Use In Low-income Countries Research Articles

Low concordance between QIAreach QuantiFERON-TB, a novel interferon-gamma release assay, and QuantiFERON-TB Gold Plus, in a population-based survey in Blantyre, Malawi.

Almost a quarter of the world's population has evidence of Mycobacterium tuberculosis (Mtb) infection. Monitoring and addressing this substantial burden of so-called "latent" tuberculosis (TB) infection will be critical to reach End TB targets. However, current interferon-gamma release assays (IGRAs) for Mtb infection are costly, and require a large volume of venous blood and significant laboratory processing, which are major barriers to their wider use in low-income countries. The novel QIAreach QuantiFERON-TB (QIAreach) assay has been designed as a more accessible alternative. We sought to evaluate it against a reference standard of QuantiFERON-TB Gold Plus, in a large cross-sectional survey in Blantyre, Malawi. To our knowledge, this is the first diagnostic evaluation of QIAreach QFT to be performed in a population-based survey in a low-income high-incidence setting, and to specifically focus on young children (a priority group for interventions targeting Mtb infection). In contrast to previous studies in other settings, we observed poor performance of QIAreach QFT, particularly in young children where there was little correlation between the novel test and the reference standard. This leads us to conclude that this test cannot be widely recommended for use in its current form; indeed manufacture is currently suspended. We believe our findings are of urgent importance to policymakers, clinicians, and researchers and underscore the importance of careful evaluation of new diagnostics in the contexts where they are intended to be used.

Practice of clean intermittent catheterisation in children with spina bifida: A scoping review

Background: Spina bifida is a congenital neural tube defect, where there is incomplete formation of the spinal cord and vertebrae, resulting in abnormal development of the neural tube. This affects bladder function and urinary incontinence. Clean Intermittent Catheterization (CIC) is used to manage bladder and bowel management.Objectives: This study aims to scope evidence on the facilitators and barriers to usage and practice of CIC in children with spina bifida in low-income countries.Method: We searched databases including PUBMED, Web of Science and SCOPUS, and screened articles for inclusion following the PRISMA-ScR guidelines. The search terms included ‘Spina Bifida ([continence management] AND [clean intermittent catheterisation]) AND ([barriers to Clean Intermittent Catheterisation] OR [Low Income Countries]) OR (myelomeningocele)’. Full-text assessment for eligibility excluded 202 articles. Twenty-two articles were reviewed and twelve full-text articles were excluded because of limited content. Ten articles published in English between 2004 and 2023 were selected for review.Results: Barriers in practicing CIC include pain and discomfort in catheter insertion, stigma and fears; inaccessibility of public toilets, unavailability of appropriate catheters, difficulty in positioning, limited quality of teaching and challenges with accessing supplies. Facilitators include starting CIC in infancy, follow-up by healthcare providers, support from family and community members, quality of training, continuous practice of CIC, utilisation of lubricants, reuse of catheters and other low-cost materials.Conclusion: Our review summarises facilitators and barriers to CIC and provides recommendations for further research, which includes the involvement of family members and community-based rehabilitation workers.Contribution: This article contributes to a better understanding of CIC use in low-income countries.

INVOLVEMENT OF ARTIFICIAL INTELLIGENCE IN HEALTHCARE

With the coming of the digital age, there is a compelling need to integrate Artificial intelligence (AI) with healthcare and other aspects of social development which will improve well-being and the quality of life of the population. Availability to the average users, rather than only rich organizations, will help revolutionize healthcare in a more rapid manner. AI technologies are largely developed by high income countries, whereas their use in low-income countries is urgent. AI is thus needed to make a transformation in overall health systems and not to be seen as only a technological solution to solve any one health problem. With innovative and sustainable development of AI in the health sector, we can come close to achieving reliable and quality universal health care for all.

