Why it is vital to get the blood pressure reading from BOTH of your arms

Have you had your blood pressure checked in one arm and the reading seemed ‘normal’? Typically it is checked by your GP or another healthcare professional, or you can even do it yourself with a home testing kit. A reading between 90/60 and 139/89 is judged to be normal.

Not many people usually request to have their other arm checked for a blood pressure reading or check it themselves, however it might be worth doing this in the future as it could just save your life.
A new American study into apparently healthy individuals discovered that in instances when there was a significant difference between the blood pressure readings in each arm, there was 38% increased risk for a heart attack, stroke or other cardiovascular problems.

Researchers from Harvard Medical School in the US decided to look at the blood pressure reading of both arms from almost 3,400 men and women over the age of 40 and deemed in good health.

Generally, a small difference between the two readings is considered normal and not sufficient to cause alarm. In this study, systolic pressure – the pressure of the blood when your heart pushes blood out and the higher of the two figures within a blood pressure reading – was found to vary by an average of roughly five points.

For 10% of the people monitored in the study, a difference of at least ten points was found between the two arms. In the subsequent 13 years, those particular men and women were 38% at a higher risk of a potentially deadly heart attack, stroke or other cardiovascular health problems.

For two readings with a large difference, it is believed that the arm showing the higher reading probably has an artery that is congested with fat.

NHS guidelines advise GPs to extract the blood pressure readings of both arm. However, many are guilty of simply getting the reading from whichever arm of the patient happens to be nearest to them.

Thembi Nkala, a senior cardiac nurse with the British Heart Foundation, importance of having your blood pressure checked in both arms, saying: “Even if someone has no other cardiovascular risk factors, uneven high blood pressure could be a sign of an increased future risk of cardiovascular problems. UK guidelines already call for blood pressure to be measured in both arms when diagnosing high blood pressure. If you’re worried about your blood pressure or cardiovascular risk, speak to your GP or practice nurse.”

In respect to a blood pressure reading, you should not instantly panic if you have one blood pressure reading that seems high, you have not actually have high blood pressure (hypertension). Many of us are nervous or may feel stressed when visiting our GP and this can cause fluctuations in blood pressure, increasing it.

In that scenario, patients can be provided with a blood pressure kit to use throughout the day to check if there is a consistent high blood pressure reading or not. Your GP could also request you to undergo blood and urine tests to see if you have conditions that increase blood pressure, such as kidney disease.

Stroke rates among younger people should act as ‘a wake-up call’

An increasing number of young to middle aged people are suffering from strokes around the world because of their unhealthy lifestyle, according to findings from a new study.

Spiralling rates of obesity and diabetes, together with lack of exercise, has caused a rise to the number of strokes effecting people aged between 20 and 64. In fact, the number has increased by a quarter in merely 20 years, calling health experts to label the worrying situation a ‘stroke epidemic’.

Strokes afflicting this age group now comprise of 31% of the global total, whereas in 1990 it was only 25%. Stroke rates among children and young people aged 20 and under have also been studied and even among this age group researchers discovered that there are over than 83,000 cases each year; 0.5% of the total number.

The findings, published in the latest issue of The Lancet, stem from a systematic analysis of data extracted from 50 countries on the causes of illness and major diseases.

Although the analysis demonstrated a decrease in deaths from stroke in the UK, Brits are still more likely to die after suffering a stroke compared to those living in France, Germany and even the U.S.
Those living in less well-off countries are also much more at risk of succumbing from a stroke, with 42% more deaths across poorer countries during 1990 to 2010 in comparison to well-off nations. Over those two decades, stroke rates dropped by 12% in the richer countries.

Numerous lifestyle risk factors are thought to be the result of increasing stroke rates in the low to middle-income countries. For example, smoking, high blood pressure (hypertension), lack of exercise and an unhealthy diet have all been pin-pointed as risk factors.

Stroke Association chief executive Jon Barrick said that the findings of the research were a “wake-up call to governments across the globe”.

Mr Barrick said: “The report reveals a shocking disparity between rich and poor, where death rates from stroke are up to 10 times higher in lower income countries,” Mr Barrick said. Closer to home, within the UK, the number of people dying from stroke is around three times higher in the most economically deprived areas, compared to the least deprived. To help close this health inequality gap, we need more investment in stroke prevention and research.”

