Adverse risk factor trends limit gains in coronary heart disease mortality in Barbados: 1990-2012.

BACKGROUND: Although most countries face increasing population levels of obesity and diabetes their effect on coronary heart disease (CHD) mortality has not been often studied in small island developing states (SIDs) where obesity rates are among the highest in the world. We estimated the relative contributions of treatments and cardiovascular risk factors to the decline in CHD mortality from 1990 to 2012 in the Caribbean island, Barbados. METHODS: We used the IMPACT CHD mortality model to estimate the effect of increased coverage of effective medical/surgical treatments and changes in major CHD risk factors on mortality trends in 2012 compared with 1990. We calculated deaths prevented or postponed (DPPs) for each model risk factor and treatment group. We obtained data from WHO Mortality database, population denominators from the Barbados Statistical Service stratified by 10-year age group (ages 25-34 up to 85 plus), population-based risk factor surveys, Global Burden of Disease and Barbados' national myocardial infarction registry. Monte Carlo probabilistic sensitivity analysis was performed. RESULTS: In 1990 the age-standardized CHD mortality rate was 109.5 per 100,000 falling to 55.3 in 2012. Implementation of effective treatment accounted for 56% DPPs (95% (Uncertainty Interval (UI) 46%, 68%), mostly due to the introduction of treatments immediately after acute myocardial infarction (AMI) (14%) and unstable angina (14%). Overall, risk factors contributed 19% DPPs (95% UI 6% to 34%) mostly attributed to decline in cholesterol (18% DPPs, 95% UI 12%, 26%). Adverse trends in diabetes: 14% additional deaths(ADs) 95% UI 8% to 21% ADs) and BMI (2% ADs 95%UI 0 to 5% ADs) limited potential for risk factor gains. CONCLUSIONS: Given the significant negative impact of obesity/diabetes on mortality in this analysis, research that explores factors affecting implementation of evidenced-based preventive strategies is needed. The fact that most of the decline in CHD mortality in Barbados was due to treatment provides an example for SIDs about the advantages of universal access to care and treatment.

The effects of policy actions to improve population dietary patterns and prevent diet-related non-communicable diseases: scoping review.

Poor diet generates a bigger non-communicable disease (NCD) burden than tobacco, alcohol and physical inactivity combined. We reviewed the potential effectiveness of policy actions to improve healthy food consumption and thus prevent NCDs. This scoping review focused on systematic and non-systematic reviews and categorised data using a seven-part framework: price, promotion, provision, composition, labelling, supply chain, trade/investment and multi-component interventions. We screened 1805 candidate publications and included 58 systematic and non-systematic reviews. Multi-component and price interventions appeared consistently powerful in improving healthy eating. Reformulation to reduce industrial trans fat intake also seemed very effective. Evidence on food supply chain, trade and investment studies was limited and merits further research. Food labelling and restrictions on provision or marketing of unhealthy foods were generally less effective with uncertain sustainability. Increasingly strong evidence is highlighting potentially powerful policies to improve diet and thus prevent NCDs, notably multi-component interventions, taxes, subsidies, elimination and perhaps trade agreements. The implications for policy makers are becoming clearer.

Obesity prevention strategies: could food or soda taxes improve health?

Evidence shows that one of the main causes for rising obesity rates is excessive consumption of sugar, which is due in large part to the high sugar content of most soda and juice drinks and junk foods. Worryingly, UK and global populations are consuming increasing amounts of sugary drinks and junk foods (high in salt, sugar and saturated fats). However, there is raised public awareness, and parents in particular want something to be done to curb the alarming rise in childhood obesity. Population-wide policies (i.e. taxation, regulation, legislation, reformulation) consistently achieve greater public health gains than interventions and strategies targeted at individuals. Junk food and soda taxes are supported by increasing evidence from empirical and modelling studies. The strongest evidence base is for a tax on sugar sweetened beverages, but in order to effectively reduce consumption, that taxation needs to be at least 20%. Empirical data from a number of countries which have implemented a duty on sugar or sugary drinks shows rapid, substantial benefits. In the UK, increasing evidence from recent scientific reports consistently support substantial reductions in sugar consumption through comprehensive strategies which include a tax. Furthermore, there is increasing public support for such measures. A sugar sweetened beverages tax will happen in the UK so the question is not 'If?' but 'When?' this tax will be implemented. And, crucially, which nation will get there first? England, Ireland, Scotland or Wales?

Exploring potential mortality reductions in 9 European countries by improving diet and lifestyle: A modelling approach.

