NHS Choices

'Magic mushrooms' may help 'reset' depressive brains, study claims

NHS Choices - Behind the Headlines -

"Magic mushrooms can 'reboot' brain to treat depression," reports the Daily Telegraph.

The news is based on a small UK study that looked at the effects of psilocybin, a chemical found in magic mushrooms, on patients with severe depression.

All 19 patients said their depression improved immediately after taking psilocybin and almost half said they still felt the benefits 5 weeks later.
However, the study didn't include a comparison group, so it's hard to know whether this benefit can be attributed to the chemical.

The patients were also given special psychological care during and after taking psilocybin, as an integral part of their treatment.

The effects of psilocybin were measured using a functional MRI scan, an advanced MRI machine that measures blood flow in the brain.

The researchers believe psilocybin helps to change how networks of nerves communicate in the brain, which might disrupt negative thought patterns.

The suggestion of "re-setting" or "rebooting" the brain is attractive in an age when we are all used to fixing computers by turning them off and on again.

However, we need to see further, larger studies to know whether this treatment offers a comparable solution to the brain as the off switch does for computers.

The authors of the study warn that people with depression should not try psilocybin or other psychedelic drugs to treat themselves.

Psilocybin and the mushrooms that contain it are illegal to possess, give away or sell in the UK, outside of clinical trials. They could be dangerous if used without medical support.

Where did the story come from?

The researchers were mostly based at Imperial College in London, with some at Hammersmith Hospital, Cardiff University and University College London. The study was published in the peer-reviewed journal Nature Scientific Reports and is free to read online.

Although for the most part the UK media reported the study accurately, none of the reports pointed out the lack of comparison group in the study, which makes it hard to attribute the study results to the drug. The Guardian otherwise gave a good explanation of the study methods and results.

The Mail Online carried comments from the researchers suggesting that people in the study had reduced depression six months later, but this information was not included in the study so can't be checked.

The Independent wrongly stated that the study showed: "Eating magic mushrooms can help treat depression," and wrongly claimed that the researchers gave mushrooms to patients, rather than administering the extract psilocybin.

What kind of research was this?

This was a small experimental study with no control group. The researchers wanted to see how psilocybin affected brain activity and if that was linked to depression.

This type of study can yield interesting information in the early stages of exploring potential medical treatments, but needs to be backed up by more reliable randomised controlled trials (RCTs) before we can say whether the treatment works.

What did the research involve?

Researchers recruited 20 patients with depression that no longer responded to standard antidepressants. They scanned their brains and measured their depression using a symptom questionnaire. They then administered two doses of psilocybin, one week apart.

They scanned the participants' brains and measured depression symptoms the day after the second treatment, then measured depression symptoms again 5 weeks later.

Finally, the researchers looked to see whether the brain scans showed differences in activity before and after taking psilocybin, and whether these changes were linked to people's depression scores.

The brain scans used functional MRI. They measured two things:

  • cerebral blood flow – how much blood flowed around the brain. This is used as a general measure of brain activity
  • resting state functional connectivity. This is used to monitor how much activity takes place through nerve networks in different areas of the brain. The researchers focused on four areas that had previously been identified as potentially important

Depression was measured using the Quick Inventory Depression Score (QIDS-SR16). Psilocybin doses were 10mg followed by 25mg. Patients were given psychological support during and after taking their medication.

The researchers analysed whether changes seen on brain scans correlated with depression symptom scores the day after the second treatment, and with patients' chances of showing a treatment response 5 weeks later. A positive treatment response was defined as a halving of their initial QIDS-SR16 score.

What were the basic results?

One person dropped out of the study, and some of the brain images were not good enough quality to use. Of the 19 patients who took part in the whole study, all had improved QIDS-SR16 scores on the day after the second treatment, and in 47% the effects were still there after 5 weeks.

Based on brain scans from 16 people, the researchers said that cerebral blood flow to the brain was decreased the day after the second treatment, compared to before treatment. They said they found no instances where blood flow increased.

They said that comparisons between blood flow to the amygdala (an area of the brain that controls many emotions, such as fear and stress) and symptom scores the day after scanning showed a "significant relationship" between the two.

Based on brain scans from 15 people, the researchers said that resting-state functional connectivity increased in two of the regions studied, and decreased in one region. They found no difference in connectivity in a fourth region.

For the three regions that did show changes, two of them were linked to a positive treatment response at 5 weeks. None of the brain regions showed changes that correlated with improved symptom scores the day after treatment.

How did the researchers interpret the results?

The researchers said their findings suggested that psilocybin might have a similar action to electroconvulsive therapy (ECT).

They say their findings showed that "default mode network" – the resting patterns of connectivity between brain regions – may have "decreased acutely, then increased (or normalised) post-acutely, accompanied by improvements in mood. This process might be likened to a 'reset' mechanism."

They call for further testing to assess the "relative contributions" of psilocybin and the accompanying psychological support.

Conclusion

For people with depression who are not helped by conventional treatment such as antidepressants and talking therapies, studies such as this one may offer a glimmer of hope. This and previous studies on psilocybin suggest it may one day become a treatment option for people with a range of psychiatric conditions.

It's important to note that this is experimental, early-stage research. The study lacked a control group, so it's hard to know whether the improvement in mood, or the changes seen on MRI scans, can be attributed to the drug.

The study is very small and we should bear in mind that half of those taking part did not see a 50% reduction in depression symptoms after 5 weeks, suggesting they gained little real benefit.

Changes in brain function may help explain the effect of psilocybin and similar drugs. Previous studies with healthy (non-depressed) volunteers have shown changes in brain function after people took psychedelic drugs.

The suggestion of a "re-set" or "reboot" sounds plausible, especially in an age when we are all used to fixing computers by turning them off and on again. The idea of temporarily "powering down" the brain to fix problems is intuitively easy to grasp. However, we need to see further studies to know whether this treatment offers a comparable solution to the brain as the off switch does for computers.

Your GP is the first port of call if you have, or think you may have, depression. We strongly advise against self-medicating with any drug for depression. Psilocybin and magic mushrooms are class A drugs in the UK.

Links To The Headlines

Magic mushrooms can 'reset' depressed brain. BBC News, October 14 2017

Magic mushrooms can 'reboot' brain to treat depression - study. The Daily Telegraph, October 14 2017

Eating magic mushrooms can treat depression, study finds. The Independent, October 14 2017

Magic mushrooms may 'reset' the brains of depressed patients, study shows. Mail Online, October 13 2017

Magic mushrooms 'reboot' brain in depressed people – study. The Guardian, October 13 2017

Links To Science

Carhart-Harris RL, Roseman L, Bolstridge M et al. Psilocybin for treatment-resistant depression: fMRI-measured brain mechanisms. Scientific Reports. Published online on October 13 2017

Hormonal fertility tests 'waste of time and money'

NHS Choices - Behind the Headlines -

"'Fertility MOTs' are a waste of money," reports The Daily Telegraph after researchers in the US found hormones tested in "ovarian reserve" fertility test kits bear no relation to how likely women were to get pregnant – at least, in the early months of trying to conceive.

These tests usually measure the levels of three hormones:

  • anti-mullerian hormone (AMH)
  • follicle-stimulating hormone (FSH)
    inhibin B

All of these hormones have been linked to measures of a woman's "ovarian reserve" – how many viable eggs she has left in her ovaries.

Researchers analysed hormone levels from 750 women aged 30 to 44 who'd been trying to get pregnant for three menstrual cycles or less.

They followed the women for 12 cycles to see how many got pregnant.

After taking account of factors including the women's age, they found hormone levels didn't affect the women's chances of becoming pregnant in any given cycle.

Levels of AMH decline over time and become undetectable at menopause, when a woman's egg supply is exhausted.

But the results of this study suggest it doesn't matter how many eggs a woman has in reserve to get pregnant – as long as she's still releasing eggs regularly.

There seems to be little reason for women to be offered these tests, which can cost more than £100 a time, unless they're undergoing fertility treatment, when the tests are used to help plan and predict IVF results.

 

Where did the story come from?

The study was carried out by researchers from the University of North Carolina, the University of Southern California, Duke University, the National Institute of Occupational Safety and Health, and the National Institute of Environmental Health Science, all in the US.

It was funded by the US National Institutes of Health.

The study was published in the peer-reviewed Journal of the American Medical Association (JAMA).

The UK media's reporting was reasonably accurate and balanced. Most headline writers focused on the cost of the tests, describing them as a "waste of money".

But the tests could also cause unnecessary emotional distress if they wrongly suggest a woman's fertility is lower or higher than it actually is.

 

What kind of research was this?

This prospective cohort study set out to learn whether women with high or low levels of specific hormones were more or less likely to get pregnant over a given period of time.

This type of study is useful for showing us whether there's a link between one factor (hormone levels) and another (pregnancy).

 

What did the research involve?

Researchers recruited 981 volunteers to take part in the study. After excluding those who didn't meet the criteria or withdrew or got pregnant before the study started, 750 women were left.

The women filled out questionnaires, and had blood and urine samples taken to test their hormone levels.

They also filled out diaries documenting menstrual bleeding, when they had sex, and the results of pregnancy tests.

The women were followed up for 12 months. Researchers adjusted their figures to take account of confounding factors, and then looked at whether hormone levels were linked to the women's chances of getting pregnant after 6, 12, or any given cycles.

Women were only included in the study if they were aged 20 to 44, had been trying to get pregnant for three cycles or less, had no history of fertility problems, and were living with a male partner.

Researchers defined normal AMH as above 0.7ng/ml, based on previous research. Normal FSH – which is higher in older women – was defined as below 10mIU/ml.

It's not currently clear if there's such a thing as a normal inhibin B level and what that would be, so the researchers considered this a continuous variable.

The outcomes measured were the cumulative probability of conception (measured by a positive pregnancy test) after 6 or 12 menstrual cycles.

The researchers took account of these potential confounding factors:

  • age
  • body mass index
  • race
  • smoking status
  • use of hormonal contraceptives in the past year

 

What were the basic results?

Of the 750 women in the study, 65% got pregnant, 17% didn't get pregnant, and the remainder dropped out before 12 months (for example, because they started fertility treatment).

After adjusting for confounding factors, the predicted probability of getting pregnant after 6 or 12 cycles wasn't lower for women who had low AMH or high FSH, and wasn't linked to inhibin B levels.

Looking at AMH:

  • 65% of women with low AMH were predicted to get pregnant within six cycles, compared with 62% with normal AMH
  • 84% of women with low AMH were predicted to get pregnant within 12 cycles, compared with 75% with normal AMH
  • the chances of getting pregnant in any given cycle was no different for women with low and normal levels of AMH (hazard ratio 1.19, 95% confidence interval 0.88 to 1.61), so the result wasn't statistically significant

Researchers also looked at different age groups to see if hormone levels made more of a difference to younger or older women. They found low AMH wasn't linked to lower chances of pregnancy in any age group.

 

How did the researchers interpret the results?

The researchers said their results were "surprising". They'd anticipated there would be a difference in fertility levels by hormone level, but say the results suggest there "may be little association between a woman's ovarian reserve and factors affecting fertility, such as egg quality".

They said their findings "do not support the use of urinary or blood FSH tests or AMH levels to assess natural fertility" for women aged 30 to 44 without fertility problems who have been trying to get pregnant for three cycles or less.

 

Conclusion

Anxiety about getting pregnant, especially at older ages, is common, and women may feel pressured into taking so-called fertility "MOT" tests to see whether they've left it too late.

But the results of this study strongly suggest that these tests don't predict how easily or quickly a woman will be able to get pregnant.

Some women may use the tests to find out whether they can delay pregnancy, and take a result showing a high ovarian reserve to mean that they have plenty of time to get pregnant.

But the tests only give a snapshot of ovarian reserve at one point in time – they don't tell you how quickly the levels may change in future.

The researchers may be right that other factors, such as egg quality or the quality of a partner's sperm (which also declines with age), are more important – as long as the woman is regularly releasing eggs.

The study was well-designed and carried out, but has some limitations.

For one, the researchers measured pregnancy rates, not birth rates. It's possible that hormone levels could affect the chances of a woman carrying a baby to term, although there's no research to suggest this is the case.

It's also important to remember that these women were all in the first few cycles of trying to get pregnant. The results may not be the same for women with known fertility problems.

There's no doubt that women do find it harder to get pregnant as they get older.

Women who want to get pregnant and have been unable to do so within six months of trying should see their doctor to find out whether there's a problem.

Women being investigated for fertility problems may well need to have these tests, which help plan and predict the success of IVF treatment.

Women who have just started trying for a baby and have no known fertility problems should probably save themselves the money and stress.

Links To The Headlines

'Fertility MOTs' are a waste of money, study finds. The Daily Telegraph, October 10 2017

Fertility MoT tests 'a waste of money'. BBC News, October 10 2017

'Fertility MOTs' for women trying to conceive may be waste of money, study suggests. The Independent, October 10 2017

Links To Science

Steiner AZ, Pritchard D, Stanczyk FZ. Association Between Biomarkers of Ovarian Reserve and Infertility Among Older Women of Reproductive Age. JAMA. Published online October 10 2017

Childhood obesity soars worldwide

NHS Choices - Behind the Headlines -

"Shocking figures show there are now 124 million obese children worldwide," reports The Guardian. A pooling of records of height and weight in children from 200 countries found the numbers of children who are obese rose from less than 1% in 1975, to 5.6% of girls and 7.8% of boys in 2016.

The numbers of children severely or moderately underweight worldwide has fallen – but not by much (from 9.2% to 8.4% in girls and 14.8% to 12.4% in boys). There were an estimated 192 million severely or moderately underweight children in the world in 2016, mostly in Asia and Africa.

In the UK, as with other high-income English-speaking countries, the rise in childhood obesity seems to have stabilised in the past decade, albeit at high levels. Around 10% of UK children are estimated to be obese according to this study.

The figures show that some middle- and low-income countries that previously had many underweight children (such as in the Middle East) had "flipped" to having many overweight children.

Children who become overweight or obese in childhood are at higher risk of developing chronic diseases in adulthood such as type 2 diabetes and some types of cancer. And sadly, research suggests they are more likely to be bullied and have low self-esteem.

Find out more about how you can help your child reach a healthy weight.

 

Where did the story come from?

The study was carried out by researchers from the international NCD Risk Factor Collaboration, and the lead researcher is based at Imperial College London. It was funded by the Wellcome Trust and AstraZeneca Young Health Programme. It was published in the peer-reviewed medical journal The Lancet on an open-access basis, so it is free to read online.

The researchers also published country-specific information in graphs on their website.

The Guardian and BBC News both published accurate stories. The Guardian took a "first-world problem" approach and did not mention the numbers of children still underweight, focusing entirely on the obesity figures.

BBC News gave a more rounded report.

 

What kind of research was this?

This was a pooled analysis of population-based measurement studies, using data sources from 200 countries around the world. Researchers wanted as many reliable studies of children’s height and weight as possible, to compare trends and figures from 1975 to 2016. They also looked at figures for adults, but focused on children aged five to 19 for this study.

 

What did the research involve?

Researchers sought out reports that included the measured weight and height of children within the general population of countries worldwide. They used data from government and health service sources, as well as any published studies, and used their international network to find all relevant data sources from their local areas.

They then analysed the information to look for trends in mean body mass index (BMI), and how many children fitted into five categories, from moderate and severely underweight to obese. They looked at trends over time and in global regions.

The researchers only used data where weight and height had been measured as part of a study, rather than self-reported weight and height. They grouped countries into 22 geographical regions for most of their analyses. They used World Health Organization (WHO) growth reference charts to categorise children, which means their figures don't compare directly with other studies that used different definitions.

 

What were the basic results?

The researchers pooled information from 2,416 data sources, which had height and weight information for about 31.5 million children aged five to 19 years.

The results showed an increase in obesity and a decrease in those severely or moderately underweight over time:

  • In 1975, 0.7% of girls (95% credible interval (CrI) 0.4 to 1.2) and 0.9% of boys (95% CrI 0.5 to 1.3) were obese.
  • In 2016, 5.6% of girls (95% CrI 4.8 to 6.5) and 7.8% of boys (CrI 6.7 to 9.1) were obese – an estimated total of 50 million girls and 74 million boys.
  • In 1975, 9.2% of girls (95% CrI 6.0 to 12.9) and 14.8% of boys (CrI10.4 to 19.5) were underweight.
  • In 2016, 8.4% of girls (95% CrI 6.8 to 10.1) and 12.4% of boys (CrI 10.3 to 14.5) were underweight.

