Medical News

Social care reforms announced

Medical News - Tue, 01/19/2038 - 06:14

Most of the UK media is covering the announcement made in Parliament by Jeremy Hunt, Secretary of State for Health, about proposed changes to social care.

The two confirmed points to have garnered the most media attention in the run-up to the announcement are:

  • a ‘cost cap’ of £75,000 worth of care costs – after this point the state would step in to meet these care costs
  • raising the current means-testing threshold for people to be eligible for state-funded social care from £23,520 to £123,000

The government expects these changes will lead to fewer people having to sell their homes in order to pay for their long-term care needs.

Speaking in Parliament, Mr Hunt said that the current system was ‘desperately unfair’ as many older people face ‘limitless, often ruinous’ costs. The minister stated that he wants the country to be ‘one of the best places in the world to grow old’.

 

What is social care?

The term social care covers a range of services provided to help vulnerable people improve their quality of life and assist them with their day-to-day living.

People often requiring social care include:

  • people with chronic (long-term) diseases
  • people with disability
  • the elderly – particularly those with age-related conditions, such as dementia

Social care services can include:

  • healthcare
  • equipment
  • help in your home or in a care home
  • community support and activities
  • day centres

 

How does the current adult social care system work?

Currently, state funding for social care is based on two criteria:

  • means – people with assets of more than £23,520 do not qualify for funding
  • needs – most local authorities will only fund care for people assessed to have substantial or critical needs

The majority of people currently requiring social care pay for it privately. These are known as ‘self-funders’.

 

What prompted these reforms to adult social care?

Put simply, on average, the UK population is getting older.

When the welfare state was created in the early 20th century, it was not expected that people would someday routinely live into their 70s, 80s, and even 90s.

The increase in life expectancy is a good thing, however, it brings a new set of challenges.

While people are living longer, they are also spending more of their lives in ill health. Older people are more likely to have potentially complex care needs that can be expensive to manage.

Many people are currently ineligible for state-funded social care under the existing laws. To meet the costs of these care needs, these ‘self-funders’ have, in many cases, had to sell or remortgage their home, or sell other assets to pay for the costs of their care.

Without reforms, experts agree that the cost of social care for both the state (through taxes) and to ‘self-funders’ is likely to become increasingly problematic.

To try and find the best way to resolve some of the difficulties of fairly funding adult social care, the Department of Health set up a commission. This independent commission reported its findings to ministers in July 2011. The government considered these findings in its white paper on care and support published in July 2012, and in the drafting of the proposed new legislation.

 

What happens next?

The government has introduced a Social Care Bill which will need to be passed by the Houses of Parliament.

If the bill is successfully passed it is expected the amendments will come into force by 2017.

 

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

Links To The Headlines

Social care: Jeremy Hunt hails 'fully-funded solution'. BBC News, February 11 2013

Social care reforms: Almost 2 million pensioners will be denied state help. The Daily Telegraph, February 11 2013

Social care reform: how your family may be affected. The Daily Telegraph, February 11 2013

Dilnot 'regrets' decision to set social care cap at £75,000. The Guardian, February 11 2013

Hunt statement on adult social care cap: Politics live blog. The Guardian, February 11 2013

Categories: Medical News

Can the so-called 'male menopause' be treated with HRT?

Medical News - 9 hours 21 min ago

"New research suggests that testosterone deficiency in older men is much more prevalent than current screening methods suggest, and that more men would benefit from hormone treatment," The Daily Telegraph reports.

The male menopause, which remains controversial, is said to be a syndrome of associated symptoms linked to the fall of testosterone, which include:

The research behind the headlines involved more than 2,000 men given trials of testosterone therapy after attending private Men's Health clinics in the UK.

The men had an average age of 54, though some were aged 90. All the men reported symptoms associated with the so-called male menopause. Most (83%) had testosterone levels that would be considered to be in the normal range, but all were given trials of testosterone therapy.

The men reported a reduction in symptoms with treatment. However, there are risks associated with testosterone therapy, including an increased risk of prostate cancer and blood clots.

The study was an audit of men attending a clinic, so there was no control group. This and other factors mean the study's results are less reliable: a randomised controlled trial would have made the research more trustworthy.

It remains to be seen whether the benefits of testosterone therapy outweigh the risks for men currently considered to have testosterone levels within the normal range, and further studies are needed. 

Where did the story come from?

The study was carried out by researchers from the Centre for Men's Health and University College Hospital, both in London, and Edith Cowan University in Australia.

Funding was not reported, but one of the three authors works for a private Men's Health clinic. The clinic offers treatments for male menopause, erectile dysfunction and prostate health – this represents a potential financial conflict of interest.

The study was published in the peer-reviewed journal The Aging Male on an open-access basis. The research is available to read for free online.

Headlines such as "Academics find the male menopause is real" from the Daily Mail are simply not true. This study was an audit of men prescribed testosterone after reporting symptoms such as difficulty getting an erection. This type of study cannot prove whether the male menopause is real or not.

Reassuringly, all of the UK media outlets that covered the study made it clear the implications of this research have been disputed by other experts.

Most sources quoted Professor Frederick Wu of Manchester University, who disputed the claims made by this research. He said, "In my opinion, this publication is not only misleading, but potentially dangerous, particularly when the author calls for many more men to be treated, inappropriately, with testosterone." 

What kind of research was this?

This was a retrospective audit of men attending private Men's Health clinics in London, Edinburgh or Manchester since 1989 with symptoms of low testosterone.

This type of study can provide an insight into whether testosterone replacement provides symptom relief, but cannot prove cause and effect.

A prospective, double-blinded randomised controlled trial would be required to prove a causal relationship, as this eliminates potential biases and confounding factors

What did the research involve?

The researchers reviewed the medical notes of 2,693 men who had attended private Men's Health clinics since 1989. Their symptoms, reported to be present for around three to five years before attending the clinics, included:

  • loss of libido
  • low energy
  • difficulty achieving and maintaining an erection
  • loss of morning erections
  • night sweats
  • joint pains
  • depression
  • irritability
  • impaired memory

The clinics diagnosed the majority of the men (2,247) with inadequate testosterone levels based on their symptoms alone: diagnosis was not based on measured testosterone levels.

The researchers said many men had been denied treatment before because their testosterone levels were in the normal range. This study questions the reliability of these tests.

All of the men diagnosed with low testosterone levels based on symptoms alone were offered testosterone therapy in different forms. These included:

  • pellet implants
  • oral testosterone
  • testosterone scrotal cream
  • scrotal gel

A symptom checklist called the Andropause Checklist assessed changes in symptoms before and during treatment. It uses 20 questions to derive a score from 0 to 80. In this study, a score of less than 10 was considered normal and was the target for treatment. 

What were the basic results?

The average age of the men was 54, with a range from 24 to 90. The average length of follow-up to assess symptoms and testosterone levels was one to two years after treatment. Treatment lasted from 3 to 12 years depending on the testosterone delivery (implant, gel, pill or cream).

Symptomatic relief – defined as a symptom score of less than 10 on a 0 to 80 scale – was achieved for all testosterone therapies two years into treatment.

Some treatments led to symptomatic relief within a year. Men with more severe symptoms were less likely to respond well to the testosterone therapy.

None of the men were reported to have an increased prostate after testosterone treatment, but the average follow-up was just one year.

An unreported proportion of the men had an increased number of red blood cells (polycythaemia) – a known side effect of testosterone treatment that increases the risk of blood clots. These men had to be treated for this by having blood taken regularly to reduce the number back to safe levels.  

How did the researchers interpret the results?

The researchers concluded that, "With appropriate and necessary monitoring of safety parameters, testosterone treatment appears safe and economic.

"Many men who could benefit in terms of symptom relief, with improvement in related clinical conditions and prevention of the long-term effects of testosterone deficiency, may remain untreated because of excessive reliance on laboratory measures of androgens for diagnosis and treatment alongside unwarranted safety concerns." 

Conclusion

This study found that offering men testosterone when they reported symptoms usually described by men with low testosterone caused a reduction in their symptoms. This was despite 83% of the men having testosterone levels considered to be in the normal range, above 10nmol/l.

The authors say that treating people according to symptoms should be more important than basing it on testosterone blood levels alone. They say these blood levels may be inaccurate, and some individuals may naturally need higher levels of testosterone than others. This is an interesting concept worthy of further robust study.

However, there are potentially serious side effects reported with testosterone therapy, and this study does not address these risks or provide evidence that more people should be treated.

This study's findings have many limitations:

  • Because of the nature of the study, there was no placebo group to act as a control.
  • The study was retrospective, which is a less reliable type of study than prospective trials.
  • The men did not have a laboratory-confirmed diagnosis of low testosterone, and the research relied on self-reported symptoms. The authors say the men's blood results may have been in the normal range for their age, but this may be lower than their individual level used to be. While this is a plausible conclusion, it is not backed by the evidence – the study did not measure each man's testosterone levels when they had no symptoms. Additionally, guidelines recommend that men are only treated if their testosterone level is below 10nmol/l, which was only the case for 17% of these men. Some had four times this cut-off, with levels of up to 40nmol/l.
  • All men were advised to make lifestyle changes, including reducing their stress levels, alcohol intake and weight if necessary, and increasing how much exercise they did, which could have influenced the results.
  • Other interventions were also started where necessary, including treatment for high blood pressure, high cholesterol and diabetes, which may also have affected the results.
  • The authors concluded that testosterone is a safe treatment, saying they have treated men in this way over the course of 25 years and have not seen known problems such as increased prostate size or blood clots. However, the average length of follow-up in this study was just one year.

The US Food and Drug Administration (FDA) issued a warning in 2014 about the increased risk of blood clots with the use of testosterone replacement. They only recommend that testosterone is prescribed for men who do not produce testosterone or who have low levels as a result of a medical condition that requires treatment, such as chemotherapy.

In the UK there are no official NHS guidelines, but the Society for Endocrinology recommends that male patients are treated on a case-by-case basis, depending on their symptoms.

If you suffer from the symptoms described above, it may be worth seeing your GP – testosterone replacement therapy is effective for men who are found to have low testosterone levels.

It remains to be seen whether the benefits of testosterone therapy would outweigh the risks for men currently considered to have testosterone levels within the normal range.

Many problems with issues such as erectile dysfunction and loss of libido are often the result of psychological, rather than physical, issues. It may be unwise to seek out hormonal treatments without first speaking to a sex therapist or a similar type of counsellor. The College of Sexual and Relationship Therapists has contact details for accredited therapists.  

Links To The Headlines

Is the 'manopause' more widespread than we thought? The Daily Telegraph, July 30 2015

Male menopause is real, claims controversial new study. The Independent, July 30 2015

Could testosterone HRT help treat the male menopause: Therapy should be provided as men also suffer hot flushes and low libido once they pass 50. Mail Online, July 30 2015

Links To Science

Carruthers M, Cathcart P, Feneley MR. Evolution of testosterone treatment over 25 years: symptom responses, endocrine profiles and cardiovascular changes. The Aging Male. Published online July 28 2015

Categories: Medical News

NICE produces new draft guidelines on caring for the dying

Medical News - Wed, 07/29/2015 - 16:30

"England's health watchdog has put forward new draft guidance to improve the care of adults in their last few days of life," BBC News reports.

The guidelines, produced by the National Institute for Health and Care Excellence (NICE), have been proposed as an alternative to the controversial Liverpool Care Pathway, which was phased out in 2014.

 

What was the Liverpool Care Pathway?

The Liverpool Care Pathway was developed during the late 1990s at the Royal Liverpool University Hospital, in conjunction with the Marie Curie Palliative Care Institute. It was intended to provide the best quality of care possible for dying patients in the last days and hours of life, whether they were in hospital, at home, in a care home or in a hospice.

It was designed to address concerns such as:

  • patients being subjected to invasive testing and treatment that offered no chance of preventing death
  • causing unnecessary pain and suffering by needlessly prolonging life

 

Why did it become controversial?

There were three main issues of controversy that were widely reported in the media:

  • the assessment that a person was dying was not always made by an experienced clinician and was not reliably reviewed
  • the dying person may have been unduly sedated as a result of poor prescribing methods
  • there were claims that hydration and some essential medicines may have been withheld, which may have a negative impact on the dying process

It appeared that while the Pathway itself was sound, some staff may not have been following its recommendations correctly. For example, withdrawal of nutrition and fluids should never be a routine option, but done only if it is felt to be in the best interests of the patient, judged on a case-by-case basis.

 

What are the main recommendations of the new draft guideline?

A summary of the most important points is provided below. 

NICE has published the complete guideline, including relevant evidence (PDF, 3.4Mb).

Recognising when a person is in the last days of their life

If it is thought that a person may be dying, information should be gathered on their:

  • clinical signs and symptoms, and medical history
  • the person's goals and wishes, as well as their psychological and spiritual needs
  • the views of those important to the person with respect to future care

The assessment of their clinical state should be made on a team basis and not just by one individual. The assessment should be reviewed at least every 24 hours.

Communication

Establish their communication needs, their current level of understanding and how much information they want to know about their prognosis. If patients or their families do want information, staff should discuss any concerns they have, while avoiding giving false hope.

Shared decision making

Find out how much the person wants to be involved in terms of shared decision making when it comes their care plan. As part of this process, find out whether the person has an advanced care plan or decision in place, as well as their goals and wishes.

Hydration

A dying person should always be supported if they wish to drink and are able to, though it is important to check for potential risks, such as swallowing problems.

Encourage friends and family to help with giving drinks and mouth care. Provide any necessary aids, such as sponges.

Discuss the risks and benefits of clinically assisted hydration, such as intravenous feeding, and their wishes about its use. It is also important to make clear that clinically assisted hydration is unlikely to prolong life.

Pharmacological interventions

Discuss what level of symptom control they would want in the last days of their life, as well as the possible benefits and harms of any medicines offered.

The plan for pharmacological interventions should be regularly reviewed.

 

How do I make my views known?

Consultation on the guidelines will finish on September 9 2015. To register a comment, you will need to belong to an eligible stakeholder organisation, such as a national organisation for people who use health and social care services, or an organisation that funds or carries out research.

Read more about the commenting and registration process

Links To The Headlines

Dying care: 'Improved' guidelines proposed. BBC News, July 29 2015

New guidelines for care of the dying proposed. ITV News, July 28 2015

'We must end our industrialised approach to death and show compassion': Professor speaks out as the NHS is forced to remind medics to give dying patients water. Mail Online, July 29 2015

Doctors and nurses ordered to stop denying dying patients water. The Daily Telegraph, July 29 2015

Categories: Medical News

Some over-the-counter drugs may be linked to falls in older men

Medical News - Wed, 07/29/2015 - 03:00

"Popular over-the-counter drugs for hay fever and insomnia may increase the risk of a serious fall among older men," the Daily Mail reports after a study suggested anticholinergic drugs, which can cause side effects such as blurred vision and drowsiness, could increase fall risk.

The study followed just under 2,700 older Irish adults, who did not have dementia, for two years. It found older men who took anticholinergic medicines were about 2.5 times more likely to have a serious fall that caused injury. No such link was found in women.

