Countrywide “best buy” interventions for noncommunicable diseases prevention and control in countries with different level of socioeconomic development

Abstract

Background

Noncommunicable diseases (NCDs) place a heavy burden on populations globally and in particular, on lower‐income countries (LIC). WHO identified a package of 16 “best buy” lifestyle and management interventions that are cost‐effective and applicable in all settings. The purpose of this study was to evaluate and compare NCD risk factors in all WHO countries and make preliminary assessment of “best buy” interventions.

Methods

Risk factors estimation was made in 188 countries. NCD attributable “best buys” concern tobacco use, unhealthy diet, physical inactivity, and harmful use of alcohol. Management issues are based on the availability of the national NCD guidelines and provision of drug therapy.

Results

Every fourth adult in high‐income countries (HIC) has raised blood pressure (RBP). Prevalence of RBP in lower‐middle‐income countries (LMIC) and LIC is 22%–23% (HIC/LMIC: t = 3.12, p < 0.01). Prevalence of diabetes in LIC is less than half of that in HIC and upper‐middle‐income countries (UMIC) UMIC/LIC: t = 8.37, p < 0.001. Obesity prevalence is gradually decreasing from HIC to LIC (HIC/LIC: t = 11.48, p < 0.001). Highest level of physical inactivity is seen in HIC, which then gradually declines to LIC (17%). Tobacco prevalence in LIC is almost less than half of that in HIC and UMIC (HIC/LIC: t = 7.2, p < 0.0001). There is a gradual decline in the implementation of “best buys” from HIC to LIC.

Conclusion

Wealthier countries have better implementation of the WHO NCD prevention strategy.

Key points/Highlights

Prevalence of raised blood pressure in low‐income countries (LIC) (23%) is close to that in high‐income countries (HIC) (25%). Prevalence of obesity, low physical activity, and smoking is increasing from LIC to HIC. Highest prevalence of smoking is registered in upper‐middle‐income countries (UMIC) (24%). Prevalence of diabetes in LIC is less than half of that in HIC and UMIC. Salt intake is increasing from LIC to HIC. Air pollution gradually grew from HIC to LIC. Wealthier countries demonstrate better implementation of the “best buy” prevention strategy. Lessons learned should facilitate implementation of the cost‐effective prevention strategy in lower‐income countries.

1. INTRODUCTION

Noncommunicable diseases (NCDs) place a heavy burden on populations and health services all over the world. They are responsible for 71% of global mortality of the 57 million deaths that occurred annually; among them, cardiovascular diseases (CVD) are 31%, cancers are 16%, chronic respiratory diseases (CRD) are 7%, and diabetes is 3%. These four diseases are largely preventable through public policies focusing their common risk factors: tobacco use, harmful use of alcohol, unhealthy diets, physical inactivity, and air pollution. ¹ To control these enormous global burdens, WHO elaborated WHO Global NCD Action Plan 2013–2020 and WHO 13th General Programme of Work 2019–2023, ² , ³ , ⁴ whose implementation at the country level will facilitate the realization of Sustainable Development Goal (SDG) with the global targets aligned to those for NCDs included in the United Nations Agenda for SDG “by 2030, reduce by one‐third, premature mortality from NCDs through prevention and treatment, and promote mental health and well‐being,” SDG target 3.4. ⁵

A clear relationship between premature NCD mortality and country income levels is evident. In 2016, 78% of all NCD deaths, and 85% of premature NCD deaths in adults aged 30–69, occurred in low‐ and middle‐income countries (LIC and MIC). People in these countries faced the highest risk of dying from an NCD (21% and 23%, respectively) almost double the rate of adults dying from an NCD in high‐income countries (HIC) (12%). Likewise, the proportion of all NCD deaths that were premature in HIC (25%) was almost half that of LIC (43%) and lower‐middle‐income countries (LMIC) (47%). ¹

Role of socioeconomic status in development of NCDs was studied in high‐middle‐income countries (HMIC). In these countries, people who have a low socioeconomic status and those who live in poor or marginalized communities have a higher risk of dying from NCDs than higher advantaged groups and communities. Smoking rates, raised blood pressure (RBP), and several other NCD risk factors are often higher in groups with low socioeconomic status than in those with high socioeconomic status. ⁶

