Search tips
Search criteria

Results 1-25 (63)

Clipboard (0)

Select a Filter Below

Year of Publication
more »
1.  Temporal trends and risk factors for readmission for infections, gastrointestinal and immobility complications after an incident hospitalisation for stroke in Scotland between 1997 and 2005 
BMC Neurology  2015;15:3.
Improvements in stroke management have led to increases in the numbers of stroke survivors over the last decade and there has been a corresponding increase of hospital readmissions after an initial stroke hospitalisation. The aim of this study was to examine the one year risk of having a readmission due to infective, gastrointestinal or immobility (IGI) complications and to identify temporal trends and any risk factors.
Using a cohort of first hospitalised for stroke patients who were discharged alive, time to first event (readmission for IGI complications or death) within 1 year was analysed in a competing risks framework using cumulative incidence methods. Regression on the cumulative incidence function was used to model the risks of having an outcome using the covariates age, sex, socioeconomic status, comorbidity, discharge destination and length of hospital stay.
There were a total of 51,182 patients discharged alive after an incident stroke hospitalisation in Scotland between 1997–2005, and 7,747 (15.1%) were readmitted for IGI complications within a year of the discharge. Comparing incident stroke hospitalisations in 2005 with 1997, the adjusted risk of IGI readmission did not increase (HR = 1.00 95% CI (0.90, 1.11). However, there was a higher risk of IGI readmission with increasing levels of deprivation (most deprived fifth vs. least deprived fifth HR = 1.16 (1.08, 1.26).
Approximately 15 in 100 patients discharged alive after an incident hospitalisation for stroke in Scotland between 1997 and 2005 went on to have an IGI readmission within one year. The proportion of readmissions did not change over the study period but those living in deprived areas had an increased risk.
Electronic supplementary material
The online version of this article (doi:10.1186/s12883-014-0257-1) contains supplementary material, which is available to authorized users.
PMCID: PMC4320501  PMID: 25591718
Incident stroke hospitalisation; Readmission; Cumulative incidence; Competing risks
3.  Smorgasbord or symphony? Assessing public health nutrition policies across 30 European countries using a novel framework 
BMC Public Health  2014;14(1):1195.
Countries across Europe have introduced a wide variety of policies to improve nutrition. However, the sheer diversity of interventions represents a potentially bewildering smorgasbord.
We aimed to map existing public health nutrition policies, and examine their perceived effectiveness, in order to inform future evidence-based diet strategies.
We created a public health nutrition policy database for 30 European countries . National nutrition policies were classified and assigned using the marketing "4Ps" approach Product (reformulation, elimination, new healthier products); Price (taxes, subsidies); Promotion (advertising, food labelling, health education) and Place (schools, workplaces, etc.).
We interviewed 71 senior policy-makers, public health nutrition policy experts and academics from 14 of the 30 countries, eliciting their views on diverse current and possible nutrition strategies.
Product Voluntary reformulation of foods is widespread but has variable and often modest impact. Twelve countries regulate maximum salt content in specific foods.
Denmark, Austria, Iceland and Switzerland have effective trans fats bans.
Price EU School Fruit Scheme subsidies are almost universal, but with variable implementation.
Taxes are uncommon. However, Finland, France, Hungary and Latvia have implemented ‘sugar taxes’ on sugary foods and sugar-sweetened beverages. Finland, Hungary and Portugal also tax salty products.
Promotion Dialogue, recommendations, nutrition guidelines, labelling, information and education campaigns are widespread. Restrictions on marketing to children are widespread but mostly voluntary.
Place Interventions reducing the availability of unhealthy foods were most commonly found in schools and workplace canteens.
Interviewees generally considered mandatory reformulation more effective than voluntary, and regulation and fiscal interventions much more effective than information strategies, but also politically more challenging.
Public health nutrition policies in Europe appear diverse, dynamic, complex and bewildering. The "4Ps" framework potentially offers a structured and comprehensive categorisation.
Encouragingly, the majority of European countries are engaged in activities intended to increase consumption of healthy food and decrease the intake of "junk" food and sugary drinks. Leading countries include Finland, Norway, Iceland, Denmark, Hungary, Portugal and perhaps the UK. However, all countries fall short of optimal activities. More needs to be done across Europe to implement the most potentially powerful fiscal and regulatory nutrition policies.
Electronic supplementary material
The online version of this article (doi:10.1186/1471-2458-14-1195) contains supplementary material, which is available to authorized users.
PMCID: PMC4251675  PMID: 25413832
Public health nutrition; Public health policy; Europe; Food policy mapping; Qualitative
4.  Quantifying Options for Reducing Coronary Heart Disease Mortality By 2020 
Circulation  2013;127(25):2477-2484.
The AHA 2020 Strategic Impact Goal proposes a 20% improvement in cardiovascular health of all Americans. We aimed to estimate the potential reduction in coronary heart disease (CHD) deaths.
Methods and Results
We used data on 40,373 CVD-free adults from NHANES (1988–2010). We quantified recent trends for six metrics (total cholesterol [TC]; systolic blood pressure [SBP]; physical inactivity; smoking; diabetes; obesity) and generated linear projections to 2020. We projected the expected number of CHD deaths in 2020 if 2006 age- and sex-specific CHD death rates remained constant, which would result in approximately 480,000 CHD deaths in 2020 (12% increase). We used the previously validated IMPACT CHD model to project numbers of CHD deaths in 2020 under two different scenarios.
A) Assuming a 20% improvement in each CVH metric, we project 365,000 CHD deaths in 2020, (range 327,000–403,000) a 24% decrease reflecting modest reductions in TC (−41,000), SBP (−36,000), physical inactivity (−12,000), smoking (−10,000), diabetes (−10,000), and obesity (−5,000). B) Assuming that recent risk factor trends continue to 2020, we project 335,000 CHD deaths (range 274,000–386,000), a 30% decrease reflecting improvements in TC, SBP, smoking and physical activity (~167,000 fewer deaths), offset by increases in diabetes and BMI (~24,000 more deaths).
Two contrasting scenarios of change in CVH metrics could prevent 24–30% of the CHD deaths expected in 2020, though with differing impacts by age. Unfavorable continuing trends in obesity and diabetes would have substantial adverse effects. This analysis demonstrates the utility of modelling to inform health policy.
