Discussion

This study found that the prevalences of certain NCD-linked lifestyle characteristics, i.e. consuming fruit and vegetables daily, taking extra salt with meals, sleeping <7 hours daily, smoking, smokeless tobacco consumption and low physical activity, were quite high among the adult population in Bangladesh in 2015–16. It was found that an inadequate diet, poor sleeping pattern, tobacco consumption and low physical activity were significantly higher in older adults, women, the uneducated, the unemployed, residents of urban areas and residents of rich households.

The adequate daily consumption of fruit and vegetables can reduce the risk of NCDs such as cancer, ischaemic heart disease and stroke (Hartley et al., Reference Hartley, Igbinedion, Holmes, Flowers, Thorogood and Clarke2013; WHO, 2019b), and can help lower the risk of obesity (Bermejo et al., Reference Bermejo, Aparicio, Andrés, López-Sobaler and Ortega2007). The WHO and FAO joint recommendation highlights the importance of consuming a minimum of 400 g of fruit and vegetables per day to tackle the overwhelming NCD burden, and the Government of Bangladesh has adopted this for the Bangladeshi people (Nahar et al., Reference Nahar, Choudhury, Sultana and Siddiquee2013). Although the present study found that four out of five adults in Bangladesh consume fruit and vegetables daily, a recent study reported that the average intake of fruit and vegetables was only 126 g (Nahar et al., Reference Nahar, Choudhury, Sultana and Siddiquee2013; Food and Agriculture Organization, 2021). Multiple factors, such as region-specific differences, socioeconomic factors, growing and storage conditions, processing methods and seasonal availability, are associated with inadequate fruit and vegetable consumption in Bangladesh (Hall et al., Reference Hall, Moore, Harper and Lynch2009; Zaman et al., Reference Zaman, Choudhury, Ahmed, Khandaker, Rouf and Malik2017). Therefore, collective multi-sectoral initiatives, such as increasing production and storage capacity for fruit and vegetables, creating a balance between prices and consumption, dietary diversification and an awareness campaign to encourage people to follow the WHO–FAO recommended eating habits, are needed to increase overall fruit and vegetable consumption in Bangladesh. It is also imperative that all people, irrespective of their place residence, sex and economic status, have access to adequate safe and healthy food. This is particularly true in the urban context as urban people in Bangladesh often do not have sufficient access to vegetables and fruit due to unavailability and high prices compared with rural areas.

The WHO have recommended a decreased sodium intake to reduce blood pressure and the risk of NCDs such as stroke and coronary heart disease (WHO, 2012). As salt is the main source of sodium, the WHO and FAO have recommended an individual consumption of less than 5 g of salt daily (WHO, 2012, 2019c). However, average salt intake has been reported to be only 15–21 g per day among Bangladeshi adults (Penney, Reference Penney2009). The present study found that nearly half of adults took extra salt with their meals. To reduce this high level of salt consumption, the habit of adding table salt to food should be stopped. Health policy should be reformed to reduce the salt content in processed food, and advocacy for eating less salty food should be implemented in restaurants and by other food providers. Bangladeshi people often follow medical advice (Islam & Jhora, Reference Islam and Jhora2012), so health professionals, including doctors and nurses, need to encourage their patients to reduce their salt intake from foods such as salted pickles and seasonal salty fruits, which are popular in Bangladesh.

Inadequate sleep exacerbates other NCD risk factors such as increased blood pressure, smoking and physical inactivity (Basnet et al., Reference Basnet, Merikanto, Lahti, Männistö, Laatikainen, Vartiainen and Partonen2016). The National Sleep Foundation recommends that adults of 35 years and above should sleep for 7–9 hours daily. Yet, sleeping patterns have not been taken into consideration in the GoB’s recent action plan to prevent and control NCDs (Government of People’s Republic of Bangladesh, 2018b). This study found that many adults sleep for less than 7 hours a day in Bangladesh. Therefore, the GoB should adopt the National Sleep Foundation guidelines and encourage people to maintain a balanced sleeping pattern. Additionally, public health campaigns should highlight the importance of having an appropriate amount of sleep, maintaining an appropriate sleeping environment (i.e. in the dark, a relaxing environment and neither too hot nor too cold) and having regular bedtimes. Moreover, the promotion of regular physical activity, maintaining a healthy diet and limiting the use of electronic devices before bedtime should be prioritized because lack of physical activity, having an unhealthy diet, watching too much TV and using smartphones can significantly reduce an individual’s sleep hours (Lemola et al., Reference Lemola, Perkinson-Gloor, Brand, Dewald-Kaufmann and Grob2015).

