Potential health gains and health losses in eleven EU countries attainable through feasible prevalences of the life-style related risk factors alcohol, BMI, and smoking: a quantitative health impact assessment.

BACKGROUND: Influencing the life-style risk-factors alcohol, body mass index (BMI), and smoking is an European Union (EU) wide objective of public health policy. The population-level health effects of these risk-factors depend on population specific characteristics and are difficult to quantify without dynamic population health models. METHODS: For eleven countries-approx. 80 % of the EU-27 population-we used evidence from the publicly available DYNAMO-HIA data-set. For each country the age- and sex-specific risk-factor prevalence and the incidence, prevalence, and excess mortality of nine chronic diseases are utilized; including the corresponding relative risks linking risk-factor exposure causally to disease incidence and all-cause mortality. Applying the DYNAMO-HIA tool, we dynamically project the country-wise potential health gains and losses using feasible, i.e. observed elsewhere, risk-factor prevalence rates as benchmarks. The effects of the "worst practice", "best practice", and the currently observed risk-factor prevalence on population health are quantified and expected changes in life expectancy, morbidity-free life years, disease cases, and cumulative mortality are reported. RESULTS: Applying the best practice smoking prevalence yields the largest gains in life expectancy with 0.4 years for males and 0.3 year for females (approx. 332,950 and 274,200 deaths postponed, respectively) while the worst practice smoking prevalence also leads to the largest losses with 0.7 years for males and 0.9 year for females (approx. 609,400 and 710,550 lives lost, respectively). Comparing morbidity-free life years, the best practice smoking prevalence shows the highest gains for males with 0.4 years (342,800 less disease cases), whereas for females the best practice BMI prevalence yields the largest gains with 0.7 years (1,075,200 less disease cases). CONCLUSION: Smoking is still the risk-factor with the largest potential health gains. BMI, however, has comparatively large effects on morbidity. Future research should aim to improve knowledge of how policies can influence and shape individual and aggregated life-style-related risk-factor behavior.

Heavy metals in hair samples: a pilot study of anaemic children in Kazakhstan, Kyrgyzstan and Uzbekistan.

BACKGROUND: Heavy metals with their potential haematotoxic effect can contribute to the risks of anaemia in children in the Central Asian Republics (CAR), where burden and exposure to these metals is still not sufficiently known and reported. METHODS: Cross-sectional study was performed in Central Asian countries in hospitals in Kazakhstan, Kyrgyzstan and Uzbekistan with the aim to investigate the potential contribution of heavy metals to anaemia in children. In each country, 20 children were recruited, all were hospitalised with diagnosed anaemia. A sample of hair was taken from each child to assess the hair concentration of lead, cadmium and mercury. RESULTS: Relatively high levels of hair lead were observed, particularly in Kyrgyzstan. While lead and cadmium concentrations did not differ significantly among countries, mercury was lower in Kazakhstan than in Kyrgyzstan (p < 0.05) and Uzbekistan (p < 0.001). Hair lead and cadmium levels were significantly positively correlated (correlation coefficient = 0.51, p < 0.001). CONCLUSION: The results of this study showed higher than expected levels of hair lead, cadmium and mercury in anaemic children. Because iron deficiency anaemia is a major public health problem in CAR, further investigation of the extent of exposure to heavy metal and its contribution in iron deficiency anaemia in the region would be recommended.

Health impacts of increasing alcohol prices in the European Union: a dynamic projection.

OBJECTIVE: Western Europe has high levels of alcohol consumption, with corresponding adverse health effects. Currently, a major revision of the EU excise tax regime is under discussion. We quantify the health impact of alcohol price increases across the EU. DATA AND METHOD: We use alcohol consumption data for 11 member states, covering 80% of the EU-27 population, and corresponding country-specific disease data (incidence, prevalence, and case-fatality rate of alcohol related diseases) taken from the 2010 published Dynamic Modelling for Health Impact Assessment (DYNAMO-HIA) database to dynamically project the changes in population health that might arise from changes in alcohol price. RESULTS: Increasing alcohol prices towards those of Finland (the highest in the EU) would postpone approximately 54,000 male and approximately 26,100 female deaths over 10 years. Moreover, the prevalence of a number of chronic diseases would be reduced: in men by approximately 97,800 individuals with diabetes, 65,800 with stroke and 62,200 with selected cancers, and in women by about 19,100, 23,500, and 27,100, respectively. CONCLUSION: Curbing excessive drinking throughout the EU completely would lead to substantial gains in population health. Harmonisiation of prices to the Finnish level would, for selected diseases, achieve more than 40% of those gains.

