Changes primarily due to swapping in slightly lower calorie items, rather than reformulation
Likely to have “moderate to limited” impact on population health, conclude researchers

Calorie labelling, which became law in April 2022 in England, is associated with only a small (2%) average reduction in the energy content of food that is available away from home, finds research published in the open access journal BMJ Public Health.

And these changes are primarily due to swapping in slightly lower calorie items, rather than reformulating existing ones, with no changes observed in continuously available items. The impact on population health is likely to be “moderate to limited,” conclude the researchers.

Eating at restaurants, fast food outlets, and ordering takeaways, collectively known as out-of-home food outlets, is common and associated with poorer dietary quality, weight gain, and obesity, explain the researchers.

Calorie labelling aims to try and counter this and improve public health by providing consumers with calorie information at the point of sale, they add.

In England calorie labelling regulations require large (at least 250 employees) food and non-alcoholic drink outlets to display kilocalories on their offerings.

The international evidence on how these policies affect what is offered is somewhat mixed, note the researchers. To strengthen the evidence base, they compared changes in the energy content of menu items before and after the introduction of calorie labelling, stratified by food group and food business (chain) type.

They used the MenuTracker database to find out what changes had been made to the average energy content (Kcal values) of new, removed, and continuously available food items, and to assess the proportions of menu items exceeding recommended energy intake  (above 600 kcal) per meal.

MenuTracker collects the food item name and description, serving size, energy, macronutrients, fibre, salt, allergens, special dietary information and menu section (children’s or sharing items, for example).

The researchers focused on data collected in September 2021 for 79 chains (before the introduction of the regulations) and September 2022 for 90 chains (after the regulations had come into force). The final analysis included 31,045 menu items from 78 chains in both time periods.

The chains were classified as: cafes and bakeries; Western fast food and takeaways; pubs, bars, and inns; restaurants; sports and entertainment venues; and Asian fast food.

And menu items were classified as appetisers and sides; baked goods; beverages; burgers; desserts; fried potatoes; mains; pizza; salads; sandwiches; soup; and toppings and ingredients.

A significant average reduction per item was observed for non-alcoholic and soft drinks of 36 kcal, equivalent to a drop of nearly 16.5% in energy content.

And the average energy content of burgers fell by 103 kcal (11% reduction), and by 30 kcal for mains (4% reduction).

But, overall, only a small reduction of 9 kcal (2% reduction) in average energy content per item was observed after the regulations had come on stream.

Analysis of chain type revealed significant average reductions per item in pubs, bars, and inns (a reduction of 52 kcal; 9%); restaurants (a reduction of 23 kcal; 5%); and sports and entertainment venues (a reduction of 49 kcal;13.5%).

But changes were driven primarily by the removal of higher (average 458) kcal items and the addition of lower (average 434) kcal new items.

And there was no significant change in energy content for continuously available items, indicating limited evidence of reformulation, say the researchers.

Before the introduction of the regulations continuously available items had an average energy content of 437 kcal; afterwards they had an average energy content of 439 kcal.

Removed items contained an average of 21 kcal more than continuously available items and 25 kcal more than new items.

As to the recommended 600 kcal limit per meal, 22% of items remained over this limit. The food groups with the most items over 600 kcal were burgers, mains, and pizzas, and the chain types with the most items exceeding this limit were restaurants and pubs, bars and inns.

The researchers acknowledge various limitations to their findings, including that MenuTracker only includes menu information from chains that posted kcal information online before and after the policy.

The calorie labelling regulations also allow kcal information to be within plus or minus 20% and permit several different methods for estimating energy content, they add.

“We found more evidence of menu change rather than reformulation, with items removed from menus being higher energy than continuous items. Thus, the impact of a calorie labelling policy on food may differ from other policies like the Soft Drinks Industry Levy, which created an economic incentive for, and was associated with, substantial reformulation,” point out the researchers.

Reformulating drinks may be easier for manufacturers to do than reformulating foods, and previous research indicates that large outlets are reluctant to reduce portion sizes because of how customers might perceive this, they acknowledge.

But they suggest: “The small reduction in average kcal of items available on menus we found is likely to have modest to limited impact on population health.”

And for these “to lead to meaningful population health improvements, consumers would need to shift purchases towards the lower calorie items,” they add.

07/10/25

Notes for editors
Research: Changes in energy content of menu items at out-of-home food outlets in England after calorie labelling policy implementation: a pre–post analysis (2021–2022) Doi: 10.1136/bmjph-2024-001905
Journal: BMJ Public Health

External funding: NIHR Policy Research Programme

Link to Academy of Medical Sciences press release labelling system http://press.psprings.co.uk/AMSlabels.pdf

Externally peer reviewed? Yes
Evidence type: Observational
Subjects: People

The post Calorie labelling linked to 2% average reduction in energy content of menu items first appeared on BMJ Group.

Use rose by 9% in serious attempts to cut down and by 13% in any attempt to curb intake
Trends especially noticeable among over 65s, women, and relatively well off

There’s been a significant rise in the use of low and alcohol-free drinks to curb alcohol intake among ‘risky drinkers’ over the past 5 years in England, Wales, and Scotland, finds research published in the open access journal BMJ Public Health.

The proportion of those using them to make serious attempts to cut down their alcohol intake rose from 35% in 2020 to 44% in 2024, while those using them in any attempt to cut down increased from 26% to 39%.

