Food supplement advice remains unheeded

Insights 2-2 food supplementsThe UK policy of recommending that women take folic acid supplements before pregnancy to prevent birth defects appears to be falling on deaf ears. This is the conclusion of a study from Queen Mary University of London, which has revealed that less than a third of women planning pregnancy take the vitamin. 

The recommendations were based on 25 year old research which showed that taking folic acid supplements before pregnancy can help prevent spina bifida and other birth defects of the brain, spine, or spinal cord (neural tube defects). 

The study, carried out by Queen Mary’s Wolfson Institute of Preventive Medicine, questioned nearly half a million women attending antenatal screening between 1999 and 2012 in England. Analysis showed that the proportion of women taking folic acid supplements decreased from an already low level of 35% in 1999-2001 to just 31% in 2011-2012. 

The findings also showed strong ethnic variations, with only 17% of Afro- Caribbean women, 20% of South Asian women and 25% of East Asian women taking folic acid supplements, compared with 35% of Caucasian women. In addition, only 6% of women under 20 were taking folic acid supplements compared with 40% of women aged 35 to 39. 

The proportion of women who started taking folic acid after finding out they were pregnant did increase from 45% to 62%. However, for the preventive benefits to be effective, the supplements need to be taken before pregnancy. 

Over 70 countries, including the US and Australia, have introduced mandatory folic acid fortification. But despite recommendations from the Food Standards Agency to fortify flour with folic acid, and evidence that such measures are effective, neither the UK nor any other EU country has mandated this. 

“The current UK policy… has failed and has also led to health inequalities among ethnic minorities and younger women,” said Jonathan Bestwick, lead author and Lecturer in Medical Statistics. “The Government should introduce mandatory fortification of flour with folic acid without delay.”


Seasonal 'flu vaccine may cut stroke risk

Receiving the seasonal influenza vaccination could reduce the risk of suffering a stroke by almost a quarter, according to a report by UK researchers. The findings, from a study carried out by the Universities of Lincoln and Nottingham showed that patients who had been vaccinated against influenza were 24% less likely to suffer a stroke in the same ’flu season. 

The study, known as IPVASTIA, analysed records of more than 47,000 patients who had suffered a stroke or TIA between 2001 and 2009. Data were drawn from the UK’s national General Practice Research Database (now the Clinical Practice Research Datalink). 

The analysis showed that ’flu vaccination was associated with a 24% reduction in risk of stroke. The reduction was strongest if the vaccination was given early in the flu season. There was no statistically significant change in risk of TIA with ’flu vaccination. 

The investigators acknowledge that this type of retrospective study design, although widely used in health research to identify risk factors in large samples, cannot prove direct cause-and-effect relationships. 

Take-up of the ’flu vaccination programme across England is lower than national targets, at 74% for over- 65s in 2011/12 and around 52% for under-65s in at-risk groups.


Smoking cessation linked to improved mental health

Recently published research from Washington University School of Medicine has shown that smoking cessation in people with mental health problems, including depression, anxiety and addiction, is strongly linked to better outcomes. 

Clinicians treating mental health conditions often have a blinkered approach, treating the condition in isolation while allowing patients to “self-medicate” with cigarettes – wrongly assuming that quitting smoking may interfere with treatment, the authors point out. 

But the study found that quitting or significantly cutting back on cigarette smoking was associated with lower risk for mood disorders like depression, as well as a lower likelihood of alcohol and drug problems. 

The Washington research team analysed data from two surveys of the same population of 4,800 daily smokers three years apart. Of the daily smokers who suffered mood or anxiety disorders when first surveyed, 42% who had continued smoking during the years between the two surveys continued to suffer from such disorders, compared with 29% of those who had quit smoking. A similar pattern was seen in those with alcohol and drug problems. 

“We don’t know if their mental health improves first and then they are more motivated to quit smoking or if quitting smoking leads to an improvement in mental health,” said lead investigator Patricia Cavazos- Rehg. “But either way, our findings show a strong link between quitting and a better psychiatric outlook.” 

