their GPs. He said recently: ‘My advice to men over 50, especially those with risk factors such as a family history, is have a PSA test.’

The Department of Health’s policy however remains unchanged. While men over 50 have the right to a PSA test, following a discussion of the pros and cons with their GP, there are no plans for a national screening programme, unlike say for breast cancer.

Many men have been left baffled. If the test works, why can’t all over-50s get it routinely? They look to the US, too, where the PSA test is commonplace and often offered during routine medicals and at walk-in clinics.

‘PSA testing does have its place,’ says Dr Sarah Cant, director of policy and strategy at Prostate Cancer UK. ‘But you have to remember that it’s a test for prostate problems, not specifically cancer.

‘Of course we’d like a screening tool which could discern not only who has cancer, but also how aggressive it is, but the PSA is not designed to do that.’

Her words of caution echo those of Richard Ablin, the US scientist who discovered the PSA protein and created the test to measure the effectiveness of treatment for prostate cancer, and was shocked when he realised some urologists believed that it could be used as a non-invasive blood test.

He told me in 2010: ‘Had it

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PSA checks save lives but wreck them too, says Victoria Lambert

The risk is pointless and painful medical therapies

not been for the test, yes, some lives might have been lost. But, woefully, due to the PSA test, many, many more cancers have been detected that have not merited any treatment.

‘The majority of these patients, an estimated million in the US, could have lived painlessly with their tumours until the natural end of their lives. Instead, they’ve undergone pointless and painful medical therapies from surgery and radiation to even possibly chemotherapy.’

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Who needs a PSA test?

Need to pee more often, have trouble starting or finishing, feel pain when peeing or ejaculating, or see blood in your urine or semen?

Yes

No

ARE YOU OVER 50?

You have symptoms which may be caused by several prostate conditions (including benign diseases) but are possibly caused by a tumour growing in the prostate. If you are also suffering aches in the bones or hips, it is possible the cancer has spread outside the prostate gland. Do see your GP urgently for a PSA and other tests.

Yes

No

One in eight men are diagnosed with prostate cancer, most commonly aged between 70-74. But all men aged over 50 who have discussed benefits, risks and limitations of the test with their GP are entitled to one free on the NHS. So visit your GP for a discussion. Especially so if…

PIXOLOGICSTUDIO/SCIENCE PHOTO LIBRARY

MORE ABOUT YOU...

Are you black?

Men with an Afro-Caribbean heritage have a one in four chance of getting prostate cancer — we’re not sure why yet. And black men have been shown to be diagnosed five years earlier than white men on average so if you’re black and in your forties, it’s worth taking medical advice.

Consider female relatives.

Has your mother or sister had breast cancer (especially if they were diagnosed under the age of 60)?

If your mother or sister has tested positive for the BRCA1 or BRCA 2 genetic fault which is linked to breast cancer, it means you could be at higher risk of prostate cancer.

Did your father or brother have prostate cancer?

You are two and a half times more likely to get prostate cancer if your father or brother had it; and your risk may be slightly more still if that relative was under 50 when diagnosed, or you have more than one close male relative with prostate cancer.

Yes

Yes

Yes

You are at increased risk of prostate cancer so monitoring your PSA levels could be a good idea. Discuss it with your GP. For a more detailed online risk assessment, go to the NHS PSA test decision-making support site at sdm.rightcare.nhs.uk/pda/psa-testing/

And here lies the UK’s problem with PSA tests — the risk of overdiagnosis and overtreatment thanks to the false positives which it can throw up: three quarters of men with a raised PSA level won’t have cancer. (It can also miss cancers too — known as a false negative — one in seven, says Dr Sarah Cant.) According to the ERSPC study, a total of 781 men would need to be invited to screening and 27 to be diagnosed with prostate cancer to avert one death from the disease.

Which is not to say that doctors or the experts at Prostate Cancer UK don’t think the PSA test doesn’t have its place. As Sarah Cant explains: ‘PSA testing can highlight the need for further testing; at the moment, it is the best we’ve got.

‘But it can’t tell us if a tumour is benign or malignant, slow or fast growing. Some cancers are so nonaggressive that they won’t harm a man in his lifetime.

‘We need a smarter diagnostic test before we can consider

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the value of a population-wide screening programme.’

Research is under way for just such a test, but in the meantime, the US and Canada are coming round to the British way of thinking. The US Preventive Services Task Force (USPSTF) now recommends against PSAbased screening for prostate cancer, as does the American Cancer Society, which warns that PSA testing should only take place when men have been

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fully informed about the test’s uncertainties, risks, and potential benefits first.

The Canadian Task Force on Preventive Health Care concurred most recently, in October last year, with Dr Neil Bell, a member of the Task Force and chair of its prostate cancer screening working group, saying the potential for harm after PSA testing outweighs the benefits.

The same official view is taken in Australia, and in France, although PSA testing rates for men in the national health insurance scheme (which covers the majority of men over 40) are high. Meanwhile in Germany, PSA tests for prostate cancer screening are not covered by statutory health insurance funds, but many doctors offer the test as something that men can pay for themselves.

This doesn’t mean that prostate cancer diagnosis is at an impasse however.

Consultant urologist Mr Marc Laniado of Heatherwood Wexham Park Hospitals NHS Trust and Windsor Urology believes that we can get more from our PSA test at the moment — as long as it is not used in isolation.

‘It’s useful in the context of a risk calculator; if PSA levels are raised, then previously, men would be given a digital rectal examination (which can only

781 According to the ERSPC study, 781 men would need to be invited to screening and 27 to be diagnosed with prostate cancer to avert one death from the disease

21% Screening men aged 55-69 with the PSA test resulted in a 21 per cent reduction in prostate cancer deaths

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assess the back of the gland missing one in four cancers), followed by a biopsy, which often led to infection.

‘If that showed up cancer, then the whole prostate would be removed, often leading to side effects including impotence and incontinence, which were extreme, given that we still don’t know which types of tumour are most aggressive.’

But the latest work in radiology suggests that if a raised PSA level combined with an assessment of other risk factors including age, ethnicity and family history, is followed by a pre-biopsy multiparametric MRI, which can show how tightly cells are packed and how blood flows in tissues as well as the chemical makeup of tissue, then, says Mr Laniado, ‘We can weed out most people who don’t have important cancer, before deciding whether to do a biopsy or not.’

He adds that surgical techniques have improved too: ‘In the past we didn’t have a good way of doing it — it was all via the back passage and vulnerable to causing infection. But now, we can investigate with MRI-targeted biopsies performed through the perineum, which is much safer and more accurate.’

The National Institute for Health and Care Excellence (Nice) currently recommends that men who have had an abnormal result from a PSA test that led to a biopsy in which no cancer was found should in future be offered a multiparametric MRI before having another biopsy. Bupa, explains Mr Laniado, is about to insist on this for its clients.

Looking further ahead, Mr Laniado points to a refined version of the PSA test which should be available in the States soon, and here not long after.

Plus there is a new algorithmbased blood test being developed at Sloan Kettering hospital in New York, the world’s oldest and largest private cancer centre, by statistician Andrew Vickers. This test — called the 4K score — will, says Mr Laniado, be much more

accurate and identify men at high risk.

He hopes too that the rise of precision medicine and the discovery of biomarkers will make individual prognoses more accurate. Then there is the development of Prolaris, a novel genetic test for prostate cancer from Salt Lake City-based Myriad Genetic Laboratories, which combines traditional risk factors with a molecular assessment of the aggressiveness of an individual patient’s cancer. This says Mr Laniado might offer a better estimate of cancer progression than the current estimates which are based around the Gleason grading system used for all cancers.

It’s not just diagnosis that is improving: therapies are becoming more sophisticated such as focal treatments which can now target an area of cancer within the prostate and potentially end the need for radical prostatectomies, leading to fewer side effects such as loss of erection.

