Medical_Tribune_November_2012_PH

November 2012

PhilHealth signs MOA with pharma

Vaccination the key to global health

FORUM

Managing HFMD in primary care

IN PRACTICE

PHILIPPINE FOCUS

AFTER HOURS

Crater culture

Step-off approach to LABA asthma therapy under scrutiny

2 November 2012

Step-off approach to LABA asthma therapy under scrutiny

Elvira Manzano

The approach of discontinuing long-act-ing β2-agonist (LABA) therapy (‘step-off’ therapy) in patients who achieve

control of their symptoms on a combination of LABA and inhaled corticosteroids (ICS) may lead to exacerbation of symptoms and reduce quality of life, according to new research.

A meta-analysis of five randomized con-trolled trials comparing step-off therapy with continued use of LABA and inhaled ICS medi-cations found that the LABA step-off approach was linked to a rise in asthma-related impair-ment. Compared with patients who contin-ued combination therapy, those who stopped treatment had fewer symptom-free days (608 vs. 622) and lower scores on questionnaires assessing quality of life and overall asthma control. They also required an average of 0.71 (95% CI 0.29 to 1.14) more puffs per day of a rescue bronchodilator and had a non-signifi-cant increase in use of oral corticosteroids (RR 1.68, 95% CI 0.84–3.38). There were no deaths and too few exacerbations in the studies to evaluate safety outcomes. [Arch Intern Med 2012; DOI:10.1001/archinternmed.2012.3250]

The findings contradict the US Food and Drug Administration’s (FDA) ‘black box’ warning that LABAs, when given with ICS, should be discontinued as soon as asthma control is achieved.

“In contrast to FDA recommendations, our analysis supports the continued use of LA-BAs to maintain asthma control,” said study author Dr. Jan L. Brozek from the department

of clinical epidemiology and biostatistics and medicine, McMaster University, Hamilton, Ontario, Canada.

Manufacturers of LABAs are conduct-ing further large-scale safety studies of their products, however the results of these will not be available for 5 years. “In the interim, the consistent trends that we identified for many asthma impairment factors, some of which were statistically significant, favor the contin-ued use of LABAs,” said Brozek.

Brozek and his fellow investigators cau-tioned that the studies were of short duration and had high withdrawal rates. Nevertheless, “our findings likely represent the current best evidence about stepping off LABA therapy in patients with asthma.”

While there is consensus that LABAs have no role in asthma monotherapy, the findings help shift the burden of proof in the debate over stepped-down withdrawal of LABAs, wrote Dr. Chee M. Chan and Dr. Andrew F. Shorr, from the division of pulmonary and critical care medicine at Washington Hospital Center, Washington D.C., US, in an accompa-nying commentary.

Moreover, they called on the FDA to recon-sider the ‘black box’ warning for these agents based on the findings. “We hope that this meta-analysis helps to lift some of the black clouds in the debate surrounding LABAs,” they said. “Similarly, physicians must now reevaluate the contents of the black box for LABAs, particularly in individuals whose asthma is well-controlled with combination LABA and ICS therapy.”

3 November 2012

Alexandra Kirsten

Celebrities can help to promote public health and are effective in doing so, says

a public health expert in Australia. While celebrities are not always health ex-

perts, unlike many health experts, they “of-ten speak personally and bring compelling authenticity to public discourse,” wrote Dr. Simon Chapman, professor of public health at the University of Sydney, Australia, in a recent editorial published in the British Medi-cal Journal. [BMJ 2012;345 DOI: http://dx.doi.org/10.1136/bmj.e6364]

Critics of celebrities in health campaigns point to examples which have gone “badly wrong.” They focus on celebrity endorsement of “flaky complementary medicine and quack diets” or incidents where celebrities have veered away from the message.

On the contrary, Chapman suggests there are many examples of celebrity engagement that have amplified news coverage about important neglected problems or celebrity involvement in campaigns to promote evi-dence-based health policy reform.

Talking about the case of Australian crick-eter Shane Warne, who accepted a six-figure sum to use nicotine replacement therapy to quit smoking, Chapman said “we should not expect perfect outcomes after celebrity en-gagement and need to be realistic about the need to sustaining public campaigns beyond their first burst.”

When photographs appeared of the sports-man smoking again, many experts “failed to exploit” the important message about the risks of relapsing, said Chapman, “instead climbing on a cynical populist bandwagon about his alleged motives.”

He also mentioned Australian singer Ky-

lie Minogue’s breast cancer, which “led to an increase in unscreened women in the target age range having mammography, but also to an increase in young women at very low risk seeking mammograms and thus being exposed to unnecessary radiation and false-positive investigations.”

The ambivalence about this effect reflects the debate about the wisdom of breast cancer screening, he said, “but it should not blind us to the potential value of celebrity engage-ment in important causes.”

In response to Chapman’s comments, Dr. Geof Rayner, former chair of the UK Public Health Association and Honorary Research Fellow at City University London, England, said he remains concerned about the influenc-es of celebrities who dabble in the public health arena. While celebrities might help to boost campaigns in the short term, Rayner said they “must tread a cautious path of support because of the risk that the celebrity becomes the story, not the campaign.” [BMJ 2012;345 DOI: http://dx.doi.org/10.1136/bmj.e6362]

Certainly celebrities help shift products, but according to Rayner this “has become mainstream marketing strategy” across so-ciety, even in politics. Rather than relying on media stunts, modern health campaign-ers “need to go on the offensive against junk food, alcohol, gambling, and other often celebrity linked, commercial propaganda.” Rayner postulated new measures to promote public health, for example campaign groups that “bring together the lobbying power of thousands of ordinary people through the internet.”

“Some celebrities might help, but let’s not look for saviours, buoyed by the happy thought that the work is done when a celebrity is in-volved. That’s a lie too”, Rayner concluded.

Do celebrities help public health campaigns?

4 November 2012 Forum

Vaccination the key to global healthExcerpted from a lecture by Edith L. Maes (Ph.D.), senior research fellow, Maastricht School of Management, the Netherlands, at a media briefing in Kuala Lumpur, Malaysia.

It has been shown by historical studies that there is a relationship between health and wealth, and that it really pays for govern-

ments to invest in health. Because of the dual relationship, there is a double dividend, espe-cially in low- and middle-income countries. The reason is that healthy populations lead to economic growth.

When people remain healthy, they also de-velop better physical and cognitive capabili-ties, so that in adulthood they become more energetic and active workers, which leads to higher incomes for their families, higher pro-ductivity and greater output, which is mea-sured as gross domestic product (GDP) for the government.

It is beneficial investing in health preventa-tive measures that do not cost much or preven-tative measures which need an investment, but have a payoff in the short- and long-term. It is important at the individual level, family or household level, and the government level.

Firstly, it is important at the individual level, especially to children, since they are vulnerable and contract diseases very easily because their immune system is not work-ing well. If children are healthy, it’s better for the families because they will be able to de-velop their cognitive and physical abilities so parents will be able to continue working and generating an income. But if the child is sick often, the family incurs huge medical costs. In many countries, because of large out-of-pocket expenses, it also costs households a lot of savings, which indirectly has a long-term

effect.At government level, it is important because

investing in health means actually investing in the workforce. So a healthy workforce is good for the country because it increases pro-ductivity and, as a consequence, its income.

One measure to express health is life expec-tancy. Health can be defined in many ways, so epidemiologists and economists as well have taken one common measure, which is life ex-pectancy, to express the benefits that accrue in a healthy population.

Life expectancy is a measure at the popula-tion level – it’s an average among all individu-als that survive in society. So, if large numbers of children die prematurely, the life expectan-cy will go down.

In the early 1900s, most countries had low levels of income and life expectancy was 55 to 60 years. Gradually, especially in western countries, health improved because of better sanitation, potable water and preventive mea-sures like vaccines, and that increased the life expectancy in developed countries to 65 to 75.

In 2010, when we cluster the countries, the high-income countries moved up to 70 to 82 years of age and their income also increased from US$14,000 to US$47,000, so their income increased accordingly to the increase in life expectancy.

So that is how economies expressed the benefits of investing in health and tried to es-tablish the relationship. Why is it that health in such nations and communities in general can improve? It is because the government

5 November 2012 Forumdecides to take measures, which can be very simple ie, educational programs to improve sanitation at home and building infrastruc-ture to provide potable water for everyone.

One of the measures that governments have been investing in is immunization for its short- and long-term benefits. In all the stud-ies that have been done, the global commu-nity has recognized that vaccination is one of the world’s most important and cost-effective health interventions, with positive socioeco-nomic effects on society. [World Economics 2005;6:15-39]

Key stakeholder benefits of vaccination in-clude reduction in morbidity and mortality among individuals, which result in healthy families, a more productive workforce and herd immunity in society. It is in the inter-est of governments to invest in vaccination programs that are successful ie, that reach a coverage level of above 85 percent. When that level of protection is reached in the commu-nity, weaker and vulnerable people will also benefit from the decreased pool of pathogens.

In the past 30 years, there has been a rapid increase in the number of vaccines. We are now at a point where we can prevent ap-proximately 20 diseases through vaccination programs, although sometimes it is only use-ful for certain target groups like travelers or healthcare workers.

Looking at the evolution of vaccines – the very first vaccine, for smallpox, was actually experimentally tested in the 1800s. The person who tested the vaccine in farmers found that those who had been primed with pieces of the smallpox virus did not develop smallpox lat-er in life. Gradually, the principle of priming the immune system started being recognized as being a very effective prevention method for certain diseases.

The first few vaccines were developed for diphtheria, tetanus and polio – those vaccines were based on simple technology and can still protect against those killer diseases.

The latest vaccines are based on complex technologies against rotavirus, pneumococcal diseases and human papillomavirus. These vaccines have taken a long time to develop, and are complex and more expensive than those developed in the 1950s and 1960s.

The Global Alliance for Vaccines and Im-munisation (GAVI) was founded in 2000 to fund vaccines in very poor countries that can-not afford any immunization programs or expand it with newer vaccines, and are also lacking a proper health infrastructure to pro-vide vaccines to children in rural areas.

The GAVI Alliance is a public-private part-nership built on international solidarity and it devised a very innovative way of financing through donor fronts from a number of coun-tries and foundations including the Bill & Me-linda Gates Foundation. There are a number of Western countries that have been pledging millions of dollars every year to vaccination, which can be used in the low-income coun-tries with incomes below US$1,500 per person per year to give them an incentive to start de-veloping their programs.

Through the GAVI Alliance, rigorous gov-ernment policies, and strengthening of vac-cination programs at the country level, over 5.5 million lives have been saved since 2000. [GAVI Alliance Progress Report 2011. www.gavialliance.org/results/gavi-progress-re-ports/ Accessed on 24 September]

The assessment of costs and effectiveness is becoming an increasingly important factor for policymakers faced with decisions about adding a new vaccine to national immuniza-tion programs.

6 November 2012 ForumTo be able to compare with other studies

and to compare between diseases, the WHO has come up with a metrics called DALY (dis-ability-adjusted life years), which is a mea-surement of the gap between current health status and an ideal health situation where the entire population lives to an advanced age, free of disease and disability. This common measure allows governments to compare across diseases and technologies.

We have seen many success stories in gov-ernments adopting the hepatitis B, pneu-mococcal and Haemophilus influenzae type B childhood vaccines.

Investing in vaccination gives a high return in the short- and long-term for both individu-als and society as a whole, and is based on the principle that health is a human right, so why would we deny it to ourselves or to our children?

7 Philippine FocusNovember 2012

Dr. James Salisi

Newborn screening in the Philippines is set to expand its coverage from the basic five to 28 disorders in 10

years. “The next ten years is about expanded newborn screening. It is anything that’s be-yond congenital hyperthyroidism and PKU (phenylketonuria). It’s talking about more metabolic disorders, hemoglibinopathies, lyzosomal diseases, very rare diseases that are being screened by developed countries,” said Dr. Carmencita Padilla, chair of the De-partment of Pediatrics of the Philippine Gen-eral Hospital. The current system screens five potentially life-threatening disorders: congenital hypo-thyroidism, congenital adrenal hyperplasia, PKU, galactosemia, and glucose-6-phosphate dehydrogynase deficiency. The new testing technology will not alter the way samples are collected now, which is to get 3 samples in one newborn screening fil-ter paper. The difference lies in the number of metabolites and diseases that can be analyzed by the machine. Whereas the classic approach analyzes one metabolite and one disease, the new approach will be able to analyze more metabolites and more diseases including he-moglobinopathies and greater than 20 amino acid disorders.