The trends were especially noticeable among the over 65s, while women and the relatively well off were more likely to consume these drinks than men and the most economically disadvantaged, the findings indicate.

The sales and availability of low and alcohol-free drinks have risen sharply in the UK since 2020, and the UK government promotes the substitution of standard alcoholic drinks with these alternatives as a harm reduction tool, explain the researchers.

But it’s not clear to what extent the increasing supply of low and alcohol-free drinks has contributed to reduction attempts, particularly among those who drink more heavily.

In a bid to find out, the researchers drew on data collected in Great Britain between October 2020 and August 2024 as part of the Smoking and Alcohol Toolkit Study, which collects monthly data on adults’ sociodemographic, smoking, and drinking characteristics.

The sample was limited to those drinking at increasing and higher-risk levels, defined as an Alcohol Use Disorders Identification Test -Consumption (AUDIT-C) score of 5 or more, and who had tried to cut down their alcohol consumption in the previous year.

They were asked if they had used low/alcohol-free drinks and which, of a variety of evidence-based support options, they had used in their attempts to curb their alcohol intake.

The final analysis included 9397 people, whose average age was 46. It showed that the proportion of those reporting the use of low and alcohol-free drinks to reduce their alcohol consumption increased significantly between 2020 and 2024..

The proportion of those using these alternatives to make serious attempts to curb their drinking rose by 9%, from 35% to 44%, and by 14%, from 26% to 39%, among those making any attempt to cut down.

Noticeably, the proportion of older adults (65+) using low and alcohol-free drinks was lower than young and middle-aged adults to start with, but rose more steeply over time.

But the proportion of those using neither these alternatives nor evidence-based approaches, such as behavioural support or drug treatment, fell. And the proportion using evidence-based options either alone or in combination with low or alcohol-free drinks remained low at around 10%, the responses showed.

This is an observational study, which only assessed trends in self-reported use of low and alcohol-free drinks for alcohol reduction attempts and, therefore, can’t make any assumptions about the effectiveness of these drinks in actually reducing alcohol consumption, emphasise the researchers.

Some respondents may also have understood the term ‘alcohol-free’ to mean soft drinks such as kombucha or flavoured sodas, they add.

“The rise in the prevalence of alcohol-free/low alcohol use in cut-down attempts in Great Britain may be driven by greater availability of alcohol-free/low alcohol drinks in pubs or increased marketing, such as the partnership between the charity organising the Dry January campaign and alcohol-free drink producers, which started in 2022,” suggest the researchers.

“It is also possible that the observed changes are consumer-driven, i.e. that people’s interest in alternatives to standard strength alcoholic drinks is growing, and the market is responding to this demand,” they add.

“In any case, it is vital for future research to establish whether alcohol-free/low alcohol drinks are an effective tool to reduce alcohol consumption…or whether people consume [these] drinks in addition to standard alcoholic drinks, therefore resulting in no change of alcohol consumption,” they point out.

And they highlight: “The socioeconomic divide is potentially concerning because alcohol-related harm is disproportionately experienced by people who are less advantaged. If alcohol-free/low alcohol drinks are shown to be effective for harm reduction, it will be vital to develop interventions targeted at people with less advantaged socioeconomic positions to reduce health inequalities.”

23/09/2025

Notes for editors
Research: Trends in use of alcohol-free or low alcohol drinks in attempts to reduce alcohol consumption in Great Britain, 2020-2024: a population-based study Doi: 10.1136/bmjph-2025-002775
Journal: BMJ Public Health

External funding: Cancer Research UK; UK Prevention Research Partnership

Link to Academy of Medical Sciences press release labelling system
http://press.psprings.co.uk/AMSlabels.pdf

Externally peer reviewed?Yes
Evidence type: Observational
Subjects: People

The post Significant rise in use of low/alcohol-free drinks among ‘risky’ UK drinkers in past 5 years first appeared on BMJ Group.

Risks especially high within 3 months of infection but last for several years
Men seem to be at greater risk than women, findings indicate

A bout of the common bladder infection, cystitis, may signal the presence of urogenital cancers—which affect parts of the body involved in reproduction and excretion—in middle aged adults, suggests research published in the open access journal BMJ Public Health.

The risks seem to be especially high within 3 months of infection, suggesting that acute cystitis might be a useful clinical marker for urogenital cancer, say the researchers. Men seem to be at greater risk than women, the findings indicate.

The lifetime prevalence of a urinary tract infection (UTI) is 50–60% in women and 13–14% in men. With the exception of a spike in young women, incidence rates of UTIs increase with age in both men and women, note the researchers.

Previously published research has shown that a bout of cystitis might be linked to an increased risk of urogenital cancers, but only a few such studies have been published and they didn’t include data from primary care facilities, which is where most cases of acute cystitis are diagnosed, they explain.

To try and plug this knowledge gap, the researchers mined several comprehensive national population and health registers and primary healthcare data sources, containing individual-level information on all people living in Sweden from 1997 to the end of 2018.

Data were available for 1,668,371 (47%) men and 1,889,211 (53%) women during this period, of whom 605,557 (17%) people were diagnosed with acute cystitis for the first time.

Most of these diagnoses (91%) were made in primary care facilities and most cases were in women (71%; 427,821).

