Publications by authors named "Simon Capewell"

255 Publications

The case for developing a cohesive systems approach to research across unhealthy commodity industries.

BMJ Glob Health 2021 Feb;6(2)

Center for International Health Protection, Robert Koch Institute, Berlin, Germany.

Objectives: Most non-communicable diseases are preventable and largely driven by the consumption of harmful products, such as tobacco, alcohol, gambling and ultra-processed food and drink products, collectively termed unhealthy commodities. This paper explores the links between unhealthy commodity industries (UCIs), analyses the extent of alignment across their corporate political strategies, and proposes a cohesive systems approach to research across UCIs.

Methods: We held an expert consultation on analysing the involvement of UCIs in public health policy, conducted an analysis of business links across UCIs, and employed taxonomies of corporate political activity to collate, compare and illustrate strategies employed by the alcohol, ultra-processed food and drink products, tobacco and gambling industries.

Results: There are clear commonalities across UCIs' strategies in shaping evidence, employing narratives and framing techniques, constituency building and policy substitution. There is also consistent evidence of business links between UCIs, as well as complex relationships with government agencies, often allowing UCIs to engage in policy-making forums. This knowledge indicates that the role of all UCIs in public health policy would benefit from a common approach to analysis. This enables the development of a theoretical framework for understanding how UCIs influence the policy process. It highlights the need for a deeper and broader understanding of conflicts of interests and how to avoid them; and a broader conception of what constitutes strong evidence generated by a wider range of research types.

Conclusion: UCIs employ shared strategies to shape public health policy, protecting business interests, and thereby contributing to the perpetuation of non-communicable diseases. A cohesive systems approach to research across UCIs is required to deepen shared understanding of this complex and interconnected area and also to inform a more effective and coherent response.
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http://dx.doi.org/10.1136/bmjgh-2020-003543DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7888371PMC
February 2021

Explaining the increment in coronary heart disease mortality in Mexico between 2000 and 2012.

PLoS One 2020 3;15(12):e0242930. Epub 2020 Dec 3.

Center for Research on Population Health, National Institute of Public Health, Cuernavaca, Mexico.

Background: Mexico is still in the growing phase of the epidemic of coronary heart disease (CHD), with mortality increasing by 48% since 1980. However, no studies have analyzed the drivers of these trends. We aimed to model CHD deaths between 2000 and 2012 in Mexico and to quantify the proportion of the mortality change attributable to advances in medical treatments and to changes in population-wide cardiovascular risk factors.

Methods: We performed a retrospective analysis using the previously validated IMPACT model to explain observed changes in CHD mortality in Mexican adults. The model integrates nationwide data at two-time points (2000 and 2012) to quantify the effects on CHD mortality attributable to changes in risk factors and therapeutic trends.

Results: From 2000 to 2012, CHD mortality rates increased by 33.8% in men and by 22.8% in women. The IMPACT model explained 71% of the CHD mortality increase. Most of the mortality increases could be attributed to increases in population risk factors, such as diabetes (43%), physical inactivity (28%) and total cholesterol (24%). Improvements in medical and surgical treatments together prevented or postponed 40.3% of deaths; 10% was attributable to improvements in secondary prevention treatments following MI, while 5.3% to community heart failure treatments.

Conclusions: CHD mortality in Mexico is increasing due to adverse trends in major risk factors and suboptimal use of CHD treatments. Population-level interventions to reduce CHD risk factors are urgently needed, along with increased access and equitable distribution of therapies.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0242930PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7714134PMC
January 2021

Potential impacts of post-Brexit agricultural policy on fruit and vegetable intake and cardiovascular disease in England: a modelling study.

BMJ Nutr Prev Health 2020 14;3(1):3-10. Epub 2020 Jan 14.

Public Health Policy Evaluation Unit, School of Public Health, Imperial College London, London, UK.

Background: Current proposals for post-Brexit agricultural policy do not explicitly incorporate public health goals. The revised agricultural policy may be an opportunity to improve population health by supporting domestic production and consumption of fruits and vegetables (F&V). This study aims to quantify the potential impacts of a post-Brexit agricultural policy that increases land allocated to F&V on cardiovascular disease (CVD) mortality and inequalities in England, between 2021 to 2030.

Methods: We used the previously validated IMPACT Food Policy model and probabilistic sensitivity analysis to translate changes in land allocated to F&V into changes in F&V intake and associated CVD deaths, stratified by age, sex and Index of Multiple Deprivation. The model combined data on F&V agriculture, waste, purchases and intake, CVD mortality projections and appropriate relative risks. We modelled two scenarios, assuming that land allocated to F&V would gradually increase to 10% and 20% of land suitable for F&V production.

Results: We found that increasing land use for F&V production to 10% and 20% of suitable land would increase fruit intake by approximately 3.7% (95% uncertainty interval: 1.6% to 8.6%) and 17.4% (9.1% to 36.9%), and vegetable intake by approximately 7.8% (4.2% to 13.7%) and 37% (24.3% to 55.7%), respectively, in 2030. This would prevent or postpone approximately 3890 (1950 to 7080) and 18 010 (9840 to 28 870) CVD deaths between 2021 and 2030, under the first and second scenario, respectively. Both scenarios would reduce inequalities, with 16% of prevented or postponed deaths occurring among the least deprived compared with 22% among the most deprived.

Conclusion: Post-Brexit agricultural policy presents an important opportunity to improve dietary intake and associated cardiovascular mortality by supporting domestic production of F&V as part of a comprehensive strategy that intervenes across the supply chain.
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http://dx.doi.org/10.1136/bmjnph-2019-000057DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7664506PMC
January 2020

Adverse Trends in Premature Cardiometabolic Mortality in the United States, 1999 to 2018.

J Am Heart Assoc 2020 12 23;9(23):e018213. Epub 2020 Nov 23.

Department of Preventive Medicine Northwestern University Feinberg School of Medicine Chicago IL.

Background Life expectancy in the United States has recently declined, in part attributable to premature cardiometabolic mortality. We characterized national trends in premature cardiometabolic mortality, overall, and by race-sex groups. Methods and Results Using death certificates from the Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research, we quantified premature deaths (<65 years of age) from heart disease, cerebrovascular disease, and diabetes mellitus from 1999 to 2018. We calculated age-adjusted mortality rates (AAMRs) and years of potential life lost (YPLL) from each cardiometabolic cause occurring at <65 years of age. We used Joinpoint regression to identify an inflection point in overall cardiometabolic AAMR trends. Average annual percent change in AAMRs and YPLL was quantified before and after the identified inflection point. From 1999 to 2018, annual premature deaths from heart disease (117 880 to 128 832), cerebrovascular disease (18 765 to 20 565), and diabetes mellitus (16 553 to 24 758) as an underlying cause of death increased. By 2018, 19.7% of all heart disease deaths, 13.9% of all cerebrovascular disease deaths, and 29.1% of all diabetes mellitus deaths were premature. AAMRs and YPLL from heart disease and cerebrovascular disease declined until the inflection point identified in 2011, then remained unchanged through 2018. Conversely, AAMRs and YPLL from diabetes mellitus did not change through 2011, then increased through 2018. Black men and women had higher AAMRs and greater YPLL for each cardiometabolic cause compared with White men and women, respectively. Conclusions Over one-fifth of cardiometabolic deaths occurred at <65 years of age. Recent stagnation in cardiometabolic AAMRs and YPLL are compounded by persistent racial disparities.
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http://dx.doi.org/10.1161/JAHA.120.018213DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7763768PMC
December 2020

Heterogeneous trends in burden of heart disease mortality by subtypes in the United States, 1999-2018: observational analysis of vital statistics.

