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INSIDE HEALTH

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Programme 6. - Tax on sugary drinks, Low libido in women, Europe's largest robotic pharmacy

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TX:Ìý 14.07.15Ìý 2100-2130

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PRESENTER:Ìý MARK PORTER

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PRODUCER:Ìý ERIKA WRIGHT

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Porter

Coming up in today’s programme:Ìý Pharminator – I visit Europe’s biggest robotic pharmacy.

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Clip

So Mark this is copper and what we use it for, particularly overnight, is to fill the robot for us.

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Wouldn’t it be great to be able to restock your kitchen like this, you’d get back from the supermarket and just empty your carrier bags and some robot would put everything away in the right place or at least somewhere where it could find it.

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More on that later.Ìý

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And we return to the thorny issue of hypoactive sexual desire disorder. It is claimed to affect one in three women to some degree. But what is HSDD and where did the diagnosis come from? Is it a label that will help millions of women, or a construct to make it easier to market new drugs? Or perhaps - a bit of both?

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Clip

Depending on what research you read what sex means, what desire means varies quite dramatically.Ìý So I’m often confused actually because if you look at the evidence it’s not actually always clear what it means at all.Ìý But I think in lay terms what it’s usually talking about is that you don’t really desire sex in any way shape or form.

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Porter

But we start with sugar and calls from the British Medical Association for a 20% tax on sugary drinks, with the revenue being used to subsidise healthier foods. The BMA has focussed on drinks because they contain lots of sugar – nine or more spoonfuls in some cans – and little else of any nutritional value making them empty calories.

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Their announcement is timely given that the Scientific Advisory Committee on Nutrition is expected to recommend a cut in the amount of sugar we consume. To no more than 5% of our total daily calorie intake. So for a teenager that would be a maximum of 25g of sugar a day – and a typical can of cola contains 40g.

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But what evidence is there that taxing sugary drinks would help? Dr Adam Briggs is Wellcome Research Fellow at the Nuffield Department of Population Health at the University of Oxford and lead author of a study predicting that introducing such a tax would reduce the number of obese adults in the UK by 180,000.Ìý As other countries who have already introduced such taxes are discovering.

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Briggs

There are good examples now coming through from France and also from Mexico, more recently, where they’ve both introduced soft drink taxes and in Mexico it’s particularly interesting because they’ve just produced their year one results on changes in purchases of soft drinks following the implementation of a 7-10% tax.Ìý And that’s very interesting because it’s showing that on average they’re reducing the amount of purchases of soft drinks by around 6% but towards the end of the year it was more like a 12% reduction in purchases.Ìý So it’s similar to what happened when cigarette were first began to be hiked, is that there are increases in the effects size of that particular taxation over time as it progressed.

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Porter

Well listening in our Glasgow studio is Dr Margaret McCartney.Ìý Margaret, I mentioned in the introduction that the scientific advisory committee on nutrition are due to report on sugar recommendations later in the week, do we know what that report’s likely to contain – this 5% figure’s been banded around a lot?

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McCartney

Yeah, so the draft scientific advisory committee on nutrition report, which was last year, had said that we should limit our total calorie intake from sugar to 5% from age two upwards, that went out for consultation and that’s due to be reported back this Friday.Ìý In the meantime the World Health Organisation in March said we should reduce free sugars in our diet to 10% but also said that 5% would be better.Ìý So I think we’re certainly going for a lower number.

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Porter

Well because 5% is pretty low and their figure – that’s based not just on added sugar in things like fizzy drinks but also naturally occurring sugars in things like orange juice for instance.

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McCartney

Yeah I think it’s to do with concentration of sugars.Ìý So an apple, an orange you’re going to get some natural sugars in that but nowhere near as much as if you concentrate those sugars down to a fruit juice packet.

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Porter

And Margaret can you put that reduction in perspective, what are we consuming on average at the moment?

