If It’s Good Enough for Wiggo – Marginal Gains and Health

Sir Bradley Wiggins is a truly extraordinary athlete, but I am sure he would be the first to admit that his achievements in recent years are in large part due to the inspirational leadership of his fellow recently appointed Knight of the Realm, Sir David Brailsford. Sir David, in large part, puts his own success down to the holistic approach he has taken to improving performance – the concept of Marginal Gains. He explained the idea to the BBC during the high point of this summer of success:

“The whole principle came from the idea that if you broke down everything you could think of that goes into riding a bike, and then improved it by 1%, you will get a significant increase when you put them all together.”

Since the Olympics, people have begun to realise that there is no requirement within the concept of Marginal Gains to have spokes, wheels or a crash helmet, and disciplines unrelated to sport are using it to develop their thinking. Teachers are leading the way in the classroom and business bloggers have also latched on to the concept. Increasingly I have found myself talking about it in the consulting room, and wondering how doctors and their patients could learn from Sir David’s idea.

Health problems often leave people facing huge, seemingly insurmountable challenges. How can I get a good night’s sleep? What can I do about my weight? How do I stop my teenager shouting all the time? The success of medical treatments for simple, single cause health problems can often lead to both doctors and patients searching by default for that elusive single solution when faced with more complex issues – which leads to frustration and demoralisation when the problem remains unmoved by this approach.

Sleep difficulties are a good example. Losing sleep night after night can be so debilitating that the prospect of a single, simple solution is understandably very attractive – which must explain why the idea of a sleeping tablet is so seductive for both patients and doctors. The patient’s motivation to reach for a quick fix that might guarantee a full night’s sleep is perhaps more noble than the doctor’s temptation to resort to a tablet in order to bring a rapid conclusion to the consultation, but both are equally understandable when other solutions seem to offer less hope of a cure. The siren call of a sleeping tablet, however, is often less effective even in the short-term than we might expect, and brings with it the very real dangers of tolerance and dependence.

I might suggest that an insomniac tries a warm bath before going to bed, or keeps the room well ventilated at night, to which I will often receive the ‘done that, been there’ response, or the raised eyebrows of someone who really can’t see how that would help, and thinks I am trying to fob them off. The problem is that we often evaluate health solutions in a linear fashion – an approach that goes: ‘If this doesn’t work, try that’ as we work through one solution after another until we hit the jackpot. There are merits to this when it comes to some aspects of medicine – like using medication or arranging investigations where to try several things at once could be hazardous, but there are many health issues that could benefit from a more holistic way of thinking, both by doctors and patients.

There is nothing new to the concept of holistic health care, but this is often in the context of teaching doctors how to think holistically about their patients, as is enshrined in the GP curriculum for trainee GPs. What we may have neglected to do, however, is to find ways of helping patients how to think holistically about themselves. I wonder if there is an opportunity within health to use the concept of Marginal Gains, and its current high profile in the public consciousness due to the success of the British Cycling team, in order to encourage a different approach to solving health problems.

If having a hot bath before bed only gives a 1% extra chance of sleeping well, what would that mean if it was combined with a 1% improvement by having the right pillow? A similar gain might be achieved by a cup of hot chocolate, a well-ventilated bedroom, a ‘stimulation curfew’ after a certain time in the evening or going caffeine free. How many more marginal gains could we think of? Relaxation tapes, getting enough exercise, and eating earlier in the evening could all make their contribution. If they added together they could really start to make a difference – and even one good night’s sleep could reduce the dread of going to bed by a further 1%, bringing its own marginal gain in a virtuous cycle of improvement. Where we apply marginal gains we need to expect only marginal improvements – which will mean we will be less inclined to lose heart and give up when we don’t see instant results.

