The Chernobyl Disaster and Beyond: Implications of the Sendai Framework for Disaster Risk Reduction 2015-2030.

On the 30th anniversary of the Chernobyl disaster, Amina Aitsi-Selmi and Virginia Murray reflect on the importance of disaster preparedness.

Households with a stunted child and obese mother: trends and child feeding practices in a middle-income country, 1992-2008.

Middle-income countries in the intermediate stages of the nutrition transition are facing a complex picture of nutrition-related diseases with child stunting and maternal obesity coexisting within single households (SCOB). A debate exists as to whether SCOB is a true phenomenon or a statistical artefact. In this study, we examine time trends and determinants of SCOB in Egypt and test the hypothesis that increased child sugary snack consumption, and reduced fruit/vegetable consumption (markers of poor dietary diversity) are associated with SCOB. Data on 25,065 mothers and their children from the Egyptian Demographic and Health Surveys from 1992, 1995, 2005 and 2008 are used to examine trends in child stunting, maternal obesity and child-mother household type [normal/non-obese, stunted/non-obese, normal/obese, stunted/obese (SCOB)]. The association of child sugary snack and fruit/vegetable consumption with household type is also examined using multinomial logistic regression adjusting for maternal age, maternal education, child age, breastfeeding, household wealth and urban/rural residence. The prevalence of SCOB increased between the periods 1992/95 and 2005/08 despite reductions in stunting levels. This increase paralleled a rise in maternal obesity. Child sugary snack consumption was associated with higher odds (51 %) of belonging to a SCOB household compared with normal/non-obese households, while fruit/vegetable consumption was associated with lower odds (24 %). The results suggest the existence of a link between the rise in maternal obesity and an increase in SCOB, and an association between child sugary snack consumption and SCOB. Addressing SCOB may require a household-rather than individual-based approach to nutrition.

Alarming predictions for obesity and non-communicable diseases in the Middle East.

OBJECTIVE: The present study aimed to model obesity trends and future obesity-related disease for nine countries in the Middle East; in addition, to explore how hypothetical reductions in population obesity levels could ameliorate anticipated disease burdens. DESIGN: A regression analysis of cross-sectional data v. BMI showed age- and sex-specific BMI trends, which fed into a micro simulation with a million Monte Carlo trials for each country. We also examined two alternative scenarios where population BMI was reduced by 1 % and 5 %. SETTING: Statistical modelling of obesity trends was carried out in nine Middle East countries (Bahrain, Egypt, Iran, Jordan, Kuwait, Lebanon, Oman, Saudi Arabia and Turkey). SUBJECTS: BMI data along with disease incidence, mortality and survival data from national and sub-national data sets were used for the modelling process. RESULTS: High rates of overweight and obesity increased in both men and women in most countries. The burden of incident type 2 diabetes, CHD and stroke would be moderated with even small reductions in obesity levels. CONCLUSIONS: Obesity is a growing problem in the Middle East which requires government action on the primary prevention of obesity. The present results are important for policy makers to know the effectiveness of obesity interventions on future disease burden.

Education is associated with lower levels of abdominal obesity in women with a non-agricultural occupation: an interaction study using China's Four Provinces survey.

BACKGROUND: The prevalence of obesity is increasing rapidly in low- and middle-income countries (LMICs) as their populations become exposed to obesogenic environments. The transition from an agrarian to an industrial and service-based economy results in important lifestyle changes. Yet different socioeconomic groups may experience and respond to these changes differently. Investigating the socioeconomic distribution of obesity in LMICs is key to understanding the causes of obesity but the field is limited by the scarcity of data and a uni-dimensional approach to socioeconomic status (SES). This study splits socioeconomic status into two dimensions to investigate how educated women may have lower levels of obesity in a context where labour market opportunities have shifted away from agriculture to other forms of employment. METHODS: The Four Provinces Study in China 2008/09 is a household-based community survey of 4,314 people aged ≥60  years (2,465 women). It was used to investigate an interaction between education (none/any) and occupation (agricultural/non-agricultural) on high-risk central obesity defined as a waist circumference ≥80 cm. An interaction term between education and occupation was incorporated in a multivariate logistic regression model, and the estimates adjusted for age, parity, urban/rural residence and health behaviours (smoking, alcohol, meat and fruit & vegetable consumption). Complete case analyses were undertaken and results confirmed using multiple imputation to impute missing data. RESULTS: An interaction between occupation and education was present (P = 0.02). In the group with no education, the odds of central obesity in the sedentary occupation group were more than double those of the agricultural occupation group even after taking age group and parity into account (OR; 95%CI: 2.21; 1.52, 3.21), while in the group with any education there was no evidence of such a relationship (OR; 95%CI: 1.25; 0.92, 1.70). Health behaviours appeared to account for some of the association. CONCLUSION: These findings suggest that education may have a protective role in women against the higher odds of obesity associated with occupational shifts in middle-income countries, and that investment in women's education may present an important long term investment in obesity prevention. Further research could elucidate the mechanisms behind this association.

