An audit looking at how many patients are with thyroid dysfunction

An audit looking at how many patients are with thyroid dysfunction What is the function of thyroid gland and thyroid hormones The thyroid gland is located in the anterior part of the neck, attached to the thyroid cartilage. It consists of two lobes, approximately 5 cm each, that lie either side of the trachea joined in the middle by an isthmus. The thyroid gland is responsible for the production of three thyroid hormones: Calcitonin (involved with calcium homeostasis), Thyroxine (T4) and Triiodothyronine (T3). Everyday, approximately 100  ¿Ã‚ ½g of T3 and T4 are secreted 90% of which are in the form T4. Most of T4 is later converted to T3 in the liver and Kidneys. T3 is 10 times more active than T4. [1] The thyroid hormones are responsible for the control of basal metabolic rate. Expand? How is Thyroid hormone regulated The functional unit of the thyroid is the follicle. A spherical arrangement of secretory epithelial cells around a protein rich colloid. It is at this cell-colloid boundary that thyroid hormones are formed by iodination of thyroglobulin formed from tyrosine.[1] The follicular cells are involved in active absorption of iodine from the plasma which is required for thyroglobulin synthesis. The formed thyroid hormone is stored in the colloid until its secretion is triggered by thyroid stimulating hormone from the anterior pituitary which triggers the degradation of thyroglobulin in the follicular cells to release thyroid hormone. Thyroid hormone secretion is under the control of the hypothalamic-pituitary axis. The hypothalamus releases Thyrotrophin Releasing Hormone (TRH) which stimulates the anterior pituitary to secrete Thyroid Stimulating Hormone (TSH). The TSH reaches the thyroid where it binds to the TSH receptors on the surface of the follicular cell, stimulating it to produce and release thyroid hormones. The homeostasis of thyroid hormone concentration is maintained by a negative feedback loop whereby increased concentration of thyroid hormone inhibits Thyroid Stimulating Hormone release from the anterior pituitary by decreasing the affinity for TRH. This leads to a decrease in TSH causing reduced amount of thyroid hormone to be released by the thyroid gland. This feedback loop enables us to monitor patients on thyroid hormone replacement therapy (such as Levothyroxine) by measuring TSH levels. If for instance the prescribed dose is insufficient, it would lead to inadequate inhibition of the pituitar y gland and a raised serum TSH level. The reverse would occur with levothyroxine excess. () This cannot be done in patients with secondary hypothyroidism. So what do we do then? Common pathologies Thyroid disease is the second most common endocrine disorder after diabetes.  ¿Ã‚ ½ Hypothyroidism Hypothyroidism is defined as an underactive thyroid gland leading to decreased levels of T3 and T4. The annual incidence of hypothyroidism in the UK is 4 per 1000 in women and 0.6 per 1000 in men.[3] Symptomatic hypothyroidism is known as myxodema. Hypothyroidism is categorised into primary and secondary. Primary hypothyroidism results from disease processes affecting the thyroid gland itself, slowly decreasing thyroid function and thyroid hormone production. Onset of symptoms is therefore gradual, developing over months or even years. Secondary hypothyroidism is relatively uncommon. Secondary hypothyroidism develops when the pituitary is unable to produce enough TSH to induce enough T3 and T4 production from the thyroid gland. The causes of secondary hypothyroidism can include a pituitary tumour. Patients with hypothyroidism could present with a number of signs and symptoms including:  ¿Ã‚ ½ Tiredness  ¿Ã‚ ½ Somnolence  ¿Ã‚ ½ Slow cognition  ¿Ã‚ ½ Cold Intolerance  ¿Ã‚ ½ Depression  ¿Ã‚ ½ Bradycardia  ¿Ã‚ ½ Weight gain  ¿Ã‚ ½ Calf stiffness  ¿Ã‚ ½ Menstrual disturbance  ¿Ã‚ ½ Carpal tunnel syndrome  ¿Ã‚ ½ Hearing impairment  ¿Ã‚ ½ Dry, thin and pale skin  ¿Ã‚ ½ Puffiness below the eyes  ¿Ã‚ ½ Bradycardia The most common cause of primary hypothyroidism in the UK is autoimmune thyroiditis. In Hashimoto ¿Ã‚ ½s thyroiditis autoantibodies are produced against thyroglobulin. This leads to inflammation of the thyroid gland as it is infiltrated by lymphocytes causing goitre formation. Hashimoto ¿Ã‚ ½s thyroiditis is remarkable in this respect that it initially causes hyperthyroidism as inflammation of the thyroid gland releases stored thyroxine. Once this released thyroid hormone is metabolised the patient progresses to normal and then a hypothyroid state. [1] Other notable causes of hypothyroidism include:[4]  ¿Ã‚ ½ Iatrogenic: Radioiodine ablation or thyroidectomy as a treatment for hyperthyroidism  ¿Ã‚ ½ Thyroiditis: Subacute (de Quervain ¿Ã‚ ½s) thyroiditis  ¿Ã‚ ½ Drugs: Lithium, Amiodarone, thalidomide, rifampicin and sutinib as well as drugs used in the treatment of hyperthyroidism  ¿Ã‚ ½ Iodine deficiency: common in some developing countries but very rare in the western world At the opposite end of the spectrum lies Hyperthyroidism where there is increased Free T4 and a reduced level of TSH and has the opposite effect on the body than the one noticed in hypothyroidism e.g. tachycardia, heat intolerance etc. Hyperthyroidism is not covered further as this audit focuses on hypothyroidism. Diagnosis and treatment Symptoms of hypothyroidism are quite non-specific and can commonly occur with other medical conditions not related to the thyroid. Diagnosis of hypothyroidism therefore should not be made on clinical symptoms alone and it is essential to test thyroid function biochemically. This is done by measuring Thyroid Stimulating Hormone and Free Thyroxine (T4) in blood. The normal reference range for TSH is 0.4  ¿Ã‚ ½ 4.0 mU/Litre.[4] A TSH level within the normal reference range has over a 99% predicted value to rule out primary hypothyroidism or hyperthyroidism.[5] In hypothyroidism the patient would have a high Thyroid Stimulating Hormone level, with or without a low Thyroxine level. Depending on thyroid function tests hypothyroidism is further divided into: a) Overt hypothyroidism: patients with a high Thyroid Stimulating hormone level and a Low serum free Thyroxine (T4) b) Subclinical hypothyroidism: Patients with a high Thyroid Stimulating Hormone but a normal Thyroxine (T4) level Treatment depends on whether the patient has overt or subclinical hypothyroidism. Patients with overt hypothyroidism should be treated with Levothyroxine to render them  ¿Ã‚ ½euthyroid ¿Ã‚ ½.[5] According to NHS statistics 12 million Levothyroxine prescriptions were issued during 2006.[6] The goal of the treatment is to reduce the TSH back to within the reference range. The dose of Levothyroxine is usually titrated up from 25-50  ¿Ã‚ ½g daily however a recent trial has shown that this is unnecessary for most patients.[7] The study recommended that patients with no cardiac symptoms should be started on the full dose of 1.6  ¿Ã‚ ½g/kg. The following figure illustrates the algorithm for treatment of -pregnant adults with primary hypothyroidism:[4] Algorithm for management of non-pregnant adults with primary hypothyroidism [4] It is very important to monitor levothyroxine therapy as over or under prescription can be dangerous. Thyroid Stimulating Hormone (TSH) is the key method of monitoring levothyroxine therapy in patients with primary hypothyroidism. Unlike the thyroid function tests used to diagnose thyroid disease, free T3 and T4 levels are not very useful in monitoring treatment as their levels are influenced by the prescribed dosage of thyroid replacement hormone and are not accurate indicators of the individual ¿Ã‚ ½s requirement. TSH without T3 and T4 is also a cheaper test to carry out in General Practice. Current guidelines state that patients should have their Thyroid Stimulating Hormone level tested eight to twelve weeks after starting levothyroxine.