more_vertGirls’ and women’s health is in transition and, although some aspects of it have improved substantially in the past few decades, there are still important unmet needs. Population ageing and transformations in the social determinants of health have increased the coexistence of disease burdens related to reproductive health, nutrition, and infections, and the emerging epidemic of chronic and non-communicable diseases (NCDs). Simultaneously, worldwide priorities in women’s health have themselves been changing from a narrow focus on maternal and child health to the broader framework of sexual and reproductive health and to the encompassing concept of women’s health, which is founded on a life-course approach.
Preference: Nutrition
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[Correspondence] Preventing childhood obesity starts during pregnancy
Tim Lobstein and colleagues (June 20, p 2510)1 highlight the global childhood obesity epidemic and the need for preventive strategies. However, greater emphasis on prevention before birth is needed. We have shown that similar fetal growth is observed in mothers at low risk of nutritional, social, and medical constraints,2 which justifies using the newly published international newborn standards3 that complement the existing WHO Child Growth Standards. These standards describe how individuals should grow, by contrast with the many current references describing how they have grown at a particular time or place.
[Correspondence] Collaborate to cure: a student perspective on global health
As the nutrition transition redefines the picture of human disease, we see already overburdened health infrastructure around the world buckling under the increasing weight of chronic illness. To address this unprecedented pressure on health-care systems, we as medical professionals must, from the beginning of our training, recognise and engage with the abundant human potential within our communities. We have witnessed the viability of this approach from tertiary care in East Africa to primary prevention in Israel’s Negev Desert.
Suburbs with higher diabetes rates have more access to takeaway food, alcohol
When looking at rising type 2 diabetes rates, we need to also look the availability of fresh food in the local geographical area, experts say.
In a perspective published in today’s Medical Journal of Australia, research has found that people living in western Sydney have a higher access to takeaway and alcohol shops than those living in Sydney’s north shore.
There are also much higher rates of Type 2 diabetes rates in western Sydney, particularly around the suburbs of Mount Druitt and Blacktown.
Dr Thomas Astell-Burt, Director of Public Health Sciences at Western Sydney University, and Dr Xiaoqi Feng, Senior Lecturer in Epidemiology at the University of Wollongong calculated the number of greengrocers, supermarkets, takeaway shops and alcohol outlets within 15–20 minutes’ walk from a person’s home.
“About 28% (868/3148) of neighbourhoods in the west had at least [a 3:1] ratio of takeaway shops to greengrocers and supermarkets, in comparison to 20% (546/2744) in the north,” they report.
“The equivalent results for alcohol outlets were 12% (365/3148) in the west and 5% (131/2744) in the north.”
Related: Food inequality a health risk
They said in Sydney’s west, the availability of fresh produce within a reasonable walking distance was limited.
These preliminary findings are from the Mapping food Environments in Australian Localities (MEAL) Project, which was initiated in 2014 to explore geographical inequities in food environment in metropolitan Sydney.
The researchers say the findings indicate that more needs to be done to help people struggling with Type 2 diabetes.
“We have to invest in multisectoral change for which the health benefits may only be realised in the long term,” they write.
Read the full perspective in the Medical Journal of Australia.
Latest news:
Folic Acid shortage sparks reminder for GPs
GPs are being urged by the Chief Medical Officer, Professor Chris Baggoley, to remind women planning to be, or who are pregnant to take their folic acid supplements. The warning comes in the wake of a global shortage of the production of folic acid for mandatory food fortification. Due to this shortage, wheat flour used in bread products may not consistently include folic acid. There is no threat to folic acid supplies for the supplement industry.
Folic acid fortification of wheat flour for bread making was introduced in 2009 to reduce neural tube defects by helping women to enter pregnancy with improved exposure to folate. Folic acid in bread provides a ‘safety net’ level of folic acid for women.
“Pregnant women and those planning a pregnancy should follow the NHMRC recommendations and continue to take a daily folic acid supplement at least one month before, and three months after conception. This is in addition to eating a healthy and varied diet as recommended in the Australian Dietary Guidelines,” Prof Baggoley said.