BMJ 2020 08 13;370:m2688. Epub 2020 Aug 13.

Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, 680 N Lake Shore Drive, Suite 1400, Chicago, IL 60611, USA

Objective: To describe trends in the burden of mortality due to subtypes of heart disease from 1999 to 2018 to inform targeted prevention strategies and reduce disparities.

Design: Serial cross sectional analysis of cause specific heart disease mortality rates using national death certificate data in the overall population as well as stratified by race-sex, age, and geography.

Setting: United States, 1999-2018.

Participants: 12.9 million decedents from total heart disease (49% women, 12% black, and 19% <65 years old).

Main Outcome Measures: Age adjusted mortality rates (AAMR) and years of potential life lost (YPLL) for each heart disease subtype, and respective mean annual percentage change.

Results: Deaths from total heart disease fell from 752 192 to 596 577 between 1999 and 2011, and then increased to 655 381 in 2018. From 1999 to 2018, the proportion of total deaths from heart disease attributed to ischemic heart disease decreased from 73% to 56%, while the proportion attributed to heart failure increased from 8% to 13% and the proportion attributed to hypertensive heart disease increased from 4% to 9%. Among heart disease subtypes, AAMR was consistently highest for ischemic heart disease in all subgroups (race-sex, age, and region). After 2011, AAMR for heart failure and hypertensive heart disease increased at a faster rate than for other subtypes. The fastest increases in heart failure mortality were in black men (mean annual percentage change 4.9%, 95% confidence interval 4.0% to 5.8%), whereas the fastest increases in hypertensive heart disease occurred in white men (6.3%, 4.9% to 9.4%). The burden of years of potential life lost was greatest from ischemic heart disease, but black-white disparities were driven by heart failure and hypertensive heart disease. Deaths from heart disease in 2018 resulted in approximately 3.8 million potential years of life lost.

Conclusions: Trends in AAMR and years of potential life lost for ischemic heart disease have decelerated since 2011. For almost all other subtypes of heart disease, AAMR and years of potential life lost became stagnant or increased. Heart failure and hypertensive heart disease account for the greatest increases in premature deaths and the largest black-white disparities and have offset declines in ischemic heart disease. Early and targeted primary and secondary prevention and control of risk factors for heart disease, with a focus on groups at high risk, are needed to avoid these suboptimal trends beginning earlier in life.
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http://dx.doi.org/10.1136/bmj.m2688DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7424397PMC
August 2020

Evaluating stakeholder involvement in building a decision support tool for NHS health checks: co-producing the WorkHORSE study.

BMC Med Inform Decis Mak 2020 08 10;20(1):182. Epub 2020 Aug 10.

Department of Public Health and Policy. Institute of Population Health Science, University of Liverpool, The Quadrangle, University of Liverpool, Liverpool, L69 3GB, UK.

Background: Stakeholder engagement is being increasingly recognised as an important way to achieving impact in public health. The WorkHORSE (Working Health Outcomes Research Simulation Environment) project was designed to continuously engage with stakeholders to inform the development of an open access modelling tool to enable commissioners to quantify the potential cost-effectiveness and equity of the NHS Health Check Programme. An objective of the project was to evaluate the involvement of stakeholders in co-producing the WorkHORSE computer modelling tool and examine how they perceived their involvement in the model building process and ultimately contributed to the strengthening and relevance of the modelling tool.

Methods: We identified stakeholders using our extensive networks and snowballing techniques. Iterative development of the decision support modelling tool was informed through engaging with stakeholders during four workshops. We used detailed scripts facilitating open discussion and opportunities for stakeholders to provide additional feedback subsequently. At the end of each workshop, stakeholders and the research team completed questionnaires to explore their views and experiences throughout the process.

Results: 30 stakeholders participated, of which 15 attended two or more workshops. They spanned local (NHS commissioners, GPs, local authorities and academics), third sector and national organisations including Public Health England. Stakeholders felt valued, and commended the involvement of practitioners in the iterative process. Major reasons for attending included: being able to influence development, and having insight and understanding of what the tool could include, and how it would work in practice. Researchers saw the process as an opportunity for developing a common language and trust in the end product, and ensuring the support tool was transparent. The workshops acted as a reality check ensuring model scenarios and outputs were relevant and fit for purpose.

Conclusions: Computational modellers rarely consult with end users when developing tools to inform decision-making. The added value of co-production (continuing collaboration and iteration with stakeholders) enabled modellers to produce a "real-world" operational tool. Likewise, stakeholders had increased confidence in the decision support tool's development and applicability in practice.
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http://dx.doi.org/10.1186/s12911-020-01205-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7418313PMC
August 2020

The for Effective and Equitable Policies to Prevent Non-communicable Diseases: Co-Production Lessons From Stakeholder Workshops.

Int J Health Policy Manag 2020 Jun 28. Epub 2020 Jun 28.

Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK.

Background: Non-communicable diseases (NCDs) account for some 90% of premature UK deaths, most being preventable. However, the systems driving NCDs are complex. This complexity can make NCD prevention strategies difficult to develop and implement. We therefore aimed to explore with key stakeholders the upstream policies needed to prevent NCDs and related inequalities.

Methods: We developed a theory-based co-production process and used a mixed methods approach to engage with policy- and decision-makers from across the United Kingdom in a series of 4 workshops, to better understand and respond to the complex systems in which they act. The first and fourth workshops (London) aimed to better understand the public health policy agenda and effective methods for co-production, communication and dissemination. In workshops 2 and 3 (Liverpool and Glasgow), we used nominal group techniques to identify policy issues and equitable prevention strategies, we prioritised emerging policy options for NCD prevention, using the MoSCoW approach.

Results: We engaged with 43 diverse stakeholders. They identified 'healthy environment' as an important emerging area. Reducing NCDs and inequalities was identified as important, underpinned by a frustration relating to the evidence/ policy gap. Evidence for NCD risk factor epidemiology was perceived as strong, the evidence underpinning the best NCD prevention policy interventions was considered patchier and more contested around the social, commercial and technological determinants of health. A comprehensive communications strategy was considered essential. The contribution of 'elite actors' (ministers, public sector leaders) was seen as key to the success of NCD prevention policies.

Conclusions: NCDs are generated by complex adaptive systems. Early engagement of diverse stakeholders in a theorybased co-production process can provide valuable context and relevance. Subsequent partnership-working will then be essential to develop, disseminate and implement the most effective NCD prevention strategies.
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http://dx.doi.org/10.34172/ijhpm.2020.99DOI Listing
June 2020

Engaging with stakeholders to inform the development of a decision-support tool for the NHS health check programme: qualitative study.

