Bente Mikkelsen

Dietary supplementation with l-arginine or placebo in women with pre-eclampsia

Background.  To investigate the effect of dietary intake of the NO‐donor l‐arginine on the diastolic blood pressure in women with pre‐eclampsia.

Socioeconomic status and non-communicable disease behavioural risk factors in low-income and lower-middle-income countries: a systematic review

Summary Background Non-communicable diseases are the leading global cause of death and disproportionately afflict those living in low-income and lower-middle-income countries (LLMICs). The association between socioeconomic status and non-communicable disease behavioural risk factors is well established in high-income countries, but it is not clear how behavioural risk factors are distributed within LLMICs. We aimed to systematically review evidence on the association between socioeconomic status and harmful use of alcohol, tobacco use, unhealthy diets, and physical inactivity within LLMICs. Methods We searched 13 electronic databases, including Embase and MEDLINE, grey literature, and reference lists for primary research published between Jan 1, 1990, and June 30, 2015. We included studies from LLMICs presenting data on multiple measures of socioeconomic status and tobacco use, alcohol use, diet, and physical activity. No age or language restrictions were applied. We excluded studies that did not allow comparison between more or less advantaged groups. We used a piloted version of the Cochrane Effective Practice and Organisation of Care Group data collection checklist to extract relevant data at the household and individual level from the included full text studies including study type, methods, outcomes, and results. Due to high heterogeneity, we used a narrative approach for data synthesis. We used descriptive statistics to assess whether the prevalence of each risk factor varied significantly between members of different socioeconomic groups. The study protocol is registered with PROSPERO, number CRD42015026604. Findings After reviewing 4242 records, 75 studies met our inclusion criteria, representing 2 135 314 individuals older than 10 years from 39 LLMICs. Low socioeconomic groups were found to have a significantly higher prevalence of tobacco and alcohol use than did high socioeconomic groups. These groups also consumed less fruit, vegetables, fish, and fibre than those of high socioeconomic status. High socioeconomic groups were found to be less physically active and consume more fats, salt, and processed food than individuals of low socioeconomic status. While the included studies presented clear patterns for tobacco use and physical activity, heterogeneity between dietary outcome measures and a paucity of evidence around harmful alcohol use limit the certainty of these findings. Interpretation Despite significant heterogeneity in exposure and outcome measures, clear evidence shows that the burden of behavioural risk factors is affected by socioeconomic position within LLMICs. Governments seeking to meet Sustainable Development Goal (SDG) 3.4—reducing premature non-communicable disease mortality by a third by 2030—should leverage their development budgets to address the poverty-health nexus in these settings. Our findings also have significance for health workers serving these populations and policy makers tasked with preventing and controlling the rise of non-communicable diseases. Funding WHO.

Evaluation of research on interventions aligned to WHO ‘Best Buys’ for NCDs in low-income and lower-middle-income countries: a systematic review from 1990 to 2015

Background Non-communicable diseases (NCDs) are the leading cause of death and disability worldwide, with low-income and middle-income countries experiencing a disproportionately high burden. Since 2010 WHO has promoted 24 highly cost-effective interventions for NCDs, dubbed ‘best buys’. It is unclear whether these interventions have been evaluated in low-income and lower-middle-income countries (LLMICs). Aim To systematically review research on interventions aligned to WHO ‘best buys’ for NCDs in LLMICs. Methods We searched 13 major databases and included papers conducted in the 83 World Bank-defined LLMICs, published between 1 January 1990 and 5 February 2015. Two reviewers independently screened papers and assessed risk of bias. We adopted a narrative approach to data synthesis. The primary outcomes were NCD-related mortality and morbidity, and risk factor prevalence. Results We identified 2672 records, of which 36 were included (608 940 participants). No studies on ‘best buys’ were found in 89% of LLMICs. Nineteen of the 36 studies reported on the effectiveness of tobacco-related ‘best buys’, presenting good evidence for group interventions in reducing tobacco use but weaker evidence for interventions targeting individuals. There were fewer studies on smoking bans, warning labels and mass media campaigns, and no studies on taxes or marketing restrictions. There was supportive evidence that cervical screening and hepatitis B immunisation prevent cancer in LLMICs. A single randomised controlled trial supported polypharmacy for cardiovascular disease. Fourteen of the ‘best buy’ interventions did not have any good evidence for effectiveness in LLMICs. Conclusions We found studies on only 11 of the 24 interventions aligned with the WHO ‘best buys’ from LLMIC settings. Most LLMICs have not conducted research on these interventions in their populations. LLMICs should take action to implement and evaluate ‘best buys’ in their national context, based on national priorities, and starting with interventions with the strongest evidence base.

