Category Archives: The Science

Osteoporosis – And Who Is At Risk

What is osteoporosis?

Osteoporosis is a bone-thinning condition but it is by no means new.  The Romans were referring to non-healing hip fractures and other similar-sounding conditions in the 6th century.  By the early 19th century, physicians were concerned about the ‘spongy’ texture of bones in old age, even before they were able to see them on X-ray.

Osteoporosis is a silent insidious disease linked to hormonal changes at the time of the menopause.  Inevitably as we age there will be some bodily changes, such as the natural thinning of the bones in both men and women’s skeletons and weaker muscles less able to support the bones. Changes may also occur in the joints with arthritis, rheumatism and backpack being painful reminders of the passing years.

Today osteoporosis is regarded in many cases as a preventable disease although there is still a great deal we don’t know about it.  Despite its association with ageing and the menopause, the condition can also affect younger women and men.  Although more cases are being diagnosed, it doesn’t necessary follow that osteoporosis is on the increase bu that more of us are living longer, and so the chance of osteoporosis increases with longevity and the condition is more recognisable as osteoporosis by doctors who are fully aware of the effects of bone thinning.  Other reasons why many women present with osteoporosis include excessive dieting, poor nutrition, sedentary lifestyles and lack of exercise and young women who miss or have irregular periods or suffer from anorexia. A study of young women suffering from anorexia and missing periods for a year showed 77% has spinal bone loss caused by poor nutrition, weight loss and loss of ovarian function.   Young women athletes who train excessively are at risk if they become underweight and their periods stop. They can lose 5% of bone density in a year.

Lets’ bone up on the facts

  • Bone consists of the compound calcium phosphate embedded in collagen fibres. The calcium gives strength and hardness, the fibres make for flexibility.
  • Bone itself is not dead, but a living tissue full of little cavities looking not unlike a honeycomb
  • Bone changes constantly with new bone repairing and replacing old bone throughout our lifetime
  • Bone is liable to fracture, however the skeleton does replace itself every 7 –10 years
  • Bone mass decreases gradually and naturally in both women and men after the age of 35
  • Genetic inheritance and other factors also contribute to bone loss in some people
  • Fast bone losers will have lost as much as 30% of bone within ten years of the menopause (average age 51)
  • A woman who has an early menopause (before 45 years old) can experience bone loss even earlier (she will have been without bone-protective oestrogen for a longer period of her life.)
  • For the same reason fast bone loss can also be expected after a premature menopause (possibly brought about by hysterectomy).
  • The likelihood of fast bone loss is even greater if one or both ovaries were removed at the time (oophorectomy).

Your weight a 1 year of age could predict bone strength in adult life.  In a study of 230 women whose weight at a year old was traced from old medical records it was found that those underweight infants did not develop as strong skeletons in adulthood as those who were bigger infants.

 There are two types of bone: trabecular and cortical. 

  • A woman will lose about 50% of trabecular bone and 35% of cortical bone in her lifetime.
  • Trabecular bone is most likely to be lost in the 10 years or so around the menopause.
  • Cortical bone is associated with slower, gradual bone loss later in life.
  • The forearms and spinal column are made up largely of trabecular bone, and fractures in these areas are a sign of post-menopausal osteoporosis.
  • Hip and shoulder bones are both cortical and trabecular (fractures here are associated with later ageing.)

Taking the oral contraceptive pill over a long period may protect against bone loss because the hormones they contain may stimulate a substance called calcitonin that inhibits bone breakdown.  Bone tissue is continually replacing itself, most rapidly in the young and more moderately in adulthood.  Peak bone mass is reached during the early 20s, and after that, if you want to look at it pessimistically, things begin to go downhill.  In women, bone loss at around the age of 30 is up to 1% a year, in men the rate is slower.  This gradual loss of bone density is common to everyone and part of the ageing process.  But in some women, the loss accelerates to between 2% and 3% a year at the onset of the menopause, and by the age of 70, a third of bone mineral mass can have disappeared.  You can see the results in the skinny ankles and so-called ‘dowager’s hump’ or stoop of some elderly women.  That stoop is the result of what are known as crush fractures in the spine.

Overweight women gain some protection from the disease because  greater body weight puts more stress on her bones and after the menopause her excess fat will store more estrogen in the fat cells.  Something  larger ladies can smile about?

What happens at the time of the menopause?

Menopause is a normal stage in a woman’s life.  It isn’t an illness although some women do have very real problems at this time and need help.  Other women sail through the mid life changes with ease.   It can be divided into three stages:

Perimenopause

  • Signifies the transitional stage, a gradual process
  • Ovaries produce less and less oestrogen.
  • Can be 3 to 5 years, until the final cessation of the periods at menopause which for most women is between the ages of 45 and 55
  • Average age of menopause being 51 years of age. (But recent research indicates that the menopause is occurring at an increasingly younger age.)

Menopause

  • Menopause signifies a woman’s last menstrual period
  • Her ovaries finally cease to function
  • Her menstrual periods stop
  • Reproduction comes to an end.

Postmenopause

  • Signifies the many years of a woman’s life left after her last menstrual period and monthly bleed. (Possibly another 1/3rd of her life)

The hormonal fluctuations during the time of the menopause can cause physiological changes which effect metabolism and emotions.

This hormonal imbalance caused by the natural drop in oestrogen levels can result in symptoms such as:

  • Hot flushes
  • Irritability
  • Anxiety
  • Poor concentration.

A natural drop in levels of hormone oestrogen at the menopause triggers an accelerated loss of calcium from the bone.  One of the mysteries surrounding osteoporosis is that though all women lose oestrogen at the menopause, not all of them suffer bone loss.  There are certain risk factors that make some women more vulnerable than others. The increased loss occurs at whatever age the menopause takes place, either naturally around the age of 51,or unnaturally through removal of the womb and ovaries for medical reasons at an earlier age.

