Public Health Nutrition Deserves More Attention

Food and nutrition deserve much more attention from public health professionals. On the grounds of prevalence alone, diet-related conditions affect enormous numbers of people. Everybody eats. Everybody is at risk for eating too little for health or survival or too much to the point of weight gain and increased risks for noncommunicable diseases. By the latest count, nearly 700 million people in the world do not get enough to eat on a daily basis, a number that has increased by tens of millions over the past five years and will surely increase by many millions more as a result of the COVID-19 pandemic.¹ At the same time, about 2 billion adults are overweight or obese, and few countries are prepared to deal with the resulting onslaught of type 2 diabetes and heart disease.² Beyond that, food production, distribution, consumption, and disposal—collectively food systems—are responsible for a quarter or more of greenhouse gas emissions; climate change affects the health of everyone on the planet.³

Public Health Nutrition: Essentials for Practitioners

Edited by Jessica Jones-Smith

Baltimore, MD: Johns Hopkins University Press; 2020

paperback: 432 pp; $99.95

ISBN-10: 142143850X

ISBN-13: 978-1421438504

The same social, behavioral, economic, and structural determinants of health affect nutritional health, and it is no accident that food choices are flash points for arguments about culture, identity, social class, inequity, and power, as well as the role of government, private enterprise, and civil society. From a public health standpoint, everyone—regardless of income, class, race, gender, or age—should have the power to choose diets that meet nutritional needs, promote health and longevity, protect the environment, and are affordable, culturally appropriate, and delicious.

NUTRITION IN 2021

For people in high-income countries, dietary prescriptions for health and sustainability advise eating a lot less meat and more foods from plant sources.⁴ Optimal diets minimize the consumption of ultraprocessed foods—those that are industrially produced, bear little resemblance to the basic foods from which they were derived, cannot be prepared in home kitchens, and are now compellingly associated with noncommunicable disease risk and mortality.⁵ We also now know that ultraprocessed foods encourage people to unwittingly take in more calories and gain weight.⁶

AGENDA FOR 2021

Today, a book for researchers and practitioners of public health nutrition needs to emphasize coordinated—triple-duty—recommendations and interventions to deal simultaneously with hunger and food insecurity, obesity and its consequences, and the effects of food production and dietary choices on the environment. Such approaches, as described by a Lancet Commission early in 2019,⁴ should encourage populations of high-income countries to eat less meat and more vegetables, those in lower- and middle-income countries to consume a greater variety of foods, and everyone, everywhere to reduce intake of ultraprocessed foods. As that commission argued, public health nutritionists must recognize that attempts to improve diets, nutritional status, nutritional inequities, and food systems face daunting barriers from governments captured by corporations, civil societies too weak to demand more democratic institutions, and food companies that have been granted way too much power to preserve profits at the expense of public health. Nutritionists need knowledge and the tools to resist food company marketing and lobbying, to champion regulatory controls of those practices, and to promote civil society actions to demand healthier and more sustainable food systems.⁷

UNFORTUNATE TIMING

The multiauthored chapters in Public Health Nutrition: Essentials for Practitioners have the bad luck of having been written before food systems, triple-duty dietary advice, ultraprocessed foods, and overcoming barriers posed by the food industry became such prominent themes, before Black Lives Matter required intentional refocusing on nutritional inequities, and before the COVID-19 pandemic so thoroughly revealed the inadequacies of existing food systems.³ Despite these disadvantages, the book has significant strengths. Intended as a graduate-level introduction to public health nutrition for researchers and practitioners, it contains chapters on public health tools, nutrition-related diseases, frameworks for considering nutrition problems, and selected policies and programs, most with multiple authors. The chapters follow a common format: learning objectives, case studies, text covering the subject at hand, key words and concepts in bold-face type, tables and figures summarizing the content, questions for discussion, and references. The book ends with a lengthy glossary of the bold-face terms and an index.

Many of the authors are prominent experts who do an excellent job of demonstrating how public health concepts apply to nutritional problems. Their detailed literature reviews cite as many as a hundred references. The tools sections cover nutritional assessment, nutritional epidemiology, and program planning and evaluation. The chapters on diet-related diseases focus largely on international aspects, especially in lower- and middle-income countries; these will be useful to readers, as will many of the tables. I particularly appreciated one that summarizes myths and realities of how to work with communities—“I already know what the needs are in this community” (p. 58; No, you don’t unless you ask)—and those on how to analyze root causes and to write process, learning, and outcome objectives. All of the chapters are worth reading; some are outstanding. The last chapter, on cash transfer programs, is a model of how to critically examine the ways these programs function in actual practice—as well as in theory. I mention theory because although several chapters devote considerable space to theoretical models of eating behavior, few go into much detail about the practicalities of what to expect from food industry opposition to public health interventions aimed at reducing intake of meat or ultraprocessed foods or how to head it off and counter it.

MORE CONTEXT WANTED

Like most multiauthored books, this one suffers from repetitions, inconsistencies, and gaps. Several chapters discuss dietary assessment methods and nutritional epidemiology, but none refer to the recent barrage of criticism of the inaccuracies of these methods and the conflation of epidemiological correlation with causation, for example, with single foods such as almonds associated with the risk of heart disease. Inconsistencies in books like these seem inevitable. A case study of the nutrition transition (from undernutrition to obesity) in Brazil mentions ultraprocessed foods but fails to cite the now-vast body of research linking them to noncommunicable disease risk. This chapter praises—justifiably in my view—Brazil’s dietary guidelines for urging avoidance of ultraprocessed foods and fast food and for encouraging resistance to industry advertising. But another chapter on international guidelines does not even mention those from Brazil.

Perhaps because the chapters were written a few years ago, only one mentions food system approaches to food and nutrition problems. Neither double- nor triple-duty approaches show up in the glossary or index; neither do the terms “food system” or “ultraprocessed.” The glossary provides excellent definitions of the terms it does list, but these do not appear in the index; finding how they are used in context is not easy. Mostly, I missed a discussion of how public health nutritionists can and should advocate policies to promote greater availability and affordability of healthier and more sustainable diets and suggestions for how to go about learning to do that.

Could I teach public health nutrition from this book? Yes, but with supplementation of its background information with additional resources that emphasize food systems, triple-duty approaches, Brazilian dietary advice, and the need to push back—forcefully—against food industry opposition to public health interventions.