Deprived Circumstances Research Articles

Dietary recommendations for children and adolescents with diabetes: an implementation paper

Summary and recommendationsI General. 1. Children with diabetes mellitus have the same basic nutritional requirements as all other children. 2. Dietary recommendations should be based on good eating habits for the whole family. Radical changes in diet involving unusual foods or eating patterns for the child with diabetes alone are not appropriate. 3. Energy requirements of children vary widely and the energy content of the diet should be based on what the child usually eats. The diet should be reviewed regularly to meet the changing needs of growth and physical exercise without obesity. 4. The insulin regimen should, as far as is possible, be chosen to fit the child's daily life‐style and preferred eating habits. Insulin type, dose and frequency should be reviewed with the diet as the child develops. 5. Regular distribution of meals and snacks throughout the day remains the most important way to avoid extremes of hyperglycaemia and hypoglycaemia. This distribution should be based on an exchange system, using handy measures and taking into account food and meal type, the particular insulin regimen and the child's exercise patterns and usual eating habits. Currently, this exchange system is based on carbohydrate foods but in the future the energy and fat contents will need further consideration. 6. Most special ‘diabetic foods’ are unnecessary. Low‐calorie sweeteners, as used in low‐calorie fruit squashes and fizzy drinks, are useful. 7. Children with diabetes from specific ethnic minority groups, or on vegan diets or living in deprived circumstances require special dietary attention for their diabetes. Those with coexisting chronic disorders such as cystic fibrosis or coeliac disease, should receive dietary advice from professionals with specialist knowledge. 8. Translating the principles of diabetic dietary management into a varied diet, arranged readily by the parents and eaten by the child, is demanding. It can best be met by a skilled dietitian working in close cooperation with child, parents, diabetes specialist nurse and doctor. n Infancy. 9. The diet should not differ from that of infants without diabetes. Breast feeding should be encouraged or a standard infant formula‐feed used. Solids may be introduced from 3 to 6 months, but breast milk or a modified infant formula is encouraged as part of the increasingly mixed diet to at least the end of the first year. 10. Diabetes is rare in infancy so expert advice should be sought from dietitians experienced in paediatric diabetes.III Under‐fives. 11. After 2 years of age the diet should slowly be changed to one relatively low in fats, with unrefined carbohydrate foods, fitting family customs and meeting energy needs. 12. Fully skimmed cows' milk contains insufficient vitamins A and D, too little fat and therefore energy for the under‐fives. However, semiskimmed milk can safely be included in a nutritionally adequate diet from the age of 2 years. 13. Vitamin supplementation may be given to children aged from 1 month to 5 years according to needs and local practice for all children. There are no specific additional requirements for the under‐fives with diabetes.IV Schoolchildren. 14. Reduction of fat intake, especially of saturated fats, is expected to reduce risk of coronary heart disease, and stroke in later life. After 5 years of age fat intake should be reduced to around 35–40% of total energy. 15. Replacing energy from fat by eating half or more of the daily food energy as carbohydrate, principally from unrefined, fibre‐rich sources, may improve both short‐ and long‐term health. Dietary carbohydrate for the child with diabetes should never be restricted below the usual family intake (usual range 45–50% of calories). 16. Schoolchildren should be encouraged to select their carbohydrate from sources which are rich in soluble fibre with physical structure intact (e.g. whole fruit, oats, porridge, peas, beans and lentils). These have been shown to improve glycaemic control. 17. Consumption of rapidly absorbed carbohydrate in the form of simple sugar such as fruit juice and sweets or refined starch such as mashed potato in isolation, should be discouraged. However, when used in conjunction with other nutrients within a meal, simple sugars and refined starch improve palatability without worsening metabolic control. 18. The use of sugars to prevent or treat hypoglycaemia should be established on an individual basis. 19. The proportion of energy taken as protein should not be increased among children with diabetes compared with their normal peers. 20. Supplements of minerals and vitamins are not required where a good balance of foods is taken. 21. Regular exercise should be encouraged, and insulin dose reduced or extra dietary energy provided as indicated by individual blood glucose monitoring.

