Press releases Monday 16 August to Saturday 21 August 2010

Please remember to credit the BMJas source when publicising an article and to tell your readers that they can read its full text on the journal's website (http://www.bmj.com).

(1) Long term sick could be identified three years prior to going on benefit
(2) Should the NHS budget be ring fenced?
(3) Green leafy vegetables reduce diabetes risk
(4) Fear of falling linked to future falls in older people

(1) Long term sick could be identified three years prior to going on benefit
(Research: Predicting which people with psychosocial distress are at risk of becoming dependent on state benefits: analysis of routinely available data)
(Editorial: Access to welfare benefits in primary care)

Individuals on long term incapacity benefit because of mental health problems could be identified by their GPs three years before they stop working, finds a research paper published on bmj.com today.

The research, led by Professor Jill Morrison at the University of Glasgow, also says that there is no significant variation across GP practices in the UK in the rate of patients claiming long term sick benefit. Morrison and colleagues argue that the varying rates of benefit claims are due to population differences and not to GPs issuing sickness certificates inappropriately.

The number of people claiming incapacity benefit and severe disablement allowance in the United Kingdom has increased by over 300% in the last 30 years and the annual cost to the UK economy is around £100 billion, says the study.

The authors investigated data from the 1995, 1998 and 2003 Scottish Health Surveys and from the 1991 to 2007 British Household Panel Survey to examine variation in incapacity benefit claims across the country.

The results show that there was a significant increase in the frequency of GP consultations for patients with mental health problems in the three years prior to them claiming incapacity benefit.

Morrison and colleagues say the current policy of getting people who are on long term benefit back to work may not be very effective. Perhaps it would be better, they argue, to identify patients who are at risk of ending up on long term benefit and focus on keeping them in work.

In conclusion, the researchers say GPs can target people who could become dependent on benefit up to three years before this occurs by identifying patients who have frequent consultations for emotional distress. However, they add that “further work should concentrate on determining what outcomes are achieved by general practitioners who provide additional emotional or occupational support for patients identified as at risk of becoming dependent on long term benefits.”

In an accompanying editorial, Professor Mark Gabbay from the University of Liverpool says “being out of work is bad for health and increasing evidence shows that good work (which reflects elements of fair pay and conditions, job control, and satisfaction) is good for health.”

Gabbay concludes that Morrison’s research is welcome and that “to improve access to welfare for those in need and to support those at risk of drifting into long term unemployment we need more investment in research that can inform policy and help translate findings into practical solutions.”

Contacts:
Research: Jill Morrison, Professor of General Practice, Division of Community Based Sciences, Faculty of Medicine, University of Glasgow, Scotland, UK
Email: jmm4y@clinmed.gla.ac.uk

Editorial: Mark Gabbay, Professor of General Practice, Institute of Psychology, Health and Society, University of Liverpool, UK
Email: mbg@liv.ac.uk

(2) Should the NHS budget be ring fenced?
(Head to Head: Should the NHS budget be ring fenced? Yes)
(Head to Head: Should the NHS budget be ring fenced? No)

Is the government’s decision to ring fence NHS funding fair? Two experts debate the issue on bmj.com today.

John Appleby, Chief Economist at the King’s Fund argues that the alternative to ring fencing is too painful. “If the NHS were not protected it would have to find cuts amounting to around 14% of its budget (equivalent to £18bn) over the next few years,” he writes.

He suggests the NHS could achieve this by cutting staff pay by 30%, sacking all consultants and general practitioners, or abolishing the NHS in Scotland and Wales. “None of these is very appealing, but it underlines just how hard it is going to be for non-protected services … and what spreading the pain would actually entail,” he writes.

Even protected, the NHS will have to make considerable improvements in its efficiency and productivity over the next few years if it is to stretch its budget to meet growing demands and costs, he warns.

A more fundamental argument for protecting the NHS is that this is what the public wants, says Appleby. In a recent poll, 82% said the NHS should not be cut, with just 2% saying it should be. “In this dismal world, spreading the pain would not be efficient given the values the public hold,” he concludes.

On the other side of the debate, David Hunter, Professor of Health Policy and Management at Durham University argues that, far from improving the public’s health, ring fencing may have the opposite effect.

He believes that, “instead of ploughing resources into rescuing growing numbers of people who are leading unhealthy lives, we need to shift the focus upstream to prevent lifestyle illnesses from becoming a drain on NHS budgets.”

“If the NHS budget was not ring fenced we could take public health and health inequalities seriously and ensure that resources are directed to where the pay off will be highest,” says Hunter. “Protecting the NHS sends a perverse signal that being unhealthy may be preferable to remaining healthy.”

Securing integrated care across the health and social care interface is also likely to get worse in future as a result of the public spending cuts and a ring fenced NHS budget, he adds.

By contrast, an integrated commissioning model for health and wellbeing, embracing the NHS, social care, and other local authority services, provides one way forward. “Investing in health will reduce the long term cost of delivering health care, “ he concludes.

Contacts:
Please note, unfortunately both authors are on holiday this week and cannot be contacted.

