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1.  Diet and Physical Activity for the Prevention of Noncommunicable Diseases in Low- and Middle-Income Countries: A Systematic Policy Review 
PLoS Medicine  2013;10(6):e1001465.
Carl Lachat and colleagues evaluate policies in low- and middle-income countries addressing salt and fat consumption, fruit and vegetable intake, and physical activity, key risk factors for non-communicable diseases.
Please see later in the article for the Editors' Summary
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.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Noncommunicable diseases (NCDs)—chronic medical conditions including cardiovascular diseases (heart disease and stroke), diabetes, cancer, and chronic respiratory diseases (chronic obstructive pulmonary disease and asthma)—are responsible for two-thirds of the world's deaths. Nearly 80% of NCD deaths, close to 30 million per year, occur in low- and middle-income countries (LMICs), where they are also rising most rapidly. Diet and lifestyle (including smoking, lack of exercise, and harmful alcohol consumption) influence a person's risk of developing an NCD and of dying from it. Because they can be modified, these risk factors have been at the center of strategies to combat NCDs. In 2004, the World Health Organization (WHO) adopted the Global Strategy on Diet, Physical Activity and Health. For diet, it recommended that individuals achieve energy balance and a healthy weight; limit energy intake from total fats and shift fat consumption away from saturated fats to unsaturated fats and towards the elimination of trans-fatty acids; increase consumption of fruits, vegetables, legumes, whole grains, and nuts; limit the intake of free sugars; and limit salt consumption from all sources and ensure that salt is iodized. For physical activity, it recommended at least 30 minutes of regular, moderate-intensity physical activity on most days throughout a person's life.
Why Was This Study Done?
By signing onto the Global Strategy in 2004, WHO member countries agreed to implement it with high priority. A first step of implementation is usually the development of local policies. Consequently, one of the four objectives of the WHO Global Strategy is “to encourage the development, strengthening and implementation of global, regional, national and community policies and action plans to improve diets and increase physical activity.” Along the same lines, in 2011 the United Nations held a high-level meeting in which the need to accelerate the policy response to the NCD epidemic was emphasized. This study was done to assess the existing national policies on NCD prevention in LMICs. Specifically, the researchers examined how well those policies matched the WHO recommendations for intake of salt, fat, and fruits and vegetables, as well as the recommendations for physical activity.
What Did the Researchers Do and Find?
The researchers searched the Internet (including websites of relevant ministries and departments) for all publicly available national policies related to diet, nutrition, NCDs, and health from all 140 WHO member countries classified as LMICs by the World Bank in 2011. For countries for which the search did not turn up policies, the researchers sent e-mail requests to the relevant national authorities, to the regional WHO offices, and to personal contacts. All documents dated from 1 January 2004 to 1 January 2013 that included national objectives and guidelines for action regarding diet, physical exercise, NCD prevention, or a combination of the three, were analyzed in detail.
Most of the policies obtained were not easy to find and access. For 24 countries, particularly in the Eastern Mediterranean, the researchers eventually gave up, unable to establish whether relevant national policies existed. Of the remaining 116 countries, 29 countries had no relevant policies, and another 30 had policies that failed to mention specifically any of the diet-related risk factors included in the analysis. Fifty-four of the 116 countries had NCD policies that addressed at least one of the risk factors. Thirty-six national policy documents contained strategies to increase fruit and vegetable intake, 20 addressed dietary fat consumption, 23 aimed to limit salt intake, and 35 had specific actions to promote physical activity. Only 14 countries, including Jamaica, the Philippines, Iran, and Mongolia, had policies that addressed all four risk factors. The policies of 27 countries mentioned only one of the four risk factors.
Policies primarily targeted consumers and government agencies and failed to address the roles of the business community or civil society. Consistent with this, most were missing plans, mechanisms, and incentives to drive collaborations between the different stakeholders.
What Do These Findings Mean?
More than eight years after the WHO Global Strategy was agreed upon, only a minority of the LMICs included in this analysis have comprehensive policies in place. Developing policies and making them widely accessible is a likely early step toward specific implementation and actions to prevent NCDs. These results therefore suggest that not enough emphasis is placed on NCD prevention in these countries through actions that have been proven to reduce known risk factors. That said, the more important question is what countries are actually doing to combat NCDs, something not directly addressed by this analysis.
In richer countries, NCDs have for decades been the leading cause of sickness and death, and the fact that public health strategies need to emphasize NCD prevention is now widely recognized. LMICs not only have more limited resources, they also continue to carry a large burden from infectious diseases. It is therefore not surprising that shifting resources towards NCD prevention is a difficult process, even if the human cost of these diseases is massive and increasing. That only about 3% of global health aid is aimed at NCD prevention does not help the situation.
The authors argue that one step toward improving the situation is better sharing of best practices and what works and what doesn't in policy development. They suggest that an open-access repository like one that exists for Europe could improve the situation. They offer to organize, host, and curate such a resource under the auspices of WHO, starting with the policies retrieved for this study, and they invite submission of additional policies and updates.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001465.
This study is further discussed in a PLOS Medicine Perspective by Stuckler and Basu
The WHO website on diet and physical activity contains links to various documents, including a diet and physical activity implementation toolbox that contains links to the 2004 Global Strategy document and a Framework to Monitor and Evaluate Implementation
There is a 2011 WHO primer on NCDs entitled Prioritizing a Preventable Epidemic
A recent PLOS Medicine editorial and call for papers addressing the global disparities in the burden from NCDs
A PLOS Blogs post entitled Politics and Global HealthAre We Missing the Obvious? and associated comments discuss the state of the fight against NCDs in early 2013
The NCD Alliance was founded by the Union for International Cancer Control, the International Diabetes Federation, the World Heart Federation, and the International Union Against Tuberculosis and Lung Disease; its mission is to combat the NCD epidemic by putting health at the center of all policies
The WHO European Database on Nutrition, Obesity and Physical Activity (NOPA) contains national and subnational surveillance data, policy documents, actions to implement policy, and examples of good practice in programs and interventions for the WHO European member states
doi:10.1371/journal.pmed.1001465
PMCID: PMC3679005  PMID: 23776415
2.  Food Pricing Strategies, Population Diets, and Non-Communicable Disease: A Systematic Review of Simulation Studies 
PLoS Medicine  2012;9(12):e1001353.
A systematic review of simulation studies conducted by Helen Eyles and colleagues examines the association between food pricing strategies and food consumption and health and disease outcomes.
Background
Food pricing strategies have been proposed to encourage healthy eating habits, which may in turn help stem global increases in non-communicable diseases. This systematic review of simulation studies investigates the estimated association between food pricing strategies and changes in food purchases or intakes (consumption) (objective 1); Health and disease outcomes (objective 2), and whether there are any differences in these outcomes by socio-economic group (objective 3).
Methods and Findings
Electronic databases, Internet search engines, and bibliographies of included studies were searched for articles published in English between 1 January 1990 and 24 October 2011 for countries in the Organisation for Economic Co-operation and Development. Where ≥3 studies examined the same pricing strategy and consumption (purchases or intake) or health outcome, results were pooled, and a mean own-price elasticity (own-PE) estimated (the own-PE represents the change in demand with a 1% change in price of that good). Objective 1: pooled estimates were possible for the following: (1) taxes on carbonated soft drinks: own-PE (n = 4 studies), −0.93 (range, −0.06, −2.43), and a modelled −0.02% (−0.01%, −0.04%) reduction in energy (calorie) intake for each 1% price increase (n = 3 studies); (2) taxes on saturated fat: −0.02% (−0.01%, −0.04%) reduction in energy intake from saturated fat per 1% price increase (n = 5 studies); and (3) subsidies on fruits and vegetables: own-PE (n = 3 studies), −0.35 (−0.21, −0.77). Objectives 2 and 3: variability of food pricing strategies and outcomes prevented pooled analyses, although higher quality studies suggested unintended compensatory purchasing that could result in overall effects being counter to health. Eleven of 14 studies evaluating lower socio-economic groups estimated that food pricing strategies would be associated with pro-health outcomes. Food pricing strategies also have the potential to reduce disparities.
Conclusions
Based on modelling studies, taxes on carbonated drinks and saturated fat and subsidies on fruits and vegetables would be associated with beneficial dietary change, with the potential for improved health. Additional research into possible compensatory purchasing and population health outcomes is needed.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
For the first time in human history, non-communicable diseases (NCDs) are killing more people than infectious diseases. Every year, more than 35 million people die from NCDs—nearly two-thirds of the world's annual deaths. More than 80% of these deaths are in developing countries, where a third of NCD-related deaths occur in people younger than 60 years old. And NCDs are not just a growing global public health emergency. They are also financially costly because they reduce productivity and increase calls on health care systems worldwide. Cardiovascular diseases (conditions that affect the heart and circulation such as heart attacks and stroke), cancers, diabetes, and chronic respiratory diseases (long-term diseases that affect the lungs and airways) are responsible for most NCD-related illnesses and death. The main behavioral risk factors for all these diseases are tobacco use, harmful use of alcohol, physical inactivity, and unhealthy diets (diets that have a low fruit and vegetable intake and high saturated fat and salt intakes).
Why Was This Study Done?
Improvements in population diets and reductions in salt intake are crucial for the control and prevention of NCDs, but how can these behavioral changes be encouraged? One potential but poorly studied strategy is food pricing—the introduction of taxes on unhealthy foods (for example, foods containing high levels of saturated fat) and subsidies on healthy foods (for example, foods high in fiber). However, although a tax on soft drinks, for example, might decrease purchases of these high-sugar drinks, it might also increase purchases of fruit juices, which contain just as much sugar and energy as soft drinks (“compensatory purchasing”), and thus undermine the intended health impact of the tax. Because randomized controlled trials of the effects of food pricing strategies are difficult to undertake, many researchers have turned to mathematical models (sets of equations that quantify relationships between interventions and outcomes) to provide the evidence needed to inform policy decisions on food taxes and subsidies. In this systematic review (a study that uses predefined criteria to identify all the research on a given topic), Helen Eyles and colleagues investigate the association between food pricing strategies and food consumption and NCDs by analyzing the results of published mathematical modeling studies of food pricing interventions.
What Did the Researchers Do and Find?
