Playground equipment contains 'toxic levels of lead paint'

Monday January 25 2016

Lead is highly poisonous

"Paint on playground equipment has been found to contain high amounts of the toxin lead – up to 40 times recommended levels," BBC News reports.

Researchers sampled levels at 26 playgrounds in the south of England and the results are worrying. Lead is well known to be a highly toxic metal and its use has been phased out over the years. Young children are particularly vulnerable to the effects of lead poisoning, which can affect both physical and mental development. Even small amounts of lead can be harmful.

As well as playgrounds, researchers also tested other public structures (272 in total) such as bridges and "traditional" telephone boxes.    

Lead was detected in the majority of all 272 public structures tested, and over a third had lead concentrations exceeding the recommended 5,000 micrograms per gram (mcg/g) limit.

The average level from all samples was around 1,000mcg/g, but some had levels up to around 100,000mcg/g. Also, it wasn't always those in a poor state of repair – some newly painted structures without visible flaking had levels exceeding the limit.

This study doesn't directly demonstrate any harms to children or people in general from touching these structures, but it does highlight an important concern for the public, and those involved in renovation and maintenance.

Encouraging your children to wash their hands after playing with playground facilities should help reduce the risk of any exposure.

Where did the story come from?

The study was carried out by two researchers from the School of Geography, Earth and Environmental Sciences, at Plymouth University. 

The study received partial funding from a Marine Institute grant from the university, and was published in the peer-reviewed scientific journal Science of the Total Environment.

The quality of the UK media's reporting of the study was mixed. While the overall findings of the study were reported accurately, many of the figures quoted do not correspond with the study. For example, the BBC says 50 playgrounds were tested, but the study only mentions 26 being tested.

What kind of research was this?

This was a cross sectional study that analysed the lead content in paint on a variety of structures in the urban and suburban environment of Plymouth. 

The toxicity of lead is well established, in particular its effect on the development of young children – the reason why the use of lead in products was phased out over several decades. However, previous research has documented that household paint particles contain various leaded pigments, causing paint to come under strict legislation. The US and other countries have set a limit for lead in consumer paints at 90 parts per million (ppm).

However, an environmental source that has received less attention is the paint used on external structures, particularly those where weather conditions lead to flaking paint. This study aimed to use a portable device – an X-ray fluorescence (FP-XRF) spectrometer – that would allow the researchers to analyse the paint content in a variety of structures in Plymouth.

This is a device that can accurately measure the amount and types of chemicals in an object.

What did the research involve?

The researchers visited 15 urban and suburban regions of Plymouth between February and April 2015. All visits were made in dry weather conditions. They examined as many painted public structures and facilities that they could access from roads or pavements, including gates, railings, post and telephone boxes and playground facilities.

They either assessed them with the FP-XRF spectrometer on site, or took samples from those that were visibly flaking for analysis in the laboratory. Overall they took 272 analyses – 58 on-site measurements and 224 paint fragments taken for laboratory analysis.

What were the basic results?

Lead was detected in 81% of all samples taken (221/272), with concentrations ranging from 20 to 389,000mcg/g of paint. The US safety limit of 5,000mcg/g was exceeded in just over a third (38%) of all of the samples analysed.  

Telephone boxes and bridges were the environmental structures with the most extensive paint flaking, and these structures had the highest lead concentrations. Their median (average) concentration was around 30-40,000mcg/g, and in 21 samples the lead exceeded 100,000mcg/g.

Looking at playgrounds specifically, 26 samples were analysed, and lead was detected in 20 of them. The average (median) lead concentration was 1,170mcg/g.

Lead was detected in all colours of paints, though levels were generally lower in grey/silver/white surfaces and higher in brown and red surfaces. 

Chromium – another toxic metal – was also detected in 106 of the samples.

How did the researchers interpret the results?

The researchers conclude: "Since the issues highlighted in the present study are neither likely to be restricted to this city, nor to the UK, a greater, general awareness and understanding of the sources and routes of exposure of exterior leaded paint is called for."

Conclusion

This research has analysed the lead content of a variety of painted public structures in the urban and suburban environment of Plymouth.

Though the research was not primarily intended to examine playground structures, as the researchers said: "Perhaps the greatest concerns arising from our research are the wide occurrence and high concentrations of lead in paints on public playground facilities."

Their tests included a variety of playground structures, such as roundabouts, climbing frames and monkey bars. Of the 26 samples measured, the average lead level was 1,170mcg/g, which is well below the recommended environmental limit of 5,000mcg/g. However, this average came from some playground samples with low levels (minimum 116mcg/g) and some with very high levels (maximum measured 115,000mcg/g).

The greatest risks are believed to be from older peeling paint on structures that children are in direct contact with, such as rails, swing or slide posts and climbing frames – particularly toddlers who are more likely to touch these surfaces and then put their hands to their mouths. However, as the researchers found, the highest levels don't necessarily always come from the oldest surfaces. One of the samples they took where lead levels exceeded 5,000mcg/g came from a range of facilities with generally intact paint that had been applied quite recently – date marked 2009.

The highest lead levels measured in the study came from bridges and telephone boxes – older structures in a poor state of repair. As the researchers suggest, the higher levels in these old structures may be the result of progressively newer paints containing less lead. 

However, the risk from these items wouldn't necessarily just be restricted to people touching these structures. Flakes of lead paint could contaminate soil, surface water and dust on roads and pavements. This could in theory result in lead particles being brought indoors on shoes and clothing.  

