Category: Effectiveness

Brain training: better off dancing

February 13, 2009 1:07 pm

The number of computer programs that promise to sharpen, train and preserve brain function seem to be proliferating. There has been a lot of press coverage about a paper in the journal Alzheimer’s and Dementia . The authors reviewed all the evidence available on interventions aimed at preserving cognitive function in healthy elderly people. Just as I say in point number five of the 10 steps to health in ’09, the authors point out that there is no decent evidence that these kinds of programs work. Furthermore, they may even come with potential harms.

As Professor Peter Snyder, one of the co-authors, wrote in an e-mail to me yesterday: ”There are several lifestyle-related things that older persons can do that have much better clinical data supporting their effectiveness, for possibly delaying onset of dementia. First, there is truly excellent physiological, neurological and clinical outcomes data supporting the role of regular exercise – even three times per week for 20 minutes per session of exercise (e.g., fast walking). Second, we know that obesity, diabetes and heart-disease are all risk factors for Alzheimer’s disease. Finally, I suspect that remaining cognitively active does indeed offer some protective benefit… the point of my paper is that there are no credible data to support the increased benefit of these marketed products and brief interventions, over maintaining a socially active lifestyle, remaining engaged and active with family and friends, learning new hobbies, music or a foreign language, playing Suduku or crossword puzzles, cooking, and reading good books on a regular basis.”

Personally, I find this advice very life-affirming.

Tags: brain training
Posted in brain training, Effectiveness, Medicine in the media, Questions about healthcare | Permalink

Smoking: Your employer is watching you

February 9, 2009 11:20 am

In the UK, smoking in workplaces is banned. But we can do what we want in our own homes and in our own time (as long at it’s legal).

Glancing through job adverts (reading them is a recurrent hobby, not a search) I note that the World Health Organisation wants to recruit only people who are non smokers – that’s not just people who are non-smokers at work, but non-smokers at home as well. This raises an interesting ethical question: should employers have any right to know what their employees are up to (in a non-lawbreaking sense) when they are off duty? Surely employees are entitled to privacy? Of course, good employers will want to ensure that they are not curtailing employees ability to be healthy – but this is a step beyond.

Now, there may be an argument that smokers are less healthy and require more sick leave than non-smokers. But this seems to be rather discriminatory. Most smokers want to stop, and more smokers belong to lower socio-economic groups. I can’t find any research indicating that people would be helped to stop smoking by this policy (if I am wrong, let me know) but there is plenty of evidence associating unemployment with worse health. All in all, this seems to me to be an invasion of privacy and really rather unfair.

Posted in Effectiveness, Public health, Smoking | Permalink

Breast screening; better information?

January 28, 2009 10:35 am

For several years I have been trying – and, evidently, failing – to suggest that the information that women get about breast screening isn’t very balanced. The problem- as I see it anyway – is that services are geared to get women to turn up for screening. Whereas, I would like services judged not on how many women turn up, but on how many women make good informed decisions about whether or not they want to have screening at all. As we have had more and better research evidence about breast screening it has become apparent that there are, as well as measurable potential benefits, also measurable potential harms. Just like operations or tablets, doctors should be explaining the pros and the cons, and trying to help people reach a decision about them. (And Gerd Gigerenzer is the master on explaining risk – his book Reckoning with Risk is brilliant.)

So, in the BMJ this week is a vastly improved information leaflet about breast screening, written by the Director of the Nordic Cochrane Centre and his colleagues; it’s available here.

I forgot to include a link to the paper – the start of it is here.

Posted in Breast problems, Effectiveness, medical ethics | Permalink

Over the counter for the overweight

January 27, 2009 2:38 pm

The EU Medicines Directive has decided that Orlistat, a weight-loss drug, can go on sale over the counter. You’ll be able to buy it without a prescription from pharmacies, and online. The difference between the over-the-counter version and the prescription variety will be the dose: the usual prescription strength is 120mg three times a day – the OTC product will be 60mg.

