NHS Choices

Gay people have 'poorer health' and 'GP issues'

NHS Choices - Behind the Headlines - Fri, 05/09/2014 - 12:30

“Lesbians, gays and bisexuals are more likely to have longstanding mental health problems,” The Independent reports, as well as “bad experiences with their GP”. A UK survey found striking disparities in survey responses compared to heterosexuals.

The news is based on the results of a survey in England of more than 2 million people, including over 27,000 people who described themselves as gay, lesbian or bisexual.

It found that sexual minorities were two to three times more likely to report having longstanding psychological or emotional problems and significantly more likely to report fair/poor health than heterosexuals.

People who described themselves as bisexuals had the highest rates of reported psychological or emotional problems. The researchers speculate that this could be due to a “double discrimination” effect; homophobia from the straight community as well as being stigmatised by the gay and lesbian communities as not being “properly gay” (biphobia).

Sexual minorities were also more likely to report unfavourable experiences with nurses and doctors in a GP setting.

Unfortunately this study cannot tell us the reasons for the differences reported in either health or relationships with GPs.

The results of this survey would certainly seem to suggest that there is room for improvement in the standard and focus of healthcare offered to gay, lesbian and bisexual people.

 

Where did the story come from?

The study was carried out by researchers from the RAND Corporation (a non-profit research organisation), Boston Children’s Hospital/Harvard Medical School and the University of Cambridge. The study was funded by the Department of Health (England).

The study was published in the peer-reviewed Journal of General Internal Medicine. This article is open-access so is free to read online.

The results of this study were well reported by The Independent and The Guardian.

 

What kind of research was this?

This was a cross-sectional study that aimed to compare the health and healthcare experiences of sexual minorities with heterosexual people of the same gender, adjusting for age, race/ethnicity and socioeconomic status.

A cross-sectional study collects data at one point in time so it is not able to prove any direct cause and effect relationships. It can be useful in highlighting possible associations that can then be investigated further.

 

What did the research involve?

The researchers analysed data from the 2009/10 English General Practice Patient Survey.

The survey was mailed to 5.56 million randomly sampled adults registered with a National Health Service general practice (it is estimated that 99% of England’s adult population are registered with an NHS GP). In all, 2,169,718 people responded (39% response rate).

People were asked about their health, healthcare experiences and personal characteristics (race/ethnicity, religion and sexual orientation).

The question about sexual orientation is also used in UK Office of National Statistics Social Surveys: “Which of the following best describes how you think of yourself?:

  • heterosexual/straight
  • gay/lesbian
  • bisexual
  • other
  • I would prefer not to say

Of the respondents 27,497 people described themselves as gay, lesbian, or bisexual.

The researchers analysed the responses to questions concerning health status and patient experience.

People were asked about their general health status (“In general, would you say your health is: excellent, very good, good, fair, or poor?”) and whether they had one of six long-term health problems, including a longstanding psychological or emotional condition.

The researchers looked to see whether people had reported:

  • having “no” trust or confidence in the doctor
  • “poor” or “very poor” to at least one of the doctor communication measures of giving enough time, asking about symptoms, listening, explaining tests and treatments, involving in decisions, treating with care and concern, and taking problems seriously
  • “poor” or “very poor” to at least one of the nurse communication measures
  • being “fairly” or “very” dissatisfied with care overall

The researchers compared the responses from sexual minorities and heterosexuals of the same gender after controlling for age, race/ethnicity and deprivation.

 

What were the basic results?

Both male and female sexual minorities were two to three times more likely to report having a longstanding psychological or emotional problem than heterosexual counterparts. Problems were reported by 5.2% heterosexual men compared to 10.9% gay men and 15% bisexual men and by 6.0% heterosexual women compared to 12.3% lesbian women and 18.8% bisexual women.

Both male and female sexual minorities were also more likely to report fair/poor health. Fair/poor health was reported by 19.6% heterosexual men compared to 21.9% gay men and 26.4% bisexual men and by 20.5% heterosexual women compared to 24.9% lesbian women and 31.6% bisexual women.

Negative healthcare experiences were uncommon in general, but sexual minorities were about one-and-a-half times more likely than heterosexual people to report unfavourable experiences with each of four aspects of primary care:

  • no trust or confidence in the doctor was reported by 3.6% heterosexual men compared to 5.6% gay men (4.3% bisexual men, difference compared to heterosexual men not statistically significant) and by 3.9% heterosexual women compared to 5.3% lesbian women and 5.3% bisexual women
  • poor/very poor doctor communication was reported by 9.0% heterosexual men compared to 13.5% gay men and 12.5% bisexual men and by 9.3% heterosexual women compared to 11.7% lesbian women and 12.8% bisexual women
  • poor/very poor nurse communication was reported by 4.2% heterosexual men compared to 7.0% gay men and 7.3% bisexual men and by 4.5% heterosexual women compared to 7.8% lesbian women and 6.7% bisexual women
  • being fairly/very dissatisfied with care overall was reported by 3.8% heterosexual men compared to 5.9% gay men and 4.9% bisexual men and by 3.9% heterosexual women compared to 4.9% lesbian women (4.2% bisexual women, difference compared to heterosexual women not statistically significant)

 

How did the researchers interpret the results?

The researchers concluded that “sexual minorities suffer both poorer health and worse healthcare experiences. Efforts should be made to recognise the needs and improve the experiences of sexual minorities. Examining patient experience disparities by sexual orientation can inform such efforts”.

 

Conclusion

This study has found that that sexual minorities were two to three times more likely to report having longstanding psychological or emotional problems and significantly more likely to report fair/poor health than heterosexuals.

Sexual minorities were also more likely to report unfavourable experiences with nurses and doctors in a GP setting.

It should also be noted that response rates to the survey were low, with only 39% people responding to the survey. It is unknown whether the results would have been different if more people had responded.

While potential reasons for these disparities may include the stress induced by homophobic attitudes, or the suspicion that a GP disapproves of their patient’s sexuality, these speculations are unproven.

As it stands, this study cannot tell us the reasons for the differences reported. However, it would suggest that healthcare providers need to do more to meet the needs of gay, lesbian and bisexual people.

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

Links To The Headlines

Gay people more likely to have mental health problems, survey says. The Independent, September 4 2014

Gay people report worse experiences with GPs. The Guardian, September 4 2014

Links To Science

Elliott MN, Kanouse DE, Burkhart Q, et al. Sexual Minorities in England Have Poorer Health and Worse Health Care Experiences: A National Survey. Journal of General Internal Medicine. Published online September 4 2014

Categories: NHS Choices

1 in 5 child deaths 'preventable'

NHS Choices - Behind the Headlines - Fri, 05/09/2014 - 12:00

“One in five child deaths ‘preventable’,” reports BBC News.

The headline was prompted by the publication of a three-part series of papers on child death in high-income countries published in The Lancet.

The reviews outlined the need for child death reviews to identify modifiable risk factors, described patterns of child mortality at different ages across five broad categories. These were perinatal causes, congenital abnormalities, acquired natural causes, external causes, and unexplained deaths. They described contributory factors to death across four broad domains: biological and psychological factors, the physical environment, the social environment, and health and social service delivery.

Although the series did report that one in five child deaths are preventable, it should be noted that this was not a new figure and was published by the government in 2011.

Leading causes of preventable child deaths in the UK highlighted by the authors include accidents, abuse, neglect and suicide.

The authors also argue that child poverty and income inequality have a significant effect on risk factors for preventable child death and they are quoted in the media as calling for the government to do more in tackling child poverty.

 

Where did the story come from?

The series of papers was written by researchers from the University of Warwick in collaboration with researchers from universities and research institutes around the world. The source of funding for this series of three papers was not reported.

The series was published in the peer-reviewed medical journal The Lancet. All three papers are open-access so are free to read online (though you will need to register with The Lancet website):

 

Child health reviews

The first paper in the series discussed child death reviews, which have been developed in several countries. These aim to develop a greater understanding of how and why children die, which could lead to the identification of factors that could potentially be modified to reduce further deaths.

In England, multiagency rapid-response teams investigate all unexpected deaths of children aged 0-18 years. However, lessons learned from child death reviews are yet to be translated into large-scale policy initiatives, although local actions have been taken.

However, the researchers report that whether child death reviews have led to a reduction in national child death rates has not been assessed.

They also suggest that child death reviews could be extended to child deaths in hospital.

 

Patterns of death in England and Wales

The second paper in the series discussed the pattern of child death in England and Wales at different ages across five broad categories (perinatal causes, congenital abnormalities, acquired natural causes, external causes, and unexplained deaths).

It found that more than 5,000 infants, children and adolescents die every year in England and Wales.

Mortality is highest in infancy, dropping to very low rates in the middle childhood years, before rising again in adolescence.

Patterns of mortality vary with age and sex; perinatal and congenital causes predominate in infancy, with acquired natural causes (for example infections or neurological, respiratory and cardiovascular disorders) becoming prominent in later childhood and adolescence.

More than 50% of adolescent deaths occur from external causes, which included traffic deaths, non-intentional injuries (for example, falls), fatal maltreatment and death from assault, suicide and deliberate self-harm.

Deaths of children diagnosed with life-limiting disorders (disorders that are likely to reduce a child’s lifespan) might account for 50% or more of all child mortality in England and Wales.

 

Why do children die in high-income countries?

In the third review of the series the researchers summarised the results of key studies that described contributory factors to child death across four broad domains:

  • Intrinsic (genetic and biological) factors that are associated with child mortality include sex, ethnic origin, gestation and growth characteristics, disability and behaviour.
  • Physical environment, for example the home and surrounding area, including access to firearms (a particular problem in the US) and poisons.
  • Social environment (for example socioeconomic status, parental characteristics, parenting behaviours, family structures, and social support).
  • Service delivery (delivery of healthcare including national policy, healthcare services and the individual doctor; and the delivery of other welfare services (such as housing, welfare benefits and social care).

 

What do the researchers suggest?

In an accompanying editorial the researchers suggest that:

  • co-ordinated strategies that reduce antenatal and perinatal risk factors are essential
  • further research is needed into preventative interventions for preterm birth
  • efforts are needed to prevent child deaths due to acquired natural causes, including improved recognition of severity of illness
  • preventative strategies involving collaboration between health authorities and other agencies, including social, education, environmental, police and legal services, industry, and consumer groups are needed to prevent deaths due to external causes

 

Conclusion

A case could be made that these series of reports are more in the realm of political debate rather than health and medicine.

The lead author, Dr Peter Sidebotham, is quoted in The Daily Telegraph as saying: "It needs to be recognised that many child deaths could be prevented through a combination of changes in long-term political commitment, welfare services to tackle child poverty, and healthcare services.

"Politicians should recognise that child survival is as much linked to socioeconomic policies that reduce inequality as it is to a country's overall gross domestic product and systems of healthcare delivery."

While most of us would agree that reducing child poverty and income inequality is a good thing, exactly how we go about achieving these goals is a matter of heated debate.

Those on the Right of the political spectrum have argued that stimulating the economic activity of the free market will provide opportunities to lift people out of poverty. Those on the Left have argued that redistributing wealth through taxation can help create a safety net that stops children falling into poverty.

Seeing as this argument has been raging for centuries, we do not expect a resolution to the debate anytime soon.

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

Links To The Headlines

One in five child deaths 'preventable'. BBC News, September 5 2014

One in five child deaths in England is preventable, study finds. The Guardian, September 5 2014

Fifth of child deaths are preventable. The Daily Telegraph, September 5 2014

1 in 5 child deaths 'could be prevented and Government must take immediate action'. Daily Mirror, September 5 2014

One In Five Child Deaths Are 'Preventable'. Sky News, September 5 2014

Links To Science

Fraser J, Sidebotham P, Frederick J, et al. Learning from child death review in the USA, England, Australia, and New Zealand. The Lancet. Published online September 5 2014

Sidebotham P, Fraser J, Fleming P, et al. Patterns of child death in England and Wales. The Lancet. Published online September 5 2014

Sidebotham P, Fraser J, Covingtion T, et al. Understanding why children die in high-income countries. The Lancet. Published online September 5 2014

Categories: NHS Choices

How immunotherapy may treat multiple sclerosis

NHS Choices - Behind the Headlines - Thu, 04/09/2014 - 12:05

“Breakthrough hope for MS treatment as scientists discover how to ‘switch off’ autoimmune diseases,” reports the Mail Online.

Autoimmune disorders, such as multiple sclerosis (MS), occur when the body’s immune system attacks and destroys healthy body tissue by mistake.

The “holy grail” of treatment is to make the immune system tolerant to the part of the body that it is attacking, while still allowing the immune system to work effectively.

Previous studies in mice have shown that tolerance can be achieved by repeatedly exposing mice with autoimmune disorders to fragments of the components that the immune system is attacking and destroying. The immune cells that were attacking the healthy tissue convert into regulatory cells that actually dampen the immune response.

This process is similar to the process that has been used to treat allergies (immunotherapy).

It is known that doses of the fragments of the components that the immune system is attacking need to start low before increasing – this is known as the dose-escalation protocol.

A new mouse study has found that a carefully calibrated dose-escalation protocol caused changes in gene activity (gene expression). This then causes the attacking immune cells to express regulatory genes and to become suppressive. So rather than attacking healthy tissue, they are now ready to protect against further attacks against healthy tissue.

The researchers hope that some of the changes in immune cells and in gene expression that they have identified can be used in clinical studies to determine whether immunotherapy is working.

 

Where did the story come from?

The study was carried out by researchers from the University of Bristol and University College London and was funded by the Wellcome Trust, MS Society UK, the Batchworth Trust and the University of Bristol.

The study was published in the peer-reviewed journal Nature Communications. This article is open-access and can be read for free.

Although most of the media reporting was accurate, it should be noted that the current study focused on how dose-escalation therapy works rather than revealing it as a new discovery.

The principles underpinning immunotherapy and similar treatments have been known for many years.

 

What kind of research was this?

This was an animal study that aimed to improve the understanding of how dose-escalation therapy works so that it can be made more effective and safer.

Animal studies are the ideal type of study to answer this sort of basic science question.

 

What did the research involve?

Most of the experiments were performed in mice that were engineered to develop autoimmune encephalomyelitis, which has similarities to multiple sclerosis (MS).

In this mouse model, more than 90% of a subset of immune cells called CD4+ T cells recognise myelin basic protein, which is found in the myelin sheath that surrounds nerve cells. This causes the immune system to attack the myelin sheath, damaging it, which causes nerve signals to slow down or stop.

The researchers injected the mice subcutaneously (under the skin) with a peptide (small protein) that corresponded to the region of myelin basic protein that was recognised by the CD4+ T cells.

The researchers initially wanted to see what the maximum dose of peptide that could be tolerated was, and what dose was most effective at inducing tolerance.

They then did further experiments in which they increased the dose of peptide and compared that with just giving the same dose of peptide on multiple days.

Finally, they looked at what genes were being expressed or repressed in CD4+ T cells during dose-escalation.

 

What were the basic results?

The researchers found that the maximum dose of peptide that could be tolerated safely by the mice was 8µg (micrograms).

The tolerance to the peptide increased as peptide dose increased. This means that when the mice were re-challenged with peptide, the immune response was lower in mice that received 8µg of peptide compared to mice that had received lower doses.

The researchers found that dose escalation was critical for effective immunotherapy. If mice received 0.08µg on day 1, 0.8µg on day 2, and 8µg on day 3, they could then tolerate doses of 80µg with no adverse effects. In addition, this dose escalation protocol suppressed activation and proliferation of the CD4+ T cells in response to the peptide.

The researchers then looked at the gene expression within CD4+ T cells during dose escalation. They found that each escalating dose of peptide treatment modified the genes that were expressed. Genes that are associated with an inflammatory response were repressed and genes that are associated with regulatory processes were induced.

