Safety of low-carbohydrate diets

Low-carbohydrate diets have re-emerged into the public spotlight and are enjoying a high degree of popularity as people search for a solution to the population's ever-expanding waistline. The current evidence though indicates that low-carbohydrate diets present no significant advantage over more traditional energy-restricted diets on long-term weight loss and maintenance. Furthermore, a higher rate of adverse side-effects can be attributed to low-carbohydrate dieting approaches. Short-term efficacy of low-carbohydrate diets has been demonstrated for some lipid parameters of cardiovascular risk and measures of glucose control and insulin sensitivity, but no studies have ascertained if these effects represent a change in primary outcome measures. Low-carbohydrate diets are likely effective and not harmful in the short term and may have therapeutic benefits for weight-related chronic diseases although weight loss on such a program should be undertaken under medical supervision. While new commercial incarnations of the low-carbohydrate diet are now addressing overall dietary adequacy by encouraging plenty of high-fibre vegetables, fruit, low-glycaemic-index carbohydrates and healthier fat sources, this is not the message that reaches the entire public nor is it the type of diet adopted by many people outside of the world of a well-designed clinical trial. Health effects of long-term ad hoc restriction of inherently beneficial food groups without a concomitant reduction in body weight remains unanswered.

Linking future ecosystem services and future human well-being

Ecosystem services are necessary, yet not sufficient for human well-being (however defined). Insufficient access to the ecosystem provisioning service of food is a particularly important factor in the loss of human well-being, but all ecosystem services contribute in some way to well-being. Although perhaps long obvious to ecologists, the links between ecosystems and aspects of human well-being, including health, have been less well understood among the social science community. This situation may now be starting to change, thanks in part to the Millennium Ecosystem Assessment (MA). Causality between ecosystem services and well-being is bidirectional; it is increasingly clear that functioning societies can protect or enhance ecosystem services, and accordingly, that societies with impaired well-being (best documented in the case of chronic diseases such as malaria and HIV/AIDS) can also experience a related decline in ecosystem services.

The future state of human well-being and of ecosystem services is more than the co-evolution of these two fundamental elements. Human well-being also depends, critically, upon the human institutions that govern relationships between human individuals and groups, and also between humans and ecosystem services.

The scenarios working group of the MA found that human well-being is highest in the Global Orchestration scenario, which assumes the fastest evolution of beneficial institutions, and is lowest in the Order from Strength scenario. Human well-being was found to be intermediate in the other two scenarios (Adapting Mosaic and Techno-Garden) even though these scenarios share a much greater recognition of the importance of ecosystem services to human well-being.

Globalisation, food and health in Pacific Island countries

Pacific Island countries (PICs) are experiencing an epidemic of obesity and consequent chronic diseases. Despite investment in the development of National Plans of Action for Nutrition (NPANs) and interventions to promote healthy eating and physical activity, nutritional status appears to show little improvement. This paper presents a synthesis of the findings from two research papers that were prepared for a 2003 food safety and quality meeting in Nadi, Fiji. The findings indicate that although lifestyle behaviours might be the immediate cause of dietary imbalances, greater attention should focus on omnipresent influences of globalisation as a critical element of the nutrition transition in the Pacific. In particular, those aspects of globalisation mediated through the World Trade Organization (WTO) Agreements that are placing pressures on food security and fostering increased dependence on imported food of poor nutritional quality. Rapid, significant and sustainable improvements in public health in PICs require interventions that can tackle these underlying contributors to ill health. There are opportunities to explore the use of food regulatory approaches to influence the composition, availability and accessibility of food products. Within the context of the WTO Agreements the legitimacy of food regulatory approaches will depend upon the case to demonstrate the relationship between the intervention and the protection of food security and public health nutrition. The challenges in realising these opportunities are: 1) to have the capacity to construct a case, 2) meet the technical and financial demands to administer and enforce regulatory approaches, and 3) to take advantage of opportunities available and to be able to fully participate in the international policy-making process.

