Publications by authors named "Nigel Unwin"

143 Publications

Evidence of a health risk 'signalling effect' following the introduction of a sugar-sweetened beverage tax.

Food Policy 2021 Jul;102:102104

Centre for Diet and Activity Research, MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Box 285 Institute of Metabolic Science, Cambridge Biomedical Campus, Cambridge CB2 0QQ, United Kingdom.

Consuming sugar-sweetened beverages (SSBs) has been associated with increased rates of obesity and type 2 diabetes, making SSBs an increasingly popular target for taxation. In addition to changing prices, the introduction of an SSB tax may convey information about the health risks of SSBs (a signalling effect). If SSB taxation operates in part by producing a health risk signal, there may be important opportunities to amplify this effect. Our aim was to assess whether there is evidence of a risk signalling effect following the introduction of the Barbados SSB tax. We used process tracing to assess the existence of a signalling effect around sodas and sugar-sweetened juices (juice drinks). We used three data sources: 611 archived transcripts of local television news, 30 interviews with members of the public, and electronic point of sales data (46 months) from a major grocery store chain. We used directed content analysis to assess the qualitative data and an interrupted time series analysis to assess the quantitative data. We found evidence consistent with a risk signalling effect following the introduction of the SSB tax for sodas but not for juice drinks. Consistent with risk signalling theory, the findings suggest that consumers were aware of the tax, believed in a health rationale for the tax, understood that sodas were taxed and perceived that sodas and juice drinks were unhealthy. However consumers appear not to have understood that juice drinks were taxed, potentially reducing tax effectiveness from a health perspective. In addition, the tax may have incentivised companies to increase advertising around juice drinks (undermining any signalling effect) and to introduce low-cost SSB product lines. Policymakers can maximize the impact of risk signals by being clear about the definition of taxed SSBs, emphasizing the health rationale for introducing such a policy, and introducing co-interventions (e.g. marketing restrictions) that reduce opportunities for industry countersignals. These actions may amplify the impact of an SSB tax.
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http://dx.doi.org/10.1016/j.foodpol.2021.102104DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8346947PMC
July 2021

Anthropometric cut-offs to identify hyperglycemia in an Afro-Caribbean population: a cross-sectional population-based study from Barbados.

BMJ Open Diabetes Res Care 2021 Aug;9(1)

The University of the West Indies George Alleyne Chronic Disease Research Centre, Bridgetown, Barbados

Introduction: Body mass index (BMI) and waist circumference (WC) cut-offs associated with hyperglycemia may differ by ethnicity. We investigated the optimal BMI and WC cut-offs for identifying hyperglycemia in the predominantly Afro-Caribbean population of Barbados.

Research Design And Methods: A cross-sectional study of 865 individuals aged ≥25 years without known diabetes or cardiovascular disease was conducted. Hyperglycemia was defined as fasting plasma glucose ≥5.6 mmol/L or hemoglobin A ≥5.7% (39 mmol/mol). The Youden index was used to identify the optimal cut-offs from the receiver operating characteristic (ROC) curves. Further ROC analysis and multivariable log binomial regression were used to compare standard and data-derived cut-offs.

Results: The prevalence of hyperglycemia was 58.9% (95% CI 54.7% to 63.0%). In women, optimal BMI and WC cut-offs (27 kg/m and 87 cm, respectively) performed similarly to standard cut-offs. In men, sensitivities of the optimal cut-offs of BMI ≥24 kg/m (72.0%) and WC ≥86 cm (74.0%) were higher than those for standard BMI and WC obesity cut-offs (30.0% and 25%-46%, respectively), although with lower specificity. Hyperglycemia was 70% higher in men above the data-derived WC cut-off (prevalence ratio 95% CI 1.2 to 2.3).

Conclusions: While BMI and WC cut-offs in Afro-Caribbean women approximate international standards, our findings, consistent with other studies, suggest lowering cut-offs in men may be warranted to improve detection of hyperglycemia. Our findings do, however, require replication in a new data set.
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http://dx.doi.org/10.1136/bmjdrc-2021-002246DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8370513PMC
August 2021

REPRINT OF: CLASSIFICATION OF DIABETES MELLITUS.

Diabetes Res Clin Pract 2021 Jul 31:108972. Epub 2021 Jul 31.

Boden Institute, University of Sydney, Australia.

Executive Summary This document updates the 1999 World Health Organization (WHO) classification of diabetes. It prioritizes clinical care and guides health professionals in choosing appropriate treatments at the time of diabetes diagnosis, and provides practical guidance to clinicians in assigning a type of diabetes to individuals at the time of diagnosis. It is a compromise between clinical and aetiological classification because there remain gaps in knowledge of the aetiology and pathophysiology of diabetes. While acknowledging the progress that is being made towards a more precise categorization of diabetes subtypes, the aim of this document is to recommend a classification that is feasible to implement in different settings throughout the world. The revised classification is presented in Table 1. Unlike the previous classification, this classification does not recognize subtypes of type 1 diabetes and type 2 diabetes and includes new types of diabetes ("hybrid types of diabetes" and "unclassified diabetes").
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http://dx.doi.org/10.1016/j.diabres.2021.108972DOI Listing
July 2021

"We used to get food from the garden." Understanding changing practices of local food production and consumption in small island states.

Soc Sci Med 2021 09 8;284:114214. Epub 2021 Jul 8.

European Centre for Environment and Human Health, University of Exeter Medical School, Truro, UK; MRC Epidemiology Unit, University of Cambridge, Cambridge, UK.

