NHS Choices

Toothbrushing advice 'conflicting'

NHS Choices - Behind the Headlines - Tue, 12/08/2014 - 11:15

"Teeth-brushing advice unacceptably inconsistent," reports The Guardian, while the Mail Online states that a "simple, gentle scrub is best".

These headlines relate to a small literature review that found diversity in the methods of manual toothbrushing recommended by dental associations, toothpaste and toothbrush companies, dental textbooks, and experts in 10 countries. The study authors concluded that this inconsistency "should be of serious concern to the dental profession".

The diversity of advice across the countries was thought to be because of a lack of good evidence about which toothbrushing technique is most effective, which further research could address.

The study has several limitations, but these are unlikely to change its overall message. Despite its small and imperfect nature, this literature review highlights a fundamental issue in dentistry – that the toothbrushing techniques currently recommended are probably not strongly evidence based.

This research may spur dental and other related organisations to provide evidence-based guidance on oral hygiene – and to let the public know which brushing technique works best for kids and grown-ups.

 

Where did the story come from?

The study was carried out by researchers from the Department of Epidemiology and Public Health at University College London (UCL), and was published in the peer-reviewed British Dental Journal.

No funding source was reported.

Generally, the media reported the story accurately, with the Mail Online including an instructional video of a man brushing his teeth circularly. However, given the research's conclusions, there is no guarantee this is the most effective technique.

 

What kind of research was this?

The researchers say dentists, dental associations and government bodies all recommend regular daily toothbrushing because it is so important for preventing periodontal disease and caries.

However, there appears to be no consensus among professional bodies on the best method of toothbrushing for the general population, or for people of different ages or with particular dental conditions.

This study aimed to investigate this by conducting a literature review assessing methods of toothbrushing recommended for both adults and children.

 

What did the research involve?

The research involved examining online material on methods of toothbrushing from:

  • dental associations
  • toothpaste and toothbrush companies
  • associated organisations providing professional advice
  • dental textbooks

The consistency of recommendations from different sources was compared narratively.

The study mainly used simple Google and Google Scholar search strategies to identify relevant material, and focused their search remit on 10 countries they deemed to have the highest dental research and recommendation outputs: Australia, Brazil, Canada, Denmark, Finland, Japan, Norway, Sweden, the United Kingdom and the United States. Google Translate was used to translate non-English websites.

A score sheet was used to record relevant information, and the techniques were categorised based on the angle of the toothbrush bristles and the movement of the toothbrush head.

Supplementary information on toothbrushing frequency, duration and powered toothbrushing recommendation was collected.

Pictures and videos that were sourced were reviewed independently by three dentists, and a consensus view was recorded on the techniques they showed.

 

What were the basic results?

Of 66 sources located, 58 had one or more items of codeable data, while eight sources did not have any useable data. It was not possible to discern a brushing technique from 19 of the sources.

The main finding was evidence of vast diversity between recommendations on toothbrushing techniques, how often people should brush their teeth, and for how long.

Links To The Headlines

Teeth-brushing advice unacceptably inconsistent, study finds. The Guardian, August 8 2014

Revealed, the perfect way to brush your teeth: Forget fancy circular motions – a 'simple, gentle scrub is best'. Mail Online, August 8 2014

Links To Science

Wainwright J and Sheiham A. An analysis of methods of toothbrushing recommended by dental associations, toothpaste and toothbrush companies and in dental texts. British Dental Journal. Published August 8 2014

Categories: NHS Choices

Growth of newborn babies' brains tracked

NHS Choices - Behind the Headlines - Tue, 12/08/2014 - 11:15

"Scans chart how quickly babies' brains grow," reports BBC News Online.

The headline follows a fascinating study that shows newborn babies' brains are about a third the size of an adult's at birth, and rapidly grow to just over half the size of an adult's within three months.

The study involved 87 healthy babies who were given an MRI brain scan within the first week of life. Most then had a second scan after a month, and some had a third scan aged around three months. The researchers measured the size of the different major structures of the brain and calculated the growth rate.

The speed of growth was greatest just after birth, increasing by 1% per day, gradually tailing off to 0.4% per day by 90 days. The baby boys' brains were slightly larger than the baby girls' brains just after birth (347cm3 compared to 335cm3) and had grown slightly faster by 90 days (66% of the size) compared with female brains (63%).

Studies such as this can help our understanding of brain development, which could help unearth abnormal processes and certain developmental conditions. Being able to monitor brain development over time with an investigation that does not appear to have any side effects is also welcome. But this small study can't be used on its own as a reference for what's normal.

 

Where did the story come from?

The study was carried out by researchers from the University of California, the University of Hawaii and the Norwegian University of Science and Technology.

It was funded by the National Institutes of Neurological Disorders and Stroke, the National Institute on Drug Abuse, and the National Institute on Minority Health and Health Disparities.

A clear conflict of interest was reported by one of the study authors, who is a founder and equity holder in CorTechs Labs – a company selling software that analyses brain volumes from MRI scans and compares these volumes to norms.

The study was published in the peer-reviewed medical journal, JAMA Neurology.

The BBC reported the study accurately.

 

What kind of research was this?

This was an observational study aiming to plot the brain development of healthy babies using repeated MRI scans.

The researchers say there are usually problems obtaining a useable MRI image for newborn infants because it is hard to get the baby to stay still, head sizes change rapidly during the first few months, and the shape of the head may have been affected by birth.

To add to the difficulties, all of the neurones are already present but squeezed into a third of the size of an adult brain, making images more difficult to interpret.

The researchers wanted to chart normal development in babies who were not distressed by illness and therefore able to sleep during the scan.

This information could provide a benchmark that could help work out how and when all sorts of disorders start to occur, and therefore potentially lead to new treatments. 

 

What did the research involve?

The researchers gave 87 babies (39 boys and 48 girls) an MRI scan about a week after birth. The scan was conducted while they were asleep, so no sedation was required.

A repeat scan was performed on 57 babies after one month, and 49 of them had a third scan two months later.

The researchers measured the size of the different major structures of the brain and calculated the growth rate.

Data was collected regarding the ethnicity of the child and the mother's medical history and use of medication during the pregnancy.

Babies were excluded from the study if:

  • they had any known neurological disorders or abnormalities 
  • they had any newborn illness requiring more than one week in intensive care
  • there was a brain abnormality
  • they had overt perinatal TORCH infections (toxoplasmosis, other, rubella, cytomegalovirus or herpes simplex) at birth, or a major neurological disorder since birth 
  • there was any chromosomal anomaly
  • there were any other contraindications for MRI studies
  • the mother tested positive for HIV infection 
  • the mother had smoked tobacco cigarettes or had more than three alcoholic drinks a month during the pregnancy

 

What were the basic results?

The baby boys' brains were slightly larger than the baby girls' brains just after birth (347cm3 compared to 335cm3).

The longer the gestational age, the bigger each section of the brain, apart from the pallidum (an area that may be important in reward and motivation) and the third ventricle (a cerebrospinal fluid-filled area involved in communication between different areas of the brain).

By 90 days, the brains had grown by nearly two-thirds, with male brains growing slightly faster (66%) compared with female brains (63%).

The highest area of growth was the cerebellum at the back of the brain, which controls movement, co-ordination and balance. This had grown by 113% in males and 105% in females.

The slowest area was the hippocampus, which is known to be involved in memory formation – on average, this grew by 47%.

On average, the brains grew from 33.5% of the average size of an adult's brain to 54.9% by 90 days.

The speed of growth was greatest just after birth, at 1% per day, gradually reducing to 0.4% per day by 90 days.

Most of the babies were of mixed race (54%), then native Hawaiian/Pacific islander (22%), Asian (13%), white non-hispanic (8%) and black (1%).

 

How did the researchers interpret the results?

The researchers reported that they have "accurately mapped out early postnatal whole-brain growth trajectories for male and female infants", which they believe is the first time this has been done.

They say if the study is repeated on a larger and more diverse group of babies, this information could provide a reference point to measure brain growth in babies who have had a brain injury, and for monitoring the effects of any treatments.

 

Conclusion

This study has mapped out the growth rate of the major structures of the brain in 87 apparently healthy neonates from within a week of birth up to 90 days.

A study of this nature can help our understanding of the growth and development of the brain and our ability to monitor brain development over time. The fact the investigation had no apparent side effects is also welcome.

However, as the authors point out, the relatively small size of the study means the results cannot be used as a reference for normal development. Larger and more ethnically diverse studies would be required.

The goal of establishing data for a reference for normal development ties in with the commercial conflict of interest mentioned earlier, as one of the authors founded a company which sells software that analyses brain volumes from MRI scans and compares these volumes to norms.

Currently, brain growth is estimated using a measuring tape to chart the baby's head circumference over time.

The circumference is compared against established norms, with deviation from the norm a potential indication of problems in development and warranting further investigation.

The MRI technique offers a potentially more accurate way of measuring growth or confirming abnormality of growth.

Assessing every child's brain development through an MRI scan is not practical and is probably not the intended endpoint. So the real use of this developing knowledge and technology appears to be providing some evidence to help establish a reference for what is normal and what is abnormal. This could allow abnormalities to be detected earlier than we can currently.

However, there would still need to be a decision made about which babies should be scanned. This would most likely be those at a higher risk of developmental problems, possibly because of a family history or a traumatic birth or pregnancy.

This study highlights the importance of the first few months of life on brain development. This can be supported, if possible, by breastfeeding a baby.

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

Links To The Headlines

'Scans chart how quickly babies' brains grow'. BBC News, August 12 2014

Links To Science

Holland D, et al. Structural Growth Trajectories and Rates of Change in the First 3 Months of Infant Brain Development. JAMA Neurology. Published August 11 2014

Categories: NHS Choices

Exercise may cut breast cancer risk, study finds

NHS Choices - Behind the Headlines - Mon, 11/08/2014 - 11:34

"Exercise lowers risk of breast cancer after menopause," reports The Independent. This and similar headlines were sparked by a large study of postmenopausal teachers that found increased recreational activity was associated with a 10% decrease in the risk of breast cancer.

The risk reduction eroded among some women who became less active over the years, suggesting keeping up a certain level of activity might be important in maintaining the benefits.

The study used questionnaires to estimate the levels of walking, cycling and sport the women did outside of work.

It found women who did the equivalent of walking at least four hours a week or doing sport for two hours a week had a reduced risk of breast cancer. Factors such as body mass index (BMI) did not change the results.

However, the majority of women in the study had a healthy BMI and were teachers, so the results may not be applicable to all postmenopausal women.

Lack of physical activity and excess body fat have been linked to an increased risk of many cancers, including breast, colon, endometrial (lining of the womb) and prostate cancer, as well as heart disease, stroke and diabetes.

Despite the limitations of this study, taking regular exercise such as walking has been found to have wide-reaching benefits – the 30 minutes a day suggested in much of the news coverage is enough to get your recommended 150 minutes of exercise a week.

 

Where did the story come from?

The study was carried out by researchers from the Nutrition, Hormones and Women's Health team at the CESP Centre for Research in Epidemiology and Population Health, Université Paris Sud, Université Hospital and the Université d’Auvergne in France.

It was funded by the Institut National du Cancer, the Fondation de France and the Institut de Recherche en Santé Publique.

The study was published in the peer-reviewed medical journal Cancer Epidemiology, Biomarkers and Prevention.

The media reported the study accurately, but did not point out that the study only involved teachers, most of whom were a healthy weight.

 

What kind of research was this?

This was a prospective cohort study looking at the association between the amount of exercise postmenopausal women did and their risk of breast cancer.

The researchers wanted to see whether exercise levels reduced the risk of breast cancer, and whether it mattered if the exercise was recent or several years before.

As this is a cohort study, it can only show an association between the two – it cannot prove that regular exercise can prevent or delay breast cancer.

 

What did the research involve?

The researchers used information gathered from a large prospective cohort study of female teachers in France conducted from 1993 to 2005.

The 59,308 postmenopausal women filled in questionnaires in 1993, 1997 and 2002 on their health status and levels of physical activity. The researchers verified the women's self-reported breast cancer by checking pathology reports and the national cause of death registry.

Physical activity level was assessed by asking the women to estimate the amount of time they spent in a typical week in both the summer and winter:

  • walking (including walking to work, shopping and leisure time)
  • cycling (including cycling to work, shopping and leisure time)
  • doing sports

The level of activity was averaged over these two weeks and graded by metabolic equivalent task (MET). One hour walking was equivalent to three MET hours, while one hour cycling or doing any sport was given six MET hours.

Women were excluded if they had:

  • cancer at the beginning of the study
  • cancer before the menopause (other than basal cell carcinoma)
  • never menstruated
  • missing information on physical activity level
  • been in the top 1% of reported physical activity

The researchers analysed the results according to the level of physical activity reported in each of the three questionnaires. These were adjusted to take into account:

  • age
  • BMI
  • energy intake
  • alcohol use
  • family history of breast cancer
  • history of benign breast disease
  • age of starting their periods and the menopause
  • use of HRT
  • the number of children they had given birth to before and after the age of 30

 

What were the basic results?

The average length of follow-up was 8.5 years. During this time, 2,155 women developed breast cancer. Most of the women (73%) had a BMI between 18.5 and 25.

The researchers calculated that women with levels of recreational activity of more than 12 MET hours a week in the previous four years had a 10% lower risk of breast cancer than those with a lower level (hazard ratio [HR] 0.90, 95% confidence interval [CI] 0.82 to 0.99).

This remained the same after taking numerous other factors into account, including BMI, waist circumference, recent change in weight, sports activities from the age of 8 to 15 years, and the use of progestogen or oral contraceptives.

Women who had done more than 12 MET hours of exercise a week five to nine years ago, but who then became less active, had a 16% increased risk of breast cancer than those who remained active (HR 1.16, 95% CI 1.01 to 1.35).

If activity levels remained the same five to nine years earlier and in the last four years, the activity level during those five to nine years was not significantly associated with breast cancer risk (HR 1.04, 95% CI 0.92 to 1.18).

There was quite a high rate of change in reported levels of physical activity, with a fifth (21%) moving from more than 12 MET hours a week to less than 12 MET hours a week in at least two consecutive questionnaires, and a fifth (20%) moving from less than 12 MET hours a week to a higher level.

 

How did the researchers interpret the results?

The researchers concluded that, "Recent recreational physical activity, even at a modest level, was associated with a breast cancer risk reduction in postmenopause; this association seemed to attenuate a few years after activity stops."

 

Conclusion

This large study has shown that increased exercise is associated with a reduced risk of breast cancer for postmenopausal women. Strengths of the study include the large number of women and that self-reports of breast cancer were verified by a pathology report in 94% of cases.

However, as the authors point out, a limitation of this study is that it was conducted on a group of teachers who were mainly of a healthy weight. This means the results may not be applicable to women of a different weight with different occupations, including more or less sedentary jobs.

The study also relied on self-reported exercise levels, which may not be entirely accurate. It also only looked at recreational physical activity, so did not include any physical activity at work (for example, it didn't distinguish PE teachers from teachers of other subjects).

For the women who developed breast cancer, it is not clear whether the diagnosis occurred before or after the levels of physical activity reduced.

Lack of physical activity and excess body fat have been linked to an increased risk of many cancers, including breast, colon, endometrial (lining of the womb) and prostate cancer, as well as heart disease, stroke and diabetes. Regardless of the limitations of this study, it is still advisable to take regular exercise.

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

Links To The Headlines

Breast cancer risk lower in women who walk 30 minutes a day for years. The Daily Telegraph, August 11 2014

Exercise lowers risk of breast cancer after menopause. The Independent, August 11 2014

Women who walk regularly cut risk of breast cancer. Daily Express, August 11 2014

How a daily walk can cut breast cancer risk: Older woman told it's never too late to start exercise. Daily Mail, August 11 2014

Links To Science

Fournier A, et al. Recent Recreational Physical Activity and Breast Cancer Risk in Postmenopausal Women in the E3N Cohort. Cancer Epidemiology, Biomarkers and Prevention. Published August 11 2014

Categories: NHS Choices

'Safe' stem cell therapy may help stroke recovery

NHS Choices - Behind the Headlines - Mon, 11/08/2014 - 11:13

BBC Online today reports that "Stem cells show promise in stroke recovery".

This accurate headline comes from a study showing how a new technique using a patient's own stem cells to aid recovery from severe ischaemic stoke is feasible and appears to be safe.

