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Tuesday, 21 October 2014

Can we count on counting calories?

reposted from: http://www.nhs.uk/news/2014/10October/Pages/Can-we-count-on-counting-calories.aspx
crabsallover highlightskey pointscomments / links.

It's a concept at the cornerstone of most diets: counting the calories of your food intake so you don't go over the limit.
But just how accurate are calorie labels? And are some calories more "equal" than others?
There is a seemingly endless stream of media articles focusing on the latest diet wonder, whether it involves intermittent fasting or feasting on fats.
Although they protest otherwise, most miracle weight loss programmes come down to calorie restriction.
Behind the Headlines takes a look at the science behind calorie counting, examining why it may be only one aspect of healthy, sustainable weight loss.

Systematic review

This article is not asystematic review, where a team carries out a synthesis of the relevant medical research on a given subject

What's in a calorie?

A calorie is a unit of measurement of how much energy is stored in a mass of food.
Confusingly, the "calories" we talk about in daily life are officially described as kilocalories, or kcals, and this is how they appear on food labels. One calorie equals one kilocalorie.
A single calorie is defined as having approximately the amount of energy needed to raise the temperature of one kilogram of water by 1C. 

Calorie allowances

An average man needs around 2,500kcal a day. For an average woman, that figure is around 2,000kcal a day.
These values can vary widely depending on levels of physical activity. For example, some Olympic swimmers have reported eating as many as 12,000 calories a day when they are competing.

How the laws of the universe affect your weight

When we're dealing with energy, there is one law we always have to consider – the first law of thermodynamics.
The first law is one of the immutable laws of the universe, up there with death, taxes and how you can't travel faster than the speed of light.
It states that energy can never be destroyed, only changed from one form to another. Most of the energy in the universe is in the form of mass: solid objects.
It's easy to underestimate how much energy is stored in mass. For example, the energy contained in a single apple is enough to boil a litre of water.
The complex chemical processes whereby the energy in food is transformed into energy in our bodies makes up part of the metabolism. Metabolism is all the chemical processes that go on continuously inside the body to keep you alive and well, such as breathing, repairing cells and digesting food.
Even when you're having a snooze, your body requires energy for automatic processes such as breathing and keeping your heart beating. This minimal energy requirement is known as your basal metabolic rate (BMR).
Your BMR accounts for anything between 40% and 70% of your body's daily energy requirements, depending on your age and lifestyle.
Any extra energy you consume above your BMR will either be used by your body when you perform any physical activity, or will be stored as mass.
If you regularly do anaerobic activities (high-intensity activities that make use of physical strength, such as sprinting and weight lifting), any extra energy should be stored as muscle (or more specifically, in the form of glycogen, a converted form of glucose found in muscle tissue).
But if, like many of us, you are not exercising enough, any excess energy will be stored as fat.

The inventor of calorie counting

Much of what we know about the calorie content of different foods is down to one man: Wilbur Olin Atwater.
Atwater was a 19th century American nutritionist who spent most of his career measuring the calorie content of different foods. He used a variety of methods that became known as the Atwater system.
Key to this system was a device he invented called the respiration calorimeter.
The body needs oxygen from the air we breathe to release energy from the food we eat. In the process, carbon dioxide is released, which we breathe out.
Atwater's respiration calorimeter was a chamber that measured the use of oxygen and the production of carbon dioxide when people were placed inside the chamber after eating certain foods.
By measuring this, the calorimeter was able to estimate the heat and metabolic activity different foods produced.
As well as using the evidence provided by calorimeters, the Atwater system also used mathematical equations to take into account factors such as energy lost through urine, faeces and various gases.

How accurate is the Atwater system?

Atwater was essentially working blind. But with no previous body of research to build on and using Victorian-era technology, his work is surprisingly (but not entirely) accurate.
And while flaws in his original techniques have been widely discussed, no credible alternative methods of measuring calorie contents have been produced.
Calorimeters – albeit more advanced versions – are still used by dietitians and food makers to estimate the calorie content of foods today.
But there is evidence that some of the underlying mathematics of the Atwater system fails to take into account certain vagaries of the human digestive system.
For example, in a 2012 study researchers had the unenviable task of picking through faeces samples from 18 healthy adult volunteers to check for undigested food stuffs.
They found the body has difficulty digesting almonds. The Atwater system failed to take this into account, so, according to the study, wrongly overestimated the energy content of almonds by 32%. The researchers argued a similar overestimation of energy content could apply to other nuts.
According to biochemist Professor Richard Feinman, this flaw in the Atwater system is the result of a failure to appreciate the second law of thermodynamics.

