Survival and costs of colorectal cancer treatment and effects of changing treatment strategies: a model approach.

New and emerging advances in colorectal cancer (CRC) treatment combined with limited healthcare resources highlight the need for detailed decision-analytic models to evaluate costs, survival and quality-adjusted life years. The objectives of this article were to estimate the expected lifetime treatment cost of CRC for an average 70-year-old patient and to test the applicability and flexibility of a model in predicting survival and costs of changing treatment scenarios. The analyses were based on a validated semi-Markov model using data from a Norwegian observational study (2049 CRC patients) to estimate transition probabilities and the proportion resected. In addition, inputs from the Norwegian Patient Registry, guidelines, literature, and expert opinions were used to estimate resource use. We found that the expected lifetime treatment cost for a 70-year-old CRC patient was €47,300 (CRC stage I €26,630, II €38,130, III €56,800, and IV €69,890). Altered use of palliative chemotherapy would increase the costs by up to 29%. A 5% point reduction in recurrence rate for stages I-III would reduce the costs by 5.3% and increase overall survival by 8.2 months. Given the Norwegian willingness to pay threshold per QALY gained, society's willingness to pay for interventions that could result in such a reduction was on average €28,540 per CRC patient. The life years gained by CRC treatment were 6.05 years. The overall CRC treatment costs appear to be low compared to the health gain, and the use of palliative chemotherapy can have a major impact on cost. The model was found to be flexible and applicable for estimating the cost and survival of several CRC treatment scenarios.

Food variety consumption and household food insecurity coping strategies after the 2010 landslide disaster - the case of Uganda.

OBJECTIVE: To evaluate the nutritional situation of the victims of the 2010 landslide disaster in Uganda, food varieties consumed and coping strategies were assessed. DESIGN: Cross-sectional. Food variety scores (FVS) were obtained as the total of food items eaten over the last week while an index was based on severity weighting of household food insecurity coping strategies. We included 545 affected and 533 control households. SETTING: Victims in the affected Bududa district in Eastern Uganda and those victims resettled in the Kiryandongo district, Western Uganda. RESULTS: Adjusted for covariates, in Bududa significantly higher mean FVS were observed among: affected than controls; farmers than others; and relief food recipients. Control households scored higher means (se) on severity of coping: 28·6 (1·3) v. 19·2 (1·2; P<0·01). In Kiryandongo, significantly higher FVS were observed among: control households; household heads educated above primary school; those with assets that complement food source; and recipients of relief food. Severity of coping was significantly higher among affected households and non-recipients of relief food. Affected households had a higher likelihood to skip a day without eating a household meal in Bududa (OR=2·31; 95 % CI 1·62, 3·29; P<0·01) and Kiryandongo (OR=1·77; 95 % CI 1·23, 2·57; P<0·01). CONCLUSIONS: Whereas FVS and severity of coping showed opposite trends in the two districts, resettlement into Kiryandongo led to severe coping experiences. Administrative measures that provide a combination of relief food, social protection and resettlement integration may offset undesirable coping strategies affecting diet.

Household food insecurity and diet diversity after the major 2010 landslide disaster in Eastern Uganda: a cross-sectional survey.