DYNAMO-HIA--a Dynamic Modeling tool for generic Health Impact Assessments.

BACKGROUND: Currently, no standard tool is publicly available that allows researchers or policy-makers to quantify the impact of policies using epidemiological evidence within the causal framework of Health Impact Assessment (HIA). A standard tool should comply with three technical criteria (real-life population, dynamic projection, explicit risk-factor states) and three usability criteria (modest data requirements, rich model output, generally accessible) to be useful in the applied setting of HIA. With DYNAMO-HIA (Dynamic Modeling for Health Impact Assessment), we introduce such a generic software tool specifically designed to facilitate quantification in the assessment of the health impacts of policies. METHODS AND RESULTS: DYNAMO-HIA quantifies the impact of user-specified risk-factor changes on multiple diseases and in turn on overall population health, comparing one reference scenario with one or more intervention scenarios. The Markov-based modeling approach allows for explicit risk-factor states and simulation of a real-life population. A built-in parameter estimation module ensures that only standard population-level epidemiological evidence is required, i.e. data on incidence, prevalence, relative risks, and mortality. DYNAMO-HIA provides a rich output of summary measures--e.g. life expectancy and disease-free life expectancy--and detailed data--e.g. prevalences and mortality/survival rates--by age, sex, and risk-factor status over time. DYNAMO-HIA is controlled via a graphical user interface and is publicly available from the internet, ensuring general accessibility. We illustrate the use of DYNAMO-HIA with two example applications: a policy causing an overall increase in alcohol consumption and quantifying the disease-burden of smoking. CONCLUSION: By combining modest data needs with general accessibility and user friendliness within the causal framework of HIA, DYNAMO-HIA is a potential standard tool for health impact assessment based on epidemiologic evidence.

Hazardous alcohol drinking in the former Soviet Union: a cross-sectional study of eight countries.

BACKGROUND: Hazardous consumption of large quantities of alcohol is a major cause of ill-health in the former Soviet Union (fSU). The objective of this study was to describe episodic heavy drinking and other hazardous drinking behaviors in eight countries of the fSU. METHODS: Data from national surveys of adults conducted in Armenia, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia, and Ukraine in 2001 were used (overall sample size 18,428; response rates 71-88%). Heavy episodic drinking, high alcohol intake, drinking alcohol during the working day, and using illegally produced strong spirits were examined. RESULTS: On average, 23% of men and 2% of women were defined as heavy episodic drinkers (> or = 2 l of beer or > or = 750 g bottle of wine or > or = 200 g strong spirits at least once every 2-3 weeks). This was more common in young males, women who are single or who are divorced/separated/widowed, in smokers, and in frequent alcohol drinkers. About half the respondents who drank strong spirits obtained at least some alcohol from private sources. Among drinkers, 11% of males and 7% of women usually took their first drink before the end of working day. CONCLUSIONS: Heavy episodic alcohol drinking is frequent in males throughout the region--although prevalence rates may have been affected by underreporting--but is still relatively rare in women. Alcohol policies in the region should address hazardous drinking patterns and the common use of illegally produced alcohol.

Socioeconomic differences in health, health behaviour and access to health care in Armenia, Belarus, Georgia, Kazakhstan, Kyrgyzstan, the Republic of Moldova, the Russian Federation and Ukraine / by Marc Suhrcke

This publication presents tables summarizing the distribution of health, health behaviour, health care access and social capital by socioeconomic status, gender and residence (urban and rural). The data come from the Living Conditions, Lifestylesand Health (LLH) Project, which conducted representative surveys in eight countries of the former Soviet Union: Armenia, Belarus, Georgia, Kazakhstan, Kyrgyzstan, the Republic of Moldova, the Russian Federation and Ukraine in October and November 2001. The statistics are descriptive and do not necessarily reflect causal relationships between socioeconomic status and health.

