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José Juan de Dios Mateo Osbaldo Botaro Lepiani Toledo (20 September 1864, Lima – 28 November 1932, Rome) was a Peruvian painter. He is primarily known for historical and patriotic scenes; notably those related to the War of the Pacific.

Biography
As a young man he worked at a series of simple jobs, such as paymaster for the central railroad. He considered art to be his natural vocation, however, so he began studying with  and Ramón Muñiz, a Spanish painter living in Lima, about whom little is known. In the 1890s, Lepiani began his series of historical scenes.

In 1903, he went to Europe, where he visited museums and exhibitions. He eventually settled in Rome, where he lived a somewhat dissolute life and created few original works, preferring instead to copy the Old Masters, such as Raphael and Titian, and sell the reproductions to American tourists. His copies were highly regarded, however, and some of the best ones were even sent home to Peru.

He returned home in 1928, prematurely old and almost blind from the arduous copying work; often done in poor light. The following year, he was back in Europe where his finances fell victim to the Crash of '29. Penniless and totally blind, he died in Rome four years later.

Among his works depicting the War of the Pacific, the best-known include the death of Colonel Francisco Bolognesi at the Battle of Arica, Alfonso Ugarte riding his horse over a cliff to prevent the Peruvian flag from being captured, and a scene from the Battle of Miraflores where weaponless civilians rise to the defense of Lima. Although lesser known, he also created canvases related to the Spanish Conquest, the War of Independence and the coup d'état of 1895, led by Nicolás de Piérola.

Sources
 Jorge Basadre: Historia de la República del Perú (1822 - 1933), Vol.10, p. 292, Empresa Editora El Comercio S. A., Lima, 2005.
 Alberto Tauro del Pino: Enciclopedia Ilustrada del Perú. 3rd. Ed., Vol. 9. Lima, PEISA, 2001.

External links

 Powerpoint presentation on Juan Lepiani by Gabriela Lavarelo Vargas de Velaochaga. Downloadable @ Holismo Planetario.

1864 births
1932 deaths
People from Lima
History painters
War of the Pacific
Peruvian people of Italian descent
19th-century Peruvian painters
19th-century Peruvian male artists
20th-century Peruvian painters
20th-century Peruvian male artists
Peruvian male painters


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Home Dietary Supplements Articles Features Breaking Down Diabetes
Breaking Down Diabetes
Diabetes is a complex subject, so we asked experts to guide us through the supplement options for this widespread condition.
The disease state known as diabetes mellitus involves dangerous blood sugar dysfunction, that much is certain. But this complex disease has many layers. There are questions regarding cause, risk, prevention, complications, means of support and potential solutions that must be addressed on an individual basis, but with an eye to the larger problem posed to society by diabetes and associated conditions.
In this feature, we tackle many of these issues through the lens of dietary supplements, including recent research, and a look at the marketing practices for products in this category. The market for supplements that target this area is relatively small at the moment, says Scott Steil, president of Nutra Bridge, Shoreview, MN. "However, my opinion is that it remains the biggest category of unmet market and customer need and will explode over the next few years," he says. The alarming growth rates in both diabetes and obesity will be met with increases in the costs of treating these conditions, Steil believes. Therefore, increased attention to supplements that help maintain healthy blood sugar and insulin function will play a vital role in improving our society's health.
Diabetes: The Science and Supplements
New insights into diabetes, as well as the interrelated set of conditions that can precede it (variously referred to as metabolic syndrome, syndrome X or prediabetes) are always pouring in. Likewise, the ways supplements can help turn the tide away from prediabetes and back toward health, or support those forced to deal with full-blown diabetes, are under constant analysis from researchers.
By way of a primer, Bilwa Bhanap, M.D., researcher with the Dr. Rath Research Institute, Santa Clara, CA, explains that metabolic syndrome is typically characterized by obesity, high blood pressure, high cholesterol and impaired glucose metabolism and insulin function. The sustained high blood sugar levels caused by these issues can lead to serious complications including atherosclerosis, stroke, kidney damage and failure, nerve damage, impaired wound healing, immune system issues, cataracts and a host of other issues, according to Bhanap. Most of these complications, she says, are due to blood vessel damage in the affected organs.
Though genetic factors are thought to play a role in the development of type 2 diabetes, it is more commonly linked with consuming high levels of artificial sugars, Bhanap says. Type 1's causes are not well understood, though genetic and environmental factors such as viruses appear to play a role, according to Trisha Sugarek MacDonald, B.S., M.S., director of R&D and national educator for Bluebonnet Nutrition Corporation, Sugar Land, TX. Type 1 diabetes is most common in children and adolescents, though this autoimmune condition has also been diagnosed in adults, she adds.
Whereas type 2 diabetes is usually spoken of in terms of insulin resistance, in type 1 diabetes, the beta cells of the pancreas that produce insulin are destroyed by the body's own immune cells. The result is a lack of insulin production, meaning glucose cannot be conveyed properly into the body's cells. Troublingly, more children are getting diagnosed and treated for the complex risk factors that lead to type 2 diabetes, conditions which in the past had been mostly linked with aging.
Diet is important in preventing and improving metabolic syndrome and diabetes. Michael Smith, M.D., senior health scientist with Life Extension, Fort Lauderdale, FL and host of Healthy Talk on RadioMD.com, says that research shows a balanced diet composed of 15–20% of calories from protein, 25–35% from healthy fat and 45–55% from complex carbohydrates like leafy greens, grains and legumes can flatten out blood sugar spikes and improve insulin sensitivity. Jay Levy, director of sales at Wakunaga of America Co., Ltd., Mission Viejo, CA, says that along with diet and exercise, supplements should be a part of the plan for people with mild to moderate diabetes They can also help to reverse the risk factors that make up metabolic syndrome, including high blood sugar levels.
Though the fact that insulin resistance (rather than a lack of insulin) is most associated with type 2 diabetes might lead to the notion that supplements are only of help to those with type 2, Smith says this isn't true. "In type 1, the patients inject insulin into their system. However, if they don't follow the prescribed diets and exercise regimens, the injected insulin can begin to dysfunction in the same way that a person with type 2 experiences," he says. Therefore, supplements that improve insulin sensitivity can help type 2 and type 1 diabetics alike.
Let's examine those places where diabetes research and supplement science have overlapped most recently. To begin with, the connection between vitamin D status and insulin function is getting stronger. "One of the newer studies, which appeared in the April issue of the American Journal of Clinical Nutrition, found that correcting a vitamin D deficiency with supplements improves insulin sensitivity in overweight teens," says Levy (1). Specifically, he adds, vitamin D improved fasting insulin levels and leptin-to-adiponectin ratios. This ratio is measured because unhealthy fat cells are thought to secrete more leptin and less of the protein adiponectin.
Another major vitamin has its place in this discussion, too. "It is important to note the similarity in the molecular structure of the sugar (glucose) molecule and the vitamin C molecule. This similarity is the key to understanding most of the cardiovascular complications in diabetes," says Bhanap. She explains that the tiny pumps in blood vessel cells that are responsible for the transport of blood sugar in and out of cells are also tasked with bringing in vitamin C.
In diabetics, the excess of sugar in cells can therefore create a vitamin C deficiency resulting in fragile blood vessel walls. These are the areas, Bhanap says, most susceptible to the development of the atherosclerotic plaque that can lead to heart attacks, eye problems, kidney failure and other health problems."Optimum daily intake of vitamin C helps to restore the balance between vitamin C and sugar metabolism inside the cells and prevent further complications," she says.
Bitter melon (Momordica charantia) contains several compounds thought to help lower blood sugar, including insulin-like peptides, Levy says. He cites a study on bitter melon that confirms the mechanism through which it activates the AMPK enzyme (2). This enzyme, Levy explains, directly helps to lower blood sugar, and is the frequent target of anti-diabetes drugs. He adds that other research suggests bitter melon can improve insulin signaling and sensitivity.
Though the arsenal of diabetes and blood sugar nutrients has been pretty well picked over, says Dallas Clouatre, Ph.D., consultant for R&D at Jarrow Formulas, Inc., Los Angeles, CA, the wild genotype of bitter melon is indeed an interesting option. He goes on to note that the similarities between the mechanisms of action of bitter melon and the diabetes drug metformin have been known for a few years, including the way they reduce excessive liver glucose output and reduce serum insulin.
Now, in a more recent study on diabetic animals, wild bitter melon has been shown to rival metformin in regulating blood glucose, and to be superior to two commercial extracts of cultivated bitter melon in nitric oxide generation (key for maintaining healthy blood pressure) and inhibition of the angiotensin-converting enzyme (ACE) (3). "These facts suggest that wild bitter melon, especially if properly extracted and preserved, may perform some of the other functions of metformin, as well, such as encouraging weight loss," Clouatre says. To cap off the bitter melon discussion, he adds that it can counterbalance the impact of fructose on the liver. Overconsumption of the simple sugar fructose can cause liver dysfunction by spurring the synthesis of fat and interfering with the liver's response to insulin signals, he says.
