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Letters to the Editor Issue 273

by Letters(more info)

listed in letters to the editor, originally published in issue 273 - September 2021

Study Launched to Investigate Diet Treatment for Long COVID

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Researchers from the University of Glasgow have been awarded £1 million from the National Institute for Health Research (NIHR) to investigate weight loss treatment for long COVID.

The multi-disciplinary research team, led by Dr Emilie Combet and Dr David Blane, will lead the Remote Diet Intervention to REduce long Covid symptoms Trial (ReDIRECT) to test whether a well-established weight management programme, delivered and supported entirely remotely, can improve symptoms for people with long COVID and overweight/obesity.

ReDIRECT is one of 15 new studies across UK to expand research that will support thousands of vulnerable people and those affected by COVID. Funded by NIHR, the study shares in almost £20 million for research projects, that will ultimately help improve understanding of long COVID and identify effective treatments

Around 10% of people infected with COVID-19 have symptoms for 12 weeks or longer (long COVID). There are, as yet, no established treatments for people living with long COVID.

Weight management programmes in adults with overweight /obesity can reduce symptoms such as fatigue, breathlessness and pains, which are also common with long COVID. However, researchers do not know how effective intentional weight loss is to reduce these symptoms for overweight people with long COVID.

Dr David Blane, Clinical Research Fellow in General Practice & Primary Care said: “We’re delighted to be doing this research, working closely with people affected by long Covid. We know that people with long Covid are frustrated by the lack of treatment and support options currently available.”

Dr Emilie Combet, Senior Lecturer in Nutrition, said: “People with long COVID have overweight/obesity to a similar extent than the rest of the population, which may worsen their symptoms. This project will tailor and test a well-established weight management programme, delivered and supported entirely remotely.”

The research team will work closely with overweight people who are experiencing long COVID to adapt and evaluate the weight management programme, which can be followed remotely from home. A trial will be conducted with 200 people, identified through their GP, patient and community groups. A key feature of the trial is its focus on patient-select key health outcomes, recognising the broad range of long COVID symptoms identified by patients.

Half of the participants will receive the personalised, professionally-supported weight management programme, while the other half receives usual care, with a goal to compare long COVID symptoms, weight loss, quality of life and value for money after 6 months. The control group will also receive the intervention, after a 6-month delay. Experiences of both groups will be documented for 12 months.

Laura Sloman, Chief Operating Officer of Counterweight, commented: “We are delighted to be collaborating with the University of Glasgow on this important research project. Obesity and type 2 diabetes have been shown to elevate the risks of hospitalisation and mortality due to COVID-19 infection.

"Our Counterweight-Plus programme has been widely used by people looking to lose weight and achieve diabetes remission in order to reduce this risk. Now we have the opportunity to investigate how following the programme may also improve recovery from long-COVID for those living with overweight and obesity.”

Professor Nick Lemoine, Chair of NIHR’s long COVID funding committee and Medical Director of the NIHR Clinical Research Network (CRN), said: “This package of research will provide much needed hope to people with long-term health problems after COVID-19, accelerating development of new ways to diagnose and treat long COVID, as well as how to configure healthcare services to provide the absolute best care. Together with our earlier round of funding, NIHR has invested millions into research covering the full gamut of causes, mechanisms, diagnosis, treatment and rehabilitation of long COVID.”

Acknowledge Citation

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Further Information

For more information contact Elizabeth McMeekin or Ali Howard in the University of Glasgow Communications and Public Affairs Office on 0141 330 4831 or 0141 330 6557; or email  or



New Hypothesis Proposed for how Chlamydia might Increase Cancer and Ectopic Pregnancy Risk

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A review of evidence by researchers at the University of Bristol and University of Edinburgh has suggested a possible new means by which chlamydia could lead to an increased risk of cancer and ectopic pregnancy. The hypothesis also provides a possible explanation for how pelvic inflammatory disease may be triggered in some women.

The review, published in the Journal of Infectious Diseases,[1] looked at evidence from lab-based studies, animal models and clinical studies on the role of chlamydia in diseases of the reproductive tract.

The researchers’ analysis of the studies’ findings suggests that chlamydia induces a particular type of change in reproductive tract cells known as ‘epithelial to mesenchymal transition’ (EMT), which can lead to inflammation and cell growth. Their hypothesis is that this chlamydia-triggered cell change contributes to the development of further disease.

“Chlamydia is a bacterial infection that stimulates EMT, which may persist after the chlamydia infection has cleared,” explains Dr Paddy Horner from the NIHR Health Protection Research Unit in Behavioural Science and Evaluation at University of Bristol, who led the review.