It is important to note, that while the potential that children or people in general could be at risk from touching painted external surfaces – or from bringing lead particles into the home – are highly plausible, they are not directly proven by this piece of research.

This study is also restricted to Plymouth, though as the researchers rightly say, there is no reason to suspect the findings would be limited to the environment of this city. Overall the findings are an important point of awareness for the public and those involved with the renovation, repair and maintenance of a wide variety of painted external structures. They also highlight the need for close regulation of the lead levels in paint. 

The best way to prevent your child being exposed to lead is to encourage them to always wash their hands after outside play and before eating. Regularly washing any of their toys or equipment they play with outside should also help. 

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Calls for research into health effects of ultrasound exposure

Wednesday January 20 2016

Some people may be more sensitive to ultrasound

"Ultrasound in public places could be triggering sickness," the Daily Mail reports.

Ultrasounds are high frequency sound waves used by a wide range of devices, and are thought to be inaudible to most humans. 

A review has highlighted how many public places are now exposed to ultrasound, and there is a knowledge gap about what effect it has on our health.

What is the basis for these reports?

The news stories are based on a report by a scientist at the University of Southampton published in the peer-reviewed journal, Proceedings of the Royal Society A.

The report comprises results from new investigations, as well as a narrative review focusing on the available evidence on ultrasound exposure and human health.

It has been made available on an open-access basis, so you can read the report for free online.

The author, Professor Timothy Leighton, said he recorded ultrasound in a number of public places, including a large library, a major railway station, and a large swimming pool.

These places were chosen because people using them had reported a number of symptoms, including feeling sick, dizzy, tired, getting headaches, and a feeling of pressure in the ears.

People have also reported getting vertigo, a combination of symptoms such as severe dizziness, loss of balance, feeling sick, being sick, and headaches.

The report points out there is very little evidence to show the potential effects of ultrasound on people's health, and current guidelines are based on a few small studies from the 1960s.

These studies were done to assess the effect of ultrasound used in industry on workers' hearing, and did not consider wider issues such as public exposure.

Professor Leighton says the guidelines are not adequate to apply to ultrasound in public spaces, which people may be completely unaware of and affect large numbers of people for long periods of time.  

What is ultrasound?

Ultrasound is sound at very high frequencies, above those most people can hear – usually above 20kHz.

It can be generated by most activities – for example, rubbing our hands together generates ultrasound – but some technologies emit constant ultrasound at higher volumes.

Examples cited in the report include public address systems, which emit a constant high-frequency noise when left switched on, and automatic door sensors. Professor Leighton said he recorded high-frequency ultrasound in these places at between 63 and 94 decibels (dB).

Some guidelines use a cut-off of 65dB for exposure to ultrasound noise at work, although the guidelines vary considerably. There are also problems comparing how ultrasound was measured when the studies were carried out and how it is measured today.

Pest control systems, which are designed to deter animals that can hear ultrasound, are another example of devices that emit ultrasound.

So too is the Mosquito device, designed to deter young people from gathering in public places by emitting an unpleasant high-pitched noise most adults cannot hear. Industrial devices that emit ultrasound include ultrasonic cleaning baths.

And, perhaps most controversially, many law enforcement agencies now employ what are known as long range acoustic devices (LRAD) to control crowds.

These are essentially next-generation loud speakers that can deliver intense beams of sound over a large distance – usually warning messages that a crowd should disperse.

An LRAD was deployed by the Metropolitan Police during the 2012 London Olympics, but was never used.  

What is the evidence that ultrasound causes harm?

There is very little evidence on the effect of ultrasound on human health, either to show that it does or does not cause harm.

This report does not provide any new evidence about possible harms from ultrasound, either. It only shows some public places have volumes of ultrasound comparable to volumes covered in industrial guidelines.

We do know high-frequency ultrasound may damage people's hearing. The industrial guidelines were intended to avoid hearing damage at the lower frequencies we use for hearing speech.

These were based on the average hearing of a small group of men in their 40s. The effects on other groups, such as women, children or older people, may be different.

The study says: "Lack of research means that it is not possible to prove or disprove public health risk or discomfort."

All we know is some people exposed to ultrasound in industrial settings reported symptoms such as nausea, dizziness, headaches, tiredness, and sensations of ear pressure.

We don't know whether the problems were caused by ultrasound or something else altogether. Most people exposed to ultrasound in public places are likely to be unaware of it.

Professor Leighton's report goes on to say: "There are no records of large numbers of complaints from the public, and this might be because only a small number are affected, or it might be because there has been no awareness of exposure and no route by which to complain."

We also don't know if there's a plausible way ultrasound could cause symptoms such as nausea, tiredness, dizziness and headaches.

Professor Leighton speculated symptoms could be caused by confusion in the brain, which perceives vibration from the ear drum, but does not get signals from the nerve that transmits sound.

He pointed out a similar confusion in the brain caused by disconnection between signals from balance receptors in the ear and what the eye can see, which is thought to be the cause of travel sickness, a condition with similar symptoms.  

How does this report affect you?

The report does not provide new evidence that ultrasound in public places causes harm to human health.

Its main message is that as technologically generated ultrasound is becoming more common in public places, we should be carrying out more research into its effects on our health.

The study also calls for the existing guidelines on ultrasound and health to be completely revised, based on new research. Due to the ubiquitous nature of ultrasound in the modern environment, these calls seem prudent. 

