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Bull World Health Organ 20199783ndash96A | doi httpdxdoiorg102471BLT18218057
Research
83
IntroductionNoncommunicable diseases are increasing in prevalence worldwide especially in low- and middle-income countries and now account for most of the global morbidity and mor-tality1 Unhealthy food and alcohol consumption and tobacco use contribute to a significant proportion of the noncommu-nicable disease burden These three risk factors collectively explain approximately one-quarter of the total disease bur-den worldwide2 Evidence suggests that globalization and in particular trade and investment liberalization may play a key role in increasing the supply of these risk factors34 Studies have shown that as countries liberalize the consumption of unhealthy commodities increases5ndash7 For example consump-tion of meats high in fat has increased in the Federated States of Micronesia due to decades of foreign dependence and food imports8 consumption of high-sugar and high-fat items has increased in Fiji after becoming increasingly reliant on food imports9 and meat and snacks consumption increased in Central America after lowering trade barriers10
Few studies have used longitudinal data from many coun-tries or causal inference methods to examine relationships between trade and investment liberalization and changes in noncommunicable disease risk factors limiting conclusions about generalizability and causality from existing studies A systematic review found that liberalizing trade and investment
was associated with increased imports and consumption of edible oils meats processed foods and sugar-sweetened bev-erages while the results for tobacco were inconclusive11 A study examining 42 countries showed that between 1970 and 1995 higher trade volume was significantly associated with increased cigarette consumption in low- and middle-income countries only12 However another study did not detect any relationship between foreign direct investment and tobacco consumption in 50 low- and middle-income countries between 1997 and 2010 The study though found a significant positive association between increased foreign direct investment and consumption of alcohol and processed foods high in salt fat and sugar5 Case-control studies have identified an increase in sugar-sweetened beverage sales in Viet Nam following its accession to the World Trade Organization (WTO)13 while no significant changes were detected of such sales in Peru following its ratification of a free trade agreement with the United States of America14
WTO agreements and institutions are an important set of trade policies As of 2017 164 countries were members of WTO 126 of whom were original members of the predecessor General Agreement on Tariffs and Trade15 Accession to the WTO is a discrete liberalizing event that is broadly comparable across countries despite variations in accession commitments between countries facilitating the comparison of countries joining the WTO with non-member countries To provide
Objective To investigate the relationship between joining the World Trade Organization (WTO) and the availability of several commodities with both harmful and protective effects for the development of noncommunicable diseasesMethods We used a natural experiment design to compare trends in the domestic supply of tobacco alcohol and seven food groups between 1980 and 2013 in 21 countries or territories joining WTO after 1995 and 26 non-member countries using propensity score weights We applied a comparative interrupted time-series framework by using multivariate random-effects linear models adjusted for gross domestic product per capita the percentages of urban population and female labour force participation In the tobacco model we controlled for Member States that had ratified the Framework Convention on Tobacco Control and in the alcohol model the percentage of the population identifying themselves as MuslimFindings Following accession to WTO member states experienced immediate increases in the domestic supply of fruits and vegetables of 55 g per person per day on average compared to non-member countries The analysis showed gradual increases in the geometric mean of the supply of tobacco and alcohol of 62 and 36 per year respectively We did not detect any significant changes in the availability of red meats and animal fats seafood nuts seeds and legumes starches or edible oils and results for sugars were inconsistent across model variationsConclusion The results suggest that WTO membership may lead to increases in both harmful and protective factors for noncommunicable disease but further exploration of country-specific variation is warranted
a Department of Health Policy and Management Bloomberg School of Public Health Johns Hopkins University 624 N Broadway Hampton House 380A Baltimore MD 21205 United States of America (USA)
b Department of Health Policy and Management Bloomberg School of Public Health Johns Hopkins University Baltimore USAc Center for a Livable Future Department of Environmental Health amp Engineering Bloomberg School of Public Health Johns Hopkins University Baltimore USA d Paul H Nitze School of Advanced International Studies Johns Hopkins University Baltimore USACorrespondence to Krycia Cowling (email kryciacogmailcom)(Submitted 15 June 2018 ndash Revised version received 6 October 2018 ndash Accepted 8 October 2018 ndash Published online 6 November 2018 )
World Trade Organization membership and changes in noncommunicable disease risk factors a comparative interrupted time-series analysis 1980ndash2013Krycia Cowlinga Elizabeth A Stuartb Roni A Neffc Daniel Magrawd Jon Vernickb amp Keshia Pollack Porterb
Research
84 Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
Tabl
e 1
Co
untr
ies a
nd te
rrito
ries i
nclu
ded
in a
naly
sis b
y WTO
mem
bers
hip
and
dom
estic
supp
ly q
uant
ity fo
r eac
h co
mm
odity
in 1
993
and
2011
Coun
try o
r te
rrito
ryCo
mm
odity
by y
ear
Toba
cco
(gc
apita
old
er
than
14
year
s)
Alco
hol
(kg
capi
ta o
lder
th
an 1
4 ye
ars)
Frui
ts a
nd
vege
tabl
es
(kg
capi
ta)
Nuts
see
ds a
nd
legu
mes
(k
gca
pita
)
Seaf
ood
(k
gca
pita
)Re
d m
eats
and
an
imal
fats
(k
gca
pita
)
Star
ches
(k
gca
pita
)Su
gars
(k
gca
pita
)Ed
ible
oils
(k
gca
pita
)
1993
2011
1993
2011
1993
2011
1993
2011
1993
2011
1993
2011
1993
2011
1993
2011
1993
2011
WTO
mem
bers
(by
WTO
mem
bers
hip
date
)a
Ecua
dor (
21 Ja
n 19
96)
321
451
75
284
557
181
914
15
50
37
72
85
259
406
187
615
52
264
201
140
153
Bulg
aria
(1 D
ec
1996
)42
635
2332
293
710
65
167
311
82
76
60
16
57
653
458
190
818
36
318
283
131
132
Mon
golia
(29
Jan
1997
)44
214
689
66
481
117
769
06
18
01
07
109
685
911
35
187
012
714
50
36
7
Pana
ma
(6 S
ept
1997
)64
03
1199
775
411
57
729
939
54
81
135
137
387
454
167
317
22
338
326
91
107
Kyrg
yzst
an (2
0 D
ec 1
998)
b36
66
2885
814
120
359
517
37
18
34
01
23
449
339
231
426
11
157
261
52
52
Latv
ia (1
0 Fe
b 19
99)b
307
399
42
329
117
913
46
162
20
33
730
325
985
679
430
76
232
944
537
72
812
3
Esto
nia
(13
Nov
19
99)b
1388
215
392
560
168
896
318
97
10
71
275
142
616
614
229
024
36
213
426
38
62
Jord
an (1
1 Ap
r 20
00)
2030
816
794
31
12
153
318
82
105
122
39
57
164
138
162
820
40
407
412
152
217
Geo
rgia
(14
June
20
00)b
268
725
314
471
465
131
510
24
42
21
38
110
209
211
203
126
48
123
309
10
69
Alba
nia
(8 S
ept
2000
)58
516
1771
914
754
219
68
439
95
710
10
96
426
856
924
25
207
329
848
78
87
6
Om
an (9
Nov
20
00)
1093
026
793
59
62
260
435
00
49
55
228
254
264
342
111
514
85
243
331
105
99
Lith
uani
a (3
1 M
ay 2
001)
b92
72
371
651
916
57
131
214
97
21
43
243
431
670
682
279
824
96
295
452
46
97
Repu
blic
of
Mol
dova
(26
July
20
01)b
9801
627
663
563
571
188
413
34
47
23
05
111
344
263
253
118
03
239
212
48
105
Chin
a (1
1 D
ec
2001
)39
313
2766
624
554
615
53
437
88
210
914
534
028
150
723
68
225
05
26
95
47
9
Arm
enia
(5 F
eb
2003
)b22
405
3054
415
610
013
64
390
70
02
21
23
221
037
124
11
188
623
036
80
47
5
Nep
al (2
3 Ap
r 20
04)
796
251
71
12
29
997
165
96
512
60
82
212
114
120
28
272
226
639
75
310
0
(contin
ues
)
85Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
Coun
try o
r te
rrito
ryCo
mm
odity
by y
ear
Toba
cco
(gc
apita
old
er
than
14
year
s)
Alco
hol
(kg
capi
ta o
lder
th
an 1
4 ye
ars)
Frui
ts a
nd
vege
tabl
es
(kg
capi
ta)
Nuts
see
ds a
nd
legu
mes
(k
gca
pita
)
Seaf
ood
(k
gca
pita
)Re
d m
eats
and
an
imal
fats
(k
gca
pita
)
Star
ches
(k
gca
pita
)Su
gars
(k
gca
pita
)Ed
ible
oils
(k
gca
pita
)
1993
2011
1993
2011
1993
2011
1993
2011
1993
2011
1993
2011
1993
2011
1993
2011
1993
2011
Cam
bodi
a (1
3 O
ct 2
004)
985
941
483
21
342
689
651
22
121
74
406
155
154
192
220
60
45
245
29
19
Saud
i Ara
bia
(11
Dec
200
5)26
242
2484
20
60
021
85
175
34
18
34
910
715
919
516
45
159
127
631
215
915
5
Viet
Nam
(11
Jan
2007
)53
39
1212
16
721
292
914
95
48
156
119
339
172
488
184
918
56
129
218
18
34
Ukr
aine
(16
May
20
08)b
1336
514
023
372
937
131
122
34
60
37
76
143
537
352
333
728
27
456
489
94
129
Cabo
Ver
de (2
3 Ju
ly 2
008)
336
128
73
407
628
859
202
95
613
714
412
131
321
418
84
177
219
020
99
28
5
WTO
non
-mem
ber a
s of
201
1Af
ghan
istan
207
079
90
00
02
630
565
43
59
01
01
215
146
183
319
14
34
92
16
32
Alge
ria19
008
1250
24
56
011
91
254
95
59
93
74
114
415
225
04
287
827
528
116
515
5Az
erba
ijanb
8924
320
956
110
689
134
524
56
32
42
30
22
165
268
231
230
55
112
161
11
27
Baha
mas
2008
115
646
657
356
228
936
37
55
27
246
295
730
568
998
101
040
743
73
76
5Be
laru
sb14
208
2830
458
097
212
50
207
11
04
11
214
474
577
633
83
305
435
539
94
718
8D
emoc
ratic
Pe
ople
s Re
publ
ic
of K
orea
3606
341
992
159
113
206
717
93
204
160
183
94
107
132
187
421
24
48
41
48
55
Ethi
opia
174
611
65
73
164
176
265
104
205
01
03
84
94
169
721
06
37
65
13
31
Fren
ch P
olyn
esia
1838
611
813
968
875
170
117
41
68
70
401
481
657
682
171
616
43
385
335
93
144
Iran
(Isla
mic
Re
publ
ic o
f)79
28
789
40
00
026
48
384
612
121
25
39
117
214
025
98
232
328
029
39
812
1
Iraq
1083
616
765
66
29
213
615
51
48
35
13
29
78
52
177
418
71
202
189
134
173
Kaza
khst
anb
1689
413
868
246
491
609
262
10
84
63
75
366
261
228
09
219
119
627
76
619
8Ki
ribat
i11
050
2304
80
00
025
32
241
82
23
073
671
114
616
520
14
204
835
243
97
94
8La
o Pe
ople
s D
emoc
ratic
Re
publ
icc
14 4
922
10 9
575
161
227
582
267
04
17
56
721
111
819
121
04
228
517
432
60
91
9
Leba
non
6887
753
266
223
229
537
229
17
260
213
35
111
284
258
186
418
22
460
492
143
186
Libe
ria38
20
249
115
316
192
061
96
53
64
84
48
98
024
66
260
319
517
117
117
4N
ew C
aled
onia
3558
924
952
113
296
212
65
175
81
46
320
128
439
452
618
27
160
423
225
916
314
3Ru
ssia
n Fe
dera
tionb
d63
04
1834
847
110
74
108
217
96
28
37
143
224
682
557
282
326
13
355
490
67
132
( continued)
(contin
ues
)
86 Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
quantitative evidence on the role of trade and investment liberalization in the global noncommunicable disease burden we studied changes in the do-mestic supply of tobacco alcohol and several food groups at the national level after WTO accession and compared to these trends in non-member countries
MethodsStudy design
We used a natural experiment approach to compare domestic supply patterns of nine commodities in 47 countries or territories from 1980 to 2013 21 countries or territories joining WTO between 1996 and 2008 (exposed group) and 26 countries not in WTO as of 2011 (unexposed group Table 1) We defined exposure as accession to WTO and the post-exposure period was therefore the beginning of each countryrsquos individual WTO joining date The years 1980 to 1995 comprise the pre-exposure period for all countries as the first countries joined the WTO in 1995
The commodities were tobacco (all types) alcohol (all types including beer wine and spirits) and seven food groups relevant to the development of noncom-municable diseases either protective or harmful These food groups were fruits and vegetables nuts seeds and legumes seafood red meats and animal fats sug-ars starches and edible oils We based the selection of these food categories on a review of common elements of indices of dietary quality16ndash19 and dietary diversity2021 and available evidence on the protective and harmful effects of major food groups for the development of noncommunicable diseases22ndash24 A list of food items included in the dif-ferent commodity groups and the data completeness for each item is available from the figshare data repository25 We hypothesized that following WTO ac-cession the supply of tobacco alcohol edible oils red meats and animal fats and sugars would increase the supply of starches and nuts seeds and legumes would decline The expected trends in fruits and vegetables and seafood were unknown
From our sample we excluded original member states of WTO and all members of the former General Agreement on Tariffs and Trade Nine countries in the unexposed group joined WTO in the final two years (2012ndash2013) Co
untr
y or
terr
itory
Com
mod
ity b
y yea
r
Toba
cco
(gc
apita
old
er
than
14
year
s)
Alco
hol
(kg
capi
ta o
lder
th
an 1
4 ye
ars)
Frui
ts a
nd
vege
tabl
es
(kg
capi
ta)
Nuts
see
ds a
nd
legu
mes
(k
gca
pita
)
Seaf
ood
(k
gca
pita
)Re
d m
eats
and
an
imal
fats
(k
gca
pita
)
Star
ches
(k
gca
pita
)Su
gars
(k
gca
pita
)Ed
ible
oils
(k
gca
pita
)
1993
2011
1993
2011
1993
2011
1993
2011
1993
2011
1993
2011
1993
2011
1993
2011
1993
2011
Sam
oad
3390
030
722
607
527
268
836
92
09
46
416
474
533
418
105
220
35
248
302
33
73
Sao
Tom
e an
d Pr
inci
pe78
216
34
469
613
292
037
10
42
81
254
281
28
109
196
815
32
160
239
72
98
Suda
ne15
06
121
858
641
883
714
36
99
169
18
21
255
348
187
416
22
271
372
79
60
Tajik
istan
bc
1605
814
87
88
14
146
618
57
14
40
05
05
130
124
189
117
56
109
190
114
107
Tim
or-L
este
283
092
23
62
79
466
498
108
126
00
60
402
328
305
521
83
33
115
11
47
Turk
men
istan
b13
616
1029
24
712
012
79
208
60
40
34
63
635
156
921
57
234
816
79
411
37
5Uz
beki
stan
b53
428
78
114
186
160
031
16
07
12
09
07
270
379
232
423
51
134
102
133
102
Vanu
atud
578
933
62
111
67
341
727
73
62
74
313
337
355
314
243
731
11
92
203
70
57
Yem
en21
044
2454
63
40
666
170
47
06
16
02
58
210
617
79
171
120
228
67
77
0
WTO
Wor
ld Tr
ade
Org
aniza
tion
a We
obta
ined
mem
bers
hip
date
s fro
m th
e W
TO w
eb si
te15
b We
anal
ysed
form
er S
ovie
t Uni
on m
embe
r sta
tes d
ata
from
199
2c W
e di
d no
t ana
lyse
dat
a af
ter 2
012
since
the
coun
try
join
ed W
TO in
201
3d W
e di
d no
t ana
lyse
dat
a af
ter 2
011
since
the
coun
try
join
ed W
TO in
201
2e D
ata
ende
d in
201
1 w
hen
coun
try
divi
ded
into
Sud
an a
nd S
outh
Sud
an
Not
e Q
uant
ities
for e
ach
com
mod
ity fo
r the
per
iods
bef
ore
and
afte
r joi
ning
the
WTO
are
pre
sent
ed fo
r the
firs
t and
last
yea
rs w
ith c
ompl
ete
data
for a
ll co
untri
es e
xcep
t for
pre
-exp
osur
e to
bacc
o da
ta fo
r Om
an w
hich
are
from
199
2
( continued)
87Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
Table 2 Baseline characteristics of countries included in study on WTO membership and changes in noncommunicable disease risk factors
Covariates WTO membersa (n = 21) WTO non-members (n = 26) Standardized difference in means (P)bc
No of countries per area NA (055)East Asia and Pacific 4 8Europe and central Asia 10 7Latin America and Caribbean 2 1Middle East and north Africa 3 5North America 0 0South Asia 1 1Sub-Saharan Africa 1 4No of former Soviet Union member states
8 7 NA (041)
Mean GDP per capita in 2005 Int$ (SD)Year 1980 5565 (8 314) 6907 (9 697) 015 (069)Year 1995 4805 (4 845) 6357 (11 005) 018 (055)Mean of female labour force participation (SD)Year 1980 441 (251) 421 (260) minus008 (082)Year 1995 519 (183) 465 (224) minus026 (037)Mean of urban population (SD)Year 1980 382 (206) 372 (219) minus005 (090)Year 1995 531 (201) 458 (209) minus035 (023)Mean of Muslim population (SD)d
Year 1980 300 (404) 360 (434) 014 (070)Year 1995 224 (362) 418 (428) 048 (011)Mean weight of commodity per capitae
Tobacco gram (SD)f
Year 1980 1890 (1 532) 2182 (1997) 016 (067) Year 1995 1358 (1 045) 1913 (2 716) 026 (038)Alcohol kilogram (SD)f
Year 1980 252 (369) 298 (330) 014 (072) Year 1995 292 (262) 263 (275) minus011 (071)Fruits and vegetables kilogram (SD) Year 1980 1089 (747) 1658 (930) 064 (009) Year 1995 1371 (611) 1590 (1132) 023 (043)Nuts seeds and legumes kilogram (SD) Year 1980 60 (35) 79 (62) 036 (034) Year 1995 44 (26) 64 (67) 038 (019)Seafood kilogram (SD) Year 1980 77 (68) 170 (178) 062 (009) Year 1995 95 (89) 139 (186) 030 (032)Red meats and animal fats kilogram (SD) Year 1980 280 (322) 272 (182) minus003 (093) Year 1995 373 (238) 287 (209) minus038 (020)Starches kilogram (SD) Year 1980 1931 (372) 2230 (521) 062 (010) Year 1995 2155 (554) 2078 (533) minus014 (063)Sugars kilogram (SD) Year 1980 244 (148) 239 (141) minus004 (093) Year 1995 232 (89) 215 (131) minus015 (061)Edible oils kilogram (SD) Year 1980 61 (45) 68 (44) 015 (070) Year 1995 73 (48) 83 (55) 019 (052)
GDP gross domestic product Int$ international dollars NA not applicable SD standard deviation WTO World Trade Organizationa Countries joining WTO between 1996 and 2008b We calculated standardized difference in means as follows (mean for non-member states ndash mean for member states)(combined standard deviation)c For continuous variables we used two-sided t-tests to calculate P-values For or categorical variables we used χ2 testsd Covariate used in alcohol models onlye Commodity available for domestic consumptionf Data for population older than 14 years
Note The years presented are the first (1980) and last (1995) years we used for analyses of the period before countries and territories included in the study started to join WTO
88 Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
or after the analysis period data for these countries were censored to exclude values in or after the year they joined For countries that comprised the former Soviet Union (eight exposed seven un-exposed) the analysis period begins in 1992 when independent countries were established
Data sources
The data sources for all commodities were the Food and Agriculture Orga-nization national commodity balance sheets (tobacco) and food balance sheets (all other commodities) which measure the annual supply of each commodity by country and are widely used as a proxy for consumption2627 We obtained covariate data on urban population and female labour force participation from the World Bankrsquos World Development Indicators28 population data from the United Nations Population Division29 gross domestic product (GDP) per capita from the Institute for Health Metrics and Evaluation30 percent-age Muslim population from the Pew Research Center31 and the ratification dates for the Framework Convention on Tobacco Control (FCTC) from the United Nations Treaty Collection32
Variables
We measured all commodity variables in units of grams (tobacco) or kilograms (all other commodities) per capita For tobacco and alcohol we restricted these measures to the population older than 14 years as is standard3334 We con-trolled for the following key confound-ers established by the existing literature in all models GDP per capita urban population and female labour force par-ticipation45 Models for alcohol included each countryrsquos proportion of population identifying themselves as Muslim as a covariate because being Muslim is linked to lower rates of alcohol use35 Models for tobacco included a variable indicating whether the country had ratified the FCTC because this ratifica-tion represents a commitment to reduce tobacco use36
Propensity score weights
With observational data the non-random assignment of the exposure (in this case WTO membership) can create imbalance in covariates and baseline levels of the outcome variables between the groups compared37 Characteristics of the groups in the pre-exposure period Ta
ble
3
Mod
el o
utpu
t fro
m b
est-
perf
orm
ing
mod
el to
stud
y WTO
mem
bers
hip
and
chan
ges i
n no
ncom
mun
icabl
e di
seas
e ris
k fa
ctor
s 19
80ndash2
013
Varia
ble
Toba
ccoa
Alco
hola
Frui
ts a
nd
vege
tabl
esNu
ts s
eeds
an
d le
gum
esa
Seaf
ooda
Red
mea
ts a
nd a
nim
al
fats
a
Star
ches
Suga
rsEd
ible
oils
a
Fixe
d eff
ect
coeffi
cien
t (P)
WTO
mem
bers
hip
009
8 (0
477
)minus
011
8 (0
133
)19
794
(00
03)
010
7 (0
171
)minus
013
7 (0
436
)0
008
(08
65)
minus6
277
(01
33)
minus2
401
(01
15)
minus0
070(
029
6)
WTO
m
embe
rshi
pye
ar0
061
(00
54)
003
7 (0
050
)minus
127
6 (0
367
)minus
001
7 (0
151
)0
032
(03
67)
000
1 (0
875
)minus
012
0 (0
904
)0
250
(01
76)
000
5 (0
730
)
GDP
per c
apita
ab
044
9 (0
004
)0
496
(lt 0
001
)7
571
(02
18)
031
3 (0
060
)0
826
(lt 0
001
)0
184
(00
20)
530
8 (0
464
)6
133
(00
03)
015
0 (0
243
)
u
rban
pop
ulat
ion
minus0
017
(00
24)
001
4 (0
160
)1
993
(00
04)
minus0
005
(04
91)
000
6 (0
637
)0
004
(05
33)
061
6 (0
189
)0
019
(08
79)
001
1 (0
052
)
fe
mal
e la
bour
fo
rce
part
icip
atio
nminus
001
0 (0
099
)minus
000
9 (0
202
)minus
102
9 (0
069
)minus
000
1 (0
804
)minus
003
6(0
016)
000
3 (0
553
)0
298
(03
71)
minus0
133
(00
88)
minus0
012
(01
02)
FCTC
ratifi
catio
ncminus
020
4 (0
032
)N
AN
AN
AN
AN
AN
AN
AN
A
M
uslim
pop
ulat
iond
NA
minus0
025
(lt 0
001
)N
AN
AN
AN
AN
AN
AN
A
Year
3eminus
972
times 1
0minus6 (0
251
)N
AN
AN
Aminus
146
times 1
0minus6 (0
875
)N
AN
AN
AN
A
Cons
tant
475
9 (lt
00
01)
minus1
088
(03
37)
726
8 (0
883
)minus
141
3 (0
265
)minus
384
5 (0
022
)1
437
(00
49)
142
441
(00
20)
minus18
940
(01
63)
006
6 (0
950
)
Rand
om e
ffec
ts v
aria
nce
(SE)
Inte
rcep
t0
944
(01
99)
166
0 (0
530
)69
170
32 (1
656
286
)3
070
(15
85)
295
0 (0
747
)0
396
(00
73)
5228
010
(1 1
232
00)
879
17 (1
929
0)8
46 times
10minus
4 (19
3 times
10minus
4 )
Slop
e7
83 times
10minus
10 (2
8 times
10minus
10)
000
3 (0
001
2)20
161
(53
45)
000
2(0
0013
)4
38 times
10minus
10 (9
97
times 1
0minus11
)2
55 times
10minus
4 (56
1 times
10minus
5 )3
667
(08
28)
018
5 (0
036
7)0
953
(01
86)
Inte
rcep
t and
slop
efminus
13
times 1
0minus5 (4
95
times 1
0minus6 )
minus0
030
(00
13)
minus25
595
9 (8
775
6)minus
007
13 (0
044
9)minus
113
times 1
0minus5 (6
86
times 1
0minus6 )
minus0
0058
(00
015)
minus93
382
(21
924)
minus2
055
(06
32)
minus0
0251
(00
061)
Resid
ual
021
5 (0
046
)0
071
(00
14)
437
215
(95
743)
007
6(0
0158
)0
162
(00
454)
001
8 (0
002
7)18
415
3 (2
820
7)12
292
(23
10)
005
2 (0
010
7)
FCTC
Fra
mew
ork
Conv
entio
n on
Toba
cco
Cont
rol G
DP
gro
ss d
omes
tic p
rodu
ct N
A n
ot a
pplic
able
SD
sta
ndar
d de
viat
ion
SE
stan
dard
erro
r W
TO W
orld
Trad
e O
rgan
izatio
na N
atur
al lo
garit
hm o
f com
mod
ity v
alue
s use
d in
mod
el
b In
2005
Inte
rnat
iona
l dol
lars
c O
nly
incl
uded
in to
bacc
o m
odel
d O
nly
incl
uded
in a
lcoh
ol m
odel
e C
oeffi
cien
t val
ues f
or in
divi
dual
yea
r fixe
d eff
ects
not
show
n (w
hen
appl
icab
le)
com
plet
e m
odel
out
put a
vaila
ble
from
the
figsh
are
repo
sitor
y25
f Dat
a pr
esen
ted
are
cova
rianc
es a
nd S
Es
89Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
are presented in Table 2 Although no differences were statistically significant to improve comparability we estimated and applied propensity score weights that optimized comparability on pre-exposure values of each commodity
In the first step we estimated pro-pensity scores to predict the probability of WTO membership as a function of annual values of each commodity in the pre-exposure period using a gen-eralized boosted regression modelling approach3839 In the second step we used propensity scores to construct weights for each country with all exposed coun-tries or territories receiving a weight of 1 and unexposed countries receiving a weight of p(1minusp) where p is the esti-mated propensity score This weighting estimates the average treatment effect on the exposed group ie the average effect of joining WTO for those countries or territories that did join
Fig 1 (available at httpwwwwhointbulletinvolumes97118-218057) displays the balance between the groups for annual values of the com-modities and covariates during the pre-exposure period before and after applying weights The balance metric is the absolute value of the difference in group means divided by the standard deviation across both groups 025 is a generally accepted balance threshold37 Improvements are reflected by the weighted values generally being closer to zero than unweighted values though in several cases improving balance on commodities sacrificed balance on co-variates However we further controlled for the influence of covariates in the regression models
Commodity models
We modelled changes in domestic sup-plies of the commodities using separate linear regression models for each of the nine commodities in a comparative interrupted time-series framework We used WTO membership as the treat-ment (t) term and used a treatmentyear interaction (ty) term to compare the pre- and post-exposure level and trend in the commodities (c) respectively in the exposed versus unexposed groups40 For unexposed countries the WTO membership variable was always 0 For exposed countries this variable ranged from 0 (before accession) to 1 (after ac-cession) for the year of each countryrsquos accession to WTO we used a fraction
reflecting the number of days of mem-bership Each commodity model had the following equation
(1)
where i indexes country j indexes year (1980 to 2013) x is a set of countries- and year-specific covariates βrsquos repre-sent coefficients estimated by the linear model and ε is the residual error term Covariates for urban population female labour force participation and percent-age Muslim population (alcohol model only) were continuous ranging from 0 to 100 The FCTC covariate (tobacco model only) ranged from 0 (not ratified) to 1 (ratified) with a fraction reflecting the number of days after ratification in the year during which each country was ratified All models were run with commodity-specific propensity score weights applied as inverse-probability-of-treatment weights
We tested multiple model varia-tions for each commodity For six com-modities (tobacco alcohol red meats and animal fats seafood nuts seeds and legumes and edible oils) we log-transformed the commodity values to constrain predicted values to be greater than 0 The key output of the best-performing model for each commodity is presented in Table 3 additional output and model fit graphs are available in the figshare repository25
Sensitivity analyses
We did several sensitivity analyses to assess whether various aspects of the study design affected the estimated ef-fects of WTO membership First to eliminate the influence of missing data we restricted the analysis period to 1993 to 2011 years with complete data for all 47 countries Second because the effects of WTO accession may take time we ex-plored lagged values of the WTO mem-bership and WTO membershipyear terms Third to examine whether the effects of WTO membership were pre-dominantly mediated through economic growth we excluded GDP per capita from all models Fourth we excluded several countries in the unexposed group that may be poor comparisons due to war famine or isolation from the global economy Afghanistan
Democratic Peoples Republic of Ko-rea Ethiopia Iraq and Sudan Lastly we stratified models by income group All analyses were conducted in Stata version 142 (StataCorp LCC College Station United States) except for the twang package for propensity scores run in R version 332 (R Foundation Vienna Austria)
ResultsFig 2 Fig 3 Fig 4 Fig 5 and Fig 6 show average trends for each commod-ity for the exposed unweighted unex-posed and weighted unexposed groups Trends during the pre-exposure period illustrate the improved comparability between the groups after weighting Outputs from the best-performing mod-els to estimate changes in supply of the commodities are shown in Table 3 The coefficients for the WTO membership and WTO membershipyear terms in-dicate whether there is any difference in the level and trend respectively of each commodity for countries and territories joining the WTO compared with non-WTO members The domestic avail-ability of fruits and vegetables increased the most the average annual supply of fruits and vegetables was 1979 kg per capita (95 confidence interval CI 660ndash3299) higher in countries or territories that have joined WTO than in non-member countries For tobacco and alcohol the WTO membershipyear coefficients suggest significant increas-ing trends in the availability of these products following WTO accession The geometric means of the supply of tobacco increased by 62 (95 CI 00ndash130) annually and of the supply of alcohol by 38 (95 CI 00ndash77) annually In the tobacco model the FCTC ratification coefficient indicates an 185 (95 CI 18ndash324) lower geometric mean supply of tobacco after ratification In the random effect model the intercept and slope are significantly different from zero for all commodi-ties indicating substantial remaining heterogeneity across countries in both the level and trend in domestic supply quantities (Table 3)
The sensitivity analyses generally supported the main findings The treat-ment effect on fruits and vegetables was robust in all sensitivity analyses The trend coefficient for the alcohol supply stayed of a consistent magnitude and
90 Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
remained significant in most analyses The trend coefficient for the tobacco supply also remained of a consistent magnitude but not always statisti-cally significant In only the lagged effect models treatment effects for sugars were significant and similar in magnitude to those in the main model providing some evidence of an initial decrease in the availability of sugars following WTO accession followed by a minimal steady increase When we stratified the analyses by country income group the results did not support any of the main conclusions However propensity score weights were generated to balance the sample and likely generated false results from these models which were run with 23 countries or less (out of the total 47) per income group Further details on each sensitivity analysis are available in the figshare repository25
DiscussionHere we show that following a countryrsquos accession to WTO there was a signifi-cant increasing trend in the domestic supply of alcohol a borderline signifi-cant increasing trend in the supply of tobacco and a significant immediate increase in the availability of fruits and vegetables compared with non-member countries Assuming that increases in supply likely translate to increases in consumption these changes have both positive and negative implications for global health For example recent re-search has indicated that any amount of alcohol consumption increases the risk of a range of negative health outcomes hence an increase in alcohol supply could be harmful41 Likewise an increase in tobacco use is negative as tobacco contributes to several noncommuni-cable diseases42 In contrast increases in fruit and vegetable consumption can protect against the development of numerous noncommunicable diseases24 The WHO recommends a 400 g intake of fruit and vegetables daily43 although even an intake of 200 g per day has been found to reduce the risk of many non-communicable diseases and premature mortality44 We estimate that average increase in the supply is about 55 g of fruits and vegetables per person per day higher in the countries after join-ing WTO
Our results provide more evidence about the links between trade liberaliza-tion and global health suggesting that
trade agreements should be considered as social determinants of health at the global scale As the burden of noncom-municable diseases continues to grow stakeholders should prioritize identify-ing the most effective strategies to curb the increase in risk factors including to-bacco and alcohol use and poor diet For example addressing aspects of trade and investment policies that alter the supply
of these products can help to tackle the noncommunicable disease burden at the root cause level This approach can be achieved through actions grounded in the Health in All Policies framework45 and the application of health impact assessment to proposed trade and in-vestment policies46 At the global level further development and consideration of international agreements to prevent
Fig 2 Changes in the supply of all forms of tobacco by joining WTO members and non-member states 1980ndash2013
All f
orm
s of t
obac
co(g
ram
sca
pita
old
er th
an 1
4 ye
ars)
2500
2000
1500
1000
500
0
Year1980 1990 2000 2010 2013
Range of WTO accession dates
Mean for joining WTO members Unweighted mean for WTO non-membersWeighted mean for WTO non-members
WTO World Trade OrganizationNotes The grey box represents the range of accession dates for countries and territories joining WTO Aberrations in trends starting in 1992 likely reflect the changing composition of countries in each exposure group due to data availability for former Soviet Union countries We obtained weighted means by applying tobacco-specific propensity score weights
Fig 3 Changes in the supply of all types of alcohol by joining WTO members and non-member states 1980ndash2013
All t
ypes
of a
lcoho
l(k
ilogr
ams
capi
ta o
lder
than
14
year
s)
60
40
20
0
Year1980 1990 2000 2010 2013
Range of WTO accession dates
Mean for joining WTO members Unweighted mean for WTO non-membersWeighted mean for WTO non-members
WTO World Trade OrganizationNotes The grey box represents the range of accession dates for countries and territories joining WTO Aberrations in trends starting in 1992 likely reflect the changing composition of countries in each exposure group due to data availability for former Soviet Union countries We obtained weighted means by applying alcohol-specific propensity score weights
91Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
Fig
4
Chan
ges i
n th
e su
pply
of f
ruits
and
vege
tabl
es a
nd st
arch
es f
or jo
inin
g W
TO
mem
bers
and
non
-mem
ber s
tate
s 19
80ndash2
013
Year
Year
1980
1990
2000
2010
2013
1980
1990
2000
2010
2013
Rang
e of W
TO ac
cessi
on da
tes
Rang
e of W
TO ac
cessi
on da
tes
Mea
n fo
r joi
ning
WTO
mem
bers
Unw
eigh
ted
mea
n fo
r WTO
non
-mem
bers
Wei
ghte
d m
ean
for W
TO n
on-m
embe
rs
Kilogramscapita Kilogramscapita250
200
150
100 50 0
250
200
150
100 50 0
Star
ches
Frui
ts an
d ve
geta
bles
WTO
Wor
ld Tr
ade
Org
aniz
atio
nN
otes
The
gre
y bo
x re
pres
ents
the
rang
e of
acc
essio
n da
tes f
or c
ount
ries a
nd te
rrito
ries j
oini
ng W
TO
Aber
ratio
ns in
tren
ds st
artin
g in
199
2 lik
ely
refle
ct th
e ch
angi
ng c
ompo
sitio
n of
cou
ntrie
s in
each
ex
posu
re g
roup
due
to d
ata
avai
labi
lity
for f
orm
er S
ovie
t Uni
on c
ount
ries
We
obta
ined
wei
ghte
d m
eans
by
app
lyin
g co
mm
odity
-spe
cific
pro
pens
ity sc
ore
wei
ghts
Fig
5
Chan
ges i
n th
e su
pply
of r
ed m
eats
and
ani
mal
fats
and
suga
rs b
y joi
ning
WTO
m
embe
rs a
nd n
on-m
embe
r sta
tes
1980
ndash201
3
Year
Year
1980
1990
2000
2010
2013
1980
1990
2000
2010
2013
Rang
e of W
TO ac
cessi
on da
tes
Rang
e of W
TO ac
cessi
on da
tes
Mea
n fo
r joi
ning
WTO
mem
bers
Unw
eigh
ted
mea
n fo
r WTO
non
-mem
bers
Wei
ghte
d m
ean
for W
TO n
on-m
embe
rs
Kilogramscapita Kilogramscapita
50 40 30 20 10 0 50 40 30 20 10 0
Red
mea
ts an
d an
imal
fats
Suga
rs
WTO
Wor
ld Tr
ade
Org
aniz
atio
nN
otes
The
gre
y bo
x re
pres
ents
the
rang
e of
acc
essio
n da
tes f
or c
ount
ries a
nd te
rrito
ries j
oini
ng W
TO
Aber
ratio
ns in
tren
ds st
artin
g in
199
2 lik
ely
refle
ct th
e ch
angi
ng c
ompo
sitio
n of
cou
ntrie
s in
each
ex
posu
re g
roup
due
to d
ata
avai
labi
lity
for f
orm
er S
ovie
t Uni
on c
ount
ries
We
obta
ined
wei
ghte
d m
eans
by
app
lyin
g co
mm
odity
-spe
cific
pro
pens
ity sc
ore
wei
ghts
92 Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
and control noncommunicable diseases like the FCTC but focused on other noncommunicable disease risk factors is warranted Such agreements can legally bind countries to health com-mitments providing a counterweight for commitments to international trade and investment rules
Our findings are suggestive but not conclusive warranting additional exploration and we suggest several po-tential avenues for future research For example given substantial unexplained country-specific heterogeneity indicated by country random effects in all models additional analyses of smaller groups of countries and individual countries are needed The effects of WTO member-ship may differ by level of economic development and other country-specific factors such as geography and climate which affect the baseline supply of various food groups tobacco and types of alcohol Researchers could recreate this analysis with one income group at a time and a similar analysis of selected low- and middle-income countries with substantial noncommunicable disease burdens may provide further insight into the links between WTO member-ship and changes in noncommunicable disease risk factors Single country studies could permit more nuanced understanding for example by looking at tariff changes for specific products and subsequent changes in their sup-ply Another area for future studies is to examine differences associated with specific provisions in WTO accession agreements and other trade and invest-ment policies as specific concessions differ Understanding which compo-nents of these treaties have the greatest influence on noncommunicable disease risk factors and other aspects of public health is important when tailoring future agreements to be more health-promoting Further researchers should also conduct similar analyses for other products that contribute to noncommu-nicable diseases particularly unhealthy foods high in fat salt and sugar
This study both supports and contradicts findings from previous research We were not able to confirm findings showing increases in consump-tion of meat10 and edible oils47 following trade liberalization Discrepancies may be due to differences in the sample previous studies examined only one to five countries in the same geographical region Studies showing trade-related
increases in sugar-sweetened beverage consumption1348 are somewhat sup-ported by our weak finding that the domestic supply of sugars increases steadily over time following WTO ac-
cession Our results confirm previous findings of increased tobacco712 and alcohol5 consumption associated with trade liberalization Finally few studies have examined fruits and vegetables
Fig 6 Changes in the supply of nuts seeds and legumes seafood and edible oils by joining WTO members and non-member states 1980ndash2013
Year
Year
Year
1980 1990 2000 2010 2013
1980 1990 2000 2010 2013
1980 1990 2000 2010 2013
Range of WTO accession dates
Range of WTO accession dates
Range of WTO accession dates
Mean for joining WTO members Unweighted mean for WTO non-membersWeighted mean for WTO non-members
Kilo
gram
sca
pita
Kilo
gram
sca
pita
Kilo
gram
sca
pita
20
15
10
5
0
20
15
10
5
0
20
15
10
5
0
Nuts seeds and legumes
Seafood
Edible oils
WTO World Trade OrganizationNotes The grey box represents the range of accession dates for countries and territories joining WTO Aberrations in trends starting in 1992 likely reflect the changing composition of countries in each exposure group due to data availability for former Soviet Union countries We obtained weighted means by applying commodity-specific propensity score weights
93Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
consumption in the context of trade liberalization but our findings support the results of an analysis showing that changes in trade policies led to an in-crease in imported fruit in five Central American countries10
This study has limitations A pri-mary limitation is the comparability of countries joining versus not joining WTO We assumed that trends would have been similar between the two groups if none of the countries joined WTO However differences in trends could be due to the influence of other unobserved events correlated with WTO accession and the outcomes of interest or innate characteristics of countries in either group
Another key limitation is the quality of the commodity data which measure
the available supply of each commodity and are only a proxy for consumption the true measure of importance for health In addition there was substantial missing data for certain items summed to create commodity variables which may affect the validity of the data for these categories The commodities ana-lysed were also limited by the available product categories importantly this did not allow us to distinguish changes in trends in the availability of specific foods high in fat salt or sugar an important determinant of obesity and noncommu-nicable diseases49 Finally for tobacco and alcohol illicit sales and homemade varieties are not captured in this data which may comprise substantial por-tions of supply and consumption in certain countries
In conclusion changes in domestic supply of alcohol tobacco and fruits and vegetables could have important implications for public health particu-larly for the development and preven-tion of noncommunicable diseases Overall findings indicated substantial country-level heterogeneity Therefore additional exploration of variations across countries is critical to identify factors that mitigate the negative role and enhance the positive role of trade and investment agreements in the global noncommunicable disease burden
Funding Krycia Cowling was supported by a Center for a Livable Future-Lerner fellowship during the time of this study
Competing interests None declared
摘要世界贸易组织成员国与非传染性疾病风险因素的变化一项断续时间序列比较分析1980ndash2013 年目的 旨在调查加入世界贸易组织 (WTO) 与获取若干商品(此类商品对非传染性疾病的形成兼具有害因素和保护因素)之间的关系方法 我 们 使 用 自 然 实 验 设 计 倾 向 评 分 权 重 来比 较 1980 年 至 2013 年 期 间 在 1995 年 之 后 加入 WTO 的 21 个国家或地区以及 26 个非成员国的烟草酒精和七类食品组在各国内的供应趋势我们采用断续时间序列框架使用多变量随机效应线性模型根据人均国内生产总值城市人口百分比和女性劳动力参与进行调整在烟草模型中我们控制了已批准
《烟草控制框架公约》的成员国在酒精模型中我们控制了自认为穆斯林国家所占的比例
结果 成员国加入世贸组织后与非成员国相比平均每人每天的水果和蔬菜国内供应量立即增长 55 克分析显示烟草和酒精每年的供应量以几何平均数的形式逐渐递增分别为每年 62 和 36我们尚未发现获取红肉和动物脂肪有任何重大变化 海鲜 坚果种子和豆类 淀粉 或食用油 以及与糖相关的结果在不同模型中是不一致的结论 结果表明成为 WTO 成员国可能会导致非传染性疾病的有害因素和保护因素增加但仍需进一步探索其针对具体国家的不同变化
ملخصعضوية منظمة التجارة العاملية والتغريات يف عوامل خطر األمراض غري املعدية حتليل سالسل زمنية مقارنة متقطعة ما
بني عامي 1980 و2013العاملية التجارة منظمة إىل االنضامم بني العالقة دراسة الغرض الضارة التأثريات ذات السلع من العديد وتوافر (WTO)
والوقائية من أجل تطوير األمراض غري املعديةاالجتاهات ملقارنة الطبيعية التجربة تصميم استخدمنا الطريقة بني غذائية جمموعات وسبع والكحول للتبغ املحيل اإلمداد يف عامي 1980 و2013 يف 21 دولة أو منطقة انضمت إىل منظمة التجارة العاملية بعد عام 1995 و26 دولة غري أعضاء باستخدام أوزان درجات النزوع طبقنا إطارا زمنيا متسلسال مقارنا متقطعا معدلة متعددة عشوائية تأثريات ذات خطية نامذج باستخدام احلرض لسكان املئوية والنسب للفرد اإلمجايل املحيل للناتج ومشاركة املرأة يف القوى العاملة يف نموذج التبغ قمنا باملكافحة ملكافحة اإلطارية االتفاقية عىل صدقت التي األعضاء الدول يف يعرفون الذين للسكان املئوية النسبة الكحول نموذج ويف التبغ
أنفسهم بأهنم مسلمني
الدول شهدت العاملية التجارة منظمة إىل االنضامم بعد النتائج األعضاء زيادات فورية يف اإلمداد املحيل من الفواكه واخلرضوات وصلت إىل 55 جم للشخص الواحد يف اليوم يف املتوسط مقارنة بالدول غري األعضاء أظهر التحليل زيادات تدرجيية يف املتوسط
اهلنديس إلمدادات التبغ والكحول بنسبة 62 و 36 يف السنة لحوم ال توافر يف جوهرية ت تغيريا أي نكتشف مل الرتتيب عىل احلمراء أو الدهون احليوانية أو املأكوالت البحرية أو املكرسات أو البذور والبقوليات أو النشويات أو الزيوت الصاحلة لألكل
وكانت النتائج للسكريات غري متناسقة عرب تنوعات النموذجقد العاملية التجارة ة منظم وية عض أن إىل النتائج تشري االستنتاج لألمراض والوقائية ة الضار مل العوا من كل يف زيادة إىل تؤدي االختالفات استكشاف من ملزيد ز تعزي هناك ولكن املعدية غري
اخلاصة بكل بلد
94 Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
Reacutesumeacute
Adheacutesion agrave lOrganisation mondiale du commerce et eacutevolution des facteurs de risque de maladies non transmissibles analyse comparative de seacuteries chronologiques interrompues 1980ndash2013Objectif Eacutetudier le lien entre ladheacutesion agrave lOrganisation mondiale du commerce (OMC) et la disponibiliteacute de diffeacuterentes denreacutees avec des effets agrave la fois nocifs et protecteurs pour le deacuteveloppement des maladies non transmissiblesMeacutethodes Nous avons utiliseacute un plan dexpeacuterience dans les conditions naturelles pour comparer entre 1980 et 2013 leacutevolution de loffre nationale de tabac dalcool et de sept groupes daliments dans 21 pays ou territoires devenus membres de lOMC apregraves 1995 et 26 pays non membres agrave laide de pondeacuterations par le score de propension Nous avons appliqueacute un cadre comparatif de seacuteries chronologiques interrompues agrave laide de modegraveles lineacuteaires agrave effets aleacuteatoires multivarieacutes rajusteacutes pour tenir compte du produit inteacuterieur brut par habitant du pourcentage de la population urbaine et de la participation des femmes agrave la vie active Dans le modegravele relatif au tabac nous avons tenu compte des Eacutetats membres ayant ratifieacute la Convention-cadre pour la lutte antitabac tandis que dans le modegravele relatif agrave lalcool nous avons tenu
compte du pourcentage de la population sidentifiant comme eacutetant de foi musulmaneReacutesultats Agrave la suite de leur adheacutesion agrave lOMC les Eacutetats membres ont connu une augmentation immeacutediate de loffre nationale de fruits et leacutegumes de 55 g par personne et par jour en moyenne par rapport aux pays non membres Lanalyse a reacuteveacuteleacute une augmentation progressive de la moyenne geacuteomeacutetrique de loffre de tabac et dalcool de 62 et 36 par an respectivement Nous navons pas constateacute de changements importants concernant la disponibiliteacute de viandes rouges et graisses dorigine animale de produits de la mer de noix graines et leacutegumineuses de feacuteculents ou dhuiles alimentaires et les reacutesultats relatifs aux sucres variaient dun modegravele agrave lautreConclusion Les reacutesultats suggegraverent que ladheacutesion agrave lOMC peut entraicircner une augmentation des facteurs agrave la fois nocifs et protecteurs pour les maladies non transmissibles mais il convient de reacutealiser de nouvelles recherches sur les variations par pays
Резюме
Членство во Всемирной торговой организации и изменения в факторах риска неинфекционных заболеваний сравнительный анализ прерванных временных рядов 1980ndash2013 ггЦель Членство во Всемирной торговой организации и изменения в факторах риска неинфекционных заболеваний сравнительный анализ прерванных временных рядов 1980ndash2013 ггМетоды Авторы использовали естественный эксперимент для сравнения тенденций внутренних поставок табака алкоголя и товаров семи продовольственных групп в период с 1980 по 2013 год в 21 стране или территории которые вступили в ВТО после 1995 года и в 26 странах не являющихся членами этой организации Анализ проводился с использованием весовых коэффициентов предрасположенности Авторы применили методику сравнительных прерванных временных рядов и многовариантные линейные модели случайных воздействий скорректированные по валовому внутреннему продукту на душу населения процентной доле городского населения и участию женщин в трудовой деятельности В модели для табака контролировались государства-члены ВТО ратифицировавшие Рамочную конвенцию по борьбе против табака а в модели
для алкоголя mdash доля населения идентифицирующая себя как мусульманеРезультаты После вступления в ВТО в государствах-членах наблюдался немедленный прирост внутренних поставок фруктов и овощей (в среднем до 55 г в день на человека) по сравнению со странами не являющимися ее членами Анализ показал постепенное увеличение среднего геометрического значения поставок табака и алкоголя на 62 и 36 в год соответственно Авторы не обнаружили существенных изменений в доступности мяса домашнего скота и животных жиров морепродуктов орехов семян и бобовых а также крахмала или пищевых масел Что касается сахара в разных моделях были получены несовпадающие результатыВывод Результаты позволяют предположить что членство в ВТО может привести к увеличению как полезных так и вредных факторов распространения неинфекционных заболеваний но необходимо проведение дальнейших исследований вариаций в различных странах
Resumen
Composicioacuten de la Organizacioacuten Mundial del Comercio y cambios en los factores de riesgo de las enfermedades no contagiosas un anaacutelisis comparativo de series cronoloacutegicas interrumpidas 1980-2013Objetivo Investigar la relacioacuten entre la adhesioacuten a la Organizacioacuten Mundial del Comercio (OMC) y la disponibilidad de varios productos baacutesicos con efectos tanto perjudiciales como protectores para el desarrollo de enfermedades no contagiosasMeacutetodos Se utilizoacute un disentildeo de experimento natural para comparar las tendencias de la oferta interna de tabaco alcohol y siete grupos de alimentos entre 1980 y 2013 en 21 paiacuteses o territorios que se incorporaron a la OMC despueacutes de 1995 y 26 paiacuteses no miembros mediante el uso de ponderaciones de propensioacuten Se aplicoacute un marco comparativo de series temporales interrumpidas siguiendo modelos lineales de efectos aleatorios multivariados ajustados seguacuten el producto interior bruto per caacutepita los porcentajes de poblacioacuten urbana y la participacioacuten de la mujer en el mundo laboral En el modelo del
tabaco controlamos a los Estados miembros que habiacutean ratificado el Convenio Marco para el Control del Tabaco y en el modelo del alcohol el porcentaje de la poblacioacuten que se identificaba como musulmanaResultados Tras la adhesioacuten a la OMC los Estados miembros experimentaron un aumento inmediato de la oferta interna de frutas y hortalizas de 55 kg por persona y diacutea de media en comparacioacuten con los paiacuteses no miembros El anaacutelisis mostroacute incrementos graduales en la media geomeacutetrica de la oferta de tabaco y alcohol del 62 y el 36 anual respectivamente No se detectaron cambios significativos en la disponibilidad de carnes rojas y grasas animales mariscos nueces semillas y legumbres almidones o aceites comestibles y los resultados para los azuacutecares fueron inconsistentes entre las variaciones del modelo
95Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
Conclusioacuten Los resultados sugieren que la pertenencia a la OMC puede dar lugar a un aumento de los factores perjudiciales y protectores de
las enfermedades no contagiosas pero es necesario seguir estudiando las variaciones especiacuteficas de cada paiacutes
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17 Haines PS Siega-Riz AM Popkin BM The Diet Quality Index revised a measurement instrument for populations J Am Diet Assoc 1999 Jun99(6)697ndash704 doi httpdxdoiorg101016S0002-8223(99)00168-6 PMID 10361532
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23 Mozaffarian D Hao T Rimm EB Willett WC Hu FB Changes in diet and lifestyle and long-term weight gain in women and men N Engl J Med 2011 Jun 23364(25)2392ndash404 doi httpdxdoiorg101056NEJMoa1014296 PMID 21696306
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27 Sheehy T Sharma S Trends in energy and nutrient supply in Trinidad and Tobago from 1961 to 2007 using FAO food balance sheets Public Health Nutr 2013 Sep16(9)1693ndash702 doi httpdxdoiorg101017S136898001200537X PMID 23286774
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ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
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35 Al-Ansari B Thow A-M Day CA Conigrave KM Extent of alcohol prohibition in civil policy in Muslim majority countries the impact of globalization Addiction 2016 10111(10)1703ndash13 doi httpdxdoiorg101111add13159 PMID 26508526
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39 McCaffrey DF Ridgeway G Morral AR Propensity score estimation with boosted regression for evaluating causal effects in observational studies Psychol Methods 2004 Dec9(4)403ndash25 doi httpdxdoiorg1010371082-989X94403 PMID 15598095
40 Linden A Adams JL Applying a propensity score-based weighting model to interrupted time series data improving causal inference in programme evaluation J Eval Clin Pract 2011 Dec17(6)1231ndash8 doi httpdxdoiorg101111j1365-2753201001504x PMID 20973870
41 Griswold MG Fullman N Hawley C Arian N Zimsen SRM Tymeson HD et al GBD 2016 Alcohol Collaborators Alcohol use and burden for 195 countries and territories 1990ndash2016 a systematic analysis for the Global Burden of Disease Study 2016 Lancet 2018 Sep 22392(10152)1015ndash35 doi httpdxdoiorg101016S0140-6736(18)31310-2 PMID 30146330
42 Peto R Lopez AD Boreham J Thun M Heath C Jr Mortality from tobacco in developed countries indirect estimation from national vital statistics Lancet 1992 May 23339(8804)1268ndash78 doi httpdxdoiorg1010160140-6736(92)91600-D PMID 1349675
43 Healthy diet Key facts Geneva World Health Organization 2018 Available from httpwwwwhointnews-roomfact-sheetsdetailhealthy-diet [cited 2018 Oct 26]
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48 Mendez Lopez A Loopstra R McKee M Stuckler D Is trade liberalisation a vector for the spread of sugar-sweetened beverages A cross-national longitudinal analysis of 44 low- and middle-income countries Soc Sci Med 2017 0117221ndash7 doi httpdxdoiorg101016jsocscimed201611001 PMID 27871042
49 Monteiro CA Moubarac J-C Cannon G Ng SW Popkin B Ultra-processed products are becoming dominant in the global food system Obes Rev 2013 Nov14 Suppl 221ndash8 doi httpdxdoiorg101111obr12107 PMID 24102801
Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057 96A
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
Fig 1 Unweighted and weighted absolute standardized biases for baseline commodity supply in countries included in the study 1980ndash1995
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0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08 0 02 04 06 08
Supply of tobacco
Supply of starches
Supply of nuts seeds and legumes
Supply of seafood
Supply of edible oils
Supply of sugars
Supply of red meats and animal fats
Supply of alcohol
Supply of fruits and vegetables
GDP gross domestic productNotes The period 1980ndash1995 represents the years before countries and territories start joining the World Trade Organization Table 1 lists countries studied We measured bias by the absolute standardized mean difference that is (mean for non-member states ndash mean for member states)(combined standard deviation)
- Table 1
- Table 2
- Table 3
- Figure 2
- Figure 3
- Figure 4
- Figure 5
- Figure 6
- Figure 1
-
84 Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
Tabl
e 1
Co
untr
ies a
nd te
rrito
ries i
nclu
ded
in a
naly
sis b
y WTO
mem
bers
hip
and
dom
estic
supp
ly q
uant
ity fo
r eac
h co
mm
odity
in 1
993
and
2011
Coun
try o
r te
rrito
ryCo
mm
odity
by y
ear
Toba
cco
(gc
apita
old
er
than
14
year
s)
Alco
hol
(kg
capi
ta o
lder
th
an 1
4 ye
ars)
Frui
ts a
nd
vege
tabl
es
(kg
capi
ta)
Nuts
see
ds a
nd
legu
mes
(k
gca
pita
)
Seaf
ood
(k
gca
pita
)Re
d m
eats
and
an
imal
fats
(k
gca
pita
)
Star
ches
(k
gca
pita
)Su
gars
(k
gca
pita
)Ed
ible
oils
(k
gca
pita
)
1993
2011
1993
2011
1993
2011
1993
2011
1993
2011
1993
2011
1993
2011
1993
2011
1993
2011
WTO
mem
bers
(by
WTO
mem
bers
hip
date
)a
Ecua
dor (
21 Ja
n 19
96)
321
451
75
284
557
181
914
15
50
37
72
85
259
406
187
615
52
264
201
140
153
Bulg
aria
(1 D
ec
1996
)42
635
2332
293
710
65
167
311
82
76
60
16
57
653
458
190
818
36
318
283
131
132
Mon
golia
(29
Jan
1997
)44
214
689
66
481
117
769
06
18
01
07
109
685
911
35
187
012
714
50
36
7
Pana
ma
(6 S
ept
1997
)64
03
1199
775
411
57
729
939
54
81
135
137
387
454
167
317
22
338
326
91
107
Kyrg
yzst
an (2
0 D
ec 1
998)
b36
66
2885
814
120
359
517
37
18
34
01
23
449
339
231
426
11
157
261
52
52
Latv
ia (1
0 Fe
b 19
99)b
307
399
42
329
117
913
46
162
20
33
730
325
985
679
430
76
232
944
537
72
812
3
Esto
nia
(13
Nov
19
99)b
1388
215
392
560
168
896
318
97
10
71
275
142
616
614
229
024
36
213
426
38
62
Jord
an (1
1 Ap
r 20
00)
2030
816
794
31
12
153
318
82
105
122
39
57
164
138
162
820
40
407
412
152
217
Geo
rgia
(14
June
20
00)b
268
725
314
471
465
131
510
24
42
21
38
110
209
211
203
126
48
123
309
10
69
Alba
nia
(8 S
ept
2000
)58
516
1771
914
754
219
68
439
95
710
10
96
426
856
924
25
207
329
848
78
87
6
Om
an (9
Nov
20
00)
1093
026
793
59
62
260
435
00
49
55
228
254
264
342
111
514
85
243
331
105
99
Lith
uani
a (3
1 M
ay 2
001)
b92
72
371
651
916
57
131
214
97
21
43
243
431
670
682
279
824
96
295
452
46
97
Repu
blic
of
Mol
dova
(26
July
20
01)b
9801
627
663
563
571
188
413
34
47
23
05
111
344
263
253
118
03
239
212
48
105
Chin
a (1
1 D
ec
2001
)39
313
2766
624
554
615
53
437
88
210
914
534
028
150
723
68
225
05
26
95
47
9
Arm
enia
(5 F
eb
2003
)b22
405
3054
415
610
013
64
390
70
02
21
23
221
037
124
11
188
623
036
80
47
5
Nep
al (2
3 Ap
r 20
04)
796
251
71
12
29
997
165
96
512
60
82
212
114
120
28
272
226
639
75
310
0
(contin
ues
)
85Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
Coun
try o
r te
rrito
ryCo
mm
odity
by y
ear
Toba
cco
(gc
apita
old
er
than
14
year
s)
Alco
hol
(kg
capi
ta o
lder
th
an 1
4 ye
ars)
Frui
ts a
nd
vege
tabl
es
(kg
capi
ta)
Nuts
see
ds a
nd
legu
mes
(k
gca
pita
)
Seaf
ood
(k
gca
pita
)Re
d m
eats
and
an
imal
fats
(k
gca
pita
)
Star
ches
(k
gca
pita
)Su
gars
(k
gca
pita
)Ed
ible
oils
(k
gca
pita
)
1993
2011
1993
2011
1993
2011
1993
2011
1993
2011
1993
2011
1993
2011
1993
2011
1993
2011
Cam
bodi
a (1
3 O
ct 2
004)
985
941
483
21
342
689
651
22
121
74
406
155
154
192
220
60
45
245
29
19
Saud
i Ara
bia
(11
Dec
200
5)26
242
2484
20
60
021
85
175
34
18
34
910
715
919
516
45
159
127
631
215
915
5
Viet
Nam
(11
Jan
2007
)53
39
1212
16
721
292
914
95
48
156
119
339
172
488
184
918
56
129
218
18
34
Ukr
aine
(16
May
20
08)b
1336
514
023
372
937
131
122
34
60
37
76
143
537
352
333
728
27
456
489
94
129
Cabo
Ver
de (2
3 Ju
ly 2
008)
336
128
73
407
628
859
202
95
613
714
412
131
321
418
84
177
219
020
99
28
5
WTO
non
-mem
ber a
s of
201
1Af
ghan
istan
207
079
90
00
02
630
565
43
59
01
01
215
146
183
319
14
34
92
16
32
Alge
ria19
008
1250
24
56
011
91
254
95
59
93
74
114
415
225
04
287
827
528
116
515
5Az
erba
ijanb
8924
320
956
110
689
134
524
56
32
42
30
22
165
268
231
230
55
112
161
11
27
Baha
mas
2008
115
646
657
356
228
936
37
55
27
246
295
730
568
998
101
040
743
73
76
5Be
laru
sb14
208
2830
458
097
212
50
207
11
04
11
214
474
577
633
83
305
435
539
94
718
8D
emoc
ratic
Pe
ople
s Re
publ
ic
of K
orea
3606
341
992
159
113
206
717
93
204
160
183
94
107
132
187
421
24
48
41
48
55
Ethi
opia
174
611
65
73
164
176
265
104
205
01
03
84
94
169
721
06
37
65
13
31
Fren
ch P
olyn
esia
1838
611
813
968
875
170
117
41
68
70
401
481
657
682
171
616
43
385
335
93
144
Iran
(Isla
mic
Re
publ
ic o
f)79
28
789
40
00
026
48
384
612
121
25
39
117
214
025
98
232
328
029
39
812
1
Iraq
1083
616
765
66
29
213
615
51
48
35
13
29
78
52
177
418
71
202
189
134
173
Kaza
khst
anb
1689
413
868
246
491
609
262
10
84
63
75
366
261
228
09
219
119
627
76
619
8Ki
ribat
i11
050
2304
80
00
025
32
241
82
23
073
671
114
616
520
14
204
835
243
97
94
8La
o Pe
ople
s D
emoc
ratic
Re
publ
icc
14 4
922
10 9
575
161
227
582
267
04
17
56
721
111
819
121
04
228
517
432
60
91
9
Leba
non
6887
753
266
223
229
537
229
17
260
213
35
111
284
258
186
418
22
460
492
143
186
Libe
ria38
20
249
115
316
192
061
96
53
64
84
48
98
024
66
260
319
517
117
117
4N
ew C
aled
onia
3558
924
952
113
296
212
65
175
81
46
320
128
439
452
618
27
160
423
225
916
314
3Ru
ssia
n Fe
dera
tionb
d63
04
1834
847
110
74
108
217
96
28
37
143
224
682
557
282
326
13
355
490
67
132
( continued)
(contin
ues
)
86 Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
quantitative evidence on the role of trade and investment liberalization in the global noncommunicable disease burden we studied changes in the do-mestic supply of tobacco alcohol and several food groups at the national level after WTO accession and compared to these trends in non-member countries
MethodsStudy design
We used a natural experiment approach to compare domestic supply patterns of nine commodities in 47 countries or territories from 1980 to 2013 21 countries or territories joining WTO between 1996 and 2008 (exposed group) and 26 countries not in WTO as of 2011 (unexposed group Table 1) We defined exposure as accession to WTO and the post-exposure period was therefore the beginning of each countryrsquos individual WTO joining date The years 1980 to 1995 comprise the pre-exposure period for all countries as the first countries joined the WTO in 1995
