Too hot to handle: how to avoid heat-related illness

 Hot weather can be extremely pleasant and relaxing, but it also comes with its dangers. Sometimes, the human body is unable to handle exposure to extreme heat and maintain the stable core temperature essential for normal bodily functioning.

The hotter it is, the more that needs to be done for the body to regulate its core internal temperature.

According to the Centers for Disease Control and Prevention (CDC), there was a total of 7,415 deaths in the US between 1999-2010 as a result of extreme heat. Despite being highly preventable, heat-related illness can be lethal.

In Europe in 2003, unprecedented heatwaves were responsible for an increase in deaths. In England, temperatures reached record highs (101 degrees) over a period of 9 days.

"There is considerable evidence that heatwaves are dangerous and can kill," states Graham Bickler of Public Health England. "In the 2003 heatwave, there were 2,000 to 3,000 excess deaths in England. Across Europe, there were around 30,000 excess deaths."

Extreme heat is defined by the CDC as "summertime temperatures that are substantially hotter and/or more humid than average for location at that time of year." Although certain groups of people are more susceptible to these temperatures than others, anyone can be affected in the wrong situation.

In this Spotlight, we take a look at the effects extreme heat have on the body and the measures that can be taken to prevent dangerous conditions such as heat stroke from occurring.

Regulating core internal temperature

Problems begin to occur in extreme heat when the body struggles to cool itself down properly. The human body has a very precise core internal temperature that needs to be maintained - a state that is known as homeostasis. A healthy core temperature should sit between 98 degrees and 100 degrees.

A part of the brain known as the hypothalamus is responsible for controlling the way in which the body regulates its temperature. If the body's core internal temperature starts to get too low or too high, then it can send signals to glands, muscles, nerves and organs activating mechanisms to adjust the body temperature.

The mechanism the body normally uses to cool itself is sweating. Liquid containing salt is released from the sweat glands, and when this sweat evaporates from the body, the body cools down. However, on some occasions, sweating is not enough.

For example, if humidity is high - when large amounts of damp air are trapped near the ground - sweat will not evaporate as quickly as it normally would, meaning that the body's ability to cool itself down is compromised.

A number of other factors limit how well the body can regulate temperature and, therefore, increase the risk of heat-related illness. These include the following:

• Old age
• Youth (age 0-4)
• Overweight and obesity
• Heart disease
• Mental illness affecting judgment
• Medical conditions that limit activity or restrain blood flow
• Sunburn
• Use of certain medications
• Use of alcohol.

In terms of medication, there are a number of different reasons why these can increase the risk of heat-related illnesses. Some, such as those taken for Parkinson's disease, can inhibit sweating while others, such as diuretic medications or "water pills," alter the balance of fluids in the body.

When the body is struggling or unable to regulate temperature properly, a number of different illnesses can occur. These vary in severity from heat rash - a common problem in hot work environments - to heat stroke, a medical emergency that can kill.

What types of heat-related illnesses are there?

Heat-related illnesses come in all shapes, sizes and levels of severity. Some present solely external symptoms, some only internal symptoms and some a combination of the two. Some can be debilitating, some can be lethal and some require nothing more than keeping an affected area of skin dry.

Heat rash

Probably the least problematic of the heat-related illnesses, heat rash is caused when the skin becomes irritated due to excessive sweating and sweat that does not evaporate. The rash is formed by clusters of red bumps or small blisters on the skin, commonly in areas such as the groin, the upper chest and in folds of the skin.

Moving to a cooler location such as the shade of a tree can help cool the body down and reduce the risk of heat-related illness.

Young children are most likely to be affected by the condition. Heat rash is best treated by keeping the affected area as dry as possible and moving to a cooler, less humid environment.

Heat cramps

Heat cramps are muscle spasms and pains that typically occur in the abdomen, arms and legs. Sweating decreases the level of salt and moisture in the body, and it is low salt levels that cause heat cramps.

These cramps normally occur in association with strenuous activity and exercise, affecting those who sweat a lot during these pursuits. Drinking water and other cool beverages helps, as does stopping strenuous activity for a few hours. If heat cramps persist for an hour, medical attention should be sought.

Heat cramps can also be a sign of more advanced heat-related illnesses - heat exhaustion and heat stroke.

