Showing papers by "Debbie A Lawlor published in 2001"

The effectiveness of exercise as an intervention in the management of depression: systematic review and meta-regression analysis of randomised controlled trials

Abstract: Objective: To determine the effectiveness of exercise as an intervention in the management of depression. Design: Systematic review and meta-regression analysis of randomised controlled trials obtained from five electronic databases (Medline, Embase, Sports Discus, PsycLIT, Cochrane Library) and through contact with experts in the field, bibliographic searches, and hand searches of recent copies of relevant journals. Main outcome measures: Standardised mean difference in effect size and weighted mean difference in Beck depression inventory score between exercise and no treatment and between exercise and cognitive therapy. Results: All of the 14 studies analysed had important methodological weaknesses; randomisation was adequately concealed in only three studies, intention to treat analysis was undertaken in only two, and assessment of outcome was blinded in only one. The participants in most studies were community volunteers, and diagnosis was determined by their score on the Beck depression inventory. When compared with no treatment, exercise reduced symptoms of depression (standardised mean difference in effect size −1.1 (95% confidence interval −1.5 to −0.6); weighted mean difference in Beck depression inventory −7.3 (−10.0 to −4.6)). The effect size was significantly greater in those trials with shorter follow up and in two trials reported only as conference abstracts. The effect of exercise was similar to that of cognitive therapy (standardised mean difference −0.3 (95% confidence interval −0.7 to 0.1)). Conclusions: The effectiveness of exercise in reducing symptoms of depression cannot be determined because of a lack of good quality research on clinical populations with adequate follow up. What is already known on this topic Depression is common Management is often inadequate and many patients do not comply with antidepressant medication The effect of exercise on depression has been a subject of interest for many years What this study adds Most studies of the effect of exercise on depression are of poor quality, have brief follow up, and are undertaken on non-clinical volunteers Exercise may be efficacious in reducing symptoms of depression in the short term but its effectiveness in clinical populations is unknown A well designed, randomised controlled trial with long term follow up is needed

Sex matters: secular and geographical trends in sex differences in coronary heart disease mortality

Abstract: Objective: To examine secular trends and geographical variations in sex differences in mortality from coronary heart disease and investigate how these relate to distributions in risk factors. Design: National and international data were used to examine secular trends and geographical variations in sex differences in mortality from coronary heart disease and risk factors. Setting: England and Wales, 1921-98; Australia, France, Japan, Sweden, and the United States, 1947-97; 50 countries, 1992-6. Data sources: Office for National Statistics, World Health Organization, and Food and Agriculture Organization of the United Nations. Results: The 20th century epidemic of coronary heart disease affected only men in most industrialised countries and had a very rapid onset in England and Wales, which has been examined in detail. If this male only epidemic had not occurred there would have been 1.2 million fewer deaths from coronary heart disease in men in England and Wales over the past 50 years. Secular trends in mean per capita fat consumption show a similar pattern to secular trends in coronary heart disease mortality in men. Fat consumption is positively correlated with coronary heart disease mortality in men (r s =0.79; 95% confidence interval 0.70 to 0.86) and inversely associated with coronary heart disease mortality in women (—0.30; —0.49 to —0.08) over this time. Although sex ratios for mortality from coronary heart disease show a clear period effect, those for lung cancer show a cohort effect. Sex ratios for stroke mortality were constant and close to unity for the entire period. Geographical variations in the sex ratio for coronary heart disease were associated with mean per capita fat consumption (0.64; 0.44 to 0.78) but were not associated with the sex ratio for smoking. Conclusion: Sex differences are largely the result of environmental factors and hence not inevitable. Understanding the factors that determine sex differences has important implications for public health, particularly for countries and parts of countries where the death rates for coronary heart disease are currently increasing. What is already known on this topic Mortality for coronary heart disease is greater in men than women in most industrialised countries The most widely accepted explanation for this difference is that women are protected by oestrogen What this study adds The sex difference in mortality from coronary heart disease varies over time and between countries in a way that cannot be explained by endogenous oestrogen These trends indicate that sex differences in mortality from coronary heart disease are driven primarily by environmental factors Sex differences in coronary heart disease are not inevitable Understanding more about the factors that cause the sex differences in mortality from coronary heart disease has important public health implications

The effect of physical activity advice given in routine primary care consultations: a systematic review

