Nutrition education in medical schools (NEMS) project: Joining ESPEN and university point of view.

BACKGROUND & AIMS: Nutrition education is not well represented in the medical curriculum. The aim of this original paper was to describe the Nutrition Education in Medical Schools (NEMS) Project of the European Society for Clinical Nutrition and Metabolism (ESPEN). METHODS: On 19 January 2020, a meeting was held on this topic that was attended by 51 delegates (27 council members) from 34 countries, and 13 European University representatives. RESULTS: This article includes the contents of the meeting that concluded with the signing of the Manifesto for the Implementation of Nutrition Education in the Undergraduate Medical Curriculum. CONCLUSION: The meeting represented a significant step forward, moved towards implementation of nutrition education in medical education in general and in clinical practice in particular, in compliance with the aims of the ESPEN Nutrition Education Study Group (NESG).

Quality of life for up to 18 months after low-energy hip, vertebral, and distal forearm fractures-results from the ICUROS.

This study used data from the International Costs and Utilities Related to Osteoporotic fractures Study (ICUROS) to estimate the quality of life (QoL) impact of fracture. Hip, vertebral, and distal forearm fractures incur substantial QoL losses. Hip and vertebral fracture results in markedly impaired QoL for at least 18 months. INTRODUCTION: The International Costs and Utilities Related to Osteoporotic fractures Study (ICUROS) is a multinational observational study that aims to describe costs and quality of life (QoL) consequences of osteoporotic fractures. To date, 11 countries have participated in the study: Australia, Austria, Estonia, France, Italy, Lithuania, Mexico, Russia, Spain, the UK, and the USA. The objective of this paper is to describe the QoL impact of hip, vertebral, and distal forearm fracture. METHODS: Data were collected at four time-points for five QoL point estimates: within 2 weeks after fracture (including pre-fracture recall) and at 4, 12, and 18 months after fracture. Quality of life was measured as health state utility values (HSUVs) derived from the EQ-5D-3L. Complete case analysis was conducted as the base case with available case and multiple imputation performed as sensitivity analyses. Multivariate analysis was performed to explore predictors of QoL impact of fracture. RESULTS: Among 5456 patients enrolled using convenience sampling, 3021 patients were eligible for the base case analysis (1415 hip, 1047 distal forearm, and 559 vertebral fractures). The mean (SD) difference between HSUV before and after fracture for hip, vertebral, and distal forearm fracture was estimated at 0.89 (0.40), 0.67 (0.45), and 0.48 (0.34), respectively (p < 0.001 for all fracture types). Eighteen months after fracture, mean HSUVs were lower than before the fracture in patients with hip fracture (0.66 vs. 0.77 p < 0.001) and vertebral fracture (0.70 vs. 0.83 p < 0.001). Hospitalization and higher recalled pre-fracture QoL were associated with increased QoL impact for all fracture types. CONCLUSIONS: Hip, vertebral, and distal forearm fractures incur substantial loss in QoL and for patients with hip or vertebral fracture, QoL is markedly impaired for at least 18 months.

Quality of life, resource use, and costs related to hip fracture in Estonia.

UNLABELLED: We assessed the impact of hip fracture on health-related quality of life (HRQoL) and costs in Estonia. The mean 18-month HRQoL loss in quality adjusted life years (QALY) was estimated at 0.31, and the average cumulative cost from a societal perspective was 8146 euros per hip fracture patient. INTRODUCTION: The aim of this study is to estimate the impact of hip fracture on HRQoL, resource consumption, and cost over 18 months after the fracture among individuals aged over 50 in Estonia. METHODS: A cohort of 205 hip fracture patients ≥50 years was followed up for 18 months. HRQoL was estimated before fracture (recall), after fracture, and at 4, 12, and 18 months using the EQ-5D instrument. Health care utilization and costs were obtained from a public health insurance fund database; social, informal, and indirect costs were estimated using patient-reported data. RESULTS: Hip fracture resulted in the mean 18-month HRQoL loss of 0.31 QALYs. The mean 18-months cumulative cost of hip fracture from a societal perspective was estimated at 8146 (95 % CI 6236-10717) euros per patient. Most of the cost was related to health care (56 %) and informal care (33 %), while social care contributed only 5 %. Utilization of outpatient rehabilitation and nursing care was low (8 % of patients). CONCLUSIONS: The impact of hip fracture on HRQoL and cost was substantial. Despite appropriate inpatient care, utilization of rehabilitation, nursing care, and social care were low and potentially insufficient to meet the needs of patients with low HRQoL. The shortfall may partially explain a remarkably high use of informal care.

