tag:theconversation.com,2011:/au/topics/liver-disease-6187/articlesLiver disease – The Conversation2024-02-05T13:34:49Ztag:theconversation.com,2011:article/2215322024-02-05T13:34:49Z2024-02-05T13:34:49ZStigma kills people with alcohol addiction<figure><img src="https://images.theconversation.com/files/572878/original/file-20240201-17-j3u58p.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C6000%2C3997&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/empty-bottles-green-container-207599350">sirtravelalot/Shutterstock</a></span></figcaption></figure><p>One of my patients, Emma (not her real name), recently told me that she didn’t seek help for her alcohol problem because she was ashamed. She said that she didn’t want to waste anyone’s time on a self-inflicted problem. She lived with it for years, hiding bottles of alcohol so her partner wouldn’t find out. Only when she turned yellow and vomited blood did she call an ambulance.</p>
<p>What stopped Emma from asking for help? The answer, in large part, is stigma. The word stigma comes from ancient Greek, meaning a mark of shame or disgrace. Originally used to label slaves and criminals, these days, stigma is used to mean a sign of something socially undesirable – in this case, alcoholism.</p>
<p>Alcoholism, or <a href="https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/understanding-alcohol-use-disorder">alcohol use disorder</a>, as it is known in medical terms, is the compulsion to drink alcohol even when it can cause physical or mental health problems. </p>
<p>Alcohol use disorder is a medical condition, not a lifestyle choice. This is different from heavy drinking and shouldn’t be used to describe someone who drinks too much by choice. </p>
<p>In people with alcohol use disorder, there may be a physical need to drink alcohol to stop withdrawal symptoms like the sweats or shakes. There may be psychological reasons including uncontrollable craving. </p>
<p>Most of the patients I see in hospital with alcohol-related liver disease have alcohol use disorder. We don’t fully understand why some people develop alcohol use disorder. It is partly <a href="https://www.nature.com/articles/s41467-019-09480-8#Abs1">genetic</a> but other factors such as social support and mental health conditions play a role.</p>
<p>Why does the stigmatisation of people with alcohol use disorder matter? As Emma’s story shows, the problem is that people don’t come forward to ask for help until it is too late and irreversible damage is already done – the case in around half of all people diagnosed with alcohol-related liver disease. </p>
<p>Worse still, one in six people diagnosed late die on their first admission to hospital and more than a third <a href="https://britishlivertrust.org.uk/new-research-reveals-late-detection-of-liver-disease-crisis-with-more-than-a-third-dying-within-a-year-of-diagnosis/">within a year</a> of their diagnosis.</p>
<h2>Stigma is common</h2>
<p>Most people with liver disease have experienced stigma <a href="https://britishlivertrust.org.uk/stigma-survey-results/">first hand</a>. </p>
<p>Several types of stigma are important to understand. First, there is public stigma. This is the most common type of stigma, where people believe in negative stereotypes, develop prejudice, and avoid or look down on people with alcohol use disorder – the drunk on the street might be aggressive so best to avoid him.</p>
<p>Second, there is stigma from healthcare professionals. Some of us do not appreciate that alcohol use disorder is a disease of addiction. We see people with alcohol use disorder time and again coming into hospital in a terrible state and perhaps consider them a hopeless cause, a drain on medical resources or a waste of our valuable time. It is disappointing that this attitude can come from doctors, nurses and other trained healthcare professionals, but it is a sad reality that my patients report.</p>
<p>Third, there is structural stigma. This is the way services are designed that might exclude certain groups of people. For example, same-day appointments with general practitioners may only be available to book early in the morning, and some people may not be able to access them.</p>
<p>All this external stigmatisation of the person with alcohol use disorder drives self-stigma: a feeling of low self-worth and self-esteem. </p>
<p>The more stigma they experience, the more self-stigma they develop and the more they feel that they deserve such treatment. They conceal and deny their alcohol use and are six times <a href="https://harmreductionjournal.biomedcentral.com/articles/10.1186/s12954-021-00587-0">more likely to avoid healthcare</a>. They enter a vicious cycle of increasing alcohol use causing more mental and physical harm to themselves.</p>
<h2>Things may have turned out differently</h2>
<p>Let me come back to Emma. She battled her addiction for several years and with the support of alcohol services and her family, managed several months at a stretch without alcohol. Sadly, she relapsed into heavy drinking and a few months later had a serious bleed from her gullet (a side-effect of severe liver disease), which couldn’t be controlled. Sadly, she died. </p>
<p>I can’t help but think that if Emma hadn’t experienced all that stigma, things may have turned out differently for her. She may have been able to get help to control her addiction and prevent liver disease from taking her life.</p>
<p>What do we learn from Emma’s story? We should remember that alcohol use disorder is not a lifestyle choice. We, the public and healthcare professionals, should reflect on how we treat people with alcohol addiction. </p>
<p>The first step in removing stigma is to recognise the prejudices and stereotypes that we hold and try to overcome these by seeing the person behind the bottle. If we work together, we can eliminate stigma and support people with this terrible medical condition.</p>
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Read more:
<a href="https://theconversation.com/what-happens-to-your-liver-when-you-quit-alcohol-220490">What happens to your liver when you quit alcohol</a>
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<p class="fine-print"><em><span>Ashwin Dhanda receives funding from the National Institute of Health and Social Care Research for a study investigating methods to tackle stigma in alcohol-related liver disease. </span></em></p>One in six people diagnosed late with alcohol use disorder die on their first admission to hospital.Ashwin Dhanda, Associate Professor of Hepatology, University of PlymouthLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2204902024-01-16T17:48:04Z2024-01-16T17:48:04ZWhat happens to your liver when you quit alcohol<figure><img src="https://images.theconversation.com/files/568930/original/file-20240111-25-sxzwan.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C4021%2C2678&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/stop-alcohol-concept-person-refuse-drink-1518344570">Pormezz/Shutterstock</a></span></figcaption></figure><p>According to Greek mythology, Zeus punished Prometheus for giving fire to humans. He chained Prometheus up and set an eagle to feast on his liver. Each night, the liver grew back and each day, the eagle returned for his feast. In reality, can a liver really grow back? </p>
<p>The liver is the largest internal organ in the human body. It is needed for hundreds of bodily processes, including breaking down toxins such as alcohol. As it is the first organ to “see” alcohol that has been drunk, it is not surprising that it is the most susceptible to alcohol’s effects. However, other organs, including the brain and heart, can also be damaged by long-term heavy alcohol use.</p>
<p>As a liver specialist, I meet people with alcohol-related liver disease every day. It is a <a href="https://britishlivertrust.org.uk/information-and-support/liver-conditions/alcohol-related-liver-disease/">spectrum of disease</a> ranging from laying down of fat in the liver (fatty liver) to scar formation (cirrhosis) and it usually doesn’t cause any symptoms until the very late stages of damage. </p>
<p>At first, alcohol makes the liver fatty. This fat causes the liver to become inflamed. In response, it tries to heal itself, producing scar tissue. If this carries on unchecked, the whole liver can become a mesh of scars with small islands of “good” liver in between – cirrhosis. </p>
<p>In the late stages of cirrhosis, when the liver fails, people can turn yellow (jaundice), swell with fluid and become sleepy and confused. This is serious and can be fatal.</p>
<p>Most people who regularly drink more than the recommended limit of 14 units of alcohol per week (about six pints of normal strength beer [4% ABV] or about six average [175ml] glasses of wine [14% ABV]) will have a fatty liver. Long-term and heavy alcohol use increases the risk of developing <a href="https://www.nhs.uk/conditions/alcohol-related-liver-disease-arld/">scarring and cirrhosis</a>. </p>
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<img alt="A man with jaundice pulls down one eyelid." src="https://images.theconversation.com/files/568934/original/file-20240111-17-txmq0o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/568934/original/file-20240111-17-txmq0o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/568934/original/file-20240111-17-txmq0o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/568934/original/file-20240111-17-txmq0o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/568934/original/file-20240111-17-txmq0o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/568934/original/file-20240111-17-txmq0o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/568934/original/file-20240111-17-txmq0o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Yellow skin and eyes are signs of a damaged liver.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/liver-disease-young-man-face-yellowish-1898063578">Creative Cat Studio/Shutterstock</a></span>
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<h2>Good news</h2>
<p>Fortunately, there is good news. In people with fatty liver, after only two to three weeks of giving up alcohol, the liver can heal and looks and functions <a href="https://arcr.niaaa.nih.gov/volume/41/1/natural-recovery-liver-and-other-organs-after-chronic-alcohol-use">as good as new</a>. </p>
<p>In people with liver inflammation or mild scarring, even within seven days of giving up alcohol, there are noticeable reductions in liver <a href="https://www.mdpi.com/2072-6643/13/5/1659">fat, inflammation and scarring</a>. Stopping alcohol use for several months lets the liver heal and return to normal.</p>
<p>In heavy drinkers with more severe scarring or liver failure, giving up alcohol for several years reduces their chance of <a href="https://www.cghjournal.org/article/S1542-3565(22)01113-2/fulltext">worsening liver failure and death</a>. However, people who drink heavily can be physically dependent on alcohol and stopping suddenly can cause alcohol withdrawal. </p>
<p>In its mild form, it causes shaking and sweating. But if severe, it can cause hallucinations, fits and even death. Going “cold turkey” is never recommended for heavy drinkers, who should seek medical advice about how to safely give up alcohol.</p>
<h2>Other benefits</h2>
<p>Giving up drinking also has positive effects on <a href="https://alcoholchange.org.uk/blog/benefits-of-dry-january-and-when-you-can-expect-to-see-them">sleep, brain function and blood pressure</a>. </p>
<p>Avoiding alcohol for long periods also reduces the risk of several types of <a href="https://www.cancerresearchuk.org/about-cancer/causes-of-cancer/alcohol-and-cancer">cancer</a> (including liver, pancreas and colon) and the risk of <a href="https://www.bhf.org.uk/informationsupport/heart-matters-magazine/medical/effects-of-alcohol-on-your-heart">heart disease and stroke</a>. </p>
<p>However, alcohol is not the only cause of ill health. Giving it up has many health benefits, but it is not a panacea. It should be seen as part of a healthy lifestyle, including a balanced diet and regular physical exercise.</p>
<p>So, to answer the question posed by the myth of Prometheus, the liver has an amazing power to repair itself after it has been damaged. But it cannot grow back as new if it was already severely scarred. </p>
<p>If you stop drinking and only have a fatty liver, it can quickly turn back to normal. If you had a scarred liver (cirrhosis) to start with, stopping alcohol will allow some healing and improved function but can’t undo all the damage that has already been done.</p>
<p>If you want to look after your liver, don’t drink alcohol. But if you must, drink in moderation and have two to three alcohol-free days each week. That way, you won’t have to rely on the liver’s magical self-healing power to stay healthy.</p>
<p><em>Correction: The sentence: “If you want to look after your liver, drink in moderation and have two to three alcohol-free days each week” has been replaced with the more accurate: “If you want to look after your liver, don’t drink alcohol. But if you must, drink in moderation and have two to three alcohol-free days each week.”</em></p><img src="https://counter.theconversation.com/content/220490/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ashwin Dhanda does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The liver has remarkable self-healing powers. But it has limits, so don’t abuse it.Ashwin Dhanda, Associate Professor of Hepatology, University of PlymouthLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2084932023-07-03T11:15:30Z2023-07-03T11:15:30ZRapid weight loss may improve advanced fatty liver disease – new research<figure><img src="https://images.theconversation.com/files/534541/original/file-20230628-23-39m7cp.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5463%2C3637&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Participants followed the 'soups and shakes' diet to help them lose weight.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/woman-pouring-yogurt-bottle-into-glass-1208875339">New Africa/ Shutterstock</a></span></figcaption></figure><p>Around 2% of adults worldwide suffer from a condition called <a href="https://www.nejm.org/doi/full/10.1056/NEJMra1503519">non-alcoholic steatohepatitis</a> (Nash), an advanced form of <a href="https://www.nhs.uk/conditions/non-alcoholic-fatty-liver-disease/">non-alcoholic fatty liver disease</a>. This occurs when fat builds up in the liver, causing inflammation and scarring. </p>
<p>Without treatment it can eventually lead to liver cirrhosis – and it can also increase the risk of other serious health conditions, such as heart disease. </p>
<p>There is currently no medication to treat Nash. Since excess fat in the liver is what causes the inflammation and scarring that is characteristic of the condition, the current mainstay treatment for patients is weight loss. </p>
<p>However, the kind of weight loss most people are able to achieve on their own is modest and not enough for significant reductions in liver fat and change inflammation and scarring.</p>
<p>But <a href="https://onlinelibrary.wiley.com/doi/10.1002/oby.23793">our recent study</a> has shown that rapid weight loss achieved through the “<a href="https://www.england.nhs.uk/2020/09/thousands-to-benefit-from-soups-and-shakes-diet-on-the-nhs-from-today/">soups and shakes</a>” diet – which is commonly used to treat obesity and type 2 diabetes – may be able to reduce the severity of Nash.</p>
<p>To conduct our study, we recruited 16 participants with obesity, Nash and moderate to advanced liver scarring. Five of the participants were female and 11 were male. Most participants were white. </p>
<p>All of the participants took part in the “soups and shakes” weight loss programme, replacing their regular meals with specially formulated soups, shakes and bars for 12 weeks. They consumed four products of their choice daily, which provided them with about 880 calories and all the essential vitamins and minerals. </p>
<p>After the initial 12-week period, they gradually began re-introducing regular food to their diet over the next 12 weeks. They were also given regular support from a dietitian to keep them on track and motivated throughout the 24-week study.</p>
<p>At the start of the study, participants were weighed, had their blood pressure taken, blood tests done and two scans that measured the health of their liver. These scans estimated how advanced their liver inflammation and scarring was and the amount of fat in their liver. </p>
<p>These tests were also repeated at 12 and 24 weeks – with an additional blood test done at four weeks.</p>
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<img alt="A digital drawing of a fatty liver." src="https://images.theconversation.com/files/534542/original/file-20230628-19-w1v274.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/534542/original/file-20230628-19-w1v274.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/534542/original/file-20230628-19-w1v274.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/534542/original/file-20230628-19-w1v274.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/534542/original/file-20230628-19-w1v274.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/534542/original/file-20230628-19-w1v274.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/534542/original/file-20230628-19-w1v274.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Untreated, Nash could lead to liver cirrhosis.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/liver-damage-such-fatty-fibrosis-cirrhosis-2286386283">crystal light/ Shutterstock</a></span>
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<p>Fourteen of the participants completed the 24-week study. Participants lost an average of 15% of their body weight, showing they largely adhered to the weight loss programme. </p>
<p>Our study also showed that the rapid weight loss was safe for participants. In the past, this kind of diet programme wasn’t recommended to Nash patients due to concerns over how safe it may be. The most common side effect patients experienced was constipation – but this was temporary and typically only mild.</p>
<p>Scans also showed that most participants had significant improvements in liver fat and in markers of liver inflammation and scarring. </p>
<h2>Bigger improvements than medication</h2>
<p>These are some of the largest improvements in liver disease severity <a href="https://pubmed.ncbi.nlm.nih.gov/34570916/">reported in research</a> to date, approaching the level of improvement seen with weight loss after <a href="https://pubmed.ncbi.nlm.nih.gov/30683512/">bariatric surgery</a>. <a href="https://pubmed.ncbi.nlm.nih.gov/34570916/">No trialled medication</a> has shown such a large improvement. </p>
<p>While some weight regain is likely to happen, if participants are able to maintain at least most of their weight loss after the study ends, this could possibly reverse the trajectory of their liver disease.</p>
<p>What’s more, systolic blood pressure and haemoglobin A1C (a marker of blood sugar control) also significantly improved in participants who’d had hypertension and type 2 diabetes at the start of the study. This may suggest that the programme could be used to reduce the risk of heart disease, which is the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4516664/">most common cause of death</a> in people with Nash.</p>
<p>Because our results are only from a small study, further research is needed to test this programme in a larger trial with more diverse participants and a control group. It will also be interesting to see whether this programme could be useful for patients suffering with more advanced forms of liver disease – such as <a href="https://www.nhs.uk/conditions/cirrhosis/">liver cirrhosis</a>. </p>
<p>But it is promising to see from our study that the diet appears to be safe for people with Nash and effective in improving their liver health.</p><img src="https://counter.theconversation.com/content/208493/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dimitrios Koutoukidis receives funding from National Institute of Health Research. The intervention was donated to the University of Oxford by Nestle Health Science with dietetic support provided by Oviva. Perspectum donated the MRI analysis. None of these associations led to payments to the author.</span></em></p>Non-alcoholic steatohepatitis affects around 2% of adults worldwide.Dimitrios Koutoukidis, Senior Researcher, University of OxfordLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2050692023-06-05T14:25:30Z2023-06-05T14:25:30ZHepatitis B is a life-threatening liver infection – our machine learning tool could help with early detection<figure><img src="https://images.theconversation.com/files/529046/original/file-20230530-15-9wf3s7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Getty Images</span></span></figcaption></figure><p>More than <a href="https://www.who.int/news-room/fact-sheets/detail/hepatitis-b">296 million people</a> worldwide live with hepatitis B, a potentially life-threatening liver infection caused by the hepatitis B virus (HBV). Most don’t know they are infected, so they don’t get medical care. Clinical care improves the patient’s outcome and can prevent them from infecting others. </p>
<p>Early detection of HBV-infected patients could therefore improve patient prognosis and stop transmission within populations. </p>
<p>The recommended test for HBV is an <a href="https://apps.who.int/iris/bitstream/handle/10665/254621/9789241549981-eng.pdf">enzyme immunoassay</a>. It detects the hepatitis B surface <a href="https://www.britannica.com/science/antigen">antigen</a> – a substance that is a sign of the presence of the virus in the person’s body. </p>
<p>But these chemical tests are very <a href="https://apps.who.int/iris/bitstream/handle/10665/254621/9789241549981-eng.pdf">expensive</a> and need dedicated facilities. They are generally out of reach for people in low-resource settings, where laboratories are few and isolated. Clinicians in these settings work with limited resources against <a href="https://www.afro.who.int/news/91-million-africans-infected-hepatitis-b-or-c">a silent killer</a> that may not show obvious symptoms for decades until the liver is severely damaged. </p>
<p>Part of the solution for public health challenges like this may lie in <a href="https://theconversation.com/what-machine-learning-can-offer-nigerias-healthcare-system-163593">machine learning</a>. This refers to the ability of computers to make sense of large amounts of information – and to build on their own “knowledge”.</p>
<p>We are among a group of researchers at the <a href="https://nceph.anu.edu.au/">Australian National University</a> who study machine learning and infectious disease. Our <a href="https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-021-06800-6">earlier research</a> found that the prevalence of HBV in Nigeria was high (9.5%, where anything above 8% is considered high). And the levels of infection varied significantly across geopolitical zones. </p>
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Read more:
<a href="https://theconversation.com/hepatitis-b-in-nigeria-fresh-data-to-inform-prevention-and-care-173018">Hepatitis B in Nigeria: fresh data to inform prevention and care</a>
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<p>Access to affordable testing was a problem in the country. So we <a href="https://www.nature.com/articles/s41598-023-30440-2">developed a tool</a> to help clinicians detect hepatitis B infections earlier.</p>
<p>Using Nigerian patient data, we developed an algorithm that learns from the patient data, identifies patterns, and makes intelligent decisions to provide alerts and detection of a patient’s HBV infection status. The aim is to enhance clinical decision-making and improve patient outcomes. Enabling earlier care should give millions of people a better quality of life and help reduce HBV prevalence.</p>
<h2>How did we do the work?</h2>
<p>To build this tool, we worked closely with colleagues at the <a href="https://nimr.gov.ng/">Nigerian Institute of Medical Research</a>. They provided access to data from 916 anonymous patients, in an ethically approved manner. The institute is Nigeria’s foremost medical research institute and it hosts a dedicated hepatitis B clinic.</p>
