NHS Choices

"Hungry shoppers 'buy more calories'," BBC News reports in a story based on a very small short-term study. The somewhat artificial study examined the effects of people skipping meals due to everything from busy lifestyles to intermittent diets such as the 5:2 diet.

These intentional or unintentional fasts may lead to unhealthy food choices being made at the shops. This research looked at whether being deprived of food for just a few hours has an effect on the types of food people opt for.

During a simulated shopping experience, the researchers found that people who were hungry selected more high-calorie foods than people who had just eaten a snack.

Similarly, people who went food shopping during times of the day when the researchers expected them to be hungry (late afternoon) purchased more high-calorie foods than people who shopped when the researchers thought they were less likely to be hungry (early afternoon).

However, no definitive conclusions can be drawn from these findings. The research had many limitations, including the fact that the first study was laboratory-based and laboratory findings may not reflect the real world. 

But it is common sense to grab a bite to eat before heading to the shops, and might be worth a try if you do find that shopping when hungry means you make less healthy food choices.

 

Where did the story come from?

The study was carried out by researchers from Cornell University in the US and was funded by the university. It was published in the peer-reviewed Journal of the American Medical Association (JAMA) Internal Medicine.

The BBC covered the study well, if slightly uncritically, as the study's limitations were not discussed.

 

What kind of research was this?

This research included two components (a laboratory study and a field study) designed to determine whether short-term food deprivation changes affect food shopping habits.

The researchers say that food deprivation has been shown to change how much food people buy, and fasting is known to alter how the brain reacts to certain foods. They were interested to know whether shopping while hungry also effects the types of food people purchase.

Laboratory and field studies can provide interesting information about how people may react in given situations, but they are prone to bias and confounding. These potential limitations should be kept in mind when considering the results of the study.

 

What did the research involve?

In the first part of the study, the researchers recruited 68 paid participants with ages ranging from 18 to 62 years. They were asked to avoid eating for five hours prior to the start of the experiment.

The participants were grouped together in sessions of six to 12 people. In half of these sessions, a plate of crackers was offered at the beginning of the experiment and participants were asked to eat enough of the crackers so that they were not hungry. The participants were not offered any food in the remaining sessions.

The groups then completed an experiment meant to simulate buying groceries online. The online store offered a mix of lower calorie foods (including fruits, vegetables and chicken breasts) and higher calorie foods (including sweets, salty snacks and red meat). The products were displayed without prices. The researchers recorded and compared the food choices of individuals who did not eat prior to the study with those who had been offered a snack.

The second study involved the observation of individuals in a more natural setting. The researchers tracked the food purchases of 82 people.

The first group were tracked during the early afternoon, or "low hunger hours" (between 13:00 and 16:00), when the researchers expected them to have had lunch and therefore not be hungry.

The second group was tracked during the early evening, or "high hunger hours" (16:00 to 19:00), when researchers thought they would have gone several hours without a meal.

The researchers characterised the food purchases as either high-calorie or low-calorie, and compared the number of foods that fell into each category between the two participant groups.

They statistically compared the number of low-calorie items, the number of high-calorie items, and the ratio of low- to high-calorie purchases between the groups.

 

What were the basic results?

The researchers found that participants in the hungry and not-hungry groups of the laboratory study chose a similar number of total items (approximately 14 in the hungry group versus 12 in the not-hungry group).

The two groups also chose similar numbers of low-calorie foods (approximately eight in both groups), but the hungry group selected significantly more high-calorie items (an average of nearly six, compared with four in the not-hungry group).

During the field study, the researchers found that participants in the evening group purchased fewer low-calorie items (approximately eight items) than the afternoon group (approximate average of 11 items). There was no statistical difference in the number of high-calorie foods purchased (approximately four in both groups).

The ratio of low- to high-calorie items (with a higher ratio indicating better food choices overall) was significantly higher in the early afternoon group (approximately four low-calorie items per each high calorie item) compared with the evening group (approximately 2.5 low-calorie items per each high-calorie choice).

 

How did the researchers interpret the results?

The researchers concluded that, "even short-term fasts can lead people to make more unhealthy food choices" by picking fewer low-calorie foods.

 

Conclusion

This study suggests that how hungry you are when you shop for food can have an impact on the food you choose.

This may not be too surprising for anyone who has made a quick trip to the shops while hungry and found themselves at the till with a basket full of crisps and biscuits, but no fruit or vegetables.

While interesting, the study has some limitations that should be noted:

• Both experiments were fairly small, with less than 100 people in each.
• A laboratory-based study such as the first experiment tends to be stronger the more it mimics the real world. A simulated online grocery shopping experience that removes item price as a contributing factor is less likely to mirror real-life decision making.
• The field study makes assumptions about hunger levels based on the time of day. This may not be a reliable manner in which to assess hunger – for instance, individuals shopping during the "low hunger hours" of 13:00 to 16:00 may have skipped lunch, while individuals in the "high hunger hours" may have had a late lunch, a snack, or an early dinner.
• Field studies are prone to confounding due to difficulties measuring and controlling for different factors that may also have an influence. It is not reported how the afternoon and evening shoppers differed, and it is possible that the relationship between the time of day and shopping choices was influenced by different participant characteristics, such as age, employment, education, or socioeconomic status, and not by hunger.

The researchers say that short-term fasting is fairly common and can arise from skipping a meal, either intentionally as part of a religious fast or in an effort to lose weight, or unintentionally due to chaotic work schedules.

However, given that it is pretty easy and low-risk to grab a snack before heading out to the supermarket, this may seem like a sensible thing to do – it may have the benefit of subtly changing the foods you buy and consume throughout the week.

If you are trying to lose weight or eat a healthier diet, it may be a good idea to plan your shopping in advance. Options include using an online grocery site or, for a more low-tech equivalent, a good old-fashioned shopping list.

The NHS Choices 5 A DAY meal planner can also help you plan your weekly shop.

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter.

Links To The Headlines

Hungry shoppers 'buy more calories'. BBC News, May 6 2013

Links To Science

Tal A, Wansink B. Fattening Fasting: Hungry Grocery Shoppers Buy More Calories, Not More Food. JAMA Internal Medicine. Published online May 6 2013

“Cure for grey hair is on its way say scientists,” the Daily Mirror reports, with The Daily Telegraph adding that grey hair will become ‘a thing of the past’.

You may be surprised to learn that the study the media reports on had absolutely nothing to do with grey hair. In fact, the stories were loosely based on a tiny study into what happens in a common skin condition called vitiligo. Vitiligo causes depigmentation (loss of colour) of the skin, leading to white patches on the skin and hair.

The current study included 10 people with what is called ‘segmental’ vitiligo, where the condition affects the area of skin supplied by a particular nerve. They found that changes in skin colour were accompanied by the accumulation of two chemicals in the skin: hydrogen peroxide and peroxynitrite.

The researchers then demonstrated that using a compound that when exposed to ultraviolet light was known to reduce hydrogen peroxide levels led to white patches on skin and eyelashes becoming repigmented.

While the results of the study could theoretically be extrapolated as providing a potential treatment for grey hair, much more research is required to see if such a treatment would be both safe and effective.

This study does offers possible hope of a treatment for segmental vitiligo though, again, further research is required.

 

Where did the story come from?

The study was carried out by researchers from E. M. Arndt University, Germany and the University of Bradford, UK. It was funded by the American Vitiligo Research Foundation and by private donations.

The study was published in the peer-reviewed Federation of American Societies for Experimental Biology (FASEB) journal.

This story was poorly reported in the media, with all headlines speculating that the findings could lead to a cure for grey hair. The current study did not investigate the causes of, or possible treatments of, grey hair. However, the research focused on vitiligo, specifically looking at segmental vitiligo.

Though the blame for the poor reporting of the study can be put at the door of the press office of the FASEB, which issued a press release almost entirely focused on the grey hair angle. This is a textbook example of public relations officers ‘sexing up’ a dry but worthy piece of research in order to gain maximum media coverage. And – credit where credit is due – they did an excellent job of that. Unfortunately, in doing so they obscured the truth.

Whether peer-reviewed journals should be engaging in these types of disingenuous practises, which arguably damage the public understanding of science, is a matter of debate. However, FASEB are not alone in this, as recent research found that academics, journals and news reporters all share the blame for the spin found in around half of all medical reporting.

 

What kind of research was this?

This was a laboratory study and case series report into the mechanics of the skin condition vitiligo and whether learning more about it could lead to new treatments.

Vitiligo can be divided into two forms: segmental and nonsegmental vitiligo. Nonsegmental vitiligo is the more common, in which the white patches that appear are symmetrical (the same places on both sides of the body, for example both hands could be affected). In nonsegmental vitiligo, two chemicals – hydrogen peroxide and peroxynitrite – accumulate in the skin.

Nonsegmental vitiligo can be treated with a pseudocatalase, which is activated by narrow-band UVB light. This reduces the concentrations of hydrogen peroxide, allowing the lost skin colour to return.

In the less common segmental form of vitiligo, the affected skin lies in a dermatome, which is a particular area of skin supplied by a single nerve, so it usually affects only one side of the body.

Segmental and non-segmental vitiligo can also co-exist, giving rise to ‘mixed’ vitiligo.

This study aimed to see whether the accumulation of hydrogen peroxide and peroxynitrite which occurs in nonsegmental vitiligo also occurs in segmental vitiligo, and if so, if the light activated pseudocatalase could also be of use in segmental vitiligo.

The laboratory study is the ideal study design to investigate the mechanism behind segmental vitiligo. However, the treatment was only tested in a very small number of people with vitiligo. Well-conducted trials involving much larger numbers of people are needed before it can be determined how effective it is.

 

What did the research involve?

The researchers looked to see whether hydrogen peroxide and peroxynitrite (and the oxidation products produced when these chemicals react with other molecules in the cell) are present in the skin of people with segmental vitiligo. To do this they examined four people with segmental vitiligo and six people with mixed vitiligo (where the person has both segmental vitiligo and nonsegmental vitiligo). For comparison, they selected five healthy controls matched for age and skin type.

The researchers then determined whether treatment with narrow-band UVB activated pseudocatalase, which reduces the levels of hydrogen peroxide, could allow repigmentation.

 

What were the basic results?

The researchers found that hydrogen peroxide and peroxynitrite (and substances that are formed by reactions of these chemicals with molecules in the cell), are present in the skin of people with segmental vitiligo.

The researchers report that treatment with narrow-band UVB activated pseudocatalase, which reduces the levels of hydrogen peroxide, allowed repigmentation of the skin and eyelashes of five people with vitiligo regardless of whether they had segmental vitiligo only, or in association with nonsegmental vitiligo.

 

How did the researchers interpret the results?

The researchers conclude that their findings, “offer new treatment intervention for lost skin and hair colour”.

 

Conclusion

This study aimed to investigate whether two chemicals – hydrogen peroxide and peroxynitrite – accumulate in the skin of people with segmental vitiligo, which affects up to a quarter of people with vitiligo.

They then looked at whether treatment with a light-activated pseudocatalase, that reduces the concentration of hydrogen peroxide, would allow the lost skin colour to return.

They found that the treatment was successful in five people with segmental vitiligo (either isolated or in combination with nonsegmental). The study offers hope of a possible treatment for segmental vitiligo, although so far it has been tested in only very few patients.

Well-conducted trials in much larger numbers of people will be needed before it can be determined how effective it is.

Although previous research has demonstrated that hydrogen peroxidase also accumulates in grey hair follicles, this study did not look at whether treatment with pseudocatalases or other substances could be used to treat grey hair.

For this rather fundamental reason, it is not possible to say from this study whether or not there could be a cure for grey hair.

However, the potential market for an effective hair colouring treatment is huge: recent figures show that the hair dye market is essentially recession-proof. It would be surprising if this study did not lead to further research into the applications of the techniques used in the study.

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter.

Links To The Headlines

Cure for grey hair is on its way say scientists. Daily Mirror, May 7 2013

Grey hair 'a thing of the past' after scientists discover why follicles become discoloured. The Daily Telegraph, May 6 2013

Is this the end of costly dyes? Scientists working on cure for grey hair. The Independent, May 6 2013

Grey Hair Treatment Discovered By Scientists. Sky News, May 6 2013

 

Links To Science

Schallreuter KU, Salem MAEL, Holtz S, Panske A. Basic evidence for epidermal H2O2/ONOO−-mediated oxidation/nitration in segmental vitiligo is supported by repigmentation of skin and eyelashes after reduction of epidermal H2O2 with topical NB-UVB-activated pseudocatalase PC-KUS. The FASEB Journal. Published online April 29 2013

Much of the UK media are covering the release of data that indicates breast cancer rates in the under-50s are now at a record high. Changes in childbirth patterns and alcohol consumption could be to blame, according to a leading charity.

The news follows new data released by Cancer Research UK. Its data shows that breast cancer diagnoses among women aged under 50 have now reached an all-time high, breaking the 10,000 mark for the first time in 2010. One in five diagnosed breast cancer cases are now in women under the age of 50.

Possible explanations for the increases are speculated to be due to known hormonal risk factors for cancer – such as having children later in life. Increased alcohol intake, another risk factor for breast cancer, could also be involved.

The rise in the number of new cases is not restricted to the under-50s: there has been a steady increase in the number of cases diagnosed for women of all ages since the 1970s.

But the rise isn’t necessarily as bad as it sounds. For example it could reflect better breast awareness and improved diagnosis and screening, which in turn might lead to early treatment and improved chances of survival.

The good news is that – despite the increase in breast cancer diagnoses – breast cancer deaths are actually falling. An increasing number of women are now survivors of breast cancer.

 

What does the data show?

Breast cancer is the most common cancer among women, accounting for almost a third of all new cancer cases in women. Cancer Research UK reports how their latest statistics revealed that in 2010, there were 10,000 new cases diagnosed among women aged under 50. This is an 11% increase from 15 years previously in 1995 when there were 7,700 cases of breast cancer diagnosed among women in this age group.

One in five breast cancers (20%) are now diagnosed in women aged under 50. Nearly half of breast cancers (48%) are diagnosed in women aged between 50 and 69 – the age group currently invited for breast cancer screening.

