Metabolic diseases

Action to incorporate evidence- based nutrition concepts in medical education is essential

Eleanor J Beck · Lauren Ball · Breanna M Lepre · Rachael McLean · Clare Wall · Melissa Adamski · Helen McCarthy · Jennifer Crowley

A 14-month-old girl was noted to have exfoliation of her peripheries on day 19 after orthotopic liver transplant for end-stage liver disease from extrahepatic biliary atresia

Jessica A Eldredge · Noel E Cranswick · Kathleen H McGrath

The obesity epidemic has been escalating for over 30 years, but little attention has been paid to delivery of effective treatments in the public system

Ahmad Aly · Michael L Talbot · Wendy A Brown

Culling low value care will cut health care carbon emissions

Alexandra L Barratt · Katy JL Bell · Kate Charlesworth · Forbes McGain

Women who undergo bariatric surgery should be managed in the perinatal period with a multidisciplinary team to improve pregnancy-related outcomes

Sarah Cheah · Yijun Gao · Shirley Mo · Georgia Rigas · Oliver Fisher · Daniel L Chan · Michael G Chapman · Michael L Talbot

We can give and consume seasonal sweets in hospitals with a clear conscience!

Dirk Stengel · Alexander Hönning · Stephan Just · Sven Mutze · Axel Ekkernkamp · Tobias Ohmann · Hajo Haase · Patric Kröpil · Leonie Gölz

A 31-year-old Caucasian woman presented to the emergency department with a 1-day history of vomiting and lethargy, but no other symptoms

Nardeen S Habashy · Hwang Tan · Emily J Hibbert

A 29-year-old Korean woman presented with a pruritic, reticulate, red-brown, papular eruption overlying her clavicle and neck, occurring in the setting of carbohydrate restriction

Blake P Mumford · Anita Lasocki

▪ Obesity is reaching pandemic proportions globally, with overweight or obesity affecting at least two‐thirds of Australian adults. ▪ Bariatric surgery is an effective weight loss strategy but is constrained by high resource requirements and low patient acceptance. ▪ Multiple endoscopic bariatric therapies have matured, with well established and favourable safety and efficacy profiles in multiple randomised controlled trials (RCTs), and are best used within a multidisciplinary setting as an adjuvant to lifestyle intervention. ▪ Three types of intragastric balloon are currently in use in Australia offering average total weight loss ranging from 10% to 18%, with others available internationally. ▪ Endoscopic sleeve gastroplasty produces average total weight loss of 15–20% with low rates of severe complications, with RCT data anticipated in December 2021. ▪ Bariatric and metabolic endoscopy is rapidly evolving, with many novel, promising therapies currently under investigation.

Dominic A Staudenmann · Zhixian Sui · Payal Saxena · Arthur J Kaffes · George Marinos · Vivek Kumbhari · Patrick Aepli · Adrian Sartoretto

In Australia, there is a paucity of coordinated strategies for preventing, detecting, and managing NAFLD

Lucy Gracen · Elizabeth E Powell

Objectives: To investigate the prevalence of non‐alcoholic fatty liver disease (NAFLD) and its risk factors in regional Victoria. Design: Prospective cross‐sectional observational study (sub‐study to CrossRoads II health study in Shepparton and Mooroopna). Setting: Four towns (populations, 6300‒49 800) in the Goulburn Valley of Victoria. Participants: Randomly selected from households selected from residential address lists provided by local government organisations for participation in the CrossRoads II study. Main outcome measures: Age‐ and sex‐adjusted estimates of NAFLD prevalence, defined by a fatty liver index score of 60 or more in people without excessive alcohol intake or viral hepatitis. Results: A total of 705 invited adults completed all required clinical, laboratory and questionnaire evaluations of alcohol use (participation rate, 37%); 392 were women (56%), and their mean age was 59.1 years (SD, 16.1 years). Of the 705 participants, 274 met the fatty liver index criterion for NAFLD (crude prevalence, 38.9%; age‐ and sex‐standardised prevalence, 35.7%). The mean age of participants with NAFLD (61 years; SD, 15 years) was higher than for those without NAFLD (58 years; SD, 16 years); a larger proportion of people with NAFLD were men (50% v 41%). Metabolic risk factors more frequent among participants with NAFLD included obesity (69% v 15%), hypertension (66% v 48%), diabetes (19% v 8%), and dyslipidaemia (63% v 33%). Mean serum alanine aminotransferase levels were higher (29 U/L; SD, 17 U/L v 24 U/L; SD, 14 U/L) and mean median liver stiffness greater (6.5 kPa; SD, 5.6 kPa v 5.3kPa; SD, 2.0 kPa) in participants with NAFLD. Conclusion: The prevalence of NAFLD among adults in regional Victoria is high. Metabolic risk factors are more common among people with NAFLD, as are elevated markers of liver injury.

