Time to Put Infant Reflux Back In Its Box

In all walks of life there are times when you get to enjoy the liberating feeling of being told something you’ve always known to be true, but never quite had the knowledge you needed to confirm your inner convictions. This happens to GPs all the time, because we have convictions and feelings about most of the medicine we encounter on a daily basis, but too little time to research all the myriad quandaries we are left puzzling over. This is where specialists have their use – they are able to dedicate years of study to one or two of the dilemmas we are faced with, and help point us in the right direction.

So it was this week, that one such specialist empowered me with something of a eureka moment over a condition that has been troubling me recently – the increasingly medicalised language surrounding ‘sicky’ babies.

By ‘sicky’ I mean milk-spitting, vomiting, puking babies that leave permanent milky-white stains on the shoulders of all their parents’ best clothes, require investment in dozens of muslin squares and lead to the pulling up of carpets in favour of wipe-clean lino just before the baby miraculously grows out of it. Or to use a lovely, old-fashioned word that we need to keep hold of: possetting.

What I do not mean, is gastro-oesophageal reflux.

Reflux is a highly medicalised word. It is not normal; it implies acid spilling backwards from stomach to oesophagus and (as any pregnant woman knows) painful heartburn. True acid reflux can occur in babies, but it is rare; paediatric gastroenterologists at the conference I attended this week were queuing up to testify as to how unusual it is to have positive tests for acid reflux in possetting babies. This fits with the experience of having a possetting baby (and I have bought my fair share of muslin in my time) – babies are not usually distressed by pain when they posset, and the milk smells just like that – milk, and not acid.

Despite the fact that the entire feed of milk seems to find its way into the washing machine rather than the infant stomach, babies who possett thrive – they put on weight and develop without problem. They are irritable some times, but most babies have times when they are more irritable than their parents would like. If possetting is very common, and irritability is very common, then there will be many babies that experience both, but that doesn’t mean that the possett is the cause of their irritation – or, more  importantly, that treating ‘reflux’ will make any difference to one or either symptom.

Many advice websites give quite a balanced view on this issue, with sites like the BabyCentre and netmums giving lots of reassurance that it is usually normal and will settle on its own before mentioning any medical treatment for it – but they still call it reflux, because the word has entered popular use. Fascinatingly, what I also learned this week is that if parents are told their baby has reflux they are more likely to want medication for it than if the doctor gives the same explanation of the problem, but avoids using the medical label.

Medical labels matter, they create anxiety that your baby has a problem that you should be trying to solve, and can turn a normal, healthy baby into a patient before they have barely got going in life. We need to normalise this process and recapture the word possetting for the nursery and not the doctor’s surgery.

So what of the science behind treatments for ‘reflux’? Well the first thing to say is that true Gastro-Oesophageal Reflux Disease can occur, although it is rare. We need to be concerned about a baby that is failing to thrive (that is, is not growing properly and putting on weight in the normal way), or if the vomit contains blood, or is associated with significant breathing difficulties. These babies may well need to see a paediatrician.

For the vast majority of possetting babies, however, the point in question is this: will any treatments that are offered make any difference to how often my baby is sick, or to how irritable they are? The answer to these two questions is a resounding ‘no.’ Simple measures such as making sure you don’t overfeed, slowing down the feed and winding regularly are all common sense, but changing feed to an expensive ‘stay down’ milk, or low allergy formula strikes me as companies exploiting an artificial niche in the market and evidence of benefit is very limited.

Medications fare no better. Antacids such as Gaviscon are frequently used, as are medicines that stop the stomach making acid in the first place, such as ranitidine and omeprazole (although this is an unlicenced use). When these medicines have been subjected to proper clinical trials they show that they reduce the acidity – but make no difference to how much a baby possetts or how irritable they are.

What is more, there are significant downsides to neutralising the stomach acidity in infants, in the form of increased risk of both gastroenteritis and pneumonia – presumably we evolved to have stomach acid for a reason, and keeping germs at bay may well be part of its role.