INVOLVEMENT OF ARTIFICIAL INTELLIGENCE IN HEALTHCARE

With the coming of the digital age, there is a compelling need to integrate Artificial intelligence (AI) with healthcare and other aspects of social development which will improve well-being and the quality of life of the population. Availability to the average users, rather than only rich organizations, will help revolutionize healthcare in a more rapid manner. AI technologies are largely developed by high income countries, whereas their use in low-income countries is urgent. AI is thus needed to make a transformation in overall health systems and not to be seen as only a technological solution to solve any one health problem. With innovative and sustainable development of AI in the health sector, we can come close to achieving reliable and quality universal health care for all.

Curcumin Mitigates Mercury-induced Memory Impairment and Neurotoxicity: Insights from the Drosophila melanogaster Model

Mercury-containing products, such as dental amalgam used for dental filling in dentistry, have been heavily criticised due to their associated toxicity. Nevertheless, it is still in use in low-income countries due to it being relatively affordable. Therefore, in this study, we evaluate the neurotoxic effects of mercury (Hg) and the possible ameliorative effects of polyphenol-curcumin using the fruit fly (Drosophila melanogaster) model. Male and female D. melanogaster, aged 3 to 5 days, were categorized into six groups, each consisting of 40 flies. To evaluate the impact of Hg exposure and the potential protective effects of curcumin, we conducted measurements on multiple parameters. These included assessing the survival rate, determining the memory index using an aversive phototaxis suppression assay, evaluating locomotor performance through negative geotaxis, and analysing various biochemical parameters associated with antioxidant status and neuronal function-related enzymes. Our findings indicate that dietary exposure to Hg resulted in a decreased survival rate and impaired locomotor performance in D. melanogaster. However, we observed a notable improvement in the antioxidant system among D. melanogaster exposed to Hg toxicity when they were fed a diet supplemented with curcumin. This improvement was evident through enhanced catalase activity, improved memory index, and modulation of acetylcholinesterase and monoamine oxidase activities. These effects were observed in comparison to D. melanogaster solely exposed to HgCl2 without curcumin supplementation. Collectively, these data showed that curcumin could mitigate the neurotoxicity associated with Hg and thus could serve as a substitute for Hg-containing products like dental amalgam.

Global pesticide use and trade database (GloPUT): New estimates show pesticide use trends in low-income countries substantially underestimated

Global pesticide use and trade database (GloPUT): New estimates show pesticide use trends in low-income countries substantially underestimated

The Global Campaign Against Headache and its future relation to IHS and WHO.

Preparations for the Global Campaign Against Headache done jointly with WHO started almost 25 years ago. It was officially incorporated 18 years ago. It is the story of a few dedicated individuals who, together with the World Health Organization, generated epidemiological data all over the world and made use of these data to gradually increase the position of headache disorders, until migraine became number two among all causes of years lost to disability. It is also the story of impressive development of scientific tools, their validation and use in low-income countries. Models of care for headache patients were developed that are adaptable and hence can be implemented in future throughout the world. The last phase of the campaign shall use the impressive data set generated to cause real improvement in the healthcare for people with headache throughout the world. The recent World Health Organization initiative: Intersectoral Global Action Plan on Epilepsy and Other Neurological Disorders invites international organizations to collaborate, and headache is mentioned. This calls for the International Headache Society and all its national members and all other organizations involved in headache to work together with Lifting the Burden, the organization in charge of the Global Campaign Against Headache.

Implementation Of The Pediatric Early Warning System In Children With Chronic Diseases: Systematic Review

ABSTRACT Pediatric early warning system (PEWS) can be an early detection of worsening in pediatric patients with chronic diseases, quantitative studies related to the implementation of PEWS in children with chronic diseases have been carried out in various countries including the USA, Guatemala and China. The purpose of this review is to determine the implementation of PEWS in children with chronic diseases. This literature study uses a review method approach, data sources through Proquest, Science Key, Pubmed, JStore and CHINIL. Search articles using Indonesian and English keywords. Inclusion criteria and articles analyzed: research on the topic of PEWS in children with cancer. Articles obtained A total of 1,260 journals were taken. However, only 22 journals met the criteria for the last 10 years. In the end, only 6 journals that met the inclusion criteria were analyzed. The results of the analysis show that PEWS is also suitable for use in low-income countries, or in developing countries. The currently developed PEWS is in accordance with the criteria for pediatric patients treated in hemato-oncology wards, and can reduce hospital costs in the country in addition to optimizing existing resource. Keywords: Implementation, Pediatric Early Warning System, Children With Cancer, Chronic Disease

