Editorial – Evaluation of health promotion programs: are we making progress?

The opportunity I have had in recent years to facilitate a number of training courses with health promotion practitioners, has affirmed the value that many place upon evaluation in program management, and provided insights into the perceived benefits, costs and risks that this may entail. As might be expected, course participants can readily identify the benefits to be gained from evaluation: finding out what works; improving how programs are delivered; adding to the evidence that others can use; increasing the prospects of future funding; and satisfaction and rewards for workers, among an array of others.     

Editorial – Advocating for public health: does the real world matter?

Researchers are, with some exceptions, notoriously reluctant to occupy the public stage. With some notable exceptions, their work is mostly done behind a screen of academic or organisational inscrutability, with findings being revealed via journals boasting a readership, if one is lucky, of a few hundred. It's not uncommon for research findings to be regarded as highly successful if they've been cited by a dozen other authors. Many articles are read and acted upon by almost no‐one, even though they may represent a considerable advance in knowledge. Attacking the academic publishing system is not the intention of this editorial, as appropriate as such an attack may be. What this does suggest, however, is that researchers concerned with improving public health and wellbeing need to re‐think strategy. Observation of the public health and health promotion record over many years suggests that health promotion should be rooted in the idea that research must be tied to action; to be effective, evidence must be operationalised. The truth may indeed set us free, but it needs to be effectively deployed before that happy consequence can be realised.     

What is population health?

Population health is a relatively new term that has not yet been precisely defined. Is it a concept of health or a field of study of health determinants? We propose that the definition be "the health outcomes of a group of individuals, including the distribution of such outcomes within the group," and we argue that the field of population health includes health outcomes, patterns of health determinants, and policies and interventions that link these two. We present a rationale for this definition and note its differentiation from public health, health promotion, and social epidemiology. We invite critiques and discussion that may lead to some consensus on this emerging concept.     

Early growth and obesity risk – What should health professionals be advising?

Obesity rates in the UK have been continuously increasing among adults and children and have been attributed to nutritional and lifestyle practices that promote a positive shift in energy balance. Over the last few decades, a growing body of evidence suggests that the origins of obesity start at the earliest stages of human development and specifically pre‐conception, in utero and during early infancy. Maternal nutritional status and early life feeding have been identified as ‘critical windows’ for obesity risk. Pre‐conception and pregnancy overweight and obesity, as well as fetal exposure to diabetes and hyperglycaemia, have been associated with high birthweight, which, in turn, has been reported to have a direct link with obesity risk later in life. A number of studies have also demonstrated low birthweight to be associated with increased risk of obesity and suggested that low‐birthweight term infants who demonstrate early ‘catch‐up’ growth have a tendency to become obese adults. Low birthweight has been associated with pre‐conception underweight and inadequate in utero nutrition. Although the links between early growth and later obesity risk implicate maternal pre‐natal nutrition, it has been suggested that nutrition during early infancy also affects later body composition. Breastfeeding has been associated with a reduced prevalence of obesity, although the evidence is still inconsistent and somewhat limited. Recent advances in the ability to manipulate infant formula composition by reducing its protein content and bringing its composition closer to that of breastmilk could potentially help prevent the rapid weight gain observed in formula‐fed infants. Early introduction of complementary foods has also been associated with increased obesity risk later in life. Unfortunately to date, the majority of evidence on the developmental origins of obesity comes from observational studies, making their interpretation difficult and providing an uncertain basis for practice. However, a number of modifiable risk factors in the pre‐natal and early post‐natal periods of human development have been identified, as well as vulnerable subgroups within the population to these risk factors, which may guide health professionals when advising women regarding lifestyle strategies to reduce the risk of obesity for their offspring and for future generations.     

What is evidence-based public health?

Evidence based Public Health is the execution and evaluation of the efficiency of interventions, plans, programs, projects and politics in public health through the application of the scientific principles of reasoning, including the systematic use of information and information systems. Evidence based public health involves the use of methodologies similar to those applied in evidence-based clinical medicine, but differs in its contents. In public health two types of evidence are described. The type I evidence in which a strong relation exists between the preventable risk and disease, and type II evidence in which there exists a relative effectivity of the public health interventions. In evidence based Public Health research designs more appropriate for the social sciences are used, as the observational and quasi-experimental studies. Likewise the decisions are more of interdisciplinary teams.     