The researchers identified 32 studies that met their predefined inclusion criteria, which included publication by researchers in a member country of the Organisation for Economic Co-operation and Development (a group of largely developed countries that promotes global development). Most of the studies were of low to moderate quality and provided uncertain and varying estimates of the impact of pricing on food consumption. Where three or more studies examined the same pricing strategy and consumption or health outcome, the researchers calculated the average change in demand for a food in response to changes in its price (“own-price elasticity”). For taxes on carbonated soft drinks, the average own-price elasticity was −0.93; that is, the models predicted that a 1% increase in the price of soft drinks would decrease consumption by 0.93%. The modeled reduction in the proportion of energy intake from saturated fat resulting from a 1% increase in the price of saturated fats was 0.02%. Finally, although the researchers' analysis suggested that for each 1% reduction in the price of fruits and vegetables, consumption would increase by 0.35%, they also found evidence that such a subsidy might result in compensatory purchasing, such as a reduction in fish purchases.
What Do These Findings Mean?
These findings suggest that pricing strategies have the potential to produce improvements in population diets, at least in developed countries, but also highlight the need for more research in this area. Notably, the researchers found insufficient data to allow them to quantify the effects of pricing strategies on health or to analyze whether the effect of pricing strategies is likely vary between socio-economic groups. Given their findings, the researchers suggest that future modeling studies should include better assessments of the unintended effects of compensatory purchasing and should examine the potential impact of food pricing strategies on long-term health and NCD-related deaths. Finally, they suggest that robust evaluations should be built into the implementation of food pricing policies to answer some of the outstanding questions about this potential strategy for reducing the global burden of NCDs.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001353.
The US Centers for Disease Control and Prevention provides information on all aspects of healthy living, on chronic diseases and health promotion, and on non-communicable diseases around the world
The Global Noncommunicable Disease Network (NCDnet) aims to help low- and middle-income countries reduce NCD-related illnesses and death through implementation of the 2008-2013 Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases (also available in French); NCDnet's Face to face with chronic disease webpage is a selection of personal stories from around the world about dealing with NCDs
The American Heart Association and the American Cancer Society provide information on many important risk factors for non-communicable diseases and include some personal stories about keeping healthy
doi:10.1371/journal.pmed.1001353
PMCID: PMC3519906  PMID: 23239943
3.  Associations between Active Travel to Work and Overweight, Hypertension, and Diabetes in India: A Cross-Sectional Study 
PLoS Medicine  2013;10(6):e1001459.
Using data from the Indian Migration Study, Christopher Millett and colleagues examine the associations between active travel to work and overweight, hypertension, and diabetes.
Please see later in the article for the Editors' Summary
Background
Increasing active travel (walking, bicycling, and public transport) is promoted as a key strategy to increase physical activity and reduce the growing burden of noncommunicable diseases (NCDs) globally. Little is known about patterns of active travel or associated cardiovascular health benefits in low- and middle-income countries. This study examines mode and duration of travel to work in rural and urban India and associations between active travel and overweight, hypertension, and diabetes.
Methods and Findings
Cross-sectional study of 3,902 participants (1,366 rural, 2,536 urban) in the Indian Migration Study. Associations between mode and duration of active travel and cardiovascular risk factors were assessed using random-effect logistic regression models adjusting for age, sex, caste, standard of living, occupation, factory location, leisure time physical activity, daily fat intake, smoking status, and alcohol use. Rural dwellers were significantly more likely to bicycle (68.3% versus 15.9%; p<0.001) to work than urban dwellers. The prevalence of overweight or obesity was 50.0%, 37.6%, 24.2%, 24.9%; hypertension was 17.7%, 11.8%, 6.5%, 9.8%; and diabetes was 10.8%, 7.4%, 3.8%, 7.3% in participants who travelled to work by private transport, public transport, bicycling, and walking, respectively. In the adjusted analysis, those walking (adjusted risk ratio [ARR] 0.72; 95% CI 0.58–0.88) or bicycling to work (ARR 0.66; 95% CI 0.55–0.77) were significantly less likely to be overweight or obese than those travelling by private transport. Those bicycling to work were significantly less likely to have hypertension (ARR 0.51; 95% CI 0.36–0.71) or diabetes (ARR 0.65; 95% CI 0.44–0.95). There was evidence of a dose-response relationship between duration of bicycling to work and being overweight, having hypertension or diabetes. The main limitation of the study is the cross-sectional design, which limits causal inference for the associations found.
Conclusions
Walking and bicycling to work was associated with reduced cardiovascular risk in the Indian population. Efforts to increase active travel in urban areas and halt declines in rural areas should be integral to strategies to maintain healthy weight and prevent NCDs in India.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Noncommunicable diseases (NCDs) and obesity (excessive body fat) are major threats to global health. Every year, more than 36 million people (including 29 million in LMICs) die from NCDs—nearly two-thirds of the world's annual deaths. Cardiovascular diseases (conditions that affect the heart and the circulation), diabetes, cancer, and respiratory diseases are responsible for most NCD-related deaths. Obesity is a risk factor for all these NCDs and the global prevalence of obesity (the proportion of the world's population that is obese) has nearly doubled since 1980. In 2008, 35% of adults were overweight and 11% were obese. One reason for the growing burden of both obesity and NCDs is increasing physical inactivity. Regular physical activity helps to maintain a healthy body weight and to prevent or delay the onset of NCDs. For an adult, 30 minutes of moderate physical activity—walking briskly or cycling, for example—five times a week is sufficient to promote and maintain health. But the daily lives of people in both developed and developing countries are becoming increasingly sedentary and, nowadays, at least 60% of the world's population does not do even this modest amount of exercise.
Why Was This Study Done?
Strategies to increase physical activity levels often promote active travel (walking, cycling, and using public transport). The positive impact of active travel on physical activity levels and cardiovascular health is well established in high-income countries, but little is known about the patterns of active travel or the health benefits associated with active travel in poorer countries. In this cross-sectional study (an investigation that measures population characteristics at a single time point), the researchers examine the mode and duration of travel to work in rural and urban India and associations between active travel and overweight/obesity, hypertension (high blood pressure, a risk factor for cardiovascular disease), and diabetes. In India, a lower middle-income country, the prevalence of overweight and NCDs is projected to increase rapidly over the next two decades. Moreover, rapid unplanned urbanization and a large increase in registered motor vehicles has resulted in inadequate development of the public transport infrastructure and hazardous conditions for walking and cycling in most Indian towns and cities.
What Did the Researchers Do and Find?
For their study, researchers analyzed physical activity and health data collected from participants in the Indian Migration Study, which examined the association between migration from rural to urban areas and obesity and diabetes risk. People living in rural areas were more likely to cycle to work than people living in towns and cities (68.3% versus 15.9%). Among people who travelled to work by private transport, public transport, walking, and cycling, the prevalence of overweight or obesity was 50.0%, 37.6%, 24.9%, and 24.2%, respectively. Similar patterns were seen for the prevalence of hypertension and diabetes. After adjustment for factors that affect the risk of obesity, hypertension, and diabetes (for example, daily fat intake and leisure time physical activity), people walking or cycling to work were less likely to be overweight or obese than those travelling by public transport, and those cycling to walk were less likely to have hypertension or diabetes. Finally, people with long cycle rides to work had a lower risk of being overweight or having hypertension or diabetes than people with short cycle rides.
What Do These Findings Mean?
These findings suggest that, as in high-income settings, walking and cycling to work are associated with a reduced risk of cardiovascular disease in India. Because this was a cross-sectional study, these findings do not prove that active travel reduces the risk of cardiovascular disease—people who cycle to work may share other unknown characteristics that are actually responsible for their reduced risk of cardiovascular disease. Moreover, this study did not consider non-cardiovascular outcomes associated with active travel that might affect health such as increased exposure to air pollution. Nevertheless, these findings suggest that programs designed to maintain healthy weight and prevent NCDs in India should endeavor to increase active travel in urban areas and to halt declines in rural areas by, for example, increasing investment in public transport and improving the safety and convenience of walking and cycling routes in urban areas.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001459.
This study is further discussed in a PLOS Medicine Perspective by Kavi Bhalla
The US Centers for Disease Control and Prevention provides information on all aspects of healthy living, on chronic diseases and health promotion, on overweight and obesity and on non-communicable diseases around the world; its Physical Activity for Everyone web pages include guidelines, instructional videos and personal success stories (some information in English and Spanish)
The World Health Organization provides information about physical activity and health, about obesity, and about non-communicable diseases (in several languages); its 2010 Global Recommendations on Physical Activity for Health are available in several languages; its Global Noncommunicable Disease Network (NCDnet) aims to help low- and middle- income countries reduce NCD-related illnesses and death through implementation of the 20082013 Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases (also available in French); Face to face with chronic diseases is a selection of personal stories from around the world about dealing with NCDs
The American Heart Association provides information on many important risk factors for non-communicable diseases and provides tips for becoming more active
Information about the Indian Migration Study is available
doi:10.1371/journal.pmed.1001459
PMCID: PMC3679004  PMID: 23776412
4.  Towards a comprehensive global approach to prevention and control of NCDs 
Globalization and Health  2014;10(1):74.
Background
The “25×25” strategy to tackle the global challenge of non-communicable diseases takes a traditional approach, concentrating on a few diseases and their immediate risk factors.
Discussion
We propose elements of a comprehensive strategy to address NCDs that takes account of the evolving social, economic, environmental and health care contexts, while developing mechanisms to respond effectively to local patterns of disease. Principles that underpin the comprehensive strategy include: (a) a balance between measures that address health at the individual and population level; (b) the need to identify evidence-based feasible and effective approaches tailored to low and middle income countries rather than exporting questionable strategies developed in high income countries; (c) developing primary health care as a universal framework to support prevention and treatment; (d) ensuring the ability to respond in real time to the complex adaptive behaviours of the global food, tobacco, alcohol and transport industries; (e) integrating evidence-based, cost-effective, and affordable approaches within the post-2015 sustainable development agenda; (f) determination of a set of priorities based on the NCD burden within each country, taking account of what it can afford, including the level of available development assistance; and (g) change from a universal “one-size fits all” approach of relatively simple prevention oriented approaches to more comprehensive multi-sectoral and development-oriented approaches which address both health systems and the determinants of NCD risk factors.
