"Adults who booze regularly but exercise for five hours a week are no more likely to die than teetotallers," the Mail Online reports.
A study suggests exercise may compensate for some, but certainly not all, of the harms associated with excessive alcohol consumption. This latest study looked at deaths from cancer and cardiovascular disease, as well as premature death in general (usually judged to be dying before the age of 75).
Researchers looked at around 10 years' worth of national survey data from UK adults aged over 40. Unsurprisingly, they found links between all-cause and cancer mortality in inactive people. But they also found increasing levels of physical activity generally removed the association with drinking habits. In fact, occasional drinking was associated with a significant reduction in all-cause mortality for the most active of people.
Although the study had strengths in its large sample size and regular follow-up, we can't be sure that any links observed were solely down to the interaction between alcohol and exercise. For example, people who are physically active may also avoid smoking and consume healthy diets. It is difficult to completely control for such influences when analysing data like this.
While regular exercise may mitigate against some of the harms associated with excessive alcohol consumption it certainly won't make you immune. Many world-class sportspeople, such as George Best and Paul Gascoigne, have had both their careers and lives blighted by drinking.
Where did the story come from?
The UK-based study was carried out by an international collaboration of researchers from Canada, Australia, Norway and the UK. The health surveys on which the study was based were commissioned by the Department of Health, UK. Individual study authors also reported receiving funding from the National Health and Medical Research Council and University of Sydney.
The study was published in the peer-reviewed British Journal of Sports Medicine.
The media coverage around this topic was generally overly optimistic, highlighting that by exercising, individuals can completely undo the harm caused by excessive alcohol consumption, which is untrue.
In particular, the Mail Online claimed "Adults who booze regularly but exercise for five hours a week are no more likely to die than teetotallers" which could send out the wrong message to the public.
What kind of research was this?
This cohort study analysed data from British population-based surveys: Health Survey for England (HSE) and the Scottish Health Survey (SHS) to investigate whether physical activity is able to moderate the risk between alcohol consumption and mortality from cancer and cardiovascular diseases.
Cohort studies like this are useful for assessing suspected links between an exposure and outcome. However, there are potentially other factors that have a role to play in such associations and therefore the study design doesn't allow for confirmation of cause and effect.
What did the research involve?
The researchers collected data on 36,370 men and women aged 40 or above from Health Survey for England (1994; 1998; 1999; 2003; 2004; and 2006) and the Scottish Health Survey (1998 and 2003). Among other things, the participants were asked about their current alcohol consumption and physical activity.
Alcohol intake was defined by six categories (UK units/week):
- never drink (lifetime abstainers)
- occasional drinkers (haven't drank anything in past seven days)
- within (previous) guidelines: <14 units (women) and <21 units (men)
- hazardous: 14-15 units (women) and 21-19 units (men)
- harmful: >35 (women) and >49 (men)
Frequency and type of physical activity in the past four weeks was questioned and converted into metabolic equivalent task-hour (MET-hours, which are an estimate of metabolic activity) per week according to national recommendations:
- inactive (≤7 MET-hours)
- lower level of active (>7.5 MET-hours)
- higher level of active (>15 MET-hours)
The surveys were linked to the NHS Central Register for mortality data and the participants were followed up until 2009 (HSE) and 2011 (SHS). There were 5,735 recorded deaths; deaths from cancer and cardiovascular disease were of most interest for this study.
The data was analysed for associations between alcohol consumption and the risk of death from all-causes, cancer and cardiovascular disease. The results were then analysed according to levels of physical activity.
Potential confounders (such as sex, body mass index and smoking status) were controlled for.
What were the basic results?
Overall, the study found a direct link between all levels of alcohol consumption and risk of cancer mortality. It also found that increasing levels of physical activity reduced this association with cancer mortality, and also reduced the link with death from any cause.
- In individuals who reported inactive levels of physical activity (≤7 MET-hours), there was a direct association between alcohol consumption and all-cause mortality.
- However, in individuals who met the highest level of physical activity recommendations a protective effect of occasional drinking on all-cause mortality was observed (hazard ratio: 0.68; 95% confidence interval (CI): 0.46 to 0.99). It should be noted that this result just skimmed the cut-off point for statistical significance.
