The healthmatters blog; commentary, observation and review
The large-scale study, “Genome-wide associations for birth weight and correlations with adult disease”, which was published in Nature on Wednesday September 28, could help to target new ways of preventing and treating these diseases.
This new research finds genetic differences that help to explain why some babies are born bigger or smaller than others. It also reveals how genetic differences provide an important link between an individual’s early growth and their chances of developing conditions such as type 2 diabetes or heart disease in later life.
The new study was jointly led by a team of researchers from six institutions including the universities of Exeter, Oxford, Bristol, Cambridge and Queensland, and the Erasmus Medical Centre in Rotterdam. The research involved more than 160 international researchers from 17 countries who are members of the Early Growth Genetics (EGG) Consortium. The work was supported by more than 120 research funders: the major sources of funding for UK researchers were the Wellcome Trust, the Royal Society, the Medical Research Council, the National Institute for Health Research and the European Union.
The research concluded that a substantial proportion (at least one-sixth) of the variation in birth weight is down to genetic differences between babies. This is seven to eight times more variation than can be explained by environmental factors already known to influence birthweight, such as the mother smoking during pregnancy or her body mass index (a measure of obesity) before pregnancy starts.
Dr Rachel Freathy, a Sir Henry Dale Fellow at the University of Exeter Medical School, who was joint lead author on the study, said: “This study has revealed how the small genetic differences between individuals can collectively have quite large effects on birth weight, and how those same genetic differences are often linked to poor health in later life. Weight at birth is influenced by many factors, including the baby’s genes and those of its parents, as well as by the nutrition made available and the environment provided by the mother. We now have a much more detailed view of the ways in which these genetic and environmental elements work together to influence early growth and later disease.”
It has been known for some time that babies whose birthweight is well below, or well above, average have a markedly increased risk of diabetes many decades later. Until now, many researchers have assumed that this link reflects the long-term impact of the nutritional environment in which the fetus develops: in other words, that events in early life can “set up” an individual’s body in ways that make them more prone to disease in later life.
In this new study, the researchers uncovered a substantial overlap in the genetic regions linked to differences in birth weight and those that are connected to a higher risk of developing diabetes or heart disease. Most of this overlap involves the baby’s genetic profile, but the team found that the mother’s genes also played an important role in influencing her baby’s birth weight, most likely through the ways in which they alter the baby’s environment during pregnancy.
Professor Mark McCarthy at the University of Oxford, and co-lead author, said: “These findings provide vital clues to the some of the processes that act over decades of life to influence an individual’s chances of developing diabetes and heart disease. These should highlight new approaches to treatment and prevention. Understanding the contributions of all of these processes will also tell us how much we should expect the many, wonderful improvements in antenatal care to reduce the burden of future diabetes and heart disease”.
The researchers analysed genetic differences throughout the genomes of nearly 154,000 people from across the world. Around half of these came from the UK Biobank cohort. By matching the genetic profiles of these people to information on birth weight, the researchers could identify sixty regions of the genome that were clearly driving differences in birthweight. They then analysed data from previous studies on conditions including diabetes and heart disease, and found that many of the same genomic regions were implicated.
Dr Momoko Horikoshi, from the Wellcome Trust Centre for Human Genetics at the University of Oxford, first author on the paper, continued, “Our results point to the key role played by genetic differences in connecting variation in early growth to future risk of disease. Our next steps will be to gather more pieces of the puzzle, including a better understanding of how the genetic profiles of mother and baby act together to modify the baby’s weight and later disease risk.”
Dr Rob Beaumont, at the University of Exeter Medical School, who worked on the study, said: “This study highlights the value of large-scale international research collaborations. It’s really satisfying to bring together a wide range of experts to analyse large scale datasets to advance understanding in key areas of human health.”
Responding to Carers UK’s report Pressure Points, Charlotte Argyle, Carers Support Programme Manager at Macmillan Cancer Support, says:
“This report highlights the urgent need to support carers in the community and ensure they are included and consulted at every stage and through every process of their loved one’s care. Our new research shows that a quarter (25%) of cancer carers say they were not involved when planning how and when the person with cancer would be discharged from hospital.
“Not involving a carer in this process can leave them and the person with cancer feeling unprepared and unable to cope. More often than not a carer will have a unique understanding of the person they care for. They must be fully involved so they know what to expect and what support is available to them.
“We want to see carers treated as equal partners in the team caring for someone with cancer, listened to and included. Currently more than half don’t view themselves as a ‘carer’ which can mean they miss out on support and are not included in vital decisions about the person in their care. Identifying cancer carers is the fundamental first step to ensuring they are heard.”
