The use of physical restraint in psychiatric hospitals has been widely reported after the publication of a report by the mental health charity MIND on the use of the practice in England. The report said that last year almost 40,000 incidents of physical restraint were recorded, with almost 1,000 cases of physical injury after a patient had been physically restrained.

MIND is particularly concerned about the use of "face-down restraint", which it says can be life-threatening and was used more than 3,000 times last year. The government is said to be considering a ban on the practice and has reportedly ordered an investigation into its use in two English trusts.

The charity's report says that from the figures it has compiled, it is clear there is "huge variation" in the use of physical restraint across England. It is calling for the government to establish national standards for the use of physical restraint and accredited training in its use for healthcare staff.

What is physical restraint in mental healthcare?

MIND quotes one definition of physical restraint from the Care Quality Commission, which says it is "the physical restraint of a patient by one or more members of staff in response to aggressive behaviour or resistance to treatment".

MIND defines "face-down restraint" as when someone is pinned face down (prone) on the floor and is physically prevented from moving out of this position. The charity says this is dangerous and can be life-threatening because of the impact it has on breathing.

Why did MIND investigate the use of physical restraint?

MIND points out that healthcare staff have a challenging job – physical intervention is often used to manage a person's behaviour if they are deemed to be a risk to themselves or others as a result of their mental health problems.

It says the issue poses a huge challenge to clinical staff, as well as those managing healthcare: "We have a huge responsibility to ensure that as clinicians the power invested in us is not abused."

What does the law say about physical restraint?

The law says that if someone is detained in hospital under the Mental Health Act (1983), staff are entitled to exercise a degree of control over them. For example, staff are allowed to prevent someone detained under the act from leaving hospital.

Under the law, force may be used to achieve this if necessary, but it must be reasonable and proportionate. The act's code of practice explains that restraint is a response of last resort and gives detailed guidance for managing disturbed or aggressive behaviour.

How did MIND uncover the extent of the use of physical restraint?

The charity sent requests under the Freedom of Information Act to all 54 mental health trusts in England, asking how they used physical restraint and the procedures and training in place governing its use. They asked for a range of data for the year 2011-12, with information broken down by both gender and ethnicity.

It received responses from 51 trusts, one of which declined the request on the grounds of cost and time. The charity says it did not approach independent providers, and further research is needed in the use of physical restraint in independent mental health units.

The charity also commissioned an independent inquiry into mental healthcare in 2010-11. Its report, published in 2011, included patients' experiences of being physically restrained.

What did MIND find out about physical restraint?

• The charity says it found a "staggering" variation in the use of physical restraint in mental health trusts. In a single year, one trust reported 38 incidents, while another reported 3,346. In total, 39,883 incidents were reported. The level of variation is "appalling", MIND says, with the data suggesting that some people may be being restrained repeatedly.
• Only half of the trusts contacted reported the use of face-down restraint, which was used in more than 3,439 incidents overall. More than half these incidents occurred in just two trusts. Four mental health trusts reported there had been no use of face-down restraint.
• Just over half of trusts responded to questions on the use of physical restraint to administer medication. More than 4,000 such incidents were reported.
• Half the trusts responded to questions about police involvement in physically restraining patients, with 361 such incidents reported.
• There were 949 incidents of physical injury following physical restraint, reported by 62% of trusts. Recorded incidents of harm varied from zero to 200.
• One quarter of trusts reported incidents of psychological harm following physical restraint, of which there were 96.
• There were 111 complaints about physical restraint reported by 68% of trusts.

The charity also says it received very little information on ethnicity and gender, with many trusts saying they did not collect this information. Failure to record ethnicity of patients being physically restrained is worrying, MIND says, given that people from black and ethnic minority backgrounds are "over-represented" in hospitals as detained patients.

What do people who have been physically restrained say?

MIND includes in its report some quotes from people who have experienced or witnessed physical restraint. It says many are taken from interviews it conducted earlier this year, although it does not give details of the patients.

For example: "It was horrific … I had some bad experiences of being restrained face down with my face pushed into a pillow. I can't begin to describe how scary it was, not being able to signal, communicate, breathe or speak."

