Progress towards universal health coverage and inequalities in infant mortality: an analysis of 4·1 million births from 60 low-income and middle-income countries between 2000 and 2019.

BACKGROUND: Expanding universal health coverage (UHC) might not be inherently beneficial to poorer populations without the explicit targeting and prioritising of low-income populations. This study examines whether the expansion of UHC between 2000 and 2019 is associated with reduced socioeconomic inequalities in infant mortality in low-income and middle-income countries (LMICs). METHODS: We did a retrospective analysis of birth data compiled from Demographic and Health Surveys (DHSs). We analysed all births between 2000 and 2019 from all DHSs available for this period. The primary outcome was infant mortality, defined as death within 1 year of birth. Logistic regression models with country and year fixed effects assessed associations between country-level progress to UHC (using WHO's UHC service coverage index) and infant mortality (overall and by wealth quintile), adjusting for infant-level, mother-level, and country-level variables. FINDINGS: A total of 4 065 868 births to 1 833 011 mothers were analysed from 177 DHSs covering 60 LMICs between 2000 and 2019. A one unit increase in the UHC index was associated with a 1·2% reduction in the risk of infant death (AOR 0·988, 95% CI 0·981-0·995; absolute measure of association, 0·57 deaths per 1000 livebirths). An estimated 15·5 million infant deaths were averted between 2000 and 2019 because of increases in UHC. However, richer wealth quintiles had larger associated reductions in infant mortality from UHC (quintile 5 AOR 0·983, 95% CI 0·973-0·993) than poorer quintiles (quintile 1 0·991, 0·985-0·998). In the early stages of UHC, UHC expansion was generally beneficial to poorer populations (ie, larger reductions in infant mortality for poorer households [infant deaths per 1000 per one unit increase in UHC coverage: quintile 1 0·84 vs quintile 5 0·59]), but became less so as overall coverage increased (quintile 1 0·64 vs quintile 5 0·57). INTERPRETATION: Since UHC expansion in LMICs appears to become less beneficial to poorer populations as coverage increases, UHC policies should be explicitly designed to ensure lower income groups continue to benefit as coverage expands. FUNDING: UK National Institute for Health and Care Research.

Changes in diet and physical activity following a community-wide pilot intervention to tackle childhood obesity in a deprived inner-London ward.

BACKGROUND: Local authorities in England have an important role in shaping healthy local environments contributing to childhood obesity. This study examined changes in diet and physical activity in primary school children following a three-year, complex, community-based intervention in Golborne ward, the second most deprived ward in London. METHODS: The Go-Golborne intervention aimed to shape the local environment across multiple settings with the engagement of a large number of local government and community stakeholders in a joint approach. Activities focused on six co-created themes to make changes to local environments and reduce sugary snacks and beverage consumption, increase fruit and vegetable intake, promote healthy snacks, increase active play and travel, and reduce screen time. We analysed changes in self-reported diet and physical activity, collected annually between 2016 and 2019, from 1,650 children aged 6-11 years through six local schools, who all received the intervention. We used multilevel, linear and logistic random-slope regression models adjusted for time on study, baseline age, gender, ethnicity, deprivation quintile, school, and baseline weight status. RESULTS: After three years of follow-up, there were reductions in sugar-sweetened beverage consumption (adjusted beta -0·43 occasions/day, 95% CI -0·55 to -0·32), fruit and vegetable consumption (adjusted beta -0.22 portions, 95% CI -0.44 to 0.001) and car travel to and from school (adjusted OR 0·19, 95% CI 0·06 to 0·66), while screen time increased (high versus moderate/low: OR 2·30, 95% CI 1·36 to 3·90). For other behavioural outcomes, there was no statistically significant evidence of changes. CONCLUSION: Local authorities have substantial powers to make positive changes to the obesogenic environment but programmes remain under-evaluated. Results from the ambitious Go-Golborne intervention demonstrated mixed results in health behaviours following programme implementation. These results underline the importance of a coordinated and comprehensive policy response to support changes in wider environmental and social conditions as well as appropriate and holistic evaluations of initiatives to inform local actions on obesogenic environments.