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McCartney

Well the World Health Organisation says that at the moment we’re consuming between 16 and 17% in the UK and in countries like Spain, they’re saying it’s lower in countries like Denmark – about 12% - but even up to 25% in Portugal.

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Porter

So quite a significant reduction if we’re to hit that target.

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McCartney

Whereas Hungary and Norway they’re saying it’s about 7 or 8%.

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Porter

Adam, do we know what proportion of our daily sugar intake fizzy drinks are responsible for or sweet drinks are responsible for?

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Briggs

Yes there’s some indication from the National Diet and Nutrition survey and one of the most telling things from that survey is that for 11-18 year olds, so teenagers and young adults, it’s the largest contributor to sugar in their diet, so 40% of sugar in their diet comes from non-alcoholic beverages.Ìý The greatest consumers of soft drinks in the UK are young adults and teenagers and so this type of intervention is likely to have the greatest effect on that cross-section of society and I think that’s in terms of our future health of our population, in terms of their workforce output and the cost to our NHS, then the long term health outcomes that we might see in terms of the benefits from this kind of approach are going to be in that generation.Ìý So that’s a really key population target and what seems like a useful way to target that population.Ìý The second thing is the government putting a tax of 20% on a soft drink doesn’t just change the price of it, it sends out a message to people that this is unhealthy, this is something that shouldn’t be seen as a normal part of someone’s diet.Ìý And it will likely encourage manufacturers and supermarkets to change their practices in terms of either reformulating those products, pushing other products, moving them around in the supermarket.Ìý And so it’s likely they’ll be wider effects than those simply seen by the economics of the price change alone.

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Porter

Adam, what do you say to people who might be worried that taxing soft drinks in this way might hit the poorest the hardest?Ìý I mean if you’re putting something like 20p or 15p on the price of a can that’s quite a lot for someone who’s on a low income.

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Briggs

I think it’s a really important point and one that people do get concerned about.Ìý With this type of taxation strategy our modelling indicated that it would affect in the poorest parts of our society, so the lowest income group, it would increase their weekly expenditure on soft drinks per person by about 9p, which works out at about £5 a year.Ìý So I’m not wanting to belittle that amount of money but in proportion to the rest of expenditure on food that’s relatively negligible.

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Porter

But let’s unpick that a bit because that’s a tiny amount, I mean that’s less than you’d have on one can, so that suggests that it’s putting them off buying it.

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Briggs

Of course this will affect people differently, so those who consume more are going to be greater affected in terms of how much they have to pay on this tax than those who consume less and that varies not only by socioeconomic group but also by age.Ìý There’s one other key thing that we need to talk about here I think is what people choose to drink instead.Ìý So where people substitute that soft drink for say diet soft drinks or for tea and coffee or for milk or for fruit juice will affect what the overall cost is to their drinks budget.

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Porter

Margaret, how do you feel about the principle of such a tax?

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McCartney

It’s really interesting.Ìý The big challenge, I think, is whenever people talk about taxing unhealthy behaviours is that people condemn this as nanny state interference.Ìý But the problem is that what we have just now is a commercial state, so we have this huge impact of commercial activity on people’s choices and I’m really concerned that people don’t get good information and knowledge about what they’re buying.Ìý So it’s quite easy to put a little button on the bottom of any packaging saying this contains X amount of Y and Z but what does that actually mean in practice.Ìý So if you go into petrol stations at the moment you can buy a big massive bar of chocolate – and I admit shamefully to have done so in the recent past – a 200 gram bar of chocolate with 960 calories in total, now say I have half of that what I really want to know is that means I have to go running for about an hour to burn that off and that’s much more useful information to me rather than just giving me a kind of bare bone number of calorie, it doesn’t help me very much.Ìý And I think that’s the problem, it’s so easy to get high calorie rich foods into a diet without hardly having to think about it.Ìý So what are we going to do about that?Ìý And I think the natural next conclusion is to look at the evidence around taxing unhealthy foods and saying well how can we use this wisely and I think it really has to be done.

