How do we educate young people to balance carbohydrate intake with adjustments of insulin?

The dietary management of childhood diabetes is complex. Is it possible to educate young people to balance carbohydrate with their insulin? Can dietary knowledge be translated into lasting behaviour change? Do present teaching methods provide the skills necessary for children and parents to adjust their insulin therapy adequately? Evidence shows great variation in glycaemic control between centres and countries but the impact of dietary education methods is poorly evaluated and its links with clinical and psychosocial outcomes is virtually unknown. There is also little evidence to suggest cohesive teamworking with clear dietary targets for glycaemic control, lipids, incidence of hypoglycaemia, compliance, effect on peer and sibling relationships, and evaluation of individual dietary components, e.g. fibre, fat, antioxidants. There is wide variation in methods of dietary education, which are often based on historic practice. They include rigid counting of grams of carbohydrate, carbohydrate portion assessments, qualitative diets, low glycaemic index diets and the more recent 'intensified' carbohydrate measures with daily adjustments of insulin (the basis also of pump management). This last method has many benefits although it requires extensive nutrition education, it allows greater flexibility and variety of food intake, is sensitive to the varying daily energy expenditure of childhood and it addresses postprandial glycaemic excursions, all of which are inadequately managed by conventional therapy. However, one of the problems of overemphasizing carbohydrate measurement is that total carbohydrate intake may be suppressed, with a resulting increase in fat, this may contribute to an increase in cardiovascular risk. The ISPAD Consensus Guidelines 2000 contain dietary recommendations but scientific evidence is often lacking. Limited dietary studies show that some countries can meet guidelines more successfully than others. There are many reasons for this, such as food availability, types of food eaten, food preferences and family/cultural/religious influences. Educational methods must be adapted to local customs. Is there enough evidence to recommend a particular dietary education method? What outcomes do we hope to achieve? The workshop explored these issues in order to develop a deeper understanding of the complexity of dietary modification in childhood diabetes.     

The GAMY Project: young people’s attitudes to genetics in the South Wales valleys

This paper explores young people’s attitudes to genetics. It describes a qualitative study involving a group of teenagers in a deprived South Wales valley town over a period of 18 months. The GAMY (Genetics and Merthyr Youth) Project involved a series of interactions with participants, including 2 interviews, 4 group days and 4 genetics tasks through which these young people learned about, and then reflected upon, issues relating to genetics and health. We have gathered data about the informed attitudes of teenagers to genetics based on deliberative learning and reflection over a long period of time, and as such this paper provides useful insights into the underlying values that are guiding young people’s views and the factors that are shaping their responses to new genetic technologies. Attitudes to genetics are complex and not easily generalisable. There were low levels of familiarity with, and knowledge of, genetics from the outset. Most young people did not have pre-existing attitudes towards genetics and had given little or no thought to the topic before the project began. However, levels of awareness and general genetic literacy increased as the project progressed. This study suggests that over time young people can develop an awareness of genetics that makes sense to them; they demonstrate that they can think creatively about genetics, and they are able to engage in considering genetic and other risk factors when thinking about health and disease.     

Ought we to sentence people to psychiatric treatment?

In principle, there seem to be three main ways in which society can react when people commit crimes under influence of mental illness. (1) The standard model. We excuse them. If they are dangerous they are detained in the interest of safety of the rest of the citizens. (2) The Swedish model. We hold them responsible for their criminal offence, we convict them, but we do not sentence them to jail. Instead, we sentence them to psychiatric treatment. (3) My model. We sentence them to jail, but offer them (voluntary) psychiatric treatment. The advantages of my model are obvious. We get a clear delineation of roles. We allow the psychiatrist to be just a doctor, not a warden. We liberate psychiatry of the objective of deciding whether people who were mentally ill when they committed criminal offences 'could have acted otherwise' -- a hopeless task. We allow that psychiatrists live up to their professional ethical code (The Hawaii Declaration). We treat psychically ill persons as 'normal', we allow them to repent their crimes, which renders easier their recovery. However, two objections to my model come to mind. First of all, is it not unfair to sentence people to jail who could not help doing what they did? And, secondly, the question of fairness set to one side, is it not inhumane to sentence mentally ill persons to jail? Is it not inhumane to the mentally ill persons themselves, and does it not mean that they will be a burden to other prisoners? In my paper I show that, if our system of criminal punishment takes a civilised form, neither of these objections carries any weight.     

Antimalarial chemotherapy: young guns or back to the future?