Many Small Island Developing States (SIDS) lead global rates in obesity and non-communicable chronic diseases (NCDs). Drivers for this are complex and include lack of food sovereignty, evidenced by an increasing reliance on cheap nutrient-poor food imports and a focus on export orientated cash crop production for much local agriculture. To better inform SIDS' policy goals of improving nutrition through increased local food production, we explored in two SIDS current practices of food production and consumption. Teams of researchers from the two main regional universities conducted 28 focus groups in Fiji in the Pacific and Saint Vincent and the Grenadines in the Caribbean with rural and urban communities of different socio-economic or land-owning status. In both countries home gardens were still common, valued as providing staple foods to households and contributing to health and livelihoods. Yet social changes had been experienced over the life course and across generations, such as increased purchase of foods, consumption of processed and often imported foods, and fast foods. While participants associated local foods with better nutrition and health outcomes than imported foods, some local foods were also acknowledged as unhealthy (e.g. locally produced tinned products, pesticide contaminated fresh produce). Finally, as food and related health advice moves globally, crossing national boundaries, and through formal and informal channels, local experiences can be confusing and contested. We suggest the need to understand temporal and spatial aspects of social practices, as social practices and their meaning change over time, travel globally and are experienced locally. To enhance and support re-localising food to counteract unhealthy consumption of ultra-processed, shop-bought, often imported foods, it is vital to understand these lived experiences of changes and resulting uncertainties, and to explicitly build on the longstanding positive relationships that people continue to express about home gardens and local food.
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http://dx.doi.org/10.1016/j.socscimed.2021.114214DOI Listing
September 2021

Protein-Lipid Interplay at the Neuromuscular Junction.

Authors:
Nigel Unwin

Microscopy (Oxf) 2021 Jul 6. Epub 2021 Jul 6.

MRC Laboratory of Molecular Biology, Francis Crick Avenue, Cambridge Biomedical Campus, CB2 0QH, Cambridge, UK.

Many new structures of membrane proteins have been determined over the last decade, yet the nature of protein-lipid interplay has received scant attention. The postsynaptic membrane of the neuromuscular junction and Torpedo electrocytes has a regular architecture, opening an opportunity to illuminate how proteins and lipids act together in a native membrane setting. Cryo-EM images show that cholesterol segregates preferentially around the constituent ion channel, the nicotinic acetylcholine receptor, interacting with specific sites in both leaflets of the bilayer. In addition to maintaining the transmembrane α-helical architecture, cholesterol forms microdomains - bridges of rigid sterol groups that link one channel to the next. This article discusses the whole protein-lipid organisation of the cholinergic postsynaptic membrane, its physiological implications, and how the observed details relate to our current concept of membrane structure. I suggest that cooperative interactions, facilitated by the regular protein-lipid arrangement, help to spread channel activation into regions distant from the sites of neurotransmitter release, thereby enhancing the postsynaptic response.
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http://dx.doi.org/10.1093/jmicro/dfab023DOI Listing
July 2021

Evidence for factors associated with diet and physical activity in African and Caribbean countries.

Bull World Health Organ 2021 Jun 1;99(6):464-472I. Epub 2021 Apr 1.

MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Box 285, Institute of Metabolic Science, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, England.

Objective: To identify and describe summarized evidence on factors associated with diet and physical activity in low- and middle-income countries in Africa and the Caribbean by performing a scoping review of reviews.

Methods: We searched the Medline®, LILACS, Scopus, Global Health and Web of Science databases for reviews of factors associated with diet or physical activity published between 1998 and 2019. At least 25% of studies in reviews had to come from African or Caribbean countries. Factors were categorized using Dahlgren and Whitehead's social model of health. There was no quality appraisal.

Findings: We identified 25 reviews: 13 on diet, four on physical activity and eight on both. Eighteen articles were quantitative systematic reviews. In 12 reviews, 25-50% of studies were from Africa or the Caribbean. Only three included evidence from the Caribbean. Together, the 25 reviews included primary evidence published between 1926 and 2018. Little of the summarized evidence concerned associations between international health or political factors and diet or associations between any factor and physical activity across all categories of the social model of health.

Conclusion: The scoping review found a wide range of factors reported to be associated with diet and physical activity in Africa and the Caribbean, but summarized evidence that could help inform policies encouraging behaviours linked to healthy diets and physical activity in these regions were lacking. Further reviews are needed to inform policy where the evidence exists, and to establish whether additional primary research is needed.
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http://dx.doi.org/10.2471/BLT.20.269308DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8164182PMC
June 2021

Ultra-processed food consumption in Barbados: evidence from a nationally representative, cross-sectional study.

J Nutr Sci 2021;10:e29. Epub 2021 Apr 22.

The George Alleyne Chronic Disease Research Centre, Caribbean Institute for Health Research, The University of the West Indies, Bridgetown, Barbados.

Our objective was to describe, for the first time in an English-speaking Caribbean country, the contribution of ultra-processed foods (UPFs) to nutrients linked to non-communicable disease. Using a cross-sectional study design, dietary data were collected from two non-consecutive 24-h dietary recalls. Recorded food items were then classified according to their degree of processing by the NOVA system. The present study took place in Barbados (2012-13). A representative population-based sample of 364 adult Barbadians (161 males and 203 females) aged 25-64 years participated in the study. UPFs represented 40⋅5 % (838 kcal/d; 95 % CI 791, 885) of mean energy intake. Sugar-sweetened beverages made the largest contribution to energy within the UPF category. Younger persons (25-44 years) consumed a significantly higher proportion of calories from UPF (NOVA group 4) compared with older persons (45-64 years). The mean energy shares of UPF ranged from 22⋅0 to 58⋅9 % for those in the lowest tertile to highest tertile. Within each tertile, the energy contribution was significantly higher in the younger age group (25-44 years) compared with the older (45-64 years). One-quarter of persons consume ≥50 % of their daily calories from UPF, this being significantly higher in younger persons. The ultra-processed diet fraction contained about six times the mean of free sugars and about 0⋅8 times the dietary fibre of the non-ultra-processed fraction (NOVA groups 1-3). Targeted interventions to decrease the consumption of UPF especially in younger persons is thus of high priority to improve the diet quality of Barbadians.
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http://dx.doi.org/10.1017/jns.2021.21DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8141678PMC
April 2021

A Systematic Scoping Review of the Impacts of Community Food Production Initiatives in Kenya, Cameroon, and South Africa.

J Glob Health Rep 2021 24;5. Epub 2021 Mar 24.

MRC Epidemiology Unit, University of Cambridge, Cambridge, UK.

Background: Even before the COVID-19 pandemic, one in two people in Africa were food insecure. The burden of malnutrition remains high (e.g. childhood stunting, anaemia in women of reproductive age) or are increasing (e.g. overweight and obesity). A range of coordinated actions are required to improve this situation, including increasing local food production and consumption. The aim of this review was to provide a systematic and comprehensive overview of recently published research into the health, social, economic, and environmental impacts of community food production initiatives (CFPIs) in Kenya, Cameroon and South Africa.