How did the researchers interpret the results?

The researchers concluded that “these findings reveal the critical importance of dose escalation in the context of antigen-specific immunotherapy, as well as the immunological and transcriptional signatures associated with successful self-antigen escalation dose immunotherapy”.

They go on to say that “with the immunological and transcriptional evidence provided in this study, we anticipate that these molecules can now be investigated as surrogate markers for antigen-specific tolerance induction in clinical trials”.

 

Conclusion

This mouse study using a mouse model of MS has found that the dose-escalation protocol is extremely important for inducing tolerance, in this case a small fragment of myelin basic protein.

Escalation dose immunotherapy minimised immune system activation and proliferation during the early stages, and caused changes in gene expression that caused the attacking immune cells to express regulatory genes and to become suppressive.

The researchers hope that some of the changes in immune cells and in gene expression that they have identified can be used in clinical studies of tolerance-inducing treatments for autoimmune disorders to determine whether therapy is working.

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

Links To The Headlines

Breakthrough hope for MS treatment as scientists discover how to 'switch off' autoimmune disease. Mail Online, September 4 2014

Could a cure for MS and diabetes be on the way? Daily Express, September 4 2014

Links To Science

Burton BR, Britton GJ, Fang H, et al. Sequential transcriptional changes dictate safe and effective antigen-specific immunotherapy. Nature Communications. Published online September 3 2014

Categories: NHS Choices

Claims e-cigarettes are a 'gateway to cocaine'

NHS Choices - Behind the Headlines - Thu, 04/09/2014 - 12:00

“E-cigarettes could lead to using cocaine and cannabis scientists say,” the Daily Mirror reports.

In an article sure to prove controversial, two neuroscientists argue that nicotine may "prime" the brain to become addicted to harder drugs, such as cocaine.

The story comes from an article that argues that nicotine alters the brain’s circuitry, lowering the threshold for addiction to other substances such as cannabis and cocaine. Electronic cigarettes, the authors point out, are “pure nicotine delivery devices”, which could increase drug addiction among young people.

The “gateway drug” hypothesis is that use of certain (usually legal) drugs such as nicotine and alcohol can lead to the use of hard illegal drugs such as cocaine. This article argues that nicotine is such a drug and includes previous research by the authors that tested this hypothesis in a mouse model. 

The authors’ argument is based on the assumption that e-cigarette (or other nicotine) users will go on to use drugs such as cocaine. This assumption is unproven. While it is true that most cocaine users are also smokers, this does not equate to stating that most smokers use cocaine.

The article is of interest but it does not prove that e-cigarettes are a “gateway” to the use of drugs such as cocaine.

 

Where did the story come from?

The article is the print version of a lecture given by two researchers from Columbia University in the US. Their previous work in this area has been funded by the Howard Hughes Medical Institute, the National Institutes of Health and the National Institute on Drug Abuse, all in the US. One of the researchers, Professor Eric Kandel, shared the 2000 Nobel Prize in Physiology or Medicine for his discoveries related to the molecular basis of memory.

The article was published in the peer-reviewed New England Journal of Medicine on an open access basis so it is free to read online.

Coverage in the UK media was accurate but uncritical.

 

What kind of research was this?

This was not research but an article, based on a lecture, that presented evidence in favour of the theory that nicotine “primes” the brain for the use of other drugs such as cannabis and cocaine.

The authors say that while studies have shown that nicotine use is a gateway to the use of cannabis and cocaine in human populations, it has not been clear how nicotine accomplishes this. They say they have brought “the techniques of molecular biology” to bear on the question, revealing the action of nicotine in the brains of mice.

 

What did the article involve?

The authors first explain the gateway hypothesis (developed previously by one of them), which argues that in western societies, there is a “well defined” developmental sequence of drug use that starts with a legal drug and proceeds to illegal drugs. Specifically, it says, the use of alcohol and tobacco precede the use of cannabis, which in turn precedes the use of cocaine and other illicit drugs. They then review their own studies in which they tested the gateway hypothesis in a mouse model. 

Using this model they examined both addictive behaviour, brain “plasticity” (changes to the structures of the brain) and activity of a specific gene associated with addiction, in various experiments in which mice were exposed to both nicotine and cocaine.

One of the behavioural experiments they report on, for example, shows that mice given nicotine for seven days, followed by four days of nicotine and cocaine, were significantly (98%) more active than controls.

They also say they found that exposing mice brains to nicotine appeared to increase the “rewarding” properties of cocaine by encouraging production of the neurotransmitter dopamine.

Other experiments they report on found that nicotine given to mice before cocaine increased the expression of a gene that magnifies the effect of cocaine.

This “priming” effect, they say, does not occur unless nicotine is given repeatedly and in close conjunction with cocaine.

They then report on studies that they say show that nicotine also primes human brains to respond to cocaine, with the rate of cocaine dependence highest among users who started using cocaine after having smoked cigarettes.

Their conclusion is that, in humans, nicotine affects the circuitry of the brain in a manner that enhances the effects of a subsequent drug and that this “priming effect” happens if cocaine is used while using nicotine.

This effect is likely to occur, they argue, whether the exposure is from tobacco smoking, passive smoking or e-cigarettes.

They also argue that e-cigarettes are increasingly used by adolescents and young adults, with the potential for creating a new generation of people addicted to nicotine. “Whether e-cigarettes will prove to be a gateway to the use of combustible cigarettes and illicit drugs is uncertain but it is clearly a possibility.”

 

Conclusion

The article is of interest but it does not prove that e-cigarettes are a “gateway” to the use of drugs such as cocaine. The authors present evidence, much of it from their own research, in support of this hypothesis, but it remains just that – a hypothesis.

You could also make the point that it is somewhat unfair to demonise e-cigarettes in this way. Any product containing nicotine, such as patches or gum, could also be classed as a “gateway drug”, but as they release nicotine slowly these are not thought to be as “addictive”.

Also, as the authors point out, the “gateway drug” hypothesis is not universally accepted by addiction specialists. There is another hypothesis that the use of multiple drugs reflects a general tendency to drug use and that it is this tendency to addiction, rather than the use of a particular drug, that increases the risk of progressing to another drug.

From 2016 e-cigarettes are likely to be classed as "medicines", which means they will face stringent checks by medicine regulator the MHRA, and doctors will be able to prescribe them to smokers to help them cut down or quit. Tighter regulation will ensure the products are safe and effective.

If you want to try a safer alternative to cigarettes but are concerned about the uncertainties surrounding e-cigarettes, you may wish to consider a nicotine inhalator. This licensed quit smoking aid, available on the NHS, consists of just a mouthpiece and a plastic cartridge. It’s proven to be safe, but the nicotine vapour only reaches the mouth rather than the lungs, so you don’t get the quick hit of nicotine that comes with e-cigarettes.

It is well known that nicotine is addictive. Despite the risk of addiction and other uncertainties, e-cigarettes are likely to be safer than cigarettes (or other tobacco products). There is no conclusive evidence that using e-cigarettes will increase your risk of developing a drug addiction.


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

Links To The Headlines

E-cigarettes could lead to using cocaine and cannabis scientists say. Daily Mirror, September 4 2014

How an e-cigarette could lead to cocaine. The Daily Telegraph, September 3 2014

E-cigarettes could act as 'gateway' to harmful illegal drugs raising the risk of addiction. Mail Online, September 4 2014

Effects of using E-cigarettes 'stronger in adolescents'. ITV News, September 4 2014

Links To Science

Kandel ER, Kandel DB. A Molecular Basis for Nicotine as a Gateway Drug. The New England Journal of Medicine. Published online September 4 2014

Categories: NHS Choices

What is proton beam therapy?

NHS Choices - Behind the Headlines - Wed, 03/09/2014 - 14:00

Proton beam therapy has been discussed widely in the media in recent days.

This is due to the controversy surrounding the treatment of a young boy called Ashya King, who has medulloblastoma, a type of brain cancer.

Ashya was reportedly taken abroad by his parents to receive proton beam therapy.

But what does proton beam therapy involve, and can it treat cancer effectively?

 

How does proton beam therapy work?

Proton beam therapy is a type of radiotherapy.

Conventional radiotherapy uses high energy beams of radiation to destroy cancerous cells, but surrounding tissue can also be damaged. This can lead to side effects such as nausea, and can sometimes disrupt how some organs function.

Proton beam therapy uses beams of protons (sub-atomic particles) to achieve the same cell-killing effect. A "particle accelerator" is used to speed up the protons. These accelerated protons are then beamed into cancerous cells, killing them.

Unlike conventional radiotherapy, in proton beam therapy the beam of protons stops once it "hits" the cancerous cells. This means that proton beam therapy results in much less damage to surrounding tissue.

 

Who can benefit from proton beam therapy?

Proton beam therapy is useful for treating types of cancer in critical areas – when it is important to reduce damage to surrounding tissue as much as possible. For example, it is used most often to treat brain tumours in young children whose brains are still developing.

Proton beam therapy can also be used to treat adult cancers where the cancer has developed near a place in the body where damage would cause serious complications, such as the optic nerve.

These types of cancer make up a very small proportion of all cancer diagnoses. Even if there was unlimited access to proton beam therapy, its use would not be recommended in most cases.

Cancer Research UK estimates that only one in 100 people with cancer would be suitable for proton beam therapy.

 

Is proton beam therapy effective?

It is important not to assume that newly emerging treatments are more effective than existing treatments.

Proton beam therapy may cause less damage to healthy tissue, but it is still unclear whether it is as good at destroying cancerous tissue as conventional radiotherapy.

As proton beam therapy is usually reserved for very rare types of cancer, it is hard to gather systematic evidence about its effectiveness when compared to radiotherapy.

People who travel abroad from the UK to receive proton beam therapy usually respond well. But these people have specifically been selected for treatment as they were seen as "optimal candidates" who would benefit the most. Whether this benefit would apply to more people with cancer is unclear.

We cannot say with any conviction that proton beam therapy is “better” overall than radiotherapy.

 

Is proton beam therapy available in the UK?

Generally not. The NHS is building two proton beam centres, one in London and one in Manchester, which are expected to open in 2018. There is an existing low energy proton machine used specifically to treat some eye cancers at the NHS Clatterbridge Cancer Centre in Merseyside. This low energy machine cannot be used to treat most brain tumours as the low energy beam cannot penetrate far enough.

The NHS sends patients abroad if their care team thinks they are ideally suited to receive proton beam therapy. Around 400 patients have been sent abroad since 2008 – most of these patients were children. Read NHS England's advice for families of children being referred for proton beam therapy at overseas clinics (PDF, 1.39Mb).

Some overseas clinics providing proton beam therapy heavily market their services to parents who are understandably desperate to get treatment for their children. Proton beam therapy can be very costly and it is not clear whether all children treated privately abroad are treated appropriately.

It is important not to lose sight of the fact that conventional radiotherapy is, in most cases, both safe and effective with a low risk of complications. While side effects of radiotherapy are common they normally pass once the course of treatment has finished.

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

Links To The Headlines

What access to proton beam therapy do UK patients have? BBC News, September 1 2014

Ashya: Opinion Divided On Proton Beam Therapy. Sky News, September 2 2014

Categories: NHS Choices

Missing breakfast linked to type 2 diabetes

NHS Choices - Behind the Headlines - Wed, 03/09/2014 - 12:30

"Skipping breakfast in childhood may raise the risk of diabetes," the Mail Online reports. A study of UK schoolchildren found that those who didn’t regularly eat breakfast had early signs of having risk markers for type 2 diabetes.

The study found that children who did not usually eat breakfast had 26% higher insulin resistance than children who always ate breakfast. High insulin resistance increases risk of type 2 diabetes, which is why the results of this study are important. It should be pointed out that while the levels were higher in children who skipped breakfast, they were still within normal limits.

The researchers questioned more than 4,000 children aged nine and 10 about whether they usually ate breakfast, and took a fasting blood sample for a variety of measurements, including their blood sugar level and insulin level. 

The results suggest that eating breakfast may reduce the risk of higher insulin resistance levels, but due to the cross-sectional design of the study (a one-off assessment), it cannot prove that skipping breakfast causes higher insulin resistance or type 2 diabetes. And, as the researchers point out, even if a direct cause and effect relationship was established, it is still unclear why skipping breakfast would make you more prone to diabetes.

Despite this limitation of the study, eating a healthy breakfast high in fibre has many health benefits and should be encouraged.

 

Where did the story come from?

The study was carried out by researchers from St George’s University Hospital in London, the University of Oxford, the Medical Research Council Human Nutrition Research in Cambridge and University of Glasgow School of Medicine. It was funded by Diabetes UK, the Wellcome Trust, and the National Prevention Research Initiative. The authors declared no conflict of interest.

The study was published in the peer-reviewed medical journal PLOS Medicine. This is an open access journal so the study is free to read online.

The UK media generally reported the study accurately, although claims the study “tracked” children over time are inaccurate. Researchers used a one-off questionnaire and blood test, and none of the results showed that the children were insulin resistant – they just had higher levels within the normal range.

Also the Mail Online’s headline “Youngsters who don't eat morning meal more likely to be insulin dependent” appears to be written by someone without any grasp of human biology. All humans are insulin dependent.

 

What kind of research was this?

This was a cross-sectional study of nine- and 10-year-old children in England. It aimed to see if there was a link between eating breakfast and markers for type 2 diabetes, in particular insulin resistance and high blood sugar levels. Higher fasting insulin levels are seen when the body becomes insulin resistant, which is a risk factor for developing type 2 diabetes. As this was a cross-sectional study, it cannot prove that not eating breakfast causes children to be at higher risk of type 2 diabetes, but it can show that there is an association.

 

What did the research involve?

The researchers used information collected from 4,116 children who had participated in the Child Heart And health Study in England (CHASE) between 2004 and 2007. This study invited children aged nine and 10 from 200 randomly selected schools in London, Birmingham and Leicester to take part in a survey looking at risk factors for type 2 diabetes and cardiovascular disease.

This included questionnaires, measures of body fat and a fasting blood sample, taken eight to 10 hours after their last meal.

One of the questions related to how often they ate breakfast, with the following possible responses:

  • every day
  • most days
  • some days
  • not usually

Children from the last 85 schools were also interviewed by a research nutritionist to determine their food and drink intake in the previous 24 hours.

They analysed the data looking for an association between breakfast consumption and insulin resistance and higher blood sugar levels adjusting the results to take into account age, sex, ethnicity, day of the week and month, and school.

 

What were the basic results?

Of the 4,116 children:

  • 3,056 (74%) ate breakfast daily
  • 450 (11%) had breakfast most days
  • 372 (9%) had breakfast some days
  • 238 (6%) did not usually have breakfast

Compared to children who ate breakfast every day, children who did not usually have breakfast had:

  • 26% higher fasting insulin levels
  • 26.7% higher insulin resistance
  • 1.2% higher HbA1c (number of red blood cells attached to glucose, which is a marker of average blood glucose concentration, higher numbers increase the risk of diabetes) 1% higher glucose (blood sugar) level

These results remained significant even after taking into account the child’s fat mass, socioeconomic status and physical activity levels.

In the subset of children asked about their food intake over the previous 24 hours, children eating a high fibre breakfast had lower insulin resistance than those eating other types of breakfasts such as toast or biscuits.

 

How did the researchers interpret the results?

The researchers concluded that “children who ate breakfast daily, particularly a high fibre cereal breakfast, had a more favourable type 2 diabetes risk profile. Trials are needed to quantify the protective effect of breakfast on emerging type 2 diabetes risk”.

 

Conclusion

This well designed study found that children who did not usually eat breakfast had 26% higher insulin resistance than children who always ate breakfast, though the level was still within normal limits.

Higher levels indicate a risk of type 2 diabetes, which is why the results of this study are important.

