Health insurance and accessibility to health services among Roma in settlements in Belgrade, Serbia--the journey from data to policy making.

The Serbian constitution and health-related laws assert that citizens and residents are universally entitled to health care, provided that they hold health insurance. However, until 2010, persons who did not hold a national identification number (ID) were required to present a plethora of documents to be granted one. We assessed the relationship between citizenship, residency and possession of health insurance cards, together with utilization of health services, among Roma residing in disadvantaged settlements in Belgrade. The Roma Health and Nutrition Survey was conducted in 2009 to assess the social determinants of health among Roma. Data were analysed, using logistic regression, to examine health insurance status and utilization of services by citizenship and residency. Eighty-nine per cent of respondents said they were Serbian citizens. Approximately 11% were refugees, 7% internally displaced persons (IDPs) and remainder domicile. Multivariate analysis revealed that non-citizens were more likely to lack health insurance [odds ratio (OR) = 9.2, confidence interval (CI) (3.5, 24.1)], as were refugees and IDPs [OR = 3.1, CI (1.4, 6.9), OR = 4.0, CI (1.4, 11.5), respectively]. Having health insurance was a positive predictor for being seen by a physician [OR = 2.3, CI (1.3, 4.2), OR = 2.3, CI (1.3, 3.9)]. Data from this survey indicated that non-citizen Roma had limited access to health services. These findings led the Serbian Ministry of Health and National Health Insurance Fund to reduce the administrative and legislative hurdles in obtaining health insurance, to ensure the Roma rights to health care. This demonstration of data-driven policies on Roma health could serve as a model for other countries.

Risk factors for low vaccination coverage among Roma children in disadvantaged settlements in Belgrade, Serbia.

BACKGROUND: Full vaccination coverage for children under 59 months of age in Serbia is over 90%. This study assesses vaccination coverage and examines its association with birth registration among Roma children who resided in disadvantaged settlements in Belgrade, Serbia. METHODS: The First Roma Health and Nutrition Survey in Belgrade settlements, 2009, was conducted among households of 468 Roma children between the ages of 6-59 months. The 2005 WHO Immunization Coverage Cluster Survey sampling methodology was employed. Vaccinations were recorded using children's vaccination cards and through verification steps carried out in the Primary Health Care Centers. For those who had health records the information on vaccination was recorded. RESULTS: About 88% of children had vaccination cards. The mean rate of age appropriate full immunization was 16% for OPV and DTP and 14.3% for MMR. Multivariate analyses indicated that children whose births were registered with the civil authorities were more likely to have their vaccination cards [OR=6.1, CI (2.5, 15.0)] and to have their full, age appropriate, series vaccinations for DTP, OPV, MMR and HepB [OR=3.8, CI (1.5, 10.0), OR=3.2, CI (1.5, 6.6), OR=4.8, CI (1.1, 21.0), OR=5.4, CI (1.4, 21.6), respectively]. CONCLUSIONS: The immunization coverage among Roma children in settlements is far below the WHO/UNICEF MDG4 target in achieving prevention and control of vaccine preventable diseases. It demonstrates the need to include "invisible" populations into the health systems in continuous, integrated, comprehensive, accessible and sensitive modes.

Nutrigenetic impact of daily folate intake on plasma homocysteine and folate levels in patients with different methylenetetrahydrofolate reductase genotypes.

BACKGROUND: Elevated plasma homocysteine level is associated with coronary artery disease (CAD). Homozygosity for the C677T mutation in the methylenetetrahydrofolate reductase (MTHFR) gene is typically but inconsistently associated with hyperhomocysteinemia. We examined the impact of daily intake of folate, a co-factor in homocysteine metabolism, on plasma homocysteine and folate levels in CAD patients in relation with MTHFR genotypes. METHODS: Daily folate intake was assessed from 3-day food records in 99 patients with CAD: 35 with the T/T (homozygous mutant) genotype and 64 with the C/C or C/T (non-T/T) genotypes. RESULTS: Patients with the T/T genotype had higher fasting plasma homocysteine levels (18.4±1.9 vs. 12.6±0.6 µmol/l, P=0.01) and lower plasma folate levels (17.8±1.7 vs. 20.8±1.0 nmol/l, P=0.02). There were no differences between the genotype groups in energy-adjusted folate intake. In patients with the non-T/T genotypes, higher folate intake was associated with higher plasma folate levels and lower plasma homocysteine levels. In T/T homozygotes this association was weaker. Linear regression analysis showed that folate intake, the MTHFR genotype, plasma vitamin B12 levels, and the interaction between plasma folate level and MTHFR genotype, predicted homocysteine elevation. (folate intake, P=0.04, MTHFR genotype, P=0.03, plasma folate, P=0.02, and plasma B12 level, P=0.004). The model explained only 29% of the variance in log-transformed plasma homocysteine levels. CONCLUSION: T/T homozygotes are more sensitive to the combination of low folate intake, low plasma folate and vitamin B12 level, than patients with non-T/T genotypes. The variability in plasma homocysteine in T/T homozygotes is only partly explained by these variables.

