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I want to die of heart disease

Every so often there's a post from someone worrying about their cholesterol, so I thought it might be apposite to crimp off a few thoughts on the subject.

Here's the thing: we're all going to die. We don't want it to happen too soon, but once we get ancient, creaky, and crinkly, we're pretty much ready to hand off the baton to the younger generation. Before that happens, I guess we all have two main concerns:

- We want a fulfilling life.

- We don't want our last years (or decades) to be filled with pain, worry, immobility, or niggling ill-health.

Now, here are the top few causes of death (in the West) for over 50s:

1) Heart disease

2) Lung cancer

3) Breast cancer

4) Prostate cancer

5) Colorectal cancer

6) Liver disease

7) Dementia

8) Stroke

And of all those choices, you know what? I'll pick heart disease any day of the week. Because the others are horrible, horrible ways to go, that drag on for years and cause your family great anguish and expense. So let us assume for a moment that the experts are right (despite the mounting evidence that they're disastrously wrong) and the meat, eggs, butter and suchlike that I eat regularly will eventually give me a heart attack. I can live with that.

In my opinion the modern obsession with alleviating heart disease is misguided. There are several long-term experiments which, with dietary interventions, or drugs, or both, have shown a statistically-significant decrease in heart disease ... but no improvement in all cause mortality, implying that while people might not be dying of heart disease, they're dying of something far more unpleasant. The headline might truthfully read: statins and low-fat diets cause cancer.

Of course I'm being a little flippant here. Cardiovascular disease - as it presents in modern society - doesn't mean a heart attack or a massive stroke. It's a slow, degenerative process not dissimilar to the other items on that list. It causes huge headaches for the NHS because the only treatments available are palliative, and expensive ones at that. It often occurs together with other intractable problems like obesity, diabetes, and idiopathic autoimmune disorders. So to that extent, one can understand the official obsession with it.

While the pharmaceutical industry fiddles about with drugs that give you cancer - and coincidentally reduce your risk of heart disease by 20% or 30% - and the government cheers them on, there's a much-neglected method of improving your chances in the disease lottery. It requires some very simple, low-cost equipment, viz., a pair of trainers and a 10-pound sledgehammer. What you do is this: you take your TV out into the garden and you smash it to pieces. Then you put your trainers on and go for a run. You have to repeat the run every day for best results, but the other aspects are one-offs. This method reliably slashes your disease risk in half, or better. Not just your risk of heart disease, but of many others too. It even keeps you young: it quite literally slows the ageing process at a cellular level. This paper demonstrates the point fairly clearly:

ncbi.nlm.nih.gov/pubmed/258...

...but there are many others. This result is so commonly reproduced that it's now accepted as "fact", although you will not hear any public-policy experts pointing out that daily exercise delivers results five times better than statins at a much lower cost.

Here's the kicker:

"These associations were consistent in men and women, across categories of body mass index and volume of MVPA, and in those with and without existing cardiovascular disease or diabetes mellitus."

In other words, if you're doing a lot of hard exercise, what you eat is of minor importance. Even your existing conditions don't appear to matter greatly. The single biggest predictor of a full life well-lived, with a properly-functioning cardiovascular system, is your level of activity.

Which is, when you think about it, rather obvious.

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The NHS does recognise the importance of exercise and attempts to encourage it, as a recent headline stated “If exercise was a pill we would prescribe it”. Unfortunately, this seems to sum it up.... many people appear to prefer the idea of taking pills rather than exercising, or perhaps feel they are the only alternative.

nhs.uk/live-well/exercise/e...

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>> many people appear to prefer the idea of taking pills rather than exercising, or perhaps feel they are the only alternative.

This is, unfortunately, a bit of a human constant. Worldwide, people love their pills, and "being on" six medications a day is a point of pride for some. But doctors don't have to prescribe them ... oh, but wait, they do, because the politicians and busybodies who have the final say on the matter have set arbitrary targets for everyone's blood cholesterol. The NHS guidelines (summarized here gpnotebook.co.uk/simplepage... imply that one-third of the adult population should be taking statins:

bmj.com/content/358/bmj.j3674

This is not to alleviate their disease risk, mark you - lowering TC and/or LDL-C doesn't have any dramatic effect on heart disease in most cases - but simply because some obscure pencil-pusher has determined that our bodies are all consistently miscalibrating our circulating cholesterol. Now, if that were actually true, the pertinent question would surely be: why is it happening? But lowering cholesterol is now a treatment goal in and of itself.