The global figures, however, mask big differences in various regions of the world.

In eastern Europe, for example, average age-standardised BMI changed very little for boys or girls. In central Latin America, by contrast, it rose by 1kg/m2 for every decade from 1975 to 2016. In high-income English speaking countries, average age-standardised BMI rose until about 2000, then the rise flattened off.

The areas of the world with the highest proportion of children estimated to be obese in 2016 are:

  • Polynesia and Micronesia (25.4% of girls and 22.4% of boys)
  • High income English-speaking countries including the UK, north America and Australia and New Zealand (around 20%, exact figures not given)

In the UK, obesity in boys rose from 2.4% in 1975 to 10.9% in 2016, while obesity in girls rose from 3% in 1975 to 9.4% in 2016. The UK ranks 73rd on the list of 200 countries for childhood obesity prevalence.

 

How did the researchers interpret the results?

The researchers say their results show that "rising trends in children's and adolescents' BMI have plateaued in many high-income countries, but have accelerated in parts of Asia."

They say that if trends continue, "child and adolescent obesity is expected to surpass moderate and severe underweight by 2022."

They say figures from east Asia and Latin America show that "the transition from underweight to overweight and obesity can be rapid", and that international policy goals should address both underweight and overweight in a coherent way.

They point out that: "While momentum might be gathering to use taxes and regulations to reduce the consumption of energy-dense foods, few policies and programmes attempt to make healthy foods such as whole grains and fresh fruits and vegetables more affordable through targeted price subsidies, (conditional) cash transfers and food vouchers, or healthy school meals. Unaffordability of healthy food options not only leads to social inequalities in overweight and obesity, but might also limit the effect of policies that target unhealthy foods".

 

Conclusion

This is a huge report with data from around the world. It found that, while obesity among children has clearly increased globally, the picture is variable from one country or region to another.

It's encouraging that the report found obesity levels among countries such as the UK are levelling off. However, that still leaves millions of children obese or overweight, which could put their health at risk in years to come. More needs to be done to reduce those numbers. More urgent is the situation in countries that have seen a rapid rise in childhood obesity that shows no sign of slowing.

It is also important not to overlook the ongoing problem of the many millions of children who are underweight, as this can lead to other long-term health risks.

The report does have some limitations to be aware of:

  • Categories of obesity, overweight etc are not "absolute" categories based on the optimum weight for health. Instead, they represent how a child's BMI compares to a "reference" population of children the same age and sex. Some debate whether this over-estimates the proportion of children categorised as obese.
  • The amount of data the researchers had available for each region varies a lot. Some regions have many reports of children's weight and height, often measured at school. For regions where children are less likely to attend school, or where such programmes are not in place, researchers made estimates relying on fewer sources.
  • Despite the researchers' efforts, they may not have found all relevant data for the study.

Obesity in children can set them up for ill health later in life. It may be harder to lose weight as an adult, than to prevent too much weight gain in childhood. Public Health England said in a statement that it was "at the forefront" of addressing the problem through reducing sugar consumption and introducing a levy on sugar-sweetened drinks.

Links To The Headlines

Child and teen obesity spreading across the globe. BBC News, October 11 2017

Shocking figures show there are now 124 million obese children worldwide. The Guardian, October 10 2017

Links To Science

NCD Risk Factor Collaboration. Worldwide trends in body-mass index, underweight, overweight, and obesity from 1975 to 2016: a pooled analysis of 2416 population-based measurement studies in 128·9 million children, adolescents, and adults. The Lancet. Published online October 10 2017

Youngest children in school year 'more likely' to get ADHD diagnosis

NHS Choices - Behind the Headlines -

"Youngest children in class more likely to be labelled hyperactive," The Times reports. A Finnish study raises the possibility that some children may have been misdiagnosed with ADHD, when in fact their behaviour was age-appropriate.

Attention deficit hyperactivity disorder (ADHD) is a group of behavioural symptoms that include inattentiveness, hyperactivity and impulsiveness.

The researchers found that the youngest children in each school year were more likely to be diagnosed with ADHD compared with the oldest children in the year. This was the case for both boys and girls.

It seems plausible that younger children may generally find it harder to keep up in class and may be more likely to be distracted than older children.

However, the study doesn't prove that the month in which a child is born directly and independently causes or increases risk of ADHD. Many other related factors – hereditary, environmental, social and lifestyle – are also likely to play a part.

It is also difficult to know how far this finding from Finland applies to children in the UK, given the differences in schooling systems and in the way ADHD is managed.

In the UK, a diagnosis of ADHD is usually only made with confidence if it is confirmed by a specialist, such as a child or adult psychiatrist, or a paediatrician.

 

Where did the story come from?

The study was carried out by researchers from the University of Nottingham, the Institute of Mental Health, Nottingham, the University of Turku and Turku University Hospital, Finland. It was published in the peer-reviewed medical journal Lancet Psychiatry.

The research was funded by the Academy of Finland, the Finnish Medical Foundation, Orion Pharma Foundation and the Finnish Cultural foundation.

The UK media covered the story accurately but the fact that the findings couldn't necessarily be applied to the UK population was not discussed.

 

What kind of research was this?

This was a cross-sectional study in which the researchers counted how many of the children born in Finland between 1991 and 2004 received a diagnosis of attention-deficit hyperactivity disorder (ADHD) from the age of seven onwards.

They then compared the children with and without ADHD, looking specifically at when in the year the children were born, age at diagnosis and time period (month of the year) in which diagnosis happened.

Although this is a suitable type of study for looking at trends, it doesn't tell us much about other factors which could influence the chances of developing ADHD. For example, the study did not look at how many siblings each child had, and whether siblings were older or younger than the child.

A better study design would be a cohort study, in which a group of children could be followed up over time and more features could be measured. However, cohort studies can be impractical, expensive and time consuming, whereas the approach the researchers used enabled them to study a far larger number of children.

 

What did the research involve?

The research involved looking at the number of children diagnosed with ADHD from the age of seven onwards, during the period 1998 to 2011 (i.e. those born between 1991 and 2004). The researchers collected data from two existing sources:

  • The Finnish Hospital Discharge Register, used to find out how many children had been diagnosed with ADHD during the study period.
  • The Population Information Centre, used to collect data on the number of children in total in the population and their month and year of birth.

The study did not include children who were twins or multiples or those who had severe or profound intellectual disabilities. The study did, however, include children who had conduct disorder, oppositional defiant disorder or learning (development) disorders alongside ADHD.

When analysing the data, the researchers looked at a number of different trends, including rates of ADHD by birth month, by calendar period (January to April vs May to August vs September to December), by gender, and whether having other related conditions such as learning disorders affected the results.

 

What were the basic results?

During the whole study period there were 6,136 eligible diagnoses of ADHD out of a total of 870,695 children born from 1991 to 2004. Most of those ADHD diagnoses were in boys (5,204 vs 932 in girls).

Compared with the oldest children who were born in the first period of the year (January to April) those born in the latter period (September to December) were more likely to be diagnosed with ADHD.

Boys born in the last period were 26% more likely to be diagnosed with ADHD than those in the first period (incidence rate ratio: 1.26; 95% confidence interval (CI): 1.18 to 1.35), while girls were 31% more likely (incidence rate ratio: 1.31; 95% CI: 1.12 to 1.54).

 

How did the researchers interpret the results?

The researchers conclude that in a health service system like Finland's that prescribes little medication for ADHD, a younger relative age was linked with an increased likelihood of receiving a clinical diagnosis of ADHD.

They suggest: "Teachers, parents, and clinicians should take relative age into account when considering the possibility of ADHD in a child or encountering a child with a pre-existing diagnosis."

 

Conclusion

Previous studies have provided mixed findings on whether age in the school year is linked with ADHD. This new study benefits from its use of a large quantity of data.

It found some interesting trends, and suggests younger children in any given school year are more likely to be diagnosed with ADHD. This finding seems plausible. You can imagine that younger children may find it harder to keep up in a class with those almost a year older than themselves and may therefore get distracted more easily.

However, it is unclear how well these trends apply to the UK population for several reasons:

In Finland the school year is structured slightly differently and children start school at a later age than they do in the UK. This means that children in the UK are exposed to the school environment at a different point in their development, which in turn could affect their behaviour.

The researchers state that Finland has relatively low diagnosis rates of ADHD and suggest that this is due to a more conservative approach to diagnosis. So it might be hard to compare the numbers of children who have been diagnosed with ADHD across the two countries.

As the researchers noted, the number of diagnoses may not be completely accurate. Teachers may have a role in the initial referral of children to be assessed for ADHD. This could lead to under-diagnosis of ADHD if some teachers do not recognise possible signs of ADHD for some children.

Perhaps most importantly, as a cross-sectional study, this research cannot prove that age in the school year on its own increases risk of ADHD.

There may be a wide range of factors that influence whether a child – young or old in their school year – may be risk of ADHD. These may include hereditary factors, home environment, school environment, peer groups, and even diet and lifestyle. The study only looked at a limited number of variables which might be associated with having ADHD.

So we can't be sure how strong the relationship between relative age and behaviour really is.

In the UK, while a teacher may raise potential red flags for ADHD (or other behavioural and developmental conditions), a diagnosis would need to be made by a specialist.

Links To The Headlines

Youngest children in class more likely to be labelled hyperactive. The Times (subscription required), October 10 2017

New questions about ADHD: Youngest children in school are being labelled with the disorder but expert warns about risk of misdiagnosis and claims they could just be immature. Mail Online, October 9 2017

Youngest children in class more likely to be labelled ADHD — but they may ‘just be immature’, study claims. The Sun, October 9 2017

Links To Science

Sayal K, Chudal R, Hinkka-Yli-Salomäki S, et al. Relative age within the school year and diagnosis of attention-deficit hyperactivity disorder: a nationwide population-based study. The Lancet Psychiatry. Published online October 9 2017

Is schizophrenia risk 'around 80% genetic'?

NHS Choices - Behind the Headlines -

"Genetics account for almost 80 per cent of a person's risk of developing schizophrenia, according to new research," the Mail Online reports. That is the main finding of a study looking at how often schizophrenia affected both twins of a pair, looking at identical and non-identical twins.

Schizophrenia is a serious mental health condition that can cause delusions and hallucinations. There is no single "cause" of schizophrenia. It is thought to result from a complex combination of both genetic and environmental factors.

The researchers looked at twins born in Denmark and found that if one identical twin had schizophrenia, the other twin (with the same genes) was also affected in about a third of cases. For non-identical twins, who only share on average half of their genes, this was true only in about 7% of cases. Based on these figures, the researchers calculated that 79% of the risk of developing schizophrenia was down to their genes.

While the findings suggest genes do play an important role in schizophrenia, this is only an estimate and the true picture is likely to be more complicated. Environmental factors clearly still have an influence on whether the person actually develops schizophrenia.

If you do have a history of schizophrenia in your family, this doesn't mean you will automatically get the condition yourself. But it may be a good idea to avoid things that have been linked to the condition, such as drug use (particularly cannabis, cocaine, LSD or amphetamines).

 

Where did the story come from?

The study was carried out by researchers from the Center for Neuropsychiatric Schizophrenia Research at Copenhagen University Hospital in Denmark. Funding was provided by the Lundbeck Foundation Center of Excellence for Clinical Intervention and Neuropsychiatric Schizophrenia Research, and Lundbeck Foundation Initiative for Integrative Psychiatric Research.

The study was published in the peer-reviewed journal Biological Psychiatry, and is available to read for free online.

The Mail's report that: "The findings suggest the genes we inherit play a far bigger role than previously believed and mean the seeds are sown before birth" isn't strictly correct. The estimates from the current study are similar to those from some previous studies.

 

What kind of research was this?

This was a twin cohort study using data from the Danish Twin Register combined with the psychiatric registry, aiming to better quantify the extent to which schizophrenia risk may be explained by the genes we inherit. Previous studies have suggested that genes play an important role, but researchers wanted to use some updated statistical methods and newer data to come up with a more up-to-date estimate.

Both genetics and environmental factors are thought to play a role in the risk of schizophrenia. Twin studies are a standard way to estimate the extent to which genetics plays a role. Both identical and non-identical twins may be assumed to have the same environmental exposure. However, identical twins have 100% of their genes in common, while non-identical twins share only 50% on average.

Therefore if identical twins are more alike than non-identical twins, marked differences in health outcomes are likely to be down to genetics. Researchers used statistical methods to estimate what role genes play in the development of a particular characteristic (called "heritability").

Previous studies show that schizophrenia affects both members of identical twins in 41% to 61% of cases, but only 0 to 28% in non-identical twins. A previous pooling of twin studies has suggested that the "heritability" of schizophrenia is 81%.

It is worth bearing in mind that this type of twin cohort study makes various assumptions to simplify the picture.

It assumes that genes and the environment do not interact. This assumption may result in over-estimating the impact of genes. For example, it could be the case that people with a specific genetic profile are more likely to use drugs. Drug use (an environmental risk factor), rather than the genes directly, could then increase the risk of schizophrenia.

Also, the results obtained are very dependent on the environment the twins are living in. So results would likely differ if the same study were carried out in different societies at different time points throughout history.

Finally, this type of study does not identify specific genes that may be involved in the risk of schizophrenia.

 

What did the research involve?

The Danish Twin Register, started in 1954, includes all twins born in Denmark. The Danish Psychiatric Central Research Register includes data on all psychiatric hospital admissions since 1969, and all outpatient visits since 1995. Diagnoses in the register are based on the long-established International Classification of Diseases (ICD), which is a way of classifying diseases according to standard criteria.

The researchers used data on 31,524 twin pairs born up to the year 2000, linked with the psychiatric registry data, and knew whether they were identical or not.

They identified the twins who had been diagnosed with schizophrenia or schizophrenia spectrum disorders (this means not fulfilling diagnostic criteria for schizophrenia, but having a disorder with similar characteristics).

They then looked at how many of these diagnoses affected both twins in a pair. They used statistical methods to estimate how much of a role genes played in the development of schizophrenia. One of the new features of the methods used was that they took into account how long each twin had been followed up.

The researchers' results only apply to schizophrenia diagnosed up to the age of 40.

 

What were the basic results?

448 of the included twin pairs (about 1% of the sample) were affected by schizophrenia, and 788 were affected by schizophrenia spectrum disorders. Average age of diagnosis of these conditions was about 28 or 29 years.

The researchers found that if one identical twin was affected by schizophrenia or schizophrenia spectrum disorders, the chance of the second being affected was about a third. For non-identical twins, the chance was far lower – only 7% for schizophrenia and 9% for schizophrenia spectrum disorders.

The researchers estimated that in the population studied, about 78% of the "liability" for schizophrenia and 73% for schizophrenia spectrum disorders could come down to genetic factors. This means that a high proportion of the co-twins may be carrying genes that make them "vulnerable" to the condition, even if they haven't developed it in this study.

 

How did the researchers interpret the results?

The researchers conclude: "The estimated 79% heritability of schizophrenia is congruent with previous reports and indicates a substantial genetic risk. The high genetic risk also applies to a broader [range of] schizophrenia spectrum disorders. The low [co-diagnosis] rate of 33% in [identical] twins demonstrates that illness vulnerability is not solely indicated by genetic factors."

 

Conclusion

This study explores how much of the risk of developing schizophrenia or related disorders may be explained by genetics.

It shows that schizophrenia and related disorders are quite rare – affecting about 1% of the general population.

Their observed co-diagnosis rate in both twins – about a third for identical and less than 10% for non-identical twins – was lower than has been observed in other studies. This seems to suggest that while a high proportion of an individual's susceptibility may come down to hereditary factors, environmental factors must still be play a substantial role.

This type of study makes a number of assumptions to simplify the picture, and these may not accurately portray reality. For example, it assumes that identical and non-identical twins would share similar environmental exposures.

However, this may not be the case. It also assumes that genes and the environment do not interact, but in reality, people with different genetic makeups may react to the same exposure in different ways.