The commodities were tobacco (all types) alcohol (all types including beer wine and spirits) and seven food groups relevant to the development of noncom-municable diseases either protective or harmful These food groups were fruits and vegetables nuts seeds and legumes seafood red meats and animal fats sug-ars starches and edible oils We based the selection of these food categories on a review of common elements of indices of dietary quality16ndash19 and dietary diversity2021 and available evidence on the protective and harmful effects of major food groups for the development of noncommunicable diseases22ndash24 A list of food items included in the dif-ferent commodity groups and the data completeness for each item is available from the figshare data repository25 We hypothesized that following WTO ac-cession the supply of tobacco alcohol edible oils red meats and animal fats and sugars would increase the supply of starches and nuts seeds and legumes would decline The expected trends in fruits and vegetables and seafood were unknown
From our sample we excluded original member states of WTO and all members of the former General Agreement on Tariffs and Trade Nine countries in the unexposed group joined WTO in the final two years (2012ndash2013) Co
untr
y or
terr
itory
Com
mod
ity b
y yea
r
Toba
cco
(gc
apita
old
er
than
14
year
s)
Alco
hol
(kg
capi
ta o
lder
th
an 1
4 ye
ars)
Frui
ts a
nd
vege
tabl
es
(kg
capi
ta)
Nuts
see
ds a
nd
legu
mes
(k
gca
pita
)
Seaf
ood
(k
gca
pita
)Re
d m
eats
and
an
imal
fats
(k
gca
pita
)
Star
ches
(k
gca
pita
)Su
gars
(k
gca
pita
)Ed
ible
oils
(k
gca
pita
)
1993
2011
1993
2011
1993
2011
1993
2011
1993
2011
1993
2011
1993
2011
1993
2011
1993
2011
Sam
oad
3390
030
722
607
527
268
836
92
09
46
416
474
533
418
105
220
35
248
302
33
73
Sao
Tom
e an
d Pr
inci
pe78
216
34
469
613
292
037
10
42
81
254
281
28
109
196
815
32
160
239
72
98
Suda
ne15
06
121
858
641
883
714
36
99
169
18
21
255
348
187
416
22
271
372
79
60
Tajik
istan
bc
1605
814
87
88
14
146
618
57
14
40
05
05
130
124
189
117
56
109
190
114
107
Tim
or-L
este
283
092
23
62
79
466
498
108
126
00
60
402
328
305
521
83
33
115
11
47
Turk
men
istan
b13
616
1029
24
712
012
79
208
60
40
34
63
635
156
921
57
234
816
79
411
37
5Uz
beki
stan
b53
428
78
114
186
160
031
16
07
12
09
07
270
379
232
423
51
134
102
133
102
Vanu
atud
578
933
62
111
67
341
727
73
62
74
313
337
355
314
243
731
11
92
203
70
57
Yem
en21
044
2454
63
40
666
170
47
06
16
02
58
210
617
79
171
120
228
67
77
0
WTO
Wor
ld Tr
ade
Org
aniza
tion
a We
obta
ined
mem
bers
hip
date
s fro
m th
e W
TO w
eb si
te15
b We
anal
ysed
form
er S
ovie
t Uni
on m
embe
r sta
tes d
ata
from
199
2c W
e di
d no
t ana
lyse
dat
a af
ter 2
012
since
the
coun
try
join
ed W
TO in
201
3d W
e di
d no
t ana
lyse
dat
a af
ter 2
011
since
the
coun
try
join
ed W
TO in
201
2e D
ata
ende
d in
201
1 w
hen
coun
try
divi
ded
into
Sud
an a
nd S
outh
Sud
an
Not
e Q
uant
ities
for e
ach
com
mod
ity fo
r the
per
iods
bef
ore
and
afte
r joi
ning
the
WTO
are
pre
sent
ed fo
r the
firs
t and
last
yea
rs w
ith c
ompl
ete
data
for a
ll co
untri
es e
xcep
t for
pre
-exp
osur
e to
bacc
o da
ta fo
r Om
an w
hich
are
from
199
2
( continued)
87Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
Table 2 Baseline characteristics of countries included in study on WTO membership and changes in noncommunicable disease risk factors
Covariates WTO membersa (n = 21) WTO non-members (n = 26) Standardized difference in means (P)bc
No of countries per area NA (055)East Asia and Pacific 4 8Europe and central Asia 10 7Latin America and Caribbean 2 1Middle East and north Africa 3 5North America 0 0South Asia 1 1Sub-Saharan Africa 1 4No of former Soviet Union member states
8 7 NA (041)
Mean GDP per capita in 2005 Int$ (SD)Year 1980 5565 (8 314) 6907 (9 697) 015 (069)Year 1995 4805 (4 845) 6357 (11 005) 018 (055)Mean of female labour force participation (SD)Year 1980 441 (251) 421 (260) minus008 (082)Year 1995 519 (183) 465 (224) minus026 (037)Mean of urban population (SD)Year 1980 382 (206) 372 (219) minus005 (090)Year 1995 531 (201) 458 (209) minus035 (023)Mean of Muslim population (SD)d
Year 1980 300 (404) 360 (434) 014 (070)Year 1995 224 (362) 418 (428) 048 (011)Mean weight of commodity per capitae
Tobacco gram (SD)f
Year 1980 1890 (1 532) 2182 (1997) 016 (067) Year 1995 1358 (1 045) 1913 (2 716) 026 (038)Alcohol kilogram (SD)f
Year 1980 252 (369) 298 (330) 014 (072) Year 1995 292 (262) 263 (275) minus011 (071)Fruits and vegetables kilogram (SD) Year 1980 1089 (747) 1658 (930) 064 (009) Year 1995 1371 (611) 1590 (1132) 023 (043)Nuts seeds and legumes kilogram (SD) Year 1980 60 (35) 79 (62) 036 (034) Year 1995 44 (26) 64 (67) 038 (019)Seafood kilogram (SD) Year 1980 77 (68) 170 (178) 062 (009) Year 1995 95 (89) 139 (186) 030 (032)Red meats and animal fats kilogram (SD) Year 1980 280 (322) 272 (182) minus003 (093) Year 1995 373 (238) 287 (209) minus038 (020)Starches kilogram (SD) Year 1980 1931 (372) 2230 (521) 062 (010) Year 1995 2155 (554) 2078 (533) minus014 (063)Sugars kilogram (SD) Year 1980 244 (148) 239 (141) minus004 (093) Year 1995 232 (89) 215 (131) minus015 (061)Edible oils kilogram (SD) Year 1980 61 (45) 68 (44) 015 (070) Year 1995 73 (48) 83 (55) 019 (052)
GDP gross domestic product Int$ international dollars NA not applicable SD standard deviation WTO World Trade Organizationa Countries joining WTO between 1996 and 2008b We calculated standardized difference in means as follows (mean for non-member states ndash mean for member states)(combined standard deviation)c For continuous variables we used two-sided t-tests to calculate P-values For or categorical variables we used χ2 testsd Covariate used in alcohol models onlye Commodity available for domestic consumptionf Data for population older than 14 years
Note The years presented are the first (1980) and last (1995) years we used for analyses of the period before countries and territories included in the study started to join WTO
88 Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
or after the analysis period data for these countries were censored to exclude values in or after the year they joined For countries that comprised the former Soviet Union (eight exposed seven un-exposed) the analysis period begins in 1992 when independent countries were established
Data sources
The data sources for all commodities were the Food and Agriculture Orga-nization national commodity balance sheets (tobacco) and food balance sheets (all other commodities) which measure the annual supply of each commodity by country and are widely used as a proxy for consumption2627 We obtained covariate data on urban population and female labour force participation from the World Bankrsquos World Development Indicators28 population data from the United Nations Population Division29 gross domestic product (GDP) per capita from the Institute for Health Metrics and Evaluation30 percent-age Muslim population from the Pew Research Center31 and the ratification dates for the Framework Convention on Tobacco Control (FCTC) from the United Nations Treaty Collection32
Variables
We measured all commodity variables in units of grams (tobacco) or kilograms (all other commodities) per capita For tobacco and alcohol we restricted these measures to the population older than 14 years as is standard3334 We con-trolled for the following key confound-ers established by the existing literature in all models GDP per capita urban population and female labour force par-ticipation45 Models for alcohol included each countryrsquos proportion of population identifying themselves as Muslim as a covariate because being Muslim is linked to lower rates of alcohol use35 Models for tobacco included a variable indicating whether the country had ratified the FCTC because this ratifica-tion represents a commitment to reduce tobacco use36
Propensity score weights
With observational data the non-random assignment of the exposure (in this case WTO membership) can create imbalance in covariates and baseline levels of the outcome variables between the groups compared37 Characteristics of the groups in the pre-exposure period Ta
ble
3
Mod
el o
utpu
t fro
m b
est-
perf
orm
ing
mod
el to
stud
y WTO
mem
bers
hip
and
chan
ges i
n no
ncom
mun
icabl
e di
seas
e ris
k fa
ctor
s 19
80ndash2
013
Varia
ble
Toba
ccoa
Alco
hola
Frui
ts a
nd
vege
tabl
esNu
ts s
eeds
an
d le
gum
esa
Seaf
ooda
Red
mea
ts a
nd a
nim
al
fats
a
Star
ches
Suga
rsEd
ible
oils
a
Fixe
d eff
ect
coeffi
cien
t (P)
WTO
mem
bers
hip
009
8 (0
477
)minus
011
8 (0
133
)19
794
(00
03)
010
7 (0
171
)minus
013
7 (0
436
)0
008
(08
65)
minus6
277
(01
33)
minus2
401
(01
15)
minus0
070(
029
6)
WTO
m
embe
rshi
pye
ar0
061
(00
54)
003
7 (0
050
)minus
127
6 (0
367
)minus
001
7 (0
151
)0
032
(03
67)
000
1 (0
875
)minus
012
0 (0
904
)0
250
(01
76)
000
5 (0
730
)
GDP
per c
apita
ab
044
9 (0
004
)0
496
(lt 0
001
)7
571
(02
18)
031
3 (0
060
)0
826
(lt 0
001
)0
184
(00
20)
530
8 (0
464
)6
133
(00
03)
015
0 (0
243
)
u
rban
pop
ulat
ion
minus0
017
(00
24)
001
4 (0
160
)1
993
(00
04)
minus0
005
(04
91)
000
6 (0
637
)0
004
(05
33)
061
6 (0
189
)0
019
(08
79)
001
1 (0
052
)
fe
mal
e la
bour
fo
rce
part
icip
atio
nminus
001
0 (0
099
)minus
000
9 (0
202
)minus
102
9 (0
069
)minus
000
1 (0
804
)minus
003
6(0
016)
000
3 (0
553
)0
298
(03
71)
minus0
133
(00
88)
minus0
012
(01
02)
FCTC
ratifi
catio
ncminus
020
4 (0
032
)N
AN
AN
AN
AN
AN
AN
AN
A
M
uslim
pop
ulat
iond
NA
minus0
025
(lt 0
001
)N
AN
AN
AN
AN
AN
AN
A
Year
3eminus
972
times 1
0minus6 (0
251
)N
AN
AN
Aminus
146
times 1
0minus6 (0
875
)N
AN
AN
AN
A
Cons
tant
475
9 (lt
00
01)
minus1
088
(03
37)
726
8 (0
883
)minus
141
3 (0
265
)minus
384
5 (0
022
)1
437
(00
49)
142
441
(00
20)
minus18
940
(01
63)
006
6 (0
950
)
Rand
om e
ffec
ts v
aria
nce
(SE)
Inte
rcep
t0
944
(01
99)
166
0 (0
530
)69
170
32 (1
656
286
)3
070
(15
85)
295
0 (0
747
)0
396
(00
73)
5228
010
(1 1
232
00)
879
17 (1
929
0)8
46 times
10minus
4 (19
3 times
10minus
4 )
Slop
e7
83 times
10minus
10 (2
8 times
10minus
10)
000
3 (0
001
2)20
161
(53
45)
000
2(0
0013
)4
38 times
10minus
10 (9
97
times 1
0minus11
)2
55 times
10minus
4 (56
1 times
10minus
5 )3
667
(08
28)
018
5 (0
036
7)0
953
(01
86)
Inte
rcep
t and
slop
efminus
13
times 1
0minus5 (4
95
times 1
0minus6 )
minus0
030
(00
13)
minus25
595
9 (8
775
6)minus
007
13 (0
044
9)minus
113
times 1
0minus5 (6
86
times 1
0minus6 )
minus0
0058
(00
015)
minus93
382
(21
924)
minus2
055
(06
32)
minus0
0251
(00
061)
Resid
ual
021
5 (0
046
)0
071
(00
14)
437
215
(95
743)
007
6(0
0158
)0
162
(00
454)
001
8 (0
002
7)18
415
3 (2
820
7)12
292
(23
10)
005
2 (0
010
7)
FCTC
Fra
mew
ork
Conv
entio
n on
Toba
cco
Cont
rol G
DP
gro
ss d
omes
tic p
rodu
ct N
A n
ot a
pplic
able
SD
sta
ndar
d de
viat
ion
SE
stan
dard
erro
r W
TO W
orld
Trad
e O
rgan
izatio
na N
atur
al lo
garit
hm o
f com
mod
ity v
alue
s use
d in
mod
el
b In
2005
Inte
rnat
iona
l dol
lars
c O
nly
incl
uded
in to
bacc
o m
odel
d O
nly
incl
uded
in a
lcoh
ol m
odel
e C
oeffi
cien
t val
ues f
or in
divi
dual
yea
r fixe
d eff
ects
not
show
n (w
hen
appl
icab
le)
com
plet
e m
odel
out
put a
vaila
ble
from
the
figsh
are
repo
sitor
y25
f Dat
a pr
esen
ted
are
cova
rianc
es a
nd S
Es
89Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
are presented in Table 2 Although no differences were statistically significant to improve comparability we estimated and applied propensity score weights that optimized comparability on pre-exposure values of each commodity
In the first step we estimated pro-pensity scores to predict the probability of WTO membership as a function of annual values of each commodity in the pre-exposure period using a gen-eralized boosted regression modelling approach3839 In the second step we used propensity scores to construct weights for each country with all exposed coun-tries or territories receiving a weight of 1 and unexposed countries receiving a weight of p(1minusp) where p is the esti-mated propensity score This weighting estimates the average treatment effect on the exposed group ie the average effect of joining WTO for those countries or territories that did join
Fig 1 (available at httpwwwwhointbulletinvolumes97118-218057) displays the balance between the groups for annual values of the com-modities and covariates during the pre-exposure period before and after applying weights The balance metric is the absolute value of the difference in group means divided by the standard deviation across both groups 025 is a generally accepted balance threshold37 Improvements are reflected by the weighted values generally being closer to zero than unweighted values though in several cases improving balance on commodities sacrificed balance on co-variates However we further controlled for the influence of covariates in the regression models
Commodity models
We modelled changes in domestic sup-plies of the commodities using separate linear regression models for each of the nine commodities in a comparative interrupted time-series framework We used WTO membership as the treat-ment (t) term and used a treatmentyear interaction (ty) term to compare the pre- and post-exposure level and trend in the commodities (c) respectively in the exposed versus unexposed groups40 For unexposed countries the WTO membership variable was always 0 For exposed countries this variable ranged from 0 (before accession) to 1 (after ac-cession) for the year of each countryrsquos accession to WTO we used a fraction
reflecting the number of days of mem-bership Each commodity model had the following equation
(1)
where i indexes country j indexes year (1980 to 2013) x is a set of countries- and year-specific covariates βrsquos repre-sent coefficients estimated by the linear model and ε is the residual error term Covariates for urban population female labour force participation and percent-age Muslim population (alcohol model only) were continuous ranging from 0 to 100 The FCTC covariate (tobacco model only) ranged from 0 (not ratified) to 1 (ratified) with a fraction reflecting the number of days after ratification in the year during which each country was ratified All models were run with commodity-specific propensity score weights applied as inverse-probability-of-treatment weights
We tested multiple model varia-tions for each commodity For six com-modities (tobacco alcohol red meats and animal fats seafood nuts seeds and legumes and edible oils) we log-transformed the commodity values to constrain predicted values to be greater than 0 The key output of the best-performing model for each commodity is presented in Table 3 additional output and model fit graphs are available in the figshare repository25
Sensitivity analyses
We did several sensitivity analyses to assess whether various aspects of the study design affected the estimated ef-fects of WTO membership First to eliminate the influence of missing data we restricted the analysis period to 1993 to 2011 years with complete data for all 47 countries Second because the effects of WTO accession may take time we ex-plored lagged values of the WTO mem-bership and WTO membershipyear terms Third to examine whether the effects of WTO membership were pre-dominantly mediated through economic growth we excluded GDP per capita from all models Fourth we excluded several countries in the unexposed group that may be poor comparisons due to war famine or isolation from the global economy Afghanistan
Democratic Peoples Republic of Ko-rea Ethiopia Iraq and Sudan Lastly we stratified models by income group All analyses were conducted in Stata version 142 (StataCorp LCC College Station United States) except for the twang package for propensity scores run in R version 332 (R Foundation Vienna Austria)
ResultsFig 2 Fig 3 Fig 4 Fig 5 and Fig 6 show average trends for each commod-ity for the exposed unweighted unex-posed and weighted unexposed groups Trends during the pre-exposure period illustrate the improved comparability between the groups after weighting Outputs from the best-performing mod-els to estimate changes in supply of the commodities are shown in Table 3 The coefficients for the WTO membership and WTO membershipyear terms in-dicate whether there is any difference in the level and trend respectively of each commodity for countries and territories joining the WTO compared with non-WTO members The domestic avail-ability of fruits and vegetables increased the most the average annual supply of fruits and vegetables was 1979 kg per capita (95 confidence interval CI 660ndash3299) higher in countries or territories that have joined WTO than in non-member countries For tobacco and alcohol the WTO membershipyear coefficients suggest significant increas-ing trends in the availability of these products following WTO accession The geometric means of the supply of tobacco increased by 62 (95 CI 00ndash130) annually and of the supply of alcohol by 38 (95 CI 00ndash77) annually In the tobacco model the FCTC ratification coefficient indicates an 185 (95 CI 18ndash324) lower geometric mean supply of tobacco after ratification In the random effect model the intercept and slope are significantly different from zero for all commodi-ties indicating substantial remaining heterogeneity across countries in both the level and trend in domestic supply quantities (Table 3)
The sensitivity analyses generally supported the main findings The treat-ment effect on fruits and vegetables was robust in all sensitivity analyses The trend coefficient for the alcohol supply stayed of a consistent magnitude and
90 Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
remained significant in most analyses The trend coefficient for the tobacco supply also remained of a consistent magnitude but not always statisti-cally significant In only the lagged effect models treatment effects for sugars were significant and similar in magnitude to those in the main model providing some evidence of an initial decrease in the availability of sugars following WTO accession followed by a minimal steady increase When we stratified the analyses by country income group the results did not support any of the main conclusions However propensity score weights were generated to balance the sample and likely generated false results from these models which were run with 23 countries or less (out of the total 47) per income group Further details on each sensitivity analysis are available in the figshare repository25
DiscussionHere we show that following a countryrsquos accession to WTO there was a signifi-cant increasing trend in the domestic supply of alcohol a borderline signifi-cant increasing trend in the supply of tobacco and a significant immediate increase in the availability of fruits and vegetables compared with non-member countries Assuming that increases in supply likely translate to increases in consumption these changes have both positive and negative implications for global health For example recent re-search has indicated that any amount of alcohol consumption increases the risk of a range of negative health outcomes hence an increase in alcohol supply could be harmful41 Likewise an increase in tobacco use is negative as tobacco contributes to several noncommuni-cable diseases42 In contrast increases in fruit and vegetable consumption can protect against the development of numerous noncommunicable diseases24 The WHO recommends a 400 g intake of fruit and vegetables daily43 although even an intake of 200 g per day has been found to reduce the risk of many non-communicable diseases and premature mortality44 We estimate that average increase in the supply is about 55 g of fruits and vegetables per person per day higher in the countries after join-ing WTO
Our results provide more evidence about the links between trade liberaliza-tion and global health suggesting that
trade agreements should be considered as social determinants of health at the global scale As the burden of noncom-municable diseases continues to grow stakeholders should prioritize identify-ing the most effective strategies to curb the increase in risk factors including to-bacco and alcohol use and poor diet For example addressing aspects of trade and investment policies that alter the supply
of these products can help to tackle the noncommunicable disease burden at the root cause level This approach can be achieved through actions grounded in the Health in All Policies framework45 and the application of health impact assessment to proposed trade and in-vestment policies46 At the global level further development and consideration of international agreements to prevent
Fig 2 Changes in the supply of all forms of tobacco by joining WTO members and non-member states 1980ndash2013
All f
orm
s of t
obac
co(g
ram
sca
pita
old
er th
an 1
4 ye
ars)
2500
2000
1500
1000
500
0
Year1980 1990 2000 2010 2013
Range of WTO accession dates
Mean for joining WTO members Unweighted mean for WTO non-membersWeighted mean for WTO non-members
WTO World Trade OrganizationNotes The grey box represents the range of accession dates for countries and territories joining WTO Aberrations in trends starting in 1992 likely reflect the changing composition of countries in each exposure group due to data availability for former Soviet Union countries We obtained weighted means by applying tobacco-specific propensity score weights
Fig 3 Changes in the supply of all types of alcohol by joining WTO members and non-member states 1980ndash2013
All t
ypes
of a
lcoho
l(k
ilogr
ams
capi
ta o
lder
than
14
year
s)
60
40
20
0
Year1980 1990 2000 2010 2013
Range of WTO accession dates
Mean for joining WTO members Unweighted mean for WTO non-membersWeighted mean for WTO non-members
WTO World Trade OrganizationNotes The grey box represents the range of accession dates for countries and territories joining WTO Aberrations in trends starting in 1992 likely reflect the changing composition of countries in each exposure group due to data availability for former Soviet Union countries We obtained weighted means by applying alcohol-specific propensity score weights
91Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
Fig
4
Chan
ges i
n th
e su
pply
of f
ruits
and
vege
tabl
es a
nd st
arch
es f
or jo
inin
g W
TO
mem
bers
and
non
-mem
ber s
tate
s 19
80ndash2
013
Year
Year
1980
1990
2000
2010
2013
1980
1990
2000
2010
2013
Rang
e of W
TO ac
cessi
on da
tes
Rang
e of W
TO ac
cessi
on da
tes
Mea
n fo
r joi
ning
WTO
mem
bers
Unw
eigh
ted
mea
n fo
r WTO
non
-mem
bers
Wei
ghte
d m
ean
for W
TO n
on-m
embe
rs
Kilogramscapita Kilogramscapita250
200
150
100 50 0
250
200
150
100 50 0
Star
ches
Frui
ts an
d ve
geta
bles
WTO
Wor
ld Tr
ade
Org
aniz
atio
nN
otes
The
gre
y bo
x re
pres
ents
the
rang
e of
acc
essio
n da
tes f
or c
ount
ries a
nd te
rrito
ries j
oini
ng W
TO
Aber
ratio
ns in
tren
ds st
artin
g in
199
2 lik
ely
refle
ct th
e ch
angi
ng c
ompo
sitio
n of
cou
ntrie
s in
each
ex
posu
re g
roup
due
to d
ata
avai
labi
lity
for f
orm
er S
ovie
t Uni
on c
ount
ries
We
obta
ined
wei
ghte
d m
eans
by
app
lyin
g co
mm
odity
-spe
cific
pro
pens
ity sc
ore
wei
ghts
Fig
5
Chan
ges i
n th
e su
pply
of r
ed m
eats
and
ani
mal
fats
and
suga
rs b
y joi
ning
WTO
m
embe
rs a
nd n
on-m
embe
r sta
tes
1980
ndash201
3
Year
Year
1980
1990
2000
2010
2013
1980
1990
2000
2010
2013
Rang
e of W
TO ac
cessi
on da
tes
Rang
e of W
TO ac
cessi
on da
tes
Mea
n fo
r joi
ning
WTO
mem
bers
Unw
eigh
ted
mea
n fo
r WTO
non
-mem
bers
Wei
ghte
d m
ean
for W
TO n
on-m
embe
rs
Kilogramscapita Kilogramscapita
50 40 30 20 10 0 50 40 30 20 10 0
Red
mea
ts an
d an
imal
fats
Suga
rs
WTO
Wor
ld Tr
ade
Org
aniz
atio
nN
otes
The
gre
y bo
x re
pres
ents
the
rang
e of
acc
essio
n da
tes f
or c
ount
ries a
nd te
rrito
ries j
oini
ng W
TO
Aber
ratio
ns in
tren
ds st
artin
g in
199
2 lik
ely
refle
ct th
e ch
angi
ng c
ompo
sitio
n of
cou
ntrie
s in
each
ex
posu
re g
roup
due
to d
ata
avai
labi
lity
for f
orm
er S
ovie
t Uni
on c
ount
ries
We
obta
ined
wei
ghte
d m
eans
by
app
lyin
g co
mm
odity
-spe
cific
pro
pens
ity sc
ore
wei
ghts
92 Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
and control noncommunicable diseases like the FCTC but focused on other noncommunicable disease risk factors is warranted Such agreements can legally bind countries to health com-mitments providing a counterweight for commitments to international trade and investment rules
Our findings are suggestive but not conclusive warranting additional exploration and we suggest several po-tential avenues for future research For example given substantial unexplained country-specific heterogeneity indicated by country random effects in all models additional analyses of smaller groups of countries and individual countries are needed The effects of WTO member-ship may differ by level of economic development and other country-specific factors such as geography and climate which affect the baseline supply of various food groups tobacco and types of alcohol Researchers could recreate this analysis with one income group at a time and a similar analysis of selected low- and middle-income countries with substantial noncommunicable disease burdens may provide further insight into the links between WTO member-ship and changes in noncommunicable disease risk factors Single country studies could permit more nuanced understanding for example by looking at tariff changes for specific products and subsequent changes in their sup-ply Another area for future studies is to examine differences associated with specific provisions in WTO accession agreements and other trade and invest-ment policies as specific concessions differ Understanding which compo-nents of these treaties have the greatest influence on noncommunicable disease risk factors and other aspects of public health is important when tailoring future agreements to be more health-promoting Further researchers should also conduct similar analyses for other products that contribute to noncommu-nicable diseases particularly unhealthy foods high in fat salt and sugar
This study both supports and contradicts findings from previous research We were not able to confirm findings showing increases in consump-tion of meat10 and edible oils47 following trade liberalization Discrepancies may be due to differences in the sample previous studies examined only one to five countries in the same geographical region Studies showing trade-related
increases in sugar-sweetened beverage consumption1348 are somewhat sup-ported by our weak finding that the domestic supply of sugars increases steadily over time following WTO ac-
cession Our results confirm previous findings of increased tobacco712 and alcohol5 consumption associated with trade liberalization Finally few studies have examined fruits and vegetables
Fig 6 Changes in the supply of nuts seeds and legumes seafood and edible oils by joining WTO members and non-member states 1980ndash2013
Year
Year
Year
1980 1990 2000 2010 2013
1980 1990 2000 2010 2013
1980 1990 2000 2010 2013
Range of WTO accession dates
Range of WTO accession dates
Range of WTO accession dates
Mean for joining WTO members Unweighted mean for WTO non-membersWeighted mean for WTO non-members
Kilo
gram
sca
pita
Kilo
gram
sca
pita
Kilo
gram
sca
pita
20
15
10
5
0
20
15
10
5
0
20
15
10
5
0
Nuts seeds and legumes
Seafood
Edible oils
WTO World Trade OrganizationNotes The grey box represents the range of accession dates for countries and territories joining WTO Aberrations in trends starting in 1992 likely reflect the changing composition of countries in each exposure group due to data availability for former Soviet Union countries We obtained weighted means by applying commodity-specific propensity score weights
93Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
consumption in the context of trade liberalization but our findings support the results of an analysis showing that changes in trade policies led to an in-crease in imported fruit in five Central American countries10
This study has limitations A pri-mary limitation is the comparability of countries joining versus not joining WTO We assumed that trends would have been similar between the two groups if none of the countries joined WTO However differences in trends could be due to the influence of other unobserved events correlated with WTO accession and the outcomes of interest or innate characteristics of countries in either group
Another key limitation is the quality of the commodity data which measure
the available supply of each commodity and are only a proxy for consumption the true measure of importance for health In addition there was substantial missing data for certain items summed to create commodity variables which may affect the validity of the data for these categories The commodities ana-lysed were also limited by the available product categories importantly this did not allow us to distinguish changes in trends in the availability of specific foods high in fat salt or sugar an important determinant of obesity and noncommu-nicable diseases49 Finally for tobacco and alcohol illicit sales and homemade varieties are not captured in this data which may comprise substantial por-tions of supply and consumption in certain countries
In conclusion changes in domestic supply of alcohol tobacco and fruits and vegetables could have important implications for public health particu-larly for the development and preven-tion of noncommunicable diseases Overall findings indicated substantial country-level heterogeneity Therefore additional exploration of variations across countries is critical to identify factors that mitigate the negative role and enhance the positive role of trade and investment agreements in the global noncommunicable disease burden
Funding Krycia Cowling was supported by a Center for a Livable Future-Lerner fellowship during the time of this study
Competing interests None declared
摘要世界贸易组织成员国与非传染性疾病风险因素的变化一项断续时间序列比较分析1980ndash2013 年目的 旨在调查加入世界贸易组织 (WTO) 与获取若干商品(此类商品对非传染性疾病的形成兼具有害因素和保护因素)之间的关系方法 我 们 使 用 自 然 实 验 设 计 倾 向 评 分 权 重 来比 较 1980 年 至 2013 年 期 间 在 1995 年 之 后 加入 WTO 的 21 个国家或地区以及 26 个非成员国的烟草酒精和七类食品组在各国内的供应趋势我们采用断续时间序列框架使用多变量随机效应线性模型根据人均国内生产总值城市人口百分比和女性劳动力参与进行调整在烟草模型中我们控制了已批准
《烟草控制框架公约》的成员国在酒精模型中我们控制了自认为穆斯林国家所占的比例
结果 成员国加入世贸组织后与非成员国相比平均每人每天的水果和蔬菜国内供应量立即增长 55 克分析显示烟草和酒精每年的供应量以几何平均数的形式逐渐递增分别为每年 62 和 36我们尚未发现获取红肉和动物脂肪有任何重大变化 海鲜 坚果种子和豆类 淀粉 或食用油 以及与糖相关的结果在不同模型中是不一致的结论 结果表明成为 WTO 成员国可能会导致非传染性疾病的有害因素和保护因素增加但仍需进一步探索其针对具体国家的不同变化
ملخصعضوية منظمة التجارة العاملية والتغريات يف عوامل خطر األمراض غري املعدية حتليل سالسل زمنية مقارنة متقطعة ما
بني عامي 1980 و2013العاملية التجارة منظمة إىل االنضامم بني العالقة دراسة الغرض الضارة التأثريات ذات السلع من العديد وتوافر (WTO)
والوقائية من أجل تطوير األمراض غري املعديةاالجتاهات ملقارنة الطبيعية التجربة تصميم استخدمنا الطريقة بني غذائية جمموعات وسبع والكحول للتبغ املحيل اإلمداد يف عامي 1980 و2013 يف 21 دولة أو منطقة انضمت إىل منظمة التجارة العاملية بعد عام 1995 و26 دولة غري أعضاء باستخدام أوزان درجات النزوع طبقنا إطارا زمنيا متسلسال مقارنا متقطعا معدلة متعددة عشوائية تأثريات ذات خطية نامذج باستخدام احلرض لسكان املئوية والنسب للفرد اإلمجايل املحيل للناتج ومشاركة املرأة يف القوى العاملة يف نموذج التبغ قمنا باملكافحة ملكافحة اإلطارية االتفاقية عىل صدقت التي األعضاء الدول يف يعرفون الذين للسكان املئوية النسبة الكحول نموذج ويف التبغ
أنفسهم بأهنم مسلمني
الدول شهدت العاملية التجارة منظمة إىل االنضامم بعد النتائج األعضاء زيادات فورية يف اإلمداد املحيل من الفواكه واخلرضوات وصلت إىل 55 جم للشخص الواحد يف اليوم يف املتوسط مقارنة بالدول غري األعضاء أظهر التحليل زيادات تدرجيية يف املتوسط
اهلنديس إلمدادات التبغ والكحول بنسبة 62 و 36 يف السنة لحوم ال توافر يف جوهرية ت تغيريا أي نكتشف مل الرتتيب عىل احلمراء أو الدهون احليوانية أو املأكوالت البحرية أو املكرسات أو البذور والبقوليات أو النشويات أو الزيوت الصاحلة لألكل
وكانت النتائج للسكريات غري متناسقة عرب تنوعات النموذجقد العاملية التجارة ة منظم وية عض أن إىل النتائج تشري االستنتاج لألمراض والوقائية ة الضار مل العوا من كل يف زيادة إىل تؤدي االختالفات استكشاف من ملزيد ز تعزي هناك ولكن املعدية غري
اخلاصة بكل بلد
94 Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
Reacutesumeacute
Adheacutesion agrave lOrganisation mondiale du commerce et eacutevolution des facteurs de risque de maladies non transmissibles analyse comparative de seacuteries chronologiques interrompues 1980ndash2013Objectif Eacutetudier le lien entre ladheacutesion agrave lOrganisation mondiale du commerce (OMC) et la disponibiliteacute de diffeacuterentes denreacutees avec des effets agrave la fois nocifs et protecteurs pour le deacuteveloppement des maladies non transmissiblesMeacutethodes Nous avons utiliseacute un plan dexpeacuterience dans les conditions naturelles pour comparer entre 1980 et 2013 leacutevolution de loffre nationale de tabac dalcool et de sept groupes daliments dans 21 pays ou territoires devenus membres de lOMC apregraves 1995 et 26 pays non membres agrave laide de pondeacuterations par le score de propension Nous avons appliqueacute un cadre comparatif de seacuteries chronologiques interrompues agrave laide de modegraveles lineacuteaires agrave effets aleacuteatoires multivarieacutes rajusteacutes pour tenir compte du produit inteacuterieur brut par habitant du pourcentage de la population urbaine et de la participation des femmes agrave la vie active Dans le modegravele relatif au tabac nous avons tenu compte des Eacutetats membres ayant ratifieacute la Convention-cadre pour la lutte antitabac tandis que dans le modegravele relatif agrave lalcool nous avons tenu
compte du pourcentage de la population sidentifiant comme eacutetant de foi musulmaneReacutesultats Agrave la suite de leur adheacutesion agrave lOMC les Eacutetats membres ont connu une augmentation immeacutediate de loffre nationale de fruits et leacutegumes de 55 g par personne et par jour en moyenne par rapport aux pays non membres Lanalyse a reacuteveacuteleacute une augmentation progressive de la moyenne geacuteomeacutetrique de loffre de tabac et dalcool de 62 et 36 par an respectivement Nous navons pas constateacute de changements importants concernant la disponibiliteacute de viandes rouges et graisses dorigine animale de produits de la mer de noix graines et leacutegumineuses de feacuteculents ou dhuiles alimentaires et les reacutesultats relatifs aux sucres variaient dun modegravele agrave lautreConclusion Les reacutesultats suggegraverent que ladheacutesion agrave lOMC peut entraicircner une augmentation des facteurs agrave la fois nocifs et protecteurs pour les maladies non transmissibles mais il convient de reacutealiser de nouvelles recherches sur les variations par pays
Резюме
Членство во Всемирной торговой организации и изменения в факторах риска неинфекционных заболеваний сравнительный анализ прерванных временных рядов 1980ndash2013 ггЦель Членство во Всемирной торговой организации и изменения в факторах риска неинфекционных заболеваний сравнительный анализ прерванных временных рядов 1980ndash2013 ггМетоды Авторы использовали естественный эксперимент для сравнения тенденций внутренних поставок табака алкоголя и товаров семи продовольственных групп в период с 1980 по 2013 год в 21 стране или территории которые вступили в ВТО после 1995 года и в 26 странах не являющихся членами этой организации Анализ проводился с использованием весовых коэффициентов предрасположенности Авторы применили методику сравнительных прерванных временных рядов и многовариантные линейные модели случайных воздействий скорректированные по валовому внутреннему продукту на душу населения процентной доле городского населения и участию женщин в трудовой деятельности В модели для табака контролировались государства-члены ВТО ратифицировавшие Рамочную конвенцию по борьбе против табака а в модели
для алкоголя mdash доля населения идентифицирующая себя как мусульманеРезультаты После вступления в ВТО в государствах-членах наблюдался немедленный прирост внутренних поставок фруктов и овощей (в среднем до 55 г в день на человека) по сравнению со странами не являющимися ее членами Анализ показал постепенное увеличение среднего геометрического значения поставок табака и алкоголя на 62 и 36 в год соответственно Авторы не обнаружили существенных изменений в доступности мяса домашнего скота и животных жиров морепродуктов орехов семян и бобовых а также крахмала или пищевых масел Что касается сахара в разных моделях были получены несовпадающие результатыВывод Результаты позволяют предположить что членство в ВТО может привести к увеличению как полезных так и вредных факторов распространения неинфекционных заболеваний но необходимо проведение дальнейших исследований вариаций в различных странах
Resumen
Composicioacuten de la Organizacioacuten Mundial del Comercio y cambios en los factores de riesgo de las enfermedades no contagiosas un anaacutelisis comparativo de series cronoloacutegicas interrumpidas 1980-2013Objetivo Investigar la relacioacuten entre la adhesioacuten a la Organizacioacuten Mundial del Comercio (OMC) y la disponibilidad de varios productos baacutesicos con efectos tanto perjudiciales como protectores para el desarrollo de enfermedades no contagiosasMeacutetodos Se utilizoacute un disentildeo de experimento natural para comparar las tendencias de la oferta interna de tabaco alcohol y siete grupos de alimentos entre 1980 y 2013 en 21 paiacuteses o territorios que se incorporaron a la OMC despueacutes de 1995 y 26 paiacuteses no miembros mediante el uso de ponderaciones de propensioacuten Se aplicoacute un marco comparativo de series temporales interrumpidas siguiendo modelos lineales de efectos aleatorios multivariados ajustados seguacuten el producto interior bruto per caacutepita los porcentajes de poblacioacuten urbana y la participacioacuten de la mujer en el mundo laboral En el modelo del
tabaco controlamos a los Estados miembros que habiacutean ratificado el Convenio Marco para el Control del Tabaco y en el modelo del alcohol el porcentaje de la poblacioacuten que se identificaba como musulmanaResultados Tras la adhesioacuten a la OMC los Estados miembros experimentaron un aumento inmediato de la oferta interna de frutas y hortalizas de 55 kg por persona y diacutea de media en comparacioacuten con los paiacuteses no miembros El anaacutelisis mostroacute incrementos graduales en la media geomeacutetrica de la oferta de tabaco y alcohol del 62 y el 36 anual respectivamente No se detectaron cambios significativos en la disponibilidad de carnes rojas y grasas animales mariscos nueces semillas y legumbres almidones o aceites comestibles y los resultados para los azuacutecares fueron inconsistentes entre las variaciones del modelo
95Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
Conclusioacuten Los resultados sugieren que la pertenencia a la OMC puede dar lugar a un aumento de los factores perjudiciales y protectores de
las enfermedades no contagiosas pero es necesario seguir estudiando las variaciones especiacuteficas de cada paiacutes
References1 Murray CJ Vos T Lozano R Naghavi M Flaxman AD Michaud C et al
Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions 1990ndash2010 a systematic analysis for the Global Burden of Disease Study 2010 Lancet 2012 Dec 15380(9859)2197ndash223 doi httpdxdoiorg101016S0140-6736(12)61689-4 PMID 23245608
2 Lim SS Vos T Flaxman AD Danaei G Shibuya K Adair-Rohani H et al A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions 1990ndash2010 a systematic analysis for the Global Burden of Disease Study 2010 Lancet 2012 Dec 15380(9859)2224ndash60 doi httpdxdoiorg101016S0140-6736(12)61766-8 PMID 23245609
3 Baker P Friel S Food systems transformations ultra-processed food markets and the nutrition transition in Asia Global Health 2016 12 312(1)80 doi httpdxdoiorg101186s12992-016-0223-3 PMID 27912772
4 Labonteacute R Mohindra KS Lencucha R Framing international trade and chronic disease Global Health 2011 07 47(1)21 doi httpdxdoiorg1011861744-8603-7-21 PMID 21726434
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6 De Vogli R Kouvonen A Gimeno D The influence of market deregulation on fast food consumption and body mass index a cross-national time series analysis Bull World Health Organ 2014 Feb 192(2)99ndash107 107A doi httpdxdoiorg102471BLT13120287 PMID 24623903
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9 Schultz JT Globalisation urbanization and nutrition transition in a developing island country a case study Fiji Globalization of food systems in developing countries impact on food security and nutrition Rome Food and Agriculture Organization 2004
10 Thow AM Hawkes C The implications of trade liberalization for diet and health a case study from Central America Global Health 2009 07 2855 doi httpdxdoiorg1011861744-8603-5-5 PMID 19638196
11 Barlow P McKee M Basu S Stuckler D The health impact of trade and investment agreements a quantitative systematic review and network co-citation analysis Global Health 2017 03 813(1)13 doi httpdxdoiorg101186s12992-017-0240-x PMID 28274238
12 Taylor A Chaloupka FJ Guindon E Corbett M The impact of trade liberalization on tobacco consumption In Jha P Chaloupka FJ editors Tobacco control in developing countries Oxford Oxford University Press 2000 pp 343ndash64
13 Schram A Labonte R Baker P Friel S Reeves A Stuckler D The role of trade and investment liberalization in the sugar-sweetened carbonated beverages market a natural experiment contrasting Vietnam and the Philippines Global Health 2015 10 1211(1)41 doi httpdxdoiorg101186s12992-015-0127-7 PMID 26455446
14 Baker P Friel S Schram A Labonte R Trade and investment liberalization food systems change and highly processed food consumption a natural experiment contrasting the soft-drink markets of Peru and Bolivia Global Health 2016 06 212(1)24 doi httpdxdoiorg101186s12992-016-0161-0 PMID 27255275
15 Understanding the WTO the organization Members and observers [internet] Geneva World Trade Organization 2017 Available from httpswwwwtoorgenglishthewto_ewhatis_etif_eorg6_ehtm [cited 2017 Mar 28]
16 Guenther PM Casavale KO Reedy J Kirkpatrick SI Hiza HA Kuczynski KJ et al Update of the healthy eating index HEI-2010 J Acad Nutr Diet 2013 Apr113(4)569ndash80 doi httpdxdoiorg101016jjand201212016 PMID 23415502
17 Haines PS Siega-Riz AM Popkin BM The Diet Quality Index revised a measurement instrument for populations J Am Diet Assoc 1999 Jun99(6)697ndash704 doi httpdxdoiorg101016S0002-8223(99)00168-6 PMID 10361532
18 Huijbregts P Feskens E Raumlsaumlnen L Fidanza F Nissinen A Menotti A et al Dietary pattern and 20 year mortality in elderly men in Finland Italy and The Netherlands longitudinal cohort study BMJ 1997 Jul 5315(7099)13ndash7 doi httpdxdoiorg101136bmj315709913 PMID 9233319
19 Panagiotakos DB Pitsavos C Stefanadis C Dietary patterns a Mediterranean diet score and its relation to clinical and biological markers of cardiovascular disease risk Nutr Metab Cardiovasc Dis 2006 Dec16(8)559ndash68 doi httpdxdoiorg101016jnumecd200508006 PMID 17126772
20 Guidelines for measuring household and individual dietary diversity [internet] Rome Food and Agriculture Organization 2012 Available from httpwwwfaoorgdocrep014i1983ei1983e00htm [cited 2017 Jan 14]
21 Indicators for nutrition-friendly and sustainable food systems InGlobal nutrition report 2015 actions and accountability to advance nutrition and sustainable development Washington DC International Food Policy Research Institute 2015 pp 85ndash96 Available from httpglobalnutritionreportorgthe-reportthe-report-2015 [cited 2017 Apr 4]
22 Micha R Khatibzadeh S Shi P Andrews KG Engell RE Mozaffarian D Global Burden of Diseases Nutrition and Chronic Diseases Expert Group (NutriCoDE) Global regional and national consumption of major food groups in 1990 and 2010 a systematic analysis including 266 country-specific nutrition surveys worldwide BMJ Open 2015 09 245(9)e008705 doi httpdxdoiorg101136bmjopen-2015-008705 PMID 26408285
23 Mozaffarian D Hao T Rimm EB Willett WC Hu FB Changes in diet and lifestyle and long-term weight gain in women and men N Engl J Med 2011 Jun 23364(25)2392ndash404 doi httpdxdoiorg101056NEJMoa1014296 PMID 21696306
24 Mozaffarian D Appel LJ Van Horn L Components of a cardioprotective diet new insights Circulation 2011 Jun 21123(24)2870ndash91 doi httpdxdoiorg101161CIRCULATIONAHA110968735 PMID 21690503
25 WTO membership and noncommunicable disease risk factors - Supplemental materials Baltimore Johns Hopkins University 2018 Available from doi httpdxdoiorg106084m9figshare7268561v1 [cited 2018 Oct 30]doi httpdxdoiorg106084m9figshare7268561v1
26 Maumlnnistouml S Laatikainen T Helakorpi S Valsta LM Monitoring diet and diet-related chronic disease risk factors in Finland Public Health Nutr 2010 Jun13 6A907ndash14 doi httpdxdoiorg101017S1368980010001084 PMID 20513259
27 Sheehy T Sharma S Trends in energy and nutrient supply in Trinidad and Tobago from 1961 to 2007 using FAO food balance sheets Public Health Nutr 2013 Sep16(9)1693ndash702 doi httpdxdoiorg101017S136898001200537X PMID 23286774
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30 Gross domestic product (GDP) estimates by country 1950ndash2015 [internet] Seattle Institute for Health Metrics and Evaluation 2017 Available from httpghdxhealthdataorgrecordgross-domestic-product-gdp-estimates-country-1950-2015 [cited 2017 Jan 6]
31 Table Muslim Population by Country [internet] Washington DC Pew Research Center 2011 Available from httpwwwpewforumorg20110127table-muslim-population-by-country [cited 2017 Apr 12]
32 Depositary WHO Framework Convention on Tobacco Control [internet] New York United Nations Treaty Collection 2025 Available from httpstreatiesunorgpagesViewDetailsaspxsrc=TREATYampmtdsg_no=IX-4ampchapter=9amplang=en [cited 2017 Apr 18]
33 Ng M Freeman MK Fleming TD Robinson M Dwyer-Lindgren L Thomson B et al Smoking prevalence and cigarette consumption in 187 countries 1980ndash2012 JAMA 2014 Jan 8311(2)183ndash92 doi httpdxdoiorg101001jama2013284692 PMID 24399557
96 Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
34 Rehm J Mathers C Popova S Thavorncharoensap M Teerawattananon Y Patra J Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders Lancet 2009 Jun 27373(9682)2223ndash33 doi httpdxdoiorg101016S0140-6736(09)60746-7 PMID 19560604
35 Al-Ansari B Thow A-M Day CA Conigrave KM Extent of alcohol prohibition in civil policy in Muslim majority countries the impact of globalization Addiction 2016 10111(10)1703ndash13 doi httpdxdoiorg101111add13159 PMID 26508526
36 About the WHO Framework Convention on Tobacco Control [internet] Geneva World Health Organization 2018 Available from httpwwwwhointfctcabouten [cited 2017 May 11]
37 Stuart EA Matching methods for causal inference a review and a look forward Stat Sci 2010 Feb 125(1)1ndash21 doi httpdxdoiorg10121409-STS313 PMID 20871802
38 Ridgeway G McCaffrey D Morral A Burgette L Griffin BA Toolkit for weighting and analysis of nonequivalent groups a tutorial for the twang package R Vignette [internet] Vienna R Foundation 2017 Available from httpscranr-projectorgwebpackagestwangvignettestwangpdf [cited 2017 Apr 18]
39 McCaffrey DF Ridgeway G Morral AR Propensity score estimation with boosted regression for evaluating causal effects in observational studies Psychol Methods 2004 Dec9(4)403ndash25 doi httpdxdoiorg1010371082-989X94403 PMID 15598095
40 Linden A Adams JL Applying a propensity score-based weighting model to interrupted time series data improving causal inference in programme evaluation J Eval Clin Pract 2011 Dec17(6)1231ndash8 doi httpdxdoiorg101111j1365-2753201001504x PMID 20973870
41 Griswold MG Fullman N Hawley C Arian N Zimsen SRM Tymeson HD et al GBD 2016 Alcohol Collaborators Alcohol use and burden for 195 countries and territories 1990ndash2016 a systematic analysis for the Global Burden of Disease Study 2016 Lancet 2018 Sep 22392(10152)1015ndash35 doi httpdxdoiorg101016S0140-6736(18)31310-2 PMID 30146330
42 Peto R Lopez AD Boreham J Thun M Heath C Jr Mortality from tobacco in developed countries indirect estimation from national vital statistics Lancet 1992 May 23339(8804)1268ndash78 doi httpdxdoiorg1010160140-6736(92)91600-D PMID 1349675
43 Healthy diet Key facts Geneva World Health Organization 2018 Available from httpwwwwhointnews-roomfact-sheetsdetailhealthy-diet [cited 2018 Oct 26]
44 Aune D Giovannucci E Boffetta P Fadnes LT Keum N Norat T et al Fruit and vegetable intake and the risk of cardiovascular disease total cancer and all-cause mortality-a systematic review and dose-response meta-analysis of prospective studies Int J Epidemiol 2017 06 146(3)1029ndash56 doi httpdxdoiorg101093ijedyw319 PMID 28338764
45 Health in All Policies framework for country action [internet] Geneva World Health Organization 2018 Available from httpwwwwhointhealthpromotionframeworkforcountryactionen [cited 2017 Aug 13]
46 Cole BL Fielding JE Health impact assessment a tool to help policy makers understand health beyond health care Annu Rev Public Health 200728(1)393ndash412 doi httpdxdoiorg101146annurevpublhealth28083006131942 PMID 17173539
47 Tonts M Siddique MAB editors Globalisation agriculture and development perspectives from the Asia-Pacific Cheltenham Edward Elgar Publishing 2011 Available from httpswwwelgaronlinecomview978184720818700010xml [cited 2017 Aug 14]
48 Mendez Lopez A Loopstra R McKee M Stuckler D Is trade liberalisation a vector for the spread of sugar-sweetened beverages A cross-national longitudinal analysis of 44 low- and middle-income countries Soc Sci Med 2017 0117221ndash7 doi httpdxdoiorg101016jsocscimed201611001 PMID 27871042
49 Monteiro CA Moubarac J-C Cannon G Ng SW Popkin B Ultra-processed products are becoming dominant in the global food system Obes Rev 2013 Nov14 Suppl 221ndash8 doi httpdxdoiorg101111obr12107 PMID 24102801
Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057 96A
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
Fig 1 Unweighted and weighted absolute standardized biases for baseline commodity supply in countries included in the study 1980ndash1995
female labour force
participation
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participation
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participation
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participation
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participation
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Tobacco
Starches
Nuts seedsand legumes
Seafood
Edible oils
Sugars
Red meatsand animal
fats
Alcohol Fruits andvegetables
GDP percapita (log)
GDP percapita (log)
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GDP percapita (log)
1980198519901995
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Absolute standardize bias
Absolute standardize bias
Absolute standardize bias
Unweighted Weighted
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08 0 02 04 06 08
Supply of tobacco
Supply of starches
Supply of nuts seeds and legumes
Supply of seafood
Supply of edible oils
Supply of sugars
Supply of red meats and animal fats
Supply of alcohol
Supply of fruits and vegetables
GDP gross domestic productNotes The period 1980ndash1995 represents the years before countries and territories start joining the World Trade Organization Table 1 lists countries studied We measured bias by the absolute standardized mean difference that is (mean for non-member states ndash mean for member states)(combined standard deviation)
- Table 1
- Table 2
- Table 3
- Figure 2
- Figure 3
- Figure 4
- Figure 5
- Figure 6
- Figure 1
-
85Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
Coun
try o
r te
rrito
ryCo
mm
odity
by y
ear
Toba
cco
(gc
apita
old
er
than
14
year
s)
Alco
hol
(kg
capi
ta o
lder
th
an 1
4 ye
ars)
Frui
ts a
nd
vege
tabl
es
(kg
capi
ta)
Nuts
see
ds a
nd
legu
mes
(k
gca
pita
)
Seaf
ood
(k
gca
pita
)Re
d m
eats
and
an
imal
fats
(k
gca
pita
)
Star
ches
(k
gca
pita
)Su
gars
(k
gca
pita
)Ed
ible
oils
(k
gca
pita
)
1993
2011
1993
2011
1993
2011
1993
2011
1993
2011
1993
2011
1993
2011
1993
2011
1993
2011
Cam
bodi
a (1
3 O
ct 2
004)
985
941
483
21
342
689
651
22
121
74
406
155
154
192
220
60
45
245
29
19
Saud
i Ara
bia
(11
Dec
200
5)26
242
2484
20
60
021
85
175
34
18
34
910
715
919
516
45
159
127
631
215
915
5
Viet
Nam
(11
Jan
2007
)53
39
1212
16
721
292
914
95
48
156
119
339
172
488
184
918
56
129
218
18
34
Ukr
aine
(16
May
20
08)b
1336
514
023
372
937
131
122
34
60
37
76
143
537
352
333
728
27
456
489
94
129
Cabo
Ver
de (2
3 Ju
ly 2
008)
336
128
73
407
628
859
202
95
613
714
412
131
321
418
84
177
219
020
99
28
5
WTO
non
-mem
ber a
s of
201
1Af
ghan
istan
207
079
90
00
02
630
565
43
59
01
01
215
146
183
319
14
34
92
16
32
Alge
ria19
008
1250
24
56
011
91
254
95
59
93
74
114
415
225
04
287
827
528
116
515
5Az
erba
ijanb
8924
320
956
110
689
134
524
56
32
42
30
22
165
268
231
230
55
112
161
11
27
Baha
mas
2008
115
646
657
356
228
936
37
55
27
246
295
730
568
998
101
040
743
73
76
5Be
laru
sb14
208
2830
458
097
212
50
207
11
04
11
214
474
577
633
83
305
435
539
94
718
8D
emoc
ratic
Pe
ople
s Re
publ
ic
of K
orea
3606
341
992
159
113
206
717
93
204
160
183
94
107
132
187
421
24
48
41
48
55
Ethi
opia
174
611
65
73
164
176
265
104
205
01
03
84
94
169
721
06
37
65
13
31
Fren
ch P
olyn
esia
1838
611
813
968
875
170
117
41
68
70
401
481
657
682
171
616
43
385
335
93
144
Iran
(Isla
mic
Re
publ
ic o
f)79
28
789
40
00
026
48
384
612
121
25
39
117
214
025
98
232
328
029
39
812
1
Iraq
1083
616
765
66
29
213
615
51
48
35
13
29
78
52
177
418
71
202
189
134
173
Kaza
khst
anb
1689
413
868
246
491
609
262
10
84
63
75
366
261
228
09
219
119
627
76
619
8Ki
ribat
i11
050
2304
80
00
025
32
241
82
23
073
671
114
616
520
14
204
835
243
97
94
8La
o Pe
ople
s D
emoc
ratic
Re
publ
icc
14 4
922
10 9
575
161
227
582
267
04
17
56
721
111
819
121
04
228
517
432
60
91
9
Leba
non
6887
753
266
223
229
537
229
17
260
213
35
111
284
258
186
418
22
460
492
143
186
Libe
ria38
20
249
115
316
192
061
96
53
64
84
48
98
024
66
260
319
517
117
117
4N
ew C
aled
onia
3558
924
952
113
296
212
65
175
81
46
320
128
439
452
618
27
160
423
225
916
314
3Ru
ssia
n Fe
dera
tionb
d63
04
1834
847
110
74
108
217
96
28
37
143
224
682
557
282
326
13
355
490
67
132
( continued)
(contin
ues
)
86 Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
quantitative evidence on the role of trade and investment liberalization in the global noncommunicable disease burden we studied changes in the do-mestic supply of tobacco alcohol and several food groups at the national level after WTO accession and compared to these trends in non-member countries
MethodsStudy design
We used a natural experiment approach to compare domestic supply patterns of nine commodities in 47 countries or territories from 1980 to 2013 21 countries or territories joining WTO between 1996 and 2008 (exposed group) and 26 countries not in WTO as of 2011 (unexposed group Table 1) We defined exposure as accession to WTO and the post-exposure period was therefore the beginning of each countryrsquos individual WTO joining date The years 1980 to 1995 comprise the pre-exposure period for all countries as the first countries joined the WTO in 1995
The commodities were tobacco (all types) alcohol (all types including beer wine and spirits) and seven food groups relevant to the development of noncom-municable diseases either protective or harmful These food groups were fruits and vegetables nuts seeds and legumes seafood red meats and animal fats sug-ars starches and edible oils We based the selection of these food categories on a review of common elements of indices of dietary quality16ndash19 and dietary diversity2021 and available evidence on the protective and harmful effects of major food groups for the development of noncommunicable diseases22ndash24 A list of food items included in the dif-ferent commodity groups and the data completeness for each item is available from the figshare data repository25 We hypothesized that following WTO ac-cession the supply of tobacco alcohol edible oils red meats and animal fats and sugars would increase the supply of starches and nuts seeds and legumes would decline The expected trends in fruits and vegetables and seafood were unknown
From our sample we excluded original member states of WTO and all members of the former General Agreement on Tariffs and Trade Nine countries in the unexposed group joined WTO in the final two years (2012ndash2013) Co
untr
y or
terr
itory
Com
mod
ity b
y yea
r
Toba
cco
(gc
apita
old
er
than
14
year
s)
Alco
hol
(kg
capi
ta o
lder
th
an 1
4 ye
ars)
Frui
ts a
nd
vege
tabl
es
(kg
capi
ta)
Nuts
see
ds a
nd
legu
mes
(k
gca
pita
)
Seaf
ood
(k
gca
pita
)Re
d m
eats
and
an
imal
fats
(k
gca
pita
)
Star
ches
(k
gca
pita
)Su
gars
(k
gca
pita
)Ed
ible
oils
(k
gca
pita
)
1993
2011
1993
2011
1993
2011
1993
2011
1993
2011
1993
2011
1993
2011
1993
2011
1993
2011
Sam
oad
3390
030
722
607
527
268
836
92
09
46
416
474
533
418
105
220
35
248
302
33
73
Sao
Tom
e an
d Pr
inci
pe78
216
34
469
613
292
037
10
42
81
254
281
28
109
196
815
32
160
239
72
98
Suda
ne15
06
121
858
641
883
714
36
99
169
18
21
255
348
187
416
22
271
372
79
60
Tajik
istan
bc
1605
814
87
88
14
146
618
57
14
40
05
05
130
124
189
117
56
109
190
114
107
Tim
or-L
este
283
092
23
62
79
466
498
108
126
00
60
402
328
305
521
83
33
115
11
47
Turk
men
istan
b13
616
1029
24
712
012
79
208
60
40
34
63
635
156
921
57
234
816
79
411
37
5Uz
beki
stan
b53
428
78
114
186
160
031
16
07
12
09
07
270
379
232
423
51
134
102
133
102
Vanu
atud
578
933
62
111
67
341
727
73
62
74
313
337
355
314
243
731
11
92
203
70
57
Yem
en21
044
2454
63
40
666
170
47
06
16
02
58
210
617
79
171
120
228
67
77
0
WTO
Wor
ld Tr
ade
Org
aniza
tion
a We
obta
ined
mem
bers
hip
date
s fro
m th
e W
TO w
eb si
te15
b We
anal
ysed
form
er S
ovie
t Uni
on m
embe
r sta
tes d
ata
from
199
2c W
e di
d no
t ana
lyse
dat
a af
ter 2
012
since
the
coun
try
join
ed W
TO in
201
3d W
e di
d no
t ana
lyse
dat
a af
ter 2
011
since
the
coun
try
join
ed W
TO in
201
2e D
ata
ende
d in
201
1 w
hen
coun
try
divi
ded
into
Sud
an a
nd S
outh
Sud
an
Not
e Q
uant
ities
for e
ach
com
mod
ity fo
r the
per
iods
bef
ore
and
afte
r joi
ning
the
WTO
are
pre
sent
ed fo
r the
firs
t and
last
yea
rs w
ith c
ompl
ete
data
for a
ll co
untri
es e
xcep
t for
pre
-exp
osur
e to
bacc
o da
ta fo
r Om
an w
hich
are
from
199
2
( continued)
87Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
Table 2 Baseline characteristics of countries included in study on WTO membership and changes in noncommunicable disease risk factors
Covariates WTO membersa (n = 21) WTO non-members (n = 26) Standardized difference in means (P)bc
No of countries per area NA (055)East Asia and Pacific 4 8Europe and central Asia 10 7Latin America and Caribbean 2 1Middle East and north Africa 3 5North America 0 0South Asia 1 1Sub-Saharan Africa 1 4No of former Soviet Union member states
8 7 NA (041)
Mean GDP per capita in 2005 Int$ (SD)Year 1980 5565 (8 314) 6907 (9 697) 015 (069)Year 1995 4805 (4 845) 6357 (11 005) 018 (055)Mean of female labour force participation (SD)Year 1980 441 (251) 421 (260) minus008 (082)Year 1995 519 (183) 465 (224) minus026 (037)Mean of urban population (SD)Year 1980 382 (206) 372 (219) minus005 (090)Year 1995 531 (201) 458 (209) minus035 (023)Mean of Muslim population (SD)d
Year 1980 300 (404) 360 (434) 014 (070)Year 1995 224 (362) 418 (428) 048 (011)Mean weight of commodity per capitae
Tobacco gram (SD)f
Year 1980 1890 (1 532) 2182 (1997) 016 (067) Year 1995 1358 (1 045) 1913 (2 716) 026 (038)Alcohol kilogram (SD)f
Year 1980 252 (369) 298 (330) 014 (072) Year 1995 292 (262) 263 (275) minus011 (071)Fruits and vegetables kilogram (SD) Year 1980 1089 (747) 1658 (930) 064 (009) Year 1995 1371 (611) 1590 (1132) 023 (043)Nuts seeds and legumes kilogram (SD) Year 1980 60 (35) 79 (62) 036 (034) Year 1995 44 (26) 64 (67) 038 (019)Seafood kilogram (SD) Year 1980 77 (68) 170 (178) 062 (009) Year 1995 95 (89) 139 (186) 030 (032)Red meats and animal fats kilogram (SD) Year 1980 280 (322) 272 (182) minus003 (093) Year 1995 373 (238) 287 (209) minus038 (020)Starches kilogram (SD) Year 1980 1931 (372) 2230 (521) 062 (010) Year 1995 2155 (554) 2078 (533) minus014 (063)Sugars kilogram (SD) Year 1980 244 (148) 239 (141) minus004 (093) Year 1995 232 (89) 215 (131) minus015 (061)Edible oils kilogram (SD) Year 1980 61 (45) 68 (44) 015 (070) Year 1995 73 (48) 83 (55) 019 (052)
