Heartburn, cancer and timing

It’s end of January, winter is doing its worst in terms of seasonal infections and busy General Practitioners across the UK are under even more pressure than usual. I expect a few of them gave a weary sigh at the timing of Public Health England’s exhortations to be more aware of the symptoms of oesophageal cancer and to see your doctor if you have persistent heartburn. The trouble with all this “awareness raising” is that there is no particular evidence that it will cut cancer deaths or change any other health-related behaviour. So maybe this particular announcement could have waited a couple of months.

Heartburn and difficulty swallowing can be signs of cancer but they are usually caused by a weak or damaged valve at the top of the stomach and reflux of gastric contents. Heartburn is incredibly common in the over 40s. It’s exacerbated by obesity – belly fat in particular, which crowds the stomach and pushes stomach acid backwards.

The most common treatment is acid blocking drugs but it can also be greatly reduced by weight loss and other self help measures outlined in my latest book.

Doctors can only properly diagnose cancer by referring the patient to the hospital for an endoscopic examination (by a thin, fibre-optic tube) and if everyone with heartburn was referred, the waiting times would be very long indeed. This could in theory slow down diagnosis of cancer - if the queue is clogged up by the worried well. So unless there are other symptoms (such as weight loss or serious difficulty swallowing) the doctor’s first action is likely to be try the acid blocking drugs and see if the symptoms are relieved.

Reflux is not only a symptom, it's one of the causes of cancer of the oesophagus (if it persists for a long time). So long-term heartburn martyrdom should definitely be avoided. Another cause is regular consumption of strong alcohol. It may well be that the reason that deaths from oesophageal cancer are climbing, and are higher in Britain than other European countries, is that us British are more overweight and drink more excessively than other nations.

Public Health England make it sound like simple issue – if more people know the symptoms, more people will go to the doctor, then more people will get diagnosed earlier and more lives will be saved. I fear that it not an easy fix and until someone comes up with a way of enthusing the British with the benefits of a healthier lifestyle the incidence of this cancer will continue to rise.

Be Clear on Cancer – Public Health England Press Release http://bit.ly/1BkuUT8

Hot flushes – a persistent problem

For many women, hot flushes are the biggest inconvenience associated with the menopause. Everyone implies they are a short phase that happens as you “go through the change”. The NHS website says: “As a result of these hormonal changes, many women have physical and emotional symptoms such as hot flushes, night sweats and irritability.” Sounds pretty transient if they result from the changes doesn’t it? Once the changes have happened then everything calms down – doesn’t it?

So we arrive at the menopause (defined as the cessation of menstruation) expecting to suffer some inconvenience during the year or so when menstruation tails off and a new, tampon and towel-free life begins. However, for a large proportion of women, the cessation of periods is just the start of what are inaccurately called “menopausal symptoms”.

Hot flushes can be highly disruptive if you have several a day (or, even, several an hour). At their worst you feel queasy for a few minutes and then the heat builds in your upper body until it feels as if you have a 2000 watt spotlight positioned just in front of your face. Blood rushes from your brain to your skin and leaves befuddlement in its wake. You have a panicky urge to escape from your clothing and fling open windows. Then, two or three minutes later you start to feel chilly, replace your discarded layers and look for another one to add.

If you happen to be lounging in the shade, watching the play of light on the sea, you just reach for you fan and take sips of ice water while the moment passes. Not so easy if you are in the middle of something - an important meeting maybe; trying to teach a class of lively teenagers or driving a car in heavy traffic. Annoying to have one's ability to function temporarily impaired. Embarrassing too and even, at times, dangerous. Hot flushes can also wake you several times in the night and, if they are accompanied by night sweats, they can drench your sheets with perspiration.

Irritability huh? I wonder what might be causing that?

HRT can be used to stop flushes in their tracks, but as with all hormone treatments, it has both benefits and risks. Whether or not to take it, and for how long, is a difficult and individual choice.

