Edentulousness (no natural teeth) and intellectual (learning) disability

Edentulousness: "The property of being edentulous; lack of teeth."

I was brought to talk about edentulousness on this blog as a result of the findings reported by Kinnear and colleagues [1] and their observations suggesting that: "Adults with IDs [intellectual disability] have a high prevalence of edentulousness."

Based on data from an "adult cohort with IDs residing in Greater Glasgow and Clyde, Scotland", researchers compared rates of edentulousness in their 560 adults with ID with (asymptomatic) population data (n=2547) on this issue. The results were pretty worrying as "rates of edentulousness were consistently higher in the ID cohort" across various different age ranges: "9% vs. 1% aged 25-34 years; 22% vs. 2% aged 35-44 years; 39% vs. 7% aged 45-54 years; 41% vs. 18% aged 55-64 years; and 76% vs. 34% aged 65-74 years." Researchers also concluded that edentulousness was quite a bit more likely in those described as having "severe IDs".

When it came to other factors outside of ID severity that might be related to edentulousness, a few issues were observed such as "taking antipsychotics" and "living in the most deprived neighbourhoods." Other variables such as the presence of a diagnosis of autism and "problem behaviours" were are told, did not reach the thresholds for 'sufficient evidence'.

Why is all this important you might ask? Well, for lots of reasons, not least that the Kinnear results potentially highlight the important (continuing) issue of health inequality in relation to learning (intellectual) disability (see here). Indeed, one of my first thoughts when I read the Kinnear results is that quite a few of those news reports about people with learning disabilities that have been seen down the years, show people missing teeth. I can't help thinking what such pictures do for a person and their self-esteem. Even worse, such findings further highlight how for some people with ID, the state of edentulousness is literally forced on them (see here) with little or no regard for the views of them or indeed their loved ones.

Such findings do suggest that organisations need to try harder when it comes to improving the oral health of those with ID. I'm minded to suggest that those people who have a history of poor diet, those who are prone to pica (eating non-edible objects), those who have bruxism (teeth grinding) and/or those who have a history of persistent vomiting should perhaps be afforded particular dental attention. The link with antipsychotic use? Well, I also think more needs to be done in this area. There is already some data on medicines affecting oral hygiene [2] among which antipsychotics seem to have a place. The hows-and-whys need a little more understanding outside of the suggestion of xerostomia (dry mouth). Despite also the lack of any significant link between 'problem behaviours' and edentulousness identified by Kinnear, I'd still like to see whether certain 'challenging behaviours' might be contributory to such a state (see here) and perhaps one reason why antipsychotics were prescribed in the first place?

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[1] Kinnear D. et al. Prevalence of factors associated with edentulousness (no natural teeth) in adults with intellectual disabilities. J Intellect Disabil Res. 2019 May 6.

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Childhood dietary patterns and ADHD?

The findings of the systematic review and meta-analysis published by Bianca Del-Ponte and colleagues [1] provide the blogging fodder today, and the suggestion that: "a diet high in refined sugar and saturated fat can increase the risk, whereas a healthy diet, characterized by high consumption of fruits and vegetables, would protect against ADHD [attention-deficit hyperactivity disorder] or hyperactivity."

The starting point: "The diet during childhood has been investigated as a factor potentially involved in the ADHD etiology." Yes it has, and Del-Ponte et al managed to find 14 studies looking at this issue published in the peer-reviewed literature. The data were boiled down and results obtained suggesting that "healthy dietary patterns were protective against ADHD (OR: 0.65; 95% CI: 044 – 0.97), while unhealthy dietary patterns were found as risk to ADHD (OR: 1.41; 95% CI: 1.15–1.74)."

The authors admit that the science upon which they made their observation is "weak" insofar as cause and effect not being proved. This is an important point (see here) that follows other research in this area too (see here and see here) together with an understanding that many different variables *might* influence the risk of something like ADHD as a diagnosis or in behaviour (see here and see here for examples).

Still, if there is even the remotest possibility that diet might be something to consider in respect of ADHD, adding it to the intervention arsenal that already exists (see here) can only be a good thing...

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[1] Del-Ponte B. et al. Dietary patterns and attention deficit/hyperactivity disorder (ADHD): A systematic review and meta-analysis. Journal of Affective Disorders. 2019; 252: 160-173.

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Pigeons, meet cat: "The Hans Eysenck affair: Time to correct the scientific record"

I'm heading off-piste with my musings today, drawing your attention to a paper by Anthony Pelosi [1] and an accompanying editorial by David Marks [2] (both open-access) that are likely to 'put the cat among the pigeons' in some quarters (with thanks to Matthew Dalby for bringing the Pelosi study to my Twitter attention). Indeed, the publishing journal - The Journal of Health Psychology - is no stranger to 'cat among the pigeons' discussions, as per their 2017 special edition [3] on the PACE trial "for patients with myalgic encephalomyelitis (ME)/chronic fatigue syndrome (CFS)." Perhaps interestingly, there is a 'psychosomatic' connection between the topic covered in the Pelosi paper and those critical musings on how to (or perhaps how not to) treat ME/CFS...

The person at the centre of the Pelosi paper is the late Prof. Hans Eysenck; a figure who anyone with the slightest interest in the discipline called psychology would probably have heard of. Personality was one of the major research interests for Eysenck, and in particular, the proposal of dimensions to personality: extroversion/introversion, neuroticism/stability, psychoticism/socialisation. Perhaps not as famously known about, but still influential, were Eysenck's views relating to "his persistent denial of the carcinogenic effects of tobacco." Indeed, his 'alternative view' that "certain personality traits that lead to smoking also increase the risk of developing cancer" is starting to look decidedly 'shaky' in modern times. More so when there is talk of 'funding' and 'sources of funding' potentially complicating the issue.

Pelosi (and Marks) make a case that the time is right for psychology and various other interconnected disciplines to start looking more critically at the collected published work of Eysenck and some of his colleagues. They argue that claims "about the alleged effectiveness of psychotherapy in preventing cancer" or that "behaviour therapy may be useful in prolonging life, as well as in preventing disease" have little place in modern, evidence-based, science and medicine. Pelosi - who has some important history of being slightly critical of some of Eysenck's findings alongside other notable names - also goes one stage further in suggesting that some of the "widely cited studies" published with Eysenck's name attached "have had direct and indirect influences on some people’s smoking and lifestyle choices." Further: "This means that for an unknown and unknowable number of individual men and women, this programme of research has been a contributory factor in premature illness and death." Strong words indeed.

