Robin Daly: Hello, welcome to the Yes to Life show here on the UK Health Radio. I am Robin Daly, host of the show and also the founder of the UK charity Yes to Life that supports people with cancer in accessing integrated medicine to help their recovery and quality of life. Over the 15 years that Yes to Life has been operating, I have witnessed the gradual opening up of healthcare to the concept of what is now called Lifestyle Medicine, changes in nutrition, exercise, sleep, stress, and more, that can profoundly affect people’s wellbeing and this in my opinion is every bit as worthy of attention as, say, drugs or surgical interventions as an aspect of health care. It has been a slow, but tangible change and one visible manifestation of this change is the arrival of BMJ nutrition, a journal under the banner of the British medical journal, specifically aimed at doctors and other healthcare workers. It is not absolutely new, but it is new to me. So having heard about it, I immediately wanted to find out more. I was lucky enough to get the opportunity to talk to its editor, Dr. Martin, Kohlmeier on the east coast of America

Hi Martin, thanks very much for coming on the show today.

Prof Martin Kohlmeier: Excellent I love to be with you.

Robin Daly: I have got to admit, up until a couple of weeks ago, I simply was not aware that BMJ nutrition actually existed. My excuse for my ignorance is that I am not any sort of doctor or practitioner, but this is a really exciting development for the UK.
When was the first edition, and how long was it in the making?

Prof Martin Kohlmeier: We are coming close to our second anniversary and there was a long felt need for a nutrition component for British Medical Journal and there has been a search I would say about a couple of years in development. I think given the short time we are up and running, we have covered a good number of very interesting topics and the journal keeps growing. I think we are really able to make a difference, obviously a lot of people are concerned about COVID 19 right now, we have a whole wide range of topics that we are addressing, health but also lifestyle, hospital-based treatment, other risks, all the way to architectural consideration of health etc. So we are really having a fairly broad remit and it is lots of fun. It is very interesting. In the end we want to be healthy, we want to be fully functional, we want to be happy, and we have to take a lot of different things into account. If somebody does not eat well and does not have good night’s sleep, then that is important. If somebody is making risky food choices, that is important. So there are a lot of issues.

Robin Daly: I imagine there are a lot that you can cover and of course it is always exciting setting up something new, a new venture and building a new audience. So a few basics before we get stuck in for content about the journal itself. Who can subscribe? How many additions a year do the subscribers pay to get it? What was the setup?

Prof Martin Kohlmeier: So we are part of the BMJ, which stands for British Medical Journal family.

It is an open journal which means it is free for all to look at and we are following the open format, we do not have rigid volumes or anything. So we are publishing continuously, we are currently building additional channels, social media, we have twitter accounts, we are currently building a blog. So we really want to be available through multiple channels.

What is very important, which is unusual about this journal of course, there are a good number of other nutrition journals that have their very good reputation, very good history. We are making this really directed for physicians and other healthcare providers in practice. So we really want to address those issues that really concern everyday people, because for some reason this does not get covered as fully as we would like to. So yes, we do have heavy science and some of our submissions, but we also really want to cover very practical issues of what should I do.

So the journal is kind of helping physicians to take care of their patients and that is a little bit of what sets us apart from similar journals.

Robin Daly: Interesting and do you have a subscriber base then with the model that you areoperating?

Prof Martin Kohlmeier: Well, we do not because we do not need to, we have very good reach. It will be different by individual submission and manuscript; we do have some of our manuscript that draws a lot of interest.

We have had the most recent publications, the best ones have been in the tens of thousands of readers. So we really get pretty good uptake and these are numbers of people that actually look at a particular manuscript, not just look at the table of content, but really actually engage. So that is very satisfying.

Robin Daly: So you can tell that they have opened it properly. What have been the most popular topics? Which ones have been in the tens of thousands?

Prof Martin Kohlmeier: Well, it is diverse. Previously there was one on the effect of nut consumption and weight loss, a very science-based, very high level population study. We had one recently addressing the potential for doing something about hangovers.

In the end, it came out that particularly getting enough fluid is important, and of course currently there is a lot of interest in COVID-19. We had very good coverage both in terms of the kind of nutrients that people may fall short of. This is because people want to do the right thing, what has put them at risk, what can they do particularly in preparation.