The effect of nutrition-specific and nutrition-sensitive interventions on the double burden of malnutrition in low-income and middle-income countries: a systematic review.

BACKGROUND: Low-income and middle-income countries (LMICs) experiencing nutrition transition face an increasing double burden of malnutrition (DBM). WHO has urged the identification of risks and opportunities in nutrition interventions to mitigate the DBM, but robust evidence is missing. This review summarises the effect of nutrition-specific and nutrition-sensitive interventions on undernutrition and overnutrition in LMICs. METHODS: We searched four major databases and grey literature for publications in English, French, Portuguese, and Spanish from Jan 1, 2000, to Aug 14, 2023. Eligible studies evaluated nutrition-specific or nutrition-sensitive interventions on both undernutrition and overnutrition, employing robust study designs (individually randomised, cluster randomised, and non-randomised trials; interrupted time series; controlled before-after; and prospective cohort studies). Studies were synthesised narratively, and classified as DBM-beneficial, potentially DBM-beneficial, DBM-neutral, potentially DBM-harmful, and DBM-harmful, using vote counting. This review is registered with PROSPERO (CRD42022320131). FINDINGS: We identified 26 studies evaluating 20 nutrition-specific (maternal and child health [MCH] and school-based programmes) and six nutrition-sensitive (conditional cash transfers and other social policies) interventions. Seven of eight MCH interventions providing food-based or nutritional supplements indicated possible DBM-harmful effects, associated with increased maternal or child overweight. Most school-based programmes and MCH interventions that target behavioural change were considered potentially DBM-beneficial. Two studies of conditional cash transfers suggested DBM-beneficial effects in children, whereas one indicated potentially harmful effects on maternal overweight. A study on a family planning service and one on an education reform revealed possible long-term harmful effects on obesity. INTERPRETATION: There is considerable scope to repurpose existing nutrition interventions to reduce the growing burden of the DBM in LMICs. In settings undergoing rapid nutrition transition, specific policy attention is required to ensure that food-based or supplement-based MCH programmes do not unintentionally increase maternal or child overweight. Consistent reporting of undernutrition and overnutrition outcomes in all nutrition interventions is essential to expand the evidence base to identify and promote interventions maximising benefits and minimising harms on the DBM. FUNDING: President's Scholarship (Imperial College London) and National Institute for Health and Care Research. TRANSLATIONS: For the Portuguese, Spanish and French translations of the abstract see Supplementary Materials section.

Global inequalities in the double burden of malnutrition and associations with globalisation: a multilevel analysis of Demographic and Health Surveys from 55 low-income and middle-income countries, 1992-2018.

BACKGROUND: Low-income and middle-income countries (LMICs) face a double burden of malnutrition (DBM), whereby overnutrition and undernutrition coexist within the same individual, household, or population. This analysis investigates global inequalities in household-level DBM, expressed as a stunted child with an overweight mother, and its association with economic, social, and political globalisation across country income and household wealth. METHODS: We pooled anthropometric and demographic data for 1 132 069 children (aged <5 years) and their mothers (aged 15-49 years) from 189 Demographic and Health Surveys in 55 LMICs between 1992 and 2018. These data were combined with country-level data on economic, social, and political globalisation from the Konjunkturforschungsstelle Globalisation Index and gross national income (GNI) from the World Bank. Multivariate associations between DBM and household wealth, GNI, and globalisation and their interactions were tested using multilevel logistic regression models with country and year fixed-effects and robust standard errors clustered by country. FINDINGS: The probability of DBM was higher among richer households in poorer LMICs and poorer households in richer LMICs. Economic globalisation was associated with higher odds of DBM among the poorest households (odds ratio 1·49, 95% CI 1·20-1·86) compared with the richest households. These associations attenuated as GNI increased. Social globalisation was associated with higher odds of DBM (1·39, 95% CI 1·16-1·65), independently of household wealth or country income. No associations were identified between political globalisation and DBM. INTERPRETATION: Increases in economic and social globalisation were associated with higher DBM, although the impacts of economic globalisation were mostly realised by the world's poorest. The economic patterning of DBM observed in this study calls for subpopulation-specific double-duty actions, which should further aim to mitigate the potential negative and unequal impacts of globalisation. FUNDING: UK Biotechnology and Biological Sciences Research Council. TRANSLATIONS: For the Spanish and Portuguese translations of the abstract see Supplementary Materials section.