People in LIC and NCD patients with low socioeconomic status have worse access to health care for timely diagnosis and treatment than do those in HIC or those with higher socioeconomic status. ⁷ , ⁸ Also, evidence suggests that the increasing burden of NCDs has grave consequences because very few people will seek treatment, leading to high morbidity and mortality rates from potentially preventable diseases. ⁹ Several studies in LIC demonstrated the growing level of NCD risk factors, which nevertheless still remains lower than in HMIC. ⁷ , ¹⁰ To prevent further increase of NCD risk and associated morbidity and mortality in LMIC, we need more comparative studies in countries with different socioeconomic status concerning traditional and new risk factors prevalence for their effective reduction or prevention of growing. It is vital for the achievement of SDG, in particular, in LMIC due to huge population of these countries. ¹¹ We need implementation of comprehensive strategies for tobacco and alcohol control, for dietary salt and transgenic fat reduction, and the need for physical activity. Same concerns the availability of high‐quality primary health care for delivery of affordable and cost‐effective preventive and management interventions for early detection and treatment of NCDs. ² , ³ , ⁴

To overcome financial barriers in delivery of the NCDs preventive strategy, WHO identified a package of 16 “best buy” lifestyle and management interventions that are cost‐effective, affordable, feasible, and scalable in all settings. The “best buys” were first designated in 2011 and were updated in 2017 based on the latest evidence of intervention impact and costs. ¹² Implementing all 16 “best buys” in all countries between 2018 and 2025 would avoid 9.6 million premature deaths, thus moving countries appreciably toward the NCDs mortality reduction targets. ¹

The purpose of this study was to evaluate and compare NCD risk factors' levels in all WHO member states and make preliminary assessment of “best buy” live style and management interventions in countries with different income levels.

2. METHODS

2.1. Risk factors assessment

Risk factors assessment was made in all WHO member states, mainly in 2016. Methods of data collection and estimations are described in NCD Country profiles 2018. ¹

RBP was defined as the percentage of the population aged ≥18 years having systolic blood pressure of ≥140 mmHg and/or a diastolic blood pressure of ≥90 mmHg. Raised blood glucose was defined as the percentage of the population aged 18 years and older who have fasting plasma glucose of 7.0 mmol/l or higher, or a history of diagnosis with diabetes or use of insulin or oral hypoglycaemic drugs.

Current tobacco smoking was defined as the percentage of the population aged ≥15 years who smoke any of the tobacco products. ¹ , ¹³

Alcohol consumption was assessed as total alcohol per capita consumption in liters per year of pure alcohol. ¹ , ¹⁴

Insufficient physical activity was assessed as percentage of population aged 18 years and older who were physically inactive, defined as not meeting the WHO recommendations on physical activity for health. ¹ , ¹⁵

Salt intake was measured in 2010 and presented as the mean population salt intake in grams per day among adults aged 20 years and older.

Obesity in 2016 was assessed in adults as the percentage of the population aged 18 years and older having a body mass index (BMI) ≥ 30 kg/m², and in adolescents, as the percentage of the population aged 10–19 years who are more than 2 standard deviation (SD) above the median of the WHO growth reference for children and adolescents. ¹ , ¹⁶

Ambient air pollution in 2016 was assessed as the exceedance of the WHO guideline level for annual mean concentration of particles of ≤2.5 mm in the air (proportion) and Household air pollution in 2016 by the percentage of the population with primary reliance on polluting fuels and technologies. ¹

2.2. Lifestyle “best buy”

NCD attributable “best buys” concern tobacco use, unhealthy diet, physical inactivity, and harmful use of alcohol. Each behavioral risk factor has a list of interventions and detailed description to modify this risk factor. We analyzed the following activities:

2.2.1. Tobacco demand reduction measures

Implementation by member states includes the following five demand‐reduction measures of the WHO Framework Convention on Tobacco Control (FCTC).

• –Reduce affordability by increasing excise taxes and prices on tobacco products.
• –Eliminate exposure to second‐hand tobacco smoke in all indoor workplaces, public places, and public transport.
• –Implement plain/standardized packaging and/or large graphic health warnings on all tobacco packages.
• –Enact and enforce comprehensive bans on tobacco advertising, promotion, and sponsorship.
• –Implement effective mass media campaigns that educate the public about the harms of smoking/tobacco use and secondhand smoke.

2.2.2. Harmful use of alcohol reduction measures

Member states have implemented, as appropriate according to national circumstances, the following three measures to reduce the harmful use of alcohol as per the WHO Global Strategy to Reduce the Harmful Use of Alcohol.

