Understanding Trump’s narcissism could be the key to deposing him | Kamran Ahmed

The debate around Donald Trump’s mental health and his fitness to continue as US president rages on. Most recently Prof Allen Frances, the psychiatrist who wrote the book (or at least the diagnostic criteria) on narcissistic personality disorder has penned a letter to the New York Times stating that although Trump is a “world-class narcissist” he does not have a mental illness as he suffers no personal distress or impairment from his condition, which is a prerequisite for the diagnosis.

In the other camp, an American psychologist who believes Trump is a “malignant narcissist” has started a petition to remove him from office and a group of mental health professionals including psychiatrists have stated that his instability makes him incapable of serving safely as president. In doing so, these psychiatrists have broken the much-cited Goldwater rule which prohibits American psychiatrists from commenting professionally on public figures without conducting a formal assessment, declaring it to be unethical to stay silent in the face of what they consider to be dangerous pathology.

The ethics of psychiatric diagnosis-from-afar are complex; psychiatrists have a duty to protect the public as well as the individual, which could be highly pertinent if the US president, a man with access to the nuclear codes, is making decisions in a state of mental ill health. On the other hand, psychiatry has a shameful history of being used to silence and oppress for political purpose and we run the risk of inadvertently stigmatising those who have a mental illness by association with a bigoted authoritarian like Trump. So we should indeed exercise caution.

Being a psychiatrist, I conduct psychiatric assessments daily and know how valuable they are. We perform a detailed clinical interview and record a specific set of observations known as a mental state examination. We familiarise ourselves with any available medical records and seek out other sources of information (speaking to relatives for example) to fill in the gaps. Collating the information gathered from this exercise and mining it for signs and symptoms of mental illness allows us to arrive at a diagnosis.

‘We have certainly had more than enough opportunity to observe Mr Trump, so are we in a position to offer a diagnosis?’ Photograph: Alamy

One might argue that although no formal psychiatric assessment has been conducted on the president, our subject has lived most of his life in the public eye and we have a wealth of information on him, especially since the election campaign. Observation over a period of time can in fact be one of the most informative methods of assessing for a mental illness. When a patient presents in distress and with an unclear diagnosis, admission to a psychiatric ward and close observation can often give the answer more convincingly than a formal assessment interview. We have certainly had more than enough opportunity to observe Trump, so are we in a position to offer a diagnosis?

Making a formal diagnosis without an assessment would be misguided, but in some situations, I imagine psychiatrists would be obliged to make their concerns about a politician’s mental health known. If a public official was displaying clear signs of a serious mental illness such as psychosis and had not received the necessary help, psychiatrists should notify the relevant authorities for the sake of the individual as well as the public, so an assessment can be conducted. However, that is not the situation we are in and irrespective of the ethics of their assertions, those who believe that Trump has a mental illness are wrong for the clinical reasons outlined by Frances.

Trump does have multiple narcissistic traits, he simply does not qualify for a diagnosis of the personality disorder

Trump does indeed have multiple narcissistic traits – the grandiose sense of self importance; the preoccupation with power, success and beauty; the need for admiration and the sense of entitlement – but without distress or impairment he simply does not qualify for a diagnosis of the personality disorder. Furthermore, the speculative diagnosis of malignant narcissism – said to include aspects of narcissism, sadism, psychopathy and aggression – is not recognised in either of the two major diagnostic manuals used by psychiatrists around the world, so should be disregarded. No “alternative diagnoses” allowed.

Although we should lay the possibility of Trump having a mental illness to rest and accept that efforts to depose him are better focused on other avenues such as peaceful protest, legal challenge and the hope of eventual impeachment, a psychiatric perspective may still be useful in helping us to make sense of his personality. A plethora of descriptions has been used already, but viewing him through the lens of his personality traits might help us to predict his behaviour and develop strategies to counter his actions.

Trump’s wealth has undoubtedly helped him to meet the expectations of his own grandiose self-image throughout his life, and the hate speech he has used to appeal to the disaffected American masses has been a key tool in helping him to attain his immense newly found power. These behaviours have allowed him to fulfil his narcissistic fantasies and in doing so, avoid distress and impairment. Shocking executive orders serve the purpose of his chief strategist Steve Bannon’s racist agenda, but they also keep him continuously in the news cycle and the subject of conversation. His behaviour will continue in this vein as narcissists need a constant stream of attention and admiration (“the narcissistic supply”).

‘The leaks are real, the news is fake’: key quotes from Trump’s press conference

Beneath narcissism festers a deep-seated sense of inadequacy; it is a defence mechanism designed to protect against the painful reality of a narcissist’s belief in their own inferiority. They possess a fragile ego vulnerable to any threat of revealing this imperfection and the associated humiliation, known as a “narcissistic injury”. That is why the suggestion that his inauguration was poorly attended was such a slight to Trump. That is why he shamelessly self-promotes while derogating his detractors with a vigour rarely seen in politics.

