NHS Choices

Uneven or large breasts can cause teen angst

NHS Choices - Behind the Headlines - Wed, 26/11/2014 - 15:43

"How your breast size affects your mental health: Having uneven or bigger boobs lowers self-esteem and causes eating disorders, study finds," reports the Mail Online.

But the second part of the headline, which mentions eating disorders, is both misleading and inaccurate.

The study in question, which took place in the US, looked at young females (aged 12 to 21) who had asymmetrical or abnormally large breasts (macromastia) and were attending breast clinics, comparing them with controls attending other hospital clinics.

Researchers found females in the former group tended to have lower reported self-esteem, but there was no evidence they developed eating disorders because of their breasts.

There were also no differences between their responses to questionnaires about general, physical and mental health after body mass index (BMI) was taken into account. Females with macromastia reported significantly worse physical problems and symptoms of pain, such as neck pain.

If very large breasts are causing you trouble, you may be eligible for breast reduction on the NHS. You will probably have to pay for breast reduction surgery if it is being performed for cosmetic reasons. The current cost of private surgery is around £5,000.

If you, or someone you know, are concerned about asymmetrical breasts, it's worth remembering many girls' breasts will take on a more symmetrical appearance once puberty has passed.

 

Where did the story come from?

The study was carried out by researchers from Boston Children's Hospital and Harvard Medical School.

It was funded by the Plastic Surgery Foundation and the authors report no conflicting financial interests.

The study was published in the peer-reviewed medical journal Plastic and Reconstructive Surgery.

The Mail Online's headline is misleading for a number of reasons:

  • A case-control study can never prove cause and effect.
  • After BMI was taken into account, there was no significant association between asymmetrical breasts or macromastia and disordered attitudes to eating.
  • None of the participants were diagnosed with an eating disorder – they just filled out a questionnaire about their eating attitudes.

 

What kind of research was this?

This was a case-control study that aimed to compare the psychological, emotional and physical impact of having asymmetrical breasts or macromastia compared with having breasts within the average range.

This type of study is appropriate to look for associations, but it cannot account for all possible factors influencing the results (confounders).

The research was described as a prospective cohort study, but this involves following participants up over a period of time and monitoring changes. This study was conducted over a period of five years, but information for each participant was only collected at one time point.

 

What did the research involve?

Adolescents and young women aged 12 to 21 with either asymmetrical breasts or macromastia and controls were recruited to the study at Boston Children's Hospital from 2008 to 2013.

The groups were compared in terms of self-esteem, quality of life, any disordered eating, and age-adjusted BMI.

Females with asymmetrical breasts were eligible if there was at least one cup size in difference, and 59 adolescents agreed to participate. Cup size difference was measured using a standard bra that fitted the larger breast, using sizing pads on the other side until the breasts looked symmetrical.

160 females with macromastia enrolled in the study. Macromastia was defined according to Schnur criteria as overgrowth in both breasts "requiring a minimum resected amount of tissue based on the patient's body surface area".  Macromastia can cause problems such as backache and neck pain.

The controls were 142 females who attended the same hospital, but did not have breast problems, an eating disorder, severe mental illness, or chronic medical or surgical problems.

They were enrolled at clinics within the Department of Plastic and Oral Surgery and the Division of Adolescent/Young Adult Medicine.

All participants completed three questionnaires:

  • the 36-Item Short-Form Health Survey, which measures health-related quality of life in several domains, each rated from 0 (low) to 100 (high)
  • the Rosenberg Self-Esteem Scale, ranging from 10 (poor) to 40 (good)
  • the Eating Attitudes Test, with scores of 20 or more indicating disordered eating (though not necessarily an eating disorder such as anorexia nervosa or bulimia) 

The control group also completed a short survey to identify if they had any concerns about their breasts their doctor was not aware of, including:

  • satisfaction with their breasts
  • if they were contemplating breast surgery to increase, decrease or make both breasts the same size (though none differed by a cup size)

 

What were the basic results?

Significantly more females with asymmetrical breasts or macromastia were overweight or obese (66.1%) compared with controls (40.1%).

After adjusting the results to take BMI into account, females with asymmetrical breasts scored significantly lower on one domain of the Short-Form 36 questionnaire: role limitations caused by emotional problems.

There were no significant differences for the rest of the domains:

  • general health
  • social functioning
  • physical function
  • physical role
  • body pain
  • vitality
  • mental health

After adjustment for BMI, females with asymmetrical breasts had lower self-esteem on the Rosenberg Self-Esteem Scale compared with controls.

Females with macromastia scored significantly lower on the following domains of the Short Form-36 than those with asymmetrical breasts after their higher average age was taken into account:

  • social functioning
  • physical function
  • physical role
  • body pain
  • vitality

There were no significant differences between females with macromastia or asymmetry for general health, emotional role, self-esteem or disordered eating attitudes.

A quarter of controls (32) were "so dissatisfied with the appearance or size of their breasts" that they would consider surgical intervention.

 

How did the researchers interpret the results?

The researchers concluded that, "Breast asymmetry may negatively impact the psychological quality of life of adolescents similar to macromastia [large breasts]."

They go on to say that, "Breast asymmetry is not just a cosmetic issue. Providers should be aware of the psychological impairments associated with asymmetry and provide proper support."

 

Conclusion

This study found young females with macromastia report lower quality of life and physical health, as well as more pain and poorer mental health than females with asymmetrical breasts or those with average breasts.

However, in this study, females with asymmetrical breasts of more than a cup size difference did report lower self-esteem.

Contrary to the media reporting, the study did not assess the impact of any treatment or surgical interventions on self-esteem, physical or mental health.

The study also did not find that females developed eating disorders because of their breasts. The researchers found women with asymmetrical breasts scored higher on a questionnaire about disordered attitudes to eating than controls, but this was no longer significant if BMI was taken into account.

In addition, none of the women with asymmetrical breasts or macromastia were reported to have an eating disorder, and the controls were not eligible for the study if they had an eating disorder.

While self-esteem was found to be lower in females with asymmetrical breasts, there were no differences between their responses to questionnaires about general, physical and mental health after BMI was taken into account. Females with macromastia reported significantly worse physical problems, pain and mental health.

A limitation of this study is the composition of the control group. They were matched to the females attending the breast clinic in terms of age, but no other features.

For example, a control group is usually matched in terms of smoking, alcohol consumption and socioeconomic status.

They were also described as "healthy" and did not have breast problems, an eating disorder, severe mental illness, or chronic medical or surgical problems, so it is not clear why they were still attending hospital outpatient clinics.

The reasons for their attendance could have a bearing on their answers to questionnaires on vitality, quality of life, and physical and mental health. In turn, this could be why very few differences were seen on these scales between females with asymmetric breasts and the controls.

If you are concerned about asymmetrical breasts of more than a cup size difference, or have symptoms such as back pain or neck pain caused by very large breasts, you can find more information on the provision of breast reduction services by the NHS.

Surgical intervention is not usually recommended for teenagers, as their breasts are still developing, so any problem with appearance or size may correct itself without the need for surgery.

Analysis by Bazian. Edited by NHS ChoicesFollow Behind the Headlines on TwitterJoin the Healthy Evidence forum.

Links To The Headlines

How your breast size affects your mental health: Having uneven or bigger boobs lowers self-esteem and causes eating disorders, study finds. Mail Online, November 25 2014

Links To Science

Nuzzi L, Cerrato F, Webb M, et al. Psychological Impact of Breast Asymmetry on Adolescents: A Prospective Cohort Study. Plastic and Reconstructive Surgery. Published online November 25 2014

Categories: NHS Choices

Are silver surfers more health savvy?

NHS Choices - Behind the Headlines - Wed, 26/11/2014 - 11:30

"Older people who use the internet … may be better equipped to keep on top of their health," BBC News reports. A survey found regular internet use in older people was associated with good health literacy.

Health literacy is a term used to describe an individual's ability to find, understand and make use of health information.

The study, which involved 4,400 adults aged 52 and over, found those who regularly used the internet were less likely to experience a drop in health literacy as they got older.

Health literacy was assessed in terms of being able to understand a mocked-up medicine label at the start of the study compared with seven years later.

There was no positive link between health literacy and reading newspapers. Indeed, certain newspapers are probably the last place you want to turn to for accurate health information. There was also a positive link for people who engage in cultural activities.

The study did not assess whether the participants were healthier, and we do not know whether being able to read a medicine label gives a reliable indication of health literacy.

Still, learning to use the internet can help combat feelings of isolation. There may be an older relative or friend you know who could benefit from "silver surfing". Organisations such as Age UK offer free internet training for older people.

 

Where did the story come from?

The study was carried out by researchers from University College London. Funding was not reported.

It was published in the peer-reviewed Journal of Epidemiology and Community Health.

The UK media reported the findings of the study accurately, but have not discussed any of its limitations.

 

What kind of research was this?

This was a cohort study that aimed to assess whether regularly reading newspapers, using the internet, and being active socially could protect against age-related reduced health literacy skills.

Only a brief study abstract of the study's findings is currently available. This means it is not possible to analyse the full methods used. A more detailed report of the study, its methodology and its findings may be published later in the year or next year.

According to the World Health Organization (WHO), "health literacy" refers to the "Cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health.

"Health literacy means more than being able to read pamphlets and successfully make appointments. By improving people's access to health information and their capacity to use it effectively, health literacy is critical to empowerment."

In this study, one measure of health literacy was assessed: being able to read a mocked-up medicine label.

This type of research cannot prove that any of these factors improve or maintain health literacy, but it can show an association or link. 

 

What did the research involve?

Adults aged 52 or over were recruited to the study from a large ongoing study called the English Longitudinal Study of Ageing (ELSA). They were assessed at baseline in 2004-05 and followed up over the next seven years.

In this piece of research, health literacy was measured using a reading comprehension test of a fake medicine label. The 4,429 participants completed this test at the beginning of the study and again in 2010-11.

Every two years, data was also collected through interviews and questionnaires on whether the participants:

  • read the newspaper daily versus never
  • used the internet consistently or never
  • engaged in civic participation or not
  • performed leisure activities or not
  • engaged in cultural activities or not
  • engaged in social networks or were socially detached

The researchers then performed statistical analyses to look for links between reading, the internet, social engagement and maintained health literacy from the beginning to the end of the study period.

They adjusted the results to take the following confounders into account:

  • baseline age
  • ethnicity
  • education
  • cognitive function
  • cognitive decline

 

What were the basic results?

People who used the internet "consistently" compared with "never" were 25% less likely to have a decline in health literacy (odds ratio [OR] = 0.75, 95% confidence interval [CI] 0.59 to 0.95).

Engaging in "consistent" cultural activities reduced the risk by 30% (OR = 0.70, 95% CI 0.55 to 0.89).

The following were not associated with health literacy decline:

  • consistently reading a daily newspaper (OR = 1.04, 95% CI 0.84 to 1.29)
  • consistent civic participation (OR not reported)
  • leisure activities (OR not reported)
  • social networks (OR not reported)

 

How did the researchers interpret the results?

The researchers concluded that, "Internet use and cultural engagement, including attending the cinema, art galleries, museums, or the theatre, appear to help older adults to maintain health literacy skills during ageing regardless of cognitive functioning."

 

Conclusion

The authors say "consistent" use of the internet and cultural engagement helps older adults maintain health literacy skills. But their study has a number of limitations, including:

  • Only a brief abstract of this study is available. This provides fairly limited information on the study, which makes it difficult to assess the complete methods.
  • No details were provided on the average age of participants. The youngest were only 52 at the start of the study and, as they were only followed up for seven years, a major decline in the ability to read a medicine label seems unlikely.
  • Health literacy appears to only have been assessed using the ability to read and understand a medicine label. It did not include the next step advocated by WHO, which is to be able to then use the health information to make good healthcare decisions. No details have been provided on the extent of the health literacy decline in people who did not use the internet or engage in cultural activities, so it is not known whether this would be large enough to be noticeable or clinically important.
  • The researchers say engaging in these activities was linked to maintaining health literacy regardless of cognitive function. Unfortunately, because of the lack of details available about the study, it is not clear whether cognitive function was formally assessed, or whether this was repeated at different time points during the study. The researchers report adjusting for cognitive function alongside age, ethnicity and education, but, with only a brief methodology available, it is unclear whether the effects of these and other potential confounders have been fully accounted for. 
  • It is not clear what "consistent" use of each of the activities means compared with "never". The participants were divided into these all-or-nothing categories, which is unlikely to be a true reflection of normal life.
  • This process was done using a mixture of questionnaires and interviews, which can be subject to recall bias and so may not be entirely accurate. In addition, reading was only considered if it was a daily newspaper, but reading books was not included.
  • While the statistical analyses did take some potential confounders into account, many other factors weren't, such as whether the participants were still in employment.

This study does not prove that internet use and cultural activities prevent age-related decline in health literacy.

Still, we would argue that health websites such as NHS Choices can provide an invaluable resource of reliable health information, news, lifestyle advice and links to other useful relevant content.

If you are reading this online, we are obviously preaching to the converted, but you may know an older person who you think would benefit from being taught how to use the internet with confidence.

As well as charities such as Age UK, most local libraries should contain details of internet training courses.

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter. Join the Healthy Evidence forum.

Links To The Headlines

'Silver surfers' may be more health-aware. BBC News, November 26 2014

Silver surfing is good for your health: Regular users found to look after themselves better because they stave off mental decline. Daily Mail, November 26 2014

Internet usage boosts health of the elderly. Daily Express, November 26 2014

Links To Science

Kobayashi LC, Wardle J, von Wagner C. OP49 The influence of regular reading, internet use, and social attachment on maintaining health literacy skills during ageing in the English Longitudinal Study of Ageing. Journal of Epidemiology and Community Health. Published online September 2014

Categories: NHS Choices

No proof 5:2 diet prevents cancer

NHS Choices - Behind the Headlines - Tue, 25/11/2014 - 12:00

"Could 5:2 diet help to ward off cancer?" is the question posed by the Mail Online after the publication of a study into experimental diets.

An honest and accurate answer to the question, based on the study, would be "we don't know".

The Mail reports on a study that gives an overview of the evidence surrounding low-calorie diets and intermittent fasting, and whether they are beneficial to our health.

But this study does not provide new evidence on the 5:2 diet or whether fasting diets ward off cancer.

As the piece didn't report the methods used to find the evidence, it is unclear whether any cherry-picking took place. That is, evidence supporting the authors' opinions may have been included, but conflicting evidence may have been ignored.

The article says we need more good-quality research on issues such as whether certain types of diet can have a wider beneficial impact on health. We would certainly agree with this view.

The best way to reduce your cancer risk is to eat a balanced diet that includes plenty of fruit and vegetables, and is low in red and processed meat and salt. 

 

Where did the story come from?

The study was carried out by researchers from many different collaborating US universities, as well as one UK and one Belgian University.

It was funded by the US National Institute on Aging Intramural Research Program and the Glenn Foundation for Medical Research, the US National Institutes for Health, the European Union's Seventh Framework Programme MOPACT, Genesis Breast Cancer Prevention (UK) and the Belgian Foundation for Scientific Medical Research.

The study was published in the peer-reviewed Proceedings of the National Academy of Sciences (PNAS).

The media reporting was generally true to the facts of the research, which focused on the speculation that a fasting diet might reduce the risk of cancer. 

But neither the Mail nor The Daily Telegraph made it clear to their readers that this study was not a systematic review, which would have given more weight to its findings. Rather, it was more of an expert opinion piece.

The Telegraph did include a useful quote from Tom Stansfeld of Cancer Research UK, who said more research was needed looking into the long-term effects of intermittent fasting.

He added: "Decades of research tell us the best way to reduce the risk of cancer through nutrition is to eat a balanced diet with plenty of fruit and veg, and low in red and processed meat and salt."

 

What kind of research was this?

This was an evidence-informed "perspective" article describing the physiological responses of people and animals to controlled variation in meal size, frequency and timing of meals, and the impact on health and disease.

The study group described how research efforts have largely ignored the importance of the frequency and timing of meals, and potential benefits of periods of no or very low energy intake. Hence, they sought to describe some of the evidence around this grey area.

They argue eating three meals a day is abnormal from an evolutionary point of view. They also describe how the habit of eating three meals a day appears to have begun when humans switched from being hunter gatherers to farmers around 12,000 years ago.

The rationale is that our bodies, which have evolved incrementally over millions of years in the context of periods of fasting, may not be best suited to this relatively modern dietary switch.

Some studies suggest restricting energy intake for as little as 16 hours can have health benefits. They say the mechanisms that mediate this benefit are metabolic shifts to using fat as an energy source, and the stimulation of cellular responses that prevent and repair molecular damage.

 

What did the research involve?

It was not clear how the evidence to inform this "perspectives" piece had been searched for, selected or synthesised, as no methods were described.

As no systematic methods were described, as would be the case with a systematic review, we cannot discount the potential influence of bias on the evidence selection, sifting and synthesis. These biases have the potential to influence the content and conclusion of the article.

What we do know is the piece considered evidence on three broad experimental diets:

  • caloric restriction (CR) – where daily calorie intake is reduced by 20-40% and meal frequency is unchanged
  • intermittent energy restriction (IER) – this involves eliminating (fasting) or greatly reducing daily food and caloric beverage intake intermittently; for example, two days a week, as is used in the popular 5:2 diet
  • time-restricted feeding (TRF) – this involves limiting daily food intake and caloric beverages to a four to six-hour period

This article also reportedly incorporated information from a workshop on eating patterns and disease. Those with a particular interest in experimental diets may find the video of the workshop interesting, though we should warn you it is more than six hours long.

