Journal Eheh

8/8/2019 Journal Eheh

1/18

Low-Fat or Low-Carb Diet: Does It Make aDifference?

If behavior-modification therapy is part of the weight-loss program, probably not.

Multiple weight-loss strategies, including low-carbohydrate and low-fat diets, have beeninvestigated; however, many study treatments have not included an extensive behavioralcomponent. In this 2-year, randomized, parallel-group trial, researchers assigned 307 women andmen (mean age, 45.5) to a low-carb or low-fat diet combined with a comprehensive lifestylemodification program.

Participants in both groups lost approximately 11% of their baseline weight in 6 to 12 months;subsequent gains resulted in a total loss of 7% of baseline weight at 2 years. Systolic blood

pressure fell with weight loss in both diet groups but did not differ significantly between thegroups at any time point. The low-fat group had a significantly greater decrease in LDLcholesterol level than the low-carb group at 3 and 6 months, but the difference did not persist

beyond 6 months. Early decreases in triglyceride level and increases in HDL cholesterol levelwere significantly greater in the low-carb group than in the low-fat group, but only the differencein HDL level remained significant at 2 years. The groups did not differ in bone-mineral densityor body composition. Significantly more patients in the low-carb group than in the low-fat groupreported adverse symptoms. The rate of attrition at 2 years, including participants who withdrewand those who missed appointments, was 32% in the low-fat group and 42% in the low-carbgroup.


2/18

Comment: These findings show that weight loss can successfully be achieved with either a low-fat or a low-carb diet when a comprehensive behavioral program is included in the treatment.Although the low-carb diet appears to have improved the cardiovascular risk profile to asomewhat greater extent than the low-fat diet, the most important factor is maintaining the diet.Ultimately, most patients, need an ELF (eat less food) diet.

Joel M. Gore, MD

Pu blished in Journal Watch Cardiology Au g u st 25, 2010

http://cardiology.jwatch.org/cgi/content/full/2010/825/4

H igh Intake of Green Leafy Vegetables IsAssociated with Lower Risk for Type 2Diabetes


3/18

E at yo u r spinach.

High intake of fruits and vegetables is associated with lower risk for cardiovascular disease andcancer. What about risk for type 2 diabetes mellitus? Investigators attempted to answer thisquestion in a meta-analysis involving six prospective studies (median length, 13.4 years) andmore than 220,000 people (age range, 3074).

The highest levels of intake of vegetables only, fruits only, and fruits and vegetables combinedwere not associated with lower risk for type 2 diabetes. However, in the four studies that

provided information on intake of green leafy vegetables (e.g., spinach, kale, lettuce), the highestintake of green leafy vegetables (about 1.4 servings daily) was associated with 14% lower risk for type 2 diabetes, compared with the lowest level of intake (0.2 servings daily). This result wassignificant.

Comment: The studies included in the meta-analysis incompletely controlled for variables thatcould have confounded the results (e.g., lifestyle factors associated with lower risk for diabetesand higher intake of green leafy vegetables). Nevertheless, results of this meta-analysis add tothe large body of evidence in support of diets based primarily on plants for health promotion anddisease prevention; moreover, green leafy vegetables seem to be especially protective. Theauthors speculate that the benefits of these vegetables are related to their richness in vitamin C,

-carotene, polyphenols (which have antioxidant properties), -linolenic acid, and magnesium.


4/18

Paul S. Mueller, MD, MPH, FACP

Pu blished in Journal Watch General Medicine September 14, 2010

http://general-medicine.jwatch.org/cgi/content/full/2010/914/3

Mumps: H ow Well Are We Protected?

T he seroprevalence of antibody to m u mps vir u s in the U.S. pop u lation is at the low end of what isneeded for herd imm u nity.


5/18

Despite the licensure of a live mumps vaccine in the U.S. in 1967, a large mumps outbreak (6584cases) occurred in 2006. This event prompted CDC investigators to evaluate the seroprevalenceof antibody to mumps virus in this country and to examine demographic factors associated withthe presence or absence of antibody.

Data and sera collected from 1999 through 2004 for the National Health and NutritionExamination Survey were analyzed. The sampling plan for this survey was based on a stratified,multistage, probability-cluster design; participants underwent household interviews, physicalexaminations, and collection of biological samples. A commercially available indirect enzyme-linked immunosorbent IgG assay reported to have a relative sensitivity of 96.6% and a relativespecificity of 90.4% was used to determine the presence of mumps antibody. Participants weregrouped in 10-year birth cohorts based on the age groups affected in the 2006 outbreak.