PMCID: PMC3795417  PMID: 23661723
heart disease; American Heart Association; epidemiology; risk factor
5.  Future Declines of Coronary Heart Disease Mortality in England and Wales Could Counter the Burden of Population Ageing 
PLoS ONE  2014;9(6):e99482.
Coronary Heart Disease (CHD) remains a major cause of mortality in the United Kingdom. Yet predictions of future CHD mortality are potentially problematic due to population ageing and increase in obesity and diabetes. Here we explore future projections of CHD mortality in England & Wales under two contrasting future trend assumptions.
In scenario A, we used the conventional counterfactual scenario that the last-observed CHD mortality rates from 2011 would persist unchanged to 2030. The future number of deaths was calculated by applying those rates to the 2012–2030 population estimates. In scenario B, we assumed that the recent falling trend in CHD mortality rates would continue. Using Lee-Carter and Bayesian Age Period Cohort (BAPC) models, we projected the linear trends up to 2030. We validate our methods using past data to predict mortality from 2002–2011. Then, we computed the error between observed and projected values.
In scenario A, assuming that 2011 mortality rates stayed constant by 2030, the number of CHD deaths would increase 62% or approximately 39,600 additional deaths. In scenario B, assuming recent declines continued, the BAPC model (the model with lowest error) suggests the number of deaths will decrease by 56%, representing approximately 36,200 fewer deaths by 2030.
The decline in CHD mortality has been reasonably continuous since 1979, and there is little reason to believe it will soon halt. The commonly used assumption that mortality will remain constant from 2011 therefore appears slightly dubious. By contrast, using the BAPC model and assuming continuing mortality falls offers a more plausible prediction of future trends. Thus, despite population ageing, the number of CHD deaths might halve again between 2011 and 2030. This has implications for how the potential benefits of future cardiovascular strategies might best be calculated and presented.
PMCID: PMC4053422  PMID: 24918442
6.  Cardiovascular Health Behavior and Health Factor Changes (1988 –2008) and Projections to 2020 
Circulation  2012;125(21):2595-2602.
The American Heart Association’s 2020 Strategic Impact Goals target a 20% relative improvement in overall cardiovascular health with the use of 4 health behavior (smoking, diet, physical activity, body mass) and 3 health factor (plasma glucose, cholesterol, blood pressure) metrics. We sought to define current trends and forward projections to 2020 in cardiovascular health.
Methods and Results
We included 35 059 cardiovascular disease–free adults (aged ≥20 years) from the National Health and Nutrition Examination Survey 1988–1994 and subsequent 2-year cycles during 1999–2008. We calculated population prevalence of poor, intermediate, and ideal health behaviors and factors and also computed a composite, individual-level Cardiovascular Health Score for all 7 metrics (poor=0 points; intermediate=1 point; ideal=2 points; total range, 0–14 points). Prevalence of current and former smoking, hypercholesterolemia, and hypertension declined, whereas prevalence of obesity and dysglycemia increased through 2008. Physical activity levels and low diet quality scores changed minimally. Projections to 2020 suggest that obesity and impaired fasting glucose/diabetes mellitus could increase to affect 43% and 77% of US men and 42% and 53% of US women, respectively. Overall, population-level cardiovascular health is projected to improve by 6% overall by 2020 if current trends continue. Individual-level Cardiovascular Health Score projections to 2020 (men=7.4 [95% confidence interval, 5.7–9.1]; women=8.8 [95% confidence interval, 7.6–9.9]) fall well below the level needed to achieve a 20% improvement (men=9.4; women=10.1).
The American Heart Association 2020 target of improving cardiovascular health by 20% by 2020 will not be reached if current trends continue.
PMCID: PMC3914399  PMID: 22547667
cardiovascular disease risk factors; epidemiology; risk factors; trends
7.  Population Assessment of Future Trajectories in Coronary Heart Disease Mortality 
PLoS ONE  2014;9(1):e85800.
Coronary heart disease (CHD) mortality rates have been decreasing in Iceland since the 1980s, largely reflecting improvements in cardiovascular risk factors. The purpose of this study was to predict future CHD mortality in Iceland based on potential risk factor trends.
Methods and findings
The previously validated IMPACT model was used to predict changes in CHD mortality between 2010 and 2040 among the projected population of Iceland aged 25–74. Calculations were based on combining: i) data on population numbers and projections (Statistics Iceland), ii) population risk factor levels and projections (Refine Reykjavik study), and iii) effectiveness of specific risk factor reductions (published meta-analyses). Projections for three contrasting scenarios were compared: 1) If the historical risk factor trends of past 30 years were to continue, the declining death rates of past decades would level off, reflecting population ageing. 2) If recent trends in risk factors (past 5 years) continue, this would result in a death rate increasing from 49 to 70 per 100,000. This would reflect a recent plateau in previously falling cholesterol levels and recent rapid increases in obesity and diabetes prevalence. 3) Assuming that in 2040 the entire population enjoys optimal risk factor levels observed in low risk cohorts, this would prevent almost all premature CHD deaths before 2040.
The potential increase in CHD deaths with recent trends in risk factor levels is alarming both for Iceland and probably for comparable Western populations. However, our results show considerable room for reducing CHD mortality. Achieving the best case scenario could eradicate premature CHD deaths by 2040. Public health policy interventions based on these predictions may provide a cost effective means of reducing CHD mortality in the future.
PMCID: PMC3897505  PMID: 24465713
8.  Continuing decrease in coronary heart disease mortality in Sweden 
Deaths from coronary heart disease (CHD) have been decreasing in most Western countries over the last few decades. In contrast, a flattening of the decrease in mortality has been recently reported among younger age groups in some countries. We aimed to determine whether the decrease in CHD mortality is flattening among Swedish young adults.
We examined trends in CHD mortality in Sweden between 1987 and 2009 among persons aged 35 to 84 years using CHD mortality data from the Swedish National Register on Cause of Death. Annual percent changes in rates were examined using Joinpoint software.
Overall, CHD mortality rates decreased by 67.4% in men and 65.1% in women. Among men aged 35–54 years, there was a modest early attenuation from a marked initial decrease. In the oldest women aged 75–84 years, an attenuation in the mortality decrease was observed from 1989 to 1992, followed by a decrease, as in all other age groups.
