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INSIDE HEALTH

Programme 4.

TX: 22.07.14 2100-2130

PRESENTER: MARK PORTER

PRODUCER: ERIKA WRIGHT

Porter

Coming up in today’s programme: Diet and inflammatory bowel disease – we counter recent reports in the media suggesting that a fondness for junk food is behind a rise in the number of people with Crohn’s disease and ulcerative colitis.

It’s that time again:

Music – School’s Out for Summer

Pupils will be looking forward to it but I’ll be finding out why teachers’ voices often need the well-earned rest too.

And do you cook with olive oil? If so – and many of us do - then keep listening, we’ve a couple of useful tips coming up.

Talking of fats, we’ll also be answering a listener’s question about cholesterol lowering drinks, yoghurts and spreads. Do the health benefits really live up to the hype?

But first, a more established way to lower cholesterol - statins. The National Institute of Health and Care Excellence has finalised changes to its guidance on who should be offered the drugs. A move that will mean that most of us over 50 now qualify, and millions more people could end up being prescribed statins in the near future.

It has been a controversial decision, widely debated in the media, not least on this programme, amid concerns from some doctors that NICE has over-estimated the benefits of statins and under-estimated their side effects. But the decision has now been made. Inside Health’s Dr Margaret McCartney is in our Glasgow studio.

So Margaret, what happens next?

McCartney

To be honest with you I’m not sure. At the moment we do gather information about patients which is in their notes and the suggestion from NICE is that we don’t just wait for people to come in but we do some kind of search using software tools that will pull out people who are thought to be at higher risk. There’s several different types of computer systems the GP has and what they have in common is an ability to have these software programmes that can reach in and grab the information and try and work out who it is that’s higher risk. But I have to say I don’t think it’s going to be foolproof because there’s going to be a lot of people who have no data on their record, maybe they don’t go and see their doctor, maybe their data isn’t up to date for example and they might be missed. The other thing is what normally happens is in an informal screening programme is that normally that’s arranged centrally, so for example like cervical screening, breast screening, aorta aneurism screening, all those things are organised centrally and letters are sent out, appointments are made, this isn’t going to run like that, this is going to be down to the individual GP practice to work out a way that suits their population and their systems to try and get these tests done.

Porter

And I suspect that’s going to vary from practice to practice. At one end of the spectrum you might get a letter from your GP inviting you in to discuss statins, at the other you might mention it when you’re in for something else and some people might not hear at all.

McCartney

Yeah and other people can go online themselves, they can go to the Q Risk 2, online programme, put in the risk factors they know about and even work it out for themselves without even going to their doctor. But I suppose there’s two problems. One is finding people and then there’s what to do with the information once you’ve got it. But what’s been missed out from an awful lot of the reporting is the recommendation that everyone aged over 85 should consider taking a statin on the basis of their age being a risk factor alone.

Porter

So it’s not just the middle aged otherwise healthy people who might be broaching this new threshold it’s everyone over the age of 85?

McCartney

Absolutely, absolutely. And previously in risk calculators there’s been a bit of a vague cut off point about when you stop using them but what NICE have said now categorically is that everyone aged over 85 should consider taking a statin and I’ve had a lot of e-mails over the last week or two from older people saying well actually I’ve got to the age of 88 or 89 without any medical interventions do I really need to start now?

Porter

They should be telling us what to do not vice versa.

McCartney

Well I think there’s a lot to be said for that.

Porter

Thank you Margaret and there is a link to the new NICE guidance on the Inside Health page of the Radio 4 website where you will also find a link to that risk calculator that Margaret mentioned to work out whether you may eligible for statins under the new lower 10% threshold.

Now on to that listener’s query about the benefits of using cholesterol lowering spreads and drinks. The active ingredients in these types of functional foods are plant derived stanols and sterols but what do they actually do?

Linda Mayne is dietetic advisor to the cholesterol charity Heart UK, which does receive some funding from both Flora and Benecol.