Other reasons for the low co-diagnosis rate could be, as the researchers acknowledge, down to study methods. For example, some may have had different severity or presentation of illness influencing diagnosis. The study also does not have lifelong data for all of the twins. Though most people with schizophrenia are diagnosed before 40 years of age, longer follow-up times would be ideal.

One final point: estimates that come out of this type of study are dependent on the environment the twins are living in. So results would likely differ if the same study were carried out in very different societies, or at different time points throughout history. Though this study benefits from using a large population-wide registry, study members were all Danish residents. The findings may not apply to different populations, with different ethnic and cultural makeups.

The study will add to the large body of literature exploring the role of hereditary and environmental risk factors for schizophrenia. However, it certainly doesn't mean we fully understand the causes of the condition, including the impact of environment on this condition.

Links To The Headlines

Seeds of schizophrenia are sown before birth: Almost 80% of a person's risk of developing the mental illness is down to genetics, reveals study. Mail Online, October 6 2017

Links To Science

Hilker R, Helenius D, Fagerlunde B, et al. Heritability of Schizophrenia and Schizophrenia Spectrum Based on the Nationwide Danish Twin Register. Biological Psychiatry. Published online August 30 2017

Three quarters of honey samples contain pesticide traces

NHS Choices - Behind the Headlines -

"Honey from across the world is contaminated with potent pesticides known to harm bees," The Guardian reports.

This is based on a study that analysed nearly 200 samples of honey, collected from diverse regions worldwide, and found that 75% contained traces of a group of pesticides called neonicotinoids.

Neonicotinoids became commercially available in the 1980s, and were marketed as a group of pesticides that cause less damage to birds and mammals. But since the 1990s, some researchers have argued they may be harmful to bees and could be at least partially responsible for the rapid drop in bee numbers in Europe.

The average concentration in the study samples was 1.8 nanograms per gram of honey (ng/g). This is far below the maximum acceptable level set in the EU, which is 50ng/g for three of the neonicotinoids and 10ng/g for two others.

The low level detected is not thought to pose any risk to humans; however, it has been linked with harm to bees and other nectar-collecting pollinators.

This study shouldn't cause undue alarm to the general public and there's probably no need to dump your honey jars in the bin. That said, pesticide use worldwide is concerning for environmental conservation. France is already said to have completely banned the use of these pesticides, although this will not come into force until 2020, and other countries may follow suit.

Where did the story come from?

The study was conducted by researchers at Université de Neuchâtel in Switzerland and published in the peer-reviewed journal Science. No sources of funding were reported. The article is freely available online.

The UK media reported the study accurately, with several sources discussing the issue of whether pesticides should be used on such a large scale.

What kind of research was this?

This was a worldwide survey looking at the presence of neonicotinoids in honey.

Neonicotinoids are the most widely used pesticides. They are absorbed by plants so can contaminate pollen and nectar. As the researchers said, there are concerns about the effects these pesticides could have not only on bees but also further down the food chain, affecting humans. Certain countries have already banned the use of these pesticides.

Looking at honey, the nectar and pollen in the hive may be harvested from as far as 12.5km away, so it can be a marker of the area's environmental quality. As honey samples are easy to obtain from a range of geographical locations, they provide a good method of worldwide analysis. This study therefore presented a global survey measuring neonicotinoid concentrations across all continents, apart from Antarctica.

What did the research involve?

The study was promoted as a "citizen science project", where people across the world, both researchers and members of the general public, were encouraged to take honey samples. The project ran between 2012 and 2016.

Details about each sample – such as region, description of honey on the label, and beekeeper – were also gathered, if available.

More than 300 samples were collected, with 198 chosen for an analysis aiming to give the broadest representation across countries and geographical regions (mountains, islands and so on).

These were then tested in the laboratory for five commonly used neonicotinoids: acetamiprid, clothianidin, imidacloprid, thiacloprid and thiamethoxam.

What were the basic results?

The researchers found that 75% of all the samples contained quantifiable amounts of at least one neonicotinoid. The proportion of affected honeys varied globally, with the largest proportion of contaminated samples in North America (86%), followed by Asia (80%), Europe (79%), Africa and Oceania, with the lowest in South America (57%).

In 30% of the samples that contained pesticide, there was only one neonicotinoid found, 45% contained two to five, and 10% contained four or five. The most common pesticide was imidacloprid, present in half of all samples. Clothianidin (16%) was the least common.

The average concentration of total neonicotinoids was 1.8ng/g. The maximum level allowed in food products in the EU is 50ng/g for acetamiprid, imidacloprid and thiacloprid; and 10ng/g for clothianidin and thiamethoxam. No individual neonicotinoid reached these levels.

However, in previous studies, the 1.8ng/g average concentration reported in these samples has been linked with deficits in learning, behaviour and colony performance in honey bees.

How did the researchers interpret the results?

The researchers said: "Our results confirm the exposure of bees to neonicotinoids in their food throughout the world. The coexistence of neonicotinoids and other pesticides may increase harm to pollinators.

"However, the concentrations detected are below the maximum residue level authorized for human consumption."

Conclusion

As the researchers made clear, the concentrations of neonicotinoid pesticides measured were far below the maximum level allowed in food products.

Some previous studies have suggested these levels could harm bees and other pollinators that directly harvest the nectar, but we are not small insects. There's no evidence that the level of pesticides reported in this study would pose any harm to human health.

There are two other points to note, if you are concerned:

  • No particular brands or varieties of honey were found to be more at risk than others: it was a global sweep of honey samples.
  • Before singling out honey as a risky food item, it's worth considering that the use of pesticides is a global issue affecting many items in the food supply, including crops, fruit, vegetables and livestock. Many other food substances could be tested and traces of pesticides found.

Nevertheless, the presence of pesticides in the majority of these honey samples is still cause for concern in terms of conservation.

The quote – often attributed to Einstein, although there's no evidence he actually said it – "If the bee disappeared off the face of the Earth, man would only have four years left to live," should still give us all pause for thought.

Links To The Headlines

Honey tests reveal global contamination by bee-harming pesticides. The Guardian, October 5 2017

Pesticides linked to bee deaths found in most honey samples. BBC News, October 5 2017

Links To Science

Mitchell EAD, Mulasuer B, Mulot M, et al. A worldwide survey of neonicotinoids in honey. Science. Published online October 6 2017

Vitamin D may prevent asthma worsening for some

NHS Choices - Behind the Headlines -

"Vitamin D supplements protect against severe asthma attacks," The Daily Telegraph reports.

The headline was prompted by a review that pooled data from seven trials comparing taking vitamin D supplements with a placebo in people with asthma.

The researchers wanted to see whether vitamin D reduced the risk of severe asthma episodes that needed hospitalisation or treatment with oral steroids, referred to as "asthma exacerbations".

Overall, the researchers found vitamin D supplements reduced the risk of asthma exacerbations by 26%. Further analysis found the protective effect was only seen in people who were vitamin D deficient to start with.

But the main limitation of this evidence is the small number of exacerbations that occurred. For example, in two trials there were no asthma exacerbations, in another only a single event.

And only 92 people from the data were vitamin D deficient at the start. This means the risk estimates are based on small numbers, which may make them less accurate.

It's currently recommended that certain groups, including those at risk of vitamin D deficiency and children aged one to four, take vitamin D supplements all year round.

All adults and children are advised to consider taking 10 micrograms (mcg) a day of vitamin D during the autumn and winter months, when there is less sunlight.

Find out what to do during an asthma attack.

 

Where did the story come from?

The study was carried out by researchers from Barts and The London School of Medicine and Dentistry, Queen Mary University of London, and other institutions in the UK, US, Ireland, Poland and Japan.

Funding was provided by the Health Technology Assessment Programme, which is run by the UK's National Institute for Health Research (NIHR).

The study was published in the peer-reviewed journal The Lancet: Respiratory Medicine.

The UK media's reporting is generally accurate, but official guidelines haven't changed on the basis of the results of this study.

 

What kind of research was this?

This systematic review and meta-analysis pooled data from people with asthma taking part in randomised controlled trials that compared vitamin D supplementation with an inactive placebo.

Previous meta-analysis of trial data has suggested that vitamin D may reduce the risk of asthma attacks and exacerbations of asthma.

But it's not known whether this effect is influenced by the person's vitamin D level to start with, so the researchers set out to investigate this.

A systematic review of randomised controlled trials (RCTs) is the best way of gathering the available evidence on the effects of an intervention.

But when it comes to trials on nutritional supplements, RCTs can vary considerably in how the treatment is given. And when the outcome of interest is relatively rare – in this case, asthma exacerbations – it can be difficult to be sure how much of the effect is down to the intervention.

 

What did the research involve?

The reviewers identified placebo-controlled trials of vitamin D supplementation (D2 or D3) in people with asthma that reported incidence of asthma exacerbations as an outcome.

The trials included had to be double-blinded in design, where neither the participants nor the assessors knew if a person was taking vitamin D or a placebo.

The reviewers collected individual patient data from the trials, contacting study investigators for clarity or to gather missing data.

They also collected information on participants' age, gender, ethnicity, BMI, blood vitamin D concentration at the start of the study, and any other factors that might influence the results (confounders).

The main outcome of interest was incidence of asthma exacerbations needing treatment with oral steroids. They also looked at emergency hospital attendance or admissions and any adverse effects associated with supplementation.

Eight trials were eligible for inclusion, but patient data couldn't be obtained for one, leaving a total of seven studies and 978 participants available for analysis. Trials came from six different countries (one from the UK), and about a third of the participants were children.

Vitamin D dosing varied from a single dose (an injection or infusion) every two months (100,000 international units, IU) to daily dosing (500 to 2,000 IU per day) or a mixture of the two. Treatment duration ranged from 15 weeks to one year.

Baseline blood vitamin D levels ranged from undetectable to 187nmol/L. Vitamin D deficiency is generally accepted to be less than 25nmol/L, so this threshold was used in the study.

 

What were the basic results?

Asthma exacerbations needing oral steroid treatment were rare. In two trials there were no exacerbations, and in another there was only one.

When pooling the participants, in all seven studies vitamin D supplementation was associated with a 26% reduced risk of asthma exacerbation needing steroid treatment (relative risk (RR) 0.74, 95% confidence interval (CI) 0.56 to 0.97).

A similar risk reduction was found when researchers just looked at the four individual studies with several exacerbations.

There was no difference between groups in the proportion of people having at least one exacerbation, but vitamin D helped reduce the risk of multiple exacerbations.

Vitamin D supplements reduced the rate of exacerbations in people with vitamin D levels less than 25nmol/l (0.33, 95% CI 0.11 to 0.98), but this was based on data from only 92 participants.

Among the 764 participants who weren't vitamin D deficient, there was no significant effect, regardless of their age, gender and ethnicity.

Vitamin D didn't increase the risk of serious adverse events, and there were no cases of high blood calcium or kidney stones reported.

 

How did the researchers interpret the results?

The researchers concluded: "Vitamin D supplementation reduced the rate of asthma exacerbations requiring treatment with systemic corticosteroids overall.

"We did not find definitive evidence that effects of this intervention differed across subgroups of patients."

 

Conclusion

This review gathers the available trial evidence to address the specific question of whether giving people with asthma vitamin D supplements could have an effect on how many asthma exacerbations they have.

The review has many strengths. It only included double-blind trials, where participants and assessors didn't know if people were taking vitamin D or a placebo.

Researchers also made careful attempts to gather all relevant data and information on confounding factors, and all but one trial had a low risk of bias.

But there are some limitations to bear in mind:

  • With the relatively small number of trials and participants, the outcome of interest – exacerbations needing steroid treatment – was quite rare. Three trials recorded no exacerbations, and a third only one. Analyses based on a small number of events can give less precise risk estimates.
  • The main aim was to see whether a person's vitamin D levels to begin with had an effect. The researchers found there was: the benefit was only seen in people who were vitamin D deficient to start with. But only 92 people fell into this category, so again the small number of events in this sample may give a less reliable result.
  • The dosing and duration of treatment varied from study to study. Along with the small sample and low number of events, this makes it difficult to know what could be an optimal dose for children or adults to take.

This study, and the research it's based on, isn't able to tell us whether there should be a change in guidelines for people with asthma. It's too soon to recommend they take vitamin D supplements, regardless of whether or not they're deficient.

Current guidelines recommend everyone should consider taking a vitamin D supplement of 10mcg a day in the autumn and winter months, when there is less sunlight. People can get all the vitamin D they need from sunlight and some dietary sources in the spring and summer.

Babies who are breastfed, all children aged one to four years, pregnant and breastfeeding women, and people at risk (such as those who are indoors a lot) are advised to take a supplement all year round.

Vitamin D supplements are available from most pharmacists and are usually safe to take as long as you don't regularly take more than 100mcg (4,000 IU) a day.

Children under 10 years should not take more than 50mcg a day, and babies under one year should not take more than 25mcg a day.

Links To The Headlines

Vitamin D supplements protect against severe asthma attacks, study shows. The Daily Telegraph, October 3 2017

This vitamin pill can reduce the chance of life-threatening asthma attacks by half. Daily Mirror, October 3 2017

Taking a daily ‘sunshine’ Vitamin D supplement cuts the risk of asthma attacks, study finds. The Sun, October 3 2017

Links To Science

Jolliffe DA, Greenberg L, Hooper RL, et al. Vitamin D supplementation to prevent asthma exacerbations: a systematic review and meta-analysis of individual participant data. The Lancet Respiratory Medicine. Published online October 3 2017

Many new cancer drugs show 'no clear benefit', argues review

NHS Choices - Behind the Headlines -

"Over half of new cancer drugs 'show no benefits' for survival or wellbeing," The Guardian reports. That was the finding of a study looking at the evidence supporting new cancer drugs approved between 2009 and 2013 by the European Medicines Agency (EMA).

The study found only half of drug approvals had clear evidence showing they either prolonged people's lives, or improved their quality of life. That's not the same as saying these drugs would not help anyone. But research presented at the time of the drugs' approval, and gathered in the three to eight following years, did not show that they worked better than existing treatments in terms of prolonging or improving quality of life.

The study raises questions about whether medicines regulators should be stricter about the type of evidence they accept when allowing drugs to be marketed. This is especially relevant in the field of cancer treatment (oncology) where a course of treatment with new drugs can cost tens of thousands of pounds.

European regulatory approval is only part of the process in the UK. New medicines are assessed by the National Institute for Health and Care Excellence (NICE). NICE looks more closely at the evidence to see whether drugs give value in terms of improving patient outcomes and quality of life before making a recommendation for it to be prescribed on the NHS.

While the issue of whether these new drugs "work" or not is still a matter of debate, the study highlights the fact that when it comes to medication, "new" doesn't automatically mean "better".

Where did the story come from?

The study was carried out by researchers from Kings College London, London School of Economics and Political Science, Riga Stradins University in Latvia, and the London School of Hygiene and Tropical Medicine. It was published in the peer-reviewed British Medical Journal and is free to read online.

Most of the UK media reported the study accurately.

Somewhat ironically, many of the newspapers reporting on the lack of evidence for these new drugs have previously run articles criticising the NHS for not funding these drugs.

What kind of research was this?

This was a cohort study, which examined evidence submitted to the European Medicines Agency which led to approvals of cancer drugs.

The researchers wanted to see:

  • what types of studies were being accepted as evidence
  • how many drug approvals were supported by clear evidence of improvement in length or quality of life
  • how many drugs approved without this evidence had evidence published after approval
  • if the evidence around living longer or improved made meaningful difference to patients in real terms

 

What did the research involve?

Researchers searched for all cancer drug approvals made by the European Medicines Agency (EMA) from 2009 to 2013. They retrieved the European Public Assessment Report (EPAR) for each approval – the document, which summarises the evidence the EMA used to decide to approve the drug. They extracted data about study type and survival and quality of life.

They then searched for studies published since the drug was approved, up to March 2017. Where drugs did show a benefit for survival or quality of life, they used a widely accepted scale to assess how clinically important these results were.

They classified the studies as randomised controlled trials (the most reliable type of study) or non-controlled trials (where there is no control group to compare the effects of the new drug).

They looked at whether researchers measured length of life or quality of life as a primary outcome.

