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NHS Choices News

  • Combined Pill may raise breast cancer risk

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

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

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

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

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

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

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

     

    Where did the story come from?

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

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

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

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

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

     

    What kind of research was this?

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

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

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

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

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

     

    What did the research involve?

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

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

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

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

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

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

     

    What were the basic results?

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

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

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

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

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

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

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

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

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

     

    How did the researchers interpret the results?

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

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

     

    Conclusion

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

    Links To The Headlines

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

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

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

    Links To Science

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



  • Study probes effect of NHS Health Checks

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

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

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

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

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

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

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

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

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

     

    Where did the story come from?

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

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

     

    What kind of research was this?

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

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

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

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

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

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

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

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

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

     

    What did the research involve?

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

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

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

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

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

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

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

     

    What were the basic results?

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

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

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

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

     

    How did the researchers interpret the results?

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

     

    Conclusion

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

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

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

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

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

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

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

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

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

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

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

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

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

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

    Links To The Headlines

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

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

    Links To Science

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



  • Warning over waistline link to type 2 diabetes

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

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

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

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

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

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

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

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

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

     

    Who produced the report?

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

     

    What is the aim of the report?

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

     

    Diabetes

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

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

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

     

    Link between obesity and diabetes

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

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

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

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

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

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

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

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

     

    Prevalence of obesity and diabetes

    The report states that in 2012:

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

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

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

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

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

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

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

     

    Other risk factors

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

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

     

    Health implications

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

    It can also result in lower life expectancy.

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

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

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

     

    Cost

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

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

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

     

    What is to be done?

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

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

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

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

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

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

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

    Links To The Headlines

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

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

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



  • Could a blood test screen for suicide risk?

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

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

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

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

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

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

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

     

    Where did the story come from?

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

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

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

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

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

     

    What kind of research was this?

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

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

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

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

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

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

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

     

    What did the research involve?

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

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

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

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

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

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

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

     

    What were the basic results?

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

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

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

     

    How did the researchers interpret the results?

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

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

     

    Conclusion

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

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

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

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

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

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

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

    Links To The Headlines

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

    Links To Science

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



  • Ebola virus threat to the UK is 'very low'

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

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

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

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

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

     

    What is Ebola?

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

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

     

    What are the symptoms of Ebola virus?

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

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

     

    How is the Ebola virus spread?

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

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

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

    Other ways people can catch the virus include:

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

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

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

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

     

    Who's at risk from Ebola?

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

     

    How is Ebola diagnosed?

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

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

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

     

    What are the treatments for Ebola?

    There's currently no specific treatment or cure for the Ebola virus, although potential new vaccines and drug therapies are being developed and tested.

    Patients need to be treated in isolation in intensive care. Dehydration is common, so fluids may be given intravenously (directly into a vein). Blood oxygen levels and blood pressure will be maintained at the correct level, and the body organs supported while the patient recovers.

     

    What is the risk of Ebola in the UK?

    The risk to the UK is thought to be very low and there have been no reported cases.

    While it is theoretically possible someone with the virus could arrive in the UK, health professionals have been told to watch out for any patient presenting with unusual symptoms.

    If this happened, the infected person would then be quickly admitted to hospital and quarantined, as was the case with a man who arrived in the UK and then developed Middle East Respiratory Syndrome in 2012.

    Ebola virus is not airborne, so there is no credible risk of a swine flu-like global pandemic.

    You cannot catch Ebola by travelling on a plane with someone who is infected, unless you come into very close physical contact with them, such as kissing.

     

    What precautions are being taken?

    Public Health England (PHE), the body responsible for public health in England, has told health professionals about the situation in west Africa and asked for vigilance about unexplained illness in people who have visited the affected area.

    PHE has provided advice for humanitarian workers planning to work in affected areas. It is also working with people from Sierra Leone living in England.

    Advice has already been issued to immigration removal centres on carrying out health assessments for people who may have been in Ebola outbreak areas within the preceding 21 days.

    And PHE is liaising with the UK Border Agency and port health authorities to update guidance for staff working in airports and ports.

    Dr Brian McCloskey, PHE's director of global health said: "The risk to UK travellers and people working in these countries of contracting Ebola is very low.

    "People who have returned from affected areas who have a sudden onset of symptoms such as fever, headache, sore throat and general malaise [sense of feeling unwell] within three weeks of their return should immediately seek medical assistance." 

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

    Links To The Headlines

    Ebola virus outbreak: live. The Daily Telegraph, July 31 2014

    Ebola virus: what is the real risk to the UK? The Guardian, July 31 2014

    Truth about incurable virus that's just one plane ride from Britain: Experts say statistics show Ebola WILL reach Britain. Mail Online, July 31 2014