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Health News from NHS Choices

Constantly updated health news across a range of subjects.

NHS Choices News

  • Vegetarian diet 'could have slight benefits in diabetes'

    "Vegetable diet will beat diabetes: Meat-free lifestyle cures killer disease," is the typically overblown headline in the Daily Express.

    But researchers actually found a vegetarian diet led to a quite modest fall in only one measure of blood glucose called HbA1C, a measure of blood glucose control.

    The paper reports on a systematic review which combined the results of six trials that involved 255 people with type 2 diabetes. They examined whether vegetarian or vegan diets improved blood glucose control compared with a control diet.

    Overall, the pooled results of five of these trials found a vegetarian or vegan diet reduced HbA1c by 0.39%. There was no significant effect on fasting glucose levels, an assessment of how efficiently the body can process glucose in the short term.

    This slight reduction in HbA1c is no cure. As the researchers themselves pointed out, the reduction is less than you would expect if a patient was being treated with the drug of choice for type 2 diabetes, metformin.

    This review also has various important limitations, including the variable design and quality of the six trials included. So, it does not prove that a vegetarian or vegan diet is better for a person with type 2 diabetes, and any media claims of a "cure" for the condition are entirely baseless.

     

    Where did the story come from?

    The study was carried out by researchers from Keio University in Japan and The George Washington University School of Medicine in the US.

    Funding was provided by the Japan Society for the Promotion of Science and the Nestlé Nutrition Council, Japan.

    One of the co-authors declared a non-financial conflict of interest. This author serves as president of the Physicians Committee for Responsible Medicine, without financial compensation.

    This organisation is described in the publication as one that, "promotes the use of low-fat, plant-based diets and discourages the use of animal-derived, fatty, and sugary foods". This represents a potential conflict of interest in the interpretation of the results.

    The study was published in the peer-reviewed medical journal, Cardiovascular Diagnosis and Therapy and the study is open access, so it is free to read the study online.

    The Daily Express' coverage of the study is accurate and contains some useful background information, so it is frustrating that its headline is totally misleading, especially as it was on the front page.

    In fact, this review of studies found vegetarian or vegan diets caused a slight reduction in HbA1c compared with non-vegetarian diets. This is not a cure in any sense of the word.

    The current thinking is that there is no such thing as a cure for type 2 diabetes. The condition can be successfully managed, but not cured.

    The study is also only applicable to type 2 diabetes, so the headlines do not apply to type 1 diabetes.

     

    What kind of research was this?

    This was a systematic review and meta-analysis combining the results of controlled trials that examined the effects of vegetarian diets on blood sugar control in type 2 diabetes.

    As the researchers say, previous research has suggested a link between a vegetarian diet and improved blood sugar control, but the relationship is not well established.

    As an interesting aside, the researchers highlight how diabetes levels were found to be lower in Seventh-day Adventists, a Protestant Christian denomination whose followers are encouraged to adopt a vegetarian diet.

    This review aimed to examine this grey area. A systematic review and meta-analysis of randomised controlled trials is the best way of examining the evidence to date that has assessed this question.

     

    What did the research involve?

    The researchers searched a number of literature databases (from their inception to 2013) to identify published clinical trials examining the effects of a vegetarian, vegan or omnivorous diet on blood sugar control in people with type 2 diabetes who were over the age of 20.

    A vegetarian diet was defined as one excluding meat, poultry and fish, while a vegan diet excluded all animal products.

    Eligible trials had an intervention duration of at least four weeks and examined the main outcome of changes in HbA1c.

    This gives an indication of blood sugar control in the longer term, as it indicates the amount of sugar being carried by red blood cells, which have a lifespan of around three months. Change in fasting blood sugar measures was a secondary outcome.

    In an added effort to find all relevant information for the review, the research team scoured the reference lists of all articles they found from the search of electronic databases, and also contacted research experts for additional material.

    The researchers assessed the quality of the studies included, and pooled studies calculating the average difference in HbA1c and fasting blood sugar between vegetarian or vegan and comparison diets.

     

    What were the basic results?

    A total of six trials met the inclusion criteria, involving 255 people with type 2 diabetes with an average age of 52-and-a-half. The average trial duration was 23.7 weeks, or about six months.

    Five of the studies examined vegan diets and one studied vegetarian diets. Four trials were conducted in the US, one in Brazil and one in the Czech Republic.

    Of the six studies, three were randomised controlled trials, one was a cluster randomised controlled trial, and two were non-randomised controlled trials.   

    In the pooled analysis of five trials, the vegetarian or vegan diet was associated with a significant reduction in HbA1c (-0.39%, 95% confidence interval [CI] -0.62 to -0.15) compared with omnivorous control diets.

    But the pooled analysis of four trials did not find a statistically significant reduction in fasting blood sugar: the average difference with the vegetarian or vegan diet compared with control was -0.36 mmol/L, 95% CI -1.04 to 0.32.