Perhaps Trump’s bigotry is also derived from his narcissism; since he must see himself as perfect to defend his fragile ego, he may also see his own characteristics (white, male, heterosexual, Christian) as superior. He is likely to do what he can to ensure those who share these characteristics remain superior by proliferating inequality and disadvantage for those who do not. In his mind, since the US has now become an extension of himself, he will act to enhance its position as the dominant power, irrespective of the cost to the rest of the world.

Declaring Trump mentally ill and calling for his removal may be erroneous and unethical, but we must not close the door on understanding his thinking and predicting his behaviour by shutting down the discourse around his personality.

Understanding Trump’s narcissism could be the key to deposing him | Kamran Ahmed

Samer Nashef: "Understanding the healthcare system is a matter of life or death"

So you’ve been told you need an operation. Can you be sure that you really should go under the knife? What is the risk of having surgery? Or the risk of not having it? Is the timing of the operation ideal for you? Is your hospital any good? Is your smart and smooth-talking surgeon with an excellent bedside manner competent?

More than 30 years have passed since I stood as a mere medical student before an audience of distinguished surgeons and delivered a talk in which I examined the success rates of their operations. I did not expect to be ostracised for daring to bring this into the open and I would never have anticipated this early skirmish with the medical establishment would lead to a lifelong dedication to the evaluation and improvement of surgical outcomes.

The subsequent two decades brought about a revolution in medical care in the UK. For the first time, the quality of care became measurable and, as a direct consequence, my own speciality of heart surgery made a quantum leap towards better and safer outcomes for patients.

Why write a book about it? Well, the public has a right to know what happens behind the operating room door. The “patient” is evolving into a “healthcare consumer”. There are reams of data available about the myriad medical and surgical treatments and the people who dish them out. My book provides you with the tools to interpret this information. Also, the study of medical risk is a young science that is constantly breaking new ground – and it is fascinating.

Not so long ago, even the most eminent doctors treated patients with absolutely no evidence that their treatments did any good. In fact, many treatments did a lot of harm. Nowadays, doctors practise evidence-based medicine, meaning that the effectiveness and safety of the treatment is backed by solid, scientific facts. The next step on the ladder towards even better medicine is how well these treatments are administered. This covers everything from performance of an operation through to the preoperative and postoperative care. It also includes the safety and quality mechanisms integrated into the structure and the governance of the hospital providing the treatment. This medical “breakthrough” is recent and has only just begun, in the last 20 years or so, to receive the attention it deserves.

Many things contribute to your surviving an operation. Discoveries in this field have been true eye-openers. Good technical surgery is very important, but surprisingly human factors, including holidays, recent events, communications and surgeons’ personalities, play a part. In fact, the only factor that seems to make not a scintilla of difference to whether you survive an operation is your choice of anaesthetist.

Data about surgical outcomes are now in the public domain in Britain. We are now beginning to have true transparency in healthcare and, in that regard, heart surgery leads the way. Transparency, although generally considered a good thing, also has unintended and nasty consequences that can cause patient harm. In The Naked Surgeon, I show the benefits of transparency, but also draw attention to the many pitfalls. In addition, I hope to give you insight into my world of heart surgery, one full of drama and humanity.

At one time or another we all have to make decisions about our health. Understanding the system, its mechanisms and thought processes, can help us make the right decisions about what can often be a matter of life or death. That’s why I wrote The Naked Surgeon.

Extract

What is amazing about heart surgery is not that it exists and works, but that it took so long to appear. After all, the heart is a pump, pure and simple. When something goes wrong with a pump, it is a plumbing problem, needing plumbing solutions. How else do you fix a blockage in a pipe, or a leaky valve? Yet, for more than 2,000 years, the heart was exclusively the domain of the physician, not the surgeon, and woe betide the surgeon who dared touch it. The taboo on operating on the heart was so strong that Theodor Billroth, one of the great founding fathers of modern surgery, stated in 1889 that “a surgeon who tries to suture a heart wound deserves to lose the esteem of his colleagues”.

More about The Naked Surgeon

Doctors are supposed to have a bedside manner: Nashef has the authorial counterpart, a knack of even making you care, for instance, about the mechanical properties of the suture material Prolene (this isn’t a mere technicality but a life-and-death matter about which Nashef cares deeply). – Peter Forbes

Buy the book

The Naked Surgeon by Samer Nashef is published by Scribe Publications at £8.99 . and is available from the Guardian Bookshop for £7.37.

Samer Nashef: "Understanding the healthcare system is a matter of life or death"

Understanding Vitamins in Foods and Supplements

Vitamins are, by definition, organic compounds which are required to be supplemented by the human body to maintain healthy functions. Vitamins can not be created by the body, and hence are required to be obtained via diet or supplementation. Less than adequate levels of vitamins in the body contribute to a variety of health problems, many of which can be prevented or treated by the reintroduction of required vitamins to the diet.

