Blogs posted for BMJ, Public health issues in Asia

Why are we so resistant to calling sugar the enemy?

Sparing developing countries the fate of obesity-associated diseases that plague the developed world is currently one of the most pressing global public health issues. Before we export wholesale the ‘follow the food pyramid, exercise, and eat no more calories than you burn’ approach, it may be time to review how effective it actually is. The answer is: not very, if a recent study by the Institute for Health Metrics and Evaluation at the University of Washington, showing that the obesity rate continues to climb even as Americans are exercising more, is anything to go by.

I recently came across the work of Peter Attia (like a lot of interesting people, I came across him via his TED talk) on obesity, diabetes and insulin resistance. He is currently exploring a novel hypothesis: that obesity is not a cause of diabetes; rather, it’s a symptom of a much deeper underlying problem. Turning conventional wisdom about diabetes on its head, Attia asserts that adding fat cells could be the lesser of two metabolic evils for a body being bombarded with excess insulin and faced with a choice between using it or storing it.

Attia is now in a team of researchers looking at the causes of obesity from multiple angles, but his, that refined carbs, the culprit of insulin resistance are the problem, is one that makes a lot of sense. Attia is the co-founder of the Nutrition Science Initiative, a non-profit research organization in San Diego. The other co-founder is Dr Gary Taubes, who recently wrote extensively and eloquently in an essay for the BMJ on how little real science is behind the energy imbalance theory of obesity and on the endocrine hypotheses that have been lost in the mists of time.

Obesity is not the only health issue that stands to benefit from a better understanding of the causes and effects of insulin resistance. As a public health researcher and writer, I study the factors that make it difficult for so many women in high-income countries to successfully initiate and sustain exclusive breastfeeding. There are many factors at play, from hospital practices to the attitudes and behaviours that travel along women’s own social networks, and not least the pervasive onslaught of propaganda from the formula industry. But recently published research into the role of insulin in milk production points to sub-optimal glucose metabolism impairing breastfeeding. The research adds to the body of knowledge and clinical trials now underway to test whether diabetes medications can be used to regulate insulin action in the mammary gland. However, the ideal approach is a preventive one, says Dr Laurie Nommsen-Rivers, a scientist at the Cincinnati Children’s Hospital Medical Centre and corresponding author of the study. “Modifications in diet and exercise are more powerful than any drug.”

It’s heartening to see Taubes’ work in the BMJ and Attia garnering the massive publicity that a TED talk can bring. Probably the most famous critic of sugar is Robert Lustig and his work on the health impact of fructose, and there are voices within the medical community trying to get the dangers of sugar on the public health agenda, such as Laura Schmidt and Clare Brindis (see the opinion piece from Schmidt on and Nature for the underlying academic paper). Still, it is fat, and saturated fat in particular, that is touted as the main dietary public enemy, and the all-pervasive presence of sugar and refined carbs does not attract similar criticism.

There are pharmaceutical interventions for diabetes and obesity, all with their own side-effects and none offering a cure. Yet there are simple, side-effect free dietary changes that can tackle the underlying issue of insulin resistance. They aren’t lucrative for anybody, except perhaps whole food retailers. Neither the pharmaceutical industry nor the agri-industrial complex will be promoting these changes any time soon. But the public health community can, and arguably should.

Jane Parry is a Hong Kong based public health and medical journalist and researcher.

24 July 2013

Blogs posted for BMJ, Public health issues in Asia

Why real-name HIV testing won’t fly in China

Two interesting documents that came across my desk this week got me thinking about how different HIV-related human rights look depending on where you’re standing. The first was a press release from UNAIDS, UNDP and the International Commission of Jurists about the first-ever judicial dialogue about HIV, human rights and the law. The second was a news story from the China Daily about legislation recently passed in Guangxi Zhuang autonomous region requiring real names to be used for HIV tests.

The authorities in Guangxi, including doctors charged with the task of treating people who are living with HIV, and keeping the epidemic under control, have sound reasons for wanting to use real-name testing. They say it will reduce loss to follow-up: it will be easier to track people down and convince them to get treated. It will also contribute to better public health policymaking because the region will have a more accurate picture of its HIV epidemic.

No it won’t, AIDS NGOs say, because people won’t come forward for testing in the first place, never mind being lost to follow-up. Instead they will at best do home self-testing, which is not accurate and could leave them with a positive test result and no clue what to do next.