Strengths of the study include the large sample size, multi-ethnicity of the participants and accuracy of the body fat measurements rather than just relying on body mass index (BMI).

A limitation of the study is that due to the cross-sectional design it cannot prove that not eating breakfast would cause diabetes, but it does show that this may begin to increase the risk. The study is also reliant on self-reporting of usual breakfast intake.

Eating a healthy breakfast rich in fibre has been linked to many health benefits and is thought to contribute to maintaining a healthy weight. As the researchers point out, further studies will be required to verify the link, such as through following children over time to see which ones develop diabetes.

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

Links To The Headlines

Children who skip breakfast 'more likely to suffer diabetes': Youngsters who don't eat morning meal more likely to be insulin dependent. Mail Online, September 3 2014

Breakfast lowers risk of diabetes. The Times, September 3 2014

Children who skip breakfast might raise diabetes risk. New Scientist, September 2 2014

Links To Science

Donin AS, Nightingale CM, Owen CG, et  al. Regular Breakfast Consumption and Type 2 Diabetes Risk Markers in 9- to 10-Year-Old Children in the Child Heart and Health Study in England (CHASE): A Cross-Sectional Analysis. PLoS Medicine. Published online September 2 2014

Categories: NHS Choices

Lumpectomy 'as effective as double mastectomy'

NHS Choices - Behind the Headlines - Wed, 03/09/2014 - 11:29

“Double mastectomy for breast cancer 'does not boost survival chances' – when compared to breast-conserving surgery," The Guardian reports.

The news is based on the results of a large US cohort study of women with early stage breast cancer in one breast.

It found that the 10-year mortality benefit associated with bilateral mastectomy (removal of both breasts) was the same as breast-conserving surgery (also known as lumpectomy, where the cancer and a border of healthy tissue is removed) plus radiotherapy.

Unilateral mastectomy (removal of the affected breast) was associated with a slightly increased risk of 10-year mortality, although the absolute difference was only 4%.

In the UK, bilateral mastectomy may be recommended for women at high risk of breast cancer due to family history, or because of a gene mutation (for example mutations in the BRCA1 and BRCA2 genes). A bilateral mastectomy can then be followed by breast reconstruction surgery, restoring the original look of the breasts.

Disadvantages of a bilateral mastectomy compared to a lumpectomy include a longer recovery time and a higher risk of complications.

This study suggests that bilateral mastectomy may not be associated with any significant survival benefit over breast conserving therapy plus radiotherapy for most women.

It is important to note that the outcome for individual patients may vary, and the type of surgery a woman with breast cancer receives will depend on a number of factors, including her personal wishes and feelings.

 

Where did the story come from?

The study was carried out by researchers from Stanford University School of Medicine and the Cancer Prevention Institute of California. This study was funded by the Jan Weimer Junior Faculty Chair in Breast Oncology, the Suzanne Pride Bryan Fund for Breast Cancer Research at Stanford Cancer Institute, and the National Cancer Institute Surveillance, Epidemiology, and End Results Program. The collection of cancer incidence data was supported by the California Department of Health Services, the National Cancer Institute Surveillance, Epidemiology, and End Results Program and the Centres for Disease Control and Prevention National Program of Cancer Registries.

The study was published in the peer-reviewed medical journal JAMA. This article is open access so it is free to read and download.

The results of this study were well covered by the UK media. However, the headlines could be misconstrued as stating that there are no benefits associated with double mastectomies.

In fact, the headlines refer to the fact the double mastectomies weren’t associated with a significantly different survival benefit compared to breast-conserving therapy with radiotherapy, rather than with no survival benefit compared to no treatment.

 

What kind of research was this?

This was a cohort study that aimed to better understand the use of and outcomes after different treatment options for women diagnosed with early stage unilateral breast cancer (cancer in one breast).

Treatment options for breast cancer include surgery, radiotherapy, chemotherapy, hormone therapy and biological treatments.

In this study, the researchers were interested in different surgical options: unilateral mastectomy (removal of the breast with the cancer), bilateral mastectomy (removal of both breasts) and breast-conserving therapy with radiotherapy.

As this is a cohort study it cannot show that the type of surgery was the cause of poorer outcomes. A randomised controlled trial would be required for this. However, the researchers state that as bilateral mastectomy is an elective procedure for unilateral breast cancer, women who want this option are unlikely to accept randomisation to a less extensive surgical procedure in a trial.

 

What did the research involve?

The researchers identified women who had been diagnosed with early stage breast cancer (stage 0-III cancer) in one breast between 1998 and 2011 from the California Cancer Registry. Stage 0 breast cancer is localised and non-invasive, while stage III cancer is invasive and has spread to the lymph nodes.

The researchers followed these women for an average of 89.1 months.

The researchers looked for factors associated with the women receiving different types of surgical treatment.

They then looked to see how many women had died, and how many women had died from breast cancer, to see if the risk was different for women who had received different surgical treatment options.

The researchers adjusted their analyses for the following confounders:

  • age
  • race/ethnicity
  • tumour size
  • grade
  • histology (how the cells look under the microscope)
  • whether the cancer had spread to the lymph nodes
  • oestrogen receptor/progesterone receptor status
  • whether women also received chemotherapy and/or radiotherapy
  • neighbourhood socioeconomic status
  • marital status
  • insurance status
  • the socioeconomic composition of patients at the reporting hospital
  • whether women received care at a US National Cancer Institute designated cancer centre
  • year of diagnosis

 

What were the basic results?

The researchers identified 189,734 women who had been diagnosed with stage 0-III cancer in one breast between 1998 and 2011 from the California Cancer Registry. Of these, 6.2% underwent bilateral mastectomy, 55.0% received breast-conserving surgery with radiotherapy and 38.8% had a unilateral mastectomy.

The percentage of women who received bilateral mastectomy increased from 2.0% in 1998 to 12.3% in 2011, an annual increase of 14.3%. The increase in bilateral mastectomy rate was greatest among women younger than 40 years: the rate increased from 3.6% in 1998 to 33% in 2011.

The researchers compared the 10-year mortality (the percentage of women who don’t survive for 10 years) of women who had received breast-conserving surgery with radiotherapy, unilateral mastectomy and bilateral mastectomy.

  • 10-year mortality with breast-conserving surgery with radiotherapy was 16.8%
  • 10-year mortality with unilateral mastectomy was 20.1%
  • 10-year mortality with bilateral mastectomy was 18.8%

The researchers found that there was no significant mortality difference with bilateral mastectomy compared with breast-conserving surgery with radiotherapy (hazard ratio [HR] 1.02, 95% confidence interval [CI] 0.94 to 1.11), although unilateral mastectomy was associated with increased mortality (HR 1.35, 95% CI 1.32 to 1.39). The results for risk of death from breast cancer were similar.

The researchers also found that there were significant differences in the women who received the different surgical options.

Compared to women who received breast-conserving therapy plus radiotherapy, women were more likely to receive bilateral mastectomy if they:

  • were younger than 50 years old
  • were unmarried
  • were non-Hispanic white women
  • were diagnosed between 2005 and 2011 (vs. 1998 to 2004)
  • had a larger tumour, lymph node involvement, lobular histology (where cancer develops inside milk producing glands), higher grade or oestrogen receptor-/progesterone receptor-negative status (where cancer does not respond to hormonal treatments)
  • did not receive adjuvant treatment (chemotherapy and/or radiotherapy)
  • had private health insurance
  • came from neighbourhoods with higher socioeconomic status
  • received care at a National Cancer Institute designated cancer centre, or a hospital predominantly serving patients with lower socioeconomic status

Compared to women who received breast-conserving therapy plus radiotherapy, women were more likely to receive unilateral mastectomy if they:

  • were any age apart from 50 to 64 years old
  • were from a racial/ethnic minority
  • were married
  • were diagnosed between 1998 and 2004 (vs. 2005 to 2011)
  • had a larger tumour, lymph node involvement, lobular histology, higher grade, or oestrogen receptor-/progesterone receptor-negative status
  • did not receive adjuvant therapy (chemotherapy and/or radiotherapy)
  • had public/Medicaid insurance
  • came from neighbourhoods with lower socioeconomic status
  • received care at a hospital predominantly serving patients with lower socioeconomic status, and at hospitals that were not a National Cancer Institute designated cancer centre

 

How did the researchers interpret the results?

The researchers concluded that “use of bilateral mastectomy increased significantly throughout California from 1998 through 2011 and was not associated with lower mortality than that achieved with breast-conserving surgery plus radiotherapy. Unilateral mastectomy was associated with higher mortality than were the other two surgical options”.

 

Conclusion

This large US cohort study of women with early stage breast cancer in one breast has found no 10-year mortality benefit associated with bilateral mastectomy (removal of both breasts) compared with breast-conserving surgery (also known as lumpectomy, where the cancer and a border of healthy tissue is removed) plus radiotherapy.

Unilateral mastectomy was associated with a slightly increased risk of 10-year mortality, although the absolute difference was only 4%.

However, as there were significant differences between the patients receiving the different surgical options it makes it likely that the increase in risk associated with unilateral mastectomy is due to incomplete adjustment for some of the measured factors, unmeasured factors (for example, the presence of other diseases such as diabetes), or differences in access to care.

This study suggests that bilateral mastectomy may not be associated with any significant survival benefit compared to breast-conserving surgery with radiotherapy for the population of women with unilateral breast cancer.

However, as this was a cohort study it cannot prove that there was no significant survival difference; this would require a randomised controlled trial.

It is important to note that the outcome for individual patients may vary, and the type of surgery a woman with breast cancer receives will depend on a number of factors, including her personal wishes and feelings.

Ultimately, if you have been told you may require breast surgery, the choice of surgery will be down to you. Questions you may wish to ask your surgeon include:

  • What are the risks of the cancer reoccurring?
  • What are the risks of complications with each type of surgery?
  • What would be the likely impact on my quality of life for each type of surgery?
  • How will surgery affect the appearance of my breasts?
  • Are there any viable non-surgical options?

Read more about preparing for surgery.

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

Links To The Headlines

Double mastectomy for breast cancer 'does not boost survival chances'. The Guardian, September 2 2014

Double mastectomy 'doesn't boost chance of surviving cancer': Women who have less drastic surgery live just as long. Daily Mail, September 3 2014

Double mastectomies may not reduce cancer survival rates, study shows. The Independent, September 2 2014

Breast cancer survival rate 'no greater' after double mastectomy despite rise in breast removals. Daily Mirror, September 2 2014

Links To Science

Kurian AW, Lichtensztajn DY, Keegan THM, et al. Use of and Mortality After Bilateral Mastectomy Compared With Other Surgical Treatments for Breast Cancer in California, 1998-2011. JAMA. Published online September 3 2014

Categories: NHS Choices

Could watching action films make you fat?

NHS Choices - Behind the Headlines - Tue, 02/09/2014 - 12:00

“Couch potatoes captivated by fast-paced action films eat far more than those watching more sedate programmes,” The Independent reports.

A small US study found that people snacked more when watching action-packed movies.

The study took 94 US student volunteers and randomly assigned them in groups to watch 20 minutes of either the action film “The Island” with sound, the same film without sound or “Charlie Rose”, a long-running American talk show.

They were provided with unlimited snacks of M&Ms, cookies, carrots and grapes.

People watching the action film with sound ate 65% more calories than those watching the talk show.

Researchers discussed the hypothesis that the frequent visual and audio variations in “The Island” (a style of filming that director Michael Bay, best known for the "Transformers" films, has become notorious for) may be distracting. This means participants may have been unaware of how much they were snacking.

However, this does not prove that action films make you fat. The study appeared to allow students to gather themselves into groups before being assigned to what they would watch. This could have meant the groups were not adjusted for factors such as food preferences, physical activity or when the students had last eaten, which could all have influenced results.

The study does remind us, however, that we need to pay attention to what we eat, including food we consume while distracted, as it all counts towards our daily calorie intake.

 

Where did the story come from?

The study was carried out by researchers from Cornell University in New York and Vanderbilt University in Nashville. It was funded by Cornell University.

The study was published in the peer-reviewed medical journal JAMA Internal Medicine.

The UK media reported the story accurately, but did not highlight any of its weaknesses. However, The Independent did helpfully publish advice from England’s Chief Medical Officer that people should do a minimum of 150 minutes (2.5 hours) of moderate activity a week.

 

What kind of research was this?

This was a randomised controlled trial that aimed to see if people ate more snacks depending on the type of TV content they were watching.

While randomising participants is the best way to get groups that are balanced in their characteristics, this study only gave limited details of how this was done. This makes it difficult to know exactly how well the randomisation worked, and if the groups were truly balanced.

 

What did the research involve?

The researchers recruited 94 undergraduate students, gathered in groups of up to 20 people, then randomly assigned them to watch TV for 20 minutes, which was either:

  • an excerpt from action movie “The Island”
  • the same excerpt from “The Island”, but without any sound
  • an interview programme (talk show) called “Charlie Rose” – a celebrity focused talk show

During the 20 minutes, four snacks were made available: M&Ms, cookies, carrots and grapes. They were allowed to eat as much of them as they wanted. The amount of snacking per person was calculated by weighing the snacks before and after the 20 minute programme.

The researchers then analysed the results by type of TV show and sex of the participant.

 

What were the basic results?

Participants watching the action film with sound ate 98 more grams (g) of food than those watching a talk show (206.5g versus 104.3g). This equated to 65% more calories (kcal) consumed in the action film with sound group (354.1kcal versus 214.6kcal).

Those watching the action film without sound also ate significantly more snacks than people watching the talk show – 36% more grams of food (142.1g versus 104.3g) and 46% more calories (314.5kcal versus 214.6kcal).

Males ate more than females in all three groups.

 

How did the researchers interpret the results?

The researchers concluded that “more distracting TV content appears to increase food consumption: action and sound variation are bad for one’s diet”. They suggest that people should either avoid snacking when watching distracting TV or use “proportioned quantities to avoid overeating”.

 

Conclusion

This study appears to indicate that the type of TV programme a person watches can influence how many calories are consumed as snacks. However, little information was provided about the methods and findings of this study, which makes it difficult to be certain how well it was performed and, therefore, how robust the results are.

The potential issues with the study that could affect interpretation of the results seen include:

  • The participants were not randomly assigned to the different groups individually – instead they “gathered” into groups, and then these groups were randomised. This might mean that friends with similar likes and preferences gathered together and ended up in the same group. These self-selected groupings may have differed in their characteristics (e.g. gender, body mass index (BMI), physical activity or socioeconomic status), and these differences could affect results.
  • It is not clear whether the same number of people were exposed to each scenario, as the number of people in the groups was not reported.
  • No information was provided on which snacks the participants chose to eat, only the overall quantity in grams and calories. While it is tempting to assume that the people eating more calories were eating the unhealthier food, we don’t know whether this was the case. Indeed, the difference between the average least amount of snacks and the highest average amount was 100g and 140kcal – this suggests that the difference was not entirely of unhealthy food, as 100g of M&Ms contains more than 544kcal.
  • It is unclear what time of day the programmes were watched or whether they were all watched at the same time of day. Time of viewing could have a large effect on snacking, depending on the timing in relation to meals.
  • The students eating the most snacks may have had a higher physical requirement for food due to their level of sport or usual activities. The study also didn’t look at whether the people who ate more in snacks compensated for this in their later meals.
  • The study was conducted on students, and their behaviour may not be representative of the population at large.

In conclusion, this study in isolation doesn’t prove that watching certain TV programmes or films makes you fat. However, it does act as a reminder that we should pay attention to what we eat, including food we consume while distracted, as it all part of our calorie intake.

It is still recommended that you aim for at least 150 minutes (2.5 hours) of moderate physical activity each week, as well as eating a healthy, balanced diet.

If you are trying to lose weight, it might be a good idea to remove snacks from situations where you may get distracted – whether that is at home watching TV or at the cinema.

