Sugar

 

 

It is now widely agreed that consumption of sugar in substantial quantities is a major cause of obesity and a major threat to public health.  This is not a finding which I accept fully.  However, it is a more complicated statement than is usually appreciated.  The great majority of the carbohydrate that we eat is starch which is the major constituent of potatoes and wheat. We absorb this as glucose, the monosaccharide sugar formed from starch when it is digested in the intestinal tract.  Why therefore is eating sugar – a disaccharide made up of glucose and fructose – so much more harmful as a cause of obesity than eating starch?  I can think of three reasons which are not mutually exclusive but which do give rise to the possibility of addressing the problem in different ways.

 

The first is that it is the fructose which does the damage.  At first sight this seems slightly unlikely since fructose is less well absorbed than glucose but it is a possible explanation and corn syrup, which contains high levels of fructose, is regarded as particularly prone to give rise to obesity.  One way of seeing whether fructose is particularly harmful would be to feed people with a polyfructose polysaccharide analogous to starch.  This is Inulin which is the main polysaccharide in Jerusalem artichokes.  Few people eat these as a major component of their diet and the well known complication of eating them is that much of the fructose is fermented by gut bacteria and this gives rise to the production of excessive amounts of flatus.  However, it would be interesting to know in experimental situations whether feeding Inulin causes obesity.  If fructose were to be found to be one of the reasons why sugar is harmful, this could be resolved by eliminating it from the sugar component of the diet by going over to glucose.  This could presumably be done by genetic modification of sugar cane and sugar beet or otherwise by removing the fructose by fractionation and using it to generate alcohol as a car fuel and using the glucose only as food.  There are already glucose only sugary drinks on the market, for example Lucozade, so this is not an impractical solution.

 

The second possibility is concerned with the rate of absorption and that it is the rapid rise of glucose levels in the circulation which stimulates insulin production and interferes with the insulin signalling pathways and that this produces obesity.  This is entirely plausible.  If that were the case, then forms of sugar that are rapidly absorbed should be more harmful than those which are more slowly absorbed.  This would be consistent with the idea that fizzy sugary drinks are particularly harmful since they are very rapidly absorbed and would support the contention that these should perhaps be banned.  On the other hand, sugar in chocolate or in cakes that are more slowly digested and absorbed would be relatively less harmful and there is some suggestive evidence that this may be the case. It should be possible to modify the preparation of cakes and chocolate in ways to make the sugars even more slowly absorbed, perhaps by associating the sugar with other molecules that are slowly absorbed. 

 

The third possibility is that the harmful effect of sugar results from its property as an appetite stimulant.  If that is a major factor, it may well be that the sugar substitutes such as aspartame which industry now puts into some fizzy drinks and other foods, may similarly stimulate appetite and may not be particularly effective in reducing this aspect of sugar’s activity. One might then have to persuade people to eschew things that taste sweet as well as, or rather than, things that contain sugar. 

 

Having answers on the relative importance of these three mechanisms might enable more logical and effective campaigns to be put in place to reduce the effects of sugar on obesity.  HH

Global Warming

 

If the Pope is about to utter on global warming – why shouldn’t I?

 

The recent actions, or intended actions, by the G7 are an encouraging sign that the government of the world is beginning to take the problem of global warming and rising CO₂ levels seriously.  The emphasis on developing nuclear energy and other renewable sources of energy such as solar and tidal power are certainly to be welcomed.  On their own, they are however likely to do little more than to slow down the process and to delay the time when the effects of global warming become serious.  The development of effective energy production by nuclear fusion – “creating a mini sun on the earth” -may be an exception to this prognosis. 

 

However, there are two measures that could deal with the situation much more effectively.

 

The first is necessary, whatever other solutions are adopted. This is to arrest the growth of the human population or indeed to secure some degree of decline.  The projections of global population growth have decreased over the last twenty years, The main factor that seems to have been involved is the improvement of living standards and particularly of women’s education in the developing world and, not least, the provision of bathrooms, which make contraception much easier.  However, there are still populations which for religious reasons remain committed to the duty to breed as a primary human concern ; and in some cases such populations aim to outbreed their neighbours for political ends.  This is a problem that needs to dealt with by governments rather than by science. 