[4] The dose can later be fine tuned accordingly to get the TSH level in the lower half of the reference range.[5] Besides monitoring TSH levels, an assessment of the patient ¿Ã‚ ½s symptoms should also be made as some younger patients may need higher doses to relieve their symptoms in which case it is acceptable to have the TSH between 0.1-0.4 mU/Litre. The Quality and Outomes Framework (QOF) guidance suggests that all Patients on long term thyroid hormone replacement therapy should have their TSH levels tested yearly to make sure their replacement dose remains optimal.[8] Audit 1. Reason for audit move it to the top to include the rest of the study Despite the yearly TSH tests, studies have shown that a considerable number of hypothyroid patients managed in primary care have TSH levels outside of the reference range. Okosieme et al reported that in 2009 data collected from 11 GP practices showed that 37.2% of the 1037 patients on the hypothyroidism register were inadequately managed.[9] When we take into account the high prevalence of hypothyroidism (9.3% in women and 1.3% in men)[3] the results of the Okosieme et al study suggests that the total number of patients with suboptimal thyroid hormone replacement is significantly large. Imperfect thyroid hormone replacement could have damaging repercussions for health. It may adversely affect blood pressure, body weight and lipid profile. Since the basal metabolic rate of the body is controlled by thyroid hormones it is perhaps not surprising that a decrease in thyroid hormone levels leads to a decrease in metabolic rate and thus can cause weight gain. Even in euthyroid subjects there is a negative correlation between free T4 and Body Mass Index (BMI).[10] This suggests that even a small under-prescription of thyroid hormones could, over a period of time, lead to obesity. Reduced Thyroxine levels also cause a dyslipidemia characterised by increased Low Density Lipoproteins (LDL) and a decrease in High Density Lipoproteins (HDL) with normal or slightly raised cholesterol levels.[11] Such a lipid profile is associated with a higher risk of atherosclerosis. The thyroid hormones also seem to have a role in blood pressure homeostasis as hypothyroid patients recorded a higher systolic and diastolic blood pressure after stopping thyroid replacement therapy.[12] Thus inadequate replacement may cause hypertension which, together with the dyslipidemia described above adds to the risk of atherosclerosis and its subsequent cardiovascular complications. Conversely, excessive thyroid hormone replacement has its own perils, having enhanced risk of atrial fibrillation, osteoporosis and fractures linked to it. Excessive thyroid hormone increases the risk of developing atrial fibrillation especially in older patients. Studies have shown that a low TSH level in patients over 60 years old have a threefold higher risk of developing atrial fibrillation.[13] Patients over treated with levothyroxine also show increased loss of bone mineral putting them at increased risk of osteoporosis.[14] Subsequent studies have shown that patients with a suppressed TSH i.e. = 0.03 mU/Litre also had an increased risk of fractures however this was not observed in patients with low but unsuppressed TSH (0.04  ¿Ã‚ ½ 0.4 mU/Litre).[15] This highlights the need for maintaining optimal thyroid hormone replacement in primary hypothyroid patients in the General Practice setting to reduce the above mentioned risk factors. The 11 GP practices used by Okosieme et al showed that there is significant room for improvement as one third of the patient population on levothyroxine had TSH levels outside the reference range.[0.11] Thus this is a worthwhile area for audit to establish current standards of care in our practice, Dr Dean Partners, Heald Green Health Centre. Since this audit has not been carried out before in the practice it would give an idea of how well the practice manages patients on thyroid hormone replacement therapy. The suggestions for improvement would be beneficial to the patients of the practice and might also help with obtaining QOF points. This audit would also be beneficial to me personally introducing me to the concept of audit cycles and giving me the opportunity to conduct my very first audit. It would also help me get a better understanding of management of hypothyroid patients which is the second most common endocrine disease in the UK after diabetes mellitus. 2. Criteria to be measured Serum Thyroid Stimulating Hormone is used as the gold standard for biochemically diagnosing hypothyroidism and monitoring thyroid hormone replacement therapy.[4] The reference range indicating adequate replacement is usually around 0.4  ¿Ã‚ ½ 4.0 mU/Litre.[4, 9] However this figure slightly varies according to local guidelines. For this I have chosen to use TSH between 0.1  ¿Ã‚ ½ 4.0 mU/Litre as a reference range for adequate thyroid hormone replacement as this is the reference range used by the local Primary Care Trust (Stepping Hill Hospital) and the practice. Patients with primary hypothyroidism on thyroid hormone replacement therapy should have a TSH level between 0.1  ¿Ã‚ ½ 4.0 mU/Litre. 3. Setting standards For setting the standard I have found that there are no specific guidelines stating what proportion of patients should be achieving the above mentioned criteria. There are no NICE guidelines for the treatment of hypothyroidism. The QOF guidance states that patients should have their TSH levels tested yearly but it does not state the standard of care required. Having discussed this with GP at the practice I have decided that a theoretically ideal standard i.e. 100% of patients meeting the above criteria would be very impractical in theory from a resources perspective. Given the fact that suboptimal thyroid hormone replacement could be harmful, it is nonetheless important to achieve a high standard of care. Therefore I have decided on an optimum standard: 90% of patients with primary hypothyroidism on thyroid hormone replacement therapy should have a TSH level between 0.1  ¿Ã‚ ½ 4.0 mU/Litre. 4. Preparation planning Before starting the audit I had a discussion with the GP tutor about worthwhile areas for audit. As I had never conducted an audit before he explained the audit cycle. As thyroid dysfunction was an area of interest for me I suggested undertaking this audit. The GP tutor agreed that this would be a useful area for audit and advised to me to review the literature to find out if it would be an appropriate audit from a clinical point of view and was an area where practice could be improved. After preliminary reading clinical reviews I formulated a step by step template of the things I felt should be covered and got the GP tutor ¿Ã‚ ½s approval to go ahead. The data was collected with the help of the GP tutor. As the practice keeps electronic records of all patients, EMIS Population manger search function. Using the search function we identified all patients who had been prescribed thyroid hormone replacement medication for the past 12 months. We then identified patients who in the past 12 months had had their TSH levels tested. We then selected patients who had a TSH =0.1 mU/Litre and TSH =4. Subtracting the number of patients which meet the TSH search parameters from the total number of patients on thyroid hormone replacement would give us the number of patients who were outside the reference range of TSH. 5. Initial data collection Criterion Number of Patients taking thyroid hormone replacement medication (n) Number of Patients with TSH levels within reference range Standard (%) Patients with primary hypothyroidism on thyroid replacement therapy should have a TSH level between 0.1  ¿Ã‚ ½ 4.0 mU/Litre. 