He added: “Rising obesity and diabetes rates, coupled with sedentary and unhealthy lifestyles, could wipe out the improvements we’ve seen in reducing stroke mortality in the UK, putting even more pressure on our limited NHS resources. This is a stark warning. We urgently need to address this global stroke crisis by prioritising stroke prevention and investment into stroke research.”

Lead scientist Professor Valery Feigin, director of the National Institute for Stroke and Applied Neurosciences at AUT University in New Zealand, commented: “The worldwide stroke burden is growing very fast and there is now an urgent need for culturally acceptable and affordable stroke prevention, management and rehabilitation strategies to be developed and implemented worldwide.”
Every year there are an estimated 152,000 strokes that occur in the UK, costing the NHS around £3.7 billion.

Broadcaster Andrew Marr suffered a stroke in January 2013 at the age of 53, and recently returned to work. In September he spoke about his experiences, saying: “I thought I’d bounce back in a couple of months. I was lying in bed completely delusional about how ill I was, and [my wife] Jackie was very good, she didn’t tell me. She kept saying, ‘Yes, dear, you’ll get to go to St Petersburg in March, I’m sure it’s going to be fine,’ knowing perfectly well that it wouldn’t. So it took quite a long time for it to sink in just how long it would be. I’ve got another two years before I’ve made a recovery.”

The political journalist has drew strength and positives from what he has gone through, and said: “You definitely see the world differently, actually, that is true. You move more slowly. You suck up experiences more intensely and you live the day more.”

He added: “And you’re much more aware of all the people all around us who have got really, really difficult disabilities who are looking after their parents, perhaps, and who frankly most of the time, like most people, I simply didn’t see. I wasn’t thinking about them. That has changed. I do see them now, I do think about it.”

Small salt reduction could save thousands of lives

UK Health experts say that thousands of deaths could be prevented every year if consumers were more aware of exactly how much salt is in the food they are eating in comparison against their daily recommended limits.

British health professionals voiced their concerns about the UK’s ignorance to the dangers of too much salt after the publication of a damning U.S.-based study that linked the high salt content in processed foods to the obesity crisis in America.

British GP Ian Campbell, medical director of charity Weight Concern, said: “The same problems exist in the UK, with heart disease a well-recognised consequence of excessive salt. Greater awareness of the harm salt can do might help people choose to reduce their intake. Processed food is high in fat, sugar and salt. Food manufacturers have significantly reduced salt content, but it’s still too high. The average person has no idea of the quantities of salt in their diet – simply because they’re not adding it, the manufacturers are. People need to be aware the food we eat does affect our health directly. If you don’t know what’s in the food you are about to eat, ask.”

High levels of salt in a person’s diet can raise your blood pressure and hypertension (high blood pressure) means you are at an increased risk of health problems such as heart disease and stroke. Doctors are adamant that if consumers paid more attention to food labels, an incredible 25,000 lives could be saved each year.

Unfortunately though, many Brits are still unaware of theirs or their children’s daily recommended maximum intake, or even any rough idea of how much salt they are currently taking in.

According to health officials, if the average salt intake was reduced by merely a single gram, this could save 6,000 lives and £1.5billion annually. If the average consumption however dropped by four grams, approximately 25,000 deaths could be averted each year. British Heart Foundation statistics say that on average, men consume around 9.7g of salt a day and women fare a little better and average 7.7g – but still way above the recommended limit.

Dr. Campbell added: “Salt is a big problem in the UK too. It’s a silent killer. Over time consuming too much of it increases the risk of high blood pressure, which can lead to heart attacks and strokes. About 80 per cent of our salt intake comes from processed foods, so it can be difficult to avoid. Many people are unaware of where salt is hidden, such as bread, soups, ready meals, even breakfast cereals and mayonnaise. The Government approach has been to encourage food manufacturers to modify the amount of salt in their products. There has been a reduction but it is taking too long. The Food Standards Agency should consider setting mandatory maximum levels for salt.”

The recommended daily salt intake for adults has been 6g for many years, (around one full teaspoon), although the World Health Organization have spoken many times in recent years stating that at the very most, 5g should be the maximum intake each day.  However, current NHS guidance still sets the current daily limits to:

. 1 to 3 years: 2g salt a day (0.8g sodium).
. 4 to 6 years: 3g salt a day (1.2g sodium).
. 7 to 10 years: 5g salt a day (2g sodium).
. 11 years and over: 6g salt a day (2.4g sodium).