The Mail Online said the IER 2-Day Diet described in the article is the forerunner to the 5:2 diet. It involves two days of eating just 600 to 1,000 calories of low-carbohydrate foods. On the other five days, the dieter eats a healthy Mediterranean diet. Women usually need 2,000 calories a day, while men need 2,500.

 

What were the basic results?

There are no clear new results presented in this article, as it presents a flowing, evidence-informed description of the state of knowledge around the timing and frequency of eating and its potential influence on health. The media picked up on the description of the IER diet section around cancer.

The research said: "IER/fasting can forestall and even reverse disease processes in animal models of various cancers, cardiovascular disease, diabetes and neurodegenerative disorders", citing a single source on the molecular mechanisms of fasting.

It then goes on to describe four general biological mechanisms by which IER might protect cells against injury and disease.

It also suggests future directions for research and society-wide implications, highlighting how recommendations for healthy patterns of meal frequency and timing may emerge as more evidence gathers consensus.

 

How did the researchers interpret the results?

The researchers indicated that, "If sufficient evidence does emerge to support public health and clinical recommendations to alter meal patterning, there will be numerous forces at play in the acceptance or resistance to such recommendations."

These, they said, included the cultural tradition dictating three meals a day, the food industry's vested interest in making people eat frequently, and the ability or willingness of health systems to emphasise prevention through lifestyle modification, overtreatment and medicalisation.

 

Conclusion

This evidence-informed article presents an overview of, and perspective on, the potential mechanisms through which low calorie or intermittent fasting diets may be beneficial to the body.

The information provided by the authors is certainly interesting. But this study does not provide new or compelling evidence proving that fasting diets actually lead to a lower risk of disease or postponement of death.

This does not appear to be a systematic review, where the authors would search the global literature to identify all relevant evidence on the effects of different eating patterns on health outcomes.

As the piece reported no methods, we do not know how evidence for the article was searched for, selected or synthesised, and it therefore has the potential to be biased. 

The main contribution of this study is as a discussion starter. From the evidence included in the piece, it seems clear there is relatively little definitive evidence pointing to the best pattern or timing of meals. In this void of evidence, there may be misinformation.

For example, the researchers say that despite equivocal and even contradictory scientific evidence, breakfast is often touted as a weight-control aid, but recent evidence has suggested it may not be.

In addressing or clarifying potential misinformation, the article says we need more clarity about these still grey issues through more and better research.

The authors also say we need to ensure that the best available evidence is informing public guidelines and knowledge on these topics. It is tough to argue against this.

Intermittent fasting diets such as the 5:2 diet may not be suitable for pregnant women and people with specific health conditions, such as diabetes or a history of eating disorders.

Because it is a fairly radical approach to weight loss, it is wise to speak to your GP first if you are considering trying intermittent fasting for yourself.
 
Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter. Join the Healthy Evidence forum.

Links To The Headlines

The 5:2 diet helps beat cancer and Alzheimer's, study finds. The Daily Telegraph, November 24 2014

Could 5:2 diet help to ward off cancer? Scientists say having longer periods without food could be good for us. Mail Online, November 24 2014

Links To Science

Mattson MP, Allison DB, Fontana L, et al. Meal frequency and timing in health and disease. PNAS. Published online November 17 2014

Categories: NHS Choices

Can a yoghurt a day reduce diabetes risk?

NHS Choices - Behind the Headlines - Tue, 25/11/2014 - 11:20

"Eating a small portion of yoghurt every day may reduce diabetes risk," The Independent reports.

This news comes from a US study that assessed the eating habits of more than 100,000 people and then followed them up every four years, looking for new diagnoses of type 2 diabetes.

Pooling the results of this study with 14 other studies, the researchers estimated each serving of yoghurt – 244 grams (g) – a day decreased the risk of developing type 2 diabetes by around 18%.

There was no significant link between total dairy intake or intake of other specific dairy products and type 2 diabetes.

A challenge facing this and similar studies is making sure all relevant outside influencing factors (confounders) have been accounted for, which is very tricky to do in practise.

If this has not been done conclusively, yoghurt consumption may be acting as a marker of a healthier lifestyle in general and has no direct influence on diabetes risk, which may be the case here.

We also don't know what sort of yoghurt the participants consumed. For example, many low-fat yoghurts are very high in sugar, which could contribute to weight gain.

It is therefore possible yoghurt may reduce the risk of developing diabetes, but may increase the risk of other diseases.

Current advice to reduce the risk of type 2 diabetes remains the same: eat a healthy diet, maintain a healthy weight, avoid smoking, moderate alcohol consumption, and take regular exercise.

 

Where did the story come from?

The study was carried out by researchers from Harvard School of Public Health and was funded by the US National Institutes of Health.

One of the study's authors declared a competing interest as he "holds membership of Unilever North America Scientific Advisory Board".

Unilever produces a huge number of commonly eaten yoghurts. It is not clear to what extent this conflict of interest may have influenced the study design, methodology or interpretation.

The study was published in the peer-reviewed medical journal BioMed Central (BMC) Medicine. It is an open access journal, meaning that anyone can read the full research publication for free.

Generally, the media reported the study accurately. But many sources chose to suggest that, "it might be a good idea to eat yoghurt regularly" without due consideration for the potential downsides of this advice.

For example, eating low-fat, high-sugar yoghurt may contribute to weight gain and weight-related diseases other than type 2 diabetes. It could also potentially increase the risk of tooth decay, particularly in children.

It also wasn't made clear what type of yoghurt was consumed, or that the association between yoghurt and diabetes may still be influenced by other factors.

 

What kind of research was this?

This was a meta-analysis combining the results of three large prospective cohort studies.

The researchers attest that the relation between the consumption of different types of dairy and the risk of type 2 diabetes remains uncertain.

They therefore aimed to evaluate the association between total dairy and individual types of dairy consumption and incident type 2 diabetes in US adults.

Type 2 diabetes is a condition where the person can't control their blood glucose, either because the body doesn't produce enough insulin or the body's cells don't react to insulin.

The rapid rise in the number of adults in Westernised nations such as the UK developing type 2 diabetes is caused by:

  • increasing obesity levels
  • a lack of exercise
  • an increase in unhealthy diets
  • an ageing population

Read more about risk factors for type 2 diabetes.

 

What did the research involve?

The research team used existing data on 41,436 men in the Health Professionals Follow-Up Study (1986-2010), 67,138 women in the Nurses' Health Study (1980-2010), and 85,884 women in the Nurses' Health Study II (1991-2009) to look at the links between diet and type 2 diabetes.

Diet was assessed by validated food frequency questionnaires and data was updated every four years. Incident type 2 diabetes was confirmed by a validated supplementary questionnaire.

Every two years, data was gathered and updated on risk factors for chronic diseases, such as body weight, cigarette smoking, physical activity, medication use and family history of diabetes, as well as history of chronic diseases such as high blood pressure and high cholesterol.

Among participants in the two nurse studies, information on menopausal status, post-menopausal hormone use and oral contraceptive use was also gathered.

The researchers analysed their results in three phases, with each phase adjusting for more and more potentially confounding factors.

The fully adjusted analysis took account of the following potential confounders:

  • age
  • calendar time with updated information at each two-year questionnaire cycle
  • body mass index (BMI)
  • total energy intake
  • race
  • smoking
  • physical activity
  • alcohol consumption
  • menopausal status
  • menopausal hormone use (Nurses' Health Study II participants only)
  • oral contraceptive use (Nurses' Health Study II participants only)
  • family history of diabetes
  • diagnosed with high blood pressure or high cholesterol at baseline
  • trans-fat intake (a type of unsaturated fat often found in processed foods)
  • glycaemic load (eating foods known to raise blood glucose levels)

As well as intakes of:

  • red and processed meat
  • nuts
  • sugar-sweetened beverages
  • coffee
  • other types of dairy foods

The team extended their work by conducting an updated meta-analysis that combined the new results from the three large cohort studies described above with findings from previous studies.

This previous research included prospective studies with cohort, case cohort or nested case-control design investigating the association between the intake of dairy products and the risk of type 2 diabetes. Literature was searched for up until October 2013.

In studies that reported the intakes by grams (g), they used 177g as a serving size for total dairy products, and 244g as a serving size for milk and yoghurt intake to recalculate the intakes to a common scale (servings per day).

 

What were the basic results?

During 3,984,203 person years of follow-up, they documented 15,156 cases of incident type 2 diabetes.

After adjustment for age, BMI and other lifestyle and dietary risk factors, total dairy consumption was not associated with type 2 diabetes risk.

The pooled hazard ratio (HR) (95% confidence interval [CI] of type 2 diabetes for one serving per day increase in total dairy was 0.99, 95% CI 0.98 to 1.01), so the this result was not statistically significant.

Among different types of dairy products, neither low-fat nor high-fat dairy intake was appreciably associated with risk of type 2 diabetes.

However, yoghurt intake was consistently and inversely associated with type 2 diabetes risk across the three cohorts with a pooled HR of 0.83 (95% CI 0.75 to 0.92) for one serving per day increment (trend analysis).

For added validity, they conducted a meta-analysis of 14 additional prospective cohorts with 459,790 participants and 35,863 incident type 2 diabetes cases.

The pooled relative risks (RRs) (95% CIs) were 0.98 (0.96, 1.01) and 0.82 (0.70, 0.96) for one serving of total dairy per day and one serving of yoghurt per day, respectively.

 

How did the researchers interpret the results?

The researchers' main conclusion was that, "Higher intake of yoghurt is associated with a reduced risk of T2D [type 2 diabetes], whereas other dairy foods and consumption of total dairy are not appreciably associated with incidence of T2D."

They added that, "The consistent findings for yoghurt suggest that it can be incorporated into a healthy dietary pattern. However, randomised clinical trials are warranted to further examine the causal effects of yoghurt consumption, as well as probiotics on body weight and insulin resistance."

 

Conclusion

This analysis of three large cohort studies, and a meta-analysis of 14 more, came up with estimates that each serving per day of yoghurt (244g) decreases the relative risk of developing type 2 diabetes by 18%.

It suggests other dairy foods and consumption of total dairy are not associated with type 2 diabetes. It was not clear over what time period this risk reduction was achieved, as follow-up times varied, but the maximum was 30 years.

The research team pointed out that their findings on total dairy intake were consistent with some, but not all, previous studies. Differences between this and previous studies may be because the current study used longer-term follow-up (more than 10 years).

The study had a number of strengths, including its large sample size, use of prospective data and ability to take account of a large number of confounding factors. 

But, as with all studies, there are also limitations to consider.

What sort of yoghurt was consumed?

Firstly, what sort of yoghurt we are talking about here? Greek, natural or added sugar, low-fat or full-fat?

From the study data presented, there are few distinctions made and all types of yoghurt are lumped together in the analysis.

This means it is not possible to know which types of yoghurt are potentially beneficial. This may depend on the levels of sugar, fat and probiotic bacteria, or other constituents.

For example, many low-fat yoghurts are very high in sugar, which could contribute to weight gain and increase the risk of harms from other weight-related diseases.

Other health outcomes not considered

This study focused exclusively on the risk of developing type 2 diabetes. The effect of diet on other diseases was not studied, so any compensating effects would go unnoticed.

For example, those eating yoghurt may be at a reduced risk of developing type 2 diabetes, but at an increased risk of developing another disease.

Were all the confounders accounted for?

Also, despite adjusting for a number of potential confounding factors, it's difficult to know whether all relevant factors have been fully accounted for.

Yoghurt consumption may be a marker of a healthy lifestyle in general, which could be associated with reduced risk of this chronic disease.

This result seems to be consistently found across the three large cohort studies and 14 other studies, which gives it some credibility.

But a systematic review and meta-analysis would be the best way to assess the link. This would ensure that all relevant material is considered. There is no guarantee that important studies were excluded from the meta-analysis of the current study, which could influence its findings.

This type of study typically feeds into the development or updating of national guidelines, which consider all the available evidence before deciding on what dietary advice to give the public. 

For now, current lifestyle advice to reduce the risk of type 2 diabetes remains the same: aim for a balanced diet high in fruit and vegetables and low in sugar, salt and saturated fats, take regular exercise in line with recommendations, avoid smoking, and moderate your alcohol consumption.

Read more about what eating a healthy, balanced diet entails. 

Analysis by Bazian. Edited by NHS ChoicesFollow Behind the Headlines on TwitterJoin the Healthy Evidence forum.

Links To The Headlines

A yoghurt a day could reduce your risk of diabetes, scientists find. The Independent, November 24 2014

How yoghurt could stave off diabetes: Just two spoonfuls a day cut odds of developing the disease by a fifth. Daily Mail, November 25 2014

A yoghurt a day may cut diabetes risk. The Times, November 25 2014

A yoghurt a day keeps diabetes away, say scientists. Daily Mirror, November 25 2014

A tablespoon of yoghurt could be key to beating diabetes, reveals new study. Daily Express, November 25 2014

Links To Science

Chen M, Sun Q, Giovannucci E, et al. Dairy consumption and risk of type 2 diabetes: 3 cohorts of US adults and an updated meta-analysis. BMC Medicine. Published online November 25 2014

Categories: NHS Choices

Therapy reduces risk of suicide or self-harm

NHS Choices - Behind the Headlines - Mon, 24/11/2014 - 11:30

“Talk therapy sessions can help reduce the risk of suicide among high-risk groups,” BBC News reports.

The headline is prompted by a large Danish study that took place over a 20-year period.

Researchers matched those who had received different psychosocial (“talking therapy”) interventions after a self-harm attempt with those who had not received a psychosocial intervention, and then compared relevant outcomes.

People who received psychological interventions had reduced risk of further self-harm, but not suicide, within the first year. Looking at longer-term follow-up, psychological interventions were associated with reduced risk of both self-harm and suicide.

However, it may be difficult to isolate the direct effect of the psychological intervention. People who had received psychological interventions were recruited from treatment clinics that required them not to be in need of psychiatric admission.

Meanwhile, those who did not receive psychological treatment were reported to include people who needed psychiatric admission, or chose not to receive suicide prevention treatment. These factors could mean that this comparison group were at increased risk of subsequent harm and death to begin with.

Also, the situation in the UK might be slightly different to Denmark. Despite this, any research that could help prevent suicides is always valuable.

 

Where did the story come from?

The study was carried out by researchers from the University of Copenhagen in Denmark and the Johns Hopkins Bloomberg School of Public Health in the US, in addition to other research institutions in Denmark and Norway. Funding was provided by the Danish Health Insurance Foundation; the Research Council of Psychiatry, Region of Southern Denmark; the Research Council of Psychiatry, Capital Region of Denmark; and the Strategic Research Grant from Health Sciences, Capital Region of Denmark.

The study was published in the peer-reviewed medical journal The Lancet Psychiatry.

BBC News was generally representative of the research’s findings, but inaccurately described participants as having “attempted suicide”. The research included participants who had self-harmed. Not all instances of self-harm are suicide attempts, so it is a mistake to conflate the two terms. For some people, certain types of self-harming, such as cutting, are a way of coping with overwhelming emotional distress, rather than an attempt to end their life.

It was not clear from the study what proportion of the self-harming events were attempted suicide.

 

What kind of research was this?

This was a cohort study comparing people who did and did not receive a psychosocial (talking) therapy after deliberate self-harm, and examined the outcomes of further self-harm, suicide or death from other causes. 

The researchers say that self-harm is a strong predictor of suicide. Research indicates that within the first year after self-harming, about 16% of people self-harm again; 0.5 to 1.8% die by suicide; and 2.3% die from another cause. However, evidence for the effectiveness of psychological interventions following self-harm is said to be missing, and this study aimed to investigate this.

 

What did the research involve?

This study compared people in Denmark who received a psychological intervention following a first episode of self-harm with those who received standard care, over the 18-year period between January 1992 and December 2010. They calculated the risk of repeated self-harm, suicide and dying of any cause after the first instance of self-harm, and compared the risks between the two groups for differences that might be due to the psychological intervention. 

The people who received psychological interventions were identified from one of seven suicide prevention clinics in Denmark. These clinics are said to receive people who are thought to be at risk of suicide, but not in need of psychiatric admission or other outpatient programmes. For the purposes of this study, participation was considered to be attendance for at least one psychological treatment session that was focused on suicide prevention. The seven different clinics used various types of therapy, including cognitive, problem-solving, crisis, dialectical behaviour, integrated care, psychodynamic, systemic, psychoanalytic approaches and support from social workers.

The controls who did not receive a psychological intervention were people who had presented to hospital with an episode of self-harm during the study period, but who did not receive any psychological intervention. They could receive any form of standard care, including admission to a psychiatric hospital, referral to outpatient treatment or a general practitioner, or discharge without referral.

The reasons why these people did not receive a psychological intervention were variable, including:

  • living in an area remote from services
  • being referred for other treatment (including hospital admission)
  • not wanting to be referred for suicide prevention treatment

All people were linked via their Danish ID numbers to the Danish Civil Register, National Registry of Patients, Psychiatric Central Registry and Registry of Causes of Death. Follow-up was to the end of 2011, giving a follow-up period for the people in the study of 1 to 20 years.

The main outcomes examined were self-harm, death by suicide, and death by any cause. People who did and did not receive psychological interventions were matched for various potentially confounding factors, including:

  • study period (1992 to 2000 or 2001 to 2011)
  • age
  • gender
  • educational level
  • socioeconomic status
  • previous episodes of self-harm
  • specific psychiatric diagnoses

 

What were the basic results?

