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Dr Suzie Edge started the What If Health podcast to explore people’s thoughts and experiences on many aspects of lifestyle medicine.

It was exciting to be invited on and, well, we could have continued for hours! Fortunately for listeners, Suzie’s editing skills mean it’s only an hour long and it’s out today. You can download it from iTunes or Soundcloud or hear it on the What If Health website.

We talked about workplace health and office cake, of course, but also the challenges of the general food environment, the Public Health Collaboration, the Dept of Health’s new prevention focus, dietary guidelines, lifestyle medicine and more. 

Hope you enjoy it!
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Main photo source: https://www.lifestylemedicine.org/What-is-Lifestyle-Medicine

Lifestyle medicine is becoming more prominent.  It’s an approach to medicine which uses lifestyle changes (for example in nutrition, physical activity, sleep, stress management and social support) to prevent, treat and reverse chronic diseases.  

In the UK, GPs Rangan Chatterjee and Ayan Panja are well known to TV viewers for BBC1’s Doctor in the house and Street doctor respectively, both using a lifestyle medicine approach to improving health. Dr Chatterjee’s lifestyle medicine book The Four Pillar Plan topped the book sales charts for weeks when it was launched earlier this year and Dr Aseem Malhotra and Donal O’Neill’s 2017 book The Pioppi Diet – A 21-day lifestyle plan continues to be a best seller. GP Dr Rupy Aujla’s website and accompanying book The Doctor’s Kitchen promotes food as medicine and he has 120,000 followers on Instagram. Every week the media report new research, books and stories about the importance of sleep and physical activity, mindfulness and managing stress on our health and wellbeing. And updates about the gut microbiome’s role in physical and mental health are very exciting. So it appears that the lifestyle medicine approach might be starting to make sense to the public.

But although professional lifestyle medicine associations are established in the UK (British Society of Lifestyle Medicine (BSLM)), Europe and internationally, it looks like GPs and other healthcare professionals are not always supported in their efforts to use a lifestyle approach with their patients.  


At the recent Inspired Medics Lifestyle Medicine Conference in Leeds, I spoke to several GPs who were keen to use a lifestyle medicine approach but were not supported by their GP partners. “It’s not proper medicine” and “you were trained to treat sick people with medication not to advise them on nutrition” were typical admonishments.  This is interesting because the use of nutrition in medicine is not exactly new. Hippocrates is reported to have said, “Let food be thy medicine and medicine be thy food”…


However, as a 2017 BMJ (British Medical Journal) article entitled Students need to understand the role of diet in health promotion and disease prevention pointed out, “The National Institute for Health and Care Excellence guidelines state that a first line intervention for diabetes, obesity, and high cholesterol is to give “lifestyle advice”—but this phrase is so vague that it is left up to doctors and patients to define it and, potentially, ignore it” (my bold text)(1). Supporting this comment, many questions to the panel of speakers at the end of the Inspired Medics conference asked whether a lifestyle approach met NICE guidelines and asked for guidance and evidence to support lifestyle medicine efforts.   One of the speakers, Dr David Unwin, a GP from Merseyside, reminded delegates that NICE recommends that with type 2 diabetes patients, an individualised approach (para 1.3.1) and low glycaemic index sources of carbohydrate (para 1.3.3) should be used – both lifestyle medicine approaches.


Dr Unwin’s presentation outlined how he has worked to improve the health of type 2 diabetes patients in his surgery (not an affluent area) using lifestyle advice, all within the usual 10 minute appointment slot. In fact, not only is patients’ blood sugar successfully managed, around half could be said to be in remission, ie technically no longer diabetic. So successful has this approach been over recent years that his surgery now has the lowest per patient spend on diabetes medication in the area, spending around £40,000 less than the average surgery in the CCG (Fig 1). If this could be replicated by all NHS GP surgeries, it would save the NHS £375m annually on diabetes medication alone – around half of the current total spend(2). But diabetes medication represents only about 6% of the cost of type 2 diabetes(2).  So if type 2 diabetes is being put into remission, the total costs including non-diabetes medication (cardiovascular disease medication constitutes the largest proportion of prescription costs for people with diabetes) as well as spend on short and long term complications will also reduce.