BMC Health Serv Res 2020 May 11;20(1):394. Epub 2020 May 11.

Department of Public Health & Policy, University of Liverpool, 3rd floor Whelan Building, Room 3.09, Liverpool, L69 3GB, UK.

Background: The NHS Health Check Programme is a risk-reduction programme offered to all adults in England aged 40-74 years. Previous studies mainly focused on patient perspectives and programme delivery; however, delivery varies, and costs are substantial. We were therefore working with key stakeholders to develop and co-produce an NHS Health Check Programme modelling tool (workHORSE) for commissioners to quantify local effectiveness, cost-effectiveness, and equity. Here we report on Workshop 1, which specifically aimed to facilitate engagement with stakeholders; develop a shared understanding of current Health Check implementation; identify what is working well, less well, and future hopes; and explore features to include in the tool.

Methods: This qualitative study identified key stakeholders across the UK via networking and snowball techniques. The stakeholders spanned local organisations (NHS commissioners, GPs, and academics), third sector and national organisations (Public Health England and The National Institute for Health and Care Excellence). We used the validated Hovmand "group model building" approach to engage stakeholders in a series of pre-piloted, structured, small group exercises. We then used Framework Analysis to analyse responses.

Results: Fifteen stakeholders participated in workshop 1. Stakeholders identified continued financial and political support for the NHS Health Check Programme. However, many stakeholders highlighted issues concerning lack of data on processes and outcomes, variability in quality of delivery, and suboptimal public engagement. Stakeholders' hopes included maximising coverage, uptake, and referrals, and producing additional evidence on population health, equity, and economic impacts. Key model suggestions focused on developing good-practice template scenarios, analysis of broader prevention activities at local level, accessible local data, broader economic perspectives, and fit-for-purpose outputs.

Conclusions: A shared understanding of current implementations of the NHS Health Check Programme was developed. Stakeholders demonstrated their commitment to the NHS Health Check Programme whilst highlighting the perceived requirements for enhancing the service and discussed how the modelling tool could be instrumental in this process. These suggestions for improvement informed subsequent workshops and model development.
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http://dx.doi.org/10.1186/s12913-020-05268-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7212552PMC
May 2020

Explaining the fall in Coronary Heart Disease mortality in the Republic of Ireland between 2000 and 2015 - IMPACT modelling study.

Int J Cardiol 2020 07 31;310:159-161. Epub 2020 Mar 31.

School of Public Health, University College Cork, Cork, Ireland. Electronic address:

Background: To investigate the contribution of individual and population factors to Coronary Heart Disease (CHD) mortality rates in Ireland between 2000 and 2015.

Methods: The Irish IMPACT CHD model was utilized with CHD Deaths Prevented or Postponed (DPPs) as outcome.

Results: CHD mortality rates in Ireland in those aged 25-84 years fell by 56% (63% in women vs. men 53%), with 4060 fewer deaths than expected in 2015. Improvements in CHD risk factors explained ~30% of the decline (785 DPPs in men; 425 in women): [population systolic blood pressure (+25% DPPs), mean cholesterol serum levels (+11%) and smoking prevalence (+5%)]. Additional deaths attributable to rises in diabetes prevalence (-6%), BMI (-4%) and physical inactivity (-2%) negatively impacted DPPs. Increased uptake of cardiology treatments explained ~60% of the decline (1620 DPPs in men; 825 in women), particularly secondary prevention and heart failure treatments. Some 10% was unexplained.

Conclusion: CHD mortality declined in Ireland between 2000 and 2015, with two-thirds attributable to increased uptake in cardiology treatments and only one-third to improvements in population risk factors, partly reflecting adverse trends in obesity, diabetes and physical inactivity. Additional investments in prevention policies and treatments will be necessary to reduce future CHD deaths.
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http://dx.doi.org/10.1016/j.ijcard.2020.03.067DOI Listing
July 2020

Different ethical standards for different ethical problems? A commentary on 'Responsibility, Prudence and Health Promotion'.

J Public Health (Oxf) 2020 Apr 6. Epub 2020 Apr 6.

University of Liverpool, Liverpool, UK.

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http://dx.doi.org/10.1093/pubmed/fdaa006DOI Listing
April 2020

The American Heart Association 2030 Impact Goal: A Presidential Advisory From the American Heart Association.

Circulation 2020 03 29;141(9):e120-e138. Epub 2020 Jan 29.

Each decade, the American Heart Association (AHA) develops an Impact Goal to guide its overall strategic direction and investments in its research, quality improvement, advocacy, and public health programs. Guided by the AHA's new Mission Statement, to be a relentless force for a world of longer, healthier lives, the 2030 Impact Goal is anchored in an understanding that to achieve cardiovascular health for all, the AHA must include a broader vision of health and well-being and emphasize health equity. In the next decade, by 2030, the AHA will strive to equitably increase healthy life expectancy beyond current projections, with global and local collaborators, from 66 years of age to at least 68 years of age across the United States and from 64 years of age to at least 67 years of age worldwide. The AHA commits to developing additional targets for equity and well-being to accompany this overarching Impact Goal. To attain the 2030 Impact Goal, we recommend a thoughtful evaluation of interventions available to the public, patients, providers, healthcare delivery systems, communities, policy makers, and legislators. This presidential advisory summarizes the task force's main considerations in determining the 2030 Impact Goal and the metrics to monitor progress. It describes the aspiration that these goals will be achieved by working with a diverse community of volunteers, patients, scientists, healthcare professionals, and partner organizations needed to ensure success.
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http://dx.doi.org/10.1161/CIR.0000000000000758DOI Listing
March 2020

Potential impact of diabetes prevention on mortality and future burden of dementia and disability: a modelling study.

Diabetologia 2020 01 15;63(1):104-115. Epub 2019 Nov 15.

Department of Public Health and Policy, University of Liverpool, 3rd Floor, Whelan Building, Brownlow Hill, Liverpool, L69 3GB, UK.

Aims/hypothesis: Diabetes is associated with an increased risk of dementia. We estimated the potential impact of trends in diabetes prevalence upon mortality and the future burden of dementia and disability in England and Wales.

Methods: We used a probabilistic multi-state, open cohort Markov model to integrate observed trends in diabetes, cardiovascular disease and dementia to forecast the occurrence of disability and dementia up to the year 2060. Model input data were taken from the English Longitudinal Study of Ageing, Office for National Statistics vital data and published effect estimates for health-state transition probabilities. The baseline scenario corresponded to recent trends in obesity: a 26% increase in the number of people with diabetes by 2060. This scenario was evaluated against three alternative projected trends in diabetes: increases of 49%, 20% and 7%.

Results: Our results suggest that changes in the trend in diabetes prevalence will lead to changes in mortality and incidence of dementia and disability, which will become visible after 10-15 years. If the relative prevalence of diabetes increases 49% by 2060, expected additional deaths would be approximately 255,000 (95% uncertainty interval [UI] 236,000-272,200), with 85,900 (71,500-101,600) cumulative additional cases of dementia and 104,900 (85,900-125,400) additional cases of disability. With a smaller relative increase in diabetes prevalence (7% increase by 2060), we estimated 222,200 (205,700-237,300) fewer deaths, and 77,000 (64,300-90,800) and 93,300 (76,700-111,400) fewer additional cases of dementia and disability, respectively, than the baseline case of a 26% increase in diabetes.