However, the rise in the number of breast cancer cases is not restricted to the under-50s. Since the 1970s there has been a gradual and steady increase in the number of breast cancer cases. Overall there was an 18% increase in rates between 1995 and 2010.

 

What are the possible reasons behind the increased rates among younger women?

Cancer Research UK says that, though it is not clear why cases of breast cancer are increasing among younger women, alcohol intake and hormonal factors may play a role.

Alcohol

Alcohol is an established risk factor for breast cancer. Cancer Research UK reports that the combined results of two large systematic reviews of the published evidence, in addition to findings from the UK Million Women Study, suggest that each additional unit of alcohol per day can increase a woman’s risk of the disease by between 7% and 12%. The research suggests that by the age of 80, roughly the following number of women will have developed breast cancer:

• 9 out of 100 if they don't drink at all
• 10 out of 100 if they have two drinks a day
• 13 out of 100 if they have six drinks a day

However, as Cancer Research UK does say, the possible risk increase from alcohol is less compared to the greater influence of other factors – particularly hormonal factors.

Hormonal factors

Very generally, increased exposure to the hormone oestrogen is associated with increased risk of breast cancer because it can stimulate breast cancer cells to grow. Higher lifetime oestrogen exposure is associated with:

• starting periods at a younger age
• going through the menopause at a later age
• use of the combined oral contraceptive pill (which contains oestrogen)
• fewer (or no) pregnancies
• shorter duration of (or no) breastfeeding
• use of HRT (which contains oestrogen)

Both having children and breastfeeding are known to be protective against breast cancer. In theory the younger a woman is when she has her first pregnancy, and the more pregnancies she has in her lifetime, further decreases her risk. Similarly, the more a woman breastfeeds will decrease her risk. Therefore, modern western lifestyles (that include women generally starting families later and having smaller families) may give some possible explanation to the increase in breast cancer rates among younger women.

 

Are there any positive signs?

Despite the increased rates among women overall and specifically among women aged under 50, Cancer Research UK does report some good news: that fewer women than ever before are now dying from breast cancer. This due to better treatment, the charity says.

The rate of women aged under 50 who are dying from breast cancer has fallen by 40% since the early 1990s. Twenty years ago, the death rate from breast cancer in the under-50s was 9 per 100,000 women in the UK.  By late 2000, this had fallen to 5 per 100,000 women. More than 8 in 10 women diagnosed with breast cancer before the age of 50 are now reported to survive the disease for at least five years.

Although not discussed by the Cancer Research UK report, the rise in cases could be a reflection of increased awareness of breast cancer and increased rates of diagnosis and improvement in screening techniques.

As a concluding message, Sara Hiom, Cancer Research UK’s director of health information, says: “Breast cancer is more common in older women, but these figures show that younger women are also at risk of developing the disease. Women of all ages who notice anything different about their breasts, including changes in size, shape or feel; a lump or thickening; nipple discharge or rash; dimpling, puckering or redness of the skin, should see their GP straight away, even if they have attended breast cancer screening.

“It’s more likely not to be cancer, but if it is, detecting it early gives the best chance of successful treatment,” she added.

 

What can I do to reduce my risk of breast cancer?

Unlike some other cancers, the body of evidence about proven methods of reducing risk is relatively small. Though most experts would recommend that:

• you stick to the recommended alcohol consumption rates for women
• you take plenty of exercise
• you maintain a healthy weight
• avoid smoking

It is also important that you attend breast cancer screening appointments when invited. Women aged 50 to 70, who are registered with a GP, are automatically invited for screening every three years.

Read more about the NHS Breast Screening Programme.

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter.

Links To The Headlines

Breast cancer cases in UK under-50s top 10,000 a year. BBC News. May 3 2013

Breast cancer rates increase among younger women. The Guardian, May 3 2013

Breast cancer cases soar to 27 a day among the under-50s... and experts fear modern lifestyles are to blame. Daily Mail, May 3 2013

Under-50s with breast cancer at record high. The Daily Telegraph, May 3 2013

Breast cancer on the rise in under 50s who now account for 1 in 5 cases. Daily Mirror, May 3 2013

Links To Science

Cancer Research UK. Breast cancer in women under 50 tops 10,000 cases for first time. May 3 2013

"Children brought up by two parents are more intelligent," is the baseless claim on the Mail Online website.

The headline fails to mention that the research the story is based on involved only mice. Not until eight paragraphs into the news story does the Mail reveal this crucial point.

The scientific study involved housing baby mice with either their mother only, with both 'parents' or with their mother and a matched female 'parent'. These baby mice were then subjected to a series of tests designed to assess their development. After the testing, researchers took tissue samples from the brains of the mice.

The researchers found that:

• male mice housed with two parents seemed to have better threat-recognition abilities than those who were raised by a single mouse mum
• female mice housed with two parents seemed to have better motor co-ordination
• being housed with two parents did seem to affect brain development, although the pattern of development differed between male and female mice

Interesting as this is, it is hard to see how it applies to human families. This study cannot be used to conclude that children raised by one parent will have behavioural differences from, or will be less intelligent than, those raised by two parents.

 

Where did the story come from?

The study was carried out by researchers from the University of Calgary in Canada and was funded by the Canadian Institutes of Health Research and awards from Alberta Innovates Health Solutions.

The study was published in the peer-reviewed scientific journal PLOS one, which is free to read for all on an open-access basis.

The Mail’s story exaggerates the findings of this unusual animal study. Most of the article reads as if the research were directly relevant to humans or carried out in humans. The Mail encourages this idea by illustrating the story with a picture of a couple with their toddler. It is only in the eighth paragraph of the Mail’s report that the fact that the study was in mice is revealed. The paper offers no thoughts about how relevant research on mice is to humans.

However, much of the exaggeration in the Mail’s reporting can be traced back to a press release about the research issued by the University of Calgary.

 

What kind of research was this?

This was animal research aiming to investigate the effect that early life experiences can have on brain development, emotions and social behaviour.

In particular, the researchers were interested in the theory that low maternal care leads to changes in the area of the brain involved with memory and emotions (the hippocampus). This may then lead to increased stress and increased sensitivity to changes in emotion and mood (emotional reactivity).

They say that previous studies have shown that when pregnant rodents have been exposed to stress the female offspring developed a smaller hippocampus. As the effect was not seen in male offspring this suggested there may be some gender difference.

This study aimed to see whether parental care offered by two rodent parents rather than one had an effect on brain cell development. Further, the researchers wanted to see whether any changes in development had an effect on the behaviour of the offspring, and whether the effect was different in male and in female offspring. 

This study may be of interest to scientists and psychologists, and offers a possible insight into the factors that may influence animal brain development and behaviour. But it is hard to determine if, or how, the results can ever be applied directly to humans.

 

What did the research involve?

This research involved eight-week-old female and male mice, who were fed a normal diet and housed under 12-hour light/dark conditions. They were allowed to mate freely. Pregnant females were removed and placed in different parental conditions for the duration of pregnancy, through birth and until weaning at 21 days. In total, 269 animals were involved.

The three conditions were:

• maternal-only condition – the offspring were housed with their mother only
• maternal-virgin condition – the offspring were housed with their mother and an age-matched virgin female mouse
• maternal-paternal condition – the offspring were housed with the mated male-female pair

When housed under the three conditions the researchers observed the time that the parent mice spent in parenting behaviours, such as nursing, licking and grooming, and nest building.

When the offspring were weaned at 21 days they were housed with their littermates. They then completed a series of behavioural tasks ranging from least to most stressful. The tasks included:

• different maze tasks, including water mazes
• light-dark tasks (seeing how long mice spent in light and dark compartments when allowed to navigate freely)
• horizontal ladder tests (looking at how well they walked across the differently-spaced rungs of a ladder)
• tests of social preference (looking at interest in exploring different objects that stimulated the senses)
• tests of passive avoidance (of an electric shock)
• tests of fear conditioning (observing their time spent frozen and motionless when they were exposed to different shocks and sounds)

The researchers also examined tissue samples from the brains of the offspring mice to investigate any biological differences in their brain development.

 

What were the basic results?

Before weaning, the researchers observed that the parenting behaviour of the mother mouse was no different in the three conditions. Nor did the displays of parenting behaviour from the virgin-female and father-mouse differ from each other in those two respective conditions.

When the researchers worked out the average time spent licking and grooming the offspring (a marker of parental attention), the offspring in the two-parent conditions (either maternal-virgin or maternal-parent) received more attention than those in the maternal-only condition.

Overall, they found effects of parenting upon offspring behaviour and brain cell development differed between male and female offspring. In the various tasks, males raised in the two-parent conditions showed more fear conditioning, by displaying more freezing behaviour than males raised in the maternal-only condition. Meanwhile, females raised in the two-parent conditions showed better co-ordination when walking across the ladder than females in the maternal-only condition. The two-parent females also displayed more interest in exploring different objects.

This suggests that being raised in an environment with the biological mother and another adult mouse (male or female), may improve or accelerate some, but not all, developmental skills.

Two-parent care also had more effect on the male mouse brain. Male offspring in both the two-parent conditions had more growth of cells in a certain part of the hippocampus (the dentate gyrus). Parenting experience didn’t seem to have an effect on the hippocampus of the female offspring. However, females raised under the two-parent conditions did show greater proliferation of the white matter (the nerve fibres) of the brain.

 

How did the researchers interpret the results?

The researchers say that early life experiences can have an effect on brain development and behaviour, and that this persists through life. Male and female offspring appear to be affected in different ways.

They note in the abstract of their published research article (but do not describe in detail in the main research methods or results) that some of the brain development and behavioural advantages due to two-parent upbringing can stay with the mice throughout life and can be transmitted to the next generation.

 

Conclusion

This animal study suggests that male and female mice raised in two-parent conditions display differences in their brain cell development and behaviour compared with mice raised with only their mother.

While there are similarities between mice and men, it would be a mistake to assume that the findings in this mice study can be applied to humans. There are many important differences between the parenting of mice and people, and many differences in biology and social development that make it impossible to translate these findings to people.

Nonetheless, this study will be of interest to scientists and psychologists and offers a possible insight into the factors that may influence animal brain development and behaviour. Future research can build on these findings.

It should not be assumed from this study that children raised by one parent will have behavioural differences from those raised by two parents. The Mail Online also mistakenly suggests that this study supports the idea that children brought up by two parents are more intelligent. Apart from the fact that it was a rodent study, the study did not examine the ‘intelligence’ of the mice, so this assumption is groundless.

The main differences observed were that male mice from two-parent families seemed to freeze more when exposed to a perceived threat, and that female mice from two-parent families were more interested in exploring objects and better at walking over a ladder. It is a distortion of the evidence to conclude from this that children from two-parent families are more intelligent.

If you are shocked by the reporting of this study, first by the University of Calgary’s press office (or to be specific, its Hotchkiss Brain Institute) and then by the Mail Online, you may want to read about a study published in 2012. It found that half of all health reporting is subject to some sort of ‘spin’ with researchers and academic press offices shouldering a large proportion of the blame.

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter.

Links To The Headlines

Children brought up by two parents are more intelligent - because they develop more brain cells. Mail Online, May 2 2013

 

Links To Science

Mak GK, Antle MC, Dyck RH, Weiss S. Bi-Parental Care Contributes to Sexually Dimorphic Neural Cell Genesis in the Adult Mammalian Brain. PLoS One. Published online May 1 2013

"NHS 111 helpline 'failing to meet targets',” says The Guardian, along with much of the media.

The new health helpline, designed for people with urgent but non-life threatening health problems, has been criticised for failing to meet patient demand.

Many patients have been unable to have their call answered quickly enough. It is reported that this failure to meet demand has placed extra pressure on accident and emergency departments and GP out-of-hours services.

Patient and doctor groups have been quoted in the media raising concerns. Dr Laurence Buckman, chairman of the British Medical Association's GP committee, told The Guardian that patients reported facing "unacceptably long waits to get through to an NHS 111 operator and suffering from further delays when waiting for calls back with medical advice".

 

What is the 111 service?

NHS 111 is a new service that's being introduced to make it easier for patients to access local NHS healthcare services.

You can call 111 when you need medical help fast, but it’s not a 999 emergency.

Unlike the NHS Direct helpline that still exists in some areas, the 111 service can book you out-of-hours GP appointments.

NHS 111 was first introduced as a pilot scheme in 2010 in a few areas. It was expected to cover the whole of England by April 2013, but has now been delayed until later this year.
 
NHS 111 is not operated as a national organisation. It is made up of 46 different local services, each reporting to the local NHS organisations.

 

How has NHS England responded?

NHS England, the body responsible for the 111 service, has carried out a review into what lessons can be learnt from the initial roll-out of the service.

NHS England says that it acknowledges "an unacceptable service on quality standards, especially at weekends".

"Performance became a particularly significant issue the weekend before Easter, which raised serious concerns about the Easter weekend, at which point NHS England put in place tighter controls. Performance over the Easter weekend was still unacceptable in some areas, but was improved in others.

"Performance has continued to improve since then. At the time of writing, there was a vastly improved picture of NHS 111 delivery across the country when compared to late March and the Easter bank holiday period. However, the service is still fragile in a number of areas."

The review recommends that further work is carried out to identify areas of the service that are underperforming, investigate why this is the case and then take necessary steps to rectify the problems.

If you are concerned about any symptoms you are having you can always try the NHS Choices symptom checker.

Edited by NHS Choices. Follow Behind the Headlines on Twitter.

Links To The Headlines

NHS 111 helpline 'failing to meet targets'. The Guardian, May 1 2013

NHS 111 advice line 'still fragile'. BBC News, May 1 2013

NHS's 111 helpline 'STILL putting lives at risk': Urgent review demanded amid fears it will not cope over Bank Holiday. Daily Mail, May 2 2013

'Babies that are abnormally heavy or underweight are at 62% greater risk' of developing autism, reports the Daily Mail. The news is based on a large study of Swedish children with and without autism spectrum disorder (ASD).