The study included a total of 5,678 people in the psychological intervention group and 17,034 matched people who had not received a psychological intervention after self-harm. Around two-thirds were women and most were in the 15 to 49 age bracket. Around 10% had a previous episode of self-harm.

During the first year of follow-up, 6.7% of people receiving a psychological intervention had a repeated self-harm attempt, compared with 9.0% of the no psychological intervention group. Psychosocial therapy was associated with a 27% reduced risk of self-harm within one year (odds ratio (OR) 0.73, 95% confidence interval (CI) 0.65 to 0.82). The absolute risk reduction (ARR), measuring how much the risk of self-harm is reduced in those who received the psychosocial therapy, was 2.3% (95% CI 1.5 to 3.1%). The number needed to treat (NNT) was 44 (95% CI 33 to 67), indicating that 44 people would need to receive psychosocial therapy after a self-harm attempt to prevent one person self-harming within one year.

There was no significant difference between groups in rates of suicide within one year, but overall mortality rates within one year were slightly lower in the psychological intervention group (1,122 compared with 1,824 per 10,000), which also meant a significant reduction in overall mortality rate (OR 0.62, 95% CI 0.47 to 0.82). When considering the longer term effects over the full 20 years of follow-up, psychological intervention was associated with a 16% decreased risk of repeated self-harm (OR 0.84, 95% CI 0.77 to 0.91), with an ARR of 2.6% (95% CI 1.5to 3.7) and NNT of 39 people (95% CI 27 to 69).

When looking at overall follow-up, psychological therapy was also associated with a 25% reduced risk of death from suicide (OR 0.75, 0.60 to 0.94), with an ARR of 0.5% (95% CI 0.1 to 0.9) and a NNT of 188 people to prevent one suicide (95% CI 108 to 725). It was also associated with significant reduction of death from any cause (OR 0.69, ARR 2.7%, NNT 37).

The results altogether suggested that during the 20 years of follow-up, 145 self-harm episodes and 153 deaths were prevented by psychological interventions, with 30 of these deaths from suicide.

 

How did the researchers interpret the results?

The researchers conclude that their findings, “show a lower risk of repeated deliberate self-harm and general mortality in recipients of psychosocial therapy after short-term and long-term follow-up, and a protective effect for suicide after long-term follow-up, which favour the use of psychosocial therapy interventions after deliberate self-harm”.

 

Conclusion

The researchers report that this is the largest follow-up study of psychosocial interventions offered after deliberate self-harm attempts. Compared to standard care, it found that psychosocial interventions were associated with a reduced risk of repeated self-harm and death from any cause within the first year of follow-up. In the longer term, psychosocial interventions were associated with reduced risks of self-harm, death from any cause and suicide, specifically.

The study benefits from its large sample size, long duration of follow-up and reliable methods of identifying participants and their outcomes. There are, however, some points to be considered when interpreting the findings.

Possible selection bias

The reasons that people did not receive a psychological treatment could have put them at higher risk of subsequent harm to start with, potentially explaining all or some of the risk difference between the two groups. Though the people who did and did not receive psychological treatments were matched for various factors, this may not have been comprehensive, and some selection bias may still be present. For example, all the people who were receiving psychological treatments had been referred to suicide prevention clinics because they were not considered to be in need of psychiatric admission or other outpatient treatment following their self-harm attempt. Meanwhile, those who did not receive psychological treatment were reported to include people who needed psychiatric admission, or chose not to receive suicide prevention treatment after their self-harm attempt.

This makes it difficult to isolate the effect of the psychological intervention compared with selection biases and other confounding factors. It could be that the reduced risk seen in the psychological intervention group is not solely a result of the intervention, but that there were other risk factors among the non-treated group that were increasing their risk of further self-harm/suicide attempts and so confounding the association.

However, some degree of selection bias is inevitable in this type of study. The only way to remove it completely would be to randomise people to treatment or no treatment, which could never be done for ethical reasons.

Uncertainty about most effective intervention

It is also difficult to conclude many treatment implications from this study in terms of what would be the best type of psychological intervention to use after a self-harm attempt (a wide variety of interventions were used in this study), whether the optimal type differs according to the individual (e.g. according to mental health diagnosis[es]), and what would be the optimal treatment duration.

Results may not be applicable to the UK

The results also apply to Denmark, which may differ from other countries – for example, in terms of healthcare and mental health services, and population health, psychosocial and environmental influences. This may mean that the results are less applicable to this country.

People in the UK who present to health services following self-harm or a suicide attempt receive assessment by specialist mental health professionals, followed by referral, hospital admission or discharge, and follow-up care and treatment as appropriate to their individual situation.

Getting help

If you are reading this because you are having suicidal thoughts, try to ask someone for help. It may be difficult at this time, but it's important to know you are not beyond help and you are not alone.

Speak to a person you trust (such as a friend or family member), make an urgent appointment with your GP or contact your local A&E department. The Samaritans (08457 90 90 90) also operates a 24-hour service available every day of the year.

Read more about getting help for suicidal or self-harming thoughts, as well as spotting possible warning signs in family members and friends.

Analysis by Bazian. Edited by NHS ChoicesFollow Behind the Headlines on TwitterJoin the Healthy Evidence forum.

Links To The Headlines

Suicide risk reduced after talk therapy, study suggests. BBC News, November 24 2014

Talking therapy 'can stop suicide'. Mail Online, November 24 2014

Links To Science

Erlangsen A, Lind BD, Stuart EA, et al. Short-term and long-term effects of psychosocial therapy for people after deliberate self-harm: a register-based, nationwide multicentre study using propensity score matching. The Lancet Psychiatry. Published online November 24 2014

Categories: NHS Choices

Vegetarian diet 'could have slight benefits in diabetes'

NHS Choices - Behind the Headlines - Mon, 24/11/2014 - 11:30

"Vegetable diet will beat diabetes: Meat-free lifestyle cures killer disease," is the typically overblown headline in the Daily Express.

But researchers actually found a vegetarian diet led to a quite modest fall in only one measure of blood glucose called HbA1C, a measure of blood glucose control.

The paper reports on a systematic review which combined the results of six trials that involved 255 people with type 2 diabetes. They examined whether vegetarian or vegan diets improved blood glucose control compared with a control diet.

Overall, the pooled results of five of these trials found a vegetarian or vegan diet reduced HbA1c by 0.39%. There was no significant effect on fasting glucose levels, an assessment of how efficiently the body can process glucose in the short term.

This slight reduction in HbA1c is no cure. As the researchers themselves pointed out, the reduction is less than you would expect if a patient was being treated with the drug of choice for type 2 diabetes, metformin.

This review also has various important limitations, including the variable design and quality of the six trials included. So, it does not prove that a vegetarian or vegan diet is better for a person with type 2 diabetes, and any media claims of a "cure" for the condition are entirely baseless.

 

Where did the story come from?

The study was carried out by researchers from Keio University in Japan and The George Washington University School of Medicine in the US.

Funding was provided by the Japan Society for the Promotion of Science and the Nestlé Nutrition Council, Japan.

One of the co-authors declared a non-financial conflict of interest. This author serves as president of the Physicians Committee for Responsible Medicine, without financial compensation.

This organisation is described in the publication as one that, "promotes the use of low-fat, plant-based diets and discourages the use of animal-derived, fatty, and sugary foods". This represents a potential conflict of interest in the interpretation of the results.

The study was published in the peer-reviewed medical journal, Cardiovascular Diagnosis and Therapy and the study is open access, so it is free to read the study online.

The Daily Express' coverage of the study is accurate and contains some useful background information, so it is frustrating that its headline is totally misleading, especially as it was on the front page.

In fact, this review of studies found vegetarian or vegan diets caused a slight reduction in HbA1c compared with non-vegetarian diets. This is not a cure in any sense of the word.

The current thinking is that there is no such thing as a cure for type 2 diabetes. The condition can be successfully managed, but not cured.

The study is also only applicable to type 2 diabetes, so the headlines do not apply to type 1 diabetes.

 

What kind of research was this?

This was a systematic review and meta-analysis combining the results of controlled trials that examined the effects of vegetarian diets on blood sugar control in type 2 diabetes.

As the researchers say, previous research has suggested a link between a vegetarian diet and improved blood sugar control, but the relationship is not well established.

As an interesting aside, the researchers highlight how diabetes levels were found to be lower in Seventh-day Adventists, a Protestant Christian denomination whose followers are encouraged to adopt a vegetarian diet.

This review aimed to examine this grey area. A systematic review and meta-analysis of randomised controlled trials is the best way of examining the evidence to date that has assessed this question.

 

What did the research involve?

The researchers searched a number of literature databases (from their inception to 2013) to identify published clinical trials examining the effects of a vegetarian, vegan or omnivorous diet on blood sugar control in people with type 2 diabetes who were over the age of 20.

A vegetarian diet was defined as one excluding meat, poultry and fish, while a vegan diet excluded all animal products.

Eligible trials had an intervention duration of at least four weeks and examined the main outcome of changes in HbA1c.

This gives an indication of blood sugar control in the longer term, as it indicates the amount of sugar being carried by red blood cells, which have a lifespan of around three months. Change in fasting blood sugar measures was a secondary outcome.

In an added effort to find all relevant information for the review, the research team scoured the reference lists of all articles they found from the search of electronic databases, and also contacted research experts for additional material.

The researchers assessed the quality of the studies included, and pooled studies calculating the average difference in HbA1c and fasting blood sugar between vegetarian or vegan and comparison diets.

 

What were the basic results?

A total of six trials met the inclusion criteria, involving 255 people with type 2 diabetes with an average age of 52-and-a-half. The average trial duration was 23.7 weeks, or about six months.

Five of the studies examined vegan diets and one studied vegetarian diets. Four trials were conducted in the US, one in Brazil and one in the Czech Republic.

Of the six studies, three were randomised controlled trials, one was a cluster randomised controlled trial, and two were non-randomised controlled trials.   

In the pooled analysis of five trials, the vegetarian or vegan diet was associated with a significant reduction in HbA1c (-0.39%, 95% confidence interval [CI] -0.62 to -0.15) compared with omnivorous control diets.

But the pooled analysis of four trials did not find a statistically significant reduction in fasting blood sugar: the average difference with the vegetarian or vegan diet compared with control was -0.36 mmol/L, 95% CI -1.04 to 0.32.

Compared with control, the vegetarian or vegan diets were also associated with significant reductions in the amount of total energy the diet provided, either through carbohydrate, protein, total fat, cholesterol and fibre.

 

How did the researchers interpret the results?

The researchers concluded that, "Consumption of vegetarian diets is associated with improved [blood glucose] control in type 2 diabetes."

 

Conclusion

This systematic review has identified six trials assessing whether vegetarian or vegan diets improve blood sugar control in type 2 diabetes compared with control.

It found the vegetarian or vegan diet gave significant improvement in one measure of blood sugar control (HbA1c), but not in another (fasting blood glucose).

However, there are some important limitations to consider before we can categorically conclude that people with type 2 diabetes should switch to a meat and fish-free diet:

The improvement in blood sugar control was quite small

The pooled results of five trials found a vegetarian or vegan diet was associated with a 0.39% reduction in HbA1c, but we don't know that this would have made any meaningful clinical difference in diabetes control for the individual.

Overall, although any reduction is likely to be a good thing, the precise benefit would depend on what a person's HbA1c level was to start with.

The target HbA1c is usually set at a level below around 7%, so it may be more useful knowing whether a vegetarian or vegan diet improved the proportion of people achieving their target HbA1c level. The review also found no improvement in fasting blood glucose control.

The intervention diets were varied

Despite the publication tending to refer to the intervention diets as vegetarian, they were actually quite varied across the trials.

Four of the trials were described as low-fat vegan, one as lacto-vegetarian (a diet that includes dairy products but not eggs), and one lacto-ovo low-protein (similar to a lacto-vegetarian diet but, as the name suggests, with a focus on low-protein foods).

The control diets were also quite varied across the trials

The researchers included diets described as omnivorous, low fat, "diabetic diet" and those that followed American Diabetic Association guidance.

Overall, this doesn't give a very clear picture of what diets were being compared, which makes it hard to conclude that a particular diet is associated with an improvement in blood sugar control compared with a particular control.

The trials had variable quality evidence

Only three of the six trials studied were true randomised controlled trials. They varied in the duration of the dietary intervention between four and 74 weeks.

Also, only one of the six trials (a controlled trial) is reported to have made any adjustment for potential confounders (sex, baseline HbA1c level and medication). The others report no adjustment.

We also don't know how the trials checked that the diets were being followed as assigned, or of any other intervention or advice that may have been given to the participants alongside the dietary intervention (such as advice about physical activity).

The review only included published trials

In their assessment of possible publication bias, the researchers observed that smaller trials that found reductions in HbA1c level were perhaps more likely to have been published and therefore included in this review.

The small number of participants

Despite this being a systematic review of trials, the total number of participants was still quite small, at only 255. This is a very small number of patients, and it might be unwise to base any firm or generalisable conclusions on such small numbers.

A vegetarian or vegan diet can be a healthy lifestyle choice for a person with type 2 diabetes if it provides balanced nutrition. But such diets can still be high in fat, salt and sugar if this is not controlled carefully.

A healthy diet needs to be combined with regular exercise for people to be able to reap further health benefits, as well as avoiding smoking and only consuming alcohol at or below nationally recommended levels.

Overall, this review does not appear to conclusively prove that a vegetarian or vegan diet is better for a person with type 2 diabetes. It certainly provides no evidence that this diet cures diabetes, as one of the news headlines suggests.

Provided you do your homework, it is possible to eat healthily on a vegetarian or vegan diet. But if you do have type 2 diabetes, we recommend that you talk to the doctor in charge of your care before making any radical changes to your diet. 

Analysis by Bazian. Edited by NHS Choices.
Follow Behind the Headlines on Twitter. Join the Healthy Evidence forum.

Links To The Headlines

Vegetable diet WILL beat diabetes: Meat-free lifestyle cures killer disease, experts claim. Daily Express, November 24 2014

How becoming a vegetarian can CURE diabetes: Plant-based diets improve blood sugar levels, scientists claim. Mail Online, November 24 2014

Links To Science

Yokoyama Y, Barnard ND, Levin SM, Watanabe M. Vegetarian diets and glycemic control in diabetes: a systematic review and meta-analysis. Cardiovascular Diagnosis and Therapy. Published online October 10 2014

Categories: NHS Choices

Air dryers 'blown away' by paper towels in germ tests

NHS Choices - Behind the Headlines - Fri, 21/11/2014 - 11:50

"Hand dryers 'splatter' users with bacteria," The Daily Telegraph reports.

The headline is prompted by an experimental study that compared the potential transfer of germs to the surrounding environment, users and bystanders when using three methods of hand drying:

  • paper towels
  • warm air dryers – the sort you see in most public toilets
  • modern "high-tech" jet air dryers, such as the Dyson Airblade model

Testers wore gloves coated in a solution of bacteria. Air samples taken after drying with the hand dryers showed significantly higher bacterial counts than when drying with paper towels, and were highest for the jet air dryers.

They then assessed the potential for spread to users and bystanders, this time using the proxy of gloves coated in black paint and a white body suit.

They found there was no contamination of the body after towel drying, but paint spots were on the body after the use of air dryers, which again was higher with jet dryers than standard warm air dryers.

One important limitation of this study is it essentially replicates the scenario of someone going to the toilet and then proceeding straight to the hand dryer without washing their hands first.

A more suitable test may have been to coat the gloves with the marker, wash them with soap and water as recommended, and then proceed to the hand dryers.

But the overall message of this study is consistent with current hand washing recommendations, including the use of disposable paper towels in healthcare settings.

 

Where did the story come from?

The study was carried out by researchers from the University of Leeds and the microbiology department at Leeds General Infirmary.

It was funded by the European Tissue Symposium (ETS), from whom one author reports having received honoraria.

The ETS produces paper tissue, including toilet paper, household towels and paper napkins, which may be seen as a potential conflict of interest.

The study was published in the peer-reviewed Journal of Hospital Infection.

The Daily Telegraph and the Mail Online's reporting was accurate, but neither appeared to have considered some of the limitations of this research.

 

What kind of research was this?

This was an experimental study that aimed to compare the tendency for three common hand drying methods – jet air, warm air hand dryers, and paper towels – to spread germs and contaminate the environment, users and bystanders.

Like thorough hand washing, thorough hand drying is just as important to prevent the transfer of germs from person to person or the surrounding environment.

According to hand washing protocols, the optimal way to dry hands is to use a disposable paper towel, which is then used to turn off the tap to avoid re-contaminating hands.

The main concern with using hand dryers is that people may not dry their hands as completely as they would with paper towels, and may go away while they are still damp. If hand dryers are used, it is advised that the hands are rubbed together under the dryer until they are totally dry.

However, another unclear and often speculated issue when using hand dryers is the possible transfer of aerosolised germs to the surrounding environment and people, possibly increasing the spread of infection.

This study aimed to compare the different hand drying methods, looking at whether they can contaminate the surrounding environment, users and bystanders.

 

What did the research involve?

The researchers carried out a series of hand drying tests in a single room with standard ventilation (not air conditioned). They first tested the possible contamination of the environment, and then people.

Gloved hands were immersed in a solution of lactobacilli bacteria (cultured from Actimel Danone yoghurt) before being dried with either:

  • a warm air dryer – hands were rubbed together for 30 to 40 seconds until dry
  • a jet air dryer – hands were placed into the unit and slowly drawn up and down for 15 seconds until dry
  • paper towels – four paper towels were taken from the dispenser and were rubbed over hands for 15 seconds until dry

The tests were conducted over six weeks. A total of 120 air samples were taken – 60 made after drying contaminated hands (20 collections after each drying method: 10 in close proximity, 10 one metre away) and 60 control air samples taken before hand drying. Air samplers were left running for 15 minutes after each drying process. 

