Researchers Study the Cycle of Chronic Back Pain and Depression

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Source: Nature World News.com by staff reporter
Apr 22, 2013Depression and chronic pain in the lower back often reinforce each other, according to a researcher from Australia. People with back pain are more likely to be depressed and people who are depressed can’t cope with pain.

The key in fighting this type of a pain-cycle is to stop it in its earliest stages. The study was conducted on a group of 300 patients who were receiving treatments for their back pain.

“The important thing is that doctors act quickly and do not wait for more severe symptoms to develop. Patients might not need anti-depressants; a variety of other treatments such as relaxation, biofeedback and cognitive behavioural therapy could help,” professor Markus Melloh from Western Australian Institute for Medical Research (WAIMR) said in a news release.

The study also included researchers from University of Berne in Switzerland. Researchers found that study participants who had symptoms of depression at the beginning of the treatment also had higher back pain scores after three weeks.

Also, participants who had back pain after three weeks were more likely to have signs of depression.

“Knowing about the reciprocal relationship between depression and back pain can make a real difference in the effectiveness of treatments for patients,” said Melloh.

The study is published in the journal Psychology Health & Medicine.

About 350 million people in the world suffer from depression, according to data from the World Health Organization.

Sleep Well, Live Well… Suffering from back pain? The Mumanu relieves lower back and hip pain while you sleep. www.mumanu.com

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Recent Research Questions the Effectiveness of Back Surgery

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Source: San Francisco Chronicle, Sturgeon Bay, WI (PRWEB) May 29, 2013

An estimated 38 to 50 billion dollars is spent yearly for the surgical treatment of lower back pain in the United States. While this is commonly accepted as the price to pay for this debilitating condition, Chiropractor and Naturopath Dr. J G Moellendorf examines two recent research studies and a neurosurgical university’s health policy questioning surgery’s effectiveness and cost.

Many victims of chronic low back pain turn to surgery when the muscle relaxers, anti-inflammatories, and pain killers fail. Considering the recent research, Sturgeon Bay, Wisconsin Chiropractor and Naturopath Dr. J G Moellendorf, DC, ND, LCP questions whether less costly alternatives to very expensive spinal surgeries might be a better solution.

A research team led by Dr. Benjamin J Keeney looked at workers compensation injuries in the state of Washington to determine if it could predict which work injuries would result in back surgeries. Their results were published in the May 15, 2013 issue of the journal Spine titled Early Predictors of Lumbar Spine Surgery After Occupational Back Injury: Results From a Prospective Study of Workers in Washington State. Out of 1,885 injured workers, 174 (9.2%) had low back surgery within 3 years of injury. The researchers discovered that if an injured worker was first seen by a surgeon, 42.7% would result in surgery, while if first seen by a Chiropractor, only 1.5% had surgery. The rate of an expensive surgery was reduced by 96.5%, just by the choice of the first doctor consulted.

Dr. Anne Froholdt’s research group at the Oslo (Norway) University Hospital followed chronic low back pain patients across a nine year period. Participants were randomly assigned to two groups. The first group had lumbar spinal fusion, while the second received cognitive training on doing daily activities without worrying about further injury, along with endurance and coordination exercises. Publishing their results in the December 2012 issue of the European Spine Journal, they found that during the nine years studied, of those who had spinal surgeries, one-third were operated on again. Of those in the non-surgery group, one-third opted to have surgery done. There were no notable differences in daily rated pain intensity, fear-avoidance beliefs, spinal muscle strength, and use of medication between the two groups. Both groups reported significantly less back and leg pain, less fear-avoidance beliefs, less emotional distress, and improved general function. Sixty-eight percent of those having surgery were out of work, while only forty-two percent of the non-surgery group were not working. Forty-four percent of the lumbar fusion group used medications for pain compared to seventeen percent in those who did not have surgery. Seventeen percent of those having surgery were dissatisfied with their results compared to only three percent among those who did not have surgery.

Dr. J G Moellendorf, DC, ND, LCP asks, “Why would we spend billions of dollars yearly on spinal surgery that has no better results than conservative therapies, while having increased disability rates and higher dissatisfaction with results?”

Realizing the high failure rate and heavy costs of back surgery, the University of Pittsburgh Medical Center (UPMC) health plan analyzed recent research for treating chronic low back pain. On January 1, 2012, UPMC implemented a comprehensive clinical initiative focused on the treatment of chronic low back pain. All lower back surgeries other than surgical emergencies require prior determination for surgical necessity. The policy states:

“To be considered for surgery, patients with chronic low back pain must have:

“This policy was developed using evidence-based literature and professional society guidelines, as well as the input of external medical professionals with expertise in the area”

Only Half of Hip, Knee Surgeries Successful

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Source: newsmaxhealth.com By Nick Tate
Friday, 05 Apr 2013Only half of arthritis patients who undergo hip or knee replacement report a significant improvement in pain and mobility, according to a study that raises new questions about the effectiveness of such procedures.

The research, led by Women’s College Hospital and the Institute for Clinical and Evaluative Sciences, is based on an analysis of 2,400 patients with osteoarthritis and inflammatory arthritis in Ontario. Nearly 480 had a hip or knee replacement and, of the 202 patients included in the study, only half reported a meaningful improvement in pain and disability one to two years after surgery.

What’s more, researchers found the patients who had worse knee or hip pain to begin with but fewer general health problems were more likely to report benefits. Nearly 83 percent of the patients had at least two troublesome hips and or knees.

“Many patients with hip and knee arthritis have the condition in more than one of their hip or knee joints,” said Gillian Hawker, M.D., who led the study, published in the journal Arthritis & Rheumatism. “So it’s not surprising that replacing a single joint doesn’t alleviate all their pain and disability — patients may need subsequent surgeries to maximize the benefits of joint replacement.”

Arthritis is a leading cause of disability in men and women. Joint damage from osteoarthritis is responsible for more than 80 percent and 90 percent of hip replacement and knee surgeries, the researchers noted. About 25 percent of patients who undergo a single joint replacement will have another joint replacement — usually the other hip or knee — within two years.

