Tuesday 5 June 2018

The Catch 22 of health promotion: a case study

It was difficult for me to ascertain the precise details of what and how (the why was unambiguous) the founder of a gym in Manakau was doing what he was doing with his lifestyle programme for the obese. But, what was clear was that he is someone who knows how to get big people to regularly attend the gym. I was shocked, therefore to meet a man not content in his success, but someone in a quandary both professionally and personally.

Given what he has achieved, he seemed proud of the fact that he was expelled from school at 15 with no qualifications, barely able to read and write. From what I could gather, apart from a gym instructors qualification and a recent hypnotherapy course, he has received little formal training at all. Speaking with him, this is difficult to believe; his understanding of business and behavioural psychology is incredibly intricate; he is impressively knowledgeable.

Using trial, error, and judgement, an attractive, effective and sustainable exercise programme for obese individuals has evolved.[1]A holistic, personal approach encompasses all the elements of what has been reported to be an effective behavioural intervention in the scientific literature.[2]In fact, this initiative for sedentary individuals has been extremely successful with almost 200 participants losing up to a combined 1000kg per year. The founder of the programme was celebrated in the field and invited to talk at a whole variety of events covering topics from diet and exercise to behaviour change and addiction. He won awards in recognition of his work and was even nominated for New Zealander of the year.
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A programme aimed at obese individuals from south Auckland (the poorer region of the city), requires subsidies to exist. It is well established that poverty is a risk factor for obesity meaning that many with this condition are unable to pay for gym membership or fresh food etc. Moreover, to incentivise individuals who have been sedentary for many years and whom are almost certainly mortified at the idea of joining a gym, to start exercising it has to be free. Fortunately, since 1998, government funding for such programmes has been available.[3]GP’s refer individuals to a partner organisation that has the facilities to train high-risk individuals. That organisation can then be reimbursed for the cost of training that person. It seems surprising therefore, that the number of individuals being referred to this particular club has fallen dramatically.

The founder thinks he knows why, I am inclined to believe him, and the reason incenses me.

It’s fair to say that he is self-taught, with years of experiential on-the-job learning. What stood out to me is the insight he is able to glean from observation of the people and environment around him; a skill that I feel is overwhelmingly undervalued by the, ehem, “intelligencia”.

In summary, what he has learned is this: That obesity is as much a mental health condition as it is a physical one. Therapy therefore, must address psychological as well as somatic issues. As someone who is quite a closed person, when speaking with this man, I couldn’t help but notice myself sharing things about myself normally tucked safely away from the public eye. At no point however, did I feel disarmed and vulnerable, quite the opposite. I felt safe and as if he genuinely cared. No doubt this characteristic leads people to trust in him and feel more confident venturing into unfamiliar territory. Added to this is an understanding of many of the barriers to lifestyle changes; priorities (family, work, church), body confidence (mirrors and scales are things of the past in some people’s lives), financial pressures. All these issues are addressed first in a private initial consultation and then in an open group discussion at the end of every training session. The way this is done is in every way complementary of behavioural change psychology and a lifestyle facilitator’s ideal intervention. He is just doing what works. Using his perceptive judgement he continues to alter and improve his service. It just so happens that what he has discovered that works for his patients is in line with research findings and practice guidelines (funny that, when you think about how science works). It is infuriating to think that Tyler’s lack of formal qualification and accreditation may be preventing organisations from recommending that patients be referred to his facility.

