Objectives

Consumption of red and processed meat (RPM) is a leading contributor to greenhouse gas (GHG) emissions, and high intakes of these foods increase the risks of several leading chronic diseases. The aim of this study was to use newly derived estimates of habitual meat intakes in UK adults to assess potential co-benefits to health and the environment from reduced RPM consumption.

Design

Modelling study using dietary intake data from the National Diet and Nutrition Survey of British Adults.

Setting

British general population.

Methods

Respondents were divided into fifths by energy-adjusted RPM intakes, with vegetarians constituting a sixth stratum. GHG emitted in supplying the diets of each stratum was estimated using data from life-cycle analyses. A feasible counterfactual UK population was specified, in which the proportion of vegetarians measured in the survey population doubled, and the remainder adopted the dietary pattern of the lowest fifth of RPM consumers.

Outcome measures

Reductions in risks of coronary heart disease, diabetes and colorectal cancer, and GHG emissions, under the counterfactual.

Results

Habitual RPM intakes were 2.5 times higher in the top compared with the bottom fifth of consumers. Under the counterfactual, statistically significant reductions in population aggregate risks ranged from 3.2% (95% CI 1.9 to 4.7) for diabetes in women to 12.2% (6.4 to 18.0) for colorectal cancer in men, with those moving from the highest to lowest consumption levels gaining about twice these averages. The expected reduction in GHG emissions was 0.45 tonnes CO2 equivalent/person/year, about 3% of the current total, giving a reduction across the UK population of 27.8 million tonnes/year.

Conclusions

Reduced consumption of RPM would bring multiple benefits to health and environment.

Article summary

Article focus

Consumption of RPM is a leading contributor to GHG emissions.

High intakes of RPMs increase the risks of several leading chronic diseases.

This research identifies a low RPM dietary pattern that is already followed by a substantial fraction of the UK population and estimates health and environmental benefits that would result from its general adoption.

Key messages

Habitual RPM intakes are 2.5 times higher in the top compared with the bottom fifth of the UK consumers.

Sustained dietary intakes at a counterfactual reduced level in the UK population would materially reduce incidence of coronary heart disease, diabetes mellitus and colorectal cancer, by 3%–12%.

The predicted reduction in UK food- and drink-associated GHG emissions would equate to almost 28 million tonnes of CO2 equivalent/year across the population.

Strengths and limitations of this study

This research uses a food-based approach, taking intake-risk associations from meta-analyses rather than assuming the mechanisms by which the foods influence disease risk.

The dietary data were collected a decade ago; however, the headline results from a more recent national dietary survey reveal that intakes of all meat categories were broadly similar, although slightly higher in 2008/2009 than in 2000/2001.

Background

There is a major gradient in burden of disease between Central and Eastern Europe compared to Western Europe. Many of the underlying causes and risk factors are amenable to public health interventions. The purpose of the study was to explore perceptions of public health experts from Central and Eastern European countries on public health challenges in their countries.

Methods

We invited 179 public health experts from Central and Eastern European countries to a 2-day workshop in Berlin, Germany. A total of 25 public health experts from 14 countries participated in May 2008. The workshop was structured into 8 sessions of 1.5 hours each, with the topic areas covering coronary heart disease, stroke, prevention, obesity, alcohol, tobacco, tuberculosis, and HIV/AIDS. The workshop was recorded and the proceedings transcribed verbatim. The transcripts were entered into atlas.ti for content analysis and coded according to the session headings. After analysis of the content of each session discussion, a re-coding of the discussions took place based on the themes that emerged from the analysis.

Results

Themes discussed recurred across disease entities and sessions. Major themes were the relationship between clinical medicine and public health, the need for public health funding, and the problems of proving the effectiveness of disease prevention. Areas for action identified included the need to engage with the public, to create a better scientific basis for public health interventions, to identify “best practices” of disease prevention, and to implement registries/surveillance instruments. The need for improved data collection was seen throughout all areas discussed, as was the need to harmonize data across countries.

Conclusions

To reduce the burden of disease across Europe, closer collaboration of countries across Europe seems important in order to learn from each other. A more credible scientific basis for effective public health interventions is urgently needed. The monitoring of health trends is crucial to evaluate the impact of public health programmes.

Introduction

Trachoma is a disease that can lead to visual impairment and ultimately blindness. Previous estimates of health losses from trachoma using the Global Burden of Disease methodology have not, however, included the stage prior to visual impairment. We estimated the burden of all stages of trachoma in South Sudan and assessed the uncertainty associated with the severity and duration of stages of trachoma prior to full blindness.