The earlier the menopause the earlier the risk of thinning bones. On average women who smoke experience menopause 3 years earlier and if you live with a smoker (even though you don’t smoke) you too are at a disadvantage.

Who is most at risk of osteoporosis?

According to the National Osteoporosis Society the risk factors are:

  • Heavy drinking and smoking
  • Heavy caffeine intake
  • Slight build, low weight
  • Early menopause before the age of 45
  • Family history of osteoporosis, especially in close female relatives, (i.e. mother or grandmother)
  • Lack of exercise
  • Prolonged bed rest or immobility
  • Fair skin
  • Lack of sufficient calcium in diet throughout life
  • High protein diet (which increases calcium loss)
  • Vitamin D deficiency (which reduces body’s ability to utilise calcium)
  • Long course cortisone or thyroid treatment
  • Women who have over dieted especially anorexia or bulimia sufferers)
  • Women who over-exercise such as marathon runners (periods diminish or disappear)

Studies in the US show that black women have stronger, thicker, larger bones than white.  Black women also tend to lose bone more slowly  and lose less calcium in their urine than white women.  Both black and white men lose bone and calcium in similar amounts.

What are the effects of bone loss?

There may be nothing noticeable at first.  It’s what happens in the long run that counts.  A typical sign is the broken wrist, a Colles fracture (which I experienced when I fell ice-skating – ouch)  You know the scenario: the person slips and falls on an outstretched hand.  Her average age will be 60, and I use the word ‘she’ advisedly, because it happens much more often to women than to men.

Fracture of the femur, the thighbone is another indicator.  It can happen through quite a minor fall.  The incidence rises with increased age in both men and women, but again its women who are statistically more prone to these injuries.

And then there are fractures of the vertebrae, or spine that become more frequent from the age of 50, again primarily in women.  These can cause loss of height through a concave or wedging effect of the weakened bones, or the spinal column may collapse because the bones are actually crushed.  One estimate suggests that about 60% of elderly women will experience wedging of bones in the spine.

Keep your  black coffee intake down.  An American study shows that drinking more than 2 cups a day reduces bone density, though coffe drinkers who also drank at least one glass of milk a day lost less bone than those who did not.

Hip fractures increase after the age of 70, and are the most serious of the four types of fracture connected with osteoporosis.  While the other kinds may cause pain they rarely need much medical care.  But hip fractures are associated with hospitalisation, permanent disability and death in old age. In the UK in 2004 we’re talking in terms of 300,000 cases of osteoporosis every year resulting in 70,000 hip fractures, 40,000 Colles fractures, and 40,000 fractures of the spine. And then there’s the financial burden, some £1.7 billion a year cost to the NHS.  Not to mention the cost in human misery and pain.   Some 14,000 people will die as a result of fractures.  And, yet again I say, some osteoporosis is preventable.

All fall down?

Fractures follow falls.  Even a minor impact can lead to a fracture when bones reach a certain stage of brittleness.  Why do people fall down more as they get older?  For a number of reasons, some medical:

  • They could be on a course of drug treatment that makes them drowsy or lose balance (tranquillisers for instance.)
  • They may suffer from muscular weakness through illness or lack of exercise.
  • Vision may not be as keen so there is a danger of tripping over (where lighting is not too good, for instance in a hall or on stairs).
  • Blackouts or fainting due to a physical condition.

A minimum of 2 or 3 units of alcohol a day (preferably less) will not affect bones directly.  But women who drink excessive amounts of alcohol may stumle and fall!

Prevention is better than cure

Not everyone has the opportunity, or the positive determinations to regain full mobility after an accident as I did.   But women with fragile bones have a lot to lose; both their physical independence and quality of life are at risk. Many accidents leading to nasty falls occur around the house, so be aware of potential hazards:

  • loose rugs
  • slippery floors
  • spilt liquids
  • Snake like flexes.

I find my visiting grandchildren, and other people’s pets are often the cause of “accidents just waiting to happen!”  Objects get moved from their familiar spots, toys get left in unexpected places as their bored little owners abandon treasured possessions in the most inconvenient places! Accidents in my kitchen are best avoided by keeping things in more accessible places, it’s too easy to lose one’s balance and tumble off the kitchen steps.  For people suffering from osteoporosis, handrails and non-slip mats in bathrooms can stop nasty falls on slippery surfaces, which could have such devastating consequences.

And cold weather can take it’s toll.  One study of elderly women admitted to hospital with fractures showed there was a mid winter peak.  But they weren’t slipping on icy pavements, most of the accidents took place indoors.  It was noted a large proportion of the women were thin, possibly suffering from poor nutrition which triggered low body temperatures, hypothermia and subsequent lack of co-ordination.

Healthy Heart

The number of factors influence the incidence of heart disease. Ones you cannot change include your family history; your are at increased risk if there is heart disease in your family. Factors that can be reduced or eliminated include high blood cholesterol levels, high blood pressure, smoking, diabetes, and being overweight and physically inactive.

Common Risk Factors

Cholesterol
The lower your cholesterol level the more you reduce your risk of heart disease. If you already have heat disease or are at a high risk of developing it, you may already be taking something natural from or prescription medication from your doctor to modify you cholesterol levels. The benefits of these are significant and their effect is enhanced by a healthy diet

High Blood Pressure
If you have high blood pressure, this adds to the workload of your heart, causing it to enlarge. As you age, your arteries harden and become less elastic, and high blood pressure speeds up this process.