Design and Evaluation of a High-Performance, Low-Cost Prosthetic Foot for Developing Countries

Abstract A novel, high-performance, cosmetic, rugged, appropriately costed, and mass-manufacturable prosthetic foot for use in low-income countries was designed and field tested. This ruggedized foot was created to accommodate the unique economic, environmental, and cultural requirements for users in India. A previous prototype that enabled able-bodied like gait was modified to include a durable cosmetic cover without altering the tuned stiffness of the overall foot. After undergoing mechanical benchtop testing, the foot was distributed to prosthesis users in India to for at least 5 months. Afterward, participants underwent clinical tests to evaluate walking performance, and additional benchtop testing was performed on the field-tested feet to identify changes in performance. The ruggedized foot endured 1 × 106 fatigue cycles without failure and demonstrated the desired stiffness properties. Subjects walked significantly faster (0.14 m/s) with the ruggedized foot compared to the Jaipur foot, and the feet showed no visible sign of damage after months of use. Additionally, the field-tested feet showed little difference in stiffness from a set of unused controls. Anecdotal feedback from the participants indicated that the foot improved their speed and/or walking effort, but may benefit from more degrees-of-freedom about the ankle. The results suggest that the foot fulfills its design requirements; however, further field testing is required with more participants over a longer period to make sure the foot is suitable for use in developing countries.

Adaptation and validation of two autism-related measures of skills and quality of life in Ethiopia

Although most children with autism and other neurodevelopmental disorders live in low- and middle-income countries, assessment tools are lacking in these settings. This study aims to culturally adapt and validate two questionnaires for use in Ethiopia: the Autism Treatment Evaluation Checklist and the Pediatric Quality of Life Inventory™ Family Impact Module. Both questionnaires were adapted to be suitable for administration in low-literate caregivers and translated using the backward translation procedure. The factor structure, reliability and validity were investigated using caregiver-reports on 300 children with neurodevelopmental disorders or physical health conditions. Confirmatory factor analysis of the Pediatric Quality of Life Inventory™ Family Impact Module data indicated an acceptable fit of the hypothesised eight-factor structure. Internal consistency was high for both measures. Test–retest reliability was excellent for the Autism Treatment Evaluation Checklist and moderate to excellent for the Pediatric Quality of Life Inventory™ Family Impact Module. Both questionnaires demonstrated adequate known-group validity, with moderate to very large effect size group differences between case and control groups. The questionnaires correlated moderately with each other. In conclusion, the Ethiopian adaptations of the Autism Treatment Evaluation Checklist and the Pediatric Quality of Life Inventory™ Family Impact Module are valid and reliable tools for use in parents of children with neurodevelopmental disorders including autism. These adapted measures may also be valuable for use in other low-income settings.Lay abstractAlthough most children with autism and other neurodevelopmental disorders live in low- and middle-income countries, reliable tools to assess these conditions are often not available in these settings. In this study, we adapted two questionnaires developed in Western high-income contexts for use in Ethiopia – the Autism Treatment Evaluation Checklist and the Pediatric Quality of Life Inventory™ Family Impact Module. Both measures are completed by a child’s caregiver and both are relatively short and easy to complete. The Autism Treatment Evaluation Checklist is used to monitor the developmental issues of the child, while the Pediatric Quality of Life Inventory™ Family Impact Module measures the impact of the child’s condition on the caregiver. We translated both tools into the Ethiopian language Amharic, and adapted them to the local cultural context. Three hundred caregivers, half of whom were parents of children with neurodevelopmental disorders, and half were parents of children with physical health problems, completed the questionnaires through a face-to face interview, so that non-literate caregivers could also take part. Both tools performed adequately, measured what we aimed to measure and were reliable. Both the Autism Treatment Evaluation Checklist and Pediatric Quality of Life Inventory™ are suitable tools to assess children with developmental and other health problems in Ethiopia and their caregivers. We believe that more similar tools should be developed or adapted for use in low-income countries like Ethiopia, to gain a better understanding of developmental problems in those settings, and allowing clinicians and service providers to use these tools in their practice. Moreover, these tools can be used in future studies to evaluate interventions to improve support for families.