Another recalled: "It made me feel like a criminal, like I had done something wrong, not that I was just ill and needed to get better."

And another person told MIND: "I've suffered physical abuse when I was younger, and being held down where someone forces their weight on you is triggering for me … it's the last thing that's going to make me conform; I don't want them touching me."

What does MIND recommend?

MIND is calling on the government to urgently ban face-down physical restraint in all healthcare settings and to include its use in the list of "never events" – events that should never occur in a healthcare setting.

It also wants the government to introduce national standards for the use of physical restraint and accredited training for healthcare staff in England. The principles of the training should be "respect-based" and endorsed by people who have experienced physical restraint. MIND has called on NHS England to introduce standard methods of fully recording the details of cases of physical restraint.

The charity also wants staff working in mental health units to commit to working without coercion, to use alternatives and communication skills to build relationships, and to ensure that physical restraint is only ever used as a last resort.

MIND also points out that overcrowded, noisy wards with "limited therapeutic input" can be a trigger for patient distress and challenging behaviour. It says that the aim of inpatient mental health wards should be to provide a safe and therapeutic environment encompassing the patients' needs. Better communication with patients and creating care plans that respond to their needs and identify triggers for distress can all help staff manage crises.

What happens now?

According to a BBC News report, health minister Norman Lamb is "very interested" in "just banning face-down restraint". He has also reportedly ordered a "specific investigation" into the use of face-down restraint in two English trusts: Northumberland, Tyne and Wear (where face-down restraint was reportedly used 923 times in 2011-12) and Southampton.

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter.

Links To The Headlines

'Excessive' use of face-down restraint in mental health hospitals. BBC News. June 18 2013

Ministers consider ban on face-down restraint in mental hospitals. The Independent. June 19 2013

Mental health trusts still using dangerous face-down restraint. The Times. June 19 2013

“Severe air pollution ‘can double risk of having autistic child’,” reports The Times.

If you’re a parent-to-be you shouldn’t be unduly worried by this story, as the science it’s based on cannot and does not show a definite link. And other than moving house or changing jobs, avoiding environmental pollutants is likely to prove difficult.

This frightening headline was based on research into the exposure to environmental pollutants of mothers with children diagnosed with autism spectrum disorder (ASD).

The study compared women in the highest 20% pollution exposure category with those in the lowest 20% of pollution levels. It found exposure to diesel, lead, manganese, mercury, methylene chloride (an industrial solvent), and an overall measure of metals were all significantly associated with a higher risk of ASD. The risks ranged from 50% higher (for overall metals) to 100% higher (for diesel and mercury). For example, children with ASD were more than twice as likely to be born to mothers with the highest 20% of diesel and mercury exposure, than the lowest 20%.

However, due to its study design this research cannot, and does not, prove that higher air pollution around the time of childbirth causes or increases the risk of a child developing ASD. The causes of ASD are not firmly established and it is likely this research has not accounted for other factors that could be influencing risk. However, it does suggest a potential link that warrants further investigation.

Where did the story come from?

The study was led by researchers from the Harvard School of Public Health in the US and was funded by the US Department of Defence, Army Medical Research and Materiel Command, and National Institutes for Health.

The study was published in the peer-reviewed medical journal, Environmental Health Perspectives.

Neither the Daily Mail nor the Daily Mirror’s coverage discussed the limitations of the research and generally took the findings at face value. However, The Times’ coverage included points from ‘other scientists’ outlining some of the study’s limitations.

What kind of research was this?

This was a case-control study exploring whether exposure to pollution around the time of a child’s birth was linked to the risk of the child developing autism spectrum disorder.

Autistic spectrum disorders (ASDs) cover a range of related developmental disorders, including autism and Asperger’s syndrome. They have key characteristics, including problems with:

• social interaction with others (such as not being able to respond to others’ emotions)
• communication (such as difficulties in having a conversation)
• having a restricted, repetitive collection of interests and activities, rigid routine or rituals

Children described with autism usually have some degree of intellectual impairment and learning difficulties, while children with Asperger’s usually have normal intelligence.

The researchers describe how air pollution contains many toxic chemicals known to affect neurological function and foetal development. Recent studies have reported associations between exposure to air pollutants around the time of childbirth and ASD in children. This study sought to explore this link further.