Diabetes type 1 and 2
People with diabetes are at risk of heart disease, stoke and peripheral vascular disease. If you have diabetes, you should follow a healthy lifestyle and use appropriate therapy.
Diana Moran’s Healthy Heart Recipe

Walnut and Banana Sunrise Smoothie
1 orange segmented
1 banana, peeled
150ml of soya/rice or skimmed
150g (5 oz) soya yogurt or natural yogurt
25g (1 oz) walnuts
3 teaspoons of natural honey

(For extra protein in this smoothie, or if you don’t have soya, you can add some natural vanilla whey protein – a natural product.
Place all ingredients in a blender and blend until smooth and frothy. Pour into two glasses.

Smoothies are great way to increase your intake of soya protein. Make the recipe with soya milk and soya yogurt to give you 10 g of soya protein.

Heart health helpers
One of the most remarkable dietary discoveries in recent years has bee the role fish can play in preventing heat disease. People, who eat fish and shellfish regularly, such as the Japanese and Greenland Inuit, have fewer heart attacks than non-fish-eaters. Oily fish is the richest source of the polyunsaturated fatty acids EPA and DHA omega-3 fatty acids.
Omega-3 fatty acids are acids play an important part in blood clotting mechanisms, making the blood less sticky and reducing the risk of thrombosis. They also reduce irregular and potentially fatal arrhythmias.

The Mediterranean-style diet is high is fruit and vegetables, which are rich in vitamins and minerals, essential fatty acids and antioxidants.
There are about 600 antioxidants and these include the ACE vitamins, (beta-carotene, which is converted to vitamin A in the body, vitamin C and vitamin E), minerals (selenium and zinc) and various other compounds that give fruit and vegetables their fabulous colours (flavonoids and phenols). Red wine and green tea is also known to be good sources of antioxidants.

Eat healthy – Avoid eating too much saturated fat and instead eat plenty of fish, poultry, fruit and vegetables, and maintain a healthy bodyweight.

Be more active – Half an hour every day is enough to make a difference and it is easy to build into your daily routine. Start off gently and gradually build up.

Be smoke-free – From the moment you stop smoking, your risk of a heart attach starts to fall and is halved within one year of giving up.

Reduce you alcohol intake – Binge drinking increases your risk of having a heart attack

Minimise stress– Find alternative ways you can relax and unwind, your local health food store will have relaxation CD’s, essential oil sprays and flower remedies that you can use to help with relaxation when needed.

Strong bones

Osteoporosis, a debilitating condition caused by the loss of bone mineral, makes the bone susceptible to fracture, especially at the hip, wrist and spine. It is most common in menopausal women as the decline in oestrogen levels leads to an increase in the normal rat of mineral loss from bone.

You can help prevent osteoporosis eating a varied diet rich in vitamins and minerals, by consuming less caffeine and alcohol and by exercising.

Are you at risk?
Height and weight…….
Statistics show that tall women are more likely to develop osteoporosis. If you’re tall, pay extra attention to the things you can do to minimise your risk of developing osteoporosis.
If you are too thin, you could run and increased risk of developing osteoporosis. An overactive thyroid gland could be causing your lack of bodyweight. In addition, you don’t have sufficient adipose (fat) you will be less likely to produce oestrogen from this source.

Carrying a slight amount excess weight can actually push calcium into your bones. It is not helpful to be considerably overweight, however, as excess weight will put great pressure on your bones. If you do decide to lose weight, be careful. Research suggests that after the menopause it is better to stay the weigh you are that to go on a sudden weight-loss programme and lose more than 10 per cent of your body weight, which can double you risk of getting osteoporosis

Exercise
Lack of exercise is a significant risk factor in the development of osteoporosis. If you sit and do nothing, calcium tends to leave your bones; if you run, calcium tends to enter your bones. The critical factor is that exercise should be more weight-bearing, such as walking, running or push-ups. The more you use your bones to make demands on them, the stronger they become. It is a great way to energise you body and becoming fitter and stronger all over.

Diet – what your bones need
Calcium
This mineral is a major component of the structure of bones. You lose some calcium everyday, mainly in your urine, and it is vital that this is replaced. A daily dose of 1,000 mg is recommended, with an increase to 1,500 mg close to and thereafter the menopause. Make sure you diet supplies a large amount of calcium. You can also help this by making some positive changes and consider taking a calcium supplement, if necessary.
Phosphorus

Calcium’s ‘partner’ in bones is phosphorus. The ideal would provide them in equal amounts, but the Western diet unusually contains an excess of phosphorus. A high phosphorus intake can remove calcium from bones and can also lead to reduced vitamin D activity and hence the absorption of calcium from the digestive system.
Meat, grains and protein-rich foods in general are rich in phosphorus, so reduce your intake of these foods to the minimum that will provide adequate protein. Most fruits and vegetables have a good balance of calcium and phosphorus. Avoid carbonated drinks.

Magnesium
About 70 per cent of the body’s magnesium is stored in the bones, where it replaces some of the calcium and has an important influence on bone structure. People with osteoporosis often have a deficiency of magnesium. Many medications prescribed for osteoporosis contains calcium and vitamin D but little or no magnesium, even though some people may need it more urgently that calcium.

Other essential minerals
In addition to those listed above, make sure that you are supplying your body with adequate levels of manganese, zinc, copper, silica and boron.

Vitamin A
Also known as retinol, vitamin A stimulates the production of progesterone, thought to be more useful than oestrogen in the prevention of osteoporosis. It is found in eggs and meat, especially liver. Carotenes, the precursors of vitamin A, are available from orange, red or green plant foods, such as carrots, beetroot, and leafy green vegetables.

Vitamins B6 and B12 and Folic Acid
These B vitamins help minimise levels of homocysteine. The effect can be enhanced by taking a supplements by taking a supplement with as much as 5 mg folic acid (ask PAUL C if this is still ok to rec). This is a safe dose, but it should be always taken in combination with vitamin B12.

