Infant formula requires mass production by the dairy industry, with plastic and other waste and degradation of land and waterways. Millions of babies, two thirds globally, now have milk formula, with ...breastfeeding in dramatic decline in Asia.
Economic thinking clarifies that markets are not perfect - price incentives can lead to excessive and inefficient environmental damage. Market prices paid to produce or use a commodity may not reflect its true resource costs. The ongoing global transition in infant and young child feeding (IYCF) toward milk formula use makes urgent the investigation of its environmental costs, including greenhouse gas (GHG) implications. Socially vulnerable populations are also particularly exposed to climate change risks, but have the least voice and agency.
Few question the scale of the baby food industry, especially in major food exporting countries. Breastfeeding advocacy non-government organisations have led the investigations, and exposed the inequitable vulnerabilities. A ground-breaking study in 2016 showed emissions from just six Asia Pacific countries were equivalent to 6 billion miles of car travel. Each kilogram (kg) of milk formula generated 4 kg of (carbon dioxide (CO
) equivalent) greenhouse gas during production. Much of this was from unnecessary toddler formula. Recent research reveals that if looking at the full product lifecycle, including consumer use, GHG emissions per kg are actually three times higher than these pioneering estimates. Environment and health harms combined with economic evidence highlight the place for a strong public health response on this issue.
Formula feeding is a maladaptive practice in the face of contemporary global environmental and population health challenges. Breastfeeding protection, support and promotion helps to safeguard planetary and human health by minimising environmental harm. It is a beneficial response to concerns about disease burdens and climate change. Breastfeeding populations are more resilient in emergencies. Effective and cost-effective policies and interventions exist for increasing breastfeeding and reducing unnecessary use of formula. Implementing such measures presents a rare opportunity to both reduce the greenhouse gas problem and improve human nutrition, health, and health equity.
Despite increasing evidence about the value and importance of breastfeeding, less than half of the world's infants and young children (aged 0–36 months) are breastfed as recommended. This Series ...paper examines the social, political, and economic reasons for this problem. First, this paper highlights the power of the commercial milk formula (CMF) industry to commodify the feeding of infants and young children; influence policy at both national and international levels in ways that grow and sustain CMF markets; and externalise the social, environmental, and economic costs of CMF. Second, this paper examines how breastfeeding is undermined by economic policies and systems that ignore the value of care work by women, including breastfeeding, and by the inadequacy of maternity rights protection across the world, especially for poorer women. Third, this paper presents three reasons why health systems often do not provide adequate breastfeeding protection, promotion, and support. These reasons are the gendered and biomedical power systems that deny women-centred and culturally appropriate care; the economic and ideological factors that accept, and even encourage, commercial influence and conflicts of interest; and the fiscal and economic policies that leave governments with insufficient funds to adequately protect, promote, and support breastfeeding. We outline six sets of wide-ranging social, political, and economic reforms required to overcome these deeply embedded commercial and structural barriers to breastfeeding.
Cancer of unknown primary (CUP) is a clinical challenge especially when it occurs in adolescents and young adults (AYA), aged 15–39 years, due to the sparse data in this population. The available ...data has not described the population‐based epidemiological features of CUP among AYA. Therefore, we collected patient information from the Surveillance, Epidemiology and End Results (SEER) registry, 1990–2015. Age, gender, ethnic, five pathological classification groups were assessed along with an aggregate level socioeconomic status (SES) index and population density at the county level. Incidence rates, modeled relative risks and survival of AYA patients with CUP were assessed. Among 2,480 AYA patients, 907 met the definition of standard pathology classifications. The majority of AYA patients with CUP had a neuroendocrine, squamous cell and poorly differentiated carcinomas with 0.4 cases per 1,000,000 population. AYA living in areas with the highest SES level had the highest risks of CUP; adjusted relative risks (ARR) of 1.17 (95% CI 1.0–1.4) and 1.99 (95% CI 1.5–2.6), respectively. AYA living in nonmetropolitan areas had a lower risk of CUP (ARR = 0.16; 95% CI 0.1–0.2). The incidence of differentiated neoplasms has been decreasing slower than undifferentiated neoplasms since the early 1990s. The median overall survival (OS) was 11 months (95% CI 9–13 months) with squamous CUP having the longest median OS 16 years (95% CI 3–24 years). In conclusion, this analysis answers several gaps in the knowledge of CUP among AYA and provides a platform to better understand this disease and its management within this group.