We could apply the same principles to many other health problems – where are the marginal gains for improving your relationship with your teenage children for instance? What small changes could start to add together in your life-long battle with your weight? What minor adjustments could you start to make to reduce the risk of burnout at work? It’s not glamorous, sexy medicine, but all too often the glamour in medicine turns out to be a mirage that lacks substance, or even does harm. In the gritty reality of the lives of real people maybe the hard, but achievable, graft of looking for marginal gains is a more honest and worthwhile approach to making a difference in health problems. And best of all, not only do you not need to become an Olympic athlete like Sir Bradley to apply start to think this way – you don’t even have to grow sideburns!

I’m sure I have more thinking to do on this one – more working it out in practice with my patients…expect more blogs to follow!

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.

Sainsbury’s 1 Tesco 0 – Still Time for an Equaliser

I can’t say that it comes naturally to me to sing the praises of a major corporation, but here goes: SAINSBURY’S: THANK YOU FOR LISTENING! WELL PLAYED!

Unaccustomed as I am to writing letters of complaint, it was with high enthusiasm but low expectations that I set out to write to two leading supermarkets about their unneccessary categorisation of cereal products into those suitable for children and those for adults. The unhelpful message to children and parents that the sugary and chocolately varieties of cereal are the only ones a child can be expected to eat has been my obvious concern. I have charted the progress of my single-handed campaign in this blog here and here, and am delighted to report an update:

On Monday I received a letter from the Head Office at Sainsbury’s saying that they had reviewed the matter and agreed with me – as such they are taking down all the signs that distinguish adult and children’s cereals! I have been skipping about for the last two days with my faith restored that one person can make a difference, common sense can be listened to, and when a company says it is committed to promoting health it is not all just hot air! I’ll say it again: Thank you Sainsbury’s!

The letter advises me that the signs should all be gone by the end of July 2012, and if I see any after that date then to please let the store manager know, or contact head office again and they will take action – so look out for them disappearing and please leave a comment here if you see one in August!

Now, come on Tesco – time to raise your game and respond in kind! There is still time for that equaliser! I’ve been reading how instantly Twitter can get a response from a the PR department of major companies these days, so a little tweet might be in order to nudge Sainsbury’s rivals into action!

It’s surprising how exhilarating it is to feel you have made a difference (I know this is a small matter really, and hardly item number one in the public agenda, but please don’t deny me my little moment of triumph!) I might even get used to this complaining thing – I think there are more letters in me. Hey, then I could graduate from being a cereal protester to become a serial protester!

Sainsbury’s Action Letter The positive response from Sainsbury’s

The right not to be lectured to

I recognise the signs now. They vary, of course. Sometimes it is the slight drop of the shoulders, the hangdog expression, the look of learned helplessness and defeat. Or it might be the just opposite – the set jaw and steely look in the eye that says: ‘Go on, then! Just you try, I’m ready for you!’

It usually happens in the second half of the consultation. We have talked about the problem, looked at the offending body part that has caused the symptoms and begun to skirt around the cause or hint at solutions, but we both know it is coming. There is no way around it – we are going to have to talk about weight. The best thing we can do is get it over with as quickly and as painlessly as possible.

I feel for my overweight patients. You can lie to me about how much you drink and admit to only half the cigarettes you smoke. You can even claim to actually get your money’s worth from your gym subscription and I will happily believe you, but you cannot leave your weight at home when you visit me or pretend it isn’t there. You know your heartburn/diabetes/foot pain/arthritis is largely down to your weight and all you can do is steel yourself for a lecture while you sit in the waiting room.

And now the Government tells me we have to have this conversation every time you come to see me.  You might come about a cough, a cold or a wart on your finger and I am to talk to you about your weight. Burst into tears with depression,    troubled with your periods, stressed at work or worried about your elderly demented mother – if it looks like you might tip my scales then I am to make every contact count and talk about your weight. And while we are at it, what about your smoking, drinking and that underused gym subscription…?

