A food policy package for healthy diets and the prevention of obesity and diet-related non-communicable diseases: the NOURISHING framework

Obesity is a major influence on the development and course of cardiovascular diseases and affects physical and social functioning and quality of life. The importance of effective interventions to reduce obesity and related health risks has increased in recent decades because the number of adults and children who are obese has reached epidemic proportions. To prevent the development of overweight and obesity throughout the life course, population-based strategies that improve social and physical environmental contexts for healthful eating and physical activity are essential. Population-based approaches to obesity prevention are complementary to clinical preventive strategies and also to treatment programs for those who are already obese. This American Heart Association scientific statement aims: 1) to raise awareness of the importance of undertaking population-based initiatives specifically geared to the prevention of excess weight gain in adults and children; 2) to describe considerations for undertaking obesity prevention overall and in key risk subgroups; 3) to differentiate environmental and policy approaches to obesity prevention from those used in clinical prevention and obesity treatment; 4) to identify potential targets of environmental and policy change using an ecological model that includes multiple layers of influences on eating and physical activity across multiple societal sectors; and 5) to highlight the spectrum of potentially relevant interventions and the nature of evidence needed to inform population-based approaches. The evidence-based experience for population-wide approaches to obesity prevention is highlighted.

Introduction Noncommunicable diseases (NCDs) are the leading cause of death globally. Of the 57 million global deaths in 2008, 36 million (63%) were due to NCDs, principally cardiovascular diseases, diabetes, cancers, and chronic respiratory diseases [1]. Mortality and morbidity data reveal the growing and disproportional impact of the epidemic in low- and middle-income countries (LMICs). Nearly 80% of the yearly NCD deaths—equivalent to 29 million people—are estimated to occur in LMICs. Without effective prevention and control, an estimated 41 million people in LMICs will die from NCDs by 2015 [2]. NCDs will evolve into a staggering economic burden over the next two decades [3]. Poor dietary quality (in particular, high salt intake, high saturated and trans-fatty acid intake, and low fruit and vegetable consumption) and insufficient physical activity are key risk factors for NCD development [4] and mortality worldwide [5], and are considered priority areas for international action [6]. The mean salt intake in most LMICs exceeds the recommended maximum intake [7]. Reducing salt intake to about 6 g/d could prevent annually about 2.5 million deaths globally [8]–[11], and a 15% reduction of salt intake over a decade in LMICs could forestall 3.1 million deaths [11],[12]. Fruit and vegetable intake is inadequate [13], and this situation contributes to 2.7 million NCD-related deaths per year. Despite evidence indicating that proper levels of physical activity are associated with a 30% reduction in the risk of ischemic heart disease, a 27% reduction in the risk of diabetes, and a 21%–25% reduction in the risk of breast and colon cancer [14],[15], approximately 3.2 million deaths each year are attributable to insufficient physical activity [6]. Physical inactivity is increasingly becoming prevalent in LMICs and already constitutes one of the leading causes of mortality [16]. There is also concern about excess intake of saturated and transfatty acids in LMICs, although large regional differences are observed [17],[18]. Preventing NCDs is not impossible [19]. Cecchini and colleagues analyzed population-based strategies to prevent NCDs in a number of LMICs with a high burden of NCDs [4]. Health information and communication strategies, fiscal measures, and regulatory measures for marketing or provision of nutrition information to children that promotes healthy eating and physical activity were found to yield substantial and cost-effective health gains, in particular in LMICs [4]. In addition, these interventions were found to be particularly effective when delivered as a multi-intervention package. Hence, it is crucial to translate the available evidence into sustainable policies in LMICs [6]. In May 2004, all WHO member states endorsed the Global Strategy on Diet, Physical Activity and Health, aiming to address NCDs through diet and physical activity [20]. Recently, a United Nations high-level meeting convened to discuss measures to prevent and control the global NCD epidemic and stressed the need to accelerate the policy response to it [21]. Monitoring this international commitment is important and can be achieved by systematic policy reviews. Previous policy reviews [22],[23], however, provided only a partial view of efforts undertaken to address NCDs, as they relied on survey data and did not consider the actual content of the policies. As policy documents are the culmination of existing social processes, they reflect the views of various