- In this high activity group, there was no link between all-cause mortality and alcohol consumption within guidelines, or even hazardous amounts, but the risk was still increased for those drinking harmful amounts.
- The risk of death from cancer increased with the amount of alcohol consumed in inactive participants, ranging from a 47% increased risk for those drinking within guidelines to 87% increased risk for those with harmful drinking.
- In people with higher activity levels (above 7.5 MET hours) there was no significant link between any amount of alcohol consumption and cancer mortality.
- No association was found between alcohol consumption and mortality from cardiovascular disease, although a protective effect was observed in individuals who reported the lower and higher levels of physical activity (>7.5 MET-hours) and (>15 MET-hours) respectively.
How did the researchers interpret the results?
The researchers concluded "we found evidence of a dose–response association between alcohol intake and cancer mortality in inactive participants but not in physically active participants. [Physical activity] slightly attenuates the risk of all-cause mortality up to a hazardous level of drinking."
This study aimed to explore whether physical activity is able to moderate the risk between alcohol consumption and mortality from cancer and cardiovascular diseases. It found that increasing levels of physical activity reduced the association for death from both all-causes and cancer.
This study has strengths in its large sample size, comprehensive assessments and long duration of follow-up. The findings are interesting, but there a few points to bear in mind:
- As the authors mention, cohort studies such as this are unable to confirm cause and effect. Though the researchers have tried to account for various potential health and lifestyle confounding variables, there is the possibility that others are still influencing the results. A notable one is dietary habits which weren't assessed. Also, for example, the former drinkers may have quit due to other health issues which may have introduced bias.
- The study was unable to look at binge drinking levels of alcohol consumption which would have likely had important health implications.
- Additionally, there is always the possibility with self-reported surveys that the participants either under or over-reported their drinking habits which can increase the chance of misclassification bias.
- Though having a large sample size, fewer people reported harmful drinking levels, so links within this category may be less reliable.
- The study has only looked at the link between alcohol and actually dying from cancer or cardiovascular disease. Links may be different if they looked at associations between alcohol and just being diagnosed with cancer or heart disease, for example.
- The study is also only representative of adults over the age of 40.
Overall, maintaining a healthy lifestyle seems to be the best bet for reducing the risk of any chronic disease, be it through physical activity, balanced diet or reasonable alcohol consumption.
Current alcohol recommendations for both men and women are to drink no more than 14 units per week.
Links To The Headlines
Two hours a week of exercise could offset the dangers of alcohol. The Daily Telegraph, September 8 2016
Exercise can cut risk from alcohol-related diseases, study suggests. The Guardian, September 8 2016
Links To Science
Perreault K, Bauman A, Johnson N, et al. Does physical activity moderate the association between alcohol drinking and all-cause, cancer and cardiovascular diseases mortality? A pooled analysis of eight British population cohorts. British Journal of Sports Medicine. Published online August 31 2016
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"Toddlers should be screened for an inherited form of heart disease … experts suggest," BBC News reports.
A new study looked at the feasibility of screening for familial hypercholesterolaemia (FH), an inherited condition that affects around 1 to 2 in every 250 people in the UK. It can cause abnormally high cholesterol levels.
It doesn't usually cause any noticeable symptoms, but people with FH aged between 20 and 40 are 100 times more likely to have a heart attack than other people their age.
UK researchers tested 10,095 one-year-olds to explore the feasibility of screening for FH. They tested the toddlers at the same time they had routine vaccinations at the age of one.
Researchers found 28 children with FH. The parents of children with FH were then also tested.
The study found not all children with an FH mutation had high cholesterol, however, and some with high cholesterol did not have a known FH mutation.
This means FH mutation testing alone would not be a useful screening test, so the researchers suggest testing cholesterol levels first.
The approach used in the study does have the added benefit of identifying parents with FH who didn't realise the condition ran in their family.
Once FH is diagnosed, it is relatively straightforward to treat through making lifestyle changes and taking drugs known to reduce cholesterol, mainly statins.
This research will help inform the UK's National Screening Committee when considering whether the benefits of screening for FH outweigh the harms.Where did the story come from?
