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ObjectiveExamine the association between country-level gender social norms and (1) cardiovascular disease mortality rates; (2) female to male cardiovascular disease mortality ratios; and (3) life expectancy.DesignEcological study with the country as the unit of analysis.SettingGlobal, country-level data.ParticipantsGlobal population of countries with data available on gender social norms as measured by the Gender Social Norms Index (developed by the United Nations Development Programme).Main outcome measuresCountry-level female and male age-standardised cardiovascular disease mortality rates, population age-standardised cardiovascular disease mortality rates, female to male cardiovascular disease mortality ratios, female and male life expectancy at birth. Outcome measure data were retrieved from the WHO and the Institute for Health Metrics and Evaluation. Multivariable linear regression models were fitted to explore the relationship between gender social norms and the outcome variables.ResultsHigher levels of biased gender social norms, as measured by the Gender Social Norms Index, were associated with higher female, male and population cardiovascular disease mortality rates in the multivariable models (β 4.86, 95% CIs 3.18 to 6.54; β 5.28, 95% CIs 3.42 to 7.15; β 4.89, 95% CIs 3.18 to 6.60), and lower female and male life expectancy (β −0.07, 95% CIs −0.11 to −0.03; β −0.05, 95% CIs −0.10 to −0.01). These results included adjustment within the models for potentially confounding country-level factors including gross domestic product per capita, population mean years of schooling, physicians per 1000 population, year of Gender Social Norms Index data collection and maternal mortality ratio.ConclusionsOur analysis suggests that higher levels of biased gender social norms are associated with higher rates of population cardiovascular disease mortality and lower life expectancy for both sexes. Future research should explore this relationship further, to define its causal role and promote public health action.

BackgroundCurrent proposals for post-Brexit agricultural policy do not explicitly incorporate public health goals. The revised agricultural policy may be an opportunity to improve population health by supporting domestic production and consumption of fruits and vegetables (F&V). This study aims to quantify the potential impacts of a post-Brexit agricultural policy that increases land allocated to F&V on cardiovascular disease (CVD) mortality and inequalities in England, between 2021 to 2030.MethodsWe used the previously validated IMPACT Food Policy model and probabilistic sensitivity analysis to translate changes in land allocated to F&V into changes in F&V intake and associated CVD deaths, stratified by age, sex and Index of Multiple Deprivation. The model combined data on F&V agriculture, waste, purchases and intake, CVD mortality projections and appropriate relative risks. We modelled two scenarios, assuming that land allocated to F&V would gradually increase to 10% and 20% of land suitable for F&V production.ResultsWe found that increasing land use for F&V production to 10% and 20% of suitable land would increase fruit intake by approximately 3.7% (95% uncertainty interval: 1.6% to 8.6%) and 17.4% (9.1% to 36.9%), and vegetable intake by approximately 7.8% (4.2% to 13.7%) and 37% (24.3% to 55.7%), respectively, in 2030. This would prevent or postpone approximately 3890 (1950 to 7080) and 18 010 (9840 to 28 870) CVD deaths between 2021 and 2030, under the first and second scenario, respectively. Both scenarios would reduce inequalities, with 16% of prevented or postponed deaths occurring among the least deprived compared with 22% among the most deprived.ConclusionPost-Brexit agricultural policy presents an important opportunity to improve dietary intake and associated cardiovascular mortality by supporting domestic production of F&V as part of a comprehensive strategy that intervenes across the supply chain.

BackgroundIn 2011, England introduced the Public Health Responsibility Deal (RD), a public-private partnership (PPP) which gave greater freedom to the food industry to set and monitor targets for salt intakes. We estimated the impact of the RD on trends in salt intake and associated changes in cardiovascular disease (CVD) and gastric cancer (GCa) incidence, mortality and economic costs in England from 2011–2025.MethodsWe used interrupted time series models with 24 hours' urine sample data and the IMPACTNCD microsimulation model to estimate impacts of changes in salt consumption on CVD and GCa incidence, mortality and economic impacts, as well as equity impacts.ResultsBetween 2003 and 2010 mean salt intake was falling annually by 0.20 grams/day among men and 0.12 g/d among women (P-value for trend both < 0.001). After RD implementation in 2011, annual declines in salt intake slowed statistically significantly to 0.11 g/d among men and 0.07 g/d among women (P-values for differences in trend both P < 0.001). We estimated that the RD has been responsible for approximately 9900 (interquartile quartile range (IQR): 6700 to 13,000) additional cases of CVD and 1500 (IQR: 510 to 2300) additional cases of GCa between 2011 and 2018. If the RD continues unchanged between 2019 and 2025, approximately 26 000 (IQR: 20 000 to 31,000) additional cases of CVD and 3800 (IQR: 2200 to 5300) cases of GCa may occur.InterpretationPublic-private partnerships such as the RD which lack robust and independent target setting, monitoring and enforcement are unlikely to produce optimal health gains.

ObjectivesThe objective of this study was to examine the prevalence of adolescent motherhood among married adolescent girls and its associations with their partners’ characteristics in low-income and middle-income countries (LMICs).DesignPopulation-based study.Participants54 285 ever married (or lived with a partner) adolescent girls (15–19 years old) were including in prevalence analysis. However, partner characteristics were assessed in a subsample of 24 433 adolescent girls who were married (or living with a partner) at the time of interview.SettingsData from the latest available Demographic and Health Survey round during 2010–2018 in 48 LMICs across different geographic regions.ResultsThe overall prevalence of adolescent motherhood was 73.98% (95% CI 70.96 to 78.10) among married adolescent girls in this study. In the pooled analysis, statistically significant and positive associations were observed between adolescent motherhood and partners’ desire for more children (adjusted marginal effect (AME): 2.34, 95% CI 1.21 to 3.47) and spousal age gap (AME: 1.67, 95% CI 0.30 to 3.04 for three plus age gap). However, no statistically significant association was observed between adolescent motherhood and partners’ education (AME: −0.36, 95% CI −1.77 to 1.05 for primary education) and partners’ agricultural occupation (AME: 1.07, 95% CI −0.17 to 2.32). Overall, there was significant variation in the associations across countries; however, the positive associations persisted between adolescent motherhood and partners’ desire for more children and spousal age gap in most of the studied countries.ConclusionsOur findings may inform policymakers about the importance of incorporating partners of married adolescent girls into the existing birth control programmes to delay age at first birth among married adolescents in LMICs. More attention should be given to the married adolescent girls who have older partners, and efforts to discourage marriages with much older partners may have a secondary benefit of reducing adolescent motherhood in LMICs.

Developed countries have enjoyed substantial falls in cardiovascular disease (CVD) mortality. However, low and middle income countries are drowning in a rising tide of CVD and other non-communicable diseases. Current and future trends in CVD mortality will therefore require increasing attention in the 21st century. The success of clinical cardiology in providing evidence-based cost-effective treatments should be celebrated. However, the growing understanding of CVD mortality trends highlights the crucial role of tobacco, diet, alcohol and inactivity as key drivers. Pro-active public health approaches focused on 'upstream' population-wide policies are increasingly recognised as being potentially powerful, rapid, equitable and cost-saving. However, the future political challenges could be substantial.

The huge falls in coronary heart disease (CHD) mortality rates which started in Western countries in the 1960s have continued into the 21st century. They represent profoundly important and much studied epidemiological phenomena. The WHO's Multinational MONItoring of trends and determinants in CArdiovascular disease (MONICA) project, Atherosclerosis Risk in Communities (ARIC) community-wide surveillance and hospital discharge study and IMPACT model studies in diverse populations highlighted the crucial contributions of decreases in both CHD incidence and case fatality to overall trends. However, such favourable trends in CHD mortality have not been universal and absolute numbers of deaths have been generally increasing throughout the world because of population growth and ageing. In their Heart paper, Degano et al 1 explore recent myocardial infarction trends in several European countries to provide a much-needed, detailed update to previous trend analyses for the new millennium. The authors performed a well-conducted analysis, using rigorous and validated protocols in well-run population-based registries in six countries in the European Union. The study was conducted using high-quality MONICA methodology, an exemplar in cardiovascular disease epidemiology. Crucially, they paid particular attention to changing acute myocardial infarction (AMI) definitions, particularly in the era of highly sensitive cardiac biomarkers, and adjusted their estimates accordingly. Degano et al examined the period 1985–2010, from the start of the MONICA project to a decade into the new century. This period reflects a rapidly changing era in cardiovascular medicine, which spans a period when new evidence-based treatments were progressively adopted. Over the study period, the authors found a consistent decline in AMI incidence and mortality rates, including both total and case fatality rates. However, they importantly …

ObjectiveTo estimate the impact and equity of existing and potential United Kingdom salt reduction policies on primary prevention of cardiovascular disease and gastric cancer in England.DesignA microsimulation study of a close-to-reality synthetic population. In the first period, 2003-2015, we compared the impact of current policy against a counterfactual ‘no intervention’ scenario, which assumed salt consumption persisted at 2003 levels. For 2016–2030, we assumed additional legislative policies could achieve a steeper salt decline and we compared this against the counterfactual scenario that the downward trend in salt consumption observed between 2001 and 2011 would continue up to 2030.SettingSynthetic population with similar characteristics to the non-institutionalised population of England.ParticipantsSynthetic individuals with traits informed by the Health Survey for England.Main measureCardiovascular disease and gastric cancer cases and deaths prevented or postponed, stratified by fifths of socioeconomic status using the index of multiple deprivation.ResultsSince 2003, current salt policies have prevented or postponed approximately 52,000 CVD cases (interquartile range (IQR): 34,000 to 76,000) and 10,000 CVD deaths (IQR: 3,000 to 17,000). In addition, the current policies have prevented approximately 5,000 new cases of GCa (IQR: 2,000 to 7,000) resulting in about 2,000 fewer deaths (IQR: 0 to 4,000). This policy did not reduce socioeconomic inequalities in CVD, and likely increased inequalities in gastric cancer.Additional legislative policies from 2016 could further prevent or postpone approximately 19,000 CVD cases (IQR: 8,000 to 30,000) and 3,600 deaths by 2030 (IQR: -400 to 8,100) and may reduce inequalities. Similarly, for GCa 1,200 cases (IQR: -200 to 3,000) and 700 deaths (IQR: -900 to 2,300) could be prevented or postponed with a neutral impact on inequalities.ConclusionsCurrent salt reduction policies are powerfully effective in reducing the cardiovascular and gastric cancer disease burdens overall but fail to reduce the inequalities involved. Additional structural policies could achieve further, more equitable health benefits.

Background Dementia is a highly disabling condition causing considerable economic and societal burden worldwide. Predictions of future dementia prevalence need to take into account that, on the one hand, cardiovascular disease risk reduction may result in reduced age-specific dementia incidence but, on the other hand, increased life expectancy may lead to a larger pool of individuals susceptible to dementia. To accurately forecast prevalence of dementia, we modelled simultaneously the two conditions. Methods We developed IMPACT-BAM to model transitions to 2030 in the England and Wales population, aged 35+, through health states of cardiovascular disease, cognitive and functional impairment, and dementia to cardiovascular and non-cardiovascular death. At each iteration of this probabilistic Markov model, age-, sex-, and calendar time-specific transition probabilities (derived from 2002–2012 data of the English Longitudinal Study of Ageing, ELSA) were used to predict prevalence of each health state at the next calendar year. As observed in ELSA, we assumed cardiovascular disease incidence will continue to decline in parallel to cardiovascular mortality. Based on the decline in prevalence of dementia observed in the Rotterdam and Cognitive Function and Ageing Study (CFAS), we inferred a relative reduction of 2% per annum in the incidence of dementia. Validity of the model was established by comparing model estimates for recent years with independent observations. Results Using ELSA 2006 data as input resulted in predicted age and sex-specific prevalence of dementia for 2011 that was consistent with observed prevalence in CFAS 2011, underpinning the validity of IMPACT-BAM model estimates. As of 2015, we estimated 842,000 people aged 65 or older live with dementia in England and Wales, representing a prevalence of 8.15% (95% CI 3.12–14.24) in this age-group. The number (prevalence) of people aged 65 or older living with dementia is expected to rise to 1,045,000 (9.3%)in 2020, 1,216,000 (9.8%) in 2015, and 1,358,000 (9.7%) in 2030. Prevalence of dementia is and will be higher in women than in men: 9.4% (95% CI 3.0–17.6) vs 6.7%, (95% CI 3.3–10.1), respectively in 2015 and 10.4% (95% CI 2.7–26.3) vs 8.9% (95% CI 4.8–16.5) in 2030. Conclusion Despite a projected decline in age-specific dementia incidence, the age-specific prevalence of dementia is likely to rise in the next 15 years, largely due to increasing longevity. We predict a substantial increase in the number of people living with dementia, resulting from rising dementia prevalence compounded by population ageing.