“We think that the association of chlamydia with ovarian and cervical cancer could be explained by the persistence of EMT changes in combination with DNA damage caused by chlamydia following chlamydia infection”, he said.

“Also, we know that EMT cells impair the integrity of the lining of the infected reproductive tract cell, making it more susceptible to invasion by other bacteria. This increases the risk of pelvic inflammatory disease from those invading bacteria.

“Furthermore, epithelial (barrier) cells in the fallopian tube that have previously been infected with chlamydia have more receptors on their surface, which are associated with an increased risk of ectopic pregnancy. There is evidence that these cell surface receptor changes could be caused by EMT.

“If our hypothesis about the role of EMT following chlamydia infection in women is correct, it could help explain some of the recent epidemiological observations about chlamydia and reproductive disease which are difficult to account for using current concepts about the immune response to chlamydia.

“It would also support the English National Chlamydia Screening Programme’s shift to earlier testing of women, as the shorter the duration of infection, the lower the risk of developing EMT changes. Further down the line, this could lead to the development of new tests for identifying women at increased risk of ovarian cancer and ectopic pregnancy and interventions that could reduce these risks.

“Obviously a lot more research is needed before we can be sure that our hypothesis is correct, but the evidence from this review suggests that further research in this area would be fruitful and could have important benefits both for patients and in the prevention of chlamydia-induced disease in the long-term.”

Munira Oza, Director of the Ectopic Pregnancy Trust, said: “This analysis helps to further our understanding of one of the possible risk factors for ectopic pregnancy and we would welcome more research in this area.

“It also highlights the importance of the change of focus of the National Chlamydia Screening Programme to opportunistically making proactive offers of a chlamydia test to young people without symptoms to reduce the risk of reproductive harm.

“With early detection through the screening programme and much-needed education to reduce the stigma of chlamydia, we hope that many women and families might be spared the health risks and heartache of ectopic pregnancy. We encourage young women to screen when given the opportunity.”

Chlamydia is the most common bacterial sexually transmitted infection worldwide. If left untreated, it can cause pelvic inflammatory disease, ectopic pregnancy, tubal factor infertility, and chronic pelvic pain due to tubal scarring.


  1. Is There a Hidden Burden of Disease as a Result of Epigenetic Epithelial-to-Mesenchymal Transition Following Chlamydia trachomatis Genital Tract Infection?’ by Paddy Horner, Heather Flanagan and Andrew Horne in the Journal of Infectious Diseases.

Further information

About the NIHR Health Protection Research Unit (HPRU) in Behavioural Science and Evaluation at University of Bristol

The NIHR HPRU in Behavioural Science and Evaluation at University of Bristol is one of 14 HPRUs across England, part of a £58.7 million investment by the NIHR to protect the health of the nation. The NIHR HPRU in Behavioural Science and Evaluation is a partnership between Public Health England and University of Bristol, in collaboration with MRC Biostatistics Research Unit at the University of Cambridge and University of the West of England. Each NIHR HPRU undertakes high quality research that is used by PHE to keep the public safe from current and emerging public health threats.

About the NIHR

The mission of the National Institute for Health Research (NIHR) is to improve the health and wealth of the nation through research. We do this by:

  • Funding high quality, timely research that benefits the NHS, public health and social care;
  • Investing in world-class expertise, facilities and a skilled delivery workforce to translate discoveries into improved treatments and services;
  • Partnering with patients, service users, carers and communities, improving the relevance, quality and impact of our research;
  • Attracting, training and supporting the best researchers to tackle complex health and social care challenges;
  • Collaborating with other public funders, charities and industry to help shape a cohesive and globally competitive research system;
  • Funding applied global health research and training to meet the needs of the poorest people in low and middle income countries.

NIHR is funded by the Department of Health and Social Care. Its work in low and middle income countries is principally funded through UK Aid from the UK government.

About The Ectopic Pregnancy Trust 

The Ectopic Pregnancy Trust provides information, education, and support to those affected by ectopic pregnancy and to the health professionals who care for them. The charity seeks to raise awareness about the condition so that the public are aware of symptoms to enable women to get medical care quickly that can be life-saving. It ensures women and families leave hospital with relevant information and have someone to talk to about their experience. The NHS signposts to The EPT's resources and its Ectopic Pregnancy Patient Information literature was Highly Commended in the 2019 BMA Patient Information Awards.