<p>We used the results of normal blood tests that measure red and white blood cells, salts, enzymes and other blood chemicals, along with results of tests for hepatitis B. Routine blood tests can be very useful in facilitating early diagnosis if the subtle interactions between measurements can be spotted. Patterns of interactions may be a signal of disease. But it’s easy to miss them. </p>
<p>Using the data, we trained an algorithm to identify pathology markers that predict a patient’s HBV infection status. One reason machine learning is so powerful is that it does not require humans to tell the computer which features to identify. Our algorithm sifts through the data to find patterns that are common to patients with HBV infection and then match those patterns in people it has not seen before. </p>
<p>Once validated, the algorithm can be integrated into routine clinical workflow in a real-world clinical setting, as an intelligent decision support system. This will help detect HBV infections earlier, without resorting to expensive immunoassay. </p>
<h2>What did we find?</h2>
<p>For the 916 people in <a href="https://www.nature.com/articles/s41598-023-30440-2">our study</a>, our algorithm could reliably make an intelligent call to accurately predict those infected with HBV. Its discrimination threshold was 90% — indicating that the algorithm was highly accurate.</p>
<p>We then translated this into a user-friendly, web-accessible app to use in further studies. The decision support tool, <a href="https://hepblivetest.app/">Hep B LiveTest</a>, was designed as a prototype.</p>
<p>The tool found that a combination of two enzymes, patient age and white blood cell count was the strongest predictor of HBV infection. The two enzymes are aspartate aminotransferase and alanine aminotransferase. When levels of these in the blood are high, it may indicate potential liver damage. Serum albumin, a liver function marker, was also identified as an important predictive marker of infection.</p>
<p>A <a href="https://onlinelibrary.wiley.com/doi/full/10.1002/jmv.23609">study of Chinese patients</a> showed trends similar to those suggested by our algorithm. Alanine aminotransferase and serum albumin were the most prominent predictors.</p>
<h2>What’s next?</h2>
<p>It is important to recognise the limitations of machine learning. Before a tool like this is put to work in routine clinical practice, it needs to be validated using diverse data. </p>
<p>Our machine learning tool was trained with data from Nigeria, so its performance may be limited to that setting. We are in the process of training our algorithm with more data from other sources and validating its robustness in other settings. This will inform how broadly applicable our algorithm is and how well it might work in other populations – particularly in settings with a low prevalence of hepatitis B infections.</p>
<p>Though our machine learning tool is only a first test, the results are highly encouraging. <a href="https://news.un.org/en/story/2021/07/1096592">A person dies from viral hepatitis B every 30 seconds</a>. We hope to put our system to work soon in the urgent fight against this <a href="https://www.nature.com/articles/d44148-022-00128-2">vaccine-preventable disease</a>. </p>
<p>We believe that machine learning has a role in enhancing the World Health Organization’s targets of <a href="https://apps.who.int/iris/bitstream/handle/10665/246177/WHO-HIV-2016.06-eng.pdf?sequence=1&isAllowed=y">eliminating viral hepatitis as a public health problem by 2030</a>.</p><img src="https://counter.theconversation.com/content/205069/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Brett A. Lidbury receives funding from the Quality Use of Pathology Program (QUPP) - Commonwealth Department of Health. He holds a Fellowship with the Royal College of Pathologists of Australasia (RCPA) Faculty of Science, and collaborates with the RCPA Quality Assurance Programme (RCPAQAP). </span></em></p><p class="fine-print"><em><span>Busayo I. Ajuwon does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Machine learning can spot patterns in patient data and help detect hepatitis B earlier, which could save lives.Busayo I. Ajuwon, Research Scientist, Australian National UniversityBrett A. Lidbury, Associate ProfessorLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1999532023-02-17T13:25:11Z2023-02-17T13:25:11ZHow vinyl chloride, the chemical in the Ohio train derailment and used to make PVC plastics, can damage your liver<figure><img src="https://images.theconversation.com/files/510674/original/file-20230216-20-8gyl1y.jpg?ixlib=rb-1.1.0&rect=204%2C43%2C6628%2C3998&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">An illustration of a human liver with cirrhosis. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/liver-cirrhosis-illustration-royalty-free-illustration/1296294408">Kateryna Kon/Science Photo Library</a></span></figcaption></figure><p><a href="https://theconversation.com/deraillement-dun-train-en-ohio-quels-sont-les-effets-du-chlorure-de-vinyle-ce-produit-chimique-qui-inquiete-les-riverains-200368"><em>Lire cet article en français</em></a></p>
<p>Vinyl chloride – the chemical in several of the train cars that derailed and burned in East Palestine, Ohio, in February 2023 – can wreak havoc on the human liver.</p>
<p>It has been shown <a href="https://doi.org/10.1002/hep.23321">to cause liver cancer</a>, as well as a nonmalignant liver disease known as <a href="https://doi.org/10.1177/0192623312468517">TASH, or toxicant-associated steatohepatitis</a>. With TASH, the livers of otherwise healthy people can develop the same fat accumulation, inflammation and scarring (fibrosis and cirrhosis) as people who have cirrhosis from alcohol or obesity.</p>
<p>That kind of damage typically requires relatively high levels of vinyl chloride exposure – the kind an industrial worker might experience on the job.</p>
<p>However, exposures to lower environmental concentrations are still a concern. That’s in part because little is known about the impact low-level exposure might have on liver health, especially for people <a href="https://doi.org/10.1016/j.apsb.2021.09.005">with underlying liver disease</a> and other risks.</p>
<p>As an <a href="https://pubmed.ncbi.nlm.nih.gov/?term=beier%2C+Ji">assistant professor</a> of medicine and environmental and occupational health, I study the impact of vinyl chloride exposure on the liver, <a href="https://doi.org/10.1515/hsz-2017-0324">particularly on how it may affect</a> people with underlying liver disease. Recent findings have changed our understanding of the risk.</p>
<h2>Lessons from ‘Rubbertown’</h2>
<p>Vinyl chloride is <a href="https://www.cancer.gov/about-cancer/causes-prevention/risk/substances/vinyl-chloride">used to produce PVC</a>, a hard plastic used for pipes, as well as in some packaging, coatings and wires.</p>
<p>Its health risks were <a href="https://www.jstor.org/stable/23386284">discovered in the 1970s</a> at a B.F. Goodrich factory in the Rubbertown neighborhood of Louisville, Kentucky. Four workers involved in the polymerization process for producing polyvinyl chloride there each developed angiosarcoma of the liver, an extremely rare type of tumor.</p>
<p>Their cases became among the most important <a href="https://www.jstor.org/stable/23386284">sentinel events</a> in the history of occupational medicine and led to the worldwide recognition of vinyl chloride as a carcinogen.</p>
<p>The liver is the <a href="https://www.stanfordchildrens.org/en/topic/default?id=how-the-liver-works-90-P02006">body’s filter</a> for removing toxicants from the blood. Specialized cells known as hepatocytes help reduce the toxicity of drugs, alcohol, caffeine and environmental chemicals and then send away the waste to be excreted.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/wbh3SjzydnQ?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">How the liver works.</span></figcaption>
</figure>
<p>The hallmark of vinyl chloride exposure to the liver is a <a href="https://doi.org/10.1177/0192623312468517">paradoxical combination</a> of normal liver function tests and the presence of fat in the liver and the death of hepatic cells, which make up the bulk of the liver’s mass. However, the detailed mechanisms that lead to vinyl chloride-induced liver disease are still largely unknown.</p>
<p>Recent research has demonstrated that exposure to vinyl chloride, even at levels below the federal limits for safety, can <a href="https://doi.org/10.1016/j.apsb.2021.09.002">enhance liver disease</a> <a href="https://doi.org/10.1002/hep4.1151">caused by</a> a “<a href="https://doi.org/10.1021/acs.chemrestox.8b00043">Western diet</a>” – one <a href="https://doi.org/10.1093/toxsci/kfz236">rich in fat</a> and sugar. This previously unidentified interaction between vinyl chloride and underlying fatty liver diseases raises concerns that the risk from lower vinyl chloride exposures may be underestimated.</p>
<h2>Outdoor exposure and the risk from wells</h2>
<p><a href="https://www.atsdr.cdc.gov/toxprofiles/tp20.pdf">In outdoor air</a>, vinyl chloride becomes diluted fairly quickly. Sunlight also breaks it down, typically in nine to 11 days. Therefore, outdoor air exposure is likely not a problem except with intense periods of exposure, such as immediately following a release of vinyl chloride. If there is a chemical smell, or you feel itchy or disorientated, leave the area and seek medical attention.</p>
<p>Vinyl chloride also disperses in water. The federal <a href="https://www.epa.gov/eg/toxic-and-priority-pollutants-under-clean-water-act">Clean Water Act</a> requires monitoring and removing volatile organic compounds such as vinyl chloride from municipal water supplies, so those shouldn’t be a concern.</p>
<p>However, <a href="https://www.youtube.com/watch?v=C0Vb1CmT98c">private wells</a> could become contaminated if vinyl chloride enters the groundwater. Private wells are not regulated by the Clean Water Act and are not usually monitored.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/510671/original/file-20230216-24-99mz94.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Train cars after the derailment are jumbled and on fire." src="https://images.theconversation.com/files/510671/original/file-20230216-24-99mz94.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/510671/original/file-20230216-24-99mz94.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/510671/original/file-20230216-24-99mz94.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/510671/original/file-20230216-24-99mz94.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/510671/original/file-20230216-24-99mz94.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/510671/original/file-20230216-24-99mz94.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/510671/original/file-20230216-24-99mz94.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Nearly a dozen train cars carrying hazardous chemicals were among those that derailed in East Palestine, Ohio, on Feb. 3, 2023, and burned.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/APTOPIXTrainDerailmentOhio/a1db9c7fca1348d491fde492696180d6/photo">AP Photo/Gene J. Puskar</a></span>
</figcaption>
</figure>
<p>Vinyl chloride readily volatilizes into the air from water, and it can accumulate in <a href="https://www.atsdr.cdc.gov/toxguides/toxguide-20.pdf">enclosed spaces</a> located above contaminated groundwater. This is especially a concern <a href="https://doi.org/10.1080/10473289.1991.10466844">if the water is heated</a>, such as for showers or during cooking. Vinyl chloride gas in enclosed spaces can therefore accumulate. This effect is similar to recent concerns <a href="https://doi.org/10.3390/ijerph20010075">about fumes from natural gas stoves</a> in poorly ventilated homes.</p>
<p>Although there are <a href="https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1017">established safety levels</a> for acute and intermediate exposure, such levels don’t exist for chronic exposures, so testing over time is important.</p>
<p>What can be done? Anyone with a private well that <a href="https://response.epa.gov/site/site_profile.aspx?site_id=15933">may have been exposed</a> to vinyl chloride should have the well <a href="https://www.atsdr.cdc.gov/toxguides/toxguide-20.pdf">monitored and tested</a> more than once. People can air out their homes and are encouraged to seek medical help if they experience dizziness or itching eyes.</p><img src="https://counter.theconversation.com/content/199953/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Juliane I. Beier receives funding from National Institutes of Health. </span></em></p>Vinyl chloride dilutes fairly quickly in outside air and water. One concern for lingering exposure from the derailment involves private wells.Juliane I. Beier, Assistant Professor of Medicine and Environmental Health, Member of Pittburgh Liver Research Center, University of PittsburghLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1947902022-12-09T11:00:21Z2022-12-09T11:00:21ZAlcohol deaths in the UK rose to record level in 2021<p>Deaths from alcohol in the UK have risen to their highest level since records began in 2001, according to the <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/alcoholspecificdeathsintheuk/2021registrations">latest data</a> from the Office for National Statistics (ONS). In 2021, 9,641 people (14.8 per 100,000) died as a result of alcohol: a rise of 7.4% from 2020. </p>
<p>The leading cause of alcohol-specific deaths (deaths caused by diseases known to be a direct consequence of alcohol) continues to be liver disease. More than three-quarters (78%) of all alcohol deaths in 2021 were attributed to this cause. The remainder of the deaths were due to “mental and behavioural disorders because of the use of alcohol” and “accidental poisoning by, and exposure to, alcohol”.</p>
<p>Although there is no such thing as a safe level of drinking, and many people would feel the health benefits of reducing consumption, most of the risks of developing health problems and dying are <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-67361831310-2/fulltext">skewed towards</a> those who drink the most. </p>
<p>Between 2012 and 2019 alcohol-specific deaths remained relatively stable. It is no coincidence that deaths rose sharply during the first two years of the pandemic: those that were already drinking at harmful levels <a href="https://www.sheffield.ac.uk/news/shifts-alcohol-consumption-during-pandemic-could-lead-thousands-extra-deaths-england">increased their consumption</a> further during this period. Although liver disease can take years to develop, this process is accelerated when those drinking at harmful levels increase their consumption further. </p>
<p>Other statistics show that unplanned alcohol-related hospital admissions <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1002627/Alcohol_and_COVID_report.pdf">decreased during this period</a>, which may have meant missed opportunities to provide help for those people experiencing problems with alcohol.</p>
<p>Looking beyond the headline figures, there are important differences in various groups within the population. Alcohol-specific deaths were not spread equally. For example, men were twice as likely to die as women. In 2021, 20.1 men per 100,000 died compared with 9.9 women.</p>
<p>Where you live in the UK matters, too, as deaths in Scotland are the highest, followed by Northern Ireland, Wales then and England – although the gap between the nations seems to be narrowing. </p>
<p>In England, deaths are highest in the north-east of England (20.4 per 100,000), which is twice as high as those in London (10.2 per 100,000). Although rates have increased in all regions; for example, there was a rise of 38% in south-west England from 2019 to 2021. This reflects what is already known about the relationship between deprivation and harm from alcohol. There is a two to fivefold <a href="https://www.thelancet.com/journals/lanpub/article/PIIS2468-26672030052-9/fulltext#:%7E:text=A%20meta%2Danalysis%20published%20in,than%20individuals%20with%20high%20SES.">higher risk</a> of dying among lower-income groups compared with those from the higher-income groups.</p>
<p>Reflecting the <a href="https://theconversation.com/why-are-young-people-drinking-less-than-their-parents-generation-did-172225">growing trend</a> of young people drinking less than older age groups, it is those aged 50 to 64 that account for most deaths due to liver disease. In 2021, for example, 39 people aged 25 to 29 died from alcohol-related liver disease, compared with 1,326 of those aged 50 to 59. This is related to a greater number of years of drinking but is also a general reflection that when older adults were younger, they tended to drink more than younger people do now. </p>
<figure class="align-center ">
<img alt="Numbers of alcohol-specific deaths, by five-year age group and individual cause" src="https://images.theconversation.com/files/499999/original/file-20221209-33842-krmmcp.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/499999/original/file-20221209-33842-krmmcp.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=492&fit=crop&dpr=1 600w, https://images.theconversation.com/files/499999/original/file-20221209-33842-krmmcp.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=492&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/499999/original/file-20221209-33842-krmmcp.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=492&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/499999/original/file-20221209-33842-krmmcp.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=618&fit=crop&dpr=1 754w, https://images.theconversation.com/files/499999/original/file-20221209-33842-krmmcp.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=618&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/499999/original/file-20221209-33842-krmmcp.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=618&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Numbers of alcohol-specific deaths, by five-year age group and individual cause.</span>
<span class="attribution"><a class="source" href="https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/alcoholspecificdeathsintheuk/2021registrations#alcohol-specific-deaths-in-the-uk">Office for National Statistics – Alcohol-specific deaths in the UK: registered in 2021, National Records of Scotland and the Northern Ireland Statistics and Research Agency</a></span>
</figcaption>
</figure>
<h2>Addressing harms</h2>
<p>So what can be done to begin to address alcohol harms? It has been estimated that almost a quarter of drinkers in the UK drink above the recommended <a href="https://www.drinkaware.co.uk/facts/alcoholic-drinks-and-units/low-risk-drinking-guidelines#:%7E:text=approach%20during%20pregnancy.-,Weekly%20guidelines,over%20three%20or%20more%20days.">low-risk drinking guidelines</a>. So this is a health and social issue that requires a national response. Low-impact initiatives, such as education and awareness raising, may not be enough. </p>
<p>The costs of alcohol to society are significant. A <a href="https://ahauk.org/news/independent-review-on-alcohol/">recent review</a> estimated this to be £27 billion annually, with only half of this offset by tax revenue on alcohol products.</p>
<p>Timely access to specialist treatment can help to reduce the health risks associated with alcohol. Unfortunately, there have been <a href="https://ahauk.org/news/new-figures-revealing-extent-of-cuts-to-treatment-services/">significant cuts</a> to funding for this type of intervention. </p>
<p>Around 80% of people classed as dependent on alcohol in England are not currently <a href="https://alcoholchange.org.uk/alcohol-facts/fact-sheets/alcohol-statistics">getting treatment support</a>. While there has recently been extra funding for drug services to try and correct historic cuts, this has not been extended to alcohol. Reversing this by investing in services could help to reduce the rising number dying prematurely from alcohol.</p>
<h2>A new strategy is long overdue</h2>
<p>The last government strategy for alcohol was published in 2012, so there is a pressing need for a new one. This must address <a href="https://global.oup.com/academic/product/Alcohol-no-ordinary-commodity-9780192844484?q=babor&lang=en&cc=gb#">all the ways</a> that the harms from alcohol can be tackled, from marketing and pricing to specialist treatment and recovery services.</p>
<p>A group, led by Liverpool MP Dan Carden, with cross-party support, recently <a href="https://ahauk.org/news/independent-review-on-alcohol/">called on the government</a> to initiate an independent review of alcohol harm, along the lines of the review led by <a href="https://www.gov.uk/government/publications/independent-review-of-drugs-by-dame-carol-black-government-response">Dame Carol Black</a>, which had a significant influence on drug policy and treatment funding. </p>
<p>Without such a review and strategy based on it, the harms caused by alcohol including premature death will continue to rise year after year. So much has changed since the last alcohol strategy in 2012 not least the current cost of living crisis. The outlook for investment in public health looks bleak, added to which this government doesn’t seem willing to curtail the efforts of the alcohol industry in marketing and protecting its products.</p><img src="https://counter.theconversation.com/content/194790/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Harry Sumnall receives and has received funding from grant awarding bodies for alcohol and other drug research. He sits on grant-awarding funding panels, and is an unpaid scientific adviser to the MIND Foundation.</span></em></p><p class="fine-print"><em><span>Ian Hamilton does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Nearly 10,000 people died from alcohol in 2021.Ian Hamilton, Honorary Fellow, Department of Health Sciences, University of YorkHarry Sumnall, Professor in Substance Use, Liverpool John Moores UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1958762022-12-05T16:10:01Z2022-12-05T16:10:01ZA liver disease drug could be repurposed to protect against COVID – new research<figure><img src="https://images.theconversation.com/files/498965/original/file-20221205-19-g89fj.jpg?ixlib=rb-1.1.0&rect=0%2C12%2C4193%2C2678&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">This drug could be effective regardless of the COVID variant. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/hepatitis-virus-human-liver-3d-illustration-1667884225">Explode/Shutterstock</a></span></figcaption></figure><p>Almost three years into the pandemic, we’re still regularly seeing <a href="https://covid19.who.int">hundreds of thousands</a> of new COVID cases recorded each day worldwide. In a <a href="https://www.nature.com/articles/s41586-022-05594-0">new study</a>, involving a combination of miniature organ models, donor organs, animals and humans, we’ve shown that a drug used to treat liver disease could be repurposed to protect against COVID-19.</p>
<p>Vaccines are one of the most potent weapons in our pandemic response, but not everyone can benefit from them. COVID vaccines work by training our immune system to recognise and destroy SARS-CoV-2, the virus that causes COVID-19. As such, they’re not effective for people with a poorly functioning immune system, for example patients taking medications to suppress immune function after <a href="https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(22)00372-8/fulltext">an organ transplant</a>.</p>
<p>The virus can also disguise itself to avoid the immune system recognising it, by mutating into <a href="https://www.nature.com/articles/s41564-022-01143-7">new variants</a> and thereby lowering vaccine effectiveness. </p>
<p>Finally, vaccines are not equally accessible, with only <a href="https://ourworldindata.org/covid-vaccinations">one in four people</a> in low income countries having received at least one dose. </p>
