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Objectives To assess the cost-effectiveness of uterine artery embolisation (UAE) and myomectomy for women with symptomatic uterine fibroids wishing to avoid hysterectomy. Design Economic evaluation alongside the FEMME randomised controlled trial. Setting 29 UK hospitals. Population Premenopausal women who had symptomatic uterine fibroids amenable to UAE or myomectomy wishing to avoid hysterectomy. 254 women were randomised to UAE (127) and myomectomy (127). Methods A within-trial cost-utility analysis was conducted from the perspective of the UK NHS. Main outcome measures Quality-adjusted life years (QALYs) measured using the EuroQoL EQ-5D-3L, combined with costs to estimate cost-effectiveness over 2 and 4 years of follow-up. Results Over a 2-year time horizon, UAE was associated with higher mean costs (difference £645; 95% CI -1381 to 2580) and lower QALYs (difference -0.09; 95% CI -0.11 to -0.04) when compared with myomectomy. Similar results were observed over the 4-year time horizon. Thus, UAE was dominated by myomectomy. Results of the sensitivity analyses were consistent with the base case results for both years. Over 2 years, UAE was associated with higher costs (difference £456; 95% CI -1823 to 3164) and lower QALYs (difference -0.06; 95% CI -0.11 to -0.02). Conclusions Myomectomy is a cost-effective option for the treatment of uterine fibroids. The differences in costs and QALYs are small. Women should be fully informed and have the option to choose between the two procedures. Tweetable abstract Fully informed women with uterine fibroids should have a choice between uterine artery embolisation or myomectomy.

Background: \ud Uterine fibroids, the most common type of tumor among women of reproductive age, are associated with heavy menstrual bleeding, abdominal discomfort, subfertility, and a reduced quality of life. For women who wish to preserve their uterus and who have not had a response to medical treatment, myomectomy and uterine-artery embolization are therapeutic options.\ud Methods: \ud We conducted a multicenter, randomized, open-label trial to evaluate myomectomy, as compared with uterine-artery embolization, in women who had symptomatic uterine fibroids and did not want to undergo hysterectomy. Procedural options included open abdominal, laparoscopic, or hysteroscopic myomectomy. The primary outcome was fibroid-related quality of life, as assessed by the score on the health-related quality-of-life domain of the Uterine Fibroid Symptom and Quality of Life (UFS-QOL) questionnaire (scores range from 0 to 100, with higher scores indicating a better quality of life) at 2 years; adjustment was made for the baseline score.\ud Results: \ud A total of 254 women, recruited at 29 hospitals in the United Kingdom, were randomly assigned: 127 to the myomectomy group (of whom 105 underwent myomectomy) and 127 to the uterine-artery embolization group (of whom 98 underwent embolization). Data on the primary outcome were available for 206 women (81%). In the intention-to-treat analysis, the mean (±SD) score on the health-related quality-of-life domain of the UFS-QOL questionnaire at 2 years was 84.6±21.5 in the myomectomy group and 80.0±22.0 in the uterine-artery embolization group (mean adjusted difference with complete case analysis, 8.0 points; 95% confidence interval [CI], 1.8 to 14.1; P=0.01; mean adjusted difference with missing responses imputed, 6.5 points; 95% CI, 1.1 to 11.9). Perioperative and postoperative complications from all initial procedures, irrespective of adherence to the assigned procedure, occurred in 29% of the women in the myomectomy group and in 24% of the women in the uterine-artery embolization group.\ud Conclusions: \ud Among women with symptomatic uterine fibroids, those who underwent myomectomy had a better fibroid-related quality of life at 2 years than those who underwent uterine-artery embolization. (Funded by the National Institute for Health Research Health Technology Assessment program; FEMME Current Controlled Trials number, ISRCTN70772394).

Objective: \ud To examine the quality of life experienced by women with symptomatic uterine fibroids who had been treated with UAE in comparison to myomectomy. We report the four-year follow-up of the FEMME randomised trial. Two-year follow-up data has been previously reported.\ud \ud Study Design: \ud Premenopausal women who had symptomatic uterine fibroids amenable to myomectomy or uterine artery embolization were recruited from 29 UK hospitals. Women were excluded if they had significant adenomyosis, any malignancy, pelvic inflammatory disease or had had a previous open myomectomy or uterine artery embolization.\ud \ud Participants were randomised to myomectomy or embolization in a 1:1 ratio using a minimisation algorithm. Myomectomy could be open abdominal, laparoscopic or hysteroscopic, according to clinician preference. Embolization of the uterine arteries was performed according to local practice, under fluoroscopic guidance.\ud \ud The primary outcome measure was the Uterine Fibroid Symptom Quality of Life questionnaire, adjusted for baseline score and reported here at four years post-randomisation. Subsequent procedures for fibroids, pregnancy and outcome were amongst secondary outcomes.\ud \ud Trial registration: ISRCTN70772394 https://doi.org/10.1186/ISRCTN70772394\ud \ud Results: \ud 254 women were randomized, 127 to myomectomy (105 underwent myomectomy) and 127 to uterine artery embolization (98 underwent embolization). At four years, 67 (53%) and 81 (64%) completed UFS-QoL quality of life scores. Mean difference in the UFS-QoL at 4 years was 5.0 points (95% CI −1.4 to 11.5; p = 0.13) in favour of myomectomy. There were 15 pregnancies in the UAE group and 7 in the myomectomy group, with a cumulative pregnancy rate to four years of 15% and 6% respectively (hazard ratio: 0.48; 95% CI 0.18–1.28). The cumulative repeat procedure rate to four years was 24% in the UAE group and 13% in the myomectomy group (hazard ratio: 0.53; 95% CI 0.27–1.05).\ud \ud Conclusions: \ud Myomectomy resulted in greater improvement in quality of life compared with uterine artery embolization, although by four years, this difference was not statistically significant. Missing data may limit the generalisability of this result. The numbers of women becoming pregnant were too small draw a conclusion on the effect of the procedures on fertility.