Because studies that show benefits in long-term survival take a long time, researchers often measure secondary outcomes (surrogates) to give a quicker estimate of whether a drug works. These include whether a tumour is shrinking and how fast the disease grows or spreads. While these measures may still be useful, they don't necessarily translate into longer or better lives for patients.

Three researchers worked on extracting data, and cross-checked each other's work. Drugs were judged to show evidence they extended life if the trial included overall survival as a primary or secondary endpoint, and showed a difference between the new drug and the control group.

Researchers judged drugs to show improvement in quality of life when there was a difference between the new drug and control group on any item or subscale of a recognised quality of life scale.

They used the European Society for Medical Oncology's Magnitude of Clinical Benefit Scale (MCBS) scoring system to grade trial results for whether they were clinically meaningful. For example, a drug that extended expected survival time for a terminal cancer by 12 months would be regarded as clinically meaningful.

 

What were the basic results?

Researchers found 48 cancer drugs had been approved for 68 uses.

At the point where the drugs were approved:

  • for 24 drug uses (35%), evidence showed that the drug prolonged life
  • for seven drug uses (10%), evidence showed that the drug increased quality of life
  • for 39 drug uses (57%), there was no evidence that they either prolonged life, or increased quality of life

In the follow-up period after approval (3.3 to 8 years), new evidence showed that three of the 39 drug indications did increase length of life, and five improved quality of life. This meant that, overall, 35 of 68 drug approvals made by the EMA (51%) had evidence to show improved length or quality of life.

Looking at the figures more closely:

  • For those drugs that had the evidence available at the time of approval, improvement in length of life ranged from 1 month to 5.8 months. The average improvement in length of life was 2.7 months.
  • Only two of the 26 drugs shown to extend life also showed improvements in quality of life.

 

How did the researchers interpret the results?

The researchers say their results show that "European regulators commonly accept the use of surrogate measures of drug benefit as primary endpoints," in trials submitted as evidence for drug approvals. They say the European Medicines Agency’s standards are "failing to incentivise drug development that best meets the needs of patients, clinicians and healthcare systems."

They say their analysis shows that "critical information about the outcomes that matter most to patients" might never be gathered, once a drug is approved for use. They say the EMA should "reconsider" its standards.

 

Conclusion

Most of us assume that when a drug has been approved by a regulator for use, that means it has been shown to work. This study suggests that is not necessarily the case, or that even if it works they might not make a meaningful difference.

The absence of evidence about the two outcomes that matter most to patients and their families – how long they will live, and how good their quality of life will be during that time – from half of the cancer drugs approved during a five-year period, is worrying. Patients cannot be expected to make informed decisions about which treatments to take, without good quality information on these outcomes.

It can be difficult to carry out the best medical research that recruits enough people and follows them for long enough to get all the evidence needed for the drug, particularly for rare cancers.

That's why people have come to accept the use of surrogate outcome measures, to make research more feasible and get new drugs to people with potentially incurable cancers more quickly in cases where time, or lack of it, is of the essence.

But if surrogate measures are accepted at the time when drugs are approved, it is essential that information about survival and quality of life is collected and published in the following years.

There are, however, some limitations to this study which should be noted:

  • Researchers didn't look at how suitable trial designs were. For example, new drugs might be compared to an ineffective or minimally effective drug, rather than to the best care otherwise available. This means that the drug benefits could have been further overestimated.
  • Researchers only looked at the key trials assessed by the regulators. There may be other trials, published or unpublished, which showed different results.
  • The studies included in the EPAR assessment reports used varying methods to demonstrate quality of life or length of life.
  • Some EPAR assessments did not make it clear whether the evidence for the drug showed a true improvement in length or quality of life. In these cases the researchers looked to the EMA's conclusions or favoured the drug giving them "the benefit of the doubt". This too may have led to an overestimation of effect.

Overall, the report suggests that regulation of new drug approvals needs to be tighter. As said, drug approval does not automatically mean that it will be recommended as a first-choice option by medical guidelines. NICE looks closely at the evidence to see whether the drug gives value in terms of making meaningful improvements to patient outcomes and quality of life before recommending its use.

Anyone worried about the evidence behind a cancer treatment they are being offered, or are taking, can talk to their cancer specialist and ask them to explain what difference it has been shown to make.

Links To The Headlines

Over half of new cancer drugs 'show no benefits' for survival or wellbeing. The Guardian, October 5 2017

Majority of recent cancer drugs approved for use in UK show no survival benefits, study finds. The Daily Telegraph, October 5 2017

The costly cancer drugs that DON'T help patients: More than half of treatments do nothing to improve or extend their lives. Mail Online, October 5 2017

Cancer patients given new drugs that won’t help them. The Times (subscription required), October 5 2017

Links To Science

Davis C, Naci H, Gurpinar E, et al. Availability of evidence of benefits on overall survival and quality of life of cancer drugs approved by European Medicines Agency: retrospective cohort study of drug approvals 2009-13. The BMJ. Published online October 4 2017

Study links vegetarian diet in pregnancy to substance abuse in offspring

NHS Choices - Behind the Headlines -

"Pregnant vegetarians are three times more likely to have kids who abuse drugs and alcohol," reports the Mail Online. Researchers claim to have found a link between substance abuse at age 15, and diet of the child's mother during pregnancy. But it is far from clear that avoiding meat in pregnancy "causes" substance abuse in teenagers.

The research was based on a long-running study in the UK. Researchers asked almost 10,000 teenagers about their use of alcohol, cannabis and tobacco, and about half responded. They then looked at the dietary records the teens' mothers had filled out in pregnancy, to see if they could spot any relationships between the two.

The study found that children of women who ate most meat in pregnancy were less likely to be users of alcohol, cannabis or tobacco at age 15, compared to those who ate little or no meat. The researchers speculate this could be because women who don't eat meat might have low levels of vitamin B12, which affects brain development.

However, we can't know that diet in pregnancy was definitely the cause. Many factors are likely to be involved in something as complex as whether a teenager uses drugs or alcohol. This study cannot rule out that factors other than diet are responsible for the link seen.

That said, it's important to be sure you get all the nutrients you need in pregnancy, including iron, vitamin B12 and calcium. You can do this without eating meat or dairy, though some women may need additional supplements.

Read more advice on vegetarian and vegan diet during pregnancy

Where did the story come from?

The researchers were from the University of Bristol in the UK, and the US National Institute on Alcohol Abuse and Alcoholism in Rockville, University of Illinois at Chicago and University of California, San Diego, all in the US. The research was published in the peer-reviewed journal Alcoholism: Clinical and Experimental Research.

The Mail Online's headline is unnecessarily scaremongering. It quotes only the most extreme link found, and does not explain any of the limitations to the study in its article. It states that "most vegetarians have a B12 deficiency while pregnant", and reports on the risks associated with vitamin B12 deficiency in pregnancy, but the study did not actually assess whether any of the women had a B12 deficiency.

This study alone cannot prove a definite link and other factors could be contributing to the findings.

 

What kind of research was this?

This was an analysis of data taken from a large, ongoing prospective cohort study called the Avon Longitudinal Study of Parents and Children (ALSPAC).

Cohort studies can identify patterns that may suggest risk factors for diseases or conditions such as substance abuse, but they can't prove that one factor (in this case maternal diet) directly causes another (in this case substance abuse). This is because it is difficult to remove the impact of all other factors.

 

What did the research involve?

The new study came out of a long-running UK project, which has tracked what happened to almost 15,000 babies born to women in the Bristol area in 1991 to 1992.

In this study, just over 5,000 children in the group (about half of those invited) answered questions about their cannabis, alcohol and tobacco use. Researchers compared their answers to the dietary records taken from their mothers 15 years earlier, during their pregnancies. They checked whether children of women who reported eating little or no meat were more likely to report using alcohol, tobacco or cannabis.

The researchers made efforts to account for other possible causes for their findings (confounding factors). They adjusted their figures for these factors:

  • housing (owned, rented or social housing) and overcrowding
  • maternal education level
  • how many children were in the family
  • social class of the parents
  • occupation
  • ethnicity
  • the mother's age when the child was born
  • family income after the child was born
    parent/child relationships

Pregnant women who eat vegetarian diets may find it difficult to get enough vitamin B12 – one of the nutrients found in meat and important for brain development. The researchers thought that the mother's levels of B12 could be responsible for their findings.

To test this, they also carried out a study in which they looked at women's genetic variations, which may affect their ability to use vitamin B12. They looked separately at women with and without these specific genetic variants and whether there was a link between meat eating and children's substance abuse.

 

What were the basic results?

Of the 9,979 teenagers invited to take part, 5,246 attended. About 10% of teenagers reported one of the following:

  • behavioural problems due to drinking alcohol (such as getting into fights because of drinking)
  • moderate use of cannabis (defined as using cannabis "at least occasionally")
  • using tobacco on a weekly basis

The researchers carried out various analyses looking at different aspects of diet and these substance use outcomes. They found that teenagers born to mothers who had a "vegetarian" diet pattern had:

  • 28% higher odds of having behavioural problems associated with alcohol (odds ratio (OR) 1.28, 95% confidence interval (CI) 1.17 to 1.41)
  • 42% higher odds of using cannabis moderately (OR 1.42, 95% CI 1.30 to 1.55)
  • 21% higher odds of using tobacco weekly (OR 1.21, 95% CI 1.10 to 1.33)

The study also found that the chances of having one of these substance abuse problems tended to lessen the more meat a woman reported eating.

The "three times more likely to have kids who abuse drugs or alcohol" figure quoted in the Mail Online's headline seems to relate to the comparison of women who never ate meat compared to women who ate meat daily in pregnancy – the teens born to women who never ate meat had 2.7 times the odds of being moderate cannabis users (OR 2.7, 95% CI 1.89 to 4.00). The links with the other substance use outcomes were lower (OR for alcohol problems 1.75, and OR for weekly tobacco use 1.85).

In the genetic part of their study, the researchers found that the links between the mother's meat intake and her child's later substance abuse were stronger in women who had genetic variations that may allow the body to use vitamin B12 more efficiently. For women with a genetic variation that meant they couldn't use B12 so well, their children's risk of substance abuse was not linked to the amount of meat they ate.

That could be because eating more meat did not translate into more vitamin B12 for women with this genetic variation.

 

How did the researchers interpret the results?

The researchers said: "This study identifies low meat consumption in the prenatal period as [a] potentially modifiable risk factor for adolescent substance use." They say that socioeconomic differences between women who did or did not eat meat were "unlikely to explain" their findings.

They say that vitamin B12 deficiency is "highly likely" to contribute to their findings, and suggest more fortification of foods with vegetarian sources of B12, and greater use of supplements.

 

Conclusion

While having too little vitamin B12 in your diet during pregnancy can affect a baby's development, it remains to be proven whether a vegetarian diet in pregnancy can cause substance abuse problems in teenage offspring.

The findings do not mean that vegetarian pregnant women need to start eating meat. It is already recommended that vegetarian and vegan mums-to-be take special care to ensure they get enough of certain nutrients that are found in meat and fish, such as vitamin B12, vitamin D and iron. The study identifies a possible link between having little or no meat consumption in pregnancy (which may have led to vitamin B12 deficiency) and substance abuse in the offspring, 15 years later.

Substance abuse is a complicated problem, it is unlikely that one factor such as maternal diet in pregnancy could have caused it. However much the researchers tried to account for other potential confounding factors, it's very difficult to untangle the mother's diet in pregnancy from everything that happened between conception and the child's 15th birthday.

More research is needed before we can come to more definitive conclusions.

The study has some limitations that may affect the reliability of the results:

  • Only half of the children invited to participate in the research at age 15 did so. We don't know what happened to the other half, or why they dropped out of the study. We don't know if their results would have supported or undermined the study findings.

  • We don't know whether the pregnant women were deficient in vitamin B12, because they weren't tested for it. We have to rely on the questionnaires they filled in about their diet back in 1991 or 1992. We don't know whether their diet changed during pregnancy, or whether they were deficient in other important nutrients.
  • We don’t know how accurate the teenagers' reports of substance abuse were, or whether they reflect long-term use of alcohol, cannabis or tobacco – the research gives us a "snapshot" view of one point in time.
  • While the researchers tried to take into account a number of socioeconomic factors, and also some aspects of the parent-child relationship, the effects of these complex factors are unlikely to have been fully removed.

While the study doesn't add much to what we already know about diet in pregnancy, it's a reminder that pregnant women do need to ensure they get all the nutrients they and their growing baby need.

Links To The Headlines

Pregnant vegetarians are three times more likely to have kids who abuse drugs and alcohol, study finds. Mail Online, October 4 2017

Eating less meat in pregnancy ‘linked to drink and drug problems’. Metro, October 4 2017

Links To Science

Hibbeln JR, SanGiovanni JP, Golding J, et al. Meat Consumption During Pregnancy and Substance Misuse Among Adolescent Offspring: Stratification of TCN2 Genetic Variants. Alcoholism: Clinical & Experimental Research. Published online October 4 2017

Regularly skipping breakfast linked to hardening of the arteries

NHS Choices - Behind the Headlines -

"Skipping breakfast may be linked to poor heart health," The Guardian reports. Researchers from Spain found that people who regularly skipped breakfast were more likely to have atherosclerosis – hardening and thickening of the arteries due to a build-up of fatty deposits known as plaques.

Atherosclerosis doesn't usually cause any noticeable symptoms at first but can eventually lead to life-threatening problems, such as heart attacks and strokes, if it gets worse.

The researchers looked at the breakfast habits and artery health of around 4,000 middle-aged bank workers who were not known to have heart disease. They found those who skipped breakfast were more likely to have plaques than those who ate a breakfast containing at least a fifth of their daily calories – this would be 500kcal or more for a man whose daily intake was the recommended 2,500kcal.

The study is planning to follow up the participants to see what happens to their arteries over time.

This study can't say for certain whether skipping breakfast was affecting artery health directly, as both were assessed at the same time. However, skipping breakfast did seem to be a habit shared by people who also tended to be unhealthy in other ways, such as being more likely to be a smoker or to have a higher body mass index (BMI).

While skipping breakfast may seem a tempting option if you're trying to lose weight, it's counterproductive if you find yourself having unhealthy snacks and overeating during the rest of the day.

 

Where did the story come from?

The study was carried out by researchers from the Centro Nacional de Investigaciones Cardiovasculares Carlos III, Santander Bank, and other hospitals and research centres in Spain and the US. It was funded by the Fundación Centro Nacional de Investigaciones Cardiovasculares Carlos III, Santander, the Instituto de Salud Carlos III and the European Regional Development Fund.

The study was published in the peer-reviewed Journal of the American College of Cardiology.

The research was covered well by The Guardian, which pointed out limitations and explained that skipping breakfast was not likely to be affecting heart health directly; instead, it was likely to be a marker for other unhealthy behaviours.

The Mail Online suggested that skipping breakfast "triggered the same emergency response in the body as starvation", but the study itself didn't assess this. Also, its headline stated that skipping breakfast to lose weight was the problem, but not all of the participants who skipped breakfast did so to lose weight.

The Daily Telegraph took a more cautious approach, explaining there may be a potential link between skipping breakfast and heart attacks but that additional research with long-term follow-up is probably required to confirm or disprove it.

 

What kind of research was this?

People who skip breakfast are thought to be at greater risk of heart disease. However, no studies have so far looked at whether breakfast habits are linked to the early build-up of fatty tissue in the arteries (atherosclerosis) before a person starts to experience symptoms. Atherosclerosis is an early sign of heart disease.

The current study was a cross-sectional analysis looking at whether people who skipped breakfast were more likely than those who ate breakfast to have atherosclerosis that was not yet causing any symptoms of heart disease.

The analysis was part of the ongoing Progression of Early Subclinical Atherosclerosis (PESA) study, which will follow the participants to see whose atherosclerosis progresses. This initial analysis cannot tell us whether breakfast habits directly caused the atherosclerosis seen, as both the people's habits and their fatty tissue build-up were measured at the same time.

 

What did the research involve?

Researchers recruited 4,082 adults aged 40 to 54 who worked at the headquarters of Santander Bank in Madrid. To be eligible, participants could not have heart or kidney disease, could not be morbidly obese (BMI of 40 or more) and could not have a serious disease that could lead to death in the next six years.