stakeholders and are considered to be a reliable account of prevailing policy paradigms in a country [24]. We carried out a stocktaking exercise on national policy actions for NCD prevention in LMICs, and assessed the extent to which these address critical risk factors for NCDs, i.e., salt, fat, and fruit and vegetable intake, and physical inactivity. We focused on the existence and content of policies for the prevention of NCDs, not on their actual implementation. Methods Collection of Policy Documents We searched the Internet (key words [“Nutrition” OR “NCD”] AND [“Policy” OR “Strategies” OR “Actions”]) for all publicly available national policies related to diet, nutrition, NCDs, and health in the countries classified as LMICs by the World Bank in 2011 [25]. We also searched the websites of the national ministries involved in nutrition or NCD prevention (i.e., ministries of health, sports, welfare, social affairs, or agriculture) and government portals as well as national nutrition societies. For those countries for which no policy was retrieved through the web search, an e-mail request stating the purpose of the study was sent to the respective bodies. A similar e-mail request was also sent to the WHO Regional Offices and to personal contacts of the research team. When no reply was obtained after repeated contact attempts and no reference to the existence of relevant policy documents was found during our Internet search, we classified the country as one for which we were unable to assess availability of policies. In addition to our search, we used the policy database of the WHO Regional Office for Europe [26] to assess policy availability. Screening and Selection of Documents The following inclusion criteria were used to include the policies in the analysis: (i) the policy is from a country classified as LMIC according to 2011 World Bank classification [25], (ii) the policy is officially approved by the national government, (iii) the policy is a publicly available document, published between 1 January 2004 and 1 January 2013, and (iv) the policy relates directly or indirectly to prevention of NCDs (Text S1). We report our findings as a systematic policy review (Text S2). Because we present our results by WHO region, we also excluded countries that were not official member states of WHO in 2011. There was no language restriction. The definitions of “policy,” “action plan,” and “program” vary broadly among the national documents. For the purpose of the present review, a broad definition of policy was used, and all national documents that included the national objectives and guidelines for action in the domain of diet and/or physical activity and/or prevention of NCDs were included. No document was excluded based on its title (e.g., “plan” versus “policy” versus “strategy”). Data Analysis Structured content analysis was conducted by coding the documents in NVivo 8 (QSR International). The documents were coded independently by two researchers to minimize bias induced by subjective coding. The coded documents were compared, and if coding agreement was 30% of total calories, compared to the First Malaysian Food Consumption Survey; Viet Nam: Proportion of households with a diet with 14% of protein, 16% of lipids and 5–68% of carbohydrates is 50% by 2015 and 75% by 2020 WHO classification of regions and countries was followed. Four of the countries (Mayotte, West Bank and Gaza, the Republic of Kosovo, and American Samoa) classified as LMICs by the World Bank in 2011 [25] were not WHO member states in 2011. a The policy document of FYRM reports that goals are in line with those of WHO [106]. The stated goal of 400 g/d Cuba: Increase the proportion of the population consuming at least 200 g of FV by 40% and consuming at least three portions of vegetables per day or 300 g by 50%; Jamaica: A 20% increase in consumption of FV by December 2008; Brazil: Increase FV consumption Indonesia: Increase consumption of FV daily; Bangladesh: Increase production of noncereal crops (FV, oilseeds, pulses) Fiji: Increase intake of FV and promote healthy and safe diets to reduce NCDs; Malaysia: Diversify diets to increase the consumption of micronutrient-rich foods including FV; increase proportion of people consuming FV; Mongolia and Samoa: Increase the consumption of FV by households; Philippines: Increase per capita total vegetable consumption from 111 g/d to 133 g/d WHO classification of regions and countries was followed. Four of the countries (Mayotte, West Bank and Gaza, the Republic of Kosovo, and American Samoa) classified as LMICs by the World Bank in 2011 [25] were not WHO member states in 2011. FV, fruits and vegetables; FYRM, the former Yugoslav Republic of Macedonia; NR, not reported. Policy Actions to Increase Physical Activity and Address Sedentary Lifestyle Public education and sensitization were the main strategies to promote physical activity in the policies (Table 4). Whereas countries such as Morocco [59], Mongolia [69], and Mauritius [63] targeted educational institutions, others, such as Bhutan [66], Guyana [79], and Malaysia [76], focused on workplaces. Samoa [80], the Niger [61], Indonesia [81], India [82], and Cambodia [71] targeted the community at large. Nine countries (Kenya [60], Morocco [59], Cuba [83], Uruguay [58], Jamaica [65], Brazil [75], Malaysia [76], the Philippines [73], and China [84]) proposed national policy targets for physical activity (Table 4). 