In the majority of cases of diabetes and metabolic syndrome, gluconeogenesis develops, meaning the liver continues to release glucose into the bloodstream, even though levels of insulin and blood sugar would be adequate to inhibit this action in a healthy person. In addition to bitter melon, Clouatre says green coffee bean extracts can help to regulate the liver, in part by reducing liver gluconeogenesis. Restoring proper liver function is crucial to improving non-alcoholic fatty liver disease (NAFLD). We will discuss NAFLD more later, but for now, Clouatre notes that improving this condition may also benefit many aspects of diabetes, including blood sugar.
Since improving upon insulin dysfunction in daily life is a primary goal in dealing with diabetes, any ingredient found to help with that task will be of special interest. By blocking both the alpha amylase and alpha glucosidase enzymes, and thereby helping regulate insulin and glucose, a seaweed extract ingredient (InSea2 from Nutra Bridge) fits the mold. Steil explains that by blocking these two enzymes, the glycemic impact of both starch and table sugar are lessened. The ingredient, therefore, offers more complete control of blood sugar than other ingredients that block only carbohydrates.
After pointing out the difficulty of totally avoiding starch and complex carbohydrates in the diet, Steil explains that supplementing with this ingredient can help reduce the quick spikes in blood glucose and insulin associated with many foods. The ingredient has been found to reduce glucose levels by 48%, peak insulin levels by 22% and total insulin levels by 12%, and to increase insulin sensitivity by 8% when compared with placebo, according to Steil. In essence, this equates to helping convert starch-rich meals from high to low on the glycemic index, an important factor for diabetics and prediabetics.
Salacia (Salacia oblonga), according to Levy, is an Ayurvedic herb also thought to help prevent blood sugar spikes via a carbohydrate enzyme-blocking mechanism. Preliminary research performed on rats found that salacia lowered blood glucose by up to 45% while boosting HDL, or good cholesterol (4). Another option that slows the rate of both the digestion and uptake of carbohydrates and sugars is white bean extract, according to Clouatre. It is perhaps best known as a carbohydrate blocker meant to reduce blood glucose levels.
Dietary fiber can play a major role in this struggle of diabetes sufferers to turn their glycemic luck around. Michael Arlen, president of NEWtritious, LLC, Los Angeles, CA, describes research he saw presented at a conference by a team of scientists from Japan. "They reported that there was a remarkable difference in the glycemic index based on the order in which foods were eaten!" he says. During the study, two groups ate the same meal, but one group was instructed to eat the green vegetables first, and other to eat the rice and meat first. There was a significantly lower glycemic impact in those that started off with the veggies. Though Arlen thinks this warrants further study, he feels the public should be made aware that they might help flatten out glycemic spikes, which can cause inflammation and degenerative disease, through such simple actions.
Arlen also points to research on the effect fiber has on satiety, weight reduction and the eventual improvement of biomarkers for diabetes. "Certain soluble fibers have been shown to lower triglycerides in the blood," he says. In addition to a slew of proprietary ingredients with impressive research backing, Arlen tabs konjac root, which contains a fibrous substance called glucomannan, for its ability to support diabetes.
"The effectiveness of any fiber on reducing appetite, blood sugar and cholesterol is based directly on the amount of water the fiber is able to absorb and the degree of thickness or viscosity the fiber imparts when in the stomach and intestine," says Michael T. Murray, N.D., director of product development and education at Natural Factors Nutritional Products, Inc., Everett, WA. The solubility and viscosity of oat bran, he says for example, allows it to support cholesterol and control blood sugar more effectively than wheat bran.
Research has shown one proprietary fiber matrix (PGX from Natural Factors) to exhibit these benefits in a powerful way. The specific areas it supports, according to Murray, range from helping to stabilize blood sugar in the overweight and obese, to reducing appetite, reducing after-meal glucose levels, lowering blood cholesterol and triglycerides, increasing insulin sensitivity and more.
As Murray explains it, the reason weight control is so central to improving one's chances against diabetes is that fat cells, or adipocytes, secrete a number of molecules that can have negative effects. Adipocytes around the abdomen in particular, when they become full of fat, release resistin, leptin, tumor necrosis factor, free fatty acids and cortisol, which combine to dampen the effect of insulin, impair insulin release by beta cells in the pancreas, impair glucose metabolism in skeletal muscle and promote liver gluconeogenesis. In fact, according to Murray, all the hormones newly discovered to be secreted by adipocytes have some experts considering adipose tissue as an element of the endocrine system (which includes the thyroid, adrenal and pituitary glands).
Murray adds that as the size and number of adipocytes increases, the release of compounds that promote insulin function is reduced, including adiponectin. "Adiponectin is not only associated with improved insulin sensitivity, but it also has anti-inflammatory activity, lowers triglycerides, and blocks the development of atherosclerosis," he says. The total effect of these actions on the part of fat cells is a severely stressed blood glucose control system, and an environment conducive to atherosclerosis.
Early on, Murray says the metabolic stress created by unhealthy adipoctyes may not affect blood glucose levels, as the pancreas simply responds with more insulin output. As the stressors increase and insulin resistance grows, the pancreas eventually cannot compensate. At this point, blood glucose can elevate, and as the condition progresses to full-blown diabetes, the insulin output from the pancreas can begin to decrease. Fortunately, Murray explains, the pancreas can recover if one works to improve insulin sensitivity and to achieve ideal body weight. Moving forward, he believes blood levels of adiponectin and other hormones secreted by fat cells may become meaningful risk factors for type 2 diabetes.
Echoing Murray on the relevance of toxic belly fat to diabetes, Don VerHulst, M.D., chief science officer of InBalance Health, Wayland, MI, says, "In my opinion, the best recent science on diabetes was done at Johns Hopkins, and correlated waist measurement with risk of type 2 diabetes." Reviewing data from upwards of 27,000 men over a 13-year period, researchers found almost exponentially greater risk of the disease with larger waistlines. Compared with the group with the smallest waist circumference, those who had 40- to 62-inch waists were 12 times more likely to develop diabetes (5). "This study proved that your waistline is your life line," says VerHulst.
Toxic belly fat can indeed become responsible for a vicious cycle of insulin resistance leading to higher blood sugar, which can in turn create more belly fat. But, VerHulst thinks the cycle can be broken by addressing the root cause. He states, "The future in successful treatment and prevention of type 2 diabetes, I believe, should and will focus on correcting insulin resistance by removing excess belly fat."
Though supplements can help in this area, VerHulst cites the importance of regular exercise in maintaining weight. "Even the Centers for Disease Control and Prevention tells us that losing only 5 to 7% of your body weight and exercising 30 minutes five times a week can prevent the progression of a prediabetic state to full-blown diabetes. This progression will occur in about 30% of prediabetics within three to five years if nothing is done to stop it," he says.
The actions of healthy fat cells, as just discussed, can help to control inflammation rather than cause it. This is key in the fight against diabetes because of the role of inflammation in general. A primary reason that sustained high blood sugar can be damaging is that it leads to oxidative stress and inflammation. Educator and author Andreas M. Papas, M.Sc., Ph.D., on behalf of A.C. Grace Company, Big Sandy, TX, addresses the inflammation issue. Papas was assisted in his responses by Allison Corkey and Klearchos Papas, Ph.D.
Emerging experimental evidence has improved our understanding of the way oxidative stress underlies diabetes and its complications, according to Papas. In diabetics, excessive free radicals are formed by glucose oxidation, nonenzymatic glycation of proteins, and the oxidative degradation of those glycated proteins, he explains, stating, "Abnormally high levels of free radicals and the resulting decline of antioxidant defense mechanisms can lead to damage of cellular organelles and enzymes, increased lipid peroxidation and the development of insulin resistance that is associated with type 2 diabetes." Tissues that are highly dependent on oxygen for energy production, like cardiac muscle, the nervous system, and insulin-producing pancreas cells, are prime areas for these defective oxidative processes, according to Papas.
Oxidative stress, especially through nitrogen radicals, contributes to inflammation, which evidence links to the development of diabetes. Papas says that pro-inflammatory cytokines including C-reactive protein, tumor necrosis factor (TNF)-alpha and interleukin (IL)-6 are found in increased levels in diabetics. These factors can lead to the major complications seen in some diabetics. "Strategies that reduce oxidative stress and inflammation provide a powerful tool in the prevention and management of diabetes, especially when combined with lifestyle modification," Papas says.
One avenue toward reducing inflammation is presented by vitamin E. The antioxidant capacity of vitamin E, which is actually a class of eight compounds, four called tocopherols and four called tocotrienols, has been brought to light by research, according to Papas. Food sources can contain all eight, and are typically rich in gamma tocopherol. In research circles, vitamin E had been synonymous in the past with only alpha tocopherol, which has led to its efficacy for various health purposes being questioned.
But gamma tocopherol, Papas says, along with its metabolite, is an effective quencher of nitrogen radicals. Tocotrienols, particularly alpha tocotrieonol, inhibit phospholipase A2, which releases fatty acids. Gamma tocotrienol, in particular, suppresses production of HMG-CoA, which is involved in LDL cholesterol production and is targeted by statin drugs, according to Papas. The general anti-inflammatory actions of the entire vitamin E class of compounds, he emphasizes, are especially applicable to diabetes.