<p>In light of these challenges, we wanted to develop a strategy to protect from COVID-19 which could complement vaccination. We decided to target the “doorway” that SARS-CoV-2 uses to infect cells, a receptor called ACE2.</p>
<h2>The ‘doorway’ to SARS-CoV-2 infection</h2>
<p>There are a couple of key reasons we targeted ACE2 receptors. First, blocking this viral entry doorway doesn’t require an optimally functioning immune system, so this method should be effective even in people who are immunocompromised. </p>
<p>And second, ACE2 receptors are produced by our own cells, so are not affected by changes in the virus (that is, new variants), hopefully making this method more resilient as SARS-CoV-2 evolves.</p>
<p>So we were optimistic when we identified an existing drug that could modify ACE2 receptors. It’s possible this drug could be rapidly repurposed against COVID-19. </p>
<hr>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/covid-antiviral-drugs-are-a-vital-weapon-but-misusing-them-could-backfire-186959">COVID: antiviral drugs are a vital weapon – but misusing them could backfire</a>
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<p>This research began from a serendipitous finding. In the Sampaziotis lab at the University of Cambridge we focus on liver regeneration and bile duct diseases, which are the leading cause of <a href="https://pubmed.ncbi.nlm.nih.gov/15880505/">liver transplantation</a> in children.</p>
<p>Bile is a digestive fluid produced by the liver and drained into the intestine through tubes called bile ducts. At the beginning of the pandemic, we were studying the effects of bile on bile ducts using miniature versions grown in a dish, known as organoids. </p>
<figure class="align-center ">
<img alt="A woman holds a glass of water and a tablet." src="https://images.theconversation.com/files/498968/original/file-20221205-20-2sa9wy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/498968/original/file-20221205-20-2sa9wy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/498968/original/file-20221205-20-2sa9wy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/498968/original/file-20221205-20-2sa9wy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/498968/original/file-20221205-20-2sa9wy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/498968/original/file-20221205-20-2sa9wy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/498968/original/file-20221205-20-2sa9wy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">UDCA is taken orally by many patients with liver disease.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/senior-woman-taking-tablet-glass-water-1498026977">Daisy Daisy/Shutterstock</a></span>
</figcaption>
</figure>
<p>We found that a bile-sensing molecule called FXR, which is abundant in the liver, controls the expression of many molecules in bile duct cells, including ACE2. When ACE2 was identified as the viral entry doorway <a href="https://www.nature.com/articles/s41591-021-01310-z">for SARS-CoV-2</a> we decided to explore whether drugs targeting FXR could reduce ACE2 receptors and therefore viral infection.</p>
<p>We identified that ursodeoxycholic acid (UDCA), a clinically approved drug currently used for liver disease, had this effect on the mini bile ducts. We successfully repeated our experiments using miniature lungs and miniature guts in the lab, as these organs are commonly affected by COVID-19. </p>
<p>We then validated these findings in hamsters to make sure our lab results held true in a living organism. To test if these findings could be translated to humans, we used a pair of donated human lungs which were not suitable for transplantation. We infected both lungs with SARS-CoV-2, but only one lung was treated with UDCA. We found that the lung that received the drug did not become infected, while the other lung did.</p>
<figure class="align-right ">
<img alt="The lungs used in the study." src="https://images.theconversation.com/files/498967/original/file-20221205-20-pflbm9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/498967/original/file-20221205-20-pflbm9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/498967/original/file-20221205-20-pflbm9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/498967/original/file-20221205-20-pflbm9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/498967/original/file-20221205-20-pflbm9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/498967/original/file-20221205-20-pflbm9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/498967/original/file-20221205-20-pflbm9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">We kept the lungs alive outside the body using warm blood-like fluid.</span>
<span class="attribution"><span class="source">Teresa Brevini</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>The next step was to test UDCA’s efficacy in reducing ACE2 receptors in humans. We recruited eight healthy volunteers, gave them UDCA, and then swabbed their noses. We observed a reduction of ACE2 in their nasal cells, the main point of entry for the virus into the body, suggesting SARS-CoV-2 would have fewer opportunities to infect these cells.</p>
<p>Finally, since UDCA is widely used in clinical practice, we examined existing data to compare COVID outcomes among people taking UDCA for their liver conditions with outcomes among people not taking UDCA. We found that people taking UDCA were less likely to develop moderate, severe or critical COVID than those who did not receive the drug. </p>
<h2>What could this all mean?</h2>
<p><a href="https://www.ncbi.nlm.nih.gov/books/NBK545303/">UDCA</a> has been on the market for 30 years, and is very safe, with few side effects. In addition, the drug is off-patent, inexpensive, and easy to manufacture, store and administer (it’s taken in tablet form), rendering it convenient to deploy during an outbreak. </p>
<p>Although our results suggest that UDCA could protect against COVID, this study is not a clinical trial and only offers data supporting this hypothesis. The next step will be to confirm our findings in a large randomised clinical trial. We don’t support the use of UDCA for COVID until appropriate policy based on robust clinical evidence is available.</p>
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<strong>
Read more:
<a href="https://theconversation.com/covid-who-recommends-two-new-treatments-heres-how-they-work-175004">COVID: WHO recommends two new treatments – here's how they work</a>
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</p>
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<p>In the future, UDCA would not replace current COVID treatments or highly effective vaccinations, but may be able to expand our arsenal of weapons against the virus. It could offer an alternative strategy which is not dependent on the immune system or subject to immune escape because of viral mutations.</p><img src="https://counter.theconversation.com/content/195876/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Fotios Sampaziotis is a founder and shareholder of Bilitech LTD. This research has been supported by a UK Research and Innovation Future Leaders Fellowship grant.</span></em></p><p class="fine-print"><em><span>Teresa Brevini does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>This drug could essentially close the door to the virus, preventing it from getting into our cells.Teresa Brevini, PhD candidate, Wellcome-MRC Cambridge Stem Cell Institute, University of CambridgeFotios Sampaziotis, UKRI Future Leaders Fellow, Wellcome-MRC Cambridge Stem Cell Institute, University of CambridgeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1918262022-10-14T12:17:26Z2022-10-14T12:17:26ZHelping the liver regenerate itself could give patients with end-stage liver disease a treatment option besides waiting for a transplant<figure><img src="https://images.theconversation.com/files/489652/original/file-20221013-15-9kim2w.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2099%2C1426&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Tylenol overdose is one of the leading causes of liver injury requiring liver transplantation.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/human-purple-liver-wireframe-low-poly-style-royalty-free-illustration/1323289190">Elena Merkulova/iStock via Getty Images</a></span></figcaption></figure><p>The liver is known for its <a href="https://doi.org/10.1038/s41575-020-0342-4">ability to regenerate</a>. It can completely regrow itself even after two-thirds of its mass has been surgically removed. But damage from medications, alcohol abuse or obesity can eventually cause the liver to fail. Currently, the only effective treatment for end-stage liver disease is <a href="https://doi.org/10.1053/j.gastro.2017.01.003">transplantation</a>.</p>
<p>However, there is a <a href="https://doi.org/10.1002/lt.25320">dearth of organs available</a> for transplantation. Patients may have to <a href="https://www.medicalnewstoday.com/articles/states-with-shortest-liver-transplant-waiting-list">wait from 30 days to over five years</a> to receive a liver for transplant in the U.S. Of the <a href="https://www.organdonor.gov/learn/organ-donation-statistics">over 11,600 patients</a> on the waiting list to receive a liver transplant in 2021, only a little over 9,200 received one.</p>
<p>But what if, instead of liver transplantation, there were a drug that could help the liver regenerate itself?</p>
<p>I am the founding director of the <a href="https://livercenter.pitt.edu">Pittsburgh Liver Research Center</a> and run a lab <a href="https://scholar.google.com/citations?user=R2awLBUAAAAJ&hl=en">studying liver regeneration and cancer</a>. In our <a href="https://doi.org/10.1016/j.xcrm.2022.100754">2022 study</a>, my team and I found that activating a particular protein with a new medication can help accelerate regeneration and repair after severe liver injury or partial surgical removal in mice.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/rOv7Sr3X-eo?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">While the liver can regenerate itself, it can’t be endlessly donated for transplants.</span></figcaption>
</figure>
<h2>Key players in liver regeneration</h2>
<p>The liver performs <a href="https://doi.org/10.1126%2Fscitranslmed.3005975">over 500 key functions</a> in your body, <a href="https://www.hopkinsmedicine.org/health/conditions-and-diseases/liver-anatomy-and-functions">including</a> producing proteins that carry fat through the body, converting excess glucose into glycogen for storage and breaking down toxins like ammonia, among others.</p>
<p>Liver cells, or hepatocytes, take on these many tasks by a divide-and-conquer strategy, also called <a href="https://doi.org/10.1016/j.ajpath.2021.09.007">zonation</a>. This separates the liver into three zones with different tasks, and cells are directed to perform specialized functions by turning on specific genes active in each zone. However, exactly what controls the expression of these genes has been poorly understood.</p>
<p>Over the past two decades, my team and other labs have identified one group of 19 proteins called <a href="https://doi.org/10.3727/105221621x16111780348794">Wnts</a> that play an important role in controlling liver function and regeneration. While researchers know that Wnt proteins help activate the repair process in damaged liver cells, which ones actually control zonation and regeneration, as well as their exact location in the liver, have been a mystery.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/o-Kvlxyj43I?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Liver disease progresses in four stages.</span></figcaption>
</figure>
<p>To identify these proteins and where they came from, my team and I used a new technology called <a href="https://doi.org/10.1038/s41592-022-01409-2">molecular cartography</a> to identify how strongly and where 100 liver function genes are active. We found that <a href="https://doi.org/10.1016/j.xcrm.2022.100754">only two of 19 Wnt genes</a>, Wnt2 and Wnt9b, were functionally present in the liver. We also found that Wnt2 and Wnt9b were located in the endothelial cells lining the blood vessels in zone 3 of the liver, an area that plays a role in a number of metabolic functions.</p>
<p>To our surprise, eliminating these two Wnt genes resulted in all liver cells expressing only genes typically limited to zone 1, significantly limiting the liver’s overall function. This finding suggests that liver cells experience an ongoing push and pull in gene activation that can modify their functions, and Wnt is the master regulator of this process. </p>
<p>Eliminating the two Wnt genes from endothelial cells also completely stopped liver cell division, and thus regeneration, after partial surgical removal of the liver.</p>
<h2>Liver regeneration after Tylenol overdose</h2>
<p>We then decided to <a href="https://doi.org/10.1016/j.xcrm.2022.100754">test whether a new drug</a> could help recover liver zonation and regeneration. This drug, an antibody called FL6.13, shares similar functions with Wnt proteins, including activating liver regeneration. </p>
<p>Over the course of two days, we gave this drug to mice that were genetically engineered to lack Wnt2 and Wnt9b in their liver endothelial cells. We found that the drug was able to nearly completely recover liver cell division and repair functions.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/489654/original/file-20221013-24-sjaj2m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Illustration of fatty liver pathology" src="https://images.theconversation.com/files/489654/original/file-20221013-24-sjaj2m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/489654/original/file-20221013-24-sjaj2m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/489654/original/file-20221013-24-sjaj2m.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/489654/original/file-20221013-24-sjaj2m.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/489654/original/file-20221013-24-sjaj2m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/489654/original/file-20221013-24-sjaj2m.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/489654/original/file-20221013-24-sjaj2m.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Left untreated, fatty liver disease can lead to severe damage.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/fatty-liver-conceptual-illustration-royalty-free-illustration/932736606">Kathryn Kon/Science Photo Library via Getty Images</a></span>
</figcaption>
</figure>
<p>Lastly, we wanted to test how well this drug worked to repair the liver after Tylenol overdose. Tylenol, or acetaminophen, is an over-the-counter medication commonly used to treat fever and pain. However, an overdose of Tylenol can <a href="https://www.ncbi.nlm.nih.gov/books/NBK548162/">cause severe liver damage</a>. Without immediate medical attention, it can lead to liver failure and death. <a href="https://www.ncbi.nlm.nih.gov/books/NBK441917/">Tylenol poisoning</a> is one of the most common causes of severe liver injury requiring liver transplantation in the U.S. Despite this, there is currently only one medication available to treat it, and it is only able to prevent liver damage if taken shortly after overdose.</p>
<p>We tested our new drug on mice with liver damage from toxic doses of Tylenol. We found that one dose was able to decrease liver injury biomarkers – proteins the liver releases when injured – in the blood and reduce liver tissue death. These findings indicate that liver cell repair and tissue regeneration are occurring.</p>
<h2>Reducing the need for transplantation</h2>
<p>One way to address liver transplantation shortages is to improve treatments for liver diseases. While current medications can effectively cure <a href="https://www.who.int/news-room/fact-sheets/detail/hepatitis-c">hepatitis C</a>, a viral infection that causes liver inflammation, other liver diseases haven’t seen the same progress. Because very few effective treatments are available for illnesses like nonalcoholic fatty liver disease and alcoholic liver disease, many patients worsen and end up needing a liver transplant.</p>
<p>My team and I believe that improving the liver’s ability to repair itself could help circumvent the need for transplantation. Further study of drugs that promote liver regeneration may help curb the burden of liver disease worldwide.</p><img src="https://counter.theconversation.com/content/191826/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Satdarshan Monga receives funding from NIDDK and NCI at National Institutes of Health. Satdarshan Monga is a consultant for Surrozen and AntlerA.</span></em></p>Liver transplant waitlists can range from 30 days to over five years. Developing treatments that spur liver regeneration could help reduce demand for scarce organs.Satdarshan (Paul) Singh Monga, Professor of Pathology and Medicine, University of PittsburghLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1225322019-09-01T19:48:55Z2019-09-01T19:48:55ZAustralia has a paracetamol poisoning problem. This is what we should be doing to reduce harm<figure><img src="https://images.theconversation.com/files/290237/original/file-20190830-115387-2lcq5f.jpg?ixlib=rb-1.1.0&rect=5%2C10%2C3438%2C2282&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Paracetamol overdoses can cause serious liver damage.</span> <span class="attribution"><span class="source">From shutterstock.com</span></span></figcaption></figure><p>Most of us take paracetamol every now and again to reduce pain or fever. As far as medications go, it’s one we’re unlikely to associate with harm.</p>
<p>But in a study published today in the <a href="https://www.mja.com.au/journal/2019/211/5/paracetamol-poisoning-related-hospital-admissions-and-deaths-australia-2004-2017">Medical Journal of Australia</a>, my colleagues and I reveal a concerning increase in paracetamol poisonings, and resulting liver damage, in Australia over the last decade.</p>
<p>In fact, paracetamol is actually the <a href="https://www.mja.com.au/journal/2018/209/2/patterns-poisoning-exposure-different-ages-2015-annual-report-australian-poisons">number one pharmaceutical</a> Australian poisons centres receive calls about.</p>
<p>Paracetamol is safe if used appropriately, at a maximum of four grams per day in adults (equivalent to eight 500mg tablets, or six 665mg modified release tablets). However when this dose is exceeded, there is a potential for harm. And the bigger the dose, the greater the risk.</p>
<p>It’s time to consider restrictions, including reducing pack sizes and changing the way paracetamol is sold. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/weekly-dose-paracetamol-may-be-our-favourite-mild-painkiller-but-it-doesnt-work-for-everything-57967">Weekly Dose: paracetamol may be our favourite mild painkiller, but it doesn't work for everything</a>
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<h2>Our study</h2>
<p>We analysed data from national hospital admissions, poisons centre calls, and coroners’ records to examine poisonings, liver injuries, and deaths. </p>
<p>The annual number of cases of paracetamol poisoning increased by 44% from 2007-2008 to 2016-2017. </p>
<p>In that time, we recorded more than 95,000 paracetamol-related hospitalisations.</p>
<p>Liver injury from paracetamol has doubled over the same period. This is likely because people are taking more tablets when they overdose than in previous years, increasing the risk of liver failure. </p>
<p>More than 200 people died from paracetamol poisoning in Australia in the ten year period.</p>
<h2>What a paracetamol overdose does to your body</h2>
<p>Paracetamol itself is not toxic, but in large amounts it overwhelms the body’s ability to process it safely. This can lead to build up of a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2637612/">toxic metabolite</a> (or break-down product), which binds to liver cells, causing these cells to die. </p>
<p>The quantity that constitutes a toxic dose depends on circumstances including the time period in which the paracetamol is taken, and the person’s weight. But any adult ingesting more than four grams in a day could be at risk.</p>
<p>In severe cases, liver failure means the person will need a liver transplant, or they won’t survive.</p>
<p>Paracetamol is the leading cause of <a href="https://www.ncbi.nlm.nih.gov/pubmed/16317692">acute liver failure</a> in the Western world. </p>
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<p>
<em>
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Read more:
<a href="https://theconversation.com/we-need-to-talk-about-this-paracetamol-problem-dont-we-19051">We need to talk about this paracetamol problem....don't we?</a>
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<p>There is an antidote to paracetamol toxicity, called N-acetylcysteine (NAC), which is given as an intravenous infusion in hospital. Importantly, NAC works best when given early: it should be started before any symptoms appear. Symptoms of paracetamol poisoning – nausea, vomiting and abdominal pain – indicate damage has already started to occur. </p>
<p>Patients who take <a href="https://www.ncbi.nlm.nih.gov/pubmed/28644687">very large overdoses</a>, and overdoses with <a href="https://www.ncbi.nlm.nih.gov/pubmed/29451045">modified release paracetamol</a>, are more likely to sustain liver failure despite treatment with the antidote.</p>
<p>Modified release paracetamol comes in a higher strength, designed to be released over a longer period, which can be confusing and result in overdose. </p>
<h2>Accidental vs intentional overdosing</h2>
<p>Overdoses can be either accidental or intentional, and our figures include both. </p>
<p>Paracetamol is not a drug people become addicted to, or dependent on, in the same way people do with opioids or other drugs.</p>
<p>Intentional poisonings occur when people knowingly take too much paracetamol as a form of <a href="https://bmjopen.bmj.com/content/9/2/e026001">self-harm</a>. In our research, about three-quarters of cases were intentional. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/290238/original/file-20190830-115391-1l9cry3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/290238/original/file-20190830-115391-1l9cry3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/290238/original/file-20190830-115391-1l9cry3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/290238/original/file-20190830-115391-1l9cry3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/290238/original/file-20190830-115391-1l9cry3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/290238/original/file-20190830-115391-1l9cry3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/290238/original/file-20190830-115391-1l9cry3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Dosing mistakes can occur when parents are giving paracetamol to their children.</span>
<span class="attribution"><span class="source">From shutterstock.com</span></span>
</figcaption>
</figure>
<p>People might accidentally overdose because they are in pain, and believe because paracetamol is so widely available, it must be safe. They take more than the recommended dose, or take multiple different paracetamol-containing products together, resulting in harm. </p>
<p>Poisons centres also receive calls about <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3447018/">children having too much paracetamol</a>, usually due to dosing errors or a child finding and ingesting the medicine. </p>
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Read more:
<a href="https://theconversation.com/research-check-does-paracetamol-in-pregnancy-cause-child-behavioural-problems-63994">Research Check: does paracetamol in pregnancy cause child behavioural problems?</a>
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<h2>Some tips to avoid accidentally overdosing</h2>
<p>It’s important to be aware of the many brands of paracetamol-containing products, including cold and flu products, to avoid doubling up. People should also read the pack and ensure they follow the dosing instructions.</p>
<p>Parents should consider the following to avoid overdosing in children: </p>
<ul>