• –Enact and enforce restrictions on the physical availability of retailed alcohol (via reduced hours of sale).
• –Advertising bans (across multiple types of media), or comprehensive restrictions.
• –Increase excise taxes on alcoholic beverage.

2.2.3. Unhealthy diet reduction measures

Member states have implemented the following measures to reduce unhealthy diets:

• –Adopt national policies to reduce population salt/sodium consumption.
• –Adopt national policies that limit saturated fatty acids and virtually eliminate industrially produced trans fatty acids in the food supply.

2.2.4. Public education and awareness campaign on physical activity

Member states have implemented at least one recent national public awareness and motivational communication for physical activity, including mass media campaigns for physical activity behavioral change.

To quantify the level of lifestyle modification achievements, we gave 2 points to fully achieved activities, 1 point to partially achieved, and 0 points to not achieved, no response, or do not know answers. For instance, in the case of physical activity, if a country managed to organize at least one national/countrywide campaign, it received 2 points. If the country promoted community involvement in local actions aimed at increasing physical activity, it received 1 point.

List of five interventions against tobacco use, for instance, could receive 10 points in case of their full achievements, six points for harmful alcohol intake, four for unhealthy diet, and two points for physical activity increasing. Hundred percent implementation of the lifestyle modification measures could bring the country 22 points.

2.3. NCD management

Management issues in our assessment are based on the availability of the people‐centered primary health care (PHC) and universal health coverage‐oriented national NCD guidelines set out in WHO Global NCD Action Plan. These evidence‐based guidelines/protocols/standards for management of major NCDs should be recognized and approved by government or competent authorities. This indicator is considered fully achieved and acquires two points, if national guidelines exist for all four NCDs and the country provides the needed supporting documentation. This indicator is considered partially achieved and obtains one point if the country has guidelines for at least two of the four NCDs but not for all four.

Drug therapy and counselling issues assumed that member states have provision of drug therapy, including glycemic control and counselling for eligible persons at high risk to prevent heart attacks and strokes with emphasis on the primary health care level. If the counselling was provided, the country reported it as fully achieved and acquired two points; if partially provided, the country reported it as partially achieved and acquired one point. Other categories of the level of achievements (0 point) were the following: NA = not achieved, not applicable to country due to national situation, DK = country responded “do not know” to that question in the survey, and NR = no response to health facilities counselling. Full implementation of NCD management issues could bring the country four points. The WHO progress monitoring indicators are well described in NCD Progress Monitor 2017 and 2020. ¹⁷ , ¹⁸ We did not analyze management of cancer (vaccination against human papillomavirus and prevention of cervical cancer) since information concerning this “best buy” was not available.

2.4. Statistical analysis

Continuous data were expressed as mean ± standard deviation (SD) and analyzed by Student's t‐test. A two‐sided p < 0.05 was considered statistically significant.

3. RESULTS

NCD risk factors assessment is presented in Table 1. Practically every fourth adult in HIC has RBP. There is no difference in the prevalence of RBP between HIC and upper‐middle‐income countries (UMIC). Although there is statistically significant difference between HIC and LMIC/LIC (prevalence is about 22% and 23%, respectively), these figures are also fairly high for LMIC and LIC. We see no difference concerning diabetes prevalence between HIC and UMIC and gradual decline in diabetes mellitus (DM) prevalence in LMIC and LIC. Prevalence of DM in LIC is almost less than half of that in HIC and UMIC, and statistically significantly less than in LMIC. In LMIC, DM prevalence is also significantly less than in HUMIC. Obesity prevalence is gradually decreasing from HIC to LIC. It is interesting that in this case, there is no statistically significant difference between HIC and UMIC. We see reverse dynamics of low level of physical activity in adults. Highest level of physical inactivity is seen in HIC, which then gradually and significantly declines to LIC. Only 17% of adults in LIC are physically inactive while in HIC, every third has this NCD risk factor. Similar decline from HIC to LIC is observed for harmful use of alcohol and salt/sodium intake. There is a significant difference between HIC, UMIC, and LMIC countries. There is no difference between LMIC and LIC for alcohol. The same dynamics are seen for salt/sodium intake with the highest intake seen in HIC and statistically significant difference between HIC and UMIC. Tobacco prevalence is still lowest in LIC, almost less than half of that in HIC and UMIC. Highest tobacco prevalence is seen in UMIC and there is no difference in tobacco prevalence between HIC and UMIC. Tobacco prevalence in LMIC is already significantly higher than in LIC and close to 20% of adult population.