Heat exhaustion

Heat exhaustion takes a little longer to develop than the forms of illness above, occurring after several days of exposure to extreme heat and imbalanced body fluid levels. The condition is due to the loss and inadequate replacement of water and salt from heavy sweating.

People with heat exhaustion can appear pale and sweat heavily, leaving their skin cool and moist. Their heartbeat will be fast but weak, and their breathing is likely to be quick and shallow. In addition to muscle cramps, people with heat exhaustion can experience headaches, nausea or vomiting, fainting and fatigue.

Heat exhaustion is most likely to affect older people, people with hypertension and people carrying out activities in hot environments. People with heat exhaustion should cool their bodies by drinking plenty of water or other cool beverages, taking a cool shower or bath and resting in a cooler environment.

Heat stroke

Heat stroke is the most dangerous of all the heat-related illnesses and occurs when the body is unable to regulate its core internal temperature. Within 10-15 minutes, the core internal temperature can rise to over 106 degrees, a dangerous increase that can lead to permanent disability or death if untreated.

The symptoms of heat stroke are far more extreme than those of heat exhaustion. The individual will no longer be able to sweat and, therefore, have red, hot and often dry skin. Their heartbeat will be rapid and strong. Other symptoms include dizziness, throbbing headaches, seizures and unconsciousness.

As heat stroke is a medical emergency, action should be taken as quickly as possible. While immediate medical assistance is summoned, the person's body must be cooled down rapidly by whatever means are available.

Removing clothing, applying ice packs, immersing the individual in cool water, spraying them with a hose, wrapping them in damp sheets, fanning them: all are methods that can help lower body temperature to safer levels.

In all instances of heat-related illness, including heat stroke, moving to a cooler location is one measure that should be taken to improving the situation. This is just one common step that everyone can take to reduce the risk of developing these illnesses.

How to keep your cool

When the body is struggling to cool itself down, cooling down the location that the body is in is a great way to prevent heat-related illness. In fact, the CDC state that "air conditioning is the number one protective factor against heat-related illness and death."

If a person's home is not air conditioned, they can derive benefit from visiting public spaces that are, such as shopping malls or libraries. Exposure to air conditioning for just a few hours a day is enough to reduce the risk of heat-related illness.

The body requires more liquid in extreme heat. Do not wait until feeling thirsty before drinking.

To improve the body's chances of cooling itself down, it is important that people drink enough fluids. In extreme heat, people should drink more water than they normally would and should not wait until feeling thirsty before drinking.

If exercising, the CDC recommend drinking two to four glasses (16-32 ounces) of cool nonalcoholic fluid every hour. Drinking sports beverages can also help by replacing the salt and minerals that are also lost through sweating.

Outdoor exercise is best carried out in the morning and evening rather than the afternoon, as these are the times of day when outdoor temperatures are coolest. Resting in shaded areas will give the body more of a chance to regulate its temperature. It is also important that people take care to pace themselves when exercising or carrying out strenuous activities in hot environments.

Wearing appropriate clothing helps. Loose, lightweight and light-colored clothing is best, as is wearing as little as you can get away with. Accessories that shade the body such as hats and umbrellas are useful. Of course, any skin that is exposed to the sun will need to be adequately protected from its rays.

As sunburn disrupts the skin's ability to cool itself and results in the loss of body fluid, apply sunscreen of SPF 15 or higher around 30 minutes before venturing outside. Be sure to follow the directions on the sunscreen's packaging concerning how frequently it should be reapplied.

In terms of keeping cool, a lot of what can be done is common sense. Large, hot meals should be avoided as they heat the body, as does the use of appliances such as ovens. To cool down, take cold showers or baths or have a swim. Keep an eye on weather reports so you can be prepared for a day of extreme heat if one is forecast.

Look out for each other!

Some of the people who are most at risk from heat-related illnesses are vulnerable individuals who depend on others for care. Be sure to look out for young children, people older than 65, people with chronic and mental disorders and pets during times of extreme heat.

Do not leave children or animals alone in cars, where interior temperatures can rise suddenly in a very short space of time, even when the windows are open slightly.

If working or exercising in hot environments, be sure to monitor the condition of your colleagues and teammates and have them do the same for you. Some heat-induced illnesses can lead to confusion and visible symptoms that others may be better placed to identify.

Most heat-related illnesses are avoidable. By keeping cool, drinking plenty of fluids and being alert, these health conditions should not stop you and others from enjoying a lovely warm summer.