Researchers compared healthy children up to the age of 17 with children who had a diagnosis of ASD. They examined whether there were any differences between the children in terms of how quickly they grew while in the womb (foetal growth) and the length of the pregnancy.

They found that babies with unusually low and unusually high levels of foetal growth had an increased risk of ASD (with or without intellectual disability).

This large study does suggest a possible association between foetal growth and ASD, but it does not prove a direct cause and effect. It could well be that there are underlying factors that cause both abnormal foetal growth and ASD.

While the researchers did try to account for a number of factors that could be linked to both foetal growth and ASD, this is not an exact science.

However, this study does raise interesting questions about how development in the womb could affect a child's risk of ASD, and will hopefully lead to further research in this field.

 

Where did the story come from?

The study was carried out by researchers from Manchester and Bristol Universities, Karolinska University Hospital in Sweden, Columbia University in the US, and other institutions. Sources of funding were not reported. It was published in the peer-reviewed American Journal of Psychiatry.

The study was covered by the Daily Mail, whose reporting was arguably not as clear as it could have been. While the main findings of the study were reported accurately, there was no discussion about the limitations of the study, or that other factors could have been at play.

The headline and much of the reporting also focuses on birth weight. However, the researchers specifically did not want to use birth weight as the prime measurement, as they said this is often prone to inaccuracy and misinterpretation. This is why they took the decision to focus on foetal growth.

 

What kind of research was this?

This was a nested case-control study within the Stockholm Youth Cohort study looking at the associations between the growth of babies in the womb, gestational age (length of the pregnancy) and ASD.

Autism spectrum disorder (ASD) is the name given to a group of developmental disorders that start in very early childhood and tend to have characteristic impairments in three main areas:

• social interaction, such as having difficulty understanding emotions
• communication and language difficulties
• a restricted, repetitive collection of interests and activities, or set routines or rituals

ASD includes both autism and Asperger syndrome. The main difference between the two disorders is that children with autism tend to have some degree of learning difficulty or intellectual impairment, while this is less common in Asperger syndrome.

In some cases, children with Asperger syndrome can be particularly gifted in certain areas, such as mathematics or computer science, though this is less common than the media would lead you to believe.

The causes of ASD are not known. Current thinking on the matter speculates that a combination of genetic and environmental factors disrupts the development of the brain during pregnancy.

A nested case-control study is a special type of cohort study where people who have the condition (cases) and a selected matched group who don't (controls) are selected from the same population, or cohort, of people (nested).

In contrast to non-nested case-control studies, data is usually collected prospectively, which means that researchers can be sure of when certain exposures or outcomes happened. This also avoids the difficulties or biases of participants remembering past events. Also, as cases and controls are selected from the same cohort, this means that they should be better matched than if researchers identified cases and controls separately.

 

What did the research involve?

The researchers used data from the Stockholm Youth Cohort study, which included all children up to the age of 17 who lived in Stockholm county between 2001 and 2007.

They identified 4,283 children with ASD (cases) and compared them with 36,588 healthy children randomly selected from the community (controls).

The cases were matched to controls by age and sex. For each child with ASD, there were nine children without the condition.

Of the children with ASD, 1,755 had an intellectual disability and 2,528 did not. Children who had been adopted or had missing data were excluded from the study.

Children with ASD were determined by linking with national registries containing information about all assessments or care of ASD in Stockholm county. The researchers say that children in Stockholm have assessments of development carried out by nurses or paediatricians at the ages of 1, 2, 6, 10-12, 18, 36, 48 and 60 months, or when there is concern about a child's development.

They say the type of care a child receives following a diagnosis of ASD is determined by whether the child also has an intellectual disability or not. This allowed the researchers to determine how many children with ASD also had an intellectual disability.

The researchers then collected information on the birth weight of each child and the length of the pregnancy (gestational age). The length of the pregnancy was determined using ultrasound dating.

They used information from the national registry of births to determine averages of foetal growth by gestational age, so they could determine which children were above or below these averages.

The researchers analysed the results to determine the risk of developing ASD (with and without intellectual disability). Results were adjusted for known factors that may have influenced the results (confounders), including:

• parent age when the baby was born
• country of birth
• socioeconomic status
• household income
• family psychiatric history
• whether the mother had diabetes or high blood pressure during pregnancy
• congenital disorders

 

What were the basic results?

The main results of this study were:

• below-average foetal growth was associated with an increased risk of ASD – the poorer the growth, the higher the risk
• foetal growth that was higher than average was associated with an increased risk of ASD, but only when the growth was in the extreme ranges of higher than normal
• these findings were for children with and without intellectual disability, although below-average foetal growth was more strongly associated with ASD with intellectual disability than without
• following adjustment, children who were born small or large for their gestational age were at greater risk of developing ASD with intellectual disability, irrespective of the length of the pregnancy
• preterm birth increased the risk of ASD independent of foetal growth

The researchers also found:

• parents of children with ASD were more likely to have experienced admission to hospital for psychiatric reasons (18.7%) compared with parents of children without ASD (11.3%)
• children with ASD were more likely to have congenital malformations compared with children without ASD

 

How did the researchers interpret the results?

The authors concluded that foetal growth above or below the average in Stockholm is an independent risk factor for developing ASD. They say this risk is greatest when growth is well below or above average, as well as for ASD with intellectual disability.

The researchers suggest these findings may allow for the possibility of early intervention in order to reduce poor developmental outcomes, through monitoring as well as follow-up, screening and the management of children who may be most at risk. 

Lead researcher Professor Kathryn Abel from Manchester University is reported as saying, "We think this increase in risk associated with extreme abnormal growth of the foetus shows that something is going wrong during development, possibly with the function of the placenta."

 

Conclusion

This large study suggests a possible link between foetal growth and very low or very high birth weight and ASD, with or without intellectual disability. However, it only observes an association and does not prove cause and effect.

Parents expecting a baby who is showing below- or above-average foetal growth, or who have a baby born with below- or above-average birth weight, should not be overly concerned that their child may be at risk of developing ASD.

If there is a direct link between foetal growth and ASD, the reasons why this may be the case are not clear. The authors' suggestions of possible reasons, such as the function of the placenta, are only theories.

Importantly, although the authors have tried to adjust for possible confounders, there could be other factors at play that may have affected the results. These include genetic, environmental or health-related conditions that the child or mother were exposed to during the pregnancy or after the birth.

Examples of possible factors not taken into consideration include alcohol and substance misuse, and obesity or weight gain around the time of the birth.

The study also only relates to a Swedish population sample. There may be environmental and population health differences between Sweden and elsewhere, meaning that care should be taken when generalising results to other countries.

Overall, the possible causes of autism spectrum disorder remain unknown, and further research is needed.

 

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter.

Links To The Headlines

Babies born weighing more than 9lb 14oz or under 5lb 5oz have a higher chance of developing autism. Daily Mail, May 1 2013

Links To Science

Abel KM, Dalman C, Svensson AC, et al. Deviance in Fetal Growth and Risk of Autism Spectrum Disorder. The American Journal of Psychiatry. Published online April 1 2013

Most of the UK media are reporting on a worrying new strain of bird flu in China – the H7N9 strain of the bird flu virus.

According to the media, virology experts at a recent press conference warned that the virus "should not be taken lightly". This warning was prompted by new genetic research into the disease and by news that the virus is thought to have killed 24 people and infected at least 126 in China.

Public health authorities in the UK are reportedly on the alert to watch for any spread of the disease out of China. However, the H7N9 flu virus is currently thought only to be spread between birds and from birds to people.

It is possible that H7N9 could mutate (change) so that it can spread from person to person. This is why experts are investigating this disease, with a view to reducing the effects of a global flu pandemic (similar to the swine flu pandemic in 2009–10).

The new genetic research indicates that the virus might have evolved from at least four other flu viruses circulating in wild bird populations, ducks and domestic chickens. The study also found that H7N9 has already evolved into two separate strains since its emergence.

At the moment there is no need to panic and the risk to anyone living in the UK is only theoretical. But international health authorities will need to keep a careful watch on the spread of this new strain.

 

Where did the story come from?

The study was carried out by researchers from the Chinese Academy of Sciences in Beijing and the Chinese Centre for Disease Control and Prevention. It was funded by several public institutions in China, including the Ministry of Science and Technology.

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

The UK coverage of the study and press conference was accurate, with most news sources highlighting the need for vigilance rather than blind panic.

 

What kind of research was this?

This was a genetic analysis of the H7N9 bird flu virus, in which scientists used information taken from global virus databases to track the potential origins of the virus, as well as any genetic changes in the virus that have taken place since it emerged.

The authors point out that the H7N9 virus causing human infections was identified in China at the end of March 2013. As of April 18, the virus had spread to six provinces and cities, with 87 people infected and 17 fatalities. While this seems a worryingly high mortality rate, it is too early to say how this might change if the virus were to mutate to enable it to spread from person to person (rather than from bird to human as is currently the case).

Preliminary analyses have shown that the H7N9 virus causing the current outbreak in China may have originated from a number of existing flu viruses in wild birds, ducks and poultry. All bird flu influenza A viruses have a genome (genetic make-up) consisting of just eight single segments of RNA. But it is often the genetic simplicity of viruses that makes them so contagious.

One of these RNA segments codes for the protein haemagglutinin (HA), and another segment codes for another protein, neuraminidase (NA), both of which are crucial in helping the virus spread from cell to cell and from organism to organism.

HA and NA are present on the surface of the virus. HA plays a key role in the entry of the virus into a cell, and NA is involved in the release of the virus from the host cell.

The HA and NA proteins can be classified into different subtypes, which gives rise to the familiar HxNy classification of influenza viruses, where x stands for one of 17 possible subtypes of HA, and y stands for one of 10 NA subtypes.

 

What did the research involve?

Scientists used information taken from global virus databases to compare the H7N9 genome to other related flu viruses.

They carried out a detailed genetic analysis that enabled them to construct evolutionary (or phylogenetic) 'trees' – the viral equivalent of a family tree – for all eight RNA fragments of the virus. This allowed them to see what the current virus could have evolved from.

The researchers also tried to determine how the particular assortment of RNA particles present in the current H7N9 virus could have arisen, using genetic information. This was done to assess where the virus originated from geographically and the type of animal it had originally infected.

 

What were the basic results?

When two different types of bird flu virus infect the same cell at the same time, the new virus produced by the host cell can contain a mix of the RNA particles from each virus, generating new types of virus. This process is called reassortment.

The scientists concluded that the new H7N9 virus appears to have originated from at least four reassortment events.

The HA gene might have originated from a bird flu virus that normally infects ducks and the NA gene might have come from a virus that affects migratory birds, which may then have infected a duck. The other genes might have come from two different viruses that affect chickens. The reassortment of these genes could have occurred in ducks or chickens.

By comparing different samples of H7N9, the authors also noticed two genetically distinct strains of the virus, implying that it has already evolved further since it emerged.

 

How did the researchers interpret the results?

The researchers say the results suggest that the HA genes of the H7N9 virus were originally circulating in the East Asian fly way – a major route used by migratory birds spanning East Asia.

The NA genes seem to have been introduced by birds migrating from Europe, transferring to ducks in China via the East Asian fly way.

The six remaining RNA segments of the virus (referred to as internal genes) appear to have originated in two different groups of H9N2 viruses infecting chickens and ducks in eastern China. 

The researchers say that the most recent common ancestor of the H7N9 virus was probably in existence around January 2012, a time when migratory birds would have been wintering in areas of mainland China near to where the H7N9 outbreak has occurred. 

They stress the need for “extensive surveillance” of the virus in human beings, poultry and wild birds. Further evolution of the virus has the potential to make it more harmful to humans, either by making people more ill when they catch it, or by increasing its ability to transmit between humans, or both.

In a linked article in the Lancet, Dr Marc Van Ranst and Philippe Lemey of the University of Leuven, in Belgium, add that the history of the virus may be particularly important, because the low severity of the virus in birds probably allowed it to spread silently in domestic and wild birds. “Containing this hidden epidemic may prove very challenging given the magnitude of the domestic and wild bird populations in China,” they say.

 

Conclusion

This is important research tracking the origins of the new H7N9 bird flu virus, which gives some clues about how it might behave in the future. Scientists are particularly concerned that a future mutation could mean it is transmitted between humans, which increases the risk of a pandemic (an epidemic of infection across countries or continents).

For travellers to China and other countries affected by bird flu, it's important to observe the following precautions:

• avoid visiting live animal markets and poultry farms
• avoid contact with surfaces that are contaminated with animal faeces
• don't eat or handle undercooked or raw poultry, egg or duck dishes
• don't pick up or touch dead or dying birds
• always follow good personal hygiene practices, including washing your hands regularly

Read more about reducing your risk of bird flu when travelling in affected countries.

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter.

Links To The Headlines

H7N9 bird flu is a 'serious threat' - researchers warn. BBC News, May 1 2013

New bird flu poses "serious threat", scientists say. Reuters, May 1 2013

Deadly bird flu poses 'real global threat to humans. Channel 4 News, May 1 2013

GPs advised how to spot bird flu as virus continues to mutate at an alarming rate. Mail Online, May 1 2013

Deadly Bird Flu Is Global Threat, GPs Warned. Sky News, May 1 2013

Deadly H7N9 bird flu strain could mutate into 'very serious' global threat, warns expert. Daily Express, May 1 2013

Links To Science

Liu D, Shi W, Shi Y, et al. Origin and diversity of novel avian influenza A H7N9 viruses causing human infection: phylogenetic, structural, and coalescent analyses. The Lancet. Published online May 1 2013

BBC News has revealed that, "Women who smoke have a higher risk of cancer than men," reporting the results of a new study examining the relationship between gender and bowel cancer caused by smoking. 

The large-scale study found that smoking increased the risk of bowel cancer in women by 19% compared with women who had never smoked. This was much larger than the (non-significant) 8% risk increase seen in male smokers.

Smoking is a recognised risk factor for bowel (colon) cancer and several other life-threatening diseases in both men and women. It is important to bear in mind that this research only looked at colon cancer. Whether there are gender differences in other smoking-related cancers, such as lung cancer, is uncertain based on the findings of this study alone.

The authors point out that their study did not take into account important risk factors known to be linked to bowel cancer, such as family history, diet, and alcohol consumption. If these had been accounted for the results may well have been different.

The study also didn't produce any firm evidence to explain why there may be a difference in risk between women and men. Future research will need to address these limitations to see if the gender differences in risk still apply and, if so, why.

 

Where did the story come from?

The study was carried out by researchers from the University of Tromsø, Norway in collaboration with researchers from institutions in Hawaii and Finland, and was funded by the Norwegian Cancer Society.

It was published in the peer-reviewed journal Cancer Epidemiology, Biomarkers and Prevention.

The BBC's coverage was generally accurate, although it wasn't initially obvious that the study only related to bowel cancer rather than all cancers, which readers may have assumed from the headline.

The BBC also discussed a second recent study (also covered by the Mail Online website) that reportedly showed how teenage girls exposed to passive smoking had lower levels of the "good" form of cholesterol that reduces heart disease risk. This, the BBC reported, gave a possible explanation as to why women who start smoking increase their risk of a heart attack.

 

What kind of research was this?

The researchers reported how smoking is a recently established risk factor for what medical professionals refer to as colon cancer, or cancer of the large bowel. They explained that the levels of colon cancer in Norwegian women are unusually high when compared with similar countries.

In men, smoking levels peaked during the late 1950s, while in women levels did not peak until the 1970s. The fact that historically women smoked less but still had high levels of colon cancer could mean they were more vulnerable to the harmful effects of smoking in terms of colon cancer risk.

To test this, the researchers carried out a cohort study to see if women may be more susceptible to smoking-related colon cancer than men.

 

What did the research involve?

The researchers recruited 602,242 Norwegians who were aged 19 to 67 at enrolment between 1972 and 2003.

They combined the information gathered from four separate cohort studies into one larger study. The researchers linked unique IDs assigned to each of the study participants to National Cancer Registry databases so they could establish whether any of the study group developed cancer.

At enrolment, and at various other points throughout the study period, participants filled out multiple questionnaires about a wide range of health and lifestyle behaviours, such as smoking, diet and physical activity levels, as well as demographic information.

Smoking levels were categorised into two main groups for analysis:

• those who had never smoked (never-smokers)
• a pooled group of current smokers and ex-smokers (ever-smokers)

The main analysis looked at how the two levels of smoking influenced the risk of developing colon cancer overall, as well as specific subgroups of colon cancer. That is, whether the cancer was located in the first part of the colon (proximal colon cancer) or lower parts of the colon (distal colon cancer).

The main analysis took account of age at enrolment, level of physical activity, body mass index (BMI) and years of education. These represented factors known to influence the risk of developing colon cancer (confounders).

 

What were the basic results?

The study followed people for an average of 14 years, during which time 3,998 people (46% women) developed colon cancer.

Female ever-smokers had a 19% increased risk of colon cancer compared with female never-smokers (hazard ratio [HR] 1.19, 95% confidence interval [CI] 1.09 to 1.32). This was much larger than the non-significant 8% increased risk found between male ever-smokers compared with male never-smokers (HR 1.08, CI 0.97 to 1.19).

Women categorised in the groups who started smoking the earliest, smoked for longest, or smoked the most cigarettes per day were at more than 20% higher risk of colon cancer (range 28-48%) than women never-smokers.

The increase in risk was much larger for proximal colon cancer, with female ever-smokers more than 40% more at risk of developing the disease compared with female never-smokers.

The researchers also tested for differences in the findings between men and women. They found this was only the case for the association between female ever-smokers and the risk of proximal colon cancer.

 

How did the researchers interpret the results?

The researchers concluded that their findings meant that, "Female smokers may be more susceptible to colon cancer, and especially to proximal colon cancer, than male smokers."

 

Conclusion

In this study, the researchers suggest that smoking played a role in increasing the risk of colon cancer in both sexes, but it seemed to play more of a role in women smokers. This particularly increased the risk of cancer of the first part of the large bowel (proximal colon cancer).

The study had many strengths, including its large size and long follow-up time. However, the research suffers from some limitations, meaning that we can't be sure that women smokers really do have a higher risk of colon cancer based on this study alone.

These limitations include:

• The study did not take account of many factors known to increase the risk of colon cancer, such as higher alcohol and red meat consumption. Had it done so, the results may have been different. The researchers point out that, generally, alcohol and red meat consumption is higher in men, putting them at an increased risk of colon cancer. Not taking these factors into account means it was less likely to find the results they did.
• The study only looked at colon cancer. This tells us nothing about whether women smokers are more susceptible than men to other types of cancers. This would need direct investigation.
• Smoking was categorised into only two groups rather than a more detailed breakdown, and did not account for passive smoking levels. There will therefore have been some error in using this simple categorisation method.

Overall, the study suggests the effect of smoking on the risk of developing colon cancer may differ by gender, but it cannot confirm this is definitely the case, or explain why this may be. Further research is required to confirm both of these questions.

 

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter.

Links To The Headlines

Smoking 'poses bigger risk to women'. BBC News, May 1 2013

Links To Science

Parajuli R, Bjerkaas E, Tverdal A, et al. The Increased Risk of Colon Cancer Due to Cigarette Smoking May Be Greater in Women than Men. Cancer Epidemiology Biomarkers Prevention. Published online April 30 2013. 

“Breast implants may harm breast cancer survival chances,” The Guardian warns, along with other media sources reporting on the same subject.

It is important to stress that the research the media has reported does not suggest that breast implants cause breast cancer.

Instead, the research suggests that breast implants may cause a delay in diagnosis in women who have breast cancer, which may increase their risk of dying from the condition.

The researchers suggest that the implants could hide cancerous tissue that would otherwise be detected during screening.

To test this, the researchers reviewed several small studies looking at whether having cosmetic breast implants was associated with (no causal association) a delay in diagnosis, and whether women with breast cancer who had implants were at increased risk of dying from the disease.

They found some evidence of an association. Women with breast implants had a 26% increased risk of being diagnosed at a later stage of breast cancer than those without implants. Women with implants also had a 38% greater risk of dying from breast cancer than women without implants.

However, as the authors rightly point out, the results of these analyses should be viewed with caution. This is because they couldn’t find previous research of high enough quality to draw firm conclusions, and better quality studies would be needed to confirm the association.

  Where did the story come from?

Links To The Headlines

Breast implants may harm breast cancer survival chances, study finds. The Guardian, May 1 2013

Do breast implants raise cancer danger? They make tumours harder to spot, says report. Daily Mail, May 1 2013

Boob jobs ‘increase risk of cancer death by 40%’. Metro, May 1 2013

Breast implants 'increase cancer death risk,' say scientists. The Independent, May 1 2013

Breast Implants 'Raise Cancer Death Risk'. Sky News, May 1 2013

 

Links To Science

Lavigne E, Holowaty EJ, Pan SY, et al. Breast cancer detection and survival among women with cosmetic breast implants: systematic review and meta-analysis of observational studies. BMJ. Published online April 30 2013

 

“Hormone treatments can cut breast cancer rates in at-risk women by 38%,” reports the Daily Mirror.

The news, covered by much of the media, is based on research into selective oestrogen receptor modulators (SERMs), a class of drug that binds to oestrogen receptors in breast cells and elsewhere.

The study making today’s news suggests that SERMs could be effective for preventing breast cancer. Researchers combined the results of several studies that had compared SERMs with other drugs in women without breast cancer.

Most of the trials recruited women who were either at high risk of breast cancer or who had osteoporosis.

Researchers found that SERMs reduced the incidence of breast cancer during 10 years of follow-up.

Links To The Headlines

500,000 to be offered daily breast cancer pill. The Times, April 30 2013

Breast cancer drug 'benefits at-risk patients'. The Daily Telegraph, April 30 2013

Drug that PREVENTS breast cancer could soon be given to half a million women on the NHS. Daily Mail, April 30 2013

Four drugs 'can reduce chance of breast cancer in at-risk women'. The Guardian, April 30 2013

Hormone treatments can cut breast cancer rates in at-risk women by 38%. Daily Mirror, April 30 2013

Links To Science

Cuzick J, Sestak I, Bonanni B, et al. Selective oestrogen receptor modulators in prevention of breast cancer: an updated meta-analysis of individual participant data. The Lancet. Published online April 30 2013

The health benefits of a Mediterranean-style diet have hit the headlines, with The Daily Telegraph reporting we should, 'Eat oily fish to prevent memory loss,' while the Mail Online focuses on how oily fish can keep the memory 'sharp'.

These somewhat overenthusiastic headlines are based on a large study that looked at how eating habits similar to those seen in Mediterranean countries could affect your chances of developing cognitive impairment.

Researchers found that older adults from the US who followed a Mediterranean-style diet were 13% less likely to have impaired cognitive abilities. This was still the case even after adjustment for other health and lifestyle factors that could also have an influence. However, this association was not seen in people with diabetes.

The Mediterranean diet has been linked to a lower risk of developing several diseases, including cardiovascular conditions such as heart disease and stroke, and forms of dementia (such as Alzheimer's disease).

Drawing conclusions from research into associations between diet and health is difficult, as it is hard to measure the influence of dietary habits properly.

In the case of this study, the diet measurements may be quite specific to the US, so the findings may not apply to British people's diets in the same way.

Overall, however, this large well-conducted study suggests that sticking to a largely Mediterranean-style diet may have benefits for the cognitive functioning of people who do not have diabetes.

 

Where did the story come from?

The study was carried out by researchers from the University of Athens, the University of Alabama at Birmingham, and other research institutes in the US and the Czech Republic. It was funded by the US National Institutes of Health and was published in the peer-reviewed medical journal Neurology.

The media headlines regarding the importance of eating oily fish instead of red meat do not fully capture the research results. While oily fish is part of the Mediterranean diet, there are many other components that could also have beneficial effects. This study assessed all the components together rather than focusing on oily fish alone, as the media suggests – in fact, the word 'fish' does not appear once in the Neurology article.

Additionally, the 19% reduction in risk quoted by both The Daily Telegraph and the Daily Mail is incorrectly attributed to "people who adhere to a Mediterranean-style diet". This figure actually only applies to non-diabetic people. The risk reduction for the entire study sample was a more moderate 13% reduction in odds. However, both newspapers covered the main methods of the study well.

 

What kind of research was this?

This was a prospective cohort study that assessed the relationship between how much people adhered to a Mediterranean diet and their odds of developing cognitive impairment over time.

The Mediterranean diet involves eating lots of fruit, vegetables and olive oil, and eating few saturated fats, meat and dairy products. According to the study's authors, the diet has been associated with longer lifespan and a reduced risk of heart conditions, some cancers and Alzheimer's disease. It is the frequent subject of research into the influence of lifestyle on health and longevity.

As a prospective cohort study, this research can tell us how people's diet is linked to new cases of cognitive impairment over time. It also confirms that diet preceded any change in cognitive function, a key factor in assessing causality.

 

What did the research involve?

As part of the Reasons for Geographic and Racial Difference in Stroke (REGARDS) study, researchers recruited more than 30,000 individuals over the age of 45 from various regions of the United States. At the beginning of the study (baseline), individuals completed a version of the food frequency questionnaire (FFQ) that assessed their dietary habits. It was adapted specifically around foods commonly eaten in the US. Their cognitive functioning was also assessed using the six-item screener (SIS).

Participants were excluded if:

• they had a history of stroke
• there was missing data from the diet questionnaire
• they completed fewer than two cognitive assessments during the study
• the baseline tests revealed impaired cognitive status

The participants were asked to complete the FFQ several times over the first year to validate the results of the baseline diet assessment. The questionnaire was scored on a 10-point scale (0 to 9), with higher scores indicating higher adherence to a Mediterranean diet.

The SIS cognitive assessment was carried out at baseline and on a yearly basis to detect changes in cognitive status and new cases of cognitive impairment. For the statistical analyses, the researchers defined incident (new) cognitive impairment as a change from intact cognitive functions (an SIS score of 5 to 6) to impaired cognitive status during follow-up assessment (an SIS score of 4 or less).

Using data from the FFQ scores, the researchers separated participants into two categories according to their adherence to a typical Mediterranean diet. Scores of 0 to 4 were taken to indicate low adherence, while scores of 5 to 9 indicated high adherence.

The researchers then calculated the odds of new onset cognitive impairment in the group with high diet adherence, and compared this with the odds of new cognitive impairment in the low adherence group.

They adjusted the analyses to control for factors shown to be associated with new-onset cognitive impairment, including:

• demographic factors, such as age, race and sex
• socioeconomic factors, such as region of residence, household income and education
• health status, such as history of heart disease, diabetes, atrial fibrillation, blood pressure, high cholesterol, use of blood pressure medications, symptoms of depression, and perceived general health
• other risk factors, such as body mass index (BMI), waist circumference, smoking status, alcohol use and physical activity level

They also assessed how having diabetes influenced the relationship between diet and cognitive impairment. For this, they carried out two separate analyses similar to those described above: one for individuals with diabetes, and the other for diabetes-free participants only.

 

What were the basic results? Main analysis

Links To The Headlines

Eat oily fish to prevent memory loss, researchers claim. The Daily Telegraph, April 29 2013

Want your memory to stay sharp in old age? Eat less red meat and more oily fish. Daily Mail, April 29 2013

Links To Science

Tsivgoulis G, Judd S, Letter AJ, et al. Adherence to a Mediterranean diet and risk of incident cognitive impairment. Neurology, April 30 2013

“Taller, skinnier women have evolved to have more babies than their shorter counterparts,” the Mail Online website has claimed.

It reports on research examining the characteristics of women in two villages in the west African nation of The Gambia over more than 50 years.

Researchers were interested in whether recent trends for decreased mortality and fertility rates in human populations over time may influence natural selection on other traits. They analysed records of just under 3,000 women between 1956 and 2010 to find their body mass index (BMI) and number of births.

