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BACKGROUND: Low-income and middle-income countries (LMICs) face a double burden of malnutrition (DBM), whereby overnutrition and undernutrition coexist within the same individual, household, or population. This analysis investigates global inequalities in household-level DBM, expressed as a stunted child with an overweight mother, and its association with economic, social, and political globalisation across country income and household wealth. METHODS: We pooled anthropometric and demographic data for 1 132 069 children (aged

BackgroundThe double burden of malnutrition (DBM), which refers to the coexistence of overnutrition and undernutrition among populations, households or individuals, is a growing problem in low/middle-income countries. The Latin America and the Caribbean (LAC) region has been particularly affected by the DBM, following a nutrition transition and a rapid increase in overweight, obesity and diet-related disease, while high levels of undernutrition persist. This study aims to describe the prevalence of four different DBM definitions in mother–child pairs across nine LAC countries and investigate the socioeconomic determinants of overweight mothers with at least one stunted child (SCOM).MethodsWe used cross-sectional data from the Demographic and Health Surveys for all analyses. We used descriptive statistics to obtain prevalence rates and conducted multiple logistic regression analyses to investigate the association between SCOM households and socioeconomic determinants, including wealth index, maternal education, place of residency and whether the mother was working, adjusted for a range of variables.ResultsOverweight/obese mothers with at least one anaemic child were the most common type of DBM, with a prevalence of 19.39%, followed by SCOM with a prevalence of 10.44%. Statistically significant socioeconomic predictors of SCOM were households with a lower wealth index, lower maternal education and living in rural areas.ConclusionThis study showed that the overall prevalence of most DBM definitions examined was high, which points to the need for urgent interventions in the LAC region. The unique set of socioeconomic predictors of SCOM identified in this study calls for future double-duty policies that simultaneously target food affordability, nutrition education and access to healthy food.

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.

ObjectiveAn industry levy on sugar-sweetened beverages (SSB) was implemented in the UK in 2018. One year later, Brexit is likely to change the UK trade regime with potential implications for sugar price. We modelled the effect of potential changes in sugar price due to Brexit on SSB levy impacts upon CHD mortality and inequalities.DesignWe modelled a baseline SSB levy scenario; an SSB levy under ‘soft’ Brexit, where the UK establishes a free trading agreement with the EU; and an SSB levy under ‘hard’ Brexit, in which World Trade Organization tariffs are applied. We used the previously validated IMPACT Food Policy model and probabilistic sensitivity analysis to estimate the effect of each scenario on CHD deaths prevented or postponed and life-years gained, stratified by age, sex and socio-economic circumstance, in 2021.SettingEngland.SubjectsAdults aged 25 years or older.ResultsThe SSB levy was associated with approximately 370 (95 % uncertainty interval 220, 560) fewer CHD deaths and 4490 (2690, 6710) life-years gained in 2021. Associated reductions in CHD mortality were 4 and 8 % greater under ‘soft’ and ‘hard’ Brexit scenarios, respectively. The SSB levy was associated with approximately 110 (50, 190) fewer CHD deaths in the most deprived quintile compared with 60 (20, 100) in the most affluent, under ‘hard’ Brexit.ConclusionsOur study found the SSB levy resilient to potential effects of Brexit upon sugar price. Even under ‘hard’ Brexit, the SSB levy would yield benefits for CHD mortality and inequalities. Brexit negotiations should deliver a fiscal and regulatory environment which promotes population health.