“We have a lot of hemoglobinopathies, a lot of organic acid disorders, a lot of fatty acid disorders and, to my surprise, cases of cystic fibrosis,” Padilla said, citing a study in Cali-fornia in a presentation at the Department of Health. She highlighted the need to increase the number of diseases screened at birth in order to save more lives.

“Newborn screening is a public health pro-gram in all parts of the world,” said Dr. Pa-dilla. She explained that it is a universally

21st Perinatal Association of the Philippines Annual Convention; September 30-October 1, 2012; Crowne Plaza, Ortigas

Newborn screening to further expand coverage

CONFERENCE COVERAGE

Newborn screening is a public health program in all

parts of the world

‘‘


accepted public health program aimed at the early identification of the infants who are af-fected by certain genetic, metabolic or infec-tious conditions. The expanded program started its prepara-tory phase in July this year and the pilot study will be implemented in December to February 2013. The national implementation will start in March 2013 and will include endocrinologic disorders, amino acid, fatty acid and organic acid disorders, and hemoglobinopathies. In preparation for the expansion, regional and provincial medical center follow-up clin-ics will be established, laboratory equipment will be upgraded and staff will be trained. Workshops for long-term follow-up of meta-bolic and hemoglobinopathy cases were done in February and August, respectively, this year. Discussion with PhilHealth to increase fund-ing for expanded screening is ongoing. A biochemical genetics reference laboratory

will be established at the National Institutes of Health in UP Manila while endocrinology con-firmatory laboratories will be set up in govern-ment and private laboratories.Regional long-term follow-up clinics will be set up to give free services to confirmed cas-es of disorders screened by the program. The Centers for Health Development of the De-partment of Health will identify the host in-stitutions of these clinics which should have at least a hematologist and a neonatologist. A grant will be given to the host institution for personal services and maintenance and opera-tions expenses. “The program will have a net benefit of 600 million pesos a year if all babies are screened and all positive cases are treated. It is a benefit for the family because they take care of the [patients],” Padilla said while citing a cost- benefit study that she did for newborn screen-ing in the Philippines.

Gabriel Angelo Sembrano

N eonates are at risk for metabolic syn-drome if he or she was conceived in

an at-risk environment but the risk could be modified if recognized and addressed pre-conceptually,” stated Dr. Lorna Abad, head of the Pediatric Endocrinology section of the Philippine Children’s Medical Center. “It had been found that the factors present in the fetal-neonatal period that correlated to later obesity risk include maternal undernu-trition, which is caused by smoking and al-

coholic intake. There is vascular insufficien-cy—even for those living in high-altitudes,” Abad added. According to Abad, it is important to take note on these factors since these are poten-tially modifiable. Success in the modification of these behaviors could benefit both the mothers and the infants. As an evidence of maternal depriva-tion posing a risk for developing metabol-ic syndrome among neonates, Abad cited the Dutch winter famine experience in the Netherlands during 1944 to 1945. The study explained that if the insult is close to the

Maternal nutrition may dictate metabolic syndrome in children


latter part of the gestation, there is a great-er risk for infants to develop glucose intolerance. “The offsprings of mothers who were pregnant at this time had impaired glucose tolerance since there was no food supply due to the war,” Abad said. According to Abad, there have been some observable patterns that suggest fetal injury at specific periods during gestation. A body mass index that is less than the normal level may reflect malnutrition at a certain period during the third trimester of pregnancy. She added that if the head circumference is be-low the normal measurement which is 33 cm to 35 cm, it reflects sluggish growth through-out gestation and further suggests that the injury took place at early stage in the fetal development. Abad pointed out that a typical example that causes fetal injury during gestation is maternal micronutrient deficiency. She cited a study by Gambling et al which showed that neonatal body weight decreases with the ex-acerbation of maternal iron deficiency; and

in contrast, iron supplementation during pregnancy leads to a higher birth weight [The Journal of Physiology, 561;195-203]. She also highlighted that the timing of iron supple-mentation is critical in reversing the effects of maternal anemia on the developing fetus. On the other hand, Abad said that maternal overnutrition could also lead to the develop-ment of metabolic syndrome among infants. She cited a study by Whitaker in 2004 which showed that children who were born to moth-ers with BMI falling under the obese category during the first trimester are twice as likely to develop obesity by two years of age. “Most of the risk factors for metabolic syn-drome are pre-natal in nature so we should make sure that obesity is prevented in preg-nancy,” Abad stressed. She added that it is ideal for obese or overweight women to lose weight prior to conception. If the woman is already pregnant and at the same time over-weight, she should at least receive behavior modification counseling to make sure that she will not gain weight beyond what is recommended.


Conference Calender

NOVEMBER

Philippine Obstetrics and Gynecology 2012 Annual Convention and 66th Anniversary CelebrationNovember 6-9, 2012Venue: Philippine International ConventionCenter and Sofitel Philippine Plaza HotelInfo: Philippine Obstetrics and Gynecology SocietyPhone: +632 921 7557; 921 9089; 435 2384, 4352385Email: [email protected]: www.pogsinc.org

34th Philippine Neurological Association Annual ConventionNovember 7-10, 2012Venue: Capt. John Hay Convention Center, Baguio CityInfo: Philippine Neurological AssociationPhone: +632 723 2102Email: [email protected]: www.pna.org.ph

Philippine Society for Parenteral and Enteral Nutrition 8th Annual ConventionNovember 13-14, 2012 Venue: Manila Diamond HotelInfo: Philippine Society for Parenteral and Enteral NutritionPhone: +632 723 0401 Local 5714Fax: +632 725 6868Email: [email protected] Website: www.philspenonline.com.ph

13th Philippine National Immunization ConferenceNovember 14-15, 2012Venue: Baguio Country ClubInfo: Philippine Foundation for VaccinationPhone: +632 254 5205Email: [email protected] Website: www.philvaccine.org

29th Annual Convention of Diabetes PhilippinesNovember 14-16, 2012Venue: EDSA Shangri-La HotelInfo: Diabetes PhilippinesPhone: +632 534 9559Email: [email protected]: www.diabetesphil.org/

63rd Philippine Orthopaedic Association ConventionNovember 14-17, 2012Venue: Crowne Plaza, Quezon CityInfo: Philippine Orthopaedic AssociationTel. No.: +632 667 3926; 667 3946Email Address: [email protected]; [email protected];[email protected]: www.philortho.org

Philippine Academy of Ophthalmology Annual Meeting 2012November 29-December 2, 2012Venue: Medical Plaza Makati Condominium, Makati CityInfo: Philippine Academy of OphthalmologyTel. No.: +632 813 5324; 813 5318Email: [email protected]: www.pao.org.ph



Music therapy eases maternal anxiety during breastfeeding

CONFERENCE COVERAGE

Dr. Yves Saint James Aquino

M usic therapy may provide relax-ation and improve new mothers’ perception of breastfeeding, ac-

cording to a study by Dr. Klarisa Mariano-Enrique done in St. Luke’s Medical center, Quezon City.

Included in the study were women who were admitted at St. Luke’s Medical Center and who had just delivered either vaginally or abdominally for the first time. Mothers with clinical problems such as encephalopa-thy, oro-facial anomalies, cardiac problems or other congenital anomalies, or those with babies admitted at the neonatal ICU were ex-cluded from the study.

A total of 78 mothers were included and were randomly divided into experimental and control groups.

Experimental subjects received music ther-apy prior to breastfeeding, with minimum duration of 10 minutes of patient’s choice of music. Both experimental and control sub-jects were observed by the research assistant as soon as the mother initiated breastfeeding. The survey immediately followed the breast-feeding attempts using a 7-point Likert scale, with 7 being the most positive (relaxed).

Results showed that the control group had higher score compared to the music group. However, comparing the pre-test and the post-test of the experimental group, results showed that there is significant improvement in mothers who were exposed to music ther-apy. Mean score of the experimental group were higher in post-test compared to pretest when asked if they are relaxed (6.36 vs 4.74; p<0.001), and when asked if they are anxious about breastfeeding in the future (6.69 vs 4.74; p<0.001).

“The outcome of the study reveals that mu-sic therapy offers a therapeutic intervention that reduces the anxiety of first time mothers who are breastfeeding in the immediate post-partum period and increases their overall sense of well-being,” said Mariano-Enrique.

Music therapy has been previously shown to promote positive effects in several areas of study, such as mental health, special educa-tion, rehabilitation and social development, said Mariano-Enrique.

The researcher recommended further studies that can improve the technique in administration of music, that can assess the use of individual music preference versus a standardized music and can study the cumulative effect of music.


Kangaroo mother care promotes neonatal growth


Dr. Nicolo Cabrera

K angaroo mother care (KMC) was shown to cost-effectively promote growth, eug-

lycemia and euthermia in infants born weigh-ing less than 2,000 g in a prospective ran-domized controlled trial done at a Level III neonatal intensive care unit (NICU) of a ter-tiary government hospital in the Philippines.

“Neonates, regardless of parents’ finan-cial capability, should receive the best pos-sible care,” opined Dr. Remelie Balleste-ros of Mariano Marcos Memorial Hospital & Medical Center in Batac, Ilocos Norte. She revealed that 20 million infants were born with low birth weight annually, compris-ing 15.5 percent of all births. She said that in the Philippines, 16.65 percent of the population were born low birthweight, emphasizing the burden of illness in our country.

A prior meta-analysis had pooled three RCTs to show that KMC reduced cause- specific mortality compared to standard care as well as five RCTs to show reduced severe morbidity. [Int J Epidiol 2010;39: i144-i154]

Among 1,821 live newborns screened in the study, 82 were born below 2,000 g. Twenty-five infants were randomized to receive KMC, another 25 to receive conventional method of care (CMC). Thirty-two were excluded. The

KMC group underwent skin-to-skin contact for two-hour periods several times a day, while the CMC group were placed in cradles under hot lamps using 5-watt incandescent bulbs.

Compared to the CMC group, the KMC group had higher daily in-hospital weight gain (7.5 versus 2.6 kg, p<0.0001); shorter hos-pital stays due to the earlier achievement of ideal weight (9.3 versus 22.0 days, p>0.0001) and higher post-discharge weekly weight gain (184.8 versus 128.0 kg, p<0.0001). Average weekly length gain was 51.7 percent better in the KMC group (p<0.0001) and average week-ly head circumference gain was 60.6 percent better as well (p<0.0001).

The KMC group had higher daily RBS av-erages (66.0 versus 56.8 mg/dL, p<0.01) and achieved ideal RBS in fewer days than the conventional care group (3.6 versus 11.6 days, p<0.0001).

The KMC group achieved ideal tempera-ture in fewer days than the conventional care group (approximately 4.0 versus 12.0 days). Eight infants receiving CMC suffered morbid-ity or mortality (eg, from infection and noso-comial sepsis) whereas none receiving KMC did.

“Evidence suggests that KMC is a safe and effective alternate method to conventional neonatal care,” posited Ballesteros.

She computed that infants below 1,500 g

CONFERENCE COVERAGE


receiving CMC stayed in the NICU about 21 days and racked health care costs up to Php 52,500.00. However, providing KMC cuts NICU stay down to nine days, saving the fam-ily Php 30,000.00.

Apart from aspects investigated in Balleste-ros’ study, the WHO also includes the follow-ing practices under the bundle of KMC: exclu-sive breastfeeding, continued KMC at home and early discharge.

Intimate partner violence screening neglected in patient careDr. Nicolo Cabrera

S creening patients for intimate partner violence (IPV) is a neglected component

of optimal health care, particularly of the pregnant woman and the child she carries, said Dr. Lyra Ruth Clemente-Chua, professor of obstetrics and gynecology at the Manila Central University-Filemon D. Tanchoco Medical Foundation.

“During conventions like this, we talk about the biomedical aspects of the care of the woman and the child, pero … ilan sa atin ang aware that this [IPV screening] is an important part also of the care?” Clemente-Chua asked.

In the Philippines, 4 percent of women who have ever been pregnant report experienc-ing physical violence during their pregnancy with an incidence that increases slightly with the number of living children the woman has. The incidence of such violence declines slight-ly with increasing age and educational level and steadily with increasing wealth quintile.