Supplementation of vitamins has been a subject debated for some time, some studies have found over the counter vitamins to be ineffective, being destroyed in the digestive system, or simply unable to be absorbed. The level of absorption from supplemented vitamins depends on upon the quality of the product, along with the method of extraction.

In contrast, some vitamins if supplemented to excess can cause additional health problems, for this reason, it is important to know the maximum daily dosage and never exceed this amount, the level of which excessive supplementation is shown to enter the range of potentially producing negative health problems is usually 300% of the required daily intake.

Fat soluble vitamins are generally more problematic than water soluble compounds, as the body regularly processes water within the body, filtering out excessive amounts of chemical compounds, fat-soluble compounds, however, remain within the bodies fat stores, causing potential problems over the long term if taken in excess, along with the inability for fast recovery from overdose symptoms.

In this article, we will run through each vitamin group, provide examples of their reliability in obtaining via cooking and via supplementation, along with the potential health problems from lack of each in the diet.

Vitamin A

Vitamin A is a fat soluble essential nutrient, the most common form of which is beta-carotene. The recommended daily intake of Vitamin A compounds is 900 micrograms (µg) per day. Lack of Vitamin A compounds in the body can result in the development of night blindness symptoms, thickening of the top two skin layers, dried out brittle hair, fingernail breaks and a decreased immune response to infection.

Excessive Vitamin A consumption to the point of reaching toxicity normally presents with early signs such as tiredness / drowsiness, pain in the abdomen, nausea, vomiting, irritability and a increases blood pressure within the brain.

When found in foods different cooking methods will alter the amount of vitamins present in each meal, regarding Vitamin A there is a 5% nutrient loss when food is frozen and 10% loss upon reheating. 50% loss occurs if the food has been dried, 25% when cooked or 35% if cooked then the liquid drained.

The best sources of Vitamin A come from Liver, milk, fish, soya milk, pumpkin, squash, spinach, carrots, leafy vegetables, oranges and yellow fruits.

Vitamin B1

Vitamin B1 is a water-soluble compound chemically named Thiamine, the recommended daily intake of Thiamine is 1.2 milligrams (mg) per day. Lack of thiamine intake is known to result in beriberi, a compounded disorder comprised of 3 separate disorders, of which the symptoms are weight loss, weakness and pain in limbs, emotional / psychiatric disturbances including amnesia and confusion, disturbance of the senses, irregular heart beat, difficulty in walking, loss of tendons, loss of muscles, involuntary eye movements, vomiting, loss of cardiac ability, a dangerous increase in jugular vein pressure, extreme shortness of breath and swelling in the lower legs.

In foods, it degrades 5% upon freezing and 40% upon reheating. When food is dried, it degrades by 30%, 55% when cooked and 70% when cooked and drained.

The best sources of Vitamin B1 come from Pork, Liver, Eggs, potatoes, vegetables, oatmeal and brown rice.

Vitamin B2

Vitamin B2 is a water-soluble compound chemically named Riboflavin, the recommended daily intake for Riboflavin is 1.3 milligrams (mg) per day. Lack of Riboflavin in the body is known to produce swelling of the mouth and lips including the tongue and throat, cracking and peeling of the lips, skin rashes resulting in oily and scaly skin around the bodies main orifices, eye problems such as itching, bloodshot, watery along with light sensitivity and anemia.

Lack of Riboflavin during pregnancy can produce birth defects in the heart and limbs.

In foods Vitamin B2 / Riboflavin does not degrade if frozen and upon reheating it degrades by 5%. When dried it degrades by 10%, 25% when cooked and 45% if cooked then drained.

The best sources of Vitamin B2 are dairy products, bananas, asparagus and green beans.

Vitamin B3

Vitamin B3 is a variety of water soluble compounds known as Niacin and Niacinamide, the recommended daily intake for Vitamin B3 compounds is 16 milligrams (mg) per day.

Lack of Vitamin B3 in the body begins to present symptoms such as fatigue, indigestion, ulcers, vomiting, depression and poor circulation throughout the body.

Prolonged deficiency is known to produce a condition known as Pellagra, the main symptoms of which are dermatitis, diarrhoea and dementia, however further symptoms also include a smoothing of and bright red appearance of the tongue, hair loss, swelling throughout the skin of the body, light sensitivity, aggression, insomnia, skin lesions, mental confusion, weakness, lack of coordination, enlarged and weak heart, paralysis of limbs and extremities and nerve damage.

In foods, Vitamin B3 / Niacin does not degrade if frozen and upon reheating it degrades by 5%. When dried it degrades by 10%, when cooked 40% and if cooked and drained 55%.

The best sources of Vitamin B3 are from Meat, Eggs, Fish, Mushrooms, Tree Nuts and most vegetables.