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Chocolate: is it really good for our health?

With the average American consuming around 4.5 kg of chocolate each year, it is safe to say it is one of the nation's most loved treats. It is not hard to fathom why; it tastes delicious and stimulates the release of endorphins - the "feel-good" hormones. And according to numerous studies in recent years, chocolate is amazingly good for our health... or is it?

The average American eats around 4.5 kg of chocolate annually.

In this Spotlight, we ask, can chocolate really be good for our health? Or are the potential health benefits of this much-loved treat overstated?

The 'food of the gods'

When we think of chocolate, many of us visualize a big, chunky bar of sweet deliciousness. But originally, chocolate was only consumed as a bitter beverage.

Chocolate - which is made using beans from the cacao tree, native to Central and South America - is estimated to date back as far as 1900 BC, when it was created by pre-Olmec cultures residing in present-day Mexico. The ancient Mesoamericans roasted the cacao beans, or cocoa beans, before grinding them into a paste that was mixed with hot water, vanilla, chili and other spices to make a frothy drink.

The Olmec, Aztec and Mayan civilizations found chocolate to be a mood-lifting drink and an aphrodisiac, so much so that they believed the beverage had spiritual qualities. The Mayans even worshipped a cacao God, and the beverage was used for religious and sacred ceremonies, hence why chocolate is often referred to as the "food of the gods."

It wasn't until 1847 that chocolate became the solid edible bar we know and love today. A British chocolate company called J.S Fry & Sons created it using cocoa butter - vegetable fat extracted from the cocoa bean - cocoa powder and sugar.

In the late 1800s and early 1900s, well-known chocolate manufacturers such as Hershey, Cadbury and Mars were formed, and they have been bringing us an array of heavenly sweet treats ever since.

But while we are thankful to these companies for catering to our chocolate needs, they are also responsible for adding potentially unhealthy ingredients to what could be an otherwise healthy - albeit less tasty - food, giving chocolate its reputation as a diet demon.

What is in our chocolate?

Cocoa beans - from which chocolate is made - are believed to contain more than 300 compounds that are beneficial to health.

They are packed full of flavanoids and flavanols, such as anthocyanidin and epicatechins. These are antioxidants, which are known to destroy free radicals in the body - chemicals that can cause damage to DNA and other cell components, accelerating aging and contributing to heart disease, cancer and other diseases.

The main ingredient in chocolate - cocoa beans - contains more than 300 compounds that are beneficial to health.

The darker the chocolate, the more flavanoids and flavanols it contains, which explains why the majority of chocolate studies have hailed dark chocolate - rather than milk or white - for its health benefits.

Cocoa beans also contain dopamine, phenylethylamine and serotonin, all of which are compounds that are known to enhance mood and promote feelings of well-being.

So if the main ingredient in chocolate is full of healthy compounds, why shouldn't we eat it by the bucketload?

Put simply, the negative health effects of chocolate primarily come from the additional ingredients that are added to it during the commercial manufacturing process. Sugar, full-fat cream and milk are just some of these ingredients, and the quantities in which they are added are not slight.

A standard 43 g bar of Hershey's milk chocolate contains 13 g of fat, 24 g of sugar and 210 calories. Eating this product in high quantities could lead to weight gain, and being overweight can increase the risk of numerous health problems, including hypertension, diabetes and heart disease.

Because of its high sugar content, chocolate may also raise the risk of dental problems - including gum disease and cavities - if consumed in high amounts.

Referring back to the Heart study, however, researchers claim that participants who consumed up to 100 g of chocolate a day were at lower risk of stroke and heart disease. This is an amount the equivalent to more than two Hershey's milk chocolate bars each day, which would take a person well above the recommended daily sugar intake of 25 g for woman and 37.5 g for men.

Can eating this amount of chocolate daily really be good for our health? Or has this study and many like it been overstated?

Are we succumbing to the media's hype?

Looking at the results of the Heart study more closely, the average daily chocolate consumption of the almost 158,000 participants studied was 7 g, while only some of the participants consumed 100 g of chocolate each day.

However, the researchers claim that higher chocolate consumption - up to 100 g daily - was associated with a greater reduction in heart disease and stroke risk. But it should be noted that most of these participants were younger with a lower body mass index (BMI) and blood pressure, and they were less likely to have diabetes.

Many studies associating chocolate with health benefits are badly conducted, but many news outlets continue to report their findings.

