NHS Choices

NHS Health Checks 'prevented thousands of heart attacks'

NHS Choices - Behind the Headlines - Fri, 15/01/2016 - 13:30

"NHS Health Checks scheme hailed as 'remarkable success'," Pulse magazine reports, while The Sun adds "GP quiz [is a] life saver".

NHS Health Checks, introduced in 2009, are offered to people aged 40 to 74 years old. They look for risk factors associated with a number of related conditions: heart disease, stroke, type 2 diabeteskidney disease and some types of dementia.

The researchers looked at how many people took part in the programme. While the uptake was initially relatively low (5.8%), this increased to about a third of those eligible in 2012-13. 

It is also encouraging that some of the more vulnerable groups – those who are older and those in the most deprived social group – were most likely to attend the checks. 

A proportion of those identified as being at high risk of heart disease in the checks started statins (19.3%) or high blood pressure treatment (8.8%). Extrapolating this data, the researchers estimated that NHS Health Checks prevented around 2,500 cases of major cardiovascular events such as stroke and heart attack over the course of five years.

However, there are inherent limitations to what the study can tell us. For example, it was not possible to directly assess whether all new prescriptions, treatments and lifestyle changes after the checks were as a direct result of the checks.

Overall, the study gives us a useful insight into the progress of the NHS Health Checks programme. Further research is likely to be needed to help give an indication of what impact it is having on people's risk factors and outcomes, especially as this is the first programme of its kind in the world.

 

Where did the story come from?

The study was carried out by researchers from Queen Mary University of London, The University of Edinburgh, and The University of Nottingham. It was independent research commissioned and funded by the Department of Health Policy Research Programme.

The study was published in the peer-reviewed medical journal BMJ Open, and is open access – meaning you can read it for free online.

The Sun briefly covered this research (only in the print edition, not online), and focused on the strokes, heart attacks, and deaths avoided. However, this was not the main focus of the study – such outcomes were only estimated in the discussion in the research paper.

The paper focused on how many people had taken part in the Health Check programme, their characteristics, and what the checks identified. The Sun did not make clear that the numbers they reported were only estimates of the major heart and vascular disease events avoided, not actual numbers. The study does not give estimates on the possible number of deaths avoided.

Pulse, the specialist magazine aimed at GPs, provided balanced quotes from supporters and critics of the programme.

 

What kind of research was this?

This was an observational study aiming to describe the uptake of and findings from the NHS Health Check programme, which aims to reduce the burden of cardiovascular diseases.

The NHS Health Check programme is offered nationally to people aged 40 to 74 years old. It aims to invite those eligible once every five years.

The check involves assessment of an individual's cardiovascular risk factors – such as their blood pressure and blood glucose and cholesterol levels. It also offers advice to support individuals to make health changes in their lives (such as stopping smoking or reducing alcohol consumption), and offers treatment to those identified as being at high risk of heart disease or as having conditions such as diabetes. People already known to have heart disease or conditions associated with an increased risk of heart disease, such as high blood pressure, or are already taking statins are not eligible for the check.

 

What did the research involve?

The researchers analysed data on the NHS Health Check programme over four years since it started in 2009. They got this data from a large electronic database that routinely collects data from 655 GP practices, and has records for 13 million patients.

Using this data, the researchers:

  • assessed how many of those eligible for the checks attended
  • compared the characteristics of those who attended with those who did not attend
  • looked at how many people who attended the checks were identified as being at high risk of heart disease (defined as having at least a 20% chance of developing heart disease over the next 10 years) or having specific conditions, such as type 2 diabetes
  • identified how many people were referred for further assessments or given new treatment in the year after attending the checks, and compared this with those not attending

The researchers were not able to carry out statistical comparisons between people attending the checks and those not attending, as they did not have enough data on the non-attendees.

 

What were the basic results?

The researchers found that about 13% (214,295 people) of the 1.68 million people eligible to have the NHS Health Check in the four years studied attended a Health Check. The proportion of people taking up the Health Check increased from 5.8% in 2010 to 30.1% in 2012.

People were more likely to attend the check if they were older or from socially disadvantaged groups (who are at higher heart disease risk). About a fifth (19.6%) of those aged 60 to 74 years old attended the check compared to 9.0% of those aged 40 to 59 years old. 

Among the most socially disadvantaged group 14.9% attended, compared with 12.3% among the least socially disadvantaged group. Attendance was highest among individuals of black Caribbean ethnicity (19.6%) and South Asian ethnicity (19.2%), and lowest among individuals of black African ethnicity (15.7%) and Chinese ethnicity (15.3%).

Individuals who attended the checks were more likely to have information such as their alcohol consumption recorded (95.9%) compared with those who did not attend (80.3%).

During the study period, the checks identified:

  • 7,844 new cases of high blood pressure (1 new case in every 27 checks)
  • 1,934 new cases of type 2 diabetes (1 new case in every 110 checks)
  • 807 new cases of chronic kidney disease (1 new case in every 265 checks)
  • 27,624 people (12.9% of all attendees) as being at high risk of heart disease

In the year after the check, those who attended were more likely to have a new condition such as high blood pressure recorded than those who did not attend. However, a lot of the non-attendees had missing data, making it difficult to carry out comparisons.

During the check, more than one in five of the participants had a risk factor identified that needed further follow-up. In the year after the check, about a fifth (19.3%) of the people who were identified as being at high risk were started on statins, and 8.8% were started on blood pressure medication.

