NEWSLETTER - DAY 04THURSDAY 21st FEBRUARY

Food marketing blamed For obesity epidemic

By RAY JOSEPHEasy 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,

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, super-sizing, 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.

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 over-eating,”

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

D espite decreas ing morta l i ty rates af ter congenita l

heart d isease (CHD) surgery wor ldwide, the qual i ty of l i fe of many of these young pat ients i s poor, a leading expert has sa id. Speaking at the S ixth World Congress of Paediatr ic Cardio logy and Cardiac Surgery, Dr Bradley Mar ino of C inc innat i Chi ldren ’s Hospita l Medica l Centre, sa id that in addit ion to focus ing on pat ients ’ phys ica l hea l th and funct ioning after intervent ion, hea l thcare providers need to pay attent ion to ch i ldren ’s psycholog ica l and soc ia l funct ioning.

“Cardio log ists ’ pr imary concern i s usua l phys ica l morbid i ty – what can pat ients do and what can ’ t they do?” sa id Mar ino. “The areas they often neglect are the pat ients ’ neurodevelopment and pyschosoc ia l funct ioning.”

For ten years, Mar ino has been compi l ing a Paediatr ic Cardiac Qual i ty of L i fe Inventory (PCQLI ) at 19 medica l centres in the US and the UK. This records the qual i ty of l i fe of ch i ldren between the ages of e ight and 12 and adolescents who are 13 to 18 years o ld with congenita l or acquired heart d isease.

“What we have found is that the greater the complexi ty of the d isease, the lower the qual i ty of l i fe,” he sa id. The number of surger ies the ch i ld has had, the number of medicat ion he takes and the

number of hospi ta l v is i ts in the past year, a l l decrease h is overa l l qua l i ty of l i fe.”

Marino added that ch i ldren f i t ted with pacemakers and those who had had Fontan procedures (a pa l l iat ive surg ica l procedure used in pat ients with complex congenita l heart defects ) scored the lowest of a l l . “These ch i ldren have to face many chal lenges in l i fe. They have cognit ive impairment and a s l ight ly lower IQ and academic achievement than normal.

“They have decreased concentrat ion sk i l l s , but th is doesn ’ t a lways meet the c lass ic cr i ter ia of a learning d isabi l i ty, which means they may not get the r ight support they need at school .”

In addit ion to neurodevelopmenta l problems, these ch i ldren struggle to cope in a soc ia l sett ing. “ In many respects, the ir antennae are of f ,” he expla ined. “They have impaired soc ia l interact ion and def ic i ts in soc ia l cognit ion, as wel l as impaired core communicat ion sk i l l s .”

Emphasis ing the need for intervent ion, Mar ino sa id that more needs to be done whi le pat ients are in hospi ta l . “Parents are under t remendous stress dur ing and after the ICU stay. We should be he lp ing these ch i ldren reach the ir fu l l potent ia l by provid ing the

improving patients’ quality oF liFeBy KATHERINE GRAHAM

services of a psycholog ist , an educat ional spec ia l i s t , a soc ia l worker and an occupat ional therapist .”

He sa id of a l l these workers, the educat ional spec ia l i s t was perhaps the most cruc ia l as she was tasked with l ia is ing with the school so that the ch i ld rece ived the support he needed. “There needs to be greater communicat ion with the school ,” he stressed.

Quality of life, post-surgery, has to improve

Bradley Marino

Patricia Hickey

takayasu’s disease in the spotlight

By SUE SEGARA d i s e a s e w h i c h i s r a r e i n m o s t p a r t s o f t h e w o r l d

b u t r e l a t i v e l y c o m m o n i n S o u t h A f r i c a b e c a u s e o f i t s p o s s i b l e l i n k t o t u b e r c u l o s i s , g a r n e r e d a t t e n t i o n f r o m c a r d i a c s p e c i a l i s t s f r o m a r o u n d t h e w o r l d w h e n t h e y m e t i n C a p e To w n t h i s w e e k .

H u n d r e d s o f d o c t o r s f r o m a l l o v e r t h e w o r l d a t t e n d i n g t h e 6 t h Wo r l d C o n g r e s s o n Pa e d i a t r i c C a r d i o l o g y a n d C a r d i a c S u r g e r y w a t c h e d t h e l i v e s t r e a m i n g o f a c h i l d u n d e r g o i n g a n i n t e r v e n t i o n a l s t e n t i n g o f t h e a o r t a .