The study was carried out by researchers from Queen Mary University of London and Great Ormond Street Hospital, and was funded by the UK Medical Research Council.
It was published in the peer-reviewed New England Journal of Medicine.
The UK media focused on figures indicating that 600 heart attacks a year could be prevented by the screening strategy. These figures, which were not quoted in the study, seem to have been an estimate made by reporters.
There's some confusion over other figures, with different news reports citing different results. That's because the researchers investigated two different cut-off points for high cholesterol.
The cut-off actually used in the study identified 28 children (0.3%), while the researchers say that if they'd used a lower cut off, it would have identified 40 children, or 0.4%.
The researchers concluded that for every 1,000 children screened, four children and then four adults would be diagnosed with FH.What kind of research was this?
This was a real-world trial of a screening strategy to see whether it was feasible, and how effective it would be at identifying people with FH.
It can't really tell us how many heart attacks might be prevented by screening. This is because it only looked at the number of people identified by the screening test, not at what happened to them afterwards or what would have happened if they'd not been identified.What did the research involve?
Researchers asked parents bringing their children for vaccination at 92 GP surgeries in the UK if they'd like their children to be screened for high cholesterol as well.
If parents agreed, the children had a small blood sample taken, which was tested for both cholesterol levels and known FH genetic mutations.
Children with high cholesterol and an FH mutation were classed as having FH, and their parents were then tested. Children with high cholesterol and no known FH mutation had a second cholesterol test.
Rather than using a standard cholesterol level as used to test adults, researchers used a measure called multiple of median.
This looks at the average (median) cholesterol score of the children – the researchers then identified children whose score was 1.53 times the average.
This method was used because the estimated optimal cholesterol levels in children are not as well established as in adults.
The researchers searched for common genetic mutations using a quick identification test first, then used more advanced genetic sequencing if children had high cholesterol but no common mutation.
Children were identified as having FH if they had high cholesterol and an FH mutation, or two tests showing high cholesterol.
The parents of these children were then tested, and the parent thought to have FH was offered treatment with statins.
Children who had an FH mutation but low cholesterol were not identified as having FH as the condition only causes problems when people have high cholesterol.
And those who had high cholesterol on two tests but no known FH mutation were assumed to have a mutation that has not yet been identified.What were the basic results?
Of the 13,000 children whose parents were invited to take part in the study, 11,010 (84%) agreed to take part.
However, 892 blood tests couldn't be used and 23 results were found to have been wrongly recorded, so the researchers based their research on the 10,095 remaining results.
With the cut-off of cholesterol 1.53 times the median score, the researchers found:
- 28 children with FH (0.3%, 95% confidence interval [CI] 0.2 to 0.4)
- 20 children with a known FH mutation
- 17 children with an FH mutation, but cholesterol lower than the 1.53 times average score
- 28 parents of children with FH were identified as also having FH, 25 of whom started treatment to lower cholesterol
The researchers then re-ran the figures to see what would have happened if they'd used a lower cut-off cholesterol level of 1.35 times median score, and only tested for FH mutation in those with cholesterol above that level.
They calculated that they would have found 40 children, 32 of them with an FH mutation, and 40 parents.
The study suggests 3 to 4 in 1,000 people have FH.How did the researchers interpret the results?
The researchers said screening children – and subsequently parents – at the same time as vaccinating children in GP surgeries was "a simple, practical and effective way of screening the population to identify and prevent a relatively common inherited cause of cardiovascular disease".
They say it's better to think of FH as "a marker that indicates an increased risk" of heart disease, as not everyone with FH mutations has high cholesterol, and not everyone with high cholesterol has heart disease.Conclusion
There's little doubt that FH is a cause of early unexpected heart attacks, and many people who have the condition are unaware of it.
At present, people are only screened for FH after a close relative, such as a parent or sibling, has a heart attack at a young age (cascade screening).
This study suggests far more people would be diagnosed if one-year-olds were screened routinely during vaccinations and the parents of children identified as having FH were then tested.
However, before introducing a screening test, it's important to be sure it has more benefits than harms.
