Circumcision is a simple surgical procedure in which the foreskin, which covers the tip of the penis, is removed. Whether a boy should be circumcised continues to be a subject of debate among parents and health professionals. While exact figures are not available, probably about one third of boys in Australia are circumcised, mostly in the newborn period, although the tendency for this procedure to be done is gradually decreasing.

Arguments for circumcision

1. Cultural or religious practice, for example in the Jewish or Muslim faiths.

2. Hygiene — a penis without a foreskin is easy to clean.

3. Medical reasons (see Foreskin, problems with the, opposite).

4. Prevention of certain conditions. Circumcision is said to decrease the risk of cancer of the penis, urinary tract infection, and perhaps sexually transmitted disease and cancer of the cervix in females although there is no hard evidence for these claims.

5.To be the same as father or peer group. The argument becomes less persuassiveas the number of circumcised boys decreases, and is probably not as important as once thought.

Arguments against circumcision

1. The procedure as performed in the newborn causes significant pain and behavioural changes, such as irritability, which can persist for some time (often days).

2. It is contraindicated if there is a medical condition such as a bleeding disorder or hypospadias, which is an anatomical abnormality of the tip of the penis.

3. There is a small but definite risk of complications, such as bleeding, infection, taking off too much or too little skin.

Ultimately, whether or not to circumcise their child is a decision for parents to make after considering the advantages and disadvantages. While circumcision for religious and cultural reasons continues, routine circumcision is performed less and less. If you are uncertain, you may want to discuss your doubts with the doctor.

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Many children suffer from pinworms (Enterobius vermicularis). These are thin, white parasites about 1 cm in length, which live in the digestive tract.

These worms can be seen wriggling on the surface of the skin surrounding the child’s anus, especially at night when the female worms emerge from the anal passage to lay their eggs. Children with pinworms complain of a very itchy anus (see p. 258) which may cause them to wake from sleep. Scratching often leads to reinfection because the child may put his fingers, which are contaminated with eggs, to his mouth.

Treatment

If you suspect that your child has worms, see your doctor who will prescribe anti-worm medicine or tablets. It is wise for the whole family to take these even if others do not have symptoms. Careful washing of hands after going to the toilet and before eating is important to prevent re-infection. Keep fingernails short. Wash all clothing and linen in hot water to destroy eggs, and vacuum or mop the bedroom floor to pick up any eggs that have dropped. Pets do not carry pinworms.

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In some children, toilet training seems extremely difficult. In a very small proportion of children, this may be due to an underlying developmental or medical cause. For example, children who have significant developmental delay will be trained at a later age than the average child because they will take longer to reach the neurological and mental capacity necessary for successful training. In rare cases, a child has an anatomical or neurological problem, or a urinary tract infection. A small number of children have difficulty in being trained because of constipation or chronic diarrhoea.

By far the main reason for difficulty in training is the interaction between the child and his parents. Whatever the characteristics of the child and parents that contribute to it, there is a power struggle going on and the more the parents try, the more the child resists. The only way out of this relatively common impasse is for the parents to opt out completely and transfer all the responsibility to the child. This is not easy to do, and often the parents may benefit from guidance provided by their family doctor or a paediatrician.

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So here’s what we can do about it. Read this section and make sure you are not ignorant about pain control. You will need to understand a fair bit about the use of painkillers yourself in order to get good pain relief. You may even have to teach your doctors and nurses something! I know it is frightening to think that your doctors and nurses may not know everything, but I believe you will be best able to deal with any pain you have if you accept this possibility. Those of you who don’t have this problem, whose doctors and nurses do understand how to use painkillers effectively, will probably still find this section helpful and interesting. For the rest of you, this section is absolutely essential.

If you are in a lot of pain right now, I suggest you ask a trusted friend or relative to read this section and help you to carry out some of my suggestions. You will have very little energy to spare until your pain is effectively treated, so ask for help.

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Vitamin E, which is one of the fat-soluble group, has been hailed as an aid to sexuality. Advertisements have stated or implied that it will improve a man’s potency, increase fertility or remove wrinkles.