Marks ends his editorial with open letters to the President and Principal of King's College London and the Chief Executive of the British Psychological Society (BPS) calling for further investigation of the points highlighted in the Pelosi paper. Pelosi has seemingly approached the BPS previously on this matter but apparently did not receive a particularly warm reception to his then request for further investigation of some of the science and conclusions made in this area (see here). Whether such a second request - made in the era of social media - will be acted upon differently this time is a 'wait and see' question. All of this taking into account the moves being made to make psychology a more credible science these days...

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[1] Pelosi AJ. Personality and fatal diseases: Revisiting a scientific scandal. Journal of Health Psychology. 2019. Feb 23.

[2] Marks DF. The Hans Eysenck affair: Time to correct the scientific record. Journal of Health Psychology. 2019. Feb 23.

[3] Marks DF. Special issue on the PACE Trial. Journal of Health Psychology. 2017. July 31..

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"people on the autism spectrum have a high prevalence of physical and mental health conditions in midlife and old age"

Should anyone really be that surprised by the findings reported by Lauren Bishop-Fitzpatrick & Eric Rubenstein [1] talking about "a high prevalence of physical and mental health conditions in midlife and old age" when it comes to autism?

Well, yes and no. No, because things like 'psychiatric symptoms and disorders' have already been talked about with regards to older age adults with autism [2] (see here also), alongside various other 'medical comorbidity' being noted in this group (see here). But also yes, because the scale of the physical and mental health conditions identified by Bishop-Fitzpatrick & Rubenstein is quite literally jaw-dropping: "immune conditions (70.6%), cardiovascular disease (49.0%) and its risk factors (46.2%), sleep disorders (85.3%), gastrointestinal disorders (49.7%), neurologic conditions (55.9%), and psychiatric disorders (72.0%) were highly prevalent in our full sample." Said full sample consisted of "de-identified Medicaid claims data for 143 adults with a recorded autism spectrum disorder diagnosis aged 40–88 years."

Researchers also mention how 44% of their sample had an intellectual (learning) disability. This kinda accords with various other data on this topic (see here). Other observations mentioned by the authors also complement existing (peer-reviewed scientific) knowledge that: (a) intellectual (learning) disability seems to bring about an increased risk of epilepsy appearing alongside autism (see here), and (b) depression and anxiety prevalence seems to be particularly elevated in those with autism without any accompanying learning disability (see here) (assuming that depression and/or anxiety are actually being screened for in those with autism + learning disability).

What do the collected data imply? Well, screening is important. Screen and screen and screen and screen. Screen for lots of things, and if something turns up, treat / manage it. If your average Jane or Joe turned up at their Doctors office with a sleep disorder or the symptoms of cardiovascular disease, medical professionals would do something about it. If the Doctor also knew that Jane / Joe might, for example, be more likely than usual to be in receipt of certain classes of medicines that potentially elevates such risks further, they'd be even more keen to screen and intervene. So it should be the same if Joe or Jane is diagnosed with autism or an autism spectrum disorder (ASD).

I'd also suggest that such data should really be leading to a lot more questioning about why? Why do people on the autism spectrum seem to be at particularly high risk of 'immune conditions' or 'digestive disorders'? Are there potential genetic links between autism and such conditions as per the notion that 'autism genes aren't necessarily just genes for autism' (see here) or that such genes might also affect other biological systems as well as the grey-pink matter floating around the skull (see here for example)? Are there other intricate connections between such classes of conditions as per the idea that sleep problems seem to follow gut problems for some (see here)? Why? Pain, discomfort, something else? And don't even get me started on the whole 'immune system - autism' connection (see here for example) which has been known about for many, many, many years. Known about but brushed under the carpet by some.

And whilst talking about the research tag-team that is Bishop-Fitzpatrick & Rubenstein, I once again would direct you to another important paper of theirs [3] about how we need to be very careful about using the word 'comorbidity' when referring to the various mental and physical issues that are over-represented around autism. As we've seen from other research (see here and see here), the core features of autism may very well predispose to a lot more than just autism and, in that respect, this might go way beyond just comorbidity...

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[1] Bishop-Fitzpatrick L. & Rubenstein E. The physical and mental health of middle aged and older adults on the autism spectrum and the impact of intellectual disability. Research in Autism Spectrum Disorders. 2019. Jan 29.

[2] Lugo-Marín J. et al. Prevalence of psychiatric disorders in adults with autism spectrum disorder: A systematic review and meta-analysis. Research in Autism Spectrum Disorders. 2019; 59: 22-33.

[3] Rubenstein E. & Bishop-Fitzpatrick L. A matter of time: The necessity of temporal language in research on health conditions that present with autism spectrum disorder. Autism Res. 2019 Jan;12(1):20-25.

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Autism and learning disability: "double disadvantage" on health status

The paper published by Kirsty Dunn and colleagues [1] continues a theme on how Census information - where data is systematically recorded about a specific population, normally a country - is influencing autism research (see here and see here). The Census in question is "Scotland's Census, 2011" and the rather forward facing step to include some questions about autism and learning (intellectual) disability in the Scottish Census for 2011.

This time around the same research group, who were very much involved in the publication of other Census based information on autism, set out with the aim to examine "the population prevalence of co-occurring intellectual disabilities and autism, and its impact on general health status." From a total population of over 5.2 million people who were included in the Scottish Census in 2011, they observed that about around 0.1% "had co-occurring intellectual disabilities and autism." Although perhaps not sounding like a lot of people, that percentage represented over 5000 people, including children and adults. Most of those with autism and learning disability were male.

Then to the headline conclusion related to the "double disadvantage" mentioned in the title of this post from the Dunn paper: "Their general health status was substantially poorer than for the rest of the population, more so for children/young people, and they had more limitations in their day-to-day activities." Researchers also mention how poor general health status was "apparent across the entire life course." They further recommended that: "Staff in services for people with either of these conditions need to be trained, equipped, resourced and prepared to address the challenge of working for people with this duality. This is essential, to address these substantial health inequalities."