‘The whole landscape for prostate cancer has changed,’ says Mr Laniado. ‘There is lots of good news.’

Dr Sarah Cant agrees: ‘We’re funding research to find a better diagnostic test — I’d hope, with global support, we’ll see one in the next decade.’

Men United is Prostate Cancer UK’s movement for men. Anyone who believes men are worth fighting for is urged to sign up.

The growing army will be called upon to push forward real change that has a lasting impact on men’s health. With the help of this force, Prostate Cancer UK is pushing for more research to be channelled into finding a new diagnostic test and finding better treatments for men, as well as investing in this itself.

Search #MenUnited, spread the word to your friends and pledge allegiance to the cause which aims to keep those friendships alive.

Men concerned about prostate cancer or the PSA test can call Prostate Cancer UK’s specialist nurses on 0800 074 8383.

21 FEBRUARY 2015 | SPECTATOR HEALTH

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12/02/2015 11:29

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18/9/14 15:01:39

An expert’s guide to eating disorders What you need to know about anorexia, bulimia and binge-eating, by Eric Johnson-Sabine What are eating disorders?

Eating disorders are characterised by abnormal attitudes towards food that lead to a change in eating habits and behaviour.

The main eating disorders are anorexia nervosa, bulimia nervosa and binge-eating disorder.

Sufferers with anorexia nervosa restrict their diet and lose significant amounts of weight. Those with bulimia nervosa have bouts of binge eating followed by compensatory purging, usually by laxative abuse or vomiting. In binge-eating disorder, individuals overeat in binges but do not purge. People who binge eat regularly usually put on a great deal of weight.

In anorexia nervosa there is a preoccupation with eating and body weight.

Those affected tend to invest weight with abnormal significance and often experience anxiety when eating; sometimes, but not always, they overestimate their body size.

Anorexia nervosa is diagnosed when weight has fallen through dieting below a BMI of 17.5 (BMI — body mass index — is weight divided by height squared, i.e. weight adjusted for height. Ideal BMI is between 18.5 and 25; a BMI of above 25 is classed as overweight.)

People with bulimia nervosa can be of normal weight and therefore their symptoms often go unrecognised. The episodes of bingeing and vomiting frequently occur in secret. The conditions often overlap and people can start with symptoms of anorexia and later develop bulimic symptoms. Some people have an atypical eating disorder where they have some, but not all, of the typical features of anorexia or bulimia.

Do these conditions have any common features?

Using the intake of food as a means of coping with stress or mood disturbance is a shared characteristic of all the eating

Anorexia has the highest mortality of any mental illness

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disorders. People with anorexia have a powerful sense of agency over their bodies when they control their sensation of hunger. This can be a huge relief if external events are anxiety-provoking and out of their control. In treatment, if dietary restraint is relinquished, then it is essential to find other ways of coping with these difficulties. It follows that patients undergoing treatment for anorexia usually feel worse in the initial stages of treatment, until they have been helped to find other ways of dealing with their feelings.

People with bulimia often have a phase of dieting but they cannot maintain it and eventually ‘rebound’ into binge eating.

Binge eating can be provoked by stressful situations and has immediate anxietyrelieving effect. This is quickly followed by anxiety about potential weight gain that, in turn, is relieved by purging, through vomiting or excessive laxative use. The diagnosis is made when these behaviours occur at least once per week.

Additionally, individuals with anorexia and bulimia are often keen to exercise as a way of controlling their weight.

People are diagnosed with bingeeating disorder if they overeat in binges, on average, at least once a week for an extended period of at least three months.

The binge occurs in a discrete period of time when a large quantity of food is consumed. There are feelings of lack of control and sufferers usually feel guilty afterwards. The triggers are often the same as for bulimia but they suffer the additional perceived humiliation of weight gain. A depressed mood is particularly associated with binge-eating disorder but can occur with all the eating disorders.

How common are the eating disorders?

The rates for anorexia are approximately one in 250 women and one in 2,000 men.

The condition usually first develops in the 21 FEBRUARY 2015 | SPECTATOR HEALTH

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teen years. Bulimia is around five times more common than anorexia and usually develops at a slightly later age.

Binge eating seems to affect males and females equally and most commonly first appears in the thirties. Up to 50 per cent of patients undergoing bariatric surgery (gastric operations for weight loss) have binge-eating disorder.

What are the complications?

For anorexia, the complications are those associated with starvation. Females lose their periods and eventually become deficient in vitamins and minerals. They lose muscle strength, although only at a late stage of the illness, and their heart functioning is at risk. Their bones become demineralised and there is an increased risk of fracture. Those who have sustained low weight are at risk of further physical deterioration should they pick up an infection. The microbes causing the infection use up additional calories and in these circumstances there can be a significant deterioration.

Anorexia has the highest mortality of any mental illness and the outcome is worse if alcoholism is an accompanying disorder.

In bulimia the main complication is the biochemical abnormity that occurs as a result of purging, especially self-induced vomiting. The blood level of potassium falls and, as potassium is involved in its electrical conduction, this puts the heart at risk. If a patient has hypokalaemia (low potassium), she can experience palpitations and there is a risk of cardiac arrest. In milder cases, the main complications of vomiting are the enlargement of the salivary glands in the cheeks (hamster cheeks) and tooth decay from stomach acid.

In binge-eating disorder the main complication is obesity with its own health risks.

Investigations For anorexia, the other causes of low weight should be excluded e.g. thyroid disease or, rarely, adrenal gland insufficiency (Addison’s disease). In addition, patients with depression often suffer loss of appetite and lose weight.

What distinguishes them from patients with an eating disorder is that they do not have the preoccupation with weight and shape and fear of eating that is so characteristic of anorexia. Patients at low weight should have a check made of their bone density (a DEXA scan). There is a simple test of muscle strength — the ability to rise

Treatment options For anorexia, the majority of patients respond to outpatient treatment where attention is paid to obvious triggering factors. In adolescents, these include peer relationships, exam pressures, low selfesteem and stresses in the family. This, combined with a structured approach to increase dietary intake, is usually effective.

Younger patients can be helped with family therapy where the focus is to explore relationships and find solutions to conflict at mealtimes.

A minority of patients have a more severe and enduring form of the illness.

They have sometimes experienced traumatic events in the past. These patients may require inpatient treatment to halt weight loss and more intensive treatment to ensure weight gain.

In addition, different psychological approaches have been tried and can be useful but there is no one form of treatment that is particularly beneficial.

What is most important is that the therapist should have experience of eating disorders.

Patients disengage from treatment with doctors, nurses and therapists who lack experience of treating the condition.

Bulimia is usually treated with cognitive behavioural therapy (CBT) and response to treatment is very favourable.

More complex cases, especially where there are additional complicating mood or personality factors, require more specialised psychological treatment. In some areas CBT is available through the GP but specialist psychological treatment is usually only available from specialist eating disorder units.

Binge-eating disorder can also be treated with CBT, often provided on a group basis. The binge eating responds well to psychological treatment but overweight is usually unaffected and will require management separately.

Medication may be used to treat bulimia or binge eating. An SSRI (selective serotonin reuptake inhibitor) can be a useful adjunct to psychological treatment.

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unaided from squatting — that indicates possible physical decompensation.

For bulimia, the blood electrolytes should be checked to exclude hypokalaemia.

For binge-eating disorder, a check should be made of medical causes of weight gain. Drugs such as steroids, antihypertensives, anti-psychotics and insulin can be associated with weight gain.

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continued from page 27

Eating disorders in rarer groups Males Although anorexia is ten times less common in men than in women, the presentation is similar as is the response to treatment. There are a few differences.