Background Cardiovascular disease (CVD) mortality burdens remain large and unequal in the US, and much is attributable to poor diets. Few data exist regarding the potential population level impact of policies aimed at improving dietary intake, and the effect on disparities through programmes such as the Supplemental Nutrition Assistance Programme (SNAP). We aimed to estimate reductions in CVD mortality and disparities achievable in the US population up to 2030 through food price changes and mass media campaign interventions targeting fruits and vegetables (F&V) and sugar sweetened beverages (SSBs). Methods We developed a US IMPACT Food Policy Model to compare four contrasting food policy scenarios targeting dietary intake: a national F&V mass media campaign, F&V price reductions of 10% universally and 30% to SNAP participants, and a universal SSB price increase of 10%. Data sources included the National Vital Statistics System, SEER single year population estimates, the US Bureau 2012 National Population projections, and NHANES. We stratified the US population into SNAP participants, SNAP eligible (but not participating), and SNAP ineligible. We modelled cumulative deaths prevented or postponed (DPP) and life years gained (LYG) using best-evidence effect sizes for each policy including differential price elasticity estimates, existing mortality rates and trends, and F&V and SSB mortality effects. We stratified by age, sex, and CVD subtype from 2015 to 2030. Probabilistic sensitivity analyses were conducted with Monte Carlo simulation. Results A universal 10% price reduction would yield the greatest national benefits, generating approximately 88,000 DPPs (95% CI: 81,000–94,000) and 1,369,000 LYGs (1,268,000–1,460,000) by 2030. This compares with between 28,000 (26,000–30,000) and 84,000 (79,000–89,000) DPPs generated through a 1-year and 15-year MMC respectively. A 10% SSB price increase could yield approximately 29,000 (25,000–33,000) DPPs, whilst a 30% F&V price reduction to SNAP participants only could reduce deaths by approximately 27,000 (24,000–30,000). This scenario would reduce disparities the greatest, reducing CVD disparities by approximately 18% between SNAP participants and ineligible population. The other scenarios would have much lower effects upon disparities. Conclusion All four dietary policies would be effective in reducing mortality. Reducing fruit and vegetable (F&V) price by 10% to the entire US would save most lives. However reducing F&V price by 30% to SNAP participants would reduce disparities the most, particularly if SNAP program coverage and penetration were improved. These results support population fiscal strategies targeting diet to reduce cardiovascular mortality and disparities in the US.

Background Increased longevity may increase the burden of disability in the near future. However, much depends on current and future trends in cardiovascular disease, dementia and their shared risk factors. We set out to forecast future trends in disability and life expectancies in England and Wales to 2025, using a model which combines the population dynamics and ongoing trends of these two diseases. Methods As part of the IMPACT-Better Ageing Model study, a probabilistic Markov model was developed and validated to track health transitions of the England and Wales population through nine states characterised by presence or absence of cardiovascular disease, dementia and disability from 2012 to 2025. Disease occurrence and age/sex/year specific transition probabilities were derived from the English Longitudinal Study of Ageing and Health Survey for England. We estimated future disability prevalence, life expectancy, disability-free life expectancy and disabled life expectancy. We assumed cardiovascular disease incidence and mortality continue their current trends and dementia incidence continues to decline by 2% per annum. Monte Carlo simulation was used to estimate 95% uncertainty intervals (UI) for all the model outputs. Results By 2025, approximately 157,000 (95% UI 142,000–176,000) additional people will live with disability, a 12.4% (11.5%–13.7%) increase from the 2015 baseline. Prevalence of disability will decrease among women (from 12.7% to 11.3%), but not men. Larger decreases in prevalence will be seen in women over 90 years of age (from 37.5% to 31.4%). In 2015, the Office of National Statistics estimated life expectancy at age 65 in England and Wales to be 18.8 years in men and 21.1 years in women. Between 2015 and 2025, we predict life expectancy at age 65 will increase to 22.0 (21.5–22.5) years in men and 24.1 years (23.0–25.5) in women. Disability-free life expectancy will increase in men by 2.0 (1.7–2.4) years and in women by 1.8 (1.0–2.6) years. However, disabled life expectancy will only increase marginally. Overall, the proportion of life expectancy lived without disabilities would remain constant at around 85.6%. Discussion Because of population ageing, the number of people in England and Wales with disability will increase by approximately 12% by 2025. However, prevalence of age-related disability is predicted to decrease over the coming decade. If the continuing downward trend in dementia and cardiovascular disease incidence is observed, the anticipated increase in life expectancy will occur without additional years lived with disability.

Background Growing evidence suggests that sugar sweetened beverage (SSB) intake can increase long-term weight gain and hence worsen the ongoing obesity epidemic. A tax on SSBs might offer an effective population wide intervention to reduce the burden of obesity, cardiovascular diseases (CVD) and common cancers. We aimed to estimate the potential impact on obesity of a 10% and 20% tax on SSBs in Turkey. Methods We developed a Markov model for the Turkish population aged 35 years and older. The model follows a closed cohort from year 2011 to 2031. The cohort has the probability of transition to healthy, overweight or obese states or to die from CVD, cancer or other causes. Model inputs were population and death records from Turkish Statistical Institute, overweight and obesity prevalence from Turkish National Chronic Disease Survey, 2011, daily mean SSB intake from Turkish National Diet and Nutrition Survey. We used DISMOD II software to estimate the incidence of overweight and obesity. The effect of tax was calculated using price elasticities obtained from previous published studies. We compared three scenarios: The baseline scenario involved no change in consumption of SSBs. In two additional scenarios, we modelled the effect of a 10% and 20% tax on decreasing SSBs intake. We then modelled the effect of this SSB decrease on BMI and obesity prevalence on the Turkish population. We further calculated the population attributable risk fraction of obesity to estimate the CVD and cancer cases potentially preventable. We also conducted a probabilistic sensitivity analysis to estimate 95% uncertainty intervals (95% UI). Results We forecast that in this closed cohort, by the year 2031, approximately 4,201,100 (4,130,000–4,270,000) men and 5,419,000 (5,305,000–5,537,000) women would be obese. However implementing a 10% SSB tax could result in approximately 21,900 (19,800–29,040) fewer obese men and 13,500 (12,900–15,400) fewer obese women. A 20% tax might result in 41,900 (40,100–48,100) fewer obese men and 24,800 (15,600–28,700) fewer obese women. Overall, a 20% tax could result in a 0.7% reduction in obesity prevalence in the whole cohort. This might result in approximately 29,700 fewer CVD cases and 13,400 fewer obesity related cancer cases by 2031. Conclusion A tax on Sugar Sweetened Beverages in the Turkish population could usefully reduce the prevalence of obesity, cardiovascular disease and common cancers. These findings reinforce the growing evidence of health benefits with SSB taxation policies in diverse countries.

Background Coronary heart disease (CHD) mortality has declined substantially in Japan for several decades. However, the contributory factors remain unclear because major CHD risk factor levels have paradoxically increased since 1980, notably cholesterol, obesity and diabetes. Our objective is to quantify the contributions of prevention and treatment to the coronary heart disease mortality trends in Japan between 1980 and 2012. Methods We used the previously validated IMPACT model to analyse mortality trends between 1980 and 2012 in the Japanese population aged 35–84 years. This model integrates data on changes in population size, CHD mortality, risk factors, and uptake of evidence-based cardiac treatments. Main data sources included official vital statistics, national patient, health and nutrition surveys, and the health insurance claims data. Relative risks and regression coefficients came from the published meta-analyses. The difference between observed and expected CHD deaths in 2012 was then partitioned among treatment benefits and risk factor changes. We also performed probabilistic sensitivity analyses to quantify the potential effects of parameter uncertainty. Results From 1980 to 2012, age-adjusted CHD mortality rates in Japan fell by 61%, resulting in 75,680 fewer CHD deaths in 2012 than if rates had not fallen. Improvements in medical and surgical treatments were associated with approximately 59% (range, 56% to 61%)of the total mortality decrease. Major contributions came from therapy for angina in the community (explaining approximately 17% of the mortality fall), antihypertensive medication (≈10%), and heart failure therapies (≈7%). Risk factor changes accounted for approximately 31% (19% to 42%) of the mortality fall. Some 24% from decreases in systolic blood pressure and 11% from falls in smoking prevalence. However, rises in cholesterol, BMI and diabetes negated some of these benefits, potentially increasing mortality by 2%, 3% and 6% respectively. Conclusion Approximately 60% of the CHD mortality fall in Japan between 1980 and 2012 was attributable to increases in evidence-based medical treatments, and 30% to falls in population risk factors. However, the substantial contributions from falls in blood pressure and smoking were offset by adverse trends in cholesterol, obesity and diabetes. Our results highlight the potential for further improvements in cardiovascular risk factors in Japan.

Studies reporting ‘new’ associations of food ingredients with diseases are common, and sensational headlines appear almost daily in the news media. Thus, in a recent provocative paper, Schoenfeld and Ioannidis,1 randomly selected 50 common ingredients from a cookbook, and reported that 40 were apparently associated with increased cancer risk in peer reviewed studies. Unsurprisingly, most of these associations disappeared in subsequent meta-analyses.1 The net result: increases in media profits, public anxiety and a number of confused politicians. Indeed, the current landscape in nutritional epidemiology research is blighted by an oversaturation of contradictory evidence which risks confusing policy makers, journalists and public about what aspects of the Western diet deserve attention and then intervention. Randomised controlled trails and meta-analyses offer an evidence ‘gold standard’ relatively free of biases. However, trials are simply not feasible, affordable or ethical for many of the most important dietary questions. We therefore fall back on analyses of long-term cohorts, at which point considerable cautions then need to be sounded. Thus, the populations under study may be highly selected (eg, US doctors or nurses), and the results may not be directly generalisable to the …

Objectives To determine health and equity benefits and cost effectiveness of policies to reduce or eliminate trans fatty acids from processed foods, compared with consumption remaining at most recent levels in England. Design Epidemiological modelling study. Setting Data from National Diet and Nutrition Survey, Low Income Diet and Nutrition Survey, Office of National Statistics, and health economic data from other published studies Participants Adults aged ≥25, stratified by fifths of socioeconomic circumstance. Interventions Total ban on trans fatty acids in processed foods; improved labelling of trans fatty acids; bans on trans fatty acids in restaurants and takeaways. Main outcome measures Deaths from coronary heart disease prevented or postponed; life years gained; quality adjusted life years gained. Policy costs to government and industry; policy savings from reductions in direct healthcare, informal care, and productivity loss. Results A total ban on trans fatty acids in processed foods might prevent or postpone about 7200 deaths (2.6%) from coronary heart disease from 2015-20 and reduce inequality in mortality from coronary heart disease by about 3000 deaths (15%). Policies to improve labelling or simply remove trans fatty acids from restaurants/fast food could save between 1800 (0.7%) and 3500 (1.3%) deaths from coronary heart disease and reduce inequalities by 600 (3%) to 1500 (7%) deaths, thus making them at best half as effective. A total ban would have the greatest net cost savings of about £265m (€361m, $415m) excluding reformulation costs, or £64m if substantial reformulation costs are incurred outside the normal cycle. Conclusions A regulatory policy to eliminate trans fatty acids from processed foods in England would be the most effective and equitable policy option. Intermediate policies would also be beneficial. Simply continuing to rely on industry to voluntary reformulate products, however, could have negative health and economic outcomes.

Background Trans fatty acids (TFA) increase coronary heart disease (CHD) incidence by 11% for each 1% of dietary energy from TFA. Many countries have already taken action to reduce or eliminate TFA from processed foods. Currently the UK relies on the voluntary cooperation of industry. In this study, we determined and compared the health and equity benefits and cost effectiveness of additional, contrasting policies to reduce or eliminate TFA from processed foods in England. Methods Using the IMPACT Food Policy model, we estimated the reduction in CHD mortality and incidence in England that might result from four distinct policy options to reduce or eliminate TFA from processed foods: total legislative ban; improved labelling; bans in restaurants; or bans in take-aways. Average TFA consumption was taken from the National Diet and Nutrition Survey, and a socioeconomic gradient in TFA consumption was inferred from the Low Income Diet and Nutrition Survey. Potential reductions in TFA consumption were based on policy implementations in other countries. Health outcomes, including deaths prevented or postponed (DPP) and quality-adjusted life years (QALY), were stratified by socioeconomic circumstance using quintiles of the Index of Multiple Deprivation (IMDQ). Economic analysis considered policy costs to government and industry and savings in direct health care, informal care, and averted productivity loss. We calculated cost-effectiveness of each policy as incremental societal cost per QALY. Analyses were conducted in R software, and probabilistic sensitivity analysis was used to assess uncertainty. Results A total ban on TFA in processed foods might prevent or postpone approximately 7,200 (95% CI: 3,000–12,700) CHD deaths in England from 2015–2020 and reduce inequality in CHD mortality by some 3,000 (1,200–5,200) deaths. Policies to improve labelling or remove TFA from restaurants or take-aways could save between 1,800 and 3,500 (700–6,100) CHD deaths and reduce inequalities by 600 to 1,500 (300–2,600) deaths, thus making them less than half as effective. Any policy we evaluated would be cost effective from a total societal perspective, even if industry incurred substantial reformulation costs. A total ban would be the most cost effective, with savings of around £15,000 (£9,000–£40,000) per QALY in 2020. Conclusion The most effective and equitable policy option would be regulation to eliminate TFA from processed foods in England (as successfully achieved in various other countries). Intermediate policies would also have some benefits. However, simply continuing to rely on industry to voluntary reformulate products could have negative health and economic outcomes.