<li>paracetamol should be stored out of reach (for example, don’t leave it on the bench or change table after use)</li>
<li>paracetamol can be dosed every four to six hours, but must not exceed four doses in a 24 hour period</li>
<li>keep track of doses given and when by writing them down</li>
<li>read the label carefully and ensure you understand how to use the syringe/dosing device correctly.</li>
</ul>
<h2>Changing the way paracetamol is sold</h2>
<p>Paracetamol poisoning and resultant liver injury is preventable, and some simple public health measures could have a significant impact. </p>
<p>In Australia, paracetamol can be purchased outside of pharmacies (for example, in supermarkets) in packs of 20 tablets. In pharmacies, packs of 100 can be purchased without needing to speak to a pharmacist. </p>
<p>In both cases, there are no legal restrictions on the number of packs one person can purchase. This is out of step with many other countries, especially the UK and Europe.</p>
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Read more:
<a href="https://theconversation.com/is-it-ok-to-give-children-pain-killers-we-asked-five-experts-95148">Is it ok to give children pain killers? We asked five experts</a>
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<p>The UK restricted packs to 32 tablets in pharmacies and 16 tablets outside of pharmacies in 1998, as a response to increasing deaths from paracetamol. This resulted in a <a href="https://www.bmj.com/content/346/bmj.f403">long-term reduction</a> in paracetamol poisonings, liver injury, and deaths.</p>
<p>Many <a href="https://www.ncbi.nlm.nih.gov/pubmed/29319222">European counties</a> don’t allow non-pharmacy sales of paracetamol, and have small packs in pharmacies. Denmark has gone one step further, restricting paracetamol sales to those aged <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/bcpt.13003">18 and over</a>.</p>
<h2>Modified release paracetamol</h2>
<p>In our study, modified release paracetamol overdoses increased by 38% each year, and were disproportionately involved in deaths. </p>
<p>Modified release paracetamol has been <a href="https://www.ema.europa.eu/en/medicines/human/referrals/paracetamol-modified-release">completely banned</a> in Europe. This is due to documented harms, including increased risk of liver failure and death. </p>
<p>The Therapeutic Goods Administration <a href="https://www.tga.gov.au/changes-way-modified-release-paracetamol-products-are-supplied-questions-and-answers">recently announced</a> modified release paracetamol would become Schedule 3 in 2020, meaning it will be behind the pharmacist’s counter.</p>
<p>This restriction is a step in the right direction, but ignores the fact regular paracetamol can be purchased in large quantities without consultation with a health-care professional. </p>
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Read more:
<a href="https://theconversation.com/curious-kids-how-does-pain-medicine-work-in-the-body-82495">Curious Kids: How does pain medicine work in the body?</a>
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<hr>
<p>Due to its widespread use, paracetamol is likely to remain a common source of poisoning. Our study shows it’s increasingly important we take measures to reduce harm from these events. </p>
<p>Restricting pack sizes and restricting availability of modified release paracetamol are crucial first steps. We also need increased public awareness of how to use paracetamol safely.</p>
<p><em>If this article has raised issues for you, or if you’re concerned about someone you know, call Lifeline on 13 11 14. For advice on suspected paracetamol overdose, call the <a href="https://www.poisonsinfo.nsw.gov.au/">Poisons Information Centre</a> on 13 11 26.</em></p><img src="https://counter.theconversation.com/content/122532/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rose Cairns receives funding from the NHMRC to study suicide prevention.</span></em></p>The annual number of paracetamol poisoning cases in Australia has increased by 44% over the last decade. To tackle this problem, we need tighter regulation around the way paracetamol is sold.Rose Cairns, Lecturer in Pharmacy, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1204612019-08-21T15:46:27Z2019-08-21T15:46:27ZLiver disease: how new intelligent testing could save thousands of lives<figure><img src="https://images.theconversation.com/files/288801/original/file-20190820-170914-1kn0n2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/diverse-people-friends-hanging-out-drinking-336896096">Shutterstock</a></span></figcaption></figure><p>Since the 1970s, liver disease in the UK has <a href="https://www.bmj.com/content/352/bmj.i124">increased</a> by more than 400%, particularly in people under 65 – in marked contrast to all other major causes of death which have been decreasing in younger age groups. This epidemic has been driven by alcohol, obesity and <a href="https://www.nhs.uk/conditions/hepatitis-c/">hepatitis C</a>.</p>
<p>The liver is the factory of the body, making vital proteins and breaking down waste products or excreting them. Liver disease is usually a silent disease in its early stages. Liver function tests (LFTs) are routinely available blood tests associated with liver damage, so should be able to detect liver problems early on. Millions of these tests are performed each year in the UK by doctors and nurses for a multitude of symptoms and problems ranging from feelings of tiredness, to yellowing of skin (in white people) or the whites of the eyes, due to <a href="https://www.nhs.uk/conditions/jaundice/">jaundice</a>.</p>
<p>LFTs are commonly abnormal due to a variety of reasons, such as drinking too much, fatty liver caused by obesity, infections, rare liver diseases and some cancers – but they can be a sign of curable potentially fatal liver disease. </p>
<p>But it is complex to sort out what to do about them – many people with abnormal LFTs are not investigated because of the complex pattern of investigation. In those who are, current care is geared to find an explanation via a lengthy process of investigation and ruling things out, with costs to patients and the NHS in terms of money and time – many people drop out along the way.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/288802/original/file-20190820-170946-3hb8hf.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/288802/original/file-20190820-170946-3hb8hf.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=266&fit=crop&dpr=1 600w, https://images.theconversation.com/files/288802/original/file-20190820-170946-3hb8hf.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=266&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/288802/original/file-20190820-170946-3hb8hf.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=266&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/288802/original/file-20190820-170946-3hb8hf.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=334&fit=crop&dpr=1 754w, https://images.theconversation.com/files/288802/original/file-20190820-170946-3hb8hf.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=334&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/288802/original/file-20190820-170946-3hb8hf.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=334&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="attribution"><span class="license">Author provided</span></span>
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<p>This misses an opportunity to diagnose and treat liver disease at an early stage. With the dramatic rise in the rate of testing and the number of resulting abnormalities, this is not sustainable. So how do we investigate the abnormal LFTs to maximise health gain and minimise health costs?</p>
<h2>Rules, clinical facts and algorithms</h2>
<p>We use a smarter application of existing knowledge and technology. To solve the problem, we developed a set of rules for the diagnosis of many liver diseases using only blood results – for both the cause of the liver damage as well the severity of it – combined with simple clinical facts, such as alcohol intake and body mass index.</p>
<p>In effect, we reduced what a liver specialist does when they see a patient to a set of rules that could be used to create algorithms that would give a specific diagnosis to many patients, and a helpful management plan to the rest who may need to manage lifestyle factors. We went on and <a href="https://www.journal-of-hepatology.eu/article/S0168-8278(19)30354-X/abstract">tested this set of rules</a> to show that they did work as well as actually consulting a liver specialist.</p>
<p>The other component that allows our new system to work is in the blood sciences laboratory. When a blood sample arrives in the lab, it has a bar code and is placed on a large track system, like a model train track. A computer directs the sample to all the machines it needs to go through to have all the required tests performed. The computer also has the ability to change what happens to the sample depending on the first results.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/288803/original/file-20190820-170922-1ywhc2h.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/288803/original/file-20190820-170922-1ywhc2h.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=383&fit=crop&dpr=1 600w, https://images.theconversation.com/files/288803/original/file-20190820-170922-1ywhc2h.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=383&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/288803/original/file-20190820-170922-1ywhc2h.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=383&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/288803/original/file-20190820-170922-1ywhc2h.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=481&fit=crop&dpr=1 754w, https://images.theconversation.com/files/288803/original/file-20190820-170922-1ywhc2h.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=481&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/288803/original/file-20190820-170922-1ywhc2h.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=481&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption"></span>
<span class="attribution"><span class="license">Author provided</span></span>
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<p>So we created “intelligent liver function testing” or “iLFT”. In the new system the GPs who suspected liver disease in a patient selected the intelligent LFT pathway in the lab test requesting system and entered clinical details – BMI, alcohol intake and presence of high blood pressure, high cholesterol or diabetes. The algorithm was integrated with the lab’s information management system, allowing appropriate biochemistry, haematology, virology and immunology tests to cascade if the initial LFTs were abnormal.</p>
<p>The iLFT algorithm then combined the clinical information, test results and fibrosis (the extent to which tissue is damaged) scores to generate a diagnosis and/or management plan available as a web link for quick access on the GPs computer. The system generates 32 outcomes, varying from a clear cut diagnosis to a description of what has been found and suggestions for further investigation. This maximises the diagnosis of early liver disease. iLFT uses a synthesis of existing evidence combined with new algorithms that can be integrated into current lab biochemical analysers and technology to produce a diagnosis in many patients.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/288804/original/file-20190820-170956-9h33xo.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/288804/original/file-20190820-170956-9h33xo.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=227&fit=crop&dpr=1 600w, https://images.theconversation.com/files/288804/original/file-20190820-170956-9h33xo.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=227&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/288804/original/file-20190820-170956-9h33xo.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=227&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/288804/original/file-20190820-170956-9h33xo.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=285&fit=crop&dpr=1 754w, https://images.theconversation.com/files/288804/original/file-20190820-170956-9h33xo.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=285&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/288804/original/file-20190820-170956-9h33xo.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=285&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption"></span>
<span class="attribution"><span class="license">Author provided</span></span>
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<p>So on any sample sent for LFTs it would be possible to generate a diagnosis or prognosis. The system was trialled and showed that all patients can be investigated, increasing diagnosis of liver disease by 44%, and over an average patient lifetime this is an average saving of £3,216 per head.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/288805/original/file-20190820-170918-do56ct.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/288805/original/file-20190820-170918-do56ct.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=281&fit=crop&dpr=1 600w, https://images.theconversation.com/files/288805/original/file-20190820-170918-do56ct.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=281&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/288805/original/file-20190820-170918-do56ct.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=281&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/288805/original/file-20190820-170918-do56ct.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=353&fit=crop&dpr=1 754w, https://images.theconversation.com/files/288805/original/file-20190820-170918-do56ct.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=353&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/288805/original/file-20190820-170918-do56ct.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=353&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="attribution"><span class="license">Author provided</span></span>
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<p>In a system that is currently failing to offer a diagnosis to all patients with abnormal results on their liver function tests, iLFT increases diagnosis, improves quality of care and is cost effective. A switch to this new system could be achieved with minor changes to working practices and existing lab systems. iLFT has won multiple awards and is now the standard care in NHS Tayside – and other units and hospitals across the UK are now exploring its potential for their own patients.</p><img src="https://counter.theconversation.com/content/120461/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>John Dillon receives funding from chief scientist's office of the Scottish department of health. </span></em></p>A new test which capitalises on existing knowledge and technology will increase diagnoses, speed up the process and save the NHS millions of pounds.John Dillon, Professor of Hepatology and Gastroenterology, University of DundeeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1123462019-04-02T10:41:42Z2019-04-02T10:41:42ZKids exposed to flame retardant PBDE are at risk for lifelong liver or cardiovascular problems<figure><img src="https://images.theconversation.com/files/266586/original/file-20190329-70986-1q75yi3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Most baby clothes, toys, bedding and furniture are treated with flame-retardant chemicals.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/baby-clothes-newborn-pastel-colors-326694860">vkuslandia/SHutterstock.com</a></span></figcaption></figure><p>What factors determine if you will experience healthy and cheerful aging or if it will turn into an endless chain of suffering from numerous health conditions? </p>
<p>Many factors shape our health, including genetics, diet, physical activity, smoking and stress. Some other factors may be as powerful but may not yet be recognized. </p>
<p>I am an environmental toxicologist studying how man-made chemicals affect our health. I was always interested in understanding how our current health is shaped by chemical exposures during the embryonic and early postnatal period – life stages that are particularly sensitive to environmental stressors. </p>
<p>To address these questions, I focused on the analysis of long-term health effects induced by a family of chemicals used as flame retardants called <a href="https://www.epa.gov/sites/production/files/2014-03/documents/ffrrofactsheet_contaminant_perchlorate_january2014_final_0.pdf">polybrominated diphenyl ethers (PBDEs)</a>. The first patent for PBDE use as a flame retardant was issued in 1960, and manufacturing of commercial products containing PBDEs, such as building materials, electronics, furnishings, motor vehicles, plastics, polyurethane foams, baby pajamas and others, <a href="https://doi.org/10.1016/j.scitotenv.2008.05.003">began in 1965</a>. PBDEs were first detected by scientists in <a href="https://doi.org/10.1016/0045-6535(87)90291-8">animal tissues in the 1980s</a>. </p>
<p>Later studies showed that concentrations of these chemicals in human blood, milk and tissues were <a href="http://doi.org/10.1021/es035082g">increasing exponentially over the past 30 years, doubling every five years</a>, while their health effects were poorly understood.</p>
<h2>Early exposures trigger lifelong changes in blood lipids</h2>
<p>In one of my experiments, I fed mice one of the PBDEs most often found in human blood and milk – BDE-47. The <a href="http://doi.org/10.1210/js.2016-1011">female mice received it</a> from day 8 of their pregnancy until the end of nursing (postpartum day 21). </p>
<p>We exposed mice to 0.2 milligrams of this chemical per kilogram of body weight. This caused BDE-47 concentrations in the fat of experimental animals to reach similar levels to concentrations found in humans living in big American cities. This comparison is used in toxicology to ensure that laboratory experiments use doses relevant for human exposures. </p>
<p>We were surprised to find that triglyceride levels were significantly altered in the offspring of exposed mothers, even though exposure to BDE-47 ceased three months earlier. Triglycerides are main constituents of body fat and cell membranes in humans and other animals.</p>
<p>To understand how BDE-47 changes blood triglycerides and other lipids, <a href="http://doi.org/10.3389/fendo.2018.00548">my laboratory conducted another experiment</a> with mice. Lipids are insoluble molecules that are used to store energy and as structural components of cell membranes. </p>
<p>We hypothesized that changes in blood lipids result from changes in liver function. It is well-known that the liver regulates composition of lipids in blood. The liver can synthesize new lipids, destroy them, secrete lipids to blood and absorb them from blood. </p>
<p>To test our hypothesis, we exposed female mice to BDE-47 daily during pregnancy or during the period of lactation and analyzed health outcomes in offspring when they reached one year old – roughly equivalent to 50 years in humans. </p>
<p>This experiment again demonstrated that short-term exposure to BDE-47 during early steps of development results in long-lasting effects on blood lipids in mice. These effects were very similar in animals that were exposed during the embryonic period or during nursing. </p>
<h2>Reprogramming the balance of lipid in blood and liver</h2>
<p>In exposed animals, levels of blood triglycerides fell by half, and <a href="http://doi.org/10.3389/fendo.2018.00548">livers accumulated 20 percent to 40 percent more lipids than in mice that were never exposed to the chemical</a>. Activity of many liver genes encoding enzymes important for lipid metabolism was altered in exposed mice. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/266845/original/file-20190401-177196-xgnkmm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/266845/original/file-20190401-177196-xgnkmm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/266845/original/file-20190401-177196-xgnkmm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/266845/original/file-20190401-177196-xgnkmm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/266845/original/file-20190401-177196-xgnkmm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/266845/original/file-20190401-177196-xgnkmm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/266845/original/file-20190401-177196-xgnkmm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/266845/original/file-20190401-177196-xgnkmm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Stages of liver damage. In severe cases, high levels of fat in the liver can lead to liver cancer.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-vector/stages-liver-damage-disease-healthy-fatty-1071451652">wowow/Shutterstock.com</a></span>
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<p>Among key proteins involved in lipid metabolism, one was particularly high. This protein – CD36 – is responsible for pumping lipids from blood to the liver. Increased amount of CD36 in exposed animals is likely responsible for lowering lipids in blood and raising them in the liver, resulting in increased accumulation of these fats in the liver. </p>
<p>We observed that lower-exposure dose (0.2 mg/kg) and higher-exposure dose (1.0 mg/kg) regulated CD36 in opposite directions. Lower dose resulted in decreased CD36 and elevated blood triglycerides, while higher dose raised CD36 and decreased blood triglycerides. We think it is important to note that both tested doses were in the range of human exposures. </p>
<h2>Do changes in CD36 pose health risks?</h2>
<p>Our findings demonstrate that exposure to BDE-47 during early development can alter the levels of CD36 in either direction in mice and that both increase and decrease in CD36 may be deleterious. </p>
<p>When we exposed mice to high doses of BDE-47, this increased levels of the CD36 protein, which causes excessive accumulation of fat in liver cells. This condition is called nonalcoholic fatty liver disease. It is the <a href="http://doi.org/10.1002/hep.20701">most common form of chronic</a> <a href="http://doi.org/10.1097/01.mpg.0000239995.58388.56">liver disease among adults and children</a>. </p>
<p>Around <a href="https://doi.org/10.1002/hep.20466">one-third of the American population has</a> nonalcoholic fatty liver disease, and it is a risk factor for <a href="https://doi.org/10.1038/nrgastro.2013.41">Type 2 diabetes, hypertension, cardiovascular and kidney disease</a>, <a href="https://doi.org/10.1016/j.jhep.2011.10.027">liver cirrhosis and liver cancer</a>.</p>
<p>On the other hand, decreased activity of CD36 will lead to higher lipid levels in the blood and result in <a href="https://medlineplus.gov/atherosclerosis.html">atherosclerosis</a> – a disease in which plaques of lipids build on the walls of vessels. Atherosclerosis is the primary risk factors for <a href="https://healthmetrics.heart.org/wp-content/uploads/2017/06/Heart-Disease-and-Stroke-Statistics-2017-ucm_491265.pdf">heart attack, which causes around 800,000 deaths annually</a> in the U.S. alone. Thus, early life exposure to this environmental chemical may completely reprogram lifelong health trajectory.</p>
<p>Studies published by other laboratories confirm that <a href="https://doi.org/10.1007/s00204-018-2292-y">PBDEs disrupt lipid metabolism in rats</a> and <a href="https://doi.org/10.1007/s00204-018-2177-0">increase risk of nonalcoholic fatty liver disease</a> in mice exposed during early steps of development.</p>