GDP gross domestic product Int$ international dollars NA not applicable SD standard deviation WTO World Trade Organizationa Countries joining WTO between 1996 and 2008b We calculated standardized difference in means as follows (mean for non-member states ndash mean for member states)(combined standard deviation)c For continuous variables we used two-sided t-tests to calculate P-values For or categorical variables we used χ2 testsd Covariate used in alcohol models onlye Commodity available for domestic consumptionf Data for population older than 14 years
Note The years presented are the first (1980) and last (1995) years we used for analyses of the period before countries and territories included in the study started to join WTO
88 Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
or after the analysis period data for these countries were censored to exclude values in or after the year they joined For countries that comprised the former Soviet Union (eight exposed seven un-exposed) the analysis period begins in 1992 when independent countries were established
Data sources
The data sources for all commodities were the Food and Agriculture Orga-nization national commodity balance sheets (tobacco) and food balance sheets (all other commodities) which measure the annual supply of each commodity by country and are widely used as a proxy for consumption2627 We obtained covariate data on urban population and female labour force participation from the World Bankrsquos World Development Indicators28 population data from the United Nations Population Division29 gross domestic product (GDP) per capita from the Institute for Health Metrics and Evaluation30 percent-age Muslim population from the Pew Research Center31 and the ratification dates for the Framework Convention on Tobacco Control (FCTC) from the United Nations Treaty Collection32
Variables
We measured all commodity variables in units of grams (tobacco) or kilograms (all other commodities) per capita For tobacco and alcohol we restricted these measures to the population older than 14 years as is standard3334 We con-trolled for the following key confound-ers established by the existing literature in all models GDP per capita urban population and female labour force par-ticipation45 Models for alcohol included each countryrsquos proportion of population identifying themselves as Muslim as a covariate because being Muslim is linked to lower rates of alcohol use35 Models for tobacco included a variable indicating whether the country had ratified the FCTC because this ratifica-tion represents a commitment to reduce tobacco use36
Propensity score weights
With observational data the non-random assignment of the exposure (in this case WTO membership) can create imbalance in covariates and baseline levels of the outcome variables between the groups compared37 Characteristics of the groups in the pre-exposure period Ta
ble
3
Mod
el o
utpu
t fro
m b
est-
perf
orm
ing
mod
el to
stud
y WTO
mem
bers
hip
and
chan
ges i
n no
ncom
mun
icabl
e di
seas
e ris
k fa
ctor
s 19
80ndash2
013
Varia
ble
Toba
ccoa
Alco
hola
Frui
ts a
nd
vege
tabl
esNu
ts s
eeds
an
d le
gum
esa
Seaf
ooda
Red
mea
ts a
nd a
nim
al
fats
a
Star
ches
Suga
rsEd
ible
oils
a
Fixe
d eff
ect
coeffi
cien
t (P)
WTO
mem
bers
hip
009
8 (0
477
)minus
011
8 (0
133
)19
794
(00
03)
010
7 (0
171
)minus
013
7 (0
436
)0
008
(08
65)
minus6
277
(01
33)
minus2
401
(01
15)
minus0
070(
029
6)
WTO
m
embe
rshi
pye
ar0
061
(00
54)
003
7 (0
050
)minus
127
6 (0
367
)minus
001
7 (0
151
)0
032
(03
67)
000
1 (0
875
)minus
012
0 (0
904
)0
250
(01
76)
000
5 (0
730
)
GDP
per c
apita
ab
044
9 (0
004
)0
496
(lt 0
001
)7
571
(02
18)
031
3 (0
060
)0
826
(lt 0
001
)0
184
(00
20)
530
8 (0
464
)6
133
(00
03)
015
0 (0
243
)
u
rban
pop
ulat
ion
minus0
017
(00
24)
001
4 (0
160
)1
993
(00
04)
minus0
005
(04
91)
000
6 (0
637
)0
004
(05
33)
061
6 (0
189
)0
019
(08
79)
001
1 (0
052
)
fe
mal
e la
bour
fo
rce
part
icip
atio
nminus
001
0 (0
099
)minus
000
9 (0
202
)minus
102
9 (0
069
)minus
000
1 (0
804
)minus
003
6(0
016)
000
3 (0
553
)0
298
(03
71)
minus0
133
(00
88)
minus0
012
(01
02)
FCTC
ratifi
catio
ncminus
020
4 (0
032
)N
AN
AN
AN
AN
AN
AN
AN
A
M
uslim
pop
ulat
iond
NA
minus0
025
(lt 0
001
)N
AN
AN
AN
AN
AN
AN
A
Year
3eminus
972
times 1
0minus6 (0
251
)N
AN
AN
Aminus
146
times 1
0minus6 (0
875
)N
AN
AN
AN
A
Cons
tant
475
9 (lt
00
01)
minus1
088
(03
37)
726
8 (0
883
)minus
141
3 (0
265
)minus
384
5 (0
022
)1
437
(00
49)
142
441
(00
20)
minus18
940
(01
63)
006
6 (0
950
)
Rand
om e
ffec
ts v
aria
nce
(SE)
Inte
rcep
t0
944
(01
99)
166
0 (0
530
)69
170
32 (1
656
286
)3
070
(15
85)
295
0 (0
747
)0
396
(00
73)
5228
010
(1 1
232
00)
879
17 (1
929
0)8
46 times
10minus
4 (19
3 times
10minus
4 )
Slop
e7
83 times
10minus
10 (2
8 times
10minus
10)
000
3 (0
001
2)20
161
(53
45)
000
2(0
0013
)4
38 times
10minus
10 (9
97
times 1
0minus11
)2
55 times
10minus
4 (56
1 times
10minus
5 )3
667
(08
28)
018
5 (0
036
7)0
953
(01
86)
Inte
rcep
t and
slop
efminus
13
times 1
0minus5 (4
95
times 1
0minus6 )
minus0
030
(00
13)
minus25
595
9 (8
775
6)minus
007
13 (0
044
9)minus
113
times 1
0minus5 (6
86
times 1
0minus6 )
minus0
0058
(00
015)
minus93
382
(21
924)
minus2
055
(06
32)
minus0
0251
(00
061)
Resid
ual
021
5 (0
046
)0
071
(00
14)
437
215
(95
743)
007
6(0
0158
)0
162
(00
454)
001
8 (0
002
7)18
415
3 (2
820
7)12
292
(23
10)
005
2 (0
010
7)
FCTC
Fra
mew
ork
Conv
entio
n on
Toba
cco
Cont
rol G
DP
gro
ss d
omes
tic p
rodu
ct N
A n
ot a
pplic
able
SD
sta
ndar
d de
viat
ion
SE
stan
dard
erro
r W
TO W
orld
Trad
e O
rgan
izatio
na N
atur
al lo
garit
hm o
f com
mod
ity v
alue
s use
d in
mod
el
b In
2005
Inte
rnat
iona
l dol
lars
c O
nly
incl
uded
in to
bacc
o m
odel
d O
nly
incl
uded
in a
lcoh
ol m
odel
e C
oeffi
cien
t val
ues f
or in
divi
dual
yea
r fixe
d eff
ects
not
show
n (w
hen
appl
icab
le)
com
plet
e m
odel
out
put a
vaila
ble
from
the
figsh
are
repo
sitor
y25
f Dat
a pr
esen
ted
are
cova
rianc
es a
nd S
Es
89Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
are presented in Table 2 Although no differences were statistically significant to improve comparability we estimated and applied propensity score weights that optimized comparability on pre-exposure values of each commodity
In the first step we estimated pro-pensity scores to predict the probability of WTO membership as a function of annual values of each commodity in the pre-exposure period using a gen-eralized boosted regression modelling approach3839 In the second step we used propensity scores to construct weights for each country with all exposed coun-tries or territories receiving a weight of 1 and unexposed countries receiving a weight of p(1minusp) where p is the esti-mated propensity score This weighting estimates the average treatment effect on the exposed group ie the average effect of joining WTO for those countries or territories that did join
Fig 1 (available at httpwwwwhointbulletinvolumes97118-218057) displays the balance between the groups for annual values of the com-modities and covariates during the pre-exposure period before and after applying weights The balance metric is the absolute value of the difference in group means divided by the standard deviation across both groups 025 is a generally accepted balance threshold37 Improvements are reflected by the weighted values generally being closer to zero than unweighted values though in several cases improving balance on commodities sacrificed balance on co-variates However we further controlled for the influence of covariates in the regression models
Commodity models
We modelled changes in domestic sup-plies of the commodities using separate linear regression models for each of the nine commodities in a comparative interrupted time-series framework We used WTO membership as the treat-ment (t) term and used a treatmentyear interaction (ty) term to compare the pre- and post-exposure level and trend in the commodities (c) respectively in the exposed versus unexposed groups40 For unexposed countries the WTO membership variable was always 0 For exposed countries this variable ranged from 0 (before accession) to 1 (after ac-cession) for the year of each countryrsquos accession to WTO we used a fraction
reflecting the number of days of mem-bership Each commodity model had the following equation
(1)
where i indexes country j indexes year (1980 to 2013) x is a set of countries- and year-specific covariates βrsquos repre-sent coefficients estimated by the linear model and ε is the residual error term Covariates for urban population female labour force participation and percent-age Muslim population (alcohol model only) were continuous ranging from 0 to 100 The FCTC covariate (tobacco model only) ranged from 0 (not ratified) to 1 (ratified) with a fraction reflecting the number of days after ratification in the year during which each country was ratified All models were run with commodity-specific propensity score weights applied as inverse-probability-of-treatment weights
We tested multiple model varia-tions for each commodity For six com-modities (tobacco alcohol red meats and animal fats seafood nuts seeds and legumes and edible oils) we log-transformed the commodity values to constrain predicted values to be greater than 0 The key output of the best-performing model for each commodity is presented in Table 3 additional output and model fit graphs are available in the figshare repository25
Sensitivity analyses
We did several sensitivity analyses to assess whether various aspects of the study design affected the estimated ef-fects of WTO membership First to eliminate the influence of missing data we restricted the analysis period to 1993 to 2011 years with complete data for all 47 countries Second because the effects of WTO accession may take time we ex-plored lagged values of the WTO mem-bership and WTO membershipyear terms Third to examine whether the effects of WTO membership were pre-dominantly mediated through economic growth we excluded GDP per capita from all models Fourth we excluded several countries in the unexposed group that may be poor comparisons due to war famine or isolation from the global economy Afghanistan
Democratic Peoples Republic of Ko-rea Ethiopia Iraq and Sudan Lastly we stratified models by income group All analyses were conducted in Stata version 142 (StataCorp LCC College Station United States) except for the twang package for propensity scores run in R version 332 (R Foundation Vienna Austria)
ResultsFig 2 Fig 3 Fig 4 Fig 5 and Fig 6 show average trends for each commod-ity for the exposed unweighted unex-posed and weighted unexposed groups Trends during the pre-exposure period illustrate the improved comparability between the groups after weighting Outputs from the best-performing mod-els to estimate changes in supply of the commodities are shown in Table 3 The coefficients for the WTO membership and WTO membershipyear terms in-dicate whether there is any difference in the level and trend respectively of each commodity for countries and territories joining the WTO compared with non-WTO members The domestic avail-ability of fruits and vegetables increased the most the average annual supply of fruits and vegetables was 1979 kg per capita (95 confidence interval CI 660ndash3299) higher in countries or territories that have joined WTO than in non-member countries For tobacco and alcohol the WTO membershipyear coefficients suggest significant increas-ing trends in the availability of these products following WTO accession The geometric means of the supply of tobacco increased by 62 (95 CI 00ndash130) annually and of the supply of alcohol by 38 (95 CI 00ndash77) annually In the tobacco model the FCTC ratification coefficient indicates an 185 (95 CI 18ndash324) lower geometric mean supply of tobacco after ratification In the random effect model the intercept and slope are significantly different from zero for all commodi-ties indicating substantial remaining heterogeneity across countries in both the level and trend in domestic supply quantities (Table 3)
The sensitivity analyses generally supported the main findings The treat-ment effect on fruits and vegetables was robust in all sensitivity analyses The trend coefficient for the alcohol supply stayed of a consistent magnitude and
90 Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
remained significant in most analyses The trend coefficient for the tobacco supply also remained of a consistent magnitude but not always statisti-cally significant In only the lagged effect models treatment effects for sugars were significant and similar in magnitude to those in the main model providing some evidence of an initial decrease in the availability of sugars following WTO accession followed by a minimal steady increase When we stratified the analyses by country income group the results did not support any of the main conclusions However propensity score weights were generated to balance the sample and likely generated false results from these models which were run with 23 countries or less (out of the total 47) per income group Further details on each sensitivity analysis are available in the figshare repository25
DiscussionHere we show that following a countryrsquos accession to WTO there was a signifi-cant increasing trend in the domestic supply of alcohol a borderline signifi-cant increasing trend in the supply of tobacco and a significant immediate increase in the availability of fruits and vegetables compared with non-member countries Assuming that increases in supply likely translate to increases in consumption these changes have both positive and negative implications for global health For example recent re-search has indicated that any amount of alcohol consumption increases the risk of a range of negative health outcomes hence an increase in alcohol supply could be harmful41 Likewise an increase in tobacco use is negative as tobacco contributes to several noncommuni-cable diseases42 In contrast increases in fruit and vegetable consumption can protect against the development of numerous noncommunicable diseases24 The WHO recommends a 400 g intake of fruit and vegetables daily43 although even an intake of 200 g per day has been found to reduce the risk of many non-communicable diseases and premature mortality44 We estimate that average increase in the supply is about 55 g of fruits and vegetables per person per day higher in the countries after join-ing WTO
Our results provide more evidence about the links between trade liberaliza-tion and global health suggesting that
trade agreements should be considered as social determinants of health at the global scale As the burden of noncom-municable diseases continues to grow stakeholders should prioritize identify-ing the most effective strategies to curb the increase in risk factors including to-bacco and alcohol use and poor diet For example addressing aspects of trade and investment policies that alter the supply
of these products can help to tackle the noncommunicable disease burden at the root cause level This approach can be achieved through actions grounded in the Health in All Policies framework45 and the application of health impact assessment to proposed trade and in-vestment policies46 At the global level further development and consideration of international agreements to prevent
Fig 2 Changes in the supply of all forms of tobacco by joining WTO members and non-member states 1980ndash2013
All f
orm
s of t
obac
co(g
ram
sca
pita
old
er th
an 1
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ars)
2500
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Year1980 1990 2000 2010 2013
Range of WTO accession dates
Mean for joining WTO members Unweighted mean for WTO non-membersWeighted mean for WTO non-members
WTO World Trade OrganizationNotes The grey box represents the range of accession dates for countries and territories joining WTO Aberrations in trends starting in 1992 likely reflect the changing composition of countries in each exposure group due to data availability for former Soviet Union countries We obtained weighted means by applying tobacco-specific propensity score weights
Fig 3 Changes in the supply of all types of alcohol by joining WTO members and non-member states 1980ndash2013
All t
ypes
of a
lcoho
l(k
ilogr
ams
capi
ta o
lder
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14
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s)
60
40
20
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Mean for joining WTO members Unweighted mean for WTO non-membersWeighted mean for WTO non-members
WTO World Trade OrganizationNotes The grey box represents the range of accession dates for countries and territories joining WTO Aberrations in trends starting in 1992 likely reflect the changing composition of countries in each exposure group due to data availability for former Soviet Union countries We obtained weighted means by applying alcohol-specific propensity score weights
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ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
Fig
4
Chan
ges i
n th
e su
pply
of f
ruits
and
vege
tabl
es a
nd st
arch
es f
or jo
inin
g W
TO
mem
bers
and
non
-mem
ber s
tate
s 19
80ndash2
013
Year
Year
1980
1990
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2010
2013
1980
1990
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2010
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Rang
e of W
TO ac
cessi
on da
tes
Rang
e of W
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tes
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n fo
r joi
ning
WTO
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eigh
ted
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n fo
r WTO
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-mem
bers
Wei
ghte
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ean
for W
TO n
on-m
embe
rs
Kilogramscapita Kilogramscapita250
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100 50 0
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Star
ches
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ts an
d ve
geta
bles
WTO
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ld Tr
ade
Org
aniz
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nN
otes
The
gre
y bo
x re
pres
ents
the
rang
e of
acc
essio
n da
tes f
or c
ount
ries a
nd te
rrito
ries j
oini
ng W
TO
Aber
ratio
ns in
tren
ds st
artin
g in
199
2 lik
ely
refle
ct th
e ch
angi
ng c
ompo
sitio
n of
cou
ntrie
s in
each
ex
posu
re g
roup
due
to d
ata
avai
labi
lity
for f
orm
er S
ovie
t Uni
on c
ount
ries
We
obta
ined
wei
ghte
d m
eans
by
app
lyin
g co
mm
odity
-spe
cific
pro
pens
ity sc
ore
wei
ghts
Fig
5
Chan
ges i
n th
e su
pply
of r
ed m
eats
and
ani
mal
fats
and
suga
rs b
y joi
ning
WTO
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embe
rs a
nd n
on-m
embe
r sta
tes
1980
ndash201
3
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Year
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1990
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2010
2013
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1990
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e of W
TO ac
cessi
on da
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Rang
e of W
TO ac
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tes
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n fo
r joi
ning
WTO
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bers
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eigh
ted
mea
n fo
r WTO
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-mem
bers
Wei
ghte
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ean
for W
TO n
on-m
embe
rs
Kilogramscapita Kilogramscapita
50 40 30 20 10 0 50 40 30 20 10 0
Red
mea
ts an
d an
imal
fats
Suga
rs
WTO
Wor
ld Tr
ade
Org
aniz
atio
nN
otes
The
gre
y bo
x re
pres
ents
the
rang
e of
acc
essio
n da
tes f
or c
ount
ries a
nd te
rrito
ries j
oini
ng W
TO
Aber
ratio
ns in
tren
ds st
artin
g in
199
2 lik
ely
refle
ct th
e ch
angi
ng c
ompo
sitio
n of
cou
ntrie
s in
each
ex
posu
re g
roup
due
to d
ata
avai
labi
lity
for f
orm
er S
ovie
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ount
ries
We
obta
ined
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ghte
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eans
by
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mm
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-spe
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92 Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
and control noncommunicable diseases like the FCTC but focused on other noncommunicable disease risk factors is warranted Such agreements can legally bind countries to health com-mitments providing a counterweight for commitments to international trade and investment rules
Our findings are suggestive but not conclusive warranting additional exploration and we suggest several po-tential avenues for future research For example given substantial unexplained country-specific heterogeneity indicated by country random effects in all models additional analyses of smaller groups of countries and individual countries are needed The effects of WTO member-ship may differ by level of economic development and other country-specific factors such as geography and climate which affect the baseline supply of various food groups tobacco and types of alcohol Researchers could recreate this analysis with one income group at a time and a similar analysis of selected low- and middle-income countries with substantial noncommunicable disease burdens may provide further insight into the links between WTO member-ship and changes in noncommunicable disease risk factors Single country studies could permit more nuanced understanding for example by looking at tariff changes for specific products and subsequent changes in their sup-ply Another area for future studies is to examine differences associated with specific provisions in WTO accession agreements and other trade and invest-ment policies as specific concessions differ Understanding which compo-nents of these treaties have the greatest influence on noncommunicable disease risk factors and other aspects of public health is important when tailoring future agreements to be more health-promoting Further researchers should also conduct similar analyses for other products that contribute to noncommu-nicable diseases particularly unhealthy foods high in fat salt and sugar
This study both supports and contradicts findings from previous research We were not able to confirm findings showing increases in consump-tion of meat10 and edible oils47 following trade liberalization Discrepancies may be due to differences in the sample previous studies examined only one to five countries in the same geographical region Studies showing trade-related
increases in sugar-sweetened beverage consumption1348 are somewhat sup-ported by our weak finding that the domestic supply of sugars increases steadily over time following WTO ac-
cession Our results confirm previous findings of increased tobacco712 and alcohol5 consumption associated with trade liberalization Finally few studies have examined fruits and vegetables
Fig 6 Changes in the supply of nuts seeds and legumes seafood and edible oils by joining WTO members and non-member states 1980ndash2013
Year
Year
Year
1980 1990 2000 2010 2013
1980 1990 2000 2010 2013
1980 1990 2000 2010 2013
Range of WTO accession dates
Range of WTO accession dates
Range of WTO accession dates
Mean for joining WTO members Unweighted mean for WTO non-membersWeighted mean for WTO non-members
Kilo
gram
sca
pita
Kilo
gram
sca
pita
Kilo
gram
sca
pita
20
15
10
5
0
20
15
10
5
0
20
15
10
5
0
Nuts seeds and legumes
Seafood
Edible oils
WTO World Trade OrganizationNotes The grey box represents the range of accession dates for countries and territories joining WTO Aberrations in trends starting in 1992 likely reflect the changing composition of countries in each exposure group due to data availability for former Soviet Union countries We obtained weighted means by applying commodity-specific propensity score weights
93Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
consumption in the context of trade liberalization but our findings support the results of an analysis showing that changes in trade policies led to an in-crease in imported fruit in five Central American countries10
This study has limitations A pri-mary limitation is the comparability of countries joining versus not joining WTO We assumed that trends would have been similar between the two groups if none of the countries joined WTO However differences in trends could be due to the influence of other unobserved events correlated with WTO accession and the outcomes of interest or innate characteristics of countries in either group
Another key limitation is the quality of the commodity data which measure
the available supply of each commodity and are only a proxy for consumption the true measure of importance for health In addition there was substantial missing data for certain items summed to create commodity variables which may affect the validity of the data for these categories The commodities ana-lysed were also limited by the available product categories importantly this did not allow us to distinguish changes in trends in the availability of specific foods high in fat salt or sugar an important determinant of obesity and noncommu-nicable diseases49 Finally for tobacco and alcohol illicit sales and homemade varieties are not captured in this data which may comprise substantial por-tions of supply and consumption in certain countries
In conclusion changes in domestic supply of alcohol tobacco and fruits and vegetables could have important implications for public health particu-larly for the development and preven-tion of noncommunicable diseases Overall findings indicated substantial country-level heterogeneity Therefore additional exploration of variations across countries is critical to identify factors that mitigate the negative role and enhance the positive role of trade and investment agreements in the global noncommunicable disease burden
Funding Krycia Cowling was supported by a Center for a Livable Future-Lerner fellowship during the time of this study
Competing interests None declared
摘要世界贸易组织成员国与非传染性疾病风险因素的变化一项断续时间序列比较分析1980ndash2013 年目的 旨在调查加入世界贸易组织 (WTO) 与获取若干商品(此类商品对非传染性疾病的形成兼具有害因素和保护因素)之间的关系方法 我 们 使 用 自 然 实 验 设 计 倾 向 评 分 权 重 来比 较 1980 年 至 2013 年 期 间 在 1995 年 之 后 加入 WTO 的 21 个国家或地区以及 26 个非成员国的烟草酒精和七类食品组在各国内的供应趋势我们采用断续时间序列框架使用多变量随机效应线性模型根据人均国内生产总值城市人口百分比和女性劳动力参与进行调整在烟草模型中我们控制了已批准
《烟草控制框架公约》的成员国在酒精模型中我们控制了自认为穆斯林国家所占的比例
结果 成员国加入世贸组织后与非成员国相比平均每人每天的水果和蔬菜国内供应量立即增长 55 克分析显示烟草和酒精每年的供应量以几何平均数的形式逐渐递增分别为每年 62 和 36我们尚未发现获取红肉和动物脂肪有任何重大变化 海鲜 坚果种子和豆类 淀粉 或食用油 以及与糖相关的结果在不同模型中是不一致的结论 结果表明成为 WTO 成员国可能会导致非传染性疾病的有害因素和保护因素增加但仍需进一步探索其针对具体国家的不同变化
ملخصعضوية منظمة التجارة العاملية والتغريات يف عوامل خطر األمراض غري املعدية حتليل سالسل زمنية مقارنة متقطعة ما
بني عامي 1980 و2013العاملية التجارة منظمة إىل االنضامم بني العالقة دراسة الغرض الضارة التأثريات ذات السلع من العديد وتوافر (WTO)
والوقائية من أجل تطوير األمراض غري املعديةاالجتاهات ملقارنة الطبيعية التجربة تصميم استخدمنا الطريقة بني غذائية جمموعات وسبع والكحول للتبغ املحيل اإلمداد يف عامي 1980 و2013 يف 21 دولة أو منطقة انضمت إىل منظمة التجارة العاملية بعد عام 1995 و26 دولة غري أعضاء باستخدام أوزان درجات النزوع طبقنا إطارا زمنيا متسلسال مقارنا متقطعا معدلة متعددة عشوائية تأثريات ذات خطية نامذج باستخدام احلرض لسكان املئوية والنسب للفرد اإلمجايل املحيل للناتج ومشاركة املرأة يف القوى العاملة يف نموذج التبغ قمنا باملكافحة ملكافحة اإلطارية االتفاقية عىل صدقت التي األعضاء الدول يف يعرفون الذين للسكان املئوية النسبة الكحول نموذج ويف التبغ
أنفسهم بأهنم مسلمني
الدول شهدت العاملية التجارة منظمة إىل االنضامم بعد النتائج األعضاء زيادات فورية يف اإلمداد املحيل من الفواكه واخلرضوات وصلت إىل 55 جم للشخص الواحد يف اليوم يف املتوسط مقارنة بالدول غري األعضاء أظهر التحليل زيادات تدرجيية يف املتوسط
اهلنديس إلمدادات التبغ والكحول بنسبة 62 و 36 يف السنة لحوم ال توافر يف جوهرية ت تغيريا أي نكتشف مل الرتتيب عىل احلمراء أو الدهون احليوانية أو املأكوالت البحرية أو املكرسات أو البذور والبقوليات أو النشويات أو الزيوت الصاحلة لألكل
وكانت النتائج للسكريات غري متناسقة عرب تنوعات النموذجقد العاملية التجارة ة منظم وية عض أن إىل النتائج تشري االستنتاج لألمراض والوقائية ة الضار مل العوا من كل يف زيادة إىل تؤدي االختالفات استكشاف من ملزيد ز تعزي هناك ولكن املعدية غري
اخلاصة بكل بلد
94 Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
Reacutesumeacute
Adheacutesion agrave lOrganisation mondiale du commerce et eacutevolution des facteurs de risque de maladies non transmissibles analyse comparative de seacuteries chronologiques interrompues 1980ndash2013Objectif Eacutetudier le lien entre ladheacutesion agrave lOrganisation mondiale du commerce (OMC) et la disponibiliteacute de diffeacuterentes denreacutees avec des effets agrave la fois nocifs et protecteurs pour le deacuteveloppement des maladies non transmissiblesMeacutethodes Nous avons utiliseacute un plan dexpeacuterience dans les conditions naturelles pour comparer entre 1980 et 2013 leacutevolution de loffre nationale de tabac dalcool et de sept groupes daliments dans 21 pays ou territoires devenus membres de lOMC apregraves 1995 et 26 pays non membres agrave laide de pondeacuterations par le score de propension Nous avons appliqueacute un cadre comparatif de seacuteries chronologiques interrompues agrave laide de modegraveles lineacuteaires agrave effets aleacuteatoires multivarieacutes rajusteacutes pour tenir compte du produit inteacuterieur brut par habitant du pourcentage de la population urbaine et de la participation des femmes agrave la vie active Dans le modegravele relatif au tabac nous avons tenu compte des Eacutetats membres ayant ratifieacute la Convention-cadre pour la lutte antitabac tandis que dans le modegravele relatif agrave lalcool nous avons tenu
compte du pourcentage de la population sidentifiant comme eacutetant de foi musulmaneReacutesultats Agrave la suite de leur adheacutesion agrave lOMC les Eacutetats membres ont connu une augmentation immeacutediate de loffre nationale de fruits et leacutegumes de 55 g par personne et par jour en moyenne par rapport aux pays non membres Lanalyse a reacuteveacuteleacute une augmentation progressive de la moyenne geacuteomeacutetrique de loffre de tabac et dalcool de 62 et 36 par an respectivement Nous navons pas constateacute de changements importants concernant la disponibiliteacute de viandes rouges et graisses dorigine animale de produits de la mer de noix graines et leacutegumineuses de feacuteculents ou dhuiles alimentaires et les reacutesultats relatifs aux sucres variaient dun modegravele agrave lautreConclusion Les reacutesultats suggegraverent que ladheacutesion agrave lOMC peut entraicircner une augmentation des facteurs agrave la fois nocifs et protecteurs pour les maladies non transmissibles mais il convient de reacutealiser de nouvelles recherches sur les variations par pays
Резюме
Членство во Всемирной торговой организации и изменения в факторах риска неинфекционных заболеваний сравнительный анализ прерванных временных рядов 1980ndash2013 ггЦель Членство во Всемирной торговой организации и изменения в факторах риска неинфекционных заболеваний сравнительный анализ прерванных временных рядов 1980ndash2013 ггМетоды Авторы использовали естественный эксперимент для сравнения тенденций внутренних поставок табака алкоголя и товаров семи продовольственных групп в период с 1980 по 2013 год в 21 стране или территории которые вступили в ВТО после 1995 года и в 26 странах не являющихся членами этой организации Анализ проводился с использованием весовых коэффициентов предрасположенности Авторы применили методику сравнительных прерванных временных рядов и многовариантные линейные модели случайных воздействий скорректированные по валовому внутреннему продукту на душу населения процентной доле городского населения и участию женщин в трудовой деятельности В модели для табака контролировались государства-члены ВТО ратифицировавшие Рамочную конвенцию по борьбе против табака а в модели
для алкоголя mdash доля населения идентифицирующая себя как мусульманеРезультаты После вступления в ВТО в государствах-членах наблюдался немедленный прирост внутренних поставок фруктов и овощей (в среднем до 55 г в день на человека) по сравнению со странами не являющимися ее членами Анализ показал постепенное увеличение среднего геометрического значения поставок табака и алкоголя на 62 и 36 в год соответственно Авторы не обнаружили существенных изменений в доступности мяса домашнего скота и животных жиров морепродуктов орехов семян и бобовых а также крахмала или пищевых масел Что касается сахара в разных моделях были получены несовпадающие результатыВывод Результаты позволяют предположить что членство в ВТО может привести к увеличению как полезных так и вредных факторов распространения неинфекционных заболеваний но необходимо проведение дальнейших исследований вариаций в различных странах
Resumen
Composicioacuten de la Organizacioacuten Mundial del Comercio y cambios en los factores de riesgo de las enfermedades no contagiosas un anaacutelisis comparativo de series cronoloacutegicas interrumpidas 1980-2013Objetivo Investigar la relacioacuten entre la adhesioacuten a la Organizacioacuten Mundial del Comercio (OMC) y la disponibilidad de varios productos baacutesicos con efectos tanto perjudiciales como protectores para el desarrollo de enfermedades no contagiosasMeacutetodos Se utilizoacute un disentildeo de experimento natural para comparar las tendencias de la oferta interna de tabaco alcohol y siete grupos de alimentos entre 1980 y 2013 en 21 paiacuteses o territorios que se incorporaron a la OMC despueacutes de 1995 y 26 paiacuteses no miembros mediante el uso de ponderaciones de propensioacuten Se aplicoacute un marco comparativo de series temporales interrumpidas siguiendo modelos lineales de efectos aleatorios multivariados ajustados seguacuten el producto interior bruto per caacutepita los porcentajes de poblacioacuten urbana y la participacioacuten de la mujer en el mundo laboral En el modelo del
tabaco controlamos a los Estados miembros que habiacutean ratificado el Convenio Marco para el Control del Tabaco y en el modelo del alcohol el porcentaje de la poblacioacuten que se identificaba como musulmanaResultados Tras la adhesioacuten a la OMC los Estados miembros experimentaron un aumento inmediato de la oferta interna de frutas y hortalizas de 55 kg por persona y diacutea de media en comparacioacuten con los paiacuteses no miembros El anaacutelisis mostroacute incrementos graduales en la media geomeacutetrica de la oferta de tabaco y alcohol del 62 y el 36 anual respectivamente No se detectaron cambios significativos en la disponibilidad de carnes rojas y grasas animales mariscos nueces semillas y legumbres almidones o aceites comestibles y los resultados para los azuacutecares fueron inconsistentes entre las variaciones del modelo
95Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
Conclusioacuten Los resultados sugieren que la pertenencia a la OMC puede dar lugar a un aumento de los factores perjudiciales y protectores de
las enfermedades no contagiosas pero es necesario seguir estudiando las variaciones especiacuteficas de cada paiacutes
References1 Murray CJ Vos T Lozano R Naghavi M Flaxman AD Michaud C et al
Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions 1990ndash2010 a systematic analysis for the Global Burden of Disease Study 2010 Lancet 2012 Dec 15380(9859)2197ndash223 doi httpdxdoiorg101016S0140-6736(12)61689-4 PMID 23245608
2 Lim SS Vos T Flaxman AD Danaei G Shibuya K Adair-Rohani H et al A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions 1990ndash2010 a systematic analysis for the Global Burden of Disease Study 2010 Lancet 2012 Dec 15380(9859)2224ndash60 doi httpdxdoiorg101016S0140-6736(12)61766-8 PMID 23245609
3 Baker P Friel S Food systems transformations ultra-processed food markets and the nutrition transition in Asia Global Health 2016 12 312(1)80 doi httpdxdoiorg101186s12992-016-0223-3 PMID 27912772
4 Labonteacute R Mohindra KS Lencucha R Framing international trade and chronic disease Global Health 2011 07 47(1)21 doi httpdxdoiorg1011861744-8603-7-21 PMID 21726434
5 Stuckler D McKee M Ebrahim S Basu S Manufacturing epidemics the role of global producers in increased consumption of unhealthy commodities including processed foods alcohol and tobacco PLoS Med 20129(6)e1001235 doi httpdxdoiorg101371journalpmed1001235 PMID 22745605
6 De Vogli R Kouvonen A Gimeno D The influence of market deregulation on fast food consumption and body mass index a cross-national time series analysis Bull World Health Organ 2014 Feb 192(2)99ndash107 107A doi httpdxdoiorg102471BLT13120287 PMID 24623903
7 Chaloupka FJ Laixuthai A Trade policy and cigarette smoking in Asia [NBER working paper series] Cambridge National Bureau of Economic Research 1996 Available from httpwwwnberorgpapersw5543 [cited 2017 Sep 4]
8 Cassels S Overweight in the Pacific links between foreign dependence global food trade and obesity in the Federated States of Micronesia Global Health 2006 07 112(1)10 doi httpdxdoiorg1011861744-8603-2-10 PMID 16834782
9 Schultz JT Globalisation urbanization and nutrition transition in a developing island country a case study Fiji Globalization of food systems in developing countries impact on food security and nutrition Rome Food and Agriculture Organization 2004
10 Thow AM Hawkes C The implications of trade liberalization for diet and health a case study from Central America Global Health 2009 07 2855 doi httpdxdoiorg1011861744-8603-5-5 PMID 19638196
11 Barlow P McKee M Basu S Stuckler D The health impact of trade and investment agreements a quantitative systematic review and network co-citation analysis Global Health 2017 03 813(1)13 doi httpdxdoiorg101186s12992-017-0240-x PMID 28274238
12 Taylor A Chaloupka FJ Guindon E Corbett M The impact of trade liberalization on tobacco consumption In Jha P Chaloupka FJ editors Tobacco control in developing countries Oxford Oxford University Press 2000 pp 343ndash64
13 Schram A Labonte R Baker P Friel S Reeves A Stuckler D The role of trade and investment liberalization in the sugar-sweetened carbonated beverages market a natural experiment contrasting Vietnam and the Philippines Global Health 2015 10 1211(1)41 doi httpdxdoiorg101186s12992-015-0127-7 PMID 26455446
14 Baker P Friel S Schram A Labonte R Trade and investment liberalization food systems change and highly processed food consumption a natural experiment contrasting the soft-drink markets of Peru and Bolivia Global Health 2016 06 212(1)24 doi httpdxdoiorg101186s12992-016-0161-0 PMID 27255275
15 Understanding the WTO the organization Members and observers [internet] Geneva World Trade Organization 2017 Available from httpswwwwtoorgenglishthewto_ewhatis_etif_eorg6_ehtm [cited 2017 Mar 28]
16 Guenther PM Casavale KO Reedy J Kirkpatrick SI Hiza HA Kuczynski KJ et al Update of the healthy eating index HEI-2010 J Acad Nutr Diet 2013 Apr113(4)569ndash80 doi httpdxdoiorg101016jjand201212016 PMID 23415502
17 Haines PS Siega-Riz AM Popkin BM The Diet Quality Index revised a measurement instrument for populations J Am Diet Assoc 1999 Jun99(6)697ndash704 doi httpdxdoiorg101016S0002-8223(99)00168-6 PMID 10361532
18 Huijbregts P Feskens E Raumlsaumlnen L Fidanza F Nissinen A Menotti A et al Dietary pattern and 20 year mortality in elderly men in Finland Italy and The Netherlands longitudinal cohort study BMJ 1997 Jul 5315(7099)13ndash7 doi httpdxdoiorg101136bmj315709913 PMID 9233319
19 Panagiotakos DB Pitsavos C Stefanadis C Dietary patterns a Mediterranean diet score and its relation to clinical and biological markers of cardiovascular disease risk Nutr Metab Cardiovasc Dis 2006 Dec16(8)559ndash68 doi httpdxdoiorg101016jnumecd200508006 PMID 17126772
20 Guidelines for measuring household and individual dietary diversity [internet] Rome Food and Agriculture Organization 2012 Available from httpwwwfaoorgdocrep014i1983ei1983e00htm [cited 2017 Jan 14]
21 Indicators for nutrition-friendly and sustainable food systems InGlobal nutrition report 2015 actions and accountability to advance nutrition and sustainable development Washington DC International Food Policy Research Institute 2015 pp 85ndash96 Available from httpglobalnutritionreportorgthe-reportthe-report-2015 [cited 2017 Apr 4]
22 Micha R Khatibzadeh S Shi P Andrews KG Engell RE Mozaffarian D Global Burden of Diseases Nutrition and Chronic Diseases Expert Group (NutriCoDE) Global regional and national consumption of major food groups in 1990 and 2010 a systematic analysis including 266 country-specific nutrition surveys worldwide BMJ Open 2015 09 245(9)e008705 doi httpdxdoiorg101136bmjopen-2015-008705 PMID 26408285
23 Mozaffarian D Hao T Rimm EB Willett WC Hu FB Changes in diet and lifestyle and long-term weight gain in women and men N Engl J Med 2011 Jun 23364(25)2392ndash404 doi httpdxdoiorg101056NEJMoa1014296 PMID 21696306
24 Mozaffarian D Appel LJ Van Horn L Components of a cardioprotective diet new insights Circulation 2011 Jun 21123(24)2870ndash91 doi httpdxdoiorg101161CIRCULATIONAHA110968735 PMID 21690503
25 WTO membership and noncommunicable disease risk factors - Supplemental materials Baltimore Johns Hopkins University 2018 Available from doi httpdxdoiorg106084m9figshare7268561v1 [cited 2018 Oct 30]doi httpdxdoiorg106084m9figshare7268561v1
26 Maumlnnistouml S Laatikainen T Helakorpi S Valsta LM Monitoring diet and diet-related chronic disease risk factors in Finland Public Health Nutr 2010 Jun13 6A907ndash14 doi httpdxdoiorg101017S1368980010001084 PMID 20513259
27 Sheehy T Sharma S Trends in energy and nutrient supply in Trinidad and Tobago from 1961 to 2007 using FAO food balance sheets Public Health Nutr 2013 Sep16(9)1693ndash702 doi httpdxdoiorg101017S136898001200537X PMID 23286774
28 World development indicators [internet] Washington DC The World Bank 2016 Available from httpdataworldbankorgdata-catalogworld-development-indicators [cited 2017 Feb 20]
29 World population prospects the 2015 Revision [internet] New York United Nations Department of Economic and Social Affairs Population Division 2015 Available from httpsesaunorgunpdwpp [cited 2017 Jan 6]
30 Gross domestic product (GDP) estimates by country 1950ndash2015 [internet] Seattle Institute for Health Metrics and Evaluation 2017 Available from httpghdxhealthdataorgrecordgross-domestic-product-gdp-estimates-country-1950-2015 [cited 2017 Jan 6]
31 Table Muslim Population by Country [internet] Washington DC Pew Research Center 2011 Available from httpwwwpewforumorg20110127table-muslim-population-by-country [cited 2017 Apr 12]
32 Depositary WHO Framework Convention on Tobacco Control [internet] New York United Nations Treaty Collection 2025 Available from httpstreatiesunorgpagesViewDetailsaspxsrc=TREATYampmtdsg_no=IX-4ampchapter=9amplang=en [cited 2017 Apr 18]
33 Ng M Freeman MK Fleming TD Robinson M Dwyer-Lindgren L Thomson B et al Smoking prevalence and cigarette consumption in 187 countries 1980ndash2012 JAMA 2014 Jan 8311(2)183ndash92 doi httpdxdoiorg101001jama2013284692 PMID 24399557
96 Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
34 Rehm J Mathers C Popova S Thavorncharoensap M Teerawattananon Y Patra J Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders Lancet 2009 Jun 27373(9682)2223ndash33 doi httpdxdoiorg101016S0140-6736(09)60746-7 PMID 19560604
35 Al-Ansari B Thow A-M Day CA Conigrave KM Extent of alcohol prohibition in civil policy in Muslim majority countries the impact of globalization Addiction 2016 10111(10)1703ndash13 doi httpdxdoiorg101111add13159 PMID 26508526
36 About the WHO Framework Convention on Tobacco Control [internet] Geneva World Health Organization 2018 Available from httpwwwwhointfctcabouten [cited 2017 May 11]
37 Stuart EA Matching methods for causal inference a review and a look forward Stat Sci 2010 Feb 125(1)1ndash21 doi httpdxdoiorg10121409-STS313 PMID 20871802
38 Ridgeway G McCaffrey D Morral A Burgette L Griffin BA Toolkit for weighting and analysis of nonequivalent groups a tutorial for the twang package R Vignette [internet] Vienna R Foundation 2017 Available from httpscranr-projectorgwebpackagestwangvignettestwangpdf [cited 2017 Apr 18]
39 McCaffrey DF Ridgeway G Morral AR Propensity score estimation with boosted regression for evaluating causal effects in observational studies Psychol Methods 2004 Dec9(4)403ndash25 doi httpdxdoiorg1010371082-989X94403 PMID 15598095
40 Linden A Adams JL Applying a propensity score-based weighting model to interrupted time series data improving causal inference in programme evaluation J Eval Clin Pract 2011 Dec17(6)1231ndash8 doi httpdxdoiorg101111j1365-2753201001504x PMID 20973870
41 Griswold MG Fullman N Hawley C Arian N Zimsen SRM Tymeson HD et al GBD 2016 Alcohol Collaborators Alcohol use and burden for 195 countries and territories 1990ndash2016 a systematic analysis for the Global Burden of Disease Study 2016 Lancet 2018 Sep 22392(10152)1015ndash35 doi httpdxdoiorg101016S0140-6736(18)31310-2 PMID 30146330
42 Peto R Lopez AD Boreham J Thun M Heath C Jr Mortality from tobacco in developed countries indirect estimation from national vital statistics Lancet 1992 May 23339(8804)1268ndash78 doi httpdxdoiorg1010160140-6736(92)91600-D PMID 1349675
43 Healthy diet Key facts Geneva World Health Organization 2018 Available from httpwwwwhointnews-roomfact-sheetsdetailhealthy-diet [cited 2018 Oct 26]
44 Aune D Giovannucci E Boffetta P Fadnes LT Keum N Norat T et al Fruit and vegetable intake and the risk of cardiovascular disease total cancer and all-cause mortality-a systematic review and dose-response meta-analysis of prospective studies Int J Epidemiol 2017 06 146(3)1029ndash56 doi httpdxdoiorg101093ijedyw319 PMID 28338764
45 Health in All Policies framework for country action [internet] Geneva World Health Organization 2018 Available from httpwwwwhointhealthpromotionframeworkforcountryactionen [cited 2017 Aug 13]
46 Cole BL Fielding JE Health impact assessment a tool to help policy makers understand health beyond health care Annu Rev Public Health 200728(1)393ndash412 doi httpdxdoiorg101146annurevpublhealth28083006131942 PMID 17173539
47 Tonts M Siddique MAB editors Globalisation agriculture and development perspectives from the Asia-Pacific Cheltenham Edward Elgar Publishing 2011 Available from httpswwwelgaronlinecomview978184720818700010xml [cited 2017 Aug 14]
48 Mendez Lopez A Loopstra R McKee M Stuckler D Is trade liberalisation a vector for the spread of sugar-sweetened beverages A cross-national longitudinal analysis of 44 low- and middle-income countries Soc Sci Med 2017 0117221ndash7 doi httpdxdoiorg101016jsocscimed201611001 PMID 27871042
49 Monteiro CA Moubarac J-C Cannon G Ng SW Popkin B Ultra-processed products are becoming dominant in the global food system Obes Rev 2013 Nov14 Suppl 221ndash8 doi httpdxdoiorg101111obr12107 PMID 24102801
Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057 96A
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
Fig 1 Unweighted and weighted absolute standardized biases for baseline commodity supply in countries included in the study 1980ndash1995
female labour force
participation
female labour force
participation
female labour force
participation
female labour force
participation
female labour force
participation
female labour force
participation
female labour force
participation
female labour force
participation
Muslim population
female labour force
participation urban
population
urban population
urban population
urban population
urban population
urban population
urban population
urbanpopulation
urban population
Tobacco
Starches
Nuts seedsand legumes
Seafood
Edible oils
Sugars
Red meatsand animal
fats
Alcohol Fruits andvegetables
GDP percapita (log)
GDP percapita (log)
GDP percapita (log)
GDP percapita (log)
GDP percapita (log)
GDP percapita (log)
GDP percapita (log)
GDP percapita (log)
GDP percapita (log)
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
Absolute standardize bias
Absolute standardize bias
Absolute standardize bias
Unweighted Weighted
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08 0 02 04 06 08
Supply of tobacco
Supply of starches
Supply of nuts seeds and legumes
Supply of seafood
Supply of edible oils
Supply of sugars
Supply of red meats and animal fats
Supply of alcohol
Supply of fruits and vegetables
GDP gross domestic productNotes The period 1980ndash1995 represents the years before countries and territories start joining the World Trade Organization Table 1 lists countries studied We measured bias by the absolute standardized mean difference that is (mean for non-member states ndash mean for member states)(combined standard deviation)
- Table 1
- Table 2
- Table 3
- Figure 2
- Figure 3
- Figure 4
- Figure 5
- Figure 6
- Figure 1
-
86 Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
quantitative evidence on the role of trade and investment liberalization in the global noncommunicable disease burden we studied changes in the do-mestic supply of tobacco alcohol and several food groups at the national level after WTO accession and compared to these trends in non-member countries
MethodsStudy design
We used a natural experiment approach to compare domestic supply patterns of nine commodities in 47 countries or territories from 1980 to 2013 21 countries or territories joining WTO between 1996 and 2008 (exposed group) and 26 countries not in WTO as of 2011 (unexposed group Table 1) We defined exposure as accession to WTO and the post-exposure period was therefore the beginning of each countryrsquos individual WTO joining date The years 1980 to 1995 comprise the pre-exposure period for all countries as the first countries joined the WTO in 1995
The commodities were tobacco (all types) alcohol (all types including beer wine and spirits) and seven food groups relevant to the development of noncom-municable diseases either protective or harmful These food groups were fruits and vegetables nuts seeds and legumes seafood red meats and animal fats sug-ars starches and edible oils We based the selection of these food categories on a review of common elements of indices of dietary quality16ndash19 and dietary diversity2021 and available evidence on the protective and harmful effects of major food groups for the development of noncommunicable diseases22ndash24 A list of food items included in the dif-ferent commodity groups and the data completeness for each item is available from the figshare data repository25 We hypothesized that following WTO ac-cession the supply of tobacco alcohol edible oils red meats and animal fats and sugars would increase the supply of starches and nuts seeds and legumes would decline The expected trends in fruits and vegetables and seafood were unknown
From our sample we excluded original member states of WTO and all members of the former General Agreement on Tariffs and Trade Nine countries in the unexposed group joined WTO in the final two years (2012ndash2013) Co
untr
y or
terr
itory
Com
mod
ity b
y yea
r
Toba
cco
(gc
apita
old
er
than
14
year
s)
Alco
hol
(kg
capi
ta o
lder
th
an 1
4 ye
ars)
Frui
ts a
nd
vege
tabl
es
(kg
capi
ta)
Nuts
see
ds a
nd
legu
mes
(k
gca
pita
)
Seaf
ood
(k
gca
pita
)Re
d m
eats
and
an
imal
fats
(k
gca
pita
)
Star
ches
(k
gca
pita
)Su
gars
(k
gca
pita
)Ed
ible
oils
(k
gca
pita
)
1993
2011
1993
2011
1993
2011
1993
2011
1993
2011
1993
2011
1993
2011
1993
2011
1993
2011
Sam
oad
3390
030
722
607
527
268
836
92
09
46
416
474
533
418
105
220
35
248
302
33
73
Sao
Tom
e an
d Pr
inci
pe78
216
34
469
613
292
037
10
42
81
254
281
28
109
196
815
32
160
239
72
98
Suda
ne15
06
121
858
641
883
714
36
99
169
18
21
255
348
187
416
22
271
372
79
60
Tajik
istan
bc
1605
814
87
88
14
146
618
57
14
40
05
05
130
124
189
117
56
109
190
114
107
Tim
or-L
este
283
092
23
62
79
466
498
108
126
00
60
402
328
305
521
83
33
115
11
47
Turk
men
istan
b13
616
1029
24
712
012
79
208
60
40
34
63
635
156
921
57
234
816
79
411
37
5Uz
beki
stan
b53
428
78
114
186
160
031
16
07
12
09
07
270
379
232
423
51
134
102
133
102
Vanu
atud
578
933
62
111
67
341
727
73
62
74
313
337
355
314
243
731
11
92
203
70
57
Yem
en21
044
2454
63
40
666
170
47
06
16
02
58
210
617
79
171
120
228
67
77
0
WTO
Wor
ld Tr
ade
Org
aniza
tion
a We
obta
ined
mem
bers
hip
date
s fro
m th
e W
TO w
eb si
te15
b We
anal
ysed
form
er S
ovie
t Uni
on m
embe
r sta
tes d
ata
from
199
2c W
e di
d no
t ana
lyse
dat
a af
ter 2
012
since
the
coun
try
join
ed W
TO in
201
3d W
e di
d no
t ana
lyse
dat
a af
ter 2
011
since
the
coun
try
join
ed W
TO in
201
2e D
ata
ende
d in
201
1 w
hen
coun
try
divi
ded
into
Sud
an a
nd S
outh
Sud
an
Not
e Q
uant
ities
for e
ach
com
mod
ity fo
r the
per
iods
bef
ore
and
afte
r joi
ning
the
WTO
are
pre
sent
ed fo
r the
firs
t and
last
yea
rs w
ith c
ompl
ete
data
for a
ll co
untri
es e
xcep
t for
pre
-exp
osur
e to
bacc
o da
ta fo
r Om
an w
hich
are
from
199
2
( continued)
87Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
Table 2 Baseline characteristics of countries included in study on WTO membership and changes in noncommunicable disease risk factors
Covariates WTO membersa (n = 21) WTO non-members (n = 26) Standardized difference in means (P)bc
No of countries per area NA (055)East Asia and Pacific 4 8Europe and central Asia 10 7Latin America and Caribbean 2 1Middle East and north Africa 3 5North America 0 0South Asia 1 1Sub-Saharan Africa 1 4No of former Soviet Union member states
8 7 NA (041)
Mean GDP per capita in 2005 Int$ (SD)Year 1980 5565 (8 314) 6907 (9 697) 015 (069)Year 1995 4805 (4 845) 6357 (11 005) 018 (055)Mean of female labour force participation (SD)Year 1980 441 (251) 421 (260) minus008 (082)Year 1995 519 (183) 465 (224) minus026 (037)Mean of urban population (SD)Year 1980 382 (206) 372 (219) minus005 (090)Year 1995 531 (201) 458 (209) minus035 (023)Mean of Muslim population (SD)d
Year 1980 300 (404) 360 (434) 014 (070)Year 1995 224 (362) 418 (428) 048 (011)Mean weight of commodity per capitae
Tobacco gram (SD)f
Year 1980 1890 (1 532) 2182 (1997) 016 (067) Year 1995 1358 (1 045) 1913 (2 716) 026 (038)Alcohol kilogram (SD)f
Year 1980 252 (369) 298 (330) 014 (072) Year 1995 292 (262) 263 (275) minus011 (071)Fruits and vegetables kilogram (SD) Year 1980 1089 (747) 1658 (930) 064 (009) Year 1995 1371 (611) 1590 (1132) 023 (043)Nuts seeds and legumes kilogram (SD) Year 1980 60 (35) 79 (62) 036 (034) Year 1995 44 (26) 64 (67) 038 (019)Seafood kilogram (SD) Year 1980 77 (68) 170 (178) 062 (009) Year 1995 95 (89) 139 (186) 030 (032)Red meats and animal fats kilogram (SD) Year 1980 280 (322) 272 (182) minus003 (093) Year 1995 373 (238) 287 (209) minus038 (020)Starches kilogram (SD) Year 1980 1931 (372) 2230 (521) 062 (010) Year 1995 2155 (554) 2078 (533) minus014 (063)Sugars kilogram (SD) Year 1980 244 (148) 239 (141) minus004 (093) Year 1995 232 (89) 215 (131) minus015 (061)Edible oils kilogram (SD) Year 1980 61 (45) 68 (44) 015 (070) Year 1995 73 (48) 83 (55) 019 (052)
GDP gross domestic product Int$ international dollars NA not applicable SD standard deviation WTO World Trade Organizationa Countries joining WTO between 1996 and 2008b We calculated standardized difference in means as follows (mean for non-member states ndash mean for member states)(combined standard deviation)c For continuous variables we used two-sided t-tests to calculate P-values For or categorical variables we used χ2 testsd Covariate used in alcohol models onlye Commodity available for domestic consumptionf Data for population older than 14 years
Note The years presented are the first (1980) and last (1995) years we used for analyses of the period before countries and territories included in the study started to join WTO
88 Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
or after the analysis period data for these countries were censored to exclude values in or after the year they joined For countries that comprised the former Soviet Union (eight exposed seven un-exposed) the analysis period begins in 1992 when independent countries were established
Data sources
The data sources for all commodities were the Food and Agriculture Orga-nization national commodity balance sheets (tobacco) and food balance sheets (all other commodities) which measure the annual supply of each commodity by country and are widely used as a proxy for consumption2627 We obtained covariate data on urban population and female labour force participation from the World Bankrsquos World Development Indicators28 population data from the United Nations Population Division29 gross domestic product (GDP) per capita from the Institute for Health Metrics and Evaluation30 percent-age Muslim population from the Pew Research Center31 and the ratification dates for the Framework Convention on Tobacco Control (FCTC) from the United Nations Treaty Collection32
Variables
We measured all commodity variables in units of grams (tobacco) or kilograms (all other commodities) per capita For tobacco and alcohol we restricted these measures to the population older than 14 years as is standard3334 We con-trolled for the following key confound-ers established by the existing literature in all models GDP per capita urban population and female labour force par-ticipation45 Models for alcohol included each countryrsquos proportion of population identifying themselves as Muslim as a covariate because being Muslim is linked to lower rates of alcohol use35 Models for tobacco included a variable indicating whether the country had ratified the FCTC because this ratifica-tion represents a commitment to reduce tobacco use36
Propensity score weights
With observational data the non-random assignment of the exposure (in this case WTO membership) can create imbalance in covariates and baseline levels of the outcome variables between the groups compared37 Characteristics of the groups in the pre-exposure period Ta
ble
3
Mod
el o
utpu
t fro
m b
est-
perf
orm
ing
mod
el to
stud
y WTO
mem
bers
hip
and
chan
ges i
n no
ncom
mun
icabl
e di
seas
e ris
k fa
ctor
s 19
80ndash2
013
Varia
ble
Toba
ccoa
Alco
hola
Frui
ts a
nd
vege
tabl
esNu
ts s
eeds
an
d le
gum
esa
Seaf
ooda
Red
mea
ts a
nd a
nim
al
fats
a
Star
ches
Suga
rsEd
ible
oils
a
Fixe
d eff
ect
coeffi
cien
t (P)
WTO
mem
bers
hip
009
8 (0
477
)minus
011
8 (0
133
)19
794
(00
03)
010
7 (0
171
)minus
013
7 (0
436
)0
008
(08
65)
minus6
277
(01
33)
minus2
401
(01
15)
minus0
070(
029
6)
WTO
m
embe
rshi
pye
ar0
061
(00
54)
003
7 (0
050
)minus
127
6 (0
367
)minus
001
7 (0
151
)0
032
(03
67)
000
1 (0
875
)minus
012
0 (0
904
)0
250
(01
76)
000
5 (0
730
)
GDP
per c
apita
ab
044
9 (0
004
)0
496
(lt 0
001
)7
571
(02
18)
031
3 (0
060
)0
826
(lt 0
001
)0
184
(00
20)
530
8 (0
464
)6
133
(00
03)
015
0 (0
243
)
u
rban
pop
ulat
ion
minus0
017
(00
24)
001
4 (0
160
)1
993
(00
04)
minus0
005
(04
91)
000
6 (0
637
)0
004
(05
33)
061
6 (0
189
)0
019
(08
79)
001
1 (0
052
)
fe
mal
e la
bour
fo
rce
part
icip
atio
nminus
001
0 (0
099
)minus
000
9 (0
202
)minus
102
9 (0
069
)minus
000
1 (0
804
)minus
003
6(0
016)
000
3 (0
553
)0
298
(03
71)
minus0
133
(00
88)
minus0
012
(01
02)
FCTC
ratifi
catio
ncminus
020
4 (0
032
)N
AN
AN
AN
AN
AN
AN
AN
A
M
uslim
pop
ulat
iond
NA
minus0
025
(lt 0
001
)N
AN
AN
AN
AN
AN
AN
A
Year
3eminus
972
times 1
0minus6 (0
251
)N
AN
AN
Aminus
146
times 1
0minus6 (0
875
)N
AN
AN
AN
A
Cons
tant
475
9 (lt
00
01)
minus1
088
(03
37)
726
8 (0
883
)minus
141
3 (0
265
)minus
384
5 (0
022
)1
437
(00
49)
142
441
(00
20)
minus18
940
(01
63)
006
6 (0
950
)
Rand
om e
ffec
ts v
aria
nce
(SE)
Inte
rcep
t0
944
(01
99)
166
0 (0
530
)69
170
32 (1
656
286
)3
070
(15
85)
295
0 (0
747
)0
396
(00
73)
5228
010
(1 1
232
00)
879
17 (1
929
0)8
46 times
10minus
4 (19
3 times
10minus
4 )
Slop
e7
83 times
10minus
10 (2
8 times
10minus
10)
000
3 (0
001
2)20
161
(53
45)
000
2(0
0013
)4
38 times
10minus
10 (9
97
times 1
0minus11
)2
55 times
10minus
4 (56
1 times
10minus
5 )3
667
(08
28)
018
5 (0
036
7)0
953
(01
86)
Inte
rcep
t and
slop
efminus
13
times 1
0minus5 (4
95
times 1
0minus6 )
minus0
030
(00
13)
minus25
595
9 (8
775
6)minus
007
13 (0
044
9)minus
113
times 1
0minus5 (6
86
times 1
0minus6 )
minus0
0058
(00
015)
minus93
382
(21
924)
minus2
055
(06
32)
minus0
0251
(00
061)
Resid
ual
021
5 (0
046
)0
071
(00
14)
437
215
(95
743)
007
6(0
0158
)0
162
(00
454)
001
8 (0
002
7)18
415
3 (2
820
7)12
292
(23
10)
005
2 (0
010
7)
FCTC
Fra
mew
ork
Conv
entio
n on
Toba
cco
Cont
rol G
DP
gro
ss d
omes
tic p
rodu
ct N
A n
ot a
pplic
able
SD
sta
ndar
d de
viat
ion
SE
stan
dard
erro
r W
TO W
orld
Trad
e O
rgan
izatio
na N
atur
al lo
garit
hm o
f com
mod
ity v
alue
s use
d in
mod
el
b In
2005
Inte
rnat
iona
l dol
lars
c O
nly
