Fat, fate and disease – giving up on a generation?

I’ve just seen Andrea Vance’s Dompost piece concerning planned changes to the types of nutrition programmes to be funded by the Ministry of Health. This follows the publication of Professor Peter Gluckman and Professor Mark Hanson’s new book Fat, Fate and Disease: Why exercise and diet are not enough.

I’ve just dashed out and picked up a copy of the book, so have only skimmed it, but essentially the authors argue that current strategies intended to alter adult behaviour are failing to halt the tide of non-communicable diseases like cardiovascular disease and diabetes, either in the developed or developing world. They also set out substantial evidence that the in utero environment and even pre-conception factors can be powerful shapers of later behaviour, metabolism and disease. Their argument is that a focus on changing the behaviour of pregnant women and both men and women who are considering having children is necessary if we are to stem the rise of non-communicable disease in future generations.

Well so far, so good. But it’s alarming the Ministry of Health proposes to stop funding existing programmes in order to fund some ones with this focus. If the Ministry is seriously intending to do this then it reveals a breath-taking lack of judgment and understanding of public health programmes’ effectiveness.

Here are some considerations:

1. It is true that the rising tide of communicable disease has not been stopped by current strategies. This is not because the programmes didn’t work but because funding was split between programmes with a sound evidence base and some that didn’t. Successive governments have not been prepared to make public policy decisions or properly resource programmes compared to money spent on promoting unhealthy behaviours (for example fast food advertising). It is quite possible to fund and implement behaviour change programmes that are effective.

2. It is not acceptable to sacrifice the health and wellbeing of both adults and children currently living in order to improve the chances of those not yet alive. Or at least, if such a trade-off is proposed, then New Zealanders must be consulted about it and agree to make it. I rather suspect that most people would say we need to do both.

3. The evidence is strong that programmes that are tightly targeted at a particular set of people are generally less effective than programmes intended to shift whole population behaviour. If we want pregnant women to do more of a particular thing we will be most effective in doing this by trying to get the whole population doing more of it. A highly targeted campaign will tend to work for the most empowered in society, typically those who least need to make the behaviour change, but will be pretty ineffective for those with the greatest needs. The same applies to campaigns based on giving people more information about benefits and risks of particular behaviours. So while the Gluckman and Hanson thesis should perhaps see greater focus put on pregnancy in community-based campaigns and greater emphasis placed on nutrition in primary care for pregnant women, we will have the greatest impact on pregnant women by getting better at whole population change.

The Ottawa Charter for health promotion sets out five evidence-based and widely endorsed action guidelines for improving health:

A. Promote healthy public policy

B. Create supportive (physical and social) environments

C. Strengthen community action

D. Develop personal skills

E. Reorient health services (towards prevention and promotion of health, rather than just treatment)

In the case of improving nutrition, say, we could and should be doing things in each of these areas, yet Tony Ryall has axed some of our existing Healthy Eating, Healthy Activity programmes and is driving public policy and social environments in the wrong direction.

Not either/or please. Evidence-based, and both.

16 thoughts on “Fat, fate and disease – giving up on a generation?

  1. One possible solution to this could be: The removal of the bicycle helmet law. This will encourage more people to get out and on their bicycle.

    Like or Dislike: Thumb up 5 Thumb down 5 (0)

  2. How about tax breaks (GST and other) for healthy and organic foods?

    Let’s get the demand and therefore economies-of-scale up for truly high quality food production, so it’s ever more affordable for us all.

    Like or Dislike: Thumb up 4 Thumb down 4 (0)

  3. Though your post doesn’t mention it, Kevin, I assume from the title of the book that there’s still plenty of obesity-epidemic-panic to be had in it. Which is sad, because promoting “healthy” eating and activity would be a fantastic thing … if we’d stop, instead, bashing fat people, when the science shows pretty clearly that weight is not a result of being a lazy, donut-scoffing stereotype, that diets don’t work, and that bullying people about their bodies just leads to worse health outcomes.

    Like you, I’m also not crazy about even more policing of pregnant women’s behaviour, either.

    Like or Dislike: Thumb up 6 Thumb down 2 (+4)

  4. I think both areas too important to select one over another – whilst it’s true that Teaching gives no assurance people will follow same. The Potential savings in Health Costs are worth that Education.
    In my Forties when Diet mattered for a whole range of reasons – I lacked the knowledge to employ the right strategies. Society indirectly and directly bore that expensive cost(which I am grateful for)- but it was slightly exasperating to learn common (!) sense at that age….these programmes were not available during my schooling – now that they are there – hopefully they will remain and the benefits for all realized.
    Knowledge is truly power!

    Like or Dislike: Thumb up 1 Thumb down 0 (+1)

  5. Do you not get to the second chapter of your post where is written:
    “…current strategies intended to alter adult behaviour…”

    and find your spine chilling?

    How can any other word be taken seriously if this is the premise on which you base policy?

