Promoting Healthy Living in Latin America and the Caribbean Governance of Multisectoral Activities to Prevent Risk Factors for Noncommunicable Diseases

This report contributes to the design and implementation of policies that promote healthy living in Latin America and the Caribbean (LAC), thus effectively preventing premature mortality from non-communicable diseases (NCDs) in the region. It examines the health and economic impact of NCDs in the region and the governance challenges in the design and implementation of multisectoral policies to prevent these conditions, including polices to improve diet, increase physical activity, and reduce tobacco use and alcohol abuse. The study focuses on how policy decisions involving multisectoral interventions to prevent health risk factors are taken, which stakeholders directly or indirectly participate in those decisions, which incentives they experience, and what strategies they use in these processes. This document is divided into six chapters: 1) non-communicable diseases in Latin America and the Caribbean, 2) risk factors for NCDs in Latin America and the Caribbean, 3) economic impact of NCDs in Latin America and the Caribbean, 4) governance of multisectoral interventions to promote healthy living: international examples, 5) multisectoral interventions to promote healthy living in Latin America and the Caribbean, and 6) lessons learned and agenda for the future.


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Non-Communicable diseases generate an important health and economic burden in Latin America and the Caribbean.There is therefore an urgent need to promote healthy living and aging to prevent some of these diseases.This can be achieved through population-wide multi-sectoral interventions aimed at improving nutrition, promoting physical activity, and reducing tobacco use and alcohol abuse, along with targeted medical interventions.

Modifiable Risk Factors
Because they share common risk factors that can be partially addressed through public policy changes, many NCDs are preventable.Cardiovascular diseases, cancers, chronic respiratory conditions, and diabetes share a number of intermediate risk factors, including high blood pressure, high blood glucose, abnormal blood lipids, and overweight or obesity (WHO 2005).These intermediate factors are the result of common modifiable risk factors such as unhealthy diets, physical inactivity, tobacco use, and the harmful use of alcohol (which is also a risk factor for road traffic accidents and violence).2005 and 2050 (Cotlear 2011).However, the prevalence of NCDs in the region is not only due to population aging, but also to exposure to health risk factors.
Despite the shortage of information on dietary patterns across time, data from countries where some information is available suggest that a large percentage of households have unhealthy high calorie diets (Table 2).These energy dense diets combined with sedentary lifestyles are likely responsible for the large percentage of overweight and obese adults (Figure 3).In most countries, this percentage is higher among women than men.In several countries, these high rates of overweight and obesity coexist with high rates of chronic malnutrition.Three of the four countries in the world with the highest percentage of overweight mothers and malnourished children are Guatemala with 13 percent of households, Bolivia with 11 percent, and Nicaragua with 10 percent (Garrett et al 2003).Often these conditions are related; for instance, low birth weight and child malnutrition have been associated with increases in the rates of hypertension, cardiovascular diseases and diabetes (WHO 2003).
Around 27.4 percent of adult men and 14.4 percent of adult women in the region smoke tobacco.In the Southern Cone countries, Cuba, and Venezuela between a third and twofifths of adult men and between a quarter and a third of adult women currently smoke.Smoking prevalence is also quite high among youth.Data from the WHO Global Youth Tobacco surveys show that Chile has the fourth largest prevalence of youth tobacco smoking among women in the world.Among male youth, Ecuador and Nicaragua are among the fifteen countries with highest tobacco prevalence with 31 and 30 percent respectively (WHO 2010, WHO 2011b, WHO 2011c, WHO 2011d).
The WHO ranks Belize, Ecuador, Guatemala, Mexico, Nicaragua, and Paraguay as the countries in the region with the highest alcohol-related health risk.These countries have the highest consumption of alcohol per drinker and the largest percentage of drinkers reporting binge drinking.In Ecuador, the average drinker consumed a staggering 29.9 liters of pure alcohol in 2005, followed by Mexico with 27 liters and Nicaragua with 20 liters (WHO 2011e).