Fig 1: Dr Unwin’s Northwood Surgery diabetes mediation spend compared to other surgeries in the same CCG (reproduced with permission) 

Several conference delegates I spoke to had moved to the private sector, were working part time or had retrained in a lifestyle-related speciality such as functional medicine. They had suffered burn out or had lost their GP mojos through the strain of trying to treat patients within a 10 minute appointment, following protocols that tackled symptoms but not root causes.  Some of the speakers mentioned this, too – that becoming a doctor to help people but never seeming to improve patients’ health was very wearing. Last year, Rangan Chatterjee and Ayan Panja set up Lobe Medical to run Royal College of GPs-accredited lifestyle medicine courses. They have said that course attendees report increased energy and satisfaction at work, partly because they can see they are making a real difference to their patients. We are short of GPs so it makes sense to keep and motivate the ones we have and encourage medical students to take an interest, both in general practice and lifestyle medicine. In fact there is a growing student-led movement to improve nutrition training for medical students. Nutritank was originally set up as a student society by Bristol University medical students to promote awareness of the need for nutrition training for medical students. It has now spread to 15 UK universities plus others in Europe. Bristol and Cambridge universities are reportedly redesigning their student curriculum to increase nutrition tuition.



A parallel education focus is encouraging UK universities to include physical activity science and therapy as part of medical and health-based curricula. A recent report commissioned by Public Health England and Sport England found universities recognised the value of physical activity education for health professionals. Even more important, they seemed keen to make the changes. Report author Ann Gates, of physical activity advocates Exercise Works said, “A qualified doctor, nurse, midwife or allied health professional may see half a million patients during their professional career: this has enormous potential for advocacy and the promotion of physical activity.”   This concept has been given a boost by organisers of the free weekly 5k runs, parkrun, who partnered with the Royal College of GPs to launch parkrun practice earlier this year.  Over 450 GP surgeries have become ‘parkrun practices’, forming close links with their local parkrun. Staff and patients benefit from any or all of the parkrun benefits of walking or running, being outside n a green space, talking to others, volunteering and being part of a community.


Looking in as an interested observer, I perceive a real appetite for lifestyle medicine. It makes so much sense in terms of prevention and treatment.  Just think. Data from Dr Unwin’s patients shows that a low GI diet and lifestyle approach not only improves diabetes symptoms, it also improves liver function, blood pressure and lipid scores.  Other research indicates improvement with mental health, gut and kidney issues and cardiovascular health.  A win for patients, a win for GPs, a win for the NHS and a win for society.


So let’s hope the lifestyle medicine movement continues to grow.


Watch this space!

 

 

 

 

 

References
  1. Womersley K, Ripullone K (2018) Medical schools should be prioritising nutrition and lifestyle education. British journal of sports medicine 52, e6-e6.
  2. Diabetes.co.uk Cost of diabetes in the UK. https://www.diabetes.co.uk/cost-of-diabetes.html (accessed Oct 2018)
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Blog, News
After completing my training, I’m now officially a Public Health Collaboration ambassador. This is an exciting honour and a great opportunity to help a great group of people make a difference to public health… although I know the work won’t provide an easy ride. 

The Public Health Collaboration (PHC) is a charity dedicated to improving public health through diet (its hashtag is #RealFoodRocks). It is tackling the root cause of the UK’s health problems by working to improve the UK’s healthy eating and weight loss guidelines. It also works with GPs, diabetes nurses and other healthcare practitioners to offer more choice to type 2 diabetes sufferers in their treatment, highlighting the NHS-approved availability of a low-carb approach to put diabetes into remission. 

