PLOTTING/MAPPING RESEARCH EVIDENCE ON ADOPTION AND IMPLEMENTATION OF THE WHO “BEST BUYS” AND OTHER INTERVENTIONS FOR THE PREVENTION AND CONTROL OF NON-COMMUNICABLE DISEASES IN SUB-SAHARAN AFRICA

ABSTRACT Sub-Sahara Africa (SSA) is challenged with morbidity and mortality from diet-related non-communicable diseases (NCDs). Effective interventions to prevent and control the incidence of mortality become very critical. Therefore, implementation of the WHO recommended “best buys” interventions for unhealthy diets is very imperative to tackle diet-related NCD morbidity and mortality … See more

ABSTRACT Sub-Sahara Africa (SSA) is challenged with morbidity and mortality from diet-related non-communicable diseases (NCDs). Effective interventions to prevent and control the incidence of mortality become very critical. Therefore, implementation of the WHO recommended “best buys” interventions for unhealthy diets is very imperative to tackle diet-related NCD morbidity and mortality in SSA. This study was undertaken to map evidence on the extent of adoption and implementation of the recommended WHO “best buys” interventions in SSA. A systematic scoping review was conducted with PubMed, Google Scholar, Science Direct, and Cochrane Library databases and searched relevant literature within SSA. Using the eligibility criteria as a guide, all eligible articles were exported to the Mendeley citation reference manager created for this study. Eligibility criteria included studies that presented evidence on the adoption and implementation of the WHO “best buys” interventions for unhealthy diet in SSA. We employed Population, Concept, and Context framework to define eligible studies from our primary research question. Two independent reviewers screened the articles for eligibility with the guide of the inclusion and exclusion criteria. The themes from the included studies were structured around the following three domains: Effective interventions with cost-effectiveness analysis (CEA) less than or equivalent to hundred United States Dollars per DALYs averted in LMICs; Effective interventions with CEA greater than hundred United States Dollars per DALYs averted in LMICs and other recommended interventions for the prevention and control of NCDs. In general, the study findings presented evidence on the extent of adoption and implementation of the WHO “best buys” interventions in sub-Sahara Africa (SSA). The study further showed that few countries in SSA had evidence of the WHO “best buys” interventions. The following countries: South Africa, Kenya, Botswana, Namibia, Rwanda, Tanzania, Uganda, Zambia, Ghana, Nigeria, and Mauritius, were shown to have evidence of “best buys” as interventions to reduce the risk of NCDs due to unhealthy diet. Despite evidence of adoption and implementation of the “best buys” interventions found in a small segment of the study population, the adequacy, effectiveness, and likely equity impact of these responses to tackle unhealthy diets has been called into question. Therefore, critical mechanisms need to be adopted to ensure effective implementation of the “best buys” interventions necessary in SSA. Although the “best buys” interventions for unhealthy diets have been adopted and implemented in some parts of SSA, they were rated as poor and ineffective to achieve the desired results. Implementing the ‘best buys” and other recommended interventions have been proven to have huge health and economic returns, particularly in SSA. The study findings from most of the included studies indicated that governments’ desire to implement these policy measures has been hindered by the conflict between their quest for economic growth and the economic implications (e.g. job losses) of diet-related policies such as SSB tax. Therefore, there is a need for strategic action by SSA governments to shift the economic discourse, promote positive public opinion and forge links with other sectors to counter the entrenched for-profit, commercially driven, global economic incentives that are currently undermining policies for unhealthy food products. Keywords: Non-communicable diseases, “best buys”, unhealthy diet, prevention and control, Sub-Sahara Africa, CHAPTER ONEIntroductionThis chapter forms the introductory part of the study. It presents the background to this scoping review including the problem statement, justification of the study, research questions, aim and objectives, and significance of the study. It also provides a general outline of the content and structure of the study. This chapter further provides general research interest on the adoption and implementation of the WHO “Best Buys” and other interventions for the prevention and control of non-communicable diseases in Sub-Saharan Africa.Background to the StudyNo communicable diseases (NCDs) are the main cause of mortality worldwide and one of the greatest public health issues of the twenty-first century (Kassa & Grace, 2019; World Health Organization (WHO), 2017; World Health Organization, 2018b). No communicable disease burden and danger remain unacceptably high, especially in Sub-Saharan Africa (SSA) (World Health Organization., 2013). NCDs' destructive impact on the social and economic development of all nations, particularly low- and middle-income countries (LMICs), has the potential to exacerbate inequities between countries and within populations (World Health Organization., 2013, 2014). NCDs are predicted to kill approximately 41 million people each year, accounting for 71 percent of all deaths worldwide, with 78 percent happening in LMICs (World Health Organization (WHO), 2018b; World Health Organization, 2018b). If nothing is done, the World Health Organization (WHO) predicts that the worldwide yearly number of deaths from NCDs would exceed 55 million by 2030. (World Health Organization. 