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Porter

Adam, we can learn a lot from our previous attempts to adjust behaviour through this sort of policy, I’m thinking obviously of tobacco, that’s the obvious example where we’ve stuck lots of taxes on, we’ve tried health warnings, we’ve tried legislation as well.Ìý Is there anything that we can learn from that that we can apply to this?

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Briggs

I think that we can just be slightly reassured that when you follow the trajectory of tobacco taxation over the past 30 years you don’t just see a step wise reduction in how much tobacco’s being consumed, you see it mirror imaging the price changes.Ìý So this isn’t people quitting and starting again, this is people modifying their behaviour based on a price.Ìý And that’s what I think we would expect to see with a soft drink tax, people would just consume a bit less.Ìý And at a population level when you’re targeting 65 million people of which two-thirds of the adults are overweight or obese then that seems like a sensible way to start.

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Porter

Dr Adam Briggs and Margaret McCartney. And there is a link to Adam’s research on the benefits of taxing sugary drinks, as well as draft proposals on how much sugar we should be consuming from the Scientific Advisory Committee on Nutrition, on the Inside Health page of the Radio 4 website.

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Earlier in the series we discussed the possible approval of a new drug for treating low libido in women. Flibanserin – or pink Viagra as it has been nicknamed by the media (although it is nothing of the sort) – is currently under review by the US Food and Drug Administration and could be approved next month to help women with hypoactive sexual desire disorder (HSDD). But what is HSDD and where has the diagnosis come from? It certainly seems to divide opinion, so we promised to dig a little deeper.

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On the one hand it is being celebrated as recognition of a problem that some experts believe afflicts around one in three women, and will mean they finally get the help they need. On the other, there is growing concern that HSDD is being used to medicalise millions of women and prepare a receptive environment for marketing a new generation of medicines.

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Ray Moynihan is senior research fellow at the Centre for Research in Evidence Based Practice at Bond University in Australia.

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Moynihan

This is an extraordinary story.Ìý One of the beginnings is back in the mid-‘90s at a conference in Cape Cod half of the people there were from drug companies and the other half were from the research community and together they started to nut out the definition of a new condition.Ìý So from the very beginning the inception of this new dysfunction the pharmaceutical industry and the small sex research community are kind of working hand in hand to create a whole new category of medical disease.

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Porter

But is that a problem if there were women out there with a range of issues that researchers simply wanted to put under one umbrella term?

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Moynihan

Well that’s certainly what the researchers would argue and they would argue that industry funding was helping them do incredibly important work, they were helping to categorise the range of difficulties that women suffer.Ìý The problem is that from the very beginning there have been attempts to frame female sexual dysfunction and its associated disorders broadly as possible in order to build potentially huge markets and in order to create the idea that there’s a massive unmet need for drug therapy.

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Boynton

Depending on what research you read what sex means, what desire means, varies quite dramatically.Ìý So I’m often confused actually about what this actual diagnostic really means.

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Porter

Petra Boynton is a psychosexual researcher working on the Wellcome funded Sense about Sex project to improve media coverage of sex and relationship issues.

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Boynton

I think that a lot of women, women like, me, women listening, will often experience genital pain, they might have had problems with sex because of an underlying physical or mental health condition, there may be body confidence issues or they might have problems in their relationship or perhaps they’ve had problems in the past with abuse.Ìý And all of those things and many more are really good reasons why you might not feel like sex, you might be with a partner who’s not really very good in bed with you or you may not feel able to ask for what you want or even know what you want and again those are really good reasons for not desiring sex.Ìý But if you take away all those factors and say everything is fine – my relationship is fine, my life is fine, I’m healthy, I’m fine – but I don’t want sex, that discrete condition I think is exceptionally unusual, most of us when we don’t want sex have a very good reason for not wanting sex.

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Alexander

There is no question that there is a small subset of women that qualify for this disorder and that have the diagnostic criteria for this condition.