Methods: We searched eight electronic databases covering health, social, environmental, economic and agricultural sciences. Primary research studies published from 1 January 2014 to 31 December 2018 were considered. Data on geographic location, study design, type of CFPI and the impacts assessed were abstracted from eligible articles.

Findings: We identified 4828 articles, 260 of which required full-text review and 118 met our eligibility criteria. Most research was conducted in Kenya (53.4%) and South Africa (38.1%). The categories of CFPIs studied were (in order of decreasing frequency): crop farming, livestock farming, unspecified farming, fisheries, home / school gardens, urban agriculture, and agroforestry. The largest number of studies were on the economic and environmental impacts of CFPIs, followed by their health and social impacts. The health impacts investigated included food security, nutrition status and dietary intake. One study investigated the potential impact of CFPIs on non-communicable diseases. Over 60% of studies investigated a single category of impact. Not one of the studies explicitly used a theoretical framework to guide its design or interpretation.

Conclusions: Our findings on research studies of CFPIs suggest the need for a greater focus on interdisciplinary research in order to improve understanding of the relationships between their health, environmental, economic, and social impacts. Greater use of explicit theoretical frameworks could assist in research design and interpretation, helping to ensure its relevance to informing coordinated intersectoral interventions and policy initiatives.
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http://dx.doi.org/10.29392/001c.19468DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7610539PMC
March 2021

Food Sources and Dietary Quality in Small Island Developing States: Development of Methods and Policy Relevant Novel Survey Data from the Pacific and Caribbean.

Nutrients 2020 Oct 30;12(11). Epub 2020 Oct 30.

European Centre for Environment and Human Health, University of Exeter Medical School, Truro TR1 3HD, UK.

Small Island Developing States (SIDS) have high and increasing rates of diet-related diseases. This situation is associated with a loss of food sovereignty and an increasing reliance on nutritionally poor food imports. A policy goal, therefore, is to improve local diets through improved local production of nutritious foods. Our aim in this study was to develop methods and collect preliminary data on the relationships between where people source their food, their socio-demographic characteristics and dietary quality in Fiji and Saint Vincent and the Grenadines (SVG) in order to inform further work towards this policy goal. We developed a toolkit of methods to collect individual-level data, including measures of dietary intake, food sources, socio-demographic and health indicators. Individuals aged ≥15 years were eligible to participate. From purposively sampled urban and rural areas, we recruited 186 individuals from 95 households in Fiji, and 147 individuals from 86 households in SVG. Descriptive statistics and multiple linear regression were used to investigate associations. The mean dietary diversity score, out of 10, was 3.7 (SD1.4) in Fiji and 3.8 (SD1.5) in SVG. In both settings, purchasing was the most common way of sourcing food. However, 68% (Fiji) and 45% (SVG) of participants regularly (>weekly) consumed their own produce, and 5% (Fiji) and 33% (SVG) regularly consumed borrowed/exchanged/bartered food. In regression models, independent positive associations with dietary diversity (DD) were: borrowing/exchanging/bartering food (β = 0.73 (0.21, 1.25)); age (0.01 (0.00, 0.03)); and greater than primary education (0.44 (0.06, 0.82)). DD was negatively associated with small shop purchasing (-0.52 (95% CIs -0.91, -0.12)) and rural residence (-0.46 (-0.92, 0.00)). The findings highlight associations between dietary diversity and food sources and indicate avenues for further research to inform policy actions aimed at improving local food production and diet.
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http://dx.doi.org/10.3390/nu12113350DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7692177PMC
October 2020

The global diet and activity research (GDAR) network: a global public health partnership to address upstream NCD risk factors in urban low and middle-income contexts.

Global Health 2020 10 19;16(1):100. Epub 2020 Oct 19.

MRC Epidemiology Unit, Institute of Metabolic Sciences Building, Addenbrookes Hospital, University of Cambridge, Cambridge, CB2 0QQ, UK.

Background: Non-communicable diseases (NCDs) are the leading cause of death globally. While upstream approaches to tackle NCD risk factors of poor quality diets and physical inactivity have been trialled in high income countries (HICs), there is little evidence from low and middle-income countries (LMICs) that bear a disproportionate NCD burden. Sub-Saharan Africa and the Caribbean are therefore the focus regions for a novel global health partnership to address upstream determinants of NCDs.

Partnership: The Global Diet and Activity research Network (GDAR Network) was formed in July 2017 with funding from the UK National Institute for Health Research (NIHR) Global Health Research Units and Groups Programme. We describe the GDAR Network as a case example and a potential model for research generation and capacity strengthening for others committed to addressing the upstream determinants of NCDs in LMICs. We highlight the dual equity targets of research generation and capacity strengthening in the description of the four work packages. The work packages focus on learning from the past through identifying evidence and policy gaps and priorities, understanding the present through adolescent lived experiences of healthy eating and physical activity, and co-designing future interventions with non-academic stakeholders.

Conclusion: We present five lessons learned to date from the GDAR Network activities that can benefit other global health research partnerships. We close with a summary of the GDAR Network contribution to cultivating sustainable capacity strengthening and cutting-edge policy-relevant research as a beacon to exemplify the need for such collaborative groups.
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http://dx.doi.org/10.1186/s12992-020-00630-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7570103PMC
October 2020

Protein-lipid architecture of a cholinergic postsynaptic membrane.

Authors:
Nigel Unwin

IUCrJ 2020 Sep 28;7(Pt 5):852-859. Epub 2020 Jul 28.

MRC Laboratory of Molecular Biology, Francis Crick Avenue, Cambridge Biomedical Campus, Cambridge CB2 0QH, United Kingdom.

