Taking a headline, and running with it. Pun intended.

obesity, overweight
Moderation is key to a longer, healthier life. Sorry it’s boring.

Today’s award for the most unhelpful headline goes to the subeditors of the BBC with this little gem:

‘Exercise ‘not key to obesity fight’

So what happens is, if they want to say something they should say, they stick it in inverted commas to make it look like they’re not really saying it, when they’re saying it. Along the lines of ‘wasn’t me, guv’nor’. BBC, you must be so proud.

An editorial in the British Journal of Sports Medicine said that it was time to ‘bust the myth’ that exercise had a big effect on obesity. Naturally the reach of the BBC is wider than that of the British Journal of Sports Medicine – and the reach of the headline is far, far wider than the reach of the detail in the story. And that’s why headlines are risky, and need to thought about responsibly. Now we’ll have a situation where people think that the disembodied quote from three experts writing in a periodical they’ll never read is licence for them never to do exercise again.

But let’s look at it. Those experts are right in one sense – our diet is so far out of whack it dwarfs our sedentary lifestyle in how damaging it is to our long-term health. We like junk food, and it’s hard to avoid since it’s so cheap and plentiful. Those who are obese can have a tremendous effect on their weight if they cut their daily calorie intake from that of a pro cyclist down to that of a sedentary person (in some cases a drop in excess of 2000 calories). The other reason they’re right is that in those who are morbidly obese, really effective exercise is impossible. The first gains need to come from curbing intake.

But the key to success remains – a deficit between what calories you need, and what you actually consume. One of the results of exercise is to boost the deficit.

What was also not addressed was the fixation on obesity. I suppose it’s easy to fixate on because it’s so visible – but generally it’s not being fat that kills you, it’s heart disease, or diabetes that leads to complications, or a stroke or whatever. Obesity increases the risk of all of these. Exercise is great at reducing the risk of these. So exercise, whether you use it for calorie busting or not, is a great thing to have in your life.

The problem with obesity is the same as the problem with politics – we get hooked on the extreme – extreme eating, extreme dieting, extreme exercise, extreme left, extreme right. Actually there’s a sweet spot, and it’s at neither end of the spectrum. A reasonable diet and reasonable exercise will have you living healthier for longer. Yes, there are those who feel the need to eat a diet of raw wizardfruit and ground unicorn horn, or whatever’s currently trendy (I lose track); there’ll always fads and extremes – it’s just not where the success is.

Today’s message is just not encouraging. Exercise does work, and it works best when you’re paying attention to diet as well. People who are trying to make changes should be supported and encouraged, not discouraged by being told half the story. Moderation is something we can all do. For some of us, that’s a habit we need to learn – but that’s OK, recognising it is the best place to start.

Journalists: Be responsible

Experts: Stop trying to be extreme to get column inches

Everyone else: Be different, be average.

Type I Diabetes

Type I diabetes occurs when there is a loss of insulin secretion ability due to automimmune destruction of the beta cells in pancreatic tissue. Patients generally present with the symptoms of hyperglycaemia including ketoacidosis.

Type I diabetes is the most common form in young people (affecting aout 0.5% of the population); bringing with it the potential for problems such as retinopathy, neuropathy, nephropathy and vascular disease.

Small amounts of insulin are produced by the pancreas throughout the day to ensure cells have access to glucose, and suppress the release of stored glucose from the liver. During fasting periods, glucagon is released to ensure glucose supplies for brain function.

Carbohydrates are digested in order to provide glucose, which results in the release of insulin titrated to the supply of glucose to use and store glucose in suitable quantities.

Insulin needs to be replaced in type I diabetes patients to ensure 24 hour cover. Boluses may also need to be prescribd to match carbohydrate intake at mealtimes. Often this can be suitably treated with a twice daily insulin if the patient’s daily routine is predictable, for patients whose lifestyle is more varied, titrated insulin may be required perhaps involving a pump or more frequent injections.

Carbohydrate awareness is important for those with type I diabetes because it is carbohydrates that affect blood glucose levels, and therefore patients need to be aware of the carbohydrate values of the foods they consume. This is particularly important for those titrating their insulin.