206 167/206 (81%) 90% Discussion Results: what they are. How close to the standard. Are they good enough? (no, didn ¿Ã‚ ½t meet the standards). Why didn ¿Ã‚ ½t they meet the standard? Merge results discussion with limitations discussion The data collected shows that the current practice is 9% below the standard set. The standard required i.e. 90% of patients with primary hypothyroidism on thyroid hormone replacement therapy should have a TSH level between 0.1  ¿Ã‚ ½ 4.0 mU/Litre. However this was the case with only 167 patients (81%). This means that 39 patients (19%) did not meet the standard set. There could be several reasons why the results did not meet the standards set. One factor influencing TSH levels is the use of medicines which interact with thyroid function. Due to the limitations of the software used in data collection (as discussed below) we were unable to exclude patients who were on medication known to interact with thyroid function such as Amiodarone, Lithium, etc. Amiodarone, a fairly commonly prescribed drug to prevent arrhythmias, can cause deranged thyroid function as it contains iodine (37mg of iodine in 100mg of Amiodarone). This can cause a severe iodine overload and can lead to hypothyroidism as well as thyrotoxicosis.[0.16] Inclusion of such patients would bring the percentage down unfairly because management of such patients is a lot more complex and the TSH levels are not always a good indication of the adequacy of their thyroid hormone dosage. Patients with hypothyroidism due to Amiodarone are monitored by their Free T4 levels instead of TSH. [0.16] Another factor which could have contributed to the high number of patients with TSH levels outside those defined in the criteria is the possibility that patients with abnormal TSH levels often don ¿Ã‚ ½t get their levothyroxine dose optimised. A study published in 1995 reported that at one GP practice in Suffolk 71% of patients with abnormal TSH levels did not have their medication dosage change as a result.[17] If patients do not have their thyroid hormone replacement optimised as a result of abnormal TSH not only does it defeat the purpose of carrying out yearly TSH tests, it also means that these patients would continue to have an abnormal TSH when tested again. Currently we do not have the data to find out how many of the patients in our practice with abnormal TSH had not had their dose changed after a previous abnormal TSH in an attempt to bring it within the reference range specified in the criteria. Ranging from poor patient compliance to the way the data has been collected Lack of dose adjustment after abnormal TSH The way results were collected. Limitations of software used. Limitations of the results collected ie things missed: how many patients actually had test done in the last 12 months (QOF points). How many were over and how many were under prescribed. This audit has limitations. The data was collected from electronic records using the EMIS Population Manager. The limited search algorithms of the software meant that we couldn ¿Ã‚ ½t distinguish patients with a TSH below the reference range from those above it. All we were able to obtain was a single figure of how many people were within the reference range. Due to the limitations of the EMIS Population Manager software we were also unable to test how many patients with hypothyroidism had actually had their TSH levels tested in the past 12 months as stated in the QOF guidance  ¿Ã‚ ½ 2004.[8] Thyroid Function Tests are done for a large number of patients whose symptoms are actually caused by a non-thyroid illness. Due to this reason we could not search for people who had their thyroid function tested in the past 12 months as that data would have included a lot of non-hypothyroid patients. Instead we had to search for patients who had been prescribed levothyroxine therapy in the past 12 months. And then further narrow the search parameters TSH levels in the past 12 months to obtain the data. This meant that the people who have not had their thyroid functions tested in the past 12 months were excluded from our data. The positive aspect of only testing people within the last 12 months is that the data reflects current level of care. The data collection software shows patients as being within the normal TSH range if they have had at least one TSH test within the normal range during the last 12 months. If the patient has been started on levothyroxine therapy recently their TSH levels wouldn ¿Ã‚ ½t have had enough time to return to normal. However this is likely to be statistically insignificant. The way to get round these limitations of the EMIS Population Manager would have been to study the clinical notes of all patients who were prescribed levothyroxine in the past year. By looking at the notes we would be able to exclude patients who are unsuitable for the purpose of this audit i.e. those patients in whom the TSH level is not a valid indicator of thyroid hormone requirement e.g. those on Amiodarone or lithium or patients with secondary hypothyroidism. Looking at the notes would also allow us to check the number of patients who had not had their TSH levels tested in the past year. Reading through the notes would also allow us to obtain more information such as age gender etc which might be helpful in indentifying some of the factors responsible for suboptimal thyroid hormone replacement. However reading the notes of over 206 patients would have taken a considerable amount of time. Since this was my first audit I decided to avoid gathering qualitative data and decided that the using electronic records would be sufficient for the purposes of this audit. Changes to practice to hit the target. Tietable to implement that change and when to re-audit? Practicality, why change? Positives and negatives of changing. There are a few approaches which could potentially be taken to improve the standard of care. In order to improve the standard of care to meet the goal of 90% all patients on the hypothyroidism register should have yearly or six monthly blood tests to measure their TSH levels. all patients with abnormal TSH levels should be invited for an appointment with the GP and should be considered for a change in their current dosage. This would be a good opportunity to assess why their TSH levels are abnormal and check that the patient is adhering to the prescribed treatment regimen. If the dose remains unchanged the reason should be recorded in the notes so that the information is available for the second cycle of the audit. Doing this will allow us to make sure that patients are kept at the optimum dose of levothyroxine to reduce the risks associated with under or over prescription. Seeing patients like this would however increase the workload placed on the surgery and its resources. However by talking the patients as and when they have their TSH levels tested the strain on the resources would be spread out over a year. Since the current audit identified 39 patients with abnormal TSH levels, this would mean an extra 3-4 patient appointments per