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INSIDE HEALTH

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Programme 2.

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TX:听 01.10.13听 2100-2130

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PRESENTER:听 MARK PORTER

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PRODUCER:听 ERIKA WRIGHT

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Porter

Coming up in today鈥檚 programme:听 Calcium supplements - prescribed to millions of people across the UK to help maintain healthy bones, but might they do more harm than good?

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Herbal medicines - is the current licensing system misleading consumers?

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And giving up smoking - we catch up with some of the 160,000 smokers who managed to give up thanks to the Stoptober challenge.

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Clip

Anybody who knew me knew I used to more or less eat the cigarettes, I just used to light them one after the other and now I am so healthy, I don鈥檛 smell, I don鈥檛 need my ventolin inhalers anymore and I can sleep without coughing.

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Porter

More from Donna later.

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But first, new research linking a flu vaccine to a rare sleep disorder in children. Fears about a pandemic of H1N1 flu - so called 鈥渟wine flu鈥� -over the winter of 2009/10 led to millions of vulnerable people across the UK being offered a new vaccine - and that included every child under the age of five.

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The most widely used form - Pandemrix - has since been linked to a dramatic rise in the number of children diagnosed with narcolepsy. Paul Gringras, Professor of Children鈥檚 sleep medicine and neurodisability at the Evelina London Children鈥檚 Hospital is one of the researchers investigating the link.听 So Paul, what is narcolepsy?

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Gringras

Narcolepsy is a sleep disorder, it鈥檚 actually a very severe sleep disorder 鈥� about one in 3,000 people might get this at any stage in their life.听 Now it鈥檚 characterised by excessive sleepiness 鈥� so being really sleepy during the day at unpredictable and irresistible moments, so you fall asleep while you鈥檙e eating, while you鈥檙e talking with friends. 听And there are a number of other features including probably the best known is cataplexy, and this is weakness where the body might go limp following an extreme emotional reaction.听 So maybe you鈥檙e with friends and laughing or you鈥檙e even telling a joke and these young people feel their knees buckle and collapse to the floor.

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Porter

You say young people, is this something that normally develops in childhood?

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Gringras

So my context is young people because I work in a children鈥檚 sleep unit and we鈥檝e got about 60 young people with narcolepsy under our care at the moment.听 Traditionally much more common in adulthood.听 Two reasons are one, it used to take a long time to get the diagnosis right, probably about 14 years so people would suffer being told that they were sleepy and being lazy at school for a long time.听 But the other really interesting thing is that we are seeing an increase in cases of narcolepsy in young people under the age of 18.

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Porter

Now in the group that was vaccinated I said there was a dramatic increase but this is still a rare condition?

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Gringras

When you compare the actual numbers in the unvaccinated versus those in the vaccinated groups sure there was a big increase and remarkably consistent whatever country you looked at - so about 14 times the increased rate.听 But this remains a very rare disorder with probably between one in 20,000 and one in 50,000 vaccination associated cases.

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Porter

Do we know what the mechanism is 鈥� presumably this is of great interest to you, someone who studies narcolepsy, to find that it鈥檚 associated with a vaccine might give you a clue as to what鈥檚 going on?

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Gringras

Yeah absolutely, so this is the big fascinating question that actually within this tragedy for the families affected we ought to be able to get much better at finding the mechanisms.听 It鈥檚 really important because we now know a lot more about the origins of narcolepsy.听 We know that there are certain cells that produce a certain neurochemical that helps keep us awake called hypocretin and we know that there鈥檚 an autoimmune reaction, so the body goes overboard in its immune response and can end up, as well as destroying the cells that are causing an infection, for example, destroying some of its own cells. So we do know that that鈥檚 part of the origins of narcolepsy and the question is what is it in the vaccine or in the adjuvant 鈥� that鈥檚 the thing that makes a vaccine powerful for the immune system 鈥� that鈥檚 triggering narcolepsy?

Porter

And it was one particular vaccine 鈥� this Pandemrix 鈥� which had a particular adjuvant in it, something to stir up the immune system?

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Gringras

Yeah for sure, so this was the interesting thing 鈥� there were a number of vaccines available and this spike, this increased rate, has only been seen in Pandemrix.听 It鈥檚 got an oil in water adjuvant, containing squalene, which is a substance found in shark liver quite naturally, but I think this particular vaccine was chosen because there was this risk of a lot of deaths from this epidemic and they needed a very powerful immune reaction so that one vaccination would be enough to cover a wide percentage of the population.

