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Dötsch-Klerk M, Bruins MJ, Detzel P, Martikainen J, Nergiz-Unal R, Roodenburg AJC, Pekcan AG. Modelling health and economic impact of nutrition interventions: a systematic review. Eur J Clin Nutr 2023; 77:413-426. [PMID: 36195747 PMCID: PMC10115624 DOI: 10.1038/s41430-022-01199-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 06/17/2022] [Accepted: 08/12/2022] [Indexed: 11/08/2022]
Abstract
Diet related non-communicable diseases (NCDs), as well as micronutrient deficiencies, are of widespread and growing importance to public health. Authorities are developing programs to improve nutrient intakes via foods. To estimate the potential health and economic impact of these programs there is a wide variety of models. The aim of this review is to evaluate existing models to estimate the health and/or economic impact of nutrition interventions with a focus on reducing salt and sugar intake and increasing vitamin D, iron, and folate/folic acid intake. The protocol of this systematic review has been registered with the International Prospective Register of Systematic Reviews (PROSPERO: CRD42016050873). The final search was conducted on PubMed and Scopus electronic databases and search strings were developed for salt/sodium, sugar, vitamin D, iron, and folic acid intake. Predefined criteria related to scientific quality, applicability, and funding/interest were used to evaluate the publications. In total 122 publications were included for a critical appraisal: 45 for salt/sodium, 61 for sugar, 4 for vitamin D, 9 for folic acid, and 3 for iron. The complexity of modelling the health and economic impact of nutrition interventions is dependent on the purpose and data availability. Although most of the models have the potential to provide projections of future impact, the methodological challenges are considerable. There is a substantial need for more guidance and standardization for future modelling, to compare results of different studies and draw conclusions about the health and economic impact of nutrition interventions.
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Affiliation(s)
- Mariska Dötsch-Klerk
- Unilever Foods Innovation Centre, Wageningen, The Netherlands.
- Unilever Foods Innovation Centre, Wageningen, Bronland 14, 6708 WH, The Netherlands.
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Flexner N, Ng AP, Ahmed M, Khandpur N, Acton RB, Lee JJ, L’Abbe MR. Estimating the dietary and health impact of implementing front-of-pack nutrition labeling in Canada: A macrosimulation modeling study. Front Nutr 2023; 10:1098231. [PMID: 37006927 PMCID: PMC10065472 DOI: 10.3389/fnut.2023.1098231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 03/01/2023] [Indexed: 03/19/2023] Open
Abstract
Background Front-of-pack labeling (FOPL) has been identified as a cost-effective policy to promote healthy diets. Health Canada has recently published FOPL regulations that will require food and beverages that meet or exceed set thresholds for sodium, sugars, or saturated fat to display a 'high in' symbol on the front of the package. Although a promising measure, its potential impact on dietary intakes and health have not yet been estimated in Canada. Objective This study aims to estimate (1) the potential dietary impact of implementing a mandatory FOPL among Canadian adults; and (2) the number of diet-related non-communicable disease (NCD) deaths that could be averted or delayed due to these estimated dietary changes. Methods Baseline and counterfactual usual intakes of sodium, total sugars, saturated fats, and calories were estimated among Canadian adults (n = 11,992) using both available days of 24 h recalls from the 2015 Canadian Community Health Survey-Nutrition. The National Cancer Institute method was used to estimate usual intakes, and adjusted for age, sex, misreporting status, weekend/weekday, and sequence of recall. Estimated counterfactual dietary intakes were modeled from reductions observed in experimental and observational studies that examined changes in sodium, sugars, saturated fat, and calorie content of food purchases in the presence of a 'high in' FOPL (four counterfactual scenarios). The Preventable Risk Integrated ModEl was used to estimate potential health impacts. Results Estimated mean dietary reductions were between 31 and 212 mg/day of sodium, 2.3 and 8.7 g/day of total sugars, 0.8 and 3.7 g/day of saturated fats, and 16 and 59 kcal/day of calories. Between 2,183 (95% UI 2,008-2,361) and 8,907 (95% UI 8,095-9,667) deaths due to diet-related NCDs, mostly from cardiovascular diseases (~70%), could potentially be averted or delayed by implementing a 'high in' FOPL in Canada. This estimation represents between 2.4 and 9.6% of the total number of diet-related NCD deaths in Canada. Conclusion Results suggest that implementing a FOPL could significantly reduce sodium, total sugar, and saturated fat intakes among Canadian adults and subsequently prevent or postpone a substantial number of diet-related NCD deaths in Canada. These results provide critical evidence to inform policy decisions related to implementing FOPL in Canada.