"It is hard to know if the lower risk comes from chocolate or those other factors," says Science Media Centre - a media watchdog based in the UK. "The authors have tried to account for these as far as possible, but the nature of the study means that it is not possible to do that perfectly. Therefore, it is possible that the protective effect might be because of something else - not chocolate."

Despite this, the Internet was engulfed with media outlets claiming, "Two bars of chocolate a day 'lowers risk of stroke and heart disease'" and "Two chocolate bars a day can SLASH the risk of heart attack and stroke."

Could such media coverage be luring the general public into potentially false beliefs that chocolate consumption can have major health benefits?

Earlier this month, news outlets around the globe reported on a study conducted by Johannes Bohannon, PhD, research director of the Institute of Diet and Health, which claimed people who ate one chocolate bar a day alongside a low-carbohydrate diet lost weight 10% faster than controls.

As MNT revealed, however, the purpose of this study was to see how easy it would be to get badly conducted research into the news. Though the study was real, it was actually conducted by a journalist called John Bohannon, and the Institute of Diet and Health does not exist.

The study, which was published in the International Archives of Medicine and covered by news outlets including the Huffington Post and The Daily Mail, was hugely flawed. It contained only 16 participants who were only assessed for a 3-week period, meaning the findings were insignificant - factors that many news reporters failed to acknowledge.

"It was terrible science," said Bohannon in an article he penned for website io9. "The results are meaningless, and the health claims that the media blasted out to millions of people around the world are utterly unfounded."

Bohannon noted, however, that the general public were very critical of the findings, asking questions that should have been addressed by the reporting journalists. This suggests that many of us are not completely taken in by attention-grabbing headlines hailing the health benefits of chocolate.

However, this is not to say chocolate consumption offers no health benefits. Some well-conducted studies have found it could be good for us.

The potential health benefits of chocolate

For years, numerous studies have associated moderate chocolate consumption with better heart health. As well as the most recent example published in Heart, in February 2014, MNT reported on a study linking daily consumption of dark chocolate to reduced risk of atherosclerosis - thickening and hardening of the arteries.

A study published in 2012, conducted by researchers from the University of California-San Diego School of Medicine, found dark chocolate may benefit patients with advanced heart failure and type 2 diabetes by enhancing the structure of mitochondria - the "powerhouses" of cells - while another study found that cocoa products may help to lower blood pressure.

The heart health benefits of chocolate have been put down to the antioxidants it contains, which, as mentioned previously, are found in cocoa beans. High levels of antioxidants can reduce the amount of low-density lipoprotein (LDL), or "bad," cholesterol that build up in artery walls, for example.

More and more studies are emerging in support of the heart health benefits of chocolate, particularly dark chocolate. However, increasingly, studies are suggesting there may be many more health benefits attached to the yummy treat.

In 2013, a study by researchers from Harvard Medical School in Boston, MA, claimed drinking two cups of hot chocolate each day may stave off memory decline in older age by preserving blood flow in working areas of the brain.

And another study, published in the Journal of Agricultural Food and Chemistry in 2014, suggested a flavanol in cocoa - called oligomeric procyandins - may protect against obesity and type 2 diabetes.

Our Knowledge Center article on the health benefits of chocolate looks at some of the other ways in which it could be good for us.

While numerous studies suggest there may be additional perks to indulging in a chocolatey treat, it should be noted that they are not conclusive, and research is ongoing to determine exactly what health benefits chocolate offers.

What is conclusive, however, is that eating excessive amounts of chocolate - as tempting as it might be - can lead to weight gain, increasing our risk of overweight and obesity and associated conditions, such as heart disease and diabetes.

But this doesn't mean we have to miss out. Like most foods high in sugar and fat, they can be consumed in moderation. As dietitian and spokesperson of the British Dietetic Association Alison Hornby says:

"As an occasional treat, chocolate can be part of a healthy diet. Eaten too frequently, it is an unhealthy choice."

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Running a marathon: how to survive the historic endurance race

As the weather improves, so does the likelihood of people going out and running. While many people go running as a simple way of keeping fit, for others, it is a necessary part of a long-term project; training for a marathon.

Millions of people around the world run marathons every year, often raising large sums of money for charity.

Those who have signed up to take part in marathons this autumn are likely to have already begun training regimes. If they are going to be running in their first ever marathon, it is recommended that they should have done. Meanwhile, others whose local marathons are held in the spring may only now be thinking about participating in one.