The overall age-adjusted seroprevalence of mumps virus antibody in U.S. population aged 6 to49 in 19992004 was 90.0% (95% confidence interval, 88.8%91.1%). The seroprevalence of antibody was significantly lower in the 19671976 birth cohort (85.7%; P


6/18

T he efficacy of live pentavalent rotavir u s vaccine against severe gastroenteritis in infants was48% in Asian co u ntries and 39% in African ones.

Every year, an estimated 425,000 infants in developing Asian and African countries die of rotavirus infections. In two multicenter, double-blind trials, researchers assessed the efficacy andsafety of RotaTeq, an oral pentavalent rotavirus vaccine, in such countries. Both trials were

partially funded by the vaccine maker.

Zaman and colleagues randomized 2036 infants in rural Bangladesh and urban and periurbanVietnam to receive three doses of vaccine or placebo at about 6, 10, and 14 weeks of age. Theinvestigators did not test for HIV or exclude HIV-positive infants. Participants received other routine vaccines, including oral poliovirus vaccine. Median age was 21 months at study end.

In per-protocol analysis, vaccine efficacy against severe rotavirus gastroenteritis was 48%overall (Bangladesh, 43%; Vietnam, 64%). Among placebo recipients, incidence of severerotavirus diarrhea during the first year of life was higher in Bangladeshi than in Vietnameseinfants (9.1 vs. 2.8 per 100 person-years). Serum IgA immune response to vaccine, assessed in a

subset of 131 infants about 14 days after the third dose of vaccine, was 88%; geometric meantiters were higher in Vietnamese than in Bangladeshi infants. During the trial, three vaccine-group and four placebo-group participants died of causes unrelated to vaccine. One nonfatal caseof intussusception occurred 97 days after a third dose of placebo.

Armah and colleagues conducted an identically designed study involving 5468 infants in urbanMali and rural Ghana and Kenya. Infants in Kenya, unlike those in other sites, received routineHIV testing. In per-protocol analysis, vaccine efficacy against severe rotavirus gastroenteritiswas 39% overall but varied substantially by country (Kenya, 64%; Ghana, 56%; Mali, 18%). Nocases of intussusception were observed. Among Kenyan infants with HIV infection, 5 of 19vaccine-group participants (26%) experienced serious adverse events, compared with 1 of 10

placebo-group participants. During the study, 3% of the infants in each group died;gastroenteritis was the most common cause of death.

Comment: Possible explanations for decreased vaccine immunogenicity in low-income populations include micronutrient deficiencies, intercurrent infections, transplacental or breast-milk antibodies, and concomitant administration of live oral poliovirus vaccine. Lower efficacynotwithstanding, rotavirus vaccines can still provide substantial benefit to children in developingcountries, especially during the first year of life. On the basis of the results of these two studies,


7/18

the WHO now recommends rotavirus vaccination for all children, but cost remains an obstacle.Programs to implement vaccination should be supported but so should research to answer questions about poor immune response and to identify ways of increasing vaccine effectivenessin low-income populations.

Mary E. Wilson, MD Pu blished in Journal Watch Infectious Diseases Au g u st 18, 2010

http://infectious-diseases.jwatch.org/cgi/content/full/2010/818/4

Ex cessive Weight Gain in Pregnancy Leads toH igher Birth Weight


8/18

B irth weight was related to maternal weight gain in consec u tive pregnancies in the same mother.

High birth weight predicts childhood obesity and might be associated with obesity-relatedmorbidity later in life. In previous studies that showed an association between maternal weightgain during pregnancy and birth weight, investigators have not controlled for potential geneticand environmental confounders. To overcome such confounding, U.S. researchers used adatabase that included 513,000 women each with more than one singleton birth tocalculate differences in weight gain and in birth weight between adjacent pregnancies for eachmother.

Birth weight was associated significantly with maternal weight gain; every additional 1 kg inmaternal weight gain was associated with a 7.35 g increase in birth weight. Differences in birthweight between adjacent pregnancies in the same mother correlated with differences in maternalweight gain. Women who gained the same amount of weight in adjacent pregnancies had infantsof similar birth weight. On average, women who gained more than 12 kg of additional weight inthe second pregnancy had infants who were 108 g heavier, whereas women who gained less than12 kg of additional weight in the second pregnancy had infants who weighed 86 g less.


9/18

Comment: By addressing genetic and environmental confounders, this study strengthens thehypothesis that excessive maternal weight gain causes higher birth weight. Long-termobservational studies are needed to characterize associations between maternal weight gain andlater morbidity in offspring.