Emerging health issues: the widening challenge for population health promotion

The spectrum of tasks for health promotion has widened since the Ottawa Charter was signed. In 1986, infectious diseases still seemed in retreat, the potential extent of HIV/AIDS was unrecognized, the Green Revolution was at its height and global poverty appeared less intractable. Global climate change had not yet emerged as a major threat to development and health. Most economists forecast continuous improvement, and chronic diseases were broadly anticipated as the next major health issue. Today, although many broadly averaged measures of population health have improved, many of the determinants of global health have faltered. Many infectious diseases have emerged; others have unexpectedly reappeared. Reasons include urban crowding, environmental changes, altered sexual relations, intensified food production and increased mobility and trade. Foremost, however, is the persistence of poverty and the exacerbation of regional and global inequality. Life expectancy has unexpectedly declined in several countries. Rather than being a faint echo from an earlier time of hardship, these declines could signify the future. Relatedly, the demographic and epidemiological   transitions have faltered. In some regions, declining fertility has overshot that needed for optimal age structure, whereas elsewhere mortality increases have reduced population growth rates, despite continuing high fertility. Few, if any, Millennium Development Goals (MDG), including those for health and sustainability, seem achievable. Policy-makers generally misunderstand the link between environmental sustainability (MDG #7) and health. Many health workers also fail to realize that social cohesion and sustainability—maintenance of the Earth’s ecological and geophysical systems—is a necessary basis for health. In sum, these issues present an enormous challenge to health. Health promotion must address population health influences that transcend national boundaries and generations and engage with the development, human rights and environmental movements. The big task is to promote sustainable environmental and social conditions that bring enduring and equitable health gains.

How much physical activity is enough to prevent unhealthy weight gain? Outcome of the IASO 1st Stock Conference and consensus statement

A consensus meeting was held in Bangkok, 21–23 May 2002, where experts and young scientists in the field of physical activity, energy expenditure and bodyweight regulation discussed the different aspects of physical activity in relation to the emerging problem of obesity worldwide. The following consensus statement was accepted unanimously.
‘The current physical activity guideline for adults of 30 minutes of moderate
intensity activity daily, preferably all days of the week, is of importance for
limiting health risks for a number of chronic diseases including coronary heart disease and diabetes. However for preventing weight gain or regain this guideline is likely to be insufficient for many individuals in the current environment. There is compelling evidence that prevention of weight regain in formerly obese individuals requires 60–90 minutes of moderate intensity activity or lesser amounts of vigorous intensity activity. Although definitive data are lacking, it seems likely that moderate intensity activity of approximately 45 to 60 minutes per day, or 1.7 PAL (Physical Activity Level) is required to prevent the transition to overweight or obesity. For children, even more activity time is recommended. A good approach for many individuals to obtain the recommended level of physical activity is to reduce sedentary behaviour by incorporating more incidental and leisure-time activity into the daily routine. Political action is imperative
to effect physical and social environmental changes to enable and encourage physical activity. Settings in which these environmental changes can be implemented include the urban and transportation infrastructure, schools, and workplaces.’

Early childhood caries: current evidence for aetiology and prevention

Background: Despite the fact that it is largely preventable, dental caries (decay) remains one of the most common chronic diseases of early childhood. Dental decay in young children frequently leads to pain and infection necessitating hospitalization for dental extractions under general anaesthesia. Dental problems in early childhood have been shown to be predictive of not only future dental problems but also on growth and cognitive development by interfering with comfort nutrition, concentration and school participation. Objective: To review the current evidence base in relation to the aetiology and prevention of dental caries in preschool-aged children. Methods: A search of MEDLINE, CINALH and Cochrane electronic databases was conducted using a search strategy which restricted the search to randomized controlled trials, meta-analyses, clinical trials, systematic reviews and other quasi-experimental designs. The retrieved studies were then limited to articles including children aged 5 years and under and published in English. The evidence of effectiveness was then summarized by the authors. Conclusions: The review highlighted the complex aetiology of early childhood caries (ECC). Contemporary evidence suggests that potentially effective interventions should occur in the first 2 years of a child's life. Dental attendance before the age of 2 years is uncommon; however, contact with other health professionals is high. Primary care providers who have contact with children well before the age of the first dental visit may be well placed to offer anticipatory advice to reduce the incidence of ECC.

