Background The social determinants of health have been widely recognised yet there remains a lack of clarity regarding what constitute the macro-economic determinants of health and what can be done to address them. An umbrella review of systematic reviews was conducted to identify the evidence for the health and health inequalities impact of population level macroeconomic factors, strategies, policies and interventions. Methods Nine databases were searched for systematic reviews meeting the Database of Abstracts of Reviews of Effects (DARE) criteria using a novel conceptual framework. Studies were assessed for quality using a standardised instrument and a narrative overview of the findings is presented. Results The review found a large ( n = 62) but low quality systematic review-level evidence base. The results indicated that action to promote employment and improve working conditions can help improve health and reduce gender-based health inequalities. Evidence suggests that market regulation of tobacco, alcohol and food is likely to be effective at improving health and reducing inequalities in health including strong taxation, or restriction of advertising and availability. Privatisation of utilities and alcohol sectors, income inequality, and economic crises are likely to increase health inequalities. Left of centre governments and welfare state generosity may have a positive health impact, but evidence on specific welfare interventions is mixed. Trade and trade policies were found to have a mixed effect. There were no systematic reviews of the health impact of monetary policy or of large economic institutions such as central banks and regulatory organisations. Conclusions The results of this study provide a simple yet comprehensive framework to support policy-makers and practitioners in addressing the macroeconomic determinants of health. Further research is needed in low and middle income countries and further reviews are needed to summarise evidence in key gaps identified by this review. Trial registration Protocol for umbrella review prospectively registered with PROSPERO CRD42017068357 .

Scientific research linking climate change to food systems, nutrition and nutrition-related health (FSNH) has proliferated, showing bidirectional and compounding dependencies that create cascading risks for human and planetary health. Within this proliferation, it is unclear which evidence to prioritise for action, and which research gaps, if filled, would catalyse most impact. We systematically searched for synthesis literature (i.e. reviews) related to FSNH, published after January 1, 2018. We screened and extracted relevant characteristics of these reviews, and mapped them in an interactive Evidence and Gap Map (EGM), supplemented by expert consultation. 844 synthesis reports met inclusion criteria (from 2,739 records) and were included in the EGM. The largest clusters of evidence were those describing climate impacts on crop and animal source food (ASF) production, and emissions from such (86%). Comparatively few reports assessed climate change related to nutrition-related health, or food manufacture, processing, storage, and transportation. Reports focused on strategies of adaptation (40%), mitigation (29%), both (19%) or none (12%). A striking lack of reports critically evaluated equity (25%), and even fewer reports suggesting changes to equity and equitable practices would alter the climate-FSNH dynamic (6%). The expert consultation mirrored the results of the EGM, and contextualised findings further. This novel map describes a wide research landscape linking climate change to FSNH. We identified four key evidence gaps, including 1) Research on whole food systems or post-harvest elements 2) Research evaluating relationships between climate change and nutrition-related health outcomes, especially among vulnerable populations; 3) Promising methods (and additional data required) that can a) identify inflection points or levers for intervention, b) incorporate complex dynamics and characterize trade-offs, c) be understood and applied in context-specific, localised ways for decision-making; and 4) Promoting interdisciplinary collaborations that enable producing and translating evidence to action, especially those that inherently consider co-production and fairness.

There is growing interest in the health and environmental benefits of whole-food plant-based (WFPB) diets. The current global food system is harmful to our planet and is a key driver of climate change, pollution and biodiversity loss. A transition to WFPB diets will mitigate against these impacts and potentially reduce agriculture greenhouse gas emissions by up to 80%. Emerging evidence suggests that such diets also have significant physical and mental health benefits and can be useful in preventing and treating a range of conditions. Psychiatrists therefore have an important role to play in promoting WFPB diets among patients.

Medusa (i) is one of a quartet of paintings completed in 2022.Within the work, serpentine coils hang down from above, truncated and pushed to the fore of the frame.Kogan's paintings are often ambiguous and defy a purely literal reading, underpinned by her interest in the materiality of the paint, communicating a subtle vibrancy and internal resonance.This is echoed in the Medusa series, which both implies the presence of the serpent motif, as evoked in the title, but also possibly a swinging rope, suspended high above our heads, adding to the sense of unease.In a wider context the forms can be seen to refl ect the duality of our internal and external worlds, both physically and psychologically.

