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  1. Five-a-day 'enough'

    The UK government's five a day target for fruit and vegetables has sometimes been controversial - but a major new study today says it is right on target.

    Some recent studies have suggested that people can make themselves even healthier by reaching seven-a-day or more. The latest study says this is not necessary.

    A team led by Professor Frank Hu of Harvard School of Public Health, Boston, USA, looked at the link between fruit and vegetable consumption and risk of death from all causes, cardiovascular disease, and cancer. They found 16 earlier studies that followed participants over time, for between five and 26 years. Among the 833,234 participants there were 56,423 deaths, of which 11,512 were from diseases of the heart and circulation and 16,817 from cancer.

    Results of their analysis appear in The BMJ.

    The findings were welcomed by British experts.

    Victoria Taylor, of the British Heart Foundation, said: “This study is another reminder that fruit and vegetables shouldn’t be an after-thought but an essential part of our meals and snacks.

    “Although our five a day message is well established worryingly 70% of adults are still not meeting this target. It may seem like a difficult task, but it doesn’t have to be."

    Writing the journal, the researchers say: "Higher consumption of fruit and vegetables was significantly associated with a lower risk of all-cause mortality."

    The risk fell by about 5% for each daily serving of fruit and vegetables. But they add: "There was a threshold around five servings of fruit and vegetables a day, after which the risk of all cause mortality did not reduce further."

    For death from heart disease, "a significant inverse association was observed", with each additional serving cutting the risk by about 4%. No benefit was seen for death from cancer.

    "This meta-analysis provides further evidence that a higher consumption of fruit and vegetables is associated with a lower risk of all-cause mortality, particularly cardiovascular mortality," they write.

    Wang, X. et al. Fruit and vegetable consumption and mortality from all causes, cardiovascular disease, and cancer: systematic review and dose-response meta-analysis of prospective cohort studies. BMJ 30 July 2014 doi: 10.1136/bmj.g4490 [abstract]

  2. Should boys get cancer vaccine?

    Boys should be vaccinated against the human papillomavirus virus in addition to girls, says a chronic illnesses lecturer today.

    The human papillomavirus (HPV) infection is common in men. Persistent infection with HPV types 6 and 11 can lead to genital warts, and types 16 and 18 may lead to head and neck, anal, or penile cancer.

    Rates are increasing, and all 12 to 13 year old girls in the UK have been offered a free vaccination since 2008. Boys in Australia, the US, two Canadian provinces, and Austria are also offered the vaccination. The UK is considering a similar move, and assessing its cost-effectiveness.

    "HPV related disease in men causes a considerable burden; therefore, vaccinating boys is likely to produce more health and economic benefits than those from a girls-only programme," writes Dr Gillian Prue of Queen's University of Belfast, UK, in The BMJ.

    She points out that cost-effectiveness calculations often focus solely on the prevention of cervical cancer, omitting the prevention of other conditions.

    "If uptake is low in girls, the benefit of vaccinating boys is easily apparent," Dr Prue states. "However, with high uptake in girls, vaccinating both sexes is less cost-effective."

    "The suffering caused by HPV related diseases is self evident," she adds. "Any decision about whether to vaccinate boys should not be based solely on cost-effectiveness. Public health, equity, and the human costs of HPV related disease for both sexes must be the main considerations."

    In an editorial, Dr Colm O'Mahoney of the Countess of Chester Foundation Trust Hospital, Chester, UK, and colleagues support vaccination for boys. "Anything else is discriminatory, inequitable, less effective, and difficult to explain," they believe. "Can the UK afford to do it? If the price is right, we can't afford not to."

    Prue, G. Vaccinate boys as well as girls against HPV: it works, and it may be cost effective. BMJ 30 July 2014 doi: 10.1136/bmj.g4834

  3. Folate test to cut neural tube defects

    Folate levels in the blood could be used to identify women at raised risk of having a pregnancy affected by neural tube defect, researchers say today.

    A woman's folic acid intake before and during pregnancy is linked to this risk, so fortification of staple foods with folic acid is widely used to cut the illness, death and costs of these conditions.

    Dr Krista Crider of the Centers for Disease Control and Prevention, Atlanta, USA, and her team say establishing a reliable biomarker would be extremely useful. Current definitions of folate deficiency are not based on prevention of neural tube defects. The researchers used figures from two studies in China with a total of 247,831 participants. A proportion of the women were given 400 micrograms per day of folic acid in a supplement before and during early pregnancy. The women's red blood cell folate concentrations were estimated at the point of neural tube closure, day 28 of gestation.

    This showed that "risk of neural tube defects was high at the lowest estimated red blood cell folate concentrations, and decreased as estimated folate concentration increased," say the team in The BMJ

    Risk of neural tube defects was "substantially attenuated" at estimated folate concentrations above about 1,000 nanomoles per litre, they add. The risks at different folate levels were "consistent with the existing literature" and with the prevalence of neural tube defects in the US population before and after food fortification.

    So they conclude that a threshold, perhaps 1000 nmol/L, could be defines for optimal red blood cell folate concentration in the population, to prevent neural tube defects. This could then be used as biomarker for those women at risk of a foetus with neural tube defects.

    Crider, K. S. et al. Population red blood cell folate concentrations for prevention of neural tube defects: bayesian model. BMJ 30 July 2014 doi: 10.1136/bmj.g4554 [abstract]

  4. Better care for heavy menstrual bleeding

    NHS care for women with heavy menstrual bleeding has improved, according to the findings of an audit published today.

    The condition affects a quarter of women between the ages of 15 and 50. It can have a severe impact on quality of life, and carries a risk of anaemia. The audit - part of the National Clinical Audit Programme - is published by the Royal College of Obstetricians and Gynaecologists. It covers care received by more than 8,000 patients in England and Wales over the last four years. All were referred by their GP to a gynaecological outpatient clinic and treated in hospital.

    The women themselves provided the information that makes up the audit. The vast majority (90%) rated their care as good, very good or excellent. Most women felt a large improvement in their quality of life in the year after their first hospital appointment, with the largest improvement among those who had surgery.

    But the rate of surgical treatment varied widely, between 20% and 60%, across NHS hospitals. This was partly linked to ethnic background.

    Non-white women were less likely to have surgery than white women, and also reported smaller improvements in quality of life.

    So the report "highlights the need for greater awareness of cultural differences", the authors say.

    Co-author Dr Tahir Mahmood said: "We have seen improvements since 2010 in the management of heavy menstrual bleeding. Half of all NHS hospitals now have written protocols in place, and have introduced new care pathways.

    "However, this important national audit has also identified a potential inequality in access to care for women of non-white ethnicity as well as those who live in more deprived areas."



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