Antitumor activity and underlying mechamisms of ganopoly, the refined polysaccharides extracted from ganodrema lucidum, in mice

Ganopoly is an aqueous polysaccharide fraction extracted from G. lucidum by patented biochemical technique and has been marketed as an over-the-counter product for chronic diseases including cancer and hepatopathy in many Asian countries. This study was undertaken to explore the anti-tumour effect and the underlying mechanisms of Ganopoly in mice and human tumor cell lines. The maximum tolerateddose (MTD) of Ganopoly in mice was estimated to be 100 mg/kg from a pilot study. Treatment of mice with oral Ganopoly for 10 days significantly reduced the tumour weight of sarcoma-180 in a dose-dependent manner, with inhibition rates of 32.3, 48.2 and 84.9% and growth delays of 1.5, 3.5, and 13.1 days at 20, 50, and 100 mg/kg, respectively. Incubation of Ganopoly at 0.05-1.0 mg/ml for 48 hours showed little or negligible cytotoxicity against human tumor CaSki, SiHa, Hep3B, HepG2, HCT116, HT29, and MCF7 cells in vitro. In contrast, 10 mg/ml of Ganopoly caused significant cytotoxicity in all tumour cells tested except MCF7, with marked apoptotic effects observed in CaSki, HepG2, and HCT116 cells, as indicated by nuclear staining and DNA fragmentation. In addition, Ganopoly enhanced concanavalin A-stimulated proliferation of murine splenocytes by 35.3% at 10 mg/ml, and stimulated the production of nitric oxide in thioglycollate-primed murine peritoneal macrophages in a concentration-dependent manner over 0.05-10 mg/ml. Addition of Ganopoly at 1 mg/ml to murine peritoneal macrophages also potentiated lipopolysaccharide-induced nitric oxide production by 64.2%. Treatment of healthy mice or mice bearing sarsoma-180 with oral Ganopoly over 20-100 mg/kg for 7 day significantly increased the expression of both TNF-α and IFN-γ (at both mRNA and protein levels) in splenocytes in a dose-dependent manner. Moreover, treatment of Ganopoly over 20-100 mg/kg significantly increased cytotoxic T lymphocyte cytotoxicity and NK activity in mice. The overall findings indicated that Ganopoly had antitumor activity with a broad spectrum of immuno-modulating activities and may represent a novel promising immunotherapeutic agent in cancer treatment.

An evidence-based approach to podiatry workforce enhancement and service provision in Western Victoria

Aims & rationale/Objectives : The objectives of this workforce and service enhancement project include: (i) establishing the magnitude of podiatry needs; and (ii) developing a model that can be used to enhance podiatry workforce and podiatry services.
Methods : Surveys to podiatrists and health agencies to determine vacancies, waiting lists, work practices and recruitment methods. Desktop analysis of predictive data for burden of disease and population changes per local government area (LGA). Meetings with podiatrists and their professional association, health care agencies, universities, and Local and State Governments.
Principal findings : Results showed
Long podiatry waiting lists (up to 12 months)
Podiatry vacancies and service gaps
Absence of qualified foot assistants
A high chronic disease burden
A population age mix that is predicted to change dramatically over the next 25 years in favour of those who are 60 years of age or older
Ineffective recruitment methods
The workforce enhancement model that emanated from the meetings with the steering group includes podiatrists as well as auxiliaries such as foot-care assistants who work together in an interprofessional model of care that expands across the region. In addition to training foot-care assistants and the development of a podiatry teaching clinic to enhance student placement, the model builds onto a current continuous professional development program for allied health professionals.
Discussion : Although the allied health workforce (including podiatry) is playing an increasingly important role in the prevention and treatment of chronic diseases, rural areas in particular are disadvantaged by recruitment and retention problems. The podiatry workforce shortage is compounded by ageing populations. Age is associated with increased podiatry usage due to chronic diseases such as diabetes, cardiovascular disease and osteoarthritis.
Implications : A strategic plan developed in consultation with stakeholders aims to improve rural podiatry services in a sustainable manner. The project will be implemented when adequate funding is allocated this year and will be evaluated on its impact on services.
Presentation type : Paper

The empowerment process in people with diabetes : an Iranian perspective

Background: Empowerment and power are well-researched concepts concerning people with chronic diseases. However, few researchers have focused specifically on the process of empowerment in Iranian people with diabetes. Understanding the empowerment process could help health professionals facilitate empowerment.
Aim: To explore the empowerment process in Iranian people with diabetes.
Method: A grounded theory research design was used incorporating in-depth interviews to collect the data from men and women aged 21–73 years (n = 16). Data were collected between February and July 2007. Constant comparative analysis was undertaken to identify key categories.
Findings: Participants indicated being embarrassed by the diagnosis, thirsting to learn, living in the shadow of fear, accepting diabetes as reality, managing diabetes and feeling empowered were distinct but interconnected phases in the empowerment process. The empowerment process was influenced by cultural and religious beliefs including the concept of the doctor as holy man, accepting diabetes as God's will, caring for the body because it was God's gift, paying attention to symptomatic disease, and support from peers and family, especially daughters.
Conclusion: The empowerment process consists of several distinct but interconnected phases. The findings will help health professionals develop a deeper understanding of how Iranian people with diabetes become empowered.