Stuart K Roberts · Ammar Majeed · Kristen Glenister · Dianna Magliano · John S Lubel · Lisa Bourke · David Simmons · William W Kemp

Current regulations address product safety, but they do not adequately ensure accuracy of formula preparation and provision Breastmilk is the optimum source of nutrition for most infants born at full term. When breastmilk is unavailable or unsuitable, the only safe and nutritious substitutes are commercial infant formulas.1 Infant formula — predominantly powdered infant formula — makes a major contribution to infant nutrition in Australia, with the 2010 Australian National Infant Feeding Survey reporting that 34% of infants had been introduced formula in their first month of life, 45% by 2 months and 69% by 6 months of age.2 In Australia, infant formula products are regulated under Standard 2.9.1 — Infant Formula Products in the Australia New Zealand Food Standards Code (Std2.9.1IFPANZC).3 All commercially produced infant formula products available in Australia and New Zealand must comply with the composition and safety requirements outlined in the Code. Std2.9.1IFPANZC specifies the mandatory nutrient content for infant formula and follow‐on formula to ensure that nutrition requirements are met. The standard includes labelling requirements, specifically prohibiting various claims, images and symbols. While these regulations address product safety, they do not adequately ensure accuracy of formula preparation and provision. In particular, potential for error remains around formula powder reconstitution, given multiple differing brands with variable scoop to water ratios, and volume of feed for differing ages and body weights. In this article, we discuss the infant formula range available in Australia, the infant formula powder reconstitution variability and the potential impacts, and the variability of manufacturer feeding guides compared with recognised recommendations and potential implications. Formula brands and types In Australia, there are more than ten brands of infant formula from which to choose. Within each brand there are often minor variations, from standard formulas meeting basic Food Standards Australia New Zealand (FSANZ) formula composition guidelines through to manufacturer‐specified gold formulas and condition‐specific formulas (Supporting information, table 1). FSANZ guidelines describe the purpose of infant formula labelling as providing information to caregivers to make informed choices, as well as information about appropriate preparation and safe use of infant formula products. Under FSANZ guidelines, all infant formulas must meet essential nutrient requirements. Specific nutrient content and health claims are prohibited in Clause 3 of Standard 1.2.7.4 Despite regulation, there are often misleading names or ingredient claims on infant formulas which construe a health claim or benefit and create doubt or sway opinion in consumers. For example, “[trade name] constipation”, as a name of a formula may be assumed by a consumer to be a superior formula for babies with constipation. Similarly, a statement of “fish oil to help support brain and eye development” could potentially be interpreted by a consumer as a health claim. There is currently no unbiased, freely available source of information to help parents choose a formula and this is often the first point of confusion. The authors frequently encounter parents swapping formulas in response to their infant's behaviour, believing that another formula may offer benefit. Typical examples in clinical practice are changing from a standard term formula to a colic, antireflux, or casein‐predominant formula when there is irritability or spilling. Powdered formula reconstitution While infant formulas are made in liquid ready‐to‐feed and in powdered forms, the latter is predominantly used in the home. Under Std2.9.1IFPANZC, the labelling of a powdered formula product must include the powder to water reconstitution ratio to achieve the specified nutritional composition, and the weight of powder in one scoop. However, the Standard does not dictate scoop size and, consequently, the scoop to water reconstitution ratio is determined by the manufacturer, although the powder weight to water ratio is relatively constant between manufacturers. In Australia, there is significant variation in reconstitution ratios across brands. Australian infant formula dilution reconstitution ratios are most commonly either one scoop per 30 mL water, per 50 mL water or per 60 mL water. The choice between a smaller or larger ratio is manufacturer‐specific. Explanations company representatives have provided for choosing a smaller scoop to water ratio include being able to make up smaller quantities of formula, greater accuracy, and a reconstitution method that yields rounded number volumes of 100 mL. In contrast, companies with larger scoop to water ratios propose reduced risk of error in sleep‐deprived parents who might lose count of scoops. However, none of these justifications are evidenced‐based. While there is a general expectation that parents use the formula label instructions or community advice, brand changes enhance potential for parental miscalculation of formula concentration. Under Std2.9.1IFPANZC, all powdered infant formula products must carry a warning stating, “Warning — follow instructions exactly. Prepare bottles and