Vice president of Edison, NJ-based Carotech, Inc., W.H. Leong, says that studies suggest the polyunsaturated nature of tocotrienols contribute to their unique potency. In addition to cholesterol support, anti-inflammation and antioxidant function, tocotrienols have been found to benefit the related areas of blood pressure support, blood glucose maintenance and insulin sensitivity, according to Leong. A palm oil-derived mixed tocotrienol/tocopherol complex (Tocomin from Carotech) has been shown to improve insulin sensitivity and glucose utilization in diabetic mice (6).
This vitamin E complex has also been studied in the context of liver function, specifically NAFLD. Leong describes NAFLD as a main risk factor for type 2 diabetes, since the liver helps to regulate glucose levels along with other functions. Where NAFLD is found, so too are obesity, insulin resistance and hyperlipidemia.
"A formerly rare condition, the rapid emergence of NAFLD has been linked to skyrocketing rates of metabolic syndrome and 'diabesity'—the term many experts use for co-occurring diabetes and obesity," Leong says. A version of the previously described proprietary vitamin E complex was used in an interventional, double-blind, placebo-controlled human clinical trial on 64 subjects over the period of a year. 50% of the subjects that received the vitamin E complex saw complete remission of NAFLD, compared with 23% for the placebo group (7). Leong calls this the first study to demonstrate the efficacy of tocotrienol for NAFLD.
The list of nutrients that can fill the antioxidant role and perform other functions in support of diabetes continues with omega-3 fatty acids. "Because of their significance as structural components of critical organs, their role in cardiovascular health and their anti-inflammatory effects, omega-3 fatty acids can play a significant role in the management of diabetes," says Papas. The omega-3 DHA, he explains, is a primary component of the brain, retina, skin, sperm and testicles. Omega-3s in general, he adds, have been shown to improve blood lipid profiles and reduce levels of inflammatory mediators.
Coenzyme Q10 (CoQ10) is a crucial part of the electron transport chain involved in respiration, and has a high concentration in the heart, Papas says. This important antioxidant is also key for mitochondrial energy production. Inefficient respiratory chain function is one way free radicals get produced, he says, adding, "Diabetes is associated with low blood levels of CoQ10, and diabetics are at higher risk of mitochondrial and other diseases associated with mitochondrial function."
The carotenoids lutein and zeaxanthin are both components of the retina and are important for diabetics, Papas says, because retinopathy is often a problem. Other carotenoids like beta-carotene, lycopene and astaxanthin exhibit antioxidant properties and may also be helpful. Alpha-lipoic acid is an essential cofactor for mitochondrial enzymes, Papas says, and may help with glycemic control and neuropathy. Clouatre says that the newer, stabilized form called R-alpha lipoic acid is likely the supplement of choice.
Adding in another antioxidant, Levy says, "Several studies suggest aged garlic extract inhibits the formation of advanced glycation end products that can contribute to diabetic complications." In a related function, aged garlic extract can also reduce the formation of free radicals, according to Levy.
A proprietary extract of the maitake mushroom (Maitake SX-Fraction from Mushroom Wisdom) has shown blood sugar support benefits, according to Donna Noonan, senior vice president of Mushroom Wisdom, Inc., East Rutherford, NJ. "Studies at Georgetown University and New York Medical College confirm that SX-Fraction possesses a potent ability to enhance insulin sensitivity," she says. One study using five volunteers with type 2 diabetes showed improved blood glucose levels in two to four weeks with the extract. Noonan says that while this trial was small, the balance of maitake extract research over the last 25 years shows a link with peripheral insulin sensitization and glycemic control.
Papas also lists cinnamon, as well as the minerals magnesium, chromium and vanadium for diabetes support. Chromium, Levy says, has a well-earned reputation for aiding blood sugar control. An essential trace mineral, it aids in processing carbohydrates and fats, and helps the body properly respond to insulin. A randomized, double-blind, placebo-controlled study found a proprietary chromium complex (Zychrome from InterHealth Nutraceuticals) to significantly decrease insulin resistance by 29.9% compared to baseline (8). Paul Dijkstra, CEO of InterHealth Nutraceuticals, Benicia, CA, says, "It is important to work with a doctor to take actions to reduce insulin resistance and lower fasting insulin and glucose levels. People may have insulin resistance for several years without noticing anything."
Combining chromium picolinate and niacin, Levy notes, enhances the mineral's absorption. In addition to this function, niacin, one of the B vitamins, also helps convert carbohydrates to energy, and research suggests it is involved in insulin metabolism and blood sugar regulation, according to Levy.
Diabetes Support Offerings
The products and ingredients below are available from companies interviewed for this piece.
A.C. Grace Company: Unique E Mixed Tocopherols Concentrate, Unique Omega E+, Unique Derma+.
Bluebonnet Nutrition Corp.: Cellular Active Ubiquinol 25, 50, 100 and 200 mg Softgels, Chromium 200 mcg Vcaps, Cinnulin PF Cinnamon Bark Extract Vcaps, Alpha Lipoic Acid Vcaps in 100, 200, 300 and 600 mg potencies.
Carotech, Inc.: Tocomin SupraBio.
Dr. Rath USA, Inc.: Healthy Blood Sugar Synergy Formula, Cardiovascular Health and Longevity formula, Healthy Cholesterol Synergy Formula, Healthy Blood Pressure Synergy Formula.
InBalance Health Corp.: INBar (blood sugar support snack bars), INBalance Glucose Management, INSupport Multi-Vitamin, INSupport Weight Management.
InterHealth Nutraceuticals: Zychrome, ChromeMate.
Jarrow Formulas, Inc.: Glucose Optimizer, Pressure Optimizer, Citrus Bergamot.
Life Extension: CoffeeGenic Green Coffee Bean Extract, Super R-Lipoic Acid, Chromium Ultra, Green Tea Extract, Optimized Chromium, CinSulin with InSea2 and Crominex, Vanadyl Sulfate, Natural Glucose Absorption Control.
Mushroom Wisdom: Maitake SX-Fraction.
Natural Factors Nutritional Products, Inc.: PGX (PolyGlycopleX).
Nutra Bridge: InSea2.
Wakunaga of America Co.: Kyolic Blood Sugar Balance, Kyolic 100, Kyolic Vitamin D3, Kyolic Omega-3, ModuChol.
"Another important aspect of supporting healthy blood sugar levels is supplying, at the cellular level, key nutrients to feed the pancreas and support healthy insulin production," says VerHulst. According to Clouatre, one herb stands out in this context. "Gymnema sylvestre is the best known and best researched of the herbs that increase insulin release," he says. However, he explains that while increasing insulin release can improve blood sugar levels, for those who are already dealing with insulin resistance, this may not be the best angle of approach. "Most prediabetics do not need to release more insulin, but rather to respond more appropriately to small amounts of insulin," says Clouatre.
In addition to wild bitter melon and green coffee bean extract, Clouatre says, "In recent years, a great deal of attention has been directed toward cinnamon extracts as insulin sensitizers." It may work by preventing and reversing impaired insulin signaling in skeleton muscle, and by promoting the expression of peroxisome proliferator-activated receptors in adipose tissue, he says.
Examining the synergistic effects of using nutrients in certain combinations is the focus of Bhanap's company. "For example, arginine and other amino acids act synergistically to increase insulin secretion and insulin sensitivity," she says, adding that the B vitamin thiamine and grape seed extract are other examples of diabetes-support nutrients that can be added to formulas.
Bhanap says a study compared the effects of a combination of nutrients to the drug metformin on several blood parameters of young, immature mice receiving a high fructose diet. The nutrient combination was found to reduce high blood pressure, high cholesterol and serum fructosamine (9). This last measure is often used to monitor blood glucose levels over periods of one to three weeks, according to Bhanap. To summarize, she states, "The synergy of essential vitamins, minerals and bioactive plant substances supports healthy glucose and carbohydrate metabolism."
Factors, overlooked. As progress is made in diabetes research, new risk factors are sometimes revealed, or a new emphasis can be placed on a previously obscure cause. Some of these cases have already been discussed in our review of the latest science. Here are a few more potentially overlooked risk factors and support options tagged by our experts.
"Statin drugs are some of the most widely prescribed drugs in the world to help maintain healthy cholesterol; however, their role in raising the risk of diabetes has been observed and studied only in recent years," says Sugarek MacDonald. Statins reduce cholesterol by blocking HMG-CoA, but they are also suspected of reducing levels of CoQ10 by this same pathway. Research has shown that supplementing with CoQ10 while taking statin drugs may help reduce the risk of diabetes by preventing statins from reducing levels of the compound GLUT4. "Altered levels of GLUT4, a compound that helps to control blood sugar levels, may contribute to insulin resistance and the onset of type 2 diabetes," Sugarek MacDonald says, adding that further study of this effect is warranted in animals and humans.
Magnesium has been listed as useful for diabetes, but Clouatre points out it may be more necessary than many realize. "We as a nation are not fond of green leafy vegetables or of whole grains and, as a result, a majority of all Americans consume inadequate magnesium," he says. A recent trial of overweight subjects supports the idea that magnesium plays a beneficial role in insulin regulation (10).