Conclusions/interpretation: Reducing the burden of diabetes could result in substantial reductions in the incidence of dementia and disability over the medium to long term.
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http://dx.doi.org/10.1007/s00125-019-05015-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6890625PMC
January 2020

Explaining income-related inequalities in cardiovascular risk factors in Tunisian adults during the last decade: comparison of sensitivity analysis of logistic regression and Wagstaff decomposition analysis.

Int J Equity Health 2019 11 15;18(1):177. Epub 2019 Nov 15.

Department of Public Health and Policy, University of Liverpool, Liverpool, UK.

Background: It is important to quantify inequality, explain the contribution of underlying social determinants and to provide evidence to guide health policy. The aim of the study is to explain the income-related inequalities in cardiovascular risk factors in the last decade among Tunisian adults aged between 35 and 70 years old.

Methods: We performed the analysis by applying two approaches and compared the results provided by the two methods. The methods were global sensitivity analysis (GSA) using logistic regression models and the Wagstaff decomposition analysis.

Results: Results provided by the two methods found a higher risk of cardiovascular diseases and diabetes in those with high socio-economic status in 2005. Similar results were observed in 2016. In 2016, the GSA showed that education level occupied the first place on the explanatory list of factors explaining 36.1% of the adult social inequality in high cardiovascular risk, followed by the area of residence (26.2%) and income (15.1%). Based on the Wagstaff decomposition analysis, the area of residence occupied the first place and explained 40.3% followed by income and education level explaining 19.2 and 14.0% respectively. Thus, both methods found similar factors explaining inequalities (income, educational level and regional conditions) but with different rankings of importance.

Conclusions: The present study showed substantial income-related inequalities in cardiovascular risk factors and diabetes in Tunisia and provided explanations for this. Results based on two different methods similarly showed that structural disparities on income, educational level and regional conditions should be addressed in order to reduce inequalities.
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http://dx.doi.org/10.1186/s12939-019-1047-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6858762PMC
November 2019

Universal or targeted cardiovascular screening? Modelling study using a sector-specific distributional cost effectiveness analysis.

Prev Med 2020 01 31;130:105879. Epub 2019 Oct 31.

University of Liverpool, Department of Public Health and Policy, United Kingdom.

Distributional cost effectiveness analysis is a new method that can help to redesign prevention programmes by explicitly modelling the distribution of health opportunity costs as well as the distribution of health benefits. Previously we modelled cardiovascular disease (CVD) screening audit data from Liverpool, UK to see if the city could redesign its cardiovascular screening programme to enhance its cost effectiveness and equity. Building on this previous analysis, we explicitly examined the distribution of health opportunity costs and we looked at new redesign options co-designed with stakeholders. We simulated four plausible scenarios: a) no CVD screening, b) 'current' basic universal CVD screening as currently implemented, c) enhanced universal CVD screening with 'increased' population-wide delivery, and d) 'universal plus targeted' with top-up delivery to the most deprived fifth. We also compared assumptions around whether displaced health spend would come from programmes that might benefit the poor more and how much health these programmes would generate. The main outcomes were net health benefit and change in the slope index of inequality (SII) in QALYs per 100,000 person years. 'Universal plus targeted' dominated 'increased' and 'current' and also reduced health inequality by -0.65 QALYs per 100,000 person years. Results are highly sensitive to assumptions about opportunity costs and, in particular, whether funding comes from health care or local government budgets. By analysing who loses as well as who gains from expenditure decisions, distributional cost effectiveness analysis can help decision makers to redesign prevention programmes in ways that improve health and reduce health inequality.
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http://dx.doi.org/10.1016/j.ypmed.2019.105879DOI Listing
January 2020

Trends in Cardiometabolic Mortality in the United States, 1999-2017.

JAMA 2019 08;322(8):780-782

Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois.

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http://dx.doi.org/10.1001/jama.2019.9161DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6714016PMC
August 2019

FDA Sodium Reduction Targets and the Food Industry: Are There Incentives to Reformulate? Microsimulation Cost-Effectiveness Analysis.

Milbank Q 2019 09 22;97(3):858-880. Epub 2019 Jul 22.

University of Liverpool.

Policy Points The World Health Organization has recommended sodium reduction as a "best buy" to prevent cardiovascular disease (CVD). Despite this, Congress has temporarily blocked the US Food and Drug Administration (FDA) from implementing voluntary industry targets for sodium reduction in processed foods, the implementation of which could cost the industry around $16 billion over 10 years. We modeled the health and economic impact of meeting the two-year and ten-year FDA targets, from the perspective of people working in the food system itself, over 20 years, from 2017 to 2036. Benefits of implementing the FDA voluntary sodium targets extend to food companies and food system workers, and the value of CVD-related health gains and cost savings are together greater than the government and industry costs of reformulation.

Context: The US Food and Drug Administration (FDA) set draft voluntary targets to reduce sodium levels in processed foods. We aimed to determine cost effectiveness of meeting these draft sodium targets, from the perspective of US food system workers.

Methods: We employed a microsimulation cost-effectiveness analysis using the US IMPACT Food Policy model with two scenarios: (1) short term, achieving two-year FDA reformulation targets only, and (2) long term, achieving 10-year FDA reformulation targets. We modeled four close-to-reality populations: food system "ever" workers; food system "current" workers in 2017; and subsets of processed food "ever" and "current" workers. Outcomes included cardiovascular disease cases prevented and postponed as well as incremental cost-effectiveness ratio per quality-adjusted life year (QALY) gained from 2017 to 2036.

Findings: Among food system ever workers, achieving long-term sodium reduction targets could produce 20-year health gains of approximately 180,000 QALYs (95% uncertainty interval [UI]: 150,000 to 209,000) and health cost savings of approximately $5.2 billion (95% UI: $3.5 billion to $8.3 billion), with an incremental cost-effectiveness ratio (ICER) of $62,000 (95% UI: $1,000 to $171,000) per QALY gained. For the subset of processed food industry workers, health gains would be approximately 32,000 QALYs (95% UI: 27,000 to 37,000); cost savings, $1.0 billion (95% UI: $0.7bn to $1.6bn); and ICER, $486,000 (95% UI: $148,000 to $1,094,000) per QALY gained. Because many health benefits may occur in individuals older than 65 or the uninsured, these health savings would be shared among individuals, industry, and government.

Conclusions: The benefits of implementing the FDA voluntary sodium targets extend to food companies and food system workers, with the value of health gains and health care cost savings outweighing the costs of reformulation, although not for the processed food industry.
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http://dx.doi.org/10.1111/1468-0009.12402DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6739614PMC
September 2019

Quantifying the impact of the Public Health Responsibility Deal on salt intake, cardiovascular disease and gastric cancer burdens: interrupted time series and microsimulation study.

J Epidemiol Community Health 2019 09 18;73(9):881-887. Epub 2019 Jul 18.

Public Health Policy Evaluation Unit, School of Public Health, Imperial College London, London, UK.

