These snippets are extracts from a monthly service called the Journal Article Summary Service. It is a service that summarises all that is new in obstetrics and gynaecology over the preceding month. If you would like to know the details of how to subscribe, please email the editor Athol Kent at email@example.com or visit the website www.jassonline.com.
Before anyone casts the first stone (!), the World Health Organization (WHO) estimates that worldwide 1.5 billion adults are overweight of whom 500 million are obese.
Humans are programmed to consume calories during times of plenty. These extra calories are stored in the form of fat to be drawn upon in times of famine. We are limited in our ability to resist food so if manufacturers make available ‘calorie-dense, ready-to-consume, inexpensive food and beverages at arm's reach’ then it is only human to be tempted to take in more than we expend.
Another point not lost on those making a profit on fast foods is the size of portions. Much of the cost of consumable products is wrapped up in the packaging, transporting and advertising of food and drink, so charging more for bigger slices or portions or cans or bottles makes economic sense. The manufacturers are not in the business of selling health. However, as Farley points out (JAMA 2012;308:1093–4) they may be persuaded by legislation to offer a wider choice by marketing smaller portions containing fewer calories but not restricting the number of products purchased.
In New York in particular, the state has a substantial record of regulating public health through smoking prohibition, cleanliness in eateries, safety belts in cars and other enforced restrictions. These are accepted by the people of the city, adding to their health; so why should the size of sugary drinks and foodstuffs not be subject to controls?
The Americans do face an economic conundrum in that the obesity epidemic is being fuelled by an industry that makes money by selling calories while others profit from weight loss programmes and slimming products to the tune of $60 billion per year and the nation's medical bills for obesity are $150 billion annually. Other astounding statistics are that 35% of the population is obese, with this rising to nearly 60% of black women. Two-thirds are overweight using the definitions of body mass indices of >30 and >25, respectively.
The toll of obesity is widespread. It reaches seat sizes, weights in lifts and aeroplanes, clothes sizes, and insurance actuarial statistics, not to mention the medical effects of the metabolic syndrome, diabetes, cardiovascular disease, malignancies, imaging, pregnancy, fertility and the bariatric surgery industry (Courcoulas JAMA 2012;308:1160–1).
More than half the world's population live in countries where overweight and obesity are linked to more deaths than underweight and malnutrition.
The USA's healthcare system remains in a parlous state. The present system is flawed morally, in that universal coverage does not exist, despite this being one of the accepted goals of public health internationally. Margaret Chan (Director General, WHO), Rodin and de Ferranti contend that it ‘is the single most powerful concept that public health has to offer’ (Lancet 2012;380:861–2).
The existing system spends $2.6 trillion per year, or 18% of its gross domestic product, on health. In most other developed countries it is 8–12% and yet the USA health outcomes are mediocre by international standards; so something is fundamentally wrong. The reason is that the system is fragmented and profit driven. There are so many people making the best living they can out of health that costs are unfettered, for example the pharmaceutical industry is the most profitable sector of any in the USA. There are no national standards of practice at preventive, screening, investigatory, diagnostic or curative levels that curtail expenditure, which has led to the Institute of Medicine estimating that $765 billion are currently wasted annually by unnecessary or inefficient services, excess administration, overpricing, missed prevention or fraud (Lancet 2012;380:949) (Figure 1). This amounts to 30 cents in every $1 spent.
Without a coordinated approach the following groups are disadvantaged—the poor, children, ethnic minorities, women and the mentally ill. The last two are worthy of reflection because the Patient Protection and Affordable Care Act (ACA) of President Obama is at risk.
Psychiatric disorders are the most common cause of disability in the USA with about 25% of its 240 million population having a diagnosable mental disorder in any given year (Jeste, Lancet 2012;380:1206–8). These people do not have powerful lobbyists pushing their case, nor are they rich or high-earning, which makes them reliant on a system based on the principles of fairness, compassion and care rather than one driven by capitalist incentives. Given the austerity that is sweeping the economic policies of many countries, the need for universal cover for mentally unwell people is more pressing than ever.