We have a case report coming up, on the history of a relatively young man who contracted the virus and was in hospital for two months. He was very seriously sick and required long-term ventilation, so we question how to deal with that kind of mind boggling challenges.

This is a little bit more focused on practicing doctors, and what they can expect during and after such a severe, serious illness. We have a very good run through about the mechanisms that maintain optimal immunity with good nutrition, how exactly it works which is very important. We have also included one of my own, on vitamin D, which I consider very important for both probably the prevention and mitigation of COVID 19 not with high dose supplements or anything , just with making sure that is no deficiency.

So we are really promoting good nutrition that is very solid and everyone can get on board with, which is very effective and is so neglected unfortunately. The current vitamin D issue is only a little tip of many icebergs floating around in this health ocean.

Robin Daly: They are deficiencies you are describing there?

Prof Martin Kohlmeier: They are for example where people just do not get enough. It is not necessarily the classical deficiency where people literally fall apart, but it makes a big difference if you do not get enough of something that you really need. And it comes through for instance with your immune system not being fully tuned and fully effective, and again this is not about high dose supplements or anything like that.

We promote food-based solutions whatever it takes. We are looking for the evidence base and good signs, and we want to really get this information from the authors who have been doing the research to the practitioners who have to apply it.

Robin Daly: Fantastic, a little kind of side story I noticed while I was on your website, another publication also that I was previously unaware of, the BMJ Open Sport and Exercise medicine. It is clearly associated with the BMJ nutrition I presume.

Prof Martin Kohlmeier: It is a large family.

Robin Daly: They both come under lifestyle medicine and the two together will cover an awful lot of really what lifestyle medicine consists of.

Prof Martin Kohlmeier: I mean I can speak only for our journal I think there is so much potential. The whole range, I mentioned sleep, I mentioned nutrition, but we also talking about of course exercise. We are talking about weight management, it is the whole argument we had recently, it was a few months ago, a really interesting investigation on how if the architecture where you live, and if the community that you spend your time in is greener, are you are less likely to have fast cognitive decline then when you have a more barren environment. It is really interesting and really a little bit far field at variant point.

Robin Daly: That came under the BMJ nutrition did it?

Prof Martin Kohlmeier: Yes, well the full title is BMJ Nutrition Prevention and Health. That is why we really want to cover it because very often you have these synergistic effects where you have a license, healthy lifestyle that brings it all together.

Robin Daly: I am so glad you gave me the full title label, it would be stretching it a bit in some people’s mind to include architecture in nutrition would it not

Prof Martin Kohlmeier: Well, that is why I found it so important maybe we want to grow some greens that we consume.

There are certainly models there; what they are proposing this is on a much broader scale where there is not speculation but actual data which is following a large community. So this is really what we want to have, it is not somebody wins or a gut feeling, but we really want to have the solid science of what do we know. What can we really give healthcare providers to talk to their patients and be efficient about it. This is fairly broad because people live one life that includes everything.

Robin Daly: I can believe the basis of that research that the greenery and people’s lives will have an effect on their health in some way. But has the research come to some conclusions about the effect on their cognitive ability?

Prof Martin Kohlmeier: In this particular investigation, they did find good evidence that the greener environment is healthier. It is not really hard to see that, but when we are talking about cognitive decline, we also have some very strict, straight and solid nutrition links where we want to do right, which is mostly long-term. It has a lot to do with cardiovascular health, which is not surprising because of course our brain vessels need to be clean to really function optimally. So everything that is good for heart health also helps with cognitive function, and then there are a number of other very interesting nutritional issues including Omega three, fatty acids, avoidance of inflammation which may come from excessive Omega six fatty acids with oils, industrial oils, particularly at dressings, mayonnaise, things like that, fast food. So it really comes together with very strong nutrition components. Such as weight balance, excessive sodium intake, a number of other nutritional components these things are continually evolving. There is exciting new research coming in, and we want to be able to keep particularly doctors, but also others who are interested current.

Robin Daly: Brilliant so with the move that is happening really from the conventional approach of kind of specialisation and separation between disciplines is kind of moving towards a more systems oriented view of the health can you see a day when the two journals that you have got there would become one, the lifestyle medicine journal.