Recent research reveals what many of us know – hot flushes are not just for a year, they commence in earnest once the menopause is complete and they can run on for decades. Researchers in Pennsylvania found that the average duration was about 5 years and a third of their group experienced medium/severe hot flushes for over 10 years. I find it interesting that this information is only now available – it highlights the incomplete knowledge that women and doctors have when they are making decisions about HRT and other drug treatments.

Many women resort to herbal remedies as an alternative to HRT but these are poorly researched and the effects of taking them daily for a decade or more are unknown.

I hope I may be excused from surmising that if a significant percentage of men, at the height of middle-age, was struck down by disabling waves of heat, many times a day, combined with significant sleep-disruption, then maybe the medical world would be taking the problem more seriously? Is it just possible that there would be a lot more research in the area? And that we wouldn’t have waited this long to have clear evidence that flushes don’t just happen when you are “going through the menopause”?

Or do those of us who suffer perhaps collude in this myth that hot flushes are really a feature of the menopause, rather than post-menopause? Is it somehow more acceptable to say that we’re going through the menopause rather than admit the reality - that we are ten or more years beyond it?

Perhaps, in the light of this research, it is time to be more open, to press for more research so that treatment options can be discussed in the light of better information.

http://www.sciencedaily.com/releases/2014/01/140130152811.htm

The Value of Vitamins

It all started with the important discovery of vitamin deficiency diseases like scurvy, pellagra and rickets and now it's become a huge industry. You can hardly venture onto public transport without seeing adverts for supplements on railway stations, in tube trains or on the backs of buses. Anyone would think vitamins and minerals were to the body what oil is to the engine of a car - a simple top up and smooth running is assured.

It's very hard for the average consumer to make informed decisions in this area - the products sound tempting and "everyone's" taking them, so they must be good, mustn't they?

Doctors tend to be conservative on the subject - "you only need vitamins if you have a vitamin deficiency disease" would be their traditional position statement.

"Nutritionists" are far more liberal. They believe that vitamins not only prevent diseases but can also "heal" all manner of ills. They recommend a vitamin (or six) for every ailment. As if that extra oil in the car could mend a broken engine part. They tend to be overly eager to support their beliefs by citing  evidence from experiments involving cells and mice.

In the middle ground we have the lucrative supplement industry with a vested interest in convincing us that we need supplements and so getting us to part with our money.

So what's the scientific take on all this?

Evidence cannot convince the scientific community unless it involves a large group of humans (not genetically modified mice), taking vitamins over a long period of time, with a "blind" comparison group taking placebos. Only then can you check whether the supplements are safe and whether any positive effects result. Such trials are, of course, very expensive and are consequently rather rare. Such studies that do exist have sometimes shown no benefit, or even demonstrated harm to those who take vitamin supplements for long periods.

In summary - the better quality evidence has generally been "disappointing" inasmuch as it has failed to show that supplements reduce your chances of avoiding colds or cancers, or that they increase your chances of living longer. Vitamins cure vitamin deficiency diseases, but evidence that they are curative in other areas is very flimsy indeed.

The other problem for consumers is that vitamins are very lightly regulated. In Europe, now, you cannot even hint on packaging that a food has an active health benefit. There are only a few examples that are approved by the European Food Standards Agency (notably oats and the cholesterol-lowering products such as Benecol margarine). Food packaging is still allowed to bear words like "fortified with Vitamin A" or "a source of vitamin C" as long as they contain minimum amounts of the relevant nutrient.

Where food supplements are concerned, as long as they are not actually toxic or contaminated and as long as they make their claims in qualified terms such as "may help support a healthy immune system" they are very lightly regulated. In other words there is not a lot of consumer protection.

Cochrane systematic reviews are a good place to look if you want to check the best evidence about supplements. A new book has been published which goes into more myth-busting detail and it looks like interesting reading.

http://www.thecochranelibrary.com/view/0/index.html

http://www.guardian.co.uk/lifeandstyle/2013/jun/07/vitamins-stop-taking-the-pills?INTCMP=SRCH

Swansea Measles Outbreak - time for a change?

