Monthly Archives: April 2015

Waking up to Sleep: A GP’s view

GP Dr Bill Vennells of Devon Doctors went along to the Waking up to Sleep conference, hosted by the University of Exeter Medical School, to gain a bit of understating and add to his professional knowledge.

Image courtesy of Shutterstock.

Image courtesy of Shutterstock.

Here am I in semi-retirement back in Medical School. The last time I was in a lecture theatre was the late 1970s. Numerous courses over many years, a variety of training and conference centres, but this course means serious business.

I learned that Rapid Eye Movement sleep helps process short term memory and counters dementia. Presentations started from first principles so we understood clinical practice. The phases of sleep were elucidated and daily Circadian rhythm patterns were clearly demonstrated.

The twists and turns in presentation kept our attention. Professor Zeman interviewed his patient about her sleep problems; Dr Whitehead lay down with a pillow on the floor for a masterly performance of Obstructive Sleep Apnoea.

I was gratified to find that my Epworth score, a measure of sleepiness, was four. Quite alert then.

The treatments for sleep disorders all work in some patients. Xyrem, a more recently available stand-alone chemical compound is, however, more effective than others.

A frustrating fact of life in General Practice is the non-availability of proven effective treatments. We discovered that this is true of Cognitive Behavioural Therapy for insomnia, recommended by NICE. The human mind is awkward and paradoxical and will resist the will to sleep. A gentle effort to stay awake is apparently the best approach to insomnia.

Other relevant facts:

  • 12 seconds of apnoea is normal under two months of age.
  • SIDS is associated with carbon dioxide build up around the nose and mouth and a reduced gasp reflex. Sadness was tangible amongst the audience.
  • Baby sleeping with Mum is risky, beware of unplanned drowsing, and alcohol – I recalled a particular tragic case.
  • “Those who say they have slept like a baby have never had one.” A good aphorism from Rachel Howells before lunch.

Over lunch I interacted with a colleague from Devon Doctors, a semi- retired Psychiatrist, a GP who did more sessional work in the winter to have more free time in the summer, and a Dutch GP who told me that in Holland GPs work in Nursing Homes. I talked to a narcolepsy sufferer whose father knew Sigmund Freud.

After lunch I learned that Sleep Apnoea was associated with depression and reduced libido. Sleepiness has a greater effect on driving error than alcohol and the great majority of accidents involve young men.

The interactive case studies after lunch were another helpful twist, linking learning to experience.

The effectiveness of antidepressants is related to their effect on REM sleep and this can predict their effectiveness. Nightmares are associated with a fivefold increase in suicides.

The day kept my attention, and enabled a lot of material from multi-disciplinary sources to be presented. The timetable available to us beforehand clearly signposted the areas to be covered, the presentations had clear summaries including take-home messages. I went home rather tired but I had added to my pool of useful information and understanding.

Waking up to Sleep 2015

Professor Adam Zeman and Dr Tim Malone organised the recent Waking up to Sleep Conference at the University of Exeter Medical School. The event considered the science and medicine of sleep and its disorders, from sleep mechanisms to narcolepsy, insomnia and sleepwalking. Here Professor Zeman looks back over the conference…

Professor Zeman speaking at the Waking up to Sleep conference.

Professor Zeman speaking at the Waking up to Sleep conference.

‘Half our days we passe in the shadow of the earth and the brother of death exacteth one third part of our lives,’ wrote Sir Thomas Browne, On Dreams.

Yet despite the importance of sleep in our lives, the intrinsic interest of sleep disorders and the scope for effective treatments, sleep medicine remains an underdeveloped area in British Medicine. Medical students are seldom taught about sleep in any depth, sleep clinics are a rarity and patients often find themselves researching their sleep disorders outside the medical system.

Over the past couple of years we (Tim Malone and Adam Zeman) have organised a day of sleep education in Exeter as a joint initiative between the Royal Devon and Exeter Foundation Trust and the University of Exeter Medical School. The day has had two main aims – to provide a brief but reasonably comprehensive introduction to the biology of sleep and its disorders, and to bring together people providing sleep services or involved in sleep research in the peninsula.
Sleep disorders can be classified into three main groups, those involving:

  1. Too much sleep – excessive daytime sleepiness,
  2. Too little – insomnia, and;
  3. Odd behaviour during sleep – the ‘parasomnias’.