The researchers estimated that at this rate of new statin and high blood pressure treatments, 2,529 people could avoid a major heart or vascular disease event over five years if 1.2 million people attended the Health Checks each year (assuming treatments reduce risk by 20%). The 1.2 million people seems to be based on applying the attendance rate seen in the study sample to the whole eligible population. The researchers suggest this could be a low estimate, as it does not take account of the fact that people may also change their behaviour as a result of the check and referrals.

 

How did the researchers interpret the results?

The researchers concluded that their study "indicates limited though improving success in the early years of a major new national preventive programme". They say that "this modest start to a major new programme at scale is likely to have made an important impact on CVD [cardiovascular diseases] events in people who have been treated with statins and [high blood pressure medication] or who improved adverse risk factors".

 

Conclusion

This descriptive study has provided information about how many people took part in the NHS Health Check programme in the first four years it was available.

While the uptake was initially relatively low, it is increasing. It is also encouraging that some of the more vulnerable groups – those who are older and those in the most deprived social group – are most likely to attend the checks.

There were limitations to the data available. For example, it was not possible to directly assess whether all new prescriptions and treatments after the checks were as a direct result of the checks. The proportion of people who took part in lifestyle change programmes as advised is also not known.

The study did not assess changes in the risk factors or outcomes of the individuals who had or did not have the Health Checks. The researchers note that it is difficult to make these comparisons in a non-randomised study, or where the data is incomplete (such as health information for those who did not attend the checks). They did calculate an estimate of major heart and vascular events that might be avoided as a result of the Health Checks over five years, under certain assumptions. However, this is a rough estimate to give some idea of possible impact, and may not be fully representative of true effects.

The authors noted that other studies, such as a review of 16 trials, have challenged the effectiveness of the Health Check. For example, a study we discussed in November 2014 questioned whether Health Checks were making a significant difference in reducing the prevalence of chronic diseases such as diabetes.

However, they point out that most of the studies (12 out of 16) included in that review were carried out more than 20 years ago, when modern statins and high blood pressure medications were not in use.

Overall, the study gives a picture of the progress of the NHS Health Checks programme since its launch in 2009. It is important that this type of programme is monitored to see how many people are taking part and what effect it is having. More research is needed to help give an indication of what impact it is having on people's risk factors and outcomes.

You can get an NHS Health Check if you're aged 40 to 74 and not already known to have existing cardiovascular disease or a condition that is a risk factor for cardiovascular disease. If you fall into this category, you can expect to receive a letter inviting you for a check.

Don't worry if you haven't got your invitation yet, as you will be invited for one over the next few years.

Read more about how you can get a NHS Health Check

Links To The Headlines

NHS Health Checks scheme hailed as 'remarkable success'. Pulse, January 14 2016

'Successful' NHS Health Check helped prevent 2,500 heart attacks, study says. GP Magazine, January 14 2016

Links To Science

Robson J, Dostal I, Sheikh A, et al. The NHS Health Check in England: an evaluation of the first 4 years. BMJ Open. Published online January 13 2016

Categories: NHS Choices

Men at high risk of getting HIV 'need preventative treatment'

NHS Choices - Behind the Headlines - Thu, 14/01/2016 - 13:00

"Giving healthy gay men HIV drugs 'could help reverse epidemic'," BBC News reports.

A modelling study looking at the effects of pre-exposure prophylaxis (PrEP), where drugs are used to prevent infection, estimated thousands of new cases of HIV could be prevented.

HIV infection continues to be a pressing concern for men who have sex with men. It is estimated there are around 44,500 men who have sex with men living with HIV in the UK. Without effective intervention strategies, that figure could rise to 57,500 by the end of the decade.

This mathematical model looked at a number of possible strategies, such as offering PrEP to men who have sex with men, regular testing, and providing early treatment for everyone who tests positive (known as "test and treat").

When the researchers looked at combinations of strategies at different levels of coverage, they found combining annual HIV testing with PrEP and test and treat could prevent 7,399 infections (43%), even if they only reached a quarter of men with a high risk of infection.

These figures are only estimates based on models created from other research findings. We don't know how well these strategies would work in the real world. 

Truvada, a drug used in the US for HIV prevention in high-risk individuals, is moderately effective. A 2012 review estimated it reduced the risk of contractive HIV by around 49%. A conference presentation we discussed in 2015 increased that estimate to 86%.

Condoms remain the most effective way of preventing HIV, and have the added bonus of not causing side effects and providing protection against other sexually transmitted infections

Where did the story come from?

The study was carried out by researchers from the London School of Hygiene and Tropical Medicine, the Medical Research Council Biostatistics Unit, the Centre for Infectious Disease Surveillance and Control, City University London, and University College London.

It was funded by Public Health England, the Medical Research Council, and the Bill and Melinda Gates Foundation. 

The study was published in the peer-reviewed journal, The Lancet HIV. It is available on an open-access basis, which means you can read it for free online.

The study was widely covered by the UK media. Perhaps because of its complexity, reports highlighted a variety of figures for the potential number of infections prevented, from The Daily Telegraph's best-case scenario of 10,000, to the more realistic 7,399.

Not all of the reporting made it clear that the latter figure was an estimate of the effect of PrEP plus increased HIV testing and test and treat. The Daily Telegraph also overstated the reliability of the figures, failing to explain they are based on estimates from hypothetical models.

