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INSIDE HEALTH

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Programme 4.

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TX:Ìý 27.01.15Ìý 2100-2130

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PRESENTER:Ìý MARK PORTER

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PRODUCER:Ìý ANNA BUCKLEY

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Porter

Hello. Coming up today:Ìý Matters of the heart - why more women than men now die from heart attacks in the UK.Ìý Gluten-free – it’s all the rage.

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In Australia now 30% of the normal population is taking a gluten-free diet, that’s mind boggling really.

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Porter

But is there any science behind going gluten-free if you don’t have coeliac disease?

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The perception of food intolerance is about eight times that of the reality if you try to formally and very carefully establish it.

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Porter

Catching up on your sleep at the weekend - could it be bad for your health and your waistline?Ìý And boilers on prescription - we examine a novel approach to helping people with chest problems.

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But first a story that is all over the news - research linking commonly used medicines to dementia. An American study has shown that elderly people who take drugs with anticholinergic side effects for long periods, drugs like bladder pills and antihistamines, are more likely to develop the condition. How likely isn’t clear. According to reports in the media people taking anticholinergic medication are at least 50% more likely to develop dementia later in life. But that figure is not in the original paper. So Inside Health contacted one of the authors to clear up any confusion.Ìý Shelly Gray told us that:

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Even taking the highest doses for the longest periods was only associated with a roughly 10% increase in the probability of developing Alzheimer’s disease or another form of dementia, earlier than someone who hadn’t been on anticholinergics.

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That’s a very different figure.

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And another point that wasn’t made clear in the media was that many of the drugs studied are already falling out of favour with GPs.

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Dr Margaret McCartney is in our Glasgow studio. Margaret, widely cited examples of anticholinergic drugs include old fashioned antidepressants, old fashioned antihistamines, and old fashioned treatments for bladder and continence issues.Ìý There is a recurring theme there.

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McCartney

Absolutely.Ìý Many of the drugs that were being analysed actually are not ones that are in our top prescribing brackets but I think there is certainly some worrying conclusions about this and things we should take from it.

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Porter

We GPs may not be prescribing as many of these drugs as we used to perhaps but they’re widely available over the counter in different forms, I’m thinking night-time versions of cold and flu remedies, night sedatives, antihistamines even.

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McCartney

Yeah, no, you’re absolutely right but it has to be said that most of the time when you buy things over the counter it is just a short course you get and what we’re really concerned about here is longer term use, people using them for months and years at a time.Ìý But certainly if you’re on something over the counter and you do happen to be using it regularly there might be a better alternative for you.

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Porter

One of the things that may concern a lot of people here is the fact that people naturally assume that if you can buy something over the counter it’s safe and effective but actually a lot of these drugs have fallen out of favour with doctors.

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McCartney

Absolutely, it’s a really interesting thing that I think we do tend to think off over the counter medicines, things you can buy in supermarkets, as generally safer.Ìý So there are numerous I think drugs available to us now, not all of which are a very good idea to be taking in the long term.Ìý Although it has to be said that we’re really worried about long term use of drugs and when you buy things over the counter if tends to be quite small pack sizes that you tend to buy.

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Porter

I must admit I wasn’t that surprised by this finding because we know that anticholinergic drugs can have an effect on brain function, they target Acetylcholine, an important neurotransmitters, whereas treatments that we use for dementia, for instance, would boost levels of that transmitter.Ìý Was it a surprise to you?

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McCartney

We’ve actually known about this for some time.Ìý As part of what I call poly-pharmacy reviews, which is when people who are taking a lot of different medications, one of the things we quite often do is look down the list of medications and work out which are the drugs that have got these anticholinergic side effects.Ìý And it’s particularly when you’re taking more than one of these drugs or taking one that’s got very strong side effects from an anticholinergic point of view, like for example, haloperidol or quetiapine, that we do start to get a little bit concerned especially in people who are already older.Ìý So it’s a cumulative effect that we’re really about.

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Porter

So Margaret, a patient of yours comes in tomorrow morning who’s been alarmed by the findings of this research, what are you going to say to them?

