Choosing Wisely: Sharks, Coconuts, Doctors and Chickens

Life is full of choices, and the choices we make are often deliberate, thought through, or based on emotion and can be instinctive, intuitive and unconscious. However, in some situations it is possible for others to deliberately manipulate the choices we make. This reflects the fact that the human psyche is pre-disposed to take a deviation and conflate it with the norm. It is the same cognitive bias that leads to some people not swimming in the sea in case they get attacked by sharks. This is despite the fact that there is a 300,000,000/1 chance of being attacked by a shark, compared to being hit and killed by a coconut (250,000,000/1). Around 150 people a year are killed by coconuts every year compared to around 40 people who are killed by sharks.

Psychologists have described the deliberate manipulation of our choices as an exploitation of the ‘availability heuristic’ (a term that once got me into all kinds of problems in the first year of becoming a Dean of School). In some ways the heuristic is a way we all make sense of the daily bombardment of information we increasingly having to face – if we didn’t we probably wouldn’t be able to cope with, and would be totally overwhelmed in having to deal with all that information. Making choices in a data and information rich world can be difficult. Occasionally we can end up making the wrong choice or feel we have no choice at all.  

Sometimes it can be easier to let others make the choice for us. Its arguably why people choose to go to A+E when a visit to their GP would be better. An informed choice might be doing nothing on the basis that the problem is likely to be self-limiting and probably not needing any medical intervention. At least 30% more time and resources could be freed up by people taking the latter course of action. And in the context of health care, it’s not just you and I that might make the wrong choice, the medical profession can also be guilty of choosing interventions that are unlikely to be of benefit. Sometime the decisions that health care professionals take can have more devastating consequences. It’s estimated there are 3790 avoidable deaths a year in the NHS – the equivalent of a jumbo jet crashing every week. Avoidable in that the deaths result from the actions or lack of action on the part of the health care professional.

The Office for National Statistics collects information on avoidable deaths in a slightly different way. Their statistics show that some 116,489 deaths in the UK were considered potentially avoidable had there been timely and effective health care or public health interventions available. They note (and the latest figures come from 2014) that people who die prematurely from avoidable causes, lose on average 23 years of life, which for children rises to 72 years of potential life. Chronic illnesses such as cancer and heart disease cause the largest number of avoidable deaths.

Choosing Wisely UK is part of a global initiative that seeks to ensure the notion of timely and effective decision making underpins patient centred care. The approach seeks to improve the conversations between patients and health care professional. Such conversations can lead to both the health care professional and the patient making better decisions about their care. The conversations are shaped around 5 questions: Do I really need this test, treatment or procedure? What are the risks or downsides? What are the possible side effects? Are their simpler, safer options? What will happen if I do nothing? The questions seem simple enough, and while they could lead to difficult conversations in some cases, they reflect the notion of ‘no decision about me, without me’. For my parents’ generation, it might have been true that the‘doctor knows best’, but that is not the case today. In the case of medical intervention just because something can be done doesn’t mean we always should do it.

And it appears that researchers in Sweden (well something has to happen there) have discovered how chickens choose wisely when it comes to mating. Researchers from Linkoping University found that hens with the largest comb gets the most attention from the cockerels. I know what you might be thinking but you are wrong. Larger combs correlate to denser bones. As the bone tissue provides calcium for the eggshells, the greater the bone mass, the more eggs she can lay, and the more attractive the hen becomes to the cockerel.

Finally, just thinking about deaths caused by sharks, coconuts or health care professionals, I can only find one case of a chicken ever killing a man. The man was one Jose Ochoe of California, a spectator at an illegal cockfight. He was stabbed in the leg by his fighting cockerel, who had a knife attached to its leg. He died 2 hours later. 