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Affiliation(s)
- Nadia Flexner
- Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Alena P. Ng
- Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Mavra Ahmed
- Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Joannah and Brian Lawson Centre for Child Nutrition, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Neha Khandpur
- Department of Human Nutrition and Health, Wageningen University, Wageningen, Netherlands
- Center for Epidemiological Research in Nutrition and Health, School of Public Health, University of São Paulo, São Paulo, Brazil
- Department of Nutrition, Harvard T. H. Chan School of Public Health, Harvard University, Boston, MA, United States
| | - Rachel B. Acton
- School of Public Health and Health Systems, University of Waterloo, Waterloo, ON, Canada
| | - Jennifer J. Lee
- Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Mary R. L’Abbe
- Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
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Neyazi N, Mosadeghrad AM, Afshari M, Isfahani P, Safi N. Strategies to tackle non-communicable diseases in Afghanistan: A scoping review. Front Public Health 2023; 11:982416. [PMID: 36908476 PMCID: PMC9992526 DOI: 10.3389/fpubh.2023.982416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 01/31/2023] [Indexed: 02/24/2023] Open
Abstract
Non-communicable diseases (NCDs) and their risk factors are the leading cause of death worldwide and contribute to 74.3% of deaths globally in 2019. The burden of NCDs is escalating in Afghanistan. Currently, every seconds, people in Afghanistan are dying of NCDs. Addressing this challenge in Afghanistan needs effective and practical interventions. This study aimed to identify the strategies developed and implemented in countries with low non-communicable premature death. To conduct a scoping review, we followed the six-step Arksey and O'Malley protocol and searched for eligible articles on eight international databases and the gray literature. The study followed the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) guidelines. The inclusion criteria were English documents and evidence produced up to 30 November 2021 for the control of NCDs. We excluded incomplete texts, duplicates, and dissertations due to lack of access. We used EndNote X9 and MaxQDA software for data management and analysis. We conducted content analysis for this study. A total of 122 documents developed between 1984 and 2021 met the inclusion criteria. We identified 35 strategies from which the most used strategies were related to unhealthy diets and smoking cessation programs. Canada (26.4%), Korea (19.8%), and the United Kingdom (19%) have the most publications on the control and prevention of NCDs among the countries included in the study. Most strategies were implemented over 2 years (41%). This study recommends specific interventions to control and prevent NCDs for the main risk factors of tobacco use, unhealthy diet, physical inactivity, and the main non-communicable diseases such as heart diseases, cancers, diabetes, and chronic obstructive pulmonary diseases. Afghanistan Ministry of Public Health, the WHO country office, and other involved stakeholders can use the findings of this review to design and implement strategies for controlling and preventing NCDs in Afghanistan. International organizations such as the World Health Organization, United Nations Agencies, the World Bank, and other involving communities should invest in strengthening good health governance in Afghanistan. The Afghan Government should focus on promoting and funding health literacy among the public and self-care to control and prevent NCDs.