So, we have a treatment that doesn’t work, for a condition that doesn’t really exist, and that might make your baby really quite unwell – any takers? Let’s instead try to put reflux back into its box, let healthy babies be healthy babies, and reclaim the word possetting – more of a laundry problem than a medical one!

The Doctor Will Not Examine You Now

I’m acutely aware of how easy it is to be hypocritical as a doctor – and no more so than when I give advice during a consultation, because sometimes I contradict my advice by my actions only a moment later.

The scenario often arises with simple childhood problems, like earache or a cough. Take earache, for instance; it is not unusual for a parent to bring their child to me within a few hours of an earache developing, hoping to ‘nip it in the bud’. I understand the logic of this, but also know that earache doesn’t work like that – most short-lived earache is due to middle ear pressure and not infection, will resolve on its own within 48 hours and antibiotics are best avoided. I don’t mind seeing children for this, but would like to save their parents the bother of having to take time out of their busy day – already stressed by having an unwell child – in order to see a doctor; I would like to empower patients to know when to self-care and when to seek medical advice.

To this aim, therefore, I like to advise parents on when they should bring their child’s unhappy ear for me to have a look at, and when they can safely manage things at home. ‘Unless your child is really poorly,’ I say, ‘there’s no need to see a doctor until there is persistent earache or fever lasting longer than 48 hours.’ So far, so good. This information is usually politely received and I feel better for having passed it on. What I then do is to undermine everything I have said.

I EXAMINE THE CHILD.

 

The child is clearly not seriously unwell, just from the way they are playing happily with the toys in my room, the earache is not yet 6 hours old and there is no fever. This is exactly the child I have just said does not need to be here – yet I proceed to do something which very few parents can do themselves at home, which is to pick up my magic auroscope and look in the child’s ear. If I have just said the child does not need to see a doctor, why am I doing something that only a doctor can do? How does this help to reassure the parent in front of me the next time their child is in the same situation that they can safely manage this at home?

Of course, the reason why I examine the child is because that is what doctors do – after the history is taken, you examine the patient. It is ingrained in us, expected of us, and seems neglectful to do otherwise. A failure to examine properly is often cited in medical negligence cases, and it is unnerving to consider not doing it – but perhaps we should be bolder and consider changing our practice.

I remember hearing a story about some office workers who were being shown round their new premises, situated several floors up in a brand new sky-scraper. The floor-to-ceiling glass walls and the unnatural view of the ground 100 feet below created such anxiety among the staff that the manager had to call the engineer who designed the windows to reassure them that they would be safe working there. All the engineer’s attempts to explain the physical properties of reinforced glass, and how it was stronger than any brick wall, was to no avail. The staff hardened their resolve, and it looked like they would refuse to move in. Finally, the engineer realised what he had to do. Standing in the middle of the room, he started to run as fast as he could; without hesitating for a moment he hit the window with such a force that the whole office shook – while he bounced harmlessly back off the glass with only a bruised shoulder to show for his trouble. The staff moved in the next day.

Perhaps, if we are to really get our health messages across, we have to show in our actions that we actually believe in them. This is what one of my partners has started to do in recent weeks: when it is appropriate he discusses the idea of not examining the child in any way that would not also be possible by the parents. He negotiates this, and does not insist on it, but so far the idea has been well-received. He does what the parents could do – has a general look at the child, takes note of what they are doing and perhaps measures their temperature, but leaves the doctor-only tools of the auroscope and the stethoscope firmly on the desk.

I have not heard of other doctors negotiating this idea of not examining the patient, nor am I aware of any research into this area. It seems radical, and I am yet to try it myself – but it also seems far more honest that the traditional approach. I would love to hear your views.

Who Gave Tesco the Right to Shape Our Children?

