- Email: [email protected]
MASS DRUG ADMINISTRATION FOR CONTROL OF MALARIA
688
result.3 Likewise, the evidence seems to show that those who prematurely increase their dietary polyunsaturated fats simply raise the risks associated with non-atherogenic disease without affecting overall
mortality.4
Fortunately, Britain accepts the advice of well-intentioned but misguided crusaders reluctantly; otherwise their potential for harm might be much greater than it is, since so much of their advice is premature conclusions derived from an inadequate conflicting data. We urge Finn and like-minded colleagues to be patient. Let us first confirm that the statistical correlation between a high serum cholesterol and raised cardiac mortality is causal. Then let us confirm the now quite strong evidence that the higher risk associated with a raised serum lowdensity-lipoprotein (LDL) cholesterol is based on genetic factors which control the number and characteristic properties of the cellular LDL-receptor, rather than on the dietary intake of fats,55 before attempting to persuade the four-fifths of the population with a normal serum cholesterol that they should eat fewer eggs or more sunflower seeds. The debate is far from over but in the meantime, those who advocate a varied diet and maintenance of normal body weight by balancing energy expenditure with energy intake (with at least as much emphasis on expenditure as intake) seem to be saying all that needs to be said.
based
on
analysis
of
occurring in the absence of a definitive report from NACHNE, although the substance of some of its working papers have become fairly widely known, and have been, as you indicated, well received. It is indeed a pity if the food industry itself is attempting to delay publication of firm nutrition guidelines for food and health, as there is a significant role for the industry, in its various manifestations, to play in the realisation of the objectives of diet policies aimed at improving the health of the population, should the industry be prepared to involve itself constructively in such endeavours. There is a total lack of official practical dietary guidelines in the UK, at a time when other countries have taken this area of preventive medicine very much more seriously (for example, USA, Australia, and Norway). It should also be noted that the dietary guidelines required need to have a quantified base to enable diets to be properly evaluated, with a clear description of the degree of dietary change which should be achieved. Such information is necessary for the
dieticians, caterers, and various types of health
professionals involved in either choosing diets or in advising the public on dietary matters. The medical and other health professions should accept an important role in health promotion activities. One way in which these professions can assist the development of health promotion in this country is to continue to demand from the Department of Health and Social Security that appropriate official dietary guidelines are promulgated and published. I hope that you will, in your columns, continue to press for the publication of the
Eggs Authority, Union House,
Eridge Road, Tunbridge Wells, Kent TN4 8HF
report from NACHNE. ALEXANDER MACNAIR
Stockport Health Authority, District Offices, Bramhall Moor Lane, Hazel Grove, Stockport SK7 5AB
CHRISTOPHER A. BIRT
SUGAR AND OBESITY
517)
that the obese are SIR,-Professor Yudkin claims (Aug 27, p obese because they eat too many sweets. The fact is that the obese are obese because they consume too much cheese, bread, and meat, too many nuts, eggs, fruit, and vegetables, and too much alcohol, in addition to not expending an equivalent amount of energy. There is evidence that the obese generally eat more of every food, but curiously eat less sugar than the slim. I agree with Yudkin that those who are significantly overweight but who have now become slim and remain slim gave up "what they used to find irresistible". To some obese people it was peanuts, French bread, camembert, and claret, or overgenerous helpings of lasagne and spaghetti that were irresistible, Yudkin is quite right in pointing out that "people eat for pleasure", but he is wrong in assuming that biscuits are any more tempting than a French baguette, or chocolates than hot pastrami on rye bread, especially in countries where people do get fat by eating too many of these delicacies and not by eating two biscuits with a cup of tea or by having an occasional chocolate. World Sugar Research Organisation Ltd, Haymarket House, 28 Haymarket,
London SW1Y 4SP
A. J. VLITOS
NEED FOR NUTRITIONAL GUIDELINES IN UK
SIR,—I was delighted to read your excellent and balanced editorial (Aug 6,
p
317)
on
diet and ischaemic heart disease. Since the
Advisory Committee on Health and Nutrition Education (NACHNE) was set up, a number of health authorities have approved their own district food and health policies, in most cases with primary prevention of coronary heart disease very much in mind, although there should of course be many other health objectives to be considered when such policies are prepared. It seems to me unfortunate that so much of this activity is National
3.