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McCartney

Well I think we have known most of what the study presents to us already, so I don’t think it’s particularly new and most patients should be under an annual review of their medication already with their doctor when they get a chance to sit down, look at the list of medication they’re on and work out if it’s still working for them or not.Ìý Any prescription is a balance of risk and harm, if you’re taking something that you’re not getting a great deal of benefit from it but it is putting you at risk of anticholinergic harms this might be the same to say do I really need to be on this and try and think about stopping it perhaps.Ìý If you’re on something that you’re getting a great deal of benefit out of you might be willing to risk the side effects.Ìý But remember it’s cumulative side effects we’re worried about, it’s sometimes people taking not just one but two or three or four drugs that have anticholinergic side effects, particularly frail elderly people, that’s the group I’m most concerned about.

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Porter

Thank you Margaret, and there is a link to the US study on the Inside Health page of the Radio 4 website.

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On my way to the studio today I stopped off for a coffee and was intrigued to see gluten-free brownies on the counter and very nice they looked too. There was a day, not that long ago, when gluten-free foods were confined to a dusty corner in health food shops, but they’ve exploded onto the market in recent years and are now available everywhere from supermarkets to fast food outlets. But what’s driving this burgeoning demand? Margaret.

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McCartney

Well in my mind there are three groups of people who are using and buying gluten-free products.Ìý The first group are people who have coeliac disease, which is an autoimmune condition that people are sensitive to gluten and shouldn’t have in their diet.Ìý The second group are people who use gluten-free products either all the time or intermittently because they think it makes them feel better, perhaps they have irritable bowel type symptoms, for example diarrhoea or bloating or constipation and who think they may feel a bit better when they use gluten-free products.Ìý And the third group of people who think gluten-free stuff is good because a lot of celebrities have advertised it as so and say that their skin is clearer or they feel better or more vibrant or energised if they go gluten-free.

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Porter

And it really has gone mainstream, whatever the reason for you taking it, I mean I remember when to find gluten-free products you’d have to look sometimes in the pharmacy.Ìý Now it’s mainstream, it’s in coffee bars, it’s in aisles in supermarkets.

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McCartney

And this is great news if you have coeliac disease – why shouldn’t people with coeliac disease be properly included in society and be able to make nice choices about what foods they have?Ìý Perfect.Ìý But I think the concern is that these very expensive, often, products are being marketed to people who are not necessarily going to get a benefit from it.

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Porter

You would hope that the majority of people with true gluten intolerance, coeliac disease, will be medically diagnosed, they know the importance of avoiding gluten, they can’t even have a tiny bit of it.Ìý But the others, I mean they’re making up their own minds aren’t they, they’re diagnosing themselves effectively.

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McCartney

And there’s a really big issue because people often describe it as a food intolerance and a food sensitivity, which is not something that’s pathological, so you can’t find a blood test or do a bile biopsy and find an abnormality but it’s people who describe clear symptoms that they definitely get after they have particular foodstuffs.Ìý But the problem is it can be really hard to work out what foods are causing what symptoms.Ìý And there’s been really interesting trials done, there was a famous one done in 2011 where they did a proper double blind trial and they examined people who had – who didn’t have coeliac disease but did have symptoms that they related to gluten and they thought at that point that actually excluding gluten made a big difference but there was a very big placebo effect – so there was a lot of people who felt better when they thought they were avoiding gluten but actually weren’t.Ìý And the same study was repeated then a few years later and actually found that they couldn’t demonstrate that gluten led to symptoms in people who thought they were sensitive.Ìý So the jury I think is still out, certainly the people who have irritable bowel type symptoms will feel worse with gluten stuff but whether that’s due to the gluten or whether that’s something else in the products that goes along with gluten but is not actually gluten itself remains to be seen.

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Porter

Because herein lies a problem in that if you’re cutting gluten out of your diet completely or reducing the amount that you consume gluten is in certain foods, particularly carbohydrate type foods, and it might be cutting out those that’s doing you the good.

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McCartney

Absolutely and there’s been research done on this stuff called fodmaps, which are different types of carbohydrates, and certainly some trials have found that when people who think they are insensitive towards gluten don’t cut out gluten but do cut out these short chain carbohydrates, they can often feel better.Ìý So I think there is lots of work still to be done and certainly people do get real symptoms but they might not always be caused by gluten.

