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Can exercise offset some of the harms of regular drinking?

NHS Choices - Behind the Headlines -

"Adults who booze regularly but exercise for five hours a week are no more likely to die than teetotallers," the Mail Online reports.

A study suggests exercise may compensate for some, but certainly not all, of the harms associated with excessive alcohol consumption. This latest study looked at deaths from cancer and cardiovascular disease, as well as premature death in general (usually judged to be dying before the age of 75).

Researchers looked at around 10 years' worth of national survey data from UK adults aged over 40. Unsurprisingly, they found links between all-cause and cancer mortality in inactive people. But they also found increasing levels of physical activity generally removed the association with drinking habits. In fact, occasional drinking was associated with a significant reduction in all-cause mortality for the most active of people.

Although the study had strengths in its large sample size and regular follow-up, we can't be sure that any links observed were solely down to the interaction between alcohol and exercise. For example, people who are physically active may also avoid smoking and consume healthy diets. It is difficult to completely control for such influences when analysing data like this.

While regular exercise may mitigate against some of the harms associated with excessive alcohol consumption it certainly won't make you immune. Many world-class sportspeople, such as George Best and Paul Gascoigne, have had both their careers and lives blighted by drinking.

 

Where did the story come from?

The UK-based study was carried out by an international collaboration of researchers from Canada, Australia, Norway and the UK. The health surveys on which the study was based were commissioned by the Department of Health, UK. Individual study authors also reported receiving funding from the National Health and Medical Research Council and University of Sydney. 

The study was published in the peer-reviewed British Journal of Sports Medicine. 

The media coverage around this topic was generally overly optimistic, highlighting that by exercising, individuals can completely undo the harm caused by excessive alcohol consumption, which is untrue.

In particular, the Mail Online claimed "Adults who booze regularly but exercise for five hours a week are no more likely to die than teetotallers" which could send out the wrong message to the public.

 

What kind of research was this?

This cohort study analysed data from British population-based surveys: Health Survey for England (HSE) and the Scottish Health Survey (SHS) to investigate whether physical activity is able to moderate the risk between alcohol consumption and mortality from cancer and cardiovascular diseases.

Cohort studies like this are useful for assessing suspected links between an exposure and outcome. However, there are potentially other factors that have a role to play in such associations and therefore the study design doesn't allow for confirmation of cause and effect.

 

What did the research involve?

The researchers collected data on 36,370 men and women aged 40 or above from Health Survey for England (1994; 1998; 1999; 2003; 2004; and 2006) and the Scottish Health Survey (1998 and 2003). Among other things, the participants were asked about their current alcohol consumption and physical activity.

Alcohol intake was defined by six categories (UK units/week):

  • never drink (lifetime abstainers)
  • ex-drinkers
  • occasional drinkers (haven't drank anything in past seven days)
  • within (previous) guidelines: <14 units (women) and <21 units (men)
  • hazardous: 14-15 units (women) and 21-19 units (men)
  • harmful: >35 (women) and >49 (men)

Frequency and type of physical activity in the past four weeks was questioned and converted into metabolic equivalent task-hour (MET-hours, which are an estimate of metabolic activity) per week according to national recommendations:

  • inactive (≤7 MET-hours)
  • lower level of active (>7.5 MET-hours)
  • higher level of active (>15 MET-hours)

The surveys were linked to the NHS Central Register for mortality data and the participants were followed up until 2009 (HSE) and 2011 (SHS). There were 5,735 recorded deaths; deaths from cancer and cardiovascular disease were of most interest for this study.

The data was analysed for associations between alcohol consumption and the risk of death from all-causes, cancer and cardiovascular disease. The results were then analysed according to levels of physical activity.

Potential confounders (such as sex, body mass index and smoking status) were controlled for.

 

What were the basic results?

Overall, the study found a direct link between all levels of alcohol consumption and risk of cancer mortality. It also found that increasing levels of physical activity reduced this association with cancer mortality, and also reduced the link with death from any cause.