They then repeated the tests, this time looking at the possible contamination of people standing nearby. This time, gloved hands were coated in black water-based paint rather than bacteria, and the user wore a disposable white hooded suit.

Another bystander in a similar suit stood diagonally adjacent to the dryer user one metre away to replicate the scenario of another user waiting to dry their hands. There was a total of 30 drying tests in this manner, 10 for each drying method.

 

What were the basic results?

The researchers found the lactobacillus count in air samples taken in close proximity to the dryers were 4.5-fold higher for the jet dryer (70.7 colony forming units, or cfu) compared with the warm air dryer (15.7cfu), and 27-fold higher compared with paper towels (2.6cfu).

Counts for the warm air dryer were also significantly higher than with paper towels.

A similar pattern was seen for the air collection one metre away, where counts were 89.5cfu with the jet dryer, 18.7cfu with the warm air dryer, and 2.2cfu with paper towels.

"Settle plates" underneath each hand dryer had the highest bacterial count for the warm air dryer (190cfu) compared with the jet air dryer (68.3cfu) and the paper towel drying (11.9cfu). Respective figures at plates one metre away were 7.8cfu, 2cfu and 0.7cfu. 

As would be expected, the control air samples taken before drying found no lactobacilli.

On the person-contamination experiments, no paint spots were seen on paper towel users. For both the jet air and warm air dryers, spots predominated in the upper body area, with the number of spots significantly higher with jet dryers (144.1) compared with warm air dryers (65.8).

The number of paint spots was higher for all body areas with jet dryers, with the exception of both arms. With both hand dryers, however, there were relatively few paint spots remaining on the hands.

The number of paint spots detectable on the bystander was generally low for both air dryers and was not significantly different between the two (average count 1.6 spots for jet dryers and 1.5 for warm air dryers).

 

How did the researchers interpret the results?

The researchers concluded that, "Jet air and warm air dryers result in increased bacterial aerosolisation when drying hands.

"These results suggest that air dryers may be unsuitable for use in healthcare settings, as they may facilitate microbial cross-contamination via airborne [spread] to the environment or bathroom visitors."

 

Conclusion

Overall, this experimental study found the airborne spread of lactobacilli bacteria from contaminated hands was significantly higher with air dryers than with paper towels. Of the two, jet dryers caused higher air bacterial counts than standard warm air dryers.

Similarly, when assessing spread on to the body of the user and bystander using the proxy measure of black paint dispersal, there was no contamination of the body with paper towels, but paint spots were on the body after use of air dryers, again higher with jet dryers than standard warm air dryers.

It is well known that thorough hand drying is as key to preventing spreading infection as thorough hand washing. One of the recognised problems with hand dryers is that people may not dry their hands as completely as they would with paper towels.

What is less clear, and is often speculated about, is the possible transfer of aerosolised germs to the surrounding environment and people, possibly increasing the spread of infection.

This study appears to demonstrate cause for this concern. However, there are some points worth consideration when interpreting this study:

  • One important limitation of the study is it may not replicate the real-life condition of someone having just thoroughly washed their hands with soap and water, and then drying their hands. In this experimental situation, the users had gloved hands contaminated with either lactobacilli or black paint and then dried their hands. In effect, this may be seen more to replicate the scenario of someone going to the toilet and then proceeding straight to the hand dryer without washing their hands first. A more suitable test may have been to coat the gloves with either bacteria or black paint, wash them with soap and water as recommended, and then proceed to the hand dryers to see how many bacteria or paint were spread.
  • The spread of heavier black paint may also not be equivalent to the spread of viruses and bacteria, though it may represent the spread of water.  
  • Aside from the assessment of the surrounding environment and bystanders, another important area of consideration would also be to compare how much bacteria remained on the surface of the users' hands after drying with each of the three methods. This is of equal importance in knowing how much bacteria remains on the users' hands that could be transferred to other surfaces. It would be valuable to know whether there was any difference. This study has not specifically examined this aspect, though in fact it did note few paint spots remained on the hands after drying with either of the hand dryers.
  • It also would have been valuable to consider comparing the amount of bacteria or paint left on the towel dispenser or hand dryers after use, and how much of this would usually be transferred to the next person's hands during hand drying.

Despite these limitations, the overall message of this study is consistent with current handwashing recommendations, particularly when it comes to healthcare settings.

Of course, disposable paper towels are not available in all facilities. If only hand dryers are available, hands need to be rubbed together until they are completely dry.

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter. Join the Healthy Evidence forum.

Links To The Headlines

Hand dryers 'splatter' users with bacteria, scientists warn. The Daily Telegraph, November 20 2014

Modern hand dryers are 'much worse' at spreading germs around a room than paper towels, study claims. Mail Online, November 20 2014

Links To Science

Best E, Parnell P, Wilcox MH. Microbiological comparison of hand-drying methods: the potential for contamination of the environment, user, and bystander. The Journal of Hospital Infection. Published online August 26 2014

Categories: NHS Choices

Breastfeeding voucher scheme 'shows promise'

NHS Choices - Behind the Headlines - Fri, 21/11/2014 - 11:50

"Initial results of a controversial scheme offering shopping vouchers to persuade mothers to breastfeed have shown promise," BBC News reports.

The scheme, which has attracted controversy since it was announced, aimed to tackle the problem of low rates of breastfeeding in the UK compared with other developed nations. Mothers who live in the poorest areas of the country have been found to be more likely to prefer bottle feeding.

This pilot scheme has tested whether it is possible to try to boost breastfeeding rates by offering new mothers shopping vouchers if they breastfeed their baby until specific ages.

The scheme was available to just over 100 women who gave birth to babies over a six-week period and lived in three areas of Derbyshire and south Yorkshire. The breastfeeding rate in these areas at six to eight weeks was 21-29%.

In the period where vouchers were available, 34.3% of women were breastfeeding at six to eight weeks. Both mothers and healthcare staff reported high levels of satisfaction with the scheme.

The researchers report they are now planning further studies in the form of a randomised controlled trial to see how effective the voucher scheme is at boosting breastfeeding rates.

 

Where did the story come from?

The study was carried out by researchers from the University of Sheffield and was funded by the Medical Research Council National Prevention Research Initiative.

The meeting abstract was published in the peer-reviewed medical journal, The Lancet.

It has been published prior to being presented at The Lancet's annual conference on Public Health Science, held jointly with the London School of Hygiene and Tropical Medicine, University College London, the UK Health Forum, and in partnership with the European Public Health Association.

The media reporting of the study was good, providing background information about the scheme and why some people are opposed to it – most critics have questioned why a scheme should reward mothers for doing the best for their child while penalising mothers who are unable to breastfeed.

It is a fair point, though a pragmatic answer would be that it's not about the mother, but the child. Also, increased breastfeeding rates may lead to a reduction in the number of childhood illnesses the NHS has to deal with, so a voucher scheme could actually save the NHS money in the long term.

But we will need to wait for the results of the planned randomised controlled trial before more detailed effectiveness and cost benefit information becomes available.

 

What kind of research was this?

This was a feasibility study to see whether it was both acceptable and possible to give women financial incentives to increase breastfeeding rates, prior to performing a randomised controlled trial to see if these financial incentives were effective. 

The results of this study have been published in the form of a meeting abstract. This means the method and results are only described briefly, and a full appraisal of the strengths and limitations of the study can't be performed. This study is actually still ongoing and the results from some time points are still being collected.

 

What did the research involve?

The researchers wanted to test whether it was acceptable and possible to give women financial incentives for breastfeeding, as young women in deprived areas are less likely to breastfeed.

They offered vouchers for breastfeeding to women with babies born within a 16-week period who lived in three neighbourhoods in Derbyshire and south Yorkshire, where breastfeeding rates were less than 30%.

The vouchers were available when their babies were five different ages:

  • two days
  • 10 days
  • six weeks
  • three months
  • six months

The vouchers were for supermarkets and high street shops for a value of £40 at each time point, so each woman could receive a maximum of £200.

To receive the vouchers, the woman and her healthcare professional had to sign statements saying she had been breastfeeding.

The researchers then interviewed 36 healthcare providers and 18 women to get their views on the scheme.

 

What were the basic results?

Fifty-eight of the 108 women (53.7%) who could have joined the scheme chose to do so.

  • 48 women (44.4%) claimed vouchers when their babies were two days old
  • 45 women (41.7%) claimed vouchers when their babies were 10 days old
  • 37 women (34.3%) claimed vouchers when their babies were six to eight weeks old

The researchers are still collecting data for the three and six-month time points.

Mothers and healthcare staff who participated reported high levels of satisfaction with the scheme.

 

How did the researchers interpret the results?

The researchers say that, "The scheme was both deliverable and acceptable to mothers and healthcare staff in this field of study.

"The scheme was extended (and will continue until at least December 2014) in all three areas. A randomised controlled trial testing the effectiveness of the scheme is now planned."

 

Conclusion

This study tested whether it is possible and acceptable to try to boost breastfeeding rates by offering new mothers vouchers if they breastfeed their baby until specific ages.

The scheme was available to just over 100 women who gave birth over a six-week period, and who lived in three areas of Derbyshire and South Yorkshire. In these areas, the breastfeeding rate at six to eight weeks was 21-29%.

In the period where vouchers were available, 34.3% of women were breastfeeding at six to eight weeks. Both mothers and healthcare staff reported high levels of satisfaction with the scheme.

The researchers report they are now planning a randomised controlled trial to see how effective the voucher scheme is at boosting breastfeeding rates.

The results of this study have been published in the form of a meeting abstract. This means the methods and results are only described briefly, and a full appraisal of the strengths and limitations of the study can't be performed.

Similarly, there is no information provided about the women who took part in the study, such as their age, medical history, family circumstances and support network.

In addition, this study is actually still ongoing and the results from some time points are still being collected.

Hopefully, the publication of the upcoming randomised controlled trial, which could be in either 2015 or 2016, will help assess how effective the scheme is and whether it is likely to be cost effective.

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter. Join the Healthy Evidence forum.

Links To The Headlines

Early results in breastfeeding vouchers trial. BBC News, November 20 2014

Scheme offering shopping vouchers to mothers who breastfeed to be extended. The Guardian, November 20 2014

NHS to 'bribe' thousands of mothers to breastfeed. The Daily Telegraph, November 20 2014

Links To Science

Relton C, Whelan B, Strong M, et al. Are financial incentives for breastfeeding feasible in the UK? A mixed methods field study. The Lancet. Published online November 19 2014

Categories: NHS Choices

Cancer guidelines may improve diagnosis rates

NHS Choices - Behind the Headlines - Thu, 20/11/2014 - 13:00

“Doctors to get more help to spot cancer early,” The Guardian reports. The National Institute for Health and Care Excellence (NICE) has produced new revised draft guidelines that may help GPs pick up on possible early warning signs of cancer. 

The aim of the draft guidelines is to improve early cancer diagnosis in children, young people and adults of all ages. The draft guidelines have been primarily written for GPs and are an update of the 2005 guidelines that were last partially updated in 2011.

 

What are the possible early warning signs of cancer?

It is misguided to think of cancer as a single disease. Cancer is an umbrella term for a wide range of different conditions, in the same way as the term “infection”.

With that in mind, specific cancers can present with a wide range of symptoms, most of which are similar to trivial conditions, such as indigestion or a sprained joint.

What you need to watch out for are symptoms that are:

  • persistent – last for more than two weeks
  • unexplained – there seems to be no logical reason why a symptom(s) develops

Specific red flags you need to watch out for include:

  • cough that lasts longer than three weeks
  • unexplained and persistent changes in bowel habits, such as chronic diarrhoea or constipation
  • unusual bleeding, such as noticing blood in your stools or urine
  • you notice an unusual, irregular and possible itchy mole on your skin
  • unexplained weight loss

Read more about possible early warning signs and symptoms of cancer

 

What has prompted the recommendations?

All NICE guidelines are updated every few years to ensure the recommendations have taken into account the latest evidence and any improvements in diagnostic techniques and treatments.

Additional reasons for these particular guidelines to have been updated are that, as the media has pointed out, the UK is just missing its target of treating 85% of people with suspected cancer within 62 days (current reported figures are 82.5%). NICE reports that signs and symptoms of cancer can often be non-specific and overlap with other less serious conditions. They also say that each GP only sees, on average, eight new cases of cancer each year out of 6,000 to 8,000 appointments. As the appointments only last 10 minutes each, NICE wanted to provide practical guidelines for GPs to use to help them spot when to initiate further tests.

 

What are the new recommendations and how do they differ from existing ones?

The draft guidelines give clearer and updated information on the recognition of early signs and symptoms of over 200 different types of cancer and the criteria that warrant further investigations or referral to specialists. The threshold for whether a sign or symptom could indicate cancer has been lowered compared to the previous guidance.

The main difference from before is that the information in the guidelines has been presented in a new format to make it easier to find the relevant recommendations. The information is laid out in tables according to particular symptoms, such as fatigue, cough or rectal bleeding, and tables according to the site of possible cancer, listing the typical signs and symptoms to look for. In each case, the next steps, such as investigations and referral thresholds, have been provided.

The timing of referrals has been updated to include situations that warrant “very urgent” referrals, where a person should be seen within 48 hours. This is in addition to the previously described referral timings, such as “urgent” referrals, where a person needs to be seen within two weeks, and immediate referrals.

Finally, there is a new section that covers patient information, support and safety netting.

 

How accurate is the reporting?

The Daily Telegraph’s rather alarmist headline that “tired patients should be fast-tracked for cancer tests” is not related to any new guidance. Persistent or unexplained fatigue has long been a recognised symptom of a number of cancers, including leukaemia in children and adults, lung cancer and ovarian cancer, and this recommendation was present in the original 2005 guidelines.

In general, the media focussed on reporting the number of people who have not met the government target of treating 85% of people with suspected cancer within 62 days. NICE reports that research has estimated that late diagnosis contributes to between 5,000 and 10,000 deaths within five years of diagnosis per year.

Somewhat tellingly, all of the UK media ignore the issue of overdiagnosis, which is where people undergo tests or diagnostic procedures that they don’t actually need. The natural assumption is probably to think “better safe than sorry”, but many diagnostic procedures themselves carry small risks of complications. For example, current evidence suggests that a colonoscopy (used to diagnosis bowel cancer) carries a one in 150 chance of causing excessive bleeding, a one in 1,500 chance of creating a hole in the wall of the bowel and a one in a 10,000 chance of causing death.

Therefore, it’s important to be sure that the potential risk of a suspected disease is high enough to justify the risks associated with diagnosis.

 

What happens next?

The draft guidance is out for public consultation until Friday 9 January 2015. This means that any relevant patient groups, organisations, Clinical Commissioning Groups (CCGs) and other GP-led bodies can register and then comment on the:

  • new recommendations 
  • old recommendations that have been reviewed but remain unchanged
  • recommendations that are due to be removed

These comments can then be taken into account before the final version of the guidelines are published, which is anticipated to be May 2015.

The NICE draft guidelines are free to access online. After the consultation period, when the full guideline is published, it should guide patient care.

Though it will give recommendations for which signs and symptoms should warrant further investigation or referral, NICE clearly states that “the guidance does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of each patient, in consultation with the patient and/or their guardian or carer”.

Analysis by
Bazian. Edited by NHS ChoicesFollow Behind the Headlines on TwitterJoin the Healthy Evidence forum.

Links To The Headlines

Doctors to get more help to spot cancer early. The Guardian, November 20 2014

GPs urged to double cancer referrals in NHS guidelines. BBC News, November 20 2014

GPs told tired patients should be fast-tracked for cancer tests. The Daily Telegraph, November 20 2014

Doctors to get fresh guidelines to help spot cancer early. ITV News, November 20 2014

GPs To Get Better Cancer Diagnosis Guidelines. Sky News, November 20 2014

GPs can't be expected to know every cancer symptom, Government says. The Independent, November 20 2014

Doctors urged to test patients with coughs for cancer: GPs given guidance over fears they are dismissing early warning signs. Daily Mail, November 20 2014

Categories: NHS Choices

Is growth in ADHD 'caused by marketing'?

NHS Choices - Behind the Headlines - Thu, 20/11/2014 - 11:10

"The global surge in ADHD [attention deficit hyperactivity disorder] diagnosis has more to do with marketing than medicine, according to experts," the Mail Online reports.

But these experts are sociologists, not clinicians, and they present no new peer-reviewed clinical evidence.

That said, they do highlight some interesting interconnected trends about ADHD that are worth attention.

The principal concern of the authors is that ADHD is being medicalised – that is, for a variety of reasons, children who may be simply "naughty" and high spirited are being misdiagnosed with ADHD, and are wrongly being treated with powerful medications such as methylphenidate, better known as Ritalin.  

This study concludes that the "global expansion" of ADHD and its subsequent medicalisation has been driven by five major causes:

  • drug industry lobbying
  • the influence of US-based psychiatry
  • the adoption of looser criteria for diagnosis
  • the influence of ADHD patient advocacy groups
  • the growth of information on the internet

This is a well-researched and interesting article which reflects current concerns about the medicalisation of symptoms that might be viewed as part of the human condition, rather than a disorder that needs drug treatment.

However, this is an opinion piece and is not the last word on this controversial subject.

If you are worried about a child or other relative's behaviour, it is important to see a health professional such as a GP.