Women are also profoundly affected by the ACA. Much of the Act focuses on preventive services rather than those that react to acute problems and curative processes. For example in recent months health insurers have been obliged to provide the following benefits without extra payment: annual examinations, HIV screening, cervical cancer screening, sexually transmitted disease counselling, domestic violence support, breastfeeding assistance and all Food and Drug Administration approved family planning. Also, it will be illegal to charge a woman more for insurance because she is a woman. Inequities are being removed and an estimated 47 million women will be eligible for new benefits (Jaffa, Lancet 2012;380:962–5).
Also central to the legislation is the issue of contraception and religious freedom. The Democrats argue that with half of the 6 million births each year being unintended, and termination of pregnancy rates double that of most developed countries—the state has an obligation to provide education and services to give men and women access to free contraception including sterilisation. Republicans take the view that this forces taxpayers to fund a choice of services ‘even if it violates our religious freedom, our religious liberty, and our conscience’.
At present American women are more hard-pressed than their European sisters to cover the costs of health care. More than 40% said that they could not afford to access recommended care, visit a doctor when sick or have a prescription filled because of financial constraints compared with less than 10% of their transatlantic counterparts. Maternity services, including gestational diabetes screening, will be covered by 2014 when obstetrics becomes part of the essential health benefits package.
There is much to be done to raise the healthcare status of American women.
Chocolate and pre-eclampsia
The origins of pre-eclampsia probably lie in crucial anatomical and functional adaptations as early as the end of the first trimester. At this stage there is cytotrophoblastic invasion of the decidua lining the myometrium. This process mainly affects the spiral arterioles, which will supply the growing placenta with blood at a low pressure but in high volume. For this to happen both the endothelium, which is thin but functionally active, and the elastic lamina, which is sensitive to vasoactive substances, have to change their nature.
The endothelium has to secrete substances that control smooth muscle reactivity of which nitric oxide and prostacyclin are the most important. In pre-eclampsia there is a deficiency of these and of anti-platelet aggregation factors. Whether this is ‘cause or effect’ is unclear but the net result is vasoconstriction as the result of an abnormal prostacyclin/thromboxane ratio and platelet deposition that is not confined to the uterus but is found throughout the entire vascular tree causing systemic reactions and multiorgan disease. Much effort has been directed at increasing nitric oxide and prostacyclin levels by supplementation or altering platelet function with aspirin but success has been limited.
Other substances that may have therapeutic potential are foods rich in anti-oxidants. Flavonoids show particular promise in cardiometabolic disorders where their action seems to improve function through increased sensitivity to insulin and the provision of vasodilatory antioxidants. Cocoa beans contain flavonoids so it is unsurprising that cocoa drinks have shown promise in people thought to have impaired cognitive function because of circulatory problems (Desideri et al. Hypertension 2012;60:794–801). Cocoa is found in abundance in chocolate so it may be an option in preventing pre-eclampsia.
There is some observational evidence in its favour (Saftlas et al. Ann Epidemiol 2010;20:584–91) with a systematic review last year showing convincingly that it has substantial antihypertensive anti-inflammatory, anti-atherogenic and anti-thrombotic effects (Buitrago-Lopez et al. BMJ 2011;343:E4488). No wonder those who are fast out of the blocks have pilot studies underway (Robson & de Costa O&G Magazine 2012;14:41–3).
The researchers’ concerns are how to prevent intervention and control groups from eating too little or too much chocolate!
Organic food and health
Intuitively organic farming methods should yield healthier products because they do not use synthetic compounds, antibiotics, growth hormones and irradiation. However, it is hard to link the consumption of organically produced foodstuffs with better health outcomes.
In a recent paper researchers were, however, able to measure less likelihood of contamination with pesticides and higher levels of phosphorus plus total phenols in organically grown crops compared with conventional produce (Smith-Spangler et al. Ann Int Med 2012;157348–66). There was also some evidence of bacteria being less resistant to antibiotics and less fungal toxin contamination but direct evidence of improved health will probably take a long time and involve careful consumers over many years.
Two Swedish women have received uterine transplants from their mothers. Both in their 30s, the recipients now possess the uterus in which they themselves were nurtured. A team of ten surgeons carried out the operations in the same hospital where research had been in progress for more than a decade (Hansen BMJ 2012;345:e6357).
One woman had a hysterectomy for cervical cancer and the other had congenital absence of a uterus. Evidently the operations were uncomplicated and the women will remain on immunosuppressant therapy for a year, after which assisted reproductive techniques will be commenced, with pregnancy the ultimate test of an entirely successful outcome.