Vitamin C
Vitamin C is essential for healthy collagen and increases the production of progesterone. It is usually found in combination with other bioflavonoid in foods such as oranges, strawberries, tomatoes and green vegetables. If choosing a supplement, look for one that contains vitamin C in calcium form (calcium ascorbate) in combination with bioflavonoids.

Vitamin D
By promoting calcium absorption from the intestinal tract vitamin D helps to maintain normal levels of blood calcium. An adequate intake of vitamin D will, for most people, make a big difference to calcium levels.

Vitamin K
The vitamin encourages calcium deposition in the bones. Many post-menopausal women stop calcium in urine whey they take vitamin K. Leafy vegetables are the richest sources. Because it is fat soluble, vitamin K should be eaten or taken with some form of fat. Another form, vitamin K2, is produced by bacteria and other microrganisms in the digestive tract. For most healthy people, this is a major source of vitamin K. Vitamin K is not stored in the body, and so is less likely to be toxic in high doses. A recommended does in 10 mg a day, but up to 50 mg has been used without any adverse effects.

Other risk factors to consider
– excess alcohol
– excess caffeine
– carbonated drinks
– smoking
– excess salt
– Prescription medication, such as sleeping pills and steroids. They are particularly harmful and can have an adverse effect on the bones. If you are taking these, speak to your doctor or a qualified practitioner about supplements you can take for bone support or natural alternatives to help reduce the medication. Look into natural alternatives to sleeping pills or steroids.

Hints for health
Eat a varied diet throughout your life as osteoporosis can start before the menopause. For strong bones, make sure your diet is especially rich in vitamins D and K, calcium and magnesium.

Recipe for strong bones
Fruit and nut crumble.
Serves 6
Preparation time 15 minutes plus soaking time
Cooking time 35-40 minutes
This can be enjoyed for an energising and wholesome breakfast, after dinner for a healthy desert or delicious midday snack.

Dried fruit such as apricots and prunes add to the iron content of the diet. Absorption of iron is by vitamin C, but inhibited by a number of factors including drinking tea. This delicious recipe contains natural foods that provide essential minerals for bone support.

6 oz dried apricots
4 oz dried pitted prunes
4 oz dried figs
2 0z dried apples
1 pint of apple juice
3 ½ oz of wholewheat /rye/spelt flour
2 oz margarine
2 oz brown unrefined sugar sifted (you can find this at local health food store)
2 oz hazelnuts chopped
To serve and garnish
Low fat yogurt – natural or soya
Rosemary springs

1. Place the dried fruits in a bowl with the apple juice and leave overnight to soak. Transfer to a saucepan and simmer for 10-15 minutes, until softened. Turn into an ovenproof dish.
2. Sift the flour into a bowl and rub in the margarine until the mixture resembles breadcrumbs.
3. Stir in the sugar, reserving a little to serve, and the hazelnuts, then sprinkle the crumble over the fruit (sugar does not need to be added to this recipe if you are trying to avoid)
4. Bake in a preheated oven at 200oC (400oF), Gas mark 6 for 25-30 minutes.
5. Serve with a low fat yogurt, if you liked, sprinkled with the reserved sugar and garnish with rosemary.

Essential Books for Public Health Professionals Working in Healthcare

 

How To Talk About Books You Have Not Read 

How To Talk About Books You Have Not Read is a wonderful book by Pierre Bayard. The book can be read at two different levels as many books can. On one level it is a humorous book, a little like the book by Stephen Potter called One-Up-Manship, which has advice on how to impress people with one’s literary credentials even though one has never read the classics. Pierre Bayard, however, makes a very serious point – that no one will ever read all the books that they need to read or could read in their particular topic. It is far more important to know about a book and its core message, preferably in the author’s own words, and to understand how that book fits into the culture and relates to other books and concepts then not to know that a book existed.

The table below presents the Top Ten Books that are essential reading in this topic area. You can see all 10 books in the bulleted list below. 

For each book there is the full reference, the ‘Distilled Message’ (the essence of the book in the author’s own words) and ‘Why Is This Book Important?’ (the relevance of the book and other related titles or key terminology to note). 

  • Public Health, Ethics, and Equity 
  • Stewardship.  Choosing Service over Self-Interest..
  • A Public Enemy.
  • Social Determinants of Health.
  • The Politics of BSE.
  • Realistic Evaluation.
  • The Strategy of Preventive Medicine.
  • Organizational Culture and Leadership 
  • The Spirit Level.  Why More Equal Societies Almost Always Do Better.
  • Effectiveness and efficiency. Random reflections on health services.  
  • ·Public Health, Ethics, and Equity.  

Sudihr Anand, Fabienne Peter and Amartya Sen. (2004)  Oxford University Press 

Distilled message  “ …it has been our aim to launch a wide investigation of the ethical issues underlying inequalities in health. In order to examine health equity from a variety of perspectives …contributions centre on 5 themes

1. What is health equity?
2. Health equity and its relation to social justice
3. Health inequalities and responsibilities for health
4. Ethical issues in health evaluation and prioritization
5. Anthropological perspectives on health equity”

Why is this book important? The scope of Public Health is difficult to define.  If we focus on health promotion for example then the obvious focus of public health effort might appear to be on cigarette smoking and the modern diet.  However it is obvious that bringing about change in these risk factors is not simply a matter of giving people clear unbiased information, important though that is.  It is necessary to tackle the social determinants of health, the social factors that lead to smoking or a bad diet or any other risk factor.  As far as the social determinants are concerned it is again possible to consider these in different levels of depth.  An economic approach focuses on deprivation and inequality but many people feel that this is still too narrow and taking what is being called the human rights approach it is necessary to have a perspective of justice and that if the word justice in the world or any country in the health of not only the poorest people but also the whole population would be better.  This obviously raises ethical issues for public health professionals.  Is it right for them to have a salary that is much greater than the poorest people in society or even of the lowest people in a health service.  

