Assessment of insulin action on carbohydrate metabolism: physiological and non-physiological methods.

Carbohydrate metabolism in humans is regulated by insulin secretion from pancreatic ß-cells and glucose disposal by insulin-sensitive tissues. Insulin facilitates glucose utilization in peripheral tissues and suppresses hepatic glucose production. Any defects in insulin action predispose an individual to glucose intolerance and Type 2 diabetes mellitus. Early detection of defects in insulin action could provide opportunities to prevent or delay progression of the disease state. There are different approaches to assess insulin action. Initial methods, such as peripheral insulin concentration and simple indices, have several limitations. Subsequently, researchers developed methodologies using intravenous glucose infusion to determine glucose fluxes. However, these methodologies are limited by being non-physiological. Newer, innovative techniques that have been developed are more sophisticated and physiological. By modelling glucose kinetics using isotope dilution techniques, several robust parameters can be obtained that are physiologically relevant and sound. This brief review summarizes most of the non-physiological and physiological methodologies used to measure the variables of insulin action.

Carotid intima media thickness: an independent marker for assessment of macrovascular risk in diabetic patients.

In view of the global epidemic of diabetes with India being the hottest reservoir of the disease, it was tried to identify carotid intima media thickness as a surrogate marker for atherosclerosis in diabetic subjects. The study becomes more relevant because diabetes is now considered a disease of the endothelium and a risk equivalent of coronary atherosclerosis (paradigm shift). The study incorporated 41 normotensive patients of diabetes and 31 age and sex matched controls. Plasma glucose and lipid profiles were assessed in all and the carotid intima media thickness was measured. Results were statistically analysed for significance and correlation coefficient between values of plasma glucose and carotid intima media thickness. Results clearly showed that carotid intima media thickness abnormality can pick up atherosclerosis even if the lipid parameters are nearly normal. So it crystallises from this small study that, as a non-invasive test carotid intima media thickness is a better and early predictor of atherosclerosis in diabetic subjects. It also revealed the linear relationship between both fasting and postprandial blood sugar with carotid intima media thickness.

Effect of transradial access on quality of life and cost of cardiac catheterization: A randomized comparison.

BACKGROUND: Transradial access is a recently developed alternative for diagnostic cardiac catheterization. Its effects on quality of life after the procedure, patient preference, and cost are unknown. METHODS AND RESULTS: We performed a randomized single-center trial in which 99 patients underwent transfemoral and 101 underwent transradial diagnostic cardiac catheterization. Quality of life was measured with the SF-36 and visual analog scales at baseline, 1 day, and 1 week. Patients were examined at 1 day and at 1 week after for complications. Costs were measured prospectively. One patient in the femoral group and 2 in the radial group crossed over to the alternative access site. There were no major access site complications. One patient in the transfemoral group had a minor stroke. Transradial catheterization significantly reduced median length of stay (3.6 vs 10.4 hours, P <.0001). Over the first day after the procedure, measures of bodily pain, back pain, and walking ability favored the transradial group (P <.05 for all comparisons). Over the week after the procedure, changes in role limitations caused by physical health, bodily pain, and back pain favored the transradial group (P <.05 for all comparisons). There was a strong patient preference for transradial catheterization as well (P <. 0001). Transradial catheterization led to significant reductions in bed, pharmacy, and total hospital costs ($2010 vs $2299, P <.0001). CONCLUSIONS: Among patients undergoing diagnostic cardiac catheterization, transradial access leads to improved quality of life after the procedure, is strongly preferred by patients, and reduces hospital costs.

Assessment of hepatic sensitivity to glucagon in NIDDM: use as a tool to estimate the contribution of the indirect pathway to nocturnal glycogen synthesis.