One of the biggest factors why people suffer with heart disease or stroke is because of high cholesterol. Salt itself does not contribute to high cholesterol levels, but consuming too much salt can cause high blood pressure that in turn is attributed to heart disease and stroke. Therefore, it is worth paying attention to the salt levels in your food.

To maintain healthy cholesterol levels you can also make other positive lifestyle changes to reduce risk factors, including: quitting smoking, lose weight if you are overweight, and limit the fat in your diet. All these will benefit blood pressure as well as cholesterol. Medication such as statins may be required if dietary alterations alone are not enough to have an effect, and for suitable patients they are obtainable from Medical Specialists Pharmacy at low prices. For more information about Crestor (rosuvastatin), Lipitor (atorvastatin), and Generic Atorvastatin, visit the Health and Lifestyle area of the Medical Specialists website.

Stroke victims are getting younger compared to previous years

Health experts have warned that the age of people suffering from a stroke is worryingly low, and that the number of young adults being struck down with them is increasing. In fact, one in five victims is under the age of 55 according to research in the American Academy of Neurology Journal. In the same report, it was stated that the average age of someone suffering a stroke has dropped from 71 years in 1993 to 69 years in 2005.

The study centred on 5,900 Ohio and Kentucky adults who had suffered a first-time stroke between the years 1993 and 2005. It was found that over this time period, 20 to 54-year-olds accounted for an increasing proportion of strokes. In what had started at 13% in 1993 had risen to almost 19% in 2005.
To delve a little deeper – during the twelve years, whites aged 20 to 54 saw a rate increase from 26 strokes for every 100,000 people, to 48 per 100,000. A similar trend was noted among African Americans. In the same time period, the rate had gone up from 83 to 128 per 100,000 people.

Study author Dr Brett Kissela, of the University of Cincinnati College of Medicine in Ohio, offered his thoughts on what could be causing the increases. He said, “The reasons for this trend could be a rise in risk factors such as diabetes, obesity and high cholesterol. Other factors, such as improved diagnosis through the increased use of MRI imaging may also be contributing. Regardless, the rising trend found in our study is of great concern for public health because strokes in younger people translate to greater lifetime disability.”

Dr Kissela did suggest things that could be done to reverse the findings from the study though. He continued, “The good news is that some of the possible contributing factors to these strokes can be modified with lifestyle changes, such as diet and exercise. However, given the increase in stroke among those younger than 55, younger adults should see a doctor regularly to monitor their overall health and risk for stroke and heart disease.”

A spokesman for the Stroke Association, linked the results from the U.S study to stroke patterns in the UK, saying, “Although this research was carried out in the US, western cultures lead very similar lifestyles and in other research parallels have often been drawn between the US and the UK. For these reasons it’s likely that the UK could face similar outcomes. However, a UK specific study hasn’t been carried out yet.”

Strokes are the single biggest reason for adult disability within the UK due to the brain damage that is inflicted, with over 150,000 occurring every year in England alone. In addition, strokes are the third largest cause of death after heart disease and cancer. However, what are they and who is at risk?
A stroke happens when the blood supply to a certain area of the brain is suddenly stopped. Brain cells always require a constant source of oxygen inside the blood so therefore after the supply is cut off, the cells in the affected area either die or become damaged.

There are two main types of stroke – ischaemic and haemorrhagic. The former kind of stroke accounts for a staggering 80% of all cases of stroke. It happens when the flow of blood to your brain is stopped by a blood clot or clump of fat. You are at risk of developing a blood clot if your arteries have narrowed and clogged with fatty deposits; known as atherosclerosis. Major risk factors for atherosclerosis include smoking, high blood pressure, high cholesterol, obesity, diabetes and a family history of heart disease or stroke.

A haemorrhagic type of stroke is brought on due a weakened blood vessel supplying the brain rupturing and resulting in bleeding into the surrounding brain and brain damage. Two types of weakened blood vessels will typically cause a haemorrhagic stroke: aneurysms and arteriovenous malformations (AVMs).