    Compared with control, the vegetarian or vegan diets were also associated with significant reductions in the amount of total energy the diet provided, either through carbohydrate, protein, total fat, cholesterol and fibre.

     

    How did the researchers interpret the results?

    The researchers concluded that, "Consumption of vegetarian diets is associated with improved [blood glucose] control in type 2 diabetes."

     

    Conclusion

    This systematic review has identified six trials assessing whether vegetarian or vegan diets improve blood sugar control in type 2 diabetes compared with control.

    It found the vegetarian or vegan diet gave significant improvement in one measure of blood sugar control (HbA1c), but not in another (fasting blood glucose).

    However, there are some important limitations to consider before we can categorically conclude that people with type 2 diabetes should switch to a meat and fish-free diet:

    The improvement in blood sugar control was quite small

    The pooled results of five trials found a vegetarian or vegan diet was associated with a 0.39% reduction in HbA1c, but we don't know that this would have made any meaningful clinical difference in diabetes control for the individual.

    Overall, although any reduction is likely to be a good thing, the precise benefit would depend on what a person's HbA1c level was to start with.

    The target HbA1c is usually set at a level below around 7%, so it may be more useful knowing whether a vegetarian or vegan diet improved the proportion of people achieving their target HbA1c level. The review also found no improvement in fasting blood glucose control.

    The intervention diets were varied

    Despite the publication tending to refer to the intervention diets as vegetarian, they were actually quite varied across the trials.

    Four of the trials were described as low-fat vegan, one as lacto-vegetarian (a diet that includes dairy products but not eggs), and one lacto-ovo low-protein (similar to a lacto-vegetarian diet but, as the name suggests, with a focus on low-protein foods).

    The control diets were also quite varied across the trials

    The researchers included diets described as omnivorous, low fat, "diabetic diet" and those that followed American Diabetic Association guidance.

    Overall, this doesn't give a very clear picture of what diets were being compared, which makes it hard to conclude that a particular diet is associated with an improvement in blood sugar control compared with a particular control.

    The trials had variable quality evidence

    Only three of the six trials studied were true randomised controlled trials. They varied in the duration of the dietary intervention between four and 74 weeks.

    Also, only one of the six trials (a controlled trial) is reported to have made any adjustment for potential confounders (sex, baseline HbA1c level and medication). The others report no adjustment.

    We also don't know how the trials checked that the diets were being followed as assigned, or of any other intervention or advice that may have been given to the participants alongside the dietary intervention (such as advice about physical activity).

    The review only included published trials

    In their assessment of possible publication bias, the researchers observed that smaller trials that found reductions in HbA1c level were perhaps more likely to have been published and therefore included in this review.

    The small number of participants

    Despite this being a systematic review of trials, the total number of participants was still quite small, at only 255. This is a very small number of patients, and it might be unwise to base any firm or generalisable conclusions on such small numbers.

    A vegetarian or vegan diet can be a healthy lifestyle choice for a person with type 2 diabetes if it provides balanced nutrition. But such diets can still be high in fat, salt and sugar if this is not controlled carefully.

    A healthy diet needs to be combined with regular exercise for people to be able to reap further health benefits, as well as avoiding smoking and only consuming alcohol at or below nationally recommended levels.

    Overall, this review does not appear to conclusively prove that a vegetarian or vegan diet is better for a person with type 2 diabetes. It certainly provides no evidence that this diet cures diabetes, as one of the news headlines suggests.

    Provided you do your homework, it is possible to eat healthily on a vegetarian or vegan diet. But if you do have type 2 diabetes, we recommend that you talk to the doctor in charge of your care before making any radical changes to your diet. 

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

    Links To The Headlines

    Vegetable diet WILL beat diabetes: Meat-free lifestyle cures killer disease, experts claim. Daily Express, November 24 2014

    How becoming a vegetarian can CURE diabetes: Plant-based diets improve blood sugar levels, scientists claim. Mail Online, November 24 2014

    Links To Science

    Yokoyama Y, Barnard ND, Levin SM, Watanabe M. Vegetarian diets and glycemic control in diabetes: a systematic review and meta-analysis. Cardiovascular Diagnosis and Therapy. Published online October 10 2014



  • Therapy reduces risk of suicide or self-harm

    “Talk therapy sessions can help reduce the risk of suicide among high-risk groups,” BBC News reports.

    The headline is prompted by a large Danish study that took place over a 20-year period.

    Researchers matched those who had received different psychosocial (“talking therapy”) interventions after a self-harm attempt with those who had not received a psychosocial intervention, and then compared relevant outcomes.

    People who received psychological interventions had reduced risk of further self-harm, but not suicide, within the first year. Looking at longer-term follow-up, psychological interventions were associated with reduced risk of both self-harm and suicide.