Males are more likely to have a history of obesity, predating the development of the eating disorder. Men and boys with eating disorder tend to have the ideal of a weight lifter’s body shape. There is said to be a higher frequency of eating disorder in the gay male population. In addition, males with weight concerns are more involved in excessive exercise than females. When exercise continues in spite of injury, this has been described as an ‘activity disorder’. If the populations with eating disorders and activity disorders are added together, the sex difference narrows.

Older patients When anorexia was first described, it was believed that it could not occur for the first time in those aged over 35.

This is not the case but late onset is still uncommon. Marital difficulties are often triggering factors in the older patient. They may present with the first occurrence of

symptoms, re-emergence of symptoms, increased awareness and distress associated with persistent mild symptoms or significant enduring symptoms for which they have never before sought help.

The cumulative effects of many years of disordered eating may have eventually precipitated a health crisis.

Athletes In common with anorexia, psychological profiles of athletes have shown features of perfectionism, competitiveness, hyperactivity, repetitive exercise routines, compulsiveness, tendency toward depression, body image distortion and a preoccupation with dieting and weight.

Elite athletes have significantly higher rates of eating disorders compared with control groups. The highest rates are in the aesthetic sports of gymnastics, ballet and figure skating.

What should you do if you are concerned about someone who may have an ED? With anorexia, the difficulty is that sufferers may not acknowledge that there is a problem. It is important nevertheless to persuade them to see their GP. A good GP will be sensitive to the problem and refer on for specialists’ help. If the GP is

dismissive of the problem and just advises to eat more, patients are unlikely to seek help again until the situation is severe.

Relatives or carers can contact Beat, the main charity concerned with eating disorders, who can point them to support groups in their area. These groups offer general advice and specific support for families. There are also self-help books and websites that have useful information.

For sufferers with bulimia there is often relief in disclosing the symptoms to an empathic and experienced professional. A good outcome is often linked with being in a non-judgmental, supportive relationship.

Conclusion Anorexia nervosa was first properly recognised in the UK in 1873 and it was in this country that bulimia nervosa was first described 1979. The UK has always been at the forefront of treatment and research into eating disorders. We are fortunate that the treatment that is available in the UK is among the best in the world.

Dr Eric Johnson-Sabine is consultant psychiatrist in eating disorders at St Ann’s Hospital, north London. He works privately at Nightingale Hospital, London NW1.

SpECTATOr EvEnTS prESEnTS:

CAn AnyOnE SAvE ThE nhS? Tuesday 17 March | The Royal College of Surgeons, WC2A 3PE

It seems that all we hear these days is bad news about the NHS. From thousands of cancelled operations to 12-hour waiting times in A&E – does any political party have the ability to fix it? Or has the 70 year old institution had its day?

SpEAKErS InCludE • Andy BurnhAm, Shadow Secretary for Health • ChrISTInA mcAnEA, Head of Health, UNISON • dr mAx pEmBErTOn, Psychiatrist and Editor of Spectator Health • STEvE mElTOn, Chief Executive, Circle More speakers to be announced This event has been organised by The Spectator in collaboration with Pfizer.

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21 FEBRUARY 2015 | SPECTATOR HEALTH

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12/02/2015 11:30

The cure for the common cold…

Still hasn’t been invented, but Dr Roger Henderson has some sound advice for staving off sniffles this winter, and flu too

I

t’s that time of year — the weather gets cold, the heating gets turned up and my waiting room fills with sniffling patients. Unfortunately, most of them don’t need to be there as there’s no specific medical treatment for their colds and flu, but recent research carried out to support a Treat Yourself Better campaign (treatyourselfbetter.co.uk) really put some meat on the bones of this problem.

One in six adults said they would choose to visit their GP or local accident and emergency department as first port of call for their winter snuffles rather than seeking advice from their local pharmacy.

The survey also highlighted that people underestimate the normal duration of winter ailments and so visit their doctor too early. Nine in ten people expected a cough to last for around a week when it can often last three times that long, and eight out of ten thought flu symptoms lasted ten days or less when in fact two weeks is normal.

It doesn’t help that there are more than 200 different cold viruses and it’s likely that most of us will catch at least one or two colds every year. A dry, scratchy sore throat is often the first sign followed by a runny nose, fatigue and loss of appetite.

Flu, by contrast, is an infection of the respiratory system caused by the influenza virus and each year up to 15 per cent of us will catch it. Unlike a cold, flu symptoms start suddenly and are more severe — high fever, extreme fatigue and aches are all common traits.

Colds and flu are highly contagious. The virus is airborne, so every time a sufferer coughs, sneezes or talks germs are spread.

The virus can also be transferred by hand contact, so it is important to wash your hands regularly.

The flu jab is free to those 65 and over, as well as at-risk groups, and is your best protection against flu, which is a serious illness and can lead to hospitalisation or even death. The flu jab contains no live virus, so it cannot give you flu, but can keep you well every winter. The virus changes every year, so you need to be vaccinated

1. Eat five portions of fruit and vegetables a day and plenty of garlic and onion, they can help fight infections.

2. Drink lots of water. It will keep your body hydrated, and also flush out toxins.

3. Drink less booze. Too much can lead to vitamin deficiencies, which can affect your immune system and ability to fight infection.

4. Get enough sleep – it’s the body’s natural way of recharging its batteries.

5. Drink tea. Green tea is one of the richest sources of antioxidants, so it’s great for giving your immune system a boost.

6. Relax more. When your body is under stress you are more susceptible to viral infections.

7. Don’t touch your face. The cold virus is often carried on the hands.

8. Get moving! Exercise is the perfect way to give your immune system a boost.

9. Blow your nose with disposable tissues – this reduces the risk of infection.

10. Get a flu jab.

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Top ten tips to help get you through the season

every year. Just because you haven’t had it before doesn’t mean you’ll be OK this time.

Having the jab means you can’t give flu to friends and family. Flu is highly infectious — 100,000 flu particles can be projected into the air with one sneeze — and is an unpleasant experience, resulting in fevers, chills, headaches, aching muscles, sore throats, runny noses and extreme fatigue.

Colds and flu myths abound and I’ve heard them all, but the usual suspects I hear in my waiting room are as follows MYTH Antibiotics cure colds and flu.

FACT Antibiotics are only suitable for the treatment of bacterial infections and do not work on viruses such as those that cause colds and flu. You will only be prescribed antibiotics if the cold turns into a secondary infection such as bronchitis.

MYTH You catch a cold or flu from someone sneezing on you.

FACT You’re more likely to be infected with a cold by touching a door handle, tea towel, or a handrail on the bus that’s been contaminated by the virus. Shaking hands also passes on germs. Once your fingers have been contaminated and you rub your eyes or nose, the virus will invade your body. However, with flu, people can become ill if they breathe in droplets containing the influenza virus that have been sneezed or coughed into the air.

MYTH Feed a cold, starve a fever.

FACT Never starve yourself! Nutritious hot drinks and soups (rather than solids) are what you need. Hot liquids increase the temperature in the nose and mouth and help kill viruses off more quickly.

MYTH If you go out with wet hair, you’ll catch a cold.

FACT It is now thought that you may actually be able to catch a cold by getting cold. When we shiver, our whole body becomes stressed, which depresses the immune system. We have bugs in our nose all the time, and when the immune system drops its guard, these seize their chance.

MYTH You can catch the same cold twice.

FACT Once the cold ends, your body has built up immunity which will protect you from catching the same virus again.

MYTH Resting will help banish a cold.

FACT Gentle exercise and fresh air are more likely to speed your recovery from a cold. But if you come down with flu, go to bed! Rest is essential to help you get better.

More than ever, I am reminded of Jonathan Swift’s saying that ‘The best doctors in the world are Doctor Diet, Doctor Quiet, and Doctor Merryman’ — sound advice at any time but especially in this season of coughs and colds.

