The American Public Health Association has been among those we've contested when they abandoned an outcomes- and evidence-based approach to public health nutrition. So it seems fair to compliment APHA when it gets it right. This week, APHA released its 2009 Agenda for Health Reform . It contains six "critical changes" to achieve "health improvement." (It also contains five recommendations for health care delivery, beyond our balliwick).

We hope APHA examines its previous program recommendations against these critical priorities and abandons, for example, its past advocacy of universal sodium reduction as inconsistent with its new policy priorities. The six "critical changes" include four goals we share, but would accord a lower priority: 1) investing more in prevention program "that have been proven to prevent disease and injury and improve the social determinants of health," 2) investing more to address "the chronic underfunding of the nation’s public health system," 3) improving programs "to reduce disparities in health," and 4) requiring "an annual report to the nation that holds the system accountable for achieving agreed upon health goals and outcomes. The federal government should develop appropriate standardized measures and health status indicators, along with methods for collecting, reporting and analyzing such data." We like the outcomes focus of #4; it almost rises to the higher priority we'd accord to APHA's other two "critical change" recommendations.

We hope the Obama Administration seriously addresses the other two recommendations which are:

Account for the real cost savings and cost avoidance of preventive and early intervention services at the individual and community levels through more accurate fiscal scoring methods. The Congressional Budget Office (CBO ) and the Office of Management and Budget (OMB ) should be directed to develop and implement methods to more accurately score the costs savings associated with community-based and other prevention programs.

and

Require methods to assess the impact federal policies and programs have on public health. Health is intricately tied to community design and directly affected by policies and programs across various sectors, including housing, transportation, environment, land use, agriculture, labor, education, trade and the economy. Therefore, health reform legislation should require a health impact assessment for all new federal policies and programs.

"Real cost" savings can only be determined by an examination of health outcomes of an intervention. We cannot support the APHA's call for a health impact on the vast array of policies -- at least as a priority recommendation -- but let's start with an assessment of policies intended to improve health. We are woefully light on real-world assessment. These two recommendations surely tie together. If we can assess real outcomes, we will better target our interventions and realize "real cost savings."

To exemplify these points, consider, naturally, the question of efforts to reduce population salt intakes. What "real cost savings" can be realized? We've seen the scary numbers produced by computer projections from models developed by salt reduction advocates. But consider the data. Three studies of the federal government's National Health and Nutrition Examination Survey have found those on the "recommended" levels of salt intake suffer between 20% and 37% greater mortality. The only two health outcomes randomized clinical trials of salt-reduction documented that high-risk congestive heart failure patients treated with low-salt diets died more often and more quickly and were readmitted to the hospital more frequently than those consuming regular amounts of salt. And evidence is now available that there exists in the human brain a "central regulation of sodium appetite " more powerful than conscious food choices which helps explain why salt intakes have been unchanged for a century and are unlikely to be modified by calls to substitute low-sodium foods for our normal diet.

So we join with APHA in endorsing new emphasis on examining actual health outcomes, not computerized models, and the real cost savings we can expect by properly targeting our interventions, abandoning those that aren't evidence-based or likely to deliver theorized benefits.