Methods

The prevalence of trachoma with normal vision, low vision and blindness in the Republic of South Sudan has been estimated previously. These estimates were used to model the incidence and duration of the different stages employing DISMOD II. Different assumptions about disability weights and duration were used to estimate the Years Lived with Disability (YLD).

Results

We have estimated the total burden of trachoma in South Sudan to be between 136,562 and 163,695 YLD and trichiasis with normal vision contributes between 5% and 21% of the total depending on the disability weight applied. Women experience more of this burden than men. The sensitivity of the results to different assumptions about the disability weights is partly dependent upon the assumed duration of the different disease states.

Interpretation

A better understanding of the natural history of trachoma is critical for a more accurate burden estimate.

Author Summary

Trachoma is an infectious disease that is endemic to the Republic of South Sudan. In the absence of appropriate treatment recurrent re-infection in an individual will lead to progressively severe states of trachoma, eventually leading to the loss of visual acuity and finally blindness. Here we distinguish between three separate states of disease: trachoma with normal vision, trachoma with low vision and trachoma with blindness. The first of these states, trachoma with normal vision, is the least severe and the impact of this state on a population has not been well investigated. Trachoma, even before any loss of vision, comes with a great deal of pain and social consequences, and thus disability. In this study we employ data from South Sudan and estimate the burden caused by trachoma with normal vision for the first time. In doing so, we also reveal the extent of the gaps in our knowledge surrounding the natural history of trachoma and highlight areas of research that require urgent attention.

Background

Reasons for the widespread declines in coronary heart disease (CHD) mortality in high income countries are controversial. Here we explore how the type of metric chosen for the analyses of these declines affects the answer obtained.

Methods

The analyses we reviewed were performed using IMPACT, a large Excel based model of the determinants of temporal change in mortality from CHD. Assessments of the decline in CHD mortality in the USA between 1980 and 2000 served as the central case study.

Results

Analyses based in the metric of number of deaths prevented attributed about half the decline to treatments (including preventive medications) and half to favourable shifts in risk factors. However, when mortality change was expressed in the metric of life-years-gained, the share attributed to risk factor change rose to 65%. This happened because risk factor changes were modelled as slowing disease progression, such that the hypothetical deaths averted resulted in longer average remaining lifetimes gained than the deaths averted by better treatments. This result was robust to a range of plausible assumptions on the relative effect sizes of changes in treatments and risk factors.

Conclusions

Time-based metrics (such as life years) are generally preferable because they direct attention to the changes in the natural history of disease that are produced by changes in key health determinants. The life-years attached to each death averted will also weight deaths in a way that better reflects social preferences.

Background

We assessed the metrics used in claims about disease importance made in the introductory sections of scientific papers published in 1993 and 2003. We were interested in the choice of metric in circumstances where establishing the relative social importance of a disease was, presumptively, a primary objective.

Methods

This study consisted of a textual examination of the introductory statements from papers retrieved from MEDLINE. Papers were published in the New England Journal of Medicine, The Lancet, and the Journal of the American Medical Association during the first halves of 1993 and 2003, and were selected on the basis of keywords found in a pilot study to be associated with claims about disease importance.

Results

We found 143 papers in 1993 and 264 papers in 2003 included claims about disease importance in their introductory sections, and characteristics of these claims were abstracted. Of the quotes identified in the papers and articles examined, most used counts, prevalence, or incidence measurements. Some also used risk estimates and economic quantities to convey the importance of the disease. There was no change in the types of metrics used between 1993 and 2003. Very few articles, even in 2003, used metrics that weighted disease onsets by the expected consequent loss of healthy time -- such as years of life lost, quality-adjusted life years, and/or disability-adjusted life years.

Conclusions

Claims about the relative importance of diseases continued to be overwhelmingly expressed in terms of counts (of deaths and disease onsets) and comparisons of counts, rates, and risks. Where the aim is to convey the burden that a given disease imposes on a society, "event-based" metrics might be less fit for the purpose than "time-based" metrics. More attention is needed to how the choice of metric should relate to the purpose at hand.

Objective

To assess the contribution of smoking to the inverse association of mortality with years of formal education in men in Australia.

Design

Data were obtained from a prospective cohort study that included 17 049 men in Melbourne recruited from 1990 to 1994, most of whom were aged between 40 and 69 years at baseline. The outcome measured was all‐cause mortality. The contribution of smoking to socioeconomic status differentials was estimated by including smoking as a variable in a Cox's proportional hazards model that also included education and other potential confounding variables.

Results

In men, the association between education and mortality was attenuated after adjustment for smoking, and the aetiological fraction for low levels of education was reduced from 16.5% to 10.6%.