Background Stroke and Cardiovascular Diseases (CVD) are the main cause of premature deaths globally. Over a third of stroke deaths occur in developing countries, including Turkey. There is substantial potential to reduce stroke mortality burden, particularly by improving diet and health behaviours at the population level. Our aim is to estimate the potential impact of improving diet and reducing smoking prevalence on future CVD and stroke deaths in Turkey up to 2022. Methods We developed a Markov model for the Turkish population over 35 years old. The model follows the stroke free population in 2012 over a time horizon of 10 years. Key model inputs were obtained from Turkish sources (population and mortality data, incidence estimated using DISMOD and case fatality rates from hospital based stroke registry). Effect sizes for changes in nutrients and smoking on mortality were obtained from the literature. We simulated three scenarios: S1, baseline scenario; S2, a conservative scenario simulating a daily reduction in dietary salt by 1 g, trans-fat by 0.5%, and saturated fat by 1%, a 5% decrease in smoking prevalence in the population and increasing fruit and vegetable (FV S3, simulating a daily reduction in dietary salt by 3 g, trans-fat by 1%, saturated fat by 3%, a 10% decrease in smoking prevalence and increasing F&V intake by 2 portions/day. Uncertainty was explored using a probabilistic sensitivity analysis. Results We forecast that approximately 655,177 (range 524,142 to 786,212) deaths may occur between 2012 and 2022 (S1). The conservative changes (S2) in food policy could result in approximately 58,000 fewer CVD deaths (30,786–119,990) in 10 years. This would represent an 11% reduction in total CVD and stroke deaths in 2022. Feasible changes (S3) might prevent some 113,000 (62,580–326,700) fewer CVD deaths. This could result in approximately a 17% reduction in total CVD and stroke deaths in 2022. Approximately 32%, 29%, 11% and 6% of that figure could be attributed to a decreased consumption of trans-fat, dietary salt, saturated fats and fall in smoking prevalence and 22% could be attributed to increased F&V consumption. Conclusion Substantial burden of CVD and stroke deaths in Turkey can be prevented by using feasible and evidence-based food policies: increasing portions of F/V and reducing excess consumption of trans-fat, saturated fat, dietary salt and decreasing smoking prevalence. Substantial reductions in stroke burden can be gained in a decade.

Background Cardiovascular disease (CVD) mortality rates have reduced dramatically in the US, yet CVD remains accountable for approximately 800,000 deaths annually. Poor diet, including poor fruits and vegetables (F&V) intake is a leading CVD risk factor. Due to a previous lack of systemically estimated effect sizes of dietary policies and effect of dietary factors on CVD mortality, scarce data exist regarding the potential population level impact of policies aimed at increasing fruits and vegetables intake. We therefore aimed to estimate CVD mortality reductions attributable to price and mass media campaign interventions in the US population up to 2030. Methods We extended the IMPACT Food policy model to compare potential effects upon CVD mortality, of two contrasting policies targeting F&V intake. Data sources included the National Vital Statistics System, SEER single year population estimates, the US Bureau 2012 National Population projections and the National Health and Nutrition Examination Survey. Using US population projections to 2030 and novel best evidence effect sizes for each policy, and fruits and vegetables mortality effect size, we modelled cumulative deaths prevented or postponed (DPP), by age, gender and CVD subtype from 2015 to 2020 and 2030 under three contrasting scenarios. In SCENARIOs A and B, we model a universal price reduction of F&V by 10 and 30% respectively In SCENARIO C we model a mass media campaign across the entire US Results were tested in a probabilistic sensitivity analysis using montecarlo simulation. Results We project 890,000 CVD Deaths in 2020, rising to 1.7 million CVD deaths by 2030 if current trends continue. Scenario A could result in approximately 35,000 (95% confidence intervals 34,000–37,000) DPPs by 2020, increasing to 91,000 (87,000–95,000) by 2030 respectively. Some 62% of these attributed to CHD, and 53% in males. Scenario B could increase the gains to approximately 106,000 (99,000–112,000) DPPs by 2020, and some 270,000 (258,000–281,000) DPPs by 2030. In contrast, Scenario C could result in approximately 38,000 (36,000–40,000) DPPs by 2020, increasing to approximately 109,000 (104,000–114,000) DPPs by 2030. Conclusion Both price reduction policies (10 and 30%) and a nationwide Mass Media Campaign would be effective in reducing mortality. A 30% price reduction policy however would save more lives in the short (2020) and medium term (2030). These results support further population level and fiscal strategies to reduce CVD mortality in the US. A further cost effectiveness analysis would be of great importance to policy makers in implementing these policies.

Background Sales and consumption of ultra-processed products (UPP) haven risen rapidly in middle-income countries in recent decades. These products are likely to contribute to the growing cardiovascular disease (CVD) burden in these countries because they are heavily marketed and nutritionally imbalanced, being typically high in unhealthy fats, salt and or sugar. In Brazil, ultra-processed products are replacing traditional diets based on fresh and minimally processed food. At the same time, use of salt, oils and sugar in culinary preparations remains high. Our aim is to estimate the likely impact of different dietary changes on preventing cardiovascular deaths by 2030 in Brazil. Methods We obtained nutritional data from the Brazilian Household Budget Survey 2008/2009. All food items purchased were categorised into 4 food groups according to the Dietary Guidelines for the Brazilian population (2014): G1 fresh and minimally processed food, G2 culinary ingredients (oils, fats, salt and sugar) , G3 Processed food and G4 Ultra-processed products . We estimated the energy and nutrient profile of each food group using the Brazilian Table of food Composition (TACO) and the United States Department of Agriculture (USDA). We then used the IMPACT Food Policy model to estimate the reduction in deaths from coronary heart disease and stroke by the year of 2030 to explore two scenarios: Scenario A, if the intakes of saturated fat, trans-fat, salt and added sugar, in Group 2 and Group 3 in Brazil were substantially reduced; and Scenario B, if we halve the amount of the same nutrients in Group 2 and Group 4. Uncertainty was assessed through a probabilistic sensitivity analyses using Monte Carlo simulation. Results Approximately 390,368 CVD deaths might be expected in 2030 if current mortality patterns persist. Under scenario A, we estimated that Brazil could experience approximately 140,580 fewer CVD related deaths in 2030 (64,700–219,900) and under scenario B, CVD mortality can be reduced by 19%, resulting in about 31,900 (13,450–50,370) fewer coronary heart disease deaths and 42,690 (20,745–66,375) fewer stroke deaths. Conclusion This study shows a substantial potential for reducing the cardiovascular disease burden through overall improvements of the Brazilian diet. This might require reducing the penetration of ultra-processed products by means of regulatory policies, as well as comprehensively improving the access and promotion of fresh and minimally processed foods that are part of Brazil traditional diet.

Background The current strategy of the Department of Health for cardiovascular disease (CVD) prevention in England promotes identification and treatment of high risk individuals through health checks. The aim of this study was to estimate the effect of health checks on CVD burden (coronary heart disease and stroke) and socioeconomic inequality vs. a population wide intervention. Methods IMPACTNCD is a stochastic, dynamic, microsimulation model. It draws information from Health Survey for England, Office for National Statistics, large cohorts and meta-analyses to simulate over time a close-to-reality synthetic population of England. Socioeconomic indicators (area deprivation), behavioural factors (diet, smoking, physical activity), and biological risk factors (body mass index, systolic blood pressure, total cholesterol) were included in this simulation. Three scenarios were considered. The baseline scenario projects secular trends in risk factors based on recent trends. The ‘health checks’ scenario (‘HC’) assumes 30% of high risk individuals are identified, optimally treated and adopt a healthier lifestyle. Finally, the population wide intervention scenario (‘PWI’) assumes a drop of 5 mmHg of systolic blood pressure, 0.5 mmol/l drop of total cholesterol, plateauing of body mass index, increasing fruit and vegetable consumption by 2 portions per day, increasing physical activity by one active day per week and a 10% relative drop in smoking prevalence. All scenarios were simulated from 2011, had a diffusion period of 5 years and a lag time between exposure and effect of five years. Cases and deaths prevented or postponed (CPP and DPP respectively), the slope and relative index of inequality (SII and RII respectively) for CVD incidence were estimated for years 2015 to 2025. Uncertainty was estimated with Monte Carlo simulation and is presented as 95% uncertainty intervals. Analysis was performed in R. Results Compared to the baseline scenario, the ‘HC’ scenario might result in approximately 56,000 (39,000 to 73,000) CPP and 2,500 (–8,000 to 12,000) DPP; SII reduced by approximately 9% (–29% to 38%) and RII reduced by approximately 1% (–16% to 17%). Under the ‘PWI’ scenario 200,000 (185,000 to 218,000) CPP and 11,000 (1,500 to 21,000) DPP were estimated; SII reduced by approximately 30% (1% to 53%) and RII reduced by approximately 3% (–15% to 18%). Conclusion Our model suggests that NHS health checks appear weaker than population wide interventions, both for primary CVD prevention and for reducing absolute and relative socioeconomic inequalities. Further research is now needed to prioritise the interventions which will achieve the fastest reductions in these unacceptable inequalities.

Background Since mid-1980s, coronary heart disease (CHD) mortality rates in Sweden have more than halved, largely reflecting improvements in cardiovascular risk factors, mainly improvements in total cholesterol. However, this favourable trend in total cholesterol has recently levelled off or even increased in some ages, associated to changes in diet that is richer in saturated fats (SFs) and low in carbohydrates. The purpose of the present study was to project future CHD mortality in Sweden taking into account future trends in dietary SFs intake. Methods The previously validated IMPACT model was used to predict changes in CHD mortality between 2010 and 2025 in the Swedish population aged 25–84. Calculations were based on a) Population numbers and projections (the Swedish National Board of Health and Welfare) b) Population risk factors levels and projections c) effects of risk factor reductions (published meta-analyses and case-control studies). We assumed that the observed historical trend in CHD mortality were to continue and compared three different scenarios for future SFs intake, with and without favourable changes in other major risk factors: - S1: Reduction in daily intake of SFs in Sweden to 10% total energy (E) assuming substitution with unsaturated fats; - S2: Continuing current trends in SFs intake; - S3: Increasing intake of SF (20% E, consistent with fat-rich, low carb diet) 95% CI were obtained using a probabilistic sensitivity analysis Results If current CHD mortality trend would continue, 5,975 deaths would be observed in 2025. For S1 scenario 810 (664–955) fewer deaths would occur, resulting in 13.6% (11.9–15.0) mortality reduction. According to S2 scenario, no change in CHD mortality is expected. However if we assume no concurrent favourable changes in other risk factors, expected number of CHD deaths for S2 would be 382 (293–485), about 6.4% (5.1–7.8) increase. For S3 number expected increase in deaths would be 21 (–59–115), but if other risk factors would remain constant this number rises to 401 (334–475), which is equivalent to 6.7% (95% CI: 6.0–7.5) CHD mortality increase. Conclusion CHD mortality can increase as a result of unfavourable trends in diets rich in SFs resulting in cholesterol increases. While favourable trends in other risk factors might reduce its impact, substituting “bad” SFS (from dairy products and meat), with “good” mono-unsaturated (such as olive oil) and poly-unsaturated fats (such as sunflower and canola) is eminently feasible. These small and achievable beneficial dietary changes would have a large effect on CHD mortality.