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Porter

So what you’re saying Margaret is cutting gluten out of your diet might actually lead to a much healthier diet, if you think of the sort of foods that are rich in gluten – so bread, biscuits, cake, pizza – the things that a lot of us eat too much of?

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McCartney

Yes, so it maybe that you feel better because you’re just having a healthier balanced diet without too much sugar and without a lot of carbohydrates that you really don’t need and are just adding up your calorie count and it may be that you’re taking in more vegetables and fruit for example as well.

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Porter

Which brings me on to my next point, I mean you don’t actually have to buy gluten-free products, per se, you can buy things that are naturally gluten-free like lots of fruit and vegetables.

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McCartney

Absolutely but of course they don’t come with sticky labels on them advertising the fact.

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Porter

Margaret McCartney.

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Well millions of people may be opting for gluten-free foods, but is their decision simply the result of a triumph of marketing over science? Is there actually any benefit from pursuing a gluten-free diet, if you don’t have proven coeliac disease?

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Dr Pamela Ewan is a Consultant Allergist at Addenbrooke’s Hospital in Cambridge and Paul Ciclitira is Professor of Gastroenterology at Kings College London.

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Ciclitira

There’s a great debate about non-coeliac gluten sensitivity.Ìý The critical thing about this from my point of view as a gastroenterologist, who focuses on food, is that in Australia now 30% of the normal population is taking a gluten-free diet.Ìý That’s mind boggling really.

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Porter

Pamela Ewan from the consultant allergist point of view, do you believe this is a clinical entity?

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Ewan

Well we have a diagnosis we call wheat intolerance.

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Porter

So you would point the finger of blame at wheat rather than its constituent – gluten?

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Ewan

Yes I would.

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Porter

People who present with wheat intolerance, what sort of symptoms do they complain of?

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Ewan

Mainly gastrointestinal symptoms, so they get tummy bloating, altered bowel habit, tummy cramps, discomfort.Ìý I think there is such a thing as wheat intolerance and patients can improve when they avoid wheat and have symptoms when they’re reintroduced and these are not patients with coeliac disease or not patients with wheat allergy.

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Porter

Paul, what does the science tell us about this, have we done much research into this area?

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Ciclitira

The research for this sort of area comes from Melbourne and there are a significant number of publications from the Melbourne group now looking at people with gastrointestinal symptoms which vary from pain, bloating to variable bowel habit and the diagnosis is invariably irritable bowel syndrome.Ìý I mean people keep going on about non-coeliac gluten sensitivity, from my point of view it’s a sub-division of irritable bowel syndrome.

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Porter

Pamela, what’s your take on the evidence for the existence of non-coeliac gluten sensitivity?

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Ewan

I think it’s extremely difficult to know because it’s extremely difficult to first of all establish that diagnosis clearly, there is no easy test for it.Ìý So you’re very reliant on people removing gluten from the diet and saying they’re better and it being given again and having symptoms.Ìý There are some interesting studies where they take patients who think they have a food induced symptom, the incidence of that is known, and then they remove the foods from the diet, reintroduce them and try and prove clearly under medical supervision if indeed the food is causing problems.Ìý And the perception of food intolerance is about eight times that of the reality if you try to formally and very carefully establish it.Ìý So a lot of people think they have a problem when probably they don’t.

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Porter

But you think this exists or not?

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Ewan

I think wheat intolerance exists and I think the difficulty with this is that if it’s on a background of a patient having something like irritable bowel syndrome, where they’ve got variable bowel symptoms, it can be quite difficult to show that changing your diet has a very clear cut effect.

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Porter

The science may be grey Paul but does it really matter if people feel better on a gluten-free diet and they follow it are there are any implications that we should worry about?

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Ciclitira

One of the problems if you take wheat out of the diet wheat actually contains a significant percentage of Ìýa western diet’s fibre content and if you take that out you alter the whole balance of the machinery of your insides as to how it works.Ìý And the crucial thing in my opinion here is to work with an experienced adequately trained dietician.

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Porter

Pamela, would it worry you if one of your patients was following a gluten-free diet when they didn’t actually have a sensitivity?

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Ewan

Not if it was only that, what worries me much more is when people sequentially start taking different foods out of their diet and so they end up on a totally inadequate diet nutritionally.Ìý And that’s another problem.

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Porter

So the gluten sensitivity starts off as the thin end of the wedge, they end up excluding other foods?