One of the ways insulin titration is done is through ‘dose adjustment for normal eating’ (DAFNE) which was designed for those with type I diabetes and can contribute to an improved quality of life and satisfaction for patients. Research shows that patients on DAFNE treatment are less likely to be admitted to hospital with ketoacidosis or hypoglycaemia, and also the treatment can make huge cost savings for providers. It consists of a 38 hour training course delivered in a group session based around competency skills. The scheme is successful in promoting understanding of diabetes, awareness of implications regarding diet, and the skills and knowledge required to count carbohydrates and titrate insulin accordingly with the use of DAFNE algorithms.

Cutting salt intake improves survival in patients with heart failure

Limiting intake fo sodium to less than 3g prolongs the survival of patients living with heart failure according to Korean study. J Clin Nursing 2011;20;3029-3038

Vegetarian Sources of Vitamins, Minerals and Nutrients

  • Vitamin A – whole milk, cheese, margarine, carrots, leafy vegetables, orange -coloured fruits
  • Vitamin B1Thiamin – wholegrains, nuts, fruit and vegetables, fortified breakfast cereals
  • Vitamin B2riboflavin – milk, eggs, rice, fortified breakfast cereals, legumes, mushrooms, green vegetables
  • Vitamin B3niacin – wheat and maize flour, eggs, dairy products, yeast
  • Vitamin B6 – milk and milk products, eggs, wholegrains, soya beans, peanuts
  • Vitamin B12 – eggs, milk and milk products, fortified breakfast cereals
  • Vitamin C – tomatoes, peppers, broccoli, cabbage, citrus fruits, melon, kiwis
  • Calcium – Milk, cheese, dairy products, green leafy vegetables, fortified soya products, bread
  • Carbohydrates – all starchy foods such as bread, rice, potatoes, pasta, cereals, cereal products, fruit, starchy vegetables, milk, dairy products
  • Vitamin D – eggs, fortified cereals and margarine, sunlight
  • Fatty acid (omega 3) – walnuts, seeds, linseed and rapeseed oils or spreads
  • Fatty acid (omega 6) – sunflower and olive oils and spreads
  • Folate/folic acid – green leafy vegetables, brown rice, peas, oranges, bananas, fortified breakfast cereals
  • Iron – pulses, nuts, eggs, dried fruit, wholegrains, dark green leafy vegetables
  • Magnesium – green leafy vegetables, nuts, bread, dairy products
  • Potassium – fruit (especially bananas), vegetables, milk, nuts, seeds, pulses
  • Protein – eggs, pulses, milk, dairy products, nuts, cereal products (including bread), mycoprotein, soya products
  • Selenium – Brazil nuts, bread, eggs
  • Zinc – milk, cheese, eggs, wholegrain cereals, nuts, pulses

(taken from British Nutrition Foundation with thanks)

Vegetarian and high fibre diets can reduce risk of diverticular disease

An Oxford study found that vegetarians were 31% less likely to suffer diverticular diease compared with adults who consumed a healthy diet containing meat and fish. Those who consumed a high intake of fibre were 41% less likely to suffer from diverticular disease.

Crowe FL et al (2011) Diet and risk of diverticular disease in Oxford cohort of European Prospective Investigation into Cancer and Nutrition (EPIC): prospective study of British vegetarians and non-vegetarians BMJ 343:d4131 doi:10.1136/bmj.d4131.

Racing Weight – Matt Fitzgerald

This book is well-researched and is geared towards endurance athletes attaining a good racing weight in order ot improve performance. It combines nutrition principles such as consuming particular foods at particular times, information on supplements, timetable and content of workouts. It’s pretty comprehensive – but you kind of need to be a little obsessed in order to play by all the rules. The diet side of it appears to be too much like a diet to be sustainable, whereas lifestyle modification would be possibly less effective but certainly more sustainable. Still, there are good principles whether you choose to adopt the whole thing or not.

UK Guidance on Diet could save around 33,000 Lives annually

A study has found if people adhered to the recommended 5 portions of fruit and vegetables each day and reduced their daily intake of salt to 3.5g as well as their saturated fat intake to 3% of their daily energy intake, this could prevent around 33,000 deaths each year. It was calculated that 20,800 coronoary artery disease deaths, 5,876 stroke deaths, amd 6,481 cancer deaths could be prevented each year by following such guidance. Around 12,500 deaths would be in the 75 years and under category.