They reported their breakfast habits over 15 days by filling out a detailed computerised questionnaire about what and when they ate and drank, and the researchers looked at their arteries to see if they showed signs of fatty tissue build-up. The results were then analysed to see whether breakfast habits were linked to artery health.

The researchers used the questionnaire information to calculate what percentage of their daily energy intake the participants consumed at breakfast. Anything eaten before 10am was considered to be breakfast, and they were grouped into those who consumed:

  • more than 20% of their daily energy intake at breakfast ("high-energy breakfast")
  • 5-20% of their daily energy intake at breakfast ("low-energy breakfast")
  • less than 5% of their total energy intake at breakfast ("skipped breakfast")

The energy level for skipping breakfast was equivalent to just having an orange juice or coffee.

The researchers used ultrasound to assess whether people had fatty build-ups in major arteries in the neck (carotid arteries), the major artery leading from the heart through the abdomen (infrarenal abdominal aorta) and major arteries in the groin (iliofemoral arteries). They also assessed the level of calcium in the walls of the arteries supplying the heart, as this is a sign of fatty deposits.

This identified people who had signs of atherosclerosis either in any of the arteries, in the arteries supplying the heart or in multiple (four or more) sites.

They then looked at whether people with different breakfast habits were more or less likely to have atherosclerosis or other unhealthy outcomes, such as being overweight or having high blood pressure. In their analyses, they accounted for potential confounders such as:

  • age
  • education level
  • physical activity level
  • smoking status
  • dietary characteristics (such as whether
  • they were dieting to lose weight)
What were the basic results?

Only 3% of the participants skipped breakfast. Most (69%) had a low-energy breakfast, and 28% had a high-energy breakfast. Those who skipped breakfast were more likely to:

  • be male
  • be smokers
  • have changed their diet to try to lose weight in the past year
  • consume most of their calories at lunch
  • have a more unhealthy diet (higher in calories, animal protein and cholesterol; and lower in fibre and carbohydrates)

Overall, about 63% of participants showed some signs of atherosclerosis, and it was more common among people who skipped breakfast than those who did not.

Once the researchers took into account other factors that could have affected the results, people who skipped breakfast were more likely to have atherosclerosis at multiple sites or in the arteries not feeding the heart.

 

How did the researchers interpret the results?

They concluded that skipping breakfast was associated with an increased likelihood of having fatty tissue build-up in multiple arteries or in arteries not feeding the heart. This increase was found to be independent of other risk factors for heart disease.

 

Conclusion

This study found a link between skipping breakfast and fatty tissue build-up in the arteries – an early sign of heart disease.

However, because it assessed people's diets and artery health at the same point in time, and fatty deposits build up gradually in arteries, we can't say their breakfast habits directly influenced their artery health. Also, as breakfast habits were only assessed over 15 days, we can't be sure they were representative of lifelong patterns.

It looks like people who skip breakfast tend to have other unhealthy habits, such as smoking and eating more. While the researchers did try to account for the impact of these other factors, it's possible they still affected the results.

But overall, it looks like skipping breakfast tends to be a sign of someone whose habits may put them at risk of heart disease.

In general, while this study can't prove that eating breakfast will reduce the risk of heart disease, eating a healthy breakfast is in line with current UK guidance from the National Institute for Health and Care Excellence (NICE). The advice is part of its guidance about preventing excessive weight gain.

NICE recommends eating breakfast, without increasing overall daily calorie intake, as one way to help prevent excess weight gain. This means you shouldn't just eat breakfast without considering your overall calorie consumption – cut down elsewhere if you need to.

What you eat at breakfast is also likely to be important. NICE recommends that breakfast should reflect existing healthy eating advice. So for example, opt for unsweetened wholegrain cereals or bread, lower-fat milk and a portion of fruit, rather than a fry-up.

Links To The Headlines

Most important meal of the day? Skipping breakfast may be linked to poor heart health. The Guardian, October 2 2017

Skipping breakfast to lose weight can INCREASE the risk of obesity and heart disease, a study claims. Mail Online, October 2 2017

Skipping breakfast could increase risk of heart attacks, study finds. The Daily Telegraph, October 2 2017

Links To Science

Uzhova I, Fuster V, Fernández-Ortiz A, et al. The Importance of Breakfast in Atherosclerosis Disease – Insights From the PESA Study. Journal of the American College of Cardiology. Published online October 2 2017

People with type 2 diabetes should 'save carbs for last'

NHS Choices - Behind the Headlines -

"Diabetics should save bread for last at mealtime to keep their blood sugar under control," the Mail Online reports. A small study found that people with type 2 diabetes who saved their carbohydrates until the end of their meal were less likely to experience a sudden rise in their blood sugar (glucose) levels. The medical term for this spike in blood sugar levels is postprandial hyperglycaemia.

Postprandial hyperglycaemia is best avoided as not only can it make the day-to-day symptoms of diabetes worse, it has also been linked to an increased risk of developing cardiovascular disease.

It has been suggested that leaving carbohydrates until the end of a meal could slow the emptying of the stomach and give it a chance to digest the protein and vegetables first, which could help prevent a blood glucose spike. The researchers wanted to see whether this was true.

This study included just 16 people who ate the foods of their meal in different orders to test which order was most effective at lowering blood sugar and related hormones. They either ate carbohydrates first, carbohydrates last, or all nutrients together at the same time.

The researchers generally found that consuming carbohydrates last was better at lowering blood sugar levels and insulin secretion when compared to the other ways of eating carbohydrates.

While the results are interesting, the study was far too small to form the basis of any firm medical guidance. For now, it's best to follow current advice, which is to consume a healthy diet and keep active to help you manage your blood sugar level. This will also help you control your weight and generally feel better.

 

Where did the story come from?

The study was carried out by US researchers from Weill Cornell Medical College, Columbia University and Boston Children's Hospital. It was funded by the Louis and Rachel Rudin Foundation Grant, and Diane and Darryl Mallah from The Diane and Darryl Mallah Family Foundation.

The study was published in the peer-reviewed BMJ Open Diabetes Research & Care. It is available on an open-access basis and can be read for free online.

The Mail Online's coverage generalised the results to all diabetics – but the study only looked at those with type 2 diabetes. People with type 1 diabetes typically require insulin injections to keep their blood sugar levels under control.

It also presented the findings as if they were a solid recommendation, but this is not the case, especially given this was an early-stage study using a very small number of people.

 

What kind of research was this?

This was a randomised crossover trial that aimed to determine the best time during a meal to eat carbohydrates to lower blood glucose levels in individuals with type 2 diabetes. The researchers also wanted to explore whether changing the order in which foods were eaten during a meal had any effect on the secretion of insulin and other glucose-regulating hormones.

Previous research has suggested that saving carbohydrates until the end of the meal lowers blood glucose levels. This follows on from the notion that eating proteins at the start of a meal stimulates insulin secretion (which helps control glucose levels). However, data on this hypothesis is limited and the researchers of this study wanted to investigate this idea further.

Crossover trials such as this are often used when the sample size is very small. Each person acts as their own control, which effectively increases sample size. The study would ideally need to be conducted using a much larger sample with people randomised to consume nutrients in different orders over a longer period to compare effects.

 

What did the research involve?

The researchers recruited 16 people with type 2 diabetes, between the ages of 35 and 65. All the participants had a body mass index (BMI) of between 25 and 40kg/m2 (covering the range from overweight to severely obese) and had been diagnosed with diabetes within the last 10 years.

All 16 people consumed the same meal on three separate days spaced out one week apart, with each meal following a 12-hour overnight fast.

The meals varied in terms of the order in which the nutrients were eaten. Participants were assigned the following meal types in random order:

  • carbohydrates first, followed by protein and vegetables 10 minutes later
  • protein and vegetables, followed by carbohydrates 10 minutes later
  • all nutrients eaten together

Blood samples were taken before consumption, and then at 30-minute intervals up to 180 minutes. The following were measured:

  • glucose levels
  • insulin levels (a hormone released in response to high glucose levels)
  • glucagon-like peptide-1 (GLP-1, a hormone secreted in the gut in response to food to signal the release of insulin)
  • glucagon levels (a hormone released in response to low glucose levels)

All participants were instructed to maintain their usual level of diet and physical activity during the full study period.

 

What were the basic results?

The following was observed:

  • When carbohydrate was consumed last, lower levels of insulin were secreted (24.8% lower than the meal with carbohydrates first), which would suggest a smaller spike in glucose. There was no significant difference between eating carbohydrates last and having all nutrients together.
  • Consistent with this, glucose levels were 53.8% and 40.4% lower in the meal with carbohydrates last compared to having carbohydrates first and all nutrients together, respectively.
  • The GLP-1 levels were higher in people who ate carbohydrates last.
  • Glucagon levels were not significantly different between the three meal conditions.

 

How did the researchers interpret the results?

The researchers concluded: "In this study, we demonstrated that the temporal sequence of carbohydrate ingestion during a meal has significant impact on postprandial glucose regulation. These findings confirm and extend results from our previous pilot study; the inclusion of a third nutrient order condition, a sandwich, had intermediate effects on glucose excursions compared with carbohydrates last versus carbohydrates first."

 

Conclusion

This crossover trial investigated the optimal time to eat carbohydrates during a meal to lower blood glucose levels in individuals with type 2 diabetes. It generally found that consuming carbohydrates last was better at lowering glucose levels and reducing insulin secretion when compared to having carbohydrates first or all nutrients together.

The researchers say that suggesting people with type 2 diabetes follow this advice may be an effective behavioural strategy to improve glucose levels after meals.

Although the findings are interesting, there are a few points to note:

  • Most importantly, this study was very small. A study using a much larger sample could give completely different results. Ideally the findings would need to be verified in a well-designed trial that randomised a much larger number of people with type 2 diabetes to consume their nutrients in a specific order, and then followed their response to this pattern over a longer period of time.
  • There may be other factors affecting individual responses to the order of carbohydrate consumption – for example, the level of physical activity was not standardised across all participants. Again this is another factor that would need to be controlled in a larger trial.
  • We are all different – and saving carbohydrates until the end of a meal may only be effective for some people with type 2 diabetes, and not others.
  • The findings cannot be applied to people with type 1 diabetes.

These findings may pave the way for further research through larger trials, which in time may result in a change in the current recommendations for meal consumption for people with type 2 diabetes.

However, they have no current implications. For now, a healthy diet and keeping active will help you manage your blood sugar level. This will also help you control your weight and generally feel better.

    Links To The Headlines

    Don't eat the bread first: Saving carbs for last at mealtime may help control blood sugar levels for diabetics, study finds. Mail Online, September 29 2017

    Links To Science

    Shukla AP, Andono J, Touhamy SH, et al. Carbohydrate-last meal pattern lowers postprandial glucose and insulin excursions in type 2 diabetes. BMJ Open Diabetes Research & Care. Published online September 14 2017

     

    Bedbugs thought to 'hitchhike' on dirty holiday laundry

    NHS Choices - Behind the Headlines -

    "Dirty laundry a powerful magnet for bedbugs, study finds," is The Guardian's headline, with The Times and The Daily Telegraph also covering this creepy-crawly story.

    Bedbugs are small blood-sucking insects that live in cracks and crevices in and around beds. They crawl out at night and bite exposed skin to feed on blood.

    The number of bedbugs has soared across the globe recently, with cheap air flights believed to play a role in their spread. But until now, it hasn't been clear how or why these tiny wingless bugs manage to travel great distances.

    The authors of this latest study now think they have the answer: dirty laundry left lying around in hotel rooms, regardless of the presence of a human host.

    In experiments done on identical rooms, researchers found bedbugs were most likely to collect in bags containing dirty clothes than in bags of clean laundry. The researchers propose that traces of body odour on dirty laundry are enough to attract the critters – the presence of humans isn't necessary.

    Once in the laundry bag, the insects can travel in a person's luggage back home and then hide under mattresses, in headboards, or along carpet edges.

    The researchers suggest a simple way of protecting yourself against the unwelcome hitchhikers: keep dirty laundry in sealed bags.

    This was a small experimental study with limitations. But as bedbug infestations are so tricky to treat, prevention is key – and it makes sense to try this simple measure the next time you're travelling.

     

    Where did the story come from?

    The study was carried out by researchers from the University of Sheffield and was funded by the university's Department of Animal & Plant Sciences.

    The study was published in the peer-reviewed journal Scientific Reports and is free to read online.

    The Telegraph headline, that "Keeping dirty laundry in the bedroom allows bed bugs to thrive," may be slightly misleading: bedbugs have to be present in the first place, so the average home is unlikely to be at risk. It is travel that's likely to pose more of a risk, which the article doesn't mention until later on.

     

    What kind of research was this?

    This was an experimental study, carried out by researchers who wanted to understand how and why bedbugs travel so easily in suitcases and clothes, given that they like to hide in crevices in and around beds and are thought to like being near sleeping people.

    The researchers of this study wanted to look into how odours may attract bed bugs while also investigating other potential reasons, such as carbon dioxide levels, which have previously been shown to influence mosquitoes.

    Experimental studies like this are useful early stage research – however, especially in a study such as this one, there could be other factors at play that can't be necessarily be accounted for in a controlled environment.

     

    What did the research involve?

    Clothes were taken from four volunteers, which had been worn for 3 hours during normal daily activity. Clean clothes were also used as a comparison. Both sets of clothes were placed into clean, cotton tote bags.

    Two temperature-controlled (22C) experimental rooms were used. One of the rooms received an increase in carbon dioxide (CO2) to imitate a human breathing in the room; the other room had normal levels of carbon dioxide.

    A sealed container with bed bugs in was placed in each room for 48 hours. Four clothing bags were then introduced into each room – two containing soiled laundry and the other two containing clean laundry, placed in such a way to alternate between clean and dirty.

    After 24 hours, the lid of the container was removed, allowing the bugs to roam free. After a further 96 hours, the number of bedbugs and their locations were noted.

    Location was categorised into three groups:

    • remaining in the original space
    • within/on clothing bag
    • on the floor of the arena (room)

    The experiment was repeated six times and the rooms were cleaned with bleach between each run. Findings were compared between the two rooms.

     

    What were the basic results?

    This study found the following:

    • Bedbugs were more likely to be on or within the bags containing soiled clothes than the ones containing clean laundry. Levels of carbon dioxide had no effect on this.
    • Higher CO2 levels did, however, affect the behaviour of bedbugs within the room: more bedbugs left the container in the high-CO2 room compared with the control room.

     

    How did the researchers interpret the results?

    The researchers concluded: "Our results show that over a period of several days bedbugs are attracted to, and remain on, soiled clothing: this provides a biologically realistic mechanism that underpins passive, long-range dispersal in bed bugs."

    They added: "Careful management of holiday clothing may be an important strategy in the prevention of bringing home bedbugs."

     

    Conclusion

    This experimental study suggests a likely way that bedbugs get into luggage and travel long distances to spread between countries.

    It found that bed bugs are more attracted to dirty laundry than clean laundry, highlighting that it is probably human body odour – regardless of whether a human is present or not – that is the magnet for bed bugs.

    The researchers suggest that worn clothing left out in the open – even just in an open suitcase – is likely to attract any bedbugs that may be present in a hotel room or hostel, and be transported back home by holidaymakers.

    But don't worry: a laundry bag in the average home probably isn't a cause for concern, where bed bugs are thankfully quite rare.

    While bedbugs aren't dangerous and don't spread disease, some people can experience a reaction to the bites.

    Signs of an infestation can include:

    • small bugs or tiny white eggs in the crevices and joints of your mattress and furniture
    • bites on your skin
    • tiny black spots on your mattress or blood spots on your sheets
    • mottled bedbug shells

    Keeping your laundry sealed in a bag the next time you're travelling is a simple measure that may reduce your chance of bringing home the unwelcome hitchhikers.

    Read more about bedbugs and how you can keep your home bug-free.

    Links To The Headlines

    Dirty laundry a powerful magnet for bedbugs, study finds. The Guardian, September 28 2017

    Keeping dirty laundry in the bedroom allows bed bugs to thrive, say scientists. The Daily Telegraph, September 28 2017

    Bed bug pandemic is linked to dirty laundry. The Times, September 29 2017 (subscription required)

    Links To Science

    Hentley WT, Webster B, Evison SEF, Siva-Jothy MT. Bed bug aggregation on dirty laundry: a mechanism for passive dispersal. Scientific Reports. Published online September 28 2017

    Has measles really been 'eliminated' in the UK?