The cholinergic postsynaptic membrane is an acetyl-choline receptor-rich membrane mediating fast chemical communication at the nerve-muscle synapse. Here, cryo-EM is used to examine the protein-lipid architecture of this membrane in tubular vesicles obtained from the (muscle-derived) electric organ of the ray. As reported earlier, the helical arrangement of the protein component of the vesicles facilitates image averaging and enables us to determine how cholesterol and phospho-lipid molecules are distributed in the surrounding matrix, using headgroup size as a means to discriminate between the two kinds of lipid. It is shown that cholesterol segregates preferentially around the receptors in both leaflets of the lipid bilayer, interacting robustly with specific transmembrane sites and creating a network of bridging microdomains. Cholesterol interactions with the receptor are apparently essential for stabilizing and maintaining its physiological architecture, since the transmembrane structure contracts, involving displacements of the helices at the outer membrane surface by ∼2 Å (1-3 Å), when this lipid is extracted. The microdomains may promote cooperativity between neighbouring receptors, leading to an enhanced postsynaptic response.
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http://dx.doi.org/10.1107/S2052252520009446DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7467168PMC
September 2020

Using nutritional survey data to inform the design of sugar-sweetened beverage taxes in low-resource contexts: a cross-sectional analysis based on data from an adult Caribbean population.

BMJ Open 2020 09 10;10(9):e035981. Epub 2020 Sep 10.

Centre for Diet and Activity Research, MRC Epidemiology Unit, University of Cambridge, Cambridge, UK.

Objective: Sugar-sweetened beverage (SSB) taxes have been implemented widely. We aimed to use a pre-existing nutritional survey data to inform SSB tax design by assessing: (1) baseline consumption of SSBs and SSB-derived free sugars, (2) the percentage of SSB-derived free sugars that would be covered by a tax and (3) the extent to which a tax would differentiate between high-sugar SSBs and low-sugar SSBs. We evaluated these three considerations using pre-existing nutritional survey data in a developing economy setting.

Methods: We used data from a nationally representative cross-sectional survey in Barbados (2012-2013, prior to SSB tax implementation). Data were available on 334 adults (25-64 years) who completed two non-consecutive 24-hour dietary recalls. We estimated the prevalence of SSB consumption and its contribution to total energy intake, overall and stratified by taxable status. We assessed the percentage of SSB-derived free sugars subject to the tax and identified the consumption-weighted sugar concentration of SSBs, stratified by taxable status.

Findings: Accounting for sampling probability, 88.8% of adults (95% CI 85.1 to 92.5) reported SSB consumption, with a geometric mean of 2.4 servings/day (±2 SD, 0.6, 9.2) among SSB consumers. Sixty percent (95% CI 54.6 to 65.4) of SSB-derived free sugars would be subject to the tax. The tax did not clearly differentiate between high-sugar beverages and low-sugar beverages.

Conclusion: Given high SSB consumption, targeting SSBs was a sensible strategy in this setting. A substantial percentage of free sugars from SSBs were not covered by the tax, reducing possible health benefits. The considerations proposed here may help policymakers to design more effective SSB taxes.
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http://dx.doi.org/10.1136/bmjopen-2019-035981DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7485232PMC
September 2020

Implications of COVID-19 control measures for diet and physical activity, and lessons for addressing other pandemics facing rapidly urbanising countries.

Glob Health Action 2020 12;13(1):1810415

MRC Epidemiology Unit, University of Cambridge , Cambridge, UK.

At the time of writing, it is unclear how the COVID-19 pandemic will play out in rapidly urbanising regions of the world. In these regions, the realities of large overcrowded informal settlements, a high burden of infectious and non-communicable diseases, as well as malnutrition and precarity of livelihoods, have raised added concerns about the potential impact of the COVID-19 pandemic in these contexts. COVID-19 infection control measures have been shown to have some effects in slowing down the progress of the pandemic, effectively buying time to prepare the healthcare system. However, there has been less of a focus on the indirect impacts of these measures on health behaviours and the consequent health risks, particularly in the most vulnerable. In this current debate piece, focusing on two of the four risk factors that contribute to >80% of the NCD burden, we consider the possible ways that the restrictions put in place to control the pandemic, have the potential to impact on dietary and physical activity behaviours and their determinants. By considering mitigation responses implemented by governments in several LMIC cities, we identify key lessons that highlight the potential of economic, political, food and built environment sectors, mobilised during the pandemic, to retain health as a priority beyond the context of pandemic response. Such whole-of society approaches are feasible and necessary to support equitable healthy eating and active living required to address other epidemics and to lower the baseline need for healthcare in the long term.
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http://dx.doi.org/10.1080/16549716.2020.1810415DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7480567PMC
December 2020

Addressing the triple burden of malnutrition in the time of COVID-19 and climate change in Small Island Developing States: what role for improved local food production?

Food Secur 2020 Jul 9:1-5. Epub 2020 Jul 9.

MRC Epidemiology Unit, University of Cambridge, Cambridge, UK.

The impacts of the COVID-19 pandemic on food and nutrition insecurity are likely to be significant for Small Island Developing States due to their high dependence on foreign tourism, reliance on imported foods and underdeveloped local food production systems. SIDS are already experiencing high rates of nutrition-related death and disability, including double and triple burdens of malnutrition due to unhealthy diets. We consider the potential role for improved local food production to offset the severity of food system shocks in SIDS and identify the need for localized approaches to embrace systems thinking in order to facilitate communication, coordination and build resilience.
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http://dx.doi.org/10.1007/s12571-020-01066-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7343409PMC
July 2020

Nutritional adequacy and dietary disparities in an adult Caribbean population of African descent with a high burden of diabetes and cardiovascular disease.

Food Sci Nutr 2020 Mar 5;8(3):1335-1344. Epub 2020 Feb 5.

The George Alleyne Chronic Disease Research Centre Caribbean Institute for Health Research The University of the West Indies Bridgetown Barbados.