Only eating in a set location, such as your kitchen or dining room, can be a good way of staying mindful of how much you are actually eating; even a few extra snacks every night can quickly add up.

There are, however, a range of 100 calories or less snacks you can try, that shouldn’t put you over your daily calorie intake.

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

Links To The Headlines

Action films make you fat, study finds. The Independent, September 1 2014

Action films most likely to make you fat, says study. BBC News, September 2 2014

Links To Science

Tal A, Zuckerman S, Wansink D. Watch What You Eat: Action-Related Television Content Increases Food Intake. JAMA Internal Medicine. Published online September 1 2014

Categories: NHS Choices

Brain can be ‘retrained’ to prefer healthy foods

NHS Choices - Behind the Headlines - Tue, 02/09/2014 - 01:00

“The brain can be trained to prefer healthy food over unhealthy high-calorie foods, using a diet which does not leave people hungry,” reports BBC News.

It reports on a small pilot study involving 13 overweight and obese people who, aside from their weight, were described as being in good health.

Researchers looked at whether a dietary weight loss programme, known as the iDiet, could change how the brain’s reward system responds to high- and low-calorie foods. The iDiet included carbohydrates that released glucose slowly into the bloodstream (a low glycaemic index), and higher fibre and protein. It also aimed to reduce calorie intake by 500 calories (kcal), to 1,000kcal per day.

Adults on the iDiet lost more weight than those not on the diet. Interestingly, MRI scans suggested that their brains had increased the “reward” in response to anticipation of eating low-calorie foods and reduced the “reward” response to high-calorie foods compared to people not on the plan.

People can change their eating habits, which can lead to sustainable weight loss. This study supports this notion, and suggests that part of this may be related to changes in our brain’s “reward” response. The researchers hope to use this knowledge to improve weight loss interventions, but as yet it is not clear whether this will become a reality.

 

Where did the story come from?

The study was carried out by researchers from Harvard Medical School and other research centres in the US. It was funded by the US Department of Agriculture (USDA) and the Jean Mayer USDA Human Nutrition Research Center on Aging. One of the authors reported that she was the co-founder of a commercial weight loss programme (the iDiet) based on the approach described in the research paper.

The study was published in the peer-reviewed journal Nutrition & Diabetes, and has been made available on an open-access basis so it is free to read online.

The UK media has covered this research in a reasonable way. Both the Mail Online and BBC include comments from the lead researcher, noting that “there is much more research to be done here, involving many more participants, long-term follow-up and investigating more areas of the brain”.

 

What kind of research was this?

This was a randomised controlled trial, testing whether a new weight loss programme could change how the brain’s reward system responds to healthy and unhealthy food.

We need food to survive, but it takes effort to find and prepare food, so the brain “rewards” us for doing these tasks in anticipation of eating, by increasing levels of chemicals such as dopamine inside our brains.

This reward reinforces this behaviour. High-calorie foods provide more reward than lower-calorie foods, and this can cause people to choose these foods in preference to healthier options.

Reinforcement of this behaviour by the brain’s reward system may contribute to over-eating of these foods and, ultimately, obesity. The researchers say whether the brain can be trained to reverse this through a behavioural weight loss intervention, and therefore help to treat obesity, is not known. Two previous randomised control trials had found no impact of a weight loss programme on the brain’s reward system.

A randomised control trial is the best way to test the impact of an intervention on a given outcome. This was a pilot study, which means that it was a small-scale test to get some initial idea of whether the intervention works. If initial signs are positive, this would be followed up by a larger study to confirm these initial findings.

 

What did the research involve?

The researchers included 15 overweight or obese adults who were otherwise healthy and who were taking part in a larger randomised control trial of a weight loss programme called the “iDiet” in their workplaces. They had brain scans before and six months into the programme to see if the reward system in their brains had changed its response to the anticipation of high-calorie and low-calorie food.

Participants were randomly allocated to either the iDiet or no weight loss intervention for six months. The iDiet aimed to help people to lose 0.5 to 1kg per week in a sustainable way. Participants took part in group sessions that aimed to get them to reduce calorie intake by 500-1,000kcal per day (roughly the calorie content of a large takeaway cheeseburger).

They received weekly hour-long sessions for 15 weeks, followed by fortnightly sessions for eight weeks.

The iDiet included elements aimed at reducing hunger and reducing existing associations between unhealthy food and reward, while reinforcing associations between healthy food and reward. The researchers provided portion-controlled menus and recipes that combined low glycaemic index carbohydrates (providing about 50% of the diet’s energy) with higher fibre (40g/day or more) and protein (about 25% of energy from protein and fat). There were also specific low-calorie “free foods” that could be eaten as desired. This combination aimed to make participants feel fuller and reduce hunger.

The researchers had specific criteria for people to be eligible to take part in the brain scanning part of the study (for example, they could not have had any psychiatric problems in the last two years). It was not clear from the reporting exactly how many people in total were in the randomised control trial and how many in total were eligible for the brain scan part of the study.

Of the 15 people who enrolled in the brain scan study, two dropped out – one lost their job and one felt claustrophobic in the brain scanner. Eight of the remaining participants were in the iDiet group, and five were in the control group.

The study used a type of brain scan called a functional MRI (fMRI), which detects activity in different parts of the brain. The researchers were particularly interested in the part of the brain called the striatum, as this has been reported to be involved in giving “rewards”. The participants were shown 40 images of commonly eaten high-calorie and low-calorie foods while they were in the scanner, to see how their brains responded. The participants also rated each food from one (not desirable at all) to four (extremely desirable).

They were also shown non-food images so that the researchers could take into account how active the brain regions normally were when not exposed to food. The brain scans were taken four hours after a meal, so about when the participants would be ready for another meal.

 

What were the basic results?

Participants on the iDiet lost 6.3kg on average over six months, while the control group gained 2.1kg. It was not clear whether these results were for the entire randomised control trial, or just those participants taking part in the brain scan part of the study.

Compared to the control group, the iDiet participants showed greater increase in activation of one part of the striatum (a reward-related brain region) when shown low-calorie foods, and more reduction in activation of another part of the striatum when shown high-calorie food after six months. Other parts of the striatum that had previously been implicated in the food reward system did not show differences between the groups.

The iDiet participants reported a greater increase in desirability of the low-calorie foods, and a greater reduction in the desirability of the high-calorie foods than the control group. However, this difference was not large enough to reach statistical significance.

The changes over time in brain response did not appear to show a relationship to changes in eating behaviour in the eight iDiet participants.

 

How did the researchers interpret the results?

The researchers concluded that this was the first randomised control trial to show changes in the brain reward system response to high- and low-calorie foods in response to a weight loss programme. They suggest that interventions that take advantage of this should be explored for their ability to enhance how effective behavioural weight loss interventions are, and how sustainable the weight loss is.

 

Conclusion

This small study has shown that a successful dietary weight loss programme is associated with changes in the brain’s response to images of high- and low-calorie food. Participants in the programme showed greater brain activity in one reward-related part of the brain in response to low-calorie foods, and less activity in another reward-related part of the brain in response to high-calorie foods. This effect was not seen in people who had not taken part in the programme.

There are a few things to bear in mind when interpreting this study:

  • The researchers are not able to say whether the change in brain response came before and contributed to the weight changes, or whether they came after and potentially resulted from the changes in weight.
  • The researchers were not able to show a relationship between eating behaviours and the level of activation in the reward centres – so they can’t say for certain that the brain changes seen were linked to changes in what people actually ate.
  • The brain activity seen was in response to pictures of food rather than actual food, and this may differ.
  • The groups did have different levels of dietary restraint at the start of the study, and this could influence results.
  • The study was small (13 people) and a relatively short-term part of a pilot randomised control trial, so findings would need to be assessed in a larger study to see if they could be confirmed in a wider sample of people over a longer period.
  • It is not possible to say whether the changes in brain activity seen are specifically related to the approach taken in the iDiet programme, or whether other dietary programmes would have a similar effect.

In conclusion, this study confirms that people can change their eating habits and weight. It also suggests that part of this may be related to changes in our brain’s “reward” response to high- and low-calorie foods. The researchers hope to use this knowledge to improve weight loss interventions, but as yet it is not clear whether this will become a reality.

For a free alternative to commercial diet plans, why not try the NHS weight loss plan.

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

Links To The Headlines

Brain 'can be trained to prefer healthy food'. BBC News, September 2 2014

You CAN train your brain to like healthy foods: Researchers reveal diet that can kick junk food addiction. Mail Online, September 2 2014

Links To Science

Deckersbach T, Das SK, Urban LE, et al. Pilot randomized trial demonstrating reversal of obesity-related abnormalities in reward system responsivity to food cues with a behavioral intervention. Nutrition and Diabetes. Published online September 1 2014

Categories: NHS Choices

Heart failure drug could 'cut deaths by a fifth'

NHS Choices - Behind the Headlines - Mon, 01/09/2014 - 12:00

“A new drug believed to cause a 20 per cent reduction in heart failure deaths could present a 'major advance' in treatment,” The Independent reports.

The drug, LCZ696, helps improve blood flow in heart failure patients. Heart failure is a syndrome caused by the heart not working properly, which can make people vulnerable to serious complications.

A new study compared LCZ696 with an existing heart failure drug called enalapril, which is also used to treat high blood pressure.

Researchers found that LCZ696 is better than enalapril for preventing death from cardiovascular causes and for preventing hospitalisation for heart failure. The results were so striking that they decided to halt the trial.

During the 27 months of the study, compared to enalapril, LCZ696:

  • reduced the risk of death from cardiovascular disease by 20%
  • reduced the risk of hospitalisation for heart failure by 21%
  • reduced the risk of death from any cause by 16%

The makers of LCZ696 must now apply for marketing authorisation before the drug can be sold. A press release from the developer of the drug, Novartis, states that it plans to file the application for marketing authorisation in the European Union in early 2015.

 

Where did the story come from?

The study was carried out by researchers from the University of Glasgow, the University of Texas Southwestern Medical Center and Novartis Pharmaceuticals, in collaboration with an international team of researchers from other universities and research institutes around the world. It was funded by Novartis, the pharmaceutical company that developed LCZ696.

The study was published in the peer-reviewed New England Journal of Medicine and has been made available on an open-access basis, so it is free to read online.

The results of the research were well covered by the UK media.

 

What kind of research was this?

This was a randomised controlled trial. It aimed to determine whether the new drug LCZ696 reduced the risk of death from cardiovascular causes or hospitalisation for heart failure in people who had heart failure with reduced ejection fraction, compared to enalapril.

Heart failure is a syndrome caused by the heart not working properly. In heart failure with reduced ejection fraction, less blood than normal is pumped out of the heart with each beat.

Enalapril is a drug already used to treat hypertension (high blood pressure) and heart failure. Enalapril is what is known as an angiotensin-converting enzyme (ACE) inhibitor, which improves heart failure by a number of different mechanisms. It inhibits an enzyme that is part of what is known as the renin-angiotensin-aldosterone system. One of the effects of this is to cause blood vessels to relax and widen.

LCZ696 also inhibits the renin-angiotensin-aldosterone system but also inhibits another enzyme called neprilysin. It was hoped that it would be more effective in treating heart failure.

A randomised controlled trial was deemed the best way of determining whether LCZ696 reduced the risk of death from cardiovascular causes or hospitalisation for heart failure compared to enalapril.

 

What did the research involve?

The researchers recruited 8,442 people with heart failure and an ejection fraction of 40% or less into the trial. Ejection fraction is a measure of how well your heart beats. A normal heart pumps a little more than half the heart’s blood volume with each beat. Normal ejection fractions range between 55% and 70%. To be included in the trial, patients had to be able to tolerate both enalapril and LCZ696; this was determined in a run-in phase before people were randomised. 

People were randomly assigned to receive LCZ696 (200mg twice daily) or enalapril (at a dose of 10mg twice daily), in addition to recommended therapy.

The researchers monitored how many people died from cardiovascular causes or were hospitalised for heart failure.

The researchers compared outcomes for people receiving LCZ696 with people receiving enalapril. 

43 of them were later excluded due to invalid randomisation, or if their hospital site had been closed.

 

What were the basic results?

The trial was stopped early because outcomes with LCZ696 were much better than outcomes with enalapril.

After people had been followed for an average of 27 months:

  • 4.7% fewer people who received LCZ696 died from cardiovascular causes or had been hospitalised for heart failure: 914 patients (21.8%) in the LCZ696 group compared with 1,117 patients (26.5%) in the enalapril group. This was equivalent to a 20% reduction in risk with LCZ696 compared to with enalapril (hazard ratio [HR] 0.80; 95% confidence interval [CI] 0.73 to 0.87). If 21 people were treated with LCZ696, one less death from cardiovascular causes or hospitalisation for heart failure would be expected than if people received enalapril.
  • 3.2% fewer people who received LCZ696 died from cardiovascular causes: 558 patients (13.3%) in the LCZ696 group and 693 patients (16.5%) in the enalapril group. This was a 20% reduction in risk with LCZ696 compared to with enalapril (HR 0.80; 95% CI, 0.71 to 0.89). If 32 people were treated with LCZ696, one less death from cardiovascular causes would be expected than if people received enalapril.
  • 2.8% fewer people who received LCZ696 were hospitalised for worsening heart failure: 537 patients (12.8%) in the LCZ696 group compared to 658 (15.6%) in the enalapril group. This was a 21% reduction in risk with LCZ696 compared to with enalapril (HR 0.79; 95% CI 0.71 to 0.89).
  • 2.8% fewer people who received LCZ696 died: 711 patients (17.0%) in the LCZ696 group compared with 835 patients (19.8%) in the enalapril group. This was equivalent to a 16% reduction in risk with LCZ696 compared to with enalapril (HR 0.84; 95% CI 0.76 to 0.93).

LCZ696 also significantly reduced the symptoms and physical limitations of heart failure.

With regards to adverse effects, more people who received LCZ696 had low blood pressure (hypotension) and non-serious angioedema (swelling of the deeper layers of the skin due to a build up of fluid), but fewer people had kidney (renal) impairment, hyperkalemia (high levels of potassium in the blood) and cough than the people who received enalapril. Overall, fewer people in the LCZ696 group stopped their medication because of an adverse event than in the enalapril group.

 

How did the researchers interpret the results?

The researchers concluded that “LCZ696 was superior to enalapril in reducing the risks of death, and of hospitalisation for heart failure.”

 

Conclusion

This was a well conducted study that achieved impressive results.

In this 27 month-long randomised controlled trial of 8,442 people with heart failure and an ejection fraction of 40% or less, compared to enalpril, the new drug LCZ696:

  • reduced the risk of death from cardiovascular disease or the risk of hospitalisation for heart failure by 20%
  • reduced the risk of death from cardiovascular disease by 20%
  • reduced the risk of hospitalisation for heart failure by 21%
  • reduced the risk of death from any cause by 16%

Marketing authorisation is now required before it can be sold. The developer of the drug, Novartis, states that they plan to file the application for marketing authorisation in the European Union in early 2015.

It is currently unclear how much LCZ696 will cost. Until this information becomes available, it is difficult to predict whether LCZ696 will be offered by the NHS.

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

Links To The Headlines

New heart drug LCZ696 could reduce heart failure deaths by 20%, scientists say. The Independent, August 30 2014

'Remarkable' new heart drug will cut deaths by a fifth - and could be available as early as next year. Mail Online, September 1 2014

New heart drug will cut deaths by a fifth. The Daily Telegraph, August 30 2014

Links To Science

McMurray JJV, Packer M, Desai AS, et al. Angiotensin–Neprilysin Inhibition versus Enalapril in Heart Failure. The New England Journal of Medicine. Published online August 30 2014

Categories: NHS Choices

Students 'showing signs of phone addiction'

NHS Choices - Behind the Headlines - Mon, 01/09/2014 - 01:00

“Students spend up to 10 hours a day on their mobile phones,” the Mail Online reports. The results of a US study suggest that some young people have developed an addiction to their phone.