10.1371/journal.pmed.1001465.t004 Table 4 National policy actions and targets to promote physical activity by WHO region and target group. Target Group African Region Eastern Mediterranean Region European Region Region of the Americas South-East Asia Region Western Pacific Region General public and consumers Ghana: Encourage regular exercisea; Mauritius: Emphasize maintaining a healthy weight by undertaking adequate PA in the dietary guidelines; Niger: Promote healthy lifestyles in families and communities so that sport and relaxation are widespread in neighborhoods; Kenya: Train health workers on PA; organize sensitization meeting on PA in counties Djibouti: Promote PA and the creation of playgrounds; Morocco: Promote PA in schools and universities Georgia: Make school sports facilities available for public use; provide nationwide evidence-based advocacy on the health, social, and economic benefits of PA; create an environment conducive for PA; urban planning policy choices should include: plan for stadia, safe walking routes, safe cycling routes, shelters from poor weather, and recreational facilities; Republic of Moldova: Population-wide communication to promote PA, including in elderly and sedentary population; Turkey: Provide correct information to the public by written and visual media on active life and obesity; FYRM: Recommendations for proper nutrition are always followed by recommendations for PA; Montenegro: Support local government in designing models for PA facilities and building of safe roads for bikers and pedestrians in settlements; conduct educative programs on the importance of PA in school curriculum; Serbia: Promote and implement PA in everyday life in population Chile: Promote PA at workplaces, disseminate PA guidelines to the population, preschool and school children; Costa Rica: Promote healthy lifestyles and PA and recreation; Cuba: Promote intersectoral participation in systematic PA at the workplace and intersectoral participation in systematic PA in the general population; Guyana: Promote PA in communities and schools; Uruguay: Develop guidelines for PA and lifestyle for the general population; Guatemala: Apply strategies and measures to promote good health that include PA, especially in the workplace and schools; multisectoral workshops for the formation of local and national PA networks; Brazil: Promote active aging, e.g., through private health plans, and encourage the elderly to engage in regular PA; encourage PA in children on an everyday basis and throughout life; promote leisure PA and healthy lifestyle for children and young people; guidelines promote providing two physical education classes a week at schools; communication and education campaign to promote health through PA Bhutan: Advocate at the population level for PA in the workplace; encourage walking and regular physical exercise, with a focus on the urban and more sedentary population; increase PA at the population level by enhancing understanding among the general public that more PA leads to better health; Indonesia: Increase understanding of the benefit of PA; increase PA of people through increase of promotion; increase in provisions of means and facilities of sports and open space, in the frame of creating awareness at all levels of society; Sri Lanka: Create of awareness on PA; promoting greater PA among school children and adults will also reduce the risk of chronic degenerative diseases; provision of facilities for outdoor recreation and making all roads safe for pedestrians and cyclists; India: Physical education to be built into the school system; creation of sports infrastructure at grassroots level in rural and urban areas; revision of the sports policy and action plan and services; involvement of corporate sector Mongolia: Introduce basic knowledge about PA into curriculum of secondary schools; population-wide promotion of PA; Samoa: PA is one of the four high-risk areas identified to focus on through health promotion programs; emphasis on community groups, women's communities, and government workers to support healthy lifestyle, including PA; promote PA in elderly homes; Solomon Islands: Assist individuals who have been disabled by disease, traumatic injury, or other causes to achieve their maximum potential in terms of PA; promote maintenance of body weight by balancing food intake with regular PA; Malaysia: Promote physical fitness activities for the general population at the workplace; Cambodia: Public awareness of healthy lifestyles, and lack of PA as a risk factor, in particular in women; encourage community leaders to develop local solutions such as walking groups or green space; China: Ensure that primary and secondary students participate in at least 1 h of physical exercise activities during the school day; the communities shall actively promote the working model of healthy lifestyle instructors and social sports instructors Government Ghana: Make PA education mandatory in all schoolsa; Mauritius: Ministries of health and finance will collaborate to have a strong focus on PA among the elderly; Madagascar: Develop a policy for the prevention of NCDs with PA recommendations Morocco: Advocate for public space and an environment conducive for PA; Jordan: Develop a national strategy for the promotion of exercise and PA: develop multisectoral committee for PA; Iran: Increase PA to prevent and control overweight and obesity in students Georgia: Develop local legislation and policy to support PA; health sector to take the leading role in making policy decisions by developing action-oriented networks with other relevant sectors and stakeholders on PA; allocate a proportion of sport funds to promoting PA; Republic of Moldova: Extend urban public green space and special grounds for PA for the population; revival of regular short breaks in schools and worksites and encouragement of PA through curricula and support; Turkey: Establish provincial coordination centers for Obesity Prevention, Nutrition and Active Life Board in 81 provinces; mainstream obesity-fighting strategies in national health strategies and policies; prepare national PA guidelines; improve education program related to PA in the educational system; improve the environment for PA in the educational system; formation of sports facilities and recreational areas within the budget possibilities, with the leadership of local administrations, for making the PA in the public widespread; development of PA applications that can be easily applied inside the house; FYRM: Increase possibility for PA through integration of PA in everyday life, e.g., in kindergartens, schools, and worksites; support for local authorities for recreational infrastructure and elimination of barriers for PA transport; Montenegro: Local governments provide conditions for development of infrastructure and facilities for PA: swimming pools, playgrounds, parks, and cycling and walking paths; conduct activities toward development of conditions for cycling and walking in traffic; development of programs for PA in kindergartens, schools, and universities; awareness creation in media; Serbia: Perform moderate PA according to national guidelines; promote PA in children, adolescents, adults, elderly individuals, healthy individuals, and patients with cardiovascular disease; upgrade programs for PA in school curriculum; educate medical and PA professionals on PA for patients with cardiovascular disease; develop and enforce the collaboration between government and NGOs in implementation of PA recommendations; government and NGO campaign “Sport for Everyone” Chile: Develop population PA guidelines; Guyana: Introduce PA as an examinable subject in all schools by 2010; Jamaica: Establish healthy communities that are conducive for community members to be physically active; provide opportunities for children and youth to participate in supervised afterschool sports activities; establish polices, laws, and regulations supportive of a PA lifestyle, and supportive environment in schools, places of work, and communities; develop guidelines on physical education and sports for target group; include PA as a component of chronic disease management at government clinics; improve and evaluate facilities for engaging in PA in health services; design life skills program for schools, communities, and workplaces covering all aspects of healthy lifestyles, including PA; provide clean, safe, and green open space for all community members to participate in PA; Brazil: Promote population-wide PA; promote building of healthy urban spaces Bhutan: Establish national standards for PA; establish a PA Act to regulate the built environment that supports active living; Ministry of Health will collaborate with Dratsang to integrate information and training sessions on PA; develop education materials for curricula aimed at encouraging PA in children, and provide supportive environments; Sri Lanka: Reactivate youth clubs, sports clubs, and young farmers club so as to promote PA; awareness program on PA for employees in institutions and also promotion of importance of PA through mass media Mongolia: Develop and enforce training program of informal and distance learning on PA; develop population-specific PA guidelines and standards; provide advice for promotional measures of physical culture and active movement; create tax measures and market incentives directed towards promotion of PA; improve accessibility and quality of sports-related roads/areas and sports equipment/facilities and improve their safety lighting; Viet Nam: Develop physical exercise programs from preschool to undergraduate education; Philippines: Develop and implement health promotion activities for PA; regulate the built environment to promote PA; Cambodia: Develop presentation materials on PA; revise school curriculum for PA and promotion of women in sports; provide adequate sports facilities for school children and university students; collect data on availability of cycle ways and public parks; develop local strategies to promote PA; China: Actively create a sports and fitness environment; strengthen scientific guidance on mass sports activities; gradually increase the accessibility and utilization of various public sports facilities; enhance environment quality monitoring and evaluation; build a healthy environment and promote regular exercise Private