I clearly missed the moment when we decided to appoint supermarkets as the powers that should determine our social norms, but it has become clear recently that this mantle has been assumed by at least one of these marketing giants. My attention was drawn to this when the campaigning organisation Let Toys be Toys discovered that Tesco was advertising its chemistry set as ‘for boys’, while its Hotpoint cooker was labelled ‘for girls.’

We need to stop and think about this for a moment – if it does not shock and outrage us in the 21st century, then it certainly should. Surely we have moved on from any suggestion that chemistry is only for boys (were the struggles of Marie Curie and Rosamund Franklin for nothing?) And as for the kitchen…

Can we imagine a school separating children by gender in this way? There would be outrage, surely? Even Michael Gove would think it was old-fashioned!

What is revealing is Tesco’s defence of their actions. When Let Toys be Toys challenged them about the signs on Twitter, they replied with:

So, what they are saying is that they have conducted market research and that is what dictates their policy. The fact that any ethical analysis of the situation can only conclude that toys do not need to be defined by gender apparently has no bearing – the market research (in other words, what sells) trumps any social obligations Tesco might be troubled by.

After some outrage on Twitter (helpfully stimulated by Ben Goldacre) the Tesco account went mysteriously quiet. Subsequently they have apologised for ‘causing upset’ (always apologise for upsetting someone, never for being wrong) and have promised to update the chemistry set as being ‘unisex.’ This they have done, while the kitchen remains distinctly ‘for girls.’ The kitchen is pink – shocking pink – is that enough of a reason to label it for girls, or should we question why on earth a kitchen should be pink in the first place? The answer is clear from the description of another kitchen in the same range:

CookerIt’s not about pink then…

Since then there has been media attention, and Tesco have apparently stated on Watchdog that they will ‘be conducting a review of the way it categorises its toys.’ Why a review and not just an apology and immediate change? Is it that hard? They have decided to change the chemistry set without requiring a review, but I can only assume that working out how to categorise a ‘Wild physic and chemistry set’ is more complicated, since it remains like this on their website:

Physics setWhy does this matter so much? And why talk about it on a health blog? Well, I don’t think we should under-estimate the subversive influences on how we shape our children, or the impact that this will have on their subsequent health as adults. Educational attainment is closely linked to health, and being told you can or can’t do something could have an enormous impact on a child. If parents wish to point their boys towards science, and girls to the kitchen, then that is something I may not agree with (my father is a chef, my wife a scientist, so I’m hardly likely to), but neither should I interfere in another’s parenting without very good reason. Tesco, on the other hand, are not parents and should not presume that they have the right to stereotype in this way.

And when it comes to stereotyping, it is not just how we educate our children that matters to health, but how we feed them. It is nearly a year since Tesco assured me that they would remove the direction to ‘Children’s cereals’ from all their stores, after I pointed out the harmful health message implicit in the signs. Well, as for my local store, I am still waiting…I imagine they are busy conducting a review.

Measles – Ignorance and Complacency are the Greatest Dangers

Listening to the news reports surrounding the current measles epidemic in South Wales this week, it has struck me afresh how much our nation is in need of a refresher course on the nature of this age-old infection. While it has been one of the resounding successes of modern medicine that this potentially devastating disease is so rare in the developed world in the 21st century, this inevitably means that we have lost a great deal of the collective knowledge and understanding that was such a valuable resource when measles was commonplace. The contrast with chicken pox is clear – we still know this illness and understand it. Parents usually diagnose it themselves and manage it without needing any medical advice, only turning to a doctor when there seem to be problems. For measles, most of us know it involves a fever and a rash, and can be serious, but not much more.

The result of this is that we are left collectively stunned by the death of a man of 25 with measles. How can that happen? Isn’t a young man of that age supposed to be in the prime of his life, having escaped the frailties of childhood but well before the vulnerability of old age? And yet the risk of death as a complication from measles in this age group is the same as that for the under 5’s. In fact the age group that is most at risk of the major complication of measles – death, encephalitis (infection of the brain), hospitalisation and pneumonia – are the over 30’s. Young children are more at risk only for diarrhoea and ear infections.