"Encouraging" exercise isn't enough when the system gives even greater encouragement for the pill-popping route, and when the pills don't work, that's completely unconscionable. Doctors (as distinct from the administration that controls them) prescribe pills that don't work only in very unusual circumstances - eg., hypochondriacs who won't go away without a prescription. And yet they're being told to do it as a matter of routine.

Perhaps the underlying problem is that the politicians recognise how much people crave medical intervention - indeed, how much some people relish the idea of being "ill" and requiring care. In some countries, a doctor's esteem depends upon the volume of pills and injections he prescribes. The NHS might not have direct customers who can go elsewhere for their fix, but for the politicians, it's a vote-buying machine, and it has to keep the punters happy, even if it's also making them sick.

Anyway, I suppose the point of my post was really this: take control. Whatever the underlying reason for the behaviour of doctors, you don't have to be complicit.

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It may be different where you are, but back in the UK cholesterol-lowering drugs are prescribed more than ever (see above - the target is 37% of adults on statins). They are also prescribed here in my part of the world, although not to such an extent simply because 'hypercholesterolemia' is not accepted as a genuine disease.

Another poster mentioned elsewhere that the NHS is great at critical care - that is, fixing a problem when it's already too late. I'm at an age where friends and acquaintances are all keeling over with lifestyle-related diseases, and being patched up by the NHS. And it's true: they do a great job. But what a pity that it ever gets to that point!

Somewhere in my rant is a question: why do people set their personal bar so low? Why are they content to get out-of-breath walking up their stairs, or being unable to run for the bus? Why do they just shrug and say, yeah, well, it's just old age? My grandparents' generation were stiff-upper-lip types who refused to accept age-related degeneration. My granddad died of a heart attack digging his garden, in his late 70s. That's a good way to go.

>> Doctors know that they can't push people into giving up smoking...and they can't stop people from over eating...and they can't push you into exercising.

Well ... yes and no. The State has a lot of control over what people believe, and that determines what they do. I can describe two other scenarios which provide an interesting point of reference:

Here (Country A) if you want a coronary-artery bypass, you have to pay for it. Not the full cost, but quite a lot. Same with pills for chronic disease: it costs (some) money to collect your medication once a month. People have a much higher incentive to look after themselves, because they know (a) it'll be expensive in the last resort and (b) the doctor can't really fix it anyway. However, the national diet is inherently healthier than most: few sweets, modest amount of carbs, lots of vegetables, no restrictions on fat. Virtually nobody is obese.

In Country B, where most of the population is obese and confirmed T2 Diabetes is about 5% (pre-diabetes is probably 20%+), healthcare is even more expensive. It's also not very good. But people fail to look after themselves because the government positively encourages a diet based on rice, bread, pasta, sweets, and junk food, and 'exercise' is a dirty word; in fact people aspire to a life of leisure. Beliefs about food and exercise are not dissimilar to American ones. So here, despite the overt expense of critical care, people are not told the truth about the cause of their illness, and it hits them as a genuine surprise because "they're doing everything right".

It occurs to me that, if the NHS are serious about helping people, they (or the government) could fix the situation by covertly funding some vocal opponents. They can't say outright that they've got it all wrong, because that would be political suicide. But they could perhaps support a powerful PR machine, with some eminent doctors behind it, to destroy the credibility of low-fat diets, statin therapy, coronary stents, and all the other "treatments" that don't work but bleed money out of the health service. They could then withdraw these things without too much fallout. My fear, though, is that The System (or the government at least) believes that powerful drugs and surgical intervention are the right and proper solutions.

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I think you make some very good points and I am always very interested to read your posts.

You seem to be suggesting that the NHS in its current form deters most people from taking personal responsibility for their health. I suspect this is true. But is this also because most people don't want to take responsibility for their own health if they get the choice? The people I know seem to fall into two general groups.

1- Those who actively reflect on what foods are best for them, try to live well and make regular exercise a priority, are healthy and on very few if any medications,

and

2- those who regularly indulge in calorific/alcoholic treats, telling themselves they deserve them, never seem to have time for regular exercise and prefer to blame others for their health problems when they invariably happen.