month over the period of a 12 months. This should be discussed at the doctors ¿Ã‚ ½ meeting. Twelve months after the implementation of the change of practice a second data collection should be done to complete the audit cycle and evaluate the impact, if any, the change in practice has had on the management of hypothyroid patients. Write to the patients to invite them to come in for a dose adjustment? Consider collecting better data by reading the notes. That would take too long. Consider specialist referral if symptoms persist. What have I learned: 1 about the condition, 2 about auditing. Conducting this audit has given me the chance to take an in-depth look at all aspects of hypothyroidism which has been an area of interest for me for some time. In the course of researching for the audit I have been able to review various guidelines, clinical reviews and other journal articles. Not only has that improved my understanding of the management of thyroid disease in primary care immensely. It has given me a sense of how a condition is followed through in general practice from first presentation to treatment to long term management. I have also realised that management of chronic conditions such as hypothyroidism is an ongoing process as the patients ¿Ã‚ ½ condition and requirements change continuously for instance if their body mass index changes significantly their thyroid hormone requirements would also change and the dose would have to be altered. Also if a patient is planning on or has become pregnant they would need to be referred to specialist endocrinologists. I have been able to review the evidence which forms the basis of current practice. Researching this topic by reading clinical reviews has made me realise the advantages of using original literature and how much beneficial it can be in achieving a comprehensive understanding of a topic. Being involved in a general practice standard-based audit has enabled me to learn about the role and significance of audits in healthcare. I have become familiar with the audit cycle and its different steps. Having conducted an audit myself, I can see the important role audits have in measuring and improving practice. It is a systematic way of monitoring standards of care and is very useful in facilitating change of practice through an evidence based approach. It has also allowed me to learn how to quickly and efficiently find relevant papers using such resources as ISI Web of science and medline. Conclusion and summary Timetable change re-audit 6. Description of change 7. Data collection (2) 8. conclusions be almost impossible to achieve due to variables like poor patient compliance or use of interactive medications e.g. Amiodarone and Lithium. It would also be vastly impractical from a reasources point of view to aim for a 100% standard.

The consumer pull demand in packaged milk

The consumer pull demand in packaged milk As the topic of the research is The consumer pull demand in (Packaged milk) industry so it involves an in depth study about the nature of the consumer, taste the consumer likes, preferences of the consumer, brand loyalty and many other characteristics related to the consumer and as well as to the product. According to this research topic the most suitable research type suppose to be used is Descriptive Research. This will help to determine the target market and segmentation done in the beverages (packaged milk) industry. Descriptive research is most commonly used and the basic reason for carrying out descriptive research is to identify the cause of something that is happening. Descriptive research is used to obtain information concerning the current status of the phenomena to describe what exist with respect to variable or condition in a situation The descriptive research will further help to conduct descriptive surveys to identify the characteristics of consumers who purchase soft drinks, for example mostly consumers tend to live in larger cities; buyers are mostly youngsters, housewives, working people and so on; it will help to determine the market potential; it will help to identify the extent of differences in the needs, perceptions and attitudes of the subgroups. 3.2 Research Hypothesis The following hypothesis will be formulated and tested by the researcher. Ho: The impact of advertising will not effect on consumer demand. H1: The impact of advertising will effect on consumer demand. Ho: Consumer preferences will not be checked about the type of milk they buy. H1: Consumer preferences will be checked about the type of milk they buy. Ho: The reason why customers will not discriminate among different brands H1: The reason why customers will discriminate among different brands. Ho: Extent of competitive forces in the market will not be checked. H1: Extent of competitive forces in the market will be checked. Ho: To analyze the consumer trends not in the market. H1: To analyze the consumer trends in the market. Ho: To monitor the extent to which consumer demand will not be affected by core features of product. H1: To monitor the extent to which consumer demand will be affected by core features of product. 3.4 Theoretical Framework Diagram The theoretical framework has been made with the help of the variables which are related to the consumer pull demand in beverages (soft drinks) industry. With the help of the variables it becomes easy to the study about the relationship between different factors affecting the consumer pull demand. PRICING Market skimming Market penetration Target market Brand image Product Diversity Brand Consumer Choice Convenience Attraction Brand Image Sales External Factors Social Cultural Economic Legal Religious Government Packaging Brand image Eye catching packaging Usage status Advertising Consumer perception Consumer preferences Brand image CONSUMER PULL CONSUMER PULL Distribution Availability Need satisfying Brand image Consumer Buying Power High household income. More than one earning member. Brand image. 3.4.1 Variable Reference List Dependent Variable Consumer pull demand Independent Variable Market stage Distribution Advertising Pricing. Product diversity. Packaging Consumer Buying Power Selective Distribution Core Product Need Satisfying Availability Consumer Perception Consumer Preference Market Penetration Marketing Skimming Target Market Demand Usage Status Brand Image Eye-catching Packaging. External Factors. Product diversity. 3.4.2 Theoretical Justifications of Variables In the framework each variable is related to the consumer pull demand and they show that how each of them affects consumer pull demand in the beverages (milk industry) industry. The variable used market stage effects the sales of milk (packaged milk) industry. Market stage helps to determine the market situation and consumer behaviors according to the changes in the market situations. Market stage includes to determine market life cycle, consumer behavior, product demand which includes that whether the demand is inelastic or elastic and these all end up to see the sales of the soft drinks industry. After doing survey on these all components of the market stage the sales can be maximized. The second variable used in the theoretical framework is distribution this also helps in maximizing the sales in the packaged milk industry. Its very important to make the product available to all the locations so that consumers may feel ease in buying the product. Distribution helps to make the product available and convenient. Distribution also includes giving the time and place advantages to the consumers so that they