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  • To assess quality independent from quantity


    To assess quality independent from quantity, Imamura and colleagues assessed dietary intake adjusted for 2000 kcal per day. An unfortunate consequence of this adjustment is that the role of unrestrained energy intake in the obesity and diabetes epidemics seems to be rendered obsolete. For example, in the USA, the mean adult energy intake increased from 1955 kcal per day during 1971–75 to 2269 kcal per day during 2003–04. Between 1980 and 2009, average body-mass index (BMI) worldwide increased from 25·5 to 28·5 kg per m for men and from 25·0 to 28·4 kg per m for women. In China, mean adult energy intake was 1978 kcal per day in 1970 and 2328 in 1992. BMI increased from 21·6 kg per m to 23·0 kg per m for men and from 21·9 to 23·0 kg per m for women in China between 1980 and 2009. If the public health agenda is to prevent non-communicable diseases in the world through changes in dietary habits, the emphasis should be on reducing energy intake and combating sedentary behaviour instead of assessing dietary patterns on the basis of insubstantial knowledge of the health properties of food items.
    The systematic assessment of dietary quality by Fumiaki Imamura and colleagues (March, 2015) examined global consumption of healthy and unhealthy foods. The investigators describe this study as the most recent and robust source of data about dietary patterns, recommending its use for policy development. Barbados, where we live and work, topped the list of highest EDC.HCl of ten “more healthy items”. Because this finding is highly discordant with our own observations, we were keen to identify and review the sources of data used by the authors. Identification of the data sources was not straightforward. In the supplementary tables of two previous publications, we found reference to an unpublished “nationally representative” survey of 280 Barbadian adults. Data were provided by an unspecified “corresponding member”, although in the list of collaborators, none are from Barbados. We believe that we have traced the source of these data to a subset of participants in the Barbados National Cancer Study, a case-control study of breast and prostate cancer. Of the 280 adults in the study subset, 35% are cases, which is hardly nationally representative. Our experience highlights two crucial issues. The first is the difficulty in identifying the data, and who provided them, on which the estimates are based; the second is the use of data without the involvement of local researchers. By their nature, global estimates will always be works in progress. Critical review by local researchers is essential. However, as we and others have noted, this process is hindered by a lack of transparency in the presentation of data sources and methods.
    Francisco Becerra-Posada (July, 2015) writes about the efforts of the Pan American Health Organization to take up the challenge of addressing the social determinants of health through action across sectors and on becoming the first in the world to adopt a Regional Plan of Action on Health in All Policies. I fully agree with his comment that “the public health community now has a unique opportunity to use a Health in All Policies approach in informing policies and practices”. However, I would like to stress that adopting a Health in All Policies plan does not automatically lead to taking health into account in all policies. For an example, Finland\'s role in promoting Health in All Policies in the European Union has been substantial, whereas the realpolitik in Finland has not always been very health-supportive. The first Finnish national programme “Health for all by the year 2000” was implemented in 1986, and at the very same year the abrupt liberalisation of Finnish financial markets led to massive unemployment and widening health inequalities. A revised programme was implemented in 1993, which was soon followed by severe austerity policies that were not allocated evenly across all public spending but were more heavily concentrated on the services for social classes with least power to resist them. The latest programme “Health 2015” was implemented in 2001, and, 3 years later, the Finnish alcohol policy was changed dramatically despite warnings given by health impact assessments, resulting in a 20% rise in alcohol-related mortality within a year.