Monday, May 27, 2013

In a post-Francis* world where institutional neglect and cruelty towards some of our most vulnerable citizens has been exposed, A Bird in a Gilded Cage suggests that the arts might offer something of an antidote to the way we support people affected by memory loss. This is a gentle polemic that sweetly kicks the ankles of those obsessed with understanding the impact of the arts on human wellbeing through crude pseudo-scientific measurements, placing creativity, culture and the arts at the heart of a conversation about quality of life.

*The final report into the care provided by Mid Staffordshire NHS Foundation Trust. The Inquiry Chairman, Robert Francis QC, concluded that patients were routinely neglected by a Trust that was preoccupied with cost cutting, targets and processes and which lost sight of its fundamental responsibility to provide safe care. His final report is based on evidence from over 900 patients and families who contacted the Inquiry with their views. 


      DIGITAL NHS...*

            DANCE YOURSELF DIZZY...*                                            

Monday, May 20, 2013

Sudden cholesterol increase? It may be psychological

There are many published studies with evidence that cholesterol levels are positively associated with heart disease. In multivariate analyses the effects are usually small, but they are still there. On the other hand, there is also plenty of evidence that cholesterol is beneficial in terms of health. Here of course I am referring to the health of humans, not of the many parasites that benefit from disease.

For example, there is evidence () that cholesterol levels are negatively associated with mortality (i.e., higher cholesterol leading to lower mortality), and are positively associated with vitamin D production from skin exposure to sunlight ().

Most of the debris accumulated in atheromas are made up of macrophages, which are specialized cells that “eat” cell debris (ironically) and some pathogens. The drug market is still hot for cholesterol-lowering drugs, often presented in TV and Internet ads as effective tools to prevent formation of atheromas.

But what about macrophages? What about calcium, another big component of atheromas? If drugs were to target macrophages for atheroma prevention, drug users may experience major muscle wasting and problems with adaptive immunity, as macrophages play a key role in muscle repair and antibody formation. If drugs were to target calcium, users may experience osteoporosis.

So cholesterol is the target, because there is a “link” between cholesterol and atheroma formation. There is also a link between the number of house fires in a city and the amount of firefighting activity in the city, but we don’t see mayors announcing initiatives to reduce the number of firefighters in their cities to prevent house fires.

When we talk about variations in cholesterol, we usually mean variations in cholesterol carried by LDL particles. That is because LDL cholesterol seems to be very “sensitive” to a number of factors, including diet and disease, presenting quite a lot of sudden variation in response to changes in those factors.

LDL particles seem to be intimately involved with disease, but do not be so quick to conclude that they cause disease. Something so widespread and with so many functions in the human body could not be primarily an agent of disease that needs to be countered with statins. That makes no sense.

Looking at the totally of evidence linking cholesterol with health, it seems that cholesterol is extremely important for the human body, particularly when it is under attack. So the increases in LDL cholesterol associated with various diseases, notably heart disease, may not be because cholesterol is causing disease, but rather because cholesterol is being used to cope with disease.

LDL particles, and their content (including cholesterol), may be used by the body to cope with conditions that themselves cause heart disease, and end up being blamed in the process. The lipid hypothesis may be a classic case of reverse causation. A case in point is that of cholesterol responses to stress, particularly mental stress.

Grundy and Griffin () studied the effects of academic final examinations on serum cholesterol levels in 2 groups of medical students in the winter and spring semesters (see table below). During control periods, average cholesterol levels in the two groups were approximately 213 and 216 mg/dl. During the final examination periods, average cholesterol levels were 248 and 240 mg/dl. These measures were for winter and spring, respectively.

One could say that even the bigger increase from 213 to 248 is not that impressive in percentage terms, approximately 16 percent. However, HDL cholesterol does not go up significantly response to sustained (e.g., multi-day) stress, it actually goes down, so the increases reported can be safely assumed to be chiefly due to LDL cholesterol. For most people, LDL particles are the main carriers of cholesterol in the human body. Thus, in percentage terms, the increases in LDL cholesterol are about twice those reported for total cholesterol.

A 32-percent increase (16 x 2) in LDL cholesterol would not go unnoticed today. If one’s LDL cholesterol were to be normally 140 mg/dl, it would jump to 185 mg/dl with a 32-percent increase. It looks like the standard deviations were more than 30 in the study. (This is based on the standard errors reported, and assuming that the standard deviation equals the standard error multiplied by the square root of the sample size.) So we can guess that several people might go from 140 to 215 or more (this is LDL cholesterol, in mg/dl) in response to the stress from exams.