Perhaps more to his disadvantage has been his outspokenness about the food industry. He is a proponent of a low carb, healthy fat diet (even though he runs a gym, he acknowledges the vital importance of diet[4]– kudos). While this alone is enough to cause controversy, he speaks of sugar consumption as an addiction (for which there is mounting evidence – or rather, exposed evidence[5],[6]) exploited, especially in low-income areas, by junk food companies. Neither of us are surprised, for example, that the first Krispy Kreme® shop in New Zealand is situated in Manakau. He is aware of the density of fast food outlets in the district and how it compares to more wealthy areas (highest in Manakau in case you were wondering). He is also prepared to bring this to the attention of policy makers, well aware of how, directly or indirectly, they are lobbied said companies. To me, this silencing is an open admission of guilt by the food industry of its role in the obesity crisis, but the power it has to hide this is frightening.
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Since my partner started research into vaccine design[7]I have had more conversations about the role of the pharmaceutical business. There are a lot of people wary of vaccines, in part because of the profits pharmaceutical companies make from widespread, mandatory vaccination. To this argument I often counter that pharmaceutical companies would make far more were children not vaccinated since treatment, particularly ongoing treatment, is far more profitable than a one-off shot. I have used a similar argument when it comes to health; “healthy” people are far less profitable than individuals with chronic conditions. Paradoxically, almost every report I have written for the last five years has begun with something along the lines of: “The burden of lifestyle disease is crippling the NHS[8], costing over 10% of the entire health budget and resulting in billions of pounds worth of lost productivity per year.”How can both sentiments be true assuming that private and public funds are not completely independent pots? Without knowing it, when confronted that the notion that lifestyle disease is a burden is rubbish, I was totally caught out and I had to go home and reflect upon the implications of this claim.

From a socialist perspective, it is true that unhealthy people require more from and are able to contribute less to public services. That is why they are there. However, sustaining public services is undesirable in societies which capitalists actually hold the power. Therefore, from this perspective, the goal is to manipulate the masses to a point where the costs of service provision exceed an ‘acceptable’[9]taxation rate or budget allocation and those who can afford the services they don’t really need don’t have to pay for those services for those who can’t and do. This goal is possible, happening in fact, because inequality is increasing in almost all developed societies. Furthermore, the voice of those at the top is by far the loudest despite this group representing the minority of the population.

In my opinion this trajectory is an inevitable result of the selfish human condition. More importantly though, I believe that what makes humans special is our ability to overcome our natural instincts. We are in the privileged position where we are not obliged to act solely in the interest of species continuity; the pressures against survival are so small. It is also short-sighted to dismiss the importance of inherited wealth (financial, health, education, location) and expect everyone to be able to climb the social ladder. Given my position as an almost middle class liberal[10]therefore, I consider it a duty to contribute to the fairer distribution of resources (I deliberately avoid the use of the word equal).

This point is not as far a digression from the question of whether the chronically ill are a financial burden or blessing as it may seem. For me, it means that the privatisation of health care is nefarious (see the USA for a perfect example) and that addressing the health of the nation is, above all, a moral issue. Until capitalism collapses in on itself (again)[11], or big food is held accountable[12], the fight against obesity cannot be fought from a financial perspective. People like the man I met are thus caught in a vicious cycle whereby they need external funding to survive, but the powers that be are reluctant to support such enterprises. I hope, and will dedicate effort to achieve, that while there is funding available, lifestyle programmes are judged based not upon their carefully written, referenced practice guidelines or the number of accredited health professionals etc., but their results. Long term results like those that have consistently produced in Manakau.

Dr Jelley



[1]These are individuals for whom surgery is too dangerous and medication is practically ineffective. For example, someone above a certain BMI must lose weight in order to be eligible for a knee replacement else the surgery might kill them or the knee will fail due to the strain.
[2]https://www.sciencedirect.com/science/article/pii/S0091743512001107
[3]https://www.health.govt.nz/our-work/preventative-health-wellness/physical-activity/green-prescriptions/how-green-prescription-works
[4]http://bjsm.bmj.com/content/early/2015/05/07/bjsports-2015-094911
[5]https://www.sciencedirect.com/science/article/pii/S2352154616300638
[6]https://www.ncbi.nlm.nih.gov/pubmed/24132980
[7]http://publicscientistno1.blogspot.com/2018/05/trust-me-im-vaccine-researcher.html
[8]The UK National Health Service which is essentially free to all; https://www.nhs.uk/pages/home.aspx
[9]In inverted commas because we all know about attitudes towards tax and tax avoidance by big business which I shan’t go into here.
[12]https://insulinresistance.org/index.php/jir/article/view/39/112#CIT0019_39

Friday 18 May 2018

Having hairy legs

I’m going to write about body hair. Specifically, my body hair. Perhaps an over-sharing warning would be appropriate… there you go.

For those of you that haven’t noticed, I have not shaved my legs for seven months. I think it’s fair to say that they have now reached natural equilibrium.

Consistent with the underwhelming nature of this blog i.e. my life, my motivation for allowing my leg hairs to grow is not exactly feminist. But, before I go into why I don’t shave, here’s a little about when I did.