But the study was tiny – just five people had the treatment. The study was also not designed to test whether the technique was effective, only whether it was feasible and safe.

This means we cannot be sure the improvements seen in the patients were caused by the stem cell treatment itself. They could have occurred anyway as a natural path of recovery post-stroke – a point the study authors explained.

A much larger trial that compares this stem cell treatment with the best available care would be needed to prove effectiveness, and is a logical future step for this treatment in development.

The well-worn path of treatment development is often long and costly, but is designed to protect patients from potentially harmful treatments, and weeds out all the treatments that are not effective.

However, we should not ignore the fact the technique was well tolerated in the five people and did not appear to lead to any side effects in the six months it was evaluated – a promising result.

 

Where did the story come from?

The study was carried out by researchers from Imperial College Healthcare NHS Trust and Imperial College London.

It was funded by Omnicyte Ltd – a British-based biotechnology company specialising in extracting the therapeutic potential and benefits of stem cell technologies.

The study was published in the peer-reviewed science journal, Stem Cells Translational Medicine.

Generally, the media reported the story accurately, with the BBC explaining that the treatment was in its very early stages and that this latest study was designed to test the safety and feasibility of the stem cell treatment, rather than its effectiveness.

 

What kind of research was this?

This was a proof-of-concept, non-randomised, open-label, human trial. It looked at whether a new stem cell infusion technique in development was feasible and safe to treat patients with acute severe stoke within seven days of it occurring.

The study focused on people who'd had an ischaemic stroke – when blood supply to the brain is cut off either because of a narrowing of the vessels supplying the brain, or because there is a blood clot in these vessels. Most strokes happen suddenly, develop quickly and damage the brain within minutes.

The study was a small feasibility study, meaning it was not designed to provide solid proof that the treatment worked. Instead, its main aim was to see if the technique was possible to use and was safe in a small number of people.

 

What did the research involve?

The researchers wanted to recruit people who could start treatment within seven days of stroke onset and if they had a stroke with particularly severe characteristics.

According to Imperial College, this "total anterior circulation stroke" (TACS) usually has a poor outcome in most people. Typically, just 4% of people who have a TACS stroke are alive and living independently six months after the stroke. For this reason, any treatments that can improve outcomes are extremely welcome.

The researchers excluded people if they were over 80, "medically unstable", had a significant narrowing of the carotid artery, or declined or were unable to participate. However, the researchers had trouble recruiting enough people with this subtype, so the inclusion criteria were widened to include the partial anterior circulation stroke (PACS) subtype of ischaemic stroke.

In the end, five patients who had experienced a clinically confirmed severe stroke in the past seven days (four had TACS stroke, one had PACS stroke) were recruited (out of 82 screened). Each had a small amount of bone marrow extracted under local anaesthetic.

This bone marrow was purified to isolate the patient's own CD34+ stem cells, which were injected into the patient's arteries one or two days later. Side effects were documented for six months after treatment.

The researchers also recorded the degree to which the stroke impaired normal daily functioning using validated clinical rating scales (National Institutes of Health Stroke Scale and modified Rankin Scale), and how well their brains recovered by looking at MRI scans.   

The researchers said they used CD34+ stem cells because they had improved functional recovery in non-human models of ischaemic stroke by promoting blood vessel and nerve cell growth.

The study was designed primarily to test safety and was not designed to prove whether the treatment significantly improves the lives of the participants with any rigour. Much larger trials involving treatment randomisation and control groups would be required for this.

 

What were the basic results?

The main results were:

  • All five patients reportedly tolerated the procedure well with no complications. There were no recurrent strokes and no nerve deterioration during the six-month follow-up period.
  • All patients showed improvements in the clinical ratings of how their stroke impaired their day-to-day functioning from the start of the trial and six months later.
  • The size of the areas of damage assessed by MRI scan reduced in all patients over the six months by 10% to 60%. The average change was 28% at six months' follow-up.
  • There were no signs of tumour growth or blood vessel malformation, which is a potential side effect of injecting stem cells.

 

How did the researchers interpret the results?

The researchers state they "have demonstrated in a phase I clinical trial that autologous CD34+ stem/progenitor cells [stem cells originating from a patient's own body], delivered directly into the middle cerebral artery within the first week of stroke symptoms, is both possible and safe."

They noted: "All patients showed improvements in clinical scores and reductions in lesion volume within six months. Although such patterns of recovery are well recognised in the usual natural history of strokes, these findings are nevertheless reassuring for future trials of CD34+ cell therapy. In particular, we found no evidence of post-intervention stroke (ischaemic or haemorrhagic), vascular malformation or tumour."

 

Conclusion

This study provides evidence that a new technique using a patient's own stem cells to aid the recovery from severe ischaemic stoke is feasible and appears to be safe. It was not designed to test whether the technique was better than doing nothing or better than other types of care or treatment.

The authors are perfectly clear that this "proof-of-concept study was not designed with a control group or powered to be able to detect efficacy". This means we cannot be sure that the improvements seen in the five patients were caused by the stem cell treatment. They could have occurred anyway as part of the natural path of recovery after a stroke – a point made by the authors.

A much larger trial that compares this stem cell treatment with the best available current care is needed to prove its effectiveness.

It may surprise some people to learn that a trial of a new treatment did not actually set out to test whether the treatment worked. This is normal in the sequence of treatment development.

When researchers find a new potential treatment, usually through animal research, they then need to demonstrate that the treatment is feasible to carry out in humans and, most importantly, that it is safe.

To do this, they typically recruit a small number of people and monitor them intensely – as happened in this study. If the treatment is deemed feasible and safe in this small group, they can design larger trials, which aim to both optimise the treatment and prove that it works.

This well-worn path of treatment development is often long and costly, but is designed to protect patients from potentially harmful treatments and weeds out ineffective treatments.

In a press release, the research team say they aim to develop a drug based on this technology, rather than performing the time-consuming bone marrow extraction, purification and injection steps.

They hope that giving the treatment quickly, and in drug form, is more likely to improve patients' chances of recovery than slower alternatives. To do this, they hope to isolate the biological factors secreted by the stem cells and harness these into a drug.

This could be stored in a hospital to be given quickly to a person admitted to A&E after a diagnosis of stroke. This could potentially shorten the treatment time from days to hours.

However, we should not ignore the fact this latest technique was well tolerated and did not appear to lead to any side effects in the six months it was evaluated – a promising result for the patients and researchers involved. The next test will be to see if it works, and how it compares to other treatments and standard care.

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

Links To The Headlines

'Stem cells show promise in stroke recovery'. BBC News, August 9 2014

Study may help victims of stroke. Daily Mail, August 9 2014

Links To Science

Banerjee S, et al. Intra-Arterial Immunoselected CD34+ Stem Cells for Acute Ischemic Stroke. Stem Cells Translational Medicine. Published online August 8 2014

Categories: NHS Choices

Restaurant dining 'as calorific as fast food'

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

"Eating in restaurants no better than fast food for health," reports The Daily Telegraph after the publication of a study on the calorie intake of eating out.

The US study found people who enjoyed dining at a full-service restaurant consumed just as many calories as those who ate fast food.

Researchers looked at the diets of more than 12,500 Americans and found those who dined out at fast-food restaurants ate 205 calories more than those who ate at home. Those eating out at non-fast-food restaurants were not far behind, at 194 calories extra calories. 

In an interview with The Daily Telegraph, lead study author Dr Binh Nguyen suggested restaurant food was higher in calories than home-cooked food because "they have more energy-dense foods and bigger portions".

However, this seems speculative as the study didn't report  portion size, making it difficult to know what diners were eating and in what quantity. This missing piece of information is important as it has the potential to significantly influence the study's findings.

In the UK, the average person eats one in every six meals outside the home and we consume up to a quarter of our calories when eating out, according to the Food Standards Agency.

Eating out has been linked to a higher risk of being overweight or obese, which increases the risk of weight-related diseases such as cardiovascular disease and diabetes.

For those who want to maintain a healthy weight, being aware of different sources of energy from food and drink may help you achieve your weight-related goals.

This includes awareness of the possible impact of eating away from the home often, where a person has less direct control over their calorie consumption compared with a home-cooked meal.

For more help and advice on healthy living, check out the NHS Choices healthy eating section.

 

Where did the story come from?

The study was carried out by researchers from the American Cancer Society and the School of Public Health at the University of Illinois, and was funded by the US National Heart, Lung and Blood Institute.

It was published in the peer-reviewed journal, Public Health Nutrition.

The media generally reported the story accurately, although few explored the potential limitations of the study.

 

What kind of research was this?

This was a cross-sectional analysis of data collected from a large US cohort study looking at whether eating away from the home influenced the number of calories people consumed in a day.

The research authors highlight that, in line with rising rates of obesity in the US, there has been a marked upward trend in total energy intake derived from food consumed away from home.

Given the large and increasing numbers of people eating away from home, the researchers wanted to assess the effect of fast-food and full-service restaurant consumption on adults' energy intake and dietary indicators.

 

What did the research involve?

The study recruited non-pregnant adults aged from 20 to 64 who were taking part in a large US nationally representative study called the National Health and Nutrition Examination Survey between 2003 and 2010.

Participants completed two dietary interviews on non-consecutive days, where they reported all foods and beverages consumed in the previous 24 hours. Based on this information, calorie consumption – a measure of the energy content of food and drink – was estimated.

The survey participants were also asked about the source of each food and beverage item in terms of where it came from – for example, from a shop, fast-food restaurant or full-service restaurant.

The full sample included 12,528 people, who completed dietary recall interviews on both days. Those with missing data were excluded from the results.

The main analysis compared the calorie intake of people who reported eating out at fast-food restaurants or full-service restaurants with those who reported eating at home. They also analysed sugar, salt and fat intake.

 

What were the basic results?

The main result was that eating at fast-food and full-service restaurants was associated with consuming more calories.

Fast-food and full-service restaurant consumption was associated with an increase in daily total energy intake of 194kcal and 205kcal respectively, and higher intake of saturated fat (3.48g and 2.52g) and salt (296.38mg and 451.06mg).

Black adults consumed more calories from eating out compared with their white and Hispanic counterparts, the study found. The same was true for middle-income compared with high-income adults.

 

How did the researchers interpret the results?

The study authors found that "adults' fast-food and full-service restaurant consumption was associated with higher daily total energy intake and poorer dietary indicators".

They observed that people did not compensate for this calorie surplus by reducing their energy intake over the rest of the day, which meant their overall calorie intake was higher on days when they ate out.

 

Conclusion

This large study of US adults suggests people eating away from home consume around 200 extra calories compared with people eating at home in any single day. The added calories associated with eating out were similar, regardless of whether people went to a full-service restaurant or a fast-food restaurant.

While the broad conclusions of the study are perfectly plausible, there are a number of limitations to be aware of.

The information on diet came from asking people to recall what they ate in the previous 24 hours, which might be prone to error. People can over or underestimate their food intake and portion size, which would influence the calorie consumption calculation and potentially bias the results.

The analysis did not take into account physical activity levels, so in theory people may have been able to burn off some of the added calories associated with eating out. Related to this, people may eat more after being physically active because of an increase in appetite.

The point is that calories consumed are only one side of the weight equation, the other side being calories burned. We therefore cannot tell whether these added calories actually contributed to long-term weight gain or an increase in disease risk.

The study did not report what the people ate or their portion size, as they were eating outside the home. There was also not enough information to glean details about what types of restaurant food might be better or worse for adding calories.

The study was based in the US, and although the UK diet is similar, there may be important differences in terms of the type of restaurant food and portion size, which means the study's results are less applicable to people in the UK.

However, we should not be complacent as many trends and findings in the US are applicable to the UK in many ways.

Overall, this study serves to remind anyone conscious of their weight to be aware of the potential effects of eating out regularly.

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

Links To The Headlines

Eating out IS worse for your waistline than dining at home: Average restaurant meal contains 200 extra calories - regardless of whether it's fast food or fine dining. Mail Online, August 8 2014

Eating in restaurants no better than fast food for health. The Daily Telegraph, August 8 2014 

Links To Science

Nguyen BT and Powell LM. The impact of restaurant consumption among US adults: effects on energy and nutrient intakes. Public Health Nutrition. Published online July 30 2014

Categories: NHS Choices

Dieting leaves some people 'feeling depressed'

NHS Choices - Behind the Headlines - Fri, 08/08/2014 - 12:26

"It's official; dieting does make us depressed," laments the Mail Online, following the publication of a study on how losing weight affects a person’s mood.

A study of 1,979 overweight and obese people found that those who lost 5% of their bodyweight were nearly twice as likely to feel some symptoms of depression, compared with those who stayed a similar weight.

As expected, it found that losing weight reduced the risk of high blood pressure and lowered levels of fats in the blood, thereby benefiting their health.

However, people who lost weight over the course of the four-year study were 78% more likely to report feelings of being in a “depressed mood” compared with participants whose weight remained stable.

Despite the headlines, the study did not prove that weight loss caused a depressed mood, as the weight loss and the change in mood occurred over the same time period.

Further studies will be needed to establish whether weight loss can cause a depressed mood.

How participants lost weight was not reported, so we can’t tell if they followed any particular diet or physical activity regime that lowered their mood. As a result, the Daily Mail’s headline of  “Dieting DOES make us depressed – even though we're healthier” is not justified, based on this study.

Overall, this study suggests that spontaneous weight loss is beneficial for people’s health, but the psychological effects are less clear – and potentially negative. These results may be worthy of further investigation.

 

Where did the story come from?

The study was carried out by researchers from University College London (UCL). It was funded by the National Institute on Aging and a consortium of UK government departments coordinated by the Office for National Statistics (ONS).

The study was published in the peer-reviewed science journal PLOS One, with the full article free to read online.

The assertion that it is “official” that “Dieting DOES make us depressed – even though we're healthier” is not justified based on this study. This is because the study did not assess depression, and we have no evidence that the people went on a diet to lose weight. They could equally have eaten the same foods as they usually do and increased their exercise a little. How the people lost weight was not reported. 

 

What kind of research was this?

This was a cohort study looking into the physical and psychological effects of weight loss in overweight or obese adults aged 50 years or older.

The researchers flag up how weight-related diseases, such as diabetes and cardiovascular disease, are on the rise, with health organisations worldwide advising overweight and obese adults to reduce their body weight. The physical benefits of weight loss are well established, but the psychological benefits are less clear.

Studies on individuals have found positive psychological benefits, but large population studies have not. This, the authors thought, might be due to the inclusion of healthy-weight individuals who have never had to lose weight.

The research group decided to examine changes following weight loss in a cohort of exclusively overweight/obese adults, to see whether there were psychological gains masked in previous studies.

 

What did the research involve?

The team collected information from 1,979 overweight and obese adults (BMI equal to or higher than 25kg/m2; age 50 and above), free of long-standing illness or clinical depression at baseline, recruited from the English Longitudinal Study of Ageing. During a four-year period, researchers monitored their weight, blood pressure and the level of lipids (fatty substances) in their blood, as well as their mood and wellbeing.

The main analysis looked at whether there were any differences in psychological measures between those who lost weight, compared to those who didn’t.

Participants were grouped according to four-year weight change:

  • participants losing 5% or more in weight
  • participants gaining 5% or more
  • participants whose weight didn’t move up or down by more than 5%

The main measures of psychological wellbeing used were:

  • depressed mood (eight-item Center for Epidemiologic Studies Depression score four or more, includes questions like "Over the last week have you felt sad?" with yes/no response options)
  • low wellbeing (scoring less than 20 on the Satisfaction With Life Scale score)

The main measures of physical wellbeing and disease risk used were:

  • hypertension (systolic blood pressure equal or above140 mmHg or taking anti-hypertensives)
  • high triglycerides (equal or above1.7 mmol/l)

The main analysis controlled for the effects of age, sex, wealth, weight loss intention, major life events that might be stressful, and impact on weight and wellbeing, as well as their health at the start of the study.

 

What were the basic results?

Around 15% of people in the overweight and obese group lost 5% or more of their bodyweight over the four-year period, and a similar proportion gained 5% or more. The vast majority, however, remained a similar weight.

Psychological wellbeing deteriorated (increased rates of depressed mood and low wellbeing) between the start of the study and follow-up across all three-weight change groups.