Scarborough P et al (2010) Modelling the impact of a healthy diet on cardiovascular disease and cancer mortality Journal of Epidemiology and Community Health. Doi:10.1136/jech.2010.114520

Potential Causes of Gastroenteritis

Gastroenteritis occurs when a person comes into contact with a causative agent which develops an inflammation of the gastro-intestinal tract. This can be caused not just by contaminated food, but also in some cases by anti-inflammatory drugs or antibiotics. It also may be as a result of a food allergy, which may present as nausea and vomiting, adominal pain and diarrhoea.

There are various bacteria that can cause gastroenteritis; shigella, salmonella, clostridium difficiel, staphylococcus, yersinia, salmonella, campylobacter jejuni. E coli is one that cause severe gastroenteritis, with patients often presenting with severe watery (non-bloody) diarrhoea and fever.

Gastroentiritis caused by viruses is frequently referred to as ‘stomach flu’ despite not being related to the influenza virus. Half of gastroetniritis is caused by norovirus, although this generally is prevalent in the period from October to April.

Rotavirus is more common in infants under one year old and is seasonal, as is the astrovirus which affects predominantly children and the elderly, whereas the adenovirus is not seasonal and generally affects children up to two years old.

Gastroenteritis can be caused by parasitic infections, generally Giardia. The parasite grows in the gut and symptoms of gastritis appear after about a week, but can last for a further six if not treated. Generally this would be treated with metronidazole. Cryptosporidium is another parasite that can cause gastroenteritis.

Care needs to be taken that the patient doesn’t become dehydrated; watching particularly for signs of dry mouth or tongue, drowsiness, dizziness or light-headedness, fainting, reduced urine output, lethargy or sunken eyes.

Excessive Alcohol Consumption is a Major Risk Factor for Cancer

A European study has found that 10% of cancers in men and 3% of cancers in women were attributable at least in part to the consumption of alcohol. These were predominantly aerodigestive tract, liver and colorectal cancers, and in women, breast cancer. This study has led to discussion on reducing the recommended upper limit of alcohol consumption to 12g for women and 24g for men.

Schütze M. et al (2011) Alcohol attributable burden of incidence of cancer in eight European countries based on results from prospective cohort study British Medical Journal doi:10.0016/bmj.d1584

Diabetes and Omega-3 Fatty Acids

A study has shown that those who have a high intake of omega-3 fatty acids, particularly from fish are at an increased risk of developing type II diabetes.

Douse L. et al. (2011) Dietary Omega-3 fatty acids and fish consumption and type 2 diabetes. American Journal of Clinical Nutrition 93. 1, 143-150

Treatment of the Patient with Oesophageal Cancer

Cancer of the oesophagus can be a particularly distressing condition as it may severely affect the patient’s ability to swallow therefore impeding their eating and drinking. This is compounded by the fact that the survival rate for the past five years remains low at around 5% (unchanged for about 20 years). This type of cancer is most common in men in their 60s (perhaps due in part to lifestyle factors, including alcohol intake, tobacco use and occupational risks).

The oesophagus is about 10 inches long and joins the pharynx to the stomach and is situated behind the trachea. It consists of several layers; the outer layer is a membrane of connective tissue, inside this is the muscle layer which helps by peristaltic action to move contents down into the stomach. Within this there are layers of mucus which help to lubricate the food to ensure it moves smoothly.

Adenocarcinoma is the most common type of oesophageal cancer, it is connected to acid reflux and obesity and generally affects the lower 2/3 of the oesophagus. If acid reflux persists it can lead to squamous cells being replaced with glandular cells (a condition known as Barrett’s oesophagus) which is a risk factor for later developing oesophageal cancer.

Squamous cell carcinoma affects the top third of the oesophagus, and it is this type of cancer which is linked with tobacco use and excessive alcohol consumption.

Oesophageal cancer generally presents as intermittent dysphagia. The dysphagia will develop with time. Patients may regurgitate food from their oesophagus, this should not be confused with the vomit of stomach contents. Coughing up copious amounts of saliva is common in the mornings as it has had chance to build up overnight.

Patients may find they are losing weight and may need to adapt their diet to include softer, moister foods. In later stages liquids only may be tolerated.

Oesophageal cancer is generally diagnosed after an endoscopy where a biopsy is also taken of any lesions found. A CT scan of the chest and pelvis may then be taken. This is to check if there has been metastasis; key areas for this are lung, liver, stomach and abdominal cavity.