BACKGROUND: Coronary heart disease (CHD) death rates have fallen across most of Europe in recent decades. However, substantial risk factor reductions have not been achieved across all Europe. Our aim was to quantify the potential impact of future policy scenarios on diet and lifestyle on CHD mortality in 9 European countries. METHODS: We updated the previously validated IMPACT CHD models in 9 European countries and extended them to 2010-11 (the baseline year) to predict reductions in CHD mortality to 2020(ages 25-74years). We compared three scenarios: conservative, intermediate and optimistic on smoking prevalence (absolute decreases of 5%, 10% and 15%); saturated fat intake (1%, 2% and 3% absolute decreases in % energy intake, replaced by unsaturated fats); salt (relative decreases of 10%, 20% and 30%), and physical inactivity (absolute decreases of 5%, 10% and 15%). Probabilistic sensitivity analyses were conducted. RESULTS: Under the conservative, intermediate and optimistic scenarios, we estimated 10.8% (95% CI: 7.3-14.0), 20.7% (95% CI: 15.6-25.2) and 29.1% (95% CI: 22.6-35.0) fewer CHD deaths in 2020. For the optimistic scenario, 15% absolute reductions in smoking could decrease CHD deaths by 8.9%-11.6%, Salt intake relative reductions of 30% by approximately 5.9-8.9%; 3% reductions in saturated fat intake by 6.3-7.5%, and 15% absolute increases in physical activity by 3.7-5.3%. CONCLUSIONS: Modest and feasible policy-based reductions in cardiovascular risk factors (already been achieved in some other countries) could translate into substantial reductions in future CHD deaths across Europe. However, this would require the European Union to more effectively implement powerful evidence-based prevention policies.

Explaining the trends in coronary heart disease mortality in Barbados: 1990–2012

OBJECTIVE: To describe the relative contributions of medical treatments and major cardiovascular risk factors to the decline in coronary heart disease (CHD) mortality from1990 to 2012 in Barbados. SUBJECTS AND METHODS: We used the IMPACT CHD mortality model to estimate the effect of improvement in uptake or efficacy of medical/surgical treatments, versus changes in major CHD risk factors on mortality trends. We obtained death data from the World Health Organization(WHO) mortality database and population denominators, stratified by age and gender from the Barbados Statistical Service. Cardiovascular risk factors and treatment data were obtained from published studies, population-based risk factor surveys, Barbados’ national myocardial infarction registry and retrospective chart reviews. RESULTS: In 1990, the age-standardized CHD mortality rate was 109.5 per 100 000, falling to 55.3 in 2012, representing a 46.1% decline in CHD deaths. This resulted in139 fewer deaths observed in 2012 versus the number expected had the rate remained as in 1990. The model indicated that 61% (n = 84) of these deaths were prevented or postponed (DPPs) because of implementation of treatment. Changes in risk factors accounted for 14% of the overall decline (19 DPPs). Improvements in cholesterol, physical inactivity, smoking and fruit/vegetable intake accounted for 51 DPPs; worsening systolic bloodpressure, diabetes and obesity levels were responsible for 32 additional deaths in 2012. CONCLUSIONS: Treatments accounted for approximately two-thirds of the mortality reduction. More effective prevention policies are urgently needed.

The contribution of primary prevention medication and dietary change in coronary mortality reduction in England between 2000 and 2007: a modelling study.

OBJECTIVE: To analyse the falls in coronary heart disease (CHD) mortality in England between 2000 and 2007 and quantify the relative contributions from preventive medications and population-wide changes in blood pressure (BP) and cholesterol levels, particularly by exploring socioeconomic inequalities. DESIGN: A modelling study. SETTING: Sources of data included controlled trials and meta-analyses, national surveys and official statistics. PARTICIPANTS: English population aged 25+ in 2000-2007. MAIN OUTCOME MEASURES: Number of deaths prevented or postponed (DPPs) in 2007 by socioeconomic status. We used the IMPACTSEC model which applies the relative risk reduction quantified in previous randomised controlled trials and meta-analyses to partition the mortality reduction among specific treatments and risk factor changes. RESULTS: Between 2000 and 2007, approximately 20 400 DPPs were attributable to reductions in BP and cholesterol in the English population. The substantial decline in BP was responsible for approximately 13 000 DPPs. Approximately 1800 DPPs came from medications and some 11 200 DPPs from population-wide changes. Reduction in population BP prevented almost twofold more deaths in the most deprived quintile compared with the most affluent. Reduction in cholesterol resulted in approximately 7400 DPPs; approximately 5300 DPPs were attributable to statin use and approximately 2100 DPPs to population-wide changes. Statins prevented almost 50% more deaths in the most affluent quintile compared with the most deprived. Conversely, population-wide changes in cholesterol prevented threefold more deaths in the most deprived quintile compared with the most affluent. CONCLUSIONS: Population-wide secular changes in systolic blood pressure (SBP) and cholesterol levels helped to substantially reduce CHD mortality and the associated socioeconomic disparities. Mortality reductions were, in absolute terms, greatest in the most deprived quintiles, mainly reflecting their bigger initial burden of disease. Statins for high-risk individuals also made an important contribution but maintained socioeconomic inequalities. Our results strengthen the case for greater emphasis on preventive approaches, particularly population-based policies to reduce SBP and cholesterol.