teats as directed. Do not change proportions of powder except on medical advice. Incorrect preparation can make your baby very ill”.3 This warning is often not obvious, and in practice, we have observed parents swapping between formulas and either assuming that the scoop to water reconstitution ratio is the same, confusing the ratios between brands, or using the incorrect scoop with a different manufacturer's powder, resulting in incorrect formula concentration. A systematic review of five studies supports this observation, finding that significant errors may be made when reconstituting formulas.5 Incorrect dilution ratio results in a formula strength that is either too dilute, increasing risks of nutrient deficiencies and faltering growth, or too concentrated, risking hypernatraemic dehydration or excessive weight gain. A review of reconstitution recipes of the major brands of standard infant formulas reveals a formula powder to water ratio of 0.142–0.15 g/mL (Supporting information, table 2) and a narrow caloric strength range of 4.8–5.2 Kcal/g. Clearly, a standardised reconstitution recipe is possible. We propose that standardisation of reconstitution ratio of powdered infant formula to water would minimise error and risk while providing clarity for parents and health professionals. Formula feeding guides Infant feeding guidelines for health workers1 state that as a formula is designed to remain at a constant strength, it is the amount of formula that should increase as the infant grows. The guidelines outline approximate formula requirements for infants (Supporting information, table 3), which correlate appropriately with the estimated energy requirements of infants as outlined in the National Health and Medical Research Council (NHMRC) Nutrient reference values for Australia and New Zealand.6 The infant feeding guidelines also note that feeding guidelines on formula packaging recommending certain amounts for various ages are guides only and do not necessarily suit every infant.1 Manufacturers of commercial infant formulas usually include a feeding guideline on the formula packaging that outlines the number and volume of feeds recommended for the corresponding ages. This is not a requirement under the Food Standards Code. There is substantial inconsistency in the feeding guidelines for volume and frequency of feed by age printed on the containers (Box), both from one manufacturer to another and also compared with the NHMRC‐recommended volumes by age and weight. The lack of weight standardisation means that the caregivers of a small infant may overfeed, while a genetically larger infant might be underfed. Greater consistency or standardisation of manufacturer feeding guides that correlate appropriately with the NHMRC feeding guidelines may help reduce both over‐ and underfeeding as well as alleviate parental confusion and anxiety around feeding volumes. While both under‐ and overfeeding may have negative clinical consequences, there are no published data to support adverse outcomes as a common consequence of parental misunderstanding. The absence of published evidence, however, should be considered in the light of anecdotal experience of health professionals within our health service, who report spilling and irritability from overfeeding and parental anxiety when their baby does not achieve volumes stated on the formula tin. Expert opinion concurs with our own clinical experience, as shown by the 2018 guideline on gastroesophageal reflux issued jointly by the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPAGHAN), where the first step in management of an infant presenting with excess vomiting is to ensure that overfeeding is avoided.7 However, there is clearly a need for further study in the area of parental interpretation and use of the feeding guides provided on formula tins to determine the impact of variation in product labelling on health outcomes. Conclusion Infant formula is commonly used with a choice of brands and types of formula. There is limited access to unbiased advice on formula selection for parents, caregivers and health professionals who encounter feeding‐related problems in daily practice. In addition, there is a wide variation in reconstitution ratios of powdered infant formula due to differences in scoop sizes between manufacturers, which may contribute to error in formula concentration. Standardisation of reconstitution ratios is an opportunity to minimise error. Lastly, formula feeding guides provided on formula tins vary between companies and, by not accounting for weight, differ from NHMRC recommendations, which may lead to over‐ or underfeeding. Standardisation of formula feeding guides in line with NHMRC feeding guidelines, with clearer warning statements, may help reduce these risks. The absence of evidence as to the effectiveness and risks of current food and nutrition policy with respect to infant formula feeding is a significant gap in ensuring the safe care of infants both in our community and worldwide. We propose that this area becomes a future focus of public health research and advocacy for child health. Box – Standard infant formulas — manufacturer-suggested feeding volume(mL) and number of feeds per day juxtaposed as mL/kg/day for a 3rd centile female infant, 50th centile female infant and 97th centile male infant (World Health Organization growth data)

