Obesity and the food system transformation in Latin America.

The Latin America and the Caribbean (LAC) region faces a major diet-related health problem accompanied by enormous economic and social costs. The shifts in diet are profound: major shifts in intake of less-healthful low-nutrient-density foods and sugary beverages, changes in away-from-home eating and snacking and rapid shifts towards very high levels of overweight and obesity among all ages along with, in some countries, high burdens of stunting. Diet changes have occurred in parallel to, and in two-way causality with, changes in the broad food system - the set of supply chains from farms, through midstream segments of processing, wholesale and logistics, to downstream segments of retail and food service (restaurants and fast food chains). An essential contribution of this piece is to marry and integrate the nutrition transition literature with the literature on the economics of food system transformation. These two literatures and debates have been to date largely 'two ships passing in the night'. This review documents in-depth the recent history of rapid growth and transformation of that broad food system in LAC, with the rapid rise of supermarkets, large processors, fast food chains and food logistics firms. The transformation is the story of a 'double-edged sword', showing its links to various negative diet side trends, e.g. the rise of consumption of fast food and highly processed food, as well as in parallel, to various positive trends, e.g. the reduction of the cost of food, de-seasonalization, increase of convenience of food preparation reducing women's time associated with that and increase of availability of some nutritious foods like meat and dairy. We view the transformation of the food system, as well as certain aspects of diet change linked to long-run changes in employment and demographics (e.g. the quest for convenience), as broad parameters that will endure for the next decades without truly major regulatory and fiscal changes. We then focus in on what are the steps that are being and can be taken to curb the negative effects on diet of these changes. We show that countries in LAC are already among the global leaders in initiating demand-related solutions via taxation and marketing controls. But we also show that this is only a small step forward. To shift LAC's food supply towards prices that incentivize consumption of healthier diets and demand away from the less healthy component is not simple and will not happen immediately. We must be cognizant that ultimately, food industry firms must be incentivized to market the components of healthy diets. This will primarily need to be via selective taxes and subsidies, marketing controls, as well as food quality regulations, consumer education and, in the medium term, consumers' desires to combine healthier foods with their ongoing quest for convenience in the face of busy lives. In the end, the food industry in LAC will orient itself towards profitable solutions, ie those demanded by the broad mass of consumers.

Creatine supplementation does not enhance submaximal aerobic training adaptations in healthy young men and women.

The benefits of dietary creatine supplementation on muscle performance are generally related to an increase in muscle phosphocreatine content. However, creatine supplementation may benefit endurance sports through increased glycogen re-synthesis following exercise. This study investigated the effect of creatine supplementation on muscle glycogen content, submaximal exercise fuel utilisation and endurance performance following 4 weeks of endurance training. Thirteen healthy, physically active, non-vegetarian subjects volunteered to take part and completed the study. Subjects were supplemented with either creatine monohydrate (CREAT, n = 7) or placebo-maltodextrin (CON, n = 6). Submaximal fuel utilisation and endurance performance were assessed before and after a 4 week endurance training program. Muscle biopsies were also collected before and following training for assessment of muscle creatine and glycogen content. Training increased quadriceps glycogen content to the same degree (approximately 20%) in both groups (P = 0.04). There was a significant training effect on submaximal fuel utilisation and improved endurance performance. However, there was no significant treatment effect of creatine supplementation. Creatine supplementation does not effect metabolic adaptations to endurance training.

Telemedicine: a new health care delivery system.

The resurgence of telemedicine can be attributed to its potential for addressing intransigent problems in health care, including limited accessibility, cost inflation, and uneven quality. After discussing definitions and the genesis of telemedicine, this review focuses on conceptual issues and an assessment of past research. The scope and methodological rigor necessary for sustained development and policy making have been limited in this area of research, owing to the nature of extant telemedicine projects and the lack of a comprehensive research strategy that specifies the objectives of telemedicine research regarding accessibility, cost, and quality. Research strategies and a framework for analysis are discussed. Without a commitment to the types of research objectives, framework, and strategy presented here, the considerable promise of telemedicine, as an innovative system of care, may not be fully realized.

Treatment of liver injuries at level I and level II centers in a multi-institutional metropolitan trauma system. The Midwest Trauma Society Liver Trauma Study Group.