People who lost 5% or more of their body weight were nearly twice (78%) as likely to report feelings of a depressed mood compared to those whose weight remained stable (odds ratio [OR] = 1.78 [95% CI 1.29– 2.47]). When this was adjusted for the effect of life events the odds ratio fell slightly to OR 1.52, 95% CI 1.07 to 2.17).

The proportion of adults with low wellbeing also increased more in the weight loss group, but the difference was not statistically significant (OR = 1.16, 95% CI 0.81–1.66). In some of the subsequent analysis, weight loss was significantly linked to a lower wellbeing.

Hypertension and high triglyceride prevalence decreased in weight losers and increased in weight gainers (OR = 0.61, 95% CI 0.45–0.83; OR = 0.41, 95% CI 0.28–0.60).

The same results were observed when the researchers accounted for illness and life stress during the weight loss period.

 

How did the researchers interpret the results?

The researchers concluded that “weight loss over four years in initially healthy overweight/obese older adults was associated with reduction in cardio-metabolic risk, but no psychological benefit, even when changes in health and life stresses were accounted for. These results highlight the need to investigate the emotional consequences of weight loss.”

 

Conclusion

This study indicates that overweight or obese people aged over 50 who lose more than 5% or their body weight over four years reap physical benefits, but do not appear to reap psychological benefits; in fact they had worse ratings of “depressed mood” than the people who maintained a stable weight.

The study population is broadly representative of the UK population over the age of 50, and the analysis was appropriate. However, there are limitations to consider when interpreting these findings.

Firstly, the reasons behind the weight loss were not documented – e.g. spontaneous increase in exercise or referral from GP to a weight loss programme. Some reports in the media suggested the low mood might be due to the punitive diets some people might be trying in order to lose weight. However, without more information on the nature and cause of the weight loss, this is pure speculation.

The researchers usefully highlighted the three possible explanations of their results – all of which are plausible, and none can be completely confirmed or dismissed based on this study alone.

  1. weight loss causes depressed mood
  2. depressed mood causes weight loss
  3. weight loss and depressed mood share a common cause

In terms of point one, the authors note that long-term maintenance of weight loss is notoriously hard, with many people failing to keep the weight off. They speculate that this may be a sign of personal costs, strains and difficulties in achieving this, which could affect a person’s mood. This suggests a plausible but unproven mechanism by which weight loss could be a psychological challenge influencing mood and wellbeing. 

In terms of point two, depressed mood may cause weight loss directly or indirectly through changes in appetite or level of physical activity. The design of the study means it was not possible to establish which came first: weight loss or depressed mood..

In terms of point three, some of the obvious common causes of weight loss and low mood include major life events, such as separation or divorce from a partner, or developing an illness – both of which were covered in the analysis. Even though these factors were partially ruled out as a common cause, we cannot rule out other factors as a potential explanation for the results.

Like all cohort studies, some factors may not have been accounted for or may not have been properly measured. A potential confounder in the present study, as noted by the authors, was the presence of underlying disease causing both weight loss and depressed mood. The analysis adjusted for limiting long-standing illness, but this was self-reported rather than diagnosed, so may not be a wholly accurate measure of health status.

Overall, this study suggests that spontaneous weight loss is beneficial for people’s health, but the psychological effects are less clear, and potentially negative. These results may be worthy of further investigation.

 

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

Links To The Headlines

It's official: Dieting DOES make us depressed - even though we're healthier. Mail Online, August 6 2014

Weight loss 'no mood boost even with health benefits'. BBC News, August 6 2014

Links To Science

Jackson SE, Steptoe A, Beeken RJ, et al. Psychological Changes following Weight Loss in Overweight and Obese Adults: A Prospective Cohort Study. PLOS One. Published online August 6 2014

Categories: NHS Choices

Lack of vitamin D may 'raise dementia risk'

NHS Choices - Behind the Headlines - Thu, 07/08/2014 - 18:05

People lacking in vitamin D have a higher risk of developing dementia report several media outlets, including BBC News and The Independent.

A study found people severely lacking in the sunshine vitamin were twice as likely to develop dementia and Alzheimer's disease compared with people with healthy levels (50nmol/l or more).

The findings are based on a study of more than 1,650 people aged 65 and above who were followed over a period of about six years to see if they developed dementia.

Researchers found the higher the vitamin D deficiency, the higher the risk of developing dementia and Alzheimer's disease.

They found severe vitamin D deficiency (less than 25nmol/l) is associated with approximately twice the risk of developing dementia or Alzheimer's disease.

Moderately low levels of vitamin D (between 25nmol/l and 50nmol/l) are associated with a 50% increase in risk.

This study was able to show an association between low levels of vitamin D and the risk of developing dementia. But it does not prove that vitamin D deficiency causes the disease.

Other factors that can increase the risk of developing dementia, including a poor diet, lack of activity and general poor health, can also cause a low vitamin D level.

More research is needed to establish whether eating vitamin D-rich foods, such as oily fish, or taking vitamin D supplements could delay or even prevent dementia.

 

Where did the story come from?

The study was carried out by researchers from the University of Exeter Medical School in the UK, Angers University Hospital in France, and Florida International University, Columbia University, the University of Washington, the University of Pittsburgh, the Veteran Affairs Ann Arbor Center for Clinical Management Research, and the University of Michigan in the US.

This study used data on people taking part in the Cardiovascular Health Study, a cohort study that aimed to investigate the underlying causes of cardiovascular disease.

It was funded by the UK National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for the South West Peninsula.

The study was published in the peer-reviewed journal Neurology and is free to read on the journal's website.

The news coverage was broadly accurate, with a number of stories including quotes from the researchers and other experts pointing out these results do not demonstrate low vitamin D levels cause dementia – they only show an association.

 

What kind of research was this?

This was a prospective cohort study that aimed to determine whether low levels of vitamin D are associated with an increased risk of dementia and Alzheimer's disease.

Cohort studies can show an association, but cannot show low vitamin D levels cause dementia or Alzheimer's disease. This is because there could be other factors responsible for the link seen. Large clinical trials are required to prove increasing vitamin D levels reduces the risk of dementia.

 

What did the research involve?

The researchers studied 1,658 people aged 65 or older who were taking part in a US-based cohort study that aimed to investigate the underlying causes of cardiovascular disease. None of the participants had dementia, heart disease or stroke at the start of the study in 1992.

Blood samples were collected at the start of the study. Researchers used the samples to measure vitamin D levels. They divided people into three categories:

  • severely deficient (vitamin D concentration less than 25nmol/l)
  • deficient (vitamin D concentration between 25nmol/l and 50nmol/l)
  • sufficient (vitamin D concentration 50nmol/l or higher)

The participants were followed for an average of 5.6 years. The researchers looked at whether these people developed dementia or Alzheimer's disease.

A committee of neurologists and psychiatrists reviewed annual brain function tests, brain scans, medical records, questionnaires and interviews, and diagnosed dementia or Alzheimer's disease according to international criteria set by the National Institute of Neurological and Communicative Diseases and Stroke/Alzheimer's Disease and Related Disorders Association.

The researchers compared the risk of developing dementia, including Alzheimer's disease, between people with severely deficient or deficient vitamin D levels and people with sufficient vitamin D levels.

The researchers adjusted their analyses for age, the time of year when vitamin D concentration was measured, education level, sex, body mass index (BMI), smoking status, alcohol consumption and depressive symptoms.

 

What were the basic results?

One hundred and seventy one people developed dementia or Alzheimer's disease during the study. This is equivalent to 10% of the cohort studied.

People with severely deficient or deficient vitamin D concentrations were at an increased risk of developing dementia or Alzheimer's disease:

  • severely deficient vitamin D levels were associated with a 125% increased risk of developing dementia or Alzheimer's disease (hazard ratio [HR] 2.25, 95% confidence interval [CI] 1.23 to 4.13)
  • deficient vitamin D levels were associated with a 53% increased risk of developing dementia or Alzheimer's disease (HR 1.53, 95% CI 1.06 to 2.21)

The researchers also looked at the risk of developing Alzheimer's disease in particular, a common type of dementia. People with severely deficient or deficient vitamin D concentrations were also at an increased risk of developing Alzheimer's disease:

  • severely deficient vitamin D levels were associated with a 122% increased risk of developing Alzheimer's disease (HR 2.22, 95% CI 1.02 to 4.83)
  • deficient vitamin D levels were associated with a 69% increased risk of developing Alzheimer's disease (HR 1.69, 95% CI 1.06 to 2.69)

The researchers repeated their analyses after excluding people who developed dementia or Alzheimer's disease within the first year of the study.

They did this because it has been suggested that people who develop these conditions may change their diet or reduce their outdoor activity, and that might be responsible for the association seen between low vitamin D levels and dementia and Alzheimer's disease.

In this study, the researchers found the association between low vitamin D levels and dementia or Alzheimer's disease remained after the exclusion of people who developed these conditions within one year.

 

How did the researchers interpret the results?

The researchers concluded: "Our results confirm that vitamin D deficiency is associated with a substantially increased risk of all-cause dementia and Alzheimer's disease. This adds to the ongoing debate about the role of vitamin D in non-skeletal conditions."

 

Conclusion

This cohort study of more than 1,650 elderly people has found that over 5.6 years, severe vitamin D deficiency is associated with approximately twice the risk of developing dementia or Alzheimer's disease.

It also found moderate deficiency is associated with a 50% increase in risk compared with healthy levels of vitamin D.

With this being a cohort study, it was not able to show that low levels of vitamin D caused dementia or Alzheimer's disease – it was simply able to show an association.

Other factors that can increase the risk of developing dementia, such as a poor diet, lack of activity and general poor health, can also cause a low vitamin D level.

A further limitation of this study is that the blood samples were only tested for vitamin D levels once. It is not known if any of the participants knew they were deficient and therefore took vitamin supplements during the study period, which could have influenced the results.

Severe vitamin D deficiency can lead to symptoms of lethargy, bone pain, headaches and difficulty concentrating, so it is also conceivable the deficiency was picked up in a number of these people and treated.

More research is needed to establish whether eating vitamin D-rich foods, such as oily fish, or taking vitamin D supplements could delay or even prevent dementia.

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

Links To The Headlines

Low vitamin D 'boosts dementia risk'. BBC News, August 7 2014

Lack of vitamin D raises risk of dementia in later life. Mail Online, August 6 2014

Vitamin D: low levels 'can double dementia risk'. The Independent, August 6 2014

Alzheimer's risk doubles with lack of vitamin D - and upping intake could PREVENT disease. Mirror, August 6 2014

Links To Science

Littlejohns TJ, Henley WE, Lang IA, et al. Vitamin D and the risk of dementia and Alzheimer disease. Neurology. Published online August 6 2014

Categories: NHS Choices

Salt content in cheese 'too high', say campaigners

NHS Choices - Behind the Headlines - Thu, 07/08/2014 - 11:20

"Halloumi and blue cheese saltier than seawater,” reports The Daily Telegraph, following the publication of research on the salt content of cheeses sold in the UK.

Researchers looked at 612 supermarket cheeses and found that salt levels were high. They also found a wide variation in salt content within the same types of cheese.

Halloumi and imported blue cheese contained the highest average amount of salt (2.71g/100g), more salty than seawater (2.5g/100g), whereas cottage cheese contained the lowest average amount of salt (0.55g/100g).

Some types of cheddar – Britain’s best-selling cheese – had much higher levels of salt than others, with supermarket own brands having lower average levels than branded counterparts.

Cheese is one of the top 10 sources of salt in our diet and is widely consumed, with the average person eating 9kg of cheese a year.

Eating too much salt can cause high blood pressure, which can lead to heart disease, stroke and chronic kidney disease.

However, salt is an integral part of the cheese-manufacturing process. It controls moisture, texture and functionality, and also controls microbial growth.

The government has issued voluntary salt targets for specific categories of cheese, to encourage manufacturers to lower their salt content.

This study found that 84.5% of the cheeses in these categories have achieved their target. Unsurprisingly, it found that cheeses without a target had a higher salt content.

Researchers say the salt content in cheese is “unnecessarily high” and are calling for “more challenging salt reduction targets to be set”.

 

Where did the story come from?

The study was carried out by researchers from the Centre for Environmental and Preventive Medicine at Barts, and the London School of Medicine and Dentistry. All researchers are employees, members or the chairman of Consensus Action on Salt and Health (CASH), a non-profit organisation set up in 1996. The study reports that it did not receive funding from any funding agency in the public, commercial or not-for-profit sectors.

The study was published in the peer-reviewed medical journal BMJ Open. It is free to read on the journal's website.

The media’s coverage of the study was generally accurate.

 

What kind of research was this?

This was a cross-sectional survey looking at the salt content of different cheeses sold in UK supermarkets. It aimed to assess whether the salt content had fallen since the government set voluntary targets for some types of cheese.

Eating too much salt puts pressure on the kidneys and can cause high blood pressure. This can lead to heart disease, stroke and chronic kidney disease. High salt intake has also been linked to increased risk of stomach cancer and osteoporosis.

Adults should have no more than 6g of salt per day, according to UK recommendations, although the World Health Assembly has agreed that the target should be for people to consume up to just 5g per day. Current UK consumption levels stand at 8.1g per day. Salt content over 1.5g per 100g in any food is considered high, according to government guidance.

Many cheeses are known to have a high salt content, and on average, the report states that people in the UK consume 9kg of cheese per year. It is therefore important to know which cheeses have a high salt content, so they can be eaten sparingly as part of a balanced diet.

 

What did the research involve?

The researchers surveyed all available cheeses from seven main supermarket chains in the UK by each visiting one large shop. The supermarkets were Asda, Marks & Spencer, Sainsbury’s, Tesco, The Co-operative and Waitrose. Due to resource limitations, only cheddar cheese and cheddar-style cheese products were collected from Morrisons.

They recorded the product name, sodium/salt per 100g, serving size and sodium/salt per portion from the label of each cheese. They categorised and analysed them according to 23 types of cheese, their country of origin, their brand and whether they were on the UK Department of Health's cheese salt reduction target list.

They excluded any cheese that did not have a sample size of at least eight products containing nutrient information on the packaging. This included Jarlsberg, mascarpone, Lancashire, Leerdammer, Maasdam, sheep, Appenzeller, Bavarian smoked and ricotta.

 

What were the basic results?

A total of 612 cheeses were included in the analysis. Halloumi and imported blue cheese had the highest average salt level (2.71g/100g) - saltier than seawater (2.5g/100g) according to CASH followed by some processed cheeses (2.48g/100g). Cottage cheese had the lowest (0.55g/100g).

There was a wide variation in salt content within each category of cheese, and this was particularly marked for parmesan, imported blue cheeses and Emmental.

Cheeses with salt targets had lower levels of salt than those without, and of the 394 cheeses that have voluntary cheese targets, 84.5% have already met their 2012 target.

The salt content of supermarket own-brand cheese was compared with branded cheese for 10 categories of cheese, and researchers found that:

  • Six classes of cheese had higher salt content in branded products than the supermarket's own brand.
  • Four classes of cheese had a higher salt content in the supermarket's own brand compared to a branded version.

 

How did the researchers interpret the results?

“Cheese is unnecessarily loaded with salt,” researchers said in an editorial released with the study. They state in their report that “salt content in cheese in the UK is high. There is a wide variation in the salt content of different types of cheeses and even within the same type of cheese”. Even though 84.5% cheeses are within the voluntary salt targets, researchers say their findings “demonstrate that much larger reductions in the amount of salt added to cheese could be made and more challenging targets need to be set, so that the UK can continue to lead the world in salt reduction”.

 

Conclusion

This study highlights the wide variation in salt content that can be found in cheese. Labelling is now making it easier to make an informed choice regarding where you wish your maximum recommended level of 6g of salt per day to come from. This is particularly important when assessing which cheese is the best option for children, who should consume lower levels of salt.

The study showed that there were many types of cheese that have a reasonably low salt content, including cottage cheese, cream cheese, mozzarella and Emmental. However, cheese is generally calorific, and over-consumption can lead to overweight and obesity and their associated health problems. 

A limitation of this study is that the actual salt content was not independently assessed, but relied on the accuracy of the labels. The authors also acknowledge that they did not investigate how the reduction in salt has been achieved, and there is the possibility that it has been replaced by other additives or ingredients.