Mobile or “cell” phone addiction is the habitual drive or compulsion to continue to use a mobile phone, despite its negative impact on one’s wellbeing.

The authors of a new study suggest that this can occur when a mobile phone user reaches a “tipping point”, where they can no longer control their phone use. Potential negative consequences include dangerous activities, such as texting while driving.

This latest study surveyed mobile phone use and addiction in a sample of 164 US students.

The students reported spending nearly nine hours a day on their mobile phones. There was a significant difference in the amount of time male and female students spent on their phones, with women spending around 150 minutes more a day using the device.

Common activities included texting, sending emails, surfing the internet, checking Facebook and using other social media apps, such as Instagram and Pinterest.

It was also found that women spent a lot more time texting than men, and were more likely to report feeling agitated when their phone was out of sight or their battery was nearly dead. Men spent more time than women playing games.

Using Instagram and Pinterest, and using the phone to listen to music, as well as the number of calls made and the number of texts sent, were positively associated with (increased risk of) phone addiction.

However, the study did not prove that any of these activities can cause mobile phone addiction.

 

Where did the story come from?

The study was carried out by researchers from Baylor University and Xavier University in the US, and the Universitat Internacional de Catalunya in Spain. No financial support was received.

The study was published in the peer-reviewed Journal of Behavioural Addictions and has been published on an open-access basis, meaning it is free to read online.

The results of the study were well-reported by the Mail.

 

What kind of research was this?

This was a cross-sectional study that aimed to investigate which mobile phone activities are most closely associated with phone addiction in young adults, and whether there are differences between males and females.

As it is a cross-sectional study, it cannot show causation – that is, that the activities undertaken cause a person to become addicted to their mobile phone.

 

What did the research involve?

164 college undergraduates in Texas aged between 19 and 22 years old completed an online survey.

To measure mobile phone addiction, people were asked to score how much they agreed with the following statements (1=strongly disagree; 7=strongly agree):

  • I get agitated when my phone is not in sight.
  • I get nervous when my phone’s battery is almost exhausted.
  • I spend more time than I should on my phone.
  • I find that I am spending more and more time on my phone.

People were also asked how much time they spent on 24 different mobile phone activities a day, including:

  • calling, texting and emailing
  • using social media applications
  • playing games
  • taking photos
  • listening to music

Finally, they were asked how many calls they made, and how many texts and emails they sent a day.

 

What were the basic results?

On average, the undergraduates spent 527.6 minutes (almost nine hours) a day on their phones. Female students reported spending significantly more time on their phone than male students.

The students spent the most time texting (94.6 minutes per day), sending emails (48.5 minutes), checking Facebook (38.6 minutes), surfing the Internet (34.4 minutes) and listening to their iPods (26.9 minutes). There were significant differences between the amount of time male and female students reported performing different mobile phone activities. Women spent more time than men texting, emailing, taking pictures, using a calendar, using a clock, on Facebook, Pinterest and Instagram, while men spent more time than women playing games.

The study identified activities that were significantly associated with mobile phone addiction. Instagram, Pinterest and using an iPod application, as well as the number of calls made and the number of texts sent, were positively associated with (increased the risk of) mobile phone addiction when males and females were analysed together. Time spent on “other” applications was negatively associated with (reduced the risk of) phone addiction.

However, there were differences between males and females.

For males, time spent sending emails, reading books and the Bible, as well as visiting Facebook, Twitter and Instagram, in addition to the number of calls made and the number of texts sent, were positively associated with mobile phone addiction. In contrast, time spent placing calls, using the phone as a clock, visiting Amazon and “other” applications were negatively associated with phone addiction.

For females, time spent on Pinterest, Instagram, using an iPod application, Amazon and the number of calls made were all positively associated with mobile phone addiction. In contrast, time spent using the Bible application, Twitter, Pandora/Spotify and an iTunes application were negatively associated with phone addiction.

 

How did the researchers interpret the results?

The researchers concluded that mobile phone addiction amongst participants was largely driven by a desire to connect socially. However, the activities found to be associated with phone addiction differed between males and females.

 

Conclusion

This study found that a sample of college students in the US reported spending nearly nine hours a day on their mobile phones, although there was a significant difference between male and female students. There were also differences in the amount of time male and female students spent performing various activities.

The study has identified some activities associated with mobile phone addiction, with differences seen between male and female students.

However, due to the study design, it cannot prove that these activities caused the mobile phone addiction directly.

This study has several limitations:

  • it was performed on a sample of college students in the US, and the results of this study may not be generalisable to the population at large
  • the mobile phone addiction scale used in this study requires further evaluation
  • participants self-reported the time spent on certain activities

Mobile phones may help us connect with people all over the world, but possibly at the cost of reducing interaction with “real” people. Failure to connect with others can have an adverse effect on a person’s quality of life. A 2013 study found an association between Facebook use and dissatisfaction – the more time a person spent on Facebook, the less likely they were to report feeling satisfied with their life.

Read more about how connecting with others can improve your mental health.

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

Links To The Headlines

Students 'addicted to mobile phones': Some spending up to ten hours a day texting, emailing and on social media. Mail Online, September 1 2014

Links To Science

Roberts JA, Yaya LHP, Manolis C. The invisible addiction: Cell-phone activities and addiction among male and female college students. The Journal of Behavioural Addiction. Published online August 26 2014

Categories: NHS Choices

Study finds plain cigarette pack fears 'unfounded'

NHS Choices - Behind the Headlines - Fri, 29/08/2014 - 12:00

"Cigarette plain packaging fear campaign unfounded," reports The Guardian.

After Australia introduced plain packaging laws in 2012, opponents of the legislation argued it would lead to a number of unintended consequences, including:

  • the market would become flooded by cheap Asian brands
  • smokers would be more likely to buy illegal unbranded tobacco (including raw unbranded loose tobacco known locally in Australia as "chop-chop")
  • smokers would be less likely to buy their cigarettes from smaller mixed businesses such as convenience stores and petrol stations, meaning that small businesses would suffer

But a new study conducted in Victoria, Australia, suggests these fears are unfounded.

Researchers compared the responses smokers gave in a telephone survey one year before the introduction of standardised packaging, with responses given one year after its introduction.

The study found no evidence the introduction of standardised packaging had changed the proportion of people purchasing from small mixed-business retailers, purchasing cheap brands imported from Asia, or using illicit tobacco.

But this study did not investigate whether there had been an increase in the use of counterfeit branded tobacco products. The researchers noted that smokers may be unaware they are smoking counterfeit products.

In conclusion, the study suggests there is no evidence for many of the "fears" proposed by opponents of standardised packaging.

 

Where did the story come from?

The study was carried out by researchers from the Centre for Behavioural Research in Cancer in Melbourne, Australia.

It was supported by Quit Victoria, with funding from VicHealth and the Department of Health for the Victorian Smoking and Health annual survey.

The study was published in the peer-reviewed journal BMJ Open, which is open access, so the study can be read online or downloaded for free.

The results of the study were well reported by the UK media.

 

What kind of research was this?

This was a serial cross-sectional study (a cross-sectional study at different time points) that aimed to determine whether there was any evidence that the introduction of standardised packaging in Australia had changed:

  • the proportion of current smokers who usually purchased their tobacco products from larger discount outlets such as supermarkets, compared with small mixed-business retail outlets
  • the prevalence of the regular use of low-cost brands imported from Asia
  • the use of illicit unbranded tobacco

In Australia, since 2012 all tobacco products have to be sold in standardised dark brown packaging with large graphic health warnings. Brand names are printed in a standardised position with standardised lettering.

The researchers state opponents of plain packaging have suggested its introduction could mean smokers would be less likely to purchase from small mixed-business retailers, more likely to purchase cheap brands imported from Asia, and more likely to use illicit tobacco.

 

What did the research involve?

Smokers aged 18 and over in Victoria, Australia were identified in an annual population telephone survey (the Victorian Smoking and Health Survey).

They were asked about:

  • the place they usually purchase tobacco products from (supermarkets, specialist tobacconists, small mixed businesses, petrol stations or other venues, including informal sellers)
  • their use of low-cost Asian brands (whether their main brand was a low-cost Asian brand)
  • their use of unbranded illicit tobacco (whether they had bought or purchased any unbranded tobacco)

The researchers compared answers from three annual surveys: 

  • 2011 – a year prior to the implementation of standardised packaging
  • 2012 – during roll-out
  • 2013 – a year after implementation

 

What were the basic results?

A total of 754 smokers were surveyed in 2011, 590 in 2012 and 601 in 2013.

The researchers found:

  • the proportion of smokers purchasing from supermarkets did not increase and the percentage purchasing from small mixed-business outlets did not decline between 2011 and 2013
  • the prevalence of low-cost Asian brands was low and did not increase between 2011 and 2013
  • the proportion reporting current use of unbranded illicit tobacco did not change significantly between 2011 and 2013

 

How did the researchers interpret the results?

The researchers concluded that, "One year after implementation, this study found no evidence of the major unintended consequences concerning loss of smoker patrons from small retail outlets, flooding of the market by cheap Asian brands and use of illicit tobacco predicted by opponents of plain packaging in Australia."

 

Conclusion

The study found no evidence the introduction of standardised packaging had changed the proportion of people purchasing from small mixed-business retailers, purchasing cheap brands imported from Asia, or using illicit tobacco in Victoria, Australia.

However, this survey was only conducted in Victoria and only among English-speaking residents, so further studies are required to confirm the generalisability of the findings. As with all surveys, there is the possibility of respondent error and misreporting.

Further studies are required to investigate whether the introduction of standardised packaging has increased the use of counterfeit branded tobacco products, as this was not assessed.

Overall, the results of this study suggest there is no evidence behind many of the "fears" proposed by opponents of standardised packaging.

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

Links To The Headlines

'Plain' packaging not a boost to illegal tobacco use, study suggests. BBC News, August 29 2014

Australia shows that plain tobacco packaging significantly cuts smoking. The Independent, August 29 2014

Cigarette plain packaging fear campaign unfounded, Victoria study finds. The Guardian, August 29 2014

Plain Cigarette Packs Do Not Hurt Retailers. Sky News, August 29 2014

Links To Science

Scollo M, Zacher M, Durkin S, Wakefield M. Early evidence about the predicted unintended consequences of standardised packaging of tobacco products in Australia: a cross-sectional study of the place of purchase, regular brands and use of illicit tobacco. BMJ Open. Published online July 18 2014

Categories: NHS Choices

Claims magnetic brain stimulation helps memory

NHS Choices - Behind the Headlines - Fri, 29/08/2014 - 01:00

“Magnetic brain stimulation treatment shown to boost memory,” The Guardian reports. A new study found that magnetic pulses improved recall skills in healthy individuals. It is hoped that the findings of this study could lead to therapies for people with memory deficits such as dementia.

Researchers investigated the effects of transcranial magnetic stimulation (TMS) every day for five days on connections within the brain and on associative memory (the ability to learn and remember relationships between items – such as “1066” and the “Battle of Hastings”).

TMS is a non-invasive technique that uses an electromagnet placed against the skull to produce magnetic pulses that stimulate the brain.

In this study, TMS of a specific area of the brain was compared to “sham” stimulation in 16 healthy adults.

TMS was found to improve performance on the associative memory test by over 20%, whereas sham stimulation had no significant effect.

While the results are interesting, there are important limitations to consider. The sample size was small, just 16 people, so the findings need to be replicated in a larger group of people. It is also unclear how long any effect would persist, and if there are any adverse effects of TMS. Long-term studies are also required to determine whether TMS is both safe and effective.

Of note, the current study involved healthy people, not people with memory deficits, so it is uncertain whether TMS would be of any benefit to people with conditions that cause memory deficits such as dementia.

 

Where did the story come from?

The study was carried out by researchers from Northwestern University and the Rehabilitation Institute of Chicago, and was funded by the US National Institute of Mental Health and National Institute of Neurological Disorders and Stroke.

The study was published in the peer-reviewed journal Science.

The results of this study were generally well reported by the media, although some headline writers overstated the implications of the results.

 

What kind of research was this?

This was a cross-over trial that aimed to determine whether electromagnetic stimulation of a particular region of the brain could improve memory in 16 healthy people.

The researchers were interested in a region of the brain called the hippocampus, which is necessary for associative memory – this includes the ability to remember the association between a word and a face. It has been hypothesised that this ability also depends on other brain regions, and that the hippocampus could act as a “hub”.

To see whether this was the case, the researchers used high-frequency TMS to stimulate part of the brain known as the lateral parietal cortex, which is thought to interact with the hippocampus in memory.

The lateral parietal cortex is part of the cerebral cortex or grey matter, and the hippocampus is located under grey matter.

 

What did the research involve?

The researchers compared the effects of high-frequency transcranial magnetic stimulation and “sham” stimulation for five days on the ability of 16 healthy people to remember the association between faces and words.  

Each person participated for two weeks – one week with TMS and one week with sham stimulation – separated by at least one week. The baseline assessment occurred one day prior to the first stimulation session, and there were five consecutive daily stimulation sessions. The post-treatment assessment occurred one day after the final stimulation session. Half the subjects received TMS first and half received sham stimulation first.

In the memory test, participants were shown 20 different human face photographs for three seconds each. A researcher read a unique common word aloud for each face. One minute after this had been completed the participants were shown the photos again and asked to recall the words associated with them.

In addition to looking at the effect of memory, the researchers also looked at the effect of TMS on connectivity within the brain, using a technique called functional magnetic resonance imaging. This technique looks at changes in blood flow, and can be used to assess connectivity by looking for variations in blood flow that are time correlated across the brain.

 

What were the basic results?

TMS improved people’s ability to remember the association between a word and a face by more than 20%, whereas sham treatment caused no significant performance change.

The researchers also gave people other cognitive tests, but found that TMS had no effect on people’s performance on these tests.

TMS also increased connectivity between specific cortical (grey-matter) regions of the brain and the hippocampus.

 

How did the researchers interpret the results?

The researchers concluded that cortical-hippocampal networks can be enhanced noninvasively and play a role in associative memory.

 

Conclusion

In this study, TMS was found to improve performance on the associative memory test by more than 20%, whereas sham stimulation had no significant effect.

TMS also increased connectivity between specific cortical (grey-matter) regions of the brain and the hippocampus.

This interesting research increases our knowledge of how memory works. However, it was a very small trial with only 16 participants. It is also unclear whether electromagnetic stimulation would be effective for people with memory disorders such as dementia. The media has reported that the researchers are now planning to study the effect of TMS on people with early loss of memory ability.

Long-term studies are also required to determine how long the improved memory performance lasts and to ensure that electromagnetic stimulation of the brain doesn’t have any adverse effects.

Dementia remains a poorly understood condition, and claims that brain training exercises have a definitive protective effect against the condition have not held up to scrutiny. That said, keeping the brain active through memory intensive activities such as learning a new language, a musical instrument, or even just picking up a book cannot hurt. Keeping the mind active has been shown to improve quality of life.

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

Links To The Headlines

Magnetic brain stimulation treatment shown to boost memory. The Guardian, August 28 2014

Electrical brain stimulation 'boosts memory'. BBC News, August 29 2014

Magnetic pulse to head could improve memory of dementia sufferers. The Daily Telegraph, August 28 2014

Links To Science

Wang JX, Rogers LM, Gross EZ, et al. Targeted enhancement of cortical-hippocampal brain networks and associative memory. Science. Published online August 29 2014

Categories: NHS Choices

Tomato-rich diet 'reduces prostate cancer risk'

NHS Choices - Behind the Headlines - Thu, 28/08/2014 - 12:30

“Tomatoes ‘cut risk of prostate cancer by 20%’,” the Daily Mail reports, citing a study that found men who ate 10 or more portions a week had a reduced risk of the disease.

