Practical Public Health Nutrition

Roger Hughes

• Publisher: Wiley-Blackwell
• Year: 2010
• ISBN:
  9781444329223
• Edition: 1
• Topic: Medicine
• Subtopic: Nutrition, Dietics & Bariatrics

Providing the reader with a practice-focussed approach to public health nutrition intervention management, Practical Public Health Nutrition is a crucial resource for dietitians, community and public health nutritionists and related health professionals in need of a practical guide to practicing public health nutrition.

Internationally recognised experts Hughes and Margetts describe in detail the rationale, processes and tools that can be used to assess population needs, analyse problems and develop effective interventions at a community level.

Exercises in each section of the book contribute to a collective PHN intervention plan, providing the reader with the opportunity to demonstrate an outcome of intervention management.

Unique in its approach to teaching the practical applications of this increasingly crucial discipline, Practical Public Health Nutrition is a vital purchase for anyone working in the public health arena.

• Clearly outlines the practice of PHN intervention management
• Covers rationale, processes and tools needed to develop effective interventions at community level
• Written by 2 internationally respected authorities on the discipline of Public Health Nutrition
• Essential text for dietitians, community and public health nutritions and related health professionals

Part 1: Introduction and context

This introductory section comprises three chapters which provide the context for consideration of public health nutrition (PHN) as an area of practice. This context is important because it helps lays the foundation of a systematic and thorough approach to practice in public health nutrition discussed in later sections.

Chapter 1 provides a big picture overview of the immense challenges and complexity of PHN as a discipline. It also situates the practitioner in this context, arguing that effective practitioners can indeed make a difference to public health.

Chapter 2 defines PHN and describes its attributes as a practice area. Of equal importance, this chapter articulates what PHN is not, helping to situate it in the health system, with a focus on the protection, maintenance and promotion of health in different populations. This chapter has significant relevance to practitioners as it considers the core functions of the PHN practitioner and the associated competency needs.

Chapter 3 introduces and describes a bi-cycle framework for PHN practice which embeds capacity building with strategic and intelligence-based decision-making at the core of PHN practice. As a stepwise process, it is proposed as a model to assist the application of the rhetoric of health promotion in practice.

Chapter 1

The big picture: The context for a textbook on public health nutrition practice

Why develop a public health nutrition textbook?

This book has been written with the bold aim to help develop competent and effective public health nutrition (PHN) practitioners and to help existing practitioners work more effectively. In this context, the term practitioner refer to individuals or groups with an interest in, responsibility for or mandate to work in the interest of protecting and promoting public health through better nutrition. This can include local health workers, school teachers and hospital dietitians. In much of this book and for most readers it relates more to specialists, such as designated public health nutritionists – a role that is increasingly becoming established in many countries worldwide. It also refers to you, the reader, even if you currently do not have a formal qualification or professional status. We hope that this book, and the processes and principles it describes, will help develop and refine the competencies you require to be effective PHN practitioners. This is important because we contend that:

• there are currently many practitioners who aren’t effective in a PHN context; and
• being effective is possible if we follow good practice.

Malnutrition is still the main game

It will come as no surprise that PHN practice is still dominated by considerations of malnutrition in its two-faced manifestations: under-nutrition and over-nutrition. At an international level there is little disagreement about the staggering burden of malnutrition in all its forms. It is now accepted that over a billion people across the world are undernourished, with more now over-nourished and probably as many people with specific micronutrient deficiencies. Many of those who are under- or overweight are also micronutrient-deficient. Whereas in the past the burden of over-nutrition was highest in developed or rich countries, the burden is now spreading to and increasing in poor or developing countries. This trend is now referred to as the double burden of disease. In some countries there is an additional burden associated with high rates of infectious diseases and/or HIV. There is a complex interplay between poverty, food and nutrition insecurity, malnutrition and infection that becomes a downward spiral, with infection adding to the metabolic demands for nutrition, while reducing the capacity to work and earn the money required to address the infection, which further reduces dietary intake. Thus a vicious cycle continues. These complex interactions spiral throughout the life-course, from infants to children, to young women having babies to babies. All this is exacerbated by basic and underlying causes, such as inequality, poverty, conflicts and natural disasters. Despite these enormous challenges, there have been improvements in some countries, but these have been largely offset by setbacks elsewhere.