The other solution, however, which could deal effectively with global warming, though it would not prevent the exhaustion of other planetary resources that will come about unless the population is controlled,  is to genetically engineer major crop plants so as to increase their efficiency of photosynthesis.  This proposal was put forward by the late Lord Porter, a former President of the Royal Society and a very distinguished photochemist, in his 1995 Rajiv Gandhi lecture.  He pointed out that if the efficiency of photosynthesis could be improved from the present level of 1% to around 5% then this would allow all the food and energy needs of the planet to be met from the amount of agricultural land under cultivation at that time.  This is not an easy problem to solve.  The initial enzyme, Rubisco, is notoriously inefficient and early attempts to increase its efficiency were unsuccessful.  However, with the greatly increased knowledge of molecular biology and of the role of chaperones it does seem possible that this could be achieved if a major effort were put into it.  Although some laboratories are currently involved in this work, it really requires an effort on the scale of the Manhattan Project since this is an innovation which could literally save the planet.  There has been some scepticism of this approach on the grounds that evolution would have achieved an increased efficiency of photosynthesis if this were possible.  This argument is, however, fallacious.  When CO₂ levels are low, there is no evolutionary advantage in raising  the efficiency of photosynthesis.  This would simply lead to the plants running out of CO₂ and being unable to continue photosynthesis.  In other words, increased efficiency of photosynthesis is valuable only when CO₂ levels are high and if we succeed in bringing them right down again using genetically engineered crops then in due course the world’s agriculture will revert to the less efficient crops that we have at the moment.  It might be of interest, if it were possible, to investigate the photosynthesis by  plants in the carboniferous age when there were indeed very high CO₂ levels and the present fossil fuels were being deposited in the ground.  It is, however, so long ago that it may not be possible to recover the genetic information one wants.  Nevertheless, this should be a project that is given huge support and one of the reasons that it isn’t is undoubtedly the irrational, but widespread, opposition to plant molecular biology and to the modification of food plants by genetic techniques. 

 

This opposition is totally irrational and is held largely by people who do not realise that all plant breeding involves genetic modification and that as a technique it is totally morally neutral.  It is, of course, necessary to take precautions about what gene one introduces to make sure that the product is not toxic or allergenic, or that the mode of insertion into the genome does not produce undesirable side effects.  That is already the case with all novel foods however they are produced.  Indeed, a common method of producing genetic variation in food plants, - irradiating the seeds,- produces much more widespread genomic change and is potentially much more damaging and therefore does require very careful control.  However, no-one should doubt that the root and branch opposition to genetic modification of plants is hugely harmful and may one day be seen as one of the main causes why we have been so inefficient in dealing with global warming and its potentially devastating consequences. 

This is an issue on which scientists should speak out.

The European Referendum

 

Now the negotiations with Europe are underway and the press is full of discussions of the referendum and the advantages and disadvantages of the UK remaining within the union.  I find it very surprising that no-one seems to mention that possibly the most important purpose of forming the European Union was to prevent another major European war.  Although it is not possible to say for certain that the EU was solely responsible, it is nevertheless true that Western Europe  has for the last seventy years  been at peace.  Sadly this does not extend to the Balkans, where there have been major conflicts, or to the rest of the world where war seems to be almost continuous.  It does, nevertheless, seem a very powerful reason for maintaining the European Union and for retaining the United Kingdom as one of its important members.   