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Porter

And it鈥檚 that, we think, that may have triggered the narcolepsy in susceptible individuals?

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Gringras

That would seem to be the case, I say seem to be because we also know that narcolepsy can get triggered by viruses, by flu, by sore throats 鈥� so different things can trigger this immune reaction but there certainly seems to be something distinct to Pandemrix as compared with other vaccinations.

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Porter

We should point out that this vaccine wasn鈥檛 tested particularly in children, as it might have been in other cases, because of the urgency.

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Gringras

I assume that that鈥檚 the case, if you鈥檝e got to bring out a vaccine very quickly in response to the strain that鈥檚 there and I think about a third of children under five were vaccinated, a quarter of children in high risk groups, and other European countries far higher, so they really did manage to immunise huge percentages.

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Porter

So what does this tell you do you think about the use of adjuvants going forward?

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Gringras

So the Pandemrix is now not going to be given to people under the age of 20 and the current vaccines don鈥檛 use an adjuvant and I think there鈥檚 just got to be a lot more work and a lot more thought and perhaps a balance against all the advantages of having a potent vaccine versus wanting to know about very rare but significant neurological side effects.

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Porter

Professor Paul Gringras, thank you very much.听 And just to be clear this is not the same vaccine as used each year to protect against seasonal flu.听 We asked the company that makes Pandemrix - GSK - for a comment and this is what they said:

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Statement

Patient safety is our number one priority and we鈥檙e actively researching how narcolepsy is triggered and how this vaccine might have interacted with other risk factors in affected individuals.听 We hope these ongoing research efforts will enable us to provide more answers.

Now October not only marks the start of the annual flu vaccine campaign, it is now also associated with the mass stop smoking campaign - Stoptober. 听A hundred and sixty thousand people completed the challenge last year by giving up for a month, we caught up with two of them.

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Osborne

My name鈥檚 Adrian Osborne, I鈥檝e been a smoker 鈥� or I was a smoker 鈥� for about 25 years and whilst towards the end I wasn鈥檛 the heaviest of smokers I was still probably smoking around 10 cigarettes a day and certainly much more on a social night out.听 And I have been able to quit for short periods before but only a few weeks or a few months at a time and certainly never before for a year.

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I think Stoptober helped me give up because with a really simple message about well if you stop smoking for 28 days you鈥檙e five times more likely to stop for good, well that felt achievable, I felt optimistic that I would do that.听 Last year, for Stoptober, I signed up and I got sent my Stoptober support pack and I think each part of that was useful in its own way.听 There was a little squeezy Stoptober stress toy, so that was sat right in front of me on my desk at work as this conscience all the way through to remind me that look you鈥檙e somebody who鈥檚 trying to quit here.听 And there was a little calendar as well with handy hints and reminders.听 So it was all that kind of stuff about well for every day you give up smoking this is the positive impact on your health.听 It provided extra motivation.听 And then on top of that getting regular daily text messages to keep me going, keep me enthused and also help me out when I did lapse and have a drag on a cigarette.

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Donna

My name is Donna.听 I have been smoking since I was 12 and I am 49 now and before October of last year I was smoking 25 plus a day.听 I鈥檝e tried to give up on loads of occasions 鈥� the longest I鈥檝e lasted was six weeks.听 The actual Stoptober website 鈥� I went on it every day and it told you how many days you鈥檙e free, it used to congratulate you and also Facebook had Stoptober on there and people were offering help and support to each other.听 At the beginning I had insomnia and I went on to the site and this particular day everybody was writing about insomnia, so it鈥檚 very helpful.听 I couldn鈥檛 have given up without it because where a load of other people were packing up smoking at the same time 鈥� like thousands 鈥� I knew I wasn鈥檛 alone and I knew that lots of other people would be struggling like I was.

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Porter

And if you want to join Adrian and Donna and become a non-smoker than it鈥檚 not too late to sign up to this year鈥檚 Stoptober challenge - details are on the Inside Health website at bbc.co.uk/radio4.

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The UK has a longstanding tradition of relying on herbal medicines but attempts to drag them into the 21st Century through increased regulation have proved controversial. While some herbal medicines in the UK have full product licences like conventional pharmaceuticals, such as Senna for constipation, the vast majority do not. The introduction of the Traditional Herbal Medicines Registration Scheme in 2005 was designed to address this and bring the UK into line with tighter regulation in Europe.听

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The scheme gave manufacturers two options - either remove their herbal remedies from the market altogether, or apply to the Medicines and Healthcare Products Regulatory Agency for inclusion on a new herbal medicines register.