During an average monitoring period of 15 years, a total of 257,026 (just over 7%) people were diagnosed with urogenital cancer, most of whom were men (77.5%; 199,144).

The average age at cancer diagnosis was 73, with prostate cancer the most common cancer type (62%), followed by bladder cancer (16.5%), and endometrial (lining of the womb) cancer (10%).

Cystitis preceded a cancer diagnosis in 24,137 people—-almost 9.5% of all those diagnosed with cancer during the study period. Their average age at diagnosis was 76: prostate cancer was the most common diagnosis (39.5%), followed by bladder (32%), and endometrial (14%) cancer.

The risks of  a urogenital cancer diagnosis were heightened across all age groups among those who had had a bout of cystitis, and peaked within 3 months of infection, especially for prostate and bladder cancers, but persisted over several years for most cancers.

For prostate cancer, the risk, measured as a standardised incidence ratio (SIR) within 3 months of infection was 7 times higher in those who had had the infection than it was in those who hadn’t.

This corresponds to an excess cancer rate of nearly 551 per 10, 000 person-years—-a unit of measurement that combines the number of people and the time during which they were observed. For example, 10,000 patients monitored for 1 year or 1000 patients monitored for 10 years.

Similarly, the risk of bladder cancer was 3.5 times higher in men and more than 3 times higher in women who had had cystitis than it was in those who didn’t have the infection during the monitoring period. This corresponds to an excess rate of around 40 and nearly 8 more cancer cases, respectively, than would be expected per /10,000 person-years.

For gynaecological cancers, the SIRs within 3 months of infection were between 4 and 8 times higher among women who had had cystitis.

Overall,  the risk of urogenital cancer was nearly 34 times higher in men and 30 times higher in women, within 3 months of infection, corresponding to nearly 484 and 96 excess cancer rates/10,000 person-years, respectively.

While the risks fell as time went on, they persisted throughout all the follow-up periods for both sexes. For example, 3–12 months after infection, the excess cancer rates/10,000 person-years were more than 79 in men and more than 19 in women. And after 5 years, these were around 9 in men and 2.5 in women.

In general, men who had had cystitis seemed to be at higher risk of urogenital cancer than women: for example, their risk of bladder cancer was twice as high for those in their 50s, 57% higher for those in their 60s, and 23% higher for those in their 70s.

This is an observational study, and as such, no firm conclusions can be drawn about cause and effect. And the researchers acknowledge that they lacked microbiological confirmation of cystitis infection or information on potentially influential factors, such smoking and underlying conditions, including obesity and undiagnosed diabetes.

But they say: “The present study adds to the accumulating evidence of infections as markers of increased cancer risk. For clinicians, the findings indicate that acute cystitis could be a clinical marker for urogenital cancer (at least when no other cause is obvious), and particularly for occult urogenital cancer, as the risks for cancers were highest within 3 months of cystitis diagnosis.”

They add: “It is plausible that urogenital cancer, and perhaps even pre-cancerous changes in the urogenital organs, might increase the risk of cystitis because of compromised urinary tract and host defence.”

16/09/2025

Notes for editors
Research: Acute cystitis and subsequent risk of urogenital cancer: a national cohort study from Sweden  Doi: 10.1136/bmjph-2024-002495
Journal: BMJ Public Health

External funding:  Swedish Research Council; Swedish governmental funding of clinical research; Swedish Society of Medicine;Tore Nilsons Stiftelse För Medicinsk Forskning; The Royal Physiographic Society of Lund; Crafoord Foundation

Link to Academy of Medical Sciences press release labelling system
http://press.psprings.co.uk/AMSlabels.pdf

Externally peer reviewed? Yes
Evidence type: Observational cohort study
Subjects: People

The post Bout of cystitis may signal presence of urogenital cancers in middle-aged adults first appeared on BMJ Group.

Affluent twice as likely to shop online for groceries as less well off
But households of lower social grade twice as likely to opt for take-away meals
And users of online food delivery apps more likely to be living with obesity

Social position—defined by household income and job role—is linked to food delivery preferences in England, suggests an analysis of consumer research published in the open access journal BMJ Public Health.

Affluent households are twice as likely as less well off ones to shop online for groceries while households in lower social grades are up to twice as likely to use food delivery apps for take-away meals. And users of these apps are more likely to be living with obesity, the findings indicate.

Digital on-demand technology has rapidly and dramatically reshaped food distribution and delivery, making grocery and prepared take-away meals more accessible and convenient, and increasing the range of options available, note the researchers.

But previous research suggests that while buying groceries online is associated with healthier food choices, use of online take-away food delivery apps is rather less so. This prompted the researchers to explore the impact of the ongoing changes to food retail.

In particular, they wanted to look at the extent to which the use of online food delivery services might be informed by indicators of social position—income and job role–and whether use of these services is associated with healthy or unhealthy weight.

They accessed data from a large consumer panel previously used in the Transport for London Study, which evaluated the impact of the removal of high fat, salt, and sugar foods advertising on the Transport for London network.

This entailed analysing food and drink purchase records and a survey of a representative sample of 1521 households in London and the north of England on the method of their daily food and drink purchases and their self-reported use of food delivery apps for prepared take-away meals in February 2019.

Social position was characterised as both household income and the social grade of the household main food shopper’s job role, and classified as: high; middle-high; middle-low; and low.