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Ewan

They can do, yes.Ìý But there’s no health downside providing it is only gluten that’s been avoided and providing the diet’s nutritionally adequate.Ìý What is of course a big downside is the cost – these products are hugely expensive compared to the normal equivalent.Ìý If you buy a gluten-free loaf it’ll be costing around £3 whereas an ordinary wheat loaf will be about £1 something.

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Porter

And you don’t actually have to pay anymore to be gluten-free in a way, I suppose if you’re looking – I mean some of the gluten-free products we have like fruit and veg – we’d all like to see people eating more of that.

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Ciclitira

Well this comes back also to this fibre business and that a lot of the patients that I’m seeing have irritable bowel syndrome and just simply increasing the fibre their diet improves their symptoms.Ìý If you are an indigenous member of South Africa and every morning you do an 18 inch poo and be very proud of it because of the fibre content of your diet, where we’re eating highly refined diets which include sugar and therefore the fibre content is reduced and many people have symptoms from that alone.

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Porter

Professor Paul Ciclitira and Dr Pamela Ewan.

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Please do get in touch if there is a health issue that you would like us to cover - email insidehealth@bbc.co.uk.

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Now heart disease in women and new research showing that the troponin blood test used to spot heart attacks works well for men but misses a lot in women. As a result a revised more sensitive test will be used from now on.Ìý

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But why the difference between men and women in the first place?Ìý A heart attack’s a heart attack isn’t it? Laura Corr is Consultant Cardiologist at Guy’s and St Thomas’ Foundation Trust in London.

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Corr

A heart attack is simply damage to the heart muscle and you can pick up a huge heart attack in men or women on an ECG, that’s the old fashioned way we used to do it.

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Porter

The electrical trace that…

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Corr

The electrical trace – absolutely – the thing that zips up and down when you see it on a television screen.Ìý But when you’re looking for early heart attacks, when it’s right at the beginning, so that you can try and get rid of it and protect people from it it’s much more difficult to pick up.Ìý And we’re looking for chemicals released by a damaged heart.Ìý And we didn’t realise that the amounts released by men and women are different.Ìý Using the old test we would only pick it up that hit a certain level, it was oh that’s heart damage, in the men, so women who were turning up with chest pain, their ECG looked fine because it was early, they did the blood test, it didn’t look as though it was quite bad enough to signal a heart attack and they were sent home.Ìý

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Porter

So even if the women do the right thing and present promptly with their symptoms they get sent home?

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Corr

Unfortunately that looks as though that’s been happening.

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Porter

What happens to the women once they’re diagnosed, is their outcome the same as the men, so assuming that everything’s done properly?

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Corr

Sadly there seems to be a difference in that too.Ìý If you look at the number of women who have stents or angiograms and surgery it’s less than men even for the same diagnosis.Ìý And their prognosis at the moment is less good, for reasons that aren’t fully understood but they’re coming out in – luckily more research is being done into this.

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Porter

Which makes it all the more shocking that still there’s this persistent belief amongst the general public and amongst the medical profession that heart attacks are something that happen mainly to men.

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Corr

It’s a real problem because the truth is more women in this country die of heart attacks than men – 82,000 women a year, compared to in the 70,000s for men.Ìý It’s actually more of a problem for women than it is for men.Ìý But you’re quite right – it’s not something that women actually think of in the same way as men.

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Porter

And why is the death toll higher in women than men?

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Corr

There’s a number of factors.Ìý The first is if you don’t think it’s a heart attack you’re not going to look for it, you’re not going to take care of it so…

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Porter

Because it happens to men.

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Corr

It happens to men – so I’ve got chest pain, I’m fairly young so it can’t possibly be a heart attack and it’s not just women who think that, it’s the doctors who think that.Ìý So there’s a whole programme of education that we need to do to actually make sure that this is picked up.Ìý The new test is going to make a huge difference to that.

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Porter

What about prevention – are we doing a better job at – I mean I’m thinking of things like cholesterol lowering drugs, aspirin, all the different things we’ve used, blood pressure lowering treatments – are we more aggressive with men than we are women?