So what can you do to limit your chances of suffering from a stroke? As Mentioned earlier, smoking is a major cause so therefore quitting smoking immediately would be advisable through the help of smoking cessation medication such as Champix. Following an online consultation and the approval from one of our GMC registered in-house Doctors; you can obtain the effective smoking cessation medication Champix from Medical Specialists Pharmacy, costing just £75.00 per pack.

Medical Specialists also provides online consultations for patients with high cholesterol, a major contributor for strokes. For suitable patients our house doctors can prescribe statin medication (Lipitor and Crestor), and our in house pharmacists can dispense to patients within 24 hours. We also dispense statins for patients who can provide a private prescription, and have recently introduced the legally available generic Atorvastatin at much lower prices for suitable patients. The World Health Organisation has estimated that nearly 20% of all strokes and over 50% of all heart attacks can be attributed to high cholesterol so clearly the dangers of this are quite apparent.

Can new weight loss drugs rival Xenical

Recently, the American Food and Drug Administration (FDA), approved two new weight loss medications (Belviq and Qysmia), and America breathed a sigh of relief. While weight loss drugs have always been a topic of controversy, over the years it has become clear that their addition to the dieting efforts of many individuals, who struggle with obesity, is extremely beneficial. And with more than one third of Americans (35.7%) falling under the obese category, it is no surprise that medical alternatives to diet and exercise, are needed to counteract the issue.

New obesity treatments are needed to bridge the gap between diet and exercise and the more radical option of bariatric surgery. This is a view backed up by Dr Sue DeCotiis, New York City based Medical Internist and Weight Loss Management Specialist, who said, “While there are potential side effects with every medication, long term studies show that overweight patients do much better losing and keeping off weight, when they are prescribed a weight loss drug.”

“Weight loss medications work in conjunction with healthy eating and exercise, and offer individuals a chance at a real lifestyle change. Those who suffer from obesity often have a host of other health problems that come with the condition. These drugs can alleviate those symptoms, and the result is that many of these patients will live longer and avoid the consequences of medical problems, such as hypertension, stroke, and heart attack.”

Listed below is a description of current weight loss drugs and how they work. Previously the only option was Xenical, but now for the first time in 13 years, Doctors will have a choice of which weight loss drugs to prescribe to overweight or obese patients.

Belviq (Locaserin)

Approved by the FDA in late June of this year, this medication works by activating a receptor in the brain that helps a person to eat less and still feel full. By regulating the appetite, it lowers the likelihood of individuals overeating. It works best in patients who suffer from weight related conditions, such as high blood pressure, type 2 diabetes, or high cholesterol. At least 47.5% of patients lost at least 5% of their body weight from the medication, as opposed to 20.3% who took a placebo during a trial study period.

Qsymia (Phentermine & Topirmate)

This combination of the drugs Phentermine (an appetite suppressant and stimulant) and Topirmate (an anticonvulsant with weight loss side effects) is the most recent of the crop of weight loss medications, that have been approved by the FDA. Drugs in this category are primarily considered appetite suppressants. With the medication producing dramatic weight loss in patients, this is one of the clearest signs of hope for those suffering from obesity related diseases. About half of the patients lost 10% of their body weight and four-fifths lost 5%.

Contrave (Bupropion & Naltrexone)

This drug that is still to be approved by the FDA, works by combining two active ingredients that have been used for over twenty years. With Bupropion initiating the weight loss, Naltrexone sustains it by preventing the body’s natural tendency to counteract efforts, to lose weight. The result of this combination is to reduce appetite and increase the body’s metabolism, giving those who are suffering from obesity related illnesses the ability to sustain continued weight loss, by addressing the portion of the brain that controls food cravings.

Xenical (Orlistat)

Xenical, which is the most established and proven of the weight loss drugs, is a lipase inhibitor. Xenical does not enter the patient’s blood stream, but works in the digestive system in the small intestine as a fat absorber. It blocks out a third of the fat in food eaten in a patient’s diet, leading to steady weight loss. Research involving 11,131 woman and 4,418 men, who had been over weight for an average of 14 years, showed that 87% lost at least 5% of total body weight, half lost at least 10%, around 20% lost more than 15% body weight and some patients lost more than 25%.

Only time will tell which of these weight loss drugs is the most successful. Unfortunately here in the UK Belviq is not expected to be released until 2013 and there has been no UK release date as yet for Qsymia and Contrave. However all is not lost as here in the UK we still have Xenical available, which has a proven track record for assisting weight loss. Here at Medical Specialists Pharmacy we can dispense Xenical after an online consultation with one of our doctors and as soon as these other weight loss drugs become available, we will be offering them. Check our news section for further updates.

