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1.  Preventing type 2 diabetes among Palestinians: comparing five future policy scenarios 
BMJ Open  2013;3(12):e003558.
Objective
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.
Design
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.
Setting
West Bank oPt.
Results
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%.
Conclusions
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.
doi:10.1136/bmjopen-2013-003558
PMCID: PMC3884589  PMID: 24362011
2.  Reduction in myocardial infarction admissions in Liverpool after the smoking ban: potential socioeconomic implications for policymaking 
BMJ Open  2013;3(11):e003307.
Objectives
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.
Participants
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.
Results
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%).
Conclusions
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.
doi:10.1136/bmjopen-2013-003307
PMCID: PMC3845049  PMID: 24282240
PUBLIC HEALTH; EPIDEMIOLOGY
3.  Myocardial infarction incidence and survival by ethnic group: Scottish Health and Ethnicity Linkage retrospective cohort study 
BMJ Open  2013;3(9):e003415.
Objective
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.
Design
Retrospective cohort study.
Setting
General resident population of Scotland.
Participants
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.
Results
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.
Conclusions
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.
doi:10.1136/bmjopen-2013-003415
PMCID: PMC3773657  PMID: 24038009
Epidemiology; Public Health
4.  Modelling the impact of specific food policy options on coronary heart disease and stroke deaths in Ireland 
BMJ Open  2013;3(7):e002837.
Objective
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.
Design
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.
Setting
Republic of Ireland.
Outcomes
Coronary heart disease (CHD) and stroke deaths prevented.
Results
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.
Conclusions
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.
doi:10.1136/bmjopen-2013-002837
PMCID: PMC3703570  PMID: 23824313
Modelling; Salt; Saturated Fat; Ireland
5.  Analysing falls in coronary heart disease mortality in the West Bank between 1998 and 2009 
BMJ Open  2012;2(4):e001061.
Objectives
To analyse coronary heart disease (CHD) mortality and risk factor trends in the West Bank, occupied Palestinian territory between 1998 and 2009.
Design
Modelling study using CHD IMPACT model.
Setting
The West Bank, occupied Palestinian territory.
Participants
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.
Results
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.
Conclusions
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.
doi:10.1136/bmjopen-2012-001061
PMCID: PMC3432845  PMID: 22923626
Cardiology; Cardiac Epidemiology; Cardiology; Myocardial infarction; Epidemiology; Public Health; Surgery; Cardiac surgery
6.  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.
Objectives
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.
Design
Cross-sectional surveys.
Setting
Scotland.
Participants
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.
Results
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.
Conclusions
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.
doi:10.1136/bmjopen-2011-000771
PMCID: PMC3364451  PMID: 22619264
7.  Associations between deprivation and rates of childhood overweight and obesity in England, 2007–2010: an ecological study 
BMJ Open  2012;2(2):e000463.
Objectives
To investigate the associations between deprivation and rates of childhood overweight and obesity in England, from 2007 to 2010.
Design
An ecological study using routine data from the National Child Measurement Programme and Indices of Multiple Deprivation (IMD) 2010 scores.
Setting
Local authority districts in England.
Participants
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.
Results
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.
Conclusions
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.
doi:10.1136/bmjopen-2011-000463
PMCID: PMC3329605  PMID: 22505306
8.  Trends in adult cardiovascular disease risk factors and their socio-economic patterning in the Scottish population 1995–2008: cross-sectional surveys 
BMJ Open  2011;1(1):e000176.
Objectives
To examine secular and socio-economic changes in cardiovascular disease risk factor prevalences in the Scottish population. This could contribute to a better understanding of why the decline in coronary heart disease mortality in Scotland has recently stalled along with a widening of socio-economic inequalities.
Design
Four Scottish Health Surveys 1995, 1998, 2003 and 2008 (6190, 6656, 5497 and 4202 respondents, respectively, aged 25–64 years) were used to examine gender-stratified, age-standardised prevalences of smoking, alcohol consumption, physical activity, fruit and vegetable consumption, discretionary salt use and self-reported diabetes or hypertension. Prevalences were determined according to education and social class. Inequalities were assessed using the slope index of inequality, and time trends were determined using linear regression.
Results
There were moderate secular declines in the prevalence of smoking, excess alcohol consumption and physical inactivity. Smoking prevalence declined between 1995 and 2008 from 33.4% (95% CI 31.8% to 35.0%) to 29.9% (27.9% to 31.8%) for men and from 36.1% (34.5% to 37.8%) to 27.4% (25.5% to 29.3%) for women. Adverse trends in prevalence were noted for self-reported diabetes and hypertension. Over the four surveys, the diabetes prevalence increased from 1.9% (1.4% to 2.4%) to 3.6% (2.8% to 4.4%) for men and from 1.7% (1.2% to 2.1%) to 3.0% (2.3% to 3.7%) for women. Socio-economic inequalities were evident for almost all risk factors, irrespective of the measure used. These social gradients appeared to be maintained over the four surveys. An exception was self-reported diabetes where, although inequalities were small, the gradient increased over time. Alcohol consumption was unique in consistently showing an inverse gradient, especially for women.
Conclusions
There has been only a moderate decline in behavioural cardiovascular risk factor prevalences since 1995, with increases in self-reported diabetes and hypertension. Adverse socio-economic gradients have remained unchanged. These findings could help explain the recent stagnation in coronary heart disease mortalities and persistence of related inequalities.
Article summary
Article focus
In Scotland, as in other developed countries, coronary heart disease mortality has declined substantially over time.
This decline may now be slowing among younger groups, and there are still large inequalities in mortality between socio-economic groups.
This study examined secular and socio-economic changes in cardiovascular disease risk factor prevalences in the Scottish population.
Key messages
In Scotland, over a 13-year period since 1995 there have been at best only moderate declines in the prevalence of behavioural risk factors and no change in their socio-economic patterning, notably for smoking and poor diet.
There has, however, been an increase in self-reported conditions predisposing to cardiovascular disease.
This threatens to maintain inequalities in coronary heart disease mortalities and stifle further declines in mortality.
Strengths and limitations of this study
This study utilised data from nationally representative surveys conducted over a 13-year period.
The declining response levels to these surveys are of concern, possibly introducing bias. However, differential non-response by the socio-economically disadvantaged may lead to an underestimation of the magnitude of inequalities.
doi:10.1136/bmjopen-2011-000176
PMCID: PMC3191578  PMID: 22021783
Cardiovascular diseases; risk factors; socio-economic factors; cross-sectional studies; Scotland; epidemiology; public health; social medicine; coronary heart disease; multilevel modelling; inequalities; modelling; prevention; health services research; mortality; routine data; statistics

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