Welcome back to the Hot Topics podcast from NB Medical with Dr Neal Tucker. In this episode we think about another year of imposed GP contract on practices in England, the BMA response and where it may lead.
In research, we have three fascinating new papers. Firstly, a paper examining how to maintain weight loss after a low-calorie diet – is structured exercise, liraglutide or both better than usual care? Secondly, in the BMJ a systematic review exploring whether exercise should be considered a genuine treatment for depression. And finally, in the NEJM, a study looking at the link between microplastics in carotid arterial plaques and subsequent risk of cardiac vascular events (hint: it’s not good news…).
References
BMA GP Contract Changes 2024/25
Lancet Discovery Science paper on weight loss maintenance
Weight maintenance author interview
NEJM Micro/nanoplastics in your arteries
www.nbmedical.com/podcast
Welcome back to the Hot Topics podcast from NB Medical with Dr Neal Tucker. In this episode we think about another year of imposed GP contract on practices in England, the BMA response and where it may lead.
In research, we have three fascinating new papers. Firstly, a paper examining how to maintain weight loss after a low-calorie diet – is structured exercise, liraglutide or both better than usual care? Secondly, in the BMJ a systematic review exploring whether exercise should be considered a genuine treatment for depression. And finally, in the NEJM, a study looking at the link between microplastics in carotid arterial plaques and subsequent risk of cardiac vascular events (hint: it’s not good news…).
References
BMA GP Contract Changes 2024/25
Lancet Discovery Science paper on weight loss maintenance
Weight maintenance author interview
NEJM Micro/nanoplastics in your arteries
www.nbmedical.com/podcast
Strike, strike, strike. Tired of bad pay and poor conditions, tired of being stuck in this situation, tired of always doing more for less. It's time to take control, time to get off the fence. The stats tell the truth. The public have spoken. We need to take action to fix what is broken.
Speaker 1:It's not about the money. It's about safety too. If you want to help your patients, you know what to do. But I'm sorry I can't strike cause I don't work Wednesdays. I'm sorry I can't strike. It's my job at the ISP. I'm doing hot yoga, gotta pick up the kids. I'm doing everything said being a GP. I'm sorry I can't strike. I'm recording a podcast. Lots of us have second jobs. You see she's a partner, and he's salaried. We're still low. Can we ever agree? We can't strip more.
Speaker 1:We're down to the bone. We're pleading for help, but we're still alone. Collector. Solidarity is what we all need. Together we can change the narrative. But I'm sorry I can't strike, but I don't work Wednesdays. I'm sorry I can't strike. It's my job. At the ISP I'm doing hot yoga. Gotta pick up the kids. I'm doing everything said being a GP. I'm sorry I can't strike, but I'm doing a scope list Now, out of hours, night shift, private dermatology it's a vocation, not a job.
Speaker 1:Let's all go private. Will we ever agree? Hey, you, are you with me? Let's strike, I'm in. But wait, you're a partner.
Speaker 1:How can you take a strike action when you own the business? Aren't you just screwing yourself? Not really the powers that be? And what about the receptionists, the admin stuff, the nurses, the ARRS? They're still coming to work, right? Or are you gonna close the practice but still pay everyone? Just not yourself. And maybe not me, if I'm with you and, to be honest, I could really use the money.
Speaker 1:Damn, this is complicated, I know. I know I was gonna really kick them in the balls. Let's refuse. Let's refuse to fill out any non-core contract forms. Your life insurance is gonna have to wait. Sorry, I can't strike. But I don't work Wednesdays. I'm sorry I can't strike. It's my job at the ICB I'm doing hot yoga. Gotta pick up the kids. I'm doing everything said being a GP. I'm sorry I can't strike.
Speaker 1:I'm recording a podcast. Lots of us have second jobs, you see, and she's a partner and he's salaried and I'm just a loaq. And will we ever agree? The Hot Topics Podcast. It's Friday, the 8th of March, and this is the Hot Topics Podcast. The Hot Topics Podcast. Welcome back to the Hot Topics Podcast from NB Medical, neil Tucker here to take you through another episode, and what an episode we've got for you today.
Speaker 1:So in research, we're going to be talking about weight loss maintenance After you've lost it through dietary means. Are GLP1 Analogs or Exercise or both better than usual care? A second paper on exercise as well, published in the BMJ a couple of weeks ago, looking at the effects of exercise on depression. Could it be considered as a standalone treatment? And finally, a paper in the New England Journal of Medicine on Microplastics and Nanoplastics In atheroma. Does it lead to more cardiac events?