The meeting surveyed all three.

Tom Whitehead, a respiratory physician, gave a highly informative and entertaining talk on obstructive sleep apnoea (OSA), the most common – and wonderfully treatable cause – of pathological sleepiness in adults. Tom’s video demonstration turned out to consist of a very audible enactment of OSA on the lecture theatre floor.

Adam Zeman, a neurologist, spoke on the neurological causes of sleepiness, aided by a patient with narcolepsy who generously agreed to tell her story to the audience: narcolepsy is one of the most distinctive disorders in medicine with its excessive sleepiness, prolific dreaming and ‘cataplexy’, loss of muscle tone on emotional arousal, and especially during laughter. Like OSA it can usually be treated very effectively.

Zenobia Zaiwalla, a sleep physician in Oxford, spoke on the parasomnias, which range from the ‘slow wave sleep arousal disorders’, such as sleepwalking and night terrors to the dream enactment seen in REM Sleep Behaviour Disorder. These must be distinguished from behaviours due to nocturnal epilepsy. Zenobia showed some memorable illustrative videos, this time on screen. Exeter is fortunate to have a trained specialist in cognitive behaviour therapy for insomnia, Stephanie Romiszewski – CBTi is the evidence-based and NICE-recommended therapy for chronic insomnia: Stephanie has recently completed a successful pilot study of CBTi at the RD&E: we are hoping that this will become a regular service.

The structure of sleep changes radically through the lifetime, and so do its disorders. Rachel Howells, a paediatrician, outline the developing features of sleep during the first year of life, the pros and cons of rival strategies for dealing with a sleepless baby and current understanding of the tragedy of sudden infant death syndrome. At the other extreme of life, Joe Butchart, an old age physician and memory clinic consultant, discussed the importance of sleep in memory and the complex interactions between sleep and dementia: sleep disturbance is both exhausting to carers and detrimental to the precarious cognition of patients with dementia.

Finally, three talks addressed fascinating but sometimes forgotten aspects of sleep.

  • Russ O’Brien, an acute physician and clinical pharmacologist, reviewed the effects, both intended and unintended, of a range of drugs on sleep.
  • Hugh Selsick, a UCH-based psychiatrist with a special interest in sleep, spoke on the interactions between sleep and mood, highlighting the predictive value of REM sleep suppression in antidepressant treatment and the antidepressant effects of sleep deprivation per se.
  • Jim Horne, the doyen of British sleep research, from Loughborough and Leicester, gave our keynote talk on sleep and safety. He teased apart the various consequences of sleep deprivation – from sleepiness, which can be partially treated by caffeine, to less easily quantified and remedied but important effects on cognition, for example on decision-making. He emphasised that we generally know when we’re sleepy – and we owe it to ourselves and to others to take it seriously. The sleepy driver should pull in, drink a strong cup of coffee and nap for 20 minutes, by when the alerting effect of the coffee should combine with the refreshing effect of the nap to allow safe onward progress.

Our varied audience – including patients, nurses, OTs, speech therapists, psychologists, GPs, junior doctors and hospital consultants – appeared engaged and the talks, as well as a case presentation session, provoked good discussion.

We must now decide whether this meeting should be an annual or just an occasional event. Either way, we think Sir Thomas Browne would probably approve.

Check back tomorrow for a GPs view of the conference from Dr Bill Vennells of Devon Doctors.

 

Fact check: would abolishing non-dom status raise more tax?

What are ‘non-doms’ and what will the impact be for Britain if this status is abolished?

This blog takes a look at both sides of this political discussion to find out what the pros and cons might be for this reform.

This article was  written by Dr Sheikh Selim, Senior Lecturer at University of Westminster and Professor Lynne Oats, Professor of Taxation and Accounting at University of Exeter.

This post appeared on The Conversation.Conversation logo

 

There are now 116,000 non-doms. It is costing at least hundreds of millions of pounds to our country. And it cannot be justified. It makes Britain an offshore tax haven for a few.

