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Diet and Physical Activity for the Prevention of Noncommunicable Diseases in Low- and Middle-Income Countries: A Systematic Policy Review Carl Lachat1,2, Stephen Otchere2, Dominique Roberfroid1, Abubakari Abdulai3, Florencia Maria Aguirre Seret4, Jelena Milesevic5, Godfrey Xuereb6, Vanessa Candeias6, Patrick Kolsteren1,2* 1Nutrition and Child Health Unit, Institute of Tropical Medicine, Antwerp, Belgium, 2Department of Food Safety and Food Quality, Faculty of Bioscience Engineering, Ghent University, Ghent, Belgium, 3Community Nutrition Department, School of Medicine and Health Sciences, University for Development Studies, Tamale, Ghana, 4International Diabetes Federation, Brussels, Belgium, 5Centre of Research Excellence in Nutrition and Metabolism, Institute for Medical Research, University of Belgrade, Belgrade, Serbia, 6Global Strategy on Diet, Physical Activity and Health, Surveillance and Population-Based Prevention Unit, Department of Chronic Diseases and Health Promotion, World Health Organization, Geneva, Switzerland Abstract Background: Diet-related noncommunicable diseases (NCDs) are increasing rapidly in low- and middle-income countries (LMICs) and constitute a leading cause of mortality. Although a call for global action has been resonating for years, the progress in national policy development in LMICs has not been assessed. This review of strategies to prevent NCDs in LMICs provides a benchmark against which policy response can be tracked over time. M e t h o d s a n d F i n d i n g s : We reviewed how government policies in LMICs outline actions that address salt consumption, fat consumption, fruit and vegetable intake, or physical activity. A structured content analysis of national nutrition, NCDs, and health policies published between 1 January 2004 and 1 January 2013 by 140 LMIC members of the World Health Organization (WHO) was carried out. We assessed availability of policies in 83% (116/140) of the countries. NCD strategies were found in 47% (54/116) of LMICs reviewed, but only a minority proposed actions to promote healthier diets and physical activity. The coverage of policies that specifically targeted at least one of the risk factors reviewed was lower in Africa, Europe, the Americas, and the Eastern Mediterranean compared to the other two World Health Organization regions, South-East Asia and Western Pacific. Of the countries reviewed, only 12% (14/116) proposed a policy that addressed all four risk factors, and 25% (29/116) addressed only one of the risk factors reviewed. Strategies targeting the private sector were less frequently encountered than strategies targeting the general public or policy makers. Conclusions: This review indicates the disconnection between the burden of NCDs and national policy responses in LMICs. Policy makers urgently need to develop comprehensive and multi-stakeholder policies to improve dietary quality and physical activity. Please see later in the article for the Editors’ Summary. Citation: 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 Academic Editor: Linda J. Cobiac, The University of Queensland, Australia Received October 25, 2012; Accepted May 2, 2013; Published June 11, 2013 Copyright: 2013 Lachat et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: There was no funding for this work. Competing Interests: The authors have declared that no competing interests exist. The authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions, or policies of the institutions with which they are affiliated. Abbreviations: NCD, noncommunicable disease; LMICs, low- and middle-income countries; WHO, World Health Organization. * E-mail: email@example.com PLOS Medicine | www.plosmedicine.org 1 June 2013 | Volume 10 | Issue 6 | e1001465 Introduction Noncommunicable diseases (NCDs) are the leading cause of death globally. Of the 57 million global deaths in 2008, 36 million (63%) were due to NCDs, principally cardiovascular diseases, diabetes, cancers, and chronic respiratory diseases . Mortality and morbidity data reveal the growing and disproportional impact of the epidemic in low- and middle-income countries (LMICs). Nearly 80% of the yearly NCD deaths—equivalent to 29 million people—are estimated to occur in LMICs. Without effective prevention and control, an estimated 41 million people in LMICs will die from NCDs by 2015 . NCDs will evolve into a staggering economic burden over the next two decades . Poor dietary quality (in particular, high salt intake, high saturated and trans-fatty acid intake, and low fruit and vegetable consumption) and insufficient physical activity are key risk factors for NCD development  and mortality worldwide , and are considered priority areas for international action . The mean salt intake in most LMICs exceeds the recommended maximum intake . Reducing salt intake to about 6 g/d could prevent annually about 2.5 million deaths globally [8–11], and a 15% reduction of salt intake over a decade in LMICs could forestall 3.1 million deaths [11,12]. Fruit and vegetable intake is inadequate , and this situation contributes to 2.7 million NCD-related deaths per year. Despite evidence indicating that proper levels of physical activity are associated with a 30% reduction in the risk of ischemic heart disease, a 27% reduction in the risk of diabetes, and a 21%–25% reduction in the risk of breast and colon cancer [14,15], approximately 3.2 million deaths each year are attribut- able to insufficient physical activity . Physical inactivity is increasingly becoming prevalent in LMICs and already constitutes one of the leading causes of mortality . There is also concern about excess intake of saturated and transfatty acids in LMICs, although large regional differences are observed [17,18]. Preventing NCDs is not impossible . Cecchini and colleagues analyzed population-based strategies to prevent NCDs in a number of LMICs with a high burden of NCDs . Health information and communication strategies, fiscal measures, and regulatory measures for marketing or provision of nutrition information to children that promotes healthy eating and physical activity were found to yield substantial and cost-effective health gains, in particular in LMICs . In addition, these interventions were found to be particularly effective when delivered as a multi- intervention package. Hence, it is crucial to translate the available evidence into sustainable policies in LMICs . In May 2004, all WHO member states endorsed the Global Strategy on Diet, Physical Activity and Health, aiming to address NCDs through diet and physical activity . Recently, a United Nations high-level meeting convened to discuss measures to prevent and control the global NCD epidemic and stressed the need to accelerate the policy response to it . Monitoring this interna- tional commitment is important and can be achieved by systematic policy reviews. Previous policy reviews [22,23], however, provided only a partial view of efforts undertaken to address NCDs, as they relied on survey data and did not consider the actual content of the policies. As policy documents are the culmination of existing social processes, they reflect the views of various stakeholders and are considered to be a reliable account of prevailing policy paradigms in a country . We carried out a stocktaking exercise on national policy actions for NCD prevention in LMICs, and assessed the extent to which these address critical risk factors for NCDs, i.e., salt, fat, and fruit and vegetable intake, and physical inactivity. We focused on the existence and content of policies for the prevention of NCDs, not on their actual implementation. Methods Collection of Policy Documents We searched the Internet (key words [‘‘Nutrition’’ OR ‘‘NCD’’] AND [‘‘Policy’’ OR ‘‘Strategies’’ OR ‘‘Actions’’]) for all publicly available national policies related to diet, nutrition, NCDs, and health in the countries classified as LMICs by the World Bank in 2011 . We also searched the websites of the national ministries involved in nutrition or NCD prevention (i.e., ministries of health, sports, welfare, social affairs, or agriculture) and government portals as well as national nutrition societies. For those countries for which no policy was retrieved through the web search, an e- mail request stating the purpose of the study was sent to the respective bodies. A similar e-mail request was also sent to the WHO Regional Offices and to personal contacts of the research team. When no reply was obtained after repeated contact attempts and no reference to the existence of relevant policy documents was found during our Internet search, we classified the country as one for which we were unable to assess availability of policies. In addition to our search, we used the policy database of the WHO Regional Office for Europe  to assess policy availability. Screening and Selection of Documents The following inclusion criteria were used to include the policies in the analysis: (i) the policy is from a country classified as LMIC according to 2011 World Bank classification , (ii) the policy is officially approved by the national government, (iii) the policy is a publicly available document, published between 1 January 2004 and 1 January 2013, and (iv) the policy relates directly or indirectly to prevention of NCDs (Text S1). We report our findings as a systematic policy review (Text S2). Because we present our results by WHO region, we also excluded countries that were