What did the research involve?

This study involved asking a group of mothers if their children had ASD and then assigning historical pollution data to their address around the time the child was born.

This study used data from the Nurses’ Health Study II, a cohort of 116,430 female nurses from 14 US states. The Nurses’ Health Study II cohort was established in 1989 and has been followed over time with biennial questionnaires.

In 2007-08, researchers sent a questionnaire to the 756 women who had previously reported having a child with ASD, asking about the affected child’s sex, birth date, and whether they were adopted. These represented the “cases” in this study. They were also asked what specific diagnosis the child had been given with autism, Asperger syndrome, and ‘pervasive developmental disorder not otherwise specified’ (PDD-NOS) as possible answers. Cases were excluded if:

• they had missing data for ASD diagnosis
• they were adopted
• the mother did not want to participate
• the child’s year of birth was missing

This yielded 325 cases that were included in the final analysis.

The ASD diagnoses were validated by telephone using a questionnaire called the Autism Diagnostic Interview Revised. The researchers used 50 randomly selected “case” mothers who indicated willingness to complete the interview.

A group of 22,098 “controls” were used as a comparison group. These were children born from 1987 to 2002 (the years when air pollution data were available) to mothers who indicated they had never had a child with ASD.

Hazardous air pollutant concentrations were assessed by the US Environmental Protection Agency (EPA) National Air Toxics Assessments in 1990, 1996, 1999, and 2002. These used an inventory of outdoor sources of air pollution, including both stationary sources (such as waste incinerators and small businesses) and mobile sources (such as traffic) to estimate average concentrations of pollutants for different communities based on pollution dispersion models.

As pollution levels were not measured every year, the children were assigned pollution concentrations from EPA assessments closest to their year of birth (births 1987 to 1993 used 1990 concentrations; births 1994 to 1997 used 1996 concentrations; births 1998 to 2000 used 1999 concentrations and births 2001 to 2002 used 2002 concentrations).

The researchers recorded family (including grandparents’ education level) and community socioeconomic factors (average community income and education level) that could potentially influence the risk of ASD. They attempted to compensate for these influences in the statistical analysis.

What were the basic results?

The final analysis compared information from 325 cases, with 22,101 controls.

The researchers categorised the children’s level of pollution exposure into fifths (20% of the study group in each pollution level category). They found that those children exposed to the highest versus lowest fifth of diesel, lead, manganese, mercury, methylene chloride, and an overall measure of metals were significantly more likely to have an ASD. The odds ratios for these exposures ranged from 1.5 (for overall metals measure) to 2.0 (for diesel and mercury). This means those in the highest fifth (the top 20%) of diesel and mercury exposure were found to be twice as likely to develop ASD compared with those in the lowest fifth (the bottom 20%).

When the researchers looked at the linear trends, these were also positive and statistically significant for these exposures. This means the risk went up directly as pollution levels went up.

For most pollutants, associations were stronger for boys (279 cases) than girls (46 cases) and were significantly different according to gender.

How did the researchers interpret the results?

The authors concluded that exposure to air pollutants around the time of child birth, “may increase risk of ASD”, and that future studies should investigate the gender differences observed.

Conclusion

The limitations in this study’s design mean it cannot prove that air pollution causes or increases the risk of developing autism spectrum disorder (ASD). However, it does tentatively suggest higher pollution levels may increase the risk, which may prompt further, more reliable investigation.

It is important to consider the limitations of this research before concluding a direct causal link between environmental pollutants and autistic spectrum disorders.

Problems with assessment of pollution levels

The air pollution data was not accurately assigned to the child’s date of birth. Some children were assigned pollution levels three years before they were born, and others three years after. This means we cannot be sure at which point (before or after child birth) pollution may be influencing the risk of ASD, or whether the timing of pollution exposure was important in any way.

This occurred because the researchers used existing pollution data and fitted this as best they could to the dates the children were born. While this was clearly a practical approach, as the dates didn’t match exactly, it will have introduced some inaccuracy. The researchers implied that exposure may be more important before birth as some pollutants can affect the developing baby.