Background Serum total cholesterol is one of the major targets for cardiovascular disease prevention. Statins are effective for cholesterol control in individual patients. At the population level, however, their contribution to total cholesterol decline remains unclear. The aim of this study was to quantify the contribution of statins to the observed fall in population mean cholesterol levels in England over the past two decades, and explore any differences between socioeconomic groups. Methods This is a modelling study based on data from the Health Survey for England (HSE). We analysed changes in observed mean total cholesterol levels in the adult England population (aged 18 and over) between 1991–92 (baseline) and 2011–12. We then compared the observed changes with a counterfactual ‘no statins’ scenario, where the impact of statins on population total cholesterol was estimated and removed. Statin effectiveness in the population was modelled based on published meta-analyses, self-reported statin uptake from HSE and the 2011 and 2012 Prescription Cost Analysis reports. We estimated uncertainty intervals (UI) using Monte Carlo simulation, where confidence intervals (CI) were impractical. The analysis was stratified by age-group, sex and quintiles of index of multiple deprivation (where possible and relevant) and was performed in R v3.1.0 statistical software. Results In 2011–12, 13.2% (95% CI: 12.5–14.0%) of the English adult population used statins at least once per week, compared with 1991–92 when the proportion was just 0.5% (95% CI: 0.3–1.0%) for any lipid lowering medication. Statin utilisation was higher among the most deprived groups. Between 1991–92 and 2011–12, mean total cholesterol declined from 5.86 mmol/L (95% CI: 5.82–5.90) to 5.17 mmol/L (95% CI: 5.14–5.20). For 2011–12, mean total cholesterol was about 5% lower in most deprived group compared to the most affluent group. In our ‘no statins’ scenario we predicted a mean total cholesterol of 5.36 mmol/L (95% CI: 5.33–5.40) for 2011–12. Statins were responsible for approximately 33.7% (95% UI: 28.9–38.8%) of the total cholesterol reduction since 1991–92. The statin contribution to cholesterol reduction was greater among the more deprived groups of women, while showing little socio-economic gradient among men. Conclusion Our model suggests that statins explained around a third of the substantial falls in total cholesterol observed in England since 1991 and their impact on reducing socioeconomic inequalities in total cholesterol was generally positive. Approximately two thirds of the cholesterol decrease can reasonably be attributed to dietary improvements.

Background While cardiovascular disease (CVD) mortality has been reducing in the US since the 1970s, CVD remains the leading cause of mortality. This reflects reductions in population level risk factors assisted by evidence based medical treatments. Rates of reduction in CVD mortality may be slowing and large shifts in population characteristics are forecasted, creating uncertainty as to future trends in CVD mortality rates as well as uncertainty regarding race CVD inequalities. We therefore aimed to compare US CVD mortality projections to 2030 under contrasting scenarios. Methods We used a well-established hierarchical Bayesian Age Period Cohort (BAPC) model to model the age, period and cohort effects in CVD mortality from 1982 to 2012 stratified by age, gender and race. Data sources included the National Vital Statistics System, SEER single year population estimates, and the US Bureau 2012 National Population projections Using US population projections to 2030, we then projected coronary and stroke deaths to 2030 under contrasting scenarios. In SCENARIO A, we held the age, period and cohort effects components constant at 2012 values. In SCENARIO B, we allowed the age, period and cohort effects to continue along their recent, linear trends, and extrapolated the resulting trajectories to 2030. We then compared the number of CVD deaths forecasted in 2030. Results In scenario A, assuming that mortality rates would persist at 2012 levels, coronary and stroke deaths were projected to INCREASE by approximately 17.1% and 50.3% respectively by 2030 (equating to some 63,400 and 64,400 additional deaths per year). By contrast, scenario B, optimistically assuming that recent declines continue, coronary and stroke mortality might FALL by approximately 21.2% and 2.7%, equating to some 78,200 and 3,100 fewer annual deaths respectively by 2030. The burden of CVD mortality is unequal by race. These inequalities vary by age and gender, however CVD mortality rates in younger (35–55 years) black Americans is double that of age matched white Americans. Conclusion The large US declines in coronary heart disease mortality rates observed over recent decades are likely to continue. However, stroke mortality rates will fall more slowly. This has major health implications. Our BAPC models simultaneously estimate age, period and cohort effects to project future trends. They therefore offer more plausible future predictions than the conventional indirect standardisation approaches. These more sophisticated projection methods may therefore be potentially valuable to future researchers and to policy makers.

Background Smoking remains common in England, with 20% of adults smoking in 2012, little changed from 21% in 2007. Smoking is more than twice as common among the most disadvantaged socioeconomic group compared to the most affluent and is a major contributor to inequalities in smoking-related mortality. The UK has comprehensive smoking policies according to the Tobacco Control Scale (TSC; score of 74 out of 100): public information campaigns; on-pack health warnings; plain packaging; ad bans; cessation; price; and smoke-free areas. However, there remains room for improvement. We aim to evaluate the cumulative effect on smoking prevalence of all TSC components, stratified by deprivation of area of residence in England. Methods We modelled the decline in smoking prevalence that might result from maximising each component of the TSC. Effect sizes and socioeconomic gradients for all seven types of smoking policy in the UK setting were adapted from systematic reviews, primary studies and other modelling studies. Smoking prevalence in England stratified by socioeconomic circumstance, age, and gender has been published by the Office for National Statistics. We used the previously-validated IMPACT Food Policy model to link predicted changes in smoking prevalence to changes in premature coronary heart disease (CHD) mortality for ages 35–74. Health outcomes with a time horizon of 2015–2025 were stratified by quintiles of lower layer super output areas ranked by their score on the Index of Multiple Deprivation for England. Inequality in CHD mortality was assessed using the Slope Index of Inequality. A model was built in R software, and uncertainty was assessed using probabilistic sensitivity analysis. Results Improving all smoking policies to achieve a maximum score of 100 on the TSC might reduce smoking prevalence in England by approximately 3% (95% CI: 1%–4%) in absolute terms, or by approximately 15% in relative terms (7%–21%). The most disadvantaged quintile would benefit more, with absolute reductions of about 5% (2%–7%). A 20% price increase via an excise tax would be responsible for about half (42%–57%) of the overall reduction. There would be some 3300 fewer premature CHD deaths (2200–4700), or about 2% fewer (1.4%–2.9%). The most disadvantaged quintile would benefit more, reducing the slope index of inequality for premature CHD mortality by approximately 260 deaths (170–540), or about 4% (3%–9%). Conclusion Further, feasible improvements in tobacco control policy in England could substantially improve population health AND reduce health-related inequalities. The health benefits would extend beyond CHD, most notably slowly reducing respiratory diseases and diverse cancers.

Objective To estimate the potential reduction in Irish cardiovascular (CVD) mortality possible by decreasing salt, trans fat and saturated fat consumption, and by increasing fruit and vegetable consumption. Methods The previously validated IMPACT Food Policy Model was used to estimate potential annual CVD mortality reductions associated with various dietary policy scenarios. Two scenarios were modelled. Firstly, a conservative scenario which involved a small reduction in salt intake by 1 g/day, trans-fat by 0.5% of energy intake, saturated fat by 1% energy intake and increasing fruit and vegetable intake by 1 portion per day. Secondly, a more substantial but politically feasible scenario that involved a reduction in salt intake by 3 g/day, trans-fat by 1% of energy intake, saturated fat by 3% energy intake and increasing fruit and vegetable intake by 3 portions per day. Population, mortality and dietary data for Irish adults aged 25–84 years were used. Results were stratified by 10 year age and sex. A probabilistic sensitivity analysis was undertaken. Best, maximum and minimum estimates were calculated using Monte Carlo simulation. Results The small, conservative changes in food policy could result in approximately 450 fewer cardiovascular deaths per year. This would comprise approximately 215 fewer coronary heart disease (CHD) deaths in men (min 167, max 286), approximately 60 fewer CHD deaths in women (min 45, max 76), approximately 115 fewer stroke deaths in men (min 92, max 146) and 65 fewer stroke deaths in women (min 50, max 79). Approximately 29% of the 450 fewer deaths could be attributable to decreased trans-fat consumption, 23% to decreased saturated fat, 23% to decreased salt consumption and 26% to increased fruit and vegetable consumption. The 450 fewer deaths would represent a 10% reduction in CVD mortality in Ireland. Modelling the more substantial but feasible food policy options, we estimated that CVD mortality could be reduced by up to 1250 deaths per year, representing a 25% decline in CVD mortality in Ireland. 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. In public health we urgently need to better understand the levers of public policy change. We can then more effectively bring decades of research on CVD aetiology to bear on actually reducing the burden of disease in the population.

Purpose In 1987, Northern Ireland had one of the highest rates of Coronary heart disease (CHD) mortality in the world. Despite rapidly declining CHD mortality over the last two decades, CHD mortality in Northern Ireland are still among the highest in Europe. The purpose of this study was to use an epidemiological modelling approach to quantify how much of the mortality decline from 1987 to 2007 could be attributed to: (1) changes in population CHD risk factors and (2) medical and surgical treatments. Methods The validated IMPACT CHD mortality model was used in all calculations to determine the number of deaths prevented or postponed (DPPs) for the period 1987–2007. For DPPs attributable to population risk factor changes, the calculation combined information on CHD deaths in 1987, prevalence of risk factor data from representative surveys (1987 and 2007) and regression coefficients (or RR) from the published literature which quantified the relationship between population changes for a specific risk factor and CHD mortality. For DPPs due to improved treatment uptake and effectiveness, the numbers of patients with CHD and their uptakes of specific treatments were obtained from local sources and combined with case death rates and RR reductions due to treatment (both sourced from published literature). Sensitivity analyses were then carried out. Results Between 1987 and 2007, the overall age-standardised CHD mortality in Northern Ireland (age 25–84 years) fell from 361 to 124 deaths per 100 000, resulting in some 3180 fewer CHD deaths in 2007. Changes in major cardiovascular risk factors accounted for approximately 60% of this decrease. Decreases in blood pressure, total cholesterol and smoking prevalence accounted for 74% of the mortality decline. However, these reductions were partially offset by adverse trends in diabetes, physical inactivity and obesity (combined 14% increase). Approximately 35% of the total mortality decrease was attributable to treatments, most notably secondary preventive therapies (15%), treatments for Heart failure (6%) and Acute Myocardial Infarction (5%). Conclusion CHD mortality in Northern Ireland decreased substantially between 1987 and 2007. Approximately 60% of this fall was attributable to major cardiovascular risk factor changes, and approximately 35% was attributable to treatments. However, adverse trends in diabetes, obesity and physical inactivity are of major concern. To decrease future CHD deaths, more aggressive policies are therefore needed to control tobacco, promote healthy food and increase physical activity, as well as maximising the coverage of effective treatments.

Background Health inequalities are evident across the United Kingdom, exemplified by large and persistent social gradients in premature cardiovascular mortality. Four simple medical therapies improve survival in patients with coronary heart disease: antiplatelet agents including aspirin, β-blockers, statins, and angiotensin converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB). But are the founding National Health Service (NHS) principles of equity and universality translating into equitable delivery of these life-saving therapies? Previous studies have been limited in size, method of classifying socioeconomic status, range of treatments examined, and trends over time. Methods Socioeconomic status was defined using the Index of Multiple Deprivation, a weighted composite of seven deprivation domains. Small areas (approximately 1500 individuals) were aggregated into equal quintiles by ranked deprivation score. Three patient cohorts were defined: myocardial infarction (n=111,990), secondary prevention (n=677,522), and stable angina (n=984,807). Treatments for all myocardial infarction patients in 2003 and 2007 was obtained from the Myocardial Ischaemia National Audit Project. Angina and secondary prevention treatment data in 1999 and 2007 were derived from the General Practice Research Database, the world9s largest longitudinal database of primary care records linked with morbidity and prescribing information. Treatment uptake estimates were age-standardised. Results The uptake of all therapies increased in all patient groups between 1999 and 2007, in both men and women. Improvements were most marked in the community, where use of β-blockers, statins, and ACEI/ARB for secondary prevention and treatment of angina essentially doubled, from around 30% to over 60%. Small age gradients persisted for some therapies, possibly reflecting ageism, appropriateness or clinical contraindications which could not assessed. No consistent gender differences were observed for ‘hard’ diagnoses (myocardial infarction, postrevascularisation), although some inequality was apparent in the treatment of younger women with angina (a less precise category). Socioeconomic gradients were likewise absent for both myocardial infarction and secondary prevention, and gradients in patients with angina apparently favoured greater treatment uptake in the most deprived. Discussion For a decade the National Service Framework has spearheaded efforts to reduce cardiovascular mortality. The marked improvements reported here represent a triumph for the NHS. An equally important success story lies behind these headlines. The NHS is generally delivering equitable cardiovascular treatment, independent of socioeconomic status. However, there is no room for complacency. Future strategies should aim to further increase overall treatment levels and eradicate the remaining age and gender inequalities.

