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Glucosamine for osteoarthritis; Alcohol addiction; Gut instinct

Duration:
28 minutes
First broadcast:
Tuesday 11 February 2014

As NICE issues its latest guidelines for treating osteoarthritis, Inside Health looks at the use of paracetamol to relieve pain and is glucosamine a recommended supplement? Also in the programme, Dr Mark Porter investigates how the latest drug treatments for problem drinking work. And how much do doctors use their gut instinct when it comes to diagnosing patients?

  • Programme Transcript - Inside Health

    Downloaded from www.bbc.co.uk/radio4

     

    THE ATTACHED TRANSCRIPT WAS TYPED FROM A RECORDING AND NOT COPIED FROM AN ORIGINAL SCRIPT.  BECAUSE OF THE RISK OF MISHEARING AND THE DIFFICULTY IN SOME CASES OF IDENTIFYING INDIVIDUAL SPEAKERS, THE BBC CANNOT VOUCH FOR ITS COMPLETE ACCURACY.

     

     

    INSIDE HEALTH

               

    Programme 4.

     

    TX:  11.02.14  2100-2130

     

    PRESENTER:  MARK PORTER

     

    PRODUCER:  ERIKA WRIGHT

     

     

    Porter

    Coming up in today’s programme:  Gut instinct – why doctors should acknowledge and embrace gut feelings. That little voice in your head questioning the diagnosis might just be right.

     

    Glucosamine – a popular alternative remedy for painful joints but the latest guidance from NICE implies it’s a waste of time and money. So why has a supplement, once prescribed on the NHS, fallen so far out of favour?

     

    Alcohol – we look at the latest thinking on the role of medication in helping problem drinkers and discover why it is never a good idea to try and drown your sorrows.

     

    Clip

    Probably people who start out being depressed may well be taking alcohol as a form of medication to try and improve their mood, which obviously it’s not going to do – it’s going to make it worse.  Equally people who are alcohol dependent may well become depressed because of the chemical changes that the alcohol has in the brain.

     

    Porter

    More about the relationship between alcohol and depression later. But first arthritis and new guidance this week from the National Institute for Health and Care Excellence on how to diagnose and treat osteoarthritis, a condition thought to affect joints like the hands, knees, hips and spines of at least eight million people in the UK.  The guidance was expected somewhat controversially to advise against the routine use of regular paracetamol to ease pain and stiffness but there are reports of a last minute change of heart.  Margaret McCartney is in our Glasgow studio.  Margaret, why were NICE concerned about paracetamol in the first place?

     

    McCartney

    Well there were two main problems.  The first one was that NICE had felt that for many people using paracetamol for osteoarthritis pain was no more effective than placebo, so they had identified a group of patients who were using paracetamol with no additional benefit beyond that placebo.  The second problem was they felt that some research had identified that paracetamol used high dose and in the long term had an increased risk of complications such as heart attacks, strokes and gastrointestinal bleeds.  Now the problem with this research evidence was that it wasn’t very strong but NICE had initially felt that it was strong enough to urge caution for doctors who were recommending long term high dose paracetamol for patients.

     

    Porter

    And I suppose this is a risk versus benefit, isn’t it, if the drug’s not working that well for a lot of people then you worry more about the side effects.

     

    McCartney

    Absolutely, it’s all about the risk/benefit ratio.  So if you’re taking something and you’re not getting any positive effect but you’re at risk of side effects, that’s one thing, but if you’re taking a drug and that’s actually having quite a good effect on you you might be quite willing to accept a small risk of complications because of that.  But I think the problem for me has been that the research evidence that NICE had relied on to make this association between a risk of side effects and this long term high usage of paracetamol actually is not terribly strong.  Additionally the problem is when you don’t recommend paracetamol well what are you going to recommend instead?  How do we know that not using paracetamol regularly is better for us than the alternative which might be using anti-inflammatory drugs, which we know have a higher risk of gastrointestinal side effects or even using opiate based drugs, which obviously have many more side effects compared with paracetamol?  So I think really what is the risk/benefit from not using paracetamol?  That’s the question we’ve still to answer.

     

    Porter

    Margaret McCartney thank you very much. 

     

    What didn’t get a reprieve though in the new guidance was the supplement glucosamine – NICE does not believe there’s enough evidence to support the use of glucosamine in osteoarthritis, with or without the other popular ingredient chondroitin.