The incidence of hip fractures in Estonia, 2005-2012.

UNLABELLED: The incidence of hip fractures among individuals aged over 50 in Estonia and trends over time were assessed for 2005-2012. The incidence among women is relatively low, with the declining trend, but the rate among men is among the highest in Eastern and Central Europe. INTRODUCTION: The aim of this study was to assess the incidence and trends of hip fractures among individuals over 50 years in Estonia in 2005-2012 and to increase understanding of the incidence of hip fractures in Eastern Europe. METHODS: We identified all patients aged 50 years or older with hip fracture (ICD-10 codes S72.0, S72.1 and S72.2) in 2005-2012 using medical claims data from the Estonian Health Insurance Fund. Crude and age-specific incidence rates were calculated for men and women using the population of Estonia in 2005-2012. To adjust for age differences in the population, standardized incidence rates (SIR) were estimated. RESULTS: The SIR per 100,000 for the entire observation period was 209.2 (95% CI 204.2 to 214.2) in women and 215.6 (95%CI 208.2 to 223.1) in men, resulting in a female to male rate ratio of 0.97 (95% CI 0.84 to 1.11). Over the period of 2005-2012 the estimated SIR/100,000 ranged from 211.5 (95% CI 196.8-226.3) in 2005 to 183.7 (95% CI 170.8-196.7) in 2012 in women, and from 238.5 (95% CI 215.4-261.7) in 2005 to 187.9 (95% CI 169.0-206.8) in 2012, in men. For women, the decrease in SIR for the study period approached statistical significance (p = 0.058), and for the period of 2009-2012, we observed an accelerated 16% decrease (p = 0.008). CONCLUSIONS: The incidence of hip fractures among Estonian women is relatively low, whereas the rate among men is among the highest in Eastern and Central Europe. In line with many countries, we found a recent decline in incidence among women.

Vitamin D as a possible independent predictor of bone mineral density in Estonian adults: a cross-sectional population-based study.

BACKGROUND: Vitamin D insufficiency and deficiency are prevalent worldwide, with the highest prevalence in the northern countries due to the lack of ultraviolet exposure. The individual effect of vitamin D on bone mineral density (BMD) has been studied but the results are inconclusive. AIM: The aim of our study was to investigate the effect of vitamin D on BMD in a random population-based cohort of Estonian adults. METHODS: A cross-sectional population-based study. A total of 273 individuals free of diseases or states known to affect bone or vitamin D metabolism participated in the study. We measured BMD, vitamin D and parathyroid hormone concentrations (in winter and in summer). Several co-variables were included in the regression analysis, including age, smoking, alcohol consumption, body mass index, physical activity, fresh milk consumption, caffeinated beverage consumption, lean tissue mass and total body fat percentage, and in women the number of children and breastfeeding history. RESULTS: We show that summer vitamin D independently correlates with BMD in lumbar spine, trochanter and total body regions (P < 0.05 to 0.01). Subgroup analysis for women showed that summer vitamin D predicts independently lumbar spine (P < 0.05) and in men total body BMD (P < 0.01). Lean tissue mass and fat mass were additional contributors of the BMD (P < 0.001). CONCLUSION: In addition to body composition indices, vitamin D could be an independent contributor of BMD in several skeletal regions in men and women.

Body mass index determines sunbathing habits: implications on vitamin D levels.