D Day for rats: a sunshine filled utopia

I undertook my nurse training nearly 40 years ago and of course I often use much of the knowledge and experience gained and built upon since then. Strangely there are a number of ‘call out’ memories that just stick in my mind, and are as vivid today as they were all that time ago. Weil’s disease is one of those memories. When I learnt about Weil’s disease (pronounced Veil’s disease) I was told it was a disease from the past and very rarely seen. It is a disease that is spread to humans through the urine of rats – and as chicken keepers of the world will tell you (and I have kept them for some 40 years), keep chickens and sooner or later you will get to know about rats. They can get in anywhere, and when they do, they cause enormous amounts of damage, steal eggs and will often kill baby chicks.

There is a persistent urban myth that we are never further than 6 feet from a rat. I’m not sure why this enduring myth is so well known, particularly as there is probably little truth in the assertion. The environmental health and housing consultant Stephen Battersby has researched British rats for much of his career. He estimates that there around 10.5 million rats in the UK and given there are over 60 million people in the UK we outnumber the rats 6 to 1. So if you divide the total urban area of the UK, around 16,000 square miles, by hypothetically distributing rats evenly across this space, you would actually be (at most) 164 feet from a rat.

All of the above came to mind as read the report last week of the death of a New Yorker, with 2 others made very ill from Leptospirosis (the medical name for Weil’s disease). All 3 cases came from the Bronx area of New York and occurred in the last 2 months. In the last 10 years there has been 26 cases. Given the nature of how the disease is spread, it is perhaps not surprising that all these cases but one, involved men. As far as I am concerned however, the wild rat has absolutely no redeeming features.

One of the other ‘call out’ memories from my nurse education is that vitamin D is not a vitamin at all.  Vitamin D is actually a hormone, and as such, it is our bodies that makes most of the vitamin D we need. 10% comes from our food, but it is the action of sunlight on our skin that first produces cholecalciferol, which gets converted by the liver to calcidiol – the active form of vitamin D is then produced by the kidneys. Too little vitamin D is most often associated with calcium deficiency and healthy bones, causing rickets in children and osteomalacia in adults. It has also been linked to the development of diabetes, multiple sclerosis, depression, heart disease and last week, research published in the British Medical Journal argued it could help spare 3 million people from suffering from cold and flu each year.

It’s true that our body’s immune system uses vitamin D to make antimicrobial ‘weapons’ that puncture holes in bacteria and viruses, and so could help prevent colds and flu. However, 1 in 5 people (1 in 10 for those aged 40 or over) in the UK have such low levels of vitamin D that they would need to take supplements to gain this protection. And that’s the rub. The team that undertook the research advocated that vitamin D supplements should be added to food or milk, which to me is taking population health to a new and unacceptable level.

Choice is everything, and these days digital technology increasingly enables us take a proactive approach to maintaining our health and wellbeing. There is a huge resource of advice available in many different media to help us make such choices and sustainable lifestyle changes. It should not be the role of the State to use and draw upon ‘scientific knowledge’ to exert social control in any form. My favourite philosopher, Foucault returned to this theme in much of his work, noting that there is a relationship between power and knowledge - and power (political, hegemonic or otherwise) should never be used to control and define knowledge.  

Coming at the same issues from a slightly different perspective was Burrhus Frederic Skinner, the famous American psychologist. Skinner believed that free will was an illusion and that human behaviour was dependent on the consequences of previous actions. You can see where Skinner took these ideas too in his famous book Walden Two. Here he describes how it’s possible to achieve an utopian society through the application of his beliefs on how behaviour can be controlled. This book can still be found and purchased on Amazon, but all I would say, before you rush out to buy it, is perhaps it is also worth remembering that Skinner was most famous for his experiments with rats.

    

A philosophical Prince of Leaves and his purple coloured hygiasticon

Last Friday I was fortunate enough to join colleagues in celebrating the 50th anniversary of the University of Salford becoming a university. The black tie dinner was an opportunity to celebrate and reflect on our achievements over the last 50 years. We were able to do so with many people who will continue to work with us over the next 50 years. The food was prepared and served by SALFOOD and they made a great job of it. The main course for us vegetarians was a Lancashire Vegetable Hotpot, and lovely it was too. However, there were no Purple Vikings, or Peruvians or Purple Majesty’s to be seen. These are varieties of purple potatoes which originate from Bolivia and Peru.