Dietary recommendations for diabetics for the 1980s—A policy statement by the British
Diabetic Association. British Diabetic Association. London 1983. Pearce ML, Hashimoto S, Dixon WJ, Tomiyasu V. A controlled clinical trial of a diet high in unsaturated fat in preventing complications of atherosclerosis. Circulation 1969; 40: Suppl II, 1-63. 5. Brown MS, Kovanen PT, Goldstein SL. Regulation of plasma cholesterol by lipoprotein receptors. Science 1981; 212: 628-35.
4.
Dayton S,
** News reaches us that the report on nutritional guidelines, prepared for NACHNE, is to be made available through the Health Education Council
early in October.-ED. L.
MASS DRUG ADMINISTRATION FOR CONTROL OF MALARIA
SIR,-The paper by Dr Garfield and Mr Vermund (Aug 27, p 500) is remarkable for several reasons. First of all, it confirms the conviction of experienced malariologists that mass drug administration, even on a national scale, can reduce but not interrupt the transmission of this infection in an endemic area; nevertheless it might be of substantial benefit to the relevant population, if the proportion of people that receive the effective drug is high. In this particular case the acceptance of a 3-day course of chloroquine and primaquine by 1.9 million Nicaraguans, or about 70% of the total population, is an extraordinary achievement. The health authorities of Nicaragua can be congratulated on the success of their "Jornada de Salud". Secondly, it is gratifying, though not unexpected, that the number of reported cases of malaria decreased within a few months from an average of about 1700 per month to an average of 700 from November, 1981, to March, 1982. This resulted in an overall "deficit" of 9200 cases in comparison with the expected number. I agree with Garfield and Vermund that the actual decrease was probably greater. Thirdly, it was rather optimistic to expect that, after one treatment by an adequate dosage of chloroquine but a much too low dosage of primaquine, a condition of near-eradication would be achieved. I concur with the authors’ interpretation of the different effects of their chemotherapeutic blitzkrieg on Plasmodium vivax and P falciparum, but I believe that the results would have been better if the treatment had been given well before the peak of the transmission period. Finally, one can only regret that this admirable (and otherwise fully justified) field experiment failed to provide two sets of valuable information-the incidence of various side-effects of primaquine different age-groups; and an assessment, in samples of the population, of the susceptibility of Pfalciparum to chloroquine, at least at the completion of the project. Wellcome Museum of Medical Science, 183 Euston Road, London NW 12BP
L. J. BRUCE-CHWATT
result.3 Likewise, the evidence seems to show that those who prematurely increase their dietary polyunsaturated fats simply raise the risks associated with non-atherogenic disease without affecting overall
mortality.4
Fortunately, Britain accepts the advice of well-intentioned but misguided crusaders reluctantly; otherwise their potential for harm might be much greater than it is, since so much of their advice is premature conclusions derived from an inadequate conflicting data. We urge Finn and like-minded colleagues to be patient. Let us first confirm that the statistical correlation between a high serum cholesterol and raised cardiac mortality is causal. Then let us confirm the now quite strong evidence that the higher risk associated with a raised serum lowdensity-lipoprotein (LDL) cholesterol is based on genetic factors which control the number and characteristic properties of the cellular LDL-receptor, rather than on the dietary intake of fats,55 before attempting to persuade the four-fifths of the population with a normal serum cholesterol that they should eat fewer eggs or more sunflower seeds. The debate is far from over but in the meantime, those who advocate a varied diet and maintenance of normal body weight by balancing energy expenditure with energy intake (with at least as much emphasis on expenditure as intake) seem to be saying all that needs to be said.