    However, it may be difficult to isolate the direct effect of the psychological intervention. People who had received psychological interventions were recruited from treatment clinics that required them not to be in need of psychiatric admission.

    Meanwhile, those who did not receive psychological treatment were reported to include people who needed psychiatric admission, or chose not to receive suicide prevention treatment. These factors could mean that this comparison group were at increased risk of subsequent harm and death to begin with.

    Also, the situation in the UK might be slightly different to Denmark. Despite this, any research that could help prevent suicides is always valuable.

     

    Where did the story come from?

    The study was carried out by researchers from the University of Copenhagen in Denmark and the Johns Hopkins Bloomberg School of Public Health in the US, in addition to other research institutions in Denmark and Norway. Funding was provided by the Danish Health Insurance Foundation; the Research Council of Psychiatry, Region of Southern Denmark; the Research Council of Psychiatry, Capital Region of Denmark; and the Strategic Research Grant from Health Sciences, Capital Region of Denmark.

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

    BBC News was generally representative of the research’s findings, but inaccurately described participants as having “attempted suicide”. The research included participants who had self-harmed. Not all instances of self-harm are suicide attempts, so it is a mistake to conflate the two terms. For some people, certain types of self-harming, such as cutting, are a way of coping with overwhelming emotional distress, rather than an attempt to end their life.

    It was not clear from the study what proportion of the self-harming events were attempted suicide.

     

    What kind of research was this?

    This was a cohort study comparing people who did and did not receive a psychosocial (talking) therapy after deliberate self-harm, and examined the outcomes of further self-harm, suicide or death from other causes. 

    The researchers say that self-harm is a strong predictor of suicide. Research indicates that within the first year after self-harming, about 16% of people self-harm again; 0.5 to 1.8% die by suicide; and 2.3% die from another cause. However, evidence for the effectiveness of psychological interventions following self-harm is said to be missing, and this study aimed to investigate this.

     

    What did the research involve?

    This study compared people in Denmark who received a psychological intervention following a first episode of self-harm with those who received standard care, over the 18-year period between January 1992 and December 2010. They calculated the risk of repeated self-harm, suicide and dying of any cause after the first instance of self-harm, and compared the risks between the two groups for differences that might be due to the psychological intervention. 

    The people who received psychological interventions were identified from one of seven suicide prevention clinics in Denmark. These clinics are said to receive people who are thought to be at risk of suicide, but not in need of psychiatric admission or other outpatient programmes. For the purposes of this study, participation was considered to be attendance for at least one psychological treatment session that was focused on suicide prevention. The seven different clinics used various types of therapy, including cognitive, problem-solving, crisis, dialectical behaviour, integrated care, psychodynamic, systemic, psychoanalytic approaches and support from social workers.

    The controls who did not receive a psychological intervention were people who had presented to hospital with an episode of self-harm during the study period, but who did not receive any psychological intervention. They could receive any form of standard care, including admission to a psychiatric hospital, referral to outpatient treatment or a general practitioner, or discharge without referral.

    The reasons why these people did not receive a psychological intervention were variable, including:

    • living in an area remote from services
    • being referred for other treatment (including hospital admission)
    • not wanting to be referred for suicide prevention treatment

    All people were linked via their Danish ID numbers to the Danish Civil Register, National Registry of Patients, Psychiatric Central Registry and Registry of Causes of Death. Follow-up was to the end of 2011, giving a follow-up period for the people in the study of 1 to 20 years.

    The main outcomes examined were self-harm, death by suicide, and death by any cause. People who did and did not receive psychological interventions were matched for various potentially confounding factors, including:

    • study period (1992 to 2000 or 2001 to 2011)
    • age
    • gender
    • educational level
    • socioeconomic status
    • previous episodes of self-harm
    • specific psychiatric diagnoses

     

    What were the basic results?

    The study included a total of 5,678 people in the psychological intervention group and 17,034 matched people who had not received a psychological intervention after self-harm. Around two-thirds were women and most were in the 15 to 49 age bracket. Around 10% had a previous episode of self-harm.

    During the first year of follow-up, 6.7% of people receiving a psychological intervention had a repeated self-harm attempt, compared with 9.0% of the no psychological intervention group. Psychosocial therapy was associated with a 27% reduced risk of self-harm within one year (odds ratio (OR) 0.73, 95% confidence interval (CI) 0.65 to 0.82). The absolute risk reduction (ARR), measuring how much the risk of self-harm is reduced in those who received the psychosocial therapy, was 2.3% (95% CI 1.5 to 3.1%). The number needed to treat (NNT) was 44 (95% CI 33 to 67), indicating that 44 people would need to receive psychosocial therapy after a self-harm attempt to prevent one person self-harming within one year.

