Evidence-based nutrition and cardiovascular disease in the Asia-Pacific region

The Asia-Pacific region is undergoing a major change in both food and health patterns, with a connection between the two more than likely. Evidence for certain traditional Asia-Pacific foods as protective agents against chronic non-communicable disease and cardiovascular disease (CVD), in particular, is growing at a time when their usage diminishes. The nature of the evidence to establish relevant Asia-Pacific food-health linkages will include randomised placebo-controlled clinical trials, but is much more extensive and meaningful. Okinawans have probably achieved one of the most successful food cultures from a health point of view and serve as a reference point for the Asia-Pacific region. The expert working party has produced, in November 2000, the 'Okinawan Recommendations on Nutrition and CVD in the Asia-Pacific region'.

Towards global benchmarking of food environments and policies to reduce obesity and diet-related non-communicable diseases : design and methods for nation-wide surveys

Introduction: 

Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013

Background: Up-to-date evidence on levels and trends for age-sex-specific all-cause and cause-specific mortality is essential for the formation of global, regional, and national health policies. In the Global Burden of Disease Study 2013 (GBD 2013) we estimated yearly deaths for 188 countries between 1990, and 2013. We used the results to assess whether there is epidemiological convergence across countries. Methods We estimated age-sex-specific all-cause mortality using the GBD 2010 methods with some refinements to improve accuracy applied to an updated database of vital registration, survey, and census data. We generally estimated cause of death as in the GBD 2010. Key improvements included the addition of more recent vital registration data for 72 countries, an updated verbal autopsy literature review, two new and detailed data systems for China, and more detail for Mexico, UK, Turkey, and Russia. We improved statistical models for garbage code redistribution. We used six different modelling strategies across the 240 causes; cause of death ensemble modelling (CODEm) was the dominant strategy for causes with sufficient information. Trends for Alzheimer's disease and other dementias were informed by meta-regression of prevalence studies. For pathogen-specific causes of diarrhoea and lower respiratory infections we used a counterfactual approach. We computed two measures of convergence (inequality) across countries: the average relative difference across all pairs of countries (Gini coefficient) and the average absolute difference across countries. To summarise broad findings, we used multiple decrement life-tables to decompose probabilities of death from birth to exact age 15 years, from exact age 15 years to exact age 50 years, and from exact age 50 years to exact age 75 years, and life expectancy at birth into major causes. For all quantities reported, we computed 95% uncertainty intervals (UIs). We constrained cause-specific fractions within each age-sex-country-year group to sum to all-cause mortality based on draws from the uncertainty distributions. Findings Global life expectancy for both sexes increased from 65·3 years (UI 65·0-65·6) in 1990, to 71·5 years (UI 71·0-71·9) in 2013, while the number of deaths increased from 47·5 million (UI 46·8-48·2) to 54·9 million (UI 53·6-56·3) over the same interval. Global progress masked variation by age and sex: for children, average absolute differences between countries decreased but relative differences increased.For women aged 25-39 years and older than 75 years and for men aged 20-49 years and 65 years and older, both absolute and relative differences increased. Decomposition of global and regional life expectancy showed the prominent role of reductions in age-standardised death rates for cardiovascular diseases and cancers in high-income regions, and reductions in child deaths from diarrhoea, lower respiratory infections, and neonatal causes in low-income regions. HIV/AIDS reduced life expectancy in southern sub-Saharan Africa. For most communicable causes of death both numbers of deaths and age-standardised death rates fell whereas for most non-communicable causes, demographic shifts have increased numbers of deaths but decreased age-standardised death rates. Global deaths from injury increased by 10·7%, from 4·3 million deaths in 1990 to 4·8 million in 2013; but age-standardised rates declined over the same period by 21%. For some causes of more than 100 000 deaths per year in 2013, age-standardised death rates increased between 1990 and 2013, including HIV/AIDS, pancreatic cancer, atrial fibrillation and flutter, drug use disorders, diabetes, chronic kidney disease, and sickle-cell anaemias. Diarrhoeal diseases, lower respiratory infections, neonatal causes, and malaria are still in the top five causes of death in children younger than 5 years. The most important pathogens are rotavirus for diarrhoea and pneumococcus for lower respiratory infections. Country-specific probabilities of death over three phases of life were substantially varied between and within regions. Interpretation For most countries, the general pattern of reductions in age-sex specific mortality has been associated with a progressive shift towards a larger share of the remaining deaths caused by non-communicable disease and injuries. Assessing epidemiological convergence across countries depends on whether an absolute or relative measure of inequality is used. Nevertheless, age-standardised death rates for seven substantial causes are increasing, suggesting the potential for reversals in some countries. Important gaps exist in the empirical data for cause of death estimates for some countries; for example, no national data for India are available for the past decade.