Clemente-Chua presented several studies demonstrating the multiple effects of IPV on the mother and the child. A woman who suf-fers abuse is at increased risk for the follow-ing health problems: blunt traumatic injury

(resulting in abruptio placenta or uterine rup-ture), elective pregnancy termination, ane-mia, sexually transmitted infection, urinary tract infection, preterm labor, chorioamnion-itis, substance abuse, depression, preeclamp-sia and poor placentation. These women tend to experience a prolonged second stage of la-bor, particularly after sexual abuse. They are also more likely to deliver low birth weight infants due to preterm delivery, prolonged premature rupture of membranes and mater-nal low weight gain.

IPV also subjects the child to stress in utero. Clemente-Chua presented research demon-strating the effects of stress during fetal life that manifest further along the child’s devel-opment such as self-regulation and tempera-ment difficulties and even attention deficit hy-peractivity disorder.

“When we see women come in with these injuries, do we ask them? Or do we just close our eyes?” Clemente-Chua posed to the au-dience. She shared that the US Centers for Disease Control and Prevention (CDC) cites four barriers to screening: time constraints, discomfort with the topic, fear of offending patient or partner, and perceived powerless-ness to change the problem.

She advised that clinicians should


suspect IPV when they see a meek woman ac-companied by a partner who answers all the clinician’s questions. The clinician may at-

tempt to speak with the woman in private by examining her in another room and should ask about IPV several times.

Clemente-Chua offered the CDC’s RADAR mnemonic to guide screening for possible victims of intimate partner violence.

1. Routinely screen every patient at first prenatal visit; at least once per trimester; at postpartum checkup; and at routine obstetricgynecological and preconception visits.2. Ask directly, kindly and nonjudgmentally.3. Document your findings.4. Assess the patient’s safety.5. Review options and provide referrals.

Interpregnancy interval affects adverse maternal outcomesGabriel Angelo Sembrano

T he number of years of interval from one pregnancy to the other may con-tribute to the development of adverse

maternal outcomes, according to a retrospec-tive review by Dr. Sheila Marie Alvarado of Delos Santos Medical Center in Quezon City.

“This study showed that there were signif-icantly more patients who developed either hypertensive complications of pregnancy or diabetes mellitus for interpregnancy interval of more than 5 years and preterm delivery and postpartum hemorrhage than those with interpregnancy interval of less than 2 years,” Alvarado explained.

“A total of 1,799 singleton pregnancies composed of pregnant women gravida 2 and above, with no medical or obstetrical com-plications or comorbidities during their first or previous pregnancies, and whose preced-

ing births were term live births delivered vaginally and without complications were included in this study,” Alavarado said, ex-plicating the inclusion criteria.

In the analysis of outcomes, Alvarado included the occurrences of hypertensive complications of pregnancy, diabetes melli-tus, preterm delivery and postpartum hem-orrhage. Furthermore, a receiver operating characteristic curve had to be shown the cut-offs for interpregnancy interval in years. Adverse maternal outcomes were then ex-amined using odds ratio at 95 percent con-fidence intervals following a logistic regres-sion analysis to account for confounding variables.

It was found out that among those who had an interpregnancy interval of more than 5 years, around 68.1 percent (n=207) had hy-pertension and 43.8 percent (n=133) had dia-betes mellitus as opposed to those who had


an interval of 5 years and below in which only 9.5 percent (n=142) had hypertension and 6 percent (n=90) had diabetes mellitus (p <0.001).

According to Alvarado, based on the re-sult of the odds ratio, those pregnant women who had an interpregnancy interval of more than 5 years are 7 times more likely to de-velop hypertension and diabetes mellitus on their succeeding pregnancies than those who had an interval of 5 years and below.

On the other hand, the study also showed that among those women who had intervals of 2 years and below, 49.1 percent (n=191) had

preterm delivery and 26.5 percent (n=103) had postpartum hemorrhage compared to those who had an interval of more than 2 years where only 0.6 percent (n=9) had preterm delivery and 1.2 percent (n=17) had postpartum hemorrhage (p<0.001).

This would suggest that women who had an interpregnancy interval of 2 years and below were almost 77 times more likely to encounter a preterm delivery and almost 22 times more likely to experience post-partum hemorrhage on their succeeding pregnancies than those women who had an interpregnancy of more than 2 years.

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TREATMENT FOCUS: Cervical Insufficiency

Redefining diagnostics and treatments for cervical insufficiencyDr. James Salisi

A 35-year-old woman on her third pregnancy presented with a y-shaped, 2-cm cervix length on

ultrasound. Her first pregnancy terminated in a missed abortion and had dilatation and curettage at 12 weeks age of gestation. Her second pregnancy was delivered preterm at 29 weeks; but despite this, she had an unremarkable prenatal course. Does this patient have an incompetent cervix? What would be the best management for her?

“Cervical incompetence has been entered into medical literature since the 1600s but only during the last 40 years that it gained significance or focus because of problems we encounter with this condition,” said Dr. Maria Luisa Acu from Saint Luke’s Medical Center in Quezon City during the 21st Perinatal Association of the Philippines Annual Convention held last September 30 to October 1, 2012 at Crowne Plaza Hotel, Ortigas.

Definitions and diagnosticsAccording to Acu, cervical incompetence

is defined by the failure of the cervix to retain the conceptus during pregnancy due to a structural and or functional weakness.

“It is the premature ripening of the cervix. If you review the current literature the term incompetent cervix has been replaced by the term cervical insufficiency

because some leading organizations think that ‘incompetent’ is a pejorative term,” Acu explained.

Causes of cervical insufficiency may be structural (congenital or acquired) or functional with no obvious pathology. Congenital causes may include collagen abnormalities, uterine anomalies and biologic variations. Acquired risk factors include obstetric trauma, mechanical dilation and treatment of cervical intraepithelial neoplasm.

Infection such as bacterial vaginosis has also been linked to a weakened cervix but

The most important cause of cervical insufficiency

is when we do overzealous dilatation and curettage

‘‘


there is not enough evidence to prove the association between the two.

“The most important cause of cervical insufficiency is when we do overzealous dilatation and curettage. Three or more first trimester-induced abortions by dilatation and curettage carry a 12 percent risk of a spontaneous pregnancy loss. While a second trimester induced abortion carries a 14 percent risk,” said Acu.

Many patients with cervical insufficiency are asymptomatic. Those with symptoms experience mild manifestations such as pelvic pressure, premenstrual-like cramping or backache, increased vaginal discharge and mild contractions. They usually present for several days or weeks from 14 to 20 weeks age of gestation.

A soft, somewhat effaced cervix with minimal dilation presents in a patient with early signs of cervical insufficiency. Valsalva’s rarely reveals membranes in the endocervical canal and there are no or infrequent contractions at irregular intervals. In contrast, late physical examinations will show advanced dilatation at greater than 4 cm and effacement at greater than 80 percent and vaginal spotting. There may be either unprovoked grossly prolapsed or ruptured membranes. The contractions seem to be inadequate to explain advanced dilatation and effacement of the cervix.

Rule out cervical insufficiency when there are signs of infection, bleeding from placental causes or multiple gestation that may cause cervical opening, advised Acu.

Traditional diagnosis relied on historical factor, resulting in delayed diagnosis until at least two pregnancy losses or births before 28 weeks of gestation.

“The preferable definition nowadays is

that we use transvaginal cervical length measurement. We can use this definition even in primigravidas or multigravidas without prior pregnancy losses,” said Acu. A cervix less than 25 mm in length and/or advanced cervical changes before 24 weeks in women with either one or more pregnancy losses or preterm births at 14 to 34 weeks, or other significant cervical risk factors.

Acu cited a study that showed a strong reproducible inverse correlation between cervix length and preterm delivery. There is a 6-fold increased risk of delivery prior to 35 weeks if the cervix length is less than 25 mm [NEJM. 1996;334:557-567]. This criterion has a sensitivity of 68 to 100 percent and a specificity of 44 to 79 percent according to the American College of Obstetrics and Gynecology practice bulletin.

Recommended treatment strategiesPlacement of cerclage significantly

reduced preterm birth (RR 0.80, 95 percent CI, 0.69-0.95) according to a Cochrane review of 9 trials including 2,898 women. [Cochrane Database Syst Rev 2012]

“In whom do we put a cerclage? We can group them into the history-indicated cerclage group. This is done at 12 to 14 weeks,” said Acu. The criteria for this group are the presence of two or more consecutive prior second trimester pregnancy losses or three or more early preterm births (less than 34 weeks), risk factors for cervical insufficiency and other causes of preterm birth have been excluded.

Supplementation of 17-alpha-hydroxypro-gesterone caproate at 16 to 36 weeks helps the pregnancy reach nearer to term in patients with cerclages.


“Just a very few women have a history-indicated cerclage. Majority will be in this group: They have suspected cervical insufficiency but do not meet the criteria for history indicated cerclage. This is where we do our screening by transvaginal scan,” said Acu. Serial measurements of cervical length are done. If the length decreases to less than 25 mm, obstetricians give progesterone and apply cerclage.

Screening in suspected cervical insufficiency patients starts at 14 weeks or as early as 12 weeks if with early second trimester losses, recurrent second trimester losses or prior large cold knife conization. If the patient has had preterm birth at 28 to 36 weeks, screening will start at 16 weeks. The

interval between cervical length monitoring inversely varies with the length of cervix at baseline. This is discontinued at 24 weeks because at this time cerclage will not be performed anymore because these preterm changes usually precede overt preterm labor by 3 to 6 weeks.

A very short cervix (<5 mm) on transvaginal ultrasound or a dilated cervix with visible membranes less than 24 weeks indicate cerclage in some patients. But prior to cerclage, the physician must ensure that there is no overt infection, ruptured membranes and significant hemorrhage.

“Majority will use antibiotics prophy-lactically, or during the procedure and tocolytics during and then stop it. Prolonged

use of unnecessary antibiotics may lead to the development of resistant strains of bacteria and other morbidity for the patient and her fetus,” said Acu.

Patients with very poor history of preterm deliveries can have preconception transabadominal cerclage placement. According to Acu, this procedure is easier, with smaller incision, safer to fetus and can be done laparascopically. The rate of carrying the pregnancy to term with prophylactic transabdominal cerclage approaches 90 percent but when it is performed on an emergent basis the success rate drops to less than 60 percent.

“We should inform our patients about complications because these are very

common. Once we put cerclage it can be displaced, that’s why we do serial monitoring. We will see if it’s in the proper position or not. As we do the procedure, we can rupture the membranes and we can induce infection,” warned Acu.

Life-threatening complications of uterine rupture and maternal septicemia are extremely rare but have been reported with all types of cerclage.

Other interventions include pessary, which supports the cervix and turns it backward towards the sacrum, obstructing the internal os. Lifestyle interventions include cessation of work and exercise, abstinence from coitus, bed rest, and limited activity.

Once we put cerclage it can be displaced, that’s why we do serial monitoring‘‘


PhilHealth signs MOA with pharma companies for discounted medicinesDr. Yves Saint James Aquino

T he Philippine Health Insurance Cor-poration (PhilHealth) recently signed a memorandum of agreement with

11 top pharmaceutical companies to de-crease prices of drugs and medicines for cer-tain illnesses under the PhilHealth Z benefit package. The MOA signing was headed by PhilHealth president and CEO Dr. Eduardo Banzon and attended by representatives of the 11 pharmaceutical companies, along with the representatives of the Philippine Cham-ber of Pharmaceuticals Inc. and the Pharma-ceutical and Healthcare Association of the Philippines (PHAP).

Included in the group of companies were PHAP members Sanofi-Aventis Philippines, GlaxoSmithKline Philippines, Novartis Healthcare Philippines, Pfizer Philippines and Roche Philippines. Astellas Pharma Philip-pines, which will soon join PHAP, also signed the agreement. Other non-PHAP members present included Ambica International Trad-ing, DeGa International Pharma Corp., Glo-bo-Asiatico Ent. Inc., Pascual Pharma and Philippine International Trading Corporation Pharma.

“We commit to provide quality benefits; likewise, we find ways that these benefits be brought to and felt by PhilHealth members by ensuring sufficient supply of drugs and med-icines in government hospitals to guarantee better health outcomes and financial risk pro-tection,” said Banzon.

