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

Assessment of vitamin D intake among Libyan women - adaptation and validation of specific food frequency questionnaire

Vitamin D deficiency (VDD) has pandemic proportions worldwide. Numerous studies report on high prevalence of VDD in sunny regions like Near East and North Africa (NENA). Previous studies indicated that Libyan population was at risk of VDD. To contribute to the body of evidence, measurement of vitamin D status on children, adults, in Misurata region was conducted, and confirmed with validated dietary intake study. Serum 25(OH)D was analysed using electrochemiluminescence protein binding assay. Existing Food Frequency Questionnaires (FFQ) were adapted to Libyan Women Food Frequency Questionnaire (LW-FFQ). Repeated 24h dietary recalls and LW-FFQ were employed in vitamin D intake evaluation. LW-FFQ was validated using 24h dietary recall and vitamin D status as referent methods. The questionnaires included anthropometry and lifestyle information. Vitamin D status assessment revealed inadequate levels (25(OH)D lt 50nmol/l) in almost 80% of participants. Women (25-64y) were identified as the most vulnerable group with vitamin D inadequacy present in 82% (61.6% had 25(OH)D lt 25nmol/l, and 20.2% had 25-50nmol/l 25(OH)D). Average Vitamin D intake within the study sample (n=316) was 3.9 +/- 7.9 mu g/d, with 92% participants below both Institute of Medicine (IOM) (10 mu g/d) and European Food Safety Authority (15 mu g/d) recommendations. Measured vitamin D status, in 13% of this group, correlated significantly (p=0.015) with intake estimates. Based on self-report, consumption of vitamin D supplements does not exist among study participants. Additional lifestyle factors influencing vitamin D status were analysed. Only 2% of study participants spend approximately 11 min on the sun daily, 60.4% were obese, 23.1% were overweight and 71.2% reported low physical activity. These findings confirm previous reports on high prevalence of VDD in women across NENA, and in Libya. The situation calls for multi-sectoral actions and public health initiatives to address dietary and lifestyle habits

Demographic and socio-economic predictors of diet quality among adults in Bosnia and Herzegovina

Objective: To evaluate associations of demographic and socio-economic factors with diet quality among population subgroups in Bosnia and Herzegovina (B&H). Design: A cross-sectional analysis of 2017 B&H dietary survey data. Diet quality was assessed by the Prime Diet Quality Score (PDQS) utilizing data from two non-consecutive 24 h diet recalls. Socio-economic variables were extracted from the 2015 B&H Household Budget Survey. Homogeneity of means across population subgroups was evaluated using multivariable regression. Setting: B&H population survey. Participants: A population-based sample of 853 adults. Results: The mean PDQS was 15 center dot 8 (range 7-28 out of a possible 42 points). In general, Bosnian adults had low PDQS due to high intakes of refined grains, high-fat dairy and processed meats, and low intakes of whole grains, nuts and fish. The PDQS was significantly higher (P lt 0 center dot 0001) among older individuals (17 center dot 0) compared with those in the youngest group (14 center dot 5), among individuals living in the central and northern regions (16 center dot 5) compared with those living in the south (15 center dot 1; P lt 0 center dot 0001), and among people who are married/cohabitating (16 center dot 1) v. single (14 center dot 8; P = 0 center dot 02). In energy-adjusted models, socio-economic status (P = 0 center dot 04) and tertiles of household spending (P = 0 center dot 002) were inversely associated with the PDQS. Conclusions: Diet quality in this population was low. Young and middle-aged individuals, singles and those living in the south had significantly lower quality diets compared with other subgroups. Public health action is needed to promote higher consumption of whole grains, nuts and fish, and a higher variety of fruits and vegetables

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 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 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

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