Renal cell cancer in Israel: sex and ethnic differences in incidence and mortality, 1980-2004.

BACKGROUND: The causes of renal cell cancer (RCC) remain largely unexplained. While the incidence is generally higher in men than in women, little has been reported on ethnic differences. We examine trends in RCC incidence and mortality rates among Israeli Arab and Jewish populations and compared with the rates in other countries. METHODS: Age-adjusted RCC incidence and mortality rates in Israel, during 1980-2004, were calculated by sex and population group, using the National Cancer Registry. They were compared with the United States based on the Surveillance Epidemiology and End Results [SEER] program and the IARC database for international comparisons. RESULTS: While RCC incidence rates in Israel are similar to the United States and the European average, the rates are significantly higher among Israeli Jews than Arabs. Men are affected more than women. Incidence rates over the last 24 years have increased among all men and Jewish women, but not among Arab women. Among men, the incidence rate ratio for Jews to Arabs declined from 3.96 in 1980-1982 to 2.34 in 2001-2004, whereas for women there was no change. The mortality rates were higher among Jews than Arab and among men than women. There were no significant change in the mortality rates and rate ratios. CONCLUSIONS: Our findings demonstrate marked ethnic differences in RCC in Israel. The lower incidence among Arabs stands in contrast to the higher prevalence of potential risk factors for RCC in this population group. Genetic factors, diet and other lifestyle factors could play protective roles.

Lead poisoning among internally displaced Roma, Ashkali and Egyptian children in the United Nations-Administered Province of Kosovo.

BACKGROUND: This study assessed the association between lead poisoning prevention activities and blood lead levels (BLLs) among children living in lead-contaminated camps for internally displaced persons in the United Nations-Administered Province of Kosovo. METHODS: We conducted a population-based study to examine the relationship among geometric mean BLLs in children (i) born before any lead poisoning prevention activities were instituted, (ii) born when specific interim interventions were instituted and (iii) born after relocation and medical therapy were available. The study population consisted of 145 of the 186 children born in the camps between December 1999 and July 2007. RESULTS: Lower mean BLLs were found in children born following implementation of the interventions as compared with the children born before the interventions. However, this decrease in mean BLLs was attenuated in children born into families suspected of informal lead smelting. CONCLUSION: Despite lower BLLs following interventions, children living in these camps have BLLs that remain unacceptably high. Further efforts are urgently needed to control or eliminate lead exposure in this population. Continued blood lead monitoring of the population is also warranted.

Relationship between dietary calcium intake, body mass index, and waist circumference in MABAT--the Israeli National Health and Nutrition Study.

BACKGROUND: It has been suggested that increased calcium intake plays a role in preventing obesity and promoting weight loss. OBJECTIVES: To assess the association between calcium intake, body mass index and waist circumference in Israel. METHODS: MABAT was a cross-sectional survey based on a random sample of 3246 Israelis aged 25 to 64. Of the 3246 survey participants, height and weight measurements were recorded for 2782 (1371 men and 1411 women). These were divided into three groups according to their BMI (group A < or = 24.9, group B 25-29.9, and group C > or = 30) and given a 24 hour dietary recall questionnaire. Waist circumference was measured in 2601 participants (1760 men and 841 women) and was considered to be excessive if > or = 102 cm for men or > or = 88 cm for women. RESULTS: The mean calcium intake was 511.5 +/- 301.8 mg for group A, 499.4 +/- 283.7 mg for group B, and 464.7 +/- 280.1 mg for group C (group A significantly differed from group C, P < 0.002). The mean daily milk consumption in group A was higher than in groups B and C (103.4 +/- 147.5, 85.7 +/- 122.25, and 84.5 +/- 135.1 g, respectively; P< 0.01). There was no correlation between daily dietary calcium intake and waist circumference for men, but women with a waist circumference below 88 cm consumed significantly more dietary calcium than those with a waist circumference > or = 88 cm (P< 0.03). CONCLUSIONS: The study confirms the inverse relationship between daily dietary calcium intake and obesity. This linkage relates to the intake of milk, but not to other dairy products.

