Dr Joe Kosterich, a former AMA office holder now promoted as a motivational speaker and consultant, has had a rather bizarre opinion piece published by Medical Observer, in which he argues that the field of public health medicine does not weigh the risks and benefits of its recommendations, and is not accountable for providing evidence-based advice in the same way that general practice is.
He writes that there is one field of medicine where “no warnings are given about possible unintended or even harmful effects. Where broad recommendations are made, and it is felt that everyone should heed the advice. Indeed, unintended effects seem to be barely considered. Yet GPs are expected to comply with the edicts handed down. This field of medicine is public health.”
Kosterich uses promotion of low-fat foods as one of the grounds for his case, arguing that this has led to increased consumption of energy-dense foods (as low-fat foods are often high in sugar). My understanding is that the food industry (and its associated experts) have had much more to do with promotion of low-fat, energy-dense foods than public health guidelines. Most of my public health contacts in this area have, for example, long stressed the merits of following overall dietary recommendations and the pitfalls of the nutrient-based recommendations so often favoured by industry promotions.
The public health field (which is, of course, broader than the field of public health medicine to which Kosterich refers), meanwhile, has a long history in developing and evaluating its evidence base. Think of The Community Guide in the US, for example, which makes public health recommendations on the basis of systematic reviews investigating not only the impact of various interventions, but also their return on investment. Recently, Australian researchers have added to this evidence base with the ACE- Prevention study (which is interesting because it subjects some treatments to the same standard of evaluation as prevention interventions).
Meanwhile, Dr Belinda Hall, a Research Fellow with the Cochrane Public Health Group, who is based at the University of Melbourne, has some related news from the Cochrane Collaboration’s public health field.
Belinda Hall writes:
The Cochrane Collaboration, an international, not-for-profit organisation, dedicated to making up-to-date, accurate information about the effects of health care readily available worldwide, is probably a familiar name to many, particularly those in clinical health fields.
Not so common however, is the knowledge that Cochrane now has a Public Health Group. The Cochrane Public Health Group, based in Australia at The University of Melbourne, publishes systematic reviews on population-level interventions targeting the social determinants of health.
The first review published by this group addressed the question of flexible working conditions and their effects on employee health and wellbeing.
There have been trends towards more flexible working arrangements for employees and families in the UK and Europe and, while it is assumed such policies are beneficial, it is important for policy makers to understand the potential health impacts in more detail. The Cochrane review included ten studies, involving a total of over 16,000 people, focused on various forms of flexible working.
Self-scheduling of working hours was found to have positive impacts on a number of health outcomes including blood pressure, sleep and mental health.
“Flexible working seems to be more beneficial for health and wellbeing where the individuals control their own work patterns, rather than where employers are in control,” said the review lead, Clare Bambra of the Wolfson Research Institute, Durham University in the UK.
Co-author Kerry Joyce, also based at the Institute, added: “We need to know more about how the health effects of flexible working are experienced by different types of workers, for instance, comparing women to men, old to young and skilled to unskilled. This is important as some forms of flexible working might only be available to employees with higher status occupations and this may serve to increase existing differences in health between social groups.”
More on the findings of the review can be found at http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD008009/frame.html
Other reviews currently underway with The Cochrane Public Health Group are:
• Collaboration between local health and local government agencies for health improvement
• Community wide interventions for increasing physical activity
• Workplace-based organisational interventions to prevent and control obesity by improving dietary intake and/or increasing physical activity
• Housing interventions for improved health and social outcomes (co-registered with The Campbell Collaboration)
• Community-based interventions for enhancing access to or consumption of fruit and vegetables (or both) among five to 18-year olds
Protocols under development with The Cochrane Public Health Group are:
• Nutritional labeling to promote healthier food purchasing and consumption
• Community-level interventions to improve food security in developed countries
• Wheat flour fortification with Iron for reducing anaemia and improving iron status in at-risk populations
• Population level interventions for improving health outcomes in ex-prisoners
• Interventions addressing gender disparities in family food distribution for improving child nutrition
• Oral health promotion interventions for improving child oral health
• Incentive-based interventions to increase physical activity
• Fortification of staple foods with vitamin A for preventing vitamin A deficiency in populations
• Welfare to work interventions and their effects on the health and wellbeing of lone parents and their children
• Knowledge translation strategies for facilitating evidence-informed public health decision making among managers and policy-makers
• Population health effects of fortification of wheat and maize flour with folic acid
• Condiment fortification with iron and/or other micronutrients for improving public health
• Fortification of wheat and maize flour with folic acid for population health outcomes
As part of the Cochrane Collaboration’s systematic review process, each protocol and subsequent review requires a team of peer reviewers. Peer reviewers are responsible for assessing the relevance and usefulness of the review for end users. If you are interested in peer reviewing please contact Jodie jdoyleATvichealth.vic.gov.au. Please make sure you let Jodie know your areas of interest.
Further information about the CPHG can be found at www.ph.cochrane.org. The Cochrane Library is free for all Australians and is available at www.thecochranelibrary.com. For more information about the Cochrane Collaboration please visit www.cochrane.org
The Cochrane Public Health Review Group acknowledges funding support from the Victorian Health Promotion Foundation (VicHealth) http://www.vichealth.vic.gov.au/, the Commowealth Department of Health and Ageing and the Jack Brockhoff Child Health and Wellbeing Program http://www.mccaugheycentre.unimelb.edu.au/research/brockhoff.
News from the Campbell Collaboration
Meanwhile, the Campbell Collaboration’s Social Welfare Coordinating Group has announced a series of new reviews and protocols.
New reviews include:
● Shared living arrangements after divorce and the wellbeing of children
● CBT interventions for young people ages 10-18 who sexually offend
● 12-steps programmes for reducing abuse of illicit drugs
● Interventions supporting informal caregivers of community living adults in need of support due to psychiatric or psychosocial problems
The bottom line, it seems to Croakey, is that evidence is not something fixed in stone. It evolves as knowledge advances and everyone, whether GPs or public health practitioners, need to keep abreast of the evolution.