based
on
analysis
of
occurring in the absence of a definitive report from NACHNE, although the substance of some of its working papers have become fairly widely known, and have been, as you indicated, well received. It is indeed a pity if the food industry itself is attempting to delay publication of firm nutrition guidelines for food and health, as there is a significant role for the industry, in its various manifestations, to play in the realisation of the objectives of diet policies aimed at improving the health of the population, should the industry be prepared to involve itself constructively in such endeavours. There is a total lack of official practical dietary guidelines in the UK, at a time when other countries have taken this area of preventive medicine very much more seriously (for example, USA, Australia, and Norway). It should also be noted that the dietary guidelines required need to have a quantified base to enable diets to be properly evaluated, with a clear description of the degree of dietary change which should be achieved. Such information is necessary for the
dieticians, caterers, and various types of health
professionals involved in either choosing diets or in advising the public on dietary matters. The medical and other health professions should accept an important role in health promotion activities. One way in which these professions can assist the development of health promotion in this country is to continue to demand from the Department of Health and Social Security that appropriate official dietary guidelines are promulgated and published. I hope that you will, in your columns, continue to press for the publication of the
Eggs Authority, Union House,
Eridge Road, Tunbridge Wells, Kent TN4 8HF
report from NACHNE. ALEXANDER MACNAIR
Stockport Health Authority, District Offices, Bramhall Moor Lane, Hazel Grove, Stockport SK7 5AB
CHRISTOPHER A. BIRT
SUGAR AND OBESITY
517)
that the obese are SIR,-Professor Yudkin claims (Aug 27, p obese because they eat too many sweets. The fact is that the obese are obese because they consume too much cheese, bread, and meat, too many nuts, eggs, fruit, and vegetables, and too much alcohol, in addition to not expending an equivalent amount of energy. There is evidence that the obese generally eat more of every food, but curiously eat less sugar than the slim. I agree with Yudkin that those who are significantly overweight but who have now become slim and remain slim gave up "what they used to find irresistible". To some obese people it was peanuts, French bread, camembert, and claret, or overgenerous helpings of lasagne and spaghetti that were irresistible, Yudkin is quite right in pointing out that "people eat for pleasure", but he is wrong in assuming that biscuits are any more tempting than a French baguette, or chocolates than hot pastrami on rye bread, especially in countries where people do get fat by eating too many of these delicacies and not by eating two biscuits with a cup of tea or by having an occasional chocolate. World Sugar Research Organisation Ltd, Haymarket House, 28 Haymarket,
London SW1Y 4SP
A. J. VLITOS
NEED FOR NUTRITIONAL GUIDELINES IN UK
SIR,—I was delighted to read your excellent and balanced editorial (Aug 6,
p
317)
on
diet and ischaemic heart disease. Since the
Advisory Committee on Health and Nutrition Education (NACHNE) was set up, a number of health authorities have approved their own district food and health policies, in most cases with primary prevention of coronary heart disease very much in mind, although there should of course be many other health objectives to be considered when such policies are prepared. It seems to me unfortunate that so much of this activity is National
3.
Dietary recommendations for diabetics for the 1980s—A policy statement by the British
Diabetic Association. British Diabetic Association. London 1983. Pearce ML, Hashimoto S, Dixon WJ, Tomiyasu V. A controlled clinical trial of a diet high in unsaturated fat in preventing complications of atherosclerosis. Circulation 1969; 40: Suppl II, 1-63. 5. Brown MS, Kovanen PT, Goldstein SL. Regulation of plasma cholesterol by lipoprotein receptors. Science 1981; 212: 628-35.
4.
Dayton S,
** News reaches us that the report on nutritional guidelines, prepared for NACHNE, is to be made available through the Health Education Council
early in October.-ED. L.
MASS DRUG ADMINISTRATION FOR CONTROL OF MALARIA
SIR,-The paper by Dr Garfield and Mr Vermund (Aug 27, p 500) is remarkable for several reasons. First of all, it confirms the conviction of experienced malariologists that mass drug administration, even on a national scale, can reduce but not interrupt the transmission of this infection in an endemic area; nevertheless it might be of substantial benefit to the relevant population, if the proportion of people that receive the effective drug is high. In this particular case the acceptance of a 3-day course of chloroquine and primaquine by 1.9 million Nicaraguans, or about 70% of the total population, is an extraordinary achievement. The health authorities of Nicaragua can be congratulated on the success of their "Jornada de Salud". Secondly, it is gratifying, though not unexpected, that the number of reported cases of malaria decreased within a few months from an average of about 1700 per month to an average of 700 from November, 1981, to March, 1982. This resulted in an overall "deficit" of 9200 cases in comparison with the expected number. I agree with Garfield and Vermund that the actual decrease was probably greater. Thirdly, it was rather optimistic to expect that, after one treatment by an adequate dosage of chloroquine but a much too low dosage of primaquine, a condition of near-eradication would be achieved. I concur with the authors’ interpretation of the different effects of their chemotherapeutic blitzkrieg on Plasmodium vivax and P falciparum, but I believe that the results would have been better if the treatment had been given well before the peak of the transmission period. Finally, one can only regret that this admirable (and otherwise fully justified) field experiment failed to provide two sets of valuable information-the incidence of various side-effects of primaquine different age-groups; and an assessment, in samples of the population, of the susceptibility of Pfalciparum to chloroquine, at least at the completion of the project. Wellcome Museum of Medical Science, 183 Euston Road, London NW 12BP
L. J. BRUCE-CHWATT