incl
uded
in to
bacc
o m
odel
d O
nly
incl
uded
in a
lcoh
ol m
odel
e C
oeffi
cien
t val
ues f
or in
divi
dual
yea
r fixe
d eff
ects
not
show
n (w
hen
appl
icab
le)
com
plet
e m
odel
out
put a
vaila
ble
from
the
figsh
are
repo
sitor
y25
f Dat
a pr
esen
ted
are
cova
rianc
es a
nd S
Es
89Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
are presented in Table 2 Although no differences were statistically significant to improve comparability we estimated and applied propensity score weights that optimized comparability on pre-exposure values of each commodity
In the first step we estimated pro-pensity scores to predict the probability of WTO membership as a function of annual values of each commodity in the pre-exposure period using a gen-eralized boosted regression modelling approach3839 In the second step we used propensity scores to construct weights for each country with all exposed coun-tries or territories receiving a weight of 1 and unexposed countries receiving a weight of p(1minusp) where p is the esti-mated propensity score This weighting estimates the average treatment effect on the exposed group ie the average effect of joining WTO for those countries or territories that did join
Fig 1 (available at httpwwwwhointbulletinvolumes97118-218057) displays the balance between the groups for annual values of the com-modities and covariates during the pre-exposure period before and after applying weights The balance metric is the absolute value of the difference in group means divided by the standard deviation across both groups 025 is a generally accepted balance threshold37 Improvements are reflected by the weighted values generally being closer to zero than unweighted values though in several cases improving balance on commodities sacrificed balance on co-variates However we further controlled for the influence of covariates in the regression models
Commodity models
We modelled changes in domestic sup-plies of the commodities using separate linear regression models for each of the nine commodities in a comparative interrupted time-series framework We used WTO membership as the treat-ment (t) term and used a treatmentyear interaction (ty) term to compare the pre- and post-exposure level and trend in the commodities (c) respectively in the exposed versus unexposed groups40 For unexposed countries the WTO membership variable was always 0 For exposed countries this variable ranged from 0 (before accession) to 1 (after ac-cession) for the year of each countryrsquos accession to WTO we used a fraction
reflecting the number of days of mem-bership Each commodity model had the following equation
(1)
where i indexes country j indexes year (1980 to 2013) x is a set of countries- and year-specific covariates βrsquos repre-sent coefficients estimated by the linear model and ε is the residual error term Covariates for urban population female labour force participation and percent-age Muslim population (alcohol model only) were continuous ranging from 0 to 100 The FCTC covariate (tobacco model only) ranged from 0 (not ratified) to 1 (ratified) with a fraction reflecting the number of days after ratification in the year during which each country was ratified All models were run with commodity-specific propensity score weights applied as inverse-probability-of-treatment weights
We tested multiple model varia-tions for each commodity For six com-modities (tobacco alcohol red meats and animal fats seafood nuts seeds and legumes and edible oils) we log-transformed the commodity values to constrain predicted values to be greater than 0 The key output of the best-performing model for each commodity is presented in Table 3 additional output and model fit graphs are available in the figshare repository25
Sensitivity analyses
We did several sensitivity analyses to assess whether various aspects of the study design affected the estimated ef-fects of WTO membership First to eliminate the influence of missing data we restricted the analysis period to 1993 to 2011 years with complete data for all 47 countries Second because the effects of WTO accession may take time we ex-plored lagged values of the WTO mem-bership and WTO membershipyear terms Third to examine whether the effects of WTO membership were pre-dominantly mediated through economic growth we excluded GDP per capita from all models Fourth we excluded several countries in the unexposed group that may be poor comparisons due to war famine or isolation from the global economy Afghanistan
Democratic Peoples Republic of Ko-rea Ethiopia Iraq and Sudan Lastly we stratified models by income group All analyses were conducted in Stata version 142 (StataCorp LCC College Station United States) except for the twang package for propensity scores run in R version 332 (R Foundation Vienna Austria)
ResultsFig 2 Fig 3 Fig 4 Fig 5 and Fig 6 show average trends for each commod-ity for the exposed unweighted unex-posed and weighted unexposed groups Trends during the pre-exposure period illustrate the improved comparability between the groups after weighting Outputs from the best-performing mod-els to estimate changes in supply of the commodities are shown in Table 3 The coefficients for the WTO membership and WTO membershipyear terms in-dicate whether there is any difference in the level and trend respectively of each commodity for countries and territories joining the WTO compared with non-WTO members The domestic avail-ability of fruits and vegetables increased the most the average annual supply of fruits and vegetables was 1979 kg per capita (95 confidence interval CI 660ndash3299) higher in countries or territories that have joined WTO than in non-member countries For tobacco and alcohol the WTO membershipyear coefficients suggest significant increas-ing trends in the availability of these products following WTO accession The geometric means of the supply of tobacco increased by 62 (95 CI 00ndash130) annually and of the supply of alcohol by 38 (95 CI 00ndash77) annually In the tobacco model the FCTC ratification coefficient indicates an 185 (95 CI 18ndash324) lower geometric mean supply of tobacco after ratification In the random effect model the intercept and slope are significantly different from zero for all commodi-ties indicating substantial remaining heterogeneity across countries in both the level and trend in domestic supply quantities (Table 3)
The sensitivity analyses generally supported the main findings The treat-ment effect on fruits and vegetables was robust in all sensitivity analyses The trend coefficient for the alcohol supply stayed of a consistent magnitude and
90 Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
remained significant in most analyses The trend coefficient for the tobacco supply also remained of a consistent magnitude but not always statisti-cally significant In only the lagged effect models treatment effects for sugars were significant and similar in magnitude to those in the main model providing some evidence of an initial decrease in the availability of sugars following WTO accession followed by a minimal steady increase When we stratified the analyses by country income group the results did not support any of the main conclusions However propensity score weights were generated to balance the sample and likely generated false results from these models which were run with 23 countries or less (out of the total 47) per income group Further details on each sensitivity analysis are available in the figshare repository25
DiscussionHere we show that following a countryrsquos accession to WTO there was a signifi-cant increasing trend in the domestic supply of alcohol a borderline signifi-cant increasing trend in the supply of tobacco and a significant immediate increase in the availability of fruits and vegetables compared with non-member countries Assuming that increases in supply likely translate to increases in consumption these changes have both positive and negative implications for global health For example recent re-search has indicated that any amount of alcohol consumption increases the risk of a range of negative health outcomes hence an increase in alcohol supply could be harmful41 Likewise an increase in tobacco use is negative as tobacco contributes to several noncommuni-cable diseases42 In contrast increases in fruit and vegetable consumption can protect against the development of numerous noncommunicable diseases24 The WHO recommends a 400 g intake of fruit and vegetables daily43 although even an intake of 200 g per day has been found to reduce the risk of many non-communicable diseases and premature mortality44 We estimate that average increase in the supply is about 55 g of fruits and vegetables per person per day higher in the countries after join-ing WTO
Our results provide more evidence about the links between trade liberaliza-tion and global health suggesting that
trade agreements should be considered as social determinants of health at the global scale As the burden of noncom-municable diseases continues to grow stakeholders should prioritize identify-ing the most effective strategies to curb the increase in risk factors including to-bacco and alcohol use and poor diet For example addressing aspects of trade and investment policies that alter the supply
of these products can help to tackle the noncommunicable disease burden at the root cause level This approach can be achieved through actions grounded in the Health in All Policies framework45 and the application of health impact assessment to proposed trade and in-vestment policies46 At the global level further development and consideration of international agreements to prevent
Fig 2 Changes in the supply of all forms of tobacco by joining WTO members and non-member states 1980ndash2013
All f
orm
s of t
obac
co(g
ram
sca
pita
old
er th
an 1
4 ye
ars)
2500
2000
1500
1000
500
0
Year1980 1990 2000 2010 2013
Range of WTO accession dates
Mean for joining WTO members Unweighted mean for WTO non-membersWeighted mean for WTO non-members
WTO World Trade OrganizationNotes The grey box represents the range of accession dates for countries and territories joining WTO Aberrations in trends starting in 1992 likely reflect the changing composition of countries in each exposure group due to data availability for former Soviet Union countries We obtained weighted means by applying tobacco-specific propensity score weights
Fig 3 Changes in the supply of all types of alcohol by joining WTO members and non-member states 1980ndash2013
All t
ypes
of a
lcoho
l(k
ilogr
ams
capi
ta o
lder
than
14
year
s)
60
40
20
0
Year1980 1990 2000 2010 2013
Range of WTO accession dates
Mean for joining WTO members Unweighted mean for WTO non-membersWeighted mean for WTO non-members
WTO World Trade OrganizationNotes The grey box represents the range of accession dates for countries and territories joining WTO Aberrations in trends starting in 1992 likely reflect the changing composition of countries in each exposure group due to data availability for former Soviet Union countries We obtained weighted means by applying alcohol-specific propensity score weights
91Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
Fig
4
Chan
ges i
n th
e su
pply
of f
ruits
and
vege
tabl
es a
nd st
arch
es f
or jo
inin
g W
TO
mem
bers
and
non
-mem
ber s
tate
s 19
80ndash2
013
Year
Year
1980
1990
2000
2010
2013
1980
1990
2000
2010
2013
Rang
e of W
TO ac
cessi
on da
tes
Rang
e of W
TO ac
cessi
on da
tes
Mea
n fo
r joi
ning
WTO
mem
bers
Unw
eigh
ted
mea
n fo
r WTO
non
-mem
bers
Wei
ghte
d m
ean
for W
TO n
on-m
embe
rs
Kilogramscapita Kilogramscapita250
200
150
100 50 0
250
200
150
100 50 0
Star
ches
Frui
ts an
d ve
geta
bles
WTO
Wor
ld Tr
ade
Org
aniz
atio
nN
otes
The
gre
y bo
x re
pres
ents
the
rang
e of
acc
essio
n da
tes f
or c
ount
ries a
nd te
rrito
ries j
oini
ng W
TO
Aber
ratio
ns in
tren
ds st
artin
g in
199
2 lik
ely
refle
ct th
e ch
angi
ng c
ompo
sitio
n of
cou
ntrie
s in
each
ex
posu
re g
roup
due
to d
ata
avai
labi
lity
for f
orm
er S
ovie
t Uni
on c
ount
ries
We
obta
ined
wei
ghte
d m
eans
by
app
lyin
g co
mm
odity
-spe
cific
pro
pens
ity sc
ore
wei
ghts
Fig
5
Chan
ges i
n th
e su
pply
of r
ed m
eats
and
ani
mal
fats
and
suga
rs b
y joi
ning
WTO
m
embe
rs a
nd n
on-m
embe
r sta
tes
1980
ndash201
3
Year
Year
1980
1990
2000
2010
2013
1980
1990
2000
2010
2013
Rang
e of W
TO ac
cessi
on da
tes
Rang
e of W
TO ac
cessi
on da
tes
Mea
n fo
r joi
ning
WTO
mem
bers
Unw
eigh
ted
mea
n fo
r WTO
non
-mem
bers
Wei
ghte
d m
ean
for W
TO n
on-m
embe
rs
Kilogramscapita Kilogramscapita
50 40 30 20 10 0 50 40 30 20 10 0
Red
mea
ts an
d an
imal
fats
Suga
rs
WTO
Wor
ld Tr
ade
Org
aniz
atio
nN
otes
The
gre
y bo
x re
pres
ents
the
rang
e of
acc
essio
n da
tes f
or c
ount
ries a
nd te
rrito
ries j
oini
ng W
TO
Aber
ratio
ns in
tren
ds st
artin
g in
199
2 lik
ely
refle
ct th
e ch
angi
ng c
ompo
sitio
n of
cou
ntrie
s in
each
ex
posu
re g
roup
due
to d
ata
avai
labi
lity
for f
orm
er S
ovie
t Uni
on c
ount
ries
We
obta
ined
wei
ghte
d m
eans
by
app
lyin
g co
mm
odity
-spe
cific
pro
pens
ity sc
ore
wei
ghts
92 Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
and control noncommunicable diseases like the FCTC but focused on other noncommunicable disease risk factors is warranted Such agreements can legally bind countries to health com-mitments providing a counterweight for commitments to international trade and investment rules
Our findings are suggestive but not conclusive warranting additional exploration and we suggest several po-tential avenues for future research For example given substantial unexplained country-specific heterogeneity indicated by country random effects in all models additional analyses of smaller groups of countries and individual countries are needed The effects of WTO member-ship may differ by level of economic development and other country-specific factors such as geography and climate which affect the baseline supply of various food groups tobacco and types of alcohol Researchers could recreate this analysis with one income group at a time and a similar analysis of selected low- and middle-income countries with substantial noncommunicable disease burdens may provide further insight into the links between WTO member-ship and changes in noncommunicable disease risk factors Single country studies could permit more nuanced understanding for example by looking at tariff changes for specific products and subsequent changes in their sup-ply Another area for future studies is to examine differences associated with specific provisions in WTO accession agreements and other trade and invest-ment policies as specific concessions differ Understanding which compo-nents of these treaties have the greatest influence on noncommunicable disease risk factors and other aspects of public health is important when tailoring future agreements to be more health-promoting Further researchers should also conduct similar analyses for other products that contribute to noncommu-nicable diseases particularly unhealthy foods high in fat salt and sugar
This study both supports and contradicts findings from previous research We were not able to confirm findings showing increases in consump-tion of meat10 and edible oils47 following trade liberalization Discrepancies may be due to differences in the sample previous studies examined only one to five countries in the same geographical region Studies showing trade-related
increases in sugar-sweetened beverage consumption1348 are somewhat sup-ported by our weak finding that the domestic supply of sugars increases steadily over time following WTO ac-
cession Our results confirm previous findings of increased tobacco712 and alcohol5 consumption associated with trade liberalization Finally few studies have examined fruits and vegetables
Fig 6 Changes in the supply of nuts seeds and legumes seafood and edible oils by joining WTO members and non-member states 1980ndash2013
Year
Year
Year
1980 1990 2000 2010 2013
1980 1990 2000 2010 2013
1980 1990 2000 2010 2013
Range of WTO accession dates
Range of WTO accession dates
Range of WTO accession dates
Mean for joining WTO members Unweighted mean for WTO non-membersWeighted mean for WTO non-members
Kilo
gram
sca
pita
Kilo
gram
sca
pita
Kilo
gram
sca
pita
20
15
10
5
0
20
15
10
5
0
20
15
10
5
0
Nuts seeds and legumes
Seafood
Edible oils
WTO World Trade OrganizationNotes The grey box represents the range of accession dates for countries and territories joining WTO Aberrations in trends starting in 1992 likely reflect the changing composition of countries in each exposure group due to data availability for former Soviet Union countries We obtained weighted means by applying commodity-specific propensity score weights
93Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
consumption in the context of trade liberalization but our findings support the results of an analysis showing that changes in trade policies led to an in-crease in imported fruit in five Central American countries10
This study has limitations A pri-mary limitation is the comparability of countries joining versus not joining WTO We assumed that trends would have been similar between the two groups if none of the countries joined WTO However differences in trends could be due to the influence of other unobserved events correlated with WTO accession and the outcomes of interest or innate characteristics of countries in either group
Another key limitation is the quality of the commodity data which measure
the available supply of each commodity and are only a proxy for consumption the true measure of importance for health In addition there was substantial missing data for certain items summed to create commodity variables which may affect the validity of the data for these categories The commodities ana-lysed were also limited by the available product categories importantly this did not allow us to distinguish changes in trends in the availability of specific foods high in fat salt or sugar an important determinant of obesity and noncommu-nicable diseases49 Finally for tobacco and alcohol illicit sales and homemade varieties are not captured in this data which may comprise substantial por-tions of supply and consumption in certain countries
In conclusion changes in domestic supply of alcohol tobacco and fruits and vegetables could have important implications for public health particu-larly for the development and preven-tion of noncommunicable diseases Overall findings indicated substantial country-level heterogeneity Therefore additional exploration of variations across countries is critical to identify factors that mitigate the negative role and enhance the positive role of trade and investment agreements in the global noncommunicable disease burden
Funding Krycia Cowling was supported by a Center for a Livable Future-Lerner fellowship during the time of this study
Competing interests None declared
摘要世界贸易组织成员国与非传染性疾病风险因素的变化一项断续时间序列比较分析1980ndash2013 年目的 旨在调查加入世界贸易组织 (WTO) 与获取若干商品(此类商品对非传染性疾病的形成兼具有害因素和保护因素)之间的关系方法 我 们 使 用 自 然 实 验 设 计 倾 向 评 分 权 重 来比 较 1980 年 至 2013 年 期 间 在 1995 年 之 后 加入 WTO 的 21 个国家或地区以及 26 个非成员国的烟草酒精和七类食品组在各国内的供应趋势我们采用断续时间序列框架使用多变量随机效应线性模型根据人均国内生产总值城市人口百分比和女性劳动力参与进行调整在烟草模型中我们控制了已批准
《烟草控制框架公约》的成员国在酒精模型中我们控制了自认为穆斯林国家所占的比例
结果 成员国加入世贸组织后与非成员国相比平均每人每天的水果和蔬菜国内供应量立即增长 55 克分析显示烟草和酒精每年的供应量以几何平均数的形式逐渐递增分别为每年 62 和 36我们尚未发现获取红肉和动物脂肪有任何重大变化 海鲜 坚果种子和豆类 淀粉 或食用油 以及与糖相关的结果在不同模型中是不一致的结论 结果表明成为 WTO 成员国可能会导致非传染性疾病的有害因素和保护因素增加但仍需进一步探索其针对具体国家的不同变化
ملخصعضوية منظمة التجارة العاملية والتغريات يف عوامل خطر األمراض غري املعدية حتليل سالسل زمنية مقارنة متقطعة ما
بني عامي 1980 و2013العاملية التجارة منظمة إىل االنضامم بني العالقة دراسة الغرض الضارة التأثريات ذات السلع من العديد وتوافر (WTO)
والوقائية من أجل تطوير األمراض غري املعديةاالجتاهات ملقارنة الطبيعية التجربة تصميم استخدمنا الطريقة بني غذائية جمموعات وسبع والكحول للتبغ املحيل اإلمداد يف عامي 1980 و2013 يف 21 دولة أو منطقة انضمت إىل منظمة التجارة العاملية بعد عام 1995 و26 دولة غري أعضاء باستخدام أوزان درجات النزوع طبقنا إطارا زمنيا متسلسال مقارنا متقطعا معدلة متعددة عشوائية تأثريات ذات خطية نامذج باستخدام احلرض لسكان املئوية والنسب للفرد اإلمجايل املحيل للناتج ومشاركة املرأة يف القوى العاملة يف نموذج التبغ قمنا باملكافحة ملكافحة اإلطارية االتفاقية عىل صدقت التي األعضاء الدول يف يعرفون الذين للسكان املئوية النسبة الكحول نموذج ويف التبغ
أنفسهم بأهنم مسلمني
الدول شهدت العاملية التجارة منظمة إىل االنضامم بعد النتائج األعضاء زيادات فورية يف اإلمداد املحيل من الفواكه واخلرضوات وصلت إىل 55 جم للشخص الواحد يف اليوم يف املتوسط مقارنة بالدول غري األعضاء أظهر التحليل زيادات تدرجيية يف املتوسط
اهلنديس إلمدادات التبغ والكحول بنسبة 62 و 36 يف السنة لحوم ال توافر يف جوهرية ت تغيريا أي نكتشف مل الرتتيب عىل احلمراء أو الدهون احليوانية أو املأكوالت البحرية أو املكرسات أو البذور والبقوليات أو النشويات أو الزيوت الصاحلة لألكل
وكانت النتائج للسكريات غري متناسقة عرب تنوعات النموذجقد العاملية التجارة ة منظم وية عض أن إىل النتائج تشري االستنتاج لألمراض والوقائية ة الضار مل العوا من كل يف زيادة إىل تؤدي االختالفات استكشاف من ملزيد ز تعزي هناك ولكن املعدية غري
اخلاصة بكل بلد
94 Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
Reacutesumeacute
Adheacutesion agrave lOrganisation mondiale du commerce et eacutevolution des facteurs de risque de maladies non transmissibles analyse comparative de seacuteries chronologiques interrompues 1980ndash2013Objectif Eacutetudier le lien entre ladheacutesion agrave lOrganisation mondiale du commerce (OMC) et la disponibiliteacute de diffeacuterentes denreacutees avec des effets agrave la fois nocifs et protecteurs pour le deacuteveloppement des maladies non transmissiblesMeacutethodes Nous avons utiliseacute un plan dexpeacuterience dans les conditions naturelles pour comparer entre 1980 et 2013 leacutevolution de loffre nationale de tabac dalcool et de sept groupes daliments dans 21 pays ou territoires devenus membres de lOMC apregraves 1995 et 26 pays non membres agrave laide de pondeacuterations par le score de propension Nous avons appliqueacute un cadre comparatif de seacuteries chronologiques interrompues agrave laide de modegraveles lineacuteaires agrave effets aleacuteatoires multivarieacutes rajusteacutes pour tenir compte du produit inteacuterieur brut par habitant du pourcentage de la population urbaine et de la participation des femmes agrave la vie active Dans le modegravele relatif au tabac nous avons tenu compte des Eacutetats membres ayant ratifieacute la Convention-cadre pour la lutte antitabac tandis que dans le modegravele relatif agrave lalcool nous avons tenu
compte du pourcentage de la population sidentifiant comme eacutetant de foi musulmaneReacutesultats Agrave la suite de leur adheacutesion agrave lOMC les Eacutetats membres ont connu une augmentation immeacutediate de loffre nationale de fruits et leacutegumes de 55 g par personne et par jour en moyenne par rapport aux pays non membres Lanalyse a reacuteveacuteleacute une augmentation progressive de la moyenne geacuteomeacutetrique de loffre de tabac et dalcool de 62 et 36 par an respectivement Nous navons pas constateacute de changements importants concernant la disponibiliteacute de viandes rouges et graisses dorigine animale de produits de la mer de noix graines et leacutegumineuses de feacuteculents ou dhuiles alimentaires et les reacutesultats relatifs aux sucres variaient dun modegravele agrave lautreConclusion Les reacutesultats suggegraverent que ladheacutesion agrave lOMC peut entraicircner une augmentation des facteurs agrave la fois nocifs et protecteurs pour les maladies non transmissibles mais il convient de reacutealiser de nouvelles recherches sur les variations par pays
Резюме
Членство во Всемирной торговой организации и изменения в факторах риска неинфекционных заболеваний сравнительный анализ прерванных временных рядов 1980ndash2013 ггЦель Членство во Всемирной торговой организации и изменения в факторах риска неинфекционных заболеваний сравнительный анализ прерванных временных рядов 1980ndash2013 ггМетоды Авторы использовали естественный эксперимент для сравнения тенденций внутренних поставок табака алкоголя и товаров семи продовольственных групп в период с 1980 по 2013 год в 21 стране или территории которые вступили в ВТО после 1995 года и в 26 странах не являющихся членами этой организации Анализ проводился с использованием весовых коэффициентов предрасположенности Авторы применили методику сравнительных прерванных временных рядов и многовариантные линейные модели случайных воздействий скорректированные по валовому внутреннему продукту на душу населения процентной доле городского населения и участию женщин в трудовой деятельности В модели для табака контролировались государства-члены ВТО ратифицировавшие Рамочную конвенцию по борьбе против табака а в модели
для алкоголя mdash доля населения идентифицирующая себя как мусульманеРезультаты После вступления в ВТО в государствах-членах наблюдался немедленный прирост внутренних поставок фруктов и овощей (в среднем до 55 г в день на человека) по сравнению со странами не являющимися ее членами Анализ показал постепенное увеличение среднего геометрического значения поставок табака и алкоголя на 62 и 36 в год соответственно Авторы не обнаружили существенных изменений в доступности мяса домашнего скота и животных жиров морепродуктов орехов семян и бобовых а также крахмала или пищевых масел Что касается сахара в разных моделях были получены несовпадающие результатыВывод Результаты позволяют предположить что членство в ВТО может привести к увеличению как полезных так и вредных факторов распространения неинфекционных заболеваний но необходимо проведение дальнейших исследований вариаций в различных странах
Resumen
Composicioacuten de la Organizacioacuten Mundial del Comercio y cambios en los factores de riesgo de las enfermedades no contagiosas un anaacutelisis comparativo de series cronoloacutegicas interrumpidas 1980-2013Objetivo Investigar la relacioacuten entre la adhesioacuten a la Organizacioacuten Mundial del Comercio (OMC) y la disponibilidad de varios productos baacutesicos con efectos tanto perjudiciales como protectores para el desarrollo de enfermedades no contagiosasMeacutetodos Se utilizoacute un disentildeo de experimento natural para comparar las tendencias de la oferta interna de tabaco alcohol y siete grupos de alimentos entre 1980 y 2013 en 21 paiacuteses o territorios que se incorporaron a la OMC despueacutes de 1995 y 26 paiacuteses no miembros mediante el uso de ponderaciones de propensioacuten Se aplicoacute un marco comparativo de series temporales interrumpidas siguiendo modelos lineales de efectos aleatorios multivariados ajustados seguacuten el producto interior bruto per caacutepita los porcentajes de poblacioacuten urbana y la participacioacuten de la mujer en el mundo laboral En el modelo del
tabaco controlamos a los Estados miembros que habiacutean ratificado el Convenio Marco para el Control del Tabaco y en el modelo del alcohol el porcentaje de la poblacioacuten que se identificaba como musulmanaResultados Tras la adhesioacuten a la OMC los Estados miembros experimentaron un aumento inmediato de la oferta interna de frutas y hortalizas de 55 kg por persona y diacutea de media en comparacioacuten con los paiacuteses no miembros El anaacutelisis mostroacute incrementos graduales en la media geomeacutetrica de la oferta de tabaco y alcohol del 62 y el 36 anual respectivamente No se detectaron cambios significativos en la disponibilidad de carnes rojas y grasas animales mariscos nueces semillas y legumbres almidones o aceites comestibles y los resultados para los azuacutecares fueron inconsistentes entre las variaciones del modelo
95Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
Conclusioacuten Los resultados sugieren que la pertenencia a la OMC puede dar lugar a un aumento de los factores perjudiciales y protectores de
las enfermedades no contagiosas pero es necesario seguir estudiando las variaciones especiacuteficas de cada paiacutes
References1 Murray CJ Vos T Lozano R Naghavi M Flaxman AD Michaud C et al
Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions 1990ndash2010 a systematic analysis for the Global Burden of Disease Study 2010 Lancet 2012 Dec 15380(9859)2197ndash223 doi httpdxdoiorg101016S0140-6736(12)61689-4 PMID 23245608
2 Lim SS Vos T Flaxman AD Danaei G Shibuya K Adair-Rohani H et al A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions 1990ndash2010 a systematic analysis for the Global Burden of Disease Study 2010 Lancet 2012 Dec 15380(9859)2224ndash60 doi httpdxdoiorg101016S0140-6736(12)61766-8 PMID 23245609
3 Baker P Friel S Food systems transformations ultra-processed food markets and the nutrition transition in Asia Global Health 2016 12 312(1)80 doi httpdxdoiorg101186s12992-016-0223-3 PMID 27912772
4 Labonteacute R Mohindra KS Lencucha R Framing international trade and chronic disease Global Health 2011 07 47(1)21 doi httpdxdoiorg1011861744-8603-7-21 PMID 21726434
5 Stuckler D McKee M Ebrahim S Basu S Manufacturing epidemics the role of global producers in increased consumption of unhealthy commodities including processed foods alcohol and tobacco PLoS Med 20129(6)e1001235 doi httpdxdoiorg101371journalpmed1001235 PMID 22745605
6 De Vogli R Kouvonen A Gimeno D The influence of market deregulation on fast food consumption and body mass index a cross-national time series analysis Bull World Health Organ 2014 Feb 192(2)99ndash107 107A doi httpdxdoiorg102471BLT13120287 PMID 24623903
7 Chaloupka FJ Laixuthai A Trade policy and cigarette smoking in Asia [NBER working paper series] Cambridge National Bureau of Economic Research 1996 Available from httpwwwnberorgpapersw5543 [cited 2017 Sep 4]
8 Cassels S Overweight in the Pacific links between foreign dependence global food trade and obesity in the Federated States of Micronesia Global Health 2006 07 112(1)10 doi httpdxdoiorg1011861744-8603-2-10 PMID 16834782
9 Schultz JT Globalisation urbanization and nutrition transition in a developing island country a case study Fiji Globalization of food systems in developing countries impact on food security and nutrition Rome Food and Agriculture Organization 2004
10 Thow AM Hawkes C The implications of trade liberalization for diet and health a case study from Central America Global Health 2009 07 2855 doi httpdxdoiorg1011861744-8603-5-5 PMID 19638196
11 Barlow P McKee M Basu S Stuckler D The health impact of trade and investment agreements a quantitative systematic review and network co-citation analysis Global Health 2017 03 813(1)13 doi httpdxdoiorg101186s12992-017-0240-x PMID 28274238
12 Taylor A Chaloupka FJ Guindon E Corbett M The impact of trade liberalization on tobacco consumption In Jha P Chaloupka FJ editors Tobacco control in developing countries Oxford Oxford University Press 2000 pp 343ndash64
13 Schram A Labonte R Baker P Friel S Reeves A Stuckler D The role of trade and investment liberalization in the sugar-sweetened carbonated beverages market a natural experiment contrasting Vietnam and the Philippines Global Health 2015 10 1211(1)41 doi httpdxdoiorg101186s12992-015-0127-7 PMID 26455446
14 Baker P Friel S Schram A Labonte R Trade and investment liberalization food systems change and highly processed food consumption a natural experiment contrasting the soft-drink markets of Peru and Bolivia Global Health 2016 06 212(1)24 doi httpdxdoiorg101186s12992-016-0161-0 PMID 27255275
15 Understanding the WTO the organization Members and observers [internet] Geneva World Trade Organization 2017 Available from httpswwwwtoorgenglishthewto_ewhatis_etif_eorg6_ehtm [cited 2017 Mar 28]
16 Guenther PM Casavale KO Reedy J Kirkpatrick SI Hiza HA Kuczynski KJ et al Update of the healthy eating index HEI-2010 J Acad Nutr Diet 2013 Apr113(4)569ndash80 doi httpdxdoiorg101016jjand201212016 PMID 23415502
17 Haines PS Siega-Riz AM Popkin BM The Diet Quality Index revised a measurement instrument for populations J Am Diet Assoc 1999 Jun99(6)697ndash704 doi httpdxdoiorg101016S0002-8223(99)00168-6 PMID 10361532
18 Huijbregts P Feskens E Raumlsaumlnen L Fidanza F Nissinen A Menotti A et al Dietary pattern and 20 year mortality in elderly men in Finland Italy and The Netherlands longitudinal cohort study BMJ 1997 Jul 5315(7099)13ndash7 doi httpdxdoiorg101136bmj315709913 PMID 9233319
19 Panagiotakos DB Pitsavos C Stefanadis C Dietary patterns a Mediterranean diet score and its relation to clinical and biological markers of cardiovascular disease risk Nutr Metab Cardiovasc Dis 2006 Dec16(8)559ndash68 doi httpdxdoiorg101016jnumecd200508006 PMID 17126772
20 Guidelines for measuring household and individual dietary diversity [internet] Rome Food and Agriculture Organization 2012 Available from httpwwwfaoorgdocrep014i1983ei1983e00htm [cited 2017 Jan 14]
21 Indicators for nutrition-friendly and sustainable food systems InGlobal nutrition report 2015 actions and accountability to advance nutrition and sustainable development Washington DC International Food Policy Research Institute 2015 pp 85ndash96 Available from httpglobalnutritionreportorgthe-reportthe-report-2015 [cited 2017 Apr 4]
22 Micha R Khatibzadeh S Shi P Andrews KG Engell RE Mozaffarian D Global Burden of Diseases Nutrition and Chronic Diseases Expert Group (NutriCoDE) Global regional and national consumption of major food groups in 1990 and 2010 a systematic analysis including 266 country-specific nutrition surveys worldwide BMJ Open 2015 09 245(9)e008705 doi httpdxdoiorg101136bmjopen-2015-008705 PMID 26408285
23 Mozaffarian D Hao T Rimm EB Willett WC Hu FB Changes in diet and lifestyle and long-term weight gain in women and men N Engl J Med 2011 Jun 23364(25)2392ndash404 doi httpdxdoiorg101056NEJMoa1014296 PMID 21696306
24 Mozaffarian D Appel LJ Van Horn L Components of a cardioprotective diet new insights Circulation 2011 Jun 21123(24)2870ndash91 doi httpdxdoiorg101161CIRCULATIONAHA110968735 PMID 21690503
25 WTO membership and noncommunicable disease risk factors - Supplemental materials Baltimore Johns Hopkins University 2018 Available from doi httpdxdoiorg106084m9figshare7268561v1 [cited 2018 Oct 30]doi httpdxdoiorg106084m9figshare7268561v1
26 Maumlnnistouml S Laatikainen T Helakorpi S Valsta LM Monitoring diet and diet-related chronic disease risk factors in Finland Public Health Nutr 2010 Jun13 6A907ndash14 doi httpdxdoiorg101017S1368980010001084 PMID 20513259
27 Sheehy T Sharma S Trends in energy and nutrient supply in Trinidad and Tobago from 1961 to 2007 using FAO food balance sheets Public Health Nutr 2013 Sep16(9)1693ndash702 doi httpdxdoiorg101017S136898001200537X PMID 23286774
28 World development indicators [internet] Washington DC The World Bank 2016 Available from httpdataworldbankorgdata-catalogworld-development-indicators [cited 2017 Feb 20]
29 World population prospects the 2015 Revision [internet] New York United Nations Department of Economic and Social Affairs Population Division 2015 Available from httpsesaunorgunpdwpp [cited 2017 Jan 6]
30 Gross domestic product (GDP) estimates by country 1950ndash2015 [internet] Seattle Institute for Health Metrics and Evaluation 2017 Available from httpghdxhealthdataorgrecordgross-domestic-product-gdp-estimates-country-1950-2015 [cited 2017 Jan 6]
31 Table Muslim Population by Country [internet] Washington DC Pew Research Center 2011 Available from httpwwwpewforumorg20110127table-muslim-population-by-country [cited 2017 Apr 12]
32 Depositary WHO Framework Convention on Tobacco Control [internet] New York United Nations Treaty Collection 2025 Available from httpstreatiesunorgpagesViewDetailsaspxsrc=TREATYampmtdsg_no=IX-4ampchapter=9amplang=en [cited 2017 Apr 18]
33 Ng M Freeman MK Fleming TD Robinson M Dwyer-Lindgren L Thomson B et al Smoking prevalence and cigarette consumption in 187 countries 1980ndash2012 JAMA 2014 Jan 8311(2)183ndash92 doi httpdxdoiorg101001jama2013284692 PMID 24399557
96 Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
34 Rehm J Mathers C Popova S Thavorncharoensap M Teerawattananon Y Patra J Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders Lancet 2009 Jun 27373(9682)2223ndash33 doi httpdxdoiorg101016S0140-6736(09)60746-7 PMID 19560604
35 Al-Ansari B Thow A-M Day CA Conigrave KM Extent of alcohol prohibition in civil policy in Muslim majority countries the impact of globalization Addiction 2016 10111(10)1703ndash13 doi httpdxdoiorg101111add13159 PMID 26508526
36 About the WHO Framework Convention on Tobacco Control [internet] Geneva World Health Organization 2018 Available from httpwwwwhointfctcabouten [cited 2017 May 11]
37 Stuart EA Matching methods for causal inference a review and a look forward Stat Sci 2010 Feb 125(1)1ndash21 doi httpdxdoiorg10121409-STS313 PMID 20871802
38 Ridgeway G McCaffrey D Morral A Burgette L Griffin BA Toolkit for weighting and analysis of nonequivalent groups a tutorial for the twang package R Vignette [internet] Vienna R Foundation 2017 Available from httpscranr-projectorgwebpackagestwangvignettestwangpdf [cited 2017 Apr 18]
39 McCaffrey DF Ridgeway G Morral AR Propensity score estimation with boosted regression for evaluating causal effects in observational studies Psychol Methods 2004 Dec9(4)403ndash25 doi httpdxdoiorg1010371082-989X94403 PMID 15598095
40 Linden A Adams JL Applying a propensity score-based weighting model to interrupted time series data improving causal inference in programme evaluation J Eval Clin Pract 2011 Dec17(6)1231ndash8 doi httpdxdoiorg101111j1365-2753201001504x PMID 20973870
41 Griswold MG Fullman N Hawley C Arian N Zimsen SRM Tymeson HD et al GBD 2016 Alcohol Collaborators Alcohol use and burden for 195 countries and territories 1990ndash2016 a systematic analysis for the Global Burden of Disease Study 2016 Lancet 2018 Sep 22392(10152)1015ndash35 doi httpdxdoiorg101016S0140-6736(18)31310-2 PMID 30146330
42 Peto R Lopez AD Boreham J Thun M Heath C Jr Mortality from tobacco in developed countries indirect estimation from national vital statistics Lancet 1992 May 23339(8804)1268ndash78 doi httpdxdoiorg1010160140-6736(92)91600-D PMID 1349675
43 Healthy diet Key facts Geneva World Health Organization 2018 Available from httpwwwwhointnews-roomfact-sheetsdetailhealthy-diet [cited 2018 Oct 26]
44 Aune D Giovannucci E Boffetta P Fadnes LT Keum N Norat T et al Fruit and vegetable intake and the risk of cardiovascular disease total cancer and all-cause mortality-a systematic review and dose-response meta-analysis of prospective studies Int J Epidemiol 2017 06 146(3)1029ndash56 doi httpdxdoiorg101093ijedyw319 PMID 28338764
45 Health in All Policies framework for country action [internet] Geneva World Health Organization 2018 Available from httpwwwwhointhealthpromotionframeworkforcountryactionen [cited 2017 Aug 13]
46 Cole BL Fielding JE Health impact assessment a tool to help policy makers understand health beyond health care Annu Rev Public Health 200728(1)393ndash412 doi httpdxdoiorg101146annurevpublhealth28083006131942 PMID 17173539
47 Tonts M Siddique MAB editors Globalisation agriculture and development perspectives from the Asia-Pacific Cheltenham Edward Elgar Publishing 2011 Available from httpswwwelgaronlinecomview978184720818700010xml [cited 2017 Aug 14]
48 Mendez Lopez A Loopstra R McKee M Stuckler D Is trade liberalisation a vector for the spread of sugar-sweetened beverages A cross-national longitudinal analysis of 44 low- and middle-income countries Soc Sci Med 2017 0117221ndash7 doi httpdxdoiorg101016jsocscimed201611001 PMID 27871042
49 Monteiro CA Moubarac J-C Cannon G Ng SW Popkin B Ultra-processed products are becoming dominant in the global food system Obes Rev 2013 Nov14 Suppl 221ndash8 doi httpdxdoiorg101111obr12107 PMID 24102801
Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057 96A
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
Fig 1 Unweighted and weighted absolute standardized biases for baseline commodity supply in countries included in the study 1980ndash1995
female labour force
participation
female labour force
participation
female labour force
participation
female labour force
participation
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participation
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participation
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participation
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participation
Muslim population
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participation urban
population
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urban population
urban population
urbanpopulation
urban population
Tobacco
Starches
Nuts seedsand legumes
Seafood
Edible oils
Sugars
Red meatsand animal
fats
Alcohol Fruits andvegetables
GDP percapita (log)
GDP percapita (log)
GDP percapita (log)
GDP percapita (log)
GDP percapita (log)
GDP percapita (log)
GDP percapita (log)
GDP percapita (log)
GDP percapita (log)
1980198519901995
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Absolute standardize bias
Absolute standardize bias
Absolute standardize bias
Unweighted Weighted
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08 0 02 04 06 08
Supply of tobacco
Supply of starches
Supply of nuts seeds and legumes
Supply of seafood
Supply of edible oils
Supply of sugars
Supply of red meats and animal fats
Supply of alcohol
Supply of fruits and vegetables
GDP gross domestic productNotes The period 1980ndash1995 represents the years before countries and territories start joining the World Trade Organization Table 1 lists countries studied We measured bias by the absolute standardized mean difference that is (mean for non-member states ndash mean for member states)(combined standard deviation)
- Table 1
- Table 2
- Table 3
- Figure 2
- Figure 3
- Figure 4
- Figure 5
- Figure 6
- Figure 1
-
87Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
Table 2 Baseline characteristics of countries included in study on WTO membership and changes in noncommunicable disease risk factors
Covariates WTO membersa (n = 21) WTO non-members (n = 26) Standardized difference in means (P)bc
No of countries per area NA (055)East Asia and Pacific 4 8Europe and central Asia 10 7Latin America and Caribbean 2 1Middle East and north Africa 3 5North America 0 0South Asia 1 1Sub-Saharan Africa 1 4No of former Soviet Union member states
8 7 NA (041)
Mean GDP per capita in 2005 Int$ (SD)Year 1980 5565 (8 314) 6907 (9 697) 015 (069)Year 1995 4805 (4 845) 6357 (11 005) 018 (055)Mean of female labour force participation (SD)Year 1980 441 (251) 421 (260) minus008 (082)Year 1995 519 (183) 465 (224) minus026 (037)Mean of urban population (SD)Year 1980 382 (206) 372 (219) minus005 (090)Year 1995 531 (201) 458 (209) minus035 (023)Mean of Muslim population (SD)d
Year 1980 300 (404) 360 (434) 014 (070)Year 1995 224 (362) 418 (428) 048 (011)Mean weight of commodity per capitae
Tobacco gram (SD)f
Year 1980 1890 (1 532) 2182 (1997) 016 (067) Year 1995 1358 (1 045) 1913 (2 716) 026 (038)Alcohol kilogram (SD)f
Year 1980 252 (369) 298 (330) 014 (072) Year 1995 292 (262) 263 (275) minus011 (071)Fruits and vegetables kilogram (SD) Year 1980 1089 (747) 1658 (930) 064 (009) Year 1995 1371 (611) 1590 (1132) 023 (043)Nuts seeds and legumes kilogram (SD) Year 1980 60 (35) 79 (62) 036 (034) Year 1995 44 (26) 64 (67) 038 (019)Seafood kilogram (SD) Year 1980 77 (68) 170 (178) 062 (009) Year 1995 95 (89) 139 (186) 030 (032)Red meats and animal fats kilogram (SD) Year 1980 280 (322) 272 (182) minus003 (093) Year 1995 373 (238) 287 (209) minus038 (020)Starches kilogram (SD) Year 1980 1931 (372) 2230 (521) 062 (010) Year 1995 2155 (554) 2078 (533) minus014 (063)Sugars kilogram (SD) Year 1980 244 (148) 239 (141) minus004 (093) Year 1995 232 (89) 215 (131) minus015 (061)Edible oils kilogram (SD) Year 1980 61 (45) 68 (44) 015 (070) Year 1995 73 (48) 83 (55) 019 (052)
GDP gross domestic product Int$ international dollars NA not applicable SD standard deviation WTO World Trade Organizationa Countries joining WTO between 1996 and 2008b We calculated standardized difference in means as follows (mean for non-member states ndash mean for member states)(combined standard deviation)c For continuous variables we used two-sided t-tests to calculate P-values For or categorical variables we used χ2 testsd Covariate used in alcohol models onlye Commodity available for domestic consumptionf Data for population older than 14 years
Note The years presented are the first (1980) and last (1995) years we used for analyses of the period before countries and territories included in the study started to join WTO
88 Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
or after the analysis period data for these countries were censored to exclude values in or after the year they joined For countries that comprised the former Soviet Union (eight exposed seven un-exposed) the analysis period begins in 1992 when independent countries were established
Data sources
The data sources for all commodities were the Food and Agriculture Orga-nization national commodity balance sheets (tobacco) and food balance sheets (all other commodities) which measure the annual supply of each commodity by country and are widely used as a proxy for consumption2627 We obtained covariate data on urban population and female labour force participation from the World Bankrsquos World Development Indicators28 population data from the United Nations Population Division29 gross domestic product (GDP) per capita from the Institute for Health Metrics and Evaluation30 percent-age Muslim population from the Pew Research Center31 and the ratification dates for the Framework Convention on Tobacco Control (FCTC) from the United Nations Treaty Collection32
Variables
We measured all commodity variables in units of grams (tobacco) or kilograms (all other commodities) per capita For tobacco and alcohol we restricted these measures to the population older than 14 years as is standard3334 We con-trolled for the following key confound-ers established by the existing literature in all models GDP per capita urban population and female labour force par-ticipation45 Models for alcohol included each countryrsquos proportion of population identifying themselves as Muslim as a covariate because being Muslim is linked to lower rates of alcohol use35 Models for tobacco included a variable indicating whether the country had ratified the FCTC because this ratifica-tion represents a commitment to reduce tobacco use36
Propensity score weights
With observational data the non-random assignment of the exposure (in this case WTO membership) can create imbalance in covariates and baseline levels of the outcome variables between the groups compared37 Characteristics of the groups in the pre-exposure period Ta
ble
3
Mod
el o
utpu
t fro
m b
est-
perf
orm
ing
mod
el to
stud
y WTO
mem
bers
hip
and
chan
ges i
n no
ncom
mun
icabl
e di
seas
e ris
k fa
ctor
s 19
80ndash2
013
Varia
ble
Toba
ccoa
Alco
hola
Frui
ts a
nd
vege
tabl
esNu
ts s
eeds
an
d le
gum
esa
Seaf
ooda
Red
mea
ts a
nd a
nim
al
fats
a
Star
ches
Suga
rsEd
ible
oils
a
Fixe
d eff
ect
coeffi
cien
t (P)
WTO
mem
bers
hip
009
8 (0
477
)minus
011
8 (0
133
)19
794
(00
03)
010
7 (0
171
)minus
013
7 (0
436
)0
008
(08
65)
minus6
277
(01
33)
minus2
401
(01
15)
minus0
070(
029
6)
WTO
m
embe
rshi
pye
ar0
061
(00
54)
003
7 (0
050
)minus
127
6 (0
367
)minus
001
7 (0
151
)0
032
(03
67)
000
1 (0
875
)minus
012
0 (0
904
)0
250
(01
76)
000
5 (0
730
)
GDP
per c
apita
ab
044
9 (0
004
)0
496
(lt 0
001
)7
571
(02
18)
031
3 (0
060
)0
826
(lt 0
001
)0
184
(00
20)
530
8 (0
464
)6
133
(00
03)
015
0 (0
243
)
u
rban
pop
ulat
ion
minus0
017
(00
24)
001
4 (0
160
)1
993
(00
04)
minus0
005
(04
91)
000
6 (0
637
)0
004
(05
33)
061
6 (0
189
)0
019
(08
79)
001
1 (0
052
)
fe
mal
e la
bour
fo
rce
part
icip
atio
nminus
001
0 (0
099
)minus
000
9 (0
202
)minus
102
9 (0
069
)minus
000
1 (0
804
)minus
003
6(0
016)
000
3 (0
553
)0
298
(03
71)
minus0
133
(00
88)
minus0
012
(01
02)
FCTC
ratifi
catio
ncminus
020
4 (0
032
)N
AN
AN
AN
AN
AN
AN
AN
A
M
uslim
pop
ulat
iond
NA
minus0
025
(lt 0
001
)N
AN
AN
AN
AN
AN
AN
A
Year
3eminus
972
times 1
0minus6 (0
251
)N
AN
AN
Aminus
146
times 1
0minus6 (0
875
)N
AN
AN
AN
A
Cons
tant
475
9 (lt
00
01)
minus1
088
(03
37)
726
8 (0
883
)minus
141
3 (0
265
)minus
384
5 (0
022
)1
437
(00
49)
142
441
(00
20)
minus18
940
(01
63)
006
6 (0
950
)
Rand
om e
ffec
ts v
aria
nce
(SE)
Inte
rcep
t0
944
(01
99)
166
0 (0
530
)69
170
32 (1
656
286
)3
070
(15
85)
295
0 (0
747
)0
396
(00
73)
5228
010
(1 1
232
00)
879
17 (1
929
0)8
46 times
10minus
4 (19
3 times
10minus
4 )
Slop
e7
83 times
10minus
10 (2
8 times
10minus
10)
000
3 (0
001
2)20
161
(53
45)
000
2(0
0013
)4
38 times
10minus
10 (9
97
times 1
0minus11
)2
55 times
10minus
4 (56
1 times
10minus
5 )3
667
(08
28)
018
5 (0
036
7)0
953
(01
86)
Inte
rcep
t and
slop
efminus
13
times 1
0minus5 (4
95
times 1
0minus6 )
minus0
030
(00
13)
minus25
595
9 (8
775
6)minus
007
13 (0
044
9)minus
113
times 1
0minus5 (6
86
times 1
0minus6 )
minus0
0058
(00
015)
minus93
382
(21
924)
minus2
055
(06
32)
minus0
0251
(00
061)
Resid
ual
021
5 (0
046
)0
071
(00
14)
437
215
(95
743)
007
6(0
0158
)0
162
(00
454)
001
8 (0
002
7)18
415
3 (2
820
7)12
292
(23
10)
005
2 (0
010
7)
FCTC
Fra
mew
ork
Conv
entio
n on
Toba
cco
Cont
rol G
DP
gro
ss d
omes
tic p
rodu
ct N
A n
ot a
pplic
able
SD
sta
ndar
d de
viat
ion
SE
stan
dard
erro
r W
TO W
orld
Trad
e O
rgan
izatio
na N
atur
al lo
garit
hm o
f com
mod
ity v
alue
s use
d in
mod
el
b In
2005
Inte
rnat
iona
l dol
lars
c O
nly
incl
uded
in to
bacc
o m
odel
d O
nly
incl
uded
in a
lcoh
ol m
odel
e C
oeffi
cien
t val
ues f
or in
divi
dual
yea
r fixe
d eff
ects
not
show
n (w
hen
appl
icab
le)
com
plet
e m
odel
out
put a
vaila
ble
from
the
figsh
are
repo
sitor
y25
f Dat
a pr
esen
ted
are
cova
rianc
es a
nd S
Es
89Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
are presented in Table 2 Although no differences were statistically significant to improve comparability we estimated and applied propensity score weights that optimized comparability on pre-exposure values of each commodity
In the first step we estimated pro-pensity scores to predict the probability of WTO membership as a function of annual values of each commodity in the pre-exposure period using a gen-eralized boosted regression modelling approach3839 In the second step we used propensity scores to construct weights for each country with all exposed coun-tries or territories receiving a weight of 1 and unexposed countries receiving a weight of p(1minusp) where p is the esti-mated propensity score This weighting estimates the average treatment effect on the exposed group ie the average effect of joining WTO for those countries or territories that did join
Fig 1 (available at httpwwwwhointbulletinvolumes97118-218057) displays the balance between the groups for annual values of the com-modities and covariates during the pre-exposure period before and after applying weights The balance metric is the absolute value of the difference in group means divided by the standard deviation across both groups 025 is a generally accepted balance threshold37 Improvements are reflected by the weighted values generally being closer to zero than unweighted values though in several cases improving balance on commodities sacrificed balance on co-variates However we further controlled for the influence of covariates in the regression models
Commodity models
We modelled changes in domestic sup-plies of the commodities using separate linear regression models for each of the nine commodities in a comparative interrupted time-series framework We used WTO membership as the treat-ment (t) term and used a treatmentyear interaction (ty) term to compare the pre- and post-exposure level and trend in the commodities (c) respectively in the exposed versus unexposed groups40 For unexposed countries the WTO membership variable was always 0 For exposed countries this variable ranged from 0 (before accession) to 1 (after ac-cession) for the year of each countryrsquos accession to WTO we used a fraction
reflecting the number of days of mem-bership Each commodity model had the following equation
(1)
where i indexes country j indexes year (1980 to 2013) x is a set of countries- and year-specific covariates βrsquos repre-sent coefficients estimated by the linear model and ε is the residual error term Covariates for urban population female labour force participation and percent-age Muslim population (alcohol model only) were continuous ranging from 0 to 100 The FCTC covariate (tobacco model only) ranged from 0 (not ratified) to 1 (ratified) with a fraction reflecting the number of days after ratification in the year during which each country was ratified All models were run with commodity-specific propensity score weights applied as inverse-probability-of-treatment weights
We tested multiple model varia-tions for each commodity For six com-modities (tobacco alcohol red meats and animal fats seafood nuts seeds and legumes and edible oils) we log-transformed the commodity values to constrain predicted values to be greater than 0 The key output of the best-performing model for each commodity is presented in Table 3 additional output and model fit graphs are available in the figshare repository25
Sensitivity analyses
We did several sensitivity analyses to assess whether various aspects of the study design affected the estimated ef-fects of WTO membership First to eliminate the influence of missing data we restricted the analysis period to 1993 to 2011 years with complete data for all 47 countries Second because the effects of WTO accession may take time we ex-plored lagged values of the WTO mem-bership and WTO membershipyear terms Third to examine whether the effects of WTO membership were pre-dominantly mediated through economic growth we excluded GDP per capita from all models Fourth we excluded several countries in the unexposed group that may be poor comparisons due to war famine or isolation from the global economy Afghanistan
Democratic Peoples Republic of Ko-rea Ethiopia Iraq and Sudan Lastly we stratified models by income group All analyses were conducted in Stata version 142 (StataCorp LCC College Station United States) except for the twang package for propensity scores run in R version 332 (R Foundation Vienna Austria)
ResultsFig 2 Fig 3 Fig 4 Fig 5 and Fig 6 show average trends for each commod-ity for the exposed unweighted unex-posed and weighted unexposed groups Trends during the pre-exposure period illustrate the improved comparability between the groups after weighting Outputs from the best-performing mod-els to estimate changes in supply of the commodities are shown in Table 3 The coefficients for the WTO membership and WTO membershipyear terms in-dicate whether there is any difference in the level and trend respectively of each commodity for countries and territories joining the WTO compared with non-WTO members The domestic avail-ability of fruits and vegetables increased the most the average annual supply of fruits and vegetables was 1979 kg per capita (95 confidence interval CI 660ndash3299) higher in countries or territories that have joined WTO than in non-member countries For tobacco and alcohol the WTO membershipyear coefficients suggest significant increas-ing trends in the availability of these products following WTO accession The geometric means of the supply of tobacco increased by 62 (95 CI 00ndash130) annually and of the supply of alcohol by 38 (95 CI 00ndash77) annually In the tobacco model the FCTC ratification coefficient indicates an 185 (95 CI 18ndash324) lower geometric mean supply of tobacco after ratification In the random effect model the intercept and slope are significantly different from zero for all commodi-ties indicating substantial remaining heterogeneity across countries in both the level and trend in domestic supply quantities (Table 3)
The sensitivity analyses generally supported the main findings The treat-ment effect on fruits and vegetables was robust in all sensitivity analyses The trend coefficient for the alcohol supply stayed of a consistent magnitude and
90 Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
remained significant in most analyses The trend coefficient for the tobacco supply also remained of a consistent magnitude but not always statisti-cally significant In only the lagged effect models treatment effects for sugars were significant and similar in magnitude to those in the main model providing some evidence of an initial decrease in the availability of sugars following WTO accession followed by a minimal steady increase When we stratified the analyses by country income group the results did not support any of the main conclusions However propensity score weights were generated to balance the sample and likely generated false results from these models which were run with 23 countries or less (out of the total 47) per income group Further details on each sensitivity analysis are available in the figshare repository25
DiscussionHere we show that following a countryrsquos accession to WTO there was a signifi-cant increasing trend in the domestic supply of alcohol a borderline signifi-cant increasing trend in the supply of tobacco and a significant immediate increase in the availability of fruits and vegetables compared with non-member countries Assuming that increases in supply likely translate to increases in consumption these changes have both positive and negative implications for global health For example recent re-search has indicated that any amount of alcohol consumption increases the risk of a range of negative health outcomes hence an increase in alcohol supply could be harmful41 Likewise an increase in tobacco use is negative as tobacco contributes to several noncommuni-cable diseases42 In contrast increases in fruit and vegetable consumption can protect against the development of numerous noncommunicable diseases24 The WHO recommends a 400 g intake of fruit and vegetables daily43 although even an intake of 200 g per day has been found to reduce the risk of many non-communicable diseases and premature mortality44 We estimate that average increase in the supply is about 55 g of fruits and vegetables per person per day higher in the countries after join-ing WTO
Our results provide more evidence about the links between trade liberaliza-tion and global health suggesting that
trade agreements should be considered as social determinants of health at the global scale As the burden of noncom-municable diseases continues to grow stakeholders should prioritize identify-ing the most effective strategies to curb the increase in risk factors including to-bacco and alcohol use and poor diet For example addressing aspects of trade and investment policies that alter the supply
of these products can help to tackle the noncommunicable disease burden at the root cause level This approach can be achieved through actions grounded in the Health in All Policies framework45 and the application of health impact assessment to proposed trade and in-vestment policies46 At the global level further development and consideration of international agreements to prevent
Fig 2 Changes in the supply of all forms of tobacco by joining WTO members and non-member states 1980ndash2013
All f
orm
s of t
obac
co(g
ram
sca
pita
old
er th
an 1
4 ye
ars)
2500
2000
1500
1000
500
0
Year1980 1990 2000 2010 2013
Range of WTO accession dates
Mean for joining WTO members Unweighted mean for WTO non-membersWeighted mean for WTO non-members
WTO World Trade OrganizationNotes The grey box represents the range of accession dates for countries and territories joining WTO Aberrations in trends starting in 1992 likely reflect the changing composition of countries in each exposure group due to data availability for former Soviet Union countries We obtained weighted means by applying tobacco-specific propensity score weights
Fig 3 Changes in the supply of all types of alcohol by joining WTO members and non-member states 1980ndash2013
All t
ypes
of a
lcoho
l(k
ilogr
ams
capi
ta o
lder
than
14
year
s)
60
40
20
0
Year1980 1990 2000 2010 2013
Range of WTO accession dates
Mean for joining WTO members Unweighted mean for WTO non-membersWeighted mean for WTO non-members
WTO World Trade OrganizationNotes The grey box represents the range of accession dates for countries and territories joining WTO Aberrations in trends starting in 1992 likely reflect the changing composition of countries in each exposure group due to data availability for former Soviet Union countries We obtained weighted means by applying alcohol-specific propensity score weights
91Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
Fig
4
Chan
ges i
n th
e su
pply
of f
ruits
and
vege
tabl
es a
nd st
arch
es f
or jo
inin
g W
TO
mem
bers
and
non
-mem
ber s
tate
s 19
80ndash2
013
Year
Year
1980
1990
2000
2010
2013
1980
1990
2000
2010
2013
Rang
e of W
TO ac
cessi
on da
tes
Rang
e of W
TO ac
cessi
on da
tes
Mea
n fo
r joi
ning
WTO
mem
bers
Unw
eigh
ted
mea
n fo
r WTO
non
-mem
bers
Wei
ghte
d m
ean
for W
TO n
on-m
embe
rs
Kilogramscapita Kilogramscapita250
200
150
100 50 0
250
200
150
100 50 0
Star
ches
Frui
ts an
d ve
geta
bles
WTO
Wor
ld Tr
ade
Org
aniz
atio
nN
otes
The
gre
y bo
x re
pres
ents
the
rang
e of
acc
essio
n da
tes f
or c
ount
ries a
nd te
rrito
ries j
oini
ng W
TO
Aber
ratio
ns in
tren
ds st
artin
g in
199
2 lik
ely
refle
ct th
e ch
angi
ng c
ompo
sitio
n of
cou
ntrie
s in
each
ex
posu
re g
roup
due
to d
ata
avai
labi
lity
for f
orm
er S
ovie
t Uni
on c
ount
ries
We
obta
ined
wei
ghte
d m
eans
by
app
lyin
g co
mm
odity
-spe
cific
pro
pens
ity sc
ore
wei
ghts
Fig
5
Chan
ges i
n th
e su
pply
of r
ed m
eats
and
ani
mal
fats
and
suga
rs b
y joi
ning
WTO
m
embe
rs a
nd n
on-m
embe
r sta
tes
1980
ndash201
3
Year
Year
1980
1990
2000
2010
2013
1980
1990
2000
2010
2013
Rang
e of W
TO ac
cessi
on da
tes
Rang
e of W
TO ac
cessi
on da
tes
Mea
n fo
r joi
ning
WTO
mem
bers
Unw
eigh
ted
mea
n fo
r WTO
non
-mem
bers
Wei
ghte
d m
ean
for W
TO n
on-m
embe
rs
Kilogramscapita Kilogramscapita
50 40 30 20 10 0 50 40 30 20 10 0
Red
mea
ts an
d an
imal
fats
Suga
rs
WTO
Wor
ld Tr
ade
Org
aniz
atio
nN
otes
The
gre
y bo
x re
pres
ents
the
rang
e of
acc
essio
n da
tes f
or c
ount
ries a
nd te
rrito
ries j
oini
ng W
TO
Aber
ratio
ns in
tren
ds st
artin
g in
199
2 lik
ely
refle
ct th
e ch
angi
ng c
ompo
sitio
n of
cou
ntrie
s in
each
ex
posu
re g
roup
due
to d
ata
avai
labi
lity
for f
orm
er S
ovie
t Uni
on c
ount
ries
We
obta
ined
wei
ghte
d m
eans
by
app
lyin
g co
mm
odity
-spe
cific
pro
pens
ity sc
ore
wei
ghts
92 Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
and control noncommunicable diseases like the FCTC but focused on other noncommunicable disease risk factors is warranted Such agreements can legally bind countries to health com-mitments providing a counterweight for commitments to international trade and investment rules
Our findings are suggestive but not conclusive warranting additional exploration and we suggest several po-tential avenues for future research For example given substantial unexplained country-specific heterogeneity indicated by country random effects in all models additional analyses of smaller groups of countries and individual countries are needed The effects of WTO member-ship may differ by level of economic development and other country-specific factors such as geography and climate which affect the baseline supply of various food groups tobacco and types of alcohol Researchers could recreate this analysis with one income group at a time and a similar analysis of selected low- and middle-income countries with substantial noncommunicable disease burdens may provide further insight into the links between WTO member-ship and changes in noncommunicable disease risk factors Single country studies could permit more nuanced understanding for example by looking at tariff changes for specific products and subsequent changes in their sup-ply Another area for future studies is to examine differences associated with specific provisions in WTO accession agreements and other trade and invest-ment policies as specific concessions differ Understanding which compo-nents of these treaties have the greatest influence on noncommunicable disease risk factors and other aspects of public health is important when tailoring future agreements to be more health-promoting Further researchers should also conduct similar analyses for other products that contribute to noncommu-nicable diseases particularly unhealthy foods high in fat salt and sugar
This study both supports and contradicts findings from previous research We were not able to confirm findings showing increases in consump-tion of meat10 and edible oils47 following trade liberalization Discrepancies may be due to differences in the sample previous studies examined only one to five countries in the same geographical region Studies showing trade-related
increases in sugar-sweetened beverage consumption1348 are somewhat sup-ported by our weak finding that the domestic supply of sugars increases steadily over time following WTO ac-
cession Our results confirm previous findings of increased tobacco712 and alcohol5 consumption associated with trade liberalization Finally few studies have examined fruits and vegetables
Fig 6 Changes in the supply of nuts seeds and legumes seafood and edible oils by joining WTO members and non-member states 1980ndash2013
Year
Year
Year
1980 1990 2000 2010 2013
1980 1990 2000 2010 2013
1980 1990 2000 2010 2013
Range of WTO accession dates
Range of WTO accession dates
Range of WTO accession dates
Mean for joining WTO members Unweighted mean for WTO non-membersWeighted mean for WTO non-members
Kilo
gram
sca
pita
Kilo
gram
sca
pita
Kilo
gram
sca
pita
20
15
10
5
0
20
15
10
5
0
20
15
10
5
0
Nuts seeds and legumes
Seafood
Edible oils
WTO World Trade OrganizationNotes The grey box represents the range of accession dates for countries and territories joining WTO Aberrations in trends starting in 1992 likely reflect the changing composition of countries in each exposure group due to data availability for former Soviet Union countries We obtained weighted means by applying commodity-specific propensity score weights
93Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
consumption in the context of trade liberalization but our findings support the results of an analysis showing that changes in trade policies led to an in-crease in imported fruit in five Central American countries10
This study has limitations A pri-mary limitation is the comparability of countries joining versus not joining WTO We assumed that trends would have been similar between the two groups if none of the countries joined WTO However differences in trends could be due to the influence of other unobserved events correlated with WTO accession and the outcomes of interest or innate characteristics of countries in either group
Another key limitation is the quality of the commodity data which measure
the available supply of each commodity and are only a proxy for consumption the true measure of importance for health In addition there was substantial missing data for certain items summed to create commodity variables which may affect the validity of the data for these categories The commodities ana-lysed were also limited by the available product categories importantly this did not allow us to distinguish changes in trends in the availability of specific foods high in fat salt or sugar an important determinant of obesity and noncommu-nicable diseases49 Finally for tobacco and alcohol illicit sales and homemade varieties are not captured in this data which may comprise substantial por-tions of supply and consumption in certain countries
In conclusion changes in domestic supply of alcohol tobacco and fruits and vegetables could have important implications for public health particu-larly for the development and preven-tion of noncommunicable diseases Overall findings indicated substantial country-level heterogeneity Therefore additional exploration of variations across countries is critical to identify factors that mitigate the negative role and enhance the positive role of trade and investment agreements in the global noncommunicable disease burden
Funding Krycia Cowling was supported by a Center for a Livable Future-Lerner fellowship during the time of this study
Competing interests None declared
摘要世界贸易组织成员国与非传染性疾病风险因素的变化一项断续时间序列比较分析1980ndash2013 年目的 旨在调查加入世界贸易组织 (WTO) 与获取若干商品(此类商品对非传染性疾病的形成兼具有害因素和保护因素)之间的关系方法 我 们 使 用 自 然 实 验 设 计 倾 向 评 分 权 重 来比 较 1980 年 至 2013 年 期 间 在 1995 年 之 后 加入 WTO 的 21 个国家或地区以及 26 个非成员国的烟草酒精和七类食品组在各国内的供应趋势我们采用断续时间序列框架使用多变量随机效应线性模型根据人均国内生产总值城市人口百分比和女性劳动力参与进行调整在烟草模型中我们控制了已批准
《烟草控制框架公约》的成员国在酒精模型中我们控制了自认为穆斯林国家所占的比例
结果 成员国加入世贸组织后与非成员国相比平均每人每天的水果和蔬菜国内供应量立即增长 55 克分析显示烟草和酒精每年的供应量以几何平均数的形式逐渐递增分别为每年 62 和 36我们尚未发现获取红肉和动物脂肪有任何重大变化 海鲜 坚果种子和豆类 淀粉 或食用油 以及与糖相关的结果在不同模型中是不一致的结论 结果表明成为 WTO 成员国可能会导致非传染性疾病的有害因素和保护因素增加但仍需进一步探索其针对具体国家的不同变化
ملخصعضوية منظمة التجارة العاملية والتغريات يف عوامل خطر األمراض غري املعدية حتليل سالسل زمنية مقارنة متقطعة ما
بني عامي 1980 و2013العاملية التجارة منظمة إىل االنضامم بني العالقة دراسة الغرض الضارة التأثريات ذات السلع من العديد وتوافر (WTO)
والوقائية من أجل تطوير األمراض غري املعديةاالجتاهات ملقارنة الطبيعية التجربة تصميم استخدمنا الطريقة بني غذائية جمموعات وسبع والكحول للتبغ املحيل اإلمداد يف عامي 1980 و2013 يف 21 دولة أو منطقة انضمت إىل منظمة التجارة العاملية بعد عام 1995 و26 دولة غري أعضاء باستخدام أوزان درجات النزوع طبقنا إطارا زمنيا متسلسال مقارنا متقطعا معدلة متعددة عشوائية تأثريات ذات خطية نامذج باستخدام احلرض لسكان املئوية والنسب للفرد اإلمجايل املحيل للناتج ومشاركة املرأة يف القوى العاملة يف نموذج التبغ قمنا باملكافحة ملكافحة اإلطارية االتفاقية عىل صدقت التي األعضاء الدول يف يعرفون الذين للسكان املئوية النسبة الكحول نموذج ويف التبغ
أنفسهم بأهنم مسلمني
الدول شهدت العاملية التجارة منظمة إىل االنضامم بعد النتائج األعضاء زيادات فورية يف اإلمداد املحيل من الفواكه واخلرضوات وصلت إىل 55 جم للشخص الواحد يف اليوم يف املتوسط مقارنة بالدول غري األعضاء أظهر التحليل زيادات تدرجيية يف املتوسط
اهلنديس إلمدادات التبغ والكحول بنسبة 62 و 36 يف السنة لحوم ال توافر يف جوهرية ت تغيريا أي نكتشف مل الرتتيب عىل احلمراء أو الدهون احليوانية أو املأكوالت البحرية أو املكرسات أو البذور والبقوليات أو النشويات أو الزيوت الصاحلة لألكل
وكانت النتائج للسكريات غري متناسقة عرب تنوعات النموذجقد العاملية التجارة ة منظم وية عض أن إىل النتائج تشري االستنتاج لألمراض والوقائية ة الضار مل العوا من كل يف زيادة إىل تؤدي االختالفات استكشاف من ملزيد ز تعزي هناك ولكن املعدية غري
اخلاصة بكل بلد
94 Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
Reacutesumeacute
Adheacutesion agrave lOrganisation mondiale du commerce et eacutevolution des facteurs de risque de maladies non transmissibles analyse comparative de seacuteries chronologiques interrompues 1980ndash2013Objectif Eacutetudier le lien entre ladheacutesion agrave lOrganisation mondiale du commerce (OMC) et la disponibiliteacute de diffeacuterentes denreacutees avec des effets agrave la fois nocifs et protecteurs pour le deacuteveloppement des maladies non transmissiblesMeacutethodes Nous avons utiliseacute un plan dexpeacuterience dans les conditions naturelles pour comparer entre 1980 et 2013 leacutevolution de loffre nationale de tabac dalcool et de sept groupes daliments dans 21 pays ou territoires devenus membres de lOMC apregraves 1995 et 26 pays non membres agrave laide de pondeacuterations par le score de propension Nous avons appliqueacute un cadre comparatif de seacuteries chronologiques interrompues agrave laide de modegraveles lineacuteaires agrave effets aleacuteatoires multivarieacutes rajusteacutes pour tenir compte du produit inteacuterieur brut par habitant du pourcentage de la population urbaine et de la participation des femmes agrave la vie active Dans le modegravele relatif au tabac nous avons tenu compte des Eacutetats membres ayant ratifieacute la Convention-cadre pour la lutte antitabac tandis que dans le modegravele relatif agrave lalcool nous avons tenu
compte du pourcentage de la population sidentifiant comme eacutetant de foi musulmaneReacutesultats Agrave la suite de leur adheacutesion agrave lOMC les Eacutetats membres ont connu une augmentation immeacutediate de loffre nationale de fruits et leacutegumes de 55 g par personne et par jour en moyenne par rapport aux pays non membres Lanalyse a reacuteveacuteleacute une augmentation progressive de la moyenne geacuteomeacutetrique de loffre de tabac et dalcool de 62 et 36 par an respectivement Nous navons pas constateacute de changements importants concernant la disponibiliteacute de viandes rouges et graisses dorigine animale de produits de la mer de noix graines et leacutegumineuses de feacuteculents ou dhuiles alimentaires et les reacutesultats relatifs aux sucres variaient dun modegravele agrave lautreConclusion Les reacutesultats suggegraverent que ladheacutesion agrave lOMC peut entraicircner une augmentation des facteurs agrave la fois nocifs et protecteurs pour les maladies non transmissibles mais il convient de reacutealiser de nouvelles recherches sur les variations par pays
Резюме
Членство во Всемирной торговой организации и изменения в факторах риска неинфекционных заболеваний сравнительный анализ прерванных временных рядов 1980ndash2013 ггЦель Членство во Всемирной торговой организации и изменения в факторах риска неинфекционных заболеваний сравнительный анализ прерванных временных рядов 1980ndash2013 ггМетоды Авторы использовали естественный эксперимент для сравнения тенденций внутренних поставок табака алкоголя и товаров семи продовольственных групп в период с 1980 по 2013 год в 21 стране или территории которые вступили в ВТО после 1995 года и в 26 странах не являющихся членами этой организации Анализ проводился с использованием весовых коэффициентов предрасположенности Авторы применили методику сравнительных прерванных временных рядов и многовариантные линейные модели случайных воздействий скорректированные по валовому внутреннему продукту на душу населения процентной доле городского населения и участию женщин в трудовой деятельности В модели для табака контролировались государства-члены ВТО ратифицировавшие Рамочную конвенцию по борьбе против табака а в модели
для алкоголя mdash доля населения идентифицирующая себя как мусульманеРезультаты После вступления в ВТО в государствах-членах наблюдался немедленный прирост внутренних поставок фруктов и овощей (в среднем до 55 г в день на человека) по сравнению со странами не являющимися ее членами Анализ показал постепенное увеличение среднего геометрического значения поставок табака и алкоголя на 62 и 36 в год соответственно Авторы не обнаружили существенных изменений в доступности мяса домашнего скота и животных жиров морепродуктов орехов семян и бобовых а также крахмала или пищевых масел Что касается сахара в разных моделях были получены несовпадающие результатыВывод Результаты позволяют предположить что членство в ВТО может привести к увеличению как полезных так и вредных факторов распространения неинфекционных заболеваний но необходимо проведение дальнейших исследований вариаций в различных странах
Resumen
Composicioacuten de la Organizacioacuten Mundial del Comercio y cambios en los factores de riesgo de las enfermedades no contagiosas un anaacutelisis comparativo de series cronoloacutegicas interrumpidas 1980-2013Objetivo Investigar la relacioacuten entre la adhesioacuten a la Organizacioacuten Mundial del Comercio (OMC) y la disponibilidad de varios productos baacutesicos con efectos tanto perjudiciales como protectores para el desarrollo de enfermedades no contagiosasMeacutetodos Se utilizoacute un disentildeo de experimento natural para comparar las tendencias de la oferta interna de tabaco alcohol y siete grupos de alimentos entre 1980 y 2013 en 21 paiacuteses o territorios que se incorporaron a la OMC despueacutes de 1995 y 26 paiacuteses no miembros mediante el uso de ponderaciones de propensioacuten Se aplicoacute un marco comparativo de series temporales interrumpidas siguiendo modelos lineales de efectos aleatorios multivariados ajustados seguacuten el producto interior bruto per caacutepita los porcentajes de poblacioacuten urbana y la participacioacuten de la mujer en el mundo laboral En el modelo del
tabaco controlamos a los Estados miembros que habiacutean ratificado el Convenio Marco para el Control del Tabaco y en el modelo del alcohol el porcentaje de la poblacioacuten que se identificaba como musulmanaResultados Tras la adhesioacuten a la OMC los Estados miembros experimentaron un aumento inmediato de la oferta interna de frutas y hortalizas de 55 kg por persona y diacutea de media en comparacioacuten con los paiacuteses no miembros El anaacutelisis mostroacute incrementos graduales en la media geomeacutetrica de la oferta de tabaco y alcohol del 62 y el 36 anual respectivamente No se detectaron cambios significativos en la disponibilidad de carnes rojas y grasas animales mariscos nueces semillas y legumbres almidones o aceites comestibles y los resultados para los azuacutecares fueron inconsistentes entre las variaciones del modelo
95Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
Conclusioacuten Los resultados sugieren que la pertenencia a la OMC puede dar lugar a un aumento de los factores perjudiciales y protectores de
las enfermedades no contagiosas pero es necesario seguir estudiando las variaciones especiacuteficas de cada paiacutes
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ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
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35 Al-Ansari B Thow A-M Day CA Conigrave KM Extent of alcohol prohibition in civil policy in Muslim majority countries the impact of globalization Addiction 2016 10111(10)1703ndash13 doi httpdxdoiorg101111add13159 PMID 26508526
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41 Griswold MG Fullman N Hawley C Arian N Zimsen SRM Tymeson HD et al GBD 2016 Alcohol Collaborators Alcohol use and burden for 195 countries and territories 1990ndash2016 a systematic analysis for the Global Burden of Disease Study 2016 Lancet 2018 Sep 22392(10152)1015ndash35 doi httpdxdoiorg101016S0140-6736(18)31310-2 PMID 30146330
42 Peto R Lopez AD Boreham J Thun M Heath C Jr Mortality from tobacco in developed countries indirect estimation from national vital statistics Lancet 1992 May 23339(8804)1268ndash78 doi httpdxdoiorg1010160140-6736(92)91600-D PMID 1349675
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48 Mendez Lopez A Loopstra R McKee M Stuckler D Is trade liberalisation a vector for the spread of sugar-sweetened beverages A cross-national longitudinal analysis of 44 low- and middle-income countries Soc Sci Med 2017 0117221ndash7 doi httpdxdoiorg101016jsocscimed201611001 PMID 27871042
49 Monteiro CA Moubarac J-C Cannon G Ng SW Popkin B Ultra-processed products are becoming dominant in the global food system Obes Rev 2013 Nov14 Suppl 221ndash8 doi httpdxdoiorg101111obr12107 PMID 24102801
Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057 96A
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
Fig 1 Unweighted and weighted absolute standardized biases for baseline commodity supply in countries included in the study 1980ndash1995
female labour force
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1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
Absolute standardize bias
Absolute standardize bias
Absolute standardize bias
Unweighted Weighted
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08 0 02 04 06 08
Supply of tobacco
Supply of starches
Supply of nuts seeds and legumes
Supply of seafood
Supply of edible oils
Supply of sugars
Supply of red meats and animal fats
Supply of alcohol
Supply of fruits and vegetables
GDP gross domestic productNotes The period 1980ndash1995 represents the years before countries and territories start joining the World Trade Organization Table 1 lists countries studied We measured bias by the absolute standardized mean difference that is (mean for non-member states ndash mean for member states)(combined standard deviation)
- Table 1
- Table 2
- Table 3
- Figure 2
- Figure 3
- Figure 4
- Figure 5
- Figure 6
- Figure 1
-
88 Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
or after the analysis period data for these countries were censored to exclude values in or after the year they joined For countries that comprised the former Soviet Union (eight exposed seven un-exposed) the analysis period begins in 1992 when independent countries were established
Data sources
The data sources for all commodities were the Food and Agriculture Orga-nization national commodity balance sheets (tobacco) and food balance sheets (all other commodities) which measure the annual supply of each commodity by country and are widely used as a proxy for consumption2627 We obtained covariate data on urban population and female labour force participation from the World Bankrsquos World Development Indicators28 population data from the United Nations Population Division29 gross domestic product (GDP) per capita from the Institute for Health Metrics and Evaluation30 percent-age Muslim population from the Pew Research Center31 and the ratification dates for the Framework Convention on Tobacco Control (FCTC) from the United Nations Treaty Collection32
Variables
We measured all commodity variables in units of grams (tobacco) or kilograms (all other commodities) per capita For tobacco and alcohol we restricted these measures to the population older than 14 years as is standard3334 We con-trolled for the following key confound-ers established by the existing literature in all models GDP per capita urban population and female labour force par-ticipation45 Models for alcohol included each countryrsquos proportion of population identifying themselves as Muslim as a covariate because being Muslim is linked to lower rates of alcohol use35 Models for tobacco included a variable indicating whether the country had ratified the FCTC because this ratifica-tion represents a commitment to reduce tobacco use36
Propensity score weights
With observational data the non-random assignment of the exposure (in this case WTO membership) can create imbalance in covariates and baseline levels of the outcome variables between the groups compared37 Characteristics of the groups in the pre-exposure period Ta
ble
3
Mod
el o
utpu
t fro
m b
est-
perf
orm
ing
mod
el to
stud
y WTO
mem
bers
hip
and
chan
ges i
n no
ncom
mun
icabl
e di
seas
e ris
k fa
ctor
s 19
80ndash2
013
Varia
ble
Toba
ccoa
Alco
hola
Frui
ts a
nd
vege
tabl
esNu
ts s
eeds
an
d le
gum
esa
Seaf
ooda
Red
mea
ts a
nd a
nim
al
fats
a
Star
ches
Suga
rsEd
ible
oils
a
Fixe
d eff
ect
coeffi
cien
t (P)
WTO
mem
bers
hip
009
8 (0
477
)minus
011
8 (0
133
)19
794
(00
03)
010
7 (0
171
)minus
013
7 (0
436
)0
008
(08
65)
minus6
277
(01
33)
minus2
401
(01
15)
minus0
070(
029
6)
WTO
m
embe
rshi
pye
ar0
061
(00
54)
003
7 (0
050
)minus
127
6 (0
367
)minus
001
7 (0
151
)0
032
(03
67)
000
1 (0
875
)minus
012
0 (0
904
)0
250
(01
76)
000
5 (0
730
)
GDP
per c
apita
ab
044
9 (0
004
)0
496
(lt 0
001
)7
571
(02
18)
031
3 (0
060
)0
826
(lt 0
001
)0
184
(00
20)
530
8 (0
464
)6
133
(00
03)
015
0 (0
243
)
u
rban
pop
ulat
ion
minus0
017
(00
24)
001
4 (0
160
)1
993
(00
04)
minus0
005
(04
91)
000
6 (0
637
)0
004
(05
33)
061
6 (0
189
)0
019
(08
79)
001
1 (0
052
)
fe
mal
e la
bour
fo
rce
part
icip
atio
nminus
001
0 (0
099
)minus
000
9 (0
202
)minus
102
9 (0
069
)minus
000
1 (0
804
)minus
003
6(0
016)
000
3 (0
553
)0
298
(03
71)
minus0
133
(00
88)
minus0
012
(01
02)
FCTC
ratifi
catio
ncminus
020
4 (0
032
)N
AN
AN
AN
AN
AN
AN
AN
A
M
uslim
pop
ulat
iond
NA
minus0
025
(lt 0
001
)N
AN
AN
AN
AN
AN
AN
A
Year
3eminus
972
times 1
0minus6 (0
251
)N
AN
AN
Aminus
146
times 1
0minus6 (0
875
)N
AN
AN
AN
A
Cons
tant
475
9 (lt
00
01)
minus1
088
(03
37)
726
8 (0
883
)minus
141
3 (0
265
)minus
384
5 (0
022
)1
437
(00
49)
142
441
(00
20)
minus18
940
(01
63)
006
6 (0
950
)
Rand
om e
ffec
ts v
aria
nce
(SE)
Inte
rcep
t0
944
(01
99)
166
0 (0
530
)69
170
32 (1
656
286
)3
070
(15
85)
295
0 (0
747
)0
396
(00
73)
5228
010
(1 1
232
00)
879
17 (1
929
0)8
46 times
10minus
4 (19
3 times
10minus
4 )
Slop
e7
83 times
10minus
10 (2
8 times
10minus
10)
000
3 (0
001
2)20
161
(53
45)
000
2(0
0013
)4
38 times
10minus
10 (9
97
times 1
0minus11
)2
55 times
10minus
4 (56
1 times
10minus
5 )3
667
(08
28)
018
5 (0
036
7)0
953
(01
86)
Inte
rcep
t and
slop
efminus
13
times 1
0minus5 (4
95
times 1
0minus6 )
minus0
030
(00
13)
minus25
595
9 (8
775
6)minus
007
13 (0
044
9)minus
113
times 1
0minus5 (6
86
times 1
0minus6 )
minus0
0058
(00
015)
minus93
382
(21
924)
minus2
055
(06
32)
minus0
0251
(00
061)
Resid
ual
021
5 (0
046
)0
071
(00
14)
437
215
(95
743)
007
6(0
0158
)0
162
(00
454)
001
8 (0
002
7)18
415
3 (2
820
7)12
292
(23
10)
005
2 (0
010
7)
FCTC
Fra
mew
ork
Conv
entio
n on
Toba
cco
Cont
rol G
DP
gro
ss d
omes
tic p
rodu
ct N
A n
ot a
pplic
able
SD
sta
ndar
d de
viat
ion
SE
stan
dard
erro
r W
TO W
orld
Trad
e O
rgan
izatio
na N
atur
al lo
garit
hm o
f com
mod
ity v
alue
s use
d in
mod
el
b In
2005
Inte
rnat
iona
l dol
lars
c O
nly
incl
uded
in to
bacc
o m
odel
d O
nly
incl
uded
in a
lcoh
ol m
odel
e C
oeffi
cien
t val
ues f
or in
divi
dual
yea
r fixe
d eff
ects
not
show
n (w
hen
appl
icab
le)
com
plet
e m
odel
out
put a
vaila
ble
from
the
figsh
are
repo
sitor
y25
f Dat
a pr
esen
ted
are
cova
rianc
es a
nd S
Es
89Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
are presented in Table 2 Although no differences were statistically significant to improve comparability we estimated and applied propensity score weights that optimized comparability on pre-exposure values of each commodity
In the first step we estimated pro-pensity scores to predict the probability of WTO membership as a function of annual values of each commodity in the pre-exposure period using a gen-eralized boosted regression modelling approach3839 In the second step we used propensity scores to construct weights for each country with all exposed coun-tries or territories receiving a weight of 1 and unexposed countries receiving a weight of p(1minusp) where p is the esti-mated propensity score This weighting estimates the average treatment effect on the exposed group ie the average effect of joining WTO for those countries or territories that did join
Fig 1 (available at httpwwwwhointbulletinvolumes97118-218057) displays the balance between the groups for annual values of the com-modities and covariates during the pre-exposure period before and after applying weights The balance metric is the absolute value of the difference in group means divided by the standard deviation across both groups 025 is a generally accepted balance threshold37 Improvements are reflected by the weighted values generally being closer to zero than unweighted values though in several cases improving balance on commodities sacrificed balance on co-variates However we further controlled for the influence of covariates in the regression models
Commodity models
We modelled changes in domestic sup-plies of the commodities using separate linear regression models for each of the nine commodities in a comparative interrupted time-series framework We used WTO membership as the treat-ment (t) term and used a treatmentyear interaction (ty) term to compare the pre- and post-exposure level and trend in the commodities (c) respectively in the exposed versus unexposed groups40 For unexposed countries the WTO membership variable was always 0 For exposed countries this variable ranged from 0 (before accession) to 1 (after ac-cession) for the year of each countryrsquos accession to WTO we used a fraction
reflecting the number of days of mem-bership Each commodity model had the following equation
(1)
where i indexes country j indexes year (1980 to 2013) x is a set of countries- and year-specific covariates βrsquos repre-sent coefficients estimated by the linear model and ε is the residual error term Covariates for urban population female labour force participation and percent-age Muslim population (alcohol model only) were continuous ranging from 0 to 100 The FCTC covariate (tobacco model only) ranged from 0 (not ratified) to 1 (ratified) with a fraction reflecting the number of days after ratification in the year during which each country was ratified All models were run with commodity-specific propensity score weights applied as inverse-probability-of-treatment weights
We tested multiple model varia-tions for each commodity For six com-modities (tobacco alcohol red meats and animal fats seafood nuts seeds and legumes and edible oils) we log-transformed the commodity values to constrain predicted values to be greater than 0 The key output of the best-performing model for each commodity is presented in Table 3 additional output and model fit graphs are available in the figshare repository25
Sensitivity analyses
We did several sensitivity analyses to assess whether various aspects of the study design affected the estimated ef-fects of WTO membership First to eliminate the influence of missing data we restricted the analysis period to 1993 to 2011 years with complete data for all 47 countries Second because the effects of WTO accession may take time we ex-plored lagged values of the WTO mem-bership and WTO membershipyear terms Third to examine whether the effects of WTO membership were pre-dominantly mediated through economic growth we excluded GDP per capita from all models Fourth we excluded several countries in the unexposed group that may be poor comparisons due to war famine or isolation from the global economy Afghanistan
Democratic Peoples Republic of Ko-rea Ethiopia Iraq and Sudan Lastly we stratified models by income group All analyses were conducted in Stata version 142 (StataCorp LCC College Station United States) except for the twang package for propensity scores run in R version 332 (R Foundation Vienna Austria)
ResultsFig 2 Fig 3 Fig 4 Fig 5 and Fig 6 show average trends for each commod-ity for the exposed unweighted unex-posed and weighted unexposed groups Trends during the pre-exposure period illustrate the improved comparability between the groups after weighting Outputs from the best-performing mod-els to estimate changes in supply of the commodities are shown in Table 3 The coefficients for the WTO membership and WTO membershipyear terms in-dicate whether there is any difference in the level and trend respectively of each commodity for countries and territories joining the WTO compared with non-WTO members The domestic avail-ability of fruits and vegetables increased the most the average annual supply of fruits and vegetables was 1979 kg per capita (95 confidence interval CI 660ndash3299) higher in countries or territories that have joined WTO than in non-member countries For tobacco and alcohol the WTO membershipyear coefficients suggest significant increas-ing trends in the availability of these products following WTO accession The geometric means of the supply of tobacco increased by 62 (95 CI 00ndash130) annually and of the supply of alcohol by 38 (95 CI 00ndash77) annually In the tobacco model the FCTC ratification coefficient indicates an 185 (95 CI 18ndash324) lower geometric mean supply of tobacco after ratification In the random effect model the intercept and slope are significantly different from zero for all commodi-ties indicating substantial remaining heterogeneity across countries in both the level and trend in domestic supply quantities (Table 3)
The sensitivity analyses generally supported the main findings The treat-ment effect on fruits and vegetables was robust in all sensitivity analyses The trend coefficient for the alcohol supply stayed of a consistent magnitude and
90 Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
remained significant in most analyses The trend coefficient for the tobacco supply also remained of a consistent magnitude but not always statisti-cally significant In only the lagged effect models treatment effects for sugars were significant and similar in magnitude to those in the main model providing some evidence of an initial decrease in the availability of sugars following WTO accession followed by a minimal steady increase When we stratified the analyses by country income group the results did not support any of the main conclusions However propensity score weights were generated to balance the sample and likely generated false results from these models which were run with 23 countries or less (out of the total 47) per income group Further details on each sensitivity analysis are available in the figshare repository25
DiscussionHere we show that following a countryrsquos accession to WTO there was a signifi-cant increasing trend in the domestic supply of alcohol a borderline signifi-cant increasing trend in the supply of tobacco and a significant immediate increase in the availability of fruits and vegetables compared with non-member countries Assuming that increases in supply likely translate to increases in consumption these changes have both positive and negative implications for global health For example recent re-search has indicated that any amount of alcohol consumption increases the risk of a range of negative health outcomes hence an increase in alcohol supply could be harmful41 Likewise an increase in tobacco use is negative as tobacco contributes to several noncommuni-cable diseases42 In contrast increases in fruit and vegetable consumption can protect against the development of numerous noncommunicable diseases24 The WHO recommends a 400 g intake of fruit and vegetables daily43 although even an intake of 200 g per day has been found to reduce the risk of many non-communicable diseases and premature mortality44 We estimate that average increase in the supply is about 55 g of fruits and vegetables per person per day higher in the countries after join-ing WTO
Our results provide more evidence about the links between trade liberaliza-tion and global health suggesting that
trade agreements should be considered as social determinants of health at the global scale As the burden of noncom-municable diseases continues to grow stakeholders should prioritize identify-ing the most effective strategies to curb the increase in risk factors including to-bacco and alcohol use and poor diet For example addressing aspects of trade and investment policies that alter the supply
of these products can help to tackle the noncommunicable disease burden at the root cause level This approach can be achieved through actions grounded in the Health in All Policies framework45 and the application of health impact assessment to proposed trade and in-vestment policies46 At the global level further development and consideration of international agreements to prevent
Fig 2 Changes in the supply of all forms of tobacco by joining WTO members and non-member states 1980ndash2013
All f
orm
s of t
obac
co(g
ram
sca
pita
old
er th
an 1
4 ye
ars)
2500
2000
1500
1000
500
0
Year1980 1990 2000 2010 2013
Range of WTO accession dates
Mean for joining WTO members Unweighted mean for WTO non-membersWeighted mean for WTO non-members
WTO World Trade OrganizationNotes The grey box represents the range of accession dates for countries and territories joining WTO Aberrations in trends starting in 1992 likely reflect the changing composition of countries in each exposure group due to data availability for former Soviet Union countries We obtained weighted means by applying tobacco-specific propensity score weights
Fig 3 Changes in the supply of all types of alcohol by joining WTO members and non-member states 1980ndash2013
All t
ypes
of a
lcoho
l(k
ilogr
ams
capi
ta o
lder
than
14
year
s)
60
40
20
0
Year1980 1990 2000 2010 2013
Range of WTO accession dates
Mean for joining WTO members Unweighted mean for WTO non-membersWeighted mean for WTO non-members
WTO World Trade OrganizationNotes The grey box represents the range of accession dates for countries and territories joining WTO Aberrations in trends starting in 1992 likely reflect the changing composition of countries in each exposure group due to data availability for former Soviet Union countries We obtained weighted means by applying alcohol-specific propensity score weights
91Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
Fig
4
Chan
ges i
n th
e su
pply
of f
ruits
and
vege
tabl
es a
nd st
arch
es f
or jo
inin
g W
TO
mem
bers
and
non
-mem
ber s
tate
s 19
80ndash2
013
Year
Year
1980
1990
2000
2010
2013
1980
1990
2000
2010
2013
Rang
e of W
TO ac
cessi
on da
tes
Rang
e of W
TO ac
cessi
on da
tes
Mea
n fo
r joi
ning
WTO
mem
bers
Unw
eigh
ted
mea
n fo
r WTO
non
-mem
bers
Wei
ghte
d m
ean
for W
TO n
on-m
embe
rs
Kilogramscapita Kilogramscapita250
200
150
100 50 0
250
200
150
100 50 0
Star
ches
Frui
ts an
d ve
geta
bles
WTO
Wor
ld Tr
ade
Org
aniz
atio
nN
otes
The
gre
y bo
x re
pres
ents
the
rang
e of
acc
essio
n da
tes f
or c
ount
ries a
nd te
rrito
ries j
oini
ng W
TO
Aber
ratio
ns in
tren
ds st
artin
g in
199
2 lik
ely
refle
ct th
e ch
angi
ng c
ompo
sitio
n of
cou
ntrie
s in
each
ex
posu
re g
roup
due
to d
ata
avai
labi
lity
for f
orm
er S
ovie
t Uni
on c
ount
ries
We
obta
ined
wei
ghte
d m
eans
by
app
lyin
g co
mm
odity
-spe
cific
pro
pens
ity sc
ore
wei
ghts
Fig
5
Chan
ges i
n th
e su
pply
of r
ed m
eats
and
ani
mal
fats
and
suga
rs b
y joi
ning
WTO
m
embe
rs a
nd n
on-m
embe
r sta
tes
1980
ndash201
3
Year
Year
1980
1990
2000
2010
2013
1980
1990
2000
2010
2013
Rang
e of W
TO ac
cessi
on da
tes
Rang
e of W
TO ac
cessi
on da
tes
Mea
n fo
r joi
ning
WTO
mem
bers
Unw
eigh
ted
mea
n fo
r WTO
non
-mem
bers
Wei
ghte
d m
ean
for W
TO n
on-m
embe
rs
Kilogramscapita Kilogramscapita
50 40 30 20 10 0 50 40 30 20 10 0
Red
mea
ts an
d an
imal
fats
Suga
rs
WTO
Wor
ld Tr
ade
Org
aniz
atio
nN
otes
The
gre
y bo
x re
pres
ents
the
rang
e of
acc
essio
n da
tes f
or c
ount
ries a
nd te
rrito
ries j
oini
ng W
TO
Aber
ratio
ns in
tren
ds st
artin
g in
199
2 lik
ely
refle
ct th
e ch
angi
ng c
ompo
sitio
n of
cou
ntrie
s in
each
ex
posu
re g
roup
due
to d
ata
avai
labi
lity
for f
orm
er S
ovie
t Uni
on c
ount
ries
We
obta
ined
wei
ghte
d m
eans
by
app
lyin
g co
mm
odity
-spe
cific
pro
pens
ity sc
ore
wei
ghts
92 Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
and control noncommunicable diseases like the FCTC but focused on other noncommunicable disease risk factors is warranted Such agreements can legally bind countries to health com-mitments providing a counterweight for commitments to international trade and investment rules
Our findings are suggestive but not conclusive warranting additional exploration and we suggest several po-tential avenues for future research For example given substantial unexplained country-specific heterogeneity indicated by country random effects in all models additional analyses of smaller groups of countries and individual countries are needed The effects of WTO member-ship may differ by level of economic development and other country-specific factors such as geography and climate which affect the baseline supply of various food groups tobacco and types of alcohol Researchers could recreate this analysis with one income group at a time and a similar analysis of selected low- and middle-income countries with substantial noncommunicable disease burdens may provide further insight into the links between WTO member-ship and changes in noncommunicable disease risk factors Single country studies could permit more nuanced understanding for example by looking at tariff changes for specific products and subsequent changes in their sup-ply Another area for future studies is to examine differences associated with specific provisions in WTO accession agreements and other trade and invest-ment policies as specific concessions differ Understanding which compo-nents of these treaties have the greatest influence on noncommunicable disease risk factors and other aspects of public health is important when tailoring future agreements to be more health-promoting Further researchers should also conduct similar analyses for other products that contribute to noncommu-nicable diseases particularly unhealthy foods high in fat salt and sugar
This study both supports and contradicts findings from previous research We were not able to confirm findings showing increases in consump-tion of meat10 and edible oils47 following trade liberalization Discrepancies may be due to differences in the sample previous studies examined only one to five countries in the same geographical region Studies showing trade-related
increases in sugar-sweetened beverage consumption1348 are somewhat sup-ported by our weak finding that the domestic supply of sugars increases steadily over time following WTO ac-
cession Our results confirm previous findings of increased tobacco712 and alcohol5 consumption associated with trade liberalization Finally few studies have examined fruits and vegetables
Fig 6 Changes in the supply of nuts seeds and legumes seafood and edible oils by joining WTO members and non-member states 1980ndash2013
Year
Year
Year
1980 1990 2000 2010 2013
1980 1990 2000 2010 2013
1980 1990 2000 2010 2013
Range of WTO accession dates
Range of WTO accession dates
Range of WTO accession dates
Mean for joining WTO members Unweighted mean for WTO non-membersWeighted mean for WTO non-members
Kilo
gram
sca
pita
Kilo
gram
sca
pita
Kilo
gram
sca
pita
20
15
10
5
0
20
15
10
5
0
20
15
10
5
0
Nuts seeds and legumes
Seafood
Edible oils
WTO World Trade OrganizationNotes The grey box represents the range of accession dates for countries and territories joining WTO Aberrations in trends starting in 1992 likely reflect the changing composition of countries in each exposure group due to data availability for former Soviet Union countries We obtained weighted means by applying commodity-specific propensity score weights
93Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
consumption in the context of trade liberalization but our findings support the results of an analysis showing that changes in trade policies led to an in-crease in imported fruit in five Central American countries10
This study has limitations A pri-mary limitation is the comparability of countries joining versus not joining WTO We assumed that trends would have been similar between the two groups if none of the countries joined WTO However differences in trends could be due to the influence of other unobserved events correlated with WTO accession and the outcomes of interest or innate characteristics of countries in either group
Another key limitation is the quality of the commodity data which measure
the available supply of each commodity and are only a proxy for consumption the true measure of importance for health In addition there was substantial missing data for certain items summed to create commodity variables which may affect the validity of the data for these categories The commodities ana-lysed were also limited by the available product categories importantly this did not allow us to distinguish changes in trends in the availability of specific foods high in fat salt or sugar an important determinant of obesity and noncommu-nicable diseases49 Finally for tobacco and alcohol illicit sales and homemade varieties are not captured in this data which may comprise substantial por-tions of supply and consumption in certain countries
In conclusion changes in domestic supply of alcohol tobacco and fruits and vegetables could have important implications for public health particu-larly for the development and preven-tion of noncommunicable diseases Overall findings indicated substantial country-level heterogeneity Therefore additional exploration of variations across countries is critical to identify factors that mitigate the negative role and enhance the positive role of trade and investment agreements in the global noncommunicable disease burden
Funding Krycia Cowling was supported by a Center for a Livable Future-Lerner fellowship during the time of this study
Competing interests None declared
摘要世界贸易组织成员国与非传染性疾病风险因素的变化一项断续时间序列比较分析1980ndash2013 年目的 旨在调查加入世界贸易组织 (WTO) 与获取若干商品(此类商品对非传染性疾病的形成兼具有害因素和保护因素)之间的关系方法 我 们 使 用 自 然 实 验 设 计 倾 向 评 分 权 重 来比 较 1980 年 至 2013 年 期 间 在 1995 年 之 后 加入 WTO 的 21 个国家或地区以及 26 个非成员国的烟草酒精和七类食品组在各国内的供应趋势我们采用断续时间序列框架使用多变量随机效应线性模型根据人均国内生产总值城市人口百分比和女性劳动力参与进行调整在烟草模型中我们控制了已批准
《烟草控制框架公约》的成员国在酒精模型中我们控制了自认为穆斯林国家所占的比例
结果 成员国加入世贸组织后与非成员国相比平均每人每天的水果和蔬菜国内供应量立即增长 55 克分析显示烟草和酒精每年的供应量以几何平均数的形式逐渐递增分别为每年 62 和 36我们尚未发现获取红肉和动物脂肪有任何重大变化 海鲜 坚果种子和豆类 淀粉 或食用油 以及与糖相关的结果在不同模型中是不一致的结论 结果表明成为 WTO 成员国可能会导致非传染性疾病的有害因素和保护因素增加但仍需进一步探索其针对具体国家的不同变化
ملخصعضوية منظمة التجارة العاملية والتغريات يف عوامل خطر األمراض غري املعدية حتليل سالسل زمنية مقارنة متقطعة ما
بني عامي 1980 و2013العاملية التجارة منظمة إىل االنضامم بني العالقة دراسة الغرض الضارة التأثريات ذات السلع من العديد وتوافر (WTO)
والوقائية من أجل تطوير األمراض غري املعديةاالجتاهات ملقارنة الطبيعية التجربة تصميم استخدمنا الطريقة بني غذائية جمموعات وسبع والكحول للتبغ املحيل اإلمداد يف عامي 1980 و2013 يف 21 دولة أو منطقة انضمت إىل منظمة التجارة العاملية بعد عام 1995 و26 دولة غري أعضاء باستخدام أوزان درجات النزوع طبقنا إطارا زمنيا متسلسال مقارنا متقطعا معدلة متعددة عشوائية تأثريات ذات خطية نامذج باستخدام احلرض لسكان املئوية والنسب للفرد اإلمجايل املحيل للناتج ومشاركة املرأة يف القوى العاملة يف نموذج التبغ قمنا باملكافحة ملكافحة اإلطارية االتفاقية عىل صدقت التي األعضاء الدول يف يعرفون الذين للسكان املئوية النسبة الكحول نموذج ويف التبغ
أنفسهم بأهنم مسلمني
الدول شهدت العاملية التجارة منظمة إىل االنضامم بعد النتائج األعضاء زيادات فورية يف اإلمداد املحيل من الفواكه واخلرضوات وصلت إىل 55 جم للشخص الواحد يف اليوم يف املتوسط مقارنة بالدول غري األعضاء أظهر التحليل زيادات تدرجيية يف املتوسط
اهلنديس إلمدادات التبغ والكحول بنسبة 62 و 36 يف السنة لحوم ال توافر يف جوهرية ت تغيريا أي نكتشف مل الرتتيب عىل احلمراء أو الدهون احليوانية أو املأكوالت البحرية أو املكرسات أو البذور والبقوليات أو النشويات أو الزيوت الصاحلة لألكل
وكانت النتائج للسكريات غري متناسقة عرب تنوعات النموذجقد العاملية التجارة ة منظم وية عض أن إىل النتائج تشري االستنتاج لألمراض والوقائية ة الضار مل العوا من كل يف زيادة إىل تؤدي االختالفات استكشاف من ملزيد ز تعزي هناك ولكن املعدية غري
اخلاصة بكل بلد
94 Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
Reacutesumeacute
Adheacutesion agrave lOrganisation mondiale du commerce et eacutevolution des facteurs de risque de maladies non transmissibles analyse comparative de seacuteries chronologiques interrompues 1980ndash2013Objectif Eacutetudier le lien entre ladheacutesion agrave lOrganisation mondiale du commerce (OMC) et la disponibiliteacute de diffeacuterentes denreacutees avec des effets agrave la fois nocifs et protecteurs pour le deacuteveloppement des maladies non transmissiblesMeacutethodes Nous avons utiliseacute un plan dexpeacuterience dans les conditions naturelles pour comparer entre 1980 et 2013 leacutevolution de loffre nationale de tabac dalcool et de sept groupes daliments dans 21 pays ou territoires devenus membres de lOMC apregraves 1995 et 26 pays non membres agrave laide de pondeacuterations par le score de propension Nous avons appliqueacute un cadre comparatif de seacuteries chronologiques interrompues agrave laide de modegraveles lineacuteaires agrave effets aleacuteatoires multivarieacutes rajusteacutes pour tenir compte du produit inteacuterieur brut par habitant du pourcentage de la population urbaine et de la participation des femmes agrave la vie active Dans le modegravele relatif au tabac nous avons tenu compte des Eacutetats membres ayant ratifieacute la Convention-cadre pour la lutte antitabac tandis que dans le modegravele relatif agrave lalcool nous avons tenu
compte du pourcentage de la population sidentifiant comme eacutetant de foi musulmaneReacutesultats Agrave la suite de leur adheacutesion agrave lOMC les Eacutetats membres ont connu une augmentation immeacutediate de loffre nationale de fruits et leacutegumes de 55 g par personne et par jour en moyenne par rapport aux pays non membres Lanalyse a reacuteveacuteleacute une augmentation progressive de la moyenne geacuteomeacutetrique de loffre de tabac et dalcool de 62 et 36 par an respectivement Nous navons pas constateacute de changements importants concernant la disponibiliteacute de viandes rouges et graisses dorigine animale de produits de la mer de noix graines et leacutegumineuses de feacuteculents ou dhuiles alimentaires et les reacutesultats relatifs aux sucres variaient dun modegravele agrave lautreConclusion Les reacutesultats suggegraverent que ladheacutesion agrave lOMC peut entraicircner une augmentation des facteurs agrave la fois nocifs et protecteurs pour les maladies non transmissibles mais il convient de reacutealiser de nouvelles recherches sur les variations par pays
Резюме
Членство во Всемирной торговой организации и изменения в факторах риска неинфекционных заболеваний сравнительный анализ прерванных временных рядов 1980ndash2013 ггЦель Членство во Всемирной торговой организации и изменения в факторах риска неинфекционных заболеваний сравнительный анализ прерванных временных рядов 1980ndash2013 ггМетоды Авторы использовали естественный эксперимент для сравнения тенденций внутренних поставок табака алкоголя и товаров семи продовольственных групп в период с 1980 по 2013 год в 21 стране или территории которые вступили в ВТО после 1995 года и в 26 странах не являющихся членами этой организации Анализ проводился с использованием весовых коэффициентов предрасположенности Авторы применили методику сравнительных прерванных временных рядов и многовариантные линейные модели случайных воздействий скорректированные по валовому внутреннему продукту на душу населения процентной доле городского населения и участию женщин в трудовой деятельности В модели для табака контролировались государства-члены ВТО ратифицировавшие Рамочную конвенцию по борьбе против табака а в модели
для алкоголя mdash доля населения идентифицирующая себя как мусульманеРезультаты После вступления в ВТО в государствах-членах наблюдался немедленный прирост внутренних поставок фруктов и овощей (в среднем до 55 г в день на человека) по сравнению со странами не являющимися ее членами Анализ показал постепенное увеличение среднего геометрического значения поставок табака и алкоголя на 62 и 36 в год соответственно Авторы не обнаружили существенных изменений в доступности мяса домашнего скота и животных жиров морепродуктов орехов семян и бобовых а также крахмала или пищевых масел Что касается сахара в разных моделях были получены несовпадающие результатыВывод Результаты позволяют предположить что членство в ВТО может привести к увеличению как полезных так и вредных факторов распространения неинфекционных заболеваний но необходимо проведение дальнейших исследований вариаций в различных странах
Resumen
Composicioacuten de la Organizacioacuten Mundial del Comercio y cambios en los factores de riesgo de las enfermedades no contagiosas un anaacutelisis comparativo de series cronoloacutegicas interrumpidas 1980-2013Objetivo Investigar la relacioacuten entre la adhesioacuten a la Organizacioacuten Mundial del Comercio (OMC) y la disponibilidad de varios productos baacutesicos con efectos tanto perjudiciales como protectores para el desarrollo de enfermedades no contagiosasMeacutetodos Se utilizoacute un disentildeo de experimento natural para comparar las tendencias de la oferta interna de tabaco alcohol y siete grupos de alimentos entre 1980 y 2013 en 21 paiacuteses o territorios que se incorporaron a la OMC despueacutes de 1995 y 26 paiacuteses no miembros mediante el uso de ponderaciones de propensioacuten Se aplicoacute un marco comparativo de series temporales interrumpidas siguiendo modelos lineales de efectos aleatorios multivariados ajustados seguacuten el producto interior bruto per caacutepita los porcentajes de poblacioacuten urbana y la participacioacuten de la mujer en el mundo laboral En el modelo del
tabaco controlamos a los Estados miembros que habiacutean ratificado el Convenio Marco para el Control del Tabaco y en el modelo del alcohol el porcentaje de la poblacioacuten que se identificaba como musulmanaResultados Tras la adhesioacuten a la OMC los Estados miembros experimentaron un aumento inmediato de la oferta interna de frutas y hortalizas de 55 kg por persona y diacutea de media en comparacioacuten con los paiacuteses no miembros El anaacutelisis mostroacute incrementos graduales en la media geomeacutetrica de la oferta de tabaco y alcohol del 62 y el 36 anual respectivamente No se detectaron cambios significativos en la disponibilidad de carnes rojas y grasas animales mariscos nueces semillas y legumbres almidones o aceites comestibles y los resultados para los azuacutecares fueron inconsistentes entre las variaciones del modelo
95Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
Conclusioacuten Los resultados sugieren que la pertenencia a la OMC puede dar lugar a un aumento de los factores perjudiciales y protectores de
las enfermedades no contagiosas pero es necesario seguir estudiando las variaciones especiacuteficas de cada paiacutes
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ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
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35 Al-Ansari B Thow A-M Day CA Conigrave KM Extent of alcohol prohibition in civil policy in Muslim majority countries the impact of globalization Addiction 2016 10111(10)1703ndash13 doi httpdxdoiorg101111add13159 PMID 26508526
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41 Griswold MG Fullman N Hawley C Arian N Zimsen SRM Tymeson HD et al GBD 2016 Alcohol Collaborators Alcohol use and burden for 195 countries and territories 1990ndash2016 a systematic analysis for the Global Burden of Disease Study 2016 Lancet 2018 Sep 22392(10152)1015ndash35 doi httpdxdoiorg101016S0140-6736(18)31310-2 PMID 30146330
42 Peto R Lopez AD Boreham J Thun M Heath C Jr Mortality from tobacco in developed countries indirect estimation from national vital statistics Lancet 1992 May 23339(8804)1268ndash78 doi httpdxdoiorg1010160140-6736(92)91600-D PMID 1349675
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48 Mendez Lopez A Loopstra R McKee M Stuckler D Is trade liberalisation a vector for the spread of sugar-sweetened beverages A cross-national longitudinal analysis of 44 low- and middle-income countries Soc Sci Med 2017 0117221ndash7 doi httpdxdoiorg101016jsocscimed201611001 PMID 27871042
49 Monteiro CA Moubarac J-C Cannon G Ng SW Popkin B Ultra-processed products are becoming dominant in the global food system Obes Rev 2013 Nov14 Suppl 221ndash8 doi httpdxdoiorg101111obr12107 PMID 24102801
Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057 96A
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
Fig 1 Unweighted and weighted absolute standardized biases for baseline commodity supply in countries included in the study 1980ndash1995
female labour force
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Absolute standardize bias
Absolute standardize bias
Absolute standardize bias
Unweighted Weighted
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08 0 02 04 06 08
Supply of tobacco
Supply of starches
Supply of nuts seeds and legumes
Supply of seafood
Supply of edible oils
Supply of sugars
Supply of red meats and animal fats
Supply of alcohol
Supply of fruits and vegetables
GDP gross domestic productNotes The period 1980ndash1995 represents the years before countries and territories start joining the World Trade Organization Table 1 lists countries studied We measured bias by the absolute standardized mean difference that is (mean for non-member states ndash mean for member states)(combined standard deviation)
- Table 1
- Table 2
- Table 3
- Figure 2
- Figure 3
- Figure 4
- Figure 5
- Figure 6
- Figure 1
-
89Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
are presented in Table 2 Although no differences were statistically significant to improve comparability we estimated and applied propensity score weights that optimized comparability on pre-exposure values of each commodity
In the first step we estimated pro-pensity scores to predict the probability of WTO membership as a function of annual values of each commodity in the pre-exposure period using a gen-eralized boosted regression modelling approach3839 In the second step we used propensity scores to construct weights for each country with all exposed coun-tries or territories receiving a weight of 1 and unexposed countries receiving a weight of p(1minusp) where p is the esti-mated propensity score This weighting estimates the average treatment effect on the exposed group ie the average effect of joining WTO for those countries or territories that did join
Fig 1 (available at httpwwwwhointbulletinvolumes97118-218057) displays the balance between the groups for annual values of the com-modities and covariates during the pre-exposure period before and after applying weights The balance metric is the absolute value of the difference in group means divided by the standard deviation across both groups 025 is a generally accepted balance threshold37 Improvements are reflected by the weighted values generally being closer to zero than unweighted values though in several cases improving balance on commodities sacrificed balance on co-variates However we further controlled for the influence of covariates in the regression models
Commodity models
We modelled changes in domestic sup-plies of the commodities using separate linear regression models for each of the nine commodities in a comparative interrupted time-series framework We used WTO membership as the treat-ment (t) term and used a treatmentyear interaction (ty) term to compare the pre- and post-exposure level and trend in the commodities (c) respectively in the exposed versus unexposed groups40 For unexposed countries the WTO membership variable was always 0 For exposed countries this variable ranged from 0 (before accession) to 1 (after ac-cession) for the year of each countryrsquos accession to WTO we used a fraction
reflecting the number of days of mem-bership Each commodity model had the following equation
(1)
where i indexes country j indexes year (1980 to 2013) x is a set of countries- and year-specific covariates βrsquos repre-sent coefficients estimated by the linear model and ε is the residual error term Covariates for urban population female labour force participation and percent-age Muslim population (alcohol model only) were continuous ranging from 0 to 100 The FCTC covariate (tobacco model only) ranged from 0 (not ratified) to 1 (ratified) with a fraction reflecting the number of days after ratification in the year during which each country was ratified All models were run with commodity-specific propensity score weights applied as inverse-probability-of-treatment weights
We tested multiple model varia-tions for each commodity For six com-modities (tobacco alcohol red meats and animal fats seafood nuts seeds and legumes and edible oils) we log-transformed the commodity values to constrain predicted values to be greater than 0 The key output of the best-performing model for each commodity is presented in Table 3 additional output and model fit graphs are available in the figshare repository25
Sensitivity analyses
We did several sensitivity analyses to assess whether various aspects of the study design affected the estimated ef-fects of WTO membership First to eliminate the influence of missing data we restricted the analysis period to 1993 to 2011 years with complete data for all 47 countries Second because the effects of WTO accession may take time we ex-plored lagged values of the WTO mem-bership and WTO membershipyear terms Third to examine whether the effects of WTO membership were pre-dominantly mediated through economic growth we excluded GDP per capita from all models Fourth we excluded several countries in the unexposed group that may be poor comparisons due to war famine or isolation from the global economy Afghanistan
Democratic Peoples Republic of Ko-rea Ethiopia Iraq and Sudan Lastly we stratified models by income group All analyses were conducted in Stata version 142 (StataCorp LCC College Station United States) except for the twang package for propensity scores run in R version 332 (R Foundation Vienna Austria)