An important consideration, according to Murray, is an individual's level of exposure to Persistent Organic Pollutants (POPs). These include such chemicals as polychlorinated dibenzo-p-dioxins (PCDDs), polychlorinated dibenzofurans (PCDFs), hexachlorobenzene (HCB), organophosphates, DDE and Bisphenyl A. As a group, they have been linked to the development of type 2 diabetes. Murray says, "Those with levels of organochlorine pesticides in the top quartile have a five times greater risk for metabolic syndrome."
Levy reminds us that many of the plant-based options for supporting healthy cholesterol levels also impact diabetes positively. Phytosterols tied to reductions in LDL cholesterol also were of benefit to those with metabolic syndrome in a recent study (11).
The overarching impact of stress and depression on diabetes risk is worth discussing at length. In his book 30 Quick Tips for Better Health, VerHulst highlights the importance of stress management for controlling blood sugar. According to Clouatre, uncontrolled stress activates the hormone cortisol in a way that promotes glucose release from the liver and lean tissues, in order to prepare for "fight or flight" reactions that are usually not necessary.
"While the role of genetics, weight, diet and exercise are universally accepted, the role of stress, emotional health and depression are receiving attention both as contributing factors and also as complications of diabetes," Papas says. Studies have tied high cortisol levels to heightened risk of both cardiovascular disease and diabetes. Normally, the "fight or flight" response subsides when the threat is removed, but if stress is chronic, blood sugar and insulin remain abnormally high, Levy explains.
Emotional disorders can also be considered a compounding factor for diabetics. Papas cites a study involving 42,000 people diagnosed with both untreated depression and diabetes. A 1.5- fold higher risk of death was found in those with both conditions (12).
An important consideration is the fact that responding positively to stress improves one's ability to control its negative aspects. To illustrate, Clouatre cites a Swedish study that found work stress and shift work may contribute to type 2 diabetes risk in women, but in men, risk was decreased by high work demands, high strain and an active job (13). Thus, the context of stress helps determine whether it might contribute to diabetes.
The basic link is clear, as Papas emphasizes that stress, both physical and emotional, is linked with increased oxidative stress and inflammation. "It is also important to note that nutrients and natural compounds such as minerals, vitamins, antioxidants, omega-3 fatty acids and others have been shown to support emotional health and help reduce the risk of depression," he says.
Levy suggests practices including meditation, yoga and exercise to relieve chronic stress and possibly mild depression. He says supplements that can help with stress include l-theanine and rhodiola, while SAMe, 5-HTP and St. John's wort have been tied to depression support.
Navigating the Market
Perhaps more so than any other large segment of the supplement market, the diabetes support space is linked with a specific disease state. Those who participate in this space must therefore tread more lightly when it comes to terminology and health claims, and selling these products comes with a similar set of concerns. Federal Trade Commission (FTC) and U.S. Food and Drug Administration (FDA) oversight ensure that explicit links between supplements and the disease are kept in check.
VerHulst explains that his company avoids making problematic claims by saying its product supports the body's ability to get and stay healthy. Indeed, as things stand now, natural diabetes-support products typically use general descriptions to imply management of healthy blood sugar levels, Leong exlplains. "Words such as 'diabetes' or 'insulin resistance' are highly sensitive and attract the attention of the authorities as they imply treatment of disease conditions," he says.
Manufacturers that utilize ingredients in this category have to look at the science to see exactly how they can position products for consumers, including what structure/function claims can be used in marketing materials and on the product label, according to Dijkstra. "Ingredients that have been clinically shown to benefit blood sugar and/or insulin levels can take advantage of a 'blood sugar management' product positioning," he says. Consumers may be looking for something more specific, Dijkstra adds, but manufacturers need to abide by regulations like the Dietary Supplement Health and Education Act (DSHEA), which sometimes makes it difficult to communicate clinically studied benefits to consumers.
Since the enactment of DSHEA, Noonan says, it has been clear what may be said and what may not be said about supplements, diabetes-support products included. "DSHEA says that dietary supplements may support the structure and function of an organ or system of the human body. Supplements that fall into this particular category may support blood sugar levels," she says.
"Clearly, disease claims must be avoided. However, supplements can play a vital role in helping consumers address key blood sugar health concerns," says Steil. His company has elected to work with terms that avoid disease claims while highlighting key benefits such as "reduced post-meal blood glucose and insulin levels" and "lower glycemic index." Steil feels metabolic syndrome is also an area that supplement companies can target, as it is not considered a disease state.
Steil says such terms and phrases resonate with consumers, as certain groups may focus in on maintaining healthy blood glucose levels, while others may be looking for help with the glycemic index of the food they eat. Most consumers, he adds, will focus on healthy insulin levels, since this represents the core concern for diabetics and prediabetics.
"Structure and function claims remain problematic for this entire category. Still, if there is proper documentation, it is usually possible to claim 'supports blood glucose regulation within the normal range,' 'supports the actions of insulin,' 'supports the metabolism of glucose and the production of energy,' and so forth," Clouatre says.
Since a large percentage of diabetes cases are related to diet, exercise and weight status, he also suggests that retailers point clients toward information on these topics. "In fact, it often is easier to talk to customers about diet and energy issues than it is to discuss diabetes, blood sugar, blood pressure or other aspects of the metabolic syndrome," Clouatre says. He asks people to keep in mind that nutritional approaches to blood sugar control usually take weeks or months to show progress. But these benefits, once achieved, should be fairly stable, so retailers should counsel patience with the use of such supplements.
More tips for promoting or communicating about blood sugar health with your customers come courtesy of Sugarek MacDonald. She suggests renovating the blood sugar health section in your store by making it attractive, interactive and informative for consumers of any age. This may include a cross-merchandised end cap featuring "blood sugar healthy" supplements and packaged foods (including low-glycemic sweeteners like stevia). Also consider providing a basket of fresh fruit and vegetables to address the requirement of five to nine servings per day.
Avoiding product redundancy is important too, Sugarek MacDonald says. For instance, one can pick out three popular blood sugar health supplements to promote on a monthly basis. She also advises retailers to pay attention to their younger customers when it comes to this category. Unfortunately, the increasing obesity problem in young people means more will have to deal with diabetes and prediabetes. It is crucial to advocate a healthy lifestyle before focusing in on supplements, and in this vein, Sugarek MacDonald suggests providing clients with literature or hosting kid-friendly educational seminars about eating healthy and getting daily exercise. WF
1. A.M. Belenchia, et al., "Correcting vitamin D insufficiency improves insulin sensitivity in obese adolescents: a randomized controlled trial," Am. J. Clin. Nutr. 97(4), 774-81 (2013).
2. T.J. Iseli, et al., "Activation of AMPK by Bitter Melon Triterpenoids Involves CaMKKβ," PLoS One. 8(4), e62309 (2013).
3. Clouatre, et al., "Bitter Melon Extracts in Diabetic and Normal Rats Favorably Influence Blood Glucose and Blood Pressure Regulation," J Med Food. 14(12), 1496-504 (2011).
4. B.M. Bhat, et al., "Antidiabetic and hypolipidemic effect of salacia oblonga in streptozotocin induced diabetic rats," J. Clin. Diagn. Res. 6(10), 1685-7 (2012).
5. "Waist Size Linked to Diabetes Risk in Adult Men," Johns Hopkins Bloomberg School of Public Health, Mar. 17, 2005, http://www.jhsph.edu/news/news-releases/2005/wang-waistsize.html, accessed May 31, 2013.
6. F. Fang, et al., "Vitamin E tocotrienols improve insulin sensitivity through activating peroxisome proliferator-activated receptors," Mol. Nutr. Food. Res. 54(3), 345-52 (2010).
7. E. Magosso, et al., "Tocotrienols and Nonalcoholic Fatty Liver: a clinical experience," The Liver Meeting, Poster Presentation No. 672 (Boston 2010).
8. S.K. Jain, "Effect of chromium dinicocysteinate supplementation on circulating levels of insulin, TNF-α, oxidative stress, and insulin resistance in type 2 diabetic subjects: randomized, double-blind, placebo-controlled study," Mol. Nutr. Food. Res. 56(8), 1333-41 (2012).
9. J. C. Cha, et al., "Nutritional improvement of metabolic syndrome parameters in immature fructose-fed wild-type mice," Mol. Med. Rep. 4(6), 1053-1059 (2011).
10. S.A. Chacko, et al., "Magnesium supplementation, metabolic and inflammatory markers, and global genomic and proteomic profiling: a randomized, double-blind, controlled, crossover trial in overweight individuals," Am. J. Clin. Nutr. 93(2), 463-73 (2011).
11. M. Rondanelli, et al., "Key points for maximum effectiveness and safety for cholesterol-lowering properties of plant sterols and use in the treatment of metabolic syndrome," J. Sci. Food. Agric. [Epub ahead of print] (2013).
12. M. Park, et al., "Depression and risk of mortality in individuals with diabetes: a meta-analysis and systematic review," Gen. Hosp. Psychiatry. 35(3), 217-25 (2013).
13. A. Eriksson, et al., "Work Stress, Sense of Coherence, and Risk of Type 2 Diabetes in a Prospective Study of Middle-Aged Swedish Men and Women," Diabetes Care. [Epub ahead of print.] (2013).
Published in WholeFoods Magazine, July 2013
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They look like they've scampered out of a thriller — sleek, four-legged Robots vaguely resembling dogs, flinging open doors and evading attacks from the humans controlling them.