Summary
The 25×25 is approach is absolutely necessary but insufficient to tackle the the NCD disease burden of mortality and morbidity. A more comprehensive approach is recommended.
doi:10.1186/s12992-014-0074-8
PMCID: PMC4215019  PMID: 25348262
Non-communicable diseases; Prevention; Health systems
5.  Drivers of Inequality in Millennium Development Goal Progress: A Statistical Analysis 
PLoS Medicine  2010;7(3):e1000241.
David Stuckler and colleagues examine the impact of the HIV and noncommunicable disease epidemics on low-income countries' progress toward the Millennium Development Goals for health.
Background
Many low- and middle-income countries are not on track to reach the public health targets set out in the Millennium Development Goals (MDGs). We evaluated whether differential progress towards health MDGs was associated with economic development, public health funding (both overall and as percentage of available domestic funds), or health system infrastructure. We also examined the impact of joint epidemics of HIV/AIDS and noncommunicable diseases (NCDs), which may limit the ability of households to address child mortality and increase risks of infectious diseases.
Methods and Findings
We calculated each country's distance from its MDG goals for HIV/AIDS, tuberculosis, and infant and child mortality targets for the year 2005 using the United Nations MDG database for 227 countries from 1990 to the present. We studied the association of economic development (gross domestic product [GDP] per capita in purchasing-power-parity), the relative priority placed on health (health spending as a percentage of GDP), real health spending (health system expenditures in purchasing-power-parity), HIV/AIDS burden (prevalence rates among ages 15–49 y), and NCD burden (age-standardised chronic disease mortality rates), with measures of distance from attainment of health MDGs. To avoid spurious correlations that may exist simply because countries with high disease burdens would be expected to have low MDG progress, and to adjust for potential confounding arising from differences in countries' initial disease burdens, we analysed the variations in rates of change in MDG progress versus expected rates for each country. While economic development, health priority, health spending, and health infrastructure did not explain more than one-fifth of the differences in progress to health MDGs among countries, burdens of HIV and NCDs explained more than half of between-country inequalities in child mortality progress (R2-infant mortality  = 0.57, R2-under 5 mortality  = 0.54). HIV/AIDS and NCD burdens were also the strongest correlates of unequal progress towards tuberculosis goals (R2 = 0.57), with NCDs having an effect independent of HIV/AIDS, consistent with micro-level studies of the influence of tobacco and diabetes on tuberculosis risks. Even after correcting for health system variables, initial child mortality, and tuberculosis diseases, we found that lower burdens of HIV/AIDS and NCDs were associated with much greater progress towards attainment of child mortality and tuberculosis MDGs than were gains in GDP. An estimated 1% lower HIV prevalence or 10% lower mortality rate from NCDs would have a similar impact on progress towards the tuberculosis MDG as an 80% or greater rise in GDP, corresponding to at least a decade of economic growth in low-income countries.
Conclusions
Unequal progress in health MDGs in low-income countries appears significantly related to burdens of HIV and NCDs in a population, after correcting for potentially confounding socioeconomic, disease burden, political, and health system variables. The common separation between NCDs, child mortality, and infectious syndromes among development programs may obscure interrelationships of illness affecting those living in poor households—whether economic (e.g., as money spent on tobacco is lost from child health expenditures) or biological (e.g., as diabetes or HIV enhance the risk of tuberculosis).
Please see later in the article for the Editors' Summary
Editors' Summary
Background
In 2000, 189 countries adopted the United Nations (UN) Millennium Declaration, which commits the world to the eradication of extreme poverty by 2015. The Declaration lists eight Millennium Development Goals (MDGs), 21 quantifiable targets, and 60 indicators of progress. So, for example, MDG 4 aims to reduce child mortality (deaths). The target for this goal is to reduce the number of children who die each year before they are five years old (the under-five mortality rate) to two-thirds of its 1990 value by 2015. Indicators of progress toward this goal include the under-five mortality rate and the infant mortality rate. Because poverty and ill health are inextricably linked—ill health limits the ability of individuals and nations to improve their economic status, and poverty contributes to the development of many illnesses—two other MDGs also tackle public health issues. MDG 5 sets a target of reducing maternal mortality by three-quarters of its 1990 level by 2015. MDG 6 aims to halt and begin to reverse the spread of HIV/AIDS, malaria, and other major diseases such as tuberculosis by 2015.
Why Was This Study Done?
Although progress has been made toward achieving the MDGs, few if any of the targets are likely to be met by 2015. Worryingly, low-income countries are falling furthest behind their MDG targets. For example, although child mortality has been declining globally, in many poor countries there has been little or no progress. What is the explanation for this and other inequalities in progress toward the health MDGs? Some countries may simply lack the financial resources needed to combat epidemics or may allocate only a low proportion of their gross domestic product (GDP) to health. Alternatively, money allocated to health may not always reach the people who need it most because of an inadequate health infrastructure. Finally, coexisting epidemics may be hindering progress toward the MDG health targets. Thus, the spread of HIV/AIDS may be hindering attempts to limit the spread of tuberculosis because HIV infection increases the risk of active tuberculosis, and ongoing epidemics of diabetes and other noncommunicable diseases (NCDs) may be affecting the attainment of health MDGs by diverting scarce resources. In this study, the researchers investigate whether any of these possibilities is driving the inequalities in MDG progress.
What Did the Researchers Do and Find?
The researchers calculated how far 227 countries were from their MDG targets for HIV, tuberculosis, and infant and child mortality in 2005 using information collected by the UN. They then used statistical methods to study the relationship between this distance and economic development (GDP per person), health spending as a proportion of GDP (health priority), actual health system expenditures, health infrastructure, HIV burden, and NCD burden in each country. Economic development, health priority, health spending, and health infrastructure explained no more than one-fifth of the inequalities in progress toward health MDGs. By contrast, the HIV and NCD burdens explained more than half of inequalities in child mortality progress and were strongly associated with unequal progress toward tuberculosis goals. Furthermore, the researchers calculated that a 1% reduction in the number of people infected with HIV or a 10% reduction in rate of deaths from NCDs in a population would have a similar impact on progress toward the tuberculosis MDG target as a rise in GDP corresponding to at least a decade of growth in low-income countries.
What Do These Findings Mean?
These findings are limited by the quality of the available data on health indicators in low-income countries and, because the researchers used country-wide data, their findings only reveal possible drivers of inequalities in progress toward MDGs in whole countries and may mask drivers of within-country inequalities. Nevertheless, as one of the first attempts to analyze the determinants of global inequalities in progress toward the health MDGs, these findings have important implications for global health policy. Most importantly, the finding that unequal progress is related to the burdens of HIV and NCDs in populations suggests that programs designed to achieve health MDGs must consider all the diseases and factors that can trap households in vicious cycles of illness and poverty, especially since the achievement of feasible reductions in NCDs in low-income countries could greatly enhance progress towards health MDGs.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000241.
The United Nations Millennium Development Goals website provides detailed information about the Millennium Declaration, the MDGs, their targets and their indicators
The Millennium Development Goals Report 2009 and its progress chart provide an up-to-date assessment of progress towards the MDGs
The World Health Organization provides information about poverty and health and health and development
doi:10.1371/journal.pmed.1000241
PMCID: PMC2830449  PMID: 20209000
6.  Social and Economic Implications of Noncommunicable diseases in India 
Noncommunicable diseases (NCDs) have become a major public health problem in India accounting for 62% of the total burden of foregone DALYs and 53% of total deaths. In this paper, we review the social and economic impact of NCDs in India. We outline this impact at household, health system and the macroeconomic level. Cardiovascular diseases (CVDs) figure at the top among the leading ten causes of adult (25–69 years) deaths in India. The effects of NCDs are inequitable with evidence of reversal in social gradient of risk factors and greater financial implications for the poorer households in India. Out-of-pocket expenditure associated with the acute and long-term effects of NCDs is high resulting in catastrophic health expenditure for the households. Study in India showed that about 25% of families with a member with CVD and 50% with cancer experience catastrophic expenditure and 10% and 25%, respectively, are driven to poverty. The odds of incurring catastrophic hospitalization expenditure were nearly 160% higher with cancer than the odds of incurring catastrophic spending when hospitalization was due to a communicable disease. These high numbers also pose significant challenge for the health system for providing treatment, care and support. The proportion of hospitalizations and outpatient consultations as a result of NCDs rose from 32% to 40% and 22% to 35%, respectively, within a decade from 1995 to 2004. In macroeconomic term, most of the estimates suggest that the NCDs in India account for an economic burden in the range of 5–10% of GDP, which is significant and slowing down GDP thus hampering development. While India is simultaneously experiencing several disease burdens due to old and new infections, nutritional deficiencies, chronic diseases, and injuries, individual interventions for clinical care are unlikely to be affordable on a large scale. While it is clear that “treating our way out” of the NCDs may not be the efficient way, it has to be strongly supplemented with population-based services aimed at health promotion and action on social determinants of health along with individual services. Since health sector alone cannot deal with the “chronic emergency” of NCDs, a multi-sectoral action addressing the social determinants and strengthening of health systems for universal coverage to population and individual services is required.
doi:10.4103/0970-0218.94704
PMCID: PMC3354895  PMID: 22628905
Cardiovascular disease; cost of illness; economic impact; India; noncommunicable diseases
7.  Looking at non-communicable diseases in Uganda through a local lens: an analysis using locally derived data 
Globalization and Health  2014;10(1):77.
The demographic and nutritional transitions taking place in Uganda, just as in other low- and middle-income countries (LMIC), are leading to accelerating growth of chronic, non-communicable diseases (NCDs). Though still sparse, locally derived data on NCDs in Uganda has increased greatly over the past five years and will soon be bolstered by the first nationally representative data set on NCDs. Using these available local data, we describe the landscape of the globally recognized major NCDs- cardiovascular disease, diabetes, cancer, and chronic respiratory disease- and closely examine what is known about other locally important chronic conditions. For example, mental health disorders, spawned by an extended civil war, and highly prevalent NCD risk factors such as excessive alcohol intake and road traffic accidents, warrant special attention in Uganda. Additionally, we explore public sector capacity to tackle NCDs, including Ministry of Health NCD financing and health facility and healthcare worker preparedness. Finally, we describe a number of promising initiatives that are addressing the Ugandan NCD epidemic. These include multi-sector partnerships focused on capacity building and health systems strengthening; a model civil society collaboration leading a regional coalition; and a novel alliance of parliamentarians lobbying for NCD policy. Lessons learned from the ongoing Ugandan experience will inform other LMIC, especially in sub-Saharan Africa, as they restructure their health systems to address the growing NCD epidemic.
doi:10.1186/s12992-014-0077-5
PMCID: PMC4240853  PMID: 25406738
Non-communicable diseases; Chronic conditions; Low- and middle-income countries; Uganda; Health system financing; Multi-sector collaboration
8.  Characterizing the Epidemiological Transition in Mexico: National and Subnational Burden of Diseases, Injuries, and Risk Factors 
PLoS Medicine  2008;5(6):e125.
Background
Rates of diseases and injuries and the effects of their risk factors can have substantial subnational heterogeneity, especially in middle-income countries like Mexico. Subnational analysis of the burden of diseases, injuries, and risk factors can improve characterization of the epidemiological transition and identify policy priorities.
Methods and Findings
We estimated deaths and loss of healthy life years (measured in disability-adjusted life years [DALYs]) in 2004 from a comprehensive list of diseases and injuries, and 16 major risk factors, by sex and age for Mexico and its states. Data sources included the vital statistics, national censuses, health examination surveys, and published epidemiological studies. Mortality statistics were adjusted for underreporting, misreporting of age at death, and for misclassification and incomparability of cause-of-death assignment. Nationally, noncommunicable diseases caused 75% of total deaths and 68% of total DALYs, with another 14% of deaths and 18% of DALYs caused by undernutrition and communicable, maternal, and perinatal diseases. The leading causes of death were ischemic heart disease, diabetes mellitus, cerebrovascular disease, liver cirrhosis, and road traffic injuries. High body mass index, high blood glucose, and alcohol use were the leading risk factors for disease burden, causing 5.1%, 5.0%, and 7.3% of total burden of disease, respectively. Mexico City had the lowest mortality rates (4.2 per 1,000) and the Southern region the highest (5.0 per 1,000); under-five mortality in the Southern region was nearly twice that of Mexico City. In the Southern region undernutrition and communicable, maternal, and perinatal diseases caused 23% of DALYs; in Chiapas, they caused 29% of DALYs. At the same time, the absolute rates of noncommunicable disease and injury burdens were highest in the Southern region (105 DALYs per 1,000 population versus 97 nationally for noncommunicable diseases; 22 versus 19 for injuries).
Conclusions
Mexico is at an advanced stage in the epidemiologic transition, with the majority of the disease and injury burden from noncommunicable diseases. A unique characteristic of the epidemiological transition in Mexico is that overweight and obesity, high blood glucose, and alcohol use are responsible for larger burden of disease than other noncommunicable disease risks such as tobacco smoking. The Southern region is least advanced in the epidemiological transition and suffers from the largest burden of ill health in all disease and injury groups.
Gretchen Stevens and colleagues estimate deaths and loss of healthy life years (measured in disability-adjusted life years, DALYs) for Mexico as a whole and its 32 states.
Editors' Summary
Background.
The impact that a particular disease has upon a population is known as the “burden of disease.” This burden is estimated by considering how many deaths the disease causes and how much it disables those still living. The relative contributions of different diseases and injuries to the loss of healthy life from death and disability vary greatly among countries. Broadly speaking, in low-income countries (such as many African countries), infectious diseases and undernutrition are the major causes of ill health and death whereas in high-income countries (for example, the United States), noncommunicable diseases such as heart disease, diabetes, and stroke are more important. As poor countries become richer, they experience a change in the pattern of disease away from infectious diseases and malnutrition and toward noncommunicable diseases. Health experts call this change the “epidemiological transition” (epidemiology is the study of the distribution and causes of diseases in populations). Governments need to know as much as possible about which diseases have the greatest burden—and about where the country is in the epidemiological transition—to help them implement effective health policies. For example, there is no point in setting up treatment centers for a specific infectious disease in a country where the disease no longer occurs. Equally importantly, governments need to know which lifestyle choices and other genetic and environmental factors affect the chances of people in their country developing specific diseases so that they can provide relevant educational and intervention programs.
Why Was This Study Done?
Most analyses of the burden of disease have been done at the national and global scale. However, in middle-income countries, different regions of the country may be at different stages of the epidemiological transition and may, therefore, have very different patterns of disease. In this study, the researchers investigate whether this is the case for Mexico, a middle-income country that has developed rapidly over the past few decades. Mexico recently reformed its health system to improve access to health care for the poor and underserved. Under this new system, individual states play an important role in allocating health-care resources (as they do in many other countries) so it is very important to know how the burden of disease varies in different states of the country.
What Did the Researchers Do and Find?
The researchers estimated deaths and loss of healthy life years caused by various diseases and injuries for Mexico and its states using data from death registers, censuses, health examination surveys, and epidemiological studies. Loss of healthy life years was measured using a metric called “disability-adjusted life years” (DALYs)—one DALY is equivalent to the loss of one year of healthy life because of premature death or disability. They also identified the major risk factors for these diseases and injuries across the country. Nationally, noncommunicable diseases (particularly heart disease, diabetes, stroke, and liver cirrhosis) caused 75% of deaths and 68% of DALYs. Undernutrition, infectious diseases, and problems occurring in mothers and infants around the time of birth (maternal and perinatal diseases) caused 14% of deaths and 18% of DALYs. The leading risk factors for disease in Mexico were being overweight, having high blood glucose, and alcohol use. When the researchers studied different regions of the country, they found that Mexico City had the lowest death rate whereas the relatively undeveloped Southern region of Mexico had the highest, particularly among young children. In Chiapas, the most southerly state of Mexico, undernutrition and infectious, maternal, and perinatal diseases caused nearly a third of DALYs. In addition to the highest infectious disease burden, the Southern region also had the highest noncommunicable disease and injury burden per head of population.
What Do These Findings Mean?
These findings indicate that Mexico as a nation is at an advanced stage of the epidemiological transition. In other words, because of the improvement in its economic status, the burden of disease caused by infectious diseases and undernutrition has decreased, and noncommunicable diseases now cause the largest share of the total burden of disease. However, the study also shows that the poorest regions of the country, which have the highest overall burden of disease, are lagging behind the richer regions in terms of their position in the epidemiological transition. Thus different health priorities need to be set in different regions of Mexico (and in other middle-income countries where the burden of disease is also likely to vary with region). Finally, the information provided by this study about the forces driving the epidemiological transition in Mexico, such as the importance of obesity and alcohol use, should help public-health officials decide how to improve the overall health of the Mexican population.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0050125.
A related PLoS Medicine Perspective by Martin Tobias further discusses this research
The World Health Organization provides information on the Global Burden of Disease Project including links to other burden of disease resources. It also provides detailed information on various aspects of health in Mexico (in several languages), and an explanation of DALYs
Read a detailed article on the “epidemiological transition” by Abdel Omran, who proposed this idea in 1971
A large amount of Mexican data is available online for Spanish speakers. Complete raw mortality statistics can be found on the Mexican Ministry of Health's Web site http://sinais.salud.gob.mx/sinais.php. Also online is the complete report of the ENSANUT survey (Encuesta Nacional de Salud y Nutrición 2006) http://www.insp.mx/ensanut/, which was one of the major data sources used to determine risk factor exposure
doi:10.1371/journal.pmed.0050125
PMCID: PMC2429945  PMID: 18563960
9.  Public policy, health system, and community actions against illness as platforms for response to NCDs in Tanzania: a narrative review 
Global Health Action  2014;7:10.3402/gha.v7.23439.
Background
Most low- and middle- income countries are facing a rise of the burden of non-communicable diseases (NCDs) alongside the persistent burden of infectious diseases. This narrative review aims to provide an inventory of how the existing policy environment, health system, and communities are addressing the NCDs situation in Tanzania and identify gaps for advancing the NCD research and policy agenda.
Methodology
A literature search was performed on PubMed and Google scholar with full text retrieval from HINARI of English language articles published between 2000 and 2012. Documents were read to extract information on what Tanzanian actors were doing that contributed to NCDs prevention, treatment, and control, and a narration was written out of these. Reference lists of all retrieved articles were searched for additional relevant articles. Websites of organizations active in the field of NCDs including the Government of Tanzania and WHO were searched for reports and grey literature.
Results
Lack of a specific and overarching NCD policy has slowed and fragmented the implementation of existing strategies to prevent and control NCDs and their determinants. The health system is not prepared to deal with the rising NCD burden although there are random initiatives to improve this situation. How the community is responding to these emerging conditions is still unknown, and the current health-seeking behavior and perceptions on the risk factors may not favor control of NCDs and their risk factors.
Conclusion and recommendation
There is limited information on the burden and determinants of NCDs to inform the design of an integrative and multisectorial policy. Evidence on effective interventions for NCD services in primary care levels and on community perceptions on NCDs and their care seeking is virtually absent. Research and public health interventions must be anchored in the policy, health system, and community platforms for a holistic response.
doi:10.3402/gha.v7.23439
PMCID: PMC4028932  PMID: 24848655
NCD; policy; health system; community response
10.  A community-based approach to non-communicable chronic disease management within a context of advancing universal health coverage in China: progress and challenges 
BMC Public Health  2014;14(Suppl 2):S2.
Paralleled with the rapid socio-economic development and demographic transition, an epidemic of non-communicable chronic diseases (NCDs) has emerged in China over the past three decades, resulting in increased disease and economic burdens. Over the past decade, with a political commitment of implementing universal health coverage, China has strengthened its primary healthcare system and increased investment in public health interventions. A community-based approach to address NCDs has been acknowledged and recognized as one of the most cost-effective solutions. Community-based strategies include: financial and health administrative support; social mobilization; community health education and promotion; and the use of community health centers in NCD detection, diagnosis, treatment, and patient management. Although China has made good progress in developing and implementing these strategies and policies for NCD prevention and control, many challenges remain. There are a lack of appropriately qualified health professionals at grass-roots health facilities; it is difficult to retain professionals at that level; there is insufficient public funding for NCD care and management; and NCD patients are economically burdened due to limited benefit packages covering NCD treatment offered by health insurance schemes. To tackle these challenges we propose developing appropriate human resource policies to attract greater numbers of qualified health professionals at the primary healthcare level; adjusting the service benefit packages to encourage the use of community-based health services; and increase government investment in public health interventions, as well as investing more on health insurance schemes.
doi:10.1186/1471-2458-14-S2-S2
PMCID: PMC4120154  PMID: 25082410
11.  Age, chronic non-communicable disease and choice of traditional Chinese and western medicine outpatient services in a Chinese population 
Background
In 1997 Hong Kong reunified with China and the development of traditional Chinese medicine (TCM) started with this change in national identity. However, the two latest discussion papers on Hong Kong's healthcare reform have failed to mention the role of TCM in primary healthcare, despite TCM's public popularity and its potential in tackling the chronic non-communicable disease (NCD) challenge in the ageing population. This study aims to describe the interrelationship between age, non-communicable disease (NCD) status, and the choice of TCM and western medicine (WM) services in the Hong Kong population.