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But there are concerns that the threshold for this type of licensing has been set too low, and that it is misleading consumers. Joining me to debate the issue is GP Dr Margaret McCartney and Dr Linda Anderson from the licensing division at the MHRA. Linda, what criteria are required for inclusion on your register?

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Anderson

You have to be around for a 30 year period, you have to show us that you鈥檙e safe, the company who applies under the traditional scheme would give us a full safety review.

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Porter

But that needn鈥檛 include 鈥� I mean when you say a safety review I mean that needn鈥檛 include any clinical trials that we would regard as gold standard for a medicine for instance?

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Anderson

Well gold standard today for a medicine in the current regulatory framework but of course we do have lots of other older medicines, I mean if you take something like calamine lotion I dare say there aren鈥檛 many clinical trials showing that that has an effect but nonetheless we would put it on our chickenpox spots if needs be.听 So there鈥檚 lots of things that 鈥� particularly in the OTC 鈥� the over-the-counter 鈥� self-medication area 鈥� where the evidence base is not perhaps state of the art because time has moved on but we don鈥檛 want to throw those old things away all the time.听 But just going back to the traditional scheme 鈥� you鈥檝e got to have this traditional evidence for 30 years and that鈥檚 to give us some sense that it鈥檚 been around, people have used it and come to no harm.听 But the other main thing is we鈥檙e trying to bring the products into regulation so that we can apply the right controls, particularly on quality 鈥� quality is a big issue with some of these products 鈥� but we want to make sure that if people are going to use them and they are using them very importantly they get the right information on the label and in the leaflet and all these traditional products now have an up to date leaflet setting out who should use the product, who shouldn鈥檛 use it and that鈥檚 often children, invariably children, often adolescents even, maybe the elderly, but telling you how long in many cases 鈥� how long you should use the product for and giving you guidance particularly if your symptoms persist or worsen that you see your doctor.听 Because the last thing we want is for people to defer effective treatment.听 Perhaps I should make the point that the traditional medicines are only ever for minor conditions that a patient would be seeking self-medication for in any event, we鈥檙e not in any way endorsing delaying effective treatment, that would be hazardous without a doubt.

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Porter

Margaret, pharmacies鈥� shelves are full of remedies for coughs and colds, most of which have no evidence base whatsoever, so what鈥檚 the difference with herbal medicines?

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McCartney

Well we discussed this in series one I think didn鈥檛 we, about cough mixtures and how many of them just don鈥檛 work at all and I think what I鈥檓 really disappointed with is the idea that we鈥檝e got a double standard and we鈥檙e just going to leave it there.听 I really don鈥檛 care whether a medicine that I prescribe is 鈥渉erbal鈥� or 鈥渘on-herbal鈥�, they鈥檙e all chemical, chemicals can be good for us or bad for us or a mixture, with pros and cons, it doesn鈥檛 matter what the origin is of a compound.听 What does matter is whether it works for a patient, whether it鈥檚 useful, whether it鈥檚 effective or not and what the side effects and benefits might be and how those weigh up together.听 What I care about is that they鈥檝e all been evaluated to the same high standard and at the moment what we鈥檙e doing is we鈥檙e just sort of basically saying okay if these products have been around for a while never mind, let鈥檚 just let them have a licence anyway which really seems to me to be a little bit of a dereliction of duty to people who want the same standard of quality of healthcare products whether or not they are herbal or whether they鈥檙e over-the-counter or not 鈥� they all should have the same standard.

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Porter

But that鈥檚 not true about conventional medicines 鈥� I mean a lot of these older medicines, the example we heard there was calamine, I mean doesn鈥檛 meet the sort of evidence base that you鈥檇 accept these days.

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McCartney

Yeah but do we really prescribe calamine lotion, I don鈥檛 think doctors do, this stuff might still be available over-the-counter 鈥� I mean personally I think chickenpox spots I usually put an ice cube in a poly bag, that was my treatment, not very evidence based either but I think there鈥檚 a degree of sense about it.听 We want to be up front about the pros and cons of hazardous and ineffective treatments so we maybe should be thinking well instead of cough bottles that have been sold from chemists let鈥檚 have the same standard of evidence for all of them and I would be delighted to see a pharmacy that had many empty shelves because they were only stocking stuff that was of high evidence, high value and high quality for patients.