Ein Blick Down Under. Selbstmanagementinitiativen und Patientenschulungen in Australien

The growing burden of chronic disease and the current nature of healthcare systems which are structurally ill-equipped to cater to the complex needs of patients with chronic conditions has led to governments and healthcare providers seeking alternative ways to improve patients own capacity to actively self-manage their chronic condition. In Australia, there has been a focus on patient education and self-management programs within the healthcare system to achieve this. These programs aim to empower patients through providing information and teaching skills and techniques to improve self-care and doctor-patient interaction with the ultimate goal of improving quality of life. Patient education and self-management programs have been supported through several national government initiatives and implemented within the healthcare setting. This paper describes the current position of patient education and self-management within the Australian healthcare system. It further describes a new collaboration project between an Australian and a German research team which aims at translating an assessment questionnaire used in Australia for the evaluation of self-management programs, the “Health Education Impact Questionnaire” (“heiQ”); this instrument is expected to be of significant use in the German rehabilitative system.

Giving young Emirati women a voice : participatory action research on physical activity

International evidence on health promotion indicates the importance of regular physical activity for preventing and reducing the incidence of obesity and chronic diseases. This study investigated the relationship between physical activity and the social milieu of young Muslim women in the United Arab Emirates. This participatory action research project included semi-structured in-depth interviews and focus groups and yielded qualitative data. Set within a context of rapid social change, perceived barriers to daily exercise influenced participants’ physical activity levels and overall well-being. Results indicated a lack of physical exercise and strategies were proposed for implementation by college staff and students.

Vitamin D: status, supplementation and immuno-modulation

Numerous studies have shown suboptimal vitamin D status in populations at high geographical latitudes, owing to a reduced capacity to synthesise vitamin D, especially during wintertime. Vitamin D supplementation has been shown to be effective at maintaining adequate vitamin D status throughout the year in these countries. Classically reported to play a central role in bone health, vitamin D has more recently been shown to modulate immune function by promoting an anti-inflammatory response, which may be related to onset or progression of autoimmune inflammatory disorders. One such condition is multiple sclerosis (MS). There is an increasing incidence of MS with increasing latitude, with higher prevalence reported in countries further away from the equator, where vitamin D synthesis is inadequate. Vitamin D has been shown to have positive effects on the animal model of MS, experimental autoimmune encephalomyelitis. However, there have been few human intervention studies to investigate the effect of vitamin D supplementation on symptoms of MS or indeed of other autoimmune disorders. Further research is required to examine the potential beneficial role of vitamin D in MS to ultimately determine the optimal vitamin D status required to alleviate symptoms and possibly prevent this and other chronic diseases.

