CORONARY HEART DISEASE RISK CALCULATION

We will no doubt be hearing more and more about prevention of coronary heart disease(CHD), diabetes and strokes as time goes on. At long last governments are now backing and to some extent financing the idea of prevention as they see the writing on the wall in terms of healthcare costs in the future.There are now a variety of ways that people who are at cardiovascular (CVD) risk can be identified and targeted at an early stage.

A group of high profile organisations including the British Cardiac Society and The British Hypertension Society consult jointly on a range of cardiovascular disorders and regularly publish guidelines for the treatment of this patient group. This is commonly known as the Joint British Societies (JBS) and their latest publication on risk assessment is known as the JBS2 risk assessment which is the gold standard for measuring risk and is in line with risk assessment that is carried out across many European countries. Risk tends to be split into percentage bands over 5 or 10 year periods – the most common being 10 years.

Keeping in mind that the assessment is designed to discover who may be at risk in the future and aimed at identifying those who do not already have evidence of cardiovascular disease, the criteria for risk assessment using the JBS2 calculations is as follows:

Aged between 40-70yrs

No evidence of existing CVD (status known)

Not diabetic (we know that diabetics fall into higher risk categories so we treat them accordingly)

The risk factors that are used for identification are the top five predictors of CVD risk:

Smoking

Cholesterol

Blood pressure

Age

Gender

The ways in which these factors interweave is crucial to the calculation. Smoking is the major risk factor and may push a calculation up into relatively high risk despite a young age and moderate cholesterol and blood pressure readings. In view of this it is difficult to make an assessment purely by looking at all the factors separately- therefore a number of risk factor calculators have been developed here and in Europe. The one that is used mainly in this country is the JBS2 risk calculator which is a chart found at the back of the doctors medicines handbook The British National Formulary (BNF). The calculation chart can also be found on-line at

http://www.escardio.org/initiatives/prevention/prevention-tools/score-risk-charts.htm

There is another calculation tool on-line here ( link below), although most are designed to be used by health professionals and may not be easy to follow.

http://www.patient.co.uk/showdoc/40000133/

The computer systems in use in GP surgeries will often automatically attempt to calculate CVD on all patients within a certain age band- the problem is that sometimes the information the computer is using may be out of date ( eg a BP reading last taken in 2003) or information may be completely absent in which case the computer may try to "guess" a reading/result and will usually over-estimate. There is currently no requirement or incentive for GPs to keep their CVD risk calculations up to date so the data can be variable from one GP Practice to another, but many GPs are aware and conscientious and will have been able to identify many of their patients who are at risk, particularly smokers and hypertensives.

It is often a surprise to people that weight is not taken into account in these calculations but research and experience shows that overweight alone- even obesity, does not significantly increase risk unless there are other risk factors like raised BP, high cholesterol. In fact since being overweight tends to adversely affect these other factors then we often pick up the overweight people simply by calculating on the main risk factors. What do the calculation results mean?

Over 10yrs the % likelihood of having a CVD 'event' - angina, heart attack, stroke etc

0- 10% low risk no treatment necessary

11-15% moderate risk lifestyle change re quired and patient monitored

16-20% high risk lifestyle change required and possible drug treatment

20% + very high risk lifestyle advice and should also be treated with drugs

CVD Risk calculation is a complex matter but one that must be attended to if we are to reduce death from CVD in the future.

Lesley Richards

MyAction

A new initiative has been launched in the Heatherwood and Wexham Park Hospitals area which, if successful, would mean that THROB would be out of business - not a bad thing when you think about it!

MyAction, as it is called, is the first service of its kind in the UK to be set up following the results of EUROACTION -the largest ever European-wide study into family based cardiology prevention which set a new standard for preventive cardiology practice for both hospitals and primary care. Reflecting the results of the study, MyAction is a community based integrated service which will be held at The Magnet Leisure Centre, targeted at people (and their families) who are either coronary patients or people at high risk of heart disease. An in-house nurse will co-ordinate a multi-disciplinary team to advise on diet, lifestyle and well being, including increasing physical activity levels under expert medical supervision.

The MyAction team will help patients by offering advice for stopping smoking, promoting healthy eating, encouraging physical activity and the achievement of healthy weight and shape. In addition the team will help patients to manage their blood pressure, blood cholesterol and blood glucose and provide an understanding of cardioprotective medications.