    NHS Choices - Behind the Headlines -

    "Measles eliminated in the UK for the first time," reports The Telegraph.

    This and other stories in the media are based on a new World Health Organization (WHO) report confirming the UK is now one of 33 countries in Europe to have "eliminated" measles.

    "Elimination" is the official term used once a country has reduced the number of cases of a disease to a low enough level to stop it spreading through the general population for at least three years.

    It doesn't mean that measles has been wiped out or eradicated in the UK. In 2016 there were more than 500 cases in England and Wales. However, the disease wasn't able to spread more widely.

    It also doesn't mean that children no longer need the MMR vaccination, which protects against mumps and rubella as well as measles. In fact it's vital that young children continue having the MMR vaccination to stop the number of measles cases rising again.

    Read more about the MMR vaccination

     

    What is measles and what is the vaccination?

    Measles is an infectious disease that can lead to serious complications, such as pneumonia. In rare cases it can be fatal. Anybody who has not been vaccinated and has not had measles before is at risk of catching it.

    Having measles can cause cold-like symptoms such as a runny nose, sore red eyes, fever and small grey-white spots inside the cheeks. A few days after this, a red-brown rash will appear, usually starting on the head or upper neck and spreading down to the rest of the body.

    Children need two doses of the MMR jab to be fully protected against measles, mumps and rubella. The first dose is usually given within a month of their first birthday. They will then be invited to have a second dose before starting school, usually at three years and four months.

     

    How does the measles vaccination work?

    The MMR vaccination works by delivering a weakened version of the measles, mumps and rubella viruses. This triggers the immune system to produce antibodies. If the person later comes into contact with one of the viruses, the immune system recognises it and produces antibodies to fight it.

    The effectiveness of the MMR vaccine means that cases of measles have dropped in the UK, but there have still been several outbreaks in recent years.

    The UK was on the verge of achieving "elimination" in the 1990s. However, a report published in 1998 claiming a link between the MMR vaccine and autism (which was unfounded) led to a drop in parents getting their children immunised, followed by large outbreaks of measles.

     

    What does the WHO report show us?

    The WHO report says the UK has "eliminated" measles. This means that, for the past three years, the number of cases has been low enough to stop the disease circulating around the country.

    If the UK wants to keep the number of cases down – and its "elimination" status – it needs to meet its targets for MMR vaccination coverage.

     

    Are we meeting our vaccination targets?

    Recent NHS data shows that 95% of children are now having their first dose of the MMR vaccination by their fifth birthday, meeting this WHO target for the first time. This means it is far more difficult for diseases to spread because so many people are immune. However, in England:

    In 2016/17, only 87.6% of children had received both doses of the MMR by their fifth birthday. This is lower than the previous two years: 2014/15 (88.6%), 2015/16 (88.2%).

    Only 91.6% had received the first dose of MMR by their second birthday, also a decrease on the previous two years: 2014/15 (92.3%), 2015/16 (91.9%).

    This drop in MMR uptake over the past few years means there is a risk that cases of measles will start to rise again, particularly in London where uptake of the vaccination is lower.

    Talking about the UK's new "elimination" status for measles, Dr Mary Ramsay, head of immunisation at Public Health England, told BBC News: "This is a huge achievement and a testament to all the hard work by our health professionals in the NHS to ensure that all children and adults are fully protected with two doses of the MMR vaccine.

    "We need to ensure that this is sustained going forward by maintaining and improving coverage of the MMR vaccine in children and by catching up older children and young adults who missed out."

    Links To The Headlines

    UK 'eliminates measles' for first time. BBC News, September 27 2017

    Measles eliminated in the UK for the first time. The Daily Telegraph, September 27 2017

    Measles wiped out in Britain for first time. The Times, September 28 2017

    Rates of newly diagnosed HIV increasing in over-50s

    NHS Choices - Behind the Headlines -

    "HIV rises among over-50s as they neglect safe sex" is the headline from The Times.

    The news is based on a European study that found more over-50s are being diagnosed with HIV compared with 12 years ago.

    The study collected data on more than 360,000 people who had been newly diagnosed with HIV between 2004 and 2015 in Europe.

    The researchers looked at infection rates over time according to age, route of transmission and country.

    They found a number of differences between the patterns of infection and diagnosis in those aged 15 to 49 and in those aged 50 and over.

    In the over-50s age group, though people remained more likely to become infected with HIV through heterosexual sex, the rate of infection in men who have sex with men and through drug injection had increased between 2004 and 2015.

    But in younger adults, infection rates hadn't changed over time and men having sex with men remains the most likely route of transmission.

    Older people were also more likely to be diagnosed when the disease was advanced compared with younger people.

    This study highlights the need for people of all ages to be aware of the risks of HIV infection from unprotected sex.

    HIV tests are free on the NHS and can be done in various places, including walk-in sexual health clinics. There are also home testing kits available.

    Find out more about HIV tests and find HIV testing services near you.

    Where did the story come from?

    The study was carried out by researchers from the European Centre for Disease Prevention and Control in Sweden in collaboration with members of the European Union/European Economic Area HIV Surveillance Network.

    It was funded by the European Centre for Disease Prevention and Control.

    The study was published in the peer-reviewed journal The Lancet. The abstract is available free online.

    Some of the media stories suggested the rise in HIV cases among older people was because this age group neglected messages about safer sex.

    Mail Online went as far as saying: "Reckless sexual behaviour by divorcees is behind an increase in HIV cases among the over-50s, a major study suggests".

    But the study didn't report on marital or relationship status, and didn't investigate sexual behaviour.

    Several stories also focused on the number of older people who have been infected through heterosexual contact.

    While heterosexual sex is the most likely transmission route for the over-50s age group, these rates have remained stable over the last 12 years.

    It's the rate of infection from sex between men and from drug injection that has increased over time for this age group.

    What kind of research was this?

    This was an observational study using data sent by EU and EEC member states to the European Surveillance System for HIV.

    This type of study is useful for identifying trends in diagnosis rates, but relies on accurate data reporting and collection.

    Actual rates of HIV may be higher, as this only takes into account people who have had a positive test.

    What did the research involve?

    The researchers collated data from 31 countries on new cases of HIV diagnosed between January 2004 and December 2015.

    The data was anonymised, but included:

    • date of diagnosis
    • age
    • sexual history
    • mode of transmission
    • country of birth
    • country of diagnosis
    • stage of disease according to CD4 count, with late diagnosis defined as less than 350 cells/µL and advanced disease as less than 200 cells/µL

    They analysed the data according to two age groups: younger people aged 15 to 49 and older people aged 50 or over.

    What were the basic results?

    Overall, between 2004 and 2015:

    • There were 312,501 new cases of HIV in people aged 15 to 49, a rate of 11.4 per 100,000 people. This rate of infection didn't change over time.
    • There were 54,102 new cases of HIV in adults over 50, a rate of 2.6 per 100,000 people. The rate of infection increased by 2.1% per year over the 12-year period.

    In the UK:

    • There was an increase of 3.6% in new diagnosis rates for older people between 2004 and 2015, from 3.1 to 4.32 new cases per 100,000 people. This is higher than the European average.
    • There was a 4% reduction in new diagnosis rates for younger adults during this time.

    Diagnosis by age group:

    • Older people were more likely to have a delayed diagnosis, with significantly lower CD4 counts than younger adults.

    Men compared with women:

    • Over the 12-year period, the average diagnosis rate for older men increased from 3.5 to 4.8 per 100,000, while older women had an increase from 1.0 to 1.2 per 100,000.
    • Over the same period, the average rate of diagnosis increased by 1.4% in younger men and reduced by 4.8% for younger women.

    Mode of transmission in 2015:

    • The most common route of infection for older adults was heterosexual contact (42.4% of cases), followed by sex between men (30.3%), "other" or unknown causes (24.6%), and injecting drugs (2.6%).
    • For younger adults, sex between men was the most common route of infection (45.1% of cases), followed by heterosexual contact (30.8%), other or unknown (19.5%), and injecting drugs (4.6%).

    Changes in mode of transmission from 2004 to 2015:

    • The rate of HIV infection from heterosexual sex remained stable in older people, and decreased in younger people.
    • Infection resulting from injecting drugs increased in older people and decreased in younger people.
    • The rates of HIV infection in men who have sex with men increased in both age groups, but more so in older people at 5.8% compared with 2.3%.
    How did the researchers interpret the results?

    The researchers concluded that the "increasing new HIV diagnoses among older adults point towards the compelling need to heighten awareness among healthcare providers and deliver more targeted prevention interventions for this age group and the total adult population".

    They were also careful to say that "no data for the reasons behind such an increase [in new HIV diagnoses in older people] have been published".

    Conclusion

    This was a well-conducted study and the results are likely to be reliable, though there are some limitations, including missing data.

    For example, the researchers had no information on the migration status or CD4 count (an indicator for stage of the disease) for a quarter of cases.

    This study found that although the overall rate of infection is higher in younger people, this has remained stable over the last 12 years while the rate of infection in older people has increased.

    Some of the media stories focused on the finding that older people are most likely to have become infected through heterosexual sex.

    While true, this is nothing new: the rate of infection from heterosexual sex has in fact been stable for over-50s over the study period, whereas the rates of infection in men having sex with men and drug use have both increased for this age group.

    What makes further analysis of this trend difficult to interpret is the high proportion of people for whom "other" or "unknown" infection was recorded.

    The finding that older people were more likely to have a delayed diagnosis highlights the importance of HIV testing for people of all ages who are at risk of infection.

    What's of most concern is that the rates of infection remain high in all age groups despite public health campaigns about practising safe sex.

    HIV tests are free on the NHS and can be done in various places, including walk-in sexual health clinics. There are also home testing kits available.

    Find out more about HIV tests and find HIV testing services near you.

    Links To The Headlines

    HIV rates climbing among over-50s in UK and Europe, researchers warn. The Guardian, September 26 2017

    Rise in new HIV cases in over-50s – study. BBC News, September 27 2017

    HIV on the rise in the over-50s: Warning that reckless sexual behaviour of 'silver splitters' has led to an increase in cases. Mail Online, September 27 2017

    HIV rising among over-50s as they neglect safe sex. The Times, September 27 2017

    Links To Science

    Tavoschi A, Gomes Dias J, Pharris A. New HIV diagnoses among adults aged 50 years or older in 31 European countries, 2004–15: an analysis of surveillance data The Lancet HIV. Published September 26 2017

    High-precision radiotherapy for prostate cancer 'shows promise'

    NHS Choices - Behind the Headlines -

    "Targeted radiotherapy 'cures' prostate cancer that kills thousands," reports The Times.

    The news is based on a UK study of the use of high-precision radiotherapy to treat men with advanced localised prostate cancer.

    Researchers wanted to see if they could safely target cancer cells that had spread outside the prostate to nearby lymph nodes without damaging nearby healthy cells, and reduce treatment side effects.

    Prostate cancer is the most common cancer in men – more than 47,000 cases are diagnosed in the UK every year.

    Some 447 men with locally advanced disease took part in the 10-year study, carried out by the Institute of Cancer Research and the Royal Marsden NHS Foundation Trust.

    The high-tech radiotherapy, called pelvic lymph node intensity modulated radiation therapy (PLN-IMRT), can modify the shape and strength of its beams to target cancerous cells more effectively.

    The main aim of the study was to look at the side effects of the treatment, specifically on the bladder and bowels.

    Five years after receiving treatment, up to 71% of patients were alive and disease-free. Only 8-16% of patients experienced bowel or bladder complications.

    This is promising research that suggests PLN-IMRT should be studied further. Later-stage randomised controlled trials would be the best way of confirming the safety and potential benefit of this treatment for men with advanced localised prostate cancer and seeing how it compares with other treatment approaches.

    Where did the story come from?

    The study was carried out by researchers from the Institute of Cancer Research and the Royal Marsden NHS Foundation Trust, both in London. It was funded by Cancer Research UK, the Department of Health, the National Institute for Health Research (NIHR) Cancer Research Network and the NHS.

    It was published in the peer-reviewed International Journal of Radiation Oncology Biology Physics and is free to read online.

    The media headlines talking of a "cure" are premature at this point. This early-stage study focused on the potential harms of PLN-IMRT.

    While the number of men surviving without disease progression was an exciting finding that should prompt further research, it's important to realise that the present study wasn't designed to give us definitive answers on whether the treatment works or how it should be delivered.

    What kind of research was this?

    This was a phase I and phase II trial designed to see whether PLN-IMRT was a feasible treatment to use in men with advanced localised prostate cancer and to look at its side effects.

    Locally advanced prostate cancer means the cancer has spread outside of the prostate to the nearby lymph nodes and tissues, such as the semen-carrying seminal vesicles.

    There are a number of treatment options, one of which is radiotherapy – but this is often targeted at the prostate and seminal vesicles rather than directly at the lymph nodes.

    This is an early-stage trial, so the participants were not randomised to the treatment they received and there was no comparison group receiving a different treatment.

    This stage of trial is important for looking at side effects and seeing if the treatment approach is feasible, but it can't provide good evidence for how effective the treatment is – that requires later-stage trials.

    What did the research involve?

    The researchers recruited 447 men with advanced localised prostate cancer. The men received radiotherapy to the prostate as well as to the prostate lymph nodes in one of five different dosage patterns.

    The dosage pattern each person received was determined by the order in which they entered the study, rather than being allocated at random.

    The dosages were:

    • group 1: 70-74 gray units of radiation (Gy) to the prostate and 50Gy to the prostate lymph nodes over 35-37 sessions
    • group 2: as group 1 but with 55Gy to the prostate lymph nodes
    • group 3: as group 1 but with 60Gy to the prostate lymph nodes
    • group 4: 60Gy to the prostate and 47Gy to the prostate lymph nodes, spread across 20 sessions over the course of four weeks
    • group 5: as group 4 but across 20 sessions over five weeks

    Everyone in the study also received long-course androgen-deprivation therapy (the male hormone, androgen, helps the cancer to grow).

    Men were not allowed to participate in the study if they were unsuitable for radical radiation therapy, or had a history of either pelvic surgery or inflammatory bowel disease.

    The main aim was to look at side effects of the treatment, particularly toxic effects on the bladder and bowel within two years of treatment.

    The researchers also got an indication of how effective the treatment was by measuring survival rates as the study progressed and how many men could be considered to be free of prostate cancer.

    However, it should be noted that, as this wasn't a randomised trial, the men in each treatment group were not necessarily directly comparable in terms of their risk factors at the start of the study.

    What were the basic results?

    The researchers found that acute bowel toxicity peaked between six and eight weeks after treatment in groups 1, 2 and 3, but it occurred earlier in group 4 (in weeks four to five) and group 5 (weeks five to six). Most cases of bladder toxicity occurred in the first few weeks following treatment.

    Rates of both bowel and bladder toxicity stabilised over time and were similar in all groups 18 weeks after treatment.

    The overall toxicity rates per group at two years after treatment were as follows:

    • group 1: bowel 8.3%, bladder 4.2%
    • group 2: bowel 8.9%, bladder 5.9%
    • group 3: bowel 13.2%, bladder 2.9%
    • group 4: bowel 16.4%, bladder 4.8%
    • group 5: bowel 12.2%, bladder 7.3%

    Disease progression occurred in 169 of 426 men (40%). The disease-free survival and overall survival rates were:

    • group 1 (26 people allocated): 38% disease-free, 76% survival
    • group 2 (59): 61% disease-free, 88% survival
    • group 3 (157): 70% disease-free, 92% survival
    • group 4 (70): 80% disease-free, 97% survival
    • group 5 (135): 78% disease-free, 95% survival
    How did the researchers interpret the results?

    The researchers described the bladder- and bowel-related toxicity rates of the treatment to be "acceptable" both in the short and longer term. They described the long-term disease-free survival of some people in the study as being consistent with other research on the same type of treatment.

    Conclusion

    This study shows some promising results for targeted pelvic lymph node radiotherapy for men with advanced localised prostate cancer.