Methods
This study is a secondary analysis of the Thematic Household Survey (THS) 2005 dataset. The THS is a Hong Kong population representative face to face survey was conducted by the Hong Kong Administrative Region Government of China. A random sample of respondents aged >15 years were invited to report their use of TCM and WM in the past year, together with other health and demographic information. A total of 33,263 persons were interviewed (response rate 79.2%).
Results
Amongst those who received outpatient services in the past year (n = 18,087), 80.23% only visited WM doctors, 3.17% consulted TCM practitioners solely, and 16.60% used both type of services (double consulters). Compared to those who only consulted WM doctor, multinomial logistic regression showed that double consulters were more likely to be older, female, NCD patients, and have higher socioeconomic backgrounds. Further analysis showed that the association between age and double consulting was curvilinear (inverted U shaped) regardless of NCD status. Middle aged (45-60 years) NCD patients, and the NCD free "young old" group (60-75 years) were most likely to double consult. On the other hand, the relationship between age and use of TCM as an alternative to WM was linear regardless of NCD status. The NCD free segment of the population was more inclined to use TCM alone as they become older.
Conclusion
In Hong Kong, most patients have chosen WM provided in the public sector as their sole outpatient service provider for NCD. Amongst TCM service users, middle aged NCD patients are more likely to choose both TCM and WM outpatient services. Meanwhile, older people without NCD are more likely to use TCM as their main form of care, but the size of this population group is small. These utilization patterns show that patients choose both modalities to manage their NCD and TCM should be considered within policies for supporting patients with NCD under the wider primary health and social care system that supports patient choice.
doi:10.1186/1472-6963-9-207
PMCID: PMC2779812  PMID: 19917139
12.  Non communicable disease multimorbidity and associated health care utilization and expenditures in India: cross-sectional study 
Background
Non communicable disease (NCD) multimorbidity is increasingly becoming common in high income settings but little is known about its epidemiology and associated impacts on citizens and health systems in low and middle-income countries (LMICs). We aim to examine the socio-demographic distribution of NCD multimorbidity (≥2 diseases) and its implications for health care utilization and out-of-pocket expenditure (OOPE) in India.
Methods
We analyzed cross-sectional nationally representative data from the World Health Organisaion Study on Global Ageing and Adult Health (WHO-SAGE), conducted in India during 2007. Multiple logistic regression was used to determine socio-demographic predictors of self-reported multimorbidity. A two part model was used to assess the relationship between number of NCDs and health care utilization including OOPE.
Results
28.5% of the sample population had at least one NCD and 8.9% had NCD multimorbidity. The prevalence of multimorbidity increased from 1.3% in 18–29 year olds to 30.6% in those aged 70 years and above. Mean outpatient visits in the preceding 12 months increased from 2.2 to 6.2 and the percentage reporting an overnight hospital stay in the past 3 years increased from 9% to 29% in those with no NCD and ≥2 NCDs respectively (p <0.001).
OOPE incurred during the last outpatient visit increased from INR 272.1 (95% CI = 249.0-295.2) in respondents with no NCDs to INR 454.1 (95% CI = 407.8-500.4) in respondents with ≥2 NCDs. However, we did not find an increase in OOPE during the last inpatient visit with number of NCDs (7865.9 INR for those with zero NCDs compared with 7301.3 for those with ≥2 NCDs). For both outpatient and inpatient OOPE, medicine constitutes the largest proportion of spending (70.7% for outpatient, 53.6% for inpatient visit), followed by spending for health care provider (14.0% for outpatient, 12.2% for inpatient visit).
Conclusion
NCD multimorbidity is common in the Indian adult population and is associated with substantially higher healthcare utilization and OOPE. Strategies to address the growing burden of NCDs in LMICs should include efforts to improve the management of patients with multimorbidity and reduce associated financial burden to individuals and households.
doi:10.1186/1472-6963-14-451
PMCID: PMC4283077  PMID: 25274447
Non-communicable disease (NCD); Multimorbidity; Health care utilization; Out-of-pocket expenditure (OOPE); WHO-SAGE; India
13.  Averting Obesity and Type 2 Diabetes in India through Sugar-Sweetened Beverage Taxation: An Economic-Epidemiologic Modeling Study 
PLoS Medicine  2014;11(1):e1001582.
In this modeling study, Sanjay Basu and colleagues estimate the potential health effects of a sugar-sweetened beverage taxation among various sub-populations in India over the period 2014 to 2023.
Please see later in the article for the Editors' Summary
Background
Taxing sugar-sweetened beverages (SSBs) has been proposed in high-income countries to reduce obesity and type 2 diabetes. We sought to estimate the potential health effects of such a fiscal strategy in the middle-income country of India, where there is heterogeneity in SSB consumption, patterns of substitution between SSBs and other beverages after tax increases, and vast differences in chronic disease risk within the population.
Methods and Findings
Using consumption and price variations data from a nationally representative survey of 100,855 Indian households, we first calculated how changes in SSB price alter per capita consumption of SSBs and substitution with other beverages. We then incorporated SSB sales trends, body mass index (BMI), and diabetes incidence data stratified by age, sex, income, and urban/rural residence into a validated microsimulation of caloric consumption, glycemic load, overweight/obesity prevalence, and type 2 diabetes incidence among Indian subpopulations facing a 20% SSB excise tax. The 20% SSB tax was anticipated to reduce overweight and obesity prevalence by 3.0% (95% CI 1.6%–5.9%) and type 2 diabetes incidence by 1.6% (95% CI 1.2%–1.9%) among various Indian subpopulations over the period 2014–2023, if SSB consumption continued to increase linearly in accordance with secular trends. However, acceleration in SSB consumption trends consistent with industry marketing models would be expected to increase the impact efficacy of taxation, averting 4.2% of prevalent overweight/obesity (95% CI 2.5–10.0%) and 2.5% (95% CI 1.0–2.8%) of incident type 2 diabetes from 2014–2023. Given current consumption and BMI distributions, our results suggest the largest relative effect would be expected among young rural men, refuting our a priori hypothesis that urban populations would be isolated beneficiaries of SSB taxation. Key limitations of this estimation approach include the assumption that consumer expenditure behavior from prior years, captured in price elasticities, will reflect future behavior among consumers, and potential underreporting of consumption in dietary recall data used to inform our calculations.
Conclusion
Sustained SSB taxation at a high tax rate could mitigate rising obesity and type 2 diabetes in India among both urban and rural subpopulations.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Non-communicable diseases (NCDs) and obesity (excessive body mass) are major threats to global health. Each year NCDs kill 36 million people (including 29 million people in low- and middle-income countries), thereby accounting for nearly two-thirds of the world's annual deaths. Cardiovascular diseases, cancers, respiratory diseases, and diabetes (a condition characterized by raised blood sugar levels) are responsible for most NCD-related deaths. Worldwide, diabetes alone affects about 360 million people and causes nearly 5 million deaths annually. And the number of people affected by NCDs is likely to rise over the next few decades. It is estimated, for example, that 101.2 million people in India will have diabetes by 2030, nearly double the current number. In Asia and other low- and middle-income countries overweight as well as obesity represent a risk factor for NCDs and the global prevalence of obesity (the proportion of the world's population that is obese) has nearly doubled since 1980. Worldwide, around 0.5 billion people are now classified as obese and about 1.5 billion more overweight. That is, they have a body mass index (BMI) of 30 kg/m2 or more (25–30 for overweight); BMI is calculated by dividing a person's weight in kilograms by the square of their height in meters. In India individuals with a BMI of 25 or more (overweight/obese) are at very high risk of diabetes.
Why Was This Study Done?
The consumption of sugar-sweetened beverages (SSBs, soft drinks sweetened with cane sugar or other caloric sweeteners) is a major risk factor for overweight/obesity and, independent of total energy consumption and BMI, for type 2 diabetes (the commonest form of diabetes). In high-income countries, SSB taxation has been proposed as a way to lower the risk of obesity and type 2 diabetes, however it is unknown if this approach will work in low- and middle-income countries. Here, in an economic-epidemiologic modeling study, researchers estimate the potential health effects of SSB taxation in India, a middle-income country in which total SSB consumption is rapidly increasing, but where SSB consumption and chronic disease risk vary greatly within the population and where people are likely to turn to other sugar-rich beverages (for example, fresh fruit juices) if SSBs are taxed.
What Did the Researchers Do and Find?
The researchers used survey data relating SSB consumption to price variations to calculate how changes in the price of SSBs affect the demand for SSBs (own-price elasticity) and for other beverages (cross-price elasticity) in India. They combined these elasticities and data on SSB sales trends, BMIs, and diabetes incidence (the frequency of new diabetes cases) into a mathematical microsimulation model to estimate the effect of a 20% tax on SSBs on caloric (energy) consumption, glycemic load (an estimate of how much a food or drink raises blood sugar levels after consumption; low glycemic load diets lower diabetes risk), the prevalence of overweight/obesity, and the incidence of diabetes among Indian subpopulations. According to the model, if SSB sales continue to increase at the current rate, compared to no tax, a 20% SSB tax would reduce overweight/obesity across India by 3.0% and the incidence of type 2 diabetes by 1.6% over the period 2014–2023. In absolute figures, a 20% SSB tax would avert 11.2 million cases of overweight/obesity and 400,000 cases of type 2 diabetes between 2014 and 2023. Notably, if SSB sales increase more steeply as predicted by drinks industry marketing models, the tax would avert 15.8 million cases of overweight/obesity and 600,000 cases of diabetes. Finally, the model predicted that the largest relative effect of an SSB tax would be among young men in rural areas.
