Monitoring the impacts of trade agreements on food environments.

The liberalization of international trade and foreign direct investment through multilateral, regional and bilateral agreements has had profound implications for the structure and nature of food systems, and therefore, for the availability, nutritional quality, accessibility, price and promotion of foods in different locations. Public health attention has only relatively recently turned to the links between trade and investment agreements, diets and health, and there is currently no systematic monitoring of this area. This paper reviews the available evidence on the links between trade agreements, food environments and diets from an obesity and non-communicable disease (NCD) perspective. Based on the key issues identified through the review, the paper outlines an approach for monitoring the potential impact of trade agreements on food environments and obesity/NCD risks. The proposed monitoring approach encompasses a set of guiding principles, recommended procedures for data collection and analysis, and quantifiable 'minimal', 'expanded' and 'optimal' measurement indicators to be tailored to national priorities, capacity and resources. Formal risk assessment processes of existing and evolving trade and investment agreements, which focus on their impacts on food environments will help inform the development of healthy trade policy, strengthen domestic nutrition and health policy space and ultimately protect population nutrition.

Antibiotics for otitis media: can we help doctors agree?

Wide variations in antibiotic prescribing for otitis media have suggested the need to discover the causes of the differences and help doctors reach agreement. Simulated cases--in the form of written clinical data extracts based on real patients--were used to study the diagnostic and prescribing behaviour of a group of six general practitioners. Clinical judgement analysis was used to model the way in which doctors diagnosed otitis media and their policy for using antibiotics. Most doctors performed consistently and their judgements could be fitted well to models using a small number of symptoms and signs. These models often differed from the policy they believed they were operating. This information was used as process feedback in a group discussion to help improve agreement within the practice on the management of otitis media. Some of the variation in behaviour observed at the start of the study was reduced by significant changes in that of the trainee. Other doctors changed little and some were sceptical of the validity of the experimental methods. The prospects for and difficulties of this type of analysis are discussed.

Controlled trial of calcitriol in the prevention of bone disease in haemodialysed patients.

Seventy-six patients receiving regular haemodialysis, without biochemical or radiological evidence of renal osteodystrophy, entered a five-year double-blind placebo-controlled trial of calcitriol (1,25-dihydroxycholecalciferol) in the prevention of bone disease. Significantly more patients on placebo developed bone disease as judged by a sustained elevation of plasma alkaline phosphatase or the development of sub-periosteal erosions on hand radiographs. Serum parathyroid hormone fell significantly in the patients receiving calcitriol and was significantly lower than in patients receiving placebo. It is concluded that calcitriol delays and may prevent the development of metabolic bone disease in patients receiving regular haemodialysis therapy.