    There was no significant difference between groups in rates of suicide within one year, but overall mortality rates within one year were slightly lower in the psychological intervention group (1,122 compared with 1,824 per 10,000), which also meant a significant reduction in overall mortality rate (OR 0.62, 95% CI 0.47 to 0.82). When considering the longer term effects over the full 20 years of follow-up, psychological intervention was associated with a 16% decreased risk of repeated self-harm (OR 0.84, 95% CI 0.77 to 0.91), with an ARR of 2.6% (95% CI 1.5to 3.7) and NNT of 39 people (95% CI 27 to 69).

    When looking at overall follow-up, psychological therapy was also associated with a 25% reduced risk of death from suicide (OR 0.75, 0.60 to 0.94), with an ARR of 0.5% (95% CI 0.1 to 0.9) and a NNT of 188 people to prevent one suicide (95% CI 108 to 725). It was also associated with significant reduction of death from any cause (OR 0.69, ARR 2.7%, NNT 37).

    The results altogether suggested that during the 20 years of follow-up, 145 self-harm episodes and 153 deaths were prevented by psychological interventions, with 30 of these deaths from suicide.

     

    How did the researchers interpret the results?

    The researchers conclude that their findings, “show a lower risk of repeated deliberate self-harm and general mortality in recipients of psychosocial therapy after short-term and long-term follow-up, and a protective effect for suicide after long-term follow-up, which favour the use of psychosocial therapy interventions after deliberate self-harm”.

     

    Conclusion

    The researchers report that this is the largest follow-up study of psychosocial interventions offered after deliberate self-harm attempts. Compared to standard care, it found that psychosocial interventions were associated with a reduced risk of repeated self-harm and death from any cause within the first year of follow-up. In the longer term, psychosocial interventions were associated with reduced risks of self-harm, death from any cause and suicide, specifically.

    The study benefits from its large sample size, long duration of follow-up and reliable methods of identifying participants and their outcomes. There are, however, some points to be considered when interpreting the findings.

    Possible selection bias

    The reasons that people did not receive a psychological treatment could have put them at higher risk of subsequent harm to start with, potentially explaining all or some of the risk difference between the two groups. Though the people who did and did not receive psychological treatments were matched for various factors, this may not have been comprehensive, and some selection bias may still be present. For example, all the people who were receiving psychological treatments had been referred to suicide prevention clinics because they were not considered to be in need of psychiatric admission or other outpatient treatment following their self-harm attempt. Meanwhile, those who did not receive psychological treatment were reported to include people who needed psychiatric admission, or chose not to receive suicide prevention treatment after their self-harm attempt.

    This makes it difficult to isolate the effect of the psychological intervention compared with selection biases and other confounding factors. It could be that the reduced risk seen in the psychological intervention group is not solely a result of the intervention, but that there were other risk factors among the non-treated group that were increasing their risk of further self-harm/suicide attempts and so confounding the association.

    However, some degree of selection bias is inevitable in this type of study. The only way to remove it completely would be to randomise people to treatment or no treatment, which could never be done for ethical reasons.

    Uncertainty about most effective intervention

    It is also difficult to conclude many treatment implications from this study in terms of what would be the best type of psychological intervention to use after a self-harm attempt (a wide variety of interventions were used in this study), whether the optimal type differs according to the individual (e.g. according to mental health diagnosis[es]), and what would be the optimal treatment duration.

    Results may not be applicable to the UK

    The results also apply to Denmark, which may differ from other countries – for example, in terms of healthcare and mental health services, and population health, psychosocial and environmental influences. This may mean that the results are less applicable to this country.

    People in the UK who present to health services following self-harm or a suicide attempt receive assessment by specialist mental health professionals, followed by referral, hospital admission or discharge, and follow-up care and treatment as appropriate to their individual situation.

    Getting help

    If you are reading this because you are having suicidal thoughts, try to ask someone for help. It may be difficult at this time, but it's important to know you are not beyond help and you are not alone.

    Speak to a person you trust (such as a friend or family member), make an urgent appointment with your GP or contact your local A&E department. The Samaritans (08457 90 90 90) also operates a 24-hour service available every day of the year.

    Read more about getting help for suicidal or self-harming thoughts, as well as spotting possible warning signs in family members and friends.

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

    Links To The Headlines

    Suicide risk reduced after talk therapy, study suggests. BBC News, November 24 2014

    Talking therapy 'can stop suicide'. Mail Online, November 24 2014

    Links To Science

    Erlangsen A, Lind BD, Stuart EA, et al. Short-term and long-term effects of psychosocial therapy for people after deliberate self-harm: a register-based, nationwide multicentre study using propensity score matching. The Lancet Psychiatry. Published online November 24 2014



  • Breastfeeding voucher scheme 'shows promise'

    "Initial results of a controversial scheme offering shopping vouchers to persuade mothers to breastfeed have shown promise," BBC News reports.

    The scheme, which has attracted controversy since it was announced, aimed to tackle the problem of low rates of breastfeeding in the UK compared with other developed nations. Mothers who live in the poorest areas of the country have been found to be more likely to prefer bottle feeding.