In 2010, a landslide in Bududa, Eastern Uganda, killed about 350 people and nearly 1000 affected households were resettled in Kiryandongo, Western Uganda. A cross-sectional survey assessed household food insecurity and diet diversity among 1078 affected and controls. In Bududa, the affected had a lower adjusted mean score of food insecurity than controls - 9·2 (se 0·4) v. 12·3 (se 0·4) (P<0·01)--but higher diet diversity score (DDS) - 7·1 (se 0·1) v. 5·9 (se 0·1) (P<0·01). On controlling for disaster and covariates, recipients of relief food had higher food insecurity - 12·0 (se 0·6) v. 10·4 (se 0·3) (P=0·02)--whereas farmers had higher DDS - 6·6 (se 0·2) v. 5·6 (se 0·3) (P<0·01). Household size increased the likelihood of food insecurity (OR 1·15; 95% CI 1·00, 1·32; P<0·05) but reduced DDS (OR 0·93; 95% CI 0·87, <1·00; P=0·04). Low DDS was more likely in disaster affected (OR 4·22; 95% CI 2·65, 6·72; P<0·01) and farmers (OR 2·52; 95% CI 1·37, 4·64; P<0·01). In Kiryandongo, affected households had higher food insecurity - 12·3 (se 0·8) v. 2·6 (se 0·8) (P<0·01)--but lower DDS - 5·8 (se 0·3) v. 7·0 (se 0·3) (P=0·02). The latter reduced with increased age (OR 0·99; 95% CI 0·97, 1·00; P<0·05), lowest education (OR 0·54; 95% CI 0·31, 0·93; P=0·03), farmers (OR 0·59; 95 % CI 0·35, 0·98; P=0·04) and asset ownership (OR 0·56; 95% CI 0·39, 0·81; P<0·01). Addressing social protection could mitigate food insecurity.

Improving nutrition surveillance and public health research in Central and Eastern Europe/Balkan Countries using the Balkan Food Platform and dietary tools.

The objective of this paper is to share experience and provide updated information on Capacity Development in the Central and Eastern Europe/Balkan Countries (CEE/BC) region relevant to public health nutrition, particularly in creation of food composition databases (FCDBs), applying dietary intake assessment and monitoring tools, and harmonizing methodology for nutrition surveillance. Balkan Food Platform was established by a Memorandum of Understanding among EuroFIR AISBL, Institute for Medical Research, Belgrade, Capacity Development Network in Nutrition in CEE - CAPNUTRA and institutions from nine countries in the region. Inventory on FCDB status identified lack of harmonized and standardized research tools. To strengthen harmonization in CEE/BC in line with European research trends, the Network members collaborated in development of a Regional FCDB, using web-based food composition data base management software following EuroFIR standards. Comprehensive nutrition assessment and planning tool - DIET ASSESS & PLAN could enable synchronization of nutrition surveillance across countries.

Perceptions on the right to adequate food after a major landslide disaster: a cross-sectional survey of two districts in Uganda.

BACKGROUND: Despite the instruments on the right to adequate food adopted by the United Nations, there exists limited information on how this right is perceived. Following a major 2010 landslide disaster in the Bududa district of Eastern Uganda and the resettlement of some affected households into the Kiryandongo district in Western Uganda, we surveyed both districts to explore perceptions about the right to adequate food among households with different experiences; disaster-affected and controls. METHODS: We deployed qualitative and quantitative techniques to a cross-sectional survey. The index respondent was the head of each randomly selected household from the landslide affected communities and controls from a bordering sub-county. Data was collected by interviews and focus group discussions (FGDs). Structured entries were tested statistically to report associations using Pearson's Chi-square at the 95% CI. Information from FGDs was transcribed, coded, sequenced and patterned. Findings from both techniques were triangulated to facilitate interpretations. RESULTS: Analysis included 1,078 interview entries and 12 FGDs. Significant differences between the affected and control households (P < 0.05) were observed with: age; education level; religious affiliation; existence of assets that complement food source; and having received relief food. Analysis between groups showed differences in responses on: whether everyone has a right to adequate food; who was supposed to supply relief food; whether relief food was adequate; and preferred choice on the means to ensure the right to adequate food. FGDs emphasized that access to land was the most important means to food and income. Affected households desired remedial interventions especially alternative land for livelihood. Despite the provision of adequate relief food being a state's obligation, there was no opportunity to exercise choice and preference. Comprehension and awareness of accountability and transparency issues was also low. CONCLUSION: Though a significant proportion of participants affirmed they have a right to adequate food, relief food was largely perceived as insufficient. Given the high regard for land as a preferred remedy, a resettlement policy is of the essence to streamline post-landslide displacement and resettlement. Information materials need to be assembled and disseminated to stimulate awareness and debate on the right to adequate food.

