Yesterday myself and a number of prominent doctors, nutritionists, sports scientists and health campaigners wrote a letter to the medical schools council, the general medical council and the secretary of state for health calling for mandatory training for medical students and practicing doctors in evidence based lifestyle interventions to prevent and treat chronic diseases including type 2 diabetes and heart disease.
As we write in our letter much, if not most of the increase in demand on the NHS is being driven by poor diet, low levels of physical activity, smoking and excess alcohol. When one combines this with millions of people taking medications of dubious benefit that come with side effects, that are a major contributor to death and disability it’s a recipe for a public health disaster and that is where we are. But if medical students and doctors are taught specifics of lifestyle changes to be used therapeutically as I demonstrate in my film, The Big Fat Fix then we would save the NHS billions in addition to improving the quality of lives of millions of UK citizens.
For example one of the signatory’s of the letter, NHS GP and founding member of the Public Health Collaboration, Dr Rangan Chatterjee spoke eloquently on BBC Breakfast this morning. He demonstrated on the BBC show”Doctor in the House”, that type 2 diabetes could be diagnosed and reversed within 30 days from simple lifestyle changes. At the heart of this, it is important to understand that this is a condition of “carbohydrate intolerance” and this is exactly what he did with Dottie. 14 months later Dottie has a HbA1c that remains in the normal range. The reality is myself and Rangan didn’t learn any of this in medical school, there is a disturbing lack of knowledge about basic nutrition and the impact of exercise amongst the overwhelming majority of healthcare professionals. Research carried out by investment bank, Credit Suisse revealed that 54% and 40% of nutritionists still thought that cholesterol in food raises blood cholesterol. Other research revealed that only one third of doctors could identify an oily fish. Most recent research carried out by Professor Chris Oliver’s team at Edinburgh University revealed only 14% of medical students knew the Chief Medical Officer’s physical activity guidelines!
The good news is that the majority of doctors and students want to be trained in evidence based lifestyle interventions, as they believe it will benefit patients. I’m pleased to share that in less than 24 hours of the letter being sent we have a result! The Chief Executive of the Medical Schools Council, Katie Petty-Saphon was quoted in the Guardian supportive of our calls.
Katie Petty-Saphon, the MSC’s chief executive, said that “areas such as unhealthy lifestyles will require greater emphasis” in medical training in the near future if the doctors of tomorrow were to be fully trained to handle the rising toll of disease related to bad diet, alcohol and smoking. It wants the GMC, which regulates doctors, to increase the priority given to nutrition and exercise when it next reviews its guidelines to medical schools on what they should be teaching.
Thank you Katie. That’s what I call progress!
Here’s the full letter we sent yesterday to Katie and the Chief executive of the GMC, Niall Dickson, also copied to the health secretary, Jeremy Hunt. The full list of signatories are included at the bottom and quotes for press.
Dear Katie and Niall,
We write to you as a group of doctors, nutritionists, sports scientists and health campaigners. We ask you as a matter of urgency, to support the introduction of evidence based lifestyle education, including basic training in nutrition and the impact of physical activity on health and chronic disease into all medical curricula. This should also extend into continuing medical education (CME) for current doctors. We also believe such training would benefit other healthcare professionals, such as nurses. The NHS is in crisis and much, if not most, of the increase in demand can be directly attributed to unhealthy lifestyles, such as poor diet, smoking, low levels of physical activity and excess alcohol. These factors now fuel the majority of global deaths and diseases, according to the Lancet (1). Taking just one example, the combined cost to the NHS and to the economy due to lost productivity of Type II diabetes, an almost entirely preventable and potentially reversible condition, is close to £20 billion and without significant action is projected to double in less than twenty years (2). The Royal College of General Practitioners’ clinical expert in diabetes Dr David Unwin, has just from simple diet advice for his pre-diabetic and type II diabetes patients saved £45,000 on diabetes medications alone, compared to the average expenditure in his clinical commissioning group (3). This extrapolated across all GP surgeries across the UK, could potentially save the NHS £423 million a year on diabetes medications. In addition there are the considerable savings from attenuating side effects through reducing the need for medication. NHS GP Dr Rangan Chatterjee also showed in his “Doctor in the House” documentary last year, that type 2 diabetes can be diagnosed and reversed within 30 days, a reversal that has proved sustainable.
But there is a lack of knowledge and understanding of the basic evidence for the impact of nutrition and physical activity on health amongst the overwhelming majority of doctors. This has its roots in the lack of early formal training.
A global survey carried out by investment bank Credit Suisse worryingly reveals a substantial level of misinformation that exists amongst doctors, with 92% believing that fat consumption could lead to cardiovascular issues. 54% of doctors and 40% of nutritionists incorrectly thought that eating cholesterol rich foods raises blood cholesterol (4).