BACKGROUND:Obesity and nutrition-related non-communicable diseases (NR-NCDs) are increasing throughout Africa, driven by urbanisation and changing food environments. Policy action has been limited - and influenced by high income countries. Socio-economic/political environments of African food systems must be considered in order to understand what policy might work to prevent NR-NCDs, for whom, and under what circumstances. METHODS:A realist synthesis of five policy areas to support healthier food consumption in urban Africa: regulating trade/foreign investment; regulating health/nutrition claims/labels; setting composition standards for processed foods; restricting unhealthy food marketing; and school food policy. We drew upon Ghana and Kenya to contextualise the evidence base. Programme theories were generated by stakeholders in Ghana/Kenya. A two-stage search interrogated MEDLINE, Web of Science and Scopus. Programme theories were tested and refined to produce a synthesised model. RESULTS:The five policies operate through complex, inter-connected pathways moderated by global-, national- and local contexts. Consumers and the food environment interact to enable/disable food accessibility, affordability and availability. Consumer relationships with each other and retailers are important contextual influences, along with political/ economic interests, stakeholder alliances and globalized trade. Coherent laws/regulatory frameworks and government capacities are fundamental across all policies. The increasing importance of convenience is shaped by demographic and sociocultural drivers. Awareness of healthy diets mediates food consumption through comprehension, education, literacy and beliefs. Contextualised data (especially food composition data) and inter-sectoral collaboration are critical to policy implementation. CONCLUSION:Evidence indicates that coherent action across the five policy areas could positively influence the healthiness of food environments and consumption in urban Africa. However, drivers of (un)healthy food environments and consumption reflect the complex interplay of socio-economic and political drivers acting at diverse geographical levels. Stakeholders at local, national, and global levels have important, yet differing, roles to play in ensuring healthy food environments and consumption in urban Africa.

Objective: To synthesise evidence of urban dietary behaviours (macronutrients, types of foods, dietary diversity and dietary practices) in two African countries in relation to postulated changes in the context of nutrition transition. Design: Systematic review and meta-analyses, including six online databases and grey literature, 1971-2018 (Protocol CRD42017067718). Setting: Urban Ghana and Kenya. Participants: Population-based studies of healthy adolescents and adults. Results: The forty-seven included studies encompassed 20 726 individuals plus 6526 households. Macronutrients were within WHO-recommended ranges: mean energy intake was 1867 kcal/d (95 % CI 1764, 1969) and the proportions of macronutrients were carbohydrate 61 center dot 2 % (58 center dot 4, 64 center dot 0), fat 25 center dot 3 % (22 center dot 8, 28 center dot 0) and protein 13 center dot 7 % (12 center dot 3, 15 center dot 1). The proportion of population consuming fruit and vegetables was 51 center dot 6 %; unhealthy foods, 29 center dot 4 %; and sugar-sweetened beverages (SSBs), 39 center dot 9 %. Two-thirds (68 center dot 8 %) consumed animal-source proteins. Dietary diversity scores were within the mid-range. Meal patterns were structured (typically three meals per day), with evidence lacking on snacking or eating out. Conclusions: Population-level diets fell within WHO macronutrient recommendations, were relatively diverse with structured meal patterns, but some indications of nutrition transition were apparent. The proportion of population consuming fruit and vegetables was low compared to healthy-eating recommendations, and consumption of SSBs was widespread. A paucity of evidence from 1971 to 2010 precluded a longitudinal analysis of nutrition transition. Evidence from these two countries indicates which aspects of dietary behaviours may be contributing to increasing overweight/obesity, namely a low proportion of population consuming fruit and vegetables and widespread consumption of SSBs. These are potential targets for promoting healthier diets.