Healthcare alone cannot improve population health. Laura Webber and colleagues advocate a “health in all policies” approach, with protected funding for preventive interventions

BackgroundNational guidance on preventing type 2 diabetes mellitus (T2DM) in the UK recommends low-intensity lifestyle interventions for individuals with intermediate categories of hyperglycaemia defined in terms of impaired fasting glucose (IFG) or ‘at-risk’ levels of HbA1c. In a recent systematic review of economic evaluations of such interventions, most studies had evaluated intensive trial-based lifestyle programmes in participants with impaired glucose tolerance (IGT). This study examines the costs and effects of different intensity lifestyle programmes and metformin in participants with different categories of intermediate hyperglycaemia. MethodsWe developed a decision tree and Markov model (50-year horizon) to compare four approaches, namely (1) a low-intensity lifestyle programme based on current NICE guidance, (2) a high-intensity lifestyle programme based on the US Diabetes Prevention Program, (3) metformin, and (4) no intervention, modelled for three different types of intermediate hyperglycaemia (IFG, IGT and HbA1c). A health system perspective was adopted and incremental analysis undertaken at an individual and population-wide level, taking England as a case study. ResultsLow-intensity lifestyle programmes were the most cost-effective (£44/QALY, £195/QALY and £186/QALY compared to no intervention in IGT, IFG and HbA1c, respectively). Intensive lifestyle interventions were also cost-effective compared to no intervention (£2775/QALY, £6820/QALY and £7376/QALY, respectively, in IGT, IFG and HbA1c). Metformin was cost-effective relative to no intervention (£5224/QALY, £6842/QALY and £372/QALY in IGT, IFG and HbA1c, respectively), but was only cost-effective relative to other treatments in participants identified with HbA1c. At a willingness-to-pay threshold of £20,000/QALY, low- and high-intensity lifestyle programmes were cost-effective 98%, 99% and 98% and 81%, 81% and 71% of the time in IGT, IFG and HbA1c, respectively. An England-wide programme for 50–59 year olds could reduce T2DM incidence by  DiscussionThis analysis suggests that current English national policy of low-intensity lifestyle programmes in participants with IFG or HbA1c will be cost-effective and have the most favourable budget impact, but will prevent only a fraction of cases of T2DM. Additional approaches to prevention need to be investigated urgently.

Summary Background Excess weight is associated with poor health and increased health-care costs. However, a detailed understanding of the effects of excess weight on total hospital costs and costs for different health conditions is needed. Methods Women in England aged 50–64 years were recruited into the prospective Million Women Study cohort in 1996–2001 through 60 NHS breast cancer screening centres. Participants were followed up and annual hospital costs and admission rates were estimated for April 1, 2006, to March 31, 2011, in relation to body-mass index (BMI) at recruitment, overall and for categories of health conditions defined by the International Classification of Diseases 10th revision chapter of the primary diagnosis at admission. Associations of BMI with hospital costs were projected to the 2013 population of women aged 55–79 years in England. Findings 1 093 866 women who provided information on height and weight, had a BMI of at least 18·5 kg/m2, and had no previous cancer at recruitment, were followed up for an average of 4·9 years from April 1, 2006 (12·3 years from recruitment), during which time 1·84 million hospital admissions were recorded. Annual hospital costs were lowest for women with a BMI of 20·0 kg/m2 to less than 22·5 kg/m2 (£567 per woman per year, 99% CI 556–577). Every 2 kg/m2 increase in BMI above 20 kg/m2 was associated with a 7·4% (7·1–7·6) increase in annual hospital costs. Excess weight was associated with increased costs for all diagnostic categories, except respiratory conditions and fractures. £662 million (14·6%) of the estimated £4·5 billion of total annual hospital costs among all women aged 55–79 years in England was attributed to excess weight (BMI ≥25 kg/m2), of which £517 million (78%) arose from hospital admissions with procedures. £258 million (39%) of the costs attributed to excess weight were due to musculoskeletal admissions, mainly for knee replacement surgeries. Interpretation Excess body weight is associated with increased hospital costs for middle-aged and older women in England across a broad range of conditions, especially knee replacement surgery and diabetes. These results provide reliable up-to-date estimates of the health-care costs of excess weight and emphasise the need for investment to tackle this public health issue. Funding Cancer Research UK; Medical Research Council; National Institute for Health Research.

Obesity has escalated to epidemic proportions over the past 30 years resulting in increased disease burden and healthcare costs. The aim of this paper was to analyse different costing methods for obesity. Several databases have been searched to identify eligible literature estimating obesity cost. These were categorized into databases, patient-attributable fraction (PAF) and modelling studies. Studies from the United States were used to explore effects of study designs on cost outcomes. Our results show that cost outcomes are largely affected by underlying study designs, such as population size, age, cost categories (medical expenditure vs. total costs), length of the data collection and body mass index cut-offs. Three study types are likely to have an impact on reported costs, with modelling studies providing the most conservative estimates. Database studies can help to increase the overall awareness of the economic burden of obesity. PAF studies can make the obesity disease more tangible by drawing connections to diseases. Decision makers need to be aware of the different purposes and weaknesses of the studies when interpreting cost outcomes. Further research is needed to refine the existing methods and provide high-quality data accounting for the complexity of the disease.

ObjectiveThe present study aimed to model obesity trends and future obesity-related disease for nine countries in the Middle East; in addition, to explore how hypothetical reductions in population obesity levels could ameliorate anticipated disease burdens.DesignA regression analysis of cross-sectional data v. BMI showed age- and sex-specific BMI trends, which fed into a micro simulation with a million Monte Carlo trials for each country. We also examined two alternative scenarios where population BMI was reduced by 1 % and 5 %.SettingStatistical modelling of obesity trends was carried out in nine Middle East countries (Bahrain, Egypt, Iran, Jordan, Kuwait, Lebanon, Oman, Saudi Arabia and Turkey).SubjectsBMI data along with disease incidence, mortality and survival data from national and sub-national data sets were used for the modelling process.ResultsHigh rates of overweight and obesity increased in both men and women in most countries. The burden of incident type 2 diabetes, CHD and stroke would be moderated with even small reductions in obesity levels.ConclusionsObesity is a growing problem in the Middle East which requires government action on the primary prevention of obesity. The present results are important for policy makers to know the effectiveness of obesity interventions on future disease burden.

Part I of this report appeared in the previous issue (Br. J. Cancer (1976) 34,585), and discussed the design of randomized clinical trials. Part II now describes efficient methods of analysis of randomized clinical trials in which we wish to compare the duration of survival (or the time until some other untoward event first occurs) among different groups of patients. It is intended to enable physicians without statistical training either to analyse such data themselves using life tables, the logrank test and retrospective stratification, or, when such analyses are presented, to appreciate them more critically, but the discussion may also be of interest to statisticians who have not yet specialized in clinical trial analyses.