Mejorando la evidencia de intervenciones y programas efectivos diseñados para aumentar el consumo de frutas y verduras a nivel mundial

Este artículo de revisión sistemática de literatura, discute las implicancias de políticas futuras y de investigación científica sobre la efectividad de las intervenciones y programas promoviendo el consumo de frutas y verduras en ambos adultos y niños a lo largo del mundo, realizadas en 2004. Los resultados indican que pequeños aumentos en el consumo de frutas y verduras son posibles en subgrupos poblacionales y que estos cambios pueden ser alcanzados desde varios acercamientos (a niveles individual, poblacional y desarrollo de políticas macro e intervenciones ambientales) tanto en niños como en adultos. Mientras muchos programas de promoción de frutas y verduras han sido conducidos o iniciados en todas las regiones del mundo, nuestro artículo muestra que los diseños de estudio utilizados han sido frecuentemente sub-óptimos para evaluar efectividad, particularmente en países menos desarrollados. Aunque es necesario mayor esfuerzo para mejorar el diseño y la evaluación de dichas intervenciones a lo largo del mundo, estos resultados son estimulantes y sugieren que los gobiernos deben seguir desarrollando políticas para mejorar la nutrición que tengan un énfasis fuerte en el consumo de frutas y verduras.

The burden of cardiovascular disease and cancer attributable to low fruit and vegetable intake in the European Union: differences between old and new Member States.

OBJECTIVE: To estimate the burden of disease attributable to low fruit and vegetable intake in the 15 countries that were members of the European Union (EU) before May 2004 (EU-15) and the 10 countries that then joined it (EU-10). DESIGN: Data on fruit and vegetable intake, target levels of intake and estimates of relative risks, deaths and disability were combined to obtain the burden of ischaemic heart disease, ischaemic stroke and four types of cancer (lung/bronchus/trachea, stomach, oesophagus, and colon/rectum) attributable to low fruit and vegetable consumption. SETTING: EU-15 and EU-10 Member States. RESULTS: The number of lives potentially saved annually from the selected outcomes if fruit and vegetable intake increased to 600 g person(-1) day(-1) reached 892,000 and 423,000 in the EU-15 and EU-10, respectively; total disease burden could decrease by 1.9% and 3.6%, respectively. The burden of ischaemic heart disease and stroke could be reduced by up to 17% and 10%, respectively, in the EU-15 and by 24% and 15%, respectively, in the EU-10; potential reductions for the selected cancers varied from 1% to 12% in the EU-15 and from 2% to 17% in the EU-10. CONCLUSIONS: The potential health gain of increased fruit and vegetable intake is particularly large in the new Member States, and particularly high for cardiovascular diseases, a main cause of health divide in Europe. This stresses the need for better nutrition programmes and policies that take account of economic, social and cultural specificities.

Getting children to eat more fruit and vegetables: a systematic review.

BACKGROUND: There is growing recognition of the need to increase consumption of currently suboptimal levels of fruit and vegetables by children, given their known beneficial effects for health. There is, however, a need for a synthesis of the evidence on interventions that might achieve this policy goal. METHODS: A systematic review of published and unpublished studies was carried out by searching 14 publication databases and contacting experts in the fields. All papers in eight languages were considered if they described individual- and population-based interventions and promotion programmes that encouraged the consumption of a diet relatively higher in fruit and/or vegetables in free-living, not acutely ill children of both genders, with follow-up periods of at least 3 months, measurement of change in intake and a control group. RESULTS: Fifteen studies focusing on children met the criteria for inclusion in the systematic review. None of the studies reviewed had a detrimental effect on fruit and vegetable consumption. Ten studies had a significant effect, ranging from +0.3 to +0.99 servings/day. CONCLUSIONS: More research is needed to examine in more depth, for longer follow-up periods, the effectiveness of interventions promoting fruit and vegetable consumption. The evidence is strongest in favor of multi-component interventions to increase fruit and vegetable consumption in children.

Drinking in the Commonwealth of Independent States--evidence from eight countries.