The Times claimed Truvada will soon be made available on prescription by the NHS. While this is a plausible prediction, it has not been officially confirmed.  

What kind of research was this?

This mathematical modelling analysis used a model of how HIV spreads within populations to assess the possible effect of different interventions.

While this is useful information for public health chiefs considering different interventions, there is a wide margin of error.  

What did the research involve?

The researchers used figures on HIV infections in men who have sex with men in the UK since 2001 to estimate transmission rates until 2020, if current HIV prevention strategies – encouraging safer sex and HIV testing – continue.

Then they used a mathematical model of how HIV spreads, using data from previous studies and surveys of sexual behaviour, to predict the effect of different interventions aimed at reducing the spread of the virus.

They did multiple calculations to assess the effects of the most successful interventions, in combination and assuming different levels of coverage.

The model included factors such as whether men were currently engaged in sexual activity and whether they had more than one new sexual partner in a year, which is considered to be high risk.

Data came from three surveys: one national survey from 2000 and two that included more recent data, but were London-based.

The interventions tested in the model were:

  • HIV testing once a year
  • HIV testing twice a year
  • test and treat – where people receive treatment immediately if they test positive
  • providing PreP to high-risk individuals
  • reducing the number of repeated sexual partners men had
  • reducing the number of one-off sexual partners men had
  • decreasing the amount of unprotected sex men had with repeated sexual partners

The researchers looked at the effects of these interventions alone, assuming a "best-case" scenario where all men who have sex with men are reached, to see which were most promising. They then looked at the effects of more realistic coverage, at 25%, 50% and 75% of men reached.

The researchers took the most effective strategies from these results and looked at how they affected infection rates, both in combination and in different practical scenarios.

They also tested the model to look for the potential effects of so-called risk compensation, where men might take more risks if they are taking PrEP. 

What were the basic results?

The best practical scenario was to combine once-yearly testing with test and treat and PrEP.

Assuming 25% of high-risk or infected men could be reached using each of these strategies, the researchers calculated this would prevent around 7,399 (interquartile range [IQR] 5587 to 9813) or 43.6% (IQR 32.9 to 57.9) of those infections expected if no additional prevention strategies were put in place.

Interquartile ranges are a statistical measure used to describe the upper and lower boundaries of an estimate, somewhat similar to a confidence interval.

Risk compensation reduces the effect of this strategy, but it would still prevent more infections than taking no additional action.

Looking at each intervention alone, with an assumed 100% coverage of men who have sex with men, PrEP had the biggest effect on new infections, followed by twice-yearly testing and a reduction in repeat sexual partners.

However, assuming 25% coverage, twice-yearly testing was most effective, followed by PrEP and test and treat.  

How did the researchers interpret the results?

The researchers said that, "PrEP could prevent a large number of new HIV infections if other key strategies, including HIV testing and treatment, are simultaneously expanded and improved."

They warned that unless PrEP is introduced in the UK, the number of men who have sex with men being newly infected with HIV was unlikely to decrease before 2020. 

Conclusion

This is a complex analysis of a number of different scenarios. It found giving PrEP treatment to HIV-negative men might have an important role to play in reducing the number of new HIV infections in the UK.

Like all mathematical models, the results rely on many different assumptions, some of which could turn out to be wrong. Although this study shows the potential for PrEP to make a big difference, we can't rely too heavily on its exact figures.

For example, one important limitation is the fact the study does not take into account the possible effects of drug resistance to HIV treatments, including PrEP.

If PrEP became less effective because of growing drug-resistant strains of the virus, it could have a big impact on how many infections can be prevented.

It's important not to focus entirely on PrEP, as the most effective of the practical scenarios assessed in the study also included regular HIV testing and prompt treatment.

For people at risk of HIV, regular testing combined with practicing safer sex is important. For those who already have the condition, treatment with antiretroviral drugs can keep you well for many years.

If you could be HIV positive, getting tested regularly means you can start treatment as soon as you need it, and increases your chances of keeping well.

PrEP as a preventative treatment for men who have sex with men is not available on the NHS at present, although NHS England is considering its use. This study may increase the likelihood that it will be made available to those at high risk of infection.

Condoms remain the most effective way to prevent HIV – and other STIs – in people who are sexually active.  

Links To The Headlines

Giving healthy gay men HIV drugs 'could help reverse epidemic'. BBC News, January 14 2016

Pill to stop HIV will be available on prescription. The Times, January 14 2016 (subscription required)

PrEP medicine 'could prevent around 7,400 extra HIV cases by 2020'. The Independent, January 14 2016

Daily HIV pill for men 'would prevent 10,000 new cases in UK by 2020'. The Daily Telegraph, January 14 2016

Links To Science

Punyacharoensin N, Edmunds WJ, De Angelis D, et al. Effect of pre-exposure prophylaxis and combination HIV prevention for men who have sex with men in the UK: a mathematical modelling study. The Lancet HIV. Published online January 13 2016

Categories: NHS Choices

A potato-rich diet before pregnancy could up diabetes risk

NHS Choices - Behind the Headlines - Wed, 13/01/2016 - 13:30

"Eating potatoes before pregnancy increases risk of diabetes," The Daily Telegraph reports. Researchers found a small, but significant, increase in gestational diabetes risk in mothers who reported eating a potato-rich diet before their pregnancy. 

Gestational diabetes is caused by raised blood glucose levels during pregnancy. It doesn't usually cause any symptoms, but can cause complications if left untreated. 