And the effects above were observed with young medical students, in response to the stress from exams. What about a middle-aged man or woman trying to cope with chronic mental stress for months or years, due to losing his or her job, while still having to provide for a family? Or someone who has just been promoted, and finds himself or herself overwhelmed with the new responsibilities?

Keep in mind that sustained dieting can be a major stressor for some people, particular when one gets to that point in the dieting process where he or she gets regularly into negative nitrogen balance (muscle loss). So you may have heard from people saying that, after months or years of successful dieting, their cholesterol levels are inexplicably going up. Well, this post provides one of many possible explanations for that.

The finding that cholesterol goes up with stress has been replicated many times. It has been known for a long time, with studies dating back to the 1950s. Wertlake and colleagues () observed an increase in average cholesterol levels from 214 to 238 (in mg/dl); also among medical students, in response to the mental and emotional stress of an examination week. A similar study to the one above.

Those enamored with the idea of standing up the whole day, thinking that this will make them healthy, should know that performing cognitively demanding tasks while standing up is a known stressor. It is often used in research where stress must be induced to create an experimental condition. Muldoon and colleagues () found that people performing a mental task while standing experienced an increase in serum cholesterol of approximately 22 points (in mg/dl).

What we are not adapted for is sitting down for long hours in very comfortable furniture (, ). But our anatomy clearly suggests adaptations for sitting down, particularly when engaging in activities that resemble tool-making, a hallmark of the human species. Among modern hunter-gatherers, tool-making is part of daily life, and typically it is much easier to accomplish sitting down than standing up.

Modern urbanites could be seen as engaging in activities that resemble tool-making when they produce things at work for internal or external customers, whether those things are tangible or intangible.

So, stress is associated with cholesterol levels, and particularly with LDL cholesterol levels. Diehard lipid hypothesis proponents may argue that this is how stress is associated with heart disease: stress increases cholesterol which increases heart disease. Others may argue that one of the reasons why LDL cholesterol levels are sometimes found to be associated with heart disease-related conditions, such as chronic stress, and other health conditions is that the body is using LDL cholesterol to cope with those conditions.

Specifically regarding mental stress, a third argument has been put forth by Patterson and colleagues, who claimed that stress-mediated variations in blood lipid concentrations are a secondary result of decreased plasma volume. The cause, in their interpretation, was unspecified – “vascular fluid shifts”. However, when you look at the numbers reported in their study, you still see a marked increase in LDL cholesterol, even controlling for plasma volume. And this is all in response to “10 minutes of mental arithmetic with harassment” ().

I tend to think that the view that cholesterol increases with stress because cholesterol is used by the body to cope with stress is the closest to the truth. Among other things, stress increases the body’s overall protein demand, and cholesterol is used in the synthesis of many proteins. This includes proteins used for signaling, also known as hormones.

Cholesterol also seems to be a diet marker, tending to go up in high fat diets. This is easier to explain. High fat diets increase the demand for bile production, as bile is used in the digestion of fat. Most of the cholesterol produced by the human body is used to make bile.

Saturday, May 18, 2013 kilter

This week your blogger is otherwise engaged and is only providing you with interesting snippets to explore, if you should so wish... 







Saturday, May 11, 2013

Wagnerian Delirium...

Mortality: Death and the Imagination
8th July – 16th August 2013 * * * * DETAILS COMING SOON

Wagnerian Delirium
Some very interesting reports coming in from Germany around the Düsseldorf opera house's production of Wagner's Tannhäuser directed by Burkhard Kosinski. The romantic opera was written in the 1840’s and set (in the mind of Wagner) in the middle ages. Kosinski chose to transpose it to 1940’s Germany under Nazi rule with depictions of mass murder, the gas chambers and SS executions.

There have been reports of people storming out of the theatre, booing and slamming doors - so much so in fact, that the staging has been pulled and it is now being performed purely as a concert. 

The furore on the internet has been prolific, with Oxford University historian, James Kennaway telling the Guardian:
"Wagner's operas have often produced extreme reactions and the list of singers, conductors and patrons who have keeled over dead after attending one and suffered a 'Wagnerian delirium' is amazing."

Debate over Wagner’s place in German culture has escalated coinciding with what would have been his 200th birthday on May 22nd. For many, Wagner has come to symbolise the seeds of anti-Semitic sentiment in German culture that would grow into the Nazi terror. A recent article in Der Spiegel commented, “Richard Wagner’s legacy prompts the question: Can Germans enjoy any part of their history in a carefree way?”

In the Guardian this weekend, Will Self suggested that, “Hitler was indeed a great music lover – get over it! He could be one, and still prosecute the deaths of untold millions by word and deed. Hitler loved music because many humans – including evil ones – love music. He loved Wagner's music both despite and because Wagner was an antisemite – it all just fed into the semiotic mix.”