2013). Furthermore, approximately 15 million premature adult deaths are documented each year, with LMICs accounting for more than 85 percent (Bigna & Noubiap, 2019; Roberts & Roberts, 2019; World Health Organization (WHO), 2018b). Cardiovascular diseases, malignancies, chronic respiratory diseases, and diabetes are the four primary NCDs, accounting for more than 80% of all premature adult fatalities; cardiovascular diseases are the leading cause of NCD mortality, accounting for 17.9 million deaths each year. Cancers account for 22 percent of all NCD fatalities and 16 percent of all worldwide deaths, accounting for 44 percent of all NCD deaths and 31 percent of all global deaths. Chronic respiratory illnesses kill around 3.9 million individuals, accounting for 10% of all NCD fatalities and 7% of all worldwide deaths. Diabetes, the least lethal of them all, accounts for 1.6 million fatalities, accounting for 4% of all NCD deaths and 3% of all worldwide deaths (Bigna & Noubiap, 2019; World Health Organization (WHO), 2018b; World Health Organization, 2018b). Tobacco use, bad food, physical inactivity, and problematic alcohol use are four frequent behavioral risk factors for these main NCDs (World Health Organization., 2013). The present increase in NCD burden in Sub-Saharan Africa is mostly driven by the four common risk factors, as well as the globalization of unhealthy lifestyles, fast unplanned urbanization, and population aging (9,10,6).Sub-Saharan Africa continues to have the largest number of disability-adjusted life-years (DALYs) caused by NCDs, with a 67 percent rise from 90.6 million DALYs in 1990 to 151.3 million DALYs in 2017. (Gouda et al., 2019). Evidence shows that premature NCD fatalities in LMICs (47%) are almost twice those in high-income countries (25%) (World Health Organization, 2018b). Deaths from NCDs are expected to overtake combined mortality from communicable, maternal, neonatal, and nutritional (CMNN) disorders as the major cause of mortality in Sub-Saharan Africa by 2030. (Bennett et al., 2018; Bigna & Noubiap, 2019; Unwin et al., 2001; WHO, 2008).Although noncommunicable disease morbidity and death mostly occur in adults, exposure to risk factors starts in childhood, especially in LMICs (World Health Organization, 2016d). In 2014, the worldwide projected overweight or obesity rate among children under the age of five years was 41 million, with Africa accounting for 25 percent of the total. From 5.4 million in 1990 to 10.3 million in 2014, the number of overweight or obese children in Africa than quadrupled (World Health Organization (WHO), 2016; World Health Organization, 2016d). Recognizing the threat of NCDs to global sustainable development, world leaders agreed to several resolutions (UN General Assembly (2018), 2018; UN World Health Assembly, 2013; 2011 United Nations General Assembly, 2011; 2014 United Nations General Assembly, 2014) and action plans (United Nations., 2015; World Health Organization., 2013; World Health Organization, 2017a) to monitor and track progress against NCDs, and to make prevention the cornerstone of NCD prevention efforts (United Nations., 2015; 2011 United Nations General Assembly, 2011; 2014 United Nations General Assembly, 2014; World Health Organization., 2013). These commitments include worldwide monitoring frameworks and objectives to reduce premature death from the four main NCDs by 25% and one-third (SDG target 3.4) by 2025 (World Health Organization (WHO), 2013) and 2030 (United Nations., 2015), respectively.Based on new evidence since the adoption of the Global Action Plan in 2013, the WHO identified a set of interventions referred to as “Best buys” that are considered cost-effective, affordable, evidence-based, and easily adaptable for implementation by all countries, particularly in SSA ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"author":[{"dropping-particle":"","family":"World Health Organization","given":"","non-dropping-particle":"","parse-names":false,"suffix":""}],"chapter-number":"Annex","container-title":"WHO Global NCD Action Plan 2013-2020","edition":"Appendix 3","id":"ITEM-1","issue":"2017","issued":{"date-parts":[["2017"]]},"page":"65-70","publisher":"WHO","publisher-place":"Geneva, Switzerland","title":"‘ Best Buys ’ and Other Recommended Interventions for the Prevention and Control of Noncommunicable Diseases; “the updated Appendix 3 of the WHO Global NCD Action Plan 2013-2020.","type":"chapter"},"uris":["http://www.mendeley.com/documents/?uuid=a0394606-d773-4fed-b0c2-0333b81ed9e2"]}],"mendeley":{"formattedCitation":"(World Health Organization, 