We don't know from the results of this study what the long-term outcome of screening would be – for example, whether it will definitely reduce the number of heart attacks.
Is the cost to the NHS of screening tens of thousands more people every year outweighed by the possible reduction in heart attacks?
The test could also cause problems. If a one-year-old is identified as having FH, it's an extra cause of worry for parents at an age when the child is not likely to see any ill effects and is too young for treatment.
Is that extra worry justified by being able to offer treatment later in life, which may or may not reduce their chances of a heart attack?
Importantly, we also need to know how accurate the test is. In the study, FH was defined as cholesterol 1.5 or 1.3 times that of the average. But what does that actually mean in practical terms?
We don't know whether the children in the study with cholesterol 1.3 times that of others their age will grow up to have heart disease.
The researchers acknowledge that by defining FH as having a certain cholesterol level, they are making a self-sustaining argument. If a condition is defined as being the same as a test result, then how do we challenge the accuracy of the test?
This study doesn't answer these difficult questions. But they need to be considered by the UK's National Screening Committee before any new screening programme can be introduced.
At present, guidance (PDF, 124kb) from the National Institute for Health and Care Excellence (NICE) recommends only screening if someone has one or more close relatives that have had a heart attack at an early age.
If you're worried about FH, talk to your GP to see if you're eligible for cholesterol testing and tests for FH mutations.
Links To The Headlines
Toddlers 'should get heart risk test'. BBC News, October 27 2016
Test cholesterol of one-year-olds to prevent early heart attacks, study suggests. The Guardian, October 27 2016
Children should be tested for heart disease at 12 months old to prevent future heart attacks. The Daily Telegraph, October 26 2016
Links To Science
Wald DS, Bestwick JP, Morris JK, et al. Child–Parent Familial Hypercholesterolemia Screening in Primary Care. The New England Journal of Medicine. Published online October 27 2016
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"A new form of therapy has for the first time been shown to improve the symptoms and behaviour of autistic children," The Guardian reports.
A new trial looked at the impact of early intervention in children with severe autism. This programme of treatment aimed to mainly focus on the parents, who were trained to pick up on communication cues from their child, which are usually much more subtle than in other children.
For example, a small shift in head movement could be a sign that the child wanted to communicate.
The hope is that once parents receive sufficient training they can then provide "around the clock" therapy to their child rather than one-off sessions provided by external therapy.
The programme, Parent-mediated social communication therapy for young children with autism (known as PACT), showed early promise. The children of parents who took the course showed improvements in symptoms such as communication and repetitive behaviour after one year. This study tested the children again, five to six years after the end of treatment, to see if the effects had lasted.
The children in the PACT group had on average lower symptoms scores for autism when compared to those who had normal care. But the difference was small enough that it could have been down to chance (it wasn't statistically significant). That doesn't mean the treatment didn't work, but arguably suggests the PACT programme should be now tested in larger groups of families affected by autism.
Where did the story come from?
The study was carried out by researchers from Kings College London, Newcastle University, the University of Manchester and Guys and St Thomas University NHS Trust and was funded by the Medical Research Council, Department of Health and National Institute of Health Research.
Most of the UK media reports were enthusiastic. The Daily Telegraph called it "the first successful treatment for autism" while The Guardian reported a "potential breakthrough".
But at the risk of sounding like a kill-joy, none of the media sources mentioned that the main finding of the study was not statistically significant.
Many made the effort to include some useful feedback and commentary from independent experts. For example, Dr James Cusack, the director of science at the charity Autistica, was quoted widely, saying: "Too often, parents fall victim to the false claims of charlatans who prey on desperate families.
"These results look promising for the many thousands of parents who want to find early interventions for their children based on solid science,"
What kind of research was this?
This was a long-term follow up of a randomised controlled trial. These types of studies are usually good ways to assess the effects of treatments.
What did the research involve?
Researchers randomly divided parents of pre-school children with autism into two groups.
One group of 75 had normal care, while in the other group, 77 parents were coached in how to communicate better with their children, using videos of play sessions to spot opportunities for communication.
The programme, called PACT, lasted for a year.
Five to six years later, researchers contacted the families again and asked them to have follow-up tests of autism symptoms.