Policy Options and the World Bank
The burden of NCDs is increasing and consequently the pressure on regional health systems is growing.In this context, treatment alone will not be fiscally sustainable as the cost of treating NCDs in general is much higher than that of communicable diseases (World Bank 2011).Thus the urgent need to promote healthy living in the region through population-wide multi-sectoral interventions to improve nutrition, promote physical activity, and reduce tobacco use and alcohol abuse.The role of the health sector is central to ensuring that multi-sectoral interventions to promote healthy lifestyles are designed and implemented along with targeted health care services.Also crucial is surveillance of NCDs and their risk factors.This function needs to be strengthened to improve information on the prevalence of NCDs and their risk factors and to respond adequately to the epidemic.
Governments in Latin America and the Caribbean are implementing multi-sectoral interventions to reduce the prevalence of NCDs risk factors.Some of these interventions fall within the list of interventions that WHO considers "Best Buys" (WHO 2011f ).
To improve diets and increase physical activity, governments can promote public awareness about healthy diets and physical activity through mass and other media.An example of this type of policy to promote physical activity in the region is that of Agita Sao Paulo in Brazil (Matsudo et al 2002).To reduce salt content of food and trans fats, a promising experience in the region is that of the Argentinean program "Less Salt, More Life" (Menos Sal, Más Vida) and the government's agreement with the industry to reduce sodium and trans fats in processed foods.About "en breve"... "en breve" is produced by the Knowledge and Learning Team of the Operations Services Department of the Latin America and the Caribbean Region of The World Bank -http://www.worldbank.org/lac.Visit the entire "en breve" collection at: www.worldbank.org/enbreve.
An example to evaluate of community-based interventions to promote healthy diets activity of where been taken to the sale junk food and mandate activity classes in schools.Another example of community-based interventions aimed at promoting physical activity is that of Academia da Cidade in different Brazilian cities1 .Finally, the city of Bogota is an example to evaluate as a city with a built an environment that promotes physical activity with its public transportation system, TransMilenio bus rapid transit, bike paths, and recreational bike routes (Sarmiento n.d.).
To reduce the prevalence of smoking, governments can increase current tax levels and harmonize this price level with neighboring countries.In addition, governments can enforce legislation to ensure smoke-free environments, marketing bans of tobacco products and restrictive warning labels.The tobacco control program in Uruguay is an example to evaluate.
To reduce alcohol abuse, governments can impose excise taxes on alcohol and impose more restrictions on access to retail alcohol.Some countries in the region do not impose taxes while others impose very low levels (WHO 2011e).
The World Bank supports many of these efforts through different knowledge, convening and financial services.For example, the Bank has developed knowledge activities in Jamaica, the Eastern Caribbean and Central America.Through lending operations, Bank projects have supported overall prevention and control programs and the strengthening of surveillance systems in Argentina, Uruguay, and Brazil.In addition, Bank projects support the financing of health services, including, NCD prevention and control interventions at the clinical level in the Dominican Republic and Panama.Finally, the Bank is currently carrying out a regional study on multi-sectoral approaches to promote healthy living and aging.WHO 2011b. World Health Observatory Data Repository -Risk Factors. WHO 2011c. World Health Observatory Data Repository -Tobacco Control. WHO 2011d. Report on the Global Tobacco Epidemic, 2011. WHO: Geneva. WHO 2011e. Global Status Report on Alcohol and Health, 2011. WHO: Geneva. WHO 2011f. Global

Figure 1 :
Figure 1: Main Causes of Death in Latin America and the Caribbean (2008) age-standardized

Figure
Figure 3: Percentage of Adults Older than 20 Years Overweight or Obese (2008) (Body Mass Index> 25 -age standardized)

Table 1 : Costs attributable to CVD in 2010 in the Americas (US$ billions) The Americas Region Total Costs (without productivity costs) Productivity costs Total costs (including productivity costs) Per capita total costs Per capita total costs (adults only)
Source: Bloom et al 2011

Table 2 : Daily Calorie Intake per Adult Equivalent in Central American Countries (in percentage)
Source: Bonilla-Chacín ME, Vázquez M (in preparation) Promotion of physical activity in a developing country: The Agita Sao Paulo experience.Public Health Nutrition 5(1A), 253-261.Sarmiento O, del Castillo AD n.d., Segura Durán E. Bogotá como ejemplo de ciudad que promueve la actividad física.(in preparation).WHO 2003.Diet, Nutrition and the Prevention of Chronic Diseases.Technical Report Series 916.WHO: Geneva.WHO 2005.Preventing Chronic Diseases: a vital investment.WHO: Geneva.WHO 2010.Gender, Women and the Tobacco Epidemic.WHO: Geneva.WHO 2011a.World Health Observatory Data Repository -Burden of Disease.
Status Report on Noncommunicable Diseases 2011.WHO: Geneva.World Bank 2011.Chronic Emergency: Why NCDS Matter.Washington DC: The World Bank