    This pilot scheme has tested whether it is possible to try to boost breastfeeding rates by offering new mothers shopping vouchers if they breastfeed their baby until specific ages.

    The scheme was available to just over 100 women who gave birth to babies over a six-week period and lived in three areas of Derbyshire and south Yorkshire. The breastfeeding rate in these areas at six to eight weeks was 21-29%.

    In the period where vouchers were available, 34.3% of women were breastfeeding at six to eight weeks. Both mothers and healthcare staff reported high levels of satisfaction with the scheme.

    The researchers report they are now planning further studies in the form of a randomised controlled trial to see how effective the voucher scheme is at boosting breastfeeding rates.

     

    Where did the story come from?

    The study was carried out by researchers from the University of Sheffield and was funded by the Medical Research Council National Prevention Research Initiative.

    The meeting abstract was published in the peer-reviewed medical journal, The Lancet.

    It has been published prior to being presented at The Lancet's annual conference on Public Health Science, held jointly with the London School of Hygiene and Tropical Medicine, University College London, the UK Health Forum, and in partnership with the European Public Health Association.

    The media reporting of the study was good, providing background information about the scheme and why some people are opposed to it – most critics have questioned why a scheme should reward mothers for doing the best for their child while penalising mothers who are unable to breastfeed.

    It is a fair point, though a pragmatic answer would be that it's not about the mother, but the child. Also, increased breastfeeding rates may lead to a reduction in the number of childhood illnesses the NHS has to deal with, so a voucher scheme could actually save the NHS money in the long term.

    But we will need to wait for the results of the planned randomised controlled trial before more detailed effectiveness and cost benefit information becomes available.

     

    What kind of research was this?

    This was a feasibility study to see whether it was both acceptable and possible to give women financial incentives to increase breastfeeding rates, prior to performing a randomised controlled trial to see if these financial incentives were effective. 

    The results of this study have been published in the form of a meeting abstract. This means the method and results are only described briefly, and a full appraisal of the strengths and limitations of the study can't be performed. This study is actually still ongoing and the results from some time points are still being collected.

     

    What did the research involve?

    The researchers wanted to test whether it was acceptable and possible to give women financial incentives for breastfeeding, as young women in deprived areas are less likely to breastfeed.

    They offered vouchers for breastfeeding to women with babies born within a 16-week period who lived in three neighbourhoods in Derbyshire and south Yorkshire, where breastfeeding rates were less than 30%.

    The vouchers were available when their babies were five different ages:

    • two days
    • 10 days
    • six weeks
    • three months
    • six months

    The vouchers were for supermarkets and high street shops for a value of £40 at each time point, so each woman could receive a maximum of £200.

    To receive the vouchers, the woman and her healthcare professional had to sign statements saying she had been breastfeeding.

    The researchers then interviewed 36 healthcare providers and 18 women to get their views on the scheme.

     

    What were the basic results?

    Fifty-eight of the 108 women (53.7%) who could have joined the scheme chose to do so.

    • 48 women (44.4%) claimed vouchers when their babies were two days old
    • 45 women (41.7%) claimed vouchers when their babies were 10 days old
    • 37 women (34.3%) claimed vouchers when their babies were six to eight weeks old

    The researchers are still collecting data for the three and six-month time points.

    Mothers and healthcare staff who participated reported high levels of satisfaction with the scheme.

     

    How did the researchers interpret the results?

    The researchers say that, "The scheme was both deliverable and acceptable to mothers and healthcare staff in this field of study.

    "The scheme was extended (and will continue until at least December 2014) in all three areas. A randomised controlled trial testing the effectiveness of the scheme is now planned."

     

    Conclusion

    This study tested whether it is possible and acceptable to try to boost breastfeeding rates by offering new mothers vouchers if they breastfeed their baby until specific ages.

    The scheme was available to just over 100 women who gave birth over a six-week period, and who lived in three areas of Derbyshire and South Yorkshire. In these areas, the breastfeeding rate at six to eight weeks was 21-29%.

    In the period where vouchers were available, 34.3% of women were breastfeeding at six to eight weeks. Both mothers and healthcare staff reported high levels of satisfaction with the scheme.

    The researchers report they are now planning a randomised controlled trial to see how effective the voucher scheme is at boosting breastfeeding rates.

    The results of this study have been published in the form of a meeting abstract. This means the methods and results are only described briefly, and a full appraisal of the strengths and limitations of the study can't be performed.

    Similarly, there is no information provided about the women who took part in the study, such as their age, medical history, family circumstances and support network.

    In addition, this study is actually still ongoing and the results from some time points are still being collected.

    Hopefully, the publication of the upcoming randomised controlled trial, which could be in either 2015 or 2016, will help assess how effective the scheme is and whether it is likely to be cost effective.