Treatment is planned around information gained from scans, history taking and biopsies to determine the size of the tumour, tumour type and metastasis.

There are several investigations that may be carried out:

  • Endoscopic ultrasound to assess how far the cancer has spread into the oesophageal wall
  • CT scan – this will show up metastasis and lymph node enlargements
  • Positron emission tomography scan wherein the patient is given an injection of a radioactive substance (fludeoxyglucose F18) that is absorbed by fast-dividing cancer cells
  • Cardiopulmonary exercise test – this is to assess a patient’s risk under general anaesthetic
  • Laparoscopy – requires a general anaesthetic, an interval inspection of the abdominal cavity

Unless there has been metastasis, surgery will be offered. If there has been metastatic spread the patient will be referred for palliative care. In this case no further tests are necessary.

The only cure of oesophageal cancer is through surgery. However, 70-80% of oesophageal cancers return after surgery. The other options, if either the patient is unsuitable for surgery or if the cancer has metastasised are chemotherapy, radiotherapy and palliative care.

Preoperative chemotherapy may be required if the tumour has progressed past two stages, this will be to shrink the tumour; chemotherapy may be scheduled for three three-week cycles before surgery. Chemotherapy is often continued after surgery as well to reduce the risk of metastasis.

The surgery itself is a major intervention and can take around eight hours. The affected part of the oesophagus is removed with up to half of the stomach. The part of the stomach that is removed is formed into a tube and used to replace the diseased part of the oesophagus.

Post-surgery the patient will be monitored for at least 24 hours in ITU with particular concern for respiratory insufficiency and also sepsis as a result of anastomatic leak. The patient will be NMB for about a week to allow healing. Fluids are administered through a central line, and nutrition through a jejunostomy tube (which stays in place for two weeks post surgery). A nasogastric tube will also be inserted to allow release of gas or fluid from the stomach. After about a week after surgery the patient may be encouraged to drink and begin eating a soft diet. The swallow may be strange at first but will improve and become normal in time.

It may take up to a year for a patient to recover after oesophageal surgery – acid reflux may be a problem as the cardiac valve is removed during surgery. Patients may find extra pillows at night may help, and not eating for an hour before bed. Diet will be modified as the stomach is smaller so the same volume of food may need to be distributed more evenly throughout the day. Patients might not get hunger sensations any more which can make the need to eat little and often more difficult.

Recurrence of the cancer is common. Most patients will experience this. Any dysphagia after surgery needs to be discussed. It might simply be over-granulation of the anastomosis which can constrict; if this is the case, a balloon dilation of the oesophagus may be necessary (sometimes more than once). It is important to remember that the survival rate for oesophageal cancer is low and that recurrence is common.

Early Menopause

This is menopause experienced before the age of 45. These patients are more at risk of health conditions associated with the menopause, such as CHS, CVA and osteoporosis if they don’t take HRT.

Early menopause can be caused by a variety of factors such as; viral infections, enzyme deficiencies, chromosome abnormalities such as fragile X syndrome, and Turner’s syndrome. It may also be caused by FSH receptor gene polymorphism and mutation of inhibin B. Other medical factors include hypothyroidism, type I diabetes, Crohn’s disease, SLE, rheumatoid arthritis, Addison’s disease and myasthenia gravis.

There are other factors of a secondary nature which include chemo/radiotherapy, or oophrectomy.

Assessment and diagnoses will require blood tests for FSH, if necessary two weeks apart if there is no calculable cycle, bloods for testosterone, prolactin (to exclude polycystic ovary syndrome) TSH, progesterone (for fertility). Chromosome analysis for fragile X syndrome may be required, also the assessment ought to include a BMI, BP and bone density scan.

Because women with early onset menopause are at greater risk of the associated conditions, it is essential that they are screened initially and also that these checks are made regularly. Patient education regarding reversible risks factors of these conditions is vital.

For early menopause, HRT or a combined contraceptive pill can be prescribed; particularly as contraception still needs to be considered.

About Lymphoedema and its Management

In 2003 studies were carried out which found that there were at least 100,000 people in the UK who were living with some type of lymphoedema, although this is a conservative estimate, and there could well be 200,00 Britons with lymphoedema (Moffatt 2003).