I know the use of the words "double disadvantage" are probably not going to be well received by everyone, particularly those who insist that autism is more about difference than disability. I'm in partial agreement that, whilst a diagnosis of autism does have a profound influence on many aspects of life, not everything is necessarily to be seen as a 'disadvantage' for everyone. When it comes however to health inequality in the context of autism (and learning disability), I don't think many people would argue with the idea that both in the context of autism alone and autism + learning disability, various aspects of health - physical and mental - can and do suffer as a result (see here and see here for examples) and are, in that light, a disadvantage. With all this in mind, the call to action made by Dunn et al is not without some substantial merit...

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[1] Dunn K. et al. The prevalence and general health status of people with intellectual disabilities and autism co-occurring together: a total population study. J Intellect Disabil Res. 2018 Nov 28.

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Long-term health conditions and autism: a Scottish perspective

There were a few things that raised my eyebrow (Roger Moore style) in the paper published by Ewelina Rydzewska and colleagues [1]. The primary finding that: "Comorbidity is substantially greater in adults with reported autism than in other people" was one of the eyebrow raisers. But also the observation that: "Scotland’s Census is one of the few country censuses that asks every person in the country whether or not they have autism, indeed it may be unique in this regard" was another. There were others too...

Back to the first point and the primary purpose of the Rydzewska study: "to investigate the prevalence and predictors of deafness or partial hearing loss, blindness or partial sight loss, intellectual disabilities, mental health conditions, physical disability and other condition, in a whole country population of adults with reported autism aged 25+ compared with their peers without autism." Said whole country was somewhere not a million miles away from where I write this post - Scotland - and results based on Scotland's Census 2011. The Census did what Census (I don't know what the plural should be!) are normally designed to do: to provide details on the population (N=5 295 403) covering everyone "whether living in communal establishments (such as care homes and student halls of residence) or private households." As mentioned, I wasn't aware that Scotland asked about whether someone has autism or not as part of the Census but I'm impressed that they do. As to the authors' testing the idea that autism is rarely a stand-along diagnosis, well let's just say that this has already been discussed a few times in the peer-reviewed science arena (see here for example) so we kinda had some clues as to what might have been observed.

Results: "There were 6649/3 746 584 (0.2%) adults aged 25+ recorded to have autism as defined here, 4610 (69.3%) of whom were men and 2039 (30.7%) women compared with 1 776 845 (47.5%) men and 1 963 090 (52.5%) women in the adult population without autism." Let me just say that again: in the Scottish 2011 Census, that covered both private households and 'communal establishments' only 0.2% of the respondents above 25 years of age were reported to have a diagnosis of a "developmental disorder (eg, autistic spectrum disorder or Asperger’s syndrome)." Interesting.

Continuing: "The rate of autism was lowest in the oldest age groups (autism may be associated with reduced life expectancy)." 'Autism may be associated with reduced life expectancy' is another important detail mentioned in the Rydzewska study and something that taps into a wealth of other science (see here for example) observing that the diagnosis of autism can, very much, be a life-limiting label for some.

Then to the main event: lots of different diagnoses/labels were seemingly over-represented alongside a diagnosis of autism. Indeed, pretty much all of the ones enquired about by researchers fell into that category. A third of participants for example, reported experiencing 'something' under the heading of "a mental health condition"; a finding also fairly consistently stretching across individual analyses based on different age bandings. When it came also to the category titled 'intellectual disabilities' (also known as learning disability here in Blighty) the figures stood out: "A high rate of intellectual disabilities in children with autism has been described previously; we have now quantified the extent of this—29% (25%–32% depending on age group; 22%–35% for men and 31%–42% for women)—in a much larger study of adults." This [roughly] accords with other independent data too (see here).

What's more to say? Well yet again, it's all about not looking at autism as some sort of 'stand alone' label given the over-representation of some pretty significant categories of health issues, covering both the somatic (physical) and the psychological. I don't think anyone would disagree with such an observation in this day and age as the words 'Autism Plus' are also mentioned in the Rydzewska paper. Once again, this also has implications for preferential screening when a diagnosis of autism is received and also the treatment/management of any issues that are detected (see here and see here for examples).

As for that 0.2% adult (over 25 years old) prevalence figure noted by the authors, I'm not going to say too much more about that for now. Aside that is, from dropping in some discussions about another adult autism prevalence study (see here) which reported that figures were potentially climbing in line with the childhood autism prevalence figures (see here). I'm sure that there are multiple discussions that could be generated around such figures but not here, not now, and not to distract from the important observation that autism rarely appears in a diagnostic vacuum...

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[1] Rydzewska E. et al. Prevalence of long-term health conditions in adults with autism: observational study of a whole country population. BMJ Open. 2018;8:e023945.

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Estimated autism prevalence in Canada in 2015: 1 in 66

"On March 29, 2018, the Public Health Agency of Canada published the first comprehensive review of the prevalence of autism spectrum disorder (ASD) in Canada."

So began the 'what did we find' summary (see here) covering the "Made in Canada" findings detailed in the Canadian National Autism Spectrum Disorder Surveillance System (NASS) 2018 Report (see here) [1]. Pertinent to the year 2015 and including some 88% of the children and young adults living in various participating Provinces and Territory, data was gathered from various sources (education, social services, health) onward to the estimated prevalence of diagnosed autism in Canada.

Their results: "Among children and youth 5–17 years old across seven provinces and territory, the combined prevalence of ASD for the year 2015 is 1 in 66 (15.2 per 1,000)" (bold text added by me).

Details, details, details... Such an estimate applies to children and young adults (youth) diagnosed with autism and does not say anything about the number of adults diagnosed with autism. It only covers those diagnosed with autism based on strict criteria: "The diagnosis of ASD is provided or confirmed by a licensed health care professional(s)... [and] The diagnosis of ASD is based on the clinical criteria in the Diagnostic and Statistical Manual (DSM) for Mental Disorders or the case is identified as ASD in the International Classification for Diseases (ICD)." It does not provide any information on how many people *might* be autistic but not yet in receipt of a diagnosis. Males made up the lion's share of those diagnosed. Most had been diagnosed by the age of 8 years (72%). Oh, and not every Province or Territory showed the same estimated prevalence rate for various potential reasons. And rest.

