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INSIDE HEALTH Programme 5. - Gestational diabetes, Low-carb diets, Needle pain

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TX:听 07.07.15听 2100-2130

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PRESENTER:听 MARK PORTER

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PRODUCER:听 ERIKA WRIGHT

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Porter

Coming up in today鈥檚 programme:听

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Cutting out the carbs to lose weight - is there something special about a low carbohydrate diet? It certainly seems to have worked for this Inside Health listener:

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Robbins

I used to catch my reflection in a shop window and not be able to look because I was a size with which I was unhappy.听 Now if I catch my reflection I think it鈥檚 my brother because he鈥檚 always been slim.

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Porter

More from the thinner Mark Robbins a little later.听 And I will be talking to a paediatrician about how a little thought can make childhood injections less traumatic - for all concerned.

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Baxter

Words like hurt, stick, pain, sting, pinch 鈥� all the words that mean something painful to a child reinforce that it鈥檚 painful.听 It鈥檚 much better to say a booster than a jab or a shot.

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Porter

But first gestational diabetes - that鈥檚 diabetes that develops during pregnancy. It is an increasingly common problem. And it鈥檚 an area that has attracted a fair amount of controversy recently after听 the UK adopted guidelines on diagnosing the condition that are out of step with much of the rest of the world. As a result some experts now believe as many as 1 in 10 affected pregnant women could be slipping through the net, putting them, and their babies, at risk.

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Around 1 in 14 pregnant women in the UK will develop gestational diabetes as the strain of the growing baby overwhelms the ability of their insulin to tightly control blood sugar levels. In a similar way to how being overweight can trigger the condition in the rest of us. Indeed the heavier a woman is the more likely she is to get gestational diabetes and it is more common in older mothers and among certain ethnic groups such as Asian and African Caribbean women.

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To find out more I went to the busy Rosie Maternity Hospital in Cambridge.

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Murphy

Hi Mark, my name鈥檚 Dr Helen Murphy, welcome to the Rosie Maternity Clinic.听 I鈥檓 in charge of the diabetes pregnancy service, so we look after, I think, about 250-300 women with gestational diabetes and about 50-100 women with pre-gestational, so with pre-existing Type 1 or Type 2 diabetes.听 And with Type 2 diabetes and gestational diabetes in pregnancy there鈥檚 a lot of overlap.听 For example, we know that women who get gestational diabetes in their pregnancies between 50 and 70% of them will go on to develop Type 2 diabetes.

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Porter

So this is a warning sign that they might well run into trouble later?

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Murphy

So that may well be the most important association of a diagnosis of gestational diabetes, it鈥檚 an early health warning for the woman that she鈥檚 really at risk of developing Type 2 diabetes.

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Vicky

My name is Vicky and I鈥檓 just back for my check after having Orla seven weeks ago.

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Porter

And Orla鈥檚 fast asleep and is she your first baby?

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Vicky

She鈥檚 my third.

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Porter

Is this the first time you鈥檝e had problems with sugar during the pregnancy?

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Vicky

No this was the second time.

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Porter

Right, so you鈥檙e a bit of an expert?

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Vicky

Yes.

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Porter

So you sort of knew that you were going to run into trouble again did you?

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Vicky

I did, I was expecting it and when I came for my blood test I already had signs and symptoms of having the diabetes.

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Porter

So what did you notice yourself?

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Vicky

Very thirsty, couldn鈥檛 quench my thirst at all.听 So that straightaway I thought I have the gestational diabetes again, so I wasn鈥檛 surprised when the results came back.

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Porter

So having had diabetes during pregnancy has that changed your diet and lifestyle at all in between?

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Vicky

It makes me very wary of what I eat and the children as well because obviously I don鈥檛 want to pass the same kind of condition down the line to them, so making sure that as much as I love my chocolate I limit it.

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Porter

Well we all love chocolate.

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Pearson

So my name is Carla Pearson and I鈥檓 one of the diabetes specialist dieticians and I work in diabetes in pregnancy.听 The main dietary advice is surrounding carbohydrates, so carbohydrates covers all foods that are starchy and sugary because the body will break all of them down and absorb them as sugar or glucose which will then impact the blood glucose levels.听 So, for example, we recommend switching to the forms of carbohydrate that are less refined and that have higher fibre, so an example of this is moving from white break over to whole grain or granary bread.听 And then this helps to slow the rise of the blood glucose levels so that the ladies are much more likely to be able to manage that.

