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1.  Assessing the impact on chronic disease of incorporating the societal cost of greenhouse gases into the price of food: an econometric and comparative risk assessment modelling study 
BMJ Open  2013;3(10):e003543.
Objectives
To model the impact on chronic disease of a tax on UK food and drink that internalises the wider costs to society of greenhouse gas (GHG) emissions and to estimate the potential revenue.
Design
An econometric and comparative risk assessment modelling study.
Setting
The UK.
Participants
The UK adult population.
Interventions
Two tax scenarios are modelled: (A) a tax of £2.72/tonne carbon dioxide equivalents (tCO2e)/100 g product applied to all food and drink groups with above average GHG emissions. (B) As with scenario (A) but food groups with emissions below average are subsidised to create a tax neutral scenario.
Outcome measures
Primary outcomes are change in UK population mortality from chronic diseases following the implementation of each taxation strategy, the change in the UK GHG emissions and the predicted revenue. Secondary outcomes are the changes to the micronutrient composition of the UK diet.
Results
Scenario (A) results in 7770 (95% credible intervals 7150 to 8390) deaths averted and a reduction in GHG emissions of 18 683 (14 665to 22 889) ktCO2e/year. Estimated annual revenue is £2.02 (£1.98 to £2.06) billion. Scenario (B) results in 2685 (1966 to 3402) extra deaths and a reduction in GHG emissions of 15 228 (11 245to 19 492) ktCO2e/year.
Conclusions
Incorporating the societal cost of GHG into the price of foods could save 7770 lives in the UK each year, reduce food-related GHG emissions and generate substantial tax revenue. The revenue neutral scenario (B) demonstrates that sustainability and health goals are not always aligned. Future work should focus on investigating the health impact by population subgroup and on designing fiscal strategies to promote both sustainable and healthy diets.
doi:10.1136/bmjopen-2013-003543
PMCID: PMC3808835  PMID: 24154517
PUBLIC HEALTH; NUTRITION & DIETETICS; EPIDEMIOLOGY
2.  Trends in social inequalities for premature coronary heart disease mortality in Great Britain, 1994–2008: a time trend ecological study 
BMJ Open  2012;2(3):e000737.
Objective
To compare trends in metrics of socioeconomic inequalities in premature coronary heart disease (CHD) mortality in Great Britain.
Design
Time trend ecological study with area-level deprivation as exposure.
Setting
Great Britain, 1994–2008.
Participants
Men and women aged younger than 75 years. No lower age limit.
Interventions
None.
Main outcome measures
CHD mortality rates.
Results
There has been a decrease in socioeconomic inequalities in CHD mortality in absolute terms but an increase in relative terms. CHD mortality rates in men aged younger than 75 years fell by 69 per 100 000 (95% CIs 64 to 74) in the least deprived quintile and by 92 per 100 000 (95% CI 86 to 98) in the most deprived quintile (p for trend: <0.001). Mortality rate ratios comparing the most deprived quintile to the least deprived quintile increased in women aged younger than 75 years from 1.77 (95% CI 1.68 to 1.86) to 2.32 (95% CI 2.14 to 2.52). There was a weak negative association between the average decline of relative rates and area deprivation.
Conclusions
It could either be said that inequalities in premature mortality from CHD between affluent and deprived areas have widened or narrowed between 1994 and 2008 depending on the measurement technique. In the context of falling CHD mortality rates, narrowing of absolute inequalities is to be expected, but increases in relative inequalities are a cause for concern.
Article summary
Article focus
CHD mortality in Great Britain has declined steadily over the past 30 years.
Socioeconomic inequalities in CHD mortality have persisted for many years.
There are different assessments as to whether inequalities in CHD are widening or narrowing, depending on whether absolute or relative measurements are considered.
Key messages
There has been a narrowing in Great Britain of absolute socioeconomic inequalities in premature CHD mortality rates over the past 15 years.
There has been a substantial widening in relative socioeconomic inequalities over this time period, particularly for women.
Although relative decline in premature CHD mortality rates over this time period is clearly socially patterned, area-level deprivation only explains a small amount of the variance in rates of decline.
Strengths and limitations of this study
The strengths of this study are that trends are examined across the whole of Great Britain over a significant period of time.
However, deprivation was only assessed at a single point in time and therefore this may have resulted in misclassification over time.
CHD is a condition with a long aetiology; therefore, area of residence at death is a limited indicator of socioeconomic status over the life course.
doi:10.1136/bmjopen-2011-000737
PMCID: PMC3378944  PMID: 22710128
3.  What is the optimal level of population alcohol consumption for chronic disease prevention in England? Modelling the impact of changes in average consumption levels 
BMJ Open  2012;2(3):e000957.
Objective
To estimate the impact of achieving alternative average population alcohol consumption levels on chronic disease mortality in England.
Design
A macro-simulation model was built to simultaneously estimate the number of deaths from coronary heart disease, stroke, hypertensive disease, diabetes, liver cirrhosis, epilepsy and five cancers that would be averted or delayed annually as a result of changes in alcohol consumption among English adults. Counterfactual scenarios assessed the impact on alcohol-related mortalities of changing (1) the median alcohol consumption of drinkers and (2) the percentage of non-drinkers.
Data sources
Risk relationships were drawn from published meta-analyses. Age- and sex-specific distributions of alcohol consumption (grams per day) for the English population in 2006 were drawn from the General Household Survey 2006, and age-, sex- and cause-specific mortality data for 2006 were provided by the Office for National Statistics.