The PHC works closely with diabetes organisation www.diabetes.co.uk to introduce healthcare practitioners to a dietary approach to type 2 diabetes treatment and to provide support with this new protocol. For years, type 2 diabetes has been considered a progressive, irreversible ie terminal condition. But in recent years, thousands have used a low carb/’real food’ approach in combination with other lifestyle changes to put their diabetes into remission or even reverse it completely. Diabetes.co.uk has developed a 10-week low carb eating programme for patients which is approved by the NHS for GPs to prescribe.   It has also received CE Mark approval. At £30 this represents good value compared to the £300 – £375 the NHS currently spends per person on diabetes treatments (and that does not include spend on complications of diabetes which take up around 80% of the total annual diabetes costs of £14bn – 16bn). But this approach is new to the NHS and it will take time for health care providers to be confident to try something different. Recognising this, diabetes.co.uk developed a 30-minute learning module for GPs and other healthcare practitioners which has been approved by the Royal College of GPs.

More alternatives to drug therapy… and more hope
Another dietary lifestyle approach to type 2 diabetes reversal includes the very low calorie diet featured on recent BBC and ITV programmes, based on the DiRECT study. Therefore, alternatives to drug therapy exist for patients, once healthcare practitioners are aware of this. Patients value being given a choice in treatment protocol and, importantly, being given hope that their condition can be either better managed or reversed. 

Type 2 diabetes affects around 6% of the UK population but takes 10% of the NHS budget. With a third of the UK population estimated to have prediabetes, it is obvious that our struggling NHS could not cope if people’s prediabetes progressed to full diabetes. And the issues that lead to prediabetes and type 2 diabetes, also predispose people to other conditions such as obesity, cardio vascular issues, fatty liver disease, kidney problems and some cancers. Increasing evidence suggests that our carbohydrate-heavy diet, particularly in terms of sugars and starchy carbs such as flour, rice, pasta and starchy bread, is a major contributor to the obesity and diabetes crisis which is why the PHC is working to revise lthe UK dietary guidelines.

Exciting times ahead!
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What has workplace health and wellbeing got to do with reversing type 2 diabetes? A huge amount and it’s a very exciting opportunity. The problem is, employers are finding it hard to start a much-needed conversation with employees that would help. But there are simple (cheap) solutions.

Last night I sat in Committee Room 11 in the Houses of Parliament and listened to three doctors, a nurse plus two formerly-diabetic patients speak about how type 2 diabetes can be reversed with lifestyle change. The most important lifestyle change revolved around diet. But something they all mentioned was how our obesogenic (obesity-generating) environment makes it difficult to prevent and treat the disease.

Professor Roy Taylor told the All Party Parliamentary Group for Diabetes how patients could get into remission, but struggled to maintain it in our food-obsessed society. He said we must challenge society to change our attitudes to snacking (we are constantly told we must “close the energy gap”), the food environment and the hidden sugar in food. Dr David Unwin said we must do something urgently, and not accept diabetes as inevitable and that changing our food environment would help. Dr Campbell Murdoch, Geoff Whitington and Mark Hancock talked about the need to support patients in a challenging food environment. Geoff, Mark and nurse Catherine Cassell spoke of the hope patients feel when they’re given a chance to come off medication and reverse a disease that is traditionally seen as progressive and terminal.  (It’s not either of those things.)

How can employers help?

Increasingly there are calls for a societal ‘whole systems’ approach to tackle obesity and obesity-related non-communicable diseases (1, 2) such as type 2 diabetes, cancers, non-alcoholic fatty liver disease, cardiovascular disease and chronic respiratory complaints. These are largely preventable and cause the majority of deaths (3). Diabetes costs the NHS is over £1.5m an hour or 10% of the NHS budget for England and Wales which equates to over £25,000 being spent on diabetes every minute (4).