ResultsFig 2 Fig 3 Fig 4 Fig 5 and Fig 6 show average trends for each commod-ity for the exposed unweighted unex-posed and weighted unexposed groups Trends during the pre-exposure period illustrate the improved comparability between the groups after weighting Outputs from the best-performing mod-els to estimate changes in supply of the commodities are shown in Table 3 The coefficients for the WTO membership and WTO membershipyear terms in-dicate whether there is any difference in the level and trend respectively of each commodity for countries and territories joining the WTO compared with non-WTO members The domestic avail-ability of fruits and vegetables increased the most the average annual supply of fruits and vegetables was 1979 kg per capita (95 confidence interval CI 660ndash3299) higher in countries or territories that have joined WTO than in non-member countries For tobacco and alcohol the WTO membershipyear coefficients suggest significant increas-ing trends in the availability of these products following WTO accession The geometric means of the supply of tobacco increased by 62 (95 CI 00ndash130) annually and of the supply of alcohol by 38 (95 CI 00ndash77) annually In the tobacco model the FCTC ratification coefficient indicates an 185 (95 CI 18ndash324) lower geometric mean supply of tobacco after ratification In the random effect model the intercept and slope are significantly different from zero for all commodi-ties indicating substantial remaining heterogeneity across countries in both the level and trend in domestic supply quantities (Table 3)
The sensitivity analyses generally supported the main findings The treat-ment effect on fruits and vegetables was robust in all sensitivity analyses The trend coefficient for the alcohol supply stayed of a consistent magnitude and
90 Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
remained significant in most analyses The trend coefficient for the tobacco supply also remained of a consistent magnitude but not always statisti-cally significant In only the lagged effect models treatment effects for sugars were significant and similar in magnitude to those in the main model providing some evidence of an initial decrease in the availability of sugars following WTO accession followed by a minimal steady increase When we stratified the analyses by country income group the results did not support any of the main conclusions However propensity score weights were generated to balance the sample and likely generated false results from these models which were run with 23 countries or less (out of the total 47) per income group Further details on each sensitivity analysis are available in the figshare repository25
DiscussionHere we show that following a countryrsquos accession to WTO there was a signifi-cant increasing trend in the domestic supply of alcohol a borderline signifi-cant increasing trend in the supply of tobacco and a significant immediate increase in the availability of fruits and vegetables compared with non-member countries Assuming that increases in supply likely translate to increases in consumption these changes have both positive and negative implications for global health For example recent re-search has indicated that any amount of alcohol consumption increases the risk of a range of negative health outcomes hence an increase in alcohol supply could be harmful41 Likewise an increase in tobacco use is negative as tobacco contributes to several noncommuni-cable diseases42 In contrast increases in fruit and vegetable consumption can protect against the development of numerous noncommunicable diseases24 The WHO recommends a 400 g intake of fruit and vegetables daily43 although even an intake of 200 g per day has been found to reduce the risk of many non-communicable diseases and premature mortality44 We estimate that average increase in the supply is about 55 g of fruits and vegetables per person per day higher in the countries after join-ing WTO
Our results provide more evidence about the links between trade liberaliza-tion and global health suggesting that
trade agreements should be considered as social determinants of health at the global scale As the burden of noncom-municable diseases continues to grow stakeholders should prioritize identify-ing the most effective strategies to curb the increase in risk factors including to-bacco and alcohol use and poor diet For example addressing aspects of trade and investment policies that alter the supply
of these products can help to tackle the noncommunicable disease burden at the root cause level This approach can be achieved through actions grounded in the Health in All Policies framework45 and the application of health impact assessment to proposed trade and in-vestment policies46 At the global level further development and consideration of international agreements to prevent
Fig 2 Changes in the supply of all forms of tobacco by joining WTO members and non-member states 1980ndash2013
All f
orm
s of t
obac
co(g
ram
sca
pita
old
er th
an 1
4 ye
ars)
2500
2000
1500
1000
500
0
Year1980 1990 2000 2010 2013
Range of WTO accession dates
Mean for joining WTO members Unweighted mean for WTO non-membersWeighted mean for WTO non-members
WTO World Trade OrganizationNotes The grey box represents the range of accession dates for countries and territories joining WTO Aberrations in trends starting in 1992 likely reflect the changing composition of countries in each exposure group due to data availability for former Soviet Union countries We obtained weighted means by applying tobacco-specific propensity score weights
Fig 3 Changes in the supply of all types of alcohol by joining WTO members and non-member states 1980ndash2013
All t
ypes
of a
lcoho
l(k
ilogr
ams
capi
ta o
lder
than
14
year
s)
60
40
20
0
Year1980 1990 2000 2010 2013
Range of WTO accession dates
Mean for joining WTO members Unweighted mean for WTO non-membersWeighted mean for WTO non-members
WTO World Trade OrganizationNotes The grey box represents the range of accession dates for countries and territories joining WTO Aberrations in trends starting in 1992 likely reflect the changing composition of countries in each exposure group due to data availability for former Soviet Union countries We obtained weighted means by applying alcohol-specific propensity score weights
91Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
Fig
4
Chan
ges i
n th
e su
pply
of f
ruits
and
vege
tabl
es a
nd st
arch
es f
or jo
inin
g W
TO
mem
bers
and
non
-mem
ber s
tate
s 19
80ndash2
013
Year
Year
1980
1990
2000
2010
2013
1980
1990
2000
2010
2013
Rang
e of W
TO ac
cessi
on da
tes
Rang
e of W
TO ac
cessi
on da
tes
Mea
n fo
r joi
ning
WTO
mem
bers
Unw
eigh
ted
mea
n fo
r WTO
non
-mem
bers
Wei
ghte
d m
ean
for W
TO n
on-m
embe
rs
Kilogramscapita Kilogramscapita250
200
150
100 50 0
250
200
150
100 50 0
Star
ches
Frui
ts an
d ve
geta
bles
WTO
Wor
ld Tr
ade
Org
aniz
atio
nN
otes
The
gre
y bo
x re
pres
ents
the
rang
e of
acc
essio
n da
tes f
or c
ount
ries a
nd te
rrito
ries j
oini
ng W
TO
Aber
ratio
ns in
tren
ds st
artin
g in
199
2 lik
ely
refle
ct th
e ch
angi
ng c
ompo
sitio
n of
cou
ntrie
s in
each
ex
posu
re g
roup
due
to d
ata
avai
labi
lity
for f
orm
er S
ovie
t Uni
on c
ount
ries
We
obta
ined
wei
ghte
d m
eans
by
app
lyin
g co
mm
odity
-spe
cific
pro
pens
ity sc
ore
wei
ghts
Fig
5
Chan
ges i
n th
e su
pply
of r
ed m
eats
and
ani
mal
fats
and
suga
rs b
y joi
ning
WTO
m
embe
rs a
nd n
on-m
embe
r sta
tes
1980
ndash201
3
Year
Year
1980
1990
2000
2010
2013
1980
1990
2000
2010
2013
Rang
e of W
TO ac
cessi
on da
tes
Rang
e of W
TO ac
cessi
on da
tes
Mea
n fo
r joi
ning
WTO
mem
bers
Unw
eigh
ted
mea
n fo
r WTO
non
-mem
bers
Wei
ghte
d m
ean
for W
TO n
on-m
embe
rs
Kilogramscapita Kilogramscapita
50 40 30 20 10 0 50 40 30 20 10 0
Red
mea
ts an
d an
imal
fats
Suga
rs
WTO
Wor
ld Tr
ade
Org
aniz
atio
nN
otes
The
gre
y bo
x re
pres
ents
the
rang
e of
acc
essio
n da
tes f
or c
ount
ries a
nd te
rrito
ries j
oini
ng W
TO
Aber
ratio
ns in
tren
ds st
artin
g in
199
2 lik
ely
refle
ct th
e ch
angi
ng c
ompo
sitio
n of
cou
ntrie
s in
each
ex
posu
re g
roup
due
to d
ata
avai
labi
lity
for f
orm
er S
ovie
t Uni
on c
ount
ries
We
obta
ined
wei
ghte
d m
eans
by
app
lyin
g co
mm
odity
-spe
cific
pro
pens
ity sc
ore
wei
ghts
92 Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
and control noncommunicable diseases like the FCTC but focused on other noncommunicable disease risk factors is warranted Such agreements can legally bind countries to health com-mitments providing a counterweight for commitments to international trade and investment rules
Our findings are suggestive but not conclusive warranting additional exploration and we suggest several po-tential avenues for future research For example given substantial unexplained country-specific heterogeneity indicated by country random effects in all models additional analyses of smaller groups of countries and individual countries are needed The effects of WTO member-ship may differ by level of economic development and other country-specific factors such as geography and climate which affect the baseline supply of various food groups tobacco and types of alcohol Researchers could recreate this analysis with one income group at a time and a similar analysis of selected low- and middle-income countries with substantial noncommunicable disease burdens may provide further insight into the links between WTO member-ship and changes in noncommunicable disease risk factors Single country studies could permit more nuanced understanding for example by looking at tariff changes for specific products and subsequent changes in their sup-ply Another area for future studies is to examine differences associated with specific provisions in WTO accession agreements and other trade and invest-ment policies as specific concessions differ Understanding which compo-nents of these treaties have the greatest influence on noncommunicable disease risk factors and other aspects of public health is important when tailoring future agreements to be more health-promoting Further researchers should also conduct similar analyses for other products that contribute to noncommu-nicable diseases particularly unhealthy foods high in fat salt and sugar
This study both supports and contradicts findings from previous research We were not able to confirm findings showing increases in consump-tion of meat10 and edible oils47 following trade liberalization Discrepancies may be due to differences in the sample previous studies examined only one to five countries in the same geographical region Studies showing trade-related
increases in sugar-sweetened beverage consumption1348 are somewhat sup-ported by our weak finding that the domestic supply of sugars increases steadily over time following WTO ac-
cession Our results confirm previous findings of increased tobacco712 and alcohol5 consumption associated with trade liberalization Finally few studies have examined fruits and vegetables
Fig 6 Changes in the supply of nuts seeds and legumes seafood and edible oils by joining WTO members and non-member states 1980ndash2013
Year
Year
Year
1980 1990 2000 2010 2013
1980 1990 2000 2010 2013
1980 1990 2000 2010 2013
Range of WTO accession dates
Range of WTO accession dates
Range of WTO accession dates
Mean for joining WTO members Unweighted mean for WTO non-membersWeighted mean for WTO non-members
Kilo
gram
sca
pita
Kilo
gram
sca
pita
Kilo
gram
sca
pita
20
15
10
5
0
20
15
10
5
0
20
15
10
5
0
Nuts seeds and legumes
Seafood
Edible oils
WTO World Trade OrganizationNotes The grey box represents the range of accession dates for countries and territories joining WTO Aberrations in trends starting in 1992 likely reflect the changing composition of countries in each exposure group due to data availability for former Soviet Union countries We obtained weighted means by applying commodity-specific propensity score weights
93Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
consumption in the context of trade liberalization but our findings support the results of an analysis showing that changes in trade policies led to an in-crease in imported fruit in five Central American countries10
This study has limitations A pri-mary limitation is the comparability of countries joining versus not joining WTO We assumed that trends would have been similar between the two groups if none of the countries joined WTO However differences in trends could be due to the influence of other unobserved events correlated with WTO accession and the outcomes of interest or innate characteristics of countries in either group
Another key limitation is the quality of the commodity data which measure
the available supply of each commodity and are only a proxy for consumption the true measure of importance for health In addition there was substantial missing data for certain items summed to create commodity variables which may affect the validity of the data for these categories The commodities ana-lysed were also limited by the available product categories importantly this did not allow us to distinguish changes in trends in the availability of specific foods high in fat salt or sugar an important determinant of obesity and noncommu-nicable diseases49 Finally for tobacco and alcohol illicit sales and homemade varieties are not captured in this data which may comprise substantial por-tions of supply and consumption in certain countries
In conclusion changes in domestic supply of alcohol tobacco and fruits and vegetables could have important implications for public health particu-larly for the development and preven-tion of noncommunicable diseases Overall findings indicated substantial country-level heterogeneity Therefore additional exploration of variations across countries is critical to identify factors that mitigate the negative role and enhance the positive role of trade and investment agreements in the global noncommunicable disease burden
Funding Krycia Cowling was supported by a Center for a Livable Future-Lerner fellowship during the time of this study
Competing interests None declared
摘要世界贸易组织成员国与非传染性疾病风险因素的变化一项断续时间序列比较分析1980ndash2013 年目的 旨在调查加入世界贸易组织 (WTO) 与获取若干商品(此类商品对非传染性疾病的形成兼具有害因素和保护因素)之间的关系方法 我 们 使 用 自 然 实 验 设 计 倾 向 评 分 权 重 来比 较 1980 年 至 2013 年 期 间 在 1995 年 之 后 加入 WTO 的 21 个国家或地区以及 26 个非成员国的烟草酒精和七类食品组在各国内的供应趋势我们采用断续时间序列框架使用多变量随机效应线性模型根据人均国内生产总值城市人口百分比和女性劳动力参与进行调整在烟草模型中我们控制了已批准
《烟草控制框架公约》的成员国在酒精模型中我们控制了自认为穆斯林国家所占的比例
结果 成员国加入世贸组织后与非成员国相比平均每人每天的水果和蔬菜国内供应量立即增长 55 克分析显示烟草和酒精每年的供应量以几何平均数的形式逐渐递增分别为每年 62 和 36我们尚未发现获取红肉和动物脂肪有任何重大变化 海鲜 坚果种子和豆类 淀粉 或食用油 以及与糖相关的结果在不同模型中是不一致的结论 结果表明成为 WTO 成员国可能会导致非传染性疾病的有害因素和保护因素增加但仍需进一步探索其针对具体国家的不同变化
ملخصعضوية منظمة التجارة العاملية والتغريات يف عوامل خطر األمراض غري املعدية حتليل سالسل زمنية مقارنة متقطعة ما
بني عامي 1980 و2013العاملية التجارة منظمة إىل االنضامم بني العالقة دراسة الغرض الضارة التأثريات ذات السلع من العديد وتوافر (WTO)
والوقائية من أجل تطوير األمراض غري املعديةاالجتاهات ملقارنة الطبيعية التجربة تصميم استخدمنا الطريقة بني غذائية جمموعات وسبع والكحول للتبغ املحيل اإلمداد يف عامي 1980 و2013 يف 21 دولة أو منطقة انضمت إىل منظمة التجارة العاملية بعد عام 1995 و26 دولة غري أعضاء باستخدام أوزان درجات النزوع طبقنا إطارا زمنيا متسلسال مقارنا متقطعا معدلة متعددة عشوائية تأثريات ذات خطية نامذج باستخدام احلرض لسكان املئوية والنسب للفرد اإلمجايل املحيل للناتج ومشاركة املرأة يف القوى العاملة يف نموذج التبغ قمنا باملكافحة ملكافحة اإلطارية االتفاقية عىل صدقت التي األعضاء الدول يف يعرفون الذين للسكان املئوية النسبة الكحول نموذج ويف التبغ
أنفسهم بأهنم مسلمني
الدول شهدت العاملية التجارة منظمة إىل االنضامم بعد النتائج األعضاء زيادات فورية يف اإلمداد املحيل من الفواكه واخلرضوات وصلت إىل 55 جم للشخص الواحد يف اليوم يف املتوسط مقارنة بالدول غري األعضاء أظهر التحليل زيادات تدرجيية يف املتوسط
اهلنديس إلمدادات التبغ والكحول بنسبة 62 و 36 يف السنة لحوم ال توافر يف جوهرية ت تغيريا أي نكتشف مل الرتتيب عىل احلمراء أو الدهون احليوانية أو املأكوالت البحرية أو املكرسات أو البذور والبقوليات أو النشويات أو الزيوت الصاحلة لألكل
وكانت النتائج للسكريات غري متناسقة عرب تنوعات النموذجقد العاملية التجارة ة منظم وية عض أن إىل النتائج تشري االستنتاج لألمراض والوقائية ة الضار مل العوا من كل يف زيادة إىل تؤدي االختالفات استكشاف من ملزيد ز تعزي هناك ولكن املعدية غري
اخلاصة بكل بلد
94 Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
Reacutesumeacute
Adheacutesion agrave lOrganisation mondiale du commerce et eacutevolution des facteurs de risque de maladies non transmissibles analyse comparative de seacuteries chronologiques interrompues 1980ndash2013Objectif Eacutetudier le lien entre ladheacutesion agrave lOrganisation mondiale du commerce (OMC) et la disponibiliteacute de diffeacuterentes denreacutees avec des effets agrave la fois nocifs et protecteurs pour le deacuteveloppement des maladies non transmissiblesMeacutethodes Nous avons utiliseacute un plan dexpeacuterience dans les conditions naturelles pour comparer entre 1980 et 2013 leacutevolution de loffre nationale de tabac dalcool et de sept groupes daliments dans 21 pays ou territoires devenus membres de lOMC apregraves 1995 et 26 pays non membres agrave laide de pondeacuterations par le score de propension Nous avons appliqueacute un cadre comparatif de seacuteries chronologiques interrompues agrave laide de modegraveles lineacuteaires agrave effets aleacuteatoires multivarieacutes rajusteacutes pour tenir compte du produit inteacuterieur brut par habitant du pourcentage de la population urbaine et de la participation des femmes agrave la vie active Dans le modegravele relatif au tabac nous avons tenu compte des Eacutetats membres ayant ratifieacute la Convention-cadre pour la lutte antitabac tandis que dans le modegravele relatif agrave lalcool nous avons tenu
compte du pourcentage de la population sidentifiant comme eacutetant de foi musulmaneReacutesultats Agrave la suite de leur adheacutesion agrave lOMC les Eacutetats membres ont connu une augmentation immeacutediate de loffre nationale de fruits et leacutegumes de 55 g par personne et par jour en moyenne par rapport aux pays non membres Lanalyse a reacuteveacuteleacute une augmentation progressive de la moyenne geacuteomeacutetrique de loffre de tabac et dalcool de 62 et 36 par an respectivement Nous navons pas constateacute de changements importants concernant la disponibiliteacute de viandes rouges et graisses dorigine animale de produits de la mer de noix graines et leacutegumineuses de feacuteculents ou dhuiles alimentaires et les reacutesultats relatifs aux sucres variaient dun modegravele agrave lautreConclusion Les reacutesultats suggegraverent que ladheacutesion agrave lOMC peut entraicircner une augmentation des facteurs agrave la fois nocifs et protecteurs pour les maladies non transmissibles mais il convient de reacutealiser de nouvelles recherches sur les variations par pays
Резюме
Членство во Всемирной торговой организации и изменения в факторах риска неинфекционных заболеваний сравнительный анализ прерванных временных рядов 1980ndash2013 ггЦель Членство во Всемирной торговой организации и изменения в факторах риска неинфекционных заболеваний сравнительный анализ прерванных временных рядов 1980ndash2013 ггМетоды Авторы использовали естественный эксперимент для сравнения тенденций внутренних поставок табака алкоголя и товаров семи продовольственных групп в период с 1980 по 2013 год в 21 стране или территории которые вступили в ВТО после 1995 года и в 26 странах не являющихся членами этой организации Анализ проводился с использованием весовых коэффициентов предрасположенности Авторы применили методику сравнительных прерванных временных рядов и многовариантные линейные модели случайных воздействий скорректированные по валовому внутреннему продукту на душу населения процентной доле городского населения и участию женщин в трудовой деятельности В модели для табака контролировались государства-члены ВТО ратифицировавшие Рамочную конвенцию по борьбе против табака а в модели
для алкоголя mdash доля населения идентифицирующая себя как мусульманеРезультаты После вступления в ВТО в государствах-членах наблюдался немедленный прирост внутренних поставок фруктов и овощей (в среднем до 55 г в день на человека) по сравнению со странами не являющимися ее членами Анализ показал постепенное увеличение среднего геометрического значения поставок табака и алкоголя на 62 и 36 в год соответственно Авторы не обнаружили существенных изменений в доступности мяса домашнего скота и животных жиров морепродуктов орехов семян и бобовых а также крахмала или пищевых масел Что касается сахара в разных моделях были получены несовпадающие результатыВывод Результаты позволяют предположить что членство в ВТО может привести к увеличению как полезных так и вредных факторов распространения неинфекционных заболеваний но необходимо проведение дальнейших исследований вариаций в различных странах
Resumen
Composicioacuten de la Organizacioacuten Mundial del Comercio y cambios en los factores de riesgo de las enfermedades no contagiosas un anaacutelisis comparativo de series cronoloacutegicas interrumpidas 1980-2013Objetivo Investigar la relacioacuten entre la adhesioacuten a la Organizacioacuten Mundial del Comercio (OMC) y la disponibilidad de varios productos baacutesicos con efectos tanto perjudiciales como protectores para el desarrollo de enfermedades no contagiosasMeacutetodos Se utilizoacute un disentildeo de experimento natural para comparar las tendencias de la oferta interna de tabaco alcohol y siete grupos de alimentos entre 1980 y 2013 en 21 paiacuteses o territorios que se incorporaron a la OMC despueacutes de 1995 y 26 paiacuteses no miembros mediante el uso de ponderaciones de propensioacuten Se aplicoacute un marco comparativo de series temporales interrumpidas siguiendo modelos lineales de efectos aleatorios multivariados ajustados seguacuten el producto interior bruto per caacutepita los porcentajes de poblacioacuten urbana y la participacioacuten de la mujer en el mundo laboral En el modelo del
tabaco controlamos a los Estados miembros que habiacutean ratificado el Convenio Marco para el Control del Tabaco y en el modelo del alcohol el porcentaje de la poblacioacuten que se identificaba como musulmanaResultados Tras la adhesioacuten a la OMC los Estados miembros experimentaron un aumento inmediato de la oferta interna de frutas y hortalizas de 55 kg por persona y diacutea de media en comparacioacuten con los paiacuteses no miembros El anaacutelisis mostroacute incrementos graduales en la media geomeacutetrica de la oferta de tabaco y alcohol del 62 y el 36 anual respectivamente No se detectaron cambios significativos en la disponibilidad de carnes rojas y grasas animales mariscos nueces semillas y legumbres almidones o aceites comestibles y los resultados para los azuacutecares fueron inconsistentes entre las variaciones del modelo
95Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
Conclusioacuten Los resultados sugieren que la pertenencia a la OMC puede dar lugar a un aumento de los factores perjudiciales y protectores de
las enfermedades no contagiosas pero es necesario seguir estudiando las variaciones especiacuteficas de cada paiacutes
References1 Murray CJ Vos T Lozano R Naghavi M Flaxman AD Michaud C et al
Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions 1990ndash2010 a systematic analysis for the Global Burden of Disease Study 2010 Lancet 2012 Dec 15380(9859)2197ndash223 doi httpdxdoiorg101016S0140-6736(12)61689-4 PMID 23245608
2 Lim SS Vos T Flaxman AD Danaei G Shibuya K Adair-Rohani H et al A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions 1990ndash2010 a systematic analysis for the Global Burden of Disease Study 2010 Lancet 2012 Dec 15380(9859)2224ndash60 doi httpdxdoiorg101016S0140-6736(12)61766-8 PMID 23245609
3 Baker P Friel S Food systems transformations ultra-processed food markets and the nutrition transition in Asia Global Health 2016 12 312(1)80 doi httpdxdoiorg101186s12992-016-0223-3 PMID 27912772
4 Labonteacute R Mohindra KS Lencucha R Framing international trade and chronic disease Global Health 2011 07 47(1)21 doi httpdxdoiorg1011861744-8603-7-21 PMID 21726434
5 Stuckler D McKee M Ebrahim S Basu S Manufacturing epidemics the role of global producers in increased consumption of unhealthy commodities including processed foods alcohol and tobacco PLoS Med 20129(6)e1001235 doi httpdxdoiorg101371journalpmed1001235 PMID 22745605
6 De Vogli R Kouvonen A Gimeno D The influence of market deregulation on fast food consumption and body mass index a cross-national time series analysis Bull World Health Organ 2014 Feb 192(2)99ndash107 107A doi httpdxdoiorg102471BLT13120287 PMID 24623903
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8 Cassels S Overweight in the Pacific links between foreign dependence global food trade and obesity in the Federated States of Micronesia Global Health 2006 07 112(1)10 doi httpdxdoiorg1011861744-8603-2-10 PMID 16834782
9 Schultz JT Globalisation urbanization and nutrition transition in a developing island country a case study Fiji Globalization of food systems in developing countries impact on food security and nutrition Rome Food and Agriculture Organization 2004
10 Thow AM Hawkes C The implications of trade liberalization for diet and health a case study from Central America Global Health 2009 07 2855 doi httpdxdoiorg1011861744-8603-5-5 PMID 19638196
11 Barlow P McKee M Basu S Stuckler D The health impact of trade and investment agreements a quantitative systematic review and network co-citation analysis Global Health 2017 03 813(1)13 doi httpdxdoiorg101186s12992-017-0240-x PMID 28274238
12 Taylor A Chaloupka FJ Guindon E Corbett M The impact of trade liberalization on tobacco consumption In Jha P Chaloupka FJ editors Tobacco control in developing countries Oxford Oxford University Press 2000 pp 343ndash64
13 Schram A Labonte R Baker P Friel S Reeves A Stuckler D The role of trade and investment liberalization in the sugar-sweetened carbonated beverages market a natural experiment contrasting Vietnam and the Philippines Global Health 2015 10 1211(1)41 doi httpdxdoiorg101186s12992-015-0127-7 PMID 26455446
14 Baker P Friel S Schram A Labonte R Trade and investment liberalization food systems change and highly processed food consumption a natural experiment contrasting the soft-drink markets of Peru and Bolivia Global Health 2016 06 212(1)24 doi httpdxdoiorg101186s12992-016-0161-0 PMID 27255275
15 Understanding the WTO the organization Members and observers [internet] Geneva World Trade Organization 2017 Available from httpswwwwtoorgenglishthewto_ewhatis_etif_eorg6_ehtm [cited 2017 Mar 28]
16 Guenther PM Casavale KO Reedy J Kirkpatrick SI Hiza HA Kuczynski KJ et al Update of the healthy eating index HEI-2010 J Acad Nutr Diet 2013 Apr113(4)569ndash80 doi httpdxdoiorg101016jjand201212016 PMID 23415502
17 Haines PS Siega-Riz AM Popkin BM The Diet Quality Index revised a measurement instrument for populations J Am Diet Assoc 1999 Jun99(6)697ndash704 doi httpdxdoiorg101016S0002-8223(99)00168-6 PMID 10361532
18 Huijbregts P Feskens E Raumlsaumlnen L Fidanza F Nissinen A Menotti A et al Dietary pattern and 20 year mortality in elderly men in Finland Italy and The Netherlands longitudinal cohort study BMJ 1997 Jul 5315(7099)13ndash7 doi httpdxdoiorg101136bmj315709913 PMID 9233319
19 Panagiotakos DB Pitsavos C Stefanadis C Dietary patterns a Mediterranean diet score and its relation to clinical and biological markers of cardiovascular disease risk Nutr Metab Cardiovasc Dis 2006 Dec16(8)559ndash68 doi httpdxdoiorg101016jnumecd200508006 PMID 17126772
20 Guidelines for measuring household and individual dietary diversity [internet] Rome Food and Agriculture Organization 2012 Available from httpwwwfaoorgdocrep014i1983ei1983e00htm [cited 2017 Jan 14]
21 Indicators for nutrition-friendly and sustainable food systems InGlobal nutrition report 2015 actions and accountability to advance nutrition and sustainable development Washington DC International Food Policy Research Institute 2015 pp 85ndash96 Available from httpglobalnutritionreportorgthe-reportthe-report-2015 [cited 2017 Apr 4]
22 Micha R Khatibzadeh S Shi P Andrews KG Engell RE Mozaffarian D Global Burden of Diseases Nutrition and Chronic Diseases Expert Group (NutriCoDE) Global regional and national consumption of major food groups in 1990 and 2010 a systematic analysis including 266 country-specific nutrition surveys worldwide BMJ Open 2015 09 245(9)e008705 doi httpdxdoiorg101136bmjopen-2015-008705 PMID 26408285
23 Mozaffarian D Hao T Rimm EB Willett WC Hu FB Changes in diet and lifestyle and long-term weight gain in women and men N Engl J Med 2011 Jun 23364(25)2392ndash404 doi httpdxdoiorg101056NEJMoa1014296 PMID 21696306
24 Mozaffarian D Appel LJ Van Horn L Components of a cardioprotective diet new insights Circulation 2011 Jun 21123(24)2870ndash91 doi httpdxdoiorg101161CIRCULATIONAHA110968735 PMID 21690503
25 WTO membership and noncommunicable disease risk factors - Supplemental materials Baltimore Johns Hopkins University 2018 Available from doi httpdxdoiorg106084m9figshare7268561v1 [cited 2018 Oct 30]doi httpdxdoiorg106084m9figshare7268561v1
26 Maumlnnistouml S Laatikainen T Helakorpi S Valsta LM Monitoring diet and diet-related chronic disease risk factors in Finland Public Health Nutr 2010 Jun13 6A907ndash14 doi httpdxdoiorg101017S1368980010001084 PMID 20513259
27 Sheehy T Sharma S Trends in energy and nutrient supply in Trinidad and Tobago from 1961 to 2007 using FAO food balance sheets Public Health Nutr 2013 Sep16(9)1693ndash702 doi httpdxdoiorg101017S136898001200537X PMID 23286774
28 World development indicators [internet] Washington DC The World Bank 2016 Available from httpdataworldbankorgdata-catalogworld-development-indicators [cited 2017 Feb 20]
29 World population prospects the 2015 Revision [internet] New York United Nations Department of Economic and Social Affairs Population Division 2015 Available from httpsesaunorgunpdwpp [cited 2017 Jan 6]
30 Gross domestic product (GDP) estimates by country 1950ndash2015 [internet] Seattle Institute for Health Metrics and Evaluation 2017 Available from httpghdxhealthdataorgrecordgross-domestic-product-gdp-estimates-country-1950-2015 [cited 2017 Jan 6]
31 Table Muslim Population by Country [internet] Washington DC Pew Research Center 2011 Available from httpwwwpewforumorg20110127table-muslim-population-by-country [cited 2017 Apr 12]
32 Depositary WHO Framework Convention on Tobacco Control [internet] New York United Nations Treaty Collection 2025 Available from httpstreatiesunorgpagesViewDetailsaspxsrc=TREATYampmtdsg_no=IX-4ampchapter=9amplang=en [cited 2017 Apr 18]
33 Ng M Freeman MK Fleming TD Robinson M Dwyer-Lindgren L Thomson B et al Smoking prevalence and cigarette consumption in 187 countries 1980ndash2012 JAMA 2014 Jan 8311(2)183ndash92 doi httpdxdoiorg101001jama2013284692 PMID 24399557
96 Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
34 Rehm J Mathers C Popova S Thavorncharoensap M Teerawattananon Y Patra J Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders Lancet 2009 Jun 27373(9682)2223ndash33 doi httpdxdoiorg101016S0140-6736(09)60746-7 PMID 19560604
35 Al-Ansari B Thow A-M Day CA Conigrave KM Extent of alcohol prohibition in civil policy in Muslim majority countries the impact of globalization Addiction 2016 10111(10)1703ndash13 doi httpdxdoiorg101111add13159 PMID 26508526
36 About the WHO Framework Convention on Tobacco Control [internet] Geneva World Health Organization 2018 Available from httpwwwwhointfctcabouten [cited 2017 May 11]
37 Stuart EA Matching methods for causal inference a review and a look forward Stat Sci 2010 Feb 125(1)1ndash21 doi httpdxdoiorg10121409-STS313 PMID 20871802
38 Ridgeway G McCaffrey D Morral A Burgette L Griffin BA Toolkit for weighting and analysis of nonequivalent groups a tutorial for the twang package R Vignette [internet] Vienna R Foundation 2017 Available from httpscranr-projectorgwebpackagestwangvignettestwangpdf [cited 2017 Apr 18]
39 McCaffrey DF Ridgeway G Morral AR Propensity score estimation with boosted regression for evaluating causal effects in observational studies Psychol Methods 2004 Dec9(4)403ndash25 doi httpdxdoiorg1010371082-989X94403 PMID 15598095
40 Linden A Adams JL Applying a propensity score-based weighting model to interrupted time series data improving causal inference in programme evaluation J Eval Clin Pract 2011 Dec17(6)1231ndash8 doi httpdxdoiorg101111j1365-2753201001504x PMID 20973870
41 Griswold MG Fullman N Hawley C Arian N Zimsen SRM Tymeson HD et al GBD 2016 Alcohol Collaborators Alcohol use and burden for 195 countries and territories 1990ndash2016 a systematic analysis for the Global Burden of Disease Study 2016 Lancet 2018 Sep 22392(10152)1015ndash35 doi httpdxdoiorg101016S0140-6736(18)31310-2 PMID 30146330
42 Peto R Lopez AD Boreham J Thun M Heath C Jr Mortality from tobacco in developed countries indirect estimation from national vital statistics Lancet 1992 May 23339(8804)1268ndash78 doi httpdxdoiorg1010160140-6736(92)91600-D PMID 1349675
43 Healthy diet Key facts Geneva World Health Organization 2018 Available from httpwwwwhointnews-roomfact-sheetsdetailhealthy-diet [cited 2018 Oct 26]
44 Aune D Giovannucci E Boffetta P Fadnes LT Keum N Norat T et al Fruit and vegetable intake and the risk of cardiovascular disease total cancer and all-cause mortality-a systematic review and dose-response meta-analysis of prospective studies Int J Epidemiol 2017 06 146(3)1029ndash56 doi httpdxdoiorg101093ijedyw319 PMID 28338764
45 Health in All Policies framework for country action [internet] Geneva World Health Organization 2018 Available from httpwwwwhointhealthpromotionframeworkforcountryactionen [cited 2017 Aug 13]
46 Cole BL Fielding JE Health impact assessment a tool to help policy makers understand health beyond health care Annu Rev Public Health 200728(1)393ndash412 doi httpdxdoiorg101146annurevpublhealth28083006131942 PMID 17173539
47 Tonts M Siddique MAB editors Globalisation agriculture and development perspectives from the Asia-Pacific Cheltenham Edward Elgar Publishing 2011 Available from httpswwwelgaronlinecomview978184720818700010xml [cited 2017 Aug 14]
48 Mendez Lopez A Loopstra R McKee M Stuckler D Is trade liberalisation a vector for the spread of sugar-sweetened beverages A cross-national longitudinal analysis of 44 low- and middle-income countries Soc Sci Med 2017 0117221ndash7 doi httpdxdoiorg101016jsocscimed201611001 PMID 27871042
49 Monteiro CA Moubarac J-C Cannon G Ng SW Popkin B Ultra-processed products are becoming dominant in the global food system Obes Rev 2013 Nov14 Suppl 221ndash8 doi httpdxdoiorg101111obr12107 PMID 24102801
Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057 96A
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
Fig 1 Unweighted and weighted absolute standardized biases for baseline commodity supply in countries included in the study 1980ndash1995
female labour force
participation
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participation
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Seafood
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Alcohol Fruits andvegetables
GDP percapita (log)
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Absolute standardize bias
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Unweighted Weighted
0 02 04 06 08
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Supply of tobacco
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Supply of red meats and animal fats
Supply of alcohol
Supply of fruits and vegetables
GDP gross domestic productNotes The period 1980ndash1995 represents the years before countries and territories start joining the World Trade Organization Table 1 lists countries studied We measured bias by the absolute standardized mean difference that is (mean for non-member states ndash mean for member states)(combined standard deviation)
- Table 1
- Table 2
- Table 3
- Figure 2
- Figure 3
- Figure 4
- Figure 5
- Figure 6
- Figure 1
-
90 Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
remained significant in most analyses The trend coefficient for the tobacco supply also remained of a consistent magnitude but not always statisti-cally significant In only the lagged effect models treatment effects for sugars were significant and similar in magnitude to those in the main model providing some evidence of an initial decrease in the availability of sugars following WTO accession followed by a minimal steady increase When we stratified the analyses by country income group the results did not support any of the main conclusions However propensity score weights were generated to balance the sample and likely generated false results from these models which were run with 23 countries or less (out of the total 47) per income group Further details on each sensitivity analysis are available in the figshare repository25
DiscussionHere we show that following a countryrsquos accession to WTO there was a signifi-cant increasing trend in the domestic supply of alcohol a borderline signifi-cant increasing trend in the supply of tobacco and a significant immediate increase in the availability of fruits and vegetables compared with non-member countries Assuming that increases in supply likely translate to increases in consumption these changes have both positive and negative implications for global health For example recent re-search has indicated that any amount of alcohol consumption increases the risk of a range of negative health outcomes hence an increase in alcohol supply could be harmful41 Likewise an increase in tobacco use is negative as tobacco contributes to several noncommuni-cable diseases42 In contrast increases in fruit and vegetable consumption can protect against the development of numerous noncommunicable diseases24 The WHO recommends a 400 g intake of fruit and vegetables daily43 although even an intake of 200 g per day has been found to reduce the risk of many non-communicable diseases and premature mortality44 We estimate that average increase in the supply is about 55 g of fruits and vegetables per person per day higher in the countries after join-ing WTO
Our results provide more evidence about the links between trade liberaliza-tion and global health suggesting that
trade agreements should be considered as social determinants of health at the global scale As the burden of noncom-municable diseases continues to grow stakeholders should prioritize identify-ing the most effective strategies to curb the increase in risk factors including to-bacco and alcohol use and poor diet For example addressing aspects of trade and investment policies that alter the supply
of these products can help to tackle the noncommunicable disease burden at the root cause level This approach can be achieved through actions grounded in the Health in All Policies framework45 and the application of health impact assessment to proposed trade and in-vestment policies46 At the global level further development and consideration of international agreements to prevent
Fig 2 Changes in the supply of all forms of tobacco by joining WTO members and non-member states 1980ndash2013
All f
orm
s of t
obac
co(g
ram
sca
pita
old
er th
an 1
4 ye
ars)
2500
2000
1500
1000
500
0
Year1980 1990 2000 2010 2013
Range of WTO accession dates
Mean for joining WTO members Unweighted mean for WTO non-membersWeighted mean for WTO non-members
WTO World Trade OrganizationNotes The grey box represents the range of accession dates for countries and territories joining WTO Aberrations in trends starting in 1992 likely reflect the changing composition of countries in each exposure group due to data availability for former Soviet Union countries We obtained weighted means by applying tobacco-specific propensity score weights
Fig 3 Changes in the supply of all types of alcohol by joining WTO members and non-member states 1980ndash2013
All t
ypes
of a
lcoho
l(k
ilogr
ams
capi
ta o
lder
than
14
year
s)
60
40
20
0
Year1980 1990 2000 2010 2013
Range of WTO accession dates
Mean for joining WTO members Unweighted mean for WTO non-membersWeighted mean for WTO non-members
WTO World Trade OrganizationNotes The grey box represents the range of accession dates for countries and territories joining WTO Aberrations in trends starting in 1992 likely reflect the changing composition of countries in each exposure group due to data availability for former Soviet Union countries We obtained weighted means by applying alcohol-specific propensity score weights
91Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
Fig
4
Chan
ges i
n th
e su
pply
of f
ruits
and
vege
tabl
es a
nd st
arch
es f
or jo
inin
g W
TO
mem
bers
and
non
-mem
ber s
tate
s 19
80ndash2
013
Year
Year
1980
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2010
2013
1980
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2013
Rang
e of W
TO ac
cessi
on da
tes
Rang
e of W
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on da
tes
Mea
n fo
r joi
ning
WTO
mem
bers
Unw
eigh
ted
mea
n fo
r WTO
non
-mem
bers
Wei
ghte
d m
ean
for W
TO n
on-m
embe
rs
Kilogramscapita Kilogramscapita250
200
150
100 50 0
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100 50 0
Star
ches
Frui
ts an
d ve
geta
bles
WTO
Wor
ld Tr
ade
Org
aniz
atio
nN
otes
The
gre
y bo
x re
pres
ents
the
rang
e of
acc
essio
n da
tes f
or c
ount
ries a
nd te
rrito
ries j
oini
ng W
TO
Aber
ratio
ns in
tren
ds st
artin
g in
199
2 lik
ely
refle
ct th
e ch
angi
ng c
ompo
sitio
n of
cou
ntrie
s in
each
ex
posu
re g
roup
due
to d
ata
avai
labi
lity
for f
orm
er S
ovie
t Uni
on c
ount
ries
We
obta
ined
wei
ghte
d m
eans
by
app
lyin
g co
mm
odity
-spe
cific
pro
pens
ity sc
ore
wei
ghts
Fig
5
Chan
ges i
n th
e su
pply
of r
ed m
eats
and
ani
mal
fats
and
suga
rs b
y joi
ning
WTO
m
embe
rs a
nd n
on-m
embe
r sta
tes
1980
ndash201
3
Year
Year
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2013
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Rang
e of W
TO ac
cessi
on da
tes
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e of W
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on da
tes
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n fo
r joi
ning
WTO
mem
bers
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eigh
ted
mea
n fo
r WTO
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-mem
bers
Wei
ghte
d m
ean
for W
TO n
on-m
embe
rs
Kilogramscapita Kilogramscapita
50 40 30 20 10 0 50 40 30 20 10 0
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92 Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
and control noncommunicable diseases like the FCTC but focused on other noncommunicable disease risk factors is warranted Such agreements can legally bind countries to health com-mitments providing a counterweight for commitments to international trade and investment rules
Our findings are suggestive but not conclusive warranting additional exploration and we suggest several po-tential avenues for future research For example given substantial unexplained country-specific heterogeneity indicated by country random effects in all models additional analyses of smaller groups of countries and individual countries are needed The effects of WTO member-ship may differ by level of economic development and other country-specific factors such as geography and climate which affect the baseline supply of various food groups tobacco and types of alcohol Researchers could recreate this analysis with one income group at a time and a similar analysis of selected low- and middle-income countries with substantial noncommunicable disease burdens may provide further insight into the links between WTO member-ship and changes in noncommunicable disease risk factors Single country studies could permit more nuanced understanding for example by looking at tariff changes for specific products and subsequent changes in their sup-ply Another area for future studies is to examine differences associated with specific provisions in WTO accession agreements and other trade and invest-ment policies as specific concessions differ Understanding which compo-nents of these treaties have the greatest influence on noncommunicable disease risk factors and other aspects of public health is important when tailoring future agreements to be more health-promoting Further researchers should also conduct similar analyses for other products that contribute to noncommu-nicable diseases particularly unhealthy foods high in fat salt and sugar
This study both supports and contradicts findings from previous research We were not able to confirm findings showing increases in consump-tion of meat10 and edible oils47 following trade liberalization Discrepancies may be due to differences in the sample previous studies examined only one to five countries in the same geographical region Studies showing trade-related
increases in sugar-sweetened beverage consumption1348 are somewhat sup-ported by our weak finding that the domestic supply of sugars increases steadily over time following WTO ac-
cession Our results confirm previous findings of increased tobacco712 and alcohol5 consumption associated with trade liberalization Finally few studies have examined fruits and vegetables
Fig 6 Changes in the supply of nuts seeds and legumes seafood and edible oils by joining WTO members and non-member states 1980ndash2013
Year
Year
Year
1980 1990 2000 2010 2013
1980 1990 2000 2010 2013
1980 1990 2000 2010 2013
Range of WTO accession dates
Range of WTO accession dates
Range of WTO accession dates
Mean for joining WTO members Unweighted mean for WTO non-membersWeighted mean for WTO non-members
Kilo
gram
sca
pita
Kilo
gram
sca
pita
Kilo
gram
sca
pita
20
15
10
5
0
20
15
10
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20
15
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Nuts seeds and legumes
Seafood
Edible oils
WTO World Trade OrganizationNotes The grey box represents the range of accession dates for countries and territories joining WTO Aberrations in trends starting in 1992 likely reflect the changing composition of countries in each exposure group due to data availability for former Soviet Union countries We obtained weighted means by applying commodity-specific propensity score weights
93Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
consumption in the context of trade liberalization but our findings support the results of an analysis showing that changes in trade policies led to an in-crease in imported fruit in five Central American countries10
This study has limitations A pri-mary limitation is the comparability of countries joining versus not joining WTO We assumed that trends would have been similar between the two groups if none of the countries joined WTO However differences in trends could be due to the influence of other unobserved events correlated with WTO accession and the outcomes of interest or innate characteristics of countries in either group
Another key limitation is the quality of the commodity data which measure
the available supply of each commodity and are only a proxy for consumption the true measure of importance for health In addition there was substantial missing data for certain items summed to create commodity variables which may affect the validity of the data for these categories The commodities ana-lysed were also limited by the available product categories importantly this did not allow us to distinguish changes in trends in the availability of specific foods high in fat salt or sugar an important determinant of obesity and noncommu-nicable diseases49 Finally for tobacco and alcohol illicit sales and homemade varieties are not captured in this data which may comprise substantial por-tions of supply and consumption in certain countries
In conclusion changes in domestic supply of alcohol tobacco and fruits and vegetables could have important implications for public health particu-larly for the development and preven-tion of noncommunicable diseases Overall findings indicated substantial country-level heterogeneity Therefore additional exploration of variations across countries is critical to identify factors that mitigate the negative role and enhance the positive role of trade and investment agreements in the global noncommunicable disease burden
Funding Krycia Cowling was supported by a Center for a Livable Future-Lerner fellowship during the time of this study
Competing interests None declared
摘要世界贸易组织成员国与非传染性疾病风险因素的变化一项断续时间序列比较分析1980ndash2013 年目的 旨在调查加入世界贸易组织 (WTO) 与获取若干商品(此类商品对非传染性疾病的形成兼具有害因素和保护因素)之间的关系方法 我 们 使 用 自 然 实 验 设 计 倾 向 评 分 权 重 来比 较 1980 年 至 2013 年 期 间 在 1995 年 之 后 加入 WTO 的 21 个国家或地区以及 26 个非成员国的烟草酒精和七类食品组在各国内的供应趋势我们采用断续时间序列框架使用多变量随机效应线性模型根据人均国内生产总值城市人口百分比和女性劳动力参与进行调整在烟草模型中我们控制了已批准
《烟草控制框架公约》的成员国在酒精模型中我们控制了自认为穆斯林国家所占的比例
结果 成员国加入世贸组织后与非成员国相比平均每人每天的水果和蔬菜国内供应量立即增长 55 克分析显示烟草和酒精每年的供应量以几何平均数的形式逐渐递增分别为每年 62 和 36我们尚未发现获取红肉和动物脂肪有任何重大变化 海鲜 坚果种子和豆类 淀粉 或食用油 以及与糖相关的结果在不同模型中是不一致的结论 结果表明成为 WTO 成员国可能会导致非传染性疾病的有害因素和保护因素增加但仍需进一步探索其针对具体国家的不同变化
ملخصعضوية منظمة التجارة العاملية والتغريات يف عوامل خطر األمراض غري املعدية حتليل سالسل زمنية مقارنة متقطعة ما
بني عامي 1980 و2013العاملية التجارة منظمة إىل االنضامم بني العالقة دراسة الغرض الضارة التأثريات ذات السلع من العديد وتوافر (WTO)
والوقائية من أجل تطوير األمراض غري املعديةاالجتاهات ملقارنة الطبيعية التجربة تصميم استخدمنا الطريقة بني غذائية جمموعات وسبع والكحول للتبغ املحيل اإلمداد يف عامي 1980 و2013 يف 21 دولة أو منطقة انضمت إىل منظمة التجارة العاملية بعد عام 1995 و26 دولة غري أعضاء باستخدام أوزان درجات النزوع طبقنا إطارا زمنيا متسلسال مقارنا متقطعا معدلة متعددة عشوائية تأثريات ذات خطية نامذج باستخدام احلرض لسكان املئوية والنسب للفرد اإلمجايل املحيل للناتج ومشاركة املرأة يف القوى العاملة يف نموذج التبغ قمنا باملكافحة ملكافحة اإلطارية االتفاقية عىل صدقت التي األعضاء الدول يف يعرفون الذين للسكان املئوية النسبة الكحول نموذج ويف التبغ
أنفسهم بأهنم مسلمني
الدول شهدت العاملية التجارة منظمة إىل االنضامم بعد النتائج األعضاء زيادات فورية يف اإلمداد املحيل من الفواكه واخلرضوات وصلت إىل 55 جم للشخص الواحد يف اليوم يف املتوسط مقارنة بالدول غري األعضاء أظهر التحليل زيادات تدرجيية يف املتوسط
اهلنديس إلمدادات التبغ والكحول بنسبة 62 و 36 يف السنة لحوم ال توافر يف جوهرية ت تغيريا أي نكتشف مل الرتتيب عىل احلمراء أو الدهون احليوانية أو املأكوالت البحرية أو املكرسات أو البذور والبقوليات أو النشويات أو الزيوت الصاحلة لألكل
وكانت النتائج للسكريات غري متناسقة عرب تنوعات النموذجقد العاملية التجارة ة منظم وية عض أن إىل النتائج تشري االستنتاج لألمراض والوقائية ة الضار مل العوا من كل يف زيادة إىل تؤدي االختالفات استكشاف من ملزيد ز تعزي هناك ولكن املعدية غري
اخلاصة بكل بلد
94 Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
Reacutesumeacute
Adheacutesion agrave lOrganisation mondiale du commerce et eacutevolution des facteurs de risque de maladies non transmissibles analyse comparative de seacuteries chronologiques interrompues 1980ndash2013Objectif Eacutetudier le lien entre ladheacutesion agrave lOrganisation mondiale du commerce (OMC) et la disponibiliteacute de diffeacuterentes denreacutees avec des effets agrave la fois nocifs et protecteurs pour le deacuteveloppement des maladies non transmissiblesMeacutethodes Nous avons utiliseacute un plan dexpeacuterience dans les conditions naturelles pour comparer entre 1980 et 2013 leacutevolution de loffre nationale de tabac dalcool et de sept groupes daliments dans 21 pays ou territoires devenus membres de lOMC apregraves 1995 et 26 pays non membres agrave laide de pondeacuterations par le score de propension Nous avons appliqueacute un cadre comparatif de seacuteries chronologiques interrompues agrave laide de modegraveles lineacuteaires agrave effets aleacuteatoires multivarieacutes rajusteacutes pour tenir compte du produit inteacuterieur brut par habitant du pourcentage de la population urbaine et de la participation des femmes agrave la vie active Dans le modegravele relatif au tabac nous avons tenu compte des Eacutetats membres ayant ratifieacute la Convention-cadre pour la lutte antitabac tandis que dans le modegravele relatif agrave lalcool nous avons tenu
compte du pourcentage de la population sidentifiant comme eacutetant de foi musulmaneReacutesultats Agrave la suite de leur adheacutesion agrave lOMC les Eacutetats membres ont connu une augmentation immeacutediate de loffre nationale de fruits et leacutegumes de 55 g par personne et par jour en moyenne par rapport aux pays non membres Lanalyse a reacuteveacuteleacute une augmentation progressive de la moyenne geacuteomeacutetrique de loffre de tabac et dalcool de 62 et 36 par an respectivement Nous navons pas constateacute de changements importants concernant la disponibiliteacute de viandes rouges et graisses dorigine animale de produits de la mer de noix graines et leacutegumineuses de feacuteculents ou dhuiles alimentaires et les reacutesultats relatifs aux sucres variaient dun modegravele agrave lautreConclusion Les reacutesultats suggegraverent que ladheacutesion agrave lOMC peut entraicircner une augmentation des facteurs agrave la fois nocifs et protecteurs pour les maladies non transmissibles mais il convient de reacutealiser de nouvelles recherches sur les variations par pays
Резюме
Членство во Всемирной торговой организации и изменения в факторах риска неинфекционных заболеваний сравнительный анализ прерванных временных рядов 1980ndash2013 ггЦель Членство во Всемирной торговой организации и изменения в факторах риска неинфекционных заболеваний сравнительный анализ прерванных временных рядов 1980ndash2013 ггМетоды Авторы использовали естественный эксперимент для сравнения тенденций внутренних поставок табака алкоголя и товаров семи продовольственных групп в период с 1980 по 2013 год в 21 стране или территории которые вступили в ВТО после 1995 года и в 26 странах не являющихся членами этой организации Анализ проводился с использованием весовых коэффициентов предрасположенности Авторы применили методику сравнительных прерванных временных рядов и многовариантные линейные модели случайных воздействий скорректированные по валовому внутреннему продукту на душу населения процентной доле городского населения и участию женщин в трудовой деятельности В модели для табака контролировались государства-члены ВТО ратифицировавшие Рамочную конвенцию по борьбе против табака а в модели
для алкоголя mdash доля населения идентифицирующая себя как мусульманеРезультаты После вступления в ВТО в государствах-членах наблюдался немедленный прирост внутренних поставок фруктов и овощей (в среднем до 55 г в день на человека) по сравнению со странами не являющимися ее членами Анализ показал постепенное увеличение среднего геометрического значения поставок табака и алкоголя на 62 и 36 в год соответственно Авторы не обнаружили существенных изменений в доступности мяса домашнего скота и животных жиров морепродуктов орехов семян и бобовых а также крахмала или пищевых масел Что касается сахара в разных моделях были получены несовпадающие результатыВывод Результаты позволяют предположить что членство в ВТО может привести к увеличению как полезных так и вредных факторов распространения неинфекционных заболеваний но необходимо проведение дальнейших исследований вариаций в различных странах
Resumen
Composicioacuten de la Organizacioacuten Mundial del Comercio y cambios en los factores de riesgo de las enfermedades no contagiosas un anaacutelisis comparativo de series cronoloacutegicas interrumpidas 1980-2013Objetivo Investigar la relacioacuten entre la adhesioacuten a la Organizacioacuten Mundial del Comercio (OMC) y la disponibilidad de varios productos baacutesicos con efectos tanto perjudiciales como protectores para el desarrollo de enfermedades no contagiosasMeacutetodos Se utilizoacute un disentildeo de experimento natural para comparar las tendencias de la oferta interna de tabaco alcohol y siete grupos de alimentos entre 1980 y 2013 en 21 paiacuteses o territorios que se incorporaron a la OMC despueacutes de 1995 y 26 paiacuteses no miembros mediante el uso de ponderaciones de propensioacuten Se aplicoacute un marco comparativo de series temporales interrumpidas siguiendo modelos lineales de efectos aleatorios multivariados ajustados seguacuten el producto interior bruto per caacutepita los porcentajes de poblacioacuten urbana y la participacioacuten de la mujer en el mundo laboral En el modelo del
tabaco controlamos a los Estados miembros que habiacutean ratificado el Convenio Marco para el Control del Tabaco y en el modelo del alcohol el porcentaje de la poblacioacuten que se identificaba como musulmanaResultados Tras la adhesioacuten a la OMC los Estados miembros experimentaron un aumento inmediato de la oferta interna de frutas y hortalizas de 55 kg por persona y diacutea de media en comparacioacuten con los paiacuteses no miembros El anaacutelisis mostroacute incrementos graduales en la media geomeacutetrica de la oferta de tabaco y alcohol del 62 y el 36 anual respectivamente No se detectaron cambios significativos en la disponibilidad de carnes rojas y grasas animales mariscos nueces semillas y legumbres almidones o aceites comestibles y los resultados para los azuacutecares fueron inconsistentes entre las variaciones del modelo
95Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
Conclusioacuten Los resultados sugieren que la pertenencia a la OMC puede dar lugar a un aumento de los factores perjudiciales y protectores de
las enfermedades no contagiosas pero es necesario seguir estudiando las variaciones especiacuteficas de cada paiacutes
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2 Lim SS Vos T Flaxman AD Danaei G Shibuya K Adair-Rohani H et al A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions 1990ndash2010 a systematic analysis for the Global Burden of Disease Study 2010 Lancet 2012 Dec 15380(9859)2224ndash60 doi httpdxdoiorg101016S0140-6736(12)61766-8 PMID 23245609
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6 De Vogli R Kouvonen A Gimeno D The influence of market deregulation on fast food consumption and body mass index a cross-national time series analysis Bull World Health Organ 2014 Feb 192(2)99ndash107 107A doi httpdxdoiorg102471BLT13120287 PMID 24623903
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11 Barlow P McKee M Basu S Stuckler D The health impact of trade and investment agreements a quantitative systematic review and network co-citation analysis Global Health 2017 03 813(1)13 doi httpdxdoiorg101186s12992-017-0240-x PMID 28274238
12 Taylor A Chaloupka FJ Guindon E Corbett M The impact of trade liberalization on tobacco consumption In Jha P Chaloupka FJ editors Tobacco control in developing countries Oxford Oxford University Press 2000 pp 343ndash64
13 Schram A Labonte R Baker P Friel S Reeves A Stuckler D The role of trade and investment liberalization in the sugar-sweetened carbonated beverages market a natural experiment contrasting Vietnam and the Philippines Global Health 2015 10 1211(1)41 doi httpdxdoiorg101186s12992-015-0127-7 PMID 26455446
14 Baker P Friel S Schram A Labonte R Trade and investment liberalization food systems change and highly processed food consumption a natural experiment contrasting the soft-drink markets of Peru and Bolivia Global Health 2016 06 212(1)24 doi httpdxdoiorg101186s12992-016-0161-0 PMID 27255275
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17 Haines PS Siega-Riz AM Popkin BM The Diet Quality Index revised a measurement instrument for populations J Am Diet Assoc 1999 Jun99(6)697ndash704 doi httpdxdoiorg101016S0002-8223(99)00168-6 PMID 10361532
18 Huijbregts P Feskens E Raumlsaumlnen L Fidanza F Nissinen A Menotti A et al Dietary pattern and 20 year mortality in elderly men in Finland Italy and The Netherlands longitudinal cohort study BMJ 1997 Jul 5315(7099)13ndash7 doi httpdxdoiorg101136bmj315709913 PMID 9233319
19 Panagiotakos DB Pitsavos C Stefanadis C Dietary patterns a Mediterranean diet score and its relation to clinical and biological markers of cardiovascular disease risk Nutr Metab Cardiovasc Dis 2006 Dec16(8)559ndash68 doi httpdxdoiorg101016jnumecd200508006 PMID 17126772
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23 Mozaffarian D Hao T Rimm EB Willett WC Hu FB Changes in diet and lifestyle and long-term weight gain in women and men N Engl J Med 2011 Jun 23364(25)2392ndash404 doi httpdxdoiorg101056NEJMoa1014296 PMID 21696306
24 Mozaffarian D Appel LJ Van Horn L Components of a cardioprotective diet new insights Circulation 2011 Jun 21123(24)2870ndash91 doi httpdxdoiorg101161CIRCULATIONAHA110968735 PMID 21690503
25 WTO membership and noncommunicable disease risk factors - Supplemental materials Baltimore Johns Hopkins University 2018 Available from doi httpdxdoiorg106084m9figshare7268561v1 [cited 2018 Oct 30]doi httpdxdoiorg106084m9figshare7268561v1
26 Maumlnnistouml S Laatikainen T Helakorpi S Valsta LM Monitoring diet and diet-related chronic disease risk factors in Finland Public Health Nutr 2010 Jun13 6A907ndash14 doi httpdxdoiorg101017S1368980010001084 PMID 20513259
27 Sheehy T Sharma S Trends in energy and nutrient supply in Trinidad and Tobago from 1961 to 2007 using FAO food balance sheets Public Health Nutr 2013 Sep16(9)1693ndash702 doi httpdxdoiorg101017S136898001200537X PMID 23286774
