Branka Legetic

Physical Activity Interventions in Latin America A Systematic Review

BACKGROUNDnRecommendations for physical activity in the Guide to Community Preventive Services (the Community Guide) have not been systematically examined or applied in developing countries such as those in Latin America. The aim of this systematic review was to assess the current evidence base concerning interventions to increase physical activity in Latin America using a modified Community Guide process and to develop evidence-based recommendations for physical activity interventions.nnnMETHODSnIn 2006, a literature review of both peer-reviewed and non-peer-reviewed literature in Portuguese, Spanish, and English was carried out to identify physical activity interventions conducted in community settings in Latin America. Intervention studies were identified by searching ten databases using 16 search terms related to physical activity, fitness, health promotion, and community interventions. All intervention studies related to physical activity were summarized into tables. Six reviewers independently classified the intervention studies by the categories used in the Community Guide and screened the studies for inclusion in a systematic abstraction process to assess the strength of the evidence. Five trained researchers conducted the abstractions.nnnRESULTSnThe literature search identified 903 peer-reviewed articles and 142 Brazilian theses related to physical activity, of which 19 were selected for full abstraction. Only for school-based physical education classes was the strength of the evidence from Latin America sufficient to support a practice recommendation.nnnCONCLUSIONSnThis systematic review highlights the need for rigorous evaluation of promising interventions to increase physical activity in Latin America. Implementation and maintenance of school physical education programs and policies should be strongly encouraged to promote the health of Latin American children.

Salt Reduction Initiatives around the World - A Systematic Review of Progress towards the Global Target

Objective To quantify progress with the initiation of salt reduction strategies around the world in the context of the global target to reduce population salt intake by 30% by 2025. Methods A systematic review of the published and grey literature was supplemented by questionnaires sent to country program leaders. Core characteristics of strategies were extracted and categorised according to a pre-defined framework. Results A total of 75 countries now have a national salt reduction strategy, more than double the number reported in a similar review done in 2010. The majority of programs are multifaceted and include industry engagement to reformulate products (n = 61), establishment of sodium content targets for foods (39), consumer education (71), front-of-pack labelling schemes (31), taxation on high-salt foods (3) and interventions in public institutions (54). Legislative action related to salt reduction such as mandatory targets, front of pack labelling, food procurement policies and taxation have been implemented in 33 countries. 12 countries have reported reductions in population salt intake, 19 reduced salt content in foods and 6 improvements in consumer knowledge, attitudes or behaviours relating to salt. Conclusion The large and increasing number of countries with salt reduction strategies in place is encouraging although activity remains limited in low- and middle-income regions. The absence of a consistent approach to implementation highlights uncertainty about the elements most important to success. Rigorous evaluation of ongoing programs and initiation of salt reduction programs, particularly in low- and middle- income countries, will be vital to achieving the targeted 30% reduction in salt intake.

Systematic review of studies comparing 24-hour and spot urine collections for estimating population salt intake

OBJECTIVEnTo examine the usefulness of urine sodium (Na) excretion in spot or timed urine samples to estimate population dietary Na intake relative to the gold standard of 24-hour (h) urinary Na.nnnMETHODSnAn electronic literature search was conducted of MEDLINE (from 1950) and EMBASE (from 1980) as well as the Cochrane Library using the terms sodium, salt, and urine. Full publications of studies that examined 30 or more healthy human subjects with both urinary Na excretion in 24-h urine and one alternative method (spot, overnight, timed) were examined.nnnRESULTSnThe review included 1 380 130 participants in 20 studies. The main statistical method for comparing 24-h urine collections with alternative methods was the use of a correlation coefficient. Spot, timed, and overnight urine samples were subject to greater intra-individual and interindividual variability than 24-h urine collections. There was a wide range of correlation coefficients between 24-h urine Na and other methods. Some values were high, suggesting usefulness (up to r = 0.94), while some were low (down to r = 0.17), suggesting a lack of usefulness. The best alternative to collecting 24-h urine (overnight, timed, or spot) was not clear, nor was the biological basis for the variability between 24-h and alternative methods.nnnCONCLUSIONSnThere is great interest in replacing 24-h urine Na with easier methods to assess dietary Na. However, whether alternative methods are reliable remains uncertain. More research, including the use of an appropriate study design and statistical testing, is required to determine the usefulness of alternative methods.

