I
- 1 Letters I to the Editor
Letters are welcomed and will be published, iffound suitable, as space permits. The editors reserve the right to edit and abridge letters, to publish replies, and to solicit responses from authors and others. Letters should be submitted in duplicate, double-spaced (including references), and generally should not exceed 400 words.
Nutrition Intervention: Bigger is Better In a recent issue of the AJPH, there is an editorial by Dr. George Owen entitled "Nutrition Intervention: Bigger is Smarter," referring to an article by Freeman et al. in the same issue. In the Guatemalan context, perhaps this aphorism is reasonably appropriate. However, if viewed more widely, it is plainly not correct. Indeed, one of the problems in relation to anthropometry in children at the moment is to insure that it is realized that there is an optimum somewhere between subnormal and excessive. Perhaps the best encapsulation of the Guatemalan results is that "stunted is dull." However, plainly one cannot advocate suggesting that our goal in nutrition is to produce ever increasingly big children and adults. This problem was well exemplified by Gyorgy and Barness some years ago when they asked if our goals in infant feeding should be to produce "giants or dwarfs, Methuselahs or savants"? Perhaps with the current world shortage of space and food, it may begin to be appreciated that overlarge is both wasteful and not productive of super-intelligence. Optimal needs to be the goal, although elusive to define. Derrick B. Jelliffe, MD E. F. Patrice Jelliffe, MPH Division of Population, Family and International Health School of Public Health University of California Los Angeles, CA 90024 780
Author's Response It is my personal philosophy that all children should be afforded the opportunity to realize their full growth potential. Realization of that goal would, in my opinion, decrease the likelihood of impairment of brain growth which might reflect nutritional inadequacies in early life. I doubt that other readers will disagree with the use of the phrase ". . . Bigger is Smarter" in the context of the editorial and as a reply to a question posed earlier by the authors themselves. George M. Owen, MD Professor ofPediatrics, Nutrition University ofMichigan School of Public Health Ann Arbor, MI 48109
On Seeking Abortion Counseling We congratulate Dr. Mary Swigar and her associates at Yale for their investigation of women who seek abortion counseling and then decide to carry the pregnancy to term (AJPH, 67:142-156, 1977). This type of information is most helpful in broadening our understanding of women who seek abortion and those who choose term delivery. Her data will be helpful in fostering an atmosphere within abortion counseling which truly allows each patient to make an unpressured, informed choice regarding the outcome of her pregnancy. Dr. Swigar, et al., found that gestational age at the time of presentation proved to be an important predictor of whether a woman would continue her pregnancy or be aborted. Women presenting after 12 weeks' gestation were nearly two times more likely to carry to term than women presenting earlier. Dr. Swigar hypothesized that height-
ened perception of fetal viability and/or the more complicated labor-like abortion procedure might have led those women presenting later to decide against pregnancy termination. Selection bias was deemed unlikely since the characteristics of early and late presenters were similar among the group of women who carried to term. We believe a third factor may have potentiated the other two. If the woman seeking abortion was 13-15 weeks' pregnant, current tenets would have her wait another 2-4 weeks until her uterus was large enough for an abdominal amniocentesis.1 The imposition of this waiting period on women facing the often difficult choice of pregnancy termination may deter them from having an abortion; indeed, the interval may lead to the perception of fetal viability. Whereas a waiting period is necessary if the abortion is to be performed by intrauterine instillation of either saline or prostaglandin F2a (PGF2a), delay is not necessary if dilatation and evacuation (D&E) is used to terminate pregnancies for women presenting at 13 weeks' gestation or later. This method has been shown to be safe and effective in the Joint Program for the Study of Abortion/CDC.2 Thus, use of D&E would avoid the labor-like procedure inherent with either saline or PGF2a instillation, and by not requiring a delay, might minimize the likelihood of the woman experiencing fetal movement. Most women do not take the decision to terminate their pregnancies lightly, and once this decision has been made, a prolonged wait not only creates additional anxiety but also adds substantial risks of morbidity and mortality. We feel that, on balance, the waiting period during the 13-15 week interval is, therefore, unjustified. Willard Cates, Jr., MD, MPH David A. Grimes, MD AJPH August, 1977, Vol. 67, No. 8
- 1 Letters I to the Editor
Letters are welcomed and will be published, iffound suitable, as space permits. The editors reserve the right to edit and abridge letters, to publish replies, and to solicit responses from authors and others. Letters should be submitted in duplicate, double-spaced (including references), and generally should not exceed 400 words.