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Porter

Caleb Alexander is Co-Director of the Centre for Drug Safety and Effectiveness at John Hopkins University in Baltimore and one the experts on the FDA panel that initially appraised flibanserin for use in women with HSDD.

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Alexander

These are women that have persistent or recurrently deficient or absent sexual fantasies and desire for sexual activity.Ìý It would have to cause marked distress and inner personal difficulty and very importantly it would have to not be accounted for by some other type of mental illness – depression for example – which is widespread, by medicines, by severe relationship stress or by a general medical condition.

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Porter

What do you think of the climate that this drug may be launched into?

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Alexander

Well I don’t envy the job of regulators in this setting.Ìý Regardless of the choice that they make as to whether or not to approve this product they’re bound to be roundly criticised by one party or another, that is this product has very vocal and vociferous advocates that it should be approved and similarly vocal opponents of its market access.Ìý And I think there’s really been a unique constellation of factors that have heightened the controversy regarding this product.Ìý At first there’s unmet need, there’s no question that there is a small population of women that do fulfil formal diagnostic criteria for this condition.Ìý Second, there’s been extensive advocacy and politicisation of this product and of its regulatory pathway.Ìý This involves women and sexual health which also adds a layer of controversy.Ìý There’s also the potential for widespread off label use.Ìý There are many, many women that may have a lack of sexual fantasies or sexual desire that is in fact caused by some other cause.Ìý And so this product may be used much more broadly among a much broader group of individuals.Ìý So all of these factors together really create the perfect storm for regulators.

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Boynton

There’s a sort of perfect storm here and initially activists started saying well how you are really defining this and is it a medical problem or is it something else?Ìý And we were looking at the safety and effectiveness of some of the drugs that they were looking to produce.Ìý But interestingly that has almost been turned on its head more recently by drug companies and particularly affiliated patient groups who are talking about their rights, their rights to pleasure and their right to desire and they should have options and choices.Ìý And we’re at the point now that that activism has turned on the initial criticism of drug companies by suggesting that if you are questioning the effectiveness of drugs that are being developed or if you’re questioning this as a medical condition that you’re somehow denying women have problems or that this isn’t a concern for them.Ìý And that is absolutely not true.Ìý This clearly is a big worry for a lot of women but part of the reason they are worried is that they are being told that if they don’t feel like having sex there’s something clinically wrong with them or that there’s something personally wrong with them.

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Moynihan

I think that the very sad outcome is that we are going to see wave upon wave of marketing occur as each new drug is approved for this so-called condition or this suite of conditions that are going to have a potentially profound cultural effect on how we think about sex, how women think about their own levels of interest in sex, have a profound effect potentially on human relationships.Ìý What is being presented as science is kind of a weird merging of marketing and medical science.

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Boynton

It’s not just the drug company involvement and push but also if you look at our media and our cultural values actually media definitions of sex is how often do you do it – so great sex is doing it all the time in lots of exciting and exotic and novel ways.Ìý It’s never about quality.Ìý And so a lot of people believe if they’re not having sex a lot and if they’re not having sex with great orgasms every single time or if they’re not really feeling like it there’s something wrong with them.Ìý So I frequently hear from women who say I’ve got desire disorder but when you actually talk to them about what pleasure might mean for them or whether their desire is responsive rather than spontaneous actually they haven’t got something wrong with them but they’ve been led to feel because they’re not having great sex all the time with spontaneity and excitement that there’s something somehow wrong with them.Ìý That’s where my worry comes in that we’re kind of hyping up what might be everyday life into a disorder that they think a pill is going to fix.Ìý If you’re in a relationship and you’re not getting on very well and you feeling under pressure and you’re worried that you’re going to lose your partner and you think a pill would make all of that go away why wouldn’t anybody in this situation want a magic bullet?

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Moynihan

The problem is that common difficulties – ups and downs – of sexual lives are being confused with medical dysfunction.