In this book the authors start by looking at inequalities of health but they move from inequality and objective variable to equity.

Equity and its opposite inequity are still confused by many with equality and inequality.

Inequality is an objectively defined judgment, for example health inequalities such as variation in mortality rates, or health service inequalities, such as variation in the provision of services to different populations. There may be equality in the provision of health services, which is not equitable, if one population has greater need than the others. Similarly there may be unequal distribution of resources that is in the interest of equity in the higher amount of money per head, allocated to a population with high levels of deprivation and need, because it has been decided to do this in the interests of equity.

  • Stewardship.  Choosing Service over Self-Interest.  

Peter Block  (1993) Berrett-Koehler, (p.xx)

Distilled message “Stewardship is to hold something in trust for another.  Stewardship is defined in this book as the choice to preside over the orderly distribution of power.  This means giving people at the bottom and the boundaries of the organization choice over how to serve a customer, a citizen, a community.  It is the willingness to be accountable for the well-being of the larger organization by operating in service, rather than in control, of those around us.  Stated simply, it is accountability without control or compliance.”
Why is this book important? The term “steward” is an old-fashioned term encountered in Tolkien, for example, and the Shorter Oxford English Dictionary has many examples of the word “steward”, usually someone who is accountable to a king or a lord, responsible for management and order of an estate or a manor house.  More recently, however, the word has come to have a different meaning and a fourth dimension.

Of central importance is the book by Peter Block entitled Stewardship, subtitled Choosing Service over Self-Interest.   This could, of course, simply be a definition of altruism and Block writes about stewardship being “to hold something in trust for another”.   

However, a new meaning of the word “stewardship” is emerging and stewardship is something which, in a book called Permaculture, subtitled Principles and Pathways beyond Sustainability, addresses the question, “Will the resource be in better shape after my stewardship?”.   This relates to what is sometimes called intergenerational equity or environmental sustainability – we have to look after the planet for future generations.   It is our duty as stewards.

Increasingly the word “stewardship” is being used in healthcare with an appeal to the clinicians to think of themselves  not only as people who use resources but as the stewards of the resources.

  • A Public Enemy 

Henrik Ibsen  (1964)  Penguin Books, (p.219)

Distilled message “The fact is that the strongest man in the world is the man who stands alone.”
Why is this book

important

The Enemy of the People is the only play about a public health professional.  The hero and, he is a hero, is the head of public health in a small Norwegian Spa town.  He is an admired and respected person in the town, until he says that the waters, the waters on which the town’s wealth is based, are unsafe.

The political pressure on him grows, but subtle and direct and a good modern depiction of the oppositions, and hostility, he faced is the early scenes of Jaws when the coastguard is trying to convince the Town Council that they have a problem that requires action.

  • Social Determinants of Health.  

Michael Marmot and Richard G. Wilkinson  (1999)  Oxford University Press, (p.232-233)

Distilled message
  • Income support.
  • Policies should focus on reducing the proportion of children born into and living in poverty.
  • Policies should aim to reduce inequalities in income and wealth within populations.
  • Policies to ensure access to educational, training, and employment opportunities.
  • Barriers to access to health and social services should be removed.
  • Adequate follow-up support is needed for those leaving institutional care.
  • Housing policies should aim to provide enough affordable housing of reasonable standard.
  • Employment policies should aim to preserve and create jobs…Improving the health of migrants.”
Why is this book

Important

Michael Marmot has led the intellectual analysis of the social determinants of health and led the campaign for the social determinants to be recognised for the importance that they have.  The approach is a little narrower than the approach of, for example Amartya Sen.  They certainly argue in favour of social justice but argue that much can be done practically by tackling problems like bad housing and low income.

It is also certainly important to try to tackle cigarette smoking and alcohol abuse, as they are the two major causes of disease directly but success will only be achieved if success of social determinants of health is also tackled.

  • The Politics of BSE.   

Richard Packer  (2006)  Palgrave MacMillan, (p.5)

Distilled message  “The word ‘politics’ covers a host of matters from major issues of elevated principle to minor matters of interest to a few individuals only.  This is because politics is a reflection of human nature, which while sometimes aspiring to the heavens is often concerned mainly with self.  Accordingly, sometimes this book moves suddenly between the large and lofty and the small and rather grubby.  I make no apology; it would not be an accurate account without both dimensions. 
Why is this book important? This is one of a number of books that give insight into the relationship between politicians, officials and scientists written by the vet who was at the heart of the BSE drama.  The relationships are subtle and not always understood by Public Health professionals.

Other books that give useful insight include:

  • Creating Public Value by Mark Moore
  • Administrative Behaviour by Herbert Simon
  • Any of the novels of CP Snow particular Corridors of Power and The New Men.
  • Realistic Evaluation.  

Ray Pawson & Nick Tilley   (1997)  Sage, (p.215-219)

Distilled message  “The New Rules of Realistic Evaluation…

Rule 1: generative causation…

Rule 2: ontological depth…

Rule 3: Mechanisms…

Rule 4: Contexts…

Rule 5: Outcomes…

Rule 6: CMO configurations…

Rule 7: Teacher-learner processes…

Rule 8: Open Systems”

Why is this book important? Clinical practice and the evidence base of clinical practice have been dominated by two research methods in the last 50 years – the randomised controlled trial and the systematic review.  

These methods have a part to play in Public Health also but in the field of public policy a new paradigm is emerging led largely by the work of Ray Pawson. 