NIDDM is associated with excessive rates of endogenous glucose production in both the postabsorptive and postprandial states. To determine whether this is due to an intrinsic increase in hepatic sensitivity to glucagon, 9 NIDDM and 10 nondiabetic subjects were studied on three occasions. On each occasion, glycogen was labeled the evening before the study with subjects ingesting meals containing [6-3H]galactose. Beginning at 6:00 A.M. on the following morning, somatostatin was infused to inhibit endogenous hormone secretion. Insulin concentrations were maintained constant at basal levels (defined as that necessary to keep glucose at approximately 5 mmol/l) in each individual. On one occasion, glucagon was infused at a rate of 0.65 ng x kg(-1) x min(-1) throughout the experiment, resulting in glucagon concentrations of approximately 130 pg/ml and a slow but comparable fall in endogenous glucose production with time in both groups. On the other two occasions, the glucagon infusion was increased at 10:00 A.M. to either 1.5 or 3.0 ng x kg(-1) x min(-1), resulting in an increase in glucagon concentrations to approximately 180 and 310 pg/ml, respectively. The increment in endogenous glucose production (i.e., area above basal) did not differ in diabetic and nondiabetic subjects during either the 1.5 ng x kg(-1) x min(-1) (0.75 +/- 0.055 vs. 0.78 +/- 0.048 mmol/kg) or 3.0 ng x kg(-1) x min(-1) (1.06 +/- 0.066 vs. 1.10 +/- 0.073 mmol/kg) glucagon infusions. In contrast, the amount of [6-3H]glucose released from glycogen was lower (P < 0.05) in the diabetic than nondiabetic subjects during both glucagon infusions. The specific activity of glycogen, calculated as the integrated release of [6-3H]glucose divided by the integrated release of unlabeled glucose, was lower (P < 0.05) in diabetic subjects than in nondiabetic subjects during both the 1.5 ng x kg(-1) x min(-1) (19.0 +/- 3.9 vs. 41.4 +/- 5.7 dpm/micromol) and 3.0 ng x kg(-1) x min(-1) (19.1 +/- 3.1 vs. 36.5 +/- 7.2 dpm/micromol) glucagon infusions, implying that a greater portion of the glucose released from glycogen was derived from the indirect pathway. We concluded that although NIDDM is not associated with an intrinsic alteration in hepatic sensitivity to glucagon, it does alter the relative contributions of the direct and indirect pathways to nocturnal glycogen synthesis.

The new international population movement: a framework for a constructive critique.

PIP: With the support of the international women's movement, the ideology and methods of traditional population policy were effectively attacked at the 1994 International Conference on Population and Development (ICPD). The author discusses some of the complaints about population policy and family planning programs, then considers the substantive, ethical, and feasibility issues of population and reproductive health policy. The majority of the international population movement's (IPM) new agenda is motivated by goals which tend to be more sensitive to individual needs and human rights than earlier, more impersonal versions of population policy in the developing world. Critical academic examination of the old IPM forced the discussion of the meaning of population policy and population research as they relate to the new reproductive health approach. However, the new population policy approach is now itself ready to be examined internally with regard to its practical recommendations and its assessment of the population problem. An internal critique developed by the movement but drawing upon the experience of mainstream population research and policy will strengthen the movement and hone its ability to match methods to goals. Internal dissent within the movement needs to be aired.^ieng

On interspecies correlations of carcinogenic potencies.

It has been established in the literature that constraints on the designs of experiments used to estimate carcinogenic potencies cause overestimation of true biological interspecies correlations of such potencies. This article explores the potential for appreciable underestimation of interspecies correlations, due to the experimental error that occurs in the estimation of carcinogenic potencies.

Towards ensuring gender equity.