Introduction Unhealthy food environments drive the increase of diet-related non-communicable diseases (NCDs). Objective We aimed to examine healthy food environment policies in Kenya and identify priorities for future action. Methods Using the Healthy Food Environment Policy Index (Food-EPI) we collected evidence on the extent of government action to create healthy food environments across 13 policy and infrastructure support domains and 43 related good practice indicators between 2017 and 2018. A panel of 15 national experts rated the extent of government action on each indicator compared to the policy development cycle and international best practice respectively. Based on gaps found, actions to improve food environments in Kenya were identified and prioritized. Results In the policy development cycle, 16/43 (37%) of good practice policy indicators were judged to be in ‘implementation’ phase, including: food composition targets, packaged foods’ ingredient lists/nutrient declarations; systems regulating health claims; restrictions on marketing breast milk substitutes; and school nutrition policies. Infrastructure support actions in ‘implementation’ phase included: food-based dietary guidelines; strong political support to reduce NCDs; comprehensive NCD action plan; transparency in developing food policies; and surveys monitoring nutritional status. Half (22/43) of the indicators were judged to be ‘in development’. Compared to international best practice, the Kenyan Government was judged to be performing relatively well (‘medium’ implementation) in one policy (restrictions on marketing breast milk substitutes) and three infrastructure support areas (political leadership; comprehensive implementation plan; and ensuring all food policies are sensitive to nutrition). Implementation for 36 (83.7%) indicators were rated as ‘low’ or ‘very little’. Taking into account importance and feasibility, seven actions within the areas of leadership, food composition, labelling, promotion, prices and health-in-all-policies were prioritized. Conclusion This baseline assessment is important in creating awareness to address gaps in food environment policy. Regular monitoring using Food-EPI may contribute to addressing the burden of diet-related NCDs in Kenya.

This study assessed community readiness to address unhealthy food and beverage consumption in women of reproductive age in urban Ghana. The Community Readiness Model (CRM) assessed the stage of readiness of communities within Accra and Ho to address the consumption of unhealthy foods and beverages. In-depth individual interviews were conducted in 2018 with 24 key informants from various sectors across the two cities. The CRM survey consists of 36 open questions addressing five readiness dimensions: community knowledge of efforts; leadership; community climate; knowledge of the issue and resources. Data available: 24 qualitative interviews transcripts (about 20 pages each), anonymized manually after collection (transmitted upon agreement and regulatory compliance: refer to Terms of Use statement); quantitative scores using the CRM protocol; documentation: interview guide and informed consent form.

Nutrition-related non-communicable diseases (NR-NCDs) are a global health problem, increasingly recognised as driven by unhealthy food environments. Yet little is known about government action to implement food environment-relevant policies, particularly in low-and lower-middle income countries. This study assessed government action, implementation gaps, and priorities to improve the food environment in Ghana. Using the Healthy Food-Environment Policy Index (Food-EPI), a panel comprising government and independent experts (n = 19) rated government action to improve the healthiness of food environment in Ghana against international best practices and according to steps within a policy cycle. Forty-three good practice indicators of food environment policy and infrastructure support were used, with ratings informed by systematically collected evidence of action validated by government officials. Following the rating exercise, the expert panel proposed and prioritized actions for government implementation. Three-quarters of all good practice indicators were rated at `low'/`very little' implementation. Restricting the marketing of breast milk substitutes was the only indicator rated "very high". Of ten policy actions prioritized for implementation, restricting unhealthy food marketing in children's settings and in the media were ranked the highest priority. Providing sufficient funds for nationally-relevant research on nutrition and NCDs was the highest priority infrastructure-support action. Other priority infrastructure-support actions related to leadership, monitoring and evaluation. This study identified gaps in Ghana's implementation of internationally-recommended policies to promote healthy food environments. National stakeholders recommended actions, which will require legislation and leadership. The findings provide a baseline for measuring government progress towards implementing effective policies to prevent NR-NCDs.

Following publication of the original article [1], the authors opted to correct the following reference on page 3.

Ghana has reached an advanced stage of nutrition transition, contributing to an increase in nutrition-related non-communicable diseases, particularly amongst urban women. Community involvement is an important factor in the success of efforts to promote healthy eating. The readiness of populations to accept a range of interventions needs to be understood before appropriate interventions can be implemented. Therefore, this study assessed how ready urban communities are to improve diets of women of reproductive age in Ghana. Using the Community Readiness Model (CRM), in-depth interviews were conducted with 24 key informants from various sectors in low income communities across two cities in Ghana: Accra and Ho. The CRM consists of 36 open questions addressing five readiness dimensions (community knowledge of efforts, leadership, community climate, knowledge of the issue and resources). Interviews were scored using the CRM protocol with a maximum of 9 points per dimension (from 1 = no awareness to 9 = high level of community ownership). Thematic analysis was undertaken to gain insights of community factors that could affect the implementation of interventions to improve diets. The mean community readiness scores indicated that both communities were in the “vague awareness stage” (3.35 ± 0.54 (Accra) and 3.94 ± 0.41 (Ho)). CRM scores across the five dimensions ranged from 2.65–4.38/9, ranging from denial/resistance to pre-planning. In both communities, the mean readiness score for ‘knowledge of the issue’ was the highest of all dimensions (4.10 ± 1.61 (Accra); 4.38 ± 1.81 (Ho)), but was still only at the pre-planning phase. The lowest scores were found for community knowledge of efforts (denial/resistance; 2.65 ± 2.49 (Accra)) and resources (vague awareness; 3.35 ± 1.03 (Ho)). The lack of knowledge of the consequences of unhealthy diets, misconceptions of the issue partly from low education, as well as challenges faced from a lack of resources to initiate/sustain programmes explained the low readiness. Despite recognising that unhealthy diets are a public health issue in these urban Ghanaian communities, it is not seen as a priority. The low community readiness ratings highlight the need to increase awareness of the issue prior to intervening to improve diets.

