Editorials Much controversy remains about whether the diabetogenic inheritance of being small at birth is mediated through effects on insulin resistance or secretion, or both. The Indian group surmise that it is the extra adipose tissue mass that is driving insulin resistance, probably through its action as a quasiendocrine organ,12 but this remains to be proved. The fetal origins theory is of greatest relevance to the developing world, and the implications of this work for global health are enormous. Around 95% of the world’s growth retarded babies are born in developing countries, and a recent report from the World Health Organization and United Nations Food and Agriculture Organization (FAO) predicted that a global epidemic of obesity driven type 2 diabetes will soon dominate health care for chronic diseases, especially in Asia.13 So how should we try to intervene to limit the damage? The obvious response to the “small baby predicts later disease” paradigm is to propose dietary supplementation of mothers to produce larger babies. To a certain extent this seems sensible; we should probably act to prevent retarded fetal growth in mothers whose diet is so poor as to limit the baby’s expected growth trajectory in relation to its parental and genetic inheritance, and to the maternal uterine environment. However, the picture is worryingly confounded by the issue of intergenerational maternal constraint. If we already have short thin-fat mothers producing small thin-fat babies, should we really be feeding them more? Possibly not if this results in augmented fetal growth which will be out of harmony with the baby’s inheritance and future growth patterns. The resolution of this conundrum will require focused
investment in international studies on the regulation of early human growth and development. Andrew M Prentice professor London School of Hygiene and Tropical Medicine, London WC1B 3DP (
[email protected])
Competing interests: None declared. 1
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Yajnik CS, Fall CH, Coyaji KJ, Hirve SS, Rao S, Barker DJ, et al. Neonatal anthropometry: the thin-fat Indian baby. The Pune Maternal Nutrition Study. Int J Obesity 2002;27:173-80. Yajnik CS, Lubree HG, Rege SS, Naik SS, Deshpande JA, Deshpande SS, et al. Adiposity and hyperinsulinaemia in Indians are present at birth. J Clin Endocrinol Metab 2002;87:5575-80. Hales CN, Barker DJP. Type 2 (non-insulin-dependent) diabetes mellitus: the thrifty phenotype hypothesis. Diabetologia 1992;35:595-601. Neel JV. Diabetes mellitus: a “thrifty” genotype rendered detrimental by “progress.” Am J Human Genetics 1962;14:353-61. Barker DJP, Hales CN, Fall CH, Osmond C, Phipps K, Clark PM. Type 2 (non-insulin-dependent) diabetes mellitus, hypertension and hyperlipidaemia (syndrome X): relation to reduced fetal growth. Diabetologia 1993;36:62-7. Lucas A, Fewtrell MS, Cole TJ. Fetal origins of adult disease—the hypothesis revisited. BMJ 1999;319:245-9. Forsén T , Tuomilehto J, Reunanen A, Osmond C, Barker D. The fetal and childhood growth of persons who develop type II diabetes. Annal Int Med 2000;33:176-82. Walton A, Hammond J. The maternal effects on growth and conformation in Shire horse—Shetland pony crosses. Proc Roy Soc Lond B 1938;125:311-8. Kelsey G, Constancia M, Dean WL, Feil RP, Reik W. Genomic imprinting of fetal growth. In Fetal Programming: influences on development and disease in later life. O’Brien PMS, Wheeler T, Barker DJP, eds. London: Royal Society of Obstetrics and Gynaecology Press, 1999:73-84. Bavdekar A, Yajnik CS, Fall CHD, Bapat S, Pandit AN, Deshpande V, et al. Insulin resistance in 8 year old Indian children. Diabetes 1999;48:2242-9. Yajnik CS. Interactions of perturbations in intrauterine growth and growth during childhood on the risk of adult-onset disease. Proc Nutr Soc 2000;59:257-65. Frühbeck G, Gomez-Ambrosi J, Muruzabal FJ, Burrell MA. The adipocyte: a model for integration of endocrine and metabolic signaling in energy metabolism regulation. Am J Physiol Endocrinol Metab 2001;280:E827-47. World Health Organization/UN Food and Agriculture Organization. Diet, nutrition and the prevention of chronic diseases. Geneva: WHO, 2003. (Technical Reports Series 916.)