Poverty and risk factors for non-communicable diseases in developing countries: a systematic review

Abstract Background The association between poverty and health is highly context-specific; in high-income countries, low socioeconomic status is associated with use of tobacco and alcohol, physical inactivity, and poor diet. We lack good quality epidemiological evidence from developing countries, especially from low and lower middle-income countries (LLMICs). This systematic review sought to fill this gap. Methods We conducted a comprehensive literature search for primary research published between Jan 1, 1990, and June 30, 2015, using 13 electronic databases, including Embase and Medline, as well as a grey literature review and hand searching of references. Two reviewers independently screened papers retrieved from 13 databases with a search devised by an experienced medical librarian combining MeSH terms and synonyms for non-communicable diseases, behavioural risk factors, poverty, and the 84 LLMICs defined by the World Bank. We included studies from LLMICs that presented data on multiple measures of socioeconomic status and tobacco use, alcohol use, diet, and physical activity. We performed narrative data synthesis. Findings After review of 4242 records, 75 studies met our inclusion criteria, representing 2 135 314 individuals aged more than 10 years from 39 LLMICs. Most studies found that, compared with high socioeconomic groups, lower status groups had a high prevalence of tobacco and alcohol use (odds ratios up to 18·8 and 3·5, respectively). Most studies also found that lower socioeconomic groups consumed less fruit, vegetables, fish, and fibre (odds ratios negligible to 12·9, depending on context). Higher socioeconomic groups were up to 4·4 times less physically active and consumed more fats, salt, and processed food; however, these dietary studies tended to be smaller with wide confidence intervals. Interpretation Despite variation in exposure and outcome measures, there is clear evidence that the burden of behavioural risk factors is affected by socioeconomic position within LLMICs. Governments seeking to meet Sustainable Development Goal 3.4—reducing premature mortality from non-communicable diseases by a third by 2030—should leverage their development budgets to address the poverty–health nexus in these settings. Our findings are also important for health workers serving these populations, and for policymakers tasked with preventing and controlling the rise of non-communicable diseases. Funding None.

Addressing NCDs: A unifying agenda for sustainable development

ABSTRACT Despite the mounting evidence that they impede social and economic development, increase inequalities, and perpetuate poverty, Noncommunicable diseases (NCDs) remain largely absent from the agendas of major development assistance initiatives. In addition, fundamental changes are developing in patterns of development assistance for health, and more of the burden for fighting NCDs is being placed on domestic budgets, thus increasing pressure on the most vulnerable countries. The paper argues, however, that a new day is coming. With the inclusion of NCDs and related targets in the 2030 Agenda for Sustainable Development, there is an unprecedented opportunity to explore linkages among the sustainable development goals, enhance policy coherence and advance the NCD agenda as part of sustainable development. International development partners (bilateral and multilateral) can help in this important effort to address NCDs and their shared risk factors by providing catalytic support to countries that are particularly vulnerable in terms of the disease burden but lack the resources (human, financial) and institutional arrangements to meet their commitments at national, regional, and global levels.

A systematic review of associations between non-communicable diseases and socioeconomic status within low- and lower-middle-income countries

Background Non-communicable diseases (NCDs) are the leading cause of death globally. Eighty-two percent of premature NCD deaths occur within low- and lower middle-income countries (LLMICs). Research to date, largely drawn from high-income countries, suggests that disadvantaged and marginalized groups have a higher NCD burden, but there has been a dearth of research studying this relationship within LLMICs. The purpose of this systematic review is to map the literature on evidence from LLMICs on the socio-economic status (SES) gradient of four particular NCDs: cardiovascular disease, cancer, diabetes, and chronic respiratory diseases. Methods We conducted a comprehensive literature search for primary research published between 1 January 1990 and 27 April 2015 using six bibliographic databases and web resources. We included studies that reported SES and morbidity or mortality from cardiovascular disease, cancer, diabetes and chronic respiratory diseases within LLMICs. Results Fifty-seven studies from 17 LLMICs met our inclusion criteria. Fourteen of the 18 papers that reported significant associations between cancer and SES suggested that low SES groups had the highest cancer risk. Eleven of 15 papers reporting significant relationships between CVD and SES suggested that low SES groups have higher risk. In contrast, seven of 12 papers reporting significant findings related to diabetes found that higher SES groups had higher diabetes risk. We identified just three studies on the relationship between chronic respiratory diseases and SES; none of them reported significant findings. Conclusions Only 17 of the 84 LLMICs were represented, highlighting the need for more research on NCDs within these countries. The majority of studies were medium to high quality cross-sectional studies. When we restricted our analyses to high quality studies only, for both cancer and cardiovascular disease more than half of studies found a significantly higher risk for those of lower SES. The opposite was true for diabetes, whilst there was a paucity of high quality research on chronic respiratory disease. Development programmes must consider health alongside other aims and NCD prevention interventions must target all members of the population. Systematic review registration number Prospero: CRD42015020169.

Time to act – reaching the sexual and reproductive health goals of Agenda 2030

Time to act – reaching the sexual and reproductive health goals of Agenda 2030 NINO BERDZULI, BENTE MIKKELSEN & KRISTINA GEMZELL-DANIELSSON World Health Organization, Regional Office for Europe, Coppenhagen,Denmark, and World Health Organization Collaborating Center, Department of Women’s and Children’s Health, Division of Obtetrics and Gynecology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden