Hospital care--where has it gone?

The past several decades have been called the economic golden years of medicine. The vast majority of health care was provided in the hospital setting. Today, however, multiple forces are at work moving health care providers to less expensive environments. This article explores the past and the future of hospital care in the United States.     

Managed care evolution--where did it come from and where is it going?

The emergence and development of managed care has been and will continue to be a major force in America's health care delivery system. Specifically reviewed in this article are those legislative initiatives that contributed to the formation of this system of reimbursement and utilization management. Also addressed are responsibilities that can be ascribed to all stakeholders in necessitating this system as well as the adjustments required to make the system more responsive to the needs of higher-risk populations. This article concludes with a series of recommended actions that will be required of all individual citizens in assuring the future economic viability of this nation's health care programs.     

The obesity pandemic: where have we been and where are we going?

Obesity, a new pandemic, is associated with an increased risk of death, morbidity, and accelerated aging. The multiple therapeutic modalities used to promote weight loss are outlined with caution, especially for patients who are very young or old. Except for very rare single gene defects, the inheritance of obesity is complex and still poorly understood, despite active investigations. Recent advances that have shed light on the pathophysiology of obesity are the recognition that 1) excess fat is deposited in liver, muscle, and pancreatic islets; 2) fat tissue secretes a large number of active signaling molecules including leptin, adiponectin, and resistin, as well as free fatty acids; and 3) activated macrophages colonize the adipose tissue. Other candidates for key roles in the causes and consequences of obesity include 1) metabolic programming, where food acts as a developmental regulator; 2) the constellation of defects known as the "metabolic syndrome;" 3) cortisol overproduction in the adipose tissue; and especially, 4) insulin resistance. The possible etiologies of insulin resistance include cytokine excess, elevated free fatty acids, and hyperinsulinemia itself, as with transgenic overproduction of insulin in mice.     

Nutrition of Malaysians: where are we heading ?

Rapid and marked socioeconomic advancements in Malaysia for the past two decades have brought about significant changes in the lifestyles of communities. These include significant changes in the dietary patterns of Malaysians, eg the increase in consumption of fats and oils and refined carbohydrates and a decreased intake of complex carbohydrates. This resulted in a decline in the proportion of energy from carbohydrates, while an increase in the percentage contribution of fat has been observed. Changes in meal patterns are also evident: more families eat out, busy executives skip meals, the younger generation miss breakfasts and rely too much on fast foods. Many Malaysians have the mistaken belief that the taking of vitamin and mineral supplements can make up for the lack of these nutrients in their daily diets. In addition, communities have become generally more sedentary. All these changes have brought about undesirable effects with significant proportions of the affluent segments of the population being afflicted with various non-communicable diseases associated with overnutrition, namely obesity, hypertension, coronary heart disease and cancers. Nutrition activities and programmes are now being directed to tackle this increasing trend, whilst still attempting to eliminate the undernutrition problems. The ultimate strategy towards achieving a healthy nation is the promotion of a healthy lifestyle, including inculcating a culture of healthy eating. Comprehensive long term programmes, including a series of Healthy Lifestyle (HLS) Programmes have been carried out by the government. Launched in 1991 for six consecutive years, the first phase of the Programme comprised one thematic campaign each year, commencing with coronary heart disease and ending with diabetes mellitus. To further strengthen this long-term strategy, another series of activities to be carried out under the second phase of the HLS programme from 1997 to 2002 was launched within the framework of the National Plan of Action on Nutrition (NPAN) for Malaysia. The implementation of these programmes is, however, a challenge to health and nutrition workers. There is a need to examine the strategies for nutrition education to ensure more effective dissemination of information. The challenge is to determine how best to promote healthy eating within the present scenerio of rapid urbanisation, "western" dietary pattern influence, a whole barrage of convenience and "health" foods and nutrition misinformation. Malaysia continues to march ahead with its development plans to elevate the nation and its people to an even higher level of socio-economic status. The crucial question is: are we able to arrest the increase in these diet-related chronic diseases ? Or are we heading towards further deterioration in dietary pattern and increase in these diseases ? It will be a difficult and challenging journey ahead, requiring the concerted effort of all in the country. It is hoped that through this conference of sharing experiences with other Asian countries, a better understanding and improved strategies could be arrived at.