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Porter

But look at this from the woman’s perspective.Ìý If a woman has a problem with low libido that fits in under this umbrella does it matter that somebody’s medicalised it, given it a name, that the drug companies produce a product, if she gets something that helps her?

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Moynihan

Well that’s a very, very good point and I and the other people that have been writing and researching in this space have no opposition to safe and effective treatments for genuine medical disorders.Ìý The problem here is that the cohort of women who do suffer genuinely severe recognisable medical conditions is much smaller than the marketing would have you believe.Ìý One of the key figures that’s been used for quite some time is that 43% of women purportedly have female sexual dysfunction.Ìý Now this gives the impression that half of the entire female population have some kind of dysfunction.Ìý This is simply untrue.Ìý I and other people have spent a lot of time drilling into this statistic, it comes from an old survey, women were asked if they experience one of seven common sexual problems – did they experience any problems with arousal or interest or feel anxious about performance, have trouble orgasming over a few months in the past year.Ìý Now if they answered yes to just one of those problems they were lumped together and categorised and so far we’ve seen a lot of potential new drugs hyped but we really haven’t yet seen anything that’s really genuinely safe and effective.

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Boynton

My nightmare scenario is that we continue to hear drug companies and practitioners and patient groups who are all allied together talking about patient choice but really meaning not actual choice, what they’re actually meaning is here’s a drug to fix the problem.Ìý And that the research that’s ongoing in this area, which I have to say is mostly weird and poor, it’s really quite bad, it’s not accessible, they all use different measures, they all have different definitions and often what they’re looking at when they’re testing drugs to treat sexual problems is that you’ll get one more sexually satisfying experience per month for taking a drug every day that may give you horrible side effects and actually doesn’t fix the underlying problems that brought the desire disorder to begin with, if it’s even a disorder.Ìý So my nightmare scenario is we continue to see not wanting sex as some kind of clinical crisis for which we should be seeking a medical fix rather than looking at can we fix this ourselves, can we fix it through sex education, could we fix it by learning about our bodies or getting on better with our partner or exploring pleasure in other ways and thinking about desire that means something to us rather than is imposed on us by some kind of pre-determined clinical condition.Ìý That would be my nightmare scenario that we don’t get to decide.

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Porter

Petra Boynton. And the FDA is expected to announce its decision on whether it will approve flibanserin next month. More details on our website.

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The sound of the future, the Triple VMax robotic pharmacy, the biggest of its kind in Europe at the brand new Southmead Hospital.Ìý And to explain how the robot works Principal Pharmacist at North Bristol NHS Trust Jane Smith.

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Smith

So this is the part of the dispensary where we are producing the labels and starting to put the drugs altogether.Ìý So we have somebody sat at the computer and the computer works as a labelling system so they key in the code for the drug or they type the drug name in and a selection will come up on the screen and then the right drug is selected.

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Porter

Now there’s 25 people here dispensing the medicines effectively but there aren’t many medicines in this room, where are they all coming from?

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Smith

Ah most of those are hiding away.Ìý Down below the robot is picking that item. So as somebody’s sat here 33 seconds later the item will arrive by magic in the tray next to them.

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Porter

Behind the computer terminal is a conveyor belt…

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Smith

Yes.

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Porter

… which allows drugs to be knocked off the conveyor belt – we can hear them dropping down in the background - off the conveyor belt, down the spiral and dropping off at the first desk, there you go.

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Smith

Okay so Mark I’m going to take you downstairs now to where it’s all happening.

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Here we are Mark, so this is the robot itself and I suppose really it’s about the size of two double garages.

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Porter

Yeah big black shiny box, it’s very smart.

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Smith

A very big black shiny box.Ìý And it’s a triple, so there’s three separate sections to it.Ìý And as you look inside you’ll see the robot heads zooming up and down.Ìý Inside we’ve got glass shelving and there’s probably 7.5 kilometres of shelving in the robot.Ìý Lots of packs in a very small space.Ìý So when you’re planning a new hospital where the hospital footprint is important and space costs money the more you can compact down the space that you need the better.