There is a reason for mentioning this although I will admit it’s slightly tangential. My co-table host was Dr Fairclough, a colleague from the School of Arts and Media and someone who has a passion for TAFKAP (or Prince to us older folk). Indeed she is organising an interdisciplinary conference on the life and legacy of Prince (due to run in May this year) entitled ‘Purple Reign’. It did occur to me that she might like to get some Purple Majesty’s in for the conference dinner…

The other reason she might like to consider purple potatoes is that apart from their earthy nutty flavour they have 4 times the level of antioxidants as ordinary white potatoes. Anthocyanin is the antioxidant that creates the purple colour. Purple potatoes are really good for your health, helping to reduce high blood pressure, increasing weight loss, helps prevent depression and can keep your skin looking younger. You can buy purple potatoes in the UK, Waitrose and Sainsbury sell them when in season, or if you can’t wait, the Fine Food Specialist online store was selling them last week. However at over £11.00 a Kg it could be an expensive sausage and mash dinner. 

Of course, potatoes are not the only vegetable that might be good for you. Way back in the 17th Century, the philosopher Leonard Lessius (who was also known as the Prince of Philosophers) described in his work ‘Hygiasticon’, the relationship of diet and health. Much later, in 1980, those canny Californian’s adopted the now famous 5-a-day phrase as way of promoting better health for all. A little later still, the World Health Organisation estimated that globally 2.7 million lives were lost each year as a direct result of low intakes of the recommended 400g of fruit and veg a day. They based this on eating 5 x 80g potions but excluded potatoes! Interestingly the 5-a-day advice wasn’t initially based upon a solid evidence base.

The WHO commissioned the European Prospective Investigation into Cancer and Nutrition (EPIC) trial, which during 1992 and 1999 looked at the diet, life style choices, anthropometric measurements, and medical histories of more than 521,000 participants from 23 centres across 10 European countries. This study did provide evidence that fruit protected against bowel cancer in women (but not men) and against lung cancer (although vegetables didn’t). It was only in 2014, that follow up data provided stronger evidence of the benefits of the 5-a-day approach.

For people eating more than 569g of fruit and veg (around 7 portions) they were found to be 15% less likely to die from a circulatory disease; 27% less likely to die from a respiratory disease; and 40% less likely to have died from a digestive system disease compared to those eating less than 249g (about 3 portions). In this later study it was vegetables that were seen to provide the most protective effect. So should we all now try and eat 7-a-day? The answer is probably no. There is evidence to suggest that for every extra portion of fruit eaten each day the overall risk of death reduces by 6% and for vegetables, 5%. However, after 5 portions, the risk of dying from any disease (other than cancer) does not reduce any further. None of the studies can confirm what the protective effect is against cancer. 

So until the next tranche of research is published I guess we should all just try and stick to the 5-a-day programme. And its likely that the next research study will produce results that once again will help us all make decisions over how we choose to live our lives. That research is likely to be carried out by those working in universities, and undertaken by those skilled in study design and in ensuring methodological rigor and outcome reliability. I am so proud to be part of a University community that is serious about research, and is committed to making a difference to people’s lives. Equally, I am also proud to be part of a community that can celebrate purple potatoes being eaten by Princes in the purple rain.

Depression and letting the sleeping dogs of learning lie

I think it might just be an age thing. I am going through a phase of only sleeping for a few hours every night. Thanks to my Fitbit, I can be very precise as to when I have slept or been awake. Currently I am enjoying around 5 hours sleep a night. Whilst I can feel tired at different times of the day, I am not actually feeling any less energetic or less interested in the world than before. I have a normal appetite and a positive outlook on the world. I am not knowingly worried about anything in particular. My BDI score is below 17 – and so I don’t think I am depressed. In case you are wondering, sleep disorders are strongly correlated with depression.