Initially, women who were shorter and with higher BMIs were more likely to reproduce successfully, but over time the reverse became true. The study did not investigate the reasons for this, but the researchers suggest that improvements in healthcare are changing the relationship between height, BMI and health in The Gambia.

Other factors could also play a role, including cultural changes (such as men’s changing preferences for sexual partners). Due to the highly specific sample population in the study, we can't say whether these trends in height, BMI and adult fertility would be found in UK women.

The wider implications of the study are that it suggests that evolution, driven by natural selection, is not just something that happened to our ancestors. It can still have a significant influence on the human population.

However, due to the highly specific sample population in the study, it is difficult to assess whether the findings would relate to women in the UK. Analysis of similar data would be required to determine whether this was the case.

 

Where did the story come from?

The study was carried out by researchers from various research centres in Germany, the UK, The Gambia, and the US.

The collection of the data analysed in the study was funded by the UK Medical Research Council, and the researchers were funded by various bodies, including the Wellcome Trust and the European Research Council.

The study was published in the peer-reviewed journal Current Biology.

Despite this being a study conducted in The Gambia, the Mail Online illustrated the story with a picture of German model Heidi Klum (who has four children).

And the Mail Online's headline, “taller, skinnier women have evolved to have more babies than their shorter counterparts”, is not strictly correct. The study did not find that being taller and having a lower body mass index are evolutionary adaptations that enable women to have more children. The fact that over time taller women with lower BMIs in the Gambia had a reproductive advantage over shorter women with higher BMIs is likely to relate to other factors such as what women’s height and BMI say about their health.

 

What kind of research was this?

This was a longitudinal study looking at the evolutionary consequences of changes in the characteristics in a population over time, in this case in The Gambia.

The researchers say that human populations have recently shown declines in both mortality (death) and fertility rates and that the evolutionary consequences of this have not been extensively investigated. In particular, they looked specifically at how the changes influenced variation in the population in ‘relative fitness’ in evolutionary terms (essentially how able individuals are to reproduce successfully).

The researchers looked at how height and BMI might have influenced this ability to reproduce successfully.

 

What did the research involve?

The researchers used data that had been collected from women in two rural villages in one district in The Gambia between 1956 and 2010. They collected data for 2,818 women, who together provided a total of 51,909 years of follow-up in total.

The women’s heights and weights had been recorded, and their BMIs calculated. Researchers used methods in their analyses that allowed them to take into account the fact that women’s measurements had not all been taken at the same age, and some women provided more than one measurement at different ages.

Births and deaths were also recorded.

The researchers used an annual measure of ‘fitness’ in the population that assessed how many babies the women had each year. They also assessed how BMI and height related to ‘fitness’, and whether this relationship changed over time.

 

What were the basic results?

The researchers found that over time, variation in ‘relative fitness’ in the population declined. This was largely as a result of reduction in the variation in survival in early life – with a reduction in deaths among girls before they reached adulthood and had a chance to reproduce. As with most developing countries, child mortality was very high in The Gambia for much of the 20th century – a trend that gradually improved over time.

Survival among girls aged under 15 increased over time and variation in relative adult fertility increased at the same time.

There was a change in how height and BMI related to adult fertility in the Gambian population. Taller women initially had lower adult fertility, but over time they showed higher adult fertility. Women with a higher BMI initially had higher adult fertility, but by the end of the study period they showed lower adult fertility. So initially, up to 1974, women who were shorter and with higher BMIs (height less than 157cm and BMI greater than 21) reproduced more, after 1975 women who were taller and with lower BMIs (height greater than 158cm and BMI less than 21) reproduced more. The researchers’ analyses suggested that the relationship may have been influenced by healthcare improvements that affected how health related to height and BMI.

 

How did the researchers interpret the results?

The researchers concluded that their findings show the changes in selective pressures on humans over time. They say that the findings suggest that changes in the characteristics of human populations and social, culture, medical and economic environment are likely to modify but not remove natural selection in humans. They say that this is likely to be increasingly driven by changes in culture – particularly in medical practice and public health measures.

 

Conclusion

This study provides insight into changes in how height and BMI have related to female reproductive fitness in The Gambia over a long period of time. While the general evolutionary principles identified in this study may apply to populations worldwide, the specific findings as they relate to height, BMI and reproductive fitness may not. Analysis of similar data from other populations would help to determine whether this was the case.

A key limitation of this research is that the women’s heights and BMIs were not all measured at the same age or on a regular basis. The researchers note that if they had annual measurements of the women’s heights and BMIs this would have allowed a more detailed look at the relationship between these factors and reproductive fitness.

Overall, the study provides interesting insight into how selection in humans changes as population characteristics and our complex social, culture, medical and economic environment changes. However, these findings are likely to be of more interest from an evolutionary perspective than a medical one. Shorter women with higher BMI should not be unduly alarmed by this news.

However, being underweight or overweight can affect your chances if you are trying to conceive.

Find out more about how to protect your fertility.

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter.

Links To The Headlines

Taller, skinnier women have evolved to have more babies than their shorter counterparts. Mail Online, April 26 2013

 

Links To Science

Courtiol A, Rickard IJ, Lummaa V, et al. The Demographic Transition Influences Variance in Fitness and Selection on Height and BMI in Rural Gambia. Current Biology. Published online April 25 2013

"New drug-resistant strains of the parasite that causes malaria have been identified," is the worrying news being reported on the BBC News website. Covering the same piece of research, The Guardian outlines the ongoing "scientific detective hunt in Cambodia to find much-needed clues to the development of resistance in the malaria parasite to the life-saving artemisinin drugs".

While most of us are aware of the issue of antibiotic resistance, the growing problem of resistance to antimalarial drugs often goes unreported, at least in the developed world. But the potential impact of increasing antimalarial resistance could be devastating. Our armoury of malarial drugs is limited, so further resistance could lead to a world where malaria is practically incurable.

The "detective hunt" that has hit the headlines involved looking at the genetic make-up of more than 800 samples from Africa and southeast Asia of the malaria-causing parasite Plasmodium falciparum (P. falciparum).

Three genetically different subpopulations showed resistance to artemisinin drugs, the medication that is the basis of current treatments for P. falciparum malaria. This suggests that resistance can be caused by different genetic variations.

Researchers will now go on to look more closely at the genetic variations they identified to see which ones contribute towards artemisinin resistance. The researchers hope that these findings and subsequent research will help us better understand how resistance to antimalarial drugs develops, with the ultimate aim of being able to eliminate the resistant strains of the parasite.

 

Where did the story come from?

The study was carried out by researchers from several international research centres, including the University of Oxford. It was published in the peer-reviewed journal Nature Genetics and was funded by the Wellcome Trust, the UK Medical Research Council Division of Intramural Research, the US National Institutes of Health, and the Howard Hughes Medical Institute.

Scientists already knew that artemisinin-resistant strains of malaria existed in western Cambodia, but they did not know much about its genetic make-up.

The research was generally well reported by the BBC and The Guardian.

 

What kind of research was this?

This was a laboratory study looking at the genetic make-up of different strains of the malaria parasite Plasmodium falciparum collected from different parts of Asia and Africa. There are several different types of malaria parasite, but P. falciparum is the most common and causes the most severe malaria infections. Some strains of the P. falciparum parasite have evolved resistance to antimalarial drugs such as artemisinin, one of the main drugs used to treat this type of malaria.

Drug resistance occurs through genetic changes in the parasites, making them less susceptible to the drugs used to kill them. Essentially, "survival of the fittest" evolutionary pressure leads to the increased spread of resistance over time.

When the drug is used on mixed populations of the parasite, some of which have resistance, the resistant parasites are more likely to survive than the non-resistant parasites. This means their genes spread through the population, causing the resistance to spread.

The researchers report that successive waves of this drug resistance originated in western Cambodia. Resistance to artemisinin and related drugs is now reported to be well established in this area. They wanted to look at whether the genetic make-up of P. falciparum from western Cambodia could give clues about why this might be the case.

 

What did the research involve?

The researchers analysed the genetic make-up of 825 samples of P. falciparum collected from 10 areas in southeast Asia (including four areas in Cambodia) and west Africa. They focused on more than 86,000 single "letter" variations at sites throughout the DNA code of the parasite. Once they identified which letter each of the samples had at these sites, they used a computer programme to analyse how the different samples were likely to be related to each other.

For example, the programme estimates which strains are joined by a common "ancestor" strain and how closely the strains are related. These relationships are shown as a "family tree" which joins all of the samples together.

The researchers also looked at resistance of these parasite samples to the drug artemisinin. They analysed data on how quickly the parasites were cleared from patients' blood when treated with an artemisinin derivative drug called artesunate.

 

What were the basic results?

The researchers found that within a relatively small area of western Cambodia there were several distinct subpopulations of P. falciparum that had an unusually high level of genetic differences. This finding was surprising, as researchers would have expected the samples from a small area to be more genetically similar than they were.

Three of these subpopulations showed resistance to the antimalarial drug artesunate. Within each subpopulation there were high levels of genetic similarity, suggesting that they had high levels of recent inbreeding.

The researchers identified a number of single letter variations among the artemisinin-resistant strains. Some of these variations lay within genes and would have an effect on the proteins that the genes encoded (carried the instructions for making). These changes could be responsible for the resistance to artemisinin-derived drugs. For example, some of these changes were in genes responsible for repairing the DNA if it gets damaged. Researchers thought this might relate to how quickly these strains in western Cambodia developed DNA mutations and resistance to antimalarial drugs.

 

How did the researchers interpret the results?

The researchers conclude that their findings provide a framework for further investigations into how artemisinin resistance arises. They say that these discoveries suggest that there could be multiple forms of artemisinin resistance because multiple subpopulations of resistant parasites were discovered, each with different genetic characteristics.

 

Conclusion

This study provides researchers with more information about the genetic make-up of different subpopulations of a type of malaria parasite taken from Africa and southeast Asia called P. falciparum, which causes the most severe malarial infections. They were surprised by the high levels of genetic diversity in parasite samples from western Cambodia, an area where resistance to a number of antimalarial drugs has developed and then spread.

Some of these Cambodian subpopulations showed resistance to the antimalarial drug artesunate. Data about their genetic variations will now be investigated further to see exactly which of these variations could be contributing to this resistance, and how.

The researchers speculate that historical, as well as genetic, factors may also have been involved. Parts of Cambodia were historically very isolated in terms of human movement due to the civil war between government forces and the Khmer Rouge, as well as poor roads in forested mountain areas. This could have created pockets of isolation ideal for parasitical inbreeding.

In addition, in the 1950s and 1960s there was mass administration of the antimalarial drugs chloroquine and pyrimethamine in one area in western Cambodia, leading to a strong selection pressure for strains resistant to these drugs.

It is hoped that these findings and subsequent research will help us better understand how resistance to antimalarial drugs develops, with the ultimate aim of being able to eliminate these resistant strains so that we can continue to treat the disease.

 

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter.

Links To The Headlines

Parasite 'resistant to malaria drug artemisinin'. BBC News, April 29 2013

Malaria resistance - it's in the parasite's genes. The Guardian, April 28 2013

Links To Science

Miotto O, Almagro-Garcia J, Manske M, et al. Multiple populations of artemisinin-resistant Plasmodium falciparum in Cambodia. Nature Genetics. Published online April 28 2013

"Children who have overprotective parents are more likely to be bullied by their peers," BBC News explains.

The news correctly presents the findings of a major study on the effects of parenting on a child’s risk of being bullied, but it focuses on the weakest finding of the research.

The study did suggest that overprotective parents may increase a child’s risk of being bullied by their peers. However, the study also found that children with neglectful or abusive parents had an even greater increased risk of being bullied.

The headlines could also have focused on the more positive results – researchers found that children brought up in an emotionally warm environment with clearly defined rules about right and wrong were less likely to be bullied. This finding is interesting given the recent news about the potentially positive effects of ‘tough-love’ parenting.

Further studies into the association between parenting and a child’s chance of being bullied could shed additional light on the importance of a parent’s behaviour. While the findings of this study are interesting, it is not easy to see how it could be used to persuade people to change their parenting styles for the better.

 

Where did the story come from?

The study was carried out by researchers from the University of Warwick and Kingston University London and was funded by the Economic and Social Research Council and the Qatar National Research Fund.

The study was published in the peer-reviewed medical journal Child Abuse and Neglect.

Media coverage of this review largely focused on one of eight studied parenting styles (overprotection or “mollycoddling”). While the Daily Mail at least mentioned the larger detrimental effects of other parenting styles, some outlets (including the BBC News and the Daily Express) focused solely on the impact of overprotective parents.

The fact that the study found that a more positive parenting style – combining a mixture of emotional warmth and “firm but fair” rules – was linked with reduced chance of being bullied was not highlighted in the reporting of the study.

 

What kind of research was this?

The study was a combination of a systematic review and meta-analysis. It examined the relationship between parenting styles, parent-child relationships and bullying.

Researchers believe that family experiences and parenting style before children start school can influence the child’s capacity to adapt and cope at school. This can influence their relationships with schoolmates, making a child less, or more, vulnerable to bullying from their peers.

The researchers pooled the results from both prospective cohort studies and cross-sectional studies. This was to investigate the association between parenting behaviour and victimisation, and from this to identify parenting styles and family relationships that may increase the risk of victimisation.

 

What did the research involve?

The researchers searched the available literature for cohort and cross-sectional studies of the association between parenting behaviour and peer victimisation or bullying. They included studies that were published between 1970 and 2012 and provided a measure of relational, physical, verbal or cyberbullying.

The researchers identified parenting variables that they classified into positive and negative parenting behaviours.

The positive parenting behaviours were:

• authoritative parenting (highly demanding, but also highly responsive parents)
• parent–child communication
• parental involvement and support
• supervision
• warmth and affection

The negative parenting behaviours were:

• abuse or neglect
• maladaptive parenting (high levels of hostility, hitting and shouting)
• overprotection (or mollycoddling, as the media termed it)

The researchers included studies that recorded two types of child outcomes – victims and those who were both bullies and victims (bully/victims). They pooled the results of identified studies for each of these parenting styles to determine whether there were specific types of parenting behaviour that were associated with either the risk of being bullied or becoming a bully/victim.

