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

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www.med.monash.edu.au/ascend

www.med.monash.edu.au/ascend

Intervention components

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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.