It is no surprise, therefore, that a woman being interviewed on the radio recently had made the assumption that measles was only really a problem for the under 5’s. Why would she think differently? This is the case for other infections, after all. Whooping cough, for instance, will give you a nasty cough for 3 months as an adult, but it is infants whose life could be in danger. Haemophilus B, part of the vaccination programme for babies, can cause meningitis in the under 2’s, but not in older children. Yet if we assume measles is not a problem for older children and adults, then the greatest risk to a successful catch-up programme for the MMR vaccine is not those ideologically opposed to vaccination, but ignorance and complacency among those with a more moderate view, but who were caught up in the confusion surrounding MMR in the late 1990’s.

It is easy to see why measles is so associated with childhood in our collective unconscious. The disease is so infectious that, before vaccination, it was rare to get to the age of 5 without having succumbed to it – and so our image of the infected patient is usually one of a child. The vaccination programme is delivered in two doses, at around 1 year of age and again pre-school – so we have no reason to associate it with any other age range. The fact that 10-18 year-olds are the primary age group affected by the outbreak in Wales, however, is a stark reminder of the naivety of these assumptions, as it is clear that this infection is no respecter of age, and anyone who lacks immunity is vulnerable.

The post-mortem of the young man who died has been described as inconclusive – there is no doubt that he had measles, but at the moment it cannot be said with certainty that this was the cause of his death. Well, it seems to me that it stretches to incredulity the idea that someone who dies with measles has not died from measles. I suspect we are making another false assumption about his death, however. The fact that he was found dead in his flat could easily make us draw the conclusion that if only he had sought medical advice, he might still be alive now. In truth it is unlikely that a hospital would have been able to do anything. We have better supportive measures these days than in the past, but there is still no treatment at all for measles encephalitis – it always has been, and remains, a lottery – the risks are low (1 in 1000 cases overall, 3 in 1000 for the over 30’s), but the stakes are devastatingly high.

Public Health England are absolutely right to launch a vaccination catch-up campaign across the country rather than just in South Wales. It would be tragic indeed if we waited for an epidemic to break out locally before anything was done, and there are many areas in the country where the drama of what has happened in Swansea could be re-enacted at any time. There is no reason to wait to hear from someone about this either – if you or your child are not fully protected (by either a clear history of having had measles, or two MMR vaccinations) then you can go to your GP this week and ask to be vaccinated. There is no upper age limit. There is also the interesting phenomenon that the children who may have missed out on MMR when they were younger are getting to an age where they can, and should, express their own views and may wish to contact their GP for advice themselves.

A final word about the situation for younger babies, which is a little more complicated. Under 6 months the MMR vaccine is not licensed, and should not be given. These babies also have a great deal of residual immunity from their mothers and so are not at great risk. Over 6 months the vaccine could be given if there was felt to be a significant risk – for instance if someone was planning to visit South Wales. This would be based on parental preference, and is not a clear recommendation. The problem with vaccinating earlier than the usual schedule is that the maternal immunity can neutralise the effects of the vaccine, and so any MMR given early does not ‘count’ towards the schedule and 2 further doses will still be required. For the most part it is best to wait and undergo the usual vaccination programme schedule.

Whooping Cough Vaccination for Pregnant Women: Neat Idea, Missed Opportunity

New medical advice is transmitted at such lightning speed these days that GPs and their patients often have to work their way through it in tandem. This was illustrated to me quite starkly on Friday morning with the announcement of a new, temporary vaccination programme in the UK for pregnant women to protect their children from whopping cough. The first I heard about the proposal was on the radio over breakfast, by mid-morning I learnt that all GPs had been sent an e-mail with the new instructions, and before lunch I was trying my best to advise one of my pregnant patients on the issue. Funny how you can feel reasonably up-to-date on Thursday evening, and behind the times only 12 hours later!