Studies on dietary fibre : analysis, epidemiological and physiological aspects

This thesis involves an investigation in three areas; first, a study of an enzymatic-gravimetric method for the analysis of dietary fibre; second, a survey of dietary fibre intake in an area of a developing country, and finally, some observations on the functional aspects of gel-forming dietary fibre in the rat. A simple and rapid enzymatic-gravimetric assay for both soluble and insoluble dietary fibre has been critically investigated. Reference samples were also analysed by a more comprehensive, enzymatic gas chromatographic method to allow testing of the relative accuracy of the enzymatic-gravimetric method. The enzymatic-gravimetric method was found to be highly reproducible but gave a slightly higher value for total dietary fibre than the more comprehensive method. This discrepancy is probably due to the presence of small quantities of resistant starch and protein residue which are recovered in the enzymatic-gravimetric method. In the enzymatic-gas chromatographic method, protein residue is not measured, and resistant starch is estimated, but not counted as dietary fibre. The enzymatic-gravimetric method was applied to the analysis of foods commonly consumed in the Padang region of West Sumatra in Indonesia, in order to estimate dietary fibre intake in the region. Daily intakes of usual foods were estimated by use of a 24-hour recall procedure aided by food photographs to assist in the estimation of portion size. Samples of approximately 60 of the most commonly consumed foods were collected and analysed for dietary fibre. These appear to be the first data which report values for dietary fibre in Indonesion foods and they represent a significant improvement upon the existing data on crude fibre content. Knowledge of the amounts of foods usually consumed and their dietary fibre content allowed an estimation of usual intakes of dietary fibre. Fibre intake was found to be lower than in the developing countries of Africa and was comparable to intakes measured in the U.K. This is the first study to show that in this part of South East Asia, a developing country area using polished rice as a staple food, dietary fibre intakes are as low as in Western countries. Low intakes of fibre are believed to be related to the prevalence of a range of diseases and, in this study, preliminary data on the rates of non-infective, chronic diseases were collected from the two main hospitals in West Sumatra. Chronic, non-infectious diseases such as inguinal hernia, appendicitis, haemorrhoids, diabetes mellitus, hypertension and malignant neoplasms of the rectum are relatively frequent in West Sumatra. While no firm conclusions can be drawn from these data, they do show the possibility of a relationship between low intakes of dietary fibre and the prevalence of these diseases, and suggest that further investigation is necessary. Some observations were made of the effect of gel-forming dietary fibre on stomach emptying and intestinal transit rate in the rat. Xanthan gum was added to iso-osmotic solutions to produce increased viscosity and phenol sulphonphthalein (phenol red) was used as a non-absorbable marker. Gavage feeding of solutions with a range of viscosities was used to study the effect of viscosity on the rate of stomach emptying and intestinal transit. Increased viscosity was observed to slow gastro-intestinal transit and this provides one mechanism by which dietary fibre of the gel-forming type ray improve glucose tolerance.

Cardiovascular health behaviours and health needs among people with psychiatric disabilities

Recent research in Australia has found that people with a mental illness experience higher mortality rates from preventable illnesses, such as cardiovascular disease, respiratory disease and diabetes compared to the general population. Lifestyle and other behavioural factors contribute significantly to these illnesses. Lifestyle behaviours that affect these illnesses include lack of physical activity, consumption of a poor diet and cigarette smoking. Research on the influence of these factors has been mainly directed towards the mainstream population in Australia. Consequently, there remains limited understanding of health behaviours among individuals with psychiatric disabilities, their health needs, or factors influencing their participation in protective health behaviours. This thesis presents findings from two studies. Study 1 evaluated the utility of the main components of Roger’s (1983) Protection Motivation Theory (PMT) to explain health behaviours among people with a mental illness. A clinical population of individuals with schizophrenia (N=83), Major Depressive Disorder (MDD) (N=70) and individuals without a mental illness (N=147) participated in the study. Respondents provided information on intentions and self-reported behaviour of engaging in physical activity, following a low-fat diet, and stopping smoking. Study 2 investigated the health care service needs of people with psychiatric disabilities (N=20). Results indicated that the prevalence of overweight, cigarette smoking and a sedentary lifestyle were significantly greater among people with a mental illness compared to that reported for individuals without a mental illness. Major predictors of the lack of intentions to adopt health behaviours among individuals with schizophrenia and MDD were high levels of fear of cardiovascular disease, lack of knowledge of correct dietary principles, lower self-efficacy, a limited social support network and a high level of psychiatric symptoms. In addition, findings demonstrated that psychiatric patients are disproportionately higher users of medical services, but they are under-users of preventive medical care services. These differences are primarily due to a lack of focus on preventive health, feelings of disempowerment and lower satisfaction of patient-doctor relationships. Implications of these results are discussed in terms of designing education and preventive programs for individuals with schizophrenia and MDD.

Collaborative care : the role of practice nurses

Background
Comorbid depression can occur with diabetes and heart disease. This article reports on a feasibility study focusing on additional roles for practice nurses in detecting and monitoring depression with other chronic diseases.
Method
A convenience sample of six practices in southeast Australia was identified. Practice nurses received training via a workshop, which included training in the use of the Patient Health Questionnaire, to detect depression.
Results
The 332 patients who participated in the project each received a comprehensive health summary to assist with self management. Depression was identified in 34% of patients in this convenience sample. After 18 months implementation, practice nurses were strongly in favour of continuing the model of care. General
practitioners gave highly favourable ratings for effectiveness and willingness to continue this model of care.
Discussion
Practice nurses can include depression monitoring alongside systematic care of diabetes and heart disease. A randomised trial is currently underway to compare the clinical outcomes of this model with usual care.