The lymphatic system maintains homeostasis by transporting interstitial fluid which contains protein, waste products and water back into the blood supply (Keen 2008). If this system fails, or is impaired, protein and fluid can accumulate in the tissues, attracting more water by osmosis which then results in a clearly visible swelling. This is known as lymphoedema (Huit 2000). A sign of lymphoedema is when there is an inability to pinch up a skin fold at the base of the second toe – this is known as Stemmer’s sign (Keen 2008). Oedema ‘pits’ when pressed, and after a few seconds the pit will disappear as the fluid returns (Nigam 2008).

Primary oedema is caused by filiaritic infection caused by mosquito bites (more prevalent in the developing world), congenital conditions such as Milroy’s disease (MacLaren 2001). Idiopathic lymphoedema is thought to occur when there is an underdevelopment of lymph vessels (King 2006).

The most common cause of lymphoedema in the UK is due to cancer treatment such as surgery or radiotherapy which cause damage to lymph nodes or removes them completely (MacLaren 2001). This is known as secondary lymphoedema, it can also be caused by trauma, inflammation (including inflammatory arthritis), or infection such as bacterial cellulitis, tuberculosis or filarial infections (Keen 2008).

Common causes of oedema are pregnancy, immobility, varicose veins and cardiac failure. All of these can contribute to the impairment of the lymph vessels’ ability to transport interstitial fluid back to the blood. Cardiac failure can result in pooling of venous stasis, pooling in the legs, which then puts pressure on the venous system, this can lead to pulmonary oedema (Nigam 2008).

Lymphoedema is not a condition that can be cured, but it can be controlled, and through treatment patients can improve their mobility, decrease the impact inflammatory episodes have on their lives, and enhance their quality of life (Huit 2000). If treatment is not initiated, the condition will gradually become worse. After time, as a result of the accumulation of the excess interstitial fluid, fat and fibrous deposits appear (King 2006). The tissue hardens and the oedema no longer pits; in such cases hyperkeratosis is common (excessive growth of skin to form scaly, horny layers), as is papillomatosis (preponderance or wart growths), and lymphorrhoea (leakage of lymph fluid) (Keen 2008), in some cases if oedema continues, massive oedema known as elephantiasis can develop as the lymph vessels become almost completely blocked, ulcers can also develop which are difficult to heal (Nigam 2008). Because the lymph fluid is protein rich, bacterial and fungal infections are common, which increases the risk of acute exacerbations (Huit 2000). Cellulitis can occur during an acute inflammatory episode and should be treated with broad-spectrum antibiotics (King 2006).

Accurate diagnosis, treatment and patient education of lymphoedema is essential if the best outcomes are to be achieved (Huit 2000). It is also important to diagnose the cause of lymphoedema in order to rule out other causes such as cardiac failure, hypertension, lipoedema, protein deficiency, DVT, or immobility. Defining the cause will ensure the most effective treatment and therefore the best outcome. Clinical presentation, previous medical history, and the results of investigations are all invaluable in determining the cause (King 2006).

Treatment (not cure) is aimed at reducing the oedema and encouraging improved lymph fluid flow (King 2006). There are several principles in the treatment and management of lymphoedema: skincare, compression, exercise, and lymphatic drainage (King 2006). From these four points, it is clear to see how essential patient education is, and how patients themselves can ensure the effectiveness of the treatment prescribed. As with all care planning, the patient should be involved in decision-making and should therefore to be able to give informed consent to proposed treatments.

It is likely that for treatment to be effective, the patient will need to make some lifestyle changes, such as increasing the level of activity and exercise taken, making changes to diet by reducing the intake of salt, and losing weight. Also patients may need to develop new habits such as elevating the affected limb(s) to aid venous return, (oedema responds to gravity and therefore if the affected limb is elevated, this assists in the drainage of the fluid back into the blood supply (Nigam 2008)), taking prescribed medication regularly, and adopt the use of compression garments (Nigam 2008). Because this may mean significant changes to a person’s lifestyle, it is particularly helpful if information can be written down for the patient in order for them to refer back to it in the future (Honner 2009).