There is a paucity of data on the extent to which basic knowledge of nutrition is taught and understood by doctors in particular. The most recent evidence comes from the USA, which shows that the majority of medical schools provide less than the recommended minimum of 25 hours of nutritional training, and less than half of all schools reported teaching any nutrition at all in the clinical years (5). Perhaps as a consequence of this, most practising doctors express self acknowledged poor understanding of nutrition, with data suggesting that 78% of physicians were willing to undergo further training and considered this would benefit patients, whilst demonstrating that over half of physicians spent less than three minutes discussing diet and lifestyle with patients. Furthermore, only a third of doctors could identify an oily fish, and under half were able to confirm that low fat diets had not been shown in randomised controlled trials to reduce the risk of cardiovascular disease(6).
This week the British Journal of Sports Medicine has published a leading editorial “Tomorrow’s Doctors Want More Teaching and Training on Physical Activity for Health” by Prof Chris Oliver and team from the Physical Activity Research Centre, University of Edinburgh. In a medical student survey In Edinburgh only 14.9% knew the recommended Chief Medical Officer Physical Activity guidelines for adults. Fewer than 10% reported that they felt adequately trained to give physical activity advice, and over 90% reported that they would like more formal training on it (7).
The documentary film co-produced by cardiologist Dr Aseem Malhotra “The Big Fat Fix”, which premieres to students and staff of Edinburgh University on Thursday October 20th hosted by Professor Chris Oliver, offers a specific prescription of lifestyle interventions, including dietary changes, the importance of regular movement, and managing stress (8). Scientific evidence reveals that these interventions are more powerful than any medication in the prevention and treatment of heart disease and come with few side effects.
Furthermore, the current model of healthcare must change. Prescribed medications in the population, which have dramatically increased in recent years, contribute to significant morbidity and mortality with estimates that up to a quarter of hospital admissions in the elderly are a result of adverse drug reactions. Furthermore, as the population ages, demands for healthcare will increase substantially if those later years are accompanied by chronic disease. A Lancet analysis found that, if rising life expectancy in the European Union means years of good health, then health expenditure caused by an ageing population, is only expected to increase by 0.7% of gross domestic product by 2060.
An over medicated population is considered such a serious concern to the nation’s health that last year the Academy of Medical Royal Colleges (which represents the views of the majority of the UK’s 220,000 doctors) launched a “Choosing Wisely” campaign; an initiative to wind back the harms of “too much medicine” (9). Shortly after this publication the medical director of NHS England, Sir Bruce Keogh, told the Telegraph newspaper that 1 in 7 operations and medical treatments in the NHS were unnecessary and should not have been carried out on patients. (10)
We commend and welcome the Secretary of State for Health, Jeremy Hunt’s ambition to reduce 30,000 premature deaths in the United Kingdom by 2020, but achieving this target and reducing demand on the healthcare system, improving quality of care and improving population health will also require a cultural shift within the medical profession to prescribing fewer drugs and deploying more lifestyle interventions. This cannot happen without equipping doctors with the necessary skills to confidently and genuinely ‘make every contact count’ as recommended by the Academy of Medical Royal Colleges’ “Measuring up” obesity report of February 2013 (11). It is also instructive to note that 50% of the NHS 1.4 million employees are also overweight or obese (12).
NHS England’s Five Year Forward View specifically talks of the pivotal importance of addressing the burden of chronic illness, and the urgent need to address public health issues that relate to preventable morbidity and mortality, and yet our health professionals are not being trained to meet this challenge. (13)
We ask you to support our calls for mandatory training for all medical students and practising doctors in evidence based nutrition education and physical activity. The future of a sustainable NHS will depend on putting lifestyle medicine at its forefront.
Dr Aseem Malhotra, London based consultant cardiologist and advisor to the National Obesity Forum
Professor Chris Oliver, Physical Activity Research Centre, University of Edinburgh and Consultant Trauma Orthopaedic Hand Surgeon, the Royal Infirmary of Edinburgh
Sir Richard Thompson, immediate past president of the Royal College of Physicians
Dr David Haslam, Chairman of the National Obesity Forum
Dr Rangan Chatterjee, NHS GP and Founding Member of the Public Health Collaboration
Dr Zafar Iqbal, Sports and exercise medicine physician and head of sports medicine Crystal Palace FC.