AIMS: To describe the frequency of alcohol consumption and beverage preferences in eight countries of the Commonwealth of Independent States (CIS). DESIGN: Cross-sectional. SETTING: Populations of Armenia, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Republic of Moldova, Russian Federation and Ukraine. PARTICIPANTS: Representative samples of the adult population of each country (overall sample size 18,428; response rates: 71-88%). MEASUREMENTS: A standardised questionnaire was administered by trained interviewers to examine alcohol consumption frequency and usual intakes of beer, wine and strong spirits. FINDINGS: Between 11 and 34% of males and 26-71% of females reported never drinking alcohol. Abstention was lowest in the Russian Federation and Belarus, two traditional spirits-drinking countries. It was particularly high in Kyrgyzstan and Georgia, two countries with a relatively low frequency of alcohol consumption but large amounts consumed per occasion (particularly Georgia). On the contrary, Moldovan respondents drank frequently, but consumed smaller amounts per occasion. As expected, spirits were consumed in largest amounts in traditional spirits-drinking countries, as well as Armenia and wine in traditional wine-drinking countries. Beer consumption was relatively high in Russia, Belarus, Ukraine and Kazakhstan (males), particularly in young respondents. CONCLUSIONS: Although cross-country comparisons of alcohol intake should be interpreted cautiously, this study suggested that drinking patterns in the countries examined are not entirely typical of usual dry/wet drinking cultures, and confirms that the CIS is very diverse in terms of drinking patterns and beverage preferences. The study provides an important baseline for future comparisons as markets open to new products, as has been the case elsewhere in Europe.

Interventions designed to increase adult fruit and vegetable intake can be effective: a systematic review of the literature.

International recommendations advise increasing intakes of fruit and vegetables to help reduce the burden of chronic diseases worldwide. This project systematically reviewed evidence on the effectiveness of interventions and programs promoting fruit and/or vegetable intake in adults. In April 2004, we contacted experts in the field and searched 14 publication databases. We considered all papers published in English, French, Spanish, Portuguese, Russian, Danish, Norwegian, and Swedish, and reporting on interventions and promotion programs encouraging higher intakes of fruit and/or vegetables in free-living not acutely ill adults, with follow-up periods > or = 3 mo, that measured change in intake and had a control group. Forty-four studies (mainly from developed countries) were included in the review and stratified by study setting. Larger effects were generally observed in individuals with preexisting health disorders. In primary prevention interventions in healthy adults, fruit and vegetable intake was increased by approximately 0.1-1.4 serving/d. Consistent positive effects were seen in studies involving face-to-face education or counseling, but interventions using telephone contacts or computer-tailored information appeared to be a reasonable alternative. Community-based multicomponent interventions also had positive findings. This literature review suggests that small increases in fruit and vegetable intake are possible in population subgroups, and that these can be achieved by a variety of approaches. More research is required to examine the effectiveness of specific components of interventions in different populations, particularly less developed countries. There is also a need for a better assessment of the effectiveness and cost-effectiveness of large community-based interventions.

The global burden of disease attributable to low consumption of fruit and vegetables: implications for the global strategy on diet.

OBJECTIVE: We estimated the global burden of disease attributable to low consumption of fruit and vegetables, an increasingly recognized risk factor for cardiovascular disease and cancer, and compared its impact with that of other major risk factors for disease. METHODS: The burden of disease attributable to suboptimal intake of fruit and vegetables was estimated using information on fruit and vegetable consumption in the population, and on its association with six health outcomes (ischaemic heart disease, stroke, stomach, oesophageal, colorectal and lung cancer). Data from both sources were stratified by sex, age and by 14 geographical regions. FINDINGS: The total worldwide mortality currently attributable to inadequate consumption of fruit and vegetables is estimated to be up to 2.635 million deaths per year. Increasing individual fruit and vegetable consumption to up to 600 g per day (the baseline of choice) could reduce the total worldwide burden of disease by 1.8%, and reduce the burden of ischaemic heart disease and ischaemic stroke by 31% and 19% respectively. For stomach, oesophageal, lung and colorectal cancer, the potential reductions were 19%, 20%, 12% and 2%, respectively. CONCLUSION: This study shows the potentially large impact that increasing fruit and vegetable intake could have in reducing many noncommunicable diseases. It highlights the need for much greater emphasis on dietary risk factors in public health policy in order to tackle the rise in noncommunicable diseases worldwide, and suggests that the proposed intersectoral WHO/FAO fruit and vegetable promotion initiative is a crucial component in any global diet strategy.