T h e c h i l d , a S o u t h A f r i c a n , w a s s u f f e r i n g f r o m Ta k a y a s u ’ s D i s e a s e .

T h e o p e r a t i o n – w h i c h t o o k a b o u t t h i r t y m i n u t e s - w a s h e a d e d u p b y R i k D e D e c k e r o f t h e R e d C r o s s C h i l d r e n ’ s M e m o r i a l H o s p i t a l , w h o w a s a s s i s t e d b y G e o r g e C o m i t i s a n d o t h e r s .

I t w a s o n e o f n u m e r o u s i n t e r v e n t i o n s w a t c h e d b y h e a r t s p e c i a l i s t s , w h o , e a r l i e r t h i s w e e k w a t c h e d w h i l e 1 4 - y e a r -o l d N a m i b i a n G i f t I h u h u a h a d a n a r t i f i c i a l v a l v e i m p l a n t e d t h r o u g h a n a r t e r y w i t h o u t c u t t i n g o p e n h i s c h e s t .

Professor John Hewitson, Chief of Cardiac Surgery at the Red Cross, sa id the operat ion was a very s imi lar procedure to that conducted on Ihuhua – adding that i t was just as exc i t ing and innovat ive.

Takayasu ’s Disease, named after the man who f i rst descr ibed i t in Japan, i s a rare d isease which i s seen more in Southern Afr ica than in the f i rst wor ld, apart f rom in some parts of the East, inc luding Japan.

“It i s a condit ion which, we th ink, i s re lated to tubercu los is and causes a narrowing of the aorta by in-growth in the wal ls ,” Hewitson sa id.

“What has t radi t ional ly been done, over the past few decades, was a surg ica l operat ion to cut out that p iece of aorta and replace i t .

“ In the intervent ional t rack which was demonstrated, a catheter was put into the gro in and fed up the aorta.

The narrowing was then ba l looned open and then a wire s tent was put in.”

Hewitson sa id the operat ion had generated a great dea l of interest at the conference.

“This i s a technique which i s not commonly done in ch i ldren so interest i s h igh.

“Addit ional ly, Takayasu ’s Disease i s a rare d isease in the f i rst wor ld.

“This i s a lso of interest because the technique i s s imi lar to more commonly performed operat ions such as those dea l ing with coarctat ion of the aorta.

Hewitson added that the Red Cross Hospita l i s recognised as having become expert in dea l ing with the d isease “because we see i t more than most do” and because of i ts adeptness at performing the intervent ion.

“It i s a d isease part icu lar to southern Afr ica and whi le the l ink to tubercu los is has not yet been proven, there i s a suspic ion that prev ious

tuberculos is has t r iggered the i l lness in the ch i ld.

“This suspic ion ex ists because some of the patholog ica l spec imens look very s imi lar to tubercu los is .”

Hewitson sa id the d isease i s part icu lar to SA “because our inc idence of tubercu los is i s very, very h igh.

“The d isease i s thought to be a response of the body to tubercu los is . I t i s not caused pr imar i ly by the tuberculos is organism but i t i s something that has been tr iggered in the body and the body gradual ly does th is narrowing of the aorta. I t happens over years.”

Hewitson sa id the Red Cross has been do ing stents for about f ive years and had now mastered the art of conduct ing the operat ions seamless ly.

This meant that South Afr ica had become a f rontrunner in Afr ica for these operat ions.

“We have moved in leaps and bounds s ince we f i rst s tarted do ing these operat ions – and a key reason for th is i s because the technology has a lso moved ahead,” he sa id.

Aortobifemoral bypass in patient with Takayasu’s disease

Rik De Decker

The 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?”,Wernovksy 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 well-being of the patient.

“That was typical of the doctor-centred 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

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.

What about the patientsBy SUE SEGAR

“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 long- term 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.”

Gil Wernovsky

Babies who are in paediatric care need their families involved as much as possible

It 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.

“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.”

h e a l i n g c h i l d r e n ’ s h e a r t s - a h u m a n i t a r i a n a p p r o a c h

By KATHERINE GRAHAM

One 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

obesity a ‘sign oF prosperity’By RAY JOSEPH

Some accosiate 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.

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

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delegates Find the spirit oF the ‘great heart’