Conclusions

In men, smoking contributes substantially to socioeconomic differentials in mortality. Effective policies and interventions that target smoking among socially disadvantaged groups may substantially reduce socioeconomic differentials in health.

Background

Our aim was to estimate the burden of fatal disease attributable to excess adiposity in England and Wales in 2003 and 2015 and to explore the sensitivity of the estimates to the assumptions and methods used.

Methods

A spreadsheet implementation of the World Health Organization's (WHO) Comparative Risk Assessment (CRA) methodology for continuously distributed exposures was used. For our base case, adiposity-related risks were assumed to be minimal with a mean (SD) BMI of 21 (1) Kg m-2. All cause mortality risks for 2015 were taken from the Government Actuary and alternative compositions by cause derived. Disease-specific relative risks by BMI were taken from the CRA project and varied in sensitivity analyses.

Results

Under base case methods and assumptions for 2003, approximately 41,000 deaths and a loss of 1.05 years of life expectancy were attributed to excess adiposity. Seventy-seven percent of all diabetic deaths, 23% of all ischaemic heart disease deaths and 14% of all cerebrovascular disease deaths were attributed to excess adiposity. Predictions for 2015 were found to be more sensitive to assumptions about the future course of mortality risks for diabetes than to variation in the assumed trend in BMI. On less favourable assumptions the attributable loss of life expectancy in 2015 would rise modestly to 1.28 years.

Conclusion

Excess adiposity appears to contribute materially but modestly to mortality risks in England and Wales and this contribution is likely to increase in the future. Uncertainty centres on future trends of associated diseases, especially diabetes. The robustness of these estimates is limited by the lack of control for correlated risks by stratification and by the empirical uncertainty surrounding the effects of prolonged excess adiposity beginning in adolescence.

Background

How advances in knowledge lead via behaviour change to better health is not well understood. Here we report two case studies: a rapid reduction in HIV transmission in homosexual men and a decline in Sudden Infant Death Syndrome (SIDS) that took place in the period before the relevant national education programmes commenced, respectively, in 1986 and 1991. The role of newspapers in transferring knowledge relevant to reducing the risk of AIDS and SIDS is assessed.

Methods

HIV

Searches were made of The Times (1981–1985), Gay News (1981–1984) and, for the key period of April to June 1983, of eight newspapers with the highest readership. Information on transmission route and educational messages were abstracted and analysed.

SIDS

Searches were made of The Times and the Guardian (1985–1991), The Sun (selected periods only, 1988–1991) and selected nursing journals published in England and Wales. Information on sleeping position and educational messages were abstracted and analysed.

Results

HIV

Forty-five out of 50 articles identified in newspapers described homosexuals as an at risk group. Sexual transmission of AIDS was, however, covered poorly, with only 7 (14%) articles referring explicitly to sexual transmission. Only seven articles (14%) associated risk with promiscuity. None of the articles were specific about changes in behaviour that could be expected to reduce risk. Gay periodicals did not include specific advice on reducing the number of partners until early 1984.

SIDS

Out of 165 relevant articles in The Times and 84 in the Guardian, 7 were published before 1991 and associated risk with sleeping position. The reviewed nursing journals reflected a pervasive sense of uncertainty about the link between SIDS and sleeping position.

Conclusion

Presumptively receptive audiences responded rapidly to new knowledge on how changes in personal behaviour might reduce risk, even though the 'signals' were not strong and were transmitted, at least partly, through informal and 'horizontal' channels. Advances in knowledge with the potential to prevent disease by behaviour change may thus yield substantial health benefits even without the mediation of formal education campaigns ('interventions'). Formal campaigns, when they came, did make important additional contributions, especially in the case of SIDS.

Background

Primary Percutaneous Coronary Intervention (PCI) is more efficacious than thrombolysis in the management of acute myocardial infarction, but, because of the requirement for prompt treatment, there are practical challenges in developing such services. We examined the proportion of patients with ST segment Elevation Myocardial Infarction (STEMI) who could receive timely treatment from a primary Percutaneous Coronary Intervention (PCI) service assuming different geographical locations of potential treatment centres in three English counties.

Methods and results

Information on the residential location of patients with new STEMI hospitalisations recorded in Hospital Episodes Statistics was analysed and the proportion of episodes of STEMI within 60' and 45' travel time isochrones from potential primary PCI centres in three English counties was calculated. There were on average 1,815 new STEMI hospitalisations per year occurring in the studied population. Introduction of a primary PCI service in one, two or three potential treatment centres would have covered respectively 28%, 73% and 90% of such episodes within 60 minutes travel time, and 17%, 51% and 69% within 45 minutes travel time.