Research for food and health in Europe: themes, needs and proposals.

BACKGROUND: Diet, in addition to tobacco, alcohol and physical exercise, is a major factor contributing to chronic diseases in Europe. There is a pressing need for multidisciplinary research to promote healthier food choices and better diets. Food and Health Research in Europe (FAHRE) is a collaborative project commissioned by the European Union. Among its tasks is the description of national research systems for food and health and, in work reported here, the identification of strengths and gaps in the European research base. METHODS: A typology of nine research themes was developed, spanning food, society, health and research structures. Experts were selected through the FAHRE partners, with balance for individual characteristics, and reported using a standardised template. RESULTS: Countries usually commission research on food, and on health, separately: few countries have combined research strategies or programmes. Food and health are also strongly independent fields within the European Commission's research programmes. Research programmes have supported food and bio-technology, food safety, epidemiological research, and nutritional surveillance; but there has been less research into personal behaviour and very little on environmental influences on food choices - in the retail and marketing industries, policy, and regulation. The research is mainly sited within universities and research institutes: there is relatively little published research contribution from industry. DISCUSSION: National food policies, based on epidemiological evidence and endorsed by the World Health Organisation, recommend major changes in food intake to meet the challenge of chronic diseases. Biomedical and biotechnology research, in areas such as 'nutrio-genomics', 'individualised' diets, 'functional' foods and 'nutri-pharmaceuticals' appear likely to yield less health benefit, and less return on public investment, than research on population-level interventions to influence dietary patterns: for example policies to reduce population consumption of trans fats, saturated fats, salt and energy density. Research should now address how macro-diets, rather than micro-nutritional content, can be improved for beneficial impacts on health, and should evaluate the impact of market changes and policy interventions, including regulation, to improve public health. CONCLUSIONS: European and national research on food and health should have social as well as commercial benefits. Strategies and policies should be developed between ministries of health and national research funding agencies. Collaboration between member states in the European Union can yield better innovation and greater competitive advantage.

Under-reporting of tobacco use among Bangladeshi women in England.

BACKGROUND: This study investigates the prevalence of under-reported use of tobacco among Bangladeshi women and the characteristics of this group. METHODS: The 1999 and 2004 Health Survey for England included 996 Bangladeshi women aged 16 years and above, 302 with a valid saliva sample and 694 without. The main outcome measure was the prevalence of under-reported tobacco use. RESULTS: Fifteen per cent of Bangladeshi women with a saliva sample under-reported their personal tobacco use. Under-reporters were very similar to self-reported users except for being much more likely to report chewing paan without tobacco (47% versus 9%, P < 0.001). Under-reporters differed significantly from cotinine-validated non-users in most respects. Regression analyses confirmed that under-reporters and self-reported users were similar in age, education level and exposure to passive smoking. Under-reporters were older and less educated than cotinine-validated non-users. Both self-reported users [odds ratio (OR): 0.11, 95% confidence interval (CI): 0.04-0.30] and cotinine-validated non-users (OR: 0.42, 95% CI: 0.20-0.89) were far less likely to report chewing paan without tobacco compared with under-reporters. CONCLUSIONS: Contrary to our a priori hypothesis, under-reporters were not young, British-born, English-speaking women likely to be concealing smoking but resembled self-reported tobacco users except for being much more likely to report chewing paan without tobacco.

Protecting the Health and Well-being of Populations from Disasters: Health and Health Care in The Sendai Framework for Disaster Risk Reduction 2015-2030.

The Sendai Framework for Disaster Risk Reduction (DRR) 2015-2030 is the first of three United Nations (UN) landmark agreements this year (the other two being the Sustainable Development Goals due in September 2015 and the climate change agreements due in December 2015). It represents a step in the direction of global policy coherence with explicit reference to health, economic development, and climate change. The multiple efforts of the health community in the policy development process, including campaigning for safe schools and hospitals, helped to put people's mental and physical health, resilience, and well-being higher up the DRR agenda compared with its predecessor, the 2005 Hyogo Framework for Action. This report reflects on these policy developments and their implications and reviews the range of health impacts from disasters; summarizes the widened remit of DRR in the post-2015 world; and finally, presents the science and health calls of the Sendai Framework to be implemented over the next 15 years to reduce disaster losses in lives and livelihoods.

Addressing non-communicable diseases in disaster risk reduction - an issue of equity.