not official member states of WHO in 2011. There was no language restriction. The definitions of ‘‘policy,’’ ‘‘action plan,’’ and ‘‘program’’ vary broadly among the national documents. For the purpose of the present review, a broad definition of policy was used, and all national documents that included the national objectives and guidelines for action in the domain of diet and/or physical activity and/or prevention of NCDs were included. No document was excluded based on its title (e.g., ‘‘plan’’ versus ‘‘policy’’ versus ‘‘strategy’’). Data Analysis Structured content analysis was conducted by coding the documents in NVivo 8 (QSR International). The documents were coded independently by two researchers to minimize bias induced by subjective coding. The coded documents were compared, and if coding agreement was ,99% (as assessed using Kappa test agreement in NVivo), the coded text was manually reviewed for inconsistencies. We coded all text that explicitly referred to actions aiming to (i) limit salt, (ii) modify fat intake, (iii) increase fruit and vegetable intake, or (iv) promote physical activity. Although we acknowledge that it is particularly the shift of fat consumption from saturated fats to unsaturated fats and the elimination of dietary trans-fatty acids that are critical for the prevention of NCDs, we extracted all strategies relating to dietary fat intake, such as reduction of total fat intake. The key words for coding were structured as a coding tree (Figure 1). A query was constructed for each topic in NVivo to extract all relevant text electronically. We present the results by the principle target audience of the actions, grouped into three categories: (i) general public and consumers, (ii) government, and (iii) private sector. National Policies for Noncommunicable Diseases PLOS Medicine | www.plosmedicine.org 2 June 2013 | Volume 10 | Issue 6 | e1001465 Results Description of Policies Out of the 144 countries classified by the World Bank as LMICs, four countries (Mayotte, West Bank and Gaza, the Republic of Kosovo, and American Samoa) were not official member states of WHO in 2011 and were excluded from the review. We note, however, the availability of a nutrition policy for West Bank and Gaza . Of the 140 LMICs found in the six WHO regions (Africa, Europe, the Americas, South-East Asia, the Eastern Mediterra- nean, and the Western Pacific), we found information on the availability of policies for 83% (116/140) countries (Figure 2; Table S1). We were unable to assess the availability of policy documents for 24 countries, and in particular in the Eastern Mediterranean Region 40% (6 out of 15 countries in the region). In the European, African, Western Pacific, and South-East Asian Regions and the Region of the Americas, this proportion was 24% (5/21), 9% (4/45), 22% (4/18), 9% (1/11), and 13% (4/30), respectively. In total, 33 countries were excluded from review as they had no policy (n=4), a policy published before 2004 (n=19), or a policy document that was not officially endorsed (n=3) or could not be circulated publicly (n=3). In an additional four countries, a policy was reported to be available , but the full document could not be obtained. For 29 countries, the policy document reviewed did not contain any of the NCD prevention strategies reviewed [28–56]. In 30 countries, policy strategies to improve dietary quality did not specify actions for any of the dietary risk factors reviewed here [28,29,32–38,40–52,55–62]. In the countries reviewed, strategies that addressed intake of salt, fat, or fruits and vegetables or the promotion of physical activity were found in 47% (54/116) of policies. These policies had a main focus on food or nutrition (n=34), general health (n=11), and, to a lesser extent, the prevention of NCDs (n=9). In total, 36 countries had explicit actions in their policies to increase fruit and vegetable intake, 20 specified actions aimed to address dietary fat consumption, 23 specified actions to limit salt intake, and 35 specified actions to promote physical activity. Although generally low, the proportion of countries with a policy that targeted at least one risk factor was higher in South-East Asia and the Western Pacific than in Africa, Europe, the Americas, and the Eastern Mediterranean. Only 12% (14/116) of the LMICs reviewed (Bhutan, Jamaica, Mauritius, the Republic of Moldova, Malaysia, Indonesia, the Philippines, Cambodia, the former Yugoslav Republic of Macedonia, Jordan, Montenegro, Brazil, Iran, and Mongolia) proposed a package that addressed all four risk factors, and approximately 23% (27/116) of countries addressed only one of the risk factors (Figure 3). Policy Actions to Limit Salt Intake Only 20% (23/116) of the countries reviewed specified strategies to limit dietary salt intake, and eight policies detailed national targets to limit salt intake (Table 1). A large majority (83%; 19/23) of the countries with salt reduction strategies outlined measures of education and awareness creation in the general public and consumers, in particular focused on food labeling and promotion of foods, snacks, and packaged seasonings with reduced salt content. Strategies targeted towards the private sector were observed in 30% (7/23) of the policies and mainly related to product reformulation. The actions targeted at the governments were essentially the establishment of fiscal measures, labeling, and development of standards for salt in food and market regulations. Of the 83 countries with a policy eligible for review, 43 contained specific measures for salt iodization, but only ten of these also mentioned the need to reduce or manage dietary salt intake. Policy Actions to Modify Fat Intake Of the countries with strategies to modify fat intake, 65% (13/ 20) proposed strategies targeting the general public and consumers via public education and awareness creation (Table 2). The use of dietary guidelines and food labeling were specifically mentioned as means of public education on dietary fat intake reduction in the Mauritius , Bulgaria , Jamaica , and Bhutan . Imposition of fiscal measures, collaboration with the food industry for product reformulation, and the establishment and enforcement of food standards were mentioned as the main actions to be implemented by the government. Only Mauritius , Bulgaria , the former Yugoslav Republic of Macedonia , Iran , and Mongolia  outlined specific strategies targeted towards the private sector. Intake of specific fatty acids, and in particular saturated fat (Mongolia , the former Yugoslav Republic of Macedonia , Jordan , Bhutan , Cambodia , Bulgaria , Seychelles , the Philippines , Montenegro , and Iran ) and trans-fatty acids (the former Yugoslav Republic of Macedonia , Bhutan , Bulgaria , Seychelles , the Philippines , Montenegro , Mauritius , Brazil , and Iran ), was addressed in ten and nine countries, respectively. Whereas Mauritius  proposed research into the safety of reused oils, others focused on the type of fat (Iran  and Cambodia ) or the number of times oil should be used (Seychelles ). Six countries (Mauritius , Bulgaria , the former Yugoslav Republic of Macedonia , Montenegro , Malaysia , and Viet Nam ) mentioned specific national fat intake targets (Table 2). Policy Actions to Increase Fruit and Vegetable Intake Compared to the other dietary risk factors reviewed, the objective of increasing fruit and vegetable consumption had the highest coverage: 31% (36/116) of the policies reviewed (Table S1). Promotion of school gardening, home gardening, and urban agriculture were the main actions to ensure availability and accessibility of fruit and vegetables (Table 3). The majority (75%; 27/36) of the policy documents with strategies for fruit and vegetable intake focused on public education and demonstrations to promote increased fruit and vegetable intake. Malaysia proposed the development of special recipe books in this regard . Other strategies, as found in Sri Lanka  and Mongolia  for instance, targeted the catering services in educational and government institutions to ensure strict inclusion of fruits and vegetables in the meals. In all of the WHO regions, policy documents that addressed increasing fruit and vegetable con- sumption included the need to produce, store, and process local fruits and vegetables, and to educate populations to consume them. Policy measures outlining responsibilities for the private sector were less frequently encountered (28%; 10/36) than those detailing actions to be implemented by the government (53%; 19/ 36) or targeting the general public (75%; 27/36). Policy Actions to Increase Physical Activity and Address Sedentary Lifestyle Public education and sensitization were the main strategies to promote physical activity in the policies (Table 4). Whereas countries such as Morocco , Mongolia , and Mauritius  targeted educational institutions, others, such as Bhutan , Guyana , and Malaysia , focused on workplaces. Samoa , the Niger , Indonesia , India , and Cambodia National Policies for Noncommunicable Diseases PLOS Medicine | www.plosmedicine.org 3 June 2013 | Volume 10 | Issue 6 | e1001465  targeted the community at large. Nine countries (Kenya , Morocco , Cuba , Uruguay , Jamaica , Brazil , Malaysia , the Philippines , and China ) proposed national policy targets for physical activity (Table 4). Four countries’ policy documents (Georgia , Mongolia , Mauritius , and Chile ) contained detailed actions and elaborated an implementation plan for