(3) Green leafy vegetables reduce diabetes risk
(Research: Fruit and vegetable intake and incidence of type 2 diabetes mellitus: systematic review and meta-analysis)
(Editorial: Can specific fruits and vegetables prevent diabetes?)

Eating more green leafy vegetables can significantly reduce the risk of developing type 2 diabetes, finds research published today on bmj.com.

The authors, led by Patrice Carter at the University of Leicester, say there is a need for further investigation into the potential benefits of green leafy vegetables.

In the last two decades there has been a dramatic increase in the number of individuals developing type 2 diabetes worldwide.

Diets high in fruit and vegetables are known to help reduce both cancer and heart disease, but the relationship between fruit and vegetable intake and diabetes remains unclear, say the authors.

The researchers also note that previous research found that in 2002, 86% of UK adults consumed less than the recommended five portions of fruit and vegetables per day, with 62% consuming less than three portions. The study says that “it was estimated that inadequate consumption of fruit and vegetables could have accounted for 2.6 million deaths worldwide in the year 2000.”

Patrice Carter and colleagues reviewed six studies involving over 220,000 participants that focused on the links between fruit and vegetable consumption and type 2 diabetes.

The results reveal that eating one and a half extra servings of green leafy vegetables a day reduces the risk of type 2 diabetes by 14%. However, eating more fruit and vegetables combined does not significantly affect this risk. Only a small number of studies were included in the meta-analysis and the benefit of fruit and vegetables as a whole for prevention of type 2 diabetes may have been obscured.

The authors believe that fruit and vegetables can prevent chronic diseases because of their antioxidant content. Green leafy vegetables such as spinach may also act to reduce type 2 diabetes risk due to their high magnesium content.

The authors argue that “our results support the evidence that ‘foods’ rather than isolated components such as antioxidants are beneficial for health … results from several supplement trials have produced disappointing results for prevention of disease.”

In conclusion, they believe that offering tailored advice to encourage individuals to eat more green leafy vegetables should be investigated further.

In an accompanying editorial, Professor Jim Mann from the University of Otago in New Zealand, and Research Assistant Dagfinn Aune from Imperial College London, are cautious about the results and say the message of increasing overall fruit and vegetable intake must not be lost “in a plethora of magic bullets,” even though green leafy vegetables clearly can be included as one of the five portions of fruit and vegetables per day.

They argue that given the limited number of studies, “it may be too early to dismiss a small reduction in risk for overall fruit and vegetable intake or other specific types of fruits and vegetables and too early for a conclusion regarding green leafy vegetables.”

Contacts:
Research: Patrice Carter, Research Nutritionist, Diabetes Research, Department of Cardiovascular Sciences, University of Leicester, UK
Email: pcl54@le.ac.uk

Editorial: Professor Jim Mann, Edgar National Centre for Diabetes and Obesity Research, Department of Human Nutrition, University of Otago, New Zealand
Email: jim.mann@otago.ac.nz

(4) Fear of falling linked to future falls in older people
(Research: Determinants of disparities between perceived and actual fall risk in community living older people)

Fear of falling is likely to lead to future falls among older people, irrespective of their actual fall risk, finds a study published on bmj.com today.

This indicates that measures of both actual and perceived fall risk should be included in fall risk assessments to help tailor interventions for preventing falls in older people, say the authors.

Fear of falling is common in older people and is associated with poor balance, anxiety, depression and falls. But the problem of irrational fear has been neglected in the scientific literature.

So a team of researchers from Australia and Belgium set out to improve their understanding of fear of falling and its impact on the risk of falls.

Five hundred people, aged 70 to 90 years, living in Sydney took part in the study and underwent an extensive medical and neuropsychological assessment. Actual and perceived fall risks were then estimated using recognised scoring scales and participants were followed up monthly over a one-year period.

The researchers found that both actual fall risk and perceived fall risk independently contribute to a person’s future fall risk.

Further analysis was then used to split the sample into four groups based on the disparity between actual and perceived risk.

Most people had an accurate perception of their fall risk. Those in the “vigorous” group (low actual and low perceived fall risk) were considered at low risk of future significant falls, while those in the “aware” group (high actual and high perceived fall risk) were considered at high risk of future significant falls.

However, about one third of elderly people either underestimated or overestimated their risk of falls.

For example, the “anxious” group had a low actual but high perceived fall risk, which was related to depressive symptoms, neurotic personality traits and poor physical functioning. In contrast, the “stoic” group had a high actual but low perceived fall risk, which was protective for falling, and related to a positive outlook on life, physical activity, and community participation.

Overall, it seems that high levels of perceived fall risk are likely to result in future falls, irrespective of the actual risk, and the disparity between actual and perceived fall risk contributes to risk mainly through psychological pathways, say the authors.

The findings also suggest that reducing fear of falling is not likely to increase the risk of falls by making older people overly confident, they add.

And they conclude that measures of both actual and perceived fall risk should be included in fall risk assessments so as to tailor interventions for preventing falls in older people.

Contact:
Stephen Lord, Senior Principal Research Fellow, Falls and Balance Research Group, Prince of Wales Medical Research Institute, University of New South Wales, Australia
Email: s.lord@neura.edu.au

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