Possibly a useful first step in terms of research would be to carry out a double blind randomised controlled trial involving people who think they are sensitive to ultrasound.

We could then see if their reported symptoms correspond to ultrasound exposure, or whether they also occur when they are exposed to other noise frequencies or no sound at all. 

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Are ads for candy-flavoured e-cigs tempting teens to vape?

Monday January 18 2016

There are more than 7,750 different e-cig flavours available

"Advertisements for … flavoured e-cigarettes could encourage children to try vaping," ITV News reports after a study found children shown these ads were more likely to express an interest in trying flavoured e-cigs.

The study included about 500 UK schoolchildren aged 11 to 16. It aimed to see whether different e-cigarette adverts influenced their views and attitudes towards smoking tobacco or using e-cigarettes.

The researchers were particularly interested in flavoured e-cigarettes. They speculated flavours such as milk chocolate could make these brands more appealing to children.

They found adverts for flavoured e-cigarettes were more appealing compared with those for non-flavoured e-cigarettes – and children said they'd be more interested in going out and buying them. But whether they would actually do this is another matter. This research has only examined attitudes, not behaviour.

The good news is the research found adverts for flavoured or non-flavoured e-cigarettes made no difference to the children's opinion of whether or not they'd be more likely to try smoking real cigarettes, regardless of whether or not the researchers showed them adverts.

However, one important limitation of this research is it excluded children who had tried smoking or used e-cigarettes before. In so doing, the researchers may have excluded a group who could have had different attitudes towards smoking or e-cigarettes.

Overall, the results suggest advertising flavoured e-cigarettes may heighten their appeal to young people, and possibly introduce them to an addictive nicotine-containing product. More research is needed to further examine this important potential risk.   

Where did the story come from?

The study was carried out by researchers from the University of Cambridge, with funding provided by the Department of Health Policy Research Programme.

It was published in the peer-reviewed medical journal, Tobacco Control, and the article is available on an open-access basis to read online or download as a PDF.

The UK media's reporting was generally accurate, with many papers including useful quotes from independent experts. 

What kind of research was this?

This randomised controlled trial (RCT) aimed to investigate how English schoolchildren aged 11 to 16 responded to different e-cigarette adverts.

Research continues to look at whether the potential benefits of e-cigarettes – essentially, helping smokers quit – outweigh the potential harms. One potential harm is their appeal to children, particularly when they come in chocolate and candy-like flavours.

This may then influence the likelihood of these children taking up tobacco smoking. E-cigarettes are reportedly now the most frequently used nicotine products among children in countries with strong tobacco control policies.

Research done by the World Health Organization (WHO) reported e-cigarettes may provide a gateway into smoking by initiating nicotine use that would not have occurred without e-cigarettes, and those who become addicted to nicotine may than sway towards tobacco. Another criticism is e-cigarettes may also "re-normalise" smoking and make it seem attractive.

This study aimed to address this gap by estimating the impact of adverts for candy-like flavoured e-cigarettes versus non-flavoured types in terms of how appealing they made tobacco smoking and using e-cigarettes.

Randomising the children to which advertisement they viewed should have ruled out differences in their characteristics that could influence the results. 

What did the research involve?

The study recruited 598 schoolchildren aged 11 to 16 from two English schools. They were randomised into three groups and provided with booklets that contained:

• 12 adverts for candy-like flavoured e-cigarettes
• 12 adverts for non-flavoured e-cigarettes
• no adverts (control condition)

The main outcome the researchers examined was the appeal of tobacco smoking, which was assessed by asking, "Please cross the circles that best describe how you feel about smoking tobacco cigarettes", with a scale of one to five ranging from "unattractive" to "attractive", "not cool" to "cool", and "boring" to "fun".

The appeal of smoking e-cigarettes was assessed similarly as a secondary outcome. Other secondary outcomes included assessing:

• the perceived harms of smoking – asking "Smoking can harm your health", "How dangerous do you think it is to smoke more than 10 cigarettes a day?", and "How dangerous do you think it is to smoke one or two cigarettes occasionally?"
• susceptibility to smoking – asking "If one of your friends offered you a cigarette, would you smoke it?", "Do you think you will smoke a cigarette at any time during the next year?", and "Do you think you will be smoking cigarettes at 18 years old?"
• the appeal of the e-cigarette advert, how much they liked it, and whether they'd then be interested in going to buy them
• awareness of e-cigarettes before this study

The researchers also asked whether the children had ever smoked cigarettes or used e-cigarettes before.

After their initial analyses revealed differences in responses between children with previous use and those without, those who had used tobacco or e-cigarettes before were removed from the sample. This left a final population of 471 children for analysis. 

What were the basic results?

The main outcome – the appeal of tobacco smoking – was rated low across all three experimental groups, with no significant differences between the groups.

Looking at the secondary outcomes, there was also no significant difference between the three groups for:

• the appeal of e-cigarettes – overall rated low
• perceived harms of tobacco smoking – overall rated high
• susceptibility to tobacco smoking

There were, however, differences in the appeal of the e-cigarette adverts and interest in buying the product.

Children exposed to the flavoured adverts rated them as significantly more appealing and had more interest in buying the product than children who saw the non-flavoured adverts.   

How did the researchers interpret the results?

The researchers concluded that: "Exposure to adverts for e-cigarettes does not seem to increase the appeal of tobacco smoking in children. Flavoured, compared with non-flavoured, e-cigarette adverts did, however, elicit greater appeal and interest in buying and trying e-cigarettes."