We have assessed the relative value of various outcome measures after THR, by the analysis of follow-up data from over 2000 patients. They had been reviewed clinically and radiologically six months after operation, at one year, and then every two years, some for 16 years. At each review their pain level, stiffness and opinion of progress were scored and a radiograph taken. We found that pain level was the most informative outcome as a predictor of revision and correlated well with the patients’ opinions. We made a comparison between the six types of implant in the series, using survival analysis and log-rank testing with different pain levels as endpoints. This analysis revealed differences which were not detected by survival analysis using the traditional endpoint of revision. We therefore recommend the use of different levels of pain as the main outcome measures after total hip replacement.

Background. The Collaborative Group on Hormonal Factors in Breast Cancer has brought together and reanalysed about 90% of the worldwide epidemiological evidence on the relation between risk of breast cancer and use of hormone replacement therapy (HRT). Methods. Individual data on 52,705 women with breast cancer and 108,411 women without breast cancer from 51 studies in 21 countries were collected, checked, and analysed centrally. The main analyses are based on 53,865 postmenopausal women with a known age at menopause, of whom 17,830 (33%) had used HRT at some time. The median age at first use was 48 years, and 34% of ever-users had used HRT for 5 years or longer. Estimates of the relative risk of breast cancer associated with the use of HRT were obtained after stratification of all analyses by study, age at diagnosis, time since menopause, body-mass index, parity, and the age a woman was when her first child was born. Findings. Among current users of HRT or those who ceased use 1-4 years previously, the relative risk of having breast cancer diagnosed increased by a factor of 1.023 (95% CI 1.011-1.036; 2p = 0.0002) for each year of use; the relative risk was 1.35 (1.21-1.49; 2p = 0.00001) for women who had used HRT for 5 years or longer (average duration of use in this group 11 years). This increase is comparable with the effect on breast cancer of delaying menopause, since among never-users of HRT the relative risk of breast cancer increases by a factor of 1.028 (95% CI 1.021-1.034) for each year older at menopause. 5 or more years after cessation of HRT use, there was no significant excess of breast cancer overall or in relation to duration of use. These main findings did not vary between individual studies. Of the many factors examined that might affect the relation between breast cancer risk and use of HRT, only a woman's weight and body-mass index had a material effect: the increase in the relative risk of breast dancer associated with long durations of use in current and recent users was greater for women of lower than of higher weight or body-mass index. There was no marked variation in the results according to hormonal type or dose but little information was available about long durations of use of any specific preparation. Cancers diagnosed in women who had ever used HRT tended to be less advanced clinically than those diagnosed in never-users. In North America and Europe the cumulative incidence of breast cancer between the ages of 50 and 70 in never-users of HRT is about 45 per 1000 women. The cumulative excess numbers of breast cancers diagnosed between these ages per 1000 women who began use of HRT at age 50 and used it for 5, 10, and 15 years, respectively, are estimated to be 2 (95% CI 1-3), 6 (3-9), and 12 (5-20). Whether HRT affects mortality from breast cancer is not known. Interpretation. The risk of having breast cancer diagnosed is increased in women using HRT and increases with increasing duration of use. This effect is reduced after cessation of use of HRT and has largely, if not wholly, disappeared after about 5 years. These findings should be considered in the context of the benefits and other risks associated with the use of HRT.

Objective To assess the efficacy of an intervention designed to improve the mother-infant relationship and security of infant attachment in a South African peri-urban settlement with marked adverse socioeconomic circumstances. Design Randomised controlled trial. Setting Khayelitsha, a peri-urban settlement in South Africa. Participants 449 pregnant women. Interventions The intervention was delivered from late pregnancy and for six months postpartum. Women were visited in their homes by previously untrained lay community workers who provided support and guidance in parenting. The purpose of the intervention was to promote sensitive and responsive parenting and secure infant attachment to the mother. Women in the control group received no therapeutic input from the research team. Main outcome measures Primary outcomes: quality of mother-infant interactions at six and 12 months postpartum; infant attachment security at 18 months. Secondary outcome: maternal depression at six and 12 months. Results The intervention was associated with significant benefit to the mother-infant relationship. At both six and 12 months, compared with control mothers, mothers in the intervention group were significantly more sensitive (6 months: mean difference=0.77 (SD 0.37), t=2.10, P

Obesity has increased at an alarming rate across the world and, in turn, rates of non-communicable diseases have escalated. In Eastern Europe, this epidemic has probably occurred at a later stage than the West due to the economic transition following the demise of communism. Knowing how these trends will change is important. We used a micro-simulation model to project obesity trends and related incidence of coronary heart disease and stroke, cancer and type 2 diabetes 20 and 40 years into the future. Where nationally representative data were available, obesity levels were shown to increase with most prominent increases seen amongst men in Latvia and Estonia, and amongst women in Croatia and Latvia. The exception was Lithuania where a decrease in overweight and obesity was observed in both men and women. We showed that interventions effective in reducing obesity would have a significant impact upon the number of new cases of each disease. It is necessary to improve surveillance of obesity and disease incidence as well as implement policies that are effective in reducing body fat.

Similar to most developed countries, obesity rates inRussiahave been steadily increasing. This has led to a high burden of obesity related diseases and associated healthcare costs. The micro-simulation model has been utilized to project body mass index (BMI) and BMI related disease burden and healthcare costs. Incidence, mortality, survival and healthcare costs were collected for thirteen diseases. The results have been simulated for 3 hypothetical scenarios to project a potential impact of policy interventions: 1) assuming no reduction in BMI; 2) 1% reduction in mean BMI across the population; 3) 5% reduction in mean BMI across the population. Nearly 58% of the female population was obese (BMI ≥30 kg/m2) or overweight (BMI 25 -29.9 kg/m2) in 2010, and the prevalence is projected to decrease to 54% in 2050. The rates are predicted to increase for men from 51% in 2010 to 76% in 2050. The prevalence rates will triple for some obesity-related diseases. A one percent decrease in BMI across the population will save more than two billion US Dollars in 2030 and 2050. Despite female obesity prevalence starting at a higher point than the men, obesity is predicted to increase in males but not females. Disease and economic burden attributed to these obesity rates are still severe and the country should implement strong policies to tackle the obesity epidemic.