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Affiliation(s)
- Narges Neyazi
- International Campus, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
- Health System Development, World Health Organization Country Office, Kabul, Afghanistan
| | - Ali Mohammad Mosadeghrad
- Health Information Management Research Center, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahnaz Afshari
- Social Determinants of Health Research Center, Saveh University of Medical Sciences, Saveh, Iran
| | - Parvaneh Isfahani
- School of Public Health, Zabol University of Medical Sciences, Zabol, Iran
| | - Najibullah Safi
- Health System Development, World Health Organization Country Office, Kabul, Afghanistan
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Flexner N, Christoforou AK, Bernstein JT, Ng AP, Yang Y, Fernandes Nilson EA, Labonté MÈ, L'Abbe MR. Estimating Canadian sodium intakes and the health impact of meeting national and WHO recommended sodium intake levels: A macrosimulation modelling study. PLoS One 2023; 18:e0284733. [PMID: 37163471 PMCID: PMC10171671 DOI: 10.1371/journal.pone.0284733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 04/09/2023] [Indexed: 05/12/2023] Open
Abstract
BACKGROUND Cardiovascular diseases (CVDs) are the second leading cause of total deaths in Canada. High blood pressure is the main metabolic risk factor for developing CVDs. It has been well established that excess consumption of sodium adversely affects blood pressure. Canadians' mean sodium intakes are well above recommended levels. Reducing dietary sodium intake through food reformulation has been identified as a cost-effective intervention, however, dietary sodium intake and the potential health impact of meeting recommended sodium intake levels due to food reformulation have not been determined in Canada. OBJECTIVE This study aimed to 1) obtain robust estimates of Canadians' usual sodium intakes, 2) model sodium intakes had foods been reformulated to align with Health Canada's sodium reduction targets, and 3) estimate the number of CVD deaths that could be averted or delayed if Canadian adults were to reduce their mean sodium intake to recommended levels under three scenarios: A) 2,300 mg/d-driven by a reduction of sodium levels in packaged foods to meet Health Canada targets (reformulation); B) 2,000 mg/d to meet the World Health Organization (WHO) recommendation; and C) 1,500 mg/d to meet the Adequate Intake recommendation. METHODS Foods in the University of Toronto's Food Label Information Program 2017, a Canadian branded food composition database, were linked to nationally representative food intake data from the 2015 Canadian Community Health Survey-Nutrition to estimate sodium intakes (and intakes had Health Canada's reformulation strategy been fully implemented). The Preventable Risk Integrated ModEl (PRIME) was used to estimate potential health impact. RESULTS Overall, mean sodium intake was 2758 mg/day, varying by age and sex group. Based on 'reformulation' scenario A, mean sodium intakes were reduced by 459 mg/day, to 2299 mg/day. Reducing Canadians' sodium intake to recommended levels under scenarios A, B and C could have averted or delayed 2,176 (95% UI 869-3,687), 3,252 (95% UI 1,380-5,321), and 5,296 (95% UI 2,190-8,311) deaths due to CVDs, respectively, mainly from ischaemic heart disease, stroke, and hypertensive disease. This represents 3.7%, 5.6%, and 9.1%, respectively, of the total number of CVDs deaths observed in Canada in 2019. CONCLUSION Results suggest that reducing sodium intake to recommended levels could prevent or postpone a substantial number of CVD deaths in Canada. Reduced sodium intakes could be achieved through reformulation of the Canadian food supply. However, it will require higher compliance from the food industry to achieve Health Canada's voluntary benchmark sodium reduction targets.
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Affiliation(s)
- Nadia Flexner
- Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada
| | | | - Jodi T Bernstein
- Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Alena P Ng
- Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Yahan Yang
- Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Eduardo A Fernandes Nilson
- Center for Epidemiological Research on Health and Nutrition, University of São Paulo, São Paulo, State of São Paulo, Brazil
| | - Marie-Ève Labonté
- Centre Nutrition, Santé et Société (NUTRISS), Institute of Nutrition and Functional Foods (INAF), Laval University, Quebec City, Quebec, Canada
| | - Mary R L'Abbe
- Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada
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Effect of the food processing degree on cardiometabolic health outcomes: A prospective approach in childhood. Clin Nutr 2022; 41:2235-2243. [DOI: 10.1016/j.clnu.2022.07.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 07/12/2022] [Accepted: 07/27/2022] [Indexed: 11/23/2022]
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Karlsen TH, Sheron N, Zelber-Sagi S, Carrieri P, Dusheiko G, Bugianesi E, Pryke R, Hutchinson SJ, Sangro B, Martin NK, Cecchini M, Dirac MA, Belloni A, Serra-Burriel M, Ponsioen CY, Sheena B, Lerouge A, Devaux M, Scott N, Hellard M, Verkade HJ, Sturm E, Marchesini G, Yki-Järvinen H, Byrne CD, Targher G, Tur-Sinai A, Barrett D, Ninburg M, Reic T, Taylor A, Rhodes T, Treloar C, Petersen C, Schramm C, Flisiak R, Simonova MY, Pares A, Johnson P, Cucchetti A, Graupera I, Lionis C, Pose E, Fabrellas N, Ma AT, Mendive JM, Mazzaferro V, Rutter H, Cortez-Pinto H, Kelly D, Burton R, Lazarus JV, Ginès P, Buti M, Newsome PN, Burra P, Manns MP. The EASL-Lancet Liver Commission: protecting the next generation of Europeans against liver disease complications and premature mortality. Lancet 2022; 399:61-116. [PMID: 34863359 DOI: 10.1016/s0140-6736(21)01701-3] [Citation(s) in RCA: 270] [Impact Index Per Article: 135.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 07/10/2021] [Accepted: 07/15/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Tom H Karlsen
- Department of Transplantation Medicine and Research Institute for Internal Medicine, Division of Surgery, Inflammatory Diseases and Transplantation, Oslo University Hospital Rikshospitalet and University of Oslo, Oslo, Norway.