are able to purchase the product because through all these ways product will be placed at every shop and consumers will have a good image about the product. This will help to increase the sales of the packaged milk. Packaging is a very important aspect in increasing the sales of a product. The packaging of the packaged milk will help the company to gain brand visual and brand identity. For positioning a product good packaging is very essential. Packaging helps to attract the consumers towards the product and from packaging. The product is differentiated from other products. So packaging is considered to be an important element for increasing the sales in soft drinks industry. Advertising is also an important element for increasing the sales of a product. Advertising can be done above the line (ATL) and below the line (BTL). Advertising can also be done through mediums such as television, radio, banners, billboards and newspapers. Advertising helps the product in gaining popularity. This will help to increase the sales. Pricing also helps for the success of the product. Pricing includes the strategies such as market skimming and market penetration. With the help of pricing it becomes easy to identify the target market and by this company can offer the prices which consumers are ready to pay. If the consumer finds the product reasonable so this is positive for the sales of the product. Product diversity plays an important role for gaining the increasing trend in the sales. Product diversity creates brand consumer choice and brand image, it also makes the consumers to get attracted towards the product. Consumers get variety in products so they dont get bore and they keep of buying new variety of products. External factors also increase the sales of the product. External factors include study on demographics, economic conditions, competition, social and cultural forces, technology and lastly the political and legal forces. In marketing external factors have a major influence on products marketing opportunities and activities. So the study of all related factors helps in increasing the sales in the soft drinks industry. 3.5.1 Examples The questions to be asked from the respondents would be based on their liking and what factors make them to buy their referred milk brand. Q1. Do you use packaged milk or loose milk? à ¢Ã‚ Ã‚ ª If yes then why à ¢Ã‚ Ã‚ ªIf no then why - Q2. Which milk brand do you use? à ¢Ã‚ Ã‚ ªOlpers à ¢Ã‚ Ã‚ ª Good milk à ¢Ã‚ Ã‚ ª Nestle Milk Pak à ¢Ã‚ Ã‚ ª Haleeb à ¢Ã‚ Ã‚ ª other please specify - Q.3. which packaged milk do you prefer but unable to purchase due to other factors like expensive, health issues etc? à ¢Ã‚ Ã‚ ªOlpers à ¢Ã‚ Ã‚ ª Good milk à ¢Ã‚ Ã‚ ª Nestle Milk Pak à ¢Ã‚ Ã‚ ª Haleeb à ¢Ã‚ Ã‚ ª other please specify - Q.4. you use packaged milk for which purpose? à ¢Ã‚ Ã‚ ª Strong bones à ¢Ã‚ Ã‚ ª Calcium à ¢Ã‚ Ã‚ ª Diet conscious à ¢Ã‚ Ã‚ ª Other Q.5. you prefer to buy your particular milk brand forà ¢Ã¢â€š ¬Ã‚ ¦. à ¢Ã‚ Ã‚ ª Disposal packaging à ¢Ã‚ Ã‚ ª Expensive packaging à ¢Ã‚ Ã‚ ª Attractive packaging à ¢Ã‚ Ã‚ ª Health hazards issues à ¢Ã‚ Ã‚ ª other please specify - Q.6. How often do you buy milk? à ¢Ã‚ Ã‚ ª Daily à ¢Ã‚ Ã‚ ª Bulk buying à ¢Ã‚ Ã‚ ª Weekly à ¢Ã‚ Ã‚ ª Monthly 3.5.2 Population, Working population and Planned sample The population of whole Pakistan is targeted for this survey. Working population is Punjab and planned sample is Lahore. The survey is limited to Punjab and further its restricted to the city Lahore due to the time constraints. As study is confined to Lahore only, therefore, the results may not be generalized well in other cities. 3.5.3 Sample Size Consideration For this study questionnaire will be made to be filled by a total of 100 consumers, living in different locations in Lahore. 3.5.4 Choice of Sampling Technique This is cross sectional study, which will be conducted in a natural setting and it will be covering both descriptive research and as well as causal. It will be based on primary and secondary research. The level of investigation in this study will be focused on the collection of data about consumer preferences in packaged milk industry. In this research the sampling technique used will be probability. And further under probability the technique used will be convenience sampling technique. Convenience sampling is useful in obtaining large number of completed questionnaire quickly and economically and large number of respondents can be obtained quickly. 3.5.5 Field work and Respondents profile This is cross sectional study, which will be conducted in a natural setting and it will be covering both descriptive research and as well as causal. It will be based on primary and secondary research. The level of investigation in this study will be focused on the collection of data about consumer preferences in beverages (soft drinks) industry. The relevant data will be collected through a survey. For this purpose a questionnaire will be designed and distributed among consumers. The questionnaire will include information regarding consumers personal preference, brand loyalty, taste preferences and other factors that attract the consumer. The target population will comprise of both male and female customers but mainly targeted to household wives because they better understand the values and needs of their household members, specially children and youngsters and by making their choice a preference they can judge more easily what they actually want. Consumption of milk is common in every age. For this study the target population will comprise consumers living in different areas of Lahore Chapter 4: Estimates, Analysis and Conclusion 4.1 Estimated Results Hypothesis Ho: The impact of advertising will not effect on consumer demand. H1: The impact of advertising will effect on consumer demand. Analysis From my findings and analysis from questionnaire and pilot study it is estimated that advertising will not affect the consumer demand so, Ho is accepted. 4.2 Analysis of Findings The ratio I found from my analysis is that the maximum age group ranges from 18-25 and 25-35, means that mostly the age group is young and can analyze the factors which can affect the consumer demands. Percentage of age group (35-45) is 22.3%, which is somewhat lower than the age group ranges from 18-35. Age group of 45-55 has a percentage of 8.0%. For above 55 percentage was 5.45 which was comparatively lower than the previous ones. Monthly income of household ranges till 30%, Mostly consumers has a monthly income above 50,000. And then percentage for income 25000-50,000 is 23.3%, for 10,000-25000 consumers percentage was 16.1% which was relatively lower than the30%. Valid percentage I found is 30.4% which for the income group of above 50,000.When I analyzed the occupation for consumers the result collected are that students has a frequency of 15 and their percentage is 15.0% of 100. House wives was the major target market for me so it has a frequency of 60 and percentage I found ou t is 53.6%, and valid percentage for house wives is 60.0, and most of the consumers were self employed the percentage for self employed consumers is 18.8% and their frequency is 21. Another ratio is 3.6% which is for businessman out of 100.and the valid percentage is for housewives which is 60.Percentage for male is 26.8% and frequency is 31. As questionnaire was designed mainly to target the housewives because preference for packaged milk was required, so they have a percentage of 61.6% ad frequency for female is 69.Marital status for married men and women is 59.8% with