Determinants of smoking in eight countries of the former Soviet Union: results from the living conditions, lifestyles and health study.

AIMS: To provide accurate and timely data on the determinants of smoking in countries of the former Soviet Union in order to facilitate the development of effective tobacco control policies in the region. Such data are urgently needed given the absence of accurate comparative data in the region and the recent changes experienced. DESIGN: Cross-sectional surveys using standardized methods and representative samples of the adult population in eight former Soviet Union countries conducted as part of the EU-Copernicus Project Living Conditions, Lifestyle, and Health study. SETTING: Armenia, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia and Ukraine. PARTICIPANTS: A total of 18 428 adults aged 18 plus; response rates 71-88%. MEASUREMENTS: The association of smoking with demographic and socio-economic factors was investigated using multiple logistic regression analyses, stratifying by gender. FINDINGS: Age was a strong determinant of smoking in both genders, with elderly individuals being less likely to smoke. Men who were more socially disadvantaged (less educated, poorer economic situation and/or less social support) were more likely to smoke. In women, living in larger urban areas was the strongest predictor of smoking. Divorced, separated or widowed women were also more likely to smoke than married women. Muslim respondents smoked less frequently compared with other respondents. CONCLUSIONS: Smoking is a major public health issue in the FSU particularly affecting socially vulnerable men and young women living in urbanized areas. These high-risk groups should be targeted in future smoking prevention and cessation strategies in the region.

Prevalence of smoking in 8 countries of the former Soviet Union: results from the living conditions, lifestyles and health study.

OBJECTIVES: We sought to provide comparative data on smoking habits in countries of the former Soviet Union. METHODS: We conducted cross-sectional surveys in 8 former Soviet countries with representative national samples of the population 18 years or older. RESULTS: Smoking rates varied among men, from 43.3% to 65.3% among the countries examined. Results showed that smoking among women remains uncommon in Armenia, Georgia, Kyrgyzstan, and Moldova (rates of 2.4%-6.3%). In Belarus, Ukraine, Kazakhstan, and Russia, rates were higher (9.3%-15.5%). Men start smoking at significantly younger ages than women, smoke more cigarettes per day, and are more likely to be nicotine dependent. CONCLUSIONS: Smoking rates among men in these countries have been high for some time and remain among the highest in the world. Smoking rates among women have increased from previous years and appear to reflect transnational tobacco company activity.

Health service utilization in the former soviet union: evidence from eight countries.

BACKGROUND: In the past decade, the countries that emerged from the Soviet Union have experienced major changes in the inherited Soviet model of health care, which was centrally planned and provided universal, free access to basic care. The underlying principle of universality remains, but coexists with new funding and delivery systems and growing out-of-pocket payments. OBJECTIVE: To examine patterns and determinants of health care utilization, the extent of payment for health care, and the settings in which care is obtained in Armenia, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia, and Ukraine. METHODS: Data were derived from cross-sectional surveys, representative of adults aged 18 and over in each country, conducted in 2001. Multistage random sample of 18,428 individuals, stratified by region and area, was obtained. Instrument contained extensive data on demographic, economic, and social characteristics, administered face-to-face. The analysis explored the health seeking behavior of users and nonusers (those reporting an episode of illness but not consulting). RESULTS: In the preceding year, over half of all respondents visited a medical professional, ranging from 65.7 percent in Belarus to 24.4 percent in Georgia, mostly at local primary care facilities. Of those reporting an illness, 20.7 percent of all did not consult although they felt they should have done so, varying from 9.4 percent in Belarus to 42.4 percent in Armenia and 49 percent in Georgia. The main reason for not seeking care was lack of money to pay for treatment (45.2 percent), self-treatment with home-produced remedies (32.9 percent), and purchase of nonprescribed medicine (21.8 percent). There are marked differences between countries; unaffordability was a particularly common factor in Armenia, Georgia, and Moldova (78 percent, 70 percent, 54 percent), and much lower in Belarus and Russia. In Georgia and Armenia, 65 percent and 56 percent of those who had consulted paid out-of-pocket, in the form of money, gifts, or both; these figures were 8 percent and 19 percent in Belarus and Russia respectively and 31.2 percent overall. The probability of not consulting a health professional when seriously ill was significantly higher among those over age 65, and with lower education. Use of health care was markedly lower among those with fewer household assets or a shortage of money, and those dissatisfied with their material resources, factors that explained some of the effects of age. A lack of social support (formal and informal) decreases further the probability of not consulting, adding to the consequences of poor financial status. The probability of seeking care for common conditions varies widely among countries (persistent fever: 56 percent in Belarus; 16 percent in Armenia) and home remedies, alcohol, and direct purchase of pharmaceuticals are commonly used. Informal coping strategies, such as use of connections (36.7 percent) or offering money to health professionals (28.5 percent) are seen as acceptable. CONCLUSIONS: This article provides the first comparative assessment of inequalities in access to health care in multiple countries of the former Soviet Union, using rigorous methodology. The emerging model across the region is extremely diverse. Some countries (Belarus, Russia) have managed to maintain access for most people, while in others the situation is near collapse (Armenia, Georgia). Access is most problematic in health systems characterized by high levels of payment for care and a breakdown of gate-keeping, although these are seen in countries facing major problems such as economic collapse and, in some, a legacy of civil war. There are substantial inequalities within each country and even where access remains adequate there are concerns about its sustainability.