Difficulty specifying causes of autistic spectrum disorders

The possible causes of ASD are not firmly established. While some effort was made to adjust for additional factors that could affect ASD risk outside of pollution, this may not have been complete. Hence, differences in factors such as socioeconomic circumstances (as well as others) may account for some or all of the differences in ASD risk observed.

Problems with comparing risks for boys versus girls

There were very few girls in the study, most likely because ASD is more common in boys than girls. The small number of girls make reliable comparisons between boys and girls difficult. As the researchers point out, for this reason, the conclusions around differences in risk versus exposure profiles between boys and girls are not reliable.

Small number of cases included

The sample size of children with ASD was quite small (325) in this study and represented less than half of the original 756 eligible for the study. Many participants were excluded because they had important information missing such as the year of birth. This small sample may not be representative of the wider group of children with ASD.

The bottom line is that this study does not prove that air pollution increases the risk of a child developing ASD. However, it does highlight a potential link that warrants further investigation.

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter.

Links To The Headlines

Autism twice as likely in babies if mum lives near busy road, study claims. Daily Mirror. June 19 2013

Risk of autism is up to 50% higher in children exposed to traffic fumes and air pollution. Daily Mail. June 19 2013

Severe air pollution ‘can double risk of having autistic child’. The Times. June 19 2013

Links To Science

Roberts AL, et al. Perinatal Air Pollutant Exposures and Autism Spectrum Disorder in the Children of Nurses’ Health Study II Participants. Environmental Health Perspectives. Published online June 18 2013

A radical overhaul of how nutritional information is displayed on the front of the packaging of many food products has been announced.

The government, food makers and food retailers have agreed the new standardised front-of-pack labelling to help make it easier for people to make healthier choices about what they buy and eat.

The Department of Health has today set out what the new food labels will look like and outlined how a colour-coding scheme of energy, salt, sugar and fat will look and how their levels are set.

Currently, food and drink labels often differ in the range of nutritional information provided. Currently, there is no law forcing retailers and manufacturers to display such information and manufacturers are currently only required by law to provide nutritional information if the product makes a nutritional claim. For instance, nutritional information must be on a product that claims to be ‘low fat’ or if vitamins or minerals have been added to the product.

Under new European Union rules, manufacturers will be required to provide particular nutritional information by December 2016. But any manufacturer that chooses to provide front-of-pack information will have to comply with the EU regulation by the end of 2014.

The new style of labels will follow the same format as this example from a packet of breakfast cereal:

What changes are being made to food labels?

Nutrition labels, when they are displayed, are often provided on the back, side or on the front of packaging. The new, standardised food labels will be displayed on the front of food and drink products and they will routinely include the following information per portion of food:

• the amount of energy (presented in kilojoules (kJ) and kilocalories (kcal), known as calories)
• the amount of fat and saturated fat
• the amount of sugar
• the amount of salt

These amounts will be shown as ‘Reference Intakes’ (formerly known as ‘Guideline Daily Amounts’). Alongside the amounts listed above, food labels will show how much of the maximum daily intake a portion of food accounts for.

Food labels will also contain red, amber and green colour-coding to visually show the nutritional value of food portions. This will allow people to see at a glance if the food product has high, medium or low amounts of fat, saturated fat, sugars and salt:

• red means high
• amber means medium
• green means low

In short, the more green lights, the healthier the choice.

Read more about the terms used on food labels.

When are these changes being made?

Standardised front-of-label packaging will be in place by December 2014 by organisations that have signed up to make the changes. Some have already made the changes and some will make changes from today.

Why are food labels being changed?

Research has shown that the different nutrition labels on food are confusing. These different nutrition labels have arisen because companies have responded to their customers’ demand for more nutritional information, but until now there has been no agreement on a consistent format. The new labelling system aims to make it easier for people to make healthier choices, by comparing the same kinds of foods to see if there is a healthier option. 

As part of the government’s efforts to improve health through reducing obesity levels, the Department of Health is working with food manufacturers and supermarkets through a programme called the Responsibility Deal. This programme aims to get business to reduce the amount of calories, salt and saturated fat in foods. The standardised front-of-pack label is a new Responsibility Deal pledge that food and drink companies can sign up to. Many companies already have taken this pledge to change their food labels.