“While demand for joint replacement surgery has increased as our population ages, physicians lack a set of established criteria to help determine what patients will benefit from surgery and at what point during the course of the disease,” said Dr. Hawker, physician-in-chief at Women’s College Hospital and a senior scientist at ICES. “As physicians, we need to do a better job of targeting treatments to the right patient at the right time by the right provider.”

© 2013 NewsmaxHealth. All rights reserved.

8 Types of Low Back Pain that Mean You Should Visit Your Doctor

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Source: advancingyourhealth.org by Susan Dreyer, MDOver 80% of the population will suffer from lower back pain at some point in their lives. Low back pain is a common complaint in medical offices and is a common issue causing many people to miss work and be unable to participate in daily life activities. Sometimes back pain is due to a pulled or strained muscle and many times will not require a trip to your doctor’s office. Other issues such as fractures, tumors and infections of the spine are very serious and need to be evaluated by a physician promptly.Patients should see a doctor immediately if they experience low back pain as a result of severe trauma. Patients should also make an appointment with a doctor if low back pain is accompanied by any of the following: fever, loss of bowel or bladder control, serious trauma, numbness, unplanned weight loss, personal history of cancer, back pain that persists more than 6 weeks, or severe night pain.

Fever and Back Pain
Fever combined with back pain can indicate an infection in your kidneys or back. A primary care physician can determine if you need antibiotics to eliminate the infection.

Loss of control of your bowel or bladder and Back Pain
If you have back pain along with new incontinence, you could have a serious back condition causing pressure on the nerves that requires immediate medical care.

Serious Trauma and Back Pain
Trauma such as a car accident or falling down a flight of stairs can cause a fracture in your back. Seek immediate care from your physician or the emergency department.

Numbness or Tingling in Leg and Back Pain
Numbness on tingling in your leg and back pain could indicate nerve irritation or nerve damage. You could have a herniated disc or spinal stenosis. A doctor can prescribe medications, treatments or even surgery to help relieve the pressure on the nerves.

Unexplained weight loss and Back Pain
If you lose a lot of weight without changing your diet or activity level and have back pain, a doctor should order imaging and blood work to check for cancers or hormonal disorders.

History of Cancer and New Back Pain
If you have had cancer, onset of back pain could be a sign that cancer has spread to you spine. You should visit your physician for further evaluation.

Back Pain at Night
Pain in your back that causes you to lose sleep should not be dismissed. This could be a sign of spinal tumors or even cancer.

Back pain that lasts more than 6 weeks
Any pain that lasts more than a month or two should be evaluated more fully.

If you experience significant trauma and back pain, an evaluation in the Emergency Department is indicated. In most other cases, your primary care physician can evaluate your condition and begin treatment. . If he or she is unable to help with your condition he can refer you to a spine specialist.

Dr. Susan Dreyer
About Susan Dreyer, MD
Dr. Dreyer is an Associate Professor in the departments of Orthopaedics and Physical Medicine & Rehabilitation at Emory University School of Medicine. Dr. Dreyer specializes in non-operative spine care and focuses on helping patients achieve their best functional level. She has taught many national and international courses on spine care and spinal injections for sciatica and other causes of back and neck problems. She is also active in several professional societies. Dr. Dreyer started practicing at Emory in 1992.

What is gestational diabetes?

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Source: ParentsPlace.com, By Henci GoerGestational diabetes (GD) simply means elevated blood sugar during pregnancy. To understand it, you must first understand the normal changes in pregnancy metabolism (34). When you are pregnant, certain hormones make your insulin less effective at transporting glucose, the body’s fuel, out of your bloodstream into your cells. This increases the amount of circulating glucose, making it available to your baby for growth and development. This “insulin resistance” increases as pregnancy advances. As a result, your blood glucose levels after eating rise linearly throughout pregnancy. By the third trimester, you will tend to have higher blood glucose levels after eating than nonpregnant women (hyperglycaemia), despite secreting normal and above normal amounts of insulin. During overnight sleep, the excess insulin has a chance to mop up, which causes morning glucose levels to be lower on average than in nonpregnant women (hypoglycemia).

In the 1950s, some researchers wondered whether sugar values at the high end of the range for pregnancy would predict the development of diabetes later in life. They tracked a population of women and in 1964, they reported that, yes, it did (40). The extra stress of pregnancy revealed a woman’s “prediabetic” status. This shouldn’t have surprised anyone, because high-weight women are much more likely to have higher glucose values in pregnancy than average-weight women and to eventually develop diabetes. However, doctors knew diabetes posed grave threats to the unborn baby, so they worried that glucose levels that were high, but not in the diabetic range, might also do harm. This concern launched what eventually became an avalanche of studies that ended by defining a whole new category of pregnancy complication called “gestational diabetes,” although “glucose intolerance of pregnancy” would be a more accurate description. Those studies, and their premise, were fundamentally flawed.

IS GESTATIONAL DIABETES A HEALTH RISK?

The theory that GD could have the same adverse effects of diabetes was faulty on its face, because GD does not share the risk factors of either type of true diabetes. In Type I diabetes, extremes of low and high blood sugar early in pregnancy can cause malformations or miscarriage. GD women make normal or above-normal amounts of insulin and have normal blood-sugar metabolism in the first trimester (22). Either Type I or II, long-standing diabetes can damage maternal blood vessels and kidneys, causing hypertension or kidney complications. These can in turn jeopardize the foetus. Gestational diabetics do not have long-standing diabetes. The one problem GD shares with both types is that chronic hyperglycaemia can over feed the foetus, resulting in a big baby. This is generally defined as a birth weight of more than 8 lbs. 13 oz. (4,000 grams) or a birth weight in the upper ten percent for length of pregnancy (large for gestational age).

Theory aside, the studies designed to test it had significant weaknesses. They included women who were known diabetics prior to pregnancy. They selected women for glucose testing based on such risk factors as prior stillbirth, current hypertension, or extreme overweight, indications that alone could explain poorer outcomes (12). They failed to account for compounding factors, such as that glucose intolerance associates with increasing maternal weight and age, which themselves strongly predict large babies and maternal hypertension. Finally, they used management protocols that increased risks such as starvation diets, early induction and withholding nourishment from the newborn (18). Despite these flaws, researchers concluded that mildly deviant glucose values in pregnancy caused serious harm.