Good hygiene and skincare is vital for people living with lymphoedema; the aim is for the skin to be kept supple, healthy and hydrated. Even tiny breaks in the skin can lead to infection (Huit 2000). Soap should be avoided as it removes the natural oils that exist to protect the skin, making it more fragile and prone to breaking. Therefore emollients should be used instead such as aqueous cream. Skin should be patted dry, and care must be taken when moisturising that products are not rubbed into the skin, but rather smoothed over the skin in a downward direction (the direction of the hair) this reduces the risk of folliculitis (Penzer 2003). Skin should be inspected daily for any signs of inflammation discolouration or breaks in the skin, as these could signal an inflammatory episode (King 2006). Patients should also be advised to take care of their affected limbs to reduce the risk of injury to them, wearing footwear at all times, or gloves when gardening or washing up, and using insect repellents and sun block adequately (King 2006).

Compression garments or bandaging can be applied to provide a graduated compression to aid vessels transporting the lymph fluid back into the blood supply, it can also prevent the oedema occurring (Huit 2000). In patients with mild oedema where the shape of the limb has not been distorted and with no contraindication (such as arterial disease, cardiac failure, VTE, or allergies), compression garments can be applied immediately with great effect. Patients need to be assessed and measured for their suitability and sizing for compression garments or bandaging (King 2006). Such garments need to be worn daily if they are to achieve their purpose. Again, this is why patient engagement is essential; without concordance most lymphoedema treatments will fail. For patients with more significant oedema, a period of intensive treatment with compression bandages may be required to reduce the oedema and develop a normal shaped limb in order to fit with compression garments. All of this needs do be done and prescribed by an adequately trained practitioner (King 2006).

Exercise is a good way of decreasing oedema, however, because the oedema itself can be a reason for limited mobility any exercise plans should be tailored for the patient’s needs and abilities (Woods 2004); if compression garments have been prescribed, they will need to be worn during exercise (King 2006). Exercise should be moderate, introducing new exercises gradually and not overdoing it. Low impact exercise such as cycling, swimming and walking are advised (MacLaren 2001).

Lymphatic drainage massage works by promoting the removal of interstitial fluid away from the oedematous areas. It should only be performed by a competent [practitioner as the technique is substantially different from regular massage techniques (Huit 2000). This is a particularly good form of treatment for those patients who are unable to tolerate compression treatments for whatever reason. Again patient involvement is vital – patients can be taught to perform this technique on themselves, which can prove effective (King 2006).

The management of lymphoedema can be difficult, there are many factors to consider, causes, contraindications to treatment, patient concordance, education and lifestyle. The more involved the patient is in their treatment, the more likely it is to be effective. Lymphoedema is often overlooked, but if poorly managed can have a seriously negative impact on a person’s lifestyle, body image, and outlook. Therefore it is imperative that lymphoedema is swiftly diagnosed, treatment determined and initiated to minimise distress and inconvenience to the patient (King 2006).


  • Honner, A. (2009) The information needs of patients with therapy-related lymphoedema Cancer Nursing Practice. 8, 7, 21-26
  • Huit, M. (2000) A guide to treating lymphoedema Nursing Standard 96, 38 42
  • Keen D.C. (2008) Non-cancer-related lymphoedema of the lower limb Nursing Standard. 22, 24, 53-6.
  • King, B. (2006) Diagnosis and management of lymphoedema Nursing Times 102, 13, 47
  • Lymphoedema Network (2006) Best Practice for the Management of Lymphoedema International Consensus. London. MEP Ltd
  • MacLaren, J.A. MA, (2001) Lymphoedema
  • Moffatt et al, (2003) Lymphoedema: an underestimated health problem. QJM med, 2003, 96: 731-738
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  • Woods, M. (2004) Causes and treatment of early Lymphoedema Cancer Nursing Practice 3, 5, 25-30

Sugar and Diabetes

According to Azmina Govindji (Diabetes Wellness News April 2011) the latest advice to those with diabetes is that a diabetic diet is a low sugar diet, rather than a ‘no sugar’ diet. A lifestyle of exercise and good healthy diet is essential for wellbeing, consuming low levels of salt, sugar and saturated fat, and high in fibre.

A small amount of sugar can be combined with low glycaemic carbohydrates (e.g. pasta and pulses) as low glycaemic foods help to stabilise blood glucose, which prevents the blood glucose increasing too rapidly. All patients with diabetes are entitled to help from a dietitian to enable a healthy yet practical plan.