Ed Miliband, Labour party leader in a speech at the University of Warwick

The Labour party wants to abolish the non-domiciled (non-dom) resident status for UK tax purpose. This includes removal of some or all of the tax advantages that non-doms enjoy, including the “remittance basis” which means they can avoid paying tax on income outside the UK.

People can claim non-dom status if they were born outside the UK, but now live here. The status, which has been around for 200 years, can also be inherited through the father. Ed Miliband, the leader of the Labour party, claimed that the reform would raise “hundreds of millions” for the UK. However, in January 2015 shadow chancellor Ed Balls contradicted the campaign by saying that scrapping the rule “would cost Britain money”. If the non-dom status is abolished using a cold-turkey approach, many non-doms may leave Britain, which could result in huge losses to the economy.

Miliband later explained that the Labour party proposes to scrap the rule giving non-doms a transition period of around two years to “get their affairs in order”.

Current non-dom tax policy

UK residents with non-dom status can currently choose whether to pay taxes in Britain on their overseas earnings. Although they are already taxed in full on their UK income and capital gains, they can opt to be taxed on the remittance basis, which allows them to pay an annual fee to avoid tax on their overseas earnings.

In particular, claiming the remittance basis implies that the non-dom loses tax-free allowance for income and capital gains in the UK, and pays an annual charge depending on how long they have been in the country. The fee is £30,000 if resident in the UK for at least seven of the previous nine years, £60,000 for 12 of the previous 14 years, or £90,000 for longer stays. Non-doms also enjoy favourable treatment of non-resident trusts.

According to the most recent available data from 2012-13 from HMRC, the Institute of Fiscal Studies, and law firm Pinset Masons, the HMRC raised £8.2 billion from the 114,800 people who claimed non-dom status in the UK, which amounts to 5 per cent of the total revenue from income tax collected by the HMRC.

Only 46,700 non-doms took advantage of the remittance basis and 5,100 of them are paying the fees. More of them are not paying the charges presumably because they have lived in the UK for less than seven years. Only 19 per cent of the total £226m total HMRC received in charges were paid by 3,700 non-doms who had lived in the UK for seven to 12 years. The remaining £183m was paid by 1,400 non-doms who had lived in the UK for more than 12 years.

According to figures released with the 2014 autumn statement, a recent increase to the fees from April 2015 will raise a further £90m a year from those who have lived in the UK for more than 12 years.

In the UK, the number of non-doms in 2013 was 6.7 per cent less than that in 2008, the year when the remittance basis and the charges were introduced. Between 2008 and 2013, the total revenue and the average revenue per person in taxes from non-doms increased by 39 per cent and 51.6 per cent, respectively. Following the introduction of the charge, in the past six years the UK has experienced a 1.7 per cent average decline in the number of non-doms per year, together with 8.8 per cent average growth in the total tax revenue from them, as the graph below shows.

Growth rates from non-doms, tax revenue from non-doms and average taxes paid by non-doms (2009-2013)
Author’s calculations using data from HMRC, IFS and Pinset Masons., Author provided

Abolishing non-dom status

There are some potential sources of additional revenue from Labour’s proposed reform. The 5,100 non-doms who had lived in the UK between seven and 12 years who pay the fees do so because it is less than the taxes on their unremitted income or capital gains would be if they were domiciled in the UK.

The majority of this group of non-doms have lived in the UK for a relatively short period and therefore may face a high cost of migration, because their “sunk cost” is high and they have not lived long enough to recover it. So the proposed reform, if implemented effectively, is likely to collect higher revenue than the total proceeds from the charges paid by this group – currently £43m.

The relatively more settled fee-paying non-doms – currently 27.5 per cent of the total – can leave the UK incurring very low cost – because they have already spent more than 12 years in the UK to recover their sunk costs. If the majority of the fee-paying non-doms – the ones who have lived less than 12 years – remain in the UK and pay taxes accordingly, it is likely to increase the total proceeds from this group.

However, this depends largely on HMRC’s set of information on the unremitted income and gains of non-doms in other countries, which is not available because currently the fee-paying non-doms do not have to disclose these. Similar uncertainty (due to lack of information) is associated with the removal of the tax advantages on non-resident trusts.

Verdict

Whether the proposed reform will generate “hundreds of millions of pounds” for the UK remains uncertain. Apart from the extreme response of leaving the UK, it is likely that the non-doms will pay accountants to avoid taxes. That will add to the existing costs of foregone revenue from and tax compliance of the non-doms, and therefore may result in loss of total revenue.