Prior to boycotting leg hair removal, l chose epilating as my preferred method. I don’t like how shaving results in hairs growing back all stubbly and spiky and I certainly wasn’t going to dedicate time to it every 2-3 days to keep up appearances. Waxing can get pretty messy and is very faffy if you do it yourself, which I would because I’m not paying for the privilege. Hair removal cream just seems wrong. Epilating suited me as I only had to do it once a fortnight. I kept this up for over five years despite the effect it had on my skin; it got really tough and I would find hairs that hadn’t been able to penetrate through the top layer of skin but I ignored it because it looked OK as long as you didn’t get too close.

So what changed? 

The reason I stopped epilating was because when I moved to New Zealand I forgot my UK shaver adapter and couldn’t justify buying a new one.

Yep, that’s it. No Amazonian cry of feminism, no rebellion against the sexist expectations of women, not even a voluntary move to go “au naturelle” in a new eco-lifestyle. It was not a statement and, until now, I have not made it one.

To my credit, when faced with the disastrous situation of not being able to mechanically pluck my leg hairs, I didn’t immediately turn to one of the aforementioned alternatives. And it was summer so I had my legs on show every day. Nonetheless, there were a lot of factors that gave me the confidence to do it:
·      I tan easily and have blond hair[1]. Apart from the hair between my shins and my ankles, my hair is short, blond and fine. I have never shaved/epilated above my knees anyway so this was nothing new. So, from my thighs to my shins, I pretty much have baby hair.
·      I already have a boyfriend and he doesn’t care. Why I ever thought he would is a mystery given that he never noticed whether my legs were smooth or not.
·      I have been to virtually no fancy events that I have dressed up for in the last six months. The odd meal out here, gig there, even work has been really quite casual so there has been little pressure to “scrub up”.
·      I moved to the other side of the world where anyone who met me for the first time would just assume I’d always been like that. On the other hand this could have been a disadvantage given that I wouldn’t expect my current friends disown me for such a thing and I’d have to convince the new ones I wasn’t … well … weird I guess.
·      A girl I met in Fiji decided she could trust me because if I had hairy legs I must be “one of the good ones”.

All in all, I’d say that if I was ever going to do this, then was it. But, hair is a BIG deal! It has taken emotional effort for me to bare my hairy legs and here is my confession: I don’t like it and I don’t feel beautiful.

I feel that this would be a good time to highlight that I have been careful to specifically say “legs” throughout. This is because (and another reason there was no feminist statement made) I do keep my bikini line tidy(ish), I shave my armpits, I pluck my eyebrows and I wear makeup. The inconsistency and irony has not escaped me, so what was I thinking?! This is the first time I have asked myself this question and you, thus far interested readers, have the privilege of exploring the answer with me.

The expectation for, almost exclusively, women to shave legs, armpits, bikini lines, eyebrows, begins almost as soon as said hair begins to appear. This is the result of a longer-than-I-thought-until-I-just-Googled-it[2] history of hair removal from the justifiable reason of safety in caveman days, through the arguable ‘for hygiene reasons’ in the middle of the previous millennium, to the unsurprising influence of fashion and marketing in the 21stcentury. Ultimately, smooth is the virtually unquestioned, thoroughly entrenched norm.

Recently, a rebellion in hair removal has gained momentum on social media, particularly for armpit hair[3], which is definitely a good thing. However, it is a rebellion, it is a statement and while I’ll concede this usually has to happen before a paradigm shift, I’m not really thatperson[4]. Incidentally, when I stopped shaving my armpits I was totally fine with how it looked but I felt as though my BO was way worse! I’m not sure if anyone else noticed but I could smell myself and that really bothered me so, quite quickly, it was bye-bye armpit hairs for me. I’m sure that psychology played a huge part in my physical response, but it was getting me down, making me anxious and self-conscious to be around people so I decided it wasn’t worth it for me – again, I wasn’t trying to make a point.

Back to my legs. My circumstances were such that I didn’t have anyone to impress (I wasn’t working for four of those seven months) and I wasn’t dressing up. These had always been the two main motivations to get the epilator out, pronto. On the occasions since going ‘au naturelle’ that I did put on a dress and/or a nice pair of sandals, I felt as though having hairy legs made me look less attractive. I have short, muscular legs (thanks Dad) and those longer, darker hairs between my shins and my ankles, I felt, made me look like I had “cankles”. Yes, I preferred the look of the shape of my legs when they were smooth. I have virtually no body hang-ups and yet here I am, thinking that my hairy legs take away from everything else that I find attractive in myself.

