Ethically spending a million pounds on useful research

Does offering financial incentives encourage mothers of newborns to breastfeed? While this may seem incredulous, a study actually was implemented in parts of England to see if this would be the case.

More than 10,000 mothers across regions such as South Yorkshire, Derbyshire and north Nottinghamshire took part in the trial, where mothers were given a hundred and twenty pounds if they breastfed their babies, and a further eighty pounds if they continued up to the point the babies were six months old. That is to say mothers received two hundred pounds if their babies were breastfed up to the age of six months.

But why was this implemented in the first place? One of the reasons the study was done was to see if financial incentives would help raise the rate of breastfeeding in the UK. In some parts of the UK, only one in eight babies are breastfed past eight weeks. The early suspension of breastfeeding causes later problems in life for babies, and this was a study to see if it would be possible to save a reported seventeen million pounds in annual hospital admissions or GP visits.

How were these women chosen? They were picked from areas which were reportedly low-income ones. There was a suggestion that in low-income areas, mothers feel obliged to return to work quickly and breastfeeding is inconvenient and a reason why mothers stop it.

The financial incentive did result in a rise of six percentage points, from 32% to 38%. This meant that over six hundred more mothers in the ten thousand breastfed their babies for up to six months instead of the hypothetical eight week line.

Should we get excited about these results? Caution is to be exercised.

As a few leading academics noted, there was no way to monitor a reported increase. The mother’s word was taken at face value but there was no way to monitor that a prolonged breastfeeding period actually took place. It would not be inaccurate to say that of these six hundred mothers, some merely reported they had breastfed for longer but without actually doing it. If you live in an income-deprived area, and were offered two hundred pounds of shopping at a time when you needed it, without having to do much apart from saying “Yes, I breastfed”, wouldn’t you take the easy money?

It was mentioned that if the results did have a high percentage of trustworthiness to them, in other words, if mothers breastfed as they said they had done, it would help normalise breastfeeding in regions where it might cause embarrassment to the mother. Why might breastfeeding cause embarrassment? For example, in some social situations it might be slightly awkward to reveal normally covered parts of the body in public.

How much did the scheme cost? If we assume that 38% of 10000 mothers breastfed and claimed these financial vouchers, that’s around 4000 mothers each claiming two hundred pounds, at a cost of eight hundred thousand pounds.

Wow. Eight hundred thousand pounds of free shopping for which an outcome cannot be undisputably proven. Where does all the money come from?

The Medical Research Council was funded to the tune of up to seven hundred and fifty-five million pounds in 2016/17, or which nearly half was provided as grants to researchers. But while all that may sound as a lot of money, surely there should be more accountability in how the money is used. Using up nearly a million pounds of that money for a trial whose results cannot be justified is not a good use of money.

But perhaps the babies’ height, weight and other factors pertaining to breastfeeding could have been taken? For example, if we know that breastfeeding has benefits in certain areas, such as in growth charts, perhaps the babies that were breastfed in that study could have been measured against babies who had not been breastfed to see if there had been any positive gain, and something that could correlate to breastfeeding over the six month period?

Imagine if this had been a study about literacy. Imagine that mothers who read two stories to their child up to the age of four years would receive two hundred pounds. Surely, at the end of the period, the research scientists would not merely be going to the mothers and saying “Did you read to your child? Yes? Here’s two hundred pounds.” They would try to assess the child, perhaps by means of a literacy test of some form, to see if any reading had actually taken place.

Otherwise it is just money down the drain for results which cannot be proven and cannot be relied on. In that case, what is the purpose of spending money on hearsay?

Did giving eight hundred thousand pounds encourage mothers in income-deprived areas to breastfeed for longer periods? Who knows? The only thing we can be sure of is that eight hundred thousand pounds made them say they did it.

Health umbrella reviews mask the real issues

You have to wonder why the breakfast tea doesn’t get the same level of attention. Or perhaps whether in France, the humble croissant is elevated to the same status. Or maybe the banana could soon be the star of another media show. But unfortunately it is coffee that headlines tomorrow’s fish and chips papers.

“Drinking three or four cups of coffee a day could have benefits for your health”. As we have seen previously, this kind of headline bears the hallmarks of a media health report:

1) repackaging of common information requiring little or no specialist examination;

2) use of a modal auxiliary verb (could) to conveniently justify or disclaim an

attention-grabbing headline – which, by the way, is point number three.