Abstract: Background Recent evidence and recommendations suggest that physical activity health promotion should be aimed at persuading the whole population to adopt an active lifestyle. Intensive medical programmes aimed at promoting physical activity amongst those at risk are not effective at achieving this aim. Brief advice from primary care professionals to quit smoking has a small but, at a population level, important effect. Brief advice in primary care to adopt a more active lifestyle may be similarly effective. The aim of this review is to determine the effect of advice given in routine primary care consultations on levels of physical activity. Methods A systematic review was carried out of trials assessing the effectiveness of advice given in routine primary care consultations. Data sources were four electronic databases (MEDLINE, EMBASE, Sport discus, Cochrane Library), and bibliographies of retrieved papers were searched. Experts were contacted. Results Eight trials, with a total of 4747 participants, were identified; the majority were from the United States. Outcome measures varied considerably between trials, including continuous measures (e.g. duration of exercise) and dichotomous measures (e.g. being active), therefore statistical pooling was inappropriate. Two of the trials were cluster randomized controlled trials, the remainder were quasi-experimental. None of the trials fulfilled all of the predetermined quality criteria and selection bias in the nonrandomized studies may have exaggerated results. Four of the six trials that presented short-term (up to 8 weeks) results found advice to be effective; only one of the four trials with long-term follow-up (4‐12 months) found a sustained effect. The two randomized controlled trials had negative short- and long-term results. Conclusions From the available evidence it appears that advice in routine primary care consultations is not an effective means of producing sustained increases in physical activity. However, these results may not be applicable to the United Kingdom, where the structure of primary care is unique. Quality research in UK primary care would be valuable.

Missed appointments in general practice: retrospective data analysis from four practices.

Abstract: Little is known about which patients miss appointments or why they do so. Using routinely collected data from four practices, we aimed to determine whether patients who missed appointments differed in terms of their age, sex, and deprivation scores from those who did not, and to examine differences between the practices with respect to missed appointments. The likelihood of someone missing at least one appointment was independently associated with being female, living in a deprived area, and being a young adult. Living in a deprived area was associated with a threefold increase in the likelihood of missing an appointment, and the extent of this association was the same across all four practices. Interventions aimed at reducing missed appointments need to be based upon these findings.

Public health and data protection: an inevitable collision or potential for a meeting of minds?

Abstract: This quote from a publication on data protection surprisingly, but not uniquely omits ‘the public’ from the public health arena. Recently it has been suggested that changes in data protection legislation may jeopardize public health practice and research. In this paper we summarize current data protection legislation and guidance and discuss the implications of these for public health practice. In addition we discuss recent changes to legislation and guidance in relation to established medical ethical principles and argue for a greater involvement of the public in the debates that will inform development of legislation in this area.

Teenage pregnancy is not a public health problem

Abstract: EDITOR—We agree with Smith and Pell's interpretation of their own and others' results that first teenage pregnancies are not associated with adverse outcomes, but we disagree with their conclusion that the associations they found between second teenage pregnancy and risk of preterm delivery and stillbirth indicate causation.1 The most likely explanation is a combination of inadequate control for socioeconomic position, which the authors concede, and differences in the interval between pregnancies among teenage compared with older mothers. Differences in pregnancy spacing cannot be …

The health consequences of fuel poverty: what should the role of primary care be?