| | - Nick Sheron
- Institute of Hepatology, Foundation for Liver Research, Kings College London, London, UK
| | - Shira Zelber-Sagi
- School of Public Health, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel; Department of Gastroenterology, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Patrizia Carrieri
- Aix-Marseille University, Inserm, Institut de recherche pour le développement, Sciences Economiques et Sociales de la Santé et Traitement de l'Information Médicale (SESSTIM), ISSPAM, Marseille, France
| | - Geoffrey Dusheiko
- School of Medicine, University College London, London, UK; Kings College Hospital, London, UK
| | - Elisabetta Bugianesi
- Department of Medical Sciences, Division of Gastroenterology, University of Torino, Torino, Italy
| | | | - Sharon J Hutchinson
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK; Clinical and Protecting Health Directorate, Public Health Scotland, Glasgow, UK
| | - Bruno Sangro
- Liver Unit, Clinica Universidad de Navarra-IDISNA and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Pamplona, Spain
| | - Natasha K Martin
- Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, CA, USA; Population Health Sciences, University of Bristol, Bristol, UK
| | - Michele Cecchini
- Health Division, Organisation for Economic Co-operation and Development, Paris, France
| | - Mae Ashworth Dirac
- Department of Health Metrics Sciences, University of Washington, Seattle, WA, USA; Department of Family Medicine, University of Washington, Seattle, WA, USA; Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Annalisa Belloni
- Health Economics and Modelling Division, Public Health England, London, UK
| | - Miquel Serra-Burriel
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Cyriel Y Ponsioen
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Brittney Sheena
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Alienor Lerouge
- Health Division, Organisation for Economic Co-operation and Development, Paris, France
| | - Marion Devaux
- Health Division, Organisation for Economic Co-operation and Development, Paris, France
| | - Nick Scott
- Disease Elimination Program, Burnet Institute, Melbourne, VIC, Australia
| | - Margaret Hellard
- Disease Elimination Program, Burnet Institute, Melbourne, VIC, Australia; Department of Infectious Diseases, Alfred Hospital, Melbourne, VIC, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Doherty Institute and School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
| | - Henkjan J Verkade
- Paediatric Gastroenterology and Hepatology, Department of Paediatrics, University Medical Centre Groningen, University of Groningen, Netherlands; European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Ekkehard Sturm
- Division of Paediatric Gastroenterology and Hepatology, University Children's Hospital Tübingen, Tübingen, Germany; European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | | | | | - Chris D Byrne
- Department of Nutrition and Metabolism, Faculty of Medicine, University of Southampton, Southampton, UK; Southampton National Institute for Health Research, Biomedical Research Centre, University Hospital Southampton and Southampton General Hospital, Southampton, UK
| | - Giovanni Targher
- Department of Medicine, Section of Endocrinology, Diabetes, and Metabolism, University of Verona, Verona, Italy
| | - Aviad Tur-Sinai
- Department of Health Systems Management, The Max Stern Yezreel Valley College, Yezreel Valley, Israel
| | - Damon Barrett
- School of Public Health and Community Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Tatjana Reic
- European Liver Patients Organization, Brussels, Belgium; Croatian Society for Liver Diseases-Hepatos, Split, Croatia
| | | | - Tim Rhodes
- London School of Hygiene & Tropical Medicine, London, UK
| | - Carla Treloar
- Centre for Social Research in Health, University of New South Wales, Sydney, NSW, Australia
| | - Claus Petersen
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
| | - Christoph Schramm
- Martin Zeitz Center for Rare Diseases, Hamburg Center for Translational Immunology (HCTI), and First Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Robert Flisiak
- Department of Infectious Diseases and Hepatology, Medical University of Białystok, Poland
| | - Marieta Y Simonova