 

Ray Pawson argues that when one is evaluating complex interventions the reductionist method of the randomised controlled trial and the systematic review with meta analysis has its limitations.  The method proposed by Pawson and Tilley can be briefly summarised by saying it is observation, intervention, and repeat observation.

This book is of great relevance and should be used more by people working in public health who need to innovate and evaluate.  That they have no control group should not put them off. The other key book by Ray Pawson is called Evidence Based Policy and it is his critique of the relevance of the systematic review that is currently used in clinical research.

Both books are important books for public health professionals.

  • The Strategy of Preventive Medicine.  

Geoffrey Rose  (1992)  Oxford University Press, (p.14)

Distilled message The following chapters will explore the principles and ramifications of both the  high risk and the population strategies of prevention and their respective strengths and limitations. Finally, the conclusion will be that preventive medicine must embrace both, but, of the two, power resides with the population strategy
the strategy of preventive medicine
Why is this book

important?

Geoffrey Rose is one of the giants of Public Health in the last decade of the 20th Century.  His book The Strategy of Preventive Medicine brought together very elegantly the high risk approach and the population approach.  He pointed out that many events would occur mostly in low risk people, because there are so many more of them even though each individual is at low risk and that it was necessary to complement and supplement the high risk approach to the population approach.  

For example, we are probably in a muddle that he would disapprove of at present.  We are identifying lots of individuals at low risk of coronary heart disease but we have not yet identified the individuals at very high risk, people with familial hypercholesterolemia.  Furthermore because so much of our effort is going on people with lower risk we are not trying to shift the whole population curve.  

The need to do this was further emphasised by George Davey Smith in the International Journal of Epidemiology.(1)  At one time it was hoped the human genome project would allow us to identify all the individuals at high risk by identifying all those with a particular genome type.  Unfortunately this does not seem to be possible and, for many years to come it will not be possible to identify people at very high risk using biomarkers other than the ones we know about already.  

Thus we still need to adopt the principles advanced by Geoffrey Rose.  We need to deal with individuals with very high risk and seek to shift the risk profile of the whole population.

  • Davey Smith J (2011) Int J Epidemiology 40:537-562.  Epidemiology; epigenetics and the ‘Glossary Prospect:  embracing randomness in population health research and practice.
  • Organizational Culture and Leadership. (3rd Edition)  

Edgar H. Schein  (2004)  Jossey-Bass, (p.17)

Distilled message “The culture of a group can now be defined as a pattern of shared basic assumptions that was learned by a group as it solved is problems of external adaptation and internal integration, that has worked well enough to be considered valid and, therefore, to be taught to new members as the correct way to perceive, think, and feel in relation to those problems.
Why is this book

important

An organisation can be said to consist of a structure, systems and a culture.  Health services change structure all the time and increasingly focus on systems but still retain the same culture.  The culture of an organization is defined in almost as many ways as team leadership, perhaps not surprisingly as the two terms are interwoven with one of the key responsibilities of the leader being to shape the culture of their organisation.

The culture of an organisation is the set of beliefs and assumptions that influence how people feel and behave. A large organisation can have many different cultures, pediatric departments have a different culture from trauma departments and within one hospital neighbouring wards can have very different cultures even though both are doing the same job.

 
  • The Spirit Level.  Why More Equal Societies Almost Always Do Better. 

Richard Wilkinson & Kate Pickett  (2009) Penguin, (P.264.265)

Distilled message “After several decades in which we have lived with the oppressive sense that there is no alternative to the social and environmental failure of modern societies, we can now regain the sense of optimism which comes from knowing that the problems can be solved.  We know that greater equality will help us rein in consumerism and ease the introduction of policies to tackle global warming.  We can see how the development of modern technology makes profit-making institutions appear increasingly anti-social as they find themselves threatened by the rapidly expanding potential for public good which new technology offers.  We are on the verge of creating a qualitatively better and more truly sociable society for all.”
Why is this book

Important

The simple message here is that societies that are more equal, using a measure called the Gini ratio, are better for everybody, including the rich.

In the 19th Century it was enlightened self interest that led to the development to the Public Health Revolution.  The rich realised that they could get cholera just like the poor and this was an important driver of change.  Richard Wilkinson, Michael Marmot and their colleagues are hoping that this awakening will occur in England, holding up Norway as a role model.

Here is their definition of the Gini co-efficient.

“There are lots of ways of measuring income inequality and they are all so closely related to each other that it doesn’t usually make much difference which you use. Instead of the top and bottom 20 per cent, we could compare the top and bottom 10 or 30 percent. Or we could have looked at the proportion of all incomes which go to the poorer half of the population. Typically, the poorest half of the population get something like 20 or 25 per cent of all incomes and the richest half get the remaining 75 or 80 per cent. Other more sophisticated measures include one called the Gini coefficient. It measures inequality across the whole society rather than simply comparing the extremes. If all income went to one person (maximum inequality) and everyone else got nothing, the Gini coefficient would be equal to 1. If income was shared equally and everyone got exactly the same (perfect equality), the Gini would equal 0. The lower its value, the more equal a society is. The most common values tend to be between 0.3 and 0.5.” 

Source: Wilkinson, R,., Pickett, K.  (2010) The Spirit Level. Why Equality is Better for Everyone.  Penguin Books (p.118).

  • Effectiveness and efficiency. Random reflections on health services

Cochrane, A.L.  (1971)  The Nuffield Provincial Hospitals Trust.