Dr Simon Poole, GP and co-author of “ The Olive Oil Diet”
Dale Pinnock, Nutritionist, author and Chef
Dr Trudi Deakin, PhD, Chief Executive and Research dietitian for X-Pert Health
Dr JS Bamrah, Consultant Psychiatrist and medical director of Manchester mental health and social care trust
Dr Kailash Chand OBE, GP and Chairman of North West British Medical Association Council
Samuel Feltham, Director of the Public Health Collaboration
1. Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015GBD 2015 Mortality and Causes of Death Collaborators, and others The Lancet, Vol. 388, No. 10053
2. Hex N, Bartlett C, Wright D, et al. Estimating the current and future costs of Type 1 and Type 2 diabetes in the United Kingdom, including direct health costs and indirect societal and productivity costs. Diabetic Medicine 2012;29:855–62
3. Unwin D, Unwin J. Low carbohydrate diet to achieve weight loss and improve HbA1c in type 2 diabetes and pre-diabetes: experience from one general practice. Practical Diabetes 2014;31(2):76-79 doi: 10.1002/pdi.1835
4. Fat; The New Health Paradigm – Credit Suisse 2015
5. Kelly M. Adams, W. Scott Butsch, and Martin Kohlmeier, “The State of Nutrition Education at US Medical Schools,” Journal of Biomedical Education, vol. 2015, Article ID 357627, 7 pages, 2015. doi:10.1155/2015/357627
6. NYU Langone Survey presentation to American College of Cardiology’s 64th Annual Scientific session March 2015
9. Malhotra A, Maughan D, Ansell J, Lehman R, Henderson A, Gray M et al. Choosing Wisely in the UK: the Academy of Medical Royal Colleges’ initiative to reduce the harms of too much medicine BMJ 2015; 350 :h2308
12. Royal College of Physicians. Action on obesity: comprehensive care for all. Jan 2013. http://www. rcplondon.ac.uk/sites/default/?les/action-on-obesity. Pdf
Dr Aseem Malhotra, Consultant Cardiologist and Advisor to the National Obesity Forum said, “Our current NHS crisis is the product of a broken system rooted in too many prescription medications of dubious benefit that come with side effects combined with unhealthy lifestyles resulting in a public health disaster. In my own experience when patients are given a transparent choice between medications and more powerful lifestyle changes for health they almost always choose the latter. But patients need specific instructions whether it’s the benefits of eating a handful of nuts daily, cutting sugar intake or taking a 30 minute brisk walk every day. The future of sustainable healthcare will require taking less drugs and utilising more lifestyle interventions which will not only save the NHS billions but improve the quality of life for millions of UK citizens”.
Professor Chris Oliver, Physical Activity Research Centre, University of Edinburgh and Consultant Trauma Orthopaedic Hand Surgeon, the Royal Infirmary of Edinburgh said, “It does not make sense that tomorrow’s doctors and allied health professionals are not taught about physical activity for health. They need to know how to prescribe physical activity. If physical activity were a pill, we would all be prescribed it. Sedentary behaviours and associated diseases are a huge health cost which could be prevented by being more active. Being told by your GP to go to the gym to exercise is not what it’s all about. Physical activity is a lifestyle change to be more active throughout your days; not taking the car, walking and cycling. Making your day a bit harder by climbing the stairs instead of using the lift”.
Dr David Haslam, Chairman of the National Obesity Forum said, “Cancer will affect 50% of people born after 1960. It would be unthinkable if cancer wasn’t included in medical school curricula. Excess weight affects many more individuals; two thirds of the population, and itself leads to cancer, diabetes, heart disease, sleep apnoea, liver disease and many other conditions leading to premature death. It is equally unthinkable that overweight and obesity are ignored by educational bodies; a situation that cannot continue if unnecessary deaths and illnesses are to be avoided.”
Nutritionist, author and chef, Dale Pinnock, BSc (hons), PgDip (Nutr Med) said, “There is a need for evidence based, clinically relevant nutrition education for all medical professionals. This subject goes way beyond calories and BMI. I developed the Sano School of Culinary Medicine to fill an educational gap. There was demand for a nutrition course that was evidence based and applied. We have several medics in our student body and the feedback we have received is that the course offers a sufficient level of information for clinical application for patients that can be incorporated into any other treatment protocol safely and effectively”.
Dr Rangan Chatterjee, NHS GP, founding member of the Public Health Collaboration and expert on BBC show “Doctor in the House” said, “I showed 4 million viewers on BBC One last year that Type 2 Diabetes could be diagnosed and fully reversed within 30 days – all through personalised nutrition and lifestyle interventions. 15 months later, without any intervention from me, this lady still does not have Type 2 Diabetes. This was achieved using skills that I did not learn at medical school. If every doctor in the land had access to this training, we could save the NHS billions of pounds every year.”
Dr JS Bamrah, Consultant Psychiatrist, Chairman of the British Association of Physicians of Indian Origin ( BAPIO) and medical director of Manchester Mental Health and Social Care trust said, “Physical and mental health are two sides of the same coin. As the WHO states, there’s no health without mental health. Therefore lifestyle factors are equally important in physical and mental health states. Maintaining a healthy diet plays a vital role in the prevention and management of many mental health conditions. So, what we eat can sow the seeds of discontentment, unhappiness, depression, body image problems, and even suicidal ideation.”