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Porter

And generally I would imagine that pregnant women are pretty motivated, it鈥檚 not just their healthy they鈥檙e looking after鈥�

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Pearson

Absolutely, yeah most definitely.

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Porter

鈥� they鈥檝e got a baby as well.听 So are they very good at following the guidance?

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Pearson

It鈥檚 often a little bit of a shock, we do have a few ladies that find it quite difficult but once you work with them and talk through their diets they鈥檙e generally really motivated.听 And because they do the finger prick blood glucose test an hour after they鈥檝e eaten it gives them a result so they can see how well they鈥檙e doing and again I think that helps to motivate them and they become their own experts.

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Porter

Because if they know if they鈥檝e done something wrong they can actually see the impact on鈥�

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Pearson

They can and so they learn from that quite quickly.

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Porter

Here at the Rosie with its specialist team 7 out of 10 women have their diabetes controlled by diet and exercise, only 3 out of 10 have to take medication.听 Diagnosing and treating gestational diabetes reduces complications when women give birth.

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Murphy
Picking up and treating gestational diabetes reduces the amount of weight that women gain during pregnancy, less gestational weight gain is then associated with less problems like blood pressure and preeclampsia in the pregnancy.听 And then for the baby it鈥檚 associated 鈥� if the mother has a higher blood sugar level that causes the baby to make more insulin and then babies that make more insulin grow more rapidly and become more overweight or obese themselves.听 So those overweight babies are more likely to be delivered instrumentally, so they may need a forceps or a ventouse delivery or they鈥檙e more likely to be delivered by caesarean section.

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Porter

Well I鈥檝e come upstairs to the delivery suite where Nadia in just a couple of hours will be having her second baby by caesarean section.听 It鈥檚 hot and a fan is working full blast to keep the room cool.

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You鈥檙e looking very calm.

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Nadia

Yeah it鈥檚 nice to kind of have a plan and something to focus on, yeah.

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Porter

So you didn鈥檛 have a problem with diabetes, that you know of, during the first pregnancy, it was picked up during this second pregnancy鈥�

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Nadia

That鈥檚 right.

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Porter

鈥� at what stage?

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Nadia

So about 28 weeks.

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Porter

How did you feel about that?

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Nadia

Anxious but then the penny sort of dropped because of the large baby last time round, it was a fairly traumatic delivery last time round so I wanted 鈥� if there was any way of avoiding that this time round that had to be a good thing.听 And gestational diabetes is something that can increase your chance of having a big baby.

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Porter

And a couple of hours after we left her Nadia had a baby boy weighing seven pounds five ounces and both mother and baby are doing well.

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Hopefully for Nadia, as with most women, her gestational diabetes will disappear now that she鈥檚 given birth but specialists like Helen Murphy insist that once it鈥檚 gone women can鈥檛 drop their guard.

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Murphy

We normally remind women that when they celebrate their baby鈥檚 birthday that鈥檚 a really good time to have a glucose test.

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Porter

And that鈥檚 because the extra load put on their metabolism by the pregnancy mirrors what might happen to them later on in life anyway.

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Murphy

That鈥檚 exactly right, so we know they鈥檙e on the trajectory, they鈥檙e on the path to developing Type 2 diabetes and we also know that there鈥檚 good evidence that you can intervene early in that path and prevent it.听 You can reduce their risk of diabetes by 50-70% either by diet and lifestyle or by a tablet, a very easy tablet called metformin.

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Porter

Are there any implications for baby鈥檚 physiology, I mean once he or she is born does it matter that they鈥檝e been exposed to high sugar levels?

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Murphy

Very much so, so we know that babies who are either born too small or too large are themselves at risk of developing complications in later life.听 And we know the government and the NHS are working really hard to tackle obesity, but it鈥檚 increasingly important that we need to start that during pregnancy.

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Porter

The gold standard test for gestational diabetes is typically done between 24 and 28 weeks of pregnancy, and involves measuring how a woman鈥檚 blood glucose levels respond to drinking a sugary drink. But how her doctors interpret that result depends on which guidelines they follow. And the UK has been accused of being out of step with much of the rest of the world after the National Institute for Health and Care Excellence - NICE - published new guidance earlier this year using a higher threshold than the one adopted by the World Health Organisation.