Dubbed ‘One with Pharma Z,’ the partner-ship aims to address the problem of accessibil-ity, especially for the marginalized sector. The program hopes to lessen the burden of Phil-

Health members afflicted with catastrophic diseases by ensuring hassle-free availment, Banzon added.

Catastrophic illness according to the Z benefit package includes acute lym-phocytic leukemia, breast cancer (stage 0 to IIIa), prostate cancer and kidney transplant.

“We offer our medicines, our expertise, and support to PhilHealth as it embarked on this program,” said Mr. Thomas Marcel Go III, representative of the PCPI.

Under the agreement, the companies will provide the initial 21 selected government Levels 3 and 4 hospitals located nationwide with drugs and medications at discounted price to be availed by members who have qualified.

Included among the contracted hospitals were Jose B. Lingad Memorial Hospital, Dr. J. Paulino Memorial Medical Center, Batan-gas Regional Hospital, Bicol Medical Center, Bicol Regional and Teaching Hospital, West-ern Visayas Medical Center, Dona Corazon Locsin Montelibano Memorial Medical Cen-ter, Vicente Sotto Memorial Medical Center,

We commit to provide quality benefits; likewise, we find ways that these benefits be brought to and felt by PhilHealth members

‘‘


Northern Mindanao Medical Center, Davao Regional Hospital, Southern Philippines Me-morial Medical Center, East Avenue Medi-cal Center, National Kidney and Transplant

Institute, Philippine Children’s Medical Cen-ter, Quirino Memorial Medical Center, Rizal Medical Center, Jose Reyes Memorial Medical Center and Baguio General Hospital.

Smart Rx. Every Time.

www.MIMS.com


Collaboration to promote maternal and newborn care

Dr. Ma. Theresa Hilario-JimenezVice PresidentPerinatology Association of the Philippines

NOTES ON LEADERSHIP

A fter 22 years, the Perinatology As-sociation of the Philippines (PAP) has gathered diverse members that

included pediatricians, obstetricians, mid-wives and nurses. The association has grown to include as its affiliate society the Philip-pine Society of Newborn Medicine, along with Philippine Pediatric Society, Philippine Obstetrical and Gynecological Society, Inte-grated Midwives’ Association of the Philip-pines and Maternal and Child Nurses Asso-ciation of the Philippines.

“When the founders were conceptualiz-ing the association, they were thinking more of the health providers that were concerned with the mother and the child,” said Dr. Ma. Theresa Hilario-Jimenez, a practicing pedia-trician.

Lasting from the 28th weeks of pregnancy up to the first 28 days of the neonatal period, perinatology is concerned with the combined care of the mother and the newborn, thus re-quiring an integrated delivery of health care.

“What we wanted is to get all the health-care providers who are in charge in order for us to help each other in improving the services that we can give the mother and the child. Ayaw namin magconcentrate lang sa doctors. If you will see, about 75 percent of deliveries are done by the midwives; it’s not done in the hospital.

“Each and every one has a role to play and each and every one has something to contribute in order to improve the health status of moth-ers and children,” added Hilario-Jimenez.

To further improve PAP’s service to the community, Hilario-Jimenez emphasized the importance of training and sharing of knowl-edge amongst the association’s members.

“We have to make sure that our nurses and midwives are updated as we help them in the skills that they need and in the knowl-edge that they need in order to manage effi-ciently and effectively the patients,” she said. A system of referral is also being promoted, with community practitioners, such as mid-wives, being taught when and how to refer when the cases are beyond their capacity.


Hilario-Jimenez explained that one of the challenges faced by the society is increasing its coverage to be able to educate more peri-natal practitioners.

“When we were doing our rounds, we have lectures in different areas. [Participants] still clamor for a lot of things and it means that they feel that they need to learn about these things. For us, it’s good, kung hindi kayo magsasalita kung anong kailangan, how will we know how to help you,” she said.

There is also a problem in the number of doctors who are practicing in communities.

“Midwives cannot handle it all. Actually, they are only on the first part of spectrum of health care. So, kailangan pa rin mas maram-ing doctors na nasa [community] to assist the midwives. One, we have to face it, we have very limited number of hospitals. Two, are they equipped? Three, do they have medi-cines? Same questions na yun, so I think yun ang pinakamalaki namin naging problema,” shared Hilario-Jimenez.

To promote the goals of the association, PAP created programs to establish partner-ship with different communities. The PAP Caravan goes to different society chapters in IloIlo, Cagayan de Oro, Ilocos, Davao, among other areas, to update members on best prac-tices and new developments in the field of perinatology.

PAP is also promoting Kangaroo Mother Care, a low-cost method of managing low-birth-weight and premature infants. PAP adopted KMC sites at the Gat Andres Boni-facio Memorial Medical Center and Bless Tetada Kangaroo Mother Care (KMC) Foun-dation Inc., to help further educate doctors, midwives and nurses on how to adopt this method.

PAP is probably one of the societies that

are founded on community partnership. The fact that the association includes members other than doctors is a testament to their mis-sion to promote a collaborative health care delivery. Whether it’s the community nurses, the midwives, the barangay health workers or the lay people, members of the commu-nity should be treated as partners.

“The first thing we should do is to make them feel that we are not there to alienate them. We are not there as somebody higher than them. We have to be co-equals. Because what we want is to decrease mortality and morbidity and improve health status of all. And if they will feel that our intentions are really for their benefit, and then for the ben-efit of the children and the mothers, I think we’re not going to have problems. Siyempre, we also have to be sincere,” said Hilario-Jimenez.

“If they’re going to see that you acknowl-edge their role, they will appreciate it. I think yun yung pinaka-primary goal namin, because we always make it a point to tell them, hindi naman namin kaya yan lahat, kasi kayo yung nasa community, you can handle them,” she added.

To hear members of the community ask-ing questions during lectures and lay fora makes all the efforts worthwhile, according to Hilario-Jimenez.

“If we hear them telling us that we come back, if we hear them that we want these topics to be discussed, for me that’s one fulfillment,” she said.

“Of course it would be more fulfilling for us if we can get the improvement in statistics. Because that’s the definite [standard]. Mas concrete yung result na makikita mo. That’s our mission, that’s our main goal to decrease the morbidity and mortality of mothers and children,” she concluded.


‘Customer displeasure’ deters self-care of Filipino diabeticsDr. Nicolo Cabrera

Customer displeasure’ was one of several deterrents to self-care behavior identified in a qualitative study of

Filipinos with Type 2 diabetes mellitus (T2DM) completed last year by Mr. Stimson Agustin, Jr. of Centro Escolar University-Manila.

Published in the Cebu Normal University Journal of Higher Education, Agustin described self-care as a “self-initiated, intentional and purposeful activity” wherein the patient “chooses the methods of healthy behaviors.” These behaviors entail the use of knowledge about their diabetes to balance their physical, emotional and activity levels as well as manage drug and nutritional intake to optimize glucose control. While he was able to access studies on self-care among Filipinos with diabetes living in the US, he found a dearth of such studies on Southeast Asians still living in their countries of origin, including Filipino diabetics still living in the Philippines. He interviewed six purposively sampled Filipinos with T2DM as well as their primary caregivers and collected self-care diaries accomplished during the three days prior to the interview.

Customer displeasure emerged as one of four deterrents or factors that prevented self-care behavior from occurring identified by the study. Long lines and waiting times were cited as sources of dissatisfaction for the patient, potentially straining the doctor-patient partnership necessary to facilitate self-care. Agustin enjoined doctors to accept that “any person seeking healthcare should be treated … as customers” who deserve efficient and convenient service. ‘The self,’ ‘stress’

and ‘fiscal constraints’ were also highlighted alongside customer displeasure as deterrents.

Enablers of self-care behavior were also extracted from the data: ‘the self as an enabler,’ ‘help from others,’ ‘the healthcare provider enabler,’ ‘spirituality,’ and ‘the environment’ or ‘the therapeutic milieu.’ When enablers dominate over deterrents, Agustin argued that effective self-care result and good outcomes and successful disease management are expected.

Agustin placed the diabetes nurse educator in a position instrumental to dealing with these enablers and deterrents to self-care. He recommended that nurses should constantly assess for these factors, especially among newly diagnosed patients. He pointed to quantitatively determining relationships between specific enablers or deterrents and long-term glycemic control and quality of life as a direction for future research.


Dr. Yves Saint James Aquino

T he Department of Health-Center for Health Development-National Capital

Region director Eduardo Janairo encouraged Metro Manila residents to use potable tap wa-ter for drinking instead of bottled water.

“Water coming from our two concession-aires namely the Maynilad Water Services, Inc. (MWSI) in West Manila and the Manila Water Company, Inc. (MWCI) in East Ma-nila are providing quality and sanitary safe potable water. The water from these two facilities is undergoing a monthly examination conducted by the Metro Manila Drinking Wa-ter Quality Monitoring Committee (MMD-WQMC) to ensure its safety for the welfare of metro residents,” said Janairo.

The health department is aiming to restore the people’s trust in the quality of tap water in Metro Manila, essentially decreasing its residents’ dependence on bot-tled water.

A report released last September 7, 2012 by the Metro Manila Drinking Water Quality Monitoring Committee (MMDWQMC) said that the water supplied by Manila Water and Maynilad at the time of sampling done last August 2012 was in compliance with the 2007 Philippine National Standards for Drink-

ing Water based on the microbiological and physio-chemical examinations.

Drinking water in the MWSS distribution system was Safe and of Sanitary Quality with adequate residual chlorine of 0.3 parts per million, pronounced the committee.

According to DOH, out of the 1,284 water refilling stations monitored in Metro Manila for the month of August 2012, 1,242 passed the potability standards set by PNSDW (42 or 3.3% failed). Janairo advised that consumers should look for the monthly microbiologi-cal quality results posted in refilling stations, ensuring that the water is safe and potable.

“The safety of our water is everyone’s responsibility. As the concessionaire’s ac-countability ends with the meter, so does our responsibility begins. We should periodically check for leaks and illegal connections in our pipelines and take time to report them. Water conservation is the first step in keeping our health safe,” concluded Janairo.

Water conservation is the first step in keeping

our health safe

‘‘

Use tap water for drinking, says DOH


WHO calls for more action against malnutrition

Gabriel Angelo Sembrano

T he World Health Organization (WHO) emphasized that expanded and sus-

tainable interventions for proper nutrition in the Western Pacific Region is more than necessary. This call for action was delivered by WHO Regional Director for the Western Pacific Dr. Shin Young-soo during a meeting in Hanoi, Vietnam last September 24 to 28, 2012, with the Regional Committee, WHO’s governing body in the region composed of 27 countries and areas in the Western Pacific.

“There is no room for complacency as the levels of maternal and young child undernu-trition continue to be too high. At the same time, the rising rates of obesity and non-com-municable diseases represent an epidemic – one that is growing fast in our region,” Shin emphasized.

Shin acknowledged that the double bur-den of malnutrition could hamper the eco-nomic growth of member states. He added that appropriate nutrition starting at the ear-liest stages of life is a very important step in ensuring proper physical and mental devel-opment that would result in long-term ben-efits and optimum productivity.

Shin also stressed that efforts should not only focus on the problems of overnutrition as what many countries do in the western pacific, but also on undernutrition and mi-cronutrient deficiencies since these continue to plague the region. He also pointed out that there is a need to expand areas for action, to

identify targets and priority actions in health and other sectors, and to adopt a time frame and indicators for monitoring.

As an answer to this call, the Regional Committee pledged to expand and sustain cost-effective nutrition programs that aim to prevent more than 100,000 under 5-year-old child deaths per year in the region. In addition, the regional committee is also set to endorse a resolution that would scale up nutrition based on the WHO Comprehensive Implementation Plan on Maternal, Infant and Young Child Nutrition.

This resolution calls for an increase in in-vestments for nutrition interventions from 2012 to 2015. This would substantially de-crease the double burden brought about malnutrition and other related mortalities and morbidities. Moreover, the plan seeks to increase exclusive breastfeeding and to stop the rapid rise of obesity among children.

The WHO also intends to augment its efforts in pushing ‘Scaling Up Nutri-tion,’ a movement composed of multiple stakeholders focused on fighting hunger and undernutrition using cost-effective interventions.