What Do These Findings Mean?
The accuracy of these findings is likely to be affected by the assumptions incorporated in the model and by the data fed into it. In particular, the accuracy of the estimates of the health effects of a 20% tax on SSBs is limited by the assumption that future consumer behavior will reflect historic behavior and by potential underreporting of SSB consumption in surveys. Nevertheless, these findings suggest that a sustained high rate of tax on SSBs could mitigate the rising prevalence of obesity and the rising incidence of diabetes in India in both urban and rural populations by affecting both caloric intake and glycemic load. Thus, SSB taxation might be a way to control obesity and diabetes in India and other low- and middle-income countries where, to date, large-scale interventions designed to address these threats to global health have had no sustained effects.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001582.
The World Health Organization provides information about non-communicable diseases, obesity, and diabetes around the world (in several languages)
The US Centers for Disease Control and Prevention provides information on non-communicable diseases around the world and on overweight and obesity and diabetes (including some information in Spanish)
The US National Diabetes Information Clearinghouse provides information about diabetes for patients, health-care professionals, and the general public, including detailed information on weight control (in English and Spanish)
The UK National Health Service Choices website provides information for patients and carers about type 2 diabetes and about obesity; it includes personal stories about diabetes and about obesity
MedlinePlus provides links to further resources and advice about diabetes and diabetes prevention and about obesity (in English and Spanish)
A 2012 Policy brief from the Yale Rudd Center for food policy and obesity provides information about SSB taxes
doi:10.1371/journal.pmed.1001582
PMCID: PMC3883641  PMID: 24409102
14.  Research Priorities for Prevention and Control of Noncommunicable Diseases in India 
India is undergoing a demographic and epidemiological transition which is influencing its health. Noncommunicable diseases (NCDs) are posing major health and development threats, while we are grappling with communicable diseases and maternal and child health-related issues. The major NCDs include cardiovascular diseases (including stroke), diabetes, cancer, chronic obstructive pulmonary diseases, mental health, and injuries. Tobacco, alcohol, diet, physical inactivity, high blood pressure, and obesity are the major risk factors common to many chronic diseases. Research on NCDs under the ICMR and through other institutions has resulted in the initiation of some national health programs such as National Cancer Control Program and District Mental Health Program. Important epidemiological descriptions have informed us on the causes and distribution of NCDs and their risk factors, including the non-health determinants (poverty, education, employment, etc) and health systems assessments, have shown the inadequacies in tackling NCDs. Several global efforts and publications have provided guidance in shaping the research agenda. The special UN NCD Summit held on 19-20 September 2011 brought the world leaders to deliberate on ways to address NCDs in a concerted manner through partnerships. In this paper the authors review the present status of NCDs and their risk factors in the country and propose a strategic research agenda to provide adequate thrust to accelerate research towards a useful outcome.
doi:10.4103/0970-0218.94713
PMCID: PMC3354900  PMID: 22628917
India; noncommunicable diseases; research
15.  A global framework for action to improve the primary care response to chronic non-communicable diseases: a solution to a neglected problem 
BMC Public Health  2009;9:355.
Background
Although in developing countries the burden of morbidity and mortality due to infectious diseases has often overshadowed that due to chronic non-communicable diseases (NCDs), there is evidence now of a shift of attention to NCDs.
Discussion
Decreasing the chronic NCD burden requires a two-pronged approach: implementation of the multisectoral policies aimed at decreasing population-level risks for NCDs, and effective and affordable delivery of primary care interventions for patients with chronic NCDs. The primary care response to common NCDs is often unstructured and inadequate. We therefore propose a programmatic, standardized approach to the delivery of primary care interventions for patients with NCDs, with a focus on hypertension, diabetes mellitus, chronic airflow obstruction, and obesity. The benefits of this approach will extend to patients with related conditions, e.g. those with chronic kidney disease caused by hypertension or diabetes. This framework for a "public health approach" is informed by experience of scaling up interventions for chronic infectious diseases (tuberculosis and HIV). The lessons learned from progress in rolling out these interventions include the importance of gaining political commitment, developing a robust strategy, delivering standardised interventions, and ensuring rigorous monitoring and evaluation of progress towards defined targets.
The goal of the framework is to reduce the burden of morbidity, disability and premature mortality related to NCDs through a primary care strategy which has three elements: 1) identify and address modifiable risk factors, 2) screen for common NCDs and 3) and diagnose, treat and follow-up patients with common NCDs using standard protocols. The proposed framework for NCDs borrows the same elements as those developed for tuberculosis control, comprising a goal, strategy and targets for NCD control, a package of interventions for quality care, key operations for national implementation of these interventions (political commitment, case-finding among people attending primary care services, standardised diagnostic and treatment protocols, regular drug supply, and systematic monitoring and evaluation), and indicators to measure progress towards increasing the impact of primary care interventions on chronic NCDs. The framework needs evaluation, then adaptation in different settings.
Summary
A framework for a programmatic "public health approach" has the potential to improve on the current unstructured approach to primary care of people with chronic NCDs. Research to establish the cost, value and feasibility of implementing the framework will pave the way for international support to extend the benefit of this approach to the millions of people worldwide with chronic NCDs.
doi:10.1186/1471-2458-9-355
PMCID: PMC2758871  PMID: 19772598
16.  Convergence of non-communicable and infectious diseases in low- and middle-income countries 
The convergence of non-communicable disease (NCD) and infectious disease (ID) in low- and middle-income countries (LMICs) presents new challenges and new opportunities to enact responsive changes in policy and research. Most LMICs have significant dual disease burdens of NCDs such as cardiovascular disease, diabetes and cancer, and IDs including tuberculosis, HIV/AIDS and parasitic diseases. A combined strategy is needed in surveillance and disease control; yet, experts, institutions and policies that support prevention and control of these two overarching disease categories have limited interaction and alignment. NCDs and IDs share common features, such as long-term care needs and overlapping high-risk populations, and there are also notable direct interactions, such as the association between certain IDs and cancers, as well as evidence of increased susceptibility to IDs in individuals with NCDs. Enhanced simultaneous surveillance of NCD and ID comorbidity in LMIC populations would generate the empirical data needed to better understand the dual burden, and to target coordinated care. Where IDs and NCDs are endemic, focusing on vulnerable populations by strengthening social protections and improving access to health services is crucial, as is the re-alignment of efforts to combine NCD and ID screening, treatment programmes, and the assessment of their impact. Integrating public health activities for ID and NCD should extend beyond health care services to prevention, which is widely seen as crucial to successful NCD and ID control campaigns alike. The convergence of NCD and ID in LMICs has the potential to overstretch already strained health systems. With some LMICs now focused on major health system reforms, a unique opportunity is available to address NCD and ID challenges with newfound urgency and novel approaches.
doi:10.1093/ije/dys135
PMCID: PMC3600620  PMID: 23064501
Chronic disease; infectious disease; development transition
17.  China’s biggest, most neglected health challenge: Non-communicable diseases 
Background
Over the past two decades, international health policies focusing on the fight against the human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), tuberculosis (TB), malaria, and those diseases that address maternal and child health problems, among others, have skewed disease control priorities in China and other Asian countries. Although these are important health problems, an epidemic of chronic, non-communicable diseases (NCDs) in China has accounted for a much greater burden of disease due to the ongoing rapid socioeconomic and demographic transition.
Discussion
Although NCDs currently account for more than 80% of the overall disease burden in China, they remain very low on the nation’s disease control priorities, attracting marginal investment from central and local governments. This leaves the majority of patients with chronic conditions without effective treatment. International organizations and national governments have recognized the devastating social and economic consequences caused by NCDs in low- and middle-income countries, including China. Yet, few donor-funded projects that address NCDs have been implemented in these countries over the past decade. Due to a lack of strong support from international organizations and national governments for fighting against NCDs, affected persons in China, especially the poor and those who live in rural and less developed regions, continue to have limited access to the needed care. Costs associated with frequent health facility visits and regular treatment have become a major factor in medical impoverishment in China. This article argues that although China's ongoing health system reform would provide a unique opportunity to tackle current public health problems, it may not be sufficient to address the emerging threat of NCDs unless targeted steps are taken to assure that adequate financial and human resources are mapped for effective control and management of NCDs in the country.
Summary
The Chinese government needs to develop a domestically-driven and evidence-based disease control policy and funding priorities that respond appropriately to the country’s current epidemiological transition, and rapid sociodemographic and lifestyle changes.
doi:10.1186/2049-9957-2-7
PMCID: PMC3710110  PMID: 23849054
Non-communicable diseases; Infectious diseases; Evidence-based public health interventions; Health system reform; China
18.  Prescription Medicines and the Risk of Road Traffic Crashes: A French Registry-Based Study 
PLoS Medicine  2010;7(11):e1000366.
Using three nationwide databases in France, Ludivine Orriols, Emmanuel Lagarde, and colleagues provide evidence that prescribed medicines contribute to the risk of experiencing a road traffic crash.
Background
In recent decades, increased attention has been focused on the impact of disabilities and medicinal drug use on road safety. The aim of our study was to investigate the association between prescription medicines and the risk of road traffic crashes, and estimate the attributable fraction.
Methods and Findings
We extracted and matched data from three French nationwide databases: the national health care insurance database, police reports, and the national police database of injurious crashes. Drivers identified by their national health care number involved in an injurious crash in France, between July 2005 and May 2008, were included in the study. Medicines were grouped according to the four risk levels of the French classification system (from 0 [no risk] to 3 [high risk]). We included 72,685 drivers involved in injurious crashes. Users of level 2 (odds ratio [OR]  = 1.31 [1.24–1.40]) and level 3 (OR  = 1.25 [1.12–1.40]) prescription medicines were at higher risk of being responsible for a crash. The association remained after adjustment for the presence of a long-term chronic disease. The fraction of road traffic crashes attributable to levels 2 and 3 medications was 3.3% [2.7%–3.9%]. A within-person case-crossover analysis showed that drivers were more likely to be exposed to level 3 medications on the crash day than on a control day, 30 days earlier (OR  = 1.15 [1.05–1.27]).