Background: In 2011, England introduced the Public Health Responsibility Deal (RD), a public-private partnership (PPP) which gave greater freedom to the food industry to set and monitor targets for salt intakes. We estimated the impact of the RD on trends in salt intake and associated changes in cardiovascular disease (CVD) and gastric cancer (GCa) incidence, mortality and economic costs in England from 2011-2025.

Methods: We used interrupted time series models with 24 hours' urine sample data and the IMPACT microsimulation model to estimate impacts of changes in salt consumption on CVD and GCa incidence, mortality and economic impacts, as well as equity impacts.

Results: Between 2003 and 2010 mean salt intake was falling annually by 0.20 grams/day among men and 0.12 g/d among women (P-value for trend both < 0.001). After RD implementation in 2011, annual declines in salt intake slowed statistically significantly to 0.11 g/d among men and 0.07 g/d among women (P-values for differences in trend both P < 0.001). We estimated that the RD has been responsible for approximately 9900 (interquartile quartile range (IQR): 6700 to 13,000) additional cases of CVD and 1500 (IQR: 510 to 2300) additional cases of GCa between 2011 and 2018. If the RD continues unchanged between 2019 and 2025, approximately 26 000 (IQR: 20 000 to 31,000) additional cases of CVD and 3800 (IQR: 2200 to 5300) cases of GCa may occur.

Interpretation: Public-private partnerships such as the RD which lack robust and independent target setting, monitoring and enforcement are unlikely to produce optimal health gains.
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http://dx.doi.org/10.1136/jech-2018-211749DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6820143PMC
September 2019

Analysis of the decrease in deaths due to coronary disease between 1995 and 2010. IMPACT CHD Argentina Study.

Rev Fac Cien Med Univ Nac Cordoba 2019 06 19;76(2):92-100. Epub 2019 Jun 19.

Hospital Italiano de Buenos Aires. Instituto Universitario Hospital Italiano..

Objetive: To quantify the contribution of risk factors and treatments in the reduction of mortality due to coronary heart disease in Argentina between 1995 and 2010.

Results: We used the validated IMPACTCHD model integrating data on effectiveness, use of treatments and changes in the risk factors between 1995 and 2010 in people older than 25 years in Argentina. The difference between the coronary deaths observed and expected in 2010 was distributed between treatments and risk factors.

Conclusions: One out of every two MPP due to coronary heart disease in Argentina between 1995 and 2010 was due to treatments and one third to the improvement of risk factors. The decrease in blood pressure, cholesterol and smoking was limited by increases in the prevalence of obesity, sedentary lifestyle and diabetes. This study was possible thanks to the collaborative work to the cardiovascular epidemiology.
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http://dx.doi.org/10.31053/1853.0605.v76.n2.22915DOI Listing
June 2019

Following in the footsteps of tobacco and alcohol? Stakeholder discourse in UK newspaper coverage of the Soft Drinks Industry Levy.

Public Health Nutr 2019 08 21;22(12):2317-2328. Epub 2019 May 21.

Department of Public Health and Policy, University of Liverpool,Liverpool,UK.

Objective: In politically contested health debates, stakeholders on both sides present arguments and evidence to influence public opinion and the political agenda. The present study aimed to examine whether stakeholders in the Soft Drinks Industry Levy (SDIL) debate sought to establish or undermine the acceptability of this policy through the news media and how this compared with similar policy debates in relation to tobacco and alcohol industries.

Design: Quantitative and qualitative content analysis of newspaper articles discussing sugar-sweetened beverage (SSB) taxation published in eleven UK newspapers between 1 April 2015 and 30 November 2016, identified through the Nexis database. Direct stakeholder citations were entered in NVivo to allow inductive thematic analysis and comparison with an established typology of industry stakeholder arguments used by the alcohol and tobacco industries.

Setting: UK newspapers.

Participants: Proponents and opponents of SSB tax/SDIL cited in UK newspapers.

Results: Four hundred and ninety-one newspaper articles cited stakeholders' (n 287) arguments in relation to SSB taxation (n 1761: 65 % supportive and 35 % opposing). Stakeholders' positions broadly reflected their vested interests. Inconsistencies arose from: changes in ideological position; insufficient clarity on the nature of the problem to be solved; policy priorities; and consistency with academic rigour. Both opposing and supportive themes were comparable with the alcohol and tobacco industry typology.

Conclusions: Public health advocates were particularly prominent in the UK newspaper debate surrounding the SDIL. Advocates in future policy debates might benefit from seeking a similar level of prominence and avoiding inconsistencies by being clearer about the policy objective and mechanisms.
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http://dx.doi.org/10.1017/S1368980019000739DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6642695PMC
August 2019

Cost-Effectiveness of the US Food and Drug Administration Added Sugar Labeling Policy for Improving Diet and Health.

Circulation 2019 06 15;139(23):2613-2624. Epub 2019 Apr 15.

Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA (Y.H., J.L., Y.L., P.W., D.M., R.M.).

Background: Excess added sugars, particularly from sugar-sweetened beverages, are a major risk factor for cardiometabolic diseases including cardiovascular disease and type 2 diabetes mellitus. In 2016, the US Food and Drug Administration mandated the labeling of added sugar content on all packaged foods and beverages. Yet, the potential health impacts and cost-effectiveness of this policy remain unclear.

Methods: A validated microsimulation model (US IMPACT Food Policy model) was used to estimate cardiovascular disease and type 2 diabetes mellitus cases averted, quality-adjusted life-years, policy costs, health care, informal care, and lost productivity (health-related) savings and cost-effectiveness of 2 policy scenarios: (1) implementation of the US Food and Drug Administration added sugar labeling policy (sugar label), and (2) further accounting for corresponding industry reformulation (sugar label+reformulation). The model used nationally representative demographic and dietary intake data from the National Health and Nutrition Examination Survey, disease data from the Centers for Disease Control and Prevention Wonder Database, policy effects and diet-disease effects from meta-analyses, and policy and health-related costs from established sources. Probabilistic sensitivity analysis accounted for model parameter uncertainties and population heterogeneity.

Results: Between 2018 and 2037, the sugar label would prevent 354 400 cardiovascular disease (95% uncertainty interval, 167 000-673 500) and 599 300 (302 400-957 400) diabetes mellitus cases, gain 727 000 (401 300-1 138 000) quality-adjusted life-years, and save $31 billion (15.7-54.5) in net healthcare costs or $61.9 billion (33.1-103.3) societal costs (incorporating reduced lost productivity and informal care costs). For the sugar label+reformulation scenario, corresponding gains were 708 800 (369 200-1 252 000) cardiovascular disease cases, 1.2 million (0.7-1.7) diabetes mellitus cases, 1.3 million (0.8-1.9) quality-adjusted life-years, and $57.6 billion (31.9-92.4) and $113.2 billion (67.3-175.2), respectively. Both scenarios were estimated with >80% probability to be cost saving by 2023.

Conclusions: Implementing the US Food and Drug Administration added sugar labeling policy could generate substantial health gains and cost savings for the US population.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.118.036751DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6546520PMC
June 2019

Commercial determinants of health: advertising of alcohol and unhealthy foods during sporting events.