Having had the luxury of the weekend to actually read the information from the Department of Health I feel a little more prepared to advise women in the coming week – and this is what is required of a GP these days. It is not sufficient simply to adhere to the Government line on these matters; patients expect, and deserve, a doctor who will consider medical advice carefully and be willing to give thoughtful guidance. And my conclusions? In a nutshell, it’s a great idea, but why, oh why, oh why are the Department of Health not conducting a proper clinical trial?

The proposal is to vaccinate all pregnant women between 28 and 38 weeks gestation against Pertussis (whooping cough) as a temporary programme in response to the significant rise in infection rates in the last 2 years. And whatever else we think, it is certainly a neat idea. We do have a problem with Pertussis at the moment, both in the UK and worldwide. The number of confirmed cases so far in the UK in 2012 is nearly 5000, compared with around 1000 for the whole of 2011. There is no doubt that this is in part due to greater awareness of Pertussis at the moment on the part of doctors (myself included) and so increased diagnosis of cases in adults that would previously have been missed. However, this seems to be more than just an artefact, since there has been a sharp rise in the number of cases in infants under the age of 3 months, many of whom become very unwell and in whom diagnosis will always have been much more accurate. It is the very young who are the concern with Pertussis, since they will not yet have immunity from the vaccination programme, and their small lungs are especially vulnerable. So far in 2012 there have been 9 deaths in babies in the UK, and many more will have been seriously unwell.

How best to protect these babies? Well if everyone was immunised then there would be no-one to transmit the infection to them (the protection afforded by herd immunity), but this is extremely difficult with Pertussis since the protection afforded by vaccination wanes within a few years. Unlike the recent measles epidemics where poor uptake of MMR is clearly to blame, most cases of Pertussis in older children and adults occur in people who have been fully vaccinated. A programme where everyone was immunised every 5-10 years would work, but the cost of this would be enormous.

The beauty of vaccinating pregnant women is that we know the woman will make antibodies against the disease, and that these can cross the placenta in late pregnancy, be taken up by the baby and could afford protection in those crucial early weeks until the childhood vaccinations have kicked in. A single vaccine therefore protects exactly the at risk individual, and there is no need to depend on herd immunity. When a mother chooses to accept the vaccine she is choosing to protect her own child – the personal potential benefit is very clear.

We have good reason to think the vaccine is safe. It is a killed vaccine, which means it cannot possibly cause active infection, and these vaccines have reliably been shown to be safe in pregnancy. The vaccine also contains diphtheria, Tetanus and Polio vaccination (there is no single Pertussis vaccine so the combination has to be used) and the first two of these have often been used in pregnant women without difficulty. While there is not much data for this exact vaccine it seems extremely unlikely that there are any risks other than local reactions in the arm and very rare allergic reactions, and only vaccine conspiracy theorists are likely to argue against this.

It is also likely to work. I agree with the conclusions of the expert committee that:

…it is reasonable to assume that this approach would provide young infants with some important, although possibly not complete, protection against pertussis, and it is likely to be the most effective immunisation strategy to provide protection to young infants.

The report also state, however, that

the effectiveness of prenatal immunisation against pertussis to protect young infants is uncertain.

There are reasons to think it might not work. Will the maternal antibodies be sufficient to truly protect? Is there any risk that the antibodies might actually interfere with the response to the infant vaccination programme, and lead to reduced immunity later in childhood? So what should a scientist do when he or she has a good hypothesis which is uncertain: Test the hypothesis with a trial. There is such an opportunity here to answer this question for both the current and future generations – we need to conduct a Government funded, blinded, randomised clinical trial. Instead of rolling out this temporary programme as a knee jerk reaction, pregnant women could be offered the chance to be in the trial. They would receive either the vaccine or a placebo injection, meaning adverse reactions in the pregnancy could be compared, as could infection rates and outcomes in the babies.