It’s a typical example of how public health policy often serves the needs of the health system instead of the patients. One of the main reasons patients prefer anonymous testing is that they want to know their status but have no inclination to share that information. Once the information leaks out of the medical system, all too common in a society where individuals’ rights are routinely trampled on by the state, people living with HIV are subject to widespread stigma and discrimination.

A 2009 survey conducted by the China Stigma Index found that over 49% of people living with HIV interviewed had experienced discrimination related to their HIV status. Over three quarters said their family had suffered the same discrimination. Pregnant women living with HIV are routinely advised to terminate their pregnancies: 12% of the respondents reported being pressured into having an abortion. The children of 9% of respondents were forced to leave school regardless of their own HIV status. Discrimination by medical staff, teachers and government officials was rampant.

So I think it’s great that eminent judges from the Asia Pacific region gathered to discuss what they can do to provide a supportive legal environment for people living with HIV and to protect those particularly vulnerable to being infected. The conversation has to start somewhere, and there were Mainland Chinese judges participating in this ground-breaking event.

But for people on the receiving end of public policy about HIV, it will be a long while yet before the target of zero discrimination is reached. And until that time, the Guangxi authorities would do well to turn around in their minds the conundrum of how to combat HIV and look at it from the perspective of their patients. Until they can guarantee that those who test positive won’t feel the chill of stigma from the very same health care workers responsible for testing and treating them, and until their communities are educated out of shunning them, real name testing is still just a good idea in theory.


Jane Parry is a Hong Kong-based public health and medical journalist and researcher.


Blogs posted for BMJ, Public health issues in Asia

Jane Parry on flu

Hong Kongers have lived through more than their fair share of bird flu scares across the border in China over the last few years, and, of course, Sars in 2003 when 299 people in the city died of the disease. Then there was the cull of Hong Kong’s entire poultry population back in 1997. It’s not surprising, then that 7 million residents of this crowded city are a little twitchy about pandemic flu threats.

The news about a suspicious outbreak of swine flu in Mexico emerged here on Friday April 24, and the news only got more sinister over the weekend. Today, Monday, while I was out running errands anyway, I decided to pop into my favourite pharmacy and pick up an extra supply of surgical masks for myself, my husband and our two children. Like every Hong Kong family, we keep a supply, because children are required to wear them to school if they have a cough or a sniffle, and a lot of adults use them in the same way, a post-Sars behavior change that has become a common courtesy to others when in public.

I checked our surgical mask stocks and reckoned we’d get through them in less than a week. The pharmacist told me he’d fielded 20-odd requests for masks by lunchtime today, but all those looking for adult-size masks were turned away empty handed- he’d already sold out by the middle of Sunday, just 48 hours after the first news report. Hong Kongers react fast, given that the nearest outbreak to us so far was in New Zealand. I was able to score a box of 30 each for my 10-year-old and six-year-old children, in kiddie sizes, with a promise he’d have more supplies soon.

Next item on my list was a packet of Tamiflu. It’s a prescription drug here too, but if you know which pharmacists to go to, you can buy pretty much anything in Hong Kong OTC. That’s why this guy is my favourite- he’ll let me self-prescribe and I have a high degree of confidence his drugs aren’t fakes. So why am I buying Tamiflu? Surely if anyone in my family needed it, we’d already be at the hospital, you may think. But we lived through Sars, and I reported on it for the BMJ. I remember that nearly 300 people here died, and although no-one in the government or Hospital Authority has ever publicly said so, I was told off the record, and it’s considered common knowledge among the population here, that many of those people went to hospital as they were told to do by the Department of Health if they had a fever, and contracted Sars while they were there.

If swine flu, or its swine/avian/ human derivative makes it to Hong Kong, the last place I would want to be if I had a sniffle is anywhere near a hospital unless I was sure I needed to be there. So at least we have a dose of antivirals in our medicine cabinet, and have the option of avoiding a hospital. I wouldn’t take them, nor would my husband unless it was a last resort, but it feels better having them. I can imagine many doctors’ hair standing on end at the thought of ‘civilians’ having their own access to such drugs, and surely easy access to antiviral and antibiotic drugs in Asia has contributed to drug resistance, but I can tell you I’m not alone in my mistrust of the local medical system. My pharmacist sold out of Tamiflu today. I know, because I bought the last packet. He’s got an order in for lots more though, and a waiting list ready to snap them up.

27 April 2009