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And that difference in thresholds has a significant impact on the number of women identified as having a problem. New research just published by a team from The Rosie Hospital estimates that as many as 4,000 women who would have received a diagnosis of gestational diabetes under the World Health Organisation criteria, fall through the net under the new NICE rules. Dr Claire Meek was one of the authors.

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Meek

Theoretically you might think these ladies would be at the milder end of the spectrum because they have blood sugar levels that might be considered borderline.听 However, our recent research shows that these women actually are quite high risk, they are at risk of having babies that grow excessively large and have problems during delivery and they鈥檙e also at risk of having caesarean sections rather than being able to deliver the babies normally.听 One of the concerns is that these ladies are high risk but they don鈥檛 know they鈥檙e high risk and their care givers don鈥檛 know that either.听 And that removes the possibility of intervening and being able to improve outcomes in these people.

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Porter

So effectively what your research showed was that 1 in 10 women with gestational diabetes in the UK currently aren鈥檛 being picked up?

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Meek

That鈥檚 true.

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Porter

Setting thresholds between what鈥檚 normal and what鈥檚 worrying is always difficult in medicine, but why is there this difference between what we use in this country thanks to NICE and what鈥檚 being used abroad?

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Meek

So the criteria that are used abroad are based on looking at women and identifying the risks of a range of complications, both complications related to the women and related to the baby.听 However, the NICE guidelines actually view the cost of the whole endeavour to UK taxpayers and so the NICE guidelines are built around cost effectiveness and making sure that the money spent gets outcomes improved.

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Porter

But according to your research these women are potentially high risk and therefore 鈥� I mean forgetting the human cost 鈥� there鈥檚 probably quite a cost to the NHS as well.

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Meek

Well we think that and actually these group are relatively understudied and so it is evident that NICE will not have had access to all that much information about them.听 But that actually doesn鈥檛 mean that it wouldn鈥檛 be cost effective to treat these women and actually our studies show that certainly for women in our hospital we would have to treat six women to improve an outcome for one of them.听 And that actually, in our view, very much worth doing.

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Porter

So do you think NICE has made a mistake?

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Meek

I think the NICE guidelines are a huge piece of work and they involve looking at countless medical studies.听 Our research is now available and we are using it to inform our practice here in this hospital.听 And certainly our plan is to remain with the international criteria for diagnosis.

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Porter

And that鈥檚 what you do at this clinic?

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Meek

That鈥檚 right.

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Porter

Do you think NICE, in light of your research, do you think NICE should change their recommendation?

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Meek

I think we would like to see more evidence of cost effectiveness of treating these women and if that evidence was available then I think NICE would be in a position to change their guidance.

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Porter

Claire, what about the criticism that you may be over-diagnosing women with diabetes?

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Meek

This is a great concern to many people involved in diabetes in pregnancy research.听 However, I鈥檓 not really sure what women think about the risk of over-diagnosis and my personal view is that women would rather have the knowledge about their risk status during pregnancy and have the opportunity to do something about that.

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Porter

Dr Claire Meek.

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I put Claire鈥檚 concerns to Professor Rudy Bilous. He runs the Diabetes in Pregnancy service at the James Cook Hospital in Middlesbrough, and chaired the development group at NICE that produced the new guidance.

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Bilous

What we did at NICE was not quite as Claire describes it.听 We didn鈥檛 set out to limit cost, what we set out to do was to identify the risk of these adverse outcomes depending on what level of blood glucose you took in the mum.听 Then we looked at randomised control trial evidence of the impact of treatment of those women and how many cases you might be able to prevent of these serious pregnancy outcomes and then we related that to the number of women we would have to screen and the cost effectiveness of preventing one of these serious outcomes.听 And that came out with our thresholds of a fasting glucose of 5.6 and a two hour post-glucose load of 7.8.听

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Porter

But what she did identify was that those 4,000 women, those extra 4,000 women if you like, were at quite significant risk, I mean there were some problems amongst them.

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Bilous

First of all the 4,000 figure we have to be a little careful about that because in Cambridge they adopted a universal screening programme which a lot of studies, both in the US and in the UK, have not been shown to be really cost effective.听 So we鈥檙e not looking at the same women in the NICE guidance and the Cambridge study, so it鈥檚 jolly hard to project the Cambridge findings to the overall UK population because they used a quite unique to them sampling and selection criteria.听 So the 4,000 I think we have to be a little bit careful about.