Calories and metabolic efficiency

The Atwater system, and calorie counting in general, is based on the principle of "a calorie is a calorie". What you eat, whether it is honey, hummus or haddock, is unimportant. It's the amount you eat, right?
Feinman argued that this approach, while seemingly logical, is flawed because it does not take the second law of thermodynamics into account.
This law states any complex system will experience increasing disorder over time. All systems have an ingrained inefficiency. The energy that drives organisms, machines and processes will always "leak out", usually in the form of heat.
Our digestive systems, as marvellous as they are, cannot overcome this ingrained inefficiency. Some energy will always leak out.
The level of inefficiency varies depending on the type of food being eaten – a concept known as metabolic efficiency. The higher the metabolic efficiency, the more energy you receive from food.
Foods with poor metabolic efficiency are known as having a "metabolic advantage" – they make your metabolism work harder, so you are less likely to gain weight from eating them.
There are many things that can affect metabolic efficiency, not least cooking. As a 2009 anthropological paper argued, it was the discovery of fire – and, by extension, cooking – that probably kept the human race from dying out during the last ice age.
Cooked foods, especially cooked carbohydrates, have a far superior metabolic efficiency compared with raw fruit and vegetables.
Cooking may also have been responsible for the rapid development in brain power that occurred over the past 100,000 years (our brains use 20% of the body's total energy intake).
This is great if you are trying to survive in your cave through the winter. But it's not so great if you are tying to lose weight.

Calories in processed foods

In industrialised countries, much of our diet is made up of processed foods such as crisps, biscuits, burgers and ready meals. Processed foods have been found to have a very effective metabolic efficiency.
2010 US study bears this out. In the study, a small group of volunteers were assigned to eat one of two cheese sandwiches:
  • a processed-food sandwich – made up of white processed bread and processed cheese "products"
  • a "whole-food" sandwich – made up of multigrain bread and cheddar cheese
The interesting part of the experiment is that both sandwiches had roughly the same nutrition content:
  • 20% protein
  • 40% carbohydrate
  • 40% fat
A spirometer (a device used to measure airflow in and out of the lungs) was then used to estimate how much energy the body used (in terms of calorie consumption) when digesting the sandwiches.
The whole-food sandwich took around 137 calories to digest, which accounted for 19.9% of the total energy provided by the meal. The processed-food sandwich only took 73 calories to digest, which accounted for 10.7% of the total energy provided by the meal.
Imagine we took two identical twin brothers – Alan and Bob – and made them stick to different diets over the course of a year, but did not allow them to exercise.
Bob – eating the processed food sandwich – would theoretically put on around twice the amount of weight as Alan, even though the nutritional content of their diet was identical in terms of protein, carbohydrates and fats.
Another concern about processed foods is that they tend to have a high sugar content. Even foods you would never suspect, such as pizza, yoghurt and cheese, are often fortified with sugar.
Campaigners have warned that added sugar increases the risk of developing type 2 diabetesmetabolic syndrome and fatty liver disease. Read more about the potential dangers of sugar.

Why a balanced diet is as important as calories

Focusing solely on the calorie content of your food at the expense of its nutritional value could lead to health problems further down the line.
Interestingly, a 2014 study looked at a series of the more fashionable diets and found they were all pretty similar in terms of achieving weight loss.
Many of these diets are based on the idea that excluding certain types of food can essentially "hack" the metabolism, causing it to burn off weight at an increased rate and increase your metabolic advantage.
For example, the Atkins diet is based on the principle that by cutting carbohydrates out of your diet, the body is forced to look elsewhere to find glucose so it starts burning fat – a process known as ketosis.
Attempting to "cheat" the metabolism comes at a cost. In the short term, ketosis resulting from a low-carb diet can lead to symptoms such as nausea and bad breath. But in the long-term, it may cause kidney problems such as kidney disease and kidney stones.
Keeping your carbohydrate intake at around the recommended levels, where they make up around a third of your dietary intake, has been shown to lower heart disease risk and reduce body weight.
Ultimately, there is no such thing as an inherently "bad" type of food. It is common for certain types of food to be demonised in the press and by the diet industry: one month it's carbohydrates, the next sugars, and the month after that saturated fats. The truth is we need all three to function properly. The important thing is to get the balance right.
Current recommendations say the main staples of your diet should be fruit and vegetables, as well as starchy foods such as rice and pasta. We should also include a moderate amount of protein, such as meat and eggs, and a moderate amount of dairy products such as milk and cheese. And then just a small amount of saturated fats and sugars completes a balanced diet.
For more detailed information, see the Eatwell plate.