Background The post-Brexit agricultural regime represents an opportunity to positively influence food systems and improve public health. Health-improving measures could include expanding the UK production of fruits and vegetables (F&V), thus increasing F&V availability. Currently, only 1.4% of total agricultural land in England is allocated to F&V. This study aims to estimate the potential impacts of allocating additional land to F&V production on cardiovascular disease (CVD) and inequalities in England between 2021 and 2030. Methods We used the previously validated IMPACT Food Policy model to translate changes in land allocated to F&V into changes in F&V intake and associated CVD mortality, expressed in number of deaths prevented or postponed (DPPs) by age, sex, and Index of Multiple Deprivation (IMD) quintile. We modelled two scenarios that assumed a linear increase in agricultural land allocated to F&V until it covers a) 10% and b) 20% of all land suitable for production of horticultural crops in England. We assumed that F&V prices would drop to a new equilibrium. We used Monte Carlo simulations to produce uncertainty intervals. Results Our model suggested that by 2030, F&V intake might increase by approximately 4% (95% Uncertainty Interval: 2%-7%) and 8% (4%-13%) respectively, under the first scenario. Under the second scenario, F&V intake could increase by approximately 17% (10%-29%) and 37% (26%-51%) respectively. These increases in F&V intake were associated with 3360 (1760-5920) CVD DPPs under the first scenario and 15700 (9000-24310) under the second scenario in 2021-2030. Our modelled scenarios could also reduce inequalities, with some 16% of DPPs occurring in the least deprived group compared with 22% in the most deprived. Conclusions Policymakers should consider the public health impacts of the post-Brexit agricultural regime in England. Increasing the land allocated to F&V production could substantially reduce the burden of CVD and associated inequalities. Key messages The post-Brexit agricultural policy can be an opportunity to improve diet and public health in the UK. Increasing the agricultural land allocated to fruit and vegetable production in England could reduce the burden of cardiovascular disease and associated inequalities.

Background Public-Private Partnerships (PPPs) are increasingly promoted as a key mechanism to improve population health, including addressing dietary risk factors for non-communicable disease. In 2011, England introduced the Public Health Responsibility Deal (RD), a PPP which gave greater freedom to the food industry to set and monitor targets for sodium intakes, and replaced an internationally recognised scheme involving more independent scrutiny. We estimated the impact of the RD on trends in population level sodium intake and associated changes in cardiovascular disease (CVD) and gastric cancer (GCa) incidence and mortality and their economic costs in England from 2011–2025. Methods We used interrupted time series models with 24-hour urine sample data to assess trends in sodium intake both before and after the implementation of the RD. We used the IMPACTNCD microsimulation model to estimate impacts of these changes in sodium consumption on CVD and Gastric Cancer incidence, mortality and economic impacts, as well as equity impacts. We modelled a baseline scenario of sodium intake continuing as it had pre-RD and compared observed intakes with this. Results Between 2003 and2010 mean sodium intake was falling annually by 0.20 grams/day among men and 0.12 g/d among women (p value for trend both Discussion These findings suggest that declines in sodium intake slowed after implementation of the RD in England and this likely generated excess CVD and cancer burdens, plus additional healthcare, and societal costs. Public private partnerships such as the RD which lack robust and independent target setting, monitoring and enforcement are unlikely to produce optimal health gains. Funding for this research was from the UK Prevention Research Partnership. UKPRP Consortium Development Grant. UKPRP_CO1_105. QUEST: QUantifying Equitable Solutions To prevent Non-Communicable Diseases. The School of Public Health at Imperial College London is grateful for the support of the NIHR SPHR.

Background Brexit might produce a new agricultural regime in the UK. The current Agriculture Bill, which will shape this regime, aims to provide financial assistance for the delivery of environmental aims. However, the current Bill may represent a missed opportunity to positively influence food systems and improve public health. Potential health-improving measures could include expanding the UK production of fruits and vegetables (F&V), thus increasing F&V availability and affordability. Currently, only 1.4% of total agricultural land in England is allocated to F&V. This study aims to estimate the potential impacts of allocating additional land to F&V production on F&V intake and associated cardiovascular disease (CVD) and inequalities in England between 2021 and 2030. Methods We used the previously validated IMPACT Food Policy model. We translated changes in land allocated to F&V into changes in F&V intake and associated CVD mortality, expressed in number of deaths prevented or postponed by age group, sex, and Index of Multiple Deprivation (IMD) quintile. The model combined publicly available data on agricultural land use and quality, F&V supply, waste, purchases and IMD-stratified intake, IMD-stratified CVD projections, and appropriate relative risks. We modelled two scenarios that assumed a linear increase in agricultural land allocated to F&V between 2021 and 2027 (the implementation period of the new policy) until it covers (a) 10% and (b) 20% of all high quality land suitable for production of horticultural crops in England. We assumed that F&V prices would drop to a new market equilibrium. We used Monte-Carlo simulations to produce uncertainty intervals. Results Our model suggested that by 2030, fruit intake might increase by approximately 4% (95% Uncertainty Interval: 2%-7%) and vegetable intake by approximately 8% (4%-13%) under the first scenario. Under the second scenario, fruit intake could increase by approximately 17% (10%-29%) and vegetable intake by approximately 37% (26%-51%). These increases in F&V intake might prevent or postpone approximately 3,360 (1,760–5,920) CVD deaths under the first scenario and 15,700 (9,000–24,310) CVD deaths under the second scenario, between 2021 and 2030. Our modelled scenarios could also reduce inequalities, with some 16% of these fewer deaths occurring in the most affluent group compared with 22% in the most deprived group. Conclusion Policymakers should urgently consider the public health impacts of the post-Brexit agricultural regime in England. Increasing the land allocated to F&V production could substantially reduce the burden of CVD and associated inequalities.