 Self-reported annual household income was measured in 3 bands of: £0–19,999; £20,000–49,999, and £50,000 or more.

Data on weight (BMI) were available for 1245 (82%) households, and classified as combined underweight and healthy weight below 25; overweight 25-29.9; and obese 30 and above.

Analysis of the purchase records showed that in February 2019, nearly 16% of households bought groceries online at least once; while survey responses revealed that 13% had used take-away food delivery apps in the past 7 days; and 3.5% said they had used both services.

After accounting for potentially influential household factors, such as age and composition of the residents, households with the highest incomes were twice as likely to buy groceries online as those with the lowest income. But there was no association with social grade.

And while the use of food delivery apps wasn’t associated with income, it was associated with social grade after accounting for potentially influential factors such as age, sex, and educational attainment.

Those in the lowest social grade had more than double the odds of using these apps as those in the highest; those in the middle-low social grade had 69% greater odds of doing so.

There were no associations between weight and online grocery shopping, but those who used food delivery apps were  84% more likely to be living with obesity and 45% more likely to be overweight as those who didn’t use them. Similar results were obtained after adjusting for social grade and household income.

This is an observational study, and as such, no firm conclusions about cause and effect can be drawn. And the researchers acknowledge that the survey responses reflect one point in time and rely on recall.

The analyses were also limited by the uneven distribution of households across social grade and income groups. And the sample of predominantly urban households in London and the north of England may not be fully representative of the country as a whole, they suggest.

But they say: “Our findings suggest that there are differences in use, both within and between the online grocery and online takeaway food sector.”

Although they didn’t scrutinise the content of the food and meals ordered online or by app,  previously published research indicates that food delivery app use is associated with lower dietary quality and that online grocery shopping tends to be of higher dietary quality than in-store purchasing, point out the researchers.

“In the grocery sector, it has been hypothesised that a shift to online grocery shopping will occur more rapidly among affluent households, and it is possible that we observed evidence for this,” they write.

“Potentially, grocery purchasing may predominantly depend on financial resources, while take-away purchasing may be linked to culture and social group,” they suggest.

Digital food delivery apps may also make it easier to make unhealthy food choices, they say, adding: “The differential use of online food delivery services may exacerbate dietary inequalities and warrants further research.”

21/08/2024

Research: Social inequalities in the use of online food delivery services and associations with weight status: cross-sectional analysis of survey and consumer data
Journal: BMJ Public Health

External funding: National Institute for Health Research School for Public Health Research

Externally peer reviewed? Yes
Evidence type: Observational; data analysis
Subjects: People

The post Social position linked to food delivery preferences in England first appeared on BMJ Group.

Strongest benefits seen for cyclists, with 47% lower risk of death from any cause

Commuters who cycle or walk to and from work or study may have lower risks of mental and physical ill health than those who don’t rely on these options, finds a large long term study published in the open access journal BMJ Public Health.

While health benefits were observed for both types of active commuting, the strongest health benefits were seen for cyclists among whom the risk of death from any cause was 47% lower, the findings show.

Active travel is considered to be one of the most practical and sustainable ways to increase daily physical activity, and there is mounting evidence in favour of its associated health benefits, note the researchers.

But the existing body of evidence has been hampered by short monitoring periods, narrow age groups, and limited health outcomes, they add.

In a bid to redress these shortcomings, the researchers drew on nationally representative data from the Scottish Longitudinal Study (SLS), which is based on 5% of the Scottish population derived from Census returns in 1991, 2001, and 2011.

The researchers focused on 16–74 year olds in 2001 who travelled to  work or study in the UK. After exclusions for incomplete data, the final analysis was based on 82,297 people.

Census respondents were asked to select which mode of travel they used for the longest part, by distance, of their usual commute. Active travel was defined as either walking or cycling. All other commuting methods were defined as ‘inactive’.

The responses were linked to national hospital admissions for all causes, cardiovascular disease, cancer, and road traffic collisions; deaths from all of these; and prescriptions for mental health issues (sedatives, anti-anxiety drugs, and antidepressants) from 2001 to 2018 inclusive.

Various potentially influential factors were taken into consideration. These included age, sex, pre-existing health conditions, as well as socioeconomic factors and distance to work/study.

Between 2001 and 2018, 4276 participants died (just over 5% of the study group), almost half of whom died of cancer (2023; 2.5%). Some 52,804 (just over 64%) were admitted to hospital, 9663 (12%) of them for cardiovascular disease, 5939 (just over 7%) for cancer, and 2668 (just over 3%) after a road traffic collision.

In all, 31,666 study participants (38.5%) were prescribed a drug associated with cardiovascular disease between 2009 and 2018, and 33,771 (41%) were prescribed a drug for poor mental health over the same period.

Compared with inactive commuters, those who walked to work/study were more likely to be female, younger, work shifts, commute shorter distances, and live in a city. They were also less likely to have dependent children and tended to have lower household income and educational attainment.

Similarly, cyclist commuters were more likely to be male, younger, shift workers and live in a city, and they were less likely to be homeowners or carers.

After accounting for potentially influential factors, active commuting was associated with lower risks of death and mental and physical ill health compared with ‘inactive’ commuting.

Specifically, commuting by bike was associated with a 47% lower risk of death, a 10% lower risk of any hospital admission, and a 24% lower risk of hospital admission for cardiovascular disease.