Table 1.

Noncommunicable diseases and risk factors in countries with different income level

NCDs and risk factors	HIC	UMIC	LMIC	LIC
Raised blood pressure	24.82 ± 6.49, n = 60	23.34 ± 5.44, n = 53	21.81 ± 3.34, n = 48	22.63 ± 2.00, n = 27
Adults aged 18+ (%)	HIC/UMIC: t = 1.32, p > 0.05		UMIC/LMIC: t = 1.72, p < 0.05
	HIC/LMIC: t = 3.12, p < 0.01		UMIC/LIC: t = 0.84, p > 0.05
	HIC/LIC: t = 2.38, p < 0.05		LMIC/LIC: t = 1.32, p > 0.05
Diabetes	10.34 ± 4.83, n = 61	10.88 ± 4.00, n = 54	8.02 ± 3.68, n = 49	5.30 ± 2.00, n = 27
Raised blood glucose adults aged 18+ (%)	HIC/LMIC: t = 2.86		LMIC/LIC: t = 4.17
	UMIC/LMIC: t = 3.78, p < 0.001		UMIC/LIC: t = 8.37, p < 0.001
Obesity adults aged 18+ (%)	26.68 ± 10.11, n = 60	23.98 ± 9.53, n = 54	13.82 ± 9.95, n = 49	7.85 ± 5.18, n = 27
	HIC/UMIC: t = 1.47, p > 0.05		LMIC/LIC: t = 3.45, p < 0.001
	UMIC/LMIC: t = 5.30, p < 0.001		HIC/LIC: t = 11.48, p < 0.001
	HIC/LMIC: t = 6.66, p < 0.001
Physical inactivity adults aged 18+ (%)	35.30 ± 9.30, n = 54	30.61 ± 10.28, n = 44	21.56 ± 9.05, n = 43	16.70 ± 8.38, n = 20
	HIC/UMIC: t = 2.34, p < 0.05		LMIC/LIC: t = 2.09
	UMIC/LIC: t = 8.59, p < 0.001		HIC/LMIC: t = 7.34, p < 0.0001
	UMIC/LMIC: t = 4.36, p < 0.001		HIC/LIC: t = 8.23, p < 0.0001
Harmful use of alcohol (litres of pure alcohol) adults aged 15+ (L/year)	8.92 ± 3.84, n = 59	6.07 ± 3.45, n = 53	4.53 ± 3.60, n = 49	3.36 ± 2.74, n = 28
	HIC/LIC: t = 7.7, p < 0.001		UMIC/LMIC: t = 2.2, p < 0.05
	HIC/LMIC: t = 6.12, p < 0.0001		UMIC/LIC: t = 3.86, p < 0.001
	HIC/UMIC: t = 4.14, p < 0.0001		LMIC/LIC: t = 1.6, p > 0.05
Salt/sodium intake adults aged 20+ (g/day)	9.82 ± 1.54, n = 55	8.76 ± 2.38, n = 52	8.40 ± 2.51, n = 48	7.00 ± 2.19, n = 28
	HIC/UMIC: t = 2.72, p < 0.01		UMIC/LMIC: t = 0.73, p > 0.05
	HIC/LMIC: t = 3.4, p < 0.001		UMIC/LIC: t = 3.33, p < 0.0005
	HIC/LIC: t = 6.1, p < 0.001
Tobacco use adults aged 15+ (%)	23.09 ± 7.38, n = 57	24.22 ± 9.36, n = 36	19.34 ± 10.02, n = 38	11.67 ± 4.86, n = 15
	HIC/LIC: t = 7.2, p < 0.0001		UMIC/LMIC: t = 2.17, p < 0.025
	HIC/LMIC: t = 1.98, p < 0.025		LMIC/LIC: t = 3.74, p < 0.001
	UMIC/LIC: t = 6.27, p < 0.0001
Ambient air pollutiona	1.56 ± 1.83, n = 62	2.15 ± 1.19, n = 54	3.16 ± 1.92, n = 49	3.52 ± 2.99, n = 29
	HIC/UMIC: t = 2.08, p < 0.05		HIC/LIC: t = 7.48, p < 0.0001
	HIC/LMIC: t = 4.59, p < 0.0001		UMIC/LMIC: t = 2.76, p < 0.001
			LMIC/LIC: ND
Household air pollutionb	5.89 ± 2.29, n = 62	25.60 ± 24.91, n = 53	60.34 ± 30.99, n = 48	84.28 ± 24.05, n = 29
	HIC/UMIC: t = 5.1, p < 0.001		LMIC/LIC: t = 4.30, p < 0.001
	UMIC/LMIC: t = 6.17, p < 0.001		HIC/LIC: t = 17.5, p < 0.0001
	UMIC/LIC: t = 10.4, p < 0.0001

Abbreviations: HIC, high income countries; LIC, low‐income countries; LMIC, lower‐middle‐income countries; NCD, noncommunicable diseases; UMIC, upper‐middle‐income countries.

