Diet and Physical Activity for the Prevention of Noncommunicable Diseases in Low- and Middle-Income Countries: A Systematic Policy Review

Background: Diet-related noncommunicable diseases (NCDs) are increasing rapidly in low-and middle-income countries (LMICs) and constitute a leading cause of mortality. Although a call for global action has been resonating for years, the progress in national policy development in LMICs has not been assessed. This review of strategies to prevent NCDs in LMICs provides a benchmark against which policy response can be tracked over time. Methods and Findings: We reviewed how government policies in LMICs outline actions that address salt consumption, fat consumption, fruit and vegetable intake, or physical activity. A structured content analysis of national nutrition, NCDs, and health policies published between 1 January 2004 and 1 January 2013 by 140 LMIC members of the World Health Organization (WHO) was carried out. We assessed availability of policies in 83% (116/140) of the countries. NCD strategies were found in 47% (54/116) of LMICs reviewed, but only a minority proposed actions to promote healthier diets and physical activity. The coverage of policies that specifically targeted at least one of the risk factors reviewed was lower in Africa, Europe, the Americas, and the Eastern Mediterranean compared to the other two World Health Organization regions, South-East Asia and Western Pacific. Of the countries reviewed, only 12% (14/116) proposed a policy that addressed all four risk factors, and 25% (29/116) addressed only one of the risk factors reviewed. Strategies targeting the private sector were less frequently encountered than strategies targeting the general public or policy makers. Conclusions: This review indicates the disconnection between the burden of NCDs and national policy responses in LMICs. Policy makers urgently need to develop comprehensive and multi-stakeholder policies to improve dietary quality and physical activity

Preparing health professionals to work in diabetes education and care: a situation analysis

Worldwide, the increasing prevalence of chronic diseases places enormous expectations of and responsibility on health systems. Preparing the health workforce to adequately respond to these increasing demands is a challenge of critical importance. The aim of this study was to provide an overview of how health professionals (HPs) are prepared to work in diabetes care and education. A one shot cross-sectional study was undertaken to collect the data using self-completed anonymous on-line questionnaires. The invitation to complete the questionnaire was sent to more than 3745 HPs. One thousand one hundred and sixteen responses were collected, 68% were from highincome countries and 32% from middle- and low-income countries (LMIC). Most HPs developed their knowledge and skills through work experience and self-study: very few attended a formal education program as part of their training. Thirty-six percent of LMIC respondents did not have a credential/certification in diabetes and 72% reported their organizations support them to learn about diabetes education/care. Moreover, 80% referred to the International Diabetes Federation publications when making clinical decisions or planning diabetes care. Results provide insight into how HPs are educationally prepared to work in diabetes education and care and could serve as a foundation for future research. These findings emphasize the emerging necessity to develop certified/credentialing programs for HPs, especially in LMIC

National policy actions and targets to limit fat intake by WHO region and target group.

<p>WHO classification of regions and countries was followed. Four of the countries (Mayotte, West Bank and Gaza, the Republic of Kosovo, and American Samoa) classified as LMICs by the World Bank in 2011 <a href="http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001465#pmed.1001465-World5" target="_blank">[25]</a> were not WHO member states in 2011.</p>a<p>The policy document of FYRM reports that goals are in line with those of WHO <a href="http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001465#pmed.1001465-World8" target="_blank">[106]</a>. The stated goal of <1% of total energy intake from saturated fat is therefore likely meant to be the WHO goal of 10%.</p><p>FYRM, the former Yugoslav Republic of Macedonia; NR, not reported.</p

Selection process of nutrition, noncommunicable diseases, and health policies from low- and middle- income countries.

<p>The WHO classification of regions and allocation of countries was used. AFR, African Region; AMR, Region of the Americas; EMR, Eastern Mediterranean Region; EUR, European Region; SEAR, South-East Asia Region; WPR, Western Pacific Region. ^¶Mayotte, West Bank and Gaza, the Republic of Kosovo, and American Samoa. *Antigua and Barbuda, Egypt, Dominica, Democratic People's Republic of Korea, Sao Tome and Principe, Dominican Republic, Micronesia, Gabon, Tonga, Kyrgyzstan, Lebanon, Libya, Algeria, Iraq, Lithuania, Palau, Marshall Islands, Uzbekistan, Yemen, Romania, Saint Kitts and Nevis, Syrian Arab Republic, Turkmenistan, and Comoros. ^§Policy issued before 2004: Belize, Venezuela, Bosnia and Herzegovina, Eritrea, Lesotho, Papua New Guinea, Albania, Armenia, Burundi, Ecuador, El Salvador, Kiribati, Namibia, Sierra Leone, Gambia, Zimbabwe, Somalia, United Republic of Tanzania, and Vanuatu; policy not officially endorsed: Democratic Republic of the Congo, Senegal, and Tuvalu; no policy : Chad, Congo, South Africa, and Tajikistan; policy was available but could not be publically distributed: Central African Republic, Cameroon, and Tunisia; policy reported to be available <a href="http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001465#pmed.1001465-World6" target="_blank">[26]</a> but could not be obtained: Azerbaijan, Belarus, Kazakhstan, and Ukraine.</p

National policy actions and targets to promote physical activity by WHO region and target group.

<p>WHO classification of regions and countries was followed. Four of the countries (Mayotte, West Bank and Gaza, the Republic of Kosovo, and American Samoa) classified as LMICs by the World Bank in 2011 <a href="http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001465#pmed.1001465-World5" target="_blank">[25]</a> were not WHO member states in 2011.</p>a<p>Obtained from <a href="http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001465#pmed.1001465-Ghana1" target="_blank">[107]</a>.</p><p>FYRM, the former Yugoslav Republic of Macedonia; NGO, nongovernmental organization; NR, not reported; PA, physical activity.</p

National policy actions and targets to limit salt intake in LMICs by WHO region and target group.

<p>WHO classification of regions and countries was followed.</p><p>FYRM, the former Yugoslav Republic of Macedonia; NR, not reported.</p

Coding tree for policy actions analyzed in the documents.

<p>Coding tree for policy actions analyzed in the documents.</p

National policy actions and targets to increase fruit and vegetable intake by WHO region and target group.

<p>WHO classification of regions and countries was followed. Four of the countries (Mayotte, West Bank and Gaza, the Republic of Kosovo, and American Samoa) classified as LMICs by the World Bank in 2011 <a href="http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001465#pmed.1001465-World5" target="_blank">[25]</a> were not WHO member states in 2011.</p><p>FV, fruits and vegetables; FYRM, the former Yugoslav Republic of Macedonia; NR, not reported.</p