They suggested other studies are needed to further examine the impact of adverts for flavoured and non-flavoured e-cigarette. 

Conclusion

This study primarily aimed to see whether exposing children to different types of e-cigarette advert influenced the appeal of tobacco smoking. The researchers found no evidence of an effect for this.

They found showing schoolchildren adverts for flavoured or non-flavoured e-cigarettes, or no adverts at all, had no effect on what the children thought about smoking tobacco, its potential harms, or how likely they were to try smoking tobacco.

In the sense of the lack of appeal tobacco has for this group, the findings seem like quite good news. But how appealing each group found the e-cigarette advert was different.

Though there were no differences between the groups in terms of how attractive or "cool" they rated smoking e-cigarettes, the adverts for the flavoured cigarettes were rated as being significantly more appealing than the non-flavoured adverts.

And, crucially, the children shown these adverts stated they had more interest in going out and buying the product.

This suggests more children with prior experience of smoking tobacco or using e-cigarettes could be lured into trying them by adverts for flavoured e-cigarettes, and hence be exposed to addictive nicotine for the first time.

Importantly, whether children would actually do this or not is another matter. The study only asked the children to rate how much they liked the advert and whether they'd be interested in buying e-cigarettes – it didn't look at whether they went on to do this.

The findings definitely seem suggestive, but other things besides adverts could influence a child's actions, including socioeconomic factors, personal characteristics, lifestyle, and peer pressure.

The study's other limitations should also be noted:

• The children were randomised into three groups, which should balance out any differences in characteristics. But the researchers found prior use of tobacco or e-cigarettes was having an effect, so these children were excluded from the sample for analysis. This may have impacted the generalisability of the results to the overall population.
• This is quite a good sample size of around 500 schoolchildren, although they are only from two English schools. Their results may be representative of children across the UK, but we don't know this for sure.
• The sample size was thought to be large enough to determine the impact of e-cig adverts on the appeal of smoking real cigarettes, the main outcome of this research. This means although the study did find differences between the groups in terms of the appeal of the adverts, there is less confidence in the reliability of this result because it wasn't the main outcome.
• There is the possibility for bias in the children's answers. That is, knowing the stigma attached to smoking, the children may be more likely to have given what they thought were the "correct" answers – smoking is harmful, I wouldn't be influenced to try it – rather than the most truthful ones.
• This study used still images of adverts. We don't know what appeal televised adverts have, for example, or the impact of children seeing these products for sale in shops.

Overall, this research highlights the important need to further examine the effect of e-cigarette advertising and its appeal to children and young people.

Current recommendations on advertising e-cigarettes state any advert should "not feature characters that are likely to resonate with youth culture or appeal to under-18s". 

Determining what and what doesn't appeal to this age group is arguably a very difficult task. There have been calls from some quarters for a blanket ban on all e-cigarette advertising in the UK. Whether this will be implemented by the government is currently uncertain. 

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Men at high risk of getting HIV 'need preventative treatment'

Thursday January 14 2016

A drug called Truvada can help prevent HIV

"Giving healthy gay men HIV drugs 'could help reverse epidemic'," BBC News reports.

A modelling study looking at the effects of pre-exposure prophylaxis (PrEP), where drugs are used to prevent infection, estimated thousands of new cases of HIV could be prevented.

HIV infection continues to be a pressing concern for men who have sex with men. It is estimated there are around 44,500 men who have sex with men living with HIV in the UK. Without effective intervention strategies, that figure could rise to 57,500 by the end of the decade.

This mathematical model looked at a number of possible strategies, such as offering PrEP to men who have sex with men, regular testing, and providing early treatment for everyone who tests positive (known as "test and treat").

When the researchers looked at combinations of strategies at different levels of coverage, they found combining annual HIV testing with PrEP and test and treat could prevent 7,399 infections (43%), even if they only reached a quarter of men with a high risk of infection.

These figures are only estimates based on models created from other research findings. We don't know how well these strategies would work in the real world. 

Truvada, a drug used in the US for HIV prevention in high-risk individuals, is moderately effective. A 2012 review estimated it reduced the risk of contractive HIV by around 49%. A conference presentation we discussed in 2015 increased that estimate to 86%.

Condoms remain the most effective way of preventing HIV, and have the added bonus of not causing side effects and providing protection against other sexually transmitted infections. 

Where did the story come from?

The study was carried out by researchers from the London School of Hygiene and Tropical Medicine, the Medical Research Council Biostatistics Unit, the Centre for Infectious Disease Surveillance and Control, City University London, and University College London.

It was funded by Public Health England, the Medical Research Council, and the Bill and Melinda Gates Foundation. 

The study was published in the peer-reviewed journal, The Lancet HIV. It is available on an open-access basis, which means you can read it for free online.

The study was widely covered by the UK media. Perhaps because of its complexity, reports highlighted a variety of figures for the potential number of infections prevented, from The Daily Telegraph's best-case scenario of 10,000, to the more realistic 7,399.

Not all of the reporting made it clear that the latter figure was an estimate of the effect of PrEP plus increased HIV testing and test and treat. The Daily Telegraph also overstated the reliability of the figures, failing to explain they are based on estimates from hypothetical models.

The Times claimed Truvada will soon be made available on prescription by the NHS. While this is a plausible prediction, it has not been officially confirmed.  

What kind of research was this?

