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INSIDE HEALTH

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TX:听 19.02.13听 2100-2130

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PRESENTER:听 MARK PORTER

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PRODUCER:听 PAM RUTHERFORD

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Porter

Hello. In today's programme:听 The anti-inflammatory diclofenac听 - we examine calls to withdraw one of the most widely used treatments for arthritis and sprains and strains because it increases the risk of heart attack.

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The hazards of living with a bird - we investigate a listener's concerns about his pet cockatiel, and learn that you don't need to keep lots of pigeons, or fancy them, to be at risk of pigeon fancier's lung.

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And hospital food - as new demands from NICE push nutrition higher up the NHS agenda, we visit an award winning hospital kitchen to find out what can be achieved if you aim for the top.

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Clip

For me I think a hospital should be the beacon of good food - any NHS hospital, they should be the ones telling people what good food is, not having to go to hospital and have a cold sandwich and a cup of tinned soup - it's wrong.听 I mean patients, if anything, need to get the best meals, not the Savoy, it should be the other way round - you should be getting your fantastic three course at a hospital and when you're fit and well you cook your own, we have to look after you here and that's what our job is.

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Porter

But first I am sure you will have heard about the plight of 18-year-old Sam Woodhead who got lost on a run, and ended up spending three days alone in the scorching heat of the Australian outback. He was on his last legs when rescuers found him - as he explained to Paddy O'Connell on Broadcasting House on Sunday morning.

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O'Connell

How dark did things become for you?

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Woodhead

Pretty dire, I turned to drinking my contact solution, as the only liquid I had, I drunk a bit of my own urine, it was getting pretty desperate stages, by the end I couldn't walk I was crawling on my hands and knees, I don't think I would have lasted another half a day, let alone another couple of days at all.听 I was properly on my last legs - I'd lost 15 kilos in three days, so I was pretty skinny and pretty [indistinct word] and everything was looking downhill to be honest.

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Porter

I wish I had a pound for every time I have been asked over the years if drinking urine helps stave off dehydration听 - and Sam Woodhead's experiences have rekindled the debate. Well for a definitive answer I am joined by Dr Kevin Fong who is a Consultant Anaesthetist at University College London with a special interest in the medical challenges of extreme environments.听 So do you do it or not Kevin?

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Fong

The advice is don't drink it, it's a bit complicated in that urine isn't a consistent liquid because it's the result of the processing of your body and sometimes it's more concentrated, sometimes it's less concentrated, it depends what you've been drinking.听 So what your kidneys do is they look at the composition of the fluids in your body, particularly in your blood stream, and they get rid of what you've got to much of - so if you've got too much water, they get rid of water in preference to the salts that you've got, if you've got too much salts in your bloodstream then it gets rid of those.听 So as you get more and more dehydrated you're trying to conserve the water and you're chucking out more and more of these salts, which in excess are going to basically be poisonous and so by the time you're in the middle of the Australian outback under the beating sun, peeing very tiny volumes of syrup like urine - that stuff is pretty concentrated poison for you.听 And worse still when you drink it, it's not like you might imagine, it's not like some fluid is better than none because then what you do is you take on this big load of salt and then you've got to get rid of it again, your body sees it and it says there's too much salt in that I'll get rid of it, and when you get rid of it you lose more water than you've taken in to get rid of that salt load.听 So it's going to dehydrate you even more in the medium term.听 And so in theory if you've had a lot of drink, in terms of water, that first catch of dilute urine might be okay to drink - it's sterile, probably is going to do you more good than harm - but later on when you're really desperate it's probably going to be so concentrated that the balance of harm is probably greater.

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Porter

So it's hard to be conclusive, the general advice is do not do it but perhaps maybe that first urine, if it was particularly dilute, might - might be of some benefit but generally not?

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Fong

Well yeah, the problem is is that when you don't know you're in trouble is probably when your urine is best for you and most drinkable, when you realise you're really in trouble you probably don't want to be drinking it.

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Porter

Okay moving on to the other one - the scenario you often hear is I'm on a boat, goes down, I'm in the life raft, I've got no fresh water, I'm surrounded by salt water - what about drinking salt water?

