Tuesday, 21 March 2017

PCSK9 Inhibitors - the new way to screw the NHS for every last penny




Did you hear the “Amazing” news about the new generation of Statin drugs that was announced at the weekend? The new PCSK9 inhibitors like Evolocumab are even more effective at lowering LDL cholesterol and according to many this makes them a wonder drug.

The issue with statin trial data was simply a question of whether it is actually valid to rate a drug on a surrogate endpoint such as lowering cholesterol rather than that of saving lives. However the trials for Evolocumab went further than this, they provided real data on the expected outcomes for patients. Great?

It was a surprise to me that these new drugs need to be taken as well as a statin; so the question of the side-effects of statins is still very much alive. Again the advocates such as Professor Rory Collins will claim that the benefits vastly outweigh the side-effects, but this article in Today’s Times puts that argument to the sword.

Put simply, the number of people that need to be prescribed Evolocumab (at more than £10 a day) to prevent one of them having a stroke or heart attack is 74. Yes, 74 people need to take the drug every day for two years, in addition to a statin, to prevent just one of them having a stroke or heart attack.  

Just to repeat, that is 74 people and £540,200 of NHS funds in order to save one stroke or heart attack.

Does that sound like good news to you?

Friday, 3 February 2017

Runner's World - A Spoonful of Sugar Keeps the Advertisers Happy


 I have been a subscriber to Runner’s World for about 12 years now. over the years it has provided much-needed advice and motivation, a little monthly run-envy and the occasionally journalistic howler.  Lately the howlers have started to become louder and a little more grating, to the point where my wife, a successful fitness business owner, now regularly asks why we bother with our subscription.  My answer is that I care what the running world looks like, even if I don't always agree with it.
So many promises
This month’s edition includes a six-page blockbuster about the role of sugar in a runner’s diet by the respected coach and nutritional expert Matt Fitzgerald entitled “Sweet Truth”,  and it has really got my goat!
The devil is in the detail!

After a first scan of the article, which reads a lot like like a sales piece for Gatorade, I thought “I wonder who pays his wages”;  but then I saw that actually the article was really just being all things to all people. It rambled around the usual sugar debates and concluded by saying “Don’t worry about sugar, you need it, but you are a runner and you will burn it off”.  Typical stuff, but 6 pages, really?

Unsurprisingly Matt’s article promised to “cut through the hype with a set of Science-Backed Sugar Rules”. I am always intrigued by the term science-backed, particularly in Runners World where the studies quoted are often ridiculously out of tune with the conclusions drawn by scatterbrain journalists. But Matt is chock-full of experience, surely we can expect some hard truths from a top guy like him. Sadly not.

There was a hollow criticism of Gary Taubes (the author of The Case Against Sugar) for "not being a scientist". It would be childish in the extreme of anyone to read this article and simply conclude that Mr Taubes is not qualified to speak on the matter. Character assassination is an ugly thing and Matt seems to have joined the happy brigade who attempt to gain kudos for slagging off other people. 

Then suddenly the RW article was tempered with recognition that overeating sugar can actually lead to insulin sensitivity and type 2 diabetes - the precise point that Taubes et al. are trying to make.  There was  criticism of certain diets but a recognition that we need to watch what we eat – most people call that dieting.  Mostly though there was the ever present implication that what is good for elite runners should be good for the rest of us.

The readers of Runners World are not elite athletes. If a bunch of elite Kenyans eat 20% of their energy from sugar this should not be used to justify the mass-marketing and magazine articles like this that tell the average runner that they should power every training effort and race with gels, PowerAde and carb-loaded snacks. The article did not mention the effect of this marketing on children, who most certainly do not need to consume sugar to power their sport and yet our schools and leisure centres are subsidised by selling energy drinks to kids.

Recognise this?
Matt then asks “If the best runners in on earth are amongst the heaviest sugar consumers then can it be so bad?”  The simple answer is Yes. The best runners in the world will be burning off this sugar on their morning run. The rest of us will not. This ‘Kenyan  paradox’ is hardly surprising, but Fitzgarald’s conclusion “They ate fewer calories than they burned” is simplistic. Maybe they ate less than they burned because there was a very real chance that by doing so they might become rich. Did the researchers ask how much time they spent feeling hungry? This is not a reasonable guideline for normal runners or the public in general.  The best way to eat less than you burn is to control your hunger. Traditional diets fail at this point; eating carbohydrate based diets does not allow you to control hunger unless you are very highly motivated – an elite runner perhaps. Eating a fat-based diet is crucially different here. People who eat a lower percentage of carbohydrates and a higher percentage of natural fats feel hungry less often and hence consume less. This is why LCHF diets consistently out-perform high carb diets in randomised controlled trials. And this is how intermittent fasting works, your body gets used to fuelling on fat and you do not feel hungry so often.

It should also be mentioned that type 2 diabetes does not normally develop quickly. Insulin resistance grows over decades and the more insulin you have to make the more resistance you are likely to develop. Has anyone measured the incidence of type 2 diabetes in retired Kenyan runners? I doubt it, as we are only interested in how they run so fast. Steve Redgrave may have developed hereditary type 2 diabetes, or it may be the result of consuming very high amounts of carbohydrates over a long and illustrious sporting career.