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Porter

What about the fact that clinics in renowned hospitals like Cambridge are using a different set of criteria, they鈥檙e sticking with the international criteria instead of adopting the new NICE guidance, does that bother you?

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Bilous

Well I mean that鈥檚 clearly an issue for the Cambridge hospital and their commissioners and so on and if you like they鈥檙e using criteria which are more stringent than the NICE criteria.听 There will be a cost for that and that鈥檚 something that they will have to negotiate locally.听 When we looked at the data we did think long and hard about what the international implications might be of us adopting criteria which were a little bit out of step.听 But you have to remember that the criteria for WHO are based upon associative outcomes, not based upon interventions or any estimate of cost benefit.听 The NICE guidance is, we think, at the state of play at the moment with all of the information that we have at the present time the most cost effective definition of gestational diabetes for the UK population.

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Porter

But you are confident that under the current NICE guidance a woman who has gestational diabetes that both her health and that of her child are best protected under the current guidance?

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Bilous

Gestational diabetes is defined by the blood glucose threshold so if you go to Cambridge they will clearly define gestational diabetes in a different way.听 We are saying that on the current best analysis, and that鈥檚 looking at cost effectiveness, at clinical effectiveness, harm to the woman, safety for the woman and for the baby, at the criteria that we鈥檝e adopted we think gives the best balance between risk and benefit for the mum and the baby.

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Porter

Professor Rudy Bilous.听 And there are links to both sets of guidelines - from NICE and the World Health Organisation - on our website. Please do get in touch if there鈥檚 a health issue that鈥檚 confusing you, you can e-mail us via insidehealth@bbc.co.uk or tweet me @drmarkporter

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Mark Robins from Southampton e-mailed to ask about something related to the diabetes theme - namely the weight loss properties of low carb diets.

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Robbins

I yo yo dieted for years and I tried many different ways 鈥� over exercising, starving myself, taking medication that reduced the uptake of fat in the gut which got a bit messy 鈥� and I started to think that this was simply how I was made and I had to just come to terms with the fact that I was unhappily large.听 My son would say come and play football in the garden dad and I would say oh I can鈥檛.听 So it was very frustrating.

Porter

Mark lost nearly four stone over the past year after switching to a low carb diet. He completed the Southampton half marathon in April and is now looking to enter a triathlon.

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Robbins

For me the low carb way of eating means I鈥檝e got my body back and I鈥檓 happy in my skin.听 I used to catch my reflection in a shop window and not be able to look because I was a size with which I was unhappy.听 Now if I catch my reflection I think it鈥檚 my brother because he鈥檚 always been slim.听 And now I am too.

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Porter

Well to discuss the evidence behind low carb weight loss diets, Inside Health鈥檚 Dr Margaret McCartney and Susan Jebb, who鈥檚 Professor of Diet and Population Health at the University of Oxford.

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Jebb

Well carbohydrates account for about half of our overall diet.听 They form into two broad categories, there鈥檚 the things we used to call starchy carbohydrates 鈥� bread, pasta, potatoes, rice, cous cous, bulgur wheat 鈥� those sorts of things.听 And then there鈥檚 the simple carbohydrates, things like sugars in all the variety of different forms that they come in the diet, whether that鈥檚 sugar in the sugar bowl or it鈥檚 fructose in fruit or it鈥檚 lactose in milk, a whole range of different kinds of sugars.

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Porter

And what鈥檚 the connection between the two, if I eat a starchy carbohydrate is it broken down into the simpler forms?

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Jebb

That鈥檚 absolutely right.听 When we digest the starchy carbohydrates our bodies split them up with some enzymes which break them down in to their constituent sugars.听 And for some carbohydrates, things like white bread for example, they鈥檙e broken down incredibly quickly.听 And so if you look at the change in your blood sugar levels after white bread versus after a sugary drink it鈥檚 almost exactly the same.听 But of course some types of carbohydrate are unrefined, they鈥檙e the whole of the grain, so they鈥檝e got all the bran in there as well, which gives them lots of extra fibre and that鈥檚 a really important distinguishing characteristic.听 So the high fibre types of carbohydrates, in general, tend to be rather better for our health, much more slowly digested, than the highly refined carbohydrates.

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Porter

You talk about roughly half our intake, in terms of calories does that mean we should be getting around 50% of our calories from carbohydrates, is that deemed to be healthy?

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Jebb

That鈥檚 the recommendation which is made both in the UK and indeed by the World Health Organisation.