Nutrition Intervention: Bigger is Better In a recent issue of the AJPH, there is an editorial by Dr. George Owen entitled "Nutrition Intervention: Bigger is Smarter," referring to an article by Freeman et al. in the same issue. In the Guatemalan context, perhaps this aphorism is reasonably appropriate. However, if viewed more widely, it is plainly not correct. Indeed, one of the problems in relation to anthropometry in children at the moment is to insure that it is realized that there is an optimum somewhere between subnormal and excessive. Perhaps the best encapsulation of the Guatemalan results is that "stunted is dull." However, plainly one cannot advocate suggesting that our goal in nutrition is to produce ever increasingly big children and adults. This problem was well exemplified by Gyorgy and Barness some years ago when they asked if our goals in infant feeding should be to produce "giants or dwarfs, Methuselahs or savants"? Perhaps with the current world shortage of space and food, it may begin to be appreciated that overlarge is both wasteful and not productive of super-intelligence. Optimal needs to be the goal, although elusive to define. Derrick B. Jelliffe, MD E. F. Patrice Jelliffe, MPH Division of Population, Family and International Health School of Public Health University of California Los Angeles, CA 90024 780
Author's Response It is my personal philosophy that all children should be afforded the opportunity to realize their full growth potential. Realization of that goal would, in my opinion, decrease the likelihood of impairment of brain growth which might reflect nutritional inadequacies in early life. I doubt that other readers will disagree with the use of the phrase ". . . Bigger is Smarter" in the context of the editorial and as a reply to a question posed earlier by the authors themselves. George M. Owen, MD Professor ofPediatrics, Nutrition University ofMichigan School of Public Health Ann Arbor, MI 48109
On Seeking Abortion Counseling We congratulate Dr. Mary Swigar and her associates at Yale for their investigation of women who seek abortion counseling and then decide to carry the pregnancy to term (AJPH, 67:142-156, 1977). This type of information is most helpful in broadening our understanding of women who seek abortion and those who choose term delivery. Her data will be helpful in fostering an atmosphere within abortion counseling which truly allows each patient to make an unpressured, informed choice regarding the outcome of her pregnancy. Dr. Swigar, et al., found that gestational age at the time of presentation proved to be an important predictor of whether a woman would continue her pregnancy or be aborted. Women presenting after 12 weeks' gestation were nearly two times more likely to carry to term than women presenting earlier. Dr. Swigar hypothesized that height-
ened perception of fetal viability and/or the more complicated labor-like abortion procedure might have led those women presenting later to decide against pregnancy termination. Selection bias was deemed unlikely since the characteristics of early and late presenters were similar among the group of women who carried to term. We believe a third factor may have potentiated the other two. If the woman seeking abortion was 13-15 weeks' pregnant, current tenets would have her wait another 2-4 weeks until her uterus was large enough for an abdominal amniocentesis.1 The imposition of this waiting period on women facing the often difficult choice of pregnancy termination may deter them from having an abortion; indeed, the interval may lead to the perception of fetal viability. Whereas a waiting period is necessary if the abortion is to be performed by intrauterine instillation of either saline or prostaglandin F2a (PGF2a), delay is not necessary if dilatation and evacuation (D&E) is used to terminate pregnancies for women presenting at 13 weeks' gestation or later. This method has been shown to be safe and effective in the Joint Program for the Study of Abortion/CDC.2 Thus, use of D&E would avoid the labor-like procedure inherent with either saline or PGF2a instillation, and by not requiring a delay, might minimize the likelihood of the woman experiencing fetal movement. Most women do not take the decision to terminate their pregnancies lightly, and once this decision has been made, a prolonged wait not only creates additional anxiety but also adds substantial risks of morbidity and mortality. We feel that, on balance, the waiting period during the 13-15 week interval is, therefore, unjustified. Willard Cates, Jr., MD, MPH David A. Grimes, MD AJPH August, 1977, Vol. 67, No. 8