It was also associated with a 30% lower risk of being prescribed a drug to treat cardiovascular disease, a 51% lower risk of dying from cancer, and a 24% lower risk of being admitted to hospital for the disease, as well as a 20% lower risk of being prescribed drugs for mental health problems.

But cyclist commuters were twice as likely as ‘inactive’ commuters to be admitted to hospital after a road traffic collision.

Pedestrian commuting was associated with an 11% lower risk of hospital admission for any cause and a 10% lower risk of a hospital admission for cardiovascular disease.  It was also associated with, respectively, 10% and 7% lower risks of being prescribed drugs to treat cardiovascular disease and mental health issues.

This is an observational study, and as such, no firm conclusions can be drawn about causal factors. And the researchers acknowledge various limitations to their research. For example, the census responses reflect just one point in time and didn’t include general physical activity levels. And prescription data were only available from 2009 onwards.

The census data didn’t capture multimodal trips either, resulting in potential overlap between active and ‘inactive’ commuters, they point out.

But they nevertheless conclude: “This study strengthens the evidence that active commuting has population-level health benefits and can contribute to reduced morbidity and mortality. That cyclist and pedestrian commuting is associated with lower risks of being prescribed medication for poor mental health is an important finding.

“These findings provide direct evidence of the health benefits of active commuting in a Scottish context, supporting current policy. This study has wider global relevance to efforts to reduce carbon emissions and to shift to more active and sustainable travel modes.”

But they caution: “Our finding that cyclist commuters have twice the risk of being a road traffic casualty compared with non-active commuters reinforces the need for safer cycling infrastructure.”

17/07/2024

Notes for editors
Research: Health benefits of pedestrian and cyclist commuting: evidence from the Scottish Longitudinal Study Doi: 10.1136/bmjph-2024-001295
Journal: BMJ Public Health

External funding: None declared

Link to Academy of Medical Sciences press release labelling system
http://press.psprings.co.uk/AMSlabels.pdf

Externally peer reviewed? Yes
Evidence type: Observational
Subjects: People

The post Active commuting linked to lower risks of mental and physical ill health first appeared on BMJ Group.

Following concerns raised with BMJ we are investigating the quality of the research and the messaging used in Excess mortality across countries in the Western World since the COVID-19 pandemic: ‘Our World in Data’ estimates of January 2020 to December 2022”, published in BMJ Public Health on 3 June 2024. An expression of concern will be placed on the paper.

The messaging gave rise to widespread misreporting and misunderstanding of the work amid claims that it implies a direct causal link between COVID-19 vaccination and mortality. In fact, the researchers looked only at trends in excess mortality over time, not its causes. This was outlined in a statement issued last week by BMJ.

BMJ’s research integrity team is in contact with The Princess Máxima Center. The Center is listed as the affiliation of three of the four authors, and has already announced that it is investigating the scientific quality of this study.

As part of the investigation the authors will be asked to review and respond to the concerns raised to BMJ about the quality and messaging of the paper. BMJ will then decide what further action is needed.

[Ends]

13/06/2024

The post Expression of concern placed on research paper published in BMJ Public Health first appeared on BMJ Group.

Despite containment and COVID-19 jabs; “serious cause for concern,” say researchers

Excess death rates have remained high in the West for three years running since the start of the COVID-19 pandemic, finds a data analysis of 47 countries published in the open access journal BMJ Public Health.

This is despite the implementation of various containment measures and the availability of  COVID-19 vaccines, giving rise to “serious cause for concern,” say the researchers who call on governments and policymakers to thoroughly investigate the underlying causes.

The researchers wanted to gauge the effectiveness of the response to the health crisis posed by the COVID-19 pandemic, as reflected in excess deaths.

These refer to the numbers of people who died from any cause above and beyond what would normally be expected for any given week/month between January 2020 and December 2022 in 47 countries in Europe, North America, Australia and New Zealand.

The researchers applied a statistical method called Karlinsky and Kobak’s estimate model. This uses historical death data in a particular country from 2015 until 2019 and accounts for seasonal variation and annual trends in deaths due to changes in population structure. 

The total number of excess deaths in the countries included in the analysis was 3,098,456. Excess deaths were reported by 41 countries (87%) in 2020, by 42 (89%) in 2021, and by 43 (91%) in 2022.

In 2020, the year in which the COVID-19 pandemic started and containment measures, such as lock-downs, social distancing, school closures and quarantines, were implemented, 1,033,122 excess deaths (11.5% higher than expected) were recorded. 

In 2021, the year in which both COVID-19 containment measures and COVID-19 vaccines were used to curb SARS-CoV-2 virus spread and infection, a total of 1,256,942 excess deaths (just under 14% higher than expected) were reported.

And in 2022, the year in which most containment measures were lifted, but COVID-19 vaccines were continued, preliminary data indicate that 808,392 excess deaths were recorded.

Greenland was the only country out of the 47 reporting no excess deaths between 2020 and 2022. Among the others, the percentage difference between the reported and projected number of deaths was highest in 13 countries (28%) during 2020, in 21 (46%) during 2021, and in 12 (26%) during 2022. 

The percentage difference between the documented and projected number of deaths was highest in 28% of countries during 2020, in 46% during 2021, and in 26% during 2022.

It’s not clear how many of these excess deaths reflect the impact of COVID-19 infection, or the indirect effects of containment measures and vaccination programmes, say the researchers.