Vitamin D is crucial for calcium and bone metabolism. Overweight people have been found to have lower levels of this vitamin. The aim of the paper was to test if sun exposure habits might differ according to weight and body fat per cent in a random population-based sample, and have an impact on vitamin D levels. The analysis of 367 persons showed that, among other established factors, differences in sunbathing also explain the lower vitamin D levels in overweight and elderly individuals.

Family doctors' assessment of patient- and health care system-related factors contributing to non-adherence to diabetes mellitus guidelines.

OBJECTIVE: The aim of this study was to assess family doctors' opinions on the patient- and health care system-related factors contributing to non-adherence to diabetes mellitus clinical practice guidelines (CPG) in Estonia. RESEARCH DESIGN AND METHODS: Descriptive postal survey using a self-administered questionnaire. RESULTS: Of the 354 doctors who received the questionnaire 46% (n=163) responded. Seventy-six percent of them have type 2 diabetes guidelines. Low awareness of diabetes and its complications as well as patients' low motivation to change their lifestyle were considered to be the biggest difficulties in managing individual patients. In addition to the most often listed problems non-compliance with medical regimen, patients' financial problems and their nonattendance were mentioned. The greatest health care system-related barriers to practices providing desirable care were the lack of special diabetes education for nurses and underfunding, and an inadequate number of patients' educational materials. The patient-related issues were regarded as problems in 96% of the cases and health care system-related factors were mentioned in 79% of the cases. CONCLUSIONS: Family doctors in Estonia consider patient-related factors to be key issues in non-adherence to diabetes mellitus clinical practice guidelines.

Patient satisfaction with care is associated with personal choice of physician.

OBJECTIVE: To evaluate whether choosing one's own primary care doctor is associated with patient satisfaction with primary health care. To evaluate factors related to population's satisfaction with primary health care. POPULATION: A random sample of Estonian adult population (N=997). STUDY DESIGN: Cross-sectional study using a pre-categorized questionnaire which was compiled by the research group of the University of Tartu and the research provider EMOR. RESULTS: Altogether 68% of the respondents had been listed in their personal physician. Their overall satisfaction with the physician as well as satisfaction with several aspects of primary health care were significantly higher compared with those of unregistered respondents. Although some other factors (practice size, patient age, health status) also influenced patient satisfaction, presence of a personal physician appeared the most important predictor of high satisfaction with physician's punctuality and understanding, effectiveness of prescribed therapy, clarity of explanations given by the physician as well as with overall satisfaction with the physician. CONCLUSION: Personal doctor system is associated with patient satisfaction with different aspects of care.

Setting national standards for practice equipment. Presence of equipment in Estonian practices before and after introduction of guidelines with feedback.

BACKGROUND: During the last few years quality assurance has received increasing attention in Estonian health care as well as in family medicine, which is a new speciality in Estonia (since 1993). The modest equipment that district doctors (former primary care doctors) had at their disposal, appeared inadequate considering family doctors' work tasks. AIM: To determine the type of equipment available in primary care practices before setting a standard, and 1 year after the minimal standard of practice equipment was introduced. To follow how well family doctors adhere to this standard. METHOD: A questionnaire was sent to a random sample of district doctors (n=157) in 1992 and to all family doctors practising as independent contractors in 1998 (n=376). Quality of equipping was assessed against the standard set by consensus of the representatives of Family Doctors' Society, based on the country's needs and family doctor's job description. RESULTS: The level of primary care doctors' office equipment in 1992 was quite low. However, by the spring of 1998, substantial improvement of the equipment in family doctors' practices was estimated. The number of doctors possessing instruments for otorhinolaryngological, ophthalmological and gynaecological work as well as for taking care of children had increased two- to three-fold. About one-half of the family doctors reported that they had all the instruments listed in the standard. CONCLUSIONS: Setting a national standard helps to improve practice equipment--an important structural aspect of quality of care. Although improvement of equipment alone cannot guarantee quality of care, it may provide an important first step towards promoting it.

Primary health care system in transition: the patient's experience.