Experimental investigation of a spherical rubber isolator for use in low income countries

This paper presents an experimental study of a low-cost seismic isolator that can be used for the protection of low-rise houses in low-income countries. The isolator is based on rolling of a rubber sphere on flat or spherical concrete surfaces. Using a closely spaced grid of such spheres may allow for avoiding of the diaphragm slab at the isolation level, or of reducing its thickness. Avoiding the cost of this extra slab is crucial for building seismically isolated low-rise dwellings economically feasible in low-income regions of the globe.The effects of the geometry of the rolling surface (i.e., flat or concave), of the diameter of the rolling sphere (i.e., 25, 50 or 100 mm), and of the applied compressive load on the seismic behavior of such isolation bearings were investigated. Initially, the rubber isolators were subjected to monotonic uniaxial compression to examine their behavior under vertical loading. Subsequently, cyclic tests were performed to obtain the lateral force–displacement diagram of the isolation system. Finally, a slab supported by 4 isolators was subjected to a group of 61 ground motions. Eight different configurations were tested, leading to a total of 488 dynamic tests.It was found that the restoring force of such systems can originate not only from the curvature of the concrete surface, but also from the vertical motion induced by the drastic change of the shape of the rubber spheres, as well. In fact, for the configurations tested, the vertical motion sourcing from shape of the deformed sphere was much larger than the vertical motion sourcing from the curvature of the concrete surfaces.Moreover, equations offering the coefficient of friction as a function of the vertical load, the size and the deformation of the sphere were derived. This is crucial for design, as the governing parameter for the design of the rubber spheres is not material failure, but excessive compressive deformation that leads to undesirably high rolling friction. Dynamic tests proved that the proposed low-cost rolling rubber isolators can substantially reduce the accelerations transmitted to the superstructure The cost of the tested 25 mm, 50 mm and 100 mm diameter natural rubber spheres is 0.6 $, 3 $ and 17$, respectively.

Housing, health and energy: a characterisation of risks and priorities across Delhi’s diverse settlements

ABSTRACT Improved housing has the potential to advance health and contribute to the Sustainable Development Goals. Research examining housing, health and energy use in low-income countries is limited; understanding these connections is vital to inform interventions for healthy sustainable human settlements. This paper investigates the low-income setting of Delhi, where rapid urbanisation, a varied climate, high pollution levels, and a wide variation in housing quality could result in significant energy use and health risks. Drawing on approaches from health and the built environment and existing data and literature, a characterisation of energy use and health risks for Delhi’s housing stock is completed. Four broad settlement types were used to classify Delhi housing and energy use calculations and health risk assessment were performed for each variant. Energy use is estimated to be nearly two times higher per household among planned housing compared with other settlement types. Health risks, however, are found to be largest within informal slum settlements, with important contributions from heat and particulate matter across all settlements. This paper highlights intervention priorities and outlines the need for extensive further research, particularly through data gathering, to establish evidence to accelerate achieving healthy, sustainable and equitable housing in Delhi.