Is food insecurity due to families being too large or wasting money on ‘junk food’, or are global food prices and the international controls on markets that make life difficult for the poorest in the least wealthy countries more to blame? Per capita food production has kept pace with the rise in population, but the biggest concern is that the rich world is consuming more than its fair share and producing more waste and greenhouse gases, while the poor are told to have fewer children so they can feed them (the same applies with consumption of fossil fuels). Food insecurity is a spectre hovering over humanity worldwide and it ebbs and flows with economic, political and environmental crises. This point was made clear in a recent FAO report on food insecurity in the world.¹ The nutrition challenges of today and into the future will continue to be essentially about inequality.

Innovative solutions are needed

The current approach to addressing global nutrition problems, articulated in many policies and resolutions at the international level, such as the Millennium Development Goals, the WHO resolution of diet, physical activity and health, etc., has moved to a model (some use the word paradigm) which relies on a therapeutic/technical approach. This involves giving supplements or fortifying staple foods as a key strategy to address the major micronutrient deficiencies of iron, vitamin A and iodine. In other words, the approach is to say, ‘If we can’t change the causes, we will treat the symptoms by giving what is missing’. Another competing paradigm argues that food is a fundamental human right and that, unless the basic causes of under-nutrition are addressed, until people have control over their lives and are consulted and become part of the solution rather than having solutions imposed on them, we will never fundamentally address health inequalities. So the challenges are enormous, but our work and role as practitioners may never be more important and needed.

Surely you don’t mean these challenges can be found in rich countries like mine?

The challenges for public health nutritionists in developed or rich-economy countries are no less complicated that those of the developing world. What is consistent is the effect of socio-economic inequalities on malnutrition (the poor and uneducated also tend to be the most overweight) and the complex array of determinants that result in disease and disability. Under-nutrition still exists in vulnerable subpopulations and the enormous social burden of preventable disease attributable to over-nutrition makes the role of the public health nutritionist just as important in the developed world as in the developing world.

Level of influence

As a practitioner operating at a national or international level, the options for interventions or approaches to solving problems may be more linked to interventions that aim to improve nutrition by increasing the uptake of supplementation or supporting other attempts to diversify food intake at a national level. Or it may be that your role is to address national priorities, which in many countries are dominated by obesity. Many more of you will be working at a local level, where the policy, goals and objectives have already been set and your role may be to design, plan, implement and evaluate interventions that address the issues mandated in national action plans or priorities. Action by practitioners at all levels is required and important. The level at which you as a current or future practitioner operate will affect how much decision-making and influence you have over the approach to identifying problems and solutions, developing policy and delivering interventions. We argue, however, that at whatever level you operate, there is a practice model that you can work within which will help you be more effective in your practice context. This book outlines the steps in this practice model.

Practice informed by a public health approach

The values, attitudes and the conceptual approaches we apply to practice have a critical influence on our practice behaviours and overall effectiveness. A public health approach (described in more detail in later chapters) is traditionally defined by its focus on prevention rather than treatment, populations rather than individuals and interventions that address the determinants of health rather than the treatment of disease. It is an approach characterised by persistence, recognising that human health requires the right conditions and opportunities to flourish, and that we cannot afford to assume that these conditions will occur or persist without planned effort and attention. Such effort and attention are a key responsibility of the health workforce, policy-makers and community leaders.

First, work to understand the causes, by looking upstream

When we are taking a public health view it is important to step back from the problem and ask, ‘Why did this problem arise?’ In other words, we need to think about the underlying causes (determinants), such as ‘Why did this child not have enough to eat or have diarrhoea? Was it because the household was food insecure or the family was poorly educated and had limited resources and access to education and health care?’ Stepping back further the question is again ‘Why is this so? Why is the family food insecure?’ This is about having reliable and affordable access to nutritious food, as well as clean water and the means to cook. At the basic level the reason many households are food insecure is that the country is poor and has little capacity to generate jobs and provide services because they are dependent on low-yield cash crops as their major source of government revenue. UNICEF described this conceptual framework many years ago, which was updated in 2008 as part of the Lancet series reviewing the evidence around causes and solutions to under-nutrition in the world (see [2–6]).

Practitioners and politics

Turning the focus back to you as a practitioner, you may be asking if the problems are more to do with politics and decisions about fairness and equity, rights, trade and the capacity of countries to look after themselves. You may be wondering what you can possibly do to make a difference. The key point of the discussion in this chapter is to make sure that you consider the wider context in which the problem in front of you arose. If your responsibility is to reduce the prevalence of obesity, telling people to ...