Bruce Soloway, MD Pu blished in Journal Watch General Medicine September 28, 2010


Additional Active Management of Labor'sThird Stage Might Lower Risk forPostpartum H emorrhage

Injection of oxytocin into the intra u mbilical vein diminished postpart u m blood loss s u bstantially.

Postpartum hemorrhage is a leading cause of maternal morbidity and mortality, particularly in

the developing world. Active management of the third stage of labor, which includes oxytocinadministration to control postpartum blood loss, is recommended by the WHO . To assess theeffects of intraumbilical vein injection of oxytocin on maternal blood loss, investigators in alarge maternity hospital in Istanbul conducted a randomized controlled trial that involved 449women at low risk for postpartum hemorrhage. All women underwent third-stage managementthat was standard at this institution (prophylactic intramuscular 10-IU oxytocin injections after delivery of the anterior shoulder, early umbilical cord clamping, and controlled cord traction); inaddition, the women were randomized to receive intraumbilical vein injections of oxytocin (20


10/18

IU) or saline after cord clamping. Blood loss was measured by weighing a specially designedoperating sheet.

Women in the oxytocin group had lower estimated blood loss (195 mL vs. 288 mL; P 500 mL (0.5% vs. 3.9%; P =0.02) and were less likely to

require additional uterotonic agents. Mean durations of the third stage were 4.5 minutes in theoxytocin group and 7.9 minutes in the control group.

Comment: Intraumbilical vein administration of oxytocin after delivery seems to be successfuland safe and is easy to add to the standard protocol for active management of the third stage of labor. Merely providing evidence that such an approach is effective, however, might not besufficient to ensure its adoption; indeed, we have good-quality evidence to support activemanagement of the third stage, but this approach has not been implemented consistently. Weshould explore better ways to implement in practice what we now know about activemanagement of the third stage of labor.

Allison Bryant, MD, MPH Pu blished in Journal Watch Women's Health September 23, 2010

http://womens-health.jwatch.org/cgi/content/full/2010/923/3

Gestational Age and Risk for Cerebral Palsy:A Surprising Discovery


11/18

Among term and postterm newborns, C P prevalence is lowest at 40 weeks' gestation and highest at 37 and 42 weeks' gestation.

Cerebral palsy (CP) is a nonprogressive motor encephalopathy characterized by impairment of

movement or posture and is presumed to be the result of injury or anomaly in the developing brain. Prevalence of CP has remained at 1.5 to 2.5 per 1000 live births for several decades.Although the etiology in most cases is unknown, the strongest risk factor for CP is preterm birth(


12/18

Follow-up through 2005 indicated that 1938 children with CP were registered in the nationalhealth insurance system. Prevalence of CP was lowest among infants born at 40 weeks' gestation,and risk was higher with earlier or later delivery (see the table ). In a subset of infants withultrasound measurements of gestational age, the association between CP risk and gestational agewas even stronger.

Comment: Full-term infants account for most cases of CP, and this study indicates that risk differs for term and postterm deliveries. Risk is lowest at 40 weeks' gestation and highest at 37weeks and at 42 weeks or later. The study's strengths include the population-based design in acountry with universal health insurance and a national registry of children with developmentaldisabilities. Should we consider changing the timing of delivery as a way to reduce the incidenceof CP? The authors caution: "Until the biological mechanisms for these patterns of risk in termand postterm births are better understood, it would be hasty to assume that interventions ongestational age at delivery could reduce the occurrence of CP."

Martin T. Stein, MD

Pu blished in Journal Watch Pediatrics and Adolescent Medicine September 22, 2010

http://pediatrics.jwatch.org/cgi/content/full/2010/922/1


13/18

Later E ffects of Psychological Abuse During

Pregnancy

P ostpart u m depression risk increases with psychological ab u se, even witho u t physical or sex u al violence.

Intimate partner violence affects 4% to 8% of pregnant women in the U.S. and is associated with postnatal depression. However, the effects of psychological violence on postpartum depressionare unclear. To assess whether intimate partner violence during pregnancy, especially

psychological abuse, is associated with later postnatal depression, researchers prospectively

followed pregnant, mostly low-income women (age range, 1849) enrolled in primary-careclinics in northeast Brazil through the postpartum period. Interviews took place during the thirdtrimester and an average of 8 months later.