The study in question gathered a year’s dietary information from 1,806 men who were found to have prostate cancer and 12,005 who were clear after random prostate checks. The researchers compared the diets and adjusted the results to take into account factors such as age, family history of prostate cancer and ethnicity.

They found that men who ate more than 10 portions of tomatoes or tomato products per week have an 18% reduced risk of prostate cancer compared to men who ate less than 10.

As this was a case controlled study, and not a randomised controlled trial, it cannot prove that eating more tomatoes prevents prostate cancer. It can only show an association.

The association is biologically plausible, because tomatoes are a rich source of lycopene, a nutrient thought to protect against cell damage. However, the jury is still out on whether it really does protect cells.

So a healthy, balanced diet, regular exercise and stopping smoking are still the way to go. It’s unlikely that focusing on one particular food will improve your health.

 

Where did the story come from?

The study was carried out by researchers from the University of Bristol, the National Institute for Health Research (NIHR) Bristol Nutrition Biomedical Research Unit, Addenbrooke’s Hospital in Cambridge and the University of Oxford. It was funded by the NIHR and Cancer Research UK.

The study was published in the peer-reviewed medical journal Cancer Epidemiology, Biomarkers and Prevention. The study is open-access so it is free to read online or download.

In general, the media reported the story accurately but also reported different numbers of study participants, ranging from 1,800 to 20,000. This is because out of the 23,720 men who were initially included in the study, a proportion were excluded from the analyses due to missing questionnaires.

Several news sources have also reported that eating the recommended five portions of fruit or veg per day reduced the risk of prostate cancer by 24% compared to 2.5 servings or less per day. This seems to have come directly from the lead researcher, but these figures are not clearly presented in the research paper.

 

What kind of research was this?

This was a case-control study looking at the diet, lifestyle and weight of men who had had a prostate check and were subsequently diagnosed with (cases) and without (controls) prostate cancer. The researchers wanted to see if there were any factors that reduced the risk of being diagnosed with prostate cancer.

A previous systematic review suggested that a diet high in calcium is associated with an increased risk of prostate cancer and that diets high in selenium and lycopene are associated with reduced risk. Selenium is a chemical element essential for life that is found in animals and plants, but high levels are toxic. Lycopene is a nutrient found in red foods such as tomatoes and pink grapefruit.

The researchers defined intake of selenium and lycopene as the “prostate cancer dietary index”. They looked at whether there was an association between men’s index scores and their risk of having prostate cancer.

In addition, in 2007, the World Cancer Research Fund (WCRF) and the American Institute for Cancer Research (AICR) made eight recommendations on diet, exercise and weight for cancer prevention. 

However, recent research has shown conflicting results as to whether these recommendations are applicable to prostate cancer. One large European study found that men who followed the recommendations did not have a lower general prostate cancer risk, and the other found that men did have a reduced risk of aggressive prostate cancer.

The researchers wanted to see if these recommendations should be changed to include any of the prostate cancer dietary index components for men and/or men at higher risk of prostate cancer.

 

What did the research involve?

The researchers used data collected from a large UK study called the ProtecT trial. In this trial, 227,300 randomly selected men aged 50 to 69 were invited to have a prostate check between 2001 and 2009.

Nearly half of the men then had a prostate specific antigen (PSA) test and 11% of them went on to have further investigations. Before the test they were asked to fill out questionnaires on:

  • lifestyle
  • diet
  • alcohol intake
  • medical history
  • family history

They were also asked to provide information on their:

  • physical activity level
  • body mass index (BMI)
  • waist circumference
  • body size aged 20, 40 and at the time they entered the study

Body size was self-estimated by looking at pictures on a scale of 1 to 9. All those selecting 1 to 3 were categorised as normal weight and those selecting 4 to 9 were considered overweight/obese.

From this study the researchers identified 2,939 men who had been diagnosed with prostate cancer and matched them with 20,781 randomly selected men by age and GP practice who did not have prostate cancer to act as controls. They then excluded anyone who did not return the questionnaires and those who did not provide all of the body metrics.

This gave a sample of 1,806 men with prostate cancer and 12,005 controls.

The dietary questionnaires assessed how frequently they had consumed 114 items of food over the previous 12 months. This included an estimate of portion sizes.

From this information, the men were assigned a score to reflect how well they had achieved the first six of the eight WCRF/AICR recommendations (they did not have enough information for “salt consumption” or “dietary supplements”).

Adherence to each recommendation was scored (1 – complete adherence, 0.5 – partial adherence or 0 – non-adherence), giving an overall score between 0 and 6.

The researchers also looked at the intake of components of the “prostate cancer dietary index”: calcium, selenium and tomato products which they used as an indicator of lycopene intake (tomato juice, tomato sauce, pizza and baked beans). To be scored as adherent, men had to:

  • eat less than 1,500mg of calcium per day
  • eat more than 10 servings of tomato and tomato products per week
  • eat between 105 and 200µg of selenium per day

Statistical analyses were then performed to determine the risk of low or high grade prostate cancer according to adherence to the WCRF/AICR recommendations or intake of any of the three dietary components of the prostate cancer dietary index. The results were adjusted to take into account the following confounders:

  • age
  • family history of prostate cancer
  • self-reported diabetes
  • ethnic group
  • occupational class
  • smoking status
  • total energy intake
  • BMI

 

What were the basic results?

After adjusting for possible confounding factors:

  • being adherent to the tomato and tomato product recommendation by eating 10 or more servings of tomatoes per week was associated with an 18% reduced risk of prostate cancer compared to eating less than 10 servings (odds ratio (OR) 0.82, 95% confidence interval (CI) 0.70 to 0.97)
  • each component of the “prostate cancer dietary index” that the men adhered to was associated with a 9% reduction in risk of prostate cancer (OR 0.91, 95% CI 0.84 to 0.99)
  • the overall WCFR/AICR adherence score was not associated with a decreased risk of prostate cancer (OR 0.99, 95% CI 0.94 to 1.05)
  • every 0.25 increase in the score for adherence to the plant food recommendation was associated with a 6% reduced overall risk of prostate cancer (OR 0.94, 95% CI 0.89 to 0.99)

A 0.25 increase in adherence score could be achieved by increasing fruit and vegetable intake from less than 200g/day to between 200 and 400g/day, or by increasing fruit and vegetable intake from between 200 and 400g/day to 400g/day or more (400g is equivalent to five portions) or by changing intake of unprocessed cereals (grains) and/or pulses (legumes).

 

How did the researchers interpret the results?

The researchers concluded that, “in addition to meeting the optimal intake for the three dietary factors associated with prostate cancer, men should maintain a healthy weight and an active lifestyle to reduce risk of developing prostate cancer, cardiovascular diseases and diabetes”. They also say that “high intake of plant foods and tomato products in particular may help protect against prostate cancer, which warrants further investigations”.

 

Conclusion

This large study has shown an association between the consumption of more than 10 portions of tomatoes per week and an 18% reduction in risk of prostate cancer. However, as this was a case controlled study, and not a randomised controlled trial, it cannot prove that eating more tomatoes prevents prostate cancer.

Strengths of the study include its large size and attempts to account for potential confounding factors, although there are some limitations to the study, including:

  • reliance on the accuracy of the dietary questionnaires
  • broad categories for self-estimate of body size

This study does not provide enough evidence to change the recommendations for reducing the risk of prostate cancer. A healthy, balanced dietregular exercise and stopping smoking are still the way to go, rather than relying on eating one exclusive food type such as tomatoes.

Following the eight WCRF/AICR recommendations as listed above should also help prevent against other types of cancer as well as chronic diseases such as obesity and type 2 diabetes. 

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

Links To The Headlines

Tomatoes 'cut risk of prostate cancer by 20%': It takes 10 portions a week - but even baked beans count. Daily Mail, August 28 2014

Tomatoes 'important in prostate cancer prevention'. BBC News, August 27 2014

Tomato-rich diet can lower prostate cancer risk by a fifth, scientists claim. The Independent, August 27 2014

New research suggests men who eat more than 10 portions of tomatoes a week are less likely to develop prostate cancer. ITV News, August 27 2014

Links To Science

Er V, Lane JA, Martin RM, et al. Adherence to dietary and lifestyle recommendations and prostate cancer risk in the Prostate Testing for Cancer and Treatment (ProtecT) trial. Cancer Epidemiology, Biomarkers and Prevention. Published online July 13 2014

Categories: NHS Choices

Depression therapy aids other cancer symptoms

NHS Choices - Behind the Headlines - Thu, 28/08/2014 - 12:00

"Depression therapy could help cancer patients fight illness," reports The Daily Telegraph.

The headline follows a study of intensive treatment of clinical depression given to people who had both depression and cancer – delivered as part of their cancer care. It found that not only did people’s mood improve, but cancer-related symptoms such as pain and fatigue were also reduced compared to that seen with the usual care given.

The treatment programme, called Depression Care for People with Cancer (DCPC), involves a team of specially trained cancer nurses and psychiatrists who work closely with the patient’s cancer doctors and GP.

A related study, also published today, found that clinical depression is a common problem for people living with cancer. For example, it found that around one in eight people with lung cancer also had clinical depression.

It should be noted that the trial involved patients with a good outlook for their cancer, which may have been a factor in their response to treatment for depression.

However, a second trial of the depression treatment programme, this time involving lung cancer patients, also published today but not analysed here, showed a similar benefit, despite their poorer cancer prognosis.

This was a randomised controlled trial, which is the best type of study to examine the effectiveness of healthcare treatments, so the results are likely to be reliable. It is hoped that the positive results will be replicated in larger populations.

 

Where did the story come from?

The study was carried out by researchers from the Universities of Oxford and Edinburgh, and was funded by Cancer Research UK and the Scottish government.

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

The study is one of three depression-related cancer studies published by The Lancet.

The first looks at how common clinical depression is in cancer patients.

The third study assesses how effective the DCPC programme is in patients with cases of lung cancer that have a poor prognosis.

The study was covered fairly by the UK media.

 

What kind of research was this?

This was a randomised controlled trial of an integrated treatment programme for clinical depression in patients with cancer, compared to the results seen with usual care.

The authors point out that clinical depression affects about 10% of people with cancer and is associated with: worse anxiety, pain, fatigue and functioning; suicidal thoughts; and poor adherence to anticancer treatments.

However, at present, there is no good evidence for how best to treat depression in cancer patients and how to integrate treatment into their cancer care.

Their integrated treatment programme involves a psychiatrist and the care manager working with the patient’s specialist doctor, GP and cancer nurses to provide an intensive systematic treatment for depression, including both drugs and psychological treatment.

It’s worth pointing out that what is new here is not the actual treatments for depression – rather the way they are delivered, as an integrated part of the patient’s cancer care.

 

What did the research involve?

Between 2008 and 2011, researchers enrolled 500 participants attending three cancer centres in Scotland. Participants were aged 18 or over, with a good cancer prognosis – with a predicted survival of at least a year. They had all been diagnosed with clinical depression of at least four weeks' duration.

253 participants were randomly assigned to the new DCPC programme, with 247 assigned to usual care.

In the DCPC group, depression care was delivered by specially trained cancer nurses, under the supervision of a psychiatrist. The programme was designed to be integrated with the patient’s cancer care, with psychiatrists working in collaboration with the patient’s oncology team and their GP.

The nurses established a therapeutic relationship with the patient, provided information about depression and its treatment, delivered psychological interventions and monitored progress, using a validated depression questionnaire. The psychiatrists supervised treatment, advised GPs about prescribing antidepressants and provided direct consultations with patients who were not improving.

The initial treatment phase comprised a maximum of 10 sessions with the nurse (at the clinic or, if necessary, by telephone) over a four-month period. After this, the patient’s progress was monitored monthly by telephone for a further eight months, and additional sessions with the nurse were provided for patients not meeting treatment targets. All cases were reviewed on a weekly basis, in supervision meetings attended by nurses and a psychiatrist.

In the usual care group, the patient's GP and cancer doctors were informed about the clinical depression diagnosis and asked to treat their patients as they normally would. This might involve the GP prescribing antidepressants, or a referral of the patient to mental health services for assessment or psychological treatment.

At 24 weeks, researchers looked at the patient's primary response to their treatment, defined as at least a 50% reduction in depression severity and measured using a self-rated symptom checklist. A 50% reduction in score has been shown to be comparable to no longer meeting diagnostic criteria for major depression.

Researchers also looked at each patient’s levels of anxiety, pain, fatigue, physical and social functioning, as well as their overall health and quality of life, using validated questionnaires, and the patient’s opinion of the quality of depression care.

They analysed the results using standard statistical methods.

 

What were the basic results?

Researchers found that in 62% of participants in the DCPC group, the severity of depression decreased by 50% or more, compared with a 17% decrease in the usual care group (absolute difference 45%, 95% confidence interval (CI) 37 to 53; adjusted odds ratio (OR) 8.5, 95% CI 5.5 to 13.4).

Compared with patients in the usual care group, participants in the DCPC group also had less anxiety, pain and fatigue, as well as better functioning, health and quality of life. They also rated their depression care as being better.

During the study, 34 cancer-related deaths occurred (19 in the DCPC group, 15 in the usual care group); one patient in the DCPC group was admitted to a psychiatric ward and one patient in this group attempted suicide. None of these events were judged to be related to the trial's treatments or procedures.

 

How did the researchers interpret the results?

The researchers say their findings suggest that DCPC is an effective treatment for clinical depression in patients with cancer, and also offers a model for the treatment of depression occurring with other chronic medical conditions.

According to lead author Professor Michael Sharpe, from the University of Oxford in the UK: “The huge benefit that DCPC delivers for patients with cancer and depression shows what we can achieve for patients if we take as much care with the treatment of their depression as we do with the treatment of their cancer.”

 

Conclusion

Not surprisingly, this well-conducted study suggests that offering cancer patients with clinical depression an intensive, systematic treatment for depression involving all the people involved in their care, works better than the current approach.

As the authors point out, the trial had some limitations. The sample was mainly women receiving follow-up or adjuvant treatment for breast and gynaecological cancers, so it is unclear whether the findings are generalisable to other cancer patients.

Also, patients and their GPs could not be “masked” as to whether they were in the DCPC group or the group receiving usual care, which might have influenced the findings.

The striking results for patients in the DCPC group is probably attributable to treatment for depression being intensive, systematically implemented and integrated with the patient’s cancer care.

It is noteworthy that in the group receiving usual care, prescribing antidepressants was not actively managed – by, for example, changing the drug or adjusting the dose, according to the patient’s response. Few patients in this group received psychological treatment, despite the option being available.

Due to the very positive results achieved using the DCPC approach, the programme is likely to be assessed using other groups of people with cancer. If it continues to prove successful, it may become part of standard cancer treatment protocols.

If you are concerned that you have mental health problems that are being left untreated, talk to your cancer nurse or GP. They should be able to provide extra support and treatment as required.

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

Links To The Headlines

Cancer patients with depression 'are being overlooked'. BBC News, August 28 2014

Do more for depressed cancer patients – study. The Guardian, August 28 2014

Depression therapy could help cancer patient fight illness. The Daily Telegraph, August 28 2014

Study: Depression among cancer patients 'overlooked'. ITV News, August 28 2014

Links To Science

Sharpe M, Walker J, Hansen CH, et al. Integrated collaborative care for comorbid major depression in patients with cancer (SMaRT Oncology-2): a multicentre randomised controlled effectiveness trial. The Lancet. Published online August 28 2014

Categories: NHS Choices

Does weight loss surgery affect dementia risk?