The condition does not usually pose a problem for women in England, as diabetes can be routinely screened for. If it is diagnosed, it can normally be controlled by diet and exercise.

This latest study involved researchers in the US looking at records for 21,693 pregnancies. They found that women who said they regularly ate potatoes were more likely to have had gestational diabetes. 

The researchers estimated that women who regularly ate five or more portions of potatoes a week had a 50% increase in gestational diabetes risk compared to women who ate none. While this may sound high, the overall rate of gestational diabetes in the study was reported to be 5.5%.

Researchers looked at potatoes because they have high glycaemic index (GI), so release a lot of glucose into the blood shortly after being eaten. Some experts think this might increase the chances of diabetes.

Although the study found an association between potatoes and diabetes, it cannot prove cause and effect.

There's no need to stop eating potatoes as a result of this study. On the other hand, a little variety in the types of food you eat, with plenty of vegetables and pulses, makes it easier to get a healthy and balanced diet that includes all the nutrients you need.

 

Where did the story come from?

The study was carried out by researchers from the National Institutes for Health, Brigham and Women's Harvard Medical School and Harvard TH Chan School of Public Health, and was funded by the National Institutes of Health and the American Diabetes Association. The study was published in the peer-reviewed British Medical Journal (BMJ) on an open-access basis, meaning it is free to read online (PDF, 304kb).

The Daily Mirror and the Daily Telegraph both over-stated the certainty of the results, with the Mirror referring to "type 2 diabetes" instead of "gestational diabetes". While there are similarities between the two conditions, their causes and likely outlooks are different.
However, the Mail Online and the BBC News gave good, balanced reports.

 

What kind of research was this?

This is a prospective cohort study, which looked to see whether there was a link between regularly eating potatoes and the chances of having gestational diabetes. Prospective cohort studies provide useful information about links between different factors, but cannot prove that one factor causes something – in this case, that eating potatoes causes gestational diabetes.

 

What did the research involve?

The researchers looked at records from a large group of women in the US. They looked at how often they ate potatoes (measured in diet questionnaires every four years) and whether they’d had diabetes in pregnancy. After adjusting for other confounding factors, they looked for links between diabetes in pregnancy and eating potatoes.

They used data from an ongoing study of 116,430 nurses in the US, picking a 10-year time period from 1991 to 2001. Researchers only looked at pregnancies during that time in women who had not had gestational diabetes before, and had not been diagnosed with cancer, diabetes or heart disease at the start of the study.

As well as looking at how often they ate potatoes, the researchers also took account of how healthy their diet was overall, how much they exercised, their weight, age, ethnic group and any family history of diabetes.

They ran several different analyses of the data, to see which factors affected the chances of women getting gestational diabetes. They used the findings to calculate the chances of getting gestational diabetes if they ate potatoes once a week, two to four times a week, or five or more times a week. They also looked to see what the effect might be if women swapped two portions of potatoes a week for other healthy food, such as wholegrains, vegetables or pulses.

 

What were the basic results?

Women who said they regularly ate two to four portions of potatoes a week were 27% more likely to have had gestational diabetes (relative risk [RR] 1.27, 95% confidence interval [CI] 1.04 to 1.55) and women who’d eaten five portions a week or more were 50% more likely to have had gestational diabetes (RR 1.50, 95% CI 1.15 to 1.96). One portion a week may also have had an effect, but the results for this group are not statistically significant, meaning the finding may be down to chance.

The overall risk of diabetes in pregnancy was quite low. There were 21,693 pregnancies and 854 cases of gestational diabetes over the 10 years of the study. The researchers said the rate of gestational diabetes in the study was 5.5%. An increase in risk of 50% from eating five or more portions a week would mean a risk of around 8%.

The researchers calculated that swapping two portions a week of potatoes for wholegrains, vegetables or pulses would reduce the relative risk by 9%, to 12%, depending on the type of food substituted.

 

How did the researchers interpret the results?

The researchers make it clear that these results do not show that potatoes cause diabetes in pregnancy. However, they say the suggestion that they might is "biologically plausible" because potatoes are starchy foods and quickly digested. 

They said that "findings from the current study raise concerns" about dietary guidelines in the UK and the US, which advise people to eat plenty of potatoes.

 

Conclusion

Although we cannot say from this study whether eating potatoes could cause gestational diabetes, it does seem worth taking seriously.

This study has a number of strengths. It's big enough to give statistically significant results and the researchers were able to adjust their results to check for many factors which could have had an effect on women's chances of getting gestational diabetes. 

They carried out sensitivity analyses to check that no one factor was skewing the results. Also, as the researchers say, there is a possible plausible scientific reason for thinking that potatoes might increase the risk of diabetes.

However, there are drawbacks to the study. The results are based on the women's own estimates of how often they ate potatoes, and also whether they had diabetes in pregnancy. It's possible they may have forgotten or misreported this. We also don't know how bad the women’s diabetes was, so we can't tell whether eating more potatoes affects the severity of diabetes in pregnancy. 

Also, most of the women in the study were white Americans, so we can't be sure the results would apply to everyone. This is particularly important, as it is known that the risks of gestational diabetes are higher in some ethnic groups, such as black women or women of South Asian origin.

Finally, even the best observational study cannot have adjusted for all possible factors affecting the outcome. That's why we can't say that potatoes are the cause of the increased risk of gestational diabetes. 