    However, these results can only be treated as preliminary findings for now. This was an early-stage trial that aimed to investigate whether the treatment approach is safe and to get an idea of what doses may be suitable for assessment in further trials. Although it can give an indication of effectiveness, this was not the main aim of the study.

    Men were not randomised to a treatment group, which means there may have been some differences in the cancers or patient characteristics of men who received the different radiation dosages. This could, in turn, have impacted how effective the treatment was and makes it hard to know at this stage what the optimal approach to delivering this treatment would be – which dose is the best, for example.

    All men in the study also received some kind of pelvic lymph node radiotherapy, which means it's not possible to say how effective PLN-IMRT is compared with more conventional treatment approaches.

    This research gives us a potential new treatment to investigate for men with locally advanced prostate cancer. Further trials looking more precisely at the effectiveness of this treatment are already in progress.

    However, it will be some time before it's known whether this could become a standard treatment option in the future.

    Links To The Headlines

    Targeted radiotherapy 'cures' prostate cancer that kills thousands. The Times, September 26 2017

    Prostate cancer treatment could cure men for whom there was no hope. The Telegraph, September 26 2017

    Three in four terminal prostate cases 'cured by new radiotherapy': Technique that blasts tumours to stop them advancing left patients free of the disease five years after treatment. Mail Online, September 26 2017

    CANCER 'CURE' Pioneering form of radiotherapy can cure prostate cancer for men previously thought inoperable, trials suggest. The Sun, September 26 2017

    Links To Science

    Reis Ferreira M, Khan A, Thomas K, et al. Phase 1/2 Dose-Escalation Study of the Use of Intensity Modulated Radiation Therapy to Treat the Prostate and Pelvic Nodes in Patients With Prostate Cancer. International Journal of Radiation Oncology, Biology, Physics. Published online August 1 2017

    Sexual harassment in the workplace linked to depression

    NHS Choices - Behind the Headlines -

    News that sexual harassment in the workplace can cause depression and work absence has hit the headlines after the results of a Danish study were published.

    Researchers surveyed 7,603 employees from 1,041 organisations in Denmark, and asked them about symptoms of depression and whether they'd been subjected to sexual harassment from colleagues or customers or clients in the past 12 months. Overall, 4% of women and 0.3% of men reported harassment.

    People who reported harassment from customers or clients scored 2.05 points higher on a 50-point depression score than those reporting no harassment. People reporting harassment from colleagues scored 2.45 points higher.

    The findings generally support the understanding that sexual harassment can have harmful effects on mental health – regardless of who it comes from.

    But this study has many limitations:

    • The one-off assessment can't show that harassment preceded depression symptoms.
    • We don't know how meaningful the small score difference was and who'd actually diagnosed the employees with depression.
    • The prevalence of harassment may be inaccurate – people being harassed may not have felt comfortable reporting this, or may not have completed the work survey at all.

    This study can only show a link between sexual harassment and depression. It can't prove that sexual harassment causes depression, no matter how plausible it seems.

    Where does the study come from?

    The study was conducted by researchers from the National Research Centre for the Working Environment, the University of Southern Denmark and the University of Copenhagen, all in Denmark.

    No sources of funding were reported and the authors declared no conflicts of interest.

    The study was published in the peer-reviewed journal BMC Public Health, and is available to read free online.

    The media generally reported the study's findings accurately, but the news stories could benefit from addressing the many limitations of what we can conclude from the results of this research.

    What kind of research was this?

    This cross-sectional study looked at the relationship between employees reporting having been sexually harassed by clients or customers, or workplace colleagues, and symptoms of depression.

    Previous research has shown that sexual harassment can have harmful effects on mental health, including depression and anxiety.

    Most past research is said to have focused on harassment in the workplace coming from colleagues or supervisors, with little attention given to clients or customers. This was therefore the specific focus of this study.

    But the main limitation of the design of this study is that because it's a one-off assessment, it can't prove the harassment preceded the depression and is the single direct cause of these symptoms, however plausible that might be. It can only show a link.

    What did the researchers do?

    The study obtained data from two sources: the Work Environment and Health in Denmark cohort study (WEHD) and the Work Environment Activities in Danish Workplaces Study (WEADW).

    The WEHD invites a random sample of employed adults (aged 18 to 64) to take part in a postal or internet-based questionnaire on their health and work environment every two years.

    The current study involves 7,603 people who responded in 2012 (covering 1,041 work organisations). They represent half of all people invited to participate in the surveys.

    The WEADW invited individual organisations and their employees to take part in the survey.

    The study included 1,053 organisations and 8,409 employees within these organisations. Again, these represented about half of the organisations and half of the employees invited to take part.

    Sexual harassment in the workplace was assessed by asking: "Have you been exposed to sexual harassment at your workplace during the last 12 months?". People who responded yes were then asked who the perpetrator was.

    The researchers grouped the responses as harassment from clients or customers, or from others in the workplace like colleagues, supervisors or subordinates.

    Depression symptoms were assessed using the Major Depression Inventory (MDI), which includes 12 questions that cover the standard diagnostic criteria for depression.

    The final score ranges from 0 to 50, with a higher score showing more symptoms of depression.

    The researchers split responses into probable depression or not, using a cut-off of above or below 20, which was established in prior research.

    They also asked if there were psychological workplace initiatives, such as health insurance to cover treatment by psychologists, or whether the workplace performed a psychosocial assessment.

    The researchers looked at the relationship between these factors, adjusting for age, gender and the nature of the workplace (for example, healthcare, industry or construction) as potential confounders.

    The final sample from the two surveys combined included 7,603 adults who completed all relevant questions, from 1,041 organisations.

    What were the basic results?

    The average age of participants was 46. Healthcare work was the most common occupational group (29%), closely followed by "knowledge work" (25%), then industry and the private sector.

    The proportion of people who reported sexual harassment was low: 4.1% of women, 0.3% of men, or 2.4% of respondents overall.

    People working in health or care were most likely to report sexual harassment from clients or customers, rather than colleagues.

    Average depression scores were 2.05 points higher (95% confidence interval [CI] 0.98 to 3.12) for people exposed to sexual harassment from clients or customers compared with those reporting no sexual harassment.

    Depression scores were 2.45 points higher (95% CI 0.57 to 4.34) when people had been sexually harassed by their colleagues.

    The risk of what the researchers called "clinical depression" wasn't significantly higher for people exposed to harassment from clients or customers. The risk of "clinical depression" was significant when people were harassed by their colleagues.

    But the researchers didn't define what they meant by "clinical depression".

    Any psychological workplace initiatives reported had no effect on the links between sexual harassment and depression.

    What do the researchers conclude?

    The researchers concluded: "The association between sexual harassment and depressive symptoms differed for employees harassed by clients or customers and those harassed by colleagues, supervisors or subordinates.

    "The results underline the importance of investigating sexual harassment from clients or customers and sexual harassment by colleagues, supervisors or subordinates as distinct types of harassment.

    "We found no modification of the association between sexual harassment by clients or customers and depressive symptoms by any of the examined psychosocial workplace initiatives."

    Conclusions

    This study in general supports the understanding that sexual harassment can have harmful effects on mental health – regardless of whether it comes from clients or colleagues.

    It's also perhaps unsurprising that health or care workers were more likely to report sexual harassment from clients or customers, as they generally have more close interaction with members of the public than many other professions.

    The researchers also pointed out that sexual harassment by clients or customers should not be normalised or ignored by employers.

    This study has advantages in its large sample size and thorough assessments, and will provide a valuable contribution to research in this area.

    But as a piece of evidence, it still can't prove that sexual harassment directly causes depression, no matter how likely this may seem.

    The study had many limitations, including:

    • This is a cross-sectional assessment, and participants were asked about symptoms of depression at the same time as they were questioned about harassment. It's not possible to determine the direction of the relationship and know whether harassment preceded depression symptoms.
    • The people involved aren't necessarily representative of all employees. Only half of eligible employees responded to the two surveys in the study. There may be differences in those who chose to respond and those who did not. People who are being harassed in their workplace may be less likely to want to complete a survey on their workplace. And some of the responses may be inaccurate as people may not feel comfortable saying they're being harassed – especially who by. Overall, the number of people currently being harassed in the workplace could be much higher than the percentage reported here.
    • The study only asked about harassment in the past 12 months. It didn't look at previous harassment situations that have now been resolved. Lifetime harassment exposure in the workplace is unknown and could be higher.
    • The study isn't able to delve into how long the harassment has been going on, or the nature of the harassment. These things could give a better indication of how it's linked with depression symptoms. 
    • The depression diagnoses aren't clear. The main finding was that people who'd been harassed were a few points higher on the 50-point depression score. It's difficult to say how much of an effect this difference would have on the person's health and wellbeing. The researchers looked at the effect on risk of "clinical depression", but it's not clear what they meant by this.
    • We can't read too much into the risk relationships identified because of several factors: the potentially non-representative sample, the small proportion of employees who reported harassment, and the uncertain diagnoses of depression symptoms.
    • The study surveyed people from Denmark. This means the findings may not easily be applied to the UK or other countries.

    Nevertheless, these limitations don't undermine the importance of these findings.

    Anyone experiencing workplace harassment in any form, whether from clients or customers or colleagues, should feel able to report it.

    It's also important to seek help from a health professional if you're experiencing symptoms of depression.

    Read more about how to look after your mental health.

    Links To The Headlines

    Sexual harassment from work colleagues causes more harm, study suggests. The Independent, September 24 2017

    Depression risk from harassment. The Times (subscription required), September 25 2017

    Links To Science

    Friborg MK, Hansen JV, Aldrich PT, et al. Workplace sexual harassment and depressive symptoms: a cross-sectional multilevel analysis comparing harassment from clients or customers to harassment from other employees amongst 7603 Danish employees from 1041 organizations. BMC Public Health. Published online September 25 2017

    Any type of physical exercise is good for the heart

    NHS Choices - Behind the Headlines -

    "Vacuuming and scrubbing the floor are enough exercise to protect the heart and extend life," reports The Telegraph, with other media sources reporting a similar finding – that physical activity in our everyday lives is just as good as going to the gym.

    This follows a large international study published in The Lancet that included more than 130,000 people from 17 countries.

    The researchers wanted to compare physical activity and heart disease levels in countries ranging from low income to high income.

    There's firm evidence that regular physical activity reduces the risk of cardiovascular disease (CVD) and other long-term diseases. However, most evidence has come from high-income countries where people often exercise for leisure – for example, going to the gym or playing sport.

    In lower-income countries, it's possible people are generally less likely to do recreational exercise but more likely to have physically active lifestyles involving manual work. The aim was to see if this sort of day-to-day activity could be just as beneficial as any other type of exercise.

    The main finding was that it made no difference. Physical activity of any type – whether it was walking or doing household chores – was clearly linked with a lower risk of death or heart disease and stroke.

    The study supports current government recommendations to do at least 150 minutes of moderate activity a week. People who achieved this had about a 20-30% reduced risk of death, heart disease or stroke compared to those who didn't.

    Where did the story come from?

    The study was carried out by researchers from Simon Fraser University and Hamilton Health Sciences & McMaster University, both in Canada, and from the University of Edinburgh, among other international institutions.

    Funding was provided by a number of organisations including the Population Health Research Institute, and the Canadian Institutes of Health Research, Heart and Stroke Foundation of Ontario, as well as pharmaceutical companies AstraZeneca, Sanofi-Aventis, Boehringer Ingelheim, Servier, GSK, Novartis and King Pharma.

    The study was published in the peer-reviewed medical journal The Lancet, and is free to read online.

    Generally, the media accurately reported the finding that the more exercise you do – regardless of the type – the better. However, headlines tended to emphasize household and other daily chores rather than recreational activities, which was slightly misleading. Housework wasn't found to be any better than other forms of activity recorded.

    What kind of research was this?

    This was an international prospective cohort study that looked at the relationship between physical activity and cardiovascular disease and mortality.

    The Prospective Urban Rural Epidemiologic (PURE) study included 17 countries around the world with different income levels to see if the benefits of exercise on the heart depended on the type of physical activity done.

    What did the research involve?

    The PURE study included three high-income countries (Canada, Sweden and the United Arab Emirates), seven upper-middle-income countries (Argentina, Brazil, Chile, Poland, Turkey, Malaysia and South Africa), three lower-middle-income countries (China, Colombia and Iran), and four low income countries (Bangladesh, India, Pakistan and Zimbabwe).

    Within the countries, different urban and rural communities were selected to represent geographical diversity. Adults aged 35 to 70 from selected households were invited to take part, mostly between 2005 and 2010.

    Participants answered questions on sociodemographics, medical health and lifestyle. They also completed the International Physical Activity Questionnaire (IPAQ), which asked them to record any activity they did – whether non-recreational (occupational, transportation, housework) or recreational.

    Total physical activity was categorised as:

    • Low physical activity – less than 600 metabolic equivalents (MET) x minutes per week, which equates to less than 150 minutes of moderate physical activity a week.
    • Moderate physical activity – 600-3,000 MET × minutes per week, which equals 150-750 minutes of moderate activity a week.
    • High physical activity – more than 3,000 MET × minutes per week, equal to more than 750 minutes of moderate activity per week.

    The main outcomes the researchers looked at were death from cardiovascular disease and having a heart attack, stroke or heart failure. In high-income countries, this information was taken from registries, but in middle- and low-income countries researchers sometimes had to rely on family or friends of participants to provide information on probable cause of illness or death.

    The analyses included 130,843 people who completed the IPAQ. Anyone who had CVD at the start of the study was excluded. Researchers looked at the relationship between activity and cardiovascular disease or heart-related deaths, adjusting the data to take into account factors that may have influenced results, such as age, sex, BMI and waist-hip ratio, smoking, high blood pressure, and diabetes. The participants were followed up over an average period of 6.9 years.

    What were the basic results?

    Overall, the total amount of physical activity and recreational activity decreased from high-income to low-income countries. Levels of non-recreational activity were similar across all countries.

    Rates of deaths, heart attacks and stroke also significantly decreased with increasing levels of physical activity. The overall rates of mortality or major cardiovascular disease events (stroke, heart attack or heart failure) were 9.46 per 1,000 people per year in the low-activity group, which reduced to 7.14 in the moderate-activity group, and to 6.60 per 1,000 per year in the high physical activity group.

    People who met current physical activity recommendations – at least 150 minutes of moderate activity each week (the moderate to high activity groups) – had a 22% lower risk of death or risk of a major cardiovascular event compared with those who with low physical activity levels (hazard ratio [HR] 0.78, 95% confidence interval [CI] 0.74 to 0.83). Risk of death was 28% reduced (HR 0.72, 95% CI 0.67 to 0.77) and risk of heart attacks or strokes was 20% reduced (HR 0.80, 95% CI 0.74 to 0.86).

    The beneficial effect of exercise (and the increased risk of heart-related deaths from lower levels of physical activity) was seen across all countries.

    How did the researchers interpret the results?

    The researchers concluded: "Higher recreational and non-recreational physical activity was associated with a lower risk of mortality and CVD events in individuals from low-income, middle-income, and high-income countries. Increasing physical activity is a simple, widely applicable, low cost global strategy that could reduce deaths and CVD in middle age."

    Conclusion

    This study shows that all physical activity, in any form, is good for us. This includes both recreational and non-recreational activities.

    Don't be misled by some of the media: non-recreational activities like housework are not "better" than recreational activities like playing sports or going to the gym.

    The fact that reduced risk was seen with non-recreational activity across all countries, but only seen with recreational activity in high-income countries was probably just because fewer people in lower-income countries play sports or go to the gym.

    The researchers estimate that 8% of all deaths and 4.6% of all cardiovascular disease events in the population could be prevented if everyone met the current physical activity recommendations: doing at least 150 minutes of moderate activity each week.

    The study had a few important limitations:

    • Participants may have inaccurately reported the amount and type of activity.
    • Disease outcomes and cause of death may be inaccurate – particularly in lower-income countries where this information could not be collected as reliably through registries and medical records. And people with pre-existing disease may not have been reliably excluded.
    • The researchers tried to adjust for confounding factors that may influence the results, but weren't able to cover them all – notably, they failed to adjust for diet.
    • Participants were from a range of countries worldwide, but this may not have been entirely representative. For example, in some lower-income countries it may have been harder to contact households. Also, the main age group represented was middle-aged adults.