You'll always get these two types of people. I'm not sure that will ever change. But it makes sense for the NHS to encourage people to be in the first group rather than the second.

Maybe the only way this will happen is if each doctors surgery becomes a gym and healthy eating cafe with an attached doctors consulting room? I'd vote for that! 👍

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>> You seem to be suggesting that the NHS in its current form deters most people from taking personal responsibility for their health.

I think it may be far worse than that. My concern is that the NHS deliberately, knowingly deprives people of control over their own lives, by convincing them that their problems are "diseases", which are the exclusive domain of clever people in white coats.

>> The people I know seem to fall into two general groups.

I'd concur. The problem is that the people in Group 1 are being fed a flood of information which is scientifically dubious or internally inconsistent. It's hard for the average person to accept that the State is either telling lies or (being charitable) has got its priorities wrong. Those Group 1 people conscientiously eat their brown rice and low-fat spreads and baked potatoes believing that this will keep them healthy. It then comes as a terrible shock to find, at the age of 50, that they're overweight, unfit, and heading for a bypass operation. The overriding emotion is confusion: what did I do wrong?

As for Group 2, I suspect the underlying cause is the same: faulty advice. It may be that they've become so jaded with listening to contradictory nonsense that they've concluded (correctly) that the powers-that-be are speaking out of the wrong orifice. Unfortunately, they tend to throw out the baby with the bathwater and assume that anything uttered by any scientist must be untrue.

>> Maybe the only way this will happen is if each doctors surgery becomes a gym and healthy eating cafe with an attached doctors consulting room?

I think such things have been discussed. The problem is that it still fosters a culture of dependency on the medical establishment. I'd like to see the government just stop funding medical solutions for problems that don't HAVE medical solutions, and for doctors to be empowered to say to their patients, "look, whether you live or die is entirely in YOUR hands, not mine".

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We have a lot of health promotion messages in Australia focusing on exercise as well as healthy eating, reducing alcohol and quitting smoking of course. Everyone knows they have to “find 30” (30 minutes a day exercise). There is still an obesity issue and people who don’t look after their health but there is a real shift in general, particularly amongst the younger generation. Statistics show that smoking and alcohol consumption have fallen dramatically over recent years and there is a huge focus on healthy eating. I see it a lot with our kids, their friends and young people I work with. I think there is a real socio-economic divide though.

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I won't smash my TV (even if it's just for watching News and Sports and the occasionally Poldark or such like), but fully agree that exercise is much more fun than dieting and seems to help keeping illness at bay. I love my tennis, even in winter! And after a hard game, the first thing you consume is water of squash anyway, filling you up and keeping those nasty sweet treats and alcohol at bay (though when the bar is open, a pint goes down well, too). So here's to exercise! But it DOES mean that at 64 years of age I do not lose the excess weight I accumulated in my sitting down working days - for me it would need calorie restriction to achieve a "normal weight" status, I think.

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Well ... weight loss is a whole different ballgame. I wasn't suggesting exercise is a substitute for eating a healthy diet, and it's pretty well-known that exercise (in the absence of a diet conducive to fat-burning) has little or no effect on bodyfat.

The research I was quoting basically shows that, for any given initial risk of CVD (which is comparatively higher if one is overweight), the risk is halved if one changes nothing else except adding some exercise to one's routine.

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Exercise is indeed good for overall health but no reasonable amount of physical activities can cover a bad diet. We have to fix out diet if we want to be healthy.

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Oh, I wouldn't disagree with that. I was simply pointing out that, if one were to do nothing else except:

1) take a pill or

2) do some exercise

Option (2) has been shown empirically to be vastly more effective than (1), and costs next-to-nothing.

This observation is the source of the idea that you can be "fat and fit". It's true, as far as it goes - that is, if one has already decided that one wishes to remain fat, then being fit will dramatically reduce the risks associated with being fat. That doesn't alter the fact that being slim and fit is a superior alternative!

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A very interesting read, thanks lots of useful messages which the establishment- politicians, NICE, NHS ‘experts’ should take on board- but how do you get them to read these messages of real patients experiences of living through all these things you discuss.