Background Coronary heart disease (CHD) remains a leading cause of UK mortality, generating a large and unequal burden of disease. CHD costs the UK in excess of £6 billion annually, with estimated statins costs exceeding £840 million. Dietary trans fats represent a powerful CHD risk factor. However, UK efforts to reduce intake (currently approximately 1% of daily energy) have been less successful than some other nations, such as Denmark and the USA. Furthermore, the potential heath and economic outcomes of a legislative ban, and the effects upon health inequalities, have not been well quantified. We therefore aimed to model the potential health and economic effects of a UK legislative ban on industrial trans fats up to 2030. Methods We extended the previously validated IMPACTsec model, to estimate the potential effects of a ban on dietary industrial trans fats upon the England and Wales population aged over 25 years. We stratified these estimates by age, sex and socio-economic circumstances. Data sources included Hospital Episode Statistics, General Practice Registry Database, and Office of National Statistics. Cost data was sourced from Department of Health, NICE and British Retail Consortium. We estimated the subsequent economic effects of a legislative ban upon healthcare, informal care, productivity, and industry and the disease burden (expected CHD deaths, life years gained (LYGs), Quality adjusted life years (QALYs) and hospital admissions) over a 15 year horizon to 2030. The baseline results were tested in a probabilistic sensitivity analysis. Results A legislative ban on industrial trans fats across the England and Wales population, reducing intake to 0.5% of daily energy intake would result in approximately 5468 fewer deaths per year, (95% confidence intervals (CI) 5459–5477), with some 6000 fewer hospital admissions (95% CI 5300–6700); and gaining approximately 43,400 additional life years (95% CI 43,200–43,700). This would also reduce health inequalities, having a substantially larger beneficial effect upon mortality and LYGs in the most deprived, than the most affluent. A legislative ban could result in savings in excess of approximately £2 billion and generate gains of over 400,000 QALYs over a 15 year period. This would include annual savings of approximately £16 million in direct healthcare costs, some £50 million productivity gains and approximately £70 million savings in informal care costs. Industry reformulation costs would be relatively small. Conclusion Eliminating the UK dietary intake of industrial trans fats could substantially decrease CHD mortality, whilst also resulting in substantial savings annually. Urgent fiscal or legislative action is warranted.

Background Blood pressure reduction is an important target for the prevention of coronary heart disease (CHD). In 1982, Rose proposed that small population-wide reductions in blood pressure, through public health measures to reduce salt intake, might deliver larger reductions in CHD mortality than by treating hypertensive patients. We aimed to estimate the potential for each strategy to reduce future CHD deaths in England and Wales. Methods We used the Stock of Health (SoH) model, where each individual is born with a 100% stock which then depreciates year-by-year, reflecting fixed and modifiable risk factors. A CHD death occurs when the individual’s CHD’s SoH falls below a critical point. Births, deaths and risk factor distributions were obtained from the Office of National Statistics and the Health Survey for England. Model parameters were calibrated using data from the US Cardiovascular Lifetime Risk Pooling Project. We modelled ten policy scenarios: population-wide, individual-based and combination strategies. The population-wide strategies were: a systolic blood pressure (SBP) reduction of 0.1 mmHg achieved by health promotion media strategies (Pop1), a 1.3 mmHg reduction achieved by mandatory salt reformulation (Pop2) and an attainable goal where SBP levels fall to those observed in the US population (Pop3). The individual-based strategies assumed that in currently uncontrolled hypertensive patients, control was then achieved in 30% (Indi1) and 50% (Indi2) of them. Results We forecast that approximately 467,200 CHD (95% CI 466,900–467,600) deaths may occur between 2013 and 2030. By controlling 30% and 50% of hypertensive patients, we predict approximately 3800 (3200–4300) and 6200 (5700–6800) fewer deaths respectively. Conversely, we predict approximately 1300 (800–1900) fewer deaths by health promotion; some 16,400 (15,800–16,900) fewer deaths by mandatory reformulation and approximately 25,400 (24,900–25,900) fewer deaths by gradual SBP declines to US levels. Combining Pop1 and Indi1 might achieve approximately 5100 (4500–5600) fewer deaths in 2030; whereas combining Pop1 and Indi2 could achieve some 7500 (2000–13,000) fewer deaths. Combining Pop2 and Indi1 might prevent approximately 19,700 (19,200–20,300) deaths; while combining Pop2 and Indi2 could prevent or postpone some 21,900 (21,400–22,400) deaths by 2030. Conclusion Both population-wide salt reduction policies and individual-based treatment strategies could substantially reduce CHD deaths in England and Wales. Even greater reductions in mortality might be achieved by reducing SBP to US levels. However, there is no clear single successful intervention, but both types of strategies are needed to maximise our chances of controlling the burden of mortality attributable to blood pressure.

Background Between 2000 and 2010, coronary heart disease (CHD) mortality rates in Scotland fell by over one third. Important contributions came from reductions in blood pressure and serum cholesterol (primary prevention). However, the relative contributions from preventive medications (anti-hypertensives and statins) in individuals and from population-wide dietary changes remain unclear. We therefore examined the impact of differential effects on health inequalities. Methods We used the previously validated IMPACTsec model to estimate the contributions of population-level risk factor changes and treatment changes to the CHD mortality decline in Scotland between 2000 and 2010 for adults aged over 25. Data were stratified using the Scottish Index of Multiple Deprivation (SIMD), a small area measure of deprivation. Model outputs were quantified as deaths prevented or postponed (DPPs) by each intervention. Sensitivity analyses were conducted using Ersatz-based Monte Carlo simulations. Results Between 2000 and 2010, 5770 fewer CHD deaths than expected occurred in Scotland; an estimated 3570 (62%) were attributable to reductions in blood pressure and serum cholesterol. Declines in blood pressure were responsible for approximately 2285 DPPs (minimum estimate 1630, maximum estimate 2915). The vast majority (2130 DPPs) came from population-wide blood pressure falls, with bigger absolute mortality decreases in the most deprived quintile compared with the least deprived (460 vs. 340 DPPs respectively); relative contributions were similar (37.2% and 37.5%). Anti-hypertension medications resulted in only 155 fewer deaths, with similar DPPs in the most (35) and least (30) deprived quintiles. Reductions in serum cholesterol resulted in 1280 fewer deaths; approximately 515 of these were attributable to population-wide changes in diet with more deaths prevented in the most deprived quintile compared with the least deprived (170 vs. 45 DPPs; relative contribution 13.8% and 4.7%). Conversely, approximately 770 fewer deaths were attributable to statin use, with very similar absolute numbers of deaths prevented in most (140) and least (140) deprived quintiles, but relatively greater contributions in the least deprived (15.4% vs 11.2%). Statin uptake was higher in the most deprived areas (17% vs 13.2%). Conclusion Population-wide falls in blood pressure helped to reduce CHD mortality; however the benefit from hypertension treatment was small. Improved diet and statins for high-risk individuals both made important contributions to the fall in population cholesterol. Population-wide falls in blood pressure and reductions due to medical treatments for hypertension were equitable between socio-economic groups. Higher socio-economic groups appeared to benefit more from statins, probably due to better compliance; this may perpetuate inequalities.

Background Sugar is seen by some as the next “public health frontier”. Indeed, increasing evidence associates excess refined sugar intakes with obesity, type 2 diabetes and heart disease. Worryingly, the estimated volume of sugary drinks purchased in the UK has more than doubled between 1975 and 2007, from 510ml to 1140ml per person per week. Might a fiscal intervention promote public health? In this study, we therefore aimed to quantify the potential benefits of putting a duty on sugary drinks. Methods We accessed National Diet and Nutrition Survey (NDNS) data and drinks manufacturers’ sales data on sugar sweetened beverages (SSBs). We then modelled plausible low, mid and high intake policy scenarios; combining this with data from two recently published models of obesity and associated diseases and Quality Adjusted Life Years (QALYs). We assumed a linear relationship between calories consumed, rates of obesity and obesity-related diseases, specifically diabetes, stroke and coronary heart disease (CHD), and cancer. We then conducted rigorous sensitivity analyses. Results In England, we estimated that a 20% SSB duty could reduce average energy consumption by approximately 8kcal per person per day. That mid consumption policy scenario might cut obesity rates by 1% (from 24.1% to 23.9% of adults) which equates to approximately 100,000 fewer obese people. This duty would result in approximately: 60,000 fewer cases of diabetes per year; 41,000 fewer cases of CHD and stroke per year; 11,000 fewer cases of cancer per year; one million QALYs gained per year; and £18 million in healthcare cost savings per year. In terms of parameters, the main driving factor for the potential reduction in obesity and associated disease was the level of SSB consumption in the population. For the low and high consumption scenarios respectively, a 20% duty could cut obesity by an estimated 0.5%–1.5%, with approximately 495,000–1.5 million QALYs gained and £9million–£28 million in healthcare cost savings per year. Conclusion A 20% duty on sugary drinks could dramatically reduce the obesity disease burden and also achieve substantial savings. Our findings support the Sustain report which recently estimated that a 20% duty could generate up to £1billion in annual tax revenues. Such revenues could be spent on interventions to improve health, such as subsidised healthy foods, food growing co-ops, walking and cycling.

Background Coronary heart disease (CHD) deaths in the UK have plummeted since the 1970s. However, CHD remains the biggest single cause of premature mortality, particularly in deprived social groups. But have all social groups benefited equally from these declines? Or do the headline figures conceal differences in rates of decline among social strata, potentially generating conflicting views on inequalities? Our analysis therefore aimed to examine whether the rapid declines in overall CHD mortality have benefited all socio-economic groups, and explore the implications for future projections. Methods We used a Bayesian analysis of an age-period-cohort model for the English population with data from Office for National Statistics (ONS). We projected age-specific CHD mortality by gender and deprivation status for the period 2007–2035, using 1982–2006 as the input. We converted the age-specific values to premature CHD death rates (ages 35–74). Deprivation status was measured by Index of Multiple Deprivation quintiles, which aggregate seven types of deprivation, including health and income. We first analysed the influence of the population-level trend in premature CHD mortality on absolute inequality, and second investigated the contributions to change in relative inequality. We quantified inequality by the variance in the probability of premature death among deprivation quintiles. Furthermore, we introduced a method to analyse the contribution of each group to the change in variance over time. Results We found that overall mortality trends conceal heterogeneities. Our models predict more rapid declines in premature CHD death for the most affluent than for the most deprived quintiles (annualised rate of decline 2006–2025, 7.9% [95% CI 4.7–11.0% ] versus 6.0% [ 1.9–10.0% ] for men, and 6.3% [ 3.5–9.0% ] versus 5.9% [ 2.2–9.5% ] for women). Absolute inequality was projected to decrease by 87% ( 29–98% ) among men and by 89% ( 48–98% ) among women. This decrease was particularly driven by the most deprived groups, reflecting their higher premature death rates. However, relative inequality was projected to rise by 60% among men ( 26–107% ) and by 10% ( -15–42% ) among women. Because premature death is declining more slowly in the most deprived, these increases are also mostly influenced by the most deprived. Conclusion Overall, premature coronary death rates in England continue to decline steeply, regardless of deprivation status. Furthermore, absolute inequalities are decreasing, reflecting declines in the high premature mortality burden in deprived groups. However, relative inequalities are projected to widen further, reflecting slower mortality declines in the most deprived groups. We suggest that more aggressive and progressive prevention policies are urgently needed.

Background Between 2001 and 2011, UK adult salt-intake fell by 15%, reflecting a comprehensive strategy led by the Food Standards Agency. Yet hypertension remains common in the UK, suggesting that further progress on salt-reduction could bring additional public health benefits. However, it is unclear how the overall effect of such policies might impact socio-economic class (SEC) inequalities in cardiovascular health. Our study therefore aimed to help inform decision making on salt-reduction policies during the next UK parliament, 2015 to 2020. Methods We extended the IMPACT SEC socially-stratified epidemiological model. We linked policy effects on salt, via systolic blood pressure, to premature CHD deaths (ages 35–74 years) in England 2015 to 2020. We used data from the Health Survey for England, published meta-analyses, and the Office for National Statistics. SEC was quantified by quintiles of the Index of Multiple Deprivation. We assessed the effects of product reformulation (voluntary or mandatory), social marketing and nutrition labelling against a forecast counterfactual of premature CHD deaths. We supplemented the scarce evidence-base on key policy parameters with expert opinion. Ten experts participated; all were scientists or policy experts in the academic or non-governmental sectors. Expert data were obtained using a pre-piloted, one-page questionnaire on the perceived effectiveness and inequality of salt-reduction interventions up to 2020. For each parameter, we elicited best, minimum, and maximum estimates. We estimated each intervention’s impact on inequality by its effect on the mortality gap between the least and most deprived SEC groups. Uncertainty was quantified using probabilistic sensitivity analysis. Results Our results suggest that, measured cumulatively over our study period, mandatory reformulation might prevent or postpone approximately 8300 premature CHD deaths ( 95% confidence interval: 5300, 11400 ) and reduce the inequality gap by some 1800 ( 1200, 2600 ) deaths. Voluntary reformulation could prevent or postpone approximately 1000 ( 200, 3800 ) deaths and reduce inequality by approximately 200 ( 0, 900 ) deaths. The estimated effects of behaviour change policies (social marketing and labelling) appeared much weaker: each might prevent or postpone approximately 100 ( 0, 400 ) deaths. They also had negligible effects on inequality: social marketing might change inequality by –6 ( –50, 20 ) deaths and labelling by –4 ( –50, 20 ) deaths. Conclusion Our model for England suggests that reformulation could be the most effective and equitable intervention against premature CHD deaths, especially if mandatory. By contrast, social marketing and labelling might have relatively little impact on the number of deaths or inequality.