That employers have a role to play, alongside the NHS and politicians, has already been pointed out (5, 6). After all, we spend between half and two thirds of our waking hours at work (7) so the workplace is an important setting for encouraging healthy lifestyles (8-10). Employer organisations, including the Chartered Institute for Personnel & Development (CIPD) and Business in the Community recognise this (11,12) and NICE has guidelines for workplace health provision and leadership and line management responsibility. Professor Cary Cooper, president of the CIPD, said, “It’s the employer’s job to create an environment where employees can make healthy lifestyle choices” (12).

But office cake culture is getting in the way. My research into office cake culture found office cake changes employee eating habits and therefore is likely to undermine health and wellbeing programmes. Many employers invest in health and wellbeing initiatives such as standing desks, healthy canteen offerings, cycle to work schemes and employee assistance programmes. But failing to stem the tide of sugar flooding our workplaces undermines that investment. Having the best wellbeing initiatives but not reducing office cake availability is like going to sea in a ship loaded with all the best safety equipment… but without fixing the leak in the hull.

Last week I discussed this with two groups of employers – a group of doctors and a group of HR and wellbeing professionals. They all helped me realise there is a glitch in my ideas for reducing office cake consumption.

My idea, informed by my research, is that if you start a conversation among employees about office cake, you begin an empowering, employee-led process that would reduce cake consumption, maximise its social benefits and minimise its unhealthy consequences. You would also make it easier for employees to make healthy choices at work and therefore help prevent non-communicable disease.

This idea is based on a key finding from my survey of nearly 1000 UK office workers: 95% thought the ideal frequency for office cake was once a week or less – much less than it is typically available. Therefore, I’ve been reasoning that if people realise they actually agree on how often cake should be available, they would, with support and encouragement, figure out among themselves how to make that happen. The result: healthier, less sugary workplaces without mandated cake bans. Empowered, bought-in employees with agency to influence their workplaces for the good. More awareness of how small changes to an office environment or culture could have a positive impact on our health.

The glitch is that employers are reluctant to start the conversation, even if they recognise the benefits of a less sugary workplace. One senior health and wellbeing executive at a large organisation (a household name) told me the cake table at their office was known as ‘the trough’. Yet with squeezed resources and, until now, little awareness that office cake changes employee eating behaviours, tackling office cake is well down the wellbeing priority list.

Birthdays, meetings, holidays, feeling fed up – there’s always a reason to have cake

Our obesogenic world makes it harder to make healthy food choices at home, when out and about, and at work. The research found it’s becoming the norm to have cake and other treats in the office almost daily for many. Birthdays and other celebrations are the main reason, followed by leftovers from meetings and events. But people also bring goodies back from business trips and holidays (“it’s traditional”) and it’s used to reward (or ‘encourage’ people to do unpopular tasks), and it’s the obvious choice when kind-hearted colleagues fancy a treat and want to share it, or when they’re having a bad day and don’t want to be the only one having a sugary pick-me-up.

Add to this national workplace cake stall our natural propensity to seek out pleasure-giving, dopamine-secreting sugary rewards and we have one explanation for our obesity and diabetes crisis. One of the doctors I talked to said one of the teams in their workplace was staffed by about 16 people all wanting to lose weight. But they had a ‘treat table’. Talk about making it hard for themselves …

Office cake is the now the norm

One reason there is so much office cake around despite 95% thinking once a week is enough, is possibly because we are herd animals and it would take a brave person to risk being ostracised by their herd for suggesting cutting down on cake. So office cake becomes the norm because no one feels comfortable speaking up to challenge it. This is a crying shame if, as the evidence showed, there is consensus around how often to have cake. We are too polite for our own good. Offices are full of people on diets yet survey respondents said cake made it harder to stick to a diet (59%), harder to eat healthily at work (38%) and harder to control bodyweight (35%).

Shouldn’t we be making it easier?