a frequency of 67, whereas for unmarried it was 29.5% with a frequency of 33.When consumers were asked that either they used packaged milk or loose milk or both the greater percentage is for both, packaged milk and loose milk as well, packaged milk has a percentage of 42.9% and that for both the percentage it is 46.4%.and there is a very small percentage for only loose milk. Consumers prefer to use both packaged mil k and loose milk for different purpose and in different ways.For a milk brand consumers has a higher percentage of 33.9 for Nestle milk pack with a frequency of 38 which is higher than olpers which has a frequency of 28 with a percentage of 25.0% which means that consumers are still loyal to their particular milk brand they try a new product for once but as their taste is developed through out so they are satisfied with their particular milk brand, whereas Haleeb has a percentage of 16.1, Good milk has comparatively lower percentage of 2.7 and consumers has other preferences as well such as flavored milk other than plain milk , they have different choices for milk . Percentage for other milk is 10.7% which includes Nurpur, Nesvita , Nirala and Dairy Queen and flavored milk as well. Higher percentage for Nestle Milk pack shows that still after facing a very tough competition in market with Oplers Haleeb and other competitors Nestle Milk Pack still has its own stand in the market and consumers still prefer Nestle Milk Pack. After analyzing almost 37.5% of the consumers prefer to buy Nesvita, Dairy Queen, Nurpur and Nirala if they are unable to purchase their particular milk brand due to health hazards issues and expensiveness. Although 25 consumers prefer to buy Olpers, and 11.6 % from them has a preference of Good milk whereas Haleeb has a percentage of 10.7 as compare to other brands. Almost 28.6% of the consumers buy their particular Milk Brand for Stronger bones and 33 of them buy for the purpose of calcium which can make your bones and body strong and fit, 17 of them were diet conscious. Consumer prefer their particular milk brand for health hazards issues with a frequency of 48, to avoid bacterial effects which are included in loose milk, 8.9% of consumers prefer their milk brand for attractive packaging which attract them through TVC, Billboards, adds in news paper etc. although 4.5% of them are status conscious and they buy their particular milk brand fo r Expensive packaging. Almost 69.6% of the consumers would buy their particular brand if their brand is changed into uncommon shape and with new features etc, and 18 of them with a percentage of 16.1 would not like to buy it. There are consumers who strongly agree that demand of their particular milk brand is affected by the price cut and their percentage is 14.3 with a frequency of 16.and 47 of them agree with this statement, whereas 34 of them are neutral about their decision whether the demand of milk brand is affected by the price cut or not, 34 consumers agree that their demand of buying a particular milk brand is affected by advertisement, and 64 of them does not agree. Although advertisement of a milk brand is very important for promotion and convincing consumers and giving awareness about their brand, through advertisement consumers can make the mind of consumers to buy their brand, 41 consumers are brand loyal thats why they buy their particular milk brand with a percentage of 36.6, and 23.2% are attracted towards advertisement for the brand and they buy their particular milk brand by watching TV commercials and through different mediums. Consumers are also attracted towards a milk brand for their packaging and their percentage is 24.1. Consumers ranked their quality of milk brand with a percentage of 61.6 and frequency for average is 7.this means that they are satisfied with their milk brand. And for packaging consumers also have a high percentage of 36.6. For pricing consumer has a preference 34.8 being the highest and 7.1 as satisfactory. Availability of their particular milk brand is good as highest percentage is 42.0. While buying milk 52.7 give preference to whiteness of milk, 38.4% gives preference to thickness, where as 50.0% prefer taste of their milk brand before buying and 46.6% of consumers prefer to buy a milk brand which is easy to use. Most of the consumers buy milk daily as their percentage is 51.8 with a frequency of 58. Whereas 24.1% of them do bulk buying, and 15 consumers consume milk weekly .Preference of household member is calculated which is 48 those who frequently ask and 25.9% ask their household member rarely before buying a particular milk and 17.9% of them never asked before buying a milk brand, reason being that mostly questioners were filled by the housewives and they are aware of choice and preference of their household members. Highest percentage of consuming milk is 1 liter and consumption for more than  ½ and 1 liter is 50.9%.and consumers like to buy a milk brand from any well reputed departmental store and 36.6% of them buy their milk brand from near by shop. After analyzing packaged milk there are consumers those who use loose milk and they use loose milk for various purposes like tea, desert, drinking etc with a percentage of 25.9. Consumers those who loose milk over packaged milk has an issue of price as their percentage is 28.6, because price of loose milk is comparatively lower than th e packaged milk. And most of them use loose milk for availability purpose as well with a frequency of 14. 4.4 Limitation of the Study The study is limited by the following factors: The study is confined to Lahore only. Therefore, the results may not be generalized well in other cities. There are many other variables which affect consumer pull demand but will not be considered in this study. It is difficult to determine the precise sample size. The consumers may vary in their interpretation of question 4.5 Conclusion People consume milk in fresh dried and concentrated forms; in grocery stores most commonly sold product to consumers is liquid milk. All types of milk (pasteurized, sterilized, UHT, Packaged) or in bulk are required in a country or locality. New packaging system of milk is a popular and for practical purposes packaged milk powders. From my analysis and finings of questionnaire, pilot study and regression analysis I found out that 58.0% consumer consume milk, and widely used packaged milk is Nestle Milk Pack with a percentage of 33.9. People have different preferences and tastes and they consume milk according to them, consumers also use flavored milk for e.g. chocolate milk, Pakola etc but their percentage is low as compare to plain liquid milk. People living in well developed and posh areas of Lahore like Defence and Gulberg have more preferences of taking packaged milk, while people with lower income bracket prefer to take milk from milk-man. Biggest reason what I find is the exten t and the level of prevailing competitiveness in the milk industry. The marketing plans are of key importance in this regard. Consumers are attracted more to the good that is marketed well. There are many advantages of packaged milk, delicious, hygienic, Status symbol and prevailing prices are justified. Milk is one of the essential diets for every age, it helps building strong bones, and milk is loaded with eight essential vitamins and minerals which are very important and plays a vital role in a human body, and percentage of consumers those who buy milk for health hazards issues are 42.9, and 29.5% of consumers buy milk for disposal packaging, this shows that consumers are quite conscious about their health issues and at the same time they prefer to buy milk which can help them preventing from bacterial affects like cholera, malaria and Diarrhea etc. price but is not affected for consumers because they have to drink milk, and if prices are increased people cannot stop drinking mil k but they adjust accordingly. Although advertising do matters for consumers to know more about their product, and children are attracted towards the jingle that now-a days milk brands are using in their advertisements, because children are more attracted towards packaged milk than loose milk reason being the taste of the packaged milk is more tastier than loose milk packaged milk is healthy, and has no bacterial affects as compare to loose milk. References: Attitude and Usage Trend Study (AUTS). Chocolate Milk. Beverage Usage Attitudes among Consumers. May 2001. International Dairy Foods Association. Milk Facts. 