While it’s likely that the indirect effects of containment measures did change the scale and nature of disease for numerous causes of death following the pandemic, those caused by restricted healthcare use and socioeconomic upheaval are difficult to prove, they add.

The researchers acknowledge various limitations to their findings, including the incompleteness of some data, particularly for 2022, because it can take months or even years before a death is registered in certain countries, they explain.

And the way in which these data are compiled differs among nations, highlight the researchers, who also point out that the data they used provided no detailed stratification of key characteristics, such as age or sex.

Nevertheless, they conclude: “Excess mortality has remained high in the Western World for three consecutive years, despite the implementation of COVID-19 containment measures and COVID-19 vaccines. This is unprecedented and raises serious concerns.

“Government leaders and policy makers need to thoroughly investigate underlying causes of persistent excess mortality and evaluate their health crisis policies.”

04/06/2024 

Notes for editors
Research: Excess mortality across countries in the Western World since the COVID-19 pandemic: ‘Our World in Data’ estimates of January 2020 to December 2022 Doi: 10.1136/bmjph-2023-000282
Journal: BMJ Public Health

External funding: World Child Cancer Foundation Netherlands

Link to Academy of Medical Sciences press release labelling system
http://press.psprings.co.uk/AMSlabels.pdf

Externally peer reviewed? Yes
Evidence type: Observational; data analysis
Subjects: People

The post High excess death rates in the West for 3 years running since start of pandemic first appeared on BMJ Group.

Making much more of potential savings might encourage more people to stub out for good 

Health concerns are still the primary motive for more than half of those who say they want to stop smoking in England, but cost is now a key factor for more than 1 in 4, finds an analysis of national survey responses, published in the open access journal BMJ Public Health.

Given this shift in thinking, making much more of the potential savings to be had might encourage more people to stub out for good, suggest the researchers.

Health concerns are generally the primary motive for people trying to stop smoking, with social and financial concerns, plus advice from a health professional, also commonly cited reasons, explain the researchers.

But since 2020, England has undergone a period of substantial societal instability, prompted primarily by the COVID-19 pandemic, which might have triggered changes in the reasons smokers give for wanting to ditch tobacco, they suggest.

To find out, the researchers looked at time trends in motives for trying to stop smoking between March 2018 and May 2023, exploring differences by age, sex, socioeconomic status, presence of children in the household and vaping status.

They drew on responses to the ongoing Smoking Toolkit Study, a monthly survey of a representative sample of around 1700 adults in England.

The responses were limited to those who were either current smokers or who had stopped smoking in the past year and had made at least one serious attempt to quit during that time.

Respondents were asked to name the reason(s) behind their most recent quit attempt from among: advice from a health professional; TV advert for a nicotine replacement product; government TV/radio/press advert; a new stop smoking treatment; cost; smoking restrictions; knowing someone else who was quitting; health warning on a cigarette packet; contact from a local NHS stop smoking service; current or future health problems; attending a local stop smoking activity or event; comments by family, friends, children; significant birthday; pregnancy; simple decision to quit; COVID-19 pandemic.

Out of the 101,919 survey respondents between 2018 and 2023, 17,812 reported smoking in the past year. Of these,17,031 (96%) provided data on quit attempts over the past 12 months, 5777 (34%) of whom reported having made at least one serious attempt to do so.

Health concerns were the most frequently cited motives, reported by more than half the sample (52%) across the entire period—especially concerns about future health, reported by more than 1 in 3 (35.5%) compared with 1 in 5 (19%) who were motivated by current health problems.

Cost was the next most frequently cited motive, reported by nearly 1 in 4 (23%), followed by social factors, reported by around 1 in 5 (19%) and advice from a health professional (12%). 

Around 4% said they were motivated by health warnings on a cigarette packet, while smoking restrictions prompted 3.5% to try and stop; a simple decision to quit was cited by just over 3%. The other reasons attracted only around 1% each.

Up to the start of 2020, 1 in 2 quit attempts was motivated by health concerns; 1 in 5 by current health problems (20%), and 1 in 3 by concerns about future health (34%). One in 5 was motivated by social factors (20%) and cost (20%), and 1 in 6 by health professional advice (16.5%).

While there was little overall change in the proportion of quit attempts motivated by health concerns across the entire study period, the proportion of quit attempts motivated by cost increased significantly, rising from just over 19% in March 2018 to just under 25.5% in May 2023.

But the proportion of quit attempts motivated by health professional advice fell significantly over the entire study period, dropping from just over 14% in March 2018 to 8.5% in May 2023.

The COVID-19 pandemic, which began to affect England in March 2020, is likely to have influenced the proportion of respondents reporting health concerns, social factors, and cost as motives for trying to stop smoking, suggest the researchers. 

The proportion of quit attempts motivated by future health concerns increased during 2020 and 2021.“It is likely the pandemic made health concerns (an already prevalent motive) even more salient, particularly during its first year when the virus was spreading rapidly and vaccinations were not yet available,” they write. 

Once the immediate threat of the virus had subsided thanks to the vaccination programme, the proportion of health-related attempts to quit returned to pre-pandemic levels.

The pandemic probably influenced other motives, suggest the researchers, because it prompted loss of income and jobs for many people.