Now, if that’s the truth, why didn’t I just shave like I did with my armpits? First of all, I told myself how ridiculous I was being. I have been blessed with many great features and I should be able to deal with this one imperfection[5]. Secondly, my skin now is great. I have no more in-growing hairs, no more bobbly spots near my knees and no more hard layer of skin on my legs. Thirdly, it’s really nice not having to set aside time to do it.

That’s really where I’m at now. We’re coming into winter and my tan is fading which means my hairs show up more and I feel less healthy. On the other hand, out come the trousers. Then again, I love wearing tights and I just know my hairs will poke out of them, which is of course unacceptable. I’m working as a professional now, and all be it in the usually casual academic setting, I feel as though my presentation is important (see “being above average”). Most importantly though, I have my self-esteem to think about. Is it taking up too much emotional energy to “stick it to the man”, or will the guilt of conforming be the greater burden? If I do decide to shave, how on earth am I going to find a method that is cheap, kind to my skin (and the environment), I don’t have to dedicate significant time to and effective?![6]

For me, those felt like very open musings – I’m not usually much of a sharer, but I found writing this post therapeutic. If you got this far, I would genuinely be interested in your opinions. Hopefully my conflictedness makes this a safe forum for honesty.

Dr Jelley



[1]This makes me a terrible candidate for laser hair removal.
[2]https://mic.com/articles/151191/the-unusual-and-deeply-sexist-history-of-women-removing-their-body-hair#.K2FJqTCzu(I realise that this is an opinion piece with few references but you get the idea)
[4]I’m the person who just does it.
[5]I’m not trying to be arrogant, this is how I feel about myself. I think I have a great body, and I know a lot of people think so too, but I’m not going to be all fake modest about it because I really love my abs.
[6]If anyone knows the answer to this, do let me know! Also, does that sentence make anyone realise how truly ridiculous this standard is?

Friday 11 May 2018

Covert eco-warrior

I feel as though this next post should be about my attitudes towards healthy living and sport, logically that flows nicely from the previous however, what has taken up more of my attention recently is plastic.

Going plastic free is now as fashionable as smashed avocado for just as, if not more, legitimate a reason. While eco-friendly products are now big business, it appears as though the wider public attitude towards single-use plastics is now universally negative and intolerant (thank you David Attenborough and China[1]). Plastic litter is a devastating problem and anyone who cares about their own health, living environment or wildlife should do what they can to reduce, reuse, recycle (in that order). I will not go into the details here, there are abundant sources describing the effects of plastic waste, my favourite of which is Blue Planet II. Watch it if you haven’t already, and then watch the rest of the David Attenborough “Planet” series.

Once you start seeing single-use plastics, you see them everywhere, and in places and by brands I would have thought might think about this from a marketing point of view. For example: Red Seal[2](“specialising in natural products”) wraps its teas in cellophane; every single jar of honey in the supermarket was plastic, even Manuka honey; a jar of coconut oil was wrapped in cellophane (just, why?); bar soap - wrapped in plastic; our new vacuum cleaner - in a box packed with cardboard (adequate?) with each attachment in its own plastic bag. I once had the choice of buying one loose avocado for $5 NZD (~£2.50) or three for $6 in a polystyrene tray wrapped in plastic. I went without avocados. For me, this unnecessary plastic is what makes me so determined to reduce my use. Plastic is extremely useful for many things, and shouldn’t be unconditionally demonised. However, plastic should be viewed as a detrimental luxury and only used as a last resort. Oh, and straws. Damnit I am perfectly capable of drinking from a glass, even one with ice in!

Quite often, one must pay more for the privilege of buying a product plastic free. Credit largely to my Mum, I have been waste conscious since childhood, before it was cool, and definitely for environmental reasons but, what I also learned was how to do it in a way that actually saves you money. So here are my almost middle class tips. There are many more that involve buying reusable items such as coffee cups but that’s not the point of these ideas as that doesn’t save money overall (unless you make your coffee at home). These are kitchen/food heavy as I’ve noticed that this is where the bulk of our plastic accumulates from.