^a Excedance of WHO guidelines level for annual PM 2.5 concentration (by a multiple of).

^b Population with primary reliance on polluting fuels and technologies (%).

There is also highly significant difference in both ambient and household air pollution among countries depending on the income level.

While analyzing dynamics of lifestyle modification measures and NCD management assessments in 2017 and 2020 (Tables 2 and 3), we found out that in 2017, lifestyle modification measures have been accomplished by 53% in HIC (11.66 points out of maximum 22 points in case of full achievement of all lifestyle modification measures, see methods), which increased to 56% in 2020 (Table 3). Positive dynamics are also seen in UMIC; however, accomplishment there is less than 50%. Situation is worse in LMIC and LIC where despite slight positive trend, lifestyle “best buy” accomplishment is only 27% and highly, statistically and significantly differs from other countries with a higher income level (Table 2). Best implementation level (more than 50%) is seen in HIC, which is significantly higher than in UMIC and LMIC. On the other hand there is a difference toward better implementation between UMIC and LMIC and LMIC and LIC both in 2017 and 2020. Thus, there is a gradual decline in the implementation of lifestyle modification measures from HIC to LIC. Similar situation concerns NCD management issues (availability of guidelines for management of major NCDs and availability of drugs and counselling to prevent heart attacks and strokes). Best implementation of NCD management “best buy” is seen in HIC, which increased from 66% in 2017 to 69% in 2020 showing a good perspective in achieving of this “best buy” accomplishment by the year 2030. Although, in general, the positive 2017–2020 dynamics are seen in all countries, the implementation level gradually declines from HIC to LIC. Encouraging dynamics is observed in UMIC where 55% of accomplishments were registered in 2020, despite the positive dynamics implementation level in LIC being more than 3 times less than in HIC and more than two times less than in UMIC. These differences are highly statistically significant. Statistically significant difference in the implementation level also exists between LIC and LMIC (Table 2).

Table 2.

Lifestyle modification measures and NCD management assessment in countries with different level of economies in 2017 and 2020

Lifestyle and NCD management	HIC n = 62		UMIC n = 54		LMIC n = 49		LIC n = 29
	2017	2020	2017	2020	2017	2020	2017	2020
Lifestyle modification measures	11.66 ± 3.90	12.37 ± 3.76	9.92 ± 4.68	10.42 ± 4.30	7.90 ± 3.39	8.00 ± 3.62	5.59 ± 3.06	6.03±3.48
	HIC/LIC		UMIC/LIC	UMIC/HIC	LMIC/LIC	LMIC/UMIC		LIC/HIC
	t = 8.06		t = 5.08	t = 2.58	t = 3.10	t = 3.97		t = 7.88
	p < 0.001		p < 0.001	p < 0.05	p < 0.01	p < 0.01		p < 0.001
	HIC/UMIC		UMIC/LMIC			LMIC/HIC		LIC/UMIC
	t = 2.16		t = 2.52			t = 4.78		t = 4.39
	p < 0.05		p < 0.05			p < 0.001		p < 0.001
	HIC/LMIC		HIC/LMIC					LIC/LMIC
	t = 5.45		t = 5.45					t = 2.38
	p < 0.001		p < 0.001					p < 0.05
NCD management assessment	2.62 ± 1.42	2.76 ± 1.31	1.94 ± 134	2.19 ± 1.42	1.37 ± 0.97	1.58 ± 1.13	0.83 ± 0.93	0.90 ± 0.90
	HIC/LIC		UMIC/LIC	UMIC/HIC	LMIC/LIC	LMIC/HIC		LIC/HIC
	t = 7.17		t = 4.42	t = 2.24	t = 2.44	t = 5.10		t = 7.89
	p < 0.001		p < 0.001	p < 0.05	p < 0.05	p < 0.001		p < 0.001
	HIC/UMIC		UMIC/LMIC			LMIC/UMIC		LIC/UMIC
	t = 2.65		t = 2.49			t = 2.42		t = 5.06
	p < 0.01		p < 0.05			p < 0.05		p < 0.001
	HIC/LMIC							LIC/LMIC
	t = 5.5							t = 2.93
	p < 0.001							p < 0.01

Abbreviations: HIC, high income countries; LIC, low‐income countries; LMIC, lower‐middle‐income countries; NCD, noncommunicable diseases; UMIC, upper‐middle‐income countries.

