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Is the ketogenic diet one more fad – or could it help manage diabetes?
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This Programme for Action does not, therefore, just address the most disadvantaged groups and areas. It also addresses the needs of a large part of the population as well as those of socially deprived groups. Choosing health sets out how we will work to provide more of the opportunities, support and information people want to enable them to choose health.

It aims to inform and encourage people as individuals, and to help shape the commercial and cultural environment we live in so that it is easier to choose a healthy lifestyle. Foreword by Tony Blair. Success in developing demand for health is not enough on its own; people need to be able to make informed choices about what action to take.

Chapter 2 par. People who are disabled or suffer from mental ill health, stretched for money, out of work, poorly qualified, or who live in inadequate or temporary accommodation or in an area of high crime, are likely to experience less control over their lives than others and are often are pressed to cope with immediate priorities.

They are often less likely to think about the consequences of everyday choices about diet, exercise, smoking and sexual behaviour on their long-term health, or to take up the childhood immunization and health screening programmes that provide protection against diseases that can kill or cause serious long-term ill-health.

Chapter 1 par. Many of the initiatives in this White Paper will be targeted first at communities and groups where opportunities to choose health are least well-developed and most progress is needed. We also need to look at ways to make healthy choices more accessible to individuals and groups who may not find it easy to use information designed to meet the needs of the general population.

It is a fact of life that it is easier for some people to make healthy choices than others.

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Existing health inequalities show that opting for a healthy lifestyle is easier for some people than others… The success of the strategy will be measured first in the increased number of healthy choices that individuals make, and then in the lives saved, lengthened and improved in quality. Preface by John Reid, Health Secretary. The new approaches set out in this chapter will help people by offering them the opportunity to develop their own personal health guides and providing access to NHS-accredited health trainers and other NHS and community resources to support them in acting on their plans for health.

Chapter 5 par. We are all strongly influenced by the people around us, our families, the communities we live in and social norms. Our social and cognitive development, self-esteem, confidence, personal resilience and wellbeing are affected by a wide range of influences throughout life, such as the environment we live in, the place in which we work and our local community. This impacts on our health and our life chances. Wider factors that shape the health and wellbeing of individuals, families and local communities—such as education, employment and the environment—also need to be addressed in order to tackle health inequalities.

We cannot just ban everything, lecture people or deliver initiatives to the public. This is not justified and will not work. Nor should we have one-size-fits-all policies that often leave the poorest in our society to struggle. This includes changing social norms and default options so that healthier choices are easier for people to make. There is significant scope to use approaches that harness the latest techniques of behavioural science to do this—nudging people in the right direction rather than banning or significantly restricting their choices.

Successive documents did show increasing reference to the impact of a wide range of factors on health social, cultural, economic and environmental. Nevertheless, these were rarely then used for policy and intervention development or for the evaluation of programmes; in both, individualism remained paramount. The responsibility falls to the individual to make the least or less risky decision.

Evidence about the wider determinants of health is used to justify interventions on health inequalities, which then paradoxically concentrate on individual behaviour. Rather than addressing the wider determinants themselves, certain groups are viewed as lacking the capacity to negotiate successfully the effects of these determinants, demonstrated by their proclivity for making unhealthy choices.

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Thus, a number of interventions focus on the provision of opportunities to enable individuals to improve their current social and economic situation through, for example, education, training and work opportunities. This focus on the individual effectively neutralizes the effects of social context and airbrushes out of the picture a number of important contextual agents and institutions—specifically the state, markets and industry.

So the state and its retreat from interventionism consequent on neo-liberal economic thinking, the role of markets as a cause of rather than a solution to the problem , and the incidental health damaging roles of the food, advertising and alcohol industries are conveniently put to one side.

The alternative view that the State has a duty to enable as far as possible everyone to have a fair opportunity to live a healthy life and that governments should try to remove inequalities that affect disadvantaged groups or individuals, including a duty of proportionate regulation, has not always been a dominant motif in policy documents. For example, obesity as a significant public health threat and an important cause of health inequalities has become engrained in policy discourse in the last decade and a half.

This is despite compelling evidence that an obesogenic environment is generating the obesity epidemic, 15 , 50 and that its structure and dynamics should be the target for arresting the epidemic. Policy solutions have persistently focused on proximal determinants, most prominently individual diet and exercise.

Implementation of the report was terminated long before effects could be appropriately evaluated. There are a small number of other examples where what we refer to as a relational approach has found its way into the public domain. One of the implications of the focus on individuals and on behaviour change is that it pushes policy interest towards proximal risk factors which the NICE Guidelines did not and the role of these in the aetiology of non-communicable disease in particular.

However, knowledge about risk and its links to behaviour in causal pathways of disease do not on their own provide any solutions as to how to change those things. For example, knowledge about the dangers of exposure to cigarette smoke or alcohol suggests that reducing exposure would be beneficial, but does not explain how to achieve that. A focus on the dynamics of the systems involved in the relations between industry, markets, advertising, human preferences, group behaviour, as well as the individual actor provides a richer theoretical frame for developing and evaluating integrated programmes to address the problem.