In Sweden, coronary heart disease deaths are still falling. We were unable to confirm a flattening of the decline in young people. Death rates continue to decline in men and women across all age groups, albeit at a slower pace in younger men since 1991. Continued careful monitoring of CHD mortality trends in Sweden is required, particularly among young adults.
PMCID: PMC3930358  PMID: 24447603
Myocardial ischemia; Mortality; Risk factors; Coronary heart disease
9.  A Cost Effectiveness Analysis of Salt Reduction Policies to Reduce Coronary Heart Disease in Four Eastern Mediterranean Countries 
PLoS ONE  2014;9(1):e84445.
Coronary Heart Disease (CHD) is rising in middle income countries. Population based strategies to reduce specific CHD risk factors have an important role to play in reducing overall CHD mortality. Reducing dietary salt consumption is a potentially cost-effective way to reduce CHD events. This paper presents an economic evaluation of population based salt reduction policies in Tunisia, Syria, Palestine and Turkey.
Methods and Findings
Three policies to reduce dietary salt intake were evaluated: a health promotion campaign, labelling of food packaging and mandatory reformulation of salt content in processed food. These were evaluated separately and in combination. Estimates of the effectiveness of salt reduction on blood pressure were based on a literature review. The reduction in mortality was estimated using the IMPACT CHD model specific to that country. Cumulative population health effects were quantified as life years gained (LYG) over a 10 year time frame. The costs of each policy were estimated using evidence from comparable policies and expert opinion including public sector costs and costs to the food industry. Health care costs associated with CHDs were estimated using standardized unit costs. The total cost of implementing each policy was compared against the current baseline (no policy). All costs were calculated using 2010 PPP exchange rates. In all four countries most policies were cost saving compared with the baseline. The combination of all three policies (reducing salt consumption by 30%) resulted in estimated cost savings of $235,000,000 and 6455 LYG in Tunisia; $39,000,000 and 31674 LYG in Syria; $6,000,000 and 2682 LYG in Palestine and $1,3000,000,000 and 378439 LYG in Turkey.
Decreasing dietary salt intake will reduce coronary heart disease deaths in the four countries. A comprehensive strategy of health education and food industry actions to label and reduce salt content would save both money and lives.
PMCID: PMC3883693  PMID: 24409297
10.  Preventing type 2 diabetes among Palestinians: comparing five future policy scenarios 
BMJ Open  2013;3(12):e003558.
This paper aims to provide estimates of future diabetes prevalence in the West Bank, occupied Palestinian territory (oPt), and to compare five future policy scenarios for diabetes prevention.
We created and refined a mathematical Markov model that integrates population, obesity and smoking trends to estimate future diabetes prevalence. Model parameters were derived from the literature. Diabetes incidence was estimated using DISMOD software. We developed the model for the Palestinian population based on data available for the period 2000–2010, and validated the model by comparing predicted diabetes prevalence to subsequent actual observed diabetes prevalence rates.
West Bank oPt.
Palestinian diabetes mellitus prevalence estimated by the model (for adults aged 25 or more) was 9.7% in 2000, increasing to 15.3% by 2010. Prevalence in men increased from 9.1% to 16.9% and in women from 10.2% to 13.6%. Comparisons of the model results with the observed prevalence in the Palestinian Family Health Survey showed a close fit. The model forecasts were 20.8% for 2020 and 23.4% for 2030. A 2.8% reduction in diabetes prevalence could be achieved if obesity trends start to decline by 5% in a 5-year period. If obesity prevalence was reduced by 35% in 10 years, as suggested by the WHO, diabetes prevalence might be decreased by 20%.
The model estimates an increase in the prevalence of diabetes which poses a large challenge to the health system. However, if bold but reasonable action is taken, effective interventions could reduce diabetes prevalence and hence the number of patients with diabetes.
PMCID: PMC3884589  PMID: 24362011
11.  Explaining the decline in coronary heart disease mortality in Turkey between 1995 and 2008 
BMC Public Health  2013;13:1135.
Coronary heart disease (CHD) mortality rates have been decreasing in Turkey since the early 1990s. Our study aimed to determine how much of the CHD mortality decrease in Turkey between 1995 and 2008 could be attributed to temporal trends in major risk factors and how much to advances in medical and surgical treatments.
The validated IMPACT CHD mortality model was used to combine and analyse data on uptake and effectiveness of CHD treatments and risk factor trends in Turkey in adults aged 35–84 years between 1995 and 2008.
Data sources were identified, searched and appraised on population, mortality and major CHD risk factors for adults those aged 35–84 years. Official statistics, electronic databases, national registers, surveys and published trials were screened from 1995 onwards.
Between 1995 and 2008, coronary heart disease mortality rates in Turkey decreased by 34% in men and 28% in women 35 years and over. This resulted in 35,720 fewer deaths in 2008.
Approximately 47% of this mortality decrease was attributed to treatments in individuals (including approximately 16% to secondary prevention, 3% angina treatments, 9% to heart failure treatments, 5% to initial treatments of acute myocardial infarction, and 5% to hypertension treatments) and approximately 42% was attributable to population risk factor reductions (notably blood pressure 29%; smoking 27%; and cholesterol 1%). Adverse trends were seen for obesity and diabetes (potentially increasing mortality by approximately 11% and 14% respectively). The model explained almost 90% of the mortality fall.
Reduction in major cardiovascular risk factors explained approximately 42% and improvements in medical and surgical treatments explained some 47% of the CHD mortality fall. These findings emphasize the complimentary value of primary prevention and evidence-based medical treatments in controlling coronary heart disease.
PMCID: PMC4234124  PMID: 24308515
Coronary heart disease; Coronary heart disease mortality; Coronary heart disease risk factors; Coronary heart disease management; Turkey; Modelling
12.  Reduction in myocardial infarction admissions in Liverpool after the smoking ban: potential socioeconomic implications for policymaking 
BMJ Open  2013;3(11):e003307.
To analyse the trends and trend changes in myocardial infraction (MI) and coronary heart disease (CHD) admissions, to investigate the effects of the 2007 smoke-free legislation on these trends, and to consider the policy implications of any findings.
Design setting
Liverpool (city), UK.
