Author: Dr J Hugh Coyne MBBS BSc PGDip (with merit) MRCGP DRCOG DCH

  • The Best Exercise For Managing High Blood Pressure

    The Best Exercise For Managing High Blood Pressure

    High blood pressure, or hypertension, remains a global health challenge, with a soaring prevalence (thanks in part to changing definitions of hypertension) and control often proving elusive. It remains one of the leading modifiable risk factors for disease and death worldwide. While lifestyle interventions have long been a mainstay in hypertension management, a growing body of research underscores the particularly pivotal role of exercise training as an effective non-pharmacological antihypertensive strategy. Recent findings, including a large-scale systematic review and meta-analysis of 270 randomised controlled trials, shed new light on the optimal exercise practices for managing blood pressure. 

    Exercise as a Cornerstone of Hypertension Management:

    The link between exercise and cardiovascular health is certainly not a novel concept. Regular physical activity has long been associated with reduced risks of heart disease and hypertension. However, contemporary research is refining our understanding of how different exercise modalities impact blood pressure.

    The Landmark Study:

    Led by Dr. Jamie J. Edwards and a team of researchers from Canterbury Christ Church University in the United Kingdom, this comprehensive study published in the BJSM examined the effects of various exercise training modes on resting blood pressure. The study analysed 270 randomised controlled trials published between 1990 and February 2023, involving a total of 15,827 participants.

    Key Findings:

    The study’s results paint a clear picture of the effectiveness of different exercise modalities in reducing both systolic and diastolic blood pressure:

    • Aerobic Exercise Training: This traditional form of exercise demonstrated significant reductions in resting systolic blood pressure (SBP) by an average of 4.49 mm Hg and diastolic blood pressure (DBP) by 2.53 mm Hg.
    • Dynamic Resistance Training: Participants engaging in dynamic resistance training experienced reductions in SBP and DBP by an average of 4.55 mm Hg and 3.04 mm Hg, respectively.
    • Combined Training: Combining aerobic and resistance training led to even more pronounced reductions, with SBP decreasing by 6.04 mm Hg and DBP by 2.54 mm Hg.
    • High-Intensity Interval Training (HIIT): HIIT, known for its time-efficient, intense bursts of activity, lowered SBP by 4.08 mm Hg and DBP by 2.50 mm Hg.
    • Isometric Exercise Training (IET): This novel form of exercise emerged as the most effective, resulting in a substantial reduction of SBP by 8.24 mm Hg and DBP by 4.00 mm Hg.

    Optimal Exercise Modes:

    The study ranked the exercise modalities based on their effectiveness, with isometric exercise training (IET) topping the list, boasting a Surface Under the Cumulative Ranking Curve (SUCRA) value of 98.3 percent. Surface Under the Cumulative Ranking Curve, or SUCRA, is a statistical tool used in network meta-analysis to evaluate the relative effectiveness of several different interventions or treatments. In the context of this study, SUCRA values were used to assess and rank the various exercise modalities in terms of their impact on resting blood pressure.

    A higher SUCRA value indicates a greater likelihood that a particular intervention (in this case, an exercise modality) is the most effective among the options being compared. In other words, a higher SUCRA value suggests that an exercise mode is more consistently and confidently ranked as the best choice for reducing blood pressure. Combined training followed closely at 75.7 percent, dynamic resistance training at 46.1 percent, aerobic exercise training at 40.5 percent, and high-intensity interval training (HIIT) at 39.4 percent.

    The Isometric Advantage:

    Isometric exercise training, particularly through activities like isometric wall squats, emerged as the most potent submodes for reducing SBP (SUCRA: 90.4 percent) and DBP (SUCRA: 91.3 percent), respectively.

    Implementing Isometric Training:

    Isometric exercise places the muscle under tension without moving the surrounding joints. To harness the benefits of isometric exercise, use the following protocol:  

    4×2-minute contractions, separated by 1–4-minute rest intervals, performed three times a week. 

    Isometric handgrip (IHG) is usually executed at 30% maximum voluntary contraction, while isometric wall squats (IWS), also known as ski squats can be performed to elicit a rate of perceived exertion (RPE) between 3.5–4.5/10 for the first bout, RPE 5–6/10 for the second bout, RPE 6.5–7.5/10 for the third bout, and RPE 8–9/10 for the fourth bout. Isometric leg extension (ILE) is performed at 20% of the maximum voluntary contraction (this is the maximum amount of force that can be generated by contracting a muscle group). So in practice, this means holding still with the legs fully straightened approximately 20% of the heaviest hold that you could shift on the leg extension machine. 

    As the prevalence of hypertension continues to rise, understanding the role of exercise in its management becomes increasingly critical. The latest research emphasises the varied and substantial benefits of lots of different exercise modalities, with isometric exercise training shining as a particularly potent antihypertensive intervention. Of the isometric exercises, wall squats, to me at least, are the most convenient to perform.

    DR J HUGH COYNE
    MBBS BSc PGDip (with merit) MRCGP DRCOG DCH

    Dr Hugh Coyne is a GP and co-founder of Coyne Medical, a private preventive health clinic at 660 Fulham Road, London. He trained at Imperial College London and has been in practice for over twenty years, with a particular focus on cardiovascular risk, metabolic health, and exercise medicine. After qualifying as a GP he went on to train in sport and exercise medicine, bringing a distinctly practical approach to prevention and long-term health.

    British Association of Sports and Exercise Medicine  ·  European Atherosclerosis Society  · 
    Independent Doctors Federation

    As seen in The Independent, The Daily Mail and Tatler

    Book a Health Screening

    For educational purposes. This article is written by a practising GP and is intended to inform, not replace a consultation with your own doctor. It does not constitute medical advice. A note on clinical guidelines: Coyne Medical is an independent private clinic. Our approach is guided by the best available evidence, tailored to each individual. This may go beyond standard NHS or NICE guidance, which is designed for population-level care and weighted by resource constraints.

    Read More Cardiovascular Health Guides
  • Everything you need to know about Ozempic & Navigating Weight Loss Injections

    Everything you need to know about Ozempic & Navigating Weight Loss Injections

    Debunking Misconceptions and Embracing Comprehensive Solutions

    The topic of weight loss injections has gained significant attention, particularly concerning medications like semaglutide, liraglutide (Saxenda, Wegovy), and Ozempic. In this article, Dr Hugh explains everything you need to know about Ozempic and navigating weight loss injections.