  • In individuals who reported inactive levels of physical activity (≤7 MET-hours), there was a direct association between alcohol consumption and all-cause mortality.
  • However, in individuals who met the highest level of physical activity recommendations a protective effect of occasional drinking on all-cause mortality was observed (hazard ratio: 0.68; 95% confidence interval (CI): 0.46 to 0.99). It should be noted that this result just skimmed the cut-off point for statistical significance.
  • In this high activity group, there was no link between all-cause mortality and alcohol consumption within guidelines, or even hazardous amounts, but the risk was still increased for those drinking harmful amounts.
  • The risk of death from cancer increased with the amount of alcohol consumed in inactive participants, ranging from a 47% increased risk for those drinking within guidelines to 87% increased risk for those with harmful drinking.
  • In people with higher activity levels (above 7.5 MET hours) there was no significant link between any amount of alcohol consumption and cancer mortality.
  • No association was found between alcohol consumption and mortality from cardiovascular disease, although a protective effect was observed in individuals who reported the lower and higher levels of physical activity (>7.5 MET-hours) and (>15 MET-hours) respectively.

 

How did the researchers interpret the results?

The researchers concluded "we found evidence of a dose–response association between alcohol intake and cancer mortality in inactive participants but not in physically active participants. [Physical activity] slightly attenuates the risk of all-cause mortality up to a hazardous level of drinking."

 

Conclusion

This study aimed to explore whether physical activity is able to moderate the risk between alcohol consumption and mortality from cancer and cardiovascular diseases. It found that increasing levels of physical activity reduced the association for death from both all-causes and cancer.

This study has strengths in its large sample size, comprehensive assessments and long duration of follow-up. The findings are interesting, but there a few points to bear in mind:

  • As the authors mention, cohort studies such as this are unable to confirm cause and effect. Though the researchers have tried to account for various potential health and lifestyle confounding variables, there is the possibility that others are still influencing the results. A notable one is dietary habits which weren't assessed. Also, for example, the former drinkers may have quit due to other health issues which may have introduced bias.
  • The study was unable to look at binge drinking levels of alcohol consumption which would have likely had important health implications.
  • Additionally, there is always the possibility with self-reported surveys that the participants either under or over-reported their drinking habits which can increase the chance of misclassification bias.
  • Though having a large sample size, fewer people reported harmful drinking levels, so links within this category may be less reliable.
  • The study has only looked at the link between alcohol and actually dying from cancer or cardiovascular disease. Links may be different if they looked at associations between alcohol and just being diagnosed with cancer or heart disease, for example.
  • The study is also only representative of adults over the age of 40.

Overall, maintaining a healthy lifestyle seems to be the best bet for reducing the risk of any chronic disease, be it through physical activity, balanced diet or reasonable alcohol consumption.

Current alcohol recommendations for both men and women are to drink no more than 14 units per week.  

Links To The Headlines

How exercise undoes the harm from drinking: Adults who booze regularly but exercise for five hours a week are no more likely to die than teetotallers. Mail Online, September 8 2016

Two hours a week of exercise could offset the dangers of alcohol. The Daily Telegraph, September 8 2016

Exercise can cut risk from alcohol-related diseases, study suggests. The Guardian, September 8 2016

Links To Science

Perreault K, Bauman A, Johnson N, et al. Does physical activity moderate the association between alcohol drinking and all-cause, cancer and cardiovascular diseases mortality? A pooled analysis of eight British population cohorts. British Journal of Sports Medicine. Published online August 31 2016

Can colic really be cured by acupuncture?

NHS Choices - Behind the Headlines -

"Is sticking needles in babies really the best way to ease distress from colic?" the Daily Mail asks.

The question was prompted by a study that looked at whether acupuncture can help with colic in babies.

Colic is a common yet poorly understood condition that causes excessive and prolonged crying in babies. It's not serious, but can be distressing for parents.

Researchers randomly assigned 157 babies aged two to eight weeks to three treatment groups: standard care, minimal acupuncture, and acupuncture based on the principles of traditional Chinese medicine.

They found the total time spent crying was reduced by around 40 minutes a day in babies allocated to the acupuncture groups.

While this is a well-designed trial, the findings should be interpreted with some caution.

The researchers set out to compare two different forms of acupuncture, but had to combine the groups as they did not analyse enough infants to reliably detect differences.

Also, as acupuncture caused crying in more than three-quarters of the babies treated, it's questionable how useful it is as an intervention to stop excessive crying. 

A larger trial would be required to confirm whether acupuncture is an effective and acceptable treatment for colic.

More traditional ways to treat colic include holding your baby during a crying episode, sitting or holding them upright during feeding to prevent them swallowing air, and avoiding too much tea, coffee and other caffeinated drinks if you're breastfeeding.

Where did the story come from?