Hospital episode statistics data on all 56 995 admissions for CHD in Liverpool between 2004 and 2012 (International Classification of Diseases codes I20–I25 coded as an admission diagnosis within the defined dates).
Primary and secondary outcome measures
Trend gradient and change points (by trend regressions analysis) in age-standardised MI admissions in Liverpool between 2004 and 2012; by sex and by socioeconomic status. Secondary analysis on CHD admissions.
A significant and sustained reduction was seen in MI admissions in Liverpool beginning within 1 year of the smoking ban. Comparing 2005/2006 and 2010/2011, the age-adjusted rates for MI admissions fell by 42% (39–45%) (41.6% in men and by 42.6% in women). Trend analysis shows that this is significantly greater than the background trend of decreasing admissions. These reductions appeared consistent across all socioeconomic groups. Interestingly, admission rates for total CHD (including mild to severe angina) increased by 10% (8–12%).
A dramatic reduction in MI admissions in Liverpool has been observed coinciding with the smoking ban in 2007. Furthermore, the benefits were apparent across the socioeconomic spectrum. Health inequalities were not affected and may even have been reduced. The rapid effects observed with this top-down, environmental policy may further increase its value to policymakers.
PMCID: PMC3845049  PMID: 24282240
13.  Myocardial infarction incidence and survival by ethnic group: Scottish Health and Ethnicity Linkage retrospective cohort study 
BMJ Open  2013;3(9):e003415.
Inequalities in coronary heart disease mortality by country of birth are large and poorly understood. However, these data misclassify UK-born minority ethnic groups and provide little detail on whether excess risk is due to increased incidence, poorer survival or both.
Retrospective cohort study.
General resident population of Scotland.
All those residing in Scotland during the 2001 Census were eligible for inclusion: 2 972 120 people were included in the analysis. The number still residing in Scotland at the end of the study in 2008 is not known.
Primary and secondary outcome measures
As specified in the analysis plan, the primary outcome measures were first occurrence of admission or death due to myocardial infarction and time to event. There were no secondary outcome measures.
Acute myocardial infarction (AMI) incidence risk ratios (95% CIs) relative to white Scottish populations (100) were highest among Pakistani men (164.1 (142.2 to 189.2)) and women (153.7 (120.5, 196.1)) and lowest for men and women of Chinese (39.5 (27.1 to 57.6) and 59.1 (38.6 to 90.7)), other white British (77 (74.2 to 79.8) and 72.2 (69.0 to 75.5)) and other white (83.1 (75.9 to 91.0) and 79.9 (71.5 to 89.3)) ethnic groups. Adjustment for educational qualification did not eliminate these differences. Cardiac intervention uptake was similar across most ethnic groups. Compared to white Scottish, 28-day survival did not differ by ethnicity, except in Pakistanis where it was better, particularly in women (0.44 (0.25 to 0.78)), a difference not removed by adjustment for education, travel time to hospital or cardiac intervention uptake.
Pakistanis have the highest incidence of AMI in Scotland, a country renowned for internationally high cardiovascular disease rates. In contrast, survival is similar or better in minority ethnic groups. Clinical care and policy should focus on reducing incidence among Pakistanis through more aggressive prevention.
PMCID: PMC3773657  PMID: 24038009
Epidemiology; Public Health
14.  Quantifying Policy Options for Reducing Future Coronary Heart Disease Mortality in England: A Modelling Study 
PLoS ONE  2013;8(7):e69935.
To estimate the number of coronary heart disease (CHD) deaths potentially preventable in England in 2020 comparing four risk factor change scenarios.
Methods and Results
Using 2007 as baseline, the IMPACTSEC model was extended to estimate the potential number of CHD deaths preventable in England in 2020 by age, gender and Index of Multiple Deprivation 2007 quintiles given four risk factor change scenarios: (a) assuming recent trends will continue; (b) assuming optimal but feasible levels already achieved elsewhere; (c) an intermediate point, halfway between current and optimal levels; and (d) assuming plateauing or worsening levels, the worst case scenario. These four scenarios were compared to the baseline scenario with both risk factors and CHD mortality rates remaining at 2007 levels. This would result in approximately 97,000 CHD deaths in 2020. Assuming recent trends will continue would avert approximately 22,640 deaths (95% uncertainty interval: 20,390-24,980). There would be some 39,720 (37,120-41,900) fewer deaths in 2020 with optimal risk factor levels and 22,330 fewer (19,850-24,300) in the intermediate scenario. In the worst case scenario, 16,170 additional deaths (13,880-18,420) would occur. If optimal risk factor levels were achieved, the gap in CHD rates between the most and least deprived areas would halve with falls in systolic blood pressure, physical inactivity and total cholesterol providing the largest contributions to mortality gains.
CHD mortality reductions of up to 45%, accompanied by significant reductions in area deprivation mortality disparities, would be possible by implementing optimal preventive policies.
PMCID: PMC3723729  PMID: 23936122
15.  Modelling the impact of specific food policy options on coronary heart disease and stroke deaths in Ireland 
BMJ Open  2013;3(7):e002837.
To estimate the potential reduction in cardiovascular (CVD) mortality possible by decreasing salt, trans fat and saturated fat consumption, and by increasing fruit and vegetable (F/V) consumption in Irish adults aged 25–84 years for 2010.
Modelling study using the validated IMPACT Food Policy Model across two scenarios. Sensitivity analysis was undertaken. First, a conservative scenario: reductions in dietary salt by 1 g/day, trans fat by 0.5% of energy intake, saturated fat by 1% energy intake and increasing F/V intake by 1 portion/day. Second, a more substantial but politically feasible scenario: reductions in dietary salt by 3 g/day, trans fat by 1% of energy intake, saturated fat by 3% of energy intake and increasing F/V intake by 3 portions/day.
Republic of Ireland.
Coronary heart disease (CHD) and stroke deaths prevented.
The small, conservative changes in food policy could result in approximately 395 fewer cardiovascular deaths per year; approximately 190 (minimum 155, maximum 230) fewer CHD deaths in men, 50 (minimum 40, maximum 60) fewer CHD deaths in women, 95 (minimum 75, maximum 115) fewer stroke deaths in men, and 60 (minimum 45, maximum 70) fewer stroke deaths in women. Approximately 28%, 22%, 23% and 26% of the 395 fewer deaths could be attributable to decreased consumptions in trans fat, saturated fat, dietary salt and to increased F/V consumption, respectively. The 395 fewer deaths represent an overall 10% reduction in CVD mortality. Modelling the more substantial but feasible food policy options, we estimated that CVD mortality could be reduced by up to 1070 deaths/year, representing an overall 26% decline in CVD mortality.