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Corr

In every aspect of heart disease diagnosis, prevention and treatment, we seem to be more aggressive in men than women.Ìý Now it could be because in the past an awful lot of research was only done in men, they didn’t actually use women because they thought it was too complicated because they had things like hormones that would upset their tests.Ìý And so the studies were all done in men and they simply didn’t know how they translated to women.

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Porter

I’m smiling because we dream of personalised medicine, where we’ll have the genetic code of a patient, be able to pick the right drug or treatment off the shelf accordingly and yet here we are saying we can’t even get it right based on their sex.

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Corr

We need to focus on the XY chromosome to start with and get that right first.

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Porter

Dr Laura Corr, thank you very much. And there is a link to the troponin study, as well as, more information on heart disease in women on our website.

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Now if, like me, you enjoy a lie at the weekend after a hectic week then you will be disappointed to learn that it may be bad for your waistline. It has long been known that disturbances in sleep patterns, due to factors like shift work, can impact on our metabolism and health, but the influence of more subtle change is only just being appreciated.

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A team from the Medical Research Unit Harwell has been investigating the effects of social jet lag - having sleep patterns during the week that differ significantly from those at the weekend. And their findings suggest that the greater that difference - or lag - the more likely you are to be obese. Dr Michael Parsons led the study.

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Parsons

Well social jet lag is a measure of the difference between your internal clock, so for example if you’re a morning person or an evening person, and the difference between that and your work schedule or your social schedule.Ìý For example, I’m an evening person but have to work nine to five job and even earlier – you have to get up even earlier now that I have a two year old son.Ìý So I would have a relatively high social jet lag.

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Porter

So effectively what we’re saying in practice is that people at the weekends might be going to bed later and waking up later, they’re having lie-ins and that gives them a degree of social jet lag across the week?

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Parsons

Yes exactly, especially – we find this more within our study for people who were evening types and had, for example, nine to five jobs or earlier shifts.

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Porter

So looking at this social jet lag, which you were measuring in the people that you studied, what did you find?

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Parsons

Well we have found that social jet lag was associated with increased risk for a number of different obesity measurements, so including BMI, body mass index, fat mass and as well as an increased risk for such things as metabolic syndrome, a marker for diabetes and a marker for inflammation.

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Porter

So these are all significant things because they can all lead to an increased risk of heart disease and stroke, two of the biggest killers.Ìý But do we know that it’s this social jet lag, the changing in their sleep patterns if you like, that’s causing this or is it that people who are overweight, for instance, tend to lie-in more at the weekends to put it simply?

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Parsons

I mean I think that’s a completely fair question.Ìý So our study is correlational, so we have just found an association between social jet lag and obesity and obesity rate of disease, so that one causes the other.Ìý So it definitely could be that the certain social factors associated with obesity that makes people more likely to have social jet lag.Ìý But from other studies involving people with shift work and involving basically jet lag type models they found that that can lead to differences in how you metabolise fat, so how well you deal with fats, how well you deal with sugars and carbohydrates and thus lead to a different resting state of how you process your food and thus likely obesity.Ìý So while that’s been found more for longer [indistinct word], it’s the first time there’s actually been an association with shorter differences between when you sleep on your weekdays and weekends.

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Porter

What lessons should we take away from this?Ìý If I’m listening to this and I’m someone who’s – I’m something of an owl, I like to do a lot in the evening, I go to bed later but I like to catch up at the weekend with a lie-in, should I be changing my – the way that I live?

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Parsons

I’m not trying to say don’t lie-in, if you’re, for example, an evening person as you suggested then I think the ideal situation would be this data to lead to a discussion of public health and policies that may be able to allow for such things as more flexible working hours, so be able to have working hours that more cater to evening people, so there is less of a discrepancy.

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Porter

If only it were that easy Michael.Ìý There’s a link to Dr Parsons’ study on our website, if you’d like to run it under your boss’s nose to make the case for starting later in the day.Ìý Good luck with that.

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As the cold snap approaches Public Health England has issued a cold weather alert, and things are look set to be even worse in Scotland over the next few days as temperatures plummet.Ìý And along with freezing weather inevitably comes a rise in serious illnesses, particularly among those living in poor housing with chest problems.