“These economic pressures probably contributed to the rise in cost-motivated attempts to quit around this time. But while the pandemic’s acute risks to health—and, as a result, attempts to quit motivated by concern for health or social factors—waned over time, its economic impacts have been compounded by a cost-of- living crisis,” they explain.

The pandemic’s impact on access to, and availability of, healthcare services may also have contributed to the decline in the proportion of respondents citing healthcare professional advice as a motivating factor, they add.

The researchers acknowledge various caveats to their findings, including that all the study data were self-reported and relied on personal recall, and may not apply to other countries with different attitudes to smoking, tobacco control policies, and provision of smoking cessation services.

But they conclude: “These findings have implications for smoking cessation interventions and clinical practice. ..They indicate that cost is an increasingly important factor motivating people to try to stop smoking. 

“Communicating the potential savings people can make by stopping smoking (even if they switch to alternative nicotine products) could therefore be an effective means for motivating attempts to quit.” 

23/04/2024

Notes for editors
Research: Trends in motives for trying to stop smoking: a population study in England, 2018–2023 Doi: 10.1136/bmjph-2023-000420
Journal: BMJ Public Health

External funding: Cancer Research UK

Link to Academy of Medical Sciences press release labelling system
http://press.psprings.co.uk/AMSlabels.pdf

Externally peer reviewed? Yes
Evidence type: Observational; survey results
Subjects: People

The post Cost increasingly important motive for quitting smoking for 1 in 4 adults in England first appeared on BMJ Group.

People with condition 30% more likely not to fully recover from COVID-19 infection

People who are ‘double jointed,’ a condition formally known as generalised joint hypermobility, may be at heightened risk of long COVID, suggests a case-control study published in the open access journal BMJ Public Health.

They were 30% more likely not to have fully recovered from COVID-19 infection than those without hypermobile joints, and to be experiencing the persistent fatigue associated with long COVID, the findings indicate.

Other than older age, the likelihood of developing long COVID seems to be greater when associated with certain underlying health conditions, including fibromyalgia, irritable bowel syndrome, migraine, allergies, anxiety, depression and back pain, explain the researchers.

These risk factors have all been independently associated with joint hypermobility, whereby some or all of a person’s joints have an unusually large range of movement.

The researchers therefore wanted to find out if double jointedness might be a risk factor for long COVID in its own right, and drew on 3064 participants in the COVID Symptom Study Biobank, all of whom had had COVID-19 infection at least once.

These participants were surveyed in August 2022 to find out if they had hypermobile joints, if they had fully recovered from their last bout of COVID-19 infection, and if they were experiencing persistent fatigue.

Most (81.5%) said they had had COVID-19 at least once. Of these, information on self-reported recovery was available for 2854, of whom 2331 (82%) were women and 2767 (97.5%) were White. Their average age was 57 (range 21–89).

Around 1 in 3 (914; 32%) said they had not fully recovered from their last bout of COVID-19 infection, and of these, 269 (just under 30%) had generalised joint hypermobility.

Among the 1940 people who said they had fully recovered, almost 1 in 4 (439; just under 23%) had hypermobile joints; 400 of them were women.

After accounting for potentially influential factors, including age, sex, ethnicity, deprivation level, educational attainment, and number of vaccinations received, joint hypermobility was strongly associated with a failure to recover fully from COVID-19 infection.

People who were double jointed were around 30% more likely to say they hadn’t fully recovered from COVID-19 infection than those with normal joints. And joint hypermobility significantly predicted high levels of fatigue, which emerged as an instrumental factor in the failure to make a full recovery.

This is an observational study, and as such, no firm conclusions can be drawn about whether joint hypermobility is a causal factor for long COVID. The researchers also acknowledge various limitations to their findings—including that most of the study participants were women and of White ethnicity.

Nor did their analysis include or correct for other potentially influential factors, such as duration of symptoms and coronavirus variant, or pre-existing conditions, such as fibromyalgia, which is itself characterised by fatigue and brain fog.

As has been suggested before, long COVID is unlikely to be a single entity, but a medley of intersecting immunological, inflammatory, autonomic nervous system, respiratory and cardiovascular processes that lead to distinct symptom profiles affecting body and brain, say the researchers.

And there are probably several causes, and therefore no one treatment strategy, for long COVID, they point out, adding: “However, these results suggest further exploration of whether [joint hypermobility] is linked to a particular phenotype or subtype of those not recovering fully from COVID-19, including long COVID.”

20/03/2024

Notes for editors

Research: Is joint hypermobility linked to self-reported non-recovery from COVID-19?Case–control evidence from the British COVID Symptom Study Biobank doi: 10.1136/bmjph-2023-000478

Journal: BMJ Public Health

External funding: None declared

Link to Academy of Medical Sciences Press releases labelling system

http://press.psprings.co.uk/AMSlabels.pdf

Externally peer reviewed? Yes

Subjects: People

The post People who are ‘double jointed’ may be at heightened risk of long covid first appeared on BMJ Group.

Studies suggest game sound levels often near, or exceed, permissible safe limits
Greater public health efforts needed to raise awareness of potential risks, urge researchers

Video gamers worldwide may be risking irreversible hearing loss and/or tinnitus—persistent ringing/buzzing in the ears—finds a systematic review of the available evidence, published in the open access journal BMJ Public Health.

What evidence there is suggests that the sound levels reported in studies of more than 50,000 people often near, or exceed, permissible safe limits, conclude the researchers. 