- Department of Gastroenterology, HPB Surgery and Transplantation, Clinic of Gastroentrology, Military Medical Academy, Sofia, Bulgaria
| | - Albert Pares
- Liver Unit, Hospital Clinic of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; CIBEREHD, Madrid, Spain
| | - Philip Johnson
- Department of Molecular and Clinical Cancer Medicine, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Alessandro Cucchetti
- Department of Medical and Surgical Sciences-DIMEC, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Isabel Graupera
- Liver Unit, Hospital Clinic of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; CIBEREHD, Madrid, Spain; Faculty of Medicine and Health Sciences, University of Barcelona, Spain
| | - Christos Lionis
- Clinic of Social and Family Medicine, Medical School, University of Crete, Heraklion, Greece
| | - Elisa Pose
- Liver Unit, Hospital Clinic of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Faculty of Medicine and Health Sciences, University of Barcelona, Spain
| | - Núria Fabrellas
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; CIBEREHD, Madrid, Spain; Faculty of Medicine and Health Sciences, University of Barcelona, Spain
| | - Ann T Ma
- Liver Unit, Hospital Clinic of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Juan M Mendive
- Prevention and Health Promotion Research Network (redIAPP), Institute of Health Carlos III, Madrid, Spain; La Mina Health Centre, Catalan Institute of Health (ICS), Barcelona, Spain
| | - Vincenzo Mazzaferro
- HPB Surgery and Liver Transplantation, Istituto Nazionale Tumori IRCCS Foundation (INT), Milan, Italy; Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Harry Rutter
- Department of Social and Policy Sciences, University of Bath, Bath, UK
| | - Helena Cortez-Pinto
- Clínica Universitária de Gastrenterologia and Laboratório de Nutrição, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Deirdre Kelly
- Liver Unit, Birmingham Women's and Children's Hospital and University of Birmingham, UK
| | - Robyn Burton
- Alcohol, Drugs, Tobacco and Justice Division, Public Health England, London, UK
| | - Jeffrey V Lazarus
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, Barcelona, Spain
| | - Pere Ginès
- Liver Unit, Hospital Clinic of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; CIBEREHD, Madrid, Spain; Faculty of Medicine and Health Sciences, University of Barcelona, Spain
| | - Maria Buti
- CIBEREHD del Instituto de Salud Carlos III, Madrid, Spain; Liver Unit, Hospital Universitario Valle Hebron, Barcelona, Spain
| | - Philip N Newsome
- National Institute for Health Research Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust, University of Birmingham, Birmingham, UK
| | - Patrizia Burra
- Multivisceral Transplant Unit, Gastroenterology, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
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Breda J, Allen LN, Tibet B, Erguder T, Karabulut E, Yildirim HH, Mok A, Wickramasinghe K. Estimating the impact of achieving Turkey's non-communicable disease policy targets: A macro-simulation modelling study. THE LANCET REGIONAL HEALTH. EUROPE 2021; 1:100018. [PMID: 33928267 PMCID: PMC8063152 DOI: 10.1016/j.lanepe.2020.100018] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND The Burden of non-communicable disease (NCDs) has continued to rise globally, particularly in low- and middle-income countries. In Turkey, NCDs account for 89% of all deaths, with nearly one in five deaths occurring before age 70. This study investigates the number of NCD deaths that could be prevented if Turkey met national and international targets for major modifiable NCD risk factors. METHODS Preventable deaths were estimated using the World Health Organization (WHO) 'Preventable Risk Integrated ModEl' (PRIME), by combining: 1) Baseline exposure data for risk factors, referenced from national surveillance and cohort studies; 2) Aetiological associations from published meta-analyses; and 3) Demographic and mortality statistics obtained from the Turkish Statistical Institute (TurkStat). Confidence intervals were estimated using Monte Carlo simulations. FINDINGS If Turkey met its NCD risk factor targets for reducing tobacco and salt consumption by 30%, and physical inactivity by 10% in 2017, an estimated 19,859 deaths (95%CI: 12,802 to 26,609) could