Of 1045 women with complete data, 321 (31%) reported partner violence during pregnancy.Psychological violence (insults, humiliation, intimidation, or threats) was most common (294women [28% of the sample]); 123 women reported physical violence, and 60 reported sexualviolence, typically along with psychological violence. Postpartum depressive symptoms were


14/18

reported by 270 women (26%). The risk for postpartum depressive symptoms was highest inwomen reporting physical or sexual violence plus psychological violence. Risk for depressivesymptoms increased progressively with greater frequency of psychological violence (from 18%of women with no psychological abuse to 63% in those most frequently abused). Even in theabsence of physical or sexual violence and after adjustment for potentially confounding factors,

psychological violence, especially when more frequent, significantly increased depression risk.

Comment: This study used a self-report scale, not DSM-IV diagnoses, to assess depressivesymptoms postpartum, and several confounders (e.g., low levels of education and social support)were associated with both partner violence and postnatal depression. Nevertheless, these resultsunderscore the importance of asking pregnant women about intimate partner violence, including

psychological abuse, which often receives less attention than physical or sexual violence.

Deborah Cowley, MD

Pu blished in Journal Watch Psychiatry September 13, 2010

http://psychiatry.jwatch.org/cgi/content/full/2010/913/2

Stillbirths and Neonatal Deaths in Survivorsof Childhood Cancer R isk was elevated among women who received irradiation to the u ter u s and ovaries beforemenarche.

Aggressive therapy of childhood cancers has improved survival rates substantially, but the long-term effects of radiation and chemotherapy on reproductive capacity is incompletely understood.

Researchers analyzed risk for stillbirth or neonatal death in 4946 singleton pregnancies carried or

fathered by 1657 women and 1148 men who had survived childhood cancer (diagnosed beforeage 21, from 1970 through 1986). Roughly 30% of survivors received both radiation andalkylating drugs, 35% underwent radiation alone, 15% received alkylating agents alone, and 20%had neither. Organ-specific (pituitary gland, testes, and uterus/ovaries) radiation exposure wasestimated for each patient.

Irradiation of the testes or pituitary gland or exposure to alkylating agents did not raise risk for stillbirth or neonatal death and neither did irradiation of the uterus and ovaries after menarche.


15/18

But women who received irradiation of the uteri and ovaries before menarche had significantlyelevated risk for stillbirth or neonatal death (up to 12-fold at the highest radiation doses),compared with those who underwent no radiotherapy.

Comment: Previous analyses of this cohort have shown excess risk for early menopause,

preterm birth, and low birth weight among female survivors of childhood cancer, particularlyamong those who received pelvic radiation. The authors note that little evidence indicates thatgonadal irradiation results in genetic damage to offspring; they argue that the elevated risk for stillbirth or neonatal death in this study probably was mediated by radiation-induced reduction of uterine volume.

Bruce Soloway, MD

Pu blished in Journal Watch General Medicine September 7, 2010


KENYA

Jury Still Out on Traditional Birth AttendantsBy Susan Anyangu-Amu

NAIROBI, Jul 26, 2010 (IPS) - The government of Kenyahas been encouraging women to deliver in hospital. H omedeliveries by traditional birth attendants are considered to

be a major contributor to maternal deaths.

TBAs are said to be ill-equipped to notice danger signs thatcould be fatal. The government has proposed banningtraditional midwives altogether.

According to the last demographic health survey, released bythe government in 2009, Kenya has one of the highest maternaldeath rates in the world at 448 per 100,000 live births. Homedeliveries are believed to be a major contributor.

"When a woman goes into labour in the middle of the night in Mathare slums," Elizabeth Sibuor,a traditional birth attendant in Nairobi, "the option of getting a taxi is out of question due to thecost and insecurity.

"Such women end up delivering with the help of TBAs. Pregnancy and labour is a matter of lifeand death, I will not sit back and let a woman and her

baby, die if I can offer assistance."

Kenyan maternity clinic: lessthan half of births take place in

facilities like these.

Credit: Kenneth Odiwuor/IRIN


16/18

Midwifing the nation

A group of women huddled together sitting on stones in front of traditional birth attendant ElizabethSibuor's home in Nairobi's Mathareslum. One of them, 21-year-oldEunice Okoth, is heavily pregnant,her face anxious. She rises asquickly as she can and followsSibuor into her one-roomed house.

The two disappear behind a curtainthat confers a thin privacy on theconsulting room and bed on whichSibuor has delivered countless

babies.

Whatever Sibuor says and does behind the cloth has the desiredeffect; when Okoth re-emerges, theanxiety has lifted from her face.