Objectives: Social isolation and loneliness have been associated with ill health and are common in the developed world. A clear understanding of their implications for morbidity and mortality is needed to gauge the extent of the associated public health challenge and the potential benefit of intervention. Study design: A systematic review of systematic reviews (systematic overview) was undertaken to determine the wider consequences of social isolation and loneliness, identify any differences between the two, determine differences from findings of non-systematic reviews and to clarify the direction of causality. Methods: Eight databases were searched from 1950 to 2016 for English language reviews covering social isolation and loneliness but not solely social support. Suitability for inclusion was determined by two or more reviewers, the methodological quality of included systematic reviews assessed using the a measurement tool to assess systematic reviews (AMSTAR) checklist and the quality of evidence within these reviews using the grading of recommendations, assessment, development and evaluations (GRADE) approach. Non-systematic reviews were sought for a comparison of findings but not included in the primary narrative synthesis. Results: Forty systematic reviews of mainly observational studies were identified, largely from the developed world. Meta-analyses have identified a significant association between social isolation and loneliness with increased all-cause mortality and social isolation with cardiovascular disease. Narrative systematic reviews suggest associations with poorer mental health outcomes, with less strong evidence for behavioural and other physical health outcomes. No reviews were identified for wider socio-economic or developmental outcomes. Conclusions: This systematic overview highlights that there is consistent evidence linking social isolation and loneliness to worse cardiovascular and mental health outcomes. The role of social isolation and loneliness in other conditions and their socio-economic consequences is less clear. More research is needed on associations with cancer, health behaviours, and the impact across the life course and wider socio-economic consequences. Policy makers and health and local government commissioners should consider social isolation and loneliness as important upstream factors impacting on morbidity and mortality due to their effects on cardiovascular and mental health. Prevention strategies should therefore be developed across the public and voluntary sectors, using an asset-based approach. (C) 2017 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.

Despite the publication of a number of governmental policy documents asserting the need for parity of esteem between mental and physical health care,1,2 it remains the case that patients with severe mental illness often receive a service that is inadequate to meet their needs or improve outcomes.3,4 The costs to individuals and society are large, with over £11 billion spent by the NHS in England annually on functional illness and comorbidity arising from mental and physical health problems5 and an estimated total societal cost of schizophrenia in England of £6.7 billion.6 The need to integrate physical and mental health care was highlighted in the NHS's Five Year Forward View and was subsequently described as the ‘new frontier for integrated care’ by the King’s Fund.5,7 The term ‘triple integration’ was used by Simon Stevens to describe new models of care proposed in the Five Year Forward View ; models in which integration of primary and specialist care, physical and mental health, and health and social care occurred.7 This article presents a case study that offers a model of integrated care. Pitsmoor Surgery serves a population with twice the city average and three times the national average of severe enduring mental illness (SEMI). The Primary Mental Health Care Project (PMHCP) was set up by one of the project partners in the mid-1990s, as it was recognised that the needs of this population were being insufficiently met by the services available at the time. The project provides a holistic model of care to patients aged >16 years, suffering with a variety of enduring mental health problems, from severe depression and anxiety to schizophrenia, personality disorder, and bipolar disorder. The project aims to promote psychological, social, and physical wellbeing among its clients. The surgery employs and manages the project staff directly and is part-funded by the …

Ghana Healthy Food environment Policy Index (Food-EPI) country scorecards and priority recommendations for action.

The extent of implementation of food environment policies in Kenya was assessed and priority actions were identified for the government to implement, with its partners, to create healthier food environments. Methods based on the Healthy Food Environment Policy Index (Food-EPI) by INFORMAS (International Network for Food and Obesity/NCDs Research, Monitoring and Action Support) were used. Between October 2017 and August 2018, a cross-country team of researchers trained by a Food-EPI expert implemented the Kenya Food-EPI exercise.