Despite a wealth of evidence of the health benefits of fruits and vegetables, their affordability, accessibility, and safety present substantial challenges to individuals in low- and middle-income ...countries. Interventions that address the whole population, such as those that influence the availability and price of fruits and vegetables, as well as their safety, may be more impactful and sustainable in the long term. Here, Siegel discusses the reasons for the lack of availability of fruits and vegetables.
Despite smaller effect sizes, interventions delivered at population level to prevent non-communicable diseases generally have greater reach, impact and equity than those delivered to high-risk ...groups. Nevertheless, how to shift population behaviour patterns in this way remains one of the greatest uncertainties for research and policy. Evidence about behaviour change interventions that are easier to evaluate tends to overshadow that for population-wide and system-wide approaches that generate and sustain healthier behaviours. Population health interventions are often implemented as natural experiments, which makes their evaluation more complex and unpredictable than a typical randomised controlled trial (RCT). We discuss the growing importance of evaluating natural experiments and their distinctive contribution to the evidence for public health policy. We contrast the established evidence-based practice pathway, in which RCTs generate ‘definitive’ evidence for particular interventions, with a practice-based evidence pathway in which evaluation can help adjust the compass bearing of existing policy. We propose that intervention studies should focus on reducing critical uncertainties, that non-randomised study designs should be embraced rather than tolerated and that a more nuanced approach to appraising the utility of diverse types of evidence is required. The complex evidence needed to guide public health action is not necessarily the same as that which is needed to provide an unbiased effect size estimate. The practice-based evidence pathway is neither inferior nor merely the best available when all else fails. It is often the only way to generate meaningful evidence to address critical questions about investing in population health interventions.
Low fruit and vegetable (FV) intake is a leading risk factor for chronic disease globally, but much of the world's population does not consume the recommended servings of FV daily. It remains unknown ...whether global supply of FV is sufficient to meet current and growing population needs. We sought to determine whether supply of FV is sufficient to meet current and growing population needs, globally and in individual countries.
We used global data on agricultural production and population size to compare supply of FV in 2009 with population need, globally and in individual countries. We found that the global supply of FV falls, on average, 22% short of population need according to nutrition recommendations (supply:need ratio: 0.78 Range: 0.05-2.01). This ratio varies widely by country income level, with a median supply:need ratio of 0.42 and 1.02 in low-income and high-income countries, respectively. A sensitivity analysis accounting for need-side food wastage showed similar insufficiency, to a slightly greater extent (global supply:need ratio: 0.66, varying from 0.37 low-income countries to 0.77 high-income countries). Using agricultural production and population projections, we also estimated supply and need for FV for 2025 and 2050. Assuming medium fertility and projected growth in agricultural production, the global supply:need ratio for FV increases slightly to 0.81 by 2025 and to 0.88 by 2050, with similar patterns seen across country income levels. In a sensitivity analysis assuming no change from current levels of FV production, the global supply:need ratio for FV decreases to 0.66 by 2025 and to 0.57 by 2050.
The global nutrition and agricultural communities need to find innovative ways to increase FV production and consumption to meet population health needs, particularly in low-income countries.
Type 2 Diabetes: A 21st Century Epidemic Jaacks, Lindsay M., PhD; Siegel, Karen R., PhD, MPH; Gujral, Unjali P., PhD, MPH ...
Best Practice & Research Clinical Endocrinology & Metabolism,
06/2016, Letnik:
30, Številka:
3
Journal Article
Recenzirano
Abstract Around 415 million people around the world have diabetes (9% of adults), and the vast majority live in low- and middle-income countries. Over the next decade, this number is predicted to ...increase to 642 million people. Given that diabetes is a major cause of mortality, morbidity, and health care expenditures, addressing this chronic disease represents one of the greatest global health challenges of our time. The objectives of this article are three-fold: (1) to present data on the global burden of type 2 diabetes (which makes up 87-91% of the total diabetes burden), both in terms of prevalence and incidence; (2) to give an overview of the risk factors for type 2 diabetes, and to describe obesity and the developmental origins of disease risk in detail; and (3) to discuss the implications of the global burden and point out important research gaps.
Cancer rehabilitation research has accelerated as great attention has focused on improving survivorship care. Recent expert consensus has attempted to prioritize research needs and suggests greater ...focus on studying physical functioning of survivors. However, no analysis of the publication landscape has substantiated these proposed needs. This manuscript provides an analysis of PubMed indexed articles related to cancer rehabilitation published between 1992 and 2017. A total of 22 171 publications were analyzed using machine learning and text analysis to assess publication metrics, topic areas of emphasis, and their interrelationships through topic similarity networks. Publications have increased at a rate of 136 articles per year. Approximately 10% of publications were funded by the National Institutes of Health institutes and centers, with the National Cancer Institute being the most prominent funder. The greatest volume and rate of publication increase were in the topics of Cognitive and Behavioral Therapies and Psychological Interventions, followed by Depression and Exercise Therapy. Four research topic similarity networks were identified and provide insight on areas of robust publication and notable deficits. Findings suggest that publication emphasis has strongly supported cognitive, behavioral, and psychological therapies; however, studies of functional morbidity and physical rehabilitation research are lacking. Three areas of publication deficits are noted: research on populations outside of breast, prostate, and lung cancers; methods for integrating physical rehabilitation services with cancer care, specifically regarding functional screening and assessment; and physical rehabilitation interventions. These deficits align with the needs identified by expert consensus and support the supposition that future research should emphasize a focus on physical rehabilitation.
To synthesize updated evidence on the cost-effectiveness (CE) of interventions to manage diabetes, its complications, and comorbidities.
We conducted a systematic literature review of studies from ...high-income countries evaluating the CE of diabetes management interventions recommended by the American Diabetes Association (ADA) and published in English between June 2008 and July 2017. We also incorporated studies from a previous CE review from the period 1985-2008. We classified the interventions based on their strength of evidence (strong, supportive, or uncertain) and levels of CE: cost-saving (more health benefit at a lower cost), very cost-effective (≤$25,000 per life year gained LYG or quality-adjusted life year QALY), cost-effective ($25,001-$50,000 per LYG or QALY), marginally cost-effective ($50,001-$100,000 per LYG or QALY), or not cost-effective (>$100,000 per LYG or QALY). Costs were measured in 2017 U.S. dollars.
Seventy-three new studies met our inclusion criteria. These were combined with 49 studies from the previous review to yield 122 studies over the period 1985-2017. A large majority of the ADA-recommended interventions remain cost-effective. Specifically, we found strong evidence that the following ADA-recommended interventions are cost-saving or very cost-effective: In the cost-saving category are
) ACE inhibitor (ACEI)/angiotensin receptor blocker (ARB) therapy for intensive hypertension management compared with standard hypertension management,
) ACEI/ARB therapy to prevent chronic kidney disease and/or end-stage renal disease in people with albuminuria compared with no ACEI/ARB therapy,
) comprehensive foot care and patient education to prevent and treat foot ulcers among those at moderate/high risk of developing foot ulcers,
) telemedicine for diabetic retinopathy screening compared with office screening, and
) bariatric surgery compared with no surgery for individuals with type 2 diabetes (T2D) and obesity (BMI ≥30 kg/m
). In the very cost-effective category are
) intensive glycemic management (targeting A1C <7%) compared with conventional glycemic management (targeting an A1C level of 8-10%) for individuals with newly diagnosed T2D,
) multicomponent interventions (involving behavior change/education and pharmacological therapy targeting hyperglycemia, hypertension, dyslipidemia, microalbuminuria, nephropathy/retinopathy, secondary prevention of cardiovascular disease with aspirin) compared with usual care,
) statin therapy compared with no statin therapy for individuals with T2D and history of cardiovascular disease,
) diabetes self-management education and support compared with usual care,
) T2D screening every 3 years starting at age 45 years compared with no screening,
) integrated, patient-centered care compared with usual care,
) smoking cessation compared with no smoking cessation,
) daily aspirin use as primary prevention for cardiovascular complications compared with usual care,
) self-monitoring of blood glucose three times per day compared with once per day among those using insulin,
) intensive glycemic management compared with conventional insulin therapy for T2D among adults aged ≥50 years, and
) collaborative care for depression compared with usual care.
Complementing professional treatment recommendations, our systematic review provides an updated understanding of the potential value of interventions to manage diabetes and its complications and can assist clinicians and payers in prioritizing interventions and health care resources.
•The SDGs’ ability to strengthen inclusiveness is heavily shaped by domestic politics, institutions and power relations.•Brazil, Paraguay and Uruguay present very different cases of how the SDGs play ...out in domestic agri-food governance.•The capacity, resources and international networks of civil society organizations affect the way they engage with the SDGs.•There is a risk that the SDGs legitimize business as usual and entrench marginalization rather than support transformation.•Actors may shift from exploiting the vagueness of sustainability as a concept to cherry-picking from the broad set of goals.
The Sustainable Development Goals (SDGs) have been heralded as a landmark achievement and a major opportunity for transformative and inclusive change towards sustainability. This promise, however, remains largely unverified. To help fill this gap, we examine how the SDGs have been taken up in the domestic politics of agri-food governance – a salient and contested policy area – in three South American countries: Brazil, Paraguay and Uruguay. Our empirical assessment is based on a scoping of the institutions set up for domestic SDG governance, document analysis of the first voluntary national reviews on the SDGs, and 63 key-informant interviews. The analysis shows that the ability of the SDGs to strengthen inclusiveness is largely shaped by domestic politics, pre-existing institutions and power relations, as well as the resources, capacities and prior experiences of civil society and subnational governments. In practice, the SDGs’ emphasis on inclusion does not necessarily mean that a wider range of perspectives are taken into account in domestic contexts. In Paraguay, the implementation of the SDGs so far mirrors the patterns of marginalization evident also in other policy processes. In Uruguay and Brazil, the SDGs have offered possibilities for at least drawing attention to a variety of perspectives by strengthening the already existing, fairly open political institutions in the case of Uruguay, and by opening up a space for contestation by civil society organizations and subnational governments in the case of Brazil. The SDGs may then be an opportunity for change, but there is also a risk that they become a justification for business as usual. Actors now employ metonymy as a tactic, cherry-picking preferred goals or targets as a sign of supposed adherence to the whole 2030 Agenda. Further research is needed with more ex-post analyses of the SDGs beyond the praising of their nominal transformative potential.