Marathons are rightly considered to be one of the most demanding physical challenges that an individual can undertake. They require months of preparation and dedicated training for the running to be a success and not hazardous to the runner's health.

What could possibly motivate someone to take on such an arduous task? And where should one begin when it comes to preparing to take on running a marathon? For many, running a marathon for the first time is a completely different prospect to any form of exercise they will have encountered before.

In this Spotlight feature, we take a brief look at what running a marathon involves, along with what levels of preparation are recommended for someone taking on the challenge.

Why would anyone want to run a marathon?

Last week, Medical News Today reported on two new studies that found exercising at extreme levels such as marathon running could lead to blood poisoning. Studies such as this beg the question: why would anyone want to run a marathon?

One reason is that people might wish to take part in a long tradition of endurance running. A tradition that has its roots in ancient history, inspired by the legend of an ancient Greek who ran from the battlefield of Marathon to Athens to spread news of a Greek military victory.

Athens was host to the first organized marathon, held at the 1896 Olympics. The original distance of the marathon was 40 km, representing the distance from Marathon to Athens, but this was extended at the 1908 Olympics in London to accommodate a request from the British royal family.

This increase in distance - allegedly done so that the course started at Windsor Castle and ended in front of the royal box at the Olympic Stadium - then became the official length for a marathon; a distance of 42.195 kilometers (26.2 miles) that runners worldwide are now familiar with.

Although once a very exclusive event only open to male athletes, marathon races are now open to all and take place all over the world. In America alone, there are more than 1,100 marathons each year, including the Boston Marathon - the world's oldest annual marathon.

As well as a desire to tackle a historical and immense challenge, marathon runners are often spurred on by charitable motives. At many marathons, elite runners will share the streets with eager amateurs running to raise money for good causes.

Marathon runners generate huge amounts of money for charity, including significant funds for various medical research groups. Last year, the Boston Marathon and the New York Marathon raised $27.5 million and $30 million respectively in funds for charities, yet these figures pale in comparison with the estimated $79.1 million raised by the London Marathon.

With figures like these, it is clear to see that marathon runners participating in these races and doing so successfully can make a big difference for charities. There is a lot of pressure to succeed, and so prospective runners do well to spend a lot of time planning out their training regimen.

The importance of well-planned physical training

Running a marathon is without doubt an extreme form of exercise. For this reason, it is recommended that people aiming to participate in one should build up a considerable amount of running experience prior to tackling one for the first time, including running shorter distance races.

It is also recommended that you inform your doctor that you plan to train for and run a marathon. If there are any personal health concerns you need to be aware of, they should be able to let you know and provide advice. You should seek medical clearance before beginning training in case you have a health condition that might make training dangerous.

"While I think that any healthy individual who is willing to commit to the training can complete a marathon, I don't recommend that runners jump right into the marathon distance," states Christine Luff, a running and jogging expert for About Health.

Training for a marathon is a long process that should build up endurance gradually and consistently.

Instead, Luff recommends that beginners first establish a regular running habit, going out around 3-4 times a week, building up a base mileage for runs gradually over the course of 6 months. Once this has been done, runners can get some experience of endurance running by entering shorter distance races, such as a 5K, a 10K or even a half marathon.

Training for a marathon is not just about practicing running for long periods of time. Runners also need to prepare their body for the immense strain that extreme exercise will put it under. Cross-training activities such as cycling and swimming not only improve your aerobic conditioning but also boost the body's resistance to injury.

Activities that increase the body's strength, such as Pilates, Yoga or using weights, can also be beneficial.

A good training schedule for around 20 weeks will include runs over a variety of distances that increase gradually, cross-training and rest days. Rest days can either involve no training at all or "active recovery," a short run at an easy pace to allow the muscles to loosen up.

Shorter training runs should be run at a moderate pace while longer runs - slowly building up toward marathon distance but never reaching it - should be taken slowly, at an easy, conversational pace.

In the final weeks before the marathon, it is important that training is tapered, cutting back on the amount of training that is done in order to allow the body and mind to recover. After 18 weeks of training, fitness is not going to improve any further, so the focus should be on keeping the body as healthy as possible.

Three weeks before the marathon, runners should run their last long run, treating it as a dress rehearsal of sorts. The subsequent weeks should see training reduced gradually, with less attention paid to cross-training and more on easy runs and resting.