Dietary Recommendations for Children and Adolescents with Diabetes: An Implementation Paper

General Recommendations: 1. Children with diabetes mellitus have the same basic nutritional requirements as other children. 2. Dietary recommendations should be based on good eating habits for the whole family. Radical changes in diet involving unusual foods or eating patterns for the child with diabetes alone are not appropriate. 3. Energy requirements of children vary widely and the energy content of the diet should be based on what the child usually eats. The diet should be reviewed regularly to meet the changing needs of growth and physical exercise without obesity. 4. The insulin regimen should, as far as is possible, be chosen to fit the child's daily lifestyle and preferred eating habits. Insulin type, dose, and frequency should be reviewed with the diet as the child develops. 5. Regular distribution of meals and snacks throughout the day remains the most important way to avoid extremes of hyperglycaemia and hypoglycaemia. This distribution should be based on an exchange system, using handy measures and taking into account food and meal type, the particular insulin regimen and the child's exercise patterns and usual eating habits. Currently this exchange system is based on carbohydrate foods but in the future the energy and fat contents will need further consideration. 6. Most special 'diabetic foods' are unnecessary. Low calorie sweeteners, as used in low calorie fruit squashes and fizzy drinks, are useful. 7. Children with diabetes from specific ethnic minority groups, or on vegan diets or living in deprived circumstances require special dietary attention for their diabetes. Those with coexisting chronic disorders such as cystic fibrosis or coeliac disease, should receive dietary advice from professionals with specialist knowledge. 8. Translating the principles of diabetic dietary management into a varied diet, arranged readily by the parents and eaten by the child, is demanding. It can best be met by a skilled dietitian working in close co-operation with child, parents, diabetes specialist nurse and doctor. Infancy 9. The diet should not differ from that of infants without diabetes. Breast feeding should be encouraged or a standard infant formula-feed used. Solids may be introduced from 3-6 months, but breast milk or a modified infant formula is encouraged as part of the increasingly mixed diet to at least the end of the first year. 10. Diabetes is rare in infancy so expert advice should be sought from dietitians experienced in paediatric diabetes. Under fives: 11.(ABSTRACT TRUNCATED AT 400 WORDS)

Citizen Activity: Who Participates? What Do They Say?

We use responses to a large-scale national survey designed to oversample political activists to investigate the extent to which participant publics are representative of the public as a whole. Building upon the finding that while voters differ from nonvoters in their demographic attributes, their attitudes as measured by responses to survey questions are not distinctive, we consider a variety of political acts beyond voting that citizens can use to multiply their political input and to communicate more precise messages to policymakers. In addition, we consider not only respondents' demographic characteristics and policy attitudes but also their circumstances of economic deprivation and dependence upon government programs. Although activists are representative of the public at large in terms of their attitudes, they differ substantially in their demographic attributes, economic needs, and the government benefits they receive. Furthermore, in terms of the issues that animate participation, groups differentiated along these lines bring very different policy concerns to their activity.

The epidemiology of rheumatoid arthritis in Indonesia.

The prevalence of RA was investigated as part of a house-to-house survey of musculoskeletal pain in a total population of 4683 rural and 1071 urban subjects 15 years of age and over in Central Java. Those identified as having peripheral joint pain of more than 6 weeks duration (82 men and 129 women) were examined by a rheumatologist (JD) and serology tests and X-rays arranged. The prevalence of definite RA by ARA criteria was 0.2% in rural and 0.3% in urban subjects. The severity of diagnosed cases was indicated by Steinbrocker's functional classification of grades 2 and 3 and erosive arthritis on hand X-rays of grades 2-4. The low prevalence rate of RA compared with that found in developed countries is due partly to the different age structure of the population and lower life expectancy. There is also evidence of high mortality from the disease. This is thought to be due to the deprived socio-economic circumstances, the intermittent use of high dose corticosteroids and the frequent presence of severe infections in these communities. These factors should be considered when assessing the low prevalence of RA in surveys in other developing countries.

A comparison of height, weight and head circumference of primary school children living in deprived and non-deprived circumstances

Heights, weights and head circumferences were obtained from two groups of primary school children: 1016 children from throughout Oxfordshire, a rural county with few areas of deprivation, and 219 children from an economically deprived part of the city of Newcastle on Tyne. Compared to Tanner and Whitehouse standards, Oxfordshire children were significantly taller, but not heavier, while the Newcastle children were significantly shorter and markedly lighter. Mean head circumference values were lower in the Newcastle than the Oxfordshire children. Existing national growth standards are outdated when applied to children in acceptably advantaged circumstances while impoverished children still fall below these standards in a pattern suggestive of under nutrition.