PIP: All people should participate in the development process. Many, however, remain excluded from the benefits of development. For example, women are privy to only a small share of developmental opportunities. The goals of equality, development, and peace were stated during the Fourth World Conference on Women held in Beijing in September 1995. The author considers whether women truly have equitable access to literacy, education, food, nutrition, health, employment, and the political and economic decision making process. She stresses that the goals pronounced at the Fourth World Conference on Women must be backed up with the necessary resources, including institutions established at the local, state, and national levels to ensure that the objectives are implemented and the implementation is monitored. The author further argues that in order for women to achieve equality with men, all girls must have access to primary and secondary schools; basic literacy is inadequate. Moreover, gender stereotyping must be avoided and gender sensitization ensured at all levels.^ieng

Explaining blood donation: the trust factor.

Appealing to people's altruism may not be the best way to reach those who never donate blood. Rather, the authors found that several variables influence the decision, including whether or not people trust blood banks. Decreasing the perception that there are health risks associated with donating blood can also go a long way toward increasing the declining pool of blood donors.

A gender more vulnerable.

PIP: The greater risks of death faced by females in India are discussed in terms of the differences between the norther and southern regions of India, culture compounding inequality, and intervention strategies. When the assumption of a sex ratio of equality of 950/1000 is make, every region in the north is below (ranging from 874-913), and every region in the south above (ranging from 960-1040). The same north/south division remains for the male probability of dying by age 5 as a proportion of female probability (rural) in 1981. 2 explanations are given for female's greater survival changes in the south. 1) Marriage and kinship systems are different. Girls in the north typically marry earlier; many times marriage is to a stranger in a distant area so that family contact is reduced. The consequence is a reduction in female autonomy and status in both her father's and her husband's home. 2) Economic roles are different. Research has revealed that male/female survival equality occurs in states with high female labor force participation rates. At the micro level, working women's children tend to have more equal death rates. Physical devaluation is not only evidenced in death and survival, but also in the disparity in schooling. The states with the greatest gender differentials in mortality also have the greatest differences in literacy. This has been interpreted as household resources are disproportionately invested in males. Cultural inhibitions about the physical freedoms of girls also are involuntary reasons for the sex differential. The example is given of the apprehension generated for a male doctor's examination of a girl, a coeducational school environment, or a school located a distance from the home. There is the tradition of female seclusion and inhibition. In combination with the dependence on sons to limit the choices open to women, and to limit the growth and development, the product is inequality. Amniocentesis has lead to the increase in numbers of sex determination and abortion clinics. There is evidence that aborted fetuses are primarily female. Without change in these practices, there will not be a reversal in the sex ratio. Interventions suggested include increasing the number of facilities for the equal development of girls and women. There must be increases in female medical staff, more girl's schools in villages, and more nutrition programs for girls, Women's economic independence must be enhanced.^ieng

Women's economic roles and child survival: the case of India.

This article provides evidence that women's employment, in spite of its other benefits, probably has one crucial adverse consequence: a higher level of child mortality than is found among women who do not work. We examine various intermediate mechanisms for this relationship and conclude that a shortage of time is one of the major reasons for this negative relation between maternal employment and child survival. However, even in the area of child survival, there is one aspect which is positively affected by female employment: the disadvantage to girls in survival which is characteristic of South Asia seems to be smaller among working mothers. This is in contrast to the effect of maternal education which may often have no clear relation to the sex ratio of childhood mortality even though absolute levels of child mortality are lower for educated mothers.

Cultural influences on health care use: two regional groups in India.

While health care services are increasingly being seen as a major proximate determinant of decreased mortality in a population, it also seems to be the case that the mere provision of services does not lead to their better utilization. However, in general, it is difficult to explore differences in utilization because the availability of services itself varies so greatly. This report presents the results of a study in India of two distinct regional groups of similar socioeconomic status, residing in the same locality and, therefore, theoretically exposed to the same health services. Both groups share a strong faith in modern medicine (especially if it is obtained from a private practitioner) for the treatment of most common illnesses. However, important cultural differentials exist in the medical services sought for childbirth and in the treatment of morbidity in children of different ages and sexes. These cultural commonalities and differentials are described, their possible causes--primary among these being the status of women--explored, and some policy recommendations made.