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

Links To The Headlines

Concern over salt levels in cheese. Mail Online, August 6 2014

Halloumi and blue cheese saltier than seawater. The Daily Telegraph, August 7 2014

Branded blue cheese and halloumi are 'saltier than seawater'. The Independent, August 6 2014

Cheese too salty and a risk to public health, study finds. The Guardian, August 6 2014

Links To Science

Hashem KH, He FJ, Jenner KH, MacGregor GA. Cross-sectional survey of salt content in cheese: a major contributor to salt intake in the UK. BMJ Open. Published online August 7 2014

Categories: NHS Choices

Saturated fat in dairy 'may protect against diabetes'

NHS Choices - Behind the Headlines - Wed, 06/08/2014 - 15:00

Saturated fat in cheese, yoghurt and other dairy products may protect against diabetes, report the Mail Online, The Daily Telegraph and The Independent.

A study has found that people with higher levels of the types of saturated fatty acid found in dairy products were less likely to develop type 2 diabetes.

Saturated fat – found in butter, cheese and red meat – is generally considered unhealthy and linked to high levels of cholesterol and heart disease, as well as type 2 diabetes.

Researchers looked at blood samples that had been taken from 12,132 people before they developed type 2 diabetes, and compared them with samples obtained from 15,164 healthy people who did not go on to develop diabetes. All participants were from across Europe.

Different types of saturated fat can be identified by looking for chain-like saturated fatty acid molecules, which contain either an odd or even number of carbon atoms.

Analysis of the samples revealed that people with higher levels of “even-chain” fatty acids were more likely to develop diabetes.

Even-chain saturated fatty acids were more likely with diets high in alcohol, soft drinks, margarine and potatoes, although the body can also produce this type of fatty acid.

People with higher levels of “odd-chain” fatty acids in their blood samples were less likely to develop the condition.

Odd-chain saturated fatty acids were more likely through diets high in dairy products, cakes and cookies, nuts and seeds, and fruit and vegetables.

Overall, this study can only tell us that there is an association between the levels of these fatty acids and the risk of developing diabetes – it cannot prove they had a role in causing the condition.

This study furthers understanding of the biological processes that may be associated with type 2 diabetes, but it cannot say that eating dairy is going to cut your risk of this getting chronic disease. 

Despite this, the increased risk from a larger waist circumference, being overweight or obese mean that the amount you eat still needs to be balanced to avoid excess weight gain.

 

Where did the story come from?

The study was carried out by researchers from the University of Cambridge, MRC Human Nutrition Research in Cambridge, the University of Oxford and other universities across Europe. It was funded by the European Commission, the Medical Research Council and the Cambridge Lipidomics Biomarker Research Initiative.

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

This study was not accurately reported by most media outlets. Contrary to several  reports, the study did not prove that saturated fat from dairy products are not bad for health or that they “beat” diabetes. It only showed that a people with a one-off reading of a higher proportion of these types of fats compared to other saturated fats had a reduced risk of developing diabetes. It did not look at any other health outcomes related to dietary intake of dairy products.

The study was also not able to say that people with higher levels of the even-chain saturated fatty acids will develop diabetes, it is only able to show an increased risk.

 

What kind of report was this?

This was a prospective case-cohort study, which looked at the blood levels of different types of saturated fat in people who developed diabetes, compared to a control group who did not develop diabetes over the next 16 years.

They aimed to see if there was a link between any of the nine different types of saturated fatty acids that they measured and type 2 diabetes. As this was a cohort study, it can only show an association between with the levels and the risk of developing diabetes during the study's timeframe. It cannot prove causation.

 

What did the research involve?

The researchers used data from a large study called the EPIC cohort, which followed 340,234 people from eight European countries from 1991 to 2007. From this study, they identified all 12,132 people who did not have a diagnosis of diabetes at the beginning of the study, but who developed diabetes at some point during the 16-year follow-up.

They also randomly selected 15,919 people who did not develop type 2 diabetes. All participants had provided a blood sample at the beginning of the study. They worked out which of these people developed diabetes during the study period from at least two of the following sources: self-report, primary care and secondary care registers, drug registers, hospital admissions and mortality data. This gave them a subgroup of 15,164 people who did not develop type 2 diabetes.

The average age of the participants was 52.

From the blood sample, they measured the levels of nine different types of saturated fatty acids and HbA1C, which is an indicator of type 2 diabetes.

Participants’ weight and height were measured by trained professionals to calculate BMI, and most participants also had their waist size measured. The participants filled in questionnaires on medical history, smoking status, educational level, physical activity level and usual diet over the previous 12 months.

They compared the levels of the different types of saturated fatty acids in the group of people who developed diabetes, compared to those who did not.

 

What were the basic results?

Higher proportions of even-chain saturated fatty acids were associated with a 43% increased risk  of type 2 diabetes, hazard ratio (HR) 1.43 (95% confidence interval (CI) 1.29 to 1.58). There was also a higher proportion in older adults, people with higher BMI and men. Higher even-chain saturated fatty acids were more likely with diets higher in alcohol, soft drinks, margarine and potatoes, and less likely with fruit, vegetables, olive oil and vegetable oil.

Higher proportions of odd-chain saturated fatty acids (mainly from dietary dairy fat intake) were associated with a 30% reduced risk of developing type 2 diabetes, HR 0.70 (95% CI 0.66 to 0.74). The proportion was also higher in people with a lower BMI and women. Higher odd-chain saturated fatty acids were more likely with diets higher in dairy products, cakes and cookies, nuts and seeds, and fruit and vegetables.

Higher proportions of longer-chain saturated fatty acids were associated with a 30% reduced risk of type 2 diabetes, HR 0.70 (95% CI 0.59 to 0.85). Little is known about these fatty acids, but they were associated with a lower alcohol intake.

The results remained significant after taking into account multiple potential confounding factors, such as age, BMI and waist size.

 

How did the researchers interpret the results?

The researchers concluded that odd-chain fatty acids, which mainly come from dairy fat in the diet, are associated with a decreased risk of developing type 2 diabetes. However, they point out that they were not able to rule out the possibility that this association was due to other nutrients present in dairy products, such as vitamin D, calcium or the fermentation process of dairy products.

They also found that even-chain fatty acids are associated with an increased risk of developing type 2 diabetes, but this relationship is more complex and not just related to diet. Even-chain fatty acids can come from a variety of places and not just dietary fat, such as carbohydrates and alcohol, and they can also be produced by the body.

Researchers say further research is required to gain a better understanding of the role of diet in this process before they can confidently advise on dietary intake of saturated fats.

Finally, they report that little is known about the origin or production of longer-chain fatty acids, and they suggest that this should be another area for future research.

 

Conclusion

This study has found an association between higher levels of odd-chain and long chain fatty acids, and a reduced risk of developing diabetes. Higher levels of even-chain fatty acids were associated with an increased risk of developing diabetes.

Strengths of the study include:

  • the large number of participants and diversity, coming from eight European countries
  • a wide range of diets
  • prospective nature of the study, capturing blood levels before diabetes onset
  • diabetes status was not determined by self-report only

However, limitations of the study include:

  • The blood measurement of the saturated fatty acids did not measure the overall amount of saturated fatty acids in the blood, it just looked at the proportion of the different types of saturated fatty acids in each individual. This means that some people may have had high overall levels of saturated fatty acids and some could have had low levels.
  • The blood sample was only taken once at the beginning of the study, and this may not have been representative of normal levels, which fluctuate through diet and activity levels.
  • Reliance on dietary questionnaires being completed accurately.

This study suggests that not all saturated fat may be bad and that the type of dietary saturated fats influence the risk of diabetes, but it does not conclusively show that dairy products are protective. Whatever the case, the increased risk from a larger waist circumference, as well as being overweight or obese, mean that the amount you eat still needs to be balanced to avoid excess weight gain.

 

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

Links To The Headlines

Say cheese: saturated fat in dairy may protect against diabetes. The Daily Telegraph, August 6 2014

Saturated fats that actually BEAT diabetes: Molecules found in some dairy items including yoghurts can cut Type 2 risk. Mail Online, August 6 2014

Some saturated fats could help protect against type 2 diabetes, study finds. The Guardian, August 6 2014

Links To Science

Forouhi NG, Koulman A, Sharp SJ, et al. Differences in the prospective association between individual plasma phospholipid saturated fatty acids and incident type 2 diabetes: the EPIC-InterAct case-cohort study. The Lancet Diabetes and Endocrinology. Published online August 6 2014

Categories: NHS Choices

Daily aspirin 'reduces cancer risk,' study finds

NHS Choices - Behind the Headlines - Wed, 06/08/2014 - 10:39

Taking aspirin every day could cut your risk of developing cancer, report BBC News and The Daily Telegraph among other news outlets, after the publication of a large-scale review of the evidence.

People aged between 50 and 65 who take aspirin every day for 10 years could cut their risk of bowel cancer by 30% and cancers of the throat and stomach by 25%, according to the study published in the Annals of Oncology.

Over 20 years, an aspirin a day would reduce people's risk of heart attacks by 7%, stroke by 9%, and dying prematurely by about 4%. 

Aspirin is an antiplatelet, which means it reduces the risk of clots forming in your blood. Platelets may also protect cancer cells in the body, and it has been suggested aspirin's effect on them may hinder this process. However, the exact mechanism is not well understood and more research is needed.

Taking aspirin every day comes with a serious health warning as it can cause serious side effects such as ulcers and bleeding from the stomach, particularly in elderly people.

However, the researchers argue the benefits of taking the drug need to be balanced against the harms. 

While the findings of this study show promise, it is not clear whether the methods used in compiling it were systematic, so the results may not be entirely reliable.

Anyone thinking of taking aspirin for prevention should talk to their GP first.

 

Where did the story come from?

The study was carried out by researchers from a number of institutions across Europe and the US, including Queen Mary University of London.

It was funded by Cancer Research UK, the British Heart Foundation and the American Cancer Society. The study was published in the peer-reviewed medical journal Annals of Oncology.

Several of the study's authors are consultants to or have other connections with pharmaceutical companies with an interest in antiplatelet agents such as aspirin.

As might be expected with cancer-related news, the research was widely covered in the press. Most of the coverage was uncritical, although most stories warned of the side effects of taking aspirin.

 

What kind of research was this?

This was a review of evidence on the association between aspirin and incidence of deaths from cancer and cardiovascular disease, and potential harmful side effects.

It is not clear whether this was a systematic review, where the evidence is rigorously appraised for its quality and risk of bias. The researchers did not carry out a meta-analysis of the results of studies included, but compiled their own estimates.

The authors say regular aspirin is known to reduce the incidence of cardiovascular disease both in the general population and in high-risk groups, although it is currently only recommended for those at high risk.

However, an increasing body of evidence suggests it may also have a role in cancer prevention. Aspirin is also associated with a risk of bleeding and peptic ulcers. The researchers argue the benefits of taking the drug need to be balanced against the harms.

 

What did the research involve?

Researchers gathered evidence on the effects of aspirin on cancer risk and cancer deaths from systematic reviews published between 2009 and 2012, as well as from some individual studies on specific cancers. Further systematic reviews undertaken by some of the researchers were not included, but were discussed at the "evidence review meeting".

It is not clear how these studies were chosen or whether further studies on the topic were excluded and, if so, what criteria were used to decide which studies to include or exclude.

Evidence for aspirin's effect on cardiovascular disease was taken from one large meta-analysis. The authors based their calculations of the effect aspirin would have on cardiovascular disease by using UK rates from 1998 for cardiovascular-related incidents and deaths, which they adjusted to take account of downward trends in recent years in both the UK and the US.

The researchers used a detailed unpublished analysis of the harmful effects of aspirin.

They calculated the overall benefits and harms for taking aspirin for 10 years, starting at ages 50, 55, 60 and 65, separately for men and women. They made several assumptions in their analysis:

  • the cardiovascular benefit and adverse effects only occur during active treatment (the 10-year period)
  • the protection against cancer begins three years after initiating aspirin and continues for an additional five years after stopping aspirin
  • the protection against cancer mortality begins five years after starting aspirin use and lasts for an additional 10 years after treatment is stopped
  • the protective effects are seen only in colorectal, oesophageal, gastric, breast, prostate and lung cancers

 

What were the basic results?

The researchers calculated that for average-risk individuals aged 50 to 65 taking aspirin for 10 years, there would be a relative reduction of between 7% (women) and 9% (men) in the number of cancer, myocardial infarction or stroke events over a 15-year period, and an overall 4% relative reduction in all deaths over a 20-year period.

Below are their calculations of the effect of aspirin in reducing the risk of cancers and cardiovascular events, giving what the researchers say are "conservative" estimates:

  • colorectal (bowel) cancer – 30% reduction in incidence and 35% reduction in deaths
  • oesophageal cancer – 25% reduction in incidence and 45% reduction in deaths
  • gastric cancer – 25% reduction in incidence and 30% reduction in deaths
  • lung cancer – no reduction in incidence, 10% reduction in deaths
  • prostate cancer – 5% reduction in incidence, 10% reduction in deaths
  • breast cancer – 5% reduction in incidence no reduction in deaths
  • heart attack – 18% reduction in incidence, 5% in deaths
  • stroke – 5% reduction in incidence, 21% increase in deaths

Their calculations on the risk of side effects from taking aspirin are:

  • major (extracranial) bleeding – 70% increase in incidence
  • gastric bleeding – 70% increase in deaths
  • peptic ulcer – 70% increase in deaths

They also say the effects are not apparent until at least three years after starting aspirin and some benefits may be sustained for several years after stopping.

They found no difference between low and high doses of aspirin in terms of health benefits, although there were no studies that did direct comparisons.

 

How did the researchers interpret the results?

The researchers say once aspirin's effect on cancer risk and mortality is taken into account, the benefits of taking aspirin outweigh the risks.

They calculate that to get any benefit, people need to start taking a daily dose of between 75 and 325mg for a minimum of five years. Longer use is likely to have greater benefits, they say.

Further research is needed to determine the optimum dose for taking aspirin and duration of use, and to identify those at increased risk of bleeding.

In an accompanying press release, lead author Professor Jack Cuzick of Queen Mary University of London said: "It has long been known that aspirin – one of the cheapest and most common drugs on the market – can protect against certain types of cancer.

"But until our study, where we analysed all the available evidence, it was unclear whether the pros of taking aspirin outweighed the cons.

"Whilst there are some serious side effects that can't be ignored, taking aspirin daily looks to be the most important thing we can do to reduce cancer after stopping smoking and reducing obesity, and will probably be much easier to implement."

 

Conclusion

While the findings on aspirin and cancer show promise, it is not clear that the results are reliable from the methods reportedly used to compile this review.

This is because it included studies of varying design and quality, with much of the evidence coming from observational studies, which, while useful, cannot be totally relied on to test the effectiveness of healthcare interventions.

It's not clear how the studies included in the review were chosen and whether others on the same topic were excluded. It is also not clear whether or not this was a systematic review, where studies are rigorously appraised for their quality and criteria are established for their inclusion.

Aspirin can cause major side effects such as bleeding from the stomach and peptic ulcers, particularly in older people. It's important to consult with your GP before deciding to take it regularly. 

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

Links To The Headlines

Daily aspirin 'cuts bowel and stomach cancer deaths'. BBC News, August 6 2014

Taking Aspirin daily significantly reduces risk of cancer new study finds. Mirror, August 6 2014

Aspirin should be taken by all over 50s to cut thousands of cancer deaths: study. The Daily Telegraph, August 6 2014

Miracle pill aspirin could even ward off major cancers: Long-term use of the drug can cut chance of developing disease by up to a third. Mail Online, August 5 2014

Daily dose of aspirin 'can cut the risk of cancer', says study. The Independent, August 6 2014 

Links To Science

Cuzick J, Thorat MA, Bosetti C, et al. Estimates of benefits and harms of prophylactic use of aspirin in the general population. Annals of Oncology. Published online August 5 2014

Categories: NHS Choices

Steep rise in antibiotic use for coughs and colds

NHS Choices - Behind the Headlines - Tue, 05/08/2014 - 15:00

GPs are still giving out antibiotics to treat coughs and colds, the Mail Online, The Daily Telegraph and BBC News report, as a study reveals efforts to curb antibiotic use has had "mixed success".

The study found the proportion of people with coughs and colds given antibiotics rose from 36% in 1999 to 51% in 2011: an increase of around 40%.

The rise comes amid warnings that the over-prescription of antibiotics could lead to the emergence of drug-resistant bacteria. 