A healthy lifestyle could reduce high blood pressure as effectively as drugs

Whilst we all know that exercising regularly, keeping our weight down, drinking in moderation and eating plenty of vegetables can affect our blood pressure, new research suggests that it can reduce the risk of developing high blood pressure, by two thirds.

The impact of these measures on high blood pressure was much higher than expected, and in some cases could even be just as effective a way to treat sufferers as prescribing drugs. Just walking to work and restricting alcohol to two drinks a day can reduce the risk markedly, according to the study of more than 20,000 people.

Every day there are 350 preventable strokes or heart attacks in the UK caused by high blood pressure. In developed countries the lifetime risk of developing high blood pressure is now 90 per cent, and six million Britons take drugs to control it.

People with hypertension (the medical term for high blood pressure) are already routinely advised to make the lifestyle changes highlighted in the study, but the effect far surpassed expectations. The Finnish study followed 9,637 men and 11,430 women aged 25 to 74, who did not have hypertension.

Their adherence to healthy lifestyle factors was recorded, which included alcohol consumption of less than 50g per week (roughly six units), exercise at least three times per week, daily consumption of vegetables, and normal weight. During a follow-up period covering an average of 16 years, 709 of the men and 890 of the women developed hypertension.

Proffesor Pekka Jousilahti, ofFinland’s National Institute for Health and Welfare said: “The risk of hypertension was only one third among those having all four healthy lifestyle factors, compared with those having none. Even having one to three healthy lifestyle factors reduced the risk of hypertension remarkably.

For example, having two healthy lifestyle factors reduced the risk of hypertension by nearly 50 per cent in men, and by more than 30 per cent in women. Alcohol consumption, physical activity, daily consumption of vegetables and keeping normal weight are the four lifestyle factors that seem to have a remarkable effect on the development of hypertension.

Professor Jousilahti went on to add “people should drink a maximum of one to two drinks of alcohol a day and that even a relatively low amount of exercise was enough to make a difference.”  This was backed up by Professor Gareth Beevers, a trustee of the Blood Pressure Association UK charity, who said: “This study shows a big effect from simple changes in lifestyle. It’s surprising and more than you would expect.”

Professor Jousilahti concluded by saying: “that although participants were healthy at the start of the study, it was likely the findings would also help those who already have high blood pressure. Patients could reduce their blood pressure by modifying the four lifestyle factors alone, or by making these modifications while taking blood pressure-lowering medication.”

Forgive and forget, for your hearts sake

We’ve all been offended by someone at one time or another and whether we choose to forgive someone or not can have a big effect on our relationship with that person however new research led by Dr Britta Larsen at the University of California, San Diego has found that whether we choose to forgive or not can have a big impact on our health especially in relation to our heart.

The research found that those who let go of their anger were less likely to suffer dangerous spikes in blood pressure. Short term rises in blood pressure are not known to be harmful however over a longer period high blood pressure can increase the likelihood of a heart attack or stroke.

The researchers at the University of California asked just over 200 people who were wired up to monitors which took their blood pressure to focus on a time a friend or loved one had upset or offended them. Half of the group were told to concentrate on how much the incident had upset or angered them whilst the other half were told to think about the incident in a more forgiving way.

It was found that the angry group saw the greatest increase in blood pressure compared to the group who were trying to see it in a more forgiving way. Interestingly after a five minute timeout period the differing effects could still be seen between the two groups.

The research published in the Journal of Biobehavioural Medicines suggested that forgiveness could lower our reactivity to stressful events and thus prevent dangerous spikes in blood pressure. It also went on to suggest that doing so could offer longer term protection in relation to heart attacks and strokes.

This could prove very helpful as around 30% of adults in the UK have hypertension (high blood pressure) and are unaware of it due to lack of obvious symptoms.

It seems even the risk of cancer cannot persuade Brits to drop their excess baggage

Brits do not seem to possess enough motivation to shift those extra pounds it seems according to findings published this week by Cancer Research UK. At Medical Specialists Pharmacy we have already looked into many serious health issues that are directly linked to obesity such as lumbar disc degeneration of the back, and how having a poor diet is linked to high blood pressure and erectile dysfunction.