Speaker 1:As usual, lots going on with NB Medical at the moment. So if you're listening to this before Saturday, the 9th of March. Then you can check out our Hot Topics in Managing Overweight and Obesity course With Stephanie DeGiorgio Fantastic Course, real Eyeopener. Do check it out. If you're later than that, you can still catch it on demand. We'll be doing another live one in June as well. And then we've got a Hot Topics course live on the 15th of March. We've got another one on the 23rd of March which is our Irish Updates. Got a bit more of an Irish tailoring to it for our Irish GP audience. And we're doing our Fantastic Urgent Care course on the 22nd of March as well. As ever, all of these will be available on demand too, so don't worry if you miss them. And remember if you sign up to NB Plus, you get to come on all of the webinars. You can see them all live on and on demand as part of your subscription. For just over £300 a year is an absolute bargain.
Speaker 1:Now what's been going on in the news and our GPs in England Slightly closer to striking? The government has imposed another miserly contract, so it's already one that's been delayed by a year. We should be having a full, proper review of the whole GP contract in England at the moment, but that's all been put back at least by a year, and they've used that as an opportunity to provide another significantly low Below inflation uplift for practices, further stretching practice finances. Failing to improve pay significantly of any practice staff, but particularly, of course, this is going to affect partners quite badly. So the BMA is currently gauging opinion in a referendum about what to do next. If you remember of the BMA, if you've got one of those emails that they've sent out, then I would really encourage you to go and do that form. Regardless of what your opinion is. Either way, your opinion does matter.
Speaker 1:For the time being, it is keeping its cards close to its chest and everyone's waiting for this report from the review body of doctors and dentists remuneration. So this is meant to be this independent body that guides government as to what kind of pay that we should receive. I'm sure the members would consider themselves independent, but the reality is their hands are really tied because the government dictates a lot of what they can actually do. They say, well, you can only do it within this percentage and this percentage, and there's this and this and this. So it's actually heavily influenced by the government, who then often just choose to ignore the recommendations anyway as part of the aspects that they have to consider. This review body must think about retention and recruitment and how these factors can impact on patients and patient safety. Given the backdrop to the current GP staffing issues, you would imagine that that might encourage them to recommend quite a good pay deal here, but in reality that seems very unlikely. What can we actually do about it? Let's say the BMA does ballot the profession to see if they want to strike. Let's say yes. We say we do want to take some kind of industrial action. What could that look like? There's a very interesting editorial impulse this week on how GPs can actually strike, just highlighting the difficulty here.
Speaker 1:Public opinion has been twisted by the media over the last few years against GPs and general practice. It feels like sympathy levels amongst the public could be quite low. What kind of impact does closing the doors of a practice actually have when patients may only come and see you once a year? And how do you even try and force the hand of a government that has already demonstrated amongst other groups of our profession that they really don't seem to have any interest in negotiation at all? The GPC England chair has said the worst thing we can do is shut our doors and put patients against us, and I think that's absolutely right. With any type of industrial action, you need the public support, and if you don't have that, then you're on a quick road to nowhere. Also, I think probably the majority of GPs wouldn't want to impact on patient care, especially when these are potentially people that you've built up a relationship with over many, many years.
Speaker 1:I don't have any solutions here. I'm glad that there are other people working with the BMA who are trying to come up with something that might actually look like a feasible and effective option. Again, I love the reporting impulse here. At the very end of one of the articles where they're talking about this they go. This week the Department of Health and Social Care said that preparations for GP industrial action are disappointing ahead of the pay review body's funding recommendation. It's disappointed. Oh the irony. Let's move away from politics onto slightly safer ground.
Speaker 1:I say safer ground because we're going to start off with this paper that published in Eclinical Medicine. That doesn't sound like one of the really big journals, but it's part of the Lancet group and this was. This was a study that was flagged up to me a couple of weeks ago as we were just putting together the Hot Topics course and one of the topics that I was writing was on obesity. It has been one of the most challenging topics I've ever had to try and understand, review the research and then write something meaningful on, especially when, by the very nature of the Hot Topics course, we're trying to condense things into a very short space of time.