Reducing Salt Intake in the Americas: Pan American Health Organization Actions

This article outlines the rationale for reducing dietary salt and some of the Pan American Health Organization actions to facilitate reductions in dietary salt in the Americas. Excessive dietary salt (sodium chloride and other sodium salts) is a major cause of increased blood pressure, which increases risk for stroke, heart disease, and kidney disease. Reduction in salt intake is beneficial for people with hypertension and those with normal blood pressure. The World Health Organization recommends a population salt intake of less than 5 grams/person/day with a Pan American Health Organization expert group recommendation that this be achieved by 2020 in the Americas. In general, the consumption of salt is more than 6 grams/day by age 5 years, with consumption of salt averaging between 9 and 12 grams per day in many countries. Recent salt intake estimates from Brazil (11 grams of salt/day), Argentina (12 grams of salt/day), Chile (9 grams of salt/day) and the United States (8.7 grams of salt/day) confirm that high salt intakes are prevalent in Americas. Sources of dietary salt vary, from 75% of it coming from processed food in developed countries, to 70% coming from discretionary salt added in cooking or at the table in parts of Brazil. The Pan American Health Organization has launched a regionwide initiative called the “Cardiovascular Disease Prevention Through Dietary Salt Reduction,” led by an expert working group. Working closely with countries, the expert group developed resources to aid policy development through five subgroups: (a) addressing industry engagement and product reformulation; (b) advocacy and communication; (c) surveillance of salt intake, sources of salt in the diet, and knowledge and opinions on salt and health; (d) salt fortification with iodine; and (e) national-level health economic studies on salt reduction.

School-based physical education programs: evidence-based physical activity interventions for youth in Latin America

This article focuses on results of the systematic review from the Guide for Useful Interventions for Activity in Latin America project related to school-based physical education (PE) programs in Latin America. The aims of the article are to describe five school-based PE programs from Latin America, discuss implications for effective school-based PE recommendations, propose approaches for implementing these interventions, and identify gaps in the research literature related to physical activity promotion in Latin American youth. Following the US Community Guide systematic review process, five school-based PE intervention studies with sufficient quality of design, execution and detail of intervention and outcomes were selected for full abstraction. One study was conducted in Brazil, two studies were conducted in Chile and two studies were conducted on the US/Mexico border. While studies presented assorted outcomes, methods and duration of interventions, there were consistent positive increases in physical activity levels for all outcomes measured during PE classes, endurance and active transportation to school in all three randomized studies. Except for one cohort from one study, the non-randomized studies showed positive intervention effects for moderate and vigorous physical activity levels during PE classes. The core elements of these five interventions included capacity building and staff training (PE specialists and/or classroom teachers); changes in the PE curricula; provision of equipment and materials; and adjustment of the interventions to specific target populations. In order to translate the strong evidence for school-based PE into practice, systematic attention to policy and implementation issues is required.

Consumer attitudes, knowledge, and behavior related to salt consumption in sentinel countries of the Americas

OBJECTIVEnTo describe individual attitudes, knowledge, and behavior regarding salt intake, its dietary sources, and current food-labeling practices related to salt and sodium in five sentinel countries of the Americas.nnnMETHODSnA convenience sample of 1 992 adults (≥ 18 years old) from Argentina, Canada, Chile, Costa Rica, and Ecuador (approximately 400 from each country) was obtained between September 2010 and February 2011. Data collection was conducted in shopping malls or major commercial areas using a questionnaire containing 33 questions. Descriptive estimates are presented for the total sample and stratified by country and sociodemographic characteristics of the studied population.nnnRESULTSnAlmost 90% of participants associated excess intake of salt with the occurrence of adverse health conditions, more than 60% indicated they were trying to reduce their current intake of salt, and more than 30% believed reducing dietary salt to be of high importance. Only 26% of participants claimed to know the existence of a recommended maximum value of salt or sodium intake and 47% of them stated they knew the content of salt in food items. More than 80% of participants said that they would like food labeling to indicate high, medium, and low levels of salt or sodium and would like to see a clear warning label on packages of foods high in salt.nnnCONCLUSIONSnAdditional effort is required to increase consumers knowledge about the existence of a maximum limit for intake and to improve their capacity to accurately monitor and reduce their personal salt consumption.

Training practitioners in evidence-based chronic disease prevention for global health.

Too often, public health decisions are based on short-term demands rather than long-term research and objectives. Policies and programmes are sometimes developed around anecdotal evidence. The Evidence-Based Public Health (EBPH) programme trains public health practitioners to use a comprehensive, scientific approach when developing and evaluating chronic disease programmes. Begun in 2002, the EBPH programme is an international collaboration. The course is organized in seven parts to teach skills in: 1) assessing a communitys needs; 2) quantifying the issue; 3) developing a concise statement of the issue; 4) determining what is known about the issue by reviewing the scientific literature; 5) developing and prioritizing programme and policy options; 6) developing an action plan and implementing interventions; and 7) evaluating the programme or policy. The course takes an applied approach and emphasizes information that is readily available to busy practitioners, relying on experiential learning and includes lectures, practice exercises, and case studies. It focuses n using evidence-based tools and encourages participants to add to the evidence base in areas where intervention knowledge is sparse. Through this training programme, we educated practitioners from 38 countries in 4 continents. This article describes the evolution of the parent course and describes experiences implementing the course in the Russian Federation, Lithuania, and Chile. Lessons learned from replication of the course include the need to build a “critical mass” of public health officials trained in EBPH within each country and the importance of international, collaborative networks. Scientific and technologic advances provide unprecedented opportunities for public health professionals to enhance the practice of EBPH. To take full advantage of new technology and tools and to combat new health challenges, public health practitioners must continually improve their skills.