We now know that GD doesn’t increase the risk of stillbirth or congenital malformations (4). A couple of modern studies have concluded otherwise, but they didn’t take into account that women with high blood sugar are more likely to have other risk factors for poor outcome, or that some women had undiagnosed diabetes prior to pregnancy (17,24). Indeed, the fact that these studies were of women whose blood sugar had been normalized by treatment proves that GD is not the culprit. Besides, GD testing and treatment could not affect the incidence of congenital malformations under any circumstances, because testing isn’t done until the third trimester. By that time, the baby is long since fully formed.

We also know that maternal glucose level correlates poorly with birth weight. While GD somewhat increases the odds of having a baby weighing in the upper ten percent (16, 36), most of this results from GD’s association with other factors, in particular, maternal weight (10, 13, 21, 28, 43, 57).

Other supposed risks of GD are pre-eclampsia, glucose intolerance in the child and childhood obesity. As before, GD is only found in company with these complications; it doesn’t cause them. For example, studies show that blood glucose level plays little if any role in high-weight children compared with maternal weight before pregnancy (8, 25). Also, as before, normalizing blood sugar fails to prevent these problems, which absolves GD (42, 44-45, 53).

All this being said, there is a needle in the haystack. About one in a thousand pregnant women tested will have sugar values in the range of true diabetes (2). These women may have been diabetic before pregnancy and not known it, or pregnancy may have been enough of a metabolic stress to tip them into diabetes. These women may benefit from being identified and treated.

HOW DO PRACTITIONERS TEST FOR GESTATIONAL DIABETES?

Testing for GD is a two-stage process. The first step is a screening test, which is generally administered to all pregnant women . The screening test is usually given somewhere between week 24 and 28. For this test, you may be asked to drink a glucose solution and have a blood sample drawn an hour later, or you may simply be asked to give a blood sample. If your blood glucose value exceeds a threshold amount, you will be asked to return for an Oral Glucose Tolerance Test (OGTT). The various protocols disagree on the amount of glucose and the threshold value (29).
For the OGTT, you will be asked to come in after fasting overnight. Blood will be drawn, you will be given a glucose solution to drink, and blood will be drawn one, two and three hours later. The glucose solution may make you nauseous. As with the screening test, the recommended amount of glucose and the diagnostic thresholds vary from protocol to protocol (29). Some guidelines only stipulate a fasting glucose and a two hour value (29).

WHAT ARE THE PROBLEMS WITH GESTATIONAL DIABETES TESTING?

A diagnostic test should be reproducible, meaning you get the same results when you repeat the test. Thresholds should be values at which complications either first appear or incidence greatly increases; and normal ranges should apply to the population being tested. The OGTT is none of the above.

Obstetricians adopted data from the original 1950s studies as the normative curve for all pregnant women , but they shouldn’t have. For one thing, those researchers tested women without regard to length of gestation, whereas today, doctors typically test women at the beginning of the third trimester. Glucose values rise linearly throughout pregnancy, but no corrections have been made for this (15). For another, they studied a population that was sixty percent white and forty percent black. Hispanics, Native Americans and Asian women average higher blood sugars than black or white women (10, 57). This means values for that 1950s population have been established as norms for all women, which in turn means that some women are being identified as diseased simply because of race.

The OGTT also isn’t reliable. When pregnant women undergo two OGTT’s a week or so apart, individual test results disagree twenty to twenty-five percent of the time (5, 23). A person’s blood sugar values after ingesting glucose (or food) vary widely depending on many factors. For this reason, the OGTT has been abandoned as a diagnostic test for true diabetes in favour of high fasting glucose values, which show much greater consistency, or values after eating of 200 mg/dl or more, which are rare (46,52). Moreover, pregnancy compounds problems with reproducibility. Because glucose levels rise linearly throughout pregnancy, a woman could “pass” a test in gestational week 24 and “fail” it in week 28 (55). These same reproducibility problems hold true for the glucose screening test that precedes the OGTT (47, 55).

More importantly, no threshold has ever been demonstrated for onset or marked increase in foetal complications below levels diagnostic of true diabetes. The original researchers chose their cut offs for convenience in follow-up, but all studies since have used their criteria or some modification thereof as a threshold for pathology in the current pregnancy. Numerous studies since have documented that birth weights and other outcomes fail to correlate with the 1950s or anybody else’s thresholds. Today’s researchers acknowledge that the risks of glucose intolerance almost certainly form a continuum and that screening and diagnostic thresholds are arbitrary (7, 29-30, 48, 51).

Several organizational bodies that have looked critically at the GD research have come out against GD testing. A Guide to Effective Care in Pregnancy and Childbirth, the bible of evidence-based care, relegates screening for gestational diabetes to “Forms of Care Unlikely to be Beneficial (12).” The American College of Obstetricians and Gynaecologists says no data support the benefits of screening (1). The U.S. Preventative Services Task Force and the Canadian Task Force on the Periodic Health Examination both conclude that there is insufficient evidence to justify universal GD screening (4, 11).

HOW IS GESTATIONAL DIABETES TREATED?

The main elements of GD treatment are:

  • Normalizing blood sugar: The first step is a diet low in sugars and carbohydrates. Some diets also limit calories. If diet fails to control blood glucose levels, insulin injections are prescribed.
  • Monitoring blood sugar: In most cases this will mean pricking your finger and testing your blood once and more commonly, several times a day.
    Many protocols include:
  • Monitoring foetal well-being: Many practitioners order repeated foetal surveillance tests beginning at or before the due date. The most common is the nonstress test, which looks at the foetal heart rate changes in response to foetal movements or Braxton-Hicks contractions (normal, nonlabour tightening of the uterus).
  • Ultrasound scan to estimate foetal weight.
  • Planned delivery: This may be either induction of labour or elective caesarean section. Induction is often at, or sometimes before, the due date.
  • Monitoring newborn blood sugar: Some protocols call for checking the baby’s blood sugar , which involves a heel stick.

WHAT ARE THE PROBLEMS WITH GESTATIONAL DIABETES TREATMENT?

