Children's bone health, calcium and vitamin D--how much do nurses and health visitors know?

Two focus groups of health visitors, practice nurses and community nursery nurses were held to find out how much health visitors and nurses know about children's bone nutrition, and whether they are able to identify dietary sources of these nutrients. Results showed that these professionals spend a significant part of their time giving nutritional advice about children and young people and answering questions on a range of dietary matters. They were well informed about the importance for bone health of calcium, vitamin D, exercise and a healthy, balanced diet. The biggest misconception was that dairy products in the UK contain vitamin D. Most of the professionals knew that bone strength develops quickly during childhood, and some that it does so in adolescence but few were aware that 90% of the full genetic potential for bone strength is achieved before adulthood. The groups reported confusion over the Government's initiatives for vitamin D supplements, and lack of guidance from Primary Care Trusts on making Healthy Start vitamins available at clinics for mothers and babies. Overall, health visitors and nurses have a good knowledge of bone health but there are gaps and more educational resources are needed, including on dietary sources of vitamin D. The Government needs to give clear guidelines about its initiatives for vitamin D supplements for mothers and children aged under five years. It is disappointing that the Dairy Council's 3-a-Day message on meeting essential calcium needs through three daily servings of dairy foods has not got through.     

Which health information systems for the evaluation of health actions?

The evaluation of health actions requires large amounts of information allowing an assessment of relevance, coherence, efficacy, efficiency and impact of these interventions. Information systems should support evaluation processes by helping to obtain pertinent indicators, tracers and standard operating procedures. To reach this objective, specific functions need to be implemented, including traceability, documentation, investigation and scientific awareness. But this supposes that health information systems respect quality criteria that this article defines. The following criteria are considered: simplicity, validity, acceptability, informative value, representativeness, continuity, reactivity, fluidity, flexibility of the system, and also confidentiality of information. The historical developments of medical informatics have induced the creation of independent information systems, answering to specific objectives. This lack of integration is an obstacle to the evaluation of health actions because of the difficulty to view transversally and longitudinally the sequence of actions for a same patient. Thus integrated health information systems, organised around patient care episodes, are necessary to support evaluation and to contribute effectively to decision making in public health, because the evaluation of health actions implies the availability of information about the individuals who are the targets of these actions.     

Dietary influences on bone mass and bone metabolism: further evidence of a positive link between fruit and vegetable consumption and bone health?

BACKGROUND: The role of nutritional influences on bone health remains largely undefined because most studies have focused attention on calcium intake. OBJECTIVE: We reported previously that intakes of nutrients found in abundance in fruit and vegetables are positively associated with bone health. We examined this finding further by considering axial and peripheral bone mass and markers of bone metabolism. DESIGN: This was a cross-sectional study of 62 healthy women aged 45-55 y. Bone mineral density (BMD) was measured by dual-energy X-ray absorptiometry at the lumbar spine and femoral neck and by peripheral quantitative computed tomography at the ultradistal radial total, trabecular, and cortical sites. Bone resorption was calculated by measuring urinary excretion of pyridinoline and deoxypyridinoline and bone formation by measuring serum osteocalcin. Nutrient intakes were assessed by using a validated food-frequency questionnaire; other lifestyle factors were assessed by additional questions. RESULTS: After present energy intake was controlled for, higher intakes of magnesium, potassium, and alcohol were associated with higher total bone mass by Pearson correlation (P < 0.05 to P < 0.005). Femoral neck BMD was higher in women who had consumed high amounts of fruit in their childhood than in women who had consumed medium or low amounts (P < 0.01). In a regression analysis with age, weight, height, menstrual status, and dietary intake entered into the model, magnesium intake accounted for 12.3% of the variation in pyridinoline excretion and 12% of the variation in deoxypyridinoline excretion. Alcohol and potassium intakes accounted for 18.1% of the variation in total forearm bone mass. CONCLUSION: The BMD results confirm our previous work (but at peripheral bone mass sites), and our findings associating bone resorption with dietary factors provide further evidence of a positive link between fruit and vegetable consumption and bone health.     

Going beyond health efficiency: What really matters?