The health reports in the media also incorporate:

4) a statistically small group of trial participants, whose results are then blown up in proportion as if to be representative of the 7 billion people on the planet.

5) Assumptions. A media report about health could simply include assumptions.

Why dwell on coffee? For starters, it is a commonly consumed drink and so any meaningful research would potentially have bearings on millions of people. It is common media practice to focus on common food and activities because of the relevance to daily life.

But if you examine this carefully, why not tea? Why not write about tea? While conspiracy theories may be slightly far fetched, it is possible that – unless it is a speciality tea – coffees cost more, and any potential health benefits would lead people to spend more, hence generating more for the economy in the forms of tax. Perhaps this is why media writers don’t waste too much ink on researching the potential life-saving benefits of bananas, even though they are widely consumed. The research isn’t going to drive people to buy bananas in bulk, and even so, the extra revenue generated from a low priced item isn’t going to raise much extra tax.

Are there any notable similarities or differences in style across different countries? One wonders whether Parisian newspapers, on a regular basis, churn out headlines such as:

“Eating two or more croissants a day could reduce your chances of heart disease.”

“Pan aux raisins linked with dementia”.

The research done was an umbrella review to potentially examine whether further research should be undertaken into researching the effects of coffee and its role in preventing liver cancer. An umbrella review meant that no actual research was undertaken, but that existing research was examined and analysed to glean insights.

The problem with umbrella reviews is that they are very generalised, no actual research is done, and they are only brief analyses of existing research. This means that first of all, an umbrella review could arrive at a particular conclusion, but in no way should that be taken as the final conclusion.

In fact, the findings of an umbrella review are only the preliminary to more detailed investigation. If an umbrella review suggested that drinking coffee could prevent cancer, then what it is saying is more research needs to be undertaken, and the media needs to be ethically responsible by not reporting “Coffee prevents Cancer”, because there are people that look at newspapers and television as the source of their information and assume just because it has been released in the public domain, it is truth. Who could conceive that newspapers spend time and resources to publish trivial information and that television is pure rubbish?

The second problem with umbrella reviews is that the outcomes are only as good as the original sources. If someone gave you a set of grainy photos, then asked you to make a collage with them, then your collage is going to be as good as the grainy photos will allow. If the original sources were not thorough or exact in their investigation, are any subsequent findings based on these merely just a waste of time?

The third issue with umbrella reviews is that under closer scrutiny, the overall picture is distorted by over focussing on small statistical variances, or sometimes minute errors are magnified and lead one down the wrong path.

If you took a picture on your phone and then blew it up to the size of a mural covering the side of your house, the picture becomes very dotty. You might see big patchy squares. But if you started looking for that big patchy square from the image in your phone… one has to wonder what the purpose of that is.

The fourth is that because umbrella reviews are a prelude to a more thorough investigation, their end results are slightly skewed from the outset. If an umbrella review is bound to provide a few avenues for later time-consuming research then it is fundamentally biased into having to provide one in the first place. Why, in that case, have such reviews in the first place? Some may point out that the flaw in the system is that umbrella reviews are relied on by those in academia and research to warrant the continued longevity of their positions. In other words, if researchers had nothing to research, they might be out of a job, so they best find something to stick their noses in.

Have you ever read the London newspaper Metro and come across some research news such as:

“Going to bed angry can wreck your sleep” (25 Sept 2017)

It is the sort of headline that makes you think “Why bother doing the research in the first place?”

It is likely that you have read a media report of an umbrella review.

What were the findings of the original coffee review?

Drinking coffee was consistently linked with a lower risk of death from all causes and from heart disease. The largest reduction in relative risk of premature death was seen in people consuming three cups a day, compared with non-coffee drinkers.

Now, when an umbrella review mentions drinking coffee is linked with a lower risk of death, it is important to be clear about what it specifically means. And what it is stating is that those who had a lower risk of death all happened to drink coffee. It might have nothing to do with the coffee itself. It might have been that they took a break to slow down a fast-paced lifestyle, and the taking of a break gave them a lower risk of death. By that logic of association, tea could also be linked with a lower risk of death.

Coffee was also associated with a lower risk of several cancers, including prostate, endometrial, skin and liver cancer, as well as type-2 diabetes, gallstones and gout, the researchers said. The greatest benefit was seen for liver conditions such as cirrhosis of the liver.

