NEWSLETTER - DAY 04 THURSDAY 21st FEBRUARY
Food marketing blamed for obesity epidemic E
asy access to fast foods has resulted in the “rewiring” of modern man’s brains and created a form of food addiction that has led to gross overeating and obesity among children, says a leading Canadian paediatric cardiologist. Obesity was now occurring in “young and younger children, as young as five, and fast food marketing was increasingly aimed at children, says Dr Brian McCrindle, of The Sick Children’s Hospital in Toronto. To fight the growing scourge of obesity it was essential to control the marketing of fast food to children, who are consuming an increasing amount of junk food while sitting in front of TV, he says. “Activity levels among children had dropped and they are spending more and more time in front of TV or playing video games, while consuming unhealthy foods.” Unlike the eating habits of man’s hunter gatherer ancestors who ate because they were hungry, modern fast food, just like other addictions,
By RAY JOSEPH triggered dopamine “rewards” in the brain. “The first step has to be to limit direct marketing of foods and the video games that are direct drivers of overeating,” Equally important in the case of adults was the need to label all foods so people could see how many calories they contained, so they could make decision on the kind of food they consumed, he says. Early man was primarily a gatherer - and sometimes hunter _ who lived on a high fibre, low calorie diet and humans were “designed” to conserve and store energy as fat. Food was scarce and there were “times of famine and feast” and ancient man tended to eat food they were sated, but with “addictive”, modern fast foods people ate to reward themselves even if they were not hungry. “There was a granular development as food source became stable and then the late 60s and 70s saw the advent of
Hunter gatherers ate due to hunger, not cravings
hyper-palatable foods, which changes the brain’s neural responses,” he says. “By the 80s we began noticing a dramatic increase in population weights ... heavier people became heavier. It was even more noted in adolescents and children,” says McCrindle. Instead of people eating because they were hungry, he says, “it became crave and reward and people were compelled to over-consume”, leading to an increase in obesity. Tasty fast foods motivate behaviour that triggers impulses in the brain’s dopaminergic centres that are related to addiction and rewards. The fast food industry tapped into the brain’s rewards process by producing hyper-palatable food, which inevitably contained unhealthy quantities of sugar, fat and salt to make it taste good. “It builds up good memories of food as entertainment and leads people to self-reward. And larger portions, supersizing, are seen as a higher reward value,” says McCrindle. Adding to the growing obesity problem was the unlimited access to fast foods that people now have, which has led to “hyper eating”. “They (fast food chains) are not concerned about health, it’s all done for profit,” he concludes.
Improving patients’ quality of life D
espite decreasing mortality rates after congenital heart disease (CHD) surgery worldwide, the quality of life of many of these young patients is poor, a leading expert has said. Speaking at the Sixth Wo r l d C o n g r e s s o f Pa e d i a t r i c Cardiology and Cardiac Surgery, Dr Bradley Marino of Cincinnati Children’s Hospital Medical Centre, said that in addition to focusing on patients’ physical health and functioning after intervention, healthcare providers need to pay attention to children’s psychological and social functioning. “Cardiologists’ primary concern is usual physical morbidity – what can patients do and what can’t they do?” said Marino. “The areas they often neglect are the patients’ neurodevelopment and pyschosocial functioning.” Fo r t e n y e a r s , M a r i n o h a s b e e n c o m p i l i n g a Pa e d i a t r i c Cardiac Quality of Life Inventory ( P CQ L I ) a t 1 9 m e d i c a l c e n t r e s i n the US and the UK. This records the quality of life of children between the ages of eight and 12 and adolescents who are 13 to 18 years old with congenital or acquired heart disease. “What we have found is that the greater the complexity of the disease, the lower the quality of life,” he said. The number of surgeries the child has had, the number of medication he takes and the
Quality of life, post-surgery, has to improve
By KATHERINE GRAHAM number of hospital visits in the past year, all decrease his overall quality of life.” Marino added that children fitted with pacemakers and t h o s e w h o h a d h a d Fo n t a n procedures (a palliative surgical procedure used in patients with complex congenital heart defects) scored the lowest of all. “These children have to face many challenges in life. They have cognitive impairment and a slightly lower IQ and academic achievement than normal. “They have decreased concentration skills, but this doesn’t always meet the classic criteria of a learning disability, which means they may not get the right support they need at school.” In addition to neurodevelopmental problems, these children struggle to cope in a social setting. “In many respects, their antennae are off,” he explained. “They have impaired social interaction and deficits in social cognition, as well as impaired core communication skills.” Emphasising the need for intervention, Marino said that more needs to be done while patients are in hospital. “ Pa r e n t s a r e u n d e r t r e m e n d o u s stress during and after the I C U s t a y . We s h o u l d b e h e l p i n g these children reach their full potential by providing the
Bradley Marino
services of a psychologist, an educational specialist, a social worker and an occupational therapist.” He said of all these workers, the educational specialist was perhaps the most crucial as she was tasked with liaising with the school so that the child received the support he needed. “There needs to be greater communication with the school,” he stressed.