    However, before delving into the specifics of these medications, it is essential to address the broader issue of obesity and the misconceptions surrounding its treatment. Many individuals who are offered these medications to manage obesity and its associated health risks often hesitate due to perceived stigma and misconceptions about the nature of their condition.

    Redefining Obesity: A Chronic Disease

    Society’s historical tendency to stigmatise individuals who are overweight has resulted in many viewing obesity as a personal failure. This perception is not only unjust but also hinders effective treatment. It is vital to understand that obesity is indeed a chronic disease and has been classified as a chronic disease since the 1990s. Its impact on health and mortality has been recognised for over 2500 years, dating back to the time of Hippocrates.

    Understanding Obesity Pathogenesis

    Obesity is not merely a matter of willpower or self-control. Its pathogenesis involves two interconnected processes. The first is a sustained positive energy balance, resulting from small, incremental imbalances between energy intake and expenditure over time. Once an individual reaches a higher-than-normal weight, the second process emerges: the resetting of the body’s weight “set point” at an elevated value.

    This phenomenon can be understood through the lens of evolutionary physiology. Our biological predisposition to store body fat for survival was advantageous in times of scarcity but poses challenges in the modern era of abundance and easy access to calorie-dense foods. Consequently, a significant portion of the population is biologically inclined toward excessive weight gain. This intrinsic physiological mechanism explains why weight loss achieved through diet and lifestyle changes often leads to eventual weight regain, posing a considerable obstacle to effective obesity treatment.

    Debunking Stigma: Obesity as a Disease

    The stigma associated with obesity not only affects individuals emotionally but also hampers their access to appropriate treatments, including medications. It’s crucial to recognise that obesity is on par with other chronic diseases, such as type 2 diabetes. Just as one wouldn’t hesitate to manage diabetes with medication, obesity also requires a multifaceted approach to treatment.

    Comprehensive Solutions: Weight loss medications

    Weight loss medications, like semaglutide, liraglutide, and others, offer valuable tools in the management of obesity. However, it’s essential to view these medications as part of a broader strategy. Behaviour modification, dietary adjustments, increased physical activity, and in some cases, surgical interventions, all play integral roles in a comprehensive treatment plan. These components work synergistically to promote sustainable weight loss and improve overall health outcomes.

    Shifting the perspective on obesity

    Shifting the perspective on obesity from personal failure to a chronic disease is a crucial step in achieving effective treatment. By understanding the physiological mechanisms driving obesity, we can debunk misconceptions and encourage individuals to consider a comprehensive approach that encompasses medications, lifestyle changes, and supportive interventions. Of course, not everyone needs medications. Just because a medications offered to you, doesn’t mean you have to take it. Ideally, we would manage disease solely through lifestyle interventions. However, embracing a holistic strategy empowers individuals to fully take charge of their health.

    Please reach out to the team if you have any questions about the contents of this article.

    DR J HUGH COYNE
    MBBS BSc PGDip (with merit) MRCGP DRCOG DCH

    Dr Hugh Coyne is a GP and co-founder of Coyne Medical, a private preventive health clinic at 660 Fulham Road, London. He trained at Imperial College London and has been in practice for over twenty years, with a particular focus on cardiovascular risk, metabolic health, and exercise medicine. After qualifying as a GP he went on to train in sport and exercise medicine, bringing a distinctly practical approach to prevention and long-term health.

    British Association of Sports and Exercise Medicine  ·  European Atherosclerosis Society  · 
    Independent Doctors Federation

    As seen in The Independent, The Daily Mail and Tatler

    Book a Health Screening

    For educational purposes. This article is written by a practising GP and is intended to inform, not replace a consultation with your own doctor. It does not constitute medical advice. A note on clinical guidelines: Coyne Medical is an independent private clinic. Our approach is guided by the best available evidence, tailored to each individual. This may go beyond standard NHS or NICE guidance, which is designed for population-level care and weighted by resource constraints.

    Read More Longevity & Healthspan Guides
  • Optimal Antibiotic Treatment for Children with Pneumonia: Why Shorter Duration Is Safer and More Effective

    Optimal Antibiotic Treatment for Children with Pneumonia: Why Shorter Duration Is Safer and More Effective

    As a parent, your child’s health and well-being are always your top priority. Although severe illnesses like community-acquired pneumonia (CAP) are not that common, finding the most effective and safe treatment is still crucial. A recent systematic review, based on 16 randomised clinical trials, has shed light on the optimal duration of antibiotic treatment for children with CAP. 

    Insights from a Recent Review

    The study’s primary objective was to compare the efficacy and safety of shorter-duration (≤5 days) versus longer-duration antibiotic treatments in children with CAP. The researchers conducted a thorough search across various databases to gather data from 16 randomised clinical trials involving 12,774 paediatric patients. All the participants were treated as outpatients with oral antibiotics.

    The analysis revealed that there were no substantial differences between shorter-duration and longer-duration antibiotics in terms of clinical cure, treatment failure, and relapse rates. This suggests that the duration of antibiotic therapy may not significantly impact your child’s overall recovery from CAP.

    Clinical Equivalence

    Shorter-duration antibiotics did not appreciably increase the risk of mortality or severe adverse events when compared to longer-duration antibiotics. This finding provides reassurance that opting for shorter courses of antibiotics is unlikely to compromise your child’s safety.

    The study indicated that shorter-duration antibiotics probably have little or no impact on the need for hospitalisation or the necessity to change antibiotics. This implies that choosing a shorter course of treatment is unlikely to result in a more severe illness requiring hospital care.

    Safety Considerations

    One of the key advantages of choosing shorter-duration antibiotics is a reduced risk of side effects. Prolonged antibiotic exposure can lead to adverse reactions, and by limiting the duration, we can minimise this risk.

    Overuse of antibiotics can contribute to the development of antibiotic-resistant bacteria, making infections harder to treat in the future. By opting for shorter courses of antibiotics when appropriate, we can help combat the growing concern of antibiotic resistance.

    Reducing Risks and Burden

    Shorter-duration antibiotic therapy also brings relief to parents by reducing the overall administration burden. Fewer days of medication mean less hassle for both you and your child.

    Positive Conclusions

    Based on the findings of this comprehensive systematic review, shorter-duration antibiotic therapy appears to be just as effective and safe as longer-duration treatment for children with community-acquired pneumonia.  Not only does this approach lead to similar patient outcomes, but it also reduces the risk of side effects, combats antibiotic resistance, and eases the burden on parents.

