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Brian Oldenburg Melbourne School of Population & Global Health
The University of Melbourne AUSTRALIA
Influencing changes in dietary behaviors and physical activity in developing countries: What do we know that works?
Evidence gaps?
1. What do we know that we know?
2. What do we know that we don’t know?
3. What don’t we know at all?
Evidence gaps – Nutrition and physical activity & sedentariness
1. What do we know, we know? THE KNOWN KNOWNS?
2. What do we know, we don’t know? THE KNOWN UNKNOWNS?
2. What don’t we know at all? THE UNKNOWN
UNKNOWNS?
Global translation and exchange
Individual & environment
Healthy eating Healthy activity Healthy weight
Environment
Individual
Changing policy and the environment…
Healthy eating Healthy activity Healthy weight
Policy & Environmental change
Individual
Formulate willingness into SMART goals
Link with personal and family goals
Identify links btw behaviour and
positive outcomes
Learn from lapses
Plan for action with linkages to community & family resources
and support: Where, when, how, with whom?
Identify “willingness” for specific
behavioural changes
Identify personal resources and social support
Our generic socio-ecological model for behavior change at an individual & population level e.g. diabetes
Identify existing lifestyle behaviours link with diabetes risk and need for
change
Establish collective commitment for
action + feedback from peers etc
Get positive feedback to
encourage and increase
motivation
10/12/2015
Review goal progress
(Re-)Assess situation
Set goals
Plan
Follow-up and
maintenance
Individual embedded in family, peer
group, neighborhood,
community
1. The Known Knowns?
What is the available evidence? 1. Review of Best Practice in Interventions to Promote
Physical Activity in Developing Countries 14
– Systematic synthesis of peer reviewed literature – Consultation process with key stakeholders
2. Cochrane review on health promotion interventions effective in reducing cardiovascular diseases15
3. Policy review on diet and PA16 4. Review on school based interventions effective in
reducing childhood obesity in LMICs17
5. Recent advances in behavioral interventions in India: Diet18 , Physical activity19 , targeting high risk individuals for DM20
Physical activity
interventions implemented currently in
LMICs14
Raise awareness of the importance and benefits of physical activity among the
population,
Educate the whole population and/or specific population
groups
Conduct local physical activity programs and
initiatives;
Build capacity among individuals implementing
local physical activity programs through training
of potential program coordinators
Create supportive environments that facilitate participation in
physical activity
Recognition/awards to individuals who live a
healthy lifestyle, engage in regular physical activity,
and encourage others to do so
1. Best practice physical activity interventions in developing countries
Best practice physical activity interventions in developing countries
Type of program Countries Nature of interventions
National program Singapore1,2, China-Hong Kong SAR3, Malaysia4, Philippines5, Marshall islands, Fiji, Thailand6, South Africa, Slovenia12, Poland13, Pakistan7,8
• Creating a supportive environment
• Raising awareness • Mass media Campaigns • Network of sports and health
workers • Community wide screenings
Mass media based health education campaigns based on the principles of social
• marketing
Workplace-based Health Education Intervention in ten locations
India • Behavioral modification strategies
• information dissemination
Community based programs targeting few areas
Islamic Republic of Iran9 Mass media, special events and exercise regulations
Best practice physical activity interventions in developing countries (cont’d)
Type of program Countries Nature of interventions
Conducted in the capital city of Bogotá, with a population of 7 million inhabitants in 20 localities
Columbia10,11 • Creating a supportive environment
• Raising awareness • Mass media Campaigns
Community based interventions in Sao Paulo
Brazil • Community-wide intervention Permanent actions by local organizations for promoting the physical activity message in the community, Supportive actions by other institutions, mega events like Agita Galera
Best practice physical activity interventions in developing countries (cont’d)
• Interventions were implemented as part of a national action plan or strategy, such as for NCD prevention and control, health promotion, or physical activity promotion (Fiji, Mauritius, Pakistan, Samoa, South Africa, Thailand, Tonga)
• Few countries had set specific committees on physical activity
promotion within a leading governmental agency.
• Evidence base in LMICs is sparse • 13 trials that recruited 7310 participants • Two trials on healthy participants , 11 among those
with cardiovascular risk, hypertension and T2DM • Turkey-3, China-1,Mexico-1,China & Nigeria-1, one
each from Brazil, India, Pakistan, Romania and Jordan • Interventions limited to dietary advice and advice on
physical activity • Duration: 6 to 13 months (mean follow up-13.3
months)
2. Key findings from Cochrane review on health promotion inventions for CVD in LMIC 15
Key findings from Cochrane review (cont’d)
• Evidence for effects on cardiovascular disease events was scarce.
• Multiple risk factors interventions may lower – systolic blood pressure – diastolic blood pressure – body mass index and – waist circumference.