stakeholders. The need to develop sports infrastructure and urban planning (e.g., bicycle lanes and recreational centers) featured in the policy documents of Georgia , the Republic of Moldova , Turkey , and Mongolia , for instance. Five countries (Mauritius , Brazil , Samoa , the Republic of Moldova , and Serbia ) mentioned the need to promote physical activity among the elderly. Only four countries (Bhutan , the Philippines , Cuba , and the Republic of Moldova ) outlined specific strategies to address sedentary lifestyles, and five (Turkey , Cambodia , Jamaica , Serbia , and India ) documented explicit actions to involve the private sector in the promotion of physical activity. Discussion Despite the global disease burden of NCDs in LMICs, policies that address at least one risk factor for NCDs were found in a minority of the LMICs reviewed, and only a handful of them comprehensively tackled NCDs through integrated action on various risk factors. Even if the 24 countries with unknown existence of a NCD prevention policy actually have such a policy, the proportion with countries tackling a risk factor would amount to 56% (78/140). This finding is discouraging, because in 2004, all countries expressed a strong commitment to action to address lifestyle, diet, and physical activity . Our results show that, in spite of that official commitment, most LMICs are poorly prepared to tackle the NCD increase and that little progress has been made in recent years. This finding is consistent with the results of Alwan et al. , who reported the results of a survey in 2010 that was limited to countries with high NCD-related mortality. Most of the policies in our review were poorly accessible and were only obtained after an extensive search or through personal contacts. Such a situation is certainly not favorable for bench- marking and communication of policies. In agreement with Sridhar et al. , we argue how better sharing of best practices and lessons learned with regard to policy development is needed to address the current NCD pandemic. Additional instruments and platforms to share lessons learned in policy development and implementation are needed. Policy databases with links to documents were created previously, but are restricted to nutrition action  or the European region . An open-access, full-text global repository of initiatives and policies to address NCDs would be a great step forward. It could also contribute to global leadership and shared accountability in the global fight against NCDs, an issue that is long overdue . Ideally, such a policy database would be connected to surveillance data on the main NCD risk factors, as suggested previously , and would facilitate tracking progress in the coming years. We are ready to organize such an open-access repository and invite interested policy makers to contact us for an update of the current database. Priority setting and clear articulation of what needs to be done by stakeholders is a second key issue that emerged in this analysis. Countries seasoned in the fight against NCDs develop compre- hensive strategies that focus on critical risk factors and what is Figure 1. Coding tree for policy actions analyzed in the documents. doi:10.1371/journal.pmed.1001465.g001 National Policies for Noncommunicable Diseases PLOS Medicine | www.plosmedicine.org 4 June 2013 | Volume 10 | Issue 6 | e1001465 Figure 2. Selection process of nutrition, noncommunicable diseases, and health policies from low- and middle- income countries. The WHO classification of regions and allocation of countries was used. AFR, African Region; AMR, Region of the Americas; EMR, Eastern Mediterranean Region; EUR, European Region; SEAR, South-East Asia Region; WPR, Western Pacific Region. "Mayotte, West Bank and Gaza, the Republic of Kosovo, and American Samoa. *Antigua and Barbuda, Egypt, Dominica, Democratic People’s Republic of Korea, Sao Tome and Principe, Dominican Republic, Micronesia, Gabon, Tonga, Kyrgyzstan, Lebanon, Libya, Algeria, Iraq, Lithuania, Palau, Marshall Islands, Uzbekistan, Yemen, Romania, Saint Kitts and Nevis, Syrian Arab Republic, Turkmenistan, and Comoros. 1Policy issued before 2004: Belize, Venezuela, Bosnia and Herzegovina, Eritrea, Lesotho, Papua New Guinea, Albania, Armenia, Burundi, Ecuador, El Salvador, Kiribati, Namibia, Sierra Leone, Gambia, Zimbabwe, Somalia, United Republic of Tanzania, and Vanuatu; policy not officially endorsed: Democratic Republic of the Congo, Senegal, and Tuvalu; no policy : Chad, Congo, South Africa, and Tajikistan; policy was available but could not be publically distributed: Central African Republic, Cameroon, and Tunisia; policy reported to be available  but could not be obtained: Azerbaijan, Belarus, Kazakhstan, and Ukraine. doi:10.1371/journal.pmed.1001465.g002 National Policies for Noncommunicable Diseases PLOS Medicine | www.plosmedicine.org 5 June 2013 | Volume 10 | Issue 6 | e1001465 expected of stakeholders . In the present analysis, the level of detail and outlining of the organization of policy actions to undertake was generally discouraging. Only a minority of the policies reviewed surpassed description of policy actions and included a budget, implementation plan, time frame, and devolvement of responsibility for strategies to combat specific risk factors. Various policies describe strategies and actions for NCD prevention as ‘‘the need to develop and review dietary guidelines and recommendations for people suffering from nutrition-related NCDs’’ or use generic statements such as ‘‘create awareness of healthy eating lifestyle to control NCDs.’’ Such general statements are not informative, and clear actions need to be outlined in the policies to mobilize stakeholders for effective action . Since its inception during the 1992 International Conference on Nutrition , the approach to streamline nutrition action in national policies has had limited success, partly because of the lack of strong leadership and commitment to lead concerted action involving various stakeholders . The current scientific evidence and international experience in the fight against NCDs consis- tently indicates the need for comprehensive and integrated action on various risk factors . Mobilization of the main actors—in particular, governments, international agencies, the private sector, civil society, health professionals, and individuals—is imperative . An important limitation of most policies included in the analysis is the absence of plans, mechanisms, and incentives to foster multi-stakeholder and cross-sector collaboration. The food and nonalcoholic beverage industry, for instance, can play a role in the promotion of healthier lifestyles. However, before engaging with the private sector, government agencies should be aware of the need to manage potential conflicts of interest between the government and the private sector and should try to address these by defining clear roles, responsibilities, and targets to be achieved as a result of their collaboration . Most strategies encountered in the policies were directed towards government agencies and consumers, and few were targeted at the business community, international agencies, or civil society. The United Nations Political Declaration on NCDs makes a strong call for multi- stakeholder partnerships to be leveraged for effective prevention of NCDs. Policy makers in LMICs may need additional support for the development of multi-stakeholder collaborations to address the burden imposed by NCDs as well as their root causes. In our review of governmental policies relating to NCD prevention in LMICs, strategies to increase fruit and vegetable intake were the most frequent dietary action for NCD prevention. This is hardly surprising, as fruit and vegetable interventions were taken up early on in LMICs, primarily to address prevailing micronutrient deficiencies such as vitamin A deficiency . Many of these experiences, however, are restricted to the development of food-based dietary guidelines or incentives targeted towards the agricultural sector. Policy measures to achieve better diet will require constructively engaging much more with a wider range of stakeholders, in particular the food industry, retail, and the catering sector . The difficulty of developing a comprehensive policy response and integrated package of strategies is not restricted to NCDs alone, and has previously been observed in an in-depth analysis of high-burden countries for child malnutrition . We also note that various countries have developed strategies to reduce total fat intake, despite convincing evidence that it is the reduction of saturated and trans-fatty acids in particular, and not total fat intake, that is effective to address NCDs . Most strategies encountered in the policy documents focused on consumers and aimed to prevent NCDs through awareness creation, education (i.e., labeling), or changing individuals’ behavior. The traditional approach to addressing lifestyle changes in individuals has met with very limited success. It is widely accepted that the environmental context drives individual diets and lifestyle  and that programs need to incorporate Figure 3. Atlas of availability of national actions to limit salt or fat intake or increase fruit and vegetable intake or physical activity. Geographic boundaries from the United Nations Cartographic Section were used . doi:10.1371/journal.pmed.1001465.g003 National Policies for Noncommunicable Diseases PLOS Medicine | www.plosmedicine.org 6 June 2013 | Volume 10 | Issue 6 | e1001465 Table1.NationalpolicyactionsandtargetstolimitsaltintakeinLMICsbyWHOregionandtargetgroup. TargetGroupAfricanRegionEasternMediterraneanRegionEuropeanRegion Regionofthe AmericasSouth-EastAsiaRegionWesternPacificRegion Generalpublic andconsumers Mauritius:Public educationonfood labelingand moderatesalt intake Sudan:Promotereductioninsaltintake; Djibouti:Promotereductionofsaltintake; Iran:Addresspoordietaryhabitsand reducetheconsumptionofsalt;public educationthroughTVregardinglowsalt consumption Bulgaria:Enforcelower saltintakeinschool canteens;Bulgariaand theRepublicofMoldova: Educateonsaltintake reduction;Serbia:Increase intakeoffoodwithhighratio ofpotassium/sodium JamaicaandCuba: Publiceducationto reducesaltintake Bhutan:Publiceducationonsalt intakereduction,targetingschool children;Indonesia:Public educationonsaltintakereduction targetinghigh-riskgroups; promotionoflow-salteating habits MalaysiaandMongolia:Public educationonsaltintake reduction;Malaysia:Encourage thepublictouselesssaltand choosefoodslowinsalt GovernmentEthiopia:Enforce foodstandardsand saltlegislation; Mauritius:Amend foodregulations toincludesignpost labelingand enforcetrafficlight signpostlabeling withreferenceto saltcontent Sudan:Proposetaxesonsaltyfoods; Jordan:Developnational recommendationsforthereduction ofsaltintake Bulgaria:Introduce standardsforupperlimits ofsaltforsomefoods; introducetaxesandfiscal measuresonhigh-salt foods;Montenegro: Developmentofguidelines forfoodproductionwith loweredcontentofsalt; Serbia:Mandatorylabeling ofsodiumcontentand potassium/sodiumratiofor foodproducers;harmonize recommendationfor reductionofsaltin processedfood Jamaica:Promote productionandsaleof foodswithlesssaltand theconsumptionof productslowinsalt; Honduras:Strengthen foodlabelingpoliciesfor salt;Brazil:Agreement andpartnershipbetween theproductionsectorand thepublicsectorto preventNCDsby promotingsaltreduction, toreachthesuggested nationalgoalsonreduction ofsalt;Colombia: Disseminate,monitor,and regulatethenutritional labelingoffoodsto controltheamountof saltinprocessedfoods Bhutan:Establishguidelinesto controlmarketingand advertisementofsaltyfoods Mongolia:Reviewandupdate legislativeactsandstandardsto promoteproduction,sale,and importationoflow-saltfoods; coordinateforeigntradepolicyto supportdecreaseinsaltintake; Philippines:Developand implementhealthpromotion activitiesforahealthydietthat limitssaltintakefromallsources; Cambodia:Incorporatenutrition messagesrelatedtolowsalt intakeinthecurriculum;develop standardsforschooland universityvendors;China: Developandpromotehealthy foodswithlowsaltcontent PrivatesectorMauritius:Train foodindustryand stakeholderson enforcementof foodlabelingwith referencetosalt content Iran:Improvenutritioninpublicplaces throughpoliciesforreducedsaltinfood industriesandrestaurants;sensitizefood producersregardingthereductionof saltinfoodproducts Bulgaria:Producefoods withreducedsaltcontent; FYRM:Changeformulation offoodstoreducesalt content Brazil:Regulatethe nutritionalcomposition ofprocessedfood; establishanagreement withtheproduction sectorandapartnership withthecivilsocietyto preventNCDsandreduce saltinfood;reducesalt inindustrializedfoodby 10%peryearon voluntarybasis Indonesia:Collaboratewith stakeholdersforreductionof saltinprocessedfoods Mongolia:Collaboratewith stakeholderstoreducesalt contentofprocessedfoods Nationalsalt intaketarget Mauritius:Reduce nationalaverage sodiumintaketo ,5g/d NRBulgaria,Montenegro, andFYRM:Reducesalt intaketo,5g/d;Serbia: Limitintakeofsalt to,6g/d Cuba:Increasethe proportionofpeople whodonotaddsalt onthetableto95%; Brazil:Reduceaverage saltconsumption NRChina:Lowernationalaverage percapitaintakeofsaltto,9g WHOclassificationofregionsandcountrieswasfollowed. FYRM,theformerYugoslavRepublicofMacedonia;NR,notreported. doi:10.1371/journal.pmed.1001465.t001 National Policies for Noncommunicable Diseases PLOS Medicine | www.plosmedicine.org 7 June 2013 | Volume 10 | Issue 6 | e1001465 Table2.NationalpolicyactionsandtargetstolimitfatintakebyWHOregionandtargetgroup. TargetGroupAfricanRegionEasternMediterraneanRegionEuropeanRegionRegionoftheAmericasSouth-EastAsiaRegionWesternPacificRegion Generalpublicand consumers Mauritius:Public educationonfatintake reductionthroughdietary guidelinesandfood labeling;Seychelles: Publiceducationonuse ofpoly-and monounsaturatedfatsand reusingoils;oilsusedfor fryingshouldnotbe reusedonmorethan twooccasions,toreduce intakeoftrans-fattyacids Pakistan:Initiatecommunity-based behaviorchangecommunication strategiestocontrolhighfatintake; Jordan:Organizecampaignsforthe importanceoflow-fatfood;Iran: Addresspoordietaryhabitsand reducetheconsumptionoffatsand oils;promotetraditionalmethods offoodpreparationandcookinge.g., useofliquidoilanddiscouraging foodfrying Bulgaria:Promote productswithlow contentoffats,saturated fattyacids,trans-fatty acids,andcholesterol; Bulgariaandthe RepublicofMoldova: Educationonfatintake reduction Jamaica:Marketalternative productsofhigh acceptabilitywithlowerfat content;labelingof productstopermit informedchoicesby consumers;promotethe consumptionofproducts lowinfat;SaintVincent andtheGrenadines: Publiceducationonfat intakereduction Bhutan:Publiceducation onfatintakereduction targetingschoolchildren, dietaryguidelines,food labeling,advertising,and marketing,toreducetrans- fattyacidandsaturatedfat intake;Indonesia:Public educationonfatintake reduction;promotionof low-fateatinghabits MalaysiaandMongolia:Public educationonfatintakereduction; reduceconsumptionoffriedand conservedfood;Mongolia: Provideintensiveinformation, education,andcommunication activitytowardsreducing consumptionofanimalfat; Malaysia:Encouragepeopleto minimizefatinfoodpreparation andchoosefoodsthatarelowin fatandcholesterol GovernmentMauritius:Healthy eatingandgoodnutrition isincludedinthe curriculumofbasic schoolstodiscouragethe consumptionoffood itemscontaininghigh levelsofoilsandfats;the NutritionTaskforceto commissionastudyinto thereuseofcookingoils andproposelegislative measurestoreducetrans- fattyacidintake;deep fryingoffoodsinoils and/orfatswillbe discouragedandwillbe excludedfrom governmentalfood servicesandgovernment functions Pakistan:Developpoliciesand strategiestolimittheproduction andaccesstogheeasamediumfor cooking;Jordan:Developnational recommendationsfortotaland saturatedfatintake;Iran:Develop andpublisheducationalmaterials regardingoil,itsusage,andthe disadvantagesofsaturatedand trans-fattyacidsforhealth personnelandotheremployees Bulgaria:Introduction ofstandardsforupper limitsoffats,saturated fattyacids,andcholesterol forsomefoods;develop dietaryguidelinesto promotelow-fatmeat productsandlow-fatmilk anddairyproducts; Montenegro: Developmentof guidelinesforfood productionwithlowered contentoffat;Serbia: Harmonize recommendationfor reductionoffatin processedfood Brazil:Setgoalsto reformulateprocessed foodbyreducingfat content;disseminateand monitoragreementsand partnershipsbetweenthe privatesectorandthecivil society,toreachthe suggestedgoalson reductionoftransfat Bhutan:Establishguidelines tocontrolmarketingand advertisementoffattyfoods, especiallytochildren;increase taxonfooditemsthatare healthharming;restrictfast foodlicenses Mongolia:Improvecontrolon nutritionqualityandfatcontent ofimportedfoodproducts,and createlegislativeenvironmentto promotehealthyfoodproducts bytaxationpolicy;update, approve,andimplementfood standardswithreducedlevelof fatcontent,i.e.,areductionof animalfatconsumption;promote healthydietbyreviewingand updatingfoodstandardsinorder toreducefatintake;coordinate andmonitorforeigntradepolicy inordertosupportconsumption oflow-fat-contentfood;China: Developandpromotehealthy foodswithlowfatcontent; Philippines:Developand implementhealthpromotion activitiesforahealthydietthat limitsenergyintakefromtotalfat andshiftssaturatedfatto unsaturatedfatandtowardsthe eliminationoftrans-fattyacids; Cambodia:Incorporatenutrition messagesrelatedtolowsaturated fatintakeinthecurriculum; developstandardsforschooland universityvendors;study potentialforsubsidieson vegetableoils National Policies for Noncommunicable Diseases PLOS Medicine | www.plosmedicine.org 8 June 2013 | Volume 10 | Issue 6 | e1001465 Table2.Cont. TargetGroupAfricanRegionEasternMediterraneanRegionEuropeanRegionRegionoftheAmericasSouth-EastAsiaRegionWesternPacificRegion PrivatesectorMauritius:Trainfood industryand stakeholderson enforcementoffood labelingwithreference tofatcontent Iran:Improvenutritioninpublic placesthroughpoliciesforreduced fatinfoodindustriesandrestaurants; increasetheproductionoflow-and zero-fatproducts(i.e.,dairysector) infoodindustry Bulgaria:Producefoods withlowcontentoffats, saturatedandtrans-fatty acids,andcholesterol; FYRM:Changecontent offoodstoreduce saturatedfattyacids andtrans-fattyacids NRNRMongolia:Encouragefood industryandcateringtoproduce andservefoodsthatdecreasethe consumptionofanimalfat Nationalfatintake target Mauritius:Decrease thenationalconsumption ofoilsandfatsby10% within5y NRBulgaria:Reduce populationfatintake to30%oftotalenergy; FYRM:Reducesaturated fatto,1%aoftotal energyintakeand trans-fattyacidsto,1% ofenergyintake; Montenegro:Reduce intakeofsaturatedfats to,10%andintakeof trans-fattyacids to,1%oftotalenergy intake NRNRMalaysia:Decreasethe proportionofpeoplewithdietary fatintake.30%oftotalcalories, comparedtotheFirstMalaysian FoodConsumptionSurvey;Viet Nam:Proportionofhouseholds withadietwith14%ofprotein, 16%oflipidsand5–68%of carbohydratesis50%by2015and 75%by2020 