Distilled message “There are two preliminary steps which are essential before this cost/benefit approach becomes a practical possibility, and it is with these two steps that I am chiefly concerned.  The first is, of course, to measure the effect of a particular medical action in altering the natural history of a particular disease for the better.  Since the introduction of the randomized controlled trial (RCT) our knowledge in this sphere has greatly increased but is still sadly limited.  It is in this sense that I use the word ‘effective’ in this book, and I use it in relation to research results. As opposed to the results obtained when a therapy is applied in routine clinical practice in a defined community.” (p2)
Why is this book

Important

Effectiveness and efficiency

This book, published in 1972, changed the paradigm in healthcare from one in which the only concern was that the care should be free and that the doctor’s experience was the only criterion for deciding whether or not a treatment was right. Its influence flourished in the 1980’s when it paved the way for the Cochrane Collaboration and Evidence Based Medicine

In the last three decades of the 20th century, health service payers and managers were appropriately preoccupied with effectiveness and efficiency and only services that did more good than harm, at reasonable cost, were considered for funding. However, of developed countries, only the United Kingdom faced serious resource constraints in the 1980s and was forced to think about opportunity costs rather than simply taking new interventions that had a favourable result from cost-benefit or cost-effectiveness analyses.  Since then, every other major developed economy, which is committed to offering healthcare to its whole population, has had to face up to limits placed on healthcare spending.  In Germany, Japan, and Italy, for example, evidence-based decision-making has become much more explicit. The United States remains an exception but President Obama is determined to end that.

It was in the United Kingdom, therefore, that the response to the work of Archie Cochrane was most enthusiastic.

‘He lived and died, a severe porphyric, who smoked too much, without the consolation of a wife, a religious belief, or a merit award, but he didn’t do too badly.’

These were the words of Archie Cochrane when he wrote his own obituary for the British Medical Journal. As befits the man, they were ironic, clear, accurate, and understated.   Few people had more influence on healthcare in the last fifty years of the 20th century than Archie Cochrane; firstly, by his insistence on the importance of the randomised controlled trial; secondly, by his challenge to the medical and research establishments that they should organise all of their knowledge properly, leading to the creation of the Cochrane Collaboration; and thirdly, by the publication of his Random Reflections on Health Services with the title Effectiveness and Efficiency. This small book, published in 1972, was ahead of its time in that it captured and predicted 20th century healthcare’s focus on effectiveness and efficiency.

The era of effectiveness

‘All effective treatments must be free.’

This, wrote Cochrane, was the device his banner carried at a Communist rally in the 1930s, written after considerable thought but making no impact on the communists on the march. But it did make an impact on Cochrane, who remained obsessed with the need for treatments to be demonstrated to be effective and then, if they were, for those treatments to be made available through a National Health Service. For Cochrane it was clear that the single best method for demonstrating the effectiveness of a treatment was the randomised controlled clinical trial and he promoted the importance of the trial with commitment, energy, intelligence, and a considerable degree of cunning throughout the rest of his professional career.   As a result, the term ‘effectiveness’ entered the general vocabulary not only of the research worker but of all those who manage and pay for healthcare.

 

 

Essential Terms for Public Health Professionals working in Healthcare

Language creates reality, it does not describe it.  That is one of the principles that has emerged from anthropology, linguistics and philosophy from authors as diverse as Ludwig Wittgenstein, John Searle and Benjamin Lee Whorf. Confusion about language and the meaning of the terms being used is one of the main causes of arguments, fruitless arguments, which disappear if everyone shares the same understanding of the terms being used.

Public Health professionals use a language that is rich in terms and which have no universally agreed definition; terms such as social justice or sustainability.  There are other terms where there is an agreed meaning, usually more technical scientific terms such as meta-analysis.  One of the reasons why public health professionals do not have a strong corporate culture is because no attempt has been made to develop a common core of concepts, and terms relating to these concepts, with the objective that everyone practising as a public health professional would use the term and concept with the same meaning.

A project has been designed to develop such a common core.  There are of course dictionaries of public health, notably by John Last and by Professor Williams in Swansea, but within the concept of a dictionary there is a glossary, a subset of terms of vital importance for everyone in the community of practice to use.  It could also be argued that if such a set of terms were identified and the meanings agreed, that they should be taught to new practitioners at an early stage in their induction to the profession.

A project was sponsored to stimulate discussion on core terms and common meanings and the first set of 10 terms represented here are a basis for discussion. For each term there is a bottom line drawn from one of the sources cited and a short commentary.

  • Culture: Culture is the set of important understandings (often unstated) that members of a community share in common.
  • Emergence: Much coming from little.
  • Equity: Equity is a subjective judgment of unfairness.
  • Health Promotion: Health promotion is the process of enabling people to increase control over, and to improve, their health.
  • Health Protection: “Health protection comprises legal or fiscal controls, other regulations and policies, and voluntary codes of practice, aimed at … the prevention of ill-health.
  •  Justice: To ask whether a society is just is to ask how it distributes the things we prize – income and wealth, duties and rights, powers and opportunities, offices and honours.
  • Risk: “The chance that something (good or bad) will happen.”
  • Sustainability: “Protecting resources from one generation to the next.”
  • System: A set of activities with a common set of objectives with an annual report
  • Value: “…value is expressed as what we gain relative to what we give up – the benefit relative to the cost.”

Population-based Healthcare

What is Population-based Healthcare?

Population healthcare focuses primarily on populations defined by a common need which may be a symptom such as breathlessness, a condition such as arthritis or a common characteristic such as frailty in old age, not on institutions, or specialties or technologies. Its aim is to maximise value and equity for those populations and the individuals within them.

The population healthcare methodology involves a collaborative working of multidisciplinary stakeholders to determine appropriate outcome measures for various systems, and getting populations reporting on these on an annual basis. Atrial Fibrillation, falls and fragility fractures, homelessness, chronic pelvic pain are some of the first set of systems being developed, and it is anticipated that this method will be used across all the 30 programmes and 100 recognised systems.

The first twenty of these programmes are based on the International Classification of Diseases (ICD), arranged in order of programme budget expenditure.