Reference: Cavazos-Rehg P, et al. Psychological Medicine , Feb. 12, 014. http://journals.cambridge.org/psm/rehg (Smoking cessation – less is more, Page 3)


DH highlights risk from farm animal births

Insights 2-2 DH highlights risk

As the lambing season approaches, the Department of Health, along with other government agencies, has re-emphasised the low but significant risks to pregnant women of zoonoses from sheep during lambing, as well as from other farm animals that are giving birth. 

It advises that women who are or may be pregnant should avoid sheep and other farm animals who are giving or who have recently given birth. 

The most significant risk to pregnant women is from ovine chlamydiosis, which causes enzootic abortion of ewes and can lead to abortion in humans. However, the advice warns that such risks are not only associated with sheep; cattle and goats that have recently given birth can also carry similar infections. 

While the number of human pregnancies affected by contact with an infected animal is extremely small, it is important that pregnant women are aware of the potential risks and take appropriate precautions, including:

  • not providing assistance with the birthing of farm animals 
  • avoiding contact with aborted or new-born lambs, calves or kids or with the afterbirth, birthing fluids or materials (e.g. bedding) contaminated by such birth products 
  • not handling soiled clothing, boots or any materials that may have come into contact with animals that have recently given birth, their young or afterbirths 
  • ensuring contacts who have attended farm animal births take appropriate health and hygiene precautions to remove any potential contamination.
Pregnant women from a farm environment should seek medical advice if they experience fever or influenza-like symptoms.
Findings point to value of interarm blood pressure measurement 

New research published in the American Journal of Medicine suggests that there is an association between significant difference in interarm systolic blood pressure and an increased risk of future cardiovascular events. The findings have prompted the researchers to recommend expanded clinical use of interarm blood pressure measurement. 

A possible link between interarm blood pressure difference (defined as ≥10mmHg) and cardiovascular risk has been suspected for some time, but until now little data existed to support the hypothesis. 

This new study examined 3,390 participants aged 40 years and older from the Framingham Heart Study. All subjects were free of cardiovascular disease at baseline, but investigators found that participants with higher interarm systolic blood pressure differences – approximately 10% of the study population – were at a much higher risk for future cardiovascular events than those with less than a 10mmHg difference between arms.

The researchers also found that participants with elevated interarm blood pressure difference tended to be older, had a greater prevalence of diabetes mellitus, higher systolic blood pressure, and a higher total cholesterol level. 

The investigators say their findings suggest that practitioners should consider including blood pressure readings in both arms in order to get the most accurate readings possible and detect any differences in interarm blood pressure. 

“Even modest differences in clinically measured systolic blood pressures in the upper extremities reflect an increase in cardiovascular risk,” said lead investigator Dr Ido Weinberg. 

“This study supports the potential value of identifying the interarm systolic blood pressure difference as a simple clinical indicator of increased cardiovascular risk.” 

Reference: www.amjmed.com/article/PIIS0002934313009728/fulltext  


EU waivers ‘deny children cancer drugs’

Children with cancer are being denied new and potentially highly effective drugs, because EU rules are allowing companies to trial some drugs only in adults, according to leading cancer experts. 

Under the current system, drug companies often gain exemptions from carrying out expensive testing of cancer drugs in patients under the age of 18 – even where a drug’s mechanism of action suggests it could work in that age group. As a result there are significant delays in new drugs becoming available for children, and some potentially effective treatments drugs may never be formally licensed for paediatric use. 

The London-based Institute of Cancer Research has called for urgent modifications to the current system of waivers and exemptions to force pharmaceutical companies to test more of their drugs in children. Specifically, the ICR wants the European Commission not to exempt pharmaceutical companies from testing cancer drugs in children, purely on the basis that the adult cancer targeted by the drug company does not occur in children.


GUIDELINES ROUND-UP

OSTEOARTHRITIS GUIDELINE HIGHLIGHTS IMPORTANCE OF EXERCISE 

Updated NICE guidelines for management of osteoarthritis (OA) have cited exercise as a core treatment. The guidance also includes new recommendations on diagnosing the condition, advice on joint surgery, and on follow-up and review. 

Around one million people present to their GP each year with OA, which also accounts for 115,000 hospital admissions in the UK annually. 