Shelley Farrent · Brian Coppin · Scott Morris

The number of tests for vitamin D deficiency in Australia rose steeply between 2000 and 2011, from 0.4 to 36.5 tests per 1000 population; the cost to Medicare increased from $1.1 million in 2000 to $95.6 million in 2010,1 and peaked at $151 million in 2012–13.2 Consequently, the Medical Benefits Schedule (MBS) items for testing (66608, 66609) were replaced in November 2014 by new items (66833–66837) with the aim of restricting testing to people at particular risk of vitamin D deficiency, including those with a history of osteomalacia or osteoporosis, elevated alkaline phosphatase levels, hyperparathyroidism, hypo‐ or hypercalcaemia, hypophosphataemia, malabsorption, chronic renal failure, deeply pigmented skin or chronic and severe lack of sun exposure, or a diagnosis of vitamin D deficiency, and people who used medications that reduce 25‐hydroxyvitamin D levels.3 The immediate effect of the new criteria was that the rate of vitamin D tests was 47% lower during 2014–16 than during 2013–14.4 However, the proportion of people tested who met none of the new MBS criteria increased from 71.3% to 76.5%, while the proportion with moderate to severe vitamin D deficiency increased only from 5.4% to 6.5%.4 Medicare data5 indicate that the testing rate has since increased, by 34% between 2015 and 2019, from 119 to 159 tests per 1000 population; the cost to Medicare rose 42%, from $73.7 million to $104.7 million (Box). The testing rate increased in all states; the rate for women increased by 30% (from 164 to 214 tests per 1000 population), and for men by 40% (from 74 to 105 tests per 1000 population) (Supporting Information, figures 1A,B). The most marked increases were for people aged 85 years or more, for whom the 2019 testing rate (women, 447 tests per 1000 population; men, 364 tests per 1000 population) exceeded the 2012 levels (women, 388 tests per 1000 population; men, 276 tests per 1000 population). Testing rates for people aged 0–25 years did not markedly change between 2015 and 2019 (Supporting Information, figures 1C,D). The Royal College of Pathologists of Australasia,6 like most medical authorities, does not recommend screening for vitamin D deficiency. The marked overall increase in testing since 2015 is not explained by changes in demographic or clinical factors, suggesting that at least some screening is unnecessary and that ordering doctors are either unaware of or do not support the new MBS vitamin D testing criteria. Evidence‐based guidelines6 and MBS policy, accompanied by education and audit activities, have failed to contain the level of vitamin D testing. Further, people who are socio‐economically disadvantaged or at particular risk of vitamin D deficiency, including Indigenous Australians, are still tested less frequently than other Australians.4 Finally, people at clear risk of vitamin D deficiency could be treated without testing, especially as the cost of supplementation ($2.25 per month) is only a fraction of that of a vitamin D test ($30.05). High quality research is needed to provide evidence for informing interventions that curb the use of low value tests in a health system that encourages a high volume of services, but not necessarily better value care. Box – Cost to Medicare of vitamin D testing (MBS items 66608 and 66609, 66833 to 66837), January 2000 – December 2019 MBS = Medical Benefits Schedule. Source: Medicare item reports.5 Our estimated rates for 2001 (2.3 per 1000 persons) and 2011 (140 per 1000 persons) differ from those estimated by Bilinski and Boyages1 using a different source of Medicare data. * The MBS items 66833 to 66837 were listed on 1 November 2014.