NHS Choices - Behind the Headlines - Wed, 27/08/2014 - 12:30

"Weight loss surgery 'reduces chance of Alzheimer's disease'," reports The Daily Telegraph. This misleading headline reports on a small Brazilian study of severely obese women before and after weight loss surgery. None of the women had any signs or symptoms of Alzheimer's.

Seventeen women with an average body mass index (BMI) of 50kg/m² had neuropsychological tests, blood tests and a brain scan before surgery and again six months later, when their average BMI had reduced to 37kg/m². Their results were compared with those of 16 women of a normal weight – the "controls".

All of the women had normal neuropsychological tests. The obese women performed one of the tests more quickly after weight loss surgery, but it cannot be assumed this is a direct result of their weight loss. It could be they were faster simply because this was the second time they had done the test. The control group of women did not repeat the test, so we do not know if they also would have performed better.

Small changes in the rate of metabolism were seen in brain scans after surgery in two areas of the obese women's brains. But because the women were not followed up over time, it is not possible to say whether this means the women were at less risk of dementia or Alzheimer's disease as a result.

Losing weight can improve cardiovascular function, which in turn can protect against some types of dementia. But, based on this very small study, weight loss surgery cannot be recommended as an effective preventative measure against dementia.

 

Where did the story come from?

The study was carried out by researchers from the University of São Paulo, Brazil and was funded by the Brazilian National Council for Scientific and Technological Development.

It was published in the peer-reviewed Journal of Clinical Endocrinology and Metabolism on an open access basis, so it is free to read the paper online (PDF, 443kb).

The media headlines overstated the results of this study – it was not able to show that weight loss "boosts brain power" or reduces the risk of Alzheimer's disease. A more accurate – if less exciting – headline would have been "Weight loss surgery may make you perform slightly better in one of several neuropsychological tests".

But credit should go to the Mail Online for including a quote from an independent expert, who warned against reading too much into the results of this small study.

 

What kind of research was this?

This was a before and after study looking at the effect of weight loss surgery on brain (cognitive) function and metabolism in severely obese people. Severe obesity is when a person has a BMI of 40 or above.

The researchers say there is a link between obesity and Alzheimer's disease. They also report that previous research has found one area of the brain, called the posterior cingulate gyrus (believed to be involved in many brain processes), which shows reduced metabolic activity in early Alzheimer's disease.

They suggest the increased activity in this region might be a compensatory mechanism that occurs before the reduction in activity later in the disease.

The researchers wanted to assess the level of activity in this part of the brain in obese women and whether weight loss could have any impact on the metabolism.

As this study did not have a randomised control group of severely obese people who did not receive surgery, it is not able to prove cause and effect, as other confounding factors may have influenced the results.

 

What did the research involve?

The researchers compared the results of six neuropsychological tests, blood tests and a PET brain scan (a type of scan that assesses brain metabolism) on severely obese women before gastric bypass surgery and six months afterwards. They also compared the obese women's results with those of a group of normal-weight women.

Seventeen severely obese women aged between 30 and 50 were selected who were due to have gastric bypass surgery. The blood tests they had measured:

  • indicators of metabolism – glucose (sugar) level, insulin and lipids
  • markers of inflammation – C-reactive protein (CRP), Interleukin-6 (IL-6) and tumour necrosis factor-alpha (TNF-α)

Sixteen normal-weight women were recruited from the gynaecology unit to have the same tests on a single occasion to act as controls. They were matched to the obese women in terms of age and educational level.

 

What were the basic results?

The obese women lost a significant amount of weight after the surgery, but were still classified as very obese. Their average BMI was 50.1kg/m² before surgery and 37.2kg/m² six months after. The BMI of the normal-weight women was 22.3kg/m².

There was no significant difference in the neuropsychological tests between the obese women (before or after surgery) and the normal-weight women. The obese women showed improvements in one part of one of the six neuropsychological tests after surgery, however. This was the Trail Making Test – B, which assesses speed of visual scanning, attention and mental flexibility.

The obese women were able to complete the test in two-thirds of the time after surgery than they had before (average 147.8 seconds before and 96.9 seconds afterwards). Their performance was within normal limits both before and after surgery.

The brain PET scan showed an increase in metabolism in two areas of the brain before surgery compared with the normal-weight women. This difference was no longer present six months after surgery.

The two areas were the right posterior cingulate gyrus (the area that may be more active in early Alzheimer's disease) and the right posterior lobe of the cerebellum (involved in motor co-ordination).

Blood glucose, insulin levels and insulin resistance were higher in obese women than normal-weight women before surgery and improved to similar levels six months after surgery. Two of the inflammatory markers – CRP and IL-6 – were also significantly higher prior to surgery but then improved.

 

How did the researchers interpret the results?

The researchers concluded that, "metabolic and inflammatory properties associated with obesity in young adults are accompanied by changes in the cerebral metabolism capable of being reversed with weight loss."

They acknowledge that, "further studies are required to improve the understanding of the pathogenesis of the cognitive dysfunction related to obesity and the effects of weight loss on the occurrence of dementia."

 

Conclusion

This small short-term study has not shown that weight loss surgery reduces the risk of dementia. The women in this study were relatively young (about 41 years old on average) and all had normal neuropsychological test performance.

What this study did show is that, unsurprisingly, weight loss for severely obese women was associated with improved insulin resistance and blood glucose levels, and reduced levels of inflammation.

The main result reported by the researchers was a higher level of metabolism in two areas of the brain in severely obese women before gastric band surgery compared with normal-weight controls. This reduced to normal levels six months after surgery, when they had lost a substantial amount of weight but were still obese.

According to the researchers, one of these parts of the brain usually has reduced levels of metabolism in Alzheimer's disease, but has higher levels of metabolism in young people with a genetically increased risk of Alzheimer's disease before the levels then reduce. But they did not test any of the women for this genetic risk factor (apolipoprotein E type 4 allele).

The study also only followed the women for six months. This means it was not able to show what happened to activity in this area over a longer period of time, or whether any of the women would go on to develop Alzheimer's disease.

Overall, this study cannot show that the increased level of activity was associated with an increased risk of dementia, or that the reduction of activity after the women lost weight would change their risk.

There were improvements in the time it took the obese women to complete half of one of the six neuropsychological tests after the surgery and weight loss, but this cannot be attributed solely to weight loss. It could be that the women were quicker simply because they had done the test before and remembered how to do it.

The normal-weight women were only tested once, and there was no randomised control group of severely obese women who did not have surgery. Therefore, there was no group that allowed the researchers to compare whether completing the test for a second time would be faster, even without weight loss. There was also no difference in the women's ability to complete the other part of this test, or in the other five tests.

Further limitations of the study include:

  • the small number of participants
  • all the participants were women, so the results may not be applicable to men
  • this was a select group of severely obese women with an average BMI of 50kg/m², so may not apply to women with other levels of obesity – a normal weight is between 19 and 25kg/m², obesity is considered for those over 30kg/m² and severe obesity for those over 40kg/m²
  • it is not clear what gynaecological conditions the control women had and whether this could have affected the results
  • there is no information about any other potential confounding factors that could have influenced the results, including other medical conditions, lifestyle factors such as smoking or alcohol use, or a family history of dementia

In conclusion, this study does not show that weight loss surgery reduces the risk of dementia. Despite this, the study does provide further evidence of the benefits of this type of surgery, including weight loss and improvements in insulin resistance, which would reduce the risk of diabetes.

Weight loss surgery should only be considered as a last resort. Many people can achieve significant weight loss through reducing their calorie intake and by taking regular exercise. This also has the added bonus of eliminating the risks of complications and after effects of surgery, such as excess skin.

For more information on losing weight, download the NHS Choices weight loss plan.

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

Links To The Headlines

Weight loss surgery 'reduces chance of Alzheimer's Disease'. The Daily Telegraph, August 26 2014

Weight-loss surgery can boost brain power and 'cut the risk of developing Alzheimer's'. Mail Online, August 26 2014

Links To Science

Marques EL, Halpern A, Mancini MC, et al. Changes in Neuropsychological Tests and Brain Metabolism After Bariatric Surgery (PDF, 443kb). The Journal of Clinical Endocrinology and Metabolism. Published online August 26 2014

Categories: NHS Choices

Antidepressant use in pregnancy linked to ADHD

NHS Choices - Behind the Headlines - Wed, 27/08/2014 - 01:00

“Pregnant women who take anti-depressants 'could raise their child's risk of ADHD',” reports the Mail Online, saying that this could explain “the rise in children with short attention spans”.

The study in question compared children with attention deficit hyperactivity disorder (ADHD) or autistic spectrum disorders (ASD) with children without these conditions. It found that children with ADHD, but not those with ASD, were more likely to have had mothers who took antidepressants during pregnancy. 

The main limitation to this study is that there is no certainty the antidepressants were having an effect, or whether other factors were at play. The researchers did try to take factors such as the mother’s depression itself into account, but acknowledge that other factors may have affected the findings. The fact that the link was no longer significant once the severity of women’s psychiatric illness was taking into account adds weight to the suggestion that other factors were involved.

While medications, including antidepressants, are generally avoided in pregnancy, the benefits of taking them may outweigh potential risks in some circumstances. Depression is a serious condition, which can have serious consequences if left untreated during pregnancy.

If you are taking antidepressants and are pregnant or planning to get pregnant, talk to your doctor. However, you should not stop taking your medicines unless advised to do so by your doctor.

 

Where did the story come from?

The study was carried out by researchers from Massachusetts General Hospital and other healthcare and research institutes in the US. It was funded by the US National Institute for Mental Health Research. Some of the authors declared receiving consulting fees or research support, having equity holdings or being on scientific advisory boards for various pharmaceutical companies. The study was published in the peer-reviewed medical journal Molecular Psychiatry.

The study was covered reasonably by the Mail, which highlighted early on in its story that any risk of taking antidepressants needed to be balanced against the risk of not treating a woman’s depression. It also very sensibly reported on current guidance from the National Institute for Health and Care Excellence (NICE) on when antidepressants should be used in pregnancy.

 

What kind of research was this?

This was a case-control study looking at whether exposure of a foetus to antidepressants in the womb might increase the risk of the child having ASD or ADHD in childhood. The researchers report that some previous studies have found a link, while others have not.

It would be unethical for researchers to randomly assign pregnant women with depression to receive or not receive antidepressants just to assess potential harms to the baby. Therefore, this type of study (called an observational study) is the most feasible way of investigating these links. The limitation to this type of study, however, is that factors other than antidepressants could be causing the link seen. For example, the depression itself might have an effect, or genetic factors contributing to the woman’s depression might also increase the child’s risk of ASD or ADHD. The researchers took measures to try and take some factors into account, particularly that ADHD and ASD might be associated with maternal depression itself. However, their effect may not be removed completely.

 

What did the research involve?

The researchers used data routinely collected from one healthcare group in the US. They identified children diagnosed with ADHD or ASD (cases), and compared them with similar children who did not have these conditions (controls). They looked at whether the mothers of children with these conditions were more likely to have taken antidepressants during their pregnancies. If this was the case, this would suggest that the antidepressant use might be linked to an increased risk of these conditions.

The researchers identified cases diagnosed between 1997 and 2010, among children aged from two to 19, who had been delivered at the three hospitals that were part of the healthcare group. For each case child, they identified three “control” children, who were:

  • not diagnosed with ADHD, ASD or an intellectual disability
  • born in the same year, ideally, or within three years if not enough controls could be found
  • born at the same hospital
  • born at the same term – either full-term or preterm (premature)
  • of the same sex
  • of the same race/ethnicity
  • of the same health insurance type (this acted as an indicator of socioeconomic status)

Children for whom no matching controls could be identified were excluded, but those with only one or two matched controls were included. The researchers ended up with 1,377 children with ASD, 2,243 children with ADHD and 9,653 healthy control children for analysis.

The children’s mothers were also identified from the healthcare database and birth certificate data. They identified whether the mothers had been prescribed antidepressants:

  • at any time before pregnancy
  • in the three months before conceiving the child
  • at any time during pregnancy (also broken down into first, second or third trimester prescriptions)

They also identified how long the prescription lasted (how many days’ worth of antidepressants the woman was prescribed).

The researchers then analysed whether prenatal antidepressant use was more or less common in mothers of cases or controls. These analyses took into account the factors that the children were matched for (such as gender and race) as well as maternal age and household income.

They also took into account whether the mother had been diagnosed with depression, looked at the effects of different types of antidepressant, an indicator of how severe the woman’s illness was (assessed by how much treatment she received and presence of other psychiatric diagnoses) – and exposure to two types of non-antidepressant medication (one drug to prevent vomiting that affected serotonin levels – something that some antidepressants also do – and any antipsychotics).

 

What were the basic results?

Maternal depression was associated with increased risk of ASD and ADHD in adjusted analyses.

Between 3% and 6.6% (approximately) of children with ADHD or ASD had mothers who had taken antidepressants either before pregnancy or during pregnancy, compared to 1% to 3.5% (approximately) of control children.

Before taking into account other factors, taking antidepressants before pregnancy or during pregnancy was associated with an increased risk of ASD and ADHD. After taking into account factors including maternal depression, taking antidepressants before pregnancy was associated with an increase in the odds of ASD (odds ratio (OR) 1.62, 95% confidence interval (CI) 1.17 to 2.23), but not of ADHD (OR 1.18, 95% CI 0.86 to 1.61). Taking antidepressants during pregnancy was associated with an increase in the odds of ADHD (OR 1.81, 95% CI 1.22 to 2.70) but not of ASD (OR 1.10, 95% CI 0.70 to 1.70).

The researchers found that if they took into account measures of how severe the woman’s illness was (how much treatment she was receiving, and whether she had other psychiatric conditions), the link between antidepressant exposure during pregnancy and ADHD was no longer statistically significant.

The researchers found no link between the anti-vomiting drug and ASD or ADHD risk, while there was a suggestion of a link between maternal antipsychotic use during pregnancy and ASD, but not ADHD.

 

How did the researchers interpret the results?

The researchers concluded that the association between maternal prenatal antidepressant use and ASDs in the children was probably due to the depression itself, rather than antidepressant use.

Maternal prenatal antidepressant use did appear to be associated with a modest increase in ADHD in the child, although this may still be due to other factors rather than the antidepressants themselves, they said. The researchers note that this potential risk needs to be weighed up against the considerable consequences of not treating the mother’s depression.

 

Conclusion

This study suggests a potential link between women taking antidepressants during pregnancy and an increased risk of ADHD, but not ASDs, in their children. The limitation to this type of study is that factors other than the antidepressants, such as the depression itself, or genetic factors increasing both depression and ADHD risk, might be causing the effect seen.

The researchers used various methods to take this into account, but acknowledge that other factors could still be having an effect. While the link with ADHD remained significant after taking maternal depression into account, it did not remain significant after taking into account measures of how severe the woman’s illness was.

Other limitations to the study include the following:

  • It could only assess what prescriptions the mothers received, and not whether they took them.
  • It could not directly assess how severe a woman’s illness was; they had to rely on data that was routinely collected on the types of treatment she was receiving and her previous diagnoses. This is unlikely to capture severity as well as a more direct assessment could.
  • If children or mothers were diagnosed or treated outside of the healthcare grouping being assessed, this information would not be available to the researchers, and this could affect results.

It is important to know that no one factor is likely to cause ADHD or ASD. These conditions are complex, and we are not yet entirely sure what causes the majority of cases. Both genetic and non-genetic (known as “environmental”) factors are thought to potentially play a part.

Medications are used sparingly in pregnancy to reduce any risk of harm to the developing foetus. However, if a woman’s condition could have serious consequences if untreated, then the woman and their doctor may decide that the benefits outweigh the harms.

NICE has guidance on how to treat depression if planning a pregnancy and during pregnancy and breastfeeding. In general, it recommends considering alternatives to antidepressant treatment, and considering doctor-supervised withdrawal of antidepressants for women already taking them. However, under certain circumstances it advises considering antidepressant treatment, such as if the women has not responded to non-drug therapies. 