have been prevented. Approximately two thirds of these preventable deaths were in men, and one in three were in adults below 75 years. A 30% relative reduction in the consumption of alcohol, tobacco, and salt, as well as physical inactivity, would prevent 180 (107 to 259); 4,786 (3,679 to 5,836); 13,112 (5,819 to 19,952); and 7,124 (5,053 to 9,212) deaths, respectively. INTERPRETATION Among major modifiable NCD risk factors, population-level reductions in salt intake and physical inactivity present the greatest opportunity for reducing NCD mortality in Turkey. These findings can help Turkey prioritise interventions to meet the Sustainable Development Goal target of reducing NCD mortality by one third, by 2030.
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Affiliation(s)
- João Breda
- WHO European Office for the Prevention and Control of Noncommunicable Diseases, Moscow, Russian Federation
| | - Luke N Allen
- GP Academic Clinical Fellow, Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
- Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Rd, Oxford OX2 6GG UK
| | - Birol Tibet
- Izmir Biomedicine and Genome Center, Izmir, Turkey
- PhD Candidate, Istanbul University Istanbul Faculty of Medicine Department of Public Health, Istanbul, Turkey
| | - Toker Erguder
- National Professional Officer, World Health Organization Noncommunicable Diseases and Promoting Health through the Life-Course
| | - Erdem Karabulut
- Hacettepe University Faculty of Medicine Department of Biostatistics, Ankara, Turkey
| | - Hasan H Yildirim
- Health Institutes of Turkey Turkish Institute for Health Policies, Ministry of Health, Ankara, Turkey
| | - Alexander Mok
- WHO European Office for the Prevention and Control of Noncommunicable Diseases Russian Federation
| | - Kremlin Wickramasinghe
- World Health Organization Regional Office for Europe Russian Federation
- WHO European Office for the Prevention and Control of Noncommunicable Diseases, 9 Leontyevsky Pereulok 125009 Moscow, Russian Federation
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Graça P, Gregório M, Freitas M. A Decade of Food and Nutrition Policy in Portugal (2010–2020). PORTUGUESE JOURNAL OF PUBLIC HEALTH 2020. [DOI: 10.1159/000510566] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
For the first time, in 2012, the Portuguese Government, through the National Program for the Promotion of Healthy Eating of the Directorate-General for Health, implemented a set of concerted measures for improving the dietary habits, nutritional status and health of the population. Prior to, and since 2007, several epidemiological, social and political circumstances converged, for later enabling the development of a national strategy throughout the decade 2010–2020. This was also supported by specific international guidelines, namely from the World Health Organization and the European Commission. The national strategy objectives have been: (a) To increase the knowledge about the population’s food consumption, its determinants and consequences; (b) to modify the access to certain food items specially in schools, workplaces and public spaces; (c) To inform and empower individuals regarding shopping, preparation and storage of healthy foods, especially amongst those most vulnerable or with a lower income; (d) to identify and promote actions capable of encouraging a healthier diet through the integration of other societal sectors, namely agriculture, sports, environment, education, social security and local authorities; and (e) to better capacitate different professionals who, owing to their roles, may influence nutritional knowledge, attitudes and behaviors. Several actions are described, including the creation of legislation to address these objectives. It is worth noting that one of the biggest challenges to this public policy has been the interventions within the environments where people live. By knowingly being central to food choice determinants, these environmental modifications were also where the stakeholders felt the greatest tensions and difficulties, but also where there are the greatest gains to be made. Solutions to overcome these problems and other perceived difficulties have been proposed here and are considered to be some of the main lessons and achievements throughout this process.