Takayasu’s disease in the spotlight A
disease which is rare in most parts of the world but relatively common in South Africa because of its possible link to tuberculosis, garnered attention from cardiac specialists from around the world when they met in Cape To w n t h i s w e e k . Hundreds of doctors from all over the world attending t h e 6 t h Wo r l d C o n g r e s s o n Paediatric Cardiology and Cardiac Surgery watched the live streaming of a child undergoing an interventional stenting of the aorta. The child, a South African, w a s s u f f e r i n g f r o m Ta k a y a s u ’ s Disease. The operation – which took about thirty minutes - was headed up by Rik De Decker of the Red Cross Children’s Memorial Hospital, who was assisted by George Comitis and others. It was one of numerous interventions watched by heart specialists, who, earlier this week watched while 14-yearold Namibian Gift Ihuhua had an artificial valve implanted through an artery without cutting open his chest.
Aortobifemoral bypass in patient with Takayasu’s disease
By SUE SEGAR Professor John Hewitson, Chief of Cardiac Surgery at the Red Cross, said the operation was a very similar procedure to that conducted on Ihuhua – adding that it was just as exciting and innovative. Ta k a y a s u ’ s D i s e a s e , n a m e d after the man who first described it in Japan, is a rare disease which is seen more in Southern Africa than in the first world, apart from in some parts of the East, including Japan. “It is a condition which, we think, is related to tuberculosis and causes a narrowing of the aorta by in-growth in the walls,” Hewitson said. “What has traditionally been done, over the past few decades, was a surgical operation to cut out that piece of aorta and replace it. “In the interventional track which was demonstrated, a catheter was put into the groin and fed up the aorta. The narrowing was then ballooned open and then a wire stent was put in.” Hewitson said the operation had generated a great deal of interest at the conference. “This is a technique which is not commonly done in children so interest is high. “Additionally, Ta k a y a s u ’ s Disease is a rare disease in the first world. “This is also of interest because the technique is similar to more commonly performed operations such as those dealing with coarctation of the aorta. Hewitson added that the Red Cross Hospital is recognised as having become expert in dealing with the disease “because we see it more than most do” and because of its adeptness at performing the intervention. “It is a disease particular to southern Africa and while the link to tuberculosis has not yet been proven, there is a suspicion that previous
Patricia Hickey
Rik De Decker
tuberculosis has triggered the illness in the child. “This suspicion exists because some of the pathological specimens look very similar to tuberculosis.” Hewitson said the disease is particular to SA “because our incidence of tuberculosis is very, very high. “The disease is thought to be a response of the body to tuberculosis. It is not caused primarily by the tuberculosis organism but it is something that has been triggered in the body and the body gradually does this narrowing of the aorta. It happens over years.” Hewitson said the Red Cross has been doing stents for about five years and had now mastered the art of conducting the operations seamlessly. This meant that South Africa had become a frontrunner in Africa for these operations. “ We h a v e m o v e d i n l e a p s a n d bounds since we first started doing these operations – and a key reason for this is because the technology has also moved ahead,” he said.
What about the patients
T
he families of children in paediatric care should be intimately involved in their care. This was the powerful message put forward by Professor Gil Wernovsky, former medical director of the Cardiac Intensive Care Unit at the Children’s Hospital, Philadelphia. In a presentation entitled “What is Patient-Centred Care and how do we practically do it?”,Wernovsky said it was crucial that families should “feel like partners” in their children’s medical journeys. Speaking during the Ethics and Patient-Centred Care session, Wernovsky cited examples of medical check-lists, dating back to the past, which did not once refer to the wellbeing of the patient. “That was typical of the doctorcentred era. In the past, so much revolved around the doctors’ convenience, rather than taking the patients and their families into account. In a moving presentation, Wernovsky said he had become passionate about patient-centred care in the second half of his 26-year career. “It is important that the family is involved because, after all is said and done, they are left with the products of our work and they absolutely
By SUE SEGAR should feel that they are partners in what we do.” Wernovsky said there had been a fundamental shift in the “paternalistic” delivery of care in hospitals – from thinking of families as “visitors” and children as “patients”, to putting the patient and the family at the centre of care. “That shift has changed policies, interactions, physical facilities of hospitals and clinics and information sharing. “The patient is no longer along for the ride but they are active participants.” Wernovsky said this shift was important for two reasons. “Firstly, in this current era of frequent hand-overs of information between caregivers, some information may get lost or dropped. A person who knows the best about the medical care of the patient is usually the patient or their family, so involving them in the process is key to providing safe and complete care. “The second reason is that it is just right. No longer is the doctor always right … It is a shared decision-making process.” Wernovsky said a “seminal event” changed his own perspective from doctor-centred to patient-centred care.