2000 Edition. Washington, D.C.: International Dairy Foods Association. November 2000, p. 34. U.S. Department of Health and Human Services, Food and Drug Administration. Code of Federal Regulations. Title 21, Chapter 1, Part 131 (Milk and cream), Subpart B (Requirements for Specific Standardized Milk and Cream). Washington, D.C.: U.S. Government Printing Office. Revised as of April 1, 2000. Childrens Chocolate Milk Survey. Prepared for National Dairy Council by McDonald Research, Inc. May 1998. Tomashek, K.M., S. Nesby, K.S. Scanlon, et. al. Commentary: nutritional rickets in Georgia. Pediatrics 107(4), April 2001. e45. http://www.pediatrics.org/cgi/ content/full/107/4 Kreiter, S.R., R.P. Schwartz, H.N. Kirkman, Jr., P.A. Charlton, A.S. Calikoglu, and M.L. Davenport. Nutritional rickets in African American breast-fed infants. J. Pediatr. 137: 153-157, 2000. Guthrie, H.A. Effect of a flavored milk option on a school lunch program. J. Am. Diet. Assoc. 71: 35-40, 1997. Anderson, G.H. Sugars and health: a review. Nutr. Res. 17(9): 1485-1498, 1997. The American Dietetic Association. Position of The American Dietetic Association: use of nutritive and nonnutritive sweeteners. J. Am. Diet. Assoc. 98: 580-587, 1998. U.S. Department of Agriculture and U.S. Department of Health and Human Services. Nutrition and Your Health: Dietary Guidelines for Americans. 5th edition. Home and Garden Bulletin No. 232. Washington, D.C.: U. S. Government Printing Office, 2000. Guthrie, J.F., and J. F. Morton. Food sources of added sweeteners in the diets of Americans. J. Am. Diet. Assoc. 100: 43-51, 2000. Washington State Dairy Council 1998, Revised National Dairy Council 2001. Think Your Drink. 2001. National Dairy Council. A protective effect of dairy foods in oral health. Dairy Council Digest 71(1): 1-6, 2000. http://www.nationaldairycouncil.org/ NationalDairyCouncil/ Gibson, S., and S. Williams. Dental caries in pre-school children: associations with social class, toothbrushing habit, and consumption of sugars and sugar-containing foods. Caries Res. 33: 101-113, 1999. Bowen, W.H., and S.K. Pearson. Effect of milk on carcinogenesis. Caries Res. 27: 461-466, 1993. Dehkordi, N., D.R. Rao, A.P. Warren, and C.B. Chawan. Lactose malabsorption as influenced by chocolate milk, skim milk, sucrose, whole milk, and lactic cultures. J. Am. Diet. Assoc. 95: 484-486, 1995 Andrew. M. Novakovic.(1995) Testimony of Fedral Dairy Policy, Cornell University Syracuse New York. Anthony Bennett, Frederic Lhoste, Jay crook and Joe Phetan.(2005) The Future of Small scale Dairying. David Zahn, LLC Windsor Road. E, North Heaven CT. Diana Beccue Brown, (1987) Consumer in Search of Value. FAO (1996) Milk and Milk products Marketing Milk Processing. Narvasana. Lewis. H. Haney, (1920). Integration in Marketing. Vol 10.No 3. (sep,1920),pp.528-545

DArtagnan :: essays research papers

D'Artagnan is a young, impoverished man from the rural area of France called Gascony. He goes to Paris in hopes of becoming one of the king's musketeers. He has few assets and relies on his wit and charm to guide him. Despite his lack of juvenility, he still deeply believes in the idea of chivalry. It is that ideal that earns him the respect and friendship of his friends Athos, Porthos, and Aramis. D'Artagnan is also a very passionate man. He pursues both his enemies and love interests with reckless abandon. An example would be D'Artagnan's pursuit of his 'evil-guiness,'; Rochefort. Also, his passion is exhibited in his quest to aid the queen. Such deeds also prove D'Artagnan's bravery. And, it is D'Artagnan's bravery that earns him the trust of the queen and allows him to pursue his love interest, Madame Bonacieux. D'Artagnan's bravery also allows him to become a soldier, and later, a musketeer. It also gives D'Artagnan the courage to battle against the cardinal, despite his power. Thus, his bravery also gets him into trouble. D'Artagnan is constantly at battle against the cardinal and his agents. However, D'Artagnan is not alone in his battles. His friends support him throughout the book. And, D'Artagnan is equally allegiant to his friends. He supports his friends whenever the need arises. An example would be D'Artagnan's choice to fight with his friends in their first melee with Rochefort. D'Artagnan is indubitably loyal to his friends, as they are to him.   Ã‚  Ã‚  Ã‚  Ã‚  Loyalty is a prominent theme in the book. It is the very essence of the characters, 'All for one and one for all.'; The four friends are devoted to each other and prove it throughout the book. The friends all nobly stand by each other in their battle against the cardinal. On several occasions D'Artangnan calls upon his comrades to help him in his quests. D'Artangnan tells them nothing of the details simply that they are likely to perish on the journey. Yet, all the friends immediately and without query agree to assist D'Artangnan. Another example is D'Artangnan's extreme loyalty to the queen and his love Madame Bonacieux. D'Artagnan accepts several dangerous missions from the queen. He risks life and limb to help save the queen from scandal. And again endangers himself in an attempt to rescue his beloved Madame Bonacieux. It is D'Artagnan's loyalty that actually makes him a musketeer.

Early American Writers Essay -- essays research papers

Early American Writers In the literature of early American writers there is one common trait among all the writings: religion. Among Anne Bradstreet and Jonathan Edwards all speak of their opinion of religion, god, heaven, and material things. Anne Bradstreet was a puritan wife, originally from England but then moved to America. Upon moving and settling into her home, her poems became full of emotion and spoke about concerns from her heart. She was religious and believed that men had superiority over women. A common concern in these religious writers was the unimportance of material things on Earth. In Bradstreet's Upon the Burning of Our House July 10th, 1666, her house was burned to the ground. Nevertheless, she did not shed to many tears because she knew that "Thou hast an house on high erect," meaning that her real home was in heaven. She found comfort in god and her belief in her made her strong and able to move on in her life. When she starts thinking about all her possessions that she had lost she would "Raise up thy thoughts above the sky . . . " and remember these things do not matter, what matters is her "house on high." Jonathan Edwards also found comfort in god, "leading me to sweet contemplations of my great and glorious God." Jonathan was also a puritan from the early America, however, he was a preache...

