Abstract

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.

Discussion

Despite the global disease burden of NCDs in LMICs, policies that address at least one risk factor for NCDs were found in a minority of the LMICs reviewed, and only a handful of them comprehensively tackled NCDs through integrated action on various risk factors. Even if the 24 countries with unknown existence of a NCD prevention policy actually have such a policy, the proportion with countries tackling a risk factor would amount to 56% (78/140). This finding is discouraging, because in 2004, all countries expressed a strong commitment to action to address lifestyle, diet, and physical activity [20]. Our results show that, in spite of that official commitment, most LMICs are poorly prepared to tackle the NCD increase and that little progress has been made in recent years. This finding is consistent with the results of Alwan et al. [23], who reported the results of a survey in 2010 that was limited to countries with high NCD-related mortality.

Most of the policies in our review were poorly accessible and were only obtained after an extensive search or through personal contacts. Such a situation is certainly not favorable for benchmarking and communication of policies. In agreement with Sridhar et al. [88], we argue how better sharing of best practices and lessons learned with regard to policy development is needed to address the current NCD pandemic. Additional instruments and platforms to share lessons learned in policy development and implementation are needed. Policy databases with links to documents were created previously, but are restricted to nutrition action [89] or the European region [26]. An open-access, full-text global repository of initiatives and policies to address NCDs would be a great step forward. It could also contribute to global leadership and shared accountability in the global fight against NCDs, an issue that is long overdue [90]. Ideally, such a policy database would be connected to surveillance data on the main NCD risk factors, as suggested previously [23], and would facilitate tracking progress in the coming years. We are ready to organize such an open-access repository and invite interested policy makers to contact us for an update of the current database.

Priority setting and clear articulation of what needs to be done by stakeholders is a second key issue that emerged in this analysis. Countries seasoned in the fight against NCDs develop comprehensive strategies that focus on critical risk factors and what is expected of stakeholders [91]. In the present analysis, the level of detail and outlining of the organization of policy actions to undertake was generally discouraging. Only a minority of the policies reviewed surpassed description of policy actions and included a budget, implementation plan, time frame, and devolvement of responsibility for strategies to combat specific risk factors. Various policies describe strategies and actions for NCD prevention as “the need to develop and review dietary guidelines and recommendations for people suffering from nutrition-related NCDs” or use generic statements such as “create awareness of healthy eating lifestyle to control NCDs.” Such general statements are not informative, and clear actions need to be outlined in the policies to mobilize stakeholders for effective action [92].

Since its inception during the 1992 International Conference on Nutrition [93], the approach to streamline nutrition action in national policies has had limited success, partly because of the lack of strong leadership and commitment to lead concerted action involving various stakeholders [94]. The current scientific evidence and international experience in the fight against NCDs consistently indicates the need for comprehensive and integrated action on various risk factors [95]. Mobilization of the main actors—in particular, governments, international agencies, the private sector, civil society, health professionals, and individuals—is imperative [96]. An important limitation of most policies included in the analysis is the absence of plans, mechanisms, and incentives to foster multi-stakeholder and cross-sector collaboration. The food and nonalcoholic beverage industry, for instance, can play a role in the promotion of healthier lifestyles. However, before engaging with the private sector, government agencies should be aware of the need to manage potential conflicts of interest between the government and the private sector and should try to address these by defining clear roles, responsibilities, and targets to be achieved as a result of their collaboration [97]. Most strategies encountered in the policies were directed towards government agencies and consumers, and few were targeted at the business community, international agencies, or civil society. The United Nations Political Declaration on NCDs makes a strong call for multi-stakeholder partnerships to be leveraged for effective prevention of NCDs. Policy makers in LMICs may need additional support for the development of multi-stakeholder collaborations to address the burden imposed by NCDs as well as their root causes.