They compared the results from the group who'd had normal care with those who'd had PACT.
In the PACT training, parents were coached to recognise what might be very subtle clues that their children wanted to engage with them and then respond appropriately, in a way that was intended to help children learn social interaction and language.
They had 12 two-hour coaching sessions over six months, then a further six support sessions over six months.
Unlike many treatments for autism, therapists worked with the parents rather than directly with the children. The aim was to produce long-lasting improvements, by changing the children's home environment.
Children were aged between two and four years 11 months when they started in the study. The average age at follow-up was 10 and a half.
Follow up assessments for the main results were done by researchers who didn't know which treatment group the children had been in.
The researchers also asked parents about their children's symptoms and behaviour.
They analysed the data in different ways, but the main result was a change in autism symptom score severity.
They looked at children's scores at the start of the study, after the 12 month treatment period, and at follow up.
What were the basic results?
The original study showed that children in the PACT group had a bigger improvement in symptom scores after treatment, compared to those who'd had usual care.
At follow-up, both groups of children had worse scores than immediately after the study.
There was still a difference between the groups, but it was no longer statistically significant.
That means we cannot be sure that, five years on from treatment, PACT improved average symptom scores more than normal care.
Average scores (1 to 10, higher being more severe) were:
- 8.0 for PACT and 7.9 for usual care at the start of the study
- 6.7 for PACT and 7.3 for usual care immediately after the study
- 7.3 for PACT and 7.8 for usual care at follow-up
Fewer children in the PACT group had severe symptom scores at follow up (46%) than those who'd had usual care (63%).
The difference between the groups was too small to be sure this was not simply a chance finding (group difference 17.2%, 95% confidence interval [CI] -2.9 to 37.3).
However, looking at the combined mean symptoms scores from immediately after the study and at follow-up compared to baseline (before treatment), the results show a statistically-significant moderate effect in favour of PACT treatment (effect size 0.55, 95% CI 0.14 to 0.91).
How did the researchers interpret the results?
The researchers say their results "are encouraging and provide evidence that sustained changes in autism symptoms can be possible after early intervention," in a way that has not been shown before.
They go on to say that "on the basis of these results, we are now able to support the use of the PACT intervention for reducing symptoms of autism in young children".
They caution that the treatment has not yet been tested in older children, or in children with autism spectrum disorder, rather than "core" autism.
This study seems to provide some much-needed good news for parents of children with autism, and has been welcomed by experts and campaigners. However, the lack of statistical significance of some of the results mean we can't be sure the findings are reliable.
Statistical significance is a way of including a margin of error in calculations and allowing for chance. So the "true result" for PACT could be between 6.3 and 8.3, and the true results for usual care could be between 6.9 and 9.6. As these results overlap, we can't be sure that PACT treatment led to better scores.
One expert said that the main outcome measure of the autism symptom scale is "insensitive to change" meaning that it may not be the best way to show improvements. Another said the effects of PACT in the study were "not dramatic" and "very variable" across the group of children.
However, most seem to think that the results are promising, especially for an intervention that does not require the intensive time and commitment of some other autism treatments.
The National Institute for Health and Care Excellence says "social communication interventions" should be considered for children with autism, although it doesn't mention PACT specifically.
Hopefully further trials of PACT in larger groups of parents will point to a significant improvement in autism symptoms.
Links To The Headlines
Study offers potential breakthrough in care of children with autism. The Guardian, October 25 2016
'Super-parenting' improves children's autism. BBC News, October 26 2016
First ever treatment for autism leads to improved social communication and reduced repetitive behaviours. Daily Mirror, October 26 2016
Scientists hail first successful treatment for children with autism. The Daily Telegraph, October 26 2016
Communication and play therapy reduces autism symptoms, study finds. ITV News, October 26 2016
‘Super-parenting’ is the first therapy ‘that actually helps BEAT autism’. The Sun, October 26 2016
Links To Science
Pickles A, Le Couteur A, Leadbitter K, et al. Parent-mediated social communication therapy for young children with autism (PACT): long-term follow-up of a randomised controlled trial. The Lancet. Published online October 25 2016
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