The Caribbean island of Barbados has a high burden of diabetes and cardiovascular disease. Dietary habits were last described in 2005. A representative population-based sample ( = 363, aged 25-64 years) provided two nonconsecutive 24-hr dietary recalls in this cross-sectional study. Mean daily nutrient intakes were compared with the Dietary Guidelines for Americans. Subgroup differences by age, sex, and educational level were examined using logistic regression. High sugar intakes exist for both sexes with 24% (95% CIs 18.9, 30.0) consuming less than the recommended <10% of energy from added sugars (men 22%; 15.0, 31.6; women 26%; 18.9, 33.7). Sugar-sweetened beverages provide 43% (42.2%, 44.4%) of total sugar intake. Inadequate dietary fiber intakes (men 21 g, 18.2, 22.8; women 18 g, 16.7, 18.9) exist across all age groups. Inadequate micronutrient intake was found in women for calcium, folate, thiamine, zinc, and iron. Older persons (aged 45-64 years) were more likely to report adequacy of dietary fiber (OR = 2.7, 1.5, 4.8) and iron (OR = 3.0, 1.7, 5.3) than younger persons (aged 25-44). Older persons (aged 45-64 years) were less likely to have an adequate supply of riboflavin (OR = 0.4, 0.2, 0.6) than younger persons. Men were more likely to have adequate intakes of iron (OR = 13.0, 6.1, 28.2), folate (OR = 2.4, 1.3, 4.6), and thiamine (OR = 3.0, 1.5, 5.0) than women. Education was not associated with nutrient intake. The Barbadian diet is characterized by high sugar intakes and inadequate dietary fiber; a nutrient profile associated with an increased risk of obesity, type 2 diabetes, and related noncommunicable diseases.
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http://dx.doi.org/10.1002/fsn3.1363DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7063363PMC
March 2020

Mortality attributable to diabetes in 20-79 years old adults, 2019 estimates: Results from the International Diabetes Federation Diabetes Atlas, 9 edition.

Diabetes Res Clin Pract 2020 Apr 15;162:108086. Epub 2020 Feb 15.

Diabetes Research Unit Cymru, Swansea University, Swansea, United Kingdom.

Aims: To estimate the number of deaths attributable to diabetes in 20-79-year-old adults in 2019.

Methods: The following were used to estimate the number of deaths attributable to diabetes: all-cause mortality estimates from the World Health Organization life table, country level age- and sex-specific estimates of diabetes prevalence in 2019 and relative risks of death in people with diabetes compared to people without diabetes.

Results: An estimated 4.2 million deaths among 20-79-year-old adults are attributable to diabetes. Diabetes is estimated to contribute to 11.3% of deaths globally, ranging from 6.8% (lowest) in the Africa Region to 16.2% (highest) in the Middle East and North Africa. About half (46.2%) of the deaths attributable to diabetes occur in people under the age of 60 years. The Africa Region has the highest (73.1%) proportion of deaths attributable to diabetes in people under the age of 60 years, while the Europe Region has the lowest (31.4%).

Conclusions: Diabetes is estimated to contribute to one in nine deaths among adults aged 20-79 years. Prevention of diabetes and its complications is essential, particularly in middle-income countries, where the current impact is estimated to be the largest. Contemporary data from diverse populations are needed to validate these estimates.
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http://dx.doi.org/10.1016/j.diabres.2020.108086DOI Listing
April 2020

Using Group Model Building to Describe the System Driving Unhealthy Eating and Identify Intervention Points: A Participatory, Stakeholder Engagement Approach in the Caribbean.

Nutrients 2020 Jan 31;12(2). Epub 2020 Jan 31.

George Alleyne Chronic Disease Research Centre, University of the West Indies, "Avalon", Jemmott's Lane, Bridgetown BB11115, Barbados.

Many Small Island Developing States of the Caribbean experience a triple burden of malnutrition with high rates of obesity, undernutrition in children, and iron deficiency anemia in women of reproductive age, driven by an inadequate, unhealthy diet. This study aimed to map the complex dynamic systems driving unhealthy eating and to identify potential points for intervention in three dissimilar countries. Stakeholders from across the food system in Jamaica (n = 16), St. Kitts and Nevis (n = 19), and St. Vincent and the Grenadines (n = 6) engaged with researchers in two group model building (GMB) workshops in 2018. Participants described and mapped the system driving unhealthy eating, identified points of intervention, and created a prioritized list of intervention strategies. Stakeholders were also interviewed before and after the workshops to provide their perspectives on the utility of this approach. Stakeholders described similar underlying systems driving unhealthy eating across the three countries, with a series of dominant feedback loops identified at multiple levels. Participants emphasized the importance of the relative availability and price of unhealthy foods, shifting cultural norms on eating, and aggressive advertising from the food industry as dominant drivers. They saw opportunities for governments to better regulate advertising, disincentivize unhealthy food options, and bolster the local agricultural sector to promote food sovereignty. They also identified the need for better coordinated policy making across multiple sectors at national and regional levels to deliver more integrated approaches to improving nutrition. GMB proved to be an effective tool for engaging a highly diverse group of stakeholders in better collective understanding of a complex problem and potential interventions.
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http://dx.doi.org/10.3390/nu12020384DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7071222PMC
January 2020

Air travel for global health: flying in the face of sustainable development?

Lancet 2019 11;394(10211):1786-1788

School of Education and Human Resource Development, Kisii University, Kisii, Kenya.

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http://dx.doi.org/10.1016/S0140-6736(19)32680-7DOI Listing
November 2019

Global and regional diabetes prevalence estimates for 2019 and projections for 2030 and 2045: Results from the International Diabetes Federation Diabetes Atlas, 9 edition.

Diabetes Res Clin Pract 2019 Nov 10;157:107843. Epub 2019 Sep 10.

Diabetes Research Unit Cymru, Swansea University, Swansea, United Kingdom.

Aims: To provide global estimates of diabetes prevalence for 2019 and projections for 2030 and 2045.

Methods: A total of 255 high-quality data sources, published between 1990 and 2018 and representing 138 countries were identified. For countries without high quality in-country data, estimates were extrapolated from similar countries matched by economy, ethnicity, geography and language. Logistic regression was used to generate smoothed age-specific diabetes prevalence estimates (including previously undiagnosed diabetes) in adults aged 20-79 years.

Results: The global diabetes prevalence in 2019 is estimated to be 9.3% (463 million people), rising to 10.2% (578 million) by 2030 and 10.9% (700 million) by 2045. The prevalence is higher in urban (10.8%) than rural (7.2%) areas, and in high-income (10.4%) than low-income countries (4.0%). One in two (50.1%) people living with diabetes do not know that they have diabetes. The global prevalence of impaired glucose tolerance is estimated to be 7.5% (374 million) in 2019 and projected to reach 8.0% (454 million) by 2030 and 8.6% (548 million) by 2045.