The Welsh measles outbreak is a sorry tale.

This is the latest news is :

·     The number of cases in the outbreak has now reached 1,136 since November 2012, up 10 cases in the last few days. There were only 19 measles cases in Wales in the whole of 2011. Despite 60,000 non-routine MMRs administered, tens of thousands of Welsh children remain unprotected.

The speed at which this outbreak took hold is sobering but not unexpected. Measles is called a "childhood disease" because before vaccination nearly everyone caught it and did so sooner in life, rather than later, because it is so infectious. In Queensland, Australia there is currently a threatened outbreak and health officials, who have been watching the Welsh outbreak with concern, are trying hard to nip it in the bud.

It is a source of shame that this Welsh outbreak has happened. Shame on Andrew Wakefield who submitted his now-discredited paper to the Lancet. Shame, for certain, on the many journalists who jumped on the "MMR causes autism" bandwagon. Shame on the doctors who, even now, are making money by offering the single measles shot. Shame on those who continue to spread the anti-vaccination message.

Should we also say shame on those parents whose anxieties were raised by the "scare" and who are now, rather belatedly, queuing to have their children vaccinated?

Even without the alarm bells of a scare story ringing in the background it is not a pleasant activity taking your baby to the clinic for its vaccinations. Someone will stick a needle in that tender little arm and your baby will probably scream in pain. It is easy to feel as if you are harming them in some way. You are, after all, exposing them to something that is closely related to an infectious substance. And we can never say that a vaccination, or any other medical procedure, is completely without risk.

Parents in the Western world are now unfamiliar with the risks and unpleasantness of "childhood diseases". So it is understandable that some of them have erred on the side of non-vaccination. One might guess though, that an African mother who has seen toddlers dying of measles might have a very different view.

Since Jenner first started promoting the smallpox vaccination there have been those who campaigned against vaccination. The arguments they put forward are weak, illogical and superficial, but nevertheless persuasive. Meanwhile public health authorities in the UK have been content to let things ride despite signs that measles and whooping cough were becoming more common. The UK has got away with this for a long time but maybe it is time for a re-think.   

Some countries require children to be vaccinated before taking up a publicly-funded school place. Maybe we should be considering something similar. It would not be unreasonable, I think, to require nurseries or primary schools to ask for a vaccination record when registering new pupils, as they do in most US states. There would be a libertarian outcry but it would soon die down. Vaccination should be viewed as one of the necessary infringements of personal liberty that come with the benefits of living in an organised society. It protects all children - in particular those with inadequate or compromised immune systems who are not able to benefit.

We do not complain about the need to adhere to driving laws, such as keeping to the left or putting children in car seats and vaccination should be viewed in the same light. 

http://www.bbc.co.uk/news/uk-wales-22641698

Souvenir Supplements - the Perfect Gift?

In Sydney airport transfer lounge, 20 hours of flying behind me and another three ahead, I cast a bleary eye over the souvenir shops. Their shelves hold aboriginal art, expensive clothing items and a wide selection of souvenir food supplements. Gone are the days when you bring home tea towels or a fridge magnet for your mum. The on-trend global traveller is more likely to say: "I'm back darling, and I've brought you something that's supposed to be really good for arthritis!"

I imagine that the product development for these supplements probably goes like this: you identify a plentiful resource like kangaroos or sheep placentas and brainstorm how you could turn them into an income stream. Having honed in on the plan of selling supplements to the gullible you then make up some marketing blurb that includes a random selection of unspecific "things it must be good for" such as boosting your immune system/ reducing inflammation/ improving mobility of joints/ rebalancing energy/ restoring vitality/ boosting sexual performance and so on. Make sure you list the scientific analysis so you have some scientific words to put on the label. Throw in a few random "facts" and then commission your packaging.

Here are three examples from down under.

Colostrum

This interesting liquid is produced by mammalian mothers in the first few days after giving birth - the perfect food for their own particular species of newborn. Mouse colostrum is ideal for newborn mice while elephant colostrum is tailored to the needs of elephant babies.