Public Health Minister, Anna Soubry, said: “The UK already has the largest number of products using a front-of-pack label in Europe, but we know that people get confused by the variety of labels that are used. Research shows that, of all the current schemes, people like this label the most and they can use the information to make healthier choices.

“We all have a responsibility to tackle the challenge of obesity, including the food industry. By having all major retailers and manufacturers signed up to the consistent label, we will all be able to see at a glance what is in our food – this is why I want to see more manufacturers signing up and using the label.” 

The labels are not designed to ‘demonise’ foods with lots of reds, but to have people consider what they are eating and make sure it’s part of a balanced diet. Download the eatwell plate (PDF, 1.6Mb) for more information about a healthy balanced diet.

Links To The Headlines

Food packaging 'traffic lights' to signal healthy choices on salt, fat and sugar. The Guardian, June 19 2013

New food labelling system launched. The Daily Telegraph, June 19 2013

Traffic light food labelling introduced by big supermarkets. Daily Mirror, June 19 2013

Food labelling: Consistent system to be rolled out. BBC News, June 19 2013

Major UK Supermarkets Launch New Food Labels. Sky News, June 19 2013

Red labels to warn of unhealthy food: Logos to appear on items considered 'bad' for health in anti-obesity drive. Daily Mail, June 19 2013

Rarely a month goes by without the papers reporting at least one health news story related to vitamin D. In recent weeks the media has reported that vitamin D can help relieve the symptoms of asthma and lower blood pressure.

There have been long-standing claims that vitamin D brings a wide range of benefits, from preventing cancer risk to improving mental health, or even reducing your risk of getting multiple sclerosis.

But is there good evidence to back up the claims? And do you need to change your diet or take vitamin D supplements to reduce your risk of disease?

What is vitamin D?

Vitamin D is a group of related molecules that the body needs to help absorb calcium and phosphate. These are substances that help keep the bones healthy and strong.

Vitamin D is somewhat unusual in that we obtain it from two difference sources:

• sunlight
• dietary sources

How much sun is needed to get enough vitamin D?

When the skin is exposed to the ultraviolet B contained in sunlight, it generates the production of vitamin D. Most people generate around 90% of the vitamin D in their body from sunlight.

Your sunshine requirements differ depending on factors such as your skin tone and your weight. A 2010 consensus statement on vitamin D (PDF, 126.69kb), released by a combination of charities, recommended a "little and often" approach. It says regularly going out with sunscreen for a few minutes in the middle of the day should provide enough exposure to create sufficient vitamin D.

You certainly don't need to get a suntan, let alone risk sunburn. Overexposure to the sun in this way can increase your risk of skin cancer.

How to get enough vitamin D through your diet

Eating a healthy balanced diet should be sufficient to top up the remaining 10% or so that experts believe we need through our diet. Dietary sources of vitamin D include:

• oily fish, such as salmon, sardines and mackerel
• eggs
• fortified fat spreads
• fortified breakfast cereals
• powdered milk

What is vitamin D deficiency?

Vitamin D deficiency is when the body does not have enough vitamin D to properly absorb the required levels of calcium and phosphate.

Mild to moderate vitamin D deficiency can lead to bone pain and weakening of the bones (osteoporosis). This could make you more likely to fracture a bone if you had a fall.

More severe levels of deficiency can lead to the development of rickets in children and osteomalacia in adults.

Rickets, osteomalacia and vitamin D

Chronic severe vitamin D deficiency in children can disrupt the normal formation of bones, causing them to become soft and malformed and resulting in the condition known as rickets.

Symptoms of rickets include:

• bone pain
• deformities
• fragile bones vulnerable to fracture

Previously regarded as a disease of the past associated with Victorian slums, rickets is now making a comeback in some parts of England.

In 2012 the Royal College of Paediatrics and Child Health released a statement highlighting the problems of vitamin D deficiency in children, reporting that rates of rickets have risen fourfold in the last 15 years.

Osteomalacia, like rickets, develops because of softening of the bones. The main symptom of osteomalacia is a dull, throbbing and often severe bone pain that usually affects the lower section of the body. Osteomalacia can also result in muscle weakness.