Food for thought: pilot randomized controlled trial of lay health trainers supporting dietary change to reduce cardiovascular disease in deprived communities.

BACKGROUND: Cardiovascular disease (CVD) accounts for 30% of UK deaths. It is associated with modifiable lifestyle factors, including insufficient consumption of fruit and vegetables (F&V). Lay health trainers (LHTs) offer practical support to help people develop healthier behaviour and lifestyles. Our two-group pilot randomized controlled trial (RCT) investigated the effectiveness of LHTs at promoting a heart-healthy lifestyle among adults with at least one risk factor for CVD to inform a full-scale RCT. METHODS: Eligible adults (aged 21-78 years), recruited from five practices serving deprived populations, were randomized to health information leaflets plus LHTs' support for 3 months (n = 76) versus health information leaflets alone (n = 38). RESULTS: We recruited 114 participants, with 60% completing 6 month follow-up. Both groups increased their self-reported F&V consumption and we found no evidence for LHTs' support having significant added impact. Most participants were relatively less deprived, as were the LHTs we were able to recruit and train. CONCLUSIONS: Our pilot demonstrated that an LHT's RCT whilst feasible faces considerable challenges. However, to justify growing investment in LHTs, any behaviour changes and sustained impact on those at greatest need should be demonstrated in an independently evaluated, robust, fully powered RCT.

Partial complementation of Sinorhizobium meliloti bacA mutant phenotypes by the Mycobacterium tuberculosis BacA protein.

The Sinorhizobium meliloti BacA ABC transporter protein plays an important role in its nodulating symbiosis with the legume alfalfa (Medicago sativa). The Mycobacterium tuberculosis BacA homolog was found to be important for the maintenance of chronic murine infections, yet its in vivo function is unknown. In the legume plant as well as in the mammalian host, bacteria encounter host antimicrobial peptides (AMPs). We found that the M. tuberculosis BacA protein was able to partially complement the symbiotic defect of an S. meliloti BacA-deficient mutant on alfalfa plants and to protect this mutant in vitro from the antimicrobial activity of a synthetic legume peptide, NCR247, and a recombinant human ß-defensin 2 (HBD2). This finding was also confirmed using an M. tuberculosis insertion mutant. Furthermore, M. tuberculosis BacA-mediated protection of the legume symbiont S. meliloti against legume defensins as well as HBD2 is dependent on its attached ATPase domain. In addition, we show that M. tuberculosis BacA mediates peptide uptake of the truncated bovine AMP, Bac7(1-16). This process required a functional ATPase domain. We therefore suggest that M. tuberculosis BacA is important for the transport of peptides across the cytoplasmic membrane and is part of a complete ABC transporter. Hence, BacA-mediated protection against host AMPs might be important for the maintenance of latent infections.

Development of public health guidance on the prevention of alcohol misuse and cardiovascular disease: the work of the National Institute for Health and Clinical Excellence, England.

In 2005, the National Institute for Health and Clinical Excellence in England was asked to extend its work from clinical practice to public health. It has since produced 35 pieces of public health guidance on interventions ranging from the specific (such as the use of pedometers to promote exercise) to major public health issues (such as behaviour change and community engagement). The workshop agreed that research on many public health interventions was lacking, particularly for population-level interventions, which might be more powerful than those targeted at individuals. Epidemiology could make a particular contribution to the evaluation of natural experiments, which have great potential for contributing to this evidence base.

Ethnic variations in heart failure: Scottish Health and Ethnicity Linkage Study (SHELS).