The two questions asked of any therapy are: “Is it safe?” and “Is it effective?” GD management is neither.

GD treatment per se has never been shown to have benefits. In fact, it is virtually untested. The first and only random assignment trial, the standard for determining care because this design eliminates many sources of bias and ensures similar groups, was published in 1997. It concluded that intensive treatment offered no advantages over advising women to eat healthy (16). Meanwhile, several studies have found that identification as a gestational diabetic in and of itself substantially increases the odds of caesarean section (3, 19, 38, 50).
INDIVIDUAL COMPONENTS OF GD PROTOCOLS ALSO FAIL THE SAFETY/EFFECTIVENESS TEST:

  • Diet or diet plus insulin therapy: The standard GD diet is a healthy diet. However, while it reduces blood glucose to normal range in most women, it has little or no effect on birth weight (54). Many women, though, are prescribed limited calorie diets. Reducing calorie intake by more than one-third causes the body to switch to a starvation metabolism (ketosis) that produces by-products known to be harmful to the baby (31). Limiting food intake can also lead to malnutrition (27). Aggressive insulin use can cause underweight babies and symptomatic episodes of low blood sugar (hypoglycaemia) (3, 32). A Guide to Effective Care in Pregnancy and Childbirth lists both diet treatment and diet plus insulin treatment under “Forms of Care Unlikely to be Beneficial (12).”
  • Tests of foetal well-being: Of the four random assignment trials of nonstress testing, the most commonly used foetal surveillance test, none found any benefit for testing, although they were in populations of women at moderate to high risk (41). All tests of well-being have high false-positive rates, meaning the test says there is a problem when there isn’t. This leads to unnecessary inductions and caesareans with all their attendant risks.
  • Foetal weight estimates: Ultrasound predictions that the baby will weigh over 4,000 grams are wrong one-third to one-half of the time (6, 9, 14, 20, 33, 56). As with foetal well-being tests, the belief that the baby is big leads to unnecessary inductions and caesareans. Two studies showed that when obstetricians believed, based on ultrasound, that women were carrying babies weighing over 4,000 grams, half had caesareans, versus less than one-third of women not thought to have babies this big, but who actually did (35,56).
  • Induction of labour or planned caesarean: Many doctors induce labour in the belief it averts caesareans due to big babies. Some think induction or planned caesarean prevents shoulder dystocia (the head is born, but the shoulders hang up). Studies of induction and planned caesarean for suspected big baby show no benefits for either practice (6, 9, 14, 20, 33, 49, 56).
  • Monitoring newborn blood sugar: The reasoning behind this is that if the mother has high blood-sugar levels, the baby will produce extra insulin. After birth, this excess insulin can cause low blood sugar . No studies have tested whether checking the blood sugar of a baby who shows no symptoms of low blood sugar has any value. However, test results can lead to the baby being given a bottle of sugar water or formula, which interferes with establishing breastfeeding, separation from the mother for observation in the nursery, or both.

Finally, treatment also fails to prevent increased incidence of pre-eclampsia, impaired glucose tolerance in children, and childhood overweight (42,44-45,53).
Another rationale given for diagnosing and treating gestational diabetics is identifying women at risk for developing Type II diabetes. However, predicting who is likely to develop diabetes can be done equally well on the basis of race, ethnicity, and weight.

Curiously, while several prominent GD researchers and experts acknowledge the lack of sound data supporting their recommendations, none have backed off (1,26,37,39). These experts devise GD guidelines for practicing doctors and midwives, most of whom have no idea how shaky the GD edifice is. Even those who doubt the value of screening all or most women for GD may have little choice if testing and treatment is the community standard of care.

HOW DOES DIAGNOSIS AS A GESTATIONAL DIABETIC AFFECT YOUR PREGNANCY AND BIRTH?

The standard GD diet is a good one; adequate calories, limit simple sugars, moderate fat intake, eat whole grains and plenty of fruits and vegetables and eat smaller meals more frequently. Also beneficial is the advice to engage in moderate, regular exercise. If that was all that happened, identification as a gestational diabetic would be a good thing. Some tracking of blood sugars to make sure they aren’t drifting into the true diabetic range is probably also a good thing, as is identifying the one in a thousand women who has or will develop glucose values in that range. However, most women will find themselves caught up in frequent doctor visits, multiple daily blood tests, restrictive diets, possibly insulin injections, repeated foetal surveillance tests and a considerable chance of a labour induction or caesarean section.

References

Gestational Diabetes: A Diagnosis Still Looking For a Disease?

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Source: The Journal of Prenatal & Perinatal Psychology and Health (JOPPPAH) Volume 19, Number 2, Winter 2004
By Dr Michel OdentPrimal Health Research: A New Era in Health Research
Published quarterly by Primal Health Research Centre
Charity No.328090
72, Savernake Road
London NW3 2JR
Summer 2004 Vol. 12 No.1

Nowhere in obstetrics is there such a discrepancy between evidence and practice as in the matter of gestational diabetes. This diagnosis has been mentioned briefly in several issues of our newsletter, in order to illustrate the frequent “nocebo effect” of prenatal care. (1,2,3,4) I have recently received so many phone calls of sorely distressed women that I find it necessary to provide updated answers to frequently asked questions.

How to explain? How to explain with simple words the real meaning of this scary diagnosis? How to explain that it is not a disease like with symptoms leading to complementary inquiries, but the mere interpretation of a laboratory test?

It is essential to emphasize that such a diagnosis is made after the “glucose tolerance test” is included in the battery of tests routinely offered to pregnant women. It is easy to illustrate this fact by referring to the results of a huge Canadian study.(5) In some parts of Ontario routine screening was interrupted in 1989, while it remained usual elsewhere in that state. It became clear that the only effect of routine glucose tolerance test screening was to tell 2.7% of pregnant women that they have gestational diabetes. It did not change the statistics of prenatal mortality and morbidity.