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<img alt="" src="https://images.theconversation.com/files/266843/original/file-20190401-177163-1eavddz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/266843/original/file-20190401-177163-1eavddz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=280&fit=crop&dpr=1 600w, https://images.theconversation.com/files/266843/original/file-20190401-177163-1eavddz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=280&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/266843/original/file-20190401-177163-1eavddz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=280&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/266843/original/file-20190401-177163-1eavddz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=352&fit=crop&dpr=1 754w, https://images.theconversation.com/files/266843/original/file-20190401-177163-1eavddz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=352&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/266843/original/file-20190401-177163-1eavddz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=352&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">High levels of blood triglycerides can cause the buildup of fatty plaques that eventually block blood flow.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/closeup-atherosclerosis-3d-rendering-1036109620">Crevis/Shutterstock.com</a></span>
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<h2>Still at risk?</h2>
<p><a href="https://doi.org/10.1021/es303879n">PBDEs were banned in Europe by 2008</a> and <a href="https://www.epa.gov/sites/production/files/2014-03/documents/ffrrofactsheet_contaminant_perchlorate_january2014_final_0.pdf">voluntarily withdrawn by industry in North America by 2013</a>. It is likely that PBDEs’ production ceased all over the world, although data are missing for many regions. However these chemicals are still present in products used in U.S. households and cars. PBDEs are very stable compounds. Once released into the environment, they accumulate in sediments and in fatty tissues of wildlife and humans and stay there for many years. For example, the <a href="https://doi.org/10.1021/es1035046">half-life of different PBDEs</a> in the human body is between one and seven years. In the environment they found their way to fatty tissues of animals, many of which represent important sources of food for us.</p>
<p>Although production of PBDEs has ceased in developed countries, some studies report that concentrations of PBDEs in human tissues in the U.S. <a href="http://doi.org/10.1021/acs.est.7b00565">continue to grow</a>. </p>
<p>People born in the U.S. and Canada during the last 15 to 20 years were exposed during their early life to environmental concentrations of PBDE, comparable to those that reprogrammed lipid metabolism in our experiments with mice. Thus, we believe that about 20 percent of the North American population may be at risk of conditions associated with altered lipid concentrations in blood and liver. </p>
<p>Will these people develop aging-related conditions more readily than previous generations? The answer is yet to come. It is likely that PBDEs are not the only culprit. Many other ubiquitous pollutants, such as <a href="https://doi.org/10.1016/j.tox.2012.07.007">polychlorinated biphenyls (PCBs)</a>, <a href="https://www.toxicology.org/pubs/docs/Tox/2018Tox.pdf">dioxin (TCDD) and perfluorinated compounds (PFOS, PFNA)</a>, are known today to affect CD36 in mice. </p>
<p>It is not yet clear if effects of these other chemicals are as long-lasting as effects of PBDE. It is also not yet clear if effects of chemical exposures observed in mice are the same in humans. Mice are the most widely used animal model for testing the toxicity of pharmaceuticals and industrial chemicals, and animal toxicology studies generally are applicable to humans, <a href="https://www.ncbi.nlm.nih.gov/books/NBK215893/">although responses of laboratory animals</a> and humans to chemicals may differ in type and severity.</p><img src="https://counter.theconversation.com/content/112346/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alexander Suvorov receives funding from:
1. University of Massachusetts - Amherst (startup funding), expired
2. Institute of general Genetics of the Russian Academy of Sciences (research contract), expired
3. USA Department of State (research grant), expired
4. USA National Institutes of Health (research grant), current</span></em></p>Brief exposure to a family of chemicals used as flame retardants early in life can permanently alter fat levels in the blood and liver, raising the risk of liver cancer and heart disease.Alexander Suvorov, Assistant Professor, UMass AmherstLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/939552018-05-23T02:52:38Z2018-05-23T02:52:38ZWhen you’re sick, the support you’ll get may depend on the ‘worth’ of your disease<figure><img src="https://images.theconversation.com/files/212751/original/file-20180331-189810-1cjsl9q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Diseases low on the hierarchy of prestige are often difficult to diagnose and treat.</span> <span class="attribution"><a class="source" href="https://pixabay.com/en/care-diagnose-disease-health-3031259/">Pixabay</a></span></figcaption></figure><p>The name of an illness can affect the level of care a person receives. Cancer sufferers experiencing fear and uncertainty may have access to <a href="https://canceraustralia.gov.au/clinical-best-practice/multidisciplinary-care">cancer care centres</a>. Donations and bequests enable these centres to offer everything from accessible parking, to wig and beauty services, to comprehensive clinical care. </p>
<p>A person with arthritis, on the other hand, may have little access to public services. For instance, there is only one <a href="https://arthritisaustralia.com.au/nurses-the-key-to-caring-for-arthritis-17-october-2017/">rheumatology nurse</a> for every 45,000 people living with rheumatoid arthritis. </p>
<p>While suffering can be severe across all diseases, access to care is uneven. The hierarchy that determines how little or how much support is available for an illness is known as “disease prestige”. </p>
<p>The idea was introduced in the 1940s and since then a <a href="https://today.mims.com/a-case-of-hierarchy-in-medical-conditions-and-specialities">number of researchers</a> have tried to classify diseases on a <a href="http://www.abc.net.au/radionational/programs/lifematters/is-there-a-social-hierarchy-for-diseases/9421840">hierarchy of prestige</a>. The higher a disease is on this hierarchy, the more resources and community support available for its sufferers. The lower a disease, the less resources.</p>
<p>Generally, high-prestige diseases are treated with technically sophisticated procedures, occur in the upper part of the body and often affect young people. Heart disease and childhood cancer are examples.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/217449/original/file-20180503-153895-g1pbus.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/217449/original/file-20180503-153895-g1pbus.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=3344&fit=crop&dpr=1 600w, https://images.theconversation.com/files/217449/original/file-20180503-153895-g1pbus.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=3344&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/217449/original/file-20180503-153895-g1pbus.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=3344&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/217449/original/file-20180503-153895-g1pbus.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=4203&fit=crop&dpr=1 754w, https://images.theconversation.com/files/217449/original/file-20180503-153895-g1pbus.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=4203&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/217449/original/file-20180503-153895-g1pbus.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=4203&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Author provided.</span>
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<p>Low-prestige diseases tend to be vague and difficult to diagnose and treat. Many carry shame and stigma, or are thought to be the “fault” of the sufferer. Examples include urinary incontinence, schizophrenia and liver disease.</p>
<h2>Urinary incontinence</h2>
<p>Urinary incontinence describes any accidental or involuntary loss of urine from the bladder. It ranges in severity from “just a small leak” to complete loss of bladder control and can seriously <a href="https://theconversation.com/urinary-incontinence-it-doesnt-have-to-be-a-secret-shame-7869">affect a person’s well-being</a>. Urinary incontinence affects <a href="https://www.continence.org.au/pages/key-statistics.html">13% of men and 37% of women</a>. It particularly affects people after surgery (such as hysterectomy or prostate cancer surgery) and women after childbirth. </p>
<p>Incontinence can be treated and managed. In many cases it can also be cured, but only a third of people who experience incontinence will <a href="https://www.continence.org.au/pages/key-statistics.html">discuss their condition</a> with a health professional. Like many people with embarrassing conditions, people who have <a href="https://theconversation.com/urinary-incontinence-it-doesnt-have-to-be-a-secret-shame-7869">urinary incontinence</a> may keep it secret due to shame. </p>
<p><strong><em>Read more: <a href="https://theconversation.com/urinary-incontinence-it-doesnt-have-to-be-a-secret-shame-7869">Urinary incontinence: it doesn’t have to be a secret shame</a></em></strong> </p>
<p>Despite the fact this condition is common and can be disabling, there is little investment in care. In 2010, the health system invested around <a href="https://www.continence.org.au/data/files/Access_economics_report/dae_incontinence_report__19_april_2011.pdf">A$270 million</a> in urinary incontinence. The remainder of the <a href="https://www.continence.org.au/data/files/Access_economics_report/dae_incontinence_report__19_april_2011.pdf">A$67 billion</a> impact of this disease fell on patients and carers. </p>
<p>Disease champions have targeted such discrepancy in different ways. The <a href="https://www.continence.org.au/">Incontinence Foundation</a>, for instance, has used comedians to promote its cause in the <a href="https://www.continence.org.au/news.php/537/laugh-without-leaking-can-comedy-cure-incontinence">“Laugh without Leaking”</a> campaign.</p>
<h2>Schizophrenia</h2>
<p>As we move down the hierarchy, we’re more likely to strike diseases with stigma, such as mental illness. <a href="https://www.sane.org/mental-health-and-illness/facts-and-guides/schizophrenia">Schizophrenia</a> is an illness that disrupts the functioning of the human mind. It causes intense episodes of psychosis, involving delusions and hallucinations, and longer periods of reduced motivation and functioning. </p>
<p>The <a href="https://www.mifa.org.au/images/Documents/Wellways/164829%20Understanding%20Schizophrenia.pdf">causes are not clear</a>, but are probably due to a combination of genetic, psychological and social factors. Schizophrenia <a href="https://www.sane.org/mental-health-and-illness/facts-and-guides/schizophrenia">affects 1% of the population</a> and often begins in adolescence. Despite the fact schizophrenia is common in the community, it is <a href="https://www.sane.org/mental-health-and-illness/facts-and-guides/reducing-stigma#introduction">poorly understood and often feared</a>. </p>
<p>Patients with mental illnesses often <a href="https://www.sane.org/mental-health-and-illness/facts-and-guides/reducing-stigma#what-is-stigma">avoid disclosing their illness</a> because of active discrimination in the workplace, at home or in institutions, such as <a href="https://www.beyondblue.org.au/about-us/about-our-work/discrimination-in-insurance">insurance companies</a>. Unfortunately, people with schizophrenia can also experience <a href="https://ama.com.au/ausmed/mental-health-stigma">significant stigma from health professionals</a> and can have poor health outcomes with <a href="https://www.livingwithschizophreniauk.org/advice-sheets/physical-health-schizophrenia/">early death from physical illness</a>. </p>
<p>American academic and schizophrenia sufferer <a href="https://www.ted.com/talks/elyn_saks_seeing_mental_illness">Elyn Saks</a> and other high-profile people living with schizophrenia are addressing the stigma, but progress is slow.</p>
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<figcaption><span class="caption">Elyn Saks shares her experiences with schizophrenia in this TED talk. Source: YouTube.</span></figcaption>
</figure>
<p>We can understand the impact of disease prestige for diseases like schizophrenia by looking at fundraising. The <a href="https://www.pinkribbon.com.au/">Pink Ribbon campaign</a> for breast cancer has raised an average <a href="https://www.pinkribbon.com.au/about-us/about-cancer-council/">A$6 million per year</a>. In contrast, schizophrenia, which causes about half the <a href="https://www.aihw.gov.au/reports-statistics/health-conditions-disability-deaths/burden-of-disease/overview">burden of disease</a> of breast cancer, raised A$100,000 last year through <a href="https://www.sane.org/images/Annual_Reports/2016-SANE-Australia-signed-financials.pdf">SANE Australia</a>. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/mood-and-personality-disorders-are-often-misconceived-heres-what-you-need-to-know-94971">Mood and personality disorders are often misconceived: here's what you need to know</a>
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<h2>Liver disease</h2>
<p>Stigmatised diseases include those that could be influenced by a person’s behaviour, such as <a href="https://www.mycause.com.au/charity/2026/AustralianLiverFoundation">cirrhosis of the liver</a>. Cirrhosis is a type of liver scarring which can be caused by excessive alcohol consumption, hepatitis B and C (which can be the result of sexual transmission or drug use), and fatty liver, common in obesity and diabetes. Stigma stops the majority of people living with viral hepatitis enjoying <a href="https://www.hepatitisaustralia.com/">the quality of life they deserve</a>. </p>
<p>However, liver disease can also <a href="http://www.liverkids.org.au/">occur in children</a>. Liver transplant is the only treatment available for children with severe acute liver failure or chronic end-stage liver disease, certain metabolic diseases and some liver cancers. In 2012, there were more than <a href="http://cart.gesa.org.au/membes/files/Resources/Deloitte_Report_FINAL_06032013.pdf">6 million Australians</a> living with liver disease and more than <a href="http://cart.gesa.org.au/membes/files/Resources/Deloitte_Report_FINAL_06032013.pdf">7,000 deaths</a> due to liver disease in Australia. However, Commonwealth research funding is low.</p>
<h2>Research funding</h2>
<p>Research funding from Commonwealth sources, such as the <a href="https://www.nhmrc.gov.au/grants-funding/research-funding-statistics-and-data">National Health and Medical Research Council</a> (NHMRC), follows the disease prestige hierarchy. <a href="https://www.aihw.gov.au/reports-statistics/health-conditions-disability-deaths/burden-of-disease/overview">Burden of disease</a> can be measured in <a href="http://www.who.int/healthinfo/global_burden_disease/metrics_daly/en/">DALYs</a> (Disease Adjusted Life Years), a way of quantifying the <a href="https://www.aihw.gov.au/reports/burden-of-disease/abds-impact-and-causes-of-illness-death-2011">healthy years lost to disease</a>. </p>
<iframe src="https://datawrapper.dwcdn.net/MRARt/3/" scrolling="no" frameborder="0" allowtransparency="true" width="100%" height="405"></iframe>
<p>If we compare the research investment across the national health priorities, we see each year of healthy life lost attracts different levels of investment, depending on the disease involved. The Medical Research Future Fund may <a href="http://health.gov.au/internet/main/publishing.nsf/Content/medical-research-future-fund-budget-2017-factsheets">extend this discrepancy</a>, with almost half of its initial investments being earmarked for cancer research. </p>
<iframe src="https://datawrapper.dwcdn.net/txwhE/5/" scrolling="no" frameborder="0" allowtransparency="true" width="100%" height="405"></iframe>
<p>The following graph shows the National Health Priority diseases, as <a href="https://www.nhmrc.gov.au/grants-funding/research-funding-statistics-and-data">reported by the NHMRC</a>, and maps the research investment per DALY. We have calculated the investment for the low-prestige diseases by searching for <a href="https://www.nhmrc.gov.au/grants-funding/research-funding-statistics-and-data">grants allocated from 2010-2016</a> that mention liver disease, schizophrenia or urinary incontinence. </p>
<iframe src="https://datawrapper.dwcdn.net/3tdbr/1/" scrolling="no" frameborder="0" allowtransparency="true" width="100%" height="406"></iframe>
<p>As a community, we should aim to reduce suffering across the hierarchy of disease prestige. We need to consider issues of justice and equity, not only across populations, but also between diseases. When we raise money for health care, we need to consider who funding supports and who it does not. We also need to create clinical, educational and research priorities that recognise the complexities of funding the breadth of illness that occurs in the community.</p><img src="https://counter.theconversation.com/content/93955/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Louise Stone does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>In the hierarchy of diseases, those suffering from ‘high prestige’ diseases benefit from strong community and clinical support, while others are left in the dark.Louise Stone, Clinical Associate Professor, ANU Medical School, Australian National UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/878702017-11-22T23:30:17Z2017-11-22T23:30:17ZThree or four cups of coffee a day does you more good than harm – our new study suggests<figure><img src="https://images.theconversation.com/files/195721/original/file-20171121-6027-aozeyu.jpg?ixlib=rb-1.1.0&rect=28%2C712%2C3840%2C1839&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/623533091?size=huge_jpg">Nobuhiro Asada/Shutterstock.com</a></span></figcaption></figure><p>Drinking moderate amounts of coffee – about three or four cups a day – is more likely to benefit our health than harm it, our <a href="http://www.bmj.com/content/359/bmj.j5024">latest research</a> shows. This is important to know because around the world over <a href="http://www.ico.org/monthly_coffee_trade_stats.asp">two billion cups of coffee</a> are consumed every day.</p>
<p>Earlier studies have suggested beneficial links between coffee drinking and liver disease. Our research group has an interest in liver conditions. As such, we had previously conducted two meta-analyses, one looking for links between coffee drinking and <a href="http://onlinelibrary.wiley.com/doi/10.1111/apt.13523/full">cirrhosis</a> and another at coffee drinking and <a href="http://bmjopen.bmj.com/content/7/5/e013739">cancer of the liver</a>. We found that there was a lower risk of both conditions in people who drank more coffee.</p>
<p>Most of the evidence, however, is from observational studies, which can only find probable associations but can’t prove cause and effect. To overcome these limitations, we plan to conduct a randomised controlled trial in patients with non-alcoholic fatty liver disease to see if coffee works as a treatment to reduce the risk of the disease progressing. </p>
<p>But before we can start giving coffee to patients, we needed to know whether coffee drinking had any recognised harms, so we decided to conduct an umbrella review to capture as much important information about coffee drinking and health as we could. Umbrella reviews combine previous meta-analyses and give a high level summary of research findings.</p>
<h2>Many benefits</h2>
<p>Overall, our umbrella analysis showed that drinking coffee is more often linked with benefits than harms. For some conditions, the largest benefit appeared to be associated with drinking three to four cups of coffee each day. This included lower risk of death from any causes, or getting heart disease. Drinking coffee beyond these amounts was not associated with harm, but the benefits were less pronounced. </p>
<p>Drinking coffee was also associated with a lower risk of developing type 2 diabetes, metabolic syndrome, gallstones, renal stones and gout. We also found that it was associated with a lower risk of getting some types of cancer, Parkinson’s disease, depression and Alzheimer’s disease. But liver diseases stood out as having the greatest benefit compared with other conditions.</p>
<p>Reassuringly, harms were not apparent apart from during pregnancy when coffee drinking was linked to low birth weight, premature birth (in the first six months of pregnancy) and miscarriage. This is not new knowledge, and there are <a href="https://www.nhs.uk/chq/pages/limit-caffeine-during-pregnancy.aspx?categoryid=54&subcategoryid=130">guidelines for limiting caffeine intake in pregnancy</a>. We also found a small increase in risk of fracture in women, but there is some discrepancy in the evidence and further investigation is needed. </p>
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<img alt="" src="https://images.theconversation.com/files/195743/original/file-20171121-6035-iubrfj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/195743/original/file-20171121-6035-iubrfj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/195743/original/file-20171121-6035-iubrfj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/195743/original/file-20171121-6035-iubrfj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/195743/original/file-20171121-6035-iubrfj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/195743/original/file-20171121-6035-iubrfj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/195743/original/file-20171121-6035-iubrfj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Coffee drinking during pregnancy is linked with low birth weight.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/premature-newborn-baby-girl-hospital-incubator-396467254?src=vui79l8Gqq43OepQB9uAaw-1-6">OndroM/Shutterstock</a></span>
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<h2>Careful how you consume it</h2>
<p>Findings of our umbrella review should be interpreted with caution. Evidence in the review came mainly from observational research, so we can’t extrapolate our findings to suggest people start drinking coffee or increasing their intake in attempts to become healthier. What we can say is that people who already enjoy moderate amounts of coffee as part of their diet are most probably getting health benefits from it, rather than harm. </p>
<p>Our research is about coffee. It’s not about sugar, syrups, biscuits, cakes and pastries. Standard health messages still apply to those types of food. In other words, if you already drink coffee, enjoy it, but try to make it as healthy as possible.</p><img src="https://counter.theconversation.com/content/87870/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Robin Poole does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A new analysis shows that coffee is associated with a host of positive health effects.Robin Poole, Specialist Registrar in Public Health, University of SouthamptonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/816722017-08-02T20:19:44Z2017-08-02T20:19:44ZDr G. Yunupingu’s legacy: it’s time to get rid of chronic hepatitis B in Indigenous Australia<p>News of the tragic death of Dr G. Yunupingu last week in Darwin at only 46 years of age has again highlighted the unacceptable gap in life expectancy between Aboriginal and Torres Strait Islanders and other Australians. Yunupingu had been <a href="http://www.abc.net.au/news/2017-07-27/dr-g-yunupingu-death-we-need-to-close-the-gap/8748562">living with chronic hepatitis B</a> since early in life, and experienced complications of this condition including liver and kidney disease.</p>
<p>Hepatitis B infections, which can lead to liver disease and cancer, are unacceptably high in Indigenous Australians. In Northern Australia, 10-20% of the Indigenous population is <a href="http://www.abc.net.au/news/2017-08-02/aboriginal-health-workers-hosted-in-alaska/8765916">infected with the virus</a>. Eliminating the impact of this infection in Indigenous Australians would make a substantial contribution to closing the gap in life expectancy.</p>
<h2>Hepatitis B in Indigenous Australia</h2>
