Recently, a colleague asked me: How can we produce action plans to counteract obesity when we do not know what really works, nor have a clear view of the problem? This uncomfortable question requires a response.
The European Charter on Counteracting Obesity1 points to the relative lack of data on the effectiveness of interventions and best practice, but claims nevertheless that there is enough information for recommending immediate action. True?
Evidence basis or action basis?
A recent reviewReference Flynn, McNeil, Maloff, Mutasingwa, Wu and Ford2 finds clear evidence of at least short-term results of interventions geared at obesity prevention and/or chronic disease prevention in children and youth. The same review reveals a lack of relevant indicators being used in intervention projects, a lack of long-term results, and a general lack of (published) programmes directed towards children and youth. The authors list a whole range of recommendations, directed to funding agencies, governments, researchers and others, based on a comprehensive process of synthesis of the review results.
Tim LobsteinReference Lobstein3 comments to the review that ‘most government initiatives are not properly evidence-based. The majority of public health practices are not based on randomised, double-blind, placebo-treated, controlled trials nor are they subject to systematic reviews’. He points at the importance of dealing with practice-based evidence rather than evidence-based practice in public health. We need to define our own templates for high-quality interventions, suitable for evaluating evidence, building on health promotion principles rather than clinical trial perspectives.
Getting what message?
There is always a risk of initially relevant health messages reaching the population in distorted or altered form. The old game Chinese Whispers demonstrates this problem clearly: the more individuals – or intermediaries – in the game, the more distorted the final message becomes.
This brings us to the discussion of knowledge management in health care. According to Sandars and HellerReference Sandars and Heller4, the key elements of knowledge management are generation of knowledge, storage of knowledge, distribution of knowledge and application of knowledge. The existence as well as distribution of a high-quality evidence base does not necessarily mean that the correct message always reaches health-care staff at the bottom of the organisation. The information pressure from other, less valid sources of information is tremendous, and sometimes health professionals adopt and transfer messages which are less valid and tend to stick to routine procedures that are not up-to-date.
Of course, information technology is of extreme importance for dissemination, on local intranets for professionals as well as the Internet. Health information is one of the most frequently sought topics on the InternetReference Lorence and Greenberg5, Reference Greenberg, D'Andrea and Lorence6. In a recent paperReference Miser7, the author claims that ‘Becoming an information master is a task that all can learn’, and that this task is essential for primary care specialists.
But isn't that the problem, with everybody trying to be their own information master, perhaps especially in the area of nutrition? All the more so since most health-care staff actually have a trivial amount of training on how to use the Internet with discrimination? Obviously there is a tremendous need for nationally and internationally renowned clearing houses for high-quality information from a knowledge management perspectiveReference Lorence and Greenberg5.
Who are the experts?
Journalists seem rarely to check the background of academics providing health information. As long as the provider of nutrition information has a medical degree, a PhD or a professor position, the information is seen as valid. However, physicians rarely have more than a limited training in nutrition and an academic title does not automatically mean a background in nutrition. Some of the more scary examples of nutrition misinformation in my home country in recent years stem from persons with academic degrees not relevant to nutrition. On the other hand, sometimes completely outrageous untruths are served by academics in nutrition, as if they have the answers to all questions. Are well-trained and well-behaved public health nutritionists not good enough in selling their expertise?
What can we do when it comes to action plans and otherwise in order to provide the public with more relevant and valid information? Certainly, we need to strengthen the evidence base on the effectiveness of interventions. Clearing houses of updated and correct information in nutrition need to be developed further, and training of relevant staff for conveying updates and appraisal of current practice and routines needs to be performed. An organisational context needs to be introduced to promote a sound information culture in health careReference Crow8. Whenever intermediaries are used for providing information to the end user, either health-care staff discussing nutrition issues with patients or in self-help groups in health-promoting ventures, we need to build in feedback systems for validation of the conveyed messages.
We also need to make sure that our own profession stands out in the blur of professionals producing nutrition messages at an ever-increasing pace. We need to show that we are trustworthy, identifiable, reachable and updated. If not us, then others will take all the initiative. And if not now, the pandemic of obesity especially among children and young people is more likely to become uncontrollable.