Is patient choice and increased availability a good thing? All drugs have side effects, and Orlistat – or Alli as the OTC version is to be called – is no exception. The side effects are mainly to do with bowels and incontinence – I will spare you any more detail. Still, it seems to suit some people, and there is evidence of benefit. How much benefit? The majority of studies on Orlistat have used the 120mg dose. Most trials also involved people being given stringent dietary and exercise advice. In trials, people taking Orlistat – with these provisos in place – have lost about 2kg-5kg more than people taking a placebo.

The problem is that we won’t know if this OTC development will work or not. As far as I can see, no one is looking into whether it will make a measurable and effective difference to people’s weight under these lower-dose and real-world conditions.

The other problem is fragmentation of care. The fact that more people are becoming involved with a patient’s healthcare without shared notes makes me concerned that we are creating problems-in-waiting. Shouldn’t we get this sorted out before even more drugs obtain an OTC licence?

Posted in Effectiveness, medical ethics, Politics of healthcare, Public health | Permalink

Can cereals reduce high cholesterol?

January 24, 2009 2:03 am

We have come a long way since the humble bowl of Corn Flakes. Kellogg’s signature cereal was famous for being best enjoyed with “ice cold” milk. Its latest cereal product, Optivita, is being sold along far more complicated lines. Current television advertisements for Optivita proudly proclaim that the cereal has been approved by Heart UK, “the cholesterol charity”. The idea is that by choosing Optivita (an amalgamation of “optimal” and “vitality”) you are going to do good things to your cholesterol, so eat on.

Let us remind ourselves what high cholesterol levels mean in practice. High cholesterol is a risk factor for cardiovascular disease, as are smoking, obesity, diabetes, high blood pressure and a sedentary lifestyle. People can also inherit high cholesterol levels – a condition called familial hypercholesterolemia, which usually requires medication.

Cholesterol receives a lot of attention because it is easily measurable and, unlike one’s family medical history or diabetes, modifiable. Statin medication helps, but many people would, very reasonably, prefer to improve their diet than take a pill. This is where breakfast comes in.

The remainder of the article can be read here. Please post comments below.

Posted in Effectiveness, Food, Public health | Permalink

We need evidence, not a register

January 20, 2009 1:00 pm

I am dismayed to note that complementary therapists are now able to register with the CHNC. Ben Bradshaw, the health minister who is also so keen on the non-evidence based ‘iwantgreatcare.org’ doctor-rating website, is reported as saying: ”I welcome the opening of the Complementary and Natural Healthcare Council (CNHC) register…which the public can turn to for help. Members of the public who use these therapies will be able to check whether the practitioner they’re seeing is registered with the CNHC. If they are, they have the reassurance of knowing that they have had to meet minimum standards of qualification … Practitioners too will benefit by increased public confidence. Public safety is paramount. Registration, whether voluntary or statutory, is about protecting patients, and I am pleased to see this important milestone in voluntary registration.”

This is nonsense. What about protecting the public from ineffective interventions? Or false hope, wasted time and effort or indeed, potential harm? What is the point of improving “public confidence” in things that don’t work? (And “alternative” therapies which do work are taken up into orthodox medicine.) Bradshaw would be serving the public far better by advising them to be cautious when engaging with healthcare interventions which have not been proven to work. Isn’t that the best way to “protect” patients? And, incidentally, Bradshaw’s signing off line — “People should always seek their GP’s advice to ensure that any other therapy they use does not conflict with orthodox treatment” – is the epitome of weasel words: how can a GP ethically end up taking responsiblity for things he or she doesn’t prescribe or suggest?

Posted in Complementary and alternative medicine, Effectiveness, medical ethics, Medical professionalism, Politics of healthcare | Permalink

Taking a “Benylin day”. Or not.

January 19, 2009 11:35 am

Thank you to a correspondent for the link to this promotional website offering workers suffering from colds all manner of unnecessary things. There are suggested out-of-office email messages (“I’m taking a BENYLIN® day or two and will reply to your email as soon as I’ve recovered!”) , recommendations for DVDs (all fairly rubbish, in my opinion) for frittering away your time until feeling better, and scripts of what to say to your boss when letting him or her know you won’t be in.