Bull World Health Organ 2019 Apr 25;97(4):290-295. Epub 2019 Feb 25.

MRC/CSOSocial and Public Health Sciences Unit, University of Glasgow, Glasgow, Scotland.

Tobacco, alcohol and foods that are high in fat, salt and sugar generate much of the global burden of noncommunicable diseases. We therefore need a better understanding of how these products are promoted.The promotion of tobacco products through sporting events has largely disappeared over the last two decades, but advertising and sponsorship continues bycompanies selling alcohol, unhealthy food and sugar-sweetened beverage. The sponsorship of sporting events such as the Olympic Games, the men's FIFA World Cup and the men's European Football Championships in 2016, has received some attention in recent years in the public health literature. Meanwhile, British football and the English Premier League have become global events with which transnational companies are keen to be associated, to promote their brands to international markets. Despite its reach, the English Premier League marketing and sponsorship portfolio has received very little scrutiny from public health advocates. We call for policy-makers and the public health community to formulate an approach to the sponsorship of sporting events, one that accounts for public health concerns.
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http://dx.doi.org/10.2471/BLT.18.220087DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6438257PMC
April 2019

Comparing Strategies to Prevent Stroke and Ischemic Heart Disease in the Tunisian Population: Markov Modeling Approach Using a Comprehensive Sensitivity Analysis Algorithm.

Comput Math Methods Med 2019 29;2019:2123079. Epub 2019 Jan 29.

Department of Public Health and Policy, University of Liverpool, Liverpool, UK.

Background: Mathematical models offer the potential to analyze and compare the effectiveness of very different interventions to prevent future cardiovascular disease. We developed a comprehensive Markov model to assess the impact of three interventions to reduce ischemic heart diseases (IHD) and stroke deaths: (i) improved medical treatments in acute phase, (ii) secondary prevention by increasing the uptake of statins, (iii) primary prevention using health promotion to reduce dietary salt consumption.

Methods: We developed and validated a Markov model for the Tunisian population aged 35-94 years old over a 20-year time horizon. We compared the impact of specific treatments for stroke, lifestyle, and primary prevention on both IHD and stroke deaths. We then undertook extensive sensitivity analyses using both a probabilistic multivariate approach and simple linear regression (metamodeling).

Results: The model forecast a dramatic mortality rise, with 111,134 IHD and stroke deaths (95% CI 106567 to 115048) predicted in 2025 in Tunisia. The salt reduction offered the potentially most powerful preventive intervention that might reduce IHD and stroke deaths by 27% (-30240 [-30580 to -29900]) compared with 1% for medical strategies and 3% for secondary prevention. The metamodeling highlighted that the initial development of a minor stroke substantially increased the subsequent probability of a fatal stroke or IHD death.

Conclusions: The primary prevention of cardiovascular disease via a reduction in dietary salt consumption appeared much more effective than secondary or tertiary prevention approaches. Our simple but comprehensive model offers a potentially attractive methodological approach that might now be extended and replicated in other contexts and populations.
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http://dx.doi.org/10.1155/2019/2123079DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6374861PMC
August 2019

Explaining the decline in coronary heart disease mortality rates in Japan: Contributions of changes in risk factors and evidence-based treatments between 1980 and 2012.

Int J Cardiol 2019 09 14;291:183-188. Epub 2019 Feb 14.

Department of Public Health and Policy, University of Liverpool, Liverpool, UK.

Background: We aimed to quantify contributions of changes in risks and uptake of evidence-based treatment to coronary heart disease (CHD) mortality trends in Japan between 1980 and 2012.

Methods: We conducted a modelling study for the general population of Japan aged 35 to 84 years using the validated IMPACT model incorporating data sources like Vital Statistics. The main outcome was difference in the number of observed and expected CHD deaths in 2012.

Results: From 1980 to 2012, age-adjusted CHD mortality rates in Japan fell by 61%, resulting in 75,700 fewer CHD deaths in 2012 than if the age and sex-specific mortality rates had remained unchanged. Approximately 56% (95% uncertainty interval [UI]: 54-59%) of the CHD mortality decrease, corresponding to 42,300 (40,900-44,700) fewer CHD deaths, was attributable to medical and surgical treatments. Approximately 35% (28-41%) of the mortality fall corresponding to 26,300 (21,200-31,000) fewer CHD deaths, was attributable to risk factor changes in the population, 24% (20-29%) corresponding to 18,400 (15,100-21,900) fewer and 11% (8-14%) corresponding to 8400 (60,500-10,600) fewer from decreased systolic blood pressure (8.87 mm Hg) and smoking prevalence (14.0%). However, increased levels of cholesterol (0.28 mmol/L), body mass index (BMI) (0.68 kg/m), and diabetes prevalence (1.6%) attenuated the decrease in mortality by 2% (1-3%), 3% (2-3%), and 4% (1-6%), respectively.

Conclusions: Japan should continue their control policies for blood pressure and tobacco, and build a strategy to control BMI, diabetes, and cholesterol levels to prevent further CHD deaths.
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http://dx.doi.org/10.1016/j.ijcard.2019.02.022DOI Listing
September 2019

Context-led capacity building in time of crisis: fostering non-communicable diseases (NCD) research skills in the Mediterranean Middle East and North Africa.

Glob Health Action 2019 ;12(1):1569838

n Population Health Research Institute , St George's, University of London , London , UK.

Background: This paper examines one EC-funded multinational project (RESCAP-MED), with a focus on research capacity building (RCB) concerning non-communicable diseases (NCDs) in the Mediterranean Middle East and North Africa. By the project's end (2015), the entire region was engulfed in crisis.

Objective: Designed before this crisis developed in 2011, the primary purpose of RESCAP-MED was to foster methodological skills needed to conduct multi-disciplinary research on NCDs and their social determinants. RESCAP-MED also sought to consolidate regional networks for future collaboration, and to boost existing regional policy engagement in the region on the NCD challenge. This analysis examines the scope and sustainability of RCB conducted in a context of intensifying political turmoil.

Methods: RESCAP-MED linked two sets of activities. The first was a framework for training early- and mid-career researchers through discipline-based and writing workshops, plus short fellowships for sustained mentoring. The second integrated public-facing activities designed to raise the profile of the NCD burden in the region, and its implications for policymakers at national level. Key to this were two conferences to showcase regional research on NCDs, and the development of an e-learning resource (NETPH).

Results: Seven discipline-based workshops (with 113 participants) and 6 workshops to develop writing skills (84 participants) were held, with 18 fellowship visits. The 2 symposia in Istanbul and Beirut attracted 280 participants. Yet the developing political crisis tagged each activity with a series of logistical challenges, none of which was initially envisaged. The immediacy of the crisis inevitably deflected from policy attention to the challenges of NCDs.

Conclusions: This programme to strengthen research capacity for one priority area of global public health took place as a narrow window of political opportunity was closing. The key lessons concern issues of sustainability and the paramount importance of responsively shaping a context-driven RCB.
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http://dx.doi.org/10.1080/16549716.2019.1569838DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6366406PMC
August 2019

Impacts of Brexit on fruit and vegetable intake and cardiovascular disease in England: a modelling study.