Also pretty important to the reported findings is the comparison with earlier years estimates: for 3 geographic locations in Canada we see the characteristic 'upward trend' in the estimated prevalence of ASD noted in other sample data from other countries, from around 4-6 per 1,000 in 2003 to between 16-20 per 1,000 in 2015. And when compared with a neighbour to the South (USA) and their estimated autism prevalence stats covering 2012 (see here) coming up with a figure of 1 in 68, the Canadian estimates are not a million miles away,. This, bearing in mind, some differences in the way the different country figures were arrived at and also the time periods covered. That also reminds me, we should be seeing the latest US stats on estimated autism prevalence from the CDC at some point in the (very) near future, and the promise that "the ADDM Network will be able to estimate ASD case status on the basis of both DSM-5 and DSM-IV-TR." Those comparisons should be rather interesting in light of other preliminary data (see here).

What else it there to say? Diagnosed autism is fairly prevalent across Canada (who have some important history in relation to the autism 'numbers game') and I assume we'll be seeing more on their tracking of the diagnosis in future times. Preparation is an important part of the figures being discussed; preparation of education, social and health services to support the numbers of children and young adults being diagnosed now and who, I assume, will eventually be transitioning to adult services. And on the topic of adult services, I'll refer you to Harold Doherty's blog and some of his opinions on adult services in a Canadian setting (see here).

Finally, is the question of 'why' the increase? Well, let's wait and see what those US CDC figures say first and how useful they might be to answering 'why' in the Canadian and other contexts too. I say this accepting that those 'better awareness', 'diagnostic switching' and 'broader criteria' arguments that have long been trumpeted as 'fact' are probably not all there is to see in this area (see here and see here).

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[1] Autism Spectrum Disorder among children and youth in Canada 2018. Public Health Agency of Canada. 2018. March 2018.

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The 'hard' martial arts and health benefits systematically reviewed

Shotokan karate is a hobby of mine. I say 'hobby' but for me it's become so much more than that. It's not just that I find myself practising my age-uke (pronounced 'aggey-uki') or various favourite kata whenever I have some space free around me; it's more in relation to how it's been a route for me to live a lot more healthier [active] lifestyle more generally. I am indeed at one with myself...

A recent paper by Sandra Origua Rios and colleagues [1] provides some good evidence that practising the martial arts - the 'hard martial arts such as karate, taekwondo or kung fu - carries quite a few health benefits for adults. Based on their searching the collected peer-reviewed research literature and use of the Effective Public Health Practice Project tool, authors concluded that most studies on such training carried positive effects "showing some improvement and maintenance of balance, cognitive function and psychological health" when practised by adults. Studies like this one from Witte and colleagues [2] tell you quite a lot about what you need to know. All this is good news indeed to the many, many practitioners of such martial arts. Also an added boost to the masses that will undoubtedly take up one or more of the arts when they watch the very best demonstrate their skills at the 2020 Olympics...

Of course it's not necessarily all 'positive' when it comes to the use of martial arts and health and wellbeing. The authors note that 'risk of injury' is always going to be a concern when engaging in disciplines that rely on strikes, blocks and throws and 'confrontation of force by force'. In the context that risk of injury is a risk carried by most, if not all sporting activities, the authors add that the majority of injuries sustained in the hard martial arts tend to be minor; particularly when practising at less than elite competitive level (as most people do). Indeed, on the specific point of injury risk, I can add a few things: (a) developing 'control' when sparring (we call it 'kumite') is a key point that comes from practice and more practice, and (b) protective equipment such as mitts and on occasion, gum shields and various, ahem, parts-of-body protectors, are available and sometimes used. Other injuries such as bruising, blistering and some occasional joint pain/stiffness are typically short-lived and clear up after a few days of rest. I might also mention that actually facing an opponent and 'not fearing getting hit' is something else important that comes from such training, given that most people aren't used to being in such an atypical situation and tend to panic (and that's when injuries can happen).

Origua Rios et al also suggest that more research is required on the risk-benefit profile of the hard martial arts including evidence based on randomised controlled trials (RCTs) tracking "morbidity and mortality in the long term." I would agree; but with the proviso that looking at hard martial arts vs. no martial arts training is not necessarily going to be the only methodological way forward in light of other, more general evidence talking about sedentary behaviour and health-related quality of life for example. Indeed, when one talks about 'cognitive functions' potentially being positively affected by martial arts training, it would be useful to see comparisons with the more 'soft' martial arts such as Tai Chi for example, to see how and why such as effect might originate and perhaps generalise. I have my ideas about where any maintenance/improvement to cognitive abilities may originate from in karate terms (try learning and retaining knowledge of all those kata!) but more scientifically-derived information is required.

I know that the hard martial arts probably won't be everyone's cup of tea. I know some people might think it's a bit too rough or challenging or something for those with sprightly athleticism who can 'do a really good high kick'. I would however caution against such preconceptions. As my instructor(s) often say: quality of movement is better than speed or height of said movement (or words to that effect).

And with physical activity (PA) and cognitive functions in mind, it's perhaps also timely that a recent meta-analysis from Celia Álvarez-Bueno and colleagues [3] has also been published talking about how: "PA, especially physical education, improves classroom behaviors and benefits several aspects of academic achievement, especially mathematics-related skills, reading, and composite scores in youth." I daresay that getting more children and young people involved in the martial arts might have a similar effect; although ensuring that due care and attention is paid to 'enjoyment' as being a big part of why someone does or does not stick to a particular sport (see here).

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[1] Origua Rios S. et al. Health benefits of hard martial arts in adults: a systematic review. J Sports Sci. 2017 Nov 21:1-9.

[2] Witte K. et al. Comparing the effectiveness of karate and fitness training on cognitive functioning in older adults—A randomized controlled trial. Journal of Sport and Health Science. 2016; 5: 484-490.

[3] Álvarez-Bueno C. et al. Academic Achievement and Physical Activity: A Meta-analysis. Pediatrics. 2017. Nov 22.

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Tobacco smoking and psychiatric illness

"The prevalence of smoking has remained alarmingly high among individuals with schizophrenia and bipolar disorder, and the disparity with those without psychiatric disorders and with the general population is increasing."