Each of the twenty condition focussed programmes has a large number of rare diseases as well as the common problems.

Where appropriate, major symptoms are associated with one relevant programme, although more than one specialty may be involved with a particular symptom such as breathlessness.

The remaining ten programmes focus on populations defined by a common characteristic such as age or having more than one problem.

Glossary: Population and Personalised Care

This Glossary is about Population and Personalised Care the latter being  a style of clinical and general management which always considers the patients’ perspective as the most important and is committed to increasing patient Engagement, Empowerment or Involvement, which may be regarded as synonyms. Personalised care is an element of patient centred care and is the other side of the coin from population care. This is a diffuse and fast moving field with language evolving at a rapid rate. Here are the key terms and concepts.

  • Value “What is gained relative to what we give up – the benefit relative to the cost but not only to the direct cost, which is the efficiency of a service, but the Opportunity Cost, or the Opportunity Lost to put it another way and there are three dimensions to value in healthcare
    • o Allocative value, determined by how the assets are distributed to different sub groups in the population
    • o Technical value, determined by how well resources are used for all the people in need in the population
    • o Personalised value, determined by how well the decisions relate to the values of each individual

Waste is any activity in a process that consumes resources without adding value for the patient

Cost effectiveness

The relationship between the cost of an intervention and its impact.

Optimality;

Optimality is reached when resources or productivity create maximal benefit with the least harm. Beyond optimality there is overuse.

Programme Budgeting and Marginal Analysis;

The fundamental idea behind programme budgeting is decision making based on explicit criteria related to the wellbeing of the whole population, as opposed to decision making by compromise among various institutional, parochial, or other vested interests. Marginal Analysis consists of starting with a particular mix of services and analyzing changes in that mix. If resources can be shifted to produce greater benefit then this should be done.

Opportunity Cost;

The value of the next best alternative forgone as a result of the decision made.

Equity;

Equity is a subjective judgment of unfairness.

  • System – A set of activities with a common set of objectives with an annual report.
  • o Network – If a system is a set of activities with a common set of objectives, the network is the set of organizations and individuals that deliver the systems.
  • o Pathway – The actual care process of care experienced by each individual patient/client; also described as maps that define best practice.
  • o Quality -The degree to which a service meets preset standards of goodness in the delivery of the system’s objectives.
  • Culture – “Culture is the shared assumptions of a group that is has learned in coping with external tasks and dealing with internal relationships. Akey cultural issue is the development of a culture of stewardship.
  • Population healthcare –the design and delivery of the care with a primary focus on the population in need, not the healthcare institutions, where the populations in need are defined not bureaucratically but by the optimum population size for high value care for individuals and the group in need Population medicine or population clinical practice – a style of practise in which the clinician feels, and is given responsibility for, all of the people in the population in need whether or not they have been referred
  • Personalised Care or Personalised Medicine  –  the tailoring of care to take into account each individual’ s unique  needs, preferences and values. The term has become popularised recently to describe clinical decision making in the era of the genome but another term for clinical decision making incorporating genomic information is
    • o Stratified Medicine – decision making based on the patients degree of risk, including risk suggested by genomics and based on the long standing practice of risk stratification of elderly people based on social and medical, but not genomic characteristics
    • o Precision Medicine decision making taking into account genomic information either in diagnosis – ‘molecular diagnostics’ –or choice of drug treatment –‘pharmacogenomics’.
  • Principal and Agent – legally the patient is the principal, the clinician the agent, even if there is no money involved. Some people feel the shift in the balance of power occurred with the founding of the NHS when the patient was not charged for consulting the GP. The pendulum swung further because of
    • o Information Asymmetry – the fact that the clinician has, until the advent of the Internet much more technical knowledge
    • o Trust – Faith in another to perform a task that is not in the other’s interest
    • o Autonomy – Freedom to make decisions or act without reference to others
    • o Informed Consent – Consent to treatment given with full understanding of the magnitude and probabilities of the good and adverse outcomes
  • Empathy – In his book on Emotional Intelligence Daniel Goldman identifies three types of empathy – cognitive empathy is the ability to understand what another person is thinking   Emotional empathy is the ability to feel what another person is feeling. Empathic concern is the ability to sense what another person needs for you.
  • Evidence and Value based decision making – Decision making that ensures the patient is fully informed about the strength of evidence about the probability and magnitude of both risks and benefits of the options being considered and that the patient has been helped to reflect on, clarify and express their preferences based on the value they place on the possible benefit, the possible harm and on the risk they are taking.
    • o Health Literacy – The cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information. The term Statistical literacy – the ability to understand and communicate probabilities which is shared by both patients and clinicians, sometimes called risk literacy is increasingly used
    • o Framing –  the conscious or unconscious presentation of data in ways that influence their interpretation and decision making
    • o Shared Decision Making – is a style of decision making in which clinicians and patients are both involved
    • o Preference Sensitive Decision Making – is a style of decision making in which the patient’s preferences are explicitly elicited, to avoid
    • o Silent Misdiagnosis – namely failure to diagnose accurately the patient’s values and preferences even though their disease has been correctly diagnosed
    • o Informed Consent
    • o Patient Decision Aids – a tool to support the patient during decision making, particularly before and after the face to face consultation and they are increasingly  delivered using digital means variously called eHealth, mHealth, digital health or Telemedicine which may be regarded as synonyms
  • Patient defined and reported outcomes are objective measures using validated tools

subjective measures of outcome, including the degree to which the treatment addressed the problem that was bothering the patient most, rather than their diagnosis and the patient’s experience.

Necessary, Appropriate, Inappropriate or Futile Classification of interventions based on the probabilities of benefit and harm

Burden of Treatment – the impact of the process of care on the affected individual and their carers