1-year impact of supervision, performance assessment, and recognition strategy (SPARS) on prescribing and dispensing quality in Ugandan health facilities

BackgroundTo strengthen appropriate medicine use (AMU) including the prescribing and dispensing quality at public sector health facilities in Uganda, the Ministry of Health introduced a multipronged approach known as the Supervision, Performance Assessment, and Recognition Strategy (SPARS). This paper assesses the impact of the first year of SPARS implementation on key AMU indicators.MethodsDistrict-based health workers trained as supervisors provide in-service training in medicines management complemented by indicator-based performance assessment and targeted supervision during each SPARS facility visit. From 2010 to 2013, health facilities that started the SPARS intervention were assessed during the first and last visit during a period of 12 months of implementing SPARS. This study examines 12 AMU indicators with 57 individual outcomes covering prescribing and dispensing quality. We also explored factors influencing 1-year improvement.ResultsWe found an overall increase in AMU indicators of 17 percentage points (p < 0.000) between the first and last visit during a period of 12 months of supervisions, which was significant in all levels of health care facilities and in both government and private not-for-profit faith-based sectors. Appropriate dispensing (25 percentage points, p < 0.005) improved more than appropriate prescribing (12 percentage points, p = 0.13). Specific facilities that reached an average score of over 75% across all AMU measures within the first year of supervision improved from 3 to 41% from the first visit (baseline). The greatest overall impact on AMU occurred in lower-level facilities; the level of improvement varied widely across indicators, with the greatest improvements seen for the lowest baseline measures. Supervision frequency had a significant impact on level of improvement in the first year, and private not-for-profit faith-based health facilities had notably higher increases in several dispensing and prescribing indicator scores than public sector facilities.ConclusionsThe multipronged SPARS approach was effective in building appropriate medicine use capacity, with statistically significant improvements in AMU overall and almost all prescribing and dispensing quality measures after 12 months of supervision. We recommend broad dissemination of the SPARS approach as an effective strategy to strengthen appropriate medicine use in low-income countries.

Low complexity (e.g., 60 Co teletherapy) is the appropriate level of radiotherapy for use in low-income countries.

Low complexity (e.g., 60 Co teletherapy) is the appropriate level of radiotherapy for use in low-income countries.

Assessing the Usability of a Task-Shifting Device for Inserting Subcutaneous Contraceptive Implants for Use in Low-Income Countries

Abstract Women in low- and middle-income countries (LMICs) have limited access to long-acting contraceptives. Access to long-acting contraceptives, such as subcutaneous contraceptive implants, could be increased by task-shifting implant administration from advanced to minimally trained healthcare providers. The objective of this study was to investigate the usability of a task-shifting device for administering subcutaneous contraceptive implants. Healthcare providers (n = 128) from multiple health centers in Ethiopia were trained to administer implants on an arm simulator with the traditional method and a method using the device. Participants were observed while inserting implants into the arm simulator, and procedural error rates were calculated. Observations were analyzed using an iterative inductive coding methodology. For the device-assisted method, minimally trained healthcare providers had larger procedural error rates than other professions (p = 0.002). For the traditional method, physicians had larger procedural error rates than nurses and midwives (p = 0.03). Several procedural errors were identified such as participants inserting and removing the trocar and plunger completely or inserting and/or removing the trocar too far or not enough. These findings reinforce the importance of performing formative usability testing during the early phases of a medical device design process, considering users' mental models, and avoiding assumptions about healthcare providers' abilities.

Tobacco use and associated risk factors in Burkina Faso: results from a population-based cross-sectional survey