Among the new and revised recommendations, the updated guidelines states that health professionals should:

  • diagnose OA clinically without investigations if a person is 45 or over and has activity-related joint pain with either no morning joint-related stiffness or morning stiffness that lasts no longer than 30 minutes 
  • offer advice to patients with clinical OA on: access to appropriate information, activity and, where appropriate, exercise, and interventions to lose weight 
  • refer for consideration of joint replacement surgery before there is prolonged and established functional limitation and severe pain. Patient-specific factors (including age, sex, smoking, obesity) should not be barriers to referral for joint surgery 
  • offer regular reviews to all people with symptomatic OA, which should cover monitoring the long-term course of the condition, reviewing the effectiveness and tolerability of treatments and other points. 
consider annual reviews for patients who satisfy one or more of the following criteria: 
  • Other illnesses or conditions 
  • Troublesome joint pain 
  • More than one joint affected 
  • Taking any drugs for their osteoarthritis.
The new recommendations also reiterate previous advice that “alternative” therapies, such as glucosamine, chondroitin and acupuncture should not be offered to manage OA as the evidence on their clinical effectiveness is uncertain. Although new data surrounding these therapies was considered, the evidence was not sufficiently compelling. 

www.nice.org


NICE RECOMMENDS WIDER USE OF STATINS

In new draft guidance, NICE is recommending that the threshold for starting preventive treatment of cardiovascular disease (CVD) should be halved from a 20% risk of developing CVD over 10 years (as assessed by the QRISK calculator) to a 10% risk. 

The new recommendations, which update 2008 guidelines, include revised advice on the identification of people at risk of CVD and on the use of statins. The guideline is being updated in part to allow consideration of new evidence on CVD risk assessment tools and to reflect changes in the price and availability of generic statins. 

Once manageable lifestyle factors have been addressed, the guideline recommends that high intensity statin therapy should be offered. This approach would significantly increase the number of people in the UK currently taking statins – currently around 7 million, at an annual cost of £450 million. 

The guidance also highlights that standard CVD risk scores will underestimate risk in people receiving certain treatments or who have an underlying condition, including:

  • People treated for HIV 
  • Those with serious mental health problems 
  • Patients taking medicines that can cause dyslipidaemia, such as antipsychotic medication, corticosteroids, or immunosuppressant drugs 
  • People with stage 1 or 2 chronic kidney disease 
  • Those with autoimmune disorders such as systemic lupus erythematosus (SLE), rheumatoid arthritis and other systemic inflammatory disorders. Registered stakeholders have until 26 March 2014 to submit their comments. 

www.nice.org 


BRIEFING RECOMMENDS LOWER BMI THRESHOLD IN ETHNIC MINORITY GROUPS 

Health professional and local authorities have been advised to use a BMI of 23kg/m2 as a trigger to take action in helping people from minority ethnicities to avoid ill health. This is a change from the usual threshold of 25 kg/m2 signalling increased risk of chronic conditions – a benchmark that remains valid for flagging risk in white European adults 

The new NICE briefing points out that people of African, Caribbean and Asian descent are up to six times more likely to suffer from type 2 diabetes, heart disease and stroke and also develop these conditions at a younger age than the wider population. 

Professor Mike Kelly, Director of the Centre for Public Health at NICE said: “In our diverse population, it’s essential that decision makers, practitioners and individuals are aware of this difference.” 

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TECHNOLOGY APPRAISALS
NICE APPROVES SELF-MONITORING OF ANTICOAGULATION THERAPY

NICE has issues guidance on a new technology for self-monitoring of long- term anticoagulation therapy. 

The provisional recommendations support the use of the Coaguchek XS system (Roche Diagnostics) as an option for people with atrial fibrillation (AF) or heart valve disease who are on long-term anticoagulation therapy for self-monitoring of international normalised ratio (INR). 

The Coaguchek XS system (Roche Diagnostics) comprises a meter and specifically designed test strips which analyses a blood sample and calculates the prothrombin time (PT) and the international normalised ratio (INR). A code chip, which contains calibration data, automatically stores the result in memory. 

More information of the Coaguchek XS system can be found at www.coaguchek.net/uk/

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