Mayne

If you like they are the cholesterol of the plant world and we know that we actually have them naturally occurring in our diet, so they come in the form of grains, nuts, seeds and we consume about 400-600 milligrams of these every single day. Now we know that isn’t actually sufficient to provide the cholesterol lowering benefit, so you have to have something like five to 10 times that amount which is why they’ve started to be put into functional foods. Normally found in the chiller cabinet and you’d be looking for Flora Proactive, which is a plant sterol and also Benecol which is a plant stanol product because both sterols and stanols are very structurally similar to cholesterol. They work primarily by reducing the absorption of cholesterol into the body from our diet but they also reduce the reabsorption of cholesterol rich bile acids. Now bile is put into the gut as part of our digestive juices, it’s there to help emulsify the fat in our diet, break it down into really small globules which are then available for digestion. So it helps reduce the reabsorption of these.

Porter

What’s the evidence that they lower cholesterol?

Mayne

Well there’s some really good evidence from a quite significant number of clinical trials. So each – the plant stanols and the plant sterols – have about 60 clinical trials each, about half of which are in human populations. And they can show that you can lower cholesterol by between 7-10% if you’re taking the required amount each day.

Porter

Can you give me some idea – if I’m using, for instance, a spread, how much of that am I having to use?

Mayne

So you need between two and three portions a day and a portion is considered to be two teaspoons of the spread, one yoghurt or a glass of the milk.

Porter

And to maintain a lower than normal cholesterol for you you’d have to keep taking these products indefinitely?

Mayne

Absolutely and that’s very key because some people believe that they can take them for a period of time, they’ve lowered their cholesterol and they’ve been to the GP, their cholesterol’s come down so they stop taking them.

Porter

Margaret McCartney, it sounds like there’s a lot of evidence out there that these actually do lower cholesterol.

McCartney

Yes so there’s lots of data that if you take these regularly for periods of time you can reduce your LDL cholesterol which is sometimes thought about being your bad cholesterol by around about 9-10%, something like that.

Porter

That’s all the TV ads that I’ve seen claim and the implication of course is that that’s good for your heart, can we make that leap?

McCartney

No we absolutely cannot. So this is what’s called a proxy marker, the idea from the marketing company is for these products is that if you take these drugs and you lower your cholesterol therefore you’ll reduce your risk of stroke, heart attack or early death – that’s what they would like you to believe. But that’s a leapfrogging of the evidence. We have evidence that they will reduce your cholesterol, what we don’t have evidence for is that these drugs will reduce your cholesterol in a clinically meaningful way allowing you to live longer without having had a heart attack, stroke or an earlier death later on.

Mayne

Absolutely agree, there aren’t the clinical end markers in clinical trials to show that they reduce the number of heart attacks, the number of strokes etc.

Porter

Have the studies actually been done, I’m intrigued, because often there’s no evidence because the trials haven’t been done or have trials been done and they’ve not been found to be effective?

Mayne

Trials have been done but in order to get an end point you would have to run these trials for very, very long periods of time and most of the trials are done in healthy people who are 20, 30, 40 years away from their heart attack, so they’re not about to keel over if you continue the trial for six months or 12 months.

Porter

But what’s your position on these products as a charity – Heart UK – because NICE, the National Institute for Health and Care Excellence, don’t advise their use in people with – who are at risk of heart disease?

Mayne

Yes and very recently the European Atherosclerosis Society did actually come out and say that there are some key groups of the population that could benefit from taking plant sterols and plant stanols. And these are people that are at a. low risk or medium risk of heart attack or a stroke because they’ve got slightly raised cholesterol, it’s also people that are at high risk and are on statins but could benefit from having the plant sterols on top of the statins and we know that they can help by almost doubling the cholesterol lowering effect of the statin and they’re also people with a condition called FH, it stands for Familial Hypercholesterolemia, or family cholesterol in the blood and this is a genetic condition that affects up to one in 500 of the population and can cause early death in people aged 20s, 30s, 40s.