Speaker 1:There's been a whole load of research that's come out over the last few years. Particularly there's been a focus, of course, on GLP1 analogs like semi-gluteide, and they're very impressive effects on on driving weight loss. Of course, one of the big issues with this type of pharmacological treatment is that if and when you stop it, there is usually a lot of weight regain. So the purpose of this study was to investigate how you may best prevent that weight regain, maintain that weight loss, and whether that could be done best with GLP1 receptor agonists or supervised exercise or a combination of both. This study was funded in part by Novor Nordisk, or rather the Novor Nordisk Foundation. Novor Nordisk is the manufacturer of semi-gluteide, so Ozenpec and Wee Govee and Liragletide, which is the drug they're looking at in this study and it's owned by the Novor Nordisk Foundation, which then provides huge sums of money for grants for research, also for clinicians providing opinions on this, also for national and international obesity organizations.
Speaker 1:It is absolutely everywhere and I almost wonder if one of the reasons this paper wasn't published in one of the more prestigious journals was because, although the headline results showed that if you give people liragletide and make them exercise, then that's the best way to prevent weight regain after weight loss from diet, you could also interpret the findings in completely different ways, as we will discover in a minute. So the idea of this study was for patients who were overweight to lose weight through diet and then see how best to maintain that weight loss. So they compared usual care so that's pretty much doing nothing to either loragalotide, daily exercise or both for a year and then they followed them up for a further year to see what subsequently happened to their weight. To be clear, the starting point for this study was that patients undertook an eight-week low-calorie, diet-induced weight loss so diet, not medication-induced and they managed to lose on average 13 kilograms. This is very impressive. And then they were allocated into the different intervention arms to see what would most effectively maintain that weight loss. It wasn't a huge study. It was 109 patients randomly allocated to one of those four intervention arms.
Speaker 1:If you're taking loragalotide, that's straightforward. It's a 3 milligram subcutaneous daily dose. If you're doing exercise, then you are encouraged to attend supervised group exercise sessions twice per week and then also undertake individual exercise two times per week as well. The group exercise was meant to be vigorous intensity, so they did indoor cycling followed by circuit training, and then when they were doing it themselves at home, it was meant to be moderate to vigorous intensity of an exercise type of their choice. If you weren't in one of the two arms that had exercise as an intrinsic component, then so the kind of usual care group and the just loragalotide group. Even they were encouraged to maintain habitual physical exercise during that 52 week intervention period.
Speaker 1:During the first year of the study, when they were on treatment, no surprise, loragalotide came out best. On top of the weight loss they'd already achieved through that eight week diet, there was an extra 1 kilogram of weight loss if they were taking loragalotide alone. About 4 kilograms of additional weight loss if they combined that with exercise, whilst exercise alone resulted in about a 2 kilogram weight regain. But the control group did worse overall again perhaps unsurprisingly with 6 kilograms of weight regain so far. This all sounds really positive for loragalotide, but what's really interesting is what happened in the year after they stopped the interventions. Overall, the group that had exercise plus loragalotide maintained the most weight loss. The group that did the worst was the group that had loragalotide by itself. That actually ended up in more weight regain than people that had placebo, and the group that did just the exercise well, they were somewhere in the middle, but not far off the group that did exercise and loragalotide.
Speaker 1:Now you might say that the difference between these groups was non-statistically significant. So you can't say that necessarily. Loragalotide by itself is worse than just having been glib given a placebo. But that doesn't stop the authors commenting that loragalotide in exercise is the most effective way to maintain that weight loss. For me, the key finding here is that structured exercise so just two hours a week that gets your heart rate elevated can reduce weight regain after weight loss through diet.
Speaker 1:It seems at the moment that one of the prevailing narratives in obesity medicine is that you can't lose weight through diet and keep it off. And to really help people lose weight you're going to need one of these new pharmacological options and you're probably going to need them in the long term to maintain that weight loss. While, of course, this new study has limitations in so far as the long term follow up, it does really challenge that idea. They've demonstrated that people with obesity can lose a significant amount of weight through a low calorie diet and then through doing structured exercise over the course of a year and hopefully carrying it on themselves Beyond that, they have successfully prevented large amounts of weight regain. Sure, if you add in loraglotide for a year, at the end of that second year you will have maintained slightly more weight loss than with exercise alone. But what's really really fascinating is that the amount of weight regain is greater in both the loraglotide groups than exercise alone. So with loraglotide and exercise they lost the most, but they actually ended up regaining more weight than if you'd just done exercise in the first place, and the trajectories of the weight regain up to the end of that one year are much higher than in the exercise group.