In our review of governmental policies relating to NCD prevention in LMICs, strategies to increase fruit and vegetable intake were the most frequent dietary action for NCD prevention. This is hardly surprising, as fruit and vegetable interventions were taken up early on in LMICs, primarily to address prevailing micronutrient deficiencies such as vitamin A deficiency [98]. Many of these experiences, however, are restricted to the development of food-based dietary guidelines or incentives targeted towards the agricultural sector. Policy measures to achieve better diet will require constructively engaging much more with a wider range of stakeholders, in particular the food industry, retail, and the catering sector [99]. The difficulty of developing a comprehensive policy response and integrated package of strategies is not restricted to NCDs alone, and has previously been observed in an in-depth analysis of high-burden countries for child malnutrition [100]. We also note that various countries have developed strategies to reduce total fat intake, despite convincing evidence that it is the reduction of saturated and trans-fatty acids in particular, and not total fat intake, that is effective to address NCDs [101].

Most strategies encountered in the policy documents focused on consumers and aimed to prevent NCDs through awareness creation, education (i.e., labeling), or changing individuals’ behavior. The traditional approach to addressing lifestyle changes in individuals has met with very limited success. It is widely accepted that the environmental context drives individual diets and lifestyle [102] and that programs need to incorporate environmental determinants (i.e., the quantity, quality, or price of dietary choices, or the built environment for physical activity) in order to be effective. Such policy measures, in particular those addressing the private sector, were poorly elaborated in the policy documents [103].

A key issue is the actual implementation of policy measures in relation to what was articulated in the documents. The findings of this review indicate that few LMICs have made significant steps in the development of a comprehensive set of strategies to address NCDs. Although an in-depth evaluation of actual implementation, effects, and resources allocated has not been opportune to date, we hope that our findings provide baseline data and encourage countries to develop monitoring and evaluation mechanisms to assess policy response in due time. Documenting the effectiveness of population-based NCD prevention policies will be a critical factor of success to ensure effective action in LMICs [4].

For this review, we were able to assess documents in all languages received. Because of language constraints, however, two of the documents [74],[87] were coded by only one researcher. To assess the content of the policy of Iran, we relied on translations by experienced senior Iranian researchers. All other policy documents were obtained in Spanish, Portuguese, French, or English and were analyzed accordingly by the research team. For China and the Russian Federation, appropriate English versions of the policies were obtained from the Chinese Centers for Disease Control and the United States Department of Agriculture, respectively. Despite indications of availability of relevant policies in the European region [26], language limitations did not allow us to search the websites of a number of countries such as Azerbaijan, Belarus, and the Russian Federation.

The restriction of our review to only national policies presents a number of limitations. The mere presence or absence of policies or strategies for NCDs in a policy document does not necessarily reflect concrete action. Conversely, nutritional interventions have been implemented in some countries without a policy being developed and published [104]. In addition, this review assessed the contents of the policy documents as they were published and did not capture local or regional activities, or initiatives that emerged after the publication of the policies. The findings from a survey in countries with a high burden of NCDs, such as Thailand and South Africa, illustrate this discrepancy [23]. The contents might have been modified over time in response to new scientific findings, emerging nutritional challenges, or changes in the countries’ priorities [91]. In addition, it is important to point out that we extracted only actions that explicitly referred to one of the risk factors analyzed. Generic statements such as “development of food-based dietary guidelines” or “establishment of fiscal measures for a healthy diet” were hence not coded.

The present review shows that the policy response to address current NCD challenges through diet and physical inactivity in LMICs is inadequate since endorsement of the Global Strategy on Diet, Physical Activity and Health [20]. LMICs urgently need to scale up interventions and develop integrated policies that address various risk factors for NCD prevention through multi-stakeholder collaboration and cross-sector involvement. Clear and prioritized actions are needed to harness the NCD epidemic. Such actions need to be documented in policy documents that are publicly available to share lessons learned, promote engagement with the stakeholders, and stimulate accountability and leadership in the fight against the burden of NCDs in LMICs. The establishment of an open-access and publicly accessible database of policy documents with regular systematic reviews of policy development might prove to be an incentive in this regard.

Source: PLOS