Mobilising the Americas for dietary salt reduction

People are over-consuming salt, causing up to 30% of all cases of hypertension. In the Pan-American region, hypertension prevalence ranges from 20% to 35%, with the higher proportions more often seen in Latin America. Salt intake, where measured, can be as high as 11·5 g a day per person, with by far the largest source in most cases being commercially processed foods. The Pan American Health Organization (PAHO) has responded with an initiative, “Cardiovascular Disease Prevention through Dietary Salt Reduction”. For a 2-year period, beginning in September, 2009, it is supporting a Regional Expert Group: 18 leaders in nutrition and chronic diseases from universities, government agencies, and research institutions in north, south, and central America, the Caribbean, and Europe. The Group fi rst developed a policy statement with the rationale and recommendations for a gradual and sustained population-wide drop in dietary salt across the Americas. Its audience is policy and decision makers in government, leaders in non-governmental organisations (representing consumers and scientifi c and health-care professionals), civil society, the food industry (including food processors and distributors), among food importers and exporters, and in PAHO. Informal civil-society groups and networks throughout the region are more likely to receive funds from private donors than through offi cial channels. Diversity in the region challenges the often unstable balance between civil-society and non-governmental organisations (NGOs). International and domestic NGOs do participate in some programmes, but are absent in other cases. Many NGOs depend entirely on grants and contracts, operate as consultancy companies, or are set up by government or businesses with little resemblance to grassroots civil society. Instead of focusing on organisations, civil society should be approached as a process of organising citizens’ action, the eff ectiveness of which should be proven rather than assumed. The future prospects of civil-society involvement seem to be uncertain. Civil-society eff orts have been eff ective in providing services to people aff ected by HIV in some areas, but have delivered less on other areas and public health issues that extend beyond one disease. Many donor and governmental organisations favour direct service-delivery to advocacy or reform, off ering limited space for citizens’ action. As a result, civil society is often passive when advocating about major issues, such as health insurance for poor people, the high price and often dubious quality of drugs, or pandemic preparedness. These concerns will probably increase in coming years if external donor funding to middle-income countries in southeast Asia decreases or internal confl icts arise unexpectedly, as in Thailand during 2009–10. New health threats are also likely to emerge, including those relating to climate change. These changes might lead to opportunities for civil-society action, but need to be balanced against existing legal and capacity restraints. We will see and understand more of these complex dynamics if we discard the idea that civil society is made up only of formal organisations and look instead to the local networks and religious and citizens’ groups that are forming at the grassroots.

Accuracy and Usefulness of Select Methods for Assessing Complete Collection of 24-Hour Urine: A Systematic Review

Twenty‐four–hour urine collection is the recommended method for estimating sodium intake. To investigate the strengths and limitations of methods used to assess completion of 24‐hour urine collection, the authors systematically reviewed the literature on the accuracy and usefulness of methods vs para‐aminobenzoic acid (PABA) recovery (referent). The percentage of incomplete collections, based on PABA, was 6% to 47% (n=8 studies). The sensitivity and specificity for identifying incomplete collection using creatinine criteria (n=4 studies) was 6% to 63% and 57% to 99.7%, respectively. The most sensitive method for removing incomplete collections was a creatinine index <0.7. In pooled analysis (≥2 studies), mean urine creatinine excretion and volume were higher among participants with complete collection (P<.05); whereas, self‐reported collection time did not differ by completion status. Compared with participants with incomplete collection, mean 24‐hour sodium excretion was 19.6 mmol higher (n=1781 specimens, 5 studies) in patients with complete collection. Sodium excretion may be underestimated by inclusion of incomplete 24‐hour urine collections. None of the current approaches reliably assess completion of 24‐hour urine collection.

Targets and timelines for reducing salt in processed food in the Americas.

Reducing dietary salt is one of the most effective interventions to lessen the burden of premature death and disability. In high‐income countries and those in nutrition transition, processed foods are a significant if not the main source of dietary salt. Reformulating these products to reduce their salt content is recommended as a best buy to prevent chronic diseases across populations. In the Americas, there are targets and timelines for reduced salt content of processed foods in 8 countries—Argentina, Brazil, Canada, Chile, Ecuador, Mexico, and the National Salt Reduction Initiative in the United States and Paraguay. While there are common elements across the countries, there are notable differences in their approaches: 4 countries have exclusively voluntary targets, 2 countries have combined voluntary and regulated components, and 1 country has only regulations. The countries have set different types of targets and in some cases combined them: averages, sales‐weighted averages, upper limits, and percentage reductions. The foods to which the targets apply vary from single categories to comprehensive categories accounting for all processed products. The most accessible and transparent targets are upper limits per food category. Most likely to have a substantive and sustained impact on salt intake across whole populations is the combination of sales‐weighted averages and upper limits. To assist all countries with policies to improve the overall nutritional value of processed foods, the authors call for food companies to supply food composition data and product sales volume data to transparent and open‐access platforms and for global companies to supply the products that meet the strictest targets to all markets. Countries participating in common markets at the subregional level can consider harmonizing targets, nutrition labels, and warning labels.