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Fong

Yeah so this is much easier.听 So the answer to this one is absolutely do not do it, do not drink the salt water from the ocean it's not going to do you any good, it's going to do you a lot of harm and there is some observational evidence that in survivors of shipwrecks of maritime disasters those who decided to drink seawater did worse, were more likely to die than those who didn't drink anything at all.

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Porter

Do not do it.听 And in this case the guy was drinking contact lens solution, we don't know if it did him any good or didn't do any good but that's slightly different from salt water in that it was a weaker mix.

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Fong

Yes and so in his survival repertoire the contact lens cleansing fluid was probably the best one because - the old solutions were very - little more than a weak salt solution that have almost exactly the same or a very similar composition to your own fluids in your body and so the makeup of the contact lens solution is not far off those sorts of sports drinks that you get.听 And it has some adulterants in it - some chemicals that help with the cleaning of the lenses - but those don't appear to be too toxic, at least as far as I understand.听 So if you have to choose between seawater, contact lens fluid and your own urine well take the contact lens fluid with you but possibly just take a GPS device with you instead.

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Porter

So you don't get lost.

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Fong

So you don't get lost in the first place.

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Porter

Kevin Fong, thank you very much.

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On to another story making the headlines now - new research that has led to calls for one of the most popular anti-inflammatories to be withdrawn because it increases the risk of heart attack.

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Diclofenac is available over-the-counter and on prescription in doses ranging from 75 - 150 milligrams a day. It is a member of the non-steroidal anti-inflammatory family - which also includes ibuprofen and naproxen - used to treat arthritis and other aches and pains. All anti-inflammatories are known to irritate the lining of the gut, and sometimes lead to ulcers and bleeds, but the link with heart attacks is not so well recognised. And it seems the link with diclofenac is particularly strong.

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Dr Patricia McGettigan is from Bart's Hospital and led the team behind the latest study.

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Patricia, what exactly did you find?

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McGettigan

We found that the riskiest of the non-steroidal anti-inflammatory drugs in terms of their risk of causing heart attack particularly was actually the drug that was most widely used.

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Porter

And That's diclofenac.听 I mean there are something like five or six million prescriptions issued every year in England alone, so that's a lot of people who are taking this drug.

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McGettigan

A lot of people take the drug, it's very effective but the issue is that there are drugs that are equally effective and less risky from a heart attack point of view.

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Porter

From a heart attack point of view can you quantify the additional risks through taking the drug?

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McGettigan

The risk - there's a relative risk increase of 40% and in the investigations that Professor Henry and I have done in the past pulling together large numbers of studies that looked at the risks associated with these drugs we find that that risk appears to be consistent whether you're quite a young person or whether you're an older person with a lot more cardiovascular risks.听 So, for example, if you're a fit young footballer, you're 23 years old, you pulled a muscle in your last match and it's aching a bit and you want to take something for the pain so you can keep training your risk of a heart attack is of the orders of fractions of a per cent, so increasing that by 40% doesn't actually matter, doesn't matter what non-steroidal you take it'll work more than likely for you.听 Now, fast forward this footballer 40 years, he's a bit overweight, he continues to smoke his 20 cigarettes a day, he's got diabetes, he's already had a heart event and he's got some kidney impairment, in other words his kidneys don't work as well as they used to because of blood pressure and the diabetes, his risk of a heart attack in the next year is of the order of 5-10%, increase that by 40%, it's now 7-14% - that's the sort of risk you want to avoid.

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Porter

And of course a lot of people who are taking diclofenac and other anti-inflammatories are in that higher risk group by nature of the sort of conditions it's used for - arthritis - these are often older people.

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McGettigan

Exactly, these are the people who unfortunately get chronic pain and require them to use the drugs fairly regularly.

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Porter

And let's be clear - are you saying that diclofenac is the only anti-inflammatory that increases the risk of heart attack?

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McGettigan

Not at all, what we're saying is that of the commonly used ones and diclofenac is by far the most commonly used, it increases the most.

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Porter

What were the safest anti-inflammatories from your research?

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McGettigan

From our research the safest were [indistinct word] ibuprofen, which was associated with a much smaller level of risk, and naproxen, which in most of the studies we looked at, came out actually risk neutral - so it neither increased nor decreased risk.