Related: Sun exposure linked to low folate levels
The target population of women aged 16-44 years should also be encouraged to consume other food sources of folate which includes dark green vegetables such as broccoli, spinach, citrus fruit, fruit juice, legumes such as lentils and peas, and whole grains.
Prof Baggoley has advised while there may not be sufficient supplies to add to wheat flour for bread for up to 12-18 months, Australia manufacturers have advised they have several months’ supply in stock.
The AMA supports food fortification where necessary.
AMA Position Statement on Nutrition
This post was first published on GP Network News
Latest news:
[Correspondence] Tackling obesity: challenges ahead
The Lancet Obesity Series 2015 addressed an important public health problem worldwide. However, it adopted a strongly nutritional focus, with limited attention to physical activity, a crucial component of energy balance.1 In order to assess how well physical activity was reflected in the Series, we carried out a bibliometric analysis of word usage across the series and examined the reference lists of each paper. For the bibliometric analysis, we identified specific terms “physical activity“, “exercise“, or “(incidental) activity“, and compared these to “nutr*“, “diet*“, or “food“ mentions in all four Series papers; we counted and coded the papers referenced in each paper; we also examined the most recent 20 publications by each author in PubMed and coded them as physical activity or nutrition focused.
Negotiating the complex maze of claims of dietary cures for cancer
How can we help our patients make sensible decisions?
In this increasingly internet-connected world, vulnerable and desperate patients with life-threatening illnesses such as cancer are often advised or motivated to negotiate their way through a seemingly expanding maze of “dietary cures”.1 As an example, a woman claimed to have cured herself of thyroid cancer by eating pineapples.2
Many negotiate their way through and make sensible choices, but my oncology colleagues and I continue to see patients who choose extreme dietary and alternative treatments for potentially curable cancers and don’t turn to us until they are quite ill and their cancer has spread and become incurable. To see patients with early disease, who would have an excellent prognosis if standard treatment protocols were followed, return with advanced disease after eschewing this standard treatment for dietary cures is extremely distressing for the patients, their loved ones and their treating doctors.
Why is this occurring and how can we as physicians and health professionals help our patients navigate this maze and make sensible decisions?
Problem: Patients with cancer are often terrified and feel out of control
Strategy: Form a trusting, empathic and therapeutic relationship with the patient
We must acknowledge and validate the patient’s values and feelings.3 We must guide and advise, but we must also empower patients in their treatment choices. This will encourage open dialogue with the patient about any alternative treatments that they may be considering using as ancillaries or replacements for standard treatments. This will also acknowledge that patients base their treatment refusals mainly on personal values and/or experience. In contrast, physicians mainly emphasise the medical perspective when evaluating patients’ treatment refusals. Our ability to accept and understand the patients’ values-orientated perspective and form a consensus with them will help them to feel understood and respected, and thus help form a better physician–patient relationship.4
Problem: Distrust of hard science combined with sophisticated online marketing and celebrity testimonials
Strategy: Education and careful explanation of the goals, benefits and adverse effects of treatments
When I started practising oncology in the early 1980s, it was a new speciality and there were far fewer effective treatments than there are now. Surgery, radiotherapy and chemotherapy were less sophisticated and far more debilitating, and many patients suffered toxicities without deriving benefits. Some patients at that time became naturally curious about individuals claiming to have had advanced cancer and to have cured themselves with diet and meditation.5,6 The dissemination of these natural cures relied on books in the self-help sections of bookshops. As more and more patients use online search engines to research their disease, their treatment options and their health generally, they find themselves being constantly beckoned, assailed and seduced by a rapidly rising number of sites, celebrities and personalities providing glowing testimonials about extraordinary new dietary “breakthroughs” that will cure their cancer (and their arthritis or multiple sclerosis), and make them more youthful, virile and joyful. More of these claims appear to be coming from individuals with implausible claims of advanced cancer and “self cure”. Some of these claims are wrapped in a cloak of pseudoscientific tests and research to give them greater credibility.7
In our current era, in which a distrust of hard scientific data appears to be finding greater voice on the many available online platforms and discussion sites, some of the practitioners and spruikers of these claims also invoke conspiracy theories that doctors don’t want patients to know about these simple, non-toxic (but often expensive) treatments because it will either reduce our role or the incomes of doctors and the pharmaceutical companies that we are “in collusion with”. We should endeavour to base our treatment recommendations on robust evidence-based medicine, to collaborate in multidisciplinary teams and to emphasise that there have been dramatic recent advances in cancer treatments, including organ-preserving treatments for many cancers such as cancers of the breast, rectum, oesophagus, larynx and bladder. Surgery can now cure many patients with colon or lung metastases from bowel cancer, and targeted radiation is now dramatically more effective for many cancers and far less toxic. The benefits and adverse effects of chemotherapy have become far better understood, and treatment choices and doses are far better tailored to the goals of therapy. Well tolerated and effective targeted therapies are replacing many chemotherapy treatments for advanced cancers. We now understand better that many cancers, such as low-grade non-Hodgkin’s lymphoma, chronic lymphocytic lymphoma and early-stage prostate cancer, often behave very indolently and require no treatment.