And for the first time this week, videos posted to YouTube by the robotic dogs' creators, Boston Dynamics, show the not-so-cuddly canines prancing around autonomously.
SpotMini robots, first unveiled by Boston Dynamics in June 2016, could become commonplace following CEO Marc Raibert's announcement Friday at a conference that his company will begin selling the robots to businesses next year. They might appear outside construction zones — surveying the sites and collecting building data — or outside offices, where they could use their cameras to provide security. They could also be used to get into hard-to-reach spaces, such as the stairwells of skyscrapers, where they could check for explosives or "bad things" that shouldn't be there, Raibert said.
In fact, the dogs could take on almost any role thanks to a customizing feature that allows third parties to run their own applications with SpotMini's computer programming. About 10 SpotMinis have already been built, and Raibert said he plans to manufacture about 100 more for testing this year before launching mass production by the middle of next year. While a price tag has yet to be determined for the robots, Raibert said the cost of building the latest prototype was about one-tenth the cost of previous versions.
Raibert revealed his plans at the TechCrunch conference, which took place at the University of California at Berkeley and focused on the expanding role of robots in everyday life.
The SpotMini's bulkier cousin, BigDog, was funded by the Pentagon's research arm as a potential battlefield ally to carry heavy ammunition and help evacuate wounded troops. But the Marine Corps decided in 2015 that BigDog was simply too loud and could give away the position to enemy troops.
A video posted to YouTube Thursday shows a SpotMini robotic dog running around an office, smoothly climbing up and down a staircase. An operator initially had to steer the robot through the course so that it could build its own map of the area. But once that's done — as shown in the video — the robot can navigate entirely on its own, using cameras to recognize obstacles.
In just over a day, the video of the robotic dog dashing up the stairs and bolting around the office on its own racked up more than 875,000 page views, a source of both wonderment and terror.
Though Boston Dynamics, which is owned by Japan's SoftBank group, did not immediately respond to a request for comment from The Post, the company's website says Atlas is the latest in a line of advanced humanoid robots it is developing.
Raibert said people often send him ideas for everyday applications of his company's robots. One idea involves a legged device that could carry people in wheelchairs onto more difficult terrain.


text:
Treatment-seeking for febrile illness in north-east India: an epidemiological study in the malaria endemic zone
Himanshu K Chaturvedi1,
Jagadish Mahanta2 &
Arvind Pandey1
This paper studies the determinants of utilization of health care services, especially for treatment of febrile illness in the malaria endemic area of north-east India.
An area served by two districts of Upper Assam representing people living in malaria endemic area was selected for household survey. A sample of 1,989 households, in which at least one member of household suffered from febrile illness during last three months and received treatment from health service providers, were selected randomly and interviewed by using the structured questionnaire. The individual characteristics of patients including social indicators, area of residence and distance of health service centers has been used to discriminate or group the patients with respect to their initial and final choice of service providers.
Of 1,989 surveyed households, initial choice of treatment-seeking for febrile illness was self-medication (17.8%), traditional healer (Vaidya)(39.2%), government (29.3%) and private (13.7%) health services. Multinomial logistic regression (MLR) analysis exhibits the influence of occupation, area of residence and ethnicity on choice of health service providers. The traditional system of medicine was commonly used by the people living in remote areas compared with towns. As all the febrile cases finally received treatment either from government or private health service providers, the odds (Multivariate Rate Ratio) was almost three-times higher in favour of government services for lower households income people compared to private.
The study indicates the popular use of self-medication and traditional system especially in remote areas, which may be the main cause of delay in diagnosis of malaria. The malaria training given to the paramedical staff to assist the health care delivery needs to be intensified and expanded in north-east India. The people who are economically poor and living in remote areas mainly visit the government health service providers for seeking treatment. So, the improvement of quality health services in government health sector and provision of health education to people would increase the utilization of government health services and thereby improve the health quality of the people.
Malaria is one of the major public health problems of many countries of world [1–3]. According to WHO report, almost 300 million cases of malaria occur worldwide and more than one million people die due to malaria every year [4]. In India, malaria is reported from many states, but several deaths of epidemic proportion reported every year from different parts of north-east India [5–7]. Assam, being the most populated (27.85 million) and geographically second largest State (78,523 km2) of north-east India, is contributing more than 5% of the total number of cases of malaria reported in India. Most districts of the State are malaria-endemic and many pockets in forest, forest fringes, and foothill villages along the inter-country/inter-state border are vulnerable to malaria outbreak as reported [8]. Chloroquine-resistant malaria is widespread in the State, and decreased sensitivity to other anti-malarial drugs has been documented [9]. The malaria cases are detected throughout the year [10], but higher incidence is reported during May to October [11]. There is often delay in reporting illness to health care providers and during these periods certain unorthodox practices are adopted as cost-saving measures.
Although investment in health sectors has been gradually increasing and many health programmes to control malaria, such as spraying DDT in high-risk areas, use of impregnated-bed nets and mass collection of blood slides form the community, have been launched by the government, but there is no appreciable change in malaria incidence. A clear understanding about the health-seeking behaviour of households is crucial for an effective control programme of malaria. For instance, the implementation of current strategy for the control of malaria is mostly based on early diagnosis. It is important to know the factors that determine the utilization of the services of a health care provider for suspected cases of malaria so that an effective strategy can be developed.
Utilization patterns of health service mainly depend on quality of service offered by health care providers and whether it is affordable by the individual user. Moreover, impact of quality differences on the use of health care facilities is to be assessed simultaneously with household and individual characteristics affecting the utilization. The preference of one health care provider over another will be affected not only by facility characteristics (quality of service and cost of service), but also by the individual characteristics such as preferences, affordability, convenient, education level, and household income.
The present study is an attempt to assess the various options of health care patients normally follow for seeking treatment of febrile illness or malaria and also estimate the factors associated with the choice of health services. In the endemic areas, fever is the most common symptom for suspected cases of malaria and is, therefore, being used interchangeably [12].
Observing high incidence of malaria, two districts of upper Assam, namely Tinsukia and Golaghat, were selected as study area for conducting the survey. A sample of 2,000 households was worked out to capture the variability in health care services and its utilization for both the districts. In the first stage, 50 PSUs (census villages/wards) were selected randomly from each district by using the method of probability proportional to size (PPS) sampling and 20 households from each PSU were selected in a second stage by systematic sampling. The household listing of selected PSUs was prepared during the survey by visiting house-to-house and enquiring whether anybody had malaria or fever in last three months. Those households who reported a fever case and also described the symptom of disease before seeking treatment were recorded in the household listing. A sample of 20 such households, who had received treatment of fever, was selected from the household listing by using systematic sampling. The limitation of such a technique without parasitological analysis is obvious, but in the rural community without laboratory facilities, malaria is diagnosed by the symptoms and clinical manifestations of the disease.
The heads of the selected households, or the most senior person, were interviewed by the trained field workers to collect the general information, whereas specific information about the treatment of fever was collected from the individual patient or mother of sick child in a pre-tested questionnaire. The questionnaire included information about the household, such as household income, education, ethnicity and the use of various options of health care providers for seeking treatment of fever, awareness about malaria, traditional belief and practices, distance of nearest health center (government/private) from residence.
Health care delivery in north-east India is mainly provided through the government, private practitioners and private industries. A structural approach to provide health services by population unit is adopted by the government, which is similar to the all-India model (World Bank 1997). The government health care system is mainly categorized in four levels, based upon amenities and service facilities. According to the facility levels, they are district hospitals, community health centers (CHC), primary health centers (PHC) and sub-centers (SHC). The second largest health care service providers are private hospitals of tea gardens, oil and coal industries, including the health clinics of private practitioners.
The traditional system on the other hand comprises the Vaidya (herbalists) and priests. The traditional Vaidya mainly use herbs for the preparation indigenous medicine and to provide treatment of diseases. The priests (ojha) are believed to 'invoke the spiritual powers' of a deity in diagnosis and treatment of disease. They perform spiritual prayer and also sacrifice of birds or animals during prayer to cure the disease. This system is still being practiced in remote areas and is popular among some tribal communities.
Self-medication is rapidly increasing among all sections of the society, because it saves consultation fees and traveling cost to the health center. In remote areas, the medicines for fever are available and sold freely in the general shop. In towns, the scenario is different, the people describe the symptoms to the drug store operator, who may not necessarily be a pharmacist, and obtain suggestions for drugs to purchase.
Data collected from the 1989 households in the survey were analysed to identify the possible associated factors with utilization of health services. Statistical tests were applied to examine the association and differences, wherever applicable [13, 14]. The geographical area of selected PSUs (villages/wards) was categorized as town, flood, forest, tea garden, and others (Plain area) on the basis of information collected in the survey. Those villages affected by flood every year were categorized as flood area, whereas villages located inside or close to forest were categorized as forest area. Occupation was mainly classified as service (permanent job with regular income and pensioners), self-employed (businessman and professionals), farmer (agriculture), housewives, and others (unemployed, labourers, students). The majority of the households were Hindu (93.6%). Ethnicity of the household respondents was grouped as Assamese (non-tribal), Assam tribes (including Missing, Sonowal, Kachari), Tea tribes of Assam (mainly confined to tea gardens), Bengali (Hindu family), Nepali (originally from Nepal) and others (mostly people who came from other States of India such as Rajasthan, Bihar, Nagaland).
