by Kevin Hague
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.