Vitamin B5

Vitamin B5 is a water-soluble compound known as Pantothenic acid, the recommended daily intake of Pantothenic acid is 5 milligrams (mg) per day.

A lack of pantothenic acid in the body is extremely rare, however when it occurs, is known to produce early symptoms such as insomnia, depression, fatigue, irritability, stomach pains, vomiting, burning sensations in the feet and upper respiratory tract infections.

The best sources of Vitamin B5 are from Broccoli, Meat, and Avocados.

Vitamin B6

Vitamin B6 is a variety of water soluble compounds known as Pyridoxine, Pyridoxamine, and Pyridoxal, the recommended daily intake for Vitamin B6 compounds is between 1.3 and 1.7 milligrams (mg) per day.

A lack of Vitamin B6 compounds in the body is known to cause nerve damage, anemia, depression, confusion, swollen tongue and scaling eczema on both edges of the lips.

In foods Vitamin B6 does not degrade when frozen however, degrades by 45% when reheated. When dried it degrades by 10%, 50% when cooked and 65% if cooked then drained.

The best sources of Vitamin B6 are from Meat, Tree Nuts, Bananas, and Vegetables.

Vitamin B7

Vitamin B7 is a water-soluble compound known as Biotin, the recommended daily intake of Biotin is 30 micrograms (µg) per day. Lack of Biotin in the body is extremely rare, however, is known to produce dermatitis, especially on the face and hair loss. At more advanced stages of deficiency, symptoms such as a lowering / lack of muscle tone, muscle cramps, seizures and a lack of coordination become present.

Vitamin B9

Vitamin B9 is a variety of water soluble compounds known as Folic Acid, and Folinic Acid, the recommended daily intake of Vitamin B9 compounds is 400 micrograms (µg) per day. Lack of Vitamin B9 / Folate is fairly common in society; most deficiencies present due to excessive alcohol intake or bowel problems.

Lack of Vitamin B9 compounds within the body can lead to poor growth especially in children, gingivitis and tongue inflammation, loss of appetite, irritability, forgetfulness, mental sluggishness, diarrhea and shortness of breath.

If a deficiency of Vitamin B9 exists during pregnancy, it can cause serious issues to the developing baby and produces a range of birth defects, including the inhibiting growth of the brain and spinal cord. This has been mostly prevented recently by the addition of folate to grain-based foods, especially in the USA.

Vitamin B9 / Folate within foods degrades by 5% when frozen and 30% upon reheating. 50% is lost if the food is dried, 70% when cooked or 75% if cooked then drained.

The best sources of Vitamin B9 are from Liver, Cereal, Bread, Pasta and Leafy Vegetables.

Vitamin B12

Vitamin B12 is a variety of water soluble compounds known as Cyanocobalamin, Hydroxocobalamin, and Methylcobalamin. The recommended daily intake of Vitamin B12 compounds is 2.4 micrograms (µg) per day.

Lack of Vitamin B12 compounds within the body is known in advanced stages to interfere with DNA production of red blood cells, the same way as found in Vitamin B9, and results in serious cases of anemia. Early symptoms of deficiency normally present with symptoms such as light headedness, tiredness, rapid heart rate, weight loss, sore tongue, bowel complaints and easily bruising / bleeding.

Vitamin B12 compounds do not degrade if frozen however 45% is lost upon reheating. There is no loss if food is dried, and when cooked it degrades by 45% or 50% if cooked then drained.

The best sources of Vitamin B12 come from Meat, Chicken, Fish, Milk, and Eggs.

Vitamin C

Vitamin C is a water-soluble compound known as Ascorbic acid, the recommended daily intake for Ascorbic Acid is 90 milligrams (mg) per day.

Lack of Vitamin C in the body is known to produce scurvy, which has early symptoms of weakness, tiredness, curling of the hair and sore arms / legs. More advanced cases of scurvy have symptoms such as the development of a low red blood cell count, gum disease and bleeding from the skin, progressive scurvy results in a decrease in wound healing, personality changes and eventually leads to death.

While cases of scurvy are extremely rare in the modern developed world, cases of scurvy do still present in the modern day, mostly in developing nations, among refugees who have little access to regular balanced meals, and in the developed world where poor diet has been a critical factor. Scurvy can be remedied by the reintroduction of vitamin C if treated early enough.

Vitamin C /  Ascorbic acid degrades by 30% if frozen and 50% upon reheating. If dried 80% is lost and upon cooking 50% is lost or 75% if cooked then drained.

The best sources of Vitamin C are Liver, Fruits, and Vegetables.

Vitamin D

Vitamin D is a variety of fat-soluble compounds named Cholecalciferol (Vitamin D3) and Ergocalciferol (Vitamin D2).The recommended daily intake of Vitamin D compounds is ten micrograms (µg) per day.