Antibiotics are medications used to treat, and in some cases prevent, bacterial infections. They are ineffective at treating coughs and colds, which are usually viral infections.

Researchers from Public Health England (PHE) and University College London (UCL) looked at trends in the prescription of antibiotics in more than 500 UK GP surgeries between 1995 and 2011.

They focused on coughs and colds, sore throats, urinary tract infections (UTIs) and middle ear infections (otitis media), which are all subject to specific government recommendations to help curb antibiotic use.

Antibiotic use for sore throats fell between 1995 and 2011, although it was still high considering that approximately 90% of sore throats resolve without antibiotics. The recommended antibiotic for acute sore throat was given in the majority of cases.

The proportion of women prescribed antibiotics for UTIs who were prescribed the recommended short course increased, although there was variation between GP practices.

For middle ear infections, the proportion of cases that were prescribed an antibiotic was broadly unchanged over the study period, but the proportion of people who were prescribed the recommended antibiotic increased.

"The implementation of national guidelines in UK primary care has had mixed success," conclude the study's authors.

Prescriptions of antibiotics for coughs and colds are now "greater than before recommendations were made to reduce it".

The study also found significant variation in antibiotic use for these conditions between GP practices, suggesting that further improvements in antibiotic prescriptions could be made.

 

Where did the study come from?

The study was carried out by researchers from PHE, the Royal College of General Practitioners Research and Surveillance Centre, and UCL.

It was funded by the Health Protection Agency (HPA) and published in the peer-reviewed Journal of Antimicrobial Chemotherapy.

Generally, the media reporting of this story was accurate.

 

What kind of research was this?

This was a cross-sectional study that analysed trends in antibiotic prescription at 537 GP practices in the UK between 1995 and 2011.

The aim of this study was to examine and compare antibiotic use over time and see whether it was in line with recommendations.

Antibiotic prescription in line with recommendations is one of the strategies being implemented to try to limit resistance to antibiotics.

 

What did the research involve?

Researchers analysed antibiotic use in 537 UK GP practices over a 16-year period.

They looked at antibiotic use, the type of antibiotic used, and the length of treatment for:

  • coughs and colds
  • sore throats
  • UTIs
  • middle ear infection (otitis media)

These conditions are subject to recommendations made in 1998 by the UK Department of Health's Standing Medical Advisory Committee (SMAC) that clinicians should:

  • not prescribe antibiotics for simple coughs and colds
  • not prescribe antibiotics for viral sore throats
  • limit prescribing for uncomplicated UTIs to three days in otherwise healthy women

This advice has been supplemented with further professional guidance on antibiotic use from the UK Public Health Laboratory Service in 2000, which recommends that:

  • antibiotics should be avoided for acute sore throat unless specific clinical criteria are met, in which phenoxymethylpenicillin may be prescribed (or clarithromycin if the patient is allergic to penicillin)
  • amoxicillin may be prescribed (or erythromycin if the patient is allergic to penicillin) for acute otitis media if specific clinical criteria are met
  • short-course trimethoprim or nitrofurantoin should be prescribed for UTIs in women if specific clinical criteria are met

The researchers looked at changes over time, as well as variation in antibiotic prescription between practices.

 

What were the basic results?

Coughs and colds
The proportion of cases of coughs and colds where antibiotics were used decreased from 47% in 1995 to 36% in 1999, before increasing to 51% in 2011.

There was marked variation by primary care practice in 2011, with 10% of practices prescribing antibiotics for less than 32% of cases and 10% of practices prescribing antibiotics for more than 65% of cases.

Sore throats
Antibiotic prescribing for sore throats fell from 77% in 1995 to 62% in 1999, and then stayed broadly stable.

Again, there was variation by primary care practice seen in 2011, with 10% of practices prescribing antibiotics for less than 45% of cases, and 10% of practices prescribing antibiotics for more than 78% of cases.

Where antibiotics were prescribed for a sore throat, the appropriate type of antibiotic was used in 69% of cases in 2011, representing a slight increase from 64% in 1995.

Urinary tract infections in women
Trimethoprim or nitrofurantoin are the recommended antibiotics for UTIs, which includes conditions such as cystitis.

The proportion of women aged 16-74 years with a UTI who were prescribed trimethoprim fell from 62% in 1995 to 54% in 2011, and the proportion who were prescribed nitrofurantoin rose from 5% in 1995 to 24% in 2011.

The researchers calculated the length of antibiotic dose from the amount of antibiotic prescribed. When trimethoprim was prescribed, the use of a recommended short course rose from 8% in 1995 to 50% in 2011. When nitrofurantoin was prescribed, the use of a recommended short course rose from 6% in 1995 to 20% in 2011.

Again, there was variation between practices, with a quarter of practices prescribing short courses in fewer than 16% of episodes that were prescribed trimethoprim in 2011.

Otitis media
The proportion of otitis media cases that were prescribed an antibiotic was broadly unchanged over the study period.

Again, there was variation between practices, with 10% of practices prescribing antibiotics for less than 63% of cases and 10% of practices prescribing antibiotics for more than 97% of cases.

Where antibiotics were prescribed, prescriptions for recommended antibiotics rose from 77% in 1995 to 85% in 2011.

 

How did the researchers interpret the results?

The researchers conclude that, "The implementation of national guidelines in UK primary care has had mixed success, with prescribing for coughs/colds, both in total and as a proportion of consultations, now being greater than before recommendations were made to reduce it. Extensive variation by practice suggests that there is significant scope to improve prescribing, particularly for coughs/colds and for UTIs."

 

Conclusion

This cross-sectional study has found the proportion of people with coughs and colds that are prescribed antibiotics rose from 36% in 1999 to 51% in 2011 – an increase of approximately 40%. This is despite the publication of guidance recommending that GPs do not prescribe antibiotics for coughs and colds.

It also found substantial variation between different GP practices, with 10% of practices prescribing antibiotics for less than 32% of cases and 10% of practices prescribing antibiotics for more than 65% of cases, suggesting that substantially lower rates of prescribing could be achieved.

The study also looked at antibiotic prescription for sore throats, UTIs and otitis media. Antibiotic prescription for sore throats fell, and prescription of recommended antibiotics increased.

Over the study period, more women with UTIs were prescribed the recommended short course of antibiotics. For otitis media, the proportion of cases that were prescribed an antibiotic was broadly unchanged, and prescriptions for recommended antibiotics rose.

There was variation between GP practices in antibiotic prescription for these conditions, suggesting that further improvements in antibiotic prescription could be made.

In conclusion, this study suggests there is a need to improve the way antibiotics are prescribed.

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

Links To The Headlines

New figures reveal soaring use of antibiotics despite warnings. The Telegraph, August 5 2014

Antibiotics use for colds 'rises 40%'. BBC News, August 5 2014

GPs dishing out MORE antibiotics just to treat colds: Number given treatment by doctors rose by 40 per cent between 1999 and 2011. Mail Online, August 5 2014

Links To Science

Hawker JI, Smith S, Smith GE et al. Trends in antibiotic prescribing in primary care for clinical syndromes subject to national recommendations to reduce antibiotic resistance, UK 1995-2011. Journal of Antimicrobial Chemotherapy. Published online August 4 2014

Categories: NHS Choices

Could HIV drugs help treat multiple sclerosis?

NHS Choices - Behind the Headlines - Tue, 05/08/2014 - 01:00

"Could MS patients be treated with HIV drugs?" ask the Mail Online and The Independent, after a new study discovered people with HIV were almost two-thirds less likely (62%) to develop multiple sclerosis (MS) than those who did not have the virus.

The study was prompted by the case of a patient who had HIV and MS, but stayed clear of any MS symptoms for more than 12 years.

Data from the medical records of about 21,000 people with HIV in the UK was analysed to see how many developed the condition, which affects the brain and spinal cord.

Researchers suggest the HIV infection itself and the antiretroviral drugs used to treat it may protect the body's immune system from developing MS. 

Their two theories are:

  • immunodeficiency caused by HIV may stop the body attacking itself
  • antiretroviral therapy may suppress other viruses in the body, such as those suggested as being responsible for causing MS

This is a well-conducted study, with a large sample size and very large number of controls. But as it is a cohort study, it can only show an association and cannot prove cause and effect.

The authors acknowledge their findings "should be regarded as speculative rather than definitive".

Overall, this interesting study paves the way for clinical trials to be conducted on the use of antiretroviral medication for people with MS.  

 

Where did the story come from?

The study was carried out by researchers from the Prince of Wales Hospital in Sydney, Australia, and Queen Mary University of London and the University of Oxford in the UK. Funding was not reported.

It was published in the peer-reviewed Journal of Neurology, Neurosurgery and Psychiatry on an open access basis, which means it is free to read online.

In general the media covered the study accurately.

 

What kind of research was this?

This was a cohort study looking at the proportion of people with HIV compared with the proportion of people without HIV who develop MS.

The researchers aimed to investigate the theory that HIV is associated with a reduced risk of developing MS. As this was a cohort study, it can only show an association and cannot prove cause and effect.

In the autoimmune disorder MS, the body attacks the myelin covering of nerves. This causes symptoms such as loss of vision, muscle stiffness, difficulties with balance and fatigue.

In the majority of cases, these symptoms occur during flare-ups and can last for a few days to a few months and then resolve. Eventually, however, many people develop secondary progressive MS, where the symptoms do not resolve and gradually get worse.

The cause of MS is not known, but research has shown links with human endogenous retroviruses (HERVs). There is no cure at present, but treatments include steroids and other drugs aimed at dampening down the immune response.

A case study was previously published about a patient with MS and HIV whose MS symptoms resolved completely for more than 12 years after starting antiretroviral drugs for HIV.

A Danish cohort study then looked for an association between HIV and a reduced risk of developing MS. Although the incidence of MS was lower in patients with HIV compared with people without HIV, the difference was not statistically significant.

The researchers involved in the current study suggest this was because the number of people in the previous cohort study was too small, so they performed a similar cohort study on a larger sample.

 

What did the research involve?

Using the English Hospital Episode Statistics (HES) data, all people in England with HIV who had been discharged from an NHS inpatient or outpatient clinic for any reason between 1999 and 2011 were identified. The earliest episode of contact for each patient was used for the analysis.

A control group without HIV was identified from people who required hospital treatment for a minor medical or surgical condition or injury between 1999 and 2011. The earliest episode of contact for the condition or injury was used for the analysis.

Both groups were followed up to see if there was a diagnosis of MS in their medical records.

The researchers excluded anyone from either group who already had a diagnosis of MS or who had a first diagnosis of MS and HIV at the same time. The personal identification of the data was then made anonymous to the study team.

They then analysed the results, accounting for age, sex, region of residence and socioeconomic region.

 

What were the basic results?

The researchers analysed the data from 21,207 people with HIV and 5,298,496 people without HIV. People involved spanned all age groups from birth to over the age of 85.

The average number of days they followed people in the HIV group was 2,454 days (6.7 years), and 2,756 days (7.6 years) for people in the other group.

The incidence of MS was significantly lower in the HIV group. People with HIV were two-thirds (62%) less likely to develop MS than people without HIV (rate ratio 0.38, 95% confidence interval 0.15 to 0.79).

Excluding people over the age of 70 made little impact on the result.

 

How did the researchers interpret the results?

The researchers conclude that, "HIV infection is associated with a significantly decreased risk of developing MS".

They say this might be a result of the "immunosuppression induced by chronic HIV infection and antiretroviral medications", but they acknowledge their findings "should be regarded as speculative rather than definitive".

They also report the first clinical trial using the antiretroviral drug Raltegravir for people with relapsing-remitting MS is currently recruiting participants in the UK.

 

Conclusion

This large cohort study indicates people with HIV appear to be at a lower risk of developing MS. It is not known what causes this association, but possible reasons put forward by the researchers include:

  • immunodeficiency caused by HIV may stop the body attacking itself in the autoimmune condition MS
  • antiretroviral therapy may suppress other viruses in the body, such as those that have been suggested as causing MS

Strengths of the study include the large sample size and the very large number of controls, which would limit any bias by confounding factors.

However, the study did have a few limitations:

  • Although the overall study period was 12 years, people were recruited to the study at any point during this time, so the follow-up period for some would have been very short.
  • The development of MS usually occurs between the ages of 20 and 40, but both cohort groups encompassed people of all ages.
  • Data was lacking on the use of antiretroviral medication, such as the type and length of time of the treatment.
  • There was limited data on ethnicity and this therefore couldn't fully be adjusted for. However, the researchers report the reduction in risk doesn't seem to be limited to one ethnic group. 

Overall, this interesting study paves the way for clinical trials to be conducted on the use of antiretroviral medication for people with MS.

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

Links To Science

Could MS patients be treated with HIV drugs? Study finds antiretrovirals could calm the immune systems of those with nerve condition. Mail Online, August 4 2014

HIV drugs could help to prevent and treat Multiple Sclerosis, say scientists. The Independent, August 5 2014

 

Categories: NHS Choices

Phone consultations do not reduce GP workload

NHS Choices - Behind the Headlines - Mon, 04/08/2014 - 12:45

Over-the-phone medical consultations “don’t cut the pressure” on busy GP surgeries, BBC News and The Daily Telegraph report.

They were reporting the findings of a two-year study into the effectiveness of phone consultations with a GP or a nurse instead of face-to-face appointments.

Telephone consultations, or triage, are increasingly used to try and manage workload in general practice and cut down on unnecessary consultations.

Around 12% of GP consultations are now done over the phone – representing a four-fold increase over the last 20 years.

Researchers looked at how many follow-up contacts were made with the GP surgeries over a 28-day period after a patient called to request a same-day appointment.

The study, which included 42 practices caring for nearly 21,000 patients, found that instead of saving time and money, the phone service actually increased the workload. 

People who had received a call from their GP or nurse made significantly more contacts with health professionals at the surgery over the following 28 days (average 2.65 and 2.81 contacts respectively) compared with patients in the surgeries providing usual care (1.91 further contacts).

Following a call from the GP, there was a decrease in the number of face-to-face consultations with the GP, but the number of further telephone conversations increased ten-fold.

The healthcare costs incurred by the surgeries operating a phone consultation service over the 28 days was roughly the same as those who didn’t.

It is worth noting that although the phone service did not reduce the workload for GPs, the study found no difference in terms of quality of care.

This is a well-designed randomised controlled trial that provides much needed information on the value of telephone triage by GP surgeries – an area where evidence has been lacking.

As the researchers conclude, telephone triage may well be useful in helping delivery of care in general practice, but the possible implications for the whole system should be assessed when considering introducing such a scheme.

 

Where did this come from?

The study was carried out by researchers from University of Exeter Medical School and the Universities of Oxford, East Anglia, Bristol and Warwick. Funding was provided by the National Institute for Health Research Health Technology Assessment Programme, and the study was published in the peer reviewed medical journal, The Lancet.

The media’s reporting is a fair representation of the findings of this study. However, it is important to note that reports of telephone triage being “ineffective” should not be wrongly interpreted to mean “poor patient care”. This study examined effectiveness mainly in terms of GP surgery workload and costs. It found no difference in terms of the quality of health care provided.

 

What kind of research was this?

This was a randomised controlled trial spanning two years, which looked at the clinical and cost effectiveness of telephone triage by GPs or nurses when patients ring their GP to request a same-day appointment.

Telephone triage involves a GP or nurse calling a patient at home to assess their symptoms, offer advice and judge whether a consultation in person is needed. This method is increasingly used to try and manage workload in general practice and cut down on unnecessary consultations.

The researchers report that currently around 12% of GP consultations are done over the phone – an increase of four times the level seen around 20 years ago. Most studies assessing the effectiveness of telephone triage have looked at nurse triage, but few studies have looked at the value of GPs calling. Despite this lack of evidence, many practices operate GP or nurse triage systems.

This study therefore aimed to provide further evidence on whether GP or nurse-led telephone triage are of any benefit compared with usual care for patients ringing to request same-day appointments.

 

What did the research involve?

The study randomised 42 GP surgeries between March 2011 and March 2013, all of which were operating a triage system. The practices were randomly assigned to operate GP triage (13 practices), nurse triage (15 practices) or usual care (14 practices).

Eligible patients were all those phoning to request a same-day, face-to-face GP consultation, unless they were seeking emergency care. Teenagers between the ages of 12 and 15 were excluded due to parent confidentiality issues (parents completed follow-up questionnaires for children under 12; those aged 16 and over completed them themselves).