BackgroundTobacco is a leading preventable cause of non-communicable diseases (NCDs). Studies characterizing the prevalence of tobacco use in low-income countries are lacking. This study describes the prevalence of tobacco use in Burkina Faso and its associated factors.MethodsData from the 2013 Burkina Faso World Health Organization (WHO) Stepwise approach to Surveillance (STEPS) were analyzed. The prevalence of any tobacco product use, cigarette smoking, and other tobacco use was calculated. Logistic regression analyses identified factors associated with tobacco use. Overall, 4691 people were included in this analysis.ResultsThe prevalence of any tobacco use was 19.8% (95% CI: 18.4–21.2). Tobacco use was higher for men (29.2% [27.0–31.5]) than women (11.8% [10.3–13.4]). The prevalence of smoked tobacco was 11.3% (10.3–12.4), with a significantly higher prevalence among men (24.5% [22.1–27.0]) than women (0.1% [0.01–0.3]). The overall prevalence of other tobacco use was 8.9% (7.4–10.7), with lower values for men (5.6% [4.1–7.2]) compared to women (11.7% [9.4–14.1]). Tobacco smoking among men was significantly associated with an increased age and alcohol consumption. The analysis of risk factors for other tobacco use stratified by gender showed that age, education, residence, and alcohol consumption were significantly associated with consumption for women, and age and alcohol consumption for men.ConclusionTobacco use is common in Burkina Faso. To effectively reduce tobacco use in Burkina Faso, a comprehensive tobacco control program should consider associated factors, such as gender, age, and alcohol consumption.

ICU Risk Stratification Models Feasible for Use in Sub-Saharan Africa Show Poor Discrimination in Malawi: A Prospective Cohort Study.

Critical illness disproportionately affects people in low-income countries (LICs). Efforts to improve critical care in LICs must account for differences in demographics and infrastructure compared to high-income settings. Part of this effort includes the development and validation of intensive care unit (ICU) risk stratification models feasible for use in LICs. The purpose of this study was to validate and compare the performance of ICU mortality models developed for use in sub-Saharan Africa. This was a prospective, observational cohort study of ICU patients in a referral hospital in Malawi. Models were selected for comparison based on a Medline search for studies which developed ICU mortality models based on cohorts in sub-Saharan Africa. Model discrimination was evaluated using the area under the curve with 95% confidence intervals (CI). During the study, 499 patients were admitted to the study ICU, and after exclusions, there were 319 patients. The cohort was 62% female, with the mean age 31years (IQR: 23-41), and 74% had surgery preceding ICU admission. Discrimination for hospital mortality ranged from 0.54 (95% CI 0.48, 0.60) for the Universal Vital Assessment (UVA) to 0.72 (95% CI 0.66, 0.78) for the Malawi Intensive care Mortality Evaluation (MIME). After tenfold cross-validation, these results were unchanged. The MIME outperformed other models in this prospective study. Most ICU models developed for LICs had poor to modest discrimination for hospital mortality. Future research may contribute to a better risk stratification model for LICs by refining and enhancing the MIME.

New molecular tools for meningitis diagnostics in Ethiopia \u2013 a necessary step towards improving antimicrobial prescription

BackgroundMeningitis remains a top cause of premature death and loss of disability-adjusted life years in low-income countries. In resource-limited settings, proper laboratory diagnostics are often scarce and knowledge about national and local epidemiology is limited. Misdiagnosis, incorrect treatment and overuse of antibiotics are potential consequences, especially for viral meningitis.MethodsA prospective study was conducted over three months in a teaching hospital in Ethiopia with limited laboratory resources. Cerebrospinal fluid (CSF) samples from patients with suspected meningitis were analysed using a multiplex PCR-based system (FilmArray, BioFire), in addition to basic routine testing with microscopy and culture. Clinical data, as well as information on treatment and outcome were collected.ResultsTwo hundred and eighteen patients were included; 117 (54%) neonates (0–29 days), 63 (29%) paediatrics (1 month-15 years) and 38 (17%) adults (≥16 years). Of 218 CSF samples, 21 (10%) were PCR positive; 4% in neonates, 14% in paediatrics and 18% in adults. Virus was detected in 57% of the PCR positive samples, bacteria in 33% and fungi in 10%. All CSF samples that were PCR positive for a bacterial agent had a white cell count ≥75 cells/mm3 and/or turbid appearance. The majority (90%) of patients received more than one antibiotic for treatment of the meningitis episode. There was no difference in the mean number of different antibiotics received or in the cumulative number of days with antibiotic treatment between patients with a microorganism detected in CSF and those without.ConclusionsA rapid molecular diagnostic system was successfully implemented in an Ethiopian setting without previous experience of molecular diagnostics. Viral meningitis was diagnosed for the first time in routine clinical practice in Ethiopia, and viral agents were the most commonly detected microorganisms in CSF. This study illustrates the potential of rapid diagnostic tests for reducing antibiotic usage in suspected meningitis cases. However, the cost of consumables for the molecular diagnostic system used in this study limits its use in low-income countries.