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Porter

And we can see the arm at work and you can hear it at work here now.Ìý I mean it’s shooting up and down but faster than someone could walk.

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Smith

Oh definitely yes.

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Porter

And then going up and down the shelves and picking the packets, as per the instructions that are being sent from up above.

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Smith

That’s it.Ìý And how robots store things is it’s all random storage.Ìý So if we were at home storing our boxes of sugar and cereal we’d store them altogether but a robot makes best use of its space, so it works out where it’s going to put it.Ìý Now if we went in there to find something we couldn’t find it but the robot knows exactly where it is and often it scatters them all around.

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Porter

My one concern I suppose looking at this would be what happens when it breaks down, as all technology does at some stage, I mean you could see things could grind to a halt here because you’re set up for this.Ìý Can you take over manually?

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Smith

Not to the same extent.Ìý So we’ve been very lucky, it hasn’t broken down for a huge length of time, and the advantage again of having a triple is that it’s often only one part of it that breaks down.Ìý But when it does break down and the whole system goes down we still can have a printout of where everything is, so we can still retrieve items if the robot can’t actually physically do it for us.

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Porter

What’s in all of this for the patient – the person receiving the medicine?

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Smith

The top thing is patient safety.

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Porter

You’re less likely to make a mistake using this system?

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Smith

Yes.

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Porter

Do we know that for a fact?

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Smith

It has been shown because certainly in dispensing it is a complex process and the biggest of the dispensing areas is the picking error.Ìý There’s a lot of drugs now that look the same.Ìý So particularly with generic products some companies use the same livery on all their packaging and it’s very difficult to differentiate.

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Porter

And the concern would be that the patient receives the wrong drug or the wrong dose of drug – what’s the most common mistake?

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Smith

Previously before we had the robots patients could be picked the wrong drug.Ìý You store everything alphabetically because it’s obviously easier for humans to find so we would, for example, have Propranolol next to Prochlorperazine and at one stage the same generic company supplied both of the drugs for us and the boxes were just about identical apart from the drug name and we’ve had items Procyclidine and Prochlorperazine where they’re both five milligrams, so the human eye to pick out the right drug that’s an area of risk.Ìý So by the robot doing it for us using a barcode it eliminates that.Ìý The other thing it does at the same time as all of this, because it’s a real multitasker, is actually put stock away, so we can actually load the stock at the front or there’s a big hopper around the side that we can put it in and we can leave it overnight and by the time we come in in the morning it will have worked all night long putting it away for us.

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Porter

Because of course robots don’t need to sleep at night so it can carry on working when you’re in bed.

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Smith

It can and that’s a real advantage for us.Ìý So Mark this is the hopper and what we use it for, particularly overnight, is to fill the robot for us.Ìý So what we do is throw in the orders, so the hopper itself is about a foot tall and about a foot wide, and it can be full all the way along.

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Porter

And it looks like someone’s just emptied a bucket of drugs into – and just let the computer sort it all out.

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Smith

That’s it, you just throw it in and the conveyors take it up into the machine and you’ll see the light flashing on and off and that’s it reading the barcode.

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Porter

So these are antibiotics but they won’t necessarily be stored together – I mean there’s lots of boxes of the same antibiotic there but what’s going to happen is that they could be put anywhere the robot’s got space.

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Smith

They could, they could go anywhere.

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Porter

Wouldn’t it be great to be able to restock your kitchen like this, you’d get back from the supermarket and just empty your carrier bags and some robot would put everything away in the right place?Ìý Or at least somewhere where it could find it.

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Chance would be a fine thing.Ìý Pharmacist Jane Smith and the Triple VMax robot.

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Just time to tell you about next week when I will be learning more about pelvic girdle pain during pregnancy and why it is important to spot it early. And knee surgery – we put athroscopy under the evidence-based spotlight.

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ENDS