“On prevention, exercise and food”
Prof. MUDr. Richard Češka is president of the Czech Society of Internal Medicine, lectures at Charles University’s Faculty of Medicine as well as abroad, and leads Charles University First Faculty of Medicine’s 3rd Medical Department – Endocrinology and Metabolism Clinic. To ensure a clear conscience, I went for the most part on foot to my meeting with Professor Češka, a renowned European expert in preventive cardiology, so that I could come closer to the recommended daily target of 10 000 steps. We met in the medical library, which was undoubtedly no coincidence since the professor enjoys frequently writing not just specialist publications, but also informative essays which are fascinating and enjoyable to read even for the general public. Besides preventive cardiology, we also discussed public education, a healthy lifestyle and the current situation in healthcare during our interview.
Professor, my first question will look to introduce your field. What actually do we not know that we already know about preventive cardiology? Why does the public not know much about this specialty?
Preventive cardiology is overshadowed by interventional cardiology, which involves great achievements such as coronary catheterisation, deployment of stents, and heart transplantation. As such, one is often unaware how successful preventive cardiology is. Since 1985, we have seen consistent positive figures in terms of a fall in cardiovascular disease rates, despite the fact that cardiovascular disease has held on to the top spot in terms of mortality statistics. In more than half of all cases, this fall is due to successful preventive measures such as treatment for high cholesterol and hypertension, anti-smoking measures and, to some degree, lifestyle changes as well. Excellent world-class interventional cardiology is responsible for a smaller proportion of this decline, even though the topic may be more attractive to the media. On the other hand, I should point out that we are the best in the world at treating heart attacks; our system of coronary units and cardiovascular centres ensures exceptional access to healthcare.
It seems to me that it’s like preventive diplomacy; it is difficult to show how effective this is since no conflict arises, and as such it is hard to produce effective statistics.
You’re right; it is easy to demonstrate effectiveness for certain patients with congenital diseases such as lipid metabolism disorders. For individual patients whom we help by treating them for high cholesterol or high blood pressure, or by optimising their diabetes treatment or helping them to stop smoking, not much actually happens; the patients receive their medication and that’s all that’s needed. Even Christiaan Barnard, who performed the first heart transplant in the world in 1967, declared: “If I had focused on preventive medicine earlier, I could have saved a thousand times more lives.” The figures speak for themselves. Although heart transplantation can be considered groundbreaking surgery, only about 100 of these complex operations are performed a year in the Czech Republic. Yet tens of thousands of people will suffer heart attacks. Few people know that preventive cardiology is further divided into two groups. These are, firstly, primary prevention for patients who have a risk of cardiovascular disease as a result of certain factors but who have not yet developed disease of the heart and blood vessels, and secondly, the equally important secondary prevention, i.e. the prevention of further disease episodes once one has already occurred. Anyone who has had a heart attack should not suffer another, as the next one could be fatal. This prevention is sometimes more complex in terms of treatment as it essentially combines post-heart-attack treatment with preventive treatment.
Today there are numerous dietary recommendations, as well as recommendations around exercise, many of which contradict one other such that it is hard for the ordinary person to make sense of them. Examples include butter and eggs, demonised in the 90s but today described as “superfoods”. What can we do to avoid further adding to the ranks of your patients?
There are a number of things you can do for your health. First of all, you need to be born into a “good family”; the genetic make-up we are born with plays a really important role. Winston Churchill hated any kind of exercise, smoked, drank and was hugely obese, yet he lived to be 90 years old. But he was an exception. So let’s get back to real life. It’s about being sensible. I don’t overestimate the effect of the now-popular Mediterranean Diet, but nor do I underestimate it, as we all probably realise that omega fatty acids are important. It would be naive to pretend that many patients without relevant education and with certain lifestyle habits are going to follow recommendations about following a Mediterranean Diet. To paraphrase, anything fatty, especially animal fats, are bad for you. Large amounts of processed meats are also bad. Eggs should also be consumed in moderation. Our advice would be two yolks per week. I’d like to give you a good example of healthy food for Czechs: pork, dumplings and sauerkraut, using lean meat, two to three dumplings and a pile of unthickened sauerkraut. Patients understand this better than advice that they should eat seafood or fish with foreign names. For me then, it’s important to eat everything in moderation.
What do you think is more important? Diet, or exercise?
I would advocate the maximum possible and a combination of both, but if I had to choose then it would be exercise. It has been demonstrated that people termed “fit-fat”, i.e. people who are overweight or slightly obese but fit, have a better prognosis in terms of heart disease than those who are so-called “non- fit, non-fat”, or people who are slim, weak and avoid exercise. At middle age and younger, it is those who are slightly overweight who have the best prognosis for a long life. I hope I have pleased many readers in saying so. In terms of cardiovascular prevention for ourselves, we can do a lot with exercise and an appropriate diet without having to try to look like Twiggy.