Protein Turnover: A Functional Appraisal

Pioneering works of Schoenheimer and his colleagues (Schoenheimer, 1942) were the first to recognize 'the dynamic state of body constituents'. Prior to that time, the cell was viewed as a chemical engine, burning exogenous fuels, but which did not itself undergo metabolic transformations. Now, however, comprehensive evidence indicates that cellular proteins are in a continual state of renewal, and that the general properties of protein turnover are similar in prokaryotes and in eukaryotes. Essentially all proteins in living organisms undergo continual replacement, although there is marked heterogeneity between fractional rates of replacement of different proteins, as well as between the same proteins in different tissues, and the great majority of protein turnover is intracellular (e.g. Goldberg & Dice, 1974; Schimke, 1975; Goldberg & St. John, 1976; Ballard, 1977; Millward, Bates & Rosochaki, 1981; Fauconneau, 1985; Mayer, 1987; Houlihan et al., 1988; Bradshaw, 1989). There are several pathways of protein degradation within cells (Dice, 1987; Bradshaw, 1989). Different rates of renewal under normal metabolic conditions are effected by selective degradation that is mostly non-lysosomal, involving calciumdependent proteolysis, as well as the ubiquitindependent pathway in which each protein is first 'targeted' by conjugation with ubiquitin molecules (Hershko et al., 1980; Ciechanover, Finley & Varshavsky, 1984; Wheatley, 1984; Ciechanover, 1987; Varshavsky, Bachmair & Finley, 1987; Gonda et al., 1989; Bachmair & Varshavsky, 1989). Alternatively, pathways by which proteins are taken up and digested in lysosomes are non-selective and inducible, being active primarily under circumstances of nutrient deprivation or stress (Dice & Chiang, 1989). In the present contribution, protein turnover refers specifically to the continuous degradation and renewal of intracellular proteins that are hydrolysed to their component amino acids, and replaced by an equal amount of freshly synthesized protein. Protein metabolism is comprised of the two separate processes both of protein degradation and protein synthesis, which may vary in the same or in opposite directions (e.g. Rennie et al., 1983; Muramatsu et al., 1987). Each process must therefore be measured to quantify turnover and identify alterations effecting changes in net balance. Under conditions of growth, rates of protein turnover are equivalent to associated rates of protein degradation. Such renewal may occur at surprising intensities. Although relatively insignificant in procaryotes, a minimum of 77% of whole-body protein synthesis effects turnover rather than net deposition among mammals generally (e.g. Waterlow, Garlick & Millward, 1978; Reeds et al., 1980). Alternatively, during periods of net protein loss and wasting, protein turnover equates with rates of protein synthesis. A variety of techniques for the measurement of these processes includes both precursor methods and end-product methods, each with potential pitfalls, but which may provide reasonable accuracy as discussed comprehensively elsewhere (e.g. Waterlow et al., 1978; Reeds & Lobley, 1980; Garlick & Fern, 1985; McNurlan & Garlick, 1989). Given associated energy costs, why should protein turnover be necessary at all? Schoenheimer (1942) believed that protein breakdown was of equal significance to protein synthesis in providing the flux that renders biological systems so dynamic and adaptable. Since then, molecular and biochemical research have continued to reveal important regulatory functions of proteins. Indeed, amino acids are now known to be the precursors of modulating molecules which include nucleic acids, haem, neurotransmitters, hormones, proteases, opioid peptides (Giugliano et al., 1988) and chaperones (Sambrook & Gething, 1989). Realization of the generality of protein turnover, and that breakdown is as important as

Ecumenical Burial Societies in South Africa: Mutual Caring and Support that Transcends Ecclesiastical and Religious Differences

Burial societies play a significant role in the African community in South Africa. Even in the most deprived circumstances, Africans concern themselves with burials of dear ones worthy of the person and the occasion. The sense of mutual support which has always been foremost in the African community comes to expression within the context of the burial societies. Each burial society is a mutual aid organization. Each member contributes towards this communal assistance. In no other organization associated with the churches are denominational and ecclesiastical barriers of so little concern as in the context of these burial societies. Here many non-Christians receive for the first time the Christian message. A few thousand such burial clubs or societies exist in South Africa, with several million members from South Africa's black community.

Peripheral metabolism of [35S]parathyroid hormone in vivo: influence of alterations in calcium availability and parathyroid status.