Speaker 1:So of course then the big question is well, what happens after that? And of course we may never know, as one of the authors of this paper put it in an interview he did after publication. He says the study almost makes me want to advise against medical treatment without increased physical exercise, especially if you do not want to be taking the drugs for the rest of your life, perhaps. Then there's two key messages that come out of this study, and they feel like they're kind of at opposite ends of the spectrum. So, on the one hand, we could say that it is possible to lose weight through diet and they maintain it through structured exercise. If you're going to do that, though, you have to put that support in place for patients to engage, to encourage and educate them on how to do that exercise and hopefully help them maintain that into the future. Just telling people to do more exercise is not helpful. The second learning point you might take away from this is, if you go on loragletide and then you stop it, you may end up getting more weight regain than before you'd even started it.
Speaker 1:Now, it's important to be clear here that no national guidelines are recommending. You just have a medication by itself, so it's always meant to be in conjunction with advice about exercise and diet as well. So if these medications are being prescribed, then there needs to be the structures in place to be able to support patients with that. If there isn't, or if people aren't able to engage with that, or they can't, or they don't want to. Then there's the question over whether these drugs should be used in the long term rather than just the short term. That may be extremely beneficial, but there's lots of uncertainties here Long term effects, long term complications, cost effectiveness, particularly if they stay at the high price that they are at the moment.
Speaker 1:Let's stay on the subject of exercise, and this is the BMJ. So this was a paper with the title Effective Exercise for Depression Systematic Review and Network Meta Analysis of Randomized Control Trials. We published an MB blog on this piece of research this week, but we've got a bit more time to go into a bit more detail in the podcast. I think what attracted me to this paper was the fact that we have loads of patients with depression. We're always selling up on talking therapies, but lots of people don't really seem to get on with those. We're often prescribing medications and often they don't seem to work very much or people get side effects.
Speaker 1:It would be great if there were some other options out there and could exercise fill this gap. I suspect most of us talk about exercise when we're having a discussion with a patient with depression, and it's normally in the kind of preamble, isn't it? So, as we're explaining about things, well, here's the simple things you could do Try and stay socially active, don't drink too much alcohol, don't do illicit substances, try and get outside, do a bit of exercise. All of these things can help, but let's be honest, it's all a bit of an amuse-boosh to the starter of talking therapies in the main course of drugs. Should exercise, though, be considered a standalone treatment for depression? So there's quite a lot of research out there on this.
Speaker 1:So in their systematic review they identified 218 unique studies, a total of 14,000 patients included, and they covered a wide range of different modalities of exercise and compared them against active controls. So that's normally usual care, or perhaps they'd had a placebo tablet. Compared then to active controls, they found moderate reductions in depression with a wide range of different exercises, so walking, jogging, yoga, strength training, mixed aerobic exercises, tai chi and qigong. I've never heard of qigong before. This is a Chinese form of exercise which I would say is a little bit like tai chi, but I know I'm going to be shot down for that, because I think, whereas tai chi is more sort of flowing movement, qigong is more sort of set movements that you might do. I've never come across it in the UK before.
Speaker 1:They found there was a link with intensity, so the more vigorous the exercise or intense the exercise, then the greater the potential benefit for depression. But they also found that even low intensity activity helped. So even just getting people walking or maybe doing some yoga could be really helpful. Overall, they found walking, jogging, yoga and strength training the most effective, and they found yoga and strength training the most acceptable. Disappointingly for me, cycling failed to show a statistically significant improvement, but I'm pretty sure that my mental health has improved. When I go out on a bike ride, I'm in the countryside, I've got the dappled sunshine coming through the trees, the sound of birdsong in a chain that probably should have been cleaned a long time ago.
Speaker 1:The authors do discuss the mechanisms or possible mechanisms as to why exercise might help with depression, and they do highlight that this review is not about identifying causal mechanisms, but they highlight things like, well, a combination of social interaction If you're doing group work mindfulness or experiential acceptance. You might get more of that with, say, yoga or perhaps a bit of Zen when I'm out on my bike Increased self-efficacy, immersion in green spaces I can really highlight the idea about green spaces and blue spaces. So being in forests, meadows, by the sea, lakes, rivers data shows this alone can improve people's mental health. And then they'd suggest neurobiological mechanisms and acute positive effect. And I don't know if any of you get that, what is described as a run as high. I guess you can get this with any form of exercise. I wish I did. I don't get that. My wife gets it after she's been out for a run. That's one of the reasons why she loves running. I just get sores. But I think that's the beauty of this that because there are a wide range of options that could be helpful, you can really tailor that to what the individual may be able to do, what they're interested in, what they ultimately might enjoy the most.