Problem: Alternative treatments are regarded as simple, natural and non-toxic
Strategy: Carefully warn the patient that there is no credible evidence that any patient with cancer has been cured by diet or a combination of alternative treatments
The reverse of this is true — recent studies have shown that high-dose vitamin therapy can worsen the prognosis of some cancers. This is not surprising as vitamins are growth factors and are required for the integrity of cell growth and division.7,8 They may also partly repair otherwise lethal DNA damage, allowing some aberrant cells to survive and proliferate. Also, these treatments can be time-consuming and can reduce quality of life.9
I also suggest that interested patients review their local Cancer Council website and read the article about cancer myths on the Cancer Research UK website.10
Problem: The claims of cures by diet are either of patients whose clinical course is within the expected natural history of the disease or are deliberately false
Strategy: Carefully explain that you and your colleagues have never observed cures by diet
I emphasise that my colleagues and I have carefully observed many patients pursue various purely dietary treatments over the past 30 years and are yet to see one whose progress has been outside the expected natural history of their particular cancer.
Problem: Some patients are reluctant to return to us after unsuccessfully pursuing alternative treatment, as they already feel ill enough without us adding any encouragement of feelings of guilt
Strategy: Try to avoid all guilt and blame
I regard guilt and blame in cancer patients as negative emotions, and try always to look ahead and to treat the patient with the compassion, care and skill that they require.
Problem: Some patients are given incorrect and overly pessimistic prognoses and feel they are being drained of all hope and/or denied the possibility of setting realistic life goals
Strategy: Emphasise the frequent difficulty of providing a very accurate prognosis
I try to answer the patient’s and family’s questions as honestly, sensitively and fully as possible, but advise them that making a prognosis, even for oncologists with 30 years of experience, is very difficult. I tell them that I am giving them a realistic range of possible prognoses based on my experience and all the available evidence about their particular circumstance and type of cancer. I try to provide the necessary time and detailed information that the patient seeks to enable them and their family to set realistic goals and plan their lives appropriately. This goal setting often entails making the necessary arrangements for their work, travel, family and financial affairs. Very often, a calm and trusting acceptance can be created by carefully and regularly assessing, reassessing and communicating any genuine possibility of cure, of a period of remission or of improvement of a symptom based on the patient’s current and sometimes constantly changing situation. This reassurance and calm that can develop from such an ongoing and open conversation between the patient, the family, the oncologist and the treating team is a vital part of maintaining the patient’s quality of life, as well as the psychological health of both the patient and their family members.
Problem: Some patients benefit from an opportunity to debrief and unpackage their thoughts and beliefs with a skilled third person
Strategy: Encourage a consultation with a skilled psycho-oncologist, psychologist or other skilled counsellor
I have been fortunate throughout my career to have worked with highly skilled psycho-oncologists, psychologists, social workers and other counsellors. They are integral to the creation of a trusting, therapeutic relationship between the patient and the health care team. Their assistance should be offered and encouraged for all patients who are searching or struggling emotionally, as should the early assistance of a specialist palliative care team for patients with advanced, incurable disease.
[Correspondence] Stunting in earthquake-affected districts in Nepal
The earthquake that struck Nepal on April 25, 2015, left 500 000 families homeless and almost 3 million people in need of humanitarian assistance.1 While there is speculation about the long-term effect of this disaster on Nepal’s tourism-driven economy, the arrival of monsoon rains raises more immediate concerns about household food security and child nutrition.