Parathyroid hormone (PTH) is rapidly metabolized, mainly by liver and kidney, to smaller fragments that are believed to be biologically inactive. The significance of this peripheral metabolism in the overall actions of PTH is unclear. Generation of circulating biologically active amino-terminal PTH fragments during metabolism in vivo has been suggested by certain observations in vitro, and what are believed to be amino-terminal fragments may be detectable in blood under pathological circumstances in vivo (such as renal failure and coexistent hyperparathyroidism) when highly sensitive assays are employed. We recently reported, however, that administration to normal rats of [35S]bovine PTH ([35S]bPTH) directly labelled at amino-terminal methionines, followed by high-resolution chromatographic analysis of extracted [35S]peptides, does not result in appearance of radioactive amino-terminal fragments in blood, even when the tracer is continuously infused to near-physiological plasma concentrations. We have now employed these techniques to address a second question regarding hormonal metabolism: is hormonal metabolism modified during metabolic perturbations such as changing calcium availability or altered levels of calciotrophic hormones? Metabolism of [35S-Met]bPTH (900 Ci/mmol), either alone or together with [3H-Pro]bPTH, however, did not lead to alterations in the rate of hormonal clearance nor to detectable circulating amino-terminal fragments, either in calcium-deprived or thyroparathyroidectomized rats or when animals were first rendered intoxicated with vitamin D or maintained on a high calcium intake. Likewise, tissue localization and specific cleavage patterns of intact hormone in liver or kidney were all unaltered by these various manoeuvres.(ABSTRACT TRUNCATED AT 250 WORDS)

Causal Attributions for Achievement of Filipino Barrio Children

Summary An investigation of the causal attributions of 82 male and 112 female school children from a depressed rural area of the Philippines found that they ascribed examination results almost equally to ability, effort, and task difficulty. Luck, although rated more important than in Western studies, was considered the least important cause. The males tended to rate unstable factors, effort and luck, as more important than did the females. Unsuccessful students were least likely to use internal ascriptions, consistent with the self-serving bias hypothesis. The results were similar to those obtained from students at a major prestigious Filipino university. In general, this study supports the Filipino literature which indicates that the outlook on life of Filipinos, even from deprived circumstances, tends to be one of “optimistic fatalism.”

The steady-state counterclockwise/clockwise ratio of bacterial flagellar motors is regulated by protonmotive force

A new aspect of the regulation of the bacterial flagellar motor is described. Protonmotive force, i.e. proton electrochemical potential across the cell membrane, not only drives motility, but was found to exert a regulatory effect on the switching of the motor between counterclockwise and clockwise senses. When motor speed was reduced by reducing protonmotive force (but not when speed was reduced by increasing external load), the motor spent a higher fraction of time in counter-clockwise rotation, although the speed in both senses remained equal; at approximately 80% of the maximum motor speed under any given external load condition, no detectable clockwise rotation remained in most cells, i.e. the motor no longer reversed and so cells swam without tumbling. The altered state of the motor remained as long as the state of low protonmotive force remained. Therefore the phenomenon was not a transient tactic response, although it did modify the response to chemotactic stimulation. The regulation of counter-clockwise xxx clockwise switching by protonmotive force appears to be rather general, having been demonstrated in Salmonella, Escherichia coli and Bacillus subtilis. A moderate reduction in protonmotive force from its normal level in actively metabolizing cells did not affect motor reversibility. Motor speed was also unaffected under these conditions (Khan & Macnab, following paper). The existence of a saturation regime with regard to both speed and reversibility suggests that the regulation of motor switching may involve the actual protons driving the motor. All general chemotaxis mutants tested, including those known to be defective in the chemotactic methylation system, were susceptible to protonmotive force regulation in a manner consistent with their normal steady-state counter-clockwise/clockwise ratio. Even mutants that appear “counterclockwise only” could be made more so upon lowering protonmotive force, in that their capacity for clockwise tactic responses was impaired. Since responses to attractants and repellents do not involve an alteration in speed, we conclude that protonmotive force and chemotactic regulatory inputs to the motor operate in parallel. the clockwise/counterclockwise ratio showed an increasing exponential dependence on motor speed. This was a result of both an increased counterclockwise→clockwise switching probability and a decreased clockwise→counterclockwise switching probability. These probabilities were found to be inversely related, so that their product was roughly independent of motor speed. An examination of the pattern of clockwise/counterclockwise switching in tactically stimulated cells and in chemotactic mutants suggests that this is a fundamental property of the motor, which may indicate that switching events in both directions are under the same controlling mechanism. We suggest that suppression of tumbling in circumstances of metabolic deprivation might have survival value by permitting a more rapid dispersal of a population from a region of scarcity of food or oxygen, even when no local gradient is present.