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

    Links To The Headlines

    Early results in breastfeeding vouchers trial. BBC News, November 20 2014

    Scheme offering shopping vouchers to mothers who breastfeed to be extended. The Guardian, November 20 2014

    NHS to 'bribe' thousands of mothers to breastfeed. The Daily Telegraph, November 20 2014

    Links To Science

    Relton C, Whelan B, Strong M, et al. Are financial incentives for breastfeeding feasible in the UK? A mixed methods field study. The Lancet. Published online November 19 2014



  • Air dryers 'blown away' by paper towels in germ tests

    "Hand dryers 'splatter' users with bacteria," The Daily Telegraph reports.

    The headline is prompted by an experimental study that compared the potential transfer of germs to the surrounding environment, users and bystanders when using three methods of hand drying:

    • paper towels
    • warm air dryers – the sort you see in most public toilets
    • modern "high-tech" jet air dryers, such as the Dyson Airblade model

    Testers wore gloves coated in a solution of bacteria. Air samples taken after drying with the hand dryers showed significantly higher bacterial counts than when drying with paper towels, and were highest for the jet air dryers.

    They then assessed the potential for spread to users and bystanders, this time using the proxy of gloves coated in black paint and a white body suit.

    They found there was no contamination of the body after towel drying, but paint spots were on the body after the use of air dryers, which again was higher with jet dryers than standard warm air dryers.

    One important limitation of this study is it essentially replicates the scenario of someone going to the toilet and then proceeding straight to the hand dryer without washing their hands first.

    A more suitable test may have been to coat the gloves with the marker, wash them with soap and water as recommended, and then proceed to the hand dryers.

    But the overall message of this study is consistent with current hand washing recommendations, including the use of disposable paper towels in healthcare settings.

     

    Where did the story come from?

    The study was carried out by researchers from the University of Leeds and the microbiology department at Leeds General Infirmary.

    It was funded by the European Tissue Symposium (ETS), from whom one author reports having received honoraria.

    The ETS produces paper tissue, including toilet paper, household towels and paper napkins, which may be seen as a potential conflict of interest.

    The study was published in the peer-reviewed Journal of Hospital Infection.

    The Daily Telegraph and the Mail Online's reporting was accurate, but neither appeared to have considered some of the limitations of this research.

     

    What kind of research was this?

    This was an experimental study that aimed to compare the tendency for three common hand drying methods – jet air, warm air hand dryers, and paper towels – to spread germs and contaminate the environment, users and bystanders.

    Like thorough hand washing, thorough hand drying is just as important to prevent the transfer of germs from person to person or the surrounding environment.

    According to hand washing protocols, the optimal way to dry hands is to use a disposable paper towel, which is then used to turn off the tap to avoid re-contaminating hands.

    The main concern with using hand dryers is that people may not dry their hands as completely as they would with paper towels, and may go away while they are still damp. If hand dryers are used, it is advised that the hands are rubbed together under the dryer until they are totally dry.

    However, another unclear and often speculated issue when using hand dryers is the possible transfer of aerosolised germs to the surrounding environment and people, possibly increasing the spread of infection.

    This study aimed to compare the different hand drying methods, looking at whether they can contaminate the surrounding environment, users and bystanders.

     

    What did the research involve?

    The researchers carried out a series of hand drying tests in a single room with standard ventilation (not air conditioned). They first tested the possible contamination of the environment, and then people.

    Gloved hands were immersed in a solution of lactobacilli bacteria (cultured from Actimel Danone yoghurt) before being dried with either:

    • a warm air dryer – hands were rubbed together for 30 to 40 seconds until dry
    • a jet air dryer – hands were placed into the unit and slowly drawn up and down for 15 seconds until dry
    • paper towels – four paper towels were taken from the dispenser and were rubbed over hands for 15 seconds until dry

    The tests were conducted over six weeks. A total of 120 air samples were taken – 60 made after drying contaminated hands (20 collections after each drying method: 10 in close proximity, 10 one metre away) and 60 control air samples taken before hand drying. Air samplers were left running for 15 minutes after each drying process. 

    They then repeated the tests, this time looking at the possible contamination of people standing nearby. This time, gloved hands were coated in black water-based paint rather than bacteria, and the user wore a disposable white hooded suit.

    Another bystander in a similar suit stood diagonally adjacent to the dryer user one metre away to replicate the scenario of another user waiting to dry their hands. There was a total of 30 drying tests in this manner, 10 for each drying method.

     

    What were the basic results?

    The researchers found the lactobacillus count in air samples taken in close proximity to the dryers were 4.5-fold higher for the jet dryer (70.7 colony forming units, or cfu) compared with the warm air dryer (15.7cfu), and 27-fold higher compared with paper towels (2.6cfu).

    Counts for the warm air dryer were also significantly higher than with paper towels.

    A similar pattern was seen for the air collection one metre away, where counts were 89.5cfu with the jet dryer, 18.7cfu with the warm air dryer, and 2.2cfu with paper towels.