<p>Hepatitis B is the most prevalent form of viral hepatitis worldwide. It’s also the leading cause of liver cancer. Interestingly, hepatitis B used to be known as <a href="http://jamanetwork.com/journals/jama/article-abstract/654843">the “Australia Antigen”</a> as it was first discovered in Australian Aboriginal people in the 1960s.</p>
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Read more:
<a href="https://theconversation.com/explainer-the-a-b-c-d-and-e-of-hepatitis-54739">Explainer: the A, B, C, D and E of hepatitis</a>
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<p>Hepatitis B is around ten times more prevalent in Indigenous communities than in the rest of Australia. Of the nearly <a href="http://onlinelibrary.wiley.com/doi/10.1111/1753-6405.12693/full">240,000 Australians</a> estimated to be living with chronic hepatitis B, over 20,000 are thought to be Indigenous people. New infections with hepatitis B remain <a href="http://www.who.int/bulletin/volumes/94/11/16-169524/en/">three times as common</a> in Indigenous people as in non-Indigenous Australians. </p>
<p>The chance of developing chronic hepatitis B depends on an individual’s age at the time of infection. Around 90% of those who were exposed as infants develop chronic hepatitis B, but only 5% of those who were exposed as adults will develop chronic infection. Most people living with chronic hepatitis B were infected as young children – often, through mother-to-child transmission at the time of birth. This is why vaccination during infancy is particularly important.</p>
<p>The <a href="https://bmcinfectdis.biomedcentral.com/articles/10.1186/1471-2334-13-403">prevalence of chronic (long-term) hepatitis B</a> in Indigenous Australians varies significantly between regions. It is most prevalent in remote areas of Australia, with the Northern Territory having the highest prevalence of any Australian jurisdiction. Around <a href="http://onlinelibrary.wiley.com/doi/10.1111/1753-6405.12693/full">1.8% of the NT population</a> live with the disease. </p>
<p>The prevalence of hepatitis B and other communicable diseases such as skin infections and influenza in Indigenous communities is intensified by the social, economic, environmental and political situation in which Indigenous Australians find themselves.</p>
<h2>Liver disease</h2>
<p>In some people, chronic hepatitis B can cause severe liver scarring (cirrhosis) or liver cancer. Less commonly, hepatitis B can damage other parts of the body, including the kidneys and blood vessels. </p>
<p>Chronic liver disease contributes significantly to the Indigenous life expectancy gap. Liver cancer is the fastest-increasing cause of cancer deaths in Australia. In 2016, it was the <a href="http://onlinelibrary.wiley.com/wol1/doi/10.1111/imj.13393/full">sixth-most-common</a> cause of cancer deaths. However, for Indigenous people it is the <a href="http://www.aihw.gov.au/publication-detail/?id=60129558547">second-most-common cause</a> of cancer-related death after lung cancer. </p>
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Read more:
<a href="https://theconversation.com/three-charts-on-cancer-rates-in-australia-where-liver-cancer-is-on-the-rise-while-other-types-fall-79572">Three charts on: cancer rates in Australia, where liver cancer is on the rise while other types fall</a>
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<p>Compared to non-Indigenous Australians living in the NT, the rate of death due to liver cancer is <a href="https://www.mja.com.au/journal/2014/201/8/hepatocellular-carcinoma-australias-northern-territory-high-incidence-and-poor">six times greater</a> in Indigenous Australians.</p>
<p>Cure is rare with liver cancer, and most Indigenous Australians die within a few months of being diagnosed. In the NT, a range of factors contribute to the unequal burden of liver cancer in Indigenous Australians, but <a href="https://www.mja.com.au/journal/2014/201/8/hepatocellular-carcinoma-australias-northern-territory-high-incidence-and-poor">hepatitis B is the most important</a> cause.</p>
<h2>Hepatitis B vaccine is one way</h2>
<p>A safe, effective vaccine for hepatitis B has been provided for all infants in Australia since 2000 – and in the Northern Territory since 1990. As a result, new hepatitis B infections in children born since 2000, as well as those who received adolescent catch-up vaccination from 1998 onwards, <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home%7Ehandbook10part4%7Ehandbook10-4-5">have fallen markedly</a>.</p>
<p>However, funded hepatitis B vaccine for Indigenous adults is available <a href="http://onlinelibrary.wiley.com/doi/10.1111/1753-6405.12316/full">only in some states and territories</a>. This limits access for Indigenous people who remain at much higher risk of infection. A <a href="http://www.who.int/bulletin/volumes/94/11/16-169524/en/">recent study</a> suggested a funded catch-up vaccination program for Indigenous adults could rapidly eliminate disparity in hepatitis B incidence.</p>
<p>Vaccination has no effect for those who already have chronic hepatitis B. It is believed over 90,000 Australians living with hepatitis B have never been diagnosed and are unaware of their infection. <a href="http://onlinelibrary.wiley.com/doi/10.1111/1753-6405.12693/full">Only 15% of those infected</a> are receiving treatment or monitoring for their condition. </p>
<p><a href="https://theconversation.com/explainer-the-a-b-c-d-and-e-of-hepatitis-54739">Unlike hepatitis C</a>, hepatitis B is not yet curable, but current treatments are very well tolerated and effective at preventing liver disease and liver cancer. The profound <a href="http://onlinelibrary.wiley.com/doi/10.1111/1753-6405.12693/full">lack of access to treatment and care</a> among Indigenous people contributes to the disproportionate impact of hepatitis B on this population.</p>
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Read more:
<a href="https://theconversation.com/australia-leads-the-world-in-hepatitis-c-treatment-whats-behind-its-success-81760">Australia leads the world in hepatitis C treatment – what's behind its success?</a>
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<h2>Other ways to reduce infections</h2>
<p>An example of innovative care has been operating in Dr G. Yunupingu’s home community of Galiwin’ku for over five years. Under the management of <a href="http://miwatj.com.au/">Miwatj Health</a>, an Aboriginal community-controlled health organisation, a hepatitis specialist visits regularly three to four times per year. </p>
<p>The specialist brings necessary diagnostic equipment and effectively provides a “one-stop shop” for individuals living with hepatitis B in Galiwin’ku. Just as importantly, a local healthcare practitioner <a href="http://miwatj.com.au/what-we-do/clinical-services/at-galiwinku/">champions the cause of hepatitis B</a> treatment and elimination. Those infected are contacted and encouraged to see the specialist team.</p>
<p>Several other regions in the world with large Indigenous populations and high hepatitis B prevalence, such as <a href="http://anthctoday.org/community/hep/about/">Alaska</a> and <a href="http://www.hepatitisfoundation.org.nz/hepatitis-b/the-hepatitis-b-follow-up-programme/">New Zealand</a>, have developed programs to test most of the population and identify those with hepatitis B infections. Affected individuals are offered regular follow-up and care to prevent cirrhosis and liver cancer. </p>
<p>When delivering such care to Indigenous communities, it’s essential to develop trust and ensure <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-14-1233">culturally appropriate approaches</a>. Also important is partnering with communities and their health workers to develop <a href="https://www.menzies.edu.au/page/Resources/Hep_B_Story/">new ways of building awareness</a> of hepatitis B as an important health issue.</p>
<p>With comprehensive public health initiatives, long-term commitment to funding and policy – including significant workforce development to ensure as many people as possible are tested and appropriately followed up – the impact of hepatitis B on Indigenous communities can be eliminated.</p><img src="https://counter.theconversation.com/content/81672/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Benjamin Cowie receives funding from the Australian Government Department of Health, the Victorian Government Department of Health and Human Services, the Royal Melbourne Hospital Office for Research, and the Cooperative Research Centre for Spatial Information.</span></em></p><p class="fine-print"><em><span>Steven Tong receives funding from the National Health and Medical Research Council and has received funding from Gilead for Hepatitis B related research projects.</span></em></p><p class="fine-print"><em><span>James Ward does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Hepatitis B rates in Indigenous communities are ten times higher than the rest of Australia. Eliminating the infection from Indigenous Australia can make a significant contribution to closing the gap.Benjamin Cowie, Director, WHO Collaborating Centre for Viral Hepatitis, The Peter Doherty Institute for Infection and ImmunityJames Ward, Associate Professor, Infectious Diseases Research Aboriginal and Torres Strait Islander Health, South Australian Health & Medical Research InstituteSteven Tong, Associate Professor, The Peter Doherty Institute for Infection and ImmunityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/817602017-07-31T06:05:17Z2017-07-31T06:05:17ZAustralia leads the world in hepatitis C treatment – what’s behind its success?<figure><img src="https://images.theconversation.com/files/180287/original/file-20170731-15340-1wjpi3b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Tens of thousands of Australians have been cured of Hepatitis C since March 2016.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p>The Australian government has <a href="http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel-yr2017-hunt072.htm">listed yet another drug</a> to cure hepatitis C on the Pharmaceutical Benefits Scheme (PBS). The drug Epclusa® – a combination of sofosbuvir 400mg and velpatasvir 100mg – is the first of the <a href="https://theconversation.com/weekly-dose-sofosbuvir-whats-the-price-of-a-hepatitis-c-cure-63208">direct-acting antiviral treatments</a> effective for all types of the disease. It will cost most patients A$38.80, and A$6.30 for concession card holders. Before the PBS listing, the cost exceeded A$20,000.</p>
<p>A number of <a href="http://www.pbs.gov.au/info/healthpro/explanatory-notes/general-statement-hep-c">hepatitis C treatments</a> have been listed on the PBS since March 2016. The government has committed to investing A$1 billion over five years to treat the <a href="http://www.hepatitisaustralia.com/inquiry-facts/">230,000 Australians</a> living with the disease. </p>
<p>Australia is a leading country in the global response to hep C. Since March 2016, around 40,000 people with hep C have <a href="https://kirby.unsw.edu.au/news/chronic-cured-could-australia-be-first-country-world-eliminate-hep-c">had treatment</a>. An estimated 95% of them have been cured.</p>
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Read more:
<a href="https://theconversation.com/weekly-dose-sofosbuvir-whats-the-price-of-a-hepatitis-c-cure-63208">Weekly Dose: sofosbuvir – what's the price of a hepatitis C cure?</a>
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<p>The <a href="http://www.who.int/mediacentre/factsheets/fs164/en/">World Health Organisation</a> recently set ambitious goals for the “elimination of hepatitis C as a major public health threat”. These included having 80% of people treated and an 80% reduction in the spread of the virus by 2030. Given there are around 70 million people infected with hep C worldwide, only 20% diagnosed, and no effective vaccine, the task ahead is enormous. </p>
<p>But Australia is impressively heading towards these targets and may present a model for other countries to adopt. A recent <a href="https://kirby.unsw.edu.au/news/chronic-cured-could-australia-be-first-country-world-eliminate-hep-c">report by the Kirby Institute</a> estimated Australia was on track to eliminate hepatitis C by 2026 – four years earlier than the WHO goal.</p>
<h2>Why are we doing this?</h2>
<p>The government has taken such a proactive approach to treating hepatitis C for several reasons. </p>
<p>The first is the large burden of serious liver disease, such as liver cancer and liver failure. A recent report from the <a href="http://www.aihw.gov.au/publication-detail/?id=60129559785">Australian Institute for Health and Welfare</a> showed rates of liver cancer increased five-fold from 1982 to 2013, with hep C the major cause. Nearly <a href="https://liver-cancer.canceraustralia.gov.au/statistics">1,500 Australians died from liver </a> cancer in 2011-2012 and that number could more than double over the coming decade. </p>
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Read more:
<a href="https://theconversation.com/three-charts-on-cancer-rates-in-australia-where-liver-cancer-is-on-the-rise-while-other-types-fall-79572">Three charts on: cancer rates in Australia, where liver cancer is on the rise while other types fall</a>
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<p>Secondly, most people affected with hepatitis C are injecting drug users. Although Australia has led harm-reduction strategies, such as needle syringe programs and access to methadone for people who inject drugs, several thousand <a href="https://kirby.unsw.edu.au/report/annual-surveillance-report-hiv-viral-hepatitis-stis-2016">new infections continue</a> to occur each year.</p>
<p>A third reason is the appeal of the new direct-acting antiviral treatments themselves, which can cure 95% of people treated and have the capacity to prevent serious liver disease and spread of hep C. By contrast, treatments such as Harvoni (sofosbuvir plus ledipasvir) and Zepatier (grazoprevir plus elbasvir), which were added to the PBS in March 2016 and January 2017 respectively, are highly effective, but only active against one or two of the hep C strains. </p>
<p>The latest treatment, <a href="http://www.pbs.gov.au/info/industry/listing/elements/pbac-meetings/psd/2016-11/sofosbuvir-plus-velpatasvir-psd-november-2016">Epclusa</a>, is one tablet, to be taken daily, which combines two existing drugs – sofosbuvir and velpatasvir. It is highly effective against all six hep C strains, has a treatment duration of around three months and minimal side effects. </p>
<p>Another treatment effective for all the strains – which combines glecaprevir and pibrentasvir – is <a href="https://www.pbs.gov.au/industry/listing/elements/pbac-meetings/agenda/pdf/pbac-meeting-agenda-july-2017.doc">expected to be available</a> in Australia in 2018. Treatment duration will be only two months for patients without advanced liver disease.</p>
<h2>What’s behind Australia’s success?</h2>
<p>Australia has managed to develop a program of unrestricted access to treat people with hepatitis C – all adults with hep C are eligible. Most countries have restricted access to those with more advanced disease. <a href="http://www.journal-of-hepatology.eu/article/S0168-8278(17)30450-6/abstract">Many have denied access</a> to people with ongoing drug and alcohol use.</p>
<p>The key to this universal access was the Australian government’s capacity to negotiate much lower drug prices than in other high-income countries, following strong advocacy from the hepatitis C sector. For instance, Australia paid an estimated <a href="http://www.sciencedirect.com/science/article/pii/S0168827817302064?via%3Dihub">ten-fold lower price per patient</a> treated in 2016 than did Germany.</p>
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<a href="https://images.theconversation.com/files/180289/original/file-20170731-16184-k7iz2h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/180289/original/file-20170731-16184-k7iz2h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/180289/original/file-20170731-16184-k7iz2h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/180289/original/file-20170731-16184-k7iz2h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/180289/original/file-20170731-16184-k7iz2h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/180289/original/file-20170731-16184-k7iz2h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/180289/original/file-20170731-16184-k7iz2h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/180289/original/file-20170731-16184-k7iz2h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Many countries restrict access to hep C treatment for injecting drug users.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
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<p>In December 2015, the government <a href="http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel-yr2015-ley154.htm">committed to providing sizeable funding</a> for tackling hepatitis C for five years with a cap in expenditure and no cap in the treatment number. Australia also managed to involve non-specialists in hep C treatment, who from March 2016 were able to prescribe the new treatments. </p>
<p>General practitioners and other non-specialists now write at least <a href="https://kirby.unsw.edu.au/sites/default/files/kirby/report/Monitoring-hep-C-treatment-uptake-in-Australia_Iss7-JUL17.pdf">half of prescriptions</a> for the new antivirals, with around 80% of treatments dispensed in community pharmacies.</p>
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Read more:
<a href="https://theconversation.com/how-new-hepatitis-c-drugs-could-tackle-liver-cancer-too-73455">How new hepatitis C drugs could tackle liver cancer, too</a>
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<p>In <a href="http://www.journal-of-hepatology.eu/article/S0168-8278(17)30450-6/abstract">almost all other countries</a>, treatment of hep C is largely through specialist hospital-based clinics. In many countries only specialists can prescribe. Australia’s history of GP involvement in HIV antiviral treatment and drug dependency treatment was an important foundation to build a concerted hep C education and training program on.</p>
<p>Australia has also reached highly marginalised populations in large numbers. An estimated 20% of <a href="https://kirby.unsw.edu.au/report/australian-nsp-survey-national-data-report-2012-2016">people who inject drugs</a> have access to the new treatments, and numbers treated through the prison system are expanding rapidly. As mentioned, Australia has been a world leader in harm reduction for people who inject drugs (resulting in <a href="https://kirby.unsw.edu.au/report/annual-surveillance-report-hiv-viral-hepatitis-stis-2016">only 1% being HIV-infected</a>), and has also led the world in evaluating the new treatments in this key population group. </p>
<p>Most Australian jurisdictions are developing programs for new treatment access in drug and alcohol services and prisons. All these measures have provided the optimal framework for taking advantage of the incredible curative potential of the hep C treatments and their capacity to improve quality of life, prevent advanced liver disease, and limit the spread of hep C. </p>
<h2>How to sustain momentum</h2>
<p>A key to ensuring momentum of the initial surge of hep C treatment will be ongoing screening of high-risk populations. These include people with current or past injecting drug use and immigrants from high-prevalence countries, such as Egypt and Pakistan, where unsafe medical procedures have been responsible for most infections. In Australia, around 20% of people with hepatitis C <a href="https://kirby.unsw.edu.au/report/annual-surveillance-report-hiv-viral-hepatitis-stis-2016">remain undiagnosed</a>.</p>
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Read more:
<a href="https://theconversation.com/eliminating-hepatitis-c-an-ambitious-but-achievable-goal-24485">Eliminating hepatitis C – an ambitious but achievable goal</a>
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<p>Finally, raising awareness through days like World Hepatitis Day and overcoming the stigma many people with hep C carry will be fundamental to success. The potential of revolutionary hep C treatments to empower the whole sector, together with continued advocacy and government support, should see Australia head towards elimination of the disease over the next decade.</p><img src="https://counter.theconversation.com/content/81760/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Greg Dore consults to Gilead, Merck, Abbvie, and Bristol-Myers Squibb. He receives research funding from NHMRC, National Institutes of Health, Australian Government Department of Health, and NSW Health; Gilead, Merck, Abbvie, and Bristol-Myers Squibb. He is affiliated with Kirby Institute, UNSW Sydney. </span></em></p>Australia has been subsidising drugs to cure hepatitis C since March 2016. Unlike in many other countries, these are available to everyone with the disease and are much cheaper for our government.Gregory Dore, Professor of Medicine, Clinical Researcher and Epidemiologist, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/789212017-06-09T05:01:06Z2017-06-09T05:01:06ZWe know too much sugar is bad for us, but do different sugars have different health effects?<figure><img src="https://images.theconversation.com/files/172880/original/file-20170608-29563-1dmhqa8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The type of sugar in popular soft drinks varies from country to country even if the brand name is the same.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p>Our recent article published in the <a href="https://www.mja.com.au/journal/2017/206/10/sugar-content-soft-drinks-australia-europe-and-united-states">Medical Journal of Australia</a> found that Australian and European soft drinks contained higher concentrations of glucose, and less fructose, than soft drinks in the United States. The total glucose concentration of Australian soft drinks was on average 22% higher than in US formulations.</p>
<p>We compared the composition of sugars in four popular, globally marketed brands – Coca-Cola, Fanta, Sprite and Pepsi – using samples from Australia, Europe and the US. While the total sugar concentration did not differ significantly between brands or geographical location, there were differences between countries in the concentrations of particular sugars, even when drinks were marketed under the same trade name.</p>
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<a href="https://images.theconversation.com/files/172874/original/file-20170608-29563-pnrhx8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/172874/original/file-20170608-29563-pnrhx8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/172874/original/file-20170608-29563-pnrhx8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=913&fit=crop&dpr=1 600w, https://images.theconversation.com/files/172874/original/file-20170608-29563-pnrhx8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=913&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/172874/original/file-20170608-29563-pnrhx8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=913&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/172874/original/file-20170608-29563-pnrhx8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1148&fit=crop&dpr=1 754w, https://images.theconversation.com/files/172874/original/file-20170608-29563-pnrhx8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1148&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/172874/original/file-20170608-29563-pnrhx8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1148&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Sucrose is made up of one glucose molecule and one fructose molecule.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
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<p>Whether these differences have distinct effects on long-term health is currently unclear. Certainly, over-consumption of either glucose or fructose will contribute to <a href="http://ajcn.nutrition.org/content/98/4/1084.full.pdf">weight gain</a>, which is associated with a host of health conditions such as <a href="https://www.ncbi.nlm.nih.gov/pubmed/15328324">type 2 diabetes</a> and <a href="http://circ.ahajournals.org/content/121/11/1356">heart disease</a>. And because the body metabolises glucose and fructose in different ways, their effects may differ.</p>