Again, to be clear, the above link means that those who were at lower risk of those cancers happened to drink coffee. But it is not necessarily stating the coffee had anything to do with it.

And coffee is such a commonly consumed drink, that it is easy to use it to draw links to anything.

If people who died from car accidents happened to drink coffee, an umbrella review might state that drinking coffee is linked with higher incidences of car accidents.

The findings can be summarised by a health analyst:

“Does coffee prevent chronic disease and reduce mortality? We simply do not know. Should doctors recommend drinking coffee to prevent disease? Should people start drinking coffee for health reasons? The answer to both questions is ‘no’.”

We should perhaps add a further third question: Did the umbrella review produce any actionable findings, and should it have been undertaken in the first place?

Probably not.

Set aside time and space for your own mental health

Work places huge demands on modern living. It goes without saying that over generations work demands have increased. For example, generations ago the concept of a traditional job for most people was a five-day working working week. The song “9 to 5” by Dolly Parton more or less captured the essence of work at the time. (Unfortunately, it is still fairly often played, to the point that people in non-Western societies assume we still only work eight hour days, five times a week, and spend our free time sunning ourselves on the beach.) Nowadays people have to work longer hours, and travel further for work. The total time spent each day traveling and working each day could easily amount to twelve hours, and it is not like the commute is down time – we still have to catch up on emails, admin, and type away busily on the laptop. We could easily spend sixty hours doing work-related things.

And the weekends? Forget the weekends. These days there is no distinction between a weekday and a weekend. Work has steadily grown its talons and where an hourly-rated individual used to get 1.5 or two times the normal rate for working on a weekend, these days it is the same. Employers realise that in an economy with job shortages, they can get away with offering less rates but will not be short of takers.

The problem with all this is that we don’t really have much of a choice when it comes to establishing our work boundaries or exercise or rights when we realise we are being pushed beyond our work boundaries. We’re made to feel that in these times, we are lucky to hold down a job, and if we complain about the increasing demands of it, and how higher managers try to force more work on us without increasing our pay, we might get told to take a hike and end up in a more difficult situation of having no job, commitments to uphold and having to start out again. There are lots of people trapped in jobs where they have to take on more and more as the years go by, and have every ounce of work and free hour extracted from them for little pay. This places increasing mental demands on the individual not just in having to cope with work demands, but the possibility of being made redundant if he or she shows weakness by having to admit an inability to cope any more. It is a no win situation.

Is it a surprising statistic that mental health illness is on the rise? Hardly.

Nowadays people are working more to live and living to work more.

What can you do to preserve some semblance of mental health?

The first thing you can do for yourself is to establish boundaries within the home. Establish a space where work does not intrude. A good idea is often the bedroom, or even have a rule that you will not work on the bed. If you end up working on your laptop in the bed, it will not do you any good – keep at least a certain physical space for yourself.

Also try to set aside a time each day for yourself if possible. It is possibly unrealistic to say an hour each day in the modern life climate, but something like twenty minutes to half an hour would be a good idea. Use this time to wind down in your personal space doing something you enjoy, that is different from work. You may think you cannot really afford that time, but it is important to disassociate yourself from work for the sake of your long-term longevity. Think of it as enforced rest. If it works better for you, take your enforced in the middle part of the working day. You don’t necessarily have to be doing something, use it to rest or catch a power nap.

Every now again, such as on a weekend, do something different from work. Do a yoga class, learn an instrument like the piano, or play a game of tennis. The possibilities for leisure are endless. But don’t bring your work approach to your leisure. Don’t start charting your tennis serve percentage, or do anything that makes your leisure activity appear like work in a different form. The only thing you must do with a businesslike approach is to meet this leisure appointment so that your life does not revolve around a continuous stretch of work.

We can moan about it but the nature of work will never revert back to how it was in the past. Those of us who long for the good old days will only make our own lives miserable with wishful thinking. Those of us who insist on working five-day weeks will find it is insufficient to maintain modern living in the twenty-first century. We will all end up working longer and harder in the current economic climate, and even if times improve, employers will be unlikely to go back to pre-existing forms of remuneration if workers have already been accustomed and conditioned to work at a certain level, because it is more cost effective to hire fewer employees who do more work than have the same work done by more employees. Employees have to recognise that adapting to increasing work loads are a working life skill, and that taking steps to negate increasing pressures will also be an essential part to maintaining our own mental health and well-being.