Determinants of disordered eating behaviors among Israeli adolescent girls.

Eating behaviors were assessed by a modified SCOFF questionnaire in a National representative cross-sectional study among 2978 Israeli schoolgirls. The mean age was 14.7. Thirty percent met the criteria for disordered eating. Being Jewish or underweight reduced the odds for disordered eating. The following increased the risk: dieting, early onset of menarche, being overweight or obese, and suffering from constipation. School socio-economic status, physical activity, and smoking status were not contributory. These results help identify possible interventions to prevent the development of disordered eating behaviors.

A global nutritional index.

BACKGROUND: A standardized global nutritional index (GNI) would provide a single statistic for each country according to its overall level of nutrition, which could then guide national policies. OBJECTIVES AND METHODS: We have developed a GNI modeled on the human development index (HDI), based on three indicators of nutritional status: deficits, excess, and food security. Calculations were made within four groups of countries (GNI) (32 developed countries, 26 countries in transition, 64 low-mortality developing countries, and 70 high-mortality developing countries) as well as between them-the Global Nutrition Index World wide (GNIg). RESULTS: Complete data were available for 192 countries. The ranking of the highest and lowest countries in the four groups (with their GNIg values) is as follows: developed countries--Japan 1 (0.989), United States 99 (0.806); countries in transition--Estonia 10 (0.943), Tajikistan 173 (0.629); low-mortality developing countries--Republic of Korea 12 (0.939), Nauru 185 (0.565); high-mortality developing countries--Algeria 47 (0.876), Sierra Leone 192 (0.420). A "double burden," in which nutrient deficits and excesses coexist in the same country, was seen in Mauritania (rank 139), South Africa (rank 146), Samoa (rank 157), Lesotho (rank 160), and Fiji (rank 169). The correlation between GNIg and HDI was intermediate (0.74, 55% of variance explained), demonstrating that good nutrition and development are not necessarily synonymous. Countries may be developed yet have a low GNIg (e.g., Australia, Canada, and the United States) and vice versa (e.g., Indonesia and China). CONCLUSIONS: Since nutrition is fundamental to a nation's health and productivity, the GNI and GNIg should be used alongside the HDI to obtain an optimal index of a country's overall well-being.

Association between consumption of Herbalife nutritional supplements and acute hepatotoxicity.

BACKGROUND/AIMS: Nutritional supplements are frequently considered to be harmless but indiscriminate use of unlabelled ingredients may lead to significant adverse reactions. METHODS: In 2004, identification of four index cases of acute hepatitis associated with Herbalife intake led to a ministry of health investigation in all Israeli hospitals. Twelve patients with acute idiopathic liver injury in association with consumption of Herbalife products were investigated. RESULTS: Eleven of the patients were females, aged 49.5+/-13.4 y. One patient had stage I primary biliary cirrhosis and another had hepatitis B. Acute liver injury was diagnosed after 11.9+/-11.1 months of initiation of Herbalife consumption. Liver biopsies demonstrated active hepatitis, portal inflammation rich with eosinophils, ductular reaction and parenchymal inflammation with peri-central accentuation. One patient developed sub-fulminant and two fulminant episodes of hepatic failure. Hepatitis resolved in eleven patients, while one patient succumbed to complications following liver transplantation. Three patients resumed consumption of Herbalife products following normalization of liver enzymes, resulting in a second bout of hepatitis. CONCLUSIONS: An association between intake of Herbalife products and acute hepatitis was identified in Israel. We call for prospective evaluation of Herbalife products for possible hepatotoxicity. Until then, caution should be exercised by consumers, especially among individuals suffering from underlying liver disease.

BMI may overestimate the prevalence of obesity among women of lower socioeconomic status.

OBJECTIVE: Our objective was to examine gender differences in height and weight associated with socioeconomic status (SES) and the consequent effect on body mass index in a multiethnic society. RESEARCH METHODS AND PROCEDURES: A cross-sectional study, the First Israeli National Health and Nutrition Survey, was performed on a representative population sample of 3246 adults 25 to 64 years of age, between the years 1999 to 2001. Height and weight were measured, and BMI and other weight-height indices were calculated. SES was assessed by income and education. RESULTS: Age-adjusted height was significantly lower at lower levels of SES among both women and men (p<0.001). As opposed to men, women of lower SES were heavier than those of higher SES, and the mean age-adjusted weight was 4.6 kg higher among those of lower SES (p<0.001). Thus, using the standard index of BMI, the prevalence of obesity was significantly higher among shorter women. DISCUSSION: In this group of Israeli adults, the unfavorable effect of low SES on BMI was evident among women, partly due to their decreased height combined with increased weight common in this socioeconomic sector. Since BMI is only partly independent of height, it may overestimate the prevalence of obesity among women of lower SES. Alternative measures for classifying obesity in the lower SES groups that put less emphasis on height may be considered and studied.

A large food-borne outbreak of group A streptococcal pharyngitis in an industrial plant: potential for deliberate contamination.

Contamination of food with streptococci could present with unusual outbreaks that may be difficult to recognize in the early stages. This is demonstrated in a large food-borne outbreak of streptococcal pharyngitis that occurred in 2003 in a factory in Israel. The outbreak was reported to the public health services on July 2 and an epidemiologic investigation was initiated. Cases and controls were interviewed and throat swabs were taken. An estimated 212 cases occurred within the first 4 days, the peak occurring on the second day. There was a wave of secondary cases during an additional 11 days. The early signs were of a respiratory illness including sore throat, weakness and fever, with high absenteeism rates suggesting a respiratory illness. As part of a case-control study, cases and controls were interviewed and throat swabs taken. Illness was significantly associated with consumption of egg-mayonnaise salad (odds ratio 4.2, 95% confidence interval 1.4-12.6), suggesting an incubation period of 12-96 hours. The initial respiratory signs of food-borne streptococcal pharyngitis outbreaks could delay the identification of the vehicle of transmission. This could be particularly problematic in the event of deliberate contamination.

Self-reported health as a cultural health determinant in Arab and Jewish Israelis MABAT--National Health and Nutrition Survey 1999-2001.

Subjective health (SH) status serves as a measure of health in many studies of health-related issues as it is a good predictor of mortality, morbidity, and use of health services. The measure is used in many population groups. However, the degree to which it measures the same condition in different ethnic groups is not clear. Within Israel's first National Health and Nutrition Survey (MABAT) conducted during 1999-2001, face-to-face interviews were held with 3222 Israeli interviewees, 2379 Jews and 843 Arabs, aged between 25-64 years. Respondents reported their SH, co-morbidity, and other socioeconomic characteristics. Arabs reported higher levels of SH than Jews. In logistic regression analysis, co-morbidity was a much stronger correlate of poorer SH in the Arab than in the Jewish population. The association between socioeconomic variables depended on ethnic group and sex. The findings indicate that SH in Jews and Arabs does not necessarily have the same meaning in relation to objective measures of health, and caution should be exercised in the use of this measure in different population groups with different cultures. Arabs tend to evaluate health better than Jews even though life expectancy is lower and morbidity and mortality are higher in the former population group. Yet diagnosis of a disease increases the frequency of reporting lower SH, more in Arabs than in Jews.

Food security and nutrition -- the Ethiopian case for action.