Background In Poland between 1991–2002, total blood cholesterol falls (reflecting better diets) explained approximately 40% of the decline in coronary heart disease mortality. In turn, these dietary improvements reflected major economic changes (stopping meat and fat subsidies plus massive imports of vegetable oils, fresh fruit and vegetables). Our current study aimed to examine the drivers for recent changes in population total cholesterol levels since 2002. Methods We used data from two independent, national-representative cross-sectional studies in adults aged 18–79 years conducted in 2002 (n = 2993) and 2011 (n = 2413). These surveys included questionnaires and cardiovascular risk factor measurements. Fasting total cholesterol was measured in venous blood samples in one central laboratory using a standardised enzymatic method. For each study participant taking statins in 2011, we calculated the expected therapeutic reduction in total cholesterol level attributable to this medication (based on published meta-analyses of efficacy for specific statins and doses). Change in mean total cholesterol between 2002 and 2011 was measured and calculated, along with estimates of values expected if statins had not been used. Probabilistic sensitivity analyses were then performed to quantify uncertainty. Statins uptake in 2002 was not accounted because this data were not collected. We assumed very low impact of statins use in this year (supported by data from a related survey showing that the total lipid-lowering drugs uptake in 2003 was 3.9%, usually using less effective drugs at lower doses). Results Statin uptake in Poland in 2011 was 11.0% (95% CI: 9.2–12.8) in men and 11.4% (95% CI: 9.6–13.2) in women overall, rising to approximately 35% and 30% respectively in men and women aged 60–79 years. Mean total cholesterol in Poland in 2002 was 206.7 mg/dL (95% CI: 204.7–208.7). By 2011, this fell by 8.1 mg/dL (95% CI: 5.5–10.7) (7.3 in men and 8.9 in women). The biggest fall, of 22.2mg/dL (95% CI: 16.8–27.6), was observed among older individuals aged 60–79 years (18.9mg/dL in men and 24.5mg/dL in women). The fall in total cholesterol estimated in 2011 if statins had not been used was only 0.8mg/dL (95% CI: 1.8–3.5) for the total adult population and 1.3mg/dL (95% CI:4.4–7.1) in people aged 60–79 years. Thus, statin use explained approximately 90% (95% CI:53–125) of the observed decreases in total cholesterol levels. Conclusion Statin medications therefore apparently explained a substantial fraction of the observed fall in population total cholesterol level in Poland since 2002, while recent improvement in diet in Poland slowed down. In conclusion, there is a pressing need to introduce more effective dietary policies in Poland.

Background Public health policy development has many uncertainties, including a lack of data on the differential socio-economic impacts of interventions. Successfully capturing quantitative prior estimates of policy outcomes from topic experts could be valuable. We therefore aimed to develop a rapid methodology to elicit experts’ quantitative assessments of the effectiveness and equity of future policies, piloted initially on salt-reduction policies in England. Methods We identified three possible future salt policy options: voluntary product reformulation, social marketing and nutrition labelling. We developed a conceptual framework that distinguished structural and agentic policies; this quantitatively described each policy by its efficacy, coverage, ultimate population effect and potential inequalities. We developed an elicitation process to obtain expert views on potential policy changes up to 2020. A draft questionnaire was piloted iteratively to refine content and language. The resulting seven item questionnaire elicited the estimated best, minimum and maximum effect sizes for each policy parameter, plus socio-economic differentials (across quintiles of the Index of Multiple Deprivation). We approached twenty scientists and policy experts in the non-governmental and academic sectors. After obtaining formal consent, each expert was given a brief introduction to the project context and invited to complete the questionnaire. We quantified uncertainty from 10,000 probabilistic samples of the experts’ estimates. Results Fourteen of the twenty experts approached agreed to participate; eleven provided complete responses. The experts estimated that further voluntary reformulation could result in approximately 39% of products being reformulated by 2020 (95% CI: 13–76%). In these products, the experts expected a 22% ( 9–45% ) salt-content reduction. Less progress was expected in the most deprived fifth, who the experts considered might experience approximately 82% ( 18–150% ) of the reduction in the most affluent fifth. We asked the experts to assume a baseline of 10% of individuals currently exposed to social marketing and 10% exposed to nutrition labelling. They estimated that this exposure would change to approximately 24% ( 8–55% ) with developments in social marketing and approximately 26% ( 9–50% ) with developments in nutrition labelling. Experts considered that the most deprived fifth might experience an increase in exposure about 45% ( 15–89% ) of that in the least deprived fifth for social marketing, and 49% ( 8–110% ) for nutrition labelling. Conclusion We describe the development of a user-friendly, transparent procedure to rapidly elicit experts’ quantitative estimates on population effects and inequalities. Such data could potentially inform debate or policy formation, populate models or guide further empirical studies.

Background Coronary Heart Disease (CHD) disease remains a leading cause of UK mortality, generating a large and unequal burden of disease. Dietary trans fats represent a powerful CHD risk factor. However, UK efforts to reduce the dietary intake of industrial trans fats (currently approximately 1% of daily energy) have been less successful than some other nations, such as Denmark, Iceland, Austria, Switzerland and the USA. Furthermore, the potential outcomes of such measures, and the effects upon health inequalities, have not been well quantified. We therefore aimed to model the potential effects of specific reductions in trans fats intake on CHD mortality, CHD related admissions, and further examined the potential distribution of these effects by socio-economic position up to 2030. Methods We extended the previously validated IMPACTsec model, to estimate the potential effects of reductions in trans fats intake upon the England and Wales population aged 25 years and above. We stratified these estimates by age, sex and socio-economic circumstances (SEC). We estimated a reduction in expected CHD deaths in 2030 attributable to a modest reduction in industrial trans fats intake (-0.5% energy) and a complete ban (-1% energy). Main output measures were deaths prevented or postponed, life years gained and hospital admissions. Results were tested in a probabilistic sensitivity analysis. Results Reducing trans fats consumption in the England and Wales population by 0.5% of daily energy intake would result in approximately 1900 fewer deaths per year (minimum estimate 1700, maximum estimate 2200), some 5000 fewer hospital admissions (min 4300, max 5700), and approximately 18,000 additional life years (min 15,000, max 22,000). This would also reduce health inequalities, preventing about six times as many deaths and gaining six times as many life years in the most deprived quintile compared with the most affluent. Complete elimination of industrial trans fats (a 1% reduction in energy) would generate approximately 3900 (min 3300, max 4400) fewer deaths, 10,000 (min 8800, max 10,300) fewer hospital admissions, and approximately 37,000 (min 30,000, max 45,000) life years gained. Reductions in inequalities would be correspondingly large. Discussion Reducing dietary intake of industrial trans fats could substantially decrease CHD mortality and hospital admissions, and gain tens of thousands of life years. Crucially, this policy could also reduce health inequalities. UK strategies should therefore aim to minimise industrial trans fats intakes, as successfully achieved in many other European countries.

Background Although cardiovascular diseases remain the most important cause of death in the Slovak Republic, mortality rates from coronary heart disease (CHD) have substantially decreased in the last two decades. The aim of this modelling study was therefore to try and quantify the main contributions to this mortality decline. Methods Data covering adults aged 25–74 years in the Slovak Republic (population 3.5 million) between the years 1993–2008 were identified, obtained and scrutinised. These data detailed trends in major population cardiovascular risk factors (smoking, blood pressure, total cholesterol, diabetes prevalence, body mass index (BMI) and physical activity levels), and also the uptake of all standard CHD treatments. The main data sources were official statistics, national representative studies, published trials and meta-analyses, and the Slovak CINDI studies. The previously validated IMPACT policy model was then used to combine and integrate these data with effect sizes from published meta-analyses quantifying the effectiveness of specific evidence based treatments, and population-wide changes in cardiovascular risk factors. Results were expressed as deaths prevented or postponed (DPPs). Uncertainties were explored using probabilistic sensitivity analyses. Results Between 1993 and 2008 age-adjusted CHD mortality rates in the Slovak Republic decreased by 23% in men and 26% in women aged 25–74 years, representing 1950 fewer CHD deaths in 2008. Improvements in the uptake of evidence based treatments explained approximately 48% of the mortality fall (mainly reflecting contributions from treatments for acute coronary syndrome, acute and chronic heart failure and primary prevention, ie. statins and anti-hypertensives). Changes in CHD risk factors explained approximately 43% of the total mortality decrease (resulting mainly from positive changes in total serum cholesterol). However, most other risk factors demonstrated adverse trends and thus generated approximately 575 additional deaths. Results remained relatively stable under a range of sensitivity analyses. Conclusion This preliminary analysis suggests that approximately half the coronary heart disease mortality fall recently observed in the Slovak Republic may be attributable to evidence based treatments, with much of the remainder coming from large falls in total serum cholesterol. The adverse trends observed in all the other major cardiovascular risk factors (smoking, blood pressure, BMI, diabetes and physical inactivity) in the Slovak Republic are deeply worrying, and emphasise the need for more energetic population-wide prevention policies.

Background Middle income countries are facing an epidemic of non-communicable diseases, especially coronary heart disease (CHD). We used a previously validated CHD mortality model (IMPACT) to examine recent trends in CHD mortality in Tunisia, Syria, the occupied Palestinian territory (oPt – West Bank) and Turkey. Methods Data on populations, mortality, patient groups and numbers, treatments and risk factor trends from national and local surveys in each country were collated over two time points. Populations of studied countries and timeframes for this analysis were: Tunisia (10 million, 1997–2009), Syria (19 million, 1996–2006), OPt (2.5 million, 1998–2009) and Turkey (73 million, 1995–2008). We integrated and analysed data using the IMPACT model, with uncertainty explored using probabilistic sensitivity analyses. We reported the percentage of the observed change in CHD deaths explained by changes in uptake of medical and surgical treatments and major CHD risk factors for each country. Results Risk factor trends: Regional smoking prevalences were high in men, persisting in Syria but decreasing in Tunisia (-11%), oPt (-25%) and Turkey (-45%). Obesity (body mass index) rose by 1–2kg/m 2 and diabetes prevalence increased by 40%–50% in all four countries. Mean systolic blood pressure and cholesterol levels increased in Tunisia and Syria but decreased in oPt and stayed constant in Turkey. Mortality trends: Age adjusted CHD mortality rates rose by 30% in Tunisia (49/10 5 to 64/10 5 ) and by 56% in Syria (108/10 5 to 169/10 5 ). Much of this increase (98% in Tunisia, and 80% in Syria) was attributable to adverse trends in major risk factors, and occurred despite some improvements in treatment uptake. CHD mortality rates fell by 25% in oPt (85/10 5 to 64/10 5 ) and by 17% in Turkey (418/10 5 to 345/10 5 ), with risk factor changes accounting for around 65% and 60% of this reduction respectively. Increased uptake of community treatments accounted for the remainder. The IMPACT model explained approximately 77% of the observed mortality trends in Turkey and oPt, but less in Syria and Tunisia. Results remained fairly consistent following sensitivity analyses. Conclusion Eastern Mediterranean countries have shown highly heterogeneous trends in blood pressure, blood cholesterol and CHD mortality. Death rates are rising in Tunisia and Syria, whilst Turkey and occupied Palestinian territories demonstrate clear mortality falls, reflecting improvements in major cardiovascular risk factors, plus contributions from community-based medical treatments. However, across the region, smoking prevalence remains very high in men, and obesity and diabetes levels are rising dramatically. Powerful prevention policies exist and should now be implemented.