It does seem highly plausible that not only the free trade area but the free movement of people between the countries of the Union does lead to increased mutual understanding and that this, as well as the attempts that the European Union makes to achieve some degree or integration, have contributed  to maintaining  the peace.  For this reason alone I will vote to stay in the Union – whatever the outcome of the “re-negotiations”

 

 However I am surprised that the criticisms of the Europe Union are nearly always aimed at the European Commission rather than at the European Parliament

The European Parliament was set up by those who wished to see much closer European integration and who envisaged the creation of a European Government and the formation of a United States of Europe rather resembling the United States of America.  In that case, there would indeed be an unarguable case for having a European Parliament to fill the same purposes that are served by the Congress of the United States.  However, we have no European Government even remotely in view but we do have a European Parliament.  This body seems to me to have a certain amount of power but  virtually no responsibility.  .  Its lack of responsibility is really very obvious.  I have had some involvement with the EU, largely through my association for many years with the Federation of European Academies of Medicine, I have carried out an informal survey not only of my British colleagues but of those from other European countries to discover how many people know even the name of their MEP.  The answer is almost none.  Members of the European Parliament do not seem to be responsible to their constituencies and indeed the way that they are elected from party lists means that the candidates have very little contact with their constituencies anyway.  Nevertheless, this unrepresentative body with no obvious function costs the community  large sums of money. In my view too many MEPs  tend to espouse extreme positions on many unreasonable causes, be it opposition to GMOs, and to various reproductive technologies; and enthusiastic support for alternative medicine.  

 

It would surely be an excellent idea to suspend the European Parliament until such time (if ever) as there is a European Government.  In the meantime, the two palaces that it occupies in Strasbourg and Brussels could be used for other purposes and perhaps bring in money rather than spend it; and the amount that is now spent on the MEPs could be used for socially much more useful purposes.   

It is remarkable that even those who reject the European Union , such as members of UKIP, nevertheless hold seats in the European Parliament and are  happy to take its money.

 Perhaps this is what Mr Cameron should be discussing with Mr Juncker and with his fellow heads of state.

Electing a New Labour Leader

I am a long-term supporter of the Labour Party who has from time to time been a member of the party and who resigned on the last occasion when Gordon Brown failed to honour his promise to take the NHS out of direct political control.  He had given this undertaking and I wrote a letter to The Times applauding this undertaking.  This elicited a response from Daniel Finkelstein who said the idea was bonkers and that a service spending so much money must be under direct political control.   I doubt whether I am alone in thinking that it is Daniel Finkelstein and not Gordon Brown’s promise that is bonkers. Political micro-management of many highly expensive services, be it the Universities, the Research Councils, the schools or the NHS, has been a marked feature of governments since Mrs. Thatcher and is slowly being recognised to be a thoroughly bad idea,  not least because the management of these services is long term and cannot be tied to the electoral timetable. 

 

  When, in 2010, Ed Milliband was elected to the Labour leadership, despite having the majority of neither MPs nor the constituency members, but solely because he was the choice of the trade union movement, I was not tempted to rejoin the party.  This is not because of any qualities that Ed Milliband did or did not have, but because I could not bring myself to regard him as a legitimate leader of the Labour party.  To his credit, he altered the system but sadly it does seem to me that the system which has now been introduced is even worse.  I had wondered when it was proposed to have a one member one vote system for those who were members of the Labour party and those who were subscribing members to the political fund of  trade unions, that there would be a time limit imposed so that only those who had been members before the last general election would be allowed to take part.  I now read in the newspapers that this is not the case, and that anybody who joins or pays up before August can take part in the leadership election.  This is an open invitation to corruption.  The trade unions may pressurise or even give inducements to members to pay up in order to be able to vote and the possibility that there will be frank bribery to get people to join the Labour Party just for this purpose can by no means be excluded, especially in view of some scandals of this kind in local government in the past.  It again offers the opportunity for large trade union leaders to exert excessive influence in determining the outcome and those of us who remember the terrible damage they did to the Labour Party in the 1970s will not be tempted to see a recurrence. 

The Full Time NHS

It is five years since I raised the topic of a 24 hours a day/7 days a week hospital service with Mr. Lansley. (see previous blog) It is good to see that the present government is showing an interest in the idea and some determination to bring it about.  It is less encouraging that the response from our medical colleagues has on the whole been negative. 