The size of the effect of parenting on a child’s risk of being bullied or becoming a bully/victim was estimated using a statistical scale called 'Hedge’s g'. This scale is widely used to assess the impact of different types of effect or effect size. For example:

• a small effect would be a Hedge’s g measurement of 0.20
• a medium effect would be a Hedge’s g measurement of 0.50
• a large effect would be a Hedge’s g measurement of 0.80

A negative effect indicates a lower likelihood of victims of bullying having parents with that particular behaviour or style compared with non-victims.

 

What were the basic results?

The researchers identified 70 cohort and cross-sectional studies that met the inclusion criteria. These studies included 208,778 children and young people aged between 4 and 25 years. The researchers found that different parenting styles were associated with varying risk of being bullied or becoming a bully/victim.

Both victims and bully/victims were more likely to be exposed to negative parenting behaviour including abuse and neglect as well as maladaptive and overprotective parenting (effect size 0.26, 95% confidence interval (CI) 0.16 to 0.37). When examining the types of negative parenting styles, the researchers found that all had a significant association with victimisation, including:

• abusive or neglectful parents (effect size 0.31, 95% CI 0.18 to 0.44)
• maladaptive parenting (effect size 0.27, 95 CI 0.15 to 0.40)
• overprotective parents (effect size 0.10, 95% CI 0.03 to 0.17)

Conversely, overall, positive parenting behaviour had a small but significant effect, reducing the likelihood of the child being bullied or becoming a bully/victim (effect size -0.19, 95% CI -0.23 to -0.15). All five of their selected styles were associated with lower likelihood of being bullied:

• authoritative parents (effect size -0.19, 95% CI -0.28 to -0.11)
• good parent–child communication (effect size -0.12, 95% CI -0.20 to -0.05)
• involved and supportive parents (effect size -0.22, 95% CI -0.29 to -0.15)
• parents providing supervision (effect size -0.16, 95% CI -0.21 to -0.12)
• warm and affectionate parents (effect size -0.22, 95% CI -0.30 to -0.14)

For victims, the effects were generally small to moderate for positive parenting styles (effect size -0.12 to -22) and negative parenting styles (effect size 0.10 to 0.31). For bully/victims the effects were generally moderate for positive parenting styles (-0.17 to -0.42) and negative parenting styles (0.13 to 0.68).

 

How did the researchers interpret the results?

The researchers concluded that negative parenting styles are associated with “small to moderate effects on victim status at school” and that “intervention programs against bullying should extend their focus beyond schools to include families and start before children enter school”.

 

Conclusion

This research suggests that certain parenting styles may protect children against bullying risk. These include:

• being authoritative
• being involved and supportive
• being warm and affectionate
• having good communication with your child
• providing appropriate supervision

On the other hand, negative parenting styles were linked with an increased likelihood of being bullied. The researchers defined negative parenting styles as both “caring too much” or being overprotective and “not caring enough” or being neglectful.

Most of the headlines state that ‘mollycoddling’ your children increases their risk of being bullied. While these headlines are supported by this research, overprotective parenting styles were in fact associated with the smallest effect on bullying risk of the eight styles investigated.

The researchers point out that the other two negative parenting styles (abuse and neglect, and maladaptive parenting) were far more likely to increase the risk of a child being bullied.

The review assessed the effects of these parenting behaviours on the likelihood of the child both being a victim of bullying as well as bullying others. Generally, the relationships between parenting and the child bullying others were stronger than those between parenting and victimisation alone. Sadly, this more important finding was largely ignored by the media.

The researchers suggest that, “intervention programs that target children who are exposed to harsh or abusive parenting, may prevent peer victimization”. They also conclude that “parental training programs may be necessary to strengthen supportive involvement and warm and affectionate parenting to improve family relationships and prevent or reduce victimization by peers”.

Read more advice and information about bullying.

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter.

Links To The Headlines

Over-protected children 'more likely to be bullied'. BBC News, April 26 2013

Youngsters mollycoddled by their parents 'are more likely to be bullied by their peers'. Mail Online, April 26 2013

Spoiled children are most bullied. Daily Express, April 26 2013

Links To Science

Lereya ST, Samara M, Wolke D. Parenting behavior and the risk of becoming a victim and a bully/victim: A meta-analysis study. Child Abuse & Neglect. Published online April 25 2013

 

“Believing in God can help treat depression,” the Mail Online website claims. But how much faith can we put in this story?

The story is based on US research examining the association between belief in ‘God or a Higher Power’ and the effectiveness of mental health treatment.

The study found that patients with a self-reported strong belief in God were more likely to respond to treatment, and that a higher level of belief was associated with greater reduction in mental health symptoms such as depression and the desire to self-harm.

There are several important points to bear in mind when considering the results of this study. These include that:

• the type of study can only show an association, it cannot prove that belief in God will help people respond to treatment for depression
• the study was conducted in a small, specific population so it may not hold true for other groups of people
• belief in God was only measured by a single question, and the reliability and validity of this method is unclear
• it only examined religious belief and did not include the effect of secular (eg political) beliefs

Go to the Moodzone for more tips on changes you can make to your life if you are feeling down.

 

Where did the story come from?

The study was carried out by researchers from Harvard Medical School and was funded by the Gertrude B. Nielsen Charitable Trust – a US-based charity with a stated interest in childcare.

The study was published in the peer-reviewed Journal of Affective Disorders.

The Mail Online covered this story relatively well, but did not discuss the inherent limitations of the study. It also mentioned two additional studies, one apparently related to prayer and treatment of cardiac patients, and the other related to the success of IVF treatments. However, it failed to provide enough detail of these studies to allow us to assess what quality of evidence was on offer.

 

What kind of research was this?

This was a prospective cohort study that examined the association between belief in ‘God or a Higher Power’ with outcomes for patients being treated for mental health disorders.

The researchers report that previous studies suggest that spiritual or religious beliefs may act as a buffer against several mental health conditions and behaviours, including depression and self-harming.

Some studies suggest, however, that spiritual struggles can worsen or bring on symptoms.

As a cohort study, this research cannot tell us about any potential causal link between belief and treatment, only whether the two factors are associated. Furthermore, it cannot tell us what it is about belief that leads to an association with treatment outcomes.

 

What did the research involve?

The researchers recruited 159 patients in a day-treatment programme at a psychiatric hospital in the US. The average age of the patients was 34 years, approximately 62% of whom were women. All patients were experiencing serious symptoms or impairment. Mental health disorder diagnosis varied across the participants, with 60% having major depression, 12% bipolar disorder, and the remaining 28% having various other diagnoses including anxiety.

Before treatment, the researchers measured the patients’ belief in God by asking a single question: “to what extent do you believe in God?”, measured on a five-point scale from “not at all (no belief at all)” to “very (a strong sense of belief)”.

The researchers followed up the patients over the course of a year, and assessed four main treatment outcomes:

• treatment response
• degree of reduction in depression symptoms over the course of treatment 
• overall psychological wellbeing
• self-harm behaviours

During the analysis, the researchers controlled for both age and gender as potential confounders, as both were associated with religious belief. They also assessed a range of variables they thought may account for, or mediate, any relationship between belief and treatment outcomes.

These factors included:

• their beliefs about treatment, including credibility (how confident the patients would be recommending the treatment to a friend who was having the same problems), and treatment expectancy (how much improvement in symptoms the patients expected to experience by the end of treatment)
• emotion regulation, which included an assessment of both positive and negative strategies to control emotions 
• degree of support provided by the patients’ congregations, based on two questions regarding the extent to which the patients obtained emotional support from the spiritual or religious communities

 

What were the basic results?

The researchers found that belief in God or a higher power was significantly higher among those patients who responded to treatment compared to those that did not. Also, a higher level of belief was linked with greater reduction in depression symptoms and self-harm behaviours, and greater gains in overall psychological wellbeing over the course of treatment.

The type of religious affiliation – such as Catholic, Jewish or Hindu – had no effect on treatment response or any other psychological or behavioural variables.

Belief in God remained significantly associated with changes in depression and self-harm even after controlling for the patients’ age and gender, two factors that could potentially confound the relationships. The patients’ perceptions regarding treatment credibility and expectations about treatment effects were associated with belief in God.

None of the other variables looked at by the researchers were found to significantly change the relationship between belief and self-harm or psychological wellbeing.

 

How did the researchers interpret the results?

The researchers concluded that, “belief in God, but not religious affiliation, was associated with better treatment outcomes. With respect to depression, this relationship was mediated by belief in the credibility of treatment and expectations for treatment gains”.

 

Conclusion

This research suggests that religious or spiritual belief may be associated with response to treatment for some mental health disorders. However, the study cannot tell us what aspects of belief may be important in terms of this link to depression symptoms, treatment response and overall psychological wellbeing.

The researchers say that their findings suggest that “belief in the credibility of psychiatric treatment and increased expectations to gain from treatment might be mechanisms by which belief in God can impact treatment outcomes”.

They say that it is “notable that faith in treatment was virtually not present in the absence of belief in God, and that few participants with high belief in God had low treatment credibility/expectancy”. They also say that “this may suggest that faith is a general cognitive attribute” that may represent an optimistic outlook in several areas, including the spiritual and medical.

There are some limitations to the study that should be considered, including the facts that:

• All of the participants in this study were in a day-treatment programme for mental health conditions, and all were experiencing symptoms that severely limited their functioning. These participant characteristics make generalisation to less severe forms of these disorders difficult. It is also important to note that the majority of people in the study being treated for mental health conditions (61.6%) reported having a belief in God or a higher power.
• The positive effects of secular or political beliefs were not studied by the researchers.
• The study was highly culturally specific: the majority of participants expressing a religious belief were Christian.
• Belief in God was assessed using a single question, with no mention of the reliability or validity of this question in measuring belief.

This study provides insight into the relationship between faith, or belief, and mental health, and suggests a potential path through which such an association may operate.

Further research could be carried out to measure the size of the effects that believing in a ‘higher power’ (whether a supreme being or a concept of ‘humanity’ and ‘goodness’) may have on mental health outcomes.

 

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter.

Links To The Headlines

The power of prayer: Believing in God can help treat depression. Mail Online, April 25 2013

Links To Science

Rosmarin DH, Bigda-Peyton JS, Kertz SJ, et al. A test of faith in God and treatment: The relationship of belief in God to psychiatric treatment outcomes. Journal of Affective Disorders. Published online October 7 2013

 

'One soft drink a day increases Type 2 diabetes risk by a fifth,' The Independent warns, reporting on a European study that has examined the relationship between type 2 diabetes and sugary drinks.

The study – one of the largest of its kind – found strong links between sugary drink consumption and an increase in a person's risk of developing type 2 diabetes. It attempted to assess the potential effects of various soft drinks on diabetes risk, including:

• sugar-sweetened drinks, such as cola
• artificially sweetened drinks, such as diet cola
• fruit juices and nectars (diluted fruit juices that may contain sugar or sweeteners)

The researchers found that people who drank sugar-sweetened drinks were at a higher risk of developing type 2 diabetes. For every additional regular can-sized, sugar-sweetened drink per day, there was an 18% risk of developing the disease. However, drinking artificially sweetened drinks, juices and nectars was not associated with any increased risk.

While this type of research cannot prove a definite cause and effect between sugary drink consumption and diabetes, it does suggest a strong association. As most popular soft drinks now come in a sugar-free alternative, they would certainly seem to be the healthier choice. But a glass of tap water is both healthier and a lot cheaper.

 

Where did the story come from?

The study was carried out by researchers from Imperial College London and colleagues from eight European countries, and was funded by the European Union.

It was published in the peer-reviewed Diabetologia, the journal of the European Association for the Study of Diabetes, and is freely available to download on an open access basis.

The study was generally covered well by the papers that reported on it. However, many papers reported the increased risk of developing diabetes from drinking sugary drinks as being 22%, which to be fair was included in the press release about the study. The actual risk increase after adjusting for factors such as BMI was 18%.

The Daily Mail also included comments from a spokeswoman for the British Soft Drinks Federation, who sensibly advised that, like most things, soft drinks should be consumed in moderation.

 

What kind of research was this?

This was a case-cohort study in which researchers used data from a large study looking at how lifestyle and genetic factors interact to increase the risk of developing diabetes. Participants in the study were drawn from the UK, Germany, Denmark, Italy, Spain, Sweden, France and the Netherlands.

The study aimed to evaluate the association between the consumption of sweet drinks (juices and nectars, sugar-sweetened soft drinks and artificially sweetened soft drinks) and type 2 diabetes in European adults.

The authors point out that the consumption of sugar-sweetened drinks has been associated with an increase in the incidence of type 2 diabetes, but previous research has largely been in US populations. This means that the same association may not necessarily apply to Europe.

Consumption of sugar-sweetened drinks, they point out, may lead to type 2 diabetes because of its effect on weight gain. These drinks also have a 'glycaemic effect' that can lead to rapid spikes in blood glucose, as well as disturbances to the hormone insulin, which normally regulates blood sugar.

The association between diabetes and other types of soft drinks, such as fruit juice and artificially sweetened drinks, is less clear.

 

What did the research involve?

From the larger study (of 330,234 people), researchers selected 12,403 people who developed type 2 diabetes during the approximately 16 years of the study. Anyone who had existing diabetes at the start of the study was excluded from this group.

A diagnosis of type 2 diabetes was ascertained at each study centre in several ways, including through patients self-reporting and linking to GP and hospital registers, hospital admissions and mortality data. For most countries, researchers sought further evidence for the development of diabetes from a minimum of two independent sources, including independent medical record reviews.

The researchers randomly selected a subgroup of 16,154 individuals from the same study (including 778 who developed diabetes during follow-up) to act as a comparison group. The final sample size was 11,684 type 2 diabetes cases and a subgroup of 15,734 (including 730 diabetes cases).