The study was carried out by researchers from Lund University in Sweden and was funded by Ekhagastiftelsen, Family Uddenäs.

It was published in the peer-reviewed journal Acupuncture Medicine on an open access basis, so it's free to read online.

This has been covered widely by the UK media.

While the actual reporting of the study has been broadly accurate, as is so often the case some headline writers have overstated the implications of the results.

A case in point is The Daily Telegraph's headline: "Acupuncture helps young babies stop crying".

The Daily Mail's headline – "Scientists split over using acupuncture to treat the condition" – is much more accurate, as it reflects the difference of opinion among independent experts.

Professor George Lewith of the University of Southampton is quoted as saying: "This looks to me to be a good-sized, fastidious, well-conducted study … which suggests that minimal acupuncture is a reasonable and, as far as we know, safe intervention for infantile colic."

A contrasting view is provided by Professor David Colquhoun, who is quoted as saying: "What parent would think that sticking needles into their baby would stop it crying? The idea sounds bizarre. It is." 

What kind of research was this?

This randomised controlled trial aimed to assess two acupuncture protocols against usual care for the treatment of colic in infants. 

This type of trial is the best way of assessing a specific intervention, as the random assignment of participants to groups reduces the risk of bias and means any differences seen are likely to be the result of the intervention.

And as all the babies were presumably unaware on a conscious level of the treatment they were receiving, there was a level of blinding normally lacking in acupuncture research.

What did the research involve?

The study was carried out at four child health centres in Sweden.

Parents seeking help for their baby's colic were informed of the trial and invited to participate if they met eligibility criteria.

The researchers randomly assigned infants to one of three treatments groups.

In addition to usual child healthcare, the infants received:

  • standardised minimal acupuncture – based on a Western understanding of the nervous system
  • semi-standardised individual acupuncture – inspired by traditional Chinese medicine, which is based on "acupuncture points"
  • no acupuncture

To be eligible for the trial, infants had to meet the following requirements:

  • fulfil criteria for colic – crying for at least three hours a day at least three days a week
  • aged two to eight weeks
  • have healthy and appropriate weight gain
  • have tried a diet excluding cow's milk protein from breastfeeding mothers or appropriate formula for at least five days

Infants were excluded if they were born preterm (earlier than 37 weeks), taking any medication, or had previously tried acupuncture.

Parents recorded their infants' fussing and crying in a daily diary at the start of the trial (baseline) and at the end of the first and second week.

At the first visit, the nurse collected informed consent and background data.

At each of the following visits, parents were asked questions about changes in crying, bowel habits and sleep patterns, and any side effects they associated with acupuncture.

Three days after completing the second week, a follow-up phone interview was carried out.

The main outcome of interest was the difference in total crying time – this is the sum of the time spent fussing, crying and colicky crying between baseline and the end of the second week.

The researchers were also interested in the number of infants in each group who continued to fulfil the criteria for colic.

The intervention was delivered by trained acupuncturists. The nurses providing assessments at the child health centres and the parents were blinded to the treatment group.

What were the basic results?

Of 157 infants randomised, a total of 147 started the intervention, and 144 completed the trial.

As the trial ended early, it was not possible for the researchers to include an adequate number of infants in each of the acupuncture groups to provide solid findings.

The acupuncture groups were therefore combined to compare the overall effects of acupuncture with no acupuncture.

While receiving either type of acupuncture, the infants:

  • did not cry on 200 occasions
  • cried for up to one minute on 157 occasions
  • cried for more than one minute on 31 occasions 

When compared with usual care alone, the total crying time at the end of week one and two was significantly lower for infants receiving acupuncture (170 versus 206 minutes a day in week one, and 137 versus 176 in week two).

However, this was no longer statistically significant at later follow-up (123 versus 164 minutes a day). 

Looking at the three individual outcomes, the overall amount of time spent crying decreased significantly more in the acupuncture groups compared with usual care (40% reduction versus 22% reduction) between baseline and the end of the second week.

However, no significant difference was seen for fussing or colicky crying by the second week.

During the follow-up period, only colicky crying showed a significant difference in favour of acupuncture (92% reduction versus 65% reduction).

More infants receiving acupuncture cried less than three hours per day – and therefore no longer fulfilled criteria for colic – in the first and second week.

Looking at adverse effects, the acupuncturists reported the babies cried during more than three-quarters of the treatment sessions.