Many children go through phases where they are restless or inattentive. This is often completely normal and does not necessarily mean they have ADHD.

 

Where did the story come from?

The study was carried out by researchers from Brandeis University in the US. There is no information about external funding.

It was published in the peer-reviewed journal Social Science and Medicine.

The Mail Online's coverage was reasonably accurate, but it used the old journalistic cliché "experts say", implying there is a single expert opinion on a subject.

This is very rarely the case, especially when you are dealing with a subject as controversial as ADHD.

 

What kind of research was this?

This was a narrative review that looked at the evidence for an increase in ADHD across the globe. The authors say how in the US, ADHD has been medicalised for 50 years, but this approach is now being applied internationally.

They document the growth of ADHD diagnosis and treatment in the UK, Germany, France, Italy and Brazil, and look at the possible causes of this expansion.

This article was a narrative review, which means it is subject to selection bias, and is not a systematic review, which looks at all of the available evidence on a topic and uses this information to draw conclusions.

This potential selection bias means the authors may have selected articles to fit their theory.

ADHD is defined as a group of behavioural symptoms that include inattentiveness, hyperactivity and impulsiveness.

There is a school of thought that the diagnosis of ADHD can be prone to medicalisation, where normal human behaviour is defined and treated as illness. 

But others argue this condition is being picked up more frequently as a result of better education and recognition of symptoms.

 

What does the study say?

The study looked at evidence for the "globalisation" of ADHD and the increase in the use of ADHD medication, such as methylphenidate (Ritalin).

In particular, it examined the prevalence and treatment of ADHD in five countries – the UK, Germany, France, Italy and Brazil.

In the UK, the authors state ADHD is now the most prevalent behavioural disorder, with an estimated 3-9% of children and adolescents having the condition.

Drug treatment for ADHD has also been on the rise here, with one recent report suggesting methylphenidate (Ritalin) prescriptions rose by 11% in GP practices, and by 24% in private practice from 2011-12. 

The authors partly ascribe this increase to changes in diagnostic criteria used in the UK. In the past, the UK adopted criteria from the World Health Organization (WHO) for a condition then called hyperkinetic disorder.

But there is now a greater use of US criteria globally, which uses different terminology and provides a lower threshold for diagnosis.

The article goes on to look at what it says are the major trends behind this rise in diagnosis and treatment in some countries.

Influence of drug companies

In the past, drugs for ADHD were heavily marketed in the US, but as this market has become saturated, the industry has expanded into international markets and promoted ADHD drug treatment around the world – first in western Europe, but also in other countries such as Brazil, Mexico and Japan.

Influence of US psychiatry

There has especially been a move towards "biological" psychiatry, where mental and behavioural disorders are treated with drugs rather than psychotherapy. More psychiatrists across the globe are now trained in the US and import US practices into their countries of origin.

Recent growth in the adoption of different criteria for ADHD

The authors say until the 1990s, many countries used the International Classification of Mental and Behavioral Disorders (ICD), published by WHO, which has strict criteria for ADHD. But since then, other countries have adopted the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association, which has a lower threshold for diagnosis of ADHD.

Wide availability of information on the internet

The authors say there is "endless information on various sites about ADHD from numerous sources, including pharmaceutical websites". In particular, they point out the availability of ADHD checklists based on US screening devices. These allow internet users to "measure" certain behaviours that could lead to a possible ADHD diagnosis, prompting more consumers to ask for drug treatment.

Influence of ADHD advocacy groups

These groups often work closely with drug companies and promote drug treatments. The authors point out how in some countries, such as France and Italy, ADHD rates are lower. This is thought to be a result of a cultural tradition of using psychoanalytic rather than drug-based approaches for behavioural problems, and restrictions on the use of ADHD medication.

 

How did the researchers interpret the results?

The authors predict the medicalisation of ADHD will expand further to cover more countries.

This could also happen to other conditions, and divert attention away from "important social and structural approaches" to global health, they argue.

 

Conclusion

This is an interesting paper that shows there has been an increase in ADHD diagnosis and treatment in several countries, including the UK, and examines the reasons why this may have occurred. The possible "medicalisation" of ADHD has been an issue of concern and debate for some time.

As the authors note, the paper has some limitations. They selected countries where there is available published literature on ADHD, so their conclusions may not be generalisable to other countries.

Further research is needed to explore the approaches to ADHD in parts of the world that have received less attention, such as Asia, eastern Europe, the Middle East and Africa.

The authors used research on ADHD to support their opinion about the medicalisation and globalisation of this disorder. Others might disagree, arguing that more awareness has led to an increase in diagnosis, and drug treatment can be helpful in many cases.

If you are worried about a child's or other relative's behaviour, it's important to see a GP or other healthcare professional. Many children go through phases where they are restless or inattentive. This is often completely normal and does not necessarily mean they have ADHD. 

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter. Join the Healthy Evidence forum.

Links To The Headlines

Rise in ADHD cases is 'due to marketing, not medicine': Study blames increase on drug companies, pushy support groups, and people self-diagnosing online. Mail Online, November 19 2014

Links To Science

Conrad P, Bergey MR. The impending globalization of ADHD: Notes on the expansion and growth of a medicalized disorder. Social Science and Medicine. Published online October 8 2014

Categories: NHS Choices

Have antibiotic changes upped heart infections?

NHS Choices - Behind the Headlines - Wed, 19/11/2014 - 11:50

"Rates of a deadly heart infection have increased after guidelines advised against giving antibiotics to prevent it in patients at risk," BBC News reports. But there is no evidence of a direct link between the two.

In 2008, the National Institute for Health and Care Excellence (NICE) produced guidelines regarding the use of antibiotics to prevent infective endocarditis – a potentially fatal infection of the lining of the heart that comes after bloodstream infection.

Prior to this guidance, common practice was to give antibiotics as a preventative measure to patients undergoing invasive procedures who were at increased risk of infective endocarditis (for example, patients with certain heart conditions).

In the 2008 guidance, NICE recommended that people undergoing dental or invasive surgical procedures were no longer given antibiotics as prevention for endocarditis, as the overall risks outweighed the benefits.

The current study examined trends before and after the guidance to see what effect the advice may have had on both antibiotic prescribing and rates of endocarditis.

This study demonstrates that the number of antibiotic prescriptions prior to invasive dental work or surgery significantly decreased after 2008. The rates of infective endocarditis have significantly increased since 2008, with an estimated 35 additional cases per month.

This is a valuable study, although this analysis of trends does not prove causation – that is, that reduced antibiotic prescribing in light of the NICE recommendations has directly caused the increase in cases. 

NICE has announced a review of their guidelines, although current recommendations remain unchanged until the review takes place.

 

Where did the story come from?

The study was carried out by researchers from Taunton and Somerset NHS Trust, the University of Surrey, the University of Sheffield School of Clinical Dentistry, John Radcliffe Hospital in the UK, and the Mayo Clinic and Carolinas Medical Center in the US.

Funding was provided by Heart Research UK, Simplyhealth and the US National Institutes of Health.

It was published in the peer-reviewed medical journal The Lancet.

BBC News provides a good account of this study.

 

What kind of research was this?

This study aimed to examine the trends before and after the publication of NICE's 2008 guidance on the prevention of infective endocarditis in people undergoing invasive procedures.

The researchers aimed to look at:

  • changes in the prescription of antibiotics for the prevention of infective endocarditis
  • changes in the number of cases of infective endocarditis diagnosed

Infective endocarditis means infection and inflammation of the inner lining of the heart chambers (endocardium).

People with existing conditions affecting their heart valves or the structure of their heart are most at risk, as they are more at risk of having existing blood clots (thrombus) present in the heart, in which an infection can start.

The infection is caused by bacteria that have circulated in the bloodstream and reached the heart, so any invasive surgical or dental procedures could potentially carry a risk.

The most common bacterial cause of infective endocarditis is Streptococcus viridans – bacteria that are naturally present in the mouth and throat.

Invasive dental work can therefore potentially lead to these bacteria entering the bloodstream.

Symptoms of infective endocarditis are variable, but commonly include fever and general symptoms of being unwell, such as flu-like symptoms, aches and pains, loss of appetite and weight loss.

A person may also present symptoms after a blood clot has travelled from the heart and lodged in another part of the vascular system (for example, with a stroke).

People also usually have new heart murmurs. The condition carries a fairly high mortality risk, and treatment usually involves intravenous antibiotics, and sometimes surgery.

Prior to 2008, a single dose of amoxicillin (or clindamycin for patients allergic to penicillin) was recommended before invasive dental work for people who were at moderate to high risk of developing infective endocarditis.

In March 2008, NICE concluded that antibiotic prophylaxis (prevention) for infective endocarditis for people undergoing invasive surgical or dental procedures was no longer routinely recommended.

This was generally because the benefits of prophylaxis were outweighed by risks associated with antibiotics – both to the individual and in terms of population health in general in contributing to antibiotic resistance.

Equivalent guidance produced in the US and Europe is said to have also reduced the number of people for whom antibiotic prophylaxis is recommended.

But the US and Europe have not recommended antibiotic use is stopped altogether, as we have in this country.

The researchers aimed to see what effect the NICE recommendations have had on the number of infective endocarditis cases.

 

What did the research involve?

The researchers aimed to look at the change in prescriptions for antibiotic prophylaxis from January 2004 to March 2013, and to look at hospitalisation for a main diagnosis of infective endocarditis from January 2000 to March 2013 in England.

The prescriptions data came from the NHS Business Services Authority, from where they also got data on the number of individuals accessing dental care services.

Data for incidence of infective endocarditis and its associated mortality came from national hospital episode statistics (HES) and used standard diagnostic codes to identify infective endocarditis.

The researchers carried out statistical analyses looking at changes in incidence of infective endocarditis before and after the introduction of the guidelines in 2008, accounting for changes in population size.

For each case they identified, they also looked back to see if this person had been "high risk" in terms of having a susceptible heart condition or a previous episode of infective endocarditis.

 

What were the basic results?

Before 2008, the prescribing of antibiotics for the prevention of infective endocarditis was fairly constant.

After the introduction of the NICE guidance, it fell significantly from an average of 10,900 prescriptions per month from January 2004 to March 2008, to only 2,236 prescriptions per month from April 2008 to March 2013. Most prescriptions were for amoxicillin, and 90% were issued by dentists.

There were 19,804 cases of infective endocarditis between 2000 and 2013. Prior to 2008, there had been a steady upward trend in the number of cases, but from March 2008 onwards there was a steep increase in the number of cases above the projected historical trend. This amounted to an additional 0.11 cases per 10 million people each month.

By March 2013, there were an estimated 35 more cases per month than would have been expected had the previous trend continued. This increase in the incidence of infective endocarditis was significant for both individuals at high risk of infective endocarditis and those not considered to be at risk.

The researchers calculated 277 antibiotic prescriptions would need to be issued to prevent one case of infective endocarditis (number needed to treat, or NNT).

 

How did the researchers interpret the results?

The researchers say: "Although our data do not establish a causal association, prescriptions of antibiotic prophylaxis have fallen substantially and the incidence of infective endocarditis has increased significantly in England since the introduction of the 2008 NICE guidelines."

 

Conclusion

This is valuable and timely research, which has looked at trends before and after NICE's 2008 guidance on the prevention of infective endocarditis in people undergoing invasive procedures. This examined:

  • changes in the prescription of antibiotics for the prevention of infective endocarditis
  • changes in the number of cases of infective endocarditis diagnosed

NICE's recommendation was based on an examination of the evidence of the effectiveness of antibiotics in preventing infective endocarditis, weighing the benefits and health outcomes (such as reduction in illness and deaths), risks and costs.  

The data collected by this study comes from reliable data sources, and the researchers took various steps to make sure their data collection was as complete and accurate as possible.

The results demonstrate a clear decrease in antibiotic prescribing as the NICE guidance came in – as would be expected – but also a significant increase in the number of infective endocarditis cases diagnosed since then.

The increase in cases was seen both in those who would be considered to be at risk of the condition and those without risk factors.

As the researchers highlight, this analysis of trends cannot prove causation. It cannot prove that the decrease in the prescription of preventative antibiotics before invasive procedures was directly responsible for the increase in the number of cases of infective endocarditis that has been seen subsequently, even though this may seem the likely cause.

We only know the number of diagnosed cases – we do not know what the actual cause in the individual cases was, and whether the person had, or had recently had, any dental or surgical procedures.

As the researchers say, they did not have reliable data on specific bacterial causes, which would have been useful – for example, in indicating whether it was bacteria normally present in the mouth, and so may have followed dental procedures. 

Other factors may be responsible for the change in trends, such as a change in the number of high-risk invasive procedures performed, or a change in the number of people at high risk of infective endocarditis.

However, the researchers did look into this and did not find a significant enough increase in the number of high-risk people with mechanical heart valves, or those having procedures for congenital heart disease, that could account for the trend.

It's also of note that there was an increase in infective endocarditis in people who weren't considered to be at risk of the condition – these people wouldn't routinely have been expected to have been offered antibiotic prophylaxis before the 2008 guidelines.

In light of this study, NICE has announced they will now review their guidelines. Until the review takes place, however, current recommendation are unchanged.

Even if there is a direct link between the 2008 guidelines and the rise in the number of cases of infective endocarditis, there are still other issues to consider.

Could it be justified to issue 277 antibiotic prescriptions to prevent one case of infective endocarditis, given the unnecessary exposure of many individuals to antibiotics, and given what we know about the growing threat of antibiotic resistance?

As with many aspects of public health, issues are never as clear cut as some media reporting would lead us to believe.

Analysis by Bazian. Edited by NHS ChoicesFollow Behind the Headlines on TwitterJoin the Healthy Evidence forum.

Links To The Headlines

Heart infection rates rise after antibiotic use cut. BBC News, November 18 2014

Links To Science

Dayer MJ, Jones S, Prendergast B, et al. Incidence of infective endocarditis in England, 2000-13: a secular trend, interrupted time-series analysis. The Lancet. Published online November 18 2014

Categories: NHS Choices

Report links obesity to advanced prostate cancer

NHS Choices - Behind the Headlines - Wed, 19/11/2014 - 10:35

"Being overweight raises risk of men developing aggressive prostate cancer," The Guardian reports.

A major new report from the World Cancer Research Fund has found strong evidence obesity increases the risk of aggressive prostate cancer.

This report, which considered the results from 104 studies involving more than nine million men, looked at diet, nutrition, physical activity, weight and the risk of prostate cancer.

It also found strong evidence that being tall – a marker of developmental factors in the womb, childhood and adolescence – increases the risk of prostate cancer.

The report found limited evidence for a link between diets high in dairy products or calcium and an increased risk of prostate cancer, and low blood levels of vitamin E or selenium and an increased risk of developing cancer. 

The report recommends maintaining a healthy weighteating a healthy diet and being physically active to reduce your risk of cancer. These recommendations seem both sensible and well founded.

 

Who produced the report?

The report was produced by the World Cancer Research Fund International as part of their Continuous Update Project.

This report aims to update a report from 2007 by analysing global prostate cancer prevention and survival research linked to diet, nutrition, physical activity and weight.

The results were well reported by the media.

 

What evidence did the report look at?

The report is based on the findings of a systematic review performed by a team at Imperial College London, and its interpretation by a panel of independent experts.

The systematic review included randomised controlled trials, and cohort and case-control studies identified from the Medline database.

The results from 104 studies were analysed. This included more than nine million men, 191,000 of whom had prostate cancer.

 

What are the main findings of the report?

The report found strong evidence that:

  • being overweight or obese (measured by body mass index [BMI], waist circumference, or waist-hip ratio) increases the risk of advanced prostate cancer (advanced, high-grade, or fatal prostate cancer)
  • developmental factors in the womb, childhood and adolescence that influence growth are linked to an increased risk of prostate cancer – for example, taller men are at an increased risk of prostate cancer
  • beta-carotene, a pigment found in certain plants and fruits (consumed from diet or supplements), had no substantial effect on the risk of prostate cancer

There was limited evidence that:

  • higher consumption of dairy products increases the risk of prostate cancer
  • diets high in calcium increase the risk of prostate cancer
  • low plasma (blood) alpha-tocopherol concentration (vitamin E) increases the risk of prostate cancer
  • low plasma (blood) selenium concentration increases the risk of prostate cancer

The report made no conclusions about whether a number of other factors increased or decreased the risk of prostate cancer. For example:

  • cereals (grains) and their products
  • dietary fibre
  • potatoes
  • non-starchy vegetables
  • fruits
  • pulses (legumes)
  • processed meat
  • red meat
  • poultry
  • fish
  • eggs
  • total fat

This is not an exhaustive list. For the complete list, you can download the report for free (PDF, 2.49Mb).

No conclusions were made because the studies identified were either poor quality, their results were inconsistent, or too few studies were identified.

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter. Join the Healthy Evidence forum.

Links To The Headlines

Being overweight raises risk of men developing aggressive prostate cancer. The Guardian, November 19 2014

Obesity 'raises prostate cancer risk': 10% of cases could be prevented if men kept themselves at a healthy weight. Daily Mail, November 19 2014

Links To Science

World Cancer Research Fund International. Diet, nutrition, physical activity and prostate cancer (PDF 2.49Mb). November 2014

Categories: NHS Choices

Does being poor make your teeth fall out?

NHS Choices - Behind the Headlines - Tue, 18/11/2014 - 16:08

"People with lower income end up with eight fewer teeth than the rich," The Independent reports.

The headline is prompted by a new study based on a 2009 national dental health survey of adults over the age of 21 in England. It found strong links between socioeconomic status (how well off a person is) and oral health.