Can you think your way thin?

As well as focusing on the physical aspects of your diet, it may also be beneficial to look at your emotional and psychological attitudes towards diet, eating and the role of food as a reward or addiction.
Focusing on only the physical issue of calories and ignoring the psychological aspect of your eating habits will probably not lead to sustainable, long-term weight loss.
There is a growing body of research to suggest that combining a calorie-controlled diet with a talking therapy known as cognitive behavioural therapy (CBT) can be effective in helping people lose weight.
CBT is based on the principles of identifying unhelpful and unrealistic patterns of thinking and behaviour, and then trying to replace them with more helpful and realistic patterns to improve health outcomes.
Many researchers are now combining elements of CBT with traditional calorie-controlled diets in an approach known as "behavioural weight loss".
2011 study looked at how well behavioural weight loss fared when compared with the standard CBT programme. It found people treated with CBT were more likely to have remissions from bingeing behaviour, but also lost a little weight.
Those treated with behavioural weight loss had a lower rate of remission (36% compared with CBT's 51%), but experienced a statistically significant drop in BMI.
And over the course of 2014 there have been three interesting studies covered by Behind the Headlines about the impact of psychology on eating habits:
If you think you could benefit from CBT or behavioural weight loss, your GP or the doctor in charge of your care should be able to provide more information.
Even if you are not a binge eater, you may find there are certain triggers that cause you to throw your good intentions out the window and have a sudden splurge.
These triggers may be emotional, such as feeling stressed, anxious or bored. They can also be environmental, such as going to the cinema, the local pub or dining out with friends.
Environmental "cues" that can trigger overeating shouldn't be overlooked. A study from August 2014 found people who ate in "posh" restaurants consumed just as many calories as those who ate fast food. Learning to spot these "diet danger zones" is a useful exercise  being forewarned is to be forearmed.
Many psychologists with an interest in weight loss have warned against adopting an extremely rigid attitude towards calorie consumption. The more rigid the rules of your diet, the more likely it is you will just give up on the whole thing if you find yourself breaking the rules.
Rather than setting a strict daily limit on calories, it may be a better idea to set weekly limits. So if you do find yourself slipping up one day, you can always make up for it over the rest of the week.

Do calories matter?

Calories do matter. There is no getting away from that fact. If you repeatedly eat more calories than you burn off, you will put on weight. It's the first law of thermodynamics.
But is obsessively focusing on the calorie content of everything you put in your mouth a healthy and sustainable way to achieve weight loss and improve your health? Possibly not.
Emerging evidence (summarised in recent NICE guidelines on managing overweight and obese adults) suggests a structured and holistic plan to change behaviour, and not just calorie intake, is the most effective way to achieve healthy, sustained weight loss.
Calories do count, but exercise and being more active, learning more about nutrition, and eating a balanced diet are also important.
An evidence-based weight loss plan that incorporates a combination of all the factors listed above can be downloaded free from the NHS Choices website. 

Links to the science

Bleich SN, Wolfson JA, Vine S, Wang YC. Diet-beverage consumption and caloric intake among US adults, overall and by body weight. American Journal of Public Health. Published online March 2014
Carmody RN, Wrangham RW. The energetic significance of cooking. Evolutionary Anthropology. October 2009
Daumit GL, et al. A Behavioral Weight-Loss Intervention in Persons with Serious Mental Illness. New England Journal of Medicine. April 25 2013
Feinman RD, Fine EJ. 'A calorie is a calorie' violates the second law of thermodynamics. Nutrition Journal. July 28 2004
Frost G, Sleeth ML, Sahuri-Arisoylu M, et al. The short-chain fatty acid acetate reduces appetite via a central homeostatic mechanism. Nature Communications. Published online April 29 2014 
Johnston BC, Kanters S, Bandayrel K, et al. Comparison of weight loss among named diet programs in overweight and obese adults: a meta-analysis. JAMA. September 3 2014
National Institute for Health and Care Excellence. Managing overweight and obesity in adults – lifestyle weight management services. May 2014
Nguyen BT and Powell LM. The impact of restaurant consumption among US adults: effects on energy and nutrient intakes. Public Health Nutrition. Published online July 30 2014
Novotny JA, Gebauer SK, Baer DJ. Discrepancy between the Atwater factor predicted and empirically measured energy values of almonds in human diets. American Journal of Clinical Nutrition. July 3 2012 

Sunday, 21 September 2014

Could meditation help combat migraines?

reposted from: http://www.nhs.uk/news/2014/09September/Pages/Could-meditation-help-combat-migraines.aspx - NHS Choices
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“Daily meditation may be the most effective way of tackling migraine,” the Daily Express reports.