This mathematical modelling analysis used a model of how HIV spreads within populations to assess the possible effect of different interventions.

While this is useful information for public health chiefs considering different interventions, there is a wide margin of error.  

What did the research involve?

The researchers used figures on HIV infections in men who have sex with men in the UK since 2001 to estimate transmission rates until 2020, if current HIV prevention strategies – encouraging safer sex and HIV testing – continue.

Then they used a mathematical model of how HIV spreads, using data from previous studies and surveys of sexual behaviour, to predict the effect of different interventions aimed at reducing the spread of the virus.

They did multiple calculations to assess the effects of the most successful interventions, in combination and assuming different levels of coverage.

The model included factors such as whether men were currently engaged in sexual activity and whether they had more than one new sexual partner in a year, which is considered to be high risk.

Data came from three surveys: one national survey from 2000 and two that included more recent data, but were London-based.

The interventions tested in the model were:

• HIV testing once a year
• HIV testing twice a year
• test and treat – where people receive treatment immediately if they test positive
• providing PreP to high-risk individuals
• reducing the number of repeated sexual partners men had
• reducing the number of one-off sexual partners men had
• decreasing the amount of unprotected sex men had with repeated sexual partners

The researchers looked at the effects of these interventions alone, assuming a "best-case" scenario where all men who have sex with men are reached, to see which were most promising. They then looked at the effects of more realistic coverage, at 25%, 50% and 75% of men reached.

The researchers took the most effective strategies from these results and looked at how they affected infection rates, both in combination and in different practical scenarios.

They also tested the model to look for the potential effects of so-called risk compensation, where men might take more risks if they are taking PrEP. 

What were the basic results?

The best practical scenario was to combine once-yearly testing with test and treat and PrEP.

Assuming 25% of high-risk or infected men could be reached using each of these strategies, the researchers calculated this would prevent around 7,399 (interquartile range [IQR] 5587 to 9813) or 43.6% (IQR 32.9 to 57.9) of those infections expected if no additional prevention strategies were put in place.

Interquartile ranges are a statistical measure used to describe the upper and lower boundaries of an estimate, somewhat similar to a confidence interval.

Risk compensation reduces the effect of this strategy, but it would still prevent more infections than taking no additional action.

Looking at each intervention alone, with an assumed 100% coverage of men who have sex with men, PrEP had the biggest effect on new infections, followed by twice-yearly testing and a reduction in repeat sexual partners.

However, assuming 25% coverage, twice-yearly testing was most effective, followed by PrEP and test and treat.  

How did the researchers interpret the results?

The researchers said that, "PrEP could prevent a large number of new HIV infections if other key strategies, including HIV testing and treatment, are simultaneously expanded and improved."

They warned that unless PrEP is introduced in the UK, the number of men who have sex with men being newly infected with HIV was unlikely to decrease before 2020. 

Conclusion

This is a complex analysis of a number of different scenarios. It found giving PrEP treatment to HIV-negative men might have an important role to play in reducing the number of new HIV infections in the UK.

Like all mathematical models, the results rely on many different assumptions, some of which could turn out to be wrong. Although this study shows the potential for PrEP to make a big difference, we can't rely too heavily on its exact figures.

For example, one important limitation is the fact the study does not take into account the possible effects of drug resistance to HIV treatments, including PrEP.

If PrEP became less effective because of growing drug-resistant strains of the virus, it could have a big impact on how many infections can be prevented.

It's important not to focus entirely on PrEP, as the most effective of the practical scenarios assessed in the study also included regular HIV testing and prompt treatment.

For people at risk of HIV, regular testing combined with practicing safer sex is important. For those who already have the condition, treatment with antiretroviral drugs can keep you well for many years.

If you could be HIV positive, getting tested regularly means you can start treatment as soon as you need it, and increases your chances of keeping well.

PrEP as a preventative treatment for men who have sex with men is not available on the NHS at present, although NHS England is considering its use. This study may increase the likelihood that it will be made available to those at high risk of infection.

Condoms remain the most effective way to prevent HIV – and other STIs – in people who are sexually active.  

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Exercise is 'most effective' method of preventing lower back pain

Wednesday January 13 2016

Exercise can both help treat and prevent back pain

"Exercise is the best medicine to banish back pain and stop people taking sick days," reports the Daily Mirror. While this may be true, the research in question did not look at treatments for existing back pain.

In fact, the researchers reviewed previously gathered evidence about what helps prevent, not treat, lower back pain. Also, the evidence that exercise reduced sick leave was judged to be poor quality.

The review found exercise with or without education about the back and back pain was the most likely intervention to prevent lower back pain. This included core muscle strengthening, stretching and aerobic exercise carried out over a period of about 3 to 18 months.

Education alone, back belts, shoe insoles, and ergonomics (changes to objects such as chairs to make them more "back friendly") were not found to prevent lower back pain. But this finding was based on low-quality studies, so it should be viewed with caution.

Some of these interventions, such as shoe insoles, were only studied in army recruits, so the results may not be applicable to other population groups.

These limitations aside, exercise would seem to be the best option based on the available evidence. Exercise is known to offer a range of benefits. This review suggests preventing lower back pain is another potential benefit. 

Where did the story come from?

The study was carried out by researchers from the University of Sydney and Macquarie University, both in Australia, and the Federal University of Minas Gerais in Brazil. No external funding was reported.