But the reasons the men are taking the drugs in the first place may be contributing to their fall risk, although the researchers did take steps to take this into account. The authors have called for further studies to check their findings.

While the news focuses on over-the-counter medications, the most commonly used medications taken in this study were actually prescription medications. It is not possible to single out the potential risk posed by over-the-counter drugs.

The study is a reminder that people should always read medication labels, not take the drugs for longer than needed, and talk to their doctor to make sure the drugs do not interfere with any prescription drugs they are using. 

Where did the story come from?

The study was carried out by researchers from Trinity College Dublin and other research centres in Ireland and the UK.

It was funded by Irish Life, the Irish Department of Health and The Atlantic Philanthropies.

The study was published in the peer-reviewed Journal of the American Geriatrics Society.

The Daily Mail focuses on over-the-counter medications, even though these were not among the most commonly used anticholinergic medications seen in this study. Most were prescription medications, such as antidepressants or drugs used to control bladder conditions.

The Mail does include a note from the study authors that people should not stop taking their prescription medication without talking to their doctor first. 

What kind of research was this?

This prospective cohort study looked at whether anticholinergic medicines are associated with falls in older people. This class of drugs block the action of one of the nervous system's signalling chemicals called acetylcholine.

These drugs are used to treat a wide variety of conditions and symptoms, including incontinence, depression and psychosis. Some anticholinergic medicines are available over the counter, such as the antihistamine chlorpheniramine, which is used to treat allergies.

Older adults are reportedly often prescribed these drugs. They also may be taking more than one medication of this type, which may make them more susceptible to side effects.

Side effects can include blurred vision, drowsiness, an unsteady gait and confusion, all of which could increase the risk of falls in older people.

This study wanted to see whether data collected from older people taking these drugs supported this theory. A prospective cohort study is a good way to assess the link between an exposure (in this case, anticholinergic drugs) and an outcome (falls).

Setting up a randomised controlled trial (RCT) just to test whether a drug has an adverse effect would be unethical. As with all studies of this type, the main limitation is it cannot rule out all other potential confounding factors

What did the research involve?

The researchers enrolled 2,696 adults aged 65 and over who did not have dementia and were living at home.

They asked them questions at the start of the study about what medications they took regularly. Participants were followed up over two years to see whether any of them had a fall.

Once they collected this data, the researchers analysed whether people taking anticholinergic medicines regularly were more likely to have fallen.

The adults in this study were taking part in a wider study called The Irish Longitudinal Study on Ageing (TILDA) and were recruited between 2009 and 2011.

The initial interviews asked people about what medicines they took regularly (every day or every week). This included prescription medications, over-the-counter medicines, vitamins, herbal remedies and alternative medicines.

The researchers also asked to see the medication packages to make sure the information was correct. For a sample of participants, researchers were also able to check what prescribed medicines the participants had been dispensed over the last 30 days.

The researchers ranked how much anticholinergic activity each of the medications had on a scale of 0 (none) to 3 (definite anticholinergic activity). They did this using the Aging Brain Care online tool, which is based on expert consensus and the literature.

They then added up the scores of all of the medications a person was taking to get their overall anticholinergic medication score.

The researchers also noted whether individuals were taking other non-anticholinergic medicines that have been linked to an increased risk of falls.

At follow-up in 2012, participants were asked whether they had fallen since the start of the study and, if so, how many times and whether they needed medical treatment as a result.

The researchers then analysed whether anticholinergic medication use was associated with a greater risk of falls. They took other factors into account that might influence the risk of falls, such as:

  • gender
  • age
  • whether a person lived alone
  • socioeconomic status
  • health and behaviours, such as alcoholism  
What were the basic results?

The study found 4% of the older adults reported regularly taking at least one medication with definite anticholinergic activity, and 37% reported regularly taking at least one medication with possible anticholinergic activity. These medications were often prescription medications, such as antidepressants or drugs for heart or bladder conditions.

About a quarter of the participants (26%) had at least one fall during the study, and in 13% this fall caused them injury that required medical treatment. Women fell more commonly than men. In women, no link was found between taking anticholinergic medications and risk of falls.

However, men who reported regularly taking medications with definite anticholinergic activity at the start of the study were about 2.5 times as likely to have an injury-causing fall as those who did not, (relative risk [RR] 2.55, 95% confidence interval [CI] 1.33 to 4.88).

There was no link between these medications and overall risk of falling or the number of falls in men. Regularly taking medications with possible anticholinergic activity was not associated with risk of falls in men.

When looking at how much anticholinergic medication men took, those with a total anticholinergic medication score of five or over (such as taking one medication with definite anticholinergic activity and one of possible anticholinergic activity) were more likely to have a fall (RR 1.71, 95% CI 1.03 to 2.84) and more likely to have a fall that caused injury (RR 4.95, 95% CI 2.11 to 11.65). 

How did the researchers interpret the results?

The researchers concluded that: "The regular use of medications with anticholinergic activity is associated with subsequent injurious falls in older men, although falls were self-reported after a two-year recall and so may have been underreported." They suggest that further studies are needed to confirm this finding. 

Conclusion

This relatively large cohort study found an association between taking medicines with definite anticholinergic activity and an increased risk of injury-causing falls in older men, but not women.

The fact that data was collected prospectively is one of this study's strengths, as is the fact that interviewers checked medicine packages to confirm self-reported medication use and could check prescription medication records for some patients.

However, this study did have some limitations:

  • Medication use was only assessed at the start of the study and may have changed after this.
  • Falls were self-reported. Participants may not have remembered all falls, particularly those that did not require medical attention.
  • Even though the study was relatively large, the numbers in some groups were small once divided into men and women, medication usage, and those who had falls or not. For example, there were only 50 men and 68 women who were regularly taking at least one medication with definite anticholinergic activity.
  • Confirmation of these findings in a larger sample size would increase confidence in the results. 
  • Although the researchers took possible confounders into account, some factors could have affected the results. For example, men who take a lot of anticholinergic medications may be doing so for conditions that increase their risk of falling – for example, heart conditions.
  • News reports have focused on anticholinergic medications available over the counter (such as antihistamines), but these were not the most commonly taken anticholinergic drugs in this study. The exact numbers of people taking these over-the-counter drugs was not reported.

While this study suggests a link worthy of further investigation, people should not stop taking any prescription medication without talking to their doctor first.

Regardless of whether or not the results are eventually confirmed, it is worth remembering that over-the counter-medications are not free from side effects or potential complications.

Always read the information leaflet that comes with any medication carefully, to make sure it is suitable for you.

Links To The Headlines

Do over-the-counter medicines for hayfever and insomnia raise the risk of serious falls in older men? Daily Mail, July 29 2015

Links To Science

Richardson K, Bennett K, Maidment ID, et al. Use of Medications with Anticholinergic Activity and Self-Reported Injurious Falls in Older Community-Dwelling Adults. Journal of the American Geriatrics Society. Published online July 22 2015

Categories: Medical News

Nose balloon could be used to treat glue ear

Medical News - Tue, 07/28/2015 - 15:00

"Using the nose to inflate a balloon helps heal glue ear," BBC News reports. The technique, known as autoinflation, was found to be effective in around half of cases of this common childhood ear condition.

Glue ear is when the middle ear becomes filled with fluid. It is common among young children and can cause hearing problems. Most cases get better without treatment, but sometimes hearing aids or grommets (small tubes inserted into the eardrum to drain fluid) may be used.

Autoinflation is where a child blows into a special balloon with their nose. It is not a new concept, but research into its effectiveness compared with other treatments for glue ear – which usually boils down to "watch and wait" – has been lacking.

More than 300 children were included in the study and received autoinflation (three times daily for one to three months) in addition to usual care or usual care alone (control). After one month, 47.3% of the autoinflation group were diagnosed as having normal hearing, compared with 35.6% in the control group.

Autoinflation will only provide a solution for children who are able to inflate the nasal balloon and can do so on a regular, daily basis. This means it may not be suitable for everyone. The technique should not be used without medical supervision and training.

Where did the story come from?

The study was carried out by researchers from the University of Southampton and the University of Oxford.

Funding was provided by the Health Technology Assessment of the National Institute for Health Research.

It was published in the peer-reviewed Canadian Medical Association Journal and has been made available on an open-access basis, so it is free to read online or download as a PDF.

This study has been reported accurately by BBC News and the Daily Mirror, although the reporting gives the impression autoinflation is a new technique. In fact the technique has been used for decades, but there has been persistent controversy about whether it is effective or not. 

What kind of research was this?

This was a randomised controlled trial (RCT) to assess the effectiveness of autoinflation in the treatment of children with glue ear.

Glue ear is when the middle ear becomes filled with fluid. It is quite common among young children – the study reports that up to half of children have been affected by the age of four to five – and can cause problems with hearing and sometimes speech and language development.

The exact cause isn't always clear, but it may be the result of previous ear infection or irritation from environmental allergic substances or smoke.

Most cases get better without treatment, but sometimes hearing aids or grommets may be used. Autoinflation, where the child blows into a special balloon with their nose, is another treatment option.

A randomised controlled study design is the best way to assess the effect of a treatment.  

What did the research involve?

This study included 320 children aged 4 to 11 with glue ear and a recent (past three months) history of hearing loss or other relevant ear-related problems. The children were recruited from 43 general practices in the UK between January 2012 and February 2013.

They were randomly assigned to autoinflation three times daily for between one and three months in addition to usual care, or usual care only (control).

Assessment of middle ear fluid was made at between one and three months by an expert who was unaware of which treatment the children received.

Ear-related quality of life was compared with the baseline values – essentially, the impact any hearing loss had on day-to-day living for each child. Data from weekly symptom diaries related to glue ear was summarised according to the number of days with symptoms.  

What were the basic results?

Baseline characteristics were similar in the two groups. The children who received autoinflation had better outcomes – 47% had no symptoms at one month, compared with 35% in the control group. At three months, the condition had cleared up in 50% in the autoinflation group, compared with 38% in the control group.

It was calculated that nine children would need to be treated with autoinflation for one additional child to benefit from the treatment, compared with what would be expected for usual care. In other words, autoinflation had a number needed to treat (NNT) of nine.

Further analyses found age (above or below 6.5 years), the severity of the symptoms, quality of life or gender had no effect on treatment outcome. Autoinflation increased ear-related quality of life, with children having fewer days with symptoms at one and three months than the usual care group.

Adverse effects were generally similar in both groups, with nosebleeds occurring most frequently (15% and 14% in each group). Mild respiratory tract infections (such as a runny nose) were more common in the autoinflation group, with 15% of children affected, compared with 10% in the control group.  

How did the researchers interpret the results?

The researchers concluded that, "Autoinflation in children aged 4 to 11 years with otitis media with effusion [glue ear] is feasible in [general practice] and effective both in clearing effusions and improving symptoms and ear-related child and parent quality of life." 

Conclusion

This RCT aimed to assess the use of autoinflation as a treatment for glue ear. More than 300 children were included in the study and were randomly assigned to receive autoinflation, in addition to usual care for up to three months, or usual care alone.

The use of autoinflation does appear to show some promise at one and three months, and the side effects were generally mild. However, this will only provide a solution for children who are able to perform the technique and do this regularly. This means it may not be a suitable treatment for everyone.

This study's main strength is that it included a representative sample of the UK population. The researchers conducted a power calculation to ensure they had enrolled a sufficient number of participants to increase the certainty of their findings.

Group assignment was also random, which reduces the risk of bias, and the analysis was by assigned group, with fairly low drop-out (8% at one month and 12% at three months).

Participants were not blinded to the treatment they were receiving, but this is not really possible with this type of intervention. However, the investigators assessing the outcome of the treatment were blinded, which is a strength.

However, the study only assessed school-age children, who were more likely to be able to perform autoinflation, and does not address very young children with glue ear.

This study also cannot inform us how autoinflation may compare with other treatments, such as the use of hearing aids or grommets, particularly in the longer term.  

Overall, this study has provided some positive results, which should be confirmed by a larger study over a longer period of time that also involves younger children.

The treatment does have the advantage of being relatively cheap and non-invasive. It could be a useful first-line treatment as part of a step-wise approach to treat glue ear. If it proves ineffective in individual cases, other treatments such as grommets could then be used.

Links To The Headlines

Blowing balloons 'treats glue ear'. BBC News, July 28 2015

Does your child suffer from glue ear? There could be a very simple way to cure it. Daily Mirror, July 27 2015

Links To Science

Williamson I, Vennik J, Harden A, et al. Effect of nasal balloon autoinflation in children with otitis media with effusion in primary care: an open randomized controlled trial. Canadian Medical Association Journal. Published online July 27 2015

Categories: Medical News

The placebo effect can still work, even if people know it's a placebo

Medical News - Mon, 07/27/2015 - 16:30

"The placebo effect is real – even if you know the treatment you've been given has no medical value, research has concluded," the Mail Online reports. The study in question aimed to further understand how placebos – inactive or dummy treatments – work.

The research involved 40 volunteers who took part in a series of experiments where a heat sensor was applied to their arm. Before the heat application, petroleum gel (Vaseline) was applied to the skin. The researchers added a blue dye to one of the batches and told the volunteers it was a pain relief gel.

The researchers ran a series of conditioning tests where they applied the blue gel or the plain gel to the skin before the heat. What they were actually doing was applying low heat after the blue gel and high heat after the plain gel.

The longer this "conditioning" went on, the greater effect it had. Even when the dyed blue gel was revealed as an identical inactive gel, some pain relief was still experienced by those who had four days of this conditioning, compared with people who had only one day.

While interesting, the study has limited direct applications. The results cannot easily inform the effect a placebo may or may not have in real-life situations.

However, the results reinforce the notion the psychological can have just as big an impact as the physical when it comes to coping with chronic pain

Where did the story come from?

The study was carried out by researchers from the University of Colorado Boulder and the University of Maryland Baltimore in the US, and was funded by the National Institute of Mental Health.

It was published in the peer-reviewed Journal of Pain.

The Mail has a simplistic take on what was quite a complex experimental study and analysis. Its reporting could benefit from recognising the limitations of this experimental research. 

What kind of research was this?

This experimental study aimed to investigate how placebo (inactive) painkillers work.

The researchers explain how recent research has suggested placebo pain relief is mediated by expectations. "Expectancy theory" implies a belief in the placebo is essential for it to work.

This study aimed to see whether placebo painkillers would work if the person was aware they were only receiving placebo, by testing the effects before and after use.

The researchers believed it was all to do with expectancy – if there was enough prior conditioning, the placebo's effect would still persist, even if was later revealed as a placebo. 

What did the research involve?

This experimental study recruited 54 adults (30 men and 24 women aged 18 to 55) via university advertisements.

They were given an initial test to assess their pain response to a thermal stimulus that would be used during the experiments. Those that did not find it sufficiently painful were excluded, leaving 40 participants (27 women and 13 men).

The participants were told they were taking part in a test comparing the painkilling effects of a cream containing an active painkilling ingredient (the placebo) with a cream containing no active ingredients (the control).