The Government has accepted in full the recommendations of the NHS Future Forum which includes the concept of making every contact count – that all health professionals, whether GPs, pharmacists, dentists, nurses or anyone else that has a professional contact with patients, should promote healthy lifestyle measures every time they see someone, whatever the reason for the contact. What is more, the recommendation is that: ‘To emphasise the importance of this responsibility, the Secretary of State should seek to include it in the NHS Constitution.’

The NHS Constitution is a list of the rights and responsibilities of patients and professionals with respect to the NHS. It is an important and helpful document that shapes health policy rather like the Human Rights Acts shapes legal judgements. I don’t deny that there is a responsibility of health professionals to promote health and well-being, as well as to diagnose and treat ill-health and disease. However, where, alongside this responsibility and the patient’s right to receive lifestyle advice, is the patient’s equally important right not to be lectured to?

Like all GPs, I regularly talk to patients about their lifestyle – where it is appropriate. The idea that GPs should promote good health has been enshrined in the very fabric of the GP consultation since at least the 1970’s. I am not afraid to confront quite forcefully when it is needed, and I know it can make a huge difference to a patient who is ready to change. I will always remember seeing a man in a hospital clinic many years ago who had recently had a stay in hospital with his first episode of angina. ‘Can you thank that young doctor who admitted me?’ he said. ‘She so frightened me about my smoking that I handed her my packet of cigarettes and haven’t touched one since!’  I was only too pleased with the result, and to pass on his thanks. What I decided not to tell him, however, was that rather than waste his cigarettes she had smoked every one!

However, there is a major difference between challenging a patient when they are ready to consider change, and lecturing, nagging and bullying patients when they are not. The latter is not only irritating and stressful for the patient, but also counter productive in terms of psychological theory – one of the basic premises of which is that if someone is not receptive to change then you should stop pushing (you can find out more about this by reading about Motivational Interviewing if you are interested). If I have not seen someone for a while then it may well be worth raising the issue of smoking even if they have come in for a quick chat about something else – maybe they are ready and I can strike while the iron is hot – but many of my patients I know better than that. We will have talked about smoking, or weight, or whatever, many times before and sometimes they just need to know they can have a break – permission to see me without being told off, without feeling guilty.

I don’t think this paper will change anything at the moment, but I worry about where the Government will go with it. Once they start to enshrine it in the NHS Constitution it is only a step away from red tape and performance targets – nurses spending yet more time away from the patient while they tick the box marked ‘Making Every Contact Count’, GPs being paid according to how often they raise lifestyle issues regardless whether the patient wants it, pharmacists being incentivised to talk about lifestyle rather than actually answering the patient’s queries – and patients being afraid to come near us all for fear of yet another lecture.

Healthy Eating – if only it were that simple.

England’s Chief Medical Officer, Dame Sally Davies, recently launched the Government’s obesity strategy by stating that ‘people need to be honest with themselves about what they eat and drink, in order to tackle rising obesity levels.’ Well it was not hard to predict the reaction to describing a few words of common sense advice as an obesity strategy: ‘Pathetic and stupid,’; ‘deeply disappointing’; and ‘lacking substance’ were just some of the predictable responses reported in the media. And yet, had Dame Sally declared a package of tighter regulation on our food industry I am sure other voices would have been quick to play the ‘Nanny State’ card, or accused the Government of squeezing industry in a time of recession. Who would want to be Chief Medical Officer?

The problem is this: What does it mean to ‘be honest with ourselves about what we eat and drink’? I might want to eat a healthy diet, and be faultless in my self-analysis of my eating habits, but do I know what ‘healthy’ is? How can I understand it when so much of the ‘healthy eating’ advice is mutually incompatible. For instance, for healthy bones I should make sure I have plenty of calcium in my diet, which primarily comes from dairy – and yet aren’t milk and cheese top of the evil list when it comes to cholesterol? To get my ‘good’ levels of cholesterol up, shouldn’t I eat plenty of oily fish and nuts – but on the other hand, while these high fat foods might have the right type of fat, it is still fat – and that means calories. If I want to lose weight then a bowl full of nuts is the last thing I need. Too much red meat is bad for my cholesterol and might even increase the risk of bowel cancer – but if I become a vegetarian will I get enough iron?