Development of a Malawi Intensive care Mortality risk Evaluation (MIME) model, a prospective cohort study

Development of a Malawi Intensive care Mortality risk Evaluation (MIME) model, a prospective cohort study

Health and nutritional aspects of sustainable diet strategies and their association with environmental impacts: a global modelling analysis with country-level detail

SummaryBackgroundSustainable diets are intended to address the increasing health and environmental concerns related to food production and consumption. Although many candidates for sustainable diets have emerged, a consistent and joint environmental and health analysis of these diets has not been done at a regional level. Using an integrated health and environmental modelling framework for more than 150 countries, we examined three different approaches to sustainable diets motivated by environmental, food security, and public health objectives.MethodsIn this global modelling analysis, we combined analyses of nutrient levels, diet-related and weight-related chronic disease mortality, and environmental impacts for more than 150 countries in three sets of diet scenarios. The first set, based on environmental objectives, replaced 25–100% of animal-source foods with plant-based foods. The second set, based on food security objectives, reduced levels of underweight, overweight, and obesity by 25–100%. The third set, based on public health objectives, consisted of four energy-balanced dietary patterns: flexitarian, pescatarian, vegetarian, and vegan. In the nutrient analysis, we calculated nutrient intake and changes in adequacy based on international recommendations and a global dataset of nutrient content and supply. In the health analysis, we estimated changes in mortality using a comparative risk assessment with nine diet and weight-related risk factors. In the environmental analysis, we combined country-specific and food group-specific footprints for greenhouse gas emissions, cropland use, freshwater use, nitrogen application, and phosphorus application to analyse the relationship between the health and environmental impacts of dietary change.FindingsFollowing environmental objectives by replacing animal-source foods with plant-based ones was particularly effective in high-income countries for improving nutrient levels, lowering premature mortality (reduction of up to 12% [95% CI 10–13] with complete replacement), and reducing some environmental impacts, in particular greenhouse gas emissions (reductions of up to 84%). However, it also increased freshwater use (increases of up to 16%) and had little effectiveness in countries with low or moderate consumption of animal-source foods. Following food-security objectives by reducing underweight and overweight led to similar reductions in premature mortality (reduction of up to 10% [95% CI 9–11]), and moderately improved nutrient levels. However, it led to only small reductions in environmental impacts at the global level (all impacts changed by <15%), with reduced impacts in high-income and middle-income countries, and increased resource use in low-income countries. Following public health objectives by adopting energy-balanced, low-meat dietary patterns that are in line with available evidence on healthy eating led to an adequate nutrient supply for most nutrients, and large reductions in premature mortality (reduction of 19% [95% CI 18–20] for the flexitarian diet to 22% [18–24] for the vegan diet). It also markedly reduced environmental impacts globally (reducing greenhouse gas emissions by 54–87%, nitrogen application by 23–25%, phosphorus application by 18–21%, cropland use by 8–11%, and freshwater use by 2–11%) and in most regions, except for some environmental domains (cropland use, freshwater use, and phosphorus application) in low-income countries.InterpretationApproaches for sustainable diets are context specific and can result in concurrent reductions in environmental and health impacts globally and in most regions, particularly in high-income and middle-income countries, but they can also increase resource use in low-income countries when diets diversify. A public health strategy focused on improving energy balance and dietary changes towards predominantly plant-based diets that are in line with evidence on healthy eating is a suitable approach for sustainable diets. Updating national dietary guidelines to reflect the latest evidence on healthy eating can by itself be important for improving health and reducing environmental impacts and can complement broader and more explicit criteria of sustainability.FundingWellcome Trust, EAT, CGIAR, and British Heart Foundation.