Both groups had completed dietary questionnaires at baseline assessment, including information about their consumption of soft drinks. For most countries, these were divided into:

• sugar-sweetened soft drinks
• artificially sweetened drinks and juices (100% fruit or vegetables, or concentrates)
• nectars (fruit juices with up to 20% added sugar)

Researchers say there was little standardised information from the different European centres on the distinction between fresh and concentrated fruit juices, or between fruit juices and nectars. These categories were therefore studied in combination. They also excluded Italy, Spain and Sweden from their analyses because data from these countries did not distinguish between the different types of soft drinks.

Sweet drinks were divided into the following categories of average consumption:

• less than one glass a month
• between one and four glasses a month
• more than one to six glasses a week
• one glass a day or more

One glass was equivalent to 250g, the standard serving used in the dietary questionnaire.

Participants also completed questionnaires on other factors that could influence results (confounders), including smoking, alcohol, physical activity and educational level. Body weight and height were measured to calculate body mass index (BMI) and participants were categorised into normal weight, overweight and obese.

Most centres also collected information on any history of chronic conditions, such as high blood pressure, high cholesterol, previous cardiovascular disease, and family history of diabetes.

The researchers used standard statistical methods to analyse the association between soft drink consumption and diabetes. They then adjusted their results for confounders such as lifestyle factors and BMI.

 

What were the basic results?

They found that one 336g (12oz) daily increment in sugar-sweetened and artificially sweetened soft drink consumption was associated with a 22% increase in risk of type 2 diabetes (hazard ratio (HR) 1.22, 95% confidence interval (CI) 1.09 to 1.38) and 1.52 (95% CI 1.26 to 1.83), respectively. An incremental risk applies to someone who had one drink (compared with someone who had none), or someone who had two drinks (compared with someone who had one), and so on.

After adjusting for energy intake and BMI, there was still an association between sugar-sweetened soft drinks and type 2 diabetes (HR 1.18, 95% CI 1.06 to 1.32), but the association with artificially sweetened soft drinks was not statistically significant (HR 1.11, 95% CI 0.95 to 1.31).

The participants' juice and nectar consumption was not associated with type 2 diabetes incidence.

 

How did the researchers interpret the results?

The researchers say the study corroborates previous research on the association between increased incidence of type 2 diabetes and the high consumption of sugar-sweetened soft drinks in European adults, independent of their BMI.

 

Conclusion

This is a large, well-designed European study that appears to confirm the health risks of regularly consuming soft drinks. However, this study did have some limitations:

• Dietary assessments were carried out only once, at the start of the study, so it did not take account of any changes in people's consumption of soft drinks over the years.
• Consumption of soft drinks was self-reported, which introduces the possibility of error.
• The definition of juices and nectars included drinks both with and without added sugar. As the authors point out, the lack of any association between this category and diabetes should be interpreted with caution.
• The study cannot establish whether the consumption of sugary drinks causes diabetes. Its results may have been affected by various other factors (called confounders), although researchers tried to take account of these.

It's important to stay well hydrated, especially in warmer weather, but water is the healthiest choice for quenching your thirst. Or, if you can't do without soft drinks, there is almost always a sugar-free alternative.

 

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter.

Links To The Headlines

One soft drink a day increases Type 2 diabetes risk by a fifth. The Independent, April 25 2013

One fizzy drink a day may raise diabetes risk by fifth. The Daily Telegraph, April 25 2013

Diabetes danger in just ONE sugary drink a day: Chance of developing Type 2 increases by a fifth. Daily Mail, April 24 2013

One fizzy drink a day 'raises the risk of diabetes by a fifth'. Metro, April 25 2013

Links To Science

The InterAct consortium. Consumption of sweet beverages and type 2 diabetes incidence in European adults: results from EPIC-InterAct (note – document is in WinZip format). Diabetologia. Published online April 2013

The MMR vaccine should be given to all unvaccinated schoolchildren aged from 10 to 16 as part of a national catch-up campaign, the government has announced.

This MMR vaccination catch-up campaign aims to prevent further measles outbreaks, following recent outbreaks in Wales.

Speaking at the launch of the national MMR catch-up programme, Professor David Salisbury, director of immunisation at the Department of Health, said that the outbreaks in Wales had been "a wake-up call for parents", and warned that "what is happening in Swansea could happen anywhere in England".

Professor Salisbury urged parents to get their children vaccinated with MMR if they were unsure whether they had previously had the jab.

 

Why is a catch-up programme required?

A catch-up programme is required to protect a generation of children, born between 1997 and 2003, who are unvaccinated or only partially vaccinated against measles.

Low levels of vaccination in this generation were caused by an unsubstantiated scare about the MMR vaccine. The scare was based on an entirely discredited piece of research that claimed that MMR could trigger autism.

Targeting this group of children, estimated to be around one million, will help reduce the potential population in which further measles outbreaks could occur.

 

Why is measles a threat now?

Due to the success of earlier vaccination programmes measles was extremely rare during the 1990s.

This began to change after researcher Andrew Wakefield published a piece of research claiming that there was a link between the MMR vaccine and the developmental condition autism. Despite serious flaws in this research, it received widespread coverage in the media. The research has been proven to be worthless and Wakefield has been struck off the medical register for acting "dishonestly and irresponsibly" in his research and “bringing the medical profession into disrepute”.

Sadly, the damage had already been done – there was a drop in coverage rates (the proportion of people vaccinated against a disease) for measles and this has led to the disease becoming more widespread. In the first quarter of 2013, there were a record 587 cases in England and, worryingly, a number of outbreaks in schools.

Many people mistakenly assume that measles is a harmless childhood disease like chickenpox. This is not the case. Immunisation expert, Dr Mary Ramsey, said: “Measles is not a mild illness – it is very unpleasant and can lead to serious complications as we have seen with more than 100 children in England being hospitalised so far this year”.

Complications of measles include:

• hearing loss, which may be partial or total
• learning difficulties, which may be temporary or permanent
• epilepsy – a condition that causes someone to have repeated fits
• cerebral palsy – a general term for a set of conditions that affect movement and co-ordination
• vision loss, which may be partial or total

 

How will the catch-up programme work?

Around a million at-risk children have been identified using GP records and similar data. Letters are to be sent to their parents recommending that they get their children vaccinated.

Vaccination can take place at GP clinics. There are also plans to set up temporary ‘vaccine clinics’ in schools, community centres and similar locations.

The programme will also be publicised in schools and on Facebook: Get Vaccinated England and Twitter at #gethemmr. The government hopes that the catch-up programme will be completed by the start of the new school year in September.

 

How accurate is the data being used by the programme?

It is thought that the data is both accurate and robust, and that the at-risk children have been identified. Even if a child is wrongly identified as being unvaccinated, receiving extra doses of the MMR vaccine will do them absolutely no harm.

 

Can I get my child vaccinated now?

Yes. You do not have to wait to be sent a letter to get your child vaccinated. If you are worried about your child’s vaccination status make an appointment with your GP as soon as possible.

Edited by NHS Choices. Follow Behind the Headlines on Twitter.

Links To The Headlines

Vaccination campaign launches with hope of halting measles outbreak. The Guardian, April 25 2013

Nationwide Drive To Boost MMR Vaccination. Sky News, April 25 2013

Measles outbreak: race to give a million children MMR jabs. The Independent April 25 2013

MMR vaccine 'only way to protect your child', says immunisation expert. The Daily Telegraph, April 25 2013

Measles epidemic fears: Campaign to urge parents of million children to get MMR jab. Daily Mirror, April 25 2013

One million children and teenagers to get measles jab amid fears of English outbreaks. Daily Mail, April 25 2013

"TV chefs 'adding to obesity crisis by encouraging us to eat fatty dishes'," reports the Metro, with similar stories blaming celebrity chefs for our bulging waistlines in much of the media.

The news is based on analysis of the nutritional values of randomly selected recipes created by celebrity chefs. Researchers found that most of the recipes analysed exceeded national healthy eating benchmarks on fat, saturated fat, sugar and salt intake.

The problem with this study, and the media’s reporting of it, is that it assumes that unhealthy recipes lead to higher rates of obesity, which has not been shown to be the case.

We cannot draw reliable conclusions on the effects of these findings because, for example, we don’t know if these recipes are cooked and eaten frequently and we don’t know how other recipes compare.

It seems unlikely that cooking some of these recipes for a special occasion or as a treat will harm your health, especially if you eat a balanced diet and compensate for treats with healthier options at other mealtimes.

Read more about healthy eating.

 

Where did the story come from?

The study was carried out by researchers from the Department of Health Professions at Coventry University, and was supported by the department and Faculty of Health and Life Sciences, Coventry University.

The study was published in the peer-reviewed journal Food and Public Health and is freely available on an open-access basis.

This story was widely covered, with nearly all papers leading with a headline blaming TV chefs for making us fatter or adding to the obesity crisis. The researchers’ claims that “Celebrity chefs are a likely hidden contributing factor to Britain’s obesity epidemic” were accepted without any serious scrutiny. The study presents no credible evidence that cookbooks containing unhealthy recipes are directly responsible for obesity rates.

Celebrity chefs can have a positive effect on people’s diets, and to blame them for Britain’s rising obesity levels is an oversimplification of the problem.

Somewhat unfairly, many of the news stories featured a photo of Nigella Lawson. While some of her recipes may be unhealthy, the celebrity chefs included in this study were not named.

A similar study, published in 2012, comparing ready meals with celebrities’ recipes was reported in the same uncritical way.

 

What kind of research was this?

This was a cross-sectional study that analysed the nutritional composition of British-based celebrity chefs’ recipes.

The researchers wanted to compare the nutrient content with national benchmark recommendations for certain nutrients and healthy eating guidelines, such as the advice to eat less than six grams of salt a day.

Although this study allows conclusions about the nutritional content of recipes to be drawn, it does not assess the impact of celebrity chefs’ recipes on people’s diets. The findings of this study do not allow us to determine whether celebrity chefs are “adding to the obesity crisis”, because, for example, we don’t know how often these meals are eaten.

 

What did the research involve?

Recipes by celebrity chefs were randomly selected. Celebrity chefs were professional cooks whose recipe books appeared on Amazon’s “top one hundred bestselling books of 2009” or who were featured on the Good Food Channel’s website as a celebrity chef.

To be eligible, recipes had to be suitable for the general public, rather than being targeted at, for example, children or people who wanted to lose weight.

In total, 904 recipes from 26 celebrity chefs were selected at random. All types of recipes (for example breakfast, lunch, starter, evening meal and dessert) were eligible for inclusion.

Researchers used computerised dietary analysis software to work out nutritional content of the recipes. For each recipe they worked out the levels of:

• total energy
• protein
• carbohydrate
• fat
• sodium
• salt

The nutritional value of each recipe was compared against national healthy eating benchmark guidelines using a ‘healthy eating index’, which measured how far each recipe deviated from national recommendations.

 

What were the basic results?

Recipes from the 26 chefs differed significantly in the energy, protein, carbohydrate, fat and salt and sodium content per portion.

Per portion:

• Recipes from 22 of the 26 chefs had fat content on average above the ‘high fat content’ criteria.
• Recipes from 24 of the 26 chefs had saturated fat content on average above the ‘high saturated fat content’ criteria.
• Recipes from 16 of the 26 chefs had sugar content on average above the ‘high sugar content’ criteria.
• Recipes from seven of the 26 chefs had salt content on average above the ‘high salt content’ criteria.

On average, recipes had nutritional levels substantially above healthy eating guidelines (meaning that on average they contained more fat, saturated fat, sugar and salt than recommended).

The researchers calculated that 13% of recipes met or were below healthy eating guidelines (meaning that on average they had less fat, saturated fat, sugar and salt than the recommended limits), whereas 87% exceeded healthy eating guidelines.

Perhaps unsurprisingly, when the meals were analysed by meal type subgroup, desserts were the meal type that exceeded healthy eating guidelines the most.

 

How did the researchers interpret the results?

The researchers conclude that, “although variation in the nutritional composition of recipes existed between celebrity chefs, there was still a general trend whereby excessive amounts of total fat, [saturated fat], sugars and salt were evident. The majority of recipes analysed had unhealthy nutritional compositions in accordance with national healthy eating benchmark recommendations, and therefore celebrity chefs could potentially be a hidden contributory factor to current public health nutrition issues, through exacerbating Britain’s already unbalanced dietary intake”.

 

Conclusion

This study has found that many celebrity chefs’ recipes exceed national recommendations for fat, saturated fat, sugar or salt intake.

However, although the researchers and the media have speculated on the effect that this may have, this research does not investigate this question and no conclusions can be drawn. For example, we don’t know if these recipes are cooked and eaten frequently, and we don’t know how the nutritional value of these celebrity chefs’ recipes compares with more humble cooks’ recipes.

It is also important to repeat the fact that celebrity chefs who targeted their recipes at people concerned about weight management or who were on a diet were excluded from the study.

Often, TV chefs’ recipes are designed to be ‘event meals’, with the meal being cooked for a special occasion such as a birthday or dinner party. It is unlikely that someone would use a cookbook to cook all their meals.

It is similarly unlikely that cooking some of these recipes for a special occasion or a treat will harm your health, especially if you eat a healthy balanced diet the rest of the time.

Read more about healthy eating and good food.

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter.

Links To The Headlines

TV chefs ‘adding to obesity crisis by encouraging us to eat fatty dishes’. Metro, April 24 2013

Television chefs adding to obesity crisis with fatty dishes warn academics. The Independent, April 24 2013

Celebrity chefs 'exacerbate Britain's obesity crisis by encouraging people to eat dishes packed with fat'. Daily Mail, April 24 2013

TV chefs get roasting for 'making us fatter'. Daily Express, April 24 2013

Links To Science

Jones M, Freeth EC, Hennessy-Priest K, Costa RJS. A Systematic Cross-Sectional Analysis of British Based Celebrity Chefs’ Recipes: Is There Cause for Public Health Concern? Food and Public Health. Published online 2013

New proposals to regulate cosmetic procedures were widely reported in the papers today, with the Daily Mail reporting the need to "rein in cosmetic surgery cowboys", and The Daily Telegraph warning that anti-wrinkle treatments are "a crisis waiting to happen".