There is, however, a body of research that suggests that sadness can incline people towards sleeping more. Earnest Hemmingway, the Nobel Prize winning author once said ‘I love sleep. My life has a tendency to fall apart when I’m awake’. Hemmingway experienced periods of clinical depression throughout his life. He was said to enjoy the escape that sleep provided for him. However, many studies have shown that for the majority of people living with depression, sleep is often a very disturbed experience. Indeed many such people report disorders of sleep as being a major feature of their depression. 

Hemmingway ended his life by suicide, using his favourite shotgun to do so. He was not the first person in his family to die by suicide. His Father, sister and brother all did, and almost 35 years after Hemmingway’s death, his granddaughter Margaux Hemmingway also took her own life. At first I was surprised at finding out that 5 people across 4 generations chose death by suicide. However, Alice Gregory, Professor of Psychology at Goldsmiths, University of London, whose research into sleep quality, anxiety and depression draws on major twin-studies, noted there is a relationship between genetics, depression and sleep problems. Other research has shown that between 15% - 20% of people diagnosed with a sleep problem will develop clinical depression.

Now as I discovered last week, there is another way to think about all of this. CS Lewis, who unlike Hemmingway, wasn’t a Pulitzer or a Nobel Prize winning author, but was a jolly good writer nevertheless. I bet you have read the Lion, the Witch and the Wardrobe. He wrote a letter that unpacked what he felt was the concept of joy. The letter was sent in 1945 to a certain ‘Mrs Ellis’ and it was discovered in the pages of a second hand book many years later. In it Lewis described joy as: ‘real joy… jumps under ones ribs and tickles down one’s back, and makes one forget meals and keeps one (delightedly) sleepless o’nights’.

I like the idea of something jumping under ones ribs. I only discovered the CS Lewis connection as I was sending out a ‘good morning’ Twitter message to other folk in the #earlyrisersclub last week and out of curiosity had looked the word up. Interestingly, (well for those who like Pub Quiz’s anyway) the word ‘joy’ appears 145 times in the Bible – 88 times in the Old Testament and 57 times in the New Testament. Joy as a concept can of course be described in lots of ways. I like the notion that joy is a state of mind and an orientation of the heart. It is a settled state of contentment, confidence and hope. It might also be something or someone that provides a source of happiness.

Of course it could just be an age thing, but I can readily identify with this notion of what joy might be and/or involve. Last Friday I took a day return trip to Dundee to take part in a professorial selection process. For me the day was the perfect illustration of this idea of joy. The main part of the journey was with Virgin Rail – so no real internet connection and difficult to stay in touch with work, which for a day felt OK. The sun shone from Preston to Dundee, allowing me to enjoy the countryside and sit and reflect. The candidates were well prepared, experienced and it was very interesting to listen to them tell their personal and professional narratives. I remembered with fondness my own journey to becoming a professor and the many people who helped me along the way. There were some special people among those that helped. The last 10 years have seen me in a position to help others achieve their ambitions, and this has allowed me to meet many people who fill me with great confidence and hope for the future. 

The 'future' was also a feature in my reading of CS Lewis. Reports of his death were overshadowed at the time by the assassination of JF Kennedy, as was the death of the writer Huxley. Kennedy, Huxley and Lewis all died within 55 minutes of each other. Huxley was the author of the famous book Brave New World, which amongst other things featured hypnopædia or ‘sleep learning’. Huxley’s book was published in 1932, and the notion of learning while you sleep was, until 2014, largely discredited. Then in 2014, 2 Swiss researchers, Thomas Schreiner and Bjorn Rasch, published their research showing that actually it was possible to learn while you sleep. However, and for what it is worth, my advice is it’s probably healthier to let the sleeping dogs of learning lie and simply enjoy uninterrupted sleep for as long as you can.