Table 3.

Dynamics of Lifestyle modification measures and NCD management assessments in countries with different income level, 2017–2020.

Accomplishments	High‐income economies, n = 62		Upper‐middle‐income economies, n = 54		Lower‐middle‐income economies, n = 49		Low‐income economies, n = 29
	2017	2020	2017	2020	2017	2020	2017	2020
Lifestyle modification measures	53%	56%	45%	47%	36%	36%	25%	27%
Management issues	66%	69%	48%	55%	34%	40%	21%	22%

Thus, the implementation level of lifestyle and management “best buys” is associated with the level of socioeconomic development, where wealthier countries have better implementation of the NCD prevention strategy and are closer to achieve UN SDG 3.4 by the year 2030.

4. DISCUSSION

Our study has demonstrated prevalence of major NCD risk factors and certain chronic diseases in 194 WHO member states. From the traditional perspective, we can clearly see that NCD is a privilege of wealthy countries, but it does not always correspond to the reality. Epidemiologic transition in developing countries characterized by transfer from communicable diseases and nutritional deficiencies to NCDs. Calorie rich diet, smoking, sedentary lifestyle, and harmful use of alcohol is a reason of this transformation. ¹⁹ , ²⁰

Hypertension, called now as a “silent killer,” once rare in LIC, is emerging as a serious endemic threat. ²¹ , ²² , ²³ Hypertension is a risk factor of stroke, coronary heart disease, some renal diseases ²⁴ , ²⁵ and often coexists with HIV, tuberculosis, and malaria, which are highly prevalent in LMIC. ²⁶ , ²⁷ , ²⁸ , ²⁹ Adedoyin et al. found that in a semi‐urban community sample of 2097 adults in Nigeria, 36.6% had RBP. ³⁰ A study in the Niger Delta region found the prevalence of hypertension to be 16% and 12% for males and females, respectively. ³¹ In a prospective study conducted in rural Nigeria, the prevalence of hypertension was 7%. ³² The impact of migration from rural to urban areas was demonstrated in a longitudinal study in Kenya, in which moving from a rural to urban setting produced significant increases in blood pressure within a fairly short time. ³³ Migration from rural areas to urban areas is linked with growing prevalence of hypertension as migrants adopt lifestyle changes in physical activity, dietary habits, and smoking. It happens regardless of gender or type of community. Advancing age is also associated with an increased prevalence of hypertension and this leads to greater burden of hypertension in LMIC. ²⁷ , ³⁴ , ³⁵

Stroke as a consequence of RBP and hypertension is the second leading cause of death worldwide and the leading cause of acquired disability. ³⁶ , ³⁷ Up to 85% of strokes worldwide occur in LMIC, ³⁸ , ³⁹ , ⁴⁰ and the incidence of hemorrhagic strokes is higher in those countries than in HIC. ⁴¹ , ⁴²

Modifiable risk factors such as RBP and hypertension, overweight and obesity, smoking, sodium and alcohol intake account for 90.3% of all strokes across the world. ⁴³ , ⁴⁴ In view of this, preventing further increase in RBD and hypertension through lifestyle interventions, ⁴⁵ , ⁴⁶ , ⁴⁷ including community‐based programs on salt reduction, ⁴⁸ , ⁴⁹ and secondary prevention with multidrug treatment are vital. ⁵⁰ , ⁵¹ In our study we see improvement of lifestyle modification measures and NCD management in LMIC and LIC (Tables 2 and 3). Although accomplishment of “best buy” in our study is far from 100%, even small changes of the lifestyle risk factors at the population level should substantially reduce the incidence of NCDS. The old saying implies “an ounce of prevention is worth a pound of cure.” ⁵² The greatest returns of population‐wide prevention efforts with relatively small inputs become obvious when compared to the cost of treating the ill. Positive dynamics of the lifestyle modification is also important in LMIC and LIC where our purpose is to prevent shift to the “western” lifestyle. Improvement of NCD management to 40% in LMIC is encouraging (Table 3). HIC demonstrate positive dynamics both in the lifestyle modifications (56%) and management issues (69%). Good dynamics is also seen for the most populated UMIC, where achievement of the management “best buy” reached 55% in 2020. This is important since globally, there is low use of effective medications in patients with stroke. Among 5650 people from HIC and MIC, 35–70 years of age with stroke or coronary artery disease, only 25% were on antiplatelet drugs, 17% on β‐blockers, 20% on angiotensin‐converting enzyme inhibitors or angiotensin receptor blockers, and just 15% on statins. Treatment rates are extremely low in LMIC. ⁵³ “Best buy” management in these countries depends on availability of essential medicines and basic technologies ¹ list of which should be regularly updated. ⁵⁴