Further Information

For more information, please contact visit University of Bristol

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People with Rare Autoimmune Diseases are at Higher Risk of Death from Covid-19

New research has revealed that people with rare autoimmune rheumatic diseases are at an increased risk of developing Covid-19 and subsequently dying from it.

Experts found that people with these conditions were 54% more likely to test positive for a Covid-19 infection, and death related to Covid-19 was 2.4 times more likely than for people in the general population when age and sex was taken into account.  Researchers say there is an urgent need to understand the effectiveness of the vaccine among people with diseases such as vasculitis and lupus.

The findings, published as a pre-print in medRxiv and currently under peer review, is the work of a team of doctors and researchers from RECORDER (Registration of Complex Rare Diseases Exemplars in Rheumatology), which is a joint project between the University of Nottingham, Nottingham University Hospitals NHS Trust and the National Disease Registration Service at Public Health England.

Research from the team earlier this year showed that people with rare autoimmune rheumatic diseases such as vasculitis, lupus, scleroderma, juvenile idiopathic arthritis, myositis and Behcet’s disease were more likely to die, from any cause, during the first two months of the pandemic. However, they were not sure why this was happening.

In this latest study, funded by the British Society for Rheumatology and Vasculitis UK, the team looked at nearly 170,000 people in England with rare autoimmune rheumatic diseases. Between March and July 2020, during the first wave of the Covid-19 pandemic in England, they found:

  • 1,874 people (1.11%) had Covid-19 infection (PCR test positive)
  • Taking age into account, the infection rate in people with rare autoimmune rheumatic diseases was 54% higher than in the general population
  • 713 (0.42%) people living with rare autoimmune rheumatic disease died related to Covid-19 infection
  • Covid-19 related death was 2.4 times more common in people with rare autoimmune rheumatic disease compared to the general population (taking age and sex into account)

Dr Megan Rutter, lead author of the study from the School of Medicine at the University of Nottingham, said: “As far as we are aware, this is the first study to show conclusively that people with rare autoimmune rheumatic diseases are more likely to die from Covid-19 infection, and that their risk is higher than that reported for people with more common autoimmune diseases.

“These findings are particularly important as recently published data show that people who are immunosuppressed, which includes many people with rare autoimmune rheumatic diseases, can have lower levels of protection from Covid-19 vaccination due to a weaker immune response.

“It is now vital that the health of people with these conditions is made a specific priority in public health policy, particularly now all restrictions have been lifted and community infection rates are high.”

Dr Sanjeev Patel, President of the British Society for Rheumatology, said: “This important work helps us to understand the risk that Covid-19 poses to people with rare autoimmune rheumatic diseases. Whilst the absolute risk of death is low for people with these conditions, the relative risk is over twice that of people without rare autoimmune rheumatic diseases. The British Society for Rheumatology will continue to support researchers to understand the impact of Covid-19 on health outcomes in people with rare rheumatic conditions.”

Paul Howard, Chief Executive of LUPUS UK, said: "These findings come at an important time, when the vast majority of Covid-19 restrictions have been lifted and case numbers remain high across the UK. Many people with diseases like lupus, vasculitis and other rare autoimmune conditions are on immunosuppressant medications and are expressing anxiety about having much less support to avoid contracting the virus whilst their risk is largely unchanged from last year. We hope these findings will encourage employers and policymakers to take additional measures to safeguard people living with these diseases."

About The University of Nottingham

The University of Nottingham is a research-intensive university with a proud heritage. Ranked 103rd out of more than 1,000 institutions globally and 18th in the UK by the QS World University Rankings 2022, the University’s state-of-the-art facilities and inclusive and disability sport provision is reflected in its crowning as The Times and Sunday Times Good University Guide Sports University of the Year twice in three years, most recently in 2021. We are ranked eighth for research power in the UK according to REF 2014. They have six beacons of research excellence helping to transform lives and change the world; they are also a major employer and industry partner - locally and globally. Alongside Nottingham Trent University, they lead the Universities for Nottingham initiative, a pioneering collaboration which brings together the combined strength and civic missions of Nottingham’s two world-class universities and is working with local communities and partners to aid recovery and renewal following the COVID-19 pandemic

British Society for Rheumatology

This study was funded by the British Society for Rheumatology. British Society for Rheumatology is the leading UK specialist medical society for rheumatology and musculoskeletal care professionals. We support our members to deliver the best care at all stages of the care pathway, to improve the lives of children and adults with rheumatic and musculoskeletal disease

Further Information

More information is available from Dr Megan Rutter at  or Charlotte Anscombe, Media Relations Manager in the Press Office at the University of Nottingham, on Tel: +44 (0)115 74 84417;  



Coffee Protects against Liver Cancer while Alcohol is Linked with Numerous Cancers, Major New Study Confirms

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Alcohol consumption is a major risk factor for several cancers including head & neck (mouth, pharynx, larynx), oesophageal and bowel cancer – as well as the more widely known links to breast and liver cancer – according to a new study funded by World Cancer Research Fund (WCRF),[1] and published this week in Nature Communications. The study also found increased coffee consumption was associated with a lower risk of developing liver cancer and basal cell carcinoma of the skin.