To raise life expectancy, ignore the television and newspapers

With increasing good health, the average human being in the developed world can expect to live a longer life, well into the eighties. This is in contrast to a century ago, where reaching the age of sixty was regarded to be a milestone. And what about the 1800s? Being 50 was an achievement, so much so that people married young and being in their twenties was considered middle aged! Life has certainly changed a lot to enable the average life expectancy to increase.

How has the average life expectancy almost doubled over the last two centuries? This can be said to be due to a few significant reasons.

The first is of course improvements in the medical world. The world of medicine has advanced significantly into the modern area, that it is undeniable that this has been the greatest single factor in the lengthening of human life expectancy. Take a look at the average supermarket medical shelf. On it you will see a mind-boggling range of medical products for a variety of symptoms, a range so wide that you may even start to examine how product A differs from product B. Two products to treat one symptom! Bear in mind that a hundred years ago, this might not have even existed! Feeling under the weather? Got a fever? Take a paracetamol or ibuprofen and sleep it off. Centuries ago the only method might have been to get plenty of rest, dabbing your forehead with a wet flannel. Or to visit the apothecary to get a mixture of powders to mix and grind according to some secret formula. And if you are adverse to medication, that makes you hesitant about taking counter medication, there are herbal remedies to explore.

Certainly the range of available medication has contributed in some way to humans living longer lives. But the range of products that you can see are not just the ones available to humans of course; these are the only ones that be purchased without prescription. For medication to treat more serious ailments such as blood pressure for example, these can be obtained via a doctor’s prescription and a subsequent visit to the pharmacist.

The medical process differs getting country to country. In the United Kingdom, you make an appointment to visit a general practitioner but depending on your practice, this could be a week later. Why make an  appointment if you need help later? It is almost as is you are having to anticipate your illness. More likely though, is the explanation that for minor ailments, you are almost expected to self medicate.

In other countries like Singapore for instance, the availability of appointments in what is termed polyclinics means if people are unwell, they merely turn up on the day to be seen. They can also turn up at any polyclinic rather than the one they normally go to, if they happen to be in another area, because medical records are readily shared – as they have been for over three decades. Ill patients are not expected to self medicate; they also go to a doctor despite illness because as doctor’s note is the only accepted evidence for absence from work.

Pharmacists do not exist in Singapore in the same context as in the United Kingdom. In the UK, patients visit the pharmacist after the doctor, and have to make trips to two separate places. In Singapore, the pharmacist is housed in the polyclinic; a separate unit called the Dispensary handles the prescription so after you see the doctor it is ready for collection within the same building.

Better medication is a reason for longer life expectancy. But improvements in medical surgery and practice have played a role in this too. We know about how to treat patients better because medical practices are shared and what used to be exclusive medical information is now widely available to all. In the previous century, for example, the practice of blood letting, removing blood from a patient, was acceptable despite its unproven results. Patients did not necessary survive when this practice was resorted to. When patients survived, surgeons would proclaim “It worked!” But when blood letting failed, surgeons would say that the patient was so weak to begin with that the process could not even save him. Advances in medical surgery have shown that blood letting, presumed to be a cure, actually weakened a patient at his most vulnerable state. But it is only improvements in medical surgery that have meant that this dangerous practice is no longer used or necessary in many cases.

Advancements in the medical world have been backed by improvements in the world of technology. In the past, when information was written down and filed in large binders and filing cabinets, the sharing was done either by executives travelling from hospital to hospital, in a top-level only way of information dissemination. But now information can be stored electronically, and shared seamlessly and knowledge is no longer the preserve of the privileged few. The advances in medical technology have been accelerated by the ability to share this information, resulting in a knowledge boost within the medical community which benefits those within its umbrella.

The availability of knowledge to the average citizen has also played a part in extending human life expectancy. Knowledge about how our bodies work, and the help and care available have helped individuals take better care of themselves. Continual research about diet, exercise and lifestyle influence how individuals live their life, hopefully positively.