Prevalence and socioeconomic determinants of the double burden of malnutrition in mother-child pairs in Latin America and the Caribbean.

Background: The double burden of malnutrition (DBM), which refers to the coexistence of overnutrition and undernutrition among populations, households or individuals, is a growing problem in low/middle-income countries. The Latin America and the Caribbean (LAC) region has been particularly affected by the DBM, following a nutrition transition and a rapid increase in overweight, obesity and diet-related disease, while high levels of undernutrition persist. This study aims to describe the prevalence of four different DBM definitions in mother-child pairs across nine LAC countries and investigate the socioeconomic determinants of overweight mothers with at least one stunted child (SCOM). Methods: We used cross-sectional data from the Demographic and Health Surveys for all analyses. We used descriptive statistics to obtain prevalence rates and conducted multiple logistic regression analyses to investigate the association between SCOM households and socioeconomic determinants, including wealth index, maternal education, place of residency and whether the mother was working, adjusted for a range of variables. Results: Overweight/obese mothers with at least one anaemic child were the most common type of DBM, with a prevalence of 19.39%, followed by SCOM with a prevalence of 10.44%. Statistically significant socioeconomic predictors of SCOM were households with a lower wealth index, lower maternal education and living in rural areas. Conclusion: This study showed that the overall prevalence of most DBM definitions examined was high, which points to the need for urgent interventions in the LAC region. The unique set of socioeconomic predictors of SCOM identified in this study calls for future double-duty policies that simultaneously target food affordability, nutrition education and access to healthy food.

Potential impacts of post-Brexit agricultural policy on fruit and vegetable intake and cardiovascular disease in England: a modelling study.

BACKGROUND: Current proposals for post-Brexit agricultural policy do not explicitly incorporate public health goals. The revised agricultural policy may be an opportunity to improve population health by supporting domestic production and consumption of fruits and vegetables (F&V). This study aims to quantify the potential impacts of a post-Brexit agricultural policy that increases land allocated to F&V on cardiovascular disease (CVD) mortality and inequalities in England, between 2021 to 2030. METHODS: We used the previously validated IMPACT Food Policy model and probabilistic sensitivity analysis to translate changes in land allocated to F&V into changes in F&V intake and associated CVD deaths, stratified by age, sex and Index of Multiple Deprivation. The model combined data on F&V agriculture, waste, purchases and intake, CVD mortality projections and appropriate relative risks. We modelled two scenarios, assuming that land allocated to F&V would gradually increase to 10% and 20% of land suitable for F&V production. RESULTS: We found that increasing land use for F&V production to 10% and 20% of suitable land would increase fruit intake by approximately 3.7% (95% uncertainty interval: 1.6% to 8.6%) and 17.4% (9.1% to 36.9%), and vegetable intake by approximately 7.8% (4.2% to 13.7%) and 37% (24.3% to 55.7%), respectively, in 2030. This would prevent or postpone approximately 3890 (1950 to 7080) and 18 010 (9840 to 28 870) CVD deaths between 2021 and 2030, under the first and second scenario, respectively. Both scenarios would reduce inequalities, with 16% of prevented or postponed deaths occurring among the least deprived compared with 22% among the most deprived. CONCLUSION: Post-Brexit agricultural policy presents an important opportunity to improve dietary intake and associated cardiovascular mortality by supporting domestic production of F&V as part of a comprehensive strategy that intervenes across the supply chain.

Impact of the economic crisis on household health expenditure in Greece: an interrupted time series analysis.