Be prepared: eat and dress appropriately

Of course, there are other measures that need to be taken when preparing oneself for a marathon. Improving fitness is crucial, but runners can give themselves a huge advantage by eating properly and wearing the right clothes.

Every runner should have proper footwear. A runner's feet are crucial to their training and their ability to complete the marathon, and so aiding and protecting them with a good pair of running shoes can make a massive difference to a runner's prospects.

With running shoes, there are a lot of factors that need to be taken into consideration when deciding what pair to go for, so discussing the available options with staff in a running store is a good place to start. Runners will need to take into account the running surfaces they will training on when making a purchase.

Appropriate clothing is also important, and women should be sure to find the right sports bra to ensure comfort while running. As a marathon training schedule is likely to take in a variety of seasonal climates, clothing that fits well, allows for good air ventilation and dries quickly is ideal. Again, the staff in a running store will be well-placed to make suggestions.

Eating healthily during the training period is beneficial, but food choices on the day of the marathon - both before and during - can have a big impact too. Dr. Ed Laskowski, co-director of the Mayo Clinic Sports Medicine Center, states that hydration and energy-boosting carbohydrates help toward running a healthy race with a low risk of injury.

In the weeks close to the marathon, a runner's diet should involve eating plenty of complex carbohydrates, such as wholegrain bread and pasta, and drinking lots of fluids. Around 65-70% of total calorie consumption should ideally come from carbohydrates. Alcohol is best avoided as it can dehydrate and disrupt sleep.

To increase fluid absorption during exercise, runners should start drinking fluids at least 4 hours prior to beginning. On the day of the race, Dr. Laskowski states that water, milk, fruit juice and sports drinks can be consumed up to 1 hour before the start.

Sports drinks are a good source of energy while running as their sodium content can replace electrolytes lost through sweat. Other options for mid-race sustenance include energy bars and gels.

When the going gets tough

Everyone who runs a marathon will have different reasons for doing it and different expectations for what they want to achieve. It is important to focus on what you personally want to get out of running a marathon, especially if it is your first time running one.

Of course, some people like to take the challenge further, particularly in the name of charity. At many marathons, spectators are likely to spot participants dressed up in costume eliciting huge cheers from onlookers.

Wearing appropriate, comfortable clothing can be crucial to marathon running success.

These costumes are rarely made for the purpose of endurance running and so present extra challenges for the runner to overcome. They can be hot and heavy, they can chafe and they can restrict vision and breathing. As such, additional preparation is needed for people taking on this extra challenge.

"Training for a marathon is always tough. I'm not the most disciplined runner in history, but adding a 10 kg hippo suit to the mix has certainly given me food for thought," Martin Neal toldThe Guardian, ahead of running last year's London Marathon.

In order to prepare himself for the rigors of running in the suit, he decided to travel to Disney World Florida for a long-distance running event at higher temperatures than he was used to. He also went for several runs while wearing the suit to get his body accustomed the challenge. "It was really hard going, incredibly hot and I used muscles I didn't know I had," he stated.

Meticulous preparation is key to running a successful and enjoyable marathon. Runners should work to prepare both their bodies and minds for all eventualities. Seeking advice from experts - trainers, doctors, people who have ran marathons before - is a great way to do this.

It is important that prospective marathon runners should be well aware of the health risks of the task ahead before beginning and also listen to their body when the going gets tough.

"Pain associated with joint swelling or that causes the joint to feel unstable should be checked," advises Dr. Laskowski. "You should also seek an evaluation for pain that persists or intensifies after rest from running or pain that causes you to compensate, change your running, or change your gait."

Running a marathon when not 100% healthy can be dangerous. Runners should not put their long-term health at risk by forcing their bodies to do things they are not adequately prepared for or able to do.

Marathon running has grown hugely in popularity over the last few decades. Around 25,000 runners were estimated to have finished marathons in the US in 1976, and by 2013 this number is believed to have risen to 541,000. With appropriate preparation, anyone can add to these numbers and if you intend to, good luck!

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Can Apple's ResearchKit change the face of medical research?

Every day, Medical News Today reports on a large number of studies. Many of these involve the recruitment of participants so researchers can obtain new and relevant data. The best of these studies will involve the participation of thousands of people, but getting hold of large numbers of willing volunteers can be difficult.