Other behavioural responses, such as transferring assets to family members abroad, spending more time abroad, or utilising the non-resident trusts more, may also add to this loss. The “higher end” non-doms, who can explore any other tax-haven and can buy a good life in any other location (such as the Middle East) can leave the UK at any stage of their residency. It is therefore very likely that following the reform, HMRC will not be able to raise the projected £90m every year from the charges.

The net revenue effect of this proposed reform remains uncertain, and the claims made by the Labour party are too premature, and to some extent, misleading. We need more details before assessing the credibility of the projection of revenue-gains from this reform.

Review

There is no question that this is extremely difficult to calculate with any precision for two reasons. First, a lack of relevant information about offshore assets owned by non-doms. It is such assets that give rise to the income and capital gains which are potentially to be brought into the UK tax net under the proposed changes. It’s also not known to what extent such income and gains will be sheltered by double tax relief for tax paid in the country of origin.

Second is the behavioural response of the non-doms, which will be mixed depending on the circumstances. Non-doms are not a homogeneous population and their motivation for remaining in the UK either physically or for tax purposes is not uniform, so their response to any change won’t be either.

To suggest, however, that being a non-dom who at present is claiming the remittance basis indicates a propensity to avoid tax (“will pay accountants to avoid taxes”) is not entirely appropriate.

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The birthday cake dilemma: Calorific energy dependence, from cellular to emotional and cultural need.

Dr Katarina Kos is a senior lecturer in the Medical School

Dr Katarina Kos is a senior lecturer in the Medical School

This blog was written by Dr Katarina Kos, a senior lecturer in The University of Exeter Medical School. Dr Kos’s work looks at adipose tissue physiology and obesity related disorders.

Dr Kos appeared on the BBC World Service programme The Forum to contribute to an episode on dependency, and discuss her work on diabetes and the way it is influenced, and complicated, by obesity.

In this blog post, she looks at what makes us eat the food we know will be bad for us.

The Forum will be broadcast on the BBC World Service between 4 – 7 April and you can download the episode on The Forum’s webpage.

You can find out more about The Forum on Twitter and Facebook.

Following an interview with the BBC World Service ‘The Forum’ programme, I was reminded of the burning issue of obesity and our relation with food. The theme of the programme was ‘dependency’, which I discussed in connection with my clinical work as a physician and my research into obesity and diabetes. Taking part made me think about communicating my work in a new light, and I wanted to share some of my thoughts about our bodies’ dependency on calories and how this relates to spiralling obesity.

To introduce myself, I am a fat endocrinologist. This not literally (I do everything possible to avoid being fat), but by the study of fat tissue. I work on increasing our understanding of the way fat/adipose tissue changes and responds to surplus calories, and how it contributes to ill health such as diabetes and heart disease. I also treat patients with weight problems who are preparing for weight-loss surgery, and patients with diabetes.

More than a quarter of adults in the UK are obese, as defined by a body mass index above 30kg/m2 if we are Caucasian or above 27.5kg/m2  if we are of Asian origin. Worryingly, this is predicted to rise to half the UK population by 2050.

The health risks of obesity are cardiovascular disease, cancer, stroke, dementia, diabetes, arthritis, and infertility. Whilst we are generally aware that surplus calories make us fat, what makes us eat them? And what specifically makes us overeat? This is a question I typically pose to patients at the beginning of my consultations, and the theme of dependency is prominent in their answers and my observations.

Physiological energy dependency  

We have to eat to survive. As we evolved through history, people with genes which predispose to obesity had a survival advantage by being able to survive famines. Scientists believe that this ‘thrifty gene’ make up is, in part, responsible for the increasing obesity epidemic becoming more noticeable in times of energy surplus.

The concept of “food addiction” is controversial, but if we accept this idea then we are faced with the difficulty that, unlike in any other addiction, we cannot avoid contact with the ‘substance of addiction’, we cannot stop eating and survive.

However, most people with severe obesity do not eat because they are hungry.