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33 Ng M Freeman MK Fleming TD Robinson M Dwyer-Lindgren L Thomson B et al Smoking prevalence and cigarette consumption in 187 countries 1980ndash2012 JAMA 2014 Jan 8311(2)183ndash92 doi httpdxdoiorg101001jama2013284692 PMID 24399557
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ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
34 Rehm J Mathers C Popova S Thavorncharoensap M Teerawattananon Y Patra J Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders Lancet 2009 Jun 27373(9682)2223ndash33 doi httpdxdoiorg101016S0140-6736(09)60746-7 PMID 19560604
35 Al-Ansari B Thow A-M Day CA Conigrave KM Extent of alcohol prohibition in civil policy in Muslim majority countries the impact of globalization Addiction 2016 10111(10)1703ndash13 doi httpdxdoiorg101111add13159 PMID 26508526
36 About the WHO Framework Convention on Tobacco Control [internet] Geneva World Health Organization 2018 Available from httpwwwwhointfctcabouten [cited 2017 May 11]
37 Stuart EA Matching methods for causal inference a review and a look forward Stat Sci 2010 Feb 125(1)1ndash21 doi httpdxdoiorg10121409-STS313 PMID 20871802
38 Ridgeway G McCaffrey D Morral A Burgette L Griffin BA Toolkit for weighting and analysis of nonequivalent groups a tutorial for the twang package R Vignette [internet] Vienna R Foundation 2017 Available from httpscranr-projectorgwebpackagestwangvignettestwangpdf [cited 2017 Apr 18]
39 McCaffrey DF Ridgeway G Morral AR Propensity score estimation with boosted regression for evaluating causal effects in observational studies Psychol Methods 2004 Dec9(4)403ndash25 doi httpdxdoiorg1010371082-989X94403 PMID 15598095
40 Linden A Adams JL Applying a propensity score-based weighting model to interrupted time series data improving causal inference in programme evaluation J Eval Clin Pract 2011 Dec17(6)1231ndash8 doi httpdxdoiorg101111j1365-2753201001504x PMID 20973870
41 Griswold MG Fullman N Hawley C Arian N Zimsen SRM Tymeson HD et al GBD 2016 Alcohol Collaborators Alcohol use and burden for 195 countries and territories 1990ndash2016 a systematic analysis for the Global Burden of Disease Study 2016 Lancet 2018 Sep 22392(10152)1015ndash35 doi httpdxdoiorg101016S0140-6736(18)31310-2 PMID 30146330
42 Peto R Lopez AD Boreham J Thun M Heath C Jr Mortality from tobacco in developed countries indirect estimation from national vital statistics Lancet 1992 May 23339(8804)1268ndash78 doi httpdxdoiorg1010160140-6736(92)91600-D PMID 1349675
43 Healthy diet Key facts Geneva World Health Organization 2018 Available from httpwwwwhointnews-roomfact-sheetsdetailhealthy-diet [cited 2018 Oct 26]
44 Aune D Giovannucci E Boffetta P Fadnes LT Keum N Norat T et al Fruit and vegetable intake and the risk of cardiovascular disease total cancer and all-cause mortality-a systematic review and dose-response meta-analysis of prospective studies Int J Epidemiol 2017 06 146(3)1029ndash56 doi httpdxdoiorg101093ijedyw319 PMID 28338764
45 Health in All Policies framework for country action [internet] Geneva World Health Organization 2018 Available from httpwwwwhointhealthpromotionframeworkforcountryactionen [cited 2017 Aug 13]
46 Cole BL Fielding JE Health impact assessment a tool to help policy makers understand health beyond health care Annu Rev Public Health 200728(1)393ndash412 doi httpdxdoiorg101146annurevpublhealth28083006131942 PMID 17173539
47 Tonts M Siddique MAB editors Globalisation agriculture and development perspectives from the Asia-Pacific Cheltenham Edward Elgar Publishing 2011 Available from httpswwwelgaronlinecomview978184720818700010xml [cited 2017 Aug 14]
48 Mendez Lopez A Loopstra R McKee M Stuckler D Is trade liberalisation a vector for the spread of sugar-sweetened beverages A cross-national longitudinal analysis of 44 low- and middle-income countries Soc Sci Med 2017 0117221ndash7 doi httpdxdoiorg101016jsocscimed201611001 PMID 27871042
49 Monteiro CA Moubarac J-C Cannon G Ng SW Popkin B Ultra-processed products are becoming dominant in the global food system Obes Rev 2013 Nov14 Suppl 221ndash8 doi httpdxdoiorg101111obr12107 PMID 24102801
Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057 96A
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
Fig 1 Unweighted and weighted absolute standardized biases for baseline commodity supply in countries included in the study 1980ndash1995
female labour force
participation
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0 02 04 06 08
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Supply of tobacco
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Supply of fruits and vegetables
GDP gross domestic productNotes The period 1980ndash1995 represents the years before countries and territories start joining the World Trade Organization Table 1 lists countries studied We measured bias by the absolute standardized mean difference that is (mean for non-member states ndash mean for member states)(combined standard deviation)
- Table 1
- Table 2
- Table 3
- Figure 2
- Figure 3
- Figure 4
- Figure 5
- Figure 6
- Figure 1
-
91Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
Fig
4
Chan
ges i
n th
e su
pply
of f
ruits
and
vege
tabl
es a
nd st
arch
es f
or jo
inin
g W
TO
mem
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and
non
-mem
ber s
tate
s 19
80ndash2
013
Year
Year
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2010
2013
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e of W
TO ac
cessi
on da
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n fo
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ning
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n fo
r WTO
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ghte
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TO n
on-m
embe
rs
Kilogramscapita Kilogramscapita250
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ches
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ts an
d ve
geta
bles
WTO
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ld Tr
ade
Org
aniz
atio
nN
otes
The
gre
y bo
x re
pres
ents
the
rang
e of
acc
essio
n da
tes f
or c
ount
ries a
nd te
rrito
ries j
oini
ng W
TO
Aber
ratio
ns in
tren
ds st
artin
g in
199
2 lik
ely
refle
ct th
e ch
angi
ng c
ompo
sitio
n of
cou
ntrie
s in
each
ex
posu
re g
roup
due
to d
ata
avai
labi
lity
for f
orm
er S
ovie
t Uni
on c
ount
ries
We
obta
ined
wei
ghte
d m
eans
by
app
lyin
g co
mm
odity
-spe
cific
pro
pens
ity sc
ore
wei
ghts
Fig
5
Chan
ges i
n th
e su
pply
of r
ed m
eats
and
ani
mal
fats
and
suga
rs b
y joi
ning
WTO
m
embe
rs a
nd n
on-m
embe
r sta
tes
1980
ndash201
3
Year
Year
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2010
2013
1980
1990
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2013
Rang
e of W
TO ac
cessi
on da
tes
Rang
e of W
TO ac
cessi
on da
tes
Mea
n fo
r joi
ning
WTO
mem
bers
Unw
eigh
ted
mea
n fo
r WTO
non
-mem
bers
Wei
ghte
d m
ean
for W
TO n
on-m
embe
rs
Kilogramscapita Kilogramscapita
50 40 30 20 10 0 50 40 30 20 10 0
Red
mea
ts an
d an
imal
fats
Suga
rs
WTO
Wor
ld Tr
ade
Org
aniz
atio
nN
otes
The
gre
y bo
x re
pres
ents
the
rang
e of
acc
essio
n da
tes f
or c
ount
ries a
nd te
rrito
ries j
oini
ng W
TO
Aber
ratio
ns in
tren
ds st
artin
g in
199
2 lik
ely
refle
ct th
e ch
angi
ng c
ompo
sitio
n of
cou
ntrie
s in
each
ex
posu
re g
roup
due
to d
ata
avai
labi
lity
for f
orm
er S
ovie
t Uni
on c
ount
ries
We
obta
ined
wei
ghte
d m
eans
by
app
lyin
g co
mm
odity
-spe
cific
pro
pens
ity sc
ore
wei
ghts
92 Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
and control noncommunicable diseases like the FCTC but focused on other noncommunicable disease risk factors is warranted Such agreements can legally bind countries to health com-mitments providing a counterweight for commitments to international trade and investment rules
Our findings are suggestive but not conclusive warranting additional exploration and we suggest several po-tential avenues for future research For example given substantial unexplained country-specific heterogeneity indicated by country random effects in all models additional analyses of smaller groups of countries and individual countries are needed The effects of WTO member-ship may differ by level of economic development and other country-specific factors such as geography and climate which affect the baseline supply of various food groups tobacco and types of alcohol Researchers could recreate this analysis with one income group at a time and a similar analysis of selected low- and middle-income countries with substantial noncommunicable disease burdens may provide further insight into the links between WTO member-ship and changes in noncommunicable disease risk factors Single country studies could permit more nuanced understanding for example by looking at tariff changes for specific products and subsequent changes in their sup-ply Another area for future studies is to examine differences associated with specific provisions in WTO accession agreements and other trade and invest-ment policies as specific concessions differ Understanding which compo-nents of these treaties have the greatest influence on noncommunicable disease risk factors and other aspects of public health is important when tailoring future agreements to be more health-promoting Further researchers should also conduct similar analyses for other products that contribute to noncommu-nicable diseases particularly unhealthy foods high in fat salt and sugar
This study both supports and contradicts findings from previous research We were not able to confirm findings showing increases in consump-tion of meat10 and edible oils47 following trade liberalization Discrepancies may be due to differences in the sample previous studies examined only one to five countries in the same geographical region Studies showing trade-related
increases in sugar-sweetened beverage consumption1348 are somewhat sup-ported by our weak finding that the domestic supply of sugars increases steadily over time following WTO ac-
cession Our results confirm previous findings of increased tobacco712 and alcohol5 consumption associated with trade liberalization Finally few studies have examined fruits and vegetables
Fig 6 Changes in the supply of nuts seeds and legumes seafood and edible oils by joining WTO members and non-member states 1980ndash2013
Year
Year
Year
1980 1990 2000 2010 2013
1980 1990 2000 2010 2013
1980 1990 2000 2010 2013
Range of WTO accession dates
Range of WTO accession dates
Range of WTO accession dates
Mean for joining WTO members Unweighted mean for WTO non-membersWeighted mean for WTO non-members
Kilo
gram
sca
pita
Kilo
gram
sca
pita
Kilo
gram
sca
pita
20
15
10
5
0
20
15
10
5
0
20
15
10
5
0
Nuts seeds and legumes
Seafood
Edible oils
WTO World Trade OrganizationNotes The grey box represents the range of accession dates for countries and territories joining WTO Aberrations in trends starting in 1992 likely reflect the changing composition of countries in each exposure group due to data availability for former Soviet Union countries We obtained weighted means by applying commodity-specific propensity score weights
93Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
consumption in the context of trade liberalization but our findings support the results of an analysis showing that changes in trade policies led to an in-crease in imported fruit in five Central American countries10
This study has limitations A pri-mary limitation is the comparability of countries joining versus not joining WTO We assumed that trends would have been similar between the two groups if none of the countries joined WTO However differences in trends could be due to the influence of other unobserved events correlated with WTO accession and the outcomes of interest or innate characteristics of countries in either group
Another key limitation is the quality of the commodity data which measure
the available supply of each commodity and are only a proxy for consumption the true measure of importance for health In addition there was substantial missing data for certain items summed to create commodity variables which may affect the validity of the data for these categories The commodities ana-lysed were also limited by the available product categories importantly this did not allow us to distinguish changes in trends in the availability of specific foods high in fat salt or sugar an important determinant of obesity and noncommu-nicable diseases49 Finally for tobacco and alcohol illicit sales and homemade varieties are not captured in this data which may comprise substantial por-tions of supply and consumption in certain countries
In conclusion changes in domestic supply of alcohol tobacco and fruits and vegetables could have important implications for public health particu-larly for the development and preven-tion of noncommunicable diseases Overall findings indicated substantial country-level heterogeneity Therefore additional exploration of variations across countries is critical to identify factors that mitigate the negative role and enhance the positive role of trade and investment agreements in the global noncommunicable disease burden
Funding Krycia Cowling was supported by a Center for a Livable Future-Lerner fellowship during the time of this study
Competing interests None declared
摘要世界贸易组织成员国与非传染性疾病风险因素的变化一项断续时间序列比较分析1980ndash2013 年目的 旨在调查加入世界贸易组织 (WTO) 与获取若干商品(此类商品对非传染性疾病的形成兼具有害因素和保护因素)之间的关系方法 我 们 使 用 自 然 实 验 设 计 倾 向 评 分 权 重 来比 较 1980 年 至 2013 年 期 间 在 1995 年 之 后 加入 WTO 的 21 个国家或地区以及 26 个非成员国的烟草酒精和七类食品组在各国内的供应趋势我们采用断续时间序列框架使用多变量随机效应线性模型根据人均国内生产总值城市人口百分比和女性劳动力参与进行调整在烟草模型中我们控制了已批准
《烟草控制框架公约》的成员国在酒精模型中我们控制了自认为穆斯林国家所占的比例
结果 成员国加入世贸组织后与非成员国相比平均每人每天的水果和蔬菜国内供应量立即增长 55 克分析显示烟草和酒精每年的供应量以几何平均数的形式逐渐递增分别为每年 62 和 36我们尚未发现获取红肉和动物脂肪有任何重大变化 海鲜 坚果种子和豆类 淀粉 或食用油 以及与糖相关的结果在不同模型中是不一致的结论 结果表明成为 WTO 成员国可能会导致非传染性疾病的有害因素和保护因素增加但仍需进一步探索其针对具体国家的不同变化
ملخصعضوية منظمة التجارة العاملية والتغريات يف عوامل خطر األمراض غري املعدية حتليل سالسل زمنية مقارنة متقطعة ما
بني عامي 1980 و2013العاملية التجارة منظمة إىل االنضامم بني العالقة دراسة الغرض الضارة التأثريات ذات السلع من العديد وتوافر (WTO)
والوقائية من أجل تطوير األمراض غري املعديةاالجتاهات ملقارنة الطبيعية التجربة تصميم استخدمنا الطريقة بني غذائية جمموعات وسبع والكحول للتبغ املحيل اإلمداد يف عامي 1980 و2013 يف 21 دولة أو منطقة انضمت إىل منظمة التجارة العاملية بعد عام 1995 و26 دولة غري أعضاء باستخدام أوزان درجات النزوع طبقنا إطارا زمنيا متسلسال مقارنا متقطعا معدلة متعددة عشوائية تأثريات ذات خطية نامذج باستخدام احلرض لسكان املئوية والنسب للفرد اإلمجايل املحيل للناتج ومشاركة املرأة يف القوى العاملة يف نموذج التبغ قمنا باملكافحة ملكافحة اإلطارية االتفاقية عىل صدقت التي األعضاء الدول يف يعرفون الذين للسكان املئوية النسبة الكحول نموذج ويف التبغ
أنفسهم بأهنم مسلمني
الدول شهدت العاملية التجارة منظمة إىل االنضامم بعد النتائج األعضاء زيادات فورية يف اإلمداد املحيل من الفواكه واخلرضوات وصلت إىل 55 جم للشخص الواحد يف اليوم يف املتوسط مقارنة بالدول غري األعضاء أظهر التحليل زيادات تدرجيية يف املتوسط
اهلنديس إلمدادات التبغ والكحول بنسبة 62 و 36 يف السنة لحوم ال توافر يف جوهرية ت تغيريا أي نكتشف مل الرتتيب عىل احلمراء أو الدهون احليوانية أو املأكوالت البحرية أو املكرسات أو البذور والبقوليات أو النشويات أو الزيوت الصاحلة لألكل
وكانت النتائج للسكريات غري متناسقة عرب تنوعات النموذجقد العاملية التجارة ة منظم وية عض أن إىل النتائج تشري االستنتاج لألمراض والوقائية ة الضار مل العوا من كل يف زيادة إىل تؤدي االختالفات استكشاف من ملزيد ز تعزي هناك ولكن املعدية غري
اخلاصة بكل بلد
94 Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
Reacutesumeacute
Adheacutesion agrave lOrganisation mondiale du commerce et eacutevolution des facteurs de risque de maladies non transmissibles analyse comparative de seacuteries chronologiques interrompues 1980ndash2013Objectif Eacutetudier le lien entre ladheacutesion agrave lOrganisation mondiale du commerce (OMC) et la disponibiliteacute de diffeacuterentes denreacutees avec des effets agrave la fois nocifs et protecteurs pour le deacuteveloppement des maladies non transmissiblesMeacutethodes Nous avons utiliseacute un plan dexpeacuterience dans les conditions naturelles pour comparer entre 1980 et 2013 leacutevolution de loffre nationale de tabac dalcool et de sept groupes daliments dans 21 pays ou territoires devenus membres de lOMC apregraves 1995 et 26 pays non membres agrave laide de pondeacuterations par le score de propension Nous avons appliqueacute un cadre comparatif de seacuteries chronologiques interrompues agrave laide de modegraveles lineacuteaires agrave effets aleacuteatoires multivarieacutes rajusteacutes pour tenir compte du produit inteacuterieur brut par habitant du pourcentage de la population urbaine et de la participation des femmes agrave la vie active Dans le modegravele relatif au tabac nous avons tenu compte des Eacutetats membres ayant ratifieacute la Convention-cadre pour la lutte antitabac tandis que dans le modegravele relatif agrave lalcool nous avons tenu
compte du pourcentage de la population sidentifiant comme eacutetant de foi musulmaneReacutesultats Agrave la suite de leur adheacutesion agrave lOMC les Eacutetats membres ont connu une augmentation immeacutediate de loffre nationale de fruits et leacutegumes de 55 g par personne et par jour en moyenne par rapport aux pays non membres Lanalyse a reacuteveacuteleacute une augmentation progressive de la moyenne geacuteomeacutetrique de loffre de tabac et dalcool de 62 et 36 par an respectivement Nous navons pas constateacute de changements importants concernant la disponibiliteacute de viandes rouges et graisses dorigine animale de produits de la mer de noix graines et leacutegumineuses de feacuteculents ou dhuiles alimentaires et les reacutesultats relatifs aux sucres variaient dun modegravele agrave lautreConclusion Les reacutesultats suggegraverent que ladheacutesion agrave lOMC peut entraicircner une augmentation des facteurs agrave la fois nocifs et protecteurs pour les maladies non transmissibles mais il convient de reacutealiser de nouvelles recherches sur les variations par pays
Резюме
Членство во Всемирной торговой организации и изменения в факторах риска неинфекционных заболеваний сравнительный анализ прерванных временных рядов 1980ndash2013 ггЦель Членство во Всемирной торговой организации и изменения в факторах риска неинфекционных заболеваний сравнительный анализ прерванных временных рядов 1980ndash2013 ггМетоды Авторы использовали естественный эксперимент для сравнения тенденций внутренних поставок табака алкоголя и товаров семи продовольственных групп в период с 1980 по 2013 год в 21 стране или территории которые вступили в ВТО после 1995 года и в 26 странах не являющихся членами этой организации Анализ проводился с использованием весовых коэффициентов предрасположенности Авторы применили методику сравнительных прерванных временных рядов и многовариантные линейные модели случайных воздействий скорректированные по валовому внутреннему продукту на душу населения процентной доле городского населения и участию женщин в трудовой деятельности В модели для табака контролировались государства-члены ВТО ратифицировавшие Рамочную конвенцию по борьбе против табака а в модели
для алкоголя mdash доля населения идентифицирующая себя как мусульманеРезультаты После вступления в ВТО в государствах-членах наблюдался немедленный прирост внутренних поставок фруктов и овощей (в среднем до 55 г в день на человека) по сравнению со странами не являющимися ее членами Анализ показал постепенное увеличение среднего геометрического значения поставок табака и алкоголя на 62 и 36 в год соответственно Авторы не обнаружили существенных изменений в доступности мяса домашнего скота и животных жиров морепродуктов орехов семян и бобовых а также крахмала или пищевых масел Что касается сахара в разных моделях были получены несовпадающие результатыВывод Результаты позволяют предположить что членство в ВТО может привести к увеличению как полезных так и вредных факторов распространения неинфекционных заболеваний но необходимо проведение дальнейших исследований вариаций в различных странах
Resumen
Composicioacuten de la Organizacioacuten Mundial del Comercio y cambios en los factores de riesgo de las enfermedades no contagiosas un anaacutelisis comparativo de series cronoloacutegicas interrumpidas 1980-2013Objetivo Investigar la relacioacuten entre la adhesioacuten a la Organizacioacuten Mundial del Comercio (OMC) y la disponibilidad de varios productos baacutesicos con efectos tanto perjudiciales como protectores para el desarrollo de enfermedades no contagiosasMeacutetodos Se utilizoacute un disentildeo de experimento natural para comparar las tendencias de la oferta interna de tabaco alcohol y siete grupos de alimentos entre 1980 y 2013 en 21 paiacuteses o territorios que se incorporaron a la OMC despueacutes de 1995 y 26 paiacuteses no miembros mediante el uso de ponderaciones de propensioacuten Se aplicoacute un marco comparativo de series temporales interrumpidas siguiendo modelos lineales de efectos aleatorios multivariados ajustados seguacuten el producto interior bruto per caacutepita los porcentajes de poblacioacuten urbana y la participacioacuten de la mujer en el mundo laboral En el modelo del
tabaco controlamos a los Estados miembros que habiacutean ratificado el Convenio Marco para el Control del Tabaco y en el modelo del alcohol el porcentaje de la poblacioacuten que se identificaba como musulmanaResultados Tras la adhesioacuten a la OMC los Estados miembros experimentaron un aumento inmediato de la oferta interna de frutas y hortalizas de 55 kg por persona y diacutea de media en comparacioacuten con los paiacuteses no miembros El anaacutelisis mostroacute incrementos graduales en la media geomeacutetrica de la oferta de tabaco y alcohol del 62 y el 36 anual respectivamente No se detectaron cambios significativos en la disponibilidad de carnes rojas y grasas animales mariscos nueces semillas y legumbres almidones o aceites comestibles y los resultados para los azuacutecares fueron inconsistentes entre las variaciones del modelo
95Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
Conclusioacuten Los resultados sugieren que la pertenencia a la OMC puede dar lugar a un aumento de los factores perjudiciales y protectores de
las enfermedades no contagiosas pero es necesario seguir estudiando las variaciones especiacuteficas de cada paiacutes
References1 Murray CJ Vos T Lozano R Naghavi M Flaxman AD Michaud C et al
Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions 1990ndash2010 a systematic analysis for the Global Burden of Disease Study 2010 Lancet 2012 Dec 15380(9859)2197ndash223 doi httpdxdoiorg101016S0140-6736(12)61689-4 PMID 23245608
2 Lim SS Vos T Flaxman AD Danaei G Shibuya K Adair-Rohani H et al A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions 1990ndash2010 a systematic analysis for the Global Burden of Disease Study 2010 Lancet 2012 Dec 15380(9859)2224ndash60 doi httpdxdoiorg101016S0140-6736(12)61766-8 PMID 23245609
3 Baker P Friel S Food systems transformations ultra-processed food markets and the nutrition transition in Asia Global Health 2016 12 312(1)80 doi httpdxdoiorg101186s12992-016-0223-3 PMID 27912772
4 Labonteacute R Mohindra KS Lencucha R Framing international trade and chronic disease Global Health 2011 07 47(1)21 doi httpdxdoiorg1011861744-8603-7-21 PMID 21726434
5 Stuckler D McKee M Ebrahim S Basu S Manufacturing epidemics the role of global producers in increased consumption of unhealthy commodities including processed foods alcohol and tobacco PLoS Med 20129(6)e1001235 doi httpdxdoiorg101371journalpmed1001235 PMID 22745605
6 De Vogli R Kouvonen A Gimeno D The influence of market deregulation on fast food consumption and body mass index a cross-national time series analysis Bull World Health Organ 2014 Feb 192(2)99ndash107 107A doi httpdxdoiorg102471BLT13120287 PMID 24623903
7 Chaloupka FJ Laixuthai A Trade policy and cigarette smoking in Asia [NBER working paper series] Cambridge National Bureau of Economic Research 1996 Available from httpwwwnberorgpapersw5543 [cited 2017 Sep 4]
8 Cassels S Overweight in the Pacific links between foreign dependence global food trade and obesity in the Federated States of Micronesia Global Health 2006 07 112(1)10 doi httpdxdoiorg1011861744-8603-2-10 PMID 16834782
9 Schultz JT Globalisation urbanization and nutrition transition in a developing island country a case study Fiji Globalization of food systems in developing countries impact on food security and nutrition Rome Food and Agriculture Organization 2004
10 Thow AM Hawkes C The implications of trade liberalization for diet and health a case study from Central America Global Health 2009 07 2855 doi httpdxdoiorg1011861744-8603-5-5 PMID 19638196
11 Barlow P McKee M Basu S Stuckler D The health impact of trade and investment agreements a quantitative systematic review and network co-citation analysis Global Health 2017 03 813(1)13 doi httpdxdoiorg101186s12992-017-0240-x PMID 28274238
12 Taylor A Chaloupka FJ Guindon E Corbett M The impact of trade liberalization on tobacco consumption In Jha P Chaloupka FJ editors Tobacco control in developing countries Oxford Oxford University Press 2000 pp 343ndash64
13 Schram A Labonte R Baker P Friel S Reeves A Stuckler D The role of trade and investment liberalization in the sugar-sweetened carbonated beverages market a natural experiment contrasting Vietnam and the Philippines Global Health 2015 10 1211(1)41 doi httpdxdoiorg101186s12992-015-0127-7 PMID 26455446
14 Baker P Friel S Schram A Labonte R Trade and investment liberalization food systems change and highly processed food consumption a natural experiment contrasting the soft-drink markets of Peru and Bolivia Global Health 2016 06 212(1)24 doi httpdxdoiorg101186s12992-016-0161-0 PMID 27255275
15 Understanding the WTO the organization Members and observers [internet] Geneva World Trade Organization 2017 Available from httpswwwwtoorgenglishthewto_ewhatis_etif_eorg6_ehtm [cited 2017 Mar 28]
16 Guenther PM Casavale KO Reedy J Kirkpatrick SI Hiza HA Kuczynski KJ et al Update of the healthy eating index HEI-2010 J Acad Nutr Diet 2013 Apr113(4)569ndash80 doi httpdxdoiorg101016jjand201212016 PMID 23415502
17 Haines PS Siega-Riz AM Popkin BM The Diet Quality Index revised a measurement instrument for populations J Am Diet Assoc 1999 Jun99(6)697ndash704 doi httpdxdoiorg101016S0002-8223(99)00168-6 PMID 10361532
18 Huijbregts P Feskens E Raumlsaumlnen L Fidanza F Nissinen A Menotti A et al Dietary pattern and 20 year mortality in elderly men in Finland Italy and The Netherlands longitudinal cohort study BMJ 1997 Jul 5315(7099)13ndash7 doi httpdxdoiorg101136bmj315709913 PMID 9233319
19 Panagiotakos DB Pitsavos C Stefanadis C Dietary patterns a Mediterranean diet score and its relation to clinical and biological markers of cardiovascular disease risk Nutr Metab Cardiovasc Dis 2006 Dec16(8)559ndash68 doi httpdxdoiorg101016jnumecd200508006 PMID 17126772
20 Guidelines for measuring household and individual dietary diversity [internet] Rome Food and Agriculture Organization 2012 Available from httpwwwfaoorgdocrep014i1983ei1983e00htm [cited 2017 Jan 14]
21 Indicators for nutrition-friendly and sustainable food systems InGlobal nutrition report 2015 actions and accountability to advance nutrition and sustainable development Washington DC International Food Policy Research Institute 2015 pp 85ndash96 Available from httpglobalnutritionreportorgthe-reportthe-report-2015 [cited 2017 Apr 4]
22 Micha R Khatibzadeh S Shi P Andrews KG Engell RE Mozaffarian D Global Burden of Diseases Nutrition and Chronic Diseases Expert Group (NutriCoDE) Global regional and national consumption of major food groups in 1990 and 2010 a systematic analysis including 266 country-specific nutrition surveys worldwide BMJ Open 2015 09 245(9)e008705 doi httpdxdoiorg101136bmjopen-2015-008705 PMID 26408285
23 Mozaffarian D Hao T Rimm EB Willett WC Hu FB Changes in diet and lifestyle and long-term weight gain in women and men N Engl J Med 2011 Jun 23364(25)2392ndash404 doi httpdxdoiorg101056NEJMoa1014296 PMID 21696306
24 Mozaffarian D Appel LJ Van Horn L Components of a cardioprotective diet new insights Circulation 2011 Jun 21123(24)2870ndash91 doi httpdxdoiorg101161CIRCULATIONAHA110968735 PMID 21690503
25 WTO membership and noncommunicable disease risk factors - Supplemental materials Baltimore Johns Hopkins University 2018 Available from doi httpdxdoiorg106084m9figshare7268561v1 [cited 2018 Oct 30]doi httpdxdoiorg106084m9figshare7268561v1
26 Maumlnnistouml S Laatikainen T Helakorpi S Valsta LM Monitoring diet and diet-related chronic disease risk factors in Finland Public Health Nutr 2010 Jun13 6A907ndash14 doi httpdxdoiorg101017S1368980010001084 PMID 20513259
27 Sheehy T Sharma S Trends in energy and nutrient supply in Trinidad and Tobago from 1961 to 2007 using FAO food balance sheets Public Health Nutr 2013 Sep16(9)1693ndash702 doi httpdxdoiorg101017S136898001200537X PMID 23286774
28 World development indicators [internet] Washington DC The World Bank 2016 Available from httpdataworldbankorgdata-catalogworld-development-indicators [cited 2017 Feb 20]
29 World population prospects the 2015 Revision [internet] New York United Nations Department of Economic and Social Affairs Population Division 2015 Available from httpsesaunorgunpdwpp [cited 2017 Jan 6]
30 Gross domestic product (GDP) estimates by country 1950ndash2015 [internet] Seattle Institute for Health Metrics and Evaluation 2017 Available from httpghdxhealthdataorgrecordgross-domestic-product-gdp-estimates-country-1950-2015 [cited 2017 Jan 6]
31 Table Muslim Population by Country [internet] Washington DC Pew Research Center 2011 Available from httpwwwpewforumorg20110127table-muslim-population-by-country [cited 2017 Apr 12]
32 Depositary WHO Framework Convention on Tobacco Control [internet] New York United Nations Treaty Collection 2025 Available from httpstreatiesunorgpagesViewDetailsaspxsrc=TREATYampmtdsg_no=IX-4ampchapter=9amplang=en [cited 2017 Apr 18]
33 Ng M Freeman MK Fleming TD Robinson M Dwyer-Lindgren L Thomson B et al Smoking prevalence and cigarette consumption in 187 countries 1980ndash2012 JAMA 2014 Jan 8311(2)183ndash92 doi httpdxdoiorg101001jama2013284692 PMID 24399557
96 Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
34 Rehm J Mathers C Popova S Thavorncharoensap M Teerawattananon Y Patra J Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders Lancet 2009 Jun 27373(9682)2223ndash33 doi httpdxdoiorg101016S0140-6736(09)60746-7 PMID 19560604
35 Al-Ansari B Thow A-M Day CA Conigrave KM Extent of alcohol prohibition in civil policy in Muslim majority countries the impact of globalization Addiction 2016 10111(10)1703ndash13 doi httpdxdoiorg101111add13159 PMID 26508526
36 About the WHO Framework Convention on Tobacco Control [internet] Geneva World Health Organization 2018 Available from httpwwwwhointfctcabouten [cited 2017 May 11]
37 Stuart EA Matching methods for causal inference a review and a look forward Stat Sci 2010 Feb 125(1)1ndash21 doi httpdxdoiorg10121409-STS313 PMID 20871802
38 Ridgeway G McCaffrey D Morral A Burgette L Griffin BA Toolkit for weighting and analysis of nonequivalent groups a tutorial for the twang package R Vignette [internet] Vienna R Foundation 2017 Available from httpscranr-projectorgwebpackagestwangvignettestwangpdf [cited 2017 Apr 18]
39 McCaffrey DF Ridgeway G Morral AR Propensity score estimation with boosted regression for evaluating causal effects in observational studies Psychol Methods 2004 Dec9(4)403ndash25 doi httpdxdoiorg1010371082-989X94403 PMID 15598095
40 Linden A Adams JL Applying a propensity score-based weighting model to interrupted time series data improving causal inference in programme evaluation J Eval Clin Pract 2011 Dec17(6)1231ndash8 doi httpdxdoiorg101111j1365-2753201001504x PMID 20973870
41 Griswold MG Fullman N Hawley C Arian N Zimsen SRM Tymeson HD et al GBD 2016 Alcohol Collaborators Alcohol use and burden for 195 countries and territories 1990ndash2016 a systematic analysis for the Global Burden of Disease Study 2016 Lancet 2018 Sep 22392(10152)1015ndash35 doi httpdxdoiorg101016S0140-6736(18)31310-2 PMID 30146330
42 Peto R Lopez AD Boreham J Thun M Heath C Jr Mortality from tobacco in developed countries indirect estimation from national vital statistics Lancet 1992 May 23339(8804)1268ndash78 doi httpdxdoiorg1010160140-6736(92)91600-D PMID 1349675
43 Healthy diet Key facts Geneva World Health Organization 2018 Available from httpwwwwhointnews-roomfact-sheetsdetailhealthy-diet [cited 2018 Oct 26]
44 Aune D Giovannucci E Boffetta P Fadnes LT Keum N Norat T et al Fruit and vegetable intake and the risk of cardiovascular disease total cancer and all-cause mortality-a systematic review and dose-response meta-analysis of prospective studies Int J Epidemiol 2017 06 146(3)1029ndash56 doi httpdxdoiorg101093ijedyw319 PMID 28338764
45 Health in All Policies framework for country action [internet] Geneva World Health Organization 2018 Available from httpwwwwhointhealthpromotionframeworkforcountryactionen [cited 2017 Aug 13]
46 Cole BL Fielding JE Health impact assessment a tool to help policy makers understand health beyond health care Annu Rev Public Health 200728(1)393ndash412 doi httpdxdoiorg101146annurevpublhealth28083006131942 PMID 17173539
47 Tonts M Siddique MAB editors Globalisation agriculture and development perspectives from the Asia-Pacific Cheltenham Edward Elgar Publishing 2011 Available from httpswwwelgaronlinecomview978184720818700010xml [cited 2017 Aug 14]
48 Mendez Lopez A Loopstra R McKee M Stuckler D Is trade liberalisation a vector for the spread of sugar-sweetened beverages A cross-national longitudinal analysis of 44 low- and middle-income countries Soc Sci Med 2017 0117221ndash7 doi httpdxdoiorg101016jsocscimed201611001 PMID 27871042
49 Monteiro CA Moubarac J-C Cannon G Ng SW Popkin B Ultra-processed products are becoming dominant in the global food system Obes Rev 2013 Nov14 Suppl 221ndash8 doi httpdxdoiorg101111obr12107 PMID 24102801
Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057 96A
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
Fig 1 Unweighted and weighted absolute standardized biases for baseline commodity supply in countries included in the study 1980ndash1995
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Absolute standardize bias
Absolute standardize bias
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Unweighted Weighted
0 02 04 06 08
0 02 04 06 08
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0 02 04 06 08 0 02 04 06 08
Supply of tobacco
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Supply of nuts seeds and legumes
Supply of seafood
Supply of edible oils
Supply of sugars
Supply of red meats and animal fats
Supply of alcohol
Supply of fruits and vegetables
GDP gross domestic productNotes The period 1980ndash1995 represents the years before countries and territories start joining the World Trade Organization Table 1 lists countries studied We measured bias by the absolute standardized mean difference that is (mean for non-member states ndash mean for member states)(combined standard deviation)
- Table 1
- Table 2
- Table 3
- Figure 2
- Figure 3
- Figure 4
- Figure 5
- Figure 6
- Figure 1
-
92 Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
and control noncommunicable diseases like the FCTC but focused on other noncommunicable disease risk factors is warranted Such agreements can legally bind countries to health com-mitments providing a counterweight for commitments to international trade and investment rules
Our findings are suggestive but not conclusive warranting additional exploration and we suggest several po-tential avenues for future research For example given substantial unexplained country-specific heterogeneity indicated by country random effects in all models additional analyses of smaller groups of countries and individual countries are needed The effects of WTO member-ship may differ by level of economic development and other country-specific factors such as geography and climate which affect the baseline supply of various food groups tobacco and types of alcohol Researchers could recreate this analysis with one income group at a time and a similar analysis of selected low- and middle-income countries with substantial noncommunicable disease burdens may provide further insight into the links between WTO member-ship and changes in noncommunicable disease risk factors Single country studies could permit more nuanced understanding for example by looking at tariff changes for specific products and subsequent changes in their sup-ply Another area for future studies is to examine differences associated with specific provisions in WTO accession agreements and other trade and invest-ment policies as specific concessions differ Understanding which compo-nents of these treaties have the greatest influence on noncommunicable disease risk factors and other aspects of public health is important when tailoring future agreements to be more health-promoting Further researchers should also conduct similar analyses for other products that contribute to noncommu-nicable diseases particularly unhealthy foods high in fat salt and sugar
This study both supports and contradicts findings from previous research We were not able to confirm findings showing increases in consump-tion of meat10 and edible oils47 following trade liberalization Discrepancies may be due to differences in the sample previous studies examined only one to five countries in the same geographical region Studies showing trade-related
increases in sugar-sweetened beverage consumption1348 are somewhat sup-ported by our weak finding that the domestic supply of sugars increases steadily over time following WTO ac-
cession Our results confirm previous findings of increased tobacco712 and alcohol5 consumption associated with trade liberalization Finally few studies have examined fruits and vegetables
Fig 6 Changes in the supply of nuts seeds and legumes seafood and edible oils by joining WTO members and non-member states 1980ndash2013
Year
Year
Year
1980 1990 2000 2010 2013
1980 1990 2000 2010 2013
1980 1990 2000 2010 2013
Range of WTO accession dates
Range of WTO accession dates
Range of WTO accession dates
Mean for joining WTO members Unweighted mean for WTO non-membersWeighted mean for WTO non-members
Kilo
gram
sca
pita
Kilo
gram
sca
pita
Kilo
gram
sca
pita
20
15
10
5
0
20
15
10
5
0
20
15
10
5
0
Nuts seeds and legumes
Seafood
Edible oils
WTO World Trade OrganizationNotes The grey box represents the range of accession dates for countries and territories joining WTO Aberrations in trends starting in 1992 likely reflect the changing composition of countries in each exposure group due to data availability for former Soviet Union countries We obtained weighted means by applying commodity-specific propensity score weights
93Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
consumption in the context of trade liberalization but our findings support the results of an analysis showing that changes in trade policies led to an in-crease in imported fruit in five Central American countries10
This study has limitations A pri-mary limitation is the comparability of countries joining versus not joining WTO We assumed that trends would have been similar between the two groups if none of the countries joined WTO However differences in trends could be due to the influence of other unobserved events correlated with WTO accession and the outcomes of interest or innate characteristics of countries in either group
Another key limitation is the quality of the commodity data which measure
the available supply of each commodity and are only a proxy for consumption the true measure of importance for health In addition there was substantial missing data for certain items summed to create commodity variables which may affect the validity of the data for these categories The commodities ana-lysed were also limited by the available product categories importantly this did not allow us to distinguish changes in trends in the availability of specific foods high in fat salt or sugar an important determinant of obesity and noncommu-nicable diseases49 Finally for tobacco and alcohol illicit sales and homemade varieties are not captured in this data which may comprise substantial por-tions of supply and consumption in certain countries
In conclusion changes in domestic supply of alcohol tobacco and fruits and vegetables could have important implications for public health particu-larly for the development and preven-tion of noncommunicable diseases Overall findings indicated substantial country-level heterogeneity Therefore additional exploration of variations across countries is critical to identify factors that mitigate the negative role and enhance the positive role of trade and investment agreements in the global noncommunicable disease burden
Funding Krycia Cowling was supported by a Center for a Livable Future-Lerner fellowship during the time of this study
Competing interests None declared
摘要世界贸易组织成员国与非传染性疾病风险因素的变化一项断续时间序列比较分析1980ndash2013 年目的 旨在调查加入世界贸易组织 (WTO) 与获取若干商品(此类商品对非传染性疾病的形成兼具有害因素和保护因素)之间的关系方法 我 们 使 用 自 然 实 验 设 计 倾 向 评 分 权 重 来比 较 1980 年 至 2013 年 期 间 在 1995 年 之 后 加入 WTO 的 21 个国家或地区以及 26 个非成员国的烟草酒精和七类食品组在各国内的供应趋势我们采用断续时间序列框架使用多变量随机效应线性模型根据人均国内生产总值城市人口百分比和女性劳动力参与进行调整在烟草模型中我们控制了已批准
《烟草控制框架公约》的成员国在酒精模型中我们控制了自认为穆斯林国家所占的比例
结果 成员国加入世贸组织后与非成员国相比平均每人每天的水果和蔬菜国内供应量立即增长 55 克分析显示烟草和酒精每年的供应量以几何平均数的形式逐渐递增分别为每年 62 和 36我们尚未发现获取红肉和动物脂肪有任何重大变化 海鲜 坚果种子和豆类 淀粉 或食用油 以及与糖相关的结果在不同模型中是不一致的结论 结果表明成为 WTO 成员国可能会导致非传染性疾病的有害因素和保护因素增加但仍需进一步探索其针对具体国家的不同变化
ملخصعضوية منظمة التجارة العاملية والتغريات يف عوامل خطر األمراض غري املعدية حتليل سالسل زمنية مقارنة متقطعة ما
بني عامي 1980 و2013العاملية التجارة منظمة إىل االنضامم بني العالقة دراسة الغرض الضارة التأثريات ذات السلع من العديد وتوافر (WTO)
والوقائية من أجل تطوير األمراض غري املعديةاالجتاهات ملقارنة الطبيعية التجربة تصميم استخدمنا الطريقة بني غذائية جمموعات وسبع والكحول للتبغ املحيل اإلمداد يف عامي 1980 و2013 يف 21 دولة أو منطقة انضمت إىل منظمة التجارة العاملية بعد عام 1995 و26 دولة غري أعضاء باستخدام أوزان درجات النزوع طبقنا إطارا زمنيا متسلسال مقارنا متقطعا معدلة متعددة عشوائية تأثريات ذات خطية نامذج باستخدام احلرض لسكان املئوية والنسب للفرد اإلمجايل املحيل للناتج ومشاركة املرأة يف القوى العاملة يف نموذج التبغ قمنا باملكافحة ملكافحة اإلطارية االتفاقية عىل صدقت التي األعضاء الدول يف يعرفون الذين للسكان املئوية النسبة الكحول نموذج ويف التبغ
أنفسهم بأهنم مسلمني
الدول شهدت العاملية التجارة منظمة إىل االنضامم بعد النتائج األعضاء زيادات فورية يف اإلمداد املحيل من الفواكه واخلرضوات وصلت إىل 55 جم للشخص الواحد يف اليوم يف املتوسط مقارنة بالدول غري األعضاء أظهر التحليل زيادات تدرجيية يف املتوسط
اهلنديس إلمدادات التبغ والكحول بنسبة 62 و 36 يف السنة لحوم ال توافر يف جوهرية ت تغيريا أي نكتشف مل الرتتيب عىل احلمراء أو الدهون احليوانية أو املأكوالت البحرية أو املكرسات أو البذور والبقوليات أو النشويات أو الزيوت الصاحلة لألكل
وكانت النتائج للسكريات غري متناسقة عرب تنوعات النموذجقد العاملية التجارة ة منظم وية عض أن إىل النتائج تشري االستنتاج لألمراض والوقائية ة الضار مل العوا من كل يف زيادة إىل تؤدي االختالفات استكشاف من ملزيد ز تعزي هناك ولكن املعدية غري
اخلاصة بكل بلد
94 Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
Reacutesumeacute
Adheacutesion agrave lOrganisation mondiale du commerce et eacutevolution des facteurs de risque de maladies non transmissibles analyse comparative de seacuteries chronologiques interrompues 1980ndash2013Objectif Eacutetudier le lien entre ladheacutesion agrave lOrganisation mondiale du commerce (OMC) et la disponibiliteacute de diffeacuterentes denreacutees avec des effets agrave la fois nocifs et protecteurs pour le deacuteveloppement des maladies non transmissiblesMeacutethodes Nous avons utiliseacute un plan dexpeacuterience dans les conditions naturelles pour comparer entre 1980 et 2013 leacutevolution de loffre nationale de tabac dalcool et de sept groupes daliments dans 21 pays ou territoires devenus membres de lOMC apregraves 1995 et 26 pays non membres agrave laide de pondeacuterations par le score de propension Nous avons appliqueacute un cadre comparatif de seacuteries chronologiques interrompues agrave laide de modegraveles lineacuteaires agrave effets aleacuteatoires multivarieacutes rajusteacutes pour tenir compte du produit inteacuterieur brut par habitant du pourcentage de la population urbaine et de la participation des femmes agrave la vie active Dans le modegravele relatif au tabac nous avons tenu compte des Eacutetats membres ayant ratifieacute la Convention-cadre pour la lutte antitabac tandis que dans le modegravele relatif agrave lalcool nous avons tenu
compte du pourcentage de la population sidentifiant comme eacutetant de foi musulmaneReacutesultats Agrave la suite de leur adheacutesion agrave lOMC les Eacutetats membres ont connu une augmentation immeacutediate de loffre nationale de fruits et leacutegumes de 55 g par personne et par jour en moyenne par rapport aux pays non membres Lanalyse a reacuteveacuteleacute une augmentation progressive de la moyenne geacuteomeacutetrique de loffre de tabac et dalcool de 62 et 36 par an respectivement Nous navons pas constateacute de changements importants concernant la disponibiliteacute de viandes rouges et graisses dorigine animale de produits de la mer de noix graines et leacutegumineuses de feacuteculents ou dhuiles alimentaires et les reacutesultats relatifs aux sucres variaient dun modegravele agrave lautreConclusion Les reacutesultats suggegraverent que ladheacutesion agrave lOMC peut entraicircner une augmentation des facteurs agrave la fois nocifs et protecteurs pour les maladies non transmissibles mais il convient de reacutealiser de nouvelles recherches sur les variations par pays
Резюме
Членство во Всемирной торговой организации и изменения в факторах риска неинфекционных заболеваний сравнительный анализ прерванных временных рядов 1980ndash2013 ггЦель Членство во Всемирной торговой организации и изменения в факторах риска неинфекционных заболеваний сравнительный анализ прерванных временных рядов 1980ndash2013 ггМетоды Авторы использовали естественный эксперимент для сравнения тенденций внутренних поставок табака алкоголя и товаров семи продовольственных групп в период с 1980 по 2013 год в 21 стране или территории которые вступили в ВТО после 1995 года и в 26 странах не являющихся членами этой организации Анализ проводился с использованием весовых коэффициентов предрасположенности Авторы применили методику сравнительных прерванных временных рядов и многовариантные линейные модели случайных воздействий скорректированные по валовому внутреннему продукту на душу населения процентной доле городского населения и участию женщин в трудовой деятельности В модели для табака контролировались государства-члены ВТО ратифицировавшие Рамочную конвенцию по борьбе против табака а в модели
для алкоголя mdash доля населения идентифицирующая себя как мусульманеРезультаты После вступления в ВТО в государствах-членах наблюдался немедленный прирост внутренних поставок фруктов и овощей (в среднем до 55 г в день на человека) по сравнению со странами не являющимися ее членами Анализ показал постепенное увеличение среднего геометрического значения поставок табака и алкоголя на 62 и 36 в год соответственно Авторы не обнаружили существенных изменений в доступности мяса домашнего скота и животных жиров морепродуктов орехов семян и бобовых а также крахмала или пищевых масел Что касается сахара в разных моделях были получены несовпадающие результатыВывод Результаты позволяют предположить что членство в ВТО может привести к увеличению как полезных так и вредных факторов распространения неинфекционных заболеваний но необходимо проведение дальнейших исследований вариаций в различных странах
Resumen
Composicioacuten de la Organizacioacuten Mundial del Comercio y cambios en los factores de riesgo de las enfermedades no contagiosas un anaacutelisis comparativo de series cronoloacutegicas interrumpidas 1980-2013Objetivo Investigar la relacioacuten entre la adhesioacuten a la Organizacioacuten Mundial del Comercio (OMC) y la disponibilidad de varios productos baacutesicos con efectos tanto perjudiciales como protectores para el desarrollo de enfermedades no contagiosasMeacutetodos Se utilizoacute un disentildeo de experimento natural para comparar las tendencias de la oferta interna de tabaco alcohol y siete grupos de alimentos entre 1980 y 2013 en 21 paiacuteses o territorios que se incorporaron a la OMC despueacutes de 1995 y 26 paiacuteses no miembros mediante el uso de ponderaciones de propensioacuten Se aplicoacute un marco comparativo de series temporales interrumpidas siguiendo modelos lineales de efectos aleatorios multivariados ajustados seguacuten el producto interior bruto per caacutepita los porcentajes de poblacioacuten urbana y la participacioacuten de la mujer en el mundo laboral En el modelo del
tabaco controlamos a los Estados miembros que habiacutean ratificado el Convenio Marco para el Control del Tabaco y en el modelo del alcohol el porcentaje de la poblacioacuten que se identificaba como musulmanaResultados Tras la adhesioacuten a la OMC los Estados miembros experimentaron un aumento inmediato de la oferta interna de frutas y hortalizas de 55 kg por persona y diacutea de media en comparacioacuten con los paiacuteses no miembros El anaacutelisis mostroacute incrementos graduales en la media geomeacutetrica de la oferta de tabaco y alcohol del 62 y el 36 anual respectivamente No se detectaron cambios significativos en la disponibilidad de carnes rojas y grasas animales mariscos nueces semillas y legumbres almidones o aceites comestibles y los resultados para los azuacutecares fueron inconsistentes entre las variaciones del modelo
95Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
Conclusioacuten Los resultados sugieren que la pertenencia a la OMC puede dar lugar a un aumento de los factores perjudiciales y protectores de
las enfermedades no contagiosas pero es necesario seguir estudiando las variaciones especiacuteficas de cada paiacutes
References1 Murray CJ Vos T Lozano R Naghavi M Flaxman AD Michaud C et al
Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions 1990ndash2010 a systematic analysis for the Global Burden of Disease Study 2010 Lancet 2012 Dec 15380(9859)2197ndash223 doi httpdxdoiorg101016S0140-6736(12)61689-4 PMID 23245608
2 Lim SS Vos T Flaxman AD Danaei G Shibuya K Adair-Rohani H et al A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions 1990ndash2010 a systematic analysis for the Global Burden of Disease Study 2010 Lancet 2012 Dec 15380(9859)2224ndash60 doi httpdxdoiorg101016S0140-6736(12)61766-8 PMID 23245609
3 Baker P Friel S Food systems transformations ultra-processed food markets and the nutrition transition in Asia Global Health 2016 12 312(1)80 doi httpdxdoiorg101186s12992-016-0223-3 PMID 27912772
4 Labonteacute R Mohindra KS Lencucha R Framing international trade and chronic disease Global Health 2011 07 47(1)21 doi httpdxdoiorg1011861744-8603-7-21 PMID 21726434
5 Stuckler D McKee M Ebrahim S Basu S Manufacturing epidemics the role of global producers in increased consumption of unhealthy commodities including processed foods alcohol and tobacco PLoS Med 20129(6)e1001235 doi httpdxdoiorg101371journalpmed1001235 PMID 22745605
6 De Vogli R Kouvonen A Gimeno D The influence of market deregulation on fast food consumption and body mass index a cross-national time series analysis Bull World Health Organ 2014 Feb 192(2)99ndash107 107A doi httpdxdoiorg102471BLT13120287 PMID 24623903
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8 Cassels S Overweight in the Pacific links between foreign dependence global food trade and obesity in the Federated States of Micronesia Global Health 2006 07 112(1)10 doi httpdxdoiorg1011861744-8603-2-10 PMID 16834782
9 Schultz JT Globalisation urbanization and nutrition transition in a developing island country a case study Fiji Globalization of food systems in developing countries impact on food security and nutrition Rome Food and Agriculture Organization 2004
10 Thow AM Hawkes C The implications of trade liberalization for diet and health a case study from Central America Global Health 2009 07 2855 doi httpdxdoiorg1011861744-8603-5-5 PMID 19638196
11 Barlow P McKee M Basu S Stuckler D The health impact of trade and investment agreements a quantitative systematic review and network co-citation analysis Global Health 2017 03 813(1)13 doi httpdxdoiorg101186s12992-017-0240-x PMID 28274238
12 Taylor A Chaloupka FJ Guindon E Corbett M The impact of trade liberalization on tobacco consumption In Jha P Chaloupka FJ editors Tobacco control in developing countries Oxford Oxford University Press 2000 pp 343ndash64
13 Schram A Labonte R Baker P Friel S Reeves A Stuckler D The role of trade and investment liberalization in the sugar-sweetened carbonated beverages market a natural experiment contrasting Vietnam and the Philippines Global Health 2015 10 1211(1)41 doi httpdxdoiorg101186s12992-015-0127-7 PMID 26455446
14 Baker P Friel S Schram A Labonte R Trade and investment liberalization food systems change and highly processed food consumption a natural experiment contrasting the soft-drink markets of Peru and Bolivia Global Health 2016 06 212(1)24 doi httpdxdoiorg101186s12992-016-0161-0 PMID 27255275
15 Understanding the WTO the organization Members and observers [internet] Geneva World Trade Organization 2017 Available from httpswwwwtoorgenglishthewto_ewhatis_etif_eorg6_ehtm [cited 2017 Mar 28]
16 Guenther PM Casavale KO Reedy J Kirkpatrick SI Hiza HA Kuczynski KJ et al Update of the healthy eating index HEI-2010 J Acad Nutr Diet 2013 Apr113(4)569ndash80 doi httpdxdoiorg101016jjand201212016 PMID 23415502
17 Haines PS Siega-Riz AM Popkin BM The Diet Quality Index revised a measurement instrument for populations J Am Diet Assoc 1999 Jun99(6)697ndash704 doi httpdxdoiorg101016S0002-8223(99)00168-6 PMID 10361532
18 Huijbregts P Feskens E Raumlsaumlnen L Fidanza F Nissinen A Menotti A et al Dietary pattern and 20 year mortality in elderly men in Finland Italy and The Netherlands longitudinal cohort study BMJ 1997 Jul 5315(7099)13ndash7 doi httpdxdoiorg101136bmj315709913 PMID 9233319
19 Panagiotakos DB Pitsavos C Stefanadis C Dietary patterns a Mediterranean diet score and its relation to clinical and biological markers of cardiovascular disease risk Nutr Metab Cardiovasc Dis 2006 Dec16(8)559ndash68 doi httpdxdoiorg101016jnumecd200508006 PMID 17126772
20 Guidelines for measuring household and individual dietary diversity [internet] Rome Food and Agriculture Organization 2012 Available from httpwwwfaoorgdocrep014i1983ei1983e00htm [cited 2017 Jan 14]
21 Indicators for nutrition-friendly and sustainable food systems InGlobal nutrition report 2015 actions and accountability to advance nutrition and sustainable development Washington DC International Food Policy Research Institute 2015 pp 85ndash96 Available from httpglobalnutritionreportorgthe-reportthe-report-2015 [cited 2017 Apr 4]
22 Micha R Khatibzadeh S Shi P Andrews KG Engell RE Mozaffarian D Global Burden of Diseases Nutrition and Chronic Diseases Expert Group (NutriCoDE) Global regional and national consumption of major food groups in 1990 and 2010 a systematic analysis including 266 country-specific nutrition surveys worldwide BMJ Open 2015 09 245(9)e008705 doi httpdxdoiorg101136bmjopen-2015-008705 PMID 26408285
23 Mozaffarian D Hao T Rimm EB Willett WC Hu FB Changes in diet and lifestyle and long-term weight gain in women and men N Engl J Med 2011 Jun 23364(25)2392ndash404 doi httpdxdoiorg101056NEJMoa1014296 PMID 21696306
24 Mozaffarian D Appel LJ Van Horn L Components of a cardioprotective diet new insights Circulation 2011 Jun 21123(24)2870ndash91 doi httpdxdoiorg101161CIRCULATIONAHA110968735 PMID 21690503
25 WTO membership and noncommunicable disease risk factors - Supplemental materials Baltimore Johns Hopkins University 2018 Available from doi httpdxdoiorg106084m9figshare7268561v1 [cited 2018 Oct 30]doi httpdxdoiorg106084m9figshare7268561v1
26 Maumlnnistouml S Laatikainen T Helakorpi S Valsta LM Monitoring diet and diet-related chronic disease risk factors in Finland Public Health Nutr 2010 Jun13 6A907ndash14 doi httpdxdoiorg101017S1368980010001084 PMID 20513259
27 Sheehy T Sharma S Trends in energy and nutrient supply in Trinidad and Tobago from 1961 to 2007 using FAO food balance sheets Public Health Nutr 2013 Sep16(9)1693ndash702 doi httpdxdoiorg101017S136898001200537X PMID 23286774
28 World development indicators [internet] Washington DC The World Bank 2016 Available from httpdataworldbankorgdata-catalogworld-development-indicators [cited 2017 Feb 20]
29 World population prospects the 2015 Revision [internet] New York United Nations Department of Economic and Social Affairs Population Division 2015 Available from httpsesaunorgunpdwpp [cited 2017 Jan 6]
30 Gross domestic product (GDP) estimates by country 1950ndash2015 [internet] Seattle Institute for Health Metrics and Evaluation 2017 Available from httpghdxhealthdataorgrecordgross-domestic-product-gdp-estimates-country-1950-2015 [cited 2017 Jan 6]
31 Table Muslim Population by Country [internet] Washington DC Pew Research Center 2011 Available from httpwwwpewforumorg20110127table-muslim-population-by-country [cited 2017 Apr 12]
32 Depositary WHO Framework Convention on Tobacco Control [internet] New York United Nations Treaty Collection 2025 Available from httpstreatiesunorgpagesViewDetailsaspxsrc=TREATYampmtdsg_no=IX-4ampchapter=9amplang=en [cited 2017 Apr 18]
33 Ng M Freeman MK Fleming TD Robinson M Dwyer-Lindgren L Thomson B et al Smoking prevalence and cigarette consumption in 187 countries 1980ndash2012 JAMA 2014 Jan 8311(2)183ndash92 doi httpdxdoiorg101001jama2013284692 PMID 24399557
96 Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
34 Rehm J Mathers C Popova S Thavorncharoensap M Teerawattananon Y Patra J Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders Lancet 2009 Jun 27373(9682)2223ndash33 doi httpdxdoiorg101016S0140-6736(09)60746-7 PMID 19560604
35 Al-Ansari B Thow A-M Day CA Conigrave KM Extent of alcohol prohibition in civil policy in Muslim majority countries the impact of globalization Addiction 2016 10111(10)1703ndash13 doi httpdxdoiorg101111add13159 PMID 26508526
36 About the WHO Framework Convention on Tobacco Control [internet] Geneva World Health Organization 2018 Available from httpwwwwhointfctcabouten [cited 2017 May 11]
37 Stuart EA Matching methods for causal inference a review and a look forward Stat Sci 2010 Feb 125(1)1ndash21 doi httpdxdoiorg10121409-STS313 PMID 20871802
38 Ridgeway G McCaffrey D Morral A Burgette L Griffin BA Toolkit for weighting and analysis of nonequivalent groups a tutorial for the twang package R Vignette [internet] Vienna R Foundation 2017 Available from httpscranr-projectorgwebpackagestwangvignettestwangpdf [cited 2017 Apr 18]
39 McCaffrey DF Ridgeway G Morral AR Propensity score estimation with boosted regression for evaluating causal effects in observational studies Psychol Methods 2004 Dec9(4)403ndash25 doi httpdxdoiorg1010371082-989X94403 PMID 15598095
40 Linden A Adams JL Applying a propensity score-based weighting model to interrupted time series data improving causal inference in programme evaluation J Eval Clin Pract 2011 Dec17(6)1231ndash8 doi httpdxdoiorg101111j1365-2753201001504x PMID 20973870
41 Griswold MG Fullman N Hawley C Arian N Zimsen SRM Tymeson HD et al GBD 2016 Alcohol Collaborators Alcohol use and burden for 195 countries and territories 1990ndash2016 a systematic analysis for the Global Burden of Disease Study 2016 Lancet 2018 Sep 22392(10152)1015ndash35 doi httpdxdoiorg101016S0140-6736(18)31310-2 PMID 30146330
42 Peto R Lopez AD Boreham J Thun M Heath C Jr Mortality from tobacco in developed countries indirect estimation from national vital statistics Lancet 1992 May 23339(8804)1268ndash78 doi httpdxdoiorg1010160140-6736(92)91600-D PMID 1349675
43 Healthy diet Key facts Geneva World Health Organization 2018 Available from httpwwwwhointnews-roomfact-sheetsdetailhealthy-diet [cited 2018 Oct 26]
44 Aune D Giovannucci E Boffetta P Fadnes LT Keum N Norat T et al Fruit and vegetable intake and the risk of cardiovascular disease total cancer and all-cause mortality-a systematic review and dose-response meta-analysis of prospective studies Int J Epidemiol 2017 06 146(3)1029ndash56 doi httpdxdoiorg101093ijedyw319 PMID 28338764