The majority of Vitamin D is synthesized due to sun exposure, leaving little requirement for food intake, however in people who regularly work indoors, or have poor access to direct outdoor sunlight for less than 30 minutes per day, food intake and supplementation will become more critical.

Lack of Vitamin D compounds in the body result in increased risk of developing multiple sclerosis, colon cancer, lowered immune response, development of autoimmune diseases, heart disease, diabetes and mental health problems.

Prolonged deficiency can result in a defective development of minerals and calcium within the bones, resulting in over time in fractures and deformities within the bones structure. Another associated disorder from lack of Vitamin D compounds is problems with regular bone metabolism, resulting in softening of the bones structure in general, symptoms include body pain over a wide area, muscle weakness, and fragile bones.

The best sources of Vitamin D in food come from Liver, Fish, Eggs, and Mushrooms. Exposure to sunlight for 15 to 30 minutes each day while avoiding sun burn is also extremely effective at boosting vitamin d levels naturally.

Vitamin E

Vitamin E is a variety of fat-soluble compounds known as Tocopherols and Tocotrienols, the recommended daily intake for Vitamin E compounds is 15 milligrams (mg) per day.

Lack of available Vitamin E compounds within the body, although extremely rare, develop symptoms such as loss of muscle mass, vision problems, abnormal eye movements, unsteady walking and muscle weakness.

The best sources of Vitamin E come from Fruits, Nuts, Vegetables and Seeds.

Vitamin K

Vitamin K is a combination of fat-soluble compounds known as phylloquinone and menaquinones, the recommended daily intake for Vitamin K compounds is 120 micrograms (µg) per day.

Lack of available Vitamin K compounds within the body can result in abnormal bleeding due to the inability of the blood to form a clot, symptoms of which include red or purple spots appearing on the body and bleeding under the skin (with an appearance similar to bruises).

Changes in Vitamin K intake can provoke extremely dangerous reactions if taking the (already very dangerous) blood thinning drug warfarin, significantly increasing the risk of blood clots and stroke.

The best sources of Vitamin K are found in Egg Yolk, Liver, and Leafy Green Vegetables.

Looking for reliable vitamin supplements? All Nutrimi products contain a high quality of vitamins, designed around a reliable extraction process for increased bio-availability.

Understanding Vitamins in Foods and Supplements

Understanding Weight Loss And Depression

It goes without saying that weight loss can be a difficult battle for just about anyone.

This is something that is definitely true when the health problem at hand is depression. Mental health is something that takes a toll on the mind as well as the entire body.

Can You Successfully Lose Weight With Depression?

The answer is yes, but it may prove to be a difficult task.

There are a lot of hurdles that need to be overcome on both mental and physical levels. If you are not in a decent state of mind, which is normal with depression, it may be that losing weight can seem nearly impossible.

Depression can lead to weight gain because a number of sufferers tend to be “emotional eaters“.

Being overweight and obesity are very serious issues when it comes to all different types of mental illness, since hunger is something that starts as a brain function.

There are far too many that die from this, usually from developing heart disease. So, this is something that needs to be cured.

Another major aspect of weight gain and those who suffer from depression will be the medications that they take. There are some medications that impact hunger, often making someone eat more.

Unfortunately, it can be the depression as well as the medication impacting your weight gain. If you happen to notice this is taking place with you, it is best that you see your physician right away.

Alcohol

Alcohol is sometimes the go to drink for many who are deeply troubled mentally. We already understand that drinking alcohol when depressed is bad idea because it can both exacerbate the issue and also will not fix the underlying causes.

However it is also well known that consuming alcohol is detrimental to your weight and overall physical health.

To someone with a sound state of mind, the occasional drink is not such a big problem, but when combined with mental health problems, alcohol can absolutely destroy your body.

How What You Eat Affects Your Mental State?

There has been lots of research that covers the connection between food and health, and the overwhelming consensus is that how we eat as well as what we eat, affects our mental state.

Essentially, some foods contribute directly to a poor mental state, which in turn can drive us into a depressive state which further leads to a “comfort eating” style of consumption…It is a cycle that is incredibly difficult to break, and one which makes weight loss particularly difficult.

So What Does This Have To Do With Depression & Weight Loss?

Even though weight loss can be possible when you are depressed, this is a road that is not easy.

Taking on a sensible diet and exercising in the right manner will be the best way to lose weight with a mental illness.

The problem may not be all about getting involved in a healthy diet and a good exercise plan, but more about having to have a healthy mind.

If your mind is not healthy, the chances of maintaining proper weight loss could go way down. People starting in on a weight loss plan and feeling like they have to overdo it or they could hit a setback could easily give up.

If you have a negative outlook on not only yourself but also your life, you can be unnecessarily hard on yourself. Coming out of this is a great chance that you could worsen your depression even further, or go on to develop an eating disorder.

Many researchers are having a tough time working to devise solid plans to help anyone with depression to lose weight.