Further research is needed to find out more about the potential links between potatoes and gestational diabetes. But what should women do if they want to get pregnant and are worried about their risk?

Advice from Public Health England remains unchanged – people should continue to eat starchy foods, including potatoes and wholegrains, to get plenty of fibre. If you are worried about how often you eat potatoes, swapping one or two portions a week for wholegrain rice, sweet potatoes, pasta or bread means you will still be following official advice, while eating a more varied diet.

There's no need to stop eating potatoes as a result of this study. On the other hand, a little variety in the types of food you eat, with plenty of vegetables and pulses, makes it easier to get a healthy and balanced diet that includes all the nutrients you need.  

Links To The Headlines

Eating potatoes before pregnancy increases risk of diabetes, women warned. The Daily Telegraph, January 12 2016

Potato-rich diet 'may increase pregnancy diabetes risk'. BBC News, January 13 2016

Eating just one baked potato a week could increase the risk of pregnancy diabetes by a FIFTH. Mail Online, January 13 2016

Eating potatoes regularly increases women's chances of diabetes when they fall pregnant. Daily Mirror, January 12 2016

Links To Science

Bao W, Tobias DK, Hu FB, et al. Pre-pregnancy potato consumption and risk of gestational diabetes mellitus: prospective cohort study. BMJ. Published online January 12 2016

Categories: NHS Choices

Exercise is 'most effective' method of preventing lower back pain

NHS Choices - Behind the Headlines - Wed, 13/01/2016 - 11:30

"Exercise is the best medicine to banish back pain and stop people taking sick days," reports the Daily Mirror. While this may be true, the research in question did not look at treatments for existing back pain.

In fact, the researchers reviewed previously gathered evidence about what helps prevent, not treat, lower back pain. Also, the evidence that exercise reduced sick leave was judged to be poor quality.

The review found exercise with or without education about the back and back pain was the most likely intervention to prevent lower back pain. This included core muscle strengthening, stretching and aerobic exercise carried out over a period of about 3 to 18 months.

Education alone, back belts, shoe insoles, and ergonomics (changes to objects such as chairs to make them more "back friendly") were not found to prevent lower back pain. But this finding was based on low-quality studies, so it should be viewed with caution.

Some of these interventions, such as shoe insoles, were only studied in army recruits, so the results may not be applicable to other population groups.

These limitations aside, exercise would seem to be the best option based on the available evidence. Exercise is known to offer a range of benefits. This review suggests preventing lower back pain is another potential benefit. 

Where did the story come from?

The study was carried out by researchers from the University of Sydney and Macquarie University, both in Australia, and the Federal University of Minas Gerais in Brazil. No external funding was reported.

It was published in the peer-reviewed Journal of the American Medical Association (JAMA) Internal Medicine on an open access basis, so you can read it for free online.

The Mirror, the Daily Express and the Daily Mail reported the story inaccurately. All three papers focused on the treatment of back pain, rather than prevention. While exercise may well help treat the symptoms of lower back pain, the study did not consider this issue.

They also did not make it clear the majority of the studies were poor quality, which makes the results less reliable. 

What kind of research was this?

This was a systematic review of all of the relevant randomised controlled trials (RCTs) that have assessed prevention strategies for lower back pain. Statistical pooling of results (meta-analysis) was carried out where possible.

The research was conducted according to international standards for systematic reviews. However, the quality of the results is also dependent on the quality of the underlying studies.  

What did the research involve?

A search was performed of four medical databases, including the Physiotherapy Evidence Database, to look for RCTs on the prevention of lower back pain.

Two reviewers sifted the results according to strict inclusion criteria, and a third researcher was consulted in cases of disagreement.

Eligible trials needed to fit the following inclusion criteria:

  • they included people without lower back pain at the start of the study or without at least one of the outcomes the study was interested in – for example, some participants might have mild lower back pain, but still be able to work if the study was looking at work absence
  • they aimed at preventing future episodes of lower back pain
  • they had an intervention group that was compared with no intervention, placebo (an ineffective "dummy" intervention) or minimal intervention
  • they followed participants up to identify any new episode of lower back pain or time off work for lower back pain

The relevant trials were assessed for quality using standard assessment systems. Trials measuring similar interventions were pooled together in the meta-analyses using appropriate statistical techniques.

Results from the studies were grouped into short-term results (findings up to a year) and long-term results (findings after a year). 

What were the basic results?

The review included 21 RCTs involving 30,850 people. Several studies were performed in the armed services. Others included airline employees, postal workers, nurses and office workers.

The main results for each intervention were as follows.

Exercise plus education:

  • moderate-quality evidence this reduces the risk of lower back pain by 45% in the short term (relative risk [RR] 0.55, 95% confidence interval [CI] 0.41 to 0.74) and low-quality evidence it does in the long term (RR 0.73, 95% CI 0.55 to 0.96)
  • low-quality evidence it has no effect on preventing sick leave as a result of lower back pain in the short term (RR 0.74, 95% CI 0.44 to 1.26) or long term

Exercise alone:

  • low-quality evidence this reduces the risk of lower back pain by 35% in the short term (RR 0.65, 95% CI 0.50 to 0.86) but very low-quality evidence it does not in the long term (RR 1.04, 95% CI 0.73 to 1.49)
  • low to very low-quality evidence this reduces risk of sick leave as a result of lower back pain by 78% in the long term (RR 0.22, 95% CI 0.06 to 0.76)

Education alone:

  • moderate-quality evidence this has no effect on reducing the risk of lower back pain in the short term (RR 1.03, 95% CI 0.83 to 1.27) or long term
  • very low-quality evidence this has no effect on risk of sick leave as a result of lower back pain in the short term (RR 0.87, 95% CI 0.47 to 1.60)

Back belt:

  • very low-quality evidence this has no effect on reducing the risk of lower back pain in the short term (RR 1.01, 95% CI 0.71 to 1.44) or long term
  • low-quality evidence this has no effect on risk of sick leave as a result of lower back pain in the short term (RR 1.44, 95% CI 0.73 to 2.86)

Shoe insoles:

  • low-quality evidence this has no effect on risk of lower back pain in the short term (RR 1.01, 95% CI 0.74 to 1.40)  
How did the researchers interpret the results?

