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The BMJ Editor's Choice

  • Red meat: another inconvenient truth

    时间:2017-05-11

    发布:Fiona Godlee, editor in chief,The BMJ

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    Evidence continues to emerge linking high meat consumption with increased mortality. This week Arash Etemadi and colleagues provide further support for the association (doi:10.1136/bmj.j1957). Their population based cohort study links high intake of red and processed meat with increased deaths from all causes and from nine specific ones.

    Dietary epidemiology studies are of course fraught with pitfalls. At their worst they attract ridicule for supporting every conceivable association, fuelling public confusion and fake news. This week’s study is large, with more than 7.5 million American person years of observation, and it’s well done. Although its main findings are based on a single dietary assessment, a subgroup had two assessments done on separate occasions, and these associations were if anything stronger. Importantly, death rates were lower in groups who ate a higher proportion of fish and poultry than red meat.

    In the accompanying commentary John Potter provides no comfort for anyone wanting to deny an inconvenient truth (doi:10.1136/bmj.j2190). “Overconsumption of meat is bad for health and for the health of our planet,” he says. It seems our ancestors ate meat at most once a week, consuming 5-10 kg a year. Modern diets in rich countries deliver more than 10 times this amount, with animal protein now providing up to a fifth of our energy requirements. The study suggests that haem iron in red meat and nitrate/nitrite in processed meat are among the culprits. But Potter says that the ill effects are likely to be caused in many different ways, including carcinogens caused by cooking, contaminants in animal feed, and reduced intake of plant based foods.

    Nor is earlier death the only concern for human health, he says. A high meat economy brings with it accelerated sexual development and antibiotic resistance, together with shortages of food, and animal to human disease epidemics thrown in for good measure. As for the effects on the planet, water depletion, methane production, and pollution of air and groundwater are just the beginning. We must of course reduce the use of fossil fuels in transport, but livestock production outstrips this as a cause of climate change.

    Potter outlines two possible courses of action. “As with many contemporary problems of resource overuse and maldistribution, we need to decide whether to act now to reduce human meat consumption or wait until the decay of sufficient parts of the global system tip us into much poorer planetary, societal, and human health.”

    What can doctors do? We can lobby for more and better research to support clearer evidence based dietary guidelines. And we can lead by example, as our predecessors did with smoking cessation, by reducing our own red meat consumption. Your own suggestions are welcome.

    BMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j2278 (Published 11 May 2017)
    Cite this as: BMJ 2017;357:j2278

  • Should doctors engage with counterterrorism?

    时间:2017-04-27

    发布:Fiona Godlee, editor in chief, The BMJ

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    Terrorists’ tactics have changed, and security services have had to change theirs in response. We are seeing fewer highly trained extremists carrying out carefully planned attacks and more lone actions by vulnerable people incited by internet propaganda. Last month’s attacks on Westminster Bridge and in Paris bear this out. But does this mean that doctors should change how they behave?

    The government’s Prevent strategy puts a duty of care on NHS trusts to report people they think are at risk of committing terrorist acts. Actual rates of referrals are low, according to information obtained by The BMJ, but concerns about the effect of the strategy on patient care and confidentiality are running high (doi:10.1136/bmj.j1998).

    Doctors interviewed by Anne Gulland are worried that the strategy is Islamophobic and will prevent patients from talking openly. They say that a system is already in place for them to raise concerns about potential for violent crime. And if they want to safeguard someone, a clear referral pathway keeps them informed of what happens to their patients afterwards. This does not seem to be the case with referrals to Prevent. Although most psychiatrists are well aware of the issues, training of other doctors is patchy and of poor quality.

    The General Medical Council offers some reassurance. Prevent does not apply to individual doctors but to NHS trusts. Nor does it change how or when doctors should report any concerns. Updated GMC guidance outlines the circumstances in which doctors would be justified in disclosing information about patients in the public interest, such as in the prevention, detection, or prosecution of serious crime.

    In an interview with The BMJ, Mark Rowley, the Metropolitan Police chief in charge of counterterrorism, says that he understands doctors’ caution. But he emphasises that this is not about surveillance (doi:10.1136/bmj.j1970). He draws parallels with safeguarding young people at risk from physical or sexual abuse, trafficking, or gangs. “If we are willing to share information and work together then we can keep this as a prevention response,” he says. “Waiting for people to try to commit serious offences then putting them in prison for ever is not as elegant a solution.”

    Lack of evidence about the effects of Prevent and lack of feedback about what happens to patients who are referred are barriers to trust. Evidence will take time to accrue, but doctors are right to insist that they are told what happens to individual patients.

    BMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j2040 (Published 27 April 2017)
    Cite this as: BMJ 2017;357:j2040

  • Our commitment is to patient partnership

    时间:2017-02-23

    发布:Fiona Godlee, editor in chief, The BMJ

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    Evidence that leads to changes practice is rarer than we might hope. In partnership with the MAGIC non-profit research and innovation programme (http://magicproject.org), we are now on the lookout for such practice changing evidence on which to base our “Rapid Recommendations” series. So far we have published one on whether patients with severe symptomatic aortic stenosis who are at low to intermediate surgical risk should have transcatheter or surgical valve replacement (doi:10.1136/bmj.i5085). We will soon be looking at knee arthroscopy and then drug treatments to reduce maternal transmission of HIV to the fetus.

    This week we focus on low intensity pulsed ultrasound (LIPUS), a form of bone stimulation intended to promote healing. As recounted by Rudolf Poolman and colleagues (doi:10.1136/bmj.j576), LIPUS was approved in the United States in 1994 for fracture healing and in 2000 for treatment of non-union. In 2010 the National Institute for Care and Health Excellence approved it for similar indications in the United Kingdom. LIPUS is now widely used in the developed world. But does it work?

    The Rapid Recommendations panel of non-conflicted reviewers has concluded that it doesn’t. Prompted by the TRUST trial, published in The BMJ last year (doi:10.1136/bmj.i5351), they collaborated with others on a systematic review (doi:10.1136/bmj.j656), incorporating 26 randomised trials. The trials at lowest risk of bias consistently found no difference between LIPUS and sham or no ultrasound. On the basis of this evidence, and the costly and cumbersome devices required, the panel makes a strong recommendation, with moderate to high certainty, against using LIPUS for bone healing.

    Crucially, the key outcomes were those that are important to patients. So, instead of simply looking at time to radiographic bone healing, the review focused on time to return to work, time to full weight bearing, and the number of subsequent operations.

    The emphasis on these outcomes is a good sign of progress towards more patient centred research. But there is much still to do. When we ask authors to tell us how patients were involved in their research, the answer is almost always not at all. We now publish statements on patient involvement in every research article to encourage a change in the culture. Other elements of our patient partnership initiative (bmj.com/campaign/patient-partnership) include review by patients of research articles, patient co-creation of educational articles, and patients’ involvement in The BMJ’s events. For the past three years we have been lucky enough to work with our inspirational patient editor, Rosamund Snow. Her death earlier this month is a great blow to us and all who knew her (doi:10.1136/bmj.j850; http://blogs.bmj.com/bmj/2017/02/15/paul-buchanan-on-rosamund-snow). But with the ongoing help of our patient panel we are more determined than ever to continue our advocacy for patient partnership in healthcare.

    BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j939 (Published 23 February 2017)
    Cite this as: BMJ 2017;356:j939