Too many factors are involved and different forms of depression that have brought us to a wide gap in results.

Researchers agree that it is fully possible for those with depression to lose weight. They further agree that it can be a difficult process that involves ups and downs throughout a particular dieting plan.

Making slow, positive changes including the implementation of a healthy diet and exercise plan can help people to feel better about themselves and work on losing weight effectively.

There can be some forms of depression where breaking a habit could be extremely difficult unless there is something to remind the patient that they are making unhealthy choices.

They can try to bring along some sort of a reminder on a card to combat this issue.

Depression and weight loss can be difficult to tackle.

There are a lot of things to consider, but this is something that is achievable. If you happen to have depression and have to lose weight, you need to be sure that you consult with your doctor in order to formulate a plan that is safe and healthy that works for you.

Understanding Weight Loss And Depression

BMA: Theresa May lacks understanding about seriousness of NHS crisis

Theresa May is failing to understand the seriousness of the situation facing the NHS as winter approaches, the British Medical Association has said after it emerged the NHS would be promised no additional funding in the autumn statement.

May dashed any hopes of a cash boost in next month’s economic announcement when she met Simon Stevens, the chief executive of NHS England, senior NHS sources have told the Guardian. Instead she told him that the NHS should urgently focus on making efficiencies to fill the £22bn hole in its finances, and not publicly seek more than the “£10bn extra” that ministers insist they have already pledged to provide during this parliament.

Dr Anthea Mowat, the BMA representative body chair, said there was “a lack of understanding from the prime minister about just how serious the situation is”. She added: “Failure to invest now will result in a disaster in the future, both financially and in terms of patient health and care.”

The idea that the NHS funding crisis could be solved with further efficiency savings was a myth, she said. “The NHS is already the most efficient healthcare system in the world. These are not savings: they are year-on-year cuts that have driven almost every acute trust in England into deficit, led to a crisis in general practice and a community and social care system on the brink of collapse.”

In the lead-up to the EU referendum, the leave campaign claimed that a vote to exit the union would free up an additional £350m a week for the NHS. Prominent leave campaigners later admitted that the figure was not accurate, and are now facing calls to explain the ongoing funding crisis for the service.

May told Stevens the NHS could learn from the painful cuts to the Home Office and Ministry of Defence budgets that she and Philip Hammond, the chancellor, had overseen when they were in charge of those departments respectively, according to senior figures in the NHS who were given an account of the discussion.

Senior Whitehall sources have confirmed that Hammond’s statement on 23 November will contain no new money for the NHS, despite increasingly vocal pleas from key NHS organisations and the public’s expectation of extra health spending when Britain voted to leave the EU.

NHS Providers, which represents 238 NHS trusts, last week accused ministers of perpetuating “a bit of a fantasy world” on how well the NHS is doing after the worst ever performance figures for key waiting time targets for A&E care, planned hospital operations and cancer treatments led to warnings that it was starting to buckle under the strain of unprecedented demand.

May with Philip Hammond. Photograph: Carl Court/PA

Health experts said the NHS would have to ration treatment, shut hospital units and cut staff if it gets no extra money soon.

Nigel Edwards, the chief executive of the Nuffield Trust thinktank, said: “If the government has firmly decided not to revisit NHS funding, this underlines that the health service faces four very difficult years. In particular, balancing the books in 2018 and 2019 when funding will flatline looks all but impossible with the current level of services. If more money from tax or borrowing is ruled out, the only choices left may be even less attractive, including reducing access and services, closures and reductions in staff.”

Jeremy Hunt, the health secretary, and Jim Mackey, the chief executive of the health service’s financial regulator, NHS Improvement, also attended the 8 September meeting, which was Stevens’s and Mackey’s first encounter with the prime minister.

“No 10’s message at the meeting was quite blunt and stark: that there will be no more money. Theresa May and Philip Hammond say that they presided over big efficiency programmes at the Home Office and MoD and didn’t whinge about it. Their view is that the NHS is already doing very well, but that’s head-in-the-sand stuff,” said one NHS insider who was among those briefed on the meeting.

A Downing Street spokesman said he could not comment on what May, Stevens and Mackey had discussed because it had been a private meeting.

NHS leaders privately fear May’s remarks indicate she will be much tougher on the service’s pleas for more cash than David Cameron and that she does not appear to appreciate the extent of its deepening problems. She is said to be sympathetic to the view of many senior Treasury officials that, as one NHS source put it, “always giving the NHS more money is throwing good money after bad, like pouring water on to sand”.

A Vote Leave battle bus is rebranded outside the Houses of Parliament by Greenpeace. Photograph: Jack Taylor/Getty Images

May’s stance raises questions over the future of Stevens, who is preparing to give evidence on the NHS’s finances to the Commons health select committee on Tuesday. The NHS boss, who had a close relationship with Cameron and George Osborne, recently irritated No 10 by publicly questioning the accuracy of the government’s claim – which May repeated at prime minister’s questions on Wednesday – that the NHS would receive £10bn extra by 2020.