Simple physiological explanations can also help reassure a certain number of women. One role of the placenta is to manipulate maternal physiology for fetal benefit. The placenta may be presented as the advocate of the baby, so that the transfer of nutrients to the fetus is optimized. It is via hormonal messages that the placenta can influence maternal physiology. The fetal demand for glucose increase gradually throughout pregnancy. The mother is supposed to react to this demand by reducing her sensitivity to insulin.(6) This leads to a tendency towards hyperglycaemia that is easily detectable after a meal or after ingesting glucose. Some women can compensate their peaks of hyperglycaemia more effectively than others by increasing insulin secretion. When hyperglycaemia peaks above a pre-determined conventional threshold, the term “gestational diabetes” is used. In general glucose tolerance will recover its usual levels after the birth of the baby.

Practical recommendations
The practical advice one can give to women carrying the label of “gestational diabetes” should be given to all pregnant women & another reason to question the practical benefits of such a diagnosis. This advice concerns lifestyle, particularly nutrition and physical activity.

Nutritional counseling should focus on the quality of carbohydrates. The most useful way to rank foods is according to their “glycaemic index” (GI). Pregnant women must be encouraged to prefer, as far as possible, low GI foods. A food has a high index when its absorption is followed by a fast and significant increase of glycaemia. In practice this means, for example, that pregnant women must avoid the countless soft drinks that are widely available today, and that they must also avoid adding too much sugar or honey in their tea or coffee. Incidentally, one can wonder if the tolerance test, which implies glucose consumption (the highest substance on the GI), is perfectly neutral and harmless. GI tables of hundreds of foods have been published in authoritative medical journals.(7) These tables must be looked at carefully, because the data they provide are often surprising for those who are still influenced by old classifications contrasting simple sugars and complex carbohydrates. Such classifications were based on the mere chemical formula.

From such tables we can learn in particular that breakfast cereals based on oats and barley have a low index. Wholemeal bread and pasta also are low-index foods. Potatoes and pizzas,(8) on the other hand, have a high index and should therefore be consumed with moderation. Comparing glucose and fructose (the sugar of fruit) is a way to realize the lack of correlation between chemical formula and GI. Both are hexoses (small molecules with six atoms of carbon) and have pretty similar chemical formulas. Yet the index of glucose is 100&versus 23 for fructose. This means that pregnant women must be encourage to eat fruit and vegetables, an important point since pre-eclampsia is associated with an oxidative stress.

The quantity of carbohydrates should also be taken into consideration. French nutritionists showed that, among pregnant women with reduced glucose tolerance, there is no risk of having high birth weight babies if the daily consumption of carbohydrates is above 210g a day.(9) This implies a moderate lipid intake. About lipids, the focus should also be on their quality, the ratio between different fatty acids. For example we must take into account the fact that monounsaturated fatty acids (such as the oleic acid of olive oil) tend to increase the sensitivity to insulin. We must also stress that the developing brain has enormous need of very long chain polyunsaturates, particularly those abundant and preformed in the sea food chain.(10)

Advice regarding physical activity is based on theoretical considerations and on the results of observational studies. Skeletal muscle cells initially use glycogen stores for energy but are soon forced to use blood glucose, thus lowering glycaemia in the short term.(11) In addition, exercise has been shown to increase the insulin sensitivity of muscles and glucose uptake into muscular cells, regardless of insulin levels,(12) resulting in lower glycaemia. The effect of exercise on glucose tolerance has been demonstrated among extremely overweight women (body mass index above 33). 10.3% of obese women who took no exercise had a significant reduction of glucose tolerance, compared with 5.7% of those who did any exercise one or more times a week.(13) “A walk in the shopping mall for half an hour to an hour a couple of times a week is all that is needed”, says author Raul Artal. According to what we currently know, the benefits of a regular physical activity in pregnancy should be a routine discussion during prenatal visits, whatever the results of sophisticated tests.

Looking for a disease
Almost everywhere in the world, “gestational diabetes” is a frequent diagnosis. We should therefore not be surprised by the tendency to assign it the status of a disease. This might appear as a feat, since this diagnosis is not based on any specific symptom, but just on the effects of an intervention (giving glucose) on blood biochemistry.

One of the ways to transform a diagnosis into a disease is to list its complications. The well-documented fact that women carrying this label are more at risk than others to develop later on in life a non-insulin dependent diabetes has often been presented as a complication.(14) But this “type 2 diabetes” is not a consequence of reduced glucose tolerance in pregnancy. It is simply the expression, in another context, of a particular metabolic type. One might even claim that the only interest of glucose tolerance test in pregnancy is to identify a population at risk of developing a type 2 diabetes. But when a woman is looking forward to having a baby, is it the right time to bother her with glucose intake and blood samples, and to tell her that she is more at risk than others to have a future chronic disease? It is probably more important to talk routinely about nutrition and exercise.

Gestational hypertension has also been presented as a complication of gestational diabetes. In fact an isolated increased blood pressure in pregnancy is a transitory physiological reaction associated with good perinatal outcomes.(15, 16, 17, 18) Once more the concomitant expression of a particular metabolic type should not be confused with the evolution of a disease towards complications.

Professor Jarrett, a London epidemiologist, made a synthesis of the questions inspired by such associations. He stressed that women who carry this label are, on average, older and heavier than the overall population of pregnant women, and their average blood pressure is higher. This is enough to explain differences in perinatal outcomes. The results of glucose tolerance tests are superfluous. According to Professor Jarrett, gestational diabetes is a “non-entity”.(19)

The concept of fetal complications is also widespread. Fetal death has long been thought to be associated with gestational diabetes. However all well-designed studies looking at comparable groups of women dismissed this belief, in populations as divers as Western European (20) or Chinese (21), and also in Singapore (22) and Mauritius.(23) High birth weight has also been presented as a complication. In fact it should be considered an association whose expression is influenced by maternal age, parity and the degree of nutritional unbalance. If there is a cause and effect relation, it might be the other way round: a big baby requires more glucose than a small one. It is significant that in the case of twins “when the demand is double” the glucose tolerance test is more often positive than for singleton pregnancies. Only hypoglycemia of the newborn baby might be considered a complication, although there are multiple risk factors.