The researchers concluded that, "Exercise in combination with education is likely to reduce the risk of LBP [lower back pain] and that exercise alone may reduce the risk of an episode of LBP and sick leave due to LBP, at least for the short-term."

They said that, "The available evidence suggests that education alone, back belts, shoe insoles, and ergonomics do not prevent LBP", and it is "uncertain whether education, training, or ergonomic adjustments prevent sick leave due to LBP because the quality of evidence is very low".

Conclusion

This systematic review and meta-analysis found exercise reduces the risk of lower back pain and sick leave as a result of lower back pain.

The types of exercise studied included improving core strength (abdominals and lumbar region), leg and back muscle strengthening, stretching and cardiovascular workouts.

Although the researchers concluded that, "education alone, back belts, shoe insoles, and ergonomics do not prevent LBP", this is based on limited low-quality evidence.

However, these interventions might prove effective for individuals in situations that have not been studied, or if tested in better-quality trials. For example, the shoe insoles were only studied on army recruits, so the results may not be generalisable to the general population.

The review also purely focused on people who have not already experienced anything other than mild lower back pain, so it does not tell us whether these interventions are effective strategies for managing the condition.

For people with non-specific lower back pain, giving education advice and advising people to stay physically active and exercise are part of the early management currently recommended by the UK's National Institute for Health and Care Excellence (NICE).

The evidence for the effect of each intervention on the risk of sick leave for lower back pain was based on between one and three small trials, which limits the reliability of the results.

These limitations aside, the study adds to the weight of evidence that one of the many benefits of exercise may be preventing back pain. Additionally, there is expert consensus it can also be effective at relieving the symptoms of back pain in most people – though, as mentioned, the study did not look at this issue.

Get more exercises recommended for back pain.

Links To The Headlines

The best cure for back pain revealed - but you're not going to like it. Daily Mirror, January 11 2016

Daily walk could help alleviate crippling back pain, new study claims. Daily Express, January 12 2016

The best way to banish back pain? Regular exercise: Working out is 'far more effective than any other treatments'. Mail Online, January 12 2016

Links To Science

Steffens D, Maher CG, Pereira LSM, et al. Prevention of Low Back Pain - A Systematic Review and Meta-analysis. JAMA Internal Medicine. Published online January 11 2016

Categories: NHS Choices

Sugary drinks linked to increased fat levels around vital organs

NHS Choices - Behind the Headlines - Tue, 12/01/2016 - 12:00

"People who consume sugary drinks are more likely to develop dangerous fat that becomes wrapped around internal organs," the Daily Mail reports after a US study found a link between the consumption of sugary drinks and increased visceral fat levels.

Visceral fat is fat that develops inside the abdominal cavity. Having high levels of visceral fat has been linked to an increased risk of developing type 2 diabetes and heart disease.

This study followed around 1,000 middle-aged adults over a period of six years after assessing how often they consumed sugar-sweetened drinks and diet fizzy drinks. Researchers used CT scans to measure the amount of visceral fat each person had.

People who drank one sugar-sweetened drink a day or more had the highest increase in this type of fat, at 852cm3, compared with 658cm3 in people who did not drink them.

But visceral fat accumulated in all the participants. It may be the case that, for many people, an increase in visceral fat is a consequence of ageing.

The results are not conclusive, as the media has reported – the number and type of drinks was only assessed at the beginning of the study and may have changed over time. There may also have been other unmeasured factors that could account for the results.

Overall, the results of this study support current UK guidelines to limit the amount of sugar we consume to no more than 30g a day for adults (roughly seven sugar cubes). Sugary drinks have no health benefits.  

Where did the story come from?

The study was carried out in the US by researchers from the National Heart, Lung and Blood Institute's Framingham Heart Study and Population Sciences Branch, Tufts University and Harvard Medical School.

It was funded by the US National Institutes of Health and the Boston University School of Medicine.

The study was published in the peer-reviewed medical journal Circulation on an open access basis, so it is free to read online.

The Daily Mail reported the story accurately and responsibly in general, but did not comment on the study's limitations.

The fact drinking diet fizzy drinks or avoiding fizzy drinks altogether did not appear to reduce the risk of increased visceral fat accumulation was also not made clear.

While The Daily Telegraph's reporting is generally accurate, it implies a direct cause and effect relationship has been established between sugary drinks and increased visceral fat. This is not the case. 

What kind of research was this?

This was a cohort study conducted on middle-aged adults in the US. Previous cross-sectional studies found people who consumed more sugar-sweetened beverages had increased visceral fat, both around their organs and under the skin.

This study aimed to see if this observation was also true over time, independently of any change in body weight.