WHOclassificationofregionsandcountrieswasfollowed.Fourofthecountries(Mayotte,WestBankandGaza,theRepublicofKosovo,andAmericanSamoa)classifiedasLMICsbytheWorldBankin2011werenotWHO memberstatesin2011. aThepolicydocumentofFYRMreportsthatgoalsareinlinewiththoseofWHO.Thestatedgoalof,1%oftotalenergyintakefromsaturatedfatisthereforelikelymeanttobetheWHOgoalof10%. FYRM,theformerYugoslavRepublicofMacedonia;NR,notreported. doi:10.1371/journal.pmed.1001465.t002 National Policies for Noncommunicable Diseases PLOS Medicine | www.plosmedicine.org 9 June 2013 | Volume 10 | Issue 6 | e1001465 Table3.NationalpolicyactionsandtargetstoincreasefruitandvegetableintakebyWHOregionandtargetgroup. TargetGroupAfricanRegion EasternMediterranean RegionEuropeanRegionRegionoftheAmericas South-EastAsia RegionWesternPacificRegion GeneralpublicLiberia:Diversifydietto improvenutritional quality,throughpromoting consumptionof micronutrient-densefood andFVtocomplement staplefoods;Malawi: Promoteschoolgardens andcookingdemonstrations inallpublicprimaryschools; developurbanagriculture andsmallgardensat homesteadsandschoolsto produceFVandother nutritionalproduce;organize community-level demonstrationsofpreparation andconsumptionoflocally availablenutritiousfoods, suchasindigenousFVand legumestoreachatleast5 millionpeople;Mali:Promote consumptionofFVinthe populationtodiversifythe agriculturalproduction; Swaziland:Promotegrowing nutritiousfoodcropssuchas FVbyindividualsand communities;increasepublic educationandawareness aboutnutritionpractices; developurbanagriculture andsmallgardensat homesteadsandschoolsto produceFVandotherproduce; Angola:Increaseconsumption offoodsthatimprovedietary patterns,suchasFV,andof traditionalfoods;Rwanda: PromoteconsumptionofFV athouseholdlevel;Guinea Bissau:Promoteproduction ofvegetablestodiversitycrop productionandincreasethe consumptionoffoodsrichin micronutrients;Ghana: PromoteFVproductionin household,school,and communitygardensand institutions Djibouti:Promotefamily orchardsandthe consumptionofFV; Jordan:Organize campaignsforthe importanceoflow-fat foodsuchasFV;Iran: Addresspoordietaryhabits andpromoteconsumption ofFV Bulgaria:Stimulateand supportlocal(ruralandurban) productionofFV,planting orchards,andthegreenhouse productionofvegetables; RepublicofMoldova: Developandpopularizethe nationalnutritionpyramidto reduceconsumptionofrefined foodsandincreaseconsumption ofFV;Montenegro:Support andoffersimulativemeasures forproductionofFVandto ensurequality,availability, andsupply Jamaica:Promoteanincreased consumptionofFV;promote consumptionofFVwithout excessincreaseinbodyweight intheyoungchildandadolescent population Bangladesh:Promote homesteadgardening, includingFVfarming, socialforestry,livestock andbackyardpoultry, inhomesteadareasin flood-freeyears; Bhutan:Health promotion,community- basedprograms,and mainstreamingof controlandprevention ofNCDsinearlylearning centers,schools, universities,and monasticinstitutionsto increaseconsumer demandforfruit; Indonesia:Promote theconsumptionofFV; assurefoodresilience onfamilyandindividual levels,withsufficient stockandaccesstofood andbalancedandsafe nutrition,includingFV commodities;increase socializationand advocacyfor consumptionofFV; SriLanka:Produce carotene-richFVin homesteads;encourage nutritiousbreakfast andsnackorfruitduring theschoolbreak; guidelinesforschool canteenstoprovidelow- cost,nutritious,clean,and wholesomefood,including localfruit;encourage growthofcarotene-rich FVinalleducational institutions;Nepal: Promotehomeproduction gardensforfruit production;India: Promotefruitsandleafy vegetablestodiversify foodforchildrenand adolescents,especially girls;promotionof community-and household-level productionofFV Fiji:Encourageandsupport sustainablecommunity-basedhealthy foodproductiontoincrease consumptionofFV;Malaysia: Promotedietarydiversificationto increasepromotionactivitiesfor micronutrient-richfoods,includingFV; Mongolia:Provideinformation, education,andcommunication activitytowardsacquiringhealthydiet behavioramongpopulationby increasingFVintake;Samoa:Promote increasedintakeofFV,e.g.,FV gardening;assistgovernmentwomen representativesinencouraging villagerstoproducevegetable gardensfornutritionpurposesand healthydiets;workwithschool canteens;VietNam:Promotionof dailyconsumptionofvegetables; Cambodia:Offerhomestead gardeninganddevelopschool vegetablegardens;encourage communityleaderstodeveloplocal solutionssuchascommunityFV gardens National Policies for Noncommunicable Diseases PLOS Medicine | www.plosmedicine.org 10 June 2013 | Volume 10 | Issue 6 | e1001465 Table3.Cont. TargetGroupAfricanRegion EasternMediterranean RegionEuropeanRegionRegionoftheAmericas South-EastAsia RegionWesternPacificRegion GovernmentLiberia:Expandproduction andmarketingofnutritious vegetablestoincreasefood availabilityandaccess throughdirectconsumption, sales,andincome; Madagascar:Improveand diversifyfoodcropproduction incommunitynutritionsites, inparticularinfood-insecure zones,bypromotinghome gardens,fruittrees,etc.; Malawi:Facilitateeconomic empowermenttoincrease householdandcommunity accesstofoodresources;setup aFVpromotioninitiative; increasetheavailabilityofFV atnationallevel;Mauritius: Establishdietary recommendationsforadultsfor thepreventionofNCDs:400 gofFVperday;launchFV consumptioninitiativeto ensureintegratedapproach usingdifferentaspects,such asproductionavailability;tea breaksatgovernmental functionswillbereplacedby healthbreaksusinghealthy alternativessuchasfruitsand nuts;Swaziland:Improve marketingofmaizeandFV; developandpromote sustainableproductionand processingofindigenousnon- timberforestproducts,e.g., ediblefruit;Seychelles: Developguidelinesand recommendationsforfreshFV Jordan:Developnational recommendationsforthe consumptionofFV Bulgaria:Stimulateand supporttheestablishment ofbetterconditionsfor productionandadequate storageoflocalFVtosupply communitiesduringthewhole year;assistinmarketing; provisionofseedlings, information,andfree consultations;establishlocal networksforthedistribution oftheproducedvegetables andplants;FYRM:Improve availabilityandaccesstoFV throughrevisedagricultural policies Colombia:thecomplianceof regulationandnutritionlabeling offoodandpromoteconsumption ofFV(visiblelabelsandother reinforcements);Cuba:Increase theavailabilityofFVandfollow thetrendofconsumerpriceindex; Brazil:Encouragefiscalmeasures toreducethepriceofhealthy foodssuchasFVandincrease theirconsumption Bhutan:Develop policiesencouraging ruralpopulationto increaseproduction andavailabilityofFV ataffordableprices; developpoliciesand strategiestoenhance productionofFVand toensurefoodsecurity, especiallyforpoorand marginalizedgroups; Bangladesh:Promote efficientuseofavailable land,agriculturalinputs, andwaterusefor irrigationandfor productionoffruit; supportappropriate researchandagricultural loans;Maldives:Expand theagriculturesectorto meethouseholdand localdemandforFV Malaysia:Developrecipebooksfor vegetablestoincreasefiberintake; Philippines:Developandimplement healthpromotionactivitiesforhealthy dietandincreasedconsumptionofFV; Cambodia:Incorporatenutrition messagesrelatedtoincreasedFV consumptioninthecurriculum; developstandardsforschooland universityvendors;Mongolia: Coordinateandmonitorforeigntrade policyinordertosupport consumptionofFV PrivatesectorLiberia:Diversifyfood produced,includingFVand livestock;Mali:Improvethe transportofperishablefoods suchasFV;Mauritius: PromoteFVincollaboration withotherstakeholdersto allowanintegratedapproach withproduction,availability, andpromotion NRBulgaria:Mandatory inclusionoffreshFVandmilk ordairyproductsinthedietof childreninkindergartensand cre `ches;strictcontrolon provisionatschoolcafeteriasof fresh,seasonalFV,milk,yogurt, andmilk/yogurt-baseddrinks Brazil:Stimulateconsumption ofhealthyfood,suchasFV Bhutan:Encourage farmerstoconsumeand growFVusingorganic fertilizersandenhance incomegeneration throughsaleofsuch products;SriLanka: Encouragecateringsector tofollowdietaryguidelines andtoofferfoodssuchas kurakkanandbreadfruit; Indonesia:Increasethe consumptionofvegetables by4.5%andfruitsby5% peryear Fiji:Encourageproperprocessingof localfoodandFV;Mongolia: Encouragefoodindustryandcatering toproduceandservefoodsthat increaseFVconsumption National Policies for Noncommunicable Diseases PLOS Medicine | www.plosmedicine.org 11 June 2013 | Volume 10 | Issue 6 | e1001465 Table3.Cont. TargetGroupAfricanRegion EasternMediterranean RegionEuropeanRegionRegionoftheAmericas South-EastAsia RegionWesternPacificRegion PolicytargetsMauritius:Increasethe consumptionofFVby 2-fold($400g/d);increase availabilityofFV,preferably bylocalproductiontoensure freshnessofproduce; Seychelles:Everymeal shouldcontainatleast100g ofFV;FVshouldbeservedin anappealingandeasy-to-eat way;asmuchaspossible, vegetablesshouldbeserved freeofaddedoilorfat; Angola:Intensifyactions thatpromoteproductionof foodsrichinvitamins, particularlytraditional vegetables,animalorigin products,andrevenue- generatingproduce;Malawi: Promotebackyardgardens andplantingoffruittrees; promoteconsumptionof adequatefoodinquality andquantitytomeetthe nutritionalneedsforrural andurbanhouseholds,with specialemphasison vulnerablegroupsand low-incomehouseholds; promoteconsumption andavailabilityofFVinthe guidelines NRBulgaria:Increasethe consumptionofFVinwinter andspringupto400gdaily; ensureproperstorageofFVin winter;constructlocal storehousesforFVandprovide accesstothemforsmallfarms; RepublicofMoldova: Promotetheconsumption ofFVandotherfoods;FYRM: Averageintakeofatleast500g