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But a small pilot project in Sunderland is testing a novel solution to the problem. The local Clinical Commissioning Group or CCG has put aside £50,000 to see if spending up to £5,000 per home on boilers, double glazing and insulation can improve the health of a group of patients with chronic chest disease - a problem which often gets worse during spells of cold or damp weather requiring medical care or even spells in hospital. And the preliminary results suggest that providing new boilers on prescription may just work. Dr Tim Ballard is Vice Chair of the Royal College of GPs.

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Ballard

It’s a small study but what they showed was really quite exciting.Ìý And it seemed to show a 28% decrease in GP attendances and also a 40% decrease in hospital attendances as well which is very, very cost effective for the NHS.Ìý The average admission for an episode of chronic obstructive pulmonary disease is round about two and a half thousand pounds.Ìý So you don’t need to save many to recoup the return on investment with this.Ìý And on top of that anecdotally the qualitative research showed was that the people who’d had this intervention were actually happier, they were warmer, their mental health improved and really importantly their discretionary spend – their ability to spend money not on fuel but on other things and better food – actually went up.Ìý

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Porter

It’s very difficult to draw a lot of conclusions from this because it’s tiny, I mean six people had the boilers, six people didn’t, they were compared, so it really is miniscule but it begs the question – was it significant enough for this research to be extended because if you could present this as hard evidence to CCGs across the country it might be something they could adopt?

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Ballard

I think it was very difficult for the old style PCT managers to lift their heads above the parapet and do innovative things like this, they were really curtailed into spending money the way it had always been spent.Ìý And I think innovations like this are really exciting and I think we do need to scale it up, we need some bigger studies to prove that we’re on the right track and then use it as a legitimate way to spend the health pound.

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Porter

Is that research ongoing now?

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Ballard

I’ve been speaking to the CCG involved, up in the North East, and there is interest from other local CCGs, what I’m hoping to do is to use our position with the Royal College of GPs and the NHS Clinical Commissioners to make the results of this study more widely available, so that each clinical commissioning group can make its own decisions about whether they’d like to dip their toe in this sort of commissioning.

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Porter

Is this not the NHS taking over responsibility for what local authorities should be doing for instance?

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Ballard

I think local authorities obviously have a really, really important part to play in this, as do the energy companies themselves in trying to target and help people in fuel poverty.Ìý It’s really innovative, I think we’re in the early days and I think in the end it will be a political decision as to how and who pays for it.Ìý What we’re saying at the moment is that it seems to be a really good idea and someone’s got to pick it up.

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Porter

Dr Tim Ballard and Margaret McCartney has been listening to that. Do you agree Margaret?

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McCartney

Well someone needs to be spending the money Mark.Ìý We know undoubtedly that cold weather increases the risk of death and these seem to be excess deaths that happen in winter in association with cold weather.Ìý We know that there’s lots of data out there saying that cold weather increases the risk of respiratory illness, cardiovascular illness, mental illness and even accidental injury – I think we can work out how that would happen.Ìý But the problem is what do you then do about it.Ìý And indeed this study, that was just looked at, is very small but there have been other studies out there done before and in fact there’s evidence over the last hundred years of people looking at housing and finding that when they improve it they tend to improve people’s health.

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Porter

But how comfortable are you, as an NHS GP, with the NHS spending its limited resources in this?

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McCartney

Well I think the big problem here is that we keep dividing healthcare and social care really artificially.Ìý What happens in our social care setting has a direct impact on what happens in healthcare.Ìý So really the answer is less separation and more joining up and realising that if people have better housing conditions the chances are that they will be healthier, we already know that social inequality, poverty in the UK, is a huge driver of premature death.Ìý So we have to do something about that and the problem is that when we use medical solutions we give social problems medical answers and that’s a really bad idea because it ends up with all the side effects and all the over-treatment aspects of medicine, that we could get a better result from in many instances with better social care and better political policies.Ìý So I would argue that we need a more joined up service rather than trying to separate things artificially that really should never have been separated in the first place.

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Porter

And I know you’re far from alone in thinking that Margaret. Thank you very much.Ìý And there a links to the evidence Margaret mentioned there in her blog. Just go to the Inside Health page of the Radio 4 website.

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Just time to tell you about next week when I will be examining proposals to improve cancer survival in the UK, including allowing the public to self-refer if they suspect they have a problem. And noisy headphones - as the French consider introducing legislation to limit how loud they can go, should we follow suit?

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ENDS