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

Links To The Headlines

Pregnant women who take anti-depressants 'could raise their child's risk of ADHD'. Mail Online, August 26 2014

Links To Science

Clements CC, Castro VM, Blumenthal SR, et al. Prenatal antidepressant exposure is associated with risk for attention-deficit hyperactivity disorder but not autism spectrum disorder in a large health system. Molecular Psychiatry. Published online August 26 2014

Categories: NHS Choices

Common bacteria could help prevent food allergies

NHS Choices - Behind the Headlines - Tue, 26/08/2014 - 13:00

"Bacteria which naturally live inside our digestive system can help prevent allergies and may become a source of treatment," BBC News reports after new research found evidence that Clostridia bacteria helps prevent peanut allergies in mice.

The study in question showed that mice lacking normal gut bacteria showed increased allergic responses when they were given peanut extracts.

The researchers then tested the effects of recolonising the mice's guts with specific groups of bacteria. They found that giving Clostridia bacteria (a group of bacteria that includes the "superbug" Clostridium difficile) reduced the allergic response.

The researchers hope the findings could one day support the development of new approaches to prevent or treat food allergies using probiotic treatments.

These are promising findings, but they are in the very early stages. Only mice have so far been studied, with a specific focus on peanut allergy and Clostridia bacteria. Further study developments from this animal research are awaited.

 

Where did the story come from?

This study was conducted by researchers from the University of Chicago, Northwestern University, the California Institute of Technology and Argonne National Laboratory in the US, and the University of Bern in Switzerland.

Funding was provided by Food Allergy Research and Education (FARE), US National Institutes of Health Grants, the University of Chicago Digestive Diseases Research Core Center, and a donation from the Bunning family.

It was published in the peer-reviewed journal PNAS.

BBC News gave a balanced account of this research.

 

What kind of research was this?

This was an animal study that aimed to see how alterations in gut bacteria are associated with food allergies.

As the researchers say, life-threatening anaphylactic reactions to food allergens (any substance that generates an allergic response) are an important concern, and the prevalence of food allergies appears to have been rising over a short space of time.

This has caused speculation about whether alterations in our environment could be driving allergic sensitivity to foods. One such theory is the "hygiene hypothesis" (discussed above).

This is the theory that reducing our exposure to infectious microbes during our early years – through overzealous sanitisation, for example – deprives people's immune systems of the "stimulation" of exposure, which could then lead to allergic disease. 

An extension of this theory is that environmental factors – including sanitation, but also increased use of antibiotics and vaccination – have altered the composition of natural gut bacteria, which play a role in regulating our sensitivity to allergens. It has been suggested that infants who have altered natural gut bacteria could be more sensitive to allergens.

This mouse study aimed to examine the role of gut bacteria in sensitivity to food allergens, with a focus on peanut allergy.

 

What did the research involve?

The researchers investigated the role gut bacteria plays in sensitivity to food allergens in different groups of mice. The research team studied mice born and raised in a completely sterile, bacteria-free environment so they were germ free.

Another group of mice were treated with a mixture of strong antibiotics from two weeks of age to severely reduce the variety and number of bacteria in their gut.

These groups of mice were then given purified extracts of roasted unsalted peanuts to assess their allergic response.

After looking at the allergic reactions in the germ-free and antibiotic-treated mice, specific groups of bacteria were reintroduced into their gut to see what, if any, effect it had on their allergic response.

The researchers focused on reintroducing Bacteroides and Clostridia groups of bacteria, which are normally present in mice in the wild.

 

What were the basic results?

Faecal samples taken from the antibiotic mice were found to have a significantly reduced number and variety of gut bacteria. These mice also had increased sensitivity to peanut allergens, demonstrating an increased immune system response that produced antibodies specific to these allergens, as well as showing symptoms of allergy.  

When the germ-free mice were exposed to peanut allergens, they demonstrated a greater immune response than normal mice and also demonstrated features of an anaphylactic reaction.

The researchers found that adding Bacteroides to the gut of the germ-free mice had no effect on the allergic reaction. However, adding Clostridia bacteria reduced sensitivity to the peanut allergen, making their allergic response similar to normal mice.

This suggests that Clostridia plays a role in protecting against sensitisation to food allergens.

This was further confirmed when Clostridia was used to recolonise the guts of the antibiotics mice and was found to reduce their allergic response.

The researchers then carried out further laboratory experiments looking at the process by which Clostridia could be offering protection. They found the bacteria increases the immune defenses of the cells lining the gut.

One specific effect seen was how Clostridia increased the activity of a particular antibody, which reduced the amount of peanut allergen entering the bloodstream by making the gut lining less permeable (so substances are less likely to pass through it).

 

How did the researchers interpret the results?

The researchers concluded that they have identified a "bacterial community" that protects against sensitisation to allergens and have demonstrated the mechanisms by which these bacteria regulate the permeability of the gut lining to food allergens.

They suggest their findings support the development of new approaches for the prevention and treatment of food allergy by using probiotic therapies to modulate the composition of the gut bacteria, and so help induce tolerance to dietary allergens.

 

Conclusion

This research examined how normal populations of gut bacteria influence mouse susceptibility to peanut allergens. The findings suggest the Clostridia group of bacteria may have a particular role in altering the immune defenses of the gut lining and preventing some of the food allergen entering the bloodstream.

The findings inform the theory that our increasingly sterile environments and increased use of antibiotics could lead to a reduction in our normal gut bacteria, which could possibly lead to people developing a sensitivity to allergens.

But these findings are in the very early stages. So far, only mice have been studied, and only their reactions to peanuts. We don't know whether similar results would be seen with other tree nuts or other foods that can cause an allergic response.

Also, although this research provides a theory, we do not know whether this theory is correct. We don't know, for example, whether people with a peanut allergy do (or did) have reduced levels of certain gut bacteria populations and whether this contributed to the development of their allergy. We also do not know whether treatments that reintroduce these bacteria could help reduce the allergy.

As the researchers say, the study does open an avenue of further study into the possible development of probiotic treatments, but there is a long way to go. 

Professor Colin Hill, a microbiologist at University College Cork, was quoted by the BBC as saying: "It is a very exciting paper and puts this theory on a much sounder scientific basis."

But he does offer due caution, saying: "We have to be careful not to extrapolate too far from a single study, and we also have to bear in mind that germ-free mice are a long way from humans."

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

Links To Science

Gut bugs 'help prevent allergies'. BBC News, August 26 2014

Probiotics may help prevent peanut allergies, animal study shows. Fox News, August 26 2014

Categories: NHS Choices

Breakfast 'not the most important meal of the day'

NHS Choices - Behind the Headlines - Tue, 26/08/2014 - 01:00

"Breakfast might not be the most important meal of the day after all,” the Mail Online reports.

The concept that breakfast is the most important meal of the day is up there in the pantheon of received wisdom with “never swim after eating” or “getting wet will give you a cold”. But is there any hard evidence to back the claim?

A new study in 38 people found that six weeks of regularly eating breakfast had no significant effect on metabolism or eating patterns for the rest of the day compared to total fasting before midday.

It also found no difference between the groups at the end of the study in body mass, fat mass, or indicators of cardiovascular health (such as cholesterol or inflammatory markers).

There are various important limitations to this trial though, including the small sample size and short follow-up time. For example, people who fasted had much more variable blood sugar levels in the afternoon and evening, and we do not know what the longer-term effects of this could be.

Overall, based on this study alone, we would not recommend completely starving your body of all nutrition before 12pm each day, not least because not eating something in the morning may not make you feel very happy or energetic, if nothing else. 

 

Where did the story come from?

The study was carried out by researchers from the University of Bath and published in the peer-reviewed American Journal of Clinical Nutrition. The study has been published on an open-access basis, so is available for free online. The work was funded by a grant from the Biotechnology and Biological Sciences Research Council. The authors declare no conflicts of interest.

In concluding that breakfast is not the most important meal of the day, the Mail does not consider the various limitations of this very small study.

 

What kind of research was this?

This was a randomised controlled trial looking at how breakfast habits were associated with energy balance in the rest of the day in people living their normal daily life.

As the researchers say, it is the popular belief that “breakfast is the most important meal of the day”. But this assumption is only grounded in cross-sectional studies observing that eating breakfast is associated with reduced risk of weight gain and certain chronic diseases (such as diabetes and cardiovascular disease). However, this does not prove cause and effect. The researchers also note that such observational studies do not take into account the fact that people who eat breakfast also tend to be more physically active, eat less fat, be non-smokers and moderate drinkers, opening up the possibility of confounding factors.

So it could be the case that rather than regularly eating breakfast making you healthy, healthy people are more likely to eat breakfast.

The researchers say that though breakfast is said to influence metabolism, studies have lacked measurement tools capable of accurately measuring this during normal daily activities. This study aimed to get a better indication of this by measuring all aspects of energy balance, including the heat generated during physical activity, and in-depth laboratory tests (including blood tests and DEXA scan of bone mineral density).

Ultimately, they wanted to find out whether eating breakfast was a cause of good health or whether it was simply a sign of an already healthy lifestyle.

 

What did the research involve?

The research was given the title the “Bath Breakfast Project”. It included a six-week trial where 38 people (of 137 invited to participate) were randomised to eat a daily breakfast (18) or to extended morning fasting (20).

Adults between the ages of 21 and 60 were eligible for the trial if they were either normal weight (20 to 25kg/m2) or overweight (25 to 30kg/m2). Each of the two randomised groups were intended to include an even balance of normal and overweight participants, and of people who frequently and infrequently ate breakfast. This was done to allow a stratified (representative) analysis based on these two factors. 

Before the trial, participants came to the laboratory to have baseline measurements taken. This included blood tests to look at hormones, metabolites and blood fats, assessments of metabolic rate, and body mass and fat mass measurements. A small tissue sample was also taken to look at key genes related to appetite and physical activity. 

The breakfast group were told to eat 3,000kJ (around 720 calories – or around two bacon sandwiches) of energy prior to 11am, with half of this provided within two hours of waking. The breakfasts were self-selected by the participants, though they were said to be provided with detailed examples of the foods that would give the appropriate energy intake. The extended morning fasting group could drink only water before 12pm each day.

During the first and last weeks of the six-week trial, participants kept detailed records of their food and fluid intakes for later analysis of daily energy and macronutrient intake. During these two weeks, they were also fitted with a combined heart rate/accelerometer to accurately record energy expenditure/physical activity habits for the entire duration of each of these seven-day periods. A glucose monitor was also fitted under the skin.

They were told when these devices were fitted: “Your lifestyle choices during this free-living monitoring period are central to this study. We are interested in any natural changes in your diet and/or physical activity habits, which you may or may not make in response to the intervention. This monitoring period has been carefully scheduled to avoid any pre-planned changes in these habits, such as a holiday or diet/exercise plan. You should inform us immediately if unforeseen factors external to the study may influence your lifestyle.”

After the six weeks of the trial, the participants returned to the laboratory for repeat body measurements.

 

What were the basic results?

The study reports data for the 33 people who completed the trial, 16 in the breakfast group and 17 in the fasting group. These people were of average age 36, and 79% of them regularly ate breakfast. These were described to be a “lean” group of people – 21 women with a DEXA fat mass index of 11 kg/m2 or less, and 12 men with a fat mass index of 7.5 kg/m2 or less (DEXA fat mass index is assessed using X-rays to give a very precise measurement of body fat).

The researchers found that compared to the fasting group those in the breakfast group generated significantly more heat energy during physical activity before 12pm, and also engaged in more physical activity, in particular more “light” physical activity. Resting metabolic rate was stable between the groups, and there was no subsequent suppression of appetite in the breakfast group (energy intake remained 539 kcal/d greater than the fasting group throughout the day).

There was no difference in waking or sleeping times, and at the end of the study there were no differences between groups in body mass or fat mass, body hormones, cholesterol or inflammatory markers. There was no difference between groups in fasting blood sugar or insulin at six weeks, but during continuous sugar monitoring in the last week of the trial the fasting group demonstrated more variability in their afternoon and evening sugar measures.

 

How did the researchers interpret the results?

The researchers conclude that “Daily breakfast is causally linked to higher physical activity thermogenesis [heat generation] in lean adults, with greater overall dietary energy intake, but no change in resting metabolism. Cardiovascular health indexes were unaffected by either of the treatments, but breakfast maintained more stable afternoon and evening glycemia [glucose control] than did fasting”.

 

Conclusion

This trial aimed to measure the direct effect that eating breakfast or fasting before 12am has on energy balance and indicators of cardiovascular health in people living their normal daily lives. The trail has been carefully designed study and has taken extensive body measurements to try and measure the direct effects of breakfast or fasting upon the body. However, there are limitations to bear in mind:

  • This was a small sample size. The target sample size for the trial for it to have statistical power to reliably detect differences between the group had been 70 people – 30 in each group – with the aim that more than 60 people would be included in their final analyses. The study actually only had half the intended amount of participants – recruiting 38, with just 33 completing the trial. This means we can’t be sure whether the lack of difference between the groups is real, or was caused by the study being underpowered to detect any such differences.
  • The intervention was intended to apply “under free-living conditions” where all lifestyle choices were allowed to vary naturally. However, it is difficult to gauge how accurately people did comply with their allocated interventions. Compliance was said to be confirmed via self-report and verified via continuous glucose monitoring; however, this only apparently happened during the first and sixth weeks of the trial. It is unclear whether compliance would have been accurately measured during the intervening weeks.
  • The study only measures the effect of a very specific intervention of eating 3,000KJ for breakfast, or eating absolutely nothing at all, except for water before 12pm. This total fasting example is quite extreme, and its effects have only been measured over six weeks. We don’t know what the longer-term effects upon health would be. For example, the study did find that people who fasted had much more variable blood glucose control in the afternoon, and we don’t know what the longer-term effects of this pattern would be.
  • The study has also not measured the wider effects upon general feelings of wellbeing, emotions, concentration, lethargy, etc, that fasting may have. Participants in the fasting group were observed to do less physical activity in the morning, and this may have been an indicator of them feeling that they had less energy.
  • Study of different timings of breakfast, or different compositions (e.g. of carbohydrate, protein or fat) or different total calories, may be more beneficial for future study than the comparison of this 3,000KJ breakfast or total fast before 12pm studied here.

Overall, this study does not settle the debate on whether breakfast is the most important meal of the day, because it may have been underpowered to detect true differences and was quite narrow in its scope. Dr Betts, a senior lecturer in nutrition, metabolism and statistics, told the Mail Online that “It is certainly true that people who regularly eat breakfast tend to be slimmer and healthier, but these individuals also typically follow most other recommendations for a healthy lifestyle, so have more balanced diets and take more physical exercise." 

In normal life situations, breakfast does therefore seem to be linked to health in some way, though direct cause and effect is difficult to apply, due to the influence of other health and lifestyle factors in relationship. However, this study does not provide many more answers of whether we should eat breakfast, or what type of breakfast we should eat.

However, based on this study alone we would not recommend missing breakfast, not least because it may have a negative impact on your mood; you could spend all morning feeling “hangry”.

If you have slipped into the habit of skipping breakfast, then it is never too late to break the habit.

Read about five breakfast recipes specifically designed for people who hate eating breakfast.

Analysis by Bazian. Edited by NHS Choices.
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Links To The Headlines

Breakfast might NOT be the most important meal of the day after all: Scientists find it doesn't speed up the metabolism or aid weight loss. Mail Online, August 25 2014

Links To Science

Betts JA, Richardson JD, Chowdhury EA, et al. The causal role of breakfast in energy balance and health: a randomized controlled trial in lean adults. The American Journal of Clinical Nutrition. Published online June 4 2014

Categories: NHS Choices

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