Here’s an example of how a cake conversation does work. Melanie said she’d seen my TEDx talk on the subject and, after outlining the research results to her team, asked whether she should continue to bring a cake to weekly team meetings. They said they’d prefer it if she didn’t because if it was there they would eat it and they were all trying to watch their weight. The TEDx talk triggered a bit of openness by all parties potentially leading to a healthier team. And they could use that new openness to explore other health-related aspects of their workplace environment. A good result coming from a conversation about cake.

There are precedents for starting successful conversations around obesity

Perhaps it is not surprising that HR and wellbeing professionals and even medics feel uncomfortable starting the conversation. No one likes to risk conflict or to upsetting anyone. Overweight and obesity is a taboo subject, and office cake discussions are often emotive. Some managers fear losing a cheap, convenient way to boost morale or say thank you (although there are other ways to do this that don’t involve unhealthy food). Others fear a backlash, should triggering the conversation be misinterpreted as accusing people of being overweight or interfering in matters of personal choice.

Employers are not alone in feeling apprehensive about tackling the obesity taboo. A trial to investigate the effectiveness of brief, opportunistic weight loss conversations by GPs with obese patients reported that GPs were “nervous” about bringing up the subject of obesity. However, 81% of patients found the intervention “both appropriate and helpful” while less than 1% felt it was inappropriate to do so (13).

Similarly, plans to conduct an exploratory survey of obesity in nurses in England (14) were initially met with hesitation by senior personal across the health sector despite their acknowledgement that obesity among nurses was a problem. Fortunately their concerns were overcome and nurses were pleased that someone was trying to help. The Weight Initiative in Nurses (WIN) interim report said: “Almost without exception, the hundreds of nurses who visited our stand at RCN Congress thanked us for taking on this challenge and working with them to help them achieve and maintain a healthy weight” and “The enthusiasm with which WIN has been greeted by obese nurses as well as senior personnel and key stakeholders, and the interest expressed in expanding it beyond England, reaffirms the importance and value of the initiative and is helping to allay concerns about the sensitivities of tackling the problem.” (15).

These are great indications that people want to be helped to tackle their obesity and those in a position to help should not shy away from the challenge.

Time to grasp the nettle

OK, so starting a conversation is challenging, but does that mean it should be avoided? When nearly two thirds of the UK population is overweight or obese (16) and in the UK we spend more on obesity-related illness and diabetes treatment than on the police, judicial system and fire service combined (17), surely we need to grasp the nettle?

As well as societal and moral reasons for employers to engage in making workplaces healthier, employee health impacts the bottom line. Studies found employees who perceive their employers to genuinely care about their health are generally healthier (18.19) and healthy employees are more likely to be happier, more engaged and more productive (20-22).

UK overweight and obesity levels have almost doubled in the last 25 years (23). Type 2 diabetes prevalence has doubled in the last 20 years (4) and this is just the tip of the iceberg with a third of the UK population having pre-diabetes. Why? What has changed in the last few decades to predispose us to such illness? The food environment is one of the culprits, but at least we have a chance to influence the food environment in our workplaces. Tackling office cake really could help us all be healthier and help provide that support and hope everyone spoke about at the Houses of Parliament last night.

Let’s do it!

Eight ideas to make it easier for employers to start a conversation about office cake