A considerable CVD burden is attributable to the excess consumption of saturated fat, trans fat, salt and insufficient fruit and vegetables. There are significant opportunities for Government and industry to reduce CVD mortality through effective, evidence-based food policies.
PMCID: PMC3703570  PMID: 23824313
Modelling; Salt; Saturated Fat; Ireland
16.  Forecasting future prevalence of type 2 diabetes mellitus in Syria 
BMC Public Health  2013;13:507.
Type 2 diabetes mellitus (T2DM) is increasingly becoming a major public health problem worldwide. Estimating the future burden of diabetes is instrumental to guide the public health response to the epidemic. This study aims to project the prevalence of T2DM among adults in Syria over the period 2003–2022 by applying a modelling approach to the country’s own data.
Future prevalence of T2DM in Syria was estimated among adults aged 25 years and older for the period 2003–2022 using the IMPACT Diabetes Model (a discrete-state Markov model).
According to our model, the prevalence of T2DM in Syria is projected to double in the period between 2003 and 2022 (from 10% to 21%). The projected increase in T2DM prevalence is higher in men (148%) than in women (93%). The increase in prevalence of T2DM is expected to be most marked in people younger than 55 years especially the 25–34 years age group.
The future projections of T2DM in Syria put it amongst countries with the highest levels of T2DM worldwide. It is estimated that by 2022 approximately a fifth of the Syrian population aged 25 years and older will have T2DM.
PMCID: PMC3673829  PMID: 23705638
17.  Trends in Total and Low-Density Lipoprotein Cholesterol among U.S. Adults: Contributions of Changes in Dietary Fat Intake and Use of Cholesterol-Lowering Medications 
PLoS ONE  2013;8(5):e65228.
Our aim was to examine the relative contributions of changes in dietary fat intake and use of cholesterol-lowering medications to changes in concentrations of total cholesterol among adults in the United States from 1988–1994 to 2007–2008.
We used data from adults aged 20–74 years who participated in National Health and Nutrition Examination Surveys from 1988–1994 to 2007–2008. The effect of change in dietary fat intake on concentrations of total cholesterol was estimated by the use of equations developed by Keys, Hegsted, and successors.
Age-adjusted mean concentrations of total cholesterol were 5.60 mmol/L (216 mg/dl) during 1988–1994 falling to 5.09 mmol/L (197 mg/dl) in 2007–2008 (P<0.001). No significant changes in the intake of total fat, saturated fat, polyunsaturated fat, and dietary cholesterol were observed from 1988–1994 to 2007–2008. However, the age-adjusted use of cholesterol-lowering medications increased from 1.6% to 12.5% (P<0.001). The various equations suggested that changes in dietary fat made minimal contributions to the observed trend in mean concentrations of total cholesterol. The increased use of cholesterol-lowering medications was estimated to account for approximately 46% of the change.
Mean concentrations of total cholesterol among adults in the United States have declined by ∼4% since 1988–1994. The increased use of cholesterol-lowering medications has apparently accounted for about half of this small fall. Further substantial decreases in cholesterol might be potentially achievable by implementing effective and feasible public health interventions to promote the consumption of a more healthful diet by US adults.
The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
PMCID: PMC3661527  PMID: 23717695
18.  Unequal Trends in Coronary Heart Disease Mortality by Socioeconomic Circumstances, England 1982–2006: An Analytical Study 
PLoS ONE  2013;8(3):e59608.
Coronary heart disease (CHD) remains a major public health burden, causing 80,000 deaths annually in England and Wales, with major inequalities. However, there are no recent analyses of age-specific socioeconomic trends in mortality. We analysed annual trends in inequalities in age-specific CHD mortality rates in small areas in England, grouped into deprivation quintiles.
We calculated CHD mortality rates for 10-year age groups (from 35 to ≥85 years) using three year moving averages between 1982 and 2006. We used Joinpoint regression to identify significant turning points in age- sex- and deprivation-specific time trends. We also analysed trends in absolute and relative inequalities in age-standardised rates between the least and most deprived areas.
Between 1982 and 2006, CHD mortality fell by 62.2% in men and 59.7% in women. Falls were largest for the most deprived areas with the highest initial level of CHD mortality. However, a social gradient in the pace of fall was apparent, being steepest in the least deprived quintile. Thus, while absolute inequalities narrowed over the period, relative inequalities increased. From 2000, declines in mortality rates slowed or levelled off in the youngest groups, notably in women aged 45–54 in the least deprived groups. In contrast, from age 55 years and older, rates of fall in CHD mortality accelerated in the 2000s, likewise falling fastest in the least deprived quintile.
Age-standardised CHD mortality rates have declined substantially in England, with the steepest falls in the most affluent quintiles. However, this concealed contrasting patterns in underlying age-specific rates. From 2000, mortality rates levelled off in the youngest groups but accelerated in middle aged and older groups. Mortality analyses by small areas could provide potentially valuable insights into possible drivers of inequalities, and thus inform future strategies to reduce CHD mortality across all social groups.
PMCID: PMC3603902  PMID: 23527228
19.  Changing patterns of cardiovascular diseases and cancer mortality in Portugal, 1980–2010 
BMC Public Health  2012;12:1126.
Cardiovascular diseases and cancer are jointly responsible for more than half all deaths in Portugal. They also share some important risk factors and act as mutual competing risks. We aimed firstly to describe time trends in death rates and years of life lost due to cardiovascular diseases and cancer in the Portuguese population from 1980 to 2010; and secondly to quantify the contribution of the variation in population and age structure, and age-independent “risk” by cardiovascular or oncological causes to the change in the corresponding number of deaths.
We estimated the annual percent change in age-standardized mortality rates from cardiovascular diseases and cancer, in each sex. The specific contribution of demographic changes (due to changes in population size and in population age structure) and the variation in the age-independent “risk” of dying from the disease to the observed trends in the number of deaths was quantified using the tool RiskDiff. Years of life lost were computed using the Global Burden of Disease method.