Objectives To explore the process of public health decision-making, and the role of research evidence, taking cardiovascular disease (CVD) as a case study. Design In-depth interview study. Setting and Participants Over 30 public health policy-makers and planners in CVD, including: commissioners, public health consultants, data analysts, librarians and knowledge managers at Primary Care Trusts; public health academics; lead consultant cardiologists; local and national guideline developers; and third sector staff. Methods In-depth semi-structured interviews were recorded and transcribed verbatim. Transcripts and field notes were analysed using the constant comparative method. Findings Participants reported that previously there was relatively little change in health care investment year on year. Consequently, it was seldom necessary to seek research evidence. However, changes had occurred in recent times. National Health Service (NHS) cuts had led to a more systematic prioritisation process necessitating the explicit use of research evidence. There was a sense that decision-makers must now take stock of what they were doing and ascertain if it was evidence-based. Unfortunately, these cuts had also removed much of the opportunity for creative thinking and for trying out new and unproven innovations. Despite most participants wishing to address “upstream” issues, a focus on short-term national targets appeared to have constrained the adoption of population-level prevention initiatives in favour of “downstream” service development approaches. Furthermore, participants anticipated increased rationing of health care in the near future. Reliable research evidence was considered essential to inform rationing decisions. However, most academic research was perceived to be aimed at clinicians. Guidelines, particularly those produced by the National Institute for Health and Clinical Excellence (NICE), as well as local data (such as hospital statistics), were currently the main sources of evidence used by policy-makers and planners. In order to facilitate future decision-making, participants requested that researchers provide unequivocal evidence on the best approaches to service delivery. Conclusions Most policy-makers and planners rely on NICE guidance and local data rather than directly accessing research evidence. Furthermore, public health decision-making in the NHS is constrained by organisational rigidity imposed by historic budgets and short-term national targets. Recent NHS cuts have led to increased systematisation and an emphasis on the evidence base. However, these cuts have also led to a focus on downstream interventions. In future, more effective health care rationing may require additional research on models of service delivery.

Purpose In 1987, Northern Ireland had one of the highest rates of coronary heart disease (CHD) mortality in the world. However, CHD mortality has declined substantially over the last 2 decades. The purpose of this study is to determine the contribution of changes in CHD risk factors to CHD mortality decline from 1987 to to 2007. Methods The validated IMPACT CHD mortality model was used in all calculations. We included data describing population size, CHD mortality and risk factor trends in adults aged 25–84 years old between 1987 and 2007. Regression coefficients and RR from the published literature quantified the relationship between population changes for a specific CHD risk factor (ie, smoking, diabetes, systolic blood pressure, total cholesterol, physical inactivity and obesity) and CHD mortality. The outcome of interest was the number of deaths prevented or postponed (DPPs) associated with changes in each specific CHD risk factor. Sensitivity analysis was applied to these estimates. Results Preliminary results from 1987 to to 2007 indicate that the overall age-standardised CHD mortality rate in Northern Ireland (age 25–84 years) fell from 361 to 124 deaths per 100 000 inhabitants, resulting in an estimated 3180 fewer CHD deaths in 2007. Changes in CHD risk factors produced a total of 2090 fewer CHD deaths (minimum estimate 1410; maximum estimate 2820) in Northern Ireland. These reductions therefore accounted for approximately 65% of the total decrease in CHD mortality. The largest effect came from the substantial fall in total cholesterol (explaining approximately 40% of the reduction in CHD mortality), followed by reductions in smoking (24%) and population systolic blood pressure (17%). However, increases in some risk factors had a negative effect, actually increasing CHD mortality: diabetes prevalence (−9%), physical inactivity (−5%) and BMI (−2%). Research is currently underway to estimate the additional contribution of improved treatment uptake and effectiveness to the reductions in CHD mortality. Conclusions Approximately two thirds of the recent large fall in CHD mortality in Northern Ireland between 1997 and 2007 was attributable to reductions in major cardiovascular risk factors. However, adverse trends in diabetes, obesity and physical inactivity are of major concern. More aggressive policies to promote healthy food and increase physical activity may therefore be needed to decrease future CHD deaths.

Background Historically, policy initiatives have made variable contributions to improvements in public health. Today there is a growing interest in translating evidence from health research into healthy public policy. Although research evidence may be a component of policy development, it is rarely enough, because policy makers are subject to a wide range of influences. Furthermore, researchers and policy makers usually work within different time frames and rules of evidence. There is a growing, albeit limited, literature on how researchers can most effectively engage with policy makers. Evidence suggests that more active and effective dialogue between researchers and policy makers is needed, in the formulation of research questions, presentation of evidence, and drafting and choice of policy options. Aim To develop, implement, and evaluate an interactive approach to informing policy for the prevention and management of cardiovascular disease (CVD) and diabetes. Setting This work is being undertaken in four eastern Mediterranean territories, known to have high burdens of CVD and diabetes: Palestine, Tunisia, Turkey and Syria. Methods and results Available epidemiological data are being identified, appraised and used to populate the IMPACT CHD Policy Model in order to examine CHD trends. Two corresponding epidemiological models have been developed to examine trends in type 2 diabetes and ischaemic stroke. An intensive review of the literature and consultation assists in the identification of efficacious policy interventions. A situation analysis is being undertaken within each country using mixed methods, which include: key informant and in depth interviews, document reviews, and participant observation. Its aim is to review current policy (stated and implemented), perceived facilitators and barriers to policy change, including health beliefs, and aspects of the health system. Policy makers are explicitly involved as key informants, participants, advisors and “lobbyists”. The epidemiological modelling, evidence based reviews, and situation analyses are together being used to generate diverse policy options. The cost-effectiveness of each chosen option will then be assessed. Conclusions We have developed a provisional framework for developing policy options, initially for the prevention of CVD and diabetes. This is based on local epidemiological data, an assessment of the socio-political-cultural context and cost effectiveness. Policy makers are involved throughout, and will be presented with costed policy options along with their potential consequences. Implemented options will then be evaluated. The framework represents a “policy effectiveness-feasibility loop”, analogous to Tugwell9s clinical effectiveness loop. The impact of this approach, and its potential generalisability, will be rigorously evaluated.

Background Poland has experienced one of the most dramatic declines in coronary heart disease (CHD) mortality rates in recent decades. This decline reflects the use of evidence based treatments and, crucially, population wide changes in diet. Our aim is to explore the potential for further gains in Poland by achieving population wide reductions in smoking, dietary salt and saturated fat intake and physical inactivity levels. Methods A validated and updated policy model was used to forecast potential decreases in CHD deaths by 2020 as consequence of lifestyle and dietary changes in the population. Data from the most recent Polish risk factor survey was used for the baseline estimates (2011). We modelled two different policy scenarios regarding possible future changes in risk factors: A) conservative scenario: reduction of smoking prevalence and physically inactivity rates by 5% between 2011 and 2020, and reduction of dietary consumption of energy from saturated fats by 1% and of salt by 10%. B) ideal scenario: reduction of smoking and physically inactivity prevalence by 15%, and dietary reduction of energy from saturated fats by 3% and of salt by 30%. We also conducted extensive sensitivity analysis using different counterfactual scenarios of future mortality trends. Results Baseline scenarios: by assuming continuing declines in mortality and no future improvements in risk factors the predicted number of CHD deaths in 2020 would be approximately 13,600 (95% CI 9838, 18184) while if mortality rates remain stable, the predicted number of deaths would approximate 22,200 (7792, 26688). Conservative scenario. Assuming continuing declines in mortality, small changes in risk factors could result in approximately 1500 (688, 2490) fewer deaths. This corresponds to an 11% mortality reduction. Under the ideal scenario, our model predicted some 4,600 (2048, 8701) fewer deaths (a 34% mortality reduction). Reduction in smoking prevalence by 5% (conservative scenario) or 15% (ideal scenario) could result in mortality reductions of 4.5% and 13.8% respectively. Decreases in salt intake by 10% or 30% might reduce CHD deaths by 3.0% and 8.6% respectively. Replacing 1% or 3% of dietary saturated fats by poly-unsaturates could reduce CHD deaths by 2.6% or 7.7%. Lowering the prevalence of physically inactive people by 5-15% could decrease CHD deaths by 1.2-3.7%. Conclusion Small and eminently feasible population reductions in lifestyle related risk factors could substantially decrease future number of CHD deaths in Poland, thus consolidating the earlier gains.

Background Between 2000 and 2007, coronary heart disease (CHD) mortality rates in England plummeted by one third. An important part of this substantial CHD mortality decline was achieved through reductions in major cardiovascular risk factors (primary prevention). However, the relative contributions from medications and from population-wide changes remains unclear, particularly the effects on health inequalities. Methods Using a previously validated policy model, the fall in CHD mortality in England was analysed. The contributions from risk factor declines in asymptomatic individuals through medications and through population-wide changes were quantified. Data were stratified using the Index of Multiple Deprivation (IMD). Model outputs were quantified as deaths prevented or postponed (DPPs). Results Between 2000 and 2007, approximately 21,900 fewer CHD deaths were attributable to risk factor declines in systolic blood pressure and cholesterol in the English population. Some 7,100 of these 21,900 fewer deaths (DPPs) were attributed to medications (32%) and approximately 14,800 DPPs were attributed to secular changes in asymptomatic individuals (68%). Substantial declines in systolic blood pressure were responsible for approximately 14,300 fewer deaths. This comprised approximately 12,500 DPPs attributable to population-wide changes and some 1,800 DPPs attributable to hypertension medications. The hypertension medications resulted in approximately 350 fewer deaths in the most affluent quintile compared with 270 DPP in the most deprived. In contrast, the population-wide (secular) falls in blood pressure resulted in approximately 2400 fewer deaths in the most deprived quintile compared with only 1900 DPPs in the most affluent. Cholesterol falls resulted in approximately 7,700 fewer deaths. This comprised some 5,300 fewer deaths attributable to statin medications and approximately 2,400 fewer deaths attributable to population-wide changes (mostly diet). Statin medications prevented more deaths in the most affluent quintile (1050 DPPs) compared with the most deprived (770 DPPs). Population-wide changes in cholesterol prevented substantially more deaths in the most deprived quintile (820 DPPs) compared with the most affluent (260 DPPs). Conclusion Population-based declines in blood pressure and cholesterol resulted in much greater reductions in CHD deaths than did primary prevention medications. Mortality falls were greatest in the most deprived quintiles, mainly reflecting their bigger initial burden of disease. Future CHD prevention policies should prioritise healthier diets ahead of medications.

Background EuroHeart II is a European programme designed to inform cardiovascular health strategies across Europe. Our project examines the role of food policies in cardiovascular disease prevention, including the development and piloting of a novel conceptual framework for categorising public health nutrition policies. Methods We conducted a mapping exercise to identify and categorise public health nutrition policy actions across 30 European countries using a novel framework. The framework was based on the traditional marketing “4Ps” approach: Price, Product, Promotion and Place (the “marketing mix”). A database was created to summarise public health nutrition policy for 30 European countries (EU 27 plus Iceland, Norway and Switzerland). National policies were classified according to Price (taxes, subsidises, other economic incentives); Product (reformulation, new healthier products); Place (schools, workplaces, community settings); and Promotion (advertising to children/general population, food labelling and health education initiatives). Results Dialogue, recommendations and nutrition guidelines are now widespread across Europe. Information and education campaigns are also widespread. These include campaigns covering the general population, and campaigns targeting schools, the workplace or communities. Subsidies for fruit in schools are almost universal through the EU School Fruit Scheme, but implementation differs across the 30 countries. New EU legislation supports limited, back of pack food labelling. Some countries have also implemented national legislation requiring more detailed label information about the nutritional value of foods (e.g. Finland). However, the presentation and information vary widely. Voluntary reformulation of foods is common, especially for salt, sugar and total fat (e.g. salt reduction in the UK). However, mandatory reformulation of products to reduce saturated fat and salt are still limited to trans fat bans in Austria, Denmark, Iceland and Switzerland. Legislation/regulation affecting salt, sugar, fat and fruit and vegetable consumption is uncommon, although several countries have legal requirements regarding the maximum salt content in certain foods (Belgium, Bulgaria, Finland, Greece, Latvia, Lithuania, Netherlands, Portugal, Romania, Slovak Republic, Slovenia and Wales). Taxes to promote healthy nutrition are currently used infrequently. However, Finland, France, Hungary and Portugal have implemented ‘sugar taxes’ on sugary foods and sugar-sweetened beverages. Hungary and Portugal also tax salty products. Conclusion The diverse public health nutrition activities across 30 European countries might initially appear complex and bewildering. However, the “4Ps” framework offers a potentially structured and comprehensive categorisation of these diverse interventions. National food policies in Europe are currently at very different stages of development and implementation. However, exemplar countries might include Denmark, Finland, Hungary, Iceland, the UK and Portugal.