Conclusion

In the study context, a primary PCI service in an existing tertiary centre would only cover a minority of STEMI events and would generate geographical inequities. A two-centre model would improve coverage and equity considerably, but may be associated with practical, clinical quality and financial challenges.

Background

The East/West gradient in health across Europe has been described often, but not using metrics as comprehensive and comparable as those of the Global Burden of Disease 2000 and Comparative Risk Assessment studies.

Methods

Comparisons are made across 3 epidemiological subregions of the WHO region for Europe – A (very low child and adult mortality), B (low child and low adult mortality) and C (low child and high adult mortality) – with populations in 2000 of 412, 218 and 243 millions respectively, and using the following measures: 1. Probabilities of death by sex and causal group across 7 age intervals; 2. Loss of healthy life (DALYs) to diseases and injuries per thousand population; 3. Loss of healthy life (DALYs) attributable to selected risk factors across 3 age ranges.

Results

Absolute differences in mortality are most marked in males and in younger adults, and for deaths from vascular diseases and from injuries. Dominant contributions to east-west differences come from the nutritional/physiological group of risk factors (blood pressure, cholesterol concentration, body mass index, low fruit and vegetable consumption and inactivity) contributing to vascular disease and from the legal drugs – tobacco and alcohol.

Conclusion

The main requirements for reducing excess health losses in the east of Europe are: 1) favorable shifts in all amenable vascular risk factors (irrespective of their current levels) by population-wide and personal measures; 2) intensified tobacco control; 3) reduced alcohol consumption and injury control strategies (for example, for road traffic injuries). Cost effective strategies are broadly known but local institutional support for them needs strengthening.

Background

Bulgaria's official stroke mortality rates are higher for rural than urban areas. Official mortality data has indicated that these rates are amongst the highest in Europe. There has been a lack of studies measuring stroke incidence in urban and rural populations.

Methods

We established intensive notification networks covering 37791 residents in Varna city and 18656 residents (55% of them village-dwellers), all aged 45 to 84, in 2 rural districts. From May 1, 2000 to April 30, 2001 frequent contact was maintained with notifiers and death registrations were scanned regularly. Suspected incident strokes were assessed by study neurologists within a median of 8 days from onset.

Results

742 events were referred for neurological assessment and 351 of these, which met the WHO criteria for stroke, were in persons aged 45 to 84 and were first ever in a lifetime. Incidence rates, standardised using the world standard weights for ages 45 to 84, were 909 (/100000/year) (95% CI 712–1105) and 597 (482–712) for rural and urban males and 667 (515–818) and 322 (248–395) for rural and urban females. Less than half were admitted to hospital (15% among rural females over 65). Twenty-eight day case fatality was 35% (123/351) overall and 48% (46/96) in village residents. The excess case fatality in the villages could not be explained by age or severity.

Conclusions

Rural incidence rates were over twice those reported for western populations but the rate for urban females was similar to other western rates. The high level and marked heterogeneity in both stroke incidence and case fatality merit further investigation.

Objective: To investigate the reasons for the decline in deaths attributed to ischaemic heart disease in Poland since 1991 after two decades of rising rates.

Design: Recent changes in mortality were measured as percentage deviations in 1994 from rates predicted by extrapolation of sex and age specific death rates for 1980-91 for diseases of the circulatory system and selected other categories. Available data on national and household food availability, alcohol consumption, cigarette smoking, socioeconomic indices, and medical services over time were reviewed.

Main outcome measures: Age specific and age standardised rates of death attributed to ischaemic heart disease and related causes.

Results: The change in trend in mortality attributed to diseases of the circulatory system was similar in men and women and most marked (>20%) in early middle age. For ages 45 to 64 the decrease was greatest for deaths attributed to ischaemic heart disease and atherosclerosis (around 25%) and less for stroke (<10%). For most of the potentially explanatory variables considered, there were no corresponding changes in trend. However, between 1986-90 and 1994 there was a marked switch from animal fats (estimated availability down 23%) to vegetable fats (up 48%) and increased imports of fruit.

Conclusion: Reporting biases are unlikely to have exaggerated the true fall in ischaemic heart disease; neither is it likely to be mainly due to changes in smoking, drinking, stress, or medical care. Changes in type of dietary fat and increased supplies of fresh fruit and vegetables seem to be the best candidates.

Key messages Among former socialist countries Poland has undergone unusually rapid social and economic changes since 1988-9, including aspects of diet Mortality from heart disease declined sharply during 1991-4 after long term increases; mortality from stroke declined less strongly This study investigated what has changed in Poland to reduce the risks of fatal events in people with established ischaemic heart disease Candidate dietary explanations were the substitution of unsaturated for saturated fats and increased consumption of fresh fruit and vegetables