They say that stress is today’s great killer. How do you personally manage to be an authority in your field, run a clinic, give lectures, hold conferences, publish and do so much more besides?
There are two types of stress. There’s positive stress when we’ve got a lot of work and we feel swamped, but this stress helps us because we enjoy the activities we are doing and they give us meaning. Negative stress, less visible but more damaging, comes from the feeling of fear that life is not giving us anything new, and it is often linked to occupational burnout. Did you know top managers suffer cardiovascular disease less than those with only a basic education? As such I wouldn’t demonise stress in itself. Let’s instead look at how we usually deal with stress, something which is a risk. We usually respond to stress by increasing our consumption of alcohol, cigarettes or sweet foods. Many people gain weight when stressed, and I am one of them. Personally, I try to perceive stress positively. I exercise every day because of problems with my back, and I play tennis and run every week. I don’t smoke. But I confess that in terms of diet and watching my weight, I have not learnt to follow my own advice.
You’re known amongst your colleagues for holding conferences and focusing a lot on education. How well-informed are the patients who come into your surgery?
We live in a media world. In terms of educating medical specialists, I’m glad that we are doing extremely well at holding successful conferences at the international level, and we can thus also promote the Czech Republic. Our young generation of doctors can then build on contacts with colleagues from around the world. Public awareness is more complex. In the current climate, news with sensational value is more attractive. It is generally known that cholesterol is a risk factor and major cause of atherosclerosis. When any report is publicised stating that cholesterol is healthy and reducing it kills you, the headline gets onto the front page. Some of the medicines we prescribe are statins. There is a campaign against these medicines, because like other medicines there are some side effects. You may experience muscle pain, reduced performance, and in perhaps one in a million cases severe muscle inflammation can occur, a condition known as rhabdomyolysis. One person who read about this extreme case recently started a campaign on how statins kill. Patients then demand to know from us why we are prescribing them these dangerous medicines. Interventional studies, however, have demonstrated that statins save thousands of lives, while causing unwanted side effects in a small number of cases. And our task is to persuade our patients of this. But patients, and people in general, are wired for negative, often unverified information. There was a large study in Denmark which confirmed that campaigns against statins increased death rates by a full eight percent, because patients stopped taking statins as secondary prevention following a heart attack, and the number of heart attacks increasedbyawholetwentypercent.TheDanes continued their investigation, and ascertained that articles about the positive effects of statins reached 1 million people, while articles about its negative effects reached 6 million people! I would definitely advise patients to seek out balanced information from verified sources. But that applies generally.
Let’s stick with science. Colleagues wished you the discovery of a gene for
atherosclerosis for your fiftieth birthday. What is your wish?
There are so many factors involved in atherosclerosis that I don’t think a single gene will be discovered. I don’t consider myself a scientist, but rather a clinician. There are not many breakthroughs in medicine; gradual development is much more important. I think the most important aspect of my activities is building up a team of young doctors who can focus on preventive cardiology. We are making small steps every day towards one day winning the battle against atherosclerosis and heart disease for the human race.
The situation regarding the lack of young doctors in the Czech Republic and their frequent leaving to work abroad is often mentioned as a time bomb for the Czech health service. How do you see this?
I think that very little is done to ensure young doctors have the best conditions to work in their profession. 15 % of young doctors do leave to work abroad, although some return. Speaking of conditions, discussion is frequently limited to financial conditions, but these are not the key criteria. Take a look at other companies who can attract employees through company nursery schools, providing great food or perhaps the option of travelling to work by bike, promoting a healthy lifestyle. There is a problem within hospitals of where to leave your bike, where employees can take a shower, etc. From a professional perspective, well-organised postgraduate education is important. Today, poorly qualified doctors often come here from abroad, meaning that our doctors are overburdened with a large number of night shifts, and are taking on too much responsibility for colleagues who often aren’t able to communicate well in Czech and thus may make mistakes. Because of all these factors, doctors don’t want to work in the system and leave. Apart from regional capitals, the current situation is alarming because wards’ senior consultants, or deputies, are often Czech, while the other doctors are from Ukraine.
What is your final message for Czech and Slovak Leaders readers?
I would like people to consider their health as one of the greatest riches in their lives, while also accepting that it is ultimately up to us to look after our own health. It is better to see a doctor early, even if there is nothing wrong, than to see them with a disease at a later stage. Prevention may sound a little hackneyed these days, but there was a proverb in ancient China which went: “The superior doctor prevents sickness, the mediocre doctor attends to impending sickness, and the inferior doctor treats actual sickness.”
By Linda Štucbartová