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12/02/2015 11:32

The other half of the heart

There’s two sides to your circulation — and a blood-pressure cuff only lets you monitor one of them, says Dr Carol Cooper

W

hat’s your circulation? Unless you’re a newspaper editor, I bet you think of it as the heart pumping oxygen-rich blood around your body to the brain, kidneys, muscles, sex organs and other vital destinations.

But the human body has another equally important circulation that is far less well known. The right side of the heart pumps out oxygen-poor blood into the arteries of the lungs at a rate of over five litres per minute. This circulation runs in tandem with the left heart’s output and has a different function. In the lungs, red blood cells are replenished with oxygen so that they can return to the heart to be sent out to the rest of the body.

Although it is the counterpart of the better-known systemic circulation, the pulmonary circulation is mentioned much less. Yet this circulation can develop high blood pressure too — a condition called, logically enough, pulmonary hypertension. The right side of the heart then struggles to cope, and heart failure can result. The consequences include poor exercise capacity, increasing shortness of breath, fluid retention, a swollen liver, cold extremities, and even collapse. It’s a life-threatening condition.

Pulmonary hypertension (PH) is a challenge to treat. Although it was first recognised in 1950s, doctors had no treatment at all for it till the early 1980s. There’s still no permanent cure, but recent years have seen a clutch of promising new treatments.

It’s hard to diagnose PH in the first place. The pulmonary arteries are deep inside the chest, so your GP can’t just sling a blood pressure cuff around them as you perch on the consulting-room chair.

The condition really merits wider recognition. PH is potentially grim and it may not be that uncommon.

Overall, 17 people in a million are thought to have it.

That’s rare by anyone’s standards, but there’s huge variation from one part of the country to another, which suggests it’s seriously underdiagnosed.

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What leads to pulmonary hypertension?

Hole in the heart Transposed great arteries Heart disease Lung disease Chronic brochitis Emphysema

Unfortunately clues are difficult to read. Make an appointment about breathlessness and feeling faint, and chances are PH won’t be at the top of your doctor’s mental list of possibilities, if it’s on the list at all. The symptoms aren’t specific. Breathlessness is often the earliest or even the only sign, but there can also be tiredness, dizziness, feeling faint, and swelling of the ankles. Some people have chest pain, especially on exertion. All of these are common symptoms of many other conditions.

A complex disorder, PH straddles two specialties: cardiology and respiratory medicine. So the guidelines for its diagnosis and treatment are a joint effort between the European Society of Cardiology and the European Respiratory Society.

There is no single test for PH. Most people have a battery of investigations before they get a full diagnosis of the condition and its cause. These begin with a simple ECG, chest x-ray and blood tests, and usually move on to a lung scan, echocardiogram (ultrasound scan of the heart) and more complicated tests. The bottom line is that it’s impossible to be sure about PH without a right heart catheter. This means a small probe inserted via the neck or groin to measure the pressure in the pulmonary artery and the heart.

It confirms the diagnosis of PH and can also shed 21 FEBRUARY 2015 | SPECTATOR HEALTH

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17 people in a million are said to have PH

20% of people with chronic lung disease develop some degree of PH

light on what caused it, so it’s a necessary if somewhat scary procedure.

When it comes to the causes of pulmonary hypertension, these range across the whole encyclopaedia of medicine. Some are easier to understand than others. Many forms of congenital heart disease can lead to PH, such as septal defects (‘hole in the heart’) or transposed great arteries.

Adult heart disease is another group. Here PH increases with age, because coronary artery disease and heart failure are more common after mid-life.

Lung diseases too can block off some of the blood vessels in the lungs, leading to a rise in pressure. This group of conditions includes chronic bronchitis and emphysema (together called ‘chronic obstructive pulmonary disease’). Both are common in smokers and some ex-smokers. Around 20 per cent of people with chronic lung disease develop some degree of PH. Then there are rheumatic diseases like lupus and even rheumatoid arthritis, where blood vessels in the lungs lose their elasticity. Some types of liver disease go hand in hand with PH, though it’s hard to see exactly why. HIV infection is also linked with PH. Again it’s not certain how or why, but, as life expectancy with HIV rises, there are now more longterm problems like PH.

For more information: Pulmonary Hypertension Association (www.phassociation.uk.com).

Carol Cooper is a London GP and a tutor at Imperial College Medical School.

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Drugs can trigger PH too. Fenfluramine and other appetite suppressants, popular in the 1960s, were withdrawn for this very reason. It’s also thought that taking cocaine, St John’s wort or amphetamines could lead to PH. One hugely important category is chronic thrombo-embolic pulmonary hypertension (CTEPH).

Here, blood vessels in the lungs are progressively narrowed by blood clots. Think what happens when scale and deposits fur up pipes in a central heating system. The system doesn’t work properly and the pump can fail. That’s pretty much what happens in the human body too, though in CTEPH the clots and debris travel to the pulmonary circulation from veins in the legs or pelvis. Deep vein thrombosis is best known for its link with long-haul flights, but most DVTs occur without going near an airport. Prolonged bed rest, knee replacements and major operations on the pelvis are all linked with DVT and pulmonary embolism, and the risks increase with age and weight.

Symptoms at the time of a pulmonary embolus can sometimes be minor, but there are consequences all the same. Up to 4 per cent of pulmonary embolism survivors develop CTEPH. When it comes to treatment, there’s a huge amount of international and cross-speciality collaboration which is making all the difference in the outlook for those with PH. New therapies, and new uses for old drugs, are driving down death rates and improving quality of life. Two established drugs, sildenafil and tadalafil, both prescribed for erectile problems, have become accepted treatments because they improve circulation in the lungs.

Surgery is an option too. Unfortunately, with CTEPH you can’t get someone in to power-flush the system to get the poor old boiler to work with a clean circuit. But taking anti-coagulants prevents new clots. And there’s an operation called pulmonary endarterectomy (PEA) which cores out the debris from the blood vessels in the lungs. PEA is actually major open-chest surgery, done on heart-lung bypass. The surgeon cuts into the pulmonary arteries and then removes the artery lining to clear the blockages. While there are several specialist centres for PH across the UK, this procedure can only be done at Papworth Hospital near Cambridge. When it’s successful, it can give a substantial improvement in life expectancy.

All the advances in treating PH are important, but the most crucial thing is taking the first few steps: paying attention to the symptoms and getting the right tests done.

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12/02/2015 11:40

What to eat

The power of protein

It’s not just for bodybuilders – making sure we get enough can help us all control our diets, writes Ian Marber

W

hat are the first things that come to mind when you think about protein? Meat? Cheese?

Muscle? Weight lifters? All quite understandable, but protein is an integral part of a healthy diet. So how much do we really need?

Dietary protein supplies the bricks and mortar of the human body, for the development and maintenance of organs, teeth, nails, muscles, brain and nerves. Protein contains organic compounds called amino acids, of which there are 22 in total. The body uses eight of the amino acids as building blocks, breaking them down and converting them into the other 14. These eight are therefore deemed ‘essential’; without even one of them, the spectrum of 22 can’t be completed.

If a food contains all eight essential amino acids, it is labelled a ‘complete protein’; if any are missing, ‘incomplete’.

In broad terms, protein derived from animal sources, such as poultry, meat and fish, is always complete, while some vegetarian sources — such as grains — can be complete but often aren’t. Quinoa is a complete protein; rice isn’t.

Getting sufficient complete protein can be a problem for vegetarians and especially vegans; but a mix of vegetarian sources will usually have the full eight in it somewhere.

Extracting energy and nutrients from food is down to the digestive system, and as carbohydrates are quite readily processed they are the preferred source of fuel.

Protein takes far longer to break down, and this can be to our advantage. Simply ensuring that you eat some protein with every meal and snack and combine it with fibrerich complex carbohydrates (granary breads rather than white, for example) should result in steady levels of glucose in the blood. This combination is a smart way to manage energy levels and appetite without having to follow a strict diet with lots of rules.