Both creams were in fact the same petroleum jelly containing no active ingredients – the only difference being the placebo was blue.

The experiments were in four stages: calibration, placebo manipulation, conditioning, and testing.

Calibration phase

Sixteen different temperature stimuli were given on eight sites of the volunteers' forearms. They were asked to respond on a visual analogue scale from 0 (no pain) to 100 (worst pain imaginable).

From this, six temperatures were derived for each individual for the remaining experiment: two low, two medium, and two high pain stimuli.

Placebo manipulation

The participants were told about the composition of the placebo cream, the active ingredients it contained and possible side effects.

Conditioning

This involved sessions where the person was given either the placebo or control cream before having the heat stimulus applied.

The difference was each time they gave "the placebo" the researchers followed this up by applying a low-heat stimulus, whereas when they gave "the control" they followed this up with a high-heat stimulus.

The participants had been divided into two groups of 20: a short group, who had only one conditioning session, and a long group, who had this conditioning given on four separate days.

Testing

This began after the last conditioning session. Participants were given a few runs with the placebo and control creams, each time being asked to assess on the visual scale how much pain relief they expected to receive with the coming heat stimulus.

The placebo was then revealed to be inactive and identical to the control cream. After a 15-minute delay, they were again tested with the placebo and control creams. 

The researchers compared differences between the creams in expected pain relief before and after the reveal, and with the effect of the short or long conditioning.  

What were the basic results?

The analysis of this study was in-depth. In brief, before the reveal, expected pain relief was higher for placebo than the control cream. This was not significantly different between conditioning groups.

After the reveal, the expected pain relief from the placebo varied among the long conditioning and short conditioning groups. There was some pain relief expectation in the long conditioning group, but there was none in the short conditioning group.

Expected pain relief for the control cream ratings did not change after the placebo reveal, and was no different between the short and long conditioning groups. 

How did the researchers interpret the results?

The researchers concluded their study "demonstrates a form of placebo analgesia that relies on prior conditioning rather than current expected pain relief".

This, they say, "highlights the importance of prior experience on pain relief and offers insight into the variability of placebo effects across individuals".  

Conclusion

This experimental study suggests reinforcing an expectation of a positive outcome – as with the long conditioning in this study – can create a placebo effect. Some pain relief seemed to be experienced, even when the placebo was finally revealed to be as inactive as the control.

In terms of any implications from these findings, there are a few points to bear in mind.

  • This was a fairly small, select group of healthy adults. In fact, they were preferentially selected from the group of volunteers as being people who experienced sufficient pain response to the heat stimulus. They are not representative of everyone, and the results could have been different in other groups.
  • This was a very experimental scenario involving a heat sensor applied to the skin. The participants knew the cause of the pain, their health was not under threat, and they were in a safe environment. This cannot be applied to real-life pain scenarios such as illness or trauma, which can obviously involve widely different forms of pain and severity, and may also involve other symptoms and emotional effects. Placebo pain relief – either applied to the skin, or taken in other forms, such as a tablet or injection – may be completely ineffective in real-life pain situations, regardless of how much the person is conditioned or manipulated to believe it will have an effect.
  • The study's results also cannot be applied to placebos used in other circumstances aside from pain relief – for example, when used in trials as an inactive comparison group to a new drug used to treat disease.   

Overall, this experimental study will be of interest in the fields of psychology and pharmacology for understanding how placebos may have effects through the expectation they will work.

If you are being troubled by chronic pain, you should contact your GP. The NHS runs pain clinics that can provide both physical and psychological advice.  

Links To The Headlines

The placebo effect IS real - even when patients know the treatment they are getting is fake. Mail Online, July 26 2015

Links To Science

Schafer SM, Colloca L, Wagner TD. Conditioned Placebo Analgesia Persists When Subjects Know They Are Receiving a Placebo. The Journal of Pain. Published online January 22 2015

Categories: Medical News

Is there really a middle-class drinking 'epidemic' in over-50s?

Medical News - Fri, 07/24/2015 - 16:00

"Middle-class over-50s have become a generation of problem drinkers," the Mail Online reports – a headline that actually has little basis in fact.

This follows the analysis of more than 9,000 adults aged over 50 from the English Longitudinal Study of Ageing. It found that over-50s falling into a "higher-risk drinking" category were more likely to have middle-class traits such as high educational achievement, better self-rated health, and being socially active.

Higher-risk drinking was defined as drinking more than 50 alcohol units per week (equivalent to five or more bottles of wine) for men, and over 35 units per week (three-and-half bottles of wine) for women.

The Mail's headline got the wrong idea though, because only 3-7% of over-50s drank at these "higher-risk" levels. While an obvious issue of concern, it a stretch to say this is a generation of problem drinkers.

There were also significantly different patterns between men and women. For example, higher-risk drinking was linked to higher income, but only in women.

These uncertainties aside, the study does reinforce the fact that alcohol misuse and the risks of drinking too much do not respect class boundaries. You can do just as much damage by drinking champagne to excess as you can by drinking cheap cider.

 

Where did the story come from?

The study was carried out by Professor José Iparraguirre from the Research Department of Age UK and was also funded by Age UK.

The study was published in the peer-reviewed medical journal BMJ Open. This is an open-access journal, meaning anyone is free to read the study online.

The Mail, The Daily Telegraph, The Times and The Guardian reported the research facts accurately, although none discussed any limitations associated with the research. All papers carried useful quotes from independent experts. For example, the Mail included a quote from Professor Sir Ian Gilmore, chairman of the Alcohol Health Alliance, who said: "Whilst it may be true that middle-class drinkers are able to offset some health problems because of healthier diets and lifestyles more generally, the risks of serious health harms are still significant. For example, even low levels of drinking increase the risk of developing cancer."

 

What kind of research was this?

This was an analysis of a longitudinal survey of ageing, estimating what risk factors might be linked to harmful alcoholic drinking in over-50s.

longitudinal study involves repeated measures over time, so is great for measuring changes in drinking behaviour. One of the disadvantages is that they tend to rely on self-reported survey estimates of alcohol intake, which can be an unreliable reporting method. Some people may deliberately under-report their drinking habits out of embarrassment or social pressure. Others might under or overestimate them by accident through not knowing how many units are in their drinks. Heavy drinkers may forget how much they drank over the course of their sessions.

By using lots of people, over and underestimates should even out to give a relatively accurate picture of what’s going on, but this is never perfect. 

 

What did the research involve?

Researchers analysed the drinking habits of 9,251 adults aged over 50, looking for links between their drinking habits and their income, lifestyle and social situation.

The drinking and other lifestyle information came from responses to the English Longitudinal Study of Ageing. This gathered data from a representative sample of UK men and women aged 50 and over from 2008 to 2011.

Their definition of harmful drinking used the highest risk category from NICE guidelines. This is called "higher-risk drinking" and describes men drinking more than 50 alcohol units per week, or women drinking more than 35 units per week. For men, this is equivalent to five or more bottles of wine a week, or 16 pints or more of strong lager, and equivalent to three-and-half bottles of wine, or 11 pints or more of strong lager for women.

They used two sources of alcohol unit measures, to see if that made any difference to the findings. The first calculated that:

  • one pint of normal-strength beer was equivalent to two units
  • a 175ml glass of wine is equivalent to two units
  • a 250ml glass of wine is equivalent to three units

The second, using the drinkaware website, calculated that:

  • one glass of wine was equivalent to three units
  • one pint of beer was equal to three units

The analysis estimated how the risk of harmful drinking was influenced by:

  • age
  • income
  • education
  • lifestyle (diet, smoking and physical activity levels)
  • depression
  • loneliness
  • self-reported health (poor to excellent)
  • marital status
  • caring responsibilities
  • children in the home
  • employment
  • social isolation

The researchers looked for a link between heavier drinking and people quitting the longitudinal survey. They found no link, suggesting that people dropping out were not an important issue.

 

What were the basic results?

The results showed different patterns for men and women:

  • The risk of women being in the higher-risk drinking category reduced steadily from the ages of 50 to 90.
  • By contrast, men’s risk peaked in their mid-60s, before declining.
  • For both sexes, reporting better health was linked to increase alcohol consumption.
  • Achieving higher educational attainment and smoking were linked to being in the higher-risk drinking category.
  • Income was linked to higher-risk drinking in women, but not men.
  • Having a job had no link overall. But retirement increased the chances of drinking at higher risk levels for women.
  • Being single, separated or divorced was linked to being in the higher-risk drinking category, although only for men.
  • Loneliness and depression are not associated with higher-risk drinking.
  • Having caring responsibilities reduces the probability of being at higher risk for women.

Some of the analysis looked at how likely people were to enter the higher-risk category from lower drinking levels over a two-year period. This found:

  • For women, being younger and having a higher income increased the probability of becoming a higher-risk alcohol drinker over time.
  • For men, not eating healthily, being younger and having a higher income increase the probability of becoming a higher-risk alcohol drinker

 

How did the researchers interpret the results?

The researchers attempted to draw some themes from their many individual results: "… we can sketch – at the risk of much simplification – the problem of harmful alcohol drinking among people aged 50 or over in England as a middle-class phenomenon: people in better health, higher income, with higher educational attainment and socially more active are more likely to drink at harmful levels."

They say the concept of: "successful ageing […] embraces components such as non-smoking, greater physical activity, more social contacts, better self-rated health and absence of depression, among others." And that their results show: "generally speaking, people aged 50 or over ageing 'successfully' in England are more at risk of drinking at harmful levels".

 

Conclusion

This study showed that higher-risk drinking was linked to a number of factors the researchers described as "middle-class", like higher educational attainment, being socially active and good ratings of health.

Professor Jose Iparraguirre, author of the research, said in the Guardian: "Because this group is typically healthier than other parts of the older population, they might not realise that what they are doing is putting their health in danger".

There are a few reasons to be cautious with these findings.

The study produced a lot of results, so there is a risk some were chance findings. This is particularly relevant, as the analysis focused on higher-risk drinking. Of the large number of people taking part in this survey, only a small chunk (3-7%) fell into this category. Analyses based on these smaller numbers are more likely to give chance findings.

Also, the study only tracked people for a maximum of three years, which isn’t particularly long. Studies tracking drinking behaviour over longer periods of time might show different patterns.

The study used a representative group of UK older adults, which is a strength. However, we can’t be sure this paints a totally realistic picture across the UK, as there may be geographical variation.

The researchers tell us that heavy drinking in older age is linked to death in the short term. This means there was a risk of higher-than-normal numbers of older moderate drinkers, as heavy drinkers might have died earlier. Usefully, the researchers re-ran the stats using an age cut-off of 70. This showed no difference to the age 90 cut-off used for the main analysis, meaning this wasn’t an important influencing factor.

Rosanna O’Connor, director of Alcohol Drugs and Tobacco at Public Health England, said in the Guardian: "Around one in five adults regularly drinks at levels that can damage their health, leading to serious, but preventable, conditions such as stroke, some cancers, depression and liver disease. Many are unaware of the harm caused, especially from drinking frequently throughout the week."

The NHS Health Check, which is available to everyone in England aged 40-74, includes an alcohol risk assessment and advice for those whose drinking may be putting their health at risk.  

Links To The Headlines

Middle class drink epidemic: Affluent over-50s 'sleep-walking' into health crisis by being most likely to consume harmful levels of alcohol each week. Mail Online, July 24 2015

Older people drinking at harmful levels is a 'hidden middle class phenomenon' say experts. The Independent, July 24 2015

'Hidden Alcohol Problem' In Affluent Over 50s. Sky News, July 24 2015

Harmful drinking is a ‘middle-class phenomenon’. The Daily Telegraph, July 24 2015

Harmful drinking among middle-class over-50s is a 'hidden phenomenon'. The Guardian, July 24 2015

Alcohol epidemic: Over 50s who 'have it all' are drinking themselves into an early grave. Daily Express, July 24 2015

Harmful Drinking Among Over-50s Branded 'Middle Class Phenomenon' By Researchers. The Huffington Post, July 24 2015

Links To Science

Iparraguirre J, Socioeconomic determinants of risk of harmful alcohol drinking among people aged 50 or over in England. BMJ Open. Published online July 23 2015

Categories: Medical News

Study says 'size really doesn't matter' when it comes to a penis

Medical News - Thu, 07/23/2015 - 15:30

"Scientists claim they've worked out what makes the perfect penis," The Independent reports.

According to Swiss researchers, women value overall cosmetic appearance of a penis over length.

The actual point of the study was to assess women's perception of the penises of men who have had surgery for hypospadias, a condition where the hole through which urine passes (meatus) is not at the tip of the penis. The condition is typically corrected in childhood by surgery.

Researchers asked women to compare pictures of men who have been treated for hypospadias with men who had been circumcised.

Overall general penile appearance was found to be the most important aspect of a penis for women and the position and shape of the meatus to be the least important.

Out of a list of eight aspects, the length of a penis was actually rated as coming sixth out of eight. Research suggests a massive disconnect between what men think is important about their penis and what women actually think. One study found that 85% of women were satisfied with their partner's penis size, while only 55% of their corresponding partners felt the same. 

Where did the story come from?

The study was carried out by researchers from University Children’s Hospital Zurich and the University of Zurich. The source of funding was not reported.

The study was published in the peer-reviewed Journal of Sexual Medicine on an open-access basis, so the study is available to read online or download as a PDF (as an advanced warning, the study does contain some graphic images of different types of penises).

This story has been reported accurately in the media with quotes from authors and a detailed report of study findings.

Much of the reporting on the study takes a lighthearted tone, but it is important not to discount the anxieties that many men, usually without justification, experience about penis size. Read more advice about penis size.

Links To The Headlines

Scientists claim they've worked out what makes the perfect penis. The Independent, July 22 2015

Why your penis size doesn't matter (but appearance does). The Daily Telegraph, July 22 2015

Is YOUR penis 'good looking'? Medical study reveals what women really rate as important (and it's NOT length). Mail Online, July 22 2015

Links To Science

Ruppen-Greeff NK, Webber DM, Gobet R, et al. What is a Good Looking Penis? How Women Rate the Penile Appearance of Men with Surgically Corrected Hypospadias. The Journal of Sexual Medicine. Published online July 20 2015

Categories: Medical News

Unhealthy thinking about body and weight 'can start in childhood'

Medical News - Thu, 07/23/2015 - 14:40

"Basis for eating disorders found in children as young as eight," The Guardian reports. A new UK survey of around 6,000 children found the roots of unhealthy thinking about body and weight can predate adolescence.

Researchers collected data from 6,140 boys and girls aged 14 years as part of an ongoing study into childhood health. Information had already been collected from the same group of children about a range of factors, including their body dissatisfaction, body mass index (BMI) and self-esteem, and whether there was a history of maternal eating disorders and family economic disadvantage.

The study reported childhood body dissatisfaction, weight and shape concern, and pressure to lose weight were all significantly higher in girls compared with boys. This predicted eating disorders in girls at age 14. Higher childhood self-esteem seemed to have a protective effect against teenage eating disorders, particularly in boys. 