It was published in the peer-reviewed Journal of the American Medical Association (JAMA) Internal Medicine on an open access basis, so you can read it for free online.

The Mirror, the Daily Express and the Daily Mail reported the story inaccurately. All three papers focused on the treatment of back pain, rather than prevention. While exercise may well help treat the symptoms of lower back pain, the study did not consider this issue.

They also did not make it clear the majority of the studies were poor quality, which makes the results less reliable. 

What kind of research was this?

This was a systematic review of all of the relevant randomised controlled trials (RCTs) that have assessed prevention strategies for lower back pain. Statistical pooling of results (meta-analysis) was carried out where possible.

The research was conducted according to international standards for systematic reviews. However, the quality of the results is also dependent on the quality of the underlying studies.  

What did the research involve?

A search was performed of four medical databases, including the Physiotherapy Evidence Database, to look for RCTs on the prevention of lower back pain.

Two reviewers sifted the results according to strict inclusion criteria, and a third researcher was consulted in cases of disagreement.

Eligible trials needed to fit the following inclusion criteria:

• they included people without lower back pain at the start of the study or without at least one of the outcomes the study was interested in – for example, some participants might have mild lower back pain, but still be able to work if the study was looking at work absence
• they aimed at preventing future episodes of lower back pain
• they had an intervention group that was compared with no intervention, placebo (an ineffective "dummy" intervention) or minimal intervention
• they followed participants up to identify any new episode of lower back pain or time off work for lower back pain

The relevant trials were assessed for quality using standard assessment systems. Trials measuring similar interventions were pooled together in the meta-analyses using appropriate statistical techniques.

Results from the studies were grouped into short-term results (findings up to a year) and long-term results (findings after a year). 

What were the basic results?

The review included 21 RCTs involving 30,850 people. Several studies were performed in the armed services. Others included airline employees, postal workers, nurses and office workers.

The main results for each intervention were as follows.

Exercise plus education:

• moderate-quality evidence this reduces the risk of lower back pain by 45% in the short term (relative risk [RR] 0.55, 95% confidence interval [CI] 0.41 to 0.74) and low-quality evidence it does in the long term (RR 0.73, 95% CI 0.55 to 0.96)
• low-quality evidence it has no effect on preventing sick leave as a result of lower back pain in the short term (RR 0.74, 95% CI 0.44 to 1.26) or long term

Exercise alone:

• low-quality evidence this reduces the risk of lower back pain by 35% in the short term (RR 0.65, 95% CI 0.50 to 0.86) but very low-quality evidence it does not in the long term (RR 1.04, 95% CI 0.73 to 1.49)
• low to very low-quality evidence this reduces risk of sick leave as a result of lower back pain by 78% in the long term (RR 0.22, 95% CI 0.06 to 0.76)

Education alone:

• moderate-quality evidence this has no effect on reducing the risk of lower back pain in the short term (RR 1.03, 95% CI 0.83 to 1.27) or long term
• very low-quality evidence this has no effect on risk of sick leave as a result of lower back pain in the short term (RR 0.87, 95% CI 0.47 to 1.60)

Back belt:

• very low-quality evidence this has no effect on reducing the risk of lower back pain in the short term (RR 1.01, 95% CI 0.71 to 1.44) or long term
• low-quality evidence this has no effect on risk of sick leave as a result of lower back pain in the short term (RR 1.44, 95% CI 0.73 to 2.86)

Shoe insoles:

• low-quality evidence this has no effect on risk of lower back pain in the short term (RR 1.01, 95% CI 0.74 to 1.40)  

How did the researchers interpret the results?

The researchers concluded that, "Exercise in combination with education is likely to reduce the risk of LBP [lower back pain] and that exercise alone may reduce the risk of an episode of LBP and sick leave due to LBP, at least for the short-term."

They said that, "The available evidence suggests that education alone, back belts, shoe insoles, and ergonomics do not prevent LBP", and it is "uncertain whether education, training, or ergonomic adjustments prevent sick leave due to LBP because the quality of evidence is very low".

Conclusion

This systematic review and meta-analysis found exercise reduces the risk of lower back pain and sick leave as a result of lower back pain.

The types of exercise studied included improving core strength (abdominals and lumbar region), leg and back muscle strengthening, stretching and cardiovascular workouts.

Although the researchers concluded that, "education alone, back belts, shoe insoles, and ergonomics do not prevent LBP", this is based on limited low-quality evidence.

However, these interventions might prove effective for individuals in situations that have not been studied, or if tested in better-quality trials. For example, the shoe insoles were only studied on army recruits, so the results may not be generalisable to the general population.

The review also purely focused on people who have not already experienced anything other than mild lower back pain, so it does not tell us whether these interventions are effective strategies for managing the condition.

For people with non-specific lower back pain, giving education advice and advising people to stay physically active and exercise are part of the early management currently recommended by the UK's National Institute for Health and Care Excellence (NICE).

The evidence for the effect of each intervention on the risk of sick leave for lower back pain was based on between one and three small trials, which limits the reliability of the results.

These limitations aside, the study adds to the weight of evidence that one of the many benefits of exercise may be preventing back pain. Additionally, there is expert consensus it can also be effective at relieving the symptoms of back pain in most people – though, as mentioned, the study did not look at this issue.

Get more exercises recommended for back pain.

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Dry January 'can lead to healthier drinking patterns long-term'

Monday January 4 2016

Giving up alcohol for a month can bring a range of benefits

"Study … found that Dry January leads to healthier drinking habits," the Mail Online reports. Dry January involves giving up alcohol for the month. There is limited evidence about whether taking part in the challenge could lead to long-term changes in patterns of drinking.