The timing of the doomed opera has coincided with the high-profile trial of neo-Nazi’s which began in Munich last week, with Beate Zschaepe being charged with a series of anti-immigrant murders, and where we can witness a bizarre and superficial media frenzy focused as much on Zschaepe's looks, as for the crimes she’s allegedly committed.

I can’t help being a little curious about what Self describes as “an assumed sharp dichotomy between high and low art, and a privileging of the discourse of the former.” Cinema goers have largely relished the excuse to cathartically grind their teeth to Schindler’s List, been remorselessly subsumed in In the Fog, or else heartily relish the extremes of Inglourious Basterds. There’s no shortage of literature that would provoke a similar range of responses and the response to Jake and Dino’s Chapman’s, Hell from some quarters, at least - was profound, with Jonathan Jones describing it as a ‘true masterpiece.’

Inequalities and denial spring to mind here and something about the gated community of an elite cultural psyche. Perhaps this version of Tannhäuser was tasteless and badly conceived? Kosminski, declined to make changes to soften the impact of the violence saying that he had been completely transparent with the opera house about his intent for the production and that he was not a “scandal director.” “It would be good if the debate continued,” Mr. Kosminski said, “and we learned what the underlying reasons were for this great emotionality.” Not perhaps art and health on an individual level, but a deeply fascinating issue.

So a question: is the portrayal of Nazi Germany permitted in popular culture and other art forms, but somehow best avoided in more genteel cultural circles?

Food production systems in Britain today are very much dictated by laws, regulations and other policies, all of which are geared toward supporting 'Big Dairy' ie the dairy farmers that milk hundreds and thousands of cows every day. Sadly, the modern approach or corporate take over of milk production and distribution is very much to the detriment of smaller producers and farmers here in Britain and around the world. The decline of the British dairy farmer in recent years has accelerated at a significant and worrying rate. 

In the past ten years, the number of dairy farms in England and Wales has fallen by 46.3%. from approximately 20,000 in 2002 to just over 10,000 in 2012. (Dairy Statistics: An insider Guide Pg 10, published by DairyCo, 2012)

The truth is, that the farming crisis in Britain is a direct result of the global restructuring of food markets and industries which has been ongoing since the early 80's. As a result of these new global food systems, agricultural produce, over the years, has become cheaper and primary commodities such as milk, even though demand has increased, the return to the farmer has not. British dairy farmers receive less today per litre of milk, than they did 17 years ago; and they continue to receive less per litre, than it actually costs them to produce. Further afield and also unable to break even, increasing numbers of frustrated and desperate small scale farmers across the globe watch demand for fresh produce increase, but without reaping any rewards. With the British dairy industry there appears to be a blockage; profits from sales are not trickling back down to the producers but pooling somewhere between (larger) processors and vendors.

A deeply worrying statement came from Tim Fortesque, Secretary General of the UK Food and Drinks Industries Council, quoted as saying:

“It is not the role of manufacturing industry to improve the health of the general public or to shoulder the responsibility of ensuring that people live longer, or lead healthier lives”

It is time that we, the modern consumer started to consciously understand methods of food production and question what role we actually play regards the shift towards industrialised farming and globalised food systems; and what exactly will the future landscape of the British countryside look like as the small farmers disappear and the factory farms take over?   

Dawn Prescott’s exhibition 'Farmgate' is at BLANKSPACE between 24 - 26 May explores the plight of the British dairy farmer. The work investigates modern methods of milk production and distribution as we witness an ongoing shift towards the industrialisation of dairy farming and the rise of the 'Mega Farm'.

What on earth does this little film have to do with arts and health? Find out very soon in Mortality: Death and the Imagination

Monday, May 6, 2013

Trip to South Korea: Hidden reasons for the leanness of its people

In September last year (2012) I went to South Korea to speak about nonlinear data analysis with WarpPLS (), initially for business and engineering faculty and students at Korea University in Seoul, and then as a keynote speaker at the HumanCom 2012 Conference () in Gwangju. Since Seoul is in the north part of the country, and Gwangju in the south, I had the opportunity to see quite a lot of the land and the people in this beautiful country.

(Korea University’s main entrance, Anam campus)

(In front of Korea University’s main Business School building)

Korea University is one of the most prestigious universities in South Korea. In the fields of business and engineering, it is arguably the most prestigious. It also has a solid international reputation, attracting a large number of highly qualified foreign students.