This study has both strengths and limitations. One of the biggest strengths is its size. It also assessed early risk factors in childhood before the onset of eating disorder behaviours.

However, though the study demonstrates associations, it does not prove causation. There was also a high drop-out rate – only 59% of children completed assessments at the age of 14. This means the results may not be representative. 

Where did the story come from?

The study was carried out by researchers from the University College London Institute of Child Health, the London School of Hygiene and Tropical Medicine, and King's College London in the UK, and Boston Children's Hospital and Harvard Medical School in the US.

It was jointly funded by the National Institute of Health Research (NIHR) and Wellchild.

The study was published in the peer-reviewed British Journal of Psychiatry on an open-access basis. It is free to read online or download as a PDF.

Overall, the UK media reported the story accurately, although some of the limitations were not fully explained.

The Guardian included a useful quote from Lorna Garner, chief operating officer at eating disorders charity, Beat: "It is evidence that one of the causes or contributing factors towards an eating disorder or something that could trigger an eating disorder is the whole thing around body image and self-esteem.

"It doesn't cause it, but it could be a large influencing factor. It is almost as though seeds that are sown pre-teens come to fruition later.

"Knowing that is incredibly helpful because it gives everybody who is involved with wanting to prevent and manage eating disorders an indication that we need to start earlier." 

What kind of research was this?

This population-based prospective cohort study aimed to investigate the prevalence of eating disorder behaviours in 14-year-old children, and how this may be associated with childhood, physical and parental risk factors.

The data source for this study was the Avon Longitudinal Study of Parents and Children, which recruited all pregnant women in Avon in the UK who were expected to have a baby between April 1 1991 and December 31 1992.

Prospective cohort studies like this one, which follow a group of people over time, are useful for looking at how different exposures may be associated with different outcomes.

They can suggest the possible causal chain of a problem, but cannot definitely prove cause and effect because unmeasured factors (confounders) could be involved in the relationship.  

What did the research involve?

This research involved a group of 6,281 children who completed assessment at the age of 14. This was representative of 59% of people taking part in the cohort.

At age 14, eating disorder behaviours were assessed using the Youth Risk Behaviour Surveillance System questionnaire.

Binge eating was assessed using a two-part question where the participants were asked about how often they had eaten a very large amount of food during the past year. Those who answered "yes" were asked a second question about whether they felt out of control during these episodes.

Purging was assessed by asking how often in the past year participants made themselves sick or used laxatives to lose weight or avoid gaining weight.

Weight and shape concerns were also assessed at 14 years using three questions as part of another survey:

  • In the past year, how happy have you been with the way your body looks?
  • In the past year, how much has your weight made a difference to how you feel about yourself?
  • In the past year, how much have you worried about gaining a little weight (as little as 1kg)?

Pressure to lose weight (from peers, family, the media, for example) was also assessed using another scale. Childhood and parental risk factors were assessed in earlier childhood.

At the age of 10.5 years, body dissatisfaction was assessed using gender-appropriate rating scales, and body mass index (BMI) was obtained from direct assessment. Self-esteem was also assessed using another scale.

Data on family financial problems was obtained from maternal reports at regular intervals throughout childhood by means of questionnaires.

Data was also collected on maternal eating disorder when the mothers were pregnant by asking them if they ever experienced anorexia nervosa or bulimia nervosa.

The researchers used various statistical methods to investigate the association between each predictor and outcome, divided by gender. 

What were the basic results?

Body dissatisfaction, weight and shape concern, and reported pressure to lose weight were all significantly higher in girls compared with boys.

Prevalence of eating disorder behaviours and cognition at 14
  • 18% of girls and 3% of boys reported they felt quite a lot of pressure from the media to lose weight
  • 40% of girls and 12% of boys reported dieting in the previous year
  • 7.5% of girls and 3.5% of boys reported bingeing
  • 7.6% of girls and 1.6% of boys reported frequent dieting
  • 0.4% of boys and 0.5% of girls reported they binged and dieted
Predictors of eating disorder cognitions
  • Maternal eating disorder with a history of both anorexia and bulimia nervosa predicted greater adolescent body dissatisfaction in girls, but not in boys.
  • Weight and shape concern in the maternal eating disorder group was higher in 14-year-old girls compared with boys.
  • Family economic conditions affected both girls and boys.
Eating disorder behaviours
  • Maternal lifetime anorexia and bulimia and economic disadvantage predicted dieting in boys, but not in girls.
  • Family economic disadvantage was associated with bingeing in both boys and girls. Overall, higher self-esteem was associated with lower odds of bingeing in girls.
  • Higher self-esteem at eight years old was associated with lower odds of purging in boys. A high odds of purging was noticed in maternal lifetime eating disorder group children.  
How did the researchers interpret the results?

Researchers said that, "We identified a strong effect of childhood body dissatisfaction on adolescent body dissatisfaction, weight and shape concern, and pressure to lose weight and dieting in girls.

"In contrast, in boys the effect of body dissatisfaction on later eating disorder outcomes was seen mainly in interaction with BMI. Boys with high BMI and high childhood body dissatisfaction had higher levels of eating disorder cognitions and behaviours, but there was no association with childhood body dissatisfaction among leaner boys."

They added that, "Maternal history of anorexia and/or bulimia nervosa was predictive of high levels of body dissatisfaction and weight and shape concern in girls, and dieting in boys. The effect was more pronounced for children of women who reported both anorexia and bulimia over their lifetime (up to child age seven years)." 

Conclusion

This population-based prospective cohort study showed body dissatisfaction, weight and shape concern, and pressure to lose weight were all significantly higher in girls compared with boys.

The study reported these concerns about body image were all significantly higher in girls compared with boys. This predicted eating disorder in girls at age 14. 

This study has several strengths and limitations. One of the biggest strengths is its size. It had a large population size, which is said to be representative of the overall UK population. This allowed a clear identification of gender-specific patterns. It also assessed various early risk factors in childhood before the onset of the eating disorder behaviours.

However, though the study demonstrates associations, it does not prove causation. Various health, lifestyle and personal factors may be involved in the development of an eating disorder, not all of which have been assessed here.

It is difficult to identify which factor or combination of factors could have been directly involved in the development of an eating disorder.

This is particularly relevant given that assessments on eating disorders or the child's body image and self-esteem are limited to the scope of the few questions used on the assessment questionnaires. These may not always give a reliable indication of how the child or adolescent may feel or what factors have contributed to this.

Another limitation is that despite the use of a large representative cohort, the study is not representative of all people – only 59% took part in the assessment at age 14. Assessment of the whole cohort may have given different results.

It is important to cultivate healthy eating and exercise habits from an early age, and children should be educated about the harmful effects of dieting and binge eating.

If you're concerned about your or your child's weight or body shape, you should see your GP or a dietitian before making any sudden changes to your diet.

Read more advice for parents on eating disorders.

Links To The Headlines

Basis for eating disorders found in children as young as eight. The Guardian, July 23 2015

Childhood anxiousness about appearance can lead to eating disorders in later life, study finds. The Independent, July 23 2015

Links To Science

Micali N, De Stavola D, Ploubidis G, et al. Adolescent eating disorder behaviours and cognitions: gender-specific effects of child, maternal and family risk factors. The British Journal of Psychiatry. Published online July 23 2015

Categories: Medical News

Sugary drinks linked to 8,000 new UK diabetes cases a year

Medical News - Wed, 07/22/2015 - 15:00

"Are sugary drinks causing 8,000 cases of diabetes every year?," the Daily Mirror asks, as a new study estimates they could cause thousands of type 2 diabetes cases in the UK, and millions in the US.

Researchers pooled the results of previous studies to estimate the public health impact of type 2 diabetes associated with sugary drinks consumption, as well as artificially sweetened drinks and fruit juice.

Researchers found that consumption of sugar-sweetened drinks may be linked to 1.8 million cases of type 2 diabetes in the US and 79,000 in the UK over 10 years. They also adjusted their results to take account of body fat (adiposity) and their results suggest that people of a healthy weight may still be vulnerable.

Artificially sweetened drinks and fruit juice also showed a positive association; however, there is thought to be bias associated with this outcome.

As the researchers themselves make clear, this type of study is unable to prove cause and effect.

government report from July 2015 has recommended that sugar should make up no more than 5% of a person’s calorie intake. Therefore, cutting out sugary drinks entirely could be a good way of doing this.

 

Where did the story come from?

The study was carried out by researchers from the University of Cambridge, University of Eastern Finland, Tenri Hospital and Kyoto University in Japan, and Harvard T H Chan School of Public Health in Boston. The study was funded by the Medical Research Council Epidemiology Unit Core Support and an American Heart Association postdoctoral fellowship grant.

The study was published in the peer-reviewed medical journal BMJ on an open-access basis, so is free to read online or download as a PDF.

This study has been widely reported in the UK media. The Guardian and BBC News highlight the fact that slim people may also be vulnerable to the potential harms of sugary drinks.

The Daily Telegraph, the Daily Mirror, Sky News and the Mail Online chose to focus on the potential public health impact estimated in the report: 79,000 new cases of type 2 diabetes in the UK over the course of 10 years and a whopping 1.8 million new cases in the US during the same period.

 

What kind of research was this?

This was a systematic review and meta-analysis assessing consumption of sugar and artificially sweetened drinks, and incidence of type 2 diabetes.

This type of study is useful in combining the results of smaller trials to draw firmer conclusions; however, the strength of the findings depends on the quality of included trials.

The information gathered was used to produce an estimate of the population attributable fraction (PAF) of sugary drink consumption on the incidence of type 2 diabetes.

A PAF is a measure used by epidemiologists to estimate the effect of a risk factor (in this case, sugary drink consumption) on the incidence of disease (in this case, type 2 diabetes) in groups of people.

The assessment of PAFs is a standard way that public health professionals and policymakers estimate the impact of individual factors on an outcome. This information is used to identify how burden of disease can be reduced.

 

What did the research involve?

This study searched PubMed, Embase, Ovid and Web of Knowledge for prospective studies of adults without diabetes at the start of the study, published until February 2014. Data was synthesised using meta-analysis and survey analysis for the PAF associated with the consumption of sugar-sweetened drinks. Data was extracted from selected studies, including:

  • baseline personal information (e.g. body mass index)
  • duration of follow-up
  • exclusion criteria
  • sample size
  • loss to follow-up
  • assessments of beverage consumption
  • incidence of type 2 diabetes
  • types of beverage consumed

Main exposures assessed were:

  • sugar-sweetened drinks, which were any sweetened drink, including sugar-sweetened fruit juice, that are not presented as diet or non-caloric
  • artificially sweetened drinks, including low-caloric soft drinks
  • fruit juice, either 100% fruit juice, or fruit juice assessed separately from fruit drinks

An estimation of PAF was then calculated. The confounding effect of body fat (adiposity) was adjusted for.

 

What were the basic results?

The study included 17 cohorts, comprising 38,253 cases of type 2 diabetes.

National surveys in the US from 2009-10 and the UK from 2008-12 were used to determine the PAFs. This consisted of a sample of 4,729 US adults and 1,932 UK adults over 20 years without prevalent diabetes, representing 189.1 million US adults and 44.7 million UK adults.

Meta-analysis found a link between higher consumption of sugar-sweetened drinks and a greater incidence of type 2 diabetes. One drink per day was associated with an 18% greater incidence in type 2 diabetes before adjusting for body fat, and 13% after adjustment. Similarly, artificially sweetened drinks showed an association with a 25% increase in incidence per one drink per day before adjustment and 8% after; for fruit juice, it was 5% and 7% after adjustment.

The consumption of sugar-sweetened drinks occurred in 54.4% of people in the US and 49.4% in the UK.

If the assumption is made that sugar-sweetened drinks are the cause of type 2 diabetes, independent of obesity status, this would result in 1.8 million cases of type 2 diabetes in 10 years in the US and 79,000 cases in the UK.  The findings also showed that young adults and men have greater numbers of type 2 diabetes due to sugar-sweetened drinks than older adults and women.

 

How did the researchers interpret the results?

The researchers conclude that, "Habitual consumption of sugar sweetened drinks was associated with a greater incidence of type 2 diabetes, independently of adiposity. Although artificially sweetened drinks and fruit juice also showed positive associations with incidence of type 2 diabetes, the findings were likely to involve bias. None the less, both artificially sweetened drinks and fruit juice were unlikely to be healthy alternatives to sugar sweetened drinks for the prevention of type 2 diabetes."

 

Conclusion

This study is a systematic review and meta-analysis that aimed to investigate the associations between consumption of sugar-sweetened drinks, artificially sweetened drinks, and fruit juice with type 2 diabetes, and to estimate the PAF for type 2 diabetes in the UK and US.

Regular consumption of sugar-sweetened drinks was associated with increased incidence of type 2 diabetes.

Artificially sweetened drinks and fruit juice also showed a positive association; however, there is thought to be confounding and publication bias associated with these outcomes.

Consumption of sugar-sweetened drinks may be linked to 1.8 million cases of type 2 diabetes in the US and 79,000 in the UK over 10 years, if we assume causality. However, this study did not prove cause and effect.

Diabetes is a growing problem, with around 3.2 million people aged 16 or over diagnosed with diabetes in England in 2013, and 630,000 people who have not been diagnosed. This is expected to increase. The rise in type 2 diabetes is mostly down to:

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

Preventative measures against type 2 diabetes can be taken, such as being more active, losing weight and eating more healthily.

Recent recommendations from the Scientific Advisory Committee on Nutrition (SACN) state that free sugars should not exceed 5% of our total dietary energy intake. This applies to all age groups from 2 years upwards. This means

  • no more than 19g a day of free sugars for children aged 4 to 6
  • no more than 24g a day for children aged 7 to 10
  • no more than 30g a day for children aged 11 or more and adults

No specific recommendations are made for children under the age of 2, because of an absence of information. However, from about 6 months of age, a gradual change to a more diverse diet that includes more wholegrains, pulses, fruit and vegetables is encouraged.

Sugary drinks can make up a large proportion of sugar intake and these should be consumed in moderation or, ideally, not at all. As always, maintaining a healthy weight, eating a balanced diet, moderating your alcohol consumption and taking regular exercise will reduce the risk of a range of chronic diseases. 

Links To The Headlines

Are sugary drinks causing 8,000 cases of diabetes every year? Daily Mirror, July 22 2015

Sugary drinks may cause type 2 diabetes regardless of size, research says. The Guardian, July 22 2015

Sugary drinks 'harmful even for slim people'. BBC News, July 22 2015

Sugary drinks behind 8,000 diabetes cases a year. The Daily Telegraph, July 22 2015

Sugary drinks linked to 8,000 type 2 diabetes cases each year: People who consume sweetened beverages every day increase their risk of the condition by 20%. Mail Online, July 22 2015

Sugary Drinks May Cause 8,000 Diabetes Cases. Sky News, July 22 2015

Links To Science

Imamura F, O’Connor L, Ye Z, et al. Consumption of sugar sweetened beverages, artificially sweetened beverages, and fruit juice and incidence of type 2 diabetes: systematic review, meta-analysis, and estimation of population attributable fraction. BMJ. Published online July 21 2015

Categories: Medical News

Night shifts 'linked to increased breast cancer risk'

Medical News - Tue, 07/21/2015 - 13:00

"Irregular sleeping patterns have been 'unequivocally' shown to lead to [breast] cancer in tests on mice, a study suggests," BBC News reports. Scientists are concerned a similar effect may occur in women working night shifts.