2017a)","plainTextFormattedCitation":"(World Health Organization, 2017a)","previouslyFormattedCitation":"(19)"},"properties":{"noteIndex":0},"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"}(World Health Organization, 2017a). This study, therefore, seeks to chart evidence on the adoption and implementation of the WHO “Best buys” and other interventions concerning reducing the risk of unhealthy diet in SSA. This study will contribute to evidence for measuring progress made on the adoption and implementation of the best buys and other interventions to reduce the risk of NCDs with a focus on an unhealthy diet.Problem StatementThe growing prevalence of NCDs remains a defining global public health challenge for the 21st century, particularly in LMICs. Over the period 2011 to 2025, LMICs are to suffer an estimated over 7 trillion economic losses from the four main NCDs if governments do not take deliberate actions to tackle them ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"ISBN":"978 92 4 156485 4","abstract":"There is growing awareness and concern about the large and escalating burden of chronic, non-communicable diseases (NCDs) not just from the public health perspective but also from the economic one. The social burdens associated with the four diseases that are the focus of the UN High-Level Meeting on NCDs cardiovascular disease, diabetes, cancer and chronic respiratory diseases include prolonged disability, diminished resources within families and reduced productivity, in addition to tremendous demands on health systems. This report addresses current information gaps in our understanding of how to mitigate these challenges by highlighting recent findings about the social costs of NCDs and the resource needs for managing these conditions. Specifically, the report brings together findings from two new studies aimed at equipping decision-makers in government, civil society and the private sector with key economic insights needed to help reduce the growing burden of NCDs: A global analysis of the economic impact of NCDs by the World Economic Forum and the Harvard School of Public Health An analysis of the costs of scaling up a core intervention package in low- and middle-income countries by the World Health Organization The economic consequences of NCDs are staggering. Under a business as usual scenario where intervention efforts remain static and rates of NCDs continue to increase as populations grow and age, cumulative economic losses to low- and middle-income countries (LMICs) from the four diseases are estimated to surpass US 7 trillion over the period 2011-2025 (an average of nearly US 500 billion per year). This yearly loss is equivalent to approximately 4% of these countries current annual output. On a per-person basis, the annual losses amount to an average of US 25 in low-income countries, US 50 in lower middle-income countries and US 139 in upper middle-income countries. By contrast, findings from the second study by the WHO indicate that","author":[{"dropping-particle":"","family":"WHO","given":"","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"World Economic Forum","id":"ITEM-1","issued":{"date-parts":[["2011"]]},"page":"1-12","title":"From Burden to “ Best Buys ”: Reducing the Economic Impact of Non-Communicable Diseases in Low- and Middle-Income Countries","type":"article-journal"},"uris":["http://www.mendeley.com/documents/?uuid=ea1db8d2-688c-4872-9d12-4559c618e71c"]}],"mendeley":{"formattedCitation":"(WHO, 2011)","plainTextFormattedCitation":"(WHO, 2011)","previouslyFormattedCitation":"(22)"},"properties":{"noteIndex":0},"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"}(WHO, 2011). Additionally, between 2011 and 2030, without effective NCD interventions, it will cost LMICs an estimated US$ 21.3 trillion in economic losses due to healthcare costs and unavoidable productive capacities ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"ISBN":"9789283204329","ISSN":"0732-183X","abstract":"This book from the International Agency for Research on Cancer, the specialized cancer agency of the World Health Organization, provides a unique global view of cancer, including cancer patterns, causes, and prevention. The World Cancer Report series is recognized as an authoritative source of global perspective and information on cancer. The first volume appeared in 2003 and the second in 2008. This third volume in the series encompasses both established knowledge and recent research achievement. World Cancer Report provides a professional, multidisciplinary assessment of all aspects of the geographical distribution, biology, etiology, prevention, and control of cancer, predicated on research. The concise nature of the text and the high graphic content (hundreds of colour maps, diagrams, and photographs) make the publication accessible to a broad readership. World Cancer Report is designed to provide non-specialist health professionals and policy-makers with a balanced understanding of cancer control and to provide established cancer professionals with insights about recent development. The book includes chapters in which distinguished scientists from around the world provide a broad overview of established