OBJECTIVE: The development of trauma systems and trauma centers has had a major impact on the fate of the critically injured patient. However, some have suggested that care may be compromised if too many trauma centers are designated for a given area. As of 1987, the state of Missouri had designated six adult trauma centers, two Level I and four Level II, for the metropolitan Kansas City, Mo, area, serving a population of approximately 1 million people. To determine whether care was comparable between the Level I and II centers, we conducted a concurrent evaluation of the fate of patients with a sentinel injury, hepatic trauma, over a 6-year period (1987-1992) who were treated at these six trauma centers. METHODS: All patients during the 6-year study period who suffered liver trauma and who survived long enough to be evaluated by computerized tomography or celiotomy were entered into the study. Patients with central nervous system trauma were excluded from analysis. Information concerning mechanism of injury, RTS, Injury Severity Score (ISS), presence of shock, liver injury scoring, mode of treatment, mortality, and length of stay were recorded on abstract forms for analysis. Care was evaluated by mortality, time to the operating room (OR), and intensive care unit (ICU) and hospital length of stay. RESULTS: Over the 6-year period 300 patients with non-central nervous system liver trauma were seen. Level I centers cared for 195 patients and Level II centers cared for 105. There was no difference in mean ISS or ISS > 25 between Level I and II centers. Fifty-five (28%) patients arrived in shock at Level I centers and 24 (23%) at Level II centers. Forty-eight patients (16%) died. Thirty-two (16%) died at Level I centers, and 16 (15%) died at Level II centers. Twenty of 55 patients (36%) in shock died at Level I centers, and 11 of 24 (46%) died at Level II centers (p = 0.428). Forty-three patients (22%) had liver scaling scores of IV-VI at Level I centers, and 10 (10%) had similar scores at Level II centers (p < 0.01). With liver scores IV-VI, 22 of 43 (51%) died at Level I centers and 10 of 14 (71%) died at Level II centers (p = 0.184). There was no difference in mean time or in delays beyond 1 hour to the OR for those patients in shock between Level I and II centers. There was a longer ICU stay at Level II centers (5.0 +/- 8.3 vs. 2.8 +/- 8.4 days, p = 0.04). This difference was confined to penetrating injuries. There was no difference in hospital length of stay. CONCLUSIONS: In a metropolitan trauma system, when Level I and II centers were compared for their ability to care for victims of hepatic trauma, there was no discernible difference in care rendered with respect to severity of injury, mortality, delays to the OR, or hospital length of stay. It was observed that more severe liver injuries were seen at Level I centers, but this did not seem to significantly affect care at Level II centers. There was a longer ICU stay observed at Level II centers owing to penetrating injuries, possibly because there were fewer penetrating injuries treated at these facilities. Although the bulk of patients were seen at Level I centers, care throughout the system was equivalent.

Experimenting with feasibility of telemedicine in Alaska: successes and lessons learned.

Alaska may be ideally suited as a test site for telemedicine. It is by far the nation's largest state, with a population of only 550,000 clustered around a few cities and towns or widely spread across an area almost two and a half times as large as Texas. Its ratio of doctors to patients is the second lowest in the nation, and the cost of medical care exceeds that in the lower 48 states by 90%. Almost half of its residents are affiliated with the federal government in some way. Active duty and retired members of the military and their families (including children) represent 70,000 of the state's residents, and another 160,000 are affiliated with the Coast Guard, the Indian Health Service, and the Department of Veteran Affairs. In 1995, a telemedicine initiative was launched under the auspices of the 3rd Medical Center at Elmendorf Air Force Base. Its mission was to integrate video conferencing and store-and-forward technology into patient care. Brief but well-documented efforts yielded many valuable lessons on how relatively simple, low-bandwidth technology can be effectively used and its limitations. In addition, unexpected changes were observed in the way health care was delivered. This experience should provide valuable lessons for those embarking on this path to health care delivery.

Managed care contracting/capitation.

Both the general approach for entering into a managed care contract and the subject of capitation are presented. The general approach section outlines the criteria that a physician group should apply in analyzing the feasibility of entering into a managed care contract with any insurer. The physician group's contracting process should be iterative and refined over time. The capitation section addresses issues revolving around the assessment of a capitated contract. The example assumes a typical health maintenance organization-primary care group contract. Not analyzed in this article are the exciting opportunities presented through specialty carveout capitation. Managing the transition to a more competitive environment will be the major challenge facing group practices. Survival in the tightening healthcare market will depend on sound strategic decisions regarding the physician group's mission as well as its relationship to its hospital partners and other delivery systems. To support these strategic decisions, a solid knowledge base and a thorough understanding of the terms and provisions regarding the formulation of these new relationships are necessary. The budget methodology is a relatively straightforward approach to establishing a capitation. Careful consideration will have to be given to the method of allocating the capitation among providers. A special concern is the risk-sharing arrangement with primary care physicians.

PPRC and the outcome of physician payment reform.

Medicine was right to support the new payment system because it will correct geographic inequities and channel more money toward primary care services, writes a member of the Physician Payment Review Commission who serves on the American Medical Association Board of Trustees.

Genetic Diversity among Rhizobium leguminosarum bv. Trifolii Strains Revealed by Allozyme and Restriction Fragment Length Polymorphism Analyses.

Allozyme electrophoresis and restriction fragment length polymorphism (RFLP) analyses were used to examine the genetic diversity of a collection of 18 Rhizobium leguminosarum bv. trifolii, 1 R. leguminosarum bv. viciae, and 2 R. meliloti strains. Allozyme analysis at 28 loci revealed 16 electrophoretic types. The mean genetic distance between electrophoretic types of R. leguminosarum and R. meliloti was 0.83. Within R. leguminosarum, the single strain of bv. viciae differed at an average of 0.65 from strains of bv. trifolii, while electrophoretic types of bv. trifolii differed at a range of 0.23 to 0.62. Analysis of RFLPs around two chromosomal DNA probes also delineated 16 unique RFLP patterns and yielded genetic diversity similar to that revealed by the allozyme data. Analysis of RFLPs around three Sym (symbiotic) plasmid-derived probes demonstrated that the Sym plasmids reflect genetic divergence similar to that of their bacterial hosts. The large genetic distances between many strains precluded reliable estimates of their genetic relationships.