OBJECTIVE: Ethnic variations in heart failure are, apparently, large (eg, up to threefold in South Asians compared with White populations in Leicestershire, UK) but data are limited and conflicting. The incidence of first occurrence of heart failure hospitalisation or death by ethnic group in Scotland was studied. DESIGN, SETTING, POPULATIONS AND OUTCOMES: A retrospective cohort study was developed of 4.65 million people using non-disclosive, computerised methods linking the Scottish 2001 census (providing ethnic group) to community death and hospital discharge/deaths data (SMR01). Annual, directly age standardised incidence rates per 100,000, incidence rate ratios (RRs) and risk ratios using Poisson regression were calculated. Ratios were multiplied by 100. Risk ratios were adjusted for age and highest education qualification. Statements of difference imply the 95% CI excludes 100 (reference), otherwise the CI is given. RESULTS: In men, other White British (RR=86.4) and Chinese (RR=54.2) had less heart failure than White Scottish (100) populations while Pakistani men had more (RR=134.9). In women, the pattern was similar to men. Adjustment for highest educational qualification attenuated differences in risk ratios in other White British men (risk ratio=75.8 to 85.4) and women (66.2 to 74.6), made little difference to Pakistani men (146.9 to 142.1) and women (177.4 to 158.1), and augmented them in Indian men (115.4 (95% CI 93.1 to 143.0) to 131.7 (107.4 to 161.5)). CONCLUSIONS: Ethnic variations in heart failure were important in this population setting and not abolished by adjusting for highest education, one important indicator of socioeconomic differences. The ethnic variations were substantial but did not support other studies showing 3-20-fold differences between ethnic groups.

Ethnic variations in the incidence and mortality of stroke in the Scottish Health and Ethnicity Linkage Study of 4.65 million people.

BACKGROUND: Ethnic variations in stroke require more European studies, especially as differences are reportedly large. METHODS: We created a retrospective cohort study of 4.65 million people in Scotland linking ethnicity from the census and stroke incidence and mortality from NHS databases. Rate ratios using direct age standardization and risk ratios were calculated, the latter to model the influence of educational qualification in a Poisson regression model. RESULTS: Age-adjusted rate ratios varied little, compared to the White Scottish group (reference value 100) and the 95% CIs usually included 100, e.g. higher in Pakistani men (120.5, 95% CI 95.2-145.8) and in African men (137.9, 95% CI 91.5-184.4) but not in Pakistani or African women. Stroke rates were low in the Other White British (78.3, 95% CI 75.4-81.2 in men and 84.9, 95% CI 82.0-87.8 in women), Other White (89.8, 95% CI 81.5-98.1 in men and 88.8, 95% CI 80.9-96.7 in women) and Chinese men (70.3, 95% CI 45.7-94.8). Adjusting for highest educational qualification attenuated some and augmented other risk ratios, e.g. in Other White British men, the risk ratio changed from 71.4 to 80.2 (95% CI 74.2-86.6) and in African men from 124.2 to 138.8 (95% CI 107.7-178.8). CONCLUSIONS: Ethnic variations deserve further study, including in White European origin subgroups and the Chinese. Extremely high rates in South Asian and African origin were not corroborated in Scotland. Linkage methods are practical in Europe.

[Population-level changes to promote cardiovascular health]. / Zmeny na úrovni populace zamerené na podporu kardiovaskulárního zdraví

BACKGROUND: Cardiovascular diseases (CVD) cause 1.8 million premature (<75 years) death annually in Europe. The majority of these deaths are preventable with the most efficient and cost-effective approach being on the population level. The aim of this position paper is to assist authorities in selecting the most adequate management strategies to prevent CVD. DESIGN AND METHODS: Experts reviewed and summarized the published evidence on the major modifiable CVD risk factors: food, physical inactivity, smoking, and alcohol. Population-based preventive strategies focus on fiscal measures (e.g. taxation), national and regional policies (e.g. smoke-free legislation), and environmental changes (e.g. availability of alcohol). RESULTS: Food is a complex area, but several strategies can be effective in increasing fruit and vegetables and lowering intake of salt, saturated fat, trans-fats, and free sugars. Tobacco and alcohol can be regulated mainly by fiscal measures and national policies, but local availability also plays a role. Changes in national policies and the built environment will integrate physical activity into daily life. CONCLUSION: Societal changes and commercial influences have led to the present unhealthy environment, in which default option in life style increases CVD risk. A challenge for both central and local authorities is, therefore, to ensure healthier defaults. This position paper summarizes the evidence and recommends a number of structural strategies at international, national, and regional levels that in combination can substantially reduce CVD.