Speaker 1:The authors conclude that exercise could be considered alongside psychotherapy and antidepressants as core treatments for depression. Also worth pointing out, however, that there are additional benefits from combining these. So they also show that if you are taking antidepressants and you also then undertake exercise on top, you get further additional benefits. If you're someone at the far end of the spectrum, with more severe depression, then of course combining different types of treatment modality is likely to be necessary and more advantageous for you. Historically, this is meant talking therapies plus antidepressant medication. Well, now we can throw exercise in the mix here as well.
Speaker 1:Finally, we're going to have a think about the New England Journal of Medicine paper with the title Microplastics and Nanoplastics in atheromas and Cardiovascular Events. I feel like I'm stretching my remit here a little bit of being a general practice related research review podcast, but I'm sure that loads of you will be really, really interested in this. The background here is well, it's not the first time that we've thought about plastics being in the human body. As the paper reports, they've been found in the placenta that's a horrible thought, isn't it? The lungs, the liver, breast, milk, urine and blood absorbed through ingestion, inhalation and skin exposure. It's suggested that plastics effects within the body are not entirely benign and also suggested that perhaps micro and nanoplastics should be a new risk factor for cardiovascular disease. But one of the reasons this paper exists is because there's been a lack of understanding about the true clinical relevance of the presence of plastics in the body, particularly in relation to the cardiovascular system.
Speaker 1:This, then, was a study conducted in Italy through secondary care clinics with asymptomatic patients who had coronary artery stenosis who were going to undergo endarterectomy when they cleared out the plaques, they sent that to be looked at under the microscope. Also, they did a wide range of radiological tests on them as well, and then they followed those patients up for about three years on average to see if there was a link between what they found in the plaque and subsequent cardiovascular events. They recruited 330 patients for this. 60% of them were found to have polyethylene in their plaques. 12% had polyvinyl chloride. According to the British Plastic Federation, this latter is a versatile material that offers many possible applications, including window frames, drainage pipes, water service pipes, medical devices, blood storage bags, cable and wire, insulation, resilient flooring, roofing membrane, stationary automotive interiors, seat coverings, fashion and footwear and more.
Speaker 1:No, where do they mention that it should be an intrinsic part of someone's arteries? It sounds like a bad idea having plastic in your plaques, and indeed it would appear that way you had four and a half times the risk of having a cardiovascular event if you had plastic in your arteries compared with those who didn't. Or, to look at it another way, in absolute terms, seven and a half percent of those patients who didn't have plastic identified in their plaques ultimately had a cardiovascular event over the next three years, compared with 20% in those where it was present. Now the authors are quick to point out that this doesn't prove causality. There may be confounding variables here. So, for example, let's say you eat processed food, it comes in plastic containers. You're more likely, therefore, to get plastic in your arteries because it's being ingested with the food. The food you're actually eating is unhealthy and that's what's driving the cardiovascular disease. But as you read the article more and the linked editorial, you realize that people don't really buy into that. They don't really think this is confounding. They think that plastic in your body is a pretty bad idea.
Speaker 1:The tricky bit is the next question that the editorial asked, which is how can we reduce exposure? There is no quick or easy solution for this, as they highlight. The first step is to recognize that the low cost and convenience of plastics are deceptive and that in fact they mask great harms, such as a potential contribution by plastics that outcomes associated with atherosclerotic plaque. That's the direct quote from the editorial. They then go and talk about single use plastics as another big problem, and, of course, any plastics. When they get into the environment they end up getting partially degraded, broken down into these micro particles or micro plastics and nano plastics. They then get into the water, into the food supply and ultimately the rest of nature and we end up ingesting them, causing these potential problems. So, ideally, use less plastics in the first place. If we can't do that, then dispose of them correctly. They highlight what we can do in healthcare looking at our own use, but of course, from the patient perspective, we need to think much more broadly than that. Like I say, no quick or easy solutions here.
Speaker 1:And as I finish this podcast now, because I'm starving and I'm gonna go for my lunch and I'm gonna reheat some leftovers from a couple of nights ago which had been in a plastic container in my fridge and is now gonna be heated up in the microwave, it makes me wonder whether maybe I need to start changing things a little bit at home as well. So thank you for joining us on the podcast today. I hope you have enjoyed some of the stuff we talked about. As always, you can get in touch. You can email on Hot Topics at nbmedicalcom. You can find us on Facebook and on Twitter at GP Hot Topics. As usual, the links to all the research and stuff we've been talking about will be put in the podcast description below, and I'll see you in three weeks time. Look after yourselves, everyone. Bye-bye. Goodbye.