     

    So why do so many people take it? And why do some studies suggest it helps arthritis, while others don't? Questions I put to Professor John Kirwan , Consultant Rheumatologist at the Bristol Royal Infirmary.

     

    Kirwan

    The situation with glucosamine is a bit of a confusing area and this is because glucosamine isn’t officially a medicine.  Theoretically it’s a food, it’s called a nutraceutical, which is a food that’s thought to have some medicinal properties and it’s possible to extract it from cocks combs – the bits on the head of chickens – and you can extract it from shell fish and there’s various other places you can get it from.  And so the way it’s licensed for use and the way it’s prescribed and the way people take it and the information that’s available isn’t the same as it would be if you had a routine medicine.  For example you don’t have to prove things in the same way for glucosamine as you would have to do for a painkiller tablet and as long as you don’t actually tell lies about it you can say whatever you like.

     

    Porter

    So you can make claims like it may help your joints and that’s not a medicinal claim per se – you’re not saying it’s treating arthritis?

     

    Kirwan

    Well the word “may” is the key here because that means it might not as well.  In fact if you look on the web, for example, or look on adverts on buses to see what is said about glucosamine the adverts focus on the reports of individual people who’ve tried it who say how good it was for them.  And that’s a true statement, that’s what these people have said but there’s all sorts of reasons why people might get less pain from their arthritis if they take glucosamine, which has got nothing to do with the actual glucosamine.

     

    Porter

    One of the things that I find confusing as a healthcare professional is you do see reports of trials into glucosamine and with osteoarthritis of the knee, for instance, I can remember a couple of those where they say that this seems to have an effect and then somewhere along the line you’d read a review that says it has no effect.

     

    Kirwan

    Well there are a variety of reports but you know life is not black and white, so that when we do our clinical trials just because you’ve done a clinical trial, even if you do it properly, it doesn’t automatically mean that you’ve got the right answer from the trial, especially if you do small clinical trials with only a few people in – a dozen or two dozen people.  It’s easy by chance to get some people who get a lot better during your trial and happening to be taking the medication or happen to have been taking the substance glucosamine.  And then you get the results of the trial and it looks like it works.  The trouble is you would do another trial with another dozen people in it and it would look like it didn’t work.  And the problem with glucosamine is that the trials that look like it works get published in the medical literature and get quoted and the trials that look like it doesn’t work just get forgotten and never get published. 

     

    And there’s a way of recognising this, there’s a scientific way of recognising this, that we actually teach our medical students and I actually use the example of glucosamine to teach this way of recognising things and it’s called publication bias.  And if you were a company making a new product that you thought might help people you could do lots and lots of small trials and some of them would say it’s helpful and some of them say it’s not helpful and you just publish the ones that say it’s helpful and then you could point to the literature, the reports in the scientific literature, and you could say look at this there are seven reports in the scientific literature that say it’s helpful.  And if you take the average of them, which is what a review normally does, it takes the average of all the reports, the average says it works but that’s because you’ve left out half of the information that says it doesn’t work and so there’s nothing to balance out the viewpoint.  The way to get round that – there’s two ways to get round that, one is to make sure that all the results for all trials are always published and there is a campaign at the moment called “The All Trials Campaign”, which you might well have heard about, which is trying to make sure that happens and if that happens then when we do these amalgamated reviews of putting all the results together they’ll be more accurate.  The other way to do it is to do big trials because on big trials you don’t get this random variation, you get a much more correct picture.  And there have been two very big trials done of glucosamine in osteoarthritis of the knee, one in the UK and one in America, and they both came to the same answer which was there’s no real benefit.

     

    Porter

    And has that answered this conundrum for you, you’re quite happy now that we know that glucosamine doesn’t help arthritis?

     

    Kirwan

    So there’s two things there, I’m quite happy that it doesn’t have a medical effect on the arthritis on the joints but there may be other reasons why glucosamine might be helpful for patients and we also talk to our medical students about these other reasons too.  There’s an attitude that people take to their illnesses called self-efficacy, which means people who have high self-efficacy feel that there’s something they personally can do that will help their disease and make their pain less and make them more able to walk around etc.  And there’s quite a lot of evidence in the psychology literature that if you have high self-efficacy you suffer less symptoms from whatever disease that you’ve got and you’re able to do more things, whatever the disease is.  Now to me when some patients who’ve got say osteoarthritis of the knee or any other problem decide that it’s time for themselves to do something about it and they’re going to go out and try these tablets out, to me that is increasing their self-efficacy, they’re feeling that they’re taking charge of the situation and doing something about it.  And I think that that sometimes makes some people feel better and have less pain and able to do more, it doesn’t have anything to do with the chemical effects of the glucosamine, it has to do with their state of mind and their approach to managing their own arthritis and their own pain.