The BMA has called off the junior doctors strikes planned for October, November and December. Whilst asserting that it is still in dispute with the government, the BMAs campaign has collapsed. As we brood on this we should remember the words of Dr Yannis Gourtsoyannis, a member of the BMA’s junior doctors committee (JDC), as quoted by the Daily Telegraph on August 12th. “It’s time to dust off our picket armbands. An escalated fight is on. Theresa May will reap what her predecessors have sown. The following two months are crucial for the Conservatives…We are about to throw a massive spanner in their works.”
He outlined plans in a message to junior doctors for repeated and crippling strikes, increasing pressure on NHS services as winter approaches in “an escalated fight” to get “more and more” out of the Government, and to wage war on its policies. He suggested that future strikes would have a still greater impact. “It’s the trade union dispute of this century. That’s no exaggeration. This is about to be ratcheted up by an order of magnitude,” he wrote. Let’s hope his clinical judgements are better than his political ones.
The adult social work sector in England needs to urgently identify its key research priorities, in an inclusive and rigorous way, if it is to generate the ideas and evidence needed to ensure that people receive the best possible support, according to researchers at the Policy Institute, King’s College London.
In a discussion paper on the state of social work research with adults in England, the researchers stress that the profession needs to be underpinned by research if it is to survive and to flourish. Among their recommendations are the establishment of a network that provides learning and mentor support for early career researchers, practitioner researchers, and managers interested in adult social work research, something that currently exists for researchers working on subjects such as ageing or in health services research.
The James Lind Alliance, a non-profit initiative that brings together end users, carers and practitioners to identify the most pressing unanswered research questions about the effects of medical and other treatments, was praised for its approach. It is singled out as providing the most potentially useful approach that could help reach agreement around the priorities for adult social work research.
Commenting on the paper’s findings and recommendations, the Chief Social Worker for Adults, Lyn Romeo, said:
“I welcome this timely report and the action plan outlined in it. It is one of my key priorities to have a sharper focus on research and evidence-based practice so that social work continues to develop and improve in working with adults, those who care for them, and their communities. I am especially keen to take forward the key recommendation regarding the work of the James Lind Alliance in building consensus on the key research questions we want to ask in relation to social work with adults. What do we do, why do we do it, how do we do it, and what positive difference is our practice making to those we are privileged to serve, are vital considerations that must underpin practice development.”
The report also highlights the present challenges in tracking what research is being undertaken in the field, given the lack of a research register and the increasing number of studies and evaluations being conducted by independent and commercial research organisations, as well as universities. Identifying if and how social work researchers are involved in such projects would be useful for broadening understanding of social work effectiveness and capacity.
More, too, should be done with regard to funding, according to the report’s authors, Professor Jill Manthorpe and Jo Moriarty, who are based at the Social Care Workforce Research Unit, part of the Policy Institute at King’s. Information about funding opportunities for adult social work research should be collated and circulated more widely to improve awareness of them, and examples of successful funding applications could be analysed to identify critical success factors that would help other applicants, they conclude.
The full report, ‘Social work research with adults in England: The state we’re in’, can be read here
The crash of the electronic pathology report system at Leeds Teaching Hospitals Trust that happened on Friday 16th September forced the Trust to declare a “critical” internal incident – the second highest level below “potential service failure” – because the crash came at the same time as extremely high levels of activity at Leeds and Bradford Hospitals. The pathology report system remained offline for a week despite efforts to recover it, leaving up to 10,000 pathology tests not done. The hospitals are prioritising tests on patients according to clinical need but anticipate delays in operating theatre start times. The Trust is asking some patients awaiting elective surgery to attend the hospitals ahead of being admitted for their blood tests. Emergency services such as major trauma and critical care are being prioritised but at the time of writing there was no indication of when the system would be running again.
The initial report in the Health Service Journal referred to an IT failure. Many Trusts have had these in the past and have triggered Business Continuity Plans to manage them. As days passed without resolution of the problem, and with calls to GPs not to do routine blood tests for two days, impressions that the Trust was coping gave way to the feeling that this incident was not quite as well managed as originally thought.
The technical problem seemed to lie with communication of results rather than failure of pathology test analysers themselves, so the Trust had to deploy staff to contact clinicians with urgent results, and arrange couriers to drop-off paper results. One HJJ commentator said: “nobody has identified a range of alternate service providers, let alone negotiated some reciprocal service level agreements for immediate implementation as soon as total service failure occurred”. Another commented: “such an extensive IT failure would put any business continuity plan under huge pressure”. News from Nowhere wonders what caused such system failure?
Brits are clueless about their health – with more than half admitting they don’t know what their own blood group is, a study has found. Millions also have no idea what their cholesterol levels are, while others don’t know what their normal blood pressure is, their BMI, or what it should be in order to be considered healthy.