Summary Rising prevalence of obesity is a worldwide health concern because excess weight gain within populations forecasts an increased burden from several diseases, most notably cardiovascular diseases, diabetes, and cancers. In this report, we used a simulation model to project the probable health and economic consequences in the next two decades from a continued rise in obesity in two ageing populations—the USA and the UK. These trends project 65 million more obese adults in the USA and 11 million more obese adults in the UK by 2030, consequently accruing an additional 6–8·5 million cases of diabetes, 5·7–7·3 million cases of heart disease and stroke, 492 000–669 000 additional cases of cancer, and 26–55 million quality-adjusted life years forgone for USA and UK combined. The combined medical costs associated with treatment of these preventable diseases are estimated to increase by $48–66 billion/year in the USA and by £1·9–2 billion/year in the UK by 2030. Hence, effective policies to promote healthier weight also have economic benefits.

The statin saga is iconic, because it highlights the need for clinical data sharing and the constant need for proper assessment of side effects.1 Apparently the Cochrane review group is not interested in seeking the data on adverse events, …

The prevalence of childhood overweight and obesity has risen substantially worldwide in less than one generation. In the USA, the average weight of a child has risen by more than 5 kg within three decades, to a point where a third of the country's children are overweight or obese. Some low-income and middle-income countries have reported similar or more rapid rises in child obesity, despite continuing high levels of undernutrition. Nutrition policies to tackle child obesity need to promote healthy growth and household nutrition security and protect children from inducements to be inactive or to overconsume foods of poor nutritional quality. The promotion of energy-rich and nutrient-poor products will encourage rapid weight gain in early childhood and exacerbate risk factors for chronic disease in all children, especially those showing poor linear growth. Whereas much public health effort has been expended to restrict the adverse marketing of breastmilk substitutes, similar effort now needs to be expanded and strengthened to protect older children from increasingly sophisticated marketing of sedentary activities and energy-dense, nutrient-poor foods and beverages. To meet this challenge, the governance of food supply and food markets should be improved and commercial activities subordinated to protect and promote children's health.

Mental illness is associated with physical illness and mortality from a variety of causes including cancer. There is little information on screening attendance among the mentally ill population. An audit was conducted of a breast screening service in inner London to determine uptake rates in women with mental illness.Cross sectional data linkage study of the local screening register and patients of the local psychiatric units. Screening uptake rates in all patients, those with a history of multiple detention in hospital, and those with psychosis were compared with the local reference population.Women in three inner London boroughs.Screening records for 933 psychiatric patients and 44 195 women without mental health problems aged 50 to 64 years.Overall, psychiatric patients were as likely as the reference group to attend breast screening. Patients with a history of multiple detention were significantly less likely to attend (OR = 0.40, 0.29 to 0.55; p0.001), as were patients with a diagnosis of psychosis (OR = 0.33, 0.18 to 0.61; p0.01). Increasing age, a history of detention in hospital, and social deprivation remained independent predictors for non-attendance.Women with severe mental health problems may be less likely to attend national screening programmes such as breast screening, and action should be taken to overcome the barriers to attendance.

Objectives: To investigate the readmission experience of a large national prospective cohort of women up to 5 years after undergoing either transcervical resection of the endometrium (TCRE) or hysterectomy to assess reasons for readmission and whether TCRE can be viewed as a definitive substitute for hysterectomy. Design and participants: Data are from the VALUE/MISTLETOE prospective national cohort studies of hysterectomy and TCRE respectively. 5294 women who underwent hysterectomy for dysfunctional uterine bleeding in 1994/5 and 4032 women who underwent TCRE in 1993/4 and who responded to postal questionnaires were included. Surgeons gathered operative details. Women completed postal follow up questionnaires at 3 and 5 years after surgery asking about readmission to hospital and reasons for readmission. Adjusted proportional hazard ratios were calculated for likelihood of readmission in each category comparing types of surgery. Results: 41.7% of women undergoing hysterectomy and 44.6% of women undergoing TCRE experienced one or more readmissions to hospital overall within 5 years (adjusted hazard ratio for all readmissions (AHR) 0.87 (95% confidence interval (CI) 0.80 to 0.95)). 12.6% of hysterectomy patients and 30.3% of TCRE patients were readmitted for gynaecological reasons (AHR 0.40 (95% CI 0.33 to 0.48)). Rates of readmission for gynaecological reasons were similar up to 6 months but were markedly reduced for hysterectomy compared with TCRE patients towards the end of the follow up period (AHR for readmission at 3–5 years 0.28 (95% CI 0.20 to 0.39)). Conclusions: There are differences in the pattern of readmission to hospital after hysterectomy and TCRE for dysfunctional uterine bleeding. Women undergoing a hysterectomy are less likely to be readmitted to hospital up to 5 years after their operation overall, and are significantly less likely to be readmitted for reasons related to their operation, particularly for gynaecological reasons. Hysterectomy appears to be a more definitive operation. The different options for surgery for dysfunctional uterine bleeding are not interchangeable; they represent different patterns of care. Information should be available to women and practitioners to inform choices between these options.

This paper examines the current status of qualitative and quantitative research in the context of UK (public) health research in cancer. It is proposed that barren competition between qualitative and quantitative methods is inevitable, but that effective synergy between them continues to be essential to research excellence. The perceived methodological utility, with respect to understanding residual uncertainties, can account for the status accorded various research techniques and these will help to explain shifts witnessed in recent years and contribute towards an understanding of what can be realistically expected in terms of future progress. It is argued that the methodological debate, though familiar to many, is worthy of rearticulation in the context of cancer research where the psychosocial aspects of living with a cancer and the related complexity of providing appropriate cancer care are being addressed across Europe, as evidenced in recent directions in policy and research.

Objective Non-communicable diseases (NCDs) are the biggest cause of death in Europe putting an unsustainable burden on already struggling health systems. Increases in obesity are a major cause of NCDs. This paper projects the future burden of coronary heart disease (CHD), stroke, type 2 diabetes and seven cancers by 2030 in 53 WHO European Region countries based on current and past body mass index (BMI) trends. It also tests the impact of obesity interventions on the future disease burden. Setting and participants Secondary data analysis of country-specific epidemiological data using a microsimulation modelling process. Interventions The effect of three hypothetical scenarios on the future burden of disease in 2030 was tested: baseline scenario, BMI trends go unchecked; intervention 1, population BMI decreases by 1%; intervention 2, BMI decreases by 5%. Primary and secondary outcome measures Quantifying the future burden of major NCDs and the impact of interventions on this future disease burden. Results By 2030 in the whole of the European region, the prevalence of diabetes, CHD and stroke and cancers was projected to reach an average of 3990, 4672 and 2046 cases/100 000, respectively. The highest prevalence of diabetes was predicted in Slovakia (10 870), CHD and stroke—in Greece (11 292) and cancers—in Finland (5615 cases/100 000). A 5% fall in population BMI was projected to significantly reduce cumulative incidence of diseases. The largest reduction in diabetes and CHD and stroke was observed in Slovakia (3054 and 3369 cases/100 000, respectively), and in cancers was predicted in Germany (331/100 000). Conclusions Modelling future disease trends is a useful tool for policymakers so that they can allocate resources effectively and implement policies to prevent NCDs. Future research will allow real policy interventions to be tested; however, better surveillance data on NCDs and their risk factors are essential for research and policy.