Louisa Gordon · Mary Waterhouse · Ian R Reid · Rachel E Neale

To the Editor: Rising obesity rates in high income countries have resulted in a growing demand for weight‐loss products.1 Unfortunately, drugs that increase energy expenditure often have severe adverse effects. 2,4‐Dinitrophenol (DNP) uncouples oxidative phosphorylation, inducing a hyper‐metabolic state. It was first used for weight loss in the 1930s but was banned due to deaths.2 It has recently had a resurgence in popularity in the body building/body sculpting arena as a “fat burner” and “pre‐event shredder”, and is available online and as an undeclared ingredient in supplements.1 DNP was up‐scheduled in Australia in 2017 to Schedule 10 (“substances of such danger to health as to warrant prohibition of sale, supply and use”).3 We used data from the New South Wales Poisons Information Centre (NSWPIC) and the National Coronial Information System (NCIS) to evaluate effects of up‐scheduling. Ethics approval was granted from the Sydney Children's Hospitals Network (LNR/16/SCHN/44) and from the Victorian Department of Justice (CF/15/18367) human research ethics committees. There were 24 DNP exposures reported to NSWPIC between 2004 and 2018, with an increasing trend (Box). Most patients (71%, n = 17) were male, 83% (n = 20) were adults aged 20–74 years, and 92% (n = 22) were in hospital or were referred to hospital by NSWPIC. The NSWPIC database showed one death — an adult man who had a cardiac arrest after taking four DNP capsules — and NCIS recorded three more deaths from DNP. All deaths occurred since 2015, with two occurring since the 2017 rescheduling. Despite up‐scheduling, we have identified rapidly increasing harms from DNP, which suggest a resurgence of DNP use. Increasing use and deaths have also been reported in the United Kingdom4 and the United States.5 This highlights the need for urgent action by state and federal law enforcement agencies and awareness campaigns targeting high risk groups. It is important to note that the Therapeutic Goods Administration makes scheduling changes but does not enforce non‐medicinal product restrictions, which is the role of police and Fair Trading. It is likely that DNP is frequently obtained online and often disguised for shipping (eg, labelled as turmeric), thus complicating detection.1 Increased incoming mail screening and awareness and education at gyms may be an option to restrain the use of DNP. Medical practitioners should warn patients of the dangers of illicit weight‐loss supplements. Box – Time trends in 2,4‐dinitrophenol exposures reported to the New South Wales Poisons Information Centre (NSWPIC) in 2004–2018. Up‐scheduling to Schedule 10 was announced in September 2016 and implemented in February 2017. The timing of deaths is censored due to low numbers; however, all deaths occurred since 2015, including two since the 2017 scheduling

Rose Cairns · Jacques Raubenheimer · Jared A Brown · Kylie McArdle · Nicholas A Buckley