Herbal medicines put into context Their use entails risks, but probably fewer than with synthetic drugs
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ecent reviews have rightly alerted us to the risk associated with herbal medicines.1 This is necessary and important. But the more important question probably is—do the risks of herbal benefits outweigh their potential for harm? Therefore I will try to put herbal medicines into context and consider the benefit they might bring. The potential benefits of herbal medicines could lie in their high acceptance by patients, efficacy, relative safety, and relatively low costs. Patients worldwide seem to have adopted herbal medicines in a major way. Survey data from the United Kingdom show that herbal medicine has been tried by about 30% of the British population.2 The associated out of pocket expenditure was estimated to amount to £31m (US$47.7m; €45m) in the United Kingdom2 and £1.3bn in Germany.3 Herbal medicines are used predominantly for minor and self limiting indications, with respiratory tract infections heading the list.3 But even for those conditions the remarkable acceptance of herbal medicines can be a good thing only if they can be shown to do more good than harm at reasonable cost. The efficacy of herbal medicines has been tested in hundreds of clinical trials, and it is wrong to say that they are all of inferior methodological quality. But this 18 OCTOBER 2003
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volume of data is still small considering the multitude of herbal medicines—worldwide several thousand different plants are being used for medicinal purposes.4 A recent overview included 23 systematic reviews of rigorous trials of herbal medicines.5 Eleven came to a positive conclusion, nine yielded promising but not convincing results, and three were negative. The relative paucity of rigorous clinical trials is mostly due to the fact that, compared with the pharmaceutical sector, the herbal industry is small and can rarely afford the considerable expense of a clinical trial. Sadly the traditional use directive, which sets out to harmonise the registration of herbal medicines in the European Union,6 lacks any incentive for companies to invest further into research. Public funds are only very rarely dedicated to research in this area.7 Even though herbal medicines are not devoid of risk,1 they could still be safer than synthetic drugs. Between 1968 and 1997, the World Health Organization’s monitoring centre collected 8985 reports of adverse events associated with herbal medicines from 55 countries.8 Although this number may seem impressively high, it amounts to only a tiny fraction of adverse events associated with conventional drugs held in the same database.8 However, the relative paucity could also 881
Editorials be due to a relatively higher level of underreporting. More conclusive evidence on the relative risks of herbal medicine versus synthetic drugs is scarce. Linde et al showed that the herbal antidepressant St John’s wort has only about half the rate of adverse effects compared with conventional antidepressants.9 Kava, an effective herbal anxiolytic,10 has recently been banned in several countries, including the United Kingdom, because of the suspicion that, in rare cases, it causes hepatotoxicity. None the less, preliminary data indicate that it probably is still safer than benzodiazepines.11 At present the relative safety of herbal medicines is undefinable, but many of the existing data indicate that adverse events, particularly serious ones, occur less often than with prescription drugs.4 A further strength of herbal medicines is that they are inexpensive, at least this is what the “herbal lobby” wants us to believe. The truth, however, is that almost no conclusive cost evaluation studies are available.12 Many, but by no means all, herbal medicines are inexpensive to buy; the potential for cost savings by using more herbal medicines could therefore be substantial—at present, however, we simply cannot be sure. Thus the evidence on herbal medicines is incomplete, complex, and confusing. They are certainly associated with both risks1 and benefits.4 As more and more people try herbal medicines, the pressure increases on healthcare professionals to be well informed about the subject, and on researchers to fill the many and somewhat embarrassing gaps in our current knowledge.