This type of study design is the best possible type when randomised controlled trials are impractical or unethical – but it is limited, as it cannot show causation.  

What did the research involve?

The researchers looked at data on 1,003 adults who were taking part in the much larger ongoing Framingham Heart Study.

These adults were men aged 35 or more and women aged 40 or more who weighed less than 160kg (the CT scan limit) and had no history of heart attack, stroke, cancer or weight loss surgery.

An initial physical examination, blood tests, CT scan and food frequency questionnaire was carried out from 2002-05. The CT scan and body mass index (BMI) was repeated six years later, from 2008-11.

On the food frequency questionnaire, sugar-sweetened drinks included:

  • caffeinated colas with sugar
  • caffeine-free colas with sugar
  • other fizzy drinks with sugar
  • fruit punches, lemonade or other non-fizzy fruit drinks

The researchers performed statistical analyses to see if increased consumption of sugar-sweetened drinks or diet fizzy drinks was associated with increased abdominal fat either around organs or under the skin, according to the CT scan measurements.

They balanced their results to take into account the following confounders:

  • sex
  • age
  • physical activity
  • smoking status
  • alcohol intake
  • intake of other foods, such as wholegrains and vegetables  
What were the basic results?

Fat around abdominal organs increased the most in people who consumed sugar-sweetened drinks on a daily basis over the six-year study.

The volume of fat increased in each group by:

  • 658cm3 in non-consumers
  • 649cm3 in occasional consumers (from one serving a month to one serving a week)
  • 707cm3 in frequent consumers (from one serving a week to one serving a day)
  • 852cm3 in daily consumers (one or more servings a day)

The volume of fat under the skin increased by a similar amount in each group: 586cm3 in non-consumers and 568cm3 in daily consumers.

There was no association between the amount of diet fizzy drinks consumed and changes in fat around abdominal organs, though this increased by similar amounts: 709cm3 in non-consumers and 748cm3 in daily consumers.

There was no significant association between the amount of sugar-sweetened drinks or diet fizzy drinks consumed and changes in body weight, with the average weight increasing in all groups by 1.6-2.8kg.  

How did the researchers interpret the results?

The researchers said that, "These findings suggest that habitual SSB [sugar-sweetened beverage] intake was associated with a long-term adverse change in visceral adiposity [fat around abdominal organs] ... independent of weight gain."

They say that, "Limiting SSB consumption as much as possible may be an effective strategy to reduce the burden of cardiometabolic disease." 

Conclusion

This US cohort study found drinking sugar-sweetened beverages on a daily basis is associated with the highest increase in fat accumulation around the abdominal organs, compared with people who do not consume them.

But there was an average increase in the amount of this fat in all people who took part in the study, although this was lowest in people who never consumed sugar-sweetened beverages.

The study was prospective, which limits some sources of bias, but it has some limitations. For example, the food frequency questionnaire was only conducted once, at baseline.

The results are therefore reliant on the participants accurately recalling the amount of each type of drink consumed, and this may have changed over the course of the study.

In addition, 85% of the participants reported they consumed a mixture of sugar-sweetened drinks and diet fizzy drinks. As this was a cohort study, there may have been other unmeasured factors that could account for the results.

Overall, the results of this study support current UK guidelines to limit the amount of sugar we consume. Drinking water instead of sugar-sweetened drinks is a cheap and easy way to cut down your sugar intake, and should be encouraged – especially in children. 

Links To The Headlines

Yet MORE evidence that fizzy drinks are harmful: Just one can a day causes dangerous fat to wrap around major organs. Daily Mail, January 12 2016

One can of fizzy drink a day increases risk of diabetes and heart disease. The Daily Telegraph, January 12 2016

Links To Science

Ma J, McKeown NM, Hwang S, et al. Sugar-Sweetened Beverage Consumption is Associated With Change of Visceral Adipose Tissue Over 6 Years of Follow-Up. Circulation. Published online January 11 2016

Categories: NHS Choices

Arthritis drug could also help combat ovarian cancer

NHS Choices - Behind the Headlines - Mon, 11/01/2016 - 11:00

"A rheumatoid arthritis drug can kill off ovarian cancer cells in women with the BRCA1 mutation," the Mail Online reports. The drug, auranofin, was found to be effective against ovarian cancer cells associated with the BRCA1 mutation.

The BRCA1 gene – along with a similar gene called BRCA2 – is designed to repair damage to DNA as cells divide. The absence of this ability increases the risk of cells developing abnormalities that can trigger ovarian cancer, as well as breast cancer.

This study was laboratory research examining the effect of the arthritis drug, auranofin, on ovarian cancer cells with and without BRCA1 mutation. Auranofin is not currently licensed in the UK.

When ovarian cancer cells were treated with auranofin in the lab, researchers found the drug's cancer-killing properties were most effective at treating ovarian cancer cells lacking a "healthy" version of the BRCA1 gene.

It seemed auranofin caused damage to the DNA of cancerous cells with BRCA1 mutations, helping to kill them. The results suggest there may be promise for this drug in the treatment of ovarian cancers associated with BRCA1 mutations.

Although auranofin is currently used in the treatment of rheumatoid arthritis in the US, and has been tested in early-stage ovarian cancer studies in humans, much more study is needed looking into its effectiveness and safety before it could be approved for use in the treatment of ovarian cancer.  

Where did the story come from?

The study was carried out by researchers from Plymouth University in the UK, and was funded by Plymouth Hospitals NHS Trust and Plymouth University.