Multinomial logistic regression analysis was used to estimate the rate ratios with respect to indicator/reference category for comparison and identification of actual associates [15]. While seeking treatment of fever, the individual has used more than one option of available treatment. In the model, initial choice of health care service providers, such as traditional system, self-medication, government and private health service, were taken as dependent (or outcome) variable and all other variables viz. residence area, gender, ethnicity, education, occupation, age and income of household, were included as independent variable. However, the analysis was repeated again with the final choice of treatment option (i.e. government or private) used by the individual to know the differences. The Statistical software, SPSS 12.0 was used for statistical analysis.
The study was conducted after obtaining approval of the Scientific Advisory Committee (SAC) of the Indian Council of Medical Research. Ethical advice was followed for conducting the survey. The district health administrations and tea garden authorities were also informed to provide local support during the study. At village level, a verbal consent of the village headman was obtained and he was consulted before conducting the survey. Before questioning, the households were apprised in the understandable local language regarding the purpose of visit by the field investigator. The interview was conducted after obtaining consent of the household respondent.
The general characteristics of household respondents such as age, household income, education, occupation, area of residence, health care services used, distance of nearest health center (government/private) from residence, are presented district-wise for comparison (Table 1). The mean household income was Rs. 2,534 ± 1,816 (INR) per month, but it was significantly lower in Tinsukia district. Variability in monthly household income was high as is reflected by the standard deviation. About 47% of respondents were illiterate and 10% educated up to secondary and above. A majority of the respondents were farmers (38.6%), followed by service class (22%) and self-employed (12.6%) people. Most of the respondents were Hindu (93.6%) and ethically belong to different tribal and non-tribal communities of Assam. The residential area of households was categorized as town (12%), forest (23.0%), flood (22.0%), tea garden (26.3%) and other (16.7%) plain area. The health care services attended initially for seeking treatment of febrile illness were traditional system (39.2%), government health services (29.3%), private health services (13.7%) and self-medication (17.8%) (Figure 1). Except self-medication, the use of health services differs significantly between the tow districts. The average distance to the nearest health center (Government/Private) was 4.2 ± 5.6 km, which was slightly lower for Golaghat district.
Diagrammatic presentation of types of health service utilization by the fever cases of households in the malaria endemic areas.
Table 1 General characteristics of household, socio-economic status, area of living and age and gender distribution of febrile case in the two selected districts.
Health care services used by the households and its differences across socio-demographic characteristics of households, residential area and patient's characteristics are presented with statistical analysis (Table 2). The association of health care services was significant with all the variables, except gender of patients. The traditional system was the first choice of treatment among majority of people residence in tea garden (60%), flood (43.7%) and forest (33.8%) areas. However, self-medication was popular in forest (25.8%) and town (25.5%) areas. A decreasing pattern in the use of the traditional system was observed with increasing level of education of household heads. It was also recorded to be high among farmers (42.5%), tea tribes (57.1%) and Nepali (50.5%) communities. As an initial choice, self-medication was high among higher educational groups, i.e. secondary+ (20.7%); farmers (24.3%); Nepali (26.9%) and Assamese (20.2%) communities. It was also recorded high among higher household income groups (21.4%). The increasing pattern of self-medication was observed with increase age group of patients.
Table 2 Health care services utilization for seeking treatment (P) and its association with residential areas of living and socio-demographic characteristics of household head and patients.
Government health service, as initial choice of seeking treatment, was high in all the residential areas (32% to 42%), except in tea garden areas (14.2%). It was also shown to be low among tea tribes of Assam (14.8%). Similarly, the private health services were commonly used in town (29.3%) and tea gardens (17.8%). Utilization of private health services was also high among tea tribes (20.3%) and higher household income group (17.7%).
Analysis of final choice of seeking treatment indicated the significant association with location, area of residence, occupation, ethnicity, household income and distance of nearest health center. However, the association of education and gender of patients was not significant. The utilization of government health services was significantly higher in Golaghat district (78.5%) compared to Tinsukia (52.5%). It was also recorded high in forest (80.6%) and flood area (78.9%). The private health services were used commonly in tea garden areas, especially by the tea tribes (Table 2).
The results of multinomial logistics regression (MLR) analysis with initial and final treatment-seeking choice are presented in Table 3. The estimated coefficients (β) of the variables in the model indicate how changes in each of the variable affect the household choice of health service providers for seeking treatment of febrile illness. Except for gender of patients, a significant effect of location, residential area, education, occupation, ethnicity, age of patients and household income was recorded with the dependent variables, i.e. health care services. Multivariate rate ratios (MRR) for traditional system as initial choice was significantly higher for residential area: tea garden (5.6), flood (3.2), forest (1.5); level of education: literate (1.7); ethnic group: Assamese (1.5) and tea tribes (3.4); and distance of health center: ≥ 5 km (1.4) compare with respective reference. It clearly indicates that the use of traditional system of medicine was much higher in tea garden, forest and flood affected area with compare to town and others. The MRR of government service as initial choice was significantly higher for education: literate (1.4); occupation: service and self-employed (2.4); others (1.9); and low household income (1.8). The household income was one of the important determinants for utilization of government services. However, there was no significant effect of residential area and ethnic background of people. The private services as initial choice shows the significantly higher value of MRR (odd) with location: Golaghat (1.5); education: literate (1.4); occupation: service and self-employed (4.1) and others (3.4); ethnic group: tea tribes (2.6); and age of patients: lower age group (1.9) compare to respective reference. However, there was no significant effect of residential area, household income and gender of patients on utilization of private health services.
Table 3 Multinomial logistic regression analysis to estimate the β coefficient and multivariate rate ratios (MRR) for seeking treatment of febrile illness.
As a final choice of seeking treatment, the MLR analysis shows the significant effect of location, education, occupation, ethnicity, household income and distance of nearest health center with government health services utilization with reference to private services. The estimated values of β and MRR shows the significant negative or decreasing effect with location: Tinsukia (-1.16; 0.3); education: literate (-0.47 & 0.6); occupation: service & self-employed (-1.15 & 0.32) and others (-0.93 & 0.2); and ethnic group: tea tribes (-1.59 & 0.2) with their respective reference. However, it was almost three times higher in favour of government health services for lower income (≤ 2000 INR) group (2.9). If the distance of health center increases (≥ 5 km), the MRR was significantly higher (1.6) in favour of government health services. The area of residence was not showing any effect with the final choice of two health services i.e. government or private.
A better understanding of health-seeking behaviour of people, especially when suffering from fever, a common symptom of malaria, is important for effective management and control of malaria. This is related with early treatment, accessibility and proper use of drugs. The most common treatment options reported by the households for seeking treatment of fever was use of traditional drugs, self-medication, government and private health services, which was also reported by others in many studies [16–19].
The use of traditional medicines was prevalent in remote areas especially in tea gardens, forest and flood affected areas. It seems that internal factors of the specific geographical region like availability and accessibility of health services; traditional belief and practices was motivating the people for seeking medical assistance from traditional system (Vaidya). Although most of the people received treatment finally from government or private health services, but majority of them initially visited to traditional Vaidya for seeking treatment of febrile illness. The strong belief in traditional system was reflected even among literate people. A study in Tanzania also reported that traditional healers are an important factor of delay for malaria treatment [18].
Self-medication and consultations at medical stores was a common practice in town and forest areas. Such practices created a situation where people wait till the patient become serious enough before reporting to health centers. Obviously, some of these patients develop complications and even die by the time they reach a hospital. No doubt, the 'wait-and-watch' attitude is not only harmful to the patients, but also contributing to increased malaria. These practices are very common not only among un-educated and poor people, but across most of the variables included in the analysis. This was also reported and discussed by others [20–22].
Over all, response of availing government health services was high by the people residing in forest and flood affected area. Moreover, the people from town and tea garden areas were seeking treatment mainly from private health services, because private health services were mainly confined in the town and private tea gardens located outside the town nearby the tea gardens. Despite longer distances and poor connectivity to motorable roads, the accessibility to government health services was recorded high among the people living in forest and flood areas. The increasing level of education of household head has decreasing effect with accessibility of government services. The MRR was also significantly low for literates with reference to illiterates. Household income is one of the important determinants for health service utilization. Similarly, increasing level of household income has decreasing effect with accessibility of government services. It was possibly due to the expensive treatment in private health centers. The socio-economic impact on choice of health services was also discussed by others [23–26].
Early diagnosis of febrile illness or malaria can yield rich dividends for effective management and control of malaria [18, 27–29]. Though the distance to a health center is one of the important factors of delay, its effect may be confounded with the place of residence. Residential areas such as forest, flood and tea garden, show the highest preference for traditional system and self-medication, which could be the reason of delay in proper diagnosis. Interestingly, there is no gender bias in the choice of seeking treatment, which is often reported as an important indicator to address this issue [29, 30]. However, the decision-making power on treatment-seeking behaviour mainly depends on male family elders [30].