This study looked at mice genetically modified to develop breast cancer. They were exposed to either a normal cycle of 12 hours of light and 12 hours of darkness or an inverted cycle. It found mice in the inverted group gained more weight and developed breast cancer sooner.

These findings appear to support previous research suggesting a link between night-shift work and breast cancer, which we discussed in 2012 and 2013.

Further human research will be required to determine if shift working does increase the risk and what measures can be taken to minimise this.

The researchers go as far as recommending that women with a known predisposition to breast cancer (such as having genetic mutations linked to breast cancer) should avoid shift work. But, obviously, not everyone has the luxury of picking and choosing what hours they work.

If you work night shifts, you can offset your risk of breast cancer and other cancers by quitting smoking if you smoke, maintaining a healthy weight, eating a healthy, balanced diet, moderating your consumption of alcohol and taking regular exercise

Where did the story come from?

The study was carried out by researchers from the National Institute for Public Health and the Environment (RIVM), Erasmus University Medical Center and Leiden University Medical Center, all in the Netherlands, and Ludwig-Maximilian University in Germany.

Funding was provided by the RIVM Strategic Programme and the Dutch Ministry of Social Affairs and Employment.

It was published in the peer-reviewed medical journal Current Biology on an open access basis, so it is free to read online or download as a PDF.

The BBC's reporting of the study was accurate and made it very clear at the start of the story that the research involved mice, so the results may not necessarily apply to humans.  

What kind of research was this?

This laboratory research assessed the effects of alternating light cycles in mice. This involved conducting two related studies – a randomised longitudinal study and a cross-sectional study – to assess breast cancer risk with alternating light cycles.

Findings from animal studies are useful for making discoveries to be investigated further in humans.  

What did the research involve?

This study aimed to investigate the causal links between chronic circadian rhythm disturbance (CCRD) and increased cancer risk. CCRD is a term used to describe persistent disruption of the body clock – the normal sleep-wake cycle. 

Breast cancer-prone mice were placed in a cycle of 12 hours of light and 12 hours of dark. At the end of every week, the light or dark phase was extended to 24 hours to invert the light-dark cycle.

Two studies were performed on the mice, controlling for other possible factors contributing to cancer risk:

  • all mice were melatonin deficient
  • neither group was exposed to sunlight
  • there was no vitamin D difference between groups

The only other possible difference between the groups was the timing of food intake, which may be disruptive to metabolism.

Longitudinal study

When the mice reached eight weeks old they were randomly assigned to remain under a normal 12:12-hour light-dark cycle or undergo a weekly alternating 12:12-hour light-dark cycle. Measurements of body weight and tumour-free survival were taken.

Cross-sectional study

Mice who did not take part in the longitudinal study were analysed further in a cross-sectional study. These mice stayed under the light-dark cycle or weekly light-dark inversion, representing circadian rhythm disturbance. After 18 cycles, blood and tissue samples were collected for analysis. 

What were the basic results?

In the longitudinal study, mice exposed to weekly light-dark inversions saw a larger increase in body weight compared with those kept in the normal light-dark conditions.

This was not the result of food intake as a significantly smaller amount of food was consumed by mice in the inversion group. This effect could be seen at six weeks, but it only became significant at week 24.

There was no significant difference in body weight gain in the cross-sectional part of the study, perhaps because there were fewer light-dark inversions.

Mice exposed to the weekly inversions showed a decrease in tumour suppression. This is carried out by certain genes that try to prevent normal cells turning cancerous.

The time taken to breast tumour development was reduced by 17% in the inversion mice compared with the control mice, at 42.6 weeks compared with 50.3 weeks.

The cross-sectional study indicated the circadian rhythm was still disrupted seven days after the light-dark pattern was switched. 

How did the researchers interpret the results?

The researchers concluded that, "Animals exposed to the weekly light-dark inversions showed a decrease in tumour suppression. In addition, these animals showed an increase in body weight.

"Importantly, this study provides the first experimental proof that CRD increases breast cancer development." 

Conclusion

This study in mice appears to support previous research suggesting a link between night-shift work and breast cancer. It looked at an inverted pattern of light and dark to assess whether this is linked to greater risk.

The researchers found mice exposed to weekly light-dark inversions saw a larger increase in body weight and quicker tumour development.

One limitation with this study is it is an animal study, which reduces the generalisability of findings. However, as there are a number of studies that have drawn similar conclusions – some in humans – these findings do add to the research in this area.

Shift working can disturb what is known as the circadian rhythm – the internal body clock. This can disrupt the normal workings of a hormone called melatonin and lead to poor sleep and chronic fatigue.

Rotating shift work and a persistent lack of quality sleep can also disrupt the production of insulin, which may increase the risk of someone developing type 2 diabetes. It has also been linked to a range of chronic conditions, such as obesity, depression, diabetes and heart disease.

The Health and Safety Executive has some useful and practical advice for people who work night shifts:

  • take extra care if you drive to and from work as your concentration may be impaired – if possible, it may be a better idea to use public transport
  • identify a suitable sleep schedule of at least seven hours a day – you may find it useful to keep a diary to assess what sleep times suit you best
  • try to create an environment that promotes good sleep – for example, heavy curtains or an eye mask may help you sleep during the day
  • make changes to your diet to improve alertness and digestion – smaller healthy snacks during your shift may be a better idea than one big meal
  • limit your use of stimulants such as caffeine or energy drinks, as well as sedatives such as alcohol – while they may bring short-term benefits, they are unlikely to help in the long term
  • try to get regular exercise of at least 30 minutes a day

If these findings are correct and shift working does increase breast cancer risk, it is even more important to modify other lifestyle factors known to increase the risk of several types of cancer.

These include quitting smoking if you smoke, maintaining a healthy weight, eating a healthy, balanced diet, moderating your consumption of alcohol and taking regular exercise.

Links To The Headlines

Poor sleeping patterns link to cancer. BBC News, July 21 2015

Links To Science

Van Dycke KCG, Rodenburg W, van Oostrom CTM, et al. Chronically Alternating Light Cycles Increase Breast Cancer Risk in Mice. Current Biology. Published online July 20 2015

Categories: Medical News

Study finds obese people may struggle to reach a healthy weight

Medical News - Mon, 07/20/2015 - 16:50

"Obese men have just a '1 in 210' chance of attaining a healthy body weight," The Independent reports. This was the findings of a study that used a GP records database to look at body mass index (BMI) measurements of almost 300,000 people recorded over a 10-year period.

Overall, it found that low proportions of people in the obese categories achieved a normal weight in subsequent measures – only 1 in 210 for men and 1 in 124 for women who had BMIs of 30 to 35, and much lower than that for the higher BMI categories.

However, this should not be interpreted to mean that if you are obese, you should give up trying to lose weight. Moving from "very obese" to a "normal weight" category may not be realistic, particularly in the short term, and achieving steady weight loss may be a better goal. 

Encouragingly, much higher proportions of obese people in this study were able to achieve 5% or more weight loss (around 1 in 5 to 1 in 10 people). Even a modest reduction in BMI can bring important health benefits.

Ultimately, without knowing the wider health and lifestyle circumstances of the individuals in this study, it is not possible to identify what aspects of obesity management may be less effective.

Rather than opting for the latest fad diet, try the NHS weight loss guide: our popular free 12-week diet and exercise plan.

 

Where did the story come from?

The study was carried out by researchers from King’s College London and the London School of Economics and Political Science, and was funded by the UK National Institutes for Health Research.

The study was published in the peer-reviewed American Journal of Public Health, and the article is open-access – meaning it is freely available to read online or download as a PDF.

The media has reported the findings of this research accurately, but it may have been beneficial to discuss some of the wider contextual issues. For example, it may have been helpful to explain what the figures meant, rather than talking of them as "chances" for someone with obesity to lose weight. That is, they were the proportions of people in each category who had attained a normal BMI each year.

The reporting also didn’t make clear that many people included in the study may not have been trying to lose weight, which could change the assessment of how effective weight loss interventions were. 

 

What kind of research was this?

This was a population-based cohort study, which followed a sample of obese men and women for 10 years to look at what proportion managed to achieve a normal body weight.

Obesity and being overweight are global problems, and finding effective ways to tackle them is an important ongoing issue. Obesity can trigger a wide range of complications, such as type 2 diabetes, heart diseasestroke and non-alcoholic fatty liver disease.

This study assessed how often either a 5% reduction in BMI, or attainment of normal BMI, happens in the general UK adult population.

 

What did the research involve?

This study obtained medical records from the UK general practice database, Clinical Practice Research Datalink (CPRD). Over the 10-year period 2004 to 2014, over 2 million adults (aged over 20) had their BMI recorded on three or more occasions.

People were grouped according to their BMI:

  • normal weight: 18.5 to 24.9 kg/m2
  • overweight: 25.0 to 29.9
  • simple obesity: 30.0 to 34.9
  • severe obesity: 35.0 to 35.9
  • morbid obesity: 40.0 to 44.9
  • super obesity: 45.0 or greater

From each category, a random sample of 30,000 people was taken, and they obtained their full medical records. After excluding those who had weight loss surgery (also called bariatric surgery), they had a final sample of 278,982 people. They then analysed changes in their BMI over the study period, from the first recorded measurement, looking for those who attained normal weight or achieved a 5% reduction in weight. This 5% weight loss outcome was chosen because it is a realistic target that is often recommended to people who are obese and trying to lose weight.

 

What were the basic results?

The average age of the people studied was 55 for men and 49 for women. There were larger numbers of obese women than men. For men, there were around 25,000 (19%) with their first BMI measurement in the normal weight category, then around 27,000 (about 21%) in each of the overweight to severe obesity categories, 14,767 (11%) in the morbid obesity category and 6,481 (5%) in the super obesity category. For women, there were 23,640 (16%) in the normal weight category, then 26,000 to 27,000 (around 18%) in each of the overweight to morbid obese categories, and 18,451 (12%) in the super obese group.

When looking at the proportion of people showing no change in their BMI during follow-up, this was greatest in the normal weight category (men 57%, women 59%).

Only 14% of men and 15% of women showed decreases in their BMI category without also showing increases. Around 1 in 5 people in the morbidly and super obese groups showed decreases in their BMI, which was the highest rate seen. More than a third of people overall showed weight cycling – both increases and decreases in BMI. This was also highest in the severely obese category, where around half showed weight cycling.

During the total follow-up period, 1,283 men and 2,245 women who were obese attained a normal BMI. Overall, this represented about 1 in 60 men and 1 in 44 women over the entire period. However, to account for people being followed up for different lengths of time, the researchers calculated these numbers for each weight category for one year of follow-up.

The probability of achieving a normal BMI from each starting BMI category over one year was:

  • simple obesity: 1 in 210 for men and 1 in 124 for women
  • severe obesity: 1 in 701 for men and 1 in 430 for women
  • morbid obesity: 1 in 1,290 for men and 1 in 677 for women
  • super obesity: 1 in 362 for men and 1 in 608 for women 

The probability of achieving a 5% reduction in weight over a year was higher:

  • simple obesity: 1 in 12 for men and 1 in 10 for women
  • severe obesity: 1 in 9 for men and 1 in 9 for women
  • morbid obesity: 1 in 8 for men and 1 in 7 for women
  • super obesity: 1 in 5 for men and 1 in 6 for women 

However, this 5% weight loss was often accompanied by weight cycling and gains of over 5% in weight at other times.

 

How did the researchers interpret the results?

The researchers conclude that, "the probability of attaining normal weight or maintaining weight loss is low". They go on to say that, "obesity treatment frameworks grounded in community-based weight management programs may be ineffective".

 

Conclusion

This research makes use of a general practice database providing just under 10 years of BMI observations for a large, nationally representative UK sample.

It demonstrates that low proportions of people in the obese categories were able to achieve a normal BMI over a year of follow-up, and the common problem of weight cycling. However, there are points to consider when interpreting these results:

  • The probability of obtaining a normal BMI over a year was very low: only 1 in 210 for men and 1 in 124 for women in the "simple obese" category of 30 to 35kg/m2, and much lower than that for the higher categories. However, these particular figures are only the proportions per year, and we don’t know how many people were attempting to lose weight, or how they were trying to do this. Other analyses showed a better picture – for example, about 1 in 5 obese people managed to reduce their BMI by at least 1 point and not increase it during follow-up.
  • Though the people in this study had 3 or more BMI measurements, we don’t know how long after the first measurement they were taken. Despite the study period being 10 years, the BMI measures may have been over the period of only 1 or 2 years. Reaching a normal BMI may not be a realistic goal in the short term, particularly if a person is in the severe to super obese categories. Achieving steady weight loss may be a better goal and, encouragingly, much higher proportions were able to achieve 5% or more weight loss.
  • The researchers conclude that community-based weight management programmes may be ineffective. However, some care must be taken in concluding that weight loss programmes do not work, because this study only has data on BMI changes. We don’t know anything about the wider health problems or lifestyle circumstances of any of these individuals, or know what care they may have been receiving. As such, we are not able to identify what aspects of obesity management may be ineffective or require a change. We can only say that many obese people did not lose weight.
  • Finally, though this study is a nationally representative sample, there are some exclusions that could influence results. The study excluded people who had received weight loss surgery. These people are likely to have achieved weight loss, and would likely have been in the more severe obesity categories. This may mean that these proportions do not give a true indication of the proportions in the severe obese categories who achieve weight loss. Also, as the researchers acknowledge, weight change may be different in the people who had fewer than two BMI measures over the course of the study; a group who were also excluded.

Nevertheless, this study highlights the growing obesity problem and the need for effective strategies to help people lose weight. If you are obese and trying to lose weight, you should not be discouraged by these results. Eating healthily and exercising have health benefits, even if you do not lose weight, and losing even small amounts of weight and keeping it off in the long term is likely to be beneficial.

Links To The Headlines

Obese men have just a '1 in 210' chance of attaining a healthy body weight. The Independent, July 17 2015

Obesity: 'Slim chance' of return to normal weight. BBC News, July 17 2015

Obese patients 'unlikely' to achieve healthy body weight, study finds. Mail Online, July 17 2015

Links To Science

Fildes A, Charlton J, Rudisill C, et al. Probability of an Obese Person Attaining Normal Body Weight: Cohort Study Using Electronic Health Records. American Journal of Public Health. Published online July 16 2015

Categories: Medical News

Sugar intake should be drastically reduced, says report

Medical News - Fri, 07/17/2015 - 18:00

"Sugar intake 'should be halved'," BBC News reports. The headline is prompted by a government report that recommends no more than 5% of our calorie intake should come from "free sugars". The previous recommendation was 10%.