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One of the factors here is a lack of energy. People are accused of being lazy, but the officially sanctioned diet creates lack of energy (to say nothing of addiction) with the high carb emphasis. (See Why We Get Fat by Gary Taubes. Must-read.) So people merely eating what's available and encouraged by our institutions MAKES them "lazy". Add the whole "doc knows everything" mentality, and the overriding dominance of the profit-driven drug industry and you've got a recipe for a healthcare disaster. Take control of your own health, indeed! And the first step is to start eating real food, no more processed, grain-based junk.

Dude, you need your own blog! Here's a post in one of mine- chronicdiseaseprevention29.... Get your own started, and I'll follow in a New York (London) minute!!! Love your posts.

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Thanks for the kind comments :)

I think you've hit the nail on the head there. I never really thought of it that way, but (dredging my memory!) you're quite right that the so-called "healthy" diet makes you less inclined to exercise - it's a rollercoaster of fatigue, hunger, and bloated lethargy.

Damn. Wouldn't that be something, if the recommended diet turned out to be the actual reason people aren't exercising enough? The interesting thing about your theory is that it's scientifically testable, and it wouldn't cost much to test it. I'll look around and see if anyone has tried.

Just looking at your Blog profile: have you read Joel Salatin?

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Yeah, it's rather eye-opening isn't it? The old hypothesis of thermodynamics- calories in/calories out is being challenged now. Here's an article that presents the newer thoughts on the subject- higher-thought.net/2010/12/... It all revolves around the hormone theory of weight gain rather than calories. Hormones (insulin primarily but also cortisol from stress, plus others) drive the process. It would explain why food restriction is generally unsuccessful, at least for the long haul, and why obesity results in "gluttony and sloth". Gary Taubes and Robert Lustig are 2 of the main names leading the charge on this one, and they have plenty of Youtube videos, blogs, twitter accounts, etc. if you're interested in checking them out.

They all expound on how exercise is pretty much worthless for weight loss because weight gain isn't driven by calorie intake, but at the same time, it's absolutely invaluable to your health overall. You're so right about how we NEED desperately to move more! Cutting carbs helps get hormones back in balance and thus helps regain energy so you can. So interesting to see all this play out, a huge paradigm shift.

Just found Joel Salatin; he looks interesting. Thanks for the tip.

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The further I read in Salatin's blog, the more familiar it sounded. I'd checked his book out at the library not long ago- Everything I Want to Do Is Illegal. Quite a read.

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yeah, the situation in the US seems to be much, much worse than in the UK. I would not choose to be a farmer there.

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There is a modicum of logic to your post; however heart disease through being obesse doesn't wait until you're 50, it kills you at 40, at 25, at 11!

I'm sick of letting my waist increase and feel crap because of it year on year... I still sample food through every culture I can find, but I'll take a shot at reaching 100 with pride over giving up on life at 40, aiming to be dead and burried in an oversize coffin by 50 anyday.

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Well ... the main problem is that it does take a very long time to actually kill you. In the meantime it sends your life inexorably down the toilet, which puts a huge drain on our (publicly-funded) health service.

I wasn't suggesting one should accept a shortened life: quite the opposite. I was focused purely on the relative merits of two different treatments for life-altering disease (drugs vs. exercise) leaving all else unchanged.

I was also attempting to draw a distinction here between the chronic and acute versions of CVD. For the past 10+ years I have completely ignored the official dietary advice. I am now slim, muscular, and have an enviable VO2max for my age (equivalent to a fit 30-year-old). And yet, according to the experts, my diet is going to give me a heart attack. I think they're wrong, but on the offchance they're right, I'm perfectly OK with that. Because if I die of a heart attack, I won't be dying of cancer, CHF, or any of the other vile diseases on the top-10 list.

Heart disease is not caused by obesity. Comorbidity is common because obesity and chronic CVD have the same root cause: a diet containing far too much starch and too little fat.

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You may be pleased to know I've just talked 2 mates into coming to pilates on the strength of a very summarised discussion of this thread (I'll have to report back on Monday whether they actually turn up!)

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Nice! Let us know how the class goes :)

I must say pilates isn't one of my favourites. I'm not very flexible...

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Why are there deaths whilst people undertake marathons? I think I previusly posted on this forum of a low-carb guru and physical trainer who died 10 minutes after walking out of the gym.

Exercise is no protection. If I have the understanding right a person can have an almost totally clogged artery system, feel physically great, exercise with the best, and still not die from a heart attack. This is because of endothelial cells which allow sufficient blood to move when main arteries are even 90% blocked.