There is no room for complacency as the levels

of maternal and young child undernutrition continue

to be too high

‘‘


MARKET WATCH

T he Philippine Neurological Association and Medichem Pharmaceuticals, Inc. hosted the

Facts and Choices to Enhance Treatment Sympo-sium (FACETS) in Nasugbu, Batangas last Au-gust 17, 2012 to discuss latest treatment strategies for neurological disorders. Dr. Troels Staehelin Jensen, a neurology and pain specialist from Denmark, discussed treat-ments in neuropathic pain, with emphasis on an-ticonvulsants like gabapentin. According to Jen-sen, numerous studies have established the effectiveness of gabapentin in treating diabetic neuropathy, postherpetic neuralgia and other neuropathic pain syndromes. Dr. Emilio Perucca, president of International League Against Epilepsy in Italy, discussed treatment options in epilepsy. He presented studies on available anti-epileptic drugs that remain effective and well tolerated. For example, valproic acid, which is considered broad-spectrum, has been proven to be more efficacious than lamotrigine and topiramate in treat-ing generalized and unclassified epilepsies and newly diagnosed absence epilepsy.

FACETS presents effective treatment for epilepsy and pain

Seven diabetes societies launched the first Philip-pine-specific diabetes nutrition algorithm for pre-

diabetes and diabetes management, which aims to help health providers incorporate nutritional strategies in diabetic therapy. “The benefit of the new algorithm is that it will systematize the way we doctors advise our patients on how to lose weight by an overall lifestyle change in-cluding exercise and physical activity,” said Dr. Cecilia Jimeno, vice-president of PSEM. The seven societies included the Philippine Society of Endocrinology and Metabolism (PSEM), Diabetes Philippines, Philippine Center for Diabetes Education Foundation, Inc., Institute for the Study of Diabetes Foundation, Philippine Association for the Study of the Overweight and Obesity, Philippine Society of Diabetes Educators and the Nutritionist Dietitians Association of the Philippines. The task force based the algorithm on extensive review of clinical practice guidelines, medical literature and expert opinions.

Diabetes societies launch first nutrition algorithm

Dr. Jimeno

Medichem and PNA representatives presenting certificates to Dr. Jensen and Dr. Perucca (sixth and seventh from left


MARKET WATCH

R es|Toe|Run, which sells the best international shoe brands, recently came out with a whole-day event showcasing various fun family activities.

One of the highlights of the day’s festivities is the Shoe Safari Contest wherein participating families had to design and decorate their very own artwork into a cosplay costume featuring one of the eight safari animals at the event. They can choose from making a zebra, crocodile, tiger, bird, leopard, fish, giraffe, or a bee. Quite a daunting task, but the kids were surely up for the challenge urging their family members to do their best and win the grand prize. Prizes at stake for the Shoe Safari Contest were P10,000 plus 8,000 worth of gift certificates for the 1st prize, P8,000 plus 5,000 worth of gift certificates for 2nd, prize, P5,000 plus 3,000 worth of gift certificates for the 3rd prize, and a bunch of consolation prizes.

Shoe safari celebrates shoe fashion for the whole family

T he Neato XV-11 is a lightweight, robotic vacuum cleaner that helps keep the house clean on its own. It is

recognized as the most powerful robotic vacuumin the market, Neato thoroughly cleans differentfloor types, including carpet, tile,hardwood, and more. The vacuum cleaner operates by a press of a button. With its laser sensors, it maps everythingin a room to clean in a pattern of straight, overlappinglines, avoiding obstacles along the way, such as tables andstairs. Once the batteries are low, it takes care of itself byreturning to its base to recharge. And once fully charged, it will return where it left off. The smart robotic cleaner also allows for setting of schedule to automatically clean at the time set. Neato Vacuum is exclusively distributed by Focus Global, Inc. For inquiries, call (02) 634-8587.

Robotic cleaner works independently


LifeScience’s 3-step medical prevention

LifeScience Center for Wellness and Preventive Medi-cine, a pioneer in preventive care and customized

health management in the country, involves a three-step program to put Filipinos on the right track to wellness. Through Consultation, Testing and Treatment, Life-Science is able to accurately identify current state of wellness and design a customized Preventive Wellness Program that will allow their patients to experience be-ing healthy in another level and live in optimum health. “LifeScience gives Filipinos, who truly value their wellness, an opportunity to take their health to a new level. By simply being proactive about our health, we are already doing something to ensure our graceful aging,” said Dr. Ben Valdecanas, Medical Director of LifeScience Center for Wellness and Preventive Medicine. More information on LifeScience is available at www.lifescience.ph. For inquiries, Life-Science can be reached at +632 828-LIFE (5433).

Invida launches new pain treatment

I nvida, local subsidiary of Menarini, recently launched dexketoprofen trometamol, which promises to provide rapid and efficacious pain relief with less gastrointestinal side effects.

The molecular structure of dexketoprofen trometamol is the key to its pain-relieving po-tency, speed of action and tolerability, said Dr. Maaliddin Biruar, director for Medical and Sci-entific Affairs, Invida Philippines, Inc. Guest speakers during the media launch included Prof. Magdi Hanna, clinical director of Analgesics and Pain Research Unit in London, and Dr. Ester Penserga, a rheumatologist with the Philippine General Hospital. Available in tablet and parenteral formulation, dexketoprofen trometamol is indicated for pain of mild to moderate intensity, such as musculoskeletal pain, dysmenorrhea, postoperative pain, low-back pain and renal colic.

MARKET WATCH

Dr.Valdecanas

30 November 2012 Conference Coverage

Stroke risk high in diabetes patients48th Annual Meeting of the European Association for the Study of Diabetes, 1-5 October, Berlin, Germany

Alexandra Kirsten

Type 2 diabetes is associated with an in-creased risk of stroke in the long term, suggests new research.

A recent large-scale study involving 1,334 patients with type 2 diabetes found a cumula-tive stroke incidence of 12 percent over a 10-year follow-up period.

“The morbidity and mortality due to stroke in persons with type 2 diabetes mellitus is 3 to 4 times higher than in the general popula-tion,” explained study author Dr. M. Bernas from the department of internal diseases and diabetology at Warsaw Medical University, Warsaw, Poland.

The study patients, who were all attending the same outpatient diabetic clinic, included 597 men and 737 women, and had an average age of 62.6 years and a mean duration since diabetes diagnosis of 9.4 years.

Clinical determinants such as BMI, blood pressure, fasting and postprandial glycemia, cholesterol, triglycerides, creatinine, albu-minuria, and co-existing complications and co-morbid states, were recorded at baseline and every year during the 10-year study pe-riod. Morbidity and mortality due to stroke were determined and correlated with poten-

tial risk factors every year separately and as a cumulative value for the whole period.

At baseline, 62 patients (4.6 percent) had a previous history of stroke. In the 10-year peri-od, 135 new episodes of stroke (in 7.5 percent of patients) were observed. The cumulative incidence of stroke was 12.1 percent, which equated to 10.8 cases per 1,000 patient-years. The cumulative mortality due to stroke was 11.0 percent.

Statistically significant risk factors included age (95% Cl 1.03-1.07; P<0.001), fasting glyce-mia (95% Cl 1.17-3.39; P<0.05), daily albumin-uria (95% Cl 1.02-4.06; P<0.05), atrial fibrilla-tion (95% Cl 1.39-6.09; P<0.01) and smoking (95% Cl 1.17-3.00; P<0.01).

These are “the main objectively established clinical risk factors for stroke,” summarized Bernas.

This information should be taken under consideration in building up an individual plan of stroke prevention since “the efficacy of the prevention of stroke stands up as the ‘hot’ problem in diabetes mellitus care”, she concluded.

Type 2 diabetes has been shown to be a long-term risk factor for stroke.

The morbidity and mortality

due to stroke in persons with

type 2 diabetes mellitus is 3

to 4 times higher than in

the general population

‘‘


Insulin infusions beneficial in diabetics post-strokeAlexandra Kirsten

Patients with type 2 diabetes who experi-ence an acute episode of stroke seem to

benefit more from continuous intravenous in-sulin infusions than from intermittent subcu-taneous injections.

“Hyperglycemia is associated with [a] worse outcome in stroke patients,” said Leo-nid G. Professor Strongin from the State Medi-cal Academy, Nizhny Novgorod, Russia. “The benefits of intravenous infusions for blood glucose control in patients with stroke and type 2 diabetes mellitus are proved at a target glucose level less than 7 mmol/L, but it is not so obvious for the more acceptable range of 7.8-10 mmol/L”, he explained.

Strongin and colleagues conducted a clini-cal study to compare the efficacy and safety of the two different insulin delivery methods in patients with type 2 diabetes who had experi-enced a stroke. A total of 73 patients were sub-divided into two comparable groups within 24 hours of the stroke event, with one group assigned to receive continuous insulin infu-sions and the other intermittent subcutaneous insulin injections, in order to achieve blood glucose levels between 7.8 and 10 mmol/L.

Overall, 97 percent of the patients in the in-sulin infusion group achieved the glucose tar-

get compared with only 71 percent of those in the injection group (P=0.012). The mean daily glycemia level was 8.7 mmol/L in the infu-sion group and 9.7 mmol/L in the comparison group (P=0.025). Additionally, the infusion group reached the target glucose levels faster (2-3h vs. 3-6h, P=0.0019) and showed a smaller amplitude of fluctuations of glycemia (0.95 mmol/L vs. 5.3 mmol/L, P<0.01). The frequen-cy of hypoglycemia was significantly lower in the infusion group than in the comparison group (9 percent vs. 22 percent, P=0.037).

Patients in the basal group presented with better scores in the Barthel Activities of Daily Living Index (BADLI) at the time of discharge (45 vs. 20 points P<0.01) and after 6 months (62 vs. 47, P=0.006). However, there were no significant differences in hospital mortality between the groups: in the infusion group 25 percent of the patients died, in the control group 32.4 percent died (P=0.32).

“Glucose control using continuous intra-venous insulin infusions has advantages in regressing neurological deficit, improving functional recovery and decreasing risk of hypoglycemia”, concluded Strongin. But, “the impact of routes of insulin administration on 6-month survival could not be proved.”

48th Annual Meeting of the European Association for the Study of Diabetes, 1-5 October, Berlin, Germany


Exercise lowers CV risk in diabetics48th Annual Meeting of the European Association for the Study of Diabetes, 1-5 October, Berlin, Germany

Alexandra Kirsten

A new study has reported that leisure-time physical activity (LTPA) can significantly

reduce the risk of cardiovascular (CV) events in patients with type 2 diabetes.

Dr. Björn Zethelius and colleagues from Uppsala University in Uppsala, Sweden re-viewed data on leisure-time physical activ-ity from 15,462 patients with type 2 diabetes registered in the Swedish National Diabetes Register (NDR). In their study, patients were grouped as either “low physical activity” (no regular exercise or exercise once per week) or “regular exercise” (between three times per week and daily exercise). If a patient died during the course of the study, his or her last recorded physical-activity level was used for the analysis.

The yearly recorded data showed that regular exercisers were significantly less likely to have a cardiovascular event or to die either from cardiovascular disease or any other cause. The level of LTPA was related to fatal CV outcomes and all-cause mortality independently of conventional CV risk factors in type 2 diabetes. An increased LTPA level during the follow-up seemed to lower both CV risk and mortality in diabetic patients.

Those in the study who reported doing little or no physical activity at baseline but who managed to increase their regular ex-ercise to at least three times per week by the end of the study period (average 4.8 years) had even greater benefits. Compared with individuals who did not improve their exer-cise habits, the number of CV-related deaths among diabetics who increased their exercise levels fell by 67 percent (95% CI 0.17-0.60). Rates of all-cause mortality were reduced by

It’s never too late to increase your physical activity, a recent study suggests

almost the same degree (95% CI 0.25-0.49).“In general, diabetics are considered to be

less likely to engage in a regular exercise pro-gram than the general population,” stated the researchers. However, approximately 1,800 patients moved from a low physical-activity category into a higher physical-activity level over the course of the study.

“We consider physical activity and dietary advice as the basal treatment for diabetes, and when it fails, different types of pharmacological treatment are added,” Zethelius explained. “But what this study shows is that it’s never too late to increase your physical activity. Even when you are on medication, if you increase your physical activity, you will lower your risk for cardiovascular diseases.”