McCartney

But again this society did not have hard evidence that these people would actually benefit from the sterol, the margarine or the yoghurt drink, they were very much looking at the proxy markers again. And I think this is a really dangerous path to go down when they’re being marketed at people in their 30s, 40s, 50s, people at low risk of heart attack or stroke. You’re asking people to take quite an expensive product daily for the rest of their life, is that really the focus to go on? And again I think we have to look at people’s holistic risk of cardiovascular death, it’s not all about cholesterol, it’s about smoking, it’s about exercise, it’s about being overweight – there’s lots of other things we can do and I think sometimes people get a bit fixated about their cholesterol level when actually for most people there’s lots of other things to do. And in the case of the genetic disorder – Familial Hypercholesterolemia – there’s very specific interventions for those groups of patients and I don’t think that any doctor in the UK would really be recommending these plant stanols as the only intervention for these people.

Mayne

Oh I absolutely agree, not the only intervention but perhaps as a range of interventions that people can take.

McCartney

The problem that I find is for many people they’re using these products at great expense and in many ways using these products gives people the illusion that they’re doing something positive for their health when actually there really is no randomised control trial proof through this product to actually deliver in terms of a reduction in heart attacks or strokes.

Porter

Is there a downside to taking these, do they have any side effects that we should be concerned about?

Mayne

There has been research in this area as well. One of the sort of effects that we believe they can cause is a reduction in the amount of fat soluble carotenoids…

Porter

So these are vitamin type…

Mayne

Yeah fruits and vegetables. However, that is more compensated for by eating an extra portion of fruit and vegetables a day, you can completely overcome that problem. The one difference that you might notice is for some people they will have an effect on your bowel motions, so they may become slightly looser but you tend to get used to that over a period of time.

Porter

Linda Mayne from Heart UK.

And just to be clear statins have much bigger cholesterol lowering effects than sterols and stanols and, unlike functional foods, there is lots of evidence to show that they prevent deaths from heart attack and stroke. Not least because the cholesterol lowering effect of statins may not be the only way that they protect us, they’re also thought to stabilise the damaged lining of vital arteries supplying the heart and brain.

And while we’re on the subject of fats, we were intrigued here at Inside Health by recent news reports in a number of newspapers claiming that you shouldn’t use olive oil for cooking? And you thought it was the healthy choice. So what’s the problem?

Bridget Benelam is Senior Nutrition Scientist at the British Nutrition Foundation.

Benelam

Well it’s a recent story but it’s not a new issue. We’ve known for some time that olive oil has a lower smoking point which means that when you heat olive oil at a certain temperature it will start to smoke and that happens at a lower temperature than for oils like, for example, rape seed oil, your standard vegetable oil or things like sunflower oil. So generally speaking we wouldn’t suggest cooking at high temperatures with olive oil, so if you want to fry something at a high temperature it’s probably better to use something like your standard vegetable oil or sunflower oil, something that has a higher smoking point.

Porter

Now I can see that posing a hazard to the person who’s standing over the cooker inhaling those fumes but there’s something also happening to the oil itself that makes it less healthy?

Benelam

Well there’s the potential if you’re heating oil a lot, if you’re heating it repeatedly at very high temperatures that the oil can oxidate and those oxidative products can potentially be harmful to health. But realistically in your normal kitchen when you’re frying and cooking normal dishes that’s probably not going to happen, that would be a concern that we’d have at industrial frying levels. I mean it’s very unlikely that in your average kitchen in a frying pan you’re going to reach those temperatures. If you are frying olive oil and it starts to smoke then probably a good idea to throw it away and start again. But there’s no reason why you can’t use olive oil in cooking. I mean one thing you might want to consider is the fact that olive oil’s a relatively expensive oil, that has a nice flavour, and you might want to keep it for times when you’re actually going to be able to taste it, so for dressings, for drizzling on to things and to keep probably cheaper oils, like vegetable oil, rape seed oil, sunflower oil, for the things that you’re going to fry and where you’re not really going to notice the taste.

Porter

You say cheaper oils like vegetable oil and you used the example of rape seed oil, I’m seeing that more and more now, are there any particular benefits from using that oil as above any other vegetable oil?

Benelam

In terms of rape seed oil it does have a very good fatty acid profile actually in terms of the balance of poly and unsaturated fatty acids, it also provides some of the Omega 3 fatty acids that are essential for the body. Go for vegetable oils – olive oils, nut and seed oils – but in terms of evidence for protective effects of any one oil over another oil we don’t really have that at the moment.

Porter

Bridget Benelam.