Another way to transform a diagnosis into a disease is to establish therapeutic guidelines. Until now, no study has ever demonstrated any positive effect of a pharmacological treatment on the maternal and neonatal morbidity rates, in a population with impaired glucose tolerance. On the contrary no pharmacological particular treatment is able to reduce the risks of neonatal hypoglycaemia.(24,25) However gestational diabetes is often treated with drugs. The frequency of pharmacological treatment has even been evaluated among the fellows of the American College of Obstetricians and Gynecologists (ACOG).(26) It appears that 96% of these practitioners routinely screen for gestational diabetes. When glycaemic control is not considered acceptable, 82% prescribe insulin right away, while 13% try first glyburide, an hypoglycaemic oral drug of the sulfonylureas family.

While practitioners are keen on drugs, there are more and more studies comparing the advantages of human insulin and synthetic insulins lispro and aspart,(27, 28) or comparing the effects of twice-daily regimen with four-times-daily regimen of short-acting and intermediate-actinginsulins.(29) Meanwhile the comparative advantages of several oral hypoglycaemic drugs are also evaluated. The criteria are always short- term and “glycaemic control” is the main objective.(30) The fact, for example, that sulfonylureas cross the placenta should lead to caution and to raise questions about the long-term future of children exposed to such drugs during crucial phases of their development.

The nocebo effect of prenatal care
After reaching the conclusion that the term “gestational diabetes” is useless, one can wonder if it is really harmless. Today we understand that our health is to a great extent shaped in the womb.(31) Furthermore we can interpret more easily the effects of maternal emotional states on the growth and development of the fetus. In the current scientific context we can therefore claim that the main preoccupation of health professionals who meet pregnant women should be to protect their emotional state. In other words the first duty of midwives, doctors and other practitioners involved in prenatal care should be to avoid any sort of “nocebo effect”.

There is a nocebo effect whenever a health professional does more harm than good by interfering with the belief system, the imagination or the emotional state of a patient or of a pregnant woman. The nocebo effect is inherent in conventional prenatal care, which is constantly focusing on potential problems. Every visit is an opportunity to be reminded of all the risks associated with pregnancy and delivery. The vocabulary can dramatically influence the emotional state of pregnant women. The term “gestational diabetes” is a perfect example.

When analyzing the most common reasons for phone calls by anxious pregnant women, I have found that, more often than not, health professionals are ignorant of or misinterpret the medical literature, and that they lack of understanding and respect for one of the main roles of the placenta, which is to manipulate maternal physiology for fetal benefit.

Prenatal care will also be much cheaper on the day when the medical and scientific literature will be better interpreted!

Michel Odent

Références :
1 – Odent M. The Nocebo effect in prenatal care. Primal Heath Research Newsletter 1994; 2: 2-6.
2 – Odent M. Back to the Nocebo effect. Primal Heath Research Newsletter 1995; 5 (4).
3 – Odent M. Antenatal scare. Primal Heath Research Newsletter 2000; 7 (4).
4 – Odent M. The rise of preconceptional counselling vs the decline of medicalized care in pregnancy. Primal Health Research Newsletter 2002;10(3)
5 – Wen SW, Liu S, Kramer MS, et al. Impact of prenatal glucose screening on the diagnosis of gestational diabetes and on pregnancy outcomes. Am J Epidemiol 2000; 152(11): 1009-14.
6 – Vambergue A, Valat AS, Dufour P, et al. Pathophysiologie du diabète gestationnel. J Gynecol Obstet Biol Reprod (Paris) 2002 ; 31(6 Suppl) : 4S3-4S10.
7 – Foster-Powell K, Holt SH, Brand-Miller JC. International table of glycemic index and glycemic load values. Am J Clin Nutr 2002; 76(1): 5-56.
8 – Ahern JA. Exaggerated hyperglycemia after a pizza meal in well-controlled diabetics. Diabetes Care 1993; 16: 578-80.
9 – Romon M, Nuttens MC, Vambergue A, et al. Higher carbohydrate intake is associated with decreased incidence of newborn macrosomia in women with gestational diabetes. J Am Diet Assoc 2001; 101(8): 897-902.
10 – Odent MR, McMillan L, Kimmel T. Prenatal care and sea fish. Eur J Obstet Gynecol Biol Reprod 1996; 68: 49-51.
11 – Chipkin S, Klugh S, Chasan-Taber L. Exercise and diabetes. Cardiol Clin 2001; 19: 489-505.
12 – Wojtaszewski JP, Nielsen JN, Richter EA. Invited review: effect of acute exercise on insulin signaling and action in humans. J Appl Physiol 2002; 93(1): 384-92.
13 – Dye TD, Knox KL, Artal R, et al. Physical activity, obesity, and diabetes in pregnancy. Am J Epidemiol 1997; 146(11): 961-5.
14 – Kim C, Newton R, Knopp R. Gestational diabetes and the incidence of type 2 diabetes: a systematic review. Diabetes Care 2002; 25: 1862-8
15 – Symonds EM. Aetiology of pre-eclampsia: a review. J R Soc Med 1980; 73: 871-75.
16 – Naeye EM. Maternal blood pressure and fetal growth. Am J Obstet Gynecol 1981; 141: 780-87.
17 – Kilpatrick S. Unlike pre-eclampsia, gestational hypertension is not associated with increased neonatal and maternal morbidity except abruptio. SPO abstracts. Am J Obstet Gynecol 1995; 419: 376.
18 – Curtis S, et al. Pregnancy effects of non-proteinuric gestational hypertension. SPO Abstracts. Am J Obst Gynecol 1995; 418: 376.
19 – Jarrett RJ. Gestational diabetes : a non-entity ? BMJ1993 ; 306 : 37-38.
20 – Roberts RN, Moohan JM, Foo RL, et al. Fetal outcomes in mothers with impaired glucose tolerance in pregnancy. Diabet Med 1993; 10(5): 438- 43.
21 – Lao TT, Ho LF. Impaired glucose tolerance and pregnancy outcome in Chinese women with high body mass index. Hum Reprod 2000; 15(8): 1826- 9.
22 – Tan Y, Yeo GS. Impaired glucose tolerance in pregnancy_is it of consequence ? Aust NZ J Obstet Gynaecol 1996; 36(3): 248-55.
23 – Ramtoola S, Home P, Damry H, et al. Gestational impaired glucose tolerance does not increase perinatal mortality in a developing country: cohort study. BMJ 2001;322: 1025-6.
24 – Jensen DM, Sorensen B, Feilberg-Jorgensen N, et al. Maternal and perinatal outcomes in 143 Danish women with gestational diabetes mellitus and 143 controls with a similar risk profile. Diabet Med 2000; 17(4): 281-6.
25 – Hellmuth E, Damm P, Moldted-Pederson L. Oral hypoglycaemic agents in 118 diabetic pregnancies. Diabetes Med 2000; 17(7): 507-11.
26- Gabbe SG, Gregory RP, Power ML, et al. Management of diabetes mellitus by obstetrician-gynecologists. Obstet Gynecol 2004; 103(6): 1229-34.
27 – Jovanovic L, Ilic S, Pettitt D, et al. Metabolic and immunologic effects of insulin lispro in gestational diabetes. Diabetes Care 1999; 22: 1422-7.
28 – Pettitt D, Ospina P, Kolaczynski J, et al. Comparison of an insulin analog, insulin aspart, and regular human insulin with no insulin in gestational diabetes mellitus. Diabetes Care 2003; 26(1): 183-6.
29 – Nachum Z, Ben-Shlomo I, Weiner E, et al. Twice daily versus four times daily insulin regimens for diabetes in pregnancy: randomized controlled trial. BMJ 1999; 319: 1223-7.
30 – Langer O, Conway D, Berkus M, et al. A comparison of glyburide and insulin in women with gestational diabetes mellitus. N Engl J Med 2000; 343: 1134-8.
31 -La banque de données du Primal Health Research Centre est spécialisée dans les études explorant les conséquences à long terme de ce qui se passe au début de la vie.