ofFVdaily;Montenegro: IncreaseFVavailability;increase consumptionto.400g/d Cuba:Increasetheproportion ofthepopulationconsumingat least200gofFVby40%and consumingatleastthreeportions ofvegetablesperdayor300gby 50%;Jamaica:A20%increasein consumptionofFVbyDecember 2008;Brazil:IncreaseFV consumption Indonesia:Increase consumptionofFV daily;Bangladesh: Increaseproduction ofnoncerealcrops (FV,oilseeds,pulses) Fiji:IncreaseintakeofFVand promotehealthyandsafedietsto reduceNCDs;Malaysia:Diversify dietstoincreasetheconsumptionof micronutrient-richfoodsincludingFV; increaseproportionofpeople consumingFV;Mongoliaand Samoa:Increasetheconsumptionof FVbyhouseholds;Philippines: Increasepercapitatotalvegetable consumptionfrom111g/dto133g/d WHOclassificationofregionsandcountrieswasfollowed.Fourofthecountries(Mayotte,WestBankandGaza,theRepublicofKosovo,andAmericanSamoa)classifiedasLMICsbytheWorldBankin2011werenotWHO memberstatesin2011. FV,fruitsandvegetables;FYRM,theformerYugoslavRepublicofMacedonia;NR,notreported. doi:10.1371/journal.pmed.1001465.t003 National Policies for Noncommunicable Diseases PLOS Medicine | www.plosmedicine.org 12 June 2013 | Volume 10 | Issue 6 | e1001465 Table4.NationalpolicyactionsandtargetstopromotephysicalactivitybyWHOregionandtargetgroup. Target Group African Region Eastern Mediterranean RegionEuropeanRegionRegionoftheAmericasSouth-EastAsiaRegionWesternPacificRegion General publicand consumers Ghana: Encourage regular exercisea; Mauritius: Emphasize maintaininga healthyweight byundertaking adequatePAin thedietary guidelines; Niger:Promote healthylifestyles infamiliesand communities sothatsport andrelaxation arewidespread in neighborhoods; Kenya:Train healthworkers onPA;organize sensitization meetingonPA incounties Djibouti:Promote PAandthecreation ofplaygrounds; Morocco:Promote PAinschoolsand universities Georgia:Makeschoolsportsfacilitiesavailablefor publicuse;providenationwideevidence-basedadvocacy onthehealth,social,andeconomicbenefitsofPA;create anenvironmentconduciveforPA;urbanplanningpolicy choicesshouldinclude:planforstadia,safewalkingroutes, safecyclingroutes,sheltersfrompoorweather,and recreationalfacilities;RepublicofMoldova:Population- widecommunicationtopromotePA,includinginelderly andsedentarypopulation;Turkey:Providecorrect informationtothepublicbywrittenandvisualmediaon activelifeandobesity;FYRM:Recommendationsfor propernutritionarealwaysfollowedbyrecommendations forPA;Montenegro:Supportlocalgovernmentin designingmodelsforPAfacilitiesandbuildingofsafe roadsforbikersandpedestriansinsettlements;conduct educativeprogramsontheimportanceofPAinschool curriculum;Serbia:PromoteandimplementPAin everydaylifeinpopulation Chile:PromotePAatworkplaces, disseminatePAguidelinestothe population,preschoolandschool children;CostaRica:Promotehealthy lifestylesandPAandrecreation;Cuba: Promoteintersectoralparticipationin systematicPAattheworkplaceand intersectoralparticipationinsystematic PAinthegeneralpopulation;Guyana: PromotePAincommunitiesandschools; Uruguay:DevelopguidelinesforPA andlifestyleforthegeneralpopulation; Guatemala:Applystrategiesand measurestopromotegoodhealththat includePA,especiallyintheworkplace andschools;multisectoralworkshopsfor theformationoflocalandnationalPA networks;Brazil:Promoteactiveaging, e.g.,throughprivatehealthplans,and encouragetheelderlytoengagein regularPA;encouragePAinchildren onaneverydaybasisandthroughout life;promoteleisurePAandhealthy lifestyleforchildrenandyoungpeople; guidelinespromoteprovidingtwo physicaleducationclassesaweekat schools;communicationandeducation campaigntopromotehealththrough PA Bhutan:Advocateatthe populationlevelforPAin theworkplace;encourage walkingandregularphysical exercise,withafocusonthe urbanandmoresedentary population;increasePAat thepopulationlevelby enhancingunderstanding amongthegeneralpublic thatmorePAleadstobetter health;Indonesia:Increase understandingofthebenefit ofPA;increasePAofpeople throughincreaseof promotion;increasein provisionsofmeansand facilitiesofsportsandopen space,intheframeof creatingawarenessatall levelsofsociety;SriLanka: CreateofawarenessonPA; promotinggreaterPAamong schoolchildrenandadults willalsoreducetheriskof chronicdegenerative diseases;provisionof facilitiesforoutdoor recreationandmakingall roadssafeforpedestrians andcyclists;India:Physical educationtobebuiltinto theschoolsystem;creation ofsportsinfrastructureat grassrootslevelinruraland urbanareas;revisionofthe sportspolicyandactionplan andservices;involvementof corporatesector Mongolia:Introducebasic knowledgeaboutPAinto curriculumofsecondaryschools; population-widepromotionofPA; Samoa:PAisoneofthefourhigh- riskareasidentifiedtofocuson throughhealthpromotion programs;emphasisoncommunity groups,women’scommunities,and governmentworkerstosupport healthylifestyle,includingPA; promotePAinelderlyhomes; SolomonIslands:Assist individualswhohavebeendisabled bydisease,traumaticinjury,orother causestoachievetheirmaximum potentialintermsofPA;promote maintenanceofbodyweightby balancingfoodintakewithregular PA;Malaysia:Promotephysical fitnessactivitiesforthegeneral populationattheworkplace; Cambodia:Publicawarenessof healthylifestyles,andlackofPAasa riskfactor,inparticularinwomen; encouragecommunityleadersto developlocalsolutionssuchas walkinggroupsorgreenspace; China:Ensurethatprimaryand secondarystudentsparticipateinat least1hofphysicalexercise activitiesduringtheschoolday;the communitiesshallactivelypromote theworkingmodelofhealthy lifestyleinstructorsandsocialsports instructors National Policies for Noncommunicable Diseases PLOS Medicine | www.plosmedicine.org 13 June 2013 | Volume 10 | Issue 6 | e1001465 Table4.Cont. Target Group African Region Eastern Mediterranean RegionEuropeanRegionRegionoftheAmericasSouth-EastAsiaRegionWesternPacificRegion GovernmentGhana:Make PAeducation mandatoryin allschoolsa; Mauritius: Ministriesof healthand financewill collaborateto haveastrong focusonPA amongthe elderly; Madagascar: Developa policyforthe preventionof NCDswithPA recommendations Morocco:Advocate forpublicspaceand anenvironment conduciveforPA; Jordan:Developa nationalstrategyfor thepromotionof exerciseandPA: developmultisectoral committeeforPA; Iran:IncreasePAto preventandcontrol overweightand obesityinstudents Georgia:DeveloplocallegislationandpolicytosupportPA; healthsectortotaketheleadingroleinmakingpolicy decisionsbydevelopingaction-orientednetworkswithother relevantsectorsandstakeholdersonPA;allocateaproportion ofsportfundstopromotingPA;RepublicofMoldova: ExtendurbanpublicgreenspaceandspecialgroundsforPA forthepopulation;revivalofregularshortbreaksinschools andworksitesandencouragementofPAthroughcurricula andsupport;Turkey:Establishprovincialcoordination centersforObesityPrevention,NutritionandActiveLife Boardin81provinces;mainstreamobesity-fightingstrategies innationalhealthstrategiesandpolicies;preparenationalPA guidelines;improveeducationprogramrelatedtoPAinthe educationalsystem;improvetheenvironmentforPAinthe educationalsystem;formationofsportsfacilitiesand recreationalareaswithinthebudgetpossibilities,withthe leadershipoflocaladministrations,formakingthePAinthe publicwidespread;developmentofPAapplicationsthatcan beeasilyappliedinsidethehouse;FYRM:Increasepossibility forPAthroughintegrationofPAineverydaylife,e.g.,in kindergartens,schools,andworksites;supportforlocal authoritiesforrecreationalinfrastructureandeliminationof barriersforPAtransport;Montenegro:Localgovernments provideconditionsfordevelopmentofinfrastructureand facilitiesforPA:swimmingpools,playgrounds,parks,and cyclingandwalkingpaths;conductactivitiestoward developmentofconditionsforcyclingandwalkingintraffic; developmentofprogramsforPAinkindergartens,schools, anduniversities;awarenesscreationinmedia;Serbia: PerformmoderatePAaccordingtonationalguidelines; promotePAinchildren,adolescents,adults,elderly individuals,healthyindividuals,andpatientswith cardiovasculardisease;upgradeprogramsforPAin schoolcurriculum;educatemedicalandPAprofessionals onPAforpatientswithcardiovasculardisease;develop andenforcethecollaborationbetweengovernmentand NGOsinimplementationofPArecommendations; governmentandNGOcampaign‘‘SportforEveryone’’ Chile:DeveloppopulationPA guidelines;Guyana:IntroducePA asanexaminablesubjectinall schoolsby2010;Jamaica:Establish healthycommunitiesthatare conduciveforcommunitymembers tobephysicallyactive;provide opportunitiesforchildrenandyouth toparticipateinsupervisedafterschool sportsactivities;establishpolices, laws,andregulationssupportiveof aPAlifestyle,andsupportive environmentinschools,placesof work,andcommunities;develop guidelinesonphysicaleducationand sportsfortargetgroup;includePA asacomponentofchronicdisease managementatgovernmentclinics; improveandevaluatefacilitiesfor engaginginPAinhealthservices; designlifeskillsprogramforschools, communities,andworkplaces coveringallaspectsofhealthy lifestyles,includingPA;provide clean,safe,andgreenopenspace forallcommunitymembersto participateinPA;Brazil:Promote population-widePA;promote buildingofhealthyurbanspaces Bhutan:Establishnational standardsforPA;establish aPAActtoregulatethe builtenvironmentthat supportsactiveliving; MinistryofHealthwill collaboratewithDratsang tointegrateinformation andtrainingsessionson PA;developeducation materialsforcurricula aimedatencouraging PAinchildren,and providesupportive environments;SriLanka: Reactivateyouthclubs, sportsclubs,andyoung farmersclubsoasto promotePA;awareness programonPAfor employeesininstitutions andalsopromotionof importanceofPAthrough massmedia