     

    Porter

    Is there a downside to taking glucosamine that you’re aware of?

     

    Kirwan

    Well there are some downsides.  I mean if you look in the British National Formulary it actually lists glucosamine in there and it says there are side effects and some people get nausea and vomiting and so on.  But the real downside to me is it might make people miss out on some otherwise good treatments because they think they should be using this instead of ordinary treatments.  The most important one is physiotherapy and exercise and so on, you can use painkillers and there are some additional treatments that you can use for osteoarthritis.  What worries me is that I do occasionally see people who somehow feel the proven treatments are something they should be avoiding and they’ll take glucosamine instead, I think that’s a bad thing.  I mean you have to spend money on it as well, although you can get it quite cheaply on the internet but if people want to spend a little bit of their own money and try it out and if they feel personally that it’s helping them it’s probably not doing any harm.

     

    Porter

    It’s quite interesting that when people look for something to help themselves they turn to a tablet like glucosamine or a capsule and they don’t look at, for instance, exercise – physiotherapy – strengthening the thigh muscles which can help in osteoarthritis of the knee.

     

    Kirwan

    It certainly can help and those would be things that we’d advise people – and weight loss if you’re overweight and regular exercise and so on.  Well you know different people expect different things from life and some people just are more tuned in to taking tablets and things and so they like to do that.  I don’t advise people to take glucosamine and if my patients ask me about it I tell them what I’ve been telling you and I’ll let them decide what to do.

     

    Porter

    Professor John Kirwan, breaking the news as gently as he can.

     

    And if there is an issue, like glucosamine, that is confusing you then please do get in touch – you can e-mail us via insidehealth@bbc.co.uk.

     

    One listener - who wishes to remain anonymous – e-mailed to ask why you hear so little about new drug based treatments for problem drinkers. Drugs like nalmefene and naltrexone have made the headlines recently, but what sort of impact do they actually have clinically?

     

    I know just the people to ask.

     

    NICE has recently looked at the role of medicines in treating alcohol abuse and Colin Drummond, Professor of Addiction Psychiatry at Kings College London, chaired the group behind the latest guidelines.  And Anne Lingford Hughes is a consultant psychiatrist and Professor of Addiction Biology at Imperial College.

     

    Hughes

    We know that from the clinical trials they are effective but we’re now starting to understand how they may affect brain mechanisms, how alcohol is affecting the brain and therefore how these drugs may interact with those mechanisms to help people stop drinking or stop the risk of relapse – so stop craving or other mechanisms like that.

     

    Porter

    Is there a common pathway that these drugs are working on or do they have unique actions?

     

    Hughes

    Each has their own particular target but we think a common theme is that they alter processes in the brain such as reward.  There are others that possibly have an effect on impulsivity and it’s this type of mechanism that we’re just now starting to unravel.

     

    Porter

    Colin, looking at the evidence for these drugs what sort of impact do they have, I mean is it pronounced?

     

    Drummond

    Yes it’s certainly a significant effect on reducing people’s alcohol consumption, providing they’re taken as directed and on a regular basis.  And also providing they’re prescribed in the context of a wider treatment plan with psychological interventions and social support.  But it seems remarkably difficult to persuade doctors to prescribe in this condition, in other words it’s not very hard to get them to prescribe for depression.  The data on prescribing that we have on drugs like acamprosate is that it is prescribed very rarely compared to what we know is the prevalence of the problem.  And this isn’t just the UK, this is true in the United States and the National Institutes of Health in the US have been scratching their heads and trying to think how do we persuade doctors to embrace these drugs more.  There’s a kind of general feeling, a sort of nihilistic feeling amongst some doctors that you just cannot do anything for this population.

     

    Porter

    Why do you think that is?