Modeling and validating the cost and clinical pathway of colorectal cancer.

BACKGROUND: Cancer is a major cause of morbidity and mortality, and colorectal cancer (CRC) is the third most common cancer in the world. The estimated costs of CRC treatment vary considerably, and if CRC costs in a model are based on empirically estimated total costs of stage I, II, III, or IV treatments, then they lack some flexibility to capture future changes in CRC treatment. The purpose was 1) to describe how to model CRC costs and survival and 2) to validate the model in a transparent and reproducible way. METHODS: We applied a semi-Markov model with 70 health states and tracked age and time since specific health states (using tunnels and 3-dimensional data matrix). The model parameters are based on an observational study at Oslo University Hospital (2049 CRC patients), the National Patient Register, literature, and expert opinion. The target population was patients diagnosed with CRC. The model followed the patients diagnosed with CRC from the age of 70 until death or 100 years. The study focused on the perspective of health care payers. RESULTS: The model was validated for face validity, internal and external validity, and cross-validity. The validation showed a satisfactory match with other models and empirical estimates for both cost and survival time, without any preceding calibration of the model. CONCLUSIONS: The model can be used to 1) address a range of CRC-related themes (general model) like survival and evaluation of the cost of treatment and prevention measures; 2) make predictions from intermediate to final outcomes; 3) estimate changes in resource use and costs due to changing guidelines; and 4) adjust for future changes in treatment and trends over time. The model is adaptable to other populations.

Iodine-induced goitre and high prevalence of anaemia among Saharawi refugee women.

OBJECTIVE: The main objective was to assess iodine status (thyroid volume (Tvol) and urinary iodine concentration (UIC)) and their determinants in Saharawi refugee women. DESIGN: A cross-sectional survey was performed during January-February 2007. Tvol was measured by ultrasound and iodine concentration was analysed in spot urine samples and in household drinking water. Anthropometry and Hb concentration were measured and background variables were collected using pre-coded questionnaires. SETTING: The survey was undertaken in four long-term refugee camps in the Algerian desert. SUBJECTS: Non-pregnant women (n 394), 15-45 years old, randomly selected. RESULTS: Median (25th percentile-75th percentile (P25-P75)) UIC was 466 (294-725) µg/l. Seventy-four per cent had UIC above 300 µg/l and 46 % above 500 µg/l. Median (P25-P75) Tvol was 9·4 (7·4-12·0) ml and the goitre prevalence was 22 %. UIC was positively associated with iodine in drinking water and negatively associated with breast-feeding, and these two variables explained 28 % of the variation in UIC. The mean (sd) Hb level was 11·8 (2·4) g/dl. In total 46 % were anaemic with 14 %, 25 % and 7 %, classified with respectively mild, moderate and severe anaemia. CONCLUSIONS: The Saharawi women had high UIC, high levels of iodine in drinking water and increased Tvol and probably suffered from iodine-induced goitre. The high prevalence of anaemia is considered to be a severe public health concern. To what extent the excessive iodine intake and the anaemia have affected thyroid function is unknown and should be addressed in future studies.

Data quality and practical challenges of thyroid volume assessment by ultrasound under field conditions - observer errors may affect prevalence estimates of goitre.