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Porter

And naproxen, in particular, would we expect offer a similar level of symptom control in terms of pain and stiffness as diclofenac?

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McGettigan

It does.听 These drugs are all on the market for 30 years if not longer, I'm talking about the three: ibuprofen, diclofenac and naproxen, and going way back there are studies looking at comparative effect on pain and inflammatory conditions and they come out as similar, depending on the doses taken.听 So yes it's equivalent.

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Porter

So the simple conclusion is that if you're taking diclofenac then you could probably have your cake and eat it by switching to a drug like naproxen which will give you equal symptom relief but would not increase your risk of heart attack?

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McGettigan

And that's exactly right and it also becomes particularly important if you've got a substantial risk of having a heart attack, like the person I described - our footballer.听 There's a small number of people for whom diclofenac might be the only anti-inflammatory that gives them pain relief and you'll find this time and again in medicine, particularly for symptoms like pain where despite studies that show different drugs as being equivalent you will find that one particular drug suits one particular patient better and that's the only one that works.听 Now if that were the situation systematically with diclofenac and people were reserving it for these risky people for whom it was the only drug that worked what we would see would be that the volume of use of diclofenac would be way, way lower, it would have a small but consistent volume of use reserved for these people who need it.

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Porter

And an individual doctor and an individual patient might well think that the benefits day to day in terms of pain and stiffness are well worth the small risk in increasing in heart disease but what you're saying is a lot of people out there who are taking the drug unnecessarily?

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McGettigan

That's exactly right, without any need to increase risk at all they could just take a different anti-inflammatory and have exactly the same effects, basically, like you said, that have their cake and eat it.

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Porter

Your research is brand new but we've known about this link for some time, why do you think it's not given the prominence that it deserves?

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McGettigan

In fact we did some of this research going back as far as 2006.听 Why?听 This is really interesting and I think it's because people are not suspicious of an old friend, like diclofenac, for many of the prescribers this drug's been around since the late '70s so they've grown up with it, and they go I haven't seen anybody have a heart attack on diclofenac.听 And the reason for that is that one, heart attacks are really common, we see them all the time, and two, the people who have heart attacks generally have other risks to have heart attacks so you don't say oh it must be the diclofenac.听 In fact the studies show that it increases the risks by 40%, so it is a player.听 If in contrast our skin fell off you'd be much more suspicious because these are very rare events - liver failures, severe skin problems - rare side effects of drugs and we sit up and take notice, heart attacks are so common, the drugs are familiar and there's probably a degree of complacency in using them.

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Porter

Do you think diclofenac should be taken off the market?

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McGettigan

I think we can be more sophisticated than that with good application of the evidence and also not wanting to deny the numbers of people who truly get benefit from it and for whom it's the only drug that gives them pain relief, because pain is of great importance to control and manage so we can have a happy day to day life.听 That said, taking this to the global picture of public health and looking at overall risk when you think of the amount of effort we put into reducing heart attack risk and managing heart risks for people it makes absolutely no sense to use the one non-steroidal that takes away with one hand what we're trying to give with the other.

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Porter

Dr Patricia McGettigan thank you very much. 听And you will find a link to that research on our website - go to bbc.co.uk/radio4 and click on I for Inside Health.听 And don't forget if there's something that confusing you that you'd like us to look into then you can get in touch by e-mailing me at insidehealth@bbc.co.uk, which is what Tim Veldre when he e-mailed from Australia with this query.

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Veldre (spoken)

My wife's grandmother had to get rid of her pet cockatiel because she developed breathing problems caused by a reaction to the bird. We have a cockatiel too and are now wondering if there is any risk to our health?

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Porter

A question I put to a world authority on the subject - Dr Kenneth Anderson is a consultant chest physician at University Hospital Crosshouse near Kilmarnock.

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Anderson

Some people with parrots and cockatiels and other birds in the house, particularly of that family, can develop what's called mainly an allergic type of lung disease.听 They develop a reaction inside the lung, having breathed in some of the dust from the feathers.听 These feathers can make them quite ill and over a long number of years can shrink the lungs and make them scar inside.听 So it's not without some concern this, it only affects may be less than 10% of people but it does occur fairly frequently and I see it from time to time at my clinic.