Healthy lifestyle is closely linked to prevention and control of overweight and obesity, which are linked with multiple chronic conditions, including stroke and diabetes. According to our study, diabetes has highest prevalence (almost 11%) in UMIC, the most populated group of countries. ¹¹ WHO Global Report on Diabetes shows highest prevalence of 13.7% in the Eastern Mediterranean Region and South‐East Asia and Western Pacific Regions shows 8.6% and 8.4%, respectively, where high percentage of countries belong to MIC. ⁵⁵ Diabetes was regarded as a rare disease in LMIC and LIC in Sub Sahara Africa (SSA) before the 1990s. ⁵⁶

Recent WHO report shows diabetes prevalence in the  African Region in 2014 as 7.1%. ⁵⁵ Since the African region is populated mainly by LMIC and LIC, these data are close to our LMIC of 8% and LIC of 5.3%. To better manage diabetes and hypertension in low‐resource settings, risk stratification charts for PHC have been developed by WHO and International Society of Hypertension. They provide the 10‐year risk of fatal or nonfatal cardiovascular events by gender, age, systolic blood pressure, total blood cholesterol, smoking status, and the presence or absence of type 2 DM. A prediction chart helps to select those who will benefit most from treatment as well as guide the intensity and nature of drug treatment. ⁵⁷

Growing diabetes prevalence is a result of the epidemiologic/nutrition transition, ⁵⁵  which leads to a larger intake of total energy, simple sugars and saturated fats, and lower consumption of fruits and vegetables, which are expensive. ⁵⁸ , ⁵⁹ According to our data, consumption of alcohol and salt, rates of physical inactivity, and obesity are also growing in parallel with the income level (Table 1).

WHO report ¹⁴ demonstrated harmful use of alcohol, progressively increasing in Africa with the total per capita alcohol consumption of the equivalent of six liters of pure alcohol per year in 2010. It was similar to our data in UMIC. Although the same report indicated a lower rate of consumption in Ethiopia at 4.1 L. ⁷ Our data demonstrate lower alcohol consumption in LMIC and LIC (4.5 L and 3.4 L, respectively) and accomplishment of lifestyle modification measures including alcohol restriction by 27% in LIC and 36% in LMIC. According to Ayano et al, ⁶⁰ LIC need a coordinated policy focused on raising awareness, restricting availability, especially to young people, enforcing drink‐driving laws and reducing demand through taxation, especially of the locally produced alcohol.

WHO estimates that 3.2 million deaths across the globe are attributed to physical inactivity each year. ¹⁵ We see a gradual decline in the level of physical activitiy from HIC to LIC. Countries need to address physical inactivity through multisector intervention, revisite the urban planning processes, and ensure cities have sufficient and suitable environments for walking, cycling, and other forms of physical activity for all age groups. Major residential areas need sports playgrounds for residents, physical fitness initiatives should be promoted, and efforts should be made to increase awareness about the risks of insufficient physical activity. The mass media, educational institutions, and religious organizations and other community structures, can be leveraged to this end. These measures will allow reducing the physical inactivity level in HMIC and preserving its growing in LMIC and LIC.