BACKGROUND: The ultrasonographic estimation of thyroid size has been advocated as being more precise than palpation to diagnose goitre. However, ultrasound also requires technical proficiency. This study was conducted among Saharawi refugees, where goitre is highly prevalent. The objectives were to assess the overall data quality of ultrasound measurements of thyroid volume (Tvol), including the intra- and inter-observer agreement, under field conditions, and to describe some of the practical challenges encountered. METHODS: In 2007 a cross-sectional study of 419 children (6-14 years old) and 405 women (15-45 years old) was performed on a population of Saharawi refugees with prevalent goitre, who reside in the Algerian desert. Tvol was measured by two trained fieldworkers using portable ultrasound equipment (examiner 1 measured 406 individuals, and examiner 2, 418 individuals). Intra- and inter-observer agreement was estimated in 12 children selected from the study population but not part of the main study. In the main study, an observer error was found in one examiner whose ultrasound images were corrected by linear regression after printing and remeasuring a sample of 272 images. RESULTS: The intra-observer agreement in Tvol was higher in examiner 1, with an intraclass correlation coefficient (ICC) of 0.97 (95% CI: 0.91, 0.99) compared to 0.86 (95% CI: 0.60, 0.96) in examiner 2. The ICC for inter-observer agreement in Tvol was 0.38 (95% CI: -0.20, 0.77). Linear regression coefficients indicated a significant scaling bias in the original measurements of the AP and ML diameter and a systematic underestimation of Tvol (a product of AP, ML, CC and a constant). The agreement between re-measured and original Tvol measured by ICC (95% CI) was 0.76 (0.71, 0.81). The agreement between re-measured and corrected Tvol measured by ICC (95% CI) was 0.97 (0.96, 0.97). CONCLUSIONS: An important challenge when using ultrasound to assess thyroid volume under field conditions is to recruit and train qualified personnel to perform the measurements. Methodological studies are important to assess data quality and can facilitate statistical corrections and improved estimates.

Endemic goitre and excessive iodine in urine and drinking water among Saharawi refugee children.

OBJECTIVE: To assess the prevalence of enlarged thyroid volume (Tvol) in Saharawi refugee children, and their urinary iodine concentration (UIC), and to identify possible sources of excess iodine intake. DESIGN: A cross-sectional survey was performed during January-February 2007. Tvol was measured by ultrasound and iodine concentration was analysed in casual urine samples, in household drinking water and in milk samples from household livestock. SETTING: The study was undertaken in four refugee camps in the Algerian desert. SUBJECTS: The subjects were 421 Saharawi children, 6-14 years old. RESULTS: Enlarged Tvol was found in 56 % (Tvol-for-age) and 86 % (Tvol-for-body-surface-area) of the children. The median (25th percentile-75th percentile, P25-P75) UIC was 565 (357-887) microg/l. The median (P25-P75) iodine concentration in household drinking water was 108 (77-297) microg/l. None of the children had UIC below 100 microg/l, 16 % had UIC between 100 and 299 microg/l, and 84 % had UIC above 300 microg/l. There was a positive association between Tvol and whether the household possessed livestock. CONCLUSIONS: The children are suffering from endemic goitre and high UIC caused probably by an excessive intake of iodine. The excessive iodine intakes probably originate from drinking water and milk.

Turning dilemmas into opportunities: a UNU/SCN capacity development network in public nutrition in Central and Eastern Europe.

Capacity development in nutrition is a process whereby individuals, groups, institutions, organizations and societies enhance their abilities to identify and meet challenges in a sustainable manner. To address these issues, in 2001 the UN System Standing Committee on Nutrition (SCN) established a Working Group on Capacity Development under the joint coordination of the United Nations University (UNU) and the International Union of Nutritional Sciences. Several regional professional networks have developed under this working group, the latest for the Central and Eastern Europe (CEE) countries. Ten CEE countries formed a network in 2006 and identified major nutritional challenges in the region, which included: irregular meal patterns; low consumption of fruits/vegetables, milk products and fish; low intake of some micronutrients; and high intakes of fat, sugar and salt. Public policies in nutrition were either weak or absent. Some countries had recently developed nutrition plans. Higher education in nutrition was seen as very important for public nutrition work by professionals in the region, who considered it a prerequisite for reversing the negative trend of the nutrition transition. The network will continue to work on issues that are still not covered adequately. Its activities to date and prospects for the future are assessed against ten principles for good capacity development suggested by the United Nations Development Programme.

A survey among potential employers for developing a curriculum in public health nutrition.