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Consumption of ultra-processed foods and non-communicable disease-related nutrient profile in Portuguese adults and elderly (2015-2016): the UPPER project. Br J Nutr 2020; 125:1177-1187. [PMID: 32878664 DOI: 10.1017/s000711452000344x] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This study aims to investigate the dietary share of ultra-processed foods and its association with the non-communicable disease (NCD)-related nutrient profile of adult and elderly populations in Portugal. Cross-sectional data from the National Food, Nutrition and Physical Activity Survey (2015-2016) of the Portuguese population were analysed. Dietary intake was assessed by two non-consecutive 24-h recalls, and food items were classified according to the NOVA system. We estimated the percentage of dietary energy provided by each of the NOVA food groups and assessed the NCD-related nutrient profile of the overall diet across quintiles of ultra-processed food consumption. Weighted t tests, besides crude and adjusted linear and Poisson regressions, were performed. Ultra-processed foods contributed to around 24 and 16 % of daily energy intake for adults and elderly, respectively. In both groups, as the consumption of ultra-processed foods increased, the dietary content of free sugars, total fats and saturated fats increased, while the dietary content of protein decreased. In adults, total energy intake, dietary energy density and content of carbohydrates also increased as the consumption of ultra-processed foods increased, while the dietary content of fibre, Na and K decreased. The prevalence of those exceeding the upper limits recommended for free sugars and saturated fats increased by 544 and 153 % in adults and 619 and 60 % in elderly, when comparing the lowest with the highest quintile of ultra-processed food consumption. Such a scenario demands for effective strategies addressing food processing in the Portuguese population to improve their diet quality and prevention against diet-related NCD.
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Goiana-da-Silva F, Severo M, Cruz e Silva D, Gregório MJ, Allen LN, Muc M, Morais Nunes A, Torres D, Miraldo M, Ashrafian H, Rito A, Wickramasinghe K, Breda J, Darzi A, Araújo F, Lopes C. Projected impact of the Portuguese sugar-sweetened beverage tax on obesity incidence across different age groups: A modelling study. PLoS Med 2020; 17:e1003036. [PMID: 32163412 PMCID: PMC7067376 DOI: 10.1371/journal.pmed.1003036] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 02/10/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Excessive consumption of sugar has a well-established link with obesity. Preliminary results show that a tax levied on sugar-sweetened beverages (SSBs) by the Portuguese government in 2017 led to a drop in sales and reformulation of these products. This study models the impact the market changes triggered by the tax levied on SSBs had on obesity incidence across various age groups in Portugal. METHODS AND FINDINGS We performed a national market analysis and population-wide modelling study using market data for the years 2014-2018 from the Portuguese Association of Non-Alcoholic Drinks (GlobalData and Nielsen Consumer Panel), dietary data from a national survey (IAN-AF 2015-2016), and obesity incidence data from several cohort studies. Dietary energy density from SSBs was calculated by dividing the energy content (kcal/gram) of all SSBs by the total food consumption (in grams). We used the potential impact fraction (PIF) equation to model the projected impact of the tax-triggered change in sugar consumption on obesity incidence, through both volume reduction and reformulation. Results showed a reduction of 6.6 million litres of SSBs sold per year. Product reformulation led to a decrease in the average energy density of SSBs by 3.1 kcal/100 ml. This is estimated to have prevented around 40-78 cases of obesity per year between 2016 and 2018, with the biggest projected impact observed in adolescents 10 to <18 years old. The model shows that the implementation of this tax allowed for a 4 to 8 times larger projected impact against obesity than would be achieved though reformulation alone. The main limitation of this study is that the model we used includes data from various sources, which can result in biases-despite our efforts to mitigate them-related to the methodological differences between these sources. CONCLUSIONS The tax triggered both a reduction in demand and product reformulation. These, together, can reduce obesity levels among frequent consumers of SSBs. Such taxation is an effective population-wide intervention. Reformulation alone, without the decrease in sales, would have had a far smaller effect on obesity incidence in the Portuguese population.