Among men, the mortality rate from all cardiovascular diseases was more than two-fold higher than cancer mortality in 1980. However, three decades later mortality from cancer surpassed cardiovascular diseases. After 2005, the years of life lost from cancer were also higher than from cardiovascular diseases. Among women, despite the decrease in death rates, cardiovascular diseases remained the leading cause of death in 2010 and their absolute burden was higher than that of cancers across the whole period, mainly due to more events in older women.
In Portugal, the 20th century witnessed a dramatic decrease in the cardiovascular disease mortality and YLL, and the transition towards cancer. In more recent years, the highest burdens of disease came from cancers in men and from cardiovascular diseases in women.
PMCID: PMC3560231  PMID: 23273040
Cancer; Cardiovascular diseases; Mortality; Trends; Portugal
20.  Explaining the increase in coronary heart disease mortality in Syria between 1996 and 2006 
BMC Public Health  2012;12:754.
Despite advances made in treating coronary heart disease (CHD), mortality due to CHD in Syria has been increasing for the past two decades. This study aims to assess CHD mortality trends in Syria between 1996 and 2006 and to investigate the main factors associated with them.
The IMPACT model was used to analyze CHD mortality trends in Syria based on numbers of CHD patients, utilization of specific treatments, trends in major cardiovascular risk factors in apparently healthy persons and CHD patients. Data sources for the IMPACT model included official statistics, published and unpublished surveys, data from neighboring countries, expert opinions, and randomized trials and meta-analyses.
Between 1996 and 2006, CHD mortality rate in Syria increased by 64%, which translates into 6370 excess CHD deaths in 2006 as compared to the number expected had the 1996 baseline rate held constant. Using the IMPACT model, it was estimated that increases in cardiovascular risk factors could explain approximately 5140 (81%) of the CHD deaths, while some 2145 deaths were prevented or postponed by medical and surgical treatments for CHD.
Most of the recent increase in CHD mortality in Syria is attributable to increases in major cardiovascular risk factors. Treatments for CHD were able to prevent about a quarter of excess CHD deaths, despite suboptimal implementation. These findings stress the importance of population-based primary prevention strategies targeting major risk factors for CHD, as well as policies aimed at improving access and adherence to modern treatments of CHD.
PMCID: PMC3485167  PMID: 22958443
Coronary heart disease; Mortality; Modelling
21.  Analysing falls in coronary heart disease mortality in the West Bank between 1998 and 2009 
BMJ Open  2012;2(4):e001061.
To analyse coronary heart disease (CHD) mortality and risk factor trends in the West Bank, occupied Palestinian territory between 1998 and 2009.
Modelling study using CHD IMPACT model.
The West Bank, occupied Palestinian territory.
Data on populations, mortality, patient groups and numbers, treatments and cardiovascular risk factor trends were obtained from national and local surveys, routine national and WHO statistics, and critically appraised. Data were then integrated and analysed using a previously validated CHD model.
Primary and secondary outcome measures
CHD deaths prevented or postponed are the main outcome.
CHD death rates fell by 20% in the West Bank, between 1998 and 2009. Smoking prevalence was initially high in men, 51%, but decreased to 42%. Population blood pressure levels and total cholesterol levels also decreased. Conversely, body mass index rose by 1–2 kg/m2 and diabetes increased by 2–8%. Population modelling suggested that more than two-thirds of the mortality fall was attributable to decreases in major risk factors, mainly total cholesterol, blood pressure and smoking. Approximately one-third of the CHD mortality decreases were attributable to treatments, particularly for secondary prevention and heart failure. However, the contributions from statins, surgery and angioplasty were consistently small.
CHD mortality fell by 20% between 1998 and 2009 in the West Bank. More than two-third of this fall was due to decreases in major risk factors, particularly total cholesterol and blood pressure. Our results clearly indicate that risk factor reductions in the general population compared save substantially more lives to specific treatments for individual patients. This emphasizes the importance of population-wide primary prevention strategies.
PMCID: PMC3432845  PMID: 22923626
Cardiology; Cardiac Epidemiology; Cardiology; Myocardial infarction; Epidemiology; Public Health; Surgery; Cardiac surgery
22.  Neighbourhood socioeconomic inequalities in incidence of acute myocardial infarction: a cohort study quantifying age- and gender-specific differences in relative and absolute terms 
BMC Public Health  2012;12:617.
Socioeconomic status has a profound effect on the risk of having a first acute myocardial infarction (AMI). Information on socioeconomic inequalities in AMI incidence across age- gender-groups is lacking. Our objective was to examine socioeconomic inequalities in the incidence of AMI considering both relative and absolute measures of risk differences, with a particular focus on age and gender.
We identified all patients with a first AMI from 1997 to 2007 through linked hospital discharge and death records covering the Dutch population. Relative risks (RR) of AMI incidence were estimated by mean equivalent household income at neighbourhood-level for strata of age and gender using Poisson regression models. Socioeconomic inequalities were also shown within the stratified age-gender groups by calculating the total number of events attributable to socioeconomic disadvantage.
Between 1997 and 2007, 317,564 people had a first AMI. When comparing the most deprived socioeconomic quintile with the most affluent quintile, the overall RR for AMI was 1.34 (95 % confidence interval (CI): 1.32 – 1.36) in men and 1.44 (95 % CI: 1.42 – 1.47) in women. The socioeconomic gradient decreased with age. Relative socioeconomic inequalities were most apparent in men under 35 years and in women under 65 years. The largest number of events attributable to socioeconomic inequalities was found in men aged 45–74 years and in women aged 65–84 years. The total proportion of AMIs that was attributable to socioeconomic inequalities in the Dutch population of 1997 to 2007 was 14 % in men and 18 % in women.
Neighbourhood socioeconomic inequalities were observed in AMI incidence in the Netherlands, but the magnitude across age-gender groups depended on whether inequality was expressed in relative or absolute terms. Relative socioeconomic inequalities were high in young persons and women, where the absolute burden of AMI was low. Absolute socioeconomic inequalities in AMI were highest in the age-gender groups of middle-aged men and elderly women, where the number of cases was largest.