So said the findings reported by Faith Dickerson and colleagues [1] who surveyed nearly 2000 people "about their cigarette smoking at enrollment into a research study for which they were selected without regard to their smoking status." Their findings make for important reading in the context that tobacco smoking is not exactly a healthy activity (see here) and could potentially contribute to some of the health inequalities already recognised when it comes to serious mental illness (SMI) (see here).

The sorts of figures of smoking prevalence observed by Dickerson et al are not to be ignored: "62% of individuals with schizophrenia, 37% with bipolar disorder, and 17% of participants without a psychiatric disorder (control group) reported that they were current smokers." This set in the context of falls in the rates of smoking in the general population. It's also worthwhile noting that being a 'current smoker' with reference to a diagnosis of schizophrenia or bipolar disorder typically meant smoking "more cigarettes per day" than the control cohort.

There are other implications from this work. Without generalising (or stigmatising) if one draws on other work talking about a possible connection between prenatal nicotine exposure and offspring [heightened] risk of schizophrenia for example (see here), a complex pattern of *association* seems to emerge. No, I'm not saying that every woman with schizophrenia who is pregnant will smoke through their pregnancy (despite evidence of some increased risk [2]) but greater focus and education on the need to restrict tobacco smoking during that critical period is perhaps warranted. Such discussions may also have implications for the whole nature-nurture debate with regards to such psychiatric diagnoses too.

Although there are many (many!) good reasons for encouraging those with a SMI to quit smoking, I do feel it is important also to understand why so many are smokers. The findings reported by Li and colleagues [3] offer something of a perspective on this issue where for example: "Smokers had a higher mental QOL [quality of life] than non-smokers... in MDD [major depressive disorder]." Similarly, Mallet and colleagues [4] discussed results that suggested that "some therapeutics may improve daily smoking behavior in smokers" in the context of schizophrenia (as others seemed to be associated with 'not improving' smoking behaviours). In short, the roads that lead to, and perpetuate tobacco smoking in the context of SMI are likely as complex as the ones needed to lead people away from such habits...

And aside from the health reasons to quit smoking particularly among those diagnosed with a SMI, the grand review, meta-analysis and meta-regression paper by Cassidy and colleagues [5] lists tobacco smoking as one potentially important (and modifiable) correlate when it comes to risk factors for suicidality in schizophrenia...

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[1] Dickerson F. et al. Cigarette Smoking by Patients With Serious Mental Illness, 1999-2016: An Increasing Disparity. Psychiatr Serv. 2017 Sep 15:appips201700118.

[2] Nilsson E. et al. Women with schizophrenia: pregnancy outcome and infant death among their offspring. Schizophr Res. 2002 Dec 1;58(2-3):221-9.

[3] Li XH. et al. Prevalence of smoking in patients with bipolar disorder, major depressive disorder and schizophrenia and their relationships with quality of life. Sci Rep. 2017 Aug 16;7(1):8430.

[4] Mallet J. et al. Cigarette smoking and schizophrenia: a specific clinical and therapeutic profile? Results from the FACE-Schizophrenia cohort. Prog Neuropsychopharmacol Biol Psychiatry. 2017 Oct 3;79(Pt B):332-339.

[5] Cassidy RM. et al. Risk Factors for Suicidality in Patients With Schizophrenia: A Systematic Review, Meta-analysis, and Meta-regression of 96 Studies. Schizophr Bull. 2017 Sep 23.

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Stepping into big data: who in the world walks the most each day?

With some journalistic flair, the BBC headline titled: 'Do you live in the world's least active country?'' caught my eye recently, discussing the findings reported by Tim Althoff and colleagues [1] (the first edition of their headline mentioned 'laziest' over 'least active'!)

The name of the research game was to analyse captured data on some "68 million days of minute-by-minute step recordings from 717, 527 anonymized users of the Argus smartphone application developed by Azumio." Said data spanned over 100 countries around the world, although researchers chose to zoom in on 46 countries where at least 1000 people had downloaded the app.

Results suggested that there were some quite considerable differences in steps per day according to the country data analysed and also variables such as gender/sex. Participants in Hong Kong for example, irrespective of gender, were top of the walking chart clocking up an average of 6800 steps per day. At the opposite end of the steps per day spectrum, those in Indonesia averaged just 3500 steps per day. The average number of steps per day across all the data analysed was round about the 5000 mark. There are some other potentially important snippets of information also included in the Althoff paper - the concept of 'activity inequality' - but I'm gonna stick with the steps per day data on this occasion.

A few times before on this blog I've talked about steps per day and walking patterns (see here and see here for examples) and what they might mean for health and wellbeing. Being partial to wearing an actigraph day-to-day, I see walking as part of the my own exercise regime and am a fan of things like the 10,000 steps a day challenge. Not least that as well as aiding in maintaining good physical health, there may be various other benefits from walking as part of a consistent exercise regime. Accepting that there may be various reasons why people don't walk perhaps as much as they should - health issues, age, environment and 'walkability' of the environment, etc - I am a little disappointed with the observations emerging from the Althoff paper insofar as how sedentary many people worldwide seemed to be. Yes, the current data was based on an app and so may have a degree of error in terms of it's recording capability (including whether a phone was carried with a person throughout the day or when engaging in other physical activities) but the average steps being counted per day seem to be quite a bit lower than many experts are advising for maintaining optimal health.

And because walking is [typically] free and can be undertaken by most people, I'd personally like to see a bigger push from Governments and the like to get more people back into walking...

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[1] Althoff T. et al. Large-scale physical activity data reveal worldwide activity inequality. Nature. 2017. 10 July.

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"medical disorders in children with ASD and ADHD appear to be widespread"

The quote titling this brief post is taken from the results of the systematic review undertaken by Jet Muskens and colleagues [1] (open-access) who surveyed the peer-reviewed science literature "on medical comorbidity in the two major developmental disorders autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD)."

Continuing an important theme (see here), the authors concluded that various categories of conditions - "immunology, neurology and gastroenterology" - are over-represented in relation to autism and ADHD and that "future studies should not only focus on psychiatric symptoms, but provide a broader evaluation of medical disorders" when it comes to those labels.

Minus too much chatter, I was impressed to see that many of the research articles covered on this blog down the years had made it into the Muskens review. So, the likes of Harumi Jyonouchi gets a well-deserved mention (see here and see here) and the focus on how the immune system might be doing so much more than just protecting us from the odd pathogen or two. The authors also bring in some of the very convincing scientific evidence that various gastrointestinal (GI) issues are over-represented in relation to autism (see here). There's even mention of how useful that Taiwanese research database has been down the years to autism and ADHD research (see here).