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Porter

But 10% of people - is that 10% of people who keep birds?

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Anderson

Yeah, you would think that that's quite a lot but in about 10% of people they will have some sort of reaction to it.听 We don't understand why but there's no doubt about that.听

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Porter

And what are they actually inhaling?

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Anderson

The reaction mainly is caused by dust which comes from the feathers of the bird, which is known as bloom.听 This material is the substance which protects and waterproofs the bird's wing or feathers and that like our own skin has got little bits and pieces of protein and things on which fight off infection and clear away things which should attack the bird's wing.听 It's quite easy to extract it from the wing actually - just rub your hand across it and your hand goes kind of silver coloured.听 So that can cause - be inhaled, go into the lung and then in a kind of step wise way produce a reaction in there which is not a good thing.

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Porter

And this sort of inflammation is known as what?

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Anderson

Well we call it parrot keeper's lung.

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Porter

Parrot keepers - now the other one I've heard of, of course, is pigeon fancier's lung, is that the same thing?

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Anderson

It is but the pigeon men in this country have a fairly well known risk of this disease and we see very many of them at the national show every year in Blackpool where 35,000 will gather and we see roughly between about 200 or 300 a year there who might have trouble.

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Porter

And the classic symptoms would be what?

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Anderson

Mainly shortness of breath but a few hours after contact with the dust some people develop muscle aches, joint aches, sweating, high temperature and feel pretty ill and then that is usually away by the following morning.听 But over time what happens with the lung is a reaction builds up which fills the air sacks in the lung, these white cells come in in very, very large numbers, it's rather like the populations of the world shifting to another country, so all the white cells in your body will be attracted to your lung and that's where the issue starts.听 And that over a long time can cause scarring in the lungs and well that's not a good end point.听 And usually people have maybe had their symptoms for about six months before they twig that there might be something they've got to speak to the doctor about.

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Porter

So if you're developing shortness of breath and you're a bird keeper it's something you need to mention to your doctor because a doctor won't automatically think of birds will they?

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Anderson

Well not usually.听 I think there are certain areas in the country where they might think about pigeons but parrots get in everywhere sneakily.

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Porter

And what about infections - are there any infections that you can catch from birds?

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Anderson

Yeah there is a specific illness known as psittacosis, that's named after the psittacine birds, parrots are psittacine birds because of the shape of their beak.

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Porter

And that's literally you're inhaling the bacteria and it's causing a conventional infection, very different from the pigeon fanciers....

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Anderson

Yeah that's a form of pneumonia and usually a person's much sicker and will contact the doctor almost automatically.

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Porter

If someone's developing problems and they're a very keen parrot keeper or a keen pigeon owner what can they do to reduce the risk or indeed how do we treat it?

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Anderson

Some people try a respirator or increasing the ventilation in the loft or in the house or having an outside aviary or keeping the bird maybe in a different area of the house where they don't go but that of course is very tricky.听 If ultimately the only cure is to get rid of the bird then that has to happen - people find that difficult.

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Porter

Dr Kenneth Anderson - and you will a find a link to more information on parrot or pigeon fancier's lung on the Inside Health page of bbc.co.uk/radio4.

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Hospital food is one of the great paradoxes of the NHS. Let's face it - if you have ever had the misfortune to have to depend on meals in hospital, I very much doubt they compare to the sort of fare you'd expect when you eat out, or what you prepare in your own home. Yet, when you are in hospital you are likely to be at your most needy and vulnerable.

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It's a mismatch that the National Centre for Healthcare and Clinical Excellence (NICE) hope will be addressed by new quality standards designed to ensure that nutrition is moved higher up the NHS agenda.