The most extreme result was that the poorest fifth of elderly people had up to eight fewer teeth than the wealthiest fifth.

The finding that those who are worst off in society have poorer oral health than the wealthiest may not surprise many, and may well correlate with poorer health in general.

However, the study provides food for thought on whether the extent of the difference is acceptable or preventable.

The study's authors argue the routes of these inequalities require action "addressing risks, beliefs, behaviours, and the living environment", and that these factors may be just as important as affordable access to professional dental treatment.

Read more advice about dental health and how to mind those gaps.

 

Where did the story come from?

The study was carried out by researchers based at the University of Newcastle and the University of London, and was funded by the UK Economic and Social Research Council as part of the Secondary Data Analysis Initiative.

It was published in the peer-reviewed Journal of Dental Research.

The report opens with a quote from Chilean poet Pablo Neruda: "Rise with me against the organisation of misery". This quote highlights the authors' conclusion that the differences they have found are avoidable and are a product of the way our society is organised.

The media generally reported the story accurately, with many carrying a similar quote from the lead study author, who stated that, "It's probably not a big surprise that poorer people have worse dental health than the richest, but the surprise is just how big the differences can be and how it affects people."

Most of the headlines led with the figure that the poorest elderly people had up to eight fewer teeth than the richest. This result was not reported in the main results section of the publication, but was only mentioned in the discussion section, as this finding was not adjusted for confounders. Nonetheless, this does not diminish its significance in the wider context.

 

What kind of research was this?

This was a secondary analysis of a pre-existing dataset originating from a 2009 national dental health survey in England.

Oral health inequalities associated with socioeconomic status are widely observed, the research team says, but may depend on the way both oral health and socioeconomic status is measured.

The aim of this study was to investigate inequalities using diverse indicators of oral health and four socioeconomic determinants for age and cohort.

Using a pre-existing dataset is a relatively quick and simple approach to investigate the link between socioeconomic status and oral health.

The main limitation in using existing datasets, however, is often they do not collect all the data required for analysis.

This is because the original survey and data collection would have been designed for a specific purpose, which may be different from the purpose of the secondary analysis.

 

What did the research involve?

Researchers used existing data collected from a 2009 UK adult dental health survey to investigate how socioeconomic status was linked to oral health for adults.

This survey was based on a nationally representative sample of 11,380 individuals (among which 6,469 adults had an oral examination) providing information on individual dental health and socioeconomic status. The team restricted data analysis to adults over the age of 21.

The researchers wanted to see whether using different measures of socioeconomic status and oral health made a difference to how they were related, so they used multiple measures of each.

Oral health measures included:

  • the presence of tooth decay
  • the existence of teeth that couldn't be restored because of decay
  • the number of decayed, missing and filled teeth
  • the existence of any periodontal pocket (where the gums pull away from the teeth, creating a pocket) of 6mm or more
  • the number of natural teeth
  • having three or more unfilled upper spaces (to capture how the teeth might look)
  • a composite measure of excellent oral health (21 or more teeth, 18 of which are "sound", with no decay or pockets greater than 4mm)

Socioeconomic measures included:

  • income
  • education
  • index of multiple deprivation occupational social class

The analysis looked for links between each of the four measures of socioeconomic status and the seven measures of oral health.

The analysis took account of multiple confounders, including:

  • age
  • sex
  • marital status
  • region of residence
  • longstanding illness
  • self-assessed health

 

What were the basic results?

The team consistently found people with lower incomes, lower occupational class, higher deprivation, or low educational attainment had the worst oral health outcomes. However, the size and significance of these inequalities depends on the clinical outcome used.

The two simple tooth decay measures – presence of tooth decay and the existence of more than one tooth that could not be restored as a result of decay – were still strongly associated with income after adjustment for confounders.

By contrast, the presence of any teeth with pockets of 6mm or more (severe periodontal disease), having unfilled upper spaces (untreated aesthetic impairment), and not having excellent overall oral health were weakly associated with income.

The number of teeth showed little or no income gradient in the young. By contrast, in older adults, those in the poorest fifth of income lost many more teeth than those in the top fifth, and the gradient was strong.

After adjustment for confounders, those in the poorest fifth had on average 4.5 fewer teeth than the richest fifth (95% confidence interval [CI], 2.2 to 6.8) but there was no difference in younger groups.

For periodontal disease, income inequalities were mediated by other socioeconomic variables and smoking, while for anterior spaces the relationships were age dependent and complex.

 

How did the researchers interpret the results?

The authors concluded that, "Oral health inequalities manifest in different ways in different age groups, representing age and cohort effects. Income sometimes has an independent relationship, but education and area of residence are also contributory.

"Appropriate choices of measures in relation to age are fundamental if we are to understand and address [oral health] inequalities."

In their discussion of the results, the researchers also added that, "In the oldest group, a huge difference between richest and poorest (based on current income) has opened up, and the unadjusted marginal difference was nearly eight teeth." This is the figure that made most of the media headlines.

 

Conclusion

This study provides a sharp look at the link between socioeconomic status and oral health. The finding that those worse off in society have poorer oral health is no surprise, and may well correlate with poorer health in general.

But what needs to be considered now is whether the extent of the difference is preventable. The most extreme result was that the poorest fifth of elderly people had up to eight fewer teeth than the wealthiest fifth.

On a more academic note, the study shows you can get slightly different results and patterns depending on which precise measure of socioeconomic status and oral health you choose – something future studies can learn from.

These findings are likely to represent a broadly accurate picture of the state of oral health in the UK and how it is related to various measures of income inequality.

But one drawback was that only four measures of socioeconomic status were tested. There are many more that are routinely used in other types of research, but the team were limited to using the information already collected as part of the original dental health survey.

The data suggests the links between different socioeconomic factors and oral health are complex. The authors themselves highlighted some wider determinants of health that may be at play, meaning a focus on treatment may not be the best approach to tackle the variation.

They remarked that, "There are many possible paths between socioeconomic position and oral health inequality that require further unpicking. However, while increasing resources for treatment services may provide benefits, the analysis here suggests that it will not resolve inequalities.

"Upstream action addressing risks, beliefs, behaviours, and the living environment are probably as important as affordable access to professional treatment."

This follows the sentiment of the Marmot Review "Fair Society, Healthy Lives", which dominates the wider public health agenda of tackling avoidable differences in health using an "upstream" approach.

An upstream approach is when rather than trying to change people's individual behaviours (such as encouraging tooth brushing), you instead change higher environment and social forces (such as adding fluoride to the water supply), which leads to beneficial effects flowing "downstream".

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter. Join the Healthy Evidence forum.

Links To The Headlines

Pulling teeth: the gaps that reveal a life of hardship. The Daily Telegraph, November 17 2014

Elderly people who are poor 'have eight fewer teeth than the richest 20% of society. Daily Mail, November 18 2014

People with lower income end up with eight fewer teeth than the rich, study finds. The Independent, November 18 2014

Links To Science

Steele J, et al. The Interplay between Socioeconomic Inequalities and Clinical Oral Health. Journal of Dental Research. Published October 24 2014

Categories: NHS Choices

Triclosan soap linked to mouse liver cancers

NHS Choices - Behind the Headlines - Tue, 18/11/2014 - 10:29

“A chemical ingredient of cosmetics, soaps, detergents, shampoos and toothpaste has been found to trigger liver cancer,” reports The Independent. The chemical in question, triclosan, is used in many products as an antibacterial.

Should you be worried if you have just washed your hands? Probably not. The link was found in mice, not humans, and the mice were given a much larger comparable dose than humans are ever likely to be exposed to.

The study found that mice fed high amounts of triclosan daily for six months suffered liver damage and were more susceptible to liver tumours induced by other cancer-causing chemicals.

The findings tell us very little about the potential health effects on people. However, it’s important not to be complacent. Further investigation may be warranted in humans, especially when it comes to topical application, and at lower exposure levels.

The concerns have resulted in an investigation by the US Food and Drug Administration (FDA), which regulates its use in America. The FDA said that it does not have enough safety evidence to recommend any “change to its use in consumer products”. This means that the evidence does not tell us whether or not triclosan is harming people through background exposure. Until further evidence accumulates, we will remain in the dark about this issue.

 

Where did the story come from?

The study was carried out by researchers from the University of California and was funded by US Public Health Service Grants.

The study was published in the peer-reviewed science journal PNAS.

Generally, the media reported the story accurately. The Independent, for example, took the commendable step of indicating that it was research on mice in their main headline. This prevents any incorrect assumptions that it was on humans. The body of the Independent article also appeared factual and not overly alarmist, discussing the views of different scientists who thought the chemical might pose a risk to humans, and those that thought it was too early to tell.

Conversely, the Daily Express chose to lead with the words "Cancer scare", which was an unnecessary step. The paper also took several paragraphs to explain that only mice were studied.

 

What kind of research was this?

This was a laboratory study using mice to investigate the potential cancer-promoting properties of triclosan.

Triclosan [5-chloro-2-(2,4-dichlorophenoxy)phenol; TCS] is a synthetic, broad-spectrum antibacterial chemical used in a wide range of consumer products, including soaps, cosmetics, therapeutics and plastics. The general population, the researchers point out, are exposed to triclosan because of its prevalence in a variety of daily care products, as well as through waterborne contamination. They say it is linked to a variety of health and environmental effects, and wanted to investigate the effect on the liver.

Researchers often use mice because, as mammals, they share similar biology with humans. Hence, research on mice can tell us what might happen in humans, without directly experimenting on them. The caveat is that there is no guarantee that results in mice will be replicated in humans as, while similar, the biology of the two organisms is not identical, and the differences can sometimes be crucial.

 

What did the research involve?

The research involved two groups of mice: one fed a normal diet and the other a diet supplemented with triclosan. After eight months on the diets, the mice were killed and their livers removed and analysed for physiological and genetic signs that the chemical was promoting cancer growth.

In a second experiment, the research team injected two groups of mice with a chemical that causes the development of cancerous liver tumours, to see whether giving triclosan (this time given in their drinking water) influenced the development of the tumours thereafter.

 

What were the basic results? Effect of long-term triclosan in the diet on liver biology

Through physiological and genetic analysis, the results suggested that triclosan increases liver cell proliferation, induces liver scarring and reactive oxygen species accumulation. Taken together, the team concluded this was a sign that triclosan damaged the liver cells, implying they may be more likely to become cancerous.

Effect of triclosan after tumour promoting injection

Triclosan-treated mice had a higher tumour number, bigger tumour size and greater tumour incidence than mice given the tumour-promoting injection alone. The number of detectable liver cancers was around 4.5 times higher in triclosan-treated mice than in control mice.

Approximately 25% of mice receiving the tumour promoting injection only exhibited small cancerous nodules, whereas more than 80% of triclosan-treated mice developed tumours. Maximal tumour diameter was also 3.5-fold larger in triclosan-treated mice.

 

How did the researchers interpret the results?

The study authors acknowledged that, “animal studies require higher chemical concentrations than predicted for human exposure”, but said their study, “demonstrates that TCS [triclosan] acts as a HCC [liver cancer] tumour promoter and that the mechanism of TCS-induced mouse liver pathology [disease] may be relevant to humans.”

 

Conclusion

This small mouse study raises the prospect that triclosan may have tumour promoting-properties that could be relevant to humans but, on its own, does not provide any conclusive evidence that it does.

Firstly, the findings in this small group of mice need to be replicated by other research teams to ensure they are reliable. This should include the effect of triclosan at different levels of exposure and through different exposure paths, such as through food, water or skin. The latter would be of particular relevance to humans, given that much of our exposure to triclosan is topical (via the skin) rather than oral.

The current mouse study, as the authors acknowledged, “require[d] higher chemical concentrations that predicted for human exposure”. This means the mice were given very high amounts of the chemical relative to what you might expect the average person to be exposed to in real life.

The second issue is that even if the results are found to be reliable in mice, there is no guarantee that the same effects will be the seen in humans, irrespective of exposure levels or exposure route. While humans and mice share many biological mechanisms and similarities as common mammals, their differences can be crucial during disease processes.

At present, we simply don’t know if similar results would be found in people. It would also be unethical to give someone a high dose of something on the premise that you are trying to prove it causes cancer. Therefore, it is likely that large and long-term cohort studies, using natural exposure levels, will give us the best evidence on the potential health effects of triclosan.

As a result, there are many unanswered questions around this research and the potential harms (or lack of) associated with triclosan that may warrant further investigation. This is especially due to its ubiquitous use in a range of both commercial and healthcare products.

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter. Join the Healthy Evidence forum.

Links To The Headlines

Cancer scare: Could your liquid hand gel be harming your health? Daily Express, November 17 2014

Toothpaste chemical may increase risk of cancer, warn scientists. The Daily Telegraph, November 18 2014

Triclosan: Soap ingredient can trigger liver cancer in mice, warn scientists. The Independent, November 17 2014

Links To Science

Yueh M-F, et al. The commonly used antimicrobial additive triclosan is a liver tumor promoter. Proceedings of the National Academy of Sciences of the United States of America. Published November 17 2014

Categories: NHS Choices

'Food environment' needs changing, doctors argue

NHS Choices - Behind the Headlines - Mon, 17/11/2014 - 12:00

"A Mediterranean diet may be a better way of tackling obesity than calorie counting, leading doctors have said," BBC News reports.

In a recently published editorial, they also argue the NHS should do more to encourage its staff to eat more healthily.

As this was an editorial, and not new evidence, it cannot prove the Mediterranean diet, which is characterised by vegetables, fruits, beans, whole grains, olive oil and fish, is "best". But the article does raise some interesting points.

They argue that the obesity epidemic is intrinsically linked to an unhealthy food environment – one in which easy access to cheap, high-energy, nutrient-poor junk food promotes poor choice by default.

Doctors cannot just issue calorie control and exercise advice ("eat less, move more"), but need to encourage healthier eating overall. The Mediterranean diet has been linked to improved cardiovascular health, as we discussed in 2013.

The authors also point out the need to promote healthy eating within the NHS – for example, providing healthy meal options for both patients and staff.

That way, healthcare professionals can inform patients and the public about how diet can improve health by leading by example.

 

Where does the story come from?

The story follows an editorial published in the peer-reviewed Post Graduate Medical Journal. It was authored by three professionals with affiliations to Frimley Park Hospital in Surrey, the Academy of Medical Royal Colleges in London, and NHS England. The authors declare no conflicts of interest.

The authors discuss the current obesity epidemic and the effect that different approaches can have on this, referencing various publications.

They do not provide any methods for identifying the various studies they reference, and this does not appear to be a systematic review.

It is not known whether all the literature relevant to the issue of healthy eating has been considered.

Therefore, this editorial must be considered as the views and opinions of the authors based on their knowledge of the literature and expert opinion. We do not know whether another systematic review of the subject would reach the same conclusions.

 

What do the researchers say about the obesity problem?

The researchers explain how the obesity epidemic currently costs the NHS about £6 billion a year, while obesity-related diseases such as diabetes cost even more.

Our diet is a powerful determinant of our weight and health. However, as the authors consider, the decisions that we make about the food we buy is often made without full conscious awareness, and we can be seduced by the brightly coloured packaging of confectionery at the till.

The authors discuss foods that have been the particular focus of attention in trying to reduce the risk of cardiovascular disease.

Fruit, vegetables, nuts, olive oil and oily fish – common in Mediterranean cuisine – contain α-linoleic acid, polyphenols and omega-3 fatty acids, which are believed to reduce inflammation and the formation of fatty blood clots in the arteries. This reduces the risk of heart diseases, such as heart attacks.

The researchers say it's estimated that increasing the world's consumption of fruit and vegetables by one portion a day, and nuts by two servings a day, would prevent 5.2 million cardiovascular deaths worldwide within a year.

It is also estimated that reducing people's sugary drink consumption by 15% would, within a year, prevent 180,000 people from becoming obese in the UK, and save the NHS £275 million.

The researchers say real progress will only be made when "the need for a healthier food environment" is understood. As they say, collective action is needed so that an individual's choices about what to eat default to healthy options rather than junk food: "healthy choice must be the easy choice".

There is currently an oversupply of cheap, high-energy, nutrient-poor food, such as confectionery, crisps and sugary drinks, in vending machines, food trollies and food outlets in NHS hospitals – the places that should be promoting positive healthy messages.

Not only does this impact on the choice of patients and visitors, but also NHS staff – half of whom are estimated to be overweight or obese.

As the researchers also consider, the effects of regular physical activity will be undermined if someone has a poor diet: "you can't outrun a bad diet".

 

What do they say about specific diets?

The researchers discuss "weight cycling" – rapid loss and regain – and how this has been associated with high blood pressure, poor blood sugar and blood fat control, and poor overall cardiovascular outcomes.

US research shows most people on rapid diets regain most of their lost weight, and two-thirds do not gain any health benefit.

In contrast, they discuss one trial that randomised 7,500 high-risk adults to either the Mediterranean diet (41% total fat, supplemented with extra virgin olive oil or nuts) or low-fat dietary advice.

They report the Mediterranean diet was associated with a 30% reduction in major cardiovascular disease events within three months.

It is unclear how this effect was calculated and whether it was compared with the low-fat group. The researchers report these reductions in cardiovascular disease risk were irrespective of weight.

They also report another study, which showed how adopting a Mediterranean diet after a heart attack is almost three times as effective as a statin at reducing mortality.

The researchers also mention another trial, which found an energy-unrestricted, high-fat, low-refined carbohydrate diet (restricting carbohydrates without fibre) resulted in more weight loss and a better blood fat profile one year later when compared with a low-fat diet.