A review of methods and tools to assess the implementation of government policies to create healthy food environments for preventing obesity and diet-related non-communicable diseases

BACKGROUND: Policies to create healthy food environments are recognized as critical components of efforts to prevent obesity and diet-related non-communicable diseases. There has not been a systematic review of existing methods and tools used to assess the implementation of these government policies. The purpose of this study was to review methods and tools used for assessing the implementation of government policies to create healthy food environments. The study conducted a systematic literature search. Multiple databases as well as the grey literature were searched. All study designs and review papers on assessing the implementation of government policies to create healthy food environments were included. A quality assessment of the methods and tools identified from relevant studies was carried out using the following four criteria: comprehensiveness, relevance, generalizability and feasibility. This quality assessment was completed by two independent reviewers. RESULTS: The review identified 52 studies across different policy areas, levels and settings. Self-administered questionnaires and policy checklists were most commonly applied to assess the extent of policy implementation, whereas semi-structured interviews were most commonly used to evaluate the implementation process. Measures varied widely, with the existence of policy implementation the aspect most commonly assessed. The most frequently identified barriers and facilitators for policy implementation were infrastructure support, resources and stakeholder engagement. The assessment of policy implementation on food environments was usually undertaken in combination with other policy areas, particularly nutrition education and physical activity. Three tools/methods were rated 'high' quality and 13 tools/methods received 'medium' quality ratings. CONCLUSIONS: Harmonization of the available high-quality methods and tools is needed to ensure that assessment of government policy implementation can be compared across different countries and settings and over time. This will contribute to efforts to increase government accountability for their actions to improve the healthiness of food environments.

Problem and solution trees : a practical approach for identifying potential interventions to improve population nutrition

Population nutrition problems have a diversity of contributory factors and, ideally, multi-sectoral solutions should be developed by the relevant stakeholders, based on a common understanding of these factors. The problem and solution tree approach is a participatory process of working through the layers of determinants and then developing potential interventions for a specific issue, using the available data and expertise. We tailored this approach for non-communicable disease-related nutrition problems in Pacific Islands and applied it in several countries. The process led to the identification of a considerable range of determinants of unhealthy diets and potential interventions to improve the situation. This practical approach also offered the additional benefit of developing stakeholder awareness in the issues. Problem trees are a relatively simple tool to implement, easy to adapt to differing needs, can generate a wealth of information and can be more widely used.

"Tell us something new!" : the response of planning and transport professionals to public health guidance on the built environment and physical activity

A large proportion of non-communicable disease can be attributed to modifiable risk factors such as poor nutrition and physical inactivity. We present data on planning and transport practitioners' perceptions and responses to government public health guidance aimed at modifying environmental factors to promote physical activity. This study was informed by questions on the role of evidence-based guidance, the views of professionals towards the guidance, the links between guidance and existing legislation and policy and the practicality of guidelines. A key informant 'snowball' sampling technique was used to recruit participants from the main professional planning organisations across England. Seventy-six people were interviewed in eight focus groups. We found that evidence-based public health guidance is a new voice in urban and town planning, although much of the advice is already reflected by the 'accepted wisdom' of these professions. Evidence-based health guidance could be a powerful driver affecting planning practice, but other legislated planning guidance may take priority for planning and transport professionals.