Splenic abscess complicating gastroenteritis due to Salmonella Virchow in an immunocompetent host
Clinical record
A 20-year-old man was admitted to a regional hospital with fevers, rigors, anorexia and left upper quadrant pain. It was his fourth presentation to the emergency department in the preceding 10 days. On the first two presentations, he had been sent home with a provisional diagnosis of renal colic. After review by his general practitioner, he had undergone outpatient imaging that identified filling defects in the pulmonary arteries of his left lower lobe, which were reported as being consistent with pulmonary emboli. In addition, two hypodense splenic lesions were identified, as well as collapse and possible consolidation of the left lower lobe. His GP had referred him to the emergency department for further review (his third presentation), after which he had commenced therapeutic anticoagulation for a presumed diagnosis of pulmonary emboli.
The patient’s history was notable for a self-limiting episode of gastroenteritis 6 weeks before his initial presentation, with sick family contacts. On his fourth presentation, he described progressive left upper quadrant and flank pain over the preceding 10 days, with intermittent fevers and rigors. He had no other focal infective symptoms on review.
On examination, he was found to have a fever (temperature, 39.3°C), sinus tachycardia (heart rate, 154 beats/min), tachypnoea (respiratory rate, 28 breaths/min), hypotension (blood pressure, 97/66 mmHg), decreased breath sounds at the left base of his lung fields and mild left upper quadrant tenderness. Investigations showed a white cell count of 16 × 109/L (reference interval [RI], 4.0–11.0 × 109/L), with a predominant neutrophilia (neutrophils, 14 × 109/L [RI, 2.0–7.0 × 109/L]). Results of his liver function tests and electrolyte, urea and creatinine levels were all within reference intervals.
A computed tomography scan of the chest and upper abdomen again showed two low-density lesions of unclear aetiology in the spleen, as well as a left-sided pleural effusion and collapse of the left lower lobe. Given the possibility that the hypodense splenic lesions represented septic emboli from a cardiac source, the patient was treated empirically with benzylpenicillin, flucloxacillin and gentamicin for a provisional diagnosis of endocarditis. However, a transthoracic echocardiogram performed the next day did not support this diagnosis, with no abnormalities detected. Beyond the radiological findings described, there were no other clinical grounds to support a diagnosis of endocarditis.
Blood cultures taken on Day 1 of admission were positive for gram-negative bacilli, with confirmation of a non-typhoidal Salmonella species (later confirmed as Salmonella Virchow) the following day. This allowed targeted antibiotic therapy, once susceptibilities were known, with ampicillin (2 g every 6 hours). Cultures of stool samples taken at admission were positive for the same isolate, consistent with the patient’s self-limiting episode of gastroenteritis 6 weeks before his first presentation.
Magnetic resonance imaging of the abdomen suggested that the two splenic lesions were likely to represent abscesses in this clinical context (Figure). Given our patient’s ongoing sepsis, a decision was made to perform a laparoscopic splenectomy for source control on Day 5 of admission. Surgical specimens tested positive for Salmonella Virchow. Histopathological testing identified cystic lymphangiomas of the spleen. Despite problems with postoperative pain and a prolonged ileus, the patient made a full recovery. He received appropriate post-splenectomy vaccinations, along with a total of 2 weeks’ intravenous ampicillin, followed by a 2-week course of oral amoxicillin.
Non-typhoidal salmonellae are common foodborne pathogens. In Australia, they are the second most frequent bacterial isolates identified in cases of acute gastroenteritis, after Campylobacter jejuni. In 2010, OzFoodNet sites reported 11 992 cases of Salmonella infection, a rate of 53.7 cases per 100 000.1 Salmonella Virchow was the third most common isolate, after Salmonella Typhimurium and Salmonella Enteritidis. Non-typhoidal Salmonella infection outbreaks are most commonly associated with consumption of poultry and eggs, but have also been linked to fresh produce and, increasingly, contact with pet reptiles.2
Up to 8% of patients with gastroenteritis secondary to non-typhoidal Salmonella infection develop bacteraemia.3 Risk factors for invasive infection include extremes of age, immunosuppressed states, malignancy, HIV infection and use of tumour necrosis factor-blocking medication.4 Our case is unusual in that bacteraemia occurred in an otherwise immunocompetent host.