Other health risks that have been linked with vitamin D deficiency

In a 2010 BMJ clinical review on vitamin D deficiency, researchers presented evidence that vitamin D deficiency may increase the risk of developing a number of chronic conditions, such as:

• heart disease
• bowel cancer
• breast cancer
• multiple sclerosis 
• diabetes

However, more research is required to prove these associations and provide evidence that people need to change their behaviour or take supplements because of potential health problems.

How common is vitamin D deficiency?

Vitamin D is thought to be much more common than most people realise. A 2007 survey estimated that around 50% of all adults have some degree of vitamin D deficiency.

In 2012 the Chief Medical Officer for the United Kingdom wrote to GPs highlighting the issue of vitamin D deficiency in high-risk groups (see below).

An independent advisory committee is also reviewing current recommendations on vitamin D, but the results of this extensive analysis are not expected until 2014.

What are the risk factors for vitamin D deficiency?

Lack of exposure to sunlight

Unsurprisingly, a significant risk factor for vitamin D deficiency is lack of exposure to the sun.

Possible factors that can result in limited exposure to sunlight include:

• overuse of sunblock
• being housebound or spending long parts of the day inside
• wearing clothes that cover up most of your body, often for cultural or religious regions

There are anecdotal reports that children may be more likely to develop vitamin D deficiency these days, as they are less likely to play outside than children did in the past.

Darker skin tone

Having a darker skin tone means you require a greater amount of sunlight exposure to generate vitamin D.

It is estimated that people with a naturally dark skin tone may require three to five times longer sunlight exposure to make the same amount of vitamin D as a white person.

Obesity

Obesity could be an overlooked cause of vitamin D deficiency. A recent study published in February 2013 suggested there is a direct relationship between increasing body mass index (BMI) and falling vitamin D levels.

The authors of the study speculated that vitamin D may become "trapped" inside fat tissue, so there is less available to circulate inside the blood.

How is vitamin D deficiency treated?

Mild to moderate vitamin D deficiency can usually be treated by making lifestyle changes such as getting more sun and eating foods rich in vitamin D. In some cases your GP may also recommend you take vitamin D supplements.

In more severe cases where the deficiency has affected bone growth and density, such as rickets, a vitamin D injection may be recommended.

Foods fortified with vitamin D

Unlike in some other countries, in England staple food items such as milk, flour and cereals are not routinely fortified with vitamin D. Fortified versions of goods such as cereals and milk are available from most supermarkets. You can read the food labels to compare the levels of vitamin D between products.

Some argue that people in the UK, especially in the north of England and Scotland, would benefit from fortification. However, the vitamin D we get from dietary sources is thought to stay in the body longer than the vitamin D we get from sunlight. Fortifying staple foods and drinks could potentially lead to dangerously high levels of vitamin D in a small number of people (vitamin D toxicity).

Other benefits of vitamin D

Links To Science

Avenell A et al. Vitamin D and vitamin D analogues for preventing fractures associated with involutional and post-menopausal osteoporosis. Cochrane Database of Systematic Reviews. April 2009

Bjelakovic G et al. Vitamin D supplementation for prevention of mortality in adults. Cochrane Database of Systematic Reviews. July 2011

Garland CF et al. Vitamin D for Cancer Prevention: Global Perspective. Annals of Epidemiology. July 2009

Holick MF et al. Evaluation, Treatment, and Prevention of Vitamin D Deficiency: an Endocrine Society Clinical Practice Guideline. Journal of Clinical Endocrinology and Metabolism. July 2011

Jagannath VA et al. Vitamin D for the management of multiple sclerosis. Cochrane Database of Systematic Reviews. December 2010

Pearce SH, Cheetham TD. Diagnosis and management of vitamin D deficiency. BMJ. January 2010

Urashima M et al. Randomized trial of vitamin D supplementation to prevent seasonal influenza A in schoolchildren. American Journal of Clinical Nutrition. March 2010

Vimaleswaran KS et al. Causal Relationship between Obesity and Vitamin D Status: Bi-Directional Mendelian Randomization Analysis of Multiple Cohorts. PLOS Medicine. Published online February 5 2013