Free Essays on Vouchers, School Choice, and Charter Schools :: Argumentative Persuasive Topics

School Choice and Charter Schools    I am not so sure I am for or against the idea of school choice as much as the idea for educational equality. If school choice and charter schools are the way this country will gain equity in the schools then I am for school choice. I feel that the impoverished are not going to get the best education that is available to them in their area. If the town fifteen miles away is a much better school, both educationally and developmentally, then I believe that the student that goes to school A should have the opportunity to attend school B. Why should someone who was born into an underpriviledged home live an underpriviledged life? This child did not choose to be born into this family, so I believe we should give them some kind of choice in their lives. A good education, along with other assets that one can gain through education, is the answer to bettering one's life. It gives these childrenm the choice to make a different life for themselves and for their children.    I am not so sure that there is an ideal school choice program, but then again does there really have to be? Choice is choice. If I am given the opportunity to choose, I will most likely make the right decision or I will fix the mistake that I made. If people are given the chance to better their lives, they will take that opportunity, if they are smart. We, as change agents, are not responsible to hold the hands of those who do not take the bull by the horn! There is only so much people can do for others. Give them the choice, and if they take it greeat, and if they don't, what else can we possibly do.    I think the only responsibilty of the change agents are to inform the public of their choices. Let the public know what is out there, and what the benefits are to school choice. Most people are going to wonder why they should take the trouble to transport their children to a school that might be a little farther than the school in the neighborhood. I believe that it is also very important to give many choices. I think it would be a mistake to limit the students to certain schools. Free Essays on Vouchers, School Choice, and Charter Schools :: Argumentative Persuasive Topics School Choice and Charter Schools    I am not so sure I am for or against the idea of school choice as much as the idea for educational equality. If school choice and charter schools are the way this country will gain equity in the schools then I am for school choice. I feel that the impoverished are not going to get the best education that is available to them in their area. If the town fifteen miles away is a much better school, both educationally and developmentally, then I believe that the student that goes to school A should have the opportunity to attend school B. Why should someone who was born into an underpriviledged home live an underpriviledged life? This child did not choose to be born into this family, so I believe we should give them some kind of choice in their lives. A good education, along with other assets that one can gain through education, is the answer to bettering one's life. It gives these childrenm the choice to make a different life for themselves and for their children.    I am not so sure that there is an ideal school choice program, but then again does there really have to be? Choice is choice. If I am given the opportunity to choose, I will most likely make the right decision or I will fix the mistake that I made. If people are given the chance to better their lives, they will take that opportunity, if they are smart. We, as change agents, are not responsible to hold the hands of those who do not take the bull by the horn! There is only so much people can do for others. Give them the choice, and if they take it greeat, and if they don't, what else can we possibly do.    I think the only responsibilty of the change agents are to inform the public of their choices. Let the public know what is out there, and what the benefits are to school choice. Most people are going to wonder why they should take the trouble to transport their children to a school that might be a little farther than the school in the neighborhood. I believe that it is also very important to give many choices. I think it would be a mistake to limit the students to certain schools.

Managing Oneself

Managing Oneself By: Peter Drucker Tami Cusick Loma Linda University EMMC 453 The article â€Å"Managing Oneself† is mainly about that in order to be successful you have to know and understand yourself. I agreed with Drucker that if you have ambition and smarts and work your way up in your profession that it doesn’t matter where you started. There are many upper level managers that started as a field employee within AMR. It is clear that they were ambitious and chose to continue on in this profession and just look at where it has taken them.Some important themes are mentioned in this article. First is knowing your strengths. With this it is important to know that we have choices and knowing our strengths will help us know where we belong. I especially enjoyed the portion where the author talks about doing a feedback analysis. I would have never thought that this simple process may explain a number of things about myself that I would never have expected before. Then ther e is the concentration on the strengths that is really important.You need to focus on your strengths which can then produce results. Something else key is use your manners. Simple please’s and thank you’s can go a long way. Even when your day is crappy and you are mad at the world, your manners may save you from an unpleasant conversation from your boss because you were rude or inappropriate with a co-worker. Another thing to remember is that in order to perform you have to know how you learn. Learning styles are an important factor in the learning process.Understanding your learning style can make a enormous difference in the knowledge that you gain in the simplest tasks. Most importantly, as the author points out, is don’t change yourself, work hard at improving yourself and try not to work on things you cannot perform at your best. In order to be effective within an organization, you must be compatible with the values of the business. For example, at AMR our mission is patient focused, care giver inspired and customer centered.This is certainly true for me. I am always focused on the patients and there needs at the time of our encounter. I like to inspire other care givers and our patients are our customers. If you focus on your patient then you are actively being customer centered. Something else to remember is that understanding the strengths of the people you work with will ultimately help you become more effective. When co-workers know and use each other’s strengths to work together and develop a better outcome.

Native American beliefs are deeply rooted in their culture Essay

They didn’t have one single religion, but they did have many beliefs. They believed in a mysterious force in nature and in spirits that were higher than human beings and influenced their lives. People depended on them when they searched for food or when people were ill. They believed EVERYTHING is sacred from the largest mountain to the smallest plant and animal. A lesson can be found in all things and experiences and everything has its own purpose. Native Spirituality; is about honor, love, and respect. Not only do they love, honor, and respect our Creator and Mother Earth, but also every living thing. They are in touch with themselves and everything around them. It is about knowing and understanding that they were a part of everything, and everything is a part of them. Native Americans valued many things like animals; buffalo, deer, and small rabbits. Meat could be cooked fresh or smoked, and stored for long journeys or winter months. They also ate vegetables and plants; berries, squash and fruits. They valued God because he created everything. Some tribes believed in one or many gods whom more powerful than others. Shamans were religious people who had close contacts with spirits. They were often medicine men and treated sick people . There is no power greater than the Natural Laws. These powers were set up by the Great Spirit in a way that the human being has no access to it, except by obeying. If they choose not to follow the Natural Laws, their life will be filled with confusion, tension, anxiety and stress. If they were to poison the Earth, they would poison themselves. If they were to poison the Water of the Earth, they were to poison themselves. What they would do to Earth, would happen to them and their children, even the children that were unborn.