NHS Choices say "this headline is not justified, as it was based on a small pilot study involving just 19 people. It showed that an eight week "mindfulness-based stress reduction course" (a combination of mediation and yoga-based practices) led to benefits in measures of headache duration and subsequent disability in 10 adult migraine sufferers, compared to nine in a control group who received usual care."
More....

Monday, 18 August 2014

Antibiotic resistance: Cameron warns of medical 'dark ages'

reposted from: http://www.bbc.co.uk/news/health-28098838
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Antibiotic resistance: Cameron warns of medical 'dark ages'

David Cameron: "We are in danger of going back to the dark ages of medicine"

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The world could soon be "cast back into the dark ages of medicine" unless action is taken to tackle the growing threat of resistance to antibiotics, Prime Minister David Cameron has said.
He has announced a review into why so few anti-microbial drugs have been introduced in recent years.
Economist Jim O'Neill will lead a panel including experts from science, finance, industry, and global health.
It will set out plans for encouraging the development of new antibiotics.
'Taking the lead'
The prime minister said: "If we fail to act, we are looking at an almost unthinkable scenario where antibiotics no longer work and we are cast back into the dark ages of medicine where treatable infections and injuries will kill once again."
Mr Cameron said he discussed the issue at a G7 leaders meeting in Brussels earlier this month and got specific support from US President Barack Obama and German Chancellor Angela Merkel.
It is hoped that the review panel's proposals will be discussed at next year's G7 summit, which will be hosted by Germany.
"Penicillin was a great British invention by Alexander Fleming back in 1928," Mr Cameron told the BBC. "It's good that Britain is taking the lead on this issue to solve what could otherwise be a really serious global health problem."
He said the panel would analyse three key issues: the increase in drug-resistant strains of bacteria, the "market failure" which has seen no new classes of antibiotics for more than 25 years, and the over-use of antibiotics globally.
'Time bomb'
It is estimated that drug-resistant strains of bacteria are responsible for 5,000 deaths a year in the UK and 25,000 deaths a year in Europe.
bacteriaA resistant strain of bacteria
Chief Medical Officer for England Prof Dame Sally Davies has been a key figure helping to get the issue on the government and global agenda.
Last year she described the threat of antimicrobial resistance as a "ticking time bomb" and said the dangers it posed should be ranked along with terrorism.
She spoke at a meeting of scientists at the Royal Society last month which warned that a response was needed akin to efforts to combat climate change.
Dame Sally said: "I am delighted to see the prime minister taking a global lead by commissioning this review.
"New antibiotics made by the biotech and pharmaceutical industry will be central to resolving this crisis which will impact on all areas of modern medicine."
Antibiotics dates of discovery timeline
Medical research charity the Wellcome Trust is providing £500,000 of funding for Mr O'Neill and his team, which will be based at their headquarters in central London.
Antimicrobial resistance has been a key issue for Jeremy Farrar, since he became director of the Wellcome Trust last year.
"Drug-resistant bacteria, viruses and parasites are driving a global health crisis," he said.
"It threatens not only our ability to treat deadly infections, but almost every aspect of modern medicine: from cancer treatment to Caesarean sections, therapies that save thousands of lives every day rely on antibiotics that could soon be lost."
'Market failure'
Antibiotics have been an incredible success story, but bacteria eventually develop resistance through mutation.
One example is MRSA, which has been a major threat for years in hospitals. It is resistant to all but the most powerful of antibiotics, and the main weapon against it is improved hygiene, which cuts the opportunity for infection to spread.
Without antibiotics a whole raft of surgical procedures would be imperilled, from hip replacements to cancer chemotherapy and organ transplants.
Before antibiotics, many women died after childbirth after developing a simple bacterial infection.
Mr O'Neill is a high-profile economist who is best-known for coining the terms Bric and Mint - acronyms to describe countries which are emerging and potential powerhouses of the world economy.
He is not, though an expert on antibiotics or microbes. But Mr Cameron told the BBC it was important to have an economist heading the review:
"There is a market failure; the pharmaceutical industry hasn't been developing new classes of antibiotics, so we need to create incentives."
Jeremy Farrar said: "This is not just a scientific and medical challenge, but an economic and social one too which would require analysis of regulatory systems and behavioural changes to solve them."
Mr O'Neill will begin work in September and is expected to deliver his recommendations next spring.
Last month antibiotic resistance was selected as the focus for the £10m Longitude Prize, set up to tackle a major challenge of our time.
Fergus Walsh, Medical correspondentArticle written by Fergus WalshFergus WalshMedical correspondent

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A nine-year-old boy who was born without ears has had a pair created from his ribs.