knowledge and then emphasize research activity and progress. In addition, text boxes distributed throughout the book provide short, in-depth discussions of selected questions or topics. A new feature of this volume is the inclusion of Perspectives considering the future development of different aspects of cancer research, written by those whose record of outstanding achievement qualifies them as individuals having unique vision.","author":[{"dropping-particle":"","family":"Bloom, D.E., Cafiero, E.T., Jané-Llopis, E., Abrahams-Gessel, S., Bloom, L.R., Fathima, S., Feigl, A.B., Gaziano, T., Mowafi, M., Pandya, A., Prettner, K., Rosenberg, L., Seligman, B., Stein, A.Z., & Weinstein","given":"C. (2011).","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Working Paper Series","id":"ITEM-1","issue":"87","issued":{"date-parts":[["2011"]]},"number":"87","number-of-pages":"1-8","title":"The Global Economic Burden of Non-communicable Diseases. World Economic Forum (WEF) and Harvard School of Public Health (HSPH)","type":"report"},"uris":["http://www.mendeley.com/documents/?uuid=77115373-a4aa-4477-83e7-0824d4b7ebf5"]},{"id":"ITEM-2","itemData":{"DOI":"10.1136/tobaccocontrol-2016-053305","ISBN":"9789241565257","ISSN":"14683318","PMID":"28138063","abstract":"Background The detrimental impact of smoking on health has been widely documented since the 1960s. Numerous studies have also quantified the economic cost that smoking imposes on society. However, these studies have mostly been in high income countries, with limited documentation from developing countries. The aim of this paper is to measure the economic cost of smoking-attributable diseases in countries throughout the world, including in low- and middle-income settings. Methods The Cost of Illness approach is used to estimate the economic cost of smoking attributable-diseases in 2012. Under this approach, economic costs are defined as either ‘direct costs’ such as hospital fees or ‘indirect costs’ representing the productivity loss from morbidity and mortality. The same method was applied to 152 countries, which had all the necessary data, representing 97% of the world’s smokers. Findings The amount of healthcare expenditure due to smoking-attributable diseases totalled purchasing power parity (PPP) $467 billion (US$422 billion) in 2012, or 5.7% of global health expenditure. The total economic cost of smoking (from health expenditures and productivity losses together) totalled PPP $1852 billion (US$1436 billion) in 2012, equivalent in magnitude to 1.8% of the world’s annual gross domestic product (GDP). Almost 40% of this cost occurred in developing countries, highlighting the substantial burden these countries suffer. Conclusions Smoking imposes a heavy economic burden throughout the world, particularly in Europe and North America, where the tobacco epidemic is most advanced. These findings highlight the urgent need for countries to implement stronger tobacco control measures to address these costs.","author":[{"dropping-particle":"","family":"World Health Organization and United Nations Development Programme","given":"","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"NCDs","id":"ITEM-2","issue":"1","issued":{"date-parts":[["2018"]]},"number-of-pages":"58-64","title":"What Legislators Need to Know; Non-Communicable Diseases","type":"book","volume":"27"},"uris":["http://www.mendeley.com/documents/?uuid=60426f40-27d9-4588-80e3-d8d5bce421f0"]}],"mendeley":{"formattedCitation":"(Bloom, D.E., Cafiero, E.T., Jané-Llopis, E., Abrahams-Gessel, S., Bloom, L.R., Fathima, S., Feigl, A.B., Gaziano, T., Mowafi, M., Pandya, A., Prettner, K., Rosenberg, L., Seligman, B., Stein, A.Z., & Weinstein, 2011; World Health Organization and United Nations Development Programme, 2018)","plainTextFormattedCitation":"(Bloom, D.E., Cafiero, E.T., Jané-Llopis, E., Abrahams-Gessel, S., Bloom, L.R., Fathima, S., Feigl, A.B., Gaziano, T., Mowafi, M., Pandya, A., Prettner, K., Rosenberg, L., Seligman, B., Stein, A.Z., & Weinstein, 2011; World Health Organization and United Nations Development Programme, 2018)","previouslyFormattedCitation":"(23,24)"},"properties":{"noteIndex":0},"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"}(Bloom, D.E., Cafiero, E.T., Jané-Llopis, E., Abrahams-Gessel, S., Bloom, L.R., Fathima, S., Feigl, A.B., Gaziano, T., Mowafi, M., Pandya, A., Prettner, K., Rosenberg, L., Seligman, B., Stein, A.Z., & Weinstein, 2011; World Health Organization and United Nations Development Programme, 2018). NCDs were also projected to cause seven out of every 10 deaths in developing countries in 2020 ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1016/j.dsx.2008.04.005","ISSN":"18780334","abstract":"Non-communicable diseases continue to be important public health problems in the world, being responsible for sizeable mortality and morbidity. Non-communicable diseases (NCDs) are the leading causes of death and disability worldwide. In 2005 NCDs caused an estimated 35 million deaths, 60% of all deaths globally, with 80% in low income and middle-income countries and approximately 16 million deaths in people less than 70 years of age. Total deaths from NCDs are projected to increases by a further 