    Collaboration with Healthcare Providers

    As always, it is essential to follow your healthcare provider’s recommendations regarding your child’s treatment. If your child is diagnosed with pneumonia, have an open and informed discussion with their healthcare provider about the best course of action based on the severity of the illness and individual medical history. With the right care and attention, your child can recover from pneumonia and get back to being their happy and healthy selves.

    DR J HUGH COYNE
    MBBS BSc PGDip (with merit) MRCGP DRCOG DCH

    Dr Hugh Coyne is a GP and co-founder of Coyne Medical, a private preventive health clinic at 660 Fulham Road, London. He trained at Imperial College London and has been in practice for over twenty years, with a particular focus on cardiovascular risk, metabolic health, and exercise medicine. After qualifying as a GP he went on to train in sport and exercise medicine, bringing a distinctly practical approach to prevention and long-term health.

    British Association of Sports and Exercise Medicine  ·  European Atherosclerosis Society  · 
    Independent Doctors Federation

    As seen in The Independent, The Daily Mail and Tatler

    Book a Health Screening

    For educational purposes. This article is written by a practising GP and is intended to inform, not replace a consultation with your own doctor. It does not constitute medical advice. A note on clinical guidelines: Coyne Medical is an independent private clinic. Our approach is guided by the best available evidence, tailored to each individual. This may go beyond standard NHS or NICE guidance, which is designed for population-level care and weighted by resource constraints.

    Read More Child Health Guides
  • Menstrual Cycle and Cardiovascular Health: A New Perspective for Women

    Menstrual Cycle and Cardiovascular Health: A New Perspective for Women

    Cardiovascular disease (CVD) remains the leading cause of death and disease for women worldwide. In Western countries, approximately 45% of women aged over 20 years are affected by CVD, and it accounts for one-third of all female deaths. Recognising the unique sex-specific aspects in preventing CVD is crucial as historically, studies in cardiovascular disease have frequently focused on men. Recently, there has been growing interest in studying menstrual cycle characteristics and their potential impact on cardiovascular health. 

    Regular menstrual cycles are a vital sign of women’s overall health, signalling normal functioning of the hypothalamic-pituitary-ovarian axis. However, about 20% of women of reproductive age experience irregular and long menstrual cycles due to endocrine disorders that disrupt this axis. These menstrual irregularities have been linked to several health conditions, including insulin resistance, metabolic disturbances, hyperandrogenism, and chronic inflammation. Consequently, they have been associated with an increased risk of coronary heart disease and related mortality, obesity, and type 2 diabetes.

    To gain further insights into the connection between menstrual cycles and CVD, researchers conducted a large population-based cohort study using data from the UK Biobank. This study included over 58,000 women aged 40 to 69 years who had no pre-existing cardiovascular disease at the study’s outset. Participants were asked to report their current menstrual cycle length and regularity. The researchers followed these women for a median duration of 11.8 years, tracking the development of incident CVD cases through national health records and follow-up visits.

    The study revealed some compelling associations between menstrual cycle characteristics and cardiovascular health. Here are the key findings:

    • Women with irregular menstrual cycles were found to have a 19% higher risk of CVD events, including heart disease and atrial fibrillation, compared to those with regular menstrual cycles.
    • Short (≤21 days) menstrual cycles were associated with a 29% higher risk of CVD events, while long (≥35 days) menstrual cycles showed an 11% increased risk. Specifically, short cycles were linked to a greater risk of coronary heart disease and myocardial infarction.
    • Both short and long menstrual cycles were associated with a higher risk of atrial fibrillation.
    • Interestingly, there was a significant interaction between irregular menstrual cycles and lower high-density lipoprotein cholesterol levels and smoking status, suggesting that these factors might influence CVD risk.

    This study adds to the growing body of evidence suggesting that menstrual cycle characteristics throughout a woman’s reproductive lifespan could be associated with cardiovascular disease. Although the findings are significant, more research is needed to fully understand the underlying mechanisms and establish causality. Future studies are crucial to fill the remaining knowledge gaps and determine on how menstrual cycles might be prospectively linked to cardiovascular disease and subsequent events.

    As we strive to ensure that women’s heart health is finally given the prominent status it deserves, understanding the potential impact of menstrual cycle characteristics on cardiovascular health becomes increasingly vital. The findings from the UK Biobank study provide valuable insights into the associations between irregular, short, and long menstrual cycles and CVD risk in women. Armed with this knowledge, women can take proactive steps towards better cardiovascular health. Regular check-ups, maintaining a healthy lifestyle, and discussing any menstrual irregularities with healthcare professionals can go a long way in safeguarding against CVD. 

    DR J HUGH COYNE
    MBBS BSc PGDip (with merit) MRCGP DRCOG DCH

    Dr Hugh Coyne is a GP and co-founder of Coyne Medical, a private preventive health clinic at 660 Fulham Road, London. He trained at Imperial College London and has been in practice for over twenty years, with a particular focus on cardiovascular risk, metabolic health, and exercise medicine. After qualifying as a GP he went on to train in sport and exercise medicine, bringing a distinctly practical approach to prevention and long-term health.

    British Association of Sports and Exercise Medicine  ·  European Atherosclerosis Society  · 
    Independent Doctors Federation

    As seen in The Independent, The Daily Mail and Tatler

    Book a Health Screening

    For educational purposes. This article is written by a practising GP and is intended to inform, not replace a consultation with your own doctor. It does not constitute medical advice. A note on clinical guidelines: Coyne Medical is an independent private clinic. Our approach is guided by the best available evidence, tailored to each individual. This may go beyond standard NHS or NICE guidance, which is designed for population-level care and weighted by resource constraints.

    Read More Women’s Health Guides
  • Unmasking the Hidden Enemy: Inflammation’s role in Cardiovascular Disease

    Unmasking the Hidden Enemy: Inflammation’s role in Cardiovascular Disease

    Cardiovascular diseases (CVDs) have long been a significant health concern, but advancements in statin therapy have helped reduce their impact. However, some patients continue to experience CVD events despite high-dose statin treatment. This is known as residual risk. Recent research suggests that this residual risk may be attributed, in part, to inflammation, which can trigger plaque ruptures. Here, we will delve into inflammation’s role in cardiovascular disease and explore the potential benefits of reducing inflammation using low-dose colchicine.