He told the public accounts committee last month: “The government would record it as £10bn. The health committee recorded it a little differently. There is an apples and pears issue there.”

Stevens has welcomed the fact that the £8bn boost Osborne pledged during last year’s general election campaign was frontloaded to give the NHS £3.8bn more this year, a rise of 1.7%, as he had requested. But he highlighted that the service had not got the sums it needed for 2017-18, 2018-19 and 2019-20. On current plans, it is due to receive increases of just 0.6%, 0.2% and 0.1% respectively, even though demand for core NHS services such as A&E care is rising at 3% or 4% a year.

Chris Ham, the chief executive of the King’s Fund thinktank, said any policy of providing no more money was unwise, “simply not credible” and would threaten standards of NHS care. “If these accounts are true, then it is clear that Downing Street does not yet fully understand the impact on patients of the huge pressures facing the NHS.

“The view from the top of government appears to be that the NHS has been given the extra money it asked for and should deliver what is expected of it. But this misses the point that demand for services is rising rapidly and the NHS is managing with the lowest funding increases in its history,” he said.

BMA: Theresa May lacks understanding about seriousness of NHS crisis

Caloric Restriction: Understanding the Genetic Basis and How Alpha Lipoic Acid Fits the Picture.

Research on caloric restriction (CR) covers a span of 80 years and study results have fluctuated between negative, to sometimes positive, to consistently positive under the right conditions, and presently to positive but of little value beyond a normal caloric intake. Recent research, in addition to confirming the value of CR on health-span and possibly longevity, has identified the genetic pathways that are activated in CR, and opened the door to interventions such as alpha lipoic acid that might mimic the positive effects of CR, without the difficulty of adhering to a low calorie diet. The most recent research on CR has highlighted the importance of the macronutrient ratio in achieving positive health effects, particularly the ratio of protein to carbohydrate.

EARLY CR STUDIES:

The first study on CR was conducted in 1935, but was based on societal problems with malnutrition, and had nothing to do with possible beneficial effects on health and aging. To the contrary, the study demonstrated retarded growth during development, poor health and a shorter lifespan. Some years later, a study was performed in rats by McKay et. al., that only restricted calories, but still provided the vitamins, minerals and micronutrients required to maintain health. Like the earlier study, developmental growth was retarded, but the animals experienced a considerably longer lifespan. During this time period, researchers concluded that the beneficial effects of CR are the result of delayed developmental growth. This conclusion was a clue to the mechanism behind the health benefits of CR, but was later proven incorrect.

Studies in the 1950’s and 1960’s demonstrated that intermittent fasting was as effective as chronic CR, providing a more user-friendly way to achieve the health benefits of CR. Considerable research, with varying results continued for several decades, but the real breakthrough came in 1996 in research that was performed on simple animal models (worms and flies) that elucidated the molecular pathways involved in CR.

CR METABOLIC PATHWAYS:

It comes as no surprise that humans have a gene-based survival system to prolong survival during periods of prolonged famine, and that this system serves as a sensor for nutrient and energy levels, and a regulator of biomass formation. What is surprising is the fact that regulation of this system can have long-term beneficial effects on health and possibly on lifespan. The discovery of this system had it’s origins in an antifungal/immunosuppressant substance that was isolated from a soil sample from the Easter Islands (Rapa Nui). It was named Rapamycin in reference to the place it was discovered. Work on microorganism resistance to Rapamycin led to the later discovery in yeast that Rapamycin inhibits a gene that produces a serine/threonine protein called mTOR (mammalian target of rapamycin), and that like CR, Rapamycin extended lifespan.

The key regulator in this metabolic pathway is a complex of mTOR and co-factors that is identified as mTORC1. mTORC1 is a signaling hub that integrates nutrient and energy signaling with growth factor signaling. Generally mTORC1 stimulates protein synthesis and anabolic growth and inhibits autophagy. Conversely, CR and Rapamycin inhibit mTORC1 which reduces protein formation, and ATP formation, and increases autophagy.

mTORC1 is a complex system that stimulates numerous downstream processes including messenger RNA translation and the transcription factor C/EBPbeta-LIP. LIP is a protein that binds to DNA metabolic regulating sites. The LIP protein can be suppressed by removing an upstream regulatory element (uORF), which produces an effect equivalent to CR or Rapamycin. As is usually the case in this type of situation, developing a drug that inhibits uORF or another critical step in the mTORC1 pathway could theoretically lead to a drug to extend health-span and lifespan.