The programme has three phases. Firstly, the client and their partner will be invited to an initial assessment by the MyAction team of specialists. They will be asked about their smoking and eating habits and how much physical activity they do. They will also have their weight, blood pressure, cholesterol and glucose levels measured. Secondly, they will then be invited to work with the MyAction team to achieve a healthier family lifestyle over a period of 16 weeks. This will include personal and professional support from a cardiac specialist nurse, a dietician and a physical activity specialist. They will also have access to weekly group education and exercise sessions. Finally, sixteen weeks after the first assessment, the client and their partner will be invited to come to the clinic for a second assessment. They will be assessed on how successful they have been in changing their family lifestyle and reducing their other risk factors for heart disease and stroke.

PULMONARY REHABILITATION

Since working in the field of exercise I have noticed that the key to most rehabilitation programmes is to promote a healthy lifestyle by encouraging physical activity. Cardiac rehabilitation is well established and has been around in the UK since the 1970's. A recent review of exercise based cardiac rehabilitation trials has highlighted several key benefits, which include an increased exercise capacity; a reduction in certain coronary artery disease risk factors; an improvement in quality of life and an increase in survival rates in patients who have sustained a heart attack. The need for cardiac rehab has been well publicised in the press and most areas in the UK now have an exercise based cardiac rehab programme.

However, a new era is beginning with the introduction of pulmonary rehabilitation to help treat patients with respiratory disease. Respiratory disease affects the lungs, which includes conditions such as Asthma and Chronic Obstructive Pulmonary Disease (COPD). Surveys of people with chronic lung disease by the British Lung Foundation suggest that 90% of chronic lung disease is due to COPD. This equates to approximately 600,000 people living in the UK have the condition. COPD is a term used for a number of conditions including chronic bronchitis and emphysema.

Exercise classes for people with chronic respiratory disease will be starting at the Magnet Leisure Centre in September on a Monday at 9.30am. If you would like more information please feel free to contact me on 01628 777003 or email tim.grove@rbwm.gov.uk

Tim Grove

DIET AND OBESITY

If when you are pounding on the bouncer at the THROB exercise class, trying to sweat off the Christmas pudding and wind back the dial on the bathroom scales, consider this: what if someone told you it was all in vain? What if no amount of exercise will make you thinner, and everything we've been led to believe about exercise and obesity is wrong?

This intriguing possibility has been raised in a book called The Diet Delusion: Challenging the Conventional Wisdom on Diet, Weight Loss and Disease by Gary Taubes which tackles the myths surrounding these issues. The author believes that, since the obesity epidemic began, back in the late 1970s, scientists have been working with faulty - or at the very least - too little data. After conducting his own studies for thirteen years he has some shocking conclusions: exercise won't make us thin; carbohydrates are what cause obesity; eating fat doesn't cause heart disease.

One of the central arguments in the book is that some people are genetically predisposed to be overweight and that no amount of exercise will change this. Some of us have bodies that want to burn calories, others store them as fat. Taubes believes the all-important relationship between carbohydrates and insulin and the way they affect fat tissue and obesity have been forgotten - or conveniently ignored - in scientific debates about obesity. According to him, carbohydrates are indeed the enemy. 'The natural question is, "What regulates fat accumulation?"' We know that the hormone insulin is what puts fat in fat tissue. Raise insulin levels and you accumulate fat; lower insulin levels and you lose fat. And we secrete insulin as a response to carbohydrates in the diet. 'We have screwed up the causality of obesity; he continues. 'Fat people are predisposed to be fat. Genetics determines how we respond to the carbohydrates. Healthy people exercise more than unhealthy people, and we know that lean people exercise more than heavy people - but that doesn't tell us that exercise will make a heavy person lean or an unhealthy person healthy.

Taubes's defence of a high-fat, low-carbohydrate regime sounds suspiciously like the Atkins diet, which proposed that a hefty slab of steak followed by cheese was less fattening than a bread roll or a bowl of pasta. The Atkins diet still has many fans, but recently seemed to have been consigned to the reject bin among health warnings and heart-attack alerts. In 2002 Taubes wrote an article for the New York Times Magazine called 'What if it's All Been a Big Fat Lie?' The article made him famous for making Dr Atkins popular again, and caused uproar in the medical community. Not only did Taubes's research seem to show that the controversial diet was best for losing weight, it also showed that the diet improved cholesterol profiles, too - the exact opposite of what its critics said it would do.