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Friday, 15 August 2014

Daily aspirin 'reduces cancer risk', study finds

Jack Cuzick has been reported here for his trials on aspirin.

reposted from: http://www.nhs.uk/news/2014/08August/Pages/Daily-aspirin-reduces-cancer-risk-study-finds.aspx
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Taking aspirin every day could cut your risk of developing cancer, report BBC News and The Daily Telegraph among other news outlets, after the publication of a large-scale review of the evidence.
People aged between 50 and 65 who take aspirin every day for 10 years could cut their risk of bowel cancer by 30% and cancers of the throat and stomach by 25%, according to the study published in the Annals of Oncology.
Aspirin is an antiplatelet, which means it reduces the risk of clots forming in your blood. Platelets may also protect cancer cells in the body, and it has been suggested aspirin's effect on them may hinder this process. However, the exact mechanism is not well understood and more research is needed.
Taking aspirin every day comes with a serious health warning as it can cause serious side effects such as ulcers and bleeding from the stomach, particularly in elderly people.
However, the researchers argue the benefits of taking the drug need to be balanced against the harms. 
While the findings of this study show promise, it is not clear whether the methods used in compiling it were systematic, so the results may not be entirely reliable.
Anyone thinking of taking aspirin for prevention should talk to their GP first.

Who may not be able to take aspirin?

Before taking aspirin, including for pain relief, you should talk to your GP or pharmacist if:
  • you are pregnant, trying for a baby or breastfeeding
  • you have a blood disorder
  • you have ever had a stomach ulcer
  • you suffer from asthma
  • you have liver or kidney problems
  • you have high blood pressure
  • you have haemophilia or any other bleeding disorder
  • you have had an unusual or allergic-type reaction to any medicine
  • you are taking other medicines
Aspirin should also not be given to children under 16 years of age

Where did the story come from?

The study was carried out by researchers from a number of institutions across Europe and the US, including Queen Mary University of London.
It was funded by Cancer Research UK, the British Heart Foundation and the American Cancer Society. The study was published in the peer-reviewed medical journal Annals of Oncology.
Several of the study's authors are consultants to, or have other connections with, pharmaceutical companies with an interest in antiplatelet agents such as aspirin.
As might be expected with cancer-related news, the research was widely covered in the press. Most of the coverage was uncritical, although most stories warned of the side effects of taking aspirin.

What kind of research was this?

This was a review of evidence on the association between aspirin and incidence of deaths from cancer and cardiovascular disease, and potential harmful side effects.
It is not clear whether this was a systematic review, where the evidence is rigorously appraised for its quality and risk of bias. The researchers did not carry out a meta-analysis of the results of studies included, but compiled their own estimates.
The authors say regular aspirin is known to reduce the incidence of cardiovascular disease both in the general population and in high-risk groups, although it is currently only recommended for those at high risk.
However, an increasing body of evidence suggests it may also have a role in cancer prevention. Aspirin is also associated with a risk of bleeding and peptic ulcers. The researchers argue the benefits of taking the drug need to be balanced against the harms.

What did the research involve?

Researchers gathered evidence on the effects of aspirin on cancer risk and cancer deaths from systematic reviews published between 2009 and 2012, as well as from some individual studies on specific cancers. Further systematic reviews undertaken by some of the researchers were not included, but were discussed at the "evidence review meeting".
It is not clear how these studies were chosen or whether further studies on the topic were excluded and, if so, what criteria were used to decide which studies to include or exclude.
Evidence for aspirin's effect on cardiovascular disease was taken from one large meta-analysis. The authors based their calculations of the effect aspirin would have on cardiovascular disease by using UK rates from 1998 for cardiovascular-related incidents and deaths, which they adjusted to take account of downward trends in recent years in both the UK and the US.
The researchers used a detailed unpublished analysis of the harmful effects of aspirin.
They calculated the overall benefits and harms for taking aspirin for 10 years, starting at ages 50, 55, 60 and 65, separately for men and women. They made several assumptions in their analysis:
  • the cardiovascular benefit and adverse effects only occur during active treatment (the 10-year period)
  • the protection against cancer begins three years after initiating aspirin and continues for an additional five years after stopping aspirin
  • the protection against cancer mortality begins five years after starting aspirin use and lasts for an additional 10 years after treatment is stopped
  • the protective effects are seen only in colorectal, oesophageal, gastric, breast, prostate and lung cancers

What were the basic results?