Although treatment expenditure is one of the important components, which influence the household choice of health service providers [21], information could not be collected in this study due to recall bias and lack of records during survey. Moreover, household income is recorded as one of the important determinants influencing the utilization of health services. The identification of various other indicators in this study provides useful information to understand the interlinked behavioural practices related to malaria. As early diagnosis is the main theme of prevention and control of malaria, the effective strategies to provide health services at nearest periphery of village/community and parallel health awareness programme with people participation are needed to circumvent the situation.
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Tolhurst R, Nyonator FK: Looking within the household: gender roles and responses to malaria in Ghana. Trans R Soc Trop Med Hyg. 2005, 100: 321-326. 10.1016/j.trstmh.2005.05.004.
The Indian Council of Medical Research, New Delhi provided financial support for conducting the study. We are grateful to all the members of scientific advisory committee including the Chairman for their valuable suggestions and advice. Authors are also thankful to the Joint Directors, District Health Department of Golaghat and Tinsukia for providing necessary help during the survey.
National Institute of Medical Statistics, ICMR, New Delhi, India
Himanshu K Chaturvedi & Arvind Pandey
Regional Medical Research Centre, N.E. Region, Dibrugarh, Assam, India
Jagadish Mahanta
Himanshu K Chaturvedi
Arvind Pandey
Correspondence to Himanshu K Chaturvedi.
HKC contributed to the conception, preparation of project proposal and design of the study, developed the questionnaire and collected data, and contributed to the analysis, interpretation of the data and to the writing of the paper. JM contributed to the conception and preparation plan of study, developed the questionnaire and the data collection. AP contributed to the interpretation of data and to write the paper. All authors read and approved the final manuscript.
Chaturvedi, H.K., Mahanta, J. & Pandey, A. Treatment-seeking for febrile illness in north-east India: an epidemiological study in the malaria endemic zone. Malar J 8, 301 (2009). https://doi.org/10.1186/1475-2875-8-301
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72 string pieced squares completed. These guys are small-only 3.5 inches square. It is nice that I was able to complete this this weekend. I also completed the 20 blocks of Dark and Creepy. I need to take a picture of that as well. I guess that just leaves getting dressed for today.....or maybe why bother as it is already 2 PM.
Good day..sewing and playing in fabric and NCIS marathon on.. Life is good. Also Henry close by. He is sitting on my lap every chance he gets.
Here is Sweet Sarah. Sarah coordinates. Notice the braces?-match the jacket. Sarah got her ears pierced this week and the earrings match as well. Sarah got her ears pierced now because her Mom got hers pierced when she was two months short of 10 as well.
Here we are waiting at the start of the race. Laurie was acting as the photographer. I look a whole lot better than I did at the end of the race. Note to self: probably not a good idea to try to walk when your back is already stiff and hurting. But I made the whole race!
Mass of humanity. I think someone said there were about ten thousand walkers/runners. Also lots of dogs.
Bonnie's directions: make 244 quarter square triangles. Done! I think I have a few extra to boot.
Ready for next step-due Friday .......and I am off..no work for 4 days.
I went back today to play some more. And I took my camera to capture our red wagons. Sarah has decorated her with garlands. She really has a great horn! Henry and Alice were visiting as you can see in Sarah's wagon. If you look REALLY close, you can spot Moda Man in the basket!
I worked some on Dark and Creepy HavenStone. I finished one block but forgot some of the pieces at home, so did not get much done. also worked on the binding for Emily Jane.
I have to say that I checked Bonnie's site before I left for work yesterday to see if clue #1 was up and it was. No need to go to work before I download it! I am ready to get started on all those quarter square triangles...448? I will try to get a few done this weekend.
Last night I went to Thimbles just because I could! I didn't really intend to sew much or stay that long but I did not get home until after ten. (Elizabeth, it's the big one!). I worked on the binding for Emily Jane. I am doing the two color binding and had to have Grandma Pat show me what to do to connect them. I will be going back today for another session. this time GRANDMA PAT will be helping me with Dark and Creepy. (I am so happy for Pat and of course Andy that they will have a grandbaby to spoil come the spring.) Emily and Russ must know that there is going to be no living with GRANDMA PAT. Can't wait to see the designs for quilts for this little bundle.
Sarah (no blog) brought her red wagon decorated with garland and Alice and Henry inside. We parked our wagons together for a photo. Moda Man and Fat Quarter (the S. H.) were in their compartment (the basket). I need to replace my horn and get one like Sarah has. Mine is just too wimpy! I will take my camera today for a picture.
As for Thimbles...it matters not whether I sew there. I so enjoy being with some of the nicest ladies in Atlanta. We used to be called Stitchin Sisters before the advent of Silver Thimbles and we truly are. We share our sewing and our fabbies but we share in so many other ways. I love you all!
And sure enough I took the wrong turn off of I75 and ended up heading toward beautiful downtown Marietta. So I took a right turn and then another right turn and I finally spotted The Big Chicken. I don't know the address of Little Quilts but I do know that it is down the road from said Chicken. And every direction in Marietta is related to where it is in relations to the Big Chicken.
Mission accomplished-I got my scissors. Place was hopping as it was a pick up day for a block of the month. Thought I was going to have to park in Smyrna! Brenda was there and we chatted and checked out some fat quarters that will be used in the next Bonnie Hunter mystery (coming this Friday). I needed some blacks to perk up my stash. Also ran into another Thimble there-Danita.
I was good and did not detour to Tiny Stitches but headed over to Alpharetta to drop off my Thksg dinner contribution-turkey gravy base from Wm Sonoma.
I first saw Pat's pattern when she brought it to a Thimbles meeting back when. I knew I had to make this one. It is the first one in her book that I want to make. I will not be making the one on pg 71! I have been collecting my neutrals. Would you believe shortage of white fabric?
At any rate, this past weekend, I started wacking up fabric. I have learned a couple of things. This block really does need good contrast and quarter inch seams are important in this block. that is not new, but I have had to start over because my blocks just don't come out at the proper size or my points don't match. I might have to wait for a tutorial on this one from the Head Thimble.
I will be keeping her busy as I need help on the binding construction for Emily Jane as well. At least I won't be whining about heinous applique. She should be happy about that!
Crazy thing happened yesterday at work. A new employee came up to me and asked me if I was from NY. Long story short-we worked in the same nursing home in NY 13 years ago! And she remembered me. Unfortunately I drew a blank.
I met with Sir Quilt Dude after work yesterday to discuss when I will be able to retire. He will be working on the numbers. Stay tuned and keep your fingers crossed!
There were times this week, that I thought it would never come. I am really tired of this whining. I don't want to whine I would really like to go back to when I enjoyed my job. It was not that long ago. It is a combination of new owners of the facility and the government who controls Medicare/Medicaid funding. An 11% cut across the board Oct 1 has caused companies nationwide to scramble and attempt to be able to care for our frail elderly. As a result, those of us in the "industry" are caught between a rock and a hard place. I am drowning in paperwork and jumping through hoops. But I am fortunate to still have a job. I know of people whose jobs have been eliminated. I know of employees who are told to do the job in less hours. I am too old for this garbage. But the sad thing is that we are aging rapidly in this country and things are going to get much worse. Who is going to take care of you when you are unable to do so?
But for now....I am going to bed. I will worry about it tomorrow.
I am not quite sure when I became a Bonnie Hunter groupie. I so love playing with little pieces. at any rate, her next mystery quilt will debut in a couple of weeks. Must get my fabbies together. I am going to use the same colors she used.
The first Bonnie Hunter quilt I made was called Orange Crush. she likes orange, me not so much. I did finish the top but I really did not like my color selection once the whole thing was together. I have collected all of her mysteries in the book.
I have made Double Delight and Carolina Christmas. I have Bonnie's autograph on the quilt label for Double Delight. Roll, Roll is done but needs to be quilted. I don't think the fabric I bought last week is enough. I will have to go to option next!
Not much sewing going on here. I have mostly done the preliminary cutting for Havenstone AKA Dark and Creepy. I am ready to start but just too darn tired to play at the end of the day. Maybe this weekend.
Had to get new toner for my printer. It only took me 20 minutes to figure out where the cartridges were and how to get them out.


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Uberwagon Cargo Comparison: 2021 Mercedes-AMG E 63 S Wagon vs 2021 Audi RS 6 Avant
Which twin-turbo V8 wagon is the better cargo hauler?
Zac Palmer
Apr 1st 2021 at 11:00AM
We declared the 2021 Mercedes-AMG E 63 S Wagon to be the superior superwagon in our comparison test where we pit it against the 2021 Audi RS 6 Avant. However! There is an epilogue to this story.
In addition to enjoying the nearly 1,200 horsepower of German muscle on the road, we decided to see which is the better family truckster when it comes to loading up for a road trip. Welcome to the Superwagon Luggage Test!
To keep things consistent with every other luggage test we've done in Michigan (as opposed to Riswick's out in Portland), we used the same array of suitcases and bags. This includes two carry-on suitcases sized (24 inches long, 15.5 wide, 10 deep); one carry-on suitcase (21.7L x 13.7W x 9 D); one medium-size suitcase you have to check (24.5L x 16.8W x 11.5D) and two larger, full-size suitcases (33.8L x 21.5W x 13D) and (28.1L x 18W x 10.5D).
The specs predict yet another Mercedes victory, as it's rated for 35 cubic-feet of space behind the rear seats to the Audi's 30 cubic-feet. However, better numbers don't always tell the whole story in the world of luggage stuffing.