Another confusing story in the headlines recently claimed that junk food was behind the increase in the number of young people developing inflammatory bowel diseases like Crohn’s and ulcerative colitis. The story originated in an interview of a specialist on Newsbeat on Radio 1. She’s since said that her reference to a link with fast food was subsequently taken out of context and blown out of all proportion. But the damage had been done.

Hookway

My name is Carla Hookway and I am the inflammatory bowel disease specialist nurse at St Richard’s Hospital in Chichester.

I felt it was very disappointing and a little bit upsetting for patients that suffer with this chronic disease day in and day out and a lot of them do live a very healthy life. The feedback I got from my patients was that it was just upsetting for them. We don’t actually know what causes inflammatory bowel disease, it’s multi-factorial and diet doesn’t actually cause inflammatory bowel disease as a single entity but it can aggravate some of the symptoms that you possibly experience.

Emmanuel

My name’s Anton Emmanuel and I’m a consultant gastroenterologist at UCH.

Porter

Anton, have you had any experience of the sort of angst that this report has caused?

Emmanuel

Certainly we’ve got quite a few of our longstanding patients with Crohn’s and colitis who lead what they think is the best life they can and then suddenly feel guilty about something. Some have taken offence and some have been concerned that they’ve done something wrong or that they’re feeding their grandchildren bad things…

Porter

The implication being that you got that because you’ve been eating junk food?

Emmanuel

Yes I think what has been lost is that actually there is no single factor that causes one to have inflammatory bowel disease, it’s a complex mixture of our own personality and our genes and our bacteria and our diet and our environment and that complexity can’t be brought down to a simple nugget.

Hookway

Every patient’s different, every patient experiences different symptoms from the disease and is affected differently by the disease, it’s not a simple disease that we can put down to one thing. One of the triggering factors is also stress, so I tend to talk to my patients a lot about stress and stress management and how to deal with that.

Porter

What sort of diet might aggravate my symptoms?

Hookway

Certainly things we know that could aggravate and that patients have said to me are things like onions, tomatoes, fruits with pips and seeds – they certainly aggravate the condition and can cause the symptoms to be worse at times.

Porter

None of which is traditionally what we’d think of as junk food. Does it worry you if patients of yours who’ve got inflammatory bowel disease are eating a junk food diet?

Hookway

Some people are not affected by what they eat, with Crohn’s and colitis, and so I tend to tell my patients that whatever they need to eat to help them and people – sometimes people exclude starchy foods or gluten or dairy and different diets work for different people, so there isn’t a set plan that I will talk to my patients about, I work with every patient individually. And I’ll often do a dietician referral if it’s something that concerns them to help them cope with their symptoms.

Porter

One of the other things that’s emerged recently in a lot of the coverage is that this is becoming an increasing frequent problem, is that something that you’d concur with?

Hookway

Recently I was talking to a paediatrician who said that they are seeing more younger patients with this disease coming through now than ever before, so it is on the increase and we know that.

Emmanuel

So the issue with diet is of course there’s [indistinct words] but it’s a question of how much you can unpick from the rest of one’s life, we don’t eat in isolation of our smoking habits, our stress levels, our antibiotic exposure, our surgical exposure – these things occur in the context and in the round and unpicking one from the other is tremendously difficult, especially as our diets vary from month to month. Actually the primary issue with inflammatory bowel disease seems to be genetic, there’s a susceptibility that people have but then certain environmental triggers can influence that, so things like antibiotic exposure, things like diet, things like smoking. Many environmental factors occur to make a genetic risk come to life, as it were. So the notion that a single factor is going to be critical is really a mistake.

Porter

And what would it be about junk food, in particular, I mean because it contains the same sort of components as any diet, doesn’t it, but perhaps not in such a healthy proportion?

Emmanuel

So it’s partly to do with proportions, it’s partly to do with the fact that these things are preserved to make them rapidly edible and rapidly served, they often have other things which may be causative in terms of triggering the illness. And the fact that there is a slightly addictive nature with these things – it’s convenient, as well as the sort of taste aspects which makes us want to crave it more and therefore one becomes two, becomes three a week and so on. So there are many aspects to where junk food could be a problem.