Safe Cosleeping Guidelines

Mothers Love

Source: Mother-Baby Behavioural Sleep Laboratory, Dr James McKenna

Guidelines to Sleeping Safe with Infants:

Maximizing the chances of Safe Infant Sleep in the Solitary and Cosleeping (Specifically, Bed-sharing) Contexts, by James J. McKenna, Ph.D. Professor of Biological Anthropology, Director, Mother-Baby Sleep Laboratory, University of Notre Dame.

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Below I have summarized and highlight some of the issues to be concerned with as you make your own decisions about where and how your infant should sleep.

What constitutes a “safe sleep environment” irrespective of where the infant sleeps?

Safe infant sleep begins with a healthy gestation, specifically without the fetus being exposed to maternal smoke.

Breastfeeding significantly helps to protect infants from death including deaths from SIDS/SUDI and from seconday disease and/or congenital conditions.

Post-natally safe infant sleep begins especially with the presence of an informed, breastfeeding, committed mother, or an informed and committed father.

Infants should sleep on their backs, on firm surfaces, on clean surfaces, in the absence of smoke, under light (comfortable) blanketing, and their heads should never be covered.

The bed should not have any stuffed animals or pillows around the infant and never should an infant be placed to sleep on top of a pillow.

Sheepskins or other fluffy material and especially bean bag mattresses should never be used. Water beds can be dangerous, too, and always the mattresses should tightly intersect the bed-frame Infants should never sleep on couches or sofas, with or without adults wherein they can slip down (face first) into the crevice or get wedged against the back of a couch.

Bed-sharing: It is important to be aware that adult beds were not designed to assure infants safety!

  • Bottle-feeding babies should always sleep alongside the mother on a separate surface rather than in the bed.
  • If bed-sharing, ideally, both parents should agree and feel comfortable with the decision. Each bed-sharer should agree that he or she is equally responsible for the infant and acknowledge that the infant is present. My feeling is that both parents should think of themselves as primary caregivers.
  • Infants a year or less should not sleep with other children siblings — but always with a person who can take responsibility for the infant being there;
  • Persons on sedatives, medications or drugs, or is intoxicated – -or excessively unable to arouse should not cosleep on the same surface with the infant.
  • Excessively long hair on the mother should be tied up to prevent infant entanglement around the infant’s neck — (yes, it has really happened!)
  • Extremely obese persons, who may not feel where exactly or how close their infant is, may wish to have the infant sleep alongside but on a different surface.
  • It is important to realize that the physical and social conditions under which infant-parent cosleeping occur, in all it’s diverse forms, can and will determine the risks or benefits of this behavior. What goes on in bed is what matters.
  • It may be important to consider or reflect on whether you would think that you suffocated your baby if, under the most unlikely scenario, your baby died from SIDS while in your bed. Just as babies can die from SIDS in a risk free solitary sleep environment, it remains possible for a baby to die in a risk-free cosleeping/bed sharing environment. Just make sure, as much as this is possible, that you would not assume that , if the baby died, that either you or your spouse would think that bed-sharing contributed to the death, or that one of your really suffocated (by accident) the infant. It is worth thinking about.

Aside from never letting an infant sleep outside the presence of a committed adult, i.e. separate-surface cosleeping which is safe for all infants, I do not recommend to any parents any particular type of sleeping arrangement since I do not know the circumstances within which particular parents live. What I do recommend is to consider all of the possible choices and to become as informed as is possible matching what you learn with what you think can work the best for you and your family.

Mumanu_Postnatal_Pillow_cosleeping

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Study Finds Breastfeeding, CoSleeping Mothers Get More Sleep

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Source: Dr Momma, By Danelle Frisbie
Tuesday, July 19, 2011Researchers at the College of Nursing at East Tennessee State University found that breastfeeding mothers get more sleep when sharing sleep with their baby (i.e. sleeping within an arm’s reach of baby, or ‘cosleeping’).

Previous studies have found that breastfed babies have protective stages of healthy sleep/wake cycles – reducing the risk of SIDS and other breathing, hormonal, and bio-regulatory irregularities. It was previously thought that because breastfed babies spend more of their day and night in an alert state, that their mothers may have less sleep than formula fed babies’ mothers.

Drs. Stephanie Quillin and Lee Glenn, who led the study at East Tennessee State, sought to address the unsolved question of whether there is an interaction between the type of feeding (breastfed or formula fed) and sleep arrangements (sharing sleep vs. solo sleeping) that impacts mothers’ postpartum sleep.

