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 economic burden of ill health due to diet, physical inactivity, smoking, alcohol and obesity in the UK : an update to 2006-07 NHS costs

Background: Estimates of the economic cost of risk factors for chronic disease to the NHS provide evidence for prioritization of resources for prevention and public health. Previous comparable estimates of the economic costs of poor diet, physical inactivity, smoking, alcohol and overweight/obesity were based on economic data from 1992–93.

Methods: Diseases associated with poor diet, physical inactivity, smoking, alcohol and overweight/obesity were identified. Risk factor-specific population attributable fractions for these diseases were applied to disease-specific estimates of the economic cost to the NHS in the UK in 2006–07.

Results: In 2006–07, poor diet-related ill health cost the NHS in the UK £5.8 billion. The cost of physical inactivity was £0.9 billion. Smoking cost was £3.3 billion, alcohol cost £3.3 billion, overweight and obesity cost £5.1 billion.

Conclusion: The estimates of the economic cost of risk factors for chronic disease presented here are based on recent financial data and are directly comparable. They suggest that poor diet is a behavioural risk factor that has the highest impact on the budget of the NHS, followed by alcohol consumption, smoking and physical inactivity.

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.

The development and validation of an urbanicity scale in a multi-country study

Background : Although urban residence is consistently identified as one of the primary correlates of non-communicable disease in low- and middle-income countries, it is not clear why or how urban settings predispose individuals and populations to non-communicable disease (NCD), or how this relationship could be modified to slow the spread of NCD. The urban–rural dichotomy used in most population health research lacks the nuance and specificity necessary to understand the complex relationship between urbanicity and NCD risk. Previous studies have developed and validated quantitative tools to measure urbanicity continuously along several dimensions but all have been isolated to a single country. The purposes of this study were 1) To assess the feasibility and validity of a multi-country urbanicity scale; 2) To report some of the considerations that arise in applying such a scale in different countries; and, 3) To assess how this scale compares with previously validated scales of urbanicity.

Methods : Household and community-level data from the Young Lives longitudinal study of childhood poverty in 59 communities in Ethiopia, India and Peru collected in 2006/2007 were used. Household-level data include parents’ occupations and education level, household possessions and access to resources. Community-level data include population size, availability of health facilities and types of roads. Variables were selected for inclusion in the urbanicity scale based on inspection of the data and a review of literature on urbanicity and health. Seven domains were constructed within the scale: Population Size, Economic Activity, Built Environment, Communication, Education, Diversity and Health Services.

Results : The scale ranged from 11 to 61 (mean 35) with significant between country differences in mean urbanicity; Ethiopia (30.7), India (33.2), Peru (39.4). Construct validity was supported by factor analysis and high corrected item-scale correlations suggest good internal consistency. High agreement was observed between this scale and a dichotomized version of the urbanicity scale (Kappa 0.76; Spearman’s rank-correlation coefficient 0.84 (p < 0.0001). Linear regression of socioeconomic indicators on the urbanicity scale supported construct validity in all three countries (p < 0.05).

Conclusions : This study demonstrates and validates a robust multidimensional, multi-country urbanicity scale. It is an important step on the path to creating a tool to assess complex processes like urbanization. This scale provides the means to understand which elements of urbanization have the greatest impact on health.

Maternal dietary intake during pregnancy has longstanding consequences for the health of her offspring

Over the past 100 years, advances in pharmaceutical and medical technology have reduced the burden of communicable disease, and our appreciation of the mechanisms underlying the development of noncommunicable disease has broadened. During this time, a number of studies, both in humans and animal models, have highlighted the importance of maintaining an optimal diet during pregnancy. In particular, a number of studies support the hypothesis that suboptimal maternal protein and fat intake during pregnancy can have long-term effects on the growing fetus, and increase the likelihood of these offspring developing cardiovascular, renal, or metabolic diseases in adulthood. More recently, it has been shown that dietary intake of a number of micronutrients may offset or reverse the deleterious effects of macronutrient imbalance. Furthermore, maternal fat intake has also been identified as a major contributor to a healthy fetal environment, with a beneficial role for unsaturated fats during development as well as a beneficial impact on cell membrane physiology. Together these studies indicate that attempts to optimise maternal nutrition may prove to be an efficient and cost-effective strategy for preventing the development of cardiovascular, renal, or metabolic diseases.

Monitoring the impacts of trade agreements on food environments

The liberalization of international trade and foreign direct investment through multilateral, regional and bilateral agreements has had profound implications for the structure and nature of food systems, and therefore, for the availability, nutritional quality, accessibility, price and promotion of foods in different locations. Public health attention has only relatively recently turned to the links between trade and investment agreements, diets and health, and there is currently no systematic monitoring of this area. This paper reviews the available evidence on the links between trade agreements, food environments and diets from an obesity and non-communicable disease (NCD) perspective. Based on the key issues identified through the review, the paper outlines an approach for monitoring the potential impact of trade agreements on food environments and obesity/NCD risks. The proposed monitoring approach encompasses a set of guiding principles, recommended procedures for data collection and analysis, and quantifiable 'minimal', 'expanded' and 'optimal' measurement indicators to be tailored to national priorities, capacity and resources. Formal risk assessment processes of existing and evolving trade and investment agreements, which focus on their impacts on food environments will help inform the development of healthy trade policy, strengthen domestic nutrition and health policy space and ultimately protect population nutrition.

Lessons from obesity prevention for the prevention of mental disorders: The primordial prevention approach

Background: Emerging evidence supports a relationship between risk factors for obesity and the genesis of the common mental disorders, depression and anxiety. This suggests common mental disorders should be considered as a form of non-communicable disease, preventable through the modification of lifestyle behaviours, particularly diet and physical activity.Discussion: Obesity prevention research since the 1970's represents a considerable body of knowledge regarding strategies to modify diet and physical activity and so there may be clear lessons from obesity prevention that apply to the prevention of mental disorders. For obesity, as for common mental disorders, adolescence represents a key period of vulnerability. In this paper we briefly discuss relationships between modifiable lifestyle risk factors and mental health, lifestyle risk factor interventions in obesity prevention research, the current state of mental health prevention, and the implications of current applications of systems thinking in obesity prevention research for lifestyle interventions.Summary: We propose a potential focus for future mental health promotion interventions and emphasise the importance of lessons available from other lifestyle modification intervention programmes.

Neighborhood environmental attributes and adults' maintenance of regular walking

Environmental initiatives to support walking are keys to non-communicable disease prevention, but the relevant evidence comes mainly from cross-sectional studies. We examined neighborhood environmental attributes associated cross-sectionally with walking and those associated prospectively with walking maintenance.