What's new?
Cancer of unknown primary (CUP) is a clinical challenge, especially when it occurs in adolescents and young adults (AYA) due to the sparse data in this population. Here, the majority of patients had neuroendocrine, squamous cell, or poorly differentiated carcinomas with 0.4 cases per 1,000,000 population. AYA living in high socioeconomic status areas had a higher risk of CUP compared to low status areas, and non‐metropolitan areas had a lower risk of CUP compared to metropolitan areas. The median overall survival was 11 months. This analysis is an important step toward understanding the etiological factors in AYA patients with CUP.
In this issue, ‘The Cost of Not Breastfeeding’ (Walters et al., 2019) launches a tool for estimating economic losses from low breastfeeding rates. The study concludes that global economic costs of ...not breastfeeding are substantial, around US$341 billion annually, but can be addressed by investing resources in key breastfeeding strategies and interventions.The authors should be congratulated for their wide-scale investigation. Their study advances the important analyses in the 2016 Lancet Breastfeeding Series (Rollins et al., 2016) and earlier studies. The pioneering economic study on this topic was in Health Policy and Planning over two decades ago (Horton et al., 1996). The authors should be congratulated for their wide-scale investigation. Their study advances the important analyses in the 2016 Lancet Breastfeeding Series (Rollins et al., 2016) and earlier studies. The pioneering economic study on this topic was in Health Policy and Planning over two decades ago (Horton et al., 1996).
Cutaneous VCL::ALK fusion spindle (ovoid) cell tumor is unique. Recently emerged RAS::MAP tyrosine kinase fusion sarcomas more commonly involve subcutis, skeletal muscle and even bone. We share our ...experience with a novel cutaneous VCL::ALK spindle cell tumor. An 11‐year‐old male presented with a back pedunculated pink–red papule thought to be a pyogenic granuloma. Biopsy histopathology revealed an epithelial collarette with pedunculated tumor extending to deep dermis/subcutis interface. The combination of spindled and epithelioid cells, an ovoid myopericytoid appearance within myxoid to collagenous stroma, low to moderate MIB1 and focal S100 protein without SOX10 immunostaining, were suggestive of a novel RAS::MAPK tyrosine kinase fusion sarcoma that is well described. ALK immunostain being positive, a next‐generation sequencing comprehensive fusion panel was performed to reveal a VCL::ALK fusion. While epithelioid fibrous histiocytoma shares this fusion and similar dermal location and collarette pedunculation, this and other entities were excluded by older patient age, deeper dermal involvement, ovoid‐to‐spindled morphology, central pericytoid vasculature, myxoid stroma, moderate cellularity with low to moderate MIB1 expression, superficial ulceration, and focal S100 protein expression. Complete excision was performed with favorable follow‐up to date. This novel VCL::ALK fusion spindle (ovoid) cell tumor of the dermis is best considered as part of the recently emerged RAS::MAP tyrosine kinase fusion sarcomas.
Policy-makers need to rethink the connections between the economy and health. The World Health Organization Council on the Economics of Health for All has called for human and planetary health and ...well-being to be moved to the core of decision-making to build economies for health. Doing so involves valuing and measuring what matters, more and better health financing, innovation for the common good and rebuilding public sector capacity. We build on this thinking to argue that breastfeeding should be recognized in food and well-being statistics, while investments in breastfeeding should be considered a carbon offset in global financing arrangements for sustainable food, health and economic systems. Breastfeeding women nourish half the world's infants and young children with immense quantities of a highly valuable milk. This care work is not counted in gross domestic product or national food balance sheets, and yet ever-increasing commercial milk formula sales are counted. Achieving global nutrition targets for breastfeeding would realize far greater reductions in greenhouse gas emissions than decarbonizing commercial milk formula manufacturing. New metrics and financing mechanisms are needed to achieve the health, sustainability and equity gains from more optimal infant and young child feeding. Properly valuing crucial care and environmental resources in global and national measurement systems would redirect international financial resources away from expanding carbon-emitting activities, and towards what really matters, that is, health for all. Doing so should start with considering breastfeeding as the highest quality, local, sustainable first-food system for generations to come.