What weight is healthy for your height and how many calories and glasses of water you should be consuming to be healthy also leave many stumped.
It also emerged 44 per cent admit it would take a health scare before they really start to worry about things such as their cholesterol levels or blood pressure. And the average Brit starts to take more notice of their health and lifestyle choices at the age of 47.
A spokesperson for Healthspan, who commissioned the research to launch its new heart health supplement Ubiquinol Max, said: “For many of us, our health is something we tend to ignore until it becomes a problem and people still seem to know little about heart health.
“As a result, unless it is something you know you need to keep an eye on, many would struggle to tell you what their blood pressure or cholesterol levels are, or even what they should be in order for them to be healthy.
“We carry on with our lifestyles without any real knowledge of the impact it could be having on our general health, as well as on important organs such as our heart. But waiting until a problem presents itself could be too late to do anything about it.
“By finding out about key areas of your health early on, and keeping an eye on things such as your blood pressure, vitamin D and cholesterol levels, you could prevent any health problem occurring before it even starts.”
The study of 2,000 Brits, found 92 per cent reckon they have a good idea about their current state of health, with 76 per cent believing themselves to be in good shape. But three quarters admit they have no idea what their cholesterol levels are with almost four in ten saying they have never had them checked. Almost half also said that even if they did, they don’t actually know what is considered healthy. Forty-three per cent also said they are unaware what their current blood pressure is, with a third also saying they don’t know what a ‘good’ reading is.
Leading cardiologist Dr Ross Walker said: “Being heart aware is vital at any age but especially once we get to our forties and fifties. Health checks should be mandatory when you hit your forties. All males should have a coronary calcium score at age 50 & females at 60. This does not involve dye or injections & is low radiation, but is easily the most predictive test for heart disease risk.”
GP Dr Sarah Brewer said: “Blood pressure and cholesterol screening forms part of the free midlife MOT (or NHS Health Check) for adults in England aged 40-74, and is offered every five years if you don’t have an existing vascular condition. Do take advantage of this.”
The study also found 68 per cent think their heart is in good health, but 42 per cent admit they have no idea what they need to do in order to keep their heart in good health. But four in ten have been told by a professional that things such as their blood pressure, cholesterol levels were or are too high and a quarter of those in their fifties were already on statins.
Dr Brewer said: “Between six and seven million people in the UK are now on statins and many because of poor lifestyle choices. If you are on a statin it’s a good idea to take both ubiquinol and vitamin D alongside the statin to support your heart health as statins lower blood levels of these important nutrients. And if you are on a statin, treat it as a wake-up call that you have important heart disease risk factors. Don’t continue eating and doing what you were before – follow your doctor’s diet and lifestyle advice to make potentially life-saving changes now, before it’s too late.”
Only one in five who are on a statin went on to make big changes to their lifestyle, although another 63 per cent made small changes.
However, despite the warning, 14 per cent just carried as they were.
Worryingly, 35 per cent of Brits have never had a medical check up.
GP, Dr Sarah Brewer said: “Reaching any age milestone is a good time to take stock and ensure that your future years remain as healthy and active as possible. If you haven’t had a thorough medical check-up in the previous five years, it’s a good idea to ask what screening is available from your doctor – even if you feel well. Having a high blood pressure or a cholesterol imbalance doesn’t cause symptoms as they slowly damage your circulation, so get them checked.”
Worryingly, 16 per cent of people also admit they don’t know anything about their family medical history and whether there are any conditions which run in the family that could affect them.
Brits are clueless – Top ten health facts Brits are least likely to know:
1. Body fat ratio
2. How much vitamin D we need each daily
3. Your cholesterol levels
4. Your BMI
5. Your blood pressure
6. Your blood type/group
7. How many calories you should consume daily to stay a healthy weight
8. How many units of alcohol are considered healthy
9. The units of water you should be drinking to be considered healthy
10. Allergies you suffer from
The NHS is a planned health service, right? Command and control is rife, isn’t it? There’s no planning blight? No, of course not, but once there was an annual planning cycle with plans traditionally launched at Christmas, when we are at our most attentive. No longer!
NHS England and NHS Improvement have published planning guidance, for a two-year period from April 2017 to March 2019, setting out new orders and priorities for Sustainability Transformation Plans, hospital and community providers and Clinical Commissioning Groups.
Dave West of the Health Service Journal identifies two main themes in the new guidance: a “breakneck” timetable for delivery, and the movement towards “managing the NHS through whole systems, not separate organisations”. So expect more mergers and efforts at integration, and lots more perturbation in the NHS.
There is no shortage of micro-management, though. The guidance states that CCGs must make plans to extend GP consultation hours. CCGs should commission at least an extra 30 minutes of GP consultation time for every 1,000 people in their populations. It is intended that this should eventually rise to 45 minutes per 1,000 population.