    "Settle plates" underneath each hand dryer had the highest bacterial count for the warm air dryer (190cfu) compared with the jet air dryer (68.3cfu) and the paper towel drying (11.9cfu). Respective figures at plates one metre away were 7.8cfu, 2cfu and 0.7cfu. 

    As would be expected, the control air samples taken before drying found no lactobacilli.

    On the person-contamination experiments, no paint spots were seen on paper towel users. For both the jet air and warm air dryers, spots predominated in the upper body area, with the number of spots significantly higher with jet dryers (144.1) compared with warm air dryers (65.8).

    The number of paint spots was higher for all body areas with jet dryers, with the exception of both arms. With both hand dryers, however, there were relatively few paint spots remaining on the hands.

    The number of paint spots detectable on the bystander was generally low for both air dryers and was not significantly different between the two (average count 1.6 spots for jet dryers and 1.5 for warm air dryers).

     

    How did the researchers interpret the results?

    The researchers concluded that, "Jet air and warm air dryers result in increased bacterial aerosolisation when drying hands.

    "These results suggest that air dryers may be unsuitable for use in healthcare settings, as they may facilitate microbial cross-contamination via airborne [spread] to the environment or bathroom visitors."

     

    Conclusion

    Overall, this experimental study found the airborne spread of lactobacilli bacteria from contaminated hands was significantly higher with air dryers than with paper towels. Of the two, jet dryers caused higher air bacterial counts than standard warm air dryers.

    Similarly, when assessing spread on to the body of the user and bystander using the proxy measure of black paint dispersal, there was no contamination of the body with paper towels, but paint spots were on the body after use of air dryers, again higher with jet dryers than standard warm air dryers.

    It is well known that thorough hand drying is as key to preventing spreading infection as thorough hand washing. One of the recognised problems with hand dryers is that people may not dry their hands as completely as they would with paper towels.

    What is less clear, and is often speculated about, is the possible transfer of aerosolised germs to the surrounding environment and people, possibly increasing the spread of infection.

    This study appears to demonstrate cause for this concern. However, there are some points worth consideration when interpreting this study:

    • One important limitation of the study is it may not replicate the real-life condition of someone having just thoroughly washed their hands with soap and water, and then drying their hands. In this experimental situation, the users had gloved hands contaminated with either lactobacilli or black paint and then dried their hands. In effect, this may be seen more to replicate the scenario of someone going to the toilet and then proceeding straight to the hand dryer without washing their hands first. A more suitable test may have been to coat the gloves with either bacteria or black paint, wash them with soap and water as recommended, and then proceed to the hand dryers to see how many bacteria or paint were spread.
    • The spread of heavier black paint may also not be equivalent to the spread of viruses and bacteria, though it may represent the spread of water.  
    • Aside from the assessment of the surrounding environment and bystanders, another important area of consideration would also be to compare how much bacteria remained on the surface of the users' hands after drying with each of the three methods. This is of equal importance in knowing how much bacteria remains on the users' hands that could be transferred to other surfaces. It would be valuable to know whether there was any difference. This study has not specifically examined this aspect, though in fact it did note few paint spots remained on the hands after drying with either of the hand dryers.
    • It also would have been valuable to consider comparing the amount of bacteria or paint left on the towel dispenser or hand dryers after use, and how much of this would usually be transferred to the next person's hands during hand drying.

    Despite these limitations, the overall message of this study is consistent with current handwashing recommendations, particularly when it comes to healthcare settings.

    Of course, disposable paper towels are not available in all facilities. If only hand dryers are available, hands need to be rubbed together until they are completely dry.

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

    Links To The Headlines

    Hand dryers 'splatter' users with bacteria, scientists warn. The Daily Telegraph, November 20 2014

    Modern hand dryers are 'much worse' at spreading germs around a room than paper towels, study claims. Mail Online, November 20 2014

    Links To Science

    Best E, Parnell P, Wilcox MH. Microbiological comparison of hand-drying methods: the potential for contamination of the environment, user, and bystander. The Journal of Hospital Infection. Published online August 26 2014



  • Cancer guidelines may improve diagnosis rates

    “Doctors to get more help to spot cancer early,” The Guardian reports. The National Institute for Health and Care Excellence (NICE) has produced new revised draft guidelines that may help GPs pick up on possible early warning signs of cancer. 

    The aim of the draft guidelines is to improve early cancer diagnosis in children, young people and adults of all ages. The draft guidelines have been primarily written for GPs and are an update of the 2005 guidelines that were last partially updated in 2011.

     

    What are the possible early warning signs of cancer?

    It is misguided to think of cancer as a single disease. Cancer is an umbrella term for a wide range of different conditions, in the same way as the term “infection”.

    With that in mind, specific cancers can present with a wide range of symptoms, most of which are similar to trivial conditions, such as indigestion or a sprained joint.