PMCID: PMC3490806  PMID: 22870916
Coronary heart disease; Acute myocardial infarction; Incidence; Socioeconomic status; Relative; Absolute; The Netherlands
23.  Analysing Recent Socioeconomic Trends in Coronary Heart Disease Mortality in England, 2000–2007: A Population Modelling Study 
PLoS Medicine  2012;9(6):e1001237.
A modeling study conducted by Madhavi Bajekal and colleagues estimates the extent to which specific risk factors and changes in uptake of treatment contributed to the declines in coronary heart disease mortality in England between 2000 and 2007, across and within socioeconomic groups.
Coronary heart disease (CHD) mortality in England fell by approximately 6% every year between 2000 and 2007. However, rates fell differentially between social groups with inequalities actually widening. We sought to describe the extent to which this reduction in CHD mortality was attributable to changes in either levels of risk factors or treatment uptake, both across and within socioeconomic groups.
Methods and Findings
A widely used and replicated epidemiological model was used to synthesise estimates stratified by age, gender, and area deprivation quintiles for the English population aged 25 and older between 2000 and 2007. Mortality rates fell, with approximately 38,000 fewer CHD deaths in 2007. The model explained about 86% (95% uncertainty interval: 65%–107%) of this mortality fall. Decreases in major cardiovascular risk factors contributed approximately 34% (21%–47%) to the overall decline in CHD mortality: ranging from about 44% (31%–61%) in the most deprived to 29% (16%–42%) in the most affluent quintile. The biggest contribution came from a substantial fall in systolic blood pressure in the population not on hypertension medication (29%; 18%–40%); more so in deprived (37%) than in affluent (25%) areas. Other risk factor contributions were relatively modest across all social groups: total cholesterol (6%), smoking (3%), and physical activity (2%). Furthermore, these benefits were partly negated by mortality increases attributable to rises in body mass index and diabetes (−9%; −17% to −3%), particularly in more deprived quintiles. Treatments accounted for approximately 52% (40%–70%) of the mortality decline, equitably distributed across all social groups. Lipid reduction (14%), chronic angina treatment (13%), and secondary prevention (11%) made the largest medical contributions.
The model suggests that approximately half the recent CHD mortality fall in England was attributable to improved treatment uptake. This benefit occurred evenly across all social groups. However, opposing trends in major risk factors meant that their net contribution amounted to just over a third of the CHD deaths averted; these also varied substantially by socioeconomic group. Powerful and equitable evidence-based population-wide policy interventions exist; these should now be urgently implemented to effectively tackle persistent inequalities.
Please see later in the article for the Editors' Summary
Editors' Summary
Coronary heart disease is a chronic medical condition in which the blood vessels supplying the heart muscle become narrowed or even blocked by fatty deposits on the inner linings of the blood vessels—a process known as arthrosclerosis; this restricts blood flow to the heart, and if the blood vessels completely occlude, it may cause a heart attack. Lifestyle behaviors, such as unhealthy diets high in saturated fat, smoking, and physical inactivity, are the main risk factors for coronary heart disease, so efforts to reduce this condition are directed towards these factors. Global rates of coronary heart disease are increasing and the World Health Organization estimates that by 2030, it will be the biggest cause of death worldwide. However, in high-income countries, such as England, deaths due to coronary heart disease have actually fallen substantially over the past few decades with an accelerated reduction in annual death rates since 2000.
Why Was This Study Done?
Socioeconomic factors play an important role in chronic diseases such as coronary heart disease, with mortality rates almost twice as high in deprived than affluent areas. However, the potential effect of population-wide interventions on reducing inequalities in deaths from coronary heart disease remains unclear. So in this study, the researchers investigated the role of behavioral (changing lifestyle) and medical (treatments) management of coronary heart disease that contributed to the decrease in deaths in England for the period 2000–2007, within and between socioeconomic groups.
What Did the Researchers Do and Find?
The researchers used a well-known, tried and tested epidemiological model (IMPACT) but adapted it to include socioeconomic inequalities to analyze the total population of England aged 25 and older in 2000 and in 2007. The researchers included all the major risk factors for coronary heart disease plus 45 current medical and surgical treatments in their model. They used the Index of Multiple Deprivation 2007 as a proxy indicator of socioeconomic circumstances of residents in neighborhoods. Using the postal code of residence, the researchers matched deaths from, and patients treated for, coronary heart disease to the corresponding deprivation category (quintile). Changes in risk factor levels in each quintile were also calculated using the Health Survey for England. Using their model, the researchers calculated the total number of deaths prevented or postponed for each deprivation quintile by measuring the difference between observed deaths in 2007 and expected deaths based on 2000 data, if age, sex, and deprivation quintile death rates had remained the same.
The researchers found that between 2000 and 2007, death rates from coronary heart disease fell from 229 to 147 deaths per 100,000—a decrease of 36%. Both death rates and the number of deaths were lowest in the most affluent quintile and the pace of fall was also faster, decreasing by 6.7% per year compared to just 4.9% in the most deprived quintile. Furthermore, the researchers found that overall, about half of the decrease in death rates was attributable to improvements in uptake of medical and surgical treatments. The contribution of medical treatments to the deaths averted was very similar across all quintiles, ranging from 50% in the most affluent quintile to 53% in the most deprived. Risk factor changes accounted for approximately a third fewer deaths in 2007 than occurred in 2000, but were responsible for a smaller proportion of deaths prevented in the most affluent quintile compared with the most deprived (approximately 29% versus 44%, respectively). However, the benefits of improvements in blood pressure, cholesterol, smoking, and physical activity were partly negated by rises in body mass index and diabetes, particularly in more deprived quintiles.
What Do These Findings Mean?
These findings suggest that approximately half the recent substantial fall in deaths from coronary heart disease in England was attributable to improved treatment uptake across all social groups; this is consistent with equitable service delivery across the UK's National Health Service. However, opposing trends in major risk factors, which varied substantially by socioeconomic group, meant that their net contribution accounted for just a third of deaths averted. Other countries have implemented effective, evidence-based interventions to tackle lifestyle risk factors; the most powerful measures involve legislation, regulation, taxation, or subsidies, all of which tend to be equitable. Such measures should be urgently implemented in England to effectively tackle persistent inequalities in deaths due to coronary heart disease.