OBJECTIVES AND SETTING: The 2008 financial crisis had a particularly severe impact on Greece. To contain spending, the government capped public health expenditure and introduced increased cost-sharing. The Greek case is important for studying the impact of recessions on health systems. This study analysed changes in household health expenditure in Greece over the economic crisis and explored whether the impact differed across socioeconomic groups. PARTICIPANTS: We used data from the Greek Household Budget Survey for the years 2004 and 2008-2017. The dataset comprised 51 654 households, with a total of 128 111 members. DESIGN: We compared pre-crisis and post-crisis trends in Greek household out-of-pocket payments for healthcare from 2004 to 2017 using an interrupted time series analysis. This study explored spending in euros and as a share of total household purchases. RESULTS: Our results indicated that the population level trend in household health spending was reversed after the crisis began (pre-crisis trend: €0.040 decrease per quarter (95% CI: -0.785 to -0.022), post-crisis trend: €0.315 increase per quarter (95% CI: -0.004 to 0.635)). We also found that spending on inpatient services and pharmaceuticals has been increasing since the start of the crisis, whereas outpatient services expenditure has been decreasing. Across all households, out-of-pocket payments incurred a greater financial burden after the crisis relative to pre-existing trends, but the poorest households incurred a disproportionately higher burden. CONCLUSIONS: This was the first study to use an interrupted time series analysis to assess the impact of the economic crisis on household health expenditure in Greece. Our findings suggest that there was an erosion of financial protection for Greek households as a consequence of the economic crisis. This effect was particularly pronounced among poorer households, which is indicative of a regressive financing system.

Quantifying the impact of the Public Health Responsibility Deal on salt intake, cardiovascular disease and gastric cancer burdens: interrupted time series and microsimulation study.

BACKGROUND: In 2011, England introduced the Public Health Responsibility Deal (RD), a public-private partnership (PPP) which gave greater freedom to the food industry to set and monitor targets for salt intakes. We estimated the impact of the RD on trends in salt intake and associated changes in cardiovascular disease (CVD) and gastric cancer (GCa) incidence, mortality and economic costs in England from 2011-2025. METHODS: We used interrupted time series models with 24 hours' urine sample data and the IMPACTNCD microsimulation model to estimate impacts of changes in salt consumption on CVD and GCa incidence, mortality and economic impacts, as well as equity impacts. RESULTS: Between 2003 and 2010 mean salt intake was falling annually by 0.20 grams/day among men and 0.12 g/d among women (P-value for trend both < 0.001). After RD implementation in 2011, annual declines in salt intake slowed statistically significantly to 0.11 g/d among men and 0.07 g/d among women (P-values for differences in trend both P < 0.001). We estimated that the RD has been responsible for approximately 9900 (interquartile quartile range (IQR): 6700 to 13,000) additional cases of CVD and 1500 (IQR: 510 to 2300) additional cases of GCa between 2011 and 2018. If the RD continues unchanged between 2019 and 2025, approximately 26 000 (IQR: 20 000 to 31,000) additional cases of CVD and 3800 (IQR: 2200 to 5300) cases of GCa may occur. INTERPRETATION: Public-private partnerships such as the RD which lack robust and independent target setting, monitoring and enforcement are unlikely to produce optimal health gains.

Impacts of Brexit on fruit and vegetable intake and cardiovascular disease in England: a modelling study.

OBJECTIVES: To estimate the potential impacts of different Brexit trade policy scenarios on the price and intake of fruits and vegetables (F&V) and consequent cardiovascular disease (CVD) deaths in England between 2021 and 2030. DESIGN: Economic and epidemiological modelling study with probabilistic sensitivity analysis. SETTING: The model combined publicly available data on F&V trade, published estimates of UK-specific price elasticities, national survey data on F&V intake, estimates on the relationship between F&V intake and CVD from published meta-analyses and CVD mortality projections for 2021-2030. PARTICIPANTS: English adults aged 25 years and older. INTERVENTIONS: We modelled four potential post-Brexit trade scenarios: (1) free trading agreement with the EU and maintaining half of non-EU free trade partners; (2) free trading agreement with the EU but no trade deal with any non-EU countries; (3) no-deal Brexit; and (4) liberalised trade regime that eliminates all import tariffs. OUTCOME MEASURES: Cumulative coronary heart disease and stroke deaths attributed to the different Brexit scenarios modelled between 2021 and 2030. RESULTS: Under all Brexit scenarios modelled, prices of F&V would increase, especially for those highly dependent on imports. This would decrease intake of F&V between 2.5% (95% uncertainty interval: 1.9% to 3.1%) and 11.4% (9.5% to 14.2%) under the different scenarios. Our model suggests that a no-deal Brexit scenario would be the most harmful, generating approximately 12 400 (6690 to 23 390) extra CVD deaths between 2021 and 2030, whereas establishing a free trading agreement with the EU would have a lower impact on mortality, contributing approximately 5740 (2860 to 11 910) extra CVD deaths. CONCLUSIONS: Trade policy under all modelled Brexit scenarios could increase price and decrease intake of F&V, generating substantial additional CVD mortality in England. The UK government should consider the population health implications of Brexit trade policy options, including changes to food systems.