Both citizens and policymakers demand the best possible results from a country's healthcare system. It is of utmost importance to accurately and objectively assess the efficiency of a healthcare system and to note the key indicators, where resources are lost, and possibilities for improvement. This paper evaluates the efficiency of health systems in 38 countries, mainly members of the Organization for Economic Co-operation and Development, using data envelopment analysis (DEA). In the first stage, bootstrapped Ivanovic distance is used to generate weights for the indicators, thus taking into consideration different country's goals, but not to the extent of reducing the possibility of comparison. The analysis shows that human resources are the most important health system resource and countries should pay special attention to developing and employing competent medical workers. The reorganization of human resources and the funds allocated to them could also increase efficiency. The second stage examines environmental indicators to find the causes of inefficiency. No proof is found that any one basic health system funding model produces better health outcomes than the others. Obesity is identified as a major issue.     

Does vitamin D during pregnancy impact offspring growth and bone?

During pregnancy, maternal and fetal Ca demands are met through increased intestinal Ca absorption. Increased Ca absorption may be more dependent on oestrogen's up-regulation of Ca transport genes than on vitamin D status. Numerous studies, however, have found that severe vitamin D deficiency with secondary hyperparathyroidism during pregnancy leads to abnormal Ca homoeostasis in the neonate. Some, but not all, studies of maternal vitamin D supplementation during pregnancy find a greater birth weight among infants of mothers with adequate vitamin D status. Observational studies find a higher incidence of small-for-gestational age (SGA) infants among mothers who are vitamin D deficient, but this effect may be modified by genetics. In addition, the effect of vitamin D status on SGA may not be linear, with increased occurrence of SGA at high maternal 25-hydroxyvitamin D (25-OHD) concentrations. Some studies, but not all, also have found that maternal vitamin D status is associated with growth trajectory during the first year of life, although the findings are contradictory. There are recent studies that suggest maternal 25-OHD, or surrogates of vitamin D status, are associated with growth and bone mass later in childhood. These results are not consistent, and blinded randomised trials of vitamin D supplementation during pregnancy with long-term follow-up are needed to determine the benefits, and possible risks, of maternal vitamin D status on offspring growth and bone development. The possibility of adverse outcomes with higher maternal 25-OHD concentrations should be considered and investigated in all ongoing and future studies.     

Dabigatran etexilate: a possible replacement for heparinoids and vitamin K antagonists?

Dabigatran etexilate is the first oral anticoagulant to be approved in the United States in decades. It works directly by inhibiting clot-bound and free factor IIa (ie, thrombin) and indirectly by inhibiting platelet aggregation induced by thrombin. It is approved in the United States for stroke prophylaxis in nonvalvular atrial fibrillation. There is evidence to suggest that it is also effective for the treatment of acute venous thromboembolism and venous thromboembolism prophylaxis after knee and hip replacement surgery. Dabigatran etexilate therapy does not require laboratory monitoring, an advantage over warfarin. Unlike the earlier direct thrombin inhibitor, ximelagatran, it has demonstrated no potential for serious hepatotoxicity. It is also subject to a much lower degree of interpatient variability in dose response, has no diet-drug interactions, and has fewer clinically significant drug-drug interactions compared with warfarin. Dabigatran etexilate appears to be a valuable addition to our anticoagulant armamentarium.     

Does high vitamin K1 intake protect against bone loss in later life?

The findings of a number of cross-sectional studies suggest benefits of high phylloquinone (vitamin K₁) intake on bone health in later life. Until recently these observational data were supported by the findings of an intervention study that showed a protective role for vitamin K₁ (together with calcium, magnesium, zinc, and vitamin D₃) on bone loss over 3 years in early postmenopausal women. Over the last 18 months, two further important intervention studies have been published, which investigated the effect of vitamin K₁ on bone loss in older subjects. These two studies add to the evidence-base but cast some doubt on the benefits of high vitamin K₁ intake on bone health in later life.     

What do we currently know about nutrition and bone health in relation to United Kingdom public health policy with particular reference to calcium and vitamin D?