IMPACT: a generic tool for modelling and simulating public health policy.

BACKGROUND: Populations are under-served by local health policies and management of resources. This partly reflects a lack of realistically complex models to enable appraisal of a wide range of potential options. Rising computing power coupled with advances in machine learning and healthcare information now enables such models to be constructed and executed. However, such models are not generally accessible to public health practitioners who often lack the requisite technical knowledge or skills. OBJECTIVES: To design and develop a system for creating, executing and analysing the results of simulated public health and healthcare policy interventions, in ways that are accessible and usable by modellers and policy-makers. METHODS: The system requirements were captured and analysed in parallel with the statistical method development for the simulation engine. From the resulting software requirement specification the system architecture was designed, implemented and tested. A model for Coronary Heart Disease (CHD) was created and validated against empirical data. RESULTS: The system was successfully used to create and validate the CHD model. The initial validation results show concordance between the simulation results and the empirical data. CONCLUSIONS: We have demonstrated the ability to connect health policy-modellers and policy-makers in a unified system, thereby making population health models easier to share, maintain, reuse and deploy.

Coronary heart disease mortality trends in the Netherlands 1972-2007.

BACKGROUND: Coronary heart disease (CHD) mortality has steadily declined since the early 1970s in the Netherlands. However, in some Western countries the rate of decline in younger groups may be starting to plateau or even rise. OBJECTIVE: To examine trends in age-specific CHD mortality rates among Dutch adults from 1972 to 2007, with a particular focus on recent trends for the younger age groups METHODS: Data for all CHD deaths (1972-2007) in the Netherlands were grouped by year, sex, age. A joinpoint regression was fitted to each age-sex-group to detect points in time at which significant changes in the trends occur. For every time period, the linear slope of the trend, p value, observed number of deaths, CHD mortality rates and change in the CHD mortality rate were calculated. RESULTS: Between 1972 and 2007, the age-adjusted CHD mortality rates decreased overall by 76% in both men and women. In men (35-54 years), the change in CHD mortality rate in the period 1980-1993 was -0.53 but attenuated in period 1993-1999: -0.16. In women (35-54 years) the decline likewise attenuated to -0.44 in period 1979-1989: and -0.05 in period 1989-2000. After 1999-2000, CHD mortality rate further declined in both men (period 1999-2007: -0.46) and women (period 2000-2007: -0.38). CONCLUSIONS: Evidence from several Western countries suggests that among young adults (< 55 years), CHD mortality rates are levelling out. In this study, similar attenuation of the decline in CHD mortality among young adults in the Netherlands has been observed. Furthermore, this is the first study to observe a subsequent increase in the pace of decline after a period of flattening. In order to better explain these encouraging changes in CHD mortality rates, a detailed analysis of recent changes in cardiovascular risk factors and treatments is now urgently required.

Increasing evidence-based treatments to reduce coronary heart disease mortality in Sweden: quantifying the potential gains.

OBJECTIVES: Between 1986 and 2002, coronary heart disease (CHD) mortality in Sweden fell by more than 50%. Approximately one-third (4800 fewer deaths) of this decline in age-adjusted CHD mortality could be attributed to treatments in patients with CHD and primary prevention medications. High treatment levels were achieved in some cases, but in others, only 50-80% of eligible patients received appropriate therapy. We therefore examined to what extent increasing the use of specific treatments in eligible patients might have reduced CHD mortality rates in Sweden. DESIGN AND METHODS: We used the previously validated IMPACT CHD model to combine data on CHD patient numbers, medical and surgical uptake levels and treatment effectiveness. We estimated the number of deaths prevented or postponed for 2002 (baseline scenario) and for an alternative scenario (if at least 60% of eligible patients were treated). RESULTS: If treatments were increased to consistently cover at least 60% of eligible patients, approximately 8900 deaths could have been postponed or prevented, representing a potential gain of approximately 4100 fewer deaths than actually occurred in 2002. Approximately 45% of the 4100 gain would have come from primary prevention with statins, 23% from acute coronary syndrome treatments, 15% from secondary prevention therapies and 15% from treatments for heart failure. CONCLUSION: Increasing the proportion of eligible patients with CHD who receive evidence-based treatment could have resulted in approximately 4100 fewer deaths in 2002, almost doubling the actual mortality reduction. These findings further emphasize the importance of aggressively identifying and treating patients with CHD and high-risk individuals.