The burgeoning global problem of malaria is largely due to the emergence of parasite resistance to our limited armamentarium of antimalarial drugs. The recognition of this impending disaster at the international level and the engagement of the pharmaceutical industry promise a more optimistic future for antimalarial drug development. This is particularly exciting when considering the advances in our understanding of parasite biology, which are currently being fuelled by the malaria genome project. This article discusses recent developments in the area of antimalarial drug discovery and evaluation. New advances, based on traditional antimalarial drug classes including the quinolines, peroxides and antifolates (‘back to the future’), are discussed, followed by a presentation of some novel targets (‘young guns’) that have been shown to be good candidates for chemotherapeutic attack.     

Reimagining the wilderness ethic to include “people and nature”

Biodiversity and Conservation - The concept of the “wilderness ethic” is at an impasse. Despite calls for action to conserve wilderness, any notion of wilderness thinking still resides...     

Is it possible to manipulate root anchorage in young trees?

The optimal root system architecture for increased tree anchorage has not yet been determined and in particular, the role of the tap root remains elusive. In Maritime pine (Pinus pinaster Ait.), tap roots may play an important role in anchoring young trees, but in adult trees, their growth is often impeded by the presence of a hard pan layer in the soil and the tap root becomes a minor component of tree anchorage. To understand better the role of the tap root in young trees, we grew cuttings (no tap root present) and seedlings where the tap root had (?) or had not (+) been pruned, in the field for 7 years. The force (F) necessary to deflect the stem sideways was then measured and divided by stem cross-sectional area (CSA), giving a parameter analogous to stress during bending. Root systems were extracted and root architecture and wood mechanical properties (density and longitudinal modulus of elasticity, E _L ) determined. In seedlings (?) tap roots, new roots had regenerated where the tap root had been pruned, whereas in cuttings, one or two lateral roots had grown downwards and acted as tap roots. Cuttings had significantly less lateral roots than the other treatments, but those near the soil surface were 14% and 23% thicker than plants (+) and (?) tap roots, respectively. Cuttings were smaller than seedlings, but were not relatively less resistant to stem deflection, probably because the thicker lateral roots compensated for their lower number. Apart from stem volume which was greater in trees (+) tap roots, no significant differences with regard to size or any root system variable were found in plants (?) or (+) tap roots. In all treatments, lateral roots were structurally reinforced through extra growth along the direction of the prevailing wind, which also improved tap root anchorage. Predictors of log F/CSA differed depending on treatment: in trees (?) tap roots, a combination of the predictors stem taper and %volume allocated to deep roots was highly regressed with log F/CSA (R ² = 0.83), unlike plants (+) tap roots where the combined predictors of lateral root number and root depth were best regressed with log F/CSA (R ² = 0.80). In cuttings, no clear relationships between log F/CSA and any parameter could be found. Wood density and E _L did not differ between roots, but did diminish with increasing distance from the stem in lateral roots. E _L was significantly lower in lateral roots from cuttings. Results showed that nursery techniques influence plant development but that the architectural pattern of Maritime pine root systems is stable, developing a sinker root system even when grown from cuttings. Anchorage is affected but the consequences for the long-term are still not known. Numerical modelling may be the only viable method to investigate the function that each root plays in adult tree anchorage.     

Can winter swimming cause people to prefer lower room temperatures?

Preferred room temperatures were determined for 16 winter swimmers who had been exposed to cold shock daily by bathing in the sea (0–6°C) during at least two winter seasons. Each subject participated in one comfort experiment (2 1/2 h) in an environmental test chamber, where the preferred ambient temperature was determined by adjusting it according to his wishes. The subjects were sedentary and clothed in a standard uniform. Skin temperatures, rectal temperature and evaporative weight loss were measured. The results were compared with similar data for two other groups: (a) a control group of 64 normal subjects and (b) 16 persons who had been working 8 h a day at 8°C during at least 6 months in the meat packing industry. The results showed no significant differences between the ambient temperatures preferred by the three groups of subjects. This indicated that man cannot be adapted to prefer lower ambient temperatures by exposing him daily to cold.     

How does physical activity and fitness influence glycaemic control in young people with Type 1 diabetes?