    Inflammation’s role in Cardiovascular Disease

    Inflammation has emerged as a key player in the development and progression of cardiovascular disease. Dr. Ridker and his team pioneered the use of high-sensitivity C-reactive protein (hs-CRP) testing to identify inflammation in patients. Their study, the Jupiter study, demonstrated the efficacy of rosuvastatin in reducing CV events in high-risk primary prevention patients identified through hs-CRP testing. However, the full potential of the inflammation strategy was not realised at that time and the potential to treat lower-risk patients was missed.

    Uncovering the Link between Inflammation and CV Events

    A recent paper explored the connection between inflammation and CV events by analysing data from three major studies: PROMINENT, REDUCE-IT, and STRENGTH. Patients were divided into quartiles based on their hs-CRP levels, and the highest quartile group was compared to the lowest.

    The results were striking. Patients in the highest hs-CRP quartile experienced a 31% increase in major adverse cardiovascular events (MACE), a 268% increase in cardiovascular mortality, and a 242% increase in all-cause mortality, highlighting the significant impact of inflammation on CV health. Comparatively, the differences in MACE, CV death, and all-cause death were not as pronounced when comparing the highest and lowest LDL-cholesterol (LDL-C) quartiles. 

    The Inflammation Conundrum

    Once patients are on effective statin therapies and their LDL-C levels are well-controlled, the threat posed by LDL-C diminishes. However, the presence of inflammation remains a driving force behind future CV events. Identifying patients with high hs-CRP levels while on high-dose statins becomes essential to intensify efforts in reducing their residual CV risk.

    Addressing Inflammation: A New Frontier in Cardiovascular Health:

    Presently, there are limited affordable therapies proven to reduce inflammation. As a result, it is crucial to prioritise preventive measures that can help combat inflammation and its consequences. Encouraging patients to quit smoking, manage abdominal obesity, reduce stress, improve sleep quality, and adopt a heart-healthy diet can significantly contribute to reducing inflammation and enhancing overall cardiovascular health. 

    The Concern of Inflammation Post COVID-19

    The aftermath of long COVID poses another concern, as inflammation from COVID-19 may also increase the risk of cardiovascular events in a large number of people. Vigilance and proactive management of inflammation in recovering COVID-19 patients are paramount to safeguard their heart health.

    The Power of Low-Dose Colchicine

    Colchicine has been used for centuries to treat joint inflammation and is frequently used to treat gout.  A recent analysis has shed light on the potential of low-dose colchicine, revealing its significant impact in the management of chronic coronary artery disease by reducing inflammation in the coronary arteries. 

    The study conducted an in-depth analysis to model the 10-year and lifetime impact of low-dose colchicine in patients with chronic coronary artery disease. The results were striking, demonstrating that low-dose colchicine has the potential to bring about a median 10-year absolute risk reduction rate of 4.6% for major adverse cardiovascular events (MACE). This reduction in risk translates into gaining 2.0 MACE-free years over a lifetime for patients.

    What makes this finding even more significant is that the estimated 10-year and lifetime benefits of low-dose colchicine are comparable to the benefits associated with intensified low-density lipoprotein cholesterol (LDL-C) and systolic blood pressure-lowering. LDL-C and blood pressure optimisation are well-established strategies in cardiovascular management, and the fact that low-dose colchicine holds similar potential is indeed promising news.

    An exciting opportunity for patients with existing chronic coronary artery disease

    The discovery of the potential benefits of low-dose colchicine presents an exciting opportunity for patients with existing chronic coronary artery disease. By adding this medication to their treatment regimen, they may experience substantial improvements in their cardiovascular health, with a reduced risk of MACE over the long term.

    Low-dose colchicine is well-tolerated and has been used for years to treat conditions like gout. As always, individual patient needs vary, and decisions about treatment should be made in consultation with healthcare providers. When managing chronic coronary artery disease, healthcare providers will consider various factors, including a patient’s medical history, risk profile, and other existing treatments. By adopting a personalised approach to care, patients can receive the most suitable treatment plan that aligns with their unique health requirements.

    Hope for a healthier & heart-protected future

    Inflammation has emerged as a critical factor in the pathogenesis of cardiovascular disease, even when LDL-C levels are well-controlled through statin therapy. Identifying patients with inflammation through hs-CRP testing can help us address their residual CV risk and implement personalised strategies to reduce inflammation. The analysis of low-dose colchicine’s impact on chronic coronary artery disease has revealed its potential to significantly reduce the risk of major adverse cardiovascular events by reducing coronary artery inflammation. The estimated 10-year and lifetime benefits are on par with those of established cardiovascular therapies like LDL-C and blood pressure optimisation. Low-dose colchicine offers an exciting new option for enhancing cardiovascular health, providing patients with hope for a healthier and heart-protected future.

    If you have chronic coronary artery disease

    If you have chronic coronary artery disease, consider discussing the potential benefits of low-dose colchicine with your healthcare provider. Together, you can create a tailored treatment plan that best suits your needs, helping you embark on a journey towards improved cardiovascular well-being. Remember, your heart health is paramount, and with the right care and support, you can take positive steps to protect your heart and live a fulfilling life.

    Please reach out to the team if you have any questions about the contents of this article.

    DR J HUGH COYNE
    MBBS BSc PGDip (with merit) MRCGP DRCOG DCH

    Dr Hugh Coyne is a GP and co-founder of Coyne Medical, a private preventive health clinic at 660 Fulham Road, London. He trained at Imperial College London and has been in practice for over twenty years, with a particular focus on cardiovascular risk, metabolic health, and exercise medicine. After qualifying as a GP he went on to train in sport and exercise medicine, bringing a distinctly practical approach to prevention and long-term health.

    British Association of Sports and Exercise Medicine  ·  European Atherosclerosis Society  · 
    Independent Doctors Federation

    As seen in The Independent, The Daily Mail and Tatler

    Book a Health Screening

    For educational purposes. This article is written by a practising GP and is intended to inform, not replace a consultation with your own doctor. It does not constitute medical advice. A note on clinical guidelines: Coyne Medical is an independent private clinic. Our approach is guided by the best available evidence, tailored to each individual. This may go beyond standard NHS or NICE guidance, which is designed for population-level care and weighted by resource constraints.

    Read More Cardiovascular Health Guides
  • The Impact of Childhood TV Viewing on Adult Health: What Every Parent Needs to Know

    The Impact of Childhood TV Viewing on Adult Health: What Every Parent Needs to Know

    One aspect of child health that has garnered increasing concern in recent years is the impact of sedentary behaviours, especially excessive screen time, on our kids’ health. In this article Dr Hugh addresses the impact of childhood TV viewing on adult health. 