The researchers calculated that for average-risk individuals aged 50 to 65 taking aspirin for 10 years, there would be a relative reduction of between 7% (women) and 9% (men) in the number of cancer, myocardial infarction or stroke events over a 15-year period, and an overall 4% relative reduction in all deaths over a 20-year period.
Below are their calculations of the effect of aspirin in reducing the risk of cancers and cardiovascular events, giving what the researchers say are "conservative" estimates:
  • colorectal (bowel) cancer – 30% reduction in incidence and 35% reduction in deaths
  • oesophageal cancer – 25% reduction in incidence and 45% reduction in deaths
  • gastric cancer – 25% reduction in incidence and 30% reduction in deaths
  • lung cancer – no reduction in incidence, 10% reduction in deaths
  • prostate cancer – 5% reduction in incidence, 10% reduction in deaths
  • breast cancer – 5% reduction in incidence, no reduction in deaths
  • heart attack – 18% reduction in incidence, 5% reduction in deaths
  • stroke – 5% reduction in incidence, 21% increase in deaths
Their calculations on the risk of side effects from taking aspirin are:
  • major (extracranial) bleeding – 70% increase in incidence
  • gastric bleeding – 70% increase in deaths
  • peptic ulcer – 70% increase in deaths
They also say the effects are not apparent until at least three years after starting aspirin, and some benefits may be sustained for several years after stopping.
They found no difference between low and high doses of aspirin in terms of health benefits, although there were no studies that did direct comparisons.

How did the researchers interpret the results?

The researchers say once aspirin's effect on cancer risk and mortality is taken into account, the benefits of taking aspirin outweigh the risks.
They calculate that to get any benefit, people need to start taking a daily dose of between 75mg and 325mg for a minimum of five years. Longer use is likely to have greater benefits, they say.
Further research is needed to determine the optimum dose for taking aspirin and duration of use, and to identify those at increased risk of bleeding.
In an accompanying press release, lead author Professor Jack Cuzick of Queen Mary University of London said: "It has long been known that aspirin – one of the cheapest and most common drugs on the market – can protect against certain types of cancer.
"But until our study, where we analysed all the available evidence, it was unclear whether the pros of taking aspirin outweighed the cons.
"Whilst there are some serious side effects that can't be ignored, taking aspirin daily looks to be the most important thing we can do to reduce cancer after stopping smoking and reducing obesity, and will probably be much easier to implement."

Conclusion

While the findings on aspirin and cancer show promise, it is not clear that the results are reliable from the methods reportedly used to compile this review.
This is because it included studies of varying design and quality, with much of the evidence coming from observational studies, which, while useful, cannot be totally relied on to test the effectiveness of healthcare interventions.
It's not clear how the studies included in the review were chosen and whether others on the same topic were excluded. It is also not clear whether or not this was a systematic review, where studies are rigorously appraised for their quality, and criteria are established for their inclusion.
Aspirin can cause major side effects such as peptic ulcers and bleeding from the stomach, particularly in older people. It's important to consult with your GP before deciding to take aspirin regularly. 

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



Thursday, 24 July 2014

'More adults should be taking statins,' says NICE

reposted from: http://www.nhs.uk/news/2014/07July/Pages/More-adults-should-be-taking-statins-says-NICE.aspx
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Reading the peer-reviewed literature on statins and other reports, I've suspected, for more than a year, that this advice (20mg/day Atorvastatin if QRISK2 10-year risk of CVD is 10% or more) would  be recommended by NICE.

"Doctors have been told to offer cholesterol-lowering statins to millions more people," BBC News reports.
New guidelines from the National Institute for Health and Care Excellence (NICE) recommend lowering the bar for statin use in adults at risk of heart disease. 
NICE suggests up to 8,000 lives could be saved every three years if everyone with a 10% risk of developing cardiovascular disease within the next 10 years is offered one of the widely used cholesterol-lowering medications.
Cardiovascular diseases are diseases affecting the heart and blood vessels, such as heart disease and stroke.
NICE says the evidence clearly shows statins are safe and effective and would be a good use of healthcare resources if given to these people.
The announcement has been met with a variable response, with the Daily Mail saying up to half of all adults could now be eligible for the drugs, and that, "GPs warn of chaos" at being "told to trawl medical records to find at-risk patients".
On the other side of the argument, Professor Baker, director of the Centre for Clinical Practice at NICE, says the new recommendations would not create an additional workload for GPs.
On the NICE website, he said: "Most patients will already be under surveillance by their GPs, so this won't add any additional workload. But you can do the QRISK2 risk assessment yourself. It can be done online or via an app, so it doesn't need to be done by the GP."
You can assess your own risk online using a risk assessment tool based on factors such as smoking history, body mass index (BMI) and family history of heart disease.
The NICE guidelines have now been published, which means they will come into effect in the NHS in England. However, NICE still recommends preventable lifestyle measures, such as losing weight or stopping smoking, are addressed first before starting statin treatment.
Ultimately, the decision to take a statin – even if it is recommended – will always remain a choice that sits with the patient.