It is possible to have too much protein: the side effects are constipation, bad breath and potential loss of bone density. There has been some conjecture in the past about high protein intake causing kidney damage, but this seems to be the case only for people who already had some kidney problems, or who have type 2 diabetes.

Men and women have different protein requirements.

The Food Standards Agency recommends that girls of 11 to 14 have 42g daily, increasing to around 45g for adult women. In pregnancy, protein requirements increase to around 75g. Men need around 55g, especially in the teenage

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Where the protein is Protein per 100g Chicken Almonds Crab Cottage cheese Venison Farmed salmon Wild salmon Pumpkin seeds Oats Eggs Tofu Soy beans Quinoa Peanut butter Natural yogurt

24g 21g 18g 12g 30g 21g 25g 28g 11g 13g 48g 36g 28g 25g 5g

A menu for 55g of protein a day Breakfast: Medium bowl of porridge with walnuts and almonds, topped with berries. 7g of protein Snack: Oatcake with tablespoon hummus. 2g Lunch: Tinned tuna (small can) or 80g tofu salad with avocado, leaves, peppers and pumpkin seeds. 22g Snack: Plain yogurt with fresh fruit. 2g Dinner: Vegetable soup with chickpeas. Chicken or Quorn stir fry with mixed vegetables and cooked quinoa and butter bean mash. 22g

years, when they’re growing quickest.

If you are thinking that 55g of protein doesn’t sound much, remember that the food you eat contains fat, carbohydrates and water too. A 100g chicken breast will contain anywhere from 20 to 35g of actual protein. Why such a range? The reasons can help us understand the role of protein more generally. A chicken raised in a confined space won’t develop much muscle, but will increase its fat stores instead. A freerange chicken with access to a chicken run is going to be more active, with more muscle and hence more protein.

In the same way, an active person requires more protein than someone who is inactive, which explains why protein shakes, powders and supplements are so popular in gyms. Protein powders are useful after exercise as they deliver concentrated levels of amino acids that help effectively repair exercised muscles, adding to their bulk.

Common signs of having too little protein in your diet are fatigue, increased appetite and cravings for sugar and the like; thinning hair, poor muscle tone and vertical ridges on finger and toe nails. Obviously these can have other causes but if that sounds familiar, then try adding a little protein to each meal and snack and check your progress.

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A quarterly spotlight on the big questions for your health Part 4 Backs

It’s behind you Be grateful to your spine, says Dr Rob Hicks

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all it what you want — spine, vertebral column, backbone or back — it’s there to support us throughout out life. Without it we’d be a lump on the floor, of little use to anyone.

The back extends from the neck and shoulders to the top of the buttocks. It consists of the spine and a range of muscles that enable us to bend forwards and backwards and from side to side, and to move our neck and shoulders. It is covered by a layer of tough skin that as well as being thicker than elsewhere on the body also has fewer nerve endings.

The spine extends from the skull to the pelvis and is made up of 26 bones. That’s 24 separate vertebrae — grouped into seven cervical, 12 thoracic and five lumbar — plus the sacrum and the coccyx, or tailbone. In front of the upper part of the spine is the ribcage that protects the lungs.

A vertebra is a ringlike bone. Granted, it’s an odd-shaped ring with bits sticking out from it like a starfish. Each vertebra has a hole in the middle and when stacked on top of each other a tunnel, called the spinal canal, is created. Imagine having a stack of Polo mints, or ring doughnuts, then you’ll get the picture. In fact, if you wanted to build your own model spine, this would be one way of doing it.

The spinal canal enables a bundle of nerve fibres — the spinal cord — to pass safely through from the brain. Small openings formed between adjacent

continued on page 34 u

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Top views of vertebrae Normal disc Spinal canal

Nucleus pulposus

Anulus fibrosus

Herniated disc Compressed nerve root

Anulus fibrosus

continued from page 33 u

vertebrae allow nerves to branch off the spinal cord and travel to various parts of the body through which nerve messages can be transmitted to and from the brain, and to and from the rest of the body.

Each vertebra sitting on top of the other forms the spinal column. It’s not a perfectly upright column, though, but one that creates the appearance of the letter ‘S’ when viewed from the side of the body. The S-shaped spine helps avoid a shock to the head when running or walking. In addition, in between each vertebra is a vertebral disc whose function is to act as a shock absorber between two vertebrae.

Discs are made up of an outer fibrous shell within which is a gel-like filling — I see we’re back to doughnuts again! More accurately called intervertebral discs because of their location in the body, these important structures don’t only act as shock absorbers but also behave like a flexible glue since while holding adjacent vertebrae together — and preventing them from grinding against each other — they also allow some movement of the vertebrae.

Of course, the spine would be a bit wobbly if it were just a tower — you’ve seen young children building towers with bricks haven’t you? So to stabilise it muscles and ligaments provide the support it needs. It’s actually injury to these, rather than to the vertebra or discs themselves, that’s responsible for the most common back problem — low-back pain.

The coccyx, or tailbone, is often thought of as having no real purpose other than to cause pain when landed on heavily. It does, however, serve as an effective anchoring point for some muscles, ligaments and tendons. It’s also weight-bearing when we’re sitting down.

So what does the spine actually do?

Essentially it helps us hold our head up high, keeps our body upright and protects the delicate nerves that make up the spinal

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cord as these traverse the spine from the brain to the rest of the body. It also enables us to bend and twist in various directions, for the most part without problem.

Back pain is one of the commonest health complaints. It most often occurs in the lower back as a consequence of minor injury, sprains and strains involving muscles, tendons and ligaments. Poor posture, twisting or bending awkwardly and lifting objects incorrectly are often responsible. It may also occur due to irritation of a nerve from pressure of a herniated, or ‘slipped’, disc. When the sciatic nerve, the largest single nerve in the body, is irritated in this way it’s called sciatica.

The spine can become inflamed in a condition called ankylosing spondylitis.

Although it’s not clear why this occurs it results in back pain, back stiffness and a reduction in spinal movement.

To remain strong our bones need an adequate supply of calcium, found in good amounts in dairy products, sardines and some vegetables and beans. To be efficiently absorbed into the body calcium requires the assistance of vitamin D, known as the sunshine vitamin since most of the vitamin D in our body is manufactured in the skin in response to sunlight. Bone is continually being broken down and rebuilt — in fact, it’s estimated that we get a completely new skeleton every ten years. During the early years of life more bone cells are laid down in bone than are lost. However, from our mid-thirties onwards the reverse is true.

It is for this reason that the bone disease osteoporosis, or brittle bone disease, develops as the bones become less dense.

In turn, this reduction in bone strength makes fractures more likely. Although bone fractures due to osteoporosis can occur anywhere in the body the spine is one of the areas most frequently affected.

Despite being such a key component of the human body the back is usually ignored — until something goes wrong. So it’s our

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duty to look after our backs, particularly in this day and age when everyday modern lifestyles make back problems more likely to occur. Spending increasing amounts of time sat at and hunched over a desk means poor posture — a major contributor to back problems — is more likely to be present. Being overweight puts an enormous strain on the back muscles, making low-back pain more likely to come a person’s way. And the need to get everything done as quickly as possible means that we often forget that awkward twisting and bending — for example, to pick up the pen that’s dropped off our desk — can so easily leave us in great discomfort.

So what can we all do to support our back and lessen the chance of it telling us it’s not happy? Well, maintaining a good posture is an essential first step. Since much of our life is now spent sitting in front of a computer it’s vital to ensure that the workstation is appropriately set up. This includes making sure objects to be used are easily accessible, that the screen is at eye level, and the chair supports the lower back.