BMJ Open 2019 01 28;9(1):e026966. Epub 2019 Jan 28.

Public Health Policy Evaluation Unit, School of Public Health, Imperial College London, London, UK.

Objectives: To estimate the potential impacts of different Brexit trade policy scenarios on the price and intake of fruits and vegetables (F&V) and consequent cardiovascular disease (CVD) deaths in England between 2021 and 2030.

Design: Economic and epidemiological modelling study with probabilistic sensitivity analysis.

Setting: The model combined publicly available data on F&V trade, published estimates of UK-specific price elasticities, national survey data on F&V intake, estimates on the relationship between F&V intake and CVD from published meta-analyses and CVD mortality projections for 2021-2030.

Participants: English adults aged 25 years and older.

Interventions: We modelled four potential post-Brexit trade scenarios: (1) free trading agreement with the EU and maintaining half of non-EU free trade partners; (2) free trading agreement with the EU but no trade deal with any non-EU countries; (3) no-deal Brexit; and (4) liberalised trade regime that eliminates all import tariffs.

Outcome Measures: Cumulative coronary heart disease and stroke deaths attributed to the different Brexit scenarios modelled between 2021 and 2030.

Results: Under all Brexit scenarios modelled, prices of F&V would increase, especially for those highly dependent on imports. This would decrease intake of F&V between 2.5% (95% uncertainty interval: 1.9% to 3.1%) and 11.4% (9.5% to 14.2%) under the different scenarios. Our model suggests that a no-deal Brexit scenario would be the most harmful, generating approximately 12 400 (6690 to 23 390) extra CVD deaths between 2021 and 2030, whereas establishing a free trading agreement with the EU would have a lower impact on mortality, contributing approximately 5740 (2860 to 11 910) extra CVD deaths.

Conclusions: Trade policy under all modelled Brexit scenarios could increase price and decrease intake of F&V, generating substantial additional CVD mortality in England. The UK government should consider the population health implications of Brexit trade policy options, including changes to food systems.
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http://dx.doi.org/10.1136/bmjopen-2018-026966DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6352794PMC
January 2019

The palatability of sugar-sweetened beverage taxation: A content analysis of newspaper coverage of the UK sugar debate.

PLoS One 2018 5;13(12):e0207576. Epub 2018 Dec 5.

MRC/CSO Social and Public Health Sciences Unit, Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom.

Background: Excess sugar consumption, including sugar-sweetened beverages (SSBs), contributes to a variety of negative health outcomes, particularly for young people. The mass media play a powerful role in influencing public and policy-makers' perceptions of public health issues and their solutions. We analysed how sugar and SSB policy debates were presented in UK newspapers at a time of heightened awareness and following the announcement of the UK Government's soft drinks industry levy (SDIL), to inform future public health advocacy.

Methods & Findings: We carried out quantitative content analysis of articles discussing the issues of sugar and SSB consumption published in 11 national newspapers from April 2015 to November 2016. 684 newspaper articles were analysed using a structured coding frame. Coverage peaked in line with evidence publication, campaigner activities and policy events. Articles predominantly supportive of SSB taxation (23.5%) outnumbered those that were predominantly oppositional (14.2%). However, oppositional articles outnumbered supportive ones in the month of the announcement of the SDIL. Sugar and SSB consumption were presented as health risks, particularly affecting young people, with the actions of industry often identified as the cause of the public health problem. Responsibility for addressing sugar overconsumption was primarily assigned to government intervention.

Conclusion: Our results suggest that the policy landscape favouring fiscal solutions to curb sugar and SSB consumption has benefited from media coverage characterising the issue as an industry-driven problem. Media coverage may drive greater public acceptance of the SDIL and any future taxation of products containing sugar. However, future advocacy efforts should note the surge in opposition coinciding with the announcement of the SDIL, which echoes similar patterns of opposition observed in tobacco control debates.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0207576PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6281206PMC
May 2019

Changes in health in the countries of the UK and 150 English Local Authority areas 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016.

Lancet 2018 11 24;392(10158):1647-1661. Epub 2018 Oct 24.

Institute for Health Metrics and Evaluation, Seattle, WA, USA; London School of Hygiene & Tropical Medicine, London, UK.

Background: Previous studies have reported national and regional Global Burden of Disease (GBD) estimates for the UK. Because of substantial variation in health within the UK, action to improve it requires comparable estimates of disease burden and risks at country and local levels. The slowdown in the rate of improvement in life expectancy requires further investigation. We use GBD 2016 data on mortality, causes of death, and disability to analyse the burden of disease in the countries of the UK and within local authorities in England by deprivation quintile.

Methods: We extracted data from the GBD 2016 to estimate years of life lost (YLLs), years lived with disability (YLDs), disability-adjusted life-years (DALYs), and attributable risks from 1990 to 2016 for England, Scotland, Wales, Northern Ireland, the UK, and 150 English Upper-Tier Local Authorities. We estimated the burden of disease by cause of death, condition, year, and sex. We analysed the association between burden of disease and socioeconomic deprivation using the Index of Multiple Deprivation. We present results for all 264 GBD causes of death combined and the leading 20 specific causes, and all 84 GBD risks or risk clusters combined and 17 specific risks or risk clusters.

Findings: The leading causes of age-adjusted YLLs in all UK countries in 2016 were ischaemic heart disease, lung cancers, cerebrovascular disease, and chronic obstructive pulmonary disease. Age-standardised rates of YLLs for all causes varied by two times between local areas in England according to levels of socioeconomic deprivation (from 14 274 per 100 000 population [95% uncertainty interval 12 791-15 875] in Blackpool to 6888 [6145-7739] in Wokingham). Some Upper-Tier Local Authorities, particularly those in London, did better than expected for their level of deprivation. Allowing for differences in age structure, more deprived Upper-Tier Local Authorities had higher attributable YLLs for most major risk factors in the GBD. The population attributable fractions for all-cause YLLs for individual major risk factors varied across Upper-Tier Local Authorities. Life expectancy and YLLs have improved more slowly since 2010 in all UK countries compared with 1990-2010. In nine of 150 Upper-Tier Local Authorities, YLLs increased after 2010. For attributable YLLs, the rate of improvement slowed most substantially for cardiovascular disease and breast, colorectal, and lung cancers, and showed little change for Alzheimer's disease and other dementias. Morbidity makes an increasing contribution to overall burden in the UK compared with mortality. The age-standardised UK DALY rate for low back and neck pain (1795 [1258-2356]) was higher than for ischaemic heart disease (1200 [1155-1246]) or lung cancer (660 [642-679]). The leading causes of ill health (measured through YLDs) in the UK in 2016 were low back and neck pain, skin and subcutaneous diseases, migraine, depressive disorders, and sense organ disease. Age-standardised YLD rates varied much less than equivalent YLL rates across the UK, which reflects the relative scarcity of local data on causes of ill health.