Emotional dependency to calories

Most people with severe obesity eat because they are stressed or feeling low, feeling lonely, or for comfort. Our brain reward and pleasure centres, such as the hippocampus and striatum, respond to calories by releasing ‘happy hormones’, particularly if we eat sugar.

Eating sugar helps to achieve short term gratification and is used as an emotional coping mechanism.

Eating sugar helps to achieve short term gratification and is used as an emotional coping mechanism.

This helps to achieve short term gratification and is used as an emotional coping mechanism. A very memorable comment from one of my patients was: ‘food is my friend and you want to take my friend away’. Thus, for many who look into weight loss, the first step should include identification of any emotional eating patterns and finding solutions in how to deal with the emotional needs such as stress and loneliness.

With food being so easily available and its acquisition hardly requiring any physical energy expenditure (from internet shopping to freezer and then microwave) the emotional fix with food or drink, including alcohol, can be detrimental to the waist line of many people. Disconcertingly, in our current time of austerity, which translates to many people as financial hardship, we observe an increased popularity of baking and comfort food. Given people’s sensitivity about their weight and the stigma of obesity with the embarrassment and shame it brings to the affected, we can easily imagine why some unfortunate people chose social isolation with food remaining one of their very few friends.

Cultural dependency on calories

Calories are an easily available and most popular treat. We bring food or drink along when we see friends and cannot party and celebrate without calories. Not serving food or drink to a guest is an insult to hospitality. In some countries obesity is not a social stigma, but is seen as sign of prosperity.

As we are all prone to conform to social norms to the amount we eat and what we should look like (and most adults are overweight or obese -more than 60% in the UK), a diversion from these social norms will make us subject to social pressure. With this in mind, when trying to lose weight it is not easy to stick to a diet plan and work on a healthy lifestyle with social norms and our friends threatening to boycott our best intentions.

Let’s consider the moral and ethical dilemma this brings: do you serve a chocolate cake to your overweight friend because he/she likes it? Do you still do it if you know your friend is trying to diet and lose weight or has diabetes, and what if it is a birthday? Do you gain satisfaction in seeing a lovely big smile on your friend’s face when indulging with the cake? Alternatively, are you prepared to risk a conflict, be a spoil sport and remind your friend about health issues of obesity such as diabetes, all because you care? (..and do your decisions depend on your own success/failure with calories?)

My research is into fat (adipose) tissue which is the culprit of obesity and obesity associated complications such as heart disease and diabetes. Energy surplus leads to deposition of superfluous energy in form of fat packed in cavities of fat cells within fat tissue. With overnutrition fat tissue becomes overworked and its storage capacity limited. It develops inflamed and scarred which makes the tissue rigid and further restricts fat cells expansion. As fat tissue is increasingly unable to deal with the demand and storage of surplus energy, fats are deposited instead within and around organs.

Examples are the fat deposition in the liver causing fatty liver disease, fat in and around the heart causing weakening of the heart muscle and surplus fat within the vascular walls of the arteries contributing to heart disease, stroke and dementia. Fat is also increasingly found in the skeletal muscle which is not specific to us humans as we may more or less consciously observe in the mottling in the muscle/meat of the breakfast bacon.

One of my biggest contributions in research is the characterisation of a specific factor called SPARC which contributes to the scarring of human fat tissue and the cross talk of fat hormones with the brain. I continue to study the role of the scarring of fat tissue in obesity and its role in obesity complications. Losing weight is tough, I believe the body tries to hang on to fat tissue as much as it can. It is part of my research to understand why, from the fat tissues perspective, this is so difficult.

More research is needed to help and identify how to keep us at least healthy as we gain weight if not help us to lose weight. However, there are no obesity charities and obesity research funding is difficult to find. Funding undernourishment is compassionate. With the WHO reporting that most of the world’s population lives in countries where overweight and obesity kills more people than underweight, why is obesity research funding so difficult to obtain?

You find more on my research on my staff profile.

In summary, we must eat to function and survive; we tend to use food as an emotional crutch. Serving food and eating helps us to conform to societal pressure and cultural expectations which allows us to be nice people and avoid conflict.

On a personal note, as I work in weight management my workplace is often devoid of cakes and chocolates. But when they do appear, despite the fact that I’m immersed in the latest research and know that I should avoid them, I can’t always resist. We are all just human.