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Two key targets included in the standards: Are that everyone admitted to hospital (or any other care setting) is screened for malnutrition and that a tailored nutritional plan is produced听 to correct problems, or meet special needs, when they are identified

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听

I know, it seems unbelievable that this hasn't been routine practice for years - but it hasn't. Better late than never. Steve Wotton is Senior Lecturer in Human Nutrition at the University of Southampton:

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Wotton

I think we're at a bit of a crossroads, I think initially we probably did see food as a medicine and we recognised the importance - if you go back to Florence Nightingale and the Crimea - then I think we moved into an era where it was hotel services, it was about feeding people whilst they're with us.听 So it suddenly lost its emphasis as a position of medicine, it was still a quality issue around giving people what they wanted and we're now at a stage where we're beginning to recognise the role of food as medicine, particularly in the context of hospital care.听 Think of conventional medicine - you make a diagnosis, take the history, take all the information, you make your diagnosis, you decide what you're going to do, so prescribing nutrition in the sense of making sure I know what my patient's needs are and giving instruction to ensure that those needs are met is going to become very, very much part of basic hospital medicine.听 So this idea of prescribing nutrition is a bit of a challenge for us, it's not what we do routinely today.听 We do it for those who come in with pre-existing clinical conditions or who have a condition where we know nutrition is critical - so if you're got intestinal failure or you can't swallow then we know we've got to do something, so prescribe nutrition.听 The problem is is in those who are not overtly malnourished and not overtly unable to eat and those individuals we just presume everything will sort of happen, in the right way at the right time and that the nutritional needs of the patient will be met.听 I think the crossroads we're at now is a recognition that that's probably insufficient, based upon the evidence, and that it's probable that we could make a difference by making active choices, active decision making, at the point of the patient being admitted into hospital.

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Porter

But the food has to taste good too otherwise patients won't eat it. And you would be surprised just how tasty hospital food can be - I certainly was when I visited the award winning kitchens at the Royal Brompton Hospital in London.

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James

Hi my name is Varghese James and I'm the catering services manager at the Royal Brompton.

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Porter

I mean looking at this menu here, so the patients can choose what they want - they've got a choice of three starters, three main courses.听 I mean the starters are roasted red pepper soup and the main course jerk chicken, sweet potato and garden peas stroganoff.听 This menu will obviously cover the vast majority of the people in the hospital, will be able to eat off this menu but there will be groups of patients who've got special needs, can you give me an example of the sort of requests you might get on a daily basis?

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James

Well you know it would range from someone who's gluten free to a soft diet to an allergy patient because we have our own diet chef and there's a diet bay that caters only for dietary needs.听 So we'll look at today's menu - you will have on the menu already they've got a gluten free dish there, the gluten free option we have got the roasted red pepper soup, the dairy free we've got the jerk chicken, the soft and vegetarian option is a sweet potato and garden pea stroganoff and a higher energy we've got egg mayonnaise and cress sandwich.听 So already on our standard menu we're intending to tick as many boxes as we can.

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Porter

Hospital food doesn't have a great reputation generally, are you proud of what you do here?

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James

Very proud, I mean I've come from the Hilton, I used to work for them for four years and I first thought when I took the job what a mistake, I'm here at the NHS, the food must be horrible, I think when I started off in catering one of the last things I was worried about was the food, it was brilliant.听 I mean the food we serve out here on a nice fancy plate with the garnish wouldn't go unnoticed at the Hilton, it would be just as good as there.听 For me I think hospitals should be the beacon of good food, any NHS hospital or any hospital in the world really should be - they should be the ones telling people what good food is, not having to go to hospital and have a cold sandwich and a cup of tinned soup - it's wrong.听 I mean patients, if anything, need to get the best meals, not the Savoy - it should be the other way round, you should be getting your fantastic three course at a hospital and when you're fit and well you cook your own, we have to look after you here and that's what our job is.

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Porter

Can I try something?

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James

Absolutely, yeah if you want to do it now I can take you to the kitchen and probably get you a plate of - what would you like, the jerk chicken?听 It's ready.

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Porter

Yeah I'll try the jerk chicken, I like jerk chicken.

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James

Yeah it's spicy and I'm sure you can handle that.听 Make sure you get the bit on top, that's got the seasoning on it.

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Porter

Massive piece here, oh it's huge, hang on.

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James

And it's hot.

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Porter

That's good, I'd be quite happy to eat that any time and pay for that in a restaurant.听 And we get spicier the longer....that's certainly got some jerk in it.

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And the patients on the wards seemed to like the food too.