17% over the next 10 years. Knowing the risk factors for chronic disease means that approximately 80% premature heart disease and stroke, 80% of Type 2 diabetes and 40% of cancers are preventable. Within next 20 years, NCDs will be responsible for virtually half of the global burden of disease in the developing countries. Risk factors, such as tobacco and alcohol use, improper nutrition and sedentary behavior contribute substantially to the development of NCDs, which are sweeping the entire globe, with an increasing trend mostly in developing countries where, the transition imposes more constraints to deal with an increasing burden of over population with existing communicable diseases overwhelmed with increasing NCDs in poorly maintained sanitation and environment. By 2020, it is predicted that these diseases will be causing seven out of every 10 deaths in developing countries. A major feature of the developmental transition is the rapid urbanization and the large shifts in population from rural to urban areas. Even the rural people are increasingly adapting urbanized lifestyle. The changing pattern of lifestyle leads to the development of obesity, stroke, stress, atherosclerosis, cancer and other NCDs. Considering the future burden of NCDs and our existing health care system we should emphasize the need to prioritize the prevention and control of NCDs. Our strategies should be directed to monitor the incidence of NCDs along with their risk factors. Some NCDs have their common risk factors which should be addressed with minimum cost but maximum output. The three key components of the strategy are surveillance, health promotion and primary prevention, and management and health care. Accordingto the WHO criteria there are three steps for screening of NCDs. Step 1: Estimation population need through assessing the current risk profile and advocate for action. Step 2: Formulate and adopt NCD policy. Step 3: Identify policy implementation steps. Management of NCDs s…","author":[{"dropping-particle":"","family":"Habib","given":"Samira Humaira","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Saha","given":"Soma","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Burden of non-communicable disease: Global overview","id":"ITEM-1","issue":"1","issued":{"date-parts":[["2010"]]},"page":"41-47","publisher":"Diabetes India","title":"Burden of non-communicable disease: Global overview","type":"article-journal","volume":"4"},"uris":["http://www.mendeley.com/documents/?uuid=5876c797-8cdd-481e-a3a3-12a6e85adf44"]}],"mendeley":{"formattedCitation":"(Habib & Saha, 2010)","plainTextFormattedCitation":"(Habib & Saha, 2010)","previouslyFormattedCitation":"(25)"},"properties":{"noteIndex":0},"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"}(Habib & Saha, 2010), with about 27% occurring in SSA ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1186/s12889-018-5825-7","ISSN":"14712458","PMID":"30168393","abstract":"Background: The increasing burden of non-communicable diseases (NCDs) in sub-Saharan Africa is causing further burden to the health care systems that are least equipped to deal with the challenge. Countries are developing policies to address major NCD risk factors including tobacco use, unhealthy diets, harmful alcohol consumption and physical inactivity. This paper describes NCD prevention policy development process in five African countries (Kenya, South Africa, Cameroon, Nigeria, Malawi), including the extent to which WHO \"best buy\" interventions for NCD prevention have been implemented. Methods: The study applied a multiple case study design, with each country as a separate case study. Data were collected through document reviews and key informant interviews with national-level decision-makers in various sectors. Data were coded and analyzed thematically, guided by Walt and Gilson policy analysis framework that examines the context, content, processes and actors in policy development. Results: Country-level policy process has been relatively slow and uneven. Policy process for tobacco has moved faster, especially in South Africa but was delayed in others. Alcohol policy process has been slow in Nigeria and Malawi. Existing tobacco and alcohol policies address the WHO \"best buy\" interventions to some extent. Food-security and nutrition policies exist in almost all the countries, but the \"best buy\" interventions for unhealthy diet have not received adequate attention in all countries except South Africa. Physical activity policies are not well developed in any study countries. All have recently developed NCD strategic plans consistent with WHO global NCD Action Plan but these policies have not been adequately implemented due to inadequate political commitment, inadequate resources and technical capacity as well as industry influence. Conclusion: NCD prevention policy process in many African countries has been influenced both by global and local factors. Countries have the will to develop NCD prevention policies but they face implementation gaps and need enhanced country-level commitment to support policy NCD prevention policy development for all risk factors and establish mechanisms to attain better policy outcomes while considering other local contextual factors that may influence policy implementation such as political support, resource allocation and availability of local data for monitoring impacts.","author":[{"dropping-particle":"","family":"Juma","given":"Pamela A.