Conclusions: Just under half a billion people are living with diabetes worldwide and the number is projected to increase by 25% in 2030 and 51% in 2045.
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http://dx.doi.org/10.1016/j.diabres.2019.107843DOI Listing
November 2019

Implications of the growing burden of diabetes for premature cardiovascular disease mortality and the attainment of the Sustainable Development Goal target 3.4.

Cardiovasc Diagn Ther 2019 Apr;9(2):140-149

Department for Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention, World Health Organization, Geneva, Switzerland.

Non-communicable diseases (NCDs) are a major cause of deaths globally, and cardiovascular disease (CVD) is the leading cause of these deaths. 42% of NCD deaths are premature (occurring before the age of 70 years). As part of the United Nations 3rd Sustainable Development Goal (SDG) on health and wellbeing, target 3.4 is to reduce premature mortality from NCDs by one third between 2015 and 2030. This target adds to the World Health Organization (WHO) target of reducing premature deaths from NCDs by 25% between 2010 and 2025. As diabetes is a major risk factor for CVD, it is important to account for the trends in diabetes when considering premature CVD mortality. We aimed to describe the global trends in diabetes prevalence and mortality, critically review the literature on the estimated attainability of the WHO and SDG targets, and determine if and how these studies accounted for trends in diabetes. Worldwide, the prevalence of diabetes is rising, with an estimated 9.0% global prevalence in adults aged 20-69 by 2030, and low- and middle-income countries (LMICs) having the largest increase of the burden in absolute numbers and age-standardized prevalence. There is a lack of data from most LMICs on the excess CVD mortality associated with diabetes and therefore no consensus on the global risk of CVD mortality in people with diabetes. Where data do exist, there are discrepancies between studies on the direction of mortality trends from diabetes over time. We reviewed 12 studies that estimated the attainability of the WHO or SDG targets for premature NCD mortality. Seven of these considered the potential impacts of achieving the 2025 WHO risk factor targets. Six studies modelled the impact of current trends in risk factors, including diabetes, continuing toward the target dates. Four studies compared this 'business as usual' model with the attainment of the risk factor targets for the world as whole and individual regions, 2 studies for NCD mortality overall, and 2 specifically for CVD mortality. On the impact of diabetes with regards to attainment of the WHO or SDG targets for premature CVD mortality, the overall results were inconclusive. Some concluded that none of the countries or regions considered would meet the targets, and others predicted that in some areas, the targets would be met. Examining the potential impact of trends in diabetes on future CVD mortality rates in LMICs is limited by a relative lack of high quality studies, including on the age specific excess mortality associated with diabetes. Filling these data gaps will enable better estimates of the potential impacts on future CVD mortality of the rapidly increasing prevalence of diabetes in LMICs and help to better inform health policy and the attainment of SDG target 3.4.
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http://dx.doi.org/10.21037/cdt.2018.09.04DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6511678PMC
April 2019

Increased taxation on cigarettes in Grenada: potential effects on consumption and revenue.

Rev Panam Salud Publica 2018 27;42:e195. Epub 2018 Dec 27.

HEU, Centre for Health Economics, The University of the West Indies, St. Augustine, Trinidad and Tobago.

Objective: To investigate the feasibility of addressing the public health concerns of tobacco consumption through increased taxation, while preserving or augmenting government revenues in Grenada.

Methods: Purposive sampling methods were used to ensure data availability and geographical representativeness. Average price per 20-pack of the most-sold brands of cigarettes was calculated using data from three major supermarkets. The World Health Organization's Tax Simulation Model was used, with excise tax rates adjusted to effect 5%, 10%, and 15% consumption decreases.

Results: A 17% to 117% excise tax increase on the cost, insurance, and freight (CIF) value would achieve a 5% consumption decrease. Total government revenues would grow 8.7% and excise tax revenues would increase 11%. The average excise tax per 20-pack would move from EC$ 3.24 (2014 US$ 1.20) to EC$ 3.80 (US$ 1.41), while the average price per pack would increase to EC$ 9.21 (US$ 3.41) from EC$8.48 (US$ 3.14). In the 10% and 15% consumption reduction scenarios, excise taxes would have to be increased by 33% and 50% (to 133% and 150% of CIF, respectively), pushing the average excise tax per pack to EC$ 4.37 (US$ 1.62) and EC$ 4.90 (US$ 1.81), respectively.

Conclusion: In Grenada, consumption can be reduced alongside growth in government revenues, making available additional resources for health. This aligns with the literature, which indicates that taxation can be effective in pursuing the public health objective of reduced incidence of smoking-related illnesses via reduced consumption.
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http://dx.doi.org/10.26633/RPSP.2018.195DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6398323PMC
December 2018

The 2007 Caribbean Community Port-of-Spain Declaration on noncommunicable diseases: an overview of a multidisciplinary evaluation.

Rev Panam Salud Publica 2018 17;42:e193. Epub 2018 Dec 17.

George Alleyne Chronic Disease Research Centre, University of the West Indies, Bridgetown, Barbados.

Objectives: Noncommunicable diseases (NCDs) are a threat to social and economic development, including in the Caribbean. In 2007 the Caribbean Community (CARICOM) held the world's first-ever summit of heads of government on NCD prevention and control and issued the landmark Declaration of Port-of-Spain: Uniting to Stop the Epidemic of Chronic NCDs. The objectives of this paper are to provide an overview of a formal evaluation of the Declaration and to highlight key findings that could inform further implementation of the Declaration's 15 mandates.

Methods: The evaluation's six research objectives were decided through stakeholder engagement and assessed by concurrent quantitative and qualitative research methods, using the following four themes: 1) trends in risk factors, morbidity, and mortality; 2) national and Caribbean-wide policy responses, and factors associated with policy successes and difficulties; 3) the international impact of the Declaration; and 4) the potential for raising revenue from tobacco and alcohol taxation in order to support NCD prevention and control.