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Montage

It's a very intelligent menu because it allows for the fact that there are days when you don't feel very well and therefore you don't want something very interesting and spicy, you want something very plain and there's always something plain.

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I'll tell you the amazing thing if you go down there again try the soups - the soups are - every day there's a different soup, cheese and biscuits, there's ice cream, there's yoghurt and they've even got kosher meals, I've never tried them yet.

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Breakfast is wonderful.听 I'm not a breakfast person at home but breakfast here is fabulous.听 I felt very greedy - I had everything.

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Porter

Around 40% of the food at the Brompton is sourced locally - much of it coming direct from the farm - and Varghese and his team manage to provide three meals and afternoon tea for less than 拢5 per head per day. Proving cheap needn't be nasty.

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But it's not just the taste that matters - the diet offered has to meet the nutritional needs of the patients too. Ione De-Brito-Ashurst is a dietician at the hospital.

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Brito-Ashurst

Within 24 hours of admission all patients should have a screening to look at their risk of malnutrition.听 That involves looking at - checking the patient's weight in relation to their height, so if it's adequate, then we look at nutritional intake - how is their nutritional intake - if it's going to be low or it has been low recently.

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Porter

So these are people that effectively - I mean you need to be feeding up I suppose?

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Brito-Ashurst

Yes.

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Porter

So how would you do that in this hospital?

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Brito-Ashurst

We have quite a few initiatives, we do have red tray, that is basically to highlight and the patients are given a red tray by the catering team and this is to highlight the need that they might need extra snack, they might need help with feeding from the nurses and they need extra time to eat their meals, so the nurse know that those patients with a red tray they will need help eating or either the nurses or voluntary workers can help the patient to eat their meals.听 There's also protected mealtimes to make sure that the patients do have the time to eat their meals without being interrupted by a phlebotomy, by a doctor on a ward round.

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Porter

Looking at today's lunch menu I mean it looks fantastic, looks very tasty, how's it assessed from a nutritional point of view, does your department have some input into what goes into the menu on a daily basis?

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Brito-Ashurst

We do, once the menus are planned then they are sent to us and we do look at the menu.听 So looking at macro-nutrient - carbohydrate, fat, protein - but also because it's a cardio-thoracic hospital we're going to be looking at sodium content, the salt content of the meals and we're going to make sure that it is within guidelines.

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Porter

So you need to be setting - leading by example here, this needs to be a healthy diet not only tasty but it needs to be very healthy as well?

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Brito-Ashurst

Definitely, especially in relation to salt.

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Wotton

In the early days food was the only treatment we could really offer, we didn't have fancy drugs or techniques or other things to do - drugs that we have today.听 So therefore food was a front line therapy.听 Now food has slightly dropped down that agenda, largely because of all the other things that are of what's perceived equally importance and because nutrition and feeding a patient is such a basic thing it's often left to the most junior staff or the least qualified members of the healthcare profession - so the healthcare assistant might be asked to do it and they may not necessarily recognise the need for that nutrition in terms of the patient's care and their journey.听 If we can discharge patients in a better condition and offer guidance to their continuing care when they leave hospital what we can then actually do is not only get patients out of the hospital quicker we can also hopefully prevent them coming back unnecessarily.

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Porter

Practically what difference do you think the new standards are going to make?听 I mean it's all very well to assess everybody and to tick the boxes - I've checked this and done that - is it actually going to make a practical difference in terms of what we offer in hospital and how we offer it?

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Wotton

I think it will but I think the other part of it is is that we now have an increasing recognition that we don't want our relatives to have poor quality care, as consumers we now expect more.听 So a combination of quality standards externally, top down management decision making being changed, we are increasing the awareness amongst doctors, nurses around nutrition and I think the consumer coming at the end of the line expecting things to be done.听 And what the quality standards do is says you have a right to expect.

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Porter

Dr Steve Wotton. And you will find a link to the new Quality Standard for Nutrition from NICE on the Inside Health page of bbc.co.uk/radio4.

听

Just time to tell you about next week's programme when I will be talking to the team behind cutting edge research suggesting that adverse events in childhood can permanently alter both the structure and the function of the developing brain. And clinical trials - are the people behind them designing the trials in such a way as to make their new drug look more of an advance than it really is?

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ENDS