sector NR NR Turkey: Increase the knowledge level regarding PA at the workplace; Serbia: Institutional organization of sport and recreative occasions, e.g., organize sport or recreative contests for workers or pensioners Jamaica: Establish supportive networks and alliances with the private sector and create a partnership with the media to promote the value of PA; Brazil: Establish agreements with the productive sector to implement programs on PA, such as the Academia da Saude India: Involvement of corporate sector to establish a sport culture Cambodia: Involve sports personalities and media to promote PA National target for PA Kenya: Proportion of population that adopts a healthy diet and PA is 15% by 2016/2017 Morocco: 70% of the general population and 80% of children active by 2019 NR Cuba: Increase proportion of adults doing PA to 40% and decrease prevalence of sedentary behavior in individuals ≥15 y to 32%; Uruguay: Average 30 min of moderate PA per day for adults and 1 h for adolescents and children; Jamaica: 40% increase in the number of persons having moderate levels of PA practiced for 30 min per day within 4 y; Brazil: Increase leisure-time PA levels NR Malaysia: Increase the proportion of people doing at least 30 min of PA per day, three times a week, compared to the First Malaysian Food Consumption Survey; Philippines: Reduction in prevalence of adults with high physical inactivity from 60.5% to 50.8%; China: Increase the proportion of the population with regular exercise to >32% WHO classification of regions and countries was followed. Four of the countries (Mayotte, West Bank and Gaza, the Republic of Kosovo, and American Samoa) classified as LMICs by the World Bank in 2011 [25] were not WHO member states in 2011. a Obtained from [107]. FYRM, the former Yugoslav Republic of Macedonia; NGO, nongovernmental organization; NR, not reported; PA, physical activity. Four countries' policy documents (Georgia [57], Mongolia [69], Mauritius [63], and Chile [85]) contained detailed actions and elaborated an implementation plan for stakeholders. The need to develop sports infrastructure and urban planning (e.g., bicycle lanes and recreational centers) featured in the policy documents of Georgia [57], the Republic of Moldova [86], Turkey [62], and Mongolia [69], for instance. Five countries (Mauritius [63], Brazil [75], Samoa [80], the Republic of Moldova [86], and Serbia [87]) mentioned the need to promote physical activity among the elderly. Only four countries (Bhutan [66], the Philippines [73], Cuba [83], and the Republic of Moldova [86]) outlined specific strategies to address sedentary lifestyles, and five (Turkey [62], Cambodia [71], Jamaica [65], Serbia [87], and India [82]) documented explicit actions to involve the private sector in the promotion of physical activity. Discussion Despite the global disease burden of NCDs in LMICs, policies that address at least one risk factor for NCDs were found in a minority of the LMICs reviewed, and only a handful of them comprehensively tackled NCDs through integrated action on various risk factors. Even if the 24 countries with unknown existence of a NCD prevention policy actually have such a policy, the proportion with countries tackling a risk factor would amount to 56% (78/140). This finding is discouraging, because in 2004, all countries expressed a strong commitment to action to address lifestyle, diet, and physical activity [20]. Our results show that, in spite of that official commitment, most LMICs are poorly prepared to tackle the NCD increase and that little progress has been made in recent years. This finding is consistent with the results of Alwan et al. [23], who reported the results of a survey in 2010 that was limited to countries with high NCD-related mortality. Most of the policies in our review were poorly accessible and were only obtained after an extensive search or through personal contacts. Such a situation is certainly not favorable for benchmarking and communication of policies. In agreement with Sridhar et al. [88], we argue how better sharing of best practices and lessons learned with regard to policy development is needed to address the current NCD pandemic. Additional instruments and platforms to share lessons learned in policy development and implementation are needed. Policy databases with links to documents were created previously, but are restricted to nutrition action [89] or the European region [26]. An open-access, full-text global repository of initiatives and policies to address NCDs would be a great step forward. It could also contribute to global leadership and shared accountability in the global fight against NCDs, an issue that is long overdue [90]. Ideally, such a policy database would be connected to surveillance data on the main NCD risk factors, as suggested previously [23], and would facilitate tracking progress in the coming years. We are ready to organize such an open-access repository and invite interested policy makers to contact us for an update of the current database. Priority setting and clear articulation of what needs to be done by stakeholders is a second key issue that emerged in this analysis. Countries seasoned in the fight against NCDs develop comprehensive strategies that focus on critical