Results: There are marked disparities in NCD mortality and trends among the 20 CARICOM member countries and territories. No CARICOM member had fully implemented all of the Declaration's 15 mandates (which were monitored by 26 indicators), with 10 CARICOM members implementing fewer than half of the indicators, and with most members lacking a well-functioning multisectoral NCD Commission. Larger CARICOM members tended to have higher levels of implementation than did smaller members. Mandates that received active support from regional institutions tended to be better implemented by the CARICOM members than did mandates that lacked that kind of support. Feasible national tobacco and alcohol tax increases could more than cover the cost of implementing the World Health Organization NCD "best buy" interventions in the CARICOM member countries and territories.

Conclusions: Priorities for further implementation of the mandates from the Port-of-Spain Declaration include establishing throughout the CARICOM member countries and territories fully functioning national bodies to support multisectoral action for NCD prevention; greater regional support in policy development and implementation for smaller countries; and greater targeted use of taxes on tobacco and alcohol to support NCD control and prevention.
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http://dx.doi.org/10.26633/RPSP.2018.193DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6385896PMC
December 2018

Regulatory measures to fight obesity in Small Island Developing States of the Caribbean and Pacific, 2015 - 2017.

Rev Panam Salud Publica 2018 17;42:e191. Epub 2018 Dec 17.

George Alleyne Chronic Disease Research Centre, Caribbean Institute for Health Research, The University of the West Indies, Bridgetown, Barbados.

This report examines the experiences of Small Island Developing States in the Caribbean- Barbados, Dominica, Jamaica, and in the Pacific- Fiji, Nauru, and Tonga with specific governmental regulatory measures to reduce the risk of obesity and associated diet-related chronic noncommunicable diseases (NCDs), as well as the obstacles and opportunities encountered. Guided by the diet-related indicators of the World Health Organization (WHO) Noncommunicable Diseases Progress Monitor 2017, the authors reviewed legislation, country reports, articles, and the databases of WHO and the World Trade Organization to identify relevant regulatory measures and to establish the extent of implementation in the selected countries. Obesity prevalence ranged from 25.9% in Dominica to 41.1% in Tonga. The principal diet-related measures implemented by the selected countries were fiscal measures, such as sugar-sweetened beverage taxes and import duties to encourage greater consumption of healthy foods. Governmental action was weakest in the area of restrictions on marketing of unhealthy foods. If they are to reduce their current high rates of obesity and associated NCDs, Caribbean and Pacific states need to intensify implementation of diet-related regulatory measures, particularly in the area of marketing of unhealthy foods and beverages to children. Key implementation challenges include financial and staffing constraints and the need for increased political will to counter industry opposition and to allocate adequate financial resources to keep advancing this agenda.
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http://dx.doi.org/10.26633/RPSP.2018.191DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6386011PMC
December 2018

Validating the self-reported annual monitoring grid for the 2007 Caribbean Community Declaration of Port-of-Spain on noncommunicable diseases.

Rev Panam Salud Publica 2018 17;42:e189. Epub 2018 Dec 17.

MRC Epidemiology Unit, University of Cambridge, Cambridge, United Kingdom.

Objectives: In 2007, the Caribbean Community (CARICOM) convened the world's first-ever heads of government summit on noncommunicable diseases (NCDs) and issued the landmark Declaration of Port-of-Spain: Uniting to Stop the Epidemic of Chronic NCDs. Since then, ministry of health (MoH) focal points in each country have self-reported annually on their NCD efforts, using a 26-indicator grid created to assess implementation of the Declaration. Our objective was to assess the validity of those grid responses, as compared to information from in-depth interviews and document reviews.

Methods: Seven national case studies on policy responses to the Declaration were undertaken in 2015. In-depth, semistructured interviews were conducted with stakeholders from multiple sectors, including the MoH. Policy documents were also identified and reviewed. The results from the 2015 case studies were compared to the 2014 MoH focal point grid responses. Kappa statistics evaluated chance agreement.

Results: The information from the grid and from the case studies agreed closely. Out of a total of 182 indicators (26 each for seven countries), there was a lack of agreement on just 9 (4.9%). All the differences were between policy statements and implementation. Except for physical activity, kappa statistics indicated that agreement was good to excellent for all the clusters of the grid and for the grid as a whole, but with wide confidence intervals.

Conclusions: In general, the monitoring grid accurately assessed the national situation, but with a possible tendency to overstate performance in some areas. These findings contributed to the design of a new, 50-indicator monitoring grid in 2016. Alongside these improvements, CARICOM countries face a substantial burden from having to complete many other required NCD reports, mainly for the Pan American Health Organization and the World Health Organization.
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http://dx.doi.org/10.26633/RPSP.2018.189DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6386129PMC
December 2018

Premature mortality from cardiovascular disease and diabetes in the Caribbean and associations with health care expenditure, 2001 - 2011.

Rev Panam Salud Publica 2018 17;42:e179. Epub 2018 Dec 17.

Medical Research Council Epidemiology Unit, University of Cambridge, Cambridge, United Kingdom.

Objective: To examine the historical trends of premature death due to cardiovascular disease and diabetes mellitus (CVD-DM) in the Caribbean and to identify any associations between these trends and health care expenditure.

Methods: Death data were obtained from the World Health Organization Mortality Database; population data, from the United Nations World Population prospects; and health care expenditure data, from the World Bank. In all, 17 Caribbean countries had mortality data; however, only 11 had both mortality and health care expenditure data available. The analyses explored country-level trends in age-standardized CVD-DM mortality rates using 3-year moving averages from 1995 - 2014 for women and men. Associations between secular mortality rate change and health care expenditure were considered.

Results: CVD-DM mortality rates ranged from 10.7 - 247.1 per 100 000, with a mean of 92.3 and standard deviation of 47.6. Of the 17 countries, 12 showed a reduction in premature CVD-DM mortality in both men and women, with others either showing no improvement or increases. Mortality rates for men were 1.46 times higher than for women. On average, there was a 68% increase in health care expenditure, with a 15.4% fall in CVD-DM mortality in women and 4.9% in men. Mixed effects modelling demonstrated a weak association between health care expenditure and declining CVD-DM mortality for both women -0.006 (95%CI = -0.014 - 0.001) and men -0.008 (95%CI = -0.017 - 0.001).