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Affiliation(s)
- Francisco Goiana-da-Silva
- Centre for Health Policy, Institute of Global Health Innovation, Imperial College London, London, United Kingdom
| | - Milton Severo
- Department of Public Health and Forensic Sciences and Medical Education, Faculty of Medicine, University of Porto, Porto, Portugal
- Epidemiology Research Unit, Institute of Public Health, University of Porto, Porto, Portugal
| | - David Cruz e Silva
- Centre for Innovation, Technology and Policy Research, University of Lisbon, Lisbon, Portugal
| | - Maria João Gregório
- Directorate General of Health, Lisbon, Portugal
- Faculty of Nutrition and Food Sciences, University of Porto, Porto, Portugal
| | - Luke N. Allen
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, England
| | - Magdalena Muc
- Department of Psychological Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Alexandre Morais Nunes
- Centre for Public Administration and Public Policies, Institute of Social and Political Sciences, University of Lisbon, Lisbon, Portugal
| | - Duarte Torres
- Epidemiology Research Unit, Institute of Public Health, University of Porto, Porto, Portugal
- Faculty of Nutrition and Food Sciences, University of Porto, Porto, Portugal
| | - Marisa Miraldo
- Department of Economics and Public Policy, Imperial College Business School, London, United Kingdom
- Centre for Health Economics and Policy Innovation, Imperial College Business School, London, United Kingdom
| | - Hutan Ashrafian
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Ana Rito
- WHO Collaborating Centre for Nutrition and Childhood Obesity, National Institute of Health (INSA), Lisbon, Portugal
| | - Kremlin Wickramasinghe
- WHO European Office for the Prevention and Control of Noncommunicable Diseases, WHO Regional Office for Europe, Moscow, Russian Federation
| | - João Breda
- WHO European Office for the Prevention and Control of Noncommunicable Diseases, WHO Regional Office for Europe, Moscow, Russian Federation
| | - Ara Darzi
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Fernando Araújo
- University Hospital of São João, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Carla Lopes
- Department of Public Health and Forensic Sciences and Medical Education, Faculty of Medicine, University of Porto, Porto, Portugal
- Epidemiology Research Unit, Institute of Public Health, University of Porto, Porto, Portugal
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Goiana-da-Silva F, Cruz-E-Silva D, Allen L, Nunes AM, Calhau C, Rito A, Bento A, Miraldo M, Darzi A. Portugal's voluntary food reformulation agreement and the WHO reformulation targets. J Glob Health 2019; 9:020315. [PMID: 31656602 PMCID: PMC6790236 DOI: 10.7189/jogh.09.020315] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Francisco Goiana-da-Silva
- Centre for Health Policy, Institute of Global Health Innovation, Imperial College London, London, United Kingdom.,Faculdade de Ciências da Saúde, Universidade da Beira Interior, Covilhã, Portugal
| | - David Cruz-E-Silva
- Center for Innovation, Technology and Policy Research, IN+, Instituto Superior Técnico, Universidade de Lisboa, Lisbon, Portugal
| | - Luke Allen
- Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom
| | - Alexandre Morais Nunes
- Centre for Public Administration and Public Policies, Institute of Social and Political Sciences, University of Lisbon, Lisbon, Portugal
| | - Conceição Calhau
- Nutrition and Metabolism, NOVA Medical School, Faculty of Medical Sciences, NOVA University of Lisbon, Lisbon, Portugal.,Center for Health Technology Services Research (CINTESIS), Porto, Portugal
| | - Ana Rito
- INSA, National Institute of Health, Lisbon, Portugal
| | | | - Marisa Miraldo
- Department of Management & Centre for Health Economics & Policy Innovation (CHEPI), Imperial College Business School, London, United Kingdom
| | - Ara Darzi
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, United Kingdom
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João Gregório M. Obesity as a Major Public Health Problem in Portugal: Achievements and Challenges. PORTUGUESE JOURNAL OF PUBLIC HEALTH 2019. [DOI: 10.1159/000502305] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Affiliation(s)
- David Watkins
- Division of General Internal Medicine, University of Washington, 325 9th Ave Box 359780 Seattle, 98104 WA, United States of America
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