A recent study looked at 857 UK adults taking part in the challenge. Around two-thirds of the sample successfully gave up drinking for one month.

Compared with those who failed to abstain, those who were successful were, unsurprisingly, more likely to drink less, have lower dependence scores, and be more able to refuse alcohol to start with.

Both successful abstainers and those who did not succeed in the challenge also had increased powers of abstinence and reduced consumption patterns up to six months later, albeit to a slightly lesser extent in those who did not succeed. So, in this sample at least, it seems taking part in the challenge brought benefits.

The important limitation of the long-term sample data was that it represented only about a quarter of those taking part in Dry January originally signed up by the researchers.

The rest didn't provide complete data for assessment. People without complete assessments had higher alcohol consumption patterns to start with, so the results could be representative of those with better chances of success.

Whether you're taking part in Dry January or not, keeping your alcohol consumption within recommended limits is wise all year round.   

Where did the story come from?

This study was carried out by two researchers from the University of Sussex and one researcher from Alcohol Concern. No sources of financial support are reported.

It was published in the peer-reviewed journal Health Psychology.

The Mail Online's reporting of this research is accurate, but does not acknowledge the study's limitations. 

What kind of research was this?

This was a prospective cohort study of adults in the UK taking part in the Dry January alcohol abstinence challenge, and followed them up at one and six months to look at their outcomes.

As the researchers say, temporary abstinence from alcohol is believed to have possible psychological health benefits and boost wellbeing.

Similar to the Stoptober campaign, where people are encouraged to quit smoking for one month, various countries are said to have set up campaigns to encourage people to abstain from alcohol for one month. 

In this study, the researchers aimed to look at what personal factors are associated with likelihood of success, as well as how successful or failed abstinence influences subsequent alcohol consumption.

They expected that those who successfully completed the month would have an increased likelihood of reducing their alcohol intake in the future.  

What did the research involve?

The research included a cohort of adults in the UK taking part in Dry January. They completed questionnaires before starting the challenge, after the dry month, and six months later.

The study included 857 people (71% female) registered on the Dry January website who were aged 18 or over, lived in the UK, and had complete questionnaire data available at all three assessment points.

The initial questionnaire included demographic details, and assessed factors such as:

• age at first drinking alcohol
• usual drinking days
• number of drinks on a typical drinking day
• longest period of abstinence since they started drinking (day, months or years)
• consumption volume, frequency, dependency or alcohol-related problems – assessed using the 10-item Alcohol Use Disorders Identification Test (AUDIT)
• drink refusal self-efficacy (DRSE) using the question, "Please use the scale below to indicate how easy it would be for you to refuse alcohol in each situation", with responses on a seven-point scale from very difficult to very easy – the situations are scenarios where people may be tempted to drink, such as when friends are drinking, when watching TV, when having emotional worries, and so on
• intentions for Dry January – such as to stop drinking altogether or just try to cut down
• whether they were doing the challenge with someone else

The assessment at one month focused on the changes in DRSE compared with baseline.

The six-month assessment questioned the number of days from the start of Dry January until they had their first alcoholic drink again. They also similarly completed DRSE and other questions from the initial assessment.

The researchers examined which factors were associated with likelihood of abstinence. 

What were the basic results?

Roughly two-thirds of the study sample successfully completed Dry January – this was not specifically defined, but assumed to mean completely abstaining from alcohol for the month.

Compared with those who were not successful, at the start of the study successful completers had:

• fewer drinking days a week and fewer drinks on a drinking day
• fewer drunk episodes during the past month
• a lower AUDIT score
• higher DRSE social and emotional sub-scores – this showed they found it easier to abstain from alcohol in social and emotional situations

At the end of the month, people who successfully completed Dry January had significantly improved DRSE scores across all domains (social, emotional and opportunistic) compared with the start of the month.

Successful completion was also associated with reductions in the number of drinking days a week and the number of drinks, and how often they were drunk at six months.

People who failed to complete Dry January still showed significant improvements in DRSE social and emotional scores at one month, and the number of drinking days and number of drinks at six months. However, these improvements were not as large as those seen in people who were successful.

A small proportion of the total sample (11%) demonstrated "rebound effects", with an increased frequency of drunkenness at six months. This was more common among unsuccessful completers.  

How did the researchers interpret the results?

The researchers concluded that, "Participation in abstinence challenges such as Dry January may be associated with changes toward healthier drinking and greater DRSE, and is unlikely to result in undesirable 'rebound effects': very few people reported increased alcohol consumption following a period of voluntary abstinence." 

Conclusion

This cohort study followed adults in the UK who took part in a Dry January alcohol abstinence challenge, looking at the factors associated with success and the effects on future alcohol consumption.

As may be expected, factors associated with the likelihood of being able to successfully abstain for one month included drinking less alcohol, having lower alcohol dependence scores, and being more able to refuse alcohol to start with.

However, although these factors were significantly different between the "successes" and the "failures", it is worth noting the differences perhaps weren't so great in actual terms.

For example, people who successfully completed Dry January drank on average 4.78 days a week and consumed 3.78 drinks on these days at the start of the study, compared with 4.96 days and 4.21 drinks among those who failed to complete.

It is also notable that though successful completers demonstrated improved refusal skills and reduced consumption at six months, so did the non-completers, albeit to a lesser extent.