Babies who are in paediatric care need their families involved as much as possible
Gil Wernovsky
“The mother of a 14-year-old patient came into my office, excused her son, picked up a research paper and held it in my face and said “you’ve known about this problem (an issue relating to the schooling issues of children with congenital heart disease) for five years” - and she was right. “She felt frustrated that we were withholding information and that her son was doing poorly. She said, had she known, she might have been able to mitigate those outcomes for her child. “That led me to my transition from being the paternalistic physician saying “this is what I prescribe for you” to the approach I take now which asks the patient “what are your expectations, what do you want to get out of this procedure and how are we going to get there together?” Patient-centred care meant being transparent with the families and letting them know they were part of the process if they wanted to be. “The leadership must say our goal is first and foremost to take care of that child. It doesn’t matter what our shift has been like or what any of our daily frustrations have been. It all must completely focus on the patient. “ The shift, said Wernovsky, had been “completely rewarding”. “I love doing what I do. I always have. I am a lucky man as I do both paediatric intensive care and longterm follow up. I am getting to see adults who I took care of as neonates. Learning what we did and didn’t do well has been very rewarding for me personally but also feeds back on how I take care of the next baby.”
Obesity a ‘Sign of prosperity’ O
ne of the reasons for obesity among black South Africans was a concern that if someone was too thin, people would think they were suffering with HIV or AIDS, according to a research who has investigated links between obesity and cardiovascular disease (CVD). “If you are thin, people think you may have AIDS and being fat is also seen as a sign of prosperity,” says Kemi Tibazwara, a medical registrar at the University of Cape Town, who delivered a paper on Weight Issues on the African Continent. Another factor behind the increase in obesity among black South Africans was the growth of a growing middle class and the proliferation of easily accessible fast foods, says Tibazwara. “Diets have changed and people are eating less healthy food with a higher sugar, fat and salt content.” Research had also found a link between children with a low birth
By RAY JOSEPH weight who then went through rapid weight increases and cardio vascular disease (CVD) in later life, says Tibazwara. Urbanisation in Africa has meant that what was previously a disease of the West, is now prevalent in lower income countries. A third of all deaths caused by non-communicable diseases in South Africa were as a result of CVDs. Research in Soweto had shown a high rate of obesity and while CVDs were most prevalent among older people in the developed world, in Africa it 2.5 times higher than in the United States among young people. Studies in 2006 among hospital patients, in clinics and at shopping centres and taxi ranks showed a direct correlation between obesity and CVDs. In one study among a group of 4162 patients in which
Some associate AIDS with looking thin
obesity was prevalent, 1593 were newly diagnosed with CVD. “Of 56 percent who were found to have CVD, 47 percent were obese,” she says. The advent of cardiovascular disease appears to begin after adolescence and accelerates rapidly among women in their 20s and men in their 30s. “Therefore we should target people at schools in order to educate them about obesity from a young age,” she says.
Healing children’s hearts - a humanitarian approach I
t is much easier and cheaper to treat children with congenital heart disease (CHD) in their home country than overseas, several leading experts in humanitarian cardiac care have said. Speaking of his experience at the Clinica Girassol in Luanda, Angola, Manuel de Magalhaes said that it cost $100 000 to fly an underprivileged child overseas for lifesaving heart surgery, compared with only $35 000 to treat him in Luanda. “Clinica Girassol is 100% subsidised by the Angolan department of health,” he said. “We train local staff and receive no foreign assistance.” To date, the hospital has performed 743 interventions, of whom 19 were adult surgery patients and 724 were paediatric interventions. The overall mortality rate is low at 4.8%. At the same session, Afskendiyos Kalangos of the Global Heart Network stressed the importance of south-south collaboration. “Globally, there are six to eight million children who need cardiac surgery and the ratio of cardiologists to the rest of the population is very low in developing countries,” he said. “I am encouraged by the example of Mauritius, which recently sent personnel from its cardiac centre to train a team in Botswana.” Samantha Colquhoun, Pacific and international rheumatic heart disease (RHD) coordinator at Menzies School of Health Research, spoke about the challenges of getting reliable data on which to base funding proposals.
By KATHERINE GRAHAM “The first question governments ask us is: ‘How big is the burden of disease and how much will it cost?’ Given that the Pacific Islands are geographically remote with a diverse population, it is difficult for us to always know the answers.” In the Fiji Islands, for example, where there was no RHD programme prior to 2005, the government is “highly engaged and supportive”, Colquhoun said. Her team has started a register there with more than 2 000 cases and has organised workshop training for health professionals. In addition, RHD has been included in Fiji’s nursing and medical curriculum and screening capacity at clinics and hospitals has been expanded. Bistra Zheleva of Children’s Heartlink said that the organisation’s early approach had been to bring children from developing countries to Minnesota for surgery, but that strategy changed in the late 1980s. “Our current focus is to build capacity locally, such as clinical capacity as well as community and regional systems. We also run programmes and partnerships,” she said. Zheleva said that in the countries where Children’s Heartlink operated, including Brazil, India, Vietnam and Ecuador, their support is done in a phased way, very intensive at first and gradually becoming less involved. “Our goal is for our support to last five to ten years, after which the clinic is completely self-sufficient.”
Delegates find the spirit of the ‘great heart’
This newsletter was produced by the team at HIPPO. www.hippocommunications.com