What's more to say? Well, preferential screening for various medical conditions in the context of an autism diagnosis yet again, receives more support. As does the idea that when a medical diagnosis is received by a person diagnosed on the autism spectrum, that medical diagnosis deserves the same healthcare management and/or treatment as it does in the context of not-autism save any further health inequalities potentially appearing (see here). The days for example of 'blaming autism' for every single physical complaint are also to be consigned to the historical dustbin. And with it, recognition that concepts such as ESSENCE or 'autism plus' (see here and see here) really need to include the somatic as well as the behavioural/psychiatric...

Whilst welcoming the Muskens review, it's important to note that others have already 'primed' for the importance of medical comorbidity in relation to a diagnosis of autism...

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[1] Muskens JB. et al. Medical comorbidities in children and adolescents with autism spectrum disorders and attention deficit hyperactivity disorders: a systematic review. European Child & Adolescent Psychiatry. 2017. July 3.

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Physical exercise as a nootropic of choice

Nootropic, defined as a 'smart drug' or cognitive enhancer, is generally taken to mean a substance/compound/medicine that has some positive effect(s) on aspects of cognition. I've talked about the possibility that various compounds might fit this bill on this blog (see here for example) but today I'm discussing another quite important potential nootropic: exercise.

It was the paper by Joseph Michael Northery and colleagues [1] (open-access) that added exercise to the nootropic categorisation on the premise of their meta-analysis results suggesting that "physical exercise interventions are effective in improving cognitive function in adults aged >50 years, regardless of cognitive status." As you can imagine, findings such as that tend to generate news headlines as per this one.

Including the results of some 39 studies where exercise and cognition were included as watchwords and trials were of the randomised-controlled design, researchers set about analysing the collected data covering various types of exercise and various cognitive outcomes. Aside from some issues with various forms of bias, most prominently with regards to blinding(!), they concluded that various types of exercise seemed to positively impact on cognitive functions. Particularly notable were the positive effects on executive functions: "a set of cognitive processes responsible for the initiation and monitoring of goal-orientated behaviours" and aspects of memory via the use of resistance training (i.e. using weights). Other more aerobic exercise regimes also seemed to have positive effects on other aspects of cognition too. It seems some combination of aerobic and resistance exercise regimes might provide the best generalised advice according to the authors "of at least moderate intensity and at least 45 min per session, on as many days of the week as possible." Just going back to that resistance training - executive functioning link being proposed, I wonder whether there may be other investigations to be carried out here with specific labels in mind [2].

Added to other research talking about 'exercise as medicine' (see here) and more particularly that exercise *might* have some important effects for aspects of psychological health and wellbeing (see here and see here for examples) there is a peer-reviewed, evidence-based picture emerging. It suggests that messages about moving more (see here) as being important for weight and BMI might be only the tip of iceberg.

And although not for everyone, I'm minded to yet again extol the virtues of the martial arts which also might have some "positive effect on some aspects of cognition" [3] (even for those under 50 years old with middle-aged hips like mine)...

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[1] Northey JM. et al. Exercise interventions for cognitive function in adults older than 50: a systematic review with meta-analysis. Br J Sports Med. 2017. April 24.

[2] Demetriou EA. et al. Autism spectrum disorders: a meta-analysis of executive function. Molecular Psychiatry. 2017. April 25.

[3] Fabio RA. & Towey GE. Cognitive and personality factors in the regular practice of martial arts. J Sports Med Phys Fitness. 2017 May 5.

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Northey, J., Cherbuin, N., Pumpa, K., Smee, D., & Rattray, B. (2017). Exercise interventions for cognitive function in adults older than 50: a systematic review with meta-analysis British Journal of Sports Medicine DOI: 10.1136/bjsports-2016-096587

I would walk 500 miles... or maybe just 8 miles (a day).

"Desk-bound workers should ‘walk EIGHT miles a day’ to slash risk of heart attacks or stroke" went one headline talking about the findings reported by William Tigbe and colleagues [1]. Drawing on data from over 110 postal workers - "(55 office-workers, 5 women, and 56 walking/delivery-workers, 10 women)" - who wore "activPAL physical activity monitors for seven days", researchers observed some potentially important trends.

Alongside wearing their activity monitors, participants were also assessed on the basis of weight, height, and blood pressure; also providing blood samples pertinent to analyses for cholesterol and triglycerides. Such collected data were used to assess cardiovascular risk based on the PROCAM risk calculator.

Results: those who were described as office workers and had a 'desk job' were generally larger at the waist and showed a slightly larger body mass index (BMI) score. They were also deemed to have an elevated risk of cardiovascular disease (over 10 years) compared with the walking/delivery workers. These observations were discussed in terms of the sedentary behaviours associated with their desk job. By contrast, those who delivered post (i.e. were active for large parts of the day) fared quite a bit better than their desk-bound colleagues, bearing in mind that all study participants were fairly healthy to begin with in terms of being non-smokers for example and not being in current receipt of blood pressure or glucose lowering medicines at time of study.

The 'walk 8 miles a day' headline that followed the Tigbe study was derived from the observation(s) that: "Those with no metabolic syndrome features walked >15 000 steps/day, or spent >7 h/day upright." Metabolic syndrome refers to a collection of symptoms - "a combination of diabetes, high blood pressure and obesity" - that increases the risk of adverse events associated with cardiovascular (dys)function. It seems that being active, or at least not being sedentary, is important for our health - a shocker indeed!

I've covered some of the other research in this area before (see here and see here for examples) and so the Tigbe results really don't come as a surprise. The strengths of the study are multiple in terms of objective measuring of activity (not reliant on the 'how much activity/exercise did you do today' type questionnaires) and all those biochemical measurements taken for participants to complement such findings. Yes, the sample size is OK but not particularly large and yes, these were pretty healthy participants to start with, but the results are nonetheless important.