    These limitations mean the study results are only estimates and cannot be taken as hard figures. Nevertheless, this is a large, good-quality study published in a highly respected medical journal, and the findings reinforce current government recommendations for physical activity.

    You should aim to do at least 150 minutes of moderate exercise per week, such as brisk walking or cycling and strength exercises on two or more days a week.

    However, if you feel this advice might be unachievable to start with, aiming for 10 minutes moderate exercise a day, such as brisk walking, is a good start. Any type of exercise is likely to be good and a gym membership isn't necessary.

    Read more about how to get and stay fit.

    Links To The Headlines

    Get up, stand up: including exercise in everyday life healthier than gym, says study. The Guardian, September 21 2017

    Vacuuming and scrubbing the floor are enough exercise to protect heart and extend life, study finds. The Daily Telegraph, September 21 2017

    Thirty minutes of exercise is the secret to living longer. Daily Express, September 22 2017

    Household chores could save your life: The tiny amounts of physical activity from cleaning the floor and tidying up cut your risk of death by 28%, study finds. Mail Online, September 22 2017

     

    Links To Science

    Lear SA, Hu W, Rangarajan S, et al. The effect of physical activity on mortality and cardiovascular disease in 130 000 people from 17 high-income, middle-income, and low-income countries: the PURE study. The Lancet. Published online September 21 2017

    Lightning Process 'could help children with chronic fatigue syndrome', study claims

    NHS Choices - Behind the Headlines -

    "Controversial Lightning Process 'helps children with chronic fatigue syndrome'," reports The Guardian.

    The story is based on a UK study investigating whether a treatment called the Lightning Process helped teenagers being treated for chronic fatigue syndrome (CFS), also known as ME (myalgic encephalomyelitis).

    The study randomly split 100 young participants into two groups: those who received standard CFS/ME treatment and those who received the standard treatment plus the Lightning Process (LP).

    LP treatment involved an intensive three-day group-therapy course aiming to teach participants how to use their brain to improve their body's health.

    Researchers found those who received the LP were more active, less tired and less anxious after six months. At 12 months, they also had improved depression scores and school attendance.

    However, this therapy is not recommended by the NHS, which currently suggests behavioural and exercise therapy for people with CFS/ME.

    There are an estimated 250,000 people affected by chronic fatigue syndrome in Britain, according to the ME Association charity.

    It's not known what causes CFS/ME, but there are a number of theories, such as it being triggered by an infection.

    Living with the condition can be difficult, with extreme tiredness and other symptoms making everyday activities challenging.

    As well as support from family and friends, it might also be useful for people with CFS/ME to talk to others with the condition and perhaps find a local support group.

    Where did the story come from?

    The study was carried out by researchers from the University of Bristol and the University of Nottingham in the UK. It was funded by the National Institute for Health Research and two charitable trusts: The Linbury Trust and The Ashden Trust.

    The study was published in the peer-reviewed medical journal Archives of Disease in Childhood, part of BMJ Journals, and is free to read online.

    The media reporting of this study was generally accurate, but the Daily Telegraph's suggestion that the therapy helps children get back to school cannot be certain – there are a range of possible explanations for why children in the LP therapy group had better school attendance.

    What kind of research was this?

    This was a randomised controlled trial involving teenagers who had been diagnosed with CFS/ME. They were randomised to receive either usual care, or usual care plus the LP.

    The LP is a therapy developed from osteopathy, life coaching and neurolinguistic programming (a behavioural psychotherapy that "retrains the brain"), and is used for a variety of conditions.

    CFS/ME is a long-term illness with a wide range of symptoms, the most common being extreme tiredness.

    It can also cause sleep problems, concentration problems, muscle or joint pain, headaches, a sore throat, flu-like symptoms, feeling dizzy or sick, or a fast or irregular heartbeat.

    Current accepted treatments in the UK health service include cognitive behavioural therapy (CBT); a structured exercise programme called graded exercise therapy; and medication to control pain, nausea and sleep problems.

    What did the research involve?

    The researchers randomised 100 children aged 12 to 18 with diagnosed CFS/ME to receive either specialist medical care (SMC) or SMC plus the LP, and followed them up at 3, 6 and 12 months.

    There were 51 participants in the SMC-only group. The SMC focused on improving sleep, and using activity management to establish a baseline level of activity (including school attendance, exercise and social activity) that was then gradually increased.

    Sessions were delivered by professionals such as doctors, psychologists and physiotherapists. The number and timing of sessions were agreed with the teenager and their family.

    There were 49 participants in the SMC-plus-LP group. In addition to the same SMC, they attended an LP course consisting of three different sessions, lasting four hours each, on consecutive days. They attended in groups of two to five.

    The first was a theory session looking at:

    • stress response
    • how the mind and body interact
    • how thought processes can be positive or negative

    This was followed by a group session in which participants were asked to think about what they could take responsibility for and change.

    The third was a practical session in which participants were asked to choose a goal they wished to achieve, such as being able to stand for a longer period of time. They were given different thinking strategies to perform before and during attempting to achieve the goal. They also chose a further goal, to be attempted at home.

    Each participant was offered two follow-up phone calls.

    Outcomes assessed were:

    • physical function, measured using the 36-Item Short-Form Health Survey Physical Function Subscale (SF-36-PFS)
    • quality of life using quality-adjusted life years (QALYs), measured using the EQ-5D-Y standardised instrument
    • fatigue, using the Chalder Fatigue Scale
    • pain, using the Visual Analogue Scale (VAS)
    • anxiety and depression, using the Hospital Anxiety and Depression Scale (HADS)
    • school attendance (days per week)
    • child's use of health services, educational services or health-related travel, and other family costs, using a questionnaire
    What were the basic results?

    At six months after randomisation, data from 81 participants showed that those in the SMC-plus-LP group were:

    More active

    They had better physical function compared with the SMC-only group according to the SF-36-PFS scale of 0 to 100, where lower scores indicate worse physical function. The SMC-plus-LP group's average increased from a baseline of 53 to 81.7, and the SMC-only group's increased from 56 to 70.2 (adjusted difference in means 12.5, 95% confidence interval [CI] 4.5 to 20.5).

    Less fatigued

    They had less fatigue, scoring 14.4 compared with 19.8 in the SMC-only group on a scale of 0 to 33, where higher scores indicate more fatigue (adjusted difference in means 4.7, 95% CI 7.9 to 1.6).

    Less anxious

    They had greater improvement in anxiety symptoms as measured by the HADS (scored from 0 to 21, with higher scores indicating worse symptoms) than the SMC-only group. The SMC-plus-LP average score was 6.1, compared with 9.0 for the SMC-only group (adjusted difference in means 3.3, 95% CI 5.6 to 1).

    At 12 months after randomisation, data from 79 participants showed that the SMC-plus-LP-group were:

    More active, less fatigued and less anxious

    They still had better physical function, less fatigue and improved anxiety symptoms compared with the SMC-only group.

    Feeling better

    The SMC-plus-LP group also had greater improvement in depression symptoms on the HADS – scored from 0 to 21, with higher scores indicating more-severe symptoms (adjusted difference in means -1.7, 95% CI -3.3 to -0.2).

    Attending school more often

    School attendance, as measured by attendance in the previous week, was better for the SMC-plus-LP group, at 4.1 days on average, than the SMC-only group's 3.1 days (adjusted difference in means 0.9, 95% CI 0.2 to 1.6).

    How did the researchers interpret the results?

    The researchers concluded: "This is the first randomised trial investigating the effectiveness of the LP for any condition. It is the first trial that has demonstrated the effectiveness of an intervention other than CBT for paediatric CFS/ME.

    "The addition of the LP to SMC improved physical function at 6 and 12 months in adolescents with CFS/ME and this difference increased at 12 months."

    Conclusion

    The results from this very small randomised controlled trial showed that people having LP therapy in addition to usual CFS/ME care had improved physical function, fatigue and anxiety symptoms at six months, and improved school attendance and depressive symptoms at 12 months.

    However, there are a number of limitations to this research that need to be considered:

    • Participants in both groups improved, so both treatments were effective to some extent.
    • This was a very small trial, and the results analysis involved fewer than the 100 people recruited. It would need to be repeated in a much larger group to demonstrate more robust findings.
    • A number of outcomes were looked at, so it was very likely that some of them would return positive findings by chance – the improvements might not have been due to the LP therapy.
    • Participants were not blinded – they were aware of the group they were in; therefore, their self-reported outcomes might have been biased. They may have been more likely to report positive outcomes because they knew they were getting additional therapy in the LP group.
    • Of all those eligible to participate in the trial, fewer than 30% agreed to take part. The reason why the majority didn't want to is unknown.

    As the LP therapy was given in addition to the usual CFS/ME care, it certainly cannot be suggested as a replacement for the current usual care.

    There's no single way of managing CFS/ME that works for everyone and, if you have the condition, you should be offered a treatment plan based on your symptoms. Your doctor should discuss all options with you and make you aware of any benefits and risks.

    Links To The Headlines

    Chronic fatigue therapy 'could help teenagers', study says. BBC News, September 21 2017

    Controversial 'light' treatment for young ME patients - endorsed by celebrities - DOES work despite being labelled as 'quack medicine'. Mail Online, September 21 2017

    Controversial Lightning Process 'helps children with chronic fatigue syndrome'. The Guardian, September 20 2017

    M.E. 'Lightning Process' trains the brain to ward off tired thoughts. The Daily Telegraph, September 20 2017

    Links To Science

    Crawley EM, Gaunt DM, Garfield K, et al. Clinical and cost-effectiveness of the Lightning Process in addition to specialist medical care for paediatric chronic fatigue syndrome: randomised controlled trial. Archives of Disease in Childhood. Published online September 20 2017

     

    Many teenagers reporting symptoms of depression

    NHS Choices - Behind the Headlines -

    Summary

    "One in four British girls hit by depression at 14 as experts blame increase in cyber bullying and academic pressure," says the Sun after a large study found 24% of 14-year-old girls in the UK report symptoms of depression.

    The Millenium Cohort Study followed more than 19,000 children born in the UK in 2000 to 2001. Parents completed surveys when the children were aged 3, 5, 7, 11 and 14 about any emotional difficulties they were having. At age 14, the children also completed a short questionnaire about their mental health.

    Levels of anxiety and depressive symptoms were similar for girls and boys up to the age of 11. At age 14, parents reported 12% of boys and 18% of girls had emotional problems. But when the 14-year-olds themselves were asked about their mental health, 9% of boys and 24% of girls reported depressive symptoms.

    Though the statistics are worrying, it is important to note that these were responses to questionnaires and not formal diagnoses of depression so the real figures are likely to be lower. However, it is still of concern that so many children are struggling with emotional problems.

    If you have concerns about yourself or a child, see your GP as there are many effective treatments available including talking therapies.

    Find more information and advice for young people on mental health problems.

    Where did the story come from?

    The study was carried out by researchers from University College London, and was funded by the Economic and Social Research Council and the Government.

    It was published by the Centre for Longitudinal Studies, an Economic and Social Research Council resource centre based at University College London and is free to read online (PDF, 554kb).

    In general, the media reported the research accurately, although few explained that the children had not been formally diagnosed with depression and had only reported some symptoms in a questionnaire.

    What kind of research was this?

    This was a cohort study in which children born in the millennium were followed up over 14 years through questionnaires given to both parents and the children themselves.

    This type of observational study is good for looking at patterns of illness in the population. However, it relies on people agreeing to take part so can be subject to selection bias whereby only people with an interest in the topic complete the survey.

    What did the research involve?

    The Millenium Cohort Study recruited the parents of 19,517 children born in 2000 to 2001 from England, Scotland, Wales and Northern Ireland.

    When the children were aged 9 months, 3, 5, 7, 11 and 14 years, the parents answered questionnaires about their physical, emotional, social, cognitive and behavioural development. They also provided details about their family relationships, economic status and family life.

    When the children were aged 3 and above, the questionnaires included the Strengths and Difficulties Questionnaire which includes parental concerns about behaviour problems, hyperactivity and bullying, and gives a score out of 10, with higher scores indicating greater problems.

    When the children were aged 14, they completed the Short Mood and Feelings Questionnaire. This consists of 13 statements. Children are asked if they felt the statements were true, sometimes true or not true reflections of how they felt in the previous two weeks:

    • I felt miserable or unhappy.
    • I didn't enjoy anything at all.
    • I felt so tired I just sat around and did nothing.
    • I was very restless.
    • I felt I was no good anymore.
    • I cried a lot.
    • I found it hard to think properly or concentrate.
    • I hated myself.
    • I was a bad person.
    • I felt lonely.
    • I thought nobody really loved me.
    • I thought I could never be as good as other kids.
    • I did everything wrong.
    What were the basic results?

    Average scores on the Strengths and Difficulties Questionnaire (0 to 10) completed by parents were low overall (a lower score indicating lesser problems):

    • Behaviour problems were more likely at the age of 3, with a score of just below 3, which then reduced and stayed around 1.
    • Emotional symptoms gradually increased from 1 to just over 2 by the age of 14.
    • Hyperactivity was the biggest problem, scoring around 3 at all ages.
    • Peer problems scored between 1 and 2 at all ages.

    The proportion of children reported to have emotional problems by their parents increased with age:

    • at the age of 3, it was 8%
    • by 11, this had risen to 12%
    • at 14, it was still 12% for boys but had increased to 18% for girls

    The proportion of children reported to have behaviour problems varied with age:

    • at the age of 3, 20% of boys and 17% of girls
    • at 5, 11% of boys and 7% of girls – at 14, 15% of boys and 11% of girls

    According to the Short Mood and Feelings Questionnaire completed by 14-year-old children:

    • 24% of girls reported high levels of depressive symptoms
    • 9% of boys reported high levels of depressive symptoms

    Ethnicity and household income results indicate that children from all backgrounds and socioeconomic status can suffer from symptoms of depression:

    • Prevalence for girls ranged from 9% of Black African and 15% of Bangladeshi background to 25% of white and 27% of mixed race.
    • Mixed-race boys were also more likely to have symptoms of depression, at 13% compared to 3% of those of Indian ethnicity.
    • 18% of girls from the highest income bracket, 23% from the lowest and up to 27% of those from the second lowest bracket had symptoms of depression.
    • 12% of boys in the second lowest bracket going down to 6% in the highest bracket had depression symptoms.
    How did the researchers interpret the results?

    The researchers concluded that "children's perspectives about their mental health may be different from their parents". They say this "highlights the importance of obtaining young people's own perspective of their mental ill-health, alongside other perspectives".

    Conclusion

    This large cohort study highlights high levels of depressive symptoms in children and adolescents.

    It is however important to note that these are symptoms – we don't know how many of the children would be diagnosed with depression.

    When parents complete the Short Mood and Feelings Questionnaire, it is estimated that it will accurately identify 75% of children with depression and 73% of children without depression. But it is less accurate when children complete it. Recent research suggests that it can identify 60% of children with depression and 61% of children without depression.

    Despite these limitations, the fact that so many children report symptoms is of concern. Various experts in the media have suggested reasons, ranging from greater awareness of mental health issues and therefore increased reporting, to greater pressure from social media. Further research is needed to identify the causes.

    It is important to seek help early for children with emotional problems and your GP is the best place to start. You can also contact the charity Young Minds that offers information and help to both young people and their parents or carers.

    Links To The Headlines

    Quarter of 14-year-old girls 'have signs of depression' BBC News, September 20 2017

    How a quarter of girls are hit by depression: Shocking figures show teenagers are struggling to cope with school, stress and pressures of social media Mail Online, September 20 2017

    Teenage Blues One in four British girls hit by depression at 14 as experts blame increase in cyber bullying and academic pressure The Sun, September 20 2017

    One in four teenage girls are depressed, by their own accounts The Daily Telegraph, September 20 2017

    One in four girls have depression by the time they hit 14, study reveals The Guardian, September 20 2017

    A quarter of all 14-year-old girls are depressed, research shows The Independent, September 20 2017

    Quarter of girls are depressed at 14 in mental health crisis The Times, September 20 2017

    Links To Science

    Patalay P, Fitzsimons E. Mental ill-health among children of the new century (PDF, 554kb) Briefing paper from Centre for Longitudinal Studies, UCL Institute of Education. Published online September 20 2017.

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