The issues raised by noncommunicable diseases (NCDs) during and after disasters are a challenge to equity within local communities, as well as between countries. Individuals with NCDs are particularly vulnerable in disasters and their aftermath given health systems are disrupted. Although welcome progress has been made in taking NCDs and equity into account in the UN General Assembly ratified agreement, the Sendai Framework for disaster risk reduction 2015-2030, there is need now for a clear plan of implementation.

Reducing risks to health and wellbeing at mass gatherings: the role of the Sendai Framework for Disaster Risk Reduction.

Mass gatherings of people at religious pilgrimages and sporting events are linked to numerous health hazards, including the transmission of infectious diseases, physical injuries, and an impact on local and global health systems and services. As with other forms of disaster, mass gathering-related disasters are the product of the management of different hazards, levels of exposure, and vulnerability of the population and environment, and require comprehensive risk management that looks beyond single hazards and response. Incorporating an all-hazard, prevention-driven, evidence-based approach that is multisectoral and multidisciplinary is strongly advocated by the Sendai Framework for Disaster Risk Reduction 2015-2030. This paper reviews some of the broader impacts of mass gatherings, the opportunity for concerted action across policy sectors and scientific disciplines offered by the year 2015 (including through the Sendai Framework), and the elements of a 21(st) century approach to mass gatherings.

Are estimates of socioeconomic inequalities in chronic disease artefactually narrowed by self-reported measures of prevalence in low-income and middle-income countries? Findings from the WHO-SAGE survey.

BACKGROUND: The use of self-reported measures of chronic disease may substantially underestimate prevalence in low-income and middle-income country settings, especially in groups with lower socioeconomic status (SES). We sought to determine whether socioeconomic inequalities in the prevalence of non-communicable chronic diseases (NCDs) differ if estimated by using symptom-based or criterion-based measures compared with self-reported physician diagnoses. METHODS: Using population-representative data sets of the WHO Study of Global Ageing and Adult Health (SAGE), 2007-2010 (n=42 464), we calculated wealth-related and education-related concentration indices of self-reported diagnoses and symptom-based measures of angina, hypertension, asthma/chronic lung disease, visual impairment and depression in three 'low-income and lower middle-income countries'-China, Ghana and India-and three 'upper-middle-income countries'-Mexico, Russia and South Africa. RESULTS: SES gradients in NCD prevalence tended to be positive for self-reported diagnoses compared with symptom-based/criterion-based measures. In China, Ghana and India, SES gradients were positive for hypertension, angina, visual impairment and depression when using self-reported diagnoses, but were attenuated or became negative when using symptom-based/criterion-based measures. In Mexico, Russia and South Africa, this distinction was not observed consistently. For example, concentration index of self-reported versus symptom-based angina were: in China: 0.07 vs. -0.11, Ghana: 0.04 vs. -0.21, India: 0.02 vs. -0.16, Mexico: 0.19 vs. -0.22, Russia: -0.01 vs. -0.02 and South Africa: 0.37 vs. 0.02. CONCLUSIONS: Socioeconomic inequalities in NCD prevalence tend to be artefactually positive when using self-report compared with symptom-based or criterion-based diagnostic criteria, with greater bias occurring in low-income countries. Using standardised, symptom-based measures would provide more valid estimates of NCD inequalities.

Education modifies the association of wealth with obesity in women in middle-income but not low-income countries: an interaction study using seven national datasets, 2005-2010.

BACKGROUND: Education and wealth may have different associations with female obesity but this has not been investigated in detail outside high-income countries. This study examines the separate and inter-related associations of education and household wealth in relation to obesity in women in a representative sample of low- and middle-income countries (LMICs). METHODS: The seven largest national surveys were selected from a list of Demographic and Health Surveys (DHS) ordered by decreasing sample size and resulted in a range of country income levels. These were nationally representative data of women aged 15-49 years collected in the period 2005-2010. The separate and joint effects, unadjusted and adjusted for age group, parity, and urban/rural residence using a multivariate logistic regression model are presented. RESULTS: In the four middle-income countries (Colombia, Peru, Jordan, and Egypt), an interaction was found between education and wealth on obesity (P-value for interaction <0.001). Among women with no/primary education the wealth effect was positive whereas in the group with higher education it was either absent or inverted (negative). In the poorer countries (India, Nigeria, Benin), there was no evidence of an interaction. Instead, the associations between each of education and wealth with obesity were independent and positive. There was a statistically significant difference between the average interaction estimates for the low-income and middle-income countries (P<0.001). CONCLUSIONS: The findings suggest that education may protect against the obesogenic effects of increased household wealth as countries develop. Further research could examine the factors explaining the country differences in education effects.