Obviously one has to be a little careful so as not to imply that being active is the only thing that leads to good health and wellbeing. Science has already heard about how 'you can't outrun a bad diet' [2] and for some people, walking 15,000 steps every day or even standing up for 7 hours a day is going to be a big ask. But as part of a package of 'interventions' to potentially ward off metabolic syndrome or related issues [3], the idea that we should all be quite a bit more active is one that really should be given a lot more consideration...

Music to close, and with the title to this post, what else could I offer?

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[1] Tigbe WW. et al. Time spent in sedentary posture is associated with waist circumference and cardiovascular risk. Int J Obes (Lond). 2017 Jan 31.

[2] Malhotra A. et al. It is time to bust the myth of physical inactivity and obesity: you cannot outrun a bad diet. Br J Sports Med. 2015 Aug;49(15):967-8.

[3] Alexander DD. et al. A Meta-Analysis of Randomized Controlled Trials and Prospective Cohort Studies of Eicosapentaenoic and Docosahexaenoic Long-Chain Omega-3 Fatty Acids and Coronary Heart Disease Risk. Mayo Clinic Proceedings. 2017; 92: 15-29.

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Tigbe WW, Granat MH, Sattar N, & Lean ME (2017). Time spent in sedentary posture is associated with waist circumference and cardiovascular risk. International journal of obesity (2005) PMID: 28138134

A (bleedin' obvious) guide to happiness

Happy New Year!

Welcome back to Questioning Answers in 2017. While we wait to see just what this year will offer in [autism research] blogging terms, I open proceedings with the answer to happiness. Yes, you heard me right, I can officially unveil the Questioning Answers guide to happiness...

Drum roll please... and "Mental health and relationships 'key to happiness'."

As I unclutch my hands from my face and those opening 'bleedin' obvious' words included in the title of this post resonate once more alongside the question: 'how much did this research cost?' I direct you to some further discussion about the Origins of Happiness study (see here) from where results were derived.

Taken from: http://voxeu.org/article/origins-happiness

"So in short. If your suffering from depression your not very happy. Dontcha just love the intellectual elite" and "So in a nutshell, have the report's authors found that people not suffering with depression are generally happier than those that are suffering with it? How much are these geniuses paid?" are just two of the comments following that BBC coverage of the study results. With all due respect to the study authors and their introduction of new watchwords like 'wellbeing creation' over wealth creation, I am kinda reeling from the idea that we actually needed a study/report like this given the lack of surprising outcomes noted.

As per Figure 1 and the 'determinants of adult life satisfaction' is anyone really that surprised that having an education, a job, an income, being in rude health, having a special someone or even special 'some people', not being incarcerated or exposed to criminality and not suffering from depression and/or anxiety actually makes people more satisfied with their lives? No, and neither should you be.

I've little more to say on this topic aside from mentioning that (a) happiness is perhaps a relative term and something that includes both short-term and long-term elements to it and (b) the focus on treating mental health issues such as depression and anxiety with 'psychological therapies' (made by the author(s)) should not necessarily be to the exclusion of other well-validated treatment measures. Indeed, I might advance the position of a greater 'correlation' between physical health and mental health in light of other research findings (see here).

So: Be Happy! (I promise that my blogging this year will get better).

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The physical health of adults with autism

Another short post today opening with the conclusion reached in the paper by Andrew Cashin and colleagues [1]: "From the findings, it can be stated with confidence that people with ASD [autism spectrum disorder] have a high rate of comorbidity and increased risk for chronic disease."

Yes, not new news to many that physical health is generally 'under-rated' when it comes to adult autism (see here and see here for examples). The question remains however: what are we all going to do about it?

Following continued acceptance that a diagnosis of autism might go WELL beyond the presented core behavioural features, how about a few more discussions about the healthcare experiences of those on the spectrum [2] (see here too) as a start and taking things from there, save ending up where another label has (see here) with regards to physical health?

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[1] Cashin A. et al. A scoping review of what is known of the physical health of adults with autism spectrum disorder. J Intellect Disabil. 2016 Sep 13. pii: 1744629516665242.

[2] Raymaker DM. et al. Barriers to healthcare: Instrument development and comparison between autistic adults and adults with and without other disabilities. Autism. 2016 Sep 22. pii: 1362361316661261.

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Cashin A, Buckley T, Trollor JN, & Lennox N (2016). A scoping review of what is known of the physical health of adults with autism spectrum disorder. Journal of intellectual disabilities : JOID PMID: 27623754

Take your vitamin D says the UK Government

"Vitamin D supplements 'advised for everyone'" was just one media headline following the publication of a report (see here) - "a government commissioned report" - by the advisory board of the Scientific Advisory Committee on Nutrition (SACN) here in Blighty recently.

After oodles and oodles of peer-reviewed research (quite a bit of it covered in that SACN report) potentially linking issues with vitamin D availability to everything from depression (see here) to schizophrenia (see here) and lots of other things besides, the time appears now for "recommending an RNI [reference nutrient intake] for vitamin D of 10 µg/d (400 IU/d) throughout the year, for everyone in the general UK population aged 4y and above." Further: "Since it is difficult to achieve the RNI/Safe Intakes from natural food sources alone, SACN is also recommending that the Government considers strategies to help the UK population consume the recommended intakes of vitamin D."

I don't mind telling you that I was pretty happy to see this publication. Quite a few times on this blog I've talked about the potential importance of vitamin D (see here) and how the 'English disease' known as rickets might be but one manifestation of too little of the so-called sunshine vitamin/hormone. For the core blogging material of this site - autism - I'm also quite convinced that there are lots more reasons to research vitamin D (see here and see here) in that context.

I might quibble with the rather sweeping generalisation that is the reference nutrient intake being suggested by the SACN report but it is a good start to recognising the importance of vitamin D to lots of aspects of health and wellbeing [1]. If I do have one caution it is that science often has a way of turning really important 'must-do' advice into something else (see here for example) and so don't be surprised to see and hear more about the idea that 'one-size-fits-all' recommendations regarding vitamin D will rarely cover the entire population...

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[1] Muscogiuri G. et al. Vitamin D and chronic diseases: the current state of the art. Arch Toxicol. 2016 Jul 18.