To the Editor: Climate change is this century's greatest global health threat. As the MJA considers the role of the health care sector in climate change, we urge readers to consider hospital food environments. Australia's health care system should be promoting diets that are healthy for both humans and the planet. A growing body of evidence suggests that healthier human diets have significant environmental co‐benefits. For example, reduced consumption of processed discretionary foods and red meats and increased consumption of fruits, vegetables and legumes have been shown to reduce the risk of certain non‐communicable diseases while also reducing diet‐related greenhouse gas emissions.1,2 Hospital food environments provide a useful intervention point to model and promote healthy, sustainable diets to Australians, as millions of meals are served to patients and their families in hospitals each year. Hospital food retailer guidelines have recently been developed by state governments and health care providers.3,4 To optimise health care food environments, a first step is to remove fast food outlets, vending machines and sugar‐sweetened beverages from hospitals. Inpatient food guidelines, however, are mostly outdated and sustainability is rarely considered. Inpatient food services should prioritise the delivery of fresh, locally sourced, unrefined foods with minimal packaging. Meals should adhere to dietary guidelines, be personalised to patients’ health needs, and minimise food waste. A recent audit by the Victorian Government into inpatient food services may provide an important opportunity to initiate reform.5 The Mater Group hospitals’ “at your request” room service exemplifies a cost‐effective food service model, showing improvements in patients’ nutrient intake, clinical outcomes, food waste reduction and patient satisfaction.6 Australia can also learn from the growing number of global initiatives to improve hospital food, including the New Zealand Ministry of Health's sustainability commitments, which include recommendations to encourage plant‐based eating, sustainable food sourcing and reductions in food waste.7 We should also look to innovative programs such as hospital rooftop gardens, hospital teaching kitchens, and traffic light labelling systems. To protect the health of humans and the planet, we urge state governments and health care providers to urgently evaluate hospital food quality, inpatient food services and retail food environments and implement new mandatory standards.

Genevieve Moseley · Luke Spajic · Georgia Behrens

Self-reported wheat sensitivity was reported by 14% of respondents in both 2015 and 2018

Michael DE Potter · Michael P Jones · Marjorie M Walker · Natasha A Koloski · Simon Keely · Gerald Holtmann · Nicholas J Talley AC

The evidence suggests that calcium and vitamin D supplements should not be provided routinely to healthy older individuals