Statins and reporting bias

Visit any medical news forum or comment board, such as the Mail Online's health section, and search for statins, and you will see stories of statins causing terrible side effects – for example, how statins left a person "crippled with pain and brain fog".

While the issue of side effects should never be ignored, the bad press statins get online could be an example of reporting bias in action – where there is selective reporting (or suppression) of information.

In other words, people who tolerated statins poorly are more likely to report that fact than people who have been taking them for years with no adverse effects. Similarly, most UK newspapers are unlikely to run an "I took statins, I had no side effects, and they probably prevented a heart attack" story. Good news rarely shifts newspapers or gets clicks on websites.

What are statins?

Statins are usually the first medication of choice to reduce the levels of low-density lipoprotein (LDL, or "bad")cholesterol in the blood.
Cholesterol and other fatty substances can build up and clog the arteries in the heart and elsewhere in the body, leading to cardiovascular diseases. Reducing cholesterol levels helps reduce the risk of cardiovascular events such as heart attack or stroke.
Examples of statin drugs aresimvastatin and atorvastatin, which come as tablets. The recommended treatment course is to usually take a tablet once a day for life.

What is NICE recommending?

NICE has published an update to its previous clinical guideline on the cardiovascular risk assessment and management of lipids (fats in the blood, which includes cholesterol and triglycerides) in people who either already have cardiovascular disease (such as those who've had a heart attack or stroke), or people who are at risk of developing cardiovascular disease.
The main new recommendations are that:
  • A systematic strategy should be used in general practice to identify people who are likely to be at high risk for developing cardiovascular disease (CVD).
  • People should be prioritised for a full risk assessment if their estimated 10-year risk of CVD is 10% or more (using the QRISK2 assessment tool).
  • Before starting lipid-lowering medications for the prevention of CVD, at least one blood sample should be taken to measure total cholesterol, high-density lipoprotein (HDL, or "good") cholesterol, non-HDL cholesterol, and triglyceride concentrations.
  • In people who have a 10% or greater risk of developing CVD within the next 10 years, the recommended statin to start treatment with is atorvastatin, given at a dose of 20mg daily.
  • In people who already have established CVD (people who have heart disease or have had a stroke), the recommended starting dose of atorvastatin is 80mg daily (unless there are side effects or other contraindications).
For people at risk of developing CVD within the next 10 years, the recommendations to start 20mg atorvastatin applies to adults of all ages, including people over the age of 85 years (in very elderly people, statins may reduce the risk of a non-fatal heart attack). This advice stands unless there are other health-related factors that make statin treatment inappropriate.
NICE does make several important provisions around decisions to start treatment for the prevention of CVD in people considered to be at risk.
These are outlined below.

Patient-doctor discussion

The decision whether to start a statin should be made after an informed discussion between the doctor and patient about the risks and benefits of treatment, taking into account factors such as:
  • possible benefits from lifestyle modifications (measures that could be tried first before starting a statin, such as exercising more, eating a healthier diet and stopping smoking)
  • patient preference
  • other medical illnesses
  • the problems of adding another tablet if the person is already taking a lot of daily medications
  • general frailty and life expectancy

Lifestyle changes

Before starting statin treatment, assessment should be made into other health and lifestyle factors that may need management, including:
  • smoking and alcohol consumption
  • blood pressure
  • BMI
  • diabetes
  • kidney or liver disease
The benefits of optimising all other modifiable lifestyle risk factors (for example, overweight/obesity or smoking) should be discussed, and people offered support for this if needed, such as exercise referral programmes.
Statin treatment may then be considered if lifestyle modifications don't work.

What is the rationale for lowering the threshold for the drugs?