I wanted to take this opportunity and try to understand why obesity prevalence is so low in South Korea, which is a common characteristic among Southeast Asian countries, even though the caloric intake of South Koreans seems to be relatively high. Foods that are rich in carbohydrates, such as rice, are also high-calorie foods. At 4 calories per gram, carbohydrates are not as calorie-dense as fats (9 calories per gram), but they sure add up and can make one obese.

Based on my observations, explanations for the leanness that are too obvious or that focus on a particular dietary item (e.g., kimchi, green tea etc.) tend to miss the point.

Let us take for example a typical South Korean meal, like the one depicted in the photos below, which we had at a restaurant in Seoul. If you are a foreigner, this type of meal would be difficult to have without a local accompanying you, because it is not easy to make yourself understood in a traditional restaurant in South Korea speaking anything other than Korean.

(Main items of a traditional South Korean meal)

(You cook your own meal)

The meal started with thin-sliced meat (with some fat, but not much) and vegetables, with the obligatory side dishes, notably kimchi (). This part of the meal was low in calories and high in nutrients. Then we had two high-calorie low-nutrient items: noodles and rice. The rice was used in the end to soak up the broth left in the pot, so it ended adding to the nutrition value of the meal.

Because we started the meal with the low-calorie high-nutrient items, the meat and vegetables, our consumption of noodles and rice was not as high as if we had started the meal with those items. In a meal like this, a good chunk of calories would come from the carbohydrate-rich items. Still, it seems to me that we ingested plenty of calories, enough to make one fat over the long run, eating these types of meals regularly.

A side note. As I said here before, the caloric value of protein is less than the commonly listed 4 calories per gram, essentially because protein is a multi-purpose macronutrient.

In our meal, the way in which at least one of the carbohydrate-rich items was prepared possibly decreased its digestible carbohydrate content, and thus its calorie content, in a significant way. I am referring to the rice, which had been boiled, cooled and stored, way before it was re-heated and served. This likely turned some of its starch content into resistant starch (). Resistant starch is essentially treated by our digestive system as fiber.

Another factor to consider is the reduction in the glycemic load (not to be confused with glycemic index) of the rice. As I noted, the rice was used to soak up the broth from the pot. This soaking up process significantly reduces the rice’s glycemic load, because of a unique property of rice. It has an amazing capacity of absorbing liquid and swelling in the process.

This was one of several traditional Korean meals I had, and all of them followed a similar pattern in terms of the order in which the food items were consumed, and the way in which the carbohydrate-rich items were prepared. The order in which you eat foods affects your calorie intake because if you eat high nutrient-to-calorie ratio foods before, and leave the low nutrient-to-calorie ones for later, my experience is that you will eat less of the latter.

Another possible hidden reason for the low rate of obesity in South Korea is what seems to be a cultural resistance to industrialized foods, particularly among older generations; a sort of protective cultural inertia, if you will. Those foods are slowly being adopted – my visit left me with that impression – by not as quickly as in other countries. And there is overwhelming evidence that consumption of highly industrialized foods, especially those rich in refined carbohydrates and sugars, is a major cause obesity and a host of other problems.

Cultural resistance to, or cultural inertia against the adoption of, highly industrialized foods among pregnant mothers limits one’s exposure to those foods at a particularly critical time in one’s life – the 9-month gestation period in the mother’s womb. This could have a major impact on a person’s propensity to become obese or have other metabolic derangements later on in life. Some refer to this phenomenon as a classic example of modern epigenetics, whereby acquired traits appear to induce innate traits across generations.

Another reason I was excited about this trip to South Korea was my interest in table tennis. I wanted to know more about their table tennis “culture”, and how it was influenced by their general culture. China dominates modern table tennis, with such prodigies as Ma Lin, Ma Long, Wang Hao, Wang Liqin, and Zhang Jike. South Korea is not far behind; two of my all-time favorite South Korean players are Kim Taek-Soo and former Olympic champion Ryu Seung-Min.

Another side note. The best table tennis player of all time is arguably Jan-Ove Waldner (), from Sweden. I talked about him in my book on compensatory adaptation (). Waldner has been one of the few players outside China to be able to consistently beat the best Chinese players at times when they were at the top of the games, including Ma Lin ().

But, as I soon learned, as far as sports are concerned, it is not table tennis that most South Koreans are interested in these days. It is soccer.

A nice surprise during this trip was a tour in Gwangju in which we visited a studio that converted standard movies to stereoscopic three-dimensional ones (photo below). These folks were getting a lot of business, particularly from the USA, in a market that is very competitive.

(A standard-to-3D movie conversion studio in Gwangju)

Let’s get back to the health angle of the post. So there you have it, two possible “hidden” reasons for the low prevalence of obesity in South Korea, and maybe in other Southeast Asian countries. One is the way in which foods are prepared and consumed, and the other is cultural inertia. These are not very widely discussed, but future research may change that.