The challenge of measuring global fruit and vegetable intake.

The WHO recently conducted, within its Global Burden of Disease 2000 Study, a Comparative Risk Assessment (CRA) to estimate the global health effect of low fruit and vegetable intake. This paper summarizes the methods used to obtain exposure data for the CRA and provides estimates of worldwide fruit and vegetable intakes. Intakes were derived from 26 national population-based surveys, complemented with food supply statistics. Estimates were stratified by 14 subregions, 8 age groups, and gender. Subregions were categorized on the bases of child mortality under age 5 y and 15- to 59-y-old male mortality (A: very low child and adult mortality; B: low child and adult mortality; C: low child, high adult mortality; D: high child and adult mortality; E: high child, very high adult mortality). Mean intakes were highest in Europe A [median = 449 g/(person.d)] and the Western Pacific Region A. They were lowest in America B [median = 192 g/(person.d)], and low in Europe C, the South East Asian Regions B and D, and Africa E. Children and elderly individuals generally had lower intakes than middle-aged adults. SDs varied considerably by region, gender, and age [overall median = 223 g/(person.d)]. Assessing exposure levels for the CRA had major methodological limitations, particularly due to the lack of nationally representative intake data. The results showed mean intakes generally lower than current recommendations, with large variations among subregions. If the burden of disease attributable to dietary factors is to be assessed more accurately, more countries will have to assess the dietary intake of their populations using comparable methods.

Physical inactivity in a country in transition: a population-based survey in Tirana City, Albania.

AIMS: This paper describes the work and leisure-time physical activity levels of adults living in Tirana City (Albania). METHODS: A cross-sectional survey was undertaken in Tirana City in mid-2001. It included 1120 adults aged 25 years and over (response rate=72.7%). RESULTS: Overall, 19.3% of male and 28.4% of female respondents reported a low level of physical activity at work. During leisure time, 49.5% of men and 57.6% of women (age-standardized prevalence [adjusted to the adult population of Tirana]: 43.4% and 51.9% for men and women respectively) said that they participated in only sedentary activities such as reading and watching television. The gender difference in the likelihood of low physical activity at work and during leisure time was significant even after adjusting for age (age adjusted odds ratios (OR)=1.86 99% confidence interval (CI) 1.12; 3.09 and OR=1.60 99% CI 1.17; 2.22 respectively). The likelihood of leisure-time sedentarity increased with age in both genders but it did not vary significantly with education level or income. Being sedentary during leisure time was also not significantly associated with other unhealthy lifestyle behaviours, including smoking, consumption of vegetables less than six days per week, and daily alcohol intake. CONCLUSIONS: In a country such as Albania that has undergone a rapid transition from a largely unmechanized society, characterized inevitably by high levels of exercise, the generalized high prevalence of low physical activity level during leisure time gives cause for concern regarding future health trends.