    The connection between childhood TV viewing habits & metabolic syndrome

    I loved watching TV growing up, the trouble was, there wasn’t much on. He-Man, Thundercats, BraveStarr and James Bond Jr (“James Bond Jr chases S.C.U.M”) were personal favourites. However,  a recent study at the University of Otago, New Zealand, sheds light on the connection between childhood television viewing habits and metabolic syndrome in mid-adulthood. This research underscores the importance of mindful screen time management for the long-term well-being of our children.

    Some background on the study

    The researchers followed a population-based birth cohort born in Dunedin, New Zealand, in 1972 and 1973, with data collected from ages 5 to 32 years. The study tracked both parent and self-reported weekday television viewing times of the participants at ages 5, 7, 9, 11, 13, 15, and 32. At age 45, the primary outcome was evaluated—metabolic syndrome.  This is defined by having three or more of the following risk factors: high glycated hemoglobin, high waist circumference, high blood triglyceride levels, low high-density lipoprotein cholesterol, and high blood pressure. The study included data from 870 out of 997 surviving participants, making it a robust and significant exploration of the subject.

    What the study revealed: the impact of childhood TV viewing on adult health

    The study revealed a compelling association between childhood television viewing habits and the risk of metabolic syndrome in mid-adulthood. Notably, the association remained consistent even after accounting for other influencing factors such as sex, socioeconomic status, and body mass index (BMI) at age 5. This finding emphasises that reducing screen time during childhood and adolescence can have a lasting positive impact on health.

    Furthermore, the researchers discovered a correlation between childhood television viewing and two essential health indicators at age 45: lower cardiorespiratory fitness and higher BMI. These findings underscore the far-reaching consequences of excessive screen time on our children’s overall health and well-being.

    What we can do as parents

    As parents, we play a crucial role in shaping our children’s habits and choices. The results of this study emphasise the need for proactive intervention in managing our kids’ screen time. By limiting television viewing and encouraging other forms of physical and mental activities, we can significantly reduce the risk of metabolic syndrome and other related health issues later in life.

    Some practical guidelines to follow

    The path to healthier screen habits begins with setting practical guidelines on television viewing and screen time usage. Here are some suggestions to consider:

    • Set daily limits: Establish specific time limits for television viewing and ensure that your child follows them.
    • Encourage physical activities: Engage your children in outdoor play, sports, or other physical activities that promote an active lifestyle.
    • Create tech-free zones: Designate certain areas in the house as tech-free zones, like the dining table or bedrooms, to encourage family interaction and relaxation without screens.
    • Be a role model: Demonstrate a healthy relationship with screens by limiting your own screen time and engaging in activities that do not involve screens.
    • Offer alternative options: Provide a variety of stimulating activities such as reading, puzzles, board games, or creative projects to keep your child engaged and entertained.

    A final note

    The study highlights the need to take proactive steps in managing screen time and promoting healthier lifestyle choices for our kids. By adopting mindful screen habits and encouraging physical activities, we can pave the way for a healthier, happier future for our children.

    DR J HUGH COYNE
    MBBS BSc PGDip (with merit) MRCGP DRCOG DCH

    Dr Hugh Coyne is a GP and co-founder of Coyne Medical, a private preventive health clinic at 660 Fulham Road, London. He trained at Imperial College London and has been in practice for over twenty years, with a particular focus on cardiovascular risk, metabolic health, and exercise medicine. After qualifying as a GP he went on to train in sport and exercise medicine, bringing a distinctly practical approach to prevention and long-term health.

    British Association of Sports and Exercise Medicine  ·  European Atherosclerosis Society  · 
    Independent Doctors Federation

    As seen in The Independent, The Daily Mail and Tatler

    Book a Health Screening

    For educational purposes. This article is written by a practising GP and is intended to inform, not replace a consultation with your own doctor. It does not constitute medical advice. A note on clinical guidelines: Coyne Medical is an independent private clinic. Our approach is guided by the best available evidence, tailored to each individual. This may go beyond standard NHS or NICE guidance, which is designed for population-level care and weighted by resource constraints.

    Read More Child Health Guides
  • Enhancing Your Child’s Nutrition: The Power of Longer Family Mealtimes

    Enhancing Your Child’s Nutrition: The Power of Longer Family Mealtimes

    As parents, we strive to provide the best nutrition for our children to ensure that they develop healthy eating habits that will benefit them throughout their lives. While we receive plenty of advice on what’s best for our kids, it’s important to know that these recommendations are supported by scientific evidence. One common belief is that family mealtimes have multiple advantages for children, including improved socialisation, stronger relationships, and potentially better nutrition. But do we really have concrete evidence to support this claim? A recent study conducted in Germany sheds light on this topic, revealing fascinating findings that can benefit both parents and their children.

    The study was a randomised controlled trial involving 50 parent–child pairs. It sought to investigate the impact of longer meal times on children’s fruit and vegetable intake. In comparison to regular mealtime lengths, extending mealtime by 50% resulted in increased consumption of fruits and vegetables by the children. Furthermore, the children in the longer mealtime group reported higher feelings of satiety and demonstrated increased water consumption. On average, the mealtime extension was only a mere 10 minutes.

    Implications for Families:

    For families struggling to encourage their children to consume recommended amounts of fruits and vegetables, this study offers a promising low-risk intervention. While the study’s sample size was small, the positive effect observed with longer mealtime durations suggests that families could potentially benefit from this strategy. The key takeaway is that even a brief extension of mealtime, averaging just 10 minutes, can provide significant nutritional advantages. This finding holds practical importance for public health, as consuming an additional daily portion of fruits and vegetables reduces the risk of cardiometabolic disease by 6% to 7%.

    Benefits of Longer Mealtime:

    The study specifically found that the increased intake of fruits and vegetables during longer meals did not result in greater consumption of other food items. This reinforces the notion that longer mealtime durations facilitate a slower eating rate, leading to increased satiety and potentially reducing snacking between meals. Additionally, longer family meals create a conducive atmosphere for fostering healthier eating habits, potentially lowering the risk of obesity in children.