Most heart attacks occur when an endothelial cells ruptures. At that moment the plaque that has built up over years if not decades (of what I consider poor dietary choices) in the main artery begins to flow out of the blood stream. The plaque finds and escape. That is the moment of an acute heart attack for 90% of cases.

For some serious education check out Dr Caldwell Essylton who has spent 60 years of continuous research in the subject with countless published peer-reviewed papers to his name.

(Exercise is very important, please don't anyone think anything else.)

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>> Why are there deaths whilst people undertake marathons?

Because a marathon is an incredibly stressful activity. The occasional casualty is inevitable, especially since there are lots of elderly people doing marathons these days. Old people die. If they run marathons, they're likely to die during a marathon.

Everybody ultimately dies of a heart that stops beating. Dropping dead from a heart attack after walking out of the gym is a much better way to go than spending five years propped up in a hospital bed with feet like balloons, breathing like Darth Vader - which is the fate that awaits the couch potato if cancer doesn't get him first.

>> Exercise is no protection

Well, it's not going to make you live forever, if that's your goal. The paper I linked to suggests that it will reduce your risk of CVD (loosely defined) by 200%+, independent of any other factor. As I said, this is a reproducible result: there was a widely publicised study a couple of years back suggesting that men over 50 who can run an 8-minute mile have a risk of CVD 300% lower than men who can't do it in 12 minutes - again, independent of any other factor.

Nobody's suggesting that exercise (or anything else) will reduce your risk of CVD to zero.

The important point is that dietary interventions alone - without exercise - don't even come close in effectiveness. Sedentary vegans and vegetarians, for example, die at about the same rate as sedentary carnivores - they have slightly lower rates of CVD and certain types of cancer, but they die of other things instead. There's some debate over exactly what they do die of, because the effects are so small as to be nearly insignificant.

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I may be misreading that study, but I can't find anywhere in it where is says that exercise is more important than diet in reducing CVD risk.

jamanetwork.com/data/Journa...

It says that even if you have a bad diet, exercise can reduce your CVD risk, which is nice to know, but doesn't tell us much about what we should do with our diets.

I believe the jogging test you mentioned may be this one:

ncbi.nlm.nih.gov/pmc/articl...

It doesn't say anything about diet, or independence from other risk factors, in fact it says "higher levels of fitness were associated with lower levels of traditional risk factors"

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>> It says that even if you have a bad diet, exercise can reduce your CVD risk, which is nice to know, but doesn't tell us much about what we should do with our diets.

No, but that's not what they were studying. And that's good: far too many nutritional studies today attempt to come up with a theory of everything and fall flat on their faces.

It's hard to compare apples with oranges, but here's a roughly-comparable study (similar age group and timeframe but a much smaller sample):

watermark.silverchair.com/1...

Which showed a 30% improvement in survival over a 6-year observational window for a "Mediterranean diet". Which is not particularly impressive compared to the results for exercise.

The interesting thing about dietary interventions in general is that virtually anything (compared to the Standard American Diet) gives you about the same result. In other words, there's really only one diet that makes you ill, and it's the one the USDA wants us to eat.

There is no magical diet which will make any real difference to your longevity or risk of chronic disease if you're determined to move as little as possible.

>> I believe the jogging test you mentioned may be this one

No, but that's interesting all the same - thanks for digging it out. It seems to show an absolutely enormous reduction in CVD risk between low- and high-fit groups over the typical 25-year observation period - if I'm reading this right, you have a 500% lower lifetime chance of dying from CVD if, at age 45, you're physically fit.

Note that the Balke protocol is a submax test for unfit individuals. What they describe as "moderately fit" for a 45-year-old (VO2max=10.8METS) is pathetic: it implies reaching your maximum heart rate at a fast-ish walking pace (5.5kph). So it's interesting how little you need to do to get these dramatic benefits.

The paper I'm thinking of specifically referred to an 8-minute mile target for over-50s, and annoyingly enough I can't find it now. An 8-minute mile (12kph) represents a metabolic power output of ~13METs (45ml/kg/min), which correlates (roughly) with a VO2max of 15.5METs (52-56ml/kg/min). My personal best is 7:40 at age 47, and I know a couple of people who can do better than that. I'm not a fanatic: I run less than 2 hours a week. So it's perfectly doable for Mr Average with a "busy lifestyle" - hence my frustration with the NHS pushing at-risk individuals to do only the bare minimum, instead of aiming for the top end of human performance.