The mother-child breastfeeding dyad is a powerful force for achieving healthy, secure and sustainable food systems. However, food system reports exclude breastfeeding and mother's milk. To help ...correct this omission and give breastfeeding women greater visibility in food systems dialogue and action, we illustrate how to estimate mother's milk production and incorporate this into food surveillance systems, drawing on the pioneering experience of Norway to show the potential value of such analysis.
The estimates use data on the proportion of children who are breastfed at each month of age (0-24 months), annual number of live births and assumptions on daily human milk intake at each month. New indicators for temporal and cross-country comparisons are considered.
It is assumed that a breastfeeding mother on average produces 306 l of milk during 24 months of lactation.
The annual number of live births is from Statistics Norway. Data for any breastfeeding at each month of age, between 0 and 24 months, are from official surveys in 1993, 1998-1999, 2006-2007, 2013 and 2018-2019.
Estimated total milk production by Norwegian mothers increased from 8·2 to 10·1 million l per year between 1993 and 2018-2019. Annual per capita production increased from 69 to 91 l per child aged 0-24 months.
This study shows it is feasible and useful to include human milk production in food surveillance systems as an indicator of infant and young child food security and dietary quality. It also demonstrates significant potential for greater milk production.
The federal Department of Health is preparing a new national breastfeeding strategy, to be adopted by all Australian Governments in late 2018. So what can we expect and will it make a difference?
Objective
To assess the long‐term safety, tolerability, and efficacy of bimekizumab in patients with active ankylosing spondylitis (AS).
Methods
Patients with active AS who completed the ...dose‐ranging, 48‐week BE AGILE randomized controlled trial were eligible to participate in an open‐label extension (OLE) study, in which patients received 160 mg of bimekizumab every 4 weeks. We present the safety and efficacy results through 156 weeks. Missing efficacy data were imputed using nonresponder imputation analysis for binary outcomes and multiple imputation for continuous outcomes.
Results
From weeks 0–156, 280 of 303 patients (exposure‐adjusted incidence rate 141.0 per 100 patient‐years) experienced ≥1 treatment‐emergent adverse event; the most frequent adverse events were nasopharyngitis (8.1 per 100 patient‐years) and upper respiratory tract infection (5.0 per 100 patient‐years). Additionally, 67 of 303 patients (9.8 per 100 patient‐years) had mild to moderate localized fungal infections (28 of 303 patients had Candida infections 3.7 per 100 patient‐years and 23 of 303 patients had oral candidiasis 3.0 per 100 patient‐years), 10 patients had serious infections (1.3 per 100 patient‐years), and no cases of active tuberculosis were reported. Active inflammatory bowel disease (1.1 per 100 patient‐years), anterior uveitis (0.7 per 100 patient‐years), and adjudicated major adverse cardiovascular events (0.3 per 100 patient‐years) were infrequent. The efficacy of bimekizumab treatment demonstrated at week 48 was sustained in the OLE study. At week 156, nonresponder imputation analysis showed that 53.7% of patients (72.6% of observed cases) met the Assessment of SpondyloArthritis international Society criteria for 40% improvement and 28.0% of patients (37.9% of observed cases) achieved partial remission; Ankylosing Spondylitis Disease Activity Scores were reduced from baseline (mean ± SEM 3.9 ± 0.1) to week 48 (2.1 ± 0.1) and week 156 (1.9 ± 0.1) (multiple imputation). Patients showed sustained improvements in pain, fatigue, physical function, and health‐related quality of life.
Conclusion
The safety profile of bimekizumab was found to be consistent with previously demonstrated findings, and no new safety signals were identified. The efficacy of bimekizumab in patients with AS was sustained through 3 years of treatment.
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