Prior to the study period, the intervention practices making doctor or nurse triage calls were trained in delivery of triage by an expert trainer.

During the study period receptionists in the intervention practices asked for a contact number and advised that a GP or nurse would call the patient within one to two hours. The doctor or nurse recorded the start and end times of each phone consultation and could give self-care advice, book the patient in for a face-to-face appointment or a further telephone appointment with a doctor or nurse.

In usual care practices, care continued as normal when the patient rang for an appointment. The patient (or parent if it was a child) was told that a questionnaire reviewing their care experience would be sent to them four weeks later, and they were asked for consent to review their medical records about 12 weeks later (to allow all relevant information following on from their initial consultation to reach the notes).

The main outcome examined was GP practice workload – that is the total number of general practice contacts taking place in the 28 days following the individual patient’s initial appointment request and triage call. This included further contacts with a GP, nurse or other health professional (face-to-face, telephone, home visits, or mode unspecified), or attendances at walk-in centres or A&E.

Other outcomes examined included specific patient health outcomes, such as deaths or urgent hospital admissions in the week following the triage call, and the patient’s care experience reported in the questionnaire, such as overall satisfaction ratings.

The economic evaluation compared costs incurred in the two interventions and usual care practices over 28 days.

What were the basic results?

During the study, each of the three groups of practices made around 7,000 triage calls or equivalent in those allocated to usual care.

Looking at the main outcome of individual patient contacts in the 28 days following their initial appointment requests, there was an increase in the number of further contacts by people who received doctor or nurse triage compared to those who received usual care in the 28 days after the initial appointment request.

The average number of healthcare contacts in the following 28 days was 1.91 by patients in usual care, 2.65 by patients in GP triage and 2.81 by patients in nurse triage.

This meant that the number of patient contacts that each person made after GP triage was increased by a third compared to usual care (RR 1.33, 95% CI 1.30 to 1.36). The increase following nurse triage was even greater: a 48% increase in the number of contacts following nurse triage compared with usual care (RR 1.48, 95% CI 1.44 to 1.52). There was also a statistically significant, but small, increase in the number of consultations in practices assigned to nurse triage compared with practices assigned to GP triage (RR 1.04, 95% CI 1.01 to 1.08). Following GP triage there was a decrease in the number of face-to-face consultations in the following 28 days compared with usual care, but the number of further telephone conversations went up ten-fold.

There was no significant difference in the number of hospital admissions between groups, though as the researchers acknowledge, numbers of admissions were small in all groups. There were only eight deaths overall across all groups in the study, and none were considered to be related to the care given. 

Patients in the GP-triage group reported that it was easier to get through to the practice on the telephone compared with usual care. Patients receiving nurse triage generally had lower satisfaction levels than the other groups and considered their care less convenient.

The total GP surgery costs were roughly the same in the three groups: £75.41 (per patient) in usual care practices, £75.21 in GP triage practices and £75.68 in nurse triage practices.

 

How did the researchers interpret the results?

The researchers conclude that “Introduction of telephone triage delivered by a GP or nurse was associated with an increase in the number of primary care contacts in the 28 days after a patient’s request for a same-day GP consultation, with similar costs to those of usual care”.

They consider that telephone triage might be useful in helping delivery of care in general practice, but the possible implications for the whole system should be assessed when considering introducing such a scheme.

 

Conclusion

This is a well-designed randomised controlled trial assessing the cost and effectiveness of GP or nurse led telephone triage compared with normal face-to-face consultations for patients requesting same-day appointments.

It found that GP or nurse-led triage didn’t cut GP workload, and the healthcare costs incurred by the GPs over the 28 days were essentially the same. This may be surprising for some: as the researchers point out, many GP surgeries have implemented triage, at least in part, to reduce an increasing workload.

However, this study suggests that this rationale may be wrong. People who received a call from their GP or nurse made significantly more contacts with health professionals at the GP surgery over the following 28 days compared with patients in the surgeries providing usual care. Following a call from the GP there was a decrease in the number of face-to-face consultations with the GP, but the number of further telephone conversations increased substantially.

It is worth noting that media reports that GP telephone triage is “ineffective” should not be wrongly interpreted to mean that patients “receive poor care”. The main outcome this study examined was whether telephone triage had any effect on workload in terms of the number of further healthcare contacts made.

For the main patient health-related outcomes examined, there was no difference between any of the groups allocated to GP or nurse triage or usual care. For example, there was no difference in the number of hospital admissions in the following 28 days (though the numbers of admissions were very small in all groups so this may not be a reliable comparison). Also, there were only eight deaths overall across all groups in the study, and none were considered to be related to the care given.

Further studies exploring other patient health and satisfaction outcomes with telephone triage would be valuable to see whether triage has any meaningful benefits or drawbacks in terms of patient care.

Overall, this study provides useful evidence on the value of telephone triage by GP surgeries in terms of workload and costs. As the researchers aptly conclude, telephone triage may well be useful in helping delivery of care in general practice, but the possible implications for the whole system should be assessed when considering introducing such a scheme.

 

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

Links To The Headlines

Telephone appointments ‘no benefit’ to busy GPs, claims study. The Independent, August 4 2014

Phone consultations 'do not cut GP surgery pressures'. BBC News, August 4 2014

GP phone consultations 50pc more likely to need follow-up. The Daily Telegraph, August 4 2014

Links To Science

Campbell J, Fletcher E, Britten N, et al. Telephone triage for management of same-day consultation
requests in general practice (the ESTEEM trial)
. The Lancet. Published online August 4 2014

Categories: NHS Choices

Video games 'beneficial' for children

NHS Choices - Behind the Headlines - Mon, 04/08/2014 - 12:00

Children who play video games for up to an hour a day are more sociable, happy and less hyperactive, The Telegraph and Daily Mail report after the publication of a study on the links between gaming and behaviour.

The study involved around 5,000 young people aged 10 to 15 who were asked to report their use of computer games, as well as complete a questionnaire assessing sociability, life satisfaction, and emotional and behavioural problems.

About 75% of the participants reported playing computer games every day. Compared with adolescents who didn't play computer games, those who played for less than one hour a day reported higher levels of social behaviour and life satisfaction, and lower levels of emotional and behavioural problems. There was no difference between non-players and those who played one to three hours a day.

Meanwhile, adolescents who played more than three hours a day were found to be less social, have lower life satisfaction, and more emotional and behavioural problems than non-players.

But the study has several limitations that the media reports failed to acknowledge. The contribution of game playing in explaining the differences in behaviour between non-players and light or heavy players was tiny – less than 1.5% – suggesting that other factors (including hereditary, environmental and lifestyle factors) are likely to be having a much greater influence. 

Also, because the study examined both levels of game playing and behaviour at the same time, even if there is a link between the two, it's not able to tell us the direction of the relationship – whether gaming for less than an hour a day makes adolescents happy and sociable, or whether happy, sociable adolescents are more likely to engage in low levels of play rather than none or more.

Other limitations of this cross-sectional study include only using self-report questionnaires, which may be open to the possibility of inaccuracies and biased reporting.

Overall, the author's conclusion that the findings inform policy making is possibly a little optimistic given the limited conclusions that can be drawn from these findings, especially given that gaming was "not robustly" associated with children's behaviour.

Where did the story come from?

The study was carried out by one author from the University of Oxford. No sources of financial support were received and the author declares no conflict of interest.

The Understanding Society study the data was drawn from is described as an initiative by the Economic and Social Research Council, with scientific leadership by the Institute for Social and Economic Research at the University of Essex, and survey delivery by the National Centre for Social Research.

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

In general, by reporting the positive findings of this study, the media failed to mention its various limitations and that no firm conclusions can be drawn from its findings.

 

What kind of research was this?

This was a cross-sectional study that asked young people aged 10 to 15 years to report the number of hours a day they spend playing computer games. Researchers then asked them to complete questionnaires assessing psychological adjustment, and analysed the relationship between the two.

Psychological adjustment in this instance included aspects such as how satisfied and happy the young people were in their lives, how they related to others, and if they had emotional or behavioural problems.

The author describes how the rising use of electronic games has given cause for both concern and possible hope in their potential to influence young people. Research to date has suggested a number of positive and negative effects, but no study has examined the balance of these potential effects in a representative sample of children and adolescents.

This study aimed to explore how time spent playing electronic games is associated with psychosocial adjustment. However, this is a cross-sectional study, so while it can examine a potential relationship between the two, it can tell us nothing about whether computer games actually cause good or bad psychological adjustment.

 

What did the research involve?

The study used information on a large sample of 2,436 males and 2,463 females aged from 10 to 15. The data was collected as part of the UK Understanding Society household longitudinal study. This study recruited people from across the UK and included information on their electronic game use, as well as social, behavioural and health data collected through surveys.

The typical amount of time participants played electronic games was assessed through surveys asking about console-based games (such as Sony PlayStation) and computer-based games, with response options from one to six that best represented the amount of time spent playing: none, one hour, one to three hours, four to six hours, and seven or more hours.

Psychosocial problems were assessed using a validated behavioural questionnaire called the Strengths and Difficulties Questionnaire (SDQ). Participants responded on a three-point response scale (1 = "not true", 2 = "somewhat true", 3 = "very true") on a list of personal statements related to emotional symptoms, conduct problems, hyperactivity and inattention, and peer relationship problems.

An overall "internalising problems" score resulted from summing emotional and peer relationship symptoms, and "externalising problems" score from summing conduct, hyperactivity and inattention problems.

A subscale of the SDQ assessed pro-social feelings such as empathy and helpful thoughts and actions with statements such as, "I try to be nice to people. I care about their feelings". Participants were also asked to rate their level of happiness across life domains related to school and school work, their appearance, family and friends.

All analyses between game playing and psychosocial problems were adjusted for survey factors, including response rate and household location.

 

What were the basic results?

The study compared three levels of gaming with those who played no computer games: low players (less than one hour a day), moderate players (one to three hours a day), and high players (more than three hours a day).

Compared with non-players, light players had higher levels of pro-social behaviour and life satisfaction, and lower levels of internalising and externalising problems.

However, the effects of game playing were found to be very small, with gaming considered to account for only roughly between 0.5% and 1.3% of the variance in psychosocial factors between these groups of people.

There was no difference between non-players and moderate players.

Compared with non-players, heavy players were described as having the "mirror image of the pattern observed for light players": they had higher levels of internalising and externalising problems, and lower levels of pro-social behaviour and life satisfaction.

The effects of game playing were found to be very small, with low levels of gaming accounting for only roughly between 0.5% and 1.3% of the variance in psychosocial factors between these groups of people.

Again, the effects of game playing were found to be very small, with gaming considered to account for only roughly between 0.3% and 1.5% of the variance in psychosocial factors between these groups of people.

 

How did the researchers interpret the results?

The author concluded that, "Links between different levels of electronic game engagement and psychosocial adjustment were small, yet statistically significant.

"Games are consistently but not robustly associated with children's adjustment in both positive and negative ways, findings that inform policy making as well as future avenues for research in the area."

 

Conclusion

This study benefits from its large size, including a representative sample of around 5,000 adolescents from across the UK, and asking them to report their use of computer games, as well as completing a validated self-report questionnaire assessing emotional and behavioural problems.

However, the findings perhaps do not tell us very much. Compared with adolescents who don't play computer games, those who played less than one hour a day reported higher levels of sociability and life satisfaction, and lower levels of emotional and behavioural problems. There was no difference between non-players and those who played one to three hours a day.

Meanwhile, the opposite pattern was seen with adolescents who played more than three hours a day, who reported to be less social, have lower life satisfaction, and more emotional and behavioural problems than non-players.

Importantly, the contribution of game playing in explaining the differences in social, emotional and behavioural problems between non-players and light or heavy players was tiny – less than 1.5% – suggesting that other factors, including hereditary, environmental and lifestyle factors, are likely to be having a much greater influence.

Furthermore, as this is a cross-sectional study that assessed levels of game playing and psychosocial symptoms at the same time, it can't tell us anything about cause and effect – whether, for example, a light level of gaming makes you more sociable and happier with life, or whether the converse is true and people who are more sociable and happy are perhaps more likely to spend less time playing computer games, possibly with other people.

Related to that, this study is not able to tell us whether people were playing alone or with others, what sort of games they were playing, or what other interests and activities they had aside from gaming.

It also only accounted for gaming on a console or a PC, but not on a smart phone or tablet computer. This is an important limitation given the huge popularity of gaming on these devices at any time of the day or night.

As the study is only based on self-report questionnaires, it is also open to the possibility of inaccuracies and biased reporting.

Overall, the author's opinion that the findings should inform policy making is possibly a little optimistic given the limited conclusions that can be drawn from the current findings. However, larger, more reliable studies may build on this preliminary work and provide more robust evidence for decision making in the future. 

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

Links To The Headlines

Playing video games for up to an hour a day 'is good for children'. The Telegraph, August 4 2014

Low-level gamers 'better adjusted'. Mail Online, August 4 2014

A little video gaming 'linked to well-adjusted children'. BBC News, August 4 2014 

Links To Science

Przybylski AK. Electronic gaming and psychosocial adjustment, Pediatrics. Published online August 4 2014

Categories: NHS Choices

Combined Pill may raise breast cancer risk

NHS Choices - Behind the Headlines - Fri, 01/08/2014 - 11:19

"Some contraceptive pills double risk of breast cancer," The Daily Telegraph reports, as a new US study found an increased risk of 50% with use of the combined oral contraceptive pill, commonly called "the pill".

The combined pill contains oestrogen and, as it is known oestrogen can stimulate breast cancer cells to grow, the potential for extra oestrogen to increase the risk of breast cancer has been recognised for some time.

However, any increase in risk needs to be seen in context. The baseline risk of women of a fertile age developing breast cancer is small, so a 50% increase in this risk doesn't amount to a "high" risk.

Also, this risk needs to be measured against the potential benefits of the pill protecting against other types of cancer, such as ovarian cancer. Unfortunately, there are often no easy answers when weighing up the benefits and risk.

What we can say is this was a robust study that included more than 1,000 US women aged 20 to 49 who had been diagnosed with breast cancer, and an age-matched control group. The researchers checked if the women used combined oral contraceptive pills in the year before their cancer diagnosis.

Overall use of any combined pill in the past year was associated with a 50% increased risk of developing breast cancer, compared with never using the combined pill or using it more than one year ago. High-strength pills more than doubled risk, but these are no longer prescribed in the UK.

You should not suddenly stop your contraceptive use based on this study alone. If you have any questions or concerns, it is best to discuss the possible options with your GP.

 

Where did the story come from?

The study was carried out by researchers from the Group Health Research Institute, the Fred Hutchinson Cancer Research Center, and the University of Washington, all in the US.

It was funded by grants from the US National Cancer Institute and the US National Institutes for Health.

The study was published in the peer-reviewed medical journal, Cancer Research.

In general the media reports are accurate, but the high-strength pills associated with the more than doubled risk are no longer prescribed in the UK. Similarly, some of the other preparations associated with higher risk may not be relevant to the UK.

The Times deserves praise for making an effort to put the increased risk into a meaningful context, equating it to the same risk associated with "drinking a large glass of wine a day".

 

What kind of research was this?

This was a case-control study including more than 1,000 US women aged 20 to 49 who had been diagnosed with breast cancer, and a group of age-matched women without breast cancer as a control.

Use of the combined oral contraceptive pill in the year before cancer diagnosis was compared between the groups using pharmacy records.

The researchers say the relationship between oral contraceptive use and breast cancer risk has been extensively studied.

Combined oral contraceptive pills, commonly called the pill, contain the hormone oestrogen. It is known oestrogen can stimulate some breast cancer cells to grow and it is possible taking synthetic oestrogen could increase risk.

New formulations of the combined pill are continually being developed. This study aimed to focus on newer combined oral contraceptive formulations used between 1989 and 2009 by women enrolled on a large US health plan.

 

What did the research involve?

The study included women aged 20 to 49 enrolled on a healthcare delivery system (Group Health Cooperative, GHC) serving the Seattle Puget Sound area in the US state of Washington between 1989 and 2009.

New cases of breast cancer were identified using the local cancer registry, the Cancer Surveillance System (CSS). For each case of breast cancer, the researchers randomly sampled up to 20 controls matched for age and time of enrolment into the healthcare system.