Prof Martin Kohlmeier: I do not think so, it is strength in multitude. So their ability, which is something that I am very excited about, comes from different angles to tackle similar problems. So I think when you start a journal today, the driving forces, the cost factors etc, are quite different from even 10 years ago. Because basically the computer power costs nothing, and so we can and do things so much more efficiently, do too much better software. We get so much software support from the BMJ mothership, and there is so much expertise that we can draw on. So it really becomes more an issue, but particularly when you do not print these things, so, you know, you don’t kill a lot of trees. It really becomes a matter of eyeballs.

I think that is a challenge for health professionals, but it is also for others who are interested in that. So what we are really interested in is building and strengthening a reputation for the being that go to a place for reliable evidence, support, and information in terms of nutrition and prevention and health.

We are working on building a relationship where we become information provider keep healthcare providers up to date on the issue of the day, where they can easily draw on our archives on our issues and when they have a question or just being drawn in for interest. So it is a different relationship than subscribing to a bound journal, which is really largely going away. There are some libraries, et cetera that still may have some printed copies now to have other journals. But, we are really moving to a very, a virtual presentation it is there if you want to and if you lose interest we never existed.

Robin Daly: It makes complete sense moving with the times, but of course, the thing that is unique in terms of what you are doing there is the fact that for a mainstream medicine if we look at the UK, the BMJ of course, is what you would call a trusted source already. So to have the BMJ nutrition is actually embracing nutrition and coming from a source that they already rely on.

So there has not been that much focus on nutrition and lifestyle in mainstream medicine. So this is actually an important move because it presents them information they feel they can trust and rely on, which is important to how they feel about it, and will therefore hopefully make an impact.

Prof Martin Kohlmeier: Maybe I should add that part of our remit and not least one of my major interests, is medical nutrition education. We have very explicitly a focus and we are very active in that. We have a good collection of articles in that direction. And as you indicated, that is very much needed. The challenge is for the practitioner who to trust as you indicated.

And there are many opinions when it comes to the question of the day and that is where we can really come in and try to bring in high level peer reviewed very important contributions. So, you know, that is a matter of trustworthiness and reliability.

Robin Daly: It is nice because at the moment there is also a kind of grass roots movement amongst doctors for nutritional education at the Nutri Tank from Bristol who we have been in touch with quite a bit and their student level, they are pushing for the same kind of thing. So it is nice to have a kind of pincer movement. I hope that will all add up to a lot of change.

Prof Martin Kohlmeier: And it is so much needed, currently in the US we have a little bit better situation because for a longer time, proper nutrition education has been required. That was very often proved at the breach. I have myself been involved for the last thirty years very much in providing particularly online medical nutrition education and it is all a matter of availability. I think this is part of the big story there is so much competition for attention.

This is almost every other week. There is something new coming on board, you have gut microbiome, you have Omix, you have new techniques in medicine, you have Nano technology and, you know, it is never ending growth, explosive growth and how do you cut through that?

How can you persuade both the doctors, but also the patients that it is not necessarily the shiny instrument or, the tiny nabobs, but also there are very solid things that they have known before, but now we know better why they are healthy when we are talking about nutrition.

So, very often the impression is, Oh it changes all the time, but when you look at it, yes it can change. Occasionally some surprising changes happen but most of the time we evolve and we get a better understanding on why and how in detail a good nutrition works. So a lot of people are confused by the headlines because it seems to pull in this and that direction.

But that those cannot recognise the fact that we know better. So this is really the very satisfying state of affairs that we learn more and they are whole new areas, whole new worlds that open up because of research that we did not even know existed, but. All in all we really know much more than five, or ten, or 20 years ago.

Robin Daly: I was talking to my guest on last week show; this was a nutritional therapist about just what an extraordinary volume of information there is now about nutrition and its effects on human health. We also discussed how probably the lion’s share of this has been generated just in the last couple of decades or even less.

I was wondering what you think is driving this research into what is after all, not an area with the lure of vast profits, like patented medicines are and what are the particular challenges facing researchers in this field?