The ingredients of Benylin Max Strength Capsules are:

Paracetamol (available on its own, at a much cheaper price)

Caffeine (available from your teapot/cafetiere, where it is supplied along with warm, tasty hydration)

Phenylephrine (a decongestant; but you might be interested to read this abstract from a 2007 US systematic review of its effects; it concludes: “There is insufficient evidence that oral phenylephrine iseffective for nonprescription use as a decongestant.” )

In other words, I think we should still call them “sick days”.

Posted in Effectiveness, Medicine on the internet, Pharmaceutical industry | Permalink

Another exciting advertisment from the MHRA

December 8, 2008 5:40 pm

Yep. In this week’s BMJ, is an advert for a ‘vacancy for a member’ for the Herbal Medicines Advisory Committee , which advises the Medicines and Healthcare Regulatory Agency on the ‘safety, quality and efficacy of herbal medicinal products for human use.’ Of further concern to me is that they wish their newly appointed member to have recent experience in paediatrics.

Herbal medicines are, if they work, nothing special – St John’s Wort, aspirin (willow extract), vincristine, a chemotherapy drug, which is derived from plants….they all have side effects and interactions with other drugs. In fact, one could say that herbal medicines which work are in fact just medicines, to be used with the same provisos as any other medicines.

These leaves the ‘other’ herbal medicines as the ones which don’t work. And which, by definition, we should be ensuring either aren’t used, or are properly researched so that we know whether they should be or not.

What is gained by having a Herbal Medicines Advisory Committee? Obfuscation, and the danger of having a different set of standards for one set of chemicals compared to another, I suggest.

Posted in Complementary and alternative medicine, Effectiveness, medical ethics, Politics of healthcare | Permalink

Breast cancer: to screen or not to screen?

December 1, 2008 2:00 pm

A very interesting paper just published in the Archives of Internal Medicine. The study followed women before and after the introduction of a breast screening programme in Norway. They were compared to a control group of women who did not take part in the screening programme, but who would have been, had the programme been started in their area. This control group were invited for a one-off screening at the end of the observation time in order to work out how many had invasive breast cancers.

When the two groups were compared, the amount of invasive breast cancers was found to be significantly higher in the group of women who had regular screening. On first glance, this may appear to be a good thing – it seems that screening picked up more invasive breast cancers. But is it? The problem is that the natural history of these “invasive breast cancers” may not be as predictable as we would like to think, in that not all may cause a life-threatening situation. The authors concluded that “it appears that somebreast cancers detected by repeated mammographic screening wouldnot persist to be detectable by a single mammogram at the endof 6 years. This raises the possibility that the natural courseof some screen-detected invasive breast cancers is to spontaneouslyregress”.

This is but one paper in a complex field, and I wouldn’t suggest that this research alone should make women decide what to do when the invitation to breast screening comes in. However, there are already uncertanties about how beneficial breast screening is. I think this paper does emphasise that there are still a lot of unknowns when it comes to breast cancer screening. The NHS Behind the Headlines service provides a useful analysis of the news coverage of this story but concludes that “women should continue to attend screening programmes”. I think this is a bit unfair; surely the best position is to invite women to weigh up the pros and cons for themselves, as they become known. But maybe this is also unfair; most people probably don’t have the time to devote to investigating this sort of thing and they should be able to expect disinterested, fair advice from their health professionals.

Posted in Breast problems, Effectiveness, medical ethics, Medical screening, Medicine in the media | Permalink

Dealing with the fall-out

November 1, 2008 2:17 am

In the wake of the subprime crisis and the stock market slide, counselling and psychotherapy services have been quick with offers of help for those dealing with the fall-out.

A generation or two ago, discussion of one’s personal problems was more commonly done in the public house, with a priest or parson, or with friends and family. This does not necessarily mean that it was ideal or even helpful. But is acquiring a professional ear for life’s troubles any better?

It would be quite normal to be upset by the loss of a much-loved job, or a lifetime’s savings. The question is whether professionally dispensed “therapy” would provide any greater comfort than one’s usual coping methods. Stressful events can act, in some people, as a trigger for anxiety or depression. But for those who are not ill, and who do not have a psychiatric disorder, indiscriminate use of therapy may actually do harm.

The remainder of the article can be read here. Please post comments below.

Posted in Effectiveness, Questions about healthcare | Permalink