    Practical Strategies for Implementing Longer Mealtime:

    Establishing longer mealtime routines may seem challenging, but there are several strategies that families can employ to make this a successful and enjoyable experience. Firstly, choose a mealtime that is most likely to succeed, avoiding rushed mornings and selecting a time when everyone can gather together. Accommodating children’s preferences, such as playing their favourite music in the background, can make the experience more enjoyable (Party in the U.S.A. being a particular favourite in our kitchen). Transparent rules, such as everyone staying at the table for a certain period, help create structure and consistency. While these strategies may not work every time, habit change requires effort and can be fostered through consistent practice.

    Strengths and Limitations:

    It’s important to note that the study was conducted in a laboratory setting, which may limit the generalisability of the findings to natural eating environments. The sample used in the study also had limited ethnic and socioeconomic diversity, warranting further exploration in more diverse populations. Additionally, the long-term sustainability of the intervention’s effects remains uncertain and requires further investigation.

    The findings of this clinical trial highlight the potential benefits of increasing family mealtime duration by as little as 10 minutes. By incorporating this simple and low-cost intervention, parents can improve their children’s diets and eating behaviours. Establishing new routines may require effort, but the long-term impact on children’s intake of fruits and vegetables can contribute significantly to addressing the major public health concern of poor nutrition. Remember, ensuring the availability of fruits and vegetables on the table is vital for maximising the effects of this intervention.

    As parents, let’s embrace the power of longer family mealtimes to nourish our children and cultivate lifelong healthy eating habits. By prioritising these moments together, we can promote not only physical well-being but also strengthen our family bonds.

    DR J HUGH COYNE
    MBBS BSc PGDip (with merit) MRCGP DRCOG DCH

    Dr Hugh Coyne is a GP and co-founder of Coyne Medical, a private preventive health clinic at 660 Fulham Road, London. He trained at Imperial College London and has been in practice for over twenty years, with a particular focus on cardiovascular risk, metabolic health, and exercise medicine. After qualifying as a GP he went on to train in sport and exercise medicine, bringing a distinctly practical approach to prevention and long-term health.

    British Association of Sports and Exercise Medicine  ·  European Atherosclerosis Society  · 
    Independent Doctors Federation

    As seen in The Independent, The Daily Mail and Tatler

    Book a Health Screening

    For educational purposes. This article is written by a practising GP and is intended to inform, not replace a consultation with your own doctor. It does not constitute medical advice. A note on clinical guidelines: Coyne Medical is an independent private clinic. Our approach is guided by the best available evidence, tailored to each individual. This may go beyond standard NHS or NICE guidance, which is designed for population-level care and weighted by resource constraints.

    Read More Child Health Guides
  • Unleashing the Power of High-Intensity Exercise: Insights from the CENIT Trial

    Unleashing the Power of High-Intensity Exercise: Insights from the CENIT Trial

    Exercise has long been recognised as a key factor in maintaining a healthy heart and reducing the risk of coronary artery disease (CAD). A recent study called the CENIT trial has provided some valuable insights into the benefits of high-intensity interval training (HIIT) for patients with established CAD. Published in the European Journal of Preventive Cardiology, this research reveals how HIIT can counteract disease progression and promote cardiovascular health. 

    Coronary artery disease occurs when atherosclerosis, or plaque, builds up in the arteries that supply blood to the heart. Over time, plaques can increase in volume and become unstable and rupture leading to a stroke or a heart attack. Atheroma volume, which measures the amount of plaque present in the arteries, is a crucial indicator of CAD severity and has been shown to increase the likelihood of future cardiac events.

    To better understand the impact of exercise on CAD, let’s examine the exercise interventions in the CENIT trial. The study consisted of two groups: the high-intensity interval training (HIIT) group and the control group. Each group had a specific exercise program.

    1. High-Intensity Interval Training (HIIT) Group: Participants in the HIIT group engaged in two supervised exercise sessions per week for a duration of 6 months. Each session began with a 10-minute warm-up at a moderate intensity (around 60% to 70% of peak heart rate). This was followed by four intervals of intense exercise, lasting for four minutes each, at an intensity of 85% to 95% of peak heart rate. Active recovery periods, lasting for three minutes at a moderate intensity, were included between intervals. The sessions concluded with a 5-minute cooldown period. The HIIT sessions involved activities such as walking or running on a treadmill, bicycling, or other exercises that engaged large muscle groups. Participants were encouraged to use a wearable device to track their heart rate and activity levels during the HIIT sessions. This allowed them to maintain the desired intensity and monitor their progress. In addition to the supervised sessions, participants were advised to engage in home-based endurance training. This included performing intervals and any other physical activities that involved dynamic work with large muscle groups.
    2. Control Group: The control group followed contemporary preventive guidelines for physical activity without receiving further supervision. They were encouraged to engage in regular physical activity of moderate intensity for 30-60 minutes on more than 5 days per week. Not only was this exercise not supervised but it was not monitored unlike in the intervention group.

    The CENIT trial focused on the effects of supervised HIIT on coronary plaque geometry in patients with stable CAD who had undergone percutaneous coronary intervention (PCI). Here’s what they found:

    1. Regression of Atheroma Volume: Patients who participated in 6 months of supervised HIIT experienced significant regression in atheroma volume compared to those following standard preventive guidelines. This means that the plaque buildup in their arteries was reduced, potentially lowering their risk of future coronary events.
    2. Improved Cardiorespiratory Fitness: The HIIT group exhibited a significant improvement in peak oxygen consumption (VO2peak), which measures cardiorespiratory fitness. By increasing VO2peak, HIIT enhances the overall health of the cardiovascular system.
    3. Positive Body Composition Changes: Patients in the HIIT group also experienced reductions in body mass index (BMI) and waist circumference. These improvements in body composition are important markers of metabolic health and can contribute to a reduced risk of CAD and related complications.

    The findings from the CENIT trial provide reasonable evidence for the effectiveness of HIIT in managing CAD and improving cardiovascular health. It is, however, difficult to tease out from the study whether it was the supervision of exercise, or wearing a monitor that someone else was tracking or the HIIT that had the greatest benefits. Based on these results, here are some key takeaways to consider:

    1. Consult An Experienced Personal Trainer: If you have established CAD or are at risk for heart disease, consult a very experienced personal trainer who is confident in managing patients who have stable heart disease. They can provide personalised recommendations based on your health status and previous exercise experience.
    2. Embrace High-Intensity Interval Training (HIIT): Consider incorporating supervised HIIT sessions into your exercise routine under professional supervision. HIIT involves short bursts of intense exercise alternated with active recovery periods, making it an efficient and time-effective workout option. But note, the intervention group did not just do HIIT, they also did low-intensity exercise. 
    3. Prioritise Exercise: HIIT’s positive impact on atheroma volume regression, improved cardiorespiratory fitness, and positive body composition changes highlight the importance of exercise as a core component of cardiac rehabilitation programs. When compared to another study looking at the effects of high-intensity statin on plaque lipid volume, high-intensity exercise combined with low-intensity exercise had an effect comparable effect to that of a high-intensity statin.
    4. Monitor Your Exercise: The intervention group wore a wearable and knew they were being monitored. Use a wearable and get an accountability partner to keep you on track. 