Prof Martin Kohlmeier: Well number one, it is still almost an inch and overall that is so much biomedicine research going on.

If you look at the investments it goes vastly in, curative medicine, new surgical, or imaging developments, etc. Very little goes into the practical nutritional aspects. But because we have overall so much more investments and because more and more countries are coming on board that really contribute. It is really why we have this fast growth and maybe I should add to this in the aspect of our journal.

We really aim and I think we succeed at being a truly global journal. So we have an editorial team that comes from all corners of the earth, and we really tried to take into account very diverse perspectives. So it is not just the usual everything at home is important and nothing national.

Because we are international and that really enriches what we know about nutrition, because it forces us constantly to reassess bring in new angles. And sometimes it may even end up in the evening news or, in the yellow press that some new exotic fruit at some amazing properties, or some practices these are the things that help us to keep this research and the practice alive.

One of the examples would be that we have had much attention, too much strain in diets, where we have very specific benefits for both preventives, but also for particular patient groups. So there is now high level research that looks at maybe not everybody responds the same way.

We know news for breast cancer prevention for people with certain genetic disposition, Mediterranean diet is particularly effective. So we really kind of blend the classic and traditional with really up to date new science.

And it makes it more effective, and this is hard work. It takes a lot of work to actually know what nutrition does in people, because you cannot just do a little experiment, a little study for two weeks. You need to do it for a years and years under controlled conditions, very expensive, very difficult.

This kind of science is being done. And think about it if we can say yes, we can actually with lifestyle credibly reduce cancer risk or be more effective in treatment. This is where we have a lot of growth; this is where there is a lot of potential because now you really have intersectionality. You will want to know how nutrition works together with medications.

How do you know new technologies allow us to identify people who are going to respond to certain lifestyles. Because it is not all the same for some people or certain kind of maybe slow walking may work for others. More intense exercise may be needed to achieve the same, and very often we have questions such as low carb, high carb, high protein, etc. Now we know people truly are different. So it is not one size fits all. That is where high level science really has made strides and we have barely seen anything yet, and this is going to continue growing.

Robin Daly: I agree, this is where genetics is kind of a slightly unexpected use of genetics really, it was not what they were thinking in the days when they were actually developing the science. But, this is really where it is coming to its own, it is actually being able to distinguish why something works with one person and does not work with another, which has been such a puzzle in the past.

Prof Martin Kohlmeier: Yes. Obviously in the cancer area, we talk about the genetics, maybe of the tumour, but at the same time we are talking about the genetics of the person responding to different things. There is a lot of excitement, obviously for things like microbiome, gut microbiome, or the kind of microbiome, which are the bacteria.

The community of bacteria and certain regions like the gut, and now we know that it does not work on its own. It really communicates throughout the body, it changes the chemicals in a certain way that may signal for instance to the brain. But at the same time, we now learn that the genetics of the host.

So people are more or less likely to harbour certain microbes. So it goes both ways. It is a web of interactions and, understanding how they interact again, this is a big theme, how individually respond or are likely to respond to certain interventions, whether they are nutritional or other lifestyle or even medication or other things, this is really a very hot topic because it becomes more and more predictable so that it used to be pathology was really great, but it worked best after the end of life.

Now we are moving so much right in the middle of when something not so good may be happening so that we can identify things, whether it is very early prediction of an increased cancer risk. But also existing cancer being diagnosed years earlier and then selecting not just medication but lifestyles.

We know more amount more about good examples, there is so much we do not know. There is no question about it. But there is a lot that we do know and this is really what this journal is a repository of, particularly at that more of the practice end. So when the information is fairly mature, so we are less interested. Of course we read these things, we have to in the very early development, it is foundational developments, but more in the more mature science and how can we use these knowledge items in practice.

It is interesting inevitably nearly all the attention goes on trying to help people who have got cancer, but I think you have already identified that reducing cancer risk is actually the important task we have ahead of us with the rate at which incidence is going up. We have actually got to find out why people are getting cancer and what we can do to actually stop that from happening. This is because otherwise we are going to get to the stage where we are predicting that people will have cancer more than once in their lifetime, so it is absolutely runaway and we are getting better at treating it. But what if the number of people carries on relentlessly growing the challenge?