 

What suggestions to the authors make?

The researchers suggest that introducing evidence-based nutrition into the training of doctors and nurses would increase their understanding of the science of healthy eating, and also allow better-informed nutrition discussion between health professionals and patients.

They also say the NHS as an employer is in a key position to set a national example by supporting 1.4 million staff to stay healthy and serve as "health ambassadors" in their local communities.

The researchers say it is time to get across the evidence base that healthy dietary change rapidly improves outcomes, and put this into the heart of the NHS.

They report the key recommendations of the "Five Year Forward View" published by NHS England and partner organisations in October 2014, which set out a vision for the future of the NHS:

  • Make information about the evidence base for healthy diets easily available to NHS staff and patients.
  • NHS employers to implement the Workplace Wellbeing Charter and require commissioners to consider this when assessing tenders.
  • Implement National Institute for Health and Care Excellence (NICE) guidance on promoting healthy workplaces throughout the NHS.
  • Reduce access to processed foods high in fat, salt and sugar on NHS premises.
  • Provide healthy diet options for all staff, including night staff.
  • Call for NHS institutions to objectively monitor and publish sales and quantities of foods deemed unhealthy, in addition to the degree of adherence to national food standards.

 

Conclusion

The focus of this research is on changing the dietary environment to a healthy rather than an unhealthy one, particularly within the NHS.

The media has focused on the Mediterranean diet, but this is not the sole focus of the study. Reports on the Mediterranean diet come from two brief references to two trials within the editorial.

From the information provided in this editorial alone, it is not possible to comment on the reliability and comprehensiveness of all the information provided.

As stated, this does not appear to be a systematic review. Therefore, without knowing the methods the researchers used, it's not possible to say whether all the relevant evidence relating to the issue of healthy eating has been considered.

With only examples of a few dietary trials discussed, we do not know whether all the evidence relevant to the comparative effectiveness of different dietary approaches (for example, Mediterranean versus low fat) has been examined.

Without looking at the individual studies behind the data in this editorial, it is also not possible to review how accurate and reliable the effectiveness data and estimates are likely to be, or how they were calculated – for example, estimates on reduction of cardiovascular deaths and obesity with specific alterations to food intake.

Nevertheless, the overall message of this editorial – to make the dietary environment a healthier one – is sensible and consistent with recommendations made by other health organisations.

Analysis by Bazian. Edited by NHS ChoicesFollow Behind the Headlines on TwitterJoin the Healthy Evidence forum.

Links To The Headlines

Mediterranean diet is best way to tackle obesity, say doctors. BBC News, November 17 2014

Links To Science

Malhotra A, Maruthappu M, Stephenson T. Healthy eating: an NHS priority A sure way to improve health outcomes for NHS staff and the public. Postgraduate Medical Journal. Published online November 16 2014

Categories: NHS Choices

Just one kiss 'spreads 80 million bugs'

NHS Choices - Behind the Headlines - Mon, 17/11/2014 - 11:15

"A single 10-second kiss can transfer as many as 80 million bacteria," BBC News reports. Dutch scientists took "before and after" samples from 21 couples to see the effect an intimate kiss had on the bacteria found in the mouth.

By studying the couples, the scientists discovered the bacteria found on the tongue are more similar among partners than unrelated individuals, but are not correlated with kissing behaviour.

In contrast, the researchers found that for bacteria in saliva to be similar, couples need a relatively high kiss frequency and a short time since their last kiss.

The researchers also estimated that a 10-second kiss transfers 80 million bacteria. These results suggest many of the transferred bacteria are not able to take hold on the tongue.

Some of the media reporting has suggested that this transfer of bacteria that occurs during a kiss is good for us.

The idea is plausible, but is not proven by the evidence presented in the current study. Sometimes, as the song goes, "a kiss is just a kiss".

 

Where did the story come from?

The study was carried out by researchers from the Netherlands Organisation for Applied Scientific Research (TNO) Microbiology and Systems Biology and Micropia, Natura Artis Magistra (Artis Royal Zoo), and VU University Amsterdam, The Netherlands.

It was funded by Natura Artis Magistra and TNO.

The study was published in the peer-reviewed scientific journal Microbiome. This study is open access, meaning it can be read online for free.

The story was well reported by BBC News. But the Daily Mail's coverage was less accurate, as its headline stated: "Kissing for ten seconds passes on 80 million bugs – but it keeps you healthy! Bacteria transferred helps improve immune system". The study made no assessment of immune function, so this statement is unsupported.

 

What kind of research was this?

This was a series of experiments on people that aimed to determine:

  • whether the mouths of kissing partners are colonised with similar bacteria 
  • if the frequency with which couples kiss and the amount of time since the last kiss influences the bacteria present in the mouth
  • the number of bacteria transferred by kissing

 

What did the research involve?

The researchers studied the bacteria in the mouths of 21 couples, including one female and one male gay couple.

The researchers collected saliva samples and samples from the back of the tongue before and after an intimate kiss of 10 seconds. Bacteria were identified by analysing the DNA sequences present in samples.

Couples were also asked to report their last year's average kiss frequency and the period of time since their last intimate kiss.

One of the partners was asked to consume 50ml of a probiotic yoghurt drink containing the bacteria Lactobacillus and Bifidobacteria.

Again, saliva and tongue samples were collected before and after an intimate kiss of 10 seconds. The researchers estimated bacterial transfer after an intimate kiss by tracking these marker bacteria.

 

What were the basic results?

The bacteria found in tongue samples were more similar for couple members than for unrelated individuals. An intimate kiss did not significantly increase the similarity in the bacteria found in tongue samples. 

The bacteria found in saliva were not more similar for couple members than for unrelated individuals, and an intimate kiss did not significantly increase the similarity in the bacteria found in saliva samples.

However, the researchers did see a correlation between the similarity of bacteria found in the saliva of couples and self-reported kiss frequencies, and the reported time since the last kiss.

The researchers estimated that 80 million bacteria are transferred per 10-second intimate kiss.

 

How did the researchers interpret the results?

The researchers concluded that, "This study indicates that a shared salivary microbiota [bacterial flora] requires a frequent and recent bacterial exchange, and is therefore most pronounced in couples with relatively high intimate kiss frequencies.

"The microbiota on the dorsal surface of the tongue is more similar among partners than unrelated individuals, but its similarity does not clearly correlate to kissing behaviour, suggesting an important role for specific selection mechanisms resulting from a shared lifestyle, environment, or genetic factors from the host."

They go on to say that, "Furthermore, our findings imply that some of the collective bacteria among partners are only transiently present, while others have found a true niche on the tongue's surface allowing long-term colonisation."

 

Conclusion

This study has investigated the effects of intimate, or french kissing, on the bacteria found in the mouth.

By studying 21 couples, it found the bacteria on the tongue are more similar among partners than unrelated individuals, but are not correlated with kissing behaviour.

In contrast, the researchers found that for bacteria in saliva to be similar, couples need a relatively high kiss frequency and a short time since their last kiss.

The researchers also estimated that a 10-second kiss transfers 80 million bacteria.

These results suggest that kissing transfers many bacteria, but many of the transferred bacteria are not able to take hold on the tongue.

This is interesting research, but the findings have limited implications. They do not tell us whether kissing is beneficial or not – for example, in terms of causing illness or, conversely, increasing our immunity by exposure to a greater range of bacteria.

Though, of course, a kiss with the right person can be fun.

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter. Join the Healthy Evidence forum.

Links To The Headlines

One kiss 'shares 80 million bugs'. BBC News, November 17 2014

Kissing for ten seconds passes on 80 million bugs - but it keeps you healthy! Bacteria transferred helps improve immune system. Daily Mail, November 17 2014

Links To Science

Kort R, Caspers M, van de Graaf A, et al. Shaping the oral microbiota through intimate kissing. Microbiome. Published online November 17 2014

Categories: NHS Choices

'Good ways to pop a pill'

NHS Choices - Behind the Headlines - Fri, 14/11/2014 - 15:36

“Just a spoonful of water helps the medicine go down: Scientists discover the best way to swallow tablets,” explains the Mail Online today.

In fact, scientists haven’t necessarily discovered the “best” ways to take your medicine, they have simply tested two options and found that they work well – and neither involves just a spoonful of water.

The best ways to swallow medicine – according to the new research cited by the Mail – are a “pop-bottle” method for tablets and a “lean-forward” technique for capsules.

German researchers asked adults with and without swallowing difficulties to swallow 16 tablets and capsules of different shapes and sizes using 20ml of water, with their eyes shut. The most difficult tablet and capsule were then chosen to test whether the two alternative techniques were better.

The pop-bottle method was rated easier to use for swallowing tablets by 60% of participants regardless of whether they had an initial swallowing difficulty. The lean-forward technique for capsules improved swallowing in 89% of people. Overall, 86% of the people said they would use the techniques in the future.

Both techniques appear to have been successful for the majority of people, and may be worth a go if you have mild difficulty swallowing pills. If you have a more general swallowing problem, speak to your GP or pharmacist about different techniques for taking medicine or alternative formulations, such as medicine in liquid form.

 

Where did the story come from?

The study was carried out by researchers from the University of Heidelberg and was funded by the Fette Compacting GmbH, the German Research Foundation, and the German Federal Ministry of Education and Research.

The study was published in the peer-reviewed medical journal Annals of Family Medicine.

The Mail Online helpfully provided diagrams to explain the two techniques, but it did not accurately reflect the experiment. Slurping from a tablespoon of water was not tried in this research, although in each of the initial pill-swallowing experiments 20ml (about a tablespoon) of water was used, but this was not found to be the most effective method.

 

What kind of research was this?

This cross-sectional study aimed to determine the optimal technique for swallowing tablets and capsules. Difficulty in swallowing pills can lead to non-compliance with medication or the need to have it administered in a different form, so the researchers wanted to find out the easiest way that the majority of people would find to take them.

 

What did the research involve?

To investigate different swallowing techniques, 151 adults from the general population in Germany were enrolled in the study. They were asked to swallow 16 dummy pills of different sizes and shapes with their eyes closed using 20ml of water, and rate the ease of swallowing. The largest tablet and capsule that had caused the most difficulty were then chosen to be swallowed again to test two particular techniques – the “pop-bottle method” for the tablet and the “lean-forward technique” for the capsule – to see if they made it easier to swallow them.

Pop-bottle method

The pop-bottle method involves placing the tablet on the tongue, tightly closing the lips around the top of a plastic bottle filled with water, and swallowing in a “swift suction movement” to overcome the “volitional phase of swallowing” (the conscious act of swallowing). No air should enter the bottle as you swallow, and the bottle will squeeze in on itself as you drink the water. This method was devised for tablets because they are usually of high density.

Lean-forward technique

The lean-forward technique requires swallowing the capsules whilst in an upright position, with the head bent forward. This version was deemed appropriate for capsules, as they are usually very light.

The researchers then compared the rating of these two techniques, with the initial rating of how easy the tablet and capsule had been to swallow.

 

What were the basic results?

Compared to swallowing with 20ml of water, the pop-bottle method improved the ease of swallowing the tablet for 60% of people. This included people who had not found it difficult in the first place.

The capsule swallowing was tested only 35 times, and the lean-forward technique was rated better by 89% of participants. This compared to the capsules lodging in the back of the throat on 10 out of 33 occasions without the technique.

Overall, 86% of participants said they would now use these techniques for swallowing pills.

 

How did the researchers interpret the results?

The researchers conclude that, “this study showed for the first time that two targeted techniques to facilitate tablet and capsule intake were remarkably effective and easy to adopt in the general population, including patients with swallowing difficulties, and should therefore be generally recommended”.

 

Conclusion

This study has demonstrated that two specific techniques for swallowing tablets and capsules were beneficial in the majority of people studied. This included people who have trouble swallowing the pills as well, as the controls who didn’t normally have swallowing problems.

While the results of this study seem impressive for these techniques, it should be noted that they were compared to swallowing the pills with just 20ml of water, which is equivalent to a sip or a small mouthful, if you have a small mouth.

The participants also had their eyes closed during this phase of the experiment, which may have been disorientating and made swallowing a pill more unnatural. Also, by the time the participants tested the new techniques, they would have just swallowed 16 tablets, so it could be argued that they would have got more used to doing so by then.

Nevertheless, it is encouraging to have two new techniques to try if you do have difficulty swallowing pills. However, bear in mind that the authors suggest the pop-bottle technique carries some potential risk of getting the pill lodged in your airway (aspiration).

If you have a condition where you have problems with swallowing in general (dysphagia), it may be better to try new techniques under medical supervision.

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter. Join the Healthy Evidence forum.

Links To The Headlines

Just a spoonful of water helps the medicine go down: Scientists discover the best way to swallow tablets. Mail Online, November 13 2014

Just a spoonful of water: doctors find best method for swallowing pills. The Guardian, November 10 2014

Links To Science

Schiele JT, et al. Two Techniques to Make Swallowing Pills Easier. Annals of Family Medicine. 2014;12:550-552.

Categories: NHS Choices

Do people who take weight loss pills eat unhealthily?

NHS Choices - Behind the Headlines - Fri, 14/11/2014 - 09:40

"Are slimming pills fuelling the obesity epidemic?" asks the Mail Online, reporting on research that suggests dieters "mistakenly believe they can eat whatever they want" after taking weight loss drugs.

There is nothing in the research to prove the Mail's headline. In fact, its headline was prompted by US experiments on the effects of marketing a weight management treatment as a "drug" or a "supplement".

The research looked at whether the difference would change healthy lifestyle beliefs and behaviour, and whether this is influenced by knowledge about weight remedies and nutrition.

Researchers found that when people were shown an advert for something marketed as a drug, it led to them eating more cookies (an unhealthy behaviour) than when the same treatment was advertised as a supplement.

They further found giving people more knowledge about weight loss remedies was more effective at mediating this unhealthy eating than giving them more knowledge about nutrition in general.

Very limited conclusions can be drawn from this study, and it does not provide evidence that taking weight loss treatments encourages unhealthy lifestyle behaviours, or that these remedies make people think they can eat what they want. These experiments were very specific one-off scenarios in relatively small samples of young adults.

Most importantly, this US study has little bearing in the UK, where drugs are not marketed to the public. Prescribed weight loss treatments have a specific set of criteria controlling their prescription.

This study is not conclusive. We don't know whether – and how – taking weight loss drugs directly influences people's beliefs about health and nutrition.

 

Where did the story come from?

The study was carried out by professors of business and marketing from three business schools in Philadelphia and New Hampshire, in the US.

Financial support was provided by the Collaboration to Reduce Disparities in Hypertension (CHORD) project funded by the Pennsylvania Department of Health, and from the Ackoff Fund of the Wharton Risk Management and Decision Processes Center.

The study was published in the peer-reviewed Journal of Public Policy and Marketing.

The Mail's conclusion that, "dieters using slimming pills mistakenly believe they can eat whatever they want" cannot be made based on this set of experimental studies, which have limited application to the situation in the UK.

The study also provides no evidence that slimming pills are fuelling the obesity epidemic.

 

What kind of research was this?

This was an experimental study conducted in the US. It explored the impact of the marketing of weight management remedies on healthy lifestyle behaviours. These remedies are described as covering "products or services designed to reduce risk and offer solutions to challenges consumers face".

The researchers investigated three main questions:

  • How does marketing of weight management remedies (specifically, the marketing of products labelled as drugs versus those labelled supplements) affect actual healthy behaviour?
  • Is the impact of weight management remedy marketing rooted in erroneous beliefs about remedies themselves? Or is the impact of weight management remedy marketing more driven by the consumer's choice between remedies (such as drugs versus supplements)?
  • Previous research has not specifically tested the impact of "health literacy" on consumer response to weight management marketing. The researchers wanted to investigate the impact of two critical dimensions of health literacy: "nutritional knowledge" and "remedy knowledge".

The researchers conducted three experiments examining these questions, which were centred on their three theories.

 

What did the research involve?Study one: how weight management remedy are marketed

The researchers believed there is a difference between the marketing of drugs and supplements. They say supplements have less association with poor health, and remind consumers of the importance of other health-protective behaviours.

On the other hand, marketing something as a drug treatment could undermine, rather than enhance, healthy lifestyle behaviour. So their first theory is that, "actual unhealthy decisions and behaviour will increase after exposure to weight management drug marketing, but decrease after exposure to supplement marketing".

This first study investigated the impact of drug and supplement marketing on food consumption behaviour. They divided 138 young adults (average age 22, made up of university staff, students and other residents of the area) into six groups and exposed them to either a drug or supplement remedy message, or a no-remedy control message. They then gave them the opportunity to consume a product framed as either relatively unhealthy or healthy (via an explicit low-fat cue).

Both the drug or supplement and no-remedy message started with the line, "Avoid fatty foods and follow a sensible eating plan. This is the only way to achieve an overall healthy lifestyle." The no-remedy message ended there.

The other two added an advertisement about a weight loss treatment that stops fat being absorbed, which was described as being either a FDA-approved drug or a supplement.

Participants were then given free access to cookies, either described as being low-fat and guilt-free, or delicious and indulgent. Participants also completed questions on their views and attitudes.

Study two: how health literacy affects people's response to marketing

The second study examined health literacy. It looked at how knowledge of nutrition and remedies influenced people's response to marketing of remedies. This was to test their theory that, "Remedy knowledge will be more effective than nutrition knowledge at mitigating the negative impact of remedy marketing on healthy lifestyle decisions and behaviours".