Cancer Research UK say there is an increasing number of kidney and womb cancer cases being diagnosed, and that more and more of these can be linked to obesity. Smoking is still the main culprit for causing cancer, but being overweight or obese comes in second in terms of cancer risks that you can actually do something about to avoid.  In fact recent data compiled by Cancer Research UK, showed that more than four in 10 cancers could be prevented by people making positive changes to their lifestyle.

Amongst those who answered questions for Cancer Research UK’s latest study, 68% of the overweight women claimed that they lacked the required willpower to lose weight. This was 8% more than the men who admitted the same thing. Overall, 87% of those surveyed did say they wanted to lose weight, but then problems such as ‘having too many other things to worry about’ and ‘ trying it before and not being successful’ were listed as reasons that eventually prevented them for losing weight.

In the midst of a recession, it can be understandable that a lack of money could be one of the main things people are ‘worrying’ about these days. But surely your short and long-term health is just as important? Overweight and obese individuals may regret the decision to decide to give up the admittedly tasking chore of losing those love handles, but bear in mind just some of the many health risks that are associated with obesity:

. High blood pressure (hypertension).
. Type 2 diabetes.
. High cholesterol.
. Joint and back pains.
. Severe tiredness or the inability to exert energy into physical activity.
. Poor circulation, ultimately leading to erectile dysfunction, as explained in great detail here.
. Psychological problems such as low self-esteem, confidence and feeling isolated.

Dr Harpal Kumar is chief executive for Cancer Research UK and he gave his views on the obesity crisis, “Unless we tackle the obesity epidemic in the UK, we risk cancer cases soaring. We understand that it can be extremely hard for people to maintain a healthy weight but keeping those extra pounds at bay could ultimately save your life.”

Dr Susan Jebb, head of diet and population health at the Medical Research Council, added to Dr Kumar’s comments and said, “It’s encouraging that most people recognise a poor diet and lack of physical activity significantly increase their risk of developing cancer. But it’s also clear that most people find it hard to turn their good intentions – to eat better and move more – into sustained changes in their lifestyle.  This gap between knowledge and behaviour helps to explain why the number of people who are obese is continuing to increase. Research shows that to make sustained changes in diet and physical activity people need tangible support from family, friends or health professionals. In the longer term, it’s important that the places we live and work make the healthier choice the easier choice, so healthy living becomes a way of life, not a matter of personal willpower.”

Calcium supplements could double the risk of a heart attack

Calcium boosters are usually taken by post-menopausal women and the elderly to deter the thinning of bones in the body. However, a new German study titled ‘the European Prospective Investigation into Cancer and Nutrition’ has indicated that these supplements may actually double the chance of the person suffering a heart attack. Researchers involved in the study, tracked 23,980 individuals in the 1990s for an average of 11 years and who were aged between 35 and 64. All participants in the study did not have any previous history of heart problems.

Studies that have been carried out in the past have shown that high calcium intake can be linked to helping combat high blood pressure, type 2 diabetes and obesity. All three are associated with heart disease. This latest German study has however highlighted the dangers of ‘calcium boosters’ in comparison to obtaining the vital mineral from dietary means such as cheese, milk, spinach and hazelnuts.

The subjects who participated in the study whose food intake was roughly about 820mg calcium each day, were found to have a 31% less risk of heart attack in comparison to those who had a lesser intake. For those with intakes of 1,100mg and above, there was no evidential benefit. The Food Standards Agency only actually recommends for adults to intake 700mg of calcium per day within their diet. Staggeringly, an 86% more risk of heart attack was discovered when scientists analysed the people who had been taking dietary supplements. The risk rose even further for those who were simply taking calcium supplements and nothing else. During the 11 year period, researchers noted 354 incidents of heart attack, 260 strokes and 267 deaths related to cardiovascular disease.

Following the alarming results, The National Osteoporosis Society have hit back and claimed there is not enough evidence to suggest the calcium supplements initiate any heart problems. Furthermore, a spokeswoman from the Department of Health is refusing to panic just yet until the full article has been published. The spokeswoman commented, “The majority of people do not need to take a calcium supplement. A healthy balanced diet will provide all the nutrients, including calcium that they need. Good sources of calcium include milk and dairy foods, fortified dairy food alternatives, e.g. soya drink, and green leafy vegetables.”