On the whole you can work your way through this minefield by applying the general and simple principle of moderation in all things, but the area of junk food, cholesterol and obesity is particularly difficult and often leads to an understandable bewilderment in the patients I see. Many overweight people say two things to me – firstly that their diet is healthy, and secondly that they do not overeat. And you know what? I believe them. I don’t think they are caught in some complex web of self-denial and deception, or that they instinctively lie to their doctor. Sure, there is probably the odd biscuit that sneaks its way in unnoticed, the occasional chocolate that slips in under the radar, but on the whole I detect genuine frustration that trying to follow the correct advice in the kitchen has not led to results on the scales.

What is at the heart of this is that while the healthy eating advice concerning cholesterol might overlap with that which relates to obesity,  we would do well to consider them as quite distinct and not blur the edges between them. Junk food, red meat and animal fat are primarily a problem for your cholesterol and heart disease – it is perfectly possible to be a normal weight and only eat beef burgers, or to be obese when you primarily live off salad. We know this from the natural world around us – the giant panda is synonymous with plump and eats only bamboo, but who can ever recall seeing pictures of an overweight lion? We also see it in the very poor correlation between weight and cholesterol. Some very obese people have exemplary cholesterol levels, while other very thin people can be stunned to find their blood cholesterol at the high-end of the scale.

At the end of the day, our weight is not dependent on the type of food we eat, only the calories that food contains. Certainly high fat food makes it easier to over-consume calories – fat is the most calorie dense type of food so a small volume will have a lot of calories – but even a ‘healthy’ diet can have too many calories if there is too much of it.

So if the real challenge is simply to eat less, why is it so difficult? I think part of the challenge is that many people who are over-weight are not currently over-eating. If your weight is stable (which is often the case even for people who are over-weight) then you are eating as many calories as you burn off – which is why I believe people when they say they do not over-eat. The problem is that if you want to lose weight you have to under eat, and this is something altogether different.

The challenge of under eating – as well as involving moments of hunger, denial and a great deal of will power – intrudes deeply into the realm of culture. What we put on our plate has as much to do with habit, social niceties and learned behaviours as it is driven by basic physiological needs. Psychologically we expect a plate to be a certain percent full. Too much and it looks greedy, too little and it seems mean – this is all to do with visual perception and learned norms, which is only loosely connected with how hungry we are, or how full we will be after we have eaten. Were it not so then no-one would ever push their plate away, having eaten every last crumb, and moan that they have eaten too much.

If you are used to putting four potatoes on your plate it has to become an act of conscious will every time you serve your dinner to put only three. It will take many repetitions for this to become learned behaviour. Even more challenging is if someone else is serving you. Imagine this scenario: I am under-weight and always have been. I like cake, and could do with eating more of it. It is my turn to slice the cake, and I am with someone who I know would like to lose weight. What do I do? The sensible thing would be to cut myself a large slice and serve a smaller piece to my friend – but the rules etiquette won’t allow it. It seems greedy to take a large slice, and mean to my friend. As well as denying them extra cake that I know they would enjoy, it also makes a clear statement that they need to lose weight and I do not, which is just plain rude. Without their express permission I am going to give us both the same size slice of cake – maybe a big piece as I am hungry. And just because they gave me that permission last week doesn’t mean I can assume it today – they may have given up trying to lose weight and the last thing they want is to be reminded that they should still be trying.

It is possible to eat less and lose weight, but we would do well to look at how much we eat rather than place the emphasis on what is healthy, and we need to tackle the cultural issues head on – for instance by deliberately changing to a smaller size plate, or to enlist the help of those close to us – giving them a ‘blank cheque’ to serve us smaller portions and help us to change our deeply entrenched behaviours. I don’t think Government policy can help us much here – at the end of the day (and my over-weight patients tell me this more than anyone) it is down to us.