Within a year we would start to get a real answer to this question. If it works then this could become a permanent and valuable addition to our fight against this serious disease. If it is shown to be ineffective then we could stop wasting time and money, go back to the drawing board and look for a better solution. What is more, the vaccine itself would be protected against unfounded claims of harm. Sadly the background rate of stillbirth is sufficiently high so that the Daily Mail headline “Whooping Cough Vaccine Killed my Baby” might as well have already been written, and without the robust clinical evidence available from a randomised trial these inevitable anecdotal stories will be much harder to evaluate. Granted, the trial would need to be large and the cost would not be insignificant, but the long-term gain of truly knowing how to protect babies from this infection must surely be worth it.

So how should I advise my patients in the lack of proper trial data – well it is a shame we shall never know for sure, but the issue is important enough to take action, and the balance of risk has to be in favour of the vaccine.

Miscarriage and Stillbirth – a Chance to Say Goodbye

There are so many good people out there, doing excellent things in our society, that it is rare to find someone engaged in something truly unique – but every so often you do come across a person, or an organisation, that has started something new and is meeting a need in society that has previously been ignored. Usually this comes about because someone has found themselves to be in need, looked around and found nothing out there – at which point most of us complain for a bit, suggest someone should do something, and then get on with our lives. When that person is full of drive, energy and determination, however, they might just rise to the challenge, fill the void and come up with something special.

Zoe and Andy Clark-Coates are just such people, and have turned the personal tragedy of recurrent miscarriage into a remarkable charity called Saying Goodbye. They have kept their remit simple, with their aim being to arrange remembrance services for couples who have lost a baby either in pregnancy or early years, but are not short of ambition – the services are held nationally, and in some of the grandest cathedrals in the land.

There is no shortage of testimony from couples who have found these services hugely beneficial as they come to terms with their own bereavement, and it is interesting to consider why there might be such a need for these shared experiences of grief. In part, I am sure it is because of the success of modern medicine. The death of a child is such a rare event in Western society nowadays – a cause for celebration for society as a whole, but a source of isolation for those who do still suffer the tragedy of losing a child. In times gone by the grief felt by those who lost a child would have been no less acute, but they would have been surrounded by family and neighbours who understood and who could share their pain. The services organised by Saying Goodbye hope to give people the opportunity:

‘To just stand in a room with hundreds of other people who have all been through a similar experience, knowing everyone is there to support one another, will be such a powerful moment, and we hope it will be life changing to many

Another, perhaps more complex, reason why these services will be significant is the uncertain status of miscarriage in our society. There is no ambivalence surrounding stillbirth – women suffering from this much rarer event are afforded the full legal and emotional status of one suffering a major bereavement, and few would argue that it is not a more significant trauma than a miscarriage in the first three months of pregnancy – but where does that leave those who do suffer miscarriage? Are they allowed to grieve? Their loss is afforded no legal status – there is no death certificate and no burial – the child they have lost is often euphemistically referred to as “the products of conception”, and society frequently expects a rapid return to normal life. Early pregnancy has an ambivalent status in our culture, as we struggle to hold two contrasting values. On the one hand we do try to acknowledge the weight of loss suffered in a miscarriage, while on the other we place a high value on the freedom of choice when it comes to the decision to continue with a pregnancy and the role of termination. There is an inherent tension between these two positions which society is unlikely to resolve, and I suspect it is easier for our collective conscience if it is miscarriage that loses out. Services of legitimised remembrance in the awe-inspiring setting of a cathedral may help to redress this imbalance.

