As briefly noted in Chapter 3, some encouraging effectiveness evidence for population-based interventions to lower saturated fat intake have come from two countries.
1) intervention, a government-led program in Mauritius (Hodge et al. 1996) changed the main cooking oil from a predominantly saturated-fat palm oil to a soybean oil high in unsaturated fatty acids. As a result, total cholesterol concentrations fell by 14 percent during the 5-year study period from 1987 to 1992. Changes in other risk factors were mixed, with reductions in blood pressure and smoking rates, yet increases in obesity and diabetes.
2) it is a natural experiment in Poland. In the early 1990s, subsidies for animal products such as
butter and lard were reduced, resulting in large-scale substitution from saturated to polyunsaturated fats (Zatonski et al. 1998; Zatonski and Willett 2005). Based on observational data the research argued that this substitution caused the decrease in mortality due to coronary heart disease of greater than 25 percent between 1991 and 2002, as it could not be explained by increased fruit consumption or decreases in smoking.
In light of the ecological nature of this conclusion, concerns about its validity do, however, remain (Ebrahim and Smith 1998). Based on the above encouraging findings on the potential for fiscal policy to change behavior (and in light of the success of tobacco taxation), more research along these lines for low- and middle-income countries would be highly worthwhile (Nugent and Knaul 2006).
One obvious further application of fiscal policy would be alcohol taxation, where an extensive literature documents the effectiveness of taxes in reducing drinking and drinking-related harm (Wagenaar et al. 2009).Moving from the population-based level to a more focused higher-risk approach, there is some evidence from India where a behavior change program has achieved a 28.5 percent reduction in the diabetes incidence among high-risk Asian Indians (Ramachandran et al. 2006).
A recently published worksite health promotion intervention in India also has shown significant reductions in cardiovascular risk factors and intermediate CVD outcomes in India (Prabhakaran et al. 2009).
Similarly positive results from lifestyle modification to reduce diabetes onset in high-risk groups come from China (Pan et al. 1997), Finland (Tuomilehto et al. 2001), and the United States (Knowler et al.2002), with a high share of these effects being sustained beyond the end of the intervention (Lindström et al. 2006). Economic evaluations of the Indian and U.S. studies find favorable cost-effectiveness. However, it remains unclear if implementation would be feasible in the South Asia context.
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