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Actual, double-blind studies are difficult at best, simply because the environment has to be completely controlled for a long period to get accurate results. Otherwise, you're at the mercy of people's honesty as to what they ate and how much they exercised. Pretty impractical to do it right, and expensive I'd imagine. Common sense has gotta kick in, with a boatload of anecdotal evidence. Common sense- exercise will get blood circulating. Huge benefit to the brain and believed to be a preventive measure for Alzheimer's/dementia. Makes sense. But diet is a factor as well, since Alzheimer's is now considered "diabetes type 3". Both are equally important. I personally think we desperately need health centers that involve professionals who major in lifestyle changes in general and a big ole gym (and pool?), all under the same roof with lots of health coaches and other support staff.

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Parts of the U.K. are now trialing exercise “prescriptions”.

eadt.co.uk/news/suffolk-gps...

Some areas also provide membership to various commercial weight management courses, if you are in the obese category.

There are still pill pushers out there, but different approaches are being tried by the NHS.

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Yes, I'm aware that there have been rumblings in that direction for a while, but I don't think it goes far enough.

"If someone walks out with something like that they are more likely to follow it."

No, they're not, because people are more complicated than that. They'll head straight off down the pub and have a rant to their friends about how useless the doctor is. Then they'll change to a different GP who will give them pills (and who will, in turn, receive a financial pat on the back from the government for meeting his cholesterol-lowering targets). Basically, this:

“If all the practices are doing it, patients will expect it,” he said. “If only one GP is doing it, they may get complaints.”

I've noticed that (in reality) the NHS seems to be a collection of different organisations all just getting on each other's nerves, rather than a monolithic whole with a coherent policy. The pills should be simply withdrawn from the BNF, in recognition of the fact that they have no therapeutic value. In other words, if you don't want to fix the problem for yourself, the doctor has no (illusory) short-cut to offer you.

The remaining problem is that NHS is still giving out faulty dietary advice, so even if people follow the exercise prescription, they won't see the results they really want (ie., weight loss). The issue there is that fat people really can't exercise: they're likely to harm themselves. A 30-minute walk twice a week might make a marginal difference to someone who would otherwise spend their entire life on the sofa, but why set the bar so low? Why can't we tell people: look, if you stop eating this and this, and improve your physical fitness by this much, you'll not just be marginally healthier; your life is going to be transformed out of all recognition.

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Like the post ! , in my book it is about helping oneself, so many people are that lazy that if they could take a pill to transport themselves everywhere they would, even at expense of their health, an instance : lady who lives nearby is 60ish, well overweight bordering obese, stopped n chatted to me other day complain about weight shes put on over years, ( i knew at 16 a svelt trim of a girl, lovelly she was,) after she’d moaned on about matters I asked if she was carrying an illness that would bring about the weight gain( be it over a good few years ) not really says she apart from minor niggles, I could’nt help but chuckle to meself as she rode off on her disability scooter 😂, what on earth goes on ?, she rides everywhere on it, I swear I never see her walk, she has NO disability !! yet she cannot understand the root of her weight gain is No self propultion, so lazyness, bit like those toning beds lol, so many nowadays lack the will to get up n walk, excersise n healthy eating n live long for your children, regardless how old n wealthy they may be 👍

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It's very sad, isn't it? I have a colleague at work (a couple of years older than me) who is massively overweight. Her similarly-overweight parents died young (of cancer and heart disease). She can barely walk down the corridor without gasping for breath. Yet she "just doesn't like exercise". I think she knows at some level she's going to be dead pretty soon, but she can't do anything about it. What on earth is going on there?

There are some unfortunate individuals who (for some reason) don't get the same sense of enjoyment out of physical activity as the rest of us. It appears to be a genetic difference. On the other hand, I can't help wondering how much of lv2sew's comment is relevant here: diets that make you fat also make you lazy. Although I've always exercised, my performance (and general desire to get out there and move) has been greatly enhanced since dumping the Establishment diet.

>> live long for your children

You would think that reason alone would be enough to drive people to take more care of themselves, wouldn't you? I really don't get it.

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Thanks

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Just remember wherever you go, there you are.

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