The study looked at data from 860 reviews (meta-analyses) of published studies, which explored the association between food and nutrient intake and the risk of either developing or dying from 11 different cancers. According to NHS Digital,[2] 65% of men and 50% of women in the UK had drunk alcohol in the last week. When alcohol is metabolized, it breaks down into chemicals which can bind to DNA, resulting in mutations which could become cancerous. Alcohol can also increase the levels of the hormones linked to the development of some types of breast cancer. 

Coffee is one of the most commonly consumed beverages at a global level and it is thought that the beneficial effects of coffee consumption might be due to the antioxidant and anti-inflammatory properties that may protect against diseases triggered by inflammation like cancer.

Dr Giota Mitrou, Director of Research and Innovation, WCRF said: “This umbrella review confirms the evidence we have for alcohol and coffee in relation to cancer. Further research needs to better understand the mechanisms involved in the links between coffee and cancer as well as between alcohol and different cancer subtypes. As always, we continue to encourage limiting alcohol intake as part of our Cancer Prevention Recommendations which include being a healthy weight, being physically active and enjoying a diet rich in wholegrains, vegetables, fruit and pulses.”

The authors of the study are calling for more targeted public health policies in order to deter the known major diet related risk factors for cancer, particularly alcohol consumption. 

About the Funding of this Study

This study was funded by WCRF, and was led by Dr Kostas Tsilidis, Senior Lecturer in Cancer Epidemiology in the Department of Epidemiology and Biostatistics of Imperial College. This study is an umbrella review to systematically evaluate the robustness of the observational meta-analytic evidence across a large number of associations with risk of cancer at 11 sites. They further evaluated whether additional research is or is not warranted to change the inferences from the existing meta-analyses using an adaptation of research synthesis methods. The findings in this study confirms the evidence from the WCRF Third Expert Report, positively linking alcohol consumption with cancers of the mouth, pharynx, larynx, oesophageal (squamous cell carcinoma), breast, colorectal, stomach and liver cancer.

About World Cancer Research Fund 

WCRF is the UK’s only charity solely dedicated to cancer prevention and survival. Over the last 30 years, WCRF has worked tirelessly to understand the links between a person’s weight, diet, and physical activity levels and their cancer risk. and Twitter, Facebook, Instagram & LinkedIn

WCRF’s Cancer Health Check tool and Cancer Prevention Recommendations help people understand what changes they could make to reduce the risk of getting cancer. Based on the latest scientific research, the advice is practical and simple to understand. 


  1. Papadimitriou, N., Markozannes, G., Kanellopoulou, A. et al.An umbrella review of the evidence associating diet and cancer risk at 11 anatomical sites. Nat Commun12, 4579 (2021). 
  2. NHS Digital, Statistics on Alcohol, England 2020. Available from: Last accessed: August 2021

Acknowledgement Citation

Published from



Bioactive Compound in Cocoa Powder and Dark Chocolate Helps Middle-Aged Adults to Exercise

A bioactive compound found in cocoa powder and dark chocolate could help middle-aged adults enjoy exercise, a new study has suggested. The research analysed the potential health benefits of ‘Cocoa flavanols’, a plant nutrient extracted from cocoa beans. Cocoa flavanols are found in abundance in cocoa powder, and to a lesser extent in dark chocolate, and can be consumed as a supplement. Because cocoa flavanols have a ‘vasodilatory’ effect, helping to increase blood flow, they’ve been shown to prevent blood clots and even combat memory decline.

Now a team of scientists from Liverpool Hope University and Liverpool John Moores University have tested the effects of cocoa flavanols when it comes to exercise in a group of ‘sedentary’ adults aged between 40 and 60 years old. And the published report found that cocoa flavanols contribute to faster oxygen uptake kinetics - with improved blood flow the likely cause. [1]

Associate Professor Simon Marwood, Subject Lead in Sport Science at Liverpool Hope University, says the findings could be important when it comes to convincing people to get off the sofa and then stick with an exercise programme.

He said:

“One barrier to starting an exercise plan is poor fitness in the first place, perhaps because of the discomfort associated with what might otherwise be light exercise.