As well, in this coronary-prone society, it has also been claimed to reduce arterio-sclerosis, or hardening of the arteries, and lower cholesterol levels in the blood.

While it has some famous people lauding its use, there is no worthwhile valid medical evidence that is acceptable to medical scientists to prove that it is of any use whatever.

Vitamin E occurs naturally in the germ of cereals and in green vegetables. An intake of 30mg a day is necessary for the development of red blood cells.

But its place in human nutrition and in the treatment of all those other situations is still very much in doubt.

Vitamin A is required for the proper nutrition of the skin and tissues of the eye. It also forms part of the chemical known as Visual Purple, which is necessary for clear vision in poor light.

It occurs in liver, dairy products and fish oils. It can be formed in the body from carotenes, which occur in green vegetables, carrots and apricots.

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It has been found that the brain produces chemicals similar to morphine. These are called endorphins. Regular exercise seems to increase the production of these chemicals and produce a feeling of wellbeing. Perhaps you can become hooked on your own endorphins.

But the picture is not all good. Those who are out of condition should begin slowly. Ligaments, joints and muscles become soft and flabby with lack of exercise and too sudden a strain by running on hard ground or doing too much too soon can lead to muscle and ligament strain.

If you are more than 35 and wish to start an exercise program, you should have a medical check before you embark on a get fit campaign.

It is recommended that those over 40 or 45 should have a stress test before starting to exercise regularly. This involves having an electrocardiograph during exercise to see if the effort of exercise reveals any evidence of heart abnormalities under stress.

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Breast cancer is the most common type of cancer in women.

A fifth of all cancers in women develop in the breast. Eventually one woman in 20 will develop breast cancer and in Australia 1600 women will die each year from it.

The cause of breast cancer is unknown.

Cancer of the breast is rare in men and also in women under 25. Its incidence is greatest in the age group 40 to 50. It is more common in the unmarried and the less fertile — just the opposite of the next commonest female cancer, that of the cervix or neck of the womb.

‘As with all cancers, the earlier it is found and treated the better the results.

Regular palpation or feeling the breasts can detect lumps, which can be further checked to see if they are cancerous.

The doctor should regularly feel his women patients’ breasts, but the woman can be taught to do this herself.

Not all lumps turn out to be cancer, but I believe a doctor should be consulted about any lump in the breast.

Biopsy is best carried out by frozen section. The lump is removed, then snap-frozen using carbon dioxide snow, cut into thin sections and examined under the microscope. An experienced pathologist can give an accurate opinion within minutes and if cancer is present the surgeon can go ahead and do the proper operation.

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I am saying that many practitioners who specialise in treating cancer routinely advise unpleasant treatment that is unlikely to produce any substantial benefit and that they persist in recommending various anti-cancer treatments right to the bitter end. These practitioners seem unable to recognise any point when the possible benefit for the person with cancer is too small to justify the ‘cost’ for the person with cancer of starting or continuing further treatment. I emphasise the words ‘for the person with cancer’ because I believe this is the key to understanding this behaviour. And let’s face it—the sorts of behaviour I have described could seem crazy to any observer with a bit of commonsense who knows what the treatments involve and how unlikely they are to produce any real benefit.

I believe the basic problem is that these practitioners do not act according to what is best for their individual patients. They behave like a conceited general whose soldiers are people with cancer, whose weapons are anti-cancer treatments and whose enemies are cancer and death. The general can observe the battles from a safe vantage point on a nearby mountain top. His aim is to win the battle, not to do what is best for his individual soldiers. Even when the odds are overwhelming and defeat certain, he refuses to give the order to surrender. The soldiers are not kept informed of the stage the battle is at nor given the opportunity to decide for themselves to surrender. The general will not order a surrender because this would mean admitting to his soldiers and to himself that he is not all-powerful and that he cannot control the enemy. He would rather that his soldiers die in battle than that they realise that there are limits to his power.

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Scientists have been studying what makes one food high and another low for more than fifteen years. There is a wealth of information that can easily confuse. We have summarised the results of their research in the following table which looks at the factors which influence the G.I. factor of a food.

The key message is that the physical state of the starch in the food is by far the most important factor influencing the G.I. value. That’s why the advances in food processing over the past two hundred years have had such a profound effect on the overall G.I. factor of the food we eat.

Amylose and amylopectin. There are two sorts of starch in food— amylose and amylopectin—and researchers have discovered that the ratio of one to the other has a powerful effect on the G.I. factor of a food.

Amylose is a straight chain molecule, like a string of beads. These tend to line up in rows and form tight compact clumps that are harder to gelatinise and therefore digest.

On the other hand, amylopectin is a string of glucose molecules with lots of branching points, such as you see in some types of seaweed. Amylopectin molecules are therefore larger and more open and the starch is easier to gelatinise and digest.

Thus foods that have little amylose and plenty of amylopectin in their starch have higher G.I. factors e.g. Calrose rice and wheat flour. Foods with a higher ratio of amylose to amylopectin have lower G.I. factors including Basmati rice and all sorts of legumes.

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RER (respiratory exchange ratio) measures, or the measure of fat and glucose utilisation, need to be looked at for intensity and duration of exercise both for fit and unfit (possibly fat) people, to gain a better appreciation of the appropriate form of exercise for those most likely to be carrying excess fat.

More vigorous exercise obviously burns more total energy in a given time period, but the graph shows that, at least in the unfit, under normal conditions (i.e. no excessively restricted energy intake), higher intensity exercise is likely to be less effective for fat loss. In other words, for an unfit person, the total amount of exercise at this intensity—even if it could be carried out by an unfit person—would not result in substantial fat loss. For a fit person, however, high intensity exercise is associated with fat burning.

Similar difference between the fit and the unfit can be seen, suggesting that the longer the effort—at least at moderate intensity—the greater the proportion of fat used in the energy cycle. In the unfit though, some of the research quoted above suggests that this may be true only up to a point, beyond which there is likely to be a decrease in fat utilisation and an increased reliance on glycogen. As fatigue sets in glycolysis plays a more important part, and glucose is thus likely to become more important as an energy source for the unfit.

These suggestions have been shown in practice in research by Dr David Kelly from the University of Pittsburgh.10 Kelly exercised obese people over a week for either 50 minutes at 70 per cent of their maximum capacity, or for 70 minutes at 50 per cent of their maximum. Both treatments resulted in exactly the same calorie expenditure. But the RER and total fat oxidation were higher for the longer, less intensely exercised group. Their total fat utilisation was estimated to be 24.5 grams for the 70 minutes, compared to 131 grams for the more intensely exercised group. Because fat utilisation is known to decrease in the unfit with duration of exercise, this suggests that for unfit people, fat utilisation would be even greater in the less intense group if the same time period (i.e. 50 minutes) was used for exercise.

All this suggests a change in thinking about the right parameters of exercise for fat loss in unfit (which include most fat) people. The FITT (frequency, intensity, time and type) mnemonic may be appropriate for improvements in fitness, but this needs to be modified for changes in fatness—at least in fat, unfit people.

Even this model has reservations when it comes to prescribing exercise for specific population sub-groups (women, older people, children etc.). Interestingly though, the new FATT factors also agree with the physical activity requirements for wider health gains. Several recent long term studies have shown that high intensity exercise is not necessary for health, or metabolic improvements, such as decreased risk of heart disease. Regular, low intensity, long duration activities can be sufficient to provide these improvements. Recently, it has also been shown that in obese people, short (10-minute) bursts of exercise, four times daily, are more effective in fat loss (and even in fitness gained) than continuous (40-minute) bouts. This is primarily because it is easier for obese people to comply with the demands of shorter bouts.

Myth-information. ‘Digital tummy trimmers’ are designed to force the abdominal muscles to contract against a tight belt. At best, this may increase some isometric muscle strength in the abdominals. It will have no effect on subcutaneous fat.

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