SummaryBackground Artificially sweetened beverages (ASBs) are promoted as healthy alternatives to sugar-sweetened beverages (SSBs) in order to reduce sugar intake, but their effects on weight control and glycaemia have been debated. This study examines associations of SSBs and ASBs with energy and sugar intake and cardiometabolic measures. Methods One thousand six hundred eighty-seven children aged 4–18 participated in the National Diet and Nutrition Survey Rolling Programme (2008/9–2011/12) in the UK. Linear regression was used to examine associations between SSBs and ASBs and energy and sugar, overall and from solid foods and beverages, and body mass index, waist-to-hip ratio and blood analytes. Fixed effects linear regression examined within-person associations with energy and sugar. Results Compared with non-consumption, SSB consumption was associated with higher sugar intake overall (6.1%; 4.2, 8.1) and ASB consumption with higher sugar intake from solid foods (1.7%; 0.5, 2.9) but not overall, mainly among boys. On SSB consumption days, energy and sugar intakes were higher (216 kcal; 163, 269 and 7.0%; 6.2, 7.8), and on ASB consumption days, sugar intake was lower (−1.0%; −1.8, −0.1) compared with those on non-consumption days. SSB and ASB intakes were associated with higher levels of blood glucose (SSB: 0.30 mmol L−1; 0.11, 0.49 and ASB: 0.24 mmol L−1; 0.06, 0.43) and SSB intake with higher triglycerides (0.29 mmol L−1; 0.13, 0.46). No associations were found with other outcomes. Conclusion Sugar-sweetened beverage intake was associated with higher sugar intake and both SSBs and ASBs with a less healthy cardiometabolic profile. These findings add to evidence that health policy should discourage all sweetened beverage consumption.

ObjectivesTo estimate the potential impacts of different Brexit trade policy scenarios on the price and intake of fruits and vegetables (F&V) and consequent cardiovascular disease (CVD) deaths in England between 2021 and 2030.DesignEconomic and epidemiological modelling study with probabilistic sensitivity analysis.SettingThe model combined publicly available data on F&V trade, published estimates of UK-specific price elasticities, national survey data on F&V intake, estimates on the relationship between F&V intake and CVD from published meta-analyses and CVD mortality projections for 2021–2030.ParticipantsEnglish adults aged 25 years and older.InterventionsWe modelled four potential post-Brexit trade scenarios: (1) free trading agreement with the EU and maintaining half of non-EU free trade partners; (2) free trading agreement with the EU but no trade deal with any non-EU countries; (3) no-deal Brexit; and (4) liberalised trade regime that eliminates all import tariffs.Outcome measuresCumulative coronary heart disease and stroke deaths attributed to the different Brexit scenarios modelled between 2021 and 2030.ResultsUnder all Brexit scenarios modelled, prices of F&V would increase, especially for those highly dependent on imports. This would decrease intake of F&V between 2.5% (95% uncertainty interval: 1.9% to 3.1%) and 11.4% (9.5% to 14.2%) under the different scenarios. Our model suggests that a no-deal Brexit scenario would be the most harmful, generating approximately 12 400 (6690 to 23 390) extra CVD deaths between 2021 and 2030, whereas establishing a free trading agreement with the EU would have a lower impact on mortality, contributing approximately 5740 (2860 to 11 910) extra CVD deaths.ConclusionsTrade policy under all modelled Brexit scenarios could increase price and decrease intake of F&V, generating substantial additional CVD mortality in England. The UK government should consider the population health implications of Brexit trade policy options, including changes to food systems.