Interaction between education and household wealth on the risk of obesity in women in Egypt.

BACKGROUND: Obesity is a growing problem in lower income countries particularly among women. There are few studies exploring individual socioeconomic status indicators in depth. This study examines the interaction of education and wealth in relation to obesity, hypothesising that education protects against the obesogenic effect of wealth. METHODS: Four datasets of women of reproductive age from the Egyptian Demographic and Health Surveys spanning the period 1992-2008 are used to examine two distinct time periods: 1992/95 (N = 11097) and 2005/08 (N = 23178). The association in the two time periods between education level and household wealth in relation to the odds of being obese is examined, and the interaction between the two socioeconomic indicators investigated. Estimates are adjusted for age group and area of residence. RESULTS: An interaction was found between the association of education and wealth with obesity in both time periods (P-value for interaction <0.001). For women with the lowest education level, moving up one wealth quintile was associated with a 78% increase in the odds of obesity in 1992/95 (OR; 95%CI: 1.78; 1.65,1.91) and a 33% increase in 2005/08 (OR; 95%CI: 1.33; 1.26,1.39). For women with the highest level of education, there was little evidence of an association between wealth and obesity (OR; 95%CI: 0.82; 0.57,1.16 in 1992/95 and 0.95; 0.84,1.08 in 2005/08). Obesity levels increased most in women who were in the no/primary education, poorest wealth quintile and rural groups (absolute difference in prevalence percentage points between the two time periods: 20.2, 20.1, and 21.3 respectively). CONCLUSION: In the present study, wealth appears to be a risk factor for obesity in women with lower education levels, while women with higher education are protected. The findings also suggest that a reversal in the social distribution of obesity risk is occurring which can be explained by the large increase in obesity levels in lower socioeconomic groups between the two time periods.

Evaluating the causal relevance of diverse risk markers: horizontal systematic review.

OBJECTIVES: To develop a new methodology to systematically compare evidence across diverse risk markers for coronary heart disease and to compare this evidence with guideline recommendations. DESIGN: "Horizontal" systematic review incorporating different sources of evidence. DATA SOURCES: Electronic search of Medline and hand search of guidelines. Study selection Two reviewers independently determined eligibility of studies across three sources of evidence (observational studies, genetic association studies, and randomised controlled trials) related to four risk markers: depression, exercise, C reactive protein, and type 2 diabetes. Data extraction For each risk marker, the largest meta-analyses of observational studies and genetic association studies, and meta-analyses or individual randomised controlled trials were analysed. RESULTS: Meta-analyses of observational studies reported adjusted relative risks of coronary heart disease for depression of 1.9 (95% confidence interval 1.5 to 2.4), for top compared with bottom fourths of exercise 0.7 (0.5 to 1.0), for top compared with bottom thirds of C reactive protein 1.6 (1.5 to 1.7), and for diabetes in women 3.0 (2.4 to 3.7) and in men 2.0 (1.8 to 2.3). Prespecified study limitations were more common for depression and exercise. Meta-analyses of studies that allowed formal Mendelian randomisation were identified for C reactive protein (and did not support a causal effect), and were lacking for exercise, diabetes, and depression. Randomised controlled trials were not available for depression, exercise, or C reactive protein in relation to incidence of coronary heart disease, but trials in patients with diabetes showed some preventive effect of glucose control on risk of coronary heart disease. None of the four randomised controlled trials of treating depression in patients with coronary heart disease reduced the risk of further coronary events. Comparisons of this horizontal evidence review with two guidelines published in 2007 showed inconsistencies, with depression prioritised more in the guidelines than in our review. CONCLUSIONS: This horizontal systematic review pinpoints deficiencies and strengths in the evidence for depression, exercise, C reactive protein, and diabetes as unconfounded and unbiased causes of coronary heart disease. This new method could be used to develop a field synopsis and prioritise future development of guidelines and research.

2006 Harben Lecture. World poverty and population health: the need for sustainable change.

Despite important recent initiatives to improve the health of the most disadvantaged in the world (the Millennium Development Goals, debt cancellation campaigns), poverty and preventable diseases still plague many parts of the globe. Sub-Saharan Africa remains one of the most severely affected. It is the only region in the world where life expectancy has not seen much improvement. Some countries have employed strategies of investment in public services, such as education, with positive results (e.g. the 'tiger economies'). Others have tried to follow prescribed strategies from global institutions such as the International Monetary Fund and World Bank with varying degrees of success. Sustainable development will require continuous commitment from donors and recipients to long-term strategies. Oxfam believes investment in public services and education is key to sustainability, in combination with more effective debt cancellation. These concepts are explored in the 2006 Harben Lecture given by Barbara Stocking, Director of Oxfam.