And given the popularity of these games, greater public health efforts are needed to raise awareness of the potential risks, they urge.

While headphones, earbuds, and music venues have been recognised as sources of potentially unsafe sound levels, relatively little attention has been paid to the effects of video games, including e-sports, on hearing loss, say the researchers.

Gamers often play at high-intensity sound levels and for several hours at a time, they add. And one estimate indicates that there were more than 3 billion gamers worldwide in 2022. 

To try and build an evidence base, the researchers trawled research databases looking for relevant studies and white papers, newsletters, reports, and proceedings, collectively referred to as ‘grey literature,’ published at any point in English, Spanish, or Chinese.

Some 14 peer reviewed studies from 9 countries in North America, Europe, South East Asia, Asia and Australasia, and involving a total of 53,833 people, were included in the review.

Eleven were cohort (epidemiological observational) studies, 6 of which looked at the associations between hearing and computer or video games; 4 focused on gaming centres or personal computer rooms, which are popular in Asia; and 1 focused on mobile devices.

Reported sound levels ranged from 43.2 decibels (dB) (mobile devices) up to 80-89 dB (gaming centres) while length of noise exposure varied by mode and frequency of access–from daily to once a month, for at least an hour at a time, averaging 3 hours/week.

Impulse sounds consist of bursts lasting less than 1 second, with peak levels at least 15 dB higher than the background sound. One study reported that impulse sounds reached levels as high as 119 dB during game play; permissible exposure limits are around 100 dB for children and 130–140 dB for adults.

The International Telecommunication Union (ITU), in collaboration with the World Health Organization, describes a time–intensity trade-off, known as an exchange rate, for permissible levels and duration of exposure, explain the researchers. 

For example, a permissible noise exposure level of 80 dB for 40 hours a week with a 3 dB exchange rate means the permissible exposure time halves with every 3 dB increase in noise level: at 83 dB it’s 20 hours; at 86 dB it’s 10 hours; at 92 dB it’s 2.5 hours; and at 98 dB it’s 38 minutes.

For children, the permissible noise exposure level is defined as 75 dB for 40 hours a week. Children can therefore safely listen to an 83 dB sound for around 6.5 hours, 86 dB for around 3.25 hours, 92 dB for 45 minutes, and 98 dB for only 12 minutes a week, explain the researchers.

Six studies reported on video gaming prevalence among young people, which ranged from 20% to 68%. Two South Korean studies reported a prevalence of gaming centre use at around 60%.

Five studies evaluated associations between gaming and self-reported hearing loss, hearing thresholds, or tinnitus. Of these, 2 found that  school pupils’ gaming centre use was linked to increased odds of severe tinnitus and high-frequency sound hearing loss in both ears.

Another large observational study reported that video gaming was associated with increased odds of self-reported hearing loss severity.

One study reported that over 10 million people in the USA may be exposed to ‘loud’ or ‘very loud’ sound levels from video or computer games. 

One study measured sound levels of 5 video games through headphones attached to the gaming console, and found that these averaged 88.5, 87.6, 85.6 and 91.2 dB for 4 separate shooter games, and 85.6 dB for a racing game.

The authors therefore concluded that the daily level of sound exposure from these video games is close to maximum permissible levels of sound exposure.

An additional 16 peer-reviewed articles and 14 grey literature sources mention gaming as a potential source of excessive sound exposure.

One grey literature source sought to discover gamers’ preferred listening levels while wearing headphones.  The author concluded that gaming headphones can reach unsafe listening levels, “which could place some gamers at risk of sound-induced hearing loss.”

Three studies evaluated gender differences in gaming behaviours. Altogether, these indicated that boys played video games more often than girls, for longer periods of time, and at higher sound intensity levels.

The researchers acknowledge that some of the included studies date back to the early 1990s, and only 2 published in the past 10 years objectively measured average sound levels from video games or at gaming centres, although both reported high sound levels in these circumstances.

“Although the data provided in this review are limited, they suggest that some gamers, particularly those who play frequently, and at or above the average sound levels described by papers included in this review, probably exceed permissible sound exposure limits, and are thus engaging in unsafe listening practices, which could put them at risk for developing permanent hearing loss and/or tinnitus,” they nevertheless conclude.

There are also several key gaps in the available evidence, they add. For example, the impact of esports, geographic region, sex, and age, on hearing loss. Further research is essential to inform preventive measures and global policy initiatives, they suggest.

“The findings suggest that there may be a need to prioritise interventions, such as initiatives focused on education and awareness of the potential risks of gaming, that can help promote safe listening among gamers,” they suggest.

17/01/2024 

Notes for editors
The World Health Organization ‘Make listening safe’ initiative aims to ensure everyone can protect their hearing while listening. More information can be found here:
https://www.who.int/activities/making-listening-safe

Research: Risk of sound-induced hearing loss from exposure to video gaming or e-sports: a systematic scoping review  doi 10.1136/bmjph-2023-000253
Journal: BMJ Public Health

Funding: None declared

Link to Academy of Medical Sciences press release labelling system
http://press.psprings.co.uk/AMSlabels.pdf

Externally peer-reviewed? Yes
Evidence type: Systematic scoping review
Subjects: People

The post Video gamers worldwide may be risking irreversible hearing loss and/or tinnitus first appeared on BMJ Group.