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Should lifestyle issues be included in the vascular checks programme?

A national vascular checks programme needs to be as broad-based as possible if it's to work, argues Dr David Haslam, and must include lifestyle measures. But Dr Gillian Jenkins questions whether including questions on weight, alcohol intake and exercise is really a good use of GPs' time

A national vascular checks programme needs to be as broad-based as possible if it's to work, argues Dr David Haslam, and must include lifestyle measures. But Dr Gillian Jenkins questions whether including questions on weight, alcohol intake and exercise is really a good use of GPs' time

Lifestyle intervention isn't an optional extra - it's crucial in the management of conditions like diabetes, heart disease, hypertension and dyslipidaemia. Neither is it an irritating chore - wasting precious time on fat people who are too idle to do anything for themselves.

If we find evidence of cardiometabolic disease as part of a patient's vascular assessment then we may also might find evidence they're a 'lazy, fat, pisshead'.

This brings the enormity of the task into stark relief. But the job is also already half done as the difficult questions have already started to be addressed. So I believe adding these questions - on weight, alcohol intake and exercise - into the National Vascular Assessment Programme will actually help minimise the burden placed on us.

If successful it will unearth a large number of patients with overt disease or multiple cardiometabolic risk factors. These individuals will increase our workload - demanding explanations, investigations and treatment - and stretch our resources. Of course there will also be a tidal wave of worried-well and hypochondriacs, but whichever category, the more information the better.

There are conditions which are asymptomatic during their early stages and only come to light on opportunistic or planned screening. Hypertension and hyperlipidaemia - familial and other - are cases in point and perfectly suited to screening programmes. Diabetes is another.

Screening is inherently a good thing. It picks up potentially serious chronic conditions early enough for appropriate management, preventing blindness and amputations in diabetes, for example.

Screening must be accurate, effective and have an acceptable pick-up rate. Most importantly there must be programmes in place to deal with what has been found, otherwise it is irresponsible.

The National Vascular Assessment Programme was introduced as a panic measure but although based on solid groundwork, it's hopelessly undercooked with regard to rollout. Currently there is chaos, with PCTs making haphazard attempts to introduce effective screening.

But be that as it may, the concept of screening - both for hard measures such as cholesterol and for 'softer' lifestyle issues - is sound.

Obesity screening is obviously something that must go ahead. The obese abdomen is a physical sign of serious underlying pathology, although awareness of the fact among clinicians and patients is poor.

Screening for alcohol consumption is admittedly less straightforward as intake is notoriously inaccurate when self-reported. And what of exercise screening? Activity can be assessed by accelerometers and pedometers, which are good motivational devices, but they are not screening tools.

I firmly believe that if a screening programme is going to be rolled out nationally then it should be as broad based and inclusive as possible. Even if self-reported levels of alcohol and exercise are dubious, they're still important factors in raising a person's risk awareness.

If we know they're lying, they certainly know they're lying, but when the deceit is over, they may be more aware of the risks they are running than they were before.

Although technically flawed and imperfect as scientific screening methods, lifestyle measures such as alcohol and physical activity should be included.

After all, the word 'screening' has been dropped from the National Vascular 'Assessment' Programme, paving the way for lifestyle measures such as alcohol and activity to be included as motivational and awareness-raising opportunities.

Dr David Haslam is chair of the National Obesity Forum and a GP in Watton-on-Stone, Hertfordshire

Bah humbug, is my typical response to the enthusiasm some have for the ever-growing role of screening in general practice. Yet it's hard to directly argue against the benefits of preventive medicine - and hence the inherent role of screening - so I won't.

My argument is that by the time patients come to me to be measured and monitored as part of the new vascular checks programme, it'll be too late.

I also question the value of this huge data-gathering exercise and the extent to which the NHS - aka the Nanny Health Service - is taking a role in lifestyle supervision. We're absolving patients of their personal responsibility for their health and replacing it with an increasing expectation that we will manage their lives on their behalf.

I'm a busy GP in a very large city practice. I run an open surgery and, just like every other GP, I'm trying my best with limited consultation time to deal with the problems patients come in to tell me about - let alone to start to address the, as yet, unforeseen ones.

Ah, you say, presenting problems would be avoided if we managed lifestyle issues earlier. Probably true, but whose responsibility is that? You might say GPs are ideally placed to advise patients about a healthy lifestyle and how to prevent weight gain - that we're best able to cajole our patients into being more active and controlling their urge to overeat and abuse tobacco, alcohol and other delights.

But given the limited resources of the NHS, I question whether we're the right people for the job. Just how effective are we at health education? Is my time not simply too expensive to be wasted on such protracted attempts at persuasion and wouldn't someone else be better value - nurses, parents, healthcare assistants, teachers, ministers or even celebrities?

The crux of the matter is this: having gathered the data from my patient I have to do something with it or I waste the precious time it's taken to get it.

So I must advise on what constitutes healthy living, offer support and develop a plan of action. But I find each of my succinct, positive and supportive messages losing power among the endless health messages that spew from central Government, mixed in with the infomercials and press releases from pharma companies, charities and other groups with a financial interest, that are channelled through the media to bounce around in my patient's subconscious.

Let's be honest, most patients are in denial. If they haven't come in asking for help to stop smoking, lose weight or drink less are they really going to listen to me suggesting it's a good idea? Call me tired and cynical, but I don't think so. They may be better influenced by a celebrity's life-story or a friendly nurse with whom they probably can be more honest. But at the end of the day it is up to the patient to do something about their state of un-health.

BMI, exercise level and alcohol consumption are all good measures, nice round numbers we can give the crunchers to chew on and tell us the state of the nation. But what does it give me to tell the patient? Look in the mirror, Mr and Mrs Bloggs, see the double chins, beer belly and nicotine stains and then tell me it won't affect your health. Maybe we should be harsher and simply deny medical care to those who won't behave and help themselves.

If we really are going to go for broke with preventive medicine, we need a programme to get parents to shoulder the responsibility from pregnancy onward, teaching their children to take personal responsibility for their health and not look to their medical carers to sort out the mess they get into.

Dr Gillian Jenkins is a GP in Bristol with an interest in obesity, weight management and diabetes

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