Yonder: Gluten-free diets, STEMI, physical activity, & place of death

Yonder: a diverse selection of primary care relevant research stories from beyond the mainstream biomedical literature

Gluten-free diets. It was once extremely difficult to find gluten-free packaged foods and those that existed were far from appealing or glamorous. How times have changed. Gluten-free diets have become immensely fashionable in recent years and have found their way into mainstream popular culture, with many healthy individuals opting to implement it for a wide range of symptoms, largely without medical supervision. Celebrity endorsement has been influential and gluten-free food production has become a huge market internationally. In Social Science and Medicine, an American anthropologist reported on an exploratory study involving 31 gluten-free dieters, of whom only six had coeliac disease.¹ When participants eliminated gluten because of one health concern, they often experienced other changes to their wellbeing that they then attributed to the diet. Some participants considered the success of the diet to represent the failure of their doctor as a diagnostician, which led them to question the doctor’s authority. Finally, participants valued opportunities to share their experiences, often tenaciously diagnosing others and promoting the diet widely, particularly among friends and family.

STEMI. Acute coronary events are now classified into distinct subcategories, which have unique treatments. Patients with ST segment elevation on ECG are classified as STEMI and are admitted immediately to the catheter laboratory for percutaneous coronary intervention. Those with inconclusive changes on ECG, meanwhile, often do not have a diagnosis straight away. They are classified as NSTEMI and can be given non-urgent angioplasty, if deemed appropriate. In a study in the European Journal of Cardiovascular Nursing, researchers from Northern Ireland sought to understand how these different treatment experiences impacted on patients’ subsequent behaviours.² They interviewed patients within 4 weeks of discharge and found that while STEMI patients viewed their illness as a serious, life-threatening event, NSTEMI patients were more confused. Some interpreted the lack of treatment urgency or need for stents as meaning they had a ‘mild’ event. Worryingly, this meant that NSTEMI patients had less motivation to adopt and maintain healthy behaviours.

Physical activity. America’s obesity crisis is well documented and has sharpened the focus on lifestyle behaviours such as physical activity. A study presented in the Journal of Primary Prevention explored whether the activity levels and BMI of US physicians influenced their ability to counsel patients about physical activity.³ The findings of 1751 online surveys demonstrate that meeting national guidelines for moderate and vigorous activity is a strong predictor of a physician’s confidence in physical activity counselling. This reinforces the significant literature suggesting that active doctors are more likely to promote exercise. However, they also found that physicians who were overweight or obese were less confident than those with normal BMI, even if they met activity guidelines. The authors suggest, perhaps rather optimistically, that all physicians should ‘aim for a normal BMI in order to improve the likelihood that they can confidently counsel their patients about physical activity.’

Place of death. In recent decades, the advantages of dying at home have been widely discussed in care policies and it is generally considered an important aspect of a ‘good death’. Despite improved end-of-life care planning across the developed world, the often uncomfortable and hostile environments of acute hospitals are still the place of death for many patients. In a Belgian qualitative study published in Health Place, family members and primary care clinicians were asked for their views about the acute hospital as a place for terminal care.⁴ While many considered the environment inadequate for end-of-life care in principle, in certain situations it was considered a ‘safe haven’ for patients and families. In particular, some patients saw it as a means to escape the fear of dying or as a setting with perceived better or more continuous support. The study urges policymakers to increase the supply of hospice beds, which the authors describe as a ‘hospital-replacing alternative’.

• © British Journal of General Practice 2014