Conclusion
The use of prescription medicines is associated with a substantial number of road traffic crashes in France. In light of the results, warning messages appear to be relevant for level 2 and 3 medications and questionable for level 1 medications. A follow-up study is needed to evaluate the impact of the warning labeling system on road traffic crash prevention.
Please see later in the article for the Editors' Summary
Editors' Summary
About 1.3 million people die each year on the world's road. 90% of road traffic deaths occur in developing countries, with pedestrians, cyclists, and users of two-wheel vehicles (scooters, motorbikes) the most vulnerable road users. Although the use of prescribed benzodiazepines has already been documented to be associated with road traffic accidents in industrialized countries, the effects of other medicines have not been well studied or have inconsistent results (for example opioids and antidepressant medications). In the European Union, it is mandatory for pharmaceutical companies to provide data about the effect of a medicine on ability to drive. In France, a multidisciplinary group of experts was appointed to classify all medicines into four levels of risk (from level 0, no or negligible risk, to level 3, major risk), in terms of their effect on driving performances. In 2006, the International Council on Alcohol, Drugs and Traffic Safety proposed a classification list similar to the French classification system.
Why Was This Study Done? There is a pressing need to understand the association between prescribed medicines and the risk of road traffic crashes and also to have a more accurate picture of the fraction of road traffic crashes that are attributable to the use of prescribed medicines. This large French study aimed to advance knowledge in this important area.
What Did the Researchers Do and Find? The researchers used three data sources to find the information they needed: the national health care insurance database (which covers the whole French population and includes data on reimbursed prescription medicines), police reports, and the national police database of injurious road traffic crashes. Drivers involved in road traffic crashes (identified by their national healthcare number) between July 2005 and May 2008 were included in the study. The researchers used a statistical model to conduct a responsibility analysis, which determined factors associated with each driver responsible for the road traffic crash and each driver who was not responsible (controls). In addition, the researchers compared medicine exposure during a period immediately before the crash (case period) with exposure during an earlier period (control period) for each driver involved in a crash. The researchers retrieved data on reimbursed medicines, dispensed within six months of the road traffic crash, by linking included drivers to the national health care insurance database using their national ID, gender, and date of birth and grouped all prescribed medicines according to the four risk levels of the French classification system.
During the study period, 72,685 drivers involved in injurious road traffic crashes were included. The researchers found that drivers who had been prescribed level 2 and level 3 medicines were at higher risk (odds ratio 1.31 and OR 1.25, respectively) of being responsible for the road traffic crash, an association that remained after the researchers adjusted for the presence of chronic diseases. Furthermore, the researchers found that the fraction of road traffic crashes attributable to the use of (prescriptions for) level 2 and 3 medicines was 3.3% and that drivers were more likely to be exposed to level 3 medicines on the day of the road traffic crash than on a control day.
What Do These Findings Mean? This study provides strong evidence for the contribution of medicines to the risk of experiencing a road traffic crash. The French drug risk classification scheme seems accurate for medicines classified as levels 2 and 3 of risk for road traffic crashes. The effect on driving abilities of level 2 medicines depends both on the pharmacodynamics of the drug and on individual susceptibility, whereas for level 3 medicines, the pharmacodynamic effect seems to be predominant. The effects of level 1 medicines seem to be so dependent on individual susceptibility that effects on driving abilities are rare, which raises questions about the relevance of the labels for these medicines. However, some limitations with the study methodology might affect the interpretation of these findings. For example, the researchers used dispensing dates for medications as a surrogate for ingestion and were not able to check for noncompliance.
However, this study provides some of the strongest evidence to date of the need for health care workers to provide patients with proper information on the potential effect of any medicine that they are prescribed (or take) on their driving abilities.
Additional Information Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000366.The World Health Organization (WHO) provides information on road traffic accidentsTwo Web sites provide information for drivers about drugs that could affect their ability to driveThe US National Institute on Drug Abuse of the National Institutes of Health has an information sheet on drugged driving
doi:10.1371/journal.pmed.1000366
PMCID: PMC2981588  PMID: 21125020
19.  Clustering of chronic non-communicable disease risk factors among selected Asian populations: levels and determinants 
Global Health Action  2009;2:10.3402/gha.v2i0.1986.
Background
The major chronic non-communicable diseases (NCDs) operate through a cluster of common risk factors, whose presence or absence determines not only the occurrence and severity of the disease, but also informs treatment approaches. Primary prevention based on mitigation of these common risk factors through population-based programmes is the most cost-effective approach to contain the emerging epidemic of chronic NCDs.
Objectives
This study was conducted to explore the extent of risk factors clustering for the major chronic NCDs and its determinants in nine INDEPTH Health and Demographic Surveillance System (HDSS) sites of five Asian countries.
Design
Data originated from a multi-site chronic NCD risk factor prevalence survey conducted in 2005. This cross-sectional survey used a standardised questionnaire developed by the WHO to collect core data on common risk factors such as tobacco use, intake of fruits and vegetables, physical inactivity, blood pressure levels, and body mass index. Respondents included randomly selected sample of adults (25–64 years) living in nine rural HDSS sites in Bangladesh, India, Indonesia, Thailand, and Vietnam.
Results
Findings revealed a substantial proportion (>70%) of these largely rural populations having three or more risk factors for chronic NCDs. Chronic NCD risk factors clustering was associated with increasing age, being male, and higher educational achievements. Differences were noted among the different sites, both between and within country.
Conclusions
Since there is an extensive clustering of risk factors for the chronic NCDs in the populations studied, the interventions also need to be based on a comprehensive approach rather than on a single factor to forestall its cumulative effects which occur over time. This can work best if it is integrated within the primary health care system and the HDSS can be an invaluable epidemiological resource in this endeavor.
doi:10.3402/gha.v2i0.1986
PMCID: PMC2785214  PMID: 20027260
chronic NCDs; risk factors surveillance; clustering; INDEPTH; Asia; WHO STEPS
20.  Urbanicity and Lifestyle Risk Factors for Cardiometabolic Diseases in Rural Uganda: A Cross-Sectional Study 
PLoS Medicine  2014;11(7):e1001683.
Johanna Riha and colleagues evaluate the association of lifestyle risk factors with elements of urbanicity, such as having a public telephone, a primary school, or a hospital, among individuals living in rural settings in Uganda.
Please see later in the article for the Editors' Summary
Background
Urban living is associated with unhealthy lifestyles that can increase the risk of cardiometabolic diseases. In sub-Saharan Africa (SSA), where the majority of people live in rural areas, it is still unclear if there is a corresponding increase in unhealthy lifestyles as rural areas adopt urban characteristics. This study examines the distribution of urban characteristics across rural communities in Uganda and their associations with lifestyle risk factors for chronic diseases.
Methods and Findings
Using data collected in 2011, we examined cross-sectional associations between urbanicity and lifestyle risk factors in rural communities in Uganda, with 7,340 participants aged 13 y and above across 25 villages. Urbanicity was defined according to a multi-component scale, and Poisson regression models were used to examine associations between urbanicity and lifestyle risk factors by quartile of urbanicity. Despite all of the villages not having paved roads and running water, there was marked variation in levels of urbanicity across the villages, largely attributable to differences in economic activity, civil infrastructure, and availability of educational and healthcare services. In regression models, after adjustment for clustering and potential confounders including socioeconomic status, increasing urbanicity was associated with an increase in lifestyle risk factors such as physical inactivity (risk ratio [RR]: 1.19; 95% CI: 1.14, 1.24), low fruit and vegetable consumption (RR: 1.17; 95% CI: 1.10, 1.23), and high body mass index (RR: 1.48; 95% CI: 1.24, 1.77).
Conclusions
This study indicates that even across rural communities in SSA, increasing urbanicity is associated with a higher prevalence of lifestyle risk factors for cardiometabolic diseases. This finding highlights the need to consider the health impact of urbanization in rural areas across SSA.
Please see later in the article for the Editors' Summary
Editors’ Summary
Background
Cardiometabolic diseases—cardiovascular diseases that affect the heart and/or the blood vessels and metabolic diseases that affect the cellular chemical reactions needed to sustain life—are a growing global health concern. In sub-Saharan Africa, for example, the prevalence (the proportion of a population that has a given disease) of adults with diabetes (a life-shortening metabolic disease that affects how the body handles sugars) is currently 3.8%. By 2030, it is estimated that the prevalence of diabetes among adults in this region will have risen to 4.6%. Similarly, in 2004, around 1.2 million deaths in sub-Saharan Africa were attributed to coronary heart disease, heart failure, stroke, and other cardiovascular diseases. By 2030, the number of deaths in this region attributable to cardiovascular disease is expected to double. Globally, cardiovascular disease and diabetes are now responsible for around 17.3 million and 1.3 million annual deaths, respectively, together accounting for about one-third of all deaths.
Why Was This Study Done?
Experts believe that increased consumption of saturated fats, sugar, and salt and reduced physical activity are partly responsible for the increasing global prevalence of cardiometabolic diseases. These lifestyle changes, they suggest, are related to urbanization—urban expansion into the countryside and migration from rural to urban areas. If this is true, the prevalence of unhealthy lifestyles should increase as rural areas adopt urban characteristics. Sub-Saharan Africa is the least urbanized region in the world, with about 60% of the population living in rural areas. However, rural settlements across the subcontinent are increasingly adopting urban characteristics. It is important to know whether urbanization is affecting the health of rural residents in sub-Saharan Africa to improve estimates of the future burden of cardiometabolic diseases in the region and to provide insights into ways to limit this burden. In this cross-sectional study (an investigation that studies participants at a single time point), the researchers examine the distribution of urban characteristics across rural communities in Uganda and the association of these characteristics with lifestyle risk factors for cardiometabolic diseases.
What Did the Researchers Do and Find?
For their study, the researchers used data collected in 2011 by the General Population Cohort study, a study initiated in 1989 to describe HIV infection trends among people living in 25 villages in rural southwestern Uganda that collects health-related and other information annually from its participants. The researchers quantified the “urbanicity” of the 25 villages using a multi-component scale that included information such as village size and economic activity. They then used statistical models to examine associations between urbanicity and lifestyle risk factors such as body mass index (BMI, a measure of obesity) and self-reported fruit and vegetable consumption for more than 7,000 study participants living in those villages. None of the villages had paved roads or running water. However, urbanicity varied markedly across the villages, largely because of differences in economic activity, civil infrastructure, and the availability of educational and healthcare services. Notably, increasing urbanicity was associated with an increase in lifestyle risk factors for cardiovascular diseases. So, for example, people living in villages with the highest urbanicity scores were nearly 20% more likely to be physically inactive and to eat less fruits and vegetables and nearly 50% more likely to have a high BMI than people living in villages with the lowest urbanicity scores.