• No difference for eating more fruit and vegetables, rates of smoking cessation, fasting blood sugar, high density lipoprotein (HDL) cholesterol, low density lipoprotein (LDL) cholesterol and total cholesterol.
• Compromised quality of trials, hence results have to be read with caution.
3. Policy response to NCD’s in LMIC’s16
• Information on the availability of policies for 83% (116/140) countries of the 140 LMICs found in the six WHO regions
• Inadequate since endorsement of the Global
Strategy on Diet, Physical Activity and Health
Policy actions taken in LMICs
Limit salt intake*
Raising awareness Food labeling Promotion of foods, snacks,
and packaged seasonings with reduced salt content
Product reformulation in private sector
*20% (23/116 countries)
Modify fat intake* Use of dietary guidelines and food
labeling Collaboration with the food industry for product reformulation, Establishment and enforcement of food standards
*13/116 countries
Increase fruit and vegetable intake*
Promotion of school gardening,
home gardening, Urban agriculture Catering services in
educational and government institutions to ensure strict inclusion of fruits and vegetables in the meals.
Special recipe books
*36/116 countries
Increase physical activity*
Public education and sensitization
Targeting educational institutions and workplace
Develop sports infrastructure and urban planning
Explicit actions to involve the private sector
*10/116 countries
Atlas of availability of national actions to limit salt or fat intake or increase fruit and vegetable intake or physical activity.
4. Evidence and gaps on school based interventions in LMICs17
• Multicomponent interventions were more effective – education-based interventions delivered by teachers, providing
additional PA sessions or integrated classes about healthy foods-nutrition, or PA to encourage children to adopt a healthy lifestyle
• Role of family was crucial • Very few of them had used a theoretical framework for the
intervention design which is very crucial to tailor the relevant proximal and distal outcomes to the participants’ context
• Lack of information on process evaluation and the cost effectiveness of the interventions
5. Recent advances in PA and diet interventions in India
• Importance of a theoretical framework of behavioral change that is context specific, culturally tailored18,19,20
• Lifestyle change strategies involve reciprocal support with family18,19,20 , peer19,20 and community18,18,20
• Family and community-based vs individualistic approach
2. The Known Unknowns?
We need to apply what we know and transfer what we know between
cultures, settings and populations recognizing that “one size/approach does not fit all”
IMPLEMENTATION SCIENCE
The Innovation
Program transfer, adoption & uptake into policy and practice
Setting • Health care or other system
Target population •Demographic variables
• At risk
Program elements •Theoretical basis • Key components
• Materials • Delivery • Training
Funding • Development • Implementation • Evaluation
Organisations • Leaders
• Strategic local partners • Strategic national partners • Operational partners • Research partners
Development <-> Implementation <-> Evaluation
Ref: Oldenburg B et al. The spread of diabetes prevention programs around the world.
TBM, 2011, 1: 270-282
Cultural Translation
12.10.2015 28 Pilvikki Absetz 2013
How do different populations understand prevention?
Cardiovascular prevention model from Kenyan slums to migrants in the
Netherlands • Steven van de Vijver et al. Globalization and
Health (2015) 11:11 • Reverse innovations
Profits and pandemics
The Lancet NCD Action Group
The science of the behavior of industries is only emerging but also remains largely unstudied. Industrial epidemics Industrial vectors
Estimated Global, Regional and National Disease Burden
Related to Sugar-Sweetened Beverage Consumption in 2010 Singh et al *
Circulation, Vol 132, August 25, 2015 Using a comparative risk assessment model, in 2010, it was estimated ~184,000 deaths and 8.5 million disability-adjusted life-years per year were attributable to sugar sweetened beverages (SSBs) worldwide; 75% of deaths and 85% of disability-adjusted life years occurred in low- and middle-income countries. * on behalf of the Global Burden of Diseases Nutrition and Chronic Diseases Expert Group
3. What do we know about the UnKnown UnKnowns?
?