The researchers included 356 participants, who they recruited online for a financial inducement. Each group read a short scenario describing the weight management treatment of an individual in a clinical trial. One group were told that he was given a drug or supplement, one was told he chose to have the drug or supplement, and the third group were told he was given a placebo.

Participants were then asked to rate on a scale the likelihood that the individual in the scenario would "follow a low-fat diet", "eat healthy foods", and "live a healthy lifestyle". Participants also rated the individual's likely motivation and effectiveness of the treatment. They then completed questionnaires assessing their remedy knowledge and nutrition knowledge.

Study three: how understanding of nutrition and remedies affects healthy decisions

The third study looked at the impact of information on actual health choices in the presence of weight management marketing.

In this study, 129 young adults (average age 20, again university staff, students and residents) read two articles compiled from Wikipedia, one focused on remedies and one focused on nutrition. They manipulated knowledge by providing information that would have varying relevance to healthy consumption behaviour.

For the "high-remedy knowledge" group, the article contained information about drugs and supplements, including how they support health. For the "low remedy knowledge" group, the article contained less information on health.

For the "high-nutrition knowledge" group, the article included World Health Organization (WHO) information on dietary health, including how to promote health and reduce risk. For the "low-nutrition knowledge" group, the article contained less information relevant to health.

Participants rated the readability and interest in the articles. They then looked at the advertisement for the same weight loss remedy as used in study one, which was described as a drug for all groups. They were then offered their choice of a relatively healthy snack (a strawberry) or a relatively unhealthy snack (a Lindt dark chocolate truffle).

 

What were the basic results?Study one: how weight management remedy are marketed

As the researchers expected, perceptions of the remedy as a "drug" were significantly higher when the same treatment was described as a US Food and Drug Administration-approved drug, rather than a supplement. Also, as expected, participants rated the same cookie as healthier when it was labelled as being "low-fat".

When the researchers analysed the interaction between different forms of marketing of the remedy and the cookie, they found some significant interactions. In particular, they found people who had seen the drug message ate significantly more cookies than those who had seen the supplement message and those who had not been given a remedy message.

Those who had seen the drug message also ate more cookies described as regular than low-fat. Meanwhile, those who had seen the supplement message ate significantly fewer cookies than those who had seen no remedy. Their consumption of cookies described as low-fat was also marginally, but not significantly, higher than those seeing no remedy.

Study two: how health literacy affects people's response to marketing

The researchers found that regardless of whether people were told the remedy was assigned to or selected by the subject, they expected his healthy lifestyle choices to be lower for a drug than a supplement.

In fact, when the researchers compared this with the control group, who were told the individual was taking a placebo, expected lifestyle ratings were no different than when told they were taking a supplement, but significantly less when told they were taking a drug.

Perceptions of motivation were found to mediate the effect of the remedy on lifestyle behaviour (for example, higher levels of motivation decreased the negative impact of the drug on lifestyle).

Study three: how understanding of nutrition and remedies affects healthy decisions

People with lower-remedy knowledge were more likely to choose the unhealthy snack compared with people with high-remedy knowledge. Nutrition knowledge had no significant effect on choice of snack, though unhealthy choices were more frequent with higher versus lower nutrition information.

 

How did the researchers interpret the results?

The researchers concluded that the three studies "demonstrate that exposure to drug (but not supplement) marketing for weight management encourages unhealthy consumer behavior, due to consumers' reliance on erroneous beliefs about health remedies".

When further exploring the possible mitigating role of health literacy (nutrition knowledge and remedy knowledge), they concluded that, "Remedy knowledge is more effective than nutrition knowledge at lessening the effect of weight management drug marketing on unhealthy behaviour".

 

Conclusion

This series of three experiments has investigated the effect that marketing a weight management treatment as a "drug" or a "supplement" has on healthy lifestyle beliefs and behaviour.

It also investigated whether people's understanding of health, in particular knowledge about weight remedies and nutrition, influences this.

The researchers found that believing something is a supplement encouraged "healthier" choices, rather than when people were told the same treatment was a drug. Their second experiment further suggested that weight management drugs undermine a healthy lifestyle by reducing motivation to engage in healthy behaviours.

They then found clues to suggest that knowledge of weight loss remedies mitigates effects on a healthy lifestyle – people were less likely to choose an unhealthy snack when they had been given more knowledge about the treatment. However, increased knowledge about nutrition didn't affect the healthy food choice.

This is an interesting study, but very limited conclusions can be drawn and it does not provide evidence that taking weight loss treatments encourages unhealthy lifestyle behaviours, or makes people think they can eat what they want.

These experiments were three very specific and one-off scenarios that may have very limited relevance to the real life situation. For example, in the first study, people were only shown an advertisement of a treatment marketed as a drug or supplement and were then offered a plate of cookies. They didn't actually take this treatment.

It is difficult to understand how just looking at an advertisement for a treatment you are not taking would directly cause you to eat fewer cookies just because you saw it called a supplement rather than a drug.

Given the large number of analyses that the researchers conducted, looking at interactions between a range of different scenarios, it could be possible that some of these findings may not show true cause and effect (causative) associations.

For example, in the first study, there were relatively small sample sizes in each group when they are broken down into the different remedy and food marketing conditions.

There was also no description of any attempt to ensure each group of adults was matched in terms of their usual eating habits, so any difference seen between the amount of cookies each group consumed may not be solely attributed to the messages they had just read.

But, most importantly, this study was done in the US and therefore has very limited applicability to the UK situation. Drugs are not marketed to the general public in the UK as they are in the US. Prescribed weight loss treatments are not advertised and have a specific set of criteria controlling their prescription. 

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter. Join the Healthy Evidence forum.

Links To The Headlines

Are slimming pills FUELLING the obesity epidemic? Dieters using them 'mistakenly believe they can eat whatever they want'. Mail Online, November 13 2014

Links To Science

Bolton LE, Bhattacharjee A, Reed A. The Perils of Marketing Weight Management Remedies and the Role of Health Literacy. Journal of Public Policy & Marketing. Published online September 22 2014

Categories: NHS Choices

Sex with funny, rich men linked with more orgasms

NHS Choices - Behind the Headlines - Thu, 13/11/2014 - 10:45

“Women have stronger orgasms if their partner is funny – and rich”, says the Mail Online.

This headline is wrong. And the research it’s based on, while fascinating, is rather inconclusive.

The study in question asked a small group of female students, who were in sexual relationships with men, to anonymously rate their sex lives and certain features of their partner, including estimates of wealth.

It found that how often a woman has an orgasm during sexual intercourse is linked to her partner’s family income, his self-confidence and how attractive he is. The intensity of a woman’s orgasm was related to how attractive she found her partner, how many times she had sex in a week and her overall rating of sexual satisfaction.

From this the authors conclude that female orgasms function to promote “good mate choices”.

It’s hardly surprising that this small, unrepresentative survey found that frequency and intensity of women’s orgasms and their general level of sexual satisfaction, was related to how attractive they found their partners. But it’s a leap of the imagination to conclude from this that female orgasm plays a role in choosing a healthy, fertile male with high quality genes.

It is interesting that the study found a link between frequency of orgasm and the male partner’s family income. For example, this may mean the couple had somewhere comfortable and private to go, so that they had sex more often.

There are many factors which influence the quality and frequency of orgasm, including a woman’s self confidence and awareness of her needs. This research only asked questions about orgasm during sexual intercourse (which does not happen as a matter of course). Many women who don’t achieve an orgasm through intercourse will do so in other ways.

 

Where did the story come from?

The study was carried out by researchers from the State University of New York. There is no information about external funding.

The study was published in the peer-reviewed journal, Evolutionary Psychology and appears to be available on an open access basis.

Predictably, the Mail went to town on the story. However, its headline linking orgasm intensity to the male partner’s wealth was incorrect. The study found a link between the partner’s family income and the women’s orgasm frequency – but not its intensity.

 

What kind of research was this?

This study set out to look at whether female orgasm “functions to promote good mate choices”, as the authors put it. The analysis was based on an anonymous online survey of 54 female undergraduate students, about their sexual behaviour and experience. It’s worth noting that this was not a random or representative sample – the students were all volunteers, were all enrolled in a psychology course, and were also given credit for participating.

The authors say that “mate choice” is not a trivial issue for women. There is growing evidence that features people find attractive in members of the opposite sex function as indicators of good genes and act as signals for health and fertility, they say. A number of studies show that the occurrence and frequency of female orgasm may be related to the characteristics of their partner such as attractiveness, wealth and masculinity, they claim.

 

What did the research involve?

The researchers recruited 54 female undergraduate students who volunteered to participate in an anonymous online survey. Participation was restricted to those who were in a committed relationship with a man that involved sexual intercourse.

The survey consisted of questions concerning the women’s subjective views on sexual behaviour, prior sexual experience, feelings toward their committed partner, and various estimates of features of their partner. They included questions on the male partner’s:

  • family income, financial independence, income potential 10 years from now
  • age (including the age gap between the partners)
  • grade point average (educational achievement)
  • ambition, creativity, responsibility, motivation
  • athleticism, health
  • discipline, conscientiousness, intelligence
  • sense of humour
  • level of focus and determination
  • self-confidence, leadership qualities, popularity
  • aggressiveness
  • muscularity, fatness, width of shoulders
  • physical attraction as rated by the woman and as rated by friends
  • protectiveness

Questions about sex included:

  • how often a woman had orgasm (with answers ranging from never to always or almost always)
  • how often she initiated intercourse (with answers ranging from never to always or almost always)
  • how many sexual partners she had had
  • age when she first had sexual intercourse
  • the intensity of orgasms during intercourse with her partner (with answers ranging from weak to very intense)
  • the number of orgasms experienced during a single encounter (with answers ranging from less than one to three or more)
  • level of sexual satisfaction with partner (with answers ranging from not at all to exceptional)

 

What were the basic results?

The researchers found that how often women experienced orgasm was related to how she rated her partner’s family income, his self-confidence, and how attractive she said he was.

Orgasm intensity was related to how attracted women were to their partners, how many times they had sex per week, and to their ratings of sexual satisfaction.

Those who said their friends rated their partners as attractive also tended to have more intense orgasms.

Sexual satisfaction (which could be said to be the most meaningful outcome) was related to how physically attracted women were to their partner and how they viewed the breadth of their partners’ shoulders.

Women who began having sexual intercourse at earlier ages had more sex partners, experienced more orgasms, and were more sexually satisfied with their partners.

Certain characteristics of the male partner – motivation, intelligence, focus, and determination – predicted how often women initiated sexual intercourse.

The partner’s sense of humour also predicted women’s propensity to initiate sex, how often they had sex, and it enhanced their orgasm frequency in comparison with other partners.

 

How did the researchers interpret the results?

The researchers say their findings suggest that “women in committed relations with high quality opposite-sex mates are putting a premium (wittingly or not) on traits that would confer an advantage in the psychological domain when it comes to how well her partner and, by implication, how well her male descendants could compete with other males for scarce resources.”

Orgasm intensity, they argue, may be a factor in the strength of vaginal and intrauterine contractions that accompany orgasm. These in turn could promote the movement of sperm up through the female reproductive tract and increase the chances of conception.

 

Conclusion

This was a small and unrepresentative survey of young female students which relied on the women self-reporting their sexual relationships in an anonymous online survey.

The fact that it found links between how attractive women found their partners and their quality and frequency of their orgasms as well as overall sexual satisfaction is hardly surprising. Whether the intensity or frequency of a female orgasm is a factor in choosing a mate for his genes remains only a theory. This study goes no way toward proving or disproving that theory.

Many factors affect female orgasm, including mood, knowledge, physical health and past experience. Help is available if you are finding that your sexual experiences are not satisfactory.

 

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on twitter. Join the Healthy Evidence forum.

Links To The Headlines

Women have stronger orgasms if their partner is funny - and rich, study finds. Daily Mail, 12 November 2014

Links To Science

Gallup G, et al. Do orgasms give women feedback about mate choice? Evolutionary Psychology. 2014;12:958-978.

Categories: NHS Choices

'Smart drug' modafinil may not make you brainier

NHS Choices - Behind the Headlines - Thu, 13/11/2014 - 08:45

“Smart drug ‘may help improve creative problem solving’,” is the headline in The Daily Telegraph.

The media reports have been prompted by a new study on the effects of modafinil – a drug licensed to treat narcolepsy. Modafinil’s claim to fame is that it’s been touted as a so-called “smart drug” that can help brain performance, and is reportedly very popular among university students.

Researchers gave 64 healthy volunteers either modafinil or a placebo and asked them to complete a spoken language test. Contrary to the Telegraph’s headline, the people who took modafinil had slowed responses, and were no more accurate than the placebo (this claim seems based on a previous trial by one of the researchers).

The exact way modafinil promotes “wakefulness” is not fully understood. The test used in the research is only one measure of cognitive function, and modafinil may show improvements in the performance of other tests.

Modafinil is a prescription-only medicine that is licensed only for the treatment of narcolepsy. The drug is not without side effects, and has been associated with a risk of serious adverse effects, including psychiatric disorders and skin reactions.

Drug regulators say that the benefits of modafinil only outweigh the risks for the treatment of narcolepsy. Therefore, just because you can buy it online without a prescription, doesn’t mean you should.

 

Where did the story come from?

The study was carried out by researchers from the University of Cambridge, the University of Nottingham and Towson University. It was funded by the Wellcome Trust.

The study was published in the peer-reviewed journal PLOS One. This journal is open access, meaning that its contents can be read for free.

Despite referencing the current study, much of the media's reporting seemed to focus on the results of a study by one of the researchers published back in September 2014, perhaps because the press release for this study mentioned the results of the previous study. Interestingly, the title of this press release was “'Smart' drugs won't make smart people smarter”. To see just how far a message can be spun in the media, compare this to the Telegraph’s headline of, “Smart drug ‘may help improve creative problem solving’”. By contrast, The Times' headline was spot on.

 

What kind of research was this?

This was a randomised controlled trial that aimed to determine the effects of modafinil (a licensed treatment for narcolepsy) on the performance of healthy people in the Hayling Sentence Completion Test. The Hayling test involves listening to sentences with a missing word and providing either the missing word or a word unrelated to the sentence.

Narcolepsy is a rare sleep disorder where there is disturbance of the normal sleep-wake cycle and people suffer from excessive daytime sleepiness. The researchers performed this experiment because it has been suggested that modafinil might improve task performance, while slowing it – a phenomenon that has been referred to as “delay-dependent cognitive enhancement”. Modafinil is reportedly used off-label (outside of its licensed indication) by some healthy people, notably students, as a “smart drug” to try to enhance cognitive performance. One student website’s survey estimates that 20% of students may have taken modafinil, with almost half buying it online and many taking it daily.

A randomised controlled trial is the ideal way to determine the effects of modafinil.

 

What did the research involve?

The researchers randomised 64 healthy people to take a single oral dose of 200mg modafinil, or a placebo.

Two hours after people were given modafinil or placebo, the researchers assessed their performance on the Hayling Sentence Completion Test.

The Hayling test consisted of 30 sentences, each missing the last word, which were constructed to strongly constrain what the missing word should be.

In the first section, people were asked to listen to sentences, and were asked to provide, as quickly as possible, a word that correctly and sensibly completed the sentence.

Participants were then asked to complete sentences, as quickly as possible, with words unrelated to the meaning of the sentences in every way.

Both responses and reaction times were recorded, and the performance of people who were randomised to modafinil compared to those randomised to placebo.

 

What were the basic results?

People who took modafinil took significantly longer to provide a word.

There was no difference in the number of errors made on the test between people who received modafinil and people received placebo, showing that modafinil did not improve accuracy.

 

How did the researchers interpret the results?

The researchers concluded that in this study, “participants administered modafinil took significantly longer to perform the Hayling Sentence Completion Test across task sections than placebo-treated participants, without showing any improvement with regard to errors on the task”.

 

Conclusion

Modafinil is reported to be frequently used outside of its licensed indication (treatment of narcolepsy) to enhance cognitive performance. This study has cast doubt upon these supposed effects. In this RCT, modafinil slowed responses while having no effect on the accuracy of performance on the Hayling Sentence Completion Test.

The exact way modafinil promotes wakefulness is not fully understood. The Hayling Sentence Completion Test is only one measure of cognitive function, and it may be that modafinil has different effects on the performance of different tests. For example, modafinil has been a way to aid concentration and avoid distraction while studying. As one student website put it: “it’s a big boost to lazy people to force themselves to work”.

However, most importantly, modafinil is a prescription-only medication that is licensed only for the treatment of narcolepsy. The drug is not without side effects; it has been associated with a risk of serious adverse effects, including psychiatric disorders and skin reactions, as well as reducing the effectiveness of hormonal contraceptives.

This study has only assessed the one-off use of this drug in a relatively small sample of people. The study has not looked at safety outcomes, and we don’t know what adverse effects there might be for healthy individuals regularly taking this drug solely for the purpose of trying to enhance cognitive performance.

The European Medicines Agency has concluded that the benefits of modafinil-containing medicines continue to outweigh the risks only for the treatment of narcolepsy. This prescription drug cannot be recommended for any other use. Therefore, it would be unwise to buy modafinil (or similar products) online without a prescription from your doctor.

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter. Join the Healthy Evidence forum.

Links To The Headlines

Smart drug "may help improve creative problem solving". The Daily Telegraph, November 12 2014

Smart drugs make bright students worse in tests. The Times, November 12 2014

Links To Science

Mohamed AD, Lewis CR. Modafinil Increases the Latency of Response in the Hayling Sentence Completion Test in Healthy Volunteers: A Randomised Controlled Trial. PLOS One. Published November 12 2014

Categories: NHS Choices

Pages