Tobacco smoking is an important risk factor for many NCDs, including cardiovascular diseases, chronic respiratory diseases, cancer and diabetes (Glantz & Gonzalez, Reference Glantz and Gonzalez2012). The GoB has taken steps to decrease smoking, for instance by establishing the National Tobacco Control Cell to coordinate tobacco control initiatives. Despite this, smoking prevalence is still very high in Bangladesh (Government of People’s Republic of Bangladesh, 2018b). This study found that smoking was more prevalent among males than females, and that the level of smokeless tobacco consumption was the same in both sexes. Awareness-raising campaigns, enforcement activities through mobile courts and high government taxation have proved to be inadequate in reducing Bangladesh’s high tobacco consumption (Government of People’s Republic of Bangladesh, 2018b). Therefore, effective strategies such as holistic education on tobacco use, appropriate school interventions, community-based counselling, strict maintenance of public smoking restrictions and smuggling controls might be useful to promote smoking cessation (Lancaster et al., Reference Lancaster, Stead, Silagy and Sowden2000). In addition, more-effective regulations are needed to reduce smoking amongst adolescents and to protect non-smokers from second-hand smoke inhalation (passive smoking) as these are leading causes of increased tobacco consumption in LMICs (Thomas & Hefler, Reference Thomas and Hefler2016).

At least 75 minutes per week of vigorous intensity physical activity, 150 minutes of moderate intensity physical activity, or an equivalent combination of vigorous and moderate activity, can reduce the risk of NCDs (WHO, 2019a). However, the level of physical activity is quite low among Bangladeshi adults (Moniruzzaman et al., Reference Moniruzzaman, Zaman, Islalm, Ahasan, Kabir and Yasmin2016). The present study found that approximately 70% of adults did not follow WHO recommendations for physical activity. To the best of the authors’ knowledge, currently there are no national recommendations on physical activity available in Bangladesh. There is therefore a need to develop national physical activity guidelines without further delay. In the 2018–2025 action plan, the government introduced a few health-related initiatives, including pedestrian-friendly footpaths, separate cycle lanes and open spaces (e.g. parks, lakes and ponds) to promote and inspire people to walk and avoid traffic (Government of People’s Republic of Bangladesh, 2018b). These initiatives require support and commitment from the government, community and individuals. Additionally, school-based and family-based interventions could be possible solutions, as these have been proven to be effective elsewhere (Strong et al. Reference Strong, Malina, Blimkie, Daniels, Dishman and Gutin2005; Okely et al., Reference Okely, Cotton, Lubans, Morgan, Puglisi and Miller2011). However, establishing these facilities will not immediately solve the problem; it is also essential to ensure that people have equitable access to these services, so they must be available, accessible, affordable and acceptable to all people.