Exercise and keeping active helps the back by strengthening the supporting back muscles and by helping to keep a healthy body weight that in turn means the back is subjected to less pressure. When lifting, bending at the knees and keeping the back straight is the way to do it, while remembering not to bend and twist at the same time. A healthy balanced diet should deliver plenty of calcium, and vitamin D from a little sun exposure during the summer months will help keep the bones of the spine strong. Smoking can reduce blood supply to the discs meaning they may be likely to degenerate over time — another good reason to give up.

Your back is there for you throughout your life. Support it, so it can support you.

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Ordinary pain

Millions of us are martyrs to our backs, says Sophia Martelli

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reatment for lower back pain is undergoing a sea change. Why? Well, mainly because it has to: according to a report released earlier this year, lower back pain is the biggest cause of disability, globally — and because of an ageing population the burden on healthcare is due to get a lot worse.

Given the number of nerves that run alongside the spine’s 24 vertebrae, protected and supported by muscles and ligaments, it’s no wonder that one in three people every year are affected by lower back pain. The back is the superhighway of the body, and about 2.5 million of us are parked on the hard shoulder — that’s how many have serious enough back pain to visit their GP each year.

The good news is that only a small minority will need surgery — around 5 per cent, according to Mr Nick Birch, orthopaedic surgeon and medical director of the Spinal Rehabilitation Unit at the Chris Moody Sports Injury and Rehabilitation Centre. The bad news?

There is no miracle cure for chronic back pain — and it affects so many of the working population.

Doctors will first discount any serious causes for back pain, asking about ‘red flag’ symptoms: a pain in the back plus a fever can equal an infection, although as Dr Dawn Richards of VitalityHealth says, ‘It’s unusual.’ She adds, ‘A fracture of the spine or collapsed vertebrae can happen without any trauma if there is an underlying cause such as osteoporosis or cancer.’

Numbness in the genital area, loss of power in bladder muscles and bowel

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Myth My back pain is due to something being ‘out of place’.

Truth X-rays rarely show any evidence of bones being ‘out of place’, ‘subluxations’ or pelvises being out of alignment. In the very small number of people with some change in their spinal alignment, this does not appear to be strongly linked to back pain.

Myth I hurt my back, so I will probably have bad back pain from now on.

T. Although back pain can be very painful initially, most people make a very good and speedy recovery. 80 per cent can return to their work and hobbies in a few days.

ooch!

disturbance may point towards cauda equina syndrome, when the nerves at the bottom of the spine are compressed.

This needs urgent medical attention to prevent permanent damage to the nerves. If a spinal disc prolapses, Myth The doctor said my spine was crumbling it can lead to pinched/compressed — surely I shouldn’t be doing any exercise? nerves, and in the case of the sciatic Truth The spine is one of the strongest parts of nerve pain, tingling and numbness the body and even as we age, exercise helps may go down the leg to the foot. protect the spine by strengthening muscles and This can be treated with muscle increasing flexibility. Resting too much weakens relaxants such as diazepam to stop muscles and stiffens joints, resulting in more the spasming or locking of the muscles, pain and difficulty in moving. and epidural injections of cortisone and local anaesthetic are often very good at relieving severe leg pain. There are also inflammatory conditions such as ankylosing spondylitis, causing pain and stiffness of the back.

If your pain is not linked to one of the above diagnoses, it may be termed ‘non-specific low-back pain’. Diagnostic imaging such as X-rays or MRI scans are not always required in these cases and are only recommended by Nice when serious pathology is suspected. ‘Diagnostic tests often do not help clinicians come to a conclusion as to what is causing the When it comes to pain, ‘The back is patient’s symptoms. There are many very stupid, for want of a better word,’ says normal changes to the spine that have Mr Birch. Most lower back pain is nonlittle to do with why the patient has pain. specific because ‘there’s a very small area The findings are often not helpful in in the brain that processes the information deciding the best course of treatment to from your back.’ Just look at the sensory help reduce symptoms,’ says John Doyle, homunculus to see why. This figure that chartered physiotherapist at Nuffield plots sensation to scale has huge eyes, ears, Health (nuffieldhealth.com/physiotherapy). tongue, hands and (ahem) genitals; but a ‘Patients will generally benefit from a tiny body. ‘The brain knows that the back is simple exercise programme as well as either “fine”, or “it hurts” — a little or a lot.’ reducing the time they spend sitting.’

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ns

Myth Back pain must be completely better before people return to work.

Truth Research shows that most people with back pain are able to continue or return to work and that their pain is no worse than if stay at home.

Myth X-rays always find the causes of pain.

Truth In most cases of back pain X-rays and scans don’t help pinpoint the cause.

Myth I need a scan or X-ray for my back pain.

Truth Every year very large sums of money are spent on investigations for back pain, but in most cases scans and X-rays are unnecessary. Many people with no back pain have disc degeneration, disc bulges and spinal arthritis when put through scans. Focussing on scan findings can be unhelpful, cause anxiety and change how people move and exercise.

Ow!

Myth The more back pain I have, the more my spine is damaged.

Truth More pain does not always mean more damage. The amount of pain felt can vary according to the patient’s outlook, mood, fears, fitness and stress.

Two people with the same injury can feel very different levels of pain.

Myth I have back pain, so I must stay in bed and rest.

Truth In the first few days after the initial injury, avoiding aggravating activities can help to relieve pain.

However keeping active and returning to all usual activities as soon as possible, including work and hobbies, aids recovery.

Myth I need an operation to cure my back pain.

Truth Few people with back pain require surgery.

Staying active, developing a better understanding of pain and identifying lifestyle improvements is the best approach.

moved on in 25 years,’ agrees Mr James Scott, orthopaedic surgeon and editor emeritus of The Bone and Joint Journal.

Low-back pain sufferers can get into a vicious cycle of avoiding movement and slowing recovery. The effect on mood, too, can put a negative spin on everything. ‘Pain is not always a sign of damage,’ says Doyle.

‘Patients often worry that if they have pain and they move, they will cause more damage, but this is not usually the case.’

He recommends that ‘patients should stay

active as this will keep the joints mobile and the muscles strong leading to quicker recovery’. There are many therapies that may help, particularly in the short term, and most episodes of back pain will settle down with no treatment at all. However those with ongoing back pain may benefit from ‘an exercise programme that gradually increases strength, mobility and fitness levels while addressing any of the worries or concerns about pain that the patient may have’. This combined physical and

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psychological approach was recommended

by Nice in their 2009 low-back pain guidelines.

‘Patients often report that their pain reduces, or that it has less impact on their lives as a consequence of regaining normal movement, improving strength, fitness and function, and having a better understanding of pain from the cognitive behavioural approach,’ says Mr Birch. The ‘lowintensity’ group therapy module of threehour sessions once a week for five weeks is proving to be the more budget-friendly, costing £750 per person, as opposed to the high-intensity inpatient model based on two- or three-week residential stays in specialist units at a costly £6,000 pp.

Ultimately, the days of resting a bad back are gone, and getting back to normal activities is what is encouraged. The research clearly shows that low-back pain places significant burden on the economy.

The costs of treating back pain and the financial impact linked to sick days and long term disability continue to grow. in these straitened economic circumstances, the state — both in terms of healthcare and sign-off-work-with-a-bad-back culture — can no longer support.

Maybe this is a good thing. Historically the medical industry has presented itself as the answer to everyone’s bodily suffering.

But to give patients the tools to deal proactively with their conditions gives sufferers back responsibility for their own health — and that should be embraced.

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‘Do those funny-looking chairs help?’

Mr Damian Fahy

Consultant Spinal Surgeon at The Lister Hospital, London Is it true that sitting on those large exercise balls or funny-looking chairs where you kneel help back pain?

One of the commonest causes of back pain is sitting with poor posture for long periods of time. We often tend to slump, especially when using a computer. It is on these occasions that sitting on a ‘Swiss’ ball is beneficial. When sitting on a ball it is necessary to sit with good posture, or you’ll fall off! When starting we should sit with our feet wide apart to provide a stable base, as we become more proficient we can move our feet closer together, becoming more unstable and needing to work harder to remain upright.