Thrity-three first time mothers and their newborns participated in the study over the course of their fourth week postpartum. Total amount of sleep, amount of night-time sleep, number of wakings, and number of sleep periods in 24 hours were recorded using a modified version of the Barnard and Eyres sleep instrument.

Results showed that breastfed babies did have less total sleep per day than formula fed babies, but that nursing, cosleeping mothers enjoyed more sleep in each 24 hour period than those who fed by bottle or put baby to sleep solo. Breastfeeding mothers also slept significantly more often than other mothers when sharing sleep at night or during naps. Bottle feeding mothers’ amount of sleep was not changed by the location of their baby, (which is not to suggest that infants didn’t benefit from sleeping near their mothers, as we know hormones, respiration, and cardiovascular systems are significantly impacted when a baby is close to his mother during sleep vs. left solo and apart from her).

Average total sleep for a four week old baby was approximately 14 hours daily. Researchers concluded that mothers do in fact receive the most sleep postpartum when breastfeeding and sleeping next to their baby. They have suggested the need for increased and improved methods and means for breastfeeding mothers and their babies to share sleep in a safe manner.

As sociological, anthropological, and historical research has shown, the system of sharing sleep is not a novel one. Most mothers and their babies around the world today, and throughout human history, sleep near to each other during the early years of vulnerability and need for night time nourishment, comfort, security and regulation. Included in this sleep sharing paradigm are all other mammals whose babies sleep near mom during early development, and who, like humans, are defined as ‘mammals’ in part due to their need for mothers’ milk.

References

Gerhardt, S. (1999). Why Love Matters: How Affection Shapes a Baby’s Brain. New York: Brunner-Routledge.

Janov, A. (2000). The Biology of Love. Amherst, NY: Prometheus.
Liedloff, J. (1985). The Continuum Concept: In Search of Happiness Lost. Cambridge, MA: Perseus Books.

Quillin, S. I. M. and Glenn, L. L. (2004). “Interaction Between Feeding Method and Co-Sleeping on Maternal-Newborn Sleep.” Journal of Obstetric, Gynecologic, and Neonatal Nursing, 33: 580–588.

Small, M. (1999). Our Babies, Ourselves. New York: Random House.

No-Diaper Babies

sleepingbaby

Source: Essential Mums, by Keiran Chug
6th May 2013

Bribes, trickery and stress go hand-in-hand with the arduous process of toilet training for many parents. But for a growing group of mothers, starting the process before their babies are six months old is transforming the experience into something positive. Their method, referred to as elimination communication, involves watching babies for cues about when they need to go – and the results are often babies who are diaper-free before they are one.

Wellington mum Hana Miller, 30, started putting daughter Willa on a potty when she was three months old, but she’d been laying the foundations from birth. From the day she was born, Hana would give Willa diaper-free time and acknowledge pees by making a “psss” sound.

“We started to notice that just before she did go she would fuss a little for no other apparent reason. So one day we put her on the potty, made the “psss” sound and sure enough heard a little trickle go in!”

Willa is now six months old and only wears a diaper when out.

Hana had been inspired by a good friend whose two children were out of diapers at 10 months. She says the process is about training parents to familiarise themselves with their baby’s signals, body language and habits.

“It made so much sense. A baby doesn’t want to go in her pants any more than the rest of us. It just takes a bit more communication and cooperation to make it possible, but it’s so great to foster that connection between parents and babies.”

She was worried about the potential for mess, but getting started was easy once she did things like put towels in place. She encourages parents to give the method a go, but warns it will keep them on their toes – accidents most often happen when she has guests over and misses signals.

“It’s a process like anything, and before you know it you’ll just be doing it and figuring out how to make it work as you go.”

A lot of people are surprised and amazed when they hear about Hana’s methods, but she says others probably think she lives in a “wee-ridden house”.

“But I’m happy to say that I have met quite a few other parents who are doing the same.”

Northland mum Mayana Sipes, 30, started training her daughters Billie at five months and Danu at birth – like Hana, she had been encouraged by a friend.

“Her baby was younger than mine and they were so onto it. She would, in mid sentence, casually take her baby for a pee. She just knew when he needed to go, she could pick up his cues.”

While it wasn’t as easy as her friend had made it look, Mayana persisted with her daughter.

“She obliged time and time again. I came to realise this is not “infant” potty training, but rather training the parent. The babies are connected to their eliminations, it is us who are not onto it and encourage them to disconnect from their functions by ignoring what is natural.”

By 15 months, Billie was fully potty trained. Danu was diaper-free at 10 months – she would pat at her crotch to let Mayana know she needed to go and they developed their own kind of sign language. However there was no doubt that once Danu was talking it also became easier for her to let others know when she needed the toilet.

Mayana says the first step is taking the diaper off and observing baby – the cues then become easy to spot. Besides watching, there are other methods of prediction – or developing a “pee-dar” as she calls it. The first is timing – pay attention to how long baby goes between wees. Mayana also suggests having a potty handy, changing baby after every missed pee, taking them to the toilet with you, getting the family involved, and talking about toileting.

The process was satisfying and deepened her relationship with her children, she says.

“I felt like a layer of the mystery was lifted. I had more tools to meet the needs of my baby and I wasn’t left wondering what my baby needed.”

Mayana says our ancestors managed without diapers and washing machines by tuning into the needs of their young, and we can do the same.

Another Wellington mum, who did not want to be named, says the best time to first try elimination communication is when babies first wake, before they start crying. Other cues to watch for are fussiness, and detaching from the breast during a feed. Her first baby was a real “timer”, going every 20 minutes when awake, while her second was great at giving signals. As for the benefits, she found that her children didn’t get diaper rash, and not having to deal with dirty diapers was another advantage.

Elimination communication is already practised widely throughout the developing world, often out of necessity. But around the western world, groups are also being established by experienced parents willing to share tips and advice. In Wellington, New Zealand, a group associated with the global Diaper Free Baby group meets regularly as well as offering new parents support.

Between them, they are keeping more diapers out of landfills, saving money and resources, and gaining the satisfaction of close bonds with their babies. Their perseverance is paying off.

– © Fairfax NZ News