Competency+4

=Identify the relationships among local, national, and global nutritional and public health problems (CEPH).=

This is the summary of my discussion thread for U8 - Health Care Systems and Policy: **Changing Society From Treatment-Based to Prevention-Oriented.**
The current US medical model focuses on treatment of diseases rather than prevention. But this is not proving effective. The overall health status of America would benefit greatly if medical care and public policy changed to emphasize health promotion and disease prevention instead of disease treatment (1). In fact, this is arguably the most urgent issue currently in American health care and public policy.

The pattern of illness has shifted from infectious diseases and pandemics, to degenerative and man-made diseases, to the current age of obesity and inactivity (2). It has been predicted that if obesity continues to increase along the present track, by 2020 almost half of US adults will be obese (2). Clearly, a public health approach is urgently needed to develop population-based strategies for weight management. Lifestyle intervention is the cornerstone of treatment.

In the Netherlands, partners from the local government, private and public sectors, including health care providers, health insurance companies, and patient organizations have formed and implemented the Dutch Approach, a national clinical program for the diagnosis and treatment of obesity. This is a public-private partnership with 20 partners from the local government, private and public sectors, working together at all levels to oversee activities involving the home, school, work, and recreational environments. This represents the first integrated, practice- and evidence-based national approach for tackling overweight and obesity (3).

So I asked if this type of model could work in the US and whether an effective nation-wide preventative approach could take place without a collaborative national health policy. How could this be accomplished?

Classmates provided extremely insightful and creative responses. The general consensus was that a multidisciplinary national program, made up of key groups working together (insurance companies, employers, community health groups) would be powerful and ideal, but accomplishing this would be very difficult. A nation-wide preventative approach can't occur without a collaborative national health policy, and this is unlikely due to diverse interests in the US. Prevention will most likely occur on smaller, community levels such as schools, work sites, and community programs.

California Endowment’s Healthy Eating, Active Communities Program, established in 2005 with a 4-year, $26 million investments for preventing childhood obesity and diabetes in low-income communities, was mentioned. This program has resulted in positive change (4). Other community wellness programs such as Shape Up Sommerville (Massachusetts) (4) and Eat Smart, Move More North Carolina are making a significant difference.

Health can be significantly impacted at the community level. I think striving toward a common goal will merge both clinical and community medicine. Poverty and social inequalities, the major obstacles in keeping Americans healthy, must be addressed as well.


 * Other key points include:**
 * Focusing on prevention is most effective.
 * The cost-effectiveness of preventative health approaches needs to be elucidated.
 * Medicine is run as a business. Money (per wealthy benefactors) can drive change.
 * Insurance providers need to step up and share responsibility in promoting prevention and healthy behaviors.
 * Clinical and community preventative approaches are distinct.
 * These lines can be blurred for a unified effort.
 * Physicians need to promote prevention and a wellness/lifestyle approach.[[image:homelessness-america.jpg width="295" height="288" align="right" caption="homelessness & poverty are not unusual."]]
 * Hopefully public policy will someday create a supportive environment upstream.
 * Until social disparities and poverty are addressed, America will not be a healthy nation.

1. How does this piece/sample relate to the competency?
 * This discussion centers around health from a community, societal, and global perspective. Obesity is a worldwide nutritional and public health issue, yet a unified solution such as the Dutch approach is unlikely in America. Under our current health policy, a preventative model will probably be driven by smaller efforts such as within communities.

2. What are the strengths and weaknesses of this piece/sample?
 * I feel that I asked relevant and provocative questions, and a strong discussion ensued, with creative dialogue and perspectives.
 * Weakness: I should have referenced more community programs.

3. What did I learn from reviewing and reflecting on this piece/sample?
 * I found the Dutch collaborative approach for obesity fascinating, and I predict that it will be quite effective. Our current treatment-based healthcare system is ineffective and the politics frustrating. However, I am encouraged by the efforts of committed commuities.

4. What do I need to work on in the future to more fully meet this competency?
 * Health is a global issue. Epidemics such as obesity require a population approach. I have shifted my focus beyond individual clinical care to community health. Because public health has no borders, I must be effective in the community and beyond and become involved in policy-making. I will continue to learn about prevention and population-targeted services to improve health. I am confident that I can integrate both clinical care and community health.


 * References:**

1. Boyle MA, Holben DH. Community Nutrition in Action: An Entrepreneurial Approach. 5th edition. Belmont, CA: Wadsworth, Cengage Learning; 2010

2. Gaziano JM. Fifth phase of the epidemiologic transition: the age of obesity and inactivity. JAMA 2010; 303(3): 275-276.

3. Renders CM, Halberstadt J, Frenkel CS, et al. Tackling the problem of overweight and obesity: the Dutch approach. Obes Facts. 2010 Aug;3(4):267-72.

4. Samuels SE, Craypo L, Boyle M, et al. The California Endowment’s Healthy Eating, Active Communities Program: A Midpoint Review. Am J Public Health. 2010; 100: 2114-2123

5. Shape Up Sommerville. Tufts University. Accessed December 3, 2010 from []

6. Cohen, J., Neuman, P., and Weinstein, M. (2008). Does Preventive Care Save Money? Health Economics and the Presidential Candidates. New England Journal of Medicine, 358, 661-663.

7. Braveman P, Egerter S. Overcoming obstacles to health: report from the Robert Wood Johnson Foundation to the Commission to Build a Healthier America. Washington, D.C. Robert Wood Johnson Foundation Commission to Build a Healthier America; 2008.