risk factors and what is expected of stakeholders [91]. In the present analysis, the level of detail and outlining of the organization of policy actions to undertake was generally discouraging. Only a minority of the policies reviewed surpassed description of policy actions and included a budget, implementation plan, time frame, and devolvement of responsibility for strategies to combat specific risk factors. Various policies describe strategies and actions for NCD prevention as “the need to develop and review dietary guidelines and recommendations for people suffering from nutrition-related NCDs” or use generic statements such as “create awareness of healthy eating lifestyle to control NCDs.” Such general statements are not informative, and clear actions need to be outlined in the policies to mobilize stakeholders for effective action [92]. Since its inception during the 1992 International Conference on Nutrition [93], the approach to streamline nutrition action in national policies has had limited success, partly because of the lack of strong leadership and commitment to lead concerted action involving various stakeholders [94]. The current scientific evidence and international experience in the fight against NCDs consistently indicates the need for comprehensive and integrated action on various risk factors [95]. Mobilization of the main actors—in particular, governments, international agencies, the private sector, civil society, health professionals, and individuals—is imperative [96]. An important limitation of most policies included in the analysis is the absence of plans, mechanisms, and incentives to foster multi-stakeholder and cross-sector collaboration. The food and nonalcoholic beverage industry, for instance, can play a role in the promotion of healthier lifestyles. However, before engaging with the private sector, government agencies should be aware of the need to manage potential conflicts of interest between the government and the private sector and should try to address these by defining clear roles, responsibilities, and targets to be achieved as a result of their collaboration [97]. Most strategies encountered in the policies were directed towards government agencies and consumers, and few were targeted at the business community, international agencies, or civil society. The United Nations Political Declaration on NCDs makes a strong call for multi-stakeholder partnerships to be leveraged for effective prevention of NCDs. Policy makers in LMICs may need additional support for the development of multi-stakeholder collaborations to address the burden imposed by NCDs as well as their root causes. In our review of governmental policies relating to NCD prevention in LMICs, strategies to increase fruit and vegetable intake were the most frequent dietary action for NCD prevention. This is hardly surprising, as fruit and vegetable interventions were taken up early on in LMICs, primarily to address prevailing micronutrient deficiencies such as vitamin A deficiency [98]. Many of these experiences, however, are restricted to the development of food-based dietary guidelines or incentives targeted towards the agricultural sector. Policy measures to achieve better diet will require constructively engaging much more with a wider range of stakeholders, in particular the food industry, retail, and the catering sector [99]. The difficulty of developing a comprehensive policy response and integrated package of strategies is not restricted to NCDs alone, and has previously been observed in an in-depth analysis of high-burden countries for child malnutrition [100]. We also note that various countries have developed strategies to reduce total fat intake, despite convincing evidence that it is the reduction of saturated and trans-fatty acids in particular, and not total fat intake, that is effective to address NCDs [101]. Most strategies encountered in the policy documents focused on consumers and aimed to prevent NCDs through awareness creation, education (i.e., labeling), or changing individuals' behavior. The traditional approach to addressing lifestyle changes in individuals has met with very limited success. It is widely accepted that the environmental context drives individual diets and lifestyle [102] and that programs need to incorporate environmental determinants (i.e., the quantity, quality, or price of dietary choices, or the built environment for physical activity) in order to be effective. Such policy measures, in particular those addressing the private sector, were poorly elaborated in the policy documents [103]. A key issue is the actual implementation of policy measures in relation to what was articulated in the documents. The findings of this review indicate that few LMICs have made significant steps in the development of a comprehensive set of strategies to address NCDs. Although an in-depth evaluation of actual implementation, effects, and resources allocated has not been opportune to date, we hope that our findings provide baseline data and encourage countries to develop monitoring and evaluation mechanisms to assess policy response in due time. Documenting the effectiveness of population-based NCD prevention policies will be a critical factor of success to ensure effective