"She is experiencing early labour but it is not yet time," Sibuor tellsIPS later. "When a woman is almostdue, the way begins to open up in

preparation for the baby and this iswhat causes pain. I have given her some traditional herbs to ease the

pain but now she must ensure shegets rest."

"(Elizabeth) delivered my first babysmoothly," Okoth says. "I want her to be with me when I deliver this

baby because she is understandingand treats me with respect and care.

I am not yet due but I am havingsome pain, she has given me somemedicine (herbs) and I believe I will

be well and will deliver this baby atthe right time."

Two thirds of Kenya's maternaldeaths are attributed to postpartum


17/18

The 2009 demographic health survey shows less thanhalf of women deliver under the care of a skilledattendant in Kenya. Fifty seven percent give birth athome with 28 percent assisted by a traditional birthattendant.

Sibuor charges 500 shillings - roughly six dollars - for adelivery; compared to 4,000 shillings ($50) if a womangives birth in a government hospital.

She often remains unpaid by her clients; of those who do,many settle their bill in small installments or in kindthrough gifts. Some cannot afford to make any payment,

but she says she turns no one away.

Dr Isaak Bashir, the head of Reproductive Health inKenya's Ministry of Public Health and Sanitation, isemphatic the government should not recognise TBAs andthat women should give birth with support from medical

practitioners.

"For anyone to be recognised as a qualified birthattendant they must have commensurate papers from arecognised medical training college. The country is not

short of qualified nurses and midwives. Institutions of higher learning are churning out enough candidates, whatneeds to be done is hire new people," Bashir says.

But Monica Ogutu the executive director of KisumuMedical and Education Trust (K-MET) says the healthsystem has failed the women of Kenya.

"No woman wants to deliver at home. The health systemis failing women. When a woman is in labour, she needs someone to listen to her and offer comfort. One midwife attending to 10 women at once will not have time for such a woman. Thisis one of the various reasons why women are opting for the services of traditional birthattendants," says Ogutu.

While the governments ban on TBAs may be well-intentioned, Ogutu says the move isdangerous.

haemorrhage (severe loss of bloodduring or after labour ), sepsis(bacterial infection in the blood),eclampsia (hypertension during

pregnancy) or a ruptured uterus: allconditions that a birth attendant likeSibuor is unable to deal with.

But despite being aware of theadvantages of delivering in hospitaland greatly reduced costs at localhealth centres - in the clinics run bythe Nairobi city council, for example, the fee for delivery is just20 shillings, roughly 25 U.S. cents -yet women like Okoth continue to

seek the services of TBAs.

Ready access remains a key factor -the Nairobi clinics are only openduring the day. If a woman goesinto labour outside of regular officehours - or experiencescomplications - she will have to goto a larger government facility,where a 4,000 shilling deposit will

be demanded - 50 U.S. dollars is

well beyond the means of mostwomen.

"Labour does not choose a particular time nor does it onlycome during the day when you caneasily access a hospital," saysElizabeth Sibuor, a traditional birthattendant in Nairobi.


18/18

Instead of demonising them, Ogutu argues the government should reinvigorate previous effortsto train TBAs as a bridge between the community and the public health system.

"For hundreds of years, TBAs have helped birth our nation and they are highly regarded in somecommunities, especially rural areas. Banning them will not make women who seek their servicesgo to give birth in hospitals," Ogutu says.

Sibuor insists that government and women - have nothing to fear from traditional birthattendants.

"I have lost count of the number of women I have assisted during delivery in my over 20 yearsexperience and no woman has died under my care," she says. "When I notice danger signs, Iaccompany the woman to the nearest health centre.

"I encourage the women to attend clinic and also take their children for vaccination. I also insistthey must get tested for HIV and if they are positive, I do not agree to deliver - they must go to ahealth facility."

Sibuor says women such as Okoth will continue to rely heavily on TBAs. Instead of being perceived as incompetent, she wants the government to identify credible TBAs and help them toimprove their service.

"The reality for a woman in Mathare slums is different from that of a woman in an affluent

background. Because labour comes at anytime and could progress very fast, the woman inMathare will continue needing my services. I will continue birthing this nation."

The Kenyan government, like other African governments, is wrestling with the challenge of extending adequate services to meet its commitment to reduce maternal mortality by two thirds

by 2015 compared to 1990 levels. The government acknowledges the important role played byTBAs, says Dr Bashir, and is in the process of coming up with a charter to re-orientate them as

birth companions.

It will be essential to accurately assess the quality of care given by women like Sibuor, and findan appropriate place within the country's public health system.

(END)

Documents

Journal Eheh