LOW BIRTH WEIGHT AND PRENATAL NUTRITION: AN INTERPRETATIVE REVIEW

Birth weight is considered as a possible crucial intervening variable in a causal sequence that leads from prenatal nutrition to perinatal mortality and retarded child development. Birth weight is shown to have a stronger correlation with perinatal mortality than length of gestation. In New York City, if black infants had the same birth weight distribution as white infants, and the same weight-specific perinatal death rates as they now do, their expected overall perinatal death rate would be the same as for white infants. Three conclusions are germane to the prevention of low birth weight: first, the fetal growth that leads to important variation in birthweight occurs in the last trimester; second, birth weight is influenced by factors in the wider environment as well as in the maternal environment; and third, birth weight is influenced by factors having their origin and effect during gestation. The role of maternal nutrition during gestation is then examined as a factor in birth weight. Observational studies of circumstances of wartime deprivation support a nutritional hypothesis, but observational studies of everyday diets in pregnancy, and quasi-experimental studies that supplement nutrition in pregnancy, have given equivocal results. The hypothesis requires fresh testing. An experimental approach can eliminate or control many extraneous and confounding variables.

Minimally invasive open lumbar discectomy: An alternative to microlumbar discectomy

Lumbar disc surgery has come a long way since its fi rst description by Dandy in 1929. Evolving through the transdural approach and a laminectomy for the removal of a disc, it now surpasses the primal technique with essentially a minimally invasive procedure, an extradural approach without laminectomy. The objective of this study is to ascertain the effectiveness of Minimally Invasive Open Lumbar Discectomy in the treatment of lumbar disc prolapse. It is a descriptive study entailing the patients with paramedian or central disc prolapse at single or two consecutive lumbosacral levels undergoing surgery at the National Institute of Neurological and Allied Sciences, Bansbari, Nepal, over a period of one and a half years. Patients who underwent either laminectomy or bilateral fenestration were excluded. Results of surgery were measured prospectively in terms of primary outcome measure (outcome at six months follow up as measured with Prolo Functional and Economic Scale) and secondary outcome measures (radicular pain relief, mobilisation, complication, and residual disc). In the series of 137 consecutive patients, 120 fulfilled the criteria. 98.33 % of patients had an improvement in the radicular pain and ambulation was commenced from the fi rst post-operative day. There were three instances of inadvertent dural tear without fascicle injury, and one instance of residual disc requiring reoperation. At 6 months, 97.5 % had good to excellent (grade 4, or 5) results reaching the premorbid states in the Prolo Functional and Economic Scale. The results of Minimally Invasive Open Lumbar Discectomy compare favourably with those of a microlumbar discectomy, and could therefore be an alternative to the latter in resource deprived circumstances.

Social Class and Attitudes of Youth Relevant for the Realization of Adult Goals

Social Class and Attitudes of Youth Relevant for the Realization of Adult Goals

The Good Physician: A Treasury of Medicine.

In his sympathetic portrait of a young man, standing unhappily on the edge of cultural life in London early in this century, E. M. Forster, in his novel,<i>Howard's End</i>, describes him as being "familiar with the outsides of books." Part of this young man's discontent came from his feeling that he was only lightly dusted with the qualities which an active appreciation of the arts is said to bring; he also felt deprived, by upbringing and social circumstances, of entry into the brilliant intellectual society to which he aspired. Today, he might have acquired a more extensive, but still superficial, knowledge of literature by reading much of the presentation of books and authors in the mass communication media. Or he might have actually handled the substance of books, if only in part, by reading anthologies like<i>The Good Physician</i>, by Mr. Davenport. A well-compiled anthology such as this has

Benign auditory and visual hallucinations.

Even before the time Esquirol introduced the term hallucination and differentiated it from illusion, the occurrence of these phenomena when met with in the psychoses have provided diagnostic criteria of considerable significance. It has become increasingly evident that under exceptional circumstances "normals" may also hallucinate.^1-3Medlicott⁴expressed his opinion and experience that hallucinatory phenomena are quite common in the sane, whether healthy or psychoneurotic. One cannot fail to be impressed with the relationship of hallucinated perception in the "normal" and concomitant circumstances of stress. The source of the stress may be from inner turmoil or from external events. I should consider occult phenomena, couvade, and hallucinations of religious content as examples of the former and circumstances of sensory deprivation, whether accidental or experimental, as examples of the latter. The culturally encouraged hallucinatory experiences of some societies likewise seem to depend upon some manner of stressful deprivation. The