Interpretation: These estimates at local, regional, and national level will allow policy makers to match resources and priorities to levels of burden and risk factors. Improvement in YLLs and life expectancy slowed notably after 2010, particularly in cardiovascular disease and cancer, and targeted actions are needed if the rate of improvement is to recover. A targeted policy response is also required to address the increasing proportion of burden due to morbidity, such as musculoskeletal problems and depression. Improving the quality and completeness of available data on these causes is an essential component of this response.

Funding: Bill & Melinda Gates Foundation and Public Health England.
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http://dx.doi.org/10.1016/S0140-6736(18)32207-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6215773PMC
November 2018

Contributions of diseases and injuries to widening life expectancy inequalities in England from 2001 to 2016: a population-based analysis of vital registration data.

Lancet Public Health 2018 12 23;3(12):e586-e597. Epub 2018 Nov 23.

Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK; MRC-PHE Centre for Environment and Health, Imperial College London, London, UK; WHO Collaborating Centre on NCD Surveillance and Epidemiology, Imperial College London, London, UK. Electronic address:

Background: Life expectancy inequalities in England have increased steadily since the 1980s. Our aim was to investigate how much deaths from different diseases and injuries and at different ages have contributed to this rise to inform policies that aim to reduce health inequalities.

Methods: We used vital registration data from the Office for National Statistics on population and deaths in England, by underlying cause of death, from 2001 to 2016, stratified by sex, 5-year age group, and decile of the Index of Multiple Deprivation (based on the ranked scores of Lower Super Output Areas in England in 2015). We grouped the 7·65 million deaths by their assigned International Classification of Diseases (10th revision) codes to create categories of public health and clinical relevance. We used a Bayesian hierarchical model to obtain robust estimates of cause-specific death rates by sex, age group, year, and deprivation decile. We calculated life expectancy at birth by decile of deprivation and year using life-table methods. We calculated the contributions of deaths from each disease and injury, in each 5-year age group, to the life expectancy gap between the most deprived and affluent deciles using Arriaga's method.

Findings: The life expectancy gap between the most affluent and most deprived deciles increased from 6·1 years (95% credible interval 5·9-6·2) in 2001 to 7·9 years (7·7-8·1) in 2016 in females and from 9·0 years (8·8-9·2) to 9·7 years (9·6-9·9) in males. Since 2011, the rise in female life expectancy has stalled in the third, fourth, and fifth most deprived deciles and has reversed in the two most deprived deciles, declining by 0·24 years (0·10-0·37) in the most deprived and 0·16 years (0·02-0·29) in the second-most deprived by 2016. Death rates from every disease and at every age were higher in deprived areas than in affluent ones in 2016. The largest contributors to life expectancy inequalities were deaths in children younger than 5 years (mostly neonatal deaths), respiratory diseases, ischaemic heart disease, and lung and digestive cancers in working ages, and dementias in older ages. From 2001 to 2016, the contributions to inequalities declined for deaths in children younger than 5 years, ischaemic heart disease (for both sexes), and stroke and intentional injuries (for men), but increased for most other causes.

Interpretation: Recent trends in life expectancy in England have not only resulted in widened inequalities but the most deprived communities are now seeing no life expectancy gain. These inequalities are driven by a diverse group of diseases that can be effectively prevented and treated. Adoption of the principle of proportionate universalism to prevention and health and social care can postpone deaths into older ages for all communities and reduce life expectancy inequalities.

Funding: Wellcome Trust.
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http://dx.doi.org/10.1016/S2468-2667(18)30214-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6277818PMC
December 2018

Implications of Brexit on the effectiveness of the UK soft drinks industry levy upon CHD in England: a modelling study.

Public Health Nutr 2018 12 9;21(18):3431-3439. Epub 2018 Oct 9.

1Public Health Policy Evaluation Unit,School of Public Health,Imperial College London,Reynolds Building,St Dunstan's Road,London W6 8RP,UK.

Objective: An industry levy on sugar-sweetened beverages (SSB) was implemented in the UK in 2018. One year later, Brexit is likely to change the UK trade regime with potential implications for sugar price. We modelled the effect of potential changes in sugar price due to Brexit on SSB levy impacts upon CHD mortality and inequalities.

Design: We modelled a baseline SSB levy scenario; an SSB levy under 'soft' Brexit, where the UK establishes a free trading agreement with the EU; and an SSB levy under 'hard' Brexit, in which World Trade Organization tariffs are applied. We used the previously validated IMPACT Food Policy model and probabilistic sensitivity analysis to estimate the effect of each scenario on CHD deaths prevented or postponed and life-years gained, stratified by age, sex and socio-economic circumstance, in 2021.

Setting: England.

Subjects: Adults aged 25 years or older.

Results: The SSB levy was associated with approximately 370 (95 % uncertainty interval 220, 560) fewer CHD deaths and 4490 (2690, 6710) life-years gained in 2021. Associated reductions in CHD mortality were 4 and 8 % greater under 'soft' and 'hard' Brexit scenarios, respectively. The SSB levy was associated with approximately 110 (50, 190) fewer CHD deaths in the most deprived quintile compared with 60 (20, 100) in the most affluent, under 'hard' Brexit.

Conclusions: Our study found the SSB levy resilient to potential effects of Brexit upon sugar price. Even under 'hard' Brexit, the SSB levy would yield benefits for CHD mortality and inequalities. Brexit negotiations should deliver a fiscal and regulatory environment which promotes population health.
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http://dx.doi.org/10.1017/S1368980018002367DOI Listing
December 2018

Systems Thinking as a Framework for Analyzing Commercial Determinants of Health.

Milbank Q 2018 09;96(3):472-498

Hertie School of Governance.

Policy Points: Worldwide, more than 70% of all deaths are attributable to noncommunicable diseases (NCDs), nearly half of which are premature and apply to individuals of working age. Although such deaths are largely preventable, effective solutions continue to elude the public health community. One reason is the considerable influence of the "commercial determinants of health": NCDs are the product of a system that includes powerful corporate actors, who are often involved in public health policymaking. This article shows how a complex systems perspective may be used to analyze the commercial determinants of NCDs, and it explains how this can help with (1) conceptualizing the problem of NCDs and (2) developing effective policy interventions.

Context: The high burden of noncommunicable diseases (NCDs) is politically salient and eminently preventable. However, effective solutions largely continue to elude the public health community. Two pressing issues heighten this challenge: the first is the public health community's narrow approach to addressing NCDs, and the second is the involvement of corporate actors in policymaking. While NCDs are often conceptualized in terms of individual-level risk factors, we argue that they should be reframed as products of a complex system. This article explores the value of a systems approach to understanding NCDs as an emergent property of a complex system, with a focus on commercial actors.

Methods: Drawing on Donella Meadows's systems thinking framework, this article examines how a systems perspective may be used to analyze the commercial determinants of NCDs and, specifically, how unhealthy commodity industries influence public health policy.

Findings: Unhealthy commodity industries actively design and shape the NCD policy system, intervene at different levels of the system to gain agency over policy and politics, and legitimize their presence in public health policy decisions.

Conclusions: It should be possible to apply the principles of systems thinking to other complex public health issues, not just NCDs. Such an approach should be tested and refined for other complex public health challenges.
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http://dx.doi.org/10.1111/1468-0009.12339DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6131339PMC
September 2018