The government hope is that the filtering of health information down to the citizens will incentivise them to manage their own health better. This is one of the aims as it moves towards a sustainable healthcare model. How can a sustainable healthcare help? It would focus diminishing resources on those who need it most, so those who cannot afford healthcare or those whose treatments are more costly, and who would normally not be able to qualify for treatments based on quality adjusted life years, would be in a better position. Theoretically, this would slowly raise life expectancy even further by targeting the more life threatening illnesses.

In a previous post I have mentioned that sustainable health is not as clear cut as it seems, but nothing ever is. But if managed right, it could be another contributing factor towards the extension of average life expectancy.

The average citizen has access to more medical information than ever before. There is so much health advice alone on the internet that if it were all only published in books, you could line them to end to end to circle the planet many times over. There are also helplines available to call for advice. Some of these are government sponsored while others are manned by volunteers. There is of course, everyone’s general practitioner to go with. There are many avenues for health information. For those who are interested to medical issues, periodicals such as the British Medical Journal after available.

Then there is also the media.

I have discussed previously that the news on television and newspapers regularly report on health issues, but as I highlighted also in another earlier post, you should take in these pieces of information cautiously, because the research that is done is often linked to a report with a dramatic headline. The lower the quality of journalism, the more outlandish the headline, and the fancier the font too, it would appear. You should not see the health section of the newspaper as the font of your health information, because what might be a fairly tenuous link, or bordering on common knowledge becomes sensationalised into the something new.

Take for instance, cats. They wander about in all hours and sometimes don’t come back, or get lost. Some have collars, some don’t. What would you feel if your cat went missing? Stressed. Sooner or later some newspaper would report Cat Collars Can Minimise Stress Levels, because if  your cat had one, and went missing, you might feel slightly better knowing someone might find it and call you, than if it had no collar and had no means of being returned to you. When this headline would be resorted to, no one can say; but it would be on a day there is nothing to report and not much going on in the world.

You see, the news and newspapers don’t exist to give you information, they exist to pad out the ads and advertising space. In a fifteen minute time slot in television, twelve and a half is filled with listed programmes, while the remaining two and a half are made from advertising that is linked to the programme. We often think of ads as the things that break up the television programme, but a better perspective is to think of the programmes as binding agents for the advertisements – unfortunately, that is how poor television has become. You can similarly think of the news in the newspaper as bits which hold the advertisements together.

The advertising is where media makes its money. But if the newspapers were little more than an Argos catalogue, they wouldn’t survive. If the ads on television were strung together, no one would watch it.

You can look at it using this similar analogy. A library loans books out. But loaning books out does not allow it to make money. A library makes money by selling advertising space on its noticeboards, renting out DVDs for cash, charging for the hire of rooms and delay in book returns. It tries to attract a user base so that it can sell these numbers to event organisers hoping to hold events on its premises.

News on the television and print media work the same way. So you could probably save a few years of your life by ignoring the headlines you encounter, such as those that say “Pet owners live XX% longer live than non pet owners”. The supposed research is the common knowledge that pets  provide companionship and relieve stress, which lead to owners having less pressures and living longer. The percentage is to lull you into thinking research was done when it was not. It may have been the group of pet owners sampled were already older than the average life expectancy and that the animals had no bearing.

What if the pets were unwanted ones, inherited, or ones that had grown to big or become to cumbersome to look after?

“XX% of pets cause stress to their owners.”

The media periodically comes up with headlines such as “Having a pet may help you live longer” – with a catch. The pet must be a dog, and you must be the one that takes it for walks. It is a way of generating column inches on the basic premise that having to walk to walk a dog means you are having to be more active and likely to live longer. There was no mention of whether active individuals who already went out for a walk got a dog for company, or if a dog encouraged individuals to go out walking.

Another headline that surfaced this year was that Grandparents who babysat tended to live longer. This was again based on the tenuous link that having grandchildren around made individuals more likely to go out more often; for those that sat in chairs watching TV most of the time, any evidence to the contrary was explained away by the “tended” in the headline.

So it would not be unfair to state that there is not anything significantly meaningful you can learn from the media to improve your health. If you wanted to live longer, there are more specialised avenues you can seek information from. The thing with health articles is that they are not time-specific, they can be written or filed away, then brought out on a day where news is fallow, in contrast to current events, where – if not reported today – the opportunity is lost. So if you wanted to learn more about living longer, forget the media; simply keep active, keep an open mind, maintain a healthy diet … and what will be, will be.