It was published in the peer-reviewed journal, Mutation Research.

The body of the Mail's coverage is generally accurate, though the headlines are slightly premature for this stage of research.

And dubbing the BRCA1 gene the "Angelina Jolie gene" – who announced she had preventative surgery because she has a high risk of developing the cancer – is arguably in bad taste.

What kind of research was this?

This laboratory research aimed to investigate the effect of a drug normally used in the treatment of rheumatoid arthritis in women with ovarian cancer and the BRCA1 mutation. Ovarian cancer is often diagnosed at a late stage, when the outlook is poor.

Women with mutations of the BRCA1 (breast cancer 1 early onset) gene are known to be at increased risk of developing both ovarian and breast cancer. Around 1 in 10 cases of ovarian cancer are associated with a BRCA1 mutation.

Normally, BRCA1 plays a major role in DNA repair. The mutation means cells are less able to repair DNA damage and are therefore more likely to become cancerous. This leads to the increased risk of cancer seen in women with a fault in this gene.

There is a need for improved treatments for ovarian cancer, which has seen ongoing research, even using drugs normally used for other purposes.

One such candidate is auranofin, a drug approved in the US for the treatment of rheumatoid arthritis. The drug is not available in the UK, however.

Auranofin disrupts an enzyme (thioredoxin reductase) and increases the production of reactive oxygen species (ROS). ROS are molecules that contain oxygen and are capable of damaging cells, leading to cell death. The combination of these two effects may have cancer-killing properties.

Though other studies have examined the use of auranofin in the treatment of ovarian cancer, none looked specifically at the effect in women with BRCA1 mutations. This is what this study aimed to do.  

What did the research involve?

The research involved human ovarian cancer cells treated with auranofin. In some of the cells, the researchers first used a special method to stop the activity of the BRCA1 gene to mimic the effect of a mutation. They then treated the cells with different concentrations of auranofin for 10 days.

After 10 days, the researchers looked at how well the cells were surviving by counting the cell clumps and examining DNA damage. They compared the results in cells that had BRCA1 depletion and those that did not.

The researchers also looked at proteins that might be responsible for the cancer-killing properties in BRCA1-depleted ovarian cells treated with auranofin. 

What were the basic results?

The researchers found BRCA1-depleted cells – in effect, those mimicking a BRCA1 mutation – were more sensitive to auranofin. At all concentrations of auranofin tested, around a third up to half fewer cells survived.

BRCA1 is known to play a key role in the repair of breaks in DNA. As expected, further laboratory examination revealed the BRCA1-depleted cells had increased number of breaks in their DNA. Those without BRCA1 depletion had only a slight increase in the number of DNA breaks after being treated with auranofin.

Further experiments suggested auranofin increased DNA damage by increasing the production of reactive oxygen species. In the BRCA1-depleted cells, because this damage was not being repaired, enough damage accumulated to trigger the cells to self-destruct. 

How did the researchers interpret the results?

The researchers concluded that, "Accumulated lethal double-strand breaks resulting from oxidative damage render BRCA1-deficient cells more sensitive to auranofin."

Conclusion

There is an ongoing need for the development of new and more effective treatments for ovarian cancer, a cancer that is notoriously detected at a late stage and often has a poor outlook as a result.

Women with mutations in the DNA repair gene, BRCA1, are known to have an increased risk of developing ovarian cancer.

This laboratory study investigated the potential of the drug auranofin, which is approved in the US for the treatment of rheumatoid arthritis. The researchers found auranofin had superior cancer-killing properties in ovarian cancer cells lacking BRCA1.

It seems depletion of BRCA1 makes the cancer cells more susceptible to the oxidative DNA damage caused by auranofin treatment, causing the cells to self-destruct.

The results suggest there may be promise for this drug in the treatment of ovarian cancers with BRCA1 mutations.

However, this research is in the very early stages – the researchers only incubated auranofin with ovarian cancer cells in the laboratory, they did not give the drug directly to women with ovarian cancer.

Auranofin is currently approved for the treatment of rheumatoid arthritis in the US and has therefore been tested in humans already, which can make the path to human trials quicker.

In fact, the drug has already been used in early-stage (phase II) ovarian cancer trials in humans, but not specifically women with BRCA1 mutations. The results of these trials are needed to give an indication of whether the drug does indeed have potential for treating ovarian cancer.

Given the results of the current study, the researchers may want to start trials specifically in women with ovarian cancer who have BRCA1 mutations. We need to await the results of these studies before we know how effective and safe it is for treating ovarian cancer.

This research is encouraging and does show promise, but the Mail Online's headline is premature by saying the drug will "give hope to millions". 

If you have a strong family history of ovarian or breast cancer, you may want to ask your GP about being tested for any BRCA mutations. You should bear in mind that testing cannot guarantee you will or won't develop cancer, and a positive result can cause considerable emotional distress.

Read more about predictive genetic tests for cancer risk genes.

Links To The Headlines

Arthritis drug could offer hope to millions with the 'Angelina Jolie gene': Drug 'kills off ovarian cancer cells with BRCA mutation'. Mail Online, January 8 2016

Links To Science

Oommen D, Yiannakis D, Jha AN. BRCA1 deficiency increases the sensitivity of ovarian cancer cells to auranofin. Mutation Research/Fundamental and Molecular Mechanisms of Mutagenesis. Published online November 28 2015

Categories: NHS Choices

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