Colostrum is very high in protein - much higher than true milk. Those who keep milk-producing animals sometimes use colostrum to cook a special dish. Just mix colostrum with some sugar and bake at a low heat. The result will apparently be a lot like egg custard. You couldn't do this with milk because its protein levels are much lower.

A significant proportion of the proteins in colostrum consist of antibodies (immunoglobulins). This download from the mother's immune system helps to protect the baby from infection until it can develop its own set of immunities to the microbes in its environment. Cow antibodies will protect against cow diseases and the kind of bacteria encountered every day in pastures and the milking parlour. Calves that are deprived of cow colostrum tend not to thrive - they seem to need it to prime their intestines. But why should the benefits of colostrum to newborn calves translate into health benefits for the adults of another species?  Adult humans don't need protecting against bovine diseases. And even if they did, why should we expect that these complex molecules would survive pasteurisation, drying, packaging and digestion by a human stomach? Is there in fact any evidence that consuming cow colostrum has any benefits to human health?

The website of the "Institute of Colostrum Research" seemed to be a promising place to find the answers to these questions. But alas no - not a single link to research could I find.

The Centre for Nutritional Research, also keen on (selling) colostrum is also long on supposition and short on research.

Lamb Placenta Extract

Many animals eat their placentas. I remember once watching my son's pet gerbil giving birth to a large litter and as each one emerged she grabbed the placenta in her front paws and nibbled it, in exactly the same way that she ate sunflower seeds. This was certainly a way of reclaiming some of the nutritional resources, such as iron, that she had devoted to pregnancy. I don't think sheep tend to eat their placentas and I can imagine that people scratching a marginal existence by herding might well scoop them up and make them into a nutritious casserole. But what on earth are pills made from sheep placentas supposed to do for your health other than perhaps act as an iron supplement? Somehow pass on the joie de vivre of a lamb?

The marketing takes a broad-brush approach and mentions things like growth hormones and the wonderful health of the sheep used in production. It's good for all kinds of things, honestly - "rejuventating your organic tissue" for example. I particularly liked the nugget of "information" that sheep's placentas have been used as medicine by the British royal family for 1400 years. Must be good stuff then.

Kangaroo Extract.

The marketing for this emphasises the vigour and sexual potency of the male kangaroo, conjuring up visions of great-grandad leaping from his wheelchair and doing a pogo dance around the lounge while singing a Rolf Harris medley and casting a flirtatious eye at the care staff. Why kangaroo extract should be any more revitalising than, say, beef extract, is not at all clear. But there are large segments of world population that believe in the "law of similars". The law that dictates that if a rhino horn reminds you of an erect penis then extract of rhino horn is bound to do wonders for the flagging erection. If you could distill the essence of a big bouncy virile 'roo, why would it not have a beneficial effect on the aging male? You know it makes sense.

This one may also play to the jokey present market.  "Didn't know what to get you dad but you've been looking a bit tired lately so I got you some Kangaroo extract."

The trouble is that these products, with their vague, "natural" marketing messages, feed into two main belief systems. One is the oriental medicine trade that greedily slaughters wild animals in the interests of producing tonics and impotence cures. Only today I read about the seizure of a large cargo of dead anteaters (pangolins) destined for this market. Endangered plants can also be plundered and rare habitats damaged. There may be plenty of 'roos but I doubt that pangolins are an inexhaustible resource.

The other is the western belief that any natural product extracted from plants or animals is not only health-inducing but somehow superior to modern medicine. It is an alluring idea, but alas, it is just not true, however much we would like it to be. Why should we care? Firstly because some people turn down conventional treatment for serious diseases, believing supplements can cure them. And secondly because people who are not well educated in scientific scepticism are tricked into spending their scarce funds on these products.

Health Advice from your Home Doctor

In the days before the NHS, when the British had to pay for a consultation, "home doctor" books seem to have been quite popular. I've been whiling away a chilly afternoon by dipping into one that was published in 1935. It contains a great deal advice on how to keep healthy. 