Implications of Brexit on the effectiveness of the UK soft drinks industry levy upon CHD in England: a modelling study.

OBJECTIVE: An industry levy on sugar-sweetened beverages (SSB) was implemented in the UK in 2018. One year later, Brexit is likely to change the UK trade regime with potential implications for sugar price. We modelled the effect of potential changes in sugar price due to Brexit on SSB levy impacts upon CHD mortality and inequalities. DESIGN: We modelled a baseline SSB levy scenario; an SSB levy under 'soft' Brexit, where the UK establishes a free trading agreement with the EU; and an SSB levy under 'hard' Brexit, in which World Trade Organization tariffs are applied. We used the previously validated IMPACT Food Policy model and probabilistic sensitivity analysis to estimate the effect of each scenario on CHD deaths prevented or postponed and life-years gained, stratified by age, sex and socio-economic circumstance, in 2021. SETTING: England. SUBJECTS: Adults aged 25 years or older. RESULTS: The SSB levy was associated with approximately 370 (95 % uncertainty interval 220, 560) fewer CHD deaths and 4490 (2690, 6710) life-years gained in 2021. Associated reductions in CHD mortality were 4 and 8 % greater under 'soft' and 'hard' Brexit scenarios, respectively. The SSB levy was associated with approximately 110 (50, 190) fewer CHD deaths in the most deprived quintile compared with 60 (20, 100) in the most affluent, under 'hard' Brexit. CONCLUSIONS: Our study found the SSB levy resilient to potential effects of Brexit upon sugar price. Even under 'hard' Brexit, the SSB levy would yield benefits for CHD mortality and inequalities. Brexit negotiations should deliver a fiscal and regulatory environment which promotes population health.

Relation of unprocessed, processed red meat and poultry consumption to blood pressure in East Asian and Western adults.

BACKGROUND: Epidemiologic evidence suggests that relationships of red meat consumption with risk of cardiovascular diseases depends on whether or not the meat is processed, including addition of preservatives, but evidence is limited for blood pressure (BP). OBJECTIVE: To examine cross-sectional associations with BP of unprocessed and processed red meat and poultry consumption, total and by type, using data from the INTERnational study on MAcro/micronutrients and blood Pressure. DESIGN: INTERnational study on MAcro/micronutrients and blood Pressure included 4680 men and women ages 40-59 years from 17 population samples in Japan, China, the United Kingdom, and the United States. During four visits, eight BP measurements, four multipass 24-h dietary recalls, and two timed 24-h urine samples were collected. RESULTS: Average daily total unprocessed/processed meat consumption (g/1000 kcal) was 20/5 in East Asian and 38/21 in Western participants. Unprocessed meat intakes comprised red meat for 75% in East Asian and 50% in Western participants. In Westerners, multiple linear regression analyses showed SBP/DBP differences for total unprocessed red meat consumption higher by 25 g/1000 kcal +0.74/+0.57 mmHg (P = 0.03/0.01) and for unprocessed poultry of +0.79/+0.16 mmHg (P = 0.02/0.50). Unprocessed red meat was not related to BP in East Asian participants. In Westerners, SBP/DBP differences for processed red meat higher by 12.5 g/1000 kcal were +1.20/+0.24 mmHg (P < 0.01/0.24), due to consumption of cold cuts and sausages (+1.59/+0.32 mmHg, P < 0.001/0.27). CONCLUSION: These findings are consistent with recommendations to limit meat intake (processed and unprocessed) to maintain and improve cardiovascular health.