The new advice says children aged 11 or over and adults should consume no more than seven teaspoons of added sugar a day – 30g, equal to less than a single can of Coca-Cola, which contains 39g.

Children should consume much less than that. The report recommends no more than 19g for children aged four to six (around the amount of sugar in a pouch of Capri Sun) and no more than 24g for children aged seven to 10 (around the amount of sugar in a Snickers bar).

The BBC tells us "all age groups in the UK consume twice as much as this limit" (in fact it's at least twice as much), so the gulf between what is good for our health and what we actually do is now wider than ever. The main sources of free sugars are sugar-sweetened drinks, cereal, chocolate, sweets, fruit juice and added sugar at the table.

The Mail Online said that, "Hitting [this] new target will mean cutting out almost all fizzy drinks from diet" and that, "Crisps and chocolate bars will need to become [a] once or twice-week luxury".

Experts generally welcomed the new recommendations, considering them evidence-based and balanced. But some cautioned against too much of a focus on sugar, warning fat is also an important source of calories and should not be overlooked.

The government has accepted the new recommendations, which will be used as part of a wider strategy to tackle obesity.

This report confirms most of us are consuming way too much sugar and it is damaging our health and our kids' health. But it is one thing setting out what people should aspire to eat to be healthy and quite another making it happen.

Read more about practical ways to lower your free sugars to meet the new recommendations.

What is the basis for these reports?

The story follows new recommendations from the Scientific Advisory Committee on Nutrition (SACN).

The SACN advises Public Health England, and other government agencies and departments on nutrition and related health issues.

Dietary carbohydrates, which include sugar and fibre, and their role in health were last considered in reports published in the 1980s and 1990s. Since then considerable new evidence has emerged, SACN says.

In 2008, the Food Standards Agency and the Department of Health asked SACN to provide clarification on the relationship between dietary carbohydrates and health and make public health recommendations. The new report was prepared in response to this request.

Links To The Headlines

Scientific experts: Sugar intake 'should be halved'. BBC News, July 17 2015

Halve the recommended daily amount of sugar in our diets, scientists tell government. ITV News, July 17 2015

Sugar should be no more than 5% of daily calories, say nutrition experts. The Guardian, July 17 2015

Remove sugary drinks from children's diets, health officials say. The Daily Telegraph, July 17 2015

Parents urged to cut sugary drinks out of their children's diets following landmark report. The Independent, July 17 2015

'Eat no more than SEVEN teaspoons of sugar a day': Government advisers tell families to slash intake by HALF (to less than one can of Coke). Daily Mail, July 17 2015

Now just ONE can of fizzy drink contains child's sugar limit - as official recommended daily amount is slashed in half for all. Daily Mirror, July 17 2015

Categories: Medical News

Homer Simpson and Peppa Pig 'linked to childhood obesity'

Medical News - Fri, 07/17/2015 - 14:35

"Peppa Pig and Homer Simpson could be fuelling the child obesity crisis by causing youngsters to eat more," The Daily Telegraph reports after a series of psychological experiments found a link between exposure to overweight characters and overeating unhealthy food.

This series of three studies involved 301 children aged 6 to 14 years. The children were exposed to images of a normal-weight character, a character drawn to be obviously overweight, or a control image of a picture of a mug, as this was a familiar object but unrelated to weight stereotypes.

Researchers found an association between a higher consumption of unhealthy foods and exposure to the overweight image. This is an interesting finding, as it may mean we need to rethink the design of characters used in marketing and cartoons.

The findings may also help policymakers work out how best to target health promotion messages at this important age group to help them potentially make changes for the rest of their lives.

But claims poor old Peppa Pig is fuelling the obesity crisis seem unfair. Tubby cartoon characters such as Porky Pig, Garfield and Fred Flintstone have been around for decades, before childhood obesity was a problem.

Ultimately, preventing childhood obesity is the responsibility of the parents. Find out more about how to help your child maintain a healthy weight

Where did the story come from?

The study was carried out by researchers from the University of Colorado, Colorado State University and Indiana University.

It was funded by a Sterling-Rice Group grant and an Association for Consumer Research Transformative Consumer Research grant.

It was published in the peer-reviewed Journal of Consumer Psychology.

This has been reported accurately, if uncritically, by the Telegraph and the Mail Online.  

What kind of research was this?

This was a series of three randomised controlled trials aiming to understand whether different body weight cartoon characters influence the amount of non-nutritious food children choose and consume.

Randomised controlled trials are the best way of assessing these associations.  

What did the research involve?

The researchers conducted three trials assessing priming in children and their consumption of more indulgent foods.

Studies one and two made use of colour prints of a normal-weight character, an overweight character or a neutral control, in this case a picture of a mug.

Study one

Sixty children with an average age of 12.9 years were recruited and told they were doing a survey about printers. The children were randomly assigned to see a colour print of a normal-weight character, an overweight character or the control.

The children completed a survey that included questions on age, gender, and family printer ownership and usage. They were also required to list the first three thoughts they had upon seeing the print and were asked to rate print clarity.

After the survey was completed they were thanked and told to take some sweets. The number of sweets taken was recorded for each child.

Study two

This study attempted to examine whether children who see an overweight cartoon character together with a healthy-weight character will choose and consume more indulgent foods than children who do not see an overweight character.

Seventy-four children were included in this study, with an average age of 11.7 years. Participants were randomly assigned to one of three groups where they either saw a picture of a normal-weight character, an overweight character, or the normal and overweight characters together. The rest of the study was the same as for study one.

Study three

The health knowledge of younger children was investigated to see if this had an effect on the amount of unhealthy food they consumed after seeing an overweight cartoon character.

In this study, 167 children with an average age of 8.3 years were randomly assigned to see either a normal or overweight cartoon character either before or after they had been asked questions to activate their health knowledge.

The children's health knowledge was activated by asking them to think about things that make you healthy, and to choose the healthiest option of each of six matched pairs presented both as pictures and words.

For example:

  • getting sleep versus watching television
  • fizzy drinks versus milk
  • playing inside versus playing outside

The activated health knowledge group completed the questions at the beginning of the study, while the non-activated health knowledge group completed the questions as the last part of the study.

Children were exposed to either a normal-weight or overweight cartoon character. The picture was turned over before the children were given a bowl of eight mini biscuits and a taste test questionnaire. They were instructed to have at least one biscuit, and taste perception was rated on a five-point scale from "yucky" to "yummy".

After the biscuits were removed, the cartoon character was turned face up on the table. Participants were instructed to make a collage that best showed what they thought the character was like using stickers.  

What were the basic results?

Study one found an average of 3.8 sweets were taken by those exposed to the overweight image – this was more than twice the amount taken in the control group, who took an average of 1.55 sweets, or the normal-weight image group, who took 1.7 sweets.

Study two found children exposed to the overweight image took an average of 3.21 sweets, compared with 1.77 in the normal-weight group. Participants who saw both the normal-weight and overweight prints took an average of 3.29 sweets.

These findings suggest exposure to an overweight cartoon character activates this stereotype, leading to a greater consumption of sweets.

Study three found when health knowledge was activated, the image shown did not have any effect on the number of biscuits eaten. For children where health knowledge was not activated, behaviour was the same as in studies one and two, with the overweight image resulting in an average of 4.23 cookies consumed, compared with 3.23 cookies in the healthy-weight image group.  

How did the researchers interpret the results?

The researchers concluded that, "Results with children from 6 to 14 years old indicate that overweight cartoon character primes can activate the overweight stereotype, leading to relatively high levels of food intake.

"This effect persisted when participants were simultaneously exposed to a normal-weight and an overweight character together, and was successfully moderated by the activation of health knowledge." 

Conclusion

This interesting study assessed the impact of overweight cartoon characters on children's consumption of unhealthy foods. It shows overweight cartoon characters can activate the overweight stereotype, which may result in a higher consumption of unhealthy foods in children. But activating health knowledge seemed to counter the effects.

The main strength of this trial is that the children were randomly assigned to each group, which reduces the risk of bias. However, this study was conducted in a fairly small number of children from one location, reducing the generalisability of these findings.

Also, the study only looked at the consumption of unhealthy foods. It would have been interesting if the researchers had investigated whether consumption was increased on the whole rather than just with unhealthy snacks, perhaps with healthy alternatives.

The overconsumption of unhealthy snacks may result in increased body weight, which is a concern to parents and society. Excess weight can lead to a range of health concerns, so it's vital to find ways to stop this before it happens.

The best way parents can help is to make sure their child eats a healthy diet and gets plenty of exercise, and to only provide sugary snacks as an occasional treat rather than a staple of their diet. Read more about healthy snack alternatives

Links To The Headlines

How Peppa Pig could be making your children fat. The Daily Telegraph, July 14 2014

Are Shrek, Homer Simpson and Porky Pig making children FAT? Overweight cartoon characters encourage young people to gorge on junk food, study warns. Mail Online, July 14 2015

Links To Science

Campbell MC, et al. Kids, cartoons, and cookies: Stereotype priming effects on children's food consumption. Journal of Consumer Psychology. Published June 17 2015

Categories: Medical News

Weak link between depression and frequent smartphone use

Medical News - Thu, 07/16/2015 - 17:30

"Smartphone behaviour 'could diagnose depression' says new scientific study," the Daily Mirror reports. But based on the data presented in the study the paper is reporting on, we would disagree.

The story was prompted by a small US study of adults who agreed to have a freeware app – Purple Robot – installed on their phone. The app tracks phone usage and physical movement via GPS.

Researchers found people who reported depressive symptoms used their phone more often, visited fewer locations, and spent more time at home than the group of people who did not have symptoms of depression.

The results should not be taken too seriously as these two groups of people were not matched, so other factors could have influenced the results (confounders).

A major factor that was not accounted for was whether any of the people involved in the study were employed, the nature of the employment, or whether they were looking after children or caring for someone. This would have had a major impact on their phone use and the amount of time they spent going out to different places.

Other factors commonly taken into account but not included in this study are a history of mental health problems, age, sex and any medical or psychiatric conditions.

In short, this study does not show smartphone use can diagnose depression.  

Where did the story come from?

The study was carried out by researchers from Northwestern University and Michigan State University, and was funded by the US National Institute of Mental Health.

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

The authors do not declare any conflict of interest. They developed an open-source app called Purple Robot, which is designed to collect mobile phone sensor data.

Purple Robot has also been used in studies designed to optimise adherence to treatment regimes for people with HIV, ulcerative colitis and Crohn's disease.

The Mail Online coverage of the story included some inaccuracies, such as saying, "The phone data turned out to be a more reliable way of detecting depression than asking participants questions about how sad they were feeling on a scale of one to 10".

But the scales used were from one to three, and it is not clear how the phone data could be "more reliable" when none of the participants were assessed for symptoms of depression other than their answers to this symptom-scale questionnaire.

The Mail also says that, "Using a phone stops people dealing with difficult feelings" without pointing out this was just the authors' hypothesis and not actually assessed in the study.

Similarly, the Daily Mirror carried a number of quotes from the lead author, such as, "We now have an objective measure of behaviour related to depression", without subjecting these comments to any scrutiny.  

What kind of research was this?

This observational study aimed to see if people who self-reported symptoms of depression were likely to use their mobile phones more than people who did not have symptoms of depression.

It also aimed to see if they were less likely to go out to different places.

This type of study can only show an association and cannot prove cause and effect.

What did the research involve?

Forty adults aged between 19 and 58 were recruited to take part in the study. They were asked to download an app called Purple Robot on to their phone.

This app measured their phone usage and mapped their location using GPS. The participants were asked to keep the phone with them at all times for two weeks.

At the beginning of the study they completed the Patient Health Questionnaire-9 (PHQ-9) to record any self-reported symptoms of depression. This questionnaire asks people to rate nine different symptoms of depression from 0 (not at all) to three (nearly every day). Scores can range from 0 to 27.

This screening questionnaire gives an indication of whether a person is likely to be depressed, but a diagnosis would require further clinical assessment. The scores suggest the following:

  • 5 to 9 – mild depression
  • 10 to 14 – moderate depression
  • 15 to 19 – moderately severe depression
  • 20 or more – severe depression

The researchers split the people into two groups – one group scored less than five on the PHQ-9 and the other group scored five or more. The researchers then analysed the results looking for any associations between depressive symptoms, phone usage and how much a person was out and about.  

What were the basic results?

Data was available for only 28 of the participants, with 14 in each group. The average PHQ-9 score for the depressive group was 9.6, which would be rated as mild.

People with depressive symptoms went out less often and spent more time at home. They also used their phone more often, but the study doesn't report if these participants used their phone for texting, surfing the internet or talking to someone.  

How did the researchers interpret the results?

The researchers concluded mobile phone use could be used to help identify people with depressive symptoms.

They say that, "While these findings must be replicated in a larger study among participants with confirmed clinical symptoms, they suggest that phone sensors offer numerous clinical opportunities, including continuous monitoring of at-risk populations with little patient burden and interventions that can provide just-in-time outreach." 

Conclusion

This small study suggests people who report higher levels of depressive symptoms may use their phone more and go out less.

However, these findings should not be taken too seriously as this study has many limitations, including:

  • a small sample size – data from only nine people in each group was used for the location data
  • there was no attempt to ensure the two groups were matched in terms of any medical illness, age, sex, whether they were employed, or any other potential confounding factors
  • it's not known whether any of the participants in either group had a diagnosis of depression or any other mental illness
  • the analysis relied on the participants keeping their mobile phone with them continuously, which may or may not have actually happened

In short, this study does not show that mobile phone use can diagnose depression. As the researchers point out, a much larger – and, in our opinion, better designed – study would be required to see if a depression app or similar would be a viable idea.

If you are feeling low, it is a good idea to talk to someone or seek professional help. The Samaritans are available 24 hours a day, 365 days a year if you are in distress and can be reached on 08457 90 90 90.

Links To The Headlines

Smartphone behaviour 'could diagnose depression' says new scientific study. Daily Mirror, July 15 2015

How your SMARTPHONE could diagnose you with depression: Using it for 68 minutes a day 'may be a sign of mental illness’. Daily Mail, July 15 2015

Links To Science

Saeb S, Zhang MI, Karr CJ, et al. Mobile Phone Sensor Correlates of Depressive Symptom Severity in Daily-Life Behavior: An Exploratory Study. Journal of Medical Internet Research.

Categories: Medical News

Should we worry about the 'flesh-eating killer bug'?

Medical News - Wed, 07/15/2015 - 12:59

A "terrifying" and "flesh-eating" bug that "kills one in four it infects invasively" is spreading around the world, warns The Daily Telegraph in news that surprisingly didn't make its front page.

So why is everyone in the country not wearing biohazard onesies? Probably because the threat from this kind of infection is extremely low.

The key fact is that while the emm89 strain of group A streptococcus bacteria was reported to kill one in four people it infects invasively, just over a hundred were infected in this way by this strain in 2013.

The case fatality rate reported in this study of 21% (actually closer to one in five than one in four) makes these invasive infections very serious. For comparison, in the latest outbreak of Ebola the case fatality rate was around 50%. Fortunately, it is not common.