With access to a smartphone, anyone anywhere in the world can now potentially participate in a medical study.

"We have sent out over 60,000 letters," says Kathryn Schmitz, PhD, of Penn Medicine, explaining the recruitment process for a recent study. "Those 60,000 letters have netted 305 women."

Some researchers will acquire a large number of subjects for their studies by using data obtained by previous investigations. This method is much quicker than signing up thousands of volunteers, but it does not give the researcher the control and flexibility that comes with recruiting new volunteers.

In developed countries, smartphones are ubiquitous. Walk down a street in any city and you will likely encounter at least one person with one of these gadgets glued to their hand or head. More than just a way of communicating with other people, for many, smartphones have become an integral part of navigating life due to the wide variety of apps available to users.

iPhones, for example, do not just contain the necessary bits and bobs needed for people to initiate conversations or access the Internet. They contain a myriad of sensors and processors that can track and measure a host of different things. The combination of widespread usage and the capacity to collect data makes smartphones an ideal tool for researchers to utilize.

Here, then, could be a solution to one of the most pressing problems experienced by medical researchers. In this Spotlight, we take a brief look at ResearchKit, the latest initiative launched by Apple, attempting to harness the power of the smartphone to transform how scientists carry out research studies.

Getting started

Smartphone apps are being increasingly used for personal health purposes, both in tracking health and fitness and for detecting illness.

But while these apps can provide users with a perspective on their health, many experts have been critical about the worth of these perspectives, questioning whether they are actually beneficial to users' health.

Last year, Apple launched their Health app and a tool for developers called HealthKit, allowing them to develop software able to pool together health data collected by other apps. The aim of this was to create a range of more empowered health tracking programs, supposedly giving users greater insight into their health than before.

In March, Apple took this work a step further with the launch of ResearchKit, an open source framework that allows developers to create apps specifically for conducting medical research studies. In addition to using data obtained by the Health app, ResearchKit also allows researchers to obtain informed consent from participants remotely.

The Asthma Health app helps people with asthma treat their condition while helping researchers investigate new ways to personalize treatment.
Image credit: Icahn School of Medicine at Mount Sinai

Dr. Eric Schadt, from Icahn School of Medicine at Mount Sinai, NY, explained to MNT that electronic consenting would eliminate many of the limitations that the traditional consenting process brought to medical research.

"Traditional research has been constrained to informing potential participants about a study, the risks, the benefits and so on, by sitting directly with the participant (or on the phone) to step them through the paperwork and other material to complete the informed consent," he said.

For each participant enrolled into a study, it takes around 30 minutes for a researcher to go through the consenting process. The fact that the process is so time-consuming limits the number of people that can be signed up for a research project due to the amount of time available to researchers.

"With electronic consenting these limitations are all addressed," said Dr. Schadt. "Potential study participants can be stepped through the informed consent using their iPhone, advanced multimedia can be used to more efficiently inform the participant as to the details of the studies as well as the risks and potential benefits."

In order to prevent users from just skipping through the informing stages of the consent process, the apps feature questions to ensure that users can only consent to take part if they fully understand what they are signing up for.

Apple and the researchers behind the first five apps developed using ResearchKit that were launched in March have been very vocal about how the consenting process is a marked improvement on how studies have traditionally been set up.

Dr. Schadt has been involved with one of these first five apps, Asthma Health - an app that combines geolocating data from the phone with air quality information to help users avoid areas where asthma symptoms could be triggered, in turn, collecting data that the developers hope will allow them to discover new ways to personalize treatment of the condition.

On the first day the app was launched, Asthma Health was downloaded by 2,500 people. It would typically take researchers around 1-2 years to recruit this many subjects for a study. In the first month, 7,500 people with asthma had signed up.

This number pales in comparison, however, with the 11,000 people who downloaded the MyHeart Counts app within 24 hours of it becoming available. An element of this may well be the novelty value of being able to sign up to research studies with newfound ease, but initial signs are certainly promising.

Lots and lots of data

The other aspect of ResearchKit that Apple and the app developers are keen to promote is how much data will be obtained by studies built using the framework.

"For the researcher, especially disease research, it is all about the phenotypes," explained Dr. Schadt. "Today, cohorts assembled for disease collect very minimal numbers of phenotypes generally relating directly to the disease, and those phenotypes are collected infrequently - at most, once a year."