Information on combined pill use came from the GHC electronic pharmacy database. The researchers focused on prescriptions filled by cases and controls in the 12 months before the breast cancer diagnosis.

They classified the prescriptions by formulation, the strength of synthetic oestrogen and the type of progestogen it contained.

They classified the number of pills used in the previous year as less than 190 or 190 and above to estimate exposure for more or less than half of the previous year, and to assess a potential dose-response effect.

After excluding women taking progestogen-only pills, they had a sample of 1,102 cases and 21,952 controls.

 

What were the basic results?

The researchers found that compared with never using the pill or use more than one year ago, combined pill use in the previous year was associated with a 50% increased risk of breast cancer risk (odds ratio [OR] 1.5, 95% confidence interval [CI] 1.3 to 1.9).

As may be expected, there was a slightly stronger association between combined pill use and oestrogen receptor-positive breast cancers (these are known as ER+ cancers, where oestrogen stimulates growth) than for oestrogen receptor-negative cancers.

There was a significant trend for the risk of breast cancer in general, and ER+ breast cancers specifically, to increase with the increasing number of pills dispensed over the past year.

The researchers also found varied risk with the different formulations containing different oestrogen strength and progestogen type.

Preparations containing low-dose oestrogen were not associated with increased risk, while preparations containing moderate doses were associated with 60% increased risk (OR 1.6, 95% CI 1.3 to 2.0) and high-dose oestrogen more than doubled risk (OR 2.7, 95% CI 1.1 to 6.2).

Triphasic preparations (where three different types of tablets are used during different phases of the menstrual cycle) containing a particular type and strength of progestogen (0.75 mg of norethindrone), or preparations containing another progestogen (ethynodiol diacetate), were associated with more than doubled risk.

As may be expected, the researchers found women with and without breast cancer differed on a number of other potential risks factors identified in their medical records. These included:

  • family history of breast cancer
  • how many children they had had
  • body mass index (BMI)
  • attendance for mammography screening

However, none of these factors were found to be confounding the relationship between combined pill use and breast cancer. Combined pill use had an independent effect on breast cancer risk.

 

How did the researchers interpret the results?

The researchers say their results "suggest that recent use of contemporary oral contraceptives is associated with an increased breast cancer risk, which may vary by formulation.

"If confirmed, consideration of the breast cancer risk associated with different oral contraceptive types could impact discussions weighing recognised health benefits and potential risks."

 

Conclusion

The combined oral contraceptive pill contains oestrogen and it is known oestrogen can stimulate breast cancer cells to grow. The potential for synthetic oestrogen to increase risk has been recognised for some time. 

In this case-control study, researchers found overall combined oral contraceptive use in the previous year was associated with a 50% increased relative risk of developing breast cancer compared with never-use or use more than one year ago.

As may be expected, there was also a slightly stronger association between combined pill use and oestrogen receptor-positive breast cancers (cancers where oestrogen stimulates growth).

Based on several large studies, Cancer Research UK currently advises there seems to be a small increase in risk of breast cancer while women are taking the combined pill. However, the risk goes back to normal 10 years after women have stopped taking the pill.

This case-control study seemed to support the idea combined pill use only increases risk while you are taking the extra oestrogen, as all risk increases with recent use were compared with women who had never used the pill or had used it more than one year ago.

As Cancer Research UK points out, fewer breast cancers develop among younger women compared with older women. So a small increase in risk related to taking the pill during this time would lead to quite a small number of extra cases of breast cancer.

The charity also highlights that balanced against this, the pill reduces the risk of some other cancers, including ovarian and womb cancers.

There is no single potential risk factor for breast cancer. You can influence some of these risk factors, such as being overweight or obese, drinking alcohol and smoking, by taking action to lose weight, stopping smoking and watching how much you drink.

The results of this particular case-control study are likely to be reliable and may be applicable to wider populations of combined pill users. But the findings need to be confirmed in other studies, particularly those more relevant to the UK population.

A more important point of note relates to the higher risk this study found with certain combined pill formulations, as these may differ from those used in other countries.

Currently, in the UK combined pills are only prescribed containing standard moderate-strength (30 to 35 micrograms) or low-strength (20 micrograms) oestrogen. High-strength pills are no longer prescribed.

Similarly, the specific progestogen types associated with a particularly high risk of breast cancer are not contained in current UK preparations.

This study adds to the large existing body of research on the association between taking the pill and breast cancer.

If you are worried about using the combined oral contraceptive pill, there are other reliable methods of contraception you may want to consider, such as progesterone-only methods (including pills, injections and implants), the coilmale condoms or diaphragms.

For more information, visit the NHS Choices Contraception guide, speak to your GP, or talk to a reproductive health charity such as FPA or Brook.

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

Links To The Headlines

Some contraceptive pills double risk of breast cancer. The Daily Telegraph, August 1 2014

High-oestrogen contraceptive pills could raise breast cancer risk by 50%, study suggests. The Independent, August 1 2014

Taking the Pill 'raises the risk of breast cancer by 50 per cent'. Daily Mail, August 1 2014

Links To Science

Beaber EF, Buist DSM, Barlow WE, et al. Recent Oral Contraceptive Use by Formulation and Breast Cancer Risk among Women 20 to 49 Years of Age. The Journal of Cancer Research. Published online August 1 2014

Categories: NHS Choices

Study probes effect of NHS Health Checks

NHS Choices - Behind the Headlines - Fri, 01/08/2014 - 11:00

"Health MOTs routinely offered to over-40s on the NHS may be a waste of time," the Mail Online reports.

The report says researchers have found no difference in the prevalence of diseases such as diabetes in GP practices that offer NHS Health Checks and those that don't.

NHS Health Checks were introduced in 2009 and are designed to act as a midlife "MOT" (as the Mail describes it).

This study compared GP practices in Warwickshire that implemented NHS Health checks between 2010 and 2013 with those that did not.

They looked at whether the checks increased numbers of diagnoses of five chronic conditions: heart disease, high blood pressure, diabeteschronic kidney disease and heart rhythm abnormality (atrial fibrillation).

Changes in the number of cases of these five chronic diseases were very small and there was no significant difference between practices with or without checks. But the study did not recruit a large enough sample to be able to reliably detect differences.

The study period was also quite short. Proponents of the NHS Health Check argue any benefits may not be noticeable for a decade.

The study has not been able to examine other health benefits that may result from the checks. For example, it could be the case some people who attend a health check receive lifestyle advice that could help prevent the future development of chronic disease.

Overall, further research in larger samples and over longer time periods is needed to examine whether the NHS Health Checks are of any benefit in improving the detection of chronic disease, or have any other beneficial health outcomes.

 

Where did the story come from?

The study was carried out by researchers in the fields of public health and general practice in Warwickshire, and was published in the peer-reviewed British Journal of General Practice. No sources of funding are reported and the authors declare no conflicts of interest. 

Overall, the Mail Online's and The Times' reporting of the study was accurate.

 

What kind of research was this?

This was a non-randomised controlled study in a mixed urban and rural population of England, designed to examine the impact of NHS Health Checks on the detection of:

  • hypertension
  • coronary heart disease
  • chronic kidney disease
  • diabetes
  • atrial fibrillation (a heart rhythm abnormality)

The NHS Health Check, introduced by the Department of Health in 2009, is sometimes called the "midlife MOT". NHS Health Checks are offered to people between the ages of 40 and 74 who haven't already been diagnosed with these health conditions.

An NHS Health Check includes questions about your lifestyle and family history of disease, as well as tests to measure your cholesterol, blood pressure, BMI and diabetes risk. It also looks at risk of vascular dementia, although this is not covered in the current study.

Your risk of developing a cardiovascular condition is calculated using a standard online calculator called the QRISK calculator. The checks are usually carried out by a nurse or trained healthcare assistant.

If a condition is detected or the person is at risk of developing a condition, they are referred to the GP for further assessment and treatment.

The researchers say no research has yet been published assessing the impact of NHS Health Checks on the number of cases of these diseases (their prevalence) in GP practices.

If the checks detect extra cases that would otherwise not be detected, then you would expect to see the prevalence of these conditions increasing.

To do this, the researchers compared the changes in disease prevalence among GP practices that have implemented the health checks with those that haven't.

 

What did the research involve?

The study looked at 38 GP practices in Warwickshire, which provided NHS Health Checks over a three-year period between June 2010 and March 2013.

It compared data from these GP practices with 41 practices within Coventry and Warwickshire that did not provide the health checks.

The researchers collected data from each practice on the number of NHS Health Checks offered and completed, and the number of new cases of diabetes, hypertension, coronary heart disease, chronic kidney disease and atrial fibrillation that were detected as a direct result of the checks.

No specific set of diagnostic criteria were used in the study to confirm the presence of these conditions – practices were expected to identify and report a case of disease using their usual diagnostic criteria.

The prevalence of the conditions for all practices diagnosed through usual medical care was obtained from the national disease registers maintained as part of a national programme to measure quality of care, called the Quality and Outcomes Framework (QOF).

The prevalence of disease at the start of the study was obtained for the financial year 2009-10 (ending March 2010), and at the end of the study for the financial year 2012-13 (ending March 2013).

When comparing prevalence in different practices, the researchers took into account practice size, average age of the population, proportion of males, baseline prevalence of disease, and how deprived the area was.

 

What were the basic results?

A total of 1,142 new cases of disease were detected through the NHS Health Checks programme from 16,669 checks. This is equivalent to one disease case being detected in 6.85% of all health checks.

Most of these newly detected cases were high blood pressure (635), followed by diabetes (210) and chronic kidney disease (198), with fewer cases of coronary heart disease and atrial fibrillation detected.

There were no significant differences between practices with and without health checks for the change in prevalence of any of the chronic diseases between 2009-10 and 2012-13.

Other factors also influenced the change in prevalence over the study period, including how common the disease was at the start of the study, average age of population, practice size, proportion of males and deprivation. 

 

How did the researchers interpret the results?

The researchers conclude that, "In practices providing NHS Health Checks, the change in the reported prevalence of diabetes, hypertension, coronary heart disease, chronic kidney disease, and atrial fibrillation did not differ from that of practices providing usual care."

 

Conclusion

This study compared practices in the Warwickshire and Coventry area who implemented NHS Health Checks between June 2010 and March 2013, with those that did not provide the health checks and gave their usual care only.

A total of 1,142 new cases of disease were detected through the NHS Health Check programme from 16,669 checks. Changes in prevalence over the study period were small – in fact, less than 0.7%.

For diabetes, chronic kidney disease and heart disease, prevalence in both groups decreased over the study period.

Meanwhile, high blood pressure and atrial fibrillation increased in both groups during the study, and increased slightly more in the health check group (0.46% increase compared with 0.30% increase).

However, there was no statistically significant difference between practices who did or did not implement health checks in terms of the change in prevalence of the five chronic diseases during the three-year study period.

The researchers say the results imply NHS Health Checks in GP practices may not increase the reported prevalence of the five conditions examined, despite the apparent detection of disease (one disease case being detected in 6.85% checks). This may mean GP practices' standard care is good at detecting these conditions.

However, there are some limitations to the study, as the researchers do acknowledge:

  • The study was unable to recruit the number of GP practices they needed to give sufficient statistical ability ("power") to detect the expected differences between the groups (79 of the target of 311 practices). This meant the study only had about a 35% chance of detecting a difference in change in prevalence between the practices of 2% or more.
  • It is not possible to know whether the health outcomes for people who have these conditions identified and treated as a result of an NHS Health Check may be any different from those detected through usual care.
  • The study itself did not specify diagnostic criteria for the diseases, which may mean practices differed in the way they diagnosed the conditions. There were also differences in the completeness of practices' records.
  • Because the practices were not randomly assigned to provide or not provide health checks, the groups cannot be guaranteed to be balanced for characteristics other than the health checks that might affect the results.
  • The study did try to take some of these characteristics into account (such as the number of patients the practice looks after and average age of the population), but there may be other characteristics having an effect, such as the ethnicity of the population.
  • The overall uptake of health checks was fairly low, at only 13.6% of all those eligible during the three-year study period. However, as the researchers say, this is reasonably similar to the national average uptake (3.1% in 2011 to 2012, increasing to 8.1% in 2012 to 2013).

The study also only examined the Coventry and Warwickshire region of the UK. Practices in other regions may have different results. It also only examined a three-year period.

And, importantly, the study is unable to detect any possible health benefits that may result from the health checks, outside of identifying people who currently have these five chronic diseases.

For example, the health check may lead to greater awareness and discussion of a person's BMI, diet, cholesterol, physical activity, smoking and alcohol intake.

This could lead to the person making healthy lifestyle changes that could then decrease their risk of actually developing these chronic diseases. Studies would be needed to see if there had been any effect on these other outcomes.

As the researchers conclude, "studies directly comparing the effect of NHS Health Checks with usual care are lacking and must be the primary focus for further research in this area".

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

Links To The Headlines

Are health MOTs for the over-40s useless? Illnesses they're designed to spot could be 'equally well detected' without the check-up. Mail Online, July 31 2014

Health MOTs may be £300m waste of time. The Times, August 1 2014

Links To Science

Caley M, Chohan P, Hooper J, Wright N. The impact of NHS Health Checks on the prevalence of disease in general practices: a controlled study. The British Journal of General Practice. Published online August 1 2014

Categories: NHS Choices

Warning over waistline link to type 2 diabetes

NHS Choices - Behind the Headlines - Thu, 31/07/2014 - 15:00

“Belly fat clearest sign of type 2 diabetes risk,” The Guardian reports. This comes as Public Health England publishes a report highlighting the links between bulging waistlines, obesity and type 2 diabetes risk.

According to a new report, men whose waist size is over 102cm (40.2 inches) are five times more likely to develop diabetes than those with a smaller waist size. Women with a waist over 88cm (34.7 inches) are three times more likely to develop the condition.

The report says that being overweight or obese is the main avoidable risk factor for type 2 diabetes.

The condition is now a major public health issue, with all types of diabetes projected to rise to 4.6 million – nearly 10% of the adult population – by 2030.

Some people may have the misconception that type 2 diabetes is an inconvenience, like back pain or arthritis, but not especially serious. This is not the case.

Type 2 diabetes can lead to blindness (diabetic retinopathy), heart problems and even reduce blood supply to the limbs, which can lead to the affected limb being amputated. People with type 2 diabetes are 15 times more likely to require an amputation than the population at large.

If you are concerned about your weight, it is recommended that you measure you waist size and ask your GP for advice. If necessary, they can arrange testing for the condition. The sooner type 2 diabetes is treated, the less likely it is to cause complications.

The key to reducing the risk of diabetes is losing weight, which can be achieved through a healthy diet and being more active.

The NHS Weight Loss plan can help you achieve both these goals.

 

Who produced the report?

The report was produced by Public Health England (PHE), a government body set up to protect and improve people’s health, and reduce health inequalities. PHE is part of the Department of Health and came into being in April 2013.

 

What is the aim of the report?

The report draws together a multitude of facts and figures to describe the relationship between obesity and type 2 diabetes. Its aim is to support decisions by public health policymakers and practitioners. It points out that, currently, 90% of adults with type 2 diabetes are overweight or obese, and that both conditions are on the increase in the UK.

 

Diabetes

The report explains that diabetes is a condition in which the body does not produce sufficient insulin to regulate blood glucose levels, or where the insulin produced is unable to work effectively. There are two main types of diabetes: 1 and 2.

The report focusses on type 2 diabetes, which accounts for at least 90% of all cases and is easily preventable by making lifestyle changes. It points out that obesity is only associated with type 2 diabetes. 

Type 1 diabetes is an autoimmune condition that has no association with obesity or other lifestyle factors, and is not preventable; people are born with the condition (though symptoms do not usually develop until around puberty).

 

Link between obesity and diabetes

The report says that being overweight or obese, with a body mass index (BMI) of 25 or above, is the main modifiable risk factor for type 2 diabetes. In England, obese adults are five times more likely to be diagnosed with the condition than adults of a healthy weight, with a greater risk among people who have been obese for longer.

In addition, a recent study found that severely obese people (with a BMI of 40 or above) are at even greater risk compared to obese people with a lower BMI (30.0-39.9).

This, it claims, may have significant implications for the NHS, given the increasing trend of severe obesity in adults.