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Porter

Linda, this is one of the concerns, isn鈥檛 it, that if a product is on the registry or 鈥渓icensed鈥� that actually the general public who are purchasing that 鈥� so they鈥檙e buying a remedy for the menopause or whatever they鈥檙e doing feels that it is somehow pucker, that this is safe, it鈥檚 been proven to be efficacious, it鈥檚 an alternative to a medicine?

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Anderson

Well I think Margaret made some very good points and in many ways I can see some of the issues that she鈥檚 raised very clearly.听 I think obviously our emphasis is on the safety of products and if they鈥檙e doing harm and sometimes we have to take maybe very modest efficacy based on almost like a well-established use in our stride.听 And I think we鈥檝e all got our own cough/cold remedy that we use and it鈥檚 probably got absolutely no evidence base but we would hate to be deprived of it because it does no harm but it gets rid of that tickle when you鈥檙e in bed at night.

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McCartney

But surely there鈥檚 a difference though between being deprived of something that you feel is useful and having a product that endorsed by the MHRA or an organisation that puts a stamp or seal of approval on it.听 So you know 鈥� and I would really hope that the stamp of approval really has gone not just to talk about a lack of harm, because how can we really know without really good quality studies, but also it鈥檚 the waste 鈥� it鈥檚 the waste that we spend a lot of money, time and effort.听 I mean the market for unproven cough/cold remedies is in the millions in the UK.听 Why do we accept the status quo, don鈥檛 we want to have a population of really better informed citizens that can make really good informed choices about healthcare or saving their money to use on stuff that鈥檚 actually useful to them and feeling free to ditch the stuff that isn鈥檛?

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Anderson

In many ways I see that point very clearly but certainly with the traditional scheme it鈥檚 very clearly on the label and in the patient leaflet that the products are only based on traditional evidence.听 And we鈥檝e made great strides in trying to communicate that to the public and trying to bring across to them the fact that these are only ever for minor conditions, they鈥檙e palliative, they鈥檙e things that don鈥檛 have a strong efficacy base.听 That鈥檚 not to say that they have no basis, I think we should remember that some of the products, in fact, were the mainstay of conventional medicine, okay maybe some while back and have been superseded by other things.听 But it wasn鈥檛 because they didn鈥檛 work, it was because other things moved in to take their places.听 I suppose we have to bring it back to some extent to consumer choice because our fear and it鈥檚 a genuine fear is that if you remove products, particularly modest products, from the market people will just go on to the internet and buy really much more dangerous commodities that could present a real hazard.听 But if they want a choice and menopause is a good example, people don鈥檛 always want the hard-line treatment that may well work, they often want to dabble in things that may just tick over and help them.听 And if we don鈥檛 provide the products with a guaranteed quality and the right information where will they turn to?

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McCartney

I mean I think you鈥檙e right 鈥� the internet is this kind of hell hole of made up pharmaceuticals that you can buy 鈥� I don鈥檛 think that problem鈥檚 going to go away and in many ways what you want is better law enforcement for people that are doing illegal things.听 But the idea about the menopause is really interesting because I think that women tend to be misled by an awful lot of the 鈥� in herbal remedies that are on shelves.听 I was in a high street chemist at the weekend and the amount of packaging, seductive claims 鈥� gentle help for the menopause, this and that 鈥� it鈥檚 really misleading I think and it鈥檚 not fair to women, we know that herbal remedies for the menopause just aren鈥檛 effective, they just don鈥檛 work very well.听 Why aren鈥檛 we just fessing up and saying look we don鈥檛 have great pharmaceutical solutions, these things that you buy over-the-counter they are placebos and they鈥檙e expensive, let鈥檚 look at other things that work, let鈥檚 be honest and open and straightforward with people.

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Porter

Linda, you鈥檝e mentioned the consumer in this a number of times but how much pressure to licence these products comes from the consumer and how much comes from the manufacturer?

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Anderson

Well I don鈥檛 there鈥檚 pressure from the manufacturer as such because they鈥檝e obviously got to go through a hoop and register their products with us鈥�

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Porter

But you insinuated that if you were to pull these products off the shelves lots and lots of people would be upset, you have proof of that?听 I mean I know lots of manufacturers would be upset.