So why should we listen to him? Taubes is not a scientist, so rather than conducting his own research he has re-examined existing research with fresh eyes. His conclusions are therefore based on information that was already out there but was being ignored. He bought the conference proceedings for every obesity conference held prior to the late 1980s- at which point they happened so frequently it became overwhelming. Reading these papers, he noticed discussions of an enzyme called lipoprotein lipase (LPL),a subject dealt with in his book. The job of determining how fuels will be used - whether we will store them as fat or burn them for energy - is carried out by the hormone insulin with LPL.. Because insulin determines fat accumulation it is quite possible that we get fat not because we eat too much or exercise too little, but because we secrete too much insulin. As it turns out, it's carbohydrates that primarily stimulate insulin secretion. Taubes has also looked again at how LPL behaves during exercise. Once we finish our workout, LPL goes to work sucking calories back into fat tissue to recoup lost energy. And we feel hungry. This is one reason Taubes believes exercise can never be that effective in helping us lose weight. The feeling of hunger is the brain's way of trying to satisfy the body's demands. The insignificant energy we might expend at the gym, Taubes says, has a negligible impact on weight and is easily undone by small changes in what we eat. Strenuous exercise only makes us hungrier.

The obesity epidemic began in America during the late 1970s, which is also when the low-fat, high-carbohydrate diet-and-exercise revolution began. 'You have a starting point,' says Taubes. 'The question is what is causing it? Then I realised that we were first told to eat less fat in the late 1970s, and, if you eat less fat, you start to eat more carbohydrates - it's a trade-off: Before that point, the medical profession's attitude to obesity was more in line with Taubes's thinking. In 1932 Russell Wilder, an obesity specialist at the Mayo Clinic, said his patients lost more weight with bed rest than with exercise. 'Pasta, bread, potatoes, rice, beer - these were the foods my mother's generation believed were fattening; if you went on a diet 50 years ago, that's what you gave up.

For all the controversy, Taubes remains jocular. He has been 'an athlete and a chronic exerciser throughout life, does yoga twice a week and visits the gym. But does he ever worry about being wrong? Taubes says he is more worried about being ignored or having his arguments dismissed as unworthy of public debate. 'All I did was follow the data. It boggles my mind that it brought me to this place where I am trying to convince the medical establishment they screwed up the biggest health issue of this half-century.

David Read (Based on an article by Melissa Whitworth, Daily Telegraph)

COULD I GET AN ENHANCED ANNUITY?

Most readers of this distinguished journal are I would guess of pensionable age. If your pension is already set up then I will not be offended if you decide to not read any more of this article, unless you feel it might help with your insomnia.

I am currently working through the process of trying to sort out the best thing to do with various pension funds that have built up over the last 30 years. I discovered from a conversation with an Independent Financial Advisor that there are five or six insurance companies who will provide what is technically known as an enhanced annuity.

These work on the idea that if you have health problems you are actuarially likely to not live as long as healthy members of the population. This means as the rest of your life is likely to be shorter they will spread the repayment of the total fund over a shorter period which means bingo!!! A larger annual pension for you. Apparently you are unhealthy if you have had an angioplasty and stent, a bypass or a heart valve operation which probably includes most of my readers. My wife, a shrewd and intelligent woman, (she has read this article) pointed out that the effect of cardiac surgeons getting better at their jobs takes some while to work through into actuarial death rates.

So, if you are still awake, I hear you say "How do I get one of these enhanced Annuities. The first thing you need to do is find an Independent Financial Adviser who covers the whole market. He will give you what looks like a long form to complete. Do not be too worried about the length of the form as it is designed to cover all sorts of conditions. You will only need to complete some personal details and a couple of pages that relate to the extent of your heart problems. There is one form that all the companies who offer these policies use. If, as is likely you will want to transfer, funds accumulated with another insurance company you will need to complete another form authorising them to transfer the funds to the provider who provides enhanced annuities.

So, complete two, or at most three forms and you too can have a larger pension. This process does take months, say two or three, but your retirement will hopefully last years rather than months. The Independent Financial Advisor will do most of the work and may not even charge for it, as he will be paid commission when the enhanced annuity is signed up.

Brian Boyland