In fact, "strep A" bacteria are generally very common and usually harmless or only slightly problematic. They live on our skin and give us sore throats, earache, and the usually self-limiting but very contagious scarlet fever.

The research behind this news brought together data on the increasing prevalence of the emm89 bacteria and genetic changes in the strain over time, and their effects on the bacteria. Researchers were surprised to find its structure was different from other types of invasive bacteria.

Infections are best avoided by maintaining good hygiene, including washing your hands. 

Where did the story come from?

The study was carried out by researchers from Imperial College London and other research centres in the UK.

It was funded by the National Institute for Health Research Biomedical Research Centre and the UK Clinical Research Collaboration.

The study was published in the peer-reviewed scientific journal mBio. This is an open access journal, meaning the study can be accessed online for free.

The news has focused on the spread of these bacteria in the UK and the high death rate in people who have an invasive infection.

But this research doesn't show that the new form of emm89 is any more deadly than other invasive forms of group A streptococcus. In fact, researchers were mainly interested in the genetics of these bacteria, prompted by the new form of emm89 becoming more common.

The Telegraph failed to make it clear that, in general, invasive infections with group A streptococcus are uncommon. There were about 1,500 cases in 2013, and only about 100 caused by emm89. The Telegraph's "terrifying" and "flesh-eating" coverage could therefore be seen as unnecessarily alarmist. 

What kind of research was this?

This laboratory study looked at the DNA of a strain of group A streptococcus bacteria.

Each year, 600 million people worldwide have a group A streptococcus infection. The bacteria are often found on the surface of the skin and in the throat, and can cause minor infections in these areas.

In rare cases, the bacteria go deeper into the body to cause more serious "invasive" infections. This can include pneumonia and the "flesh-eating" skin infection, necrotising fasciitis.

One type, called emm89, has become one of the main group A streptococcal bacteria that causes disease. Over the last 10 years, the researchers have found an increase in invasive disease caused by emm89.

Because the emm89 strain has not been widely studied, researchers wanted to study its genetic makeup and how it has changed over time. They wanted to understand whether these changes might explain why it has become more common. 

What did the research involve?

The researchers used national data on all cases of invasive group A streptococcal disease in England and Wales between 1998 and 2013. They wanted to know how common the emm89 strain was and how many people died from the invasive infection.

The researchers also analysed the DNA of 131 emm89 samples (58 invasive, 73 non-invasive) collected between 2004 and 2009 to see how it had changed.

They used computer analysis to look at how these changes were likely to have arisen over time, and looked at how these changes might impact the biology of the bacteria.

Finally, the researchers investigated how the genetic changes made differences to the properties of the bacteria in a lab. 

What were the basic results? Prevalence of the streptococcus A emm89 strain

The researchers found an increase in the amount of invasive group A streptococcal disease caused by the emm89 group of bacteria in England and Wales between 1998 and 2013.

Between 1999 and 2005 all forms were increasing, but between 2005 and 2009 emm89 was increasing more than other types of group A streptococcus. Emm89 was responsible for 10% of all invasive A streptococcal disease in 2005, and 18% in 2007.

Between 2003 and 2013 about a fifth of people with invasive A streptococcal disease died within 30 days.

Genetic changes in the streptococcus A emm89 strain

The researchers identified genetic changes in the emm89 group over time in the UK. Analysis suggested a group of emm89 bacteria with one particular set of genetic changes had emerged in the 1990s and taken over as the main form of the bacteria over time.

The researchers found this group (or "clade") had changes in two regions of its DNA known to affect how infectious the bacteria are. This included losing the genes that usually make the outer coating of the bacteria.

This was surprising – without these genes, the bacteria cannot produce this coating, which had been thought to be essential for the bacteria to infect cells and stop the immune system destroying them.

The researchers found bacteria from this clade could stick to and grow on a plastic surface in the lab better than other forms of emm89. All the forms survived and multiplied in human blood in the lab similarly well.  

How did the researchers interpret the results?

The researchers concluded that, "The rise of emm89 iGAS in the United Kingdom coincided with the emergence and increased prevalence of a variant acapsular clade that differed from the rest of the emm89 population." 

Conclusion

Unlike in the BBC 4 drama, "Cordon", it's unlikely that the streets will be barricaded because of an outbreak of this deadly infection featured in today's news.

The study behind the headlines looked at genetic changes over time within the emm89 form of group A streptococcus bacteria. It found a new form emerged that has become more common over time, and identified the genetic changes that may have contributed to this rise.

This type of study is useful for researchers to look at how infectious organisms change over time and become more successful. It can help researchers track the spread of different forms of bacteria, and may help us develop ideas about new ways to treat them.

There are some points to note about this study. The researchers observed there was no evidence this new clade caused more severe invasive disease than other strains.

Also, although the papers call this a "flesh-eating bug", many of the infections caused by group A streptococcus are mild. The term "flesh eating" is news-speak for one form of invasive group A streptococcus infection called necrotising fasciitis, which makes up only some of the invasive cases of group A streptococcus disease.

Links To The Headlines

Flesh-eating bug 'kills one-in-four of people it infects in UK'. The Daily Telegraph, July 15 2014

Surge in terrifying new strain of flesh-eating bug across the world: Infection KILLS one in four victims in severe cases. Daily Mail. July 14 2015

Links To Science

Turner CE, et al. Emergence of a New Highly Successful Acapsular Group A Streptococcus Clade of Genotype emm89 in the United Kingdom. mBio. Published July 14 2014

Categories: Medical News

Researchers identify protein that spreads cancer

Medical News - Tue, 07/14/2015 - 15:00

"Scientists have found a way of preventing the spread of cancer from the site of the original tumour," The Independent reports. Targeting proteins called DNA-PKcs could prevent cancer cells moving to other parts of the body. This is known as metastatic cancer and is often fatal.

The research involved mice as well as tissue samples from more than 200 prostate cancer patients. Researchers found mice treated with an inhibitor to block DNA-PKcs had reduced cancer spread compared with mice that were not treated.

Patients whose prostate cancer tissue samples showed higher DNA-PKcs levels were more likely to have had cancer progression (metastasis). As yet we do not know if a DNA-PKcs inhibitor would have the same outcome in humans as it did in mice.

This research furthers our knowledge about the biology of cancer progression and has identified another possible way to tackle the spread of cancer. Further investigation in humans would be required to confirm whether these findings are of use for improving outcomes for prostate cancer patients.  

Where did the story come from?

The study was carried out by researchers from Thomas Jefferson University, the University of Michigan, Cleveland Clinic, the University of California, Los Angeles (UCLA), the Mayo Clinic, Columbia University Medical Centre, and GenomeDx Biosciences.

It was funded by the Prostate Cancer Foundation (PCF), PCF/Movember and Evans Foundation, PA CURE, the US Department of Defense, UCLA, the National Cancer Institute, and the National Institutes of Health.

The study was published in the peer-reviewed journal Cancer Cell.

This research has been reported in the media as a breakthrough – the Daily Express goes as far as talking about a possible "cure". However, while certainly promising, the research is at an early stage. Crucially, we do not know whether these findings will result in new treatments in humans.  

What kind of research was this?

This laboratory and animal study in mice looked at whether the protein DNA-PKcs is linked to cancer progression. This type of animal study is used to understand the biology of human disease better.

While there are a lot of similarities in the biology of different species, there are some key differences. This means that while results do give an indication of what is likely to happen in humans, we cannot be certain that any findings would be exactly the same.

Researchers looked at some prostate cancer tissue samples to see if their findings looked like they might apply to people, but the human research is at an early stage. 

What did the research involve?

The researchers first studied DNA-PKcs in cells in the lab to look at what it does in the cell. It was believed to aid the spread of cancer cells.

They then used mice injected with human prostate cancer cells to investigate whether it is possible to stop cancer spread by targeting the DNA-PKcs protein.

Mice were either treated with an inhibitor that blocks the DNA-PKcs protein or an inactive control treatment. The size of their tumours was monitored by live imaging.

After 31 days three mice were selected from the control arm and switched to receive the DNA-PKcs inhibitor to investigate the impact. Three mice were also selected from the protein inhibitor group and stopped receiving this treatment.

The researchers went on to analyse cancer tissue samples from 232 patients with prostate cancer, and measured the amount of DNA-PKcs the cells contained. The researchers looked at how their DNA-PKcs levels related to their outcomes. 

What were the basic results?

The laboratory tests showed the DNA-PKcs protein was involved in controlling the activity of genes cancer cells need to move and spread. The researchers also found blocking DNA-PKcs reduced the spread of cancer in mice.

Mice who crossed over from the control arm to the protein inhibitor did not show a reduction in tumour size. This implies the DNA-PKcs inhibitor blocked the spread of cancer rather than suppressing tumour growth.

When mice stopped receiving the DNA-PKcs inhibitor, their cancer spread. Mice who stayed on the DNA-PKcs inhibitor and did not cross over were found to have less cancer spread than those who stayed in the control arm.

The patient samples showed men with higher DNA-PKcs levels were more likely to have had prostate cancer progression and to have died. 

How did the researchers interpret the results?

The researchers concluded they have identified DNA-PKcs as a protein that drives prostate cancer progression and spread.

Higher levels of DNA-PKcs in prostate cancer tissue were an independent predictor of metastasis, recurrence and poor survival. Researchers hope this discovery will pave the way for new drug treatments. 

Conclusion

This lab study in mice found a protein called DNA-PKcs is involved in the spread of cancer cells, and assessed whether it is possible to stop this spread by targeting the protein.

It demonstrated that mice with human prostate cancer cells treated with an inhibitor to block the protein had reduced cancer spread compared with those who were not treated.

Analysis of patient prostate cancer samples showed higher DNA-PKcs levels were linked to a greater risk of cancer progression. This suggests the protein may be playing a similar role in humans, and researchers will want to go on to see if DNA-PKcs inhibitors could be used as a new treatment to stop the spread of cancer.

This protein is involved in the spread of cancer but does not appear to be involved in cancer growth, so any new drugs blocking it would also need to be used alongside other drugs. It's also not yet clear whether the findings only apply to prostate cancer cells.

While this research seems to show promise, the findings on the DNA-PKcs inhibitors were in mice and therefore may not be applicable to humans. Headlines reporting this as a cancer "breakthrough" should be taken with caution.

Researchers will need to determine whether these inhibitors seem safe and effective enough in animals before they could be tested in humans. Once this is done, a randomised trial in humans would be required before we know its effects.   

Links To The Headlines

Scientists discover way of targeting 'lynchpin' molecule to prevent the spread of cancer. The Independent, July 13 2015

Cancer breakthrough as scientists discover 'master switch' that causes the disease to spread, paving the way for new life-saving treatments. Mail Online, July 13 2015

New drug to beat cancer: Breakthrough as scientists find key to stopping disease. Daily Express, July 14 2015

Links To Science

Goodwin JF, Kothari V, Drake JM, et al. DNA-PKcs-Mediated Transcriptional Regulation Drives Prostate Cancer Progression and Metastasis (PDF, 4.43Mb). Cancer Cell. Published online July 13 2015

Categories: Medical News

No proof tea is the 'elixir of life'

Medical News - Mon, 07/13/2015 - 16:30

"Is the elixir of life as simple as two cups of tea?," the Mail Online asks, prompted by a study looking at whether tea drinking is associated with a longer life expectancy in women.

This study included more than a thousand older women with an average age of 80. The women completed food and drink questionnaires, and the data from this was put into special databases to estimate their flavonoid intake.

Flavonoids are plant compounds found in various foods and drinks, including tea, chocolate and wine. They are said to have an antioxidant effect by helping prevent cell damage.

The researchers looked at how flavonoid intake was linked to the women's risk of death from any cause over the next five years.

They found those with the highest intake had a reduced risk of death compared with those with the lowest. In this group of older women, black tea contributed the most to total flavonoid intake.

However, although the study did find a link, this does not prove that tea or flavonoids are the single direct cause of reduced mortality. Various unmeasured health and lifestyle factors (confounders) could have influenced the results.

There are also possible inaccuracies in the estimation of flavonoid intake, and the results of this older group of Australian women cannot be applied to everyone.

Overall, this study does add to the body of research assessing flavonoids, but provides no proof that the compound – or tea specifically – reduces mortality in older women.

Where did the story come from?

The study was carried out by researchers from the University of Western Australia.

It was funded by Kidney Health Australia, Healthway Health Promotion Foundation of Western Australia, Sir Charles Gairdner Hospital Research Advisory Committee, and project grants from the National Health and Medical Research Council of Australia.

It was published in the peer-reviewed American Journal of Clinical Nutrition.

The Mail Online's coverage hailing tea the "elixir of life" has not taken into account the important limitations of this research. 

What kind of research was this?

This prospective cohort study followed a group of older women over the course of five years to explore any links between flavonoid intake and overall mortality.

Flavonoids are plant compounds thought to have various potential health benefits, including effects on the cardiovascular system and glucose metabolism. Particularly rich sources include tea, chocolate, fruit and red wine.

Though previous research has investigated the link between flavonoids and particular health outcomes such as cardiovascular disease and cancer, there is said to have been little research investigating all-cause mortality.

Cohort studies such as this can demonstrate associations but cannot prove cause and effect, as other factors could be involved.  

What did the research involve?

This study included 1,136 postmenopausal women (aged over 75) taking part in the Calcium Intake Fracture Outcome Age Related Extension Study that started in 2003. This was an extension of a randomised controlled trial of calcium supplements to prevent fractures.

The study included 1,063 women who completed food questionnaires in 2003. These questionnaires included questions on average tea and coffee consumption over the past 12 months.

The study then followed up all-cause mortality over the following five years to 2008, linking the women to database registries. These recorded cardiovascular and cancer events using valid medical codes, and deaths were also identified in the mortality register.

The researchers used two different databases on the flavonoid composition of different foods and drinks so they could estimate flavonoid intake.

They then looked at the link between all-cause mortality and flavonoid intake. They took into account potential confounders recorded at the start of the study.

These included existing cardiovascular disease and cancer recorded in the registries, age, body mass index (BMI), self-reported smoking status, alcohol consumption, fruit and vegetable intake, and physical activity. 

What were the basic results?

Over the five years of follow-up, there were 129 deaths (12% of women). Average daily flavonoid intake was 674-696mg a day, depending on which of the two databases was used to estimate flavonoids.

Higher flavonoid intake was associated with a reduced risk of all-cause mortality. Compared with women with the lowest intake (less than 525 or 547mg a day), those with the highest intake (above 788 or 813mg a day) had a 62-64% significantly reduced risk of mortality – again, depending on which database was used to estimate flavonoids.

The researchers found similar results when looking specifically by cause of death, whether cardiovascular or cancer.

When the researchers looked specifically at flavonoids, black tea appeared to be the major dietary contributor. Tea accounted for between 59% and 82% of the total flavonoid intake.  

How did the researchers interpret the results?