What is consumer-directed health care?

To control health care costs, someone must choose between health care and other uses of money. The value of most health care is experienced subjectively, as is the value of other goods and services. No one is in a better position to make these subjective trade-offs than patients themselves. The current system not only systematically denies patients the opportunity to make such choices, it distorts the incentives of providers in the process. Chronic patients in particular would be much better off if they could manage more of their own health care dollars and if providers were free to compete to meet their needs.     

Editorial: What is a nutrient?

Nutrient:a substance that an organism must obtain from its surroundings for growth and the sustenance of life.In the old days of food composition work, we took certain comfort in the simple characterization of the food components we measured--they were nutrients. But if they were not nutrients, they could still be neatly classified as antinutrients, toxicants, or just interesting non-nutrients. Of course, components are not so simply characterized these days. Polyphenols, measured in at least two of the studies in this issue of JFCA, were referred to as antinutrients in the not-too-distant past. In recent years, we rarely see that kind of characterization. Many of the polyphenols are now characterized as beneficial bio-active non-nutrients, with the occasional suggestions that some could even be called nutrients. The same is true for isoflavones and coumestrol, for which we have more new data in this issue.A further confounding situation exists with functional characterizations of food components. Let's take what many papers in the scientific literature refer to as "antioxidant nutrients". The provitamin A carotenoids show up on this list, but some of the most potent antioxidant carotenoids cannot be classified this way because they have no provitamin A activity, i.e. they are not antioxidant nutrients.We also have the reverse situation. Any essential divalent cation, for example iron, can be an antinutrient or toxicant, by inducing deficiencies of other essential divalent cations even at therapeutic levels, or by straightforward poisoning at toxic levels. By preventing absorption of nutrients in a meal, dietary fibre or various fractions of dietary fibre are characterized as antinutrients.For these and other reasons, many scientists have called for, and some have created, new definitions for the word nutrient. From a chemical and physiological point of view this is reasonable. It is also reasonable from a research point of view. Is dietary analysis different from an exposure or risk assessment? Not really. Is a food composition database different from an additive, contaminant or toxicant database? No, not fundamentally. Do we miss assessment opportunities in clinical and epidemiological research by not having extensive compositional data--beyond nutrients--in our food databases? Surely we do.Some national food composition database developers are including many food components in their databases. As long as all the samples and values are properly documented, there is no down-side to this activity; there is huge potential benefit. The new edition of the German Food Composition and Nutrition Tables by Souci, Fachmann and Kraut, reviewed in this issue of JFCA, is a good example of printed tables presenting a more comprehensive picture of the chemical composition of foods. This is to be encouraged and applauded.     

What is a national health policy?

Unfortunately, most nation states have taken "health policy" to mean "medical care policy." Medical care, however, is only one variable in a nation's health equation. The article describes what the main components of a national health policy should be, including (1) the political, economic, social, and cultural determinants of health, the most important determinants of health in any country; (2) the lifestyle determinants, which have been the most visible types of public interventions; and (3) the socializing and empowering determinants, which link the first and second components of a national health policy: the individual interventions and the collective interventions. The author discusses the indicators that should be used for each component and for each intervention. The feasibility of this approach depends to a large degree on the political will of the national authorities and the broad understanding of the actual determinants of health. A good first step is the National Health Policy plan developed by the Swedish social democratic government. This article builds on and expands on that model.     

What is the health care product?

Because of the current competitive environment, health care providers (hospitals, HMOs, physicians, and others) are constantly searching for better products and better means for delivering them. The health care product is often loosely defined as a service. The authors develop a more precise definition of the health care product, product line, and product mix. A bundle-of-elements concept is presented for the health care product. These conceptualizations help to address how health care providers can segment their market and position, promote, and price their products. Though the authors focus on hospitals, the concepts and procedures developed are applicable to other health care organizations.