What Do These Findings Mean?
These findings indicate that, across rural communities in Uganda, even a small increase in urbanicity is associated with a higher prevalence of potentially modifiable lifestyle risk factors for cardiometabolic diseases. These findings suggest, therefore, that simply classifying settlements as either rural or urban may not be adequate to capture the information needed to target strategies for cardiometabolic disease management and control in rural areas as they become more urbanized. Because this study was cross-sectional, it is not possible to say how long a rural population needs to experience a more urban environment before its risk of cardiometabolic diseases increases. Longitudinal studies are needed to obtain this information. Moreover, studies of other countries in sub-Saharan Africa are needed to show that these findings are generalizable across the region. However, based on these findings, and given that more than 553 million people live in rural areas across sub-Saharan Africa, it seems likely that increasing urbanization will have a substantial impact on the future health of populations throughout sub-Saharan Africa.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001683.
This study is further discussed in a PLOS Medicine Perspective by Fahad Razak and Lisa Berkman
The American Heart Association provides information on all aspects of cardiovascular disease and diabetes; its website includes personal stories about heart attacks, stroke, and diabetes
The US Centers for Disease Control and Prevention has information on heart disease, stroke, and diabetes (in English and Spanish)
The UK National Health Service Choices website provides information about cardiovascular disease and diabetes (including some personal stories)
The World Health Organization’s Global Noncommunicable Disease Network (NCDnet) aims to help low- and middle-income countries reduce illness and death caused by cardiometabolic and other non-communicable diseases
The World Heart Federation has recently produced a report entitled “Urbanization and Cardiovascular Disease”
Wikipedia has a page on urbanization (note that Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
doi:10.1371/journal.pmed.1001683
PMCID: PMC4114555  PMID: 25072243
21.  Preparedness of Tanzanian health facilities for outpatient primary care of hypertension and diabetes: a cross-sectional survey 
The Lancet Global Health  2014;2(5):e285-e292.
Summary
Background
Historically, health facilities in sub-Saharan Africa have mainly managed acute, infectious diseases. Few data exist for the preparedness of African health facilities to handle the growing epidemic of chronic, non-communicable diseases (NCDs). We assessed the burden of NCDs in health facilities in northwestern Tanzania and investigated the strengths of the health system and areas for improvement with regard to primary care management of selected NCDs.
Methods
Between November, 2012, and May, 2013, we undertook a cross-sectional survey of a representative sample of 24 public and not-for-profit health facilities in urban and rural Tanzania (four hospitals, eight health centres, and 12 dispensaries). We did structured interviews of facility managers, inspected resources, and administered self-completed questionnaires to 335 health-care workers. We focused on hypertension, diabetes, and HIV (for comparison). Our key study outcomes related to service provision, availability of guidelines and supplies, management and training systems, and preparedness of human resources.
Findings
Of adult outpatient visits to hospitals, 58% were for chronic diseases compared with 20% at health centres, and 13% at dispensaries. In many facilities, guidelines, diagnostic equipment, and first-line drug therapy for the primary care of NCDs were inadequate, and management, training, and reporting systems were weak. Services for HIV accounted for most chronic disease visits and seemed stronger than did services for NCDs. Ten (42%) facilities had guidelines for HIV whereas three (13%) facilities did for NCDs. 261 (78%) health workers showed fair knowledge of HIV, whereas 198 (59%) did for hypertension and 187 (56%) did for diabetes. Generally, health systems were weaker in lower-level facilities. Front-line health-care workers (such as non-medical-doctor clinicians and nurses) did not have knowledge and experience of NCDs. For example, only 74 (49%) of 150 nurses had at least fair knowledge of diabetes care compared with 85 (57%) of 150 for hyptertension and 119 (79%) of 150 for HIV, and only 31 (21%) of 150 had seen more than five patients with diabetes in the past 3 months compared with 50 (33%) of 150 for hypertension and 111 (74%) of 150 for HIV.
Interpretation
Most outpatient services for NCDs in Tanzania are provided at hospitals, despite present policies stating that health centres and dispensaries should provide such services. We identified crucial weaknesses (and strengths) in health systems that should be considered to improve primary care for NCDs in Africa and identified ways that HIV programmes could serve as a model and structural platform for these improvements.
Funding
UK Medical Research Council.
doi:10.1016/S2214-109X(14)70033-6
PMCID: PMC4013553  PMID: 24818084
22.  What are the Evidence Based Public Health Interventions for Prevention and Control of NCDs in Relation to India? 
The accelerating epidemics of noncommunicable diseases (NCDs) in India call for a comprehensive public health response which can effectively combat and control them before they peak and inflict severe damage in terms of unaffordable health, economic, and social costs. To synthesize and present recent evidences regarding the effectiveness of several types of public health interventions to reduce NCD burden. Interventions influencing behavioral risk factors (like unhealthy diet, physical inactivity, tobacco and alcohol consumption) through policy, public education, or a combination of both have been demonstrated to be effective in reducing the NCD risk in populations as well as in individuals. Policy interventions are also effective in reducing the levels of several major biological risk factors linked to NCDs (high blood pressure; overweight and obesity; diabetes and abnormal blood cholesterol). Secondary prevention along the lines of combination pills and ensuring evidenced based clinical care are also critical. Though the evidence for health promotion and primary prevention are weaker, policy interventions and secondary prevention when combined with these are likely to have a greater impact on reducing national NCD burden. A comprehensive and integrated response to NCDs control and prevention needs a “life course approach.” Proven cost-effective interventions need to be integrated in a NCD prevention and control policy framework and implemented through coordinated mechanisms of regulation, environment modification, education, and health care responses.
doi:10.4103/0970-0218.94705
PMCID: PMC3354911  PMID: 22628907
Evidence base; India; NCD; public health interventions
23.  Towards reframing health service delivery in Uganda: the Uganda Initiative for Integrated Management of Non-Communicable Diseases 
Global Health Action  2015;8:10.3402/gha.v8.26537.
Background
The burden of non-communicable diseases (NCDs) in low- and middle-income countries (LMICs) is accelerating. Given that the capacity of health systems in LMICs is already strained by the weight of communicable diseases, these countries find themselves facing a double burden of disease. NCDs contribute significantly to morbidity and mortality, thereby playing a major role in the cycle of poverty, and impeding development.
Methods
Integrated approaches to health service delivery and healthcare worker (HCW) training will be necessary in order to successfully combat the great challenge posed by NCDs.
Results
In 2013, we formed the Uganda Initiative for Integrated Management of NCDs (UINCD), a multidisciplinary research collaboration that aims to present a systems approach to integrated management of chronic disease prevention, care, and the training of HCWs.
Discussion
Through broad-based stakeholder engagement, catalytic partnerships, and a collective vision, UINCD is working to reframe integrated health service delivery in Uganda.
doi:10.3402/gha.v8.26537
PMCID: PMC4292588  PMID: 25563451
Non-communicable diseases; Health system strengthening; Integration; Multi-sectoral collaboration
24.  How to Effectively Monitor and Evaluate NCD Programmes in India 
Program monitoring and evaluation (M and E) are important components of any program and are critical to sound strategic planning. The Ministry of Health and Family Welfare, Government of India, launched the National Programme for Prevention and Control of Cancer, Diabetes, Cardio-vascular diseases and Stroke (NPCDCS) with the objectives to prevent and control common noncommunicable diseases (NCDs) through behaviour and lifestyle changes, and to provide early diagnosis and management of common NCDs. M and E of program requires identification of indicators that measure inputs, process, outputs, and outcomes. The frequency of collecting information for these indicators will vary depending on the level of use and type of indicator as well as time interval over which we expect to see a change in that parameter. A group of indicators for different domains in the three major strategies has been proposed. For effective monitoring and evaluation of NPCDCS, the way forward is to finalize the list of indicators; evolve sustainable systems for surveillance; collect baseline assessment of the indicators at district level; fix targets for each indicator for different time frames; periodic review at state and national level for monitoring progress; and establish external review mechanisms. Monitoring and evaluation require complex set of co-ordinated action, responsibility for which has to be taken up by the NCD Cell within the Ministries of Health at state and national level. However, the routine data collection and compilation could be the responsibility of Central Bureau of Health Intelligence. Integrated population-based surveys with existing disease and behaviour surveillance could be undertaken by National Centre for Disease Control. The national NCD cell should compile all these information into a meaningful policy brief so that appropriate programmatic interventions can be identified. The launch of a national program to tackle the burden of NCDs is just the beginning, and the final success of the program will depend on how effectively we monitor and evaluate it.
doi:10.4103/0970-0218.94710
PMCID: PMC3354904  PMID: 22628913
Health planning; program evaluation; health services research; chronic disease; cardiovascular diseases; equity; risk factor; India
25.  Burden of NCDs, Policies and Programme for Prevention and Control of NCDs in India 
Noncommunicable diseases and injuries account for 52% of deaths in India. Burden of noncommunicable diseases and resultant mortality is expected to increase unless massive efforts are made to prevent and control NCDs and their risk factors. Based on available evidence, cancer, diabetes, hypertension, cardiovascular diseases, stroke, chronic obstructive pulmonary disease, chronic kidney disease, mental disorders and trauma are the leading causes of morbidity, disability and mortality in India. Government of India had supported the States in prevention and control of NCDs through several vertical programs since 1980s. However, during the 11th plan, there was considerable upsurge to prevent and control NCDs. New programs were started on a low scale in limited number of districts. However, there has not been any considerable change in the burden of NCDs. Based on experiences in the past, there is need to emphasize on health promotion and preventive measures to reduce exposure to risk factors. Facilities and capacity for screening, early diagnosis and effective management are required within the public health care system. Public awareness program, integrated management and strong monitoring system would be required for successful implementation of the program and making services universally accessible in the country.
doi:10.4103/0970-0218.94703
PMCID: PMC3354897  PMID: 22628916
Disease burden; life style diseases; NCD policy and programs; noncommunicable diseases; risk factors

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