There were reports of blood in 15 out of 200 treatments. Otherwise, no adverse effects were reported. 

How did the researchers interpret the results?

The researchers concluded that, "Among those initially experiencing excessive infant crying, the majority of parents reported normal values once the infant's crying had been evaluated in a diary and a diet free of cow's milk had been introduced.

"Therefore, objective measurement of crying and exclusion of cow's milk protein are recommended as first steps to avoid unnecessary treatment.

"For those infants that continue to cry more than three hours a day, acupuncture may be an effective treatment option. The two styles of [acupuncture] tested in [the trial] had similar effects; both reduced crying in infants with colic and had no serious side effects.

"However, there is a need for further research to find the optimal needling locations, stimulation and treatment intervals." 

Conclusion

This randomised controlled trial aimed to compare two types of acupuncture treatment with usual care in infants with colic.

This trial has a number of strengths and limitations. It was well designed, and the researchers increased its validity by using a robust study protocol. Assessors were also blinded to treatment group.

However, the researchers did not analyse enough infants to be able to reliably detect a meaningful difference between the two different types of acupuncture, and therefore had to pool the groups.

As such, the study only looks at acupuncture in general and cannot provide information on a particular form of delivery.  

It's also possible that parents who were willing to try acupuncture were not representative of all parents of children with colic.

These cases may be more severe, causing parents to try more controversial treatments.

The follow-up period was short at two weeks, and we do not know if any effects seen would be sustained without continuous treatment.

There was also an imbalance at baseline in the number of infants who were breastfed – as this is a risk factor for colic, this may have increased the risk of bias.

The researchers reported no serious side effects. But considering that this is a treatment for excessive crying, you could question the merit of a procedure that causes further crying.

As this trial was not able to look at the effects of the two different forms of acupuncture on colic, a larger trial is required to confirm whether acupuncture could be an effective and acceptable form of treatment for colic, and how it could be delivered.

If your baby has colic, there are lots of ways you can try to comfort them: you can try holding your baby during a crying episode, sitting or holding them upright during feeding to prevent them swallowing air, and avoiding drinking too much tea, coffee and other caffeinated drinks if you're breastfeeding.

Read more about treating colic and soothing a crying baby.

Links To The Headlines

Is sticking needles in babies really the best way to ease distress from colic? Scientists split over using acupuncture to treat the condition. Daily Mail, January 17 2017

Acupuncture helps young babies stop crying – new research. The Daily Telegraph, January 16 2017

Two weeks of acupuncture could 'STOP your baby crying, curing colic'. The Sun, January 16 2017

Links To Science

Landgren K, Hallström I. Effect of minimal acupuncture for infantile colic: a multicentre, three-armed, single-blind, randomised controlled trial (ACU-COL). Acupuncture in Medicine. Published online January 16 2017

Hot red chilli peppers linked to longer lifespan

NHS Choices - Behind the Headlines -

"How hot chilli could help you live longer," the Daily Mail reports. A US study found that people who reported eating red hot chilli peppers had around a 13% reduced risk of premature death compared to those who avoided them.

The study looked at adults in the 1980s and 90s who reported eating any hot chillies over the past month – which could range from a single chilli to several chillies every day.

There were no significant links found when drilling down to specific cause of death rather than just overall mortality.

Ultimately this study proves very little. The researchers attempted to account for possible contributory factors, such as other dietary factors, income and age, but as they admit, unmeasured health and lifestyle factors could be influencing the link.

It is plausible that hot chillies could be linked beneficial effects. There is some evidence that the active ingredient in red hot chilli peppers, (the food, not the band) capsicum may have anti-inflammatory or anti-oxidant effects, while also boosting the metabolism. But with the exception of one study in China (which we analysed in 2015) the research has involved rodents.

It is always unwise to rely on a single "superfood", such as assuming that chillies could be the spice of a long life. It is better to follow standard recommendations and eat a balanced diet high in a variety of fruit and vegetables, limit salt, sugar and saturated fat – stay activeavoid smoking and moderate your consumption of alcohol.

 

Where did the story come from?

The study was carried out by two researchers from University of Vermont College of Medicine in the US. The authors report receiving no funding for their study and declare no conflict of interest. The study is published in the peer-reviewed journal PLOS ONE, an online open-access journal so the study is free to read online.

The Mail's coverage rather takes these findings at face value. This study does not prove that eating hot chillies will help you live longer.