Let's start with the Audi. Upon opening the hatch, it's immediately apparent that Audi has compromised total utility for maximum style — and boy does it look good. The roof angles downward into the pillars before finally standing up straight partway down the rear of the car. It's similar to how a crossover coupe's roof angle cuts into what would otherwise be a square, utilitarian shape. In addition to this, the hatch's opening is on the narrow side. It's already not looking good versus the much more traditionally-shaped E 63 S Wagon.
We toss all but the one medium-sized bag in right away, and it all sort of fits. The bags are below the rear seat line, meaning that you can still see uninhibited out the rear window. There is one problem with the wild card fancy bag (22L x 8.8W x 12D). It's smushed in the corner. If it were full of un-squishable items, there's no way that bad would fit in the bottom corner where it is. The RS 6 Avant's width is enough to accommodate both full-size suitcases side-by-side, but there's a limit to how wide it can go.
Seeing nowhere else to go but up, we put the medium bag on top. This ended up being a futile effort, though. It's far too tall, and even switching up the orientation with one of the smaller bags on top wouldn't work. As an anecdotal Deutschland aside, I rented a regular A6 Avant in Germany a year ago, and it just barely fit four full-size suitcases (side-by-side and stacked one on another). The roof angle almost ruined that genius rental car idea, too, but it worked.
Mercedes time.
You don't need to do much investigative work or spec comparisons to deduce that the Mercedes cargo area is larger than the Audi's. One look at its more upright pillars and traditional wagon shape makes it obvious that the geometry is in Stuttgart's favor.
This hunch is proved when we stuff all the bags minus the medium bag in easily. The load floor in the Mercedes is lipless, unlike the Audi that forces you to lift items up and out. It's a small thing, but it makes loading and unloading this number of bags all that much easier.
You'll notice that the bags in the back of the Mercedes have more room to breathe. The fancy bag can be fully packed and left in the corner, and there's still a perfectly good view out the back. All that empty space up top got us wondering …
Voila! The medium bag that was laughably too large for the Audi fits above the other suitcases in the Mercedes. You will lose rearward vision on one side and there's a chance it would fly forward during sudden braking, but this is where those extra cubes in the E 63 S Wagon come in handy. Notice how the interior roofline angles upward from either side of the car to make more room for things toward the ceiling. It's this thoughtful design that allows you to stack the Mercedes higher. If we had another suitcase and, crucially, a cargo cage to keep suitcases from flying forward, the Mercedes could safely fit even more items.
So there you have your winner, again. The 2021 Mercedes-AMG E 63 S Wagon is a marvel of engineering. It's invigorating and mind-tingling to drive on the right stretch of pavement. Plus, it'll take you and your little ones on a long road trip with space to spare. The only thing missing is the optional third row offered in the non-AMG wagon. If only the kids could enjoy going 0-60 mph in 3.4 seconds while sitting backwards … now we're dreaming.
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Bethlehem, West Bank — More than 30 Mennonites and Brethren in Christ from North America encountered kindred spirits March 7-10 at the fourth biennial Christ at the Checkpoint Conference, hosted by Bethlehem Bible College at the Orient Palace Hotel in the town of Christ's birth.
The theme was "The Gospel in the Face of Religious Extremism," a topic that reflects the current context of the Middle East but has special meaning for Palestinian Christians.
The number of Christians in the West Bank and Gaza has diminished significantly in the past two decades as the churches face Israel's occupation of Palestinian lands, a choked economy and violence between Palestinians and Israelis.
The conference — named to highlight the barriers Israel has erected along the borders of the occupied territories — brought together more than 500 participants from 24 countries, with the largest numbers coming from the U.S. and Europe. About 80 participants were locals from the West Bank and 40 from neighboring Israel.
In plenary sessions, worship times and intervening meet-the-speaker conversations, delegates wrestled with theological and practical responses to religious violence, whether by Christians, Muslims or Jews.
An array of more than 25 speakers included Fuller Theological Seminary's president, Mark Labberton, who gave daily Bible studies on the Sermon on the Mount.
At least half the speakers were Palestinian or Israel-based theologians and peace activists — Munther Isaac, Salim Munayer, Jonathan Kuttab, Yohanna Katanacho and Jack Sara of Bethlehem Bible College and Jesuit theologian David Neuhaus. Others were visiting professors and church leaders from Africa, Asia, Europe and the U.S. (including African-Americans Regina Henderson and Lisa Sharon Harper, speaking out of the context of the civil rights movement). There were also representatives of Messianic Jewish communities who are seeking common ground with Palestinian Christians.
More than previous conferences, this one also included voices from outside the mainstream Christian community, including Muslim theologian Mustafa Abu Sway, American activist and Jewish rabbi Arik Aeschleman and Lisa Loden, a Messianic Jew from Israel.
Thirty-three participants from Anabaptist churches in North America attended. Most were part of two learning tours — one initiated by West Coast Mennonite Central Committee and the other jointly sponsored by MCC Alberta and Mennonite Church USA. Three couples were on short-term volunteer assignments in Palestine and Israel.
A number of tour group participants were intrigued, even surprised, at the conference's consistent emphasis on peace, nonviolence, humility and love.
John Hawbaker, a regional missions administrator for the Brethren in Christ, found it encouraging that the Palestinian Christians attending and hosting the conference showed so little spirit of revenge in their biblical teaching and in the stories they shared.
Scott Holman, pastor of Butler Avenue Mennonite Brethren Church in Fresno, Calif., wants to take the Palestinians' hopeful spirit back to his own congregation, which worships in a neighborhood where there is poverty and violence.
"I want to bring encouragement from Palestine to Fresno that says, 'Don't give up; there is reconciliation,' " he said.
The MCC worker who coordinated the tours was pleased with the combination of learning tours and Christ at the Checkpoint.


text:
Voices home
SBS Emerging Writers' Competition
12 Feb 2016 - 10:42am
New research reveals how to lower the risk of death in extremely pre-term babies
New research has identified the perfect range of oxygen saturation in premature babies, removing a degree of guess work currently used in clinical practices. (Getty Images)Source: Getty Images
Extremely pre-term babies will have a greater chance of surviving to their second birthday and living a life free of disability if their blood is saturated with a slightly higher level of oxygen during hospital care.
Yasmin Noone
12 Feb 2016 - 9:58 AM UPDATED 12 Feb 2016 - 10:42 AM
The lives of thousands of fragile premature babies, born before 28 weeks gestation, could be saved and lifelong disabilities avoided, if doctors adopt new research recommendations on how much they should saturate a newborn's blood with oxygen, as they struggle to survive.
International findings published in the New England Journal of Medicine, shows that premature babies born with weak lungs or other breathing-related issues face a greater risk of dying before they reach their second birthday if their blood is saturated with slightly too little oxygen during clinical attempts to keep them alive.
The new study identifies the perfect range of oxygen saturation levels as 91-95 per cent, eliminating a degree of guess-work currently used in clinical practices which could result in infant death, eye disease or permanent neurologic damage.
We now know that if you give 20 babies the higher target, one extra baby who wouldn't have normally survived, will survive and live without disability.
"Through this research, we wanted to ensure we are not condemning a high proportion of babies to a risk of disability or death that can be avoided," says co-principal investigator of the study, Professor William Tarnow-Mordi from University of Sydney.
"…This evidence will help prevent thousands of deaths worldwide each year."
Up until now, the amount of oxygen saturation a premature baby requires to survive, and live without disability or disease, has been a moving target – between 85 and 95 per cent saturation, and dependent on the treating physician.
This research conducted on over 2,100 babies in hospitals across Australia, New Zealand, Canada and the USA shows that doctors who target the lower levels within this range, 85-89 per cent oxygen saturation, increase an infant's risk of death by 45 per cent.
"In terms of public health, these findings mark a major advance as this is about an everyday treatment that happens in every neonatal clinic across Australia," Prof Tarnow-Mordi explains.
In terms of public health, these findings mark a major advance as this is about an everyday treatment that happens in every neonatal clinic across Australia.
The findings come as good news to current and future parents of premature babies, born before 28 weeks gestation.
"These findings mean that parents can be reassured…There's never been a better time for premature babies to be born now because of all the research that has gone on.
"The issue of deaths in premature babies is never going to go away but with these findings, we can make a difference in survival rates of very premature babies."
The human body requires and regulates a very precise and specific balance of oxygen in the blood to survive and function in good health.
The expert estimates that around one per cent of all babies are born up before 28 weeks gestation, accounting for 700,000 to a million babies a year who are born three months early worldwide.
According to the NSW Pregnancy & Newborn Services Network, extremely pre-term babies have an 80 per cent chance of surviving their first birthday.
The Better Health Channel Victoria says one third of babies born at 24 weeks gestation who are admitted to a neonatal intensive care unit (NICU) will not survive. Meanwhile, babies born at 30 weeks gestation have a 98 per cent of living.
Prof Tarnow-Mordi says all the doctors who took part in this study across the world reported back that they will change their neonatal practices to reflect the research's recommendations and help save the lives of extremely pre-term babies.
"They are keen for this result to influence the way they set their policies from now on."
Related viewing: Edge of Life