In this way, not only are we sitting with better posture but also we are exercising the key ‘core’ muscles essential for spinal health. Kneeling chairs are an alternative; they also encourage us to sit with improved posture.

painkillers such as paracetamol or ibuprofen are useful.

Stronger painkillers can be prescribed if needed. If the pain is severe or doesn’t settle in a few days, physiotherapy, chiropractic or osteopathy are all likely to be beneficial. It is also important to keep moving.

If these measures do not succeed, invasive treatments such as spinal steroid injections will probably help, but these should be undertaken only after an MRI scan to identify the exact cause of the trapped nerve. Surgery is the last resort, used in fewer than 5 per cent of cases, it may be considered earlier if there is any evidence on examination or imaging of nerve damage.

Would you recommend a hard mattress or soft mattress? Does it really matter? What about foam mattress versus traditional spring mattresses? I’ve always heard that you should spend as much money as you can afford on a mattress, but wonder if that rumour was started by a mattress company.

My partner has a trapped nerve in his neck. He’s under a neurologist who has said there’s nothing that can be done. It causes him incredible pain. Do you have any advice?

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Mattresses are a very individual issue. The key issue is that the mattress supports the normal curves of the spine in all positions of sleep. Too soft and we sag, too hard and we lie on top of the mattress on a few points. A mattress that moulds to our shape is best. This can be achieved with a good quality spring mattress with a high spring count or with a memory foam mattress. It is certainly not always true that most expensive is best.

Can you explain what a laminectomy is and what it’s used for? My mother has been told she needs one but the family GP hasn’t been able to give us much information.

A laminectomy is a relatively old-fashioned operation in which a piece of bone is removed from the back of the spine to relieve compression of the nerves produced by narrowing of the spinal canal (spinal stenosis). It is very effective in relieving pressure on the nerves in this situation. It is not very effective at relieving back pain and may indeed make this worse. As much bone is removed as necessary to release the nerves but as little as possible to avoid making the spine unstable. If it is necessary to remove a relatively large amount of bone making the spine potentially unstable, the operation will need to include a procedure to stabilise the spine artificially using screws and rods as internal scaffolding (a fusion). Depending on how large the operation is, the

recovery takes six to 12 weeks although patients are mobile straight away.

I am pregnant and have been experiencing really bad back pain. I’ve never had this before. Why has it suddenly come on and is there anything I can do or take to make it better? I want to avoid painkillers for obvious reasons.

Back pain in pregnancy at some level is normal. In most instances it is due to the action of the hormones produced during pregnancy which are preparing the mother for delivery. Part of this involves relaxing the ligaments of the lower back and pelvis, this leads to low-back pain. As weight increases during pregnancy the pain becomes more of an issue. It is vital to keep as fit as possible during pregnancy, it may mean changing a normal exercise routine so that there is less impact. Swimming, cycling, using a cross trainer and walking are all fine. It is normal to gain some weight during pregnancy but it is important to keep that weight gain to reasonable levels.

Pilates for pregnancy is a good way of keeping the back strong during the pregnancy, helping back pain before, during and after delivery. Any pain that is severe or constant or any problems with nerve function should be discussed with your GP or midwife. It is also best to discuss exercise plans with your midwife or GP in advance.

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It’s very common. Thousands of people find that knee pain becomes an increasingly stressful part of their lives. Ordinary life becomes strained. Work becomes a burden.

W HAT C A N B E D O N E ?

Knee pain can start as nagging discomfort. If left untreated, the pain grows steadily worse over months and years until walking itself becomes difficult and distressing. In its early stages, pain killers and antiinflammatories usually bring some pain reduction.

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Spring awakening

A palatial spa near Porto lets our anonymous reviewer rediscover the wonders of ‘taking the waters’

The Spa Inspector Vidago Palace Portugal

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lthough spas have been around for centuries, they soared in popularity towards the end of the Victorian era, when it was common practice for the well-to-do to ‘take the waters’ on the Continent in order to alleviate symptoms ranging from neurological problems to stomach ache. While the term ‘spa’ used to mean resorts built around mineral springs, now every upmarket hotel has a health spa in which its clientele may be pampered.

But what has become of the good old-fashioned thermal spas? We sent our inspector to investigate a hotel that is considered one of the best spas in Europe: Vidago Palace. It has four natural springs in its grounds, and a large marbleclad spa suite that, alongside all the usual massages and facials, also offers special treatments using the mineral water. A doctor is on hand to ‘prescribe’ varying daily quantities of the water to be taken, depending on the symptoms.

The place Driving up to Vidago Palace, you feel like royalty. As you might guess from the name, it was intended as a palace, but was completed on 6 October 1910 — just as the Portuguese monarchy fell. A four-year refurbishment that began in 2006 has made it the height of luxury. It is a 45-minute drive from Porto, and is set in wonderful woods with a remodelled 18-hole golf course.

The symptoms Your spa sleuth has a poor diet because of a high-pressure job, and a longstanding medical condition affecting the bowel and liver; she felt under the weather and in need of a bit of time apart from the smartphone and the takeaway.

She wanted a good start to her new healthy eating plan and a bit of gentle exercise.

The treatment The Spa Inspector was enrolled on the detox programme, which included treatment designed to relax and rejuvenate as well as an individually tailored menu for the entire stay. The ‘Vichy shower’, which involved being given a massage while lying on a bed with dozens of tiny jets of water directed at her, felt like nothing she had ever experienced. She was scrubbed

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and rubbed to within an inch of her life. She also did Pilates for the first time, one-to-one with a very gentle instructor, and was taken for runs around the grounds with a fitness instructor. Although it was not part of the programme, she was invited to sample spa water directly from the source and was astonished to find it was naturally sparkling.

The process The best way to organise your trip is to email the spa in advance and discuss what it is you need. Guests can choose between simply relaxing in the hotel and taking treatments when they wish, or enrolling on a tailored programme. Though Vidago Palace is a five-star hotel, the current economic climate in Portugal and its location outside Porto make prices quite reasonable.

The verdict The stay had a profound impact on this spa sleuth. She felt relaxed and rested in a way she had not done for years, as well as more energised and less bloated. Since returning she has continued to eat healthily and has even enrolled in Pilates classes. She is also drinking much more water, although the taste of London tap is not quite as good as the spring at Vidago.

The medical view Dr Max Pemberton: Doctors have long advocated water treatments, although it’s difficult to assess the health claims from each spring. There is no doubt that waters which are high in some elements, compounds and minerals can have benefits for certain conditions. The Romans knew this, as they advocated drinking from lithium-enriched springs to help what we now know as bipolar disorder.

The feelgood factor There is one simple fact about this trip that tells you everything you need to know. The Spa Inspector has stayed in lots of very nice hotels and visited some of the best spas in the world.

However, staying at Vidago was such a pleasure and its surroundings were so lovely that, on returning home, she booked to go back there six weeks later, unable to keep away. This spa sleuth has never done anything like that before and can’t think of a better endorsement.

The details Room rates start at €140 per night, including breakfast, in a standard room, rising to €930 for a suite.

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Sex ex and relationships

Alternative activities Sex doesn’t always have to mean intercourse, say Christine Webber and Dr David Delvin ‘Who can tell …

What the Hell …

Women want?’

S

o runs the men’s chorus from Act Two of The Merry Widow.

And indeed quite often it is pretty difficult for males to understand what females want — at least, in the bedroom department.

But a new study by Professor Jane Ussher, of the University of Western Sydney, will bring enlightenment to a lot of men. She has discovered that many women of a certain age are very happy with what is termed ‘non-penetrative sex’.

In other words, they often prefer to be erotically fondled rather than have coitus.

Ussher claims: ‘The foreplay reminiscent of youthful days can bring a lot of pleasure, often lasting longer than sex focused on intercourse.’

Whether she is right or not, her findings will be welcomed by men who are beginning to have a little difficulty with their erections, and who are not quite sure whether they can always maintain penetration. The pressure to perform is taken off them a little.

Professor Ussher also makes the valid point that over a certain age, some woman may find penetration painful. For that reason, the Prof also recommends the use of artificial lubricants.

She also makes a case for employing sex toys as an alternative to intercourse.

These days of course vast numbers of women do own vibrators. But we do not recommend that when setting out on a first date you should pop one in your handbag — they tend to make a bit of a racket if they accidentally switch themselves on.

When two people are in a relationship,

there is much to be said for mutually agreeing that sex won’t always be penetrative, and that sometimes the repertoire will comprise other activities.

As an example, in the files of our Harley Street therapy practice there is the case of Jemima (not her real name), an elegant and extremely successful corporate lawyer. She consulted us because she had been unable to form a successful relationship since her divorce, seven years earlier.

What concerned her was that all the men she dated seemed to think that the main purpose of the evening was simply to get her horizontal as a prelude to swift penetration. ‘And as a rule,’ she

Her husband thought that the thing to do with a woman was get inside and hump away complained, ‘they ejaculate far too soon, leaving me frustrated and cross.’

Not surprisingly, that had also been the characteristic sexual strategy of her former husband, who appeared to have learned at boarding school that the correct sexual behaviour towards a woman was to get inside her as fast as possible, hump away, and then roll over and say goodnight.

After Jemima had had a few consultations with one of us, it became evident that when choosing a date, she was unconsciously selecting males who had the same rather apelike tendencies.

Fortunately, once she was alerted to this she was able to change her attitudes, and to start picking men who had a less aggressive approach to sex. Furthermore,

Christine Webber and Dr David Delvin are sex experts and the co-authors of Sex: How To Make It Better. They are married to each other.

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she developed a habit of saying to the men she liked: ‘We’re going to have such fun tonight — but without intercourse.

Trust me, you’ll love it!’

The result was that she embarked on a series of relationships in which kissing, fondling and non-penetrative sex were the main features of each evening. Often the excitement was heightened, despite there being no coitus. As Jemima said: ‘It reminded me of those happy youthful days when I was still just about a virgin.’

When we last heard of Jemima, she was settled with a nice surgeon and happily heading towards matrimony.

Of course it is undeniable that for the majority of men and women, the ultimate object of sexual dalliance will always be what the Italians call la penetrazione profonda. Nonetheless, in almost any sexual relationship the couple would do well to make time for the gentle arts of touching and petting.

As Hermann Hesse says in his novel Siddhartha: ‘So, she gently taught him that one cannot take pleasure without giving pleasure, and that every gesture, every caress, every touch, every glance … has its secret — which brings happiness to the person who knows how to wake it.’

Finally, we stress that Professor Ussher’s findings are very good news for men who are slightly anxious about their penises — about size or perhaps waning capabilities. Remember, chaps: that woman in your arms — whether she is a new love or an older one — can be wildly thrilled by your intimate, romantic language and your digital or lingual skills.

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12/02/2015 11:47

Well worried

Migraine mysteries Maureen Lipman thinks she may have finally solved her headache problem – but then she’s thought that before…

S

ince I relinquished my Sundaynight Chinese takeaway — with emphasis on the seaweed starter and crispy duck pancakes — I can honestly say that my battle with migraine has been 90 per cent won. It took me a mere 40 years to discover that monosodium glutamate is my trigger (along with chocolate and cow’s cheese). Now, if I am stressed, gluttonous or drink more than a couple of glasses of wine, I might succumb to the Large Hadron Collider of headaches, but I can generally catch it early with a couple of Solpadeine or, at worst, knock it on the head via the other end.

Without being too graphic, a strong antiinflammatory in suppository form will bypass the already-upset stomach and stem the pain; I hope I haven’t hereby demolished my feminine enigma in one swell enema.

Over the years I’ve come to realise that no one can explain migraine, especially the migraine experts. I’ve sat in the salons of men whose names are followed by more letters than a Royal Mail delivery van. They’ve interrogated me on my sleep patterns, my make of pillow and ability to orgasm, and they’ve all reached the same conclusion.

‘Mrs Rosenthal,’ they chorus, ‘you have migraine. That’ll be £275 please, and don’t bang the door on your way out because I’ve got a blinder.’

In my 48 years of doing what the late actor Patrick Troughton called ‘shouting in the evenings’, I’ve only ever missed two performances. Both were due to migraine. Not a bad record, although needless to say I seem to have since met the entire audience of both shows. ‘Ooh, Maureen, we came all the way from Shanklin on four buses, a Sinclair C5 and

a mule to see you and when we got to the theatre you’d put your understudy on! We were gutted! Did you feel like a night off? Your understudy was great — has she got anything in the pipeline?’

Frequently, it was uber-reflexologist Tony Porter who kept me going through the show, driving miles to my dressing room to pulverise my feet to such an extent that I forgot the pain in my head. ‘Mmmm, liver…’ he’d murmur, as I hit the ceiling, growling, or, as he ground a finger into the side of a toe, ‘Adrenals, hold on tight, you may feel this… .’ Regular acupuncture helps and so does detox. When pregnant with my daughter I was migraneous for the first three months. A naturopath put me on

Six times, the magic worked.

I couldn’t wait for the next neck-tightening, the dull feeling behind the eyes a strict diet of vegetables and it seemed to do the trick, although the first time I ate meat again it was like chewing gabardine.

But migraine is a slippery foe. My late mother, who suffered from them badly as a girl, managed them in later life by making herself sick. Afterwards she would be perfectly well again. I hated throwing up so much that I simply refused to follow suit, but a few years ago, headed for a chat-show couch with a pounding skull and a rigid spinal column, I dissolved a few salt crystals in warm water in the hope it would act as an emetic. About an hour later it struck me: not only had I not been sick, but I no

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longer had migraine. It couldn’t be that simple, could it? Could a dozen chips of pink Himalayan salt and some boiled water be the holy grail? Pfizer would have me pulverised! GlaxoSmithKline would take out a contract on my life!

Johnson & Johnson would bury me in baby powder!

For six subsequent migraines, the saltwater worked its magic. I thought about taking out a patent. I couldn’t wait for the next neck-tightening, the dull feeling behind the eyes, the shutting down of all bodily functions and the inability to eat for days, the wrecking throbbing pain as the car negotiates the potholes in my drive. I excitedly relayed my discovery to my GP. He did his level best to hide his smirk.

Reader, the seventh time I tried it, it failed — and it has never worked since. There is something to be said, as always, about the power of suggestion.

Once, after an operation followed by a blood transfusion, I had a migraine for 12 weeks. The hospital had me on suppositories twice a day and couldn’t get rid of me fast enough; I was a constant rebuke. But the migraine came with me, and stayed. Nobody believed me until a Vietnamese surgeon told me he’d seen this after transfusions in war zones. He said the bloods didn’t quite match and that after the 12th week it would go. Suggestible as ever, by week 13 I was cured.

Did you hear about the migrainestricken Brit on holiday in France? He was given suppository pain relievers at the pharmacy, but couldn’t understand the instructions. Next day he went back to the pharmacy to complain: ‘For all the good they did me,’ he declared, ‘I might as well have shoved them up my arse.’

21 FEBRUARY 2015 | SPECTATOR HEALTH

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12/02/2015 11:50

‘The “my cat/dog/alpaca smelled my cancer” trope is well-established, but it is, as far as I can see, codswallop.’

For health news without the hysteria, read the Spectator Health blog.

www.spectator.co.uk/surgery

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11/02/2015 17:35

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12/02/2015 14:41