Currently, one-third of deaths in the UK are caused by cardiovascular disease, accounting for around 180,000 deaths each year.
Cardiovascular disease is well known to have a significant burden of disability. It is believed £8 billion of healthcare resources are tied up in the disease.
Professor Mark Baker, director of the Centre for Clinical Practice at NICE, says: "Doctors have been giving statins to 'well people' since NICE first produced guidance on this in 2006. We are now recommending the threshold is reduced further.
"The overwhelming body of evidence supports their use, even in people at low risk of CVD. The effectiveness of these medicines is now well proven and their cost has fallen. The weight of evidence clearly shows statins are safe and cost effective for use in people with a 10% risk of CVD over 10 years."
Dr Anthony Wierzbicki, from Guy's and St Thomas' Hospitals, London, and chair of the Guideline Development Group, also commented on the new guidance: "We've been able to simplify the guideline so it's now much easier for patients to be assessed and for GPs and nurses to make sense of the results. There is greater clarity, a simpler framework, and a systematic way of identifying people who could benefit from treatment.
"We've got the best evidence base, huge numbers, and the biggest set of clinical trials ever done. Other areas of medicine would give their teeth for this evidence, it's that good. Statins work, they are very cheap, and are becoming considerably cheaper as they come off-patent, which, in a cost-limited health service, is a big consideration.
"That enables us to actually say that we should treat people with heart disease a lot more intensively because we know that will prevent further events. In people with diabetes or kidney disease, giving a statin will reduce heart attacks and strokes. For people at risk of heart disease, if lifestyle measures fail, we have a second option of giving them a statin if they want and require it."

Are there any risks or side effects with statins?

Statins are fairly safe drugs, though there are a range of possible side effects and groups of people who should use them with caution. This includes people with an underactive thyroid, kidney disease and liver disease. Women should also not take statins while pregnant or breastfeeding.
Possible side effects include headaches and dizziness, sleep disturbances, fatigue, tummy disturbances, altered sensation, and sensitivity reactions such as rash or itching.
Very rarely, statins have been associated with the risk of having a toxic effect on the muscles, causing muscle pain and weakness, and even a serious condition called rhabdomyolysis, where the muscle fibres start to break down.
However, the risks and benefits would be discussed and taken into account for any individual before a statin is prescribed, including their personal and family medical history.

How has the announcement been received by the media?

As the BBC News headline indicates, NICE's decision has been met with controversy. 
Professor Mark Baker, the director of the Centre for Clinical Practice at NICE is quoted as saying: "Prevention is better than cure. One of the mainstays of modern medicine is to use treatments to prevent bad things happening in the future. It's why we use vaccines and immunisation to prevent infectious disease, it's why we use drugs to lower blood pressure to prevent heart attacks, strokes, and kidney disease, and it's why we're using statins now."
Meanwhile, in opposing camps there is debate about "medicalising" a nation and encouraging people to just pop a pill rather than following a healthy lifestyle.
The British Medical Association's General Practitioner Committee is quoted as saying: "There is insufficient evidence of significant overall benefit to low-risk individuals to allow GPs to have confidence in the recommendation. The measure would distort health spending priorities and disadvantage other patients."
However, as quoted in the Daily Mail, Professor Baker responded: "It is ludicrous to suggest that we are overmedicalising the population when the whole point of using modern, safe and effective drugs in an economic way is to prevent bad things happening in the future."
Dr Chaand Nagpaul, chair of the British Medical Association's GP committee, feels NICE has not taken into account the additional pressures they'll be placing on GPs. "In making their decision, NICE has failed to take the current pressures on general practice into account, and the further impact this will have on already overstretched GPs and those patients requiring treatment for other illnesses."
Despite the extensive debate and opposition, as BBC News also highlights, the 10% threshold for statin treatment is comparable to that already used in other European countries.
As the president of the Academy of Medical Sciences, Professor Sir John Tooke, points out on the BBC News website: "Whether or not someone takes drugs to diminish their risk is a matter of personal choice, but it must be informed by accurate information on the balance of risk and benefit in their particular case. The weight of evidence suggests statins are effective, affordable and have an acceptable risk-benefit profile."

Conclusion

Despite somewhat hysterical media coverage to the contrary ("millions more to be given statins," according to the Daily Express), nobody will be forced to take statins.
If your GP does recommend statins, you should ask them to explain the benefits and risks for you personally of starting statin treatment. You may want to find out more about statins before making up your mind – the NHS Choices Health A-Z information on statins is a good place to start.
If you do experience troublesome side effects while taking statins, contact your GP or the doctor in charge of your care. It could be the case that adjusting your dosage or switching to a different type of statin could help relieve any side effects.
Analysis by Bazian. Edited by NHS ChoicesFollow Behind the Headlines on TwitterJoin the Healthy Evidence forum.