Prof Martin Kohlmeier: The challenge is with treatment that tends to be very expensive, but particularly end of life. If we can shift more to gaining high quality years of life even with cancer that is very good. And ideally, as you say, preventing the very best but very often we do not know that there is something, but we now know just for example and it just happens to be a line of work that I am deeply engaged in understanding how people with certain genetic dispositions will respond to nutrition. For instance, to increase at the risk of let’s say prostate cancer or breast cancer that you can then target in one particular example by getting more like a beam. So that is the red colour in tomatoes and watermelons, not by popping a bill, but simply being able to say as a doctor we do everything that we can if you have the cancer diagnosed but meanwhile this may help you to get a better chance to deal with it.

For instance, just making sure you get some of your red in your food most days which could be a pizza, which could be spaghetti sauce, could be watermelons, is that not amazing?

You know, being able to tell patients, all you have to do is eat some of your favourite foods.

It does not have to be high fat and all that stuff. But in this case, and for individuals who have certain genetic disposition, which we can detect now you just make sure you get some of that pretty much every day.

I think this kind of merging of evidence and science and knowledge that is going to make a difference.

Robin Daly: I certainly hope so, it is empowering people to help themselves basically, and not to rely on medical interventions all the time and to actually know how to keep themselves healthy so absolutely.

Prof Martin Kohlmeier: Yes.

Robin Daly: Well, we are on to talking about cancer, which is the focus of the show. I am glad to hear you talking about nutrition in relation to cancer and of course, BMJ nutrition is very welcome for this reason. At this point, how much of the content do you think is relevant to oncology and are there any plans to develop the area further?

Prof Martin Kohlmeier: Absolutely. Obviously the older we get, the more likely it will be that we will encounter this challenge.

That is a very simple fact of life and so it is very important at all levels preventively early intervention, but then also sustained treatment. So yes that is a very important component now, I think you understand the challenge. We are not usually writing these, papers we are a repository. We will come to these and so we facilitate them. The way we do it, as you know, we do collections, we invite people who are working in the field and this is how we do it.

Robin Daly: That is great because with your description earlier of how you do it, you do it internationally but you have got British in your title as well.
So you are actually bringing international content to a British audience. I mean, it probably goes to lots of other audiences too, but I am thinking British because that is where I am interested to see change. That is excellent because there is this terrible insularity and tendency to only look at what we do here and there is ridiculous things where you find them repeating the same extent, standard and expensive experimentation in one country and another, because it is not our research which is just seems to me completely ridiculous.

Prof Martin Kohlmeier: But actually research tends to be pretty international.

Robin Daly: Yes well that’s good, I am glad to hear that is the case. I am so happy to hear that you are interested to build this area in the journal in the UK, the GPs seem to be the ones who are leading the charge in adopting lifestyle medicine to their practices. But at this point, despite the accumulating weight of science behind lifestyle medicine, according to our beneficiaries it is largely failing to find its way into oncology. I am wondering what you think can be done, or maybe it is already been done, to raise awareness of the potential of lifestyle interventions amongst our UK oncologists.

Prof Martin Kohlmeier: I think that’s a good question because bringing nutrition to physicians in general, and I do not want to pick on oncologists, is a challenge because of course it is tempting to have the latest and greatest tools in the box.

You do want that, but I think by being able to really provide good evidence for instance relating to the interaction between treatment modalities to start moving away from one size fits all moving away from we use just our high powered tools to some of them style oriented, softer approaches that I really wanted to use the full toolkit.

It is not either and when one of the aspects since news, I mean it is a long education process to even take note of the existence of these different universes. So a lot of people take dietary supplements, which may undermine the effectiveness of ongoing medication treatment Chemotherapies, etc.

So just for example, if you look at what is happening, some people taking high dose vitamin C or high dose beta-Carotene at the same time that they are undergoing chemotherapy or that they are undergoing radiation therapy and the oncologist probably does not even know because the patient does not dare to tell.

And the physician finds, it may be a little bit distracting to ask about such things as vitamin C when they have much more massive interventions, but now they are cross purposes. So those worlds need to come together and they do but it is an effort. And we talked earlier about the need for physician education. This is where it all comes together because the education is not just at the undergraduate level. It needs to be an ongoing concern if you are oncologist and you have your basic training twenty years ago guess what happened since then.