    The CENIT trial provides evidence that high-intensity interval training, supervised by a personal trainer and the wearing of a fitness tracker can effectively counteract disease progression and improve cardiovascular health in patients with established coronary artery disease. Participating in supervised HIIT sessions can lead to a reduction in atheroma volume, improved cardiorespiratory fitness, and positive body composition changes.

    DR J HUGH COYNE
    MBBS BSc PGDip (with merit) MRCGP DRCOG DCH

    Dr Hugh Coyne is a GP and co-founder of Coyne Medical, a private preventive health clinic at 660 Fulham Road, London. He trained at Imperial College London and has been in practice for over twenty years, with a particular focus on cardiovascular risk, metabolic health, and exercise medicine. After qualifying as a GP he went on to train in sport and exercise medicine, bringing a distinctly practical approach to prevention and long-term health.

    British Association of Sports and Exercise Medicine  ·  European Atherosclerosis Society  · 
    Independent Doctors Federation

    As seen in The Independent, The Daily Mail and Tatler

    Book a Health Screening

    For educational purposes. This article is written by a practising GP and is intended to inform, not replace a consultation with your own doctor. It does not constitute medical advice. A note on clinical guidelines: Coyne Medical is an independent private clinic. Our approach is guided by the best available evidence, tailored to each individual. This may go beyond standard NHS or NICE guidance, which is designed for population-level care and weighted by resource constraints.

    Read More Cardiovascular Health Guides
  • Don’t Neglect Your Blood Pressure: Safeguard Your Brain Health

    Don’t Neglect Your Blood Pressure: Safeguard Your Brain Health

    Life is busy. Many of my patients are so busy that they, to paraphrase Gustav Stresemann, are walking “on the edge of a volcano.” It just takes one small event to teeter over the brink. When life is this hectic, it can be easy to neglect something that isn’t causing you any symptoms. Blood pressure is just one of those things. They don’t call it the “silent killer” for nothing. High blood pressure stalks many of us from middle age without us knowing, waiting for an opportunity to push us over the edge. 

    Ignoring your blood pressure in early middle age can have a compound adverse effect on your cardiovascular health. It is a bit like having debt on a credit card that you never get around to paying off but keep spending on in order to accrue the Air Miles. 

    High blood pressure in middle age can have a particular impact on brain health in older age. Almost half of the burden of Alzheimer’s disease and related dementia is due to factors that are within our power to change. High blood pressure is one of the most common of these factors. 

    A recent study conducted by researchers at the University of California has shed more light on the connection between blood pressure and brain health. Their findings underscore the importance of monitoring and managing blood pressure, especially in early adulthood. 

    The study followed a diverse group of participants and found that individuals with hypertension (high blood pressure) or those who transitioned to hypertension in early adulthood had smaller brain volumes and poorer white matter integrity in late life. Interestingly, the negative impact of hypertension on brain volumes was more pronounced in men compared to women.

    Previous research has already indicated a link between hypertension and neurodegenerative conditions such as dementia. This recent study reinforces those findings and highlights the importance of considering hypertension earlier in life, even during early adulthood. Early adulthood hypertension and increases in blood pressure were associated with differences in brain volumes and white matter integrity, which are key indicators of cognitive decline and dementia.

    Notably, the study used updated guidelines for diagnosing hypertension, taking into account lower thresholds for diagnosis. This suggests that even individuals previously classified as having prehypertension or normal blood pressure could still be at risk for neurodegenerative changes associated with dementia.

    The study also uncovered some interesting sex differences. Hormonal factors appear to play a role in protecting women from the detrimental effects of hypertension on the brain, particularly before menopause. Men, on the other hand, seem to experience a stronger negative association between hypertension and brain volumes. The findings of this study emphasise the critical role of managing blood pressure throughout life, starting from early adulthood.

    It’s vital not to overlook the significance of blood pressure management. Just as neglecting credit card debt can result in mounting interest and financial distress, ignoring blood pressure can have a compounding effect on brain health. By regularly monitoring and managing blood pressure, particularly in middle age and early adulthood, you can take proactive steps to protect your brain health and reduce the risk of cognitive decline in later years. Consult with your doctor, make lifestyle changes, and adhere to any prescribed medications to keep your blood pressure in check. 

    DR J HUGH COYNE
    MBBS BSc PGDip (with merit) MRCGP DRCOG DCH

    Dr Hugh Coyne is a GP and co-founder of Coyne Medical, a private preventive health clinic at 660 Fulham Road, London. He trained at Imperial College London and has been in practice for over twenty years, with a particular focus on cardiovascular risk, metabolic health, and exercise medicine. After qualifying as a GP he went on to train in sport and exercise medicine, bringing a distinctly practical approach to prevention and long-term health.

    British Association of Sports and Exercise Medicine  ·  European Atherosclerosis Society  · 
    Independent Doctors Federation

    As seen in The Independent, The Daily Mail and Tatler

    Book a Health Screening

    For educational purposes. This article is written by a practising GP and is intended to inform, not replace a consultation with your own doctor. It does not constitute medical advice. A note on clinical guidelines: Coyne Medical is an independent private clinic. Our approach is guided by the best available evidence, tailored to each individual. This may go beyond standard NHS or NICE guidance, which is designed for population-level care and weighted by resource constraints.

    Read More Cardiovascular Health Guides
  • Trucheck™ vs. Galleri®: Comparing Advanced Blood Tests for Early Cancer Detection

    Trucheck™ vs. Galleri®: Comparing Advanced Blood Tests for Early Cancer Detection

    Introduction – The Future of Cancer Screening with Advanced Blood Tests

    Cancer screening has taken a significant leap forward with the introduction of advanced blood tests like Trucheck™ and Galleri®. These innovative screening methods aim to detect cancer at its earliest stages, providing vital information for timely interventions and improved outcomes. In this blog, we will compare Trucheck™ and Galleri®, exploring their scientific principles, advantages, and considerations, to help you make informed decisions about cancer screening.