This has been the case with the success of tobacco control in the UK. We have highlighted extensive cross-disciplinary evidence about the relational nature of health inequalities, and causal mechanisms beyond individual choice and responsibility. We have shown that this evidence rarely follows through to preventive programmes.

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Health inequalities persist in the UK driven largely by the social patterning of non-communicable disease. Interventions designed to reduce health inequalities are still primarily shaped by a focus on individual behaviour. Yet, there is substantial evidence of supra-individualistic and relational mechanisms relevant to health inequalities from a range of disciplines including sociology, history, biology, neuroscience, philosophy and psychology.

This evidence is not yet applied systematically in policy or action, where it may inform the design and implementation of more effective policies. A perspective recognizing the complexity of the systems in which public health must practice, including its politics, shifts us away from narrowly focussed linear behaviour change models to a focus on reflexive systems and the power of players in those systems. In order to move towards integrating this thinking into policy considerations, we have developed a set of questions to use in writing and critiquing policy papers, which aim to ensure that proposed interventions to address health inequalities take into account relational and dynamic factors, as well as individual behaviour Table 3.

These questions can be used not only by policy-makers and service developers but also by academic researchers to ensure that relational and dynamic factors are brought to the forefront of policy evaluation. Table 3 Questions to use in the formulation and critique of policies to address health inequalities.

This is not a comprehensive or systematic review of all documents relating to English policy recommendations to address health inequalities. Current policies dominating efforts to reduce health inequalities through prevention of non-communicable disease target individual behaviour change and have not worked well. We have argued that an individualistic epistemology limits their impact. Programmes predominantly focus on individual behaviour change foregrounding individual choice and responsibility.

There exists strong and extensive evidence that interconnecting and interacting factors, beyond the individual, impact on health including place, context, power, economics, institutional relationships and biology, over time and across generations. The existence of such evidence, however, has not been sufficient to garner policy action even when existing strategies have failed to successfully address health inequalities. We propose a list of questions that researchers and policy-makers can use when writing or critiquing policy in order to bring this broader perspective to the forefront of their analysis of the problem.

This is one small step in moving from the rhetoric of whole systems interventions to long-term intervention and evaluation and towards broadening the range of approaches and evidence we use to unpack the problems of health inequalities and work towards policies to address them. Natasha Kriznik is in receipt of funding for health services research from the Wellcome Trust.

He also has one consultancy for providing general evidence-based advice on obesity prevention to Slimming World.

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We are grateful to members of the Reading Group for their insightful and helpful comments on earlier drafts of the paper. We would also like to thank the Reviewers for their suggestions and comments for improving the article. Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide. Sign In or Create an Account. Sign In. Advanced Search. Article Navigation. Close mobile search navigation Article Navigation.

Volume Article Contents. Moving towards more dynamic thinking: power, history and the relationship between the biological and the social. Conflicts of interest. Moving beyond individual choice in policies to reduce health inequalities: the integration of dynamic with individual explanations N M Kriznik. Address correspondence to N. Kriznik, E-mail: nmk33 medschl. Oxford Academic. Google Scholar.

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A L Kinmonth. T Ling. M P Kelly. Article history. Revision Received:. Cite Citation. Permissions Icon Permissions. Abstract Background. Table 1. To understand how a phenomenon comes to be understood as a problem in social policy problematization , including the causes of the problem. To understand the discursive practices surrounding the representation of the problem archaeology , i. How has this representation come about? To understand the history genealogy of the development of understanding of a problem. What is left unproblematic in this problem representation? To identify silences and highlight explanations which are not discussed and to consider why these views might be excluded from this particular representation of the problem.

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To understand the creation of subjectivities produced by representations of problems in policies: how individuals and population groups are conceptualized. How has it been or could it be questioned, disrupted and replaced? To identify where this representation of the problem has been reproduced, including in other policy documents.

Table 2. The smoking related diseases, alcoholism and other drug dependencies, obesity and its consequences, and the sexually transmitted disease are among the preventable problems of our time and in relation to all of these the individual must choose for himself p. People cannot be forced to behave sensibly in terms of their smoking, eating, exercise, alcohol or personal sexual habits. But efforts can be made to ensure that when they choose, they are exercising informed choice in circumstances where this is possible.

Progress can be made on three fronts: first, through the continued general pursuit of greater economic prosperity and social wellbeing; second, through trying to increase understanding of the variations, and the action which might effectively address them; third, through specific initiatives to address the health needs of particularly vulnerable groups, whether geographical, ethnic, occupational or others who need specific targeted help. The reason is simple. We live in an age where many of these main causes of premature death and unnecessary disease are related to how we live our lives.

Foreword Everyone has a part to play in improving health… To seize the opportunity, people need information to help make the right choices. But we also believe that there are steps we can take to help support the decisions people make. If you can, stop. Follow a balanced diet with plenty of fruit and vegetables. Keep physically active. Manage stress by, for example, talking things through and making time to relax. If you drink alcohol, do so in moderation. Cover up in the sun, and protect children from sunburn. Practise safer sex. Take up cancer screening opportunities. Be safe on the roads: follow the Highway Code.