  • When faced with situations like the avocado and honey examples, if there is no plastic free option, can you go without? Boycotting packaged food will also result in healthier eating.
  • When you do have to buy plastic (for example the $3 yoghurt because the one in a glass jar is $12), wash and keep as food storage containers. No more cling film.
  • In NZ you can get zip-lock bags free when you buy bulk items. I wash these and reuse them as sandwich bags etc. until they fall apart. You can do the same with veg bags. Never buy freezer bags again!
  • Similarly, I have never bought bin bags, just use the ones from the supermarket (when you forget your reusable ones)
  • There is really no need to drink bottled water. Be organised and take a bottle with you everywhere. Either wash one that has had something else in it, or buy one. It doesn’t have to be fancy.
  • Bamboo toothbrushes are about the same price as plastic ones.
  • Bar soap is much cheaper and lasts longer than the runny stuff in pump bottles. The chemical properties of soap make it naturally antibacterial, there is no need for added antibacterial agents[3].
  • Ladies, get a moon cup[4]. This is an initial investment, but after that you never have to buy another sanitary product again. I could (and probably will) write a whole blog post on getting used to a moon cup, but, especially for those who use the green/orange tampons, once you’ve mastered it, it’s revolutionary!
  • Buy timeless pieces of clothing. The environmental impact of clothing is very high as more and more people buy synthetic (essentially plastic) items they only wear for one season (or even once when it comes to dresses for fancy events). I've had some of my clothes for years, many are hand-me-downs - yes, even at 29 - and I once even wore the same dress to two weddings in one summer.

None of these ideas are particularly sexy. A rinsed out squash bottle doesn’t look as cool as a wood grain stainless steel flask, crumpled zip lock bags aren’t as attractive as organic cotton eco bags[5]and natural beeswax wrap definitely looks better than old yoghurt pots. Earthy colours, brown paper packaging and mason jars all look beautiful and are biodegradable or safe, but, your choices should not be made based on image, they should be made based on impact. Therefore if, inevitably, you have found yourself with numerous plastic items lying around, I figure that you may as well use them rather than throwing them straight in the recycling and buying an eco-friendly alternative.


Dr Jelley

Tuesday 19 January 2016

A place for high-intensity interval training in disease management


Since writing my previous piece on HIT in which I wrote about the benefits to physical fitness(http://www.ll.dlpa.bru.nihr.ac.uk/brublogs-5072.html), I have focussed my attention on metabolic responses and the effects it might have for those with or at risk of type 2 diabetes. As a side, I've also been interested in its practical application; however great HIT might turn out to be in the lab, will people do it on a day to day basis?  

What I have found over the past 18 months of research is that, ultimately, HIT works. It's good for fitness and it's beneficial for glucose regulation. It's not necessarily better than traditional continuous exercise, but it's certainly better than nothing. I also believe (and I have no money to make from saying this) that, if sold properly (unlike in this article I was asked to contribute towards - I did not say it had to hurt; https://www.sciencenews.org/blog/scicurious/high-intensity-interval-training-has-great-gains-%E2%80%94-and-pain), HIT, or to be more accurate "interval training", is the best way to get a non-exerciser to exercise. 

What is HIT?
First I should explain what HIT is. The academic definition puts it simply; "short bursts of vigorous intensity exercise interspersed with periods of recovery or absolute rest". If you try to explain this in more detail however, you realise how nuanced this form of exercise training is and the range of work it encompasses. 

Firstly, "vigorous intensity" is categorised as any physical activity that elicits a heart rate of 77% or greater of an individual's maximum. This sounds high, but in fact can range from work that feels relatively easy to all-out maximal efforts. How "hard" the intensity feels depends on factors such as age and fitness. Things are complicated further when you consider that even when exercising at their maximum HR, individuals can keep on working at higher speeds, gradients or watts. In the HIT research, effort intensities range from the lower end of the vigorous spectrum to all-out maximal efforts. 

Next you have to work out how long to sustain the effort for. Intuitively, the higher the intensity, the shorter the effort.  In the literature, intervals range from 6 seconds to 4 minutes. 

The duration and intensity of the recovery periods also need to be determined. The extent to which the exerciser recovers between intervals affects the type of adaptation that the activity will stimulate. 