On weekdays General Practices should offer pre-bookable and same day appointments after 6.30pm to provide an extra hour and a half of consultation time per day, and pre-bookable same day appointments on both Saturdays and Sundays. They should use “digital approaches to support new models of care” in general practice.
In addition CCGs should provide “robust evidence” for which services should be available throughout the week, and ensure uptake of the expanded services is automatically measured.
All this will be very popular in general practice, so we should expect some huffing and puffing from local medical committees and the BMA, very soon.
Health Economics is not exactly light entertainment, but there are writers at the Academic Health Economists blog who write clearly and simply about it, well enough for News from Nowhere moles to grasp a point or two. Sam Watson, blogging on September 22nd, is a good example. Pondering on the debate about whether there is a weekend effect on death rates of people admitted to hospital, he says:
“I think part of the problem lies with the mindset of there either is or there isn’t a weekend effect on death rates. It’s a bad way to think about it; care does differ between the weekend and weekdays therefore it is quite plausible that care quality differs as well. I don’t think many people believe in what we’ll call strong weekendism, which might be described as there being no patient who would experience a different overall health outcome if they are admitted at the weekend or on a weekday. However, some people may take the weak weekendism position, which might state that no patient who was admitted on a weekend and who died would have survived had they been admitted on a weekday. However I think both the strong and weak positions are too strong, the most plausible position in my view is that care quality is worse at the weekend. It’s just a question of how much”.
The Royal Society for Public Health (RSPH) is supporting renewed calls from the Chartered Institute of Environmental Health (CIEH) for the extension of smoking exclusion zones. The
CIEH is calling for a smoking ban in places where children play or learn, including parks, playgrounds and local markets – backed by majority public support for the measures.
The CIEH found: 56% of all adults in the UK would support a smoking ban in public parks. Parents who smoke in front of their children are more likely to do so when they are away from the home in pub gardens (45%) and public spaces (42%), such as parks and playgrounds, compared to when they are at home (27%) or in the car (13%). More than 1 in 2 people (56%) think that more should be done to raise awareness of the need for smoke-free public places. Parents are more likely to move their children away when someone they know is smoking near their children (54%) and only 13% would ask them to stop or ask them to move away (15%).
The call follows original research published by RSPH in its August 2015 paper ‘Stopping smoking through other forms of nicotine’ which proposed that extending the hugely successful indoor smoking ban to encompass school gates, immediately outside pubs and bars, and public events aimed at families, would help to de-normalise smoking and prevent people from picking up their first cigarette.
Under these proposals e-cigarettes would be exempt from the exclusion zones. Research from PHE found that e-cigs are 95% less harmful than tobacco cigarettes and should be considered as a vital tool in smoking cessation efforts – keeping them exempt would encourage tobacco smokers to make the switch.
Shirley Cramer CBE, Chief Executive, RSPH said: “Every year in the UK 270,000 children will take up smoking – an addiction that will end up killing half of them. De-normalising smoking around children must be a top public health priority to help prevent them from taking up this deadly habit.
This compelling data which shows strong public support for measures that tackle smoking in public, particularly around children, is a welcome addition in our bid to make our communities smoke-free. Future generations shouldn’t have to grow up learning and playing in environments where smoking is portrayed as a normal behaviour. Anything we can do as a society to de-normalise smoking should be encouraged for the sake of our future generations’ health and wellbeing. Extending the smoking ban to outside areas would certainly be a positive step towards realising this goal.”
Responding to the Royal College of Physicians report ‘Underfunded, Underdoctored, Overstretched – the NHS in 2016’, the NHS Confederation, welcomed its strong focus on workforce, doctor numbers and urged further development in community settings rather than continual increases.
Dr Johnny Marshall, Director of Policy at the NHS Confederation said: “We look forward to working with the RCP and welcome its strong focus on developing the workforce. Their report represents an important contribution to the debate on the future of the NHS. Further growth in doctor numbers is currently necessary but it will become unaffordable if allowed to continue indefinitely – putting healthcare at risk. It must go hand in glove with developing new roles, such as that of Physician Associates and developing new models of care that are more in-tune with patients’ needs, such as moving services from hospital settings to community settings.
“If the RCP could expand its focus in one area, we believe it could further encourage the expansion of community services and better coordination between GPs, pharmacists and other local care – making it more fully aligned with patients’ needs. We must move care and treatment closer to people’s homes.
“It is helpful that the RCP explores areas like Community Education Provider Networks, which can help lay the groundwork for future training and ways of working. It’s important that such initiatives aren’t slowed down by finite resources being used-up on existing services.
We continue to urge all parts of the system, including local government and national bodies, to work hard to overcome barriers to necessary change.”