We conducted a systematic review of studies evaluating the cost-effectiveness (CE) of interventions to prevent type 2 diabetes (T2D) among high-risk individuals and whole populations.
Interventions ...targeting high-risk individuals are those that identify people at high risk of developing T2D and then treat them with either lifestyle or metformin interventions. Population-based prevention strategies are those that focus on the whole population regardless of the level of risk, creating public health impact through policy implementation, campaigns, and other environmental strategies. We systematically searched seven electronic databases for studies published in English between 2008 and 2017. We grouped lifestyle interventions targeting high-risk individuals by delivery method and personnel type. We used the median incremental cost-effectiveness ratio (ICER), measured in cost per quality-adjusted life year (QALY) or cost saved to measure the CE of interventions. We used the $50,000/QALY threshold to determine whether an intervention was cost-effective or not. ICERs are reported in 2017 U.S. dollars.
Our review included 39 studies: 28 on interventions targeting high-risk individuals and 11 targeting whole populations. Both lifestyle and metformin interventions in high-risk individuals were cost-effective from a health care system or a societal perspective, with median ICERs of $12,510/QALY and $17,089/QALY, respectively, compared with no intervention. Among lifestyle interventions, those that followed a Diabetes Prevention Program (DPP) curriculum had a median ICER of $6,212/QALY, while those that did not follow a DPP curriculum had a median ICER of $13,228/QALY. Compared with lifestyle interventions delivered one-on-one or by a health professional, those offered in a group setting or provided by a combination of health professionals and lay health workers had lower ICERs. Among population-based interventions, taxing sugar-sweetened beverages was cost-saving from both the health care system and governmental perspectives. Evaluations of other population-based interventions-including fruit and vegetable subsidies, community-based education programs, and modifications to the built environment-showed inconsistent results.
Most of the T2D prevention interventions included in our review were found to be either cost-effective or cost-saving. Our findings may help decision makers set priorities and allocate resources for T2D prevention in real-world settings.
Evaluation of geographic disparities in type 2 diabetes (T2D) onset requires multidimensional approaches at a relevant spatial scale to characterize community types and features that could influence ...this health outcome. Using Geisinger electronic health records (2008–2016), we conducted a nested case-control study of new onset T2D in a 37-county area of Pennsylvania. The study included 15,888 incident T2D cases and 79,435 controls without diabetes, frequency-matched 1:5 on age, sex, and year of diagnosis or encounter. We characterized patients’ residential census tracts by four dimensions of social determinants of health (SDOH) and into a 7-category SDOH census tract typology previously generated for the entire United States by dimension reduction techniques. Finally, because the SDOH census tract typology classified 83% of the study region’s census tracts into two heterogeneous categories, termed rural affordable-like and suburban affluent-like, to further delineate geographies relevant to T2D, we subdivided these two typology categories by administrative community types (U.S. Census Bureau minor civil divisions of township, borough, city). We used generalized estimating equations to examine associations of 1) four SDOH indexes, 2) SDOH census tract typology, and 3) modified typology, with odds of new onset T2D, controlling for individual-level confounding variables. Two SDOH dimensions, higher socioeconomic advantage and higher mobility (tracts with fewer seniors and disabled adults) were independently associated with lower odds of T2D. Compared to rural affordable-like as the reference group, residence in tracts categorized as extreme poverty (odds ratio 95% confidence interval = 1.11 1.02, 1.21) or multilingual working (1.07 1.03, 1.23) were associated with higher odds of new onset T2D. Suburban affluent-like was associated with lower odds of T2D (0.92 0.87, 0.97). With the modified typology, the strongest association (1.37 1.15, 1.63) was observed in cities in the suburban affluent-like category (vs. rural affordable-like–township), followed by cities in the rural affordable-like category (1.20 1.05, 1.36). We conclude that in evaluating geographic disparities in T2D onset, it is beneficial to conduct simultaneous evaluation of SDOH in multiple dimensions. Associations with the modified typology showed the importance of incorporating governmentally, behaviorally, and experientially relevant community definitions when evaluating geographic health disparities.
Over the last two decades, natural resource governance has become an increasingly important element of South American regionalism as commodities became a central driver for regional development ...strategies. Yet, due to socio-environmental impacts and dissatisfaction with decision-making processes, it is also frequently contested. This article focuses on one particularly prominent contestation with transboundary and regional repercussions, the case of the pulp mill conflict which escalated between Argentina and Uruguay in the 2000s. Using the concepts of regionness and politics of scale, it examines in which ways the pulp mill conflict affected regional cohesion and seeks to understand why it evolved in this way. This shows that the way national governments address socio-environmental conflicts is an important additional obstacle to regional cohesion which has received little attention in studies of South American regionalism so far.
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