Editorial development by UBM Medica. The opinions expressed in this publication are not necessarily those of the editor, publisher or sponsor. Any liability or obligation for loss or damage howsoever arising is hereby disclaimed. © 2012 UBM Medica. All rights reserved. No part of this publication may be reproduced by any process in any language without the written permission of the publisher.

UBM Medica c/o MediMarketing Inc11/F Equitable Bank Tower, 8751 Paseo de Roxas,1226 Makati, Philippines T: +632 886 0333 • F: +632 886 0350 E-mail: [email protected] site: www.ubmmedica.com

Smashing the ABCs of IBS “Irritable Bowel Syndrome: The Mind, Gut and More”

Sponsored Symposium Highlights

Prof. Guy Boeckxstaens,MD PhDProfessor, Department of Gastroenterology,University of Leuven,Belgium

Associate Editor, Gut

The Philippine Society of Gastroenterology (PSG) in partnership with Invida Philippines, Inc. held a Grand Symposium at the SMX Convention Center, Mall of Asia, Pasay City last August 22, 2012. The one-day program emphasized current concepts regarding the management of Irritable bowel syndrome (IBS). Guest speaker Professor Guy Boeckxstaens conducted a lecture on IBS entitled “IBS: The Mind, Gut and More”. Local experts in the field of Gastroenterology also attended the symposium and discussed both traditional and novel concepts in the management of IBS. The symposium also highlighted the use of Otilonium bromide (Spasmomen®, Invida Philippines, Inc.), a spasmolytic that shows promising results in the treatment of IBS.

Irritable bowel syndrome (IBS) is a functional bowel disorder in which abdominal pain or discomfort is associated with relief after defecation or a change in bowel habit. There are also features of disordered defecation.1 It is a multifactorial disorder and diagnosis

is primarily symptom-based.2,3 Although the global prevalence data is far from complete, it is estimated that 10% to 15% are affected in Western countries, while Asian prevalence varies from 0.8% to 15.9%. It is clear however, that the occurrence of IBS is increasing in the Asia-Pacific region, particularly in countries with developing economies.4

The symptom pattern of IBS is characterized by different pathophysiological mechanisms ranging from central to enteric nervous system (CNS-ENS) dysregulation, visceral hypersensitivity, psychological factors, altered gut flora and mucosal immune activation (Figure 1).2 The disease model includes several factors that may start as early as perinatal life and persist or be compounded by other causes until late into adulthood.5 Studies show that particular triggers such as post-salmonella infection and psychosocial factors may increase the risk of developing IBS (relative risk [RR] as high as 4.8).6,7

Figure 1. Different Pathophysiological Mechanisms Leadingto Symptom Pattern of IBS 2

Unlike healthy individuals, IBS patients have both neuromuscular and sensory dysfunction leading to uncomfortable abdominal symptoms. Research shows that motor responses among IBS subjects are significantly higher compared to healthy subjects exposed to the same amount of stress (in the form of corticotropin-releasing hormone concentration) over the same duration of time.8,9 Approximately 60% of IBS patients also exhibit visceral hypersensitivity.10 This observation is further reinforced by microscopic evidence of marked inflammation in IBS-afflicted intestines.11

Consequently, inflammation seems to be a predominant factor for the neuromuscular and sensory dysfunction seen in IBS. Mast cell activation, in particular, is increased and appears to be more activated in such a disease.12 Another mechanism under investigation is the change in the normal intestinal microbiota among IBS patients. Dysbiosis in the intestinal flora may lead to increased mucosal permeability leading to abdominal symptoms.13 Such findings lead to the possibility of using probiotics and antibiotics in the treatment of IBS.14

The standard of care for IBS involves a multifactorial approach. This includes dietary and lifestyle measures, and the use of spasmolytics and/or laxatives and antidiarrheal agents. Adjunctive treatment to address the central or peripheral nervous control of symptoms may also be employed using antidepressants, psychotherapy or even hypnosis. A meta-analysis by Ford et al in 2009 favored the use of tricyclic anti-depressants and selective serotonin reuptake inhibitors in IBS. However, larger studies are needed to establish their effectiveness.3,15 All of these treatments are focused on reducing the bothersome abdominal symptoms of IBS.3

Pharmacologic therapy provides relief from the most predominant symptoms of IBS: diarrhea or constipation and abdominal pain.1 A meta-analysis of 17 high-quality clinical studies show that the spasmolytic myorelaxant Otilonium bromide (OB) produces effects that are significantly different from those of other spasmolytic drugs (Figure 2).16

Figure 2. Meta-Analysis of High-Quality Studies EvaluatingSpasmolytics in IBS16

OB is a spasmolytic that modulates the entry and release of calcium from the sarcoplasmic reticulum, thereby inhibiting smooth muscle contractions. It can also reduce pain perception by blocking the hyperalgesic effect of stimulated neurokinin-2 receptors on afferent nerves, increasing the threshold of pain for pressure and distention. Only approximately 1% of the drug is absorbed into the systemic circulation.Hence, it is virtually devoid of cholinergic side effects while effectively inhibiting intestinal smooth muscle contractions in both in vitro and in vivo preparations. OB is also proven to have similarly effective response rates in all IBS subtypes (mixed, with constipation and with diarrhea).3

Since IBS is a chronic disease, relapse is a common problem after the end of therapy.17 Compared to placebo, studies proved that OB can provide prolonged symptom-free intervals even at the end of treatment (Figure 3).18 Hence, symptom relapse is often delayed compared to other IBS treatments.3

Figure 3. Prolonged Symptom-Free Interval with Otilonium Bromide Compared to Placebo After End of Treatment18

Although insight into the pathophysiological mechanisms of IBS is still rather limited, there is increasing interest in novel treatment approaches. Promising new compounds in the pipeline that are not yet approved for clinical use include the serotonin antagonist ramosetron, heat-stable enterotoxins and linaclotide, k-opioid agonists and the antibiotic rifaximin. Data from all these coupled with the current standard of care will hopefully lead to better treatment regimens in the near future.3

GLOBAL ASSESSMENT OF EFFICACY OUTCOMEMeta-analysis of 17 high-quality trials

Pinaverium bromide

Cimetropium bromide

SPASMOMEN® 148 / 317 102 / 325 1.9

Drug Treatmentn/N

Controln/N

OR(95% CI Random)

19 / 25

30 / 48

17 / 25

28 / 47

1.5

1.1

0.01Favors placebo Favors treatment

0.1 10 1001

Mebeverine

Hyoscine

6 / 40

106 / 182

12 / 40

91 / 176

0.4

1.3

References:1. Longstreth GF, et al. Gastroenterology 2006. 2. Simrén M. Gastroenterology 2009. 3. Boeckxstaens G, PSG Grand Symposium, 2012. 4. World Gastroenterology Association, 2009. 5. Mayer EA, et al. N Engl J Med 2008. 6. Mearin F, et al. Gastroenterology 2005. 7. Spiller R, Garsed K. Gastroenterology 2009 . 8. Manabe N, et al. Neurogastroenterol Motil 2010. 9. Fukudo S, et al. Gut 1998. 10. Mertz H, et al. Gastroenterology 1995 11. Akbar A, et al. Gut 2008. 12. Barbara G, et al. Gastroenterology 2007. 13. Gecse K, et al. Gut 2008. 14. Manabe N, et al. Curr Gastroenterol Rep 2010. 15. Ford AC, et al. Gut 2009. 16. Lesbros-Pantoflickova D, et al. Aliment Pharmacol Ther 2004. 17. Jones J, et al. Gut 2000. 18. Clavé P, et al. Aliment Pharmacol Ther 2011.

OR, odds ratioGlobal assesment means assessment of patients’ wellbeing which includes reduction of the abdominal pain intensity and frequency, abdominal distention and satisfied bowel movement.

Adapted from Lesbros-Pantoflickova 2004

PRODUCT-LIMIT SURVIVAL FUNCTION ESTIMATES

Otilonium bromidePlacebo

Surv

ival

pro

babi

lity

Weeks

Log rank p=0.0379

1

0.8

0.6

0.4

0.2

00 2 4 6 8 10

No. of subjects Event Censored Median Survival (95% CI)1 82 66% (54) 34% (28) 5.000 (3.000 - 8.000)2 79 76% (60) 24% (19) 1.000 (1.000 - 4.000)

Where: Relapse = at least 2 episodes of abdominal pain per week or the use of rescue medication

SPASMOMEN HB.indd 1 10/10/12 4:41 PM

34 November 2012 In Pract ice

Managing HFMD in primary care

Hand, foot and mouth disease (HFMD) is a common viral infectious disease that affects all age groups, but young

children are especially susceptible. HFMD can be easily spread through direct

contact with saliva, nasal discharge, feces or fluid from the blisters of an infected person. Generally, it is a mild self-limiting illness that resolves in 7-10 days. HFMD rarely recurs or persists, and serious complications are also rare.

Although HFMD affects all age groups, children under the age of 5 are highly prone to infection because they interact closely with one another, in the classroom or on the play-ground, for example, at preschools. Human contact is one of the most common causes for infections to spread person to person.

Individual cases of HFMD occur constant-ly but these can spiral into outbreaks affecting many children rapidly.

For example, HFMD has become more prevalent in Singapore of late. Cases of HFMD infection have risen from 20,687 in 2011 to 31,590 as of September 2012.

Education for prevention Primary care physicians are in the ideal

position to educate parents and caregivers on the importance of hygiene and help pre-vent the spread of infection. Simple messages teaching parents and children the proper way to wash their hands is an effective method of preventing outbreaks.

Dr. K. Vijaya Director, Youth Health Division Singapore Health Promotion Board

The Singapore Health Promotion Board (HPB) advocates eight target areas for effec-tive hand washing (Box).

Diagnosing HFMDPrimary care physicians need to pay close

attention to symptoms to ensure that patients are diagnosed early so that infected children are prevented from spreading disease to others in the school. The burden of HFMD is likely to be concentrated within young, school-going children, but rates may vary. For example, the number of HFMD cases in Sin-gapore reached a record high of 1,687 in May 2012, which far exceeded the epidemic level of 780 cases a week.

The incubation period of HFMD lasts ap-proximately 1 week and patients may only present with a sore mouth or throat. There-fore, symptoms may not be apparent initial-ly and early symptoms may be mistaken for other illnesses.

In addition to looking out for symptoms, physicians can also check if there are other cases of HFMD within the family or in the school the child attends.

A child with HFMD usually presents with the following symptoms: • Fever for 2-3 days • Sore throat and runny nose • Rash (flat or raised red spots, some with

blisters) on the hands (especially the palms), feet, and occasionally on the but-tocks, arms and legs

• Mouth ulcers • Vomiting and diarrhea • Tiredness and weakness

A child is infectious throughout the dura-tion of the illness.

35 November 2012 In Pract iceLaboratory testing is available to isolate

and identify the causative agent. Howev-er, testing is usually not necessary because HFMD diagnosis is typically based on clinical grounds.

Treating HFMD There is no specific treatment for the infec-

tion other than relief of symptoms. Treatment with antibiotics is not effective or indicated as HFMD is a viral infection. Easing the patient’s discomfort and helping them recover is the priority.

Physicians should ask parents and caregiv-ers to: • Encourage the child to drink plenty of

fluids • Change to a soft diet (eg, porridge, pureed

fruit) if the mouth ulcers are a problem • Medications can be provided to ease the

discomfort, such as paracetamol syrup to relieve fever and pain

• Keep the child at home to allow plenty of rest In most cases, HFMD is mild. However, a

few children who are infected with the EV71 strain of the virus can become very ill, with signs and symptoms such as: • Disorientation, drowsiness and/or irritabil-

ity • Fits • Severe headache, dizziness or neck stiff-

ness • Breathlessness or turning blue • Dehydration – this can happen due to con-

tinuous vomiting, diarrhea or pure fluid intake as a result of painful mouth ulcers. The child will be very tired, have a dry tongue and may pass very little urine. A child with any of these symptoms should

be immediately referred to a hospital emer-

gency department. In most cases, patients do not require fol-

low up care. Physicians should closely moni-tor young children (especially infants) for development of dehydration. Rarely, patients with central nervous system manifestations of HFMD such as encephalitis or aseptic men-ingitis may require hospitalization.

HFMD is highly contagious. A child is also susceptible to getting other infections when they have HFMD. Physicians can advise par-ents the following: • Keep the child away from public places.• Get everyone at home to wash their hands

frequently with soap.• Keep child’s toys, books, eating utensils,

towels and clothes separate from others, and disinfect them regularly

• Inform the school, kindergarten or child care center as soon as possible. They can monitor other children closely and take ad-ditional precautions to prevent the spread of HFMD.

• Keep the child at home until he or she is ful-ly recovered, after the expiry of the medical certificate (MC) given by the family doctor.

• Ensure that any siblings are well before sending them to the school, kindergarten, or child care center.

Conclusion Primary care physicians need to educate

parents and caregivers about keeping their child away from public places and schools during the infection period to avoid creating an outbreak. HFMD is present all year round in Southeast Asia, with seasonal outbreaks every year. Parents and caregivers should closely monitor their children to help prevent such outbreaks in childcare centers, kinder-gartens and schools.

Focusing on the value of nutrition in diabetes management, the workshop aimed to address the following learn-ing objectives:

•Tobrieflyreviewthepathophysiology oftype2diabetesmellitusand relatedoutcomes •Todiscussoverallnutritional interventionsfordiabetesandits impactonclinicaloutcomes •Todiscusspracticalconsiderations inlifestylemodificationstrategiesin type2diabetesmellitus

Program OutlineMay17,2012(Thursday)

Pathogenesis and Lifestyle Risk Factors of Type 2 Diabetes MellitusProfessorAliceKong

Nutritional Management as Component of Standard of Care for DiabetesDrRosaAllynSy

Clinical Relevance of Low Glycemic Index Diet in Diabetes and Metabolic ControlProfessorAliceKong

Practical Considerations on Meal Planning for DiabetesMsGemmaDimaano

Exercise Prescription for Diabetes and Weight ManagementCoachJimSaret

Effective Techniques in Motivating Diabetic Patients on Dietary and Lifestyle ModificationMsGemmaDimaano

3rd Diabetes Nutrition Workshop: Optimizing Nutrition andLifestyle Strategies for Diabetes Management in Daily Practice

OnMay17,2012,theNestléNutritionInstituteheldits3rdDiabetesNutritionWorkshopinManila,Philippines.TheprogramwasmoderatedbyDrAimeeAndag-Silvaandgatheredexpertsindiabetescare;namely,ProfessorAliceKong,Associate

Professor,DepartmentofMedicineandTherapeutics,ChineseUniversityofHongKong;DrRosaAllynSy,SectionHeadofEndocrinology,andDirectoroftheDiabetesCareClinic,CardinalSantosMedicalCenter;MsGemmaDimaano,RegisteredNutritionist-DietitianwithCertificationsinPediatric&AdultWeightManagement,andaDiabetesEducator;andMrJoseJimboSaret,SportsTrainingConsultant,PhilippineOlympicCommittee.

Professor Alice PS KongAssociate Professor

Division of EndocrinologyDepartment of Medicine and Therapeutics

The Chinese University of Hong Kong

Pathogenesis and lifestyle risk factors of type 2 diabetes mellitusType 2 diabetes mellitus (T2DM) is a multifac-eted disease affecting at least 170million peopleworldwide.1 Its pathogenesis is incompletely un-derstood, though interplay between genetic andenvironmentalfactorsisclearlyinvolved.Inpatientswith impairedglucose tolerance (IGT)ordiabetes,mechanisms that normally regulate postprandialhyperglycemia are impaired by delayed and re-ducedinsulinsecretion,lackofglucagonsuppres-sion,andhepaticandperipheralinsulinresistance.2

Apart from classical risk factors such as dyslipi-demia, hypertension and smoking, novel risk fac-torsforT2DMrepresentunmetclinicalneedstobeaddressedinthenextdecade.Dietisanimportantlifestylefactorthatplaysaroleinthedevelopmentofobesityanddiabetes.Whenbothconditionsarepresent,glycemicgoalsaregenerallymoredifficulttoachieve.3

SleepisalsoincreasinglyrecognizedtobeanovellifestyleriskfactorinT2DMandobesity.Sleepdep-rivationleadstoincreasedproductionofstresshor-monesandhasaharmfulimpactoncarbohydratemetabolismandendocrinefunction.Itseffectsaresimilar to those seen in normal aging.3 As showninarandomized,crossoverstudyinvolvinghealthymalevolunteers,shortsleepdurationwasassoci-atedwithdecreasedleptinlevels,increasedghrelinlevels,andincreasedhungerandappetite.4

Traditional pharmacologic agents for diabetes in-clude oral antidiabetic agents, which commonlycauseweightgain,aswellasbasaland intensiveinsulin therapy.Lifestylemodifications remainoneofthecrucialelementsinthemanagementofT2DMand is recommended by the American DiabetesAssociationand theEuropeanAssociation for theStudyofDiabetestohelpachievecontrolofhyper-glycemiaatallstagesofmanagement.

References1. IDFDiabetes Atlas - Fifth edition. http://www.idf.org/atlasmap/atlasmap. Ac-cessed July 9, 2012. 2. Weyer C, Tataranni PA, Bogardus C, Pratley RE.Dia-betes Care 2001;24:89-94.3.KongAP,ChanNN,ChanJC.Curr Diabetes Rev 2006;2:397-407.4.SpiegelK,TasaliE,PenevP,VanCauterE.Ann Intern Med 2004;141:846-850.

Clinical relevance of low glycemic index diet in diabetes and metabolic controlExcessweighthasbeenassociatedwithsignificantmorbidity and mortality related to hypertension,type2diabetesmellitus(T2DM),dyslipidemia,ath-erosclerosis and certain types of cancer.1 AmongAsians,additionaldietaryfactorssuchasfrequentwhitericeintakemaycontributetotheriskofdeve-lopingdiabetesandothermetabolicdiseases.2

Traditionally, weight management programs havefocusedonrestrictingenergyconsumptionthroughreduced fat and carbohydrate intake.3-6 However,low-fat, energy-restricted diets may elicit physi-ological adaptations that promote weight regain,leadingtohighfailureratesinthelong-term.

The lowglycemic index (GI)diet is apotential al-ternative dietary intervention for sustainedweightmanagement and glucose homeostasis, andmayalsoplayaroleinimprovingothercardiometabolicriskfactors(Figure1).1

Glycemic index and glycemic loadTheconceptofGIwasfirstintroducedbyJenkinsand colleagues in the early 1980s as part of thedietarymanagementofdiabetes, recognizing thatsubstantial variations in thephysiologic effects ofcarbohydratesmade their classification difficult.7,8 Interpretedinthesimplestterms,foodswithalowGI are digested and absorbed more slowly thanfoodswithahighGI.9

Technically, GI is defined as the incremental areaunder the curve (AUC) for the blood glucose re-sponseafterconsumptionofafoodrelativetothatproducedbya reference foodsuchasglucoseorwhite bread given in an equivalent carbohydrateamount (50gor25g).7,10LowGI foodsare thosewithGI≤55andhighGIfoodsarethosewithGI≥70(Table).11,12FactorsthatincreaseGIrankingincludeamylopectin, cooking time andmethod, ripeness,temperatureandalkalinity.

Glycemicload(GL)isafunctionofafood’sGIandits total available carbohydrate content. Whereas

GI rankscarbohydratesbasedon their immediateblood glucose response (ie, glycemic quality),GLhelps predict blood glucose response to specificamountsofcarbohydratefood(ie,glycemicqualityandquantity).

Low GI diets help manage metabolic risk factorsSeveral clinical trials have studied associationsbetween lowGIdiets,obesityandobesity-relatedcardiovascular risk factors inchildrenandadoles-cents.13Inameta-analysisof14 studiescomprising356subjects,lowGIdietsreducedhemoglobinA1c(HbA1c)levelsby0.43%points(confidenceinterval[CI]0.72to0.13)overandabovethatproducedbyhighGI diets.14 Taking both HbA1c and fructosa-

mine data and adjusting for baseline differences,glycatedproteinswerereduced7.4%(CI8.8to6.0)moreonthelowGIdietthanonthehighGIdiet.

Inanotherstudy,bloodpressureanddietarydatawere taken from 858 students aged 12 yearsat baseline.15 Among female subjects, each 1- standard deviation increase in dietary GI, GL,carbohydrate and fructose intake was concur-rentlyrelatedtoanincreaseof1.81(p=0.001),4.02(p=0.01),4.74(p=0.01)and1.80mmHg(p=0.03)insystolicbloodpressure,respectively,after5years.

High-density lipoprotein cholesterol (HDL-C) is anadditionalriskfactorthatmaybeinfluencedbydi-etaryGI.Usingdatafrom13,907participantsaged≥20years inthe3rdNationalHealthandNutritionExamination Survey (1988 to 1994), age-adjustedHDL-ClevelswerefoundtobeinverselyrelatedtodietaryGIandGL.16

Given the increasingprevalenceofobesityworld-wide, low GI diets may need to be started evenamong younger patients. An ongoing 12-month,randomized, controlled dietary intervention trialhas found a high frequencyof fatty liver (73.3%),prediabetesandothercardiometabolicriskfactorsinobeseHongKongChineseadolescents(n=104;meanage16.7yearsand16.8yearsinthelowGIandcontrolgroups,respectively).17

After adjustment for age and sex, subjects in thelowGIgrouphadsignificantreductioninobesityin-dicesincludingbodymassindex,bodyweightandwaist circumference compared to subjects in thecontrolgroup(allp<0.05).

GI-based dietary guidelinesSignificant physiologic benefits can be achievedwhenGIisusedtoguidedietaryinterventions.Un-likeastandardfoodpyramidwhichpromotesmini-mizingintakesofoil,sugarandsaltwhilemaximiz-ingcerealconsumption,alowGIdietplacesrefinedgrains, potatoes and sweets at the topof the re-stricted food list (Figure 2). International diabetesassociations currently agree that consumption oflowGIfoodsmayplayanimportantroleinoptimiz-ingglucosecontrolinpatientswithT2DM.18-20

SummaryChoosing lowGI foods inplaceof refinedcarbo-hydrates or high GI foods has a small but clini-cally useful effect on glycemic control in diabeticpatients.Othermetabolic risk factorssuchashy-pertensionandlowHDL-Cmayalsobebetterman-agedbyfollowingnutritionalrecommendationsthatincorporateGIconcepts.InAsia,wherewhitericeconsumptionmay increasediabetes risk,earlydi-etaryinterventionmaybeappropriateevenamongapparentlyhealthyyoungindividuals.References1. RadulianG, Rusu E, Dragomir A, PoseaM.Nutr J 2009;8:5.2. Hu EA, PanA,MalikV,SunQ.BMJ 2012;344:e1454.3.GibsonLJ,PetoJ,WarrenJM,dosSantos Silva I. Int J Epidemiol 2006;35:1544-1552. 4. Thomas H.Health Educ Res 2006;21:783-795.5.KrishnanS,RosenbergL,SingerM, et al.Arch Intern Med 2007;167:2304-2309.6. VillegasR, Liu S,GaoYT, et al.Arch Intern Med 2007;167:2310-2316.7.JenkinsDJ,WoleverTM,TaylorRH,etal. Am J Clin Nutr 1981;34:362-366.8.LudwigDS.JAMA2002;287:2414-2423.9.WoleverTM,Jen-kinsDJ,JenkinsAL,JosseRG. Am J Clin Nutr 1991;54:846-854.10.HofmanZ,DeVanDrunenJ,KuipersH.Asia Pac J Clin Nutr2006;15:412-417.11.MilonH,etal.Thai J Paren and Enter Nutr 2003;14:24-30.12.TheUniversityofSydney.http://www.glycemicindex.com.AccessedMarch20,2012.13. KongAP,ChanRS,NelsonEA,ChanJC.Obes Rev 2011;12:492-498.14.Brand-Miller J,HayneS,PetoczP,ColagiuriS.Diabetes Care2003;26:2261-2267.15.GopinathB,FloodVM,Rochtchina E, et al.Hypertension 2012;59:1272-1277.16. Ford ES, Liu S.Arch Intern Med2001;161:572-576.17.ChineseUniversityofHongKong.Clinical-Trials.govIdentifierNCT01278563.18.SkylerJS,BergenstalR,BonowRO,etal.Diabetes Care2009;32:187-192.19.MannJI,DeLeeuwI,HermansenK,etal.Nutr Metab Cardiovasc Dis2004;14:373-394.20.BerardLD,BoothG,CapesS,QuinnK,WooV.Can J Diabetes2008;32(Suppl1):S1-S201.

Editorial development by UBM Medica. The opinions expressed in this publication are not necessarily those of the editor, publisher or sponsor. Any liability or obligation for loss or damage howsoever arising is hereby disclaimed. © 2012 UBM Medica. All rights reserved. No part of this publication may be reproduced by any process in any language without the written permission of the publisher.

UBM Medica c/o MediMarketing Inc11/F Equitable Bank Tower, 8751 Paseo de Roxas, 1226 Makati, Philippines T: +632 886 0333 • F: +632 886 0350 • E-mail: [email protected] site: www.ubmmedica.com

SPONSORED SYMPOSIUM HIGHLIGHTS

EAT LESS

EAT MORE

REDUCED FAT DAIRYLEAN PROTEIN

NUTS AND LEGUMES

Low GI diets andmetabolic syndrome

Insulin resistance

Cardiovascular risk

Dyslipidemia

Glycemia

Free fatty acids

Inflammation

Endothelial dysfunction

Prothrombotic factors

β-cell dysfunction

Hyperinsulinemia

Figure 1. Metabolic benefits of low GI diets1

Table. Glycemic index of common foods11,12

Figure 2. Low GI diet

CEREAL Brownrice 50Mediumgrainwhiterice 83Glutinousrice 98Ricevermicelli,Kongmoon 58Spaghetti 42Sobanoodle 46Whitebread 70Wholewheatbread 73Cornflake 72Allbranbreakfastcereal 30STARCHY VEGETABLE AND BEANMashedpotato 88Bakedpotatowithskin 56Sweetpotato 48Cannedbakedbeans 40SUGARS AND SUGARY FOODFructose 20Sucrose(tablesugar) 58Glucose 100Coke 53Icecream,chocolate 68FRUITOrange,whole 48Orangejuice 57Banana 51Watermelon 72Lychee,canned 79DAIRY AND OTHERSSkimmilk 32 NUTREN Diabetes 31(vsbreadstandard) 22(vsglucosestandard) Red text, high glycemic index foods; green text, low glycemic index foods.

REFINED GRAINSPOTATO AND SWEETS

REFINED GRAINSAND SWEETS

FRUITS AND VEGETABLES(cooked or dressed with

healthful oil)

37 November 2012 CalendarNovember

2012 Scientific Sessions of the American Heart Association 3/11/2012 to 7/11/2012 Location: Los Angeles, California, US Info: American Heart Association Tel: (1) 214 570 5935 Email: [email protected] Website: www.scientificsessions.org

8th International Symposium on Respiratory Diseases & ATS in China Forum 20129/11/2012 to 11/11/2012Location: Shanghai, ChinaInfo: UBM Medica Shanghai Ltd.Tel: (86) 21-6157 3888 Extn: 3861/62/64/65Fax: (86) 21-6157 3899Email: [email protected]: www.isrd.org

63rd Annual Meeting of the American Association for the Study of Liver Diseases9/11/2012 to 13/11/2012 Location: Boston, Massachusetts, US Info: American Association for the Study of Liver Diseases Tel: (1) 703 299 9766 Website: www.aasld.org

9th International Diabetes Federation-West Pacific Region Congress25/11/2012 to 27/11/2012Location: Kyoto, JapanInfo: Japan Convention Services, Inc.Tel: (81) 6 6221 5931Fax: (81) 6 6221 5939E-mail: [email protected]: www2.convention.co.jp/idfwpr2012

DecemberNational Diagnostic Imaging Symposium 2/12/2012 to 6/12/2012Location: Orlando, Florida, USInfo: World Class CME Tel: (980) 819 5095Email: [email protected]: www.cvent.com/events/national-diag-nostic-imaging-symposium-2012/event-summary-d9ca77152935404ebf0404a0898e13e9.aspx

Asian Pacific Digestive Week 20125/12/2012 to 8/12/2012Location: Bangkok, ThailandTel: (66) 2 748 7881 ext. 111Fax: (66) 2 748 7880E-mail: [email protected]: www.apdw2012.org

World Allergy Organization International Scientific Conference (WISC 2012)6/12/2012 to 9/12/2012Location: Hyderabad, IndiaInfo: World Allergy OrganizationTel: (1) 414 276 1791 Fax: (1) 414 276 3349E-mail: [email protected]: www.worldallergy.org

54th American Society of Hematology Annual Meeting8/12/2012 to 11/12/2012Location: Georgia, Atlanta, USInfo: American Society of HematologyTel: (1) 202 776 0544Fax: (1) 202 776 0545Website: www.hematology.org

17th Congress of the Asian Pacific Society of Respirology14/12/2012 to 16/12/2012Location: Hong KongInfo: UBM Medica Pacific LimitedTel: (852) 2155 8557Fax: (852) 2559 6910E-mail: [email protected]: www.apsr2012.org

Upcoming16th Bangkok International Symposium on HIV Medicine16/1/2013 to 18/1/2013Location: Bangkok, ThailandInfo: Ms. Jeerakan Janhom (Secretariat)Tel: (66) 2 652 3040 Ext. 102Fax: (66) 2 254 7574E-mail: [email protected]: www.hivnat.org/bangkoksymposium

28th Congress of the Asia-Pacific Academy of Ophthalmology17/1/2013 to 20/1/2013Location: Hyderabad, IndiaInfo: APAO SecretariatTel: (852) 3943 5827Fax: (852) 2715 9490 Email: [email protected]: www.apaoindia2013.org

38 November 2012 Calendar

International Meeting on Emerging Diseases and Surveillance (IMED 2013)15/2/2013 to 18/2/2013Location: Vienna, AustriaInfo: International Society for Infectious DiseasesTel: (617) 277 0551Fax: (617) 278 9113 Email: [email protected]: www.isid.org/imed/Index.shtml

Asian Pacific Society of Cardiology 2013 Congress21/2/2013 to 24/2/2013Location: Pattaya, ThailandInfo: Kenes Asia (Thailand Office)Tel: (66) 2 748-7881Fax: (66) 2 748-7880Email: [email protected]: www2.kenes.com/apsc2013/pages/home.aspx

23rd Conference of the Asia Pacific Association for the Study of the Liver7/3/2013 to 10/3/2013Location: SingaporeInfo: Gastroenterological Society of Singapore, The Asian Pacific Association for the Study of the LiverTel: (65) 6292 4710Fax: (65) 6292 4721Email: [email protected]: www.apaslconference.org

62nd American College of Cardiology (ACC) Annual Scientific Session9/3/2013 to 11/3/2013Location: San Francisco, California, USInfo: American College of Cardiology FoundationTel: (415) 800 699 5113Email: [email protected]: www.accscientificsession.org/Pages/home.aspx

4th Biennial Congress of the Asian-Pacific Hepato-Pancreato-Biliary Association27/3/2013 to 30/3/2013Location: Shanghai, ChinaInfo: Asian Pacific Hepato-Pancreato-Biliary AssociationTel: (86) 21 350 30066Fax: (86) 21 655 62400Email: [email protected]: www.aphpba2013shanghai.org/

39 November 2012 Humor

“Give it to me straight doctor, should I start dating?”

“He likes his steak and mashed potatoes intravenously!”

“At our hospital we either perform a Cesarian, or the

Heimlich maneuver. Which one do you prefer?”

“This here? I cut myself shaving!”

“I sent your brown suit to the cleaners. It will match the mahogany casket perfectly!”

“I wouldn't worry about it. He won't get far without lungs!”

40 November 2012 After Hours

Crater cultureYen Yen Yip investigates the music and magic of Lake Toba in North Sumatra, Indonesia.

T he Batak man sits in front of a multihued dis-play of souvenir T-shirts and ulos, the tradi-tional cloth of North Sumatran Bataks. A two-

stringed mandolin is cradled in his arms. He opens his mouth to sing and reveals a row of broken teeth. With one hand clasping, moving and pressing down on alternate string positions, he strums, coaxing a twanging melody out of the mandolin to accompany his hoarse voice. The song is harsh and strangely el-emental; it conjures up images of men sitting around a fire at night, drinking palm fruit toddy after a day of fishing on Lake Toba.

One of the most famous features of Lake Toba is a caldera – a crater lake that was formed when a su-per-volcano erupted more than 69,000 years ago. The eruption blew up about 2,800km3 of material and created a colossal hole about 906m above sea level, which gradually filled with water. Tens of thou-sands of years later, the Austronesian people trav-eled to Sumatra, made their way inland and found a beautiful lake ringed with forested dusky-blue sil-houettes of mountains. The ones who settled on the surrounding mountainous regions and Samosir, the island in the middle of the lake, became known as the Toba Bataks.

Accounts of Batak traditions date back to the 1200s. Some customs have survived the test of time. For in-

stance, traditional music played with Batak instru-ments such as the two-stringed mandolin, flute and drums is still used during ceremonies and festivities. At these events, ulos – cloth weaved with Batak designs – are folded length-wise and draped over a shoulder. Some Bataks on Samosir continue to live in houses called rumah adat, built with distinctive roofs that sweep upwards on either end like buffalo horns, the gables adorned with elaborate carvings of thumb-print-like whorls and lines.

Other tribal rituals, such as cannibalism, have died out. Early accounts of the Bataks’ predilection for human flesh came from the European explorer Marco Polo, who traveled to Sumatra in the 1290s and wrote about stories told to him of “man-eaters” who eat humans “stump and rump”. In the 1800s, Sir Stamford Raffles and other colonialists studied cannibalistic rituals of the Bataks and reported that human flesh was typically eaten when tribes waged war against neighboring villages and captured pris-oners, or if a tribe member was accused of legal in-fringements such as murder, rape or theft.

In Samosir, these grisly details can be recounted in full at Ambarita, a tribal village in Samosir which features a set of historic stone chairs where a judicial council would have sat to decide the fate of a pris-oner. If the prisoner was condemned to execution, he

41 November 2012 After Hours

Getting There Lake Toba is a five hour drive from Medan, the largest city in North Sumatra. Tourists can fly in to Medan through Polonia International Airport.

What to Do• Diveintothedeliciouscoolwatersof

the crater lake• Dancewiththelocalsinatraditional

Batak performance• Hikethepeaceful,rollinghillsof

Samosir and drink in the scenery• Takeasipofpalmfruittoddy

would be beheaded; the body would be disposed in the lake, but the blood collected and the liver extract-ed for consumption.

The Bataks believed that all humans possess a tondi, or a life-soul, which can affect his or her phys-ical well-being: a weakened tondi can lead to illness and even death. The blood and the liver, consid-ered to be rich in tondi, were consumed to heal and strengthen the eater’s spiritual self. In 1890, the Dutch colonial government passed a law banning canni-balism. Rumors of cannibalism among the Bataks persisted until the early 20th century.

Today’s Toba Bataks have mostly converted to Christianity. Brightly colored churches with steeples glinting in the sun are frequently spot-ted in the middle of rice paddies and agricultural fields along the dusty, empty roads of Samosir. Be-fore the advent of Christianity, however, the Batak religious worldview was animistic. Divina-tion and magic were commonly practised. Da-tuks – animistic shamans – recorded magic spells, healing charms, prophecies and other mystical notes in arcane Batak characters on push-tahas, books made of tree bark, folded and opened in concertina style.

Certain burial practices have endured until to-day. At death, the Bataks are buried twice. It was traditionally believed that the tondi of a deceased person will vanish from the body; however, the begu, or the death-soul, remains. A priest is re-quired to perform rituals at the first funeral to ad-vise the begu to leave the family and the village. Re-burial typically takes place about 8 years after death,

during which the bones are exhumed and cleaned, to be reinterred in a bone house that is elevated above ground to be closer to the heavens.

The tomb of the Batak rajah Sidabutar rests on a hill in Tomok, a village in southern Samosir, past about half a kilometre of souvenir stalls lining a nar-row meandering lane. His sarcophagus is carved in stone and sits out in the sun, bleached and silent. Legend has it that the monarch was a just and wise ruler whose affections were spurned by a Batak beauty, Anting Malela. In vengeance, the rajah cursed the woman and drove her insane through black magic. The rajah’s unrequited love persisted at his deathbed: he had a stat-ue of Anting Malela carved to adorn his tomb. Today, the sarcophagus is the object of tourist fascination and camera clicks.

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