On alcohol consumption readers were advised thus:

"The counsel of perfection would be that of complete abstention from alcoholic liquor." The author though, obviously feels this is unrealistic and without explaining why he deems it unhealthy to consume too much liquor, goes on to recommend a sensible daily consumption:

"A glass of beer, light wine or claret at the middle-day meal is quite reasonable, but it is wise to eschew spirits, port, sherry etc" ... A sherry between 6 and 7 pm (the cocktail hour) is preferable to a "spirituous" cocktail "and with the evening meal, a glass or two of white wine, claret or burgundy may be taken as routine" ... "A glass of whisky and soda last thing at night may round off the day, and the average man has had all he wants in the way of alcoholic stimulant for twenty-four hours."

Sounds like a fair bit to me - five drinks a day - but it rather sounds as if this is what the author consumed routinely. So it must be alright.

On tobacco he starts by saying: "It is at least doubtful whether the habit often does any really very great harm," - an interesting sentence that reveals his conflicted feelings. We know that the majority of doctors smoked in the mid 20th century because in the huge study of the effects of smoking, conducted on a large group of British doctors, only 17% were lifelong non-smokers. He goes on to list a number of forms of possible harm caused by the habit: irritation and inflammation of the airways, smokers cough ("too well known to require description"), irregular heart beat, colitis, gastritis, constipation and a form of blindness.

On the subject of exercise the good doctor is cautious, recommending a brisk, 15 minute walk, out of doors, every day, ensuring that one's breathing is deep, head is thrown back and arms are swinging naturally. This is seen as primarily beneficial to the lungs and the reader is reminded: "It almost goes without saying that smoking should not be considered during such a walk."

He cautions against launching into team sports without prior conditioning and recommends that that such activities do not combine well with alcohol or smoking. Running meets with cautious approval but "Except in rare cases, men of over thirty-five years of age should not partake in competitive athletics."

It is notable that the tone of the book is of one middle class gentleman, advising another. Women are considered when specific female problems are dealt with, such as the menopause. Female readers are warned against the habitual consumption of brandy, whisky, gin or aspirin and: "Emotionalism is to be avoided."

There are many pages devoted to areas of life into which health professionals would never dream of venturing today, such as the time of day to take a hot (but not overly hot) bath. The evening is deemed the appropriate time, with perhaps a cold dip in the morning.

There are pages given over to the kind of clothing appropriate for the maintenance of health. Wool next to the skin is strongly recommended but not "old, washed and felted woollen garments" which are, apparently, "a common source of colds." Undergarments made from other fabrics are given cautious approval. Tight collars are mentioned, which "certainly hide that Adam's Apple, but they do impede a free flow of blood between the head and the heart".

He ends the section on clothing with the following: "It should be remembered that to be well dressed is to be inconspicuously dressed, and some of the various freaks and vagaries of attire one so often sees in some individuals are quite unnecessary and usually a sign of exaggerated self-importance." 

The only place that science informed health advice of the 1930s was the diet because it had recently revealed the existence of the key nutrients, so the importance of having a balanced diet was understood. 

We sometimes gripe today about ever-changing recommendations about diet or the consumption of alcohol, so it is interesting to look back and notice how much has changed since the childhood of today's great-grandparents. Long gone are the days when doctors thought that colds were caused by woolly undergarments that had seen better days and the time when they had no idea that smoking caused lung cancer and cardiovascular disease.

Thanks to a great deal of careful scientific enquiry, we all have much better knowledge about the factors that affect health than anyone could have dreamed of in 1935. The official health advice we receive is not perfect, but it is no longer based on firmly held opinions and nothing more.

The Modern Home Doctor, published by the Daily Express in 1935 and written by "members of the Medical Profession".

Doll R, Hill AB. (1954). "The mortality of doctors in relation to their smoking habits". BMJ 328 (7455): 1529.