     

    Drummond

    I think it’s partly there’s a lack of training, I think also alcohol is competing with all the other things that doctors have to do in the course of what it is now seven minute interview, they’re being asked to look at smoking, diet, other lifestyle issues and…

     

    Porter

    Not asked to look at alcohol though specifically in most people, I mean we do in the over 40s but it’s interesting that it’s been left out of that sort of list of tick boxes.

     

    Drummond

    Exactly and yet we have very effective interventions.

     

    Porter

    It’s an oft abused cliché but it does have the ring of the Cinderella of the addiction world and I’m just intrigued as to how it’s got there, it’s just been left behind has it?

     

    Drummond

    Well in a policy sense I think the excitement in government has been around drugs and drug misuse and what to do about that.

     

    Porter

    And the war on smoking has been all consuming hasn’t it.

     

    Drummond

    Absolutely and not just about helping people to quit but actually making tobacco less available.

     

    Porter

    You must look at the protocols with envy from the alcohol.

     

    Drummond

    I think we could learn a lot from the tobacco field to be honest.

     

    Hughes

    So I’m aware of people who do contact us wanting medication but either their GP doesn’t know about it enough, which I think is perfectly understandable, as Colin’s already discussed about training etc., is a major issue, but I have had the situation where it’s been hard for me to start in specialist care, the GP may be willing but the approvals aren’t in place.

     

    Porter

    Is there concern from some quarters of the medicalisation of this?

     

    Drummond

    It sort of comes down to partly what you think the problem is, if you think the problem is a sort of lifestyle choice or a psychological issue then you’re probably not going to see much of a role for drugs.  But I think Anne and I would probably see it as a much more complex picture.  Alcohol is a drug itself, it’s having effects on the brain, that’s what’s producing the dependence and the drugs, although we don’t completely understand how they work, are probably reversing some of those effects.

     

    Porter

    And these sorts of effects that the drugs are reversing are they the result of long term drinking or are they something that might have pre-existed that made the person more likely to be a problem drinker in the first place?

     

    Hughes

    Probably both, we don’t understand that yet but certainly we’ve got a large scanning programme on at the moment looking at reward mechanisms and impulsivity and sort of emotional stress and looking at how a drug like naltrexone might modulate those responses and we’re just starting to get the data out now.  But certainly we know that naltrexone can change reward responding in the brain, it can change impulsivity activity in the brain, so we think it’s getting some of the core mechanisms.

     

    Porter

    And it would dampen down the reward and make you less impulsive – that would be the aim which you would say – would suggest would be helping someone control their drinking?

     

    Hughes

    Yes. I mean interestingly alcoholics have a blunted reward system to alcohol salient cues and that’s because we’re probably in a sense got tolerant to the cues, their natural – so-called natural pleasure/reward system isn’t working properly.  Now that taps into depression, which has been mentioned a few times, that many people with alcohol problems are depressed.  Well if alcohol has done that to your reward system then you won’t get the non-drug pleasures out of life.  So one of the things naltrexone might do in this case is tend to normalise this function to help you respond to the non-drug pleasures but dampen the drug related pleasures down.  And I think it’s understanding that because it is odd, in a sense, the most common drug probably prescribed to a person with alcohol problems is an anti-depressant, whereas the clinical trials are very clear that they don’t improve either depression unless you’re severely depressed nor alcohol consumption.

     

    Drummond

    Another problem is that if you’re prescribing anti-depressants and treating depression in somebody with alcohol dependence you’re delaying treating the alcohol dependence, which is the thing that’s going to have change before the depression is going to improve.  But the good – the positive news is that people that we see coming into treatment with both alcohol dependence and depression, and it’s very, very common, the studies have shown 60-70% of people coming in to treatment for alcohol dependence are depressed, but the vast majority of them the depression improves very quickly after they stop drinking but they may have been suffering from depression for years.

     

    Hughes

    So what generally happens is that a patient may present with depression, they get prescribed an anti-depressant before the extent of their alcohol use has either been acknowledged by the individual themselves or picked up by a professional and the anti-depressant does not work, often they then re-present, they’re tried on a second anti-depressant and this was very common in my clinical practice – you see people on their second or third anti-depressant and they’re almost getting labelled as treatment resistant but in fact their alcohol misuse has not come to light.  And we know very clearly from trials that in this situation the anti-depressant will not be doing anything to their alcohol consumption and will be having marginal if any effects on the depression.  So the patient who says if you give me an anti-depressant I won’t be depressed anymore, it will make me feel better, then I won’t need to drink we can say that there is no evidence to support that.