Mongolia:Developandenforce trainingprogramofinformaland distancelearningonPA;develop population-specificPAguidelines andstandards;provideadvicefor promotionalmeasuresofphysical cultureandactivemovement;create taxmeasuresandmarketincentives directedtowardspromotionofPA; improveaccessibilityandqualityof sports-relatedroads/areasand sportsequipment/facilitiesand improvetheirsafetylighting;Viet Nam:Developphysicalexercise programsfrompreschoolto undergraduateeducation; Philippines:Developand implementhealthpromotion activitiesforPA;regulatethebuilt environmenttopromotePA; Cambodia:Developpresentation materialsonPA;reviseschool curriculumforPAandpromotionof womeninsports;provideadequate sportsfacilitiesforschoolchildren anduniversitystudents;collectdata onavailabilityofcyclewaysand publicparks;developlocal strategiestopromotePA;China: Activelycreateasportsandfitness environment;strengthenscientific guidanceonmasssportsactivities; graduallyincreasetheaccessibility andutilizationofvariouspublic sportsfacilities;enhance environmentqualitymonitoringand evaluation;buildahealthy environmentandpromoteregular exercise Private sector NRNRTurkey:IncreasetheknowledgelevelregardingPAat theworkplace;Serbia:Institutionalorganizationofsport andrecreativeoccasions,e.g.,organizesportorrecreative contestsforworkersorpensioners Jamaica:Establishsupportivenetworks andallianceswiththeprivatesector andcreateapartnershipwiththemedia topromotethevalueofPA;Brazil: Establishagreementswiththeproductive sectortoimplementprogramsonPA, suchastheAcademiadaSaude India:Involvementof corporatesectorto establishasportculture Cambodia:Involvesports personalitiesandmediatopromote PA National Policies for Noncommunicable Diseases PLOS Medicine | www.plosmedicine.org 14 June 2013 | Volume 10 | Issue 6 | e1001465 environmental determinants (i.e., the quantity, quality, or price of dietary choices, or the built environment for physical activity) in order to be effective. Such policy measures, in particular those addressing the private sector, were poorly elaborated in the policy documents . A key issue is the actual implementation of policy measures in relation to what was articulated in the documents. The findings of this review indicate that few LMICs have made significant steps in the development of a comprehensive set of strategies to address NCDs. Although an in-depth evaluation of actual implementa- tion, effects, and resources allocated has not been opportune to date, we hope that our findings provide baseline data and encourage countries to develop monitoring and evaluation mechanisms to assess policy response in due time. Documenting the effectiveness of population-based NCD prevention policies will be a critical factor of success to ensure effective action in LMICs . For this review, we were able to assess documents in all languages received. Because of language constraints, however, two of the documents [74,87] were coded by only one researcher. To assess the content of the policy of Iran, we relied on translations by experienced senior Iranian researchers. All other policy documents were obtained in Spanish, Portuguese, French, or English and were analyzed accordingly by the research team. For China and the Russian Federation, appropriate English versions of the policies were obtained from the Chinese Centers for Disease Control and the United States Department of Agriculture, respectively. Despite indications of availability of relevant policies in the European region , language limitations did not allow us to search the websites of a number of countries such as Azerbaijan, Belarus, and the Russian Federation. The restriction of our review to only national policies presents a number of limitations. The mere presence or absence of policies or strategies for NCDs in a policy document does not necessarily reflect concrete action. Conversely, nutritional interventions have been implemented in some countries without a policy being developed and published . In addition, this review assessed the contents of the policy documents as they were published and did not capture local or regional activities, or initiatives that emerged after the publication of the policies. The findings from a survey in countries with a high burden of NCDs, such as Thailand and South Africa, illustrate this discrepancy . The contents might have been modified over time in response to new scientific findings, emerging nutritional challenges, or changes in the countries’ priorities . In addition, it is important to point out that we extracted only actions that explicitly referred to one of the risk factors analyzed. Generic statements such as ‘‘development of food-based dietary guidelines’’ or ‘‘establishment of fiscal measures for a healthy diet’’ were hence not coded. The present review shows that the policy response to address current NCD challenges through diet and physical inactivity in LMICs is inadequate since endorsement of the Global Strategy on Diet, Physical Activity and Health . LMICs urgently need to scale up interventions and develop integrated policies that address various risk factors for NCD prevention through multi-stakeholder collaboration and cross-sector involvement. Clear and prioritized actions are needed to harness the NCD epidemic. Such actions need to be documented in policy documents that are publicly available to share lessons learned, promote engagement with the stakeholders, and stimulate accountability and leadership in the fight against the burden of NCDs in LMICs. The establishment of an open-access and publicly accessible database of policy documents with regular systematic reviews of policy development might prove to be an incentive in this regard. Table4.Cont. Target Group African Region Eastern Mediterranean RegionEuropeanRegionRegionoftheAmericasSouth-EastAsiaRegionWesternPacificRegion National targetfor PA Kenya: Proportionof populationthat adoptsa healthydiet andPAis15% by2016/2017 Morocco:70% ofthegeneral populationand 80%ofchildren activeby2019 NRCuba:Increaseproportionofadults doingPAto40%anddecrease prevalenceofsedentarybehaviorin individuals$15yto32%;Uruguay: Average30minofmoderatePAper dayforadultsand1hforadolescents andchildren;Jamaica:40%increase inthenumberofpersonshaving moderatelevelsofPApracticedfor 30minperdaywithin4y;Brazil: Increaseleisure-timePAlevels NRMalaysia:Increasetheproportionof peopledoingatleast30minofPAper day,threetimesaweek,comparedto theFirstMalaysianFoodConsumption Survey;Philippines:Reductionin prevalenceofadultswithhighphysical inactivityfrom60.5%to50.8%;China: Increasetheproportionofthe populationwithregularexerciseto .32% WHOclassificationofregionsandcountrieswasfollowed.Fourofthecountries(Mayotte,WestBankandGaza,theRepublicofKosovo,andAmericanSamoa)classifiedasLMICsbytheWorldBankin2011werenotWHO memberstatesin2011. aObtainedfrom. FYRM,theformerYugoslavRepublicofMacedonia;NGO,nongovernmentalorganization;NR,notreported;PA,physicalactivity. doi:10.1371/journal.pmed.1001465.t004 National Policies for Noncommunicable Diseases PLOS Medicine | www.plosmedicine.org 15 June 2013 | Volume 10 | Issue 6 | e1001465 Supporting Information Alternative Language Abstract S1 Portuguese translation of the abstract by VC. (DOCX) Alternative Language Abstract S2 Spanish translation of the abstract by FMAS. (DOCX) Alternative Language Abstract S3 French translation of the abstract by DR. (DOCX) Table S1 Availability of national policy documents and strategies for noncommunicable disease prevention in low- and middle- income countries by WHO region. (XLSX) Text S1 Original review protocol. (PDF) Text S2 PRISMA checklist of the review. 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Available: http://www.un.org/Depts/Cartographic/map/ profile/world.pdf. Accessed 25 April 2012. 106. World Health Organization (2003) Diet, nutrition and the prevention of chronic diseases: report of a joint WHO/FAO expert consultation. World Health Org Tech Rep 916: 1–149. 107. Ghana Ministry of Health (2007) National health policy: creating wealth through health. Accra: Ghana Ministry of Health. 66 p. National Policies for Noncommunicable Diseases PLOS Medicine | www.plosmedicine.org 18 June 2013 | Volume 10 | Issue 6 | e1001465 Editors’ Summary Background. Noncommunicable diseases (NCDs)—chronic medical conditions including cardiovascular diseases (heart disease and stroke), diabetes, cancer, and chronic respiratory diseases (chronic obstructive pulmonary disease and asth- ma)—are responsible for two-thirds of the world’s deaths. Nearly 80% of NCD deaths, close to 30 million per year, occur in low- and middle-income countries (LMICs), where they are also rising most rapidly. Diet and lifestyle (including smoking, lack of exercise, and harmful alcohol consumption) influence a person’s risk of developing an NCD and of dying from it. Because they can be modified, these risk factors have been at the center of strategies to combat NCDs. In 2004, the World Health Organization (WHO) adopted the Global Strategy on Diet, Physical Activity and Health. For diet, it recommended that individuals achieve energy balance and a healthy weight; limit energy intake from total fats and shift fat consumption away from saturated fats to unsaturated fats and towards the elimination of trans-fatty acids; increase consumption of fruits, vegetables, legumes, whole grains, and nuts; limit the intake of free sugars; and limit salt consumption from all sources and ensure that salt is iodized. For physical activity, it recom- mended at least 30 minutes of regular, moderate-intensity physical activity on most days throughout a person’s life. Why Was This Study Done? By signing onto the Global Strategy in 2004, WHO member countries agreed to imple- ment it with high priority. A first step of implementation is usually the development of local policies. Consequently, one of the four objectives of the WHO Global Strategy is ‘‘to encourage the development, strengthening and implemen- tation of global, regional, national and community policies and action plans to improve diets and increase physical activity.’’ Along the same lines, in 2011 the United Nations held a high-level meeting in which the need to accelerate the policy response to the NCD epidemic was emphasized. This study was done to assess the existing national policies on NCD prevention in LMICs. Specifically, the researchers examined how well those policies matched the WHO recommendations for intake of salt, fat, and fruits and vegetables, as well as the recommendations for physical activity. What Did the Researchers Do and Find? The researchers searched the Internet (including websites of relevant ministries and departments) for all publicly available national policies related to diet, nutrition, NCDs, and health from all 140 WHO member countries classified as LMICs by the World Bank in 2011. For countries for which the search did not turn up policies, the researchers sent e-mail requests to the relevant national authorities, to the regional WHO offices, and to personal contacts. All documents dated from 1 January 2004 to 1 January 2013 that included national objectives and guidelines for action regarding diet, physical exercise, NCD prevention, or a combi- nation of the three, were analyzed in detail. Most of the policies obtained were not easy to find and access. For 24 countries, particularly in the Eastern Mediterranean, the researchers eventually gave up, unable to establish whether relevantnationalpoliciesexisted.Oftheremaining116countries, 29 countries had no relevant policies, and another 30 had policies that failed to mention specifically any of the diet-related riskfactors included intheanalysis. Fifty-four ofthe116countries had NCD policies that addressed at least one of the risk factors. Thirty-six national policy documents contained strategies to increase fruit and vegetable intake, 20 addressed dietary fat consumption, 23 aimed to limit salt intake, and 35 had specific actions to promote physical activity. Only 14 countries, including Jamaica, the Philippines, Iran, and Mongolia, had policies that addressed all four risk factors. The policies of 27 countries mentioned only one of the four risk factors. Policies primarily targeted consumers and government agencies and failed to address the roles of the business community or civil society. Consistent with this, most were missing plans, mechanisms, and incentives to drive collab- orations between the different stakeholders. What Do These Findings Mean? More than eight years after the WHO Global Strategy was agreed upon, only a minority of the LMICs included in this analysis have comprehensive policies in place. Developing policies and making them widely accessible is a likely early step toward specific implementation and actions to prevent NCDs. These results therefore suggest that not enough emphasis is placed on NCD prevention in these countries through actions that have been proven to reduce known risk factors. That said, the more important question is what countries are actually doing to combat NCDs, something not directly addressed by this analysis. In richer countries, NCDs have for decades been the leading cause of sickness and death, and the fact that public health strategies need to emphasize NCD prevention is now widely recognized. LMICs not only have more limited resources, they also continue to carry a large burden from infectious diseases. It is therefore not surprising that shifting resources towards NCD prevention is a difficult process, even if the human cost of these diseases is massive and increasing. That only about 3% of global health aid is aimed at NCD prevention does not help the situation. The authors argue that one step toward improving the situation is better sharing of best practices and what works and what doesn’t in policy development. They suggest that an open-access repository like one that exists for Europe could improve the situation. They offer to organize, host, and curate such a resource under the auspices of WHO, starting with the policies retrieved for this study, and they invite submission of additional policies and updates. Additional Information. Please access these websites via the online version of this summary at http://dx.doi.org/10. 1371/journal.pmed.1001465. N This study is further discussed in a PLOS Medicine Perspective by Stuckler and Basu N TheWHOwebsiteondietandphysicalactivitycontainslinksto various documents, including a diet and physical activity implementation toolbox that contains links to the 2004 Global Strategy document and a Framework to Monitor and Evaluate Implementation N There is a 2011 WHO primer on NCDs entitled ‘‘Prioritizing a Preventable Epidemic’’ N A recent PLOS Medicine editorial and call for papers addressing the global disparities in the burden from NCDs N A PLOS Blogs post entitled ‘‘Politics and Global Health—Are We Missing the Obvious?’’ and associated comments discuss the state of the fight against NCDs in early 2013 N The NCD Alliance was founded by the Union for International Cancer Control, the International Diabetes Federation, the World Heart Federation, and the International Union Against Tuberculosis and Lung Disease; its mission is to combat the NCD epidemic by putting health at the center of all policies N The WHO European Database on Nutrition, Obesity and Physical Activity (NOPA) contains national and subnational surveillance data, policy documents, actions to implement policy, and examples of good practice in programs and interventions for the WHO European member states National Policies for Noncommunicable Diseases PLOS Medicine | www.plosmedicine.org 19 June 2013 | Volume 10 | Issue 6 | e1001465 on specifically any of the diet-related riskfactors included intheanalysis. Fifty-four ofthe116countries had NCD policies that addressed at least one of the risk factors. Thirty-six national policy documents contained strategies to increase fruit and vegetable intake, 20 addressed dietary fat consumption, 23 aimed to limit salt intake, and 35 had specific actions to promote physical activity. Only 14 countries, including Jamaica, the Philippines, Iran, and Mongolia, had policies that addressed all four risk factors. The policies of 27 countries mentioned only one of the four risk factors. Policies primarily targeted consumers and government agencies and failed to address the roles of the business community or civil society. Consistent with this, most were missing plans, mechanisms, and incentives to drive collab- orations between the different stakeholders. What Do These Findings Mean? More than eight years after the WHO Global Strategy was agreed upon, only a minority of the LMICs included in this analysis have comprehensive policies in place. Developing policies and making them widely accessible is a likely early step toward specific implementation and actions to prevent NCDs. These results therefore suggest that not enough emphasis is placed on NCD prevention in these countries through actions that have been proven to reduce known risk factors. That said, the more important question is what countries are actually doing to combat NCDs, something not directly addressed by this analysis. In richer countries, NCDs have for decades been the leading cause of sickness and death, and the fact that public health strategies need to emphasize NCD prevention is now widely recognized. LMICs not only have more limited resources, they also continue to carry a large burden from infectious diseases. It is therefore not surprising that shifting resources towards NCD prevention is a difficult process, even if the human cost of these diseases is massive and increasing. That only about 3% of global health aid is aimed at NCD prevention does not help the situation. The authors argue that one step toward improving the situation is better sharing of best practices and what works and what doesn’t in policy development. They suggest that an open-access repository like one that exists for Europe could improve the situation. They offer to organize, host, and curate such a resource under the auspices of WHO, starting with the policies retrieved for this study, and they invite submission of additional policies and updates. Additional Information. Please access these websites via the online version of this summary at http://dx.doi.org/10. 1371/journal.pmed.1001465. N This study is further discussed in a PLOS Medicine Perspective by Stuckler and Basu N TheWHOwebsiteondietandphysicalactivitycontainslinksto various documents, including a diet and physical activity implementation toolbox that contains links to the 2004 Global Strategy document and a Framework to Monitor and Evaluate Implementation N There is a 2011 WHO primer on NCDs entitled ‘‘Prioritizing a Preventable Epidemic’’ N A recent PLOS Medicine editorial and call for papers addressing the global disparities in the burden from NCDs N A PLOS Blogs post entitled ‘‘Politics and Global Health—Are We Missing the Obvious?’’ and associated comments discuss