OBJECTIVE: To find out how Estonian people evaluate the changes in primary health care (PHC), how they perceive the acceptability of the new PHC system, and to assess patients' satisfaction with their primary care doctor. DESIGN: Face-to-face interviews using structured questionnaires. SETTING: Estonia. STUDY PARTICIPANTS: A random sample of Estonian residents aged 15-74 years (n = 997). MAIN MEASURES: Acceptability of PHC system (accessibility, the patient-practitioner relations, amenities, and patient's preferences) and patients' satisfaction with primary care doctor. RESULTS: Of the 997 respondents, 46% were sufficiently informed about the transition to the general practitioner (GP)-based PHC system; however, 45% of respondents had not personally experienced any changes. Of the 997 persons interviewed, 68% were registered on the patient list of a GCP, and 62% of those who had health problems preferred to consult the primary care doctor first. The waiting time for an outpatient appointment was brief (0-2 days). Of the 997 respondents, 68% were satisfied with their primary care doctor. Satisfaction was dependent on: (i) how patients evaluated the competence of the physician; (ii) comprehensibility of doctor's explanations; and (iii) comfort of the clinic. The right of patients to choose their own primary care doctor and having sufficient information about the changes in PHC system had a positive influence on the level of satisfaction. CONCLUSIONS: Patients' opinions are important in the evaluation of PHC. To increase the level of satisfaction, people need to understand the nature and intent of the primary care reforms. Personal choice of primary care doctor and good patient-doctor relationships are important factors too.

Sex education and contraceptive methods: knowledge and sources of information among the Estonian population.

A survey on sex education and contraceptive methods was carried out within a monthly EMOR Omnibus Survey. By using a questionnaire, knowledge and attitudes, as well as the main sources of information on contraceptive methods and sex education, among the Estonian adult population (n = 618) was investigated. Of the respondents, 68% were female and 32% were males: the mean age was 34 years. Almost all respondents expressed the opinion that sex education should start at school and that education on contraceptive methods would reduce the number of abortions. The majority of the respondents believed that it would be more convenient to visit a family doctor than a gynecologist for family planning. Main sources of information on contraception were: literature, doctors and journals, as rated by females; and literature, partners and television, as rated by males. The roles of the school nurse, father and siblings were rated as comparatively small. The level of respondents' knowledge of contraceptive methods was not too high. It is concluded that the prerequisites for changing sexual behavior and knowledge over a short time are wider use of mass media and better sex education at schools. Also, it is necessary to prepare family doctors to offer family planning services to their patients.

Task profiles of district doctors in Estonia and general practitioners in Finland.

OBJECTIVE: To compare the task profiles of primary care doctors in two societies: district doctors in Estonia and general practitioners in Finland. DESIGN: A uniform questionnaire was developed and used in 30 European countries in 1993 (The European Study of GP Task Profiles). The questionnaire was sent to a random sample of Estonian district doctors and Finnish health centre doctors. Data from 139 respondents in Estonia and 239 respondents in Finland were obtained. MAIN OUTCOME MEASURES: Personal and practice information, proportion of doctors performing certain medical procedures in their practices by themselves and being the first contact in relation to different problems. RESULTS: The Finnish general practitioners (GPs) had more consultations per day, the Estonian district doctors made remarkably more home visits. Participation in on-duty work was 82% among the Finnish and 22% among the Estonian doctors. Most of the Finnish GPs worked by appointment, while this was uncommon in Estonia. More than 80% of the Estonian district doctors reported that they seldom or never performed the listed procedures by themselves. In Finland, more than 80% of the respondents carried out the procedures almost always by themselves. Handling children's and women's health problems was more frequent in Finland than in Estonia. The profiles of managing acute problems and problems of the elderly people were quite similar in both countries. The tackling of psychosocial problems as the first contact showed lower performance in both countries compared with somatic health problems. CONCLUSIONS: The task profiles of the Estonian district doctors and the Finnish GPs differed considerably. The distribution of the Estonian doctors' answers gives evidence for the existence of specialization already within primary health care where certain problems almost never reach the district doctor. The results of the present study supported the curriculum design for the retraining of currently practising district doctors.