In particular, a large waist circumference is associated with increased risk of diabetes. Men with a raised waist circumference (greater than 102cm) are five times as likely to have doctor-diagnosed diabetes, compared to those without a raised waist circumference. 

Women with a raised waist circumference (greater than 88cm) are more than three times as likely to get the condition.

The precise mechanism for this association remains unclear, says PHE. Some hypotheses include:

  • Abdominal obesity may cause fat cells to release inflammatory chemicals that disrupt the body’s response to insulin.
  • Obesity may trigger changes to the body's metabolism that cause adipose (fat) tissue to release substances involved in the development of insulin resistance.

It is also uncertain why not all people who are obese develop type 2 diabetes, and why not all people with type 2 diabetes are obese.

 

Prevalence of obesity and diabetes

The report states that in 2012:

  • an estimated 62% of adults (aged 16 years and over) were overweight or obese in England (with a BMI of 25 or above)
  • 24.7% were obese (with a BMI of 30 or above)
  • 2.4% were severely obese (with a BMI of 40 or above)

The prevalence of obesity has increased sharply since the 1990s, and some forecasts predict that by 2050, obesity will affect 60% of adult men and 50% of adult women.

The rise in obesity has led, and will continue to lead, to a parallel rise in diabetes.

In 2013, 2.7 million – equivalent to 6% of the adult population – had diagnosed diabetes in England, representing an increase of 137,000 people since 2012.

However, when undiagnosed cases are taken into account, it has been estimated that the true prevalence in England is around 3.2 million, or 7.4% of the adult population.

This figure is projected to rise to 4.6 million, or 9.5% of the adult population, by 2030. 

Approximately a third of this increase is attributable to obesity, while the rest is due to ageing and the changing ethnic structure of the population.

 

Other risk factors

Although obesity and being overweight are the major risk factors for type 2 diabetes, other risk factors include:

  • Increasing age. The National Institute for Health and Care Excellence (NICE) states that being older than 40, or older than 25 for some black and minority ethnic groups, is an important risk factor for developing type 2 diabetes.
  • Lifestyle factors. Both obesity and type 2 diabetes are strongly associated with unhealthy diet and physical inactivity.
  • Ethnicity. All minority ethnic groups (with the exception of Irish) have a higher risk of diagnosed diabetes than the general population. For example, women of Pakistani ethnic origin are five times more likely, and those of Bangladeshi or Caribbean origin three times more likely, to be diagnosed with diabetes compared to women in the general population. Type 2 diabetes also affects people of South Asian, African-Caribbean, Chinese or black African descent up to a decade or more earlier than white Europeans.
  • Deprivation. In England, type 2 diabetes is 40% more common among people in the most deprived quintile (where a sample of the population is divided into fifths), compared with those in the least deprived quintile. People in social class V (unskilled manual) are three-and-a-half times more likely to be ill as a result of diabetic complications than those in social class I (professional), while the short-term mortality risk from type 2 diabetes is higher among those living in more deprived areas in England. 

 

Health implications

People with diabetes are at risk of a range of health complications. Uncontrolled diabetes is associated with cardiovascular disease (CVD), blindness, amputation, kidney disease and depression.

It can also result in lower life expectancy.

Life-long diabetes can also have a profound impact on lifestyle, relationships, work, income, and health and wellbeing.

The report points out that diabetic eye disease is the leading cause of preventable sight loss in people of working age, while up to 100 people a week have a limb amputated in the UK as a result of diabetes.

In England, diabetes is a major cause of mortality, with over 23,000 additional deaths in 2010-11. 

 

Cost

In the UK, it is estimated that overweight, obesity and related illnesses cost the NHS £4.2 billion in 2007, and these costs are predicted to reach £9.7 billion by 2050.

Wider total costs to society (such as loss of productivity) of overweight and obesity are estimated to reach £49.9 billion by 2050. To put that figure in context, that would be enough to pay the annual wages of just under three-and-a-half million newly qualified nurses.

A recent economic study estimated that in 2010-11 the cost of treating type 2 diabetes and its associated complications in the UK was £8.8 billion. The indirect costs (such as loss of productivity due to increased death and illness and the need for informal care) were £13 billion.

 

What is to be done?

The report itself makes no recommendations for the public, nor does it encourage people to whip out the tape measure, as some newspaper reports have implied.

However, according to a BBC report, PHE’s chief nutritional adviser, Dr Alison Tedstone, urged people to "keep an eye on your waist measurement" as losing weight is "the biggest thing you can do" to combat the disease.

"People get it wrong, particularly men,” she is reported as saying.

"They measure their waist under their bellies, saying they haven't got fatter because their trouser size is the same, forgetting they're wearing their trousers lower and lower.

"So the tip is to measure across the belly button."

Read more about how to measure your waist size and why your waist size matters.

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

Links To The Headlines

'Tape measure test' call on type 2 diabetes. BBC News, July 31 2014

35-inch waist triples female diabetes risk... And for men, 40 inches raises risk by FIVE times. Mail Online, July 31 2014

Belly fat clearest sign of type 2 diabetes risk. The Guardian, July 31 2014

Categories: NHS Choices

Could a blood test screen for suicide risk?

NHS Choices - Behind the Headlines - Thu, 31/07/2014 - 13:00

"People with certain gene mutation 'may be more likely to end their life'," reports the Mail Online. A postmortem study found a gene called SKA2 was less active in the brains of people with mental illness who had committed suicide.

They also found lower activity of this gene in blood samples taken from people who had suicidal thoughts.

However, the study was conducted on a small number of people, and the results could have been caused by other factors. No causal link was shown between the gene activity, suicidal thoughts or actions.

As reported in a similar study last year, there are questions around the usefulness of such a test.

People who are having suicidal thoughts are often secretive about their intent, so it is unlikely they would volunteer for testing.

The management of someone who has suicidal thoughts or severe depression would also not change if they happened to have a negative blood test for this gene.

The test may be useful if used in other ways or in conjunction with other tests, however.

 

Where did the story come from?

The study was carried out by researchers from Johns Hopkins University School of Medicine and Johns Hopkins Bloomberg School of Public Health.

It was funded by a National Institute for Mental Health grant, the Johns Hopkins Center for Mental Health Initiatives, the Solomon R and Rebecca D Baker Foundation, and the James Wah Award for Mood Disorders. 

There is a potential conflict of interest, as two of the authors are listed as co-inventors on a patent to evaluate risk of suicidal behaviour using genetic and epigenetic variation at the SKA2 location.

The study was published in the peer-reviewed medical journal, the American Journal of Psychiatry.

The Mail Online generally overstated the ability of this test to accurately predict who is at risk of suicide and its practical usefulness in real-world situations.

 

What kind of research was this?

This was a combination of a postmortem study, a cross-sectional study and cohort studies.

The authors report the annual suicide rate in the US has been relatively stable over the last 60 years at 10 to 12 suicides per 100,000 people.

As part of efforts to reduce this rate by 20% over five years, the researchers wanted to find a way to identify and target people at greatest risk.

They aimed to identify associations in gene expression in the brain tissue of people who had committed suicide compared with those who had not. They then wanted to assess whether these would be present in blood samples and if the levels were raised in times of stress and anxiety.

The researchers also measured the levels of the hormone cortisol in a small group of participants and looked at whether this had an association with suicidal thoughts and the level of gene expression.

Cortisol is essential for life and regulates the response to all types of stress, including illness, physical exertion and emotional stress.

Cortisol levels vary over the day and are highest on waking and lowest before sleep, and increase in response to stress.

 

What did the research involve?

The researchers performed a genome-wide screen for DNA methylation in samples of brain tissue from 98 people who had committed suicide compared with 70 people who had died from other causes. All 98 people either had major depression, bipolar disorder or schizophrenia.

DNA methylation is one of the ways a cell can dampen down the expression of a certain region of DNA. Where methylation occurs, it physically blocks the mechanism by which DNA is read. This disrupts gene activity, but not to the extent that we would say a genetic mutation had occurred, as the actual structure of the gene is unchanged. 

The level of expression of the identified gene was then measured in blood samples from people who were enrolled in three other studies:

  • 22 samples from the Genetics of Recurrent Early-Onset Depression (GenRED) offspring study – adolescents and adults who had a parent with a mental illness
  • 325 samples from the Prevention Research Center study
  • 51 samples from a cohort of pregnant women who had previously suffered from major depression or bipolar disorder

The researchers compared the blood results from people who had suicidal thoughts at any point in their life with those who had not (according to questionnaires or interviews).

They also took cortisol blood samples from the GenRED group and looked at the level of gene expression and the level of anxiety during the test. These were taken on waking, 30 minutes later and then 60 minutes after waking.

They adjusted the results to account for age, sex, race and length of time between death and postmortem.

 

What were the basic results?

A gene called SKA2, which codes for a protein necessary for cell division, was found to be less active in the brain samples of people who had committed suicide compared with people who had not. The DNA methylation, which reduces the gene activity, was correspondingly higher.

The level of DNA methylation of SKA2 was higher in the blood samples of people who had suicidal thoughts compared with those who did not.

Waking cortisol levels were higher in people who reported suicidal thoughts, but there was no association 30 and 60 minutes after waking.

 

How did the researchers interpret the results?

The researchers concluded their findings "implicate SKA2 as a novel genetic and epigenetic target involved in the aetiology of suicide and suicidal behaviours".

They say that, "Early screening of those at risk for suicidal ideation and suicide attempt may be possible, allowing for the identification of individuals at risk, proactive treatment, and stress and anxiety reduction."

 

Conclusion

This study has shown an association between reduced levels of activity of the SKA2 gene and suicide. However, no causal link was shown between the gene activity, suicidal thoughts or actions.

There are questions around the usefulness of such a test becoming commonly used. Presumably screening would be voluntary, so people considering suicide may simply not turn up for screening.

And the management of someone who has suicidal thoughts would arguably not change if they happened to have a negative blood test for this gene. If someone had severe depression, you couldn't discount a potential suicide risk.

There were also several limitations of this study, which include:

  • All the people who committed suicide had a diagnosed mental illness. This or other confounding factors could have accounted for the difference seen in SKA2.
  • There was no standardised measure of the presence of suicidal ideation (thinking about committing suicide) across the three groups of living participants.
  • People were considered to have suicidal ideation regardless of when the thoughts occurred, and the severity or frequency of the thoughts was not measured.
  • The measurement of cortisol and links with suicidal ideation and SKA2 was only conducted on 22 people, which is a very small sample size. It may not be representative of larger groups.
  • The study claimed a blood test for the DNA methylation markers could predict future suicidal ideation and suicide attempt with more than 80% accuracy. However, the authors acknowledged these results were based on very few people, so may not be reliable.

If you have suicidal thoughts, help is available through your GP or helplines such as the Samaritans, who can be reached 24 hours a day, 365 days a year on 08457 90 90 90.

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

Links To The Headlines

The blood test that could help prevent SUICIDE: People with certain gene mutation 'may be more likely to end their life'. Mail Online, July 30 2014

Links To Science

Guintivano J, Brown T, Newcomer A, et al. Identification and Replication of a Combined Epigenetic and Genetic Biomarker Predicting Suicide and Suicidal Behaviors. The American Journal of Psychiatry. Published online July 30 2014

Categories: NHS Choices

Ebola virus threat to the UK is 'very low'

NHS Choices - Behind the Headlines - Thu, 31/07/2014 - 12:00

Health news has been dominated in recent days by the outbreak of the Ebola virus in west Africa, with more than 1,200 confirmed cases and 672 deaths.

Cases have been confirmed in Sierra Leone, Liberia and Guinea. The World Health Organization estimates the current outbreak has a mortality rate of 56%.

It is important to note there is currently no direct threat to people in the UK from the Ebola virus.

Outbreaks of Ebola are nothing new, but health professionals are concerned about the size of the outbreak.

The majority of cases are confined to rural areas, but there has been a reported case of a man infected with the virus arriving via plane in the Nigerian city of Lagos. The man later died.

 

What is Ebola?

Ebola is a virus that can be spread through blood and bodily fluids. The virus originated in the west African rainforest and is thought to have spread to humans by handling or eating infected animals.

Once the virus enters the body it can replicate very quickly, causing a range of increasingly harmful symptoms, including internal bleeding. Left untreated it can have a mortality rate as high as 90%.

 

What are the symptoms of Ebola virus?

An infected person will typically develop a fever, headache, joint and muscle pain, sore throat, and intense muscle weakness. These symptoms start suddenly 2 to 21 days after becoming infected.

Diarrhoea, vomiting, a rash, stomach pain and impaired kidney and liver function follow. The infected person may then bleed internally, as well as from the ears, eyes and mouth.

 

How is the Ebola virus spread?

People can become infected with the Ebola virus if they come into contact with the blood, body secretions or organs of an infected person.

Some traditional African burial rituals may have played a part in its spread. The Ebola virus can survive for several days outside the body, including on the skin of an infected person.

In parts of Africa it is common for mourners to touch the skin of the deceased. A person then only needs to touch their mouth to become infected.

Other ways people can catch the virus include:

  • touching the soiled clothing of an infected person and then touching their mouth
  • having sex with an infected person without using a condom (the virus is present in semen for up to seven days after an infected person has recovered)
  • handling unsterilised needles or medical equipment that have been used on the infected person
  • handling infected animals or coming into contact with their body fluids

A person is infectious as long as their blood and secretions contain the virus.

Ebola virus is generally not spread through routine social contact such as shaking hands with patients without symptoms.

The virus is not airborne, so it's not as infectious as diseases such as the flu – you'd need to get close to it to catch it.

 

Who's at risk from Ebola?

Anyone who has close contact with an infected person or handles samples from patients is at risk of becoming infected. Hospital workers, laboratory workers and family members are at greatest risk.

 

How is Ebola diagnosed?

It's difficult to know if a patient is infected with Ebola virus in the early stages. The early symptoms of Ebola, such as fever, headache and muscle pain, are similar to those of many other diseases.

But health workers are on standby to act quickly. If anyone in the UK develops the above symptoms and has potentially been in close contact with the virus, they will be admitted to hospital and will most likely be quarantined.

Samples of blood or body fluid can be sent to a laboratory to be tested for the presence of Ebola virus, and a diagnosis can be made rapidly. If the result is negative, doctors will test for other diseases, such as malaria, typhoid fever and cholera.

 

What are the treatments for Ebola?

There's currently no specific treatment or cure for the Ebola virus, although potential new vaccines and drug therapies are being developed and tested.

Patients need to be treated in isolation in intensive care. Dehydration is common, so fluids may be given intravenously (directly into a vein). Blood oxygen levels and blood pressure will be maintained at the correct level, and the body organs supported while the patient recovers.

 

What is the risk of Ebola in the UK?

The risk to the UK is thought to be very low and there have been no reported cases.

While it is theoretically possible someone with the virus could arrive in the UK, health professionals have been told to watch out for any patient presenting with unusual symptoms.

If this happened, the infected person would then be quickly admitted to hospital and quarantined, as was the case with a man who arrived in the UK and then developed Middle East Respiratory Syndrome in 2012.

Ebola virus is not airborne, so there is no credible risk of a swine flu-like global pandemic.

You cannot catch Ebola by travelling on a plane with someone who is infected, unless you come into very close physical contact with them, such as kissing.

 

What precautions are being taken?

Public Health England (PHE), the body responsible for public health in England, has told health professionals about the situation in west Africa and asked for vigilance about unexplained illness in people who have visited the affected area.

PHE has provided advice for humanitarian workers planning to work in affected areas. It is also working with people from Sierra Leone living in England.

Advice has already been issued to immigration removal centres on carrying out health assessments for people who may have been in Ebola outbreak areas within the preceding 21 days.

And PHE is liaising with the UK Border Agency and port health authorities to update guidance for staff working in airports and ports.

Dr Brian McCloskey, PHE's director of global health said: "The risk to UK travellers and people working in these countries of contracting Ebola is very low.

"People who have returned from affected areas who have a sudden onset of symptoms such as fever, headache, sore throat and general malaise [sense of feeling unwell] within three weeks of their return should immediately seek medical assistance." 

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

Links To The Headlines

Ebola virus outbreak: live. The Daily Telegraph, July 31 2014

Ebola virus: what is the real risk to the UK? The Guardian, July 31 2014

Truth about incurable virus that's just one plane ride from Britain: Experts say statistics show Ebola WILL reach Britain. Mail Online, July 31 2014

Categories: NHS Choices

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