Higher leptin levels in Asian Indians than Creoles and Europids : a potential explanation for increased metabolic risk

Background and purpose: Leptin predicts cardiovascular diseases and type 2 diabetes, diseases to which Asian Indians are highly susceptible. As a risk marker, leptin’s intra-individual and seasonal stability is unstudied and only small studies have compared leptin levels in Asian Indians with other populations. The aim of this study was to explore ethnicity related differences in leptin levels and its intra-individual and seasonal stability.

Methods: Leptin and anthropometric data from the northern Sweden MONICA (3513 Europids) and the Mauritius Non-communicable Disease (2480 Asian Indians and Creoles) studies were used. In both studies men and women, 25- to 74-year old, participated in both an initial population survey and a follow-up after 5–13 years. For the analysis of seasonal leptin variation, a subset of 1780 participants, 30- to 60-year old, in the Vasterbotten Intervention Project was used.

Results: Asian Indian men and women had higher levels of leptin, leptin per body mass index (BMI) unit (leptin/BMI) or per cm in waist circumference (WC; leptin/waist) than Creoles and Europids when adjusted for BMI (all P<0.0005) or WC (all P<0.005). In men, Creoles had higher leptin, leptin/BMI and leptin/waist than Europids when adjusted for BMI or WC (all P<0.0005). In women, Creoles had higher leptin/BMI and leptin/waist than Europids only when adjusted for WC (P<0.0005). Asian Indian ethnicity in both sexes, and Creole ethnicity in men, was independently associated with high leptin levels. The intra-class correlation for leptin was similar (0.6–0.7), independently of sex, ethnicity or follow-up time. No seasonal variation in leptin levels was seen.

Conclusion: Asian Indians have higher levels of leptin, leptin/BMI and leptin/waist than Creoles and Europids. Leptin has a high intra-individual stability and seasonal leptin variation does not appear to explain the ethnic differences observed here.

The role of policy in improving diets : experiences from the Pacific obesity prevention in communities food policy project

There is global interest in using multisectoral policy approaches to improve diets, and reduce obesity and non-communicable disease. However, there has been ad hoc implementation, which in some sectors such as the economic sector has been very limited, because of the lack of quality evidence on potential costs and impacts, and the inherent challenges associated with cross-sectoral policy development and implementation. The Pacific Obesity Prevention in Communities food policy project aimed to inform relevant policy development and implementation in Pacific Island countries. The project developed an innovative participatory approach to identifying and assessing potential policy options in terms of their effectiveness and feasibility. It also used policy analysis methodology to assess three policy initiatives to reduce fatty meat availability and four soft drink taxes in the region, in order to identify strategies for supporting effective policy implementation.

A review of population-based prevalence studies of physical activity in adults in the Asia-Pacific region

Background: Physical activity (PA) surveillance is an important component of non-communicable disease risk factor monitoring, and occurs through national and international surveillance systems. This review identifies population PA estimates for adults in the Asia-Pacific region, and examines variation in trends and prevalence rates obtained using different PA measures.

Methods: Data were obtained from a MEDLINE search; World Health Organization’s Global Health Infobase; Government websites and reference lists of relevant papers. Inclusion criteria included: national studies or those reporting large scale population-level data; data published from 2000 to 2010 and trend data prior; sample sizes over n = 1000, or fewer subjects in small nations.

Results: In total, 56 population surveys from 29 Asia-Pacific countries were identified. Data on ‘sufficient physical activity’ amongst adults were available from 45 studies (80%), with estimates ranging from 7% to 93% (median 62%, inter-quartile range 40%-85%). For 14 countries, estimates of ‘sufficient activity’ were documented in multiple surveys using different methods, with the largest variation from 18% to 92% in Nepal. Median or mean METminutes/ day, reported in 20 studies, ranged from 6 to 1356. Serial trend data were available for 11 countries (22%), for periods spanning 2-10 years. Of these, five countries demonstrated increases in physical activity over time, four demonstrated decreases and three showed no changes.

Conclusions: Many countries in the Asia-Pacific region collect population-level PA data. This review highlights differences in estimates within and between countries. Some differences may be real, others due to variation in the PA questions asked and survey methods used. Use of standardized protocols and measures, and combined reporting of data are essential goals of improved international PA surveillance.