    What you need to watch out for are symptoms that are:

    • persistent – last for more than two weeks
    • unexplained – there seems to be no logical reason why a symptom(s) develops

    Specific red flags you need to watch out for include:

    • cough that lasts longer than three weeks
    • unexplained and persistent changes in bowel habits, such as chronic diarrhoea or constipation
    • unusual bleeding, such as noticing blood in your stools or urine
    • you notice an unusual, irregular and possible itchy mole on your skin
    • unexplained weight loss

    Read more about possible early warning signs and symptoms of cancer

     

    What has prompted the recommendations?

    All NICE guidelines are updated every few years to ensure the recommendations have taken into account the latest evidence and any improvements in diagnostic techniques and treatments.

    Additional reasons for these particular guidelines to have been updated are that, as the media has pointed out, the UK is just missing its target of treating 85% of people with suspected cancer within 62 days (current reported figures are 82.5%). NICE reports that signs and symptoms of cancer can often be non-specific and overlap with other less serious conditions. They also say that each GP only sees, on average, eight new cases of cancer each year out of 6,000 to 8,000 appointments. As the appointments only last 10 minutes each, NICE wanted to provide practical guidelines for GPs to use to help them spot when to initiate further tests.

     

    What are the new recommendations and how do they differ from existing ones?

    The draft guidelines give clearer and updated information on the recognition of early signs and symptoms of over 200 different types of cancer and the criteria that warrant further investigations or referral to specialists. The threshold for whether a sign or symptom could indicate cancer has been lowered compared to the previous guidance.

    The main difference from before is that the information in the guidelines has been presented in a new format to make it easier to find the relevant recommendations. The information is laid out in tables according to particular symptoms, such as fatigue, cough or rectal bleeding, and tables according to the site of possible cancer, listing the typical signs and symptoms to look for. In each case, the next steps, such as investigations and referral thresholds, have been provided.

    The timing of referrals has been updated to include situations that warrant “very urgent” referrals, where a person should be seen within 48 hours. This is in addition to the previously described referral timings, such as “urgent” referrals, where a person needs to be seen within two weeks, and immediate referrals.

    Finally, there is a new section that covers patient information, support and safety netting.

     

    How accurate is the reporting?

    The Daily Telegraph’s rather alarmist headline that “tired patients should be fast-tracked for cancer tests” is not related to any new guidance. Persistent or unexplained fatigue has long been a recognised symptom of a number of cancers, including leukaemia in children and adults, lung cancer and ovarian cancer, and this recommendation was present in the original 2005 guidelines.

    In general, the media focussed on reporting the number of people who have not met the government target of treating 85% of people with suspected cancer within 62 days. NICE reports that research has estimated that late diagnosis contributes to between 5,000 and 10,000 deaths within five years of diagnosis per year.

    Somewhat tellingly, all of the UK media ignore the issue of overdiagnosis, which is where people undergo tests or diagnostic procedures that they don’t actually need. The natural assumption is probably to think “better safe than sorry”, but many diagnostic procedures themselves carry small risks of complications. For example, current evidence suggests that a colonoscopy (used to diagnosis bowel cancer) carries a one in 150 chance of causing excessive bleeding, a one in 1,500 chance of creating a hole in the wall of the bowel and a one in a 10,000 chance of causing death.

    Therefore, it’s important to be sure that the potential risk of a suspected disease is high enough to justify the risks associated with diagnosis.

     

    What happens next?

    The draft guidance is out for public consultation until Friday 9 January 2015. This means that any relevant patient groups, organisations, Clinical Commissioning Groups (CCGs) and other GP-led bodies can register and then comment on the:

    • new recommendations 
    • old recommendations that have been reviewed but remain unchanged
    • recommendations that are due to be removed

    These comments can then be taken into account before the final version of the guidelines are published, which is anticipated to be May 2015.

    The NICE draft guidelines are free to access online. After the consultation period, when the full guideline is published, it should guide patient care.

    Though it will give recommendations for which signs and symptoms should warrant further investigation or referral, NICE clearly states that “the guidance does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of each patient, in consultation with the patient and/or their guardian or carer”.

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

    Links To The Headlines

    Doctors to get more help to spot cancer early. The Guardian, November 20 2014

    GPs urged to double cancer referrals in NHS guidelines. BBC News, November 20 2014

    GPs told tired patients should be fast-tracked for cancer tests. The Daily Telegraph, November 20 2014

    Doctors to get fresh guidelines to help spot cancer early. ITV News, November 20 2014

    GPs To Get Better Cancer Diagnosis Guidelines. Sky News, November 20 2014

    GPs can't be expected to know every cancer symptom, Government says. The Independent, November 20 2014

    Doctors urged to test patients with coughs for cancer: GPs given guidance over fears they are dismissing early warning signs. Daily Mail, November 20 2014