Results
The optimum median consumption level for drinkers in the model was 5 g/day (about half a unit), which would avert or delay 4579 (2544 to 6590) deaths per year. Approximately equal numbers of deaths from cancers and liver disease would be delayed or averted (∼2800 for each), while there was a small increase in cardiovascular mortality. The model showed no benefit in terms of reduced mortality when the proportion of non-drinkers in the population was increased.
Conclusions
Current government recommendations for alcohol consumption are well above the level likely to minimise chronic disease. Public health targets should aim for a reduction in population alcohol consumption in order to reduce chronic disease mortality.
Article summary
Article focus
Alcohol consumption is a risk factor for many chronic diseases, while providing modest protection from others. Assessments of the impact of alcohol on individual chronic diseases can therefore result in contradictory advice about the level of alcohol consumption that is optimal for health.
The UK Government currently recommends that men should consume no more than three to four units per day (24–32 g/day of pure alcohol) and women should drink no more than two to three units per day (16–24 g/day). However the net impact of this level of consumption on chronic disease mortality is unclear.
The aim of this study was to estimate the impact of achieving alternative population alcohol consumption levels on chronic disease mortality in England.
Key messages
Results suggest that the optimum population level of alcohol consumption for minimising chronic disease mortality in England is just 5 g (approximately half a unit) per day.
Current recommendations for alcohol consumption are well above this level and may not be compatible with optimum protection of public health. Substantial reductions in recommendations and in population alcohol consumption levels would be needed to minimise the chronic disease burden associated with alcohol consumption in England.
Community beliefs in the protective role of alcohol in cardiovascular disease are widespread; however, our modelling shows that when multiple conditions are considered simultaneously, the levels of alcohol that would actually be likely to be associated with reduced risk of chronic disease are much lower than is generally accepted or recommended by government.
Strengths and limitations of this study
The study used a detailed modelling approach to synthesise the best available evidence from meta-analysis of prospective cohort studies and provide for the first time an estimate of the level of alcohol associated with theoretical minimum risk of a range of chronic diseases, considering both harmful and protective effects simultaneously.
The model is dependent on the meta-analyses selected to define the parameters. Results may vary significantly in other contexts with varying levels of disease, alcohol consumption and other risk factors. Furthermore, results depend on the quality of the available epidemiological evidence, which remains contested in some areas.
The approach used also relies on chronic (average) consumption of alcohol and is not able to take account of to take account of patterns of drinking (eg, binge drinking). Furthermore, the results are based on the assumption of a steady-state relationship between alcohol consumption patterns and RR of disease and cannot estimate the time required between changes in population alcohol consumption levels occurring and the achievement of changes in mortality rates.
doi:10.1136/bmjopen-2012-000957
PMCID: PMC3367150  PMID: 22649178
4.  Differences in coronary heart disease, stroke and cancer mortality rates between England, Wales, Scotland and Northern Ireland: the role of diet and nutrition 
BMJ Open  2011;1(1):e000263.
Introduction
It is unclear how much of the geographical variation in coronary heart disease (CHD), stroke and cancer mortality rates within the UK is associated with diet. The aim of this study is to estimate how many deaths from CHD, stroke and cancer would be delayed or averted if Wales, Scotland and Northern Ireland adopted a diet equivalent in nutritional quality to the English diet.
Methods
Mortality data for CHD, stroke and 10 diet-related cancers for 2007–2009 were used to calculate the mortality gap (the difference between actual mortality and English mortality rates) for Wales, Scotland and Northern Ireland. Estimates of mean national consumption of 10 dietary factors were used as baseline and counterfactual inputs in a macrosimulation model (DIETRON). An uncertainty analysis was conducted using a Monte Carlo simulation with 5000 iterations.
Results
The mortality gap in the modelled scenario (achieving the English diet) was reduced by 81% (95% credible intervals: 62% to 108%) for Wales, 40% (33% to 51%) for Scotland and 81% (67% to 99%) for Northern Ireland, equating to approximately 3700 deaths delayed or averted annually. For CHD only, the mortality gap was reduced by 88% (69% to 118%) for Wales, 58% (47% to 72%) for Scotland, and 88% (70% to 111%) for Northern Ireland.
Conclusion
Improving the average diet in Wales, Scotland and Northern Ireland to a level already achieved in England could have a substantial impact on reducing geographical variations in chronic disease mortality rates in the UK. Much of the mortality gap between Scotland and England is explained by non-dietary risk factors.
Article summary
Article focus
Scotland, Wales and Northern Ireland experience excess cardiovascular and cancer mortality compared to England.
How much of this excess mortality is associated with differences in diet and nutrition in the four countries of the UK?
Key messages
Modelled results suggest that if Wales and Northern Ireland achieved an average diet equivalent in nutritional quality to the average diet in England, then 81% of the excess cardiovascular and cancer mortality experienced in these countries would be removed.
If Scotland achieved an average diet equivalent in nutritional quality to the average diet in England, then 40% of the excess cardiovascular and cancer mortality would be removed.
For Wales, Scotland and Northern Ireland, changes in diet would have the biggest impact on inequalities in coronary heart disease mortality.
Strengths and limitations of this study
The macrosimulation model used for the analysis is parameterised using meta-analyses of cohort and case–control studies, and considers 10 different dietary factors and 10 mortality outcomes.
Uncertainty analysis, allowing parameter estimates to vary stochastically according to distributions reported in the literature, allow for an assessment of the uncertainty of the presented results.
The model is parameterised from meta-analyses of observational studies, and therefore it is not possible to exclude the possibility of residual confounding.
doi:10.1136/bmjopen-2011-000263
PMCID: PMC3227806  PMID: 22080528

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