     

    Porter

    Treating the wrong problem.

     

    Hughes

    Exactly, you have – whether or not you get treated for your depression you have to enter into treatment for your alcoholism.  And that message has come up time and time again but unfortunately it is very hard and understandably hard when you have a depressed person in front of you who won’t go and seek help or even entertain the idea they may have a problem with alcohol, you can see why the clinical situation arises.

     

    Drummond

    There’s a kind of overlap of the two conditions and probably people who start out being depressed may well be taking alcohol as a form of medication to try and improve their mood which obviously it’s not going to do, it’s going to make it worse.  Equally people who are alcohol dependent may well become depressed because of the chemical changes that the alcohol has in the brain.

     

    Porter

    But the simple message is that if you’re dealing with someone who has depression then it’s very important to ask them about their alcohol consumption.

     

    Drummond

    Absolutely, they’re going to be a high risk group for alcohol problems.

     

    Porter

    Professors Colin Drummond and Anne Lingford Hughes. And there is a link to the latest NICE guidance on alcohol – which includes a section on the role of medication – on our website.

     

    Now, you know that little voice in your head that questions if you’ve locked the car properly or turned the iron off. That uneasy feeling that you get when you think there is something that you should be doing, but you just can’t remember what it is?

     

    More often than not these are groundless anxieties that simply reflect that many of us are born worriers, but sometimes that voice in your head - that gut feeling - warrants your attention.

     

    And many doctors, particularly GPs, do pay it attention when faced with a patient that doesn’t quite fit the description in the textbook – all may appear well on the surface but you are left with a nagging doubt that all is not quite as it seems.

     

    So are doctors right to heed their gut instincts?  Ann Van Den Bruel is a GP and research fellow at the University of Oxford.

     

    Van Den Bruel

    A lot of GPs especially they recognise this feeling that they get sometimes although not everybody admits or acknowledges that they sometimes act upon it, it’s seen as something mysterious or maybe you should not talk about it.  But it is real and when you talk to GPs about it they’re really happy to be able to share that experience of having this gut feeling and using it sometimes in their medical decision making.  So it is something real but it’s not always acknowledged as a valid or a useful tool.

     

    Porter

    Well do we know if it’s useful?

     

    Van Den Bruel

    Well we do because we’ve been doing studies in, for example, serious infections in children, so that’s meningitis or pneumonia, and we have found that gut feeling is the most powerful predictor in general practice of a serious infection in a child.

     

    Porter

    But how do you go about measuring the effect of something like gut feeling?

     

    Van Den Bruel

    Well we asked doctors to record whether they felt something like gut feeling or an instinct that something was wrong in 4,000 children and then we compared those recordings with what ultimately happened to those children and we were able to calculate the diagnostic accuracy, if you want, of gut feeling.  And we found that it is very, very accurate, it’s very useful.  It’s not a hundred per cent right but the chance that something serious is going on is much higher when a doctor has a gut feeling.

     

    Porter

    Well Margaret McCartney’s been listening in from our Glasgow studio.  Margaret, I suspect that none of this will come as a surprise to you.

     

    McCartney

    No and I think gut instinct is one of those real rich seams of general practice that kind of goes under explored and I think unacknowledged as well.  When you talk to doctors over coffee one of the things that we’re always saying to each other is – just not quite sure about that lady or I’m just not quite sure about that hanging together.  But I think there’s also a little bit of shame that goes along with it, I think sometimes it’s seen as being a bit unscientific – just having this gut instinct, this sort of feeling about someone and it’s a kind of slightly romantic idea that harks back to the old style videos of pictures of doctors just having a feeling about someone.  For me it’s not unscientific at all, it’s actually highly scientific because what you’re doing is you’re saying actually out of all the people that I’ve seen with similar symptoms you’re just a bit different from everyone else, it’s almost like recognising that this person just doesn’t quite fit the pattern but you’re not quite sure in what way they don’t fit in with that pattern.  So what you’re doing is you’re opening up to saying well I’m unsure, I’m uncertain and the possibilities here are potentially something quite serious and I’m not going to just let that go.

     

    Porter

    And this isn’t the only piece of evidence that suggests that it’s a powerful tool.