The first objective is to project obesity trends to 2030 based on the current data from Poland. The second objective is to test the effect of a 1% or 5% decrease in population BMI upon future incidence and prevalence of related non-communicable diseases. A two-stage modelling design projecting overweight and obesity trends and related diseases in a microsimulation model was developed. Epidemiological data for entry into a microsimulation model were gathered from Poland. This study used population level data from Poland creating a virtual population within a microsimulation model. Obesity and overweight in Poland was found to increase to very high levels in men while trends remained unchanged in women. In a country that currently has about 38 million inhabitants, it is anticipated that by 2030, there might be more than 9 million new cancer cases; 10 million CHD and stroke cases, and 7 million new cases of type 2 diabetes. These findings have policy implications highlighting the need for action to curb trends and to reduce increases in the rates of diet-related non-communicable disease.

Public health does not need to be led by doctors {#article-title-2} For years lead positions in public health have been restricted to those with a medical background, and it is still impossible for individuals to be accredited as specialists in public health without medical training. But does such exclusivity have repercussions? Here a professor of epidemiology and two directors of public health present their views. # For {#article-title-3} Public health is the science and art of promoting, protecting, and improving health and wellbeing through organised efforts of society.1 It encompasses all influences throughout life and, because the diversity is crucial, must be multidisciplinary.2 Whether medical training enables unique qualities for leadership in public health is certainly plausible but unproved, and justifications have so far been little more than special pleading. Public health in the United Kingdom is, and has been, led by many people from several core disciplines: Chadwick, Chalmers, Cochrane, Day, Davey Smith, Doll, Farr, Greenwood, Hill, Morris, Nightingale, Peto, Rose, Titmus, Stacey to name but a few. It will surely continue to do so. Yet for half a century a medical hegemony (legitimate or otherwise) has implied medical ownership and protection of careers, training, and accreditation in public health. All top public health jobs in the NHS and elsewhere from the chief medical officer down are protected, if not by law, by the BMA. It remains impossible to be accredited as a specialist in public health and, until quite recently, to attend postgraduate public health courses without a medical training. Funding for training and career opportunities are still grossly unequal and all this has clearly tended to confine others to roles different from, or ancillary to, public health. Until the need for this is satisfactorily justified it is a scandal. The academic sector is only now becoming an exception, where for too long the research, the teaching (exclusively of doctors), … Correspondence to: Edward Coyle

Summary Background In a previous study of pooled data from published trials, we found no evidence to support the claim that postmenopausal hormone therapy (PHT) is associated with a decrease in cardiovascular disease. The purpose of this study was to see whether reports of clinical trials attached to drug-licensing applications in Finland could be obtained for scientific purposes, whether they are useful for studying cardiovascular events resulting from PHT, and if so, whether these unpublished reports corroborate the results of published reports. Methods Since clinical trials in drug-licensing documents are confidential, we had to obtain special permission from the Ministry of Social Affairs and Health to use the data for research purposes. After permission was granted, we studied the clinical sections of licensing documents for PHT drugs sent by drug companies to the Finnish Drug Agency. We aimed to identify trials that compared PHT and a placebo (or no therapy, or vitamin-mineral drugs), and that reported on cardiovascular and thromboembolic events or superficial phlebitis. New trials were identified and their data were pooled with those of published trials. Findings 17 licensing applications for drugs used as PHT were found. The number, type, and quality of reporting of clinical trials varied widely between applications. The trials and their reporting of unanticipated adverse events were mostly inadequate. Six new trials (ie, those fulfilling the inclusion criteria and not included in our earlier report) were found. The new trials added little to the conclusions of previously published studies: the calculated odds ratios of cardiovascular and thromboembolic events for women taking PHT versus those not taking it was 1.97 (95% Cl 0.84-4.63), compared with 1.65 (0.65-4.21) in our previous study. Interpretation In this case, unpublished trials added only a little to the data available from published trials, mainly due to the type of clinical data used in the licensing applications. The new data did not change the previous conclusion that clinical trials do not support a beneficial effect of PHT on cardiovascular diseases.

Background The existence of a U-shaped relationship between alcohol consumption and all-cause mortality complicates the calculation and interpretation of mortality attributable to alcohol consumption. Methods We used the relationships between all-cause mortality and alcohol consumption from four British cohort studies. For each study we defined a ‘sensible drinking level’ as the level with lowest observed mortality. We estimated the fractions of deaths that were attributable to (1) any drinking (compared with not drinking), (2) drinking more than the ‘sensible level’, and (3) drinking less than the ‘sensible level’. Results Data from the Doctors’ study suggest that on balance 22.3 per cent of deaths are prevented by alcohol consumption, yet the fractions of deaths attributable to drinking more than 8‐14 units per week and less than 8‐14 units per week are nearly equal (6.5 per cent and 6.4 per cent, respectively). In a sensitivity analysis we show that it is possible for alcohol consumption to prevent deaths overall yet for more deaths to be attributable to drinking above a sensible level than are attributable to drinking below the sensible level. Conclusions The balance of deaths attributable to or prevented by alcohol consumption provides no information about the deaths attributable to drinking above or below sensible levels. Using all-cause data in this way is likely to exaggerate the protective effect of alcohol consumption, so our results are only illustrative.