It is essential that such choices should be informed by clear and accurate advice. Schools have a vital part to play while charities and healthcare professionals, including community pharmacists and dentists, can advise how to quit smoking, offer exercise on prescription, identify patients at risk of heart disease and provide services for substance misusers.

Unfortunately, the effects can be passed on from generation to generation. Foreword by Tony Blair Success in developing demand for health is not enough on its own; people need to be able to make informed choices about what action to take. Preface by John Reid, Health Secretary The new approaches set out in this chapter will help people by offering them the opportunity to develop their own personal health guides and providing access to NHS-accredited health trainers and other NHS and community resources to support them in acting on their plans for health.

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These change as we progress through the key transition points in life—from infancy and childhood, through our teenage years, to adulthood, working life, retirement and the end of life. Even before conception and through pregnancy, social, biological and genetic factors accumulate to influence the health of the baby. Table 3. Questions to use in the formulation and critique of policies to address health inequalities. Are proximal risk factors used as the primary justification for solutions to address health inequalities?

To highlight the type of evidence being used to justify solutions and to identify any gaps particularly around wider determinants of health. Is evidence included relating to the influence of the wider determinants of health? Have the recommended approaches to addressing health inequalities appeared in policy documents in the last 2, 5, 10 and 15 years? Have these approaches shown cost-effectiveness in formal studies over sufficient time intervals? Are there clear steps from identification of a cause of the problem to actionable interventions?

To ensure that factors listed as contributing to health inequalities are adequately addressed through causal pathways. Policies should include a guide to implementation of interventions in order to move from rhetoric to action. Are the mechanisms of action of the recommended intervention described?

Are the recommendations grounded in the social and economic contexts of everyday life? To draw attention to the importance of social context in enabling or restricting change, and to the nature of power. How are the relationships between the state, industry, civil society and individuals taken account of in explanations for health inequality and proposals for action?

What evidence of historical social conditions have been used in the analysis? We do not need to wait for our children to develop severe PEM before giving them food. Mothers can be taught how to prepare such mixtures at home for their children using mentor mothers. Burundi, with the assistance of an international non-governmental organization, presents a model of how mentor mothers can be used to reduce PEM in a community using what they called Maman Lumieres Light Mothers.

Maman Lumieres are the key community implementers for a positive-deviance hearth PD-Hearth nutrition initiative using an approach that identifies affordable, culturally acceptable, effective, and sustainable practices that are already being used by individuals within a community to prevent malnutrition; by seeing these behaviors, families are empowered to adopt better practices even with limited resources and access to services.

This helps them reach out to their communities and alleviates the long distances and difficult terrain encountered when traveling to a health facility — a trip that can take a day of walking. Community resources can also be used to encourage breast feeding culture in Nigeria. The recommendation is that babies should be exclusively breast fed EBF for the first 6 months, and thereafter, breast feeding needs to be continued into the second year of life along with appropriate complementary diets.

There is an urgent need to mobilize the available resources to step up our exclusive breast feeding rate and encourage breast feeding into the second year of child's life with timely and appropriate complementary feeding. In view of the persisting high number of children with PEM in Nigeria and associated high mortality rate with the severe forms of PEM even in hospital settings, community-based strategies that can help preventive PEM need to be encouraged and strengthened. Source of Support: Nil.

Conflict of Interest: None declared. National Center for Biotechnology Information , U. Ann Med Health Sci Res. Author information Copyright and License information Disclaimer. Address for correspondence: Dr. E-mail: ku. This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.

This article has been cited by other articles in PMC. Abstract There is still a high burden of protein—energy malnutrition in Nigeria. Introduction Protein-energy malnutrition PEM is still a major public health issue in developing countries. PEM and Determinants of Health It has been argued that inadequate management of severe PEM is the cause of an unacceptable high case-fatality rate in Nigeria today, and insufficient skilled manpower and poorly equipped health facilities to deal with life-threatening emergencies can be blamed for this.

Micronutrient Supplementation as a Key Strategy A number of strategies have been documented to help reduce the incidence and severity of PEM. Household Food Security The incidence of PEM can be reduced by improving on storage and preservation of various food items during the harvest season. Safety Nets PEM is usually found among the children of low socioeconomic families.

Community Level Strategies The community-based organizations also have a role to play in contributing to household food security. Conclusions In view of the persisting high number of children with PEM in Nigeria and associated high mortality rate with the severe forms of PEM even in hospital settings, community-based strategies that can help preventive PEM need to be encouraged and strengthened. Footnotes Source of Support: Nil. References 1. Muller O, Krawinkel M. Malnutrition and health in developing countries.

J Health Popul Nutr. A new classification of acute protein energy malnutrition. J Trop Pediatr. Thailand Burma Border Consortium, WHO Severe Acute Malnutrition. World Food Programme. Gurung G. Social determinants of protein-energy malnutrition: Need to attack the causes of the causes. Anger B. Poverty eradication, millennium development goals and sustainable development in Nigeria. Can Africa Reduce Poverty by Half by ? Ibekwe VE, Ashworth A. Management of protein energy malnutrition in Nigeria: An evaluation of the regimen at the kersey nutrition rehabilitation center, Nigeria.

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