Public health policy in the UK related to nutrition and bone health has been shaped by reports from the Department of Health (DH), Food Standards Agency and WHO. Dietary reference values (DRV) for a number of nutrients were published in 1991 by the DH Committee on Medical Aspects of Food and Nutrition Policy. The subsequent DH report on nutrition and bone health in 1998 concentrated particularly on Ca and vitamin D, but also briefly addressed the effect of body weight, alcohol and other nutrients. Although this reviewed more recent evidence relating to the effect of higher intakes of Ca and vitamin D from longitudinal and interventional studies, no changes were made to the existing DRV. The Food Standards Agency published a report from their Expert Group on Vitamins and Minerals in 2003, which recommended safe upper limits for eight vitamins and minerals, with guidance provided on a further twenty-two nutrients, where there was less information on safety. The WHO report on diet, nutrition and the prevention of chronic diseases in 2003 addressed the prevention of osteoporosis, making recommendations on Ca, vitamin D, Na, fruit and vegetables, alcohol and body weight. The present paper examines current views on what constitutes an adequate dietary Ca intake and optimal vitamin D status, the DRV for vitamin D in subjects with little or no exposure to sunlight and the results of recent epidemiological studies on the relationship between fracture risk and body weight, alcohol intake and the consumption of other nutrients.     

Leptin and bone: does the brain control bone biology?

The means by which obesity leads to high bone density and protects individuals from osteoporosis is not known. The study of bone biology in two mouse models of obesity, leptin-deficient (ob/ob) and leptin receptor-deficient (db/db) mice, points to a role for leptin in the control of bone density. When leptin action is missing in these mice, bone density is high. This is true despite concurrent hypogonadism and hypercortisolism, two strong proresorptive signals that would normally lead to low bone density. Curiously, leptin does not have a direct effect on osteoblasts, which suggests the existence of a central, neuroendocrine pathway that controls bone mass.     

The Indian and Chinese health biotechnology industries: potential champions of global health?

India and China have made major progress toward establishing research- and innovation-based health biotechnology sectors. Local health needs, including diseases that predominantly affect the poor, have driven much of this success. We argue that emerging domestic firms can play an important role as reliable and high-quality suppliers of existing products and as innovators for global health needs. Indeed, these firms' participation may make existing global health approaches more sustainable. However, global health stakeholders, including international donors and the Indian and Chinese governments, will need to fashion incentives for these companies to retain a strategic focus on the global poor.     

Translating words into actions: are governments acting on the advice of the World health report?

Every year, WHO produces the World health report: the 2005 report concentrated on maternal, neonatal and child health. But what is the value of these reports? Are they ritualistic publications designed to promote WHO, or are they worthy of proper discussion and debate? One would think that given the current crises in global health, the annual report of the UN''s primary agency for health would be important. However, unless there is evidence that these reports are taken seriously, discussed and debated, and shown to have an effect, a conclusion might be drawn that they are largely insignificant. And that would consign WHO to a level of insignificance that it does not warrant. In this discussion of the 2005 report, I aim to provoke a response from both WHO and the international health community to demonstrate that the annual World health reports are meaningful. Furthermore, I suggest here that WHO shows its commitment to the recommendations of the 2005 report by monitoring how well recommendations have been taken forward.     

The health of students in institutes of higher education: an important and neglected public health problem?

BACKGROUND: A survey of students in three UK higher education establishments was undertaken to obtain information about students' physical and emotional well-being, their attitudes to, and beliefs about health, and the prevalence of risk factors for future ill health. METHODS: Health was measured by the prevalence of longstanding illness and by the SF-36 health status measurement tool. Survey results were compared with equivalent data for 18- to 34-year-olds in the local population. The prevalence of long-standing illness was also compared with two national surveys. RESULTS: The survey achieved a 49 per cent response rate. More than one-third of respondents reported a long-standing illness, a higher prevalence than in all comparison surveys. Students scored significantly worse than their peers in the local population on all eight SF-36 dimensions. The greatest difference was for role limitations as a result of emotional problems. The main sources of emotional distress were study or work problems and money. CONCLUSION: The poor response rate in this survey dictates the need for caution in interpretation of the results. However, they suggest that the health of students is poor relative to that of their peers, and that their emotional health is more of a problem than their physical health. Public health practitioners might want to pay more attention to the health of this important and relatively neglected group. Worries about studies and money appear to be affecting students' academic work, and this should be of concern to higher education establishments.