Background Despite rapidly declining coronary heart disease (CHD) mortality rates over the last two decades, CHD mortality rates in the British Isles are still amongst the highest in Europe. Greater risk factor reductions have been achieved in many other countries in Europe and beyond. This study aimed to use a modelling approach to assess the potential impact of alternative future risk factor scenarios relating to smoking and physical activity levels, dietary salt and saturated fat intakes on future CHD mortality in three countries: Northern Ireland (NI), Republic of Ireland (RoI) and Scotland. Methods CHD mortality models previously developed and validated in each country were extended to predict potential reductions in CHD mortality from 2010 (baseline year) to 2030. For each country, using risk factor data from recent surveys as a baseline, we modelled alternative future risk factor scenarios: Absolute decreases in (i) smoking prevalence and (ii) physical inactivity rates of up to 15% by 2030; (iii) relative decreases in dietary salt intake of up to 30% by 2030 & (iv) relative decreases in% energy from dietary saturated fat of up to 6% by 2030 (replacing by polyunsaturated fats). Sensitivity analyses were then conducted. Results Projected populations by 2030 (adults aged 25-84) were 1.3, 3.9 and 3.9 million in NI, RoI and Scotland respectively. By 2030: assuming continuing declines in mortality: 15% absolute reductions in smoking could decrease CHD deaths by 6–8% (approximately 40, 130 and 210 fewer deaths In NI, RoI and Scotland respectively). 15% absolute declines in physical inactivity levels might decrease CHD deaths by 4% (approximately 30, 90 and 90 fewer deaths respectively). Relative reductions in salt intake of 30% could decrease CHD deaths by 3–4% (approximately 25, 75 and 110 fewer deaths respectively) and 6% in saturated fat intake might decrease CHD deaths by some 9–10% (approximately 65, 170 and 265 fewer deaths In NI, RoI and Scotland respectively). These projections remained stable under a wide range of sensitivity analyses. Conclusion Modest and feasible reductions in four CHD risk factors (which have already been achieved elsewhere) could translate into substantial reductions in future CHD deaths. More aggressive polices are therefore needed in the British Isles to control tobacco, promote healthy food and increase physical activity.

Background Coronary heart disease (CHD) and stroke account for approximately half of all-deaths in Syria. The country’s CHD mortality rate has escalated by nearly two-thirds between 1996 and 2006, partly reflecting substantial increases in systolic blood pressure (SBP). In high income countries, reduction of dietary salt intake represents a cost effective means of decreasing CHD events via reduced SBP levels. This study aims to assess the potential costs and benefits of implementing contrasting salt reduction policies in Syria, with particular emphasis on the feasibility of policies within the country’s socioeconomic and political realities. Methods A projected 10-year period cost-effectiveness analysis of salt reduction policies was conducted comparing three different approaches: health promotion campaign about salt reduction, labelling of salt content on packaged foods, reformulation of salt content within packaged foods, or a comprehensive strategy involving all three approaches. The incremental cost of a policy was calculated as the sum of CHD-related savings in healthcare costs and the costs of implementing and monitoring the policy, with costs presented in international dollars using 2010 purchasing power parity (PPP) exchange rates. Benefits were defined as life years gained (LYG) due to fewer CHD events. Data sources included existing national resources, international literature, and interviews with local food producers, manufacturers, and government agencies. The effect of salt reduction on SBP was based on review of the literature. Health care costs, LYG and expected CHD events were calculated using the IMPACT CHD model. Sensitivity analyses were conducted to account for the uncertainty in the reduction of salt intake. Results All policy combinations resulted in LYG when compared to no policy. Health promotion and labelling of salt content were both associated with low private sector costs and large healthcare savings. This resulted in cost savings for both policies alone and the comprehensive approach combining all three policies. Reformulation alone, reformulation plus health promotion, and reformulation plus labelling were not cost saving due to high private sector costs associated with reformulation (+PPP $96,000,000). However, the three policy approaches were very cost-effective with incremental costs of $5453 PPP, $2125 PPP, and $2201 PPP per LYG, respectively (well below the region’s established cost effectiveness threshold of PPP$12,250). Conclusion All salt reduction policies analysed resulted in a reduction of CHD deaths and were either cost-effective or even cost saving. This paper will provide further details concerning the feasibility of such policies in the context of a developing country.

Background Although Coronary Heart Disease (CHD) death rates have halved since the 1970s, CHD remains a major cause of mortality in the UK. Furthermore, population ageing plus recent increases in obesity and diabetes may soon increase total CHD deaths. Future CHD mortality predictions are thus potentially problematic. Our aim was therefore to explore future projections of CHD mortality in England & Wales under conventional but contrasting assumptions. Methods In SCENARIO 1, we assumed a conventional counterfactual, that recent CHD mortality rates (ONS, ICD10 codes I20-I25) in 2006 would persist unchanged. The future number of deaths was then calculated by projecting those rates into 2020 population estimates. In SCENARIO 2, we assumed that recent changes in CHD mortality rates would continue. We used a well-established hierarchical Bayesian Age Period Cohort (APC) model, which works under the assumption that variability in incidence data can be explained by age, period and cohort effects. We fitted this model to observed CHD mortality rate trends from 1982 to 2006. We then used the model to predict mortality rates in 2020, and then these rates applied to the 2020 population to compute future deaths. Results In SCENARIO 1 by assuming that 2006 mortality rates would continue at that level to 2020, the number of CHD deaths would substantially increase: +49% in men and +25% women (104,500 total CHD deaths in 2020). In SCENARIO 2, assuming recent trends continued, the APC model suggested that number of deaths would decrease by -48% (95% CI -25%, -64% in men); and -59% (-39%, -73%) in women (36,425 total deaths in 2020, despite a predicted slowing of the mortality decline in groups aged 35-64 years). Conclusion The decline in CHD mortality has been reasonably continuous since 1982, and there is little reason to believe it will soon abruptly halt, (the dubious underlying assumption of a commonly used mortality counterfactual). By contrast, the Bayesian APC model offers a far more plausible prediction of future trends by simultaneously considering age, period and cohort effects. Therefore, despite population ageing, the number of CHD deaths will most likely halve again between 2006 and 2020. However, CHD mortality rates elsewhere have previously shifted rapidly due to changes in population risk factors. There is thus no room for complacency.

Background Population-wide policy actions to promote a healthy diet offer potentially large benefits in terms of reducing the non-communicable disease burden. However, there are wide ranges of potential options, with varying effectiveness. In order to make sense of this diversity, we conducted a rapid scoping review and tested a simple conceptual framework for categorising policies based on the marketing “4Ps” approach (Price, Product, Place and Promotion). Methods We searched six electronic databases for quantitative assessments of the effectiveness of policies to improve people’s healthy eating; to change awareness, knowledge or attitudes towards healthy eating; or to improve self-efficacy, skill or competency concerning these behaviours. Reference lists were screened, and key informants identified additional evidence. Items were systematically assessed for inclusion. We initially sought systematic reviews, followed by primary studies and modelling studies. Extracted data were categorised using the marketing 4Ps framework. Combinations of interventions were categorised as “multi-component”. Included studies were synthesised as a narrative review (being too heterogeneous to combine quantitatively). Results Price interventions are potentially powerful, with greater effects likely in vulnerable (low income) groups who are generally more price sensitive (1 systematic review; 3 econometric modelling studies). Product interventions mostly aim to reformulate products to reduce salt, fat or sugar content. There is some evidence for their effectiveness, however, formal evaluations are few (2 primary evaluations; 2 modelling studies). Promotion interventions suggest modest benefits for national media campaigns (such as “5 a day”), but more limited benefits for health education, food labelling, marketing or dietary advice (4 systematic reviews; 4 primary evaluations; 1 modelling study). Place interventions targeting food product availability have shown some success in schools and workplace settings (5 systematic reviews; 10 primary evaluations). However, more research is needed into community and neighbourhood interventions. Overall, the evidence is most convincing for comprehensive and multi-component interventions, notably those targeted at decreasing salt and trans fats consumption or increasing fruit and vegetable consumption (5 systematic reviews; 7 primary studies). Empirical and modelling evidence, across the 4Ps, supports the logical assumption that interventions are more effective when reinforced by mandatory rather than voluntary regulation. Conclusion The marketing 4Ps framework offers a potentially useful approach for categorising the effectiveness evidence spanning a very wide range of healthy food policies. It helps identify promising interventions (such as taxes/subsidies and multi-component school/workplace interventions) as well as areas where further evidence is required (for example, on how to modify food availability in the community).

Background Cardiovascular disease (CVD) is one of the main contributors to health inequalities. CVD primary prevention includes potentially powerful interventions to promote healthy eating. However, might some dietary interventions actually widen the heath gap between rich and poor, thus leading to intervention-generated inequalities? Objective To systematically review the evidence for differential socio-economic effects associated with healthy eating policy interventions. Methods We initially searched two bibliographic databases (MEDLINE & Psycinfo) using a piloted search strategy. Results from further databases and additional sources will be reported in the final review. Search results were screened independently by two reviewers. We included evaluations of policy interventions to promote healthier diets, (defined as the reduced intake of salt, sugar, trans fats, saturated fat, total fat, or total calories, or increased consumption of fruit and vegetables). All quantitative studies were eligible for inclusion. Studies were only included if quantitative results were presented by socio-economic group (SEG), defined by income, education level, ethnicity, or occupational status. Extracted data were categorised with a modified version of the 4Ps marketing framework: Price, Product, Place and Promotion, with a 5th “P” labelled “Personal”, relating to person-based health education. Based on preliminary findings included studies were synthesised as a narrative review due to their heterogeneous nature. Results We identified 14,449 studies in the initial search and reviewed 47 full text papers. Following screening, only 14 articles met the inclusion criteria. Preliminary results analysed using the “5 P’s” framework suggest that some food policy interventions may generate socio-economic differentials. Price interventions showed the greatest potential to reduce health inequalities (3 of 5 studies). Conversely, Personal interventions tended to widen inequalities (3 of 4 studies showed preferential outcomes in higher SEGs). Results relating to Place interventions were mixed, with 2 school-based studies reporting a preferential outcome in higher SEGs, and 1 work-based study reporting a preferential outcome in lower SEGs. Evidence for Product and Promotion interventions appears sparse, with only 1 study found for each category. However, both reporting preferential outcomes in higher SEGs. Conclusion Interventions categorised by the “5 P’s” show differential effects on healthy eating outcomes by SEG, with interventions categorised as Personal appearing the most likely to increase health inequalities. However the vast majority of studies retrieved did not explore differential effects by socio-economic group. Future policies aimed at improving population health should be routinely evaluated for their potential impact on health inequalities.

Background EuroHeart 2 is a European research programme led by the European Heart Network and European Society of Cardiology (http://www.ehnheart.org/euroheart-ii.html). One aspect of the project aimed to identify the most effective public health nutrition policies, in order to inform future evidence-based strategies to promote cardiovascular health. We interviewed senior policy-makers and thought-leaders in 14 diverse EU countries to elicit their views on a very wide range of possible nutrition strategies covering the entire public health policy spectrum aimed at improving approaches to public health nutrition. Methods We first mapped national nutrition policies across 30 European countries. We then identified contacted and recruited potential participants in 14 diverse countries. Policy-makers, thought-leaders and others active in the field of public health nutrition at the national level were interviewed. Questions were first developed and piloted with senior stakeholders in the UK. The interviews were conducted in English, either by person, telephone or Skype. The interviews typically lasted between 45 and 60 minutes. The interviews were transcribed and entered into NVIVO software. The Framework approach was used to analyse the transcripts. Results We conducted 66 interviews in 14 countries across Europe. The interviews enabled more up to date and accurate information than was provided on websites or in reports. Responses revealed important differences between official lists of food policies and their actual implementation “on the ground”. European countries are at very different stages of addressing public health nutrition issues. Most are promoting dialogue, recommendations and guidelines (often considered an early part of the policy process). Voluntary reformulation of foods is also common, especially for salt, sugar and total fat. However, legislation regulation or fiscal interventions targeting salt, sugar, fat or fruit and vegetable consumption are still uncommon. Many interviewees expressed a preference for regulation and fiscal interventions and generally believed they were more effective, albeit politically more challenging. Conversely, information-based interventions were often seen as being more politically feasible. Conclusion Public health nutrition policies in Europe represent a complex, dynamic and rapidly changing arena. Encouragingly, the majority of countries are engaged in activities intended to increase consumption of health food, and decrease the intake of junk food and sugary drinks. Exemplar countries demonstrating notable progress might include Finland, Norway, Iceland, Hungary, the UK and Portugal. However, most countries fall well short of optimal activities. Implementation of potentially powerful nutrition policies remains frustratingly patchy across Europe.