Diabet. Med. 29, e369-e376 (2012) ABSTRACT: Aims To assess physical activity and fitness levels of young people with Type?1 diabetes compared with siblings without diabetes, and to investigate the association between physical activity, physical fitness and glycaemic control (HbA(1c) ) in those young people with diabetes. Methods The study consisted of 97 young people aged 8 to 16?years (62% male) from a Paediatric Diabetes Service in South West England. Sixty participants (67% male) had Type?1 diabetes and 37 participants (54% male) were siblings without diabetes (control group). We measured weight, height and waist circumference, calculated BMI and waist-height ratio and recorded pubertal status, blood pressure and current insulin regimen information. We assessed physical activity by accelerometry, from which we calculated light and moderate-to-vigorous intensity activity. We measured physical fitness by multistage sub-maximal bicycle ergometer test. We obtained HbA(1c) by venipuncture. Results There were no differences between the young people with diabetes and siblings without diabetes in body composition, blood pressure, physical activity and fitness. Moderate-to-vigorous physical activity was associated with better glycaemic control, accounting for 30-37% (R(2) =?0.295-0.374) of the variance for HbA(1c) . Physical fitness was not associated with HbA(1c.) Conclusions Moderate-to-vigorous physical activity was associated with better glycaemic control while fitness was not. Findings suggest that developing strategies to increased moderate-to-vigorous physical activity may prove an effective method of improving glycaemic control in young people with diabetes.     

Visiting sick people: is it really detrimental to our health?

Intuitively, keeping ones distance from a source of infection would appear to be the best way to limit the occurrence of disease. However, this overlooks the importance of repeated infections in maintaining efficient immune defenses. When acquired immunity has partly waned, re-exposure to the pathogenic agent may lead to mild disease that boosts the immune system. This prevents the total loss of immunity that would lead to classical disease in cases of re-infection. Here, using a mathematical model, we show that avoiding the pathogenic agent is detrimental in some situations, e.g. for pathogens that are highly transmissible, are not excessively lethal and that induce rapidly waning immunity. Reducing exposure to pathogenic agents is among the objectives of most, if not all, public health measures. A better understanding of the factors influencing the severity of a disease is required before applying measures that reduce the circulation of pathogenic agents.     

Is Europe prepared to meet the oral health needs of older people?

OBJECTIVE: To discuss the preparedness of the social and health care systems and the health workforce in Europe to manage the increasing general and oral health care needs of older adults. BACKGROUND AND DISCUSSION: There are large inequalities across European countries and regions in the demographic, socioeconomic and health status of the elderly. The ageing of the population and the economic crisis put at risk the existing social and health care systems and are expected to further widen the existing inequalities. Despite the increase in funding for the general health care, public funding for dental care has reduced, limiting the access for the disadvantaged elderly. Dental care is isolated from health care policies and funding. At the same time there is a significant shortage of adequately trained personnel in the care of the elderly and a shortage of training opportunities particularly at a postgraduate and continuing education level. CONCLUSION: Immediate action is needed and appropriate strategies need to be implemented. Oral health prevention, delivery policies and funding should be integrated within the general health care system. Clinical protocols and guidelines need to be developed on the oral care of the elderly. Interdisciplinary training in the care of the elderly needs to be implemented for all health care workers (dentists, physicians, nurses, health care aids, social workers) at all education levels to enhance comprehensive care.     

How effective is nicotine replacement therapy in helping people to stop smoking?

OBJECTIVE--To assess the efficacy of nicotine replacement therapy in helping people to stop smoking. DESIGN--Analysis of the results of 28 randomised trials of nicotine 2 mg chewing gum, six trials of nicotine 4 mg chewing gum, and six trials of nicotine transdermal patch. SUBJECTS AND SETTING--Subjects were self referred (responding to advertisements or attending anti-smoking clinics) in 20 trials and invited (general practice or hospital patients) in 20. Therapists in self referred trials were generally experienced in helping people stop smoking but not in invited trials. MAIN OUTCOME MEASURE--Efficacy was defined as difference in percentages of treated and control subjects who had stopped smoking at one year. RESULTS--Efficacy was highly significant (P < 0.001) for both gum and patch. Nicotine 2 mg chewing gum had an overall efficacy of 6% (95% confidence interval 4% to 8%), greater in self referred subjects than in invited subjects (11% v 3%). Efficacy depended on the extent of dependence on nicotine as assessed by a simple questionnaire; it was 16% (7% to 25%) in "high dependence" smokers, but in "low dependence" smokers there was no significant effect. The 4 mg gum was effective in about one third of "high dependence" smokers. The efficacy of the nicotine patch (9% (6% to 13%) overall) was less strongly related to nicotine dependence, perhaps because the patch cannot deliver a bolus of nicotine to satisfy craving. CONCLUSIONS--Both gum and patch are effective aids to help nicotine dependent smokers who seek help in stopping. Among the most highly nicotine dependent smokers (those craving a cigarette on waking) the 4 mg gum is the most effective form of replacement therapy; it could enable one third to stop. In less highly dependent smokers the different preparations are comparable in their efficacy but the patch offers greater convenience and minimal need for instruction in its use. Overall, nicotine replacement therapy could enable about 15% of smokers who seek help in stopping smoking to give up the habit.