Porter

And the diet that’s rich in junk food is likely to be low in some of the healthier components that you might want your patients to be on.

Emmanuel

Correct.

Porter

So there isn’t a sort of set diet which you know can perhaps help people or make them worse, you’ve not seen that from the research?

Emmanuel

There is some research emerging, interestingly, about something called the Low Fodmap’s Diet which has a reduced amount of fermentable content in the diet, so it reduces certain amounts of fruit and vegetable which have an ability to be a substrate for fermentation and therefore cause more gas and water being retained in the bowel and therefore more colic and diarrhoea, some of the sort of spasmy symptoms that associate with inflammatory bowel disease. That can be made easier by a Low Fodmap’s diet but again it’s about really – without repeating a cliché – discussing it with one’s specialist to find out whether it’s appropriate.

Porter

It’s interesting because the things that are doing the fermentation are the bacteria that live in the bowel, which suggests that they might have some sort of influence on inflammatory bowel disease – is there any research in that area?

Emmanuel

Oh tremendous, Mark, tremendous. I mean – so a lot of the genes I mentioned earlier on that are present in some patients with Crohn’s disease, those genes seem to be especially implicated in determining what bacteria we hold in our guts and bacteria are undoubtedly a bit part of the story of inflammatory bowel disease in terms of causation but also in terms of what causes flare ups.

Porter

So the diet can influence the bacteria which in turn might influence your symptoms, might be one possible part of it?

Emmanuel

Absolutely, so this complex interaction of genes and diet and bacteria is at least part of the story plus then you throw in antibiotics and stress, all of which we know can alter gut bacteria.

Porter

So nature loads the gun if you like but it’s the environment – the diet, the lifestyle, lots of different factors – that decide whether the trigger’s pulled or not?

Emmanuel

That is the critical message to take home. It reflects how complex the problem is that actually there is a need to sort of bullet point a complicated story, it’s human nature to try and simplify things.

Porter

Dr Anton Emmanuel. And if you would like to know more about the symptoms and treatment of inflammatory bowel disease – including details of the Fodmap’s Diet Anton mentioned – there are some useful links on our page of the Radio 4 website.

Don’t forget if there is a health issue that’s confusing you or perhaps coverage of one that has annoyed you then please do get in touch, you can e-mail us at insidehealth@bbc.co.uk

Now what do think this lot might have in common?

Clip

Opera music/Football Match/David Cameron Speech

Singers, football fans and MPs, all of them at risk of straining their voices and developing so-called singers’ nodules on their vocal cords. But they’re not the only ones at risk. So if you’re a teacher and breaking up this week for the summer holiday sit back, keep quiet and listen carefully.

Costello

The phrase singers’ nodules is a bit of a misnomer because it implies that this problem happens just in singers.

Porter

Declan Costello is a consultant ENT surgeon at Queen Elizabeth Hospital in Birmingham.

Costello

In fact the majority of people who have nodules are not singers, in fact the people who run into problems with their voice most frequently are people who are using their voice an enormous amount and generally at high intensities, particularly in teachers and boys aged about 10 who have two older brothers and who like playing football so they’re doing a lot of yelling and the other group is young adult females, typically undergraduates, who may be are using their voices going out a few nights a week in a way that they’re not accustomed to. So in my practice the teachers who particularly run into difficulties are primary school teachers who are often projecting their voices over large groups of noisy young children.

Porter

I’ve heard it described as a callus of the vocal cords, a crude description but it quite nicely sums up the fact of why you get it.

Costello

That’s about right. The nodules happen when the vocal cords are coming together very hard at one particular point and where they’re coming together at high velocity the vocal cord thickens and that’s called a soft nodule and if that then carries on it forms essentially a callus, as you say, and that can become a firm nodule.

Porter

And this is where the name singers’ nodules initially came from, presumably these people are using their voices a lot. So why do singers not get it but teachers do?

Costello

Singers trained in the Western classical tradition are less likely to run into these problems because although they’re using their voices quite intensely they’ve developed a way of projecting their voice that doesn’t involve high collision forces of the vocal cords. So classical singers are less prone to nodules. The group who is a little bit more prone to them are pop singers and singers in the West End, the musical theatre style, because that requires a lot more intensity and bringing the vocal cords together much harder.