The researchers said that, "Using the most comprehensive flavonoid databases, we provide evidence that high consumption of flavonoids is associated with reduced risk of mortality in older women. The benefits of flavonoids may extend to the [disease cause] of cancer and cardiovascular disease." 

Conclusion

Flavonoid plant compounds have been researched extensively, with studies exploring their possible health benefits.

In this research, there is an association between higher flavonoid intake and a reduced risk of death from any cause over five years in a cohort of older women.

However, this study provides no proof that drinking tea will help you live longer. There are several important points to bear in mind:

  • The design of this study cannot prove cause and effect. Though it has adjusted for various potential health and lifestyle confounders, it is unlikely to have taken all of them into account. It is therefore not possible to say that flavonoids are the single direct cause of reduced mortality.
  • This is a very specific population group: postmenopausal women with an average age of 80 who were recruited to a trial investigating calcium supplements to prevent fractures. They therefore may not be representative of all older women – for example, the women in this trial were of quite high socioeconomic status. Their results can certainly not be applied to women as a whole, or men.
  • Foods and drinks were assessed by food frequency questionnaire. Although these may be validated ways of assessing intake, they are still subject to inaccuracy. For example, people may not be able to give a reliable indication of their tea consumption over the past year.
  • This information on foods and drinks was put into two different databases to estimate flavonoid intake. As the results showed, the total intake amounts, or the risk reductions, varied depending on which of the two databases were used. This means these may not be completely accurate estimates of flavonoid intake.
  • The media linked these findings to tea, as black tea was the major source of flavonoids, though the main risk analyses were not solely based on flavonoid intake from tea. The researchers say an intake of about 350mg is equivalent to approximately two cups of tea, so the highest intakes of 788 or 813mg a day would be equivalent to more than four cups of tea.

Overall, this study adds to the body of research assessing the benefits of flavonoids, but provides no proof that they – or tea specifically – reduce mortality in older women.

Read more about health advice for women aged 60 and above.

Links To The Headlines

Is the elixir of life as simple as two cups of tea? Daily cuppas 'can dramatically increase longevity in older women'. Mail Online, July 10 2015

Drinking daily cups of tea makes women live longer, a new study finds. Metro. July 11 2015

Links To Science

Levy  KL, Hodgson JM, Croft KD, et al. Flavonoid intake and all-cause mortality. The American Journal of Clinical Nutrition. Published online April 1 2015

Categories: Medical News

Are teens confused about their size and weight?

Medical News - Fri, 07/10/2015 - 20:00

"Third of overweight teenagers think they are right size, study shows," The Guardian says in one of many headlines on widely covered English research.

The research, which looked into English 13-15-year-olds' understanding of their own weight, led the Mail Online to refer unkindly to "generation fat-blind".

The large study demonstrated that while most normal-weight adolescents correctly see themselves as about the right weight, a large number of overweight or obese adolescents wrongly thought they were about the right weight or too light.

Parents probably ought to refrain from a "told you so" attitude to this news, as so-called fat shaming is not considered a great way to help anyone lose weight.

Helping a teen to understand that familiar media images of overweight and obese people don't necessarily give the full picture, and that addressing the problem can improve the quality and length of their life, may be more successful.

The findings may also help policymakers work out how best to target health promotion messages at this important age group and help them potentially make changes for the rest of their lives. 

Where did the story come from?

The study was carried out by researchers from University College London and was funded by Cancer Research UK.

It was published on an open-access basis in the peer-reviewed International Journal of Obesity.

This study was accurately reported by a number of media sources, with a good explanation of its key findings and the risks associated with obesity.

However, there was a general lack of information about the limitations of this study. The Mail's headline use of the term "fat-blind" may be seen as pejorative and misleading, especially when we do not necessarily understand all the reasons for the research findings. 

What kind of research was this?

This study analysed data from the Health Survey for England looking at adolescents' perception of their weight.

Looking at this data is a good way to understand adolescents' weight perceptions because measurements were taken professionally and weight perception questions were self-reported in the survey.

However, this type of study can have chunks of missing data, particularly where people declined to be weighed, which may have biased the results. 

What did the research involve?

The researchers used data for 4,979 teens aged 13 to 15. The data was taken from the results of the Health Survey for England between 2005 and 2012.

This annual survey presents a representative sample of the general population of England. It surveys adults and up to two children under 16 (selected at random in families with three or more eligible children).

Researchers weighed and measured the teens at home, and then calculated their body mass index (BMI). Weight status was defined according to the International Obesity Taskforce criteria, which classifies BMI values according to age and sex as:

  • thin (underweight)
  • normal weight
  • overweight
  • obese

The 13-15-year-olds were also asked: "Given your age and height, would you say that you are about the right weight, too heavy, or too light?".

The researchers also included age, sex, ethnicity and the socioeconomic status of the teens in their analyses. 

What were the basic results?

The data showed nearly three-quarters (73%) of adolescents in the study had a BMI placing them in the normal weight range, but 20% were overweight and 7% were obese.

Normal-weight adolescents generally felt they were the correct weight (83%), with just 7% who thought they were too heavy, while 10% thought they were too light.

More girls (11%) considered themselves too heavy than boys (4%). Girls (6%) were also less likely to consider themselves too light than boys (13%).

Overestimation was more likely among those on the heavier end of the normal-weight group (10%) than the lighter end (2%).

About 60% of the overweight/obese group felt they were too heavy, 39% thought they were about the right weight, and 0.4% felt they were too light.

Again, girls (68%) who were overweight or obese were more likely to think so than boys (53%).

Girls (32%) were also less likely than boys (47%) to think they were the right weight or too light. Overweight adolescents were much more likely to underestimate their weight (52%) than those who were obese (7%).

The researchers excluded adolescents who were underweight from the analysis as this group consisted of 248 people, which they say was too small to calculate meaningful results. 

How did the researchers interpret the results?

The researchers concluded that, "Overestimation of body weight among normal-weight adolescents is relatively uncommon; potentially a cause for celebration.

"However, almost half of boys and a third of girls with a BMI placing them in the overweight or obese BMI range perceived themselves to be about the right weight.

"Lack of awareness of excess weight among overweight and obese adolescents could be cause for concern." 

Conclusion

This study aimed to see whether English teenagers' perception of their weight matched up with reality. It demonstrated that most normal-weight adolescents correctly see themselves as about the right weight and they overestimated their weight fairly rarely.

But a large proportion of overweight and obese adolescents thought they were about the right weight or even too light.

This study had a large population size, and analyses were weighted to match key population characteristics.

However, the weight measurements were not available for all adolescents in the survey – this may have represented those who were more concerned about their weight and declined measurement, leading to biased results.

Also, overweight and obese adolescents may not have completed the questionnaires truthfully through embarrassment or fear of the consequences.

Only people aged 13 to 15 were analysed, so further research would need to be carried out in other age groups to target issues associated with weight perception if necessary.

Overweight and underweight teens are a concern to both their parents and society. They are likely to grow into overweight or underweight adults, particularly if they do not see that they are not a healthy weight.

The reasons teenagers don't see themselves as overweight may include the commonly seen images of severely obese individuals in the media used to represent stories about weight issues. These could lead to the impression that only those who have a visibly very high body weight are overweight or obese.

Excess weight can lead to a range of other health concerns, including an increased risk of type two diabetes and certain cancers.

Even if teenagers aren't interested in these long-term health messages, it's vital to find ways to improve their understanding of the implications of their weight. And if they understand, it's vital we're able to give them simple advice on achieving a healthy weight in a way that doesn't make them feel patronised.

Links To The Headlines

Third of overweight teenagers think they are right size, study shows. The Guardian, July 9 2015

Generation 'fat-blind': More than a third of obese teenagers think their weight is 'about right', study warns. Daily Mail, July 9 2015

Overweight teens 'do not see themselves as too heavy'. BBC News, July 9 2015

Links To Science

Jackson SE, et al. Weight perceptions in a population sample of English adolescents: cause for celebration or concern? International Journal of Obesity. Published July 9 2015

Categories: Medical News

Online symptom checkers' reliability assessed

Medical News - Thu, 07/09/2015 - 15:00

"The danger of an online diagnosis: Millions of emergencies are MISSED through symptom checker websites," the Mail Online reports. American researchers have assessed the accuracy and reliability of 23 symptom checkers, including the NHS Choices symptom checker.

The researchers were looking at both accuracy of diagnosis and triage. Triage is the process of determining the severity of a condition.

They did this by using a series of symptoms and medical history known to be associated with specific conditions. These types of combination are known as clinical vignettes.

The NHS Choices symptom checker doesn’t offer a diagnosis – it only provides triage advice.

Researchers found that the NHS Choices symptom checker correctly identified emergency and urgent conditions in 87% of cases. But it also incorrectly triaged non-emergency or non-urgent conditions in 80% of cases, which theoretically would result in an unneeded visit to A&E or a call for an ambulance.

While symptom checkers are far from perfect, they are better than just leaving people "Googling" their symptoms, which is estimated to have a 64% success rate in identifying emergency and urgent cases.  

Where did the story come from?

The study was carried out by researchers from Harvard Medical School, Brigham and Women’s Hospital, Boston Children’s Hospital and Beth Israel Deaconess Medical Center, all in Boston. It was funded by the US National Institutes of Health.

Researchers involved in this study say they have not been, nor plan to be, involved in the development, evaluation, promotion, or any facet of a Harvard Medical School-related symptom checker and they had no support from any organisation for the submitted work. This includes no financial relationships with any organisations that might have an interest in the submitted work in the previous three years, or other relationships or activities that could appear to have influenced the submitted work.

In the interests of transparency, we should also point out the Behind the Headlines editorial team is employed by the Health & Social Care Information Centre, which is the same NHS organisation that runs the NHS Choices symptom checker.

The study was published in the peer-reviewed British Medical Journal on an open-access basis, so the study is free to read online or download as a PDF.

It was reported by the Mail Online website in the UK. Overall, the Mail reported the story accurately, but the limitations of the study were not fully explained. Its headline "Millions of emergencies are MISSED through symptom checker websites, study warns" is untrue. The study provides no estimate of how many emergency cases were misdiagnosed by symptom checkers around the world.

 

What kind of research was this?

This was an audit study that aimed to assess the diagnostic and triage accuracy of online symptom checkers (tools that use computer algorithms to help patients with self-diagnosis or self-triage). Triage is the process of determining the priority of patients' treatments, based on the severity of their condition.

With improvements in technology and access to the internet, people are increasingly using the internet to research their health concerns. For example, researchers quote that the NHS Choices website has over 15 million visits per month. That figure was actually based on 2012 data; the figure for 2015 averages around 50 million visits a month.

Although there are many advantages to using symptom checkers, such as providing out-of-hours advice and reducing the burden on GP and A&E departments, they cannot always take the place of face-to-face clinical assessment.

 

What did the research involve?

Researchers searched for online symptom checkers that were in English, free to access, publicly available, and did not focus on a single type of condition.They used terms like "symptom checker" or "medical diagnosis" to find symptom checkers in Google and Google Scholar, and also searched for any relevant apps in the Apple app store and Google Play.

After searching and sifting, they finally included 23 online symptom checkers for further analysis. They categorised symptom checkers by whether they facilitated self-diagnosis, self-triage, or both. They also categorised them according to the type of organisation they were operated by, the maximum number of diagnoses provided and whether they were based on Schmitt or Thompson nurse triage guidelines. These are decision support protocols commonly used in telephone triage for paediatric and adult consultations, respectively.

To evaluate the diagnosis and triage performance of the symptom checkers, they used 45 standardised patient vignettes. They say they used this method to assess the performance of the symptom checkers, because this method is commonly used by physicians and other clinicians on their diagnostic ability and management decisions. These 45 clinical vignettes were further divided as either "common" or "uncommon" diagnoses. Triage advice was further divided into three groups:

  • Emergency, which included advice to call an ambulance, go to the emergency department, or see a general practitioner immediately.
  • Non-emergency, which included advice to call a general practitioner or primary care provider, see a general practitioner or primary care provider, go to an urgent care facility, go to a specialist, or go to a retail clinic.
  • Self care, which included advice to stay at home or go to a pharmacy.

Each standardised patient vignette was entered into each website or app, and resulting diagnosis and triage advice was recorded.

 

What were the basic results?

The 23 symptom checkers included in this study were based in the UK, US, the Netherlands and Poland. The 45 standardised patient vignettes used to assess the performance of these symptom checkers included 26 common and 19 uncommon diagnoses.

Performance on diagnosis

Overall, the correct diagnosis was listed first 34% of the time. For different levels of triage, the percentage of the correct diagnosis being listed first is below:

  • 24% (95% confidence interval (CI) 19% to 30%) for emergency evaluations
  • 38% (95% CI 32% to 34%) for non-emergency evaluations
  • 40% (95% CI 34% to 47%) for self care evaluations
Performance on triage advice

The included online symptom checkers correctly gave triage advice 57% of the time. For different levels of triage, the percentage of correct advice is below:

  • 80% (95% CI 75% to 86%)  for emergency care evaluations
  • 55% (95% CI 47% to 63%) for non-emergency evaluations 
  • 33% (95% CI 26% to 40%) for self care evaluations

 

How did the researchers interpret the results?

Researchers concluded by saying, "Physicians should be aware that an increasing number of their patients are using new internet-based tools such as symptom checkers and that the diagnosis and triage advice patients receive may often be inaccurate. For patients, our results imply that, in many cases, symptom checkers can give the user a sense of possible diagnoses, but also provide a note of caution, as the tools are frequently wrong and the triage advice overly cautious."

They added, "Symptom checkers may, however, be of value if the alternative is not seeking any advice or simply using an internet search engine. Further evaluations and monitoring of symptom checkers will be important to assess whether they help people learn more and make better decisions about their health."

 

Conclusion

This audit study showed that online symptom checkers sometimes correctly diagnose and advise people according to their symptoms, but they can be inaccurate. Though the appropriate triage advice was only accurate, on average, 57% of the time, the study found this advice erred on the side of caution, advising people to seek help. 

There are several limitations to this study, including:

  • The study did not include real people, but relied on clinical vignettes to assess the performance of the online symptom checkers. These vignettes included medical terms, which would not necessarily be used by people accessing the sites. Actual patients may sometimes find it difficult to express their symptoms or use different terms. On the other hand, people may refine or add more detail if the advice received was not what was expected.
  • The study might not have captured all the online symptom checkers available.
  • The study does not compare the diagnosis and advice of the online symptom checker to the diagnosis and advise that would have been provided by a doctor.

Overall, it is important to note that symptom checkers should be used as an indicator, and not viewed as an alternative to seeking medical advice, especially if you think it may be a medical emergency.

Like symptom checkers themselves, when it comes to assessing a situation, it is always better to err on the side of caution.

Links To The Headlines

The danger of an online diagnosis: Millions of emergencies are MISSED through symptom checker websites, study warns. Mail Online, July 9 2015

Links To Science

Semigran HL, Linder JA, Mehrotra A, et al. Evaluation of symptom checkers for self diagnosis and triage: audit study. BMJ. Published online July 8 2015

Categories: Medical News