action in LMICs [4]. For this review, we were able to assess documents in all languages received. Because of language constraints, however, two of the documents [74],[87] were coded by only one researcher. To assess the content of the policy of Iran, we relied on translations by experienced senior Iranian researchers. All other policy documents were obtained in Spanish, Portuguese, French, or English and were analyzed accordingly by the research team. For China and the Russian Federation, appropriate English versions of the policies were obtained from the Chinese Centers for Disease Control and the United States Department of Agriculture, respectively. Despite indications of availability of relevant policies in the European region [26], language limitations did not allow us to search the websites of a number of countries such as Azerbaijan, Belarus, and the Russian Federation. The restriction of our review to only national policies presents a number of limitations. The mere presence or absence of policies or strategies for NCDs in a policy document does not necessarily reflect concrete action. Conversely, nutritional interventions have been implemented in some countries without a policy being developed and published [104]. In addition, this review assessed the contents of the policy documents as they were published and did not capture local or regional activities, or initiatives that emerged after the publication of the policies. The findings from a survey in countries with a high burden of NCDs, such as Thailand and South Africa, illustrate this discrepancy [23]. The contents might have been modified over time in response to new scientific findings, emerging nutritional challenges, or changes in the countries' priorities [91]. In addition, it is important to point out that we extracted only actions that explicitly referred to one of the risk factors analyzed. Generic statements such as “development of food-based dietary guidelines” or “establishment of fiscal measures for a healthy diet” were hence not coded. The present review shows that the policy response to address current NCD challenges through diet and physical inactivity in LMICs is inadequate since endorsement of the Global Strategy on Diet, Physical Activity and Health [20]. LMICs urgently need to scale up interventions and develop integrated policies that address various risk factors for NCD prevention through multi-stakeholder collaboration and cross-sector involvement. Clear and prioritized actions are needed to harness the NCD epidemic. Such actions need to be documented in policy documents that are publicly available to share lessons learned, promote engagement with the stakeholders, and stimulate accountability and leadership in the fight against the burden of NCDs in LMICs. The establishment of an open-access and publicly accessible database of policy documents with regular systematic reviews of policy development might prove to be an incentive in this regard. Supporting Information Alternative Language Abstract S1 Portuguese translation of the abstract by VC. (DOCX) Click here for additional data file. Alternative Language Abstract S2 Spanish translation of the abstract by FMAS. (DOCX) Click here for additional data file. Alternative Language Abstract S3 French translation of the abstract by DR. (DOCX) Click here for additional data file. Table S1 Availability of national policy documents and strategies for noncommunicable disease prevention in low- and middle- income countries by WHO region. (XLSX) Click here for additional data file. Text S1 Original review protocol. (PDF) Click here for additional data file. Text S2 PRISMA checklist of the review. (PDF) Click here for additional data file.

A well-resourced, comprehensive, population-based set of strategies is needed to attenuate and eventually reverse the current trends of increasing obesity prevalence now apparent in most countries. The Epidemiological Triad (host, vector, environment) has proven to be a robust model for other epidemics and is applied to obesity. Host-based strategies are primarily educational and these tend to be most effective among people with higher incomes and higher educational attainment. The main vectors for a high-energy intake are energy-dense foods and drinks and large portion sizes and, for low energy expenditure, machines that promote physical inactivity. Vector-based strategies that alter food formulation can have a significant impact, particularly through influencing common, high-volume foods. The increasingly 'obesogenic' environments are probably the main driving forces for the obesity epidemic. There are many environmental strategies that can influence the physical, economic, policy or socio-cultural environments, but the evidence base for these potentially powerful interventions is small. Children should be the priority population for interventions, and improving the general socio-economic conditions for disadvantaged, marginalized or poor population sectors is also a central strategy for obesity prevention. The key settings for interventions are schools, homes, neighbourhoods, primary health care services and communities. The key macroenvironments for interventions are the transport and infrastructure sector, the media and the food sector.