This large-scale cross-sectional study highlights future demands and approaches for establishing and developing national guidelines on desirable lifestyle characteristics to prevent NCDs in Bangladesh. Although the GoB has adopted the global strategic plan for surveillance and prevention of NCDs, the majority of the recommended actions remain unimplemented or only partially implemented (Government of People’s Republic of Bangladesh, 2018b). The findings of this study suggest that community education interventions need to be focused on public awareness of NCDs and their associated risk factors through the appropriate use of social marketing and mass media. A multi-modality approach could be useful for preventing and treating NCDs (Lavie et al., Reference Lavie, Laddu, Arena, Ortega, Alpert and Kushner2018). Bangladesh has a structured health care system with three tiers: primary care, backed by district hospitals providing secondary and tertiary levels of care (Islam & Biswas, Reference Islam and Biswas2014). Despite having a relatively good health system infrastructure in multiple tiers, health care services for the prevention and control of NCDs are still largely non-functional (Biswas et al., Reference Biswas, Pervin, Tanim, Niessen and Islam2017). There is one community clinic for every 6000 people at the grassroots level providing primary health care services to the local community (Ahmed et al., Reference Ahmed, Alam, Anwar, Begum, Haque and Khan2015). However, preventive services are still mostly restricted to maternal health, child health and immunization at these clinics (Normand et al., Reference Normand, Iftekar, Rahman, Normand and Rahman2002). They could be effectively used for the primary prevention of NCDs and would be particularly important for smoking cessation, as well as blood pressure and diabetes control (Eldridge et al., Reference Eldridge, McFarlin, McFarland and Williams2017). Moreover, involving trained CHWs in promoting desirable lifestyle characteristics through these community clinics could be a useful way to sustain NCD prevention interventions, which have already proved effective in other health care settings (Bittencourt & Scarinci, Reference Bittencourt and Scarinci2014; Wewers et al., Reference Wewers, Shoben, Conroy, Curry, Ferketich and Murray2016). In addition, community engagement is necessary to make the different initiatives (e.g. smoking cessation and enhance physical activity) effective. Systematic monitoring of interventions should be highlighted in policy guidelines, which is a key concern in developing countries such as Bangladesh.

It is also essential to note that health behaviours are not only influenced by individual- and household-level factors, but social, economic and environmental characteristics also modulate healthy lifestyle behaviours (Amarasinghe & D’Souza, Reference Amarasinghe and D’Souza2012). The Government of Bangladesh has adopted several policies to address these, including banning advertisements and using plain packaging for tobacco products, and adopting the National Safe Food Act of 2013 (Biswas et al., Reference Biswas, Pervin, Tanim, Niessen and Islam2017) and the National Policies of Safe Water (Hadi, Reference Hadi2019). However, the present research highlights the importance of revising current policies and implementing them properly to promote healthy lifestyle behaviours. Notably, national agricultural policy should focus on producing diversified crops, including fruit and vegetables, and making them more available, especially to city dwellers. Emphasis also needs to be given to rectifying policies on making open spaces available for physical activity, while the existing policy of encouraging walking and cycling for commuting should be implemented appropriately (Hadi, Reference Hadi2019).

Region-specific strategies can also be of value as wide disparities in health indicators are noticeable in different regions of Bangladesh. For example, some parts of Sylhet division are inundated with water for nearly 6 months of the year, with acute food shortages during this period (Food Planning and Monitoring Unit, 2016). Therefore, policymakers should consider this area as vulnerable and support adequate food supply during this inundation period. Moreover, the coastal region has a salinity problem associated with an increased prevalence of hypertension (Khan et al., Reference Khan, Awan, Archie, Sultana and Muurlink2020). Therefore, policymakers should also focus on ensuring an adequate and safe water supply for people residing in coastal areas. Furthermore, they should also emphasize access of all people to services that encourage the lifestyle changes identified in the present study (healthy diet, physical exercise), as merely establishing these services will not ensure access. Issues such as availability, accessibility, affordability and acceptability all need to be considered.

Despite its strengths, the study has some limitations. First, it followed a cross-sectional study design, and thus causal inference could not be made. Second, data on lifestyle factors were self-reported so there was a possibility of measurement error. Third, adherence to appropriate guidelines for lifestyle characteristics can be guided by the level of knowledge of participants, which was not explored in the study. Fourth, information was not collected on some important lifestyle factors, such as the over-consumption of meat and alcohol, which are considered important risk factors for developing NCDs.

In conclusion, this paper, based on data collected in a large-scale study of lifestyle characteristics among the population of Bangladesh, highlights that NCD-related lifestyle characteristics are poorly compliant with standard guidelines among adults in the country. The findings will help policymakers formulate and activate effective public health policies on lifestyle modification to prevent the overwhelming NCD burden of the country. Future longitudinal studies are required to understand causal pathway and to develop effective prevention policies to tackle the growing NCD burden in Bangladesh.