PHARMACOLOGIC INTERVENTION IN mTORC1 PATHWAY:

The scientific community and the media are conditioned to judge the value of a research finding by the possibility of developing a drug to achieve a therapeutic objective. History, while uniformly disregarded, has shown that drugs designed to block physiological processes rarely act on only the process being targeted. The result is an effective drug, with serious side effects that emerge during clinical trials or after the drug is marketed. To my amazement, society is becoming more accepting of these serious side effects as reflected in the marketing of most biologics. I believe that Rapamycin fits this description as a drug to combat aging. Rapamycin clearly inhibits mTORC1, but has many serious side effects that make it unsuitable for widespread chronic use. This hasn’t stopped the media from touting Rapamycin as the Fountain of Youth drug, and I sense that drug companies will eventually promote the drug for this use and attempt to justify the side effects as reasonable vs. the benefits.

There are many naturally-occurring substances that have epigenetic effects similar to the actions of more powerful drugs, and generally without the serious side effects. One such substance is the widely researched and less widely used alpha lipoic acid. In addition to its favorable effects on oxidative stress and diabetic neuropathy, more recent research has recognized the multi-functional properties of alpha lipoic acid, with particular emphasis on the stimulation of AMPk and the corresponding inhibition of mTORC1 activity. As described in the research reports referenced below, alpha lipoic acid, along with other energy restriction mimetics (resveratrol, rapamycin, metformin and spermidine) stimulates formation of kinase activated AMP, that in turn signals that the cell is in an energy restricted state, and mTORC1 is inhibited. The paper by Nikolai et.al. states that these CR mimetics can have serious side effects and have not been proven safe for long-term use. Contrary to this position it should be noted that alpha lipoic acid has been studied extensively for several decades and has been cited in almost 5000 scientific papers, the vast majority of which report beneficial effects. It is true that alpha lipoic acid has not been subjected to extensive controlled, double-blind studies in humans, but it is commonly used by many health conscious consumers, with no reports of adverse events. Because alpha lipoic acid is a naturally occurring substance that cannot be patented, it is unlikely that funding will be made available for controlled clinical studies or education of the public regarding its many benefits.

PROTEIN: The FINAL NAIL in the CR COFFIN:

Research on CR has focused attention on all of the factors in the design of studies that have had unexpected outcomes. One of these factors was the macronutrient composition used in the study, with particular attention to the ratio of protein to carbohydrate. Using a research tool designated the Geometric Framework nutritional modeling method, researchers Raubenheimer and Simpson (Sydney, Australia), found that diets that were low in protein and high in carbohydrates produced a health-span comparable to CR. A low protein diet was defined as <5% calories from protein, a moderate protein diet as 10% – 20%, and a high protein diet as >20%. Disease and mortality was surprisingly high for the high protein diet, but ameliorated by substituting plant protein for animal protein. This effect was observed in persons under age 65, but the reverse was true for people over age 65, who had higher disease and mortality with a low protein diet and better health and longevity with a high protein diet. The mechanism behind the negative effects of a high protein diet appear to be related to stimulation of the mTORC1 pathway by nutrient sensing of the high availability of amino acids in the cells. It isn’t clear why this protein effect reverses at age 65, but presumably has to do with the accelerated loss of muscle mass with aging, which would be exacerbated with inhibition of the mTORC1 pathway.

CONCLUSION:

It is well-established that under the right conditions, CR is an effective way to lose body mass, extend health-span and possibly extend lifespan. Research studies on CR have contributed to the discovery and understanding of the mTORC1 pathway, which is the major regulator of metabolic activity in humans. While CR is beneficial in itself in reducing chronic disease, it is a difficult regimen to follow and certainly not in sync with modern lifestyles. CR research has led to the discovery that equivalent beneficial effects can be realized with a normal diet, provided that the ratio of protein and carbohydrate are optimized for age. Elucidation of the mTORC1 pathway has also opened the door to user-friendly means of inhibiting the mTORC1 pathway through design of drugs that block or inhibit steps in the regulatory process, or preferentially the application of naturally-occurring molecules such as alpha lipoic acid that stimulate formation of AMPk and down-regulation of mTORC1.

REFERENCES:

1. The ratio of macro-nutrients, not caloric intake, dictates cardiometabolic health, aging, and longevity in ad libitum fed mice.  Solon-Biet, SM  et. al., Cell Metab. 2014 Mar 4: 19 (3); 418-430.


2. Alpha-Lipoic Acid Supplementation Reduces mTORC1 Signaling in Skeletal Muscle from High Fat Fed, Obese Zucker Rats.  Zhuyun Li, Cory M. Dungan, Bradley Carrier, Todd C. Rideout, David L. Williamson.  Lipids. Dec 2014, Volume 49, Issue 12, pp 1193-1201.


3. Energy restriction and potential energy restriction mimetics.  Nikolai, S et. al., Nutr Res Rev. 2015 Dec;28(2):100-120. Epub 2015 Sep 22.

Caloric Restriction: Understanding the Genetic Basis and How Alpha Lipoic Acid Fits the Picture.