Background: Evidence from prospective cohort studies indicates that consumption of processed meats is associated with higher incidence of CHD. Processed meats are high in saturated fatty acids, cholesterol, and preservatives including sodium that may unfavorably influence blood pressure (BP), but evidence is limited. We therefore investigated associations with BP of unprocessed and processed meat consumption, including types of processed meats. Methods: We used cross-sectional data from the INTERMAP Study on 4,680 men and women aged 40-59 years from Japan, China, UK, and US. During four visits, eight BPs and four 24-hr dietary recalls were collected. Processed meats included preserved meats; fresh processed meats (ready-made, salted, and/or spiced, no curing), bacon, ham (cured and cooked), cold cuts and sausages, and canned meat products. Country-specific linear regression coefficients were estimated and pooled, weighted by inverse of their variance. Adjustments were made for demographic (age, gender, sample), lifestyle (total energy, alcohol, smoking, education, supplement use, adherence to special diet, low-fat dairy, fruit, vegetables, fiber-rich grain products, fish and shellfish), and clinical confounders (history of cardiovascular diseases or diabetes, family history of hypertension, use of anti-hypertensive, cardiovascular, or diabetes medication, BMI). The influence of adjustment for urinary sodium, total cholesterol, and total saturated fatty acids was additionally investigated. Results: Average daily unprocessed/processed meat consumption (g/1000 kcal) was 41/10 in Asian participants and 82/47 in Western participants. In Western participants, processed meats comprised fresh processed meat (36%), cold cuts and sausages (34%), ham (16%), and bacon (7%). Meat consumption was not associated with BP in Asian participants. After adjustment for demographic and lifestyle factors, significant associations with systolic BP were observed per each 50 g/1000 kcal higher intake of unprocessed (+1.19 mm Hg, P=0.02) and processed (+2.00 mm Hg, P=0.01) meat consumption in Western participants. However, these associations attenuated and did not remain significant after adjustment for BMI. We further examined types of processed meat in Western participants. Consumption of cold cuts and sausages higher by 12,5 g/1000 kcal was associated with a systolic BP difference of +0.72 mm Hg (P=0.02). Consumption of ham higher by 12,5 g/1000 kcal was associated with a systolic BP difference of -0.92 mm Hg (P=0.03). These associations prevailed after adjustment for urinary sodium excretion, intakes of saturated fatty acids, and total cholesterol. Conclusion: Unprocessed and processed meat consumption was not associated with BP, however, some types of processed meat may influence BP in opposite directions.

Background An industry levy on sugar-sweetened beverages (SSB) will be implemented in the UK in 2018. It aims to reduce SSB consumption, a major risk factor for coronary heart disease. Brexit might change the present UK trade system with unknown implications for sugar price. We aimed to estimate the effect of potential changes in the price of sugar due to Brexit, combined with the SSB levy, on coronary heart disease mortality and inequalities in English adults, in the first year after Brexit (2020). Methods We modelled a baseline SSB levy scenario, a SSB levy under so-called soft Brexit (in which the UK establishes a free trading agreement with the European Union), and a SSB levy under a so-called hard Brexit (in which the UK takes a World Trade Organization default position). We extended the previously validated International Model for Policy Analysis of Agricultural Commodities and Trade to estimate the effect of each scenario on coronary heart disease deaths prevented or postponed and life-years gained, and we used probabilistic sensitivity analysis to account for uncertainty. The model combined routine data on sugar and SSB trade and price, SSB intake, and coronary heart disease mortality stratified by socioeconomic circumstance. We estimated the change in production costs of SSBs and assumed that the industry would pass the cost increase to the consumer. We assumed an immediate effect of SSB intake on coronary heart disease. Findings The SSB levy could result in about 390 deaths prevented or postponed from coronary heart disease (95% uncertainty interval 230–590) and 4710 life-years gained (2790–7070) in 2020. The effect of the levy on coronary heart disease mortality would increase by 4% (about 10 deaths) under soft Brexit and by 8% (about 30 deaths) under hard Brexit, compared with baseline. The levy, even under hard Brexit, will particularly benefit the most deprived socioeconomic quintile, with about 140 deaths prevented or postponed (60–240) in the most deprived group compared with 70 (30–120) in the most affluent group. Interpretation Our study found the SSB levy to be resilient to potential Brexit effects on sugar price. Even when trading under World Trade Organization regulations, the SSB levy would yield benefits for coronary heart disease mortality and inequalities. Brexit negotiations are an important opportunity to introduce further fiscal policies within comprehensive UK strategies to promote healthier diets. Funding PS, AAL, and CM are funded by the National Institute for Health Research (research professorship award to CM).