Studies conducted via iPhone app will differ in this respect. "With the health apps being built we can collect phenotypes that relate across the disease and wellness spectra and we can do it at high frequency, every day, or 10 or 100 times a day," said Dr. Schadt.

There are a number of inbuilt devices in iPhones that can prove useful to researchers. Data obtained by the microphone, gyroscope, accelerometer, touch screen and the global positioning system of the smartphone can all provide data relevant to research projects.

"All of these variables can be collected numerous times a day over any number of days or years, thus providing a far more detailed profile of the user than could ever be reasonably generated in a medical setting," stated Dr. Schadt.

Not only is the variety of forms of available data beneficial but the frequency by which it is collected is great for researchers too. Many studies are limited by only taking measurements at the baseline - the starting point of the study - and then one or two further times after that.

Infrequent measuring can make results unreliable. Let's say a study wants to examine the effects of a particular diet on body mass index (BMI), and then measures the participants' BMI at the beginning of the study, 6 months later and then after 1 year.

The results of such a study might then show minimal change in BMI after this period. But, if the two periods where BMI was measured came shortly after holidays where the participants drank a lot of alcoholic beverages and did not exercise, the results would inevitably be skewed. This skewing would be exacerbated if the study used a small number of participants.

Such a problem - the ebbing and flowing of symptoms as Apple describes it - is solved by gathering data far more regularly than many studies are able to.

In addition to this, the pool of potential volunteers is much larger with ResearchKit than it is for most studies, typically confined to a small geographic area. The ubiquity of the iPhone means that volunteers can sign up to take part no matter where they live in the world.

This also allows researchers to have access to more varied study populations, although they will be relying on participants that have access to smartphones, still a restricted demographic.

An open source framework for all

What is possibly the most interesting aspect of ResearchKit, however, is that Apple have made the whole thing open source. The core framework can be used by anyone who wishes to use the software to make their own study, and the codes for the five initial apps launched alongside the framework are also available for examination and customization.

While initial access to ResearchKit is confined to iPhones, thanks to the open sourcing of the framework, it will eventually be available to users of every kind of smartphone.

For a company that is renowned for keeping as many aspects of its products as exclusive to the brand as possible, this was a surprising move, but one that could prove incredibly beneficial.

ResearchKit was made available to developers to use from April. Although the initial apps were only available for iPhone users, the fact that the software is open source means that eventually studies will be accessible to users of Android and Windows products.

Science Practice had a go at trying out the newly available framework and commented on how quick it was to construct simple consent forms and participant surveys. Already, too, a small online community has developed in which new ideas and suggestions are being shared on how to use and improve the framework.

A major concern raised with ResearchKit is how private and secure the obtained data will be. Considering how data from the Health app could be loaded up onto the iCloud and how that platform has been hit with several high-profile hacking incidents, the concern is a valid one.

Dr. Schadt informed Yahoo! Tech that "the only people who have access to the data are the investigators of the study," stating that the data is encrypted and meets all industry standards for the transfer of sensitive data. "Apple never touches the data," he reported.

Being an open source framework may also help with privacy, according to Adrian Gropper, chief technology officer of the nonprofit group Patient Privacy Rights.

"Open source encourages people to report bugs in the software and get them fixed," he told Bloomberg Business. "The gold standard is open source because security by obscurity has been shown not to work."

Work in progress

"We believe that these studies represent an entirely new way to perform human health research, putting the participant truly at the center with frequent feedback and control of how their data are used," Dr. Andrew Trister.

"Furthermore, the power of these pervasive devices on quantifying health on an individual is tremendous, opening up real opportunities for truly personalized medicine."

Dr. Trister is a senior physician with Sage Bionetworks, a nonprofit research organization that has worked with Apple to develop ResearchKit.

There are still a number of limitations that the studies conducted by these apps will be subject to. Data provided by the instruments in a smartphone may not be as precise as those obtained using specifically-designed medical instruments. With the study being conducted remotely, it is also harder for investigators to assess the suitability of participants for their study.

Developers might argue that the sheer volume of participants now available to researchers may overshadow these limitations. At this stage, before the results of any of the studies have been processed, it feels as though the positive of having increased and easy access to large numbers of participants is the main point to take from the project.

The most reliable studies are those that are conducted over a long period of time and, as a result, it may be some time before we can effectively gauge the contribution that ResearchKit will make to the field of medical research.

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