Extraintestinal focal infections have been reported to occur in 5% to 10% of patients with non-typhoidal Salmonella bacteraemia.3 The best recognised complications are endovascular infections, most commonly involving the aorta, that result from seeding of atherosclerotic plaques and aneurysms.5 However, focal infections of almost all organ systems have been reported.
Splenic abscesses are most commonly seen as a complication of infective endocarditis, occurring in about 5% of patients.6,7 They are also found as a rare complication of non-typhoidal Salmonella infections. In one case series of 49 patients from southern Taiwan, Salmonella species were the third most common pathogens isolated from splenic abscesses, accounting for 11% of cases.8 The most common presentations among the 49 patients with splenic abscesses were fever (47 patients), abdominal pain confined to the left upper quadrant (33 patients), left pleural effusion and splenomegaly (both 27 patients), all of which were present in our patient.
About 50% of patients presenting with splenic abscesses have pre-existing anatomical abnormalities.9 The cystic lymphangiomas identified in our patient almost certainly predisposed him to developing splenic abscesses.
According to the literature, the mainstay of treatment for splenic abscesses is splenectomy. Data from 287 cases published between 1987 and 1995 suggested that non-operative management, which included invasive treatment with percutaneous aspiration and catheter drainage, had a success rate of less than 65%.10 The same series suggested that antimicrobial therapy alone had a success rate of less than 50%. Salvage splenectomy, however, was not shown to result in increased mortality. Another retrospective study of 51 patients in a tertiary hospital between 1998 and 2003 reported survival rates of 48% with antimicrobial therapy alone, 45% with pigtail catheter insertion and drainage in addition to antimicrobial therapy, and 100% with splenectomy and antimicrobial therapy.11 These results may be influenced by selection bias but do suggest improved outcomes with splenectomy over less invasive strategies.
Lessons from practice
- Splenic abscesses are a rare but potentially life-threatening complication of non-typhoidal Salmonella bacteraemia.
- Splenic abscesses should be considered as a possible source of infection in patients presenting with unexplained fevers and left upper quadrant or left flank pain.
- Splenectomy plus appropriate antimicrobial therapy remains the mainstay of treatment for splenic abscesses.
- Interventional radiological techniques should be considered as a spleen-preserving strategy on a case-by-case basis and where experienced radiologists are available.
Splenic abscesses are a rare but serious complication of non-typhoidal Salmonella bacteraemia that may occur in otherwise immunocompetent individuals. Splenic abscesses should be suspected in patients with unexplained fevers and left upper quadrant pain. The mainstay of treatment is splenectomy with appropriate antimicrobial therapy.
GPs failing to help patients lose weight
A study has found Australian general practitioners are confusing lack of motivation with low health literacy resulting in a failure to help those who are overweight and obese lose weight.
It’s believed one in five Australians have low health literacy, meaning they don’t have a good understanding of their own health, the measures they can take to improve it and how the healthcare system can help them.
The UNSW study examined how GPs and practice nurses managed overweight and obese patients in 20 practices in disadvantaged areas of Sydney and Adelaide.
It found few of the 61 health staff surveyed assessed a patient’s health literacy, which Professor Mark Harris, Executive Director of UNSW’s Centre for Primary Health Care and Equity, said was important as health professionals often confuse low health literacy with poor motivation.
“Many medical professionals wrongly assume the growing ranks of overweight and obese Australians are not sufficiently motivated to lose weight. Instead, existing research suggests low health literacy may be the culprit,” Professor Harris said.
There are National Health and Medical Research Council (NHMRC) obesity management guidelines to assess health literacy in patients.
Professor Harris and his team are assessing how the NHMRC guidelines can best be incorporated into GP practices.
“In this age when we are drowning in information about lifestyle and weight management, it is important that people with low health literacy are not left behind,” Professor Harris said.
“Tailoring our approach to the needs of those with low health literacy is part of the solution to reversing this trend.”
The results of the study are being presented at the Primary Health Care Research Conference in Adelaide.