    How Do Trucheck™ and Galleri® Blood Tests Work?

    Trucheck™ – Detecting Circulating Tumor Cells (CTCs)

    Trucheck™, developed by Datar Cancer Genetics, focuses on detecting circulating tumour cells (CTCs) and circulating ensembles of tumour-associated cells (C-ETACs) in peripheral blood samples. By employing primary negative enrichment, Trucheck™ enables the survival of malignant cells while allowing non-malignant cells to undergo apoptosis (programmed cell death). The subsequent analysis of tissue-specific markers on these cells helps identify cancer types and their likely organ of origin. Trucheck™ offers high sensitivity, specificity, and an overall advantage in detecting over 70 solid organ cancers.

    Galleri® – Analyzing Cell-Free DNA (cfDNA) for Cancer Detection

    Galleri®, another groundbreaking blood test, detects over 50 types of cancer and predicts the origin of cancer signals with high accuracy. This test examines the methylation patterns of cell-free DNA (cfDNA) found in the bloodstream. Methylation patterns, which regulate gene expression, can be altered in cancer, contributing to tumour growth. By leveraging next-generation sequencing (NGS) and machine-learning algorithms, Galleri® analyses the methylation patterns of cfDNA to identify cancer-specific abnormalities. These patterns provide valuable information about the presence and origin of potential cancers.

    Accuracy & Sensitivity of Each Test

    Trucheck™ demonstrates an overall sensitivity ranging from 82.5% to 88.2% for different cancer types. It boasts a specificity of 99%, correctly identifying 99 out of 100 individuals without cancer. False positives occur at an estimated rate of 1% to 3% according to the studies available so far. Trucheck™ has been designed as a complement to, not replacement for, standard cancer screening, offering peace of mind to individuals with negative results while prompting further tests or referrals for those with positive results.

    Galleri®, as demonstrated in the SYMPLIFY study, achieved a sensitivity of 66.3% overall, ranging from 24.2% for stage I cancers to 95.3% for stage IV cancers. This demonstrates Galleri’s ability to detect cancer signals across various stages but that it is most reliable with later-stage tumours. With a positive predictive value (PPV) of 75.5% and a negative predictive value (NPV) of 97.6%, Galleri®shows promise in accurately identifying individuals with cancer. The test’s specificity stands at 98.4%, further enhancing its precision in distinguishing cancer from non-cancer cases.

    Availability & Cost – Which Test is More Accessible?

    Trucheck™ is available as a standalone test or add-on service for patients undergoing health screening at Coyne Medical and several other private clinics in London and beyond. It may not be covered by healthcare insurance or the NHS prior to a formal cancer diagnosis. Further diagnostic procedures and referrals prompted by positive results may require self-payment.

    On the other hand, Galleri® is currently being evaluated in clinical trials and is not widely available outside of these trials. The SYMPLIFY study demonstrated its potential in a cohort of patients referred for diagnostic investigations related to suspected gynaecological, lung, and gastrointestinal cancers. It is not currently available in the UK in private care. It is only available through NHS research trials. 

    Considerations and Future Implications:

    Both Trucheck™ and Galleri® have the potential to revolutionise cancer screening, but it’s important to consider certain factors. Trucheck™ offers a broader range of tests for different cancer types, while Galleri’s focus lies in detecting over 50 cancer types. Trucheck™ uses CTCs and their clusters as biomarkers, primarily for solid organ malignancies, whereas Galleri® examines cfDNA methylation patterns.

    While Trucheck™ and Galleri® boast impressive sensitivity, it’s crucial to understand that false negatives can still occur. Neither test can replace standard screening methods such as mammograms, colon cancer screening, or cervical screening. Additionally, the emotional impact and potential for anxiety associated with both tests’ results should be taken into consideration.

    Looking ahead, the development of advanced blood tests like Trucheck™ and Galleri® brings us closer to a future where early cancer detection becomes a reality. These tests have the potential to complement existing screening methods, offering individuals a comprehensive and personalised approach to cancer prevention and treatment.

    Trucheck™ and Galleri® blood tests represent groundbreaking advancements in cancer screening, utilising cutting-edge technologies and scientific understanding to improve early detection rates. Trucheck™ focuses on CTCs, while Galleri® examines cfDNA methylation patterns. Both tests demonstrate considerable accuracy and hold promise for transforming cancer diagnosis and treatment.

    It is essential to consult with healthcare professionals to determine the most suitable screening approach based on individual risk factors, age, and personal medical history. By considering these innovative blood tests alongside standard screening methods, we move closer to a future where early cancer detection becomes the norm, leading to better outcomes and improved quality of life. Trucheck™ cancer screening blood test is available at Coyne Medical. Learn more on our website here.

    Book a Cancer Blood Test in London at Coyne Medical

    It is essential to consult with healthcare professionals to determine the most suitable screening approach based on individual risk factors, age, and personal medical history. By considering these innovative blood tests alongside standard screening methods, we move closer to a future where early cancer detection becomes the norm, leading to better outcomes and improved quality of life. Trucheck™ cancer screening blood test is available at Coyne Medical.

    BOOK MULTICANCER EARLY DETECTION BLOOD TEST

    DR J HUGH COYNE
    MBBS BSc PGDip (with merit) MRCGP DRCOG DCH

    Dr Hugh Coyne is a GP and co-founder of Coyne Medical, a private preventive health clinic at 660 Fulham Road, London. He trained at Imperial College London and has been in practice for over twenty years, with a particular focus on cardiovascular risk, metabolic health, and exercise medicine. After qualifying as a GP he went on to train in sport and exercise medicine, bringing a distinctly practical approach to prevention and long-term health.

    British Association of Sports and Exercise Medicine  ·  European Atherosclerosis Society  · 
    Independent Doctors Federation

    As seen in The Independent, The Daily Mail and Tatler

    Book a Health Screening

    For educational purposes. This article is written by a practising GP and is intended to inform, not replace a consultation with your own doctor. It does not constitute medical advice. A note on clinical guidelines: Coyne Medical is an independent private clinic. Our approach is guided by the best available evidence, tailored to each individual. This may go beyond standard NHS or NICE guidance, which is designed for population-level care and weighted by resource constraints.

    Read More Cancer Health Guides