Finally, the number of intervals completed can be decided upon. This is generally dependent on the desired energy expenditure or overall time commitment the work out requires. Deciding upon a prescription for a certain audience requires consideration of a number of factors including ability and desired outcome. 

HIT and type 2 diabetes

Ideally, evaluating the effect of HIT on markers related to type 2 diabetes would pool results from studies employing the same HIT protocol investigating the same outcomes. However, HIT has only recently been applied in a health setting and there is not enough information available to come to a conclusion regarding the specific effects of specific protocols. I therefore did my best to combine the results from the available studies, which used different HIT protocols, and run some analyses that would help to tease out which might be the most influential components. 

While I found that overall, the various HIT programmes that had been tested improved insulin sensitivity1, reduced HbA1c2 and, consistent with other reviews, physical fitness, I was unable to determine what it was about HIT specifically that stimulates these improvements . There is clearly something about this mode of exercise that enhances the body's adaptations to physical activity because equivalent benefits to moderate-intensity activity are observed following a substantially lower volume of exercise. The mean "active" duration (i.e. not including rest periods) of the HIT work-outs I analysed was 21 minutes compared to 44 minutes of moderate-intensity exercise and yet greater or equal benefits were produced. 

Taking the HIT programmes alone, I looked at whether the magnitude of the improvements observed were related to the interval intensity, total exercise volume or duration of training programme. In other words, do you get better effects with higher intensities, longer exercise sessions or more weeks of training? I found that none of these factors predicted outcomes. There are a number of possible reasons for this. First of all it is quite likely that the variation in the studies I included diluted the effects each factor was having; its not to say that there is no relationship, but I was unable to see one. Secondly, it could be something else; the change from high to low intensity for example, which predicts how well HIT works. 
The article can be accessed here: http://www.ncbi.nlm.nih.gov/pubmed/26481101
What this means is that currently we know that HIT can work, but we don't know why it works. 

Practically speaking though, that's what is important. Other research groups are investigating the mechanism of action of HIT and this will help to optimise HIT protocols for different populations. For now though, we can tentatively recommend HIT in the prevention and management of type 2 diabetes.  

Working alongside healthcare professionals for the past 2 years has led me to be sceptical about the uptake of HIT by a clinical population. Indeed, participation in any physical activity by the population as a whole is remarkably low and now I want those who are suffering most from the consequences of inactivity to exercise hard?!  

The media attention HIT has received, I feel, has appealed largely to Lycra-clad gym-goers; a minority population. It has focussed on all-out, maximal effort HIT the intervals of which cause the participant to grunt and groan and leave them gasping for breath. Yes, HIT needs to feel hard, but as alluded to earlier, 'hard' can start at 'not comfortable'. Then of course you've got the rest periods; you get to stop! Perhaps placing more emphasis on the recovery periods will attract a wider range of people to HIT. 

Admittedly, to date, my patient contact has been limited to a few willing study participants (not entirely typical of the general population), but what I have consistently observed is that once someone has tried HIT, they realise that it is not as unpleasant as they thought and, in many cases, easier overall than continuous exercise of a lower intensity. In my opinion, the biggest challenge with HIT is selling it right. One of my ideas is to drop the 'H' and call it 'interval training'. This way you remove the focus from the high-intensity part and emphasise the change in intensity between intervals.  

As part of my follow-up project to the meta-analysis, I will be asking participants to rate how hard they find HIT compared to continuous exercise. By the end I should have some idea as to how people rate each type of exercise, as well as how effective they are in controlling blood glucose. 

In conclusion, there are still many unanswered questions with HIT, but what we know is that as long as heart and breathing rates have risen, and/or 'hard' effort has been exerted during the workout, HIT is going to have some kind of beneficial effect. The difficulty is breaking the barriers associated with HIT and convincing people it is safe and achievable. 

__________

 1 Insulin sensitivity reflects the bodies ability to utilise the insulin it produces. It is a term used widely in research as it is the physiological state which precedes type 2 diabetes. Insulin resistance has not been employed as a clinical term due to the difficulty of its measurement and lack of normal range values. 

2 HbA1c  is glycated haemoglobin, which is a measure of an individuals' average blood glucose over a period of weeks.