And this does not just concern chemotherapy or surgical approaches, but also lifestyle and nutritional approaches. I mean, they are worlds apart now twenty years is a lifetime at this stage.

Robin Daly: It is, but I think you are right most people seem to agree that the aim here is not to try and turn doctors into a nutritional therapist as well. But they are actually trying to raise awareness amongst them of the power of lifestyle medicine to actually help the patient to get through their treatment successfully, to get through it without so many side effects, so much damage, rather than the traditional thing is I do not think about that so I just tell them not to do any of it, which is this point with the resources of lifestyle, medicine is almost a crime. You know, everybody should have the resources of lifestyle medicine if they are going through cancer, in my opinion.

Prof Martin Kohlmeier: So when we are talking about not just lifestyle medicine, but also specifically nutrition, a lot of cancer patients die from under nutrition. That is a major problem that is where the oncologist absolutely has to work together with the nutritionists and dietitians and really support and pull in the same direction optimal outcomes because I mean it is the classical thing you have a surgery went well, but your patient died. You do not want to have a patient responding well to treatment but then they die from malnutrition, from an infection, or something else. Likewise one of the risks is refeeding syndrome, which happens when at the very moment when treatment is effective, the patient feels better, starts eating again.

And comes potentially into a life threatening situation because now they get to too much too quickly of the food, but particularly carbohydrates and within days you have a wonderful result. You may have an emergency situation or even a fatal situation. So, these are the things where it really is highly relevant to bring them all together.

In the end it is the dying patient that we are dealing with. And I think one of the issues is really also it is maybe the less popular items in our journal, but I think they are particularly important. Those are from the dietitian’s aspects and how to really provide the critically needed support to really bring that perspective to the attention of other healthcare providers.

Robin Daly: Let’s hope the BMJ nutrition is going to do some stunning work bringing this all together, bringing attention to that in your field.

Prof Martin Kohlmeier: We will certainly work on that. I hope we can get that done.

Robin Daly: There are lots of things I have not talked to you about. We are getting very close to the end of time, and I just want to throw in one question. You will have to give us a quick answer. On one level, it is a surprise that the editor of this British publication is not only American but is actually based in the America. But on another, it does actually make complete sense from what you said earlier about the embracing of lifestyle medicine in America, as opposed to Britain. So I just wanted to ask a little bit about how you got to where you are, and how you came to be appointed, and what was it particularly in your background that made them appoint you as the editor?

Prof Martin Kohlmeier: I am an MD PhD, I have completed medical school and at the same time, a biochemist and geneticists. I have had for many years, a close collaboration with my British colleagues. I have for several years been a visiting fellow at the University of Cambridge, Wilson college which I enjoy very much. So I am actually in the UK a bit, and there is this global perspective. This came about because of a shared interest in better nutrition education training and dissemination of knowledge. We will have to see. I do not think it matters as much where you are, as long as you are staying close to where the service is delivered.

Robin Daly: Fantastic I think it is actually perfect. I like the global perspective and I like the fact that you are bringing in your own view; you are bringing things to the journal, which would be less likely to come from somebody in the UK.

Prof Martin Kohlmeier: Let me just emphasise, I have an excellent editorial team, including colleagues from the UK, highly competent. So it is not me in the end, and I can fall back on them and it is a team effort.

Robin Daly: Fair enough okay Martin; it has been a fascinating talk. Thank you very much, indeed, for telling us all about this journal.

Prof Martin Kohlmeier: Thanks for talking to me and do not hesitate to ask more questions.

Robin Daly: Okay and to you. I have really enjoyed it thank you, Martin. Stay safe.

Prof Martin Kohlmeier: Thank you, and enjoy the summer.

Robin Daly: BMJ nutrition, and bringing about change in UK healthcare; in healthcare education, particularly, in oncology. That is all for today, thanks for listening and do, please join me again next week for another Yes to Life show on UK Health Radio goodbye.

==

Radio show transcript edited by Jade Higgins, Literary Transcript Editor