Additional Information
Please access these Web sites via the online version of this summary at
The World Health Organization has information about the global statistics of coronary heart disease
The National Heart Lung and Blood Institute provides a patient-friendly description of coronary heart disease
The National Heart Forum is the leading UK organization facilitating the prevention of coronary heart disease and other chronic diseases
The British Heart Foundation supports research and promotes preventative activity
Heart of Mersey is the UK's largest regional organization promoting the prevention of coronary heart disease and other chronic diseases
More information about the social determinants of health is available from WHO
PMCID: PMC3373639  PMID: 22719232
24.  Trends in cardiovascular disease biomarkers and their socioeconomic patterning among adults in the Scottish population 1995 to 2009: cross-sectional surveys 
BMJ Open  2012;2(3):e000771.
To examine secular and socioeconomic changes in biological cardiovascular disease risk factor and biomarker prevalences in the Scottish population. This could contribute to an understanding of why the decline in coronary heart disease mortality in Scotland has recently stalled along with persistence of associated socioeconomic inequalities.
Cross-sectional surveys.
Scottish Health Surveys: 1995, 1998, 2003, 2008 and 2009 (6190, 6656, 5497, 4202 and 4964 respondents, respectively, aged 25–64 years).
Primary outcome measures
Gender-stratified, age-standardised prevalences of obesity, hypertension, hypercholesterolaemia and low high-density lipoprotein cholesterol blood concentration as well as elevated fibrinogen and C reactive protein concentrations according to education and social class groupings. Inequalities were assessed using the slope index of inequality, and time trends were assessed using linear regression.
The prevalence of obesity, including central obesity, increased between 1995 and 2009 among men and women, irrespective of socioeconomic position. In 2009, the prevalence of obesity (defined by body mass index) was 29.8% (95% CI 27.9% to 31.7%) for men and 28.2% (26.3% to 30.2%) for women. The proportion of individuals with hypertension remained relatively unchanged between 1995 and 2008/2009, while the prevalence of hypercholesterolaemia declined in men from 79.6% (78.1% to 81.1%) to 63.8% (59.9% to 67.8%) and in women from 74.1% (72.6% to 75.7%) to 66.3% (62.6% to 70.0%). Socioeconomic inequalities persisted over time among men and women for most of the biomarkers and were particularly striking for the anthropometric measures when stratified by education.
If there are to be further declines in coronary heart disease mortality and reduction in associated inequalities, then there needs to be a favourable step change in the prevalence of cardiovascular disease risk factors. This may require radical population-wide interventions.
Article summary
Article focus
In Scotland, as in other developed countries, coronary heart disease mortality has substantially declined over time.
This decline may have slowed among younger ages and there are still large socioeconomic inequalities in mortality.
Examination of the secular and socioeconomic changes in biological cardiovascular disease risk factor and biomarker prevalences in the Scottish population.
Key messages
In Scotland, over a 14-year period since 1995, there has been a substantial increase in the prevalence of obesity with a persistence of large inequalities.
At the same time, the prevalence of hypertension has changed little, while that of hypercholesterolaemia has declined, albeit from a very high level. Inequalities were generally smaller and, in the case of cholesterol in men, ill defined.
Such trends can only serve to curb any further declines in coronary heart disease mortality and maintain associated inequalities.
Strengths and limitations of this study
This study utilised data from nationally representative surveys conducted over a 14-year period.
Bias may have been introduced by declining survey response levels. Differential non-response by the socioeconomically disadvantaged may lead to an underestimation of the magnitude of inequalities.
PMCID: PMC3364451  PMID: 22619264
25.  Associations between deprivation and rates of childhood overweight and obesity in England, 2007–2010: an ecological study 
BMJ Open  2012;2(2):e000463.
To investigate the associations between deprivation and rates of childhood overweight and obesity in England, from 2007 to 2010.
An ecological study using routine data from the National Child Measurement Programme and Indices of Multiple Deprivation (IMD) 2010 scores.
Local authority districts in England.
Schoolchildren in Reception year (age 4–5 years) and Year 6 (age 10–11 years) attending non-specialist maintained state schools in England.
Primary and secondary outcome measures
Prevalence of overweight in both Reception and Year 6, prevalence of obesity in both Reception and Year 6 and IMD 2010 scores for each local authority.
In 2009–2010, local authority IMD 2010 scores were strongly correlated with obesity rates among schoolchildren in Reception (r=0.625, p<0.001) and Year 6 (r=0.733, p<0.001). There were no statistically significant changes in association between obesity in Reception or Year 6 and IMD from 2007–2008 to 2009–2010. In contrast, the prevalence of overweight was not statistically significantly correlated with local authority IMD scores in Reception (r=0.095, p=0.092) and only weakly correlated in Year 6 (r=0.184, p=0.001). There were no statistically significant changes in association between overweight in Reception or Year 6 and IMD from 2007–2008 to 2009–2010.
Childhood obesity rates in England are strongly associated with deprivation. Given the enormous public health implications of overweight and obesity in the population, these findings suggest that significant effort is required to tackle unhealthy weight in children in all local authorities and that this should be a priority in areas with high levels of deprivation.
Article summary
Article focus
Associations between local authority 2010 IMD scores and prevalence of overweight and obesity in Reception (age 4–5 years) and Year 6 (age 10–11 years) schoolchildren, 2007–2010.
Key messages
At local authority level, there is a substantial association between obesity prevalence in Reception year and Year 6 and the IMD 2010.
The associations between childhood overweight and obesity prevalence and IMD 2010 have not changed significantly from 2007 to 2010.
Primary healthcare professionals have a key role to play in delivering childhood obesity prevention messages to new parents, as part of a broad strategy to address childhood obesity.
Strengths and limitations of this study
Participation bias is likely to have resulted in some underestimation of Year 6 obesity rates for 2007–2008 and 2008–2009.
The IMD have some limitations but provide the best available means of comparing area deprivation in England.
Changes were made to local authority boundaries in 2009; however, the sensitivity analysis demonstrated that this had no meaningful impact on the results.
The strength of this study in comparison with previous analyses of the National Child Measurement Programme data is in using a more up-to-date measure of deprivation to quantify the association between local authority deprivation and childhood overweight and obesity.
PMCID: PMC3329605  PMID: 22505306

Results 1-25 (63)