 

What kind of research was this?

This was a cohort study which aimed to see whether consumption of hot chilli peppers was linked with mortality.

The researchers say that evidence on the health effects of spice consumption is lacking, particularly from Western populations. Therefore they aimed to investigate this using a large cohort of US citizens. The difficulty is that observational studies can never prove cause and effect between single dietary factors and health outcomes. Many other factors may be confounding any link. Self-assessments of frequency and quantity of consumption of individual food items can also commonly be subject to recall bias.

 

What did the researchers do?

The research used data from the National Health and Nutritional Examination Survey version III (NHANES III). Data was collected between 1988 and 1994 and the participants were at least 18 years old and said to be representative of the US adult population.

Survey participants took part in interviews assessing their health, lifestyle and socioeconomic factors. As part of this they completed an 81-item food frequency questionnaire assessing usual consumption of food and drink items over the past month.

Hot red chilli pepper consumption per month was assessed from responses to the question "How often did you have hot red chili peppers? Do not count ground red chili peppers." The researchers considered any response other than no chillies per month as a chilli consumer.

The researchers followed up mortality (by cause) by linking with the National Death Index to end of 2011. In their analyses between mortality and chilli pepper consumption the researchers adjusted for these confounders:

  • age, gender and ethnicity
  • marital status
  • educational level, employment and annual income
  • physical activity
  • consumption of meats, vegetables and fruits

 

What did they find?

A total of 16,179 adults had complete data for analysis.

Various factors were linked with increased chilli consumption, for example being younger, male, white, Mexican-American, being a smoker and drinking alcohol, and consuming more meat and other vegetables.

During an average follow-up of 18.9 years there were 4,946 deaths – 21.6% of the chilli consumers died compared with 33.6% of the non-consumers.

In the model adjusted for all confounding variables, any level of chilli consumption was linked with a 13% reduced risk of dying during follow-up (hazard ratio [HR] 0.87, 95% confidence interval [CI] 0.77 to 0.97).

When looking by specific cause of death, however, no significant links were found between chilli consumption and any cause of death.

 

What did the researchers conclude?

The researchers conclude: "In this large population based prospective study, the consumption of hot red chili pepper was associated with reduced mortality. Hot red chili peppers may be a beneficial component of the diet."

 

Conclusions

The researchers conclude from their observational study that hot chillies may be beneficial to health.

However, there are several points to bear in mind:

  • This is observational survey data that can't prove direct cause and effect. The researchers have made a valiant attempt in following the survey participants for mortality outcomes for almost 20 years, and tried to adjust for many different health and lifestyle factors that could be influencing the link. However, it is still likely that these adjustments have not been able to fully account for all of these factors – and there may be other unmeasured factors that are influencing the link.
  • The analysis only looks at the very general link with any hot chilli consumption in the past month vs. none. It doesn't look at quantity or frequency of chilli consumption – or type of chilli for that matter. Therefore the "chilli consumers" could include anything from a person who included a single chilli in a curry over the past month, for example, to people who daily eat several of the hottest chillies. Therefore it doesn't give you a great deal to go on.
  • No links were found with any particular cause of death – only the overall association with mortality that has compiled all deaths. This makes it more difficult to draw much meaning from the results. Even if chillies are directly influencing mortality, this study can't tell us by what mechanism they could be doing this.
  • The study has only looked at a specific US population sample – and their chilli consumption was assessed over 20 years ago. They may not be representative of people today, of the US culture or others.

It is plausible that hot chillies could be linked with health effects – possibly similar to how flavonoids or pigments of other fruit and vegetables have been linked with anti-inflammatory or anti-oxidant effects – or it could be down to capsicum, the active ingredient in chillies. But this is just speculation – there's no good evidence around this.

Ultimately, rather than looking for a single "superfood" that will boost health and reduce mortality risk, you're probably better off just following the standard recommendations. Eat a balanced diet high in a variety of fruit and vegetables, limit salt, sugar and saturated fat – stay activeavoid smoking and moderate your consumption of alcohol.

Links To The Headlines

How hot chilli could help you live longer: Regularly eating the peppers found to reduce the chance of dying by 13%. Daily Mail, January 16 2017

Links To Science

Chopan M, Littenberg B. The Association of Hot Red Chili Pepper Consumption and Mortality: A Large Population-Based Cohort Study. PLOS ONE. Published online January 9 2017

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