OBJECTIVES: To describe which functions potential employers of public health nutritionists in Norway find important for a person trained in public health nutrition to be able to carry out. Further, to illustrate how the findings were used in the development of a curriculum for a bachelor in public health nutrition at Akershus University College. DESIGN: A non-random, cross-sectional survey using a questionnaire with both pre-coded and open-ended questions. SUBJECTS: Ninety-one establishments working in various fields more or less related to nutrition responded (response rate of 45 %). RESULTS: Local offices of the Norwegian Food Safety Authority were over-represented among respondents. Functions related to communication and food and nutrition laws and regulations were most frequently rated as important by the respondents. Functions in nutrition research, project work and policy and planning were also regarded important by more than half of the respondents. The priorities of the potential employers together with the additional comments and suggestions were taken into account when a new curriculum on public health nutrition was developed. CONCLUSIONS: The assessment of functions prioritized by employers of public health nutritionists gave a valuable input for developing a new curriculum in public health nutrition. It reflected the challenges of the real world that public health nutritionists will work in and therefore helped making the curriculum potentially more relevant.

Nutrición: la base para el desarrollo

Presenta un estudio de como es importante la nutrición para el desarrollo, como en la educación, población, salud, medio ambiente, agricultura, género, pobreza, en los momentos de crisis, derechos humanos, en las comunidades y en la política.

Women's iodine status and its determinants in an iodine-deficient area in the Kayes region, Mali.

OBJECTIVE: To assess iodine status and its determinants in women of childbearing age in a rural area in the Kayes region, Mali, West Africa. DESIGN: Cross-sectional study where women's iodine status was indicated by urinary iodine concentration (UIC) and level of goitre based on palpation. Salt iodine was assessed semi-quantitatively at household level. Individual characteristics were collected using questionnaires. SETTING: Fifteen villages in a rural area in the Kayes region of Mali. SUBJECTS: Women aged 15-45 years (n=423). RESULTS: Median UIC was 2.7 microg dl(-1), and only 6% of the women had adequate iodine status of UIC >10 microg dl(-1). Most women (60%) had visible goitre, and only 9% were classified as without goitre. Only 39% of the households were using salt with any iodine, and level of knowledge about salt iodisation was low. Main determinants of UIC were breast-feeding and level of salt iodisation; currently breast-feeding women had lower UIC, and UIC increased with increasing level of iodine in household salt. Prevalence of goitre was lower in older women with higher body mass index. CONCLUSION: The study indicates severe iodine deficiency in the study area. Urgent action is needed to improve the situation through enforcing salt iodisation legislation and increasing the level of knowledge about the importance of iodised salt in the population.

Validation of the second version of a quantitative food-frequency questionnaire for use in Western Mali.

OBJECTIVE: To assess the relative validity of the second version of a quantitative food-frequency questionnaire (QFFQ), designed to measure the habitual food and nutrient intake in one season in rural populations in Western Mali, West Africa. DESIGN: The dietary intake during the previous week was assessed with the 164-item QFFQ administered by interview. This was compared with the intake from a 2-day weighed record (WR) with weighed recipes. SETTING: The village of Ouassala in the Kayes region, Western Mali. SUBJECTS: Thirty-four women and 36 men aged 15-45 years, from 29 households. RESULTS: The QFFQ gave a lower intake of lunch and dinner and a higher intake of snacks than the WR. The discrepancies were larger for women than for men. The median proportion of subjects classified in the same quartile of intake was 29% for food groups and 36% for energy and nutrients. For classification into extreme opposite quartiles, the median proportion was 6% for food groups and 7% for energy and nutrients. Spearman's rank correlation for energy and nutrients ranged from 0.16 (% energy from protein) to 0.62 (retinol equivalents). CONCLUSIONS: The second version of the QFFQ tends to underestimate total food weight. The methods used for estimating food portion size should therefore be applied with caution. The changes made from the first version had little effect. The ability to rank subjects according to dietary intake is similar with both versions. The improved layout of the new QFFQ makes it a more user-friendly tool for comparing dietary intake between population groups and for measuring changes over time.