Salt consumption in our study is above the WHO recommendation of less than 5 g of salt or 2 g of sodium per day. ¹ , ⁶¹ High salt consumption is a risk factor for RBP. ⁶² WHO recommends key interventions to reduce salt intake at the population level: surveillance on salt intake, such as through the WHO STEPS (STEPwise approach to Surveiilance) survey; promoting the reformulation of foods and meals to contain less salt; implementing standards for proper labeling and marketing of food; increasing consumer awareness; and environmental changes to increase the availability and affordability of healthy food. ⁶³ A review study in SSA showed that both legislative and voluntary strategies for reducing dietary sodium can be effective. According to the study, salt reduction strategies resulted in improved outcomes as measured by changes in systolic blood pressure, mean arterial blood pressure, and 24‐h urinary sodium excretion. ⁶⁴ Overall, the population‐level interventions proposed by WHO would save lives and reduce the health care costs of individuals and governments. ²

Prevalence of smoking strongly depends on the global activities of the FCTC launched in 2003. ¹³ Since 2000, global tobacco prevalence in individuals 15 years and older decreased from 27% to 20% in 2016 ⁵   demonstrating most visible decline in HIC. ¹ The goal of Global NCD Action Plan was a 30% relative reduction in the prevalence of current tobacco use by 2025. ² Countries should intensify effective tobacco control to achieve this goal. Our efforts should be more focused on LMIC where prevalence is growing and approaching to UMIC and HIC. Low prevalence of tobacco smoking in LIC should be preserved and not allowed to further increase. Implementing, for instance, the four elements of the WHO FCTC, namely taxation, smoke‐free environment, warning the public about tobacco dangers, and banning tobacco advertisement, ¹³ is estimated to save 15–18 lives per 100,000 over a 10‐year period, while the combined cost of interventions requires just USD $0.10 per person. Furthermore, a 21.4% increase in the real price of tobacco products through higher taxation decreases tobacco consumption by 10%. ⁶⁵ Beyond taxation, the full implementation of the other articles of the WHO FCTC framework is important, as it plays a significant role in reducing tobacco use.

Strike difference in air pollution, both ambient and household, could be a reason for growing NCD in lower‐income countries.

Indoor air pollution, commonly caused by biomass fuels, is an important risk factor for NCDS in LMIC where a majority of the population lives in the rural areas. ⁶⁶ Over the past years, there has been a strong response by governmental and international organizations to develop global strategies for the universal adoption of clean cookstoves and fuels. ⁶⁷ Improved cookstoves seem to achieve reductions of about 40% to 80% in particulate matter of 2.5 µg/m³, ⁶⁸ , ⁶⁹ but the resulting concentrations are still 2–7 times higher than those recommended by the WHO. ⁷⁰

Fortunately, reducing air pollution can result in prompt and substantial health gains. ⁶⁶ Sweeping policies affecting a whole country, such as banning secondhand smoke from the workplace in Ireland, reduced all‐cause of mortality within weeks. Local programs, such as reducing traffic and tempering an industrial polluter, have also promptly improved many health indicators. ⁶⁷

The WHO guidelines can be used as a starting point for improving the existing interventions on clean energy and developing appropriate policies and strategies to address air pollution effectively for the health of all nations. ⁶⁸ Regretfully, WHO lacks any specific indicator to track air pollution among its member states to be included in its NCD progress monitor.

Same concerns assessment of some dietary habits; for instance, fruits and vegetable consumption. One point seven million deaths occur globally each year due to diets that are deficient in fruits and vegetables. ⁷¹ WHO recommends a daily consumption of 400 g or five servings of fruits and/or vegetables (excluding potatoes and other starchy tubers) for protection against NCDs. ⁶¹ Reducing the high consumption of saturated fat and transgenic fatty acids also requires policy interventions and monitoring.

As deaths from infectious diseases and in early life (between 12 and 18 years) in LMIC decline, health systems in these countries increasingly need to manage patients with NCDs. Most health systems are currently not well prepared to manage the pandemic, but there are many low‐cost ways to prevent, diagnose, and treat NCDs. “Best buy” interventions have a good financial perspective. They are practical and achievable starting point for incorporating NCD interventions into health benefit packages for universal health coverage, costing as little as USD$1 per person, per year, in lower‐income settings between 2018 and 2025, and in the case of taxation not only delivering health benefits but also generating additional government revenues. ⁷² These resources could be used for further improvement and promotion of NCD prevention and control strategies in LMIC based on their own research experience.

AUTHOR CONTRIBUTIONS

Dr. Khaltaev collected data, performed the statistical analysis, and prepared the manuscript. Dr. Akselrod collected the data and provided intellectual contribution as well as critical revision.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

ETHICS STATEMENT

None.

Khaltaev N, Axelrod S. Countrywide “best buy” interventions for noncommunicable diseases prevention and control in countries with different level of socio‐economic development. Chronic Dis Transl Med. 2023;9:44‐53. 10.1002/cdt3.49

DATA AVAILABILITY STATEMENT

Data supporting the results can be obtained from the corresponding author.