The stories are based on an independent review of regulations governing the UK cosmetic industry, which is worth an estimated £3.6 billion. The review was chaired by the NHS medical director, Professor Sir Bruce Keogh, who said anyone having cosmetic procedures should be better protected than at present. People carrying out cosmetic procedures should be trained to a high standard, Professor Keogh said.

The review particularly highlights concerns about non-surgical cosmetic procedures, such as:

• dermal fillers (injections of an acid to reduce the appearance of wrinkles and scars)
• Botox (injections of a toxin used to smooth the skin)
• chemical peel (where chemicals are used to remove dead skin)
• laser hair removal

Under current regulations, all of these procedures can legally be performed by anyone, whatever their level of medical training. This is in spite of the fact that, if performed incorrectly, these procedures can result in a range of complications such as burning, scarring, infection and even blindness.

The review proposes that much tighter and rigorous regulation is required for these types of non-surgical cosmetic procedures to ensure their safety.

 

Why was the cosmetic interventions review commissioned?

The review into the regulation of cosmetic ‘interventions’ was commissioned by the government following the scandal over faulty PIP (Poly Implant Prothesis) breast implants, which came to light at the end of 2011.

The report says the scandal exposed “woeful lapses in product quality, aftercare and record keeping” in certain sections of the global cosmetic industry. 

The French-made PIP implants caused global concern after it was revealed they contained industrial-grade silicone rather than medical-grade fillers, and that they were more prone to rupture and leakage. It is estimated that nearly 50,000 women in the UK had the implants, most of which were provided privately.

The events surrounding the PIP implants scandal, says the new report, raised wider concerns about the regulation of cosmetic interventions. These concerns led to troubling questions, such as:

• why such unsafe products were on the market
• why it was difficult to trace women who had had cosmetic implants
• whether vulnerable people were put under “inappropriate pressure” to have cosmetic procedures (for example, whether women with body dysmorphic disorder, a psychological condition that causes people wrongly to perceive defects in their body, were inappropriately treated with cosmetic procedures)

The report points out that cosmetic interventions are a “booming business”. Cosmetic interventions include both surgical interventions such as face-lifts, tummy tucks and breast implants, and non-surgical procedures such as Botox, dermal fillers and the use of laser or intense pulsed light (IPL).

 

What did the cosmetic interventions review find?

The review committee gathered evidence from those working in the cosmetic procedures sector, the public, academics and international policymakers.

Their review report says that cosmetic interventions have become “normalised”, with men as well as women increasingly likely to consider them. It says advances in technology mean there is a growing range of – mainly non-surgical – interventions available.

The report also found that the industry is highly fragmented, with a range of different interest groups, product manufacturers and practitioners. It makes the case that the rapid growth of the sector means that quality control is hard to police. The existing laws have been developed in piecemeal fashion rather than systematically, the report says, with previous attempts at self-regulation by the industry deemed to have largely failed. As a result, someone having a non-surgical cosmetic procedure “has no more protection and redress than someone buying a ballpoint pen or a toothbrush”, the report points out.

The review found that dermal fillers are a particular cause for concern because anyone can set themselves up as a practitioner, with no requirement for knowledge, training or previous experience. There are insufficient checks in place on the quality of the products used during the procedure, the report says, pointing out that “most dermal fillers have no more controls than a bottle of floor cleaner”.

The report also found a need for greater protection for vulnerable people – particularly girls and younger women. It quotes a Guide Association survey that suggested younger people “see cosmetic procedures as a commodity – something they might ‘get done’”, this is attributed, in part, to the influence of “celebrities”.

The report also points out that:

• Cosmetic surgery is not defined as a surgical speciality with a common qualification or an organisation responsible for setting standards.
• There are no restrictions on who can carry out non-surgical procedures.
• Only some of the products implanted or injected into the body are regulated as medical devices.
• There is little reliable data to help people consider the risks and effectiveness of different cosmetic treatments, and consent procedures are poor.
• People are often offered time-limited discounts for surgery – for example, they are given a discount if they sign a binding contract at the end of a first consultation.

 

What recommendations have the review group made?

The review committee’s report concludes that there are three key areas in which change is needed:

• high quality care
• an informed and empowered public
• access to ‘redress’ in case things go wrong

High quality care

The report outlines the need for safer products, more highly skilled practitioners and more responsible providers. It calls for:

• EU regulations on medical devices to be extended to cover all cosmetic implants including dermal fillers, and new UK laws to make this happen sooner
• dermal fillers to be classified as prescription-only
• the Royal College of Surgeons to set standards for cosmetic surgery practice and training and to issue formal certification of competence
• all those performing cosmetic procedures to be registered
• qualifications to be developed for providers of non-surgical procedures
• surgical providers to provide patients and their GPs with proper records – and individual outcomes for surgeons to be made available on the NHS Choices website
• a breast implant registry to be set up within 12 months and extended to other cosmetic devices as soon as possible, to provide better monitoring of outcomes and device safety

An informed and empowered public

The report highlights the need for people to be given accurate advice and for vulnerable people to be protected, specifically calling for:

• the Royal College of Surgeons to develop a patient consent procedure for cosmetic operations that consists of several stages
• the college to develop “evidence-based” patient information on cosmetic procedures, with input from patient organisations – and for these to be made available on the NHS Choices website
• providers of non-surgical procedures to hold a record of their patients’ consent
• existing advertising recommendations and restrictions to be updated and better enforced
• financial inducements and time-limited deals promoting cosmetic interventions to be banned

Accessible resolution and redress

The report wants clear ways for people to be able to take action if anything goes wrong with their cosmetic intervention, calling for:

• the role of the Parliamentary and Health Service Ombudsman (the current role of which is to investigate patient complaints within the NHS) to be extended to cover the whole private healthcare sector including cosmetic procedures of all kinds
• all individuals performing cosmetic procedures to be required to have adequate professional indemnity cover
• surgeons working in this country, but who are insured abroad, to have indemnity insurance that is “commensurate with similar UK policies”
• insurance products to be developed to cover the failure of products and certain complications of surgery

 

What is the best way of finding reputable, effective and safe cosmetic treatments?

If you are considering a surgical procedure, such as breast implants, your GP is often the best person to contact first. As Professor Simon Kay, consultant plastic surgeon and member of the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) explains, “your GP knows the local situation, such as who is a well-established surgeon”.

Make sure you get as much information as you can about the surgery, its potential risks, its perceived benefits and any other relevant information before consenting to surgery. Read more about choosing a cosmetic surgeon.

If you are considering a non-surgical cosmetic procedure, it is important to realise that some people offering these types of treatment may not be medically qualified. The Treatments You Can Trust (TYCT) register can tell you about the qualifications of the provider.

Read more advice about non-surgical cosmetic procedures.

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on twitter.

Links To The Headlines

'Cosmetic crisis' waiting to happen. BBC News, April 24 2013

Q&A: Cosmetic review. BBC News, April 24 2013

Cosmetic surgery crackdown is needed, says NHS medical director. The Guardian, April 24 2013

Anti-wrinkle treatments are a 'crisis waiting to happen', review finds. The Daily Telegraph, April 24 2013

Calls for tighter regulation for cosmetic surgery. ITV News, April 24 2013 

"Smoking just a few cigarettes a day more than doubles a woman's risk of developing rheumatoid arthritis," the Mail Online website reveals. The website reports on a Swedish study that found women who only smoke a small number of cigarettes a day significantly increase their risk of developing the condition.

This large study followed more than 30,000 women over a seven-year period to look at whether smoking increased their risk of developing rheumatoid arthritis. Smoking is already recognised as a possible risk factor for developing the condition. 

But this study showed that the risk increased even at relatively low levels of smoking. It found that even smoking as many as between one and seven cigarettes per day more than doubled a woman's chance (2.31 times) of developing rheumatoid arthritis compared with a woman who had never smoked.

Although this study provides further evidence about the dangers of smoking, it does have a number of limitations. For example, it is not clear how many women dropped out of the study, which could have biased the results. It is also unclear whether similar risk patterns would be seen in men (the condition is more common in women) or a more ethnically diverse group.

Nonetheless, this study provides evidence of yet another disease that smokers may be at significantly increased risk of developing, even if they are considered to be 'light' smokers.

 

Where did the story come from?

The study was carried out by researchers from the Karolinska Institutet in Sweden and was funded by research grants from the Swedish Research Council's Committee for Medicine, Committee for Research Infrastructure for maintenance of the Swedish Mammography Cohort, and the Swedish COMBINE inflammation research consortium.

It was published in the peer-reviewed science journal Arthritis Research and Therapy.

The Mail Online's coverage of the study was generally accurate, and included information about the study sample size and an idea of the prevalence of the condition.

 

What kind of research was this?

This was a cohort study that aimed to discover how much a woman needs to smoke in order to increase her risk of developing rheumatoid arthritis.

The authors pointed out that previous studies have shown that cigarette smoking was directly associated with a higher risk of developing rheumatoid arthritis. What was unclear was whether this risk was associated with so-called 'light' smoking and whether quitting smoking reduced the risk.

The focus of this study was therefore on examining how much the risk of developing rheumatoid arthritis increased depending on how much a woman smoked and how long they had smoked for, and whether it was possible to reduce this risk if a woman quit smoking.

Rheumatoid arthritis is what is known as an autoimmune condition, where the body's own immune system starts to attack the cells that line the joints, causing pain and swelling. Hands, feet and wrists are commonly affected, but it can also damage other parts of the body.

The condition is estimated to affect more than 580,000 people in England and Wales, and occurs more frequently in women than men. It is most common between the ages of 40 and 70, but can affect people of any age.

Exactly how smoking can increase the risk of a person developing rheumatoid arthritis is still uncertain. One theory is that that it can disrupt the normal workings of the immune system, leading to the type of abnormal immune response associated with the condition.

 

What did the research involve?

The researchers used an existing cohort of women called the Swedish Mammography Cohort, which included 34,101 women aged 54 to 89 years. For the current study, the group were followed from January 1 2003 to December 31 2010, in which time 219 cases of rheumatoid arthritis occurred.

Women were asked about various aspects of their diet and lifestyle via questionnaire, as well as additional questions about their smoking habits and history, physical activity, and their use of some medications and dietary supplements.

The current study population of 34,101 excluded women from the mammography cohort who had missing data on their smoking status (797), as well as women with non-rheumatoid arthritis joint conditions (2,052). Women already diagnosed with rheumatoid arthritis were also excluded.

Cases of rheumatoid arthritis were identified by linking the records of women in the cohort to medical databases. The researchers also had access to a national rheumatology register so they would be notified if a diagnosis of rheumatoid arthritis was made.

The analysis estimated the relative risk (RR) between various aspects of smoking behaviour – such as intensity, duration and time since quitting – and the risk of developing rheumatoid arthritis. The analysis took into account a variety of potentially modifying factors (confounders), including alcohol consumption, menopausal status, educational level and body mass index.

 

What were the basic results?

Over the seven-year study period, 219 cases of rheumatoid arthritis occurred from within the group of 34,101 (0.6% of the cohort). There was a statistically significant association between smoking intensity and the risk of developing rheumatoid arthritis.

Women who smoked between one and seven cigarettes per day were 2.31 times more likely to develop the condition compared with never smokers (RR 2.31 95% confidence interval (CI) 1.59 to 3.36) over the course of the seven-year study.

There was also a statistically significant association between how long a woman had smoked for and the risk of developing rheumatoid arthritis. Women who had been smoking for between one and 25 years were 1.60 times more likely to develop the condition compared with never smokers (RR 1.60, 95% CI 1.07 to 2.38).

Compared with never smokers, the risk for these smokers was still significantly elevated (to about twice the risk of never smokers) 15 years after the women had quit smoking (RR 1.99, 95% CI 1.23 to 3.20).

Among former smokers, there was a suggested trend that the risk of rheumatoid arthritis decreased over time since stopping smoking. For example, women who stopped smoking 15 years before the start of the study had a non-significant 30% lower risk of rheumatoid arthritis compared with those who had stopped only a year before the start of the study (RR 0.7, 95% CI 0.24 to 2.02).

 

How did the researchers interpret the results?

The researchers concluded that, "even light smoking is associated with increased risk of rheumatoid arthritis in women and that smoking cessation [stopping smoking] may reduce, though not remove, this risk".

 

Conclusion

This research indicates that a relatively low level of smoking (one to seven cigarettes per day) is associated with an increased risk of developing rheumatoid arthritis compared with women who had never smoked. This adds further knowledge to previous research that has suggested that cigarette smoking is directly linked to a higher risk of developing rheumatoid arthritis.

While this study is relatively robust and its results believable, it does have limitations that should be considered. It was not clear how many women dropped out of the study. If this was a large proportion of the women who started, it could significantly bias the results of the study.

The study also only recruited women. The same risk pattern may not have been seen if the study had recruited men, who are at lower risk of developing the condition than women. Similarly, the size of the risk differences between different smoking behaviours may be slightly different in men than women. Further research is needed to establish whether this is the case.

Another drawback is that women were recruited from just two Swedish counties. While no ethnicity data was reported, it is likely they were fairly similar ethnically, and it could be that different ethnicities may have different risk profiles for developing rheumatoid arthritis. This means that the results may differ if the study was repeated in a more ethnically diverse population.

This relatively robust study suggests that smoking can significantly increase a woman's risk of developing rheumatoid arthritis compared with women who never smoked, even if a woman only smokes relatively low levels of between one and seven cigarettes per day.

It adds to a growing body of evidence that there is no such thing as a safe level of smoking. Aside from the risk of rheumatoid arthritis, 'light' smoking can significantly increase your risk of developing lung cancer, heart disease and stroke.

Read more about how the NHS can help you quit smoking.

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter.

Links To The Headlines

Smoking just a few cigarettes a day can double a woman's risk of arthritis. Mail Online, April 22 2013

Links To Science

Giusueppe DD, Orsini N, Alfredsson L, et al. Cigarette smoking and smoking cessation in relation to risk of rheumatoid arthritis in women. Arthritis Research and Therapy. Published online April 22 2013