PIP: While health care services are increasingly being seen as a major proximate determinant of decreased mortality in a population, it also seems to be the case that the mere provision of services does not lead to their better utilization. However, in general, it is difficult to explore differences in utilization because the availability of services itself varies so greatly. This report presents the results of a study in India of 2 distinct regional groups of similar socioeconomic status, residing in the same locality and, therefore, theoretically exposed to the same health services. Both groups share a strong faith in modern medicine (especially if it is obtained from a private practitioner) for the treatment of most common illnesses. The treatment of illness episodes according to ethnic origin, type of illness, and age in Uttar Pradesh and Tamil Nadu, 1985-86 are shown in tabular form; as is the distribution of living children according to immunization status in the same 2 places for the same years. However, important cultural differentials exist in the medical services sought for childbirth and in the treatment of morbidity in children of different ages and sexes, based primary on the status of women. Sample households believed in antibiotics, particularly injectables. Preventive vaccinations are mistrusted and feared. The figures for the acceptance of at least 1 dose of triple antigen are low. The numbers of children who receive the full recommended 3-dose course has fallen sharply. According to the 1979 Survey of Infant and Child Mortality, 94% or rural Uttar Pradesh births were delivered by untrained personnel, in rural Tamil Nadu, 50% of births were delivered by untrained personnel. The women will accept only a trained doctor for delivery, or an untrained neighbor or helper. The usual sex differential in child and infant mortality, with boys having an advantage, exists in much of South Asia. There is a sex differential in health care. In Matlab, Bangladesh, when free treatment of diarrhea was offered, in spite of the fact that incidence levels of diarrhea were nearly equal, male children were more likely than females to be brought for treatment.

The domestic servant as family planning innovator: an Indian case study.

This paper reports on the relatively low fertility of female domestic servants in India. domestic servant have fewer numbers of ever-born and living children than women working in other occupations and women who are unemployed. This low fertility, which appears to be volitional, may have its roots in the incompatibility between the servant's reproductive and the productive roles, as well as in the changing values generated by continued exposure to a wealthier lifestyle. It is suggested that family planning messages aimed at and elicited by more "elite" classes may have a greater impact on fertility behavior than message from prompters with a socioeconomic background similar to the clients', which tend to concentrate on the harsher day-to-day realities of poverty.

PIP: The National Council of Applied Economic Research in Delhi, India surveyed 578 ever-married 15-49 year-old women who had migrated to Delhi from the southern Indian state of Tamil Nadu. Researchers learned that domestic servants had fewer numbers of ever-born and living children (2.33 and 1.85 respectively) than women working in other occupations (3.12 and 2.47) and women who are unemployed (2.40 and 2.06). The researchers suggested that this low fertility, which they believe to be volitional, may have been due to the incompatibility between the servant's reproductive and productive roles and the changing values caused by continued exposure to a wealthy lifestyle. They recommended that, at least in urban settings as described in this report, middle-to-upper class housewives employed on a part-time basis should promote family planning to the poor. The researchers further suggested that these well-off women may have a greater impact on fertility behavior than family planning workers from a similar background. They admitted, however, that there may be problems as to the ethical value of this approach given that the poor and the wealthy are distinguished by much more than different fertility levels.

Ignorance of family planning methods in India: an important constraint on use.

Interviews wih women in six villages in India and with educated, working women selected to be trained as interviewers in five states, and evidence from formal studies are discussed to support the conclusions that (1) the low overall rates of contraceptive use in India are at least partly due to low levels of knowledge about different methods of birth control, especially of the modern reversible methods; and (2) the low use of all methods except sterilization is a good proxy for lack of knowledge about these methods. It is suggested that, both in the interests of achieving demographic targets and in the interests of the clientele of the family planning program, much greater emphasis must be placed on spreading practical information about reversible contraception. The information dissemination activities of the program so far have tended to concentrate on the why of family planning and neglect the how, except in promoting sterilization.