    Like or Dislike: Thumb up 2 Thumb down 0 (+2)

  6. In 1973 the leading cause of death in NZ was heart disease, affecting 1 in 23 people. In 2008 the leading cause of death was heart disease affecting 1 in 10 people. Surely the current ideas are wrong and the doctors don’t know anything about health. Wouldn’t it be a good idea to concentrate on teaching people how to stay healthy instead of trying to fix them when they get sick.

    Like or Dislike: Thumb up 6 Thumb down 0 (+6)

  7. Hi Peter,

    Road rules (everybody, they’re changing on 25 March) are intended to alter adult behaviour.

    Are they in the same bucket (“spine chilling” or not) for you as health promotion messages?

    Bearing them in mind, can you tell us more about the shape and contents of the bucket?

    Like or Dislike: Thumb up 1 Thumb down 2 (-1)

  8. Lets get real. With busy lives and multiple demands, people generally eat what is convenient and get around in the ways that are most easily accessed. The environment we live in counts for a lot.
    There is lots of research showing that the way that neighborhood spaces are arranged hugely impacts on how much exercise people get. There is plenty of evidence that highly-processed, industrialized foods are not very nutritious, yet they are the cheapest, most abundant, and most convenient. It is very difficult to buy nutritious food at the supermarket, yet the majority of us shop there because it is cheap and convenient.
    What is the sense in funding behaviour-change programmes that teach us behaviours that are simply too difficult to sustain in the reality of our lives? Perhaps that money should be redirected towards providing spaces in which walking or cycling is the most convenient way to get around, and helping to make nutritious foods more available (and I emphasise nutrition, not low fat, some fats are really important for our health and can help people lose weight!).

    Like or Dislike: Thumb up 3 Thumb down 0 (+3)

  9. Thank you Kevin. I too am greatly concerned about this direction being taken which ignores several generations. I’m not convinced that this ‘nifty’ idea of focusing solely on pregnant women will stand the test of time. It speaks more of being a very convenient (read cheap) idea which aligns with other agendas of the current government (such as reducing public spending).

    Like or Dislike: Thumb up 1 Thumb down 0 (+1)

  10. “I’ve just dashed out and picked up a copy of the book, so have only skimmed it, but essentially the authors argue that current strategies intended to alter adult behaviour are failing to halt the tide of non-communicable diseases like cardiovascular disease and diabetes,”

    As a type-1 diabetic (Insulin-dependant), it would be nice to see this clarified. The tide of diabetes is actually the tide of type-2 diabetes which is largely preventable, not type-1 diabetes which at this point in time is not preventable.

    Type-2 diabetes tends to affect overweight people, type-1 on the other hand usually affects lean people. Lumping type-1 and type-2 diabetes together is not particularly helpful as they are quite different to each other with different causes and different treatments.

    Like or Dislike: Thumb up 2 Thumb down 0 (+2)

  11. A couple of people have commented about the usefulness or otherwise of initiatives aimed at changing behaviour through providing information. This is something I’ve blogged about several times and know pretty well. Take any and all of the behaviour-related diseases and map them through New Zealand. Strangely they will all “cluster” in communities that are marginalised in some way. The challenge then to adherents of a health behaviour model is “what is it about people living in those communities that caused them to be worse at making choices? Would more information make a difference?” In other words the model fails to satisfactorily explain what is actually observed.

    The Ottawa Charter approach instead boils down to empowering communities and creating supportive environments around them, and this will have positive effects across a very wide range of both health and other indicators. Within this approach communities themselves determine how best to tackle the health issues facing them. Interestingly the only information-based programmes that work for the most marginalised communities are those designed and delivered by members of those communities (peer education).

    So an Ottawa Charter approach focuses on the factors that cause marginalisation and does provide for community-run education and skills-development initiatives, but is also fundamentally interested in changing the policy environment on issues like the price and availability of healthy/unhealthy foods.

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  12. I agree with your premise, Kevin. The either/or option always leaves someone out of the equation. I want those people already impacting the health system to recieve support to make change; I know it happens, my partner works at the ‘coalface’ & regularly sees change happen. We also need to create change that impacts at the very beginning; as many women get pregnant unexpectedly, only moving society as a whole will benefit those new lives. Lets face it the ambulance at the bottom of the cliff model has never worked, Tony Ryall needs to break that habit.

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  13. 1. ‘Aimed at changing adult behaviour’. Your words. Then qualified later as ‘changing behaviour through providing information’.

    Which is it?

    Bob each way?
    In what way is the latter any less sinister?
    Strikes me, its any way that will ensure re-election.

    2. I have re-read your piece, and it is now even more laughable and sinister.
    to quote, again:
    “1. It is true that the rising tide of communicable disease has not been stopped by current strategies. This is not because the programmes didn’t work but because funding was split between programmes with a sound evidence base and some that didn’t.”

    Notwithstanding the leap required to understand your grammar, and hence meaning; what do you actually mean? Did the programmes work or not? You say they did, but did not.

    3. Now that you are enlightened about the differnces in diabetes, perhaps you could consider your use of the term ‘communicable disease’ in this context?

    In the light of what you are promoting – your message being “if only people would do as we tell them!” do you think it is worth having even a vague notion of your subject matter?

    Someone, somewhere will notice.

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