"Don’t worry about fructose says" Matt. The Harvard study he refers to concludes that eating certain whole fruits can be better for preventing weight gain than some vegetables; he doesn’t mention which fruits. The answer is blueberries and apples, but the implication and matts Rule #1 (Don’t worry about natural sugars) is that fructose is therefore good for you. The study does not say this.  Bad use of science Matt!   Most people don’t know the difference between fructose and sucrose and they don’t know the difference between whole fruit and fruit juice; they gorge on orange juice or smoothies thinking that they are healthy.

Lovely fattening smoothies!
Matt says “eat refined sugar in moderation”. Again this statement is problematic because most people do not know what it means; they don’t know what the recommended amounts are, and so what exactly is moderation? For a Runner's World audience fixated by timeings, measurements, performance improvement and measurability, what does “moderation” mean?  Meanwhile every petrol station, office or shop we go to is bombarding us with sugary temptations and saying ”let me be the one to supply your moderate amount of sugar today”.   If we want people to understand how low the World health organisation recommendation on daily sugar intake is, then we need show them. Give them a glossy picture of one large apple; and make it clear that sugar in general is bad for you.

When you consider that it is not very difficult for runners to switch to burning fat instead of sugar it is a wonder that Runners World covers the subject so little – there is a lot of mileage in the subject! 

Matt is not right when he says that you will not perform at your very best if you skip sugar; some people will and some won’t. But I would suggest that most runners would be somewhat richer, a lot healthier, rather happier, and would enjoy their running a whole lot more if they were to exchange those few extra seconds from  their marathon PB for life of running without sugar.  I simply don’t have to think about refuelling when I run a marathon and I finish happier and stronger than anyone I know (well there might be the odd sub-3 exception here!). I am also a little faster at 51 than I was at 45 having recently knocked 6 minutes off my off-road marathon PB.

Matt also provides an anecdote about Julie Benson and her difficulties with the No Sugar No Grain diet which left her feeling drained of energy during her training. This sounds to me like a typical simple case of not having enough energy; in other circumstances this is known as starving. I could be wrong here, but I don’t see references to replacing your energy intake with healthy fats on NSNG diet web sites. Yes it is true that some people do not adapt to fat burning as well as others but these people are certainly a minority of the readers of Runners World.

He introduces stress as a performance inhibitor and suggests that the worry associated with strictly following a formula diet is a common thing. This can be true. But there is nothing particularly stressful about a Real Food diet and no reason to worry if you accidentally fall off the waggon and eat slice of cake. The LCHF waggon is much easier to jump back onto than most for the simple reason that the food is very tasty! Contrast that with the constant warnings from sports nutritionists like Matt whose “Rules” say we MUST replace energy as we run and we MUST follow every run with the right amount of a mixture of carbs and protein. What if we forget, or get the mixture wrong? Will all our effort be wasted? Worry, worry, worry! 

In fact the “science” behind this post-run recovery advice does not support this widely held conclusion; it is based on runners performing in a fasted state, so of course their bodies needed energy and protein after a run. Most people do not run in a fasted state, do they?  And following this advice is precisely why so many runners put on weight during their marathon training. Personally I never feel hungry after a 3-hour run (although a creamy coffee is nice) and I generally recover fast enough to spend the afternoon gardening and run again the next day should I wish to. No stress there then.

Fitzgerald's declaration that runners fear an insulin spike after consuming sugar while running is interesting. I have never heard of this idea before. As far as I am aware most runners have never experienced an insulin spike and wouldn’t recognise one if it hit them in the head; people who fear consuming sugar during exercise are generally referring to the sugar that they will consume in their life and the possibility that it might lead to long-term weight gain or insulin sensitivity.  Yes, consuming sugar delays fatigue, but teaching your body to burn fat will delay it a lot longer.

Finally the article admits that eating sugar can become addictive, and that effort is required to overcome the affliction of having a “sweet tooth” is non-trivial, and may require the assistance of a qualified nutritionist.  Try to square this with the general advice of “eat less and move more” and you will be left with a head-ache.
Eat less more more?
So much of the advice we read neglects the simple fact that we are all habit-based creatures. Matt presumably finds it easier than most people to train hard and eat well because it has become a habit, part of his lifestyle and there are clear incentives for him to retain these habits.  For most people their lifestyle is far more sedentary and revolves around a constant stream of temptations to eat badly. Cakes in the kitchen, sweets in the jar by the door, coffee (and cake) with friends etc.  These habits are hard to break and nutritionists are bonkers if they think that it is a simple thing to adopt a philosophy of "all things in moderation" as Matt and so many others suggest. If it were that easy we would not have an obesity epidemic. 

I would prefer to call a spade a spade; use simple statements. Smoking is bad for you, so avoid it. Drinking alcohol is bad for you so avoid it. Sugar is bad for you, so avoid it. Un-refined food is good for you, eat it.   I am not saying that that this is easy to do, but having commonly agreed guidelines would be a good start. 