PIP: Interviews with women in 6 villages in India and with educated, working women selected to be trained as interviewers and evidence from formal studies are discussed. Poor knowledge of family planning favors high fertility in India. The awareness and ever use of different birth control methods among married women, aged 15-49, are given. There is much ignorance and misinformation as shown by data on awareness of contraceptives in 1970 awareness of family planning methods among general responders and local leaders is also poor. Why is knowledge so low? Some reasons are socioeconomic development factors. Women reporting knowledge of various methods of contraception, by urban-rural residence and for urban sample, education and type of housing is given, as is of respondents who had heard of various contraceptive methods in Uttar Pradesh and Narangwal. Sterilization is fairly well accepted, however more knowledge is needed on reversible methods. The program needs to increase its level of IEC activities, and change the content of these activities by shifting the emphasis from why birth control is essential (most couples are now aware of the officially propagated advantages of small families) to how a small family can be achieved by methods less drastic than an operation.

Fertility decline and differences in less-developed countries: an anthropological microstudy of some communities of West Bengal, India and Upper Khumbu, Nepal.

The role of socioeconomic and other cultural factors as determinants of fertility change has been widely discussed, with some scholars emphasising an inverse relation between socioeconomic development and fertility, others suggesting that no such relation necessarily exists, and yet others indicating that by using data from various sources it is possible to "prove" that a given country's crude birth rate has declined, remained unchanged or increased. Demographic data are presented on age-sex structure, completed and total fertility rates, and age specific fertility rates by age cohorts of women, from several small, anthropological population units of West Bengal, India and Upper Khumbu, Nepal, exposed to various physical and cultural environmental stresses. The data show that fertility has declined in most of the populations/subpopulations studied and that the decline may, deductively, be attributed to economic development via greater family planning practices.

PIP: It is generally believed that fertility has declined in India and particularly in West Bengal and Nepal, but it may have actually increased. Demographic data on several ecologically and socioculturally distinct populations/subpopulations, collected through intensive anthropological surveys, were examined for evidence of fertility decline. Efforts were made to identify the environmental factors leading to fertility differences by comparing populations and subpopulations varying with respect to 1 major factor but similar with respect to others in order to deductively suggest possible explanations for fertility decline, if any. 3 types of data are presented: population pyramid (age-sex structure); completed family size (CFS) and total fertility rate (TFR); and age specific fertility rate (ASFR). The multidisciplinary studies have been carried out since early 1976 in the high and medium altitude regions of the eastern Himalayas in Nepal and India and the alluvial plains of West Bengal. A constriction at the base of the pyramid, suggesting a recent fertility decline, was detectable in Upper Khumbu and Kalimpong, Mirpur and Balaramchak, and all 3 economic subpopulations in Chakpota. It was absent in Rango and unclear in Gopalchak and Bamanchak. Such a general pattern of constriction at the base of the population pyramid in populations inhabiting diverse physical and cultural environments is compatible with the overall fertility/population growth decline in India but the lack of such constrictions in several others indicate that the pattern is not universal. Having found that fertility declined between older and younger women in most populations/subpopulations studied, the attempt was made to identify the possible factors leading to such decline. Both CFS and TFR were lower in Upper Khumbu than in Kalimpong suggesting that the environmental stresses associated with high altitude tend to reduce fertility. The relatively lower fertility of the more modernized/urbanized Kalimpong population compared to the remote Rango, as shown by the CFS values and the pyramidal bases, as well as the ASFR values except for age period 25-29 years, may suggest that modernization/urbanization may indeed inhibit fertility. That modernization/urbanization, socioeconomic development in general, may be negatively related to fertility is further confirmed by the 3 Chakpota subpopulations in which the constriction at the pyramidal base increases in magnitude with increasing economic condition, TFR decreases in that order, and the ASFR values are generally lower in the high than in the low economic group with the medium group taking an intermediate position in general.