We combined data from 5 prospective studies to compare the death rates from common diseases of vegetarians with those of nonvegetarians with similar lifestyles. A summary of these results was reported previously; we report here more details of the findings. Data for 76172 men and women were available. Vegetarians were those who did not eat any meat or fish (n = 27808). Death rate ratios at ages 16-89 y were calculated by Poisson regression and all results were adjusted for age, sex, and smoking status. A random-effects model was used to calculate pooled estimates of effect for all studies combined. There were 8330 deaths after a mean of 10.6 y of follow-up. Mortality from ischemic heart disease was 24% lower in vegetarians than in nonvegetarians (death rate ratio: 0.76; 95% CI: 0.62, 0.94; P5 y. Further categorization of diets showed that, in comparison with regular meat eaters, mortality from ischemic heart disease was 20% lower in occasional meat eaters, 34% lower in people who ate fish but not meat, 34% lower in lactoovovegetarians, and 26% lower in vegans. There were no significant differences between vegetarians and nonvegetarians in mortality from cerebrovascular disease, stomach cancer, colorectal cancer, lung cancer, breast cancer, prostate cancer, or all other causes combined.

A retrospective comparison of cancer incidence data and, where relevant, population data with 16 955first-time users (patients, relatives and friends) of a national cancer information service (CancerBACUP) during the period April1995 to March 1996 is presented. The number of events observed was compared with the number of events expected, were the nationalrates of cancer incidence and population demographics apply. Standardized incidence ratios (SIRs) (observed – expectedratios) were used to indicate any differences. Statistically significant differences (P< 0.001) in the observed andexpected sex, age and primary site distribution of patients enquired about were found. Statistically significant differences(P< 0.001) were also identified for the age, employment status, socioeconomic class and geographical location offirst-time enquirers (patients, relatives and friends). Enquiries about brain, testis and breast cancers and non-Hodgkin'slymphoma (NHL) were substantially higher than expected; enquiries about bladder, lung, stomach and colorectal cancers were muchlower than expected. As the service is provided via a freephone number, it is available to all, and users might be expected to berandomly distributed across the variables listed. The underlying reasons for the differences identified need to be investigated,and the role of information in the care of cancer patients should be formally evaluated. © 1999 Cancer Research Campaign

This is the first of four articles Evaluations of healthcare interventions can either randomise subjects to comparison groups, or not. In both designs there are potential threats to validity, which can be external (the extent to which they are generalisable to all potential recipients) or internal (whether differences in observed effects can be attributed to differences in the intervention). Randomisation should ensure that comparison groups of sufficient size differ only in their exposure to the intervention concerned. However, some investigators have argued that randomised controlled trials (RCTs) tend to exclude, consciously or otherwise, some types of patient to whom results will subsequently be applied Furthermore, in unblinded trials the outcome of treatment may be influenced by practitioners' and patients' preferences for one or other intervention. Though non-randomised studies are less selective in terms of recruitment, they are subject to selection bias in allocation if treatment is related to initial prognosis. #### Summary points Treatment effects obtained from randomised and non-randomised studies may differ, but one method does not give a consistently greater effect than the other Treatment effects measured in each type of study best approximate when the exclusion criteria are the same and where potential prognostic factors are well understood and controlled for in the non-randomised studies Subjects excluded from randomised controlled trials tend to have a worse prognosis than those included, and this limits generalisability Subjects participating in randomised controlled trials evaluating treatment of existing conditions tend to be less affluent, educated, and healthy than those who do not; the opposite is true for trials of preventive interventions View this table: Threats to validity of evaluative research and possible solutions These issues have led to extensive debate, although empirical evidence is limited. This paper is a brief summary of a more detailed review1 of the impact of these potential threats. The review focused …

Alcohol consumption may increase the risk for at least six types of cancer, although the evidence is not uniformly strong. Alcohol is not a carcinogen in standard tests but is likely a cocarcinogen, at least in the digestive tract. The strongest association is with cancer of the oral cavity and pharynx (seven-fold increase for heavy consumption). For moderate consumption (2–3 drinks/day for men and 1–2 drinks/day for women), the risks never increase above twofold and are mostly less than 25% above baseline. The evidence from the epidemiological literature suggests that 25g/d of alcohol is associated with a relative risk of 1.9 for cancers of the oral cavity and pharynx, 1.4 for cancers of the esophagus and larynx, about 10% for colorectal cancer (mechanisms unclear), and 20% for liver cancer (mechanisms well described). The association between alcohol and breast cancer is not strong and not necessarily causative, at least for moderate consumption. In the United Kingdom, cancer deaths attributable to alcohol consumption above the recommended limits (caused mostly by colorectal cancer) are maximal for men aged 65 to 74 years and for women at ages 75 to 84 years. It is postulated that if everyone in the United Kingdom drank “sensibly,” there would be a marked increase in cancer deaths.

The purpose of this paper was to study the relationship of post-menopausal hormone therapy to cardiovascular mortality by time trend analysis. Mortality and incidence figures by age and sex in 1970–1993 in Finland were obtained from published and unpublished statistics and the extent of hormone therapy use by age from previous nationwide surveys. Percent changes in mortality were calculated for different age groups and time periods (1970–1976, 1977–1987 and 1988–1993, chosen by the extent of hormone use). A theoretical reduction in mortality among 50–54 and 55–59 year old women was calculated by using the time trends among men and older women (60–64 years) as the bases and by multiplying the proportion of users by four hypothetical estimates (100, 50, 30, and 0% of benefit among users). The actual reduction in ischaemic heart disease and total cardiovascular mortality in the age groups with highest post-menopausal hormone use was not larger than in other female age groups or among men. Until 1987, the actual mortality of 50–54 and 55–59 year old women was lower than that predicted from both the data of older women and men and from the assumed benefits of hormone therapy. In the last time period the actual mortality was relatively nearer the predicted mortality both among 50–54 and 55–59 year old women. This time trend analysis does not support the claim that post-menopausal hormone therapy notably prevents cardiovascular mortality.