     

    McCartney

    No and what I find really fascinating is when you go and ask doctors around the world, as some researchers have done, do you experience a similar kind of phenomena, all doctors will say that they do.  Some people will describe it as feeling something in their stomach, something just not quite right, other doctors will say that they feel it in their bones that something’s just not right and it’s just this idea that you get something that jars, something that just doesn’t quite fit properly together and you have a sense that you’re not actually very certain about what’s going on here at all.

     

    Van Den Bruel

    In general practice we have to deal with a lot of uncertainty, we don’t have all the tests and all the technology the hospital doctors do have and so we’re used to dealing with uncertainty and we’re used to not having that much at our disposal to make our decisions.  So gut feeling for us is like our safety net, when we feel I’m not really happy about this then we may want to ask a second opinion or we may want to schedule another appointment or we may want to give the parents very detailed information on when to come back – that’s how we want to deal with that uncertainty that is left at the end of the consultation.

     

    Porter

    It’s interesting in this day and age because we’re very protocol driven, so examining a sick child, for instance, we look for pulse rate, the colour of their skin, tone, lots of other things that are laid out – there’s this little tick box that you can go through to evaluate whether a child is seriously ill or not.  And what you’re saying is that the gut feeling’s not on that but we should be listening to our gut feeling.

     

    Van Den Bruel

    Yes, well I think first of all doctors should be doing it systematically and they should look at all the things that you just mentioned – colour, temperature, breathing rate – so that’s what they should do because they’re very, very useful in detecting serious illness.  But on top of that they should also listen to their gut feeling – so when everything seems to be alright, when the breathing rate is normal and the temperature is not that abnormal, in addition to all these things when you have a gut feeling then you might pick up some children with a serious infection over and above what you have done in your tick box.

     

    Porter

    Another problem with our sort of modern healthcare system is that when you’re referring patients in for specialist treatment or for emergency treatment sometimes you are expected to jump through certain diagnostic hoops and you can’t really tick a box for gut instinct can you?

     


    Van Den Bruel

    No, I think healthcare should allow for flexibility in referrals, so we need the systematic referral process but we also need some flexibility to circumvent the systematic referral process where doctors are unhappy with presentation, doctors feel uneasy about this patient and they should be able to refer that patient despite a systematic examination being normal.

     

    Porter

    And what your research shows is that we shouldn’t be embarrassed about it, it’s a useful thing to have.

     

    Van Den Bruel

    Yes.

     

    McCartney

    I suppose this is what really frustrates me about the way that medicine is going.  When I want to refer someone to hospital very often I’ve got a form to fill in and very often that form has lots of boxes that I have to tick on it and for example if I’m concerned that someone has a serious underlying bowel condition there is lots of boxes to tick – have you had blood in your stools, have you had diarrhoea, have you had weight loss – those kind of things are what we’d call red flag signals, something that’s quite definitively abnormal, something that’s not right.  But in actual fact people don’t always come in like that, they’ll say well I’m just not quite sure, things are a little bit different normal but not terribly abnormal.  And actually when you look through the data about doctors that refer patients outside strict guidelines actually when doctors are concerned very often there’s a good reason for that and the serious diagnoses that are uncovered through referrals with guidelines are actually relatively fairly high.  So I think we really have to listen to this gut instinct and really enable doctors to work with it rather than trying to work against it all the time because I think it means something and I think it’s something very useful.

     

    Porter

    Are you implying that protocols are designed to guide us to improve our diagnostic skills on the one hand may actually be blunting this gut instinct on the other?

     

    McCartney

    I absolutely think so.  Often guidelines are quite useful, they can help symptom sort, they can help out work out probabilities but they will not tell you about everyone and I think that doctors when they feel that something isn’t right we should be allowed to feel that something isn’t right and we should be able to refer people for further investigations when we’re concerned about them anyway.  And I think sometimes with guidelines and being judged according to how well we follow guidelines is not really a way to embrace these kind of intuitions and use that to get our diagnostic skills better.

     

    Porter

    Margaret McCartney and Ann Van Den Bruel reminding us to listen to the little voices in our heads. And you will find a link to Ann’s research on the Inside Health page of the Radio 4 website.   

    Next week I will be learning more about the impact of air pollution on our health, and how cyclists, joggers and pedestrians can reduce their exposure. Join me then to find out more.

     

    ENDS 

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