  • Create a setting where discussing workplace food is appropriate, even expected eg a health and wellbeing event. Not got one planned? Plan one! Employees who perceive their employer genuinely cares about their health is more likely to be healthy (18,19)
  • Ask your workplace wellbeing champions to watch the TEDx talk then introduce the topic with colleagues. Alternatively, consult them about how best to broach the topic. They have the networks and local knowledge and could suggest appropriate ways to start the conversation. If you don’t have wellbeing champions, consider it. The Royal Society of Public Health runs Workplace Health Champions training plus other relevant qualifications.
  • Start a competition for the most creative, healthy cake alternative. Many people love a bit of team rivalry. Create a gallery of photos of healthy creations in a break out room or kitchen. Why not feature creative cake of the month on your intranet or employee magazine?
  • Ask leaders and managers to identify individuals and teams who might be amenable to/interested in a conversation. Trialling it in one group would provide evidence and generate confidence that a cake conversation has merit.
  • Be confident that initiatives around caring about employee health are appropriate and relevant for employers, and onsite food provision is part of that. Employers should feel confident consulting employees to discuss, survey and learn about employee food needs and preferences in the context of health and safety, improved productivity and wellbeing. All aspects of onsite food provision, cake culture, meeting refreshments, vending and catering for shift workers are relevant topics. The British Dietetic Association’s Work Ready initiative and NICE Workplace Health guidelines both recommend consulting employees and involving them in new initiatives. You could start by consulting on general food provision to start a general food conversation, then introduce a cake conversation at a later date. 
  • When situations have been identified or created where a conversation could be appropriate, share the TEDx talk (11 mins) and ask for reactions. Download the It’s time to rethink office cake research report for background, information and suggestions for ways to reduce cake consumption while retaining opportunities to get together socially at work.
  • If a the water’s been tested and people seem amenable to finding out more, consider conducting a short, anonymous questionnaire among employees to a) get people thinking and talking about it and b) get objective data on the prevailing opinion. Then that data can be shared and form the basis of a conversation.
  • It can start small. It might take months to get a conversation going across the whole company. Don’t be afraid to start small, test the water and work with enthusiasts at first.

Lou Walker is a workplace health and wellbeing consultant, specialising in obesity and office cake culture. She uses talks, training workshops and surveys to help improve workplace environments so that healthy choices become the easy choices. Visit www.louwalker.com to find out about how she can help your workplace become healthier and more productive.


References

  1. House of Commons Health Committee (2018). Childhood obesity: Time for action.
  2. A whole systems approach – Leeds Beckett University
  3. World Health Organisation (2018). Noncommunicable diseases fact sheet. Retrieved 26 June 2018.
  4. Diabetes.co.uk.
  5. Crisp, N. et al (2016). Manifesto for a healthy and health-creating society. The Lancet (388) No 10062, e24-e27
  6. Tackling obesity seriousy: the time has come. The Lancet Public Health (3)
  7. World Health Organisation (2013). Global action plan for the prevention and control of noncommunicable disease 2013-2020.
  8. Black, C (2008). Working for a healthier tomorrow.
  9. Heinen, L., & Darling, H (2009). Addressing obesity in the workplace: The role of employers. The Millbank Quarterly, 87(1).
  10. NiMhurchu, C., Aston, L., Jebb, S. (2010). Effects of worksite health promotion interventions on employee diets: A systematic review. BMC Public Health, 10(1).
  11. Chartered Institute of Personnel & Development (2018). Health and Well-being at Work, 2018
  12. Business in the Community. Workwell Model. Accessed 26 June 2018
  13. Aveyard, P. et al. (2016). Screening and brief intervention for obesity in primary care: a parallel, two-armed, randomised trial.
  14. C3 Collaborating for Health/The Healthy Weight Initiative for Nurses. (WIN.) (2018). Final report.
  15. C3 Collaborating for Health/The Healthy Weight Initiative for Nurses. (WIN.) (2016). Interim report November 2015 – November 2016.
  16. Health Survey for England (2017). Health Survey for England, 2016.
  17. Public Health England (2017). Health matters: obesity and the food environment.
  18. Tabak, R., Hipp, J. A., Marx, C., & Brownson, R. (2015). Workplace social and organizational environments and healthy-weight behaviors. PLoS One, 10(4).
  19. Lemon, S. et al. (2010). Step Ahead: A worksite obesity prevention trial among hospital employees. American Journal of Preventative Medicine, 38(1).
  20. Department for Business Innovation & Skills (2014). Does worker wellbeing affect workplace performance?
  21. National Institute for Health and Care Excellence (2015). Workplace health: management practices.
  22. Millar, M. (2005). Vielife-IHPM health and performance research study
  23. National Statistics/NHS England (2018). Statistics on obesity, physical activity and diet.
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