Failing to do (and fund) this work would, in my view, constitute the true risk associated with herbal medicines. E Ernst director Complementary Medicine, Peninsula Medical School, Universities of Exeter and Plymouth, Exeter EX2 4NT (
[email protected])
Competing interests: EE’s unit has received research fellowships from herbal manufacturers and retailers: Lichtwer UK, Pharmaton Switzerland, and Boots UK. Financial support for other research projects was also received from Schwabe Germany and Novogen Australia. 1
Corns CM. Herbal remedies and clinical biochemistry. Ann Clin Biochem 2003;40:489-507. Thomas KS, Nicoll JP, Coleman P. Use and expenditure on complementary medicine in England: a population based survey. Complement Ther Med 2001;9:2-11. 3 Marstedt G, Moebius S. Inanspruchnahme alternativer Methoden in der Medizin. Gesundheitsberichtserstattung des Bunds 2000;9:1-37. 4 Ernst E, Pittler MH, Stevinson C, White AR, Eisenberg D. The desktop guide to complementary and alternative medicine. Edinburgh: Mosby, 2001. 5 Ernst E. Herbal medicinal products: an overview of systematic reviews and meta-analyses. Perfusion 2001;14:398-404. 6 Barnes J. Quality and safety at heart of new herbals directive. Pharm J 2003;270:201-2. 7 Ernst E, Wider B. Medical research charities should fund more trials. BMJ 2002;325:1245. 8 Farah MH, Edwards R. International monitoring of adverse health effects associated with herbal medicines. Pharmacoepidemiol Drug Safety 2000;9:105-12. 9 Linde K, Ramirez G, Mulrow CD, Pauls A, Weidenhammeer W, Melchart D. St John’s wort for depression—an overview and meta-analysis of randomised clinical trials. BMJ 1996;313:253-8. 10 Pittler MH, Ernst E. Kava extract for treating anxiety. Cochrane Database Syst Rev 2003;(1):CD003383. 11 Schulze J, Raasch W, Siegers CP. Toxicity of kava pyrones, drug safety and precautions—a case study. Phytomedicine 2003;10 Suppl 4:68-73. 12 White AR, Ernst E. Economic analysis of complementary medicine a systematic review. Complement Ther Med 2000;8:111-8. 2
Equality for people with disabilities in medicine Time for action and partnerships
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s a result of our advances in medical science and technology more lives are being saved than ever before, although many people who are saved from death are left disabled. Add to this the expansion of the ageing population, in whom the prevalence of physical impairments is highest, and disability emerges as a major facet of modern society—one in four people in the United Kingdom has a disability or is closely associated with someone who has.1 Disability has become part and parcel of our human experience. By definition, therefore, the challenges facing citizens with disabilities are now a major “mainstream issue,” both for society in general and for the medical profession in particular. Yet several reports and studies indicate that doctors commonly fail to identify and tackle disability issues.2–6 Why is it that health professionals often seem unwilling or unable to engage with people with disabilities? One reason may be the poor record that the medical profession in the United Kingdom has in treating people with disabilities as equal within its own ranks. We recently organised a two day conference to explore the issues faced by doctors with disabilities or long term illness in today’s NHS.7 This multidisciplinary conference had a wide range of participants, including doctors with current or recent long term physical disabilities or chronic mental or physical ill health and others with an interest in or responsibility for recruitment and 882
retention of doctors. We collectively identified barriers at several levels—the individual, the attitudes of colleagues, the attitudes of employers, and the stance of the profession (including the General Medical Council). The “macho” ethos that still pervades the medical profession and the inflexibility of the system were themes that recurred throughout the two days. The issue of discrimination against doctors or medical students with a disability recently gained national prominence in the United Kingdom because of the case of Heidi Cox,8 a medical student who developed paraplegia as a result of a spinal injury and had been accepted to complete her medical studies by Oxford University. The GMC, however, ruled that she should not continue her studies, a stance that she challenged legally through the Disability Discrimination Act 1995. Although she won her initial complaint, the GMC successfully appealed this initial ruling on the technicality that as a regulatory body it is not a trade organisation. Owing to the timing of the case, the incorporation of the Human Rights Act into the law of member states of the European Union (which took place in 2001) was not applicable. The GMC would have a responsibility under the Human Rights Act not to discriminate in respect of disability or serious communicable diseases.8 Some years ago the BMA reported the accounts of almost 50 doctors and medical students with disabilBMJ VOLUME 327
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