<h2>Sucrose, glucose and fructose</h2>
<p>Soft drinks, as they are referred to in Australia, or “sodas” in the US and “fizzy drinks” in the UK, are non-alcoholic, carbonated, sugar-sweetened beverages. <a href="http://www.coca-colacompany.com/cs/tccc-yir2012/operating_groups.html">Australia ranks seventh out of the top ten countries</a> for soft drink sales per capita.</p>
<p>Sugars are the chief ingredient in soft drinks and include glucose, fructose and sucrose. The source of sugars in popular soft drinks varies between global regions. This is because sugars are sourced from different crops in different areas of the world. </p>
<p>Soft drinks in Australia are primarily sweetened with sucrose from sugar cane. Sucrose, often referred to as “table sugar”, is composed of one glucose molecule and one fructose molecule joined by chemical bonds. This means equal amounts of glucose and fructose are released into the bloodstream when sucrose is digested.</p>
<p>Overseas, soft drinks are sweetened with sucrose-rich sugar beet (Europe) or high-fructose corn syrup (US). High-fructose corn syrup is also made up of glucose and fructose, but contains a higher fructose-to-glucose ratio than sucrose.</p>
<h2>Do they have different health impacts?</h2>
<p>Fructose over-consumption is <a href="https://www.ncbi.nlm.nih.gov/pubmed/26055949">known to contribute</a> to <a href="http://christinecronau.com/wp-content/uploads/2011/10/nrgastro.2010.41.pdf">fatty liver disease</a>. Fatty liver disease affects <a href="https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/liver-fatty-liver-disease">about one in ten people</a> in the West. Non-alcoholic fatty liver disease is the leading cause of liver disease.</p>
<p>Some researchers have suggested too much fructose in the diet can harm the liver in a similar fashion to alcohol. However, this concern is related to <em>added</em> fructose in the diet, not natural sources. Natural sources of fructose, such as fruit, honey and some vegetables, are not generally over-consumed and provide other important nutrients, such as dietary fibre and vitamins. So, fruit does not generally pose a risk for fatty liver disease.</p>
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<a href="https://images.theconversation.com/files/173054/original/file-20170609-1721-1lht3p3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/173054/original/file-20170609-1721-1lht3p3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/173054/original/file-20170609-1721-1lht3p3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=406&fit=crop&dpr=1 600w, https://images.theconversation.com/files/173054/original/file-20170609-1721-1lht3p3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=406&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/173054/original/file-20170609-1721-1lht3p3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=406&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/173054/original/file-20170609-1721-1lht3p3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=510&fit=crop&dpr=1 754w, https://images.theconversation.com/files/173054/original/file-20170609-1721-1lht3p3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=510&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/173054/original/file-20170609-1721-1lht3p3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=510&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Natural sources of fructose, such as fruit, are generally not over-consumed.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
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<p>High glucose consumption rapidly elevates blood glucose and insulin. This may affect <a href="https://www.ncbi.nlm.nih.gov/pubmed/15451897">brain function</a>, including <a href="https://lipidworld.biomedcentral.com/articles/10.1186/1476-511X-13-195">mood and fatigue</a>. Because high blood glucose is <a href="https://www.ncbi.nlm.nih.gov/pubmed/16919548">linked to diabetes</a>, consumption of high-glucose drinks may also raise the risk of diabetes and cardiovascular (heart) disease. </p>
<p>All soft drinks are considered energy-dense, nutrient-poor and bad for health. However, one of the inherent challenges in the field has been an inability to determine the actual dose of glucose or fructose in these drinks. </p>
<p>Studies that follow people over time, and link soft drink consumption to adverse health effects, are complicated by not knowing whether individuals in these studies are simply eating too many energy-rich foods, and whether soft drink consumption coincides with other poor health behaviours. So, further research is required to determine whether soft drinks containing different concentrations of fructose and glucose are associated with differing health risks. </p>
<h2>Soft drink policies</h2>
<p>There is still much to learn about the differences in composition of sugars and patterns of soft drink intake between countries. A small number of countries, including <a href="https://www.theguardian.com/society/2017/feb/22/mexico-sugar-tax-lower-consumption-second-year-running">Mexico</a> and <a href="http://www.bbc.com/news/world-europe-38767941">France</a>, have already implemented taxation on soft drinks. It remains to be determined whether these actions reduce the incidence of obesity, diabetes and heart diseases.</p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/173056/original/file-20170609-32402-pssvkt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/173056/original/file-20170609-32402-pssvkt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/173056/original/file-20170609-32402-pssvkt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/173056/original/file-20170609-32402-pssvkt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/173056/original/file-20170609-32402-pssvkt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/173056/original/file-20170609-32402-pssvkt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/173056/original/file-20170609-32402-pssvkt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/173056/original/file-20170609-32402-pssvkt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Over-consumption of any kind of sugar leads to weight gain.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>Australian policymakers are yet to take action to reduce soft drink consumption. A range of intervention strategies have been considered, including banning sugary soft drinks in schools and hospitals, taxation, and regulating beverage marketing. </p>
<p>The <a href="http://www.abc.net.au/news/2017-06-08/sugary-drinks-to-be-phased-out-of-nsw-health-facilities/8599820">New South Wales Health Department</a> has just announced sugary drinks will be phased out of vending machines, cafes and catering services in the state’s health facilities by December. This is a great move. Importantly, we must continue to increase public awareness of the adverse health effects of sugary soft drinks.</p><img src="https://counter.theconversation.com/content/78921/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Bronwyn Kingwell receives funding from the National Health and Medical Research Council of Australia.</span></em></p><p class="fine-print"><em><span>Pia Varsamis and Robyn Larsen do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A recent study found Australian soft drinks had higher concentrations of glucose than US soft drinks, which had more fructose. Does this mean Australian drinks are worse for health than US drinks?Bronwyn Kingwell, Head, Metabolic and Vascular Physiology NHMRC, Senior Principal Research Fellow, Baker Heart and Diabetes InstitutePia Varsamis, PhD Student, Metabolic and Vascular Physiology, Baker Heart and Diabetes InstituteRobyn Larsen, Postdoctural Research Fellow in Nutritional Biochemistry, Baker Heart and Diabetes InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/553302016-03-07T13:45:07Z2016-03-07T13:45:07ZCould some types of sugar actually be good for you?<figure><img src="https://images.theconversation.com/files/114055/original/image-20160307-31272-1uytsa0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Not all sugar is created equal. While we tend to think of sugar as the white foodstuff we buy in bags and that’s a major contributor to conditions such as <a href="https://theconversation.com/sugar-isnt-just-empty-fattening-calories-its-making-us-sick-49788">obesity and diabetes</a>, there are actually many types of sugar molecule with different properties and effects. Now scientists have found that one naturally-occurring kind of sugar called trehalose could actually help prevent a type of liver disease. Could it be that eating sugar may not be so bad for us after all – if only we can find the right type?</p>
<p>Although all sugars are composed of the same basic ingredients (carbon, hydrogen and oxygen), these components can be arranged in different ways, which can have very different effects on the body. For example, glucose is a type of sugar which is readily absorbed and converted to energy by all cells of the body. By contrast, <a href="https://theconversation.com/what-role-does-fructose-have-in-weight-gain-7424">fructose</a> is taken up almost entirely by liver cells, where it is converted directly into fat.</p>
<p>Eating too much fructose, which is found in fruit but <a href="https://theconversation.com/the-amount-of-hidden-sugar-in-your-diet-might-shock-you-21867">also in soft drinks</a>, can cause your liver to build up fat inside its cells, as can drinking too much alcohol. The non-alcoholic version of fatty liver disease (NALFD) is actually a <a href="http://www.nhs.uk/conditions/fatty-liver-disease/Pages/Introduction.aspx">relatively benign condition</a> and the majority of those affected experience limited or no symptoms. But sometimes it can progress to hepatitis (inflammation of the liver), cirrhosis (tissue damage) and even liver cancer.</p>
<p>This has become a serious public health problem because NALFD is now so common. It affects over <a href="http://www.nature.com/nrgastro/journal/v10/n11/full/nrgastro.2013.171.html">one billion people</a> worldwide and is found in up to <a href="bit.ly/21K9H84">80% of obese people</a>. At least <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4229518/">one in ten</a> liver transplants are due to conditions that progressed from NAFLD. Yet no drugs are presently available that reverse the build-up of fat in liver cells.</p>
<h2>Cellular spring cleaning</h2>
<p>Scientists at Washington University School of Medicine in St. Louis wanted to see if liver cells <a href="http://stke.sciencemag.org/content/9/416/ra21.abstract">could be tricked</a> into thinking that they were short of energy and so would eat their own internal fats, a process called autophagy. Recent research suggests this process of cellular spring-cleaning could reverse the build-up of damaging deposits related to a number of different diseases, including <a href="http://www.jbc.org/content/282/8/5641.long%5D%20and%20Parkinson%E2%80%99s%20disease%20">Huntington’s disease</a> and <a href="http://link.springer.com/article/10.1007%2Fs12035-015-9173-7">Parkinson’s disease</a>.</p>
<p>To trick the cells, the Washington researchers turned to trehalose sugar, which is found in shiitake and oyster mushrooms. They found the trehalose efficiently blocked the uptake of glucose into liver cells. Confirming earlier work <a href="http://www.jbc.org/content/282/8/5641.long">by other groups</a>, they also showed that trehalose reduced energy levels in the cells and induced the hallmark features of autophagy. This proved that the liver cells had been tricked into a sense of starvation.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/114054/original/image-20160307-30506-ygesxs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/114054/original/image-20160307-30506-ygesxs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=455&fit=crop&dpr=1 600w, https://images.theconversation.com/files/114054/original/image-20160307-30506-ygesxs.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=455&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/114054/original/image-20160307-30506-ygesxs.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=455&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/114054/original/image-20160307-30506-ygesxs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=572&fit=crop&dpr=1 754w, https://images.theconversation.com/files/114054/original/image-20160307-30506-ygesxs.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=572&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/114054/original/image-20160307-30506-ygesxs.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=572&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Sugar’s chemistry can vary hugely.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p>The scientists then fed trehalose to mice that had developed fatty livers after eating a high fructose diet for ten days. Adding 3% trehalose to the mice’s drinking water induced markers of autophagy in their livers, reduced their blood levels of fat and cholesterol and prevented the accumulation of liver fat.</p>
<p>The researchers suggest this means trehalose sugar may have the potential for use as a <a href="http://www.news-medical.net/health/What-are-Nutraceuticals.aspx">novel “nutraceutical”</a> – a food product with medicinal or health-promoting properties – to treat NAFLD or even other diseases by triggering autophagy. </p>
<h2>Unknown side effects</h2>
<p>This isn’t the first time a sugar-related molecule has been proposed to have potential health-promoting effects. Oligofructose and inulin are both long chains of sugar molecules that increase levels of “good bacteria” in our guts and impart far fewer calories to the body than more commonly used sugars, although they are also much less sweet. As a result, they are considered by some to be <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3705355/">beneficial for health</a>. </p>
<p>But before we start stirring trehalose into our tea, we should recognise that we don’t know what other effects large doses of the sugar might have on the rest of our body.</p>
<p>For example, the way it blocks glucose uptake by cells is similar to the process that causes raised blood sugar levels in diabetes. Human intestines also contain the enzyme trehalase, which converts most of the trehalose we eat <a href="http://www.pnas.org/content/60/3/1007">into glucose</a>, so a large dose would probably be needed for the trehalose to reach the liver. For humans, ingesting an equivalent amount of trehalose as the mice in the experiment would mean consuming an additional 1,000 calories per day, which could result in significant weight gain.</p>
<p>It seems unlikely that eating any sugar in large amounts would not come without potential health drawbacks. But even if trehalose does not turn out to be a new wonder sugar with the potential to treat human diseases, this new research at least gives us hope of finding a new way to tackle non-alcoholic fatty liver disease.</p><img src="https://counter.theconversation.com/content/55330/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Clett Erridge does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Scientists have discovered a type of sugar that could actually protect the liver.Clett Erridge, Honorary research fellow, Department of Cardiovascular Sciences, University of LeicesterLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/497882015-10-27T19:43:18Z2015-10-27T19:43:18ZSugar isn’t just empty, fattening calories – it’s making us sick<figure><img src="https://images.theconversation.com/files/99753/original/image-20151026-18435-11ee0q4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Don't add sugar.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-116939734/stock-photo-wooden-bowl-of-sugar-with-metal-spoon.html?src=JQV6o_KbozN-HPe3TJY8Mg-1-64">Sugar bowl via www.shutterstock.com</a></span></figcaption></figure><p>Children are manifesting increased rates of adult diseases like <a href="http://www.ncbi.nlm.nih.gov/pubmed/15175438">hypertension or high triglycerides</a>. And they are getting diseases that used to be unheard of in children, like <a href="http://dx.doi.org/10.1111/nyas.12030">Type 2 diabetes and fatty liver disease</a>. So why is this happening?</p>
<p>Everyone assumes this is the result of the obesity epidemic – too many calories in, too few out. Children and adults are getting fat, so they’re getting sick. And it is generally assumed that no one specific food causes it, because “a calorie is a calorie”.</p>
<p>I’ve been studying the role that <a href="http://www.uctv.tv/shows/Sugar-The-Bitter-Truth-16717">sugar</a> plays in contributing to chronic disease for years, and my research group at the University of California, San Francisco has just published <a href="http://dx.doi.org/10.1002/oby.21371">research</a> in the journal Obesity that challenges this assumption. If calories come from sugar, they just aren’t the same.</p>
<h2>Diabetes is increasing faster than obesity</h2>
<p>It’s clear that the cause of rising rates of health conditions like Type 2 diabetes isn’t as simple as people just eating too many calories.</p>
<p>Obesity is increasing globally at 1% per year, while diabetes is increasing globally at <a href="http://dx.doi.org/10.1126/science.1257099">4% per year</a>. If diabetes were just a subset of obesity, how can you explain its more rapid increase? </p>
<p>And certain countries are obese without being diabetic (such as Iceland, Mongolia and Micronesia), while other countries are <a href="http://dx.doi.org/10.1371/journal.pone.0057873">diabetic without being obese</a> (India, Pakistan and China, for instance). Twelve percent of people in China have diabetes, but the obesity rate <a href="http://dx.doi.org/10.1016/S2213-8587(14)70144-5">is much lower</a>. The US is the fattest nation on Earth and our diabetes prevalence is <a href="http://www.diabetes.org/diabetes-basics/statistics/">9.3%</a>. </p>
<p>While 80% of the obese population in the US <a href="http://diabetes.diabetesjournals.org/content/53/3/585.full.pdf">is metabolically ill</a> (meaning they have conditions like <a href="http://www.ncbi.nlm.nih.gov/pubmed/14988241">diabetes</a>, hypertension, lipid problems and <a href="http://dx.doi.org/10.1016/j.jacc.2011.04.047">heart disease</a>), 20% is not. Conversely, 40% of the normal weight population <a href="http://dx.doi.org/10.1016/j.jacc.2011.04.047">has metabolic syndrome</a>. </p>
<p>If normal weight people have these conditions, how then are they related to obesity? Indeed, we now know that obesity is a marker <a href="http://dx.doi.org/10.1542/peds.2011-2912">rather than a cause</a> for these diseases. </p>
<p>Epidemiological studies have found a correlation between added sugar consumption and health conditions like <a href="http://circ.ahajournals.org/content/120/11/1011.abstract">cardiovascular disease</a>. So could cutting excess sugar out of our diets reverse metabolic syndrome? </p>
<h2>What happens when you stop feeding kids added sugar?</h2>
<p>Our group at UCSF <a href="http://dx.doi.org/10.1002/oby.21371">studied</a> 43 Latino and African-American children with obesity and metabolic syndrome over a 10-day period. We started by assessing their metabolic status – insulin and glucose levels, as well as blood fats and other markers for disease, like lactate and free fatty acids – on their home diet. </p>
<p>For the next nine days, each child ate an individual tailored diet. We catered their meals to provide same number of calories and protein and fat content as their usual home diet. We gave them the same percentage of carbohydrate, but we substituted starch for sugar. The big difference: this special diet had <em>no</em> added sugar. This means their diet had no sugar from sugarcane or high fructose corn syrup. The kids consumed foods such as fruits and other whole foods that naturally contain some sugar. These foods also have fiber, which reduces the rate of sugar absorption, so they don’t affect the body the same way that added sugar does. </p>
<p>We took chicken teriyaki out. We put turkey hot dogs in. We took sweetened yogurt out. We put baked potato chips in. We took donuts out. We put bagels in. We gave them unhealthy processed food, just with no added sugar. Each child was given a scale to take home, and if their weight was declining, we made them eat more. Then we studied them again. </p>
<p>The children had eaten the same number of calories and had not lost any weight, and yet every aspect of their metabolic health improved. With added sugar cut out of their diet for 10 days, blood pressure, triglycerides, low-density lipoprotein (LDL, or “bad cholesterol”), insulin sensitivity and glucose tolerance all improved. And remember, we weren’t giving them just leafy greens and tofu – we fed the kids processed foods, just ones without sugar.</p>
<p>Further studies are needed to see if this will also work in adults, and if the benefits are short-term or long-term. </p>
<h2>Sugar is like alcohol</h2>
<p>This study demonstrates that a calorie is <em>not</em> a calorie, and that sugar is a primary contributor to metabolic syndrome, unrelated to calories or weight gain. By removing added sugar, we improved metabolic health. </p>
<p>Sugar may not be the only contributor to chronic disease, but it is far and away the easiest one to avoid. Kids could improve their metabolic health – even while continuing to eat processed food – just by dumping the sugar. Can you imagine how much healthier they’d be if they ate real food?</p>
<p>The naysayers will say, “But sugar is natural. Sugar has been with us for thousands of years. Sugar is food, and how can food be toxic?” </p>
<p>Webster’s Dictionary <a href="http://www.merriam-webster.com/dictionary/food">defines food</a> as:</p>
<blockquote>
<p>material consisting essentially of protein, carbohydrate, and fat used in the body of an organism to sustain growth, repair, and vital processes and to furnish energy.</p>
</blockquote>
<p>Sugar by itself furnishes energy, and that’s about it. In that sense, sugar is like alcohol. It’s got calories, but it’s not nutrition. There’s no biochemical reaction that requires it. And at high doses, alcohol can fry your liver.</p>
<p>Same with sugar. Fructose, the sweet molecule in sugar, contains calories that you can burn for energy, but it’s not nutrition, because there’s no biochemical reaction that requires it. In excess, it can fry your liver, just <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3649103/">like alcohol</a>. And this makes sense, because where do you get alcohol from? Fermentation of sugar.</p>
<p>Too much sugar causes diabetes, heart disease, fatty liver disease and <a href="http://www.ncbi.nlm.nih.gov/pubmed/26261186">tooth decay</a>. When consumed in excess, it’s a <a href="http://www.nytimes.com/2011/04/17/magazine/mag-17Sugar-t.html">toxin</a>. And it’s addictive – <a href="http://www.ncbi.nlm.nih.gov/pubmed/23493539">just like alcohol</a>. That’s why children are getting the diseases of alcohol – Type 2 diabetes and fatty liver disease – without alcohol. But our research suggests we could turn this around in 10 days – if we chose to.</p><img src="https://counter.theconversation.com/content/49788/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Robert Lustig does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Researchers have found that cutting sugar out of kids’ diets can improve their blood pressure, cholesterol readings and other markers of metabolic health.Robert Lustig, Professor of Pediatrics, University of California, San FranciscoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/376292015-02-16T19:35:16Z2015-02-16T19:35:16ZScary berries: how food gets contaminated and what to do<figure><img src="https://images.theconversation.com/files/72105/original/image-20150216-6142-g6hcxr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Only a small proportion of people who eat these berries will become infected.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/chiotsrun/3702753026">Chiot's Run/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span></figcaption></figure><p>Food distributor Patties Foods has recalled two brands of frozen mixed berries — <a href="https://www.facebook.com/NannasAU">Nanna’s</a> and <a href="https://www.facebook.com/CreativeGourmet">Creative Gourmet</a> — due to reports of three people in Victoria, four in Queensland and two in New South Wales developing hepatitis A after eating the products. The cause of a <a href="http://www.brisbanetimes.com.au/queensland/three-qld-hepatitis-a-cases-linked-to-frozen-mixed-berries-contamination-20150216-13g33q.html">fourth Queensland case</a> is still in doubt.</p>