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Anderson

Well I think we would definitely know that people would be upset because of the usage and certainly every time we鈥檝e taken action, even on something that we think is clearly unsafe, we find patients slightly up in arms about the fact that we鈥檝e withdrawn something, where we can explain very clearly that this is hazardous.听 So I think there is a body of people.听 And鈥�

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McCartney

Surely this should not be about popularity though, surely the MHRA is not there in order to keep consumers happy 鈥� to have whatever they want 鈥� surely that鈥檚 entirely the wrong approach, I mean surely you should just be going out there and saying okay we鈥檙e going to start from the beginning, make sure everything鈥檚 approved properly and really telling the public when things don鈥檛 work and they shouldn鈥檛 be wasting their money on it?

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Anderson

I mean I can see your point of view that these things shouldn鈥檛 exist but I think the fact of life is that throughout the European Union there鈥檚 a very longstanding tradition in herbal medicine and it鈥檚 not going to vanish overnight, even if us, as the UK, wanted it to.听 And our job at the moment is to drive up the quality standards and the information standards.听 The traditional scheme has offered us an opportunity that we didn鈥檛 have before.听 The market before was in a dire state now we鈥檙e moving forward.

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Porter

Margaret, does it make a difference to you where these products are being sold, I mean presumably they鈥檙e sitting on the shelves next to proper medicines in some cases?

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McCartney

Absolutely.听 Where I have a real issue is that a lot of pharmacies now are offering NHS services like stop smoking or sexual health testing and what I really object to is that these products are on a shelf underneath an NHS banner.听 And to me the ethos of the NHS should be about evidence based compassionate healthcare, not about herbal remedies that happen to have been around for a long time, don鈥檛 seem to have killed anyone and so are given a product licence.听 And I think that makes a real 鈥� really difficult for consumers to know what it is that they鈥檙e buying, who鈥檚 approving it and what efficacy they can expect from that product.

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Porter

We must leave it there, Margaret McCartney and Dr Linda Anderson, than you both very much.

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Now, we have had an e-mail from listener Robin Hill:

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Hill (Read)

Studies have been reported in the press claiming that calcium supplements cause an 87% increase in the risk of heart disease.听 This has been a worry and concern for myself and many other people using this supplement to help osteoporosis.听 Please can you establish the truth and risk of this worrying suggestion and hopefully put our minds at rest or at least quantify the true risk?

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Porter

It is thought that around five million people in the UK - most of them women - take some form of high dose calcium supplement to keep their bones healthy. So what is the latest thinking on their use? Juliet Compston is emeritus Professor of Bone Medicine at the University of Cambridge.

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Compston

The consensus at present is that when we see a patient and we鈥檙e considering treatment for osteoporosis we do a rough assessment of their dietary calcium 鈥� this is just done in the clinic by asking questions about dairy produce intake, because dairy produce has by far the highest amounts of calcium, and they are other foods like pulses and some vegetables which also contain calcium.听 And if the dietary intake appears to be adequate, based on that sort of questioning, then we wouldn鈥檛 prescribe additional calcium supplements.听 But if, for example, the patient says well I never have any dairy products at all then there would be a case for giving calcium supplements with the osteoporosis treatment.

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Porter

Now that might well be happening in a clinic like yours but I suspect there are many women out there who are taking calcium who have just been prescribed them without proper assessment of their dietary intake, does that matter?

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Compston

The ideal situation is certainly to assess dietary intake before deciding whether or not to use calcium supplements.听 Having said that most people in the UK have rather lower calcium intake in their diet than the recommended daily intake and so prescribing an extra supplement may not be harmful at all.听 On the other hand because of the concerns that have been voiced recently about a possible link between calcium and cardiovascular disease we would prefer to err on the side of caution and only prescribe calcium supplements in those people where dietary calcium intake is insufficient.

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Porter

A review of the recent evidence in the medical journal Heart suggested roughly that women taking calcium supplements 鈥� older women taking calcium supplements 鈥� were something like 20% more likely to have a heart attack and 15% more likely to have a stroke than women who did not take supplements, what鈥檚 your take on that research, is this something we should be worried about?

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Compston

My take on the research in general is that the evidence is very conflicting.听 So there have been some studies suggesting a possible link between calcium supplements and heart disease and in some cases stroke as well but these studies have not been designed to show whether or not heart disease or stroke are increased in people taking calcium supplements, they鈥檝e been studies where people have looked at other trials, usually with fracture or bone mineral density as an outcome, and examined the adverse effects in those studies.听 And that kind of study 鈥� and there have been many meta-analyses too 鈥� are prone to a number of flaws, there have been weaknesses in the statistical approach that鈥檚 been used, there may be other factors which predispose to heart disease in these women which are not accounted for in the data in those studies.听 And so the other thing to say is that there have been a number of studies which have shown absolutely no link at all between calcium supplements and cardiovascular disease and stroke.听 So it鈥檚 a very controversial area.听 The consensus amongst experts in the field at present I would say is that there鈥檚 no well proven link between calcium supplementation and heart disease or stroke but it would be nice clearly to have further studies in this area.