Milk fat does not affect the symptoms of lactose intolerance.

OBJECTIVE: This study investigated the role of the fat content of milk on symptoms of lactose intolerance. DESIGN: Subjects recorded intolerance symptoms using a visual analogue scale (VAS) following ingestion of three test milks for varying fat content for a two-day period. SUBJECTS/SETTING: The subjects were thirty adult volunteers, patients of two Estonian out-patient clinics with diagnosed lactose intolerance. The study milks were drunk at home or at work. All thirty subjects completed the study protocol. INTERVENTION: Each subject drank, in random order, fat-free milk (4.9% lactose), high-fat milk (8% fat, 4.9% lactose), and a lactose-free and fat-free control milk. They drank 200 ml of the milk twice a day for two days, one milk type per session, with five days between sessions. The subjects noted their gastrointestinal symptoms during the test periods and during a 5 d milk-free period at the beginning of the study. The occurrence and severity of symptoms were compared. A global measure of the severity of symptoms was defined by computing the sum of the symptoms scores. RESULTS: The sum of symptoms was higher during all milk periods than during the milk-free period (P < 0.01). There were no statistically significant differences in the occurrence or severity of symptoms during the fat-free milk period compared with the high-fat milk period. CONCLUSIONS: Even a marked difference in the fat content of milk did not affect the symptoms of lactose intolerance. Consequently, there seems to be no case for recommending full-fat milk products in the treatment of lactose intolerance.

[The self-perception of their professional role of the primary care physicians of Estonia and Finland]. / Autopercepción del rol profesional de los médicos de atención primaria de Estonia y Finlandia.

OBJECTIVE: To find out how experienced primary care physicians working in different societies see themselves as doctors. DESIGN: A cross-sectional study. SETTING: Primary health care in Estonia and Finland. PARTICIPANTS: Estonian district doctors (n = 110) and Finnish specialists of general practice (n = 211). METHODS: In a postal questionnaire the respondents were asked to evaluate how well 18 different expressions described them as doctors on a 5-step scale from "1 = very poorly" to "5 = very well". RESULTS: Four of the five expressions that were thought most accurate and telling--"Listener", "Vocational doctor", "Helper", and "Family physician"--were the same in Estonia and Finland. CONCLUSIONS: Even though there are differences in health care systems, the self-images of primary care doctors in both countries were more or less consistent with the international definitions of the general practitioner's job and role.

How Estonian and Finnish primary care doctors rate their need for common drugs.

OBJECTIVE: To compare ratings of the necessity of drugs in the daily practice of experienced primary care doctors in Estonia and Finland to find out the differences and similarities in the therapeutic traditions of the two different societies. METHODS: A questionnaire was sent to all Estonian district doctors born in the 1940s and to all Finnish specialized general practitioners born in the 1940s, who then evaluated the necessity of the listed drugs on a visual analogue scale. The ratings, from 0 to 100, were entered into a computer, using a graphic tablet and a pressure sensitive pointer. RESULTS: The six most highly-evaluated drugs among the Estonian respondents were digoxin, glyceryl trinitrate, aspirin, calcium-channel blockers, beta-adrenoceptor blockers and frusemide; and among the Finnish general practitioners (GPs) were penicillin, insulin, glyceryl trinitrate, beta-adrenoceptor blockers, frusemide and angiotensin-converting enzyme (ACE) inhibitors. The ratings of 15 out of 33 drugs/drug groups were very similar both in Estonia and Finland. The biggest differences between the opinions of the Estonian and Finnish doctors appeared in the ratings regarding the necessity of antacids, cimetidine, insulin, sulphonylureas, reserpine. ACE inhibitors, oral contraceptives, penicillin, metronidazole, trimethoprim, indomethacin, phenobarbital and theophylline. CONCLUSION: The revealed differences are suggested to be related to the different health care systems (different task profiles of doctors, different pharmaceutical services), different education of doctors, different availability of drugs in the past and different prices, all of which influence therapeutic traditions.