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Mohamed","given":"Shukri F.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Matanje Mwagomba","given":"Beatrice L.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ndinda","given":"Catherine","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Mapa-Tassou","given":"Clarisse","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Oluwasanu","given":"Mojisola","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Oladepo","given":"Oladimeji","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Abiona","given":"Opeyemi","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Nkhata","given":"Misheck J.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Wisdom","given":"Jennifer P.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Mbanya","given":"Jean Claude","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"BMC Public Health","id":"ITEM-1","issue":"Suppl 1","issued":{"date-parts":[["2018"]]},"title":"Non-communicable disease prevention policy process in five African countries authors","type":"article-journal","volume":"18"},"uris":["http://www.mendeley.com/documents/?uuid=f3e51f58-1a09-4afa-811f-3b0621e2c0ec"]}],"mendeley":{"formattedCitation":"(Juma, Mohamed, et al., 2018)","plainTextFormattedCitation":"(Juma, Mohamed, et al., 2018)","previouslyFormattedCitation":"(26)"},"properties":{"noteIndex":0},"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"}(Juma, Mohamed, et al., 2018). Among the four common risk factors of NCDs, an unhealthy diet has been classified as the leading contributor to the global burden of NCDs ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"author":[{"dropping-particle":"","family":"Grosso","given":"G","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"European Journal of Public Health","id":"ITEM-1","issue":"Issue Supplement_4, November 2019","issued":{"date-parts":[["2019"]]},"page":"27-29","title":"Impact of nutritional risk factors on chronic non-communicable diseases.","type":"article-journal","volume":"Volume 29"},"uris":["http://www.mendeley.com/documents/?uuid=e6761cbe-7846-4ffe-a232-8992c172fc55"]},{"id":"ITEM-2","itemData":{"DOI":"10.1016/S0140-6736(19)30041-8","ISSN":"1474547X","PMID":"30954305","abstract":"Background: Suboptimal diet is an important preventable risk factor for non-communicable diseases (NCDs); however, its impact on the burden of NCDs has not been systematically evaluated. This study aimed to evaluate the consumption of major foods and nutrients across 195 countries and to quantify the impact of their suboptimal intake on NCD mortality and morbidity. Methods: By use of a comparative risk assessment approach, we estimated the proportion of disease-specific burden attributable to each dietary risk factor (also referred to as population attributable fraction)among adults aged 25 years or older. The main inputs to this analysis included the intake of each dietary factor, the effect size of the dietary factor on disease endpoint, and the level of intake associated with the lowest risk of mortality. Then, by use of disease-specific population attributable fractions, mortality, and disability-adjusted life-years (DALYs), we calculated the number of deaths and DALYs attributable to diet for each disease outcome. Findings: In 2017, 11 million (95% uncertainty interval [UI]10–12)deaths and 255 million (234–274)DALYs were attributable to dietary risk factors. High intake of sodium (3 million [1–5]deaths and 70 million [34–118]DALYs), low intake of whole grains (3 million [2–4]deaths and 82 million [59–109]DALYs), and low intake of fruits (2 million [1–4]deaths and 65 million [41–92]DALYs)were the leading dietary risk factors for deaths and DALYs globally and in many countries. Dietary data were from mixed sources and were not available for all countries, increasing the statistical uncertainty of our estimates. Interpretation: This study provides a comprehensive picture of the potential impact of suboptimal diet on NCD mortality and morbidity, highlighting the need for improving diet across nations. Our findings will inform implementation of evidence-based dietary interventions and provide a platform for evaluation of their impact on human health annually. Funding: Bill & Melinda Gates Foundation.","author":[{"dropping-particle":"","family":"Afshin","given":"Ashkan","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Sur","given":"Patrick John","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Fay","given":"Kairsten A.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Cornaby","given":"Leslie","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ferrara","given":"Giannina","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Salama","given":"Joseph S.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Mullany","given":"Erin C.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Abate","given":"Kalkidan 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