At the base of the opposition, I think, is a misunderstanding.  If the whole hospital service were to go from working on average, say, in the region of 10 hours a day and five and a half days a week (which is a guess, not an accurate estimate) this would amount to  55 hours a week.  To make all the hospital facilities work 24 hours a day and seven days a week would raise this to 168 hours, i.e. it would expand the hospital service threefold!  Whereas this might be thought desirable in theory, it is quite clearly impossible in practice and the proposal to go to a “168 hour per week service” is quite different. 

 

If in a large medical centre a number of services -  the operating theatres, the diagnostic departments and the acute medicine departments were to go to 168 hours per week, then it would need to follow that a much of these services currently provided on the 55 hour a week model in reasonably nearby hospitals would have to be discontinued.  One can envisage that some hospitals might close altogether, thereby making large savings on the maintenance of the estate and on the administration which are both expensive.  The relevant staff  would be transferred to the 168 hour a week hospital to enable it to function at that level. 

 

However, there is also a real need for “low intensity” hospital facilities which used to exist and have largely disappeared.  There has been much discussion of bed-blocking by patients who have no need for intensive facilities but for whom there are no facilities in the community, and there are also other patients who still require some degree of medical care but who do not require the expensive facilities of an acute hospital.  For such patients, it would be desirable to have low intensity hospitals which provide accommodation, nursing care and basic medical care but without the expensive facilities to be found in the large hospitals.  Some years ago it was estimated that a high intensity bed cost £500 a night and a low intensity one £100 a night, so that there are also large savings to be made here. 

 

Quite clearly, changes of this description cannot be brought about nation-wide, or all at once.  In urban areas, or in regions where there is a large hospital within reach, such changes may be made without the need for training new staff and the added expense of paying staff for unsocial hours would be more than recompensed by the savings that can be made by reducing activity in the surrounding hospitals.  Where this looks feasible, it could be initiated quite quickly.  In other areas where the distance of travel would make for serious problems, the arrangements may be more difficult to bring about. In any case gradual introduction of change with the old and new systems running side by side, will allow comparisons to be made - seeing where the benefits and  the difficulties  lie and seeing  which delivers more QUALYS per £. Sad experience has shown clearly enough that this is always preferable to trying to introduce  nationwide, untested changes tied to an electoral timetable!

 

The situation with regard to general practice is quite different but here also one can envisage changes being gradually brought in which would reduce the existing work-load while allow seven day a week access. 

A major change that has occurred in general practice since the introduction of the NHS, has come with major advances in medicine which have led not to the cure of chronic diseases but to their management.  There are now large numbers of patients, and not only the elderly, that suffer from chronic conditions such as diabetes, hypertension, asthma and chronic lung disease, angina and chronic heart disease, rheumatoid arthritis and related rheumatological diseases among others, who require regular assessment and care over many years. This care has increasingly been put onto general practitioners.  This, however, is contrary to the clinical evidence.  There is good evidence most of these diseases, that patients’ outcomes are significantly better when they are cared for in specialised clinics set up for their particular disease.  This is by no means surprising.  Not only it is probably advantageous for  doctors to see many instances of these diseases rather than a few, but such clinics will also have access to specialised ancillary services (for example dieticians and podiatrists for diabetes, as well as the diagnostic services that are required.  Furthermore clinical trials on newer treatments are easier to carry out in this environment., There is therefore be a strong case to be made for establishing diabetic clinics, hypertension clinics, chronic respiratory disease clinics etc in large central hospitals where outpatient care is provided  for the management of long-term conditions.  It is almost certain – and could be properly evaluated -  that this would improve outcomes.  It would also save a great deal of time in general practice which would allow GPs to concentrate on their other functions and to provide a seven day a week service.  Again, such changes cannot be brought in all at once and would have to be allowed to develop slowly where the conditions are favourable.  All these changes should be closely monitored so that, again, their value in QUALYS per £ spent can be evaluated.