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Porter

So what do we mean by a low carbohydrate diet, as a scientist what would you consider to be low carb?

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Jebb

If you鈥檙e having about 50% of your energy as carbohydrate that鈥檚 going to give you around about 250 grams of carbohydrate each day.听 The low carb diets, which are promoted, often recommend consuming as little as 20 grams a day of carbohydrate.听 Sometimes they're a little bit more generous later on, they let you increase it slightly but it鈥檚 very rare to see a low carbohydrate diet which is more than about 100 grams of carb a day, or at least that鈥檚 what they recommend.

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Porter

Now let鈥檚 move on to the evidence.听 Margaret, are you impressed by the evidence for low carb diets in terms of weight loss, I know you must have seen lots of people who鈥檝e managed successfully to lose weight on it in your consulting room, I certainly have?

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McCartney

A question I鈥檓 asked time and time again 鈥� what is the best diet for me, how can I lose weight.听 And one of the really big problems from so many studies about diet and nutrition is that they don鈥檛 tend to look in the long term, so a lot of studies will look at three months, six months, a year is a pretty long study in terms of the current literature, but you don鈥檛 often get studies that are looking at three years down the line, five years down the line 鈥� what makes the difference.听 So there is quite a lot of evidence around weight loss in terms of a year at least and there was a very comprehensive meta-analysis, a study that looked at all the evidence, on types of diet that was published in the Journal of the American Medical Association last year.听 And it looked really to compare whether or not a low fat diet compared with a low carbohydrate diet was best.听 And what they basically found was if you could stick to them they more or less worked the same, which was pretty well.

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Porter

Is that your take on the evidence in general Susan?

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Jebb

Absolutely, the best diet is the one you can stick to.听 And actually adherence is the key feature.听 And for some people it鈥檚 easier just to say I鈥檓 going to cut out carbohydrates, it鈥檚 one relatively simple rule to follow.听 Other people actually find that far too inflexible, they want the variety in their diet that comes from eating carbohydrates and they prefer just to eat a bit less of a whole range of things.

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Porter

Is there a scientific reason, a rational explanation, as to why going on a low carb diet might make weight loss easier, or is just simply calorie restriction?

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Jebb

As far as we can tell it鈥檚 just calorie restriction.听 When you do the controlled metabolic studies where you feed people the same number of calories but you just change where those calories come from the effect on weight is pretty well identical.

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McCartney

Just to pick up on Susan鈥檚 point about the diet you can stick to.听 There was a really super study published in the annals of Internal Medicine recently and they took a group of dieters and put them head to head, it was obese over a year, and they compared low fat diet to low carb diet and these people had regular reviews from dieticians, they had one supplementary food per day, so they wouldn鈥檛 have a full meal, they would have a food supplement instead, they were coached, they were encouraged and the analysis over the year showed that as time went on people could stick to it less and less.听 And that鈥檚 the really important thing the diet that will work is the sensible diet that you can stick to.

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Porter

Well Mark Robbins, our listener, lost four stone or nearly four stone in less than a year on a low carb diet, he鈥檚 very pleased, obviously worked for him, but what about the health implications, is there a problem with following a low carb diet from a health point of view, might people get it wrong in some way?

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Jebb

If people were sticking to a low carbohydrate absolutely resolutely and consuming less than 20 or 50 grams of carbohydrate a day I would start to worry that they might miss out on some of the essential vitamins and minerals that we generally get from carbohydrate rich foods.听 But in particular I鈥檇 be concerned about the lack of fibre in the diet.听 Cereal fibre is what really keeps our gut healthy and functioning well.听 But you know the truth is that very few people stick to low carb diets quite, quite that rigorously.听 Even if you鈥檙e losing four stone in a year you can probably do that by having a moderate amount of carbohydrate in your diet, particularly if you鈥檙e choosing those fibre rich varieties.

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Porter

Because the other concern has been historically that if you鈥檙e following a low carb diet 鈥� I鈥檓 thinking of the Atkins diet, that sort of diet 鈥� that you can have a massive fry up for breakfast because it hasn鈥檛 got any carbs in it but it鈥檚 got lots of fat and things that might not be so good for you.