Adapting maternal and child health system…….dressi
Communicable Diseases in a lower-middle income Country – Sri La Approach
Healthy Village Program in Sri Lanka
www.med.monash.edu.au/ascend
www.med.monash.edu.au/ascend
www.med.monash.edu.au/ascend
www.med.monash.edu.au/ascend
www.med.monash.edu.au/ascend
www.med.monash.edu.au/ascend
Intervention components
43
K-DPP Intervention components K-DPP Outcomes
Peer leaders
Participants
Two x 2-days group facilitation training delivered by the K-DPP intervention team
Two diabetes prevention education sessions by the expert panel members
Peer leader workbook
Ongoing support from the K-DPP intervention team
Participant handbook, participant workbook and health education booklet
11 small group sessions led by trained peer
leaders
Ongoing support from a local resource person
Participant outcomes
1. Behavioural outcomes • Improved diet • Increased physical activity • Reduced tobacco use • Reduced alcohol consumption 2. Psychosocial outcomes • Reduced stress • Improved quality of life 3. Clinical outcomes • Reduced blood pressure • Reduced waist circumference • Reduced body fat 4. Biochemical outcomes • Reduced incidence of diabetes • Improved glycaemic control • Improved lipid profile
Peer leader and Peer group outcomes
1 Increased provision of emotional and social support to /within the group
2 Increased utilization of community resources by the group
3 Increased linkages to social support networks of the group
Process of scaling up of interventions
National
State
District
Local
Institutionalization Expansion/Replication
Scale up
Reach large numbers at relatively low cost;
address multiple health behaviors;
generate large data useable in “real time” to guide dynamic, adaptive and more effective and sustainable interventions;
reduce amount of direct, human contact required for delivery
Annu Rev Public Health. 2015 18;36:483-505
Potential of new technologies
References 1. http://www.hpb.gov.sg/hpb/ 2. http://www.moe.gov.sg/cpdd/pe/taf/ 3. http://www.lcsd.gov.hk/healthy/en/index.php 4. http://dph.gov.my/ncd/index.htm and http://dph.gov.my/ncd/scc/index.htm 5. http://www.doh.gov.ph/healthylifestyle/healthylifestyle.htm 6. http://www.anamai.moph.go.th/engver/intro.html 7. Nishtar S (2003). Cardiovascular disease prevention in low resource settings: lessons from the Heartfile experience in Pakistan. Ethnicity and
Disease, 13(S2):S2/138–148. 8. Nishtar S (2004). Prevention of non-communicable diseases in Pakistan: an integrated partnership-based model. Health Research Policy and
System, 13, 2(1):7. 9. Sarraf-Zadegan N, et al (2003). Isfahan Healthy Heart Programmeme: a comprehensive integrated community-based programme for
cardiovascular disease prevention and control. Design, methods and initial experience. Acta Cardiologica, 4 (58), 309–320. 10. CELAFISCS: http://www.agitasp.com.br 11. Physical Activity Network of the Americas: http://www.rafapana.org 12. www.cindi-slovenija.net/ [Slovenian] 13. www.cindi.org.pl/ [Polish] 14. A. Bauman, S. Schoeppe and M Lewicka (Center for Physical Activity and Health, School of Public Health, University of Sydney, Australia), in
collaboration with T. Armstrong, V. Candeias and J. Richards (WHO Headquarters, Geneva, Switzerland), for the WHO Workshop on Physical Activity and Public Health, Beijing, China, held on 24–27 October 2005.
15. Uthman OA, Hartley L, Rees K, Taylor F, Ebrahim S, Clarke A. Multiple risk factor interventions for primary prevention of cardiovascular disease in low- and middle-income countries. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD011163. DOI: 10.1002/14651858.CD011163.pub2
16. Lachat C, Otchere S, Roberfroid D, Abdulai A, Seret FMA, et al. (2013) Diet and Physical Activity for the Prevention of Noncommunicable Diseases in Low- and Middle-Income Countries: A Systematic Policy Review. PLoS Med 10(6): e1001465. doi:10.1371/journal.pmed.1001465
17. Roosmarijn Verstraeten, Dominique Roberfroid, Carl Lachat, Jef L Leroy, Michelle Holdsworth, Lea Maes, and Patrick W Kolsteren. Effectiveness of preventive school-based obesity interventions in low- and middle-income countries: a systematic review. Am J Clin Nutr 2012;96:415–38
18. Meena Daivadanam, Rolf Wahlstrom, T.K. Sundari Ravindran, P.S. Sarma, S. Sivasankaran, K.R. Thankappan. Design and methodology of a community-based cluster randomized controlled trial for dietary behaviour change in rural Kerala. Glob Health Action 2013, 6: 20993 - http://dx.doi.org/10.3402/gha.v6i0.20993
19. Elezebeth Mathews, Michael Pratt, Thankappan KR.Effectiveness of a sox month peer support based interventions to promote physical activity among sedentary women in Thiruvannathapuram City, Kerala (unpublished)
20. Thirunavukkarasu Sathish, Emily D Williams, Naanki Pasricha, Pilvikki Absetz, Paula Lorgelly, Rory Wolfe, Elezebeth Mathews, Zahra Aziz, Kavumpurathu Raman Thankappan, Paul Zimmet, Edwin Fisher, Robyn Tapp, Bruce Hollingsworth, Ajay Mahal, Jonathan Shaw, Damien Jolley, Meena Daivadanam , Brian Oldenburg (2013) Cluster randomised controlled trial of a peer-led lifestyle intervention program: study protocol for the Kerala Diabetes Prevention Program. BMC Public Health; 13:1035. doi: 10.1186/1471-2458-13-1035.