<p>Initially, only one-kilogram bags of Nanna’s mixed berries were recalled, but that has now been extended to 300-gram and 500-gram bags of Creative Gourmet mixed berries. The berries came from Chile and China.</p>
<p>Authorities are <a href="http://www.abc.net.au/news/2015-02-15/second-brand-of-frozen-mixed-berries-recalled/6106490">warning people against eating</a> one-kilogram packets of <a href="http://www.foodstandards.gov.au/industry/foodrecalls/recalls/Pages/Nanna%27s-Mixed-Berries.aspx">Nanna’s mixed berries</a> with best-before dates until and including November 22, 2016. For <a href="http://www.foodstandards.gov.au/industry/foodrecalls/recalls/Pages/Creative-Gourmet-Mixed-Berries.aspx">Creative Gourmet</a>, the date ranges are up to and including December 10, 2017 for 300-gram packets and October 6, 2017 for 500-gram packets.</p>
<p>Only product lines that show sufficient evidence of risk to consumers are recalled in outbreaks such as this one. It’s common, though, for the lines affected to change as more information comes to light.</p>
<h2>Hepatitis A</h2>
<p>The berries are linked with an outbreak of <a href="http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Hepatitis_A_affects_the_liver">hepatitis A</a>, a viral infection of the liver. Symptoms include fever, nausea, abdominal discomfort, diarrhoea, dark urine and jaundice (yellow skin and eyes). The illness can be quite severe, particularly in people who are already unwell. </p>
<p>Most people recover within several weeks and young children often show mild or no symptoms. But the serious cases result in hospitalisation and liver failure.</p>
<p><a href="http://www.cdc.gov/hepatitis/HAV/">Infection</a> is acquired when people ingest the virus, which is excreted in an infected person’s faeces. Infection can result from close contact with an infected person, eating contaminated food or drinking contaminated water. Symptoms appear between 15 and 50 days after exposure to the virus, which makes it difficult to identify possible sources.</p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/72109/original/image-20150216-18500-1v8n6x6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/72109/original/image-20150216-18500-1v8n6x6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=899&fit=crop&dpr=1 600w, https://images.theconversation.com/files/72109/original/image-20150216-18500-1v8n6x6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=899&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/72109/original/image-20150216-18500-1v8n6x6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=899&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/72109/original/image-20150216-18500-1v8n6x6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1130&fit=crop&dpr=1 754w, https://images.theconversation.com/files/72109/original/image-20150216-18500-1v8n6x6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1130&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/72109/original/image-20150216-18500-1v8n6x6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1130&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Hepatitis A is spread through food and water contamination.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/julien_harneis/589718393">Julien Harneis/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>Food-borne outbreaks of the disease occur when a person eats food that has been contaminated by the virus – either by contamination during growing or processing, or when a person prepares food while they are infectious. Sometimes the outbreak is caused by water contaminated by human sewage.</p>
<p>The number of <a href="http://www.health.gov.au/internet/publications/publishing.nsf/Content/cda-cdi34suppl.htm%7Ecda-cdi34suppl-3-vpd.htm%7Ecda-cdi34suppl-3-vpd3.htm">hepatitis A cases in Australia</a> has been declining dramatically since the late 1990s. This is probably due to a range of factors, including a reduction in the number of people in high-risk groups susceptible to hepatitis A virus infection, and vaccination campaigns in target groups, such as Aboriginal and Torres Strait Islander children in 2005 and 2007.</p>
<p>These days Australian health authorities receive reports of a couple of hundred cases each year. Almost all of these are acquired when people who haven’t been <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/handbook10-4-4">vaccinated against the illness</a> travel overseas.</p>
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<h2>Scary berries</h2>
<p>Berries have caused large outbreaks of gastroenteritis and hepatitis A in the past, <a href="http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20941">particularly in Europe</a> and <a href="http://online.liebertpub.com/doi/pdfplus/10.1089/fpd.2014.1821">the United States</a>. Health agencies have increasingly become aware of fruits, vegetables and herbs as a cause of disease outbreaks. Awareness has grown in parallel with global food distribution networks, which started garnering the attention of food safety authorities in the late 1990s.</p>
<p>In Australia, we haven’t recorded large outbreaks associated with berries, but New Zealand identified an <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2870016/">outbreak of 39 cases of hepatitis A</a> associated with locally grown blueberries.</p>
<p>The main likely sources of fresh food contamination are:</p>
<ol>
<li><p>Being grown in contaminated water.</p></li>
<li><p>Getting contaminated by infected animals, such as livestock, rats, mice or bats, at some stage in the production cycle.</p></li>
<li><p>Being picked by people who are infected with hepatitis A.</p></li>
<li><p>Mixing with other ingredients contaminated with hepatitis A virus during processing.</p></li>
<li><p>Being washed in contaminated water.</p></li>
</ol>
<p>There is evidence that fruits, such as<a href="http://www.ncbi.nlm.nih.gov/pubmed/25662970"> berries</a>, and some vegetables, such as <a href="http://www.ncbi.nlm.nih.gov/pubmed/23377940">tomatoes</a> and <a href="http://www.ncbi.nlm.nih.gov/pubmed/12969285">sprouts</a>, can sometimes internalise bacteria and viruses during growing. This means that the disease-causing agent may actually be inside the fruit and is almost impossible kill except by cooking. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/72106/original/image-20150216-6128-1l5c4x6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/72106/original/image-20150216-6128-1l5c4x6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=720&fit=crop&dpr=1 600w, https://images.theconversation.com/files/72106/original/image-20150216-6128-1l5c4x6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=720&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/72106/original/image-20150216-6128-1l5c4x6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=720&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/72106/original/image-20150216-6128-1l5c4x6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=905&fit=crop&dpr=1 754w, https://images.theconversation.com/files/72106/original/image-20150216-6128-1l5c4x6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=905&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/72106/original/image-20150216-6128-1l5c4x6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=905&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Throw away any recalled berries you have in the freezer.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/35126681@N07/15932972972">Philippa McKinlay/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<p>The hepatitis A virus is easily killed by cooking to more than 85 degrees Celsius, which would deal with most other bacteria and viruses. Washing is useful for getting rid of surface contamination of fruits and vegetables, which is sufficient most of the time. But if there is a possibility that foods, such as berries, are contaminated with disease-causing agents, it is best to avoid them altogether.</p>
<p>After a food recall such as this one, investigations by health and food safety agencies will try to create a picture of what happened and when.</p>
<p>In the meanwhile, the key thing for consumers is to avoid infection by making sure they do not eat any of the recalled berries that may be in their freezer. </p>
<p>It is likely that only a small proportion of people who eats these berries will become infected. But if you have eaten them and started to develop any of the symptoms listed above, you should see a doctor as soon as possible.</p><img src="https://counter.theconversation.com/content/37629/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Martyn Kirk receives funding from the Australian Research Council and the Commonwealth Health Department, Food Standards Australia New Zealand, the ACT Government and the New South Wales Food Authority.</span></em></p>Food distributor Patties Foods has recalled two brands of frozen mixed berries — Nanna’s and Creative Gourmet — due to reports of three people in Victoria, four in Queensland and two in New South Wales…Martyn Kirk, Convener, Master of Philosophy in Applied Epidemiology, Australian National UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/211012013-12-10T06:33:30Z2013-12-10T06:33:30ZThere’s no such thing as a free lunch from tobacco companies<figure><img src="https://images.theconversation.com/files/37151/original/p7fpvr4c-1386346258.jpg?ixlib=rb-1.1.0&rect=3%2C27%2C1014%2C700&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Not so appetising when you think about it.</span> <span class="attribution"><span class="source">GS+</span></span></figcaption></figure><p>Almost all companies contribute money to charity and many would argue that corporate donations make a positive difference in the world. But this hopeful take on corporate philanthropy sits uneasily with the findings of a growing <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2636524/">number of studies</a> based on tobacco industry documents, which are <a href="http://legacy.library.ucsf.edu/">publicly available</a> from litigation in the US. These provide a compelling reminder of the principle that what is good for business isn’t necessarily good for everyone else.</p>
<h2>For your eyes only</h2>
<p>Confidential internal emails, memos, and strategy <a href="http://legacy.library.ucsf.edu/">documents</a> give us an unmediated record of what corporate executives were really thinking when they made decisions. And they suggest tobacco industry largesse isn’t driven solely (or even primarily) by philanthropic impulses, but by misanthropy and the desire for political influence. The aim is to prevent evidence-based policies that limit tobacco use – still the <a href="http://www.who.int/tobacco/health_priority/en/">number one cause</a> of preventable death in the world.</p>
<p>A <a href="http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0080864">recent study</a>, which we published in PLOS ONE, looked in depth at British American Tobacco (BAT), one of the big four multinational tobacco companies. Using documents from the digital archives of the Legacy Tobacco Documents Library (LTDL), we found that concerns in the 1990s over increasing efforts by national governments to introduce public smoking restrictions led to BAT making large, conspicuous donations to education institutions, health organisations and NGOs – all essentially aimed at increasing the company’s political footprint. </p>
<h2>Diversionary techniques</h2>
<p>The BAT documents suggest that money was allocated to form partnerships with NGOs in the hope of exploiting links with policy-makers and was earmarked for specific causes that overlapped with government policies, precisely because of their potential to facilitate access to policy-makers. </p>
<p>Evidence also emerged in the documents of donations being used to divert attention away from the human cost of tobacco-related disease by highlighting other risks to health. Support for the then Beijing Liver Foundation, for example, was designed to raise <a href="http://legacy.library.ucsf.edu/tid/ehi45a99">the profile of hepatitis</a>, which BAT considered “should be of greater significance to the [People’s Republic of China] and the WHO” than smoking. The donation, highlighted in one <a href="http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0050251">2008 study</a> was to “reprioritise the agenda” of the Chinese Ministry of Public Health and “divert the public attention from smoking and health issues to liver diseases”. </p>
<p>Recent donations aimed at combating the impact of diseases such as malaria, <a href="http://www.bat.com/group/sites/uk__3mnfen.nsf/vwPagesWebLive/DO6ZKMKN?opendocument&SKN=1">tuberculosis</a> and <a href="http://www.batsa.co.za/group/sites/BAT_7N3ML8.nsf/vwPagesWebLive/DO7NAHFA?opendocument&SKN=1">HIV/Aids</a> in Africa and Asia show that corporate reputation in the area of health is a high priority and good for business.</p>
<p>BAT’s support for scholarships also illustrates the long-term thinking behind political philanthropy and its role in the company’s efforts to create a political class more inclined to overlook the negative impact of tobacco on aggregate social welfare. </p>
<p>One document from the late 1990s, for example, highlighted <a href="http://legacy.library.ucsf.edu/tid/puk61a99">the importance</a> of providing finance for overseas postgraduate students as part of a “long-term investment in potential leaders in developing markets”. Another explained that funding scholarships in tertiary education <a href="http://legacy.library.ucsf.edu/tid/vak23a99">would create</a> “alumni that will in future be part of the national leadership of the world in which we do business.” </p>
<p>Such blunt efforts to shape political cultures sit alongside more subtle attempts, which rest on the potential for charitable donations to change perceptions through the associations they create. Our research suggests that in low and middle-income countries, philanthropy has been used to link BAT to social and economic development while in high-income countries, donations to social and economic projects have been aimed at training, economic regeneration, and the alleviation of poverty.</p>
<h2>In whose interest?</h2>
<p>Linking the tobacco industry to development in middle and low-income countries is <a href="http://www.who.int/tobacco/publications/mdg_final_for_web.pdf">perverse on several levels</a>. Smoking can strike down workers in their prime, <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1747588/pdf/v010p00212.pdf">exaggerate the impact</a> of poverty, and <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2975973/">suck scarce capital</a> out of struggling economies. </p>
<p>For tobacco companies, such gifts are meant to countervail work by the <a href="http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/EXTHEALTHNUTRITIONANDPOPULATION/EXTETC/0,,contentMDK:20361460%7EmenuPK:478880%7EpagePK:148956%7EpiPK:216618%7EtheSitePK:376601,00.html">World Bank</a>, which highlights these negative social and economic impacts and shows that reducing tobacco use is economically beneficial. </p>
<p>BAT’s donations <a href="http://www.bat.com/group/sites/uk__3mnfen.nsf/vwPagesWebLive/DO6RZGHL?opendocument&SKN=1">in high-income countries</a>, which we also considered in our study, work in a broadly similar way. By emphasising that the company provides capital for programmes which ameliorate the social effects of de-industrialisation, these types of donations convey the continuing relevance of the company to the long-term social and economic success of richer nations. This is despite tobacco being the <a href="https://www.cancerresearchuk.org/sites/default/files/cruk_tobacco_inequalities_briefing_june_2013.pdf">leading risk factor</a> in health inequalities.</p>
<h2>Philanthropy is perfect</h2>
<p>Philanthropy works particularly well for the tobacco industry. When done right, donations shift relations between corporate and public officials from low-trust, low-frequency access to high-trust, high-frequency access. Trust, the essence of all effective political lobbying, is effectively cemented through the normalisation of engagement and dialogue, which shifts policy-makers’ perceptions of the credibility of information conveyed to them by tobacco companies. In short, philanthropy holds out the promise of unwinding some of the effects of the <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3755635/">industry’s poor reputation</a>. </p>
<p>While corporations’ political strategies vary enormously between different sectors, emerging evidence suggests uncomfortably close similarities between tobacco industry philanthropy and how companies in other sectors use charitable donations. </p>
<p>In 2011, the Foundation for a Healthy America, a nonprofit created by the American Beverage Association (ABA) – the trade association of the soft drinks industry in the US – <a href="http://philadelphia.cbslocal.com/2011/03/16/soft-drink-industry-gives-10-million-to-chop-for-child-obesity-work/">donated US$10m</a> to the Children’s Hospital of Philadelphia. A <a href="http://articles.philly.com/2011-03-17/news/29139048_1_obesity-program-children-s-hospital-children-s-hospital-s">report by the Philadelphia Inquirer</a> later revealed that the gift had originally been made when Philadelphia’s City Council was debating a proposed tax on sugar-sweetened beverages.</p>
<p>Only the very trusting would fail to see this as an attempt to weaken support for effective policy change after doctors from the hospital had given testimony <a href="https://phila.legistar.com/LegislationDetail.aspx?ID=1234260&GUID=9126E72B-B761-47E5-A0F5-E21D760D50FD&Options=&Search=">to the council</a> on the dangers of sugar-sweetened drinks.</p>
<p>Corporate donations from the tobacco industry are a false economy, and while tobacco companies are rightly vilified for pushing a product that kills half of its users, their political duplicity also seems to provide important clues to understanding charitable giving by other companies.</p><img src="https://counter.theconversation.com/content/21101/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Gary Fooks and Anna Gilmore receive funding from the US National Cancer Institute at the National Institutes of Health (Grant Number RO1CA160695) and are members of the UK Centre for Tobacco and Alcohol Studies (UKCTAS), a UK Centre for Public Health Excellence funded by the UK Clinical Research Collaboration. </span></em></p><p class="fine-print"><em><span>Anna Gilmore is European Editor of Tobacco Control and a member of the Smokefree South West Steering Committee and Programme Board.</span></em></p>Almost all companies contribute money to charity and many would argue that corporate donations make a positive difference in the world. But this hopeful take on corporate philanthropy sits uneasily with…Gary Fooks, Corporate Criminologist, University of BathAnna Gilmore, Director, Tobacco Control Research Group, University of BathLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/154272013-06-25T13:25:44Z2013-06-25T13:25:44ZProtein from sushi snack may help detect liver diseases<figure><img src="https://images.theconversation.com/files/26163/original/xmvf35kx-1372156537.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The molecule that causes the eel to glow when blue light is shone on it is unlike any found in other living organisms.</span> <span class="attribution"><span class="source">Akiko Kumagai & Atsushi Miyawaki</span></span></figcaption></figure><p>Researchers have discovered a fluorescent protein in a Japanese eel consumed as a popular sushi snack. The discovery could help develop simpler and more sensitive tests to detect jaundice and other diseases.</p>
<p>The idiom “seeing is believing” has been revived by biologists through the use of fluorescence microscopy, where specifically tagged proteins glow green when a laser is shone on them. This green glow allows researchers to observe phenomena at very minute scales (at some billionths of a meter).</p>
<p>The importance of such proteins called green fluorescent proteins (GFPs) was recognised by the <a href="http://www.nobelprize.org/nobel_prizes/chemistry/laureates/2008/">2008 Nobel Prize in Chemistry</a>. But so far all the GFPs have been derived from non-vertebrate animals - those that lack a spinal cord - such as jellyfish and corals.</p>
<p>The discovery of the new fluorescent protein, named UnaG after the Japanese eel unagi, is important not just because it comes from a vertebrate animal but also because it is very different from any of the GFPs currently available.</p>
<h2>A special glow</h2>
<p>The first GFP was discovered in a jellyfish called <em>Aequorea victoria</em> almost 50 years ago. Since then tiny tweaks to this GFP and others that were discovered later on have given researchers a reliable tool to probe how a cell works.</p>
<p>Uncovering the cell’s molecular machinery is key to developing new medicines and tools to diagnose diseases. The use of GFPs allows scientists to pinpoint a single class of proteins among thousands that are at work in a cell.</p>
<p>The results of the new discovery were published in the journal <a href="http://www.sciencedirect.com/science/article/pii/S0092867413006442">Cell</a> recently. A team led by Atsushi Miyawaki at the RIKEN Institute in Japan found UnaG when they were studying the muscle fibres of freshwater eels.</p>
<p>The protein was unique not just because it was found in a vertebrate animal, but also because of the way it fluoresced. Most GFPs use a chromophore, which is a part of the molecule that can absorb and emit light. Instead UnaG glows by integrating a molecule from outside the protein.</p>
<p>This molecule turns out to be bilirubin, which is present in eel muscles but is also formed when haemoglobin breaks down in human blood. Levels of bilirubin have been used for decades as a test to assess liver health and diagnose diseases such as jaundice. So this ability of UnaG gives it the potential to detect bilirubin and act as an indicator for liver malfunction.</p>
<p>Binding to bilirubin gives UnaG some more special properties that no other GFP currently has. First, it is only half the size of current GFPs, which makes it handy to tag proteins without interfering with their function. Second, most GFPs require oxygen to produce their chromophore and thus become fluorescent. UnaG does not. This means it could for the first time allow the illumination of cells in tissues where oxygen is scarce, such as some cancerous tumours.</p>
<p>Biology has always been driven by the ability to “see” nature. Modern tools have allowed scientists to see beyond what the naked eye could offer. And the race is on to see phenomena happening on <a href="https://theconversation.com/new-method-can-image-single-molecules-and-identify-its-atoms-14869">ever smaller scales</a>. UnaG is one big step in that direction.</p>
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<p class="fine-print"><em><span>Luc Henry does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Researchers have discovered a fluorescent protein in a Japanese eel consumed as a popular sushi snack. The discovery could help develop simpler and more sensitive tests to detect jaundice and other diseases…Luc Henry, Postdoctoral Fellow, EPFL – École Polytechnique Fédérale de Lausanne – Swiss Federal Institute of Technology in LausanneLicensed as Creative Commons – attribution, no derivatives.