Conclusions: Findings suggest that progress has been made to reduce premature CVD-DM related mortality in a number of Caribbean countries. Differences between countries may be partly related to differences in health care system performance, although further research that considers confounders is needed.
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http://dx.doi.org/10.26633/RPSP.2018.179DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6386007PMC
December 2018

Health and other impacts of community food production in Small Island Developing States: a systematic scoping review.

Rev Panam Salud Publica 2018 17;42:e176. Epub 2018 Dec 17.

Medical Research Council Epidemiology Unit, University of Cambridge, Cambridge, United Kingdom.

Objective: To explore what is known on community-based food production initiatives (CFPIs) in Small Island Developing States, particularly the health, social, economic, and environmental impacts of and on CFPIs.

Methods: This was a systematic scoping review using 14 electronic databases to identify articles published from 1997 to 2016 on the topic of CFPIs in Small Island Developing States. From 8 215 articles found, 153 were eligible and abstracted. Analysis focused on geographic location, typology, methodology, study design, theoretical frameworks, and impacts.

Results: Most research was conducted in the Pacific or Caribbean (49% and 43% of studies, respectively) and primarily focused on fishing and crop farming (40%, 34%). Findings indicate a predominance of research focusing on the environmental impact of marine and coastal resources on CFPIs, and very limited evidence of CFPI impact on human health, particularly nutrition and diet-related outcomes. There was a lack of explicit theoretical frameworks to explain the impacts of CFPIs.

Conclusions: Evidence of impacts of CPFIs in Small Island Developing States is limited and the approaches taken are inconsistent. This review demonstrates the need and provides a basis for developing a coherent body of methods to examine the impacts of CFPIs and provide evidence to guide policy, especially as it relates to health.
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http://dx.doi.org/10.26633/RPSP.2018.176DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6385939PMC
December 2018

Evaluating policy responses to noncommunicable diseases in seven Caribbean countries: challenges to addressing unhealthy diets and physical inactivity.

Rev Panam Salud Publica 2018 17;42:e174. Epub 2018 Dec 17.

European Centre for Environment & Human Health, University of Exeter Medical School, Truro, United Kingdom.

Objective: To identify, assess, and compare existing policies on noncommunicable diseases (NCDs) in the Caribbean, gaps in policy responses, and the factors influencing successful policy development and implementation following the Port of Spain Declaration of 2007. Specifically, to examine policies that target the upstream determinants of two NCD risk factors-unhealthy diets and physical inactivity.

Methods: A total of 76 semi-structured interviews with 80 relevant stakeholders in government, the private sector, and civil society were complemented by policy document analysis. Interviews were analyzed pragmatically, framed by the CARICOM government commitments, the WHO NCD Action Plan, a Multiple Streams framework approach, and realist evaluation ideas.

Results: The most widely-reported policy successes involved health promotion activities (e.g., school meal programs) that leveraged multisectoral collaboration among government ministries, such as Health, Education, and Agriculture. Large policy gaps still exist around creating legislative, physical, and social environments to support healthy eating and physical activity at the population level. Multisectoral NCD commissions successfully reached across sectors, but had limited influence on policy development. Different policy levels emerged with national-level policies considered a lengthy process, while "On-the-ground" programming was considered faster to implement than national policies. External barriers included a reliance on food imports enabled by international trade agreements limited availability, quality, and affordability of healthy foods. International pushback limited legislation to reduce food imports and the absence of an international/regional framework, similar to the Framework Convention on Tobacco Control, further impedes efforts.

Conclusions: Regional collaboration and political support across sectors are essential to accelerating the pace of action to support healthy eating and active living environments. Policy "blueprints" could accelerate the process of development. Regional "NCD champions" could spearhead such responses and approaches.
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http://dx.doi.org/10.26633/RPSP.2018.174DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6385641PMC
December 2018

An updated systematic review and meta-analysis on the social determinants of diabetes and related risk factors in the Caribbean.

Rev Panam Salud Publica 2018 17;42:e171. Epub 2018 Dec 17.

Medical Research Council Epidemiology Unit, University of Cambridge, Cambridge, United Kingdom.

Objectives: To conduct an analysis of the most recent data on diabetes and its risk factors by gender and other social determinants of health to understand why its prevalence is higher among women than men in the Caribbean; to inform policy agenda-setting for diabetes prevention and control in the Caribbean; and to identify gaps in the evidence that require further research.

Methods: A previous systematic review of the literature describing studies conducted in the Caribbean that presented the distribution of diabetes, its outcomes, and risk factors, by one or more social determinants, was updated to include sources from 1 January 2007 - 31 December 2016. Surveys by the World Health Organization (WHO) were also included. Where data were sufficient, meta-analyses were undertaken.

Results: A total of 8 326 manuscripts were identified. Of those, 282 were selected for full text review, and 114, for abstraction. In all, 36 papers, including WHO-related surveys, had sufficient information for meta-analysis. More women compared to men were obese (OR: 2.1; 95%CI = 1.65 - 2.69), physically inactive (OR: 2.18; 95%CI = 1.75 - 2.72), and had diabetes (OR: 1.48; 95%CI = 1.25 - 1.76). More men smoked (OR: 4.27; 95%CI = 3.18 - 5.74) and had inadequate fruit and vegetable intake (OR: 1.37; 95%CI = 1.21 - 1.57).

Conclusion: Thirty-six papers were added to the previously conducted systematic review; of those, 13 were added to the meta-analysis. Diabetes and its risk factors (primarily obesity and physical inactivity) continue to disproportionately affect women in the Caribbean. Smoking interventions should be targeted at men in this geographic area.
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http://dx.doi.org/10.26633/RPSP.2018.171DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6385809PMC
December 2018

Global diet and health: old questions, fresh evidence, and new horizons.

Lancet 2019 05 4;393(10184):1916-1918. Epub 2019 Apr 4.

Medical Research Council Epidemiology Unit, University of Cambridge School of Clinical Medicine, Cambridge CB2 0QQ, UK; George Alleyne Chronic Disease Research Centre, University of the West Indies, Bridgetown, Barbados.

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http://dx.doi.org/10.1016/S0140-6736(19)30500-8DOI Listing
May 2019
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