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Jebb

Again if you have too much saturated fat then you may well get adverse effects on your blood cholesterol levels.听 But in general what鈥檚 shown over the short term that these studies have been done is that the weight loss that comes probably offsets that increase in cholesterol.听 But in the longer term, as Margaret says, you鈥檝e got to take a much, much more holistic view.听 And the fact is we need to constrain calories, not have too much saturated fat, make sure you鈥檙e getting a bit of fibre in as well and that鈥檚 going to give you the foundation for a healthy diet and one which will help you to lose weight too.

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Porter

Is there any truth that by restricting your carbohydrate intake, which is an important source of energy for the body, that your body has to somehow work harder using other forms of energy, it鈥檚 less efficient and that鈥檚 why you lose weight?

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Jebb

No.

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Porter

No.

听

Professor Susan Jebb with possibly the shortest answer we鈥檝e ever had on Inside Health.

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Here is another question - this time it鈥檚 for you.

听

How often have you said 鈥淥oh it will only sting a bit鈥� or 鈥渏ust a little pinch鈥� when taking you鈥檙e taking your child for their immunisations? Or, if you are a healthcare professional, when you have been injecting them? I know I have used both plenty of times. But this is exactly what we shouldn鈥檛 be saying, according to new research by American paediatrician Dr Amy Baxter, who has found that not only is a fear of needles becoming more common in children, but that it is also likely to have a significant impact later in life.

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Baxter

Right well what we found was that if children only got two injections at once then only 9% of them were afraid five years later but if they got four jabs on the same day 42% of them were afraid.听 And then I followed them to see if they got their HPV vaccine and if they were in the severely afraid group they were two and a half times less likely to start their vaccine series, even though they were only 12 or 13 at that time.听 So in theory their parents should have been the ones making the call.

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Porter

What about parental behaviour, how does that influence all of this because I mean children are very good at picking up on cues from the parents?

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Baxter

That鈥檚 a great question and it sort of hinges on what we can do better.听 Fifty percent of a child鈥檚 distress is predicted by their parents鈥� behaviour.听 Warm versus cool behaviour on the part of the parents and authoritarian and firm versus wishy washy or passive.听 And the children do best when they have a warm but firm parent.听 So if the parent鈥檚 like 鈥� Yeah I understand being worried but we鈥檙e going to make this more comfortable and it鈥檚 something that鈥檚 going to make you healthy.听 So putting it together with a firm guidance that doesn鈥檛 leave any room for wiggling out of it but also is warm and understanding.

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Porter

Okay looking at it from the other side of the desk, what should the doctor, nurse or healthcare professional be doing?

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Baxter

Well the important thing is to realise that the pain that happens does have effects down the road.听 And there are several different things that can make it better for the child.听 One is just to acknowledge and work with the parent.听 The parent knows their child the best.听 So there鈥檚 something called position of comfort, rather than holding someone down which causes my stress, more fear, encouraging the child to sit in a comfortable position on their parent鈥檚 lap.听 The other thing is that if you look at distress for a child it鈥檚 the fear of the experience, it鈥檚 what they鈥檙e focused on during the experience, as well as the actual feeling or pain of the experience itself.听 So nurses can give, for younger children, give the most painful injection last.听 Now the UK does something that鈥檚 better than in the US because you鈥檝e got the five in one that was introduced in 2004 and that dramatically reduces鈥�

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Porter

Combination vaccine.

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Baxter

鈥� right, reduces the number of jabs, which seems to be the important thing.听 Parents can also bring with them something to distract the child and it turns out that visual distraction like counting, finding things, is one of the most active and best ways to distract and the doctors鈥� offices can support that by having posters or pictures that have countable items on them.

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Porter

Are there some common mistakes that parents or healthcare professionals might be making at the moment that are actually making things worse inadvertently for their children?

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Baxter

Right, so language has been studied and words like hurt, stick, pain, sting, pinch 鈥� all the words that mean something painful to a child reinforce that it鈥檚 painful.

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Porter

It鈥檚 only going to be a little sting or a little pinch.

听

Baxter

Exactly, now you want to be honest and say well you may be getting a booster but it鈥檚 much better to say a booster than a jab or a shot.听 Certainly threatening 鈥� you鈥檇 better sit there and be still or this is really going to hurt is not an appropriate approach.

听

Porter

Dr Amy Baxter.

听

Just time to tell you about next week when I visit Europe鈥檚 largest robotic pharmacy. And we investigate female hypoactive sexual desire disorder. What is it, and where did it come from? Is it a new diagnosis that will transform the sex lives of millions of women, or a contrivance that medicalises normality to boost drug company revenues? Join me next week to find out.