This means the differences – both before and after the challenge – between those who successfully abstained for one month and those who didn't are not as vast as might be expected. Overall, it seemed that just participating in the Dry January challenge had a positive effect, at least in this sample.

This brings us to the key limitation of this study – the people who were not included. Although there is a relatively large sample size, the study only had results for around a quarter (23%) of those registered for Dry January who would have been eligible to participate. Those missing did not have full questionnaire data available.

The researchers report that those with complete six-month data were more likely to have completed a dry month in the past, drank fewer drinks on a drinking day, reported less frequent drunkenness, had lower AUDIT scores, and had greater social DRSE.

The researchers did use statistical techniques to take account of the differences between people participating in follow-up or not. However, the results may still not be fully representative of what would be seen if all people who attempted Dry January had been followed up.

Also, the study does not include the many adults who don't choose to take part in the challenge, who may have different drinking habits or willingness to abstain.

As the researchers rightly acknowledge, without a control group it is not possible to know whether alcohol consumption might decrease among the population anyway at this time, as part of the general turn to "healthier behaviour" that many of us take at the start of a new year.

Other potential limitations include the reliance on self-reported data, which may include inaccuracies. For example, people may not be able to accurately recall the longest period they have ever gone without a drink during their lives.

Overall, this study provides observations on the reported effects of Dry January in a UK sample. However, the limitations described make it difficult to draw firm conclusions on the campaign's long-term effectiveness as a behaviour-change initiative to improve alcohol consumption patterns in the adult population in the UK.

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The top 10 news stories of 2015

Wednesday December 30 2015

Last year it was Ebola, this year it's Calpol

10. E-cigarettes may make lungs vulnerable to infection

In February, there was concern that the vapour produced by e-cigarettes contains free radicals – atoms and molecules that are toxic to cells – and that this could damage people's lungs. Our conclusion: are e-cigarettes safer than normal cigarettes? Almost certainly. Are they 100% safe? Probably not.

9. Meningitis B vaccine 'available from September' 

There was good news in June, with the announcement that a new vaccine for meningitis B – a highly aggressive strain of bacterial meningitis – would be added to the NHS childhood vaccination schedule. This was the world's first publicly funded vaccination programme for the potentially fatal disease. 

8. UK life expectancy expected to rise to late 80s by 2030

In April, a new modelling study looking at trends in life expectancy estimated that male babies born in 2030 could live to an average of 85.7 years, with females living an average of 87.6 years. The research also highlighted the stark effect that economic inequalities can have on health – for example, it estimated that life expectancy in the affluent London borough of Kensington and Chelsea would be five to six years higher than the working class area of Tower Hamlets.  

7. Child obesity rates are 'stabilising' 

According to BBC News in January, the rise in childhood obesity "may be beginning to level off". While it was encouraging to see that the child obesity epidemic is not worsening, there were no clear signs that it's getting any better. Underlying factors, such as low activity levels and easy access to calorie-rich, nutrient-poor foods, still need to be addressed. 

6. Strenuous jogging 'as bad as doing no exercise' claim 

"Too much jogging 'as bad as no exercise at all'," BBC News reported in February. But the results of the Danish study this headline comes from were not as clear-cut as the media made out. One of the study's major limitations was that once the joggers were split into groups by duration, frequency and pace, some individual groups – particularly the most active groups – were much smaller. And, to be honest, people overexercising is not a pressing concern in the UK: the more common problem is people not doing enough.

5. Drinking 'plenty of red wine' won't help you lose weight

If it sounds too good to be true, then it probably is. And that was the case with The Daily Telegraph's headline from June: "How to lose weight – drink plenty of red wine". The headline was simply nonsense. The study it's based on did not involve red wine. And it was carried out on mice, not humans. Drinking "plenty of red wine" will not help you to lose weight – if anything, the opposite is true. A standard 750cl bottle of red wine contains around 570 calories, which is more than two McDonald's hamburgers. 

4. E-cigarettes '95% less harmful than smoking' says report 

"E-cigarettes are 95% less harmful than tobacco and could be prescribed on the NHS in future to help smokers quit," BBC News reported. This was the main finding of an evidence review carried out by Public Health England published in August. Once e-cigarettes are regulated as medical products – which is expected in 2016 – some brands could be made available on prescription.   

3. Is long-term paracetamol use not as safe as we thought?

A review of previous observational studies carried out in March found that long-term use of paracetamol was linked to an increased risk of adverse events such as heart attacks, gastrointestinal bleeds (bleeding inside the digestive system) and impaired kidney function. While the increase in risk was small, the fact the drug is used by millions means further investigation is required. 

2. Media dementia scare over hay fever and sleep drugs

Another drug scare from January saw claims being made that a class of over-the-counter drugs known as anticholinergics, which are used to treat allergies and muscle cramps, increased the risk of dementia. However, the risk only seemed to be associated with people taking these types of drugs daily on a long-term basis.  

1. Minor ailment scheme doesn't provide free Calpol for all

The most popular news story of the year, attracting more than 100,000 views, was triggered by a Facebook post that quickly went viral, where a mother claimed that all medicines are free under the minor ailments scheme. But, like a lot of Facebook content, it was complete nonsense: the NHS does not provide free Calpol to all parents. Liquid paracetamol (brands other than Calpol are available) may be given at the pharmacist's discretion to parents who have registered with the scheme.

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

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