OBJECTIVE: To assess the 1999-2000 food security situation and the food relief programmes in Ethiopia, and evaluate the need for a national food and nutrition policy. DESIGN: A systematic search of data sources from the Ethiopian Disaster Prevention and Preparedness Commission (DPPC), the Ethiopian Central Statistical Authority, the World Food Programme (WFP) and United Nations Children's Fund (UNICEF), the bibliographic database Medline and direct contacts with associations, institutions and people concerned with food security in Ethiopia. SETTING: Consultations to WFP Ethiopia. RESULTS: Food availability was severely restricted due to recurrent disasters such as drought, flood, war and a lack of diversity of food items. Food accessibility was limited due to a weak subsistence-agriculture-based economy, depletion of assets, absence of income diversity and a lack of alternative coping mechanisms. Food intake adequacy was rarely achieved due to food shortages, improper diet and poor sanitary conditions. There was a lack of early warning data to monitor food security indicators. Food aid programmes did not meet the requirements for food quantities and composition, and faced major obstacles in logistics and targeting of the vulnerable population. CONCLUSIONS: Improvements in food security and the eradication of famine will require investment in sustainable projects. There is an immediate need for better planning and targeting of food aid and a national food security monitoring system. A national food and nutrition policy is recommended, focusing both on relief efforts and on underlying factors contributing to the famine.

Teaching nutrition in an International Master of Public Health program.

The health of populations is related to the norms and characteristics of society and its socio-economic organization. The causes of food-related ill health are located at the national and international levels and the cure must be sought in good governance. Thus, it is obvious that a Master's Degree in International Public Health must include a thorough overview of the "food chain" from "plough to plate" within the political, economical, socio-economic changes, environmental, industrial, scientific, and health contexts. Nutritional deficiencies are addressed by a variety of measures, including food supply and utilization programs, specific supplementation for high-risk groups, and food fortification to reach a general population. All are part of a wide-based public health nutrition approach, applicable in developed, redeveloping, and newly developing countries. This article is based on experience in teaching Public Health Nutrition to a mixed group of foreign students from different countries. Our goal is to prepare students for a variety of public health careers related to nutrition and health. The aim of this course is to introduce current roles and aspects of food and nutrition policy, focusing on food and nutrition security, human rights for food and nutrition, and the complex interactions among local and global systems. Students are introduced to nutrition screening, assessment, and research skills, and nutrition in emergency situations and in disaster relief. During the course the students learn about the design and the evaluation of nutrition interventions at the individual, community, and national level. The course gives a broad-based examination of major themes related to development and underdevelopment, poverty and wealth, equality and inequality. It also introduces program planning from the perspective of international organisations such as the World Food Program and the Food and Agriculture Organisation and the World Health Organisation of the United Nations. More specific objectives include: 1. To define the nutritional problems at the level of the individual, family, the community, and the nation. Use of Causal Modelling. 2. To learn in what ways data may be gathered. 3. To suggest methods of intervention according to priorities. 4. To monitor the effects of such interventions. 5. To assess the scientific evidence underlying the connections between diet and disease.

Surveillance of neural tube defects in Israel.

BACKGROUND: Open neural tube defects are among the most common malformations of the fetus. Secondary prevention by early diagnosis during pregnancy and abortion of affected fetuses result in a marked reduction of NTD incidence at birth. The dramatic effect of folic acid for primary prevention of these defects led to recommendations for folic acid supplementation in women of reproductive age. OBJECTIVE: To describe the epidemiologic features of NTD in Israel in 1999-2000. METHODS: A national registry of NTD was begun in 1999. During the years 1999-2000, a non-syndromic NTD was diagnosed in at least 394 pregnancies (166 anencephaly, 166 spina bifida, 43 encephalocele, and 19 with other types of NTD). The religious-ethnic affiliation was known in 392 cases (209 Jews and 183 non-Jews). RESULTS: Despite a marked decline in the rate of NTD at birth in the last few decades, the total rates during pregnancy did not change significantly, demonstrating that the changes were secondary to termination of affected pregnancies. At birth, NTD were almost four times more frequent among non-Jews (3.6 per 10,000 live births for anencephaly and 5.9 for spina bifida) than among Jews (anencephaly 1/10,000 live births, spina bifida 1.4/10,000 live births). The complete data of the registry showed an approximately twofold difference in the overall rates during pregnancy between Jews (anencephaly 5.3, spina bifida 4.6, total 11/10,000 live births) and non-Jews (anencephaly 8.8, spina bifida 10.3, total 22.3/10,000 live births). The registry demonstrated that the significant differences in NTD incidence observed at birth between Jews and non-Jews are secondary to a combined effect of a higher frequency of the malformations among non-Jews and a lower proportion of termination of affected pregnancies among non-Jews. CONCLUSIONS: The data presented here will serve as a basis for evaluating the impact of the Ministry of Health recommendations for folic acid supplementation on the incidence of NTD.