45 Health in All Policies framework for country action [internet] Geneva World Health Organization 2018 Available from httpwwwwhointhealthpromotionframeworkforcountryactionen [cited 2017 Aug 13]
46 Cole BL Fielding JE Health impact assessment a tool to help policy makers understand health beyond health care Annu Rev Public Health 200728(1)393ndash412 doi httpdxdoiorg101146annurevpublhealth28083006131942 PMID 17173539
47 Tonts M Siddique MAB editors Globalisation agriculture and development perspectives from the Asia-Pacific Cheltenham Edward Elgar Publishing 2011 Available from httpswwwelgaronlinecomview978184720818700010xml [cited 2017 Aug 14]
48 Mendez Lopez A Loopstra R McKee M Stuckler D Is trade liberalisation a vector for the spread of sugar-sweetened beverages A cross-national longitudinal analysis of 44 low- and middle-income countries Soc Sci Med 2017 0117221ndash7 doi httpdxdoiorg101016jsocscimed201611001 PMID 27871042
49 Monteiro CA Moubarac J-C Cannon G Ng SW Popkin B Ultra-processed products are becoming dominant in the global food system Obes Rev 2013 Nov14 Suppl 221ndash8 doi httpdxdoiorg101111obr12107 PMID 24102801
Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057 96A
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
Fig 1 Unweighted and weighted absolute standardized biases for baseline commodity supply in countries included in the study 1980ndash1995
female labour force
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Absolute standardize bias
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0 02 04 06 08
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Supply of tobacco
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Supply of red meats and animal fats
Supply of alcohol
Supply of fruits and vegetables
GDP gross domestic productNotes The period 1980ndash1995 represents the years before countries and territories start joining the World Trade Organization Table 1 lists countries studied We measured bias by the absolute standardized mean difference that is (mean for non-member states ndash mean for member states)(combined standard deviation)
- Table 1
- Table 2
- Table 3
- Figure 2
- Figure 3
- Figure 4
- Figure 5
- Figure 6
- Figure 1
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93Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
consumption in the context of trade liberalization but our findings support the results of an analysis showing that changes in trade policies led to an in-crease in imported fruit in five Central American countries10
This study has limitations A pri-mary limitation is the comparability of countries joining versus not joining WTO We assumed that trends would have been similar between the two groups if none of the countries joined WTO However differences in trends could be due to the influence of other unobserved events correlated with WTO accession and the outcomes of interest or innate characteristics of countries in either group
Another key limitation is the quality of the commodity data which measure
the available supply of each commodity and are only a proxy for consumption the true measure of importance for health In addition there was substantial missing data for certain items summed to create commodity variables which may affect the validity of the data for these categories The commodities ana-lysed were also limited by the available product categories importantly this did not allow us to distinguish changes in trends in the availability of specific foods high in fat salt or sugar an important determinant of obesity and noncommu-nicable diseases49 Finally for tobacco and alcohol illicit sales and homemade varieties are not captured in this data which may comprise substantial por-tions of supply and consumption in certain countries
In conclusion changes in domestic supply of alcohol tobacco and fruits and vegetables could have important implications for public health particu-larly for the development and preven-tion of noncommunicable diseases Overall findings indicated substantial country-level heterogeneity Therefore additional exploration of variations across countries is critical to identify factors that mitigate the negative role and enhance the positive role of trade and investment agreements in the global noncommunicable disease burden
Funding Krycia Cowling was supported by a Center for a Livable Future-Lerner fellowship during the time of this study
Competing interests None declared
摘要世界贸易组织成员国与非传染性疾病风险因素的变化一项断续时间序列比较分析1980ndash2013 年目的 旨在调查加入世界贸易组织 (WTO) 与获取若干商品(此类商品对非传染性疾病的形成兼具有害因素和保护因素)之间的关系方法 我 们 使 用 自 然 实 验 设 计 倾 向 评 分 权 重 来比 较 1980 年 至 2013 年 期 间 在 1995 年 之 后 加入 WTO 的 21 个国家或地区以及 26 个非成员国的烟草酒精和七类食品组在各国内的供应趋势我们采用断续时间序列框架使用多变量随机效应线性模型根据人均国内生产总值城市人口百分比和女性劳动力参与进行调整在烟草模型中我们控制了已批准
《烟草控制框架公约》的成员国在酒精模型中我们控制了自认为穆斯林国家所占的比例
结果 成员国加入世贸组织后与非成员国相比平均每人每天的水果和蔬菜国内供应量立即增长 55 克分析显示烟草和酒精每年的供应量以几何平均数的形式逐渐递增分别为每年 62 和 36我们尚未发现获取红肉和动物脂肪有任何重大变化 海鲜 坚果种子和豆类 淀粉 或食用油 以及与糖相关的结果在不同模型中是不一致的结论 结果表明成为 WTO 成员国可能会导致非传染性疾病的有害因素和保护因素增加但仍需进一步探索其针对具体国家的不同变化
ملخصعضوية منظمة التجارة العاملية والتغريات يف عوامل خطر األمراض غري املعدية حتليل سالسل زمنية مقارنة متقطعة ما
بني عامي 1980 و2013العاملية التجارة منظمة إىل االنضامم بني العالقة دراسة الغرض الضارة التأثريات ذات السلع من العديد وتوافر (WTO)
والوقائية من أجل تطوير األمراض غري املعديةاالجتاهات ملقارنة الطبيعية التجربة تصميم استخدمنا الطريقة بني غذائية جمموعات وسبع والكحول للتبغ املحيل اإلمداد يف عامي 1980 و2013 يف 21 دولة أو منطقة انضمت إىل منظمة التجارة العاملية بعد عام 1995 و26 دولة غري أعضاء باستخدام أوزان درجات النزوع طبقنا إطارا زمنيا متسلسال مقارنا متقطعا معدلة متعددة عشوائية تأثريات ذات خطية نامذج باستخدام احلرض لسكان املئوية والنسب للفرد اإلمجايل املحيل للناتج ومشاركة املرأة يف القوى العاملة يف نموذج التبغ قمنا باملكافحة ملكافحة اإلطارية االتفاقية عىل صدقت التي األعضاء الدول يف يعرفون الذين للسكان املئوية النسبة الكحول نموذج ويف التبغ
أنفسهم بأهنم مسلمني
الدول شهدت العاملية التجارة منظمة إىل االنضامم بعد النتائج األعضاء زيادات فورية يف اإلمداد املحيل من الفواكه واخلرضوات وصلت إىل 55 جم للشخص الواحد يف اليوم يف املتوسط مقارنة بالدول غري األعضاء أظهر التحليل زيادات تدرجيية يف املتوسط
اهلنديس إلمدادات التبغ والكحول بنسبة 62 و 36 يف السنة لحوم ال توافر يف جوهرية ت تغيريا أي نكتشف مل الرتتيب عىل احلمراء أو الدهون احليوانية أو املأكوالت البحرية أو املكرسات أو البذور والبقوليات أو النشويات أو الزيوت الصاحلة لألكل
وكانت النتائج للسكريات غري متناسقة عرب تنوعات النموذجقد العاملية التجارة ة منظم وية عض أن إىل النتائج تشري االستنتاج لألمراض والوقائية ة الضار مل العوا من كل يف زيادة إىل تؤدي االختالفات استكشاف من ملزيد ز تعزي هناك ولكن املعدية غري
اخلاصة بكل بلد
94 Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
Reacutesumeacute
Adheacutesion agrave lOrganisation mondiale du commerce et eacutevolution des facteurs de risque de maladies non transmissibles analyse comparative de seacuteries chronologiques interrompues 1980ndash2013Objectif Eacutetudier le lien entre ladheacutesion agrave lOrganisation mondiale du commerce (OMC) et la disponibiliteacute de diffeacuterentes denreacutees avec des effets agrave la fois nocifs et protecteurs pour le deacuteveloppement des maladies non transmissiblesMeacutethodes Nous avons utiliseacute un plan dexpeacuterience dans les conditions naturelles pour comparer entre 1980 et 2013 leacutevolution de loffre nationale de tabac dalcool et de sept groupes daliments dans 21 pays ou territoires devenus membres de lOMC apregraves 1995 et 26 pays non membres agrave laide de pondeacuterations par le score de propension Nous avons appliqueacute un cadre comparatif de seacuteries chronologiques interrompues agrave laide de modegraveles lineacuteaires agrave effets aleacuteatoires multivarieacutes rajusteacutes pour tenir compte du produit inteacuterieur brut par habitant du pourcentage de la population urbaine et de la participation des femmes agrave la vie active Dans le modegravele relatif au tabac nous avons tenu compte des Eacutetats membres ayant ratifieacute la Convention-cadre pour la lutte antitabac tandis que dans le modegravele relatif agrave lalcool nous avons tenu
compte du pourcentage de la population sidentifiant comme eacutetant de foi musulmaneReacutesultats Agrave la suite de leur adheacutesion agrave lOMC les Eacutetats membres ont connu une augmentation immeacutediate de loffre nationale de fruits et leacutegumes de 55 g par personne et par jour en moyenne par rapport aux pays non membres Lanalyse a reacuteveacuteleacute une augmentation progressive de la moyenne geacuteomeacutetrique de loffre de tabac et dalcool de 62 et 36 par an respectivement Nous navons pas constateacute de changements importants concernant la disponibiliteacute de viandes rouges et graisses dorigine animale de produits de la mer de noix graines et leacutegumineuses de feacuteculents ou dhuiles alimentaires et les reacutesultats relatifs aux sucres variaient dun modegravele agrave lautreConclusion Les reacutesultats suggegraverent que ladheacutesion agrave lOMC peut entraicircner une augmentation des facteurs agrave la fois nocifs et protecteurs pour les maladies non transmissibles mais il convient de reacutealiser de nouvelles recherches sur les variations par pays
Резюме
Членство во Всемирной торговой организации и изменения в факторах риска неинфекционных заболеваний сравнительный анализ прерванных временных рядов 1980ndash2013 ггЦель Членство во Всемирной торговой организации и изменения в факторах риска неинфекционных заболеваний сравнительный анализ прерванных временных рядов 1980ndash2013 ггМетоды Авторы использовали естественный эксперимент для сравнения тенденций внутренних поставок табака алкоголя и товаров семи продовольственных групп в период с 1980 по 2013 год в 21 стране или территории которые вступили в ВТО после 1995 года и в 26 странах не являющихся членами этой организации Анализ проводился с использованием весовых коэффициентов предрасположенности Авторы применили методику сравнительных прерванных временных рядов и многовариантные линейные модели случайных воздействий скорректированные по валовому внутреннему продукту на душу населения процентной доле городского населения и участию женщин в трудовой деятельности В модели для табака контролировались государства-члены ВТО ратифицировавшие Рамочную конвенцию по борьбе против табака а в модели
для алкоголя mdash доля населения идентифицирующая себя как мусульманеРезультаты После вступления в ВТО в государствах-членах наблюдался немедленный прирост внутренних поставок фруктов и овощей (в среднем до 55 г в день на человека) по сравнению со странами не являющимися ее членами Анализ показал постепенное увеличение среднего геометрического значения поставок табака и алкоголя на 62 и 36 в год соответственно Авторы не обнаружили существенных изменений в доступности мяса домашнего скота и животных жиров морепродуктов орехов семян и бобовых а также крахмала или пищевых масел Что касается сахара в разных моделях были получены несовпадающие результатыВывод Результаты позволяют предположить что членство в ВТО может привести к увеличению как полезных так и вредных факторов распространения неинфекционных заболеваний но необходимо проведение дальнейших исследований вариаций в различных странах
Resumen
Composicioacuten de la Organizacioacuten Mundial del Comercio y cambios en los factores de riesgo de las enfermedades no contagiosas un anaacutelisis comparativo de series cronoloacutegicas interrumpidas 1980-2013Objetivo Investigar la relacioacuten entre la adhesioacuten a la Organizacioacuten Mundial del Comercio (OMC) y la disponibilidad de varios productos baacutesicos con efectos tanto perjudiciales como protectores para el desarrollo de enfermedades no contagiosasMeacutetodos Se utilizoacute un disentildeo de experimento natural para comparar las tendencias de la oferta interna de tabaco alcohol y siete grupos de alimentos entre 1980 y 2013 en 21 paiacuteses o territorios que se incorporaron a la OMC despueacutes de 1995 y 26 paiacuteses no miembros mediante el uso de ponderaciones de propensioacuten Se aplicoacute un marco comparativo de series temporales interrumpidas siguiendo modelos lineales de efectos aleatorios multivariados ajustados seguacuten el producto interior bruto per caacutepita los porcentajes de poblacioacuten urbana y la participacioacuten de la mujer en el mundo laboral En el modelo del
tabaco controlamos a los Estados miembros que habiacutean ratificado el Convenio Marco para el Control del Tabaco y en el modelo del alcohol el porcentaje de la poblacioacuten que se identificaba como musulmanaResultados Tras la adhesioacuten a la OMC los Estados miembros experimentaron un aumento inmediato de la oferta interna de frutas y hortalizas de 55 kg por persona y diacutea de media en comparacioacuten con los paiacuteses no miembros El anaacutelisis mostroacute incrementos graduales en la media geomeacutetrica de la oferta de tabaco y alcohol del 62 y el 36 anual respectivamente No se detectaron cambios significativos en la disponibilidad de carnes rojas y grasas animales mariscos nueces semillas y legumbres almidones o aceites comestibles y los resultados para los azuacutecares fueron inconsistentes entre las variaciones del modelo
95Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
Conclusioacuten Los resultados sugieren que la pertenencia a la OMC puede dar lugar a un aumento de los factores perjudiciales y protectores de
las enfermedades no contagiosas pero es necesario seguir estudiando las variaciones especiacuteficas de cada paiacutes
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17 Haines PS Siega-Riz AM Popkin BM The Diet Quality Index revised a measurement instrument for populations J Am Diet Assoc 1999 Jun99(6)697ndash704 doi httpdxdoiorg101016S0002-8223(99)00168-6 PMID 10361532
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23 Mozaffarian D Hao T Rimm EB Willett WC Hu FB Changes in diet and lifestyle and long-term weight gain in women and men N Engl J Med 2011 Jun 23364(25)2392ndash404 doi httpdxdoiorg101056NEJMoa1014296 PMID 21696306
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27 Sheehy T Sharma S Trends in energy and nutrient supply in Trinidad and Tobago from 1961 to 2007 using FAO food balance sheets Public Health Nutr 2013 Sep16(9)1693ndash702 doi httpdxdoiorg101017S136898001200537X PMID 23286774
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ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
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35 Al-Ansari B Thow A-M Day CA Conigrave KM Extent of alcohol prohibition in civil policy in Muslim majority countries the impact of globalization Addiction 2016 10111(10)1703ndash13 doi httpdxdoiorg101111add13159 PMID 26508526
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39 McCaffrey DF Ridgeway G Morral AR Propensity score estimation with boosted regression for evaluating causal effects in observational studies Psychol Methods 2004 Dec9(4)403ndash25 doi httpdxdoiorg1010371082-989X94403 PMID 15598095
40 Linden A Adams JL Applying a propensity score-based weighting model to interrupted time series data improving causal inference in programme evaluation J Eval Clin Pract 2011 Dec17(6)1231ndash8 doi httpdxdoiorg101111j1365-2753201001504x PMID 20973870
41 Griswold MG Fullman N Hawley C Arian N Zimsen SRM Tymeson HD et al GBD 2016 Alcohol Collaborators Alcohol use and burden for 195 countries and territories 1990ndash2016 a systematic analysis for the Global Burden of Disease Study 2016 Lancet 2018 Sep 22392(10152)1015ndash35 doi httpdxdoiorg101016S0140-6736(18)31310-2 PMID 30146330
42 Peto R Lopez AD Boreham J Thun M Heath C Jr Mortality from tobacco in developed countries indirect estimation from national vital statistics Lancet 1992 May 23339(8804)1268ndash78 doi httpdxdoiorg1010160140-6736(92)91600-D PMID 1349675
43 Healthy diet Key facts Geneva World Health Organization 2018 Available from httpwwwwhointnews-roomfact-sheetsdetailhealthy-diet [cited 2018 Oct 26]
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48 Mendez Lopez A Loopstra R McKee M Stuckler D Is trade liberalisation a vector for the spread of sugar-sweetened beverages A cross-national longitudinal analysis of 44 low- and middle-income countries Soc Sci Med 2017 0117221ndash7 doi httpdxdoiorg101016jsocscimed201611001 PMID 27871042
49 Monteiro CA Moubarac J-C Cannon G Ng SW Popkin B Ultra-processed products are becoming dominant in the global food system Obes Rev 2013 Nov14 Suppl 221ndash8 doi httpdxdoiorg101111obr12107 PMID 24102801
Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057 96A
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
Fig 1 Unweighted and weighted absolute standardized biases for baseline commodity supply in countries included in the study 1980ndash1995
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0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08 0 02 04 06 08
Supply of tobacco
Supply of starches
Supply of nuts seeds and legumes
Supply of seafood
Supply of edible oils
Supply of sugars
Supply of red meats and animal fats
Supply of alcohol
Supply of fruits and vegetables
GDP gross domestic productNotes The period 1980ndash1995 represents the years before countries and territories start joining the World Trade Organization Table 1 lists countries studied We measured bias by the absolute standardized mean difference that is (mean for non-member states ndash mean for member states)(combined standard deviation)
- Table 1
- Table 2
- Table 3
- Figure 2
- Figure 3
- Figure 4
- Figure 5
- Figure 6
- Figure 1
-
94 Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
Reacutesumeacute
Adheacutesion agrave lOrganisation mondiale du commerce et eacutevolution des facteurs de risque de maladies non transmissibles analyse comparative de seacuteries chronologiques interrompues 1980ndash2013Objectif Eacutetudier le lien entre ladheacutesion agrave lOrganisation mondiale du commerce (OMC) et la disponibiliteacute de diffeacuterentes denreacutees avec des effets agrave la fois nocifs et protecteurs pour le deacuteveloppement des maladies non transmissiblesMeacutethodes Nous avons utiliseacute un plan dexpeacuterience dans les conditions naturelles pour comparer entre 1980 et 2013 leacutevolution de loffre nationale de tabac dalcool et de sept groupes daliments dans 21 pays ou territoires devenus membres de lOMC apregraves 1995 et 26 pays non membres agrave laide de pondeacuterations par le score de propension Nous avons appliqueacute un cadre comparatif de seacuteries chronologiques interrompues agrave laide de modegraveles lineacuteaires agrave effets aleacuteatoires multivarieacutes rajusteacutes pour tenir compte du produit inteacuterieur brut par habitant du pourcentage de la population urbaine et de la participation des femmes agrave la vie active Dans le modegravele relatif au tabac nous avons tenu compte des Eacutetats membres ayant ratifieacute la Convention-cadre pour la lutte antitabac tandis que dans le modegravele relatif agrave lalcool nous avons tenu
compte du pourcentage de la population sidentifiant comme eacutetant de foi musulmaneReacutesultats Agrave la suite de leur adheacutesion agrave lOMC les Eacutetats membres ont connu une augmentation immeacutediate de loffre nationale de fruits et leacutegumes de 55 g par personne et par jour en moyenne par rapport aux pays non membres Lanalyse a reacuteveacuteleacute une augmentation progressive de la moyenne geacuteomeacutetrique de loffre de tabac et dalcool de 62 et 36 par an respectivement Nous navons pas constateacute de changements importants concernant la disponibiliteacute de viandes rouges et graisses dorigine animale de produits de la mer de noix graines et leacutegumineuses de feacuteculents ou dhuiles alimentaires et les reacutesultats relatifs aux sucres variaient dun modegravele agrave lautreConclusion Les reacutesultats suggegraverent que ladheacutesion agrave lOMC peut entraicircner une augmentation des facteurs agrave la fois nocifs et protecteurs pour les maladies non transmissibles mais il convient de reacutealiser de nouvelles recherches sur les variations par pays
Резюме
Членство во Всемирной торговой организации и изменения в факторах риска неинфекционных заболеваний сравнительный анализ прерванных временных рядов 1980ndash2013 ггЦель Членство во Всемирной торговой организации и изменения в факторах риска неинфекционных заболеваний сравнительный анализ прерванных временных рядов 1980ndash2013 ггМетоды Авторы использовали естественный эксперимент для сравнения тенденций внутренних поставок табака алкоголя и товаров семи продовольственных групп в период с 1980 по 2013 год в 21 стране или территории которые вступили в ВТО после 1995 года и в 26 странах не являющихся членами этой организации Анализ проводился с использованием весовых коэффициентов предрасположенности Авторы применили методику сравнительных прерванных временных рядов и многовариантные линейные модели случайных воздействий скорректированные по валовому внутреннему продукту на душу населения процентной доле городского населения и участию женщин в трудовой деятельности В модели для табака контролировались государства-члены ВТО ратифицировавшие Рамочную конвенцию по борьбе против табака а в модели
для алкоголя mdash доля населения идентифицирующая себя как мусульманеРезультаты После вступления в ВТО в государствах-членах наблюдался немедленный прирост внутренних поставок фруктов и овощей (в среднем до 55 г в день на человека) по сравнению со странами не являющимися ее членами Анализ показал постепенное увеличение среднего геометрического значения поставок табака и алкоголя на 62 и 36 в год соответственно Авторы не обнаружили существенных изменений в доступности мяса домашнего скота и животных жиров морепродуктов орехов семян и бобовых а также крахмала или пищевых масел Что касается сахара в разных моделях были получены несовпадающие результатыВывод Результаты позволяют предположить что членство в ВТО может привести к увеличению как полезных так и вредных факторов распространения неинфекционных заболеваний но необходимо проведение дальнейших исследований вариаций в различных странах
Resumen
Composicioacuten de la Organizacioacuten Mundial del Comercio y cambios en los factores de riesgo de las enfermedades no contagiosas un anaacutelisis comparativo de series cronoloacutegicas interrumpidas 1980-2013Objetivo Investigar la relacioacuten entre la adhesioacuten a la Organizacioacuten Mundial del Comercio (OMC) y la disponibilidad de varios productos baacutesicos con efectos tanto perjudiciales como protectores para el desarrollo de enfermedades no contagiosasMeacutetodos Se utilizoacute un disentildeo de experimento natural para comparar las tendencias de la oferta interna de tabaco alcohol y siete grupos de alimentos entre 1980 y 2013 en 21 paiacuteses o territorios que se incorporaron a la OMC despueacutes de 1995 y 26 paiacuteses no miembros mediante el uso de ponderaciones de propensioacuten Se aplicoacute un marco comparativo de series temporales interrumpidas siguiendo modelos lineales de efectos aleatorios multivariados ajustados seguacuten el producto interior bruto per caacutepita los porcentajes de poblacioacuten urbana y la participacioacuten de la mujer en el mundo laboral En el modelo del
tabaco controlamos a los Estados miembros que habiacutean ratificado el Convenio Marco para el Control del Tabaco y en el modelo del alcohol el porcentaje de la poblacioacuten que se identificaba como musulmanaResultados Tras la adhesioacuten a la OMC los Estados miembros experimentaron un aumento inmediato de la oferta interna de frutas y hortalizas de 55 kg por persona y diacutea de media en comparacioacuten con los paiacuteses no miembros El anaacutelisis mostroacute incrementos graduales en la media geomeacutetrica de la oferta de tabaco y alcohol del 62 y el 36 anual respectivamente No se detectaron cambios significativos en la disponibilidad de carnes rojas y grasas animales mariscos nueces semillas y legumbres almidones o aceites comestibles y los resultados para los azuacutecares fueron inconsistentes entre las variaciones del modelo
95Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
Conclusioacuten Los resultados sugieren que la pertenencia a la OMC puede dar lugar a un aumento de los factores perjudiciales y protectores de
las enfermedades no contagiosas pero es necesario seguir estudiando las variaciones especiacuteficas de cada paiacutes
References1 Murray CJ Vos T Lozano R Naghavi M Flaxman AD Michaud C et al
Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions 1990ndash2010 a systematic analysis for the Global Burden of Disease Study 2010 Lancet 2012 Dec 15380(9859)2197ndash223 doi httpdxdoiorg101016S0140-6736(12)61689-4 PMID 23245608
2 Lim SS Vos T Flaxman AD Danaei G Shibuya K Adair-Rohani H et al A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions 1990ndash2010 a systematic analysis for the Global Burden of Disease Study 2010 Lancet 2012 Dec 15380(9859)2224ndash60 doi httpdxdoiorg101016S0140-6736(12)61766-8 PMID 23245609
3 Baker P Friel S Food systems transformations ultra-processed food markets and the nutrition transition in Asia Global Health 2016 12 312(1)80 doi httpdxdoiorg101186s12992-016-0223-3 PMID 27912772
4 Labonteacute R Mohindra KS Lencucha R Framing international trade and chronic disease Global Health 2011 07 47(1)21 doi httpdxdoiorg1011861744-8603-7-21 PMID 21726434
5 Stuckler D McKee M Ebrahim S Basu S Manufacturing epidemics the role of global producers in increased consumption of unhealthy commodities including processed foods alcohol and tobacco PLoS Med 20129(6)e1001235 doi httpdxdoiorg101371journalpmed1001235 PMID 22745605
6 De Vogli R Kouvonen A Gimeno D The influence of market deregulation on fast food consumption and body mass index a cross-national time series analysis Bull World Health Organ 2014 Feb 192(2)99ndash107 107A doi httpdxdoiorg102471BLT13120287 PMID 24623903
7 Chaloupka FJ Laixuthai A Trade policy and cigarette smoking in Asia [NBER working paper series] Cambridge National Bureau of Economic Research 1996 Available from httpwwwnberorgpapersw5543 [cited 2017 Sep 4]
8 Cassels S Overweight in the Pacific links between foreign dependence global food trade and obesity in the Federated States of Micronesia Global Health 2006 07 112(1)10 doi httpdxdoiorg1011861744-8603-2-10 PMID 16834782
9 Schultz JT Globalisation urbanization and nutrition transition in a developing island country a case study Fiji Globalization of food systems in developing countries impact on food security and nutrition Rome Food and Agriculture Organization 2004
10 Thow AM Hawkes C The implications of trade liberalization for diet and health a case study from Central America Global Health 2009 07 2855 doi httpdxdoiorg1011861744-8603-5-5 PMID 19638196
11 Barlow P McKee M Basu S Stuckler D The health impact of trade and investment agreements a quantitative systematic review and network co-citation analysis Global Health 2017 03 813(1)13 doi httpdxdoiorg101186s12992-017-0240-x PMID 28274238
12 Taylor A Chaloupka FJ Guindon E Corbett M The impact of trade liberalization on tobacco consumption In Jha P Chaloupka FJ editors Tobacco control in developing countries Oxford Oxford University Press 2000 pp 343ndash64
13 Schram A Labonte R Baker P Friel S Reeves A Stuckler D The role of trade and investment liberalization in the sugar-sweetened carbonated beverages market a natural experiment contrasting Vietnam and the Philippines Global Health 2015 10 1211(1)41 doi httpdxdoiorg101186s12992-015-0127-7 PMID 26455446
14 Baker P Friel S Schram A Labonte R Trade and investment liberalization food systems change and highly processed food consumption a natural experiment contrasting the soft-drink markets of Peru and Bolivia Global Health 2016 06 212(1)24 doi httpdxdoiorg101186s12992-016-0161-0 PMID 27255275
15 Understanding the WTO the organization Members and observers [internet] Geneva World Trade Organization 2017 Available from httpswwwwtoorgenglishthewto_ewhatis_etif_eorg6_ehtm [cited 2017 Mar 28]
16 Guenther PM Casavale KO Reedy J Kirkpatrick SI Hiza HA Kuczynski KJ et al Update of the healthy eating index HEI-2010 J Acad Nutr Diet 2013 Apr113(4)569ndash80 doi httpdxdoiorg101016jjand201212016 PMID 23415502
17 Haines PS Siega-Riz AM Popkin BM The Diet Quality Index revised a measurement instrument for populations J Am Diet Assoc 1999 Jun99(6)697ndash704 doi httpdxdoiorg101016S0002-8223(99)00168-6 PMID 10361532
18 Huijbregts P Feskens E Raumlsaumlnen L Fidanza F Nissinen A Menotti A et al Dietary pattern and 20 year mortality in elderly men in Finland Italy and The Netherlands longitudinal cohort study BMJ 1997 Jul 5315(7099)13ndash7 doi httpdxdoiorg101136bmj315709913 PMID 9233319
19 Panagiotakos DB Pitsavos C Stefanadis C Dietary patterns a Mediterranean diet score and its relation to clinical and biological markers of cardiovascular disease risk Nutr Metab Cardiovasc Dis 2006 Dec16(8)559ndash68 doi httpdxdoiorg101016jnumecd200508006 PMID 17126772
20 Guidelines for measuring household and individual dietary diversity [internet] Rome Food and Agriculture Organization 2012 Available from httpwwwfaoorgdocrep014i1983ei1983e00htm [cited 2017 Jan 14]
21 Indicators for nutrition-friendly and sustainable food systems InGlobal nutrition report 2015 actions and accountability to advance nutrition and sustainable development Washington DC International Food Policy Research Institute 2015 pp 85ndash96 Available from httpglobalnutritionreportorgthe-reportthe-report-2015 [cited 2017 Apr 4]
22 Micha R Khatibzadeh S Shi P Andrews KG Engell RE Mozaffarian D Global Burden of Diseases Nutrition and Chronic Diseases Expert Group (NutriCoDE) Global regional and national consumption of major food groups in 1990 and 2010 a systematic analysis including 266 country-specific nutrition surveys worldwide BMJ Open 2015 09 245(9)e008705 doi httpdxdoiorg101136bmjopen-2015-008705 PMID 26408285
23 Mozaffarian D Hao T Rimm EB Willett WC Hu FB Changes in diet and lifestyle and long-term weight gain in women and men N Engl J Med 2011 Jun 23364(25)2392ndash404 doi httpdxdoiorg101056NEJMoa1014296 PMID 21696306
24 Mozaffarian D Appel LJ Van Horn L Components of a cardioprotective diet new insights Circulation 2011 Jun 21123(24)2870ndash91 doi httpdxdoiorg101161CIRCULATIONAHA110968735 PMID 21690503
25 WTO membership and noncommunicable disease risk factors - Supplemental materials Baltimore Johns Hopkins University 2018 Available from doi httpdxdoiorg106084m9figshare7268561v1 [cited 2018 Oct 30]doi httpdxdoiorg106084m9figshare7268561v1
26 Maumlnnistouml S Laatikainen T Helakorpi S Valsta LM Monitoring diet and diet-related chronic disease risk factors in Finland Public Health Nutr 2010 Jun13 6A907ndash14 doi httpdxdoiorg101017S1368980010001084 PMID 20513259
27 Sheehy T Sharma S Trends in energy and nutrient supply in Trinidad and Tobago from 1961 to 2007 using FAO food balance sheets Public Health Nutr 2013 Sep16(9)1693ndash702 doi httpdxdoiorg101017S136898001200537X PMID 23286774
28 World development indicators [internet] Washington DC The World Bank 2016 Available from httpdataworldbankorgdata-catalogworld-development-indicators [cited 2017 Feb 20]
29 World population prospects the 2015 Revision [internet] New York United Nations Department of Economic and Social Affairs Population Division 2015 Available from httpsesaunorgunpdwpp [cited 2017 Jan 6]
30 Gross domestic product (GDP) estimates by country 1950ndash2015 [internet] Seattle Institute for Health Metrics and Evaluation 2017 Available from httpghdxhealthdataorgrecordgross-domestic-product-gdp-estimates-country-1950-2015 [cited 2017 Jan 6]
31 Table Muslim Population by Country [internet] Washington DC Pew Research Center 2011 Available from httpwwwpewforumorg20110127table-muslim-population-by-country [cited 2017 Apr 12]
32 Depositary WHO Framework Convention on Tobacco Control [internet] New York United Nations Treaty Collection 2025 Available from httpstreatiesunorgpagesViewDetailsaspxsrc=TREATYampmtdsg_no=IX-4ampchapter=9amplang=en [cited 2017 Apr 18]
33 Ng M Freeman MK Fleming TD Robinson M Dwyer-Lindgren L Thomson B et al Smoking prevalence and cigarette consumption in 187 countries 1980ndash2012 JAMA 2014 Jan 8311(2)183ndash92 doi httpdxdoiorg101001jama2013284692 PMID 24399557
96 Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
34 Rehm J Mathers C Popova S Thavorncharoensap M Teerawattananon Y Patra J Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders Lancet 2009 Jun 27373(9682)2223ndash33 doi httpdxdoiorg101016S0140-6736(09)60746-7 PMID 19560604
35 Al-Ansari B Thow A-M Day CA Conigrave KM Extent of alcohol prohibition in civil policy in Muslim majority countries the impact of globalization Addiction 2016 10111(10)1703ndash13 doi httpdxdoiorg101111add13159 PMID 26508526
36 About the WHO Framework Convention on Tobacco Control [internet] Geneva World Health Organization 2018 Available from httpwwwwhointfctcabouten [cited 2017 May 11]
37 Stuart EA Matching methods for causal inference a review and a look forward Stat Sci 2010 Feb 125(1)1ndash21 doi httpdxdoiorg10121409-STS313 PMID 20871802
38 Ridgeway G McCaffrey D Morral A Burgette L Griffin BA Toolkit for weighting and analysis of nonequivalent groups a tutorial for the twang package R Vignette [internet] Vienna R Foundation 2017 Available from httpscranr-projectorgwebpackagestwangvignettestwangpdf [cited 2017 Apr 18]
39 McCaffrey DF Ridgeway G Morral AR Propensity score estimation with boosted regression for evaluating causal effects in observational studies Psychol Methods 2004 Dec9(4)403ndash25 doi httpdxdoiorg1010371082-989X94403 PMID 15598095
40 Linden A Adams JL Applying a propensity score-based weighting model to interrupted time series data improving causal inference in programme evaluation J Eval Clin Pract 2011 Dec17(6)1231ndash8 doi httpdxdoiorg101111j1365-2753201001504x PMID 20973870
41 Griswold MG Fullman N Hawley C Arian N Zimsen SRM Tymeson HD et al GBD 2016 Alcohol Collaborators Alcohol use and burden for 195 countries and territories 1990ndash2016 a systematic analysis for the Global Burden of Disease Study 2016 Lancet 2018 Sep 22392(10152)1015ndash35 doi httpdxdoiorg101016S0140-6736(18)31310-2 PMID 30146330
42 Peto R Lopez AD Boreham J Thun M Heath C Jr Mortality from tobacco in developed countries indirect estimation from national vital statistics Lancet 1992 May 23339(8804)1268ndash78 doi httpdxdoiorg1010160140-6736(92)91600-D PMID 1349675
43 Healthy diet Key facts Geneva World Health Organization 2018 Available from httpwwwwhointnews-roomfact-sheetsdetailhealthy-diet [cited 2018 Oct 26]
44 Aune D Giovannucci E Boffetta P Fadnes LT Keum N Norat T et al Fruit and vegetable intake and the risk of cardiovascular disease total cancer and all-cause mortality-a systematic review and dose-response meta-analysis of prospective studies Int J Epidemiol 2017 06 146(3)1029ndash56 doi httpdxdoiorg101093ijedyw319 PMID 28338764
45 Health in All Policies framework for country action [internet] Geneva World Health Organization 2018 Available from httpwwwwhointhealthpromotionframeworkforcountryactionen [cited 2017 Aug 13]
46 Cole BL Fielding JE Health impact assessment a tool to help policy makers understand health beyond health care Annu Rev Public Health 200728(1)393ndash412 doi httpdxdoiorg101146annurevpublhealth28083006131942 PMID 17173539
47 Tonts M Siddique MAB editors Globalisation agriculture and development perspectives from the Asia-Pacific Cheltenham Edward Elgar Publishing 2011 Available from httpswwwelgaronlinecomview978184720818700010xml [cited 2017 Aug 14]
48 Mendez Lopez A Loopstra R McKee M Stuckler D Is trade liberalisation a vector for the spread of sugar-sweetened beverages A cross-national longitudinal analysis of 44 low- and middle-income countries Soc Sci Med 2017 0117221ndash7 doi httpdxdoiorg101016jsocscimed201611001 PMID 27871042
49 Monteiro CA Moubarac J-C Cannon G Ng SW Popkin B Ultra-processed products are becoming dominant in the global food system Obes Rev 2013 Nov14 Suppl 221ndash8 doi httpdxdoiorg101111obr12107 PMID 24102801
Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057 96A
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
Fig 1 Unweighted and weighted absolute standardized biases for baseline commodity supply in countries included in the study 1980ndash1995
female labour force
participation
female labour force
participation
female labour force
participation
female labour force
participation
female labour force
participation
female labour force
participation
female labour force
participation
female labour force
participation
Muslim population
female labour force
participation urban
population
urban population
urban population
urban population
urban population
urban population
urban population
urbanpopulation
urban population
Tobacco
Starches
Nuts seedsand legumes
Seafood
Edible oils
Sugars
Red meatsand animal
fats
Alcohol Fruits andvegetables
GDP percapita (log)
GDP percapita (log)
GDP percapita (log)
GDP percapita (log)
GDP percapita (log)
GDP percapita (log)
GDP percapita (log)
GDP percapita (log)
GDP percapita (log)
1980198519901995
1980198519901995
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1980198519901995
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Absolute standardize bias
Absolute standardize bias
Absolute standardize bias
Unweighted Weighted
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08 0 02 04 06 08
Supply of tobacco
Supply of starches
Supply of nuts seeds and legumes
Supply of seafood
Supply of edible oils
Supply of sugars
Supply of red meats and animal fats
Supply of alcohol
Supply of fruits and vegetables
GDP gross domestic productNotes The period 1980ndash1995 represents the years before countries and territories start joining the World Trade Organization Table 1 lists countries studied We measured bias by the absolute standardized mean difference that is (mean for non-member states ndash mean for member states)(combined standard deviation)
- Table 1
- Table 2
- Table 3
- Figure 2
- Figure 3
- Figure 4
- Figure 5
- Figure 6
- Figure 1
-
95Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
Conclusioacuten Los resultados sugieren que la pertenencia a la OMC puede dar lugar a un aumento de los factores perjudiciales y protectores de
las enfermedades no contagiosas pero es necesario seguir estudiando las variaciones especiacuteficas de cada paiacutes
References1 Murray CJ Vos T Lozano R Naghavi M Flaxman AD Michaud C et al
Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions 1990ndash2010 a systematic analysis for the Global Burden of Disease Study 2010 Lancet 2012 Dec 15380(9859)2197ndash223 doi httpdxdoiorg101016S0140-6736(12)61689-4 PMID 23245608
2 Lim SS Vos T Flaxman AD Danaei G Shibuya K Adair-Rohani H et al A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions 1990ndash2010 a systematic analysis for the Global Burden of Disease Study 2010 Lancet 2012 Dec 15380(9859)2224ndash60 doi httpdxdoiorg101016S0140-6736(12)61766-8 PMID 23245609
3 Baker P Friel S Food systems transformations ultra-processed food markets and the nutrition transition in Asia Global Health 2016 12 312(1)80 doi httpdxdoiorg101186s12992-016-0223-3 PMID 27912772
4 Labonteacute R Mohindra KS Lencucha R Framing international trade and chronic disease Global Health 2011 07 47(1)21 doi httpdxdoiorg1011861744-8603-7-21 PMID 21726434
5 Stuckler D McKee M Ebrahim S Basu S Manufacturing epidemics the role of global producers in increased consumption of unhealthy commodities including processed foods alcohol and tobacco PLoS Med 20129(6)e1001235 doi httpdxdoiorg101371journalpmed1001235 PMID 22745605
6 De Vogli R Kouvonen A Gimeno D The influence of market deregulation on fast food consumption and body mass index a cross-national time series analysis Bull World Health Organ 2014 Feb 192(2)99ndash107 107A doi httpdxdoiorg102471BLT13120287 PMID 24623903
7 Chaloupka FJ Laixuthai A Trade policy and cigarette smoking in Asia [NBER working paper series] Cambridge National Bureau of Economic Research 1996 Available from httpwwwnberorgpapersw5543 [cited 2017 Sep 4]
8 Cassels S Overweight in the Pacific links between foreign dependence global food trade and obesity in the Federated States of Micronesia Global Health 2006 07 112(1)10 doi httpdxdoiorg1011861744-8603-2-10 PMID 16834782
9 Schultz JT Globalisation urbanization and nutrition transition in a developing island country a case study Fiji Globalization of food systems in developing countries impact on food security and nutrition Rome Food and Agriculture Organization 2004
10 Thow AM Hawkes C The implications of trade liberalization for diet and health a case study from Central America Global Health 2009 07 2855 doi httpdxdoiorg1011861744-8603-5-5 PMID 19638196
11 Barlow P McKee M Basu S Stuckler D The health impact of trade and investment agreements a quantitative systematic review and network co-citation analysis Global Health 2017 03 813(1)13 doi httpdxdoiorg101186s12992-017-0240-x PMID 28274238
12 Taylor A Chaloupka FJ Guindon E Corbett M The impact of trade liberalization on tobacco consumption In Jha P Chaloupka FJ editors Tobacco control in developing countries Oxford Oxford University Press 2000 pp 343ndash64
13 Schram A Labonte R Baker P Friel S Reeves A Stuckler D The role of trade and investment liberalization in the sugar-sweetened carbonated beverages market a natural experiment contrasting Vietnam and the Philippines Global Health 2015 10 1211(1)41 doi httpdxdoiorg101186s12992-015-0127-7 PMID 26455446
14 Baker P Friel S Schram A Labonte R Trade and investment liberalization food systems change and highly processed food consumption a natural experiment contrasting the soft-drink markets of Peru and Bolivia Global Health 2016 06 212(1)24 doi httpdxdoiorg101186s12992-016-0161-0 PMID 27255275
15 Understanding the WTO the organization Members and observers [internet] Geneva World Trade Organization 2017 Available from httpswwwwtoorgenglishthewto_ewhatis_etif_eorg6_ehtm [cited 2017 Mar 28]
16 Guenther PM Casavale KO Reedy J Kirkpatrick SI Hiza HA Kuczynski KJ et al Update of the healthy eating index HEI-2010 J Acad Nutr Diet 2013 Apr113(4)569ndash80 doi httpdxdoiorg101016jjand201212016 PMID 23415502
17 Haines PS Siega-Riz AM Popkin BM The Diet Quality Index revised a measurement instrument for populations J Am Diet Assoc 1999 Jun99(6)697ndash704 doi httpdxdoiorg101016S0002-8223(99)00168-6 PMID 10361532
18 Huijbregts P Feskens E Raumlsaumlnen L Fidanza F Nissinen A Menotti A et al Dietary pattern and 20 year mortality in elderly men in Finland Italy and The Netherlands longitudinal cohort study BMJ 1997 Jul 5315(7099)13ndash7 doi httpdxdoiorg101136bmj315709913 PMID 9233319
19 Panagiotakos DB Pitsavos C Stefanadis C Dietary patterns a Mediterranean diet score and its relation to clinical and biological markers of cardiovascular disease risk Nutr Metab Cardiovasc Dis 2006 Dec16(8)559ndash68 doi httpdxdoiorg101016jnumecd200508006 PMID 17126772
20 Guidelines for measuring household and individual dietary diversity [internet] Rome Food and Agriculture Organization 2012 Available from httpwwwfaoorgdocrep014i1983ei1983e00htm [cited 2017 Jan 14]
21 Indicators for nutrition-friendly and sustainable food systems InGlobal nutrition report 2015 actions and accountability to advance nutrition and sustainable development Washington DC International Food Policy Research Institute 2015 pp 85ndash96 Available from httpglobalnutritionreportorgthe-reportthe-report-2015 [cited 2017 Apr 4]
22 Micha R Khatibzadeh S Shi P Andrews KG Engell RE Mozaffarian D Global Burden of Diseases Nutrition and Chronic Diseases Expert Group (NutriCoDE) Global regional and national consumption of major food groups in 1990 and 2010 a systematic analysis including 266 country-specific nutrition surveys worldwide BMJ Open 2015 09 245(9)e008705 doi httpdxdoiorg101136bmjopen-2015-008705 PMID 26408285
23 Mozaffarian D Hao T Rimm EB Willett WC Hu FB Changes in diet and lifestyle and long-term weight gain in women and men N Engl J Med 2011 Jun 23364(25)2392ndash404 doi httpdxdoiorg101056NEJMoa1014296 PMID 21696306
24 Mozaffarian D Appel LJ Van Horn L Components of a cardioprotective diet new insights Circulation 2011 Jun 21123(24)2870ndash91 doi httpdxdoiorg101161CIRCULATIONAHA110968735 PMID 21690503
25 WTO membership and noncommunicable disease risk factors - Supplemental materials Baltimore Johns Hopkins University 2018 Available from doi httpdxdoiorg106084m9figshare7268561v1 [cited 2018 Oct 30]doi httpdxdoiorg106084m9figshare7268561v1
26 Maumlnnistouml S Laatikainen T Helakorpi S Valsta LM Monitoring diet and diet-related chronic disease risk factors in Finland Public Health Nutr 2010 Jun13 6A907ndash14 doi httpdxdoiorg101017S1368980010001084 PMID 20513259
27 Sheehy T Sharma S Trends in energy and nutrient supply in Trinidad and Tobago from 1961 to 2007 using FAO food balance sheets Public Health Nutr 2013 Sep16(9)1693ndash702 doi httpdxdoiorg101017S136898001200537X PMID 23286774
28 World development indicators [internet] Washington DC The World Bank 2016 Available from httpdataworldbankorgdata-catalogworld-development-indicators [cited 2017 Feb 20]
29 World population prospects the 2015 Revision [internet] New York United Nations Department of Economic and Social Affairs Population Division 2015 Available from httpsesaunorgunpdwpp [cited 2017 Jan 6]
30 Gross domestic product (GDP) estimates by country 1950ndash2015 [internet] Seattle Institute for Health Metrics and Evaluation 2017 Available from httpghdxhealthdataorgrecordgross-domestic-product-gdp-estimates-country-1950-2015 [cited 2017 Jan 6]
31 Table Muslim Population by Country [internet] Washington DC Pew Research Center 2011 Available from httpwwwpewforumorg20110127table-muslim-population-by-country [cited 2017 Apr 12]
32 Depositary WHO Framework Convention on Tobacco Control [internet] New York United Nations Treaty Collection 2025 Available from httpstreatiesunorgpagesViewDetailsaspxsrc=TREATYampmtdsg_no=IX-4ampchapter=9amplang=en [cited 2017 Apr 18]
33 Ng M Freeman MK Fleming TD Robinson M Dwyer-Lindgren L Thomson B et al Smoking prevalence and cigarette consumption in 187 countries 1980ndash2012 JAMA 2014 Jan 8311(2)183ndash92 doi httpdxdoiorg101001jama2013284692 PMID 24399557
96 Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
34 Rehm J Mathers C Popova S Thavorncharoensap M Teerawattananon Y Patra J Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders Lancet 2009 Jun 27373(9682)2223ndash33 doi httpdxdoiorg101016S0140-6736(09)60746-7 PMID 19560604
35 Al-Ansari B Thow A-M Day CA Conigrave KM Extent of alcohol prohibition in civil policy in Muslim majority countries the impact of globalization Addiction 2016 10111(10)1703ndash13 doi httpdxdoiorg101111add13159 PMID 26508526
36 About the WHO Framework Convention on Tobacco Control [internet] Geneva World Health Organization 2018 Available from httpwwwwhointfctcabouten [cited 2017 May 11]
37 Stuart EA Matching methods for causal inference a review and a look forward Stat Sci 2010 Feb 125(1)1ndash21 doi httpdxdoiorg10121409-STS313 PMID 20871802
38 Ridgeway G McCaffrey D Morral A Burgette L Griffin BA Toolkit for weighting and analysis of nonequivalent groups a tutorial for the twang package R Vignette [internet] Vienna R Foundation 2017 Available from httpscranr-projectorgwebpackagestwangvignettestwangpdf [cited 2017 Apr 18]
39 McCaffrey DF Ridgeway G Morral AR Propensity score estimation with boosted regression for evaluating causal effects in observational studies Psychol Methods 2004 Dec9(4)403ndash25 doi httpdxdoiorg1010371082-989X94403 PMID 15598095
40 Linden A Adams JL Applying a propensity score-based weighting model to interrupted time series data improving causal inference in programme evaluation J Eval Clin Pract 2011 Dec17(6)1231ndash8 doi httpdxdoiorg101111j1365-2753201001504x PMID 20973870
41 Griswold MG Fullman N Hawley C Arian N Zimsen SRM Tymeson HD et al GBD 2016 Alcohol Collaborators Alcohol use and burden for 195 countries and territories 1990ndash2016 a systematic analysis for the Global Burden of Disease Study 2016 Lancet 2018 Sep 22392(10152)1015ndash35 doi httpdxdoiorg101016S0140-6736(18)31310-2 PMID 30146330
42 Peto R Lopez AD Boreham J Thun M Heath C Jr Mortality from tobacco in developed countries indirect estimation from national vital statistics Lancet 1992 May 23339(8804)1268ndash78 doi httpdxdoiorg1010160140-6736(92)91600-D PMID 1349675
43 Healthy diet Key facts Geneva World Health Organization 2018 Available from httpwwwwhointnews-roomfact-sheetsdetailhealthy-diet [cited 2018 Oct 26]
44 Aune D Giovannucci E Boffetta P Fadnes LT Keum N Norat T et al Fruit and vegetable intake and the risk of cardiovascular disease total cancer and all-cause mortality-a systematic review and dose-response meta-analysis of prospective studies Int J Epidemiol 2017 06 146(3)1029ndash56 doi httpdxdoiorg101093ijedyw319 PMID 28338764
45 Health in All Policies framework for country action [internet] Geneva World Health Organization 2018 Available from httpwwwwhointhealthpromotionframeworkforcountryactionen [cited 2017 Aug 13]
46 Cole BL Fielding JE Health impact assessment a tool to help policy makers understand health beyond health care Annu Rev Public Health 200728(1)393ndash412 doi httpdxdoiorg101146annurevpublhealth28083006131942 PMID 17173539
47 Tonts M Siddique MAB editors Globalisation agriculture and development perspectives from the Asia-Pacific Cheltenham Edward Elgar Publishing 2011 Available from httpswwwelgaronlinecomview978184720818700010xml [cited 2017 Aug 14]
48 Mendez Lopez A Loopstra R McKee M Stuckler D Is trade liberalisation a vector for the spread of sugar-sweetened beverages A cross-national longitudinal analysis of 44 low- and middle-income countries Soc Sci Med 2017 0117221ndash7 doi httpdxdoiorg101016jsocscimed201611001 PMID 27871042
49 Monteiro CA Moubarac J-C Cannon G Ng SW Popkin B Ultra-processed products are becoming dominant in the global food system Obes Rev 2013 Nov14 Suppl 221ndash8 doi httpdxdoiorg101111obr12107 PMID 24102801
Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057 96A
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
Fig 1 Unweighted and weighted absolute standardized biases for baseline commodity supply in countries included in the study 1980ndash1995
female labour force
participation
female labour force
participation
female labour force
participation
female labour force
participation
female labour force
participation
female labour force
participation
female labour force
participation
female labour force
participation
Muslim population
female labour force
participation urban
population
urban population
urban population
urban population
urban population
urban population
urban population
urbanpopulation
urban population
Tobacco
Starches
Nuts seedsand legumes
Seafood
Edible oils
Sugars
Red meatsand animal
fats
Alcohol Fruits andvegetables
GDP percapita (log)
GDP percapita (log)
GDP percapita (log)
GDP percapita (log)
GDP percapita (log)
GDP percapita (log)
GDP percapita (log)
GDP percapita (log)
GDP percapita (log)
1980198519901995
1980198519901995
1980198519901995
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1980198519901995
1980198519901995
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1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
Absolute standardize bias
Absolute standardize bias
Absolute standardize bias
Unweighted Weighted
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08 0 02 04 06 08
Supply of tobacco
Supply of starches
Supply of nuts seeds and legumes
Supply of seafood
Supply of edible oils
Supply of sugars
Supply of red meats and animal fats
Supply of alcohol
Supply of fruits and vegetables
GDP gross domestic productNotes The period 1980ndash1995 represents the years before countries and territories start joining the World Trade Organization Table 1 lists countries studied We measured bias by the absolute standardized mean difference that is (mean for non-member states ndash mean for member states)(combined standard deviation)
- Table 1
- Table 2
- Table 3
- Figure 2
- Figure 3
- Figure 4
- Figure 5
- Figure 6
- Figure 1
-
96 Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057
ResearchWTO membership and noncommunicable disease risk factors Krycia Cowling et al
34 Rehm J Mathers C Popova S Thavorncharoensap M Teerawattananon Y Patra J Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders Lancet 2009 Jun 27373(9682)2223ndash33 doi httpdxdoiorg101016S0140-6736(09)60746-7 PMID 19560604
35 Al-Ansari B Thow A-M Day CA Conigrave KM Extent of alcohol prohibition in civil policy in Muslim majority countries the impact of globalization Addiction 2016 10111(10)1703ndash13 doi httpdxdoiorg101111add13159 PMID 26508526
36 About the WHO Framework Convention on Tobacco Control [internet] Geneva World Health Organization 2018 Available from httpwwwwhointfctcabouten [cited 2017 May 11]
37 Stuart EA Matching methods for causal inference a review and a look forward Stat Sci 2010 Feb 125(1)1ndash21 doi httpdxdoiorg10121409-STS313 PMID 20871802
38 Ridgeway G McCaffrey D Morral A Burgette L Griffin BA Toolkit for weighting and analysis of nonequivalent groups a tutorial for the twang package R Vignette [internet] Vienna R Foundation 2017 Available from httpscranr-projectorgwebpackagestwangvignettestwangpdf [cited 2017 Apr 18]
39 McCaffrey DF Ridgeway G Morral AR Propensity score estimation with boosted regression for evaluating causal effects in observational studies Psychol Methods 2004 Dec9(4)403ndash25 doi httpdxdoiorg1010371082-989X94403 PMID 15598095
40 Linden A Adams JL Applying a propensity score-based weighting model to interrupted time series data improving causal inference in programme evaluation J Eval Clin Pract 2011 Dec17(6)1231ndash8 doi httpdxdoiorg101111j1365-2753201001504x PMID 20973870
41 Griswold MG Fullman N Hawley C Arian N Zimsen SRM Tymeson HD et al GBD 2016 Alcohol Collaborators Alcohol use and burden for 195 countries and territories 1990ndash2016 a systematic analysis for the Global Burden of Disease Study 2016 Lancet 2018 Sep 22392(10152)1015ndash35 doi httpdxdoiorg101016S0140-6736(18)31310-2 PMID 30146330
42 Peto R Lopez AD Boreham J Thun M Heath C Jr Mortality from tobacco in developed countries indirect estimation from national vital statistics Lancet 1992 May 23339(8804)1268ndash78 doi httpdxdoiorg1010160140-6736(92)91600-D PMID 1349675
43 Healthy diet Key facts Geneva World Health Organization 2018 Available from httpwwwwhointnews-roomfact-sheetsdetailhealthy-diet [cited 2018 Oct 26]
44 Aune D Giovannucci E Boffetta P Fadnes LT Keum N Norat T et al Fruit and vegetable intake and the risk of cardiovascular disease total cancer and all-cause mortality-a systematic review and dose-response meta-analysis of prospective studies Int J Epidemiol 2017 06 146(3)1029ndash56 doi httpdxdoiorg101093ijedyw319 PMID 28338764
45 Health in All Policies framework for country action [internet] Geneva World Health Organization 2018 Available from httpwwwwhointhealthpromotionframeworkforcountryactionen [cited 2017 Aug 13]
46 Cole BL Fielding JE Health impact assessment a tool to help policy makers understand health beyond health care Annu Rev Public Health 200728(1)393ndash412 doi httpdxdoiorg101146annurevpublhealth28083006131942 PMID 17173539
47 Tonts M Siddique MAB editors Globalisation agriculture and development perspectives from the Asia-Pacific Cheltenham Edward Elgar Publishing 2011 Available from httpswwwelgaronlinecomview978184720818700010xml [cited 2017 Aug 14]
48 Mendez Lopez A Loopstra R McKee M Stuckler D Is trade liberalisation a vector for the spread of sugar-sweetened beverages A cross-national longitudinal analysis of 44 low- and middle-income countries Soc Sci Med 2017 0117221ndash7 doi httpdxdoiorg101016jsocscimed201611001 PMID 27871042
49 Monteiro CA Moubarac J-C Cannon G Ng SW Popkin B Ultra-processed products are becoming dominant in the global food system Obes Rev 2013 Nov14 Suppl 221ndash8 doi httpdxdoiorg101111obr12107 PMID 24102801
Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057 96A
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
Fig 1 Unweighted and weighted absolute standardized biases for baseline commodity supply in countries included in the study 1980ndash1995
female labour force
participation
female labour force
participation
female labour force
participation
female labour force
participation
female labour force
participation
female labour force
participation
female labour force
participation
female labour force
participation
Muslim population
female labour force
participation urban
population
urban population
urban population
urban population
urban population
urban population
urban population
urbanpopulation
urban population
Tobacco
Starches
Nuts seedsand legumes
Seafood
Edible oils
Sugars
Red meatsand animal
fats
Alcohol Fruits andvegetables
GDP percapita (log)
GDP percapita (log)
GDP percapita (log)
GDP percapita (log)
GDP percapita (log)
GDP percapita (log)
GDP percapita (log)
GDP percapita (log)
GDP percapita (log)
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
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1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
Absolute standardize bias
Absolute standardize bias
Absolute standardize bias
Unweighted Weighted
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08 0 02 04 06 08
Supply of tobacco
Supply of starches
Supply of nuts seeds and legumes
Supply of seafood
Supply of edible oils
Supply of sugars
Supply of red meats and animal fats
Supply of alcohol
Supply of fruits and vegetables
GDP gross domestic productNotes The period 1980ndash1995 represents the years before countries and territories start joining the World Trade Organization Table 1 lists countries studied We measured bias by the absolute standardized mean difference that is (mean for non-member states ndash mean for member states)(combined standard deviation)
- Table 1
- Table 2
- Table 3
- Figure 2
- Figure 3
- Figure 4
- Figure 5
- Figure 6
- Figure 1
-
Bull World Health Organ 20199783ndash96A| doi httpdxdoiorg102471BLT18218057 96A
ResearchWTO membership and noncommunicable disease risk factorsKrycia Cowling et al
Fig 1 Unweighted and weighted absolute standardized biases for baseline commodity supply in countries included in the study 1980ndash1995
female labour force
participation
female labour force
participation
female labour force
participation
female labour force
participation
female labour force
participation
female labour force
participation
female labour force
participation
female labour force
participation
Muslim population
female labour force
participation urban
population
urban population
urban population
urban population
urban population
urban population
urban population
urbanpopulation
urban population
Tobacco
Starches
Nuts seedsand legumes
Seafood
Edible oils
Sugars
Red meatsand animal
fats
Alcohol Fruits andvegetables
GDP percapita (log)
GDP percapita (log)
GDP percapita (log)
GDP percapita (log)
GDP percapita (log)
GDP percapita (log)
GDP percapita (log)
GDP percapita (log)
GDP percapita (log)
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
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1980198519901995
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1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
1980198519901995
Absolute standardize bias
Absolute standardize bias
Absolute standardize bias
Unweighted Weighted
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08
0 02 04 06 08 0 02 04 06 08
Supply of tobacco
Supply of starches
Supply of nuts seeds and legumes
Supply of seafood
Supply of edible oils
Supply of sugars
Supply of red meats and animal fats
Supply of alcohol
Supply of fruits and vegetables
GDP gross domestic productNotes The period 1980ndash1995 represents the years before countries and territories start joining the World Trade Organization Table 1 lists countries studied We measured bias by the absolute standardized mean difference that is (mean for non-member states ndash mean for member states)(combined standard deviation)
- Table 1
- Table 2
- Table 3
- Figure 2
- Figure 3
- Figure 4
- Figure 5
- Figure 6
- Figure 1
-
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