Porter

And with teachers it’s just the fact that they’re having to raise their voices and use them a lot?

Costello

Yes exactly that, combined with the fact that teachers have very little, if any, voice training in the course of their teacher training. They may run into problems with completely losing their voices once or twice a term and teachers are a very devoted group of people who don’t like to not show up for work so they will frequently push on through and actually that pushing of the voice in the context of vocal cords that are already slightly swollen can make things worse.

Porter

How would somebody know that they were developing problems?

Costello

Initially the voice would be a little husky, a little breathy and quite often would feel tired and the throat would feel quite achy towards the end of the day and the ache is simply a reflection of the fact that the muscles are getting tighter and tighter as the day goes on – so it’s a muscle ache. And typically the voice would improve a little bit overnight and be a bit better the next morning and for a teacher the voice might get progressively worse as the term goes on and then recover over the holiday and then have the same pattern next term. So hoarseness and breathiness principally for speakers. For singers the symptoms would be a little bit more subtle, they might involve a change in their ability to sing at high pitches for example and they would also notice a degree of huskiness. If the hoarseness persists for more than three or four weeks and is there constantly, in other words you never have any periods of having a normal voice, then that should trigger some alarm bells. The way we look at the larynx in an ENT clinic is either with an endoscope that goes through the nose and has a look down over the back of the throat or with a rigid endoscope that sits on the tongue and looks over the back to look at the vocal cords. But either way the only way you can genuinely know what’s going on with the vocal cords is to have a look at them.

Porter

What can you do about it?

Costello

The first thing to say is that nodules almost never require surgery, around about 5% of patients with nodules will require surgery. One of the concerns from singers who come to see me is that nodules are going to signal the end of their career and that comes out of historical problems with surgeons who’ve been a little bit too vigorous with the surgery they’ve done…

Porter

Of course the most famous case and most people will be aware of was Julie Andrews, I mean her singing career was cut short, she had an operation which didn’t go too well.

Costello

That’s my understanding of her case is that she had an operation in which slightly too much of the vocal cord was removed and that’s led to scarring. And it’s by understanding the very fine microscopic layered structure of the vocal cords that we can tailor the surgery much better and we now understand that cutting deep into the vocal cord causes scarring which is very problematic.

Porter

You say this is an unusual problem in trained singers but what about the poor teacher and a noisy classroom, how does he or she look after their voice?

Costello

Very difficult. The speech and language therapists have techniques that involve softening the way the voice is being used, some of our teachers coming through the clinic will have personal microphones to amplify sound. Most of the teachers I see are very diligent about picking up on the therapy they’ve had, in other words the techniques they’re given to reduce the abuse of their vocal cords really carry through and they’re able to do that. And that’s the key thing after surgery, if you go back to using the voice in the same way you were beforehand you’re likely to run into problems again but if you can use it in a non-abusive way from thereon you shouldn’t run into problems.

Porter

If a teacher or a singer needs to have surgery how quickly do they recover and what’s the outlook?

Costello

For patients who are having laryngeal surgery under my care I say they need to completely rest their voice for two days, by which I mean total silence. I then would tell them to use their voice very sparingly for a two week period, at which point I would check them and if their vocal cords are healing well then they can gradually build up the use of their voice. For a singer or for a teacher I would say they’re going to have at least six weeks off full on voice usage and then if everything okay at the end of that then they should be able to go back.

Porter

And the chances of them ending up with a normal voice?

Costello

Very high. Done correctly the chances of the voice returning to normal are very high as evidenced by Bjork who had laryngeal surgery and has recovered very well.

Music – Bjork

Porter

Thanks to Bjork and Mr Declan Costello.

Music – Bjork

And just to re-iterate what Declan said there – unexplained continual hoarseness that persists for more than a few weeks always warrants further investigation - whatever your job!

Just time to tell you about next week when we will be examining new legislation on driving under the influence of drugs and it just won’t apply to illegal drugs like cannabis, but some medicines too. And I will be asking why tens of thousands of hospital patients in the UK are receiving blood thinning drugs they probably don’t need.

ENDS