For many it takes a compelling event (such as the doctor telling them they have heart disease or type 2 diabetes) to force them to confront the truth and alter their life-long habits.  These days we all seem to want the moon on a stick, but life is harder than that. People should see LCHF as a way  of life, not a dietary fad. 

I do not have diabetes or heart disease. My compelling event came when I read that I could run faster for longer if I changed my diet. That was three years ago and it worked; my improved health (weight stable and all blood markers improved) is a rather nice side-effect of my competitiveness!

I have only ever read one article on running on fat in Runners World. A journalist took up the diet for a few months to see what effect it would have on her marathon time. She found it hard, but lost weight and did rather well; she then gave it up because she missed beer and pizza !  Desperate to get a sub-four-hour time she introduced carbs back into her diet for the last 3 weeks of training, just as she was reducing her weekly milage she confused her body with un-needed carbs. This was a big mistake and as a result she hit some kind of wall at 16 miles, and despite getting a big PB she was disapointed at missing her target. It's OK to race on carbs, although I have never needed to; but you mustn't undo all that good work by carb-loading.

The benefits of LCHF on running do not come as cheaply as this; over time we adapt to oxidise a steadily higher volume of fat per minute, and our performance improves.Runner's World feeds us with a deluge of expert advice like Matt’s telling us that we will not run like a champion unless we eat like a champion.  The science here is desperately poor and generally financed by sports nutrition companies. I know that a lot of RWs advertising income is from big sugar producers like SIS and Lucozade but I would like to see RW place a stronger emphasis on public health, after all most of its readers seem to have taken up running to become more healthy, not to run a sub-2:30 marathon.

Wednesday, 7 December 2016

The Tank Tracks - Fuelled by Fat

About 2 miles from my home is a rather odd path up a hill with no name. There’s a grand view from the top but the path itself is now rather dull, being mostly down in a ditch and lined on both sides with bushes.

Locals refer to this path as The Tank Tracks. This is a reference to the fact that it was created and graded by the army during the second world war.

The path runs for one kilometre in a mostly straight line up an even sloped hill. The grading is largely crumbled away now but most of the path is still firm all year round and this makes it the easiest local path by which to ascend to the ridge of the South Downs.
Two views from almost the same spot taken 66 years apart.


















Perhaps it is the quirky name, or possibly its ease of use but this path has become an attraction for runners near and far.  Local running groups meet at the bottom or jog out from the nearby villages of Hassocks, Keymer and Ditchling and use it for a lung-busting hill climb. The route is especially popular with the local group "We Run! Hassocks" and many local runners have experienced their first proper hill run here.

It can take a novice 10 to 15 minutes to climb the 130 vertical meters from the gate at the bottom to the signpost at the top. Elite runners have been attracted to the route as well; the current record of 5 minutes and 6 seconds is held by Maximilian Nicholls from Tonbridge Athletics Club who also holds Strava records for climbing Snowdon!


Before I took up hill running I used to stand on the platform at Hassocks Station and look up at the local hills and think “I should be able to run up there”. You can see the line taken by the Tank Tracks from the platform.  So I took up running and sure enough after a few weeks I was running up there. And I have been running up there for 12 years now and I’ve probably run this path over 100 times since then. It was particularly useful in the winters of 2008 and 2011 when I was training for the 
3 Peaks Fell Run as it allowed me to build up my stamina for mountain running no matter what the state of the countryside. I put down a respectable PB of 7:10 back then.

There are nicer paths by which to reach the South Downs Way, and there are certainly harder ones; the best is probably the path from Clayton Rec to Jack and Jill Windmills, and the hardest is probably the direct route up Ditchling Beacon from the lower car park. However the great appeal of the Tank Tracks is its reliability in all seasons. I’ve run up there in deep snow, in the dark, in torrential rain and in a howling gale and I’ve never had a trip or fall.  This means that it can be used as a marker of how fit you are. Run up the path as fast as you can and compare it to your best, or your worst, or your average.  Many folks are not the least bit concerned by such things and that is fine, but I often am. When considering a target time for a hilly race I will always have a run up the Tank Tracks to judge how strong I am.


I have lost count of the number of times that friends have exclaimed about the wonderful view from the top of the hill by the signpost. You can see for 40 miles in most directions on a good day. It reveals just how wonderful our local countryside is, and it’s only 2 miles from home.

I am certainly not one of the fastest up the Tank Tracks. In fact I am nearly 2 minutes slower than the record holder. But I might have one claim to Tank Tracks fame; I think I might be the only person to have run it twelve times in one morning, and I am sure that I’m the only one to have done this on a zero carb diet..   

And lastly, having mentioned the diet, I am very pleased to say that last week I beat my PB on the Tank Tracks; for good measure I did it on another local hill as well this week.  

Lots of fitness experts suggest that it is not possible to perform at your best in short distance threshold training or racing when burning fat rather than carbs. I like to think when it comes to 2nd rate runners like myself, I may have proved them wrong.