STUDY OBJECTIVES: To ascertain the determinants and experiences of hormone replacement therapy (HRT) use by menopausal women doctors. DESIGN: Postal questionnaire. SETTING: UK. PATIENTS: A randomized stratified sample of women doctors who obtained full registration between 1952 and 1976, taken from the current Principal List of the UK Medical Register. MAIN OUTCOME MEASURES: Current and previous use of HRT; reasons for and against HRT use; menopausal status; hormonal contraceptive use; lifestyle patterns; family and personal history of disease. MAIN RESULTS: While 73.2% of 471 users had started HRT for symptom relief, 60.9% cited prevention of osteoporosis and 32.7 prevention of cardiovascular disease. Altogether 18.7% had started for preventive purposes alone. Significant predisposing factors to starting HRT were the presence and severity of menopausal symptoms, surgical menopause, past use of hormonal contraception, and a family history of osteoporosis. HRT users were also more likely to use skimmed rather than full fat milk, to try to increase their intake of fruit, vegetables, and fibre, and to undertake vigorous physical activity at least once a week. They were less likely to have had breast cancer. Long duration users were more likely than short duration users to be past users of hormonal contraception and to be using HRT for prevention of osteoporosis as well as symptom relief; they were less likely to have experienced side effects. CONCLUSIONS: The high usage of HRT by women doctors reflects the fact that many started HRT on their own initiative and with long term prevention in mind. The results may become generalisable to the wider population as information on the potential benefits of HRT is disseminated and understood. However, HRT users may differ slightly from non-users in health-related behaviour and a substantial minority may never take up HRT, at least until the benefit-risk ratio is more clearly established.

ObjectiveAlong with other countries having high and low-to-middle income, Mexico has experienced a substantial change in obesity rates. This rapid growth in obesity prevalence has led to high rates of obesity-related diseases and associated health-care costs.DesignMicro-simulation is used to project future BMI trends. Additionally thirteen BMI-related diseases and health-care costs are estimated. The results are simulated for three hypothetical scenarios: no BMI reduction and BMI reductions of 1 % and 5 % across the population.SettingMexican Health and Nutrition Surveys 1999 and 2000, and Mexican National Health and Nutrition Survey 2006.SubjectsMexican adults.ResultsIn 2010, 32 % of men and 26 % of women were normal weight. By 2050, the proportion of normal weight will decrease to 12 % and 9 % for males and females respectively, and more people will be obese than overweight. It is projected that by 2050 there will be 12 million cumulative incidence cases of diabetes and 8 million cumulative incidence cases of heart disease alone. For the thirteen diseases considered, costs of $US 806 million are estimated for 2010, projected to increase to $US 1·2 billion and $US 1·7 billion in 2030 and 2050 respectively. A 1 % reduction in BMI prevalence could save $US 43 million in health-care costs in 2030 and $US 85 million in 2050.ConclusionsObesity rates are leading to a large health and economic burden. The projected numbers are high and Mexico should implement strong action to tackle obesity. Results presented here will be very helpful in planning and implementing policy interventions.

Objective To determine the bias associated with frequency of visits by physicians in adjusting for illness, using diagnoses recorded in administrative databases. Setting Claims data from the US Medicare program for services provided in 2007 among 306 US hospital referral regions. Design Cross sectional analysis. Participants 20% sample of fee for service Medicare beneficiaries residing in the United States in 2007 (n=5 153 877). Main outcome measures The effect of illness adjustment on regional mortality and spending rates using standard and visit corrected illness methods for adjustment. The standard method adjusts using comorbidity measures based on diagnoses listed in administrative databases; the modified method corrects these measures for the frequency of visits by physicians. Three conventions for measuring comorbidity are used: the Charlson comorbidity index, Iezzoni chronic conditions, and hierarchical condition categories risk scores. Results The visit corrected Charlson comorbidity index explained more of the variation in age, sex, and race mortality across the 306 hospital referral regions than did the standard index (R2=0.21 v 0.11, P

We reviewed the records of the long-term outcome of 208 Charnley and 982 Stanmore total hip replacements (THR) performed by or under the supervision of one surgeon from 1973 to 1987. The Stanmore implant had a better survival rate before revision at 14 years (86% to 79%, p = 0.004), but the difference only became apparent at ten years. The later Stanmore implants did better than the early ones (97% to 92% at ten years, p = 0.005), the improvement coinciding with the introduction of a new cementing technique using a gun. Most of the Charnley implants were done before most of the Stanmore implants so that the difference between the results may in part be explained by improved methods, but this is not the complete explanation since a difference persisted for implants carried out during the same period of time. We conclude that improved techniques have reduced failure rates substantially. This improvement was much greater than that observed between these two designs of implant. Proof of the difference would require a very large randomised controlled trial over a ten-year period.

Blood lipids data were available for 3773 subjects from a cohort study of 11 000 individuals, 6000 of whom do not eat meat. The effects of dietary, lifestyle and physical factors on concentrations of total and HDL cholesterol were investigated. Meat, cheese and dietary fibre, with smoking habit and height were found to be significantly related to total cholesterol in men. For women, meat, cheese, dietary fibre and tomatoes, and type of spreading fat were all significantly related to total cholesterol. Current alcohol consumption and body mass index were significantly related to HDL cholesterol concentration for men. The same factors, plus type of spreading fat, were related to HDL cholesterol levels in women. The findings provide further evidence of the hypolipidaemic effect of vegetarian or near vegetarian diets with a high fibre content and limited use of meat and cheese. The exclusion of meat from the diet might result in a 15–25% reduction in CHD risk.

In the reorganized British National Health Service (NHS), purchasers are supposed to assess the health care requirements of their resident populations and contract for an appropriate volume of services. In the case of elective surgical procedures this can be problematic when there is no reliable information on health needs and no consensus on appropriate rates of use. An examination of hysterectomy rates in 8 districts in 1 Regional Health Authority found a nearly 2-fold variation in population-based rates, a difference which had persisted for at least 12 years. A detailed comparison of a high- and a low-rate district was conducted to assess the extent to which the variations in the rates were related to indices of data quality, resource availability, use of alternative surgical procedures, use of private hospitals, differences in gynaecologists' admission thresholds and differences in demand. The difference was not accounted for by supply factors, but there were significant differences between the 2 districts in levels of demand for specialist gynaecology services and differences in gynaecologists' admission thresholds. It seems likely that the low-rate district contained a greater number of general practitioners who were willing to treat patients themselves rather than refer them to specialists. Because of the sparsity of scientific evidence on which to base judgements about appropriateness and the lack of consensus about need, it will be impossible to specify a target figure for an optimal hysterectomy rate.

Non-communicable diseases (NCDs) such as cardiovascular disease and stroke are a major public health concern across Latin America. A key modifiable risk factor for NCDs is overweight and obesity highlighting the need for policy to reduce prevalence rates and ameliorate rising levels of NCDs. A cross-sectional regression analysis was used to project BMI and related disease trends to 2050. We tested the extent to which interventions that decrease body mass index (BMI) have an effect upon the number of incidence cases avoided for each disease. Without intervention obesity trends will continue to rise across much of Latin America. Effective interventions are necessary if rates of obesity and related diseases are to be reduced.