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Muscogiuri G, Altieri B, Annweiler C, Balercia G, Pal HB, Boucher BJ, Cannell JJ, Foresta C, Grübler MR, Kotsa K, Mascitelli L, März W, Orio F, Pilz S, Tirabassi G, & Colao A (2016). Vitamin D and chronic diseases: the current state of the art. Archives of toxicology PMID: 27425218

Physical activity in children and youth: themes and consensus

'Physical activity boosts kids' brain power and academic prowess' went the press release accompanying the consensus statement published by Jens Bangsbo and colleagues [1] (open-access).

The consensus statement brought together researchers from around the world "and from a variety of academic disciplines" to emphasise how undertaking all-manner of different kinds of exercise "are still a good investment in academic achievement" when it comes to children aged between 6-18 years of age.

The statement is open-access but a few choice passages are particularly worthy of highlighting including the idea that there are various positive physical effects from exercise (as if you needed telling): "Frequent moderate-intensity and, to a lesser extent, low-intensity exercise improves cardiometabolic fitness in children and youth." I might at this point also refer you to the findings by Ekelund and colleagues [2] that made some headlines recently suggesting that about 65-70 minutes of "moderate intensity physical activity" a day might be something to aim for across different age groups. Yes, move more.

Perhaps just as important are the various associations being made between exercise and other important areas of health and well-being including that: "Physical activity before, during and after school promotes scholastic performance in children and youth" and: "Mastery of fundamental movement skills is beneficial to cognition and scholastic performance in children and youth." Being careful not to fall into the trap that is 'those who exercise are more 'smarter' than those who don't' the idea that mastering movement skills might be another positive from exercise is an important point to make. As I've said before on this blog (see here) one particular pastime ticks a lot of boxes in terms of exercise and a particular focus on fine and gross motor skills: the martial arts. Added to the fact that some important life skills can be gained from disciplines such as karate (e.g. self-confidence) and I'd be the first to advocate more children and young adults getting involved in such activities. Indeed, this is something else covered in the Bangsbo article: "Physical activity-based positive youth development programmes that have an intentional curriculum and deliberate training are effective at promoting life skills (eg, interpersonal, self-regulation skills) and core values (eg, respect and social responsibility) in children and youth."

Finally, I leave you with another important point raised in the consensus statement: "Social inclusion can be promoted by providing equal access to opportunities within physical activity and sports settings regardless of children and young people's social, cultural, physical and demographic characteristics." Wearing my autism research hat, I might agree with the tenets of this point (see here) applied to the autism spectrum and how participation in sports and exercise can be a really important part of social inclusion strategies.

Now, added to exercise potentially improving academic outcomes, how about some outdoor learning too and importantly, making sure that children and young people get enough [quality] sleep?

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[1] Bangsbo J. et al. The Copenhagen Consensus Conference 2016: children, youth, and physical activity in schools and during leisure time. Br J Sports Med. 2016 Jun 27. pii: bjsports-2016-096325.

[2] Ekelund U. et al. Does physical activity attenuate, or even eliminate, the detrimental association of sitting time with mortality? A harmonised meta-analysis of data from more than 1 million men and women. Lancet. 2016. July 27.

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Bangsbo J, Krustrup P, Duda J, Hillman C, Andersen LB, Weiss M, Williams CA, Lintunen T, Green K, Hansen PR, Naylor PJ, Ericsson I, Nielsen G, Froberg K, Bugge A, Lundbye-Jensen J, Schipperijn J, Dagkas S, Agergaard S, von Seelen J, Østergaard C, Skovgaard T, Busch H, & Elbe AM (2016). The Copenhagen Consensus Conference 2016: children, youth, and physical activity in schools and during leisure time. British journal of sports medicine PMID: 27354718

Iodine and autism (again)

Welcome back to Questioning Answers in 2016.

Let's continue our travels down the autism peer-reviewed research path by starting with some brief discussion of the findings reported by Anna Błażewicz and colleagues [1] talking about iodine and autism.

With the aim of assessing "the iodine status of Polish boys with severe autism compared to their healthy peers" (authors words not mine), researchers reported results for various iodine and related measures (including metabolites related to thyroid function). They concluded that: "Thyroid hormones were within normal reference ranges in both groups while urinary iodine was significantly lower in autistic boys suggesting that further studies into the nonhormonal role of iodine in autism are required."

I've previously covered the topic of iodine and autism on this blog (see here). That time as this, we are talking about quite a few participants with autism presenting with iodine deficiency keeping in mind that the measurement of iodine in urine is actually quite a good way of ascertaining nutritional iodine status [2]. Błażewicz et al also suggested that various presented symptoms pertinent to autism might 'correlate' with iodine status; something again suggested in previous, independent results [3].

Insofar as the 'nonhormonal' uses of iodine and what deficiency in [some] autism might mean, I'd be minded to point other areas of interest outside of just cognitive effects [4]. The intersection between iodine, selenium and iron is worthwhile mentioning in light of the various co-dependencies of these nutrients in maintaining health and wellbeing. Other research has noted deficiencies in these three nutrients as part of a pattern in some autism [5]. Together with a suite of peer-reviewed literature suggesting that there maybe much more to see when it comes to micronutrient levels in at least some cases of autism, the onus once again is on screening followed by evidence-guided decisions on possible intervention(s).

Music, and as always at this time of year, think Vienna and An der schönen blauen Donau...

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[1] Błażewicz A. et al. Iodine in autism spectrum disorders. Journal of Trace Elements in Medicine and Biology. 2015. Dec 4.

[2] Delange F. et al. Determining median urinary iodine concentration that indicates adequate iodine intake at population level. Bulletin of the World Health Organization. 2002; 80: 633-636.

[3] Hamza RT. et al. Iodine Deficiency in Egyptian Autistic Children and Their Mothers: Relation to Disease Severity. Arch Med Res. 2013 Oct 9. pii: S0188-4409(13)00222-1.

[4] Redman K. et al. Iodine Deficiency and the Brain: Effects and Mechanisms. Crit Rev Food Sci Nutr. 2015 Apr 16:0.

[5] Blaurock-Busch E. et al. Toxic Metals and Essential Elements in Hair and Severity of Symptoms among Children with Autism. Maedica (Buchar). 2012 Jan;7(1):38-48.

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Błażewicz, A., Makarewicz, A., Korona-Glowniak, I., Dolliver, W., & Kocjan, R. (2015). Iodine in autism spectrum disorders Journal of Trace Elements in Medicine and Biology DOI: 10.1016/j.jtemb.2015.12.002