Sunday, May 5, 2013

...drowning by numbers

Short and sweet this week and straight on to business. Just a note that Ivan Wadeson, Co-Chief Executive of The Audience Agency, responded to Culture Secretary Maria Miller's speech last week in diplomatic style and pulling out some key comments that Ms Miller has made, particularly:

“The arts stimulate us, educate us, challenge and amuse us […] their social benefits are numerous and beyond doubt.”

“Culture is able to deliver things which few other sectors can. It brings our country to life and encourages people to visit our shores; it develops a sense of community and attracts visitors to disparate parts of our nation... it cultivates the creativity which underpins our wider industrial efforts.”

“The arts are not an add-on; they are fundamental to our success as a nation.”

You can read Ivan’s comments by clicking on the empty theatre seats.

Thanks to my friend Dr. R for his updates on all things BMJ and RSPH and for last weekends article about trumpet playing conservative MP, Jesse Norman. Once ostracised for his rebellious ways, he has been welcomed back to the heart of politics as a member of his party’s policy advisory board. It’s a curious article not least because Norman is one of the architects of the Big Society agenda and is a man who has a lot to say, including attacking crony capitalism. He is particularly keen that the government should do more to support the arts, suggesting that an interesting test will be met when we emerge from the financial crisis and there is money to spend which could possibly be ploughed into new ways of promoting social cohesion. My eyes were particularly drawn to a very pithy quote: “I don’t think anything important can be quantified - you can’t put a pound sign beside love and happiness.” I wonder perhaps, is the time right to be thinking about the ways in which our arts and public health agenda should be woven into a far more sophisticated policy framework?

I try not to advertise too many events that cost on this blog, but this years annual conference form The Reader is a 1/3 cheaper than last year! It has a great programme with some interesting speakers, of which Andy Burnham MP, Shadow Health Secretary, will be discussing ‘The Books that Built Me’ at the event taking place at the British Library on Thursday 16th May. Other speakers at the conference include Professor Louis Appleby, National Clinical Director for Offender Health and Chair of the National Suicide Prevention Advisory Group, who will be discussing ‘Finding A New Language for Mental Health’. Find out more by clicking on the plea to read me, above.

Last week saw the first teaser for my new paper, A Bird in a Gilded Cage - but what on earth was it about? The royal family - battery farms - synchronised swimming and wistful coach rides into the sunset? You bet - oh, that and the way we live and die today. Above is another version of that same little film with a few words thrown in for good measure. The paper will be on ixia’s website this month.

Hey, in the dead of night, do you ever wake up and wonder, what ever happened to Open Art? We do. To find out what the brilliant Deborah Munt and Leisa Gray and their colleagues did next, click on the love above for more.

For many years Dawn Prescott worked at Arts for Health where she ran a tight ship, and when she left for pastures new, it was LIME Arts that benefited from her superb skills and warmth. Now Dawn is holding her first exhibition at BLANKSPACE between 24 - 26 May. The exhibition farmgate is a work that explores the plight of the contemporary British dairy farmer. I’ll post more details of this exhibition next week, but pop it in your diary if you’re anywhere near Manchester later in the month.

Big Launches New Programme to Improve Lives of Older People
The Big Lottery Fund (BIG) has announced a new fund to improve the lives of vulnerable older people in England. The BIG hopes that the funding, provided through the Fulfilling Lives: Ageing Better programme, will reduce isolation, help older people deal better with change and build confidence for the future.  BIG are inviting 100 local authorities to submit an expression of interest to be considered for funding.  30 areas will be shortlisted.  The shortlisted areas will then be required to submit a full 'vision and strategy' for their area. At this stage each area will form a partnership led by a voluntary and community sector organisation.  BIG expect to make awards to 15 to 20 areas of between £2 and £6 million over three to six years.  Development funding of up to £20,000 will be available to those areas we shortlist. The closing date for submission of EOI forms is the 17th May 2013. Read more at:

Principal fires security guards to hire art teachers — and transforms elementary school
...and finally, a big thanks to Kait Wittig for sharing this story from the US.

Orchard Gardens School in Roxbury, Massachusetts was built in 2003 but was plagued by violence and disorder from the start and by 2010 it was rank in the bottom five of all public schools in the state. Enter Andrew Bott — the sixth principal in seven years — but with new ideas: “We got rid of the security guards,” said Bott, who reinvested all the money used for security infrastructure into the arts. Now, three years later, the school is almost unrecognisable. You can read more here, by clicking on the comforting image of school security above.

...thank you as ever...C.P.