To compare the ability of two methods--Acute Physiology and Chronic Health Evaluation (APACHE II) and Mortality Prediction Model (MPM)--to predict hospital outcome for a large group of intensive care patients from Britain and Ireland.Prospective, multicenter, cohort study.Twenty-six general intensive care units in Britain and Ireland.A total of 8,724 patients admitted to the study.None.Probabilities of hospital death for patients were estimated by applying APACHE II and MPM. Predicted risks of hospital death were compared with observed outcomes using four methods of assessing the overall goodness of fit. APACHE II performed better than MPM; the calibration curve for APACHE II lay closer to the line of perfect predictive ability. Lemeshow-Hosmer chi-square statistics were 81 and 57 for APACHE II, and 2515 and 1737 for MPM. The overall correct classification rate for APACHE II was 79%, and this classification rate was 74% for MPM, applying a decision criterion of 50%. The area under the receiver operating characteristic curve was 0.83 with APACHE II and 0.74 with MPM. Even after modifications to the MPM for the assessment of coma, the performance of APACHE II was superior.APACHE II demonstrated a higher degree of overall goodness of fit, which was superior to MPM for groups of intensive care patients from Britain and Ireland.

The simultaneous increases in obesity in almost all countries seem to be driven mainly by changes in the global food system, which is producing more processed, affordable, and effectively marketed food than ever before. This passive overconsumption of energy leading to obesity is a predictable outcome of market economies predicated on consumption-based growth. The global food system drivers interact with local environmental factors to create a wide variation in obesity prevalence between populations. Within populations, the interactions between environmental and individual factors, including genetic makeup, explain variability in body size between individuals. However, even with this individual variation, the epidemic has predictable patterns in subpopulations. In low-income countries, obesity mostly affects middle-aged adults (especially women) from wealthy, urban environments; whereas in high-income countries it affects both sexes and all ages, but is disproportionately greater in disadvantaged groups. Unlike other major causes of preventable death and disability, such as tobacco use, injuries, and infectious diseases, there are no exemplar populations in which the obesity epidemic has been reversed by public health measures. This absence increases the urgency for evidence-creating policy action, with a priority on reduction of the supply-side drivers.

More informative information for women on the benefits and harms of mammographic screening has been sought for a long time.1 2 In December 2010 a revised leaflet finally appeared, but it is still misleading.3 The benefits cited are based on the programme’s own review. …

Outcomes research typically focuses on the technical capabilities associated with treatment that predicts patients' post-therapy outcomes adjusting for health-related factors. Research on the ability of placebo therapy to alter outcomes suggests that a patient's expectations about therapy can also influence outcomes. Few studies have examined the effects of expectations and their implications for assessing outcomes. This study followed 348 patients who had surgery for benign prostatic hyperplasia. Four hypotheses are tested: whether positive expectations about improvement influence: 1) patients' postoperative reports of symptoms; 2) their belief that they have improved; 3) their overall health after treatment; and 4) whether these effects persist during the year following treatment. Using step-wise regression to control for sociodemographic and clinical factors, we found positive expectations did not appear to strongly influence a patient's report of postoperative symptoms or their overall health. However, we found strong support for positive expectations increasing the likelihood of reporting they felt better after surgery, even after controlling for symptom changes. This effect persisted throughout the postoperative year. We conclude that positive expectations result in a more optimistic view of improvement after surgery rather than altering reports of outcomes or health.

OBJECTIVES--To compare outcome between intensive care units in Britain and Ireland both before and after adjustment for case mix with the American APACHE II method and to validate the American APACHE II method in Britain and Ireland. DESIGN--Prospective, cohort study of consecutive admissions to intensive care units. SETTING--26 general intensive care units in Britain and Ireland. SUBJECTS--8796 admissions to the study intensive care units. MAIN OUTCOME MEASURE--Death or survival at discharge from intensive care unit and hospital. RESULTS--At discharge from both intensive care unit and hospital there was a greater than twofold variation in crude mortality between the 26 units. After adjustment for case mix, variations in mortality were still apparent. For four intensive care units the observed numbers of deaths were significantly different from the number predicted by the American APACHE II equation. The overall goodness of fit, or predictive ability, of the APACHE II equation for the British and Irish data was good, being only slightly inferior to that obtained when the equation was tested on the data from which it had been derived. When patients were grouped by various factors such as age and diagnosis, the equation did not adjust across the subgroups in a uniform manner. CONCLUSIONS--The American APACHE II equation did not fit the British and Irish data. Use of the American equation could be of advantage or disadvantage to individual intensive care units, depending on the mix of patients treated.

As part of a prospective cohort study of 388 men undergoing TURP for benign prostatic hypertrophy, the Nottingham Health Profile (NHP) was self-administered before and at 3, 6 and 12 months after surgery. By comparison of pre- and post-operative NHP scores with other patient-reported health measures the criterion validity of the Profile was examined. Before surgery, statistically significant linear trends were observed for increasing NHP score (i.e. having more health problems) with both worsening self-rated general health and increasing severity of prostatic symptoms. One year after surgery, the extent of reduction in NHP score was significantly linearly associated with a perceived favourable outcome of surgery and to a lesser extent with a reduction in prostatic symptoms. In addition, changes in NHP scores during follow-up were associated with perceived changes in operative outcome during the same period, patients with the greatest reduction in NHP score tending to report more successful surgery at 12 months than at the 3 month assessment.

Over 40 000 lives could be saved in the UK, and millions of people spared the suffering of living with the effects of heart disease and stroke, simply by producing healthier food states new NICE guidance published on 22 June.1 The guidance calls for the food industry to further reduce the salt and saturated fats in the food it produces, building on the good work already started. In the UK, over five million men and women are living with the devastating and disabling effects of cardiovascular disease—mainly heart disease and stroke. Over 40 000 people die from premature cardiovascular disease (CVD) each year.2 However, premature CVD is largely preventable by making simple changes to diet, smoking and physical activity.3 This new guidance from NICE therefore focuses mainly on food production and its powerful influence on the nation's diet. This is the first time that all of the evidence has been brought together in one place on what works in improving food production, together with the figures showing how much health could be improved. The NICE recommendations are aimed at making small changes across the whole population, because these will actually translate into surprisingly large improvements in health overall.1 The NICE guidance focuses on structural changes to the social environment: in other words, what government and industry can do to make it easier for people to make healthy choices, by producing food in a …