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Porter

But in the meantime it would make sense, would it not, that women only take supplements if they need them.听 What sort of daily intake in milligrams should women be consuming?

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Compston

Well recommendations vary a bit but generally between 750 and 1,000 milligrams a day.听 A pint of milk is about 750 milligrams, so you鈥檙e almost there if you have a pint of milk a day.听 And if you have, let鈥檚 say, half a pint of milk and you have some cheese and yoghurt you鈥檙e going to reach pretty much the recommended levels.

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Porter

And assuming that you鈥檙e not and you turn to supplements what sort of dose of supplements should be taking 鈥� you鈥檙e suggesting just enough to get you up to that recommended daily intake?

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Compston

Yes I mean most people have some calcium in their diet so a supplement of between 500 and 1,000 milligrams of calcium would be appropriate, probably more like 500 in many women than a thousand because they will already have some intake in their diet.

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Porter

Professor Juliet Compston. Dr Margaret McCartney has been listening to that, Margaret, forget the potential harms for the moment, how convincing is the evidence that calcium supplements help protect against thinning bones in the first place?

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McCartney

We are prescribing calcium supplements because we think that it will reduce the amount of fractures people get because of osteoporosis but the bottom line is we really don鈥檛 have the evidence to say that.听 And it makes me feel very uncomfortable because there is the risk that we are actually doing harm to people by increasing the risk of heart disease and stroke.听 So I think we鈥檙e in a bit of a dilemma at the moment and certainly I think we need better trial evidence so that we can be sure that we鈥檙e helping people more than we鈥檙e potentially harming them.

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Porter

Common sense would dictate that being on calcium supplements 鈥� let鈥檚 put this very simply 鈥� ensures that you鈥檙e getting enough bricks delivered to the building site to maintain healthy bones so therefore you would expect your bones to be healthier 鈥� but that doesn鈥檛 translate into reduced fractures.

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McCartney

No, no鈥�

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Porter

Do you know why that is?

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McCartney

No and I think like so many things in medicine what seems eminently sensible and reasonable just doesn鈥檛 work out quite that logically in real life.听 And what鈥檚 really interesting as well is in America the US Preventive Services Taskforce came out in February to say that actually they felt they didn鈥檛 have good enough evidence of prescribing calcium supplements in post-menopausal women.

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Porter

So they might be falling out of favour slightly?

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McCartney

Well I think we just need better evidence so that we know really what we鈥檙e doing and at the moment鈥�

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Porter

But we鈥檝e had these for decades, I mean they鈥檙e not new.

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McCartney

Yes it鈥檚 shocking and I really wonder sometimes what direction medicine鈥檚 going on, such a fundamental question we haven鈥檛 started to answer it yet.听 But what I think it鈥檚 important to know is that there鈥檚 lots of other ways to think about reducing the risk of osteoporosis 鈥� things like not smoking, things like weight bearing exercise and actually not being underweight, which is a risk factor as well.

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Porter

What about this thing about assessing your patient鈥檚 intake before you prescribe them to make sure that they鈥檙e not taking more than a thousand milligrams or whatever 鈥� the sort of figure that they need 鈥� do you do that?

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McCartney

No I don鈥檛, in my defence I have to say that most of the patients that we鈥檙e asked to prescribe calcium supplements for will come from having a DEXA scan, a bone density scan, where the recommendations are usually made after they鈥檝e been seen by a nurse in the clinic there.听 But I am going to go back and find out whether or not these women have had a dietary assessment done of how much calcium they鈥檙e taking in.

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Porter

Margaret McCartney.听 And if that has left you even more confused then there is a simple overview, including how to work out how much calcium you may need, on our website. Go to bbc.co.uk/radio4 and click on I for Inside Health.

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Next week I will be learning more about the science behind mixing alcohol and caffeine based energy drinks, and discovering why doctors are particularly worried about people who binge drink on the combination.

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And the latest on eating disorders - we dispel the myths that continue to surround anorexia. Join me then to find out more.

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ENDS