Abstract: British Journal of General Practice, June 2001 435 The health consequences of fuel poverty: what should the role of primary care be? THE Chief Medical Officer (CMO) for England has recently asked all primary health care professionals to identify people whose health is at risk from cold and damp housing and to refer them to the new Home Energy Efficiency Scheme.1 This is part of the Government’s commitment to reducing the health effects of fuel poverty, but can the primary health care team really make a difference to this largely social problem? Fuel poverty is generally defined as the inability to afford adequate home heating, or more specifically as the need to spend 10% or more of household income on heating the home to an acceptable standard.2 Even with the most rigid government definition, 4.4 million households in England live in fuel poverty.3 A recent report using evidence from the European Household Panel Survey found that the proportion of households in the United Kingdom (UK) and Ireland that reported being unable to keep their home adequately warm was more than five times that in Germany or the Netherlands.4 Although fuel poverty is associated with low income, it arises from the combination of low household income with inadequate and expensive forms of heating and energy inefficiency in the home. The solution lies as much in capital investment to improve the quality of housing as it does in increasing income.2 This distinction from poverty in general may explain why excess winter mortality in England has not been found to be associated with standard measures of deprivation.5,6 A direct causal link between cold homes and ill health is difficult to establish, but associations between cold homes and poor mental health, respiratory disease, heart disease, and early deaths have been found.2,7,8 In addition, fuel poverty may lead indirectly to poor health through social isolation or the need to spend more income on fuel at the expense of, say, a healthy diet.2 Many of the health consequences are the direct result of cold exposure and one of the major health risks associated with cold housing, and that which most concerns the Government and CMO in the UK, is excess winter mortality.8-10 In the UK, deaths in winter are nearly 20% higher than during the rest of the year.9 The phenomenon of excess winter mortality is seen in many countries but is greater in the UK than in areas with much colder climates, such as Scandinavia, which suggests that these deaths are preventable.8-10 The contribution of cold housing to excess winter mortality has been debated for some years. A study in the 1980s found that providing unrestricted central heating to elderly residents of housing association homes had no impact on winter mortality.11 The proportion of households with central heating in England and Wales has increased substantially since the 1960s but has not been accompanied by an acceleration in the already downward trend in excess winter mortality from the 1940s.9 However, central heating may not affect winter mortality if the house remains cold because it is poorly insulated and/or the household can not afford to have the heating on. Recent international ecological data suggests that both indoor and outdoor cold exposure are important, and that excess winter mortality in the UK could be reduced by improving indoor temperatures and persuading individuals to dress adequately when outdoors in the cold.8,10 So what should the role of primary care be in combating the health consequences of fuel poverty? Some areas of the UK have already made attempts to follow the CMO’s recommendations. For example, a scheme already exists in Brighton, in the South of England, which trains primary care workers to identify vulnerable households and refer them to the appropriate agencies for help. In Bradford, in the North, there are plans to set up a similar project. There are, however, several problems with this approach. There is no good quality evaluation of its impact on health or cost-effectiveness. Such an evaluation should use techniques being developed to assess health impact in areas traditionally seen as outside the health service12 but would still face the difficulties of identifying a suitable control area, avoiding contamination, and controlling for confounding factors. Unless such a scheme is set up nationally and the evaluation is carried out at this level, many decades would need to pass before an effect on excess winter mortality could be detected in one district. As well as the problems of evaluation, primary care workers in general, and general practitioners in particular, may not be receptive to taking on this wider health role13 — fuel poverty is but one of many social issues that are seen in primary care. Others may be more obvious in the consulting room, where most contact is made, and seem more readily amenable to interventions by health professionals. Most importantly it is unlikely that such activities will have a substantial effect and they may simply serve as a smoke screen for the government. Committed political interventions, such as capital investment to systematically renew the UK’s old and poor quality housing stock, abolition of valueadded tax (VAT) on fuel, and changes to housing legislation that makes energy efficiency a priority, are likely to be the most effective means of reducing the consequences of fuel poverty.3,7 Therefore, perhaps the most important role for health professionals is to act as advocates of the fuel poor, putting pressure on the government to undertake the large scale changes to British housing needed to enable all households to be able to afford to keep warm during the winter.

Aspirin use for the prevention of cardiovascular disease: the British Women's Heart and Health Study.

Abstract: Low dose aspirin is effective, safe, and economical in the secondary prevention of cardiovascular disease. We have found that only one-third of post-menopausal women with cardiovascular disease are using aspirin and that the majority of women who are using aspirin are doing so for primary prevention. Improvements in this area of medical practice are both necessary and feasible.

Water, tobacco, and global inequalities

Abstract: These photographs are used to illustrate the public health impact of lack of water and global inequalities. Southern Africa experienced one of the worst droughts in history in the early 1990s. For Mozambique, one of the world's poorest countries and at the time devastated by the effects of a US and South African backed guerrilla war the impact was immense. The first photo shows …

The public health benefits of mobile phones

Abstract: The bread and butter of public health on call is identifying contacts in the case of suspected meningococcal disease. On the whole this is straightforward but can occasionally cause difficulties. Most areas that I have worked in include several universities, and during October it is common to experience the problem of contact tracing in the student population. There are two main problems. The first is how to define household contacts when the index patient lives in a hall of residence containing several hundred students. Finding the appropriate university protocol and not being too …