“Without frequent exercise, ageing results in a slowing in the rate at which our oxygen consumption increases at the onset of exercise. This is due to impairments in the ability to supply blood to the exercising muscles at the onset of exercise.

“In previous studies we have shown that this slowing of the rate of increase of oxygen consumption has a direct and inhibiting effect on the ability to tolerate exercise.

“The finding of faster increases in oxygen consumption at the onset of exercise with cocoa flavanols supplementation is therefore really encouraging for this age group since it suggests that a simple nutritional supplement can improve exercise tolerance, and therefore enhance the likelihood of sustaining an exercise programme.

“This is a relatively small study but it’s encouraging and has significant results, which could be the basis for further research.”

Lead author Daniel Sadler, of Liverpool John Moores’ School of Sport and Exercise Science, concludes:

“These novel effects of Cocoa Flavanols, in this demographic, may contribute to improved tolerance of moderate-activity physical activities, which appear commonly present in daily life.”

The research was published in the journal European Journal of Applied Physiology.[1]

Professor Marwood says it’s important to note that over-consumption of chocolate, dark or otherwise, isn’t to be encouraged, although dark chocolate may contain cocoa flavanols. And the substance is most commonly available as a supplement which is often used by amateur athletes to boost performance.

The research itself focused on a group of healthy, middle-aged men and women with an average age of 45 years old and who typically engaged in less than two hours of structured exercise training per week.

Over a period of five weeks, prior to consuming the cocoa supplement, the group was put through a series of trials, using a lab-based exercise bike, where they were incrementally pushed to ‘exhaustion’. These trials were performed in order to establish a person’s ‘VO2 peak’, the maximum amount of oxygen the body can use during exercise, as well as power output.

The test subjects were then given either a daily 400 mg cocoa flavanol supplement or a placebo over the course of seven days. And at the end of that week, they got back on the cycle ‘ergometers’ and took part in a series of ‘step’ exercise tests, where they started pedalling at a baseline before the load was ramped up to either moderate or severe-intensity work rates.

The key measurement being analysed was pulmonary VO2 kinetics, or ‘τVO2’, the time it takes for oxygen delivery to respond to the demands of exercise.  The shorter the response time, the better equipped someone is to tolerate the given exercise.

 And what the research team discovered was that when the test subjects who’d consumed the cocoa flavanols were subjected to ‘moderate’ exercise, the VO2 kinetics time was ‘significantly reduced’ from around 40 seconds to 34 seconds. This reduction of 6 seconds is ‘important’, the team states, because it ‘exceeds the minimum physiologically relevant change of around 5 seconds.

The scientists add:

“The reduction in τVO2 observed after cocoa flavanol supplementation in our middle-aged individuals reflects a shift towards values typically observed in younger healthy individuals.”

And the report states:

“Ultimately, the findings of the present study may have clinical potential in contributing to improved tolerance of daily life activity in middle-aged adults.”

Flavonoids aren’t just found in cocoa - they’re also abundant in green tea, fruit and vegetables - and have anti-inflammatory as well as antioxidant properties.

Liverpool John Moores’ Daniel Sadler says you shouldn’t rely on eating dark chocolate to get an effective dose of flavanols.

He explains:

“It is preferable to take supplements over eating dark chocolate since potential beneficial effects of cocoa-flavanols occur during exercise when high doses are consumed – greater than 400 mg flavanols – and because dark chocolate contains fat and sugar that may negate the beneficial potential of any bioactive constituents.”

In April this year a separate study by researchers at the University of Birmingham found blood vessels were able to function better during mental stress when test subjects were given a cocoa drink containing high levels of flavanols compared to when drinking a non-flavanol enriched drink.  The study, published in the journal Nutrients, could help to combat stress-induced ischemia while also paving the way for offering ‘improved guidance to people about how to make the most of their dietary choices during stressful periods.”[2]


  1. Sadler, D.G., Draijer, R., Stewart, C.E. et al. Cocoa-flavanols enhance moderate-intensity pulmonary V˙O2 kinetics but not exercise tolerance in sedentary middle-aged adults. Eur J Appl Physiol 121, 2285–2294 (2021).
  2. Baynham, R.; Veldhuijzen van Zanten, J.J.C.S.; Johns, P.W.; Pham, Q.S.; Rendeiro, C. Cocoa Flavanols Improve Vascular Responses to Acute Mental Stress in Young Healthy Adults. Nutrients 2021, 13, 1103.

Source and Contact Information

Liverpool Hope University,



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