Ian R Reid · Mark J Bolland

To the Editor: Recreational misuse of nitrous oxide remains a significant public health problem,1 sustained in part by the ready availability online of gas‐containing canisters intended for use in the catering industry. Known as “nangs” or “whippits” and usually purchased in bulk, each canister contains 8 g of nitrous oxide. When inhaled, this gives a seconds‐long “high”, which is typically prolonged by using several “nangs” in a single session. Some individuals can consume hundreds each day. Prolonged exposure to nitrous oxide leads to the oxidisation of vitamin B12, rendering it unusable in key enzymatic reactions necessary for normal myelin synthesis.2 Over time, this leads to a potentially devastating neuropsychiatric syndrome that commonly presents with ataxia.3 Notably, the culprit shortage of vitamin B12 is a qualitative one and can be purely so, meaning that marked clinical deficits emerge in the presence of serum B12 levels that appear normal on standard laboratory assays. Furthermore, with continued exposure to nitrous oxide, these deficits will respond poorly to vitamin B12 supplementation. In a year‐long clinical audit at Royal Prince Alfred Hospital (2017–2018), seven nitrous oxide users, all aged between 20 and 30 years, presented with ataxia that ranged from mild to severe (Box 1). Most patients also had psychiatric symptoms. Nearly every patient estimated using 100 or more canisters of nitrous oxide per day in the months before being seen. Four patients also reported engaging in B12 supplementation (both oral and parenteral), aiming to circumvent the harmful sequelae of prolonged nitrous oxide misuse. Laboratory studies showed that all seven patients had accumulated homocysteine, as is usually seen when vitamin B12 is in short supply in the body.2 Individuals who reported taking supplements had serum B12 levels that were either normal or in excess of normal, implicating a qualitative deficiency of metabolically useful B12. Evidence of demyelination was seen on spinal cord imaging in six patients, including all those who used supplements, with the “inverted V” sign4 visible on T2‐weighted magnetic resonance imaging sequences (Box 2). Despite treatment according to best practice guidelines, all patients left hospital with persistent symptoms, and most were unable to walk or to attend to their bodily needs without the assistance of family members (modified Rankin score, 4). Sadly, one of the least affected individuals re‐presented to hospital with worsened symptoms because of continued nitrous oxide misuse. At every opportunity nitrous oxide users should be reminded of the futility of B12 supplementation, as one of many reasons why they should choose to avoid this profoundly destructive drug. Box 1 – Patients presenting with symptoms due to nitrous oxide misuse Age (years) Sex Canister use Duration of use B12 supplementation Ataxia severity* Psychiatric symptoms† Homocysteine level Serum B12 (active) MRI: “inverted V” sign‡ mRS: Day 1 mRS: discharge 20 Female 250/day 1 year No Severe Yes High Low (low) Yes 4 4 30 Male 60/day 1 year No Moderate Yes High Low (low) Yes 1 1 30 Male 100/day 6 months No Mild No High Low (normal) No 1 1 21 Male 200/day 1 year Yes Severe Yes High Normal (normal) Yes 4 4 23 Female 300/day 2 months Yes Severe Yes High Normal (high) Yes 4 4 23 Female 200/day 2 months Yes Severe Yes High High (high) Yes 4 4 28 Male 300/day 1 year Yes Mild No High Normal (normal) Yes 1 1 MRI = magnetic resonance imaging; mRS = modified Rankin score of neurological disability. * Ataxia: mild = visible gait disturbance; moderate = frequent falls; severe = inability to walk without assistance. † Psychiatric symptoms included mood disturbance, memory impairment and psychosis. ‡ MRI findings: “inverted V” sign on T2‐weighted MRI spinal cord imaging (Box 2). mRS: 0 = no symptoms; 1 = no significant disability despite symptoms; 2 = slight disability; 3 = moderate disability; 4 = moderately severe disability, unable to walk or attend to bodily needs without assistance; 5 = severe disability, bedridden; 6 = dead. Box 2 – T2‐weighted magnetic resonance imaging sequence showing “inverted V” sign, indicating the presence of dorsal column demyelination

Christopher Blair · Chris Tremonti · Leon Edwards · Paul S Haber · G Michael Halmagyi

The increasing age and obesity rates of the Australian population are contributing to the higher prevalence of patients with obstructive sleep apnoea presenting for surgery

Nicolette R Holt · Glenn Downey · Matthew T Naughton

Lessons from practice

Anthony M Whitfield · Ai Van B Tran Nguyen · Kashif Sheikh

The knownThe future pancreatic cancer burden attributable to tobacco smoking has not been estimated in Australia. The newNearly 22% of the future burden of pancreatic cancer is attributable to current and former smoking, 15% (5500 cases over the next 10 years) to current smoking alone. The smoking‐related burden of pancreatic cancer is markedly higher for men and for people under 65. The implicationsReducing smoking rates among men and people under 65 would have the greatest impact on reducing the future burden of pancreatic cancer in Australia.

Maria E Arriaga · Claire M Vajdic · Robert J MacInnis · Karen Canfell · Dianna J Magliano · Jonathan E Shaw · Julie E Byles · Graham G Giles · Anne W Taylor · Tiffany K Gill · Vasant Hirani · Robert G Cumming · R Paul Mitchell · Emily Banks · Julie Marker · Barbara‐Ann Adelstein · Maarit A Laaksonen

The known: Iodine deficiency re‐emerged in Australia in the 1990s, motivating mandatory fortification of bread with iodised salt in 2009.

Gurmeet R Singh · Belinda Davison · Gary Y Ma · Creswell J Eastman · Dorothy EM Mackerras