The services are open to people of any faith, or no faith at all, and the intention is to be as inclusive as possible. They won’t be for everyone – people are naturally resilient, and when sorrow occurs most of us find our own way to come to terms with what has happened. For many couples who lose a baby in pregnancy they will have worked their own way through their grief and will not feel a need to revisit their loss. One thing I have learnt about grief, however, is that there is a danger in both too much grieving and too little – and that the ‘right’ amount of grieving is different for every person. Too little opportunity to grieve shackles us to the past and we are afraid to move on for fear of leaving some of ourself behind, while if we focus too much on the process of bereavement we may forget that we have both a present and a future. For those who are on the painful journey of bereavement there are no easy answers and no shortcuts, but for some the services organised by Saying Goodbye may provide some life-giving refreshment along the way.

To find out more about Saying Goodbye, visit their website: www.sayinggoodbye.org, or follow them on Twitter: @SayingGoodbyeUK

On Tesco’s Late Equaliser and the Value of Bite-Sized Chunks

I was delighted to hear from Tesco yesterday in response to my campaign to change the labelling of breakfast cereals in supermarkets. Three letters and a few tweets have finally borne fruit, and Tesco are following Sainsbury’s lead by removing the misleading signs from all their stores. If you have not been following my campaign against the concept of “Children’s Cereals” then you can follow the story in the blog here, here and here. I was even more pleased when I had cause to visit my local Sainsbury’s later that day to find that their signs have indeed disappeared as promised.

Cereals for all – Tesco are removing the sign denoting children’s cereals

It is comforting to know that I will now be able to venture into both stores without having my blood pressure challenged in the cereals section, but this is only a small part of a wider public debate on how we treat our children: If we believe that children will only eat food that is coated in sugar or high in saturated fat, then the chances are that they will grow up wanting to eat food that is coated in sugar or high in saturated fat. It is a debate that we must keep in the public domain, and a war that must be waged on many fronts.

It struck me that there is a parallel with many seemingly insurmountable health problems here, and that this has been a helpful lesson in the immense value of breaking down problems into bite-sized chunks. My overwhelming problem is the challenge society faces with the frightening increase in childhood obesity – surely it is impossible for me to impact this and it seems ridiculous to try. Even if I break it down to the role of the supermarkets and how food is marketed to children I am still defeated into a state of inactivity, believing I cannot succeed. Reduce it further to the issue of two small signs in the cereal aisle and I am starting to think about action – still not confident that I will succeed, but willing to give it a go. And it turns out that it was possible after all. I haven’t changed the world, my problem has not gone away, but I have changed something, and perhaps I can now change something else.

So too with health problems. Maybe I feel crushed by my failure to lose weight, cannot consider how to face the week without the comfort of a bottle of wine or am overwhelmed by anxiety every time I consider venturing from my home. The scale of my problem is so great that my spirit is broken from the start, and I tolerate the status quo for months, even years, because I cannot even imagine any other way. The way forward has to be to imagine a different future, look at the problem in a new light and find a bite-sized chunk that I know I can break off, where I have some confidence that in a small way I can succeed.

So with weight loss – to set the challenge of losing a certain amount of weight in a set time often sets us up to failure – but perhaps it is not so unrealistic to aim to make one small change: maybe the biscuit with your coffee becomes an apple, maybe three potatoes becomes two, or the lift is exchanged for the stairs. The lover of wine might not be able to contemplate cutting down to recommended limits just yet, but perhaps they can consider having one day a week that is alcohol free; and the person with anxiety may not be ready to book a holiday to Venice, but could they find a friend to help them and venture somewhere new just a little outside their comfort zone?

When we break things down it is vital that we are careful how we measure our success. If I were to measure my campaign against the level of childhood obesity in the UK I would clearly see no impact at all and might berate myself for trying. In the